You've heard of a pull-up and a dip, but now bodybuilders and CrossFit fanatics everywhere are opting out to incorporate another chest involved exercise to their daily workout regime which is called a muscle up.
A muscle up is simply a pull-up that is followed with a dip motion, so it's a combination of a pull-up as well as a dip. You can either use a bar or a set of rings to perform a muscle up, so you can conveniently perform this at home or the gym.
Out of the three motion mentioned above, muscle ups are hands down the most difficult to accomplish since a lot of individuals find it difficult to transition between a dip and pull up without having their arms give out.
How To Do A Muscle Up?
Before you figure out how to correctly perform a muscle up, you'll need to train your body so it can support you while you attempt to do a muscle up.
Perform Strict Pull-Ups: You'll need to have a strict pull-up underneath your belt before you can go on to a harder exercise such as a muscle up.
Strict pull-ups play a role in developing your trapezius, latissimus dorsi, and other muscle groups located around your chest and arms, which come in handy when you're doing a muscle up.
As a side note, when you practice by performing a strict pull-up, it's recommended not to use the suicide grip which consists of curling your thumb next to your fingers, but instead to grip with your thumbs placed underneath the bar.
Develop Core Strength: You shouldn't forget about improving your core strength since a muscle up requires more than just arm and chest strength to achieve a single rep successfully.
Core exercises that will help to strengthen your abdominal muscles so you can easily perform a muscle up consists of crunches, push ups, planks, and deadlifts.
Perform a Kipping Pull Up: Other than strengthening your muscles as part of your muscle up training process; you'll also need to develop your skills and movement techniques, so you don't risk injuring yourself by incorrectly performing a muscle up.
To perform a kipping motion, two elementary skills that are ideal to start honing are the hollow and arch since they're two movement phases involved in the kipping motion.
You can start practicing the hollow and arch on the ground and make sure to position your legs as you would if you were performing a kipping pull up on a bar. Specifically, your legs will be glued together in a straight and tight fashion and will stay this way while you transition from a hollow position to an arch position.
You'll know you'll have mastered kipping pull-ups when you can perform ten or more of them back to back with no problems or strain.
Now that you have an idea of the amount of training involved that will lead up to you expertly achieving a muscle up, you can use it as a guide to help you incorporate muscle ups to your exercise routine.
To get yourself into position, you'll need to use a pull-up bar and hang from it with a false grip, which consists of your thumbs being placed on top of the bar and not around it.
Once your hands and arms are locked into place, you'll want to use all that arm strength training to pull yourself up to the point where your chin is bar level.
The moment your chin is on the level with the bar, you'll have to use the bar as support to roll your chest over so you can transition from a pull-up to a dip.
After the rolling motion is complete, all that's left is the press your hands in a downward motion and continue to push your body upwards, which is the "dip" part of the muscle-up.
Since a muscle up consists of a pull-up and a dip, it's no surprise that you need to separately master hot to perform a clean pull up and dip with a full range of motion.
A full range of motion exercise helps to keep your joints flexible, so you don't endure any injuries to your elbows and knees, which is common with muscle ups.
By performing exercises stressing full range of motion movements, such as Russian dips, you're allowing your body to gain the muscle strength it needs to apply one hundred percent control over your ability to perform a muscle up.
When comparing pull-ups to muscle ups, the latter is considered to be more of an achievement since they are harder to achieve and only a handful amount of people can do so.
You'll notice that individuals who partake in hiking expeditions, as well as parkour, find muscle ups to be a much more useful exercise since it consists of complex transitions and movements. In fact, muscle ups combine difficult transitions with strength building movements to result in the ultimate workout experience.
Pull-ups are much more of an isolated action that doesn't require any transitional skill, so you shouldn't expect your parkour abilities to improve if you solely dedicate your time to performing pull-ups as part of your training regime.
Bodybuilders to professional athletes all agree that muscle ups are the optimal exercise that will ensure you improve on all physical activity related facets of your life without having to wait months at a time for results.
Now that you have a thorough understanding of what a muscle-up is and how it can enhance your physical capabilities, you should begin training now, so, within a month's time, you can show off at the gym and have everyone asking you for tips.
You can't go wrong incorporating muscle ups since not only do they strengthen your muscles but also improve on your transition motion skills when it comes to moving from exercise to exercise without having to lock your joints into place.
In regards to a muscle up, you'll know you can call yourself a master when you can effortlessly transition from a pull up to a dip without breaking a sweat, which is harder than you may think.


Next message: Fred Moseley: "[OPE-L:2546] reply to Andrew - Part 2"
Previous message: Michael Perelman: "[OPE-L:2544] responding to gil"
even clearer in Andrew's most recent post.
of surplus-value, and S is this total surplus-value determined in Volume 1.
different quantitative results (more on this below).
is the maximum solution for 1/(1+r), which equals Fred's 1/(1 + S/(C+V)).
treated as an unknown and which are solved to determine the rate of profit.
determined according to Sraffian theory.
GIVEN which is determined prior to individual prices by equation (1) (i.e.
NOT = r is the different effects that technological change in "luxury goods"
argued, then his argument concerning Dept. 3 is also wrong.
whole argument - assumes only circulating capital, i.e. no fixed capital.
assumed to be an unknown which is determined by equation (2).
results as Sraffian theory. The assumption of long-run equilibrium (i.e.


text:
News Energy & environment Policy & business Renewables Skills and careers
Doosan to invest £170m in Scottish wind power
By The Engineer	 22nd March 2011 4:20 pm 16th December 2015 12:40 am
Supported by Scottish Enterprise, Doosan Power Systems has announced a major initiative that will see the company enter the Scottish wind-power business with an investment of up to £170m over the next 10 years.
The company intends to locate its research and development centre of excellence for renewables at its current site at Westway in Renfrew, near Glasgow, creating up to 200 jobs.
A second phase will advance a further proposal for the establishment of assembly and manufacturing facilities in Scotland — now the company's favoured location for wind-turbine prototype build and manufacturing.
Altogether, the venture is expected to create up to 1,700 new jobs — of which Doosan Power Systems will directly recruit approximately 700, with a further 1,000 set to be employed through the supply chain. The details of the plans are subject to final discussions and agreement between Doosan and Scottish Enterprise.
Doosan Power Systems currently offers a 3MW wind turbine and is developing a 6MW-plus version for offshore applications.
Sensor relies on enhanced Raman scattering architecture
22nd March 2011 1:08 pm 16th December 2015 12:41 am
Motion detection system assesses condition of horses
1st March 2011 12:00 am 18th January 2019 1:27 pm
Atkins wins design contract for north-east Crossrail route
23rd March 2011 4:08 pm 16th December 2015 12:38 am
News Aerospace
Biofuel could be an alternative to fossil-based jet fuel
24th March 2011 4:47 pm 16th December 2015 12:37 am
Watson-Marlow reports annual sales and profit increase
23rd March 2011 9:34 am 16th December 2015 12:40 am

redpajama_set_name: RedPajamaCommonCrawl


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Hi Suzanne, I'm in my first year at CQU now and studying for my exams next month. I'm really enjoying the course. I'm studying part-time which suits me fine.
19/01/2012 · If information about HECS isn't included in your offer, it is safe to assume you will be required to apply for it later in person at university. Again, have your TFN handy. If you don't know your TFN, definitely find it or apply for one sooner rather than later.
Application process If you make a mistake on your application. If you realise your application did not include information it should have, or there is an error, you should correct it as soon as possible by requesting an amendment.


text:
Alert cop foils daylight robbery bid
In a filmy style action, an Assistant Sub-Inspector of Police yesterday afternoon foiled a bid by a group of local miscreants to swindle Rs. 20 lakh from a jeweller from Bangalore, after luring him with offers of getting gold at a much lower rate.
ASI Sampath Shetty of Lakshmipuram Police Station, who noticed a skirmish near Gopalaswamy Shishuvihara on Narayana Shastry Road in city, managed to nab Hemanth Kumar alias Bond, son of Mahadevappa, residing at #46, 5th cross, Muniswami Nagar near J.P. Nagar in city and recovered Rs. 19.5 lakh from him. Since a group of curious onlookers had gathered at the spot, four others of the gang managed to escape in the melee.
It is reported that a five-member group comprising one Fazal of Kundapura had lured Santhosh, a jeweller from Rajajinagar in Bangalore. They first approached Santhosh's uncle Gururaj Bhat in Mysore, offering him gold at a price much below the market price. Bhat spoke to Santhosh over phone about the tempting offer. A date and place was agreed upon to exchange money for the gold.
Tempted by the offer, Santhosh brought Rs. 20 lakh in a bag, travelling in a Maruti Wagon-R car (KA-04, MK-206) along with his wife Archana, their child, brother Ravindra and uncle Gururaj Bhat, who was well acquainted with Mysore.
As the car approached Gopalaswamy Shishuvihara at around 4 pm, a group of five persons including Fazal reportedly stopped the car and handed over a box saying that it contained gold. They then snatched the cash bag from Santhosh.
Santhosh, who had reportedly pledged his family jewels for Rs.19.5 lakh at Federal Bank in Rajajinagar, got suspicious by the group's behaviour and demanded to return his cash bag. An argument ensued between him and the gang which drew the attention of passersby who gathered at the scene.
