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June 4, 2015 5:33 pm
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You can take the budget deficit into your own hands. There are plenty of ways to save the government money, and great ideas are just about anywhere.
Steve Kelman, a professor of public management at Harvard University, joined In Depth with Francis Rose to discuss a simple new cost-saving idea.
Kelman, who writes a column for Federal Computer Week, said a reader provided this idea: When federal employees travel, if they're able to find a better deal on a hotel than what the per diem rate allows for, they should be able to keep half the difference between the negotiated rate and the rate the employee pays.
In his column, Kelman said he liked this idea and others like for a number of reasons:
What impact will the Trump administration have on feds? Read the latest in our First 100 Days section.
What impact will the Trump administration have on feds? Read the latest in our First 100 Days section.
First, while this proposal would make only the smallest of impacts on the deficit, the cost to the government of getting these savings is zero — it's pure deficit reduction. Second, I like the idea of putting this cost-saving activity in the hands of employees, because once they start helping save money, it gets them in the spirit to make other efforts as well.
Photos of the amazing, moving, important and amusing things happening in the federal community.
A daily update of important moments in the history of the U.S. government.


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Bel Air Pro 57 upstart in show
Pro´57 start up the racecar in the show at Street Cars Fest Finals 2008
Pro Street Heroes at the Street Machine Nationals in Du Quoin, Illinois V8TV Video
http://www.v8tvshow.com - 314.783.8325 - If you're a fan of Pro Street cars, the Street Machine Nationals in DuQuoin, Illinois, is the place for you. Once again, some of the legendary cars came out for the Heros of Pro Street display, where back-halved chassis, giant engines, steamroller rubber, and wild colors rule the streets.
Robert's 1956 Pro Street Chevy
Robert's 1956 Pro Street Chevy, alky injection, big block, blown, custom, etc.
57 Chevy Gasser with a Blown 871 Littlefield at Good Guys Del Mar 2010
Getting ready to cruise in to the Good Guys 2010 Del Mar Show. This is running with the headers closed. Thanks to Superior Automotive in Anaheim, Ca.


text: Seller: tolboothantiques (433) 100%, Location: Peterhead, Ships to: GB, Item: 182361804031 Multi-Drawer Haberdashery Type Medical Cabinet Cabinet (No 2 of 2 available) Height 55" x Width 64" x Depth 20" (Base Height 34")Drawer internal measurements: 240mm wide x 155mm high x 395mm deepA very fine quality Antique Multi-Drawer Medical Cabinet, possibly ex-chemist shop or similar. Comprising of 18 individual storage drawers in an upper section with glass frontages on the drawers and original metal pull handles. The drawers all run freely. The lower section consists of sliding doors which run freely with a single shelf interior. It stands well, is completely original and all drawers run freely. We date this piece as early 20th century Condition is very good overall, there are light marks and scratches commensurate with use over the years. It was obviously fitted within a shop at some time and the very bottom front is open - probably had a skirting fitted around it. The sides are more basic in finish than the frontage as might be expected having been part of a fitted shop, the top has ridges which may have been to fit a further layer of drawers on top. It is sound - no woodworm, splits or bad damage and an excellent example of a large storage cabinet . It is large and heavy so delivery will have to be by a professional furniture removal company, which we will subsidise to a maximum charge for UK delivery of £120 (subject to confirmation wrt your location) Shipping and Terms Delivery Costs: (Sorry It is a Very Heavy Piece therefore we have to charge accordingly) Down Through Central England (including London and surrounding areas ) £80 - we are regularly in these areas. For Deliveries to South Coast of England - Portsmouth/Plymouth/ Dorset/Devon, Wales and similarly distant places - please contact us for a quote. Non Mainland – Please Contact us for Details Delivery of larger items is normally 3-4 weeks depending on Van route Please provide a contact telephone number at checkout or on payment as this will allow us to process delivery more quickly. Terms of Sale Payment can, if preferred, be made by card over the Telephone – please Contact Michael in advance to arrange this. (see contact numbers below). We are focused on customer satisfaction, and put every effort into describing our items accurately. If you have any concerns with your purchases please get in touch we will make every effort to resolve any matter. If you wish to return your goods please advise us within 14 days of receipt of your item. Provided the goods are returned in the same condition that they were originally delivered to you, then a full refund will be provided. You will be responsible for cost of returning goods. Contact Details Email – through ebay Call sales manager (Michael) – 07801480686 Call main shop office – 01779 474888 Call main Mill of Clola Showroom – 01771 623876 (note it is a large premises – please be patient) Powered by eBay Turbo Lister


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Truck Fail Compilation 2015
Best Truck Fails And Accidents Compilation 2015 http://www.tube-vid.com Epic Fail Video. VideoFailEpic.
Southeast Showdown 2011 (Part 2).wmv
Part 2 from the show.
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Scrapin' The Coast 2012 Ep. 6 - The Last Ride
The famous wrecked hardbodies video! The first clip is of the two hardbodies going to park in the Coliseum after a night of cruising. Late that night a drunk driver smashed into the back of the copper hardbody and sent it flying a full car length into the back of the green hardbody. It was a hit and run but they caught the drunk girl and threw her ass in jail. The same guy owned both of the trucks; I don't know what I would do if I was him. That sucks.


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Beef Fajitas with Guacamole Salsa
Steaks with Chipotle Guacamole
Soft and Crunchy Fish Tacos
Peach Guacamole with Lime
Grilled Guacamole
Chunky Guacamole
Add Mexican flavor to your meal! Enjoy this easy avocado dip that's ready in 45 minutes.
To serve guacamole in avocado shells, cut unpeeled avocados in half lengthwise. Remove pits; scoop fruit from shells with spoon. Prepare recipe as directed above. Fill shells with dip; refrigerate at least 30 minutes before serving.
Bacon Guacamole: Stir in 2 slices crisply cooked bacon, crumbled, with the tomato and green chiles.
Creamy Guacamole: Add 1/4 cup mayonnaise or sour cream.
© 2016 ®/TM General Mills All Rights Reserved


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Category Archives: Farming
Planting Garlic – A Fall Favorite
Leaves are turning golden, days are bright yet shorter, and it's time for one of my favorite chores in the garden: PLANTING GARLIC! I have blogged my 'how to's a few times on this blog and have several links to … Continue reading
Filed under Birdsong Farm, Farming, Gardening, Vegetables
Homestead Update: July 1 2014
Late again – but July has been busy already with Fiber Friends, a growing garden, and lots of hot buns in the barn to take care of. So, without further delay, let me take a quick pause to reflect on … Continue reading
Filed under Birdsong Farm, Ducks, Farming, Gardening, The Homestead
Prevent Duckling Drownings – Easy DIY Duckling Ramp
Ducks! They LOVE water and are a joy to watch floating, splashing and bathing in a pond or kiddy pool. But sadly, ducklings can easily drown. Ducklings ARE born quite buoyant and float easily, but they are tiny and can … Continue reading
Filed under Birdsong Farm, Critters, Ducks, Farming
Farm Gates
When one constructs a fence, one must provide access through said fence. A good garden/farm gate is sturdy, large enough for people or vehicles to pass through, opens/closes easily and most importantly: keeps critters out or in. Gates can of … Continue reading
Filed under Birdsong Farm, DIY, Dogs/ Corgis, Farming, Home, The Homestead


