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Pubblicazioni - De Maria Dott.ssa Renata
Effectiveness of a home-based therapeutic exercise program on lower back pain and functionality in Sickle Cell Disease (SCD) patients.
Hematol Transfus Cell Ther2020 Jun;():. doi: S2531-1379(20)30075-4.
Zanoni Camila Tatiana, Galvão Fábio, Maria Renata Manzano, Zulli Roberto, Ricciardi Janaina Bosso, Cliquet Alberto, Saad Sara Teresinha Olalla
To investigate the effectiveness of a home-based therapeutic exercise program on lower back pain and functionality of SCD patients.
A Hematology and Transfusion Medicine Center, University of Campinas (HEMOCENTRO-UNICAMP).
This was a prospective study, with a three-month follow-up of SCD patients with lower back pain. The lumbar spine functionality was evaluated by questionnaires, trunk flexion and extension analyses by fiber-optic-electrogoniometry and measurements of muscle strength of trunk flexor and extensors. The Intervention Group (IG) comprised 18 volunteers, median age 44y (28-58) and the control group (CG) comprised 15 volunteers, median age 42y (19-58), who did not perform exercises. The protocol consisted of daily home-based exercises with two evaluations: at the beginning and end of a three-month program. In order to compare the groups at baseline, the Fisher´s exact test and Mann-Whitney test were used for categorical and numeric variables, respectively. The Wilcoxon test was used for related samples comparing numeric measures of each group over time with a 5% (p?0.05) significance level.
After the intervention, patients demonstrated a significant improvement, according to the Visual-Analog-Scale (VAS; p?=?0.01), Rolland Morris Disability questionnaire (RMDQ; p?0.01) and trunk flexion and extension muscle strength (p?0.01). No significant differences were found for the Start-Back-Screening-Tool-Brazil (SBST) and in measures of trunk flexion and extension range-of-motion (RoM).
Results suggest that daily home-based exercises for a three-month period ameliorate pain and improve disability related to lower back pain and muscle strength.
Copyright © 2020 Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular. Published by Elsevier Editora Ltda. All rights reserved.
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Coping, Mood, Quality of Life, and Outcomes in Recipients of Left Ventricular Assist Devices: A Cluster Analysis.
Psychosom Med;81(2):192-199. doi: 10.1097/PSY.0000000000000658.
Modica Maddalena, Minotti Anna, De Maria Renata, Scaglione Anna, Bordoni Bruno, Cipriani Manlio, Russo Claudio, Racca Vittorio, Ferratini Maurizio
Left ventricular assist devices (LVADs) are increasingly used for temporary circulatory support until transplant or as destination therapy for patients with end-stage heart failure. Understanding patients' attitudes and resources is crucial to support them.
Sixty-one LVAD recipients (55 [10] years, 10% women, 15% destination therapy) participating in cardiac rehabilitation (CR) postimplant underwent assessment of coping styles (Coping Orientation for Problem Experiences), quality of life (Medical Outcomes Study Short-Form 36, Minnesota Living with Heart Failure Questionnaire), and mood (Hospital Anxiety and Depression Scale).
Cluster analysis identified two homogeneous groups: C1 (n = 18) patients had higher anxiety (9.6 [5.0] versus 4.0 [2.7], p < .001), depression (10 [3.0] versus 4 [2.7], p < .001), and avoidant coping (29 [5.2] versus 21.2 [3.8], p < .001) scores and worse quality of life (Short-Form 36 of the Medical Outcomes Study Physical Component Scale 31 [5.3] versus 35.6 [6.9], p < .001; Mental Component Scale 34.3 [6.8] versus 50.3 [8], p < .001; MLHFQ physical 26 [7.2] versus 13.9 [8.2], p < .001; emotional 17.7 [3.4] versus 3.86 [3.2], p < .001) than C2 participants (n = 43). During 31 (15-54) months, 20 patients (33%) died. By Cox multivariable analysis, after adjustment for age, sex, Interagency Registry for Mechanically Assisted Circulatory Support level at surgery, and meters walked during 6 minutes at CR discharge, C1 was associated with mortality (hazard ratio = 2.858; 95% confidence interval = 1.102-7.408, p = .031; model ? = 7.286, df = 5, p = .20). Survival was 44% in C1 and 77% in C2 (log-rank p = .033).
Among patients discharged from CR after LVAD implant, one third show a profile characterized by worse perceived quality of life, mood disorders, and dysfunctional coping that is associated with long-term mortality, and these factors are potential targets for post-LVAD intensive support.
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[ANMCO position paper on sacubitril/valsartan in the management of patients with heart failure].
G Ital Cardiol (Rome)2018 Oct;19(10):568-590. doi: 10.1714/2978.29843.
Di Tano Giuseppe, Di Lenarda Andrea, Gabrielli Domenico, Aspromonte Nadia, De Maria Renata, Frigerio Maria, Iacoviello Massimo, Mortara Andrea, Murrone Adriano, Nardi Federico, Oliva Fabrizio, Pontremoli Roberto, Scherillo Marino, Senni Michele, Urbinati Stefano, Gulizia Michele Massimo
Sacubitril/valsartan, the first-in-class angiotensin receptor neprilysin inhibitor (ARNI), is the first medication to demonstrate a mortality benefit in patients with chronic heart failure and reduced ejection fraction (HFrEF) since the early 2000s. Sacubitril/valsartan simultaneously suppresses renin-angiotensin-aldosterone system activation through blockade of angiotensin II type 1 receptors and enhances the activity of vasoactive peptides including natriuretic peptides, through inhibition of neprilysin, the enzyme responsible for their degradation. In the landmark PARADIGM-HF trial, patients with HFrEF treated with sacubitril/valsartan had a 20% reduction in the primary composite endpoint of cardiovascular death or heart failure hospitalization, a 20% lower risk of cardiovascular death, a 21% to 20% lower risk of a first heart failure hospitalization, and a 16% to 20% lower risk of death from any cause, compared with subjects allocated to enalapril (all p<0.001).Following the trial, new international guidelines endorsed sacubitril/valsartan as a class I recommendation for the management of patients with HFrEF who remain symptomatic despite optimal medical management. In Italy, sacubitril/valsartan is reimbursed by the National Health Service since March 2017 within criteria set by the Italian Medicines Agency subject to patient inclusion in a dedicated monitoring registry. Although numerous post-hoc analyses of the original trial suggested that the benefits of this innovative medication may extend across a variety of subgroups, many questions do not yet have an evidence-based answer.In this position paper, we discuss the current role of sacubitril/valsartan in the management of chronic HFrEF, treatment eligibility and the modulating role of patients' characteristics. Moreover, we address concerns elicited by the PARADIGM-HF study and shortcomings of this novel drug, to clarify the place of this new therapy in the context of global care of heart failure in Italy. Our aim is to provide clinical cardiologists with a concise and practical guidance on when and how to use sacubitril/valsartan, to assist clinicians in closing the gap between scientific innovation and real-world experience.
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A handbook for the clinical cardiologist about CRT/ICD. A practical guide about how to survive during an on call shift.
Minerva Cardioangiol2018 Oct;66(5):631-645. doi: 10.23736/S0026-4725.17.04476-0.
Lucà Fabiana, Biscottini Emilia, Cipolletta Laura, Marini Marco, Caretta Giorgio, Lavorgna Alberto, Vagnarelli Fabio, Di Fusco Stefania A, Procaccini Vincenza, Riva Letizia, Vianello Gabriele, De Maria Renata, Giardina Achille, Gulizia Michele M
Cardiac resynchronization therapies (CRTs) have been demonstrated to improve the clinical management and prognosis of selected patients with heart failure. CRT devices include both CRT pacemakers (CRT-P) and CRT defibrillators (CRT-D), with the latter being used to treat life-threatening ventricular arrhythmias. A significant advantage of CRTs is the ability to monitor several vital parameters which, thanks to advanced technology, may be remotely assessed. Personalized programming options allow patients to receive the maximum benefit from these treatments. In this review we report the main diagnostic and therapeutic algorithms used in clinical practice.
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[Noninvasive ventilation and sedation: evidence and practical tools for its utilization].
G Ital Cardiol (Rome)2017 Jun;18(6):513-518. doi: 10.1714/2700.27612.
Battistoni Ilaria, Marini Marco, Caretta Giorgio, Vagnarelli Fabio, Lucà Fabiana, Biscottini Emilia, Lavorgna Alberto, Procaccini Vincenza, Riva Letizia, Vianello Gabriele, Aspromonte Nadia, Iacoviello Massimo, De Maria Renata, Valente Serafina, Gulizia Michele Massimo
Noninvasive ventilation (NIV) has gained increased acceptance inside the critical area, since it has been shown to be effective in reducing or avoiding the need for oro-tracheal intubation. NIV efficacy is dependent on the selection of the appropriate patients and on their compliance to therapy. Actually, full collaboration is not easily reached especially in agitated patients.Sedation during NIV is useful to reduce the rate of treatment failure, but robust data to guide the development of best practice are limited and sometimes local customs appear to exert a strong influence on patterns of care. Different sedative drugs are ready for use but none of currently available agents fulfill the criteria for the ideal drug. Knowledge of the pharmacological and hemodynamic characteristics of every single sedative agent is crucial to choose the right drug for every clinical scenario. Close monitoring is mandatory to avoid adverse effects. The aim of this article is to review the currently available literature, to recognize the contraindications for sedation use and to provide practical guidance.
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Antioxidant and inflammatory biomarkers for the identification of prodromal Parkinson's disease.
J Neurol Sci2016 Nov;370():167-172. doi: S0022-510X(16)30615-3.
Campolo Jonica, De Maria Renata, Cozzi Lorena, Parolini Marina, Bernardi Stefano, Proserpio Paola, Nobili Lino, Gelosa Giorgio, Piccolo Immacolata, Agostoni Elio C, Trivella Maria G, Marraccini Paolo
We explored the role of oxidative stress and inflammatory molecules as potential Parkinson (PD) biomarkers and correlated biological with non-motor abnormalities (olfactory impairment and dysautonomia), in patients with idiopathic REM behavior disorder (iRBD) (prodromal PD) and established PD.
We recruited 11 iRBD and 15 patients with idiopathic PD (Hohen&Yahr 1-3, on L-DOPA and dopamine agonists combination therapy) and 12 age- and sex-matched controls (CTRL). We measured total olfactory score (TOS), autonomic function [deep breathing (DB), lying to standing (LS) and Valsalva manoeuvre (VM) ratios], blood reduced glutathione (Br-GSH), oxidative stress and inflammatory markers (neopterin).
Anosmia was similarly prevalent in iRBD (36%) and PD (33%) patients, but absent in CTRL. Orthostatic hypotension was more common among iRBD (73%) and PD (60%) than in CTRL (25%). By univariable ordinal logistic regression, TOS, Br-GSH, LS and VM ratio worsened from CTRL to iRBD and PD groups. Only reduced Br-GSH levels (p=0.037, OR=0.994; 95%CI 0.988-1.000) were independently associated to PD. TOS correlated with Br-GSH (R=0.34, p=0.037), VM ratio (R=0.43, p=0.015), and neopterin (rho=0.39, p=0.016).
Reduced systemic antioxidant capacity is found in prodromal and overt PD and may represent, in association with olfactory loss and cardiovascular dysautonomia, a useful biomarker for an integrative, early diagnosis of PD.
Copyright © 2016 Elsevier B.V. All rights reserved.
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[Natriuretic peptides for the management of patients with heart failure: a bridge between primary care and cardiology?].
G Ital Cardiol (Rome)2016 Jan;17(1):41-7. doi: 10.1714/2140.23188.
D'Ambrosio Gaetano, Parretti Damiano, De Maria Renata, Cricelli Iacopo, Di Tano Giuseppe, Aspromonte Nadia
The increasing prevalence of heart failure (HF) mandates the establishment of shared strategies between primary care physicians (PCP) and cardiologists to offer patients continuity of care. Easily available, low-cost biomarkers hold potential to facilitate this process. Data on the diffusion of natriuretic peptides (NP), a major novelty in the HF field in the last decade, in primary care are scarce.
The Cardiovascular Area of the Italian General Practice Society led a web survey among its members to investigate knowledge, perceptions and use of NP for HF management among Italian PCP.
Over 700 PCP took part in the survey, three out of four declared they never or only occasionally prescribed NP assays. Among participating PCP, 86% reported that PN values were not regularly mentioned in discharge summaries of their patients hospitalized for acute HF. Conversely, only 4% reported to receive regularly PN prescription by cardiologists for their outpatients with chronic HF. One of five respondents ignored whether the assay was reimbursed by the National Health Service. The high negative predictive value for HF of elevated NP levels, the strongest evidence-based indication of NP, was correctly pointed out only by 13% of PCP.