Meanwhile, ASI Sampath Shetty, who was on patrol in the vicinity, noticed the crowd and reached the spot. He tried to nab the gang, but could only apprehend Hemanth Kumar. Four others managed to escape.
On interrogation, Hemanth is said to have confessed that there was no gold with them and that they had lured Santhosh only to swindle him. Lakshmipuram Inspector Suryanarayana Rao has registered a case.


Neapolitan double scoop ice cream cone earrings. These are handcrafted ice cream cones made from polymer clay and are 5/8" long. The cone has a raised texture on the outside making it look very realistic and old-fashioned style. The ice cream looks good enough to eat! They come on silver plated shepherds hook earrings.


text:
Users Online: 715 Home | About the Journal | Instructions | Current Issue | Back Issues | Login
REVIEW: PROGRESS IN MEDICINE
Pediatric multiple sclerosis
Yashma Patel, Vikram Bhise, Lauren Krupp
Department of Neurology. Stony Brook University Medical Center, Stony Brook, NY 11794, USA
Date of Submission 22-Jul-2009
Date of Decision 22-Jul-2009
Date of Acceptance 22-Jul-2009
Lauren Krupp
Department of Neurology. Stony Brook University Medical Center, Stony Brook, NY 11794
Pediatric multiple sclerosis (MS) represents a particular MS subgroup with unique diagnostic challenges and many unanswered questions. Due to the narrow window of environmental exposures and clinical disease expression, children with MS may represent a particularly important group to study to gain a better understanding of MS pathogenesis. Acute disseminated encephalomyelitis (ADEM) is more common in children than in adults, often making the differential diagnosis of MS, particularly a clinically isolated syndrome, quite difficult. Although both disorders represent acute inflammatory disorders of the central nervous system and have overlapping symptoms, ADEM is typically (not always) self-limiting. The presence of encephalopathy is much more characteristic of ADEM and may help in distinguishing between the two. Young children (under ten years old) with MS differ the most from adults. They have a lower frequency of oligoclonal bands in their cerebrospinal fluid and are less likely to have discrete lesions on MRI. Problems of cognitive dysfunction and psychosocial adjustment have particularly serious implications in both children and teenagers with MS. Increased awareness of these difficulties and interventions are needed. While clinical research on therapies to alter the disease course is limited, the available data fortunately suggests that disease-modifying therapy is well tolerated and likely to be effective. Ultimately, multinational research studies are necessary to advance our knowledge of the causes, symptoms, and treatment of pediatric MS and such collaborations are currently underway.
Keywords: Pediatric multiple sclerosis
Patel Y, Bhise V, Krupp L. Pediatric multiple sclerosis. Ann Indian Acad Neurol 2009;12:238-45
Patel Y, Bhise V, Krupp L. Pediatric multiple sclerosis. Ann Indian Acad Neurol [serial online] 2009 [cited 2021 Jan 16];12:238-45. Available from: https://www.annalsofian.org/text.asp?2009/12/4/238/58281
Pediatric multiple sclerosis (MS) has long been an under-recognized and undertreated MS subgroup. However, awareness has grown of the special diagnostic challenges, the clinical course, and the special needs of these patients in the past ten years. As pediatric MS occurs in most of the world, an International Pediatric MS Study group was created that is committed to clarifying the frequency and treatment patterns of children with MS worldwide. While some aspects of the clinical disease in children resemble those of adults, children can also dramatically differ in clinical, radiological, and laboratory features. The family unit plays a different role in pediatric MS than in adult MS. Management is complicated by the lack of clinical trials in this age group. Nonetheless, experience in evaluating and treating children has rapidly grown and the current review summarizes this experience.
The proportion of patients with MS below the age of 16 years is estimated to be 2.7-5%. [1],[2],[3],[4] The frequency is much lower and is estimated to be 0.2-0.7% among young children (age 10 and younger),. [5],[6],[7],[8],[9] A prospective study found an incidence of 0.9% of initial demyelinating events (IDE) in childhood. [10] As in adults with MS, pediatric MS displays an overall female preponderance. However, the gender ratio varies with age of onset. In children with an onset before six years, the female to male ratio is almost equal at 0.8:1. But the female to male ratio increases to 1.6:1 for an onset between six and ten years of age and even further to 2:1 for an onset over ten years of age. [11] Some additional aspects of the demographic profile of pediatric MS differ from those of adults with MS. A higher proportion of African-Americans was found in the pediatric onset category compared to the adult onset MS group (7.4 vs. 4.3%) in an outpatient center in Boston. [8] Others have noted greater ethnic diversity and ancestry in pediatric MS compared to adult MS. [12],[13] A positive family history of MS is seen in 6-20% of the children with the disease. [1],[14]
Risks for developing MS after an initial demyelinating event
One of the most challenging aspects of pediatric MS is determining whether a child with an IDE will develop subsequent events that are consistent with MS or whether the IDE will remain a self-limiting disorder. [Table 1] summarizes IDE features that are suggestive of an ultimate diagnosis of MS. [15],[16],[17] One prospective study of 296 pediatric IDE patients found that after a mean observation period of 2.9 years, 57% experienced two or more episodes of demyelination. [15] Several studies indicate that factors associated with an increased risk of a second attack include age over ten years, family history of optic neuritis (ON) or MS, intact mental status, lack of isolated myelitis, a monofocal rather than polyfocal onset, absence of seizures, and lack of meningismus. The presence of oligoclonal bands or an elevated IgG index increases the risk of MS. [15],[16],[17],[18]
While a history of ON also increases the risk of MS, particularly when the brain MRI is abnormal; [19] the second attack confirming MS may occur many years after the initial event. [16],[20]
As shown in [Table 2], certain MRI findings are closely associated with MS. An increased risk of MS is associated with the presence of three out of four Barkhof criteria; namely, one or more gadolinium-enhancing lesions, three or more periventricular lesions, one or more juxtacortical lesions, and one or more infratentorial or spinal cord lesions. [21] The KIDMUS study also identified MRI criteria that were associated with an increased risk of a second demyelinating event. These criteria were the presence of one or more lesions that were perpendicular to the long axis of the corpus callosum, and the sole presence of well-defined lesions. [22] Callen criteria for MS were established for a different purpose. [23] The findings of five or more T2 lesions, two or more periventricular lesions, and one or more brainstem lesions differentiated pediatric MS from other nondemyelinating neurological disorders.
Clinical features of MS
Children present with a wide variety of symptoms including sensory deficits, ON, brainstem-related deficits, motor deficits, and gait disorders. Some studies suggest that children are more commonly polysymptomatic (50-70%) than adults [7],[15],[24] although a monosymptomatic (30-50%) presentation is not uncommon. Of the children with monosymptomatic presentation, 30% will have motor symptoms, 30% sensory symptoms, 25% brainstem symptoms, 10-22% present with ON, and 5-15% with ataxia. [7],[24],[25],[26] Isolated transverse myelitis is seen in < 10% [1],[4],[15] and ADEM as an initial presentation of pediatric onset MS is seen in 18-29% of the patients. [11],[15],[16],[18],[27],[28] Seizures are estimated to occur in 5% [26] and visual-evoked potentials were found retrospectively to be abnormal in 56% of 85 patients in whom only 40% had visual complaints in the past. Thus, ON may be underreported in pediatric MS, especially in younger children who may have difficulties in verbalizing this symptom or who have not yet started to read. [29]
Several clinical features are more common in young MS patients (those under 11 years of age). [5] These include a history of preceding infection, more frequent severe cognitive problems, seizures, optic nerve dysfunction, and brainstem or cerebellar involvement. In contrast, it is less common for younger to have isolated spinal cord presentations. Younger patients also have more confluent disease on brain MRI with lesions that tend to vanish more quickly. [11],[17],[30],[31],[32] One study found that those under the age of 12 years had a longer relapse-free interval and lower number of relapses in the first two years of disease compared to those older than 12 years. [6]
Fatigue that limits recreational and scholastic activities is a common symptom of pediatric MS. [26],[33] Children also appear to be exceptionally vulnerable to cognitive disability. The most common impairments are complex attention, visuomotor integration, confrontation naming, receptive language, and executive function while verbal fluency tends to be relatively intact. [33] The frequency of cognitive impairment ranges in different studies from 30 to 66%. [11],[33],[34],[35] Unfortunately, preliminary data suggest that as many as 70% of children decline in cognitive ability over two years. [36] This is in contrast to adults where cognitive decline is typically more gradual.
