text:
Changes in HIV needs identified by the National AIDS Hotline of Trinidad and Tobago
Cambios en las necesidades relacionadas con el VIH identificadas por la Línea Directa Nacional de Trinidad y Tobago sobre Sida
Sandra D. ReidI; Anders L. NielsenII; Rhoda ReddockIII
IPsychiatry Unit, Faculty of Medical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago. Send correspondence to: Sandra D. Reid, Psychiatry Unit, Faculty of Medical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago; e-mail: firstname.lastname@example.com
IIDepartment of Medicine, University of the West Indies, Cave Hill, Barbados
IIIInstitute for Gender and Development Studies, University of the West Indies, St. Augustine, Trinidad and Tobago
OBJECTIVES: To examine utilization of the National AIDS Hotline of Trinidad and Tobago (AIDSLINE), evaluate its validity as a reliable data source for monitoring national HIV-related needs, and identify changes in caller requests between two different time periods.
METHODS: A total of 7 046 anonymous hotline calls in 19982002 (T1) and 2 338 calls in 2007 (T2) were analyzed for associations between caller characteristics and call content. A subsample of the data was also analyzed qualitatively. T1 findings were compared with HIV-related data collected by national policy-makers during that period, to evaluate the hotline's validity as a data source, and findings from T2, to reveal changes in call content over time.
RESULTS: In T1, the hotline was well utilized for information and counseling by both the general population and those living with HIV/AIDS. Call content from T2 indicated an increase versus T1 in 1) general awareness of HIV and other sexually transmitted diseases; 2) HIV testing; and 3) knowledge of HIV symptoms and transmission. HIV-related mental health needs, and the relationship between HIV and both child sexual abuse (CSA) and intimate partner violence (IPV), were identified as emerging issues.
CONCLUSIONS: AIDSLINE is a well-utilized tool for providing information and counseling on national HIV-related issues, and a valid, cost-effective, easily accessed information source for planners and policy-makers involved in HIV management. Over the two study periods, there was an increase in HIV awareness and testing and in requests related to mental health, CSA, and IPV, but no change in sexual behaviors.
Key words: HIV; sexually transmitted diseases; monitoring; hotlines; Trinidad and Tobago.
OBJETIVOS: Evaluar la utilización de la Línea Directa Nacional de Trinidad y Tobago sobre Sida (AIDSLINE) y su validez como fuente confiable de información para monitorear las necesidades nacionales sobre el VIH, e identificar cambios en las preguntas de los usuarios en dos momentos diferentes.
MÉTODOS: Se buscaron asociaciones entre las características de los usuarios y el contenido de 7 046 llamadas anónimas recibidas entre 1998 y 2002 (T1) y 2 338 recibidas en 2007 (T2). Se tomó una submuestra para análisis cualitativo. Se compararon las características de las llamadas de T1 con: 1) los datos de la autoridad nacional sobre la infección por VIH en ese período, para evaluar la validez de AIDSLINE como fuente de información, y 2) con las de T2 para revelar los cambios en el contenido de las llamadas en el tiempo.
RESULTADOS: En T1, AIDSLINE se utilizó ampliamente para buscar información y consejería, tanto por la población general como por personas con VIH/sida. El contenido de las llamadas en T2 indicó un incremento con respecto a T1 en: 1) preocupación general sobre el VIH y otras enfermedades de transmisión sexual; 2) detección de la infección por el VIH; y 3) información sobre los síntomas de la infección y su transmisión. Se identificaron como preocupaciones emergentes las necesidades en salud mental relacionadas con el VIH y la relación entre esta infección y el abuso sexual de menores (ASM) y la violencia de pareja (VDP).
CONCLUSIONES: AIDSLINE es una herramienta ampliamente utilizada para brindar información y consejería sobre el VIH en el país y una fuente de información válida, efectiva en función del costo y de fácil acceso para los encargados de planear y elaborar políticas relacionadas con el VIH. Con respecto a T1, en T2 aumentaron la preocupación por el VIH y su detección y las preguntas sobre la salud mental, el ASM y la VDP, pero sin cambios en cuanto a la conducta sexual.
Palabras clave: VIH; enfermedades de transmisión sexual; monitoreo; líneas directas; Trinidad y Tobago.
Trinidad and Tobago, the southernmost country in the Caribbean, has a population of 1.05 million (1). National prevalence of human immunodeficiency virus (HIV) among adults (those aged 1549) was 1.5% at the end of 2007, a small increase over the 1.4% prevalence found in 2002 (2), and one of the highest rates of HIV in the Caribbean region. The epidemic has garnered considerable attention from health planners and national policy-makers in the last two decades (36), and various education-oriented strategies have been implemented to reduce risky sexual behaviors (7). Knowledge of common sexual beliefs and practices within the population, including misconceptions about sexual behaviors and HIV transmission, is crucial for planning and designing appropriate and effective interventions. In Trinidad and Tobago, the norms of music, dress, language, popular culture, and casual interactions are highly sexually charged, yet open discussion about sexual beliefs and behaviors, and their relevance to transmission of HIV and other sexually transmitted diseases (STDs), are strikingly absent (8, 9). Questions among individuals with concerns or inaccurate beliefs that are not addressed in national educational campaigns may remain unasked due to embarrassment or fear.
An anonymous AIDS hotline can provide callers with a source of accurate information and confidential counseling and national policy-makers with a repository of data that can serve a vital function in identifying sexual misconceptions, inaccurate information, counseling needs, and barriers to prevention efforts among the population. The individualized and confidential nature of the hotline interaction is likely to result in the revelation of information that would not be forthcoming in other types of surveys. This supposition was borne out in a review of local AIDS hotlines in two U.S. states that found that many individuals utilizing the hotlines had information needs related to their own personal experiences that were not addressed through media campaigns or other means of mass public health education (10).
Assessment of the effectiveness of prevention interventions is vital for management of the HIV epidemic. When resources are limited and thus seem best directed to acute management of the epidemic, individual and community randomized trials, while scientifically rigorous, become difficult to implement, and may not be cost-effective. In these cases, a national anonymous hotline can be an effective and affordable surveillance tool for documenting changes in sexual beliefs and behaviors as well as HIV-related needs and concerns.
The National AIDS Hotline of Trinidad and Tobago (AIDSLINE) was established in 1988 through the collaborative efforts of the Ministry of Health, the U.S. Agency for International Development (USAID) AIDS Public Health Communication Project (AIDSCOM), and the Caribbean Epidemiology Centre (CAREC). Funded by various private organizations and international funding agencies, as well as a government subvention, AIDSLINE provides general information, anonymous and confidential counseling, and referral services designed to address the needs of its users on matters related to HIV/AIDS and other STDs. The hotline is manned by a group of volunteers that receive a minimum of 40 contact hours of training and regular educational updates.
Despite the widespread use of AIDSLINE since 1988, there has been no in-depth research on the nature of its usage. The current study aimed to fill this gap by examining valid hotline calls (those classified by hotline operators based on predefined criteria) to identify caller characteristics, HIV/AIDS information and counseling needs, and sexual and HIV-related misconceptions, as well as any correlations between certain types of callers and the questions they asked. It also compared caller/call data from 1998 to 2002 with the same type of data from 2007 to determine any significant changes in national HIV-related needs after one decade of HIV management, and assessed the validity of AIDSLINE as a means of identifying these needs.
The specific objectives of the research were to examine the utilization of AIDSLINE, identify any changes in callers' HIV needs from the two study periods, and explore the assertion that HIV/AIDS hotlines can serve as reliable and affordable vehicles for monitoring national HIV - related needs. The study assumed any changes in hotline use or call content from 19982002 to 2007 reflected emerging HIV/AIDS needs as well as the impact of national HIV-related interventions.
AIDSLINE records information about anonymous telephone calls, including the demographic characteristics of the caller and the reason(s) for the call, on standardized data collection forms that include an open-ended section for brief description of 1) any special needs of the caller, 2) other comments, and 3) the action(s) taken by the hotline operator. Data collected from callers in the five-year period from 1998 to 2002 (T1) and for the year 2007 (T2) were gathered from these forms, coded into a database, and analyzed. This exploratory-descriptive study was conducted in accordance with guidelines described in the Policy of Research Ethics of the University of the West Indies (1998).
Data analysis
The data obtained from AIDSLINE callers and recorded on standard AIDSLINE paper forms were scanned using TELEform® Elite data capture software (Cardiff Software Inc., San Diego, CA, USA) and automatically coded to an electronic database with automated validation (11).
Quantitative data were prepared for analysis using the query function in Microsoft Access 2000 (Microsoft, Seattle, WA, USA), and tables for statistical analysis were exported from the database to statistical package Statistica, version 7.1 (StatSoft, Tulsa, OK, USA).
Before analysis, all data were plotted using three-dimensional (3D) plots. No seasonal or monthly variation was spotted in the data sets. The observations were tested using the Student's t-test for independent variables. The larger data set (from T1) was collapsed into 60 groups (one for each month of the five-year study (5 years ¥ 12 months/year = 60 months)). The data from T2, which only included one year of observations, were collapsed into 12 groups (by number of the month when the observations occurred). Associations were analyzed using the Pearson correlation coefficient using a level of significance (P-value) of 0.05.
The qualitative data obtained from the open-ended sections of the AIDSLINE forms were manually tabulated and included in the electronic database. A stratified random sample of these qualitative recordings for 3 000 randomly selected calls (T1 = 2 000; T2 = 1 000) was analyzed.
A general inductive approach described by Thomas (12) was used to analyze the qualitative data and to identify content categories that suggested unique needs of the caller. Based on multiple reviews of the data and discussions among the researchers (a psychiatrist, a psychologist, and a sociologist, all with experience in HIV research), various categories of content were determined. Categories were then combined to determine major themes. Consistency checks were carried out by an independent expert, who assigned a subsample of 100 comments from the AIDSLINE forms to the predetermined categories.
Number and source of calls
AIDSLINE received 7 046 valid (classified) calls during T1 and 2 338 during T2, indicating a 66% increase in the average number of valid monthly calls (from 118 ± 16 calls per month in T1 to 195 ± 42 calls per month in T2; P < 0.01). No seasonal or monthly pattern was determined with regard to the number of calls received over the two study periods. The vast majority of calls (99.78% in T1 and 100% in T2) were from citizens of Trinidad and Tobago.
Characteristics of callers
The mean age of an AIDSLINE caller in T1 was 30 years (±11; range 11 to 84 years). The median age was 29 years, and most calls (38.6%) came from the 2029 year age group. In T2, the mean age had decreased to 27 years (±9) and the median had decreased to 25 years. Both of these decreases were significant (P < 0.01). The decline was more marked among females than males. Table 1 compares selected national indicators with the findings of this study.
The male-to-female ratio among callers in T1 was 0.79; by T2, it had increased to 0.85. Both of these ratios were significantly lower than that of the comparable age group in the general population. The increase between the two study periods was not statistically significant, and there was no significant difference in age between the two sexes. In T1, there was a trend in the sex ratio toward more female callers in the older age groups (with 1.05 male versus female callers under age 15 compared to 0.8 male versus female callers among those 65 and over), similar to the ratio seen in the general population. In T2, there was a significantly greater proportion of female callers versus male callers among those under age 15.
Among all hotline callers, 28.5% reported being married. Few callers revealed both marital status and known HIV status (for 89.7%, this information was either missing, not stated, or not applicable), and few revealed information about illicit drug use (not stated or missing among 95.4% in T1 and 95.3% in T2), and condom use (not stated or not applicable among 89.7% in T1 and 86.3% in T2). Of all 1 043 callers (T1+T2) that did provide information on condom use, 76.6% reported engaging in unsafe sex (with 53.4% reporting "no condom use" and 23.2% reporting that he/she "sometimes uses a condom").
Of all 429 callers (T1+T2) who gave information on illicit drug use, 28 reported positively (6.5%).
Between T1 and T2, the number of callers revealing their sexual preference/ orientation (n = 5 630 and 1 296 for the two study periods respectively) decreased from 79.9% to 55.4%. Among those who revealed this information, most described themselves as heterosexual (77.7% in T1 and 54.7% in T2). In T1, 2.1% of the callers reported homosexual behavior (1.5% homosexual and 0.6% bisexual), compared to 0.8% in T2 (0.6% homosexual and 0.2% bisexual). The small numbers in T2 precluded analysis, but of those who revealed sexual preference/orientation, the proportion of persons describing themselves as homosexual fell from 1.5% to 1.08%, while those self-described as bisexuals fell from 0.75% to 0.39%. Table 2 shows the data for callers who revealed both their sex and sexual preference/orientation (n = 5 504 and 1 292 for the two study periods respectively).
Table 3 shows the reported HIV status of callers during the two study periods. In both periods, females were more likely to report being HIV positive. This difference was significant in T1 (6.5% females versus 4.1% males; P < 0.01).