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After reporting encouraging results in the first quarter of
Comerica Inc.
) has again come up with an impressive second quarter. The company
reported earnings per share of 73 cents, comfortably beating the
Zacks Consensus Estimate of 62 cents. Results also compared
favorably with earnings per share of 66 cents in the prior quarter
and 53 cents in the year-ago quarter.
Comerica's results reflect growth in its top line. The company
experienced growth in its average loans, helped by higher average
commercial loans. Average deposits also advanced in the quarter.
However, lower loan yields partially offset the benefit.
Furthermore, the company experienced growth in fee income. Also,
expenses were well-controlled.
Comerica's total revenue of $681 million in the reported quarter
remained flat sequentially and advanced 8% year over year. Total
revenue also surpassed the Zacks Consensus Estimate of $638
Quarter in Detail
Comerica's net interest income decreased 2% sequentially to $435
million in the reported quarter. Sequentially, the benefit
from an increase in average loans was offset by a decrease in the
accretion of the purchase discount on the acquired Sterling loan
portfolio and lower loan yields.
However, net interest income advanced 11% from the prior-year
period. Net interest margin fell 9 basis points (bps) sequentially
and 4 bps year over year to 3.10%.
Average total loans advanced 2% sequentially as a result of an
increase of 5% in commercial loans, partially offset by a decrease
of 2% in commercial real estate loans. Average deposits increased
1% from the prior quarter, largely attributable to an increase of
2% in noninterest-bearing deposits.
In the reported quarter, Comerica's non-interest income was $211
million, up 2% sequentially and 4% year over year. The sequential
uptick primarily resulted from a $5 million annual incentive bonus
received in the quarter from the company's third party credit card
provider, higher customer-driven fee income and an increase in net
income from principal investing and warrants.
Non-interest expenses totaled $433 million, down 4%
sequentially. The decline was primarily driven by a decrease in
salaries expense and smaller declines in several other categories
of non-interest expenses, partially offset by an increase in merger
and restructuring charges related to the Sterling acquisition.
However, expenses were up 5% year over year.
Credit Quality
Credit quality continued to be solid at Comerica. Net
credit-related charge-offs remained stable sequentially at $45
million and fell from $90 million in the year-ago quarter.
Nonperforming assets to total loans and foreclosed property
equaled 1.85% in the reported quarter, down from 2.14% in the prior
quarter and 2.66% in the year-ago quarter.
Provision for credit losses fell 14% sequentially and 58% year
over year to $19 million. The allowance for loan losses to total
loans ratio was 1.52% as of June 30, 2012, down from 1.64% as of
March 31, 2012, and 2.06% as of June 30, 2011.
For rest of the year, the company expects provision and net
charge-offs to be at or near the second quarter levels.
Capital Position
During the reported quarter, Comerica's capital levels remained
strong. As of June 30, 2012, total assets and common shareholders'
equity were $62.7 billion and $7.0 billion, respectively, compared
with $62.6 billion and flat with $7.0 billion, respectively, as of
March 31, 2012.
As of June 30, 2012, Comerica's tangible common equity ratio was
10.27%, up 6 bps sequentially. Moreover, the estimated Tier 1
common capital ratio moved up 5 bps sequentially to 10.32% as of
June 30, 2012.
Capital Deployment Update
Comerica's capital deployment initiatives through dividend
payment and share buybacks exhibit its capital strength. Following
the Federal Reserve's consent to its capital plan, the company made
a 50% hike in its quarterly cash dividend in April 2012.
Moreover, it also authorized the repurchase of additional shares
of common stock (by about 6 million shares) to execute its capital
plan. The plan provided for up to $375 million in equity
repurchases between first quarter 2012 and first quarter 2013.
Notably, during the reported quarter, Comerica had bought back
2.9 million shares for a total of $88 million. This, combined with
increased dividend, resulted in a total payout of 81% net income to
shareholders in the second quarter. We expect such activities to
boost to investors' confidence in the stock.
Outlook 2012
Comerica has provided a detailed outlook for 2012. Given the
continuity of the current economic environment, Comerica's outlook
for full year 2012 is a modest one. Compared to the full year 2011
level, management expects a 3-5% increase in net interest income,
supported by 5-6% growth in average loans.
Non-interest income is projected to expand 1- 2% while
non-interest expenses are anticipated to rise or fall 1%. Net
credit-related charge-offs and provision for credit losses are
likely to exhibit a declining trend.
Peer Performance
One of the closest peers of Comerica,
M&T Bank Corporation
's (
) second quarter 2012 operating earnings of $1.82 per share were
significantly above the Zacks Consensus Estimate of $1.68.
The results were aided by increased net interest and
non-interest income as well as lower operating expenses. Mortgage
banking revenues posted a decent rise in the quarter. Moreover,
improved capital ratios also reflected the company's strong capital
position. However, the mixed credit metrics were the dampeners.
Besides Comerica and M&T Bank, a number of major Wall Street
Banks such as
JPMorgan Chase & Company
Wells Fargo & Company
) and
Citigroup Inc.
) have also reported better-than-expected results this quarter. We
believe this will help in sustaining a positive mood in the
Our Take
Going forward, we believe that Comerica's continuous geographic
diversification beyond its traditional and slower-growing Midwest
markets could drive growth over the next cycle. Revenue synergies
from the Sterling acquisition should augment its top-line growth.
The company also announced hikes in dividend and share buyback,
which augur well for investors.
Yet, the company's significant exposure to riskier areas such as
commercial real estate markets, unsettled economic environment, low
interest rate and regulatory issues are concerns.
Comerica currently retains a Zacks #3 Rank, which translates
into a short-term Hold rating. Considering the fundamentals we have
a Neutral recommendation the stock.
The views and opinions expressed herein are the views and opinions of the author and do not necessarily reflect those of Nasdaq, Inc.
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text: Novels That Put The Fun Back Into The Post-ApocalypseCharlie Jane Anders12/10/08 5:51pmFiled to: Post-apocalyptic picaresqueBooksPublishingTopNick harkawayBrian Francis SlatteryThe Gone Away WorldLiberationFeatureGawker253EditPromoteShare to KinjaToggle Conversation toolsGo to permalink A new literary sub-genre is being born today, while you nap at your desk. It features larger-than-life, and often comical, characters having bizarro adventures after the end of the world. Advertisement Call it "post-apocalyptic picaresque." Two of the most intriguing fall books fall into this category: Brian Slattery's Liberation, and Nick Harkaway's The Gone Away World. We talked to Slattery and Harkaway about putting the fun back into the post-apocalypse.To be sure, there have been funny books about the apocalypse forever. Just look at Good Omens by Terry Pratchett and Neil Gaiman. Or the zombie/robot survival guides. Slattery also cites A Boy And His Dog, and the movie Hell Comes To Frogtown. Harkaway cites Neal Stephenson's Snow Crash: "That's definitely one. Post-collapse and funny as hell, just a little scary because it seems too plausible for comfort." Harkaway also mentions Don DeLillo's White Noise. Advertisement Says Slattery:I was pretty inspired by the Buffy the Vampire Slayer/Men in Black take on apocalypses — that even though the very fate of the world hangs in the balance, they're sort of a dime a dozen and nothing to get all that upset about. And both of those were pretty mainstream things. But with novels like The Road achieving mainstream acceptance, it definitely seems as though post-apocalyptic novels have room to expand and create some new niches for themselves, including comical ones. "I'm not sure that post-apocalyptic is a genre, exactly. It would be a very, very broad one," Harkaway says. But he does agree that that type of story has gotten more acceptance lately. "Perhaps it's more that the reaction to this kind of story is less knee-jerk now, and more people are taking them seriously since Cormac McCarthy wrote The Road."And once you start writing more silly books about the apocalypse, it opens the door to satire. You can use the end of the world to poke fun at the ways the world is messed up today. Says Harkaway: Sponsored In The Gone-Away World, I was definitely taking a few swings at the world we live in now. Not so much saying it's absurd as using absurdity to point out how awful it is, and how stupid. We really could make ourselves an apocalypse the way we're going, and we need to get it together. I believe our only hope is in being more human, in finding points of commonality and not, ever, allowing ourselves to be lazy. Peace is not a state of being, it's a constant action - like love. Slattery says he set out to satirize the ridiculousness of our present-day world when he wrote Liberation, which portrays a massive economic collapse leading to the fall of the United States. It was just his weird luck that the events of his novel started appearing more realistic after it was published. Advertisement Advertisement I'm not in the prediction business at all—that current events and the publication of Liberation converged as they did is really creepy and weird to me. When I wrote Liberation, economic collapse wasn't nearly as immediate a threat as it is now, and my intention was entirely to use it more as a tool for satire—to hold up a funhouse mirror to some of our more serious problems.The other thing that jumps out at me about both Liberation and TGAW is that they're ultimately sort of hopeful stories. Not everybody dies in the apocalypse, because that wouldn't be much of a story. And they both end with a glimmer of hope that the survivors will be able to create some kind of a just society.It's like I wrote ages ago: we don't consume post-apocalyptic stories to think about the end of everything. We consume them because we want to imagine surviving the worst disaster imaginable, both because that's intrinsically hopeful, and also because it would mean a simpler life. Says Harkaway: Advertisement I agree entirely that post-apocalyptic stories can be hopeful - some of them aren't, because they're really about how the last of the population dies - and I think they're also attractive because they often promise a simpler life - one without mortgages or difficult choices about environment vs. consumerism. Mine, of course, isn't simpler; the people in TGAW are up against many of the same choices we are - including whether to sacrifice their fellows for their own convenience.In both Liberation and TGAW, our heroes are rogues, rather than paragons of virtue. In Liberation, the story follows the members of the Slick Six, a colorful group of criminals (sort of) led by Marco, a ruthless killer. And in TGAW, the main survivors are a group of oddballs, including the somewhat demented Gonzo Lubitsch. Why is it more hopeful, or more interesting, to imagine such flawed characters surviving the end of the world? Advertisement "Everybody loves a rogue," says Harkaway. "They bring colour to otherwise very bleak situations. They return the human to a world which is otherwise alarmingly stark and humourless... Rogues offer hope - not just of survival, but of fun; the beginning of a new life, rather than just an endless series of hunter-gatherer actions to satisfy basic needs." But of course, Harkaway's characters become less rogueish and more heroic as the story goes on, in a progression he compares to Han Solo going from "smuggler to lover to general."Also, Slattery says it was important to him to avoid any kind of utopianism or survival of the fittest in Liberation's post-collapse storyline: Advertisement A postapocalyptic story in which only the "best" people survive strikes me as kind of misanthropic and even carries the whiff of eugenics and genocide. (Thanks to Orwell and Huxley, who I read as an impressionable kid, I have a serious distrust of utopias because I always end up asking "Utopia for whom?") Because I really like people, I couldn't resist writing about as diverse a group of characters as I could.Reply25 repliesLeave a reply


