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Forget everything you think you know about raves—unless you
think of them as a conscious gathering of like-minded folks striving for
enlightenment. The new raves are drug, alcohol, and smoke-free yoga-oriented
dance parties, and they are gaining popularity as an alternative to traditional
The concept has been subtly invading the yoga scene for a
few years, from Shiva Rea's Yoga Trance Dance, to Friday night black light flow
classes. For those who feel a common thread between the mental, physical, and
spiritual effects of a good yoga class and dancing or singing, these events can
be a great way to enjoy a night of healthy socializing.
This idea is what inspired Argentinians Rodo Bustos and Nico
Pucci, of the So What Project! to start throwing yoga rave house parties five
years ago. They "realized
that so many people want a different place, want a different orientation to have
fun." Their parties quickly outgrew houses and had to make the move to
larger venues. As volunteers for the Art
of Living Foundation, they realized they had found a way to promote peaceful
community gatherings while giving back to the community, and the non-profit Yoga Rave was born. They now organize yoga
raves in eight countries with the vision of creating "a movement that will
support all people to come together in deeper connection and celebration,
without the fallout." Proceeds from Yoga Rave events support stress reduction
for youth and prisoners.
While they may have the rights to the domain name, the Yoga
Rave organization is far from being the only group throwing yoga raves. Natural
Highs, a teen-led group in Boulder, Colorado recently threw a yoga rave led by
yoga wiggle-worm David Sye. The groups founder, Avani Dilger, feels these events reflect the true origins of
the rave movement, a movement she says started with the intention of creating
community celebrations where altered states of consciousness were reached
through movement, dance, and music rather than with drugs. She thinks yoga
raves may not only help redefine public perception of what a rave is, they may
also introduce more people to yogic practices. She points out "people who do yoga
know that they feel ecstatic at the end, but a lot of people who do drugs don't
know that yoga does that…we're teaching people that you don't need drugs and
alcohol to feel extraordinary states."
There are currently so many events merging live music,
dancing, yoga, and mantra in varying combinations, that there really is no one
formula for a yoga rave, and many of these events don't actually use the word
"rave." Often
individual studios and teachers find their own unique way of naming their event,
the one thing they have in common with each other and the raves of the
nineties—glow sticks are required.
Do you know of or have you been to any yoga raves in your
Disclosure: YogaBasics.com participates in several affiliate programs. As an Amazon Associate, we earn from qualifying purchases. When you click on external links, we may receive a small commission, which helps us keep the lights on.


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Cetearyl Alcohol
Veterinarian Reviewed on January 9, 2012 by Paulina Nelega, RH
Posted in Uncategorized
Cetearyl Alcohol
Cetearyl alcohol, along with Cetyl Alcohol, Myristyl alcohol and Behenyl alcohol are described as being white wax-like in appearance. These are the major components of many skin care products because of their ability to bind an emulsion together; they act as binders to keep the emulsions from separating into oil and liquid. Cetearyl alcohol is also used as a thickener in liquid preparations and also to stabilize foamy liquid products.
Cetearyl alcohol is one of the key ingredients of personal care products and without it, skin care preparations would separate and would be unable to foam up when they are used.
History and Origin
Cetearyl alcohol is considered straight chain alcohols with a combination of Cetyl and Stearyl alcohol. It is also called Cetostearyl alcohol, C16-18 or simply alcohol. It is derived from vegetable oils or from other synthetic sources.
Ancient Uses
The use of Cetearyl alcohol was never heard of during the ancient times. Vegetable oil, which is one of the main sources of this type of alcohol was usually used in cooking, as well as in therapeutic health remedies. Other oil sources such as nuts were mostly used for their medicinal value.
Modern Uses
In today's more modern times, Cetearyl alcohol is used for its many properties to help preserve solutions and emulsions. It was first derived from vegetable and plant sources, but then it was later synthetically produced in the lab. First of all, it is an emulsion stabilizer that keeps an emulsion from separating to its liquid ingredient and oil based ingredients. It makes skin care products easy to use, as well as easy to be absorbed by the skin. This is essential for lotions, moisturizing products and skin care treatments created especially for dry skin.
Cetearyl alcohol is also a surfactant that boosts a products foaming capacity. This property is important in bath soaps, hand soaps, shampoos, conditioners and many other personal care products.
It can increase the viscosity of a particular solution which is important in food preparation. This property can be useful in thickening skin care products for easy application on any type of skin. Cetearyl alcohol is also a main ingredient in cosmetics such as foundations, concealers, liquid lipsticks and mascaras to stabilize a solution and to prevent the separation of emulsions.
Side Effects
Cetearyl alcohol is considered safe by the Food and Drug Administration (FDA) for use as a food additive to stabilize, thicken and preserve commercially prepared foods. This alcohol is also safe as an indirect food additive to improve taste to food as well.
Cetearyl alcohol is also considered safe by the Cosmetic Ingredient Review (CIR) Expert Panel. It can be used as an additive for cosmetics without causing harm or irritation. Although it is evaluated as safe to be used as an ingredient in personal skin care products, there may be still a small number of people who are sensitive to products that do contain Cetearyl alcohol. If you have extra sensitive skin, consult a dermatologist for the most appropriate skin care product to use. Young children and infants that do have sensitive skin should also seek a consultation with a dermatologist for a milder and gentler skin care product to use.
Suggested Products
Our Expert
Paulina Nelega, RH, has been in private practice as a Clinical Herbalist for over 15 years. She has developed and taught courses in herbal medicine, and her articles on health have appeared in numerous publications. She is very passionate about the healing power of nature. Ask Dr. Jan

subset: commoncrawl


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Page 1
|1 of 1
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16 HASKINS & SELLS February The first half of the book is devoted to a partial justification of our money and profits system, wherein it is pointed out that the profit incentive is probably the most satisfactory motive for individual effort and initiative; that profits and losses are a necessary result of the business risks which are inherent in a progressive society; and that competition must remain in our economic order, together with security of private property. The last part deals with adverse criticisms of our economic system demonstrating, among other things, that the present money and profit economy does not enable consumers, year in and year out, to obtain the required money to buy goods quite as rapidly as they are produced, which is necessary to attain the desired economic aim of constantly advancing the material well-being of the people generally; and that there is consequently no possibility of sustained economic progress, and extreme alternations of prosperity and depression are inevitable. It is contended that consumer buying does not keep pace with production for two reasons: first, because approximately one-half of all industrial profits are invested in increasing production rather than disbursed to consumers to buy the goods already produced; second, because consumers, under the necessity of saving, cannot spend even as much money as they receive. Dollars saved instead of spent are used to a large extent for the production of more goods, thereby increasing the difference between production and consumption. One of the more important factors which tends to make up for the deficit in consumer buying is the expansion of the volume of money. However, the money is expanded mainly to facilitate the production, rather than the consumption of goods, and the goods must be sold to consumers for more money than the expansion has provided. Although the authors analyze and discuss the problems without offering a solution, the general statement is made that our greatest economic need to sustain a forward movement in business is adequate consumer purchasing power. This contemplates a flow of money to consumers which, after providing for savings, would always be approximately equal to the flow of finished goods. The book differs from the average discussion of economic principles in that the terminology used is well adapted for those who are more practical minded. It is one of a series of publications of the Pollak Foundation for Economic Research, which offers a prize of $5,000 for the best adverse riticism of the arguments advanced. News Items Colonel Carter returned from Europe on January 25, on the S.S. Berengaria, after spending a month visiting our London, Paris, and Berlin offices. Mr. Forbes returned from the Orient early in January after having assisted in the opening of our new office located in the Pacific Building, Manila. He also visited Shanghai and several cities in Japan in connection with other professional matters. Mr. C. M . Doiseau, of the systems division of the Technical Procedure Department, has resigned to become vice-president of The Cambridge Tile Manufacturing Company, Covington, Kentucky. Mr. H. W. Scott, of our Detroit office, recently has received the C. P. A. certificate of the State of Michigan, as a result of the November, 1926, examination. Mr. E. K. Ford, of our Philadelphia staff, also is to be congratulated upon passing the November, 1926, C. P. A. examination of the State of Pennsylvania. PRESS OF WILLIAM GREEN, NEW YORK
Object Description
News items
|Personal Name
Carter, Arthur Hazelton
Forbes, John Franklin
Doiseau, Clarence M.
Scott, Harold W.
Ford, Earl Kratz
Haskins & Sells. London Office
Haskins & Sells. Paris Office
Haskins & Sells. Berlin Office
Haskins & Sells. Manila Office
Haskins & Sells. Shanghai Office
Haskins & Sells. Technical Procedure Department
Haskins & Sells. Detroit Office
Haskins & Sells. Philadelphia Office
Haskins & Sells Bulletin, Vol. 10, no. 02 (1927 February), p. 16
|Originally published by: Haskins & Sells
|Deloitte Digital Collection
|Digital Publisher
|University of Mississippi Libraries. Accounting Collection
|Date-Digitally Created
|HS Bulletin 10-p16


