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There is, so far as we know, no literature on the outcome of heart transplants in patients with schizophrenia. In fact, having a diagnosis of schizophrenia is an automatic exclusion criterion for heart transplant in the majority of transplant programs worldwide. Here we present the case of a young man with schizophrenia who was initially denied a heart transplant because of assumptions about his psychiatric vulnerability, his ability to communicate, and his likelihood of complying with complex posttransplant treatment. There was little objective information to support these assumptions, and this article describes how we brought this case before the ethics committee of the hospital and succeeded in overturning the initial rejection. We also describe the subsequent successful medical and psychiatric outcomes of the heart transplant operation.
Our patient, Mr. A, is a 37-year-old African American man who has never married and lives with his mother, two brothers, and a sister. Mr. A attends our state hospital outpatient psychiatric clinic in his neighborhood. He is unemployed and supported by Supplemental Security Income.
Mr. A first entered the psychiatric system at the age of 16, when he was hospitalized for 2 months with a diagnosis of schizophreniform disorder. He was discharged and returned home, only to be rehospitalized a few months later for continued psychotic behavior. He was then transferred to a long-term state hospital, where he stayed for 3 months. At discharge he was referred to our outpatient clinic, where he continues to receive psychiatric care. The same psychiatrist has treated him for the past 15 years. Mr. A, therefore, has had a level of continuity of care that gives us the opportunity to offer a complete history of his case.
Mr. A was eventually diagnosed with chronic undifferentiated schizophrenia. He attended special education classes until age 16, when he dropped out of school at the onset of his psychiatric illness. At the age of 18, Mr. A developed an initially mild movement disorder of his upper extremities. Despite multiple evaluations by academic neurologists specializing in movement disorders at the movement disorders clinic of the affiliated general hospital, it remains unclear whether this is a primary movement disorder or is secondary to medications. The movements have become more prominent with time but seem unaffected by changes in or withdrawal of medication.
Mr. A's mental status has been consistent since his first admission to the clinic. He has chronic auditory hallucinations that can be either persecutory or friendly. He refers to the friendly voices as "the family" or as "my friends." Mr. A has slow, slurred, and sometimes inarticulate speech, which, according to family report, has been present since early childhood. Mr. A also has perseveration and at times paranoid delusions. Over the years these symptoms have responded minimally to medications despite many medication trials. Although he remains very symptomatic, he functions quite well, and after his initial hospitalizations, Mr. A was not hospitalized again for 14 years.
Mr. A lives relatively independently and is an active member of the clinic community. He plays an essential role in his home as well, by assisting with the care of his older brother, who is severely retarded. Mr. A has had a job in the clinic's transitional employment program for the past 10 years. His job is to arrange the lunchroom tables and chairs for meals and meetings and to clean off the lunchroom tables after meals. He takes his work seriously and has rarely missed a day. Mr. A has had intermittent episodes of breakthrough symptom exacerbation while taking medication, but he has always attended the clinic and cooperated with his treatment team, and his treatment has been managed successfully without hospitalization.
Mr. A functioned at his usual baseline for 14 years, when he was rehospitalized for psychotic exacerbation. He improved but at discharge appeared more anxious and had multiple somatic complaints, which were attributed to his psychiatric illness. Two months later Mr. A had an upper respiratory infection and was absent from the clinic for approximately 1 week. On his return Mr. A began to complain of arm pain bilaterally. He was also observed to have worsening of his movement disorder and additional facial grimacing and blinking. All of these somatic complaints were attributed to exacerbation of his preexisting movement disorder. Mr. A began taking vitamin E and was sent back to the movement disorders clinic at the affiliated general hospital for a further workup, which produced no significant findings.
Over the next 8 months Mr. A continued to have somatic complaints, worsening of his movement disorder, and an increase in persecutory auditory hallucinations. He was less able to do his job at the clinic and to interact with peers and staff. He became more isolated, and many of the other patients began "checking" on him when he would go into the interview rooms alone "to rest." Nine months after the upper respiratory infection Mr. A experienced another one. He again missed several days of clinic and returned visibly more anxious. Two months after the second respiratory ailment he uncharacteristically stopped taking his medications, and his psychotic symptoms worsened. His medications were quickly restarted, and his symptoms improved. Two months later Mr. A began complaining of increased muscle pain in his arms and chest and problems breathing. His treatment team began to worry that all of these symptoms could not be attributed to his psychiatric or neurological illnesses. He was seen by the clinic's consulting internist, who felt that Mr. A's respiration was similar to a Cheyne-Stokes breathing pattern because of a central nervous system problem. Mr. A was referred to the general hospital for further neurological workup, which produced no remarkable results. His breathing pattern was then considered to be volitional.
Two months later Mr. A came into clinic stating, "I can't put my shoes on." A physical examination indicated that he had a 2/6 systolic ejection murmur, decreased breath sounds bilaterally, and bilateral pedal edema. Mr. A was rushed to a general hospital emergency room for evaluation. During this workup he was found to be in full-blown congestive heart failure with a low ejection fraction and four-chamber cardiac dilation. His condition was felt to be secondary to viral myocarditis. He was admitted to the general hospital and subsequently followed by the heart failure team, and he was treated with cardiac medications. While Mr. A was hospitalized his treatment team at the psychiatric clinic raised the question of his eligibility for a heart transplant given his new medical condition. The consultation-liaison psychiatrist for the heart transplant team was contacted and asked to evaluate Mr. A. The consultation service felt that given Mr. A's limited ability to communicate clearly, the presence of schizophrenia with persistent psychotic symptoms, the possibility of further psychotic exacerbation secondary to immunosuppressive medications, and the questionable ability of Mr. A to adhere to the required intensive medical follow-up, Mr. A would not be a good candidate for a transplant. No further workup was done. The heart failure team felt that Mr. A's prognosis was very poor without a transplant and, since this was denied, he had only months to live. At this point, all of Mr. A's treatment teams, including his psychiatric treatment team, accepted the decision that he was not eligible for a heart transplant, and preparations were being made to keep Mr. A "as comfortable as possible" for the remainder of his life.
Mr. A returned home from the cardiac service while taking multiple medications and with follow-up appointments. Over the next 7 months he continued to attend our program, although he was very weak and debilitated. He needed a wheelchair and special transportation, and he was often too lethargic to participate in any clinic activities. He kept all of his cardiac appointments but required five medical hospitalizations and three psychiatric hospitalizations in approximately 1 year. The psychiatric hospitalizations were primarily for Mr. A's extreme anxiety and for the comfort of the clinic staff and patients, who worried that his medical condition could deteriorate and that he might even die in the clinic. Mr. A had, in fact, stated that if he died, he wanted to die at the clinic. His desire to die in the clinic was both endearing and discomforting for the staff and patients, and it was difficult for his family as well. The staff of the inpatient unit felt that there was not much that they could do to relieve his suffering. Mr. A did not have a "do not resuscitate" (DNR) order nor was he receiving aggressive cardiac therapy at this time. Death was a real possibility.
Ten months after the initial diagnosis of heart failure, Mr. A stopped attending the clinic because he was too debilitated to leave home. The topic of DNR instructions was raised again with Mr. A and his family because of his rapidly deteriorating condition. Mr. A, however, refused to agree to a DNR order, and the psychiatric staff felt that he had the capacity to make the decision. The staff and Mr. A's family began to feel that there was nothing left to do but to make him comfortable and watch him die. The clinic staff and other patients slipped into a state of mourning as Mr. A slowly deteriorated.
With the overwhelming emotion evoked by Mr. A's impending death, his clinicians began to question their own initial acceptance of the decision that Mr. A was unfit to be a transplant candidate. There remained some concerns about Mr. A's ability to truly understand the seriousness of his medical condition and the consequences of the two options: 1) to institute a DNR order for Mr. A and arrange for end-of-life medical services or 2) to push for a reevaluation of his eligibility for a heart transplant and possibly save his life. Mr. A's psychiatric treatment team, faced with this ethical and clinical dilemma stemming from the denial of a transplant for Mr. A, decided to present his case to the chairperson of the general hospital's ethics committee. The ethics committee reviewed the case. They concluded that the only criteria for denying Mr. A a heart transplant were 1) that the transplant would not significantly improve the quality of his life or 2) that he could not comply with the rigorous treatment protocols and the follow-up care required after transplant. The first criterion was ruled out because Mr. A had no other significant medical problems. The second criterion was ruled out because Mr. A had a supportive family, a psychiatric treatment team, and about 80 fellow patients who were more than willing to do whatever was necessary to help Mr. A comply with posttransplant care. The ethics committee concluded that there was no compelling reason not to present his case for a full heart transplant evaluation, and a meeting was set up with the transplant team.