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Happy acid surfboard bokeh wednesday
Ok i do know its more usually called Christmas eve!
Morning dew and low winter sun create bokeh possibilities on my longboard. I decided to try and chase the cold away by jumping in the sea again, sometimes i think i'm too clever for my own good :)
er, check this out over at TWTME... s0ulsurfing
24,214 views
138 faves
78 comments
Taken on December 17, 2008


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The High School Student Research Program, a part of the Life Sciences Summer Institute, has openings for interns this summer. Developed for high school students interested in gaining hands-on laboratory research experience, the program helps students looking into the life science industry and related fields of research. Read more.
Full Story:sandi.net


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1972 Chevelle SS Burnout!!!!!!
Doin a little burnout in my Chevelle :) (This is how its done) Check out my other vids stock 350 ;) muncie 4-speed posi with 3:73 gears corvette rallys 15x8 in front 15x10 in the back
Drifting Chevelle
Jonnie (one of Lindberg brothers) have fun with his big block 1970 Chevelle. Lindbergbros.com
Blake's 72 Chevelle Burn out
72 Chevelle doing its thing
PINKS '87 Toyota Supra vs '69 Chevelle


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Single-barrelled air pump, late 18th century.
© Science Museum / Science & Society Picture Library
This pump is very similar to the one designed by John Smeaton (1724-1792) in 1750. Smeaton's design had a single barrel and the valves and pistons were carefully designed to allow as much air as posible to be exhausted. George Adams, and later, Edward Nairne and Blunt made pumps to Smeaton's design. It may be that this pump was made by one of these makers.
Image Ref.


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Wego.com.sg recently found 2 hotels in Melbu, Norway. Book last minute hotel or find great hotel deals such as Melbu Hotel for S$250 per night. Save more on cheap hotels with rates from as low as S$250 per night.
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Melbu Hotels 3 Star Hotels Melbu Cheap Hotels Melbu Cheap Accommodation Melbu
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Treasuring The Handwritten Card
BlogHer 11 was my very first BlogHer conference. I loved so many aspects of attending, but one stands out in my mind, 6 months later, as having made a lasting impact.
Hallmark was one of the sponsors at BlogHer11, and they hosted a Recharge Suite where they provided a relaxing, beautifully lit, comfortable space to not only juice up your electronics, but chill out and center yourself. To take a moment for you amidst the sessions, events, and unrelenting socialization.
The wonderful women at Hallmark encouraged conference-goers to sit and chat, to partake of the gourmet chocolate chip cookies and other refreshments in the suite. We were invited to make use of the private skype stations they had set up to make calls to friends and family back home, and to investigate and try out the new recordable storybooks in their line of products.
My favorite aspect of the Hallmark Suite at Blogher was the unique and generous way that greeting cards were invited to be shared. Hallmark provided free greeting cards, with no limit on amount, for conference attendees to write in, address, and send to loved ones outside the conference, free of charge.
We were also encouraged to send cards to other conference attendees. Just by writing the twitter username of the person we wished to gift with a card, Hallmark would @ them and announce that they had mail waiting in the Hallmark suite. In another generous move, if an attendee didn't get to the suite, or didn't receive the alert until after the conference, Hallmark contacted the recipient for postal information and sent the card to them at home.
I'm a words person. I love to encourage others. I was over-the-moon excited that I could take a few minutes and hand-write a Hallmark card to some of my favorite blogging friends, and give them a small gift from me to take home from BlogHer. One of the cards I sent was to my friend Eileen.
I had hoped that my words would mean something to her. I treasure her friendship, made totally over twitter, and BlogHer 11 was our first chance to meet in person. We were both so happy that our friendship transitioned easily into real life, and found that we were both as authentic as we had seemed to each other online.
I asked Eileen about receiving the card,and she had this to say: "I get messages and emails and tweets all day long, but this card was different. This card was a symbol that my virtual world and my real world had crossed paths. Your card means so much to me. It showed me that we connected here in the real world and that our connection was more than something online. The card meant we were real-world friends."
BlogHer's 2011 conference and the Hallmark Suite contributed to creating a lot of special communication, deep bonds of friendship, and important memories. The encouragement from the staff planning the suite at BlogHer to gift others with handwitten cards in the age of tweets, texts, e-cards, and blog comments shows a true committment to real communication. I'm so grateful to have had an opportunity to give my words to my friends in such a memorable and significant way.
If you've attended a conference where Hallmark has offered a card-sending suite, did you participate? If you attended a conference where one was offered, would sending or receiving cards be a fulfilling experience for you?


text: You are browsing through zazzle's all the rage faces meme gifts section where you can find many styles, sizes and colours of customisable all the rage faces meme shirts, mugs, posters, bumper stickers and other products. Most products are ready to be customised with text, photos or artwork, but all can be bought as shown. There is no minimum order size.


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Anthony Haden-Guest Wears Size XL
Browsing Black Book, as one is wont to do when lunching at Schillers, our eyes are drawn to a line in the table of contents: "Anthony Haden-Guest attends an orgy." Quick as can be, we're on page 106, reading "Sex and the the New New York Scene":
A Spanish woman was taking on all comers. She grabbed one fellow's member as he approached, like a trout taking a fly, and began giving him an energetic blowjob. She snuffed and snorted and and seemed well content, then opened her legs and pointed preemptorily. It was an.... order!
He prepared to enter. "You have no condom!" she snapped... He went back to the main room and sought out Palagia, who provided the necessary.
Word had got around that there was a customer for the XL when he returned to the bedroom. A woman weighed his equipment as though checking out vegetables in a produce store.
Anthony, man, wouldn't it be easier just to write in the first person?
(Photo of Haden-Guest by Eliot Shepard from yesterday's Jonathan Ames Party Crash.)


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You missed it This great deal for Bob Altavilla Interiors is over. But don't despair, we've got more great deals every day.
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text: Home > Lifestyle > Woman > Your body Your body All sections in Woman » Friends and family » Menstruation » Your body » Your home » Your life » Woman News Divorce may shrink older women's waistline A study found that divorce may shrink older women's waistline – and marriage, on the other hand, may widen it. Quiz Is my diet healthy? » 10 odours our noses can identify 6 body language mistakes to avoid Regular exercise keeps the over-60's in good health A group of elderly women are setting the pace in the Free-state with their exercise sessions every morning outside the Bohlokong municipal offices. Movies may help end female genital mutilation A team from Switzerland and Sudan found that changing attitudes through entertainment could contribute to the abandoning of female genital mutilation (FGM). Women's 3 biggest body gripes and how to fix them Whether it's cellulite that bothers you or a saggy bottom, try these tips to deal with your body gripe. Rape survivor gets back on her feet Rape crisis Change a Life initiative helped rape survivor, Fumana gain financial independence with workshops that are offered at the centre. FDA warns make-up users about lead poisoning A beauty clay sold at major retail outlets may put users at risk for lead poisoning, the FDA warned and users are urged to stop using the product. Goodbye to hairy legs Most women spend a lifetime keeping the hair on their legs as short as possible. As a result, hair removal can become a bit of a hassle. Here are some tips, courtesy of the FDA. Why I'd never ditch my bra We asked users how they feel about wearing a bra. Here's what they said. Get 25% off your fertility consultation & scan The Infertility Awareness Association of SA is offering a discount on fertility assessments done at selected clinics during Reproductive Health Month (1 - 29 February 2016). 10 common health warnings you should not ignore There may be more to your random bouts of tiredness than you think; it could be your body's way of alerting you to underlying health issues. load more articles advertisement From our sponsors 10 facts about diabetes and insulin you need to know How to care for your vaginal flora JHB - Free Caregiver Workshop with TENA experts - 15 February JHB - Free home visit and assessment with a TENA nurse advisor Live healthier Hello? » SEE: Interesting facts about hearing loss Earworms: Let it go Is it bad to sleep with earplugs all the time? SEE: Do women hear better than men? The reason why men often appear not to be listening could be because they actually can't hear you. Confident smile? » Acidic drinks can harm your kids' smiles The facts on bleaching your teeth Am I taking good care of my teeth? Why are my teeth stained? We know the rules – brush your teeth twice a day and floss to keep them healthy. But, have you ever wondered what causes those stains that sometimes appear?


