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Table of Contents
- Acute HIV Infection and the Sexual Transmission of HIV
- Prevention as Part of Clinical Care
- Negative Results From a Quality-Improvement Study
- Directly Observed Therapy in the United States?
- Histoplasmosis Maintenance Therapy Can Be Stopped After Immune Recovery
- What Happens After PI Failure?
- Exactly How Does the Immune System Fit Into the ART Equation?
- A Possible Explanation of How GBV-C Infection Might Inhibit HIV Replication
- Is HAART Less Effective Against HIV-2 Infection in the United States?
- Use of Nelfinavir for HIV-1 Type C Infection
- The International AIDS Disaster: Which Route Will China Take?
- Joint Problems With HIV Infection -- Yes and No
- References
Acute HIV Infection and the Sexual Transmission of HIV
An increased rate of syphilis in men who have sex with men (MSM) in the United States,1 plus a possible increase in new HIV infections,2 clearly mean that our HIV prevention efforts are failing. This study underscores the importance of increasing HIV awareness among high-risk populations, and awareness of the role played by recently infected persons in transmitting HIV to others.
Pilcher CD, Tien HC, Eron JJ, et al, for the Quest Study and the Duke-UNC-Emory Acute HIV Consortium. Brief but efficient: acute HIV infection and the sexual transmission of HIV. J Infect Dis. May 15, 2004;189(10):1785-1792.
This interesting study from North Carolina researcher Christopher Pilcher et al assessed concurrent blood and semen HIV-1 concentrations in 30 men experiencing acute HIV infection who were participating in 2 large, acute-infection cohorts. All of the semen samples were obtained 14 to 84 days (median 38 days) after the estimated time of infection. Semen HIV-RNA levels in that group were significantly higher (mean 4.1 log copies/mL) than those in a comparison group of patients with chronic HIV infection (mean 3.49 log copies/mL; P = .04). Semen levels were significantly higher during the initial stage than in the later stages of acute infection (P<.01). In addition, over time, acute-infection semen and blood HIV levels were significantly correlated.
The authors creatively constructed a model examining HIV-1 levels in semen. This model was used in conjunction with a previously published probabilistic model of male-to-female transmission of HIV-1 as a function of R5 HIV levels in ejaculate and CCR5 receptor cell levels in cervicovaginal tissues.3 This model assumes that R5 (or macrophage-tropic) HIV is responsible for most heterosexual transmission of HIV, and that the R5 receptor density on the surface of susceptible cervicovaginal tissue relates to the risk for HIV acquisition.
The results of this study confirm that men are hyperinfectious during acute HIV infection due to increased genital shedding of HIV. The model suggests that the probability of HIV transmission is 8- to 10-fold higher 20 days after infection (when HIV-RNA levels peak) than after the viral set point has been reached (>day 54 after infection).
Depending on the frequency of intercourse, men could infect 7-24% of their susceptible female partners during the first 2 months of their HIV infection. (This study just looked at heterosexual transmission models.) The rate of transmission would be even higher in the presence of a sexually transmitted disease (STD) in either partner.
An additional conclusion from the study was that in the absence of an STD, HIV viral dynamics and blood levels mirror those in the genital tract. To prevent additional HIV infections, this study clearly emphasizes how critical both behavioral and antiretroviral interventions are for the recently infected.
Prevention as Part of Clinical Care
Clinicians are in a unique position to prevent HIV infections. Given the increased rates of syphilis and new HIV infections among MSM in the United States, it is important that clinicians become involved. But how do we incorporate prevention counseling into the typically hectic setting of a clinic? The following timely study from 6 Californian clinics and the U.S. Centers for Disease Control and Prevention provides a useful blueprint for clinic-based HIV prevention counseling.
One concern I have with the practical implications of this study is that adding even another 3 to 5 minutes per patient would be difficult in already overstretched clinic schedules. Ideally, having another healthcare provider responsible for the prevention message would be more expedient, although, in our currently collapsing healthcare system, it's unlikely we'll be able to find the funds to pay for that.
Richardson JL, Milam J, McCutchan A, et al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: a multi-clinic assessment. AIDS. May 21, 2004;18(8):1179-1186.
How, or even whether, to include safe-sex counseling during HIV clinic visits are subjects that have never received enough attention. In this study, investigators recruited 585 sexually active, HIV-infected persons seen at 6 HIV clinics in California. Three different approaches to safe-sex counseling were used (2 clinics used each of the 3 approaches).
One approach used something called "gain-framed" counseling that emphasized the positive benefits of practicing safer sex (i.e., emphasizing the benefits for patients of protecting themselves and others from STDs or superinfection with other strains of HIV). Another approach used a "loss-framed" counseling strategy that emphasized the negative consequences of unsafe sex (i.e., encouraging patients to make choices that do not put themselves or others at risk). The third approach, termed "attention control," emphasized adherence to antiretroviral therapy (ART).
Providers and clinic staff were trained to deliver the counseling intervention that the researchers had randomly assigned to their clinic. The intervention was then delivered during a 10- to 11-month period in 1999-2000. A trained interviewer made baseline behavior assessments prior to the intervention period. The cohort was then reassessed during a period of up to 7 months after the intervention ended.
The intervention was called "Partnership for Health," emphasizing the importance of the provider-patient relationship in helping the patient to stay as healthy as possible. The counseling period, which occurred during regular clinic encounters, was brief (3 to 5 minutes) and was given at all visits except those related to acute medical problems. Every patient received similar written materials. The primary outcome measure was the self-reported rate of unprotected vaginal or anal intercourse with any partners during the previous 3 months. For subjects who had just 1 baseline sexual partner, there were no significant changes after the intervention for any of the 3 groups. Among subjects with 2 or more baseline sexual partners, the rate of unprotected vaginal or anal intercourse decreased by 4% in the attention-control group, increased by 10% in the gain-framed group (P = .64), and decreased by 38% in the loss-framed group (P<.001).
The authors note4 that 36-63% of all HIV-infected adults in the United States receive ongoing medical care, and that this population is responsible for transmitting a significant percentage of HIV infections in the United States, powerfully underscoring the need to carry out more prevention interventions in HIV clinics.
According to the results of this study, the loss-framed counseling technique, as employed by a provider, appears to capture a patient's attention more strongly than the other 2 approaches. Combining both the gain- and loss-framed techniques is another approach that has not been studied much in this setting, which the paper itself suggests is worth trying!
Since relatively small numbers of heterosexual men and women were included in the study, the results are most applicable to MSM. The researchers concluded that counseling that emphasizes the risks associated with unsafe sex may help people with baseline risky profiles to avoid acquiring other STDs or strains of HIV, and avoid transmission to others. The authors note that their study needs to be followed up with additional research, since there is a paucity of information about how to effectively counsel patients to practice safe-sex behaviors in a variety of settings and populations.
Negative Results From a Quality-Improvement Study
Measuring and improving quality of care has become critical in many areas of medicine. There has also been much discussion regarding the fact that negative results do not get published at the same rate as studies demonstrating a positive effect of quality-of-care interventions. This study examined the effectiveness of a program that was designed to increase rates of quality-of-care measures at clinics receiving funding from the Ryan White CARE Act.
Landon BE, Wilson IB, McInnes K, et al. Effects of a quality improvement collaborative on the outcome of care of patients with HIV infection: the EQHIV study. Ann Intern Med. June 1, 2004;140(11):887-896.
Landon and his group used 44 intervention clinics and 25 control clinics matched by general clinic characteristics. Measures examined included use and effectiveness of highly active antiretroviral therapy (HAART), screening and prophylaxis, and access to care. The researchers looked at the care of 9,986 patients.
The differences in quality of care after the intervention were not significant. The proportion of patients with suppressed viral loads increased from 40 to 51% in the intervention group, compared with an increase from 44 to 49% in the control group (P = .18). Details are lacking about some of the actual interventions used in this study, but I suspect that many of them fall within the realm of community standards of care, so the difference between the intervention and control groups may become blurred. The authors suggest that additional research is needed to achieve better results by improving methods of teaching and implementing quality-improvement projects.
One of the biggest problems with this study involved the quality indicator(s) used. Having worked exclusively at public hospitals and clinics serving an indigent patient population with a multitude of unmet housing, mental health and chemical dependency needs for many years, I have been cautious about starting HAART before a patient is ready or needs such therapy. In addition, it is unclear whether the pharmacies and clinics that care for this type of patient can properly monitor adherence for a large number of these patients simultaneously.
The quality marker used in this study that was particularly troublesome related to the use of HAART in patients with CD4+ cell counts <500 cells/mm3 and viral loads >10,000 copies/mL. Although the use of HAART for these patients was not the practice for many clinicians, it was part of the recommendations for treatment from 1996-2000 (the study was done in 2000). More recent recommendations from the International AIDS Society-USA Panel5 and the U.S. Department of Health and Human Services (DHHS) (www.aidsinfo.nih.gov/guidelines) have shifted these recommendations, based on accumulated experience and study results, to a more conservative treatment philosophy.
In addition, the other "quality markers," such as tuberculosis screening, hepatitis C screening, and use of vaccinations, may have little data indicating that such tests or interventions clinically benefit key segments of the HIV-infected population (such as patients with CD4+ cell counts <200 cells/mm3).
Now that there are waiting lists in many states for HIV-infected patients to receive ART, it is imperative to critically examine how to optimally use the available but limited resources to protect the health of those at risk for HIV-related morbidity and mortality. Regional HIV-related morbidity and mortality statistics would be better markers for evaluation of the Ryan White program than simply tabulating the percentage of patients on HAART or those who had a particular laboratory test obtained. It is my opinion that many quality-improvement projects are imposed on an already busy and often beleaguered staff, so that there are neither the funds nor the staff to do a good job. Given the increasingly underfunded state of HIV care in the United States, the window for high-quality studies of this nature under the auspices of the Ryan White CARE program may have closed, as the funds must be used to provide necessary antiretroviral drugs in the setting of budget shortfalls.
Directly Observed Therapy in the United States?
Studies of the effectiveness of ART have consistently shown that high compliance rates result in better outcomes.6 In many real-world settings, the effectiveness of HAART seems lower than in published clinical trials in which pre-selected patients, chosen for their likelihood to be compliant, are followed in well-staffed research clinics.
Because directly observed therapy (DOT) has been shown to be effective in the control and treatment of tuberculosis,7,8 there has been interest in adapting DOT strategies for the treatment of HIV infection. One problem with indefinite DOT, which would be necessary since HIV infection is incurable, is the high cost of healthcare workers in the United States when funding is already strapped in many public and private settings.
Paul Farmer has achieved well-deserved fame for his humanitarian and clinical efforts in Haiti, and his writings regarding the interaction of poverty and health. He helped develop a DOT-HAART program in rural Haiti using people they call "accompagnateurs" -- low-cost healthcare workers -- to promote maximum adherence. The accompagnateur also provides psychosocial support and links patients to clinical staff and other available resources. In this article, Farmer summarizes his experience with the Haitian program and a similar program in Boston for patients with drug-resistant HIV disease who had experienced failure during unsupervised therapy.