When the transplant team convened the meeting, Mr. A's case was presented. His psychiatrist, his cardiologist, the psychiatric consultation-liaison team, the ethics committee, and Mr. A's mother were present. Mr. A was accepted for a heart transplant. He was then given aggressive medical treatment through an indwelling 24-hour pump to optimize his cardiac status. He was also given a defibrillator vest to wear and the "transplant beeper" to carry. The transplant beeper went off on Thanksgiving Day, and Mr. A had the transplant procedure the following morning. An anonymous hospital benefactor had donated money to cover a heart transplant for an indigent patient, and these funds were used to cover all of Mr. A's transplant costs.
After the operation, Mr. A did well and returned home 24 days later. One week after discharge he attended the clinic Christmas party wearing a surgical mask. The staff and patients were instructed not to kiss or hug him because of his immunosuppression. When he walked into the clinic on his own, a great cheer erupted. Mr. A returned to his prior psychiatric baseline and was physically able to do many of the things that he had not been able to do for many months, such as walk and feed himself. Mr. A was rehospitalized briefly the following January to rule out possible pulmonary infiltrate. Since then he has returned to the clinic and has resumed his usual daily activities.
Mr. A's auditory hallucinations have persisted and have required some increase in his antipsychotic medication. At the same time, he has been increasingly able to identify and describe the nature of these hallucinations, all of which relate to the theme of gender confusion. The treatment team has considered the possibility that his greater openness is a reflection of Mr. A's greater trust of his clinicians. This improved trust or attachment may in part stem from the team's role in obtaining his medical treatment and, ultimately, his transplant. It is interesting, however, to consider what dynamic might have been expressed if Mr. A's treatment team had not advocated his care but instead had "chosen to let him die." It is possible that this knowledge might have been incorporated in a paranoid delusion that his doctors were trying to "kill him" instead of help him. This would most likely have had a negative effect on the attachment and transference in the case. In our experience, however, we have observed that in a time of crisis, even the most psychotic patients can often organize themselves and appear less psychotic and more cooperative.
Mr. A has been compliant with his medical follow-up and attended all of his weekly cardiac biopsy appointments to assess for signs of rejection. He has now functioned well for more than 3 years with no significant medical complications from the transplant, and he has had no significant psychiatric exacerbation. In fact, Mr. A initially had some reduction in his psychotic symptoms and in his movement disorder after the transplant. It is unclear whether this improvement was related to the transplant or to the new combinations of immunosuppressant and psychiatric medications that he was taking. When asked about his heart, Mr. A said, "My old heart was not working so I got a new one." As an afterthought he added, "My new heart came from a 16-year-old boy. That makes me younger!" and he smiled.
As was illustrated in this case, life-saving health care, including organ transplants, can be denied on the basis of a diagnosis of schizophrenia and related preconceived, stereotypical judgments regardless of other relevant clinical findings. This attitude contributes to the increased morbidity and mortality among patients with schizophrenia. Levenson and Olbrisch (1) conducted a survey of heart transplant programs throughout the United States regarding their psychiatric evaluation process, criteria for transplant, and outcomes. They found that there were wide discrepancies among programs regarding inclusion criteria and rates of refusals following psychosocial evaluation. Seventy percent of the programs excluded patients on the grounds of active schizophrenia, dementia, current suicidal ideation, history of multiple suicide attempts, severe mental retardation, current alcohol abuse, and current use of addictive drugs. This study also found some variability with regard to controlled schizophrenia. In a second study (2), the same authors found that 92% of the programs for heart transplants, 67% of those for liver transplants, and 73% of those for kidney transplants viewed active schizophrenia as an absolute contraindication to transplant. In addition, they found that 33% of heart, 15% of liver, and 7% of kidney programs viewed even controlled schizophrenia as an absolute contraindication. That we have found no published cases of heart transplants in people with schizophrenia is therefore unsurprising. It is also not surprising, given this information, that Mr. A was initially denied a transplant.
The two main arguments against heart transplants for this population are that people with schizophrenia 1) could become more psychotic because they will be taking steroids or because they will have "someone else's heart" and 2) will not be able to adhere to the rigors of the postoperative follow-up. We know of no data to support either of these arguments.
DiMartini and Twillman (3) published case reports on two men with schizophrenia who had transplants of other organs. The first was a 44-year-old man diagnosed with chronic schizophrenia who received a bone marrow transplant for chronic myelogenous leukemia. The patient had stable but chronic auditory hallucinations, mild delusional beliefs, and residual negative symptoms. Before the transplant, the patient was treated with thioridazine and amitriptyline. The patient was switched to haloperidol just before the procedure to allow for intravenous administration. He tolerated the transplant and postoperative treatment with prednisone and cyclosporine, and he had no psychiatric complications during or after the transplant. His twice-weekly cyclosporine plasma levels were all within the expected range, which suggested that he was adhering to the medication regimen. This patient, however, developed sepsis and died 246 days after the transplant.
The second patient, who received a liver transplant, was a 27-year-old, Spanish-speaking man with schizoaffective disorder and end-stage autoimmune hepatitis. Before the transplant he was frankly psychotic, with hallucinations, paranoid ideation, and significant thought disorder. He had acute dystonic reactions to haloperidol and perphenazine, but his symptoms improved with thioridazine treatment. At this point, the operation went forward. The patient tolerated the transplant but had several days of postoperative delirium, which cleared as his metabolism improved. The patient had no other medical problems and no psychiatric exacerbation. He adhered to all of his treatments and follow-up care.
In neither of these cases did psychiatric illness interfere with the patient's ability to adhere to treatment or put the patient at greater risk of medical complications. In both cases, either family members or psychiatric clinicians were involved in the patient's ongoing care and recovery. The authors felt that having a support system in place is an important aspect of care that needs to be assessed when considering transplants for people with schizophrenia and that schizophrenia should not in itself be a disqualification for transplantation. Mr. A attended all of his postoperative appointments with the support of his family and coordination with his psychiatric treatment team. The practice of doing a good psychosocial assessment helps to ensure that the patient has a good support system in place before the transplant. This, however, should apply for all candidates, not just those with schizophrenia.
Castelnuovo-Tedesco (4) explored the psychodynamics of organ transplants in two people with no prior psychiatric diagnosis, one of whom received a kidney transplant and the other a heart transplant. He described an "altered body image" due to "adding something into the body." In the kidney transplant case, the patient, who was in a psychologically regressed state before the transplant, felt that he would be "stealing something" that did not belong to him. After the transplant the patient felt elated, "reborn," and "given a second chance" at life. In the heart transplant case, the patient was concerned about the sex of the donor and the possibility of taking on the donor's characteristics. In general, the author discussed the need to explore the significance of the transplant to help the patient with adjustment both before and after the procedure. Mr. A is able to talk about his transplant in concrete terms and has had no difficulty in accepting "someone else's heart."
Several articles have addressed the issue of psychosis secondary to the use of immunosuppressants after transplant (5–11). In particular, the use of steroids has been associated with acute psychosis in the general population. To our knowledge, there are no published data that show that people with preexisting psychotic illness are at higher risk of steroid-induced psychosis. In fact, Hall et al. (6) suggested that people with histories of psychiatric illness are not more susceptible to "steroid psychosis" than those without such histories. Hall et al. (6), DiMartini and Twillman (3), and Freeman et al. (12) all agree that appropriate use of antipsychotics is usually enough to control this complication when it occurs in people with or without mental illness. In this case, Mr. A's psychiatric symptoms actually improved after the operation, and he had no complications while taking the steroids.
In general, people with severe and persistent mental illness are at greater than average risk for morbidity and mortality from medical illness. They are usually poor and must depend on the public health care system. Access to preventive health care is limited in poorer neighborhoods, where people with severe and persistent mental illness live. Poor nutrition and poor housing also contribute to the higher risk for illness in this population. The high risk for illness in this population is also, in part, due to psychiatric symptoms that tend to distract attention from people's medical health needs. In this case, Mr. A was a young, medically healthy man who had significant psychiatric and movement disorders that could have been the cause of his distress. The new medical illness was not clinically obvious until he had frank symptoms of heart disease. His early complaint of arm pain my have been a nonspecific presentation of cardiac pain. Had he presented this somatic complaint in a medical setting instead of a psychiatric setting, cardiac disease might have been high on the list of possibilities in the differential diagnosis. Had Mr. A complained of "chest pain" early in the course of his illness or "shortness of breath," he may have been treated sooner and more aggressively. Such treatment might have improved his condition and possibly decreased his need for a transplant. As psychiatrists, we must not forget about our general medical training and should consider a broad range of conditions in our differential diagnosis when psychiatric patients present somatic complaints.
