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Why you should add Mumbai to your RTW/Indie trip
- India is the true indie travel destination, and Mumbai is the perfect introduction to the madness that is India
- Sitting on the Arabian sea is the home of the Indian film industry
- Use it as your gateway to India and especially southern India
- A day's bus ride from Goa
- Experience one of the fastest developing cities in India
- Try to arrange your visit during one of the many festivals
Why you should not add to your RTW travel list
- If you aren't an experienced traveler, Mumbai and India can overwhelm. Hell, even if you are an experienced traveler, India can get the best of you.
- Compared to the rest of India, Mumbai can be expensive, especially accommodations.
- If you do add India to your RTW trip itinerary, don't do it first or last. Somewhere in the middle when you are firmly in your travel groove would be ideal.
Indie travel tips for Mumbai
- Strolling around Mumbai will give you a good feel and introduction to India. Just walk with an air of confidence and get used to saying "No!" or you will be busy fending off shop owners and touts.
- If you want to get away from the near-constant harassment, take a stroll along Marine Drive along the water.
- As a white westerner, you may be approached to be an extra in a Bollywood film. This is not a scam, and if you want a nice Indian cultural experience and have a day to waste, say yes.
- While the beaches and water aren't exactly good for swimming, if you want to hang out with a bunch of local Indians, head to a beach in Northwest Mumbai on a Sunday evening.
- Don't be afraid to eat at a street stall in Mumbai. You'll get some of the best and cheapest Indian food around. Just make sure you eat at a crowded one with high turnover. Delhi belly exists in Mumbai, too.
- There's nothing quite like an Indian market, and they pop up on the streets all over the city. Have fun exploring and bargaining for cheap souvenirs to bring home.


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Green plates cut waste at PDX
The Portland International Airport is expanding their reusable plate program after seeing great results from the pilot.Read More…
Phone: 503-823-7037
Email: email@example.com
At some point, most of us have stood over the garbage can holding a half-empty can of oven cleaner or a burned-out compact fluorescent bulb and wondered, "Is dropping this in here really okay?"
Sometimes the answer is a strong, "No." A partially full can of oven cleaner, complete with its many warning messages, might be an obvious no-no, but you may be dismissing many products as harmless when they are, in fact, hazardous.
Two hazardous items our sustainability advisors sometimes see in the trash are fluorescent bulbs (cfls, tube lighting, etc.) and leftover paint. The bulbs likely contain mercury. The paint might be able to be remixed and reused. These are just a few of the reasons that we encourage businesses to identify and develop a safe and consistent way to dispose of hazardous waste in their workplaces.
Taking care with these products not only protects you and your staff, but also all of the people "downstream" from whatever you discard — janitorial and building staff, waste and recycling workers, and the general public. Safely disposing of these items also minimizes the impact they could have on plants, birds, aquatic animals, bees, etc.
Contacting Metro is one of the best ways to identify what is or isn't hazardous, and to learn how to safely dispose of it. It's much better to be sure than to guess. Metro recycling staff can be reached at (503) 234-3000 or through their webpage at Metro's Find A Recycler.
You'll learn that some hazardous waste can even be reused. MetroPaint is one of our favorite examples of this. Close the loop by donating leftover paint to Metro and then buying a "new" can of MetroPaint for your next project.
Images courtesy of Metro

subset: commoncrawl


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The textured and leveraged handle of the Wisconsin contour comfort notary embosser provides enhanced grip and control and is designed to fit comfortably in the notary's hand for an effortless and easy embossing action. The unique and new attractive modern metallic design of this notary embosser is built to last for the whole duration of your notary commission. The notary seal impression is 1 5/8 inches.
A free one year membership to AAN - a $19.00 value - is included with the purchase of this pocket Wisconsin notary seal embosser at no additional cost to you and with no obligation to renew. This valuable membership includes the following exceptional benefits (and much more): essential updates on new Wisconsin notary law; expert advice from top professionals in the notary field; an e-notary journal (as allowed by law); your own business webpage; a free listing in our national online notary and signing agent locator; discounts on notary supplies; and access to our membership rewards program.
View Shipping & Return Policy
8811 Westheimer
Suite 207
Houston, Texas 77063


