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Tradition Field still on the table as possible future Astros site | Dodgertown surprised to be among proposed sites
The words that are unwritten tell the story best. It is frightening that there are still those who think that men should naturally "control" the money, and have the right to chase down a wife who does not behave in a way he approves of. This alone is a good reason to have a completely safe place.
I suggest you folks who think the present system is just fine read todays article on IRC Medical replacement of emergency room Doctors. This is a great example of overly expensive care. Doctors who are paid over $400K per year as a perc. plus they are also permitted to bill the patient. And this is just fine with you? Don't you know that while those with no insurance get treated, they most likely will not be able to pay the bill, so you get to pay it for them. And this is the system you think should be preserved. Who is deluded?
Does anyone really NEED to go shopping on Thanksgiving Day? Really ?
Thank you for standing up to the pressure to break your promise...if you had caved on this one case, then no one would ever feel safe. Obviously this man had a reason for wanting to be able to trace his missing wife, but it does not appear that it was a broken heart, since he was able to divorce her, and form a relationship with and marry another woman all within 9 months of her leaving. Actions speak louder than words.
This trial is over. The jury made their decision based on what was presented to them. They did not consider all the other commentary floating around. Each attorney presented his case. The jury brought their verdict based on the law. It is over. Now we are left with a future that somehow seems more dangerous than before. Some of you feel that the deceased kid was destined to a life of drug use and violence. Did who his parents are make you think that? Perhaps his brother? Or a friend who didn't enjoy being talked down to by an attorney? I am left with questions. Do 17yr olds, (regardless of their size) make careful decisions? Should 28 yr olds be able to make more reasoned decisions? Have any great adults ever tried a little marijuanna, gotten into a fight, made a bad decision, talked back, said or did anything that they may have later regretted? Were they given another chance to do better? Have your children ever done anything you did not approve of? Based on their past bad behavior, would it be OK with you if they were "profiled" as trouble makers, followed, chased, maybe even had a gun pulled on them? Would it be OK with you if in a similar altercation they were shot dead? Do you warn your children not to wear hoodies, even if it is raining? Do you tell them that if challenged they should stop immediately, keep their hands in sight, make no sudden movements, answer all questions with "yes sir" or "No sir", and under no circumstances talk back? Do you tell them this could mean their life or death? Does the"stand your ground" law as written in Fl. apply to 17yr olds too? Is it possible that a scared kid being persued by a man with a gun, and finding himself armed only with a pack of Skittles might resort to his only weapon, his fists, in order to prevent "grevious bodily harm" ? Yes, we should review our laws from time to time, to make sure that they are doing what we want them to do. And, lastly, if you have ever said" I'm not a racist, but...", you are one.
Really, how sad, anyone who thinks that the only things to do in Sebastian are drink and fish, is completely uninformed. A person who never reads the Press Journal, and one who never speaks to people not found in an adult arcade. I could provide a long list of things to do and so could you Russ. Just to name one,the Sebastian Senior Center. Lots of friendly people, games to play, coffee to dirnk, and all for a $1.00.
Very well stated. Every time I read a letter stating that this nation is based on "christian" values, I just want to scream "read your basic history". This nation was clearly founded on an individuals right to choose his own religion. Throughout history more people have been killed in the name of God (many different ones) than for any other reason. Keeping specific religion out of government was one of the most important issues to the founders of this nation. Unfortunately, it is the few "raging" Christians who have insisted, wheedled, and cajoled, in trying to force their religious beliefs on all. Try as they will, this is not the way to win converts, as is proven by dwindeling memberships.
This is sad news, and nothing to be proud of. In reality access to affordable health care and counceling has been eliminated from this county. Where will the 600 women who needed care and had no other alternative go now? Since there never were any abortions done here that seems a pretty poor excuse for thinking it is right to force your beliefs on others, by denying them basic care. The protesters are the ones who should be ashamed for not offering comparable services to those who need care. Oh yes I know that some churches do offer a few services, but not without obligation. Perhaps those who no longer have access to this health care should phone Rosemary Wilson or Dr. McGarvey I'm sure they would be happy to send them to their own Doctors, and gladly pick up the tab. While this may be a dream come true for the selfish demonstraters, it is a nightmare to those without options.
Let's see here, we seem to have NO solution that works. Certainly the current situation where people who do work can't afford insurance, and can't afford health care isn't working, And the (very nicely insured) state legislators don't want to expand a "broken" system. Anitliberal feels bad that some folks can't afford health care, but offers no solution, only "get government and insurance out of it". How about a list of Doctors, clinics, and hospitals willing to accept "common sense" fees, based on actual REAL costs. Come on, step forward and be first in line for this one !! This all sounds like "let them eat cake"!
