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Recent literature about diabetes and disorders of glucose metabolism in people with HIV/AIDS contains conflicting messages. Some studies indicate an increased risk of diabetes mellitus (generally referred to simply as "diabetes") in people taking HAART, specifically protease inhibitors (PIs). Other studies indicate that nucleoside reverse transcriptase inhibitors (NRTIs) are the culprit. It is clear that traditional risk factors for diabetes, such as family history of the disease, obesity, and sedentary lifestyle, are important in people with HIV. Other issues, such as the role of fat deposition abnormalities, HIV/hepatitis C coinfection, and dyslipidemia (a metabolic disorder), require further investigation.
People with HIV can work to prevent diabetes by maintaining a healthy weight and increasing physical activity. Diabetes treatment, with oral agents or insulin, can be initiated when preventive efforts are not sufficient. This article reviews current research and areas for future study in the relationship between HIV, insulin resistance, and diabetes, presents basic principles of diabetes management, and highlights specific concerns for HIV positive diabetic women.
Diabetes and Insulin Resistance
Type 1 diabetes is typically diagnosed in children and young adults. The disease is caused by destruction of the pancreatic islet beta cells, which produce insulin. People with type 1 diabetes therefore have a lifelong dependence on insulin therapy. Type 2 diabetes is usually diagnosed later in life, and is the result of tissue (muscle, liver, fat) insensitivity to insulin. The pancreas overcompensates by increasing insulin secretion, but eventually it cannot keep up. More than 90% of the approximately 18 million known diabetics in the U.S. have type 2 diabetes.
The long-term consequences of uncontrolled diabetes are devastating. They include vascular disease (heart attacks and stroke) and kidney disease (diabetic nephropathy), which may eventually lead to end-stage renal disease requiring dialysis. Diabetic retinopathy causes vision changes and eventually blindness, and diabetic neuropathy, which causes painful burning and tingling or numbness in the limbs, can be debilitating. Skin infections, especially of the feet, take longer to heal in diabetics than in non-diabetics, placing diabetics at higher risk for amputation.
Glucose, the main sugar that the body makes from food, is carried through the bloodstream to provide energy to all of the body's cells. The fasting blood glucose test measures the level of glucose in a blood sample taken after the patient has fasted for at least eight hours (for example, first thing in the morning). A fasting blood glucose of 126 mg/dL or higher in blood samples taken on two separate occasions is diagnostic of diabetes. A randomly sampled blood glucose level greater than 200 mg/dL, in conjunction with symptoms of diabetes (such as blurry vision, weight loss, or frequent urination), is also diagnostic of diabetes.
The oral glucose tolerance test can also be used to diagnose diabetes. This test requires ingestion of a 75-gram glucose load (usually in the form of a sweet liquid), with the blood glucose level checked two hours later. If the blood glucose is greater than 200 mg/dL, and a subsequent fasting blood glucose is greater than 126 mg/dL, the diagnosis of diabetes is confirmed.
There are other "pre-diabetes" conditions that have garnered attention in the era of HAART therapy. Insulin resistance, the precursor to diabetes, is measured clinically via tests of impaired glucose tolerance and impaired fasting glucose. Impaired glucose tolerance is determined by performing an oral glucose tolerance test, as described above. A blood glucose of 140-199 mg/dL two hours after the 75-gram glucose load indicates impaired glucose tolerance. Impaired fasting blood glucose is diagnosed with a fasting blood glucose of 100-125 mg/dL. Fasting insulin levels are often checked in clinical trials to determine insulin resistance but are not used clinically.
Insulin Resistance, Diabetes, HIV/AIDS and HAART
As people with HIV live longer with HAART, their care providers must be more vigilant about chronic conditions like diabetes and high blood pressure that can cause significant damage if not well controlled. Since the late 1990s, when glucose abnormalities began to appear in people taking HAART, multiple studies have examined the relationships between HIV/AIDS, HAART, insulin resistance, and diabetes.
Several mechanisms contribute to insulin resistance, and subsequently diabetes, in individuals with HIV. These include chronic inflammatory changes caused by HIV, and side effects of antiretroviral medication, such as the interference of protease inhibitors (PIs) in the activity of glucose transporters, the damage to mitochondria caused by NRTIs, fat deposition in the liver, and abnormal levels of free fatty acids caused by lipodystrophy (fat redistribution in the form of central obesity, or excess belly fat, and fat loss from the limbs).
Data From the Multicenter AIDS Cohort Study
A large study of diabetes in men with and without HIV by Todd Brown, MD, of Johns Hopkins University and colleagues showed higher baseline prevalence of diabetes in men with HIV taking HAART than in men without HIV. Of 1,278 men from the Multicenter AIDS Cohort Study (MACS), 47 of 411 men with HIV using HAART (14%) had diabetes at baseline compared with 33 of 710 men without HIV (5%). Of the 680 study participants who were followed prospectively, men on HAART had an incidence rate of diabetes of 4.7 per 100 person-years (PY), compared with 1.4 cases per 100 PY in men without HIV, indicating a four-fold increased risk of developing diabetes for men on HAART, adjusted for age and body mass index (BMI). With regard to specific PIs, only ritonavir (Norvir) was associated with an increased risk of either diabetes or hyperglycemia (high blood sugar); however, the authors noted that 94% of subjects taking ritonavir were using it in combination with another PI.
|Calculating BMI
Body mass index, or BMI, is an indicator of total body fat, which is related to an individual's risk for obesity-related illnesses like diabetes. The following formula is used to calculate BMI:
[body weight in pounds ÷ (height in inches × height in inches)] × 703 = BMI score
When compared with the categories shown below, BMI scores can help alert individuals and their clinicians to possible weight-related health risks.
BMI Category BMI Score
Note: This formula is not a reliable measure for children, may overestimate total body fat in highly athletic people (because muscle tissue weighs more than fat), and may underestimate total body fat in the elderly and others who may have lost muscle mass.
Another interesting finding was that among 229 HAART users who were followed in the study, 157 men whose nadir (lowest ever) CD4 cell count was less than 300 cells/mm3 developed either hyperglycemia or diabetes, compared with 72 men whose lowest CD4 cell count was greater than 300, for a relative risk of 1.67 among those with a low nadir CD4 cell count.
Brown and colleagues also published data from the MACS group regarding insulin resistance among 1,288 men, 533 with HIV and 755 without HIV. Having HIV was independently associated with insulin resistance and fasting hyperinsulinemia (excess levels of insulin in the blood). Length of cumulative exposure to NRTIs, but not PIs, was also associated with insulin resistance. NRTIs have also been linked to peripheral fat wasting in other studies. Although the exact mechanisms are unclear, both metabolic and body shape abnormalities clearly stemmed from NRTI use.
Data From the Swiss HIV Cohort
A study from Switzerland by Bruno Ledergerber, MD, of the University Hospital, Zurich, and colleagues revealed much lower incidence of diabetes than the U.S. studies. The Swiss HIV Cohort, established in 1988, followed 6,513 persons (about one-third of whom were female) and collected plasma glucose levels and information on diabetes diagnoses starting in March 2000. During the study, 123 patients developed new-onset diabetes, an incidence of 4.42 per 1,000 PY. The investigators found male sex, older age, African or Asian ancestry, AIDS diagnosis, and central obesity to be associated with diabetes.
With regard to antiretroviral therapy, the Swiss investigators found that ongoing therapy with an NRTI, NRTI/PI, and NRTI/PI with a non-nucleoside reverse transcriptase inhibitor (NNRTI), but not NRTI/NNRTI therapy, increased the risk of incident diabetes two to three fold. In terms of specific drugs and drug combinations, indinavir (Crixivan), lamivudine (Epivir; 3TC) plus stavudine (Zerit; d4T), didanosine (Videx; ddi) plus stavudine, and didanosine plus tenofovir (Viread) were associated with new diabetes cases.
The study authors observed a much lower rate of incident diabetes than studies in the U.S. have shown, but noted that the population in the Multicenter AIDS Cohort Study was older and had a higher median BMI than their population. In addition, the definition of diabetes in the MACS study was based on a single fasting glucose determination, whereas in the Swiss study, individual physicians were contacted if a blood glucose level was high to determine whether the patient had been diagnosed with diabetes.
Data From the D:A:D Study
The D:A:D (Data Collection on Adverse Events of Anti-HIV Drugs) study is a multinational, prospective, observational study with data collection from over 33,000 patients at 212 clinics in Europe, the U.S., Australia, and Argentina. The study was designed to examine the cardiovascular disease risk associated with antiretroviral therapy. Data on diabetes were collected as a secondary endpoint of the study.
Of the 33,389 study patients, 952 had diabetes at baseline, for a prevalence of 2.85%. During the follow-up period, 744 patients were diagnosed with diabetes, an incidence of 5.72 per 1,000 PY of follow up. Of these cases, over 60% were diagnosed by obtaining two fasting blood glucose values greater than 126 mg/dL; the remainder had a diabetes diagnosis and started a new glucose-lowering drug.
New cases of diabetes were associated with longer total duration of antiretroviral therapy, and in particular, with stavudine therapy. Zidovudine (Retrovir; AZT) and didanosine were also associated with an increased risk. Exposure to the PI ritonavir and the NNRTI nevirapine (Viramune) were associated with a slightly decreased risk. The authors proposed that stavudine has direct effects on diabetes risk by increasing insulin resistance, in addition to indirect effects through the development of lipodystrophy.
In the study group, men were more likely to develop diabetes than were women; other factors included older age, higher BMI, and African ancestry. In further multivariate analyses, high total cholesterol, low HDL cholesterol (the "good" cholesterol), and manifestations of lipodystrophy, either as peripheral fat loss or central fat gain, were associated with new-onset diabetes.
Data From the Women's Interagency HIV Study
The Women's Interagency HIV Study (WIHS), established in 1994, is a large study based in six U.S. cities that tracks the disease progression of women with and at risk for HIV using semi-annual study visits. Data regarding diabetes was published at three different time points, with increasingly detailed information each time.
One such study, by Jessica Justman, MD, of Columbia University's HIV Center for Clinical and Behavioral Studies and colleagues, examined the incidence of diabetes in the WIHS group from 1994 to 1998. Participants included 1,435 women living with HIV and 350 HIV negative women. The investigators compared women in three groups: those who used PIs in a regimen containing one PI and at least one NRTI and/or NNRTI, those who used NRTIs and/or NNRTIs but no PIs, and those who received no antiretroviral therapy at all.
Sixty-nine new cases of diabetes were reported among all study participants, for an incidence of 1.5 per 100 PY overall. Breaking down the incidence by HIV status and antiretroviral therapy group, the incidence of diabetes in women without HIV was 1.4 per 100 PY, incidence among women using NRTIs and/or NNRTIs was 1.2 per 100 PY, and incidence in HIV positive women not taking antiretroviral therapy was also 1.2 per 100 PY. The incidence of diabetes was highest in women taking PIs, at 2.8 per 100 PY -- a statistically significant difference. The authors also noted that the highest risk of developing diabetes occurred among women who were obese.