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I guess I'll post another one I wasn't sure about posting :x
Yeaaaah I do weird shit dancing alone in my room. Don't judge me. >.>
(Source: banggungifs)
- That strapline proved to be somewhat prescient, regarding the prequels.
- The cover looks like a postcard (from the edge) in the making, doesn't it? "Having a great time, wish you were here. Love, Carrie."
Juliana Salimeni
testando um gif animado ok


text:
Linear Tape File System - Enterprise Edition (LTFS-EE) - New enhancements –
With the explosion of digital information worldwide, organizations are struggling to manage storage costs while meeting end-user demands for accessibility. LTFS EE helps to reduce IT expenses by transparently replacing tiered disk storage (Tier 2 and Tier 3) with IBM tape libraries. The PGA1 release of LTFS EE became generally available on December 20, 2013. This session will overview LTFS EE, highlighting the enhancements in the new PGA1 release. The session will include a live demo with time for Q&A.
This webinar has been completed. Please feel free to access the materials using the links below.
Audio available at: http://ibmstg.adobeconnect.com/replay-acceleratewithats-jan16/
Presentation available at: http://ibmstg.adobeconnect.com/acceleratewithats-ltfs-ee-jan16/
Jeff Ziehm - ATS
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To describe zolpidem-associated complex behaviors, including both daytime automatisms and sleep-related parasomnias.
A case series of eight clinical patients and six legal defendants is presented. Patients presented to the author after an episode of confusion, amnesia, or somnambulism. Legal defendants were being prosecuted for driving under the influence, and the author reviewed the cases as expert witness for the defense. Potential predisposing factors including comorbidities, social situation, physician instruction, concomitant medications, and patterns of medication management were considered.
Patients and defendants exhibited abnormal behavior characterized by poor motor control and confusion. Although remaining apparently interactive with the environment, all reported amnesia for 3 to 5 hours. In some cases, the episodes began during daytime wakefulness because of accidental or purposeful ingestion of the zolpidem and are considered automatisms. Other cases began after ingestion of zolpidem at the time of going to bed and are considered parasomnias. Risk factors for both wake and sleep-related automatic complex behaviors include the concomitant ingestion of other sedating drugs, a higher dose of zolpidem, a history of parasomnia, ingestion at times other than bedtime or when sleep is unlikely, poor management of pill bottles, and living alone. In addition, similar size and shape of two medications contributed to accidental ingestion in at least one case.
Sleep driving and other complex behaviors can occur after zolpidem ingestion. Physicians should assess patients for potential risk factors and inquire about parasomnias. Serious legal and medical complications can occur as a result of these forms of automatic complex behaviors.
Poceta JS. Zolpidem ingestion, automatisms, and sleep driving: a clinical and legal case series. J Clin Sleep Med 2011;7(6):632-638.
The ingestion of zolpidem and other hypnotic sedative medications for the treatment of insomnia has been associated with sleepwalking and other complex behaviors including sleep eating and sleep driving.1–5 When ingested during the daytime, hypnotic sedatives impair cognition, memory, and motor performance.6 There are also reports of a high frequency of blood levels of hypnotic sedatives in drivers apprehended for driving under the influence (DUI).7–9 An advisory letter was sent and change in package insert information occurred on March 14, 2007, alerting physicians and the public to the possibility of complex behaviors with all hypnotic sedatives.
According to the prescribing information for Ambien and Ambien CR, zolpidem is an imidazopyridine chemical class agent available in the US since 1992. It is chemically unrelated to benzodiazepine and barbiturate hypnotic sedatives. Zolpidem in vitro binds the BZ1 receptor of the GABA(A) complex with high affinity ratio for the alpha1/alpha5 subunits. Mean peak concentrations were 59 (range 29 to 113) after ingestion of the 5 mg tablet and 121 (range 58 to 272) after ingestion of the 10 mg tablet (ng/mL). Time to maximum concentration was 1.6 h for both doses (but 2.2 h if taken with food) with a half-life of approximately 2.6 h (range 1.4 to 4.5) The zolpidem extended release formulation 12.5 mg tablets produced a maximum concentration of 134 (69 to 197) at 1.5 hours. Co-administration with fluoxetine increased half-life by 17%, and co-administration with sertraline increased peak concentrations by 43%.10
Current Knowledge/Study Rationale: Sleep driving has been noted to occur after the ingestion of hypnotic sedatives. The nature and cause of this complex behavior is not widely appreciated by clinicians.
Study Impact: This unique series describes in detail the timing of drug ingestion, patient rationale, and medication blood levels in cases of sleep driving and other complex behaviors. Because of these details, clinicians can better understand and assess risk factors, differential diagnosis, and legal ramifications for zolpidem-associated complex behaviors.
Although complex behaviors and sleep driving after zolpidem ingestion have been described, the timing of the ingestion and the legal ramifications of the behaviors are not commonly appreciated by the clinician. A recent review has highlighted the lack of specific clinical information in legal case series presently available in the literature and called for more detailed histories of sedative-related DUIs.11 It also raised the question of whether physician and patient education could help prevent sedative-related DUIs. The case series presented here describes in detail sleep driving after zolpidem ingestion, the related clinical syndrome of daytime zolpidem-induced automatism, and identifies potential risk factors for these occurrences.
A 65-year-old man presented for neurologic evaluation 2 days after a spell of strange behavior with amnesia while on vacation in rural Kenya. During breakfast he was observed by his wife to suddenly stop talking and to "stare off." He was able to give short and slow verbal responses to her questions such as a soft "yes" or "OK." He remained in this quiet, awake, but poorly responsive state for over an hour, and was then transported by jeep and by plane to a hospital in the capitol. About four hours after onset he began to ask spontaneous questions about where he was and what was going on, and he became more appropriate. He was examined in hospital and found to have a normal physical examination, brain CT scan, EKG, blood counts, and chemistries. He returned to his normal mental and physical state later that day, but with no memory of events between breakfast and the hospital. He flew home to San Diego and was again examined. He had recently been diagnosed with polymyalgia rheumatica and was on a tapering dose of prednisone (now 2 pills of 10 mg). Because of insomnia associated with the steroid, he had been prescribed zolpidem 10 mg tablets. He was found to have a normal ESR and TSH. An EEG, repeat EKG, brain MRI, and carotid duplex Doppler were normal. Upon further questioning, he had put all his pills in the same bottle for the trip to Africa. He realized that he had taken two 10 mg zolpidem tablets instead of two prednisone tablets on the morning of the illness.
A 38-year-old woman and homemaker presented with daily headache for 5 years. She had a history of chronic migraine with medication overuse. She had failed prophylactic treatments with topiramate, amitriptyline, propranolol, and botulinum toxin injections. Depression and anxiety were adequately controlled on bupropion and venlafaxine.
For about 4 years she had been taking zolpidem 5 or 10 mg to treat headache in the late afternoon. She would do this on days when her children were safe (such as with the nanny) and when the headache was severe—which was almost every day. She took some care to lock the doors and to remain in the house. After zolpidem ingestion she would stay awake and do chores such as preparing dinner for the family. She would occasionally nap, but usually would remain awake and then go to sleep at about 9 or 10 PM. The husband would arrive home and find her to be clumsy and unsteady, and she seemed inebriated. She would leave dishes strewn about and pots on the stove. He was extremely upset about her zolpidem ingestion because the next day she never remembered activities or conversations from the evening.
Substitute treatment with oral alprazolam and rapidly dissolving clonazepam were partially effective but did not adequately relieve the headache pain. She reverted to using zolpidem again. The prescribing physician was advised of the problem.
Table 1 shows the 2 cases described above, 3 additional cases of accidental daytime ingestion, and 3 cases of sleep-related complex behavior including one case of sleep driving. Doses of zolpidem and other medications, as well as whether the event was a daytime automatism or was sleep-related, are indicated. All cases of accidental daytime ingestion presented because of unexplained change in behavior with amnesia. Two of the daytime accidental cases were physicians (50-year-old male and 43-year-old male) who routinely put all their pills in one bottle. These patients had 3 to 5 h of amnesia, confusion, ataxia, and were looked after by spouses until the spell passed. The 28-year-old woman accidently took her sleeping pill in the morning and her antidepressant at night for several days and was brought in by family because of confusion and ataxia. In this case, the similar shape and color of Ambien 10 mg and Zoloft 100 mg led to the accidental ingestion.
Clinical cases
(more ...)
The 65-year-old woman went to bed and then drove without incident to a fast food restaurant parking lot about 20 miles from her home and slept there until morning. There is no definite information on timing of the ingestion or the driving. The 49-year-old woman who flooded her apartment was also taking temazepam and had been prescribed positive airway pressure for obstructive sleep apnea (OSA), but adherence was poor. The last clinical case was a 54-year-old man who presented with weight gain after experiencing sleep eating with amnesia almost every night one hour after he took his zolpidem and retired. He was found to have generalized anxiety and severe periodic limb movements in sleep (PLMS). Treatment with ropinirole, low doses of clonazepam, and a cognitive behavioral program allowed him to stop zolpidem and the sleep eating disappeared.
Legal cases were defended by San Diego County court-appointed public defenders. The author was compensated for expert witness evaluation of records and testimony for the defense. Table 2 summarizes these cases.
Legal defendants
At 3 AM, a Toyota Sequoia struck several parked cars. Police followed skid and gouge marks for 5 blocks to an alley and found the vehicle. The driver appeared intoxicated, diaphoretic, and agitated. He would not follow commands and was handcuffed on the ground while kicking and screaming.
The 42-year-old defendant later stated that he took his usual sleeping pills at about 11 PM and remembered nothing until being in custody. At the initial police interview, after he had calmed down, he said that possibly he had driven to see his friend. He thought he might have hit a light post, but did not remember hitting vehicles or driving for several blocks on the right front wheel rim. The forensic toxicology screen was positive for zolpidem 25 ng/mL and for cannabinoids. The defendant was HIV positive and was receiving medical marijuana.
The author's written opinion was that the defendant had suffered an episode of zolpidem-associated sleep driving and that he was not in control of his behavior. Further, I did not think that he could have anticipated this problem since he had been taking zolpidem for some time, had gone to bed as usual, and was not otherwise intoxicated. He had not been alerted to the possibility of such behavior by his doctor or his pharmacist. Charges of felony DUI and resisting arrest were reduced, and the case was settled.
At 2:50 AM, a police officer noticed an automobile stopped at a green light. He pulled behind the car, but the car did not proceed through the light even after the use of the air horn. After activating the police car lights and siren the car began to move. The vehicle was weaving left and right at 40 MPH in both lanes and several times almost hit the curb. The vehicle turned, continued to weave at 52 MPH, stopped at a red light, waited for the green, and then made a U-turn. Two patrol cars were now behind the vehicle, which was moving at speeds up to 60 MPH. After another U-turn the vehicle hit the curb and flattened the right front tire. The driver was taken into custody and was noted to have trouble following commands, was swaying while walking, had red watery eyes, and was not making sense while speaking. He said that he was taking pain medications.