Of the 992 persons in T1 who revealed their HIV status, 38.6% were HIV positive without symptoms, 60.3% were HIV negative, and 1.1% had been diagnosed with AIDS. By comparison, in T2 (n = 398), 19.3% were HIV positive and 80.7% were HIV negative.
Among persons who described their sexual preference/orientation as heterosexual in T1 (including those who did not reveal gender), 315 of 5 474 reported being HIV positive (5.8%) while 532 reported testing negative (9.7%). In T2, 46 of 1 279 self-described heterosexuals reported being HIV positive (3.6%), and 281 (22%) reported testing negative.
In T1, HIV status was revealed by 27 out of 116 males who reported homosexual behavior (23.3%) and by 154 of 568 males self-described as heterosexuals (27.1%). Among the callers with self-described male homosexual behavior, 19 (70.4%) were known to be HIV positive, and eight (29.6%) had tested HIV negative. There was a significantly higher proportion of HIV-positive persons among callers with homosexual behaviors than among heterosexual callers.
During both study periods, most people who called AIDSLINE were doing so for the first time (78.8% in T1 and 83.4% in T2) and were calling on behalf of themselves (78% in T1 and 83.2% in T2). In T2, there was an increase in the male-to-female ratio among repeat callers (from 1.00 in T1 to 1.98 in T2). For both study periods, the percentage of callers who reported being HIV positive or having been diagnosed with AIDS was significantly lower among first-time callers (3.8% in T1 and 2.5% in T2) than among repeat callers (15.2% in T1, P < 0.01; 9.9% in T2, P = 0.06).
Reasons for calling
The standard form used by AIDSLINE operators to classify callers' reasons for requesting hotline information and counseling included seven predefined categories with four to nine subcategories each. In both study periods, across all age groups, and for both sexes, the most common reasons for calls to AIDSLINE were 1) "HIV-related" (desire for information and counseling as a result of personal experiences with HIV infection) and 2) "transmission and prevention" (information-seeking to avoid contracting the disease). During T1, many callers also sought information about testing, medication, and treatment for STDs (mainly HIV). During T2, callers often expressed concern about STDs other than HIV. A side-by-side comparison of the two study periods, listing the number and proportion of calls classified according to the standard AIDSLINE categories, is shown in Table 4.
HIV-related calls. The most common need expressed by AIDSLINE callers (22.2% of calls in T1 and 52.2% of calls in T2; P < 0.01) was "wants HIV test." The ratio of callers that wanted an HIV test was relatively constant over each month of the years under review (rT1 = 0.85; rT2 = 0.879). Females tended to be more likely than males to want an HIV test during T1, but this trend was not statistically significant (P = 0.09).
In T1, 400 callers were concerned about being HIV positive (5.7% of all calls). Women were more likely to call about this concern than men (male-to-female ratio, 0.61; P < 0.01). There was a significant drop in calls for this reason in T2 (1.1%; P < 0.01).
The number of callers experiencing symptoms they feared were associated with AIDS decreased from 3.93% in T1 to 0.8% in T2. However, these numbers were too small for statistical evaluation or gender analysis. Among the 2 000 calls in T1 for which qualitative analysis was applied, symptoms that evoked this concern included blood in ejaculate, vaginal rash, tingling sensation on penis, and vaginal itching. When concern about AIDS was expressed in T2, the symptoms were also genital-related but were more likely to be known symptoms of HIV-related illness, including oral thrush, diarrhea, steady weight loss, and persistent lymph nodes.
In T1, 5.0% (n = 465) of all callers contacted the hotline because they had tested HIV positive. Females constituted a significantly greater proportion of these callers (male-to-female ratio, 0.36; P < 0.01). Only nine persons (0.4%) called the hotline for this reason in T2.
Transmission and prevention. For both study periods, more males than females called for information on HIV transmission and prevention (with a male-to-female ratio of 1.83 and 1.76, P < 0.01, for T1 and T2 respectively). The number of inquiries for each of the nine predefined subcategories for HIV transmission and prevention is shown in Table 4, by study period. In both T1 and T2, most inquiries for this category concerned the risk of HIV transmission through oral/anal sex and kissing.
For T1 cases in which open-ended comments were reviewed and qualitative analysis was carried out, queries about HIV prevention and transmission were wide-ranging, and included concerns about the risk of contracting the disease via mosquito bites, heavy foreplay, fingering, lesbian sex, menstrual blood, semen in the toilet, tattooing, water from a burst sewer, "quickies" (brief, rushed sexual encounters), blood in ketchup, contact sports, dental tools, nail cutters, sex toys, and breast milk from HIV-positive mothers. Callers also inquired about the risk of contracting HIV through contact with shaving sets, plates, toilet paper, restrooms, roll-on deodorant, food, and clothing used or touched by infected persons; hand-shaking; massages; fondling; playing with an infected child; and being stuck with a sharp object.
Information was also sought on the effectiveness of using double condoms, not ejaculating, urinating frequently after intercourse, and washing after intercourse as methods of HIV prevention, and medication or blood replacement as a means of reversing a positive HIV status; the risks of condom use; and how to have sex safely with an HIV-positive person or a commercial sex worker.
During T2, the predominant query related to prevention and transmission was on the safety of non-coital sexual contact, including kissing, oral sex, body-to-body massages, and lap dancing. Queries were also raised about incidents involving the potential exchange of blood (e.g., being stuck by a used needle, exposed to a barber's razor, or bitten by a human).
No association between HIV status or sexual orientation and the type of information requested about HIV transmission and prevention was found in either study period.
Other categories of calls. The numbers of calls related to the five other categories defined by AIDSLINE were small and reflected no significant findings.
There was a significant decline in the number of referrals made by AIDSLINE operators from T1 to T2 (71.8% to 61.2% of calls; P < 0.01). Most referrals were for HIV testing and evaluation/treatment of symptoms.
Qualitative results
A review of caller comments recorded by AIDSLINE operators in the open-ended section of the data collection forms for the T1 study period revealed the need for HIV-related information and counseling in five main categories: risk assessment of personal experiences; HIV testing, exposure, and diagnosis; mental health; disclosure of HIV status; and information exchange with philanthropic individuals (queries and feedback from citizens concerned about people living with HIV/AIDS) (Table 5).
During T2, four major categories of needs were identified from caller comments: HIV testing and diagnosis; mental health; specific information related to HIV and other STDs (e.g., testing, symptoms, and risks); and issues related to children (sexual abuse, HIV, other STDs, AIDS) (Table 6).
This study examined the utilization of AIDSLINE and its effectiveness in identifying the HIV-related needs of callers. A comparison of the age and sex of AIDSLINE callers with national statistics for the general population suggests the hotline served the general population as well as people living with HIV/AIDS, with the latter group over-represented in both study periods. There were significantly more calls to the hotline from younger persons, particularly adolescent females, in T2 versus T1, indicating increasing awareness and positive action among this vulnerable subgroup, which registered a national prevalence of HIV infection six times higher than that of adolescent males in 2005 (13).
Overall, women were significantly more likely than men to call the hotline, in both study periods, with the male-to-female ratio of callers significantly lower than that in the general population. Among HIV-positive callers, women were also disproportionately represented, supporting reports of gender disparities in the HIV/AIDS epidemic in Trinidad and Tobago (14). However, the study's findings on the sex and HIV status of repeat hotline callers suggest the sex ratios observed among all hotline callers may result not only from the feminization of the epidemic but also from gender disparity in help-seeking for HIV. Repeat callers appeared to have more serious health problems than one-time callers (an observation supported by the finding that there were four times as many HIV-positive people among the former group versus the latter), and a greater proportion of repeat callers versus one-time callers were men (with the male-to-female ratio among the former group approaching, in 19982002, and exceeding, in 2007, that of the general population). Furthermore, in 19982002, women were more likely than men to express fears of being HIV positive, and to call the hotline because they had tested positive, whereas men were more likely to call the hotline because they had experienced symptoms feared to be AIDS. Together, these observations indicate that men are less likely than women to seek help for HIV in its early stages. Possible explanations for this may be that men are more likely to deny a possible HIV-positive status, and may have more fatalistic attitudes or be more concerned about stigma and discrimination related to dominant gender norms, until the development of symptoms poses a real threat. These issues have been recorded among men in Africa (15, 16), where HIV transmission is primarily heterosexual and fueled in part by gender inequity (17), as it is in Trinidad and Tobago. Delayed help-seeking delays diagnosis, increases the risk of HIV transmission, and increases the cost of health care. It is therefore important to explore reasons for this behavior among men.
There was a significant drop in the number of persons who did not know their HIV serostatus between the two study periods (from 64% in T1 to 47% in T2). Low rates of HIV testing are driven by poor access to testing services and concerns about stigma (1820). Both issues seemed to apply among callers in 19982002. Consistent with other AIDS hotline analyses (10, 21, 22), the majority of callers during T1 wanted an HIV test. The second most common reason for calling the hotline during that period was to locate HIV/other STD testing outlets, suggesting that this information was not well known among the general population. By comparison, although the number of persons wanting an HIV test in 2007 increased significantly, the number of queries about the location of testing sites was negligible. Stigma and disclosure may have also been significant factors in the 19982002 time period, when queries were received from both HIV-positive and non-infected persons on how to facilitate communication about HIV and encourage help-seeking or disclosure. In 2007, no significant theme related to stigma and/or discrimination was identified, nor did callers seek reassurance about the confidentiality of the service as they had in the earlier study period. Therefore, the study findings suggest increased knowledge of HIV testing facilities among the general population, decreased fear of stigmatization, and increased HIV testing. However, compared to 19982002, in 2007, more than twice the proportion of persons calling the hotline chose not to reveal their HIV status, suggesting that some HIV stigma still existed.
As in other studies (10, 22), males were more likely than females to seek information on HIV transmission. The proportions of all callers seeking information about HIV transmission and prevention declined slightly from T1 to T2. Qualitative analysis revealed there were also changes in the types of misconceptions held by callers over the two study periods. During 19982002, callers did not seem knowledgeable about HIV/ AIDS symptoms, or how to interpret test results. In addition, despite a basic knowledge of how HIV is acquired and transmitted, most callers were not aware of the details of transmission. For example, many calls included inquiries about non-risky situations and how to use condoms safely. In 2007, there seemed to be fewer misconceptions with regard to transmission, and inquiries were more specific. Callers were concerned about risks of non-coital sexual behaviors and blood exchange. While earlier callers appeared to panic over perceived risky behaviors, fearing the possibility of infection, in 2007 the concerns were for quick, reliable, and convenient HIV testing after risky sexual behavior. There was no indication of any change in sexual behavior between the two study periods.
During the 19982002 period, HIV/ AIDS programs in Trinidad and Tobago aimed to increase awareness of HIV/ AIDS transmission and prevention (23) and reduce risky sexual behaviors. These efforts were conducted through educational campaigns, primarily focused on the "ABC" approach (abstinence, being faithful, consistent use of condoms). Since 2002, the Government of Trinidad and Tobago has provided free antiretroviral (ART) medication to all citizens, and improved access to treatment at specialized centers. In 2007, callers' inquiries about HIV were more informed, and there were marked reductions in the numbers of calls from HIV-positive persons, caregivers of persons living with AIDS, and persons needing referrals for testing or treatment. These findings point to increased awareness of HIV and availability of treatment resources.
Evidence of the apparent simultaneous lack of changes in risky sexual behavior despite increased awareness of HIV transmission points to the need to reevaluate the ABC approach as an appropriate strategy for HIV prevention. This is consistent with previous findings among Trinidadians that knowledge of HIV is associated with concern about personal risk of infection and condom possession but not consistent condom use (24), and supports the recommendation that HIV prevention programs should employ a poly-theoretical approach (24).
The observation of increased awareness of HIV transmission is consistent with reports from Trinidad and Tobago in 20062007 (25) that showed that before the 2005 implementation of the National AIDS Coordinating Committee youth prevention campaign "What's Your Position?" only 56% of 15-to-24 year olds correctly identified ways of preventing sexual transmission of HIV, whereas in 2007, 90% of those surveyed were able to identify six key measures to reduce HIV transmission (with no noticeable differences by age group). This suggests that programs to increase HIV awareness among the general population may not have been as effective among the youth as those specifically targeting young persons. AIDSLINE presents a convenient way of readily monitoring inadequate knowledge and misconceptions about HIV/AIDS in the general population, and providing information for the development and refining of prevention programs.