Another study from the WIHS group, published in 2005 by Ann Danoff, MD, of the New York University School of Medicine and colleagues, was a cross-sectional examination of the prevalence of diabetes, prediabetes, and insulin resistance among a subset of WIHS participants. The substudy enrolled 258 women, most of whom (72%) were overweight or obese, and 81% of whom were African American or Latina. Eighty-eight women did not have HIV, 74 women had HIV and were not on HAART, and 96 women had HIV and were taking HAART. Study participants underwent oral glucose tolerance testing and measures of fasting blood glucose and insulin to determine the prevalence of diabetes, prediabetes, and insulin resistance. The investigators determined diabetic status, then compared diabetic status among women with and without HIV and women using or not using HAART.
Contrary to the prior study, there was no significant difference in the prevalence of prediabetes or diabetes based on HIV status, nor was there a significant difference in prevalence of prediabetes or diabetes based on HAART use among HIV-positive participants. Only higher BMI was associated with prediabetes and diabetes. The investigators hypothesized that in a sample composed mainly of overweight women, the impact of BMI on prediabetes and diabetes overshadowed any small differences related to HIV or HAART use.
A third study from the WIHS group, published in 2007 by Phyllis Tien, MD, of the University of California, San Francisco, and colleagues, was the most robust. Data were collected prospectively from 2,088 women (1,524 women with HIV, 564 without HIV). The investigators used fasting blood glucose greater than 126 mg/dL or use of a medication for diabetes for diagnosis, rather than patient self-report of diabetes. Use of HAART was classified as no therapy, monotherapy, combination therapy, PI-based HAART, or non-PI-based HAART. Length of cumulative exposure to HAART drugs was determined. Additional data were collected on race/ethnicity, smoking status, BMI, hip and waist size, and hepatitis C antibody status. In the entire study group of 2,088 women, 152 women developed diabetes (116 women with HIV, 36 women without HIV), and 1,710 women (1,213 with HIV, 497 without HIV) completed the study without diabetes. (The remaining 226 women were lost to follow up or died.) Of the 116 women with HIV who developed diabetes during the study, 82 reported using HAART immediately prior to diagnosis.
The incidence rate for diabetes was 1.96 per 100 PY in women without HIV, compared with 1.53 per 100 PY in women with HIV and not on HAART, 2.5 per 100 PY in women on PI-based HAART, and 2.89 per 100 PY in women on non-PI based HAART. These differences were not statistically significant. Further analyses showed that longer cumulative exposure to NRTIs (more than three years) was associated with a higher risk of new-onset diabetes; longer cumulative exposure to PIs or NNRTIs was not associated with higher risk. With regard to specific NRTIs, there was no association between cumulative exposure to abacavir (Ziagen), stavudine, or zidovudine and new-onset diabetes. However, a higher incidence of diabetes was associated with greater than one year of exposure to lamivudine.
The study authors suggested that the differences between the results of the earlier and later WIHS study results were due to widespread use of indinavir in the earlier studies. Indinavir use is associated with insulin resistance, even in HIV negative people who have taken the drug in clinical trials.
Hepatitis C, HIV and Diabetes
Studies have shown an association between hepatitis C virus (HCV) infection and the development of diabetes in people without HIV. Rates of HIV and HCV coinfection in the U.S. are high, estimated at 15% to 30%. A study by Shruti Mehta, PhD, of Johns Hopkins University and colleagues examined hyperglycemia in people with HIV, with specific attention to HAART and HCV status.
The study enrolled 1,230 people with HIV receiving their first HAART regimen. Of the 1,230 participants, 845 (69%) were on a PI, 269 (22%) were on an NNRTI, and 116 (9%) were on both; 579 (47%) did not have HCV, and 651 (53%) had HCV. The investigators looked for hyperglycemia in the study participants, defined as a random blood glucose of greater than 200 mg/dL, confirmed either by repeat blood glucose testing or diagnosis of diabetes in the participant's medical history.
The investigators found new-onset hyperglycemia in 5.8% of participants with HCV/HIV coinfection and 2.8% of participants with HIV only -- a statistically significant difference. The data also showed highest incidence of hyperglycemia in people taking PI-based HAART compared with those on NNRTI-based or PI- and NNRTI-based HAART. This highest incidence of hyperglycemia (at 6.4%) was seen in participants who were HIV/HCV coinfected and receiving a PI. The authors concluded that HIV and HCV coinfection and PI use increase risk of hyperglycemia, independent of age, race, and body weight.
A cross-sectional study by Andrea Howard, MD, of the Albert Einstein College of Medicine and Montefiore Medical Center and colleagues involved 267 people with HIV and 179 people without HIV from the Menopause Study and the Cohort of HIV at-risk Aging Men's Prospective Study (CHAMPS). Of the 446 subjects enrolled, 265 (59%) had HCV, and 98 participants (22% of the total) had impaired glucose tolerance or diabetes. HCV infection was associated with insulin resistance, even after adjusting for traditional risk factors for insulin resistance such as higher BMI, sedentary lifestyle, and older age. Among the HIV positive participants in this study, insulin resistance was greatest in those with higher CD4 count (greater than 500 cells/mm3) and higher BMI. This study found no difference in insulin resistance with regard to antiretroviral therapy use. It is still unclear how HCV is linked to insulin resistance, although it has been hypothesized that the infection interferes with insulin signaling, the process by which insulin affects target cells.
Managing Diabetes
In their excellent review article on the metabolic complications of HIV infection, David Wohl, MD, of the University of North Carolina, Chapel Hill and colleagues summarize the risk factors for disorders of glucose metabolism in HIV infection: obesity, lipoatrophy, PIs, NRTIs (especially stavudine), older age, family history of diabetes, non-white race, and HCV coinfection. A review by Todd Brown and Joseph Cofrancesco, MD, of Johns Hopkins University also includes low nadir CD4 count as a risk factor. Various medications, including steroids, growth hormone, certain antipsychotics, and the appetite stimulant megestrol acetate (Megace) also contribute to glucose abnormalities.
Wohl and colleagues recommend clinical monitoring with fasting blood glucose testing before initiating HAART and every three to six months thereafter. Furthermore, they recommend an oral glucose tolerance test in patients with risk factors for diabetes, including fat redistribution. In terms of switching antiretroviral therapy, there is some data suggesting that NNRTIs and certain PIs, such as atazanavir, cause less insulin resistance; however, all treatment decisions should be made on an individual basis with the primary care provider.
While diabetes treatment involves physicians, nurses, dieticians, and other health care professionals, self-care is crucial for managing diabetes. Good self-care includes following the recommendations discussed below regarding diet, exercise, monitoring, and medications.
Diet, Exercise, and Smoking Cessation. Diabetics are advised to perform moderate-intensity exercise for 150 minutes per week (if approved by their clinician). Both aerobic and strength training activities are beneficial. Diabetics should strive to maintain a healthy weight with a diet that limits saturated fats, concentrated sweets, and alcohol. Individualized nutritional plans can be made in conjunction with a registered dietician.
Smoking cessation is crucial to reduce the risk of diabetic complications, especially heart disease. For more information about quitting, see "Smoking and Your Health: How to Quit (and Why You Should)" in the Winter 2008 issue of BETA.
Monitoring Blood Glucose Levels. Diabetics on insulin therapy are typically advised to check their blood glucose at least three times a day. Home blood glucose monitoring may also help diabetics who are not on insulin therapy achieve their blood sugar goals, but the optimal frequency of monitoring is not known. Blood glucose should be between 70 and 130 mg/dL before meals and no more than 180 mg/dL one to two hours after meals.
Home blood glucose monitoring should be used in conjunction with the hemoglobin A1C test, which measures the average blood glucose over a few months. The goal for diabetics is an A1C lower than 7%, which corresponds to an average blood sugar level below 170 mg/dL. In addition to blood glucose monitoring, diabetics should have regular cholesterol and blood pressure checks.
Monitoring for diabetes complications is individualized and may include an electrocardiogram (ECG or EKG) or a stress test to check for cardiovascular complications, based on risk factors and symptoms. Yearly blood and urine tests to check kidney function are recommended, and eye exams to evaluate diabetic retinopathy and simple clinical tests for nerve damage (especially in the lower limbs) should also be performed annually.
Diabetics should also monitor for symptoms of hyperglycemia, which include blurry vision, frequent urination, severe thirst, and unintentional weight loss. Symptoms of hypoglycemia (low blood sugar) include racing heart, sweating, shakiness/weakness, hunger, and headache.
Because diabetes increases the risk of foot infections and ulcers, diabetics are advised to check their feet daily for any signs of injury or infection. (The primary care provider should also examine a diabetic client's feet at every visit.) Feet should be carefully washed and dried daily, and socks and supportive footwear are highly recommended. Trimming toenails straight across the tops of the nails can help prevent infections.
Medications. Type 1 diabetics require intensive insulin therapy to achieve and maintain tight glucose control and minimize diabetic complications. The management of type 2 diabetes typically starts with metformin (Glucophage) and lifestyle modifications, including changes to diet and exercise habits and smoking cessation. Metformin decreases production of glucose by the liver, limits absorption of glucose, and improves insulin sensitivity (increasing the uptake and use of glucose). If lifestyle changes and metformin alone do not bring blood glucose under control within two to three months, another oral medication, such as a sulfonylurea agent (e.g., Glipizide, Glyburide), which increases insulin secretion, or a glitazone (e.g, rosiglitazone [Avandia], pioglitazone [Actos]), which increases insulin sensitivity, may be used.
These are the two most commonly used classes of oral medications for controlling blood glucose; however, other classes with a variety of mechanisms of action are available. Side effects and contraindications to all oral therapies should be discussed with the primary care provider. Insulin therapy is an excellent treatment option for type 2 diabetics and is available in short-, intermediate-, and long-acting forms. Initial insulin therapy usually involves one dose of an intermediate- or long-acting form, and treatment can be intensified as needed.
For patients with high blood pressure in addition to diabetes, blood pressure should be controlled to less than 130 mmHg systolic and 80 mmHg diastolic (130/80), which may require medication. LDL cholesterol ("bad" cholesterol) should be less than 100 mg/dL, and even lower in very high-risk patients. If LDL cholesterol cannot be brought under control with diet and exercise, then a lipid-lowering agent should be considered. Some patients with diabetes and other risk factors for heart disease benefit from aspirin therapy (in consultation with the primary care provider).
Diabetics are also advised to receive a yearly influenza vaccine and at least one pneumococcal vaccine to prevent pneumonia.
Additional Considerations for Diabetic Women
Blood glucose control and the menstrual cycle. Some diabetic women have decreased insulin sensitivity around the time of menstruation, which may lead to difficulty with glucose control; more intensive monitoring may be needed.