The 33-year-old defendant later made the statement that he had been prescribed Ambien CR in 2007 when on temporary disability from work with back pain. He took the medication consistently for over a year with no problems and then tapered and stopped the medication for the last month. He again developed insomnia, so he went to his doctor on the day of the accident and was prescribed Ambien CR 6.25 mg tablets. He was told that if one pill did not work to take another. He picked up his prescription at 4 PM and took one Ambien CR at approximately 9:30 PM and went to bed. He was not getting drowsy so he went downstairs to take another pill and to get a bite to eat. The next thing he remembers was being arrested in front of his car. Upon release from jail in the morning, he was surprised to find he had no wallet; just shorts, flip flops, and a tank top. When he returned home he counted the remaining pills and there were 23 of 28, suggesting that he had in fact taken 5 Ambien CR (31.25 mg).
The toxicology report from a blood sample drawn soon after the arrest, probably at about 4 AM, showed diphenhydramine and a zolpidem level of 252 ng/mL, consistent with a dose at 10 PM and additional doses after 11 PM.
I testified to the jury that the defendant was under the influence of zolpidem when he left his residence and began to drive. His behavior and rapid improvement to a normal state were typical of zolpidem effect. The jury found the defendant not guilty on all counts, including Evading Police and DUI Drugs. Some of the jurors were not as interested in whether or not the defendant was actually advised of or read the warnings about sleep-related complex behaviors because sleep driving would seem to be so rare a condition that he could not have anticipated it. Many jurors found it persuasive that he had no personal effects on him such as his wallet or cell phone, and that he was driving a route that he took every day—perhaps more likely to occur during an automatism. They also believed that he could have taken the extra pills after the first dose had taken effect.
At 11 PM a police officer noticed a (34-year-old) woman driving about 40 MPH on the freeway drifting back and forth between lanes. She exited and stopped at a green light. As the light turned to yellow she proceeded. She later stopped at a red light but behind the limit line. She stayed at this location through one entire light cycle before proceeding and then struck a raised median with her vehicle. She continued and eventually turned into a parking lot. She was interviewed on the scene. She said that she was driving from home to her Bible study class. She said that she had one beer and that she took Lamictal. Her field sobriety tests showed that she was swaying and could not stand on one leg. There was no nystagmus. She was considered as DUI, handcuffed, and arrested. She was transported to headquarters to obtain a chemical sample.
The toxicology report showed a zolpidem level of 428 ng/mL and no other substances.
The statement from the defendant was that she remembered nothing after about 10 PM until she was in police custody. She had had dinner with her boyfriend at about 7 PM and had one beer. She decided against going to her Bible study class, but then got into an argument with her boyfriend. When alone at about 9 PM she was very anxious and even panicky. She believed that she followed the recommendation from her doctor to take two alprazolam and two zolpidem if she was having a panic attack and couldn't sleep. Her Bible was found in the car and she had parked at the Bible class location.
My written report expressed the opinion that the defendant was under the influence of a high level of zolpidem at the time of the arrest, had followed her physician's instructions, and that her behavior was consistent with an episode of zolpidem-associated sleep driving. The Public Defender was able to settle the case for a lesser charge (misdemeanor reckless driving).
At approximately 8 PM the 33-year-old defendant's vehicle struck another car, sideswiped two parked cars, and then caused a head-on collision. The occupants of the other vehicle were seriously injured. The defendant was seen to be acting strangely (e.g., climbed out of the window of the car and staggered). He had also run a red light, was driving without headlights on, and did not stop his vehicle despite several impacts. At the hospital his zolpidem level was 78 ng/mL, his blood alcohol level was 0.23%, and field breathalyzer had been 0.182%.
The statement from the defendant and family members as well as review of his medical records indicated that he had suffered from insomnia for at least 7 years and had often been prescribed zolpidem, either 10 mg or Ambien CR 12.5 mg, using about 30 per month. An alcoholic with previous DUI conviction, the medical records indicated that he was not using alcohol in recent years. He and his family stated that in the past he had often had sleepwalking and sleep eating after taking zolpidem. His family also stated that since the previous DUI, he staunchly avoiding driving if he had been drinking.
On the afternoon before his arrest he had four rum and cokes. He wanted to sleep from about 5 or 6 PM until midnight, because the agreement with his wife was that he would take care of their newborn twins starting at midnight. He remembered taking one Ambien CR 12.5 mg at about 6 PM, and next remembers being in the hospital.
I opined that the defendant was under the influence of both zolpidem and alcohol at the time he was driving. He had a previous history of sleep eating with zolpidem suggesting a predisposition to zolpidem-associated complex behaviors. He pled guilty to DUI, the case settled and he was sentenced to probation and seven years in state prison, suspended.
At 11:35 AM, the 54-year-old defendant's vehicle struck a parked car while turning and then rear-ended a car stopped in traffic. The defendant had wandered off briefly and was unsteady on his feet. He was making nonsensical statements to a witness (needed coffee; did not acknowledge accident) and then underwent a sobriety check by the officer. He was clearly impaired, dysarthric, had poor balance, and had difficulty making coherent sentences. He denied drinking alcohol but admitted to taking prescription drugs including pain killers and a sleeping pill. He said he was going to the store but did not remember driving or having an accident.
He was wearing pajama bottoms and his dog was in the vehicle. He was taken into custody where a blood sample was obtained. The zolpidem level was 80 ng/mL. Other medications found in his blood were trazodone (29 ng/mL), paroxetine (12 ng/mL), levetiracetam (10 mg/L), gabapentin (6 mg/L), and morphine (23 ng/mL [considered negative]). The defendant was HIV positive and had a painful peripheral neuropathy. The medical records indicated that he took Ambien CR 12.5 mg for the first time on the day of the accident.
It was my opinion that zolpidem contributed to his impairment and the accident, and that taking the medication at 8 AM, even though he hoped to sleep, had produced a state of complex automatic behavior. Later statements indicated that this defendant, after a restless and difficult night, "just wanted to get some sleep" and so took the zolpidem at 8 AM. The case went to trial for one day, a mistrial occurred, and a settlement was negotiated for a charge less than felony DUI.
A 34-year-old woman with no criminal or civil record went through her usual routine and, after putting her 12-year-old son to bed at 9 PM, took zolpidem 10 mg. She next remembers being in police custody with disheveled clothes, no purse, and having crashed her car at 11:15 PM. She hit several parked cars over a two-block range before hers was disabled. She was incoherent and insisted that the damaged car in front of her was not hers because hers "is not crashed like that." She said that she had had 3 drinks. Her zolpidem level was 140 ng/mL and her breathalyzer alcohol level was 0.11%.
In her statement the defendant remembered putting her son to bed and taking her zolpidem as she had been doing every night for the last few years. Her son said that she later came into his room with a glass in her hand and was talking strangely.
I thought it possible that during a zolpidem-associated complex automatic state (possibly sleepwalking) she had ingested the alcohol without conscious awareness and then had driven. The jury found her guilty of misdemeanor DUI. The prosecution had emphasized the fact that she may have been drinking prior to taking the sleeping pill (high alcohol level) and they noted the short time duration between her activities with the child, drinking, taking the medication, and the accident.
A clinical syndrome characterized by poor motor control, confusion, dysarthria, and anterograde amnesia occurs after zolpidem ingestion both during the daytime and at sleeping times. Whether or not the behavior can be considered a parasomnia depends on the time of ingestion, the occurrence of sleep prior to the behavior, and on patient characteristics. Both the waking and sleeping activities can, however, be termed zolpidem-associated complex behaviors, one of them an automatism and the other a parasomnia. As indicated in a review of sleep driving by Pressman, the intoxicated behavior during the arrests is often not consistent with sleepwalking alone. Pressman suggests that the onset of the event could be a parasomnia, but as the event continues the sleep-related elements disappear, leaving the person now intoxicated but not in bed.11 This concept of an initial sleep walking episode followed by a complex automatic state is supported by the legal cases in this series based on the stated timing of ingestion, the lack of motive for driving, and the behaviors recorded at the scene.
Both the clinical and the legal cases suffer from lack of information that inhibits drawing firm conclusions. First, the medical condition of the defendants is mostly unknown. Other sleep disorders, including for example sleep apnea, could not be ruled out. Their statements, while generally under oath, were made in the context of trying to avoid DUI conviction. Even the clinical cases were reported retrospectively, and only three were studied in detail with polysomnography.
Sleepwalking does not have a well-understood pathophysiology and is considered to be a dissociative state occurring in slow wave sleep (N3), in which elements of wakefulness and sleep coexist.12,13 Its prevalence in adults has been estimated at 0.4% in the Finnish Twin Cohort.14 About 90% of adult cases of sleepwalking also had childhood sleepwalking in this study. In the United Kingdom, a representative telephone survey of 4972 adults found that sleepwalking was present in 2% and was associated with younger age, breathing difficulty, and sleep talking.15 The prevalence of sleep walking suggests that there might be coincidental overlap in some patients who are prescribed hypnotic sedatives. The likelihood of sleepwalking and other NREM parasomnias is increased by factors or conditions that increase slow wave sleep (such as sleep deprivation) or cause arousals during slow wave sleep.16 In some of the legal cases, sleep deprivation was likely present based on the statements and lifestyles of the defendants.
The selective binding of zolpidem at the BZ1 receptor may explain the relative absence of myorelaxant, anxiolytic, and anticonvulsant effects, as well as the preservation of deep sleep.17–20 Zolpidem produces impairment of memory, motor, and cognitive functions.21–23 Profound impairment of driving ability is present 4 hours after ingestion of both 10 and 20 mg doses, and lasts perhaps as long as 6 hours.24–27 However, most studies of the effect of zolpidem on driving have examined the next day residual effect and have shown no impairment when conducted eight or nine hours after ingestion.28,29
The reason that zolpidem is often implicated in sleep-related complex behaviors is not clear, but it is the most often prescribed sleeping pill in the United States. For example, the VONA database, which captures over one-half of the US prescriptions, found that 63% of the hypnotic sedatives prescribed by primary care providers in 2007 were zolpidem or zolpidem extended release, compared to only 29% for eszopiclone and temazepam combined.30 The West Virginia Medicaid program database indicated that in 2003, zolpidem represented 43% of claims, trazodone 46%, temazepam 10%, and triazolam, flurazepam, estazolam, and zaleplon less than 2%.31 In Norway, a study found higher rates of zopiclone then zolpidem in drivers, reflecting the prescribing bias of the physicians in that country.8 It is important to note that no study has prospectively studied the propensity for any hypnotic sedative to trigger a parasomnia.