Over time, children with MS develop repeated relapses and accumulate increasing disability. Annual relapse rates vary in different studies from 0.5 to 2.8, [2],[8],[37],[38] depending on differences in prospective vs. retrospective design of the studies and duration of follow-up. Overall, when compared to adults, children with MS have a higher rate of relapse within the first two years of disease but progress more gradually. [7],[25],[32] In several retrospective studies, the time to reach an EDSS of 6.0 from diagnosis varied from 19 to 29 years. [6],[14] At higher levels of EDSS, the likelihood is that the course will have transitioned to secondary progressive MS. The risk of secondary progressive MS in children (as in adults) is associated with a higher frequency of relapses and shorter intervals between attacks in the first few years of the disease. [2],[7]
An essential feature of the diagnosis of MS is that there is dissemination in time and space. Further, non-neurological involvement or systemic disease is absent. A more complete review of the differential diagnostic disorders and the laboratory work-up are reviewed elsewhere. [39],[40]
The most common and perhaps the most difficult differential on first presentation is acute disseminated encephalomyelitis (ADEM). Considered a post- or parainfectious demyelinating process, this disorder also presents with multiple lesions and multiple neurological deficits. [41] A large part of the confusion stems from the lack of inclusion of a standard definition for ADEM in many publications. The International Pediatric MS Consensus definitions provide provisional diagnostic criteria for MS, ADEM, and other acquired demyelinating disorders of the central nervous system (CNS). [42] Criteria for ADEM are that the syndrome is multifocal and requires encephalopathy. However, this definition is likely to be too restrictive as some multifocal, nonencephalopathic patients will have a self-limiting disease course as would occur in ADEM. [16] Additional variants of ADEM which appear to be rare, are recurrent ADEM or multiphasic ADEM. A second inflammatory event develops in these variants. However, unlike an MS attack, encephalopathy is present and the MRI shows characteristic features of ADEM. Further, the disease is subsequently self-limiting without further events after the second episode. [30],[42]
In a retrospective chart review study comparing MS and ADEM, patients with ADEM were found to be more likely to have nonspecific symptoms such as fever, headache, vomiting, meningismus, encephalopathy, and bulbar symptoms such as dysarthria and dysphagia. [43] A history of recent viral illness or vaccination is usually elicited in ADEM. Other important features include seizures, cranial neuropathies, and ON. [16],[17],[41] CSF studies tend to show a mild to moderate leukocytosis, elevated protein, and a lower frequency of oligoclonal bands compared to MS. Typically, the MRI in ADEM shows large (≥ 2 cm) lesions which can involve deep grey matter as well as white matter. MRI features favoring ADEM as opposed to MS, include the presence of diffuse bilateral lesions, a lack of two or more periventricular lesions, and a lack of black holes. [44] Often, a subsequent change in MRI or the clinical course reveals the correct diagnosis. [45]
Another inflammatory disorder of the CNS that can mimic MS is neuromyelitis optica (NMO), formerly referred to as Devic's disease. The criteria for its diagnosis require optic neuritis and transverse myelitis, and either a longitudinally extensive lesion on spinal cord MRI or a positive NMO IgG antibody titer. [42] The presence of brain involvement is not uncommon in children and does not exclude the diagnosis. [46]
Infection and other disorders
Encephalitic or meningo-encephalitic infectious etiologies must be ruled out in patients with acute presentations, particularly when there is fever and CSF leukocytosis. CNS Lyme disease may manifest with multifocal white matter lesions and a relapsing/remitting clinical course. Similar patterns may be seen with HIV encephalomyelitis, HTLV-1, neurosyphilis, progressive multifocal leukoencephalopathy (PML), Whipple's disease, subacute sclerosing panencephalitis (SSPE), and various parasites.
Vascular and autoimmune disorders
CNS vasculitis can be difficult to distinguish from MS. The presence of beading on CT angiograms can suggest the diagnosis, as can an elevated C-reactive protein level or erythrocyte sedimentation rate (ESR). A brain biopsy may be necessary in cases of isolated CNS angiitis. Other disorders to include in the differential diagnosis are systemic lupus erythematosus (SLE), Behηet disease, neurosarcoidosis, and Sjogren's disease. Vascular diseases mimicking MS are fortunately rare in younger individuals and would include moyamoya disease and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). In some cases of CADASIL, there is marked overlap on brain MRI with MS. The family history, stroke-like events, and migraines help lead to the correct diagnosis with confirmation of a Notch3 mutation. Other disorders to consider are Langerhans cell histiocytosis and hemophagocytic lymphohistiocytosis.
Cranial neoplasms, particularly CNS lymphoma, may mimic a tumefactive presentation of MS on neuroimaging and complicate the diagnosis. [40],[47] Including MRS studies with the routine MRI might help in the differential diagnosis in these instances.
Leukodystrophies
Leukodystrophies can be subdivided into myelination failure, delay or breakdown, and those associated with malformations. Key features are bilateral and symmetric involvement on MRI that appears fairly homogenous. Adrenoleukodystrophy and adrenomyeloneuropathy can be confusing as they show preferential involvement of the peritrigonal white matter, splenium of the corpus callosum, posterior limb of the internal capsule, the crus cerebri, and the cerebellar white matter. [40] The inclusion of very long chain fatty acids in the laboratory work-up of suspected cases leads to the correct diagnosis.
Macrocrania with white matter dystrophy suggests either Alexander disease or Canavan disease. Whereas the infantile onset of leukodystrophies is usually clearly differentiated from MS, those with a juvenile onset can overlap. For example, juvenile cases of Alexander disease may lack macrocephaly and the posterior fossa may be preferentially involved. The bilateral frontal white matter involvement may be less conspicuous. Persistent contrast enhancement can also occur. A very extensive review of the MRI appearance of white matter disorders that may be confused with MS is available elsewhere. [48] A case of Pelizaeus Merzbacher has been described which overlapped considerably with MS, both in clinical and radiological manifestations. Marked nystagmus led to testing of the proteolipid 1 protein abnormality and the correct diagnosis was established. [49] In general, progressive cognitive decline (as was present in the Pelizaeus Merzbacher case) is typical for leukodystrophies but extremely rare in MS. Degenerative and metabolic diseases that may mimic MS include metachromatic leukodystrophy, Krabbe disease, Refsum disease, vanishing white matter disease, Wilson's disease, Fabry disease, vitamin B12 deficiency, folate deficiency, vitamin E deficiency, and celiac disease.
The course for mitochondrial disorders is typically progressive and may be marked by bilateral basal ganglia involvement on MRI. Further red flags, such as visual loss, bilateral hearing deficit, short stature, ophthalmoplegia (Kearns-Sayre), cardiac involvement (Kearns-Sayre/CPEO), stroke-like events (MELAS), myoclonic epilepsy (MERRF), or bone marrow failure (Pearson), can help reveal the specific cytopathy. Brainstem involvement is a feature seen in Leigh syndrome.
A standard diagnostic evaluation beyond imaging and CSF should include: CBC, ESR, and ANA, whereas extended testing for specific conditions might include Lyme antibody titers, MR angiography, MR spectroscopy, evoked potentials, CSF lactate, serum vitamin levels (B12, D, E, folate), anti-Ro, anti-La, serum angiotensin-converting enzyme levels, HIV, rapid plasma reagent, HTLV-1 PCR, serum EBV and mycoplasma titers, NMO antibody, very long chain fatty acids, and GFAP mutation. Further laboratory testing for specific disorders is more thoroughly reviewed elsewhere. [39],[40]
Communicating the Diagnosis
Being told of the diagnosis of MS can be traumatic for the patient and family. That the prognosis is uncertain and the condition is rare contributes to the difficulty the family faces in adjustment. A number of considerations should go into the process of conveying the diagnosis. It is important to emphasize to the family that they are not alone and that online social network groups, support groups, and literature specific to the topic of pediatric MS are available.
Management of relapses
The usual treatment for an acute relapse is corticosteroids with doses of parenteral methylprednisolone ranging from 10 to 30 mg/kg. In most instances, the maximum dose is 1000 mg administered intravenously (IV) once daily in the morning for 3-5 days; an oral prednisone taper is optional. An alternative to IV steroids is high-dose, oral prednisone (same dose as IV therapy) which in adults may be as effective as IV treatment [50] in managing acute relapses. [51] High-dose oral prednisone (up to 1200 mg/day) in adults has been found to have good bioavailability compared to IV therapy [52] but is untested in children or adolescents. Adverse effects of steroids such as insomnia as well as mood disturbances including psychosis, hyperglycemia, and hypertension need to be monitored. Prolonged steroid use can also possibly retard growth in youngsters. Despite its long-term risks, short courses of steroid therapy are reasonably safe and well tolerated by most children.
Plasmapheresis or intravenous immunoglobulin (IVIG) are options for when IV steroids fail to improve a severe relapse. The use of either modality is based on its success in a limited number of cases of children or adults. [53],[54] Usually five exchanges every other day are administered. IVIG treatment can also be used at a dose of 0.4 g/kg for five days and be continued one day per month at 0.4 g/kg. This therapeutic approach has been studied in only small samples of ADEM and its variants. [55],[56]
Treatment with disease modifying therapy (DMT)
Multiple studies have demonstrated treatment of pediatric MS to be well tolerated [Table 3]. To the extent that efficacy can be established in the absence of placebo controlled trials, the body of evidence supports treatment. The bulk of studies demonstrating treatment efficacy is drawn from comparisons of pretreatment relapse frequency to that during treatment. However, a comparison of untreated to treated patients was also found to favor treatment. In this study, 197 pediatric MS patients were followed after their MS-defining event for an average of 5.5 years. A total of 24 patients began interferon therapy 3.6 months (mean period) after their relapse whereas 73 remained untreated. Those treated had a relative reduction in relapses over the subsequent first two years on therapy with a hazard ratio of 0.40, P < 0.01. However, the benefit was less apparent over the four years of follow-up. [57]
Interferon (IFN)
IFN-beta 1a intramuscular (IM) injection at a dose of 30 micrograms (μg) once weekly is usually well tolerated in children with MS. In the largest study to date, a total of 53 children under the age of 16 years were started on therapy and followed for a mean of 43 ΁ 20 months. [58] Of this group, 19 discontinued treatment and the reasons for discontinuing were most often due to a switch to what was considered a more effective therapy (n = 13). Adverse events and laboratory changes were similar to those of treated adults. There was a drop in relapse rate from pretreatment to during therapy of 1.9 to 0.4 for the entire group. [58],[59],[60] The standard adult dose of 30 micrograms (μg) IM once per week has been used effectively even in some ten year-old children but half the dose is often used for very young children aged three years and younger.
