text:
Multidrug-resistant tuberculosis in Belarus: the size of the problem and associated risk factors
Alena Skrahina a, Henadz Hurevich a, Aksana Zalutskaya a, Evgeni Sahalchyk a, Andrei Astrauko a, Sven Hoffner b, Valiantsin Rusovich c, Andrei Dadu d, Pierpaolo de Colombani d, Masoud Dara d, Wayne van Gemert e & Matteo Zignol e
a. Republican Scientific and Practical Centre for Pulmonology and Tuberculosis, Avenue Dolginovskitrakt 157, 220053 Minsk, Belarus.
b. Department of Preparedness, Swedish Institute for Communicable Disease Control, Stockholm, Sweden.
c. World Health Organization Country Office, Minsk, Belarus.
d. TB and M/XDR-TB Programme, World Health Organization Regional Office for Europe, Copenhagen, Denmark.
e. Stop TB Department, World Health Organization, Geneva, Switzerland.
Correspondence to Alena Skrahina (e-mail: firstname.lastname@example.com).
(Submitted: 08 March 2012 – Revised version received: 23 October 2012 – Accepted: 30 October 2012 – Published online: 26 November 2012.)
Bulletin of the World Health Organization 2013;91:36-45. doi: 10.2471/BLT.12.104588
The increasing prevalence of infection with drug-resistant Mycobacterium tuberculosis represents a global public health emergency. At any given time, about 630 000 people in the world are thought to carry strains of M. tuberculosis showing resistance to the two drugs that are currently the most effective against tuberculosis (TB): isoniazid and rifampicin.1 So far, the magnitude of the problem posed by multidrug-resistant TB (MDR-TB) has been estimated in about two thirds of all countries worldwide through disease surveillance and surveys. Each year, as more studies are conducted, new hot spots of MDR-TB are documented.2 Among the countries that have been most severely affected by MDR-TB are several that formerly lay within the Soviet Union, including Belarus.
In 2006, Belarus established a national TB control programme and introduced international standards for TB care.3 Patients in Belarus who are newly diagnosed with TB receive 2 months of treatment with isoniazid, rifampicin, pyrazinamide and ethambutol followed by 4 months of treatment with just isoniazid and rifampicin. An 8-month regimen is used for patients with a previous history of TB treatment. In addition to the isoniazid, rifampicin, pyrazinamide and ethambutol given to new cases, this longer regimen includes streptomycin (given for 2 months) and ethambutol (given for 8 months).4 All TB patients undergo drug-susceptibility testing at the time of diagnosis and are switched to a standardized regimen containing the appropriate second-line drugs if MDR-TB is detected.
In recent years, the annual incidence of TB in Belarus has been slowly but progressively falling: 84 and 70 new cases were recorded per 100 000 population in 2000 and 2011, respectively.1 However, the high prevalence of MDR-TB among TB patients in Belarus has raised major concerns. In a survey conducted in 2010 in Minsk, the capital city, nearly one out of every two (47.8%) TB patients investigated was found to have MDR-TB; this was the highest prevalence of MDR-TB ever recorded among TB patients worldwide.5 The Minsk survey was, however, relatively small and limited to a highly urbanized area. The national Ministry of Health therefore decided to conduct a larger, nationwide survey, not only to have a better understanding of the levels of drug resistance throughout Belarus but also to investigate the risk factors for the development of MDR-TB. In this paper we report the results of the first national survey of drug resistance to be conducted among TB cases in Belarus and present an analysis of the data collected, during the same survey, on sociobehavioural risk factors for the development of MDR-TB.
Study design
The sampling frame consisted of patients who had pulmonary, smear-positive TB in any of the 196 health-care facilities in Belarus where TB can be diagnosed by the direct microscopical examination of sputum. In line with the guidelines of the World Health Organization (WHO), given that the frequencies of drug resistance among smear-positive and smear-negative cases of TB are similar, smear-negative cases were excluded from the study to avoid an excessive workload in the laboratories where M. tuberculosis isolates were to be cultured and tested.6 For the same reason, patients with extrapulmonary disease were also excluded from the survey. The target sample sizes for new and previously treated TB cases were calculated using the notification data for 2009. For example, the target sample size for new cases was set at 927 on the basis of the number of new sputum-smear-positive cases of pulmonary TB reported in the country in 2009 (n = 1201), an expected prevalence of MDR-TB among new cases of TB of 20%, a predicted inability to test 10% of the collected samples (for reasons such as culture loss or failure), and a precision, for the 95% confidence intervals (CIs), of ± 1.5%. Similarly, the target sample size for patients with previously treated TB was set at 396 on the basis of the number of sputum-smear-positive cases of pulmonary TB reported in the country in 2009 (n = 878), an expected prevalence of MDR-TB among the previously treated cases of 60%, a predicted inability to test 10% of the collected samples, and a precision, for the 95% CI, of ± 4.0%.
The survey was conducted between June 2010 and June 2011. All consecutive sputum-smear-positive (new or previously treated) pulmonary TB patients who were aged ≥ 15 years, registered for treatment and gave their informed consent were included. Sputum specimens for the isolation of M. tuberculosis were collected before the initiation of treatment. New and previously treated patients were defined according to international guidelines.6,7 For each enrolled patient, information on treatment history for TB, demographic characteristics, education, living and employment conditions and history of imprisonment, use of alcohol, and smoking was collected, on the same day as the sputum, in an interview based on a structured questionnaire. Alcohol abuse was defined as the drinking of at least 5 units of alcohol per day for at least 5 days in the previous month.8,9 A history of smoking was defined as the use of any tobacco product on a regular basis in the past 5 years. When available, the patient's medical records were reviewed to confirm the reliability of the information gathered in the questionnaire. If the patient had been tested for human immunodeficiency virus (HIV), the results of that testing were also recorded. A patient was considered HIV-negative if, within the previous 6 months, he or she had been tested for HIV at one of the oblast-level HIV diagnostic laboratories and found negative. Any patient who had ever been found positive in both an initial and confirmatory HIV test was considered HIV-positive. All patients with unknown HIV status were invited to undergo HIV testing and counselling. Antiretroviral therapy was provided to all patients with TB and HIV co-infection. Treatment with second-line anti-TB drugs was offered to those patients found to have drug-resistant TB during the course of the survey, as per national guidelines.4
Ethics approval
The Ethics Committee of the Republican Scientific and Practical Centre for Pulmonology and Tuberculosis, in Belarus, reviewed and approved the survey protocol.
Laboratory methods
Each participant who consented to participate in the survey was requested to provide two sputum samples. One sample was smeared and then checked for acid-fast microorganisms by direct microscopy at a health centre, after Ziehl–Neelsen staining. The other sample was cultured on BACTEC MGIT 960 (Becton Dickinson, Sparks, United States of America)10 and/or on solid Lowenstein–Jensen medium at one of eight TB laboratories (i.e. one in each of the six oblasts that form Belarus, one serving the country's penitentiary system, or the National TB Reference Laboratory). The drug susceptibility of every successful isolate of M. tuberculosis was then investigated at the National TB Reference Laboratory by using BACTEC MGIT 960 supplemented with isoniazid (0.1 μg/ml), rifampicin (1.0 μg/ml), ethambutol (5.0 μg/ml) or streptomycin (1.0 μg/ml). The isolates found to be multidrug-resistant were then tested for resistance to second-line anti-TB drugs10,11 with BACTEC MGIT 960 supplemented with kanamycin (2.5 μg/ml), amikacin (1.0 μg/ml), capreomycin (2.5 μg/ml) or ofloxacin (2.0 μg/ml). An MDR-TB isolate that showed resistance to ofloxacin and at least one of the injectable drugs used for second-line treatment (i.e. amikacin, kanamycin and/or capreomycin) was considered to be an extensively drug-resistant (XDR) isolate. Random samples of isolates (25% of those found to be resistant and 10% of those found to be susceptible) were sent to the Supranational Reference Laboratory in Stockholm, Sweden, for retesting. The results of the retesting showed either 100% agreement with the data recorded in Belarus (isoniazid, rifampicin, streptomycin, ofloxacin and capreomycin) or 90–100% agreement (amikacin and kanamycin), depending on the drug involved.
ELISA-HIV-1,2-AT (ECOlab, Moscow, Russian Federation), a commercial enzyme immunoassay, was used for HIV screening and a commercial immunoblot assay (Blot-HIV-1; ECOlab) was used to confirm the positive results of the screening.
Data analysis
Data were double-entered into version 3.5.1 of the EpiInfo software package (Centers for Disease Control and Prevention, Atlanta, USA) and analysed using version 12.0 of the Stata package (StataCorp. LP, College Station, USA). Pearson's χ2 statistics or two-sided Fisher's exact tests were used for the comparison of categorical variables, as appropriate. In all the analyses, a P-value of < 0.05 was considered indicative of a statistically significant difference or association. Univariate and multivariate analyses were performed by logistic regression. All determinants whose P-value in the univariate analysis showed statistical significance were included in the multivariate analysis. Confounding effects were checked using backward regression analysis (a cut off P-value of < 0.05 was used to exclude variables from the model). The contribution made to the model by each variable was evaluated using likelihood ratio χ2 tests. All CIs and P-values were corrected for the finite population.
During the intake period of the survey, 1420 patients with sputum-smear-positive pulmonary TB were eligible for enrolment (Fig. 1). No patient was excluded because of refusal to participate in the study. Most (94.6%) of those eligible for enrolment were included in the final analysis. Of the 1344 patients who were enrolled (934 newly diagnosed cases and 410 patients with a previous history of TB treatment), 1075 (80.0%) were male and 1293 (96.2%) were born in Belarus. The median age of those enrolled was 46 years (range: 15–91). Additional characteristics of the study population are shown in Table 1.
Fig. 1. Selection of the population included in a study of multidrug resistant tuberculosis in Belarus, 2010-2011
Table 1. Characteristics of patients enrolled in a study of multidrug-resistant tuberculosis, Belarus, 2010–2011
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As shown in Table 2, MDR-TB and XDR-TB were detected in 612 (45.5%) of the enrolled patients and 73 (11.9%) of the patients with MDR-TB, respectively (Table 3). When categorized as the capital city or one of the six oblasts, the region of residence affected both the prevalence of MDR-TB among the enrolled patients (range: 33.5–56.7%) and the prevalence of XDR-TB among the enrolled patients with MDR-TB (range: 7.1–27.5%). The patients enrolled in the penitentiary system and the health-care centres in Gomel Oblast showed both the highest prevalences of MDR-TB (60.0% and 56.7%, respectively) and the highest prevalences of HIV among the patients with MDR-TB (23.8% and 23.7%, respectively).
Table 2. Resistance to first-line drugs in Mycobacterium tuberculosis isolates, Belarus, 2010–2011
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Table 3. Resistance to second-line drugs in multidrug-resistant Mycobacterium tuberculosis isolates, Belarus, 2010–2011
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MDR-TB was found in 302 (32.3%) of the 934 new TB cases who were enrolled in the survey, and 23 (7.6%) of the 302 were found to have XDR-TB. Of the 410 enrolled patients who had had previous treatment for TB, 310 (75.6%) had MDR-TB and 50 (16.1%) of the 310 were found to have XDR-TB. Additional information on resistance patterns to first- and second-line anti-TB drugs is shown in Table 2 and Table 3, respectively.
As indicated in Table 4, a history of previous treatment for TB was the strongest independent risk factor for MDR-TB (odds ratio, OR: 6.1). Several additional factors were found to be independently associated with the risk of MDR-TB in the multivariate analysis. An age of ≥ 35 years at diagnosis was negatively associated with MDR-TB (OR: 0.7). Patients with a history of imprisonment had a statistically significant increased risk of MDR-TB (OR: 1.5), like those who were disabled in such a way as to be unable to work (OR: 1.9), alcohol abusers (OR: 1.3) and smokers (OR: 1.5). Finally, the multivariate analysis showed that HIV co-infection was a strong, independent risk factor for MDR-TB in Belarus, with an OR of 2.2. Associations between MDR-TB and sex, country of birth, education, size of household and living conditions were not found to be statistically significant.
Table 4. Risk factors for multidrug resistance among tuberculosis cases, Belarus, 2010–2011
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Although regression analyses were conducted to explore the risk factors for XDR-TB, the number of XDR-TB patients enrolled was too small to allow the detection of any meaningful association.
In this manuscript we report the results of the first national survey of TB drug resistance in Belarus. The results show that the alarming levels of drug-resistant TB recently detected in Minsk5 are not confined to the capital city but are widespread throughout the country. The prevalence of MDR-TB detected among the new smear-positive cases enrolled in the nationwide survey (32.3%) is similar to the corresponding values previously reported in Minsk city (35.3%)5 and the neighbouring Pskov Oblast in the Russian Federation (28.0%).12 This high level of MDR-TB among new TB cases indicates enormous on-going transmission of resistant strains of M. tuberculosis in the community. The fact that an age of < 35 years was found to be an independent positive risk factor for MDR-TB supports this hypothesis, as younger generations are more likely to get TB by transmission rather than by re-activation of M. tuberculosis.1,13 As, unfortunately, the extent of transmission of resistant strains could not be assessed in the present study, further studies based on genotyping should be conducted. In addition to the lack of genotypic data, the present study was limited by the exclusion of sputum-smear-negative TB patients and patients with unknown smear results. The decision to exclude such patients was taken following WHO guidelines, to prevent the network of TB laboratories being overloaded. Although the overall conclusions of the survey should not have been affected, the exclusion of patients with sputum-smear-negative TB may have resulted in an enrolment bias against patients with HIV, who are more likely to have smear-negative TB, and consequently led to an underestimate of the burden posed by TB–HIV co-infection. Another limitation of this study is that all of the data on education, living and employment conditions, history of imprisonment, use of alcohol and smoking history that were used for identification of risk factors were reported by the enrolled patients and could not be verified. Finally, although extensive efforts were made to implement the survey carefully, the possibility of minor reporting errors cannot be ruled out.