People with schizophrenia also tend to have a higher pain threshold and often will not complain of pain or discomfort until it is severe (13–16). Mr. A may have had clinical signs of congestive heart failure as early as 1 year before his pitting edema was noted. However, he did not complain of pain or significant physical distress until much later. In people with schizophrenia, therefore, medical illness may not be picked up until it is late in the course of the illness, and then it is more difficult and costly to treat.
Given the tendency for people with schizophrenia not to complain of illness, it is important for psychiatric clinicians to follow up with patients about their general medical health. As was exemplified in this case, it was the psychiatric team that initiated the workup for this patient's heart disease and sought proper treatment, which included overruling the decision to deny him a heart transplant. Properly designed and funded community psychiatry programs could help reduce medical morbidity and mortality for people with severe and persistent mental illness by having psychiatric services and medical health care services in the same program. One of the benefits of this type of treatment program would be that patients could be screened for the early stages of illness and preventive care could be initiated sooner.
The field of organ transplantation is growing, although donor resources remain limited. Therefore, the decision to perform a transplant must continue to be based on the merits of the individual case and on evidence-based medicine. Transplants must not be denied solely on the grounds of a preexisting diagnosis. Psychiatrists, as direct care physicians and as liaisons to medical care, can take a leadership role in changing the practice of discrimination against people with schizophrenia and other psychotic disorders.
Received July 6, 2004; revision received Sept. 1, 2004; accepted Sept. 10, 2004. From the Washington Heights Community Service, New York State Psychiatric Institute. Address correspondence and reprint requests to Dr. Le Melle, Washington Heights Community Service, New York State Psychiatric Institute, Box 75, 1051 Riverside Dr., New York, NY 10032; email@example.com (e-mail). The authors thank Dr. Prager and the ethics committee, Dr. Matthew Maura and the heart failure clinic, Dr. Peter Shapiro and the psychiatric consultation-liaison committee, and the heart transplant team at New York-Presbyterian Hospital, and they thank the staff of the Audubon Clinic and the Washington Heights Community Service for their care of people with severe and persistent mental illness.
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Easy Eagle Tattoo Designs
34 Amazing Eagle Tattoo Designs : Easy Eagle Tattoo Designs
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3 stocks that could really clean up
Global economic expansion means more output and more waste. These companies look to be clear beneficiaries of this long-term trend.
By Tom Aspray, MoneyShow.com
Better-than-expected iPhone sales put a shine back on the stock market, and Apple (AAPL) jumped 9% in afternoon trading Wednesday.
With AAPL back over $600 per share, the question now is how many of those who bought the stock at $630 to $640 will stay with their long positions. The drop from $644 to the recent low of $555 may have been too much for many investors to handle.
The market internals improved Wednesday, but the negative divergence I discussed on April 9 has not been resolved, so it is too early to say that the correction is over.
Though many people in the financial media will be debating the outlook for Apple's overseas sales, there is one commodity whose strong long-term outlook can't be disputed. Unfortunately, I am referring to waste, as some experts expect global waste production to double between 2005 and 2025.
The data show a clear correlation between increased GDP in emerging markets and a higher waste production. These three waste management companies came up on my scans last weekend, and both Waste Management Inc. (WM) and Stericyle Inc. (SRCL) have earnings reports due out this week.
Chart Analysis: Waste Management is probably the best-known name in the industry, as it is a $16 billion company that provides a wide range of waste management services throughout the U.S. The company is scheduled to report earnings at 10 am ET on Thursday, April 26.
- The daily chart shows that WM closed convincingly above the resistance at $35.56-$35.76 last week
- This corresponds to last October's highs, and a monthly chart close above this resistance should have intermediate-term significance
- The resistance from 2011 is at $38, and in 2007, WM had a high of $41.19
- Daily relative performance, or RS analysis, has been improving since late March but is still below resistance at line d
- Weekly RS analysis (not shown) has also not yet completed a bottom
- Daily on-balance volume (OBV) did break through its downtrend in early April and is well above its rising weighted moving average (WMA). The weekly OBV is above its weighted moving average
- There is good additional support in the $34.60-$35 area
Stericycle is a $7.4 billion waste management company that focuses on medical waste both in the U.S. and globally. SRCL has resistance in the $90.80 area (line a) from the fall of 2011. Company earnings are scheduled for release after the close on Wednesday.
- SRCL had an all-time high in 2011 of $93.77
- The daily RS line has broken its downtrend, line i, suggesting that it has recently been outperforming the S&P 500. A move above the early-2012 highs is needed to confirm a bottom
- Daily OBV is in a short-term uptrend with key resistance at line k. The OBV has support at its weighted moving average and the uptrend, line k
- Weekly OBV (not shown) is above its weighted moving average
- There is first support in the $84.50-$86 area with monthly support in the $81.80 area, line h
Covanta Holding Corp. (CVA) is a $2.1 billion company that provides municipal waste management services in the U.S., as well as Europe, Asia, and Latin America. It also operates large-scale waste-to-energy facilities, and the stock currently yields 3.8%.
- The weekly chart shows that in April, CVA approached the 38.2% retracement support in the $15.35 area. Last fall's highs in the $15 area provide further support
- Weekly relative performance is holding above its flat weighted moving average and is testing its downtrend. A move above the February highs is needed to complete a major bottom
- Weekly OBV is acting much stronger, as it formed a bullish divergence at the December lows, line d. This was confirmed when the OBV moved through its downtrend, line c, in February
- Next resistance is at $16.20-$16.40 and then at $16.85
What It Means: In analyzing over 20 years of data, the seasonal trend is for Waste Management to bottom in late February and rally through the end of June. The weekly analysis of both Waste Management and Stericycle is not strong enough, in my opinion, to take a position ahead of their earnings reports.
Even though the overall stock market can still correct further, Covanta does look more attractive, as the volume analysis suggests that an important low was completed in December.
How to Profit: For Covanta, go 50% long at $15.82 and 50% long at $15.56 with a stop at $14.84 (risk of approx. 5.4%).
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US markets were able to rally hard and largely trim the day's losses. Meanwhile, a bounce in crude oil could be in the offing.
Top Stocks provides analysis about the most noteworthy stocks in the market each day, combining some of the best content from around the MSN Money site and the rest of the Web.
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Task Force opposes nomination of Dr. James Holsinger for U.S. surgeon general
Roberta Sklar, Director of Communications
WASHINGTON, June 5 — The National Gay and Lesbian Task Force today announced its opposition to the nomination of Dr. James W. Holsinger for U.S. surgeon general. Dr. Holsinger is a University of Kentucky professor and a member of the United Methodist Judicial Council, the denomination's "supreme court."
In his role on the United Methodist Judicial Council, Holsinger opposed a decision to allow a lesbian to be an associate pastor, and he supported a pastor who would not permit an openly gay man to join the church. As member of the Committee to Study Homosexuality in the United Methodist Church, Holsinger authored a 1991 paper titled "Pathophysiology of Male Homosexuality," which essentially equates homosexuality with disease in lurid terms.
According to the United States Department of Health and Human Services, the surgeon general is "America's chief health educator, giving Americans the best scientific information available on how to improve their health and reduce the risk of illness and injury."
Statement by Matt Foreman, Executive Director
National Gay and Lesbian Task Force
"With the nomination of Dr. Holsinger for surgeon general, the Bush administration is once again elevating ideology over public policy and once again throwing red meat to its ravenous anti-gay supporters. Dr. Holsinger's record shows that his own biases will not allow him to look objectively at scientific information. Consequently, he is not qualified to be surgeon general and we call upon the Senate to promptly reject his nomination."
Statement by the Rev. Troy Plummer,
Executive Director of Reconciling Ministries Network of United Methodists
and National Religious Leadership Roundtable Member
"For the last 20 years, James Holsinger has been the worst kind of bully inside the United Methodist Church. As a member of a sexuality study team in 1991, he used his position as a medical doctor to promote skewed and inaccurate information regarding gay men. As the chair of the Judicial Council, the 'supreme court' of the United Methodist Church, he has used his power to disregard the Constitution of the Methodist Church and block from membership faithful gay and lesbian Christians. As a pastor, he has promoted 'reparative therapy' — a practice that is nothing short of torture of gay and lesbian people and is not condoned by any professional psychological association; in fact, many call it medical malpractice.
"In short, when he has been called to be a leader in the United Methodist Church, to offer the hand of Christian fellowship, he has slammed the door in the face of faithful gay and lesbian persons. What, then, might he do as surgeon general? As the primary medical educator of our nation, I have no faith that Holsinger would refrain from these practices which are unscientific at best and torturous at worst. When Holsinger's 'all' does not mean 'all' in the Methodist Church, can it mean all for American citizens? What kind of education from the surgeon general could gay and lesbian families expect? What could bisexual and transgender people expect?
"As a psychotherapist, a pastor and an American citizen myself, I can only hope that James Holsinger will not be given the opportunity to use the office of the surgeon general as a bully pulpit for hatred."
