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This may be the biggest innovation in the history of rifle making! The new Rossi
W's revolutionary stock design allows you to shoot with every popular caliber imaginable, plus all shotguns, two muzzleloaders, .22 Rimfire and .22 Rimfire Magnum. Simply choose which barrels you want and you're ready to go.
The W's ingenious design allows you to transfer any barrel quickly and easily. It's like having 23 rifles and shotguns in one! The W is the year round system for every hunting and shooting application truly a gun for all seasons.

subset: commoncrawl


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Discuss House's Season Premiere here.
When Della (Alyson Stoner), a seemingly healthy and active 14-year-old, suddenly collapses during a skateboarding exhibition, House and his team struggle to diagnose her condition and reassure her parents who already have to cope with their son's terminal illness. After her body rejects a donor lung, and with time running out to save her life, Della's family is left with little hope of securing a new donor and faced with a seemingly impossible decision regarding the fate of both children. Meanwhile, House tries to appease an elderly father and his son at the clinic, as he and Cuddy begin facing the challenges of taking their romantic relationship into the workplace.
BTS Photos
Sneak Peeks


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Search not working on my IIS 5 Web site
I'm trying to get search to work on my IIS 5 Web site (Windows 2000 Server standalone) but I get the error HTTP 403.1 Forbidden: Execute Access Forbidden. What rights do I need to change to get this search to work?
I'm not sure what application you're using for the search, but it's odd that it requires Execute permissions. Well, if you view the virtual directory that your application lives within, you'll see the option of choosing between Scripts Only and Scripts And Executables. You need to select Scripts And Executables.
It's dangerous to enable executables, so please do read up on IIS security issues: http://www.microsoft.com/technet/security/prodtech/iis/.
Dig Deeper on Microsoft Internet Information Services (IIS)
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Please add a title for your question
Get answers from a TechTarget expert on whatever's puzzling you.
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According to general relativity, the frequency of electromagnetic radiation is altered by the expansion of the universe. This effect—commonly referred to as the cosmological redshift—is of utmost importance for observations in cosmology. Here we show that this redshift can be reproduced on a much smaller scale using an optical analogue inside a dielectric metamaterial with time-dependent material parameters. To this aim, we apply the framework of transformation optics to the Robertson-Walker metric. We demonstrate theoretically how perfect redshifting or blueshifting of an electromagnetic wave can be achieved without the creation of sidebands with a device of finite length.
©2010 Optical Society of AmericaFull Article | PDF Article
OSA Recommended Articles
Damián P. San-Román-Alerigi, Ahmed B. Slimane, Tien K. Ng, Mohammad Alsunaidi, and Boon S. Ooi
Opt. Express 21(7) 8298-8310 (2013)
Fei Sun, Yichao Liu, Fanglin Bao, and Sailing He
Opt. Express 25(10) 11065-11077 (2017)
Sangeeta Chakrabarti, S. Anantha Ramakrishna, and Harshawardhan Wanare
Opt. Express 16(24) 19504-19511 (2008)


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Enable Two-Finger Scrolling in Ubuntu
Here's a small hack I stumbled across in the Ubuntu Forums: you can enable support for two-finger scrolling on your Synaptics touchpad with a couple lines added to the "synaptics" section of your /etc/xorg.conf.
Option "VertTwoFingerScroll" "1"
Option "HorizTwoFingerScroll" "1"
Here's what the entire section looks like for me:
Section "InputDevice"
Identifier "Synaptics Touchpad"
Driver "synaptics"
Option "SendCoreEvents" "true"
Option "Device" "/dev/psaux"
Option "Protocol" "auto-dev"
Option "HorizScrollDelta" "0"
Option "VertTwoFingerScroll" "1"
Option "HorizTwoFingerScroll" "1"
There are a lot more options described in the forum thread linked above, like assigning a different mouse click to each corner of the touchpad. Once you make these changes, just restart X (or your computer), and you should be able to scroll with your fingers!
I'm running Ubuntu Feisty with the latest version of the Synaptics driver (synclient -V says 0.14.6), but I think this should work with any distribution or desktop environment, assuming you're using the Synaptics driver. Additional configuration instructions can be found in the Ubuntu Community Documentation.


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One of the great traditions of film festivals everywhere is a trailer produced by either a well-known or inspiring filmmaker every year to encourage attendance. Depending on such things as size and budget, the hope is that the commissioned piece, even as a teaser, becomes a short film unto itself.
And the Chesapeake Film Festival is part of that club. Year after year, filmmakers are selected to entice and intrigue viewers to take a break and come to see the film screenings. And this year it has been produced by Talbot County's Kindall Rende of 3 More Frames. The Spy received an early preview copy to share for the CFF which starts October 11.
This video is approximately two minutes in length. For more information on the Chesapeake Film Festival for 2018 please go here


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Sell anything,anywhere,anytime!
Neat and well kept three bedroom double stack townhouse with build in cupboards newly revamped bathroom and a guest toilet downstairs. This is a must see. Call met today to view this stunning townhouse.
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I love random holidays: National Hot Dog Day (which was yesterday), National Slushie Day (a few weeks ago), and National Doughnut Day (back in June). Who doesn't like celebrating their favorite foods and treats?
Today is National Tequila Day and you better believe I will be celebrating with a margarita or two on the plane to Texas tonight. If you are wanting to indulge as well check out my Go-To Margarita Recipe Here.
Delicious, easy, and minus all that sugary syrup you find in a mix.
|My mom and I always make a few when I am home.
But, if you don't feel like playing mixologist you can always indulge in my favorite quick version :
|Gosh, I love these things!


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Every boy should have two things: a dog, and a mother willing to let him have one. ~ Anonymous
Bailey is our 1 1/2 year old Chocolate Lab.
Bailey is our 1 1/2 year old Chocolate Lab.
Then grew into a lanky pup full of energy.
Her job was to roam the fields and to find the best puddles.
She has also become very helpful cleaning up debris.
Plus, she is great about challenging the boys to a good race.
When the boys are outside, she is by their side. If she's not dropping a ball gently at their feet for a game of fetch, she is lying nearby watching them. If someone comes into the yard, she immediately takes her bodyguard stance between the stranger and her boys. She makes it known that she is their protector.
She may be crazy, goofy, unpredictable and every bit puppy, but what she is truly good for is protection, loyalty and love!
This post is part of the Blogging Through the Alphabet series at Ben and Me, so check out what others are talking about this week! Also linked to Pet Parade, so if you're an animal lover, head on over!
©2011-2013 Mom's Heart. All rights reserved. All text, photographs, artwork, and other content may not be reproduced or transmitted in any form without the written consent of the author. http://www.moms-heart.blogspot.com


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Animal Welfare Basics
Our Standards for How the Animals Are Raised
If you're looking for more than great taste and freshness in meat and poultry, we're here for you. We believe that quality on the table has a lot to do with quality of care in raising the animals. Over decades we've developed true partnerships with farmers, ranchers and animal-welfare experts to ensure the treatment of animals is guided by care, responsibility and respect.
No Added Hormones
Giving hormones to animals raised for meat accelerates their growth, getting animals to market faster and reducing feed costs. We believe that good management and focus on the animals' well-being is all the growth incentive they need! Our quality standards for our meat department have always prohibited the administration of hormones. This includes for beef cattle and lamb, the only two species for which the USDA permits the use of hormones. Beta agonists, which are used to enhance the development of lean muscle tissue in livestock, are also prohibited.
No Antibiotics, Ever
Farm animals are given antibiotics for different reasons. Some producers administer them regularly to prevent disease and promote growth. This is an unnecessary practice that we have always prohibited for products in our meat department. In 2002, we deepened our meat department standards to also prohibit antibiotics for treating disease or infection. The health of livestock is maintained by good management, including innovative practices and alternative remedies found effective in treating animals. To ensure that sick animals do not suffer, if an injury or illness does not respond to alternative methods, we require that the animal is treated; however, the meat from that animal cannot be sold to Whole Foods Market meat department.
Animal Care
Caring for farm animals goes beyond prohibiting antibiotics and added hormones. We also take into account the comfort, physical safety and health of the animals. For everything in our meat department, we require producers to verify that their practices meet our requirements. Our meat standards outline our requirements, species by species. For fresh beef, pork, chicken, lamb and turkey (except kosher turkey), we require certification by Global Animal Partnership's 5-Step Animal Welfare Rating, which encourages and rewards farmers and ranchers for continually improving their animal-welfare practices. We require kosher turkey farms to be third-party audited to meet our animal welfare standards.
We also have animal welfare standards for hens that lay eggs. All eggs we offer in our dairy case are cage-free, and we're going beyond that with our Whole Foods Market Animal Welfare Standards for Laying Hens. All eggs used in our own kitchens and bakeries are cage-free, too.
The way farm animals are raised and treated on the farm or ranch is only part of the story. We also require third-party audits of animal welfare at slaughter plants. The criteria and areas of evaluation were developed by animal-welfare expert Dr. Temple Grandin, and they include:
- Condition of animals upon arrival
- Calm, efficient unloading procedures
- Animals handled with patience, skill and respect
- Well-designed and –maintained facility ensuring quiet movement of animals
- Non-slip flooring and ramps to reduce the risk of injury to the animals
- Critical stunning efficacy requirements
- 99% successful stun at first attempt
- 100% of animals unconscious before slaughter
- Proper condition and upkeep, plus regular testing of all equipment
What Else Makes Our Meat Different
Our meat department has some of the strongest standards in the business, and in our stores. Here's more info about what goes into our high-quality meat and poultry.