The very high prevalence of MDR-TB found in our study is probably a reflection of the generally poor management of patients with TB in Belarus and other countries of the former Soviet Union14,15 over several decades. The barriers to effective management of TB in such countries often include a poorly structured laboratory network for the diagnosis of TB; the use of non-standardized treatment regimens; prolonged treatment in hospitals that have poor infection control; failures in the directly observed treatment of TB cases, with insufficient patient support; the intermittent supply of anti-TB drugs, and little, if any, monitoring of control programme performance by the cohort analysis of treatment outcomes. Although TB control in Belarus has recently improved, several factors that can fuel the emergence of drug resistance remain. These include the suboptimal management of patients in outpatient facilities, which results in interrupted treatment in many cases;1 the absence in several parts of the country of rapid molecular tests for the early diagnosis of drug resistance, and inadequate infection control measures, particularly in hospitals and dispensaries.16
One of the most striking findings of the present study was that the majority of TB patients in Belarus who have had previous treatment for the disease have MDR-TB. This finding, similar to an observation made in Minsk,5 indicate that the common practice of re-treating TB cases with only first-line drugs will generally be ineffective in Belarus.4
In the epidemiological situation described, to avoid the further spread of drug-resistant strains and provide all patients with the most appropriate treatment regimen, it is imperative to implement a series of measures. First, molecular diagnostic tests, such as line probe assays17 and Xpert MTB/RIF,18 should rapidly be introduced throughout Belarus so that all patients with TB can be quickly screened for drug resistance at the time of diagnosis. Second, more effective infection-control measures should be established to prevent, or at least to reduce, the nosocomial spread of drug-resistant strains of M. tuberculosis. These measures should include limiting hospitalization to infectious cases only and strengthening outpatient services. Since most patients enrolled in the present study were found to live in small households, have satisfactory accommodation and have a good level of education, it seems reasonable to assume that many or all of the patients with non-contagious TB, who are currently being hospitalized for very long periods of time, could complete their treatment as outpatients or via other forms of ambulatory care. Third, given that nearly half (49%) of the patients enrolled in this study declared themselves unemployed and over half (57%) admitted to at least one episode of binge drinking in the previous month, a strong and patient-centred system of incentives and enablers should be made available. This system should be designed to support adherence to treatment, particularly after discharge and among patients at greater risk of default.
The importance of socioeconomic determinants and other potential risk factors in the development of TB has been reiterated in numerous publications.19–24 In the present study, in addition to a history of previous TB treatment and young age, several factors independently associated with MDR-TB were identified. For example, HIV-positive TB cases were found to have a significantly higher risk of MDR-TB than their HIV-negative counterparts. The overlapping of the HIV and MDR-TB epidemics is increasingly being documented in eastern Europe25,26 and is cause for concern because, compared with MDR-TB on its own, MDR-TB with HIV co-infection requires more complex patient management and is associated with fewer treatment options, poorer treatment outcomes and greater disease transmission. In the present study, smokers and those who abused alcohol also showed significantly increased risks of MDR-TB. Alcohol abuse and alcohol use disorders are known to play a role in the development of TB as well as in the outcomes of TB treatment.27,28 However, the link between alcohol and MDR-TB may not be a direct causal relationship; instead, MDR-TB may be the result of interruptions in treatment, which are themselves attributable to the sociobehavioural problems of TB patients who regularly abuse alcohol.29,30 The integration of alcohol screening and treatment of alcohol-use disorders with clinical services for TB has been piloted in Estonia and the Russian Federation.30,31 If shown to be feasible and cost-effective, such integration should be implemented in other settings to improve the outcomes of TB treatment and reduce disease transmission. Although why smoking should increase the risk of MDR-TB among TB patients remains unclear, it seems possible that patients who smoke are likely to make other poor decisions with regard to their health, including being non-adherent to TB treatment.32
Patients with a history of imprisonment were also found to have a significantly increased risk of MDR-TB, as reported in three previous studies.26,33,34 Finally, self-reported disability that was severe enough to prevent work was also positively associated with MDR-TB. However, this apparent association may be an artefact produced by the social security system in Belarus, which categorizes those who are receiving extended treatment for MDR-TB as disabled.
The levels of MDR-TB documented in Belarus are among the highest ever recorded globally. In light of these findings, rapid testing for drug resistance for all patients with TB, a revised treatment regimen for patients with a history of previous TB treatment, an uninterrupted supply of second-line drugs, and measures to reduce the nosocomial transmission of M. tuberculosis, including the shortened hospitalization of non-contagious patients, should be rapidly introduced. Furthermore, the positive association between MDR-TB and HIV infection observed in this study calls for stronger collaboration between TB and HIV control programmes to provide greater support to co-infected patients. To improve TB treatment adherence and reduce opportunities for the development of MDR-TB, the integration of treatment for alcohol use disorders with TB services and the strengthening of patient incentives and enablers should also be explored.
This study was supported by the United States Agency for International Development through a grant to the World Health Organization, and by the Global Fund to Fight AIDS, Tuberculosis and Malaria.
Competing interests:
None declared.
- Global tuberculosis control. Geneva: World Health Organization; 2012 (WHO/HTM/TB/2012.6).
- Zignol M, van Gemert W, Falzon D, Sismanidis C, Glaziou P, Floyd K, et al., et al. Surveillance of anti-tuberculosis drug resistance in the world: an updated analysis, 2007–2010. Bull World Health Organ 2012; 90: 111-119D doi: 10.2471/BLT.11.092585 pmid: 22423162.
- International standards for tuberculosis care. The Hague: Tuberculosis Coalition for Technical Assistance; 2006. Available from: http://www.who.int/tb/publications/2006/istc_report.pdf [accessed 22 October 2012].
- Clinical guidelines on tuberculosis management. Minsk: Ministry of Health; 2009. Russian.
- Skrahina A, Hurevich H, Zalutskaya A, Sahalchyk E, Astrauko A, van Gemert W, et al., et al. Alarming levels of drug-resistant tuberculosis in Belarus: results of a survey in Minsk. Eur Respir J 2012; 39: 1425-31 doi: 10.1183/09031936.00145411 pmid: 22005924.
- Guidelines for surveillance of drug resistance in tuberculosis. 4th ed. Geneva: World Health Organization; 2009 (WHO/HTM/TB/2009.422).
- Treatment of tuberculosis guidelines. 4th ed. Geneva: World Health Organization; 2009 (WHO/HTM/TB/2009.420).
- DSM-IV: diagnostic and statistical manual of mental disorders. Washington: American Psychiatric Association; 1994.
- Mulia N, Schmidt LA, Ye Y, Greenfield TK. Preventing disparities in alcohol screening and brief intervention: the need to move beyond primary care. Alcohol Clin Exp Res 2011; 35: 1557-60 pmid: 21599711.
- Krüüner A, Yates MD, Drobniewski FA. Evaluation of MGIT 960-based antimicrobial testing and determination of critical concentrations of first- and second-line antimicrobial drugs with drug-resistant clinical strains of Mycobacterium tuberculosis. J Clin Microbiol 2006; 44: 811-8 doi: 10.1128/JCM.44.3.811-818.2006 pmid: 16517859.
- Rüsch-Gerdes S, Pfyffer GE, Casal M, Chadwick M, Siddiqi S. Multicenter laboratory validation of the BACTEC MGIT 960 technique for testing susceptibilities of Mycobacterium tuberculosis to classical second-line drugs and newer antimicrobials. J Clin Microbiol 2006; 44: 688-92 doi: 10.1128/JCM.44.3.688-692.2006 pmid: 16517840.
- Tuberculosis in the Russian Federation 2010. Moscow: Ministry of Health; 2011. Russian.
- Brooks-Pollock E, Cohen T, Murray M. The impact of realistic age structure in simple models of tuberculosis transmission. PLoS One 2010; 5: e8479- doi: 10.1371/journal.pone.0008479 pmid: 20062531.
- Atun R, Olynik I. Resistance to implementing policy change: the case of Ukraine. Bull World Health Organ 2008; 86: 147-54 pmid: 18297170.
- Floyd K, Hutubessy R, Samyshkin Y, Korobitsyn A, Fedorin I, Volchenkov G, et al., et al. Health-systems efficiency in the Russian Federation: tuberculosis control. Bull World Health Organ 2006; 84: 43-51 doi: 10.2471/BLT.04.018705 pmid: 16501714.
- Skrahina AM, Astrauko AP, Kalechic OM, Zalutskaya OM, Klimuk DA. Overview of possible infection control measures to reduce nosocomial transmission of TB in hospitals. Presented at the: Conference on modern health care technologies in diagnosis, treatment and follow up of patients with tuberculosis; 7–8 June 2012; Minsk, Belarus. Russian.
- Skenders G, Fry AM, Prokopovica I, Greckoseja S, Broka L, Metchock B, et al., et al. Multidrug-resistant tuberculosis detection, Latvia. Emerg Infect Dis 2005; 11: 1461-3 doi: 10.3201/eid1109.041236 pmid: 16229783.
- Boehme CC, Nabeta P, Hillemann D, Nicol MP, Shenai S, Krapp F, et al., et al. Rapid molecular detection of tuberculosis and rifampin resistance. N Engl J Med 2010; 363: 1005-15 doi: 10.1056/NEJMoa0907847 pmid: 20825313.
- Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M. Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Soc Sci Med 2009; 68: 2240-6 doi: 10.1016/j.socscimed.2009.03.041 pmid: 19394122.
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- Lönnroth K, Castro KG, Chakaya JM, Chauhan LS, Floyd K, Glaziou P, et al., et al. Tuberculosis control and elimination 2010–50: cure, care, and social development. Lancet 2010; 375: 1814-29 doi: 10.1016/S0140-6736(10)60483-7 pmid: 20488524.
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- Dubrovina I, Miskinis K, Lyepshina S, Yann Y, Hoffmann H, Zaleskis R, et al., et al. Drug-resistant tuberculosis and HIV in Ukraine: a threatening convergence of two epidemics? Int J Tuberc Lung Dis 2008; 12: 756-62 pmid: 18544200.
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- Rehm J, Samokhvalov AV, Neuman MG, Room R, Parry C, Lönnroth K, et al., et al. The association between alcohol use, alcohol use disorders and tuberculosis (TB): a systematic review. BMC Public Health 2009; 9: 450- doi: 10.1186/1471-2458-9-450 pmid: 19961618.
- Lönnroth K, Williams BG, Stadlin S, Jaramillo E, Dye C. Alcohol use as a risk factor for tuberculosis – a systematic review. BMC Public Health 2008; 8: 289- doi: 10.1186/1471-2458-8-289 pmid: 18702821.
- Mathew TA, Yanov SA, Mazitov R, Mishustin SP, Strelis AK, Yanova GV, et al., et al. Integration of alcohol use disorders identification and management in the tuberculosis programme in Tomsk Oblast, Russia. Eur J Public Health 2009; 19: 16-8 doi: 10.1093/eurpub/ckn093 pmid: 19112073.
- Greenfield SF, Shields A, Connery HS, Livchits V, Yanov SA, Lastimoso CS, et al., et al. Integrated management of physician-delivered alcohol care for tuberculosis patients: design and implementation. Alcohol Clin Exp Res 2010; 34: 317-30 doi: 10.1111/j.1530-0277.2009.01094.x pmid: 19930235.
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- Ruddy M, Balabanova Y, Graham C, Fedorin I, Malomanova N, Elisarova E, et al., et al. Rates of drug resistance and risk factor analysis in civilian and prison patients with tuberculosis in Samara Region, Russia. Thorax 2005; 60: 130-5 doi: 10.1136/thx.2004.026922 pmid: 15681501.
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text:
Volcom gray shirt from Cut Bank seen with Liam Hemsworth (Dwayne McLaren)
As Seen on Dwayne McLaren (Liam Hemsworth) in Cut Bank
COUNTRY HEARTTHROB: Welcome to Cut Bank, Montana, land of flannel shirts, cowboy hats, and handsome country heartthrob Dwayne (Liam Hemsworth). But when he becomes the star witness to the town's first murder, his quiet life in the country starts to unravel. In this noir crime thriller, Dwayne keeps a low profile in sneakers and jeans as he tries to pick up the pieces.
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Star Wars Travel Posters
Dream of a Galaxy Far, Far Away With Star Wars Planet Travel Posters
Some vagabonds plaster images of far-off locales on their walls as a representation of their travel "bucket list," but being the ultimate Star Wars fanatic, the sad fact is you'll never get to step foot onto Hoth or Tattooine in real life. Visiting a few of the actual Star Wars filming locations will have to suffice until science figures out that whole warp speed thing. In the meantime, you can adorn your walls with these retro-style Star Wars travel posters. For just $19 each, you can daydream about visiting the woodsy world of Endor or the secluded desert planet of Tatooine, all while sprucing up your apartment.
Each poster is clean and simple, which means it doesn't scream "geek," but those who know Star Wars will appreciate its artful style. Get a closer look at each poster (plus a bonus graphic illustration that's just plain cool) in the slideshow!


