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Osteoporosis and HIV Disease
Summer 2001
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Bone disorders have emerged as a worrisome complication in persons with HIV infection. Over the past few years there have been increasing reports of osteoporosis (wasting of bone tissue due to bone mineral depletion) and osteopenia (moderate bone mineral depletion) in HIV-positive adults and children. (Osteonecrosis, or death of bone tissue -- a complication apparently unrelated to bone mineral depletion also found in persons with HIV -- will be examined in an upcoming issue of BETA.) To date, the causes of bone mineral deficiencies in those with HIV have not been well characterized, and data related to bone health in this population are now increasingly being collected and analyzed. Though they are currently uncommon in HIV-positive individuals, skeletal fractures associated with osteoporosis can be painful, debilitating, and potentially life-threatening, offsetting any quality-of-life advantages gained by current use of antiretroviral medications where available.
Bone BackgroundBones, which make up the skeleton, are composed of cells embedded in hard intracellular material (known as the matrix) made of mineralized substances and collagen fibers. Bones provide structural support, protect soft body parts (e.g., the brain), serve as protected sites for specialized tissues (e.g., bone marrow), and act as reservoirs of essential minerals (calcium and phosphates). Like all body tissues, bones are in a continuous state of flux. The mechanical integrity of the skeleton and the maintenance of appropriate bone mineral levels depend on a dynamic process called bone remodeling.
Bone remodeling, or turnover, involves two contrasting events: resorption (destruction and assimilation) of bone tissue by osteoclast cells and formation of bone tissue by osteoblast cells. The resorption of bone tissue allows calcium and phosphates stored in bones to enter the bloodstream as needed to maintain an array of physiologic functions, such as blood coagulation (clotting), interneuronal (nerve) transmission, and cell membrane permeability (allowing free passage of fluids). Bone formation acts as a replacement mechanism for bone tissue lost to resorption. Approximately 15% of bone in healthy adults is replaced by turnover each year. Irregular rates of bone resorption and formation -- leading to more bone loss than formation -- are a hallmark of several metabolic bone diseases.
Osteoporosis and OsteopeniaOsteoporosis is a common metabolic bone disorder affecting approximately 25% of women and 13% of men over the age of 50 in the U.S. The disease is characterized by severely low bone mineral density (BMD) and a critical loss of bone mass and strength. Persons with osteoporosis generally have suboptimal rates of bone formation and their stores of calcium in the bone are depleted due to resorption, causing their bones to become more porous and brittle. Osteopenia is a more prevalent condition indicating a less severe reduction in bone mass. Persons with osteoporosis, and to a lesser degree with osteopenia, are at high risk for bone fractures. Thinner bones particularly in the hip and forearm (between the elbow and the wrist) are more likely to break following trauma, such as a fall, or minor stresses that would normally not affect the bone. Persons with thinner bones are also more likely to experience spontaneous fractures in the vertebrae (bones of the spine), which cause curvature of the back visible in older persons with osteoporosis. All types of bone fractures can cause deformities and chronic, disabling pain; some, such as hip fractures, can even lead to death due to secondary complications.
Imbalances in bone metabolism (i.e., remodeling) contribute to many cases of osteoporosis, and several risk factors for bone loss have been identified or proposed. Chief among these is the fact that bone demineralization, or loss of BMD, occurs normally as people age (see "Risk Factors" section below). Individuals who do not achieve peak (optimal) BMD during childhood and adolescence are also more likely to develop osteoporosis, even in the absence of accelerated bone loss in later life.
T-Scores and Z-ScoresBMD is widely used to diagnose osteoporosis and predict risk of fracture. Although BMD accounts for only about 70% of bone strength, bone mineral measurements correlate strongly with fracture risk and load-bearing capacity of the spine and hip.
Measures of BMD are commonly expressed in terms of T-scores and Z-scores. T-scores describe how a given BMD measurement compares with the average (median) peak bone mass in a sex-matched reference population of young adults approximately 30 years of age. T-scores are routinely used to confirm a diagnosis of osteoporosis and to distinguish between normal, osteopenic, and osteoporotic BMD levels. As BMD is generally higher in men than in women, any given T-score in a man will likely signify a higher BMD than the same T-score in a woman. Z-scores are similar to T-scores, except that the average BMD value is drawn from an age- and sex-matched reference population. While Z-scores can provide valuable information, they compare an individual's BMD to only a narrow population group -- which, in the case of elderly persons, may include many people with low BMD -- and are not recommended for diagnosing osteoporosis.
The World Health Organization (WHO) defines osteoporosis as a T-score of -2.5 or lower, or at least 2.5 standard deviations (SDs) below the average for a young, healthy, sex-matched control group. (See "BMD and Standard Deviations" below for an explanation of SDs.) The WHO alternately defines osteoporosis as a T-score of -2 or lower in conjunction with a fracture. Severe osteoporosis is indicated by a T-score of -2.5 or lower in conjunction with a fracture. A T-score between -1 and -2.5 (without fracture) indicates osteopenia. The WHO also classifies persons with Z-scores below -2 as being osteoporotic.
Measuring Bone Mineral Density and Bone LossDual energy x-ray absorptiometry (DEXA) is the standard technology used to measure BMD. This technique, which is one of several forms of densitometry (measuring density by means of light waves), assesses the absorption of radiation by the skeleton. DEXA is highly precise and delivers a very low dose of radiation (less than one-tenth the dose delivered by a chest x-ray). DEXA scans can measure BMD in the spine, hip, and forearm. Bone DEXAs are preferable to soft tissue (fat and lean tissue, e.g., muscle) DEXAs, as they more accurately measure BMD and are more useful in predicting risk of fractures.
Another method used less frequently by clinicians to evaluate the risk of bone loss and response to osteoporosis therapy involves measuring certain biochemical markers of bone turnover, such as alkaline phosphatase and osteocalcin, in blood serum and/or urine samples. Improvements in the technology of these tests may heighten their reliability and accuracy, and efforts to reduce their costs may likewise make them more accessible. One such testing device, known as the Osteomark NTx Point-of-Care, monitors the efficacy of antiresorptive drugs by detecting levels of the NTx peptide (a byproduct of osteoclastic activity) in the urine. The hand-held, disposable device -- similar in concept to a so-called home pregnancy test -- was granted clearance by the Food and Drug Administration (FDA) on August 15, 2001, and can now be purchased at pharmacies with a physician's prescription and be used at home.
Risk FactorsPrimary and secondary forms of osteoporosis should be considered when examining risk factors for the disease. Primary osteoporosis, which is found in both sexes at any age, normally develops in later life as a result of naturally occurring bone demineralization (due in part to the body's gradual loss of efficiency in absorbing dietary calcium). Most men and women lose approximately 0.5-1.0% of bone tissue per year from about age 35. In women who do not take hormone replacement therapy, the lack of sex hormones such as estrogen during and after menopause accelerates this rate of bone loss. Increasing age is therefore a major risk factor for primary osteoporosis, as is female gender and family history of the disease.
Secondary osteoporosis may arise from conditions not associated with normal metabolism or aging. These include a large variety of disorders and diseases such as hyperthyroidism (increased activity of the thyroid gland, which controls the body's metabolism rate) and other endocrine (gland) disorders, blood disorders, genetic disorders, gastrointestinal diseases (e.g., celiac disease, inflammatory bowel disease), rheumatoid arthritis, low sex hormone levels (e.g., hypogonadism), neuropsychiatric disorders (e.g., depression, anorexia nervosa), end-stage renal (kidney) disease, heart failure, and alcoholism.
Chronic use of certain medications -- particularly glucocorticoids -- adversely affects bone density. Glucocorticoids are steroid-based anti-inflammatory and immunosuppressive agents (e.g., prednisolone, hydrocortisone) prescribed for a wide variety of diseases, including rheumatoid arthritis and Crohn's disease (chronic inflammation of the intestines), and also used in persons who have undergone organ transplantation. Glucocorticoids are a subset of corticosteroids. A higher rate of fracture is associated with long-term (beyond two months) use of glucocorticoids. (Nasal steroids such as fluticasone [Flonase, Flovent] act locally, however, and do not adversely affect bone -- although some studies suggest potential bone mineral loss in persons taking nasal steroids as well as ritonavir [Norvir].) Other medications that contribute to bone thinning include ketoconazole (Nizoral; used to treat fungal or yeast infections), anticonvulsants such as phenobarbital (Luminal) and phenytoin (Dilantin), aluminum-based antacids (such as Rolaids) when used excessively, and pentamidine (Pentam, Nebupent; used to prevent and treat Pneumocystis carinii pneumonia [PCP]).
Additional significant risk factors for bone loss include nutritional deficiencies (notably a low intake of calcium or vitamin D), smoking, lack of exercise, low weight, low body mass index (BMI, which is weight divided by height squared), high levels of cytokines (immune system messenger proteins; see "Additional Factors" below), a history of previous fractures, suboptimal BMD during childhood and adolescence, and racial origin (highest risk is seen in Caucasians and Asians).
Risk factors for bone fractures include conditions associated with low BMD. A 2-fold increase in risk of fracture is seen in persons with osteopenia (compared with those having normal BMD). Persons with osteoporosis have a 4- to 5-fold higher risk of fracture. In those with severe osteoporosis (osteoporosis with a previous fracture), the risk for further fractures is increased by 20-fold compared with normal, healthy controls. In addition, fractures are more likely to occur in the presence of other clinical risk factors related to falling. Among these are impaired vision, impaired cognition (mental awareness and judgment), diminished physical functioning, a history of falls, taller height, and environmental hazards (e.g., slippery surfaces).
Osteoporosis in HIV-Positive PersonsRecent reports of low BMD in individuals with HIV disease have confounded health experts. While it is true that in any group of people a certain number will have osteopenia and fewer still osteoporosis (see the normal distribution curve), men, women, and children with HIV infection appear to be far more prone to low BMD than their age-matched, HIV-negative counterparts. Remarkably, fractures related to low BMD in persons with HIV have been extremely rare to date -- but the risk is nevertheless very real and will likely increase over time.
The problem of thinning bones in HIV-positive persons has been described in the literature and at medical conferences only in the past few years. Mary Romeyn, M.D., of the University of California, San Francisco (UCSF) and Julia Ireland, D.O. (Doctor of Osteopathy), of the University of Southern California (USC) were among the first to report on this problem. At the 3rd International Conference on Nutrition and HIV Infection, held April 22-25, 1999, in Cannes, France, Drs. Romeyn and Ireland reported that among 20 HIV-positive men with CD4 cell count nadirs (lowest levels) at or below 100 cells/mm3, nine (45%) had evidence of osteopenia and eight (40%) were diagnosed with osteoporosis. Only three (15%) of the twenty subjects had normal BMD levels. Eight other men with CD4 cell nadirs above 100 cells/mm3 all showed signs of bone density deficiencies: one (13%) had osteoporosis and the remaining seven (87%) had osteopenia. At the 7th Conference on Retroviruses and Opportunistic Infections (CROI) held in San Francisco in early 2000, Pablo Tebas, M.D., and colleagues from Washington University in St. Louis, MO, reported that among 64 HIV-positive subjects taking protease inhibitors (PIs), 32 (50%) were found to have osteopenia and 14 (21%) had osteoporosis. At the same conference, Jennifer Hoy, M.D., of Alfred Hospital in Melbourne, Australia, reported that among a cohort of 74 HIV-positive persons with evidence of lipodystrophy (defined as total body fat less than 20% by DEXA scanning) and suppressed viremia (viral load below 400 copies/mL), 21 (28%) had evidence of osteopenia at baseline and an additional seven (9%) had osteoporosis.
At the 8th CROI this past winter, at least 15 abstracts, posters, and late-breaker presentations focused on bone mineral disorders. Overall, according to various reports presented at the 8th CROI, evidence of osteopenia (based on lumbar spine [comprising the lower back] studies) was found in 21-45% of persons with HIV infection.
Role of HAARTIt is unknown what role, if any, highly active antiretroviral therapy (HAART) plays in the development of low BMD. Studies conducted so far offer conflicting evidence as to whether HAART use lowers BMD and which specific drug classes are more likely to be involved. At this early stage, theories regarding causes of bone mineral deficiencies in those with HIV disease are merely speculative.
The unexpectedly high rates of bone mineral loss reported by Drs. Tebas and Hoy (mentioned above) were found in cohorts of persons with extensive histories of PI therapy. Dr. Tebas' research team also noted that persons taking PI-containing regimens had rates of osteopenia (40-50%) about twice as high as those found in persons taking non-PI-containing regimens or no therapy (20-23%). Other researchers have noted similarly higher rates in persons taking PIs.
The precise mechanisms explaining how PIs might give rise to bone wasting are not known. Dr. Tebas has reported on in vitro (test-tube) studies showing that three PIs -- ritonavir, indinavir (Crixivan), and nelfinavir (Viracept) -- inhibit the conversion of 25(OH)-vitamin D3 (the natural form of the vitamin) to its most potent (bioactive) metabolite, known as 1,25(OH)2-vitamin D, by 80%, 66%, and 31%, respectively. Vitamin D must be in its most bioactive form to properly regulate calcium homeostasis (balance), and therefore BMD levels, in the body. These findings have yet to be reproduced in human studies.
Other researchers discount the possible role of PIs in bone wasting. Drs. Romeyn and Ireland have found in their cohort of 44 HIV-positive men that those with greater exposure to non-nucleoside reverse transcriptase inhibitors (NNRTIs) were more likely to have osteoporosis. PI use did not seem to affect rates of bone loss in this cohort (26% of whom were diagnosed with osteoporosis). These data appeared in a poster presentation at the 4th International Conference on Nutrition and HIV Infection held April 19-21, 2001, in Cannes.
Some researchers believe that lactic acidemia and proposed mitochondrial toxicity associated with nucleoside analog (NRTI) use may be the main culprit. (Lactic acidemia refers to increased levels of lactic acid, which can reduce the normal pH of blood. Mitochondrial toxicity refers to dysfunction of mitochondria, which produce energy within cells.) At the 2nd International Workshop on Adverse Drug Reactions and Lipodystrophy held September 23-25, 2000, in Toronto, Andrew Carr, M.D., and colleagues from St. Vincent's Hospital in Sydney, Australia, reported results of a study assessing BMD in 221 HIV-positive men (mean age of 43 years) recruited to a lipodystrophy (fat redistribution) prevalence survey. The Australian researchers evaluated several parameters (markers) that they hypothesize may be linked with low BMD, including symptoms and signs associated with lactic acidemia (such as nausea, fatigue, and loss of at least 3 kg of body weight within the preceding three months). Forty-four subjects (20%) were found to have osteopenia and seven (3%) had osteoporosis. The only significant independent risk factors associated with low BMD were higher lactate levels (odds ratio [OR] of 2.39 per 1 mmol/liter) and lower weight (OR of 1.06 per 1 kg decrease) prior to starting antiretroviral therapy. (Lactate is the salt form of lactic acid found in the blood.) Both lactic acidemia and duration of NRTI therapy were associated with low spinal (but not low total) BMD. Associations, however, do not necessarily imply a cause-and-effect relationship.
Dr. Carr's team postulated that osteopenia in HIV-positive men may be more likely with lower body mass prior to antiretroviral therapy and "the cumulative duration and magnitude of NRTI-induced lactic acidemia." Dr. Carr suggested that NRTIs may have a direct, damaging effect on the mitochondria of osteoblasts, rendering them less able to form bone. (He did not prove this, however.) He has also suggested that chronic lactic acidemia may cause a bone salt vital to the compressional strength of the vertebrae (hydroxyapatite) to be leached from bone to buffer a higher acid load in the bloodstream.
To date, theories regarding lactic acidemia, NRTIs, and low BMD have not been adequately supported with data and remain controversial. Study design, as always, impacts the value of data and their potential to be widely applicable. Dr. Carr's study mentioned above was cross-sectional (evaluating subjects at one particular time), not prospective (evaluating subjects forward over time). Prospective, or longitudinal, studies yield more reliable data and are almost always preferable. Interestingly, another report given at the 8th CROI by S. Claxton and colleagues from Washington University School of Medicine in St. Louis found no association between osteopenia and lactate levels (or levels of leptin, a neurotransmitter that regulates appetite) in HIV-positive men. These nearly opposite findings may relate to differing methodologies used by the research teams.
Low Bone Mineral Density in Antiretroviral-Naive PersonsSeveral very recent studies have found high rates of bone mineral loss in HIV-positive persons who have never taken anti-HIV drugs. Such reports make it difficult to determine why bone mineral abnormalities were not commonly associated with HIV disease in the literature prior to widespread use of HAART (although anecdotal reports of low BMD in HIV-positive individuals date back to at least 1995, before the era of potent antiretroviral therapy). The majority of data presented at the 8th CROI this past February suggested that persons treated with HAART were not more likely to experience osteopenia than those who were antiretroviral-naive. For example, Adeyemi Lawal, M.D., and colleagues from St. Luke's-Roosevelt Hospital in New York City found equivalent rates of reduced BMD in a cohort of 36 HIV-positive men assessed in 1993 (pre-HAART) and a cohort of 22 HIV-positive, HAART-treated subjects (three women, 19 men) assessed in 1998. (However, there may have been confounding factors in those tested in 1993, e.g., use of corticosteroids as part of treatment for PCP and antifungal therapy.) Hernando Knobel, M.D., Ph.D., and colleagues from the Hospital del Mar in Barcelona found osteopenia in four of 16 antiretroviral-naive subjects (25%), and a statistical difference in osteopenia rates between only HIV-positive and HIV-negative subjects (not between HIV-positive subjects taking HAART and those who had never taken therapy).