Management of yeast infections. Yeast infections are very common, with about three-quarters of all women having one at least once in their lives. Symptoms include vaginal itching and thick, white vaginal discharge. Diabetes, especially poorly controlled diabetes, is a risk factor for yeast infections; high glucose levels promote yeast attachment and growth, and also interfere with immune responses in the host. Candida albicans is the most common pathogen, but other forms of Candida, such as Candida glabrata, that are less susceptible to conventional treatment are commonly found in diabetics. First-line treatment typically involves creams or ointments that are applied directly to the affected areas. Oral treatments are also available but may have interactions with oral medications for diabetes; consultation with a primary care provider is advised. Whether an oral or topical medication is chosen, treatment must include achieving optimal blood glucose control.
Contraceptive options for diabetic women. Diabetic and non-diabetic women have the same contraceptive options, including barrier products (such as diaphragms and male and female condoms), intrauterine devices (IUDs), hormonal methods, and tubal ligation. However, the latter two options carry some risks that HIV positive diabetic women should discuss with their health care providers. (In addition, only condoms protect both women and their male sex partners against HIV and other sexually transmitted infections.)
Combination oral contraceptive pills have a low failure rate when taken correctly and consistently, and there are minimal metabolic abnormalities associated with their use. However, there are known interactions between oral contraceptives and some PIs and NNRTIs. Hormone levels may increase or decrease in the presence of these drugs, and the effectiveness of oral contraceptives may be diminished; using an additional method of contraception is recommended.
Women with type 1 and type 2 diabetes are advised to use the lowest-dose combination oral contraceptive available, but there is no known worsening of diabetes with oral contraceptive use. That said, there are other risks associated with oral contraceptives, including increased risk of deep venous thrombosis and pulmonary embolism (blood clots in the extremities and lungs), especially in women who smoke. The interaction between oral contraceptives and some PIs and NNRTIs may raise the risk of these side effects. All decisions about oral contraceptives should therefore be made by the individual woman in conjunction with her doctor.
Other hormonal contraceptive products, such as rings, patches, and injectable medroxyprogesterone acetate (DepoProvera), have not been studied extensively in women with HIV, but their hormone components are similar to those of oral contraceptives. A backup method is advisable, and decisions regarding their use -- and potential interactions with antiretroviral drugs -- should be made with the primary care provider.
Tubal ligation ("having your tubes tied") is another contraceptive option available to diabetic women. Most cases are laparoscopic, using a special camera and several small incisions rather than open surgery. Blood sugar control should be optimized prior to surgery to minimize operative complications. Tubal ligation is considered to be a permanent procedure, and women should discuss the benefits, drawbacks, and what to expect post-surgery with their medical providers.
Heart disease in diabetic women. There is evidence that women with diabetes are at higher risk for cardiovascular complications of diabetes than are men. A study in Finland with 1,296 diabetic and 835 non-diabetic middle-aged participants studied the effects of type 2 diabetes on risk for heart attacks and heart disease-related deaths, specifically comparing these effects in males and females. After 13 years of follow-up, the investigators reported a significantly higher relative risk of a major cardiac event in diabetic women compared with diabetic men. More women at baseline had risk factors for heart disease (high blood pressure, elevated BMI, and high triglycerides with low HDL cholesterol), but even controlling for these added risks, there was still a higher burden of heart disease in diabetic women than in diabetic men. Poor blood glucose control contributed to heart disease in both groups.
Study data are mixed regarding the influence of NRTIs compared with PIs on insulin resistance, and the exact mechanisms of the development of insulin resistance and diabetes in HIV disease are still unclear. Until these questions are answered, HIV positive people and their health care providers must understand the importance of maintaining optimal weight through regular exercise and a healthy diet for diabetes prevention.
Additionally, close monitoring of blood glucose, with supplemental testing for people at high risk, will help identify cases of diabetes early so that appropriate treatment can be initiated. Through lifestyle changes and monitoring, HIV positive people can avoid the complications of uncontrolled diabetes and instead concentrate on living well with HIV.
Anne Monroe, M.D., is a resident in Internal Medicine at Jackson Memorial Hospital in Miami, Florida. She has a longstanding interest in HIV clinical trials and women's health.
Selected Sources
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American Association of Clinical Endocrinologists. State of Diabetes Complications in America. 2007. www.aace.com/newsroom/press/2007/images/DiabetesComplicationsReport_FINAL.pdf
American Association of Diabetes Educators. Side by Side: A Partner Approach to Diabetes Self-Care. http://mydiabetespartner.org/wp-content/themes/aade001/pdf/271260_English.pdf.
American Diabetes Assocation. Standards of medical care in diabetes -- 2008. Diabetes Care 31(Supplement 1):S12-S54. January 2008.
Bohannon, N. Treatment of vulvovaginal candidiasis in patients with diabetes. Diabetes Care 21(3):451-56. March 1998.
Brown, T. and others. Antiretroviral therapy and the prevalence and incidence of diabetes mellitus in the Multicenter AIDS Cohort Study. Archives of Internal Medicine 165(10):1179-84. May 23, 2005.
Brown, T. and others. Cumulative exposure to nucleoside analogue reverse transcriptase inhibitors is associated with insulin resistance markers in the Multicenter AIDS Cohort Study. Acquired Immune Deficiency Syndrome 19(13):1375-83. September 2, 2005.
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When he first began shooting, Jeremiah Zagar, 27, intended to use his film camera as a means of getting to know his father Isaiah, famous in Philadelphia for creating breathtakingly unique mosaics on many of the city's buildings.
When he first began shooting, Jeremiah Zagar, 27, intended to use his film camera as a means of getting to know his father, Isaiah, famous in Philadelphia for creating breathtakingly unique mosaics on many of the city's buildings.
In the seven years it took to film "In a Dream," Zagar got much more than he bargained for. The documentary, playing next week at the second annual Salem Film Fest, gives viewers an inside glimpse of Isaiah Zagar's tortured mind, as his son uncovers secrets never before revealed to his family.
In a similar vein, "Life. Support. Music." by filmmaker Eric Daniel Metzgar tracks the life of Cambridge-based musician Jeremy Crigler after he suffers a devastating brain hemorrhage onstage that wipes away his memory and ability to physically function. Crigler's family comes together to help him rebuild his life and slowly ease back into the world again.
"In a Dream," the darker of the two films, centers around the moment when Isaiah Zagar admits to his son that he is having an extramarital affair. In the scenes that follow, the Zagar family falls apart. Father moves out, brother checks into drug rehab, mother struggles to start a new life. And just when the audience thinks it couldn't get much worse, suddenly things take an unexpected upward turn.
Though dark in mood, "In a Dream" is a visual feast of color, following Isaiah Zagar as he works at creating stunning mosaics out of bottles, tile and mirror. In piecing together the film, Jeremiah paid tribute to his father's colorful art by creating a kind of collage that incorporates slides, Super 8 footage and sketches brought to life by stop-motion animation. Wide camera shots and long angles capture the vastness of mosaic covered rooms, making the viewer feel they're standing inside one of Isaiah's otherworldly creations.
"We wanted to show the contrast between the ways in which we dream and view reality," Zagar says. "We wanted to make the audience feel as if they were part of the dream and vision."
Since it first stormed onto the film festival circuit last year, "In a Dream" has garnered much attention, winning awards across the country. It was chosen as one of 15 semifinalists for Best Documentary Feature at this year's Oscar Awards.
Did he have hard time filming his family's personal struggles? Zagar admits that his mother cried often and his father was "a monster" at times, but says he found himself unable to turn away, driven by the desire to tell his family's story. What kept him going, in part, was the idea that honesty, though sometimes painful, is crucial both in art and in life.
"My father puts all his intimate secrets on walls all over the city," he says. "It isn't strange to expose inner life within our family and our community. … What destroyed my father was when he stopped being open and he kept secrets from my mother and his family."
With its unbiased eye, Jeremiah admits, the camera played an important role in getting his father to open up to him.
"It was there for seven years," he reflects. "It enabled my father to be honest in front of me. I certainly judge his actions, but the camera doesn't …"Getting by with a little help from his friends
"Life. Support. Music." tells the story of Jeremy Crigler, a healthy 30-something guitarist known around the New York City music scene who, while playing a show in 2004, walks offstage with a terrible headache that has him falling to the floor in pain. His wife, Monica, calls an ambulance and Crigler is taken to the hospital where grim-faced physicians declare he's suffered a brain hemorrhage and will never fully function again on his own.
Crigler lies in a hospital bed curled into what his sister refers to as "a human pretzel," unable to move his body or recall the details of his own life. Despite this fact, his family refuses to accept the doctors' prognosis, taking turns visiting him in the hospital and working with him to get his withering body moving again. The camera follows his progress as Crigler slowly regains his ability to speak, walk and play music.
Perhaps most touching are scenes, shot by nurses, documenting the daily physical therapy sessions where Crigler learns to move again, and footage taken by his family during the birth of his daughter, an event he would have otherwise missed.
Looking back on these scenes, Crigler admits, can be difficult. "There's a strange element," he says. "Seeing yourself doing all these things you have no memory of … It's a bizarre twilight sensation but I feel proud of how far I've come."
Since it debuted last year, the film has toured cities in the U.S. and abroad, winning awards everywhere from Boston to Rome.
These days Crigler is almost completely back to his former self, living in Cambridge with his wife and daughter and playing regular gigs in Boston and New York. He has a new album out with songs he wrote about his trauma, and he has devoted much of his free time lately to giving talks about his recovery to people who have suffered similar brain injuries.
Crigler shies away from using the word "miracle" to describe his recovery, explaining it in more practical terms.
"Music is a real home base of mine in a lot of ways …" he says. "It was a real motivator. There was lot of hard work and a lot of love … And there have been studies that have shown that patients being filmed will work harder. This could have been the case for me."
"In a Dream" plays at CinemaSalem on Saturday, Feb. 28 at 9:30 p.m. and Wednesday, March 4 at 7:45 p.m. (in the screening room). Filmmaker Eric Daniel Metzgar will attend the Feb. 28 screening.
"Life. Support. Music." plays Saturday, Feb. 28 at 7 p.m. Jason Crigler, the subject of the film, will attend.
Visit www.salemfilmfest.com for more details about the festival and specific films. To purchase Jason Crigler's album, visit www.jasoncrigler.com.