While the HIV epidemic in Trinidad and Tobago is classified as heterosexual, researchers acknowledge a simultaneous homosexual epidemic (26), and the elevated risk of HIV infection for men who have sex with men (MSM) (27, 28). This study limits discussion to self-described homosexual and bisexual men because only very small numbers of females reported homosexual behavior. However, the number of callers identifying themselves as MSM was sufficient for analysis only during the earlier period. Consistent with previous reports (2729),1 MSM had significantly higher rates of HIV infection than those reporting exclusively heterosexual behavior, suggesting greater HIV risk.
The number of callers stating their sexual preference/orientation, and the proportion of those who stated it as homosexual or bisexual, declined from 1998 2002 to 2007. Because the proportion of MSM in the general population is unlikely to have changed between the two study periods, and there was no obvious change in societal attitude toward homosexual behavior, this finding may be attributed to budgetary allocations made to MSM support and advocacy groups in 2003 through the national HIV plan, which resulted in MSM-specific interventions for HIV education and support and thus a reduced need for the national hotline among this population.
These findings may also be explained by homophobia and forced heteronormativity in the population. Homophobia limits the inclusion of MSM in national HIV prevention interventions. Over the decade comprising the two study periods, in terms of public perception, HIV/ AIDS has been transformed from a homosexual disease to a heterosexual one. This may have created complacency among MSM with a tendency toward reduced HIV information- and help-seeking behavior. Simultaneously, management of the HIV epidemic provided the opportunity for discussions on human rights and sexual orientation. This focus on homosexual behavior in a homophobic society could increase the level of secrecy and forced heteronormativity as MSM feel more threatened by persistent societal discrimination and potential violence. In turn, more secrecy, and complacency, increases the likelihood of HIV transmission between MSM (regardless of whether they acknowledge their sexual orientation) and heterosexual women. Therefore, there is a need for HIV prevention messages specifically targeted to the MSM population. This requires a reduction in homophobia and other cultural taboos that reduce the availability and effectiveness of prevention messages to this subpopulation.
Qualitative analysis of comments made by callers to AIDSLINE identified the need for mental health counseling and other services in both study periods. These needs included sustained support after HIV testing, and counseling related to bereavement and relational issues for HIV-positive persons and their relatives. Callers in 2007 more overtly reported inadequate coping as well as intimate partner violence (IPV) in response to situations of risky sexual contact and HIV diagnosis within relationships. The relationship between IPV and HIV risk has been previously reported (30, 31) but remains an area to be explored in Trinidad and Tobago.
Other callers reported symptoms suggestive of mental illness. Very little has been written about the mental health needs of HIV-positive persons in Trinidad and Tobago. In a study of HIV-positive persons attending a community support group, 78% of persons evaluated had a current psychiatric diagnosis and 41% had more than one diagnosis.2 There is a need to further explore the prevalence, timing, and associations of mental health symptoms among HIV-positive persons. The U.S. Centers for Disease Control and Prevention (CDC) National AIDS Hotline (32) noted that 16% of all calls were related to mental health. Other studies have shown the range of psychosocial problems associated with a positive HIV serostatus (33, 34) that require specific intervention beyond the post-test phase.
In 2007, AIDSLINE documented direct and indirect expressions of concerns about the risk of HIV transmission to victims of child sexual abuse (CSA) through queries about testing for HIV and other STDs after sexual molestation, and reports of children diagnosed as HIV positive within a family where an older relative had died of AIDS, respectively. This raises the important issue of the relationship between CSA and HIV infection. No studies have documented this association in Trinidad and Tobago, but it has been reported in Jamaica (35). Investigating this association is difficult (36), but this study's findings indicate a need to explore the relationship between CSA and HIV in Trinidad and Tobago.
This study concludes that an analysis of calls to Trinidad and Tobago's AIDSLINE between 1998 and 2002, and in 2007, establishes the hotline as a useful and well-utilized vehicle for providing accurate information, clarifying misconceptions, and providing counseling for the general population as well as those infected with the HIV virus. The hotline does this in an anonymous, confidential, nonjudgmental, and personal manner and can therefore play a vital role in HIV/AIDS education and prevention for all sectors of the population.
The analysis of calls between 1998 and 2002 identified several areas of HIV management requiring improvement. Independent of any review of the hot-line data, Trinidad and Tobago's National HIV/AIDS Strategic Plan (January 2004December 2008) focused on the same issues identified by the AIDSLINE analysis, providing evidence that the hotline is a valid source of information on the HIV epidemic.
By comparing calls made to AIDSLINE from 1998 to 2002 with those made during 2007, this study documented trends in the epidemic and changes in HIV-related concerns and needs. It also identified other areas that have yet to capture the attention of HIV/AIDS program planners.
Public health professionals and policy-makers must have ready access to information on the needs of the public for effective management of the HIV epidemic. Major barriers to information access include time, resource reliability, and trustworthiness/credibility of information (37). Using AIDSLINE as a source of information is a fast, convenient, and low-cost way of obtaining the information that is needed for HIV policy-making and program planning. This study shows that AIDSLINE provides valid, relevant data, including information that may not be available from other sources. Continuous analysis of calls made to the hotline allows for the early detection of trends and needs, facilitating better-focused decision-making. Because AIDSLINE callers represent the general population as well as the community living with HIV/AIDS, the information gathered by the hotline is relevant to general as well as HIV policy-making. Data are collected continuously by AIDSLINE as an integrated part of the routine service and are therefore cost-effective and easily accessible.
This study had several limitations, including the small size of the sample self-reported as members of populations at high risk for HIV. The minimal number of callers who gave information on condom use, drug use, and homosexual behaviors did not allow for adequate exploration of the specific information needs and concerns of HIV-vulnerable groups. In addition, the data recorded in the AIDSLINE form did not provide sufficient information for categorizing callers' risk, and there were problems with the way calls were classified, as many subject areas overlapped. The assumptions that the self-report of sensitive information was accurate and that the training of AIDSLINE operators was consistent over the two study periods could also be considered study limitations.
Acknowledgments. The researchers wish to thank Professor Courtenay Bartholomew, Chairman of AIDSLINE, and Mrs. Helena Joseph, voluntary AIDSLINE coordinator, for their support in conducting this project.
1. Central Intelligence Agency (US). CIA world factbook 2008. Central America and Caribbean: Trinidad and Tobago. New York: Skyhorse Publishing; 2007.
2. Joint United Nations Programme on HIV/ AIDS; World Health Organization. UNAIDS/ WHO epidemiological fact sheet on HIV and AIDS. Core data on epidemiology and response. Trinidad and Tobago. 2008 update. Geneva: UNAIDS/WHO; 2008.
3. Narain JP, Hull B, Hospedales CJ, Mahabir S, Bassett DC. Epidemiology of AIDS and HIV infection in the Caribbean. Bull Pan Am Health Organ. 1989;23(12):429.
4. Henry G, Chong J, Bratt DE, Cameron E. Paediatric acquired immunodeficiency syndrome (PAIDS) in Trinidad and Tobago. West Indian Med J. 1990;39(3):1747.
5. Henry R, Newton E. AIDS costs in Trinidad and Tobago. Stud Comp Int Dev. 1994;29(4):6889.
6. Baird DS, Yearwood EL, Perrino CS. Small islands, big problem: HIV/AIDS and youth in Trinidad and Tobago. J Child Adolesc Psychiatr Nurs. 2007;20(4):24351.
7. Ransome D. Prevention and care: Trinidad's twin messages. AIDS Watch. 1990;(9):57.
8. Lewis L. Exploring the intersections of gender, sexuality, and culture in the Caribbean: an introduction. In: Lewis L, editor. The culture of gender and sexuality in the Caribbean. Gainesville (FL): University Press of Florida; 2003. p. 121.
9. Kempadoo K. Sexing the Caribbean: gender, race and sexual labor. New York: Routledge; 2004.
10. Kalichman SC, Belcher L. AIDS information needs: conceptual and content analyses of questions asked of AIDS information hotlines. Health Educ Res. 1997;12(3):27988.
11. Cardiff Software introduces TELEform Elite: high performance data collection system combines existing form recognition with electronic filler; powerful new addition to Teleform line targets companies processing 2,50025,000 forms daily [press release]. Business Wire. 1996 Apr 1 [cited 2009 Sept 7]. Available from: http://www.highbeam. com/doc/1G1-18146881.html.
12. Thomas DR. A general inductive approach for qualitative data analysis. Auckland: University of Auckland; 2003 [cited 2006 Feb 16]. Available from: http://www.fmhs.auckland. ac.nz/soph/centres/hrmas/_docs/Inductive 2003.pdf.
13. Inciardi JA, Syvertsen JL, Surratt HL. HIV/ AIDS in the Caribbean Basin. AIDS Care. 2005;17 Suppl 1:S925.
14. Joint United Nations Programme on HIV/ AIDS; World Health Organization. UNAIDS/ WHO epidemiological fact sheets on HIV/ AIDS and sexually transmitted infections. Trinidad and Tobago. 2004 update. Geneva: UNAIDS/WHO; 2004 [cited 2008 Aug 18]. Available from: http://data.unaids.org/ Publications/Fact-Sheets01/trinidad-tobago_ en.pdf.
15. Kalichman SC, Simbayi LC. HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in Cape Town, South Africa. Sex Transm Infect. 2003;79(6):4427.
16. Pearson S, Makadzange P. Help-seeking behaviour for sexual-health concerns: a qualitative study of men in Zimbabwe. Cult Health Sex. 2008;10(4):36176.
17. Beyrer C. HIV epidemiology update and transmission factors: risks and risk contexts16th International AIDS Conference epidemiology plenary. Clin Infect Dis. 2007;44(7): 9817. Epub 2007 Feb 26.
18. deGraft-Johnson J, Paz-Soldan V, Kasote A, Tsui A. HIV voluntary counseling and testing service preferences in a rural Malawi population. AIDS Behav. 2005;9(4):47584.
19. Hutchinson PL, Mahlalela X. Utilization of voluntary counseling and testing services in the Eastern Cape, South Africa. AIDS Care. 2006;18(5):44655.
20. Bwambale FM, Ssali SN, Byaruhanga S, Kalyango JN, Karamagi CA. Voluntary HIV counselling and testing among men in rural western Uganda: implications for HIV prevention. BMC Public Health. 2008;8(1):263. doi:10.1186/1471-2458-8-263.
21. Scott SA, Jorgensen CM, Suarez L. Concerns and dilemmas of Hispanic AIDS information seekers: Spanish-speaking callers to the CDC National AIDS hotline. Health Educ Behav. 1998;25(4):50116.
22. Bos AE, Visser GC, Tempert BF, Schaalma HP. Evaluation of the Dutch AIDS information helpline: an investigation of information needs and satisfaction of callers. Patient Educ Couns. 2004;54(2):2016.
23. Marquez PV, Sierra VH, Gayle J, Crown R, Griffin C. HIV/AIDS in the Caribbean: issues and options. Report No. 20491-LAC. Washington: World Bank; 2000.
24. Norman LR, Carr R. The role of HIV knowledge on HIV-related behaviours: a hierarchical analysis of adults in Trinidad. Health Educ. 2003;103(3):14555.
25. Office of the Prime Minister, National AIDS Coordinating Committee (TT). UNGASS country progress report: Trinidad and Tobago. Reporting period: January 2006December 2007. Port of Spain: NACC; 2008 [cited 2008 Aug 25]. Available from: http://data.unaids.org/pub/Report/2008/trinidad_and_tobago_ 2008_country_progress_report_en.pdf.
26. Caribbean Epidemiology Centre; Pan American Health Organization; World Health Organization. Homosexual aspects of the HIV/AIDS epidemic in the Caribbean: a public health challenge for prevention and control. Port of Spain: CAREC/PAHO/WHO; 2006.
27. Bartholomew C, Saxinger WC, Clark JW, Gail M, Dudgeon A, Mahabir B, et al. Transmission of HTLV-I and HIV among homosexual men in Trinidad. JAMA. 1987;257(19):26048.
28. Baral S, Sifakis F, Cleghorn F, Beyrer C. Elevated risk for HIV infection among men who have sex with men in low- and middle-income countries, 20002006: a systematic review. PLoS Med. 2007;4(12):e339.
29. Dougan S, Payne LJC, Brown AE, Fenton KA, Logan L, Evans BG, et al. Black Caribbean adults with HIV in England, Wales, and Northern Ireland: an emerging epidemic? Sex Transm Inf. 2004;80(1):1823.
30. Maman S, Campbell J, Sweat MD, Gielen AC. The intersections of HIV and violence: directions for future research and interventions. Soc Sci Med. 2000;50(4):45978.
31. Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD. Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet. 2004;363(9419):141521.
32. Safran MA, Waller RR. Mental healthrelated calls to the CDC National AIDS Hotline. AIDS Educ Prev. 1996;8(1):3743.
33. Joseph EB, Bhatti RS. Psychosocial problems and coping patterns of HIV seropositive wives of men with HIV/AIDS. Soc Work Health Care. 2004;39(12):2947.
34. Catalan J, Beevor A, Cassidy L, Burgess AP, Meadows J, Pergami A, et al. Women and HIV infection: investigation of its psychosocial consequences. J Psychosom Res. 1996; 41(1):3947.
35. Lowe GA, Gibson RC, Christie CDC. HIV infection, sexual abuse and social support in Jamaican adolescents referred to a psychiatric service. West Indian Med J. 2008;57(3):30711.
36. Gutman LT, Herman-Giddens ME, McKinney RE Jr. Pediatric acquired immunodeficiency syndrome: barriers to recognizing the role of child sexual abuse. Am J Dis Child. 1993; 147(7):77580.
37. Revere D, Turner AM, Madhavan A, Rambo N, Bugni PF, Kimball A, et al. Understanding the information needs of public health practitioners: a literature review to inform design of an interactive digital knowledge management system. J Biomed Inform. 2007;40(4):41021. Epub 2007 Jan 11.
Manuscript received on 8 June 2009.
Revised version accepted for publication on 17 September 2009.
1 Lee RK, Poon King C, Legall G, Trotman C, Samiel S, O'Neil C. Risk behaviours for HIV among men who have sex with men in Trinidad and Tobago. Int AIDS Conf. 2006: abstract no. CDD0366. Available from: http://www.iasociety.org/Default.aspx?pageId=11&abstractId=2198563.
2 Reid SD, Nadathur S, Clarke N, Fifi A, Peters J, Chang Kit A, et al. Prevalence of psychiatric symptoms among HIV-positive persons attending a support group. Unpublished manuscript; 2003.


