text:
South Dakota legislator's green light four bills aimed at improving teen driving. And it's not without input from Rapid City high school students.
"If you're going 55mph, and you look down at your phone for five seconds, you will go the length of a football field," said Courtney Denett, a student at Steven's High School in Rapid City.
The group of four Steven's High School students may seem to be an unlikely group to advocate for increased restrictions on teen driving.
"We're not trying to take away people's rights, but we're looking out for the safety of everyone," said Molly McCaskell, a student at Steven's High School in Rapid City.
Monday, a handful of students from Steven's High School lent their voice to legislation in hopes of lowering South Dakota's startling teen driving statistics.
Nationwide, 8% of teen deaths can be attributed to car crashes. In South Dakota, that number has more than tripled to 25%. Those figures have Senators taking notice.
Senate bill 106 would prohibit the use of wireless communication devices for anyone under 16 with a learners or restricted permit.
"It's a changing world with mobile devices and our job as legislatures is to change with the world and change with technology," said Senator Shantel Krebs, district 10.
Nut some lawmakers saw some clear enforcement problems with the teen texting bill.
"How do we enforce this? You're putting a burden on law enforcement officers. Don't we have a careless driving law for that?" said Senator David Omdahl, district 11.
"I would go back to say most people, especially kids obey the law when there is a law," said Senator Craig Tieszen, district 34.
But for these Steven's students, there's too much at stake to stop now.
"I think a lot of the time we're distracted more than we think we are. A lot of time little things can make a huge difference," said McCaskell.
The teens advocated for four teen driving bills Monday.
All passed through the Senate Transportation committee, including a bill to limit how many passengers a teen driver can have, how long they must have a permit before an official license and the establishment of a state wide driver education program.


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Social Media and Finance Internship Want to work in the world of wealth management? Get a taste of what its like to work in the finance field and put all of those math courses to use. Urban Wealth Ma…
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Police question owner of Canadian train that killed 15-45 peopleThe head of the Canadian railway company whose train derailed and crashed into a small Quebec town has been taken in for police questioning after saying that an employee failed to set the train's brakes properly.Edward Burkhardt, the chairman of the Montreal, Maine, & Atlantic Railways, was led away by police after holding a news conference in Lac-Megantic, the town that was set ablaze when the runaway train barrelled into it early Sunday morning.Fifteen people died in the crash and ensuing fire, and another 45 people are still missing.
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Gender: Male
Years in Practice: 35 Years
Languages Spoken: English
Medical School: University of Minnesota Medical School at Minneapolis
Graduation Date: 1979
Hospital Affiliations: Fairview Southdale Hospital
Specialties: Endocrinology, Diabetes & Metabolism, Diabetology
©2005-2014 WebMD, LLC. All rights reserved.
WebMD does not provide medical advice, diagnosis or treatment. See additional information.


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Traverse City Record-Eagle
---- — The British medical journal "The Lancet-Neurology" recently published research about collaborative efforts to improve stroke care at Munson Medical Center and 23 other hospitals around Michigan through a stroke study from 2008-10.
Munson and the other hospitals participated in the "Increasing Stroke Treatment through Interventional Change Tactics" (INSTINCT) study.
All hospitals were in the lower peninsula and were chosen at random from among hospitals with at least 100 stroke discharges per year.
All hospitals that participated stayed in the trial until data collection ended in 2010.
Munson also was recently designated a primary stroke center by The Joint Commission and also recognized by the Michigan Stroke Registry Quality Improvement program for its efforts on stroke care.
The Northern Michigan Association of Health Underwriters, a 501C6 nonprofit serving insurance agents in northern Michigan and providing actions to support the community, has teamed with the Goodwill Inn to help the homeless and provide the Inn with additional revenue in 2013.
NMAHU recently presented a check for $500 to Goodwill Inn representatives. It also donated undergarments for the Goodwill Inn's undergarment pantry and donated food provided by The Dish Restaurant and Harbor 22 Restaurant.


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As an author/editor, you will often times need a way to
include additional information in a document that does not
actually appear in the flow of text. This information may
include a glossary, and bibliographic references. There are many
ways to include this type of information, but for our purposes,
we have chosen to create a new CNXML tag named
glossary, and have chosen to use an xml language
called bibteXML for references. The two are described below. I
have also included the glossary and bibteXML file examples in
the source of this document. Scroll to the bottom of the page to
see how these examples would be rendered.
"BibteXML is a bibliography DTD for XML that expresses the content model of BibTeX, the bibliographic system for use with LaTeX. It provides conversion tools for tagging your bibliographic data in XML, or export it to HTML or native BibTeX syntax, saving typing time." [source]In plain language, this means that bibtexml is an XML version of the popular and widely accepted latex extension bibtex. One can markup references in their document using semantic tags such as
author and
editor. More info will be provided below.
The 'Glossary' Tag
Often in textbooks there will be a list of definitions
included at the end of the book. In the same way, the
glossary tag will contain a list of definitions
that will be included at the end of a module. One can link
to these definitions using the
term tag (see
Example 2).


text:
Moira McKinnon
CHP/PCOR Project Manager (former)
(650) 724-8309 (voice)
Moira joined CHP/PCOR as a project manager in November 2006. She is responsible for overseeing two projects: the Center on the Demography and Economics of Aging (CDEHA) and the Center on Advancing Decision Making in Aging (CADMA), which entails managing operations relating to IRB approval, budgets, requests for research proposals, and more.
Among her varied experience, she has worked at the Stanford Graduate School of Business in the Executive Education Department, taught English as a second language in India, and worked with troubled adolescents at a therapeutic boarding school on a ranch in Montana. Prior to joining CHP/PCOR, she completed post-bacc/pre-med courses at Montana State University. There, she volunteered at a sliding-scale reproductive health clinic and a sexual assault and domestic violence crisis center. Moira holds a BA in History, Literature and the Arts from Stanford University, and plans to apply to medical school in the future.
- Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination)
Kathryn M. McDonald, Vandana Sundaram, Dena M. Bravata, Robyn Lewis, Nancy D. Lin, Kraft SA, Moira McKinnon, Paguntalan H, Douglas K. Owens
AHRQ Technical Reviews and Sumaries vol. 4, 07 (2007)
- Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Vol. 7: Care Coordination
Kathryn M. McDonald, Vandana Sundaram, Dena M. Bravata, Robyn Lewis, Nancy D. Lin, SA Kraft, Moira McKinnon, H Paguntalan, Douglas K. Owens
Stanford-UCSF Evidence-based Practice Center, for the Agency for Healthcare Research and Quality (2007)