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Clacton And District Local History Society
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Why ACA Enrollees Need Support After They Sign Up
Providing support for Affordable Care Act enrollees to connect with care they are happy with can help minimize the risk that they will stop seeking routine health care.
Oct 11, 2017 The Hill
Open Enrollment, Take 2: What Matters for the ACA Marketplace?
As the Affordable Care Act's second open-enrollment period draws to its February 15 close, relatively few of the millions of Americans eligible to switch plans have revisited their options. What actions can be taken to ensure that people know they have the right to a new choice each year?
Feb 11, 2015 The Health Care Blog
RAND Helps to Develop From Coverage to Care, a New CMS Initiative
Health coverage is a means to an end: the aim is to help more Americans use their coverage to access routine primary care and preventive services. For many of the newly insured, however, the leap between obtaining insurance and establishing a regular source of care is substantial.
Jul 29, 2014 The RAND Blog
Quick Takes: Health Literacy and ACA Enrollment
The Affordable Care Act (ACA) expands coverage to millions of Americans. But the newly eligible may face challenges enrolling if they lack understanding of how the health care system itself works. Laurie Martin explains the role of health literacy in determining how successful the ACA will be in providing coverage for America's uninsured.
Nov 7, 2013 The RAND Blog
Next Big Obstacle for Obama's Affordable Care Act? It's Not Just the Supreme Court
The success of the Affordable Care Act to enroll those newly eligible in an appropriate insurance plan depends on clear communication to individuals who have limited health literacy, write Laurie T. Martin and Ruth M. Parker.
Oct 3, 2011 Christian Science Monitor
Insurance Expansion and Health Literacy
The ongoing evolution of the health care system is leading US households toward greater responsibility for their own well-being. With this responsibility, however, comes an increasing need to be able to find, trust, use, and act on relevant information to make informed choices, write Laurie T. Martin and Ruth M. Parker.
Aug 9, 2011 The Journal of the American Medical Association