text:
Some things are better left undiscovered!
Part V
Charlie silently followed her as she stepped across the threshold, and as she did a faint blue glow illuminated the center of the room. She stopped and stepped back, suddenly unsure if she should continue, and the blue light faded to darkness. Stepping forward again, she was rewarded with the return of that blue glow that seemed to emanate from the center of the room.
Following the beam of her flashlight, they both ventured deeper into the chamber, coming to a stone bench on their right. She played the beam of the flashlight over the dust-covered surface of the bench, noting how it curved to the left as it vanished into the shadows. There was another bench thee feet in front of the first, it too curving into the emptiness that pressed in on all sides. With growing confidence she pushed on, coming to a third bench in front of the second one.
As they ventured deeper into the chamber, she slowly became aware that the blue glow was coming from an object to her immediate front. She stopped, took a deep breath, and switched off her flashlight.
"Turn off your light," she said.
"Are you nuts?"
"Just do it."
Charlie complied and as her eyes adjusted to the darkness the blue glow grew stronger until she could make out the shape of a large blue globe hanging suspended an unknown distance before her. More details came into focus and she began picking out tiny spots of light high above her head all around her. The image reminded her of a planetarium during a showing and she suddenly realized that what she was gazing upon was the home world of whatever had built this structure.
"Can you see it?"
"See what?"
"Close your eyes for a minute and let them adjust to the dark." Sandra closed her own eyes and when she reopened them that alien solar system was once again laid out before her with that faint blue sun in the center.
"What the hell," Charlie said.
"I think that's why they came here."
"Those who built this structure. Their sun was dying."
"What is it?"
"A star system, their home."
"Of course, who did you think I was talking about?"
"How can you be so sure?"
"I'm not absolutely certain. Not one hundred percent. But the explanation fits."
"Then where are they now?"
Sandra shrugged. "I don't know."
They had moved forward to a raised dais a foot higher than the rest of the floor. Stepping up together, they approached the blue sphere, beneath which rested a small white box. Charlie reached the item first, marveling at the craftsmanship that had gone into constructing this small object. It looked like fine marble cut into very thin sheets, somewhat transparent, its contents were a faint smudge against the white.
"What is it?" Charlie said.
"I don't know." Sandra touched the surface of the box and when she did her mind was suddenly filled with ancient images of an alien place that was all but a memory.
She saw a vast valley beneath a blue sun. From the floor of the valley rose an immense tower. The spires of Beizel in the valley of tears. The name came to her from the black depths of a consciousness that stretched into the antediluvian void of their past. She could feel them around her, the followers who had trekked to this desolate plain, and the faithful who had come to seek redemption. Their thoughts washed over and around her, a single voice in a seething populace whose movements were so perfectly timed they took on the appearance of the surface of the ocean as gentle swells raced from one end to the other in a continuous cycle.
They had come seeking salvation and found it in the singularity of one thought that washed through them with a solitary voice. The individual parts of the whole had come together to form a distinct thought, and that was survival of the species. Their sun was dying, the time for the planet, for their reign, had come to a close. But one chance remained, the survival of the species lay with the chosen who would reach out into the great beyond; to ensure the survival of the species they would venture into the farthest reaches of the cosmos in their search for a new planet to call their own.
Sandra stepped back from the box, her fingers numbed by the contact, struggling to catch her breath as the true meaning of what she had briefly seen began to sink in.
They did not belong here.
In the shadows around her their memories moved with a sinuous ease through the deeper night.
"Are you all right?" Charlie said, resting his hand on her shoulder as he stepped forward to look at the box resting on the raised dais.
"Don't touch it," she warned him. But he ignored her, reaching out to grasp the box in one hand as he softly whispered, "So beautiful."
Before she could stop him, he had flipped open the delicate hasp and was raising the lid to gaze upon what the box contained. Sandra became aware of movement in the shadows all around her as that ozone aroma intensified. Her hair felt like it was standing on end in response to the suddenly charged atmosphere. Tentacles of darkness slithered across the dais towards them.
To be continued
Click on cover for more info or to order!
Also available from these fine online retailers.
Also available in print from Createspace