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Game details
- Game:
- Uncharted 2: Among Thieves
- Uncharted 2
- Genre:
- Action
- Sub Genre:
- Adventure
- Release Date (US):
- October 13th, 2009
- Release Date (UK):
- October 16th, 2009
- Players:
- 1
- Online Players:
- 2-10
- Developers:
- Naughty Dog
- Publisher:
- Rating:
- T [Teen]
- PSU Rank:
- 33 of 1166 Games
- PSU Rank on PS3:
- 31 of 0 Games
- Additional Information:
- Only on PS3
About Uncharted 2: Among Thieves
Sequel to Uncharted: Drake's Fortune, the celebrated PlayStation 3 action spectacular.
- PSU Review Score
- 10.0
- Avg. user review score:
- 9.5
You must be logged in to rate a game
With Among Thieves, Naughty Dog has shattered the proverbial bar it created with the 2007 original. This is quite possibly the best game to have graced the PS3, and without a doubt one of the greatest titles ever conceived.
We like
- The stunning visuals that draw you into the complex and engrossing story
- The strategic, fast-paced combat and superb multiplayer component
- The breathtaking experience that is created by a marriage of stellar gameplay, beautiful graphics, and exciting action
We dislike
- The occasional hiccup with the controls
- Having to wait for Uncharted 3!
See PSU's review on Metacritic & GameRankings
With the release of Uncharted 2: Among Thieves, Naughty Dog has created an epic game that rivals the storytelling of Hollywood's finest feature films, with seamless gameplay that sets a new benchmark for future releases. The stunning graphics and fluent cut-scenes deliver the ultimate visual presentation, while the tight action, puzzle, and navigation mechanics ultimately cement Among Thieves as one of the greatest title...
- Posted Oct 23rd 2009
- Read full review
Uncharted 2: Among Thieves News
Uncharted 1 & 2, free DLC coming to PlayStation Network
Naughty Dog today revealed that the first two entries in the critically-acclaimed PlayStation-exclusive Uncharted series will be making their way to the digital distribution storefront. Uncharted: Drake's Fortune and Uncharted 2: Among Thieves will be available for download on June 26, ...
- Posted May 22nd 2012
- Read more
Uncharted 3 beta kicks off July 5, Naughty Dog unleashes new screens and trailer
The worldwide Uncharted 3 multiplayer beta will begin on July 5, 2011, Naughty Dog today announced on the PlayStation Blog. "Our goal has always been to take the signature Uncharted gameplay and our penchant for awesome set-piece moments to serve as the key building blocks for creating a m...
- Posted Apr 18th 2011
- Read more
Uncharted 2 stimulus package: Triple cash for Presidents' Day weekend
In honor of Presidents' Day weekend in the U.S., Naughty Dog is offering triple cash (experience) to players who jump back into Uncharted 2's online multiplayer modes. The promotion runs in all online game modes until Tuesday, February 22 at 1:00 PM EST, at which point Uncharted 2's virtual econ...
- Posted Feb 19th 2011
- Read more
Sony plans 'exclusive PS3 reveal' for next month, Uncharted 3 to debut at VGAs?
Sony's teased that the platform holder will be hosting a special event in Hollywood on December 12 – that's the day after Spike's VGAs, in case you didn't know – for an "exclusive PlayStation 3 reveal." As expected, the company is remaining tight-l...
- Posted Nov 22nd 2010
- Read more
ICO has inspired Naughty Dog's latest game
Naughty Dog big cheese Evan Wells has named Fumito Ueda's 'boy meets girl' classic ICO as a major influence for the studio, letting slip that the developer is currently in the process of working on a similar "linear, narrative-driven experience" for its next project. Wells was ...
- Posted Nov 16th 2010
- Read more
OPM poll crowns Uncharted 2 as greatest ever PlayStation title
Readers of the Official PlayStation Magazine have voted Naughty Dog's stellar adventure sequel Uncharted 2: Among Thieves as the greatest PlayStation title ever released. The poll comes in light of the publication's 50th issue and the15th anniversary of the original PlayStation in the UK, w...
- Posted Oct 1st 2010
- Read more
Sony spills the beans on Uncharted 2 Game of the Year Edition
Sony America has announced that it will be bringing Uncharted 2: Among Thieves Game of the Year Edition to retailers across the U.S. on October 12, 2010. Set to retail for $49.99 USD, this special re-release of the critically acclaimed Naughty Dog adventure romp will include the original game in ...
- Posted Sep 28th 2010
- Read more
Elena to appear in new Uncharted 2 DLC
Uncharted actress Emily Rose has confirmed via Twitter that she is in the process of recording fresh dialogue for her character Elena Fisher in L.A. this week. However, the voice work isn't for the inevitable and eagerly anticipated Uncharted 3, Sony has said, and instead pertains to some n...
- Posted Sep 7th 2010
- Read more
Uncharted 2 gets even more new content, skins and dynmic theme
Naughty Dog really seems to love its fans. The company is throwing even more support for its smash 2009 hit, Uncharted 2, with new DLC coming next week, according to the PlayStation Blog. The Sidekick Skins pack will be available on Tuesday, Aug. 17 via the PlayStation Store, and with it comes more ...
- Posted Aug 12th 2010
- Read more
Uncharted 2 title update 1.09 detailed, goes live today
Uncharted 2: Among Thieves is getting an update today. Title update 1.09 includes changes to the multiplayer components of the game, in addition to some changes to the money system. Naughty Dog has posted information at its blog regarding the change. The company says we can expect the following ...
- Posted Jul 28th 2010
- Read more
Uncharted 2: Among Thieves Features
3 PS3 sequels that didn't innovate, but we didn't care
Innovation is instrumental to a healthy life for any entertainment medium, videogames included. If companies don't take risks and try new things, the videogames industry – as well as film and music for that matter – would stagnate, shrivel and dry up at the drop of a hat. Whether i...
- Posted Dec 31st 2012
- Read more
Five Stunning Uncharted Moments
Naughty Dog's Uncharted franchise is renowned for its technical wizardry and eye-popping set pieces over the years, offering some of the most visually striking spectacles on Sony's black powerhouse to date. Since its inception in 2007, the series' combination of meticulously-realiz...
- Posted Jul 24th 2011
- Read more
Badass Bosses: Zoran Lazarevic
Love them or loathe them, boss battles are an intrinsic part of the videogame experience. Serving as both the source of immense accomplishment and red mist, hair-pulling frustration, these crucial sequences require patience, some flexible finger action and – more than often – plain o...
- Posted Jun 28th 2010
- Read more
In the Spotlight: Nathan Drake
Welcome to the inaugural entry in our 'In the Spotlight' feature, where PSU subjects some of the most memorable heroes and villains to have graced a Sony platform under the microscope, extolling their roles as iconic titans of modern day gaming, plucking some of our favourite quotes/mome...
- Posted Dec 5th 2009
- Read more
Game of the Month: October 2009
As the videogames industry shuffles inexorable towards the lucrative Christmas holiday season, we're already starting to see a substantial rise in not only the quantity of titles hitting store shelves, but more importantly, the quality. October 2009 proved to be one of the most anticipated...
- Posted Nov 4th 2009
- Read more
PSU's top 10 most anticipated games for Q4 2009
With so many games getting pushed back to 2010, it may appear we have nothing new to look forward to between now and the New Year. We've already seen the likes of BioShock 2 and Singularity receive delays, and now many gamers are waiting anxiously for the release of Final Fantasy XIII, Heavy R...
- Posted Sep 1st 2009
- Read more
[WINNERS] Uncharted 2 beta code giveaway
The contest period has concluded, and we've randomly picked the winners. Here they are: Winners: #379 - Gmmex #104 - Amusimbel #651 - hadesguide #11 - HurricaneCRUZ #281 - suparmonkees #573 - Engelbert! #101 - whatisdelicious #653 - blanco_7_raul #370 - Jrod #505 - djramoncardona #...
- Posted Jun 7th 2009
- Read more
Five features we want to see in Uncharted 2
We'd challenge anyone attempting to extol the offerings of the PlayStation 3's vastly growing software library not to give mention to the critically lauded Uncharted: Drake's Fortune. Developed by the talented coders at Naughty Dog, Uncharted remains one of the PS3's most celebrate...
- Posted Mar 3rd 2009
- Read more
Uncharted vs. Uncharted 2 visual comparison
When Uncharted: Drake's Fortune released on the PS3 in late 2007, it was regarded as one of the most visually stunning titles to date, surpassing anything previously shown on consoles. With Uncharted 2: Among Thieves on the way, it's almost surprising to see that Naughty Dog is able to improve upon ...
- Posted Jan 2nd 2009
- Read more
PSU Impressions: Uncharted 2 trailer
Nathan Drake's inaugural adventure last year proved to be one of the most rewarding titles we've played on Sony's black box thus far. Featuring gripping narrative, sumptuous visuals and beautifully crafted environments, Uncharted combines explosive shootouts with pugnacious pirates...
- Posted Dec 15th 2008
- Read more


text:
VPN Unlimited is an easy to use and hassle free way to secure your WiFi connection
There aren't a lot of really good VPN apps out there for iOS. The ones that are sometimes aren't the easiest to use. VPN Unlimited aims to change that by letting you create a virtual private network in only a few steps. With that VPN you then can enjoy unlimited bandwidth and connection speed along with added security.
If you are concerned about the privacy of your WiFi connection, a VPN network is one kind of solution you can use. With VPN Unlimited, you can have your own virtual private network up and running in less than 30 seconds.
Aside from security, VPNs can also offer faster connection speeds, better bandwidth, and in comes cases, it can even bypass content on the internet that may be blocked by your ISP. These are all things VPN Unlimited says they can handle for you.
VPN Unlimited comes with a 10 day risk free trial which means you can try the service out before actually paying anything for it. If you feel you want to try out the service for a little longer, you can extend the trial to one month for $3.99 by means of an in-app purchase. Actual pricing for VPN Unlimited is reasonable and maxes out at $27.99 for an entire year.
For those who want a simple, easy to use solution for creating virtual private networks, give VPN Unlimited a try and be sure to let us know what you think.
- Free - Download Now
There are 9 comments. Add yours.
I would like to recommend iVPN for Mac you can basically use your own home computer as a VPN server.
Or with a few easy steps you can setup an AWS Ec2 instance with PPTP on a linux box and run in the cloud.
Does this company keep logs and is it based outside the US?
Sent from the iMore App
No logs stored for any customers usage etc, only common statistics on about account registration time and remained prepaid period. Head office based on NY.
You can find additional info and support contacts on http://vpnunlimitedapp.com
I always use VPN & recommend friends use it on open WiFi networks but for my minimal use I've had no problems with Security Kiss (http://www.securitykiss.com/). It has a daily data cap but for my casual use it works perfectly. If I depended on VPN for heavy use I'd probably try a paid version but for the "average joe/jane" I think a free VPN solution (even a lousy one) is probably better than being naked on open Wifi for hacks.
If you have the bandwidth (and that usually is the problem) buy a Raspberry Pi and install a VPN server on it and you can then use a PPTP connection and it doesn't mean leaving a high-power system running all the time if you want to go through your home connection. Of course this doesn't deal with geo-location fences.
Tried this on my iPhone 5. I went to Safari and then to MSN.com and it would only link to the Dutch MSN web site. No matter what I did to go to the US site, it wouldn't work. A no go for me... had to uninstall it.
It doesn't let you watch BBC I player you need to use expat shield.... there is a fee but it's worth it..
Sent from the iMore App
I use Tunnelbear. It's $30/year and you can choose between Canada, US, UK, German and Japanese servers. Works great for Netflix, huluplus, pandora etc.
You should try supervpn.net free vpn account. It is very easy to get it, you just need to share their page on some socila networks. Also, you can apply for 7 days free trial.


text:
Long time USFSA judge. Among other competitions, she judged many adult events, including Adult Nationals.
Long time USFSA judge. Among other competitions, she judged many adult events, including Adult Nationals.
Hometown article: http://news.cincinnati.com/article/2...figure-skating
Mark Ladwig tweeted today: "I just heard Nancy Meiss's passing. A great lady, true lover of skating, Olympic judge and mentor to many. I will miss her."
"Randy [Starkman (1960-April 16, 2012)] lived by the same motto as the rest of us. The Olympics isnt every four years, its every single day. He just got it." --Canadian Olympic kayaker Adam van Koeverden
Great lady, RIP. Her most famous quote lives on; asked at a 2002 ice dance committee about risque lifts, she said, "If I want a young man waving his partner's assets in my face, I can rent a porn video. The males are acting like pimps." It was used and reused so often in the press, I think she regretted saying it.
She sounds like a great lady, and to live to be 90 years old, we all can only wish to live that long, especially as a skating fan! What memories she must've had, and all the changes she saw throughout the decades...
She really will be missed. She still actively judged a few test sessions locally in 2012, though she has been winding down her judging in the past few years (less far reaching travel, etc.).
I only crossed paths with her over the past few years. When we talked it really was "all about the kids" (or at least "the skaters" in the case of adults), and she was great about "telling it the way it is" while still remaining welcoming and encouraging.
It sure feels like we're loosing a disproportional amount of US Figure Skating judges in recent years due to death or health reasons -- a strong, enthusiastic generation of very active and positively influential judges. Many low ranking judges we've lost have also made a great impact on the sport in more close-knit local levels. For as much of a "bad rap" judges in general seem to get from the fans, the long-time skaters, skating parents, and coaches really come to understand and appreciate the majority of judges who volunteer an incomprehensible amount of time for the good of their sport.
From the quotes I read above and the article it seems this was a truly special lady, clearly dedicated to her sport. May she rest in peace and heart-felt prayers to her friends and loved ones.