Behforouz HL, Farmer PE, Mukherjee, JS. From directly observed therapy to accompagnateurs: enhancing AIDS treatment outcomes in Haiti and in Boston. Clin Infect Dis. June 1, 2004;38(suppl 5):S429-S436.
The HIV Equity Initiative in Haiti built on their ongoing tuberculosis therapy program, which utilized DOT with an extensive network of community health workers. The accompagnateur is the centerpiece for the tuberculosis therapy and DOT-HAART programs.
Farmer emphasizes that the accompagnateur's role is more complex than simply watching patients take pills. The accompagnateurs are respected in their community and serve as the key link between the patient and the clinic.
At the patient's request, an accompagnateur is selected from among the clinic staff or hired from the community. In Haiti, the majority of accompagnateurs are peasant farmers or market women. They receive training on clinical aspects of HIV, confidentiality and ways to provide emotional support. They observe patients taking their HIV medications once or twice daily.
The data provided in this article are descriptive, providing only general observations and results. The Haitian program, which managed 100 patients in this manner, was outstanding, with an impressively low (<2%) dropout rate.
It is immensely appealing to try and use potentially lower-cost personnel to achieve better outcomes with challenging patient populations. In future articles, I look forward to further details about how the accompagnateur concept could be set up in U.S. sites, and how such programs could be funded and sustained.
Histoplasmosis Maintenance Therapy Can Be Stopped After Immune Recovery
In the pre-HAART era, my patients who succumbed to AIDS suffered through an average of 4 to 5 AIDS-defining conditions. Successful treatment of one opportunistic infection seemed only to allow survival to the next one, as a patient's immune system seemed permanently stuck in reverse. I still remember the excitement of the arrival of potent ART in 1996. The revolution of that moment was not only that a patient's HIV level could be decreased to the detection limit, but that CD4+ cell counts could be increased to never-before-seen levels. Sick patients got better, and at-risk patients did not get sick.
As time went on, successive studies9,10 demonstrated that adequate immune recovery would allow the discontinuation of prophylaxis or maintenance therapy for conditions such as Pneumocystis, Mycobacterium avium and cytomegalovirus. This study, led by Mitch Goldman from the AIDS Clinical Trials Group (ACTG), reports that maintenance therapy for disseminated histoplasmosis can also be safely stopped after adequate immune recovery.
Goldman M, Zackin R, Fichtenbaum CJ, et al. Safety of discontinuation of maintenance therapy for disseminated histoplasmosis after immunologic response to antiretroviral therapy. Clin Infect Dis. May 15, 2004;38(10):1485-1489.
This was a prospective observational study conducted by the ACTG to evaluate the safety of stopping maintenance therapy for disseminated histoplasmosis among HIV-infected patients after at least 12 months of antifungal therapy and 6 months of HAART. All patients had documentation of prior disseminated histoplasmosis. Details of ART regimens or nadir CD4+ cell counts were not provided. Negative results of fungal blood cultures, urine and serum Histoplasma antigen levels <4.1 units, and CD4+ cell counts >150 cells/mm3 were required. Thirty-two subjects were enrolled, with a median CD4+ cell count of 289 cells/mm3. No relapse of histoplasmosis was observed after a median follow-up of 24 months -- a rate of zero cases per 65 patient-years. The median CD4+ cell count at the end of the study was 338 cells/mm3.
The authors reasonably concluded from this study that maintenance therapy for disseminated histoplasmosis can be safely stopped for patients with similar characteristics. That is good news for HIV-infected patients in the Midwestern United States where histoplasmosis is endemic.
What Happens After PI Failure?
One of the major issues currently facing clinicians is the selection of first-line HIV therapy. This first choice is critical in planning future treatment options. If a patient starts on a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen and fails, for example, the presumption is that a protease inhibitor (PI)-based regimen (generally boosted with ritonavir [RTV, Norvir]) will usually be successful as a follow-up regimen. However, there are few published studies looking at long-term outcomes after failure of initial NNRTI-based therapy.
Alternatively, if the initial regimen is PI-based, it is even less clear how successful the subsequent regimen will be. Obviously, it depends on many factors, such as available drugs, specific drugs used in the initial regimen, adherence habits and amounts of resistance. This study reviews reports published in the HAART era (Jan. 1, 1997 to May 31, 2003) to examine what happens when patients are switched to a follow-up regimen after the failure of an initial PI-based regimen.
Losina E, Islam R, Pollock AC, Sax PE, Freedberg KA, Walensky RP. Effectiveness of antiretroviral therapy after protease inhibitor failure: an analytic overview. Clin Infect Dis. June 1, 2004;38(11):1613-1622.
The overall results are quite disappointing. Only a minority of patients achieved high-level, durable suppression with the follow-up regimen. One problem with the study is that relatively fewer ritonavir-boosted regimens were used in both the initial regimen and the follow-up regimen, so the results really reflect a past era of the use of PIs. My experience with agents such as lopinavir/ritonavir (LPV/r, Kaletra) is that failure rates with PI resistance are low, and that use of lopinavir/ritonavir after initial failure of a non-boosted PI is generally successful when resistance tests guide use of the entire regimen.
The authors screened 154 studies and then collectively analyzed results from 12 studies (7 clinical trials and 5 observational cohorts involving 1,197 patients) that met the predetermined definition of providing follow-up data for at least 24 weeks for the salvage regimen. An intent-to-treat form of meta-analysis was used, with the primary endpoint being the number of subjects with HIV RNA <500 copies/mL at 24 weeks.
Follow-up regimen types were characterized into 4 categories: (1) no new drug classes used, (2) boosted PI regimen without addition of any new class, (3) addition of NNRTI in NNRTI-naive subjects, and (4) addition of NNRTI and boosted PI in subjects naive to both.
The overall rate of virologic suppression (<500 copies/mL) at 24 weeks was 38%. The lowest rate was seen in subjects with no new drug classes added (16%), compared with 27% for the boosted-PI group, 39% for the new-NNRTI group, and 54% for addition of both a first NNRTI and boosted PI.
Regression analysis of predictors of success at week 24 found that baseline HIV-RNA level and the rescue regimen type were significant, whereas baseline CD4+ cell count was not. The fact that the success rate was highest for the group adding a first NNRTI and boosted PI is not very relevant when the DHHS-recommended first ART regimens contain either efavirenz (EFV, Sustiva, Stocrin) or lopinavir/ritonavir.
I also have concerns about the durability of a regimen when adding only a new NNRTI in the setting of both PI and nucleoside reverse transcriptase inhibitor (NRTI) failure. Current practice in the United States is to evaluate the effectiveness of ART using a more sensitive assay (usually <50-75 copies/mL), which, if used in the studies reviewed here, would undoubtedly have decreased the success rate significantly.
The use of resistance tests to guide the choice of drugs within classes is also the community standard. It is therefore disappointing that many of the studies did not use this tool to help them select the regimen.
Also, why do so many current rescue studies designate a regimen that is often suboptimal and does not allow the full use of all available drugs and regimens? A major challenge is not only to develop new drugs that are active against resistant virus, but to design studies utilizing the best that current knowledge and resources can offer, so that more meaningful results can be obtained.
Exactly How Does the Immune System Fit Into the ART Equation?
With all of the understandable focus on the benefits of ART, the relevance of the immune system to the effectiveness, or lack thereof, of treatment remains an enigma. Many patients demonstrate a lack of CD4+ cell response, while others have an unexpectedly fabulous CD4+ cell response, though all have high-level HIV suppression. It is still unclear and often unpredictable why there is so much variation from patient to patient. This study from the Immunology Group of the ACTG sheds new light on this issue.
Mildvan D, Bosch RJ, Kim RS, et al. Immunophenotypic markers and antiretroviral therapy (IMART): T cell activation and maturation help predict treatment response. J Infect Dis. May 15, 2004;189(10):1811-1820.
The Immunophenotypic Markers and Antiretroviral Therapy (IMART) study used a novel data-sharing strategy involving data from 5 ACTG trials that measured naive and activated CD4 and CD8+ T cells in 324 subjects.
A regression model that adjusted for baseline CD4+ cell count, plasma HIV-RNA level and study demonstrated that high pretreatment CD8+ cell activation predicted subsequent virologic failure (P = .046). Another model revealed that the greatest increases in CD4+ cell counts were seen in subjects with the highest pretreatment-naive CD4+ cell counts, an effect that was magnified by high CD4+ cell and low CD8+ cell activation rates. The total lymphocyte count also predicted the subsequent change in CD4+ cell count.
The authors concluded that T-cell markers are predictive of treatment outcome, and may have merit in the study or management of HIV-1 infection.
A Possible Explanation of How GBV-C Infection Might Inhibit HIV Replication
In the April 2004 edition of The Body Pro's HIV JournalView, David Wohl highlighted several studies regarding the impact of GB virus C (GBV-C) on the natural history of HIV infection (the conclusion was that it has a seemingly positive impact). In this article, just published in The Lancet by Jack Stapleton and colleagues from the University of Iowa, the authors evaluated peripheral blood mononuclear cells (PBMCs) coinfected with GBV-C and HIV. The conclusion was that GBV-C induces inhibitory chemokines and downregulates CCR5 expression. As the Lancet editors note, that mechanism provides useful insight into potential new strategies for both anti-HIV medication and disease-modifying vaccine development.
Xiang J, George SL, Wünschmann S, Chang Q, Klinzman D, Stapleton JT. Inhibition of HIV-1 replication by GB virus C infection through increases in RANTES, MIP-1a, MIP-1B, and SDF-1. Lancet. June 19, 2004;363(9426):2040-2046.
Previously published data provided by the study authors have generally, but not universally, reported that persistent GBV-C infection slows the progression rate of HIV to AIDS. Though there were a variety of proposed mechanisms for that effect, there was little actual data.
In this study, the investigators coinfected PBMCs with GBV-C and HIV, then monitored infectivity and HIV p24 antigen production. GBV-C infection of PBMCs resulted in decreased replication of both clinical and laboratory strains of HIV. The degree of inhibition was related to the dose and timing of GBV-C infection: higher inhibition was seen with higher doses of GBV-C and with increased time between GBV-C and HIV infection. This inhibition was seen with both the CCR5- and CXCR4-tropic strains of HIV. Expression of mRNA for the chemokines RANTES, MIP-1a, MIP-1b and SDF-1, and secretion of those chemokines into the culture supernatant, were higher in the GBV-C-infected cells than in controls. PBMC surface expression of CCR5 was lower in the GBV-C-infected cells. Finally, the inhibitory effect of GBV-C infection on HIV infection was blocked by neutralizing antibodies against the respective chemokines.
These intriguing results provide a plausible explanation for the effect of GBV-C infection on HIV. The study needs to be repeated in additional trials and different laboratories but, if confirmed, should stimulate research into novel anti-HIV drug and vaccine strategies.
The debate around the effects of GBV-C on the natural history of HIV infection underscores how much we still need to learn about how factors other than the standard surrogate markers of HIV-RNA levels and CD4+ cell count -- such as human leukocyte antigen type, chemokine and receptor levels, drug-metabolizing genotypes and thymic restorative capacity -- influence the clinical course of HIV infection in patients, and how we can use this information in decision making.
Is HAART Less Effective Against HIV-2 Infection in the United States?
HIV-2 infection has been fairly limited to West Africa, with a small number of imported cases in the United States. Available data suggest that HIV-2 is less pathogenic than HIV-1. The natural history of HIV-2 infection appears to involve a longer period of clinical latency, though it can still result in AIDS. There is little published data on how well HIV-2-infected patients respond to standard HAART regimens.