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Celebrated California Artist/Chef Wendy Brodie is known for her creative style with food, presentation and table decor. In fact, she is often described as an artist whose medium is food.
With her husband, Bob Bussinger, CHA, Brodie was co-owner of Lincoln Court Restaurant in Carmel, which had become a very popular local restaurant, which generated outstanding reviews (see press page).
She has her own local weekly television show, "Art of Food," broadcast daily on Comcast cable and is also viewed weekly on Public Television stations nationwide in the United States and Canada.
A graduate of the first class of the California Culinary Academy of San Francisco, Brodie has held executive chef positions at prestigious world-class resorts, including the Preserve at Rancho San Carlos, where she developed her own innovative style of ranch cuisine, Stonepine Inn and Gardiner's Tennis Ranch, all in Carmel Valley.
Brodie, who was born in San Francisco and grew up there and in Palo Alto, has written food columns, lectured and demonstrated cooking and tabletop designs at such venues as Filoli Center, Macys, Bloomingdale's and Neiman Marcus.
She has been a guest chef, developing menus to represent California cuisine, at numerous four and five-star hotels in Europe and the Jockey Club in Hong Kong. Wendy has sailed with the Crystal Cruise Line as their Celebrity Guest Chef.
She has cooked for and with numerous celebrity chefs including Julia Child, Jacques Pepin, Roy Yamaguchi, Paul Prudhomme and Martha Stewart. She has also been a guest chef at the Masters of Food and Wine in Carmel and the Monterey Wine Festival. She is one of the featured chefs in the Masters of Food and Wine cookbook.
In 1991 Brodie was selected to attend Madeleine Kamman's graduate program at the School for American Chefs at Berringer Wine Estates and has been inducted as an honorary member of the American Academy of Chefs of the American Culinary Federation. She was awarded the 1982 Chef-of-the-Year of the Monterey Peninsula. Currently she gives classes of her artful style with food, table décor and entertaining in her demonstration kitchen in the Carmel Highlands. She also teaches cooking classes as team-building and spousal programs.
Brodie is affiliated with The Confrerie de la Chaine des Rotisseurs, Les Toques Blanches, Knights of the Vine, American Institute of Wine & Food, International Wine and Food Society, American Culinary Federation and has been an officer and board member of several of them.
She also operates Art of Food Catering, which handles all styles of groups and events. Wendy appears as guest chef throughout the U. S. and other countries. She consults for home kitchen design, for businesses menu development and is personal kitchen shopper.
Wendy's father is Howard Brodie, a Who's Who artist journalist who covered World War II, Korea and Vietnam in the battlefield with pencil and paper. He also covered the most sensational trials of the 20th Century with CBS Evening News with Walter Cronkite. He was recently elected to the Illustrators Hall of Fame, along with Norman Rockwell, Winslow Homer, Gibson Maxfield Parrish, N.C. Wyeth and others. Brodie covered WW II for Yank Magazine, Korean War for Collier's and Vietnam for CBS. He taught for several decades and was on the board of directors at the California Academy of Art in San Francisco.
The first restaurant: (1972) Esperanto, a coffeehouse/bistro in Carmel, which was very popular among locals. Clientele comprised of all segments of Peninsula society from actors and musicians to politicians and community leaders.
General Manager: (1976) General Store and Forge in the Forrest; at its infancy acquired the liquor license and operated full lunch and dinner service as well as full bar.
Food Service Director: (1978) Lodge at Pebble Beach; along with the chef and beverage manager oversaw all the food service at the various venues, particularly the Cypress Room and Tap Room. Oversaw initial set-up of the Galley restaurant and participated in the many discussions which eventually led to the development of the Spanish Bay Resort.
Vice President/General Manager: (1979) Ventana Big Sur, achieved 4-star status for the restaurant in 1981 and at the Inn in 1983. Operated under the original owner for about a year after which Transamerica Corp. purchased the property. Received the designation of Vice President/General Manager and operated the inn, restaurant, gift shop, campground, service station, deli, bakery as well as housing for employees. Advanced the property from 24-rooms and a sad reputation of service to world-class recognition and the title of "Most Romantic Inn in the World" (Conde Nast and Harper's Hideaway Report). Shepherded the process of development procedures through the California Coastal Commission and Monterey County Planning for over 9-years to completely build out to the existing 62-rooms and expanded the dining room as well as added cabins and units for 120 employees. I resigned in 1995 to pursue consulting and personal ventures.
Co-owner/President: (1995) Hospitality Consultants International. With his wife Executive Chef Wendy Brodie, HAAC, established a consulting firm for small hotels, restaurants and spas. Clients encompassed areas of California, the Northwest, Germany, Hong Kong and Switzerland. Assisted in site development, operations and general management. Had experience in the turn-around of a resort in Washington State. Took command of total operation and evaluated personnel and systems. Made changes to systems, created new ones and trained or replaced management staff. In Oregon worked with a landowner to design and develop a new hotel. Developed pro-forma for staffing plan, operating systems and budget as well as design and décor of the rooms and public space, which included food service, spa and sports activities center.
Co-owner: (2000) Lincoln Court Restaurant. With his wife, Executive Chef Wendy Brodie, HAAC and son, Chef D. Michael Bussinger established and operated a fine dining restaurant in Carmel. Received numerous editorial praises throughout the community and received referrals from all over the country. Sold the restaurant to pursue Wendy's T.V. cooking show, Art of Food TV®.
Producer/Manager: (2003) Art of Food® and Lincoln Court Catering. Art of Food® is a half-hour TV cooking and lifestyle show broadcast weekly on PBS throughout the United States and Canada as well as every day on Comcast Cable.
Robert also develops clientele and administers high-end catering and cooking classes done by Wendy Brodie.
Robert also hosted a weekly one-hour radio talk-show for four years (1991-1995) on Public Radio. He interviewed guests in all areas of food and wine; from growers, chefs, winemakers, authors etc. He had guests such as local chefs and farmers as well as Julia Child, Jacques Pepin, Charlie Trotter and many more.
Robert has been a founding board member of the local chapter of the American Institute of Wine and Food, Monterey County Hospitality Association, Monterey County Restaurant Association and the Big Sur Chamber of Commerce (past president). A Board Member of the Monterey Peninsula Chamber of Commerce and VCB, Pacific Repertory Theater (past president), the International Wine and Food Society (president), Monterey Bay Advertisers Association (past vice-president) and chair of the marketing committee for the Monterey Museum of Art's capital campaign for the Dart Wing at La Mirada.
Robert's long term residence and strong public image on the Monterey Peninsula has allowed him to develop friends and acquaintances throughout the community in every strata of society.