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NOW OPEN! Darwin's Hottest New Steakhouse...
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The darker shades of our Skinny Lipping range in it's own little bundle! A long lasting, light formula allows this smooth consistency meaning your lips will look great without feeling heavy and clogged up with... View full product details
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Property Location
A stay at Hotel Cabana Pahar ganj places you in the heart of New Delhi, convenient to Lady Hardinge Medical College and Palika Bazaar. This hotel is within close proximity of India Gate.
Make yourself at home in one of the 17 air-conditioned rooms featuring minibars and LCD televisions. Complimentary wireless Internet access keeps you connected, and satellite programming is available for your entertainment. Private bathrooms with showers feature rainfall showerheads and designer toiletries. Conveniences include phones, as well as safes and desks.
Take in the views from a rooftop terrace and make use of amenities such as complimentary wireless Internet access and shopping on site. This hotel also features a television in a common area and tour/ticket assistance.
Enjoy a meal at a restaurant, or stay in and take advantage of the hotel's 24-hour room service.
Business, Other Amenities
Featured amenities include complimentary high-speed (wired) Internet access, a computer station, and express check-in. A roundtrip airport shuttle is provided for a surcharge (available 24 hours), and free self parking is available onsite.


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Modified Estuarine wetlands, Willapa basin, 1995Entry ID: Inforain_Est_Wetlands
Abstract: This data set involves an inventory of modified estuarine wetland ecological
systems in the Willapa basin.
This data set is part of the Inforain project which allows users to better
understand their watershed. This data goes along with other data sets from the
Inforain project.
Related URL
Geographic Coverage
Spatial coordinates
Data Set Citation
Dataset Originator/Creator: Interrain Pacific
Dataset Title: Modified Estuarine wetlands, Willapa basin, 1995
Dataset Release Place: United States
Dataset Publisher: Ecotrust
Data Presentation Form: GIS mapOnline Resource: http://www.inforain.org/dataresources/theme_details.cfm?DataLayerID=76
Temporal Coverage
Start Date: 1995-01-01Stop Date: 1995-12-31
Location Keywords
Science Keywords
ISO Topic Category
Ancillary Keywords
Data Set Progress
Originating Center
Data Center
Distribution Media: ftp
Fees: No fees
Role: DIF AUTHOR
Phone: (301) 614-6898
Fax: 301-614-5268
Email: Tyler.B.Stevens at nasa.gov
Contact Address:
NASA Goddard Space Flight Center Global Change Master Directory
City: Greenbelt
Province or State: MD
Postal Code: 20771
Country: USA
Role: TECHNICAL CONTACT
Email: michele at ecotrust.org
Contact Address:
Ecotrust Jean Vollum Natural Center, Suite 200 721 NW Ninth Avenue
City: Portland
Province or State: OR
Postal Code: 97209
Country: USA
Extended Metadata Properties
(Click to view more)
Creation and Review Dates
DIF Creation Date: 2003-08-19
Last DIF Revision Date: 2016-11-18


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Sprigman: You can always sue. That's America.
Starr: But that forces the author to defend the suit, which could be costly, even if it's defeated, as in Bridgeman v. Corel.
Sprigman: The threat of a lawsuit may be the ultimate intimidation. The only thing I would say though to help people not to be so intimidated is that the copyright law provides for fee shifting, so that if you get sued for using a public domain image and you successfully defend the lawsuit there's a good chance that the plaintiff will wind up paying your attorney fees.
Starr: As we've noted, institutions are apparently avoiding initiating these suits.
Sprigman: That's true. The last thing they want is litigation because they are likely to lose. Can I guarantee that? No, because federal courts are notoriously inexpert in and uninterested in copyright. But if the case comes out in any way that it should under the law they will lose.
Starr: So what would you advise those who are hesitant to use photos of works that are in the public domain?
Sprigman: They should know that under the law if the image is "slavish," a mere reproduction, a plain unadorned exact image, they can use it and do not have to pay anyone a licensing fee.
Starr: Thank you, Professor Sprigman.


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"Great writing at its best"
AWESOME IN EVERY WAY. SUPERB! It was amazing to see how far the Governor came to his current position!
Your not a true Walking Dead fan until you finish this book. If you think you know all there is to know about Phillip Blake your wrong. This book was ten times better than I thought it could be and the narrator did a great job of giving you the feeling that you are fighting for life against the walking dead
"Really enjoyed this book!"
As a fan of the comic and tv show, I loved this book and the background story of the governor character. Although there are some similarities between the three storylines, the differences keep you listening and not knowing what to expect next. Would definitely recommend to others. For fans, this is a must read! The production was well done and easy to listen to. 5 Stars
"New perspective"
I've read the graphic novels and watched the show. Both great. This is also great - and yet a slightly different perspective in my opinion -so far. I am enjoying the experience.
"Great voice! Great writing!"
The perfect narrator tells the infamous story of "the governor" in one of TWDs best storylines.
The insight the show and the novels were lacking but is filles in perfectly
"Philip likes to RAPE, torture, and bully."
If the main character (Philip) had not been a rapist. He rapes 2 women over the course of the story. His sadistic torture of prisoners and the constant neanderthal bullying of his brother and friend gets tiring. Philip quickly becomes the character you wish would get dead.
Maybe. I will give the second one a try since it sounds like there is a different main character.
Dramatic pause.
The rape of April and the rape of the the junkie prisoner by Philip.
If you don't hate Philip before the end of this book, there is probably something wrong with you.
"Highly recommend The Walking Dead:Rise of The Gov."
I enjoyed this book very much, it was well written and kept my attention from beginning to end. Several parts even causing my hand to rise to my mouth in either fear or shock, like When the zombie almost got Penny from the back of the motorcycle. Or when Phillip tortured the couple out in the barn... But mostly how the book ends. (I won't give THAT away). I love this narrator, he puts himself into the story and you can actually feel the emotions of characters. HIGHLY RECOMMENDED.
Beth Anne Bell
"Nice job!"
I loved this! Being a Walking Dead junkie, I loved to hear how the governor came about. And the characters came to life while listening, which always decides me on the total rating.
Would love to hear more!
"Awesome more than awesome"
started off a little slow but hold on for a bumpy ride, cant wait to read more
"I thoroughly enjoyed this book."
I've gone through all the books in this series (so, far) and loved every one of them. These books tell the story from The Walking Dead TV series but from different characters' point if view. Also, when the TV characters do come into this book the story follows but with some differences so there are some surprises still in store.


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Maintain radiant skin throughout the day with this Anti-Oxidising Daily Radiance Moisturiser from Dr Botanicals. The protective day moisturiser hydrates the skin, and guards it from environmental irritants and external aggressors. Your complexion is left bright and deeply hydrated.
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Fou Jewellery is a unique brand with a focus on fascinating textures and forms found in nature, exuding an unusual and gothic aesthetic.
The collections have been created using traditional jewellery making techniques alongside cutting-edge technology.
By combining these contrasting production methods, Fou Jewellery hopes to create contemporary, elegant, and stylish jewellery for both men and women.
All of the Fou Jewellery products are created and finished by founder Cassandra Bassett, in her small jewellery studio at The Custard Factory, in Birmingham.
Cassandra trained at the renowned School of Jewellery in Birmingham, West Midlands, where she was taught to design and make jewellery by hand, and using 3D modelling software, enabling her to create innovative, beautiful, and tactile pieces of jewellery.
Drawing inspiration from the natural world and her surroundings, Cassandra challenges herself to create collections which are thoughtful and engaging, and made to the highest standard possible.


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9 Comments
Awesome, reminds me of 30 Days Of Night+1 nice shading too
BenjaminPhantom Artist from Florida, United States
Nice! +1
kik ass.
ApathyDinosaur Artist
epic +1
rafaelsencebe Artist
wow, nice work. +1
Beautiful design. +1
DesignLawrence Artist from MI, United States
wow… the shading is awesome. you got my vote.
3quartermoon Artist
Love this one!!!