The mission of the National Gay and Lesbian Task Force is to build the grassroots power of the lesbian, gay, bisexual and transgender (LGBT) community. We do this by training activists, equipping state and local organizations with the skills needed to organize broad-based campaigns to defeat anti-LGBT referenda and advance pro-LGBT legislation, and building the organizational capacity of our movement. Our Policy Institute, the movement's premier think tank, provides research and policy analysis to support the struggle for complete equality and to counter right-wing lies. As part of a broader social justice movement, we work to create a nation that respects the diversity of human expression and identity and creates opportunity for all. Headquartered in Washington, D.C., we also have offices in New York City, Los Angeles, Miami, Minneapolis and Cambridge.
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Exxon Mobil's Stock Price is at the Mercy of Oil Prices
John is a member of The Motley Fool Blog Network -- entries represent the personal opinion of the blogger and are not formally edited.
Exxon Mobil (NYSE: XOM) has been pushing against that '87'resistance level since early January no less than 10 times but just cannot find the strength to push through. The company has fared well than some of its rivals by maintaining a high price. This as compared to ConocoPhilip (NYSE: COP) that has dropped about 8% in the last 6 weeks. This is due in part to the price of oil going down. Considering ConocoPhilips also spun off its exploration company and is a pure oil and natural gas producer, Exxon has fared much better.
What will it take for Exxon to push through that 87 level? The company has a lot of potential. We do know that the company is joining forces with the Russian company Rosneft to explore for oil in Russia's arctic and Black Sea regions. Sinking about $500 billion into the project together over time, they have estimated the reserve they found in the Black Sea has 9 billion barrels. Unfortunately, it will be a few years before any gain is seen from that venture. 2018 is the earliest oil will be seen from these sites.
It is likely that future projects are not going to raise Exxon's stock. Instead, Exxon's stock price will be influenced by the price of oil, so where is oil going this year?
Short Term Oil Prices
Short term, EIA has lowered the forecast 2012 average U.S. refiner acquisition cost of crude oil by $2 per barrel from last month's Outlook to $112 per barrel, still $10 per barrel higher than last year's average price. Oil prices dropped after the government said U.S. supplies grew more than expected last week. U.S. crude supplies grew by 3.8 million barrels recently while analysts expected the growth to be 400,000 barrels. Motorists are not filling up as expected. Gas is likely to rise to around $4 per gallon during the next few weeks as more refiners switch to producing summer blends of fuel.
Long Term Oil Prices
Long term, oil prices are expected to climb. Shell Oil CEO Peter Voser says oil's long-term price trend will only go in one direction, and that's up. Mobil Corp is cutting its long-term production forecast due to higher oil prices. Exxon Mobil Chief Executive Rex Tillerson said the company estimates its total oil-and-gas production in 2014 will be up 2% to 3% from 2009, instead of its previous estimate of an increase of 4% to 5% over the period. It also expects crude prices to remain high for the next few years to come.
Exxon Mobil will be pushing up through that resistance level until oil prices go back up again, which could be down the road according to forecasts. Since short-term oil prices will be held back by a combination of less usage and production cut backs, it does not look like an increase will take place before the third quarter of 2012. It is after this time that we may see enough revenue increase that Exxon may be able to push through that barrier it continues to struggle with.
The Motley Fool has no positions in the stocks mentioned above. johnmylant has no positions in the stocks mentioned above. Try any of our Foolish newsletter services free for 30 days. We Fools may not all hold the same opinions, but we all believe that considering a diverse range of insights makes us better investors. The Motley Fool has a disclosure policy.


text:
Each week Patch will feature a cartoon from artist David Tovey. You fill in the caption to make your own funny and we'll name the caption king or queen every week.
You have from Wednesday to Monday to comment and we'll announce the winner on Tuesday, along with the original version of the cartoon with the caption included.


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CHARLOTTE — Here's what the Falcons were saying after the game:
"They were much better than us today. They beat us in all three phases. We couldn't sustain drives on third down offensively. We couldn't even come close to getting them off the field on third downs (defensively.)"
Falcons coach Mike Smith on the game
"We misfit some runs. We lost some leverage and we missed tackles. When you do that, you're going to give the number of yards and points that we gave up. Again, it was not up to our standards whatsoever. They were definitely the better team today. My hat is off to them."
Smith on the run defense, which gave up 195 yards rushing, four yards shy of the season-high 199 they gave up to the Panthers on Sept. 30.
"Not at all, I thought we had a very good week of practice. On Tuesday we came back and had a Falcons on Falcons day and then we started our game planning on Wednesday. I thought we had very good practices. They played well and we didn't play up to our standards. Again, my hat is off to them. That's a good football team. We had a good battle over there in Atlanta and they were definitely better today."
Smith on if the Falcons came out flat against the Panthers.
"We just have to work hard. We have an opportunity to play against a great team coming in. The Super Bowl champs. We'll just work harder. We'll learn from the mistakes. We'll go in tomorrow, watch it and try to learn from it. We made a lot of mistakes. It was uncharacteristic of us, but ultimately we just have to move on."
Linebacker Sean Weatherspoon on the game
"There are a lot of men in this locker room. He didn't have to say anything to get the guys going. We know how to win. We know how to play ball. Ultimately, when it comes do it, we have to bounce back."
Weatherspoon on what Smith said to the team after the game.
"They just made more plays that us. We didn't make enough plays. We have to execute better. It was more about us not tackling and making plays."
Cornerback Robert McClain on the game
"We are going to keep fighting. We get paid to play football. We're going to keep fighting. We are going to learn from this. We are going to get better. We have a pretty good football team coming in next week."
Center Todd McClure on rebounding
"It took a little while. We didn't really find a rhythm there until the second half. They stayed on the field and we didn't. It's hard to get in a rhythm when you're not out there. We didn't start the way we wanted to. We started slow. They played hard. They were the better team today."
McClure on the offense's play against the Panthers.
"It's a tough scheme to stop. We've got to get back to the drawing board and do a good job. We had some spurts where we were OK in the second half. But, for the most part, we have to do a better job across the board."
Defensive tackle Corey Peters on the Panthers
"He's a big strong guy. I could only get one hand on him. My job, I failed on that play. Whenever I get my hands on the quarterback I need to get him down. That's on me. That's my failure."
Peters on his near sack against Cam Newton
Cornerback Asante Samuel, safety William Moore are questionable for Panthers
Falcons at Panthers: 3 key matchups
Q&A with Falcons wide receiver Julio Jones, who's closing in on his first 1,000-yard season
Falcons amused by tough talk from Panthers defensive end Greg Hardy
Offensive coordinator Dirk Koetter not worried about dip in Matt Ryan's numbers
Falcons avenge their only loss to improve to 11-1
Turner becomes franchise's all-time leading touchdown leader
Falcons quoteboard: What they were saying after the game
Defense ends Drew Brees streak of 54 games with a touchdown pass
Video: Ledbetter discusses 23-13 win over the Saints
December 9th, 2012
5:43 pm
Everywhere we goooO,
Everywhere we goooO,
People wanna knooOw,
People wanna knooOw,
Who we aaa are,
Who we aaa are,
So we tell theem, So we tell theem,
We are the FALCONS!! We are the FALCONS!!
December 9th, 2012
5:56 pm
What's that clown Bill Shanks doing there?
December 9th, 2012
7:16 pm
roddy and the Atl were just flat—next weak, they will beat the giants easy.
December 9th, 2012
7:29 pm
We were whipped today no doubt but when you have nothing to lose as the Pansies you can play hard like that and take the chances cause if you lose you lost nothing…………Falcons had a shot at coming back on em though late in the fourth, just not enough defense out there today to hold em for the comeback.
It is better to lose one or two now and get back on that winning streak with the playoffs coming soon than to be hot now and sizzle in the playoffs like so many times before………………………………………………………………
December 9th, 2012
7:34 pm
before I go I got to compliment the offense of Atlanta on one thing, when they get in that groove with that no-huddle it is like watching a sewing machine in action………………one stitch after another. This team looks like a playoff contender this year, no doubts !
December 9th, 2012
7:59 pm
What the hell where you matching you stupid Michael M.?
December 9th, 2012
8:00 pm
Show me something better than that product you put on the field today. Put your big boy pants on and step it up.
December 9th, 2012
8:12 pm
And the Falcons and us Falcon fans wonder why the sports anouncers down us. The next time a Facon or one of us Falcon fans asks that question just show clippings ffrom this game. On offense we seem to have a hard time exploiting mismatches with the other teams defense. But it seems the oter teams offense have no trouble finding our weakeness and boy do they exploit them. D. Robinson you robbed the Falcons. I see why Ga. did not recruit you.