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Ben Meadows:
- Price:
- $21.75
- Description
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Versatile and comfortable, this glove features reinforced fingertips, a terry brow wipe on the thumb, and a padded palm made of synthetic leather. The vibrantly colored Spandex top provides extra visibility if the glove is lost in the field, and a Velcro® closure on the cuff keeps debris out of the glove. Machine washable.
We encourage our customers to let us know what experiences they have had with our products, whether good or bad. By submitting a review, you can share your experiences with others and also provide valuable feedback to us as well. With just a few simple steps, you can add your review of this product.
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As a dual-mandate organization—one that has worked in both humanit
Country Info
CARE started its operations in Bangladesh (then East Pakistan) in 1949. Today, CARE Bangladesh amplifies the voices of the poor and the marginalized in ways that influence public opinion, development practices, and policy at all levels by drawing on grassroots experience and relationships with civil society, government, and the private sector.
We have made a long-term commitment to specific marginalized and vulnerable groups to achieve a lasting impact on the underlying causes of poverty and social injustice.
Latest News from Bangladesh
Voices From the Families of SHOUHARDO
CARE, USAID and the Bangladesh government launched the SHOUHARDO program in 2004 to reduce child malnutrition in Bangladesh's poorest communities.
Bottom of the Pyramid Selling
Researchers studied a sales program that employs Bangladeshi women at the proverbial bottom of the pyramid, run by the Bangladesh arm of CARE.
Myanmar Refugee Crisis
706,000 people and counting have fled violence in Myanmar
The work we do in Bangladesh
Sustainable Economies
We've worked with governments and communities to ensure sustainable food security for the world's...
Child Poverty
Half of all children live in poverty, spending their formative years struggling to survive.
Access to Market
More inclusive markets and access can help poor people improve their lives.
There's a "savings revolution" taking place in many developing countries.
Youth Empowerment
Addressing the needs of the 1.8 billion young people in the world is critical to ending poverty.
Girls' Education
The majority of the 57 million children out of school are girls — their future is at risk.
Sexual and Reproductive Health and Rights
Family planning is a proven strategy in reducing maternal mortality.
Poverty is both a cause and consequence of HIV and AIDS.
Child Survival
This year, more than 7 million children will die before their 5th birthday.
Poverty & Social Justice
Everyone in the world has the right to a life free from poverty, violence and discrimination.
Maternal Health
Hundreds of thousands of women die in pregnancy and childbirth, mostly from preventable causes.
By failing to close the gender gap in agriculture, the world is paying dearly.
Climate Change
Climate change threatens the very survival of people living in poverty all over the world.
Malnutrition affects 200 million children and the consequences can last a lifetime.
Child Marriage
Child marriage is a gross human rights violation that puts young girls at great risk.
Gender-Based Violence
Gender-based violence is one of the most pervasive and yet least-recognized human rights abuses.
Why Women & Girls?
Why does CARE fight global poverty by focusing on women and girls? Because we have to.
Resources from Bangladesh
In the context of CARE's focus on impact at scale and USAID's
Tackling the Taboo highlights gender-transformative programs from organizations working at the intersection of child marriage and...
2 page summary of the Made By Women Impact Report for 2018
Made by Women is a regional strategy designed to scale the impact of our work by pursuing shared aims and approaches to promoting...
2 page summary on the national scale up of the multi-sector approach to nutrition strengthening.
Executive summary of the Ensuring Sustainability Report
This 24 page report highlights the results of CARE's projects using Food For Peace's Sustainability Framework. It draws from 193...
4 page brief highlighting how market access interventions in Bangladesh change families' socio-economic status
Aiming to visualize it's all operations/ coverage and to find out the scope of improvement, identifying how scattered way the services...
Dairy producers in Bangladesh are seeing an impressive result of having stronger market access.
4 page learning brief highlighting impacts from the Digital Fat testing process.
4 page learning brief from the perspective of BRAC, the private sector company partnering with CARE Bangladesh's SDVC project. Mr.
4 page learning brief on private sector and market-based solutions in Bangladesh
20 page illustrated story on how the Sustainable Diary Value Chains project changed milk production--told from the point of view of milk...
This 2 page brief highlights the findings of the Social Return on Investment study in the Pathways program
This 4 page document highlights the approach and evidence behind CARE's Farmers Field and Business School
This 42 page document highlights the key findings oin CARE's impact in Bangladesh from 2010-2015, including helping more than 41,000...
Want to get to empower women?
This 6 page brief highlights women's participation in Dairy Value Chains and the research that IFPRI conducted on how working with...
This 4 page brief highlights the Krishi Utsho approach--using social enterprises to sustainably solve the problem farmers have in...
This 4 page brief makes the business case for how Digital Fat Testing Machines are revolutionizing the dairy value chain in Bangladesh...
This 6 page brief from the Sustainable Dairy Value Chain project highlights the impacts the project was able to have on women's...
This 6 page brief highlights the impact that working with value chains and women has had on women's empowerment, and how CARE measured...
This 4 page brief highlights the successes of using the Digital Fat Tester--a machine that allows producers to get a premium for high...
This 2 page brief highlights the accomplishments of the Margaret A.
This 2 page document shows the progress of CARE's Pathways program as of January 2016.
Findings from CARE's Tipping Point Project Community Participatory Analysis Research
Innovative USAID-funded program that links food aid with building long-term food and nutrition security
This 70 page report documents the findings of the SHOUHARDO II program, a Food For Peace program in Bangladesh that aims to reduce...
The Farmers' Field and Business Schools are a product of the CARE Pathways program, and focus on a learning by doing approach, putting...
The Farmers' Field and Business Schools are a product of the CARE Pathways program, and focus on a learning by doing approach, putting...
The Farmers' Field and Business Schools are a product of the CARE Pathways program, and focus on a learning by doing approach, putting...
The Farmers' Field and Business Schools are a product of the CARE Pathways program, and focus on a learning by doing approach, putting...
The Farmers' Field and Business Schools are a product of the CARE Pathways program, and focus on a learning by doing approach, putting...
The Farmers' Field and Business Schools are a product of the CARE Pathways program, and focus on a learning by doing approach, putting...
The Farmers' Field and Business Schools are a product of the CARE Pathways program, and focus on a learning by doing approach, putting...
Combining world-class documentary films and local engagement campaigns, Women and Girls Lead Global (WGLG) advances gender equality and...
WASHplus is USAID's flagship global Environmental Health project.
This 54 page document describes the SHOUHARDO food security program in Bangladesh and how it uses a women's empowerment model to...
4 page brief that describes CARE's child marriage prevention programming in Bangladesh and Nepal, including our focus on underlying...
Digging Up the Roots to Replant the Future. This one page fact sheet shows key statistics about child marriage globally, and in...
The Tipping Point initiative is addressing child marriage through a dynamic process of innovation, insight (analysis and learning), and...
Making a Difference: Empowering Girls, Expanding Knowledge, Addressing Poverty
Results of a baseline assessment from six countries in Africa and Asia
This report is an analytical review of CARE's programs and projects undertaken with partners and allies in 16 countries over the period ...
Empowering Women in Agriculture
Push, Pull and Cross-Cutting Strategies
A Pathways Programming Approach
Results of a Baseline Assessment From Six Countries in Africa and Asia
UN and Leading Humanitarian Organizations Launch Appeal Not to Forget Millions of Flood Survivors in South Asia
Bangladesh faces one of the highest rates of domestic violence worldwide.
Among women participating in the program, average incomes more than doubled.
Not every marriage lasts forever, but early marriage has lifelong consequences for girls.
Feb 2012 Girls Leadership Program Brief
How scenario modeling can be used to create a successful inclusive business plan.
The aim of this document is to provide an introduction to the potential contribution that Social Enterprise (SE) can make to CARE's...
The brand Living Blue stands for high quality, hand-made products, made by artisans in Bangladesh, based on optimum technical recall,...
CARE Enterprises creates lasting market-based solutions to poverty.
CARE Enterprises bridges the supply/demand gap that exists between formal markets and many of the world's poorest communities.
From micro‐finance programs to innovative last‐mile distribution projects, CARE has learned over the years how to harness the power of...
Push, Pull and Cross-Cutting Strategies
Quick facts about the SHOUHARDO project in Bangladesh.
Migrant experiences between India, Nepal and Bangladesh.
An 8-country study to understand rainfall, food security and human mobility.
Proven approaches for empowering women smallholders and achieving food security
An International Framework to Address 'Loss And Damage' from Climate Change Impacts
Analysis of and lessons learned from civil society advocacy on climate change
September 2012 Issue of CARE's Poverty Environment & Climate Change Network Newsletter
Why is gender important in climate change adaptation?
Mapping Emerging Trends and Risk Hotspots
CARE's approach to climate change adaptation is grounded in the knowledge that people must be empowered to transform and secure their...
Adaptation to climate change is critical to sustainable development and will require action across multiple sectors at all levels.
We are beginning to see the results of our efforts in promoting, protecting and supporting optimal infant and young child feeding.
Among the most persistent challenges facing Bangladesh is child malnutrition.
The Innovation through Sport project uses the "convening power of sports" to minimize the effects of poverty and social injustice on...
As we celebrate International Day of the Girl, we can't help remind ourselves of our own childhood.
We believe that the greatest obstacle to girls' education is the low social status in which girls are held.
The right to education is fundamental to the attainment and exercise of all human rights.
In 2008, CARE launched an ambitious Market Engagement Strategy that aims to empower 10 million women and girls to transition from...
Currently, CARE is implementing over 74 economic development programs in 66 countries.
CARE's programs in Economic Development work to improve the economic security and income opportunities of the poor.
CARE's HIV & AIDS programming and policy advocacy has highlighted the centrality of women's empowerment.
Gender, Sex and the Power of Solidarity: The Implications of Empowering Women at Risk of HIV and AIDS
We know that empowering women is fundamental to ending poverty and protecting human rights and dignity.
Gender, Sex and the Power to Survive: The Impact and Implications of Empowering Women at Risk of HIV and AIDS
CARE recognizes the need for analysis into ways in which our HIV prevention programs affect women's vulnerability to HIV.
CARE's Nutrition Plus Team Capacity and Experience
Lack of nutritious food is a barrier to health and wellbeing for the most vulnerable, poor and marginalized people in the world.
WE-MEASR: A New Tool for Measuring Women's Empowerment in Health Programs
In order to strengthen and standardize our measurement of women's empowerment in our programs, CARE has developed a new survey tool....
CARE's Pathways program empowers women to more fully engage in equitable agriculture systems.
Empowering women to ensure family planning coverage, quality and equity
CARE's 2013 HIV/ and AIDS Capacity Statement
CARE's 2013 HIV and AIDS Capacity Statement
CARE's Approach to Sexual, Reproductive, and Maternal Health
A poverty-fighting program in Bangladesh helps children grow and underscores the need to empower women and girls worldwide.


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Innovation offers furniture that makes a difference in everyday life. Good design that combines style, comfort and functionality. Innovation is not just a name, but what we do. Combining decades of experience in the furniture business with an eagerness to evolve and surprise. In this way we can offer attractive and useful furniture for modern people.
� 2011 www.beemod.com , All rights reserved. Modern Furniture - BeeMod is UpFront


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The exclusive "Wasteland Beautiful" video below — a behind-the-scenes look at the making of the environments – shows what happens when nature starts reclaiming its territory, as dense foliage has begun overtaking the game's crumbling cities. The creative team at developer Naughty Dog discusses how light and shadow help create a believable, fully immersive world that despite the devastation, is beautiful in its own eerie way.
Oh WOW. Just environments here for those who don't like spoiler videos. The interesting thing in this video -- for me at least -- is the fact that we now see an unknown character dragging the ladder onto the bus. Is this perhaps the multiplayer?
Oh god, this has made the wait even more unbearable. This game could & proberly will be THE survival horror game of all time.
This game will set a new benchmark for survival horror of that iam certain.
Damn it June can't come soon enough. Really can't wait to get this this game. Naughty Dog and Retro Studios are among my favorite devs EVER because they but so much love into their work and it shows in every single game that they make.
I knew this would make ppl want the game even more. So beautiful.


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Posted by Editoress on 06/22/02
National Team Veteran Doug Baron retires
Courtesy CCA
Doug Baron of Calgary, a member of Canada's National Track Cycling Team since 1993, has made the difficult decision to retire from the National Team Program.
Over the years, Doug's success, both on and off the track, has been evident in everything he sets his mind to. His commitment to the National Team has always been unquestionable. His dedication to his job as a physical therapist, and to his wife and daughter Cassandra, remain his top priority.
Doug has been one of Canada's best sprinters on the track, demonstrated by his numerous National Sprint Champion titles. Over the past 9 years with the National Team, Doug has participated in many National Team projects, with outstanding results. Among the many international events Doug has participated in are the 1999 Winnipeg Pan American Games and the 1998 Malaysia Commonwealth Games
In his own words, here are Doug's feelings regarding his retirement: It is with mixed emotions that I announce my retirement from the National Track Cycling Team program.The past 9 years have been very rewarding for me. I have met many different people around the worldand made lifelong friendships. Although I am not able to train anymore at the intensity required forinternational competition, I will continue to race at the local level (maybe even nationals occasionally).As well, the possibility of coaching looms on the horizon. I wish to thank all the supporters that I have had over the years. My wife Lynn and the rest of my familyhave been very supportive of my endeavours. I want to recognise my personal sponsors as well.Oakley (eyewear/clothing), Paris Sport (Continental Tires) and Shimano (pedals and shoes) deserve to be mentioned here for providing awesome products over the years. Also, the national team sponsors provide us with bikes (Look/Devinci), wheels (Mavic), clothing (Louis Garneau) and financial suppor t(Tim Hortons). My current status with Sport Canada allows me to continue to receive financial support. I plan to support 2 young athletes who represent the future of the CCA in international competitions in thecoming years. In this way I hope to re-invest in a sport that I would love to see grow even bigger inCanada. I wish all the best to the entire team selected to the Commonwealth Games in July.
Cheers, Doug Baron
Canadian National Track Cycling Team
The CCA wishes Doug and his family all the best, and we look forward to our continuing relationship with him in the future.
Some of Doug's Results:
National Champion, Olympic Sprint
Gold - Pan Am Championships, Olympic Sprint
Silver - National Championships, Match Sprint & Keirin
4th - Pan Am Championships, Match Sprint
2000: National Champion, Sprint & Olympic Sprint
Bronze - National Championships, Kilo
Bronze - Pan Am Championships, Kilo & Keirin
14th World Olympic Sprint Championships
Pan Am Games 3rd Kilo; 4th Olympic Sprint; 7th Sprint
1st - Kilo, EDS Track Cup round 3
1999 Arvid Geldsetzer Memorial Track Meet: 1st - Match Sprint; 1st - Olympic Sprint; 1st - Kilo
1999 Bikeshevik Grand Prix: 1st - Match Sprint; 1st - Kilo
3rd - 500m TT and Match Sprint - Barbados Invitational
|Return to Canadian Cyclist homepage | Back to Top