Obviously the City of Vero Beach does not value this service, since they pay nothing toward it, and also refuse to even bear the cost of maintianing the hub that serves their city. Shamefull. The previous 2 comments are just plain stupid. Without even surveying the ridership, you two assert that only those who are lawless are riders. Perhaps the Go Line should just forget about serving those in Vero Beach?
Congratulations to Mr. Hill, and Mr. Adams. I know you will both work hard for the benefit of all the citizens. While I may not always agree with your specific viewpoint on some issues, I believe that you each have the best of intent, and I thank you for being willing to accept the challange. Mr. Gilliams, please stop being such a slow learner. You will never make a good impression until your behavior is moderated. (read good)
Bill, I like you and respect you, I just do not agree with you about Damien. And I do think that Mr. Adams will do an excellent job. I do not know him well, but base my opinion on his behavior. I base my opinion of Damien on his behavior as well. The job of council person is a pretty thankless job. The responsability is large, the time committment is great, and the pay is small both in dollars, and if certain persons choose to vilify you in respect as well. I hope that I never find that I must choose one evil over another. Thus far in my life I have been blessed with always an alternative that while maybe not exciting is at least honorable. I do indeed enjoy a good debate with a free and open exchange of ideas and viewpoints. I do not however think that hostile charachter assassination, lies of ommission, name calling, and insinuations ever lead to a productive outcome. That is why I still prefer to vote for Mr. Adams, based on his ability to listen with his ears instead of with his mouth, and Mr. Hill who does not always see things my way, but has done a decent job for the city thus far. As for "stacking the deck" I'm not making that assertion, but I also do not want to see any time or energy wasted on accusations. It is better to "avoid the pothole" in the road rather than assume that no harm will come by runing through it.
There will always be those who hate the success of others. The small parking area and sidewalk is NOT a GIFT to Captain Hirems, but rather a public parking area which happens to be located near that business. When and if Captain Hirems expands they will, as always in the past be required to provide their own private parking to accomodate the use. I have attended council meetings regularly for almost 17 yrs, and I have never known Captain Hirem's or any other business for that matter to be given a pass on building code or zoning requirements. In fact, the local practice in order to obtain permits is long and demanding. There are significant layers of applications, and meetings with staff, planning and zoning, and council. The planning and zoning and council meetings are all held in the open and offer opportunities for public input. For Ruth to insinuate that there are frequent and substantial abuses is insulting and not accurate in the slightest. Her assertion that CRA monies would be added to the general fund is completely innaccurate. The CRA program is not an invention of the local government, and is a program used all over the state and in similar forms all over the United States. It is a mechanization to upgrade specific districts which are in need of improvements to infrastructure and exhibit blight and or need of rehabilitation in order to improve viability of the district. The funding does NOT come from the general fund. Part of improving the riverfront district is to provide additional parking within the district which is not restricted to the use of a specific business. Every visitor to the area offers us an opportunity to create a good impression as a desirable place to live, work, do business and recreate, or we can leave the impression of a place where whilenice, is too much hassel to bother coming back. Mrs. Sullivan has had an ongoing personnal bias toward Captain Hirems which has been going on for years. As Rodney King said "can't we all just get along?"
He says "it is not necesary to like someone to respect them", and "ridicule is inappropriate". He wants to be treated fairly and the Press Journal should not offer a biased slant with innuendo or snide comments. How then does he not follow his own directive as exhibited in his 3rd paragraph from the end with his own innuendo and snide comments directed toward others? Respect is not given to those who demand it, but rather to those who have earned it, and that would not be you Mr. G.
It is obvious that Mr. Romney has only one faithful objective and that is to say anything in order to be President. If all of you folks who are supporting him are not mega rich, you are in for a big surprise. You obviously haven't been paying attention, or you would know that he has absolutly NO plan on how to run the government. He has supporters who can twist him to their objectives easily, since again his only clear and unwavering objective is to be the President. The thought that he could be elected by people who only hear what they want to hear,and have closed their minds to hearing any other prospective, or think that his record as a venture capitalist has any relationship to making their lives better is downright frightening!
I'll be voting NO on all of these. This is simply an example of our elected officials refusing to do their jobs and take a stand on issues. NONE of these should be part of the constitution. Only in Florida do the legislators push off their responsibility to the public. Maybe we should just eliminate the legislature and ask the general public to vote on every issue. Just think, we could end up in the book of World records for the largest constitution in the universe.