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Eggless Bread Pudding / Caramel Bread Pudding
A very Happy New Year to all my readers!!
It's been really a long time I have not posted anything on my blog...Life is really busy with work, commitments and unscheduled holiday trips!! :).. It's not that I haven't missed my blog or my personal space with you all but I had to prioritize other works at that point of time which were important. Even now also I have piled of works but couldn't resist myself to share my feelings with you all!
How have you been all these days" How was your Christmas, Year End and New Year celebrations" Do you have any new resolutions this year "" Or you just wanna go with the flow ;)...I think the second one is very easy to follow which does not give you much stress...Isn't it"
Celebrations are incomplete without sweet so today's post is all about an easy eggless pudding recipe. I am sharing the recipe of Eggless Bread Pudding or Caramel Bread Pudding Recipe. You don't need any fancy gadget for this simple recipe. You can prepare this pudding using your leftover breads too. You can avoid adding caramel to your pudding if you don't want to eat too much sweet. But personally I would recommend to add it because caramel gives a completely different taste and texture to your pudding.
Eggless Bread Pudding / Caramel Bread Pudding
Bread Slices - 4 to 5Milk - 3/4 to 1 cupSugar - 5 to 6 tablespoons (according to the sweetness you prefer)Sugar for caramel - 2 to 3 tablespoonVanilla Essence - 1//2 teaspoonRefined oil - one or two drop for greasingAluminium foil Procedure
1. Tear the breads into small pieces and keep it in a bowl. Now add milk into it and allow to soak. Be careful while adding milk too much milk will make the bread mixture runny and watery. Pour little milk at a time and till the amount breads are soaked properly.
2. Keep the vessel ready by greasing it with little oil.
3. Heat a pan with 2 tablespoon of sugar and little water. Keep it stirring on medium heat to avoid burning. After sometime the colur starts changing and turn into dark golden yellow.
4. Caramel is ready now. Pour it into the prepared vessel. Tilt the vessel to coat the bottom properly. Allow it to set for 3 to 4 minutes.
5. Next add the bread mixture on top of the caramel coating and spread evenly. 6. Now cover the vessel with a aluminium foil and make holes on the top of the aluminium sheet by pricking to pass on the steam.
7. Fill a pressure cooker (I used 3 litre pressure cooker) with 1 cup of water and place the vessel inside it on a stand. Close the lid of the cooker without using the gasket and the whistle/weight valve. Steam it for 25 to 30 minutes.
8. Now switch off the gas and take out the vessel. Allow it to cool and refrigerated for at least 2 to 3 hours.
9. Remove the aluminium foil. Before inverting the vessel use a sharp knife to remove the sides of the pudding from the wall of the vessel. Do it carefully.
10. Take a plate and ...
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It's hot and hazy
I feel like Alonzo Spellman when he went crazy
Hitchhiking in a hospital gown
Until Samurai Mike came and cooled him down
Man, Maureen made a real nice spread
Cole slaw, kabobs, noodles and deviled eggs
I feel like The Fridge when he met Reagan
Filet mignon, baked potato, sour cream and bacon
I haven't felt this way since Superbowl Twenty
Or that time I met the Beringers outside of Ricobene's
Ozzie Guillen
Ozzie Guillen
I swear O'Douls never made me feel like this
Dancing to Phil Collins, loose by the hips
I feel like Willie Gault, normally I'm Steve Fuller
It's not my fault that I knocked over the cooler
The meat's from Moo and Oinks in the dirt, wash it off
Raise up your flame and put on some extra 'que sauce
I keep whizzing, I keep eating all the chicken
I jumped in the pool with Maureen's dog Mittens
I'm sopping wet
My Zubaz are off
My Brooks are so heavy
Ozzie Guillen
Ozzie Guillen
Ozzie Guillen
Man, O'Douls is making me tired
My Craig Hodges jersey is dirty
My shorts are in the dryer
I feel like Mongo in '86 in his suite
Hanging out with McMahon after the Bears got beat
Or Lee Smith when they lost to the Padres
Or when "Hawk" Dawson got hit in the face and got dazed
I still don't forgive Eric Show to this day
Or Scottie Pippen when told Phil he wouldn't play, like
Ozzie Guillen
Oh, you gonna let Toni Kucoc take the last shot?
Ozzie Guillen
I lost to a kid in checkers
And if I drive home this way call Victory Auto Wreckers
Now it's night and I'm sleeping on Maureen's hood
Sleeping on a Thunderbird with no shorts don't feel good
Jueles has my keys and folded up my dry shorts
She opens up the Fiero and I hop in head first
Juelie, my Brooks are soaking wet
My O'Douls just didn't taste right
Jueles said "Hey Kenny," I said "Yeah"
She said "Kenny baby, you know you were drinking Bud Light?"
I said "What?"
Ozzie Guillen
Ozzie Guillen
Ozzie Guillen
(Good job with the noodles, Maureen.)
Ozzie Guillen