This article is important for several reasons. First, it summarizes details for 10 HIV-2-infected persons in the United States, which is helpful for those of us that have not seen many cases of HIV-2 infection.
Information relating to diagnosis of HIV-2 infection, measurement of quantitative HIV-2 RNA levels (performed at the Harvard School of Public Health using an in-house method), CD4+ cell counts and clinical features is provided. Finally, details about the response to a range of fairly standard HAART regimens are provided.
Mullins C, Eisen G, Popper S, et al. Highly active antiretroviral therapy and viral response in HIV type 2 infection. Clin Infect Dis. June 15, 2004;38(12):1771-1779.
Chris Mullins and colleagues have provided a useful service by summarizing experience with 10 HIV-2-infected patients (7 from Cape Verde and 1 each from Guinea, Ivory Coast and Sierra Leone) who received HAART in the United States from 1994-2004. The approach to HAART for these HIV-2-infected patients mirrored that for HIV-1, with the major exception being that NNRTI-based regimens were not used (currently approved NNRTIs are generally not active against HIV-2).
Three subjects were asymptomatic. The CD4+ cell counts for asymptomatic subjects were higher than for those who were symptomatic (median levels 639 and 175 cells/mm3, respectively). Plasma HIV-2 RNA was also higher for the symptomatic than for the asymptomatic subjects (median levels 4.7 and 2.5 log copies/mL, respectively). All of the symptomatic subjects had low CD4+ cell counts and elevated viral loads.
Treatment responses in the 7 symptomatic subjects were generally disappointing. Three of the 7 subjects had increased CD4+ cell counts, but none had a greater than 2-log reduction in HIV-2 RNA. Four of the 7 did not improve clinically, with 2 of those subjects having problems with adherence.
Some of the treatment regimens for those 7 patients would be considered marginally acceptable by today's standards (i.e., they took triple NRTIs or stavudine [d4T, Zerit] plus didanosine [ddI, Videx] plus nelfinavir [NFV, Viracept]). No subjects received an initial boosted-PI regimen, and some had prior dual-NRTI therapy. No resistance information was provided.
Importantly, the HIV-2 diagnosis for 3 of these patients was made after an initial diagnosis of HIV-1, with additional tests ordered after laboratory tests or response to treatment seemed not to fit the usual pattern. The treatment response reported here is disappointing but understandable, since many of the patients had prior suboptimal therapy with a variety of regimens. As the authors point out, more data is needed, particularly using subjects who from the beginning were given potent boosted PI-based regimens. This article is a good reference for clinicians to use if they encounter an HIV-2-infected patient.
Use of Nelfinavir for HIV-1 Type C Infection
In the United States, most HIV-1 infections involve subtype B virus but, worldwide, HIV-1 subtype C is probably the most common infection. The majority of the data regarding the use of ART has come from resource-rich countries, and therefore involves subtype B infections. However, different HIV-1 subtypes possess distinct amino-acid sequences in their proteins, including the viral protease. This study looked at the use of nelfinavir in patients infected with HIV-1 subtype C.
Nelfinavir's most desirable characteristic is that it preserves other PI treatment options after virologic failure when the D30N PI mutation develops. Data on that issue,11 however, have been mostly restricted to patients with subtype B HIV-1. This study compares the genotypic and phenotypic replication capacity of HIV-1 isolates from nelfinavir-treated patients infected with subtype B or C HIV-1. The results demonstrate that use of nelfinavir in patients infected with HIV-1 subtype C results in broader cross-resistance to other PIs than has been the experience in those infected with subtype B.
Grossman Z, Paxinos EE, Averbuch D, et al. Mutation D30N is not preferentially selected by human immunodeficiency virus type 1 subtype C in the development of resistance to nelfinavir. Antimicrobial Agents Chemother. June 2004;48(6):2159-2165.
Jonathan Shapiro and colleagues from ViroLogic and the Sheba Medical Center in Israel reported on the virologic features of 159 subtype-C-infected and 65 subtype-B-infected patients failing nelfinavir as their first PI.
The characteristic D30N PI mutation was seen in only 7% of the subtype-C-infected patients, compared with 23% of the subtype-B-infected patients (P = .03). Significant differences were also found in the occurrences of M36I (98 vs. 36%), L63P (35 vs. 59%), A71V (3 vs. 32%), V77I (0 vs. 36%) and I93L (91 vs. 32%) (.0001<P<.05) between subtype C and B HIV isolates from these patients. The subtype C isolates with the D30N mutation showed a change in 50% inhibitory concentration (IC50) in susceptibility to nelfinavir only -- much less than the change seen in subtype B isolates with the D30N mutation -- while other mutations increased the IC50 values for all PIs.
The replication capacity of the subtype C virus was reduced relative to a subtype B reference virus (details were not provided in the paper). The ViroLogic database was reviewed for the replication capacity of subtype C virus with the D30N versus the L90M and/or other mutations. Both groups had a lower replication capacity compared to wild-type virus, but there were no obvious differences between the 2 groups (data not provided).
This study has numerous limitations, notably that samples were not from patients in any form of randomized study, and in addition, information about adherence or treatment response was not available.
There may be some demographic differences between the patient populations. Subtype C patients are more likely to be from Africa, with lower socioeconomic standing, which could influence treatment outcomes. Nonetheless, the results confirm other reports that HIV-1 subtype-C-infected patients failing treatment with nelfinavir generally have a different resistance pathway than subtype-B-infected patients and develop broader PI cross-resistance, possibly due to different baseline polymorphisms. Use of nelfinavir as the first PI in subtype-C-infected patients would be less likely to preserve other PI treatment options than has been the experience in subtype-B-infected patients.
The International AIDS Disaster: Which Route Will China Take?
Although not a research article, this report provides an excellent overview of the HIV/AIDS situation in China. This is the third collection of articles in Science magazine's series on HIV in Asia (the first, published Sep. 19, 2003, focused on Southeast Asia; the second, published Apr. 23, 2004, focused on India). As the most populous country in the world, with a booming economy, China seems to be at high risk for a disastrous problem, while simultaneously having the resources to blunt the impact, if it can gather the political will to do so.
Cohen J. HIV/AIDS in China: poised for takeoff? Science. June 4, 2004;304(5676):1430-1439.
The introduction begins with a description of the Premier of China, Wen Jiabao, shaking hands with Sun Fuli, an HIV-infected taxi driver from Shanxi Province, on Dec. 1, 2003 -- World AIDS Day. The story was widely carried throughout China, and seemed to send a powerful message of the Chinese government's intentions to get serious about the threat of HIV.
Increased spending on treatment and education, pilot needle exchange and methadone treatment programs, and roll-outs of limited antiretroviral drug treatment programs all indicate that China has become serious about dealing with the country's estimated 840,000 HIV-infected persons -- two-thirds of whom are intravenous drug users (IDUs) -- as well as ramping up prevention efforts.
Although there are still many problems, the Chinese HIV situation has improved considerably relative to several years before. The history of the AIDS epidemic in China has been divided into 3 phases. From 1985 to 1988, the country reported only 22 infections, so the disease was viewed as a foreign problem. The government stated that the disease could be kept in check, because of limited homosexual activity as well as a believed low rate of promiscuity. In addition, they barred foreigners with HIV from living in the country. However, in 1989, around 150 IDUs in Yunnan Province tested positive for HIV. This signaled the "spreading phase" of the epidemic.
Adding to this was the fact that during the early 1990s, many commercial firms pooled blood from paid donors and returned the blood cells to the donors while keeping the plasma for sale. That and a lack of clean needles and HIV testing standards led to an estimated 250,000 infections.
The current "expansion phase" of the epidemic includes spread of HIV from IDUs to their partners and children, and now the rise of infection in sex workers and gay men. Another explanation for the rapid rise in reported HIV cases is clearly the government's more accurate reporting and expanded testing opportunities.
There is still considerable concern about human rights issues for HIV-infected persons in China. In addition, another article12 in this series discusses the limited availability of antiretroviral drugs.
When I was in China in May 2004, numerous physicians expressed their frustration that their only medications were didanosine and stavudine, which provide only marginal benefit and lead to high rates of neuropathy and pancreatitis.
This series makes for worthwhile reading, with specific articles on efforts to educate IDUs, the story of HIV-infected plasma donors in Henan Province and efforts to develop vaccines customized for China.
Joint Problems With HIV Infection -- Yes and No
Although not part of last month's journal publications, this additional review may be of interest. From early in the epidemic, HIV has been reportedly associated with various rheumatologic disorders. However, the diagnostic possibilities can be numerous when confronted with an HIV-infected patient with joint complaints. I often refer such patients to a rheumatologist to help sort out the likely cause and best approach to therapy. After one such referral of an HIV-infected, African-born patient, the rheumatologist sent the following 2 articles to help me beef up on the topic.
Solinger AM. Rheumatic manifestations of human immunodeficiency virus. Curr Rheumatol Rep. June 2003;5(3):205-209.
Various rheumatic, musculoskeletal or other immune disorders are associated with HIV infection. Reactive arthritis, psoriatic arthritis, acute nonspecific arthritis, Sjögren syndrome and inflammatory myositis have been reported. During the early years of the AIDS epidemic, there were numerous reports of "acute painful joints," which seem to have diminished. This review of the literature concludes that the possible association between HIV and rheumatic or definable autoimmune disorders is fairly limited to the reactive arthritidies. Vasculitis has more recently been associated with hepatitis C coinfection.
There actually seems to be a decreasing frequency of rheumatoid arthritis in the setting of HIV infection, with a worsening of pre-existing rheumatoid arthritis after the initiation of potent ART (possibly supporting the role of CD4+ cells in inflammatory synovitis). There also seems to be an increased incidence, though solid epidemiological evidence is sparse, of secondary muscle and joint infections in HIV patients.
Centers for Disease Control and Prevention. Primary and secondary syphilis -- United States, 2002. MMWR. November 21, 2003;52(46):1117-1120.
Centers for Disease Control and Prevention. Increases in HIV diagnosis -- 29 states, 1999-2002. MMWR. November 28, 2003;52(47):1145-1148.
Chakraborty H, Sen PK, Helms RW, et al. Viral burden in genital secretions determines male-to-female sexual transmission of HIV-1: a probabilistic empiric model. AIDS. March 30, 2001;15(5):621-627.
Bozzette SA, Berry SH, Duan N, et al. The care of HIV-infected adults in the United States. N Engl J Med. December 24, 1998;339(26):1897-1904.
Yeni PG, Hammer SM, Hirsch MS, et al. Treatment for adult HIV infection: 2004 recommendations of the International AIDS Society-USA Panel. JAMA. July 14, 2004;292(2):251-265.
Paterson DL, Swindells S, Mohr J, et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Intern Med. July 4, 2000;133(1):21-30.
Farmer P, Kim JY. Community based approaches to the control of multidrug resistant tuberculosis: introducing "DOTS-plus". Br Med J. September 5, 1998;317(7159):671-674.
Mitnick C, Bayona J, Palacios E, et al. Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru. N Engl J Med. January 9, 2003;348(2):119-128.
Lopez Bernaldo de Quiros JC, Miro JM, Pena JM, et al. A randomized trial of the discontinuation of primary and secondary prophylaxis against Pneumocystis carinii pneumonia after highly active antiretroviral therapy in patients with HIV infection. N Engl J Med. January 18, 2001;344(3):159-167.
Currier JS, Williams PL, Koletar SL, et al. Discontinuation of Mycobacterium avium complex prophylaxis in patients with antiretroviral therapy-induced increases in CD4+ cell count: a randomized, double-blind, placebo-controlled trial. Ann Intern Med. October 3, 2000;133(7):493-503.
Clotet B, Ruiz L, Martinez-Picado J, Negredo E, Hill A, Popescu M. Prevalence of HIV protease mutations on failure of nelfinavir-containing HAART: a retrospective analysis of four clinical studies and two observational cohorts. HIV Clin Trials. July-August 2002;3(4):316-323.
Cohen J. HIV/AIDS in China: a new treatment campaign, but with limited weapons. Science. June 4, 2004;304(5676):1433-1434.