It is also possible that zolpidem's receptor specificity and its rapid pharmacokinetics underlie this complication. For example, if zolpidem does not decrease anxiety at the time sleep is induced,18 in the anxious but now asleep state, ingestion of more medication, alcohol, food, or other means of relieving anxiety might occur. It is also possible that because zolpidem appears to have less muscle relaxant properties than benzodiazepines, the motor system might remain relatively more engaged compared to the amount of sleep induction that occurs.32 Lastly, the preservation of stage N3 that occurs with zolpidem relative to traditional benzodiazepines might increase likelihood of a parasomnia or confusional arousal based on current models that suggest deeper sleep is a risk factor for these events.16,33
All cases of daytime accidental ingestion in this series demonstrated rapid onset confusion, ataxia, and amnesia, which led physicians to consider the diagnoses of cerebral ischemia (stroke), partial complex seizure, or transient global amnesia. Table 3 lists the dominant clinical findings during the episodes. Mixing pills together in the same bottle was responsible for most of the accidental cases. In addition, the similar look of different medications was responsible in one case. It is possible that use of generic equivalents might make distinction between pills more difficult for some patients. Two of the clinical cases had concomitant sleep disorders, suggesting that arousal from OSA or PLMS triggered these parasomnias. Indeed, treatment of PLMS in one patient was associated with disappearance of nightly sleep eating.
Features of zolpidem-associated complex behaviors
Poor motor control, dysarthria and ataxia.
Responsiveness to the environment; apparent wakefulness to observers
Confusional ideation and irrational speech
Impaired or absent memory for the time period, usually lasting 3 to 5 hours (anterograde amnesia)
Onset and offset of symptoms over 1 to 6 hours
The legal cases represent complex behaviors following zolpidem ingestion intended to induce sleep, a situation that could variably be considered an altered state with amnesia (automatism) or a form of parasomnia (sleep driving), or both. It is not possible to know with certainty that the defendants ever actually slept before driving. Defendants used sleepwalking triggered by zolpidem as a defense for their DUI on the grounds that such activity could not be reasonably anticipated based on what they were told about the medication by the prescribing physician and pharmacist. The body of reports of parasomnia associated with hypnotic sedative use would seem to support such a defense, as opposed to the voluntary ingestion of alcohol.34 Such a defense would seem to be stronger if there is a history of prior parasomnia and if the medication was used properly.
The legal cases provide some details that suggest underlying risk factors as well as real-world prescribing instructions and patient use of sleeping medications. Table 4 lists some of these risk factors. Some cases were more likely a parasomnia in onset because of appropriate timing, dose, and bedtime behavior. In some cases the drug was combined with other medications and with varying doses of alcohol that would increase risk of automatism. The ingestion of additional doses of zolpidem (of which the person had no memory) was established in one case. In another case, the ingestion of high doses of zolpidem when upset may not have induced sleep, allowing for the expression of a state of complex automatic behavior. Similarly, the ingestion of zolpidem at 8 AM, even if exhausted and wearing pajamas, does not guarantee sleep. Lastly, it is clear that patients and physicians may not always communicate about complications of medications and use of alcohol.
Potential risk factors for zolpidem-associated auto-matisms and parasomnias
Concomitant ingestion of alcohol or sedating medications
Concomitant sleep disorder such as OSA or PLMS
A history of parasomnia
Hypnotic sedative ingestion at times other than habitual bedtime
Hypnotic sedative ingestion during agitated state with decreased likelihood of sleep
Hypnotic sedative ingestion when sleep deprived
Poor management of pill bottles
Living alone
One risk factor for zolpidem-associated sleep driving is suggested from this series that had not been previously noted—living alone. I suggest that this is because a spouse might notice certain behaviors and then inform the patient, for example, in the nights before sleep driving when less active parasomnias might occur such as simple sleep talking or sleep eating. The drug could then be stopped or the dose lowered. Alternatively, if there were no preceding minor events, many spouses might notice a bed partner leaving the house and starting up the car at midnight, and disaster might be averted.
As is obvious from the behavior in all cases, sleep driving and daytime automatism must be considered potential serious adverse effects of zolpidem ingestion with high potential for fatality. Physicians should be aware of this possibility and can perhaps minimize the likelihood of occurrence by following certain prescribing principles. These include evaluation and treatment of the underlying cause of the insomnia, assessing patient risk factors prior to prescribing, starting with very low doses, minimizing nights of patient use, asking about minor parasomnia behaviors at follow-up, and emphasizing good sleep habits and regular schedules. A cautious clinician might consider instructing the patient not only to "ingest immediately prior to going to bed," but add "at your usual bedtime only." This instruction would be implicit if all physicians included the basics of behavioral treatments and good sleep hygiene with any prescription for hypnotic sedatives.35,36 The degree to which zolpidem-associated sleep driving in an individual case is caused by poor compliance on the part of the patient, is a rare unavoidable side effect of the drug, or is the fault of physician and pharmacist instruction might only be determined by a jury in the court room.
This was not an industry supported study. The author has served as a consultant for San Diego County.
Hoque R, Chesson AL Jr., authors. Zolpidem-induced sleepwalking, sleep related eating disorder, and sleep-driving: fluorine-18-flourodeoxyglucose positron emission tomography analysis, and a literature review of other unexpected clinical effects of zolpidem. J Clin Sleep Med. 2009;5:471–6. [PubMed Central][PubMed]
Doane JA, Dalpiaz AS, authors. Zolpidem-induced sleep-driving. Am J Med. 2008;121:e5
Mendelson WB, author. Sleepwalking associated with zolpidem. J Clin Psychopharmacol. 1994;14:150[PubMed]
Schenck C, Connoy D, Castellanos M, et al., authors. Zoplidem induced amnestic sleep-related eating disorder in 19 patients. Sleep. 2005;28:A259Abstract supplement.
Dolder CR, Nelson MH, authors. Hypnosedative-induced complex behaviours: incidence, mechanisms and management. CNS Drugs. 2008;22:1021–36. [PubMed]
Zammit G, author. Comparative tolerability of newer agents for insomnia. Drug Saf. 2009;32:735–48. [PubMed]
Logan BK, Couper FJ, authors. Zolpidem and driving impairment. J Forensic Sci. 2001;46:105–10. [PubMed]
Gustavsen I, Al-Sammurraie M, Morland J, Bramness JG, authors. Impairment related to blood drug concentrations of zopiclone and zolpidem compared to alcohol in apprehended drivers. Accid Anal Prev. 2009;41:462–6. [PubMed]
Jones AW, Holmgren A, Kugelberg FC, authors. Concentrations of scheduled prescription drugs in blood of impaired drivers: considerations for interpreting the results. Ther Drug Monit. 2007;29:248–60. [PubMed]
Sanofi. Package inserts.
Pressman MR, author. Sleep driving: Sleepwalking variant or misuse of z-drugs? Sleep Med Rev. 2011;
Schenck CH, Boyd JL, Mahowald MW, authors. A parasomnia overlap disorder involving sleepwalking, sleep terrors, and REM sleep behavior disorder in 33 polysomnographically confirmed cases. Sleep. 1997;20:972–81. [PubMed]
Terzaghi M, Sartori I, Tassi L, et al., authors. Evidence of dissociated arousal states during NREM parasomnia from an intracerebral neurophysiological study. Sleep. 2009;32:409–12. [PubMed Central][PubMed]
Hublin C, Kaprio J, Partinen M, Heikkila K, Koskenvuo M, authors. Prevalence and genetics of sleepwalking: a population-based twin study. Neurology. 1997;48:177–81. [PubMed]
Ohayon MM, Guilleminault C, Priest RG, authors. Night terrors, sleepwalking, and confusional arousals in the general population: their frequency and relationship to other sleep and mental disorders. J Clin Psychiatry. 1999;60:268–76; quiz 77. [PubMed]
Pilon M, Montplaisir J, Zadra A, authors. Precipitating factors of somnambulism: impact of sleep deprivation and forced arousals. Neurology. 2008;70:2284–90. [PubMed]
Crestani F, Martin JR, Mohler H, Rudolph U, authors. Mechanism of action of the hypnotic zolpidem in vivo. Br J Pharmacol. 2000;131:1251–4. [PubMed Central][PubMed]
Langtry HD, Benfield P, Zolpidem, authors. A review of its pharmacodynamic and pharmacokinetic properties and therapeutic potential. Drugs. 1990;40:291–313. [PubMed]
Sanger DJ, Joly D, Zivkovic B, authors. Effects of zolpidem, a new imidazopyridine hypnotic, on the acquisition of conditioned fear in mice. Comparison with triazolam and CL 218,872. Psychopharmacology (Berl). 1986;90:207–10
Cirignotta F, Mondini S, Zucconi M, Gerardi R, Farolfi A, Lugaresi E, authors. Zolpidem-polysomnographic study of the effect of a new hypnotic drug in sleep apnea syndrome. Pharmacol Biochem Behav. 1988;29:807–9. [PubMed]
Troy SM, Lucki I, Unruh MA, et al., authors. Comparison of the effects of zaleplon, zolpidem, and triazolam on memory, learning, and psychomotor performance. J Clin Psychopharmacol. 2000;20:328–37. [PubMed]
Danjou P, Paty I, Fruncillo R, et al., authors. A comparison of the residual effects of zaleplon and zolpidem following administration 5 to 2 h before awakening. Br J Clin Pharmacol. 1999;48:367–74. [PubMed Central][PubMed]
Rush CR, Griffiths RR, authors. Zolpidem, triazolam, and temazepam: behavioral and subject-rated effects in normal volunteers. J Clin Psychopharmacol. 1996;16:146–57. [PubMed]
Verster JC, Volkerts ER, Olivier B, Johnson W, Liddicoat L, authors. Zolpidem and traffic safety - the importance of treatment compliance. Curr Drug Saf. 2007;2:220–6. [PubMed]
Partinen M, Hirvonen K, Hublin C, Halavaara M, Hiltunen H, authors. Effects of after-midnight intake of zolpidem and temazepam on driving ability in women with non-organic insomnia. Sleep Med. 2003;4:553–61. [PubMed]
Leufkens TR, Lund JS, Vermeeren A, authors. Highway driving performance and cognitive functioning the morning after bedtime and middle-of-the-night use of gaboxadol, zopiclone and zolpidem. J Sleep Res. 2009;18:387–96. [PubMed]
Verster JC, Volkerts ER, Schreuder AH, et al., authors. Residual effects of middle-of-the-night administration of zaleplon and zolpidem on driving ability, memory functions, and psychomotor performance. J Clin Psychopharmacol. 2002;22:576–83. [PubMed]
Staner L, Ertle S, Boeijinga P, et al., authors. Next-day residual effects of hypnotics in DSM-IV primary insomnia: a driving simulator study with simultaneous electroencephalogram monitoring. Psychopharmacology (Berl). 2005;181:790–8
Bocca ML, Le Doze F, Etard O, Pottier M, L'Hoste J, Denise P, authors. Residual effect of zolpidem 10 mg and zopiclone 7.5 mg versus flunitrazepam 1 mg and placebo on driving performance and ocular saccades. Psychopharmacology (Berl). 1999;143:373–9
Cascade EF, Kalali AH, Reites J, authors. Current status of hypnotic prescribing habits in the United States. Psychiatry (Edgmont). 2007;4:24–5
Roy AN, Smith M, authors. Prevalence and cost of insomnia in a state Medicaid fee-for-service population based on diagnostic codes and prescription utilization. Sleep Med. 2010;11:462–9. [PubMed]
Griebel G, Perrault G, Letang V, et al., authors. New evidence that the pharmacological effects of benzodiazepine receptor ligands can be associated with activities at different BZ (omega) receptor subtypes. Psychopharmacology (Berl). 1999;146:205–13
Zadra A, Pilon M, authors. NREM parasomnias. Handb Clin Neurol. 2011;99:851–68. [PubMed]
Pressman MR, Mahowald MW, Schenck CH, Bornemann MC, authors. Alcohol-induced sleepwalking or confusional arousal as a defense to criminal behavior: a review of scientific evidence, methods and forensic considerations. J Sleep Res. 2007;16:198–212. [PubMed]
Morgenthaler T, Kramer M, Alessi C, et al., authors. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An American Academy of Sleep Medicine report. Sleep. 2006;29:1415–9. [PubMed]
Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW, authors. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med. 2004;164:1888–96. [PubMed]