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The Sunflower Fellowship is a Christian charity, set up to build and fund Casa Valentin; a staffed home in Romania providing a holiday for sick or underpriveleged children. It also provides a Social programme; allowing poorer school, and kindergarten children a good meal and help with homework, all in a loving, Christian environment. Click for more details...
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Registered Charity Office: 52 Hatch Road, Brentwood, Essex, CM15 9PX. Registered Charity No. 1090120.
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You are here
Pretty, Polished Garden in Illinois
A polished new garden design gracefully brings out the best of a grand property
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Homes along a particular historic road in Peoria Heights, Illinois, command breathtaking views of the Illinois River valley, but from the windows of Mary Ann and Denne Knell's handsome Georgian, the view across the garden to the vista beyond needed some improvement.
The Knells had lived in their home for 20 years when they asked Douglas Hoerr, a landscape architect in Chicago, to take a look at their property. The couple knew they wanted a more distinctive landscape, plus a pool in the back. "They were open to change," Hoerr says, "so I said, 'Let's just brainstorm.' "
Photography: Bob Stefko
Landscape architect: Douglas Hoerr
Before: Front of House
The house had beautiful lines, but the existing landscaping didn't take advantage of them. Hoerr's goals were to create a garden with strong bones that would look beautiful even in Peoria's snowy winters, and to extend the stately architecture of the house out into the landscape.
Existing foundation plantings did not do justice to the style of the house or enhance the views from inside, landscape architect Douglas Hoerr says.
After: Front of House
Hoerr fashioned a grand new entrance in keeping with the style of the house and the splendor of the view. By eliminating a driveway that ran all the way through the property to the next street, he made room for a formal entrance court, a comfortable new open-air living space, a 30-foot lap pool, and a gracious and useful circle drive by the garage in back.
In the new design, the architecture of the home extends into the landscape.
Cascading Flowers
Trailing annual fan flower (Scaevola) cascades from an urn near the front drive.
Before: River View
Mainting the striking view of the river was of upmost importance.
After: River View
Out front, "it was a sacred view," Hoerr says. "I had to treat it like artwork." He suggested an elegant planting of boxwoods, yews, and dwarf crabapples on either side of a wide approach laid with reclaimed granite street pavers and handsome granite curbs. The texture and gravity of the materials complement the home and give the scene depth; a smooth driveway would have made the house seem closer to the street. "It's a painterly convention," Hoerr says.
From the front door, the view across the formal parterre out into the sweeping vista of the Illinois River valley takes one's breath away.
Garden Gate
A wrought-iron gate at the side of the house separates the back and front gardens.
Backyard Rooms
Space at the back and partly along one side of the house, which lacked shade and was seldom used, became a world unto itself. Hoerr created a sheltered outdoor sitting room with a fireplace, a dining area open to the stars, and a lap pool punctuated at the corners with boxwoods, as neat as the buttons on a double-breasted coat. The geometry is strong and polished, but light and inviting.
"Everything is a little more fanciful in the back," Hoerr says. "More like a jewel box."
The seating and dining areas are on the same level but feel like separate rooms.
Seating Area
The outdoor sitting room is warmed by a fireplace, with a television concealed behind panels above the mantel.
Before: Pool Patio
The backyard was space ripe for opportunity.
After: Pool Patio
Three wide, gracefully curved steps and low walls separate the sitting and dining areas from the pool. The change in elevation "makes a big difference in how you experience the space," Hoerr says. Sinking the pool and the elegant patio around it makes the space appear larger than it really is.
Bluestone pavers with limestone accents connect the porch to the pool area. Crabapple trees, boxwoods, and yews echo the elegant design of the front-yard garden. Short, emphatic curves are repeated throughout the back garden area—in the brick walls between the dining area and pool, around flower beds near the gate, and in the patio's limestone accents.
Garden Door
Hoerr often starts with snapshots when he works with clients on projects, sketching right on top of the images to show how landscaping can transform the way a property is seen and used. Then his crew spray-paints the outline of a working design on the ground. Plantings can always be adjusted, he says, but the hardscaping has to be just right.
When it all comes together, as it did for the Knells, "it changed their perception of their own house, and brought them a lot of joy," Hoerr says. "I always love it when it works out that way."
Before: Back of House
A driveway along the side of the house took up a chunk of the back yard.
After: Back of House
The pool was enclosed for privacy and to meet building codes. To accomplish this, Hoerr set the pool in a walled garden.
Poolside Lounge Chairs
Chaises are arrayed on one side of the lap pool. Low walls and wide steps separate the pool and patio from the porch and dining area.
Poolside Jets
Water jets can be turned on when no one is swimming, turning the pool into a relaxing water feature.
Clean Boxwoods
Neatly trimmed boxwoods in urns anchor the corners of the pool.
Colorful Plantings
Violet 'Supertunia' petunias front Green Velvet boxwood.
Pink 'Knock Out' roses bloom all summer long.
A blue lacecap hydrangea blooms in shade in the new back garden.
Blooming Hosta
Pretty purple Hosta flowers stand at attention.
Homeowner Portrait
Homeowners Mary Ann and Denne Knell


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Thanks for the memories!
We asked you to share your favorite Aquarium moments with us, and here are just a few of the wonderful stories about inspiration, connection and love that you submitted. Your support over the past 30 years has helped the Aquarium flourish and we're so grateful.
"...loved seeing them together and the sense of wonder that the Aquarium inspires."
We LOVE the Aquarium and have many fond memories, but one of my favorites is from when my 81 year old grandmother flew in (by herself) from Arkansas to visit. I took her and my three-year-old daughter to the Aquarium and loved seeing them together and the sense of wonder that the Aquarium inspires.
Thank you for all that you do, inspiring awe in generations to come!
Stephanie Sanford
"Monterey Bay Aquarium is inspiring and helping grow tomorrow's scientists..."
We not only toured the Aquarium on our West Coast summer vacation, we participated in some of the morning feedings. Monterey Bay Aquarium is inspiring and helping grow tomorrow's scientists and problem solvers who also love the world they live in.
"...his enthusiasm and smiles were priceless!"
One of our favorite memories at the Monterey Bay Aquarium was our son participating in the underwater explorer program. Benjamin has autism. Not only are we very grateful he was given such a fantastic opportunity but his enthusiasm and smiles were priceless! ( He still has his underwater explorer book. He was 15 at the time he is 21 now.)
Thank you for the Memories Monterey Bay Aquarium.
David, Susan and Benjamin Flores
"...my wife and I fell in love with the Aquarium and, more importantly, its mission..."
I remember the day my wife and I fell in love with the Aquarium and, more importantly, its mission, like it was yesterday! We were both students just trying to make ends meet but it was important to us that we join and become members. Throughout the years as life and careers have become better for us we've increased our yearly contributions to the Aquarium. And despite living almost 400 miles away and some years not even being able to make it up there we love knowing that as Donors we help propel the mission of The Monterey Bay Aquarium. Thanks for all that you have done and will continue to do for our planet!
Brad Mattocks
"I saw a living being who needs to be protected, along with other ocean animals."
My most memorable moment was seeing a great white shark, in person, in the big tank. We've all seen these sharks in photos and movies, but the way they are normally portrayed makes us dislike these animals. Seeing one in person changed that. I saw a living being who needs to be protected, along with all the other ocean animals.
Kristi Muhic
"The Monterey Bay Aquarium has literally changed my day-to-day life, and been part of my happiest memories."
The Aquarium was a framework for my early love of the ocean. At the age of nine, my parents took me and I was enthralled by the kelp forest, loved the otters, and was amazed by the velvety feel of a ray. I became an advanced scuba diver in college, and participated in ocean conservation projects, all with the Monterey Bay Aquarium in my mind. I had my first date with my husband, as we sat and had a meal in the cafe overlooking the water. The Monterey Bay Aquarium has literally changed my day-to-day life, and been part of my happiest memories. Thank you.
Dr. Anne Kennard, Phoenix, AZ