text:
Parliant's new iPod solution tames the pile of paper that greets attendees at trade shows, conferences and annual meetings. more
Trust the Mac and iOS experts at Parliant to build your app. more
From all perspectives, this meeting exceeded our expectations - the delivery of content via the iPod touch was a huge hit for the 3,383 medical attendees, from the highly techno savvy medical students - to veteran neurosurgeons unaccustomed to using such devices.
— Thomas A. Marshall, AANS Executive Director


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Morris Sun Tribune
Cyrus Post Office hours will be reduced
Stevens County Auditor/Treasurer submits resignation
Sales of the Week 071914
Highway 29 detour between Benson, Highway 40 begins July 28
Stevens County non-emergency contact number will be down this weekend
More Topics
No. 4-seeded Morris VFW swings past Willmar
NL-S upends Morris Legion in District 7 tourney
Eagles edge win over Legion in exhibition action
Two-Niners fall to No. 1 Osakis
Results of Marv Meyer Fun Run
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Kathleen Fitzgerald
Irene Blocher
Gail Lindor
Maxine Golombiecki
Nicholas Bolluyt
Daniel Savaloja: Minnesota's biodiesel mandate is costly, risky and unfair
Capitol Chatter: U.S. House races bring in money, too
Alert driving improves safety for all road users
Caroline Little: What the newspaper trends of 2014 mean for the industry's future
Letter: Challenge yourself to end hunger
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local commentary
Lia Marie Francois
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Area Student Accomplishments 071914
Open Houses 071914
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open house
Features From the Farm 062814
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Weather Forecast
July 23, 2014
Trey Owen Domnick
Trey Owen Domnick was born on July 18, 2014 at Stevens Community Medical Center, Morris, to Kurtis and Rachel Domnick of Morris. Trey Owen weighed 7 lbs. 5 oz. and was 20 1/2" long. Grandparents are Gary and Velma Domnick of Morris and Lloyd and Sherry Stoller of El Paso, Ill....
celebrations / births
16 hours 40 min ago
Lia Marie Francois
Lia Marie Francois was born on July 17, 2014 at Stevens Community Medical Center, Morris, to Claudy and Ashlee Francois of Morris. Lia Marie weighed 7 lbs. 10 oz. and was 21 3/4" long. Grandparents are Steve and Connie Nuest of Morris and Odette Francois of Haiti.
celebrations / births
17 hours 55 min ago
July 22, 2014
Kellan Nathan Long
Kellan Nathan Long was born on July 15, 2014 at Stevens Community Medical Center, Morris, to Nathan Long and Shana Stevens of Kensington. Kellan Nathan weighed 7 lbs. 6 oz. and was 20 1/4" long. Grandparents are Sherman and Sherry Long of Hoffman and Vicki Ackerson of Kensington...
celebrations / births
July 22, 2014 - 3:14pm
Schaefer-Martin Engagement
Stan and Bev Schaefer of Hancock wish to announce the engagement of their son, Brent, to Melinda Martin, daughter of Ed and Gladys Martin of Dunlap, Ill. An Aug. 24, 2014 wedding is being planned in Wyoming, Ill.
celebrations / engagements
July 22, 2014 - 2:16pm
July 18, 2014
Area Student Accomplishments 071914
Scholarships, Dean's List, Enrollment, Awards, Graduations Peter Ericksen of Morris is one of approximately 1,600 additional winners of National Merit Scholarships financed by colleges and universities. Ericksen joins the approximately 2,500 other college-sponsored award recipients...
celebrations / accomplishments
July 18, 2014 - 3:25pm
Open Houses 071914
An open house bridal shower will be held in honor of Dayna Schultz, daughter of Mike and Kim Schultz, and bride to be of Aaron Harren, son of Jim and Becky Harren of Big Lake, Saturday, July 26, from 2 to 4 p.m. at LaFave House, 305 College Ave., Morris. The couple is registered at...
celebrations / open house
July 18, 2014 - 3:23pm
July 17, 2014
Krosch-Barsness Engagement
Amanda Krosch and Mark Barsness are pleased to announce their engagement. Parents of the couple are Jim and Jackie Krosch of Alberta and Richard and Barbara Barsness of Farwell. Grandparents are Stella Raasch of Chokio and Carl and Norma Carlson of Cokato. An August 30, 2014 wedding...
celebrations / engagements
July 17, 2014 - 11:54am
July 16, 2014
Julia Louise Geiszler Peterson
Julia Louise Geiszler Peterson was born June 17, 2014 at St.Luke's Hospital in Duluth to Mike Peterson and Anna Geiszler of Hermantown. Julia Louise weighed 7 lbs. 14 oz. and was 19.8" long. Grandparents are Dale and Lois Peterson of Morris, Don and Solange Geiszler of Morris,...
celebrations / births
July 16, 2014 - 11:20am
July 15, 2014
Kopel-Rudnicki Engagement
Jen Kopel and Scott Rudnicki, La Crosse, Wis., announce their engagement. Parents are Rob and Kathy Kopel of Donnelly, Patty Rudnicki of Fargo, N.D., and Ernest Rudnicki of Avon. Jen graduated in 1998 from Morris Area High School and in 2002 from MSUM, Moorhead with a degree in...
celebrations / engagements
July 15, 2014 - 3:55pm
Schultz-Harren Engagement
Dayna Schultz and Aaron Harren are happy to announce their engagement. Parents of the couple are Mike and Kim Schultz of Morris and Jim and Becky Harren of Big Lake. Dayna is a 2005 graduate of Morris Area High School and is employed at Health Partners in St. Cloud. Aaron is a 2003...
celebrations / engagements
July 15, 2014 - 10:49am
July 11, 2014
Area Student Accomplishments 071214
Scholarships, Dean's List, Enrollment, Awards, Graduations Tyler Hansen of Morris was named to spring semester 2014 deans list at the University of Minnesota, Crookston. To qualify for a place on the deans list, students must complete 12 or more letter-graded credits while attaining...
celebrations / accomplishments
July 11, 2014 - 3:28pm
Open Houses 071214
There will be an open house wedding reception for Wade Feutchenberger and Anita Knowblock on Saturday, July 19 at the Morris Senior Center from 6 to 7:30 p.m. s28 There will be an open house wedding reception for Michael and Erica (Domnick) Joos, on Sunday, July 13, from 2:30...
celebrations / open house
July 11, 2014 - 3:25pm
July 10, 2014
Norah Joe Naig
Norah Joe Naig was born on July 1, 2014 at Stevens Community Medical Center, Morris, to Jamie Naig and Mandi Vlach of Hancock. Norah Joe weighed 9 lbs. 7 oz. and was 21 3/4" long. Grandparents are Joe and Julie Vlach of Benson and Barb Naig of Benson. Great grandparents are...
celebrations / births
July 10, 2014 - 3:27pm
Ava Lynn Evink
Ava Lynn Evink was born on June 30, 2014 at Stevens Community Medical Center, Morris, to Brent and Angela Evink of Hancock. Ava Lynn weighed 10 lbs. 3 oz. and was 22 1/4" long. Grandparents are Rodney and Linda Giese of Donnelly and David and Melinda Evink of Hancock. Great...
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July 10, 2014 - 3:25pm
July 8, 2014
Wiegandt-Thooft Engagement
Alyssa Wiegandt and Travis Thooft are happy to announce their engagement. Parents of the couple are Mark and Leslie Wiegandt of Larimore, N.D. and Tom and Susan Thooft of Cyrus. Alyssa is a 2009 graduate of Larimore High School, and a 2014 graduate of North Dakota State University...
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July 8, 2014 - 2:20pm
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PERRY -- Mariah Smith, a sophomore at Perry High School, is trying to adjust to classwork after missing several days due to hip surgery.
She enjoys her classes and especially likes math, but she faces challenges other students dont because she has cerebral palsy.
Her wheelchair prevents her from using the desks her classmates do, so she often works on a plastic tray.
From now on, though, Mariah will be able to sit at a desk like everyone else thanks to a donation spearheaded by a Warner Robins teenager.
Earlier this month, Christy Jones, who teaches orthopedic impaired students at Houston County schools, delivered three custom-built desks to Perry High that were specifically designed for students like Mariah who have cerebral palsy. A fourth desk was delivered to Bonaire Middle School for a student with muscular dystrophy.
Morgan Carr, a 14-year-old Boy Scout representing Troop 550 in Warner Robins, made the construction of those desks the focus of his Eagle Scout service project.
The service project is a major requirement for young men wishing to reach the highest rank attainable in the Boy Scouts of America. It calls for a service project that demonstrates leadership and benefits the community.
Morgans father, Elmer, estimated that Morgan and other Troop 550 Scouts spent 70 to 80 hours building the four desks.
Morgan and his father researched the design of the desks online and discussed the design with Jones before starting the project in October.
Morgan said he thought of a cousin who began using a wheelchair after a car accident. A custom-built desk would have helped him when he was younger, Morgan said.
Giving the four desks adjustable heights was the biggest challenge, Elmer Carr said, because the Scouts had to figure out how to mount special hinges.
Besides having adjustable heights and sturdy legs, the tops of the desks can be lifted up for more accessible angles. They also feature a bookshelf and pencil holders.
And the desks have half-moons cut out of them so the students can get close to their work, the elder Carr said.
Morgan received donations from friends and family for the project. He also received a $100 grant from Lowes, which he used to purchase brushes, hinges and other materials.
Elmer Morgan is in his third year as Troop 550s leader. He said Scouting gives young men an opportunity to learn to be leaders and better citizens and prepares them for life in the outside world.
Morgan was in class at Feagin Middle School when Jones delivered the desks he built to Perry High.
During her world history class that day, Mariah sat behind a desk just like everybody else.
Outside, Jones unloaded the last of the new desks from a pickup.
This project is going to last for years and help students for years to come, she said.
To contact writer Andres David Lopez, call 744-4382.