subset: commoncrawl


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Wednesday's endorsement of Senate Bill 191 by the American Federation of Teachers did not phase many in Colorado but caused quite a stir around the nation.
Nevertheless, AFT President Randi Weingarten said her organization's support of the bill shouldn't come as a surprise.
In January, Weingarten made a speech urging her 1.4 million members to accept a form of teacher evaluation that takes student achievement into account.
In that speech Weingarten called for more frequent and more rigorous evaluations and said she wanted standardized test scores and other measures of student performance to be part of the process.
The high-profile national union leader on Wednesday told The Denver Post that she was able to support the bill offered by Sen. Michael Johnston, D-Denver, only after a handful of amendments were added at the behest of Colorado AFT President Brenda Smith.
"What's happened here is they have totally worked, in terms of the amendments, to insure that evaluations are done with teachers not to teachers," Weingarten said. "If you've watched this, this is very consistent with what the Douglas County teachers union and Douglas County School Board had agreed to a few weeks after the speech I made in January, where their evaluations will be overhauled in a way that helps assess both teacher practice and student learning, using multiple measures of student learning, not just test scores. That there be both a real voice and a grievance process to ensure the evaluation process is fair, that there is a voice in hiring in a way that there are hiring committees that include teachers to insure there is the right fit in a school and not simply a principal … and that seniority as well as performance is part of a (reduction in force) procedure."
Still, Colorado's largest teacher union, the Colorado Education Association, said on Thursday morning, hours before the House education committee met about the bill, that it is still "strongly opposed to the bill."
CEA President Beverly Ingle released the statement saying the organization is "working with legislators to make this bill more about teacher effectiveness and student achievement and less about punishing teachers and undermining the profession."
Nevertheless, Weingarten said AFT Colorado and the national organization is pleased with the bill because its sponsors listened to concerns of the union, albeit a small 2,500-member collective in Colorado.
"AFT Colorado took a situation just like (Florida Education Association) in Florida is trying to do, just like Ohio and Pennsylvania are trying to do," she said. "This is about trying to find ways so that states can compete for Race to the Top in a way that does things collaborative with teachers not to teachers. We raised legitimate concerns about the original bill, just like we have done in Florida and in other places. What has happened here is Sen. Johnston worked with us to try to create a better bill that included the voice of teachers."
Weingarten said her union's support of the bill shouldn't be a surprise, even though education reformers across the nation were immediately buzzing about the AFT's endorsement.
"What has happened in some of the so-called reformers is they haven't looked at what has happened in Maryland, Ohio, Pennsylvania, Providence (R.I.) and New Haven (Conn.)," she said. "We are the change agents in education. Just because some people are trying to pigeonhole us into a different role doesn't mean that is happening."
Education reformers, she said, are working at the system from the outside and don't understand that the best way to make changes are from within.
"You have so-called reformers who want to unilaterally change things that we don't think will work and you have change agents like Brenda Smith and the AFT who say, 'lets figure things out that are good for kids and fair to teachers,'" she said. "That's what she did here and AFT nationally is supporting AFT Colorado."