December 9th, 2012
8:13 pm
This loss was necessary. Needed another loss to gt refocused. We didn't play until second half and only lost by 10 points. They just had an off game. of course the panthers are going to play hard, they haven't won any games.
Just need to get back to the boards and begin to get hot right now for the playoffs. 1 more loss is it though based on the expectations for this team. Gt refocused, try and run the ball and stop the run, the best formula for the playoffs. We're fine, no need to panic
December 9th, 2012
8:14 pm
Bad news for Falcon fans. The Falcons are self destructing before our eyes. I hate to broach the
subject, but the Falcons have a record of teasing their fans with some wins and then falling apart.
I've watched them since 1966 and thats how it usually turns out. The Giants will humiliate the
Falcons. as if the Panthers did'nt. Sorrry but thats the way the Falcons have always been.
December 9th, 2012
8:28 pm
Lost two games the whole year and the doubters are paranoid and the whiners are furious………..hahahaha………..you can't win em all, it is football, onwards and upwards baby
December 9th, 2012
8:32 pm
Final 1 2 3 4 Tot
New Orleans 7 6 14 0 27
NY Giants 14 7 14 17 52
What will the score be next week???-Manning just had a warmup game
December 9th, 2012
8:40 pm
we still need a running back a M/linebacker won't get far without it, andwhat the hell is franks doing on punt returns
December 9th, 2012
8:52 pm
Wow, that was a pretty pitiful "effort" today…
December 9th, 2012
8:54 pm
Michael M.
December 9th, 2012
8:28 pm
Lost two games the whole year and the doubters are paranoid and the whiners are furious………..hahahaha………..you can't win em all, it is football, onwards and upwards baby
^ a product of the Georgia public school system……a delusional idiot.
December 9th, 2012
9:18 pm
Was obvious to see by the 3rd play of Carolinas first series that our team had no interest in playing today.
December 9th, 2012
11:02 pm
December 9th, 2012
11:19 pm
Have you guys seem Tom Brady or Peyton Manning after a press conference? Even Drew Brees they all have that fire a look of anger. I like Ryan and i think that this has been his best year but anytime a team gets physical with him he folds; he gets happy feet and fails to make easy throws. Its not just me being critical of him look at what former guys who played the postion say about him. I hope he proves me wrong but unless he gets hot the Falcon are going to have a tough time in the playoffs.
December 10th, 2012
5:58 am
Fact…FAILCANTS one and done in playoffs…never will win a SB…
December 10th, 2012
6:24 am
The weakness is still the offensive and defensive line. Upgrades have been made in all areas, but still short of championship caliber on the lines–the most important part.
December 10th, 2012
8:31 am
I'm sticking with the Falcons. I said I would, but Mike Smith needs to ride their ass like zorro, because they are going to the super bowl. We are going to be together on this. Falcons and their Fans!!!! S?!+
December 10th, 2012
9:09 am
December 10th, 2012
9:13 am
They say they're getting better every week and thats a flat out lie.lol I laugh b/c the same rhetoric over and over has become humorous to me at this point. They looked really bad against a 3-9 team. This team has major underlying issues. Next week is a HUGE smell test…but for me honestly I dont care about seeding. Maybe we NEED to start as a 4th seed and no bye….bc if the team I saw yesterday shows up…it'll be more of the same. I've been a loyal fan through 3-13 seasons,etc….but this new Smitty-ball reg season champ stuff is even worse. If they dont at least win a playoff game this year (bc I dont see Super Bowl written anywhere on this team even with our record), I guarantee you guys that SirReal wont be seen on here much b/c I'll be too busy advocating against the new stadium this team wont deserve.
December 10th, 2012
9:47 am
Sounds like a bunch of excuses…
December 10th, 2012
10:01 am
matt ryan is the sorriest qb in the national football league. he calls out all that garbage behind the center blue, okra, or whatever it doesn't mean a thing. he is still sorry. and michael turner is one big fat dog turd. the falcons needs to draft a qb and some running backs period.
December 10th, 2012
10:02 am
No one wants to hear these canned, standard responses they have after a loss. Fans want to know why the same issues (OL, DL, predictable playcalling, Ryan getting antsy in the pocket, INCONSISTENCY) from five years ago hasn't been fixed? Same old, same old Falcons. They still haven't found the right Captain to steer this ship. Smitty ain't it!!!
December 10th, 2012
10:54 am
The problem with the Falcons is undoubtedly the lack of poise and athletic instinct in Matt Ryan. He's an ok QB at best. He needs more time in the pocket than your average so called "good or great" QBs need in order to be productive. He has all the physical capability but his athletic instinct is little to none at best. Give Matt Ryan more than 5 seconds in the pocket and he can be great. Anything less, where he has to make a play on his own, not gonna happen. What i mean by that is, if Matt Ryan is hurried or the designed play is not there, then he's going to either throw it away or throw to the spot anyway and get picked off. All the so called "good to great" QBs will use their athletic instinct to make plays when the designed play is not there or if they are flushed out of the pocket. Bottom line is, Matt Ryan is "THE" reason why the Falcons lost to the Panthers and why the Falcons has been a one and done team all this time.
The Falcons have devoted a lot of money to get many explosive weapons for Ryan. Still, the Falcons is not and has not shown that they are an explosive team. That is why they have not earned the respect of anyone in the football world. Bottom line, trade Ryan and a first rounder to get Manziel, "Johnny Football" when he comes out of college and our problems in Atlanta would be 90% solved. Add a good blocker and Another good nose tackle to help stop the run and the super bowl is as good as ours!
December 10th, 2012
10:56 am
thank you "old falc" for hitting the nail on the head. I've been scratching my head all year at our punt returner Franks. He is not worth 2 cents. He fair catches when he doesn't have to and doesn't fair catch when he should. When he finally does try to run one back he runs scared. Is that the best we can come up with? Bring back Billy White Shoes he could do better in his 60s.
December 10th, 2012
11:04 am
I agree it was obvious at the beginning of the game that the Falcons looked lethargic, sleepy, tired, don't care at all about this game attitude. #28 (or #27?) gets burned for the first TD and he is laughing and smiling big for all to see how stupid he is. Our coach does nothing. I wish we had a coach with the balls to send him to the showers immediately and put in a bench-riding please give me a chance DB to take his place for the remainder of the game. Parcells, Ditka, Bellichek, all the best coaches would do that. Not our coach. Probably patted him on the butt.
December 10th, 2012
11:09 am
Look, I know Matt Ryan is no Brady, Manning, or Brees and probably never will be. BUT he has won enough games as our QB to qualify as a Good NFL QB. He does have his problems. Anytime he gets close to a little pressure he is ready to pee his pants. He is not as bad this year as last year, so I do see improvement in that area. If you look back at last year he was a big fat WIMP everygame. His rookie year was way better. This year he has improved over last year but still shows signs of being wimpy. I wish he would roll out more when the pocket is not there instead of getting so scared (its so obvious). I do believe he can get us to a SB (hopefully this year) and I sure hope he can do his part to win it. QB can't do everything himself. Got to have a supporting cast doing their job also! Go Falcons!
December 10th, 2012
11:19 am
It was clear that the Falcons showed up to collet a pay check yesterday, not to play football. Pathetic. Fan and ticket holder since 1968. This team will lose 1st round I'm afraid to say.Pathetic.
December 10th, 2012
11:53 am
I think Mr. Blank or our Head Coach should get everyone together and "suggest" that any player who played at least 1 play in that joke of a game yesterday to VOLUNTARILY donate their paycheck from that game to Tripp Halstead, the little boy about to have surgery on his skull today, to go towards his massive medical bills. Nobody that played against the last-place Panthers yesterday deserves to keep their paycheck. That will help them earn the respect of their fans and then they can get back to work to get ready for the Giants, the same Giants that embarassed their ass in the playoffs last year.
December 10th, 2012
11:55 am
Was on the road yesterday, but listened to the game on Sirius XM. It was pretty hard to listen to. I can only imagine how hard it was to watch.
December 10th, 2012
12:23 pm
You people that are blaming Ryan for this loss are NUTS. Did you watch the game? The defense gets 80% of the blame for not getting to Newton, making stops, or stopping all the 3rd down conversions. The O line gets the other 20%. When he HAS TIME Ryan can make the throws.
December 10th, 2012
12:28 pm
@hitithard i would give almost anyting to see what van brocklin would have done with turner after some of his runs and the o/l he'd take'm behind the bleachers playing that way should never have let harvy D. leave
December 10th, 2012
1:14 pm
Come on y'all….The Falcons are 11-2. Get Real, they had a bad game…..it happens. Look at San Francisco they haven't beaten the Rams all year. Any given Sunday. And for those of you who don't like Coach Smith or Ryan. Get a life….this is the best era in Falcons history!