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MartinPacker 11000094DH Visits (7742)
Nowadays - actually thenadays :-) but more so nowadays - the value of a web page is related to how well structured it is. Well structured from a mashup programmer's point of view... As I often say you have to assume that people will want to take your web pages and mash them up in ways you never thought likely. If your web page is hard to navigate, extract material from, etc then people will use... [More]


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Story highlights
- Ilyse Hogue: It's odd House GOP voted to kill Census Bureau's American Community Survey
- She says survey makes government more efficient, is a critical tool for businesses
- Without it, she says, government will lack crucial information on where citizens are, their needs
- Hogue: If it's a tea party-driven yen to cut waste, it will do the opposite by misdirecting funds
It's always been a mystery to me why Republican lawmakers who denounce the evils of government choose to run for office. If your belief is that the private sector holds the answers to all that ails us, it seems like you would want to go out and prove the case. So the May 9 vote by the House GOP to eliminate the American Community Survey, which collects statistics about the nation's population, is confusing.
Doing away with the data collection would seem to commit two cardinal sins against the right's ideology: Make government less efficient and eliminate a critical tool for profit-driven business.
You may not know the American Community Survey as separate from the U.S. census. While the census takes place once every 10 years, the ACS is an ongoing data collection survey administered by the U.S. Census Bureau to provide more in-depth and current statistics about demographic patterns in America.
This information is crucial if you care about smart direction of the $400 billion in annual state and federal grants to schools, hospitals, infrastructure projects and other critical services.
The data derived from the survey provides guidance about how to divvy up best those hard-earned taxpayer dollars so that they are spent with as much care and precision as possible.
Apparently, that dynamic is lost on U.S. Rep. Daniel Webster, a Republican who beat Alan Grayson to win Florida's 8th Congressional District in 2010. He introduced the amendment to repeal the survey as a way to make good on his campaign promise to "stop wasteful spending." With the affirmative House vote, he hopes to save $2.5 billion over the next decade. Here's the rub though. If Webster gets his way, Americans will spend $4 trillion in that same time period with no data to guide the funds -- essentially shooting in the dark with a massive amount of money.
That's the antithesis of efficiency; vastly more than $2.4 billion is likely to be wasted in the process. It seems that along with climate change and evolution, statistical science now appears to be viewed with suspicion by the tea party. I've not heard an alternative: perhaps a dartboard with pictures of all the states on it?
The GOP claims the survey is intrusive. But I have to wonder if the vote to repeal the survey is just a step toward tea party Republicans' Holy Grail of eliminating government spending entirely and with it, the $400 billion in annual disbursements.
If that is the path forward, let's look at where that road functionally leads us: Without the American Community Survey, we won't know where veterans are living, so we can't get them the financial assistance they're owed for their service to our country. Without the federal and state grants, we simply can't take care of them at all once they come home.
Without the survey, we can't know where there are pockets of uninsured people, so health care funds can be directed toward offsetting the costs of emergency room visits.
Without the state and federal grants, doctors will be forced either to let people suffer and die or raise costs on all their patients to make good on their Hippocratic oath.
Without the survey, we won't know where Americans still lack flush toilets and therefore risk contaminating the groundwater we all drink. Without the federal and state grants, we can't mitigate the impact of raw sewage on our water supply and prevent disease from spreading when our water gets tainted.
Webster might say: "Let the private sector take care of it." On that point, we can agree: The private sector can and should play a larger role maintaining the health of our country. The flaw in that plan is that our business sector is very reliant on the American Community Survey in making decisions about how best to serve their customers. That's why trade groups, including the U.S. Chamber of Commerce and the National Association of Homebuilders have voiced their opposition to the Webster amendment.
The data provided from the survey has informed everything from where to locate new stores to what kinds of products are popular with consumers.
These trade groups are hardly a bastion for government expansionists, and their opposition to this bill reveals the critical wedge in the Republican coalition. The business-first wing of the party is all too happy to allow government to foot the bill -- in this case, for solid market research -- when it's convenient for them. The small-government ideologues are more than happy to dismantle government piece by piece even when it harms business and creates bad spending strategies.
When asked about the elimination of the survey, MIT economist Jonathan Gruber said, "If you're opposed to the survey, you're opposed to understanding what's going on in America." For this reason, it will be an uphill climb to get the measure to pass the Senate and get signed by the president. Still, the initiative and the vote are telling.
If knowledge is power and ignorance is bliss, eliminating the American Community Survey will only pay dividends for those who live in powerful bliss. The rest of us would have to suffer through the mess being made of the informed and democratic process.
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Pottery & Porcelain Marks – Flower & Tree: Almost all of the marks of flowers and trees are realistic and are from the 19th century. Trees and parts of trees, leaves and acorns, were used as marks. The more modern flowers or leaves used in the 20th and 21st centuries tend to be uncomplicated and stylized.
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By: Don Davies, St. Paul Bureau, DL-Online
ST. PAUL – Mike Kilgore says the green Minnesotans pay in a higher tax beginning Wednesday will mean a greener Minnesota in a year.
Minnesota forests will stay green, prairies will turn greener and some wetlands will return to their green state thanks to a sales tax increase voters approved last November, Kilgore said.
The increase, upping the state's portion of the sales tax from 6.5 percent of purchases to 6.875 percent of purchases, is to provide money to clean up the state's water, protect and restore wetlands and prairies, support parks and trails and preserve arts and cultural heritage activities.
The constitutional amendment that voters easily passed is the first statewide sales tax increase since 1994.
The state estimates the higher tax will bring in $234 million in the next year and $247 million the following year.
Kilgore said that it is a good investment.
For instance, he said, 180,000 acres of northern Minnesota forest land will be preserved by the state buying rights to the land, preventing development. Another 200,000 acres of prairies and wetlands will be improved with the money.
Kilgore is chairman of the newly created Lessard-Sams Outdoor Heritage Council, which recommends to legislators how to spend part of the funds. The University of Minnesota professor said the 12-member council received 99 requests for funds and handed lawmakers a recommendation, which was accepted, for 18 projects.
Funds are due to be spent on projects ranging from restoring shallow lakes as waterfowl homes to improving state parks to cleaning water to increasing arts education.
The constitutional amendment that raised the sales tax was designated for outdoors and arts programs, with most discussion about outdoors issues. Legislators approved most of the spending earlier this year, and businesses begin collecting the tax Wednesday, the start of the state's new two-year budget.
Revenue Commissioner Ward Einess said the latest estimates show $481 million will be collected in the next two years.
"Sales taxes have been down pretty consistently every month," Einess said. "I would expect these numbers are the best-case scenario."
The department has heard of no problems from businesses getting ready to collect the new tax, despite the fact that since the last statewide sales tax increase occurred in 1994 many businesses have changed cash registers and computers that figure taxes.
Tax collectors expect some smaller businesses will have problems, or forget to collect the higher tax.
"There is a little bit of a grace period for the first 30 to 60 days," Einess said, although his department will mail reminders to those who do not appear to be collecting the new tax.
The higher sales tax is not the only one Minnesotans will pay. They also face a 1.6 cent-per-gallon gasoline tax increase, part of a 2008 transportation tax increase plan. The tax will continue to rise each July 1 for several years.
Outdoors program supporters gathered Monday on the banks of the Mississippi River in St. Paul, as well as in Duluth and Rochester, to promote work that will begin later this year with the new sales tax money.
"Minnesotans care," declared Paul Aasen, interim executive director of the Minnesota Center for Environmental Advocacy.
But while the money will help preserve and save many of the state's natural features, Jim Cox warned Minnesotans not to expect miracles.
The funds are "not enough to compensate for human progress," said Cox, the Lessard-Sams council vice chairman. "Nowhere near are we going to get Minnesota back to the strong state of health."
Louis Smith, former Minnesota Waters official, said that money going to cleaning up the state's water is vital. But, like Cox, said changes will not happen overnight. "We need to counsel a bit of patience."
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Former Army Captain to Receive Medal of Honor in October
American Forces Press Service
WASHINGTON, Sept. 16, 2013 - President Barack Obama will award the Medal of Honor to former Army Capt. William Swenson for conspicuous gallantry during Sept. 8, 2009, combat operations in Afghanistan's Kunar province.
At the time, Swenson served as an embedded trainer and mentor of the Afghan national security forces with Afghan Border Police Mentor Team, 1st Battalion, 32nd Infantry Regiment, 3rd Brigade Combat Team, 10th Mountain Division.
In a White House statement announcing the ceremony, officials said Swenson will be the sixth living recipient to be awarded the Medal of Honor for actions in Iraq or Afghanistan. He and his family will join the president at the White House to commemorate his example of selfless service.
Swenson separated from the Army on Feb. 1, 2011, and now lives in Seattle. He is single.
The Medal of Honor is the nation's highest award for battlefield gallantry.