subset: commoncrawl


text:
A WWF study which analysed the river flow on ten major Canadian rivers has reported that the South Saskatchewan River is the most at risk. Climate change, agricultural and urban infrastructure water use, and dams producing hydroelectricity, have all combined to reduce the flow of the South Saskatchewan River. Developers and governments have been cautioned to protect and restore the river with sustainable projects and limit water diversion.
This section provides an overview of risks and pressures within the South Saskatchewan River Basin.


text:
The Ben Stiller Collection
2005 Comedy Not Rated
|In Theaters
|On 4K UHD
|Not Available
|On Blu-ray
|Not Available
|On DVD
|Not Available
Principal Cast
This is a multiple-item set. We have not yet added the individual components.
Set is not rated. Films may be rated individually.
Released by Universal. See more credits.


text:
Q&A With Damesly Founders
Hi, I'm Liz! As a long time fan of Damesly, I was given the chance to ask the founders, Kelly and Aly some questions about their amazing women-only tour company.
So let's just dive right in, what is Damesly and why should I join you ladies on these trips?
Aly: Damesly is more than just a trip, the reason to join us is to connect with women who share your passions and interests, learn new skills, all the while happening to be in an amazing destination.
Kelly: Damesly was formed in an effort to take awesome women on amazing trips. We wanted to build a community of creative and entrepreneurial women. When you join a trip, you get to see an amazing destination and also leave feeling inspired to pursue the next level in your career or business.
Couldn't I just do this trip on my own? What is the benefit for me?
Aly: The benefit is meeting and befriending amazing women who you may not have gotten to know otherwise. Sharing an adventure together and learning together is a rewarding experience.
Kelly: Sure, most places you probably could. The difference here is in the workshops and the community. In these ways, we offer something no one else can.
Why is Damesly only for women?
Aly: There is a lack of female mentors in most industries. By bringing together women with a shared interest we want to foster building an organic network of kickass ladies around the world.
Kelly: We believe women our each other's biggest strength when it comes to encouraging one another climb in our creative pursuits. We wanted to harness the magic that happens every year at Women's Travel Fest, and take it traveling. And it's amazing!
Question: What types of women travel with Damesly?
Aly: Women who want to explore not only the world but better themselves with immersive experiences and by connecting with others.
Kelly: Creative, entrepreneurial, badass, fun, smart women. Women who need a refresh or a jolt of inspiration. Women not afraid to chase their dreams.
Well, I definitely fit the bill! Typically, how many of these badass women are on each trip?
Aly: Up to 8 right now.
What does the future for Damesly look like?
Kelly: I want to grow Damesly to be a real resource for women, meaning I want chapters across the country and world that can serve to boost women up. I want to host meet ups, conferences and inspiring events that feature women in their communities. The important thing for us is community, and growing that so that there are not just trips, but chapters and masterminds, so to speak, happening all of the time.
What are some upcoming trips I should be excited about?
Kelly: Aly and I are each excited for separate trips! I'm excited for Iceland for the raw beauty, and particularly pumped for our Lake Powell, Arizona trip as part of our new Damesly mini series we just launched: affordable 3-day workshops!
Aly: I'm excited about the "Makers + Magnolias" weekend held in New Orleans because it's not only right in my backyard but showcases so many people and places that I've been dying to meet/check out together with a creative workshop aimed at makers who need that push to put their project/product out there into the world.
But I'm honestly excited about all of them. Each is a unique trip that can't be replicated anywhere else.
How is Damesly different from other women's travel groups?
Aly: We're a place for women to connect based more on their passions and professional level than just the interest in a destination. We replace conference rooms with the Grand Canyon, after work black-dress networking events with a hike in Iceland.
If I have a great idea for a trip, can I lead a Damesly adventure?
Aly: We currently vet our leaders based on either their expertise in a certain field or of a destination. If you have a unique insight or skill you want to share. Then we want to hear from you.
Kelly: Sure! If you've got a great idea for a workshop and can turn it into a killer trip, we'd love to hear from you. Shoot an email to firstname.lastname@example.com.
For more information about Damesly and the incredible trips they are launching, visit damesly.com.
Liz Beeson is an Associate Producer for a digital advertising agency based in New York City. She is a freelance photographer and a contributing writer for Thrillist.com. In addition to her work, she just co-founded the all lady dance group, Big Apple Babes, and serves on the engagement advisory board for The New York Women's Foundation.


text:
Ontology for Biobanking
An ontology built for annotation and modeling of biobank repository and biobanking administration
The Ontology for Biobanking (OBIB) is an ontology for the annotation and modeling of the activities, contents, and administration of a biobank. Biobanks are facilities that store specimens, such as bodily fluids and tissues, typically along with specimen annotation and clinical data. OBIB is based on a subset of the Ontology for Biomedical Investigation (OBI), has the Basic Formal Ontology (BFO) as its upper ontology, and is developed following OBO Foundry principles. The first version of OBIB resulted from the merging of two existing biobank-related ontologies, OMIABIS and biobank ontology.
- ID Space
- obib
- http://purl.obolibrary.org/obo/obib.owl
- License
- Homepage
- https://github.com/biobanking/biobanking
- Contact
- Jie Zheng
- Trackers
- https://github.com/biobanking/biobanking/issues
- Domain
- biobanking, specimens, bio-repository, biocuration
See metadata guide


text:
How to Update Mario & Luigi: Bowser's Inside Story + Bowser Jr.'s Journey
Step-by-step instructions for installing the update for Mario & Luigi: Bowser's Inside Story + Bowser Jr.'s Journey.
As of 20 March 2019, new update data for Mario & Luigi: Bowser's Inside Story + Bowser Jr.'s Journey has been made available for download in Nintendo eShop. We recommend that all players download and install this update data.
Additional Information:
- Save data will still be available for use after downloading the update.
- After downloading the update, please do not delete the update data. Update data can be viewed in the "Downloadable Content" area of the Data Management menu.
- Updates can be applied to both digital and physical copies of Mario & Luigi: Bowser's Inside Story + Bowser Jr.'s Journey.
What to Do:
- Perform a system update to ensure you have the most up-to-date version.
- For information about connecting your system to the internet, click here.
- Download the software update from Nintendo eShop.
Update Details:
Click the version number below for information about the update. Each update also includes all previous updates.
Version 1.2
- Addressed an issue where sound wouldn't play for music from the Nintendo DS version of Mario & Luigi: Bowser's Inside Story in the Music Menu, under Records.
Version 1.1
The issue where players would sometimes get stuck on a certain map when controlling Luigi solo and trying to save the game progress by using the Save Block, has been fixed.
- By downloading the update data, the issue will no longer occur.
- If the issue has already occurred, it will be fixed so that players can continue.