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Tom Lynch Watercolor Palette
by Speedball
Lightweight palette has a central large mixing area and 16 individual wells that allows colors to be pulled in to the center for mixing separate wells. Air tight cover designed to be used as mixing well for large amounts of color for glazing and backgrounds. Keeps paints moist and separate between painting sessions. Excellent for studio work or transporting to painting sites. Includes Tom's own painting tips and techniques for using the palette. Measures 16 1/4 in. long x 12 in. wide x 1 in. deep.
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On September 5, 2006, millions of Americans tuned in to see perky TV personality Katie Couric's ascension to the CBS News anchor's chair. Some have hailed Couric's rise as a commendable step forward for women; she is, after all, the first female to serve as a solo-anchor on a national network news broadcast. Others have decried the filling of such a prominent news position with a figure from the entertainment-journalism world. Still others contend that the fusion of news and entertainment represents simply an inevitable next step in the evolution of broadcast news—and not necessarily for the worse. But as this collection of Atlantic writings makes clear, the American news media has long been in flux. Indeed, as times have changed, the ideals we've looked for in an anchor have shifted, and the motives and values of those stepping up to fill that role have changed as well.
In "The Power and the Profits," a comprehensive article published in January and February of 1976, David Halberstam chronicled the history of CBS news, offering a look back at the figures who pioneered our ideals of what an anchor should be. Before the first bright smile or clean-cut suit appeared on the air, Halberstam reminded readers, there were only the disembodied voices of radio. He conjured early radio broadcasting pioneer Edward R. Murrow, whose rich voice and dramatic pauses ("This…is London"), along with his rigorous political commentary, made an indelible impression on listeners—especially with his live reports from Europe in the midst of World War II. Murrow, Halbersam emphasized, was "an innately elegant man in an innately inelegant profession." His intellectual sophistication and his interest in imparting political ideas to his audience made him, Halberstam explained, as much an educator to the nation as a journalist. To a significant extent, Halberstam suggested, it was Murrow who "ma[d]e radio respectable as a serious journalistic profession" and, later, made television "journalistically legitimate too."
When news broadcasting made the transition from radio to television, however, Murrow's articulate political views became something of a liability. "[Television] moved people as radio never could," Halberstam wrote. "The people who controlled the networks knew this and were uneasy, and in some cases, terrified." It was a tense era of communist accusations and McCarthy censorship, and in recognition of this, Murrow tried to balance his intellectually and politically challenging programming with lighter fare. But CBS opted to steer a course away from him nonetheless. In the early sixties, when CBS went hunting for an anchor for its new, longer Evening News program, they chose Walter Cronkite, an "outsider," rather than one of Murrow's protégés.
[Cronkite] came through as straight, clear, and simple, more interested in hard news than analysis or deep meanings. There was little of Murrow's introspection in him. Viewers could more readily picture Walter Cronkite jumping into a car to rush out and cover a ten-alarm fire than they could picture him doing analysis on a great summit meeting in Geneva.
Though less analytical than Murrow, Cronkite was by no means an insubstantial showman. He embodied an old fashioned, non-flashy outlook, and to viewers, Halberstam explained, represented "Mr. Average Citizen"—a man who would get to the bottom of what was going on each day, and tell it like it was.
In the years that followed, the broadcast news medium continued to evolve. In 1988, Nicholas Lemann reviewed a book by Ed Joyce, a former president of CBS news, which contained, Lemann notes, "many little image-deflating anecdotes about the on-air stars." Joyce ("Grinding his axe joyously," according to Lemann) attributed the ills of the new era of infotainment to the broadcast journalists' relentless quest for personal fame.
[T]he stars have been pushing for goals that are essentially theatrical, not journalistic: more air time, better billing, constant adulation. They have used their supposed commitment to hard-news values as a smokescreen to cover a takeover of control of the news divisions…Entertainment values, if they mean better presentation of the same news, are good and if they mean softer stories and misleading, worked-up presentation techniques, then the stars haven't really fought them.
Another of Joyce's criticisms was that broadcast news seemed to have spawned a meta-category: news about news. Joyce described the way anchors at CBS played with press coverage about themselves and even used the press to "wage internal warfare." Joyce singled out certain on-air reporters for particular criticism. One of these, Lemann noted, was Dan Rather:
Rather, who often saunters in to work in mid-afternoon (according to Joyce) and whose real job is simply to read the copy he is given, is especially successful at making the press believe that he spends his days as a newspaper-style managing editor of the broadcast and as a watchdog of press freedom. Joyce says that Rather makes command decisions about story assignment and composition only when there's a newspaper reporter watching, and that he is … a master of the art of leaking energetically to further his interests and then proclaiming himself to be shocked and mystified by the nonsense the press is publishing about CBS News.
Several years later Atlantic correspondent James Fallows lobbed some criticisms of his own at the broadcast journalism world. In "Why Americans Hate the Media," he expressed concern that the attitude of journalistic detachment now being cultivated to excess by TV journalists could create a troubling disconnect between journalists and viewers. By way of example, he described a 1987 episode of a PBS series called Ethics in America, in which a difficult moral question was put to broadcasting personalities Mike Wallace and Peter Jennings. They were asked to imagine they were covering a war and were embedded with some enemy combatants. If, while traveling, they stumbled upon an American unit whom the enemy would surely ambush, they were asked, would they act as journalists and cover the story, or would they try to warn the soldiers? Jennings instantly replied that he would warn the soldiers. But Mike Wallace derided Jennings's answer, insisting that the wellbeing of the story was more important than the wellbeing of the story's subject. Embarrassed, Jennings rescinded his first answer. Both men were then sharply criticized by a panel of politicians and military officers, who reminded them that the soldiers they would have let die would not have let Jennings or Wallace face the same end if the roles were reversed.
Fallows also pointed out that the kind of substantive information that the general public wants to know about its politicians—what will each candidate do about gun control, for example, or programs for at-risk kids?—bears little relation to the kinds of questions journalists actually ask. Fallows pointed to one typical on-air interview with Senator Kennedy.
When Edward Kennedy began giving his views about the balanced-budget amendment, Rather steered him back on course: "Senator, you know I'd talk about these things the rest of the afternoon, but let's move quickly to politics. Do you expect Bill Clinton to be the Democratic nominee for re-election in 1996?"
Fallows noted that this widening gap between what the public wants and needs from its broadcast journalists and what those journalists actually deliver has led, over the years, to a growing cynicism and disillusionment. Journalists, he pointed out, have fallen far in the public's estimation:
Since the early 1980s the journalists who have shown up in movies have often been portrayed as more loathsome than the lawyers, politicians, and business moguls who are the traditional bad guys in films about the white-collar world.… Movies do not necessarily capture reality, but they suggest a public mood—in this case, a contrast between the apparent self-satisfaction of the media celebrities and the contempt in which they are held by the public.
Americans, it seems clear, are ready for a change. As for whether CBS anchor Katie Couric holds out, the answer remains to be seen.
We want to hear what you think about this article. Submit a letter to the editor or write to email@example.com.


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This is Hotline Miami. It looks like the most gruesome 1980s action movies come to life, only instead of coming to life wearing bandanas and grenade belts, it's wearing hot pink and a pulsing soundtrack.
It's also sporting one hell of a logo.
Hotline Miami is the work of indie dev Jonatan Söderström, aka Cactus, and artist Dennis Wedin.
Hotline Miami [Official Site]


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Our Voice: We all live with decisions that we did not vote for
Two completely separate election items lead to the same conclusion: People who live in parts of Benton and Franklin counties outside the Tri-Cities are not being discriminated against when it comes to the ballot.
Aquatic center
At first glance it seems strange that all voters living in our region would not be included in the vote on a regional water park.
However, the Regional Public Facilities District is made up of Pasco, Kennewick and Richland, so residents in those cities will be the ones casting the votes.
This process has been a long time coming and required legislative action. The Legislature limited participating entities to those that already had a PFD, and designed this regional approach as a means of financing civic projects for urban populations.
The regional PFD started as a great possibility. What could we do if we pulled together? Aug. 6 will answer that question.
If the aquatic center is approved, everyone who shops inside the taxing district will pay the additional tax, including those who couldn't vote on the measure and those who didn't bother to return their ballot.
But that's part of the appeal of using a sales tax for public projects -- everyone who shops here helps pay for the improvements, diluting the cost to residents.
Plenty of nonvoters will pay -- people under 21, visitors from near and far, noncitizens, felons and folks who never bothered to register.
There needs to be a logical boundary for participating in the election, and it can't be everyone who might be charged the higher tax.
Pasco city government
It's a similar situation for people who live outside of the Pasco city limits who want to reform the city government.
In November, Pasco voters will decide two issues: one would reduce the size of the city limits and one would change the form of government from a city manager hired by the city council to a strong mayor elected by the voters.
Both of these measures are on the ballot because a vocal and active group of nonresidents have been busy circulating petitions.
If you're not a resident of the city, you can gather signatures but you can't sign the petition or vote on the measure.
You also shouldn't be allowed to write ballot statements.
In fact, it's astounding that people who don't live in Pasco have been the driving force to get the measures on the ballot.
We don't share much common ground with Roger Lenk, a leader behind both measures. Each proposal he comes up with seems more about lashing out at Pasco than improving local government, but we will grant that he is thorough.
Which is why we're surprised he thinks he ought to be able to write the ballot statement for a measure he can't vote on.
The smart aleck response from us is that if those in the county want to vote on city measures, the should request annexation -- the very thing they are trying to avoid.
The more civil answer is that since this is a matter regarding the city of Pasco, the residents of Pasco will decide on the outcome. People who live in Kennewick, Richland or Franklin County's doughnut hole, don't get a say.
We have a diverse group of voters. Every ballot issue is going to leave part of the population unhappy regardless of the outcome.
It's called "the will of the people" despite the fact that not all the people share the same will.
It works well if not perfectly.


text:
Featured Paper by T. Christen
The design of modern electric insulation devices for medium and high voltage (HV) applications requires computational work that goes beyond solving just a Laplace equation for the electric potential, and limiting the electric field below critical values. Both field calculation and determination of breakdown limits are often challenges for the development of HV insulation systems. Two examples are discussed. First, it is shown how the field distribution is modeled and simulated if injected space charge dominates the electrical behavior, which occurs particularly in gas insulation with Corona discharge or in in HV direct current (HVDC) solid polymer insulation. Secondly, a recipe is provided for modeling and simulation of dielectric breakdown of gases via electric sparks in the form of streamers.