Interferon beta 1a subcutaneous (SC) injection has also been successfully administered to pediatric MS patients. Treatment was well tolerated among 51 children under the age of 16 years who were started on IFN-beta 1a SC therapy. [38] The mean annual relapse rate decreased from 1.9 prior to initiation of therapy to 0.8. Adverse events were similar to those of treated adults. [58],[60],[61] The dose for IFN-beta 1a SC for children can be the same as adults: 44 μg three times a week with a minimum of 48 hours between each dose at a lower dose of 22 μg three times a week. [38]
A multicenter collaborative effort was completed among 43 individuals who all started on IFN-beta 1b SC therapy prior to their 18 th birthday. [62] There were no serious adverse events. Flu-like symptoms (35%), elevated LFTs (25%), and injection site reactions (21%) were the most frequent side effects. [62],[63] Dosing was the same as in adults. The relapse frequency on therapy was lower relative to pretherapy with a mean reduction in the annualized relapse rate of 50%. [62]
Glatiramer acetate (GA)
In a study of seven patients aged 9-16 years who were treated with GA, all did well at standard doses of 20 mg daily and without escalation. [64] In controlled clinical trials of adults, the most commonly observed adverse experiences associated with the use of GA were: injection site reactions, vasodilatation, chest pain, asthenia, infection, pain, nausea, arthralgia, anxiety, and hypertonia. These side effects have also been reported in children.
Breakthrough disease
Unfortunately, many children treated with first-line DMTs experience breakthrough disease and need to be switched to either another first-line treatment or to second-line therapies. In a preliminary study of 164 treated children, 25% had breakthrough disease with initial DMT. Of these, eight children were switched to chemotherapy, two went on natalizumab, and two were treated with pulse IVIG. [65] Other children do well with cyclophosphamide. [66]
Natalizumab in pediatric MS
A total of four children treated with natalizumab have been reported [67],[68] who were 12-13 years of age at the time of therapy and had failed first-line DMTs (interferons and glatiramer acetate). A dose of 3-5 mg/kg of body weight was administered, leading to a decrease in disease activity and, in three patients in whom it was recorded, improved quality of life. All patients tolerated the treatment well, but none at the time of the report had been followed for more than 24 months. The potential development of PML remains a substantial concern in choosing this treatment option.
Compliance requires acknowledgement of the diagnosis by the family and patient, participation, and agreement in the treatment plan. Poor adherence can result from poor family dynamics, limited education of the disease, and incomplete understanding of the purpose of therapy. Moreover, a transition in responsibility occurs in adolescence, although greater compliance is seen with parental involvement. [6]
Symptomatic therapy
There are no clinical trials of symptomatic therapy in children with MS. There have been studies showing efficacy of oral and intrathecal baclofen for spasticity in children with other neurological disorders. [69],[70]
Pediatric MS is a chronic disorder with variable risk following an initial clinical attack. [66] Clearly some patients whose presentation resembles ADEM will subsequently be reclassified as MS. The differential diagnosis and clinical features differ slightly from adults with the disease and are most distinctive in the youngest patients. The management of the disease includes educating and reassuring the family, using medications to modify the disease course, and addressing the daily symptoms and psychosocial consequences of the disease.
1. Duquette P, Murray TJ, Pleines J, Ebers GC, Sadovnick D, Weldon P, et al. Multiple sclerosis in childhood: Clinical profile in 125 patients. J Pediatr 1987;111:359-63.
2. Boiko A, Vorobeychik G, Paty D, Devonshire V, Sadovnick D. Early onset multiple sclerosis: A longitudinal study. Neurology 2002;59:1006-10.
3. Ghezzi A, Deplano V, Faroni J, Grasso MG, Liguori M, Marrosu G, et al. Multiple sclerosis in childhood: Clinical features of 149 cases. Mult Scler 1997;3:43-6. [PUBMED] [FULLTEXT]
4. Sindern E, Haas J, Stark E, Wurster U. Early onset MS under the age of 16: Clinical and paraclinical features. Acta Neurol Scand 1992;86:280-4. [PUBMED] [FULLTEXT]
5. Ruggieri M, Polizzi A, Pavone L, Grimaldi LM. Multiple sclerosis in children under 6 years of age. Neurology 1999;53:478-84. [PUBMED] [FULLTEXT]
6. Renoux C, Vukusic S, Mikaeloff Y, Edan G, Clanet M, Dubois B, et al. Natural history of multiple sclerosis with childhood onset. N Engl J Med 2007;356:2603-13. [PUBMED] [FULLTEXT]
7. Simone IL, Carrara D, Tortorella C, Liguori M, Lepore V, Pellegrini F, et al. Course and prognosis in early-onset MS: Comparison with adult-onset forms. Neurology 2002;59:1922-8. [PUBMED] [FULLTEXT]
8. Chitnis T, Glanz B, Jaffin S, Healy B. Demographics of pediatric-onset multiple sclerosis in an MS center population from the Northeastern United States. Mult Scler 2009;15:627-31. [PUBMED] [FULLTEXT]
9. Compston A. McAlpine's multiple sclerosis. 3rd ed. London: Churchill Livingston; 1998.
10. Banwell B, Kennedy J, Sadovnick D, Arnold DL, Magalhaes S, Wambera K, et al. Incidence of acquired demyelination of the CNS in Canadian children. Neurology 2009;72:232-9. [PUBMED] [FULLTEXT]
11. Banwell B, Ghezzi A, Bar-Or A, Mikaeloff Y, Tardieu M. Multiple sclerosis in children: Clinical diagnosis, therapeutic strategies, and future directions. Lancet Neurol 2007;6:887-902. [PUBMED] [FULLTEXT]
12. Krupp L. Racial and ethnic findings in pediatric MS: An update. Neurology 2008;S70:A135.
13. Kennedy J, O'Connor P, Sadovnick AD, Perara M, Yee I, Banwell B. Age at onset of multiple sclerosis may be influenced by place of residence during childhood rather than ancestry. Neuroepidemiology 2006;26:162-7. [PUBMED] [FULLTEXT]
14. Deryck EA. Clinical characteristics and long term prognosis in early onset multiple sclerosis. J Neurol 2006;252:720-3.
15. Mikaeloff Y, Suissa S, Vallee L, Lubetzki C, Ponsot G, Confavreux C, et al. First episode of acute CNS inflammatory demyelination in childhood: Prognostic factors for multiple sclerosis and disability. J Pediatr 2004;144:246-52.
16. Neuteboom RF, Boon M, Catsman Berrevoets CE, Vles JS, Gooskens RH, Stroink H, et al. Prognostic factors after a first attack of inflammatory CNS demyelination in children. Neurology 2008;71:967-73. [PUBMED] [FULLTEXT]
17. Dale RC, de Sousa C, Chong WK, Cox TC, Harding B, Neville BG. Acute disseminated encephalomyelitis, multiphasic disseminated encephalomyelitis and multiple sclerosis in children. Brain 2000;123:2407-22. [PUBMED] [FULLTEXT]
18. Dale RC, Pillai SC. Early relapse risk after a first CNS inflammatory demyelination episode: Examining international consensus definitions. Dev Med Child Neurol 2007;49:887-93. [PUBMED] [FULLTEXT]
19. Bonhomme GR, Waldman AT, Balcer LJ, Daniels AB, Tennekoon GI, Forman S, et al. Pediatric optic neuritis: Brain MRI abnormalities and risk of multiple sclerosis. Neurology 2009;72:881-5. [PUBMED] [FULLTEXT]
20. Lucchinetti CF, Kiers L, O'Duffy A, Gomez MR, Cross S, Leavitt JA, et al. Risk factors for developing multiple sclerosis after childhood optic neuritis. Neurology 1997;49:1413-8. [PUBMED] [FULLTEXT]
21. McDonald WI, Compston A, Edan G, Goodkin D, Hartung HP, Lublin FD, et al. Recommended diagnostic criteria for multiple sclerosis: Guidelines from the International Panel on the diagnosis of multiple sclerosis. Ann Neurol 2001;50:121-7. [PUBMED] [FULLTEXT]
22. Mikaeloff Y, Adamsbaum C, Husson B, Vallee L, Ponsot G, Confavreux C, et al. MRI prognostic factors for relapse after acute CNS inflammatory demyelination in childhood. Brain 2004;127:1942-7.