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The State University of New York (SUNY) Downstate Medical Center has created a Clinical Site Hub and Spoke NETT to join a national clinical research network. Our 5-hospital NETT, included within federally designated underserved areas, serves a large minority population, will conduct clinical trials designed to develop effective treatments for patients with neurological emergencies. Our existing infrastructure of the Hub at SUNY Downstate Medical Center, with joint experienced leadership from Emergency Medicine and Neurology, has established 2 large spokes: Lincoln Hospital (south Bronx), serving primarily Hispanics, and Maimonides Medical Center (Brooklyn), one of the largest independent teaching hospitals in the US. We work collaboratively with investigators and clinicians in critical care, neurosurgery, Trauma, Stroke, and Epilepsy Centers, Neuroradiology, Rehabilitation, Community Engagement/ Disparities Research, Fire Department of New York (FDNY) Pre-Hospital 911 System, Pharmacy, and Information Technology. Our goal is to identify, recruit, and retain a large number of participants from highly diverse backgrounds in high quality clinical research in neurological emergencies using best research practices and the highest ethical standards of research conduct. We will facilitate the transfer of research results to clinical practice via active dissemination of study findings. We are mentoring junior faculty, including minority investigators, in the conduct of phase 3 randomized clinical trials. Our growing infrastructure includes a recently NINDS-funded SUNY NeuroNEXT UIO for phase 2 trials among other formalized and funded research and training programs. This NETT is jointly led by experienced clinical trialists well-versed in complex multi-center administrative structure and projects with established mentoring programs and a growing cadre of acute neurology subspecialists. Our NETT includes a combined annual ED volume of over 350,000 visits, with over 3,500 neurological emergencies. Strengths include the extremely diverse, large patient pool, extensive NIH clinical trials experience, detailed ED visit data from all hospitals, acute telemedicine experience, expertise in exemption from informed consent, and well-established, extensive community networks and engagement.
Neurological Emergencies are a major cause of morbidity and mortality in the US and are extremely costly illnesses. There is a great need to develop proven treatments for these conditions. There is also a disproportionate risk and burden on underrepresented minorities (URM) for many types of neurological emergencies which our NETT Clinical Hub Site and Spokes has been focusing on for recruitment. We also will train UBM investigator's in the conduct of clinical trials.
|Gropen, Toby I; Gokaldas, Reshma; Poleshuck, Rebecca et al. (2014) Factors related to the sensitivity of emergency medical service impression of stroke. Prehosp Emerg Care 18:387-92
|Rao, Neal M; Levine, Steven R; Gornbein, Jeffrey A et al. (2014) Defining clinically relevant cerebral hemorrhage after thrombolytic therapy for stroke: analysis of the National Institute of Neurological Disorders and Stroke tissue-type plasminogen activator trials. Stroke 45:2728-33
|Tark, Brian E; Messe, Steven R; Balucani, Clotilde et al. (2014) Intracerebral hemorrhage associated with oral phenylephrine use: a case report and review of the literature. J Stroke Cerebrovasc Dis 23:2296-300
|Brandler, Ethan S; Sharma, Mohit; Sinert, Richard H et al. (2014) Prehospital stroke scales in urban environments: a systematic review. Neurology 82:2241-9
|Lederman, Yitzchok S; Balucani, Clotilde; Lazar, Jason et al. (2014) Relationship between QT interval dispersion in acute stroke and stroke prognosis: a systematic review. J Stroke Cerebrovasc Dis 23:2467-78
|Re-examining Acute Eligibility for Thrombolysis (TREAT) Task Force:; Levine, Steven R; Khatri, Pooja et al. (2013) Review, historical context, and clarifications of the NINDS rt-PA stroke trials exclusion criteria: Part 1: rapidly improving stroke symptoms. Stroke 44:2500-5


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final cut pro editor needed for weekly online videoshow
This project was awarded to clicplix for $11 USD / hour.Get free quotes for a project like this
Project Budget$8 - $15 USD / hour
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I am producing a weekly videoshow and I need someone on a weekly basis to help me edit the raw material in final cut pro, render the material and send it back to me to be published. I have 1 long (15 - 20 mins) video a week, that's also going to be cut into smaller snippets of 2 - 3 minutes each.
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- Forbes
- The New York Times
- Time
- Wall Street Journal
- Times Online


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Newegg.com - A great place to buy computers, computer parts, electronics, software, accessories, and DVDs online. With great prices, fast shipping, and top-rated customer service - once you know, you Newegg.
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Showing Results: Most Recent
This review is from: Energy Take Classic 5.1 5.1 CH Premium Home Theater System
Pros: Speaker build quality and drivers.
Solid subwoofer to complement great speakers.
Cons: none
Other Thoughts: I use Klipsch speakers for 2 Home theater systems but must say these really impress me with sound quality. Have these hooked up to marantz NR1403 in home office and am wowed by system.
Best of all I got these on sale from Newegg at $299.00.
This review is from: GIGABYTE GeForce GT 610 DirectX 11 GV-N610D3-1GI 1GB 64-Bit DDR3 PCI Express 2.0 x16 HDCP Ready Low Profile Video Card
Pros: Easy install. Took 5 minutes only.
Brought Windows index from 3.1 to 4.5
Best bang for buck for improving Video performance.
Cons: NoneREAD FULL REVIEW


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THE DETAILS: Many plastic floor coverings—particularly vinyl, which is made from polyvinyl chloride (PVC)—are popular because they're cheap and relatively easy to install. Unfortunately they're laden with phthalates, some of which have been linked to breathing problems, sexual development problems in baby boys, low sperm count in men, and possibly cancer. Preliminary research is also finding a possible link between phthalates and obesity. In the current study, scientists found that homes with more plastic products in them tended to have higher phthalate levels in the carpeting. The carpets apparently offer a cushy hiding spot not only for pet dander and dirt, but also chemical irritants like phthalates that can exacerbate asthma.
WHAT IT MEANS: If you're in the market for new flooring, you may want to scratch carpeting and vinyl off your list. Vinyl has been dubbed "the poison plastic" by many public health and environmental advocates, and Healthy Building Network researchers recently released an analysis of resilient flooring and chemical hazards naming vinyl "worst in class" because of its cancer-causing by-products and slow-releasing chemicals that off-gas in homes throughout the vinyl's lifespan. And while carpets don't necessarily contain phthalates, they trap them along with other harmful pollutants, often including formaldehyde, a known carcinogen.
While all this talk may tempt you to rip out your flooring, don't. The key to keeping dangerous chemicals at bay involves ecominded cleaning:
• Know how to dust. It's particularly important to keep dust under control if you have little ones in your home because they crawl on the floor and can't resist shoving their hands in their mouths. That increases their exposure not only to phthalates, but also flame-retardant chemicals shed from curtains, furniture, and electronic products. If you have carpeting, use a vacuum with a HEPA filter to capture dust. Set the vacuum to clean bare floors if you have hardwood or other noncarpet surfaces, or wet-mop with a mixture of 1 gallon water and ½ cup white vinegar. Avoid sweeping with a broom beforehand because it just kicks dust up into the air. Feather dusters are another no-no, says Sarah Janssen, MD, physician and scientist with Natural Resources Defense Council. Instead, use a wet cloth to dust furniture and other surfaces.
• Battle the stink safely. Air fresheners and harsh cleaning products are often packed with phthalates, which are used to carry artificial fragrances. What's worse, using harsh cleaning products on vinyl and other plastics can speed their leeching of harmful chemicals. If you've got a funky smell in your house, don't cover it up—get rid of it. Open the windows, set out baking soda or a bowl of white vinegar to absorb the stink, and use a white vinegar solution or regular soapy water to clean up a mess. "You don't need heavily fragranced antibacterial soaps," says Dr. Janssen.