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Diastolic dysfunction is associated with cardiovascular (CV) events in end-stage renal disease (ESRD) on continuous ambulatory peritoneal dialysis (CAPD). However, conventional measurement of LA volume and E/e' using Doppler echocardiography has been limited to predict CV events in patients with ESRD on CAPD.
From September 2007 to September 2008, 30 consecutive patients with exertional dyspnea in ESRD on CAPD and normal systolic function was prospectively enrolled and underwent laboratory testing, coronary angiography, and treadmill exercise stress echocardiography (TESE). We divided the patients according to the presence of exercise-induced change of E/e' tissue Doppler and investigated whether this factor predicted CV events in ESRD on CAPD.
Mean CAPD duration of all patients (70% male; mean age, 49 years) was 12 months. Patients with exercise-induced elevated E/e' (n = 12, 40%) and non-elevated E/e' (n = 18, 60%) demonstrated similar baseline characteristics. Exercise-induced elevated E/e' was predictable (cut-off value 14%, sensitivity 63%, and specificity 95%), with a hazard ratio of 1.13 (confidence interval, 1.03 to 1.24; p = 0.005), and significantly associated with CV events compared to the non-elevated E/e' group (log-rank, p = 0.007).
Diastolic dysfunction (DD) with normal systolic function is associated with increased cardiovascular (CV) events in patients with end-stage renal disease (ESRD) [1]. However, DD in ESRD may be under-diagnosed due to the changeable volume status and hemodynamic parameters in clinical settings [2,3]. The ratio of early diastolic mitral inflow velocity to early diastolic mitral annulus velocity (E/e') determined by using echocardiography has been used as a marker of DD [4]. In addition, E/e' by Doppler was also demonstrated to be a prognostic factor for CV mortality which is extended to be applicable in the real disease as previously reported [4-8]. However, in ESRD on continuous ambulatory peritoneal dialysis (CAPD), the value of the exercise-induced E/e' as a predictor for CV event has not been reported yet. Therefore, we investigated the change of E/e' during treadmill exercise stress echocardiography (TESE) and its association with CV events in ESRD patients on CAPD.
A total of 40 consecutive patients with exertional dyspnea who were treated with CAPD due to ESRD at Eulji University Hospital, Daejeon, South Korea between September 2007 and December 2008 were prospectively enrolled in this study. The study protocol adhered to the Declaration of Helsinki and was approved by the Institutional Review Board of Eulji University Hospital. Written informed consent was obtained from all patients. All patients underwent routine baseline chest radiograph, laboratory testing, electrocardiography, TESE, and coronary angiography. Among these patients, 10 among all patients were excluded for the following reasons: peritoneal dialysis duration < 3 months (n = 1), left ventricular (LV) systolic dysfunction (ejection fraction [EF] < 55, n = 5), severe valvular disease (n = 1), and significant coronary artery disease (n = 3).
Data collection
Patients' baseline and clinical characteristics such as age, sex, and comorbid conditions were recorded. At the same time, laboratory parameters such as hemoglobin serum albumin, blood urea nitrogen, creatinine, calcium, phosphorus, intact parathyroid hormone, and C-reactive protein were measured. A peritoneal equilibrium test (PET) was conducted, and dialysis adequacy and residual renal function were measured within 2 months after the initiation of CAPD. Equilibration ratios were measured with a standardized PET protocol that involved a 2-L 4.25% dextrose dwell with dialyzed samples taken at 0, 2, and 4 hours and a plasma sample at 2 hours.
Creatinine and urea nitrogen were measured in blood, urine, and drained dialysate. The residual glomerular filtration rate was calculated as the mean of urinary creatinine and urea clearances standardized to 1.73 m2 body surface area (BSA). Weekly Kt/V urea was calculated as the ratio of urinary and 24-hour dialysate urea clearance to total body water [9].
Coronary angiography
An invasive coronary angiogram was performed subsequently for evaluation of exertional dyspnea. The conventional Judkins' technique was used with at least four views of the left and two views of the right coronary artery. Lesions were examined in orthogonal views, and severity of luminal stenosis was determined by the consensus of two experienced cardiologists who performed quantitative assessment of stenosis severity using standard techniques.
Echocardiographic examinations were performed using an imaging protocol according to the American Society of Echocardiography recommendations [10,11]. This examination was performed in CAPD patients with an empty abdomen. Standard echocardiography analysis included two-dimensional, M-mode, and Doppler flow measurements and used commercially available ultrasound equipment (Acuson Sequoia, Siemens Medical Solutions, Mountain View, CA, USA; GE Vivid 7 and 9, GE Healthcare, Wauwatosa, WI, USA). The LV systolic function was determined from the LVEF using a modified biplane Simpson's method from apical two- and four-chamber views and systolic dysfunction was defined as EF < 55%. The LV mass was calculated by the method described by Devereux and Reichek [12]. The left ventricular mass index (LVMI) was calculated by dividing LV mass by BSA, and LV hypertrophy was defined as a LVMI > 131 g/m2 for men and > 100 g/m2 for women [13]. The left atrial (LA) volume was assessed by the biplane area-length method from apical four- and two-chamber views, with measurements obtained in end systole from the frame preceding mitral valve opening, and the LA volume was indexed for BSA. According to population-based studies, a value of 32 mL/m2 was considered the upper limit of normal left atrial volume index (LAVI) [14]. Mitral inflow was assessed with pulse-wave Doppler echocardiography from the apical four-chamber view. The Doppler beam was aligned parallel to the direction of flow, and a 1- to 2-mm sample volume was placed between the tips of the mitral leaflets during diastole. From the mitral inflow profile, peak E-wave velocity and its deceleration time, peak A-wave velocity, and the isovolumetric relaxation time were measured, and Doppler tissue imaging of the mitral annulus was also obtained. From the apical four-chamber view, a 1- to 2-mm sample volume was placed in the septal mitral annulus. An early mitral inflow velocity to peak mitral annulus velocity (E/e') ratio > 15 was regarded as indicating abnormally elevated LV filling pressure [6,15].
Treadmill exercise stress echocardiography
All patients underwent TESE with standard protocols (Bruce and modified Bruce) chosen as previously reported [16,17]. Post-exercise echocardiographic images were acquired within 30 to 60 seconds after the termination of treadmill exercise. Treadmill exercise was conducted according to the Bruce protocol in 20 patients, and modified Bruce protocol in 10 patients. Patients were asked to stop taking calcium channel blocker or β-blockers at least 12 to 24 hours prior to TESE. All patients exercised to exhaustion, irrespective of the achieved heart rate, and were asked not to hold on to the handrails. However, the test was terminated prematurely if patients developed severe chest pain, symptomatic hypotension, systolic blood pressure > 250 mmHg, significant arrhythmia, severe ST segment changes, or per the patient's request. Patients were monitored for heart rate, blood pressure, rhythm, symptoms, electrocardiogram changes, and rate of perceived exertion (on a 1 to 10 scale, with 10 indicating maximum exertion) at rest and at every stage of the exercise protocol. Exercise capacity in metabolic equivalents (METs; 1 MET = 3.5 mL/kg/min of oxygen consumption) was estimated on the basis of the protocol, speed, and grade achieved [18].
Clinical follow-up and cardiovascular events
Patients were divided into two groups: exercise-induced elevated E/e' (n = 12) and non-elevated E/e' (n = 18) by comparison baseline E/e' with E/e' after treadmill exercise in each patient. These groups were followed for CV events including CV death and heart failure (HF) hospitalization, which were monitored regularly on an outpatient basis.
Statistical analysis
Statistical analyses were performed using SPSS version 15.0 (SPSS Inc., Chicago, IL, USA) and MedCalc Software (Acacialaan, Ostend, Belgium). Continuous data were expressed as mean ± standard deviation, and categorical data were expressed as number (percentage). The two groups were compared by t test or chi-square test. The relationship between paired variables was analyzed using the Pearson sample correlation coefficient. Cumulative survival curves were generated by the Kaplan-Meier method, and between-group survival was compared by the log-rank test. Univariate analysis included clinical, echocardiographic and hemodynamic variables, and variables with a p < 0.15 in the univariate analysis were entered into the multivariate analysis. The independent prognostic value for CV event was analyzed by multiple Cox regression analysis. Hazard ratio (HR) and 95% confidence interval (CI) were calculated with the use of the estimated regression coefficients and standard errors. The predictive value for CV event was analyzed by receiver operating characteristic (ROC) curve analysis with calculated area under the ROC curve (AUC). All probabilities were two tailed, and the threshold for significance was set at 0.05.
Baseline and clinical characteristics
The comparison of baseline and clinical characteristics between the groups defined by elevated E/e' were shown in Table 1. Patients' mean age was 49 ± 10 years, and most (70%) were male. The primary etiology of ESRD was hypertension, and 73% of ESRD patients were also taking anti-diabetic medication (Table 2). No previous cerebrovascular disease exists in all patients. Body mass index, diastolic and systolic blood pressure, and heart rate were similar between the two groups. In addition, there was no significant difference in any baseline parameters except for triglyceride, including blood urea nitrogen, creatinine, high density lipoprotein cholesterol, low density lipoprotein cholesterol, total cholesterol, parathyroid hormone, calcium, total protein, albumin, cardiac biomarkers, and C-reactive protein (Table 2).
Treadmill exercise stress echocardiography
The baseline echocardiographic measurements and changes in these parameters after exercise are presented in Tables 3 and 4. In the comparison of echocardiographic findings including LVMI, LVEF, and LAVI were similar between the two groups. Hemodynamic parameters of TESE are shown in the Table 5. The average exercise capacity and exercise duration in all patients were 7.7 MET and 6.5 minutes. Heart rate and blood pressure were similar between the groups both at rest and upon exercise-induced elevation. In the exercise condition, diastolic A velocity and tricuspid annular plane systolic excursion were higher in the non-elevated E/e' group and lower in the elevated E/e' group, with a statistically significant difference between the groups, and LAVI was lower in the non-elevated E/e' group and higher in elevated E/e' group. Interestingly, the absolute value of post-exercise E/e' was not different between two groups, but delta E/e' was significantly elevated in the elevated E/e' group which is more important parameter to predict CV events.
Elevated E/e' as a predictor of clinical outcomes
During follow-up of 35 ± 6 months, six of 30 patients (20%) experienced CV events including cardiac death (n = 4; suspicious sudden cardiac death [n = 3] and suspicious decompensated HF [n = 1], 13%) or HF hospitalization (n = 2, 6%). The event rate of CV death was higher in the elevated E/e' group than in the non-elevated E/e' group (p < 0.001). Baseline and post-exercise E/e' were not significantly different between CV event-free and CV events group but exercise-induced change of E/e' was significantly higher in CV events group (Supplementary Table 1). The ROC curve for CV events indicated that elevated E/e' at a cut-off value of 14% was predictive of CV event with a sensitivity of 64% and specificity of 95% (AUC = 0.861 [0.686 to 0.959] with p < 0.001) (Fig. 1). Kaplan-Meier curve also representing a greater risk of CV events in the elevated E/e' group (log-rank test, p = 0.007) (Fig. 2). In the Cox proportional hazards model, conventional risk factors of ESRD including age, sex, hypertension, diabetes, hemoglobin, uric acid, brain natriuretic peptide, EF, and LAVI were analyzed. In the multivariate analysis, exercise-induced elevated E/e' was an independent predictor of CV events (HR, 1.135; 95% CI, 1.039 to 1.241; p = 0.005) (Table 6).
Our study suggests that exercise-induced elevated E/e' is feasible for predicting the occurrence of CV events and might be a useful predictor of CV events in ESRD on CAPD who have normal systolic function.