23. Callen DJ, Shroff MM, Branson HM, Lotze T, Li DK, Stephens D, et al. MRI in the diagnosis of pediatric multiple sclerosis. Neurology 2009;72:961-7. [PUBMED] [FULLTEXT]
24. Ozakbas S, Idiman E, Baklan B, Yulug B. Childhood and juvenile onset multiple sclerosis: Clinical and paraclinical features. Brain Dev 2003;25:233-6. [PUBMED] [FULLTEXT]
25. Ghezzi A, Pozzilli C, Liguori M, Marrosu MG, Milani N, Milanese C, et al. Prospective study of multiple sclerosis with early onset. Mult Scler 2002;8:115-8. [PUBMED] [FULLTEXT]
26. Gusev E, Boiko A, Bikova O, Maslova O, Guseva M, Boiko S, et al. The natural history of early onset multiple sclerosis: Comparison of data from Moscow and Vancouver. Clin Neurol Neurosurg 2002;104:203-7. [PUBMED] [FULLTEXT]
27. Mikaeloff Y, Caridade G, Husson B, Suissa S, Tardieu M. Acute disseminated encephalomyelitis cohort study: Prognostic factors for relapse. Eur J Paediatr Neurol 2007;11:90-5.
28. Banwell B, Krupp L, Kennedy J, Tellier R, Tenembaum S, Ness J, et al. Clinical features and viral serologies in children with multiple sclerosis: A multinational observational study. Lancet Neurol 2007;6:773-81. [PUBMED] [FULLTEXT]
29. Pohl D, Rostasy K, Treiber-Held S, Brockmann K, Gartner J, Hanefeld F. Pediatric multiple sclerosis: Detection of clinically silent lesions by multimodal evoked potentials. J Pediatr 2006;149:125-7.
30. Tenembaum S, Chamoles N, Fejerman N. Acute disseminated encephalomyelitis: A long-term follow-up study of 84 pediatric patients. Neurology 2002;59:1224-31. [PUBMED] [FULLTEXT]
31. Castillo T, Chabas D, Waubant E. MS Onset before puberty: A distinct MRI. Neurology 2008;70:A134.
32. Mikaeloff Y, Caridade G, Assi S, Suissa S, Tardieu M. Prognostic factors for early severity in a childhood multiple sclerosis cohort. Pediatrics 2006;118:1133-9. [PUBMED] [FULLTEXT]
33. MacAllister WS, Belman AL, Milazzo M, Weisbrot DM, Christodoulou C, Scherl WF, et al. Cognitive functioning in children and adolescents with multiple sclerosis. Neurology 2005;64:1422-5. [PUBMED] [FULLTEXT]
34. Banwell BL, Anderson PE. The cognitive burden of multiple sclerosis in children. Neurology 2005;64:891-4. [PUBMED] [FULLTEXT]
35. Amato MP, Goretti B, Ghezzi A, Lori S, Zipoli V, Portaccio E, et al. Cognitive and psychosocial features of childhood and juvenile MS. Neurology 2008;70:1891-7. [PUBMED] [FULLTEXT]
36. Amato M. Cognitive and psychosocial features of childhood and juvenile multiple sclerosis: A reappraisal after 2 years. Neurology 2009;3:A97.
37. Ghezzi A, Amato MP, Capobianco M, Gallo P, Marrosu G, Martinelli V, et al. Disease-modifying drugs in childhood-juvenile multiple sclerosis: Results of an Italian co-operative study. Mult Scler 2005;11:420-4. [PUBMED] [FULLTEXT]
38. Pohl D, Rostasy K, Gartner J, Hanefeld F. Treatment of early onset multiple sclerosis with subcutaneous interferon beta-1a. Neurology 2005;64:888-90.
39. Chitnis T. Pediatric multiple sclerosis. Neurologist 2006;12:299-310. [PUBMED] [FULLTEXT]
40. Hahn JS, Pohl D, Rensel M, Rao S. Differential diagnosis and evaluation in pediatric multiple sclerosis. Neurology 2007;686:S13-22.
41. Tenembaum S, Chitnis T, Ness J, Hahn JS. Acute disseminated encephalomyelitis. Neurology 2007;686:S23-36.
42. Krupp LB, Banwell B, Tenembaum S. Consensus definitions proposed for pediatric multiple sclerosis and related disorders. Neurology 2007;686:S7-12.
43. Brass SD, Caramanos Z, Santos C, Dilenge ME, Lapierre Y, Rosenblatt B. Multiple sclerosis vs acute disseminated encephalomyelitis in childhood. Pediatr Neurol 2003;29:227-31. [PUBMED] [FULLTEXT]
44. Callen DJ, Shroff MM, Branson HM, Li DK, Lotze T, Stephens D, et al. Role of MRI in the differentiation of ADEM from MS in children. Neurology 2009;72:968-73. [PUBMED] [FULLTEXT]
45. Hynson JL, Kornberg AJ, Coleman LT, Shield L, Harvey AS, Kean MJ. Clinical and neuroradiologic features of acute disseminated encephalomyelitis in children. Neurology 2001;56:1308-12. [PUBMED] [FULLTEXT]
46. Banwell B, Tenembaum S, Lennon VA, Ursell E, Kennedy J, Bar-Or A, et al. Neuromyelitis optica-IgG in childhood inflammatory demyelinating CNS disorders. Neurology 2008;70:344-52. [PUBMED] [FULLTEXT]
47. Hahn CD, Shroff MM, Blaser SI, Banwell BL. MRI criteria for multiple sclerosis: Evaluation in a pediatric cohort. Neurology 2004;62:806-8. [PUBMED] [FULLTEXT]
48. Van der Knaap MS. Magnetic resonance of myelination and myelin disorders. 3rd ed: Springer; 2005.
49. Gorman MP, Golomb MR, Walsh LE, Hobson GM, Garbern JY, Kinkel RP, et al. Steroid-responsive neurologic relapses in a child with a proteolipid protein-1 mutation. Neurology 2007;68:1305-7. [PUBMED] [FULLTEXT]
50. Barnes D, Hughes RA, Morris RW, Wade-Jones O, Brown P, Britton T, et al. Randomised trial of oral and intravenous methylprednisolone in acute relapses of multiple sclerosis. Lancet 1997;34905:902-6.
51. Martinelli V, Pulizzi A, Annovazzi P, Rocca M, Rodegher M. A short-term MRI study comparing high-dose oral versus intravenous methylpredisolone in MS relapse. Neurology 2008;70:A83-4.
52. Morrow SA, Stoian CA, Dmitrovic J, Chan SC, Metz LM. The bioavailability of IV methylprednisolone and oral prednisone in multiple sclerosis. Neurology 2004;63:1079-80. [PUBMED] [FULLTEXT]
53. Weinshenker BG, O'Brien PC, Petterson TM, Noseworthy JH. A randomized trial of plasma exchange in acute central nervous system inflammatory demyelinating disease. Ann Neurol 1999;46:878-86.
54. Duzova A, Bakkaloglu A. Central nervous system involvement in pediatric rheumatic diseases: current concepts in treatment. Curr Pharm Des 2008;14:1295-301. [PUBMED] [FULLTEXT]
55. Hahn JS, Siegler DJ, Enzmann D. Intravenous gammaglobulin therapy in recurrent acute disseminated encephalomyelitis. Neurology 1996;46:1173-4. [PUBMED] [FULLTEXT]
56. Nishikawa M, Ichiyama T, Hayashi T, Ouchi K, Furukawa S. Intravenous immunoglobulin therapy in acute disseminated encephalomyelitis. Pediatr Neurol 1999;21:583-6. [PUBMED] [FULLTEXT]
57. Mikaeloff Y, Caridade G, Tardieu M, Suissa S. Effectiveness of early beta interferon on the first attack after confirmed multiple sclerosis: A comparative cohort study. Eur J Paediatr Neurol 2008;12:205-9. [PUBMED] [FULLTEXT]
58. Ghezzi A, Amato MP, Capobianco M, Gallo P, Marrosu MG, Martinelli V, et al. Treatment of early-onset multiple sclerosis with intramuscular interferonbeta-1a: Long-term results. Neurol Sci 2007;28:127-32. [PUBMED] [FULLTEXT]
59. Waubant E, Hietpas J, Stewart T, Dyme Z, Herbert J, Lacy J, et al. Interferon beta-1a in children with multiple sclerosis is well tolerated. Neuropediatrics 2001;32:211-3. [PUBMED] [FULLTEXT]
60. Mikaeloff Y, Moreau T, Debouverie M, Pelletier J, Lebrun C, Gout O, et al. Interferon-beta treatment in patients with childhood-onset multiple sclerosis. J Pediatr 2001;139:443-6. [PUBMED] [FULLTEXT]
61. Tenembaum SN, Segura MJ. Interferon beta-1a treatment in childhood and juvenile-onset multiple sclerosis. Neurology 2006;67:511-3. [PUBMED] [FULLTEXT]
62. Banwell B, Reder AT, Krupp L, Tenembaum S, Eraksoy M, Alexey B, et al. Safety and tolerability of interferon beta-1b in pediatric multiple sclerosis. Neurology 2006;66:472-6. [PUBMED] [FULLTEXT]
63. Adams AB, Tyor WR, Holden KR. Interferon beta-1b and childhood multiple sclerosis. Pediatr Neurol 1999;21:481-3. [PUBMED] [FULLTEXT]
64. Kornek B, Bernert G, Balassy C, Geldner J, Prayer D, Feucht M. Glatiramer acetate treatment in patients with childhood and juvenile onset multiple sclerosis. Neuropediatrics 2003;34:120-6. [PUBMED] [FULLTEXT]
65. Yeh A. Breakthrough disease in pediatric MS patients: A pediatric network experience. Multiple Sclerosis in press.
66. Makhani N, Gorman MP, Branson HM, Stazzone L, Banwell BL, Chitnis T. Cyclophosphamide therapy in pediatric multiple sclerosis. Neurology 2009;72:2076-82. [PUBMED] [FULLTEXT]
67. Borriello G, Prosperini L, Luchetti A, Pozzilli C. Natalizumab treatment in pediatric multiple sclerosis: A case report. Eur J Paediatr Neurol 2009;13:67-71. [PUBMED] [FULLTEXT]
68. Huppke P, Stark W, Zurcher C, Huppke B, Bruck W, Gartner J. Natalizumab use in pediatric multiple sclerosis. Arch Neurol 2008;65:1655-8.