In our PCP sample, we documented a marginal use of NP in the management of HF patients. This is likely, at least in part, linked to a perceived scarce indication of NP values in discharge summaries and limited prescription in HF outpatients by cardiologists. Overall, PCP knowledge of the evidence on NP assay use for diagnosis, risk stratification and guided therapy of HF was limited. Two expert cardiologists were asked to comment on these findings and on the controversial aspects of the current use of NP in HF patients to better define their role as a tool for shared care between cardiologists and PCP.
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The 30-day metric in acute heart failure revisited: data from IN-HF Outcome, an Italian nationwide cardiology registry.
Eur J Heart Fail2015 Oct;17(10):1032-41. doi: 10.1002/ejhf.290.
Di Tano Giuseppe, De Maria Renata, Gonzini Lucio, Aspromonte Nadia, Di Lenarda Andrea, Feola Mauro, Marini Marco, Milli Massimo, Misuraca Gianfranco, Mortara Andrea, Oliva Fabrizio, Pulignano Giovanni, Russo Giulia, Senni Michele, Tavazzi Luigi,
Unplanned readmissions early after a discharge from acute heart failure hospitalization are common and have become a reimbursement benchmark and marker of hospital quality. However, the competing risk of short-term post-discharge mortality is substantial.
Using data from the prospective, nationwide Registry IN-HF Outcome, we analysed the incidence and predictors of 30-day mortality or readmissions and associated days-alive-out-of-hospital (DAOH) in 1520 patients discharged alive after admission for acute heart failure. Within 30 days after discharge, 94 patients (6.2%) were readmitted (91% for cardiovascular causes; 60% recurrent heart failure) and 42 (2.8%) died, 10 of which occurred during readmission. Overall, 126 patients (8.3%) met the combined endpoint. By multivariable logistic regression, worsening chronic heart failure as clinical presentation [odds ratio (OR) 1.83, 95% confidence interval (CI) 1.21-2.77, P = 0.005), inotropes during admission (OR 2.19, 95% CI 1.40-3.43, P = 0.0006), length of stay (OR 1.02, 95% CI 1.01-1.04, P = 0.002) and renin-angiotensin system inhibitors at discharge (OR 0.52, 95%CI 0.35-0.77, P = 0.001) independently predicted 30-day all-cause mortality and/or readmission (c-statistic = 0.695). Per cent 30-day DAOH was lower in patients with in-hospital inotrope use, no renin-angiotensin system inhibitors prescription at discharge, New York Heart Association III-IV class at discharge, and correlated inversely with length of stay and age.
A clinical and biohumoral profile consistent with chronic advanced heart failure and end-organ damage identifies acute heart failure patients discharged home from cardiology units, who are at highest risk of early death and/or readmission. These findings have practical implications for tailoring specific follow-up.
© 2015 The Authors European Journal of Heart Failure © 2015 European Society of Cardiology.
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Identification of genetic markers for treatment success in heart failure patients: insight from cardiac resynchronization therapy.
Circ Cardiovasc Genet2014 Dec;7(6):760-70. doi: 10.1161/CIRCGENETICS.113.000384.
Schmitz Boris, De Maria Renata, Gatsios Dimitris, Chrysanthakopoulou Theodora, Landolina Maurizio, Gasparini Maurizio, Campolo Jonica, Parolini Marina, Sanzo Antonio, Galimberti Paola, Bianchi Michele, Lenders Malte, Brand Eva, Parodi Oberdan, Lunati Maurizio, Brand Stefan-Martin
Cardiac resynchronization therapy (CRT) can improve ventricular size, shape, and mass and reduce mitral regurgitation by reverse remodeling of the failing ventricle. About 30% of patients do not respond to this therapy for unknown reasons. In this study, we aimed at the identification and classification of CRT responder by the use of genetic variants and clinical parameters.
Of 1421 CRT patients, 207 subjects were consecutively selected, and CRT responder and nonresponder were matched for their baseline parameters before CRT. Treatment success of CRT was defined as a decrease in left ventricular end-systolic volume >15% at follow-up echocardiography compared with left ventricular end-systolic volume at baseline. All other changes classified the patient as CRT nonresponder. A genetic association study was performed, which identified 4 genetic variants to be associated with the CRT responder phenotype at the allelic (P<0.035) and genotypic (P<0.031) level: rs3766031 (ATPIB1), rs5443 (GNB3), rs5522 (NR3C2), and rs7325635 (TNFSF11). Machine learning algorithms were used for the classification of CRT patients into responder and nonresponder status, including combinations of the identified genetic variants and clinical parameters.
We demonstrated that rule induction algorithms can successfully be applied for the classification of heart failure patients in CRT responder and nonresponder status using clinical and genetic parameters. Our analysis included information on alleles and genotypes of 4 genetic loci, rs3766031 (ATPIB1), rs5443 (GNB3), rs5522 (NR3C2), and rs7325635 (TNFSF11), pathophysiologically associated with remodeling of the failing ventricle.
© 2014 American Heart Association, Inc.
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Effects of sapropterin on endothelium-dependent vasodilation in patients with CADASIL: a randomized controlled trial.
Stroke2014 Oct;45(10):2959-66. doi: 10.1161/STROKEAHA.114.005937.
De Maria Renata, Campolo Jonica, Frontali Marina, Taroni Franco, Federico Antonio, Inzitari Domenico, Tavani Alessandra, Romano Silvia, Puca Emanuele, Orzi Francesco, Francia Ada, Mariotti Caterina, Tomasello Chiara, Dotti Maria Teresa, Stromillo Maria Laura, Pantoni Leonardo, Pescini Francesca, Valenti Raffaella, Pelucchi Claudio, Parolini Marina, Parodi Oberdan,
Cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), a rare autosomal dominant disorder caused by NOTCH3 mutations, is characterized by vascular smooth muscle and endothelial cells abnormalities, altered vasoreactivity, and recurrent lacunar infarcts. Vasomotor function may represent a key factor for disease progression. Tetrahydrobiopterin, essential cofactor for nitric oxide synthesis in endothelial cells, ameliorates endothelial function. We assessed whether supplementation with sapropterin, a synthetic tetrahydrobiopterin analog, improves endothelium-dependent vasodilation in CADASIL patients.
In a 24-month, multicenter randomized, double-blind, placebo-controlled trial, CADASIL patients aged 30 to 65 years were randomly assigned to receive placebo or sapropterin 200 to 400 mg BID. The primary end point was change in the reactive hyperemia index by peripheral arterial tonometry at 24 months. We also assessed the safety and tolerability of sapropterin. Analysis was done by intention-to-treat.
The intention-to-treat population included 61 patients. We found no significant difference between sapropterin (n=32) and placebo (n=29) in the primary end point (mean difference in reactive hyperemia index by peripheral arterial tonometry changes 0.19 [95% confidence interval, -0.18, 0.56]). Reactive hyperemia index by peripheral arterial tonometry increased after 24 months in 37% of patients on sapropterin and in 28% on placebo; however, after adjustment for age, sex, and clinical characteristics, improvement was not associated with treatment arm. The proportion of patients with adverse events was similar on sapropterin and on placebo (50% versus 48.3%); serious adverse events occurred in 6.3% versus 13.8%, respectively.
Sapropterin was safe and well-tolerated at the average dose of 5 mg/kg/day, but did not affect endothelium-dependent vasodilation in CADASIL patients.
https://www.clinicaltrialsregister.eu. Unique identifier: 2007-004370-55.
© 2014 American Heart Association, Inc.
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Gender differences in illness behavior after cardiac surgery.
J Cardiopulm Rehabil Prev;34(2):123-9. doi: 10.1097/HCR.0000000000000043.
Modica Maddalena, Ferratini Maurizio, Spezzaferri Rosa, De Maria Renata, Previtali Emanuele, Castiglioni Paolo
Differences in the ways male and female patients confront their illness after cardiac surgery may contribute to previously observed gender differences in the outcomes of cardiac rehabilitation. The aim of this cross-sectional study was to verify whether there are gender-related differences in illness behavior (IB) soon after cardiac surgery and before entering cardiac rehabilitation.
Patients (N = 1323) completed the IB Questionnaire and Hospital Anxiety and Depression Scale (HADS) 9 ± 5 (mean ± SD) days after cardiac surgery. The scores were tested for gender differences in score distributions (Mann-Whitney U test) and in prevalence of clinically relevant scores (the Pearson ?² test). Multivariate regression analyses were made with IB Questionnaire and HADS scores as independent variables, and gender, age, education, marital status, and type of surgery as predictors.
Denial was significantly (P < .01) prevalent among the men (3.6 ± 1.4) versus women (3.2 ± 1.6), whereas disease conviction (men = 2.1 ± 1.5, women = 2.5 ± 1.6), dysphoria (men = 1.5 ± 1.5, women = 2.0 ± 1.6), anxiety (men = 6.0 ± 3.6, women = 6.9 ± 3.9), and depression (men = 5.3 ± 3.8, women = 6.5 ± 4.0) were significantly more prevalent among women. The prevalences of clinically relevant scores for disease conviction, anxiety, and depression were also significantly higher in women. Multivariate analysis showed that gender predicted these scores even after the removal of confounders.
Gender differences exist in denial, disease conviction, and dysphoria, probably depending on the culturally assigned roles of men and women. As these aspects of IB may compromise treatment compliance and the quality of life, the efficacy of cardiac rehabilitation programs might be improved taking into account the different prevalences in men and women.
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Clinical assessment of spasticity in individuals with spinal cord injury.
Acta Ortop Bras2013 ;21(6):310-4. doi: 10.1590/S1413-78522013000600002.
Tancredo Janaina Roland, Maria Renata Manzano, Azevedo Eliza Regina Ferreira Braga Machad de, Alonso Karina Cristina, Varoto Renato, Cliquet Junior Alberto
To evaluate the effect of neuromuscular electrical stimulation on spasticity in patients with spinal cord injury.
The study included eleven subjects with spinal cord injuries (C4 to T5). The modified Ashworth scale and pendulum test, which is accomplished through the Pendular Test Device - PTD (equipment which has a quartz crystal transducer accelerometer and optic fiber flexible electrogoniometer measuring the tensions and angular displacements). Patients underwent neuromuscular electrical stimulation (NMES) to the quadriceps muscle from fibular nerve, and the tests were administered before and after therapy.
The data show a decrease in spasticity after NMES, with features such as increased variation between maximum and minimum peaks, i.e. increased amplitude of the curves. Furthermore, data from the subjective scale, and modified Ashworth scale after neuromuscular electrical stimulation also showed a reduction in the values of spasticity.
The data suggest that NMES is effective in reducing spasticity immediately after completion. Level of Evidence II, Therapeutic Studies-Investigating the Results of Treatment .
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[What cardiologists should know to manage acute complications in mechanical circulatory support recipients].
G Ital Cardiol (Rome)2013 Oct;14(10):659-68. doi: 10.1714/1335.14832.
Marini Marco, Raineri Claudia, Di Tano Giuseppe, Cipriani Manlio, Oliva Fabrizio, De Maria Renata,
Patients with advanced heart failure refractory to optimal medical treatment have a high mortality and a poor quality of life with frequent hospital admissions. The lack of alternative treatment options has prompted the development of mechanical circulatory support (MCS) devices, first as bridge to heart transplant and subsequently as destination therapy as a valid alternative to transplant. Last generation MCS devices are mechanically reliable and their management has become increasingly less complex. Nowadays, medium-term survival does not significantly differ between MCS and heart transplant recipients. MCS management programs require a multidisciplinary team to optimize the pathway leading to rehabilitation and improved quality of life and decrease the frequent occurrence of complications. However, in the near future with the growing number of implants, the chances for clinical cardiologists to come across a MCS recipient will increase. The management of general or acute problems will no longer be limited to tertiary implanting centers. A key issue to improve patient outcomes is the provision of a smooth and careful transition from the hospital environment to home care. The aim of this review is to start this process by providing basic notions and general indications through several scenarios of MCS recipients presenting to the emergency room for acute clinical problems.