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PLATTSBURGH — The cause of a fire that heavily damaged a house in Peru Friday night is under investigation.
The call came in for structure fire at a rental home at 3061 Main St. at about 6:20 p.m., said Peru Fire Chief Brian Westover.
First Assistant Fire Chief Tyler Williams said a passer-by reported the fire and it appears to have started in the kitchen.
Williams said the home will "more than likely" be a total loss.
Westover said he didn't think anyone was home when it started and no one was injured.
No pets were known to be in the building, either, Westover said.
Westover, who left the fire site at about 9:15 p.m., said roughly 50 firefighters responded to help fight the blaze.
Providing mutual aid to the Peru Volunteer Fire Department were departments from South Plattsburgh, Keeseville and Morrisonville.
Just before 7:30 p.m., dispatch called an engine and crew from District 3 to stand by at the fire station in Peru.
No further information was available at press time.
Email Felicia Krieg:email@example.com: @FeliciaKrieg


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Clinical Guide > HIV Treatment > PMTCT
Author: Carolyn K. Burr, EdD, RN
January 2011
This chapter describes strategies for reducing the risk of perinatal HIV, based on the U.S. Department of Health and Human Services (DHHS) Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. It is not intended to be a comprehensive discussion of these topics, and all HIV-infected pregnant women should be treated by an HIV-experienced obstetrician and an HIV specialist. For centers that do not have HIV specialists available, experts at the National Perinatal HIV Consultation and Referral Service are available for consultation through the Perinatal HIV Hotline (888-448-8765). For more information on other aspects of caring for HIV-infected pregnant women, see chapter Care of HIV-Infected Pregnant Women.
Unless otherwise referenced, the information in this chapter is based on the most recent DHHS perinatal guidelines available at the time this chapter was published. Consult the AIDSinfo website for the most current recommendations.
In the absence of antiretroviral (ARV) prophylaxis or other interventions, the rate of perinatal HIV transmission in the United States ranges from 16% to 25%. Antiretroviral therapy (ART) is highly effective in reducing the risk of perinatal transmission of HIV, to as low as 1-2%. All pregnant women with HIV infection should be educated about the risks of perinatal HIV transmission and offered ART and other medical management to maintain or improve their own health and to reduce the risk of HIV transmission to their infants.
In 1994, the Pediatric AIDS Clinical Trial Group study 076 (PACTG 076) found that ARV treatment during pregnancy could significantly reduce the risk of HIV transmission to infants. The intervention, consisting of zidovudine (ZDV) given PO to the women during the last weeks of pregnancy and IV during labor and delivery, as well as to the newborns for 6 weeks, reduced the rate of infant infection from 25.5% to 8.3%. The ZDV regimen quickly became the standard of care in the United States and other high-income countries. Subsequent studies showed that combination ARV regimens with suppression of maternal HIV viral load to undetectable levels further reduced the risk of perinatal infection.
Studies in resource-limited countries as well as in resource-abundant areas have examined various ARV strategies for reducing the risk of perinatal HIV transmission. The Petra study, a placebo-controlled trial in a breast-feeding population in Uganda, South Africa, and Tanzania, found a transmission rate of 8.9% among women who received PO ZDV plus lamivudine (3TC) intrapartum and for 1 week postpartum and whose infants also received 1 week of ZDV/3TC, compared with a rate of 15.3% in the placebo group. The HIV NET 012 trial in a breast-feeding population in Uganda compared the efficacy of a single dose of nevirapine given to the mother at the onset of labor plus a single dose given to the newborn 48 hours postpartum with that of PO ZDV given to the mother during labor and to the newborn. The transmission rate was 11.8% in the nevirapine arm compared with 20.0% in the ZDV arm. The results of this study and the low cost of nevirapine prompted a number of resource-limited countries to institute nevirapine prophylaxis as the standard of care for preventing mother-to-child transmission of HIV. Numerous other trials have demonstrated the efficacy of various ARV strategies, combining different ARVs with different treatment durations and given to mothers, newborns, or both, in both breast-feeding and non-breast-feeding populations. Research has shown that ARV interventions even late in the peripartum or newborn periods may decrease the infant's risk of HIV infection. A retrospective study of subjects in New York found that the rate of perinatal HIV transmission was 9.3-10% if ZDV was given either to both the mothers intrapartum and their newborns or to the newborns only, compared with 26.6% if no ARV medication was given. This study underscores the importance of offering ARV interventions to pregnant women with HIV infection whenever they are identified in pregnancy or during labor and delivery, or as an intervention with the newborn.
In the United States, the PACTG 076 regimen remains an important component in the prevention of perinatal HIV transmission, and usually is incorporated into combination ART for pregnant women. For international settings, other guidelines have been developed by global agencies such as the World Health Organization (see References, below) and by individual governments.
Mother-to-child transmission also can occur through breast-feeding. Recent studies have shown that ART given to the nursing mother and/or to her infant decreases the risk of transmission to the infant. However, because substitute feeding in the United States is safe, affordable, feasible, sustainable, and available, mothers in the United States should not breast-feed.
The success of interventions to reduce the risk of perinatal HIV transmission has been achieved through the routine HIV testing and counseling of all pregnant women. Interventions to prevent transmission can be effective only if women know their HIV status and have access to treatment. The DHHS has recommended universal HIV counseling and testing for pregnant women since 1995. Many national professional and governmental organizations, including the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the U.S. Preventive Services Task Force, endorse those recommendations. Current recommendations from the U.S. Centers for Disease Control and Prevention (CDC) feature the following three approaches to HIV testing during pregnancy:
State laws regarding HIV testing during pregnancy vary widely, and many are currently under review. A number of states have adopted the opt-out approach, whereas some still require written informed consent before an HIV test is done. Others require patient education and a chart note from the providers. Clinicians should be familiar with relevant state laws regarding HIV testing during pregnancy, opt-out or consent provisions, and regulations about rapid HIV testing during the intrapartum or newborn period. (Information on state laws regarding HIV testing during pregnancy can be found at the National HIV/AIDS Clinicians' Consultation Center's Compendium of State HIV Testing Laws. Whatever the consent process, a woman should know that an HIV test is being done and should receive at least the information outlined below.
Educating pregnant women about the importance of HIV testing is a critical element in preventing perinatal HIV transmission. However, extensive pretest counseling is not essential. A woman must be told that HIV testing is a standard component of prenatal care, that her clinician recommends the tests, and that all pregnant women should be tested for HIV because knowing about HIV infection is important for their health and the health of their babies. Research has shown that a provider's strong endorsement of HIV testing is a major predictor of whether a woman receives an HIV test. Testing should be voluntary and free of coercion, and a woman should know that she can decline testing without the risk of being denied care. A woman's age, cultural background, educational level, and primary language may influence her knowledge about HIV transmission and her willingness to be tested; the clinician should consider these factors carefully when providing education and information.
The following minimum information should be provided through an educational session with a health care provider or through written or electronic media (e.g., brochures, videos):
Women should be told that test results are confidential to the extent allowed by law and that medical and other services are available for women with HIV infection. Reporting requirements for the specific state should be explained.
HIV testing should be performed as early in pregnancy as possible to allow for interventions to prevent transmission and for effective management of a woman's HIV infection, if the woman is found to be HIV seropositive. The CDC recommends repeat HIV testing in the third trimester for women who receive health care in jurisdictions with an elevated incidence of HIV or AIDS among women, as well as for women at high risk of acquiring HIV (e.g., a history of injection drug use, exchange of sex for money or drugs, multiple sex partners, or a partner known to be HIV infected). Jurisdictions in which repeat third trimester testing is recommended include Alabama, Connecticut, Delaware, District of Columbia, Florida, Georgia, Illinois, Louisiana, Maryland, Massachusetts, Mississippi, Nevada, New Jersey, New York, North Carolina, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, Tennessee, Texas, and Virginia. Any pregnant woman with signs or symptoms of acute HIV infection should be evaluated (see chapter Primary HIV Infection) and receive an HIV plasma RNA test as well as an antibody test. A number of states mandate a third-trimester HIV test for all pregnant women. If the client declines testing at any point, the clinician should inquire about her reasons and follow up at subsequent visits. If the provider is persistent, the woman may choose to have an HIV test at a later visit.
In the United States, the vast majority of pregnant women who are tested for HIV will be HIV seronegative. When giving test results to an HIV-negative woman, the clinician should take the opportunity to discuss risk-reduction strategies to help ensure that she remains uninfected by HIV. Women at high risk of HIV infection should be referred for more extensive counseling because some research indicates that pregnancy may place them at greater risk of acquiring HIV infection, and acute HIV infection may confer greater risk of transmission to the fetus.
Counseling a pregnant woman with a positive HIV test result requires knowledge and sensitivity. The clinician should explain that, even though the woman may feel well, she is infected with the virus. The woman should be told about the importance of medical management of HIV for her own health and for the prevention of perinatal transmission, and she should be guided to the medical and social services available in her local community. She also should be referred to an HIV obstetric specialist who can work closely with her primary obstetric and HIV providers to manage her care during the pregnancy. The patient may be surprised or shocked upon receiving the HIV diagnosis, or she may have known her status but been reluctant to disclose it. The clinician should emphasize the importance of emotional and social support, assess the patient's social support resources, and offer her referrals as needed.
As discussed earlier, beginning ART during pregnancy offers the greatest chance for preventing perinatal transmission of HIV, but interventions during the intrapartum and neonatal periods also offer opportunities to decrease the risk of HIV transmission. Rapid HIV testing for women who present in labor with unknown or undocumented HIV status can identify women who are infected with HIV so that interventions can be offered. Available rapid HIV antibody tests are both sensitive and specific and provide results in as little as 20 minutes.
Women who should receive HIV testing during labor include the following:
Education and counseling for the woman in labor who needs an HIV test should incorporate the information for prenatal education discussed earlier, with consideration given to the special circumstances of labor. Special educational formats such as flip charts have been developed to help with patient education. Confidentiality should be assured for the information and consent process and for treatment. If an opt-out approach is used in the labor setting, a woman of unknown serostatus should be told that no HIV test is found on her chart, that HIV testing is part of routine care, and that she can decline if she wishes, but that experts recommend HIV testing because available interventions can decrease her baby's risk of becoming infected with HIV if she is found to be seropositive.
Perinatal transmission is most likely to occur in the intrapartum period. Several factors influence the risk of transmission from mother to infant. One of these is the mother's HIV RNA level (viral load). Clinical trials and observational studies have shown a strong positive correlation between maternal HIV viral load during pregnancy or at delivery and the risk of perinatal HIV transmission, even among women receiving treatment with ARVs. However, HIV transmission may occur at any level of maternal HIV RNA, including (rarely) when the viral load is undetectable. ARV prophylaxis is a critical factor in reducing HIV transmission. For women on effective combination ART with undetectable HIV RNA, the rate of perinatal HIV transmission is approximately 1%. Thus, ARV prophylaxis with full suppression of HIV RNA is recommended for all pregnant women with HIV infection, regardless of HIV viral load. Note that ART may exert protective effects not only by lowering maternal HIV RNA but also (for ARVs with good transplacental passage) by providing preexposure and postexposure prophylaxis.
Other maternal factors associated with increased risk of perinatal transmission include low CD4 cell count, sexually transmitted infections, active genital herpes during labor, illicit drug use, cigarette smoking, and unprotected sex with multiple partners.
Obstetric factors also affect the risk of HIV transmission. Infection risk increases linearly with the increased duration of ruptured membranes, although the effect of ruptured membranes in women with low viral loads is not known. Invasive procedures performed at any time during pregnancy, such as amniocentesis, placement of scalp electrodes, artificial rupture of membranes, episiotomy, or operative (forceps) delivery may increase risk by exposing the fetus to maternal blood; these procedures should be avoided (though the risk of transmission in women on fully suppressive ART is not clear). In addition, the mode of delivery, whether vaginal or cesarean, can influence the risk of HIV transmission. Scheduled cesarean delivery decreases the rate of perinatal infection for women with an HIV RNA level of >1,000 copies/mL, but its efficacy is not clear for women whose labor has begun or for those whose membranes have ruptured; see "Intrapartum Management and Mode of Delivery," below, for further information.
Infant risk factors for HIV infection include premature birth, low birth weight, skin and mucous membrane lesions such as thrush, and breast-feeding. Breast-feeding increases the risk of HIV transmission by 5-20%. In the United States, where safe, affordable replacement feeding and clean water routinely are available, women with HIV should not breast-feed. However, some women with HIV will be under tremendous cultural and familial pressure to breast-feed and will need the clinician's ongoing support to use substitute formula.
Because many factors that affect the risk of perinatal HIV transmission may be modified, clinicians should educate pregnant women carefully about the importance of ARV prophylaxis and other strategies to reduce the risk of maternal-fetal transmission of HIV.
The goals of ART for the pregnant woman are the same as those for any person living with HIV:
An additional, and crucial, goal of ART for pregnant women is to reduce the risk of perinatal HIV transmission through maximal HIV suppression. The DHHS recommendations discuss in detail the multiple issues that must be considered when balancing the woman's need for therapy for her own health and the need to decrease the risk of transmission to the infant. Combination ART is recommended for all HIV-infected pregnant women regardless of CD4 count or HIV viral load. Decisions about ART are complex and should be made by the woman and her health care provider after discussing the risks and benefits. Clinicians are urged to consult an HIV specialist and the most current DHHS recommendations when making therapeutic decisions. The Perinatal HIV Hotline (888-448-8765) provides free clinical consultation on all aspects of perinatal HIV care. The following discussion addresses some of the issues in determining ART strategies and is taken from the DHHS Perinatal ARV Guidelines.
The DHHS Perinatal HIV Guidelines Working Group recommends fully suppressive combination ART for all pregnant women, unless there are compelling reasons based on pregnancy-specific maternal and fetal safety issues to modify this approach. Key recommendations from the DHHS Perinatal ARV Guidelines include the following:
A fundamental principle of the guidelines is that therapies of known benefit should not be withheld during pregnancy unless they may cause adverse effects to the woman, fetus, or infant, and these adverse effects outweigh the potential benefits. Thus, women should be advised of the potential risks and benefits of ART (to the woman, fetus, and infant) and of the limited long-term data on outcomes for infants with in utero exposure to ARVs, but treatment decisions should be guided by the woman's clinical, virologic, and immunologic status and by the goal of preventing perinatal transmission. Women should be educated and counseled on the importance of close adherence to the ART regimen (see chapter Adherence).
Drug-resistance testing should be conducted for all pregnant women before the initiation of therapy, and for women who are already on ART without fully suppressed HIV RNA.
All women receiving ARVs during pregnancy for prophylaxis or for treatment should receive a combination containing at least three agents, with the aim of viral suppression to undetectable levels (i.e., <40-75 copies/mL, depending on the assay). Monotherapy (e.g., with ZDV) and dual therapy are not as effective and generally are not recommended. The regimen should include two nucleoside reverse transcriptase inhibitors (NRTIs) and either a nonnucleoside reverse transcriptase inhibitors (NNRTI) or a protease inhibitor (PI). Regimen selection should be individualized on the basis of factors such as anticipated safety and efficacy, ARV history, results of resistance testing, and comorbidities (e.g., hepatitis B virus [HBV]) (see chapter Antiretroviral Therapy for considerations in selecting ARVs). It should be recognized that only limited information is available for many ARVs and ARV combinations regarding potential toxicities for the fetus or infant (see Table 4 of the Guidelines), and for dosage requirements with pregnant women.
The DHHS Perinatal ARV Guidelines offer recommendations on the use of specific ARV agents during pregnancy. The table below shows "recommended" and "alternative" ARVs; others are classified as "Use in special circumstances" or "Insufficient data to recommend use." For more complete information, see Table 5 of the Guidelines).
|ARV Class
|Recommended Agents
|Alternative Agents
The guidelines' preferred NRTI component is ZDV/3TC, because of data showing safety and efficacy in pregnancy. The specific alternative NRTIs listed above may be used for women with severe intolerance to ZDV (e.g., severe anemia) or documented resistance to ZDV (see "Safety and Toxicity of Antiretroviral Medications During Pregnancy," below).
Of the NNRTIs, nevirapine may be used for women with CD4 counts of <250 cells/µL or continued for women who are already on nevirapine-containing regimens. Nevirapine generally should not be used for treatment-naive women with CD4 counts of >250 cells/µL because of an increased risk of symptomatic and potentially fatal hepatic and rash toxicity. Efavirenz is not recommended for use during the first trimester because of potential teratogenicity, but it can be considered in later stages of pregnancy if other agents are not appropriate (see "Safety and Toxicity of Antiretroviral Medications During Pregnancy," below). There are insufficient pharmacokinetic and safety data to recommend the use of etravirine during pregnancy.
Lopinavir/ritonavir is the recommended PI based on efficacy studies in adults and experience in pregnant women. Alternative PIs include ritonavir-boosted atazanavir, saquinavir, and indinavir, although data during pregnancy are limited and the latter two agents may be less well tolerated. Nelfinavir, another alternative agent, has been used widely for pregnant women but generally is not recommended for nonpregnant adults because of inferior efficacy compared with first-line agents. Darunavir, fosamprenavir, and tipranavir are not recommended because of lack of data in pregnancy, but they may be considered if other agents are not tolerated or are not appropriate.