text:
Avon Archaeology Limited
Heritage and Research
Post Excavation & Other Services
St George's Hall, Brandon Hill, Bristol.
Avon Archaeology
Friday, October 14, 2016
Newlands Farm, Emersons Green, South Gloucestershire
Avon Archaeology Ltd were commissioned by The University of Bath to undertake a programme of archaeological mitigation, comprising excavation, building survey and watching brief monitoring, at Newlands, Emerson's Green, South Gloucestershire prior to the construction of facilities for The Institute for Advanced Automotive propulsion Systems (IAAPS) https://www.bath.ac.uk/research-institutes/iaaps/ The excavation was located where the development was most likely to adversely impact buried
Crop Marks, South Gloucestershire
This summer's heat wave has provided perfect conditions to observe crop marks, due to the lack of moisture within the ground. As reported across the media, a treasure trove of hidden history has been recorded across the UK. In South Gloucestershire, underneath several farming fields, a substantial roadside Roman settlement appears every few decades, in the parch marks which form during particularly dry weather. We were asked by one of the region's local archaeology societies and the
St Mary De Crypt, Southgate Street, Gloucester
In November 2017 Avon Archaeology Limited were commissioned by Discover DeCrypt to lead the archaeological work required during the ambitious renovation project of the St Mary de Crypt Church and School Room, located on Southgate Street in central Gloucester. The renovation work aims to transform and renovate the buildings into a community facility where the public will be able to explore the fascinating history of the church, attend concerts and simply enjoy this great building. The project
Portal Road, Monmouth, South Wales
During 2016, we were commissioned to carry out a watching brief on land near to Portal Road, Monmouthshire, South Wales related to the development of a new Premier Inn. The town of Monmouth has its origins in the early Roman period with the construction of a fort in circa 55AD. Identified by name as 'Blestium', it was one of several forts forming a line of auxiliary fortifications established to control the Monow Valley into mid-Wales. Although the site had potential for interesting
Wade Street, St Judes, Bristol
One of our very first excavations was carried out on a parcel of land on the north side of Wade Street, back in 2014. The full report was published online at Internet Archaeology (see link below). Our excavation at the site at Wade Street, in the St Jude's area of Bristol, demonstrated in striking fashion that the surviving historic map evidence does scant justice to the sheer complexity of the developmental sequence of building on the site, although perhaps the nature of the site itself might
Former Royal Oak Garage
The former Royal Oak Garage building lies within the constraint area of the Scheduled Monument known as 'Nailsea Glassworks' (National Heritage List ref. 1021462, SAM 28884), although the building itself is excluded from this Schedule. It dates to the later part of the 1860s and appears on an 1870 plan of the glassworks (BRO 37959 (22)) as a 'French Kiln'. The same plan identified the partly standing walls to the south of the building formed the 'Gas Retort' associated with the firing of
Bristol Old Vic Theatre
BRISTOL OLD VIC We have recently completed a building survey and watching brief as part of the redevelopment of the renowned Bristol Old Vic theatre. The current theatre comprises two 18th century buildings; Coopers Hall, constructed between 1733 and 1734; and The Theatre Royal, constructed between 1764 and 1766. Coopers Hall, designed by William Halfpenny, is perhaps King Streets most recognisable buildings with its highly ornate façade incorporating Corinthian columns. The survey revealed
ss Great Britain, Bristol (click to see full text)
We are currently involved in a building survey of two buildings just to the north of the ss Great Britain Dock, the North Range and the Dock Office. The North Range, a former ship repair shed erected during World War II, which has subsequently undergone significant alteration, is earmarked for demolition as part of an upcoming development project. The Dock Office, which incorporates Brunel's original drawing office on its first floor, will be retained, with some minor alterations. The project
Roman Shirehampton (click to see full text)
We were commissioned to carry out a simple strip and record project on the site of a former school building in central Shirehampton, with a remit to excavate a box section in order to establish the presence/absence of Pleistocene gravels in the area. However, it all became a little more exciting when, on excavating a test pit, we discovered a number of pottery sherds that were clearly of Romano - British date. In addition to the remains of foundations belonging to a 19th century school
building survey
watching brief
wade street
south wales
south goucestershire
brunell's bristol
medieval gloucester
ss great britain
post medieval gloucester
steam ship
roman gloucester
school room
brandon hill
st mary de crypt
crop marks
music hall
heat wave
parish of st augustine
roadside settlement
st augustine
roman buildings
st georges hall
roman road
bristol old vic
south gloucestershire
bristol old vic theatre
advanced automotive propulsion systems
bath university
theatre restoration
bristol and bath science park
historic glass works
emersons green
industrial archaeology
nailsea glass works
st judes