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Diabetic Nephropathy
Diabetes is the most common cause of end-stage renal disease (ESRD) in the United States today.1 Approximately 40% of patients with type 1 diabetes and 5 - 15% of patients with type 2 diabetes eventually develop ESRD, although the incidence is substantially higher in certain ethnic groups.2
This is thought to be a potentially preventable calamity. Sensitive tests are available to identify patients with renal involvement early in the clinical course, when preventive measures may have greatest impact. For these reasons, it is imperative that clinicians who care for patients with diabetes be knowledgeable about diabetic nephropathy and attentive to its prevention, onset, progression, and treatment in their patients.
The pathophysiologic mechanisms of diabetic nephropathy are incompletely understood but include glycosylation of circulating and intrarenal proteins, hypertension, and abnormal intrarenal hemodynamics. The earliest demonstrable abnormalities include intrarenal hypertension, hyperfiltration (increased glomerular filtration rate [GFR]), and microalbuminuria. Clinically, the most important screening tool for identifying early nephropathy is detection of microalbuminuria.
Risk factors for development of diabetic nephropathy include hyperglycemia, hypertension, positive family history of nephropathy and hypertension, and smoking. Key elements in the primary care of diabetes include glycemic control, blood pressure control, and screening for microalbuminuria. In general, the goal for glycemic control is a blood glucose level as close to normal (HbA1c <7%) as possible without causing dangerous hypoglycemia. Blood pressure control is at least as important as glucose control, especially after the onset of renal damage, and blood pressure should be consistently <130/85. Screening for diabetic nephropathy involves monitoring at least yearly for urinary albumin excretion >30 mg per day.
For purposes of this discussion, diabetic nephropathy will be a generic term referring to any deleterious effect on kidney structure and/or function caused by diabetes mellitus. More specifically, diabetic nephropathy is thought of in stages, the first being that characterized by microalbuminuria (30Ł300 mg urinary albumin per 24 hours). This may progress to macroalbuminuria, or overt nephropathy (>300 mg urinary albumin per 24 hours). Later still, progressive renal functional decline characterized by decreased GFR results in clinical renal insufficiency and ESRD.
Glucose combines with many proteins in circulation and in tissues via a nonenzymatic, irreversible process to form advanced glycosylation end products (AGEs). The best known of these is glycosylated hemoglobin, a family of glucose-hemoglobin adducts. Hemoglobin A1c (HbA1c) is a specific member of this group and is useful as an indicator of average glycemia during the 2Ł3 months before measurement. The assay of HbA1c was standardized for the Diabetes Control and Complications Trial (DCCT) and is now widely accepted as the standard measurement of glycosylated hemoglobin. Other AGEs are presumed to contribute to the complications of diabetes, such as glycosylated proteins of the basement membrane of the renal glomerulus.
Diabetes and its costs are a problem of enormous importance in the United States today. Costs of caring for the complications of diabetes account for 90% of the direct and indirect costs of diabetes care.3 Diabetic nephropathy accounts for 35% of ESRD in the United States today and costs approximately $50,000 per patient per year,4 exceeding $2 billion per year for all patients.1
Patients with type 1 diabetes are at highest individual risk of nephropathy, but those with type 2 diabetes are also at significant risk.5 There is evidence that the incidence of renal failure in type 1 diabetes may be decreasing, perhaps because of better preventive treatment.6 The incidence of renal complications in type 2 diabetes, however, may be increasing.5,7,8 In the San Antonio Heart Study,9 the incidence of new- onset type 2 diabetes during 7Ł8 years of follow-up among Mexican Americans enrolling in the study increased significantly from 5.7% among those enrolling in 1979 to 15.7% among those enrolling in 1988. Among non-Hispanic whites, the several-fold increased incidence was borderline significant (P = 0.07). Since type 2 diabetes accounts for at least 90% of all patients with diabetes, the number of type 2 patients with nephropathy and ESRD exceeds those with type 1 diabetes overall. The prevalence of microalbuminuria in patients with diabetes is 10Ł30%.10
The combination of hypertension and diabetes is an especially dangerous clinical situation, both for risk of microvascular and macrovascular complications of diabetes and for diabetes-related and overall mortality. Hypertension is unfortunately also very common in patients with diabetes. Hypertension occurs in 50% of patients with diabetes and results in a sevenfold increase in mortality.11 Concomitant nephropathy in patients with diabetes and hypertension results in a 37-fold increase in mortality.
Important clinical concomitants of diabetic nephropathy are retinopathy and cardiovascular disease. Nearly all patients with diabetic nephropathy will also have developed retinopathy. This has important implications for screening and attention to preventive measures in the care of patients with diabetes. The reverse is not as frequently true. That is, a much lower percentage of patients with retinopathy will have evidence of renal involvement.
Diabetic renal disease is also closely associated with coronary artery disease. The presence of microalbuminuria is a powerful predictor of death from cardiovascular disease. Thus, the presence of diabetes, especially if accompanied by microalbuminuria, is a signal for very aggressive attention to all cardiovascular disease risk factors and for improvement to the fullest extent possible by lifestyle modification and pharmacotherapy when appropriate. In addition to direct microvascular effects of diabetes on the heart, associated mechanisms may include hyperlipidemia, hypertension, and coagulation abnormalities.
A variety of factors contribute to the renal damage seen in diabetes. By definition, hyperglycemia is a common etiologic factor in diabetic patients with nephropathy, but a genetic predisposition and smoking contribute as well. Most significant, however, is the presence of hypertension, not only before and after the onset of microalbuminuria but probably also as another familial marker of risk, since patients with diabetes and a positive family history of hypertension are at higher risk of nephropathy.
Genetics and Ethnicity
Although a sizable percentage, only a minority of patients with diabetes are destined to develop ESRD. In addition to the risks of poor glycemic control and hypertension, a subset of patients may be at greater risk for nephropathy based on inherited factors.12 Familial clustering of patients with nephropathy may result from similarly poor glycemic or blood pressure control or may have additional independent genetic bases.12,13
Diabetic siblings of patients with diabetes and renal disease are five times more likely to develop nephropathy than diabetic siblings of diabetic patients without renal disease.14 There is a strong concordance of both nephropathy and renal histopathology in twins with type 1 diabetes.15 In a study of Brazilian families with two or more diabetic members, the presence of diabetic nephropathy in the probands was significantly associated with a 3.75-fold increased risk of diabetic nephropathy in the diabetic siblings.16
Postulates have been advanced linking diabetic nephropathy as well as cardiovascular disease and hypertension with inherited abnormalities of sodium-lithium countertransport.17,18 In a study of 89 patients with type 1 diabetes, an increased maximal velocity of sodium-lithium countertransport and a parent with hypertension each significantly increased the risk of nephropathy in the study patients.17 Moreover, the parents of patients with type 1 diabetes complicated by nephropathy have decreased survival, notably a fourfold increased risk of strokes.19
Familial clustering and the beneficial effects of angiotensin-converting enzyme (ACE) inhibition on diabetic nephropathy have also led to investigation of the genetics of the renin-angiotensin system. Increased levels of ACE have been found in patients with type 1 diabetes and nephropathy, particularly carriers of certain abnormal alleles of the ACE gene.20 In a study of type 1 patients with ESRD compared with type 1 patients with diabetes for at least 15 years and no microalbuminuria, the presence of the DD genotype at the ACE locus increased the risk of end-stage nephropathy twofold.21
ESRD is known to be more prevalent in certain ethnic groupsNative Americans, Mexican Americans, and African Americansthan in Caucasian Americans. Certainly, there is reason for special vigilance for early signs of nephropathy in these high-risk populations, whose members presumably have a genetic predisposition to nephropathy.
It is well established that poor metabolic control is critical in the etiology of diabetic nephropathy. Nephropathy is uncommon in patients with HbA1c consistently <7.5Ł8.0%.10,22 The degree to which glucose toxicity itself is directly causative in the renal lesion is still debated. At the very least, glucose is a meaningful and clinically relevant marker for the metabolic abnormality that leads to nephropathy, as shown in the DCCT23 and other treatment trials that demonstrate decreased nephropathy with lowered serum glucose.
Other hyperglycemia-dependent metabolic abnormalities that may also play a role in the development of nephropathy include AGEs and polyols. AGEs are the result of nonenzymatic covalent attachment of glucose to proteins, which not only changes the tertiary structure of proteins but also results in intra- and intermolecular crosslinking. Proteins of many types are affected by this process, and levels of circulating and tissue AGEs have been shown to correlate with microalbuminuria in diabetic patients. In a study of low- and high-molecular-weight AGEs in subjects with and without diabetes, AGE content in arterial wall collagen was fourfold higher in diabetes.24 Diabetic patients with ESRD had twice as much tissue AGE as patients without renal disease. Circulating AGEs were elevated in patients with diabetes compared to those without diabetes, and the levels correlated directly with creatinine.
Flux through the polyol pathway beginning with the conversion of glucose to sorbitol by aldose reductase is enhanced in hyperglycemia. The resultant increase in tissue sorbitol has been postulated to contribute to the microvascular complications of diabetes. Clinical trials of aldose reductase inhibitors have not shown beneficial effects in reducing microalbuminuria in humans; however, research continues in this arena.
Hypertension is probably both a cause and an effect of diabetic nephropathy. In the glomerulus, an early effect of systemic hypertension is dilatation of the afferent arteriole, contributing to intraglomerular hypertension, hyperfiltration, and hemodynamically mediated damage. Renal responsiveness to the renin-angiotensin system may be abnormal in the diabetic kidney.25 For these reasons, agents that help to correct the abnormal intraglomerular pressures are preferentially selected for treatment of hypertension in diabetes. ACE inhibitors specifically decrease the efferent arteriolar pressure, thereby decreasing intraglomerular pressure and helping to protect the glomerulus from further damage, as seen in their beneficial effect on microalbuminuria.
Particularly after microalbuminuria is present, metabolic control is only one factor in preventing the progression of renal disease. Hypertension at this stage predicts a more rapid downhill progression of the renal damage. Blood pressure control is increasingly important once the renal lesion is present and as renal damage progresses.
Several lines of evidence have shown that smoking increases the risk and progression of diabetic nephropathy.26,27 In the Appropriate Blood Pressure in Diabetes Trial, 61% of enrollees were smokers. Analysis of a number of risk factors showed a 1.6-fold increased risk of nephropathy among smokers.28
The key pathophysiologic event in diabetic nephropathy is basement membrane damage.29 With renal damage, there is progressive thickening of the basement membrane, pathologic change in mesangial and vascular cells, formation of AGEs, accumulation of polyols via the aldose reductase pathway, and activation of protein kinase C.22,30,31 Passage of macromolecules through the basement membrane may also activate inflammatory pathways that contribute to the damage secondarily.32
The renal hemodynamic abnormality is similar in type 1 and type 2 diabetes.8 An early physiologic abnormality is glomerular hyperfiltration33 associated with intraglomerular hypertension.31 This is accompanied by the onset of microalbuminuria, the first practical evidence of renal involvement in diabetes. This is a critical time in the evolution of diabetic renal disease, since the greatest impact of treatment is to intercept this point in the otherwise inexorable downward path of renal function.
A clinically asymptomatic period of decline follows, with progression of microalbuminuria (30Ł300 mg albumin per day) to macroalbuminuria (>300 mg albumin per day). Once overt nephropathy (macroalbuminuria) has developed, renal function falls at a significant but variable rate (decline in GFR of 2Ł20 ml/min/year). The rate of decline depends on type of diabetes, genetic predisposition, glycemic control, and, very importantly, blood pressure. Hypertension is the single most important cause of progression and point of successful intervention in diabetic nephropathy. Later stages may also be accompanied by clinically significant albuminuria, edema, and nephrotic syndrome. Eventually, the characteristic clinical picture of renal failure develops.
It has become clear over time that once overt nephropathy has developed, treatment is a delaying rather than a preventive tactic. Though not all patients with early renal involvement (microalbuminuria) will progress to ESRD, the likelihood is much greater among these patients, and our ability to stabilize or reverse the downward progression once started is diminished. Ideally, it would be useful to be able to predict which patients were at risk for ESRD before onset, but there is currently no way to definitively identify those patients at increased risk. Consequently, a high priority in the care of patients with diabetes is screening for early signs of microvascular disease so that measures can be taken to prevent progression to overt complications. For this reason, regular screening for microalbuminuria should be part of routine diabetic preventive care.
Among the earliest changes demonstrable in diabetic nephropathy is glomerular hyperperfusion. This is accompanied by microalbuminuria, which serves as a sensitive early indicator of adverse effects of diabetes on the kidney and is a powerful predictor of the subsequent course. Eighty percent of type 1 diabetes patients with microalbuminuria will progress to overt nephropathy within 10Ł15 years. Of those, 50% will develop ESRD within 10 years and 75% within 20 years in the absence of specific intervention.1 Among patients with type 2 diabetes, 20Ł40% of patients with microalbuminuria will progress to overt nephropathy, though only 20% of those patients will go on to ESRD within the next 20 years.1 Microalbuminuria is also a powerful predictor of cardiovascular disease in both type 1 and type 2 diabetes.
Microalbuminuria is defined as the urinary excretion of 30Ł300 mg of albumin per day. Standard urinalysis dipsticks are not sensitive enough to detect this level of albuminuria, so more sensitive tests must be done for effective screening. If protein is detectable on a standard urinalysis dipstick, macroalbuminuria (>300 mg of urinary albumin per day) is probably already present. In type 1 diabetes, annual screening should begin after puberty and 5 years after initial diagnosis. In type 2 diabetes, because of the likelihood that diabetes has been present for several years by the time it is diagnosed, annual microalbuminuria screening should begin at the time of diagnosis.