text:
If you are looking for the perfect holiday destination which encompasses outdoor fun, scenic landscapes, and plenty to see and do, then the Forest of Dean could certainly be for you.
This large and beautiful area sits in western England, in Gloucestershire, and is surrounded by many historical and natural wonders to explore, such as Clearwell Caves and Dean Heritage Centre.
If you choose to go on a holiday to the Forest of Dean then a cottage is the ideal place to stay. This way you get to enjoy the home away from home feel of a holiday home, without the mass tourism of hotels, but you also get a luxurious place to lay your head too, which really is the best of both worlds. There are holiday cottages to suit every budget, so certainly shop around for your ideal cottage, and see what you can find.
Once you arrive in the Forest of Dean area you will be instantly drawn into the beautiful nature. The green hills, seemingly endless trees, winding rivers, and the small villages which run alongside, are all fantastic for the eye to see, as well as offering many outdoor activities to enjoy too. Ross on Wye is a popular town in the area, and this is somewhere which is a must visit, as well as Symonds Yat Rock, which is another must do.
Much of this area is about the great outdoors, as you can imagine, so hiking, mountain biking, walking, rock climbing, fishing, and nature rambling are all fantastic activities to enjoy, making this is the ideal destination for a summer family break. The weather is usually much more pleasant in this particular region, compared to the further north of the country, so you can expect warmer temperatures and a little less in the way of rain too.
Of course, a lot of the area is about nature, as we have mentioned, and you will be able to bird spot and check out the huge variety of different birds which call the area home. The forest is made up of various different species of tree, including oak and beech, as well as sweet chestnut. In terms of flora and fauna, a simple walk will show you various types of foxgloves and other colourful wild flowers too. Deer are often spotted in the forest, as well as wild boar, and those aforementioned birds. The forest is known for its large range of colourful birds, including wood warblers, hawfinches, redstarts, and pied flycatchers, to name just a few. You can also spot many different types of butterfly and interesting species of glow worms and dragonflies.
The Forest of Dean is the ideal getaway from the hustle and bustle of daily life, and should certainly be on your shortlist of destinations.


text:
- Fee assured
- Verified this account
This healthcare professional let us know that they are currently available for:
- Face-to-face consultations
- Phone consultations
- Video consultations
Last updated: 12 Nov 2020
Specialises in
- Foot & Ankle
- Knee
About me
I principally manage foot and ankle conditions including arthroplasty and arthroscopic surgery of the foot and ankle, deformity correction and arthrodesis of the forefoot, mid foot, hind foot and ankle and the management of sports injuries.
I have a secondary interest in arthroscopic knee surgery and knee replacement.
I have been the Clinical Lead and Governance Lead for the Orthopaedic Department at Harrogate District Hospital. I was the inaugural Chairman of the Medical Advisory Committee for Harrogate Harlow Private services & the MAC speciality representative for BMI The Duchy Hospital. I am currently the Chairman of the Medical Advisory Committee for BMI The Duchy Hospital. I am the Sector Tutor for Orthopaedic Higher Surgical Training and run the annual regional Mock FRCS (Tr & Orth) exams. I teach on local, national & international instructional courses.
I have presented and published research on foot, ankle & knee surgery nationally & internationally.
Areas of interest
Forefoot surgery; Mid-foot surgery; Hind-foot surgery; Ankle surgery; Orthopaedics; Arthroscopy; Knee surgery; Knee arthroscopy; Knee replacement; Partial knee replacement; Sports injuries; Minimally invasive surgery; Joint replacement; Ankle arthroscopy; Ankle replacement; 1st MTP replacement; Deformity correction; Hallux valgus; Bunion surgery; Toe deformity; Stress fractures; Neuroma surgery; Mortons neuroma; Ankle instability; Ligament reconstruction; Achilles tendon problems; Cartilage surgery; Tendon repair; Flat foot surgery.
Medical secretaries
- Kirstin Russell
- Nuffield Health Leeds Hospital 2 Leighton Street Leeds LS1 3EB
- 0113 388 2189
- 0113 388 2174
- firstname.lastname@example.com
- Private Patient Coordinator
- The Harlow Suite Harrogate District Hospital Lancaster Park Road Harrogate HG2 7SX
- 01423 555430
- firstname.lastname@example.com
- Sue Hale
- Harrogate District Hospital Lancaster Park Road HARROGATE HG2 7SX
- 01423 554411
- 01423 555460
- firstname.lastname@example.com
Anaesthetists worked with
- Dr Martin Huntley Fee Assured
- Dr Chunda Sri-Chandana Not Fee Assured
- Dr Thomas Collyer Not Fee Assured
- Dr Brian Withington Fee Assured
- Dr Mark Simenacz Fee Assured
- Dr Abhinav Kant Fee Assured
- Dr David Earl Fee Assured
External resources
- Yorkshire Foot & Ankle Clinic
- Mark Farndon
- Yorkshire Orthopaedics
- Harrogate Harlow Private Heathcare Service
Current NHS consultant posts held
Consultant in Trauma & Orthopaedic Surgery, Harrogate and District NHS Foundation Trust
Research interests
Minimally invasive surgery
Foot surgery
Ankle surgery
Knee surgery
Trauma / fracture surgery
Cartilage repair / replacement
Personal interests
Running, cycling, triathlon, snowboarding, travel, cookery, rugby.
Awards received
MBBS (with Distinction)
(Additional) Languages spoken
- French
The Knee
EFORT Textbook of Orthopaedics & Trauma
The Journal of Bone & Joint Surgery (British volume)
The British Journal of Surgery
Foot and Ankle International
Journal of Foot & Ankle Surgery
Journal of Arthoscopy & Joint Surgery
Journal of Nuclear Medicine & Radiation Therapy
Courses offered to GPs
Sports injuries of the foot & ankle
Compartment syndromes
Stress fractures
Forefoot pain
Revision forefoot surgery
Minimally invasive foot & ankle surgery
Ankle replacement / ankle fusion
Chronic achilles rupture
Ankle arthroscopy
Complex regional pain syndrome
View photos of my work
Click an image to enlarge and read a description
View videos on youtube
- MBBS (with distinction) Newcastle University Medical School 1998
- BMedSci(Hons) Newcastle University Medical School 1997
Additional training
- MRCS(Eng) Royal College of Surgeons of England 2003
- FRCS(Tr&Orth) Royal College of Surgeons of England 2007
GMC registration
Reference number 4539504
Professional bodies (positions held - last 3 yrs)
- Clinical Lead for Trauma & Orthopaedics Harrogate & District NHS Foundation Trust 2017
- Clinical Lead for Trauma & Orthopaedics Harrogate & District NHS Foundation Trust 2015
- Clinical Lead for Trauma & Orthopaedics Harrogate & District NHS Foundation Trust 2016
Details of entry to specialist register
- Trauma and Orthopaedics (GMC 4539504), 2010
Affiliations / memberships
British Medical Association
British Orthopaedic Foot & Ankle Society
Royal College of Surgeons of England
European Foot & Ankle Society
British Orthopaedic Association
International Cartilage Repair Society
International Society of Arthoscopy, Knee Surgery and Orthopaedic Sports Medicine
European Society of Sports Traumatology, Knee Surgery & Arthroscopy
Practice hours
Appt Bookings
- BMI The Duchy Hospital, HG2 0HF
- Tuesday
- 13:30 - 17:00
- 0113 388 2189
- BMI The Duchy Hospital, HG2 0HF
- Wednesday
- 08:00 - 12:30
- 0113 388 2189
- Nuffield Health LEEDS, LS1 3EB
- Monday
- 14:00 - 17:30
- 0113 388 2189
- Nuffield Health Leeds, LS1 3EB
- Wednesday
- 14:00 - 17:00
- 0113 388 2189
- Nuffield Health Leeds, LS1 3EB
- Thursday
- 14:00 - 17:00
- 0113 388 2189
- Thorpe Park Clinic
- Thursday
- 08:00 - 17:00
- 0113 388 2189
Post treatment communication
Following treatment of a Bupa member, I will communicate with GPs in line with Department of Health, GMC and appropriate professional bodies guidelines.
In the event of an urgent query following treatment, Bupa members should use the following contact details


text:
Read this tip to make your life smarter, better, faster and wiser. LifeTips is the place to go when you need to know about Health Insurance Tips and other Health Insurance topics.
Most health plans limit mental-health therapist coverage to 30 visits a year. If you're seeing a therapist every week, this can be very costly. If you go to a certified counselor or clinical social worker instead, you might be able to cut your bill in half (the average fee: $90 an hour) instead of a psychologist (around $120). Most studies find no difference in effectiveness.
|Guru Spotlight
|Ray Lokar


text:
Intuitive Business creates space for transformation and in this space Jennifer Mitchell facilitates business strategy, change and culture transformation and personal awareness. For the past 15 years she has used this mix in assisting businesses to grow their revenue and become more productive, competitive and profitable. For individuals, she supports them to be aware, present and know themselves.
Business transformation
Jennifer works with your business to develop creative, realistic solutions:
Personal awareness
Jennifer facilitates group and one-on-one sessions within businesses to develop change capability, leadership and team cohesiveness.
For personal clients, she supports leaders, teams and individuals to discover their untapped potential and know themselves.
Latest blog ...
Can you be present and be at work? A key part of integrating self-awareness and presence is to practice it in all situations, not just at home when there is more perceived time and space. And it's not about zoning out at your desk.


text:
Charity chit chat's broad focus is 'Concerning Charity' where chit chat will highlight problems of control, integrity and general performance within registered charities and related sectors. This will highlight concerns include contrasts with business and good practice. Using analysis of published reports and accounts from selected organisations it is intended to help illuminate their scale and relative efficiency and effectiveness. By expressing concerns it may be possible, in our current posts section, to provide insights into improvements for deeper investigation and consideration.
Secondly Charity Chit Chat (CCC) will try to broaden the general knowledge about the complexity of our charitable world. Some pages of background information on charitable purpose and objectives are available. Resources includes links for those thinking about charity as a career plus some of the key organisations and contact points for those already involved with a charity.
It is not the intention of CCC to question or criticise the need for any particular charitable work or purpose. Rather we would encourage more charitable output and economic results via more and better activity.
Charity chit chat continues to develop content for publication but the cameos under the 'current posts' tab may be of some interest. It is also simple to search within CCC using the box (type your query here) top right.


text:
Columbus, OH – With it's shitty-tasting white bread no longer appealing to today's discriminating and wheat-hungry bread eaters, the Sunbeam Bread company announced plans to close its kitchen doors for good here within the next couple months.
To keep its employees productive to the bitter end, management put numerous productivity-related incentives in place. But those enticements have proven no match for the comedic stylings of 38-year-old Master Baker Seth MacLean, whose well-timed Scottish Brogue continues to crack up the assembly line, and recently cost Mikey the bread slicer a good chunk of his right thumb and forefinger.
"Pretty soon we'll be out of a job," 38-year-old Master Baker Seth MacLean, 28, said. "I'm just trying to make the guys forget about that is all." MacLean then turned to the guys, adjusted his hairnet and imaginary kilt for effect and screamed, "Yee bastahds bettah be gittin to worrrrrrrk! We cont teke it much morrrrrrrrrre."
MacLean will mark 10 years with the company next week but says he looks forward to the challenges of certain, prolonged unemployment.
"We be gettin' down to the heiney piece, lads." MacLean said, using a last-piece-of-bread-in-the-loaf metaphor to prep the "troops" for battle. "Lits be givin these fardigin iceholes all wee got."