Although very preliminary, reports of bone mineral loss in antiretroviral-naive persons are particularly troublesome, as they suggest that prolonged duration of HIV infection or some mechanism linked to HIV disease may be a key factor in the prevalence of the condition. The reports also appear to refute claims that various antiretroviral drugs are responsible for lowering BMD. Nevertheless, it may be that some anti-HIV medications are a cofactor in bone mineral loss if other cofactors are present.
Additional FactorsNumerous other factors, either alone or in combination, might explain unusually high osteopenia and osteoporosis rates in HIV-positive individuals. Interest in these potential contributing causes will likely increase, as data regarding loss of bone tissue in antiretroviral-naive persons continue to accumulate.
Some additional risk factors are characteristics found in older people that are present in some (nonelderly) people with HIV, especially those with later-stage disease and AIDS-related wasting syndrome. These include immobilization or extended bed rest, malnutrition, malabsorption (reduced capacity to absorb dietary nutrients), severe weight loss, and reduced production of sunlight-associated vitamin D.
Hypogonadism, a condition that commonly affects both older individuals and persons with HIV, is a particular concern. Hypogonadism refers to inadequate function of the gonads (sex organs including the ovaries or testes) characterized in part by deficient hormone secretion (estrogen or testosterone). Below-average serum testosterone levels (male hypogonadism) are found in approximately 25% of asymptomatic HIV-positive men who are not taking anti-HIV treatment and up to 50% of men with untreated AIDS. Low levels of sex hormones are known to cause low BMD in both men and women. Nevertheless, not all studies have shown significant bone loss in HIV-positive persons with low testosterone levels. (Women also produce small amounts of testosterone and may develop complications as a result of low levels.) Studies of BMD in HIV-positive women with low female sex hormone levels remain to be conducted.
Researchers have also been looking into the roles played by growth hormone and insulin-like growth factor 1 (IGF-1). Among its other effects on the body, growth hormone (secreted by the pituitary gland) profoundly influences the body's ability to regenerate lost bone tissue. Secretions of growth hormone trigger production of IGF-1 in the liver; IGF-1 in turn stimulates osteoblasts to increase bone mass. As people age, their growth hormone levels often progressively decrease, and adults with a deficiency of growth hormone and IGF-1 have been shown in some studies to have lower BMD. As the growth hormone-IGF-1 axis (or feedback loop) is known to be impaired in those with HIV infection, this metabolic disturbance may have a significant effect on BMD and bone loss in this population.
High cytokine levels also may be a risk factor for bone loss in people with HIV. Cytokines coordinate immune responses by communicating among immune system cells and between immune system cells and the rest of the body. Proinflammatory cytokines amplify immune responses, while anti-inflammatory cytokines diminish immune responses. Certain proinflammatory cytokines -- including interleukins 1, 6, 8, and 12, and tumor necrosis factor (TNF) -- intensify the resorptive activity of osteoclasts; aberrations in cytokine levels thus may lead to increased bone destruction and risk of osteoporosis. As cytokines arise from white blood cells, including CD4 cells, HIV-positive persons with higher activated CD4 cell levels tend to have higher levels of certain cytokines. Whether this phenomenon corresponds with higher rates of osteopenia and osteoporosis remains to be proven in clinical trials. Approaches to anti-HIV therapy may be affected if different classes of antiretroviral drugs influence cytokines in different ways.
Calcium homeostasis in the body is maintained partly by vitamin D activity and in part by a feedback loop that involves the interplay of two hormones: calcitonin and parathyroid hormone (PTH, or parathormone). Calcitonin, which is produced in the thyroid gland, lowers the level of calcium in blood plasma by inactivating osteoclasts and helps to maintain a strong, dense bone matrix. PTH, which is secreted by the parathyroid glands, enables bone resorption (and indirectly promotes increased intestinal absorption of calcium) by activating osteoclasts. PTH levels tend to increase with age and, reportedly, in those with HIV disease. While the mechanisms disrupting the PTH-calcitonin axis are not known, future research may shed light on ways to inhibit this phenomenon.
Unusually high levels of thyroid hormone (thyroxine) can also cause bone loss. Excess thyroxine may be due to hyperthyroidism or poorly monitored thyroxine replacement therapy in persons with hypothyroidism (diminished thyroid function).
Lipodystrophy and WastingSome researchers have conjectured that bone mineral deficiencies may be associated with body fat abnormalities (also called lipodystrophy) seen in HIV-positive persons, as low BMD was first widely detected in people enrolled in lipodystrophy studies. However, studies to date have not shown a correlation between bone wasting and raised levels of blood lipids (fats) and/or disturbances in the locations and quantity of adipose (fat-storing) tissue.
Dr. J.S. Huang and colleagues from Massachusetts General Hospital and Children's Hospital, Boston, reported at the 8th CROI that increased visceral (intra-abdominal) fat among 41 HIV-positive subjects was significantly associated with decreased BMD. In this cross-sectional, observational study, Dr. Huang's team found that the association between low BMD and an accumulation of visceral fat remained significant after controlling for age, PI use, lowest body weight, BMI, and extremity fat (in the arms and legs) in a multivariate analysis. (Once again, however, an association does not necessarily imply a cause-and-effect relationship.) At the same conference, Dr. Tebas and colleagues from Washington University reported that increased intra-abdominal fat did not affect BMD T-scores of the lumbar spine in their cohort of 34 subjects (one woman, three African-Americans). Osteopenia was observed in 15 HIV-positive subjects (45%) regardless of the quantity of adipose tissue in their abdominal region. No significant correlation was found between lumbar spine BMD T-scores and visceral adipose mass or the visceral fat/total abdominal area ratio using DEXA and magnetic resonance imaging (MRI) scans.
Unlike those with lipodystrophy, persons with AIDS-related wasting syndrome clearly exhibit known risk factors for bone deficiencies; it is therefore not surprising that studies have shown low BMD levels in this population. Steven Grinspoon, M.D., and colleagues from Massachusetts General Hospital and Harvard Medical School recently described low lumbar spine and total hip BMD values among 54 men with AIDS wasting compared with 35 healthy, HIV-negative controls. Total hip T-scores were below -1 (indicating osteopenia of the hip) in 17 (33%) of the men with AIDS wasting. All of the subjects with AIDS wasting had free (unbound) testosterone levels in the normal range; hypogonadism was therefore not a factor in the development of osteopenia in these men. Dr. Grinspoon's team published their study data in the May 2001 issue of the Journal of Clinical Endocrinology and Metabolism.
As with HIV-positive adults, bone mineral deficiencies in HIV-positive children and adolescents have been reported only recently. Evidence of osteopenia and osteoporosis in these young people is particularly disturbing not only because they are at risk for achieving suboptimal peak bone mass (a risk factor for osteoporosis) but also because their BMD levels appear to decrease with age. Stephen Arpadi, M.D., M.S., of St. Luke's-Roosevelt Hospital in New York City described a cross-sectional study of 51 HIV-positive children and 282 healthy control children (average age was 8.4 years; 52% males and 48% females) in a late-breaker session at the 8th CROI. Dr. Arpadi's team found that abnormal reductions in total body bone mineral content (TBBMC) were significantly associated with HIV status in their cohort and that TBBMC reductions progressed with age. TBBMC levels were not significantly associated with CD4 cell counts, CD4 cell percentages, or use of PI drugs.
TreatmentWhile researchers and physicians attempt to identify the cause or causes of brittle bones in HIV-positive persons, those who have this health problem are in need of interventions. Fortunately, several standard treatments have been used to prevent further bone deterioration and a handful of possible therapies may even reverse the loss of bone. Physiologic differences between women and men, as well as between younger and older women, must be taken into account when considering treatment strategies related to bone health.
Adequate intake of calcium and vitamin D should be part of any treatment regimen involving loss of bone. Calcium is the most essential micronutrient for achieving and sustaining bone mass and for treating osteoporosis. However, while calcium supplementation helps to maintain adequate BMD in postmenopausal women, it has not been shown to prevent loss of bone by itself. The National Academy of Sciences recommends a daily calcium intake of 1,000mg in adult women aged 19-50 and 1,200-1,500mg per day in postmenopausal women (above age 50). Currently no standard recommendations have been established for men or persons with HIV. Good sources of dietary calcium include dairy products, fruits, and vegetables. Calcium supplements also may be used, although they may cause adverse effects such as constipation. Vitamin D, which is fat-soluble (able to dissolve in fat), helps to maintain normal blood levels of calcium and phosphorous, and allows for optimal absorption of calcium. The National Institutes of Health (NIH) recommends an intake of 200 IU (international units) per day in adults aged 19-50, 400 IU per day in adults aged 51-69, and 600 IU in adults aged 70 and older (recommendations are identical for women and men). At least part of the recommended daily intake may be met with 15 minutes or more of (unclothed) skin exposure to natural sunlight three times per week. Good dietary sources include fish-liver oils, egg yolks, and milk and other foods such as breads and breakfast cereals that are fortified with vitamin D. Persons taking PI drugs for HIV should consult with a health-care provider before considering raising vitamin D intake, as PIs tend to result in high rather than low levels of vitamin D and other fat-soluble vitamins.
Weight-bearing, or high-impact, exercise is also highly recommended (by the American Academy of Orthopaedic Surgeons, among many others) in persons with low BMD. Weight-bearing exercise -- in which force is exerted against the weight of gravity -- stimulates bone formation and strengthens muscles that are attached to bone. It also improves overall balance and agility, which reduces risk of falls and bone injuries. Examples of this type of exercise include weight training, use of Nautilus or Thera-Band equipment, brisk walking, hiking, jogging, and exercising on a stair-climbing or cross-country ski machine. (Weight training and use of Nautilus-type machinery are also known as progressive resistance exercise.) Swimming and bicycling are not weight-bearing activities and do not put adequate stress on bone. To gain maximum benefit, weight-bearing exercise should be performed for one hour at least three times per week on a regular basis.
A variety of drug and hormonal interventions has shown efficacy in treating either the disrupted mechanisms of bone metabolism and/or low BMD and brittle bones in people who are HIV negative. Biphosphonates are antiresorptive molecules that help to restore bone mass in persons with established osteoporosis and reduce the incidence of fracture. Two biphosphonates have been approved by the FDA to treat osteoporosis in women: alendronate (Fosamax) and risedronate (Actonel). These two drugs, in addition to etidronate (Didrocal, which is not FDA-approved for treating osteoporosis), all increased BMD of the spine and hip in a dose-dependent manner and reduced the risk of vertebral fractures by 30-50% in placebo-controlled, randomized clinical trials. Data for use of biphosphonates in men are still being gathered for review. Calcitonin supplementation has been shown in some settings to reduce the risk of fracture. A small prospective study done by Drs. Romeyn and Ireland found that calcitonin stabilized or improved BMD in some osteoporotic HIV-positive men who were also receiving optimal care for their HIV infection, endocrine deficiencies (all were hypogonadal), and nutritional needs (all had a history of AIDS wasting). However, the five-year Prevent Recurrence of Osteoporotic Fractures (PROOF) study of calcitonin involving 1,255 women was inconclusive due to the lack of a dose-dependent response (a significant reduction in vertebral fracture risk was found in the 200 IU daily calcitonin dose but not in the 100 IU and 400 IU doses), the lack of supporting BMD data, and a 60% dropout rate. Salmon calcitonin (Miacalcin) inhaled as a nasal spray is preferable to oral forms in development, which may cause nausea and diarrhea.
Remarkably, PTH may also be used to treat osteoporosis. As mentioned above, PTH enables bone destruction and opposes the bone strengthening activity of calcitonin. However, research presented in the May 10, 2001 issue of the New England Journal of Medicine suggests that PTH (1-34), also called Forteo -- an experimental form of parathyroid hormone comprising the first 34 (of 84) hormonal amino acids -- has the opposite effect by stimulating osteoblasts and promoting bone growth. In their study of 1,326 postmenopausal women in 17 countries, Robert M. Neer, M.D., of Harvard Medical School and colleagues found that treatment with PTH (1-34) in 20 µg and 40 µg doses increased spinal BMD by an average of 11% (compared with placebo), and decreased the risk of vertebral and nonvertebral fractures by an average of 67% and 37%, respectively (compared with placebo). PTH (1-34) was well-tolerated; the most common adverse events were nausea and headache, which were more prevalent in the 40 µg arm. PTH (1-34) must be taken daily by self-injection, a potential drawback for some people. In addition, the study was halted when osteosarcomas (malignant bone tumors) were found in rats during a separate, long-term toxicologic study of the drug. While none of the women developed bone tumors in the clinical trial conducted by Dr. Neer and colleagues, future use of the drug may be limited in persons with compromised immune systems.
As mentioned previously, adequate sex hormone levels are important for bone health in both men and women. Supplementation with testosterone is recommended in HIV-positive men who have low levels of the hormone (compared with healthy controls). According to Dr. Grinspoon, testosterone treatment also benefits eugonadal men (i.e., with normal testosterone levels) experiencing AIDS wasting. (Testosterone supplementation in women may cause unwanted masculinizing effects and is under study at this time.) Similarly, anabolic steroids (synthetic testosterone derivatives) such as oxandrolone (Oxandrin) may prove beneficial as bone treatments. Human growth hormone (HGH, somatotropin, Serostim) is also being investigated by some physicians to counteract bone loss in people with HIV, perhaps by restoring imbalances in the growth hormone-IGF-1 axis. Like testosterone and anabolic steroids, HGH is used mainly to treat AIDS-related wasting syndrome and, in some cases, visceral fat accumulation. Statin drugs (e.g., pravastatin [Pravachol]), which are used to treat high blood lipid (fat) levels, have not been associated with a reduction in the risk of bone fractures. For women, hormone (typically estrogen) replacement therapy or selective estrogen receptor modulators (SERMs, e.g., raloxifene [Evista]) are accepted osteoporosis treatment strategies.
Therapies that address potential causes of low BMD such as altered cytokine levels might play a role in the future management of the condition. Proinflammatory cytokine modulators may include omega-3 fatty acids (found in fish oils) and flavonoids (plant extracts) such as quercetin, curcumin, boswellia, and Pycnogenol. Ipriflavone, however, is not recommended as a treatment for bone wasting. This synthetic flavonoid has not been found in clinical trials to prevent bone loss or improve biochemical bone markers and it appears to induce lymphocytopenia (a reduction in blood lymphocytes).
In addition to therapeutic and dietary interventions, reducing alcohol intake and eliminating tobacco smoking should be encouraged in all persons with low BMD. Almost all studies to date have shown that even moderate levels of alcohol consumption (1-2 drinks per day) contribute to osteopenia, although one curious study published in the November 2000 issue of the American Journal of Clinical Nutrition found that moderate alcohol consumption increased BMD in an analysis of 489 postmenopausal women. As with alcohol intake, tobacco smoking has been linked to osteopenia. Nicotine may also inhibit fracture repair.
PreventionUntil more is known about the etiology (cause) of osteopenia and osteoporosis in HIV-positive persons, certain lifestyle behaviors may contribute to optimal skeletal health. These include sufficient calcium and vitamin D intake throughout life; an adequate, balanced diet; regular weight-bearing exercise; avoidance of tobacco and alcohol; and limited glucocorticoid use.
RecommendationsEven though nearly all HIV-positive persons with osteopenia and osteoporosis to date have been asymptomatic, reports of fractures are expected to increase in the coming years. Routine BMD screening for all persons with HIV infection is strongly recommended by Dr. Romeyn and other (though not all) researchers. Screening should include a baseline DEXA measurement as well as annual BMD monitoring. Osteoporosis screening is especially needed for people with HIV who are more prone to severely low bone mineral levels and related adverse effects, including those with a documented episode of AIDS wasting, a low CD4 cell nadir, or a history of prior fractures. In addition, improved treatments for osteoporosis should continue to be explored and tested. Future strategies to combat bone deterioration will clearly benefit the general population.
This report is Part I in a two-part series of articles related to bone disease. Part II will focus on osteonecrosis in HIV-positive persons and will appear in the Winter issue of BETA.
Nicholas Cheonis is Associate Editor of BETA.
Selected Sources
A note from TheBody.com: The field of medicine is constantly evolving. As a result, parts of this article may be outdated. Please keep this in mind, and be sure to visit other parts of our site for more recent information!
This article was provided by San Francisco AIDS Foundation. It is a part of the publication Bulletin of Experimental Treatments for AIDS. Visit San Francisco AIDS Foundation's Web site to find out more about their activities, publications and services.