Despite the importance of microalbuminuria screening, however, it has not yet become a routine practice, probably because of lack of understanding of the difference between microalbuminuria and macroalbuminuria. In a study of more than 1,000 primary care physicians, 86% screened more than half of their type 1 patients and 82% screened more than half of their type 2 patients for overt macroalbuminuria, mostly by dipstick techniques. However, only 17% screened type 1 patients and 12% screened type 2 patients for microalbuminuria.34
Several methods are available for screening and give comparable results. The gold standard is the 24-hour urine collection (normal albumin excretion <30 mg per 24 hours), which, if accompanied by serum and urine creatinine, also allows calculation of creatinine clearance rate and serves as a reference for future comparison. Somewhat more convenient for the patient is the albumin/creatinine ratio on a spot urine sample (normal <30 mg albumin per g creatinine) or albumin excretion rate in a timed specimen (4 hours or overnight, normal <20 mg albumin per min). Measuring albumin without relating it to a duration of collection or creatinine concentration is less sensitive and specific because of dilution variability.
Clinicians should remember that there is a diurnal variation in urinary protein excretion, with less glomerular protein leak during nighttime and recumbency. Thus, measurement on collections of less than 24 hours may show the effect of time of day. There is also considerable variation from day to day, so three collections should be carried out over a 6-month period with the designation of microalbuminuria reserved for those with elevations on two out of three measurements. Furthermore, screening should avoid other factors that may temporarily induce albuminuria, such as poor glycemic control, exercise, fever, urinary or systemic infections, and marked hypertension.
Significant progress has been made in recent years in understanding the pathophysiology, prevention, and treatment of diabetic nephropathy. Median survival after the onset of nephropathy has increased from 6 to 15 years.35 Benefits accrue not only in younger patients with many years of potential life expectancy but also in the elderly.36
Both glycemic control and rigorous control of blood pressure have significant impact on prevention and progression of diabetic nephropathy.37 Identification of patients with microalbuminuria selects a population of patients with increased mortality. Studies in both type 1 and type 2 patients show that the use of ACE inhibitors leads to decreased albumin excretion and may postpone or even prevent overt nephropathy.3
The importance of prevention cannot be overemphasized, however. Once overt nephropathy is present, progression cannot be halted, only slowed. It is much more effective to screen for early nephropathy with sensitive tests for microalbuminuria and to prevent or halt the earliest stages of damage by vigorous control of hyperglycemia and hypertension.
Additional targets of potential intervention include smoking, hyperlipidemia, AGEs, the polyol pathway, and systemic and intrarenal vasoactive substances and pathways.30 Earlier trials of inhibitors of the aldose reductase pathway production of polyols did not show the hoped-for benefit, but research continues in this area.
Glycemic Control
Tight glycemic control has been shown in several studies to decrease the risk of microvascular disease in both type 1 and type 2 diabetes.22,23,38,39 In the DCCT, intensive glucose control in patients with type 1 diabetes decreased the incidence of microalbuminuria by 39% in the primary prevention group and decreased the progression from microalbuminuria to macroalbuminuria by 54% in the secondary prevention group.23 In the United Kingdom Prospective Diabetes Study (UKPDS), there was a 34% decrease in the risk of microalbuminuria in patients with type 2 diabetes treated more intensively for glycemic control.38
The DCCT benefit in type 1 diabetes was accomplished with an average 20% reduction in HbA1c (9.0Ł7.1%). In the UKPDS, the benefit was seen with an 11% reduction in HbA1c (7.9Ł7.0%). This suggests that there is benefit to be gained by decreasing hyperglycemia at any level of starting glucose control. Furthermore, it suggests that this benefit can be attained in patients with either type 1 or type 2 diabetes.
Glycemic control remains critical in stabilizing and slowing nephropathy even with established renal damage. As noted above, not only was primary prevention of microalbuminuria slowed by tight glycemic control in the DCCT, but also secondary progression from microalbuminuria to macroalbuminuria was slowed.23 A similar result was found in the Steno studies.40 Very persuasive was a study of eight patients with type 1 diabetes who received pancreas transplants and were studied with renal biopsies before transplantation and at 5 and 10 years after transplantation.41 All patients had lesions of diabetic nephropathy, from mild to advanced, at the time of transplantation and normal glycosylated hemoglobin after transplantation. At 5 years after transplant, microalbuminuria had improved, but basement membrane thickness had not changed, and creatinine clearance and mesangial volume had worsened compared with pretransplant values. At 10 years, however, albumin excretion had returned to normal, creatinine clearance had stabilized, and basement membrane thickness and mesangial volume had improved.
In general, the goal for glycemic control is blood glucose as close to normal as possible without causing significant hypoglycemia or other dangerous complications/side effects. Specific goals outlined by the American Diabetes Association (ADA) for optimum glycemic control include preprandial blood glucose levels of 80Ł120 mg/dl, bedtime blood glucose levels of 100Ł140 mg/dl, and HbA1c <7%.42
Blood Pressure Control
Hypertension is more common in people with diabetes than in the nondiabetic population43 and is well established as a contributing cause of the microvascular complications of diabetes.44 Hypertension control decreases albuminuria, delays nephropathy, and improves survival in both type 1 and type 2 diabetes.3
The renin-angiotensin system has become the target of the most effective strategy for both hypertension control and, independently, for reduction of the pathophysiologic abnormalities that lead to renal protein leakage.45 This is best established in type 1 diabetes, but evidence is accumulating that the same pathophysiologic principles and treatment also apply in type 2 diabetes.44 In addition, hypertension is probably a common primary risk for the renal and other nonrenal cardiovascular complications of diabetes.7,46
ACE inhibitors should be used when microalbuminuria is present regardless of the presence or absence of hypertension in type 1 diabetes1,47 and are widely used in normotensive patients with type 2 diabetes, as well.48,49 The effect of ACE inhibitors is probably not only via lowered systemic blood pressure but also via direct effects on intraglomerular hemodynamics.50 In a prospective study of type 2 diabetic patients with microalbuminuria but normal blood pressure, patients were randomized to enalapril (Vasotec) 5 mg/day or no treatment.51 After 4 years, urinary albumin excretion had increased in the untreated patients from 93.9 to 150.0 mg per 24 hours. In the enalapril-treated group during this 4-year period, however, albumin excretion decreased significantly from 115.4 to 75.3 mg per 24 hours. There was no change in creatinine clearance, blood pressure, or HbA1c in either group, suggesting that the beneficial effect of the ACE inhibitor was independent of its systemic antihypertensive action.
The debate is expanding to include normotensive, normoalbuminuric patients and the role of ACE inhibitors in preventing diabetic nephropathy before there is any evidence of its presence.32 In a double-blind, placebo-controlled trial, 156 type 2 diabetic, normotensive patients without micro- albuminuria were randomized to treatment with enalapril (10 mg/day) or placebo.52 After 6 years, microalbuminuria developed in 19% of placebo patients and 6.5% of enalapril patients. During this period, creatinine clearance decreased at a rate of 2.4 ml/min/year in the placebo group and 1.5 ml/min/year in the enalapril group. HbA1c decreased slightly in both groups, and blood pressure remained normal. If confirmed and expanded, these studies have important implications for strategies to prevent diabetic nephropathy at or before the earliest stages of damage.
Currently most evidence and published guidelines suggest ACE inhibitors as first-choice antihypertensives in patients with diabetes.1,53 The extent of blood-pressure lowering, however, rather than the class of antihypertensive agent used appears to be the most important factor in renal protection. Blood pressure <130/85 mm Hg is associated with preserved renal function.46,54-57 Calcium-channel blocking agents have been shown to have beneficial effects,35 and combinations of ACE inhibition and calcium-channel blockade have shown positive results,58 but further clarification is needed of the relative effects of dihydropyridine versus nondihydropyridine agents. Evidence is accumulating that angiotensin II receptor blockers have similar renal protective effects in diabetes,59 with further studies now in progress.7
Current ADA recommendations are to lower the blood pressure to 130/85 mm Hg in nonpregnant adults.1 For patients with isolated systolic hypertension >180 mm Hg, the goal is systolic pressure <160 mm Hg, and for those with isolated systolic pressure 160Ł179 mm Hg, the goal is to lower systolic pressure by 20 mm Hg. The use of ACE inhibitors is recommended in patients with type 1 diabetes and microalbuminuria even if they are normotensive. In type 2 patients, the evidence for ACE inhibitor use in normotensive patients with microalbuminuria is not as conclusive at this point, but it is accumulating.48,49,52
Dietary Protein Restriction
High dietary protein has renal hemodynamic effects that include increased GFR, hyperfiltration, and increased intraglomerular pressure. This effect is probably accentuated by poor glycemic control. The typical diet in most industrialized societies contains considerably more protein than required for nutritional balance, and dietary protein has been shown to decrease renal functional deterioration in both type 1 and type 2 diabetes.60,61 In a 5-year prospective study of patients with type 1 diabetes,62 those on a protein- and phosphate-restricted diet showed a decline of GFR of only 0.26 ml/min/month compared with 1.01 ml/min/month in those on unrestricted diets.
Current recommendations are for dietary protein at the level of the Recommended Dietary Allowance of 0.8 g/kg/day, accounting for 10% of total calories. In selected patients with decreasing GFR, it may be useful to decrease the prescribed protein intake to 0.6 g/kg/day as directed by a professional nutritionist.
The single most common cause of ESRD in the United States today is diabetic nephropathy, and the incidence in type 2 diabetes appears to be increasing. Several factors probably contribute to the renal damage, including hyperglycemia and other metabolic by-products of elevated glucose, hypertension (both systemic and intrarenal), and a genetic predisposition in some patients. Patients with diabetic nephropathy usually also have diabetic retinopathy and have a much higher mortality from coronary artery disease.
Critically important is attention to prevention as preferential to treatment of diabetic nephropathy. Once overt nephropathy is present, progression cannot be avoided, only delayed. The earliest clinical indicator of renal damage is microalbuminuria, which should be screened for at regular intervals with sensitive tests.
Several studies demonstrate the preventive effect of lowered blood glucose on the microvascular complications of diabetes, including nephropathy, and serve as the rationale for the emphasis on tight rather than casual glycemic control. Before and especially after the onset of early nephropathy, blood pressure control is critical in preventing or slowing the progression of renal damage. First-choice agents for treating microalbuminuria are the ACE inhibitors, but lowered blood pressure by any means is the single most important factor in saving the diabetic kidney from the downward path to ESRD.
2DeFronzo R: Diabetic nephropathy: etiologic and therapeutic considerations. Diabetes Rev 3:510-64, 1995.
3Parving H: Is antihypertensive treatment the same for NIDDM and IDDM patients? Diabetes Res Clin Pract 39 (Suppl):S43-47, 1998.
4Kobrin S: Diabetic nephropathy. Disease-A-Month 44:214-34, 1998.
5Ismail N, Becker B, Strzelczyk P, Ritz E: Renal disease and hypertension in non-insulin-dependent diabetes mellitus. Kidney Int 55:1-28, 1999.
6Bojestig M, Arnqvist H, Hermansson G, Karlberg B, Ludvigsson J: Declining incidence of nephropathy in insulin-dependent diabetes mellitus. N Engl J Med 330:15-18, 1994.
7Ritz E, Rychlik I, Miltenberger-Miltenyi G: Optimizing antihypertensive therapy in patients with diabetic nephropathy. J Hypertens Suppl 16:S17-22, 1998.
8Ritz E, Keller C, Bergis K, Strojek K: Pathogenesis and course of renal disease in IDDM/NIDDM: differences and similarities. Am J Hypertens 10:202-207S, 1997.
9Burke JP, Williams K, Gaskill S, Hazuda H, Haffner S, Stern M: Rapid rise in the incidence of type 2 diabetes from 1987 to 1996: results from the San Antonio Heart Study. Arch Int Med 159:1450-56, 1999.
10Deferrari G, Repetto M, Calvi C, Ciabattoni M, Rossi C, Robaudo C: Diabetic nephropathy: from micro- to macroalbuminuria. Nephrol Dial Transplant 13 (Suppl 8):11-15, 1998.
11MacLeod M, McLay J: Drug treatment of hypertension complicating diabetes mellitus. Drugs 56:189-202, 1998.
12Krolewski A, Fogarty D, Warram J: Hypertension and nephropathy in diabetes mellitus: what is inherited and what is acquired? Diabetes Res Clin Pract 39 (Suppl):S1-14, 1998.
13Strojek K, Grzeszczak W, Ritz E: Risk factors for development of diabetic nephropathy: a review. Nephrol Dial Transplant 12 (Suppl 2):24-26, 1997.
14Seaquist E, Goetz F, Rich S, Barbosa J: Familial clustering of diabetic kidney disease: evidence for genetic susceptibility to diabetic nephropathy. N Engl J Med 320:1161-65, 1989.
15Fioretto P, Steffes M, Barbosa J, Rich S, Miller M, Mauer M: Is diabetic nephropathy inherited? Studies of glomerular structure in type 1 diabetic sibling pairs. Diabetes 48:865-69, 1999.
16Canani L, Gerchman F, Gross J: Familial clustering of diabetic nephropathy in Brazilian type 2 diabetic patients. Diabetes 48:909-13, 1999.
17Krolewski A, Canessa M, Warram J, Laffel L, Christlieb A, Knowler W, Rand L: Predisposition to hypertension and susceptibility to renal disease in insulin-dependent diabetes mellitus. N Engl J Med 318:140-45, 1988.
18Fujita J, Tsuda K, Seno M, Obayashi H, Fukui I, Seino Y: Erythrocyte sodium-lithium countertransport activity as a marker of predisposition to hypertension and diabetic nephropathy in NIDDM. Diabetes Care 17:977-82, 1994.
19Lindsay R, Little J, Jaap A, Padfield P, Walker J, Hardy K: Diabetic nephropathy is associated with an increased familial risk of stroke. Diabetes Care 22:422-25, 1999.
20Freire M, van Dijk D, Erman A, Boner G, Warram J, Krolewski A: DNA polymorphisms in the ACE gene, serum ACE activity and the risk of nephropathy in insulin-dependent diabetes mellitus. Nephrol Dial Transplant 13:2553-58, 1998.
21Vleming L, van der Pijl J, Lemkes H, Westendorp R, Maassen J, Daha M, van Es L, van Kooten C: The DD genotype of the ACE gene polymorphism is associated with progression of diabetic nephropathy to end stage renal failure in IDDM. Clin Nephrol 51:133-40, 1999.
22Di Landro D, Catalano C, Lambertini D, Bordin V, Fabbian F, Naso A, Romagnoli G: The effect of metabolic control on development and progression of diabetic nephropathy. Nephrol Dial Transplant 13 (Suppl 8):35-43, 1998.
23The DCCT Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New Engl J Med 329:977-86, 1993.