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SCN NEWSLETTER: WEEK of 01/18-01/22 Releases
New This week:
4 new products this week. 2010 Wheels Elements will be the first product with Danica and also $25 and $100 Cash vouchers inside the boxes. Should be an interesting concept and should sell well based on recent Press Pass racing releases. 2009/10 UD SPX HK should also be a consistant seller especially with the Rookie Auto Patches of Tavares. With UD 1, Artifacts and Black Diamond all well over factory cost, SPX HK should make a nice run higher. The main focus this week is on the Rookie based products. 2010 UD USA Team Baseball sets are Loaded. With 7 Auto's per Box and all the Hype around Bryce Harper, this product has a much better price point than last year at about 1/2 the direct cost. Early auctions show Harpers Auto Patches going for $600-$1000+. Anytime you have 1 card that can sell for over the Case price, the product will do well. There should be alot of other players coming out of this set also over the next few years. There are only 650 cases made. This would be an extremely small number for a $2000+ case but for a Case that costs less than $700 direct, these will dissapear quickly. Put a case away and see what comes out of it years from now.
2009 Donruss Elite Extra Edition Baseball is what you call "Bang for your Buck". Panini loaded every box with at least 6 AUTOS and Hot Boxes will contain 10 AUTOS ! Tons of parallels, Die cuts, Patches. There are so many elements in this break that have value. This product will continue to move higher.
TIDBITS of NEWS:
A few things we are hearing. UD has announced they are sold out of 2009 UD Ultimate Collection BB and 2010 UD Series 1 BB at the factory. UD will have a National pack promotion on Sat. March 6th. Strasburg will headline the Autos in 2010 Bowman BB. Aroldis Chapman from Cuba already has Autos in 2009 Elite Extra. Also watch out for many of the Base Rookies in Elite extra that are #'dd to 99. If any of them get HOT, those cards will be the most sought after around. Panini released The Souvenir Cuts Checklist along with print runs for Elite Extra BB and Contenders College Tickets SP's. UD has made plans to produce 2010 Baseball products that are not licensed by MLB but collectors will deterimine the true value or collectability. Those products start with 2010 SPX, SP Authentic and Goudey. Imagine if the UD products sell better than the Topps Licensed products in 2010. That could open up a whole new can of worms with Manufacturers not needed a league license to produce cards. It would also open up the playing field for any small company to produce trading cards. It all comes down to the collectors and what you decide to purchase. That's where the power lies. Pierre garcon Rookies in 2008 are on the move higher. 2010 Topps National Chicle Baseball could be a surprise release with upside based on the painting card concept and fresh new ideas that remind us of the original A & G BB and T-206 releases. The Industry Trade summit is planned for April 11-24th in Las Vegas. This replaces the Hawaii Trade show. There are already a few 2010 Topps Variations noted as the early breaks start to roll in. The Hobby version is live this week and Jumbos are pushed back til next week. Makes you wonder is Jumbos will have some sort of added twist. Everything we discussed can also be found in full depth articles on our homepage along with all the Market report Breakdowns. SportsCardNation.com. Market Reports, Card Values, and the Hottest Auctions Online today.
Products on the move higher:
2009 Topps Tribute BB, 2009 Topps UFC series 2, 2008 Donruss Elite Extra Ed BB, 2009 Bowman Draft Picks BB, 2008 Donruss Threads BB, 2008 UD SP Authentic BB, 2007 UD SP Legendary Cuts BB, 2009 Topps Triple Threads BB, 2009/10 Panini Limited bskt, 2009/10 UD Artifacts HK, 2007 UD Sweet Spot Classic BB, 2009/10 UD Black Diamond HK,2009/10 Bowman 48 bskt..
That's it for this week.
This week at SCN, we have reviewed the following products. Our goal is to give you the most up to date web site for market conditions and information in the HOBBY!
2010 Upper Deck USA Baseball
2010 Press Pass Wheels Element Racing
2009/10 UD SPX Hockey
2009 Donruss Elite Extra Edition Baseball
Looking into NEXT WEEK, the following products are Tentatively Scheduled to be Reviewed:
Yugioh Duelist Pack Yusei 2 Booster
2009 Topps National Chicle Football
2010 Topps Series 1 Baseball Hobby
WWE Slam Attax Evolution Trading Card Game Booster & Starter
2009 Playoff National Treasures Football
2010 Rittenhouse LOST Trading Cards
2009 Topps Sterling Baseball
2009 UD Signature Stars Baseball
2009/10 ITG Heroes & Prospects Hockey
2009 UD Ultimate Collection Baseball
SCN is your Source for Immediate Sportscard Information. When a player gets HOT or when a
Product JUMPS in value, SCN will showcase all the Auctions so that YOU the collector will have
all the information available within seconds.
Stay tuned for more announcements !
-The Staff at SCN
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Pumpkin Surprise Muffins
From Sarah Lipoff, LilSugar
- For the Muffins:
- 1 15-ounce can pumpkin puree
- 1/2 cup brown sugar
- 1/4 teaspoon vanilla
- 1/4 teaspoon cinnamon
- 2 eggs
- 1 tablespoon vegetable oil
- 1/4 cup plain yogurt
- 1 teaspoon baking soda
- 1 teaspoon baking powder
- 1 1/2 cup flour
- White sugar for dusting muffins (optional)
- For the Filling:
- 4 ounces room temperature cream cheese
- 1/4 teaspoon vanilla
- 1/4 teaspoon cinnamon
- 1/4 cup powdered sugar
- Preheat your oven to 375F. Invite your child to mix together the pumpkin puree, brown sugar, vanilla, and cinnamon, stirring until the mixture is nice and smooth.
- Carefully break the eggs and add to the pumpkin batter along with the vegetable oil and yogurt. Stir until the eggs are incorporated.
- Sprinkle in the baking soda and baking powder and then measure and add the flour to create a smooth pumpkin muffin batter.
- Lightly grease a muffin tin and then invite your child to place a big spoonful of the batter in each muffin cup. Along learning basic culinary skills, scooping the pumpkin mixture into the muffin tins encourages your tot's hand-eye coordination [2].
- To make the yummy surprise hidden in each pumpkin muffin, whip together the cream cheese, vanilla, cinnamon, and powdered sugar.
- Now your child can put a small spoonful of the creamy filling in the center of each muffin tin, evenly distributing the filling so each of the muffins has the same amount.
- Top each muffin with another dollop of the pumpkin batter covering the dollop of creamy filling.
- Bake the muffins for 22 to 25 minutes or until the tops have slightly browned. To create a sweet crust to the muffins, give each a sprinkle of sugar before placing in the oven to bake.
Makes 12 muffins
- Category
- Snacks