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Closed plants and shrinking payrolls, along with recovering corporate profits, have allowed many companies to stockpile cash in record amounts. In February, President Obama cited a figure of almost $2 trillion cash and liquid assets sitting in American businesses' coffers. If you're lucky enough to have a job, is this the time to ask for a raise?
Well, that depends. A study released in August by Towers Watson, a human resources consulting firm based in New York, offered standout employees good news: Companies are planning average pay increases of 4.5 percent in 2012 for salaried non-executive employees with high performance reviews.
Employees who get average reviews, meanwhile, are looking at increases 2 percentage points lower. "The recession has allowed certain employees to shine and has let management see who the real value creators are," says Michael Cavendish, a lawyer in Jacksonville, Fla., who is part of the management team that decides raises and bonuses at his firm.
So this may be a value creator's window of opportunity. If you decide to make your case, human resources experts recommend providing your boss concrete examples, with documentation, of how you have saved the company money or increased revenues, and the ways you have volunteered to step in to shoulder new responsibilities as the company has shed staff. Alan Guinn, an HR consultant based in Bristol, Tenn., suggests being prepared to "define your competency and quantify the value you bring to the company" in 500 words or less.
Getting extra compensation is most likely if you time your move carefully, notes Cavendish. It's probably better to speak up while you're basking in congratulations after a major accomplishment than on the day after the company posts a huge loss.
Copyright U.S. News & World Report; distributed by Tribune Media Services