24Makita Z, Radoff S, Rayfield E, Yang Z, Skolnik E, Delaney V, Friedman E, Cerami A, Vlassara H: Advanced glycosylation end products in patients with diabetic nephropathy. New Engl J Med 325:836-42, 1991.
25Velasquez M, Bhathena S, Striffler J, Thibault N, Scalbert E: Role of angiotensin-converting enzyme inhibition in glucose metabolism and renal injury in diabetes. Metabolism 47 (12 Suppl 1):7-11, 1998.
26Marcantoni C, Ortalda V, Lupo A, Maschio G:
Progression of renal failure in diabetic nephropathy. Nephrol Dial Transplant 13
27Ritz E: Nephropathy in type 2 diabetes. J Intern Med 245:111-26, 1999.
28Mehler P, Jeffers B, Biggerstaff S, Schrier R: Smoking as a risk factor for nephropathy in non-insulin-dependent diabetics. J Gen Intern Med 13:842-45, 1998.
29Rudberg S, Osterby R: Diabetic glomerulopathy in young IDDM patients: preventive and diagnostic aspects. Horm Res 50 (Suppl 1):17-22, 1998.
30Cooper M: Pathogenesis, prevention, and treatment of diabetic nephropathy. Lancet 352:213-19, 1998.
31Clark C, Lee D: Drug therapy: prevention and treatment of the complications of diabetes mellitus. N Engl J Med 332:1210-17, 1995.
32Remuzzi G, Ruggenenti P: Prognosis of diabetic nephropathy: how to improve the outcome. Diabetes Res Clin Pract 39 (Suppl):S49-53, 1998.
33Wardle E: How does hyperglycaemia predispose to diabetic nephropathy? Quart J Med 89:943-51, 1996.
34Kraft S, Lazaridis E, Qiu C, Clark C, Marrero D: Screening and treatment of diabetic nephropathy by primary care physicians. J Gen Intern Med 14:88-97, 1999.
35Rossing P: Promotion, prediction and prevention of progression of nephropathy in type 1 diabetes mellitus. Diabetic Med 15:900-19, 1998.
36Samos L, Roos B: Diabetes mellitus in older persons. Med Clin North Am 82:791-803, 1998.
37O'Connor P, Spann S, Woolf S: Care of adults with type 2 diabetes mellitus: a review of the evidence. J Fam Pract 47 (5 Suppl):S63-64, 1998.
38UK Prospective Diabetes Study Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352:837-53, 1998.
39Molitch M: The relationship between glucose control and the development of diabetic nephropathy in type I diabetes. Sem Nephrol 17:101-13, 1997.
40Feldt-Rasmussen B, Mathiesen E, Jensen T, Lauritzen T, Deckert T: Effect of improved metabolic control on loss of kidney function in type 1 (insulin-dependent) diabetic patients: an update of the Steno studies. Diabetologia 34:164-70, 1991.
41Fioretto P, Steffes M, Sutherland D, Goetz F, Mauer M: Reversal of lesions of diabetic nephropathy after pancreas transplantation. N Engl J Med 339:69-75, 1998.
42American Diabetes Association: Position statement: Standards of medical care for patients with diabetes mellitus. Diabetes Care 22 (Suppl 1):S32-41, 1999.
43Bretzel R: Effects of antihypertensive drugs on renal function in patients with diabetic nephropathy. Am J Hypertens 10:208-17S, 1997.
44Luno J, Garcia de Vinuesa S, Gomez-Campdera F, Lorenzo I, Valderrabano F: Effects of antihypertensive therapy on progression of diabetic nephropathy. Kidney Int Suppl 68:S112-19, 1998.
45Ritz E, Miltenberger-Miltenyi G, Wagner J, Rychlik I: Diabetes--renal function--what are the special problems? Basic Res Cardiol 93 (Suppl 2):125-30, 1998.
46Nosadini R, Abaterusso C, Dalla Vestra M, Bortoloso E, Saller A, Bruseghin M, Sfriso A, Trevisan M: Efficacy of antihypertensive therapy in decreasing renal and cardiovascular complications in diabetes mellitus. Nephrol Dial Transplant 13 (Suppl 8):44-48, 1998.
47Marks J, Raskin P: Nephropathy and hypertension in diabetes. Med Clin North Am 82:877-907, 1998.
48Ravid M, Lang R, Rachmani R, Lishner M: Long-term renoprotective effect of angiotensin-converting enzyme inhibition in non-insulin-dependent diabetes mellitus: a 7-year follow-up study. Arch Intern Med 156:286-89, 1996.
49Ravid M, Savin H, Jutrin I, Bental T, Katz B, Lishner M: Long-term stabilizing effect of angiotensin-converting enzyme inhibition on plasma creatinine and on proteinuria in normotensive type II diabetic patients. Ann Intern Med 118:577-81, 1993.
50Lewis E, Hunsicker L, Bain R, Rohde R: The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. N Engl J Med 329:1456-62, 1993.
51Sano T, Hotta N, Kawamura T, Matsumae H, Chaya S, Sasaki H, Nakayama M, Hara T, Matsuo S, Sakamoto N: Effects of long-term enalapril treatment on persistent microalbuminuria in normotensive type 2 diabetic patients: results of a 4-year, prospective, randomized study. Diabetic Med 13:120-24, 1996.
52Ravid M, Brosh D, Levi Z, Bar-Dayan Y, Ravid D, Rachmani R: Use of enalapril to attenuate decline in renal function in normotensive, normoalbuminuric patients with type 2 diabetes mellitus: a randomized, controlled trial. Ann Intern Med 128:982-88, 1998.
53Mogensen C: Microalbuminuria, blood pressure and diabetic renal disease: origin and development of ideas. Diabetologia 42:263-85, 1999.
54Makrilakis K, Bakris G: Diabetic hypertensive patients: improving their prognosis. J Cardiovasc Pharmacol 31 (Suppl 2):S34-40, 1998.
55Bakris G: Progression of diabetic nephropathy: a focus on arterial pressure level and methods of reduction. Diabetes Res Clin Pract 39 (Suppl):S35-42, 1998.
56Nosadini R, Brocco E, Saller A, Cernigoi A, Abaterusso C, Bortoloso E, Dalla-Vestra M, Maioli M, Piarulli F, Fioretto P: Renal function in noninsulin-dependent diabetes mellitus patients treated with angiotensin-converting enzyme inhibitors and calcium channel blockers. J Hypertens Suppl 16:S27-32, 1998.
57UK Prospective Diabetes Study Group: Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes (UKPDS 39). Brit Med J 317:703-13, 1998.
58Bakris G, Weir M, DeQuattro V, McMahon F: Effects of an ACE inhibitor/calcium antagonist combination on proteinuria in diabetic nephropathy. Kidney Int 54:1283-89, 1998.
59Hollenberg N: Non-insulin-dependent diabetes mellitus, nephropathy, and the renin system. J Hypertens Suppl 15:S7-13, 1997.
60Barsotti G, Cupisti A, Barsotti M, Sposini S, Palmieri D, Meola M, Lenti C, Morelli E: Dietary treatment of diabetic nephropathy with chronic renal failure. Nephrol Dial Transplant 13 (Suppl 8):49-52, 1998.
61Toeller M, Buyken A: Protein intake--new evidence for its role in diabetic nephropathy. Nephrol Dial Transplant 13:1926-27, 1998.
62 Zeller K, Whittaker E, Sullivan L, Raskin P, Jacobson H: Effect of restricting dietary protein on the progression of renal failure in patients with insulin-dependent diabetes mellitus. N Engl J Med 324:78-84, 1991.
Timothy C. Evans, MD, PhD, is an assistant professor and Peter Capell, MD, is a clinical professor in the Department of Medicine at the University of Washington School of Medicine in Seattle.
Note of disclosure: Dr. Evans is a stock shareholder in the Merck and Pfizer pharmaceutical companies and has received honoraria from Merck and Bristol-Myers Squibb. These companies manufacture products for the treatment of diabetes and/or hypertension.
Copyright ® 2000American Diabetes
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There's that cool giant drum.
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Loosely detailed map in an odd two color print.
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With everyone wanting to save as much money as possible these days, many of us spend a great deal of time planning to make a vacation as frugal as possible.
We watch airfares for months, we buy flights on the best days, and we bid on hotel rooms and get good deals.
And while all of those things definitely contribute to making our vacations as cost-effective as possible, they are not the only costs involved. Often we can sabotage our vacation budgets by the "little things" that occur once we get to the airport or train station or when we put the car in drive and head off on our road trip.
Planning ahead for all aspects of a vacation is the #1 thing we can do to cut costs. If we only consider how we're going to get there and where we'll stay, chances are we'll find ourselves spending way more money than we want to.
Here are some ways to save on travel when you're at the airport, train station, or in your car:
Eat Outside of the Airport – Your best bet is always going to be eating at home, if your schedule allows. If you can't eat at home, pick up something on the way; it's still going to be cheaper than eating in the terminal. Yes, it might be fast food, but there are healthier fast food options available for you to choose from.
Bring a Few of Your Own Snacks – Even if you eat a meal before you get to the airport or train station, it's easy to find yourself with a case of the munchies before you board. Snacks are rarely cheap in airports or train stations. If you pack your own, you'll be better prepared to resist the urge to make an impulsive purchase.
Make sure your snacks are dry goods and don't include liquids or gels, though. If you're driving, take a small cooler with drinks and even picnic items. Stop at a park and give the kids a chance to get out of the car for a bit. It's a win-win.
Bring My Own Reading Material – Load up some books on your eReader or bring some from home. Better yet, go to the library and pick up a few or share eBooks with a friend. If books are too heavy, consider borrowing magazines instead. Rarely is one magazine going to be enough for one vacation, and if you wait to buy them while you're away, then you're looking at extra money.
Carry On Your Bags – Checked baggage fees are astronomical these days. Inasmuch as you are able, pack lightly and take a carry on bag instead of a large piece of luggage. If you're traveling as a family, try to pack everything into fewer suitcases than you have family members. You will still have fees, of course, but less than you would have if everyone took his/her own.
Catch a Ride to the Airport or Train Station – Parking fees will add up if you are gone for even just a few days. Another way to save money is to ask a friend or a family member to drop you and your family off and have them pick you up when you arrive home.
Sure, it might be inconvenient for them, but offering to reimburse them for gas money is still probably going to be cheaper than if you paid parking fees or for a taxi service.
Use Public Transportation – Sure it would be nice to jump in a taxi and be dropped off at your hotel, but it is going to cost more money than if you were to take a bus or subway. It would be helpful if you researched routes before you left home, so that you could already have your plan in mind before you even picked up your baggage.
Consider Off-Site Car Rental – An additional way to save is to rent a car from a location away from the airport. Just be sure to note what time the off-site office opens and closes and plan your pick-up/drop-off accordingly because you'll want to leave yourself enough time to clear security after dropping the car off.
You'll also want to consider the price of getting to/from the airport to the car rental site, which might involve public transportation or hailing a taxi back to the airport, another expense.
Refuel Your Rental Car Yourself – Their gas is always more expensive because you're paying them for the time and effort it takes to refuel the car after you've returned it. Save yourself a few bucks and fill it up at a gas station down the street before you return it.
Carpool to Save Money on Gas – Going on a road trip in the family minivan? Depending on how much space you have, is it possible to invite a friend or another family to join you? It sure would help save on gas and other expenses, not to mention add more adventure to your vacation!
Many of these ideas might seem insignificant, but they add up over time—especially if you're traveling as a family and not an individual. And, let's be honest, who doesn't like to save on travel when they can?
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A senior at a south-central Washington high school faked her pregnancy for the past six months as a social experiment for her senior project.
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Gaby Rodriguez revealed she was not pregnant Wednesday by taking off the belly bundle in front of a stunned student assembly at Toppenish High School in Yakima, Wash., that ended with a standing ovation.
For six-and-a-half months, Gaby wore a homemade prosthetic "bulge," made out of wire mesh and cotton quilt batting. The Yakima Herald-Republic reported only a handful of people knew Gaby was faking, including her mother, boyfriend and the principal. They helped keep the secret from some of her own siblings and her boyfriend's family and students and teachers.
Before the revelation, she asked several students and teachers to read quotes people said about her during the course of her experiment.
"Her attitude is changing, and it might be because of the baby or she was always this annoying and I never realized it," her best friend, Saida Cortes, read.
It grew quiet in the gym as more and more quotes were read aloud, Yakima Herald-Republic reported. Then Rodriguez dropped her bomb: "I'm fighting against those stereotypes and rumors because the reality is I'm not pregnant."
She had been nervous about how the crowd might react. After all, she had been lying to them since October.
TODAY Moms: Would you let your teen do something like this?
The surprise presentation was part of her report about the perceptions of a pregnant student. The 17-year-old A-student will share her findings in May before she graduates.
Gaby's story caught the attention of media outlets across the country.
Read more: Student's story attracts attention of national media
"It's gone big; it's been quite a day," school principal Trevor Greene told The Herald-Republic. "We didn't anticipate that by the end of the day we'd be getting calls from, like, the TODAY show."
At least one college recruiter wanted to speak with Gaby, and a local business owner was so impressed with her that she wanted to offer Gaby a college scholarship, The Herald reported.
"In essence, she gave up her senior year," said Greene. "She sacrificed her senior year to find out what it would be like to be a potential teen mom."
"I admire her courage. I admire her preparation. I give her mother a lot of credit for backing her up on this," he said.
At first Rodriguez's mother wasn't sure what to make of the idea, either.
"I thought she was crazy," says 52-year-old Juana Rodriguez, adding it was difficult to lie to family members.
But she felt she needed to support her daughter, who enlisted two mentors from Yakima Valley Memorial Hospital's Childbirth Education Program to help her with the project.
Rodriguez began wearing her homemade, basketball-sized, prosthetic belly to school after spring break. Before that, she wore baggy sweaters and sweat shirts to conceal her faux pregnancy.
Her supposed due date was July 27, not quite two months after graduation.
Rodriguez and her boyfriend, 20-year-old Jorge Orozco, met at the homecoming game when she was a freshman and he was a senior. They started dating just over three years ago.
When Rodriguez told him her plan, "I thought she was nuts," the 2009 Toppenish High School graduate said. "I thought I was going to end up getting into problems with her brothers. I didn't really want to get into problems with anybody."
"I was doing it for her," he says, adding, "My parents thought it was going to be a boy."
Rodriguez — who has a grade-point average of 3.8 — came up with the idea during her sophomore year Advanced Placement biology class with Shawn Myers. She's in his anatomy class this year.
"You saw the side comments and the looks at her stomach," says Myers, who says he wasn't disappointed — "just concerned" — when she told him she was pregnant.
He says he wondered: "How are we going to take all of the potential that's in this girl and make sure it manifests itself and not let this define who she is and let it be a roadblock to what she wants to accomplish?"
It's a question Hispanic teens are more likely to face than white teens, Rodriguez found in her research. Black and Hispanic teens continue to have higher pregnancy rates than white teens.
And most teens at Toppenish High School — about 85 percent — are Hispanic, Yakima Herald-Republic reported.
Rodriguez plans to attend Columbia Basin College to study social work or sociology in the fall. And, she said, "I'm not planning to have a child until after I graduate."
The Yakima Herald contributed to this report.