subset: commoncrawl


text:
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The NHL and NHLPA continue to talk. Will it lead to a deal?
NHL people are superstitious by nature, and labor negotiators tend to do their best to keep things close to the vest, so it was a very careful dance that Gary Bettman and Donald Fehr performed on Tuesday night after the latest round of negotiations between the NHL and NHLPA. With about 10 days left to finalize a new collective bargaining agreement, end the lockout and salvage a partial season, nobody wanted to say the word "progress."
For the second straight day, there was a new proposal on the table, as the NHL on Tuesday offered what Fehr called a "comprehensive response" to the NHLPA's Monday counteroffer. It is now up to the union to make the next move, and another meeting is likely to take place Wednesday.
"We asked a couple of questions," Fehr said. "Now we have to go through the document, try to make sense out of it, compare it, and see what the appropriate thing is to do next. That's what we're going to do."
That was what the NHL did on Monday night and most of Tuesday. The bargaining session was initially expected to take place around noon but wound up starting around 9 p.m. as the league took time to put together its response. Time may be running short in order to get a season under way by the league's stated deadline of Jan. 19 (a deal must be in place about a week before that), but it also is not a time to be sloppy.
It also is not a time for the posturing and public relations spinning that characterized negotiations from July until late last week. As such, Fehr limited his news conference to 43 seconds, while Bettman, speaking second, spoke for a little more than two minutes because he received more questions. Not that he was in much of a mood to provide expansive answers.
"I don't think it helps the process to give what our expectations are right now," the commissioner said. "It's up to the Players' Association to come back to us now in response to what they've been given this evening. … There's a process that's ongoing, and I'm thankful for that."
That process could have just as easily taken place in the summer, but there is little use now in revisiting the failures that resulted in the cancellation of half the season. The point is that now, finally, there is actually something happening that sounds like a negotiation.
"In our response, there were certain things that the Players' Association asked for that we agreed to," Bettman said. "There were some things that we moved in their direction, and there were other things that we said 'No.' That's what the process is."
Bettman would not say how many "things" fit into each category, nor would he estimate how many issues remain to be resolved. Of the few details to leak out, Renaud Lavoie of the Canadian network RDS reported that revenue sharing between owners "is close to a done deal," while the NHLPA has conditionally accepted the NHL's request for a 10-year CBA. The union had been seeking an eight-year term for the labor agreement. Other key areas to deal with include the maximum length of player contracts and pensions.
While there was a hangup on the pension issue on Tuesday, according to Chris Johnston of the Canadian Press, it clearly was not a big enough disagreement to send either side scurrying from the negotiating table. That is a marked change from the earlier stages of negotiations. Progress, one might even say. Or not say.
"It's better to be meeting than not," Fehr said. "But I'm not saying anything else."
This is a re-post from an article that I found


text:
1981 Learned Societies Conference fonds
- Fonds
- 1979-1981
Fonds consists of conference reports, press clippings, information on individual and society participants, and administration and planning documents.
Learned Societies Conference.
14 results with digital objects Show results with digital objects
1981 Learned Societies Conference fonds
Fonds consists of conference reports, press clippings, information on individual and society participants, and administration and planning documents.
Learned Societies Conference.
A Search for Collective Bargaining : The Nova Scotia Government Employees Association Experience
File contains a student essay titled, "A Search for Collective Bargaining : The Nova Scotia Government Employees Association Experience," written in 1979 by Kevin Reilly for a course on Canadian working class history taught by Dr. Gregor...
Reilly, Kevin
A tribute of sympathy and affection written to Mrs. James Harris on the death of her husband
Item is a tribute of sympathy and affection written by officials at Halifax's Charles Street Church to Mrs. James Harris on the death of her husband in 1902.
Harris, Eliza, 1850-1921
Fonds contains minute books; cash books; ledgers; correspondence; income tax returns; financial statements; and other records from A. M. Bell & Co.
A. M. Bell and Company
The fonds consists of administrative papers, blueprints, business and personal correspondence, cable code books and other reference works, export orders and papers, financial documents, insurance papers, legal documents, packaging samples, photogr...
A.M. Smith and Company.
This fonds consists of diaries; correspondence; manuscripts of articles, books and sermons; published works; research files and class notes; scrapbooks; an assortment of personal materials; and photographs.
Myers, A.J. Williams, 1877-1975
Duggan, A.M.
Fonds contains William McKenzie's notebook and several loose sheets detailing timber purchases; three memos to William McKenzie, including one from Jessie Hoyt, who managed the company; the second [1896] and third [1898] published annual repo...
McKenzie, William
Acadia Gas Engine Company fonds
Fonds contains three product catalogues produced by the Acadia Gas Engine Company. The earliest dated catalogue was published in January, 1969 and another was published in 1973. One catalogue is undated.
Acadia Gas Engine Company.
Acadian Supplies Company fonds
The Acadian Supply Company fonds consist of correspondence, financial, legal, sales and shipping records and vessel papers. Also included is correspondence from Lunenburg Mayor Douglas Adams, church papers from LaHave United Church and the Parish ...
Acadian Supplies Company.
Account books and correspondence regarding barques captained by Martin Leslie Forbes
File contains pages from an account book for the barque Aspototgan and some loose accounts and correspondence regarding the barque Nellie Moody.
Forbes, Martin Leslie, 1843-1919
Account journal and letter of Charles Tupper Logan
File consists of one journal of daily accounts (1926-1928) and a letter of appointment to the School Board of Cumberland County (1943).
Logan, Charles Tupper, 1867-1961
The fonds consists of records which document the business activities and interests of Adams & Knickle Ltd. from 1897 until 1968. Information contained in this fonds provides insight into the company's role as a major fishing and shipping partn...
Adams and Knickle Limited.
Address on Thomas McCulloch given by Harvey Veniot on the opening of Pictou Academy's new auditorium and gymnasium
Item is an address on Thomas McCulloch's work as an educator given by Harvey Veniot on the opening of Pictou Academy's new auditorium and gymnasium on September 15, 1961.
Veniot, Harvey Alfred, Hon., 1915-2009
Addresses to Robert Murray in celebration of his jubilee as editor of The Presbyterian Witness
File consists of addresses to Robert Murray in celebration of his jubilee as editor of The Presbyterian Witness.
Murray, Robert, Rev.
Administrative records of the Oil, Chemical, and Atomic Workers' International Union, Local 9-825
Accession includes the minute book from the founding year of 1942 until 1955, collective agreements between the Oil Chemical and Atomic Workers' International Union and S. Cunard & Co. Ltd, E.S.F. Ltd, and Archibald Fuels Ltd. Also includ...
Oil Chemical and Atomic Workers International Union. Local 9-825.
Administrative records of the Technical University of Nova Scotia
Accession contains the minute books of the Board of Governors from September 1907-May 1937 and May 1938-May 1947, as well as published Annual Reports from 1959-1990.
Technical University of Nova Scotia.
Fonds includes Alan Creighton's diaries, which cover many of the years from 1920 to 2000. Writings from the period 1920 to 1954 (many undated) are mainly short stories and poems. These writings include handwritten and typed, complete and inco...
Creighton, Alan
Fonds consists of sheet music, scripts, and programs from different musical plays that Blanche and Alan Lund performed, directed or choreographed. Also includes audio reel-to-reel and video tapes of some of the performances.
Lund, Alan
Fonds consists of one pharmacy notebook.
MacKintosh, Albert Scott
Fonds contains personal documents of Alexander E. Kerr, including sermons, notes, personal writings and essays, certificates and degrees, pamphlets, publications, newspaper clippings, two photographs, and some correspondence.
Kerr, Alexander Enoch
Fonds contains five early reports from the Sterling County Study. One report contains a covering letter from J.S. Robertson (Deputy Minister of the Department of Public Health) to C.B. Stewart.
Leighton, Alexander H. (Alexander Hamilton), 1908-2007
Alexander John Murchison fonds
Fonds consists of papers and reports on Child Welfare.
Murchison, Alexander John, Dr.
Fonds consists of correspondence with J.G. MacGregor and copies of published articles. Additional information, including biographical and professional sketches, are in the Case File.
Reid, Alexander Peter, Dr.
Fonds comprises family correspondence (including that of his father, Hugh Ross), matriculation records, testimonial letters, personal account books, a diary, school inspectors' reports and other papers and bonds.
Ross, Alexander
Alexander Russell's notes from George Lawson's chemistry lectures at Dalhousie College
File contains chemistry lecture notes taken by Alexander Russell during classes with Professor George Lawson.
Russell, Alexander, G., 1845-1911
Fonds consists of a notebook containing lecture notes on obstetrics and other subjects.
Atherton, Alfred B., Dr.
This fonds consists of records which document the personal and business activities and interests of Alfred Dickie and, to a lesser extent, those of his immediate family and employees. Although the records span Dickie's lifetime, few relate to his ...
Dickie, Alfred
Fonds contains textual records relating to the history of the activities of the Dalhousie University English Department and to Bevan's academic activities. The fonds consist of research notes generated during Bevan's study of Dryden'...
Bevan, Allan, Dr., 1913-1981
Story, Allan
Fonds comprises personal and professional correspondence and papers relating to the schooners Rowena (1903-1907); Lizzie Rich (1905), Stella Maud (1907-1910) and the Carrie C. Ward, including registers, bills, and ship inventories.
Ward, Amos P.
Fonds consists of materials created and collected by Andrew Merkel. The fonds contains correspondence to and from friends and associates, including Charles Bruce, Kenneth Leslie, and Robert Norwood; manuscripts of articles, poems, and plays; Atlan...
Merkel, Andrew Doane, 1884-1954
Andrew Walter Herdman Lindsay fonds
Fonds consists of biographical information as well as correspondence associated with the Provincial Medical Board and other papers.
Lindsay, Andrew Walter Herdman, Dr.
Fonds consists of patient records, autopsy reports, correspondence, various medical reports from several institutions, and business records including a ledger and daily journals.
Murray, Angus Edward, Dr., 1901-1986
Fonds consists of correspondence belonging to Mrs. Angus Morton and a copy of a poem written by Dr. Morton.
Morton, Angus McDonald, Dr., 1871-1944
Fond consists of letters written by Captain Graham Roome to Annie Belle Hollett, and other miscellaneous correspondence recieved by Annie Belle Hollett. Many of the letters are accompanied by their original envelope. There is also a file containin...
Roome (née Hollett), Annie Belle, 1895
Annie Logan Barnwell's scrapbook of Pictou Academy's history
The item is a hard-backed, ribbon-bound scrapbook compiled by the donor comprising newspapers clipping, photographs, correspondence and notes about the history of Pictou Academy.
Annie Logan Barnwell
Annotated copy of Memoir of the Rev. James MacGregor, D.D.
Item is a memoir of the Rev. James MacGregor published in 1859 by George Patterson. Item includes corrections, annotations and loose notes made by Patterson.
Patterson, George, The Reverend, 1824-1897
Item is a handwritten sermon in German dated August 15, 1797 with additional delivery dates of 1800, 1808, and 1811.
Fonds consists of research notes, program notes, annotated copies of sheet music, and programs of performances, used and created by Anthony Pugh in his work as a program note writer. Most of his research and program notes date from his time at the...
Pugh, Anthony
Fonds contains diaries, correspondence, manuscripts of published and unpublished writings, research notes, materials related to MacMechan's research and teaching and other university-related activities, artwork, memorabilia, scrapbooks, photo...
MacMechan, Archibald McKellar
Archibald Woodbury McLelan fonds
Fonds comprises business correspondence, bills of lading, receipts, and miscellaneous papers connected to McLelan's shipping business.
McLelan, Archibald Woodbury, 1824-1890
The Archival Formats Collection is a collection of deaccessioned archival materials that have been retained for teaching and training purposes. It contains samples of various formats found in archives, including glass plate negatives, slides, text...
Dalhousie University. University Libraries. Killam Memorial Library. University Archives.
Armand Therrien Photograph Collection
Collection consists of over 500 photographs of ships. Collection also contains French-language clippings: Liste des newspages dans le Monde d'Apres Le Journal Courrier De Londres et Gazette de la Grand Bretagne 1804-1807; Registre des Navires...
Therrien, Armand
This fonds consists of 143 set, furniture, and prop designs for Neptune sketched on paper ca. 65 x 76 cm and smaller.
Penson, Art
Fonds consists of student tickets from Halifax Medical College, Dalhousie College and University, Montreal General Hospital, and both the Provincial and City hospitals.
Hawkins, Arthur, Charles
Fonds consists of newspaper clippings, correspondence, and a Canadian Medical Corps Christmas card (ca. 1916).
Blackett, Arthur Edwin , Dr., 1892-1957
Arthur Fordham and Company fonds
Fonds contains records documenting Arthur Fordham's leather merchant activities from 1899-1967. Fonds includes miscellaneous early records, 1899-1933; sales and purchases journals, 1921-1953; cash books, 1918-1962; ledgers, 1921-1967; corresp...
Arthur Fordham and Company
Arthur H. Whitman's diary of a trip to England
Item is a diary that describes a trip to England between November, 30 1888 and January 17, 1889. The diary contains daily entries that describe Whitman's activities, church attendance, meals, business and social visits, and letters sent and r...
Whitman, Arthur Hanfield
Arthur Lismer's Dalhousie sketches
Collection includes 41 original pen and ink drawings by Arthur Lismer commissioned ca. 1919 by Dalhousie's Centenary Committee to illustrate its history of the university's first century: One hundred years of Dalhousie, 1818–1918, which ...
Lismer, Arthur