A previous study demonstrated that Doppler parameters can provide information about LV filling pressure [19]. However, controversy remains concerning which parameters, such as E/e' or LAVI, provide predictive information for DD and which parameter is a more powerful prognostic indicator of CV events. Integrating multiple Doppler-derived indices can be useful for the diagnosis and grading of DD. Therefore, integration of the E/A, E/e', and LAVI has been used by international consensus and recommendation to classify DD [20]. This grading DD was known to predict CV events only in the general population. However, recently, DD-associated CV events have also been investigated in ESRD [21,22]. These findings suggest that an assessment of DD using multiple echocardiographic indices can increase the predictive power for future CV events in ESRD patients. Recent reports have also shown that Doppler-derived E/e' may diagnose DD and predict CV events [4,23]. In the chronic kidney disease of stages III to V with DD, Kim et al. [8] also demonstrated that 5-year mortality rate was 60% and the increased E/e' significantly associated with CV events. In addition, Doppler-derived LA volume was reported to be significantly correlated with CV events in ESRD [24,25]. However, Doppler-derived E/e' and LAVI can vary according to the systemic volume status and heart rate in ESRD. Therefore, we tried to focus that the CAPD patients without CV disease was more stable than hemodialysis patients in the clinical status, which may not be influenced by several different factors such as the change of serum ionized calcium concentration, renal anemia, the presence of an arteriovenous fistula with high flow rate, sympathetic hyperactivity, increased oxidative stress, LA volume during hemodialysis treatment, LV compliance, and disease of smaller resistance vessels [14,26-29].
Ha et al. [30] and Bergeron et al. [31] demonstrated that patients with unexplained dyspnea have a high likelihood of CV events, and that exercise echocardiography provides independent information to identify patients at risk and evaluate diastolic HF in the general population. In addition, Wang et al. [21] also demonstrated that Doppler-derived E/e' estimation provided independent prognostic value for predicting long-term CV events in ESRD patients. Aljaroudi et al. [32] found that hypertrophic cardiomyopathy patients with worse DD had impaired exercise tolerance, with an odds ratio of 3.0 and suggested that TESE should remain a valid tool in the hypertrophic cardiomyopathy irrespective of baseline DD.
In our study, we selected stable CAPD patients with exertional dyspnea and minimized influencing factors such as coronary artery disease, cardiomyopathy, valvular heart disease, and LV dysfunction. We hypothesized that stable CAPD with exertional dyspnea may be correlated with the change of E/e' on TESE and divided patients into two groups accordingly: exercise-induced elevated E/e' and non-elevated E/e' groups. With prospective enrollment, the baseline and clinical characteristics were similar between the two groups, including baseline laboratory and echocardiography findings. Comparison of exercise-induced elevated E/e' and non-elevated E/e' revealed no significant differences except A velocity which may be explained by change of LA function on the stress exercise. In addition, Doppler-derived E' velocity in the elevated E/e' group was lower than that in the non-elevated E/e' group without statistically significance which explained by stress exercise-related influences on diastolic function such as worsening of LV stiffness and LV diastolic filling pressure. In addition, the change in LAVI significantly differed between the elevated E/e' and non-elevated E/e' groups, as previously reported [24]. In the ROC curve analysis, exercise-induced elevated E/e' demonstrated predictability for CV events, with sensitivity of 64%, specificity of 95% (cut-off value 14%), and AUC = 0.861 (0.686 to 0.959) with p < 0.001, as shown in Fig. 1. In multiple Cox regression analysis, exercise-induced elevated E/e' was the strongest predictor for CV events (HR, 1.13; 95% CI, 1.03 to 1.24; p = 0.005) (Table 4) and significantly associated with CV events compared to the non-elevated E/e' group (log-rank, p = 0.007) (Fig. 2).
This study has some limitations. First, we did not evaluate the exact volume status of study patients before and after CAPD with an objective tool, and it is possible that some patients will have experienced significant volume overload even after optimal peritoneal dialysis treatment. Second, the results are based on a small number of patients, and more patients should be examined in future studies. However, this study used a well-controlled prospective design in the specific ESRD on CAPD. Third, TESE results can show interobserver and intraobserver variability. Forth, definition of increased E/e' may be ambiguous, we focused on the arbitrary absolute value delta of E/e' after exercise compared with prior to exercise using by ROC curve analysis. Therefore, we suggested that increased delta 14% may be statistically significant cut-off value to discriminate the prediction of CV events in our study. However, large population study should be needed to confirm its value. Finally, the study observation of clinical follow-up should be sufficient to demonstrate CV events; but it was not enough to assess long-term effects. However, it may show the relative trend of CV events in ESRD on CAPD.
In conclusion, this study is the first to demonstrate that CAPD with exertional dyspnea who demonstrate exercise-induced elevated E/e' on TESE are at higher risk for the occurrence of CV events. In such patients, exercise-induced elevated E/e' by Doppler was feasible and could hold prognostic value for the occurrence of CV events in the future.
1. Treadmill exercise stress echocardiography was feasible for evaluation of exertional dyspnea with normal systolic function in the end-stage renal disease (ESRD) with continuous ambulatory peritoneal dialysis (CAPD).
2. Exercise-induced elevated E/e' by Doppler implicates prognostic value for the occurrence of cardiovascular events in the ESRD with CAPD.
Conflict of interest
This research was supported by Handok Pharmaceutical Co., Ltd., Republic of Korea.
Supplementary Materials
Supplementary Table 1.kjim-2016-254-supple1.pdf
Table 1.
Table 2.
Values are presented as mean ± SD or number (%).
eGFR, estimated glomerular filtration rate; PTH, parathyroid hormone; CRP, C-reactive protein; NT-proBNP, N-terminal prohormone of brain natriuretic peptide; ACEi/ARB, angiotensin converting enzyme inhibitor/aldosterone receptor antagonist; CCB, calcium channel blocker.
Table 3.
Values are presented as mean ± SD.
LVEDD, left ventricular end diastolic dimension; LVESD, left ventricular end systolic dimension; LVEDVI, left ventricular end diastolic volume index; LVESVI, left ventricular end systolic volume index; LVEF, left ventricular ejection fraction; LVMI, left ventricular mass index; LAVI, left atrial volume index; DT, deceleration time; RVSP, right ventricular systolic pressure; TAPSE, tricuspid annular peak systolic excursion.
Table 4.
Table 5.
Table 6.
1. Pecoits-Filho R, Bucharles S, Barberato SH. Diastolic heart failure in dialysis patients: mechanisms, diagnostic approach, and treatment. Semin Dial 2012;25:35–41.
2. Scharer K, Schmidt KG, Soergel M. Cardiac function and structure in patients with chronic renal failure. Pediatr Nephrol 1999;13:951–965.
3. Mitsnefes MM, Daniels SR, Schwartz SM, Meyer RA, Khoury P, Strife CF. Severe left ventricular hypertrophy in pediatric dialysis: prevalence and predictors. Pediatr Nephrol 2000;14:898–902.
4. Hillis GS, Moller JE, Pellikka PA, et al. Noninvasive estimation of left ventricular filling pressure by E/e' is a powerful predictor of survival after acute myocardial infarction. J Am Coll Cardiol 2004;43:360–367.
5. Mehrotra P, Labib SB, Schick EC. Differential effects of dobutamine versus treadmill exercise on left ventricular volume and wall stress. J Am Soc Echocardiogr 2012;25:911–918.
6. Burgess MI, Jenkins C, Sharman JE, Marwick TH. Diastolic stress echocardiography: hemodynamic validation and clinical significance of estimation of ventricular filling pressure with exercise. J Am Coll Cardiol 2006;47:1891–1900.
7. Tita C, Karthikeyan V, Stroe A, Jacobsen G, Ananthasubramaniam K. Stress echocardiography for risk stratification in patients with end-stage renal disease undergoing renal transplantation. J Am Soc Echocardiogr 2008;21:321–326.
8. Kim MK, Kim B, Lee JY, et al. Tissue Doppler-derived E/e' ratio as a parameter for assessing diastolic heart failure and as a predictor of mortality in patients with chronic kidney disease. Korean J Intern Med 2013;28:35–44.
9. Cannella G, Paoletti E, Ravera G, et al. Inadequate diagnosis and therapy of arterial hypertension as causes of left ventricular hypertrophy in uremic dialysis patients. Kidney Int 2000;58:260–268.
10. Devereux RB, Lutas EM, Casale PN, et al. Standardization of M-mode echocardiographic left ventricular anatomic measurements. J Am Coll Cardiol 1984;4:1222–1230.
11. Garcia MJ, Thomas JD, Klein AL. New Doppler echocardiographic applications for the study of diastolic function. J Am Coll Cardiol 1998;32:865–875.
12. Teichholz LE, Kreulen T, Herman MV, Gorlin R. Problems in echocardiographic volume determinations: echocardiographic-angiographic correlations in the presence of absence of asynergy. Am J Cardiol 1976;37:7–11.
13. Unger P, Wissing KM, de Pauw L, Neubauer J, van de Borne P. Reduction of left ventricular diameter and mass after surgical arteriovenous fistula closure in renal transplant recipients. Transplantation 2002;74:73–79.
14. Foley RN, Parfrey PS, Kent GM, Harnett JD, Murray DC, Barre PE. Serial change in echocardiographic parameters and cardiac failure in end-stage renal disease. J Am Soc Nephrol 2000;11:912–916.
15. Galderisi M. Diastolic dysfunction and diastolic heart failure: diagnostic, prognostic and therapeutic aspects. Cardiovasc Ultrasound 2005;3:9.
16. Cole CR, Blackstone EH, Pashkow FJ, Snader CE, Lauer MS. Heart-rate recovery immediately after exercise as a predictor of mortality. N Engl J Med 1999;341:1351–1357.
17. Arruda-Olson AM, Juracan EM, Mahoney DW, McCully RB, Roger VL, Pellikka PA. Prognostic value of exercise echocardiography in 5,798 patients: is there a gender difference? J Am Coll Cardiol 2002;39:625–631.
18. Jette M, Sidney K, Blumchen G. Metabolic equivalents (METS) in exercise testing, exercise prescription, and evaluation of functional capacity. Clin Cardiol 1990;13:555–565.
19. Pritchett AM, Mahoney DW, Jacobsen SJ, Rodeheffer RJ, Karon BL, Redfield MM. Diastolic dysfunction and left atrial volume: a population-based study. J Am Coll Cardiol 2005;45:87–92.
20. Nagueh SF, Appleton CP, Gillebert TC, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr 2009;22:107–133.
21. Wang AY, Wang M, Lam CW, Chan IH, Zhang Y, Sanderson JE. Left ventricular filling pressure by Doppler echocardiography in patients with end-stage renal disease. Hypertension 2008;52:107–114.
22. Duran M, Unal A, Inanc MT, Esin F, Yilmaz Y, Ornek E. Effect of maintenance hemodialysis on diastolic left ventricular function in end-stage renal disease. Clinics (Sao Paulo) 2010;65:979–984.
23. Rosello A, Torregrosa I, Solis MA, et al. Study of diastolic function in peritoneal dialysis patients: comparison between pulsed and Tissue Doppler. Nefrologia 2007;27:482–488.
24. Kim SJ, Han SH, Park JT, et al. Left atrial volume is an independent predictor of mortality in CAPD patients. Nephrol Dial Transplant 2011;26:3732–3739.
25. Park HJ, Jung HO, Min J, et al. Left atrial volume index over late diastolic mitral annulus velocity (LAVi/A') is a useful echo index to identify advanced diastolic dysfunction and predict clinical outcomes. Clin Cardiol 2011;34:124–130.
26. Gulel O, Soylu K, Yuksel S, et al. Evidence of left ventricular systolic and diastolic dysfunction by color tissue Doppler imaging despite normal ejection fraction in patients on chronic hemodialysis program. Echocardiography 2008;25:569–574.
27. Fatema K, Hirono O, Takeishi Y, et al. Hemodialysis improves myocardial interstitial edema and left ventricular diastolic function in patients with end-stage renal disease: noninvasive assessment by ultrasonic tissue characterization. Heart Vessels 2002;16:227–231.
28. McIntyre CW, Burton JO, Selby NM, et al. Hemodialysis-induced cardiac dysfunction is associated with an acute reduction in global and segmental myocardial blood flow. Clin J Am Soc Nephrol 2008;3:19–26.
29. Weiner DE, Tighiouart H, Vlagopoulos PT, et al. Effects of anemia and left ventricular hypertrophy on cardiovascular disease in patients with chronic kidney disease. J Am Soc Nephrol 2005;16:1803–1810.
30. Ha JW, Oh JK, Pellikka PA, et al. Diastolic stress echocardiography: a novel noninvasive diagnostic test for diastolic dysfunction using supine bicycle exercise Doppler echocardiography. J Am Soc Echocardiogr 2005;18:63–68.
31. Bergeron S, Ommen SR, Bailey KR, Oh JK, McCully RB, Pellikka PA. Exercise echocardiographic findings and outcome of patients referred for evaluation of dyspnea. J Am Coll Cardiol 2004;43:2242–2246.