subset: commoncrawl


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News Release: February 21, 2013
Docket Nos. ER13-85-000, ER13-83-000, ER13-88-000
Item Nos. E-1 & E-2
FERC Acts on First of Order No. 1000 Compliance Filings
The Federal Energy Regulatory Commission (FERC) today issued its first two orders on Order No. 1000 compliance filings, focusing on the regional planning requirements of the landmark transmission rule.
Order No. 1000 requires public utility transmission providers to improve transmission planning processes and allocate costs for new transmission facilities to beneficiaries of those facilities. It also requires public utility transmission providers to align transmission planning and cost allocation. These changes will remove barriers to development of transmission facilities.
In the first order, FERC rejected a proposal by Alcoa Power Generating Inc. (Yadkin) and the North Carolina utility subsidiaries of Duke Energy Corp. for failing to form a transmission planning region that meets the regional scope requirements of Order No. 1000.
The rule states that a single public utility transmission provider, by itself, cannot satisfy the regional scope requirement. Duke Energy Carolinas LLC and Carolina Power and Light Company (Duke-Progress) comprise a single transmission provider for the purpose of complying with this requirement, the Commission said. The inclusion of Yadkins very limited transmission facilities, which currently only exist to serve its hydroelectric facility, is not enough to create a transmission planning region of sufficient regional scope to comply with Order No. 1000. Duke-Progress and Yadkin have 90 days to submit new compliance filings.
In todays second order, FERC waived the regional transmission planning requirements for Maine Public Service Company (MPS), citing a unique geographic and electrical situation that makes it impossible for MPS to meet the regional scope requirement. However, MPS must comply with the requirement that its local transmission planning process consider transmission needs driven by public policy requirements.
MPS has 90 days to make a filing that, among other things, defines public policy requirements and describes how its local transmission planning process will identify transmission needs driven by those requirements.