text:
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I am waist deep in lake water with mud squishing underfoot as the starter says "Go!" I start mad paddling as 100 other arms make a unique turbulence on all sides. Three people bump into me and I see only their goggles, caps and hands.
If you currently subscribe or have subscribed in the past to the Henry County Local, then simply find your account number on your mailing label and enter it below.
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Reality Bit
NOTE: This post was written several days ago, and was not intended to be a commentary on any breaking news events. My sincere apologies to any who may find it offensive.
Cake artists, can we talk? I feel like we need to have a little heart-to-heart.
Ok, here's the deal: I know that you guys are talented - I do! - and I get that you like to showcase your talent with the cakes you make.
The only problem is, when you make something like this:
Photo removed at baker's request
Not to mention it's depressing; could that look any more funereal?
Look at it from the cake consumer's perspective: would you want to slice into a sleeping baby?
Or worse, have a toddler's eyeball staring up at you from your plate?
So cake sculptors, please, stop making us choose between cake deprivation and feeling like a cannibal. If you must make a baby cake, make it nice and cartoony - preferably with no basis in reality whatsoever.
You know, like this:
Update: Tons of you are saying that's a butt crack, not an arm. (The rest claim it's Epcot.) I can almost see that, but I still think it looks more like an arm. ;)
- Related Wreckage: You Say Goodbye, and I Say Hello


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hci g
hci g
Special | A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z | ALL
The investigation of social structure, social relationships, and individual social action through an emphasis on culture—originally "other cultures" but increasingly the emphasis is on "home" cultures.
considering machines (especially computers) as if they have human capabilities or responsibilities
A computational architecture using resource scheduling and reactive planning (techniques from artificial intelligence). More information can be found in Freed (1998). It has been used as a GOMS modeling tool (John, 2002; Remington, et al., 2002).
A diverse class of human-created systems, applications, tools, and conventions, including language and mathematics, that mediate human activity. Artifacts are the products of prior human activity; they both enable and constrain current human activity, and their use helps to orient the design of future artifacts. An information artifact (as used in the cognitive-dimensions framework) is an artifact designed to store, create, present, or manipulate information, whether noninteractive (e.g., a book or a map) or interactive (e.g., a spreadsheet or a heating controller).
automatic cognitive processes
Processes that are relatively quick and effortless, requiring little attention or monitoring. Well-practiced skills, like walking and driving, or signing one's name, are examples of automatic cognitive processes. See also controlled cognitive processes.
an icon or other visual depiction used to represent the user in an information display
bounded rationality
The idea, from Herbert Simon (e.g., Simon, 1982), that human agents are rational in that they act so as to meet their goals according to their knowledge; they are only boundedly rational, however, in that they cannot necessarily compute ideal, optimal decisions. Instead, their decisions are bounded by environmental constraints on their performance (such as the need to act quickly), interacting with limits on access to knowledge and limits on the ability to process relevant information.
See cognitive complexity theory.
a structured collection of information that acts as a single unit with respect to storage and information processing capacity
claims analysis
An analytic evaluation method involving the identification of scenario features that have significant positive and negative usability consequences.


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I've got one of these and still have LOTS of questions about how to make my Ubuntu work smoothly.
1. Battery Power.
The fan is ALWAYS ON, even if I don't use any apps. So, instead of the promised 8 hours I only get 3 hours of battery life
Tried all the powertop hints. Maybe I have to switch to that internal graphics card?
2. Suspend.
Latest Bios installed, however just suspend/resume does not work.
3. Boot.
Sometimes the GRUB freezes after a few seconds instead of continuing the countdown. So, I have to always hit the Enter Key when the boot menu pops up.
4. Network Manager
The ubuntu/Gnome Networkmanager drives me crazy. I can not edit configurations - it asks me for a password but then still tells me I have not enough privileges!? Why can't it just connect my 3G stick automatically? And what's that stupid keyring??
Great to get some advice from you people who have figured out some of these problems!


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Brussels, 6 February 2007
Commission study points the way forward for better regulation of new media and the digital economy
In a rapidly evolving digital world, self- and co-regulatory models can be attractive alternatives to traditional regulations, according to a study for the European Commission presented today on Europe's "Safer Internet Day".
"For the media and Internet industry to flourish responsibly, the regulatory framework needs to strike the right balance between fairness and firmness while still allowing industry to respond quickly to change," said Information Society and Media Commissioner Viviane Reding at the occasion of the presentation of the study on co-regulation in the media sector today in Brussels. "This study underlines my firm belief that self-and co-regulation offer very real alternatives to traditional legislative approaches in the media sector today. Where such self- and co-regulatory models are credible and efficient, the European Commission will encourage their use, in particular for the online environment. This is the spirit included also in the provisions of the European Commission's proposal for modernising the Television Without Frontiers Directive, which I expect to be agreed between European Parliament and Council in the months to come."
Particularly in the digital economy, driven by rapid technological change and enhanced user control, traditional regulations are finding it difficult to keep up with the speed of technological, economical and social changes, and the problem of decentralised information. Traditional regulatory approaches also may suffer from enforcement problems.
The European Commission therefore views self- and co-regulation as a way to achieve better regulation, an important goal of the Barroso Commission (see IP/05/96). Self regulation, where industry regulates itself, and co-regulation, the combination of state and non-state regulation, will help cope with the increasing risk of failure of traditional approaches, and will hand back responsibility to society and interested parties where appropriate.
The study on co-regulation measures in the media sector was undertaken for the Commission by the Hans-Bredow Institut for media research, at the University of Hamburg, in cooperation with the Institute for European Media Law in Saarbrücken, and presented today in Brussels. It concluded that, in general, industry needs sufficient incentives to support such a regime. Having a state run regulator in the background often gives self-regulatory bodies the power they need to work effectively. In addition, sufficient means to enforce regulations, such as adequate and proportional sanctions seem to be necessary for a co-regulatory system to be workable.
Transparency and openness were also found to be vital to build trust in the mechanisms, particularly where non-State organisations are responsible for regulating, or where interest groups are not involved.
The study examined the different approaches to co-regulation already active in different countries for two important sectors (the protection of minors, and advertising), and found that there was no reason to assume that these were insufficient for implementing European directives.
Self- and co-regulation are therefore explicitly encouraged by the European Commission in the proposed modernisation of the "Television Without Frontiers" Directive, currently being debated in the European Parliament and Council. The text of the proposed Directive is the first legislative proposal from the Commission related to the media sector where such an explicit reference to self- and co-regulation is made (in Recital 25 and in Article 3(3): "Member States shall encourage co-regulatory regimes in the fields coordinated by this Directive. These regimes shall be such that they are broadly accepted by the main stakeholders and provide for effective enforcement.").
Further good examples of current self- and co-regulation in the EU include:
§ Today's signing by mobile operators of a European Framework agreement on safer use of mobile phones by children (see IP/07/139).
§ The Film Online Charter signed by the film and content industries in May 2006 (see IP/06/672)
§ The management of the .eu domain by the private not-for-profit agency EURid, entrusted with this task by the European Parliament and the Council (see IP/05/1510, IP/06/476 and MEMO/06/332).
§ The food industries efforts to fight obesity (IP/06/1530).
§ The role of the European Aviation Safety Agency in safeguarding Europe's skies (IP/05/1422).
Further Information
The full study on "Study on co-regulation measures in the media sector" is online at:
The Commission's proposal for modernising the "Television Without Frontiers" Directive and accompanying material can be found at:
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I deliberately didn't take setlist notes because I wanted to be able to just immerse myself in the 3 hour moment, which I and the thousands of others certainly did. But looking at the setlists from the beginning of this leg of the tour, I'd say it was exactly the same.
I'll have to trawl back over earlier postings to see if there was anything said/done differently in this show but one thing I don't recall having read about before was his commenting on his financial distress saying that he didn't recommend bankruptcy as a route to spiritual salvation. (Sorry if I'm misremembering the phrase he used.) But that and the localisation in Hallelujah, which was "I didn't come here to Queensland..." (rather than "Brisbane") are the only differences that occur to me.
I have to echo what so many other people have said over the past many months. Leonard was 100% committed and sincere in everything he did, it all appearing so smooth and immaculate that it gave the illusion of being effortless. The warmth and respect he showed every member of the band, and which they offer back to him and to each other, were exemplary, and contributed enormously to the momentous feeling of warmth, camraderie, poetry and humanity that we all took away with us. The musical vituosity of every performer was stunning, but always perfectly in tune with the moment and the song. I shall certainly be exploring some back catalogues!
I was impresed by Paul Kelly and his son Daniel, who seemed a very fitting opening act, and whom Leonard mentioned at the end, saying it had been "an honour to share the stage with the very fine Paul Kelly".
Final tiny point: I can't remember ever going to any other gig (by any artist) which not only started absolutely bang on time, but had the interval and other breaks timed to the minute if not to the second. Bravo! (When I saw Springsteen at the same venue 7 years ago I think waited an hour for the show to start.)
I think it'll take days for me to come down off my current post-concert high.
London 1979 (?), London 1983 (?), Brisbane 2009