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Chef Ernst Dorfler and Gerry Sayers invite you to experience their unforgettable combination of breathtaking views of Vancouver, award winning West Coast cuisine and gracious hospitality in their newly renovated Five Sails Restaurant located at the Pan Pacific Vancouver.
The restaurant features an exclusive private dining room for up to 20 guests, a chic new bar and lounge area with a modern fire feature, the addition of more relaxed dining at cozy elevated banquettes or bar and world class fine dining in a beautiful setting.
Proprietors with a passion for excellence, the experienced husband and wife team of Chef Ernst Dorfler and Gerry Sayers offer their vision of highly personalized hospitality and expertly prepared modern classics inspired by the West Coast region.
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A heartfelt thank you to all of our loyal guests and friends of the Five Sails. We are retiring effective January 1st!
Proprietors – Chef Ernst Dorfler & Gerry Sayers
Suite 410 - 999 Canada Place
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Canada V6C 3E1
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Dress Code: Smart/Business Casual
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A 61-year-old woman with past medical history of restless legs syndrome, and hypothyroidism presents for evaluation of snoring. Her medications include pramipexole 0.25 mg taken at 9 PM, clonazepam 0.5 mg daily, and desiccated thyroid 120 mg daily.
She goes to bed at 10 PM, wakes up at 6 AM unrefreshed, and takes two brief daytime naps. Review of systems is negative for headaches, visual changes, nasal congestion, sore throat, shortness of breath, wheezing, chest pain, palpitations, abdominal pain, numbness, or weakness.
Her Epworth Sleepiness Scale score is 12/24, and body mass index is 26 kg/m2. Physical examination revealed enlarged inferior nasal turbinates bilaterally and Mallampati IV. The remainder of the cardiopulmonary and neurological exam was normal.
Diagnostic polysomnogram (PSG) revealed a total sleep time (TST) of 440 minutes; sleep efficiency of 89%; sleep latency of 2 minutes; and wake after sleep onset of 51 minutes. TST apnea-hypopnea index was 1.7, average oxygen saturation was 96%, and the minimum oxygen saturation was 86%. A 2-h period during the recording shows decreased oxygen saturations to 86% to 92%. A typical epoch is shown in Figure 1.
5-minute polysomnogram sample from stage N2
(more ...)
QUESTION: What is the best explanation for the decrease in oxygen saturation seen in Figure 1, epochs 534-540?
ANSWER: Reduced plethysmography waveform amplitude provides evidence of artifact in the pulse oximetry.
Pulse oximeters calculate the oxyhemoglobin saturation (ratio of oxyhemoglobin to reduced hemoglobin in arterial blood) by spectrophotometry, the quantification of compounds by their light absorption characteristics. The peak absorption frequency of reduced hemoglobin is 660 nm, and the peak absorption frequency of oxyhemoglobin is 940 nm. The pulse oximeter emits red (600-750 nm) and infrared (850-1000 nm) light. A photoreceptor on the other side of the finger receives and isolates the pulsatile signal from which the oxygen saturation is calculated. The pulsatile wave signal also generates a "plethysmogram."1
In the sleep laboratory the plethysmogram wave is utilized to distinguish a non-artifactual oximetry signal from a signal distorted by motion. The shape and amplitude of the plethysmographic waveform provides a representation of changes in blood volume. A decrease in preload can result in plethysmographic waveform variation.2 Vasoconstriction of the upper extremity from sudden exposure to cold has been shown to result in immediate decreases in plethysmography pulsatile amplitude.3 Reduction in plethysmographic pulse amplitude; width and area have been observed in proportion to progressive reduction in stroke volume with an immediate restoration of the pulse wave amplitude, width, and area with normalization of stroke volume.4
Pulse oximetry may also be falsely low due to many factors including: methemoglobin, dark nail polish, hypotension, peripheral vasoconstriction (e.g., hypothermia), or excessive limb movement. In our patient a reduction in plethysmographic pulse wave amplitude was seen when she moved from the supine position to the right lateral decubitus position. The pulse oximeter was on the patient's right index finger. Shift from supine to right lateral decubitus position may have resulted in right upper extremity arterial compression with reduction in plethysmograph waveform amplitude, and artifactual oxygen desaturation. Shift from right lateral decubitus position to supine resulted in improvement in the plethysmograph waveform amplitude and improvement in displayed oxygen saturation.
When a reduction of plethysmographic signal is seen in the supine position, adjusting pulse oximeter placement may also be necessary. In Figure 2, a 2-min sample taken from the PSG of another patient in the supine position shows low plethysmograph amplitude with falsely low oxygen saturation.5 The sleep technologist moved the oximeter to another finger on the patient, which resulted in improved plethysmography amplitude and increased oxygen saturation values. In PSG systems that do not provide for plethysmography, a sudden unexpected drop in pulse oximetry without an accompanying respiratory event should prompt the technologist to check the patient's position for possible compromise of pulse oximetry accuracy.
Reproduced with permission.
Two-minute polysomnogram sample from another patient showing decreased plethysmography amplitude with falsely low oxygen saturation that improved with transfer of the oximeter to another fingerReproduced with permission.
Shape and amplitude of the pulse oximeter plethysmographic waveform provide a representation of blood volume in the monitored extremity.
Compression of an extremity (more likely in the lateral decubitus sleep position) may produce a decrease in pulse oximeter plethysmograph waveform amplitude and inaccurate oxygen saturation.
When the pulse oximetry does not fit the clinical picture, the technologist should change the probe, finger, or body posture if the extremity used in pulse oximetry measurement is compressed.
During PSG interpretation review of the video is important in assessing whether patient position has compromised pulse oximetry accuracy.
This was not an industry supported study. The authors have indicated no financial conflicts of interest.
Hoque R; DelRosso L. Persistent low oxygen saturation on polysomnogram. J Clin Sleep Med 2013;9(9):967-969.
This work was performed at the Louisiana State University School of Medicine in Shreveport, Louisiana.
Wagner JL, Ruskin KJ, authors. Pulse oximetry: basic principles and applications in aerospace medicine. Aviat Space Environ Med. 2007;78:973–8. [PubMed]
Shamir M, Eidelman LA, Floman Y, Kaplan L, Pizov R, authors. Pulse oximetry plethysmographic waveform during changes in blood volume. Br J Anaesth. 1999;82:178–81. [PubMed]
Evans ML, Geddes LA, authors. An assessment of blood vessel vasoactivity using photoplethysmography. Med Instrum. 1988;22:29–32. [PubMed]
McGrath SP, Ryan KL, Wendelken SM, Rickards CA, Convertino VA, authors. Pulse oximeter plethysmographic waveform changes in awake, spontaneously breathing, hypovolemic volunteers. Anesth Analg. 2011;112:368–74. [PubMed]
DelRosso L, Hoque R, authors. RomyNotes atlas of polysomnography. 2013. Charleston: CreateSpace.