Pharmacokinetic and safety data in pregnancy are not sufficient to recommend the use of raltegravir, maraviroc, or enfuvirtide, but these may be considered for use by women for whom drugs in other classes have failed; they should be prescribed in consultation with HIV and obstetric specialists.
Some key recommendations of the DHHS guidelines are that ZDV should be included in the ARV regimen if possible, that the ZDV prophylaxis regimen used in PACTG 076 should be administered intrapartum (i.e., IV ZDV during labor), and that PO ZDV should be given to newborns for 6 weeks. The guidelines emphasize that the PACTG 076 regimen is effective not only for women whose clinical status is similar to that of the participants in the original study, but also for women with advanced HIV disease, low CD4 counts, and previous ZDV therapy.
The DHHS Perinatal ARV Guidelines offer recommendations on ARV prophylaxis to reduce perinatal HIV transmission based on four clinical scenarios, categorized by whether the mother needs ART for her own health and by her ART status when she presents for care (see Table 6 of the Guidelines).
Women already receiving ART should, in general, continue to receive it during pregnancy if it is suppressing viral replication. If the woman has detectable virus (e.g., >500-1,000 copies/mL) on therapy, HIV drug-resistance testing should be performed, and the regimen should be optimized to maximize the likelihood of achieving virologic suppression. Women presenting in the first trimester should be counseled about the risks and benefits of ART during this period. Discontinuation of therapy could lead to increased viral load and potential for transmission to the fetus.
Efavirenz should be avoided or be substituted for in the first trimester. Pregnant women receiving nevirapine-containing regimens should continue them, regardless of CD4 count, if they are virologically suppressed and tolerating the regimen.
Any pregnant woman who meets the standard criteria for ART under the DHHS guidelines for adults and adolescents should receive standard, potent, combination ART as soon as possible, including during the first trimester. The drug regimen should be based on the recommendations of the Perinatal ARV Guidelines (see above and Table 5 of the Guidelines). As in other scenarios, drug-resistance testing should guide ARV selection. Efavirenz should be avoided during the first trimester.
ART is recommended as perinatal prophylaxis with pregnant women for whom treatment is not required for their own health. This recommendation applies to all pregnant women regardless of viral load. Rates of transmission are very low among women with undetectable or low viral loads (<1,000 copies/mL) but transmission has occurred at all RNA levels. ARV medications decrease the risk of transmission, including in women with low viral loads. Antenatal ART not only lowers maternal viral load but also provides the infant with preexposure prophylaxis during the birth process; the neonate also receives postexposure prophylaxis through neonatal ZDV.
Women should be counseled about the benefits of ART in preventing perinatal transmission. Because the risk of teratogenic effects on the fetus is greatest during the first 10 weeks of gestation, the woman may wish to defer starting a regimen until after 12 weeks' gestation. As discussed above, efavirenz should be avoided during the first trimester.
Consideration can be given to discontinuing ART in women who do not have indications for continued ART; see "Postpartum Follow-Up of HIV-Infected Women," below.
In some instances, a pregnant woman has been on ART for prophylaxis during a previous pregnancy and subsequently discontinued the medication. ARV drug-resistance testing should be conducted prior to initiating ART. The regimen should be chosen on the basis of previous ART experience and the reasons for stopping and results of past and current resistance testing, with avoidance of drugs and combinations with teratogenic (e.g., efavirenz ) or adverse maternal effects. The selection of an ART regimen for women with advanced HIV disease or a history of extensive prior therapy can be challenging, and consultation with an HIV specialist is recommended. As discussed above, efavirenz should be avoided during the first trimester.
Physiologic changes that occur during pregnancy (e.g., prolonged gastrointestinal transit time, increase in body fat and water, and changes in cardiac, circulatory, hepatic, and renal function) may affect the kinetics of drug absorption, distribution, and elimination. Few pharmacokinetic studies have been conducted on levels of ARVs during pregnancy, but available data suggest that altered dosing for some PIs (e.g., lopinavir/ritonavir) may be required (see Table 5 of the Guidelines).
In selecting ARVs, providers must decide whether to concurrently treat HBV, using NRTIs that have activity against both HIV and HBV (i.e., lamivudine, emtricitabine, and tenofovir). Making these decisions is complicated, and consultation with an expert is recommended. Also see the relevant discussion in the DHHS Perinatal ARV Guidelines, and chapter Hepatitis B Infection in this manual.
HBV-infected pregnant women who are not immune to hepatitis A should be vaccinated. Infants born to coinfected women should receive HBV immune globulin and start the HBV vaccine series within 12 hours after birth (with subsequent vaccine doses per usual protocol).
Treatment for hepatitis C (HCV) is not recommended during pregnancy. Recommendations for ART during pregnancy are the same for women who are coinfected with HCV as for those without HCV coinfection.
Coninfected pregnant women should be tested for immunity to hepatitis A and HBV; if not immune, they should be vaccinated. Infants born to coinfected women should be evaluated for HCV infection.
See the relevant discussion in the DHHS Perinatal ARV Guidelines, and chapter Hepatitis C Infection in this manual.
Limited data are available on the safety of ARVs in pregnancy, particularly when ARVs are used in combination. The existing safety and toxicity information is derived from animal and human studies, clinical trials, registry data, and anecdotal experience.
Several drugs are of special concern when used during pregnancy (see DHHS Perinatal ARV Guidelines; Table 4), including the following:
In addition, PIs have been associated with an increased risk of new-onset diabetes, worsening diabetes, and diabetic ketoacidosis. Of course, pregnancy itself is a risk factor for hyperglycemia. Clinicians should monitor the glucose levels of pregnant women taking PIs and should educate them about the symptoms of hyperglycemia. The DHHS Perinatal ARV Guidelines recommend that pregnant women on ART should be screened with a standard 50 g glucose loading test at 24-28 weeks (see chapter Care of HIV-Infected Pregnant Women).
Information on ARV toxicity during pregnancy should be consulted carefully before treatment choices are made. The DHHS guidelines provide information on each ARV drug, including preclinical and clinical data, pharmacokinetic and toxicity data, and recommendations regarding use during pregnancy. These guidelines are updated routinely as information is received (see Tables 4 and 5 of the Guidelines). Numerous other medications also are contraindicated for use during pregnancy, and potential toxicity should be considered carefully before any medication is given to a pregnant woman.
A European study found an approximately twofold increase in risk of preterm birth among mothers who took combination therapy during pregnancy (whether started before or during pregnancy). A metaanalysis of seven clinical trials in the United States, however, found that ARV use was not associated with preterm labor, low birth-weight, low Apgar scores, or stillbirth. Subsequent data have been conflicting, but clinicians should be aware of a possible small increased risk of preterm birth among women who receive PIs. However, the benefit of PIs for the mother's health and for prevention of perinatal transmission is clear, and PIs should not be withheld. Until more is known, pregnant women who are taking combination regimens should be monitored closely for complications and toxicities and should be educated about the signs of premature labor.
The Antiretroviral Pregnancy Registry collects observational data on HIV-infected pregnant women taking ARV medications to determine whether patterns of fetal or neonatal abnormalities occur. This is a project initiated by the pharmaceutical industry and overseen by an advisory committee comprising representatives from the CDC, National Institutes of Health, FDA, pediatric and obstetric providers, and others. Providers who care for pregnant women taking ARVs are encouraged to enroll patients in the registry at the time of initial evaluation. Information is confidential and patients' names are not used. More information can be obtained by visiting the registry website or by calling 800-258-4263, 8:30 a.m. to 5:30 p.m. eastern time.
All pregnant women with HIV infection should receive the intrapartum and neonatal components of ZDV prophylaxis used in the PACTG 076 protocol, as outlined earlier. IV ZDV should be given to the woman during labor as a 1-hour loading dose of 2 mg/kg followed by a continuous infusion of 1 mg/kg per hour until delivery. Women on ART should continue their regimen on schedule as much as possible during labor, except that women receiving ZDV or a ZDV-containing fixed-dose combination should be given IV ZDV, with other components continued PO. For women on a stavudine-containing regimen, the stavudine component should be discontinued while IV ZDV is being administered.
For women who have detectable viral load at the time of delivery, the addition of the single-dose nevirapine protocol (single dose to the woman during labor, single dose to the neonate) generally is not recommended in the United States, because clinical trials conducted to date, although small, have not shown benefit and there is a risk of nevirapine resistance. However, single-dose nevirapine may be considered in special circumstances for women with high HIV RNA levels, especially when a patient is not on ART and delivery is vaginal rather than via a scheduled cesarean delivery. If single-dose nevirapine is given, most specialists recommend also giving NRTIs (e.g., ZDV/3TC), and continuing the NRTIs for at least 7 days to decrease the risk of nevirapine resistance.
Studies conducted before the availability of viral load testing found that cesarean delivery performed before the onset of labor or rupture of membranes significantly reduced the risk of perinatal transmission. However, now that many HIV-infected pregnant women in the United States and other high-income settings are receiving potent combination ART, rates of HIV transmission rates are very low (about 1.2-1.5%, unadjusted for mode of delivery); it is difficult to determine whether delivery by cesarean section further decreases the risk of peripartum transmission.
For a woman with a viral load of <1,000 copies/mL, the decisions on mode of delivery should be individualized and based on discussions between the woman and her obstetric clinician. The woman and her health care providers should decide about mode of delivery before the onset of labor, based on her current viral load, her health status, and the outcome of discussions about other concerns, which should include counseling about the risks and benefits of cesarean delivery. For women with HIV RNA levels of >1,000 copies/mL at or near the time of delivery (this would apply to many women on ART for whom viral suppression has not been achieved by the time of delivery because of late entry into care, issues of adherence, or viral resistance), the DHHS Perinatal ARV Guidelines and the American College of Obstetricians and Gynecologists recommend delivery by scheduled cesarean section at 38 weeks' gestation. IV ZDV should be started 3 hours before a scheduled cesarean delivery. Prophylactic antibiotics are recommended at the time of cesarean delivery for HIV-infected women to decrease the risk of maternal infection.
It is not clear whether cesarean delivery provides any benefits in preventing perinatal HIV transmission once labor has begun or membranes are ruptured. Management of a woman for whom a scheduled cesarean was planned but who presents in labor or with ruptured membranes should be individualized on the basis of her HIV viral load, current ART regimen, length of time since membrane rupture, duration of labor, and other clinical factors.
The DHHS Perinatal ARV Guidelines outline four scenarios in which the clinician must decide whether cesarean delivery is needed (see Table 9 of the Guidelines). The data on the benefits of cesarean delivery are complex and must be considered alongside the increased risk to the mother after surgery. The clinician should consult an obstetric/HIV specialist to discuss specific situations.
A woman who presents in labor without a documented HIV status should receive a rapid HIV antibody test and, if the result is positive, should be presumed to be infected until the confirmatory HIV test result is received. She should receive IV ZDV immediately to prevent perinatal transmission. She will need confirmation and staging of her HIV infection (e.g., CD4 cell count, HIV RNA viral load) as well as referral to care for her own health and ongoing psychological support.
Questions remain about the management of labor when a vaginal delivery is planned. Because the duration of ruptured membranes is a risk factor for perinatal transmission, pregnant women with HIV infection should be counseled to go to a hospital for care at the first signs of labor or rupture of membranes. If the membranes rupture spontaneously before labor occurs or early in labor, the clinician should consider interventions to decrease the interval to delivery, such as administration of oxytocin. Procedures that potentially increase the neonate's exposure to maternal blood, such as the use of scalp electrodes or artificial rupture of membranes, should be avoided. Operative interventions with forceps or vacuum extractor and episiotomy should be performed only in select circumstances.
For management of postpartum hemorrhage owing to uterine atony, note that methergine has significant interactions with PIs and with efavirenz and should not be administered to women taking these medications, if possible. If alternative treatments are not available and methergine must be used, it should be given at the lowest possible low dosage and for the shortest duration possible.
Women with HIV infection who have recently delivered need access to a comprehensive array of services for themselves and their infants. The clinician should refer the postpartum woman not only to her primary obstetric and HIV providers for family planning and HIV management but also to a pediatric HIV specialist for care of her infant. She should be referred as needed for mental health, substance abuse, and social support services. The clinician should be alert for indications of postpartum depression and should offer treatment promptly, if indicated. Adherence to ARV regimens may be particularly difficult for a woman in the immediate postpartum period because of postpartum physical and psychological changes and the demands of caring for a newborn; accordingly, the woman may require new or continued support services.
Women who are diagnosed through preliminary rapid HIV testing in labor will need thorough evaluation and management including confirmatory HIV testing and referral for medical and social services. They should not breast-feed unless the results of the confirmatory tests are received as negative.
Women should be evaluated regarding their ongoing need for ART postpartum. If ART was given only or primarily to reduce the risk of perinatal transmission, and if the woman's CD4 count has always been above the threshold recommended for treatment in the current adult and adolescent guidelines and she does not have other factors that would recommend treatment, the woman and her clinician, in consultation with an HIV specialist, may consider discontinuing therapy after pregnancy, with the option to resume ART in the future. On the other hand, for women with a CD4 nadir below the currently recommended threshold for treatment initiation or a history of symptoms or conditions caused by HIV, long-term ART should be recommended.
If ART is being discontinued, all drugs should be stopped at the same time if they have similar half-lives. NNRTIs have longer half lives than other agents, so a NNRTI should be discontinued at least 7 days before other ARVs, in order to avoid a period of NNRTI monotherapy and the development of NNRTI resistance mutations. Alternatively, a PI may be substituted for the NNRTI several weeks before stopping the ART. Note that, for women with HBV coinfection, discontinuation of NRTIs with anti-HBV activity (e.g., 3TC, emtricitabine, tenofovir) may result in a flare of HBV; consult with an expert before discontinuing ART.
Contraceptive counseling is an important aspect of postpartum care. Women should be offered dual-method contraception if pregnancy is not desired in the short-term future or if the ART regimen contains potentially teratogenic drugs such as efavirenz. (See chapters Care of HIV-Infected Pregnant Women and Health Care of HIV-Infected Women Through the Life Cycle.)
Breast-feeding is not recommended in the United States or other parts of the world where replacement feeding is affordable, feasible, acceptable, sustainable, and safe. Women may experience culture-based and family pressure to breast-feed and may need support to use replacement feeding.
The HIV-exposed neonate born to a mother with HIV infection should receive ZDV syrup at a dosage of 2 mg/kg body weight per dose Q6H beginning as soon as possible after birth, preferably within 6-12 hours, and continuing for 6 weeks. Newborns should be discharged home with a supply of PO ZDV syrup. The use of ZDV for the neonate is recommended regardless of whether the mother has a history of resistance to ZDV. Few data are available to guide decision making regarding the use of additional ARVs (i.e., combination therapy) for neonates; consult with a pediatric HIV expert. Every HIV-exposed infant should be referred to a pediatric HIV specialist for diagnostic testing and monitoring of health status.
For an infant born to a mother whose HIV status is unknown, rapid HIV testing of the mother or the infant should be done as soon as possible. If the result for either is positive, ZDV prophylaxis for the infant should be started immediately. A confirmatory HIV test (e.g., Western blot) should be done at the same time and prophylaxis should be discontinued if the result is negative. If positive, the infant should be tested with an HIV DNA polymerase chain reaction (PCR) assay or an HIV RNA assay. If the newborn's HIV viral load test result is positive, prophylaxis should be discontinued and the infant should be referred urgently to a pediatric HIV specialist for management of HIV infection using combination ART.
Traditional HIV antibody testing cannot be used with infants because maternal antibodies may persist for up to 18 months. Diagnosis of HIV infection in infants requires virologic testing (HIV DNA or HIV RNA). Virologic testing should be performed by age 14-21 days, then at 1-2 months, and at 4-6 months. HIV can be diagnosed in an infant on the basis of two positive results from virologic tests done on separate blood samples at any time. HIV can be excluded presumptively in an infant with two or more negative results from virologic tests, with one done at ≥14 days of age and one done at ≥1 month of age, or one negative virologic test done result done at ≥2 months of age, or one negative HIV antibody test result done at ≥6 months of age. HIV can be excluded definitively with two or more negative virologic tests, one done at age ≥1 month and one done at ≥4 months, or two negative HIV antibody tests from separate specimens done at age ≥6 months. However these tests may not be accurate in infants who are receiving combination ART. Some experts recommend retesting, using an antibody test, at age 12-18 months as a confirmatory test.
Infants should have a baseline complete blood count and should be monitored for anemia while they are taking ZDV. Pneumocystis jiroveci pneumonia (PCP) prophylaxis for HIV-exposed infants is recommended for infants with indeterminate HIV status starting at 6 weeks when the ZDV prophylaxis regimen is completed until they are determined to presumptively or definitively HIV seronegative. Initiation of PCP prophylaxis should be stopped or avoided altogether when HIV has been presumptively excluded.
Parents and family caregivers must be taught how to monitor the infant for signs of illness until an HIV diagnosis is made or ruled out. They also need to know that the infant's exposure to ARV agents in utero is an important part of the infant's medical history and should be shared with future health care providers. Although no enduring consequences of ARV exposure have been confirmed, the child may be at risk of long-term problems.