text:
02201.NET website analysis & traffic stats. Website value calculator, how much it worth is. Who owns domain name 02201.net and when it's registered, changed and expired.
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Domain Name www.02201.net/ 02201.net was registered on May 9, 2019 at Alibaba Cloud Computing (Beijing) Co., Ltd. and until now 02201.net has been living for 264 days (About 264 days ).
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Domain Name: 02201.NET Registry Domain ID: 2388948131_DOMAIN_NET-VRSN Registrar WHOIS Server: grs-whois.hichina.com Registrar URL: http://www.net.cn Updated Date: 2019-05-19T05:24:45Z Creation Date: 2019-05-09T09:41:46Z Registry Expiry Date: 2020-05-09T09:41:46Z Registrar: Alibaba Cloud Computing (Beijing) Co., Ltd. Registrar IANA ID: 420 Registrar Abuse Contact Email: DomainAbuse (at) service.aliyun.com Registrar Abuse Contact Phone: +86.95187 Domain Status: ok https://icann.org/epp#ok Name Server: F1G1NS1.DNSPOD.NET Name Server: F1G1NS2.DNSPOD.NET DNSSEC: unsigned URL of the ICANN Whois Inaccuracy Complaint Form: https://www.icann.org/wicf/ >>> Last update of whois database: 2019-06-12T11:32:37Z <<< For more information on Whois status codes, please visit https://icann.org/epp NOTICE: The expiration date displayed in this record is the date the registrar's sponsorship of the domain name registration in the registry is currently set to expire. This date does not necessarily reflect the expiration date of the domain name registrant's agreement with the sponsoring registrar. Users may consult the sponsoring registrar's Whois database to view the registrar's reported date of expiration for this registration. TERMS OF USE: You are not authorized to access or query our Whois database through the use of electronic processes that are high-volume and automated except as reasonably necessary to register domain names or modify existing registrations; the Data in VeriSign Global Registry Services' ("VeriSign") Whois database is provided by VeriSign for information purposes only, and to assist persons in obtaining information about or related to a domain name registration record. VeriSign does not guarantee its accuracy. By submitting a Whois query, you agree to abide by the following terms of use: You agree that you may use this Data only for lawful purposes and that under no circumstances will you use this Data to: (1) allow, enable, or otherwise support the transmission of mass unsolicited, commercial advertising or solicitations via e-mail, telephone, or facsimile; or (2) enable high volume, automated, electronic processes that apply to VeriSign (or its computer systems). The compilation, repackaging, dissemination or other use of this Data is expressly prohibited without the prior written consent of VeriSign. You agree not to use electronic processes that are automated and high-volume to access or query the Whois database except as reasonably necessary to register domain names or modify existing registrations. VeriSign reserves the right to restrict your access to the Whois database in its sole discretion to ensure operational stability. VeriSign may restrict or terminate your access to the Whois database for failure to abide by these terms of use. VeriSign reserves the right to modify these terms at any time. The Registry database contains ONLY .COM, .NET, .EDU domains and Registrars.
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text:
Lots of men like kids
I simply have to comment on Phoebe Weiskopf's answer to your "Question of the Week" about the much loved Mr. Rogers [March 6] (http://www.readthehook.com/93153/question-week-what-did-you-think-mr-rogers), and her statement that "It's unnatural for a man to have that much interest in children's affairs."
How about the wonderful fathers today who take over many duties connected with raising children, sometimes even to the extent of being "stay at home Dads"? They give bottles and change diapers just as willingly as their wives who may be at work. How about those who make numerous arrangements in order to attend a child's sporting event and go to school for parent conferences?
And how about the small children who have no one to show them love and attention at home? Their baby-sitter is often TV with its violence and wrenching personal stories. Both parents often have jobs and don't have time or energy to give the support young children need.
One mother told me that her child said to her as she watched Mr. Rogers, "He's my friend."
And how about pediatricians and psychiatrists who devote their careers to working with children? There are good and kind men out there who are doing what is natural, helping to care for their young, and they are not one bit less masculine.
I hope Ms. Weiskopf meets one some day.
Naomi Wallace


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Gov. Dannel P. Malloy in a press release urged residents to avoid travel during the first significant snowstorm of the season. The National Weather Service has issued Winter Storm Watches for most of the state from tomorrow afternoon until Sunday morning.
"Although this does not appear to be a major storm, it does have the potential to produce a significant amount of snowfall and create hazardous driving conditions," said Malloy in the release. "I am asking residents to use caution as they head out on Saturday and to limit their travel during the height of the storm beginning at 8 p.m. on Saturday night."
Total snow accumulations are currently forecasted to range from 6" to 9" in Southern Connecticut and up to 10" to 14" in Northern Connecticut. Travel is expected to become very hazardous after midnight with heavy snow blowing across roads and Northeast winds 15 to 25 mph gusting to 35 mph at times.
The Division of Emergency Management and Homeland Security (DEMHS) will continue to monitor the storm's progress and is ready to coordinate any response or assistance that may be necessary.


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Texans WR Kevin Walter went on The Big Show on 790 in Houston this morning to talk Sunday's battle for the heart of the AFC South. You can listen to the whole interview over there, but we've pulled out the bulletin board material, as the kids like to say. Walter, who will probably be covered by Finnegan with Andre Johnson out, had some choice things to say about the man who drove the mild-mannered Johnson to blows last year.
But, because football players are diplomatic and boring, of course he says he'd love to have Finnegan as a teammate.


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Pelvic Inflammatory Disease (PID)
Pelvic inflammatory disease or PID is an infection of a woman's reproductive tract. It can affect the uterus, fallopian tubes, and the ovaries. Scar tissue grows between internal organs leading to ongoing pelvic pain. It can also lead to ectopic pregnancy. This is when the fertilized egg grows outside the uterus. If left untreated, PID can lead to chronic infection. Also, you may not be able to get pregnant.
Bacteria cause PID. Often the same type of bacteria that causes sexually transmitted diseases (STDs). PID may also develop if bacteria travel through the vagina and the cervix from the use of an intrauterine device (IUD).
Women of any age can get PID. But, those at greater risk of PID from sexually transmitted bacteria include:
- Women under 25 who are sexually active
- Women of childbearing age
- Women who use intrauterine devices (IUDs)
These are the most common symptoms of PID.
- Pain and tenderness spread throughout the lower part of the belly
- Pelvic pain
- Increased foul-smelling vaginal discharge
- Fever and chills
- Vomiting and nausea
- Pain during urination
- Belly pain (upper right area)
- Pain during sex
The symptoms of PID may look like other conditions or health problems. Always talk with your healthcare provider for a diagnosis.
Your healthcare provider will do a medical history and a physical and pelvic exam. Other tests may include:
- Exam of vagina and cervix samples under a microscope
- Blood tests
- Pap test. For this test, cells are taken from the cervix and checked under a microscope. It's used to find cancer, infection, or inflammation.
- Ultrasound. This test uses high-frequency sound waves to make an image of the organs.
- Laparoscopy. This is a minor procedure done using a laparoscope. That is a thin tube with a lens and a light. It is inserted into an incision in the abdominal wall to view the reproductive tract.
- Culdocentesis. For this test, a needle is inserted into the pelvic cavity through the vaginal wall to get a sample of pus.
Your healthcare provider will discuss the best treatment with you based on:
- How old you are
- Your overall health and medical history
- How sick you are
- How well you can handle specific medicines, procedures, or therapies
- How long the condition is expected to last
- Your opinion or preference
Antibiotic pills are used to treat PID, especially if it's due to a STD. For severe infection, you may need to stay in the hospital for intravenous (IV) antibiotics. Sometimes, surgery is needed.
- Pelvic inflammatory disease (PID) is an infection of a woman's reproductive tract. It can affect the uterus, fallopian tubes, and/or the ovaries.
- Left untreated, chronic infection and infertility can develop.
- It is caused by bacteria, often the same type of bacteria that causes STDs.
- Sexually active women under age 25, and those of childbearing age are at the greatest risk of getting PID from an STD.
- PID can cause pelvic pain, belly tenderness, vaginal discharge, fever, chills, and pain during urination and sex.
- Treatment includes antibiotics, especially if you have a STD.
- Know the reason for your visit and what you want to happen.
- Before your visit, write down questions you want answered.
- Bring someone with you to help you ask questions and remember what your provider tells you.
- At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
- Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
- Ask if your condition can be treated in other ways.
- Know why a test or procedure is recommended and what the results could mean.
- Know what to expect if you do not take the medicine or have the test or procedure.
- If you have a follow-up appointment, write down the date, time, and purpose for that visit.
- Know how you can contact your provider if you have questions.
January 16, 2018
Pelvic Inflammatory Disease (PID). American College of Obstetricians and Gynecologists, Pelvic inflammatory disease: Pathogenesis, microbiology, and risk factors. UpToDate, Pelvic inflammatory disease: Clinical manifestations and diagnosis. UpToDate, Pelvic inflammatory disease: Treatment. UpToDate
Reviewed By:
Burd, Irina, MD, PhD,Freeborn, Donna, PhD, CNM, FNP