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InterLeague is Good For the Fan's Soul Joe
It is sometimes pretty rare for me to not go totally along with something Tampa Bay Rays Manager Joe Maddon says. Usually I am not above drinking the team's Kool Aid at times, particularly when it comes to some of their personnel moves.
But I have to take exception with one of Maddon's recent vocal oratories. I am all for the InterLeague format. Been on their bandwagon since the First Pitch, and will be an adamant supporter of it to its last swing. Even though I can side with some of Maddon's concerns, as a fan, InterLeague gives me a chance to see players and teams I would have to travel great distances to see in-person.
Sure it plays a bit of havoc on the Ray's already crowded 162-game schedule, but it has advantages that sometimes miss the mindset of the 30 dugout leaders of Major League Baseball. We all know without question Maddon's admiration and affection for a possible future balanced schedule. But it might not happen in MLB Commissioner Bud Selig's tenure.
Where else can a Manager have a chance to play devil's advocate with no pressure from the playoffs than at this juncture in mid-May and June. Suddenly they can insert, delete or even tinker without the worry of a 3, 5 or 7-game series hinging on their line-up card. Plus it gives the fans and added impact via opinions, blogs and even Twitter to voice their own preferences towards DH or non-DH starters in games.
The main appeal of InterLeague to me is still the match-ups that constantly revolve to give our American League team a chance to see budding superstars, aging stars and some part-time focus on things outside our AL-realm of thinking. The National League plays a different game at times than the power conscious AL.
For that reason alone it brings back into play the skill set and imagination of all 30 MLB Managers, their rosters potential, and also bring to light some of the obvious flaws we see even in a championship squad. The NL frame of mind is firmly planted into moving runners into scoring position and systematically ( hopefully) bringing the home in before the third out.
AL seems to play more wing and a prayer long ball with the potential of each pitch possibly bringing a victory. Put the two systems together and you get a massive human Chess match that can be dominated in a nano second by the more versatile club. But that is not the InterLeague's biggest drawing point to me.
I remember seeing Barry Bonds in the Trop a few years ago when the San Francisco Giants were not "World beaters". It brought a figure who was larger to life into the cool confines of the Trop when if not for InterLeague, Rays fans would have had to travel to the city by the bay, or go to an Arizona Spring game to see Bonds.
Take this season's match-ups of the 2010 surprising Cincinnati Reds and their budding superstar 1B Joey Votto and the return of former Rays fav Jonny Gomes since his exit from the Rays Republic. This match-up pushed together two equally matched teams on the hill with offenses that strive to score and produce at will at times. But in the Rays disadvantage is this is a home series where the team has been…well dreadful.
Or maybe you have the dates that the St. Louise Cardinals, who trained in these parts for over 25 years come back to the Trop and bring former Rays RP Trever Miller and some guy named Pujols. Tell me Sir Albert will not bring the Rays fans in droves to see a star that is still shining bright and hope to see a long ball deposited into the seats of the Trop. InterLeague makes these kind of meeting possibly outside the realm of the World Series. But maybe it was the quote in an article by the St. Petersburg Times where Maddon voiced his displeasure for this wild yearly adventure that evoked the most emotion from me.
Maddon was quoted in that article stating: " I Think in the beginning it was an idea that fans kind of got into and it was kind of interesting. I don't know that it's interesting any more."
Sorry to give you the news Joe, but it is relevant to us in the Rays Republic. We love seeing guys like Pujols, Votto and old friends like Gomes and Miller strut into the Trop and play creative baseball with our Rays. The most interesting thing here is that I finally found something to disagree with you on. That doesn't happen with regularity, just like the InterLeague season.
(Sitting at the Rays Watch Party at Courtside Grille as I submit this blog……Where are you?)