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Tony Dorsett hopes a proposed $765 million settlement with the NFL can make a difference in the lives of thousands of former players who are suffering from dementia and other concussion-related brain injuries.
Tony Dorsett hopes a proposed $765 million settlement with the NFL can make a difference in the lives of thousands of former players who are suffering from dementia and other concussion-related brain injuries.
Players like Dorsett himself, a Hall of Fame running back.
"There's definitely a dire need for help for these guys ? for us guys," Dorsett told The Associated Press on Thursday.
The settlement would mean immediate compensation for ailing former players and their families, as well as medical exams and treatment for all other retirees ? a group that could total more than 20,000. It also would set aside $10 million for research that the plaintiffs hope will protect future generations from the devastating effects of repeated blows to the head.
The settlement still has to be approved by Senior U.S. District Judge Anita Brody in Philadelphia, something lead plaintiffs' lawyer Christopher Seeger said he expects to happen in the next 60 to 90 days.
"I don't know all the details so I really can't speak to the specifics, but I'm glad to see there's been some movement and some reaction to all this," said Dorsett, who starred for the Dallas Cowboys after winning the 1976 Heisman Trophy at Pittsburgh. Dorsett is the most accomplished and best-known plaintiff in the mass of lawsuits.
"Wow," Dorsett said, pausing. "I'm glad to see this has come to somewhat of an end. But the research obviously is going to be important, the safety of the players is going to be extremely important."
Dorsett and Super Bowl-winning quarterback Jim McMahon were among the more than 4,500 former athletes ? some suffering from dementia, depression or Alzheimer's ? who have sued the NFL since the first case was filed in Philadelphia in 2011. They accused the league of concealing the long-term dangers of concussions and rushing injured players back onto the field, while glorifying and profiting from the kind of bone-jarring hits that make for spectacular highlight-reel footage.
"I'm shocked that it is settled. I'm used to the NFL taking a hard-line approach as they have throughout the years with strikes and everything else," said former offensive tackle Lomas Brown, a seven-time Pro Bowler with Detroit, Arizona, Cleveland, the New York Giants and Tampa Bay. "I'm curious how they came up with the figure and I've got a lot of questions, but I am happy that it's done. Any time the NFL acknowledges they are ready to settle something, it shows they knew they had some sort of negligence."
The NFL has insisted that safety has always been a top priority, and in settling the thousands of cases it admitted no wrongdoing. While a trial could have forced the NFL to disclose what it knew, and when, about concussion-linked brain problems, Seeger said the plaintiffs' greater concern was a fair settlement ? and one that would be paid immediately.
Had the lawsuits gone to trial, it could have been years before the players saw any money. Years the players might not have.
"It's a good day, because we're getting help for those who need help," said Mark Rypien, the MVP of the 1992 Super Bowl for the Washington Redskins. "And a sad day, because we didn't get this done earlier to help guys in the past."
Already, Pro Bowler Junior Seau and former Atlanta Falcon Ray Easterling, one of the first players to file a lawsuit, have committed suicide. Former Philadelphia Eagles fullback Kevin Turner has amyotrophic lateral sclerosis, or Lou Gehrig's disease, at 44, and fears he might not live to see his 50th birthday. Dorsett finds himself forgetting how to get places he's been going for 30 years, and his 10-year-old daughter now complains that they can't do certain things together because "Daddy won't remember how to do it."
"Football has been my life and football has been kind to me," Dorsett said. "But when I signed up for this, I didn't know some of the repercussions; I did know I could get injured, but I didn't know about my head or the trauma or the things that could happen to me later on in life. I'm glad, again, that they've come to some type of resolution, but I've got to see how it all plays out. I hope it will benefit some guys that need help. That's the good thing."
The settlement would cost the league $765 million, the vast majority of which would go to compensate athletes with certain neurological ailments, plus plaintiffs' attorney fees. Under the settlement, individual payouts would be capped at $5 million for men with Alzheimer's disease; $4 million for those diagnosed after their deaths with a brain condition called chronic traumatic encephalopathy; and $3 million for players with dementia.
"They deserve it, there's no question about it," said Mike Ditka, who played tight end for the Chicago Bears and later coached the 1986 Super Bowl winners. "It's absolutely good to see that. I think people have hid behind this too long. It's time it's out in the open."
The settlement also sets aside $75 million for medical exams, and all former NFL players are eligible to seek care, screening or compensation ? whether they suffered a documented concussion or not. The amounts they receive will be based on their age, condition and years of play.
They do not need to prove their health problems are connected to playing football.
"My whole deal, and the other lawsuit with images, is all about health care, which we don't have," said Joe DeLamielleure, the Hall of Fame offensive lineman with the Buffalo Bills. "Some reporter called and said, 'That comes out to $170,000 per man.' I said, 'Good, I don't want that. I want health care.' Because what good is the money going to do you?"
Many had expected the litigation, or at least the negotiations, to drag on longer. And most expected the settlement to be larger.
"I'm not going to say it was settled. I'm going to say it was a good start," said Rayfield Wright, the Hall of Fame offensive lineman with the Dallas Cowboys. "It's not the end of it because there are a lot of other players that will come up with the same situations, so I think the league has to find some kind of way to address the issue because it's going to happen. Those are issues that have to be resolved, and I don't think they're going to be resolved overnight."
But it's better than what the players had before.
"My whole thing through this whole thing is we lived our dreams, the players, and now our families live our nightmares," DeLamielleure said. "Let's help take care of the women and the kids who have to take care of their dads from this stuff."


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Don't Say You Heard It From Me, But, Did You Know…Rod Stewart
Singer Rod Stewart holds the attendance record for most people at a rock concert. On New Year's Eve, 1994, an estimated 3.5 million people showed up at the Copacabana Beach in Rio De Janeiro for a free concert to hear his greatest hits!!


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Now you can configure the LispWorks image to your taste. In the distribution directory
there are two files that have been preloaded into the LispWorks image:
Take a look at the settings in
to see if there is anything you want to change. In particular, you must change the value of
if you have chosen a location for the library which is different to that in the supplied image and moved the image away from the top-level of the installation directory.
If you already have a
personal initialization file in your home directory, examine the supplied example
file for new settings which you may wish to add. Otherwise, make a copy of
in your home directory, naming it
. This file is loaded into LispWorks when you start it up, allowing you to make personal customizations to LispWorks not in the image your fellow users see.
LispWorks Release Notes and Installation Guide - 23 Dec 2011


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I've moved
Due to a change in url I have moved my blog. Don't worry all the same posts and even your comments can now be found at www.crystalcattle.com. So what do you need to do so you don't miss a beat.
1. Head over to www.crystalcattle.com and refollow
Since, my blog moved you'll have to refollow me on the new blog.
2. If you have me in your blog's blog roll (thank you very much by the way) you'll need to update it to www.crystalcattle.com
3. If you have my blog bookmarked change the url to www.crystalcattle.com
Simple as that. This blog will be deleted in the near future so I hope you'll follow me at the new blog.


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Debating when to really change the oil
"We need to talk."
No good conversation begins with those words.
Especially when they're spoken by a dealership service adviser. And all I wanted was a simple oil change.
The guy who answered when I called to schedule an appointment looked me up in his computer and was confused: "Did you get an oil change somewhere else since your last one here?"
Not that I signed any sort of exclusive contract, or tearfully promised to always be true when I bought the car, but no, I didn't. It had been eight months, and I had driven a little more than 9,000 miles. This was apparently very troubling to him, though the car seemed pretty OK with the way things were going.
I had dutifully watched the oil-life monitor count down. I called the next day after it alerted me to "change engine oil soon." This all seemed very straightforward to me.
The service adviser saw it differently. "We need to talk about you going 10,000 miles between oil changes," he said.
When I hung up, feeling fortunate that I hadn't been grounded, I sought a second opinion from the owner's manual. Here's what General Motors -- or at least the poor guy who wrote the 446-page Chevrolet Traverse owner's manual, probably after his boss said, "We need to talk" -- has to say: "When the CHANGE ENGINE OIL SOON message displays, service is required for the vehicle as soon as possible, within the next 1,000 km/600 miles. If driving under the best conditions, the engine oil life system might not indicate the need for vehicle service for more than a year."
The same page also explains, helpfully, that the warning "FUEL LEVEL LOW" appears "if the fuel level is low." Faced with such a looming catastrophe, Owner's Manual Writer Guy suggests I stay calm and "refuel as soon as possible." Clearly, he knows his stuff.
My takeaway was that nine months between oil changes seemed perfectly reasonable, especially given that we drive a lot of highway miles. Still, in the two days before my appointment, I turned to the infallible wisdom of the Internet to see if I had the wrong idea.
Was I actually mistreating my car by only attending to its needs after it told me to? After all, waiting to put my 2-year-old to bed until he admits to being tired is a very, very bad idea.
The conclusion I reached is that, while it obviously wouldn't hurt to go in for service sooner, I'd rather go by the recommended maintenance schedule and the oil-life monitor than become more of a regular in the service-department lounge.
Basically, it comes down to this: GM, which already got my money when I bought the car, says I don't need service more often. The dealership, which stands to profit each time I go in for service, says I do.
Besides, I had taken the car to the same dealership a month earlier for an unrelated warranty repair, and no one urged me to get an oil change then, even after I specifically pointed out that I was close to needing one.
All of this is a lot more than I should have to think about when all I want is an oil change. Most cars today are programmed to tell the owner when service is needed, and almost none need it every 3,000 miles anymore. But the service advisor at my dealership was confident, even before he had seen the car in person, that I was overdue.
That type of approach can quickly build mistrust between dealerships and their customers. If customers get the feeling that the dealership is trying to upsell them into something they probably don't really need, future interactions become suspect.
I'm sure Owner's Manual Writer Guy would agree.
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Bradley Manning Willing To Admit To Leaking Info To Wikileaks, Hoping For More Limited Trial
from the ongoing-process dept
Manning did not plead guilty to the charged offenses in the plea notice. However, significantly, he did indicate with this notice that he is willing to admit to the fact that the act of providing information to WikiLeaks did occur or that the government has evidence that would prove he did commit the act and so he is willing to plea to it.Notably, that report, from Firedoglake's Kevin Gosztola, points out that even if this goes through, Manning could still end up with life in prison for "aiding the enemy."
The notice was a plea to lesser-included offenses—charges with different elements that the judge could agree upon if there is no evidence for the more severe charges. Pleading to lesser-included offenses makes it possible to not plea to committing offenses under the Espionage Act or Computer Fraud and Abuse Act (CFAA). Importantly, he can plead guilty without accepting the government's charge that he "aided the enemy" or "exceeded authorized access" on his computer
Meanwhile, Andy Greenberg notes that merely making this offer does not bind Manning into this admission -- especially if the government doesn't accept the deal (the judge has to accept it first). He can rescind it, and it can't be used against him. It's basically an attempt to speed up the process, along with the recognition that Manning almost certainly is going to be found guilty of something, so the attempt is to narrow down the possible charges to things that aren't quite as severe.