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Taking a look at the submissions we realized that... mmh no submissions at all... We already knew that solving this challenge requires high skills but it seems like more time is needed in order to solve the Forensic Challenge 11 - "Dive Into Exploit". For this reason we decided to extend the submission deadline to 2012, July 1st.
Have fun (and don't be shy)!
Angelo Dell'Aera
The Honeynet Project


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Bourbon County
Black History Month: Women's clubs played key role in lives of black women
When she was growing up, it was assumed that Anna Allen-Edwards would join the Phyllis Wheatley Charity Club in Paris.
"It was understood you'd go to college. It was understood you'd join the club," Allen-Edwards said.
It was, and is, a family tradition.
Today, Allen-Edwards' 11-year-old great-niece, Hannah Moore, is the fifth generation of the family to join.
The club, which has 18 members, focuses on helping others in myriad ways, from buying books for college students to stocking the pantry of a mother who lost her job.
"We try to give quietly, without fanfare," said Allen-Edwards, 57.
The 102-year-old women's club is one of just a few such groups left in the state.
At one time, there were hundreds of them affiliated with the National Association of Colored Women's Clubs and its Kentucky chapter.
In addition to providing a social outlet for middle-class women, the clubs were known for helping the poor and striving to improve the neighborhoods where they lived.
"They were community builders," said Karen Cotton McDaniel, who has researched the Kentucky clubs extensively.
Women's clubs became popular in the decades after the Civil War, as blacks worked to make a place for themselves in American society.
"They came out nationally in defense of women," McDaniel said. Black women who had been raped by white men had been labeled "predators" by whites, she said.
"They were just battling so many different stereotypes," said Nancy O'Malley, assistant director of the William S. Webb Museum of Anthropology at the University of Kentucky. "They really sought to help people of color sort of pull themselves up. ... There was this idea that you should be aspiring for a sort of social position.
"It was very much fueled by the black middle class."
George C. Wright wrote in A History of Blacks in Kentucky: In Pursuit of Equality, 1890-1980, that the women "optimistically believed that improvement in decorum, health conditions, and especially the neighborhoods where their race predominated would lead eventually to the breaking down of racial barriers in society.
"In short, blacks would show whites they were indeed worthy to be treated as equal citizens."
The Kentucky Association of Colored Women's Clubs was founded in 1903, with 13 clubs and 180 members.
By 1934, there were 125 Kentucky clubs with 2,000 members. But the groups declined after the civil rights movement, presumably as a result of the traction blacks did gain in the effort to be treated equally.
Today, there are just two or three women's clubs in Kentucky, McDaniel said.
In its heyday, the statewide association had a host of departments focused on education, black history and interracial relations and on home economics, art and health.
The "club women" of Kentucky adopted the motto "Looking upward not downward, outward not inward, forward not backward."
In 1945, when Lucy Harth Smith of Lexington compiled the Pictorial Directory of the Kentucky Association of Colored Women, she listed a host of clubs, each with its own niche.
There was an embroidery club in Louisville that made bedding for orphans, the elderly and sick folks.
The George Washington Carver Art Club in Winchester tried to foster an "appreciation for art, charity and education."
In Elizabethtown, the Jolly Matrons Improvement Club focused on school needs.
Lexington had 40 such groups at one point, McDaniel said.
There was the Tip Top Tippers Club, which bought eyeglasses for the needy and sponsored an annual fashion show.
The Dorie Miller Chapter of American War Mothers did patriotic work and served veterans.
And the Woman's Improvement Club ran a day care for children whose parents worked.
The day care on Pine Street had "cared for thousands of children" by the time Smith compiled her directory.
"These children are taught politeness, good table manners, love of God and obedience to the laws of society and government," according to the publication.
A 1934 issue of The Kentucky Club Woman reported that the "day nursery" provided care for about 35 children each day, and many more when tobacco-sales season came.
The Woman's Improvement Club supported the day care through donations from city commissioners and the Lexington Community Chest, and with membership dues and rent from a house the club owned.
Smith, principal of Booker T. Washington School for 20 years, led a group of women who raised money to start a Lexington summer camp aimed at feeding hungry children.
McDaniel said Smith talked local lumber yards into donating the lumber, and they built a kitchen.
The "health camp" opened in 1944 with 40 children and was serving 120 children by the summer of 1946.
Elizabeth "Lizzie" Fouse of Lexington was a leader in the National Association of Colored Women and founded a "scholarship loan fund" to help young people attend college.
In her role as chairwoman of the national association's Better Homes Department, she advocated for affordable housing and home ownership.
According to Wright's book, the Kentucky club women formed a committee in 1918 to lobby the legislature in the interest of women and children.
The organization was successful in getting two books on black history and culture added to the list of materials approved for study in Kentucky schools.
Wright also credited the women with urging black doctors and nurses to move to Lexington and Louisville, and with helping those professionals set up offices when they arrived.
At a time when there was no government safety net, the clubs worked to fill the void.
They also stepped in to make sure black people got the care they needed from a segregated system that often neglected their health care needs.
McDaniel said the club women in Frankfort helped support a hospital for blacks because "they couldn't go to the other hospital."
Paris' Phyllis Wheatley Charity Club started as a knitting or sewing group that made sure the segregated ward for blacks at the local hospital had the necessary linens, Allen-Edwards said.
Without the club women, "we probably would've lost a lot of people," McDaniel said.


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Church: Church Steps: How People Move Through the Steps by Matt Dabbs [required reading]
"… thinking in steps, not in programs. … All of us should be thinking … 'how can I help someone get to the next step?'"
Church, discipleship & the missional movement: Problems With Missional by Matt Dabbs
"There have been some posts addressing the problems with the missional movement. Here are a few you may want to read."
Church unity: The Dangerous Center Aisle of a Church by Ron Edmonson
"Would you join a church that couldn't get along with itself?"
Football: A Conversation With James Franklin
"James Franklin … is the starting quarterback for the University of Missouri … He is the fourth child of Willie and Pam Franklin. His father, a well-known minister in the Dallas area, was once a standout receiver for the University of Oklahoma and played in the NFL for the Baltimore Colts. … "
Free will: Free Will as a Reflection of God by Neal Whitlow
"… what if our free will wasn't just a curious experiment during God's creative process? What if there was no highly debated executive decision on the part of the Trinity who decided to breathe life into a man who had the freedom of choice to defy the perfect and holy Creator of the Universe and go his own way? What if our free will was actually the result of being made in the image of God?"
Islam: Survey of Islam by Dr. Timothy Tennent
Legalism & Phariseeism: 6 Warning Signs We're Becoming Accidental Pharisees by Larry Osborne [required reading]
"I've found that becoming a modern-day, accidental Pharisee is a lot like eating at Denny's. No one wants to go there. We just end up there."
Patience: Jesus as Oprah by Richard Beck
"No worries. Jack's a Christian. His Lord commands him to be patient."
Privacy, porn & social networking: 'Parasite' Porn Websites Stealing Images and Videos Posted by Young People
"A study by the Internet Watch Foundation (IWF) reveals that 88% of self-made sexual or suggestive images and videos posted by young people, often on social networking sites, are taken from their original online location and uploaded on to other websites."
Same-sex issues: Let's Face It by Carole Lattin
"… "the opposite of homosexuality is not heterosexuality. It's holiness … the goal is to lay down the lesser love of homosexuality and embrace the greater love of Christ's atonement."