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text: Directions: Scoop a mound of mince into one side of the baller and use the scissor tongs to squeeze the sides together. Scrape off any excess. Release the ball gently onto a surface. This will create evenly sized meatballs which prevents them cooking at different rates. Top tip: egg white is the perfect ingredient to encourage the meat to stick.


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Metropolitan Canteens run the Padua College canteens at each campus. There is an extensive menu at the Mornington Campus, however please note that there is a more limited menu at Rosebud and Tyabb Campuses due to the smaller student population there, so some of the items listed will not be available on a daily basis.
Bakery Menu (62 KB)
Breakfast Menu (88 KB)
Sandwich Menu (50 KB)
Ice-Cream Menu (50 KB)
Soft Drink Menu (74 KB)


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This is an appointment based program where you will set appointments with a Personal Trainer that will coach you through Specific Training objectives to accomplish your fitness goals. Appointments can be set as early as 5am and as late as 10pm and anytime during the day that works best for your schedule.
This program includes:
Personal Training Sessions by appointment with a highly qualified Personal Trainer to achieve your fitness and performance goals.
If you are a member in the Team Fitness Program we can add 1 or 2 Personal Training Sessions a week at a significant discount.
We have single rates, family rates, corporate rates, military, law enforcement and student discounts.
Come try any of our programs free for one week!