December 10th, 2012
1:17 pm
Looks like this team is practicing up for the playoffs. A new stadium?? For what?
December 10th, 2012
1:41 pm
Falcons took a good whuppin……..
Falcons need to shake up things offensively……..HD isn't the answer at slot receiver…..He is too undersize to go into the teeth of defense…..Drew Davis need to be given starting position at slot………
Falcons run defense better start tackling or it is going to be a short postseason……
Falcons on three, DOMINATE….
December 10th, 2012
1:56 pm
We now have a rival we hate ALMOST as much as the Caints.
December 10th, 2012
7:10 pm
I read several comments that generally support the falcons overall efforts this season It's true, the birds are 11 wins and 2 losses. The truth of the matter is, they played 8 of those games well. Matt Ryan and the offense moved the ball with precision. The defense played lights out with intensity and imagination. That was against the "weak" part of the schedule. The past 5 games have have been another storey. All phases of the game have been going down like the Titanic. Games have been lost by the opponents, not won by the Falcons. Matt Ryan is throwing interceptions or throwing the ball inaccurtately. It seems to me he is playing scared. Throwing the ball in places that his receivers have to make almost miracle catches. The running game has been absent in 85% of the games. The line play is a major part of this along with a running back that seems to run with his eyes closed. How many times have you seen Michael Turner crash into a mass of bodies when there is a running lane 2 feet away. I was sceptical when the Howie Longs of the world didn't recognize the Falcons progress. Now I know he was absolutely right. These Falcons are 1 and done in the playoffs. I feel very bad for Tony Gonzalez. You're a damn good man Tony…the dirty birds don't deserve you..go ahead and retire
December 10th, 2012
7:10 pm
No other Falcons' teams has ever had the offensive weapons that Matt Ryan has!!! Infact, no current NFL Team today has the explosive offensive support that Matt Ryan has. I guarantee you that if Matt Ryan was playing for the Jaguars this year, he would be lucky to win 1 game and probably lucky to even maintain his job as a starting QB.
December 10th, 2012
7:54 pm
matt is a very good QB theline was bad last year right? the defence needs to practice against a good running back with speed,TURNER was agood back but hes lost a step tim toone needs to be running back punts and kickoffs good luck FALCONS
December 10th, 2012
8:07 pm
What is Roddy White's status after taking that shot to the knee on the 3rd to last play of the game? Why on earth did Mike Smith have his starters on the field with 1:30 left in a 3 possession game? which, to be frank wasn't all that important to win in the first place. If it was Matt Ryan who got hurt . . .
December 10th, 2012
10:07 pm
December 10th, 2012
10:08 pm
December 10th, 2012
10:10 pm
December 10th, 2012
10:15 pm
December 10th, 2012
10:19 pm
December 10th, 2012
10:22 pm
December 10th, 2012
10:24 pm


text:
|A cluster randomised trial of a school-based resilience intervention to decrease tobacco, alcohol and illicit drug use in secondary school students: study protocol
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text:
EL PASO — A gunman tried to rob two Eastside hotels within minutes of each other and El Paso police want him caught.
On January 17 at about 3:40 a.m., the man walked into La Quinta Inn on Gateway West and Lomaland wearing a ski mask and asking about a room. Instead, he demanded money from an employee and ran off with some cash.
About 20 minutes later, he tried to do it again at La Quinta Inn on Gateway East and Yarbrough.
"Right as he had done that, a security guard that had been doing his rounds there at the motel was going into the lobby area. The suspect sees the security guard approaching, panics and flees the scene without taking any of the money," said Javier Sambrano with the El Paso police Department."
The robber was wearing a gray hooded sweater, light blue jeans, white sneakers and gloves.
If you have any information, call Crime Stoppers at 566-TIPS.


text:
An excellent ensemble of singers perform a programme of beloved opera arias and other famous vocal works in the heart of Venice.
Add this musical highlight to your visit to Venice's stunning Piazza San Marco.
Tue 16.12.2014 21:00
Thu 18.12.2014 21:00
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text:
Sorry! There are no remaining departures for "Kruger & the Garden Route" (DAKG), but here are some similar trips.
Arrival transfer included. Welcome meeting in the evening.
If you arrive a few days earlier in Cape Town enjoy this vibrant city with optional activities such as a visit to the Castle of Good Hope, the Aquarium at the V & A Waterfront, Table Mountain and Robben Island. The more adventurous should go for cage diving and have a close encounter with great white sharks.
Cape Town's name originated from the term Cape of Good Hope when Bartholomew Diaz and other seafarers looked forward to the sight of Table Mountain, like an inn that promised hospitality and prosperity. The city is steeped in a rich history and is a cultural melting pot with its diverse and vibrant character being derived from Khoxisan and other African tribes from the north, and Indonesian, French, Dutch, British and German settlers. Cape Town is the third most populous city in South Africa, with over 3 million inhabitants, and is the provincial capital of the Western Cape. It is also the legislative capital of South Africa, where the National Parliament and many government offices are located.
For shopping, dining and entertainment the V&A Waterfront is a hotspot for foreigners and locals alike. Still a working harbor, the Waterfront is an example of creative architecture and restoration and has become South Africa's most visited tourist attraction. The Waterfront offers over 250 shops from designer boutiques to craft stalls, a host of restaurants and coffee shops.
If you still have time, visit Red-Hill pre-school, one of our Planeterra project. Planeterra - the G Adventures Foundation is our non-profit organization that was developed to give back to the people and places we visit on our tours. Planeterra supports local community projects, non-profit organizations and international charities that focus on the areas of health, education, community development, environmental conservation and employment skills training.
Approximate distance: 150km
Estimate Travel Time: 2 hrs
Enjoy shore-based whale-watching during Jun-Oct, go on an optional boat cruise, or a hike or just linger in this picturesque coastal town.
Our next stop is the picturesque coastal town Hermanus, world famous for its whales. Hermanus, also described as the Riviera of the South, offers the best shore-based whale watching in the world. Nature lovers from all over the world visit Hermanus to view these magnificent creatures from the cliffs.
Look out for whales on the cliff paths or on an optional boat cruise, swim in the Indian Ocean, go canoeing, diving, surfing or those who need the adrenalin rush there are the thrills of hang gliding and powerboat racing.
Approximate distance: 500 km
Estimated travel time: 5-6 hrs
We take a scenic drive to travel via the wine route 62 into the area known as Klein Karoo ("Little Karoo"), where we make the quiet town of Oudtshoorn our base. Tonight you will enjoy a traditional south african meal.
Visit an Ostrich farm upon arrival and visit the Cango Caves the next morning before we continue traveling to Plettenberg.
Oudtshoorn is notably the ostrich capital of the world. Here ostriches are found in great numbers and the region produces the world's best feathers, leather products and meat. Amidst the 400 ostrich farms surrounding the town, three have distinguished themselves worthy enough to be named show farms.
The Cango Caves are sculptured by nature through the ages, and is filled with mysterious and breathtaking limestone formations in a wide variety of natural colours. They lie in the Swartberg Mountain Range in a limestone belt measuring 1.5km in width and almost 16km in length. This part of the continent was once below the ocean. As the continent rose, the Little Karoo found itself above the water level. The caves started to form some 20 million years ago, when the water level dropped to such an extent that the ground water could start to seep into the limestone. As the water seeped into the ground it absorbed carbon dioxide from the decaying plant and animal matter in the soil and this made it fairly acidic. As it seeped into the limestone, cavities were created that filled with water. Rivers also formed on the surface and cut deeply enough into the limestone to allow them to reach the level of the water pockets. This caused the water to flow out about 4 million years ago. The cave was then, for the first time, exposed to air and the speleothems (cave formations) began to form. The portion of the caves that are accessible to the public extends for 1.2km, with a further 4.1km being kept closed for conservation.
Approximate Distance: 250 km
Estimate Travel Time: 2 1/2 Hours
Enjoy this popular and scenic stretch of the south-eastern coast of South Africa on our way to Plettenberg Bay, our next stop. The Garden Route stretches from the Tsisikamma National Park to Mossel Bay. Just linger in this picturesque coastal town of Plettenberg Bay, go on an optional boat cruise or hike, or simply hang out and relax on the beach. For the more adventurous, optional activities include abseiling, sea kayaking, mountain biking, bungee jumping, you will definitely find something to keep the adrenaline pumping.
Originally christened "Bahaia Formosa" (Beautiful bay) by early Portuguese explorers, the beautiful sweeping golden beaches characterize Plettenberg Bay, set on a rocky peninsula, with intriguing lagoons and towering forests nearby.
Day 5 we will visit the Tsizikamma National Park where you have the opportunity to go on self guided hikes.