69. Hoving MA, van Raak EP, Spincemaille GH, van Kranen-Mastenbroek VH, van Kleef M, Gorter JW, et al. Safety and one-year efficacy of intrathecal baclofen therapy in children with intractable spastic cerebral palsy. Eur J Paediatr Neurol 2009;13:247-56. [PUBMED] [FULLTEXT]
70. Brochard S, Remy-Neris O, Filipetti P, Bussel B. Intrathecal baclofen infusion for ambulant children with cerebral palsy. Pediatr Neurol 2009;40:265-70. [PUBMED] [FULLTEXT]
[Table 1], [Table 2], [Table 3]
1 Evolution of diagnostic criteria for multiple sclerosis
Joanna Przybek,Inga Gniatkowska,Dagmara Mirowska-Guzel,Anna Czlonkowska
Neurologia i Neurochirurgia Polska. 2015; 49(5): 313
2 Changes in Gross Grasp Strength and Fine Motor Skills in Adolescents with Pediatric Multiple Sclerosis
Mary Squillace,Sharon Ray,Maria Milazzo
Occupational Therapy in Health Care. 2015; 29(1): 77
3 Cortical thickness at the time of the initial attack in two patients with paediatric relapsing–remitting multiple sclerosis
Alberto Fernández-Jaén,Daniel Martín Fernández-Mayoralas,Ana Laura Fernández-Perrone,Mar Jiménez de la Peña,Manuel Recio Rodríguez,Beatriz Calleja-Pérez,Nuria Muñoz Jareño,Rafael Arroyo,Jacobo Albert
European Journal of Paediatric Neurology. 2013;
4 result 1 Document Guideline for the diagnosis and management of multiple sclerosis in children
Govender, R.
South African Medical Journal. 2013;
5 One case of pediatric multiple sclerosis with convulsions as initial symptoms
Xiong, M., Ni, C.
Source of the Document Chinese Journal of Contemporary Pediatrics. 2013;
6 Treatment of cognitive impairment in patients with multiple sclerosis
Francesco Patti
Expert Opinion on Investigational Drugs. 2012; 21(11): 1679
7 Relative Incidence of Inherited White Matter Disorders in Childhood to Acquired Pediatric Demyelinating Disorders
Adeline Vanderver,Heather Hussey,Johanna L. Schmidt,William Pastor,Heather J. Hoffman
Seminars in Pediatric Neurology. 2012; 19(4): 219
8 Pediatric multiple sclerosis and occupational therapy intervention
Squillace, M.
OT Practice. 2011; 16(14): 19-23
Patel Y
Bhise V
Krupp L
Risks for develo...
Clinical feature...
Differential Dia...
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BLK BOX LIVE Recap
...and that's a wrap.
Wow. BLK BOX LIVE went off with a bang. Firstly, to those who bought tickets and attended the weekend, thank you very much. We hope you enjoyed every second of it.
BLK BOX LIVE took place over two days at our HQ in Belfast. It was an opportunity for us to open the doors and give a behind-the-scenes look at where the magic happens in our manufacturing warehouse and showroom. It was also our chance to showcase and experience our new in-house retail store, which, lots of you seemed to enjoy.
It's quite difficult to put into words the atmosphere in which Friday night's 'Under The Lights' event created. The energy on the warehouse turned competition floor energy was electrifying. The grandstand was packed full of enthusiastic onlookers. A huge thank you to Scott Britton and Sam Cornforth for taking to the mic and entertaining the crowd for the evening.
Between BLK BOX Athlete Emma McQuaid going unbroken in practically all three workouts, to 14-year-old Lucy McGonigle winning the hearts of the crowd, it was a night to remember.
The men's lineup of athletes certainly didn't disappoint. From our homegrown athletes PD Savage, Micky Walsh and Micky Smith, to some of the top CrossFit Athletes in the UK & Europe, Harrison Bell and Dan Tai, it was all eyes on the competition floor as they all battled for the BLK BOX Live Winning title. Savage and McQuaid were crowned the Winners of the night, taking home Male and Female first place.
Saturday saw some of the top leading coaches and industry leaders take the microphone in our showroom turned seminar space. We want to extend a huge thank you to Ollie Marchon and Coach Jenz from Marchon & The PFCA, Omnia Performance, Redpill Training and Nick Winkleman for sharing their wisdom and knowledge with the BLK BOX community.
We'd also like to extend our thanks to our partners at Turf Games for hosting a serious session in our workshop area. It was great hosting you at our HQ. Alongside this workshop, we had the fantastic Sean Brown and Team Training guys who kept everyone on their toes with gymnastic and weightlifting sessions. There was nowhere to hide when these guys took the reigns. Thank you for putting our attendees through their paces and helped them work off their Slims Healthy Kitchen burgers and beers.
The day was spent taking notes, selfies and purchasing the new BLK BOX apparel range, that launched just in time for the event. You can still purchase the range here.
A special thank you to Slims Healthy Kitchen, Nocco Ireland, All Real and The Butcha's Dog for attending the weekend too and keeping everyone fed and watered. We could continue to talk about the event as there were so many highlights, but we will wrap it up here. Thank you to everyone who made it so special.
© 2023, BLK BOX Drevet af Shopify


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Twenty one year old, Alex O'Connor, or Rex Orange County as he's more commonly known, has caused quite a stir in the music community since the release of his first album 'Bcos U Will Never B Free' in 2016 at the age of 18. The albums' rustic and dreamy sound, layered with almost a sheet of melancholy gained Rex a small following in the music community, and followed this release with three singles: 'Best Friend', 'Sunflower' and 'Untitled'. These singles took a shinier and more upbeat approach to the sound Alex had crafted. His follow up album 'Apricot Princess' was released weeks later, treating listeners to more of what Alex had to offer on his first album, but developed a jazzier sound with richer production. It was a combination of these sounds that caught the ear of rapper Tyler, The Creator, as he brought Alex in during the 'Flower Boy' sessions. Rex Orange County appeared on two tracks on Tyler's 2017 album gaining him a lot of attention he may have otherwise never seen. Alex released 'Loving Is Easy', a song I'm sure you've all heard on plenty of adverts, towards the tail end of 2017 gaining him coverage on stations such as Radio 1. Oh, he also headlined The Park stage at Glastonbury last year.
So I guess you could say he's had a pretty busy few years.
With not much other than a few shows here and there, Alex has been pretty quiet recently. Luckily last Friday he dropped his third album, 'Pony', which sees him expand on his sound to create a fresher, cleaner and polished idea of who Alex O'Connor is. Lead single '10/10' helps us understand where he is in his life right now – being forced to grow up, cut people out and find his way from a darker place to where feels like home. As the song progresses it feels as though we are on this adventure growing with him, just to be greeted with a euphoric guitar solo as the song nears an end. It feels as though through this song Alex has found the motivation to write new music, 'And though it's still hard work to find the words / I'm still gonna write this f***ing song', and is starting to feel settled in himself amidst all the change.
However this feeling isn't maintained throughout the rest of the record, lyrically at least anyway. 'Pony' doesn't take the melancholic approach of his previous two albums, instead gospel voices, strings and crystal clear production creates a very heavenly and bubbly feel to the album, despite some of the lyrical topics. It's clear that he's had a lot of time to himself to ponder on what his life has actually become since finding success, and within that has realised he actually doesn't have it all figured out.
'Stressed Out' sees Alex hit a realisation that there are people in his life taking advantage of his fame for their own personal use but not looking out for him in the process: "They wanna lie and still be friends / But when you're at your worst, they're not there / And you discovered they don't care". The lyrics are sung over a soft organ-like synth, with layers of acoustic guitar and tambourine creeping in, making it feel surprisingly comforting. If there's one thing 'Pony' excels in its making you feel comforted.
'Always' has a very distinct feeling of a ballad from the 70's with the way Alex belts its chorus, almost something like Randy Newman would do. We see him sing about how he feels as though he is still the same person despite all the change in his life. Although it's not a song for every mood, and sometimes may feel like something your auntie might share on Facebook, it feels very humble and sincere.
'Never Had The Balls' caught me off guard first listen with its quirky and danceable vibe that the rest of the album has seemed to lack, with some of the lyrics came across as almost cringe inducing at times; "This could be the best decision that you ever make" bridge mostly. However, the more and more I listened to this song the more I fell in love with it. It radiates similar energy to that of 'Best Friend'; unapologetically uplifting and optimistic. The lyrics "I shouldn't waste my precious time / On anybody feeding off of mine" sees Alex progress from his headspace during 'Stressed Out' and taking care of himself. We see him start doing things for himself and feeling free by doing so, it's a true highlight of the album.