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[Heart failure in women: challenges and opportunities].
G Ital Cardiol (Rome)2012 May;13(5 Suppl 1):3S-5S.
Frigerio Maria, De Maria Renata
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Genetic variants of the renin-angiotensin-aldosterone system and reverse remodeling after cardiac resynchronization therapy.
J Card Fail2012 Oct;18(10):762-8. doi: 10.1016/j.cardfail.2012.07.008.
De Maria Renata, Landolina Maurizio, Gasparini Maurizio, Schmitz Boris, Campolo Jonica, Parolini Marina, Sanzo Antonio, Galimberti Paola, Bianchi Michele, Brand Stefan-Martin, Parodi Oberdan, Lunati Maurizio
Reverse remodeling (RR) after cardiac resynchronization therapy (CRT) is associated with favorable clinical outcomes in heart failure (HF). The renin-angiotensin-aldosterone system (RAAS) is involved in the remodeling process.
We assessed the association between RR and 8 common RAAS gene variants, which were determined by TaqMan assays, in 156 outpatients with chronic HF. RR was defined as a >15% decrease in left ventricular end systolic volume (LVESV) at 9 (interquartile range 7-12) months after CRT. We matched 76 patients who did not show RR (RR-) to 80 RR+ control subjects by age, sex, HF etiology, New York Heart Association (NYHA) functional class and left ventricular ejection fraction (LVEF). The frequency of the minor allele of the NR3C2 gene (rs5522 C/T), encoding the mineralocorticoid receptor, was higher in RR- than in RR (24/126 vs 10/150; P value after false discovery rate correction: <.0193). Conversely, LVESV decreased significantly less after CRT in carriers of the NR3C2 minor C allele (P = .02). After adjustment for age, sex, NYHA functional class, previous myocardial infarction, atrial fibrillation, and LVEF, RR- remained independently associated with NR3C2 C allele carriage (odds ratio 3.093, 95% confidence interval 1.253-7.632).
The association of RR- after CRT with a common polymorphism in the mineralocorticoid receptor gene involved in aldosterone signaling suggests a possible role for variants in RAAS genes in progressive LV function decline, despite apparently effective CRT.
Copyright © 2012 Elsevier Inc. All rights reserved.
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[Role of outpatient heart failure clinics and primary care physicians in the tailored follow-up of heart failure patients].
G Ital Cardiol (Rome)2010 May;11(5 Suppl 2):38S-44S.
De Maria Renata, Misuraca Gianfranco, Milli Massimo, Filippi Alessandro
Continuity of care is pivotal to appropriately manage patients affected by heart failure (HF). HF is a chronic disease with frequent exacerbations that requires long-term care at different complexity levels. The lack of adequate communication between hospital cardiologists and primary care physicians (PCPs) is the main pitfall in continuity of care for HF patients. To overcome this problem, all dedicated outpatient HF clinics should organize together with PCPs in the community educational and auditing initiatives, based on locally derived performance measures to assess the appropriateness and effectiveness of integrated care pathways. The primary task of PCPs is to follow up stable HF patients and focus assessment on patient empowerment, adjustment of drug therapy, assessment of clinical stability and the early identification of worsening signs and symptoms. The progress of information technology should help in achieving adequate communication between hospital professionals and PCPs; outpatient clinical records should in any case comply with qualitative standards of discharge summaries for all patients taken in charge by PCPs. Systematic assessment of shared care between hospital cardiologists and PCPs will be a main objective of the outpatient HF clinic network in the near future.
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[Inotrope therapy in acute heart failure: a critical review of clinical and scientific evidence for levosimendan in the context of traditional treatment].
G Ital Cardiol (Rome)2009 Jul;10(7):422-33.
Ambrosio Giuseppe, Di Lenarda Andrea, Fedele Francesco, Gabrielli Domenico, Metra Marco, Oliva Fabrizio, Perna Gianpiero, Senni Michele, De Maria Renata
The clinical heterogeneity of acute heart failure and the low number of controlled trials, to date, are the main causes of the lack of agreement on therapeutic objectives, uncertainty on the most appropriate management, and difficulties to obtain robust evidence for the treatment of this syndrome. The inappropriate use of inotropic agents is one the most common pitfalls shown by registries. Two to 10% of patients admitted for acute heart failure present with a low output syndrome, a clinical profile associated with high mortality, where inotropes may be a rational therapeutic choice. Crucial points for an effective use of inotropes are an accurate evaluation and selection of patients, tailoring of therapeutic schemes and strict patient monitoring. Beta-adrenergic agonists and phosphodiesterase inhibitors increase myocardial oxygen demand, favor arrhythmias and may cause peripheral vasodilation with a secondary decrease in coronary perfusion pressure. These effects may translate in myocardial ischemia, loss of cardiomyocytes and accelerated ventricular remodeling with worse prognosis. Levosimendan, a novel inotropic agent studied according to the principles of evidence-based medicine, augments myocardial contractility without changes in intracellular calcium concentrations, and with minimal impact on myocardial oxygen consumption. This paper, based on an expert consensus, aims to suggest criteria for the appropriate use of inotropic agents in acute heart failure, based on a critical appraisal of the existing evidence and clinical experience.
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Redox state, oxidative stress and endothelial dysfunction in heart failure: the puzzle of nitrate-thiol interaction.
J Cardiovasc Med (Hagerstown)2007 Oct;8(10):765-74.
Parodi Oberdan, De Maria Renata, Roubina Elena
Endothelial dysfunction, a critical component in the progression of heart failure, may result from increased oxidative stress, secondary to activation of the adrenergic and the renin-angiotensin systems and to the production of inflammatory cytokines, which in turn contribute to reduced bioavailability of nitric oxide (NO). Oxidative stress, determined by excess production of reactive oxygen species and impairment in the antioxidant defence, is responsible for both the decline of diffusible NO and the decrease in the concentration of essential co-factors of NO synthases. Reactive oxygen species are formed from NO in the presence of oxidants and are involved in the nitration of protein tyrosine residue that can alter protein function. Recent studies re-addressed the impact of nitrate treatment in heart failure in view of the beneficial vascular and cellular effects of NO, and of the discovery of abnormalities in NO pathways in this disease. Concerns exist, however, on the safety of nitrates in this setting. Nitrates stimulate vascular superoxide anion production via activation of NADPH oxidase, and induction of uncoupling of NO synthase. Furthermore, by using donors of sulfhydryl groups, such as cysteine and glutathione, for NO production, nitrates may favour depletion of the intracellular thiol pool, thus impairing the antioxidant defence mechanisms.
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Baseline characteristics of patients recruited in the AREA IN-CHF study (Antiremodelling Effect of Aldosterone Receptors Blockade with Canrenone in Mild Chronic Heart Failure).
J Cardiovasc Med (Hagerstown)2007 Sep;8(9):683-91.
Boccanelli Alessandro, Cacciatore Giuseppe, Mureddu Gian Francesco, de Simone Giovanni, Clemenza Francesco, De Maria Renata, Di Lenarda Andrea, Gavazzi Antonello, Latini Roberto, Masson Serge, Porcu Maurizio, Vanasia Massimo, Gonzini Lucio, Maggioni Aldo Pietro
Excess aldosterone activity contributes to the pathogenesis and progression of heart failure (HF). Aldosterone antagonists improve clinical outcome in patients with severe HF or left ventricular (LV) dysfunction after myocardial infarction, but knowledge of their impact in mild chronic HF is sparse. AREA IN-CHF was planned to investigate the effects of canrenone on progression of LV remodelling in mild HF.
AREA IN-CHF is a multicentre, randomised, double-blind, parallel group comparison of canrenone (up to 50 mg/day) versus placebo in mild stable HF. The primary endpoint is change in echocardiographic LV end-diastolic volume over 12 months. Patients had New York Heart Association class II HF, LV ejection fraction < or =45%, stable standard therapy, creatinine < or =2.5 mg/dl, potassium < or =5.0 mmol/l. Follow-up examinations were scheduled monthly for the first 3 months and every 3 months thereafter. Aldosterone was measured at baseline, brain natriuretic peptide and procollagen type III amino-terminal peptide (PIIINP) at baseline and at 6 months. Echocardiography was performed at baseline, at 6 and 12 months.
Among 467 patients, median age 64 years (interquartile range (IQR) 56-70 years), 84% were men, 52% had ischaemic HF, 96% were receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, 79% beta-blockers. Brain natriuretic peptide, aldosterone and PIIINP were 88 pg/ml (IQR 35-185 pg/ml), 118 pg/ml (IQR 75-177 pg/ml), and 5.38 microg/l (IQR 3.98-7.14 microg/l), respectively. LV end-diastolic volume was 79 ml/m (IQR 64-105 ml/m) and LV ejection fraction was 40% (IQR 33-45%).
The role of aldosterone blockade in patients with mild HF remains to be established. AREA IN-CHF is addressing this issue in a large population on optimal medical therapy.
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Effects of long-term treatment with carvedilol on myocardial blood flow in idiopathic dilated cardiomyopathy.
Heart2007 Jul;93(7):808-13.
Neglia Danilo, De Maria Renata, Masi Stefano, Gallopin Michela, Pisani Patrizia, Pardini Silvia, Gavazzi Antonello, L'abbate Antonio, Parodi Oberdan
To assess whether chronic treatment with carvedilol can increase myocardial blood flow (MBF) and MBF reserve in idiopathic dilated cardiomyopathy (IDC).
In a double-blind, placebo-controlled trial, 16 consecutive patients with IDC were randomised to treatment with either carvedilol up to 25 mg twice a day (n = 8, 7 men, mean (SD) age 60 (9) years, mean (SD) left ventricular ejection fraction (LVEF) 30% (5%)), or placebo (n = 8, 6 men, mean (SD) age 62 (9) years, mean (SD) LVEF 28% (6%), NS vs carvedilol group). Before and 6 months after treatment, regional MBF was measured at rest and after intravenous injection of dipyridamole (Dip; 0.56 mg/kg in 4 min) by positron emission tomography and using (13)N-ammonia as a flow tracer. Exercise capacity was assessed as the time duration in a maximal bicycle exercise stress test.
Carvedilol induced a significant decrease in heart rate at rest and during maximal exercise, and an increase in exercise capacity. Absolute MBF values did not significantly change after carvedilol or placebo treatment, either at rest or during Dip injection, although Dip-MBF tended to improve after treatment. Coronary flow reserve significantly increased following carvedilol treatment (from 1.67 (0.63) to 2.58 (1.04), p<0.001), whereas it remained unchanged following the placebo treatment (from 1.80 (0.84) to 1.77 (0.60), NS). Stress-induced regional perfusion defects decreased after carvedilol treatment (from 38% to 15%).
Long-term treatment with carvedilol can significantly increase coronary flow reserve and reduce the occurrence of stress-induced perfusion defects, suggesting a favourable effect of the drug on coronary microvascular function in patients with IDC.
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The negative prognostic synergism of anemia and heart disease in female nursing home residents.
Am J Cardiol2005 Nov;96(10):1460-2.
De Maria Renata, Ripamonti Vittorino, Sandri Riccardo, Ceretti Aldo Pisani, Ferratini Maurizio
This study assessed functional and cognitive status, hemoglobin, serum creatinine, and heart disease from chart reviews in 441 female nursing home residents (mean age 86.8 +/- 7.5 years) and correlated the findings with 1-year survival. Independent predictors of outcome were older age (hazard ratio [HR] 1.76, 95% confidence interval [CI] 1.13 to 2.73), Barthel index (HR 0.31, 95% CI 0.15 to 0.62), and the combined presence of anemia (hemoglobin < or =11 g/dl) and heart disease (HR 3.50, 95% CI 1.50 to 7.47). Survival rates were 92% in the reference group with neither anemia nor heart disease, 91% in anemic subjects without heart disease, 87% in nonanemic patients with heart disease, and 72% in women with the 2 conditions (p <0.001). Anemia is highly prevalent in this population and when present in subjects with heart disease determines a threefold increase in mortality risk.
Guarda su PubMed