Plettenberg Bay to Port Elizabeth 237km's (3-4 hours drive)
Flight Port Elizabeth to Johannesburg: approx 2hrs.
Take in more beauty of the world famous Garden Route. Flight from Port Elizabeth to Johannesburg. Airport transfer from Johannesburg airport to Johannesburg Hotel. Attend a pre-departure meeting for the second portion of your trip tonight.
Please note: As this is a combination trip (Garden Route and Kruger portion), some of your tour members may depart in Port Elizabeth and you may be joined by some new travelling companions on Day 7. As such, the CEO's and/or particular vehicles operating your tour may change between tour segments.
Estimate Driving Times: 7 hrs (including lunch)
Please note that today is a transfer shuttle bus service only and not a tour or safari and will also transfer other passengers than G Adventures bookings. Your CEO will say good-bye to you and will help you check in for the shuttle transfer. Your CEO will pick you up again on Day 10. There is no CEO needed for the next 2 days as you will be taken care of the game ranger and lodge manager.
The driver will stop en-route for a leisure break and lunch (at own expense). We will use a Toyota Quantum (14 seats) with trailer. The transfer shuttle service will drop you of just outside the Timbavati Gate where you are met by a representative of the lodge.
For the next two days enjoy morning and evening game drives in our open safari vehicle in Timbavati Private Nature Reserve, adjoining the Kruger National Park, searching for elephant, lion, rhino, leopard and buffalo - Africa's famed Big 5. Nocturnal animals, including the big cats are regular sightings at night. Keep an eye out for white lions which the Timbavati Private Nature Reserve is known for, as it is one of very few places in the world which hosts those species.
This is how your next two days will be:
Early morning wake up call (around 5am), coffee/tea & rusks on the deck before the morning open vehicle game drive (approx 3 hours) starts. Return to the Lodge for brunch followed by some leisure time. Enjoy the pool or the lodge's wooden deck overlooking the river, read a book or take an afternoon nap. Around 14:30pm enjoy High Tea (light lunch and cakes) before you hop on your late afternoon/ evening open safari vehicle game drive.
Return, freshen up and meet for pre-dinner drinks and enjoy dinner.
In 1993 the fences between the Kruger National Park and the Timbavati Reserve were removed to encourage natural species migration. Today the Timbavati Private Nature Reserve (TPNR) comprises 53,392 hectares of private land adjoining the Kruger National Park (KNP). Currently, there are over 40 mammal species in the Timbavati including the Big Five as well as 360 species of bird life.
While relaxing and enjoying the breathtaking views from the lodge's wooden deck overlooking the river, we listen to the sounds of Africa and search for shooting stars piercing through the night sky before we overnight in our luxury accommodation at the Simbavati River Lodge, meaning 'lions that come down from the stars'.
Approximate Distance: 220 km
Estimated Travel Time: 8 hrs (including lunch stop and game viewing in own vehicle)
Hop on your last early morning game drive in Timbavati Private Nature Reserve. Enjoy more game driving inside Kruger National Park in our own vehicle. Search for more lion, elephant, rhino and many other animals in one of Africa's most well-known wildlife areas on our transfer through Kruger National Park in our own vehicle, making our way south towards our camp Nkambeni. Enjoy an optional late afternoon game drive in an open vehicle where you will have a chance to search out some more incredible wildlife.
The world-renowned Kruger National Park offers a wildlife experience that ranks with the best in Africa. Established in 1898 to protect the wildlife of the South African Lowveld, this national park of nearly 2 million hectares is unrivaled in the diversity of its life forms and a world leader in advanced environmental management techniques and policies.
Truly the flagship of the South African national parks, Kruger is home to an impressive number of species: 336 types of trees, 49 fish, 34 amphibians, 114 reptiles, 507 birds and 147 mammals. Man's interaction with the Lowveld environment over many centuries - from bushman rock paintings to majestic archaeological sites like Masorini and Thulamela - is very evident in the Kruger National Park. These treasures represent the cultures, persons and events that played a role in the history of the Kruger National Park and are conserved along with the park's natural assets.
Explore world famous sites like Blyde River Canyon, Bourke's Luck Potholes and God's Window along the Panorama Route.
Look out the window to view a wonderful landscape complete with mountains, panoramic passes, valleys and waterfalls. Enroute, we visit Dullstroom, one of the foremost fly fishing areas in South Africa, the Mac Mac Falls and Pilgrims Rest. Pilgrim's Rest is situated on the magnificent Panorama Route on the eastern Escarpment region of the Mpumalanga province of South Africa. The area is richly imbued with a diversity of natural, cultural and historic gems. The uniqueness of this historic village is vividly evident in its museums and historic sites. It offers the visitor a fascinating window into the past and captures the spirit of a bygone era and its people in their quest for gold.
The entire town of Pilgrim's Rest was declared a National Monument in 1986 as a living memory of the early gold rush days in South Africa during the late 1800s / early 1900s.
En route we stop by to view the 65 m high Mac Mac Falls in the Mac Mac River which is a declared as a National Monument. This waterfall was originally a single stream, but gold miners blasted it with dynamite to divert the river in an attempt to work the rich gold-bearing reef over which it plunges.
Estimated Travel Time: 7 hours
Approximate Distance: 425km
After an early breakfast we return to Johannesburg. Along the way we stop for lunch (at own expense). Tour ends in Johannesburg in the late afternoon.
*If you are departing Johannesburg today we highly recommend that you do not book your departing flight until 8pm or later.
Johannesburg, also known as eGoli, is the most populous city in South Africa. The city is affectionately known as "Jo'burg", "Jozi" and "JHB" by South Africans.
Johannesburg is the site of a large-scale gold and diamond trade due to its location on the mineral-rich Witwatersrand range of hills. Johannesburg is also served by Johannesburg International Airport, the largest and busiest airport in Africa and a gateway for international air travel to and from the rest of southern Africa.


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Great Day in Harlem
Published on Saturday, October 5, 2013 - 9:10am
Film and Discussion with Jazz historian, Rusty Hassan
Please join us in the Black Studies Center on Tuesday, Oct. 8 at 6:30 p.m. for a showing of A Great Day in Harlem.
This film gives a behind-the-scenes look at the famous 1958 photograph that brought together most of the era's jazz legends.
Noted radio personality and jazz historian Rusty Hassan will introduce the film and lead a discussion afterwards.
In the Black Studies Center, Room 316.


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Of course the main story is Michael Phelps with his many gold medals, his pot smoking shame and his "ladies", however, when it came time to perform in the pool, Michael did so and the US team triumphed in the 400 meter medley
Part of that team in Eric Shanteau and he, not Phelps, is the feel good story of the weekend.
Eric competed in the Beijing Olympics, after being diagnosed with testicular cancer. He put off treatment so he could compete and while he didn't shine, not making it to the final, he went public with his illness. He was an inspiration to athletes everywhere.
Now he is back, competing again after treatment of the cancer, and it seems he has something to prove. His times are faster and he has already made one trip to the podium.
Eric, I have a feeling it is only the first of many.
Eric Shanteau comes back from testicular cancer to help USA medley relay team to victory
8/3/09 in Olympics, Summer | Debi_L | 11868 respect


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Remembering Jimi Hendrix
Monterary Pop Festival
A series of singles were released that all gained top 10 rankings followed including Hey Joe and Purple Haze and set the stage for his appearance at the Monterary Pop Festival in California, USA. This performance ended with him holding a burning guitar about his head which re-introduced him to an American audience and made him an instant celebrity. From then on his albums sold in millions in the USA.
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latest entertainment news
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Using new media to talk aboutcultural difference and promote diversity
Let's talk about cultural difference and diversity.
Check it out on YouTube.
Find out how Talking Difference is engaging communities to talk about cultural diversity
The conversation starts here
Meet some of the artists
Are you proud of your skin colour?
On Monday 28th of May we ran our last set of Talking Difference comic drawing wo...
After over 1,000kms and five residencies in public libraries around the State, t...
Last Saturday we filmed the first half of the Mockumentary the TD Pilot Team hav...
Since July, Ana has been busily working on her own Talking Difference project.
A collection of videos and animations created by participants, part...
Facilitating dialogue about cultural difference and promoting diversity
what hardships did they face
To read the latest tweets from @immigration_mv
Follow Immigration Museum on
I am doing a report on Cambodia, and I would like to know what hardships did Cambodians face and what were the benefits of the migration experience.


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About P&T JournalContacts:
Editorial: Sonja Sherritze, Editor
Advertising: Maureen Dwyer Liberti,
Vice President, Group Publisher
Production: Mary Ellen Curry,
Director of Production Services
Circulation: Jackie Ott, Circulation Manager
Statement of Purpose
Guidelines for Authors
Editorial Board
Recent Issues
- 2014
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September 2006
Clostridium difficile–Associated Diarrhea: A Review and Update on Changes in Disease Virulence and Treatment Response
The authors review the increased incidence of antibiotic-associated diarrhea as well as its pathogenesis, diagnosis, prevention, and treatment.