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Nearly half of high-net-worth investors plan to include nontraded real estate investment trusts in their portfolios, according to an IPA survey. The result indicates a renewed interest in REITs; only 30% of respondents currently invest. "After the significant downturn in the real estate market, investors are now saying that the market has turned a corner," IPA President and CEO Kevin Hogan said.
Full Story:GlobeSt.com


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How wonderful to have a feminist as minister for Women! It's a comfort to know that Maria Miller has our interests at heart. She doesn't want to reduce the abortion limit from 24 to 20 weeks because she disapproves of abortion. Oh, no. She's "driven by the practical impact that late-term abortion has on women". And she says that medical advances allow more premature babies to survive. She's even a "very modern feminist".
Odd, that. You'd think a very modern feminist would take more care with the facts. For it turns out that medical advances have had no effect on babies' survival rates below 24 weeks. A study in the BMJ showed that, while many more babies now survive at 24 and 25 weeks, survival rates haven't risen at all for those born at 23 weeks or less.
Moreover, these very premature babies have an extremely high risk of disability. Only 1 per cent born at 22 weeks survive and 70 per cent of them are severely disabled. Of those born between 23 and 24 weeks, two-thirds have moderate or severe disabilities. By the time the baby is 25 or 26 weeks, it has only a one-third chance of being disabled. So, from the point of view of the baby's viability, the current 24-week limit looks just about right. What about the effect on the mother, though?
No woman would choose to have an abortion that late. It involves inducing a stillbirth and it must be distressing. These late abortions are very rare: they account for less than 2 per cent of the total. Some happen because babies have severe abnormalities that only show up on the 20-week scan. Reducing the limit to 20 weeks would force those mothers to carry the baby to term with the prospect of it dying at, or shortly after birth, or living a horribly damaged and dependent life.
When medical science advances enough to make a 22-week foetus genuinely viable, it may make sense to lower the abortion limit. Until then, it's not for Maria Miller to decide whether individual women will suffer more from having an abortion or from giving birth.Reuse content