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About this blog
I See Elsie
The Ithaca College London Centre
Tagged as "Packing"
Monday, July 26, 2010
I don't really know why oversize suitcases were invented. It's like there is someone out there taunting students and willing them to over pack. Over packing is an elementary error that can become painfully apparent the moment you try and pick up your suitcase. The amazing thing is that a suitcase that is too heavy to move is sometimes not a deterrent to make the packer pack less. Sometimes it's not until the case is weighed at the airport that the packer decides that there may be too much stuff in their bag. And, more depressingly, some people don't realize that they have over packed until they get off the plane, having not slept very much, and try to lift their bags off the carousel. Sometimes this is the moment of sad realization that they didn't need to bring four month supply of soap, shampoo and conditioner from home.
September to December in London are not the warmest months, so you probably don't need to designate too much luggage space to summer clothes. That space may be better used for your coat. It's easy to forget to pack your coat in August, but often within a few weeks the wind will remind you how much warmer you would be with a coat on. Another thing that's easy to forget is a towel. Though you are likely to be looking for furnished flats to live in, this is something that is best provided by you. You can of course get a towel here when you arrive, but in the past many students have brought an old one from home and then chucked it at the end of the semester. On the other hand, sheets may be something that are better to purchase here. Most people don't know until they find a flat what size bed they will be sleeping in.
You may also want to bear in mind that many students accumulate things that they want to bring back when they leave. This could be stretching some people's ability to forward plan, but saving space in your suitcase from the beginning is a lot cheaper that having to having to pay for an extra suitcase or post things back home. Many, though not all, flats have washing machines in them, so you don't need to bring every scrap of clothing that you own. You may want to have a quick think before you start packing about the kinds of things that you think you will be doing while here. Is there a dress code at your internship?
Have you picked up your London Centre school uniform from the bookstore?Some good things to remember are that plugs in the UK are different from plugs in the USA and both are different from plugs in continental Europe. It's wise to bring your own adaptor before you get here, or else you will be carefully conserving your laptop battery. There is also a different voltage in the UK. Most laptop power cords have a transformer built into them, but many other electrical goods don't, and no one likes the smell of flaming alarm clock in the morning. Another good thing to remember is that in these four months abroad you will get to experience food from around the world. Leave that massive jar of peanut butter at home, give it's place in your suitcase to some more clean socks and consider the joy you will feel when you get home to your old favorite foods that you relinquished for British delicacies. Before you fly find out the airline's weight limits for luggage. Hand held luggage scales may make it easier to know how much you are carrying before you even leave home. And make sure you can lift your own bags; most blocks of flats don't have elevators.
Here is a parting narrative in the form of four limericks:


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Polling places across the country will open today (Tuesday, June 5), with voters exercising their right to participate in the Democratic process. Get the real time results for local elections as we live blog the coverage through Cover It Live.
Glendora residents will vote for representatives for the 48th Assembly District, 25th Senate District, and the 32nd and 27th Congressional District.
Meanwhile, voters across California will also vote on Propositions 28 and 29, which seek to and , respectively.
Do you know where to go to vote? Enter your address into the Los Angeles County Clerk's polling place finder to determine where you need to cast your ballot. Polls open at 7 a.m. and close at 8 p.m.
And follow Patch for updates. We'll be live streaming election coverage though Cover it Live, providing up to date polling figures, reactions from voters and comments from the candidates.


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Terre Haute, Ind. - March 14, 2009 - Nikki Hay was named an All-American after she finished fifth in the triple jump in the 2009 NCAA Division III Men's and Women's Indoor Track and Field Championships.
The 2009 New England Women's Field Athlete of the Year finished in fifth place with a distance of 38-11, or 11.86 meters. The event winner proved to be Akeye Aimable of Wartburg College, who jumped a distance of 39-6 (12.04m). In the prelims, Hay was the ninth qualifier for the finals with a distance of 37-9 1/2 (11.52m).
Hay entered the event with the top distance to date in Division III, a mark of 11.97 meters or 39-3 1/4, that she reached on March 7 at the ECAC Division III Championships.
Hay rebounded from last year's competition in which she did not make the finals of the event. The Norwalk, Conn. native also earned All-America status last May when she finished third in the triple jump at the NCAA Division III Outdoor Track and Field Championships.
As a team, thanks to Hay's four points, Springfield finished in a tie for 39th. Wartburg won the national title with 51 points.