text:
Insights and Stories that thread our fascination with fashion.
I got a grade of 'D" on my first piece I made in my high school sewing class. I cried all the way home. The perceived failure was a gift in courage and determination to still pursue my dreams. Twenty years later, I became Vice President of Merchandising for the Walt Disney Company. EDGE followers, designers, retailers – real risk can bring real failures and mistakes, but the lessons can lead to long term success. Go for it!
Additional photo credit [first photo]: Sewing Class Howard University, Washington D.C. 1900 [Wikimedia Commons]. Reportedly displayed as part of the American Negro exhibit at the Paris Exposition of 1900.; Title from caption card.; Images collected by W.E.B. Du Bois and Thomas J. Calloway for the "American Negro Exhibit" at the Paris Exposition of 1900 (Exposition universelle internationale de 1900).
Find more stories, features, images, videos, and Looks of EDGE on our website and social media platforms. Connect to EDGE's world! Like us on Facebook, follow us on Twitter, Instagram, and YouTube.


text:
Student & Graduate Reviews
Michael Kent Hushion - 3/23/2017
Degree: English
Graduation Year: 2016
"Kent State University's English program provided me with so much more than a simple degree or basic education. The program's teachers are active, engaging, knowledgeable, and extremely creative with their courses. In my last semester, Fall 2016, I had the opportunity to study Shakespeare and Jane Austen, side-by-side, in a course structured around the Folger Shakespeare Library's dual exhibit of both authors in Washington D.C. The course provided each student with the opportunity to learn about and from two of the most influential authors in the history of the English language. But it was more than just that, Professor C., who constructed and instructed the course, inspired each student to think critically about the topics each author presents, and did brilliantly in modernizing each studied work through hands on instruction and interpretation. I could go on and on about each course my English degree provided me, and the intellectual benefits of each, but a list of such would be exhaustive. Kent State University, as a whole, and my English degree in particular, has provided to my personal benefit more than I could have ever expected upon my enrollment in the Fall of 2012."
Ashton - 3/15/2017
Degree: Psychology
Graduation Year: 2018
"Kent State is a wonderful place full of diversity and courses that truly do prepare you for success. The faculty at Kent State are kind, and extremely intelligent and know what they are doing. In addition to this, the campus dining options are great, the residence hall floor plans are good, and the atmosphere and aesthetics on campus are breathtaking."
astumpf - 2/16/2017
Degree: Jewelry Design
Graduation Year: 2016
"You will find professors who care so much and will push you to become an amazing artist but higher ups get in the way. Make sure you find teachers who won't let the administration push them around. Take the classes you want to take to make you the arrest you want to be even if it means being in school longer you will thank yourself in the long run."
Sarah - 2/4/2017
Degree: English
Graduation Year: 2011
"The English program at Kent State is satisfactory, however English is the most pointless degree. So I had to mark low for earning potential and prepared for career since not too many jobs hire you to read classics all day and write reports/evaluations on them."
Gabrielle Ciofani - 2/7/2016
Degree: English
Graduation Year: 2006
"I felt like there were plenty of resources available for me as an undergrad, especially considering the Wick Poetry Center and all of their opportunities for young teachers and poets. It is a program unlike any of its kind in the nation and if you are interested in writing, poetry, TEFL or English education, I would highly recommend Kent State. The largest problem I encountered at Kent State was with student services. There is a high level of incompetency with the student services department at Kent State- the bursar's office would just shuffle you back and forth between them and the financial aid department in order to delay solving very minor problems. One semester, all of my classes were canceled due to inefficiency on their end and the classes filled up before I had the issue resolved, preventing me from taking a class I need to specifically take that semester. There are huge wait times on the phone, huge lines in person, and very rude people working in that department. It's hard giving that large of a chunk of money to an institution that does not seem to respect you or your education in the slightest. There is also a huge scam on campus called "Parking Services." If you plan to go to Kent State, simply put- ride a bicycle or walk. They keep upping enrollment and not upping the amount of available parking spaces. If you do spend a couple of hundred dollars on a parking pass/semester, especially during your first couple of years, the parking lot where you will have to park your car at during the daytime isn't even on campus. If you park in a different lot, like one just outside of your class, they WILL find you and they WILL ticket you. Parking tickets are like... $35-50/each and if you have a few of them in a semester, they boot your car and then tow it away. It costs at least $200 to get your car back. If you get a parking ticket after you graduate, they won't release your diploma until after you pay the ticket. Say you're working late on campus, it's snowing, you need to park nearby. You come back out after a hard night of work at 2 a.m. to find your car is gone and is locked away until the following Monday in an impound lot a couple of miles down the road from campus, charging you by the night. That is how Kent State rewards hard workers. Consider yourselves warned."
Collin Alberts - 2/4/2016
Degree: Chemistry
Graduation Year: 2016
"#1. Amazing Faculty and Teachers The fact that you feel like an individual in a school which is comprised of 30,000 students is incredible. KSU is home to amazing teachers who challenge their students, serve as networking contacts and wrote me letters of recommendation. In 3 years I had only 1-2 poor performing professors and when I contacted upper faculty about it, they handled the issues and were sympathetic. I had at least 2-3 amazing professors each semester. Instructors like Dr. de Szalay, Dr. Ortiz, Dr. Drew and Dr. Groff. This is only naming a few but these teachers are excited and enthusiastic about their course material and care a lot about their students. #2. The Campus Environment, TONS OF PARKING Kent is SUPER SAFE, there is tons of restaurants, bars, etc. to keep you busy as well as hiking and biking trails. Campus has an open layout, but is designed in such a way that max walking distance between classes is 10-15 minutes. There is tons of parking and I have never failed to find a parking spot, and every day I actually find an end spot to keep my car from getting dinged up. The Gym is great, they just redid it and added a ton of machines. The facilities are new and updated, and the campus itself is beautiful. #3. Lively Campus There is tons of classes, different activities, plays, basketball games, clubs, and even lectures from scientists being given on campus. The water symposium is a great example of which you can hear world renowned scientists lecture about climate and water resource changes."
casper - 1/16/2016
Degree: Business
Graduation Year: 2016
"Kent is a great school to attend if quality education is your goal. It was a great experience for me, and I highly recommend it to anyone, as you will feel time and money've been spent in the proper place. The program helped me through my career and tough me a lot-I would do I again in a heartbeat!"
Anonymous - 11/30/2015
Degree: Psychology
Graduation Year: 2014
"This university had great diversity of classes and students. A beautiful campus!"
Htown - 11/9/2015
Degree: Interior Design
Graduation Year: 2012
"I loved going to Kent State University. It's a pretty campus with a safe environment. The campus was spacious but still capable of getting from one side to the other in a reasonable amount of time. Downtown Kent is not too far from campus and offers many things for students to do."


text:
Making the decision to separate from a long term partner is rarely easy, but staying in a deeply unhappy relationship is no walk in the park either. If you've been struggling with the decision, it can be difficult to know what to do and it's even more complicated if children are involved. You have to juggle their needs as well as yours, and … [Read more...] about What to Do When You Decide to Separate
How to Save Your Marriage From Divorce
Divorce is costing Australia over $14 billion a year The end of a relationship is not something people enjoy thinking about. Nobody enters into a marriage with the expectation of divorce, and yet the fact is that a significant proportion of marriages dissolve eventually. Marriages are complicated. But, as with so many things in life, a little … [Read more...] about How to Save Your Marriage From Divorce
Getting a Divorce? How to Divorce with Your Pride and Dignity Intact
The high-profile divorce announced yesterday of Rupert Murdoch and his third wife Wendi Deng Murdoch has apparently shocked those closest to the couple. The couple have been together for 14 years and have 2 young children together, Grace, 11, and Chloe, 9. What's also being reported is their close friends had no idea they were having any marital … [Read more...] about Getting a Divorce? How to Divorce with Your Pride and Dignity Intact
Couple Money Problems: Binding Financial Agreements [Video]
One of the main issues that all couples struggle with is related to money. Money issues are particularly challenging when couples have differing levels of income and asset pools when they enter into a relationship. I recently spoke with Sydney solicitor Bhavesh Mistry about binding financial agreements and how they can help couples … [Read more...] about Couple Money Problems: Binding Financial Agreements [Video]
New Trend: Divorce Parties
I was asked by a journalist at MSN.com this week to comment on the new trend of divorce parties for those couples that are getting divorced. You can read my responses in the MSN.com article published online: New Trend: Divorce Parties. This reminded me of an acquaintance from over 15 years ago who threw a divorce party when … [Read more...] about New Trend: Divorce Parties


text:
Marijuana is what's called a Schedule I substance. The federal government has placed it on the same "forbidden" list as heroin.
But Dr. Igor Grant, director of the Center for Medicinal Cannabis Research (CMCR), and two other investigators have just published a study in The Open Neurology Journal, flatly stating that the Schedule I classification of marijuana is "not tenable." CMCR is based at the University of California San Diego and has overseen extensive research on the therapeutic effects of cannabis. Their study categorically contradicts the government's position: "It is not accurate that cannabis has no medical value, or that information on safety is lacking."
Of course, DEA Administrator Michele Leonhart might be hard-pressed to agree. Check out her positively embarrassing performance before a House oversight hearing.
More @ www.opposingviews.com