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As usual, that day we hit an early bird again. We had barely a day to visit Jaipur, since at half past five in the afternoon our train left in the direction of Kota to go to Bundi. For that reason, we ordered breakfast so that at 7.30 am I was ready. However, when we went down to the dining room very timely, they were just starting to prepare it and, instead of leaving at 8 am as we had planned, we left the hotel around 8.30 am.
In the same hotel, we asked if they could call us at a tuk-tuk to have it during the day and thus not waste time haggling. In the end, we agreed that we would be with him from 8.30 to 16.30. We climbed the three in the vehicle and headed for our first morning destination: the strong amber. It was Sunday and at that time of the morning there was hardly anyone in the street. As it was cold, we had to snuggle between us to get a little warm. Our driver's name was Sameer, a young but uncertain boy who had his tuk-tuk tuned with a sound equipment worthy of MTV Tunning and that occupied all the space dedicated to the trunk. And so, we meandered through the half-empty streets of Jaipur to the sound of Manu Chao, which was totally surreal.
It took about 20 minutes to reach the fort. Sameer parked and told us that the time it would take would wait for us there. One of the things that Mireia had in mind from the beginning when planning the trip was the ride elephant in the fort. Indeed, it is one of the most expensive tourists in India, but what are we if you are not mere tourists? So we went straight to look for an elephant.
The problem was that we were wrong on the way and we ended up in the middle of the ramp where the elephants went up and down. Instead of telling us to get out of there before some pachyderm crushed us, the drivers told us to descend half a kilometer until we reached the platform where you got on the animal. So, for 500 meters, we committed the recklessness of walking among elephants as if we were walking along the Ramblas.
Upon arriving at the platform, there was a long line of tourists waiting anxiously to climb the animal on duty. The price is fixed: 900 rupees for a maximum of two people. Since there were three of us, Mireia and Sonia went up to one together and the other went up by myself. Since I had space to spare, I stretched which one maharani and I prepared to enjoy the ascent to the fort, but it seems that I became too comfortable and ended up being the attraction of the tourists that surrounded me, because they did not stop taking pictures.
My moment of fame was truncated when the elephant driver asked me if I liked animals. Faced with such a question, innocent of me, I said yes and the driver began to give me the stick that I had a company that organized safaris and that if I wanted to do one and such and which non stop. When I told him that I was not interested, then he began to tip me incessantly, although there was a huge sign that clearly informed that elephant drivers should not be tipped (I imagine because it was already more than included in the 900 rupees it was worth the little walk).
By 250 rupees We decided to hire the official guide that was offered to us at the entrance, since we wanted to know better the history of the fort. The guides only speak English, so I acted as interpreter of all the explanations that the guide was giving me. However, my translations had my personal touch and, on more than one occasion, Mireia and Sonia started laughing without the guide knowing why.
Formerly, Amber It was the capital of the state of Jaipur. The city was surrounded by a wall, inside which housed the palace-fort (Amber) and a military fort (Jai). The palace was ordered to build the Marajá Man Singh in 1592, Rajbar commander of Akbar and was successively extended until its completion in the seventeenth century, already during the government of Jai Singh I. However, the walls remained small and began to scarce the water and that is when Jai Singh II moved the capital to Jaipur in 1727.
We climbed the steps that led to the Ganesh Pol's door, door of the entrance to the palace and we access a courtyard where there was a room (Divan-i-Am) where the marajá He gave his audience. A few meters further inside, we expected the Jai Mandir, the royal council room or hall of mirrors. Undoubtedly, that room is what I liked most about the fort even though it couldn't be seen from inside. The room is covered in white marble and has mirrors embedded in the walls. In fact, it is currently not possible to access it because people ripped off mirrors and embedded stones to take them as it would happen. Formerly, at night the room was illuminated with oil lamps and the wind, when rocking them, gave it a special lighting thanks to the reflection of the mirrors.
Then we visited the palace women area, its rooms and the patio. The best thing about the fort is to get lost in its corridors and explore it calmly, which we couldn't do because the guide took us at two hundred an hour. At the exit there were a little expensive souvenir stops, but as Mireia left the next day, we stopped to do some shopping, such as incense and puppets of the Rajasthan. Then, in the museum shop, we took the opportunity to buy some postcards and the occasional book. My advice is that if you can avoid it, do not buy anything there because it is hypercarious.
Later, while we were going to the parking lot, a few photographers approached us to try to sell us the photos they had taken during the climb with the elephant, and in the end I bought one of my photos for 40 rupees because I knew that it is difficult to get focused photos while you ride elephant.
We went back to rickshaw and took us to him Gatore Ki Chhatriyan museum, although we have not just discovered what treasures it exhibited because we did not feel like wasting the few hours we had in Jaipur inside a museum. Therefore, we told the driver to continue with the route. Then we set course to the sanctuary of the monkeys, a kind of small temple on top of a hill that offers great views of Jaipur. Unfortunately, due to pollution we could barely see the city.