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Although La Crosse virus (LACV) is one of the most common causes of pediatric arboviral infections in the United States, little has been done to assess its geographic distribution, identify areas of higher risk of disease, and to provide a national picture of its clinical presentation. Therefore, the objective of this study was to investigate the geographic distribution of LACV infections reported in the United States, to identify hot-spots of infection, and to present its clinical picture.
Methods and Findings
Descriptive and cluster analyses were performed on probable and confirmed cases of LACV infections reported to the Centers for Disease Control and Prevention from 2003–2007. A total of 282 patients had reported confirmed LACV infections during the study period. Of these cases the majority (81 percent) presented during the summer, occurred in children 15 years and younger (83.3 percent), and were found in male children (64.9 percent). Clinically, the infections presented as meningioencephalitis (56.3 percent), encephalitis (20.7 percent), meningitis (17.2 percent), or uncomplicated fever (5 percent). Deaths occurred in 1.9 percent of confirmed cases, and in 8.6 percent of patients suffering from encephalitis. The majority of these deaths were in patients 15 years and younger. The county-level incidence risk among counties (n = 136) reporting both probable and confirmed cases for children 15 years and younger (n = 355) ranged from 0.2 to 228.7 per 100,000 persons. The southern United States experienced a significantly higher (p<0.05) incidence risk during the months of June, July, August, and October then the northern United States. There was significant (p<0.05) clustering of high risk in several geographic regions with three deaths attributed to complications from LAC encephalitis occurring in two of these hot-spots of infections.
Both the incidence risk and case fatality rates were found to be higher than previously reported. We detected clustering in four geographic regions, a shift from the prior geographic distributions, and developed maps identifying high-risk areas. These findings are useful for raising awareness among health care providers regarding areas at a high risk of infections and for guiding targeted multifaceted interventions by public health officials.
Citation: Haddow AD, Odoi A (2009) The Incidence Risk, Clustering, and Clinical Presentation of La Crosse Virus Infections in the Eastern United States, 2003–2007. PLoS ONE 4(7): e6145. doi:10.1371/journal.pone.0006145
Editor: Laurent Rénia, BMSI-A*STAR, Singapore
Received: May 22, 2009; Accepted: June 3, 2009; Published: July 3, 2009
Copyright: © 2009 Haddow, Odoi. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: Tennessee Agricultural Experiment Station provided partial funding. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
La Crosse virus (LACV) is a member of the genus Orthobunyavirus, family Bunyaviridae, and is the causative agent of LACV infections. LACV was first isolated in 1964 [1], and has become one of most common causes of pediatric arboviral infections in the United States [2], [3]. The majority of LACV infections are transmitted to humans through the bite of the primary vector, the eastern tree-hole mosquito, Aedes triseriatus [4], [5]. The virus is maintained in nature through a vertical and horizontal transmission cycle involving Ae. triseriatus [6], [7], [8] and the primary amplification hosts: the eastern chipmunk, Tamias striatus, the gray squirrel, Sciurus carolinensis, and the fox squirrel Sciurus niger [9], [10].
LACV has traditionally been associated with forested areas in the upper-midwestern United States [11], but more recently as an emerging disease in the Appalachian region of the United States [12], [13], [14]. Unlike West Nile virus (WNV) infections that are more severe in the adults [15], the majority of severe LACV cases occur in children 15 years and younger [11], [16], [17], [18], with an average of 79 nationally reported cases per year since 1964, though pockets of higher infection risk have been reported [19]. The incidence risk in children 15 years and younger was believed to be 20–30 cases per 100,000, with a case fatality rate of less than 1 percent [13], [16], [17]. However, the true incidence of LACV infections are unknown as cases are typically under diagnosed, under-reported, and some are asymptomatic [18], [19], [20], [21]. In this study, we examined probable and confirmed cases of LACV infections from 2003–2007, to determine incidence risk, case fatality rates, and to assess the current spatial patterns of disease risk so as to identify those areas of highest risk for the implementation of future disease control strategies.
Study area
Our study area encompassed the eastern United States, the geographic region that includes the majority of previously reported LACV infections and the range of the primary vector, Ae. triseriatus [2], [16], [18], [22]. County level incidence risks were calculated and spatial analyses performed on 24 states in the study area. Seventeen of the 24 states reported probable and confirmed cases of LACV infections in children 15 years and younger (Table 1). The following states were part of the study area but did not report any LACV infections in children 15 years and younger during the study period: Arkansas, Delaware, Florida, Maryland, Missouri, New Jersey, and Pennsylvania. All of these states have reported LACV infections in the past.
Disease data
This study was conducted for all states reporting probable and confirmed cases of LACV infections in the United States, 2003–2007, through the ArboNET surveillance system [23]. The ArboNET surveillance system was established by the Centers for Disease Control and Prevention in 2000 to monitor the spread of West Nile virus in the United States. In 2003, the system was expanded to collect data on other arboviral diseases. Through ArboNET, participating health departments report human cases of arboviral disease. The ArboNET system was queried by the Centers for Disease Control and Prevention to search for all LACV infections.
Personal identifiers of patients were deleted before database construction. Clinical and epidemiological LACV data for 151 probable and 275 confirmed cases of LACV infections reported during this time period were provided by the Centers for Disease Control and Prevention. Cases that acquired infection outside of the county/state were excluded from spatial analyses (n = 10). This research was deemed exempt from review and certification by the University of Tennessee's Institutional Review Board following review by the Department of Entomology and Plant Pathology's Departmental Review Committee under the University of Tennessee's guidelines for research involving human subjects.
Case definition
Confirmed cases of LACV infections are required to meet both the clinical and laboratory requirements set by the Centers for Disease Controls and Prevention's case definition for neuroinvasive domestic arboviral diseases [24]. This definition is reprinted below:
In the absence of a more likely clinical explanation as documented by a physician, confirmed cases must meet all of the following criteria:
Clinical Criteria. 1) Fever, AND
2) Acutely altered mental status, or other acute signs of central or peripheral neurologic dysfunction, or pleocytosis associated with illness clinically compatible with meningitis, AND
Laboratory Criteria. 3) a four-fold or greater change in virus-specific serum antibody titer, or isolation of virus from or demonstration of specific viral antigen or genomic sequences in tissue, blood, CSF, or other body fluid, or virus-specific immunoglobulin M (IgM) antibodies demonstrated in CSF by antibody-capture enzyme immunoassay (EIA), or virus-specific IgM antibodies demonstrated in serum by antibody-capture EIA and confirmed by demonstration of virus-specific serum immunoglobulin G (IgG) antibodies.
Probable Case Criteria. Cases that met the clinical definition and had stable (less than or equal to a two-fold change) but elevated titer of virus-specific serum antibodies, or virus-specific serum IgM antibodies detected by antibody-capture EIA but with no available results of a confirmatory test for virus-specific serum IgG antibodies in the same or a later specimen, are deemed probable.
Population and geographic data
The 2005, United States Census Bureau, Estimated County Population Dataset [25], was used to calculate the total population and the population 15 years and younger for each county. These populations were used to provide the denominators for calculating incidence risk at the county level. As the United States Census Bureau does not provide yearly population estimates that include sex, age, and race for the county level, the 2000 United States Census [26] was used to provide the denominators for calculating the sex - age - and race - specific incidence risk for all counties reporting LACV infections. Geographic boundary files were downloaded from the United States Census, TIGER, Geodatabase [27], and used for all cartographic displays.
Statistical and geographic analyses
Incidence risk was calculated and spatial analyses were performed on 123 probable and 232 confirmed cases 15 years and younger and on 151 probable and 275 confirmed cases for all ages occurring during the study period for which county level data were available (Table 1). Incidence risk was calculated for all counties in the study area (n = 1924) and for counties reporting both confirmed and probable cases of LACV infections under the age of 15 (n = 136) and for all ages (n = 161). Incidence risks were expressed as the number of cases per 100,000 persons.
To determine if there was a significant difference in incidence risk by month between states reporting cases in the northern (n = 7) and southern (n = 10) regions of the study area, we calculated the incidence risk by region and month using the both probable and confirmed cases 15 years and younger. The northern region was comprised of Illinois, Iowa, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. The southern region was comprised of Alabama, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia.
All incidence risk computations and descriptive analyses were performed using STATA 10.0 [28]. Spatial empirical Bayesian (SEB) smoothing was used to adjust incidence risk due to spatial autocorrelation and high variances resulting from a small number of cases reported in some counties [29], [30], [31], [32]. The resulting smoothed incidence risks allow for better visualization of the spatial patterns compared to the unsmoothed risk.
Global Moran's I [33] and the Moran Local Indicators of Spatial Association (LISA) were used to assess for evidence of spatial clustering [34]. Statistical significance of both global and local Moran's I statistics were tested using 9999 permutations. All spatial analyses were performed using GeoDa Version 0.95i [35], and cartographic displays were done using ArcView GIS 9.2 [36].
Descriptive analyses of cases
A total of 282 patients had confirmed LACV infections reported to the Centers for Disease Control and Prevention (Table 2). Most cases presented during July (24.9 percent), August (32.6 percent), and September (23 percent). Cases ranged in age from 0.5 to 86 years, with a median age of 9 years; 83.3 percent were under the age of 15 years, and the majority were males (64.9 percent).
The sex-specific incidence risk (per 100,000 persons) for all counties reporting confirmed cases was 1.9 and 1.0 for males and females, respectively. The age-specific incidence risk was 1.2 for children under one year; 5.4 for 1–5 years; 6.8 for 6–10 years; 4.7 for 11–15 years; 0.5 for 16–20 years; and 0.2 for 21 years and older. Blacks had the lowest race-specific incidence risk (0.3 per 100,000 persons) and American Indians had the highest (4.9 per 100,000 persons). The incidence risk for all counties reporting probable and confirmed cases combined in children 15 years and younger was 7.2 per 100,000 persons (mean 30.2), and 1.6 per 100,000 persons (mean 5.8) for the total population.
The incidence risk was significantly higher in the states in the southern region than those states in the northern region for June (p = 0.0018), July (p = 0.0002), August (p = 0.0033), and October (p = 0.0053) (Table 3). There was no statistically significant difference (p>0.05) in the incidence risk between the states in the northern and southern regions for the months of March, April, May, September, and November.
Clinically, the infections presented as meningioencephalitis (56.3 percent), encephalitis (20.7 percent), meningitis (17.2 percent), uncomplicated fever (5 percent), or other (0.7 percent) (Table 2). Deaths accounted for 1.9 percent of confirmed cases, and were reported in Indiana, Michigan, Tennessee, and West Virginia. All deaths occurred in patients suffering from LAC encephalitis (100 percent). Of those patients presenting encephalitis 8.6 percent died. The majority (80 percent) of these deaths were in patients 15 years and younger (median age 6, range 4–86) and occurred in males (80 percent). Three deaths occurred in the high risk clusters in West Virginia and in Tennessee.
Spatial distribution
In children 15 years and younger (probable and confirmed combined), state-level incidence risk ranged from 0.7 to 56.4 per 100,000 persons whereas at the county-level incidence risk in counties reporting cases, ranged from 0.2 to 228.7 per 100,000 persons (Table 1). Geographically, the highest incidence risks were observed in western and central Illinois, northeastern Iowa, south central Minnesota, southwestern Wisconsin, and the Appalachian region (south central Kentucky, south central Ohio, western North Carolina, central and eastern Tennessee, south central West Virginia) (Figure 1). The spatial patterns are more easily recognizable when smoothed (Figure 1b) as compared to the unsmoothed incidence risk map (Figure 1a). The global Morans I value for children 15 years and younger, was 0.1904 (p = 0.0001) for only confirmed cases and 0.2223 (p = 0.0001) for both probable and confirmed cases combined. Forty-seven of the counties in the study area showed evidence of significant high incidence risk (p<0.05) detected by LISA using confirmed cases, while 54 counties had evidence of significant clustering of high risk (p<0.05) detected using both probable and confirmed cases. The spatial patterns for both confirmed cases and for probable and confirmed cases combined were similar. Therefore, only the spatial patterns using both the probable and confirmed cases are presented in Figure 2. The clusters detected by using both probable and confirmed cases combined were found in northeastern Iowa/southwestern Wisconsin, and in south central Ohio, western North Carolina/eastern Tennessee/northeastern Georgia, and south central West Virginia/eastern Kentucky/northwestern Virginia (Figure 2). The mean incidence risk for children 15 years and younger at the county-level for those counties that were part of the significant high clusters was 54.6 per 100,000 persons, and ranged from 4.7 to 228.7 per 100,000 persons.
The map on the left represents the distribution of a) unsmoothed risk, and on the right b) smoothed risk of La Crosse virus infections at the county level for the eastern United States.