This is followed by 'Pluto Projector', another definite highlight of Rex Orange County's career. A gentle guitar with the lyrics: "The great protector / Is that what I'm supposed to be? / What if all this counts for nothing / Everything I thought I'd be / What if by the time I realise / It's too far behind to see?" opens the track hitting you with a whopping combo of loneliness and self doubt. The way this track is orchestrated is phenomenal, and Alex's voice echoes that feeling of loneliness throughout the track, as he sings about how he doesn't truly understand himself. There's a sense of comfort in the way the track progresses, almost like he's coming to terms with the fact that he'll never really understand his innate workings. The last 30 seconds sounds similar to a Frank Ocean track, as the vocals are pitch shifted to sound deeper; something I could happily listen to more than 30 seconds of.
'Face To Face' hits you with a blissful accapella within the first few seconds, as several layers of Alex's voice sing the opening lines. He sings about how he feels comforted when he's with a girl, a character that seems to appear several times throughout the album, and how he wishes he was with her; it feels undeniably wholesome. 'It Gets Better' starts with an earworm synth lead, quickly followed by a salsa-esque drum beat. The tune eventually elevates into a spacey and light dance groove; something I'd love to hear Rex do more of in the future.
However, the album does come with its flaws. 'Every Way' is the weakest of the bunch here, as he sings about his love for this girl over a piano. Although it's a cute two minute endeavour, it doesn't feel as though it has as much of a reason to be placed on the album when compared to the rest of the track list. An additional blow is that it follows a pretty solid run of tracks including two of the best songs of his career: 'Pluto Projector' and 'Never Had The Balls'. 'Laser Lights' is by no means a bad song, but it feels as though it's dragging itself along at times. Regardless the horn and woodwind section in this song accompanies that feeling pretty successfully, as it makes you feel as though you're just waking up in the morning, rolling your eyes and pulling yourself out of bed, just to sit on the edge of your bed for the next several minutes.
Album closer, 'It's Not The Same Anymore', is a beautiful moment as Alex discusses and accepts how the changes in his life have affected his mental state, implying that writing music isn't what it used to be for him and how he feels like has lost the desire to write that he used to have: "I used to be so hungry / Right now my stomachs full as hell". However in the last verse "I'm doing this for myself / It's not the same anymore / It's better" I feel as though Alex has come circle and become content with the change around him.
All in all, 'Pony' is an album about dealing with change and going into adulthood, about not having all the answers but coming to terms with the fact that we never will, and about keeping those who care for you close. There is a feeling of heartache as in most songs he sings about missing a girl, which makes 'Pony' feel as though it's his journey through constant rapid change with only one person remaining constant in his life. The album feels humble and sincere, a feeling Alex's music has always carried, and is a valiant change of pace for Rex Orange Country. Although it's not a perfect album, I've had the record on repeat over the last few days. The album feels undeniably cathartic, as it feels as though Alex has got a lot off his chest and is a definite step in the right direction for Rex Orange County.
Best Songs: '10/10', Face To Face', 'Stressed Out, 'Never Had The Balls', 'Pluto Projector'
Worst Songs: 'Every Way'
#review #Music


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Have you taken advantage of all HSLDA offers you? Perhaps you haven't known how! Here are a few pointers to help you.
>> To ask a legal question: Browse our website, go to www.hslda.org/contactstaff, or call and ask for your state's legal assistant.
>> To find an answer to a membership question: Call and ask to speak to your state's membership coordinator, or email us through www.hslda.org/contactstaff.
>> To read the latest homeschooling news and legislative alerts: Subscribe to the HSLDA E-lert Service. You can select the e-lerts you wish to receive.
>> To save money: Check out our exclusive member PerX, offering discounts with 52 providers of curriculum resources, computer software, travel services, and more. You may also want to visit our Curriculum Market, which auctions new and used curriculum.
>> To receive member discounts at the HSLDA Bookstore: View our available products, enter your membership account number, and place your online order.
>> To be encouraged and seek advice for your homeschooling: Take advantage of the resources provided by our early years, high school, and struggling learner coordinators. Check out our program websites for helpful online resources. Or, call and talk to our coordinators—they're happy to provide advice for your specific situation!
The Early Years helps parents of preschool, elementary, and middle school children begin homeschooling and find resources to continue.
Homeschooling Thru High School helps you plan for your child's high school years, deals with details such as testing and recordkeeping, and prepares your teen for the post-graduation years.
Homeschooling Your Struggling Learner is full of helpful resources for parents whose children have a learning glitch or special needs.
>> To find a support group in your state: Go to www.youcanhomeschool.org, click on Support Groups, and select your state for a list of homeschool organizations.
>> To join our affiliate program: Sign up online, and your organization will earn $20 for every member who joins HSLDA using your code.
>> To share your family's story of how HSLDA has helped you: Email your story of 150 words or less to memberstories@hslda.org. Selected stories will be published in the Court Report.
>> To hear inspiring stories and practical suggestions for homeschooling: Tune in to our radio program, Home School Heartbeat. You can find a station in your area or sign up for daily email transcripts.
>> To participate in live homeschooling seminars and workshops online: Visit and Sign up for HSLDA's new @home-events. These exciting webinars are designed to equip and encourage you in the comfort of your own home. Watch the next Court Report for more details!
These services are just a sampling of HSLDA's many resources for homeschoolers. We are always looking for ways to better serve our members. If you have ideas or suggestions, please share them at www.hslda.org/contactstaff or 540-338-5600. We look forward to hearing from you!
Chuck Hurst is HSLDA's director of membership and human resources.


BG03 introduced in 2018 means some Exisiting Installations AND Blowdown vessel ranges WILL NOT COMPLY.
Abbotts began making boilers in 1870, and continues to make blowdown vessels, blowdown tanks and equipment for the heating and steam industries.
Our Blowdown Vessels are: CE Marked Built to PD5500 CAT 3 BG03 (was HSE PM60) compliant SIZED – to your needs.
A very outdated and more of historic interest – but still including some interesting facts and figures.
It provides advice to ensure safe discharge of blowdown from boilers but does not contain guidance on all possible arrangements of boiler blowdown equipment which should only be installed after the design, construction and installations have been approved by a competent person.
This publication deals with the blowdown arrangements on boilers with a maximum evaporative capacity of about 8.8 kg/s (7000 lb/h) and a design pressure not exceeding 27.5 BAR G (400 PSIG). Large watertube boilers are excluded ie those with multiple blowdown circuits, but watertube boilers with one main blowdown line are included.
The blowdown tanks which have been considered here are steel pressure vessel of circular cross section. Design criteria for steel blowdown tanks of non-circular shape are not included and if these are used they must be designed and constructed as pressure vessels with similar design, construction and inspection criteria applied to them as for steel pressure vessels of circular cross section.
Advice given here only applies to the safe use of existing brick/concrete pits. Such pits are not normally recommended for new boiler installations as experience has shown that the general deterioration and state of repair is difficult to monitor. The effects of serious undetected leakage have been known to undermine foundations. If pits are necessary for new installations, they must be designed by a competent person and built under his supervision.
Steam Boilers are blown down at regular intervals to remove some of the suspended and dissolved solids which result from raising steam. These solids in the boiler water can give rise to foaming and overheating of the heat transfer surfaces of the boiler.
It is therefore necessary to control their concentration in the boiler by blowing down, which may be carried out intermittently (either manually or automatically) or continuously, or both. Intermittent blowdown is essential for boilers operating with internal feedwater treatment; it is the most effective method of removing sludge , particularly when applied in short sharp bursts.
Continuous blowdown is usually automatic in operation, and used when the quantity of blowdown to be discharged makes it necessary to supplement the intermittent blowdown through the main blowdown valve. The system is such that the correct amount of water is discharged from the boiler in order to keep the dissolved and suspended solids in the boiler water within predetermined limits.
When continuous blowdown is installed, it may be economic to recover the heat content of the discharge. When heat recovery equipment is installed, the pressure and temperature is reduced and the cool residual blowdown may then normally be discharged directly to drain rather than into the blowdown receiver.
The sudden or rapid discharge of high temperature hot water is hazardous and because of the considerable amount of energy released, structures such as drainage ducts, culverts and sewers are likely to be damaged and unsecured manhole lids and slabs over blowdown pits are liable to be lifted. There is also a significant risk of injury to persons working in the vicinity of an inadequately protected discharge. Unsuitable blowdown tanks can fail catastophically under pressure and are potentially dangerous.
Section 2 – requires employers to provide plant and systems of work which are, so far as is reasonably practicable, safe.
Section 6 – requires designers, manufacturers, importers, suppliers and installers to ensure that articles for use at work are safe when properly used. It also requires adequate information to be made available to the user.
all valves or taps controlling the entry of steam or hot water are closed and securely locked, and, where there id a common blowdown pipe or vessel, the blowdown valve on each boiler is so constructed that it can only be opened by a key which cannot be removed until the blowdown valve is closed and is the only key in use for that set of blowdown valves.
Section 27 (1)(b) – prohibits the passing into public sewers of waste steam or any liquid of a temperature higher than 110oF (43oC).