subset: commoncrawl


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Mumia Abu-Jamal AM8335; SCI Mahanoy; 301 Morea Rd; Frackville, PA 17932
Commentaries from Prison Radio correspondents are listed below, and you can view all commentaries by year here.
Deceased April 3, 2016. Rest in Peace.
In 2016 three San Francisco teenagers wrote to Prison Radio correspondents across the country to ask them to call into Prison Radio and read Assata Shakur's poem "Affirmation." Here are the responses they collected.
Albert Woodfox & Herman Wallace recorded at Angola State Penitentiary 2002, 2005.
150005, CMCF-2A B-Zone 162, P.O.
An Evening for Justice and Freedom 4 6 19
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Herman was one of the Angola 3. He died on October 4, 2013. May he rest in peace.
Higher Quality Audio files available, email us: firstname.lastname@example.com (c) 2012 Prison Radio/Herman Wallace, (c) Prison Radio/Albert Woodfox
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Chelsea Manning was freed from prison on May 17, 2017.
In the spring of 2019 Chelsea Manning was ruturned to prison.
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Change is Possible: A Rite of Struggle and Passage
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Murder Inc Book Event May 6th
Murder Inc Excerpts
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Mondo We Langa's poetry is published in the book, "The Black Panther is an African Cat", which can be ordered from The AfraAmerican Bookstore. 402-455-9200. aframericanbookstore.com
Yafeu Iyapu I


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This was written on the date above but I'm not posting it until now because I was having a computer issue. I couldn't get my Mac to connect to my home network and when I was at the coffee house I forgot to post it. I also forgot about it when I was at home and could have moved it to my flash drive and then posted it online using my other computer. So, a day late, but here it is.
Before I went to bed last night I set my alarm for 9:30 and 10AM. I had the intentions of getting up and going to town – about an hour away from where I live, an hour and half away from where I work – because I wanted to enjoy a day out and needed to do some shopping for work. There's a few items we need and can't get in the town I work in. Then I remembered….
I forgot to get money from work to pay for the things I needed and I had also left most of the money I had left in my office, too. I know, it's always a good idea to leave your personal money in your office at work. I haven't gone to the banking center yet to deposit it and didn't want to carry it around with me. Smart, I know.
And I was just reminded, when I had to type in my password to install an update, I need to go through all my websites which I have a password for and change the password. I had to give my password out to two different people this week – again, I know, not smart – and I would like to change that.
So I remembered this little fuck up while I was at Walmart looking for a cool pad for my Mac.
I recently tweeted, I think, that I had resisted the urge to buy some things that I don't need. I also resisted the urge to buy a cool pad last night because I do have one I don't like that I can clean the dust and cat hair from that my dad used to use. (#runon much?) I'm also going to go online and look for one that is 13 inches but I don't have to buy that one right now. So there has been a little progress in the life of a serial shopping: a shopaholic. But part of that may also be the fact that I think I'm about out of money.
So last night I decided I would have to drive into work before going to town. This morning – and by morning I totally mean "noon" – when I finally got out of bed I didn't move very far. I was reading a book a little while ago and got sleepy. Luckily I decided not to go back to bed. I got up and started moving by ironing my clothes for today. So props to me for resisting that urge, too.
I also wanted to clean out and wash my car today, but I don't think that is going to get done. At least if it does it won't happen until late tonight, right before I return home.
One of the places I needed to go in town closes at 5 and are closed on Sunday. It is now 3PM and that will not happen. I don't want to go next week so I don't know what I'll do. Maybe I will go next week but that will just take even more time out of what I really need to do! That or I'll have to get up super early one morning which I don't like doing.
As for today, I don't know what I'm going to do. I want to get some writing done. I would like to go in and get a little paperwork done at work. I really need to clean my fucking office, and organize all the paperwork that is strewn all over the fucking place. At the moment I think I'll get ready, pick up my money, probably go to the coffee shop first and get a little writing done. I'm not going to go to town. The other place I wanted to go in town was a used bookstore that I know will be closed tomorrow. But I didn't really need to go there…but I really, really wanted to. I bet I could find some books about my Mac there. That thought really makes me want to go but, oh well.
But the biggest point I'd like to make is that I'm not going to beat myself up for not getting up and 9:30 like I wanted to and not getting more accomplished today. It is, after all, Saturday, a day for me to rest and recoup my sanity. Something that really does need to be done frequently! Maybe more will get done tomorrow, and maybe it won't. We will just have to see how today ends up.