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Though security forces and guerrillas have been fighting a brutal war here for the past 12 years, none of the combatants seems to lack the will to continue.
The British Army has suffered 344 dead and 3,438 wounded, yet it carries on as it has done in the many antiterrorist campaigns Britain has fought since 1945 in such places as Malaya, Kenya, Cyprus, and Aden.
But if British troops are demonstrating their traditional resilience, so, too , is the Provisional wing of the illegal Irish Republican Army (IRA), observers here point out.
The claim that the "corner is being turned in the war against the terrorists, " made by Roy Mason when he was secretary of state for Northern Ireland in 1977, bears an uncanny resemblance to Pentagon pronouncements during the Vietnam war. In fact the IRA is still very active.
One of its "active service units" recently killed a soldier on the border and attacked a British Army post in west Belfast's Whiterock Road, lobbing seven homemade mortar shells at it from the back of a truck. Four shells exploded in the camp, slightly wounding five soldiers. A small boy was seriously injured by shrapnel another shell that stuck neighboring houses. After the mortar attack, troops and terrorists fought a gun battle, the IRA reportedly using US-made Armalite rifles.
In addition three policemen and a policewoman had a narrow escape in Londonderry last month when their Land-Rover was rocked by an explosion set off in a derelict building.
The IRA is not lacking in bombmaking materials, it appears. An Army foot patrol recently discovered 560 pounds of explosives packed into seven milk churns near Greencastle, County Tyrone. The massive bomb, placed in a culvert beneath a road used frequently by the security forces, would have been fired electrically from a hill 100 yards away. An Army explosives expert took seven hours to defuse it.
In early June an Army bomb disposal team spent some tense hours at a farm in the village of Camlough near Bessbrook neutralizing 700 pounds of explosives that had been discovered under a pile of dung.
In the violent ebb and flow of the guerrilla war, the IRA has probably gained the propaganda initiative in recent weeks. The Army concedes that the drive against it received something of a "setback" after the deaths in May of hunger strikers Bobby Sands, Francis Hughes, Raymond McCreesh, and Patsy O'Hara.
Indeed Irish-Americans are thought to have dug deeper into their pockets on behalf of the IRA as a result of their deaths and may continue to do so following the deaths earlier this month of hunger strikers Joe McDonnell and Martin Hurson.
If many British troops loathe service in Ulster, and many of them do -- as much for its frustration and boredom as its perils -- they generally feel they are performing a necessary though thankless task. "I don't actually hear soldiers complaing," says a Royal Artillery colonel. "There is a great deal of job satisfaction in being here. No day is the same as the next."
But the British Army clearly finds urban counterinsurgency a frustrating business. Officers bewail their inability to bring decisive firepower to bear on the IRA. Nevertheless, the Army's frequent distaste for its Ulster assignment is offset by a fierce professionalism and an intense regimental pride.
While troops continually run the risk of being felled by a sniper or blasted by a bomb in Northern Ireland, there are medals to be won and careers to be made in this war. For gallantry a soldier can be awarded the Military Medal and an officer the Military Cross. Bomb disposal officers with a clear head and a steady hand can win the George Medal.
In addition, a general service medal with a clasp bearing the words "Northern Ireland" is awarded to all soldiers who serve over 30 days in the province. Ironically, the present British commander in Ulster, Maj.-Gen. Richard Lawson has been honored by the Pope. He was named a commander of the Order of St. Sylvester by Pope John XXIII when, attached to the UN Congo force in 1962 and armed only with a swagger stick, he rescued a Belgian priest from a mob.
While the Protestant community views the British Army's presence in Ulster with appreciation, though feeling it could do more to crush the IRA, Republicans regard it as an occupying force and charge it with persistent harassment and brutality.
"Morale is very, very high," insists a spokesman at the Army's Northern Ireland headquarters at Lisburn near Belfast. He admits, however, that "everyone would like the whole wretched situation to disappear overnight." There are now 10,850 troops in Ulster as opposed to 21,000 in July 1972 during the height of "the troubles."
The Royal Ulster Constabulary, which suffered its 100th fatality recently when two gunmen shot a Roman Catholic constable in a Newry public house, makes similar claims for its morale. Indeed, it maintains that its losses only make the men and women in its ranks more determined to defeat the IRA and that the dangers it faces daily have not adversely affected recruiting.The force, whose armory contains US M-1 carbines, is attempting to increase its numbers by 400 -- to 7,500.
IRA terrorism has also taken the lives of 52 members of the RUC Reserve. Some 4,000 policemen and reservists have been wounded in the current campaign. "It's a long, ongoing struggle," says an RUC spokesman, conceding that the recent escape of eight Provisionals from the Crumlin Road Jail "tends to knock you back a bit."
Despite the fact that the Ulster Defense Regiment (UDR) has lost 114 men, this 7,518-strong, chiefly part-time force is enjoying "excellent" morale, according to Philip Goodhart, parliamentary undersecretary of state for the armed forces. There is a waiting list to join its full-time batallions, he says.
The regiment has taken over many duties from the British Army in what would appear to be an "Ulsterization" of the antiguerrilla campaign. It was called "a heavily armed gang of loyalist bigots" by the Provisional IRA newspaper Republican News last year. The UDR is an almost entirely Protestant force created to replace the RUC's discredited Special Constabulary, or "B Specials," and is reputed to have connections with loyalist paramilitary groups.
For the British Army in Ulster the battle against the IRA has been essentially one of intelligence. Details about the guerrilla army are obtained from the uniformed RUC, informers (who run the risk of being shot through the knees), undercover police and military units, and, it is thought, from telephone tapping and various electronic surveillance techniques. According to Richard McAuley, Provisional Sinn Fein spokesman in the Ulster capital, "Most telephones in west Belfast are bugged."
Although the Army has "lifted" hundreds of IRA terrorists and seized numerous caches of arms and ammunition, information-gathering by its undercover operatives is a dangerous and difficult undertaking.
"To be successful they actually have to be in the areas," explained a member of the IRA's general headquarters staff to Sinn Fein's Iris magazine recently. "They have to infiltrate reasonably tightknit communities. They have to put themselves into surveillance vantage points in either derelict buildings in urban areas or dugouts [trenches] in rural areas."
A further hindrance to intelligence gathering has been the reorganization of the IRa into a cellular format. "The structure which existed before was basically a command structure based on local areas," the senior IRA man told the magazine. "Now we are based on autonomous cells . . . unknown to all but a very small group of people."
But Britain does appear to have successfully employed one clandestine unit in Northern Ireland.London Sunday Times journalist Tony Geraghty in his book about the elite Special Air Service (SAS) entitled "Who Dares Wins" asserts that one of its most "impressive achievements" in Ulster has been its record of arms hauls and terrorist arrests. In Republican circles the regiment, which pulled off a dramatic hostages rescue at the Iranian Embassy in London last year, is regarded as something akin to the hated "Black and Tans" and Auxiliaries, who waged a ruthless campaign against the IRA in 1920-1921. Activist priests Denis Faul and Raymond Murray have accused the unit of over a score of murders.
In tackling the IRA, the Army and police have not only had to take on its hardened gunmen but its women members as well, who place firebombs, gather intelligence, and find shelter for IRA men. Likewise the youth wing of the IRA has fought on its own way -- transporting guns and bombs, staging incidents, carrying messages, and warning of approaching security forces.
To flush the IRA from the Catholic ghettos of Belfast and Londonderry, military experts say, the British Army would have to employ the sort of ruthlessness and widespread torture that French para-troops under Gen. Jacques Massu used when they rooted National Liberation Front terrorists out of the Algiers casbah in 1957 -- tactics wholly unacceptable to the British government.
The Army's official position on its 12-year campaign against IRA guerrillas is that it has "contained them so that the vast majority of the people in the province can live normal lives." But it has no illusions about defeating the terrorist movement, regarding that as the task of politicians, many of whose positions have become increasingly polarized of late.
When it admits that the struggle could "easily" go on for another 12 years, it is perhaps mindful of the top-secret report prepared in 1978 by the intelligence staff of the British ministry of Defense that predicted the IRA "will probably continue to have the manpower they need to sustain violence during the next five years."
The report, which mysteriously fell into IRA hands in 1979, declared, in the words of its author, Brig. [now Maj.-Gen.] James Glover, that "intelligent, astute, and experienced terrorists" provided the organization's backbone. The caliber of the rank and file, it added, did not support the view that they are "mindless hooligans drawn from the unemployed and unemployable." With a disinterested professionalism the brigadier praised the IRA's bombing techniques and improvised mortars, and suggested that it might improve its arsenal by acquiring, among other things, Israeli-made Uzi submachine guns.
General Glover and those he consulted saw little prospect of any political development "which would seriously undermine the Provisionals' position." His report predicted that the IRA would retain sufficient popular support to maintain secure bases in the traditional Republican areas, support that the best efforts of the security forces have failed to eliminate, as Sinn Fein spokesman Richard McAuley points out.
After 12 years of hunting the IRA through the grim working-class districts of Belfast and Londonderry, and through the fields and hedgerows of the border country, the British Army can console itself with the fact that it has become as adept as an army can be at countering revolutionary guerrilla warfare, particularly in an urban context. Though officers recoil at the suggestion it might be used on the mainland to contain any renewed rioting, they do concede that experience in Ulster has uniquely fitted it for such a role.
The British Army in Ulster will fight on as its predecessors did in the jungles of Malaya and the mountains of Cyprus, waiting patiently for a political solution to the bitter conflict.
But the Royal Artillery colonel is not confident that, as yet, there is a solution. "I feel a miracle is required to bring people to their senses," he says.


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Weekend Cabin: Whistable, England
We have featured an Adventure Journal Weekend Cabin before on Apartment Therapy, and recently another in the series one has caught my fancy.
London-based Danish designer Nina Tolstrup designed her 388-square foot chalet on the beach in Whistable, England and had the structure pieced together by a local builder. About the size of a caravan, the simplistic and modern little cabin is nestled in the middle of a row of twenty-five other chalets.
Click over to The Adventure Journal for more photos of Tolstrup's beautiful space and for more Weekend Cabins.
Images from The Adventure Journal