Public parking often happens to be located adjacent or near to a private business. As long as there is a sign stating that this lot may be used by the public, there is no problem. This is not a free parking lot for Captain Hirems. They have and will provide all of the required parking to support their business endeavors. Lets not forget that many times people who are not customers of a business freely park in the lots owned and maintained by a business. Perhaps some of the people who park in the lot may choose to visit Captain Hirems, but these people are also "the public". The public interest should not be the enemy of private business. There is a simbiotic relationship between a community and it's businesses whereby each should benefit from the other. Captain Hirems not only provides employment to many, but it brings many visiters to the city, provides an interesting place for local residents to entertain themselves and their guests, and has supported cheritable efforts through gifts and sponsorships. A healthy business community means that the tax load for citizens is lessened. A thriving business is not the enemy of the people, but rather a partner in a healthy community.
I also attended the Presidents speach in Melbourne. I am not a Dem. or Repbu. & I work to keep an open mind. It was awsome to see our political process at work. Mr. Obama is an excellent speaker who is able to address a diverse crowd and make difficult concepts understandable without having to explaine a couple of days later what he intended to say. Anyone who watched the Romney interview yesterday heard yet again another partial explination of his tax plan of how the very richest would actually have some loopholes closed, and he would actually keep some of the health care plan... so, the waffeling goes on...lol
It would be good for the city to have several differing viewpoints represented. I am looking forward to hearing where this candidate stands on the many challanges facing the city. Welcome.
I did see the 2 pages of proposed constitutional ammendments...I couldn't read them though, because I couldn't find my magnifying glass. In order to make them fit ONLY 2 pages the type was to small for human eyes. One would think that the constitution is such a carefully constructed document that only Major changes in society would make ammendments necessary. A good example, the U.S. Constitution which is much older, and has had very few ammendments. Perhaps these changes permit changes of law without legislators having to take responsibility of their jobs.
Those of us who support the constitution without putting our own spin on it find it hard to understand why any church would want to have the government involved in any personal secular or religeous decision a citizen should make. Let's be absolutely honest and fess up to the fact that many "churches" want to take all the advantages afforded a religeous organization, including running businesses under the name of the "church" in order to claim various exemptions. The Republican party has somehow morphed into a "faith based" organization. This is indeed frightening, since the "faith" they seem to have determined as the only acceptable "faith" is not mine. Maybe not your's either, but that does not matter. They seem to feel that the government should decree how you manage your most personal and medical decisions in order to conform to THEIR faith. And, if you happen to be a woman, just keep quiet, you are not to be trusted to make your own health decisions. As for those church run or controlled businesses, in my opinion, if you wish to be a business, then you follow all the rules of any business, if you wish to be a church, then you may avail yourself of the expemptions afforded, but honestly, you can not be both a business and a church, that is just a convenient and opportunisitic lie.
Perception is everything. From my viewpoint, I am overwhelmed at the generosity of the city for providing such an excellent benefit. In private induestry even Mega employers who operate all union operations can no longer offer vision, dental, and 100% coverage to an employee with the employee paying only $25 per month!! The latest "great benefit" package I have heard of in private industry pays 80% of prescriptions, regular care, and no dental, no vision. (vision and dental were dropped 7 yrs ago),and the employee contributes $15 per month for each family member covered.
I guess you forgot that you are paying taxes to more than just the city, part of your tax bill is also for the county, and the schools and other various entities as well. The city is the least part of your bill.
For all you folks in favor of maintaining the status quo, may I suggest that you get out your calculators and begin to compound this abuse into the future. Not only are we sacrificing that which could be accomplished in order to pay out these magical retirement bonuses, but future generations will be held captive by this debt. It is shameful that it has taken these hard times to get anyone to acknowledge this. The Press Journal is absolutely on target with repeating this until we are awakened. In order to fix this it will take some heros. Heros who are elected, and heros who admit that they knew they were participating in a scam on the public. It needs to stop sooner than later. As for bonuses for those in the private sector...come on...if there is no money, jobs are cut, bonuses are not paid, and always profitability is a concern. In private industry there is no endless source of funds. Come on people, wake up. We cut lifegards, and days that the pool can be open, instituted furlough days, and on and on because we have this growing monster to feed!!
Are you really serious?!! This sounds so socialist. We need to legislate to force people to put something away to provide for appropriate (who determines this) future maintenance of their private residances? I think that the writer has forgotten all of the other things that we may not be able to handle on our own as we age, like shopping, personal grooming (we don't want to live among those who are looking too shabby) selecting and being able to afford a great wardrobe, cooking nutricious meals, etc,etc,etc. There are places where this writer would be more happy, where those who are afraid that their neighbors would make inappropriate decisions if left on their own are not an issue. They are called Condos, or Assisted living homes, or prisons. More legislation to control the foolish homeowners? I think not!!