This map shows the significant clustering of La Crosse virus infections at the county level detected by the Moran's I Local Indicators of Spatial Autocorrelation (LISA) for the eastern United States. Four types of spatial autocorrelation are observed using the LISA statistic (High-High, Low-Low, High-Low, and Low-High). Positive spatial autocorrelation is represented by High-High and Low-Low, and negative spatial correlation by High-Low and Low-High. Positive spatial autocorrelation (i.e. an association of areas of similar values) were represented as either High-High (i.e. a high risk in an area surrounded by similarly high values in neighboring areas) or Low-Low (i.e. a low risk in an area surrounded by similarly low values in neighboring areas). Negative spatial autocorrelation (i.e. an association of areas of dissimilar values) was represented as either High-Low (i.e. a high rate in an area surrounded by low values in neighboring areas) or Low-High (i.e. a low rate in an area surrounded by high values in neighboring areas).
Our study provides the first risk map of LACV infections for the United States, and presents insights into the clinical picture of LACV infections. We found both a higher incidence risk than previously reported ranging up to 228.7 cases per 100,000 persons in children 15 years and younger and a case fatality rate of 1.9 percent [5], [7], [8]. This study highlights the differences of the clinical presentation of LACV infections as meningioencephalitis, encephalitis, meningitis, uncomplicated fever, or other; rather than the traditional method of reporting of infections as purely LACV encephalitis. To our knowledge this is the first use of smoothing techniques, the global Moran's I, and the Moran Local Indicators of Spatial Association (LISA) to detect spatial clustering of LACV infections at a national level in the United States. We identified high risk clusters in four regions of the United States. These high risk clusters should be targeted for future studies and intervention efforts.
The majority of cases reported occurred in the summer months (June, July, and August) in agreement with previous studies [2], [17], [18], with a significantly higher incidence risk occurring in southern states during the months of June, July, August, and September. This is likely due to the transmission cycle of LACV, which involves both horizontal and vertical transmission. The burden of infected mosquitoes would continue to increase into the summer months as each successive generation of mosquitoes fed upon viremic amplification hosts, followed by increased transovarial transmission of the virus to their progeny. The highest risk of infection would thus occur during the height of this amplification process when the highest burden of infected mosquitoes would be reached. The height of this viral amplification coincides with the summer months when humans are most apt to spend the most time outdoors, thus putting themselves at an increased risk for coming into contact with infectious mosquitoes.
Temperature may play a role in the higher incidence risk in southern region of the United States. Given that transovarial transmission following one gonotrophic cycle is likely rare in nature [6], orally infected Ae. triseriatus, likely need to complete at least two gonotrophic cycles to transovarially transmit the LACV to their eggs [37]. As only a small percentage of Ae. triseriatus may survive to complete their second gonotrophic cycle in nature [37], an increase in the ambient temperature would increase the number of gonotrophic cycles possible in lifespan of a vector. Additionally, higher temperatures would have the added effect of increasing viral dissemination, titers, and transmission in vectors [38], [39]. Warmer temperatures, which are traditionally present for longer periods of time in the southern United States could therefore be playing a substantial role in increasing overall vectorial capacity.
Previous studies have shown that over 90 percent of reported cases occur in children 15 years and younger [16], with approximately 64 percent of these cases occurring in males [16]. Our study confirms these findings with roughly 83 percent of confirmed cases occurring in children 15 years and younger and 64.9 percent of these cases occurring in males. Clinical studies have demonstrated similar findings [13], [40], [41]. The tendency for children to develop severe LACV infections may be due to a variety of factors including differences in the pediatric and adult immune system, virus dose, and/or the longer time children may spend outdoors, though such risk factors are not well understood. It has been hypothesized elsewhere that the higher incidence risk in males may be due to the greater time boys spend outdoors, thus increasing their risk of contact with infectious vectors [21], [42].
Of the 426 reported probable and confirmed LACV infections during our study period, the Appalachian region including West Virginia, North Carolina, Ohio, and Tennessee reported 22.2 percent, 20.8 percent, 18.5 percent and 22.2 percent of reported cases, respectively, and accounted for 74.5 percent of all cases during the study period. A previous study from 1964–1981, reported 1348 cases in the United States of which 88.8 percent came from Ohio, Wisconsin, Minnesota, Illinois, and Iowa [16], while only 2 percent came from North Carolina, Tennessee, and West Virginia. Though our results encompass only a five-year period, the higher incidence risk in these states may indicate a shift in LACV infections from the upper Midwest to the Appalachian region of the United States [12], [13], [14]. The reason for this shift is unclear, but could be due to a number of factors including changes in diagnosis, reporting, prevention strategies, as well as changes in the epidemiology of the disease.
Though our finding of an mean incidence risk of 30.2 per 100,000 persons for children 15 years and younger in probable and confirmed cases combined for eastern United States was similar to previous reports of an incidence risk of 20 to 30 per 100,000 persons in the same age group [43], [44], our mean incidence risk in the significantly high spatial clusters was numerically higher, 54.6 per 100,000 persons, then the incidence risk previously reported for the same age group [43], [44]. In the individual counties reporting cases of LACV infections we found the incidence risk in children 15 years and younger ranging from 0.16 to 165.4 per 100,000 persons using only confirmed cases, and from 0.2 to 228.7 per 100,000 persons using both confirmed and probable cases combined. These results indicate the wide variation that occurs due to the focal nature of the virus within counties reporting LACV infections, and highlights the need to report the range of incidence risk, rather than reporting only the mean incidence risk which may not provide an accurate assessment of risk within these focal areas.
A recent study of the incidence of WNV infections in the United States by Lindsey et al. [45], analyzed five years of WNV infection data reported to the ArboNET surveillance system. The authors found a state level incidence risk for WNV infections ranging from 0.2 to 32.2 per 100,000 for the total population and a county level incidence risk ranging from 0.1 to 241.2 per 100,000 for the total population. Though the range of our state level incidence risk for LACV infections in the at-risk population was higher, ranging from 0.7 to 56.4 per 100,000 in children 15 years and younger, our county level incidence risk for LACV infections was similar to their findings, 0.7 to 228.7 per 100,000 persons in children 15 years and younger. These results indicate that the incidence risk of LACV infections are similar to that of WNV infections.
When the results from our analysis of those counties in the study area reporting both probable and confirmed cases of LACV infections are compared with pediatric WNV infection cases reported in Cuyahoga County, Ohio, in 2002 [15], LACV infections had a higher incidence risk in the pediatric population than that estimated for WNV infections, 7.2 per 100,000 persons in children 15 years and younger to 1.4 per 100,000 persons in children 5 to 17 years of age, respectively. In those counties reporting probable and confirmed cases of LACV infections in the population >16 years and older we found an incidence of 0.34 per 100,000 persons, while in Cuyahoga County, Ohio, LeBeaud et al. [15] estimated the incidence risk in the population ≥18 years and older to be 14.3 per 100,000 persons. It is clear that the severe infections caused by these two arboviruses present in the pediatric and adult populations differently, with severe LACV infections having a much higher incidence risk in children than adults, the opposite of that of WNV infections. The cause(s) for the differences in incidence risks between these two arboviruses within the pediatric and adult populations remains unknown, but warrants further investigation.
From the results of LACV serosurveys conducted in endemic regions it is clear that the risk of asymptomatic infections is much higher than symptomatic infections, with estimates of asymptomatic infections to clinical infections in pediatric populations ranging from 2∶1 to 1500∶1 [19], [20], [21]. The incidence risk of LACV infections are therefore likely much higher, as only the most severe cases typically present for medical care and hence get reported. The results from these studies suggest that there are most likely several hundred thousand infections per year in the United States [19], [20], [21], but our findings suggest that there are many more cases than previously estimated. The spatial distribution (Figure 1) reaffirms the focal nature of these infections, and identifies the areas with the highest risk.
The use of probable and confirmed cases combined increased overall cluster detection from 47 to 54 counties. The significant high risk clusters detected should be targeted for future studies and for interventions by public health officials. Reporting the mean incidence risk at the state or county level may lead to a distorted picture of the spatial patterns of LACV infections and thus decrease the perception of risk. Future reporting should include the range of incidence risk occurring in those counties reporting cases. This will minimize misperceptions of risk, as the use of incidence risk continues to remain the most used tool to identify high risk areas for education, prevention, and intervention.
Though LACV infections are typically reported as LAC encephalitis there appear to be four distinct clinical syndromes, as well as asymptomatic infections [2], [13], [40], [41], [46], These include the most severe LAC encephalitis, LAC meningioencephalitis, LAC meningitis, and LAC fever. It is difficult to assess the true incidence of these syndromes since they have often been collectively reported as LAC encephalitis in previous reports/studies [40], [41], [47]. Accurate reporting of the patients' clinical syndrome is necessary to determine and monitor the future rates of disease presentation.
Our study found a case fatality rate of 1.9 percent in confirmed cases, with all of the deaths occurring in patients presenting encephalitis. The majority of deaths were in children 15 years and younger. This finding is much higher than the case fatality rate of 0.3 percent reported in a previous study of LACV infections in the United States [16]. The reason for the higher case fatality rate is unclear, but many factors should be considered including variation in the virulence of the LACV strain(s) circulating in this region of the United States [48]. These findings suggest that LACV infections may be more severe than sometimes reported in medical literature. Three deaths (probable and confirmed cases combined) occurred in two of the four highly significant clusters of probable and confirmed cases of LACV infections in West Virginia and Tennessee.
Our study has some limitations. Probable and confirmed cases were reported through a passive surveillance system, which inherently suffers under-reporting. Not withstanding this limitation we feel that the majority of cases progressing to severe illness were diagnosed and reported to public health officials. Using only confirmed cases as well as probable and confirmed cases combined, we were able to demonstrate similar high incidence risk and case fatality rates. We were also able to show similar patterns in disease clustering. Clinical data was reported from multiple state health departments to the Centers for Disease Control and Prevention, which did not allow for the verification of laboratory results and the diagnosis of the specific clinical presentation for each patient. We feel that this is a small limitation and that the majority of cases reported have been correctly separated into the four manifestations of severe LACV infections by clinicians.
One drawback to using the LISA is the issue of multiple comparisons which increases type I error rates. We didn't make an attempt to adjust for this because some authors have suggested that any adjustments made to reduce the type I errors would increase type II errors [30], [49], in turn reducing the test's power to detect truly significant clusters.
Our findings of a high incidence risk within significantly high spatial clusters and high case-fatality rate indicate a much higher burden of disease than previously reported, and demonstrate that LACV infections are much more common than previously reported. We have demonstrated the usefulness of these spatial statistical techniques to detect hot-spots of infections, thus allowing for targeted interventions by public health officials while raising awareness among health care providers of geographic areas at the highest risk of disease.
Our results will allow focused national serological studies, form the basis for the development of predictive models of virus transmission, provide a methodology for the use spatial analyses at a national level for other infectious diseases, and demonstrate the need for the reporting of arboviral and other disease cases at smaller geographic scales.
We would like to thank the Arboviral Diseases Branch of the Centers for Disease Control and Prevention for releasing the surveillance data to our group, and their comments on the draft manuscript. We would also like to offer our sincere thanks to the staff of all the many local and state health departments who collected La Crosse virus infection case data and submitted them to the Centers for Disease Control and Prevention. Without their contributions this work would not have been possible.
Author Contributions
Conceived and designed the experiments: ADH AO. Performed the experiments: ADH AO. Analyzed the data: ADH AO. Wrote the paper: ADH AO.
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Pianist | Organist | Keyboardist | Instructor | Arranger | Producer The ambitious,…
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Jamaica, NY
Astoria, NY
Astoria, NY
I am a singer, pianist, and guitarist. I have 10+ years of experience as a cantor…
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Astoria, NY
East Rockaway, NY
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Old Greenwich, CT
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