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When I started out as a reporter more than 20 years ago, the newsrooms sang with the clatter of typewriters. Within little more than a decade, they'd been replaced by computers and the internet was changing the world so fast it was almost mind blowing.
I sometimes hanker for the good old days when you lived off your wits, your expenses claims and the largesse of the licensed trade. Fishing was different back then too. Like the nicotine-stained newsrooms of my younger days, the internet had yet to make its mark on the river bank. Ditto mobile phones.
I can still remember when my first-ever mobile went off while I was tench fishing with my Old Man and his mates - '94, '95 maybe.
A year or two later, a slightly smaller phone than the old brick went off as I was unhooking a jack, which a much bigger fish had swirled at as it neared the net on the weirpool I was fishing.
I can't talk now, I remember saying, as one of the Sunday desks in London rang to query some shock horror I'd filed. I'm out fishing. I'm sure it's all in the story if you read down through the quotes. But, but, no, hold on, hold on, we're going big on it, we just need to know if, did he really say that he ......
I hung up, lit a Benny Hedgehog and stuck a half pound chub on, like you did in those days. But the phone went off again and again, the old der-der derrr derrr, der-der derrr derrr Nokia tune as the float buried and I pulled into a brute as it hit the bait and dived under the weir sill like a U-boat.
I fished the future of communication out of my pocket, still ringing, and threw it in the river, as I pumped the pike to the surface and slid the net under it. Der-der derrr derrr, der-der derrr derrr *plop*. It's probably still down there somewhere, in the depths of that weirpool.


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Frequently asked questions
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text:
Texmaker is a free, modern and cross-platform LaTeX editor for Windows systems that integrate many tools needed to develop documents with LaTeX, in just one application. Texmaker includes Unicode support, spell checking, auto-completion, code folding and a built-in PDF viewer with syntax support and continuous view mode.
What is new in this release:
Version 4.0.3 includes updated ES, LV, El, AR and IT translations, tool to convert source files to Unicode, and users can now check if a new version is available via a new option in the "Help" menu.


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Occupational Therapy issues for autistics
Occupational therapy issues for autistics
When my child first began OT, I was told by the OT (Occupational Therapist) he "had trouble feeling his body in space."
I thought what she meant was about my child's ability to walk, run, skip, swim–all full body movements that typical people take for granted once they've learned how to walk.
My child had already learned how to walk (at age 16 months), yet he was very uncoordinated and physically awkward.
I'm very athletic, and he's not athletically gifted.
What did I learn about him and how his autism affects his entire body?
I learned about OT and I learned about occupational therapy issues in autistics.
Turns out that OT issues were a hard-to-learn skill in many autistics.
I'll eventually go into a full blown definition of OT, but at one point in my son's life, I was shocked to learned just how much is encompassed in term "occupational therapy."
And, for this post, I'm going to discuss one OT concern in particular–oral issues.
Over the years, I have seen many children on the spectrum chew on their shirts, on a toy, on something they shouldn't have in their mouths, or simply on their fingers. There are many reasons why autistics have mouth area issues. Nervousness, over-stimulation, something just bothers them for some reason.
My child had one–on and off–for several years. It was teeth grinding.
What are some things that are helpful?
1. The Chewy T
The Chewy T is a safe-to-chew piece of plastic shaped in the letter "t." Children with oral issues can chew on them to help them through whatever it is that is bothering them. I bit on it once, and (in my opinion) it doesn't really taste very good. However, I have seen it help many children.
2. Dried out gummy bears
Our DTT supervisor (Discreet Trail Training-a sub-set of Applied Behavioral Analysis ABA) suggested getting some gummy bears, drying them out so that they're hard to chew, and giving them to my son.
He chewed on dried out gummy bears for years.
What happens?
The result is a calming down of whatever oral issue are happening to smooth out any behaviors.
With my child, we always had signals. We could hear his teeth grinding.
A lot of times, our kids aren't great at telling us what's wrong with them.
Gummy bears worked so well for my son that he used them at school. We had it written in his IEP that he could have his container of gummy bears and eat them when necessary.
This extended to some useful communication.
With gummy bears in mind, our son had to learn to communicate with his aide.
"My teeth are bothering me," or "My mouth is bothering me," or "I need to chew a gummy bear."
We asked him to work on his communication so that the gummy bears were not used as treats. They were for an oral issues and only when needed.
If other kids in class commented on the gummy bears (and I don't think this happened) then the aide would simply explain that they are needed only from time to time. They were being as a tool. A very useful tool.
For more OT strategy ideas, check out this website: http://www.kidzoccupationaltherapy.com/2011/10/07/five-practical-sensory-strategies-for-the-classroom/


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17B Beare Street, CLARE SA 5453Leased
House - CLARE SA
Sited in a great residential position, this stunning low maintenance home offers a great lifestyle opportunity. With 3 bedrooms there is also a large 2 way bathroom, walk in robe & built-ins in the 2nd bedroom. To the rear there is an expansive open plan family dining area with a large kitchen, underfloor heating & split system air conditioning. This opes out onto a fantastic undercover outdoor entertaining area and the property's own terraced garden. There is also a double garage with remote roller-doors. A great looking home that provides great lock up & leave versatility & or great rental viability.
Property Features
- House
- 3 bed
- 1 bath
- 2 Parking Spaces
- 2 Garage
- Secure Parking
- Built-In Wardrobes
- Close to Schools
- Close to Shops
- Close to Transport
- Garden


text:
Signed in as:
Our mission is to serve, with respect, individuals in our community with mental illness, intellectual disabilities and developmental delays in order to enhance their quality of life and provide an opportunity to reach their fullest potential.
Individuals with disabilities face stigmatizing language use that can be demeaning. It's important when choosing the words we use to not let a disability define a person, or allow them to be seen as unequal to individuals who are able-bodied. Pennsylvania Department of Human Services
#yorkcountypa #mentalhealth #idd #disabilities #stigma
Language is powerful — especially when talking about addiction, mental health, or disabilities. Stigmatizing language perpetuates negative perceptions, while "person-first" language focuses on the person, not the disorder.
Reducing stigma can help people living with a substance use disorder or behavioral health condition know that they are not alone, resources and help are available, and they are not limited or defined by a mental health condition or substance use disorder. Pennsylvania Department of Human Services
#languagematters #fightthestigma #helppeople #substanceabuse #recovery
Do you have stress in your life? Take this life stress inventory quiz to reflect on your past 12 months. Check back later today for some self-care ideas!
74 Self-Care Ideas from Live Bold and Bloom! Which ones work well for you? Which ones do you want to add into your daily routine?
See more great ideas here: https://liveboldandbloom.com/09/self-improvement/self-care-ideas and lots of great resources here: www.YorkCountyHumanServices.org
#selfcare #selfimprovement #onestepatatime #humanservices #moveforward
York County Human Services
100 West Market Street York, PA 17401 US


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The pick up line– the first utterance when boy meets girl. It can also occur when boy is losing girl and needs to get her back. Either way – the line can fail miserably, or be the one you'll remember for the rest of your life.
When it comes to great pick up lines – who better to deliver them than Cary Grant, Jack Nicholson, Tom Cruise or Jack Lemmon.
"I was bored to death. I hadn't seen one attractive woman on this ship since we left. Now, isn't that terrible? I was alarmed. I said to myself, 'Don't beautiful women travel anymore?' And then I saw you, and I was saved – I hope."
"Tell me, have you been getting results with a line like that, or would I be surprised?"
"If you'd be surprised, I'd be surprised."
(Cary Grant and Deborah Kerr, An Affair to Remember, 1957)
"You make me want to be a better man."
(Jack Nicholson and Helen Hunt, As Good As It Gets, 1997)
"I used to live like Robinson and Crusoe, shipwrecked among eight million people. But one day I saw a footprint in the sand and there you were."
(Jack Lemmon to Shirley Maclaine, The Apartment, 1960)
"You…complete me."
(Tom Cruise to Renee Zellweger, Jerry Maguire, 1996)
What's your favorite pick up line from a romance book or movie?


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I a have a shopify account and I want to integrate payment with Aly pay.
I am stuck in the part where its says in the wallee website:
'The encryption key for the production environment has been generated. If you havent already done so, you should download it and send it to AliPay before you can use the processor.
Download The Key'
2 questions:
1/ I downloaded many times the key, that a cannot read. How do i read it?
2/ How do I send it to AliPay to be able to use the processor?
Thanks a lot!
Hi Karine
Not sure what you mean when you say you "cannot read" the key, but it's just a file that is not intended to be human-readable. You can simply send the file to Alipay along with your merchant PID to the following email address: firstname.lastname@example.com
Please check for more details in the Alipay processor setup documentation:
Also see on this Alipay documentation page, under the "Step 2" heading:


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Hohe Tauern National Park Master Plan
Michael Jungmeier, Daniel Zollner, Stefan Lieb
Kärntner Nationalparkfonds
By means of the master plan, those responsible for the National Park want to set the physiographic development goals for the Carinthian part of the Hohe Tauern National Park for the next 20 years, in the course of which, the setting up of wilderness areas in an adequate size and number is given particular emphasis. The development of the technical principles and spatial data analyses is carried out by means of the Integrated Nature Information System (I.N.I.S.) which was developed by E.C.O. Based on that, and in cooperation with regional and international experts, the main features of the master plan are worked out and cartographically represented in workshops.