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Sharon Clements
Sharon Clements is walking in the Brent A. Rosenberg Family Fair & Walk. You can walk too or start a walking team.Share this page on Facebook Tweet this page on Twitter
Meet the Team
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You can still participate by volunteering or donating to the cause.
I can't walk, but want to Cheer the Children!
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Magento 2 developer guide pdfJobs
I need you to write some articles.
It is a short travel guide which in total just over 15 minutes split into 10 smaller files. Each point ranges between 1 and 2.5 minutes. Please provide a voice sample which demonstrates your work.
Write a book Guide to saving tax (UK version) 300 pages
I am a travel consultant and i'm looking to use free travel guides as a way to captures leads for my business. im looking for someone who can write fluent english and has good knowledge on the destinations or holiday types. i would like a nice finished product with nice pictures and good tips.
...SEO keywords in mind. Independent and Motivated – GameSkinny prizes writers who bring savvy research and Google Trends know-how to the table. You know that editors can help guide you, but you are comfortable pitching and delivering your own researched topics. Knowledgeable – Your primary focus is gaming. You do what you write and you know the ins and
...offering and we are super excited. Launching the 1st week in October only leaving us 2 weeks. We need to have consistent and clear direction on our branding and that any PR or marketing is in line with our Brand. So need to engage assistance in the creation of a style guide/Brand bible....
Hi! I'm Renata from Senior Group Srl from Italy. Our company's mission is to make elderly people's life quality better with the help of using our products. We do not want to provide only products but also to act as an expert and be able to help to choose the right product. For this reason we would like to add some illustrations in our product guides. I'm looking for a freelance...
The people who know a city best are either the locals and the travellers. We called them "Chief," and our story began.… Discover the cities, meet with the chiefs, take their advices and send a message to them! ** All details about the places of cities here. Directions, Public Transportation Infos, Visiting Hours, Entrance Fees, Contact Numbers and more... It is also possible to...
Vær venlig at Tilmelde dig eller Log ind for at se detaljer.
Create a corporate style guide for website and infographics that provide color choices to be used for website fonts and colors for custom graphics based on a written style guide. not looking for graphic design but a guide to provide to designers to follow. Person must have previous experance in providing a style guide.
The project is to create a welcome guide document with good design and copy from a provided template layout . There is freedom to create the document with some style to make it unique and fit for purpose . we want the designer to suggest adaptions and be critical of the content to ensure a well deigned product . PDF attached as a guideline off content
We need find a SMM/SEM coach to guide our team make good sales for shopify store. Check following link for detail: [log ind for at se URL]
This is to built a new website CITY GUIDE showing the very best of a city and 12-14 towns around. Website in two languages. Only the best will be selected and will receive more information. Thanks
...would like someone to create 2 x user guides for me, 1 for a user and 1 for an admin It is pretty simple and is for a meeting room system. I need proper annotations, print screens and arrows point and things, and it also has to be very simple to follow. 1 for the user to book meeting rooms and register an account etc 2 for the admin to approve bookings
I am looking for a [python?] script tat would prompt a user to select a single image, then a folder of images and have the images in the folder modified, and saved, to show the same color profile as the model image. Using: Histogram Contrast/brightness Exposure Whatever method may produce reliable results to "normalize" a folder of image sto have the same or similar color and exposure ...
...repair guide to give to our customers when they order phone lcd the flyer must be folder in small size , book style , tri folded a5 page folded size + 1 extra just create me 1, and i can create for all other models we sell to look the repair we take this as example [log ind for at se URL] Front will have our logo , and text for which repair guide this
This project has many features like views slideshow.I want to disable the view slideshow and add responsive [log ind for at se URL] has features such ...[log ind for at se URL] has features such as google translate .It is an educational college website.I want to add the marquee feature.I want to know the region where the logo is [log ind for at se URL] guide and tutorial is required.
I need a Tunisian help me to find the best trip i can have in Tunis Water Parks, Malls,Shopping Sites,Parks,Restaurants,Hotels,Museum,Best Transportation service or Private Taxi , Sea Trips, Translator, Tattoo and much more.....
Hello .. I'm not a Delovber, I just have an idea of app name brides guide .. This app is a Guide of many shops .. So that when you open the app You will find a slide show of many shops Down you'll find a category , Example:- You you enter on the weeding hall You find a weddings hall names and address .. And when you open the final screen You'll
Looking for a smart, savvy content writer to help us with our how to guide content about variouse types of automotive cutting tools. We need 30 core pages written averaging between 500-800 words each, although a few will only require a paragraph or two. Our website is scheduled to launch in about three weeks so we would need the content to be finalized
...Linux/OpenVPN skills to give me an idiots guide to changing the IP Address/Gateway and Subnet Mask. I want step by step commands so that I can make these changes myself. I have no experience in OpenVPN/Linux and have a platform that we can test changes on. I am looking for something like this... 1. command to change ip address 2. command to change gateway 3.
I need guide to start my own smartphone manufacturing company and also want to create os for that. I will pay u for course happy bidding
Hi i need help to setup this python code : [log ind for at se URL] this python code : [log ind for at se URL] I need a Step by step guide to implement CXXT in this script for the use of KRAKEN.
Copywriting a company profile, product user guide, data sheet, etc... for a company working in the software and E-commerce industries.
I have a 100 page labour guide which i need to have creatively designed to look professional so that i could potentially sell it. The guide needs to have a table of contents which allows for quick hyperlink navigation to various sections of the document I would also like to have the ability to make small changes to the document now again I need the
...43 page document that requires to be neatly formatted and prepared as to produce a nice quality finish. Attached is a sample of the document to be reviewed. Also a style guide to set the tone is attached also. Preference is to have it designed within google slides so we can update it in the near future, as it is a slight work in progress atm.
...need a tree size guide image designed similar to the one attached but amended to our branding. - Fonts to use are Nunito and Poppins (attached) - Our gold colour code is #C1A162 - see our website here for our branding style [log ind for at se URL] - Dark background - Our logo is attached We would like the size guide to show sizes 4'
Bonjour, Je souhaiterai faire rédiger un article type Guide de moins de 2 pages à partir d'un sommaire sur le thème du Fiançailles.
...000 entirely new words. Each guide covers a country and this one will only cover one city within that country. The project would involve doing research to fill in various sections in the template. You'd need to follow the style and type of language used, as my name will be appearing on the book. The language of the guide will be UK English. I am not
...location, tour difficulty, price, estimated time of arrival from current location. Then there should be a tab with says " Find Tour Guide" at that point a search will automatically be made to find the nearest tour guide in the area. A list of guides will pop up showing the closets one first, if there are many in the same area "cluster" it should show
Step by Step guide to Starting your cannabis company. It should be related to starting a business in the cannabis industry. You have to research and create a powerful business guide. Further Details on CHAT!!
I need a new website. I need you to design and build my personal website.
I need a new website. I already have a design, I just need you to build my personal website.
On [log ind for at se URL] ([log ind for at se URL]) you can get the lastest guides for beginners, who make the first steps in online gambling, and useful info for the pros as well. I will help you to avoid making mistakes when choosing trusted online casino for your enjoyment.
I need a plugin to integrate a carrier to Woocomerce (Wordpress) to ad guide number and print / download guide label.
1, I am developing a specific tool for potentially thousands of users belonging to about 6 different segment types such as Accountants, Directors etc. 2.I need to get guidance on which tools to use 3.I also need some guidance on the development process - Which do I do first - identify all I want to do and develop each solution one by one or start
Write and design a professionally branded business start-up guide for entrepreneurs. The guide can be high-level but should include graphics/pictures that fit with the brand and theme. The high level steps should be linked with resources or places where they can find additional help and info. My group, "Business Buds" is a monthly business workshop
This position is for SHARE SCREEN and VOICE DISCUSSION sessions. No automatic replies. Please read the whole job description below. Educational tutoring. English Speaker a must. I want to learn the following: *Writing video to Amazon EFS, both in its original form and as transcoded into multiple formats, *Watermarked Video Streaming (HLS) and MP4, migratation to Amazon S3. *Amazon CloudFront s...
Need a document or presentation that collates all troubleshooting guide for SE starters
We have a new logo with style guide but need further strategy and implementation to roll it out. Graphic design, web based design, email templates etc.
Guide me on how to add products, collections and links to Mega Menu in Shopify
I need a guide about 2-6 momentum trading patterns/strategies. It needs to be 10-50 pages long
Dibutuhkan aplikasi sejenis City Guide untuk skala Kelurahan. 1. Ada fasilitas penunjuk arah (peta) dari lokasi user ke titik tujuan. 2. User lain bisa registrasi dan login untuk menambahkan lokasi (misal: rumah makan, event kegiatan, kantor sekretariat, dll). 3. Ada deskripsi dari masing-masing tempat tujuan (nama, profil singkat, foto, kontak
I'm looking to convert an international idea and make it local. Initially I was looking to build an application similar ...to build a website instead. It is less expensive and I personally have build websites for a few companies through wordpress. However, I'm not a coder myself and I need a developer to work with me. Let me know if you're interested.
My mom does not speak English so I need a translator for section 8 housing project
That from where i can get [log ind for at se URL],construtions, and all Data with owner name email
...attractive PDF version of a 20 page health transformation guide that is currently in word format. I basically want it to be visually appealing with a nicely designed cover page and other design elements throughout the guide. Various formats of my logo are attached and feel free to use stock images that are consistent with the purpose of the guide for the
I need artist to make an e-book on step wise drawing guide
i will need a female tour/ translator in Ho chi minh city to make arrangements to to travel to Long Khah...travel to Long Khahn, Dong Nia city outside HMC to meet my friends mother that only speaks Vietnamese on 9-15-18 go there for lunch and return back to HMC 4-6 hours day one day 2 show me around the city not sure on price so please inquire
Hi i need a guide written on how to compile qt altcoin wallets from start to finish. guide would need to include all software links and dependencies links and download locations. written in an easy to follow instructions for a newbie to linux commands. i would need to know what linux version i would need to use to follow the instructions etc.