text:
Let $D$ be a square free integer. I am looking at primes representable as $x^2+Dy^2$, where $x,y\in\mathbb Z$. I wonder whether it is always true that this set of primes is the union of finitely many arithmetic progressions intersected with the set of all primes?
This looks like a classical questions but I could never find an answer. It is certainly true if $\mathbb Z[\sqrt D]$ is a principal ideal domain. I think I had a proof in the case of class number two but I cannot remember it. It is of course true if one looks at norms of ideals rather than norms of elements but this is not what I want.


text:
August 10, 2010
Iwashi Shoyuyaki: Sardines in soy sauce
I adore sardines, those unbelievable tasty, full of omega-3's, take-me-back-to-the -Mediterranean fish that I've cooked (and blogged about) quite a few times before: Finnish way with vodka, in a casserole as a substitute to Baltic Herring, I've stuffed them with parmesan and I've also crispy fried them with haloumi. That said I have probably well and truly proved my love for sardines, but my sardine recipe collection would not be complete without the Japanese version.
This recipe is from one of my favourite Japanese blogs Kyoto Foodie.
Iwashi Shoyuyaki (Sardines sauteed in soy sauce)
8 sardines, cleaned & butterflied (for excellent step-by-step instructions on how to clean sardines, see this page)*
a thumb size piece of ginger, chopped
4 tbs cooking sake
1 tbs mirin
2 tbs soy sauce
olive oil for frying
cooked brown rice, to serve
*I usually buy sardines frozen, but if you can, use fresh fish.
Heat the oil in a frying pan, add the sardines and the ginger. Saute for a few minutes. Turn the sardines over and continue on the other side. Add sake, mirin and soy sauce and let simmer for a further few minutes until the sauce slightly thickens and the fish has cooked through. Serve the fish on a bed of brown rice with the sauce and the ginger.
10 comments:
You know, I love sardines but have never cooked with them. If they come frozen, then I will seek them out - your recipe looks so simple yet tasty.ReplyDelete
Wow how simple - the sardines have such a lovely strong flavour of their own I guess you don't have to do anything too complicated with them - this looks so fresh and tasty - lovely photosReplyDelete
Maria, these look delicious. I usually don't go for sardines but I think these would definitely change my mind! :DReplyDelete
Only recently tried sardines and thought they were quite tasty, I don't count the canned variety my parents fed me in my younger years as an experience.ReplyDelete
I've heard sardines are quite hard to fillet due to their small size and fine bones - how long did it take you for this lot?ReplyDelete
I have yet to cook with sardines. I keep meaning to, but it just hasn't happened yet.ReplyDelete
I like the simplicity of this recipe and I think you've motivated me to finally try them.
btw...I can't believe those fish in your photo are defrosted sardines, they look so fresh!
I love sardines, they tend to have a awesome flavor. And the palette looks very inviting.ReplyDelete
I love the shot of the whole fish! your making me scrounge around for all my japanese cookbooks. I think another cookbook re-arranging is in order.ReplyDelete
yum! sardines have such a strong flavour that it's gotta be cooked right. I'm sure you've done it perfectly!!! I just eat the ones from the can doused in tomato sauce hehehe :)ReplyDelete
Very healthy and delicious!ReplyDelete