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Spring is all about candy box colours and dreamy pastels, right? Wrong! Spring 2020 is all about deep, earthy and bold tones. Here are some must-have gel nail polish shades that'll help you stay ahead of the curve this coming season, courtesy of Pantone.
Chive green
Think fragrant herb gardens, deep pine forests and camo - we just love this deep, natural green. Couple it with stone grey and cream fabrics for a soft, earthy look, or add pops of red for a bold look.
Image by Tiko Giorgadze
Get the nails:
Shimmering Spruce is a gorgeous green glitter with a touch of gold, encased in a clear gel nail polish.
Cinnamon stick
Who says you can't wear autumnal colours in spring? Not us! This burnt orange-brown shade is sugar and spice and all things nice.
Image by Kin Li
Get the nails:
Make My Heart Beet is a warm chestnut shade with a glossy finish. Wear it with blue denim or dark teal for the perfect colour balance.
Grape compote
This deep berry shade is almost good enough to eat. Pair it with black or white for the office, or with gold or dark green for a classy evening look.
Image by Nicolas D
Get the nails:
Royal Pain In The... is a playful purple gel nail polish that's fit for a princess.
Flame scarlet
Scarlet never gets old, and whenever we see it crop up as a seasonal colour trend, we jump for joy. Great for all skin tones, and the perfect combination of classy and glamorous, it's hard to go wrong with bold reds.
Image by Melody Jacob
Get the nails:
Ooze confidence and sophistication with Out of the Red, a bold, high-shine gel nail polish that'll stay chip free for up to two weeks.
Header image by Dan Gold


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A popular problem for the self-obsessed is that everything seems to be happening to them, whereas in fact it's just confusing old reality going about its business in its usual chaotic fashion.
Every day I walk down Mill Road and more often than not I'll spot something that seems particularly out of the ordinary, and the other day I decided to keep a daily logbook of odd events to test scientifically for especial weirdness. I'll call them Weirdest Recent Mill Road Happenstances.
Weirdest Recent Mill Road Happenstance: Up ahead of me I see the guy with one leg attempting to cross the road, but unfortunately his false leg has come off and is slipping down out of his trouser leg. Obviously the poor fucker is mortified because he's in the middle of the road and there's a car waiting for him while he gets his shit together, but he's flustered and he's trying to do everything too quickly. The leg looks really unsettling because it's a fucking leg but it's totally at the wrong angle and so on. Matey is so desperate to get out of the road that he just hops vigorously to the kerb with the leg trailing awkwardly out of his slacks, and the held-up motorist moves off as though driving on eggshells.


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Hadrien is a specialist in the fields of production and post-production of films, documentaries, TV programmes and web based media. Before joining INS, he was in charge of supervision of all production and post-production projects at several content production companies in the private, public and institutional sectors. From budget creation to delivery of masters, with technical workflow design and team management.
Since 2004, having held positions such as director, cameraman, production manager, post-production director and team coordinator, Hadrien has accumulated the necessary skills to ensure stable and reliable production.
In addition to his native French, Hadrien speaks fluent English.


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The Lunarlon technology introduced by Nike is an extreme improvement on impact runners and overall comfort no matter what silhouette incorporates it into the design. On this runner, featured on the Lunarglide 5, Nike has thrown in some attractive perks – both structurally and aesthetically. The underlying Cheetah printed graphic uppers on this runner feature […]Continue reading
Tag Archives: Nike+ Sneakers


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On September 15, nearly 50,000 United Automobile Workers (UAW) union members formed picket lines outside of General Motors factories across the United States. Launched in response to problems negotiating their contract, it was the union's first strike since 2007.
More than three weeks later, the UAW-GM strike continues. Over the course of negotiations, GM has cut off, and restored, healthcare coverage for striking employees. The company has lost an estimated $600 million, and 34 of its plants have temporarily shuttered.
To better understand the implications of the strike, the College Hill Independent spoke with retired labor organizer and social activist Frank Hammer. Over the course of his 32 years working at GM, Hammer held the positions of President and Chairman of UAW Local 909 in Warren, Michigan, as well as UAW-GM International Representative. He also co-founded Autoworker Caravan, an advocacy group linking current and retired autoworkers. Hammer discussed the automotive industry crisis of 2008-10, class consciousness in union organizing, and transnational labor solidarity.
It's been 12 years since the UAW last voted to strike General Motors. Can you explain your demands this time around and why you're striking?
The strike, of course, is the result of GM and the UAW not being able to come to terms on a new contract. The 2015 contract expired, and they did not reach agreement on new terms for the contract. That's what prompted the strike. The UAW describes the issues in a very general way, in terms of what they're actually bargaining for, but that includes things like job security, a means by which temporary workers can become permanent workers, the question of health care for the current workers, [...] the question of the future of the four US plants that were idled. Those are some of the issues. One of the strong issues has to do with the multiple-tier system that exists in all the GM locations, in terms of people doing similar work and getting different rates of pay and different benefits.
When did that multiple-tier pay system emerge?
In GM, it emerged in 2007. That's when the two-tier system was first negotiated. It was actually before the Wall Street financial crisis, before the bankruptcy bailout in 2009—it was actually implemented a couple years before that. It was basically done on the argument that the UAW would either accept the two-tier structure in the plants, or GM would outsource the work to non-union locations, and the UAW would have to go out and organize unorganized workers where the work would have been sent. So the UAW preferred to keep workers in the plants, and they conceded to the two-tier system.
Can you talk about the Wall Street crash and other economic events of the last 12 years, and what effect they've had on the UAW?
My view on that question is different from what's generally out there. The general view is that the US government under President Obama had rescued the auto industry and it survived and the companies thrived and so on. My view is actually that the auto companies were looking for such a financial crisis to actually implement cutbacks against the UAW agreements [...] and they used that as an opportunity, with the US government's help, to really decimate the contractual rights that were previously won. For example, we lost the right to strike—the right to strike was suspended for half a dozen years. We lost overtime pay premium after eight hours. Contractually, they had to pay us time-and-a-half after eight hours, but now they only have to do what the law requires, which is after 40 hours, and things of that order. There were a lot of changes for the UAW.
There have been several rounds of contract negotiations in the past five years. Why is this one different? Why are you striking now?
I think one of the main reasons, if you were to ask rank-and-file workers, is that everybody understands that all the concessions that have been made in the UAW agreements, going back to 2007, have resulted in General Motors regaining profitability. Over the last three years, I think, they have made 35 billions dollars, and in the meantime, workers in the plants are in very onerous situations with this multi-tier structure and workers getting $15 dollars an hour or less. I think that people thought it was time to demand that the company share that surplus value that workers are generating, that more of it ought to go to the workers and not so much to the bankers and to the GM financiers of Wall Street.
You've been involved in activism for 50 years and you've had a lot of different roles in this union. You're also a former General Motors employee. Could you talk about how you've seen labor organizing change over the years, through all the different positions you've occupied?
Back in the '70s, when I hired in at GM, there were 450 or 500 thousand workers that, alone, just worked for GM. We were a massive force, as manufacturing workers in the Big Three. If you fast-forward to today, GM is now the smallest employer of UAW members [among car manufacturers] in the US, with around 46,000. We've been shaved to one-tenth of what we were, just as a force to be reckoned with. It's happened through automation, it's happened through the decline in market share, it's happened through outsourcing. In many ways, we're not the formidable force that we were in the '70s. This has made for changes in terms of power, workers' sense of their own power, and so on. That's one change.
The other change that I've observed that is critical is the agenda of management and union partnership. Even though it was present, even in the '70s, it really grew and became a thing, and actually took over the entire ideology of the union and the union leadership. So that had an impact as well, in terms of disarming the workers from seeing themselves as class-conscious fighters versus being a partner and helping GM become more competitive in the name of job security.
What exactly is management-union partnership?
The idea was that we shouldn't be adversaries, that the conflicts were of no benefit to either party. That's the theory of it, that we should instead work cooperatively, and that if the union looked after GM's competitiveness, GM in turn would look after the workers' benefits and job security and so on. That was the formula, and it was institutionalized in things that were called "joint activity centers." They were institutionalized through a financing mechanism that was agreed to through the contractual agreements. It became an army of joint activity-appointed personnel and appointed workers, downtown in its own building, and then also in all the plants. So, a real structural change in the structure of the way the union operated within General Motors. It became this partnership at all levels, and you had all kinds of advocates of it who were appointed staff in order to carry it out.
How do you see union organizing now? What place do you think it has in progressive politics more generally? It's something that's been talked about a lot recently, because there have been high-profile strikes, with the teachers union and others. How do you see this strike fitting into that?
I think that this strike is quite significant, in the sense—and I am speaking partly from having been on some of the picket lines in Detroit—that there really is an outpouring of class feeling among autoworkers, and a sense of solidarity. For example, my plant is one of the four that are in the process of being closed, and there are only a handful of individuals working at my plant. So our picket lines are staffed by Ford workers and Chrysler workers. They're doing it as an act of solidarity and this class feeling—that we're all in this together, that Ford and Chrysler workers understand, "hey, we're next," that we're all family. To me, it really represents a very interesting dynamic that you wouldn't have seen without the strike. Now that it's out there, now that people have had these feelings of solidarity, walking the picket lines with each other, supplying food and supplying water, all of those kinds of things, I think that it's opened up a new avenue to see the manufacturing workers in the US in a different light. Most of what you're talking about—the strikes, the organizing efforts—have been in the public sector or in the service sector. So I think this is a major break from that, and it portends, depending on where things go, that there's going to be more organizing in the manufacturing sector than previously.
What's the general sense of where you're at with negotiations right now? Also, how can people who aren't directly connected to the UAW support the strike or get involved?
The latest communication [from UAW leadership], which was over the weekend, established that negotiations aren't going so well, that, in some ways, they went backwards. For example, GM earlier on—at the very beginning, before the strike began—said that they were offering to put some work in the Detroit location, and over in Lordstown, Ohio. Now, the word was that they're withdrawing those offers. I think the way it's being presented to the public is that negotiations are getting to a tenuous moment. It could be that these are public pronouncements to wear the strikers down to get them to be accepting of an agreement that's not quite up to their standards, and that that might be the intention. But that's speculation—we'll see. There's no doubt that General Motors is playing hardball, and that GM showed itself when, without notice and without warning, it cut off the healthcare of all striking workers, which it had to retreat on and reinstate it. I don't know what the status is now. Clearly, GM is wanting to get its way. I think that workers understand that and will continue with the striking process.
In terms of how people can support, clearly the best way is—if you're in a town or an area where there is a GM distribution center or a GM facility—coming out in support of the picket lines is the best way of engaging in support. I know that there are folks in non-GM locations that have talked about organizing informational tickets—for example, at auto dealers. I don't know that that's actually going on, but I know that, for people who want to lend some support and be visible about it, that's one of the ways that people have spoken about doing it. In terms of contributions and donations, I know that the local unions can't accept financial donations, but strikers can receive donations in kind. That's probably one of the best ways to help the picketing workers, by keeping them supplied with foodstuffs, rain gear, any one of a number of ways that people can lend support to the strikers.
Is there anything else that you think is important to highlight about this movement?
One is that those of us who are activists within the ranks have really tried to promote an international approach to this struggle, because we understand that GM is an international corporation, and, as it is, we have workers around the world who are currently engaged in fights with General Motors, and that it would be incumbent upon us to close ranks and reach out to the workers. For example, there are strikers right now in South Korea who are striking over issues with GM. We have Mexican workers who work at a truck plant in Silao who were laid off as a result of parts shortages due to the strike. But I know that some of them were fired because of support for the GM strikers in the States. We have workers in Brazil, members of a union called Con Lutas, who are also engaged in the campaign against precarious work with GM in São Paulo. And we have workers in Colombia who are engaged in the fight with GM who are workers who sustain injuries in the workplace and are subsequently fired because of those injuries, and are cast out on the street without any compensation. They're engaged in a battle with General Motors to get their jobs back, to get compensation. There are all these organized fights, it seems, for people who are strikers here in the US to reach out and become more unified across borders.
What steps do you think should be taken to create solidarity across national borders?
A couple of us are in Oshawa right now, and last night there was a wonderful solidarity rally by members of the Unifor Local 222 who themselves are confronted with the closure of their GM facility in Oshawa. Many workers turned out in solidarity with GM workers in the States. We had a great rally, a great gathering, and I think it's energized the Canadian workers. I think more gatherings and more connections of that order are what we should be doing.
CATE TURNER B'21 doesn't know how to drive, but does know to stand with the union.