Boiler Blowdown Tanks should be constructed as pressure vessels to British Standard 5500 Unfired Fusion Welded Pressure Vessels, Category 3 or an equivalent national standard. (Note this is now PD5500 design code and a similar) A Boiler Blowdown Tank is not only designed to withstand internal pressure, but must possess sufficient structural strength to sustain the shock loading associated with intermittent blowdown, and be able to carry the weight of external attachments, and to withstand external pipe loadings etc.
For the pressures within the scope of this guidance note, past experience has indicated that it is good practice to design a blowdown tank on the basis of at least 25% of the maximum permissible working pressure of the boiler to which it is connected, subject to its possessing sufficient structural strength.
On a multi-boiler installation with boilers of varying working pressures, the highest maximum permissible working pressure should be used to determine the design criteria. The design temperature of the blowdown tank should be the temperature of saturated steam at a pressure equal to the design pressure. Adequate access must be provided to allow for cleaning and inspection.
whether the blowdown enters the tank above or below the standing water level.
It acts as a seal to prevent flash steam discharge through the water outlet to drain.
It cools the incoming blowdown, so that the resulting water going to drain is at an acceptably low temperature. The degree of cooling depends on the water capacity in the tank and the quantity and frequency of blowdown. The water quantity in the tank should be at least twice that of the quantity of blowdown. Approximately half of the tank's volume should be occupied by standing water and the remainder as airspace.
The testing of the low water cut-out and lock-out functions on an automatically controlled steam boiler consists of evaporating the boiler water down to the first low alarm level, after which the boiler is blown down to the second low water level, at which point an alarm sounds and the boiler goes to lockout.
If the amount of water blown out of the boiler between the first and second low water levels is greater than that discharged during routine blowing down of the boiler, the former quantity should be taken into account when calculating the size of the blowdown tank.
Blowdown piping is subject to rapid pressurisation, high velocity flow, thermal shock and vibration, all of which can be severe. Pipework should be suitably supported, bends should be of large radius and its length should be kept as short as possible.
Piping should comply with British Standard 806 Specification for design and construction of ferrous piping installation for and in connection with land boilers.
Fittings should comply with British Standard 759 Part 1:1984 Specification for valves, mountings and fittings for application to boilers and to piping installations for and in connection with boilers or other appropriate national standards.
the maximum permissible rise in pressure within the blowdown tank (see 'the vent pipe'.
Table 1 gives the sizes of vent pipe and outlet pipe which are typical for the conditions stated. Any variation from theses figures should be by agreement with the manufacturer and/or approved by a competent person.
This must be at least equal in cross sectional area to that of the blowdown pipe or manifold. It can be either discharge into standing water or be located between the water level in the tank and the top of the tank. In the latter case, a deflection plate or baffles should be fitted in the tank to protect the shell against erosion.
The venting arrangements of the blowdown tank should be designed so that the internal pressure does not exceed 0.35 BAR (5 PSIG) and should ensure that flash steam is vent safely and that there is no significant carryover of water at the exit of the vent pipe. The vent pipe must be taken from the highest point of the vessel and should not be less than the sizes given in Table 1. It should be as straight as possible with no valve or other obstruction to prevent free flow and ideally terminate in a suitable exhaust head with an adequate condensate drain. The vent should discharge into the atmosphere where it is not liable to cause personal injury or material damage.
The cross sectional area of the outlet should be at least 1.5 times the area of the inlet pipe. No valve or other obstruction should be fitted in the outlet pipe which should be connected to the tank so that the tank will remain approximately half full of water after each blowdown. The outlet connection may require a water seal incorporated in its design to prevent steam discharge. This may be achieved by extending the vertical leg of the water seal to within 150 mm (6 in) of the bottom tank. The top water seal should have a suitable opening to serve as a siphon breaker.
The above figures have been produced assuming 18.3 m 960 ft) equivalent length of blowdown pipework, a vent height of 6.1 m (20 ft), a boiler pressure of 13.8 BAR G (200 PSI G) and a pressure build up within the tank not exceeding 0.35 BAR G (5 PSI G).
Equivalent length. A pipework system consists of straight pipe and fittings such as bends, elbows, tees etc and valves, all of which cause resistance to flow. To find the total resistance through a pipework system it is usual to express the frictional resistance of fittings & valves as being the equivalent of the pressure drop through a number of linear metres of straight pipe. This length added to the length of the existing pipe is known as 'equivalent length'.
Drainage – the vessels should be fitted with a suitable drain valve.
Pressure Gauge – means should be provided for attaching a test pressure gauge.
Water Level Gauge – this is not considered necessary but, if fitted, should be adequate for the design conditions.
When used in conjunction with a multiple steam boiler installation, the blowdown tank should be sized to suit the boiler with the biggest blowdown rate. FOR SAFETY REASONS IT IS ESSENTIAL THAT ONLY ONE BOILER CAN BE BLOWN DOWN INTERMITTENTLY AT ANY TIME AND TO DO THIS WITH MANUALLY OPERATED INTERMITTENT BLOWDOWN VALVES, ONLY ONE BLOWDOWN VALVE KEY SHOULD BE AVAILABLE.
Manually operated intermittent blowdown valves should be so constructed that the valve key cannot be removed until the valve is fully closed. Where blowdown lines connect to an inlet manifold to the tank each of them must be fitted with a screw down non-return or alternatively a non-return valve and an isolating valve.
This is to prevent the possibility of steam and pressurised hot water being blown from a working boiler into another undergoing maintenance and in which men may be working. The manifold should be at least equal in cross sectional area to the largest boiler blowdown valve in the installation.
The blowdown lines from the boiler control chambers and water gauges should be piped into the main boiler blowdown line or manifold. The discharge should be led to a separate inlet on the blowdown tank.
In certain cases, such as multiple boiler installations where the total volume of blowdown from all the boilers exceeds the cooling capacity of the standing water in the tank, or continuous blowdown systems, it will be necessary to cool the water leaving the blowdown tank before it goes into the public drainage system.
This can be achieved simply by the use of an after cooler or by using multiple units ie, more than one blowdown line for the purpose of reducing the temperature and pressure of the discharge. The advice of a competent person should be sought when considering the use of blowdown tanks in series.
A water cooling device should be fitted to the tank if a blowdown tank is liable to contain hot water of such a temperature that blowdown causes the outlet temperature to exceed the permissible limit. As a result of blowdown the blowdown vessel can become very hot, so precautions should be taken to prevent accidental contact.
The precautions should guard against accidental contact, without interfering with the natural cooling contents of the tank, i.e. the use of guard rails may be preferable to insulating the tank.
Blowdown can be noisy and if this noise becomes a nuisance or a hazard measures should be taken to reduce it, which can be done at the design stage by keeping velocities lower than usual or by installing the tank elsewhere. Silencers may be fitted to the vents pipes, if necessary.
The tank and pipework should either be installed where the water will not freeze in cold weather, be protected so as to prevent freezing, or in cold weather be drained of all water, in which case THE TANK MUST BE FILLED TO ITS NORMAL LEVEL BEFORE BLOWING DOWN. The disposal of discharge should conform to any relevant Local Water Authority Regulations and, in any case the water temperature should not exceed 110oF (43oC).
Brick/concrete pits must be properly maintained. They should be drained, thoroughly cleaned out and examined by a competent person once in every 14 months, or at such intervals as recommended by a competent person. This person does not need to be the same competent person as the one who carries out the thorough examination of the boiler. Particular attention must be paid to the adequate venting of the pit so that it cannot be pressurised over 0.1 BAR G (1.5 PSI G).
Access to the pit should be properly safeguarded and the covers adequately secured unless they are properly fenced. Rubbish should not be swept into the pit. The vent pipe of the brick/concrete pit must be located at its highest point, and be protected against blockage.
It should discharge into the atmosphere where it is not liable to cause personal injury or material damage. Consideration should be given to changing over to a suitable steel blowdown tank where an existing pit is not of sufficient capacity or is not provided with an adequate vent pipe or requires major repairs.
Approximately every 14 months or at every thorough examination of the steam boilers, or at such intervals as are determined by a competent person, the blowdown tank should be positively isolated (i.e. double shut-off or blank flange) from the boiler(s), the tank drained, thoroughly cleaned out and examined. If the quality of the boiler feed is poor the blowdown tank may require draining and/or cleaning more often.
The positive isolation required by above paragraph is to ensure safety during examination of the blowdown tank. Where it is necessary for persons to enter a boiler in a multi-boiler installation, the fitting of a suitable blank flange in the blowdown line of the out-of-service boiler will provide the highest protection.
Where any anti-siphon hole is located in the top of the outlet pipe inside the tank, it should be kept clear of any blockage.


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Private Forests Tasmania, supported by funding from the Australian Government Department of Agriculture, Fisheries and Forestry under its Forest Industries Climate Change Research Fund Program, received a grant of over $255,000 to undertake a new project, Carbon Plantations - Extending research and development to best management practices for carbon sequestration, wood production and new investment opportunities on private land in Tasmania, in 2010-2011.
The project aims to assist landholders understand climate change impacts, emissions trading, and options to invest in, grow and manage plantations as part of their climate change management practices.
The project partners include: Private Forests Tasmania; CSIRO Sustainable Agriculture Flagship; Rural Development Services; AK Consultants; Livingston Natural Resource Services; and AFG-TreeSmart.
The Carbon Plantations Kit, Case Studies and full reports are available as a consolidated single document.