text:
This guest post is by Emily Roberts.
Viral marketing denotes word-of-mouth marketing which is smarter and faster than other traditional forms of marketing.
To survive in this competitive world, you must be strong enough to withstand the competition or you have to adapt to the surroundings.
Several business strategies have come up according to the needs and one among such strategies is viral marketing. It's essential for your online business as it's inexpensive and is faster too reach your clients.
Here are a few tips to denote the importance of viral marketing for your online marketing.
1. Better credibility
As the whole network works on recommendations made by your friends, the chances of building the credibility is high.
This works as you are recommended by their friends and networks and hence your credibility is increased among the people.
This helps to promote your products and services which definitely generate a lot of buzz.
2. Inexpensive
This is the cheapest means to market your business as it doesn't need a lot of investments.
This type of marketing is less pricey but effective. There are various types of viral marketing such as email marketing, newsletters, blogging and more.
This is the fastest medium to reach out the masses without investing a large amount. Hence, viral marketing is important.
3. Enables the business to remain afloat
This strategy helps the business to stay positive.
As you will be updating it on regular basis you don't have to worry about the acceptability or loss of customers.
You would have already build the credibility of your business and this enables them not to leave your services, thus ensuring your business stability.
4. Creates a global platform
This helps in creating a global platform for business purpose.
You can now easily reach to potential clients worldwide and spread your business across the globe.
You can utilise affiliate marketing, content marketing and so on to develop your clients and your business.
5. New word-of-mouth concept
This strategy enables you to spread your business as it works on peer-to-peer reference.
It can be of the service or the product you sell. This helps to generate local interest which in turn generates revenue.
A few tips to help you with viral marketing:
- Email marketing. All you need to do is compose an email and mail to all your clients.
- Content marketing is another important aspect. Ensure that you post relevant content on your blogs.
- Update your blogs regularly with fresh contents.
- Utilise social networking sites such as Facebook, twitter and more as the whole world is present on these sites.
One of the biggest mistake people make is when they think viral marketing is just advertisements that people share – it's not.
Traditional marketing is about promoting your product, showing how good it is, giving it center stage – and generally being incredibly selfish (and possibly using supermodels or movie stars).
But guess what, nobody cares about you!
Focus exclusively in creating a good and interesting story. Sure, you can add you product into the mix, but it mustn't be the most important thing.
"Going viral" can make a powerful impact on your business and lead to a plethora of future opportunities.
All it takes is a relevant idea that is valuable, well-executed and optimized for sharing.
Emily Roberts is a tech writer from UK with a passion for Finances and Internet Marketing. Same day loans are instant cash loans which help you in financial crisis. Follow her on @Financeport.


text:
For any man forty is a milestone, but for medal winner Richard Whitehead it's becoming a golden age in Brasil. And this is part of a wider trend we've noticed here at MH. With more time on their hands and more disposable income, men in their forties are in the best shape of their lives. We spoke to one MH man to find out why and how he, like Whitehead, is making progess at this stage of his life,
Introducing...The Gym Daddy
Having reached a certain age – and with ambition renewed – the Gym Daddy is now pushing toward his physical prime, proving that the rest of your life begins at 40
See: Hugh Jackman
The case study: David Ison, 49, Southampton
The enterprising entrepreneur
I'm a retired tennis player and fulltime coach. On average I work 40-50 hours a week as I'm trying to build two businesses: a local performance centre and the Bassett Lawn Tennis Club, Southampton. I find my job very rewarding – and having played tennis professionally for nearly a decade, it was a natural progression – but in five years I hope to be spending less time coaching and more time managing both businesses.
I measure my happiness in terms of how happy my children are and whether or not I feel I'm doing an effective job at work. Day to day, I don't think about money – I own my house and have a few years left to pay on the mortgage – but I have recently begun the process of saving for the future. All being well, I'd like to retire by age 60.
For me, diet is the most important factor in staying fit. I always eat breakfast and as I've got older I've tried to cut down on carbs and increase my protein intake. I generally try to eat healthily, but finding time for shopping and meal preparation can be an issue. I've never smoked and haven't really drunk at all over the last 10 years. I still go on as many holidays as I used to, but I find that I very rarely have time to go out and socialise, again, mostly due to work commitments.
Fitness is more important to me than ever and I'm lucky that my daily workout routine revolves around my work. I spend an hour at the gym as often as my coaching schedule allows, but when I was a tennis player myself – between the ages of 18 and 28 – I attended the gym daily. The difference between then and now is that now work commonly interferes with my plans. Most of the time I focus on core stability, bodyweight exercises and flexibility. I can still touch my toes and the feeling after a good session is what motivates me to work out. Given more leisure time, I'm sure I'd be able to build the body I want.
What you can do… The Longevity Masterplan
Slow down and pick up the slack outside of work to ensure long-term gains
I\ Plan your escape
Before complaining that you never have time to yourself, it's worth checking you're actually taking all of the annual leave you're entitled to. Jetting off isn't just about hitting the refresh button – researchers from the Finnish Institute of Occupational Health found that overworking more than doubles your risk of suffering a major depressive episode.
II\ Lose your looks
With less than half of men feeling content with their bodies, it's time to reverse your goals. Rather than focusing on aesthetics alone, signing up to an endurance event will promote long-term, practical fitness. Get the approach right, and the body will follow. May we suggest Men's Health Survival of the Fittest? (mhsurvival.co.uk)
III\ Lower the steaks
Defying a slowing metabolism doesn't mean living off greens and lean meat. The American Journal of Clinical Nutrition found wholegrains cut your risk of hypertension by a life-saving 19% – as well as powering your workouts. And with recent research suggesting protein overload is as fattening as sugar, you'd best balance your macros.
IV\ Carry on deadlifting
Reaching middle age doesn't mean you have to cut out big lifts. Fast-twitch muscle fibres waste quicker in your forties, so they're more essential than ever. Devote more time to protecting joints: the American Journal of Physiology found the inability to touch your toes leads to arterial stiffening. Stay mobile and smash PBs for years to come.
What to know more about the men in your age bracket? Read the full feature in the current issue of MH, on sales now


text:
In her article about journaling, Julie has mentioned Rhodia notebooks. Their iconic orange and black covers are undoubtedly familiar to many, especially those of us who love school and office supplies. In addition to their bound notebooks, Rhodia also offers spiral-bound notebooks and pads of paper. The Rhodia Clic Bloc Mouse Pad / Note Pad is designed to sit by your keyboard for easy note-taking or sketching. It's 7.5″ X 9″, and it's filled with 30 sheets of Rhodia's 80g paper with a grid design. It has a non-skid backing and is bound on two sides, which makes it a sturdy mousing pad, too. The Clic Bloc is available at Jetpens. It's $10 for a single Clic Bloc or $30 for a pack of five.
Support The Gadgeteer: The Gadgeteer's main sources of revenue are advertising and affiliate links in articles like this one. Even though we may receive compensation, we always give our honest opinions about our experiences with each product.


text:
Program Description
The Institute of Spatial and Environmental Planning (ISEP) is one of the fastest growing and dynamic planning research environments in the UK.
Planning at Queen's is now rated ninth in Russell Group submissions.
Our research programme is based on the concept of spatial planning and whilst our empirical work is partly grounded in the region, it is built on strong international, interdisciplinary and theoretical references. Our particular strength is the staff team who have built a track record in scholarly and applied research and a wide-ranging portfolio of publications, research grants and Doctoral studentships. The Institute has built an international reputation and attracted a stream of major research funding linked to our main areas. The Institute values the connection between our research and teaching programmes and the application of our empirical work in a learning environment and continues to innovate and develop teaching programmes to reflect a rapidly changing market place, problem and policy context and changes in professional standards.
Mode of study/duration
Registration is on a full-time or part-time basis, under the direction of a supervisory team appointed by the University. You will be expected to submit your thesis at the end of three years of full-time registration for PhD, or two years for MPhil (or part-time equivalent).
Research information
Associated Research
ISEP has built a strong postgraduate group which is effectively integrated into our research projects, teaching and School activities. We offer dedicated support and mentoring within the School to complement training available from the wider University. Moreover, we have the staff expertise within ISEP and our School to offer comprehensive support to postgraduate students across a range of projects in spatial planning. Our research strengths centre on two objective areas:
Interpreting the spatial planning implications of ethnic territoriality and community cohesion, connecting our analysis of contested places within the UK with international scholarship; and developing critical insights into the sustainable creation of place and the role of participatory governance in regulating the shaping of social and environmental space.
Current projects involve a range of studies on contested spaces that build on our strong international research partnerships in North America, South Africa, Europe and the Middle East. The global challenge of development is also reflected in projects on climate change, marine spatial planning and urban design.
We encourage and support fieldwork in international settings and current students have conducted their empirical studies in Bangladesh, Australia and the USA.
Career Prospects
For further information on career opportunities at PhD level please contact the Faculty of Engineering and Physical Sciences Student Recruitment Team on firstname.lastname@example.com.
Our advisors - in consultation with the School - will be happy to provide further information on your research area, possible career prospects and your research application.
Entrance requirements
The minimum academic requirement for admission to a research degree programme is normally an Upper Second Class Honours degree from a UK or ROI HE provider, or an equivalent qualification acceptable to the University. Further information can be obtained by contacting the School.
International Students
For information on international qualification equivalents, please check the specific information for your country.
English Language Requirements
Evidence of an IELTS* score of 6.5, with not less than 5.5 in any component is required. *taken within the last 2 years
International students wishing to apply to Queen's University Belfast (and for whom English is not their first language), must be able to demonstrate their proficiency in English in order to benefit fully from their course of study or research. Non-EEA nationals must also satisfy UK Visas and Immigration (UKVI) immigration requirements for the English language for visa purposes.
If you need to improve your English language skills before you enter this degree programme, INTO Queen's University Belfast offers a range of English language courses. These intensive and flexible courses are designed to improve your English ability for admission to this degree.
- Academic English: an intensive English language and study skills course for successful university study at degree level.
- Pre-sessional English: a short intensive academic English course for students starting a degree programme at Queen's University Belfast and who need to improve their English.
About the School
The Faculty of Engineering and Physical Sciences spans disciplines that impact lives today and will shape our future. Our international mix of staff and students make up a vibrant community that is ho ... Read More


text:
BSOD in Win'2k3, Vista x86 and x64 by nonpriviledged user Nov 09 2008 01:54AM
support killprog com
BSOD or hard system hang due to race condition in win32k. sys code that processes UnhookWindowsHookEx. Reproduced when thread calls many times UnhookWindowsHookEx in the same time with switching active windows desktop object (SwitchDesktop) from desktop where hooks are unhooked and broadcasting windows messages to windows on that desktop. Sample exploit code can be downloaded from: http://killprog.com/whk.zip Works on Win'2k3 and Vista. XP seems to be immune to this.
[ reply ]
Privacy Statement