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The 7th National Community Health Nurses Conference: "Blueprint for Action: Influence, Inform and Inspire"
Kelowna, British Columbia
June 17-19, 2013
Delta Grand Okanagan
Community Health Nurses of Canada (CHNC) are pleased to invite you to participate in the 7th National Community Health Nurses Conference in Kelowna, BC.
This conference brings together individuals who have an interest in Community Health Nursing from practice, research, administration, policy and education. It is a forum to explore issues of mutual concern as well as exchange knowledge, share evidence and ideas, and generate solutions.


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Minnesota-bred producer Cardo dishes on his new Drake and Migos tracks—and his own project
It's been a hell of a week for Cardo.
As co-producer of Drake's "God's Plan," the record-breaking new song that's a welcome return to Drizzy's Take Care-era sound, the Twin Cities-bred producer Cardo (aka Cardo Got Wings) has the biggest hit of his career on his hands. Plus, following his production on Migos' Grammy-nominated Culture, he also contributed to the Atlanta rap trio's brand-new follow-up, Culture II.
Still, Cardo—who grew up on Minneapolis' Northside and St. Paul's Eastside, and now splits his time between Dallas and Los Angeles—is more invested in his new album with Detroit rapper and Doughboyz Cashout member Payroll Giovanni. Big Bossin' Vol. 2, the pair's first album for Def Jam, builds on the warm, luxuriant G-funk of 2016's Vol. 1 by incorporating jazz instrumentation and even elements of ambient music. It's Cardo in top form, and with Pay at his vivid best as a lyricist, the album tops its predecessor.
Cardo spoke with City Pages about "God's Plan," joining the Def Jam roster, the making of Big Bossin' Vol. 2, and more.
City Pages: Did you expect "God's Plan" to immediately make the impact that it has?
Cardo: With Drake being who Drake is, he's a very big deal to the music world, period, and he ain't dropped nothin' in a while. I was expecting a lot of crazy shit going on, but with records being broken and having the No. 1 record in the world, it's just crazy to me. I ain't never had a No. 1 record.
CP: How does it feel for you and Payroll to be on the Def Jam roster together?
C: It means a lot to us. It's a label we looked up to as youngins coming up in the game of music and whatnot. It's an honor to be a part of history with a label that's done so much for the culture. We get to be a continuation of that path and that journey. It's very, very dope for us to be on that roster.
CP: What made you and Payroll want to make a second Big Bossin'?
C: The fans' reaction [to Vol. 1], and us being super cool and close. We had so much material, we're like, "The world needs to hear it." Vol. 2 really came from the fans and of course ourselves. The vibe and groove is always there; we don't never want to shake that chemistry.
CP: How do you think Vol. 2 compares to Vol. 1?
C: I think Vol. 1 was a whole different bounce, but it was in that same realm, the same groove and that pocket. I feel like we had to amp it up a little bit, beef it up with Vol. 2, and kinda kick somethin' new to 'em. That's where we came with the more jazzy feel, the more ambient feel. It kinda got a little dark toward the end of it, which is a good thing—that's what we wanted it to come out like. But it still has that bounce to it some way. I feel like it's better than Vol. 1 to me, even though that's saying a lot
CP: You made a post on Instagram with a caption suggesting it was difficult to complete this album. What made you say that?
C: It was a bunch of madness going on, period, with personal lives, and us trying to figure out the next move, and Payroll losing a close friend [Doughboyz Cashout member Doughboy Roc]. It was just a bunch of shit going on—just the whole ordeal of this whole album, just getting it finished. But we made it through and got over that obstacle.
CP: Why have you been calling you and Payroll "the new Dre and Snoop" on social media?
C: It's really the energy, 'cause Snoop was laidback and cool with his flows. That's what Payroll reminds me of, and his substance and choice of words. That's what I get from him.
Dre and Snoop created a whole new wave for the West Coast. Me and Pay, we're creating a whole new wave for the Midwest. For people who are sleeping or whatever, we're presenting a whole new avenue for them. For some of them who aren't hip to what we're doing yet, they're gonna get hip and see what we're doing.
CP: You're someone who likes producing an entire project for one artist. Why is that?
C: It's like building a sculpture. It's like building a skyscraper-type shit. You're building a foundation, and it's something you either work on or work around with. You never know what you could possibly do at your full potential, as far as creating or being an innovator
CP: With all the major artists you've worked with in the past couple years, does it feel like you're in the prime of your career so far?
C: I kinda feel like a newcomer, but I also feel like I'm … I don't wanna say an "O.G." in the game, 'cause I ain't been in the game that damn long. I feel like I was an underdog. It's all new to me: ["God's Plan"] is my first No. 1 record that I ever had in my entire career, and I had a lot of records, but as far as a No. 1 overall, I ain't never had that. Ever. I had top 100 records, but not No. 1. So it's all new. It's just refreshing, and it's also inspiring, 'cause it's like, "OK, I'm doing everything in the right way. Let me just keep doing it so I can get my bro Pay on that same level, if not bigger and better."
CP: You have production on two of the Best Rap Album nominees at the Grammys: Kendrick's DAMN. and Migos' Culture. Do you think one of those albums will win?
C: It's gon' be Kendrick. I'm going for my brother. That's my dawg from day one. I'd love to see him get this because he deserves it; he worked his ass off all 2017, all 2016. That's my bro forever. He's opened up so many doors for me.
[Editor's note: Yep, it was Kendrick.]


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The following Value Added Tax guidance note by Tolley provides comprehensive and up to date tax information covering:
This guidance note provides an overview of specific types of insurance transactions and the associated VAT treatment. This note should be read in conjunction with the Insurance overview and Insurance intermediaries and agents guidance notes.
The sale of part-paid endowment policies are not exempt under the insurance exemption due to the fact that the risk covered by the underlying insurance remains with the original policyholder. However, this will be treated as a finance transaction so any consideration received will be exempt.
Businesses may offer engineering insurance that is intended to protect large capital items of machinery against damage or faults. The insurer may also offer the customer an inspection service in connection with the insurance product which may be used to reduce claims or the level of cover offered.
If the inspection services are provided separately and are not incidental to the supply of the insurance, they may be liable to VAT at the standard rate. If they are supplied in connection with the insurance, then the business needs to ascertain whether a single composite supply of exempt insurance has been provided. Please see the Single or multiple supplies ― application of Card Protection Plan and Levob Verzekeringen guidance note for more information on what constitutes a single supply for VAT purposes.
These types of organisations normally provide insurance against accident, sickness, redundancy, old age, etc. They are not for profit organisations and their insurance capital is derived from the payments made by their members.
If the payments made by the members are in exchange for the provision of
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