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Cute Ukulele Tune is a sunny and positive track featuring happy glockenspiel melodies, bouncy reggae kind of beat, and of course the ukulele. Perfect for commercials, animations, presentations and personal videos with a positive, lively vibe.
The File you get includes two versions:
Cute Ukulele Tune – 2:36
Cute Ukulele Tune (Shorter Version) – 1:53
The preview track also includes both of these versions! Please skip to 2:37 for the shorter version.
Please, don't forget to rate your purchase! Thank You!
You might also like: Happy Ukulele Rock or Sunny Side Of The Street


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Outdoor Valentine's Decor: How to Stencil Snow With Beet Juice!
Beet juice is one of those things you likely avoid at all costs - the intense red posing a serious threat to all that is porous and pristine. For this reason, "white" and "beets" are not usually such a good match. Well, I beg to differ... so long as the "white" refers to snow! Check out how I, er, beet the odds with this sweet and simple outdoor decor project, just in time for Valentine's Day.
What You Need
Jar of beets or water from boiled beets
Rubber gloves
Empty Spray bottle
Heavy Paper
1. Using the funnel, decant beet juice into empty spray bottle. Dilute with equal parts water if using jar juice. I recommend doing this over the sink while wearing rubber gloves.
2. Fold paper evenly in two.
3. Cut half-heart shape on the fold, being sure to leave 3" or more around the edges.
4. Head out into the cold and lay stencil upon crisp white snow!
5. Set spray nozzle to mist.
6. Mist the beet juice evenly on the cut-out, bottle angled to avoid spraying outside the edge of the paper
7. Carefully remove stencil and repeat!
Additional Notes: The less absorbent the paper the better. Acetate also works, but does not like to be folded! Also, it's best to check the forecast before you begin; what a shame it would be to have your hard work covered up by a fresh snow-fall!
Want more smart tutorials for getting things done around the home?
See more How To posts
We're looking for great examples of your own household intelligence too!
Submit your own tutorials or ideas here!
(Images: MaryAnne Petrella)


text: In Winnipeg Lawrence worked as a set builder and painter with Actors' Showcase – a theatre company for children, The Manitoba Theatre Centre, and The Warehouse Theatre.He moved to Vancouver in 1975 after spending a summer at The Banff School of Fine Arts and worked for The Arts Club Theatre and the Playhouse Theatre before joining The Conservatory, a group of artists and actors who promoted alternate theatre for Vancouver audiences. For the Conservatory, as well as creating sets, he produced posters and theatre programs.In 1979, he attended Langara College's Fine Arts program where he met and studied with Canadian artist Leslie Poole. Following art school, he began painting, while continuing to work in theatre. As his painting developed he began showing his work in various galleries around Vancouver, as well as doing graphic work for other small theatre companies, and publishing cartoons in local magazines.He now makes his home in Crescent Beach, where he continues to paint. Some of his work can be seen in the art rentals program at the Semiahmoo Recreation and Arts Centre where he also volunteers.Artist's Statement In my paintings I want to suggest emotion through visual story-telling, juxtaposing ordinary elements in unusual ways to trigger thoughts or feelings that might not otherwise arise, the way images appear in dreams, inviting deeper investigation.


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Question: Is this accessory needed to be able to have the Raspberry pi's 3.3v GPIO out signals to pilot an 8 channel 5v opto-isolated relay board?
So far I see the 3.3v with a voltmeter, the signal appears fine and stable, when triggering the out on the GPIO pin using BerryIO... so the pin outputs the voltage just fine, although the relay board doesn't seem to work even when everything is powered on and connected as it should. Could anyone lend a hand? Do I need the 8-channel Bi-directional Logic Level Converter - TXB0108 to get a usable signal that could drive the relay board?
Thanks in advance for any and all help.
Cheers! :)


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Individual Rights of Access
Types of Information
Individuals already have the right of access to information about them ('personal data') which is held on computer, and in some paper files, under the Data Protection Act 2018. As far as public authorities are concerned, Freedom of Information will extend this right to allow access to all types of information held, whether personal or non-personal. This right came into effect in January 1995.
The Act does, however, set out some exemptions to this right and it also places a number of obligations on public authorities about the way in which they provide information. Subject to the exemptions, anyone making a request has the right to be told whether information exists and the right to receive the information. In general, a response must be provided within 20 working days.
There is also a duty on public authorities to provide advice or assistance to anyone seeking information (for example, in order to explain what is readily available or to clarify what is wanted).
More information about making a Right of Access request under Freedom of Information can be found on this website.


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It is human nature to want to make a good impression. Whether we know it or not, we tend to influence the perception of others with a goal in mind by using impression management. It is often seen in different forms, such as, the way we dress for a job interview, the type of cars we drive, and technology we embrace.
We create an image of ourselves in order to claim personal identity and how we present ourselves is reflective of that image. It is who we are as humans to do this process, consciously or unconsciously. But what about your brand? Do you use impression management for your organization, as well? Of course you do. We are all well aware of the importance of brand management and how it can affect the decisions of consumers if the implementation is properly done or not. In reality, we often use impression management for organizations and tie it into brand management.


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Yvonne Richards, 76
Yvonne Marie Richards, age 76 of Broken Bow, passed away at her home May 31, 2013. She was born at Pleasant Townshipof Cass County Iowa to Albert and Emma Rudig. She graduated high school May 13, 1955, at Griswold , Iowa. May 12, 1955, she married Earl Edward Richards at Council Bluffs Iowa. While living in Iowa she worked at her brother Richard Rudigs cafe.She also worked at a hardware store , grocery store and at the school. In November 1979, Earl, Yvonne and son Max moved to Thedford where they lived on a ranch. She worked several places including a cook at the school; she enjoyed the school kids. Her yard was always in tip-top shape and decorated for every season andholiday. She loved Nebraska football and did alot ofcoaching at the tv set!! After her husband passed away she moved toBroken Bow where she lived in an apartment. Shemade many great friends and had alot of fun. Surving her are her children, Linda (Tim) Stattler, Susan (Jeff) Davis, Mike (Colleen) Richards, Max (Christy) Richards; hersister, Anna Mae Courcer; two brothers, Dennis and Stanley; 11 grandchildrenand many great-grandchildren. She was proceded in her passing by husband Earl; brothers, Richard, Dale, Albert JR, and her faithful dog Pugs. Memorial graveside services will be Friday, June 7, 2013, at 1 p.m. CDTat the Hillcrest Cemetery in Thedford. The Rev. Linda Martin and the Rev. Steve Shanno will officiate. Memorials may go to St. Jude's Children's Hospital. Arnold and Mullen Funeral Homes are in charge of arrangements.Published in Custer County Chief, June 6, 2013


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Stokke Tripp Trapp Baby Set-Aqua
$ 69.00
Brand Stokke
The Tripp Trapp Baby Set is designed specifically for babies and smaller children to let them sit securely and comfortably at the table, where they will start imitating the social, verbal and motor skills of those around them.The baby set consists of high back and rail supports. Your child can start using Tripp Trapp with the Tripp Trapp Baby Set when they are able to sit up unaided, usually around the age of 6-9 months. It can be used until your child is approximately 3 years, providing protected seating for your child. The baby set is available in the same color range as the Tripp Trapp chair. Dishwasher safe


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Veterans Group IAVA Honors Sesame Founder Joan Ganz Cooney
By Graydon Gordian
On Tuesday night the Iraq and Afghanistan Veterans of America (IAVA) hosted their sixth annual Heroes Gala, and Sesame Workshop co-founder Joan Ganz Cooney and her husband, Chairman Emeritus of the Council on Foreign Relations Peter G. Peterson, were honored at the event. Mrs. Ganz Cooney received the IAVA's 2012 Civilian Service Award in recognition of all the work Sesame Workshop does to help military families, but in particular Sesame's Talk, Listen, Connect outreach initiative, which focuses on providing military parents with the tools they need to discuss complex issues like deployment, relocation, injury and the loss of a parent with their children.
"Many parents don't have the right words to help explain to their child what happens when they must go away, how to reassure their children when they return from service injured, or worst of all, when a parent dies," Mrs. Ganz Cooney said while accepting the award. "But with the right language, support, and the help of the Muppets, we are able to help. Since its launch, our Talk, Listen, Connect initiative has grown to reach virtually every U.S. military family with young children."
Mrs. Ganz Cooney went on to thank the IAVA, saying, "It makes it all the more meaningful to receive this honor from an organization that is working every day to advocate for and support our veterans and their families."
To learn more about the Talk, Listen, Connect initiative, click here. To get a firsthand look at the resources and tools we provide for military families, visit Military Families Near and Far.


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The most nervous Sam Smith has been for a performance during his young career took place about three weeks ago at Studio 8H in New York City's Rockefeller Plaza.
The 21-year-old British soul singer was the musical guest on "Saturday Night Live" March 29, hosted that week by actor and comedian Louis C.K. Smith said he wasn't very familiar with the show's format but was well aware of its significance and reach.
"I've never been that happy after a performance," said Smith over the phone from Los Angeles April 15. "Seven million people viewing, I haven't got an album out, nobody knew who I was and I'm put on one of the biggest TV shows ever. Yeah, it felt scary. But it was empowering."
Smith — set to perform Tuesday at The Vic — said most of his family and friends back home knew it would be big moment for him. And if they didn't realize it before he sang "Stay With Me" and "Lay Me Down," they did once his name was trending on Twitter afterward.
With tequila in one hand, Smith recalled, he excitedly read as many of the tweets as he could. Can you blame him? This wasn't some jaded singer who has been there and done that, but a relatively unknown artist in the U.S. trying to enjoy the moment.
Smith was introduced to audiences when he guested on Disclosure's 2012 single "Latch" and Naughty Boy's 2013 single "La La La," both of which landed on Billboard's Hot 100 chart. Now he's ready to take the next step with his debut album, "In the Lonely Hour," which is scheduled to hit stores June 17. It purposely doesn't include any guests. Smith has done the collaboration thing and wants to show what he can do on his own.
Isolation, after all, is the theme of the album.
"I've never been in a relationship," Smith said. "I wanted to write love songs — that's the music I adore. But the only kind of love I can talk about is unrequited love, when someone doesn't love you back. I fell in love with someone that didn't love me back. I was feeling so lonely and wanted to get over it. And I have by writing this album.
"When I'm feeling sad, I like to hear music that explains my feelings. This whole album, I didn't want to put out a happy album and hide and lie. I wanted to be honest."
Sad music doesn't always translate well in concerts. How does Smith compensate for the isolation in his songs when he's performing live?
"My key is to sing my (butt) off," Smith said, "and pray they stay with me."
Last Sunday, Smith got on stage with Disclosure to perform "Latch" in front of thousands of people at the Coachella music festival in Indio, Calif. It wasn't the biggest crowd he's played for. He performed the song with Disclosure at a 2013 radio station show in front of a crowd of 80,000 at Wembley Stadium in London.
"I'm more comfortable performing in front of 50,000 people than five people — it's easier," Smith said, pointing out that you don't really see faces in the crowd when there's a large audience. "When there's that many people, I feel like I'm alone. When I perform in front of only a few people, it's scary."
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Sam Smith
When: 8 p.m. Tuesday
Where: The Vic, 3145 N. Sheffield Ave.
Tickets: Soldout, victheatre.com