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Wall, Wizards finish off Bulls in Game 5
CHICAGO — John Wall capped his first career playoff series in style.
The Washington guard scored 24 points, leading the Wizards to a 75-69 victory over the Chicago Bulls at the United Center on Tuesday and a 4-1 win in the best-of-seven, first-round Eastern Conference playoff series.
Washington won a playoff series for the first time since 2005, when it beat the Bulls, and for just the second time since 1982.
The fifth-seeded Wizards will face the winner of the Indiana Pacers-Atlanta Hawks series, which the eighth-seeded Hawks lead 3-2.
"It means a lot because it means we get a little rest now," second-year Wizards guard Bradley Beal said. "We have been through so much together. We've played great basketball in this series, and we can only continue to get better no matter who we play in the next round."
Coming off a one-game suspension for head-butting Bulls guard Jimmy Butler, Wizards forward Nene delivered another strong offensive performance, scoring 20 points. Throughout the series, he was nearly automatic on his quick lean-back jumpers.
Beal added 17 points for the Wizards, while center Marcin Gortat grabbed 13 rebounds.
Chicago shot just 33.3 percent from the field, while Washington hit 40.5 percent of its field-goal attempts.
"When we started this series, we knew no matter what the teams did on offense, it was defense that was going to win," Wall said. "We played great defense, and that is why we came out with the win."
Trailing by nine points at the start of the fourth quarter, the Bulls closed within 65-62 on guard Kirk Hinrich's 3-pointer. Wall answered with a 3-pointer and later added a fast-break scoop to put Washington ahead 70-62 with 5:23 remaining.
A 3-pointer by Butler and jumper from forward Carlos Boozer brought Chicago back within 70-67. After the teams traded points, Washington took more than a minute off the clock when Gortat grabbed or tipped three consecutive offensive rebounds.
The Bulls finally got the ball back, but Boozer missed a driving attempt.
After forcing a 24-second violation, Chicago got another chance trailing by three with 22.4 seconds to go. The Bulls tried to run a quick-hitter to Butler, who missed a layup attempt.
Chicago could have had another chance to tie when Wizards guard Andre Miller missed two free throws with 16.2 seconds left, but Nene tipped the offensive rebound back out, and the Wizards finished the scoring at the foul line.
The Bulls are no strangers to injury misfortune, with former MVP Derrick Rose missing all but 10 games this season with a knee ailment. With 7:51 left in the fourth quarter Tuesday, forward Taj Gibson was helped off the court after turning his left ankle while trying to block a Wall shot attempt.
"It was just tough the whole game," Gibson said. "The way we started the game, the way we came out the beginning of the third. After I got hurt, watching in the back. It's just frustrating."
Earlier in the second half, Chicago center Joakim Noah limped noticeably after appearing to get hit in the right knee by teammate Mike Dunleavy while fighting for a defensive rebound.
Hinrich and Butler led the Bulls with 16 points each. Gibson scored 12 and Boozer 10, with Noah pulling down a game-high 18 rebounds.
"Right now, it's tough because we just lost. It's always frustrating," Noah said. "We gave it our all. Disappointed. You look back and wish there were things you could have done better."
The Bulls were focused on getting off to a better start after falling behind 14-0 in Sunday's Game 4. It went OK for a while, with Chicago holding a 10-9 lead midway through the first quarter, but the Bulls went on a cold-shooting streak, hitting just one of their next 15 shots to fall behind 28-16.
Chicago snapped out of its offensive funk and went on a 17-4 run, taking a 37-36 lead on a Noah jumper.
The score was tied 41-41 at halftime, which was a noticeable improvement by the Bulls' defense. In the first four games of the series, Washington averaged 52.5 points in the first half.
The Wizards controlled the third quarter, limiting Chicago to 11 points on 4-of-16 shooting (25 percent). Washington scored seven straight points in the middle of the quarter, opening a 56-48 advantage with 5:13 left on Nene's jumper.
By the end of the third quarter, the Wizards led 61-52 and Chicago was shooting just 32.2 percent as a team.
"In this game, we had to grind it out," said Washington's Randy Wittman, who earned his first playoff series victory as a head coach. "I am proud of those guys. For a lot of them, this is the first time dealing with this. Not only being in the playoffs, but closing out the series. They realize how hard it is. They never lost their focus of being satisfied with a couple wins."
NOTES: Both coaches in the series have ties to Los Angeles Clippers coach Doc Rivers. Chicago's Tom Thibodeau was on Rivers' staff in Boston from 2008-10, while Washington's Randy Wittman played with Rivers on the Atlanta Hawks from 1983-88. "I'm trying to be there for him," Wittman said before Tuesday's game. "I think he's handled it as well as he can handle it. I just wanted to be there to support him and try to help him get his mind back to where it should be, and that's playing basketball." ... The Bulls trailed 3-1 in a playoff series 10 times, and they lost each time. ... Washington took a 3-1 lead in the playoffs for the sixth time, and they won each of the series. However, Tuesday was the first time they closed out one of those series in Game 5. ... Wizards F Trevor Ariza shot 46.5 percent (13-for-28) from 3-point range in the series. He was 0-for-1 beyond the arc in Game 5.


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The mackerel tabby pattern has vertical, gently curving stripes on the side of the body. Even though not all American Curls essentially have curved ears, it is enviable for show cats having ears that curve all the way back to the center of their heads, a bit away from their face. As the testing becomes much more established and if required, comparisons of cats of the exact same breed from diverse nations may be achievable. The white patterns over her eyes make her appear cute and the circular tiger like cheek markings. Eye colour is gold or yellow, even though the Siamese ancestry often produces blue or green eyes. Devon Rex cat has large eyes, prominent cheekbones curly whiskers, quick muzzle, and low-set massive, ears producing a typical elfin is a medium build, tiny cat. They might get pleasure from the company of another active cat even though they can become jealous if another cat appears to be taking their spot in the property or if they are not receiving enough interest. This accounts for the breed being named soon after the Indian city of Bombay (contemporary Mumbai).
The spectacular looking Bombay cat is the ideal pet for any owner seeking for a jet black pedigree pet. The head and face retain the wild or feral appear of the Asian Leopard ancestor, with small rounded ears and strong whisker pads. It is nevertheless permitted to add to the gene pool and outcross the breed by mixing in a pedigree black American Shorthair or sable Burmese, but most Bombays these days are bred from inside the breed. The American shorthair is America's individual cat variety whose ancestors moved to North America with early on settlers from Europe. The mixture of the different variants produces a exclusive genetic profile for your cat. If a breed or unknown cat race is not in the database, the profile will be matched to the subsequent best race or breed that is present, giving an inaccurate result.
Bengals will match to the Bengal breed or potentially to the domestic breed most recently employed, such as Abyssinian or Egyptian Mau. I have a maine coon, she is the ideal cat iv ever had, shes truly smoochy and loves to sit or sleep subsequent to me, can play fetch and loves water. The Egyptian Mau's characteristic spots are not only on the hairs of the coat but are also visible in the skin pigmentation if the cat is shaved.
Amongst the cat breeds, they are the most competitive fighter and the one particular with highest chance of survival in harsh environment. The breed was developed in the USA in the 1960s and 1970s by Mrs Jean Mill, who crossed an Asian Leopard cat with an American Shorthair and continued producing offspring. If your cat genuinely is a direct relative of a breed, Cat Ancestry will detect that relationship with high probability. Nikki Horner's aim was to produce a 'baby panther' breed of cat that would resemble a miniature version of the black leopard, popularly identified as the black panther, which is a native species of India.
The eye color is usually Gooseberry Green, nevertheless, in the starting of their life they have Amber colored eyes. The population that has the most related profile with your cat will be reported as its race of origin. Please consider supporting the improvement of the test by delivering samples from Servals, Jungle Cats or Leopard Cats that have utilised in breed improvement.