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Wedding Professional Photographer in 2017
A marriage professional photographer isn't just any professional photographer who arrives to take a few photographs they will be able to connect inside a friendly and assured manner, using the bride, groom, parents, grandma and grandpa and then any children in the wedding and often, your pet dog too. The professional photographer should feel all of the feelings and explore a full day, what i mean is they should comprehend the feelings of those attending the marriage, in the end, how else can the marriage professional photographer capture these feelings on camera, when they do not feel and understand them.
The romance, excitement and also the final realisation of several weeks, possibly even years, of planning that one day and it is the marriage photographer's job to capture these feelings inside a realistic yet, beautiful way. The wedding couple is going to be nervous, the mother and father wishing everything runs as easily because they have planned for and also the kids, trying to not look too bored with the fuss around them. I frequently capture some good photographs from the children at weddings. The pictures should reflect the occasions during the day in a way that, searching back, when you are a classic husband and wife, it'll appear such as the wedding was just yesterday.
Every detail have to be photographed, such as the church or venue for that ceremony not to mention, the reception. Like a wedding professional photographer, I contemplate it part of my work, to reach early, become familiar with design of wedding venue, pick a qualified positions and angles for that shots that I wish to capture, throughout the ceremony and make an effort to produce incredible photos.
Regrettably, you may still find many people who'll not permit the religious ceremony to become photographed that is one more reason I love to arrive early, to provide myself the chance to talk using the minister, priest or official who definitely are performing the ceremony and when possible, obtain a little compromise, in such instances. A great wedding professional photographer will be familiar with all of the areas to think about for each occasion. The wedding is going to be unique as well as your wedding photographs ought to be unique.
I selected to concentrate on photography, initially since i did not possess a photography studio however, as i operate a photography business, I additionally get a lot personal enjoyment from photographing weddings, and that i wouldn't get it every other way.
My method of photography is extremely relaxed I favor the marriage photojournalism approach, since many top professional wedding photographers do. My wedding portfolio is filled with photographs of relaxed couples enjoying their big day and getting together with buddies and family not, the professional photographer. These photographs are much more enjoyable to check out as well as assistance to capture the wedding's occasions because they unfold, naturally.
In a nutshell, photography is extremely a specialised area and photography ought to always be left towards the professional. Weddings can not be re-photographed inside a photography studio. The professional photographer who decides to photograph weddings, ought to know precisely what they're doing and then understand it properly, each time. It is a huge responsibility and needs an accountable wedding professional photographer.
The Wedding Music Around the World
Here Comes the bride to be might be performed at each wedding you attend, but that is and not the situation all over the world. Wedding music traditions change from nation to nation, as well as in one religion to a different inside the same country.
Here Comes the bride to be continues to be a popular for that bride's walk lower the aisle, but Pachelbel's Canon in D Major has turned into a close contender. Songs include hymns, popular music, and classic music…essentially regardless of the couple desires, as lengthy because the event venue does not stop it. In The Usa, weddings might be held anywhere, as lengthy like a minister or justice from the peace conducts the ceremony and proper documents is filed using the government.
Much like in the usa, Here Comes the bride to be may be the song preferred by the bride's entrance. British weddings are extremely walked in custom and tradition, a lot of brides might want to use a harpist. In England, law requires weddings to become locked in an authorized place-mostly places of worship. Like Americans, British weddings could have a mixture of music, but British events are often very traditional and formal.
Pachelbel's Canon in D Major is popular here, along with lots of the standard love ballads used at wedding events in the usa. One factor that differs around australia may be the signing ceremony, that also can involve music. In the finish from the ceremony, the pair signs the marriage certificate while everybody watches. British events may incorporate instruments for example bagpipes along with a didgeridoo.
The standard Japanese wedding is known as a shinzen shiki, a ceremony conducted with a Shinto Priest along with a shrine assistant. The wedding couple either can put on an outfit and tuxedo or traditional Japanese wedding garb, with a kimono and hakama. These traditional weddings use flutes and drums. Summer time Candle lights and Dolphin Ring by Anri are generally popular wedding songs. Much like American and British weddings, Japanese weddings include sappy love songs.
As the Mexican marriage ceremony might be serious and traditional, the reception is really a full party, with salsa and mariachi music getting everybody on their own ft. Mariachi music involves a multitude of music, including guitars, drums, as well as violins. Canon in D Major can also be popular for that bride's processional here.
It ought to be no real surprise that bagpipes are famous Irish weddings. A lot of couples are selecting to recognition their country's wealthy tradition, so Celtic music is extremely famous Irish weddings. The Irish Wedding Song is frequently performed at receptions and Danny Boy and Irish Eyes Are Smiling will always be popular at gatherings in Ireland.
White-colored gowns don't have any place in a Hindu wedding. The bride to be typically wears an attractive red sari so they cover her ft and hands in henna tattoos, referred to as henna staining in India. Music plays a leading role within the Hindu marriage ceremony and lots of popular wedding songs (including Aaj Mere Yaar Ki Shaadi Hai) happen to be utilized in Bollywood movies. The marriage ceremony and publish-ceremony are extremely involved and could serve you for a couple of days, such as the bride departing her groom to participate her new family and also the wedding ceremony welcoming the bride to be to her new house.
Music offers the backdrop for those wedding events. Wherever the wedding is placed, the sensation of wealthy tradition remains the same. Came From Here Comes the bride to be to Aaj Mere Yaar Ki Shaadi Hai, brides around the globe are celebrating their love with music.
Pre-Wedding Rituals of Bhumihar Wedding Relevance of Culture and Ethics
Bhumihar caste includes the Brahmins. They are classified as Bhumihar Brahmins. Once the girl within their family reaches age wedding, they plan things. The quest for the partner begins. If it is an arranged wedding then your bride and also the groom get wed inside the same caste. They get the opportunity to speak to one another so when that they like one another, the talks are taken one step forward. In Bhumihar matrimony, you will find that the weddings have lots of customs and rituals. Yes, they're very worthwhile however they continue for any couple of days. Thus, when there's a marriage in your own home, you will notice a couple of pre-wedding events too.
The pre-wedding events
In Bhumihar weddings, there is also a quantity of pre-wedding rituals. They're:
There's a convention known as as Siddhanth custom. Within this, the priest sits and appears in to the panchang to repair the marriage date. Also, he needs to see panjis of both families. These folks also have confidence in horoscopes which plays a vital role during these weddings.
There's yet another various and strange custom. Each day prior to the wedding or even the day's a marriage, you will find that the bride to be needs to take benefits of the washer man's wife. It is because it's thought that a washer man's wife will invariably die before her husband and therefore she'd always remain suhagan.
At the time from the wedding, once the groom enters the marriage premises, the lady in the bride family would welcome him with sandalwood paste.
Within this, the pair needs to go for that kul devi shrine. The bride's father takes them. Thus, your daughter's groom would get the opportunity to seethe kul devi mandir from the bride's father.
Gauri puja can also be quite important as part of Bhumihar matrimony. This really is mainly performed to help keep the evils from the marriage ceremony.
Thus, you will notice that there are several interesting rituals as observed in Bhumihar weddings too. You'll really find these rituals quite significant. Bhumihar is straightforward people. But they're quite strict concerning the wedding and also the wedding rituals.
Within the occasions once the more youthful generation is leaving rituals, the more youthful generation of Bhumihar caste continues to be quite thinking about the marriage within an authentic and traditional way. This is the charm of Indian weddings. Much like other weddings, there's fun too active in the wedding. Obviously, additionally, you will manage to find food and attractive food offered towards the visitors within an authentic way. You'll know that wedding it's time when two families would unite. Thus, it becomes an important ceremony. Thus, all of the functions and occasions ought to be transported out correctly. Bhumihar is straightforward Brahmins. But they're knowledgeable and educated. The bride to be and also the groom will also be well introduced up plus they be aware of relevance of culture and ethics too. That's the reasons you will find these weddings classical.


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Wakefield man faces more than 100 charges in child sex abuse case; allegedly had 13 victims in towns north and west of Boston
WOBURN — A Wakefield man allegedly videotaped himself as he raped and sexually abused 13 small children — some as young as 8 days old — while providing day care for people at their homes in various towns outside Boston, Middlesex District Attorney Gerard T. Leone Jr. said today.
John Burbine, 49, has been indicted on 100 counts. He gained access to the children through the child care service, Waterfall Education Center, run by his wife, prosecutors said.
"This is among the most troubling and disturbing cases of child abuse ever prosecuted in Middlesex County,'' Leone said in a statement.
The victims are from Stoneham, Medford, Newton, Reading, Melrose, Woburn, and Waltham. They were both male and female and ranged in age from 8 days to 3½ years old. The assaults occurred from August 2010 and through August 2012, prosecutors said.
Leone said his office first received a complaint about the treatment of children in late September and that his office obtained a court order shutting the facility down while the criminal investigation continued.
Burbine's wife, Marian, 46, is also charged with six counts of reckless endangerment of a child and two counts of operating an unlicensed day care business.
Prosecutors said that they believe that the wife did not know about the crimes that her husband was committing while he assisted her with her business.
John Burbine faces charges of aggravated forcible rape of a child, subsequent offense (40 counts), aggravaged indecent assault and battery on a child, subsequent offense (17 counts), posing a child in a state of nudity (12 counts), posing a child in sexual conduct (11 counts), possession of child pornography (13 counts), dissemination of material harmful to a minor (2 counts), and operating an unlicensed child care program.
Leone said at a news conference this afternoon that the penalties on the charges were such that "he will never get out of jail.''
Prosecutors said the Burbines advertised child care and tutoring on various websites, including parenting and coupon sites. The Waterfall Education Center offered short and long term child care, group child care, overnight newborn care, and summer camp alternative care, prosecutors said.
Prosecutors alleged that Burbine "often assisted'' his wife and that Marian Burbine would tell parents that her husband was an experienced and problem-free babysitter.
John Burbine was originally arrested Sept. 28 by state troopers assigned to Leone's office after an investigation into unlicensed child care at Waterfall uncovered evidence of sexual assault on a child, prosecutors said. He was arraigned Oct. 5 in Malden District Court where he was held without bail under the dangerousness statute.
After his arrest, prosecutors allegedly discovered more victims as well as video evidence showing the assaults that led to his indictment today. Prosecutors said an arraignment on the charges in the indictment had not yet been scheduled.
Marian Burbine was arraigned Oct. 1 in Middlesex Superior Court in Woburn. She is free on bail, with conditions that she wear a GPS monitoring bracelet, stay in her home during the nighttime hours, and stay away from victims, clients, former emloyees, and any children under the age of 16. Her next date is Dec. 20 for a pre-trial hearing.