Wow!! It seems that only those in Martin county are concerned about the unbelievably plush pay their county administrators are getting ! Am I the only one in Indian River Co. who thinks that our county administrator is paid about double what his job should command (note personalities aside folks, this is about what is right for the job) We are also paying over $100K for an assistant? Have we just slipped into the land of the outrageously wealthy and enormously stupid? Every time I hear of another cut to services provided by our government I think of this abuse. And to top it off, this overpayment has not made our administrator pleased and happy, he seems to hold us all in contempt. Perhaps we deserve it for being so complacent. If we advertised outside of Florida to fill these jobs at this rate of pay, we'd have to hire another person just to open the response mail. PALEEEEEEES!
I am distressed that the County Commission apparently is willing to "wink" at this sort of behavior. If Mr. Baird was working in the private sector and he behaved this way toward an employee, I would think he needed to attend some anger management classes, and maybe he needs some training on how to NOT create a hostile workplace. This sort of behavior is so sad and unnecessary. The officer was doing her job, responding to a call, (even if he thinks it's not a real*****ing job). Agressive behavior is often called for in the job law enforcement, but I fail to see how it could be useful in the position that Mr. Baird holds, unless this county thinks that bullying by upper management is the way to go. And a word for Mr. Baird...It is difficult to feel respect for one who does not offer respect to others. In this economy Indian River County could be doing sooooooooo much better for lots less money, all you have to do is look outside the State of Florida to see what talant is available for significantly less.
As I recall, watching the impeachment hearings Pres. Cinton pretty much took a public beating. He has had to live with having his "dirty laundry" dragged through public, and I am sure he had some pretty difficult times dealing with shame and guilt with his family. (even if only the guilt of having been caught) However, since that incident he has continued to use his skills to try to make the world a better place. While we may hate the sin, we can still appreciate the sinner. As for Ms. L. I don't recall her ever stating that she said "no". In fact she WAS a temptress, and got exactly what she was after, the thrill of doing something "forbidden" with the POTUS. If she were truly innocent she would not have preserved the "blue dress", nor shared her story with someone who anyone could have guessed would use it. If Linda Tripp had been a real friend she would have told Ms. L. to stop immediately before she got involved in a mess with a life of it's own. Instead she encouraged her to essentially " light the fire". She got her 15 min. of fame, and has gone on to accomplish what? It would appear that her only accomplishments have been shabby attempts to use and re-use her tired old story. She could have stepped over the mess and moved on with a useful life instead of wallowing.
Charging $5 & $10 should not be called a "discount", but rather a gift. And, maybe it is just me, but can anyone explain why police dept. volunteers qualify for this benefit and other city volonteers do not? Understand that I do not think that ANY volunteers should receive this gift. In my personal opinion this move does not correct the situation, but rather attempts to placate with a half measure. Life in a small town can be a challange when it comes to fairness and evenhanded application of the rules.
You didn't really think that they actually operated their own labratories, medical research centers, and health care outlets did you? Just like many respected and beyond question charities, their job is to collect the money and distribute it to the places where it will do the most good. Yes, we all should investigate any charitable cause we contribute to so that we are sure that they are using the money for the purposes we subscribe to. Your letter implied that there is something questionable going on in general. While their use of the funda may not meet your personal criteria, it suits me just fine. LK
This whole thing is just disgusting. Mr. Hill says that there was no malice, which may be the case, but since it was never mentioned to 95% of the people who would have been entitled to this perk under this "unwritten" policy, we can rightly assume that it was intentionally hidden. (hidden with no malice has the exact same result as hidden maliciously!!) In what world is having an unwritten policy which is not revealed to anyone other that the few "privilaged" pals not "cloaked in darkness"? This is just another example of some who greedily grab off all they can get away with, and keep a low profile so that they won't have to reveal that the policy would not be affordable if administered fairly to all who qualify. ( note that when there is no written policy there is no policy)
I have always been a defender of the way the city of Sebastian does business, but this is one of the most dissappointing issues. Firstly let me say that if you are proud of something you wouldn't hide it. I have server on numerous committees over the past 15 yrs, and never have been made aware that I might play golf at a discount. Who knew, and how did they find out about this great deal? To call this a "discount" is an insult to anyones' inteligence. In an effort to treat all employees, commission/committee members, and volunteers fairly, this benefit should have been openly made available and there should absolutely have been a written policy. If there is no written policy, there is no policy! To have Mr. Gilmore glibly respond that those who don't get the benefit becasue they don't play golf should take it up speaks clearly of his attitude that feeding at the trough is his entitlement. There are those who will say that this is an insignificant issue, but I think that the records (if they can be produced) will show the loss of many thousands of dollars. There are numerous questions that this situation brings up about the fair and equitable treatment of employees, accurate bookkeeping, loading the costs of the privilaged few (I'm not speaking of the course employees) onto the backs of the already burdened taxpayer. I'm now wondering if there might be other"freebies" available to some? And, is 90% +/- fee reduction a discount, or part of a compensation package? This whole thing smells pretty rotten to me.