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Apple Releases Updated Mac OS X 10.5.7 Developer Beta, Build 9J56
Date: Thursday, April 23rd, 2009, 14:48
Category: News, Software
The Mac OS X 10.5.7 update, which appears to be close to release, went through yet another pre-release build late last week with developers working out additional tweaks for the operating system.
According to AppleInsider, build 9J56 focuses on "Bluetooth compatibility and stability fixes" per sources familiar with the software.
A number of recent Mac mini purchasers have complained about intermittent Bluetooth connection problems on their new systems, though similar problems are believed to be plaguing a variety of Macs.
Another fix in the latest build targets an issue with Personal File Sharing and AFP volumes not being properly recognized as Time Machine shares. However, the other three fixes were relatively minor, two of which add once-missing descriptive information to certain crash logs.
The Mac OS X 10.5.7 update is expected to offer more than 110 code corrections spanning over two dozen areas of the operating system. Earlier this month, Apple added Help Viewer to the list of key software components where beta testers should focus their testing efforts.
Though its believed that Mac OS X 10.5.7 remains close to release, Apple still notes that the software is incompatible with the public beta of Safari 4 — the OS update's lone known issue.


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© 2005 MLB Advanced Media, L.P. All rights reserved.
Lopez receives deserving All-Star nod
Young shortstop underwent grueling offseason preparation
By Kyle Jepson / Special to MLB.com
CINCINNATI -- Felipe Lopez began the season as a reserve on the Reds. Now he'll be a reserve on the National League All-Star squad. Lopez will be making his first appearance at the All-Star Game, to be held at Detroit's Comerica Park on Tuesday, July 12 at 8 p.m. ET. It will be televised nationally by FOX Sports and televised around the world by Major League Baseball International. ESPN Radio will provide exclusive, national radio coverage, while MLB.com will provide extensive online coverage and MLB Radio will provide exclusive play-by-play coverage of the game on the Internet. "Coming into the season, on Opening Day if you'd a said, 'We're going to have one guy make the All-Star team, who's it going to be?' [Lopez] probably would've been 20th on our list," manager Jerry Narron said. "To start the season and not be a starter, and to come on and make the All-Star team is just outstanding." To begin this season, Lopez wasn't even slated as the No. 1 shortstop on the team. Splitting time with Rich Aurilia, Lopez played well enough in Spring Training to be considered for the starting role. But come Opening Day, he was on the bench. Since then, he's become arguably the No. 1 shortstop in the National League. "I was excited," Lopez said of the All-Star bid. "It was a good feeling. I think I deserve the chance, and I'm honored to be picked." When the season began, Lopez admitted that an All-Star Game selection didn't even cross his mind. But that doesn't mean he's shied away from the nomination. "My goal is to, everyday, just keep grinding," he said. "In the past, I've tried to do too much, and it's too much pressure. ... I just [made sure I was] ready at all times. Even when I wasn't playing, I still stayed ready for whenever they gave me the chance." Lopez got that chance. And he wasted no time making it clear that he was ready for the spotlight. Lopez made the most of the scant playing opportunities he received in the season's first month. And by the time he launched his first career grand slam on April 27 in Chicago, it was becoming clear he deserved a regular spot in the lineup. It was only a matter of days after that. Back on May 4, Lopez was slotted into the starting lineup for good, but at second base. After Aurilia went down with a hamstring injury on May 11, Lopez became the team's regular shortstop. Even his current manager, and then-bench coach, Narron took notice of how fast Lopez took off.
Kyle Jepson is a contributor to MLB.com. This story was not subject to the approval of Major League Baseball or its clubs.


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Salt Marsh and Songbirds: Eco-Bike Adventure
1:00 Sat, May 26 - Mon, May 28, 2012
Venue: MA Eco-Bike Adventure
Newburyport, Newburyport, MA 01950Contact:
0 people saved this
Explore the vast richness of Massachusetts's Great Salt Marsh and national wildlife refuges on this three day guided bike tour through the Boston, MA North Shore. Discover a destination world famous for nature study, encompassing thousands of acres of salt marsh along with stunning beaches. The May eco-bike tour is timed to coincide with the return of songbirds to one of the finest bird-watching destinations in the eastern United States and the spring bloom of colorful native azaleas and rhododendrons. Pedal flat roads through a diverse habitat of barrier beaches, dunes, tidal salt marshes and coastal forests. Stay at the elegant Garrison Inn and explore fun, vibrant Newburyport and historic Ipswich. Please visit the website to learn more.
MA Spotlight on Carole Copeland Thomas
Enriching Multicultural Tourism in Massachusetts Carole Copeland Thomas is a thought leader and public speaker...
Search All Listings Here.


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JOHNS CREEK, Ga. — SarahCare at Johns Creek and at Powers Ferry are sponsoring an upcoming event to help seniors live well and keep families together longer.
Sarah Carson, an Alzheimer's Association family support programs manager, will teach families about Alzheimer's disease, its causes, risk factors, stages and treatment.
The event and dinner begins at 5:30 p.m. Oct. 15 at Norman's Landing restaurant, 365 Peachtree Parkway in Cumming.
SarahCare Adult Day Care Center, 4265 Johns Creek Parkway in Johns Creek, has been operating in the area since 2006.
Visit http://sarahcare.com/johnscreek for more information.


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All the way from here to there! Merry Christmas
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Joined IHG® Rewards Club at a Hotel?
Joining is easy and free
Earn points at over 5,200 hotels
Redeem points for free rooms and more
Contact your local IHG® Rewards Club Customer Care to source your PIN and to update your profile with your email address. When you receive your PIN you can also update your email address via www.ihg.com/updateemail.
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It's not everyday you get to skate the Volcom Warehouse, drink free beer (those over 21) and watch a video premiere all in the same day. Well, Bill Weiss and Digital Skateboarding made it all possible and premiered their new video entitled, Everyday, at the Volcom Warehouse on Tuesday November 25th. The skatepark was open from 7 to 9 p.m., as was the free booze area. Just by watching you were able to tell who was over and who was under. All the under-agers would v-line for the skatepark while us legalized drinkers kicked back and caught up on times.
EVERYDAY -- The Video
Everyday has a refreshing cast of Pros and Ams alike. Featured skaters included LBC's Evan Hernandez, New Expedition Pro Ryan Gallant, Russ Milligan, Joey Poiriez and Bryan Herman. The Almost Pro Ryan Sheckler also debuted on the big screen with a stellar first ever-street performance.
Everyday starts with the smooth skating of Evan Hernandez. Damn! You thought his TransWorld part was good, wait until you see this. Everyday ends with an "almost" perfect part from Ryan Sheckler. Ryan reminds me of a mix between a little Terminator and the Energizer bunny. He'll never stop destroying it and he keeps going and going and going... With those young legs, his potential is endless. At the young age of 29, it's hard to believe how talented Ryan actually is.
Everyday I'd like to watch the montages that Everyday has. Personally these are my favorite parts of the video. Amazing moves were being thrown down left and right at such a pace that I couldn't remember who was who. All I remember is that it left me wanting to go skateboarding-- and everyday since that's what I've done. I'm going to have to get a hold of Weiss and ask him for a copy (DVD- hint).
All the skaters seem to be down for the Digital Skateboarding crew. The list of contributing skaters alone tells you that, and along with the 300+ that showed to watch it insures that view. It's just skateboarding, and that's what they do. Another Picasso!
Too bad everyday couldn't be like the day Everyday was premiered.
Support your everyday habits and check out the Digital website. It's not fully finished yet, but peep it regardless. You'll soon be able order videos like Everyday everyday.


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Hot Melt Thickness Measurement with the MCT360 Gauge for Paper, Film, and Foil
Paraffin Wax is largely accepted as the first hot melt coating application. Polymer and copolymer resins brought a host of formulations for improved performance properties that continue to expand the horizons of Hot Melt applications.
Roll Coaters, Die Coaters, extruders, and doctor blade configurations are among the methods of applying hot melt adhesive. Roll coaters offer more flexibility than die application methods as they change over more quickly and allow for stripe coating. Die Coaters offer more precision across the web, especially in the 15 to 20 GSM. Hot melt applications of 100 GSM are very common and the range can go from 0-400 GSM.
Please click through here to view the Hot Melt Gauge Paper