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Latest News Archives - QuarterBunny
Latest Reviews
El-Shaddai Take-AwaysNovember 5, 2010 | Luke Comins
Had a crazy deadline and needed some divine intervention. We have recently discovered that there are quite a few bunny-selling outlets along Umgeni Road – but dare to venture into the broad road that leads to construction… with the new … Read More
Curry Up Take AwaysOctober 27, 2010 | Luke Comins
27 October 2010
'Try Us Now For A Taste U Will Neva Forget' is their motto at the bottom of their take away menu… Well, after I'd eaten their quarter broad beans for lunch today I'd certainly say that I'm in … Read More
House of Curries on FloridaSeptember 2, 2010 | Luke Comins
Due to a recent request and invitation by the owner of House of Curries on Florida, we have 're-reviewed' this establishment. A good contingent of QB went to see if Trevor was being clever… and he certainly has been.
Trevor … Read More
Favourites Take AwayAugust 31, 2010 | Luke Comins
Now here's one I haven't tried in ages.
I was on one of my missions to fetch my boy from pre-school and take him home, swap the child friendly Golf for the Vespa and return to work. I'm a rather … Read More
Govenders House of CurriesJanuary 29, 2010 | Luke Comins
This is our second tie-in with our 'Month of Govenders' review and we have, after last week's first Govender disappointment, now regained hope in the 'House of Govender'…
We were a bit thin on the QuarterBunny® team for this review … Read More
Citi FoodsDecember 11, 2009 | Luke Comins
OK, I did say we weren't going to bother with any more bunny outlets on Ummm…geni Road…
On a previous visit to Cha Cha's (almost next door) I noticed Citi Foods and quickly popped my head around the door to check the … Read More
Mrs Govender's Curry Kitchen and Take AwayJanuary 22, 2010 | Luke Comins
"… my favourite places are those dodgy looking corner tea rooms found in weird industrial areas that you only hear about from some old Aunty selling curried pineapple along the Durban beachfront. I think another general rule to selecting your … Read More
Nabibya's Fast FoodsJanuary 11, 2010 | Luke Comins
Another year, another bunny… it was the first day that we were all back at the office after our year-end leave, rather ampt to get back to the plot – to klup more bunnies!
Where to now? Our lahnee mentioned … Read More
Musgrave Pie & CurryJanuary 9, 2010 | Luke Comins
Yet another outlet that we've seen on a few occasions but never at the right meal time… On this occasion I had an appointment with a bank in the centre next door but the bank representative didn't keep her side … Read More
Bushman's Nek HotelDecember 31, 2009 | Luke Comins
I wasn't expecting to get another bunny down before the end of 2009, considering I was now on a family holiday up in the Southern Drakensberg. I suppose Christmas can be full of surprises…
We decided to take time out … Read More


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The Tempe Copper Round Gas Fire & Water Bowl combines simplicity and style to form a decorative centerpiece in your yard or patio. This round fire & water bowl radiates with beauty and charm that will impress your guests for years to come!
- Decorative round gas fire & water bowl
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Designed with a copper finish and sleek style, this powerful Tempe Copper Round Gas Fire & Water Bowl is perfect for illuminating your backyard with dancing flames and shimmering waters. The included mounting hardware makes this unit easy to install and flourish in your backyard decor. The hammered copper bowl has an oil rubbed look that sets it apart from other bowls or fire pits that you would find on the market. Choose a gas type and ignition type that best works for you.


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Germany sends Argentina home in the quarterfinals of the World Cup on Saturday with a crushing 4-0 victory.
Germany's spacing, pace and stingy defense made the Argentines look out of sorts all afternoon. Argentina didn't get their first shot on goal until the 33rd minute, and any time they appeared on the verge of making something happen, the German defense shut it down.
Miroslav Klose scored twice to move into a tie for second on the all-time World Cup scoring list. The dominant display - along with Germany's two other four-goal games - should demand the attention of everyone still playing in South Africa.
U.S. & World
"It was absolute class," Germany coach Joachim Loew said.
Hard to argue with that.
Argentina had been one of the tournament's darlings, with coach Diego Maradona's every move causing a stir and superstar Lionel Messi showing you don't need to score to be sublime. The Argentines rolled into the quarterfinals as one of only two teams to win all its games - the Netherlands was the other - and had been so powerful they never trailed.
No wonder a star-studded crowd was on hand at Green Point Stadium, with German chancellor Angela Merkel, Mick Jagger, Leonardo DiCaprio and South Africa's own Charlize Theron were all spotted in the VIP seats.
But Germany overwhelmed the Argentines, and shut down Messi in the process.
The reigning FIFA world player of the year leaves South Africa without a goal, and was in tears after the game. Maradona walked slowly to midfield with his hands jammed in his pockets when the game ended, and couldn't muster any energy or enthusiasm at his news conference.
"Are you joking?" Maradona said when asked if he was satisfied with his team's performance. "This is a country where you live and breathe football. I don't think that any will be happy when the team loses 4-0."
It was enough to make Maradona clutch his fists in agony, looking as if he was physically pained. The sight of the German offense couldn't have made him any happier.
"To lose like that is very painful," forward Carlos Tevez said. "We played badly and sometimes when you make mistakes you go home."
Germany will play the winner of Paraguay-Spain in the semifinals Wednesday in Durban. This will be Germany's third straight trip to the semis and its 12th overall - nobody has more. But the three-time champions haven't won a title since 1990.
Maybe that's why their celebration was so low-key - the Germans are hoping for something bigger in a week. Players hugged and high-fived each other before walking around the edge of the field to salute the crowd.
"It's important that we should not emotionally overreact," Loew said.
There was no such restraint from the fans. Several hundred stuck around Green Point Stadium for more than a half-hour after the game, dancing, singing and banging on drums.


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|By Pat Romanski
Article Rating:
|May 7, 2012 06:00 AM EDT
Cloud Expo New York $500 Savings here!
Hadoop, MapReduce, Hive, Hbase, Lucene, Solr? The only thing growing faster than enterprise data these days is the landscape of big data tools. These tools, which are designed to help organizations turn big data into opportunities, are gaining deeper insight into massive volumes of information. A recent Gartner report predicts that enterprise data will increase by 650% over the next five years, which means that the time is now for IT decision makers to determine which big data tools are the best - and most cost-effective - for their organization.
In his session at the 10th International Cloud Expo, David Lucas, Chief Strategy Officer at GCE, will run through what enterprises really need to know about the growing set of big data tools - including those being leveraged by organizations today as well as the new and innovative tools just arriving on the scene. He will also help attendees gain greater insight on how to match the right data center tools to a specific enterprise challenge and what processes need to change to handle big data.
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Cloud Expo, Cloud Expo East, Cloud Expo West, Cloud Expo New York, Cloud Expo Silicon Valley, Cloud Expo Europe, Cloud Expo Tokyo, Cloud Expo Prague, Cloud Expo Hong Kong, Cloud Expo Sao Paolo are trademarks and /or registered trademarks (USPTO serial number 85009040) of Cloud Expo, Inc.
- Most Powerful Voices in Security
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- CIA was Headed to an Enterprise Cloud All Along: Jill Tummler Singer
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- Cloud Expo New York Speaker Profile: Jill T. Singer – Federal CIO Emeritus
- Exclusive Q&A with Rich Marcello - Unisys President, Systems & Technology
- Viewpoint: Seven Technical Security Benefits of Cloud Computing
- Deputy CIO of the CIA to Keynote 1st Annual GovIT Expo
- Unisys Named "Platinum Sponsor" of Cloud Computing Expo
- 1st Annual Government IT Conference & Expo: Themes & Topics