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The closer we get to the NFL Draft, the more likely it seems Tim Tebow will be drafted in the first or second round. Today's story is straight from Bob Tebow, Tim's father.
You know how everyone got a kick out of an unnamed NFL prospect telling Tim Tebow to, "Shut the f-up," prior to Wonderlic testing? Now, Tebow is putting himself out there by saying it never happened.
As if Tim Tebow needed something else to hurt his draft stock.
OHMYGOD, Joe Haden will never play in the NFL after running a 4.57 and 4.6 at the NFL Combine today.
He can hit, but is he ready for the NFL?
An immediate impact player and future All-Pro lockdown cornerback.
So much potential, but does he have the desire to become a better player?
A consistent but not dominant defensive end.
Very fast return man but might be too small for the NFL. Also coming off foot surgery.
Fast WR who needs to work on route running but can block like an offensive tackle.
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Gregory Z65
4-star: 4
3-star: 0
2-star: 1
1-star: 0
|3 lb 15 oz / 180 kg
|4 lb 3 oz / 1.90 kg
|4 lb 7 oz / 2.00 kg
|3539 cu in / 58 L
|3906 cu in / 64 L
|4272 cu in / 70 L
|Torso length
|16 in - 18 in
|18 in - 20 in
|20 in - 22 in
I just got this pack in March, and have only used…
Design: Top/front loading internal frame
Size: large men's
Number of Pockets: 3, not including 2 water-bottle pockets and 2 small, zippered pockets on the waist belt
Max. Load Carried: 35 lbs so far
Height of Owner: 6-1
Price Paid: $190
I just got this pack in March, and have only used it once so far, on a one-night snow-camping trip. The trudge up was only 2.5 miles, but had a 2000' elev gain, and much of it was through deep snow, being rained on.
This pack is so comfortable, I thought I must have forgotten a bunch of gear, or something; but no. It's roomy enough so I don't have to be too clever in packing. The air-flow through the low back section seems to be a great thing (although I was plenty cool enough in the weather we had). The pack conforms to my body really nicely too, so it feels like an extension of my body, even loaded.
Only reason I didn't give it 5 stars is because I haven't used it much.
Here's something else, though. I've been a little worried that the waist buckle system is a bit wimpy, and might snap - a horrifying thought! I emailed Gregory, and they immediately offered to send a replacement, just in case, free of charge. Having that extra buckle along will be a great weight off my mind (and shoulders, if I have to use it!). I thought that was very good customer service.
This new design by Gregory revolutionizes the basic…
Source: bought it new
Price Paid: $175
This new design by Gregory revolutionizes the basic backpack harness by distributing more weight from your shoulders, making for more comfortable and longer trips.
- Durability
- Lightweight
- Design
Tried on several packs before settling with the Gregory Z65. Comfort and equal weight distribution helps considerably in long trips. I've put this pack through its paces, been on 20+ trips, and I am well pleased.
By far most comfy I've been.
Great weekend pack that is super comfortable on summer…
Source: bought it new
Price Paid: $230
Great weekend pack that is super comfortable on summer hikes.
- Air flow across back
- Suspension system
- Overall build quality
- Waterproof zippers can hestitate under high load pulls
- Center compartment can be hard to use if the pack if full
I'm 5'11" and 190 pounds, with a 18.5 inch torso. I've used my Z65 as my primary pack for a wide range of weekend and multi-day excursions. The suspension is comfortable and supportive at loads up to and slightly over 30 lbs.
Although this isn't a ultralight pack, the fabric and build have performed well over nearly four years of monthly use (abuse?) without a tear, broken strap or hardware failure.
Great hauler of loads under 45 lbs loads. Fit: Sizing…
Source: bought it new
Price Paid: $139.99
Great hauler of loads under 45 lbs loads.
- Light for the amount of space and support
- Ease of pack ability
- Small hip belt pockets
Fit: Sizing is true to form for Gregory, as usual measured my torso and found appropriate size on the chart and bam it fit.
Comfort: The ventilation is fantastic when doing summer trips in the RRG Kentucky.
Capacity: I had it packed for a fall fly fishing trip and I topped out at 47 lbs and it was a little rough the first couple days. Since that time I have kept all my loads under 35 lbs, which it preforms remarkably well
Organization & Accessibility: Having the two entry points allows for easy packing opportunity and load balance (you don't have to worry where you put things you can go by weight) thanks to the panel entry. I also enjoy having the large pocket on the back for items that i need to get to quickly and do not want to mess with re-compressing my pack.
Ride: It is remarkable balanced and stable with loads under 45 lbs, loads under 30 you don't even know it's there.
Compression: The compression strap were designed with thought in mind and usability.
Ease of Use: No torso adjustments, just measure, find your size, packet it up, put it on and rock out.
Features: The only downside I have had is the hip belt pockets are smaller than other pack companies provide, which is not that big an issue but a little more space would be appreciated.
I have had this backpack for a couple of months now.
Price Paid: $289
I have had this backpack for a couple of months now. I have been highly satisfied with this pack, so far it is really comfortable and lightweight.
This pack is great for a weekend hike in the spring through the early fall. I would recommend this pack to anyone who has been thinking about purchasing it. When fully geared up the pack is comfortable and snug make sure to get the correct size I am a large it most everything I wear but the medium size fit great.
The only downside to this pack is the foam material used in the straps is very thin and lightweight so if your pack is heavy you will notice it when hiking for a long distance but nothing to unbearable to overcome mind over matter.
The longest trip I have taken this pack on was in the Blue Ridge mountains on the parkway at the Three Ridges Wilderness 14 mile trip pack was doin great.
On the heavy side and the shoulder straps are uncomfortable.
Source: bought it new
Price Paid: $160
On the heavy side and the shoulder straps are uncomfortable. Good size for 3-5 day trips.
- Plenty of room
- Uncomfortable shoulder straps
Have taken this pack on about 10 trips over the last two years, from 1-4 night trips. Plenty of room for packing. I found shoulder straps uncomfortable tho.
Loaded weight was at 31#, and it was like nothing…
Source: bought it new
Price Paid: $169 on sale at REI
Loaded weight was at 31#, and it was like nothing on my back. I put the same things in two other packs and both hurt within minutes.
What was most impressive was after an all day hike I was checking out tents sites before dropping my pack, which has never happened before. This pack is a real keeper.
As an update after several years use this is still an awesome pack, it did start squeaking in the waistbelt but Tim at my local REI store was able to remedy that problem.
Purchased the large olive color Z65 last year. Was…
Design: INternal front / top loading
Size: 3000
Max. Load Carried: 48
Height of Owner: 5' 7"
Price Paid: $189
Purchased the large olive color Z65 last year. Was great for a 6-day hike from Onion Valley down the JMT, a five day trek over the Teton Crest Trail, and a four day hike from the Hermit Trail.
This pack is very comfortable and will sit solid. The design of the hip strap and padding was a dream. The designed space between your back and the pack allows good ventilation. Love the front (actually the back of the pack) access! My previous pack only had the top access- bummer. Just the right size and weight. My bear canister stowes easily.
The Z65 is a rock-solid pack that can take a punch. My search for my perfect pack is over. Thanks Gregory and Moosejaw.
Where to Buy
Gregory Z65
$180.99 - $259.00


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Chelsea will travel to Middlesborough next Wednesday to play for a place in the last eighth of the FA cup. The Blues also have tough away game against Manchester City in the Premier league on Sunday, but Rafa Benitez has insisted that he is fully focused on betting through to the last 16 of the Europa league tonight.
Chelsea have given themselves every chance with a 1-0 victory in the away leg against Sparta Prague, but Rafa says he will not be taking any chances and is taking the competition seriously.


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You have until 2014-07-31 at 14:00 Mexico City Time (CST) to pick up The Work. Then it's gone forever.
The Work, written from 2010-2014.
Digital Warriorships I and II, Reverb, Terminal, Attention Detox. The entire body of work from 2010-2014.
Everything you need to
The work is a distillation of the best I offered from 2011 to 2014. The journey starts in Boulder, Colorado, goes to Tokyo, Japan, Singapore, New York City, and ends in Mexico City, Mexico.
Terminal is a technology book dedicated to making the hidden visible. As I became a programmer, I realized much of the mystique around being a programmer happens on the command line. I wrote Terminal to demystify things. For a programmer, the terminal is how you access the guts of your machine; this is an access point to those guts. Terminal is a collection of interviews to guide you onto the command line and into the world of programming.
Terminal offers the why of computing as you read the how of Miserable Git. Before you even approach the terminal, you have to have some idea why the terminal exists and why it matters. If you don't already have it, you'll get that in Terminal.
Technical Skill Level: Intermediate | HTML | Included in The Work
Digital Warriorship II
In the second version of Digital Warriorship, we tackle experiments in paying better, closer attention.
If you're hooked, this'll help you unhook.
Technical Skill Level: Beginner | PDF | Original Price $39 | Included in The Work
You want people to listen to the stories you're telling? Tell better stories.
Reverb lights the way.
Technical Skill Level: Beginner | PDF | Original Price $49 | Included in The Work
Attention Detox
An Attention Detox helps you keep track of your attention for 168 hours. It's guaranteed to bring into focus how distracted you are, and what you need to do reclaim your attention.
The original version included a guided version - I watched, shared observations and guided participants. The attention detox included with The Work is self-guided.
Technical Skill Level: Intermediate | PDF | Original Price $149 | Inluded in The Work
Digital Warriorship
To be present for others, first see and hear yourself.
Align your real self with your digital self. My path from scrolling for empathy to taking digital sabbaticals and what I learned. Here's an introduction to start developing your presence.
Technical Skill Level: Beginner | PDF | Original Price: $30 | Included in The Work
I would not have become a programmer if I had not done the things that I rolled into The Work. Now that I am a programmer and writer, I can build the houses that hold the work I do. Do you know how liberating it is to be self-reliant enough to build your own digital homestead?
Liberating. The Work is the path I took.
The work includes every relevant conversation, experiment and resource - everything I used to get to where I am now, doing what I love every day.
It's every relevant conversation, experiment and resource - everything I used to get to where I am now, doing what I love every day.
Get it before 14:00 Mexico City Time (CST) on 31 July 2014.


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Dr. Robert Morrison of the Faculty of English has been nominated for a top British literary award for his biography of Thomas De Quincey, The English Opium Eater: A Biography of Thomas De Quincey.
"I am gobsmacked," Morrison said in a news release. "Being shortlisted for the oldest literary prize in Britain seems impossible. I am absolutely elated."
Two Queen's research projects looking at improved outcomes for joint surgery have received National Science and Engineering Research Council (NSERC) funding. James Stewart and Randy Ellis (School of Computing) each received close to $300,000 over the next three years.
Doctoral student Erin Tolley is the first Queen's student to have been named a Trudeau Scholar. The Trudeau Scholarships are among the most coveted awards of their kind in Canada. They reward excellence and provide doctoral students with the best conditions to ground their work in the real world. The Pierre Elliott Trudeau Foundation was created in 2001 and gives out 15 awards each year to scholars in various fields.