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River restoration project near prison supported by Waikato Regional Council
Prisoners will be growing and planting eco-sourced trees for a project given $126,750 by Waikato Regional Council's Natural Heritage Fund.
Prisoners will be growing and planting eco-sourced trees for a project given $126,750 by Waikato Regional Council's Natural Heritage Fund.
The health warning issued last week for parts of Lake Taupō has now been lifted by the Medical Officer of Health.
NIWA is fast-tracking analysis of samples collected from potentially toxic algae-affected sites at Lake Taupō, with results expected on Friday.
Samples collected from Acacia Bay for testing for toxin-producing algae species, but weather hampers monitoring work at other sites at Lake Taupō today.
The local Medical Officer of Health is reminding the public to exercise caution when looking to cool off in Lake Taupō.
A toxin-producing species of algae bloom has been identified during provisional screening of samples collected from Halletts Bay over the weekend.
Waikato Regional Council staff have collected samples from algae blooms found during an inspection of south-eastern Lake Taupō swimming sites this weekend.
Dense mats of potentially toxic algal species have been found at five sites around Lake Taupō.
At Waikato Regional Council staff have got each other's backs.
The arrival of warm, humid days means velvetleaf and other nasty weeds will be starting to appear on farms.
Waikato Regional Council scientists believe fish deaths in the Waiomu Stream on the Coromandel Peninsula over the weekend are likely due to natural causes.
Waikato's multiagency regional transport committee issues a plea to motorists to take extra care on the roads with the Christmas holiday period almost upon us.
The Waitekauri River in the region's east has had a cut of almost 20 per cent in levels of E. coli bacteria every year for the past 10 years.
Community groups are being praised for efforts to combat kauri dieback.
Two former directors of a failed piggery operation, which posed a significant risk to the environment, have been convicted and fined thousands of dollars each.
Open day for Lake Waikare and Whangamarino wetland.
A multi-agency steering group has been set up to tackle the damaging agricultural pest velvetleaf in the Waikato region.
Farmers are being encouraged to get ahead of the game and prepare now for whatever final new environmental rules are rolled out for Waikato and Waipa rivers.
Harbourmasters say heed boating safety messages over bar crossings or risk death and serious injury.
It's been 20 years since Ruben the Road Safety Bear launched. His look might have changed, but the foundation road safety skills he teaches hasn't.


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TMC - Technology, Media & Telecommunications
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Deer hunter killed in southeast Missouri
The Associated Press
CENTERVILLE, Mo. (AP) — A southeast Missouri sheriff says the weekend killing of a deer hunter was purely accidental.
KFVS-TV reports (http://bit.ly/XtRzi5 ) the 50-year-old man was among a group of hunters who went out Sunday morning in Reynolds County.
Sheriff Tom Volner says the hunters had fanned out when the victim was shot and killed by another member of the group from about 50 to 75 yards away.
The sheriff says the victim was not wearing any orange clothing and had a white beard. He says the shooting is not considered suspicious.
The man's name was not released. The shooting happened near the small town of Lesterville, not far from the county seat of Centerville.
Information from: KFVS-TV, http://www.kfvs12.com
Copyright 2012 The Associated Press.


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The Identipen Markers by Sakura are not acid-free. These markers contain alcohol solvents.- Answered by MisterArt on 17-Dec-12
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Board chair Jonathan RosenbergSecretary Linda MokraneV. Chairs S Brade Julie BundyCEO Andy WatsonEstablished 1990Member of: NHF HOS HCA L3939Local authority: City of Westminster
WECH - A Community Land TrustPrivacy Policy | Cookie PolicyTerms & Conditions | Site MapEmergency Gas leaks 0800 111 999Emergency out of hours contacts:JUST 24/7 Ltd 020 8979 2220K&T for Heating 020 8269 5995
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Luhrs 28
Have It Your Way The Luhrs 28 Open is a perfect balance of fisherman and family-friendly design.From the smart,functional layout to the wealth of std features like the livewell and washdowns,everything about the 28 Open is designed to provide you with all the versatility you need. The sculpted lines,Carolina flare and gently rising sheer are about more than just a stylish custom look-they all contribute to the boat's exceptional bluewater handling and comfortable, dry ride. Whether you 're a hardcore competitor or just looking for a fantastic family outgoing,the Luhrs 28 Open truly delivers.
Call now and live your dream!!
Dimitris Sakellariou
Sales Director
M / WhatsApp:+30 694 694 5267
Website: www.bluegame.it
Agios Dimitrios, P.O.Box 2540


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Derek Jeter Gossip
Derek Jeter gossip, latest news, photos, and video.
Smutty Social Media, February 13, 2017
Wenn, FameFlynet, Kevork Djansezian/ John Shearer/ Jeff Kravitz/ Getty Images
When your twin is also having a fire year. (I really like Riz even though I couldn't get through The Night Of.) Met my 🇬🇧 twin last night #WeGetTheJobDone pic.twitter.com/TbgO4sDeLc Full Story
Ben Affleck at the ESPYs
GONZALO/ Bauergriffin.com/ Splash News, Kevin Mazur/ Kevin Winter/ Getty Images
Ben Affleck was a surprise guest at the ESPYs last night, graciously presenting to Derek Jeter. By the way, Jeter walked the carpet with Hannah Davis. I saw her before I saw him, because holy sh-t, you can't not notice her face. It's incredible. As you can see, Ben was wearing his ring on stage. Full Story
Derek & Hannah: MET Substitute for Tom & Gisele
Jamie McCarthy/ Dimitrios Kambouris/ Larry Busacca/ Getty Images
I'm still not over the fact that Tom Brady and Gisele Bundchen weren't there. Instead we got Derek Jeter and Hannah Davis. OK. I can work with this. Because… I can't remember the last time Derek Jeter walked a red carpet with a girlfriend. And he never, ever walked the MET Gala with Minka Kelly. Full Story
Dear Gossips,
Derek Jeter will play in his final MLB all-star game tonight. And everyone is making a big deal of it (because he IS a big deal, and has been for 20 years)...except Derek Jeter. Which is so Derek Jeter. To honour Jeter's career, Nike put out an ad, celebrating two decades of his talent, featuring some very big names. Read Full Intro
Minka & Derek holiday in Paris
They confirmed their split in August. By October he was back in South Beach with her and a reconciliation was inevitable. Click here. Then Charlie's Angels was cancelled, eliminating one reason, maybe the only reason, for them to be apart. So here are Minka Kelly and Derek Jeter over the holiday in Paris and in love. Full Story
Minka & Derek back together?
After the Yankees lost game 5 of the ALDS last Thursday, Page Six that Derek Jeter was seen with his ex-girlfriend Minka Kelly in Miami where she's been working on Charlie's Angels. It was breakfast. You know. Some sources say they're talking about reconciling, others say it's friendship strictly. Full Story
Minka Kelly & Derek Jeter split
I like Derek Jeter a lot. I like the way he conducts himself professionally. I like how he plays his game. I like his consistency. I like his drive. I like that he didn't have 5 kids by the time he was 22. This is always what I say to Jacek about hockey players. I don't know if it's the small town-ness of hockey players but so many of them have 5 kids before they turn 25. Full Story
Manslinger fan recognition
Thanks to Nancy for sending this along… The photo came with this caption: Baseball fan Chris Sessa holds a sign with a picture New York Yankees' Alex Rodriquez and Kate Hudson during a ticker-tape parade along Broadway celebrating their 27th World Series championship on Friday, Nov. Full Story
Kate, Minka…and Chace?
The Yankees celebrated their World Series victory last night at 1Oak and their WAGs were invited. All the ladies, and Chace Crawford too. Because he's, like, so totally into sports. Please. Chace is barely qualified to hold Matsui's bat. Still… a man party is a man party and Chace has man bangs he wants to show off. Full Story
Major League Upgrade
Minka Kelly once dated Taylor Kitsch – first season of Friday Night Lights. It's hard to follow up on Taylor Kitsch. And her subsequent romance with John Mayer failed in that regard. Happily their hook up was shortlived. And like Jessica Simpson before her, Minka too has found herself a athletic upgrade even MORE impressive than Porny's. Full Story


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I thought I'd share a new Cars and Coffee for the Portland/Vancouver metro area that we are calling Cascade Cars and Coffee Portland.
It is being held every Saturday the whole year RAIN OR SHINE with roll-in at 8am and will last until at least 10am. The location is the Cascade Station Starbucks by the Portland International Airport just off I-205.
10119 NE Cascades Parkway, Portland, OR 97220 - Google Maps
10119 Northeast Cascades Parkway
Portland, OR 97220
In addition to sweet cars there's Starbucks, Quiznos, Jamba Juice, IHOP, Buffalo Wild Wings, Famous Dave's BBQ, shopping and more!
Hope to see some sweet cars and enthusiasts there!