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Ideas based on my personal experiences in learning how to manage type 2 diabetes. I stress that I am a diabetic, not a doctor nor a dietician. I have no medical qualifications beyond my own experience. Nothing written here is intended as medical advice, and any ideas you may decide to use should be discussed first with your doctor.
About Me
Monday, June 22, 2009
Choices, Consequences and Responsibility
Naturally we seek qualified professional advice to help us make those choices. Some of us place our lives in the hands of those advisors, some of us use them as just one source of information and seek input from others such as other diabetics, support groups, forums, the internet, blogs, books and similar to assist us.
But that has dangers. There is an awful lot of dangerous nonsense on the web. That is particularly true concerning diabetes, diet and medications. So we must filter those sources using common sense, research and our medical advisors to pick the good information from the rubbish.
There is no doubt that our medical advisors should be our first port of call and the source of the best information. We should value that source above all others. But sometimes that is not always true. Our medical advisors can only offer advice based on their training and professional experience; however, that training syllabus may not always be up to date. If it is current, the research leading to that training may still be continuing, making new discoveries that change the basic premises that advice is based on.
For example, the diagnostic blood glucose levels for diabetes have been steadily reducing over the past few decades. I was not diagnosed for several years when my fasting blood glucose levels were around 7.9mmol/l(140) but a diagnostic fasting blood glucose of 8 applied in Australia. Of course, when I was finally diagnosed the official level had come down to 7(126).
Similarly the guidelines for good blood glucose levels are slowly being reduced. Despite that I see many people reporting their doctors quoting the old ADA guidelines of 2hr post-meal BGs of less than 180 as "tight control" or that it does not matter how high the peak BG spike is, provided that your 2hr BGs have returned to an acceptable level. I mentioned earlier the nonsense we hear from many official sources about our vital need for lots of "good, healthy" carbohydrates.
If those examples are representative of the quality of advice you are receiving from professional sources, try this small test. A multi-choice question for you.
Choose one answer.
Who or which of the following may go blind, lose a limb, suffer kidney failure or have a heart attack if the advice from your Doctor, your Dietician, your Diabetes Educator or the ADA/NHS/DA (Diabetes Australia) is discovered to be incorrect in ten years time?
A. Your Doctor
B. Your Diabetes Educator.
C. Your Dietician
D. The ADA/NHS/DA
C. You.
D. Me.
D. None of the above.
You may use the following links as reference materials while considering your answer:
Research Connecting Organ Damage with Blood Sugar Level
Blood Glucose Targets
Cheers, Alan
Everything in Moderation - Except Laughter.
3 comments:
To an extent this ties in with your previous post. Here in the UK it's not uncommon for doctors, nurses and even dieticians to say things like
"Of course a low carb diet is an excellent idea but I'm not allowed to tell you that"
- 6/26/2009 4:55 am
I also had the classic comment from my GP last week - "Oh, your A1c is amazing, I haven't got the time today to argue with you about your prescription for test strips" :D
- 6/28/2009 5:48 am
- Jim the Guacamole Diet guy said...
"From the start we have to choose who to listen to, who to ignore, what foods to eat, what exercise to do, what medications to take; the list goes on and on."
I think it's odd when people tell me that I should always follow my doctor's advice. On the contrary, if a doctor's advice doesn't make sense to me, I just find another doctor.
- 6/29/2009 1:55 pm


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London Check and Leather International Bifold Wallet
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Item 80060621


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Home >> Course Descriptions >> College of Arts and Sciences
Theories of Counseling and Psychotherapy
Three semester hours.
Familiarizes the student with the principles and practices of a variety of counseling and psychotherapy theoretical models. Concurrent enrollment in PSYC 5301 is required. Prerequisites: PSYC 4301 and PSYC 4303 or permission of instructor. Enrollment in this course is restricted to those TAMIU students who are currently matriculating through either the M.A. Counseling Psychology Program, M.S. in Education (with School Counseling Certification), or completing the School Counseling Certificate.
Home - General Information - Student Services -
Academic Undergraduate Regulations -
Undergraduate Degrees - Academic Graduate Regulations -
Graduate Degrees - Course Descriptions - Faculty -
Appendix A - Appendix B - Appendix C - Appendix D


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A group of young agronomists combined RDP support with innovative financial solutions like crowdfunding to develop a self-sufficient farm growing local, quality organic products.
Projects & Practice
A young female farmer used RDP support to develop a farm business that would provide her with sufficient income in order to become a full time farmer.
RDP support enabled a family farm to improve the quality of the organic wine they produce by financing the purchase of new equipment.
A small group of young farmers started an initiative of collecting and sharing low tech on farm solutions, which then evolved into an digital open platform for disseminating innovations.
A French hazelnut farm used EAFRD support to develop a visitor centre, helping boost direct sales and educate citizens on hazelnut production and processing.
Local authorities in France's Midi-Pyrénées region used EAFRD funding to develop a medical centre to improve the quality of health services particularly for the elderly.
A winemaking cooperative in France's Jura region used EAFRD funding to develop a bio-purification system for managing waste in an environmentally sustainable way.


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Shares of Douglas Dynamics Inc. (PLOW) are heading in a near-term positive direction as the most recent close of the company has stayed above the Balance Step. The Balance Step reading takes into account the last 5 balance points of the weekly period plotted in step formation on a daily chart.
Some investors may be struggling after adding the wrong stocks to the portfolio. Creating a specific plan for investing may help turn the ship around. The stock market is still producing plenty of green arrows, and investors need to be able to capitalize. It is quite reasonable to be optimistic about the investment environment heading into the second half of the year. The next couple of weeks may be the perfect time for investors to put the pedal down and try to develop a strategy that will beat the market over the next quarter. Most investors realize that there are no certainties when it comes to equity investing. It is never a guarantee that a stock or an index will go up or down from one day to the next. Investors who prepare themselves for any scenario should be in a much better place than those who don't.
Stock market investors are typically searching for solid quality companies to help boost the portfolio. There are plenty of quality companies out there, the tricky part may be determining what constitutes as quality. Many investors look for companies that are solid sales leaders within a market that is growing. Going further, investors may be studying a company's proven track record and gauging the competence of current management. Adding other factors such as brand recognition and prospects for steady growth, investors may eventually find a company that is worth taking the risk for future returns.
Investors and traders using technical analysis to examine stocks may be interested in taking a look at the ATR or Average True Range in addition to the Balance Step. Currently, Douglas Dynamics Inc. (PLOW) has a 14-day ATR of 1.08. The Average True Range is an investor tool used to measure stock volatility. The ATR is not used to figure out price direction, just to measure volatility. The ATR is an indicator developed by J. Welles Wilder. Wilder has developed multiple indicators that are still quite popular in today's investing landscape. The general interpretation of the ATR is the higher the ATR value, the higher the volatility.
The Williams Percent Range or Williams %R is another technical indicator worth checking out. Douglas Dynamics Inc. (PLOW) currently has a 14 day Williams %R of -35.40. The Williams %R fluctuates between 0 and -100 measuring whether a security is overbought or oversold. The Williams %R is similar to the Stochastic Oscillator except it is plotted upside-down. Levels above -20 may indicate the stock may be considered is overbought. If the indicator travels under -80, this may signal that the stock is oversold. Chart analysts may also use the indicator to project possible price reversals and to define trends.
The Average Directional Index or ADX is technical analysis indicator used to discern if a market is trending or not trending. The ADX alone measures trend strength but not direction. Using the ADX with the Plus Directional Indicator (+DI) and Minus Directional Indicator (-DI) may help determine the direction of the trend as well as the overall momentum. Many traders will use the ADX alongside other indicators in order to help spot proper trading entry/exit points. Currently, the 14-day ADX for Douglas Dynamics Inc. (PLOW) is 50.27. Generally speaking, an ADX value from 0-25 would indicate an absent or weak trend. A value of 25-50 would indicate a strong trend. A value of 50-75 would signal a very strong trend, and a value of 75-100 would indicate an extremely strong trend.
Traders may be leaning on technical stock analysis to help with investing decisions. Douglas Dynamics Inc. (PLOW) currently has a 14-day Commodity Channel Index (CCI) of 27.23. Despite the name, CCI can be used on other investment tools such as stocks. The CCI was designed to typically stay within the reading of -100 to +100. Traders may use the indicator to determine stock trends or to identify overbought/oversold conditions. A CCI reading above +100 would imply that the stock is overbought and possibly ready for a correction. On the other hand, a reading of -100 would imply that the stock is oversold and possibly set for a rally.
Traders are paying renewed attention to shares of Douglas Dynamics Inc. (PLOW). The current 14-day RSI is presently sitting at 67.11, the 7-day is 60.85, and the 3-day is 43.34. The RSI, or Relative Strength Index is a popular oscillating indicator among traders and investors. The RSI operates in a range-bound area with values between 0 and 100. When the RSI line moves up, the stock may be experiencing strength. The opposite is the case when the RSI line is heading lower. Different time periods may be used when using the RSI indicator. The RSI may be more volatile using a shorter period of time. Many traders keep an eye on the 30 and 70 marks on the RSI scale. A move above 70 is widely considered to show the stock as overbought, and a move below 30 would indicate that the stock may be oversold. Traders may use these levels to help identify stock price reversals.
Successful investors are usually adept at expecting and reacting to sudden change. Things may be all roses when the markets are riding the bulls higher, but environments shift and can leave investors suddenly in the lurch. When times are good, investors may be well served by maintaining a watchful eye on the portfolio. Becoming complacent when everything seems to be working can become a disaster very quickly without the proper attention. Setting up a plan for different market scenarios can greatly benefit the investor. Routinely studying portfolio contents may help when the need to release some underperformers comes. Keeping close tabs on the portfolio may also help fend off a personal panic if events take a dramatic turn for the worse.
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