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Brendon S needed a new logo design and created a contest on 99designs.
A winner was selected from 31 designs submitted by 14 freelance designers.
Brain Life Trust need life giving, vitality evoking new logo.
Brain Life Trust
Desired Color Scheme:
Blue, yellow
This new business using online testing to aid brain function (mostly in older people) by re-invigorating various channels.
The logo needs to indicate:
life giving
vitality evoking
health and vigour
with a brain featured, perhaps a flash of inspiration/electricity/etc going through.
Please note I'm going away for the weekend, so cannot provide feedback until Monday. Thanks and good luck.
Preferred colors: Dali/Windows screen blue
Find out how a design contest works or learn more about our logo design services.


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Classes, Screenings & Support Groups
Insulin Pump Support Group
This support group provides information and support for individuals using an insulin pump and anyone interested in learning more about pump therapy. Please call (925) 941-5076 for more information about topics, dates, and times.
Cost: FREE
Register for any three fee-based* classes during one transaction and receive a 20% discount.
(* some exclusions may apply)
(* some exclusions may apply)


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SPOKANE, Wash. - Jasmine Hassell scored six of her 13 points in the final 3 minutes and fourth-seeded Georgia beat top-seeded Stanford 61-59 on Saturday night to reach the NCAA women's regional finals for the first time since 2004.
Georgia overcame three major scoring droughts, including falling behind 9-0, to oust the No. 1 seed from the Spokane Regional and end Stanford's hopes of reaching the Final Four for the sixth straight year.
Jasmine James led Georgia (28-6) with 16 points, including a pair of free throws with 23.5 seconds left that gave the Lady Bulldogs a 60-56 lead. It's the 11th trip to the regional finals for coach Andy Landers in his long tenure at Georgia.
Chiney Ogwumike led Stanford (33-3) with 26 points, but was held to eight points in the second half. She also had 12 rebounds.
Tiaria Griffin scored 13 points, and Shacobia Barbee added nine as the Lady Bulldogs turned in another superb defensive effort to stymie Stanford and ruin any hopes of a Pac-12 showdown with No. 2 seed California in the regional final.
Georgia will play for a trip to the Final Four on Monday night against either the Golden Bears or No. 6 seed LSU. Georgia has not made the Final Four since 1999. Georgia reached the round of 16 in 2005-07 and 2010-11, only to get ousted at that stage each time, including a 73-36 loss to Stanford in 2010.
Amber Orrange added 17 points for Stanford, but was only 7 of 24 from the field. The Cardinal shot 29 percent in the second half and struggled to find open looks for Ogwumike, who was dominant with 18 points in the first half. Ogwumike simply didn't have enough of a supporting cast. Second-leading scorer Joslyn Tinkle struggled with foul trouble in the first half and went more than 35 minutes of game time without scoring. She finished with five points.
Georgia overcame a 5-minute scoreless drought to start the game, another 5 minutes with just two free throws late in the first half and another 7-minute lapse in the second half with just one basket that allowed Stanford to build a 42-34 lead with 11:50 remaining.
Still, the Lady Bulldogs were hanging around because Stanford made just 3 of 20 shots to start the second half. Georgia scored eight straight points, capped by a basket from Hassell to pull even at 42 with 8 minutes left.
The lead then went back and forth over the closing minutes with neither team leading by more than four points. Orrange dropped in a 16-footer for a 50-46 Stanford lead with 4:22 remaining, before Georgia's closing surge.
Barbee converted a three-point play and after Ogwumike followed Orrange's miss with a basket, Anne Marie Armstrong knocked down a 3-pointer for a 52-all tie. Orrange hit a 3, but Hassell hit consecutive shots and Georgia was back in front 56-55 with 1:45 left.
Mikaela Ruef missed in close twice and was fouled on the third attempt with 1:21 left. Ruef, a 53 percent free throw shooter on the season, split the pair for the fifth tie of the game, but Hassell answered right away for Georgia for a 58-56 lead with 1:02 left. Tinkle then lost control of a pass underneath. Georgia ran the clock before Griffin missed a 3. Barbee got the offensive rebound and James was fouled with 23.5 seconds left. She hit the pair for a four-point lead.
Stanford struggled to get a good look, but Tinkle finally hit a 3 with 5.1 seconds left. Georgia threw long to James on the inbound pass and the Lady Bulldogs were able to run off all but the final 0.8 seconds before Barbee was fouled. She split her free throws for the final margin and Georgia ran off the floor celebrating the upset.


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With our bespoke mouldings service we are able to match exactly any profile that you have. Simply send us a physical sample of the existing mould to the address below or send us an accurate drawing of the profile, including detailed measurements to the email address email@example.com.
TimberCut4UElm Park SawmillsLevenFifeKY8 4PS
Firstly we need a physical sample or a drawing of the moulding that you wish us to produce and the quantity required. As we need to produce tooling for bespoke items, the minimum charge is £100.00 per item. Material costs are then added on top of this depending on the volumes required.
0 products£0.00
Like what you see? Click on the icons in the top right of the image for more options.
Silktrim is one of the UK's leading brands in MDF mouldings. The range on this site includes architraves and skirting.
"Versatility, consistent high quality, extensive choice and ease of application...the advantages of specifying Silktrim are clear."
Silktrim mouldings are manufacturerd using Moisture Resistant MDF, and are twice primed as standard, with a minimum of two coats of a high solid content, water-based, white acrylic paint applied to the surface. This makes Silktrim mouldings a consistent high-quality you can trust.
As Silktrim MDF mouldings have two coats of priming paint added, they are supplied and delivered to you in semi-finished form.
This 5mm Rad profile is a more contemporary design with clean lines, giving a more modern look to the more traditional moulding types.
Our mouldings are all spiral wrapped before shipping to protect them from damage in transit.
DISCLAIMER Timber is a natural product and may differ from the sample seen in colour and figure. Certain species of timber will contain a small percentage of sap and knots in line with international grading standards.
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PLEASE NOTE:The prices quoted are for a single side of a door. If you require an architrave for both sides, you will need to double the quantity required.
Please choose your requirements from the options below and click the Calculate Price button for pricing and delivery information.


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Burlington, NC Office
Home health care services in Greensboro, NC
Winner of the SeniorAdvisor.com 2018 Best of Home Care award
- Awarded to fewer than one percent of providers nationwide -
This is the 4th year in a row that we are honored with this award!
9 Options offices received the 2019 award - View Winning Offices
SAGECare Platinum Certified
Our Pledge
OPTIONS CORP is dedicated to helping senior adults cope with the expediencies of everyday life. We do that in the comfort and safety of our care recipients' homes. We provide distant or busy families with a break from daily care giving responsibilities, and reassure them that their loved ones are attended to by the team that has the most experience and the widest resources.
Our Mission
"To provide respect, compassion and empowerment to seniors by supporting their dignity, encouraging their independence and appreciating their uniqueness as they remain in the comfort of their own home."
Office Locator For Territories We Serve


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Slim & Skinny Classic Band
from $110.00 USD
Designed to match several of our engagement rings, our 2mm Low Dome Band is a minimal, sleek, and low-profile wedding band option.
The warranty does not include normal wear and tear, damage made by the customer, loss or theft. Any alterations or repairs made to the jewelry by someone other than Aide-mémoire Jewelry voids the warranty. The customer is responsible for all shipping charges.
Please note regular maintenance and periodic restoration work is to be expected on fine jewelry to maintain its integrity. This is especially true with rings since they are a very high wear item. Rings with prongs should be taken in to a local repair shop on a regular basis to be inspected and re-tipped when necessary.
If you are interested in insuring your jewelry, we have more information on that here.
from $110.00 USD
from $135.00 USD
from $145.00 USD


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Arduino: d2, highArduino > PC: [request_data](ao terminar transmissão) d2, lowPC > Arduino: [data]
void controlPin(uint8_t controlBusPin){ controlBusDirection = controlBusPin; pinMode(controlBusPin, OUTPUT);//Pin that Control Data Direction digitalWrite( controlBusPin,HIGH);//Enable Transmitter,Disable Receiver on default state}
/transmitMode set the control pin HIGH to enable the RS485 transivervoid txMode(){ digitalWrite(controlBusDirection,HIGH);//Enable Transmitter,Disable Receiver }void rxMode(){ digitalWrite(controlBusDirection,LOW);//Enable Transmitter,Disable Receiver }
I usually use Thread.Sleep(xxxx) where XXX is in miliseconds.you need to add "Using System.Threading" as well.Also I usually introduce Application.DoEvents() here and there to make the GUI more responsive. adding Application.DoEvents() can also slow it down slightly.
you need to add "Using System.Threading" as well.