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Your best bet if you want a courtside seat to watch the Macy's building be demolished on Sunday is if you know someone who owns a property nearby.
City officials say there will be no "safe viewing site lines" to watch the demise of the 10-story structure at 1110 Main. Swamplot posted a map showing where you'll run into blockades.
Street closures from Fannin to Milam and from Polk to McKinney will start at 6 a.m. The implosion is scheduled for 10 minutes after sunrise (7:10 a.m.) on Sunday.


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Wealthfront Inc., an online financial advisory firm, is in talks to raise about $30 million in a round of financing led by Index Ventures, according to people familiar with the situation.
The fundraising, which also includes new investors such as Ribbit Capital, is at least two weeks away from closing and final terms could change, said the people, who asked not to be identified because the discussions are private. The Palo Alto, California-based company is set to be valued at about $300 million, said one of the people.
Online financial startups have become a popular venture capital category in recent years, with new companies specializing in peer-to-peer lending and mobile payments springing up to challenge banks and credit card companies. In November, LendingClub Corp. received a secondary investment that valued the largest U.S. peer-to-peer-lender at $2.3 billion. Mobile finance startup Check Inc. raised $24 million in September.
In 2013, financial-services startups attracted $550.7 million, twice as much as the prior year and the most since 2007, according to the National Venture Capital Association.
Andy Rachleff, Wealthfront's executive chairman, didn't return requests seeking comment. Amy Sezak, a spokeswoman for Index Ventures, didn't return a call for comment.
KaChing's Birth
Founded in 2008 by former venture capitalist Rachleff, Wealthfront was earlier named KaChing and billed itself as a investor talent discovery service. The company, renamed Wealthfront in 2010, now uses software to balance investors' portfolios among different asset classes, mostly through index funds.
The startup targets technology executives in Silicon Valley who are looking for an alternative to traditional financial services. The minimum investment is $5,000, and the fee is 0.25 percent of assets per year. That compares with the $1 million minimum and 1 percent-plus fee of a typical wealth manager.
Wealthfront has raised $30 million in the past from investors, including Greylock Partners.
–With assistance from Ari Levy and Peter Burrows in San Francisco.


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Cracked Out Chicken Pasta - chicken, and bacon tossed in a quick homemade cheesy ranch sauce! Ready in under 15 minutes. Such an easy weeknight meal!! Everyone in the family loves this! Serve with a salad and some crusty garlic bread - so delicious! We make this all the time!
Chicken Ranch Pasta - Crack Chicken Pasta
- 8-ounces penne pasta
- 1 Tbsp butter
- 1 Tbsp flour
- 2 Tbsp dry ranch dressing seasoning mix
- 2 cups milk
- 1 cup shredded cheddar cheese
- 1/3 cup cooked, chopped bacon
- 2 cups cooked chopped chicken
- In a large pot, cook pasta according to package directions. Drain and set aside.
- In same pot melt butter. Add flour and stir. Cook flour for 1 minute. Slowly whisk in milk. Continue cooking until sauce thickens. Stir in ranch dressing mix and cheese. Stir until cheese melts. Add chicken, bacon and pasta. Stir to coat.


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Former CSU star Becky Hammon again named one of WNBA's all-time greats
Becky Hammon left Colorado State with several major scoring and assist records in hand. She dominated college basketball as a Rams star.
And the WNBA didn't notice. Hammon went undrafted in 1999.
So she MADE them notice. Hammon signed as a free-agent with the New York Liberty. She went on to play with the team through 2006, then was traded to the San Antonio Silver Stars where she's played since 2007.
An ESPN panel on Friday listed Hammon as one of the greatest WNBA players in the league's history.


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BOULDER, CO - May 9, 2006
Spyware staged a significant counterattack during the first quarter of 2006, according to latest State of Spyware report issued today by Webroot Software, the leading anti–spyware developer. A dramatic rise in the prevalence of adware combined with a significant increase in the most malicious types of Trojans and system monitors resulted in the highest consumer infections rates since the first quarter of 2005.
According to the report, the first quarter of 2006 saw a 15 percentage point jump in the share of consumer PCs infected with spyware: from 72 percent in Q4 2005 to 87 percent in Q1 2006. The average instances of spyware on infected machines increased 18 percent over the previous quarter to an average of 29.5 instances of spyware per infected PC, up from 24.9 instances in Q4 2005. Webroot also witnessed a significant rise in Trojan horse infection rates with an increase to 29 percent, up from 24 percent during the fourth quarter of 2005. The overall incidence of the most prevalent Trojan horse, Trojan–Downloader–Zlob, doubled during the first quarter.
"These alarming figures illustrate that spyware is a problem that Internet users are going to be battling for years to come," said C. David Moll, CEO of Webroot Software. "Spyware has proven itself as more than a simple 'flash in the pan' security threat. This is a real threat that is financially motivated and will not stop spreading. It is imperative that users protect themselves with a proven anti–spyware solution that offers superior blocking, deploys frequent updates and protects against the most dangerous types of keyloggers, system monitors and Trojans."
Most surprising – and perhaps most alarming – is the dramatic rise in the prevalence of adware during the last quarter. Despite recent litigation and legislation designed specifically to thwart the efforts of unlawful adware vendors, Webroot recorded that the percentage of PCs with adware increased to 59 percent, up from 45 percent in the last quarter of 2005.
"The significant rise in the prevalence of adware should be received as evidence that adware vendors have found new channels of distribution and new infection methods, in spite of the industry's best efforts to legitimize the practice," said Moll.
Within the enterprise, the average instances of spyware on infected PCs held steady at 21.5. The consistent number of Trojans may indicate that many enterprises still rely on legacy anti–virus programs or perimeter anti–spyware solutions to protect their networks. Unfortunately, the large economic potential of a spyware–infected enterprise to a spyware developer is driving an innovation cycle that is greatly outpacing these limited defenses.
"Businesses have a serious responsibility to ensure their proprietary assets and employees' personal information is safeguarded," continued Moll. "Our research shows that the most malicious types of spyware – Trojan horses and system monitors – are becoming increasingly sophisticated in how they penetrate and attack networks. Therefore, enterprises and SMBs must be sure they have best–of–best anti–spyware protection before they consider themselves safe."
This latest edition of the State of Spyware report comes on the heels of the release of Webroot's "Spyware & Small Business", an informative guide developed exclusively for small and medium–sized businesses to educate and inform them on the massive risks spyware poses to their company's networks and assets. In preparation for this guide, Webroot found that more than 50 percent of SMBs experienced a spyware attack during the first quarter of 2006. Smaller businesses are especially attractive to spyware criminals due to their often limited IT resources and lack of network security. The ramifications of these spyware attacks are particularly disturbing. Sixty–five percent of affected SMBs experienced slowed system performance, 58 percent reported a reduction in employee productivity, 35 percent experienced a negative impact on their bottom line and 20 percent reported a loss in sales.
The State of Spyware report is issued quarterly as an in–depth review and analysis of the impact of spyware, adware and unwanted software on consumers and enterprises. The foundation for much of the analysis and trends reporting comes from Webroot's consumer and corporate SpyAudit tools and from online research culled by Phileas, Webroot's automated spyware research system. The SpyAudit tools invite both consumers and enterprises to scan specific PCs and determine spyware infection levels.
The complete State of Spyware Report is available at www.webroot.com/sosreport.


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The fish can be served on top of the vegetables along with rice pilaf and garnished with parsley. Salmon or chicken breast can be used in place of red snapper.
Nutrition Facts
Ingredients and Preparation
- In a large skillet, heat olive oil over medium heat. Add onion, red pepper, carrot, and garlic. Sauté 10 minutes. Add wine and bring to boil. Push vegetables to one side of the pan.
- Arrange fillets in a single layer in center of skillet. Cover. Cook for 5 minutes.
- Add tomato and olives. Top with cheese. Cover. Cook for 3 minutes, or until fish is firm but moist.
- Transfer fish to serving platter; garnish with vegetables and pan juices.