April D. Miller, PharmD, Kelly M. Smith, PharmD, P. Shane Winstead, PharmD, and Craig A. Martin, PharmD
P&T Around the World
Anatomy of a Global Sentinel Event: Vaccine Safety in Vietnam
A mysterious illness in several Vietnamese children sets off an investigation that has worldwide implications for vaccine supply chains and safe handling practices.
Peter G. Teichman, MD, MPA, and Nguyen Tri Doan, MD
Factors Associated with Epoetin Response: Drug Utilization Evaluation
Epoetin alpha (recombinant human erythropoietin) is effective for anemia in patients with chronic kidney disease or cancer, but not all patients respond favorably. The authors sought to predict which patients would be likely to respond before therapy is begun.
Justin Welch, PharmD, BCPS, Matthew Webb, PharmD, Ji Koo, PharmD, and Curt Doetkott, MS
Epilepsy, Prolonged Phenytoin Usage, and Its Effects on Bone
The author explores the interrelationships of calcium, vitamin D, and phenytoin and their effects on bone health in patients with epilepsy.
Alexander Motylev, RPh, PhD
Meeting Highlights
42nd Annual Meeting of the American Society of Clinical Oncology
Cancer progress and a vaccine for vaginal/vulvar cancers are reviewed.
Lawrence M. Prescott, PhD, and Sharon L. Prescott
Pharmaceutical Approval Update: Oncology
Dasatinib (Sprycel), bevacizumab plus IV 5-fluorouracil (Avastin), and topotecan injection (Hycamptin) plus cisplatin are discussed.
Marvin M. Goldenberg, PhD, RPh, MS
STHFT Happens!
David Nash, MD, MBA, discusses the Sheffield Teaching Hospitals NHS Foundation Trust and its goal of implementing rational drug therapy in Britain.
David Nash, MD, MBA
Medication Errors
The Virtues of Independent Double-Checks: They Really Are Worth Your Time!
Matthew Grissinger, RPh, FASCP, explains how double-checks by a second person can reduce discrepancies and errors in drug prescriptions and specialized regimens for high-risk patients.
Matthew Grissinger, RPh, FASCP
Prescription: Washington
Medication Errors Return to the Forefront: New IOM Report Stresses Unfinished Business
Stephen Barlas takes another look at the Institute of Medicine's 1999 report, To Err Is Human, and the lack of progress made in reducing medical errors since then.
Stephen Barlas
New Drugs/Drug News/New Medical Devices
P&T presents the latest studies and information about FDA approvals, drug indications, industry updates, and new devices.
Drug Forecast
Fluarix: An Influenza Virus Vaccine
Olga Hilas, PharmD, and Lisa Charneski, PharmD, review Fluarix influenza virus vaccine.
Olga Hilas, PharmD, BCPS, and Lisa Charneski, PharmD, BCPS


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Narrow your search
WOA is the latest term to confuse developers. However REST and SOA can be best friends.
Windows 8 on ARM will launch at the same time as Windows 8 on Intel-AMD, but there are key differences. Case in point: you don't turn off a Windows-8-on-ARM PC.
Microsoft explains how Windows 8 will run on ARM-based tablets. Expect it to look a lot like your desktop PC, but with a touchscreen layer.
Employees are bringing their personal laptops, tablets, and smartphones to work rather than using the devices assigned to them by the organization they work for. No problem, the company says.
Windows RT merged into Windows Blue? An Asia-based report doesn't provide much clarity for the claim.
Windows 8 is the official name of the next version of Windows client. Here are details on the three SKUs that are in the pipeline.
Now that it's available for public download, you might be wondering whether your PC or tablet can handle it. Here are some guidelines.
Intel is demonstrating a Windows 8 tablet at CES that uses its future Clover Trail Atom processor--which will be Intel's platform for Windows 8 tablets.
Windows RT is in product purgatory. Not popular and nowhere to go. The problem is, ARM is everywhere.
Mozilla might contemplate antitrust action to get full-fledged Firefox onto Windows RT. But with ARM processors and iPad sales, competition is different for Microsoft now than in the 1990s.


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Photo Credit: Charles Hewitt/Hulton Archive/Getty Images
The Big Picture: If caught early, prostate cancer ihas a 95 percent survival rate.
Cases: Annual new cases reported (U.S. in 2012): 242,000 per year Annual deaths (U.S. in 2012) 28,000 per year
Detection and Screenings: The question of screening is a personal and complex one. It's important for each man to talk with his doctor about whether prostate cancer screening is right for him.
When to start screening is generally based on individual risk. For those at high risk (genetic predispositions or strong family histories of prostate cancer at a young age), age 40 is a reasonable time to start screening . For otherwise healthy men at high risk (strong family histories or African American men), age 40-45 is a good time to start checking.
The purpose of screening is to detect prostate cancer at its earliest stages, before any symptoms have developed.
That's when the cancer can be treated most effectively. There are two quick and easy tests that can be done right at the doctor's office: the PSA (prostate-specific antigen) blood test and the digital rectal exam (DRE), which is a little more invasive but still a relatively easy procedure.
Risk Factors: There are four major factors that influence one's risk for developing prostate cancer:
- Age: The average age at diagnosis of prostate cancer in the United States is 69 years. After that age, the chance of developing prostate cancer becomes more common than any other cancer in men or women.
- Race: African Americans are more likely to develop prostate cancer and have more than twice the risk of dying from it. Conversely, Asian men who live in Asia have the lowest risk; however when they migrate to the west, their risk increases.
- Family history: A man with a father or brother who has prostate cancer has a twofold-increased risk for developing it. This risk is further increased if the cancer was diagnosed at a young age (less than 55 years of age) or affected three or more family members.
- Where you live: Men who live north of 40 degrees latitude (north of Philadelphia, Columbus, Ohio, and Provo, Utah) have the highest risk for dying from prostate cancer of any men in the United States -- this effect appears to be mediated by inadequate sunlight during three months of the year which reduces vitamin D levels.
Prevention: Although genetic and environmental risk factors for prostate cancer have been identified, the evidence is not strong enough for conclusive recommendations. As a result, early detection is key.
Sources and Resources: www.pcf.org/prostatecancer/support and cancer.org/prostratecancer


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Mali's Habib Koité is nothing less than an Afro-pop god, descended from an 800-year-old noble line of Khassonké griots, storytellers who preserve the history of a village and/or family through oral tradition. Koité cherishes his griot mother who taught him … Continue reading
Eric Bibb RSS
The Montréal en lumière festival announces its 2013 arts lineup
Photo of Bénabar by Christophe Rihet; courtesy of the Montreal en lumiere festival. Bénabar will make a swift return to Montreal when he performs at Metropolis next March 1, as part of the 14th annual Montréal en lumière festival. The … Continue reading


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After some exciting thunder and rain, the hot weather appears to be back in Ilfracombe We have the odd nights here and there for anyone thinking of a last minute get away.
4 poster or superior double 2 nights £199 for Sunday 18th, Monday 19th only!!
Call 01271863377 to book


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Welcome! You are viewing an archived issue of SaskSecrets, Tourism Saskatchewan's Online Newsletter, from December 2011. To read the current issue of SaskSecrets, click here
December 2011 SaskSecrets
Happy December everyone! This month's issue of SaskSecrets features stories about some fun winter events, such as the 2012 Tim Hortons Brier coming to Saskatoon in March, and exciting options to help you ring in the new year in locations across Saskatchewan.
We are also excited to announced our new "Choose Your Saskatchewan Adventure Contest", which features some amazing prizes. Plus, we are happy to announce the winners of the Explore Saskatchewan Contest, which recently closed.
The feature package is a mix of exciting outdoor activities like dog sledding, very comfortable accommodations, and great food. And the trivia question tests your knowledge of dog sledding.
Enjoy your December 2011 issue of SaskSecrets.


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The Last Days, episode 10. Tale of Two Cities, and Albert Pike - Ministry Videos
Book of Revelation, Section 2: Scroll with Seven Seals...Episode 3: The Judgment Has Been Passed on Satan - @lionandlambministry
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In This Episode we discuss the Best of Times and The Worst of Times of the Christian Ecclesia today, and Albert Pike.
In This Episode we discuss the Best of Times and The Worst of Times of the Christian Ecclesia today, and Albert Pike.
The Last Days. A New study on The Last Days and the involvement of Satan, Fallen Angels, Demons, and the Global Elite, with a fresh look at the roles they are to play. This is episode 10.
The Last Days, a new multi-part series from The Lion and Lamb Ministry.
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