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Berkshire Hills school district explores ways to streamline education
GREAT BARRINGTON -- Berkshire Hills Regional School District has been chosen as one of six public school districts to participate in a state pilot project aimed at boosting student learning by improving and streamlining labor-management communications.
Berkshire Hills joins Boylston, Fall River, Leominster, Malden and Springfield in participating in the new District Capacity Project (DCP), a program of the Massachusetts Education Partnership, which also launched this year.
The District Capacity Project is an education reform measure supported with experts from the Rennie Center for Education Research & Policy. The DCP is a two-year venture that will actively foster and facilitate collaboration between management, labor and school committee leaders.
"By participating in the DCP, we are building on our strengths by bringing teachers, administrators, School Committee and community members together to support student growth, close gaps and refine our professional practices," said Berkshire Hills Superintendent Peter Dillon.
Steve Estelle, president of the Berkshire Hills Education Association and a full-time math teacher at Monument Mountain Regional High School, is among the eight-member DCP leadership team formed by the district.
"From an association and education perspective, we can get stuck in the monotony of trying to solve the small stuff," he said. "This project encourages us to work together in a collaborative spirit. We haven't had enough time to do that in the past."
Each district DCP team is assigned a facilitator. Mary Ellen Shea of Amherst, a collective bargaining specialist, now serves Berkshire Hills.
In addition to a facilitator, who will offer bargaining techniques and coaching, DCP benefits include access to training institutes three times a year, bringing all six districts together, and participation in a statewide network of K-12 labor-management collaboration leaders.
Dillon said the team meets within the district every two weeks, and is currently developing a focus on how teams of teachers, staff, administrators and others can better collaborate to support student growth and success.
"This could be a horizontal team of second-grade math teachers working on Common Core curriculum, or it could be a vertical team of math teachers from pre-K through Grade 12," Dillon said as an example.
The goal for DCP school districts is to collaborate across groups to focus on a specific, pressing challenge based on their own local needs.
"It can be challenging to move beyond labor-management issues that, at their worst, create a paralyzing stalemate in some school districts," said Chad D'Entremont, executive director of The Rennie Center. "Berkshire Hills and other DCP participants were selected in part because of their demonstrated commitment and accomplishments in this difficult space."
D'Entremont said the strengths of the new labor-management initiative include the fact that all the work is done in-district, with support and access to resources from the Massachusetts Education Partnership.
He cited the recent labor conflict in Wisconsin and the Michigan right-to-work clash as examples of how labor and management negotiations can stall progress.
"There's a whole host of reforms happening in Massachusetts right now, from Innovation Schools to teacher evaluations, Common Core standards and a new assessment in development which will require people with competing agendas to find compromise," he said. "This is why the DCP is doing what it is. It's important to build capacity to take on reforms in a productive manner."
To reach Jenn Smith:
or (413) 496-6239
On Twitter: @JennSmith_Ink
If you'd like to leave a comment (or a tip or a question) about this story with the editors, please email us. We also welcome letters to the editor for publication; you can do that by filling out our letters form and submitting it to the newsroom.


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Stauffer struggles late in Padres' loss to Royals
Reliever gives up four eighth-inning runs; Hundley homers
By Dick Kaegel / MLB.com
SURPRISE, Ariz. -- Hot-hitting Nick Hundley belted a two-run homer in the first inning, but the Padres couldn't hold an early lead and lost to the Royals, 7-5, in a split-squad Cactus League game on Friday at Surprise Stadium.
The win improved the Royals' record to 16-2-1 after the first game of their day-night doubleheader.
Left-hander Will Smith had his roughest outing for the Royals, yielding five runs in four innings. Hundley tagged him for his homer in the first inning although all three runs in the inning were unearned.
"It was a first-pitch fastball, I was just trying to get a strike," Smith said. "It was up, belt-high and he did what he was supposed to do with it -- crushed it."
Hundley, who has a .469 (15-for-32) average, boosted his RBI total to seven in 12 games.
"I came in with a lot of confidence with the work I put in the offseason, but it's nice to see the results," Hundley said. "At the same time, if the results weren't there I'd still have confidence in my swing. Results, no doubt, are a nice thing as well."
The Royals' third error, by Smith, also made one of two runs in the third inning unearned.
Behind 5-0, the Royals came back with three runs against Padres starter Jason Marquis in the third inning. David Lough contributed a double, his second hit, and he finished the day with a .548 (17-for-31) average. Lorenzo Cain had a two-run single and Brandon Wood contributed an RBI single.
Luke Hochevar made his first appearance since being switched to the Royals' bullpen on Wednesday and worked two perfect innings.
After Minor Leaguers took over the Royals' lineup, they wiped out the Padres' 5-3 lead by batting around in a four-run eighth inning. Most of the damage came against Tim Stauffer, pitching his third inning. Paulo Orlando started the rally with a double, Alex Llanos belted a two-run double and Angel Franco added a run-scoring single.
"They all did a great job," Royals manager Ned Yost said. "When you give those kids an opportunity, it's big. It's experience for them and to do what they did today was exciting for me. This is as excited as I've been all Spring Training just to see those kids have success and to come back and win a ballgame like that."
Up next: The Padres face the D-backs at 1:05 p.m. PT on Saturday at the Peoria Sports Complex, live on Gameday Audio. This will be another chance for pitcher Tyson Ross to separate himself from the rest of the candidates for the No. 5 spot in the starting rotation. Ross, who is scheduled to go four or five innings, hasn't allowed a run in each of his last two appearances, both spanning three innings. Prospect Donn Roach, he of the advanced sinker, will follow Ross and will likely throw three innings.
Dick Kaegel is a reporter for MLB.com. This story was not subject to the approval of Major League Baseball or its clubs.


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Of all
the green cars on the road today, the two that get the most attention tend to
be the pure electric Nissan Leaf and the Chevy Volt, which is classified as a
plug-in hybrid. The two cars are selling well and it looks like the price will
be increasing for the 2012 model year on both of the vehicles.
Nissan has announced that the price on the Leaf will go up significantly in both base trim and SL
trim for 2012. The base Leaf will see its price rise from $32,780 to $35,180.
The SL will see an even larger price increase going from $33,720 to $37,250.
Nissan also announced that it would up the lease price of the Leaf slightly to
$369 monthly from $349 monthly for the 2011 model year.
Brian Carolin, senior vice president, sales and marketing for Nissan North
America said, "Many enthusiastic consumers have eagerly anticipated
ordering a Nissan Leaf of their own, and now we can make zero-emissions
mobility a reality in more markets." He also noted, " In response to
direct feedback from Nissan Leaf owners, the features that customers want most
will come standard on the 2012 Nissan Leaf — including quick charging and
cold-weather features."
The quick charge feature allows the Leaf to be hooked to a 480v charger. That
allows the Leaf to recharge in 30-minutes from a dead battery to 80% capacity.
The cold weather gear includes a battery heater, heated seats, and a heated
steering wheel.
GM is
also offering pricing details on its 2012 Volt. The base Volt for 2012 will
have a price of $39,995 including the $850 destination charge. In 2011, the
Volt started at $41,000. The Volt with navigation and Bose sound is rising in
price by $990 compared to 2011 models.
In June,
GM reports that it sold 2,745 Volts while Nissan reports selling 4,400 Leaf
Nissan is
also already putting thought into what to do with Leaf batteries when the cars reach the end
of their usable life.


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|Related Sections:
|Fort Lewis
|Pierce County
Fort Lewis Golf Course - Green/Red CourseMounts Rd
Fort Lewis, WA 98433
Phone: (253)967-6522Fax: (253)964-2789
This club has three nine hole courses that are played in three eighteen hole combinations. The green fees for playing these challenging military courses are determined by rank. The green fees indicated above are guest fees. There are numerous trees that can affect your shots. Water hazards (one lake and two small ponds) come into play on three holes.
|Holes: 18
|Greens: Bent Grass
|Fairways: Bluegrass
|Greens Fees:
|Course Type:
|Dress Code:
|No tank tops or cutoffs
|Open all year
|Guest Policy:
* Update this Course: Update/modify the details for this golf course's listing.
*All Greens Fees provided are subject to change. Please call the golf course to confirm the current fees.


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Behold the man posturing and asserting his manliness by firing guns on camera, as if that is a talent or an accomplishment. You will not be able to watch this video without thinking "What an ass…"
He's the police chief of some tiny little town in Eastern Pennsylvania, a place a fifth the size of Morris, Minnesota. I think he might be overcompensating a little bit with the gun-waving.
But besides being an arrogant idiot, he's a real danger — this is not the kind of tinpot tyrant you want armed and eager to open fire. But at least it leads to a little amusement.
He went to a bar, got involved in a bar fight, and drew a gun. Already you're thinking this man has crossed the line and ought to be in jail. But here's the funny part:
Mark Kessler is what you get when you give Barney Fife an M-16. Which is kind of a metaphor for America, if you think about it.