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Personalized High-Back Drafting Chair by Flash Furniture Best Choices
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CMPC chairman resigns
Chinese Nationalist Party (KMT) Legislator Alex Tsai (蔡正元) yesterday resigned as chairman of Central Motion Pictures Corp (CMPC, 中影公司) in the wake of a gunshot fired at the iron door of his office in Nangang, Taipei, on Saturday. The CMPC yesterday held an ad hoc board meeting and approved Tsai's resignation. It subsequently elected Lin Li-chen (林麗珍) as its new chairwoman. Tsai on Saturday had said that the gunshot incident may have been related to shareholding disputes. Tsai has been accused by former CMPC vice president Chuang Wan-chun (莊婉均) of stealing her shares in the corporation.
Biodiesel fuel on sale
Biodiesel fuel is on sale on a trial basis as part of the nation's attempts to reduce oil imports and carbon dioxide emissions. Gas stations in two counties, Taoyuan and Chiayi, began selling petroleum diesel mixed with 1 percent biodiesel fuel over the weekend, the Economic Ministry said on its Web site. The blended diesel will be sold nationwide by next year. By 2010, the mix will be increased to 2 percent biodiesel, resulting in the consumption of an estimated 100,000 kiloliters of biodiesel fuel per year, it said. The trial sale this year is aimed at encouraging farmers to grow more soybeans, sunflowers and rape plants to produce the alternative fuel. The government has made the production of biodegradable fuel one of its core policies to help cut oil imports, increase farm yields and reduce the output of carbon dioxide to help combat global warming, the ministry said.
Patient to return from China
Arrangements have been made to return the "runaway" tuberculosis patient surnamed Lee (李) from China, where he flew on July 21 with his wife despite a flight travel ban for those with drug-resistant strains of tuberculosis, a Center for Disease Control official said yesterday. The center's deputy director, Chou Chih-hao (周志浩), said he could not give details on the patient and his wife's whereabouts and declined to answer when and how Lee and his wife would return. Lee's wife also suffers from tuberculosis, although she has not been diagnosed with the same drug-resistant strain as her husband. "The couple have asked to remain anonymous so we don't want to cause them unpleasantness by exposing their itinerary," Chou said. "However, I want to reassure the public that precautions will be taken to ensure that the couple are safely isolated during the return trip." Upon their return to Taiwan, Chou said, the couple will be quarantined until they are no longer infectious.
Tao boat reaches Tamsui
The largest traditional Tao wooden boat ever made, which departed from Lanyu (蘭嶼, Orchid Island) more than a month ago for Taiwan proper arrived at Tamsui (淡水), Taipei County, last night. The hand-rowed boat is named Ipanga na 1001, which means "from here to there and further" in the Tao Aboriginal language. The boat can carry 20 rowers, the Council for Indigenous Peoples said. A traditional Tao boat usually seats up to 10 people. Premier Chang Chun-hsiung (張俊雄), council Minister Icyang Parod, Aboriginal lawmakers and Taipei County Commissioner Chou Hsi-wei (周錫瑋) all attended a ceremony last night to welcome the boat. The boat will be on display for a week at the Taipei 101 tower, council spokesman Sewaya Teason said.


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Single Doctoral-Level Psychology Courses
At CalSouthern, students may enroll in a course at the doctoral level without committing to a degree program. It's a great option for students who want to:
- Get a feel for online learning at CalSouthern before pursuing a doctoral degree
- Earn credits that can be applied toward a doctorate at CalSouthern or another institution*
- Gain knowledge and expertise at the highest academic level in a topic of particular interest
Choose any of the doctoral courses from the CalSouthern's School of Psychology. You'll find a vast selection of subjects available, on topics as diverse as addiction, human sexuality, trauma, sports psychology, domestic violence and neuroscience.
Getting started is a quick and simple process. No entrance exams are required and you don't have to provide official transcripts. A master's degree is not required to take doctoral-level courses. (However, if you wish to commit to CalSouthern's Doctor of Psychology program, a master's degree is a prerequisite.) Courses start every month; you'll never encounter a closed course or waiting list!
*Although credits from regionally accredited institutions like CalSouthern are readily accepted by other universities, acceptance is at the discretion of the receiving institution.
Doctoral Courses
PSY 87551 Positive Psychology II
This course further explores the scientific study of human strengths and virtues. Although seeking to increase objective knowledge in this domain, the focus of study for this course is in applying such knowledge to help individuals, couples, and families to function more effectively and to provide interventions for their enhanced wellness, job satisfaction and self-fulfillment in the workplace.Learning Outcomes:
- Evaluate course concepts critically and competently through interaction with Learners and Faculty Mentor
- Integrate course concepts through the use of the Taylor Study Method
- Analyze the Maslach Burnout Inventory and its usefulness in assessing and treating burnout
- Identify three methods for increasing resilience among mental health practitioners including peer supervision, journaling, and mindfulness training
- Assess personality styles which enhance growth and self actualization
- Synthesize multicultural counseling with positive psychology aims and goals
- Examine narrative therapy as a tool for personal growth with clients
- Demonstrate ethical behavior in regard to emerging relevant technologies applicable to psychology


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More Manic Monday Market Movement
It's just another manic Monday in the markets.
The Dollar has calmed down and is back to 81.20 and that's goosing the Futures up more than half a point with gold rocketing back to $1,591 and congrats to all our GLD, GDX, ABX and HMY players – all picks (or re-picks) from last week's exciting and silly pullback.
Speaking of exciting: Remember last week when we liked the Nikkei Futures at 11,200 (even 11,300 pre-market on Thursday – as noted in the post)? The Nikkei stopped just under 11,700 this morning and has settled at 11,675 as they Yen is back down (up) to 94 to the Dollar, despite it's weakness.
That means you don't need Sherlock Holmes to deduce that the Euro must be way up and it is – back over $1.33 today as all those silly worries over the Italian election turned out to be exactly the BS we expected them to be, along with all the other worries we discounted in last week's very extensive review of "10 Big Worries."
Oil is back testing $94 and, unfortunately, gasoline (/RB) shot up to $3.30 again – up .20 since Friday's close. We took the money and ran on our oil shorts as we came up just short of our $92.50 goal but it was gold we chose to ride long, not oil – which is still in a World of fundamental pain. I was in California last week and they LOVE electric cars out there. California often sets national trends and retail gasoline in the state is about $4.60 and probably $4.80 today so they have good reason to love hybrids and electric cars – not to mention that LA smog, which makes Chinese visitors feel right at home.
Fortunately, I got out of LA-proper this weekend and went to Malibu and then spent Sunday at Hermosa Beach before heading to the airport and there I met many ex-New Yorkers and I was considering what Billy Joel said about "Los Angelenos":
Los Angelenos
All come from somewhere
To live in sunshine
Their funky exile
Hiding up in the mountains
Laying low in the canyons
Goin' nowhere on the streets
With their Spanish names
It's true – California is a place for people who want to start over and it filters out the kind of people who worry about the Future (as their future almost certainly includes a disastrous earthquake) so it's a state full of risk-takers and optimists and dreamers who mainly came from the East Coast and got a chance to start fresh and tried to avoid making the same mistakes we did – hence more public lands, more preserved environment, more concern about health and individuality and less concern about money and finance.
In fact, an East-Coast Finance guy said to me "it's like being a shark in a pond full of minnows" but I think that's a simplification. Californians play a longer game than New Yorkers and it's easy to jump in and do well in the short run but the real survivors in California are a tougher breed, but also a nicer one than what we are used to on the East Coast, where survival of the fittest is what we win BEFORE we start competing.
Could I live in California? I thought not when I was in LA/Beverly Hills most of the week and I've visited before and seen most of it but Hermosa reminds me of my precious Lerici in Italy, which is on my short list of retirement spots so, next time I'm in California, I'll spend more time south of LA – an area I've missed in previous travels.
Anyway, where was I? Oh yes, so if California is buying smaller cars, hybrids and more electric cars (not to mention no cars at all for a lot of people) then I don't think the rest of the US is that far behind – especially with these sustained, ridiculous fuel prices.
Notice that the spike in oil prices in 2007-8 led to a 5-year change of habits among US motorists that is a continuing trend. For some reason, the NYMEX crooks have decided to remedy the situation by raising gas prices but I think they ain't seen nothin' yet as far as consumers cutting back is concerned. While we talk about TSLA, the stock here at PSW (one of my picks of the year and right on track so far!) – in California they talk about Tesla the car and how long it takes to get one and when do I think they'll be more affordable because "everyone wants one."
And it's not just cars, of course – it's LED lights and solar homes (saw plenty of those) and sure, they are marginally cost-effective at the moment but the same thing could be said about early VCRs, CD players, Computers, etc – things that have great public demand tend to get cheaper as they are mass produced. Oil is sealing it's own fate – even in an inflationary environment and we welcome the attempt to take it higher as we only get to short it again (and again).
All our market gains this morning are a reaction to Dollar losses so we'll watch and wait (for clarity) today. The UK lost it's AAA rating but, DUH! to that and the bears will have to work a lot harder to stop this runaway train of a market. European stocks in general have been missing the rally so far this year and we know China is tightening on property inflation as well as allowing fuel prices over there to rise for the first time since September.
That and the drop in commodities (which scare people out of emerging markets) leaves US equities as the "best" place to park your global investment Dollars for moment and we keep waiting for a shoe to drop, just like the bears but, unlike the bears, we're happy to participate in the gains while we wait.