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Dedicated to the sound management of government financial resources, GFOA provides professional development training opportunities to state, provincial, and local level government officials and other finance practitioners each year. Training courses are presented as basic, intermediate, advanced, update, or overview.
- Group-live courses - Take advantage of training close to home or in your area by participating in a one or two-day seminar with a GFOA instructor
- Immersion courses - Maximize your training opportunities by taking part in GFOA's week-long Accounting or four-day Budget Academy.
- Internet-based seminars - Enjoy the convenience of training at your desktop by viewing GFOA's one or two-hour presentations
- Live-Streaming courses - Save on travel by watching a live video stream of the training on your computer
- Preconference and annual conference sessions - Thousands of public finance professionals gather each year for this three-day conference to share ideas, develop technical and managerial skills, view new products, and network with peers.
Group Discounts: To qualify for group discounts, registrations must be received and paid together. The discount cannot be applied to online registrations processed through GFOA's e-store.


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(Phoenix, Ariz. -- September 17, 2010) Attorney General Terry Goddard today announced that Janet Thor, 59, of Phoenix, a former principal in the Kyrene School District, has pleaded guilty to one count of theft and one count of misuse of public monies related to her stealing more than $34,000 from two public schools where she worked.
She will be sentenced Oct. 18 in the courtroom of Maricopa County Superior Court Commissioner James Rummage. The terms of the plea agreement call for Thor to be placed on supervised probation. Thor has paid the full amount owed in restitution.
Thor is alleged to have taken money donated to two schools where she was principal and used it for personal expenses. The indictment states that while Thor was principal at Kyrene de los Cerritos Elementary School, she stole over $18,000. These funds were gifts to the school from parents, business organizations and the school's PTO.
Thor became principal at Cerritos on July 1, 2004. On July 1, 2007, she became the principal at Kyrene del Cielo. Between that date and her resignation in April of 2009, Thor is alleged to have stolen over $15,000. These funds were also donations from parents, community members and business organizations intended to benefit the school.
"This is a tragedy for a trusted principal to steal money donated to her schools," Goddard said. "The one positive note is that those funds have now been fully repaid by the defendant."
The case was prosecuted by Assistant Attorney General Michael Flynn. The investigation was conducted by the Kyrene School District, Tempe Police Department and the Auditor General's Office.
For more information, contact Press Secretary Molly Edwards at (602) 542-8019.


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NASHVILLE, Tenn.-Lipscomb Lady Bisons softball coach Kristin Ryman will welcome six new players for the 2013-14 academic year.
There are two main themes for this class - versatility and pitching.
"Our goal is always to bring in players who can immediately step in and challenge our older girls," Ryman said. "If they are talented enough to play at a young age, they are going to gain a ton of experience and make our program better down the road.
"Our plan with this class was to focus on good athletes and pitching. We are losing two of our best all-around athletes in Kelsey Cartwright and Bree Thurman, and we wanted some versatile players who could fill multiple roles for us."
One of the additions is Mikayla "Mimi" Cartwright, Kelsey's sister. Both of her parents are also Lipscomb alumni. Mimi, 5-foot-5, fills the versatility role as a third baseman, second baseman and outfielder. She plays for Goodpasture Christian School where she won the team most valuable player award in 2012. She has been named TSWA All-State, 2012 MTCA AA All-Middle Tennessee and First Team All-Midstate.
"Mimi is a true utility player and will immediately be able to fill multiple roles for us," Ryman said. "She has extensive experience playing both third base and middle infield, has the athleticism to play outfield, and has also pitched at every level."
"Mimi is a very consistent, finesse type of player who has a lot of natural athleticism. She will be able to drive the ball well to all fields, which will allow her to contribute and be a factor in our lineup early on in her career. Ultimately, she will be that player who will challenge everyone all over the field to get better because she can do so many things well."
Mimi is also accustomed to winning. While at Goodpasture she has played on one Class AA State Championship team and two State-Runners-up.
"She is a great fit for us," Ryman said. "We are excited to see Mimi grow and develop more in our system, and we look for her to come in and challenge right away."
Rebecca "Becca" Dean, 5-6, is an outfielder-second baseman from Liberty-Benton High School in Findlay, Ohio. She set school records in 2012 for batting average (.612), stolen bases (43) and runs scored (37). Her career stats are a .531 batting average with 106 stolen bases and 95 runs scored.
She is also exceptional in the classroom with a 4.0 grade point average.
"Becca just recently made her decision to attend Lipscomb, and we are very excited that she did," Ryman said. "She is a speedy utility player who will add depth to both the outfield and middle infield.
"We will look for her to compete mostly in the outfield with her ability to read the ball and get good jumps. Becca is also a lefty hitter which will give us options with our lineup. We are excited to have more players in this class that can put pressure on the defense with their speed, and Becca will be a base-stealing threat every time she gets on."
Dean is a three-time team MVP, three-time All-District performer and three-time team captain. She has also been named to the All-State team once.
"She is a leader by example and quietly goes about her business and gets the job done," Ryman said. "Like our other signees, she is also a great student and will impact our program with her work ethic."
Kasey Gibson, a 5-5 outfielder from Churubusco High School in Churubusco, Ind., is expected to make an immediate impact.
"Kasey has great speed and has experience playing all three outfield positions which makes her immediately valuable," Ryman said. "At the plate, she is a lefty slapper who is very smart and able to get on base in multiple ways. She is a table-setter type of player who has great discipline and works extremely hard to improve her game."
She is an NFCA Second-Team All-Region Player in 2011 and 2012. She was a first team All-State selection in 2012. For the past two seasons she has served as team captain.
Gibson is a career .533 hitter and is second on the all-time stolen base list in Indiana.
"Kasey will be a very coachable player, and to us that is one of the best qualities a player can have," Ryman said. "She understands the game and has a great approach at the plate. She knows how to go to the plate with a plan and execute…again, a great quality to have as a young player.
"She has been well-trained and has been very steady and successful against the best. Kasey knew she wanted a smaller school, and once we were able to get her on campus, she fell in love with Lipscomb. Overall, she is a great fit for our program…she is a great person, a strong student, and a player who will make our program better."
Whitney Jordan, 5-9, is expected to be an impact player in the middle infield. She is a shortstop-second baseman from Athens High School in Athens, Ala.
She has won a number of honors. In 2011 she was the Alabama 5-A Hitter of the Year, an Alabama Super All-State and 5-A All-State team member. In 2010 she was also a member of the 5-A All-State Team.
"Whitney is a strong, athletic middle infielder who will impress with her defense, and she is a power-hitting right-hander who will compete in the middle of our lineup," Ryman said. "Whitney possesses quick hands at the plate and has a lot of homerun potential at this level. She has a feistiness about her hitting that will add a spark to the way we play.
"She is a tireless worker, and through the recruiting process, we were consistently impressed with her overall athleticism and how she plays the game. She knows how to win, and we are excited to see how much more she can improve at the next level. Whitney will be a fun player to watch for years to come."
The Lady Bisons are always searching for ways to bolster the pitching rotation. Ryman and her staff are confident they have found two good prospects to join Ashley Anderson, Tanner Sanders and Heather Parker.
Taylor Neuhart is a right-handed pitcher who can also play first base. She plays for Hayfield Secondary School in Alexandria, Va.
"Taylor will bring nice diversity to our staff," Ryman said. "She is an extremely hard worker with nice movement and a great change. She is going to be a great complement to the pitchers we already have, and will have the ability to either start or pitch in relief. She knows how to enter in relief in tough situations and get outs, and that is rare for an incoming freshman."
Neuhart, 5-6, is a two-time All-Region and three-time All-District performer. She was the team MVP in 2012 and returns as the team captain for 2013.
She struck out 240 batters in 2012 and has six no-hitters in her high school career.
"Taylor is very coachable which is going to allow her to get better quickly," Ryman said. "On top of her pitching, Taylor has the ability to hit and play a good first base.
"She is a smart player who will be a true student of the game. Taylor knew that Lipscomb was the place for her when she arrived in Nashville and walked on campus. She will be a great fit for us, and her versatility will potentially allow for her to be more than just a pitcher."
McCarley Thomas is also a right-handed pitcher with experience as a first baseman. She plays for Lipscomb Academy and is from Brentwood, Tenn.
"When we think about McCarley the first word that comes to mind is potential," Ryman said. "She has a tremendous amount of ability and is working to get every ounce out of her 6-1 frame.
"She has had a few setbacks over the last year, but we feel that with more advanced instruction, she can grow leaps and bounds at the next level. She is a hard-throwing right-hander with really good raw tools. She also has experience hitting in the middle of the lineup, and we look forward to exploring her power potential at this level."
She is a three-time All-District team member and was All-District Player of the Year in 2012. She also served as team captain in 2012.
"McCarley wants to learn and is another player that is extremely coachable," Ryman said. "She has a great work ethic, and that shows in every aspect of her life. She is very familiar with our campus and the expectations of our program. We are thrilled to welcome her family into ours."
One of Ryman's main goals in recruiting has been to build team depth. She likes the options these new players provide.
"Everyone has their "off" days, but our goal is to put the best nine hitters in the lineup every game," Ryman said. "The more versatile they are defensively, the better chance we have to adjust and have a solid lineup every day.
"Our depth is getting better and better to the point where we have really great options coming off the bench. That is something that separates good teams from great teams. When you have players that are going to challenge each other every day in practice, the competitive edge builds and the bar is raised. We are not going to settle for finishing in the top half of the A-Sun…our goal is championships and consistent trips to the NCAA Tournament."
Written by Mark McGee, Senior Publisher/Director of Media Relations.


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Aloha from DLNR!
Mission Statement
The OCCL is responsible for overseeing approximately 2 million acres of private and public lands that lie within the State Land Use Conservation District. In addition, to privately and publicly zoned Conservation District lands, OCCL is responsible for overseeing beach and marine lands out to the seaward extent of the State's jurisdiction.


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StoryCorps Shorts: A Life, Complete
Special | 2m 20s
John Banvard and Jerry Nadeau are military veterans who served in World War II and Vietnam, respectively. John, 100, and Jerry, 72, sat down at the veterans home where they live to reflect on nearly 25 years together.
Aired: 01/30/19
Expires: 01/30/23Video has closed captioning.
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Major funding for POV is provided by PBS, The John D. and Catherine T. MacArthur Foundation, the John S. and James L. Knight Foundation, Bertha Foundation, Marguerite Casey Foundation, Corporation for Public Broadcasting, National Endowment for the Arts and the New York State Council on the Arts, with special support from The Fledgling Fund.