If I were a bar owner on the river which offered musical entertainment, I would rush to put my arm around the new owners of Suzy's (they are the offenders) and let them know that "self regulation" is what we all want. These folks bitterly opposed another business on the waterfront, and now it seems that they are blasting everyone else out as well. Not too neighborly, and not a place to enjoy an evening on the water, unless you enjoy shouting over the "music" and leaving with your ears ringing. The " I'll only restrict my invasion on the rights of others when there is a law" costs us all, and gains them no friends.
There is certainly enough "wrong" to go around. A "beautiful person" would never allow children to go through this kind of abuse. A beautiful person would stand up for humanity (not just sports principals"). A beautiful person would say " there is no amount of money or fame that is worth the risk of another child having this horror forced upon him" . My heart is sick at the thought that there are any who could justify the behavior of those who failed the test of humanity. At the end of the day, Mr Paterno, the entire coaching staff (they all knew something was wrong) the entire board of directors, and the HR department were/are cowards. Money became the only thing that mattered. How can they forgive themselves?
I'm thankful for Russ, and the Press Journal for printing his stuff, and for a country where individual opinions are not just permitted, but encouraged.
Many church groups, clubs, travel agents, and other orgainzations will be happy to introduce you to another person who is traveling alone. Most "sponsored" cruises also will strive to link you with a cabin mate. I've done this many times and always had a great time.
This issue is not about taking away private property rights at all. Please remember that in order to have a good neighbor one must be a good neighbor. Please think a little outside the box. In order for the city/code enforcement to lodge a legitimate complaint with a mortgage holding bank of one of these abandoned houses we first must have an ordinance. As for helping out a neighbor who is having a difficult time keeping up with the general upkeep of his home, I think you would find that in truth, there are many many instances of neighbors helping neighbors. Usually those who help others as a way of life rearly seek or get noticed for their good deeds. And also, being poor has never been synonomous with being a slob. While hard to fathom, there are some people who are so wrapped up in their own rights that they think it is OK to create a junkyard in their neighborhood. We only need an ordinance when for whatever reason the golden rule fails. But you are right, it would have no meaning for you unless you had to live with it.
The unnamed "man of the year" - every year. This man could (and does by example) teach good citizenship.
Unconditional One has an absolute right to his personal opinion, as do we all. I will note that he has NOT quoted any unverifiable information as fact when it has not been proven so. I have no problem with expressing OPINION as such, I only object to those who present conjecture as fact. Thanks for making sure that we Americans have the ongoing right to express our opinions freely.
It is pretty obvious that most if not all of the posters here are dealing with and regurgitating halftruths and outright fabrications. They all quote a $100,000.00 loss. Got any proof of that? Remember,(hard as this may be to believe) there are people who plow ahead with their personal plans without "asking permission" assuming that once they have established their own adjenda they can "ask forgiveness", as in "nobody said we couldn't do that", "we've been injured, so the people we did not ask permission of should repay us for having been caught". Admittedly, this is an oversimplification, but lets remember that the"grand opening" with music etc. came without any notification. Up till that time the place was incomplete. I know for a fact that Mrs. M. WAS asked why she was installing oversized equipment. If any of you were actually there, and if you are honest, you could tell that the "junk shop" tables, etc. certainly did not add up to the value you are tossing around. Even the cost of the equipment (which she may remove by the way) has been quoted as double what it costs. I just do not understand why you folks are so intent on spreading this negative stuff, especially when you have NO firsthand knowledge. If Mrs. M has any complaint, she needs to look to her landlord (which is not the city) or to her attorney who advised her that her business plan would comply with the grant stipulations (oh right, she didn't bother to check or hire an attorney to check for her) come on people, this is not a game, this is the grown up business world...a commercial venture... As for Damien G. He is a promoter with a long reputation for "missappropriation" and misrepresenting, (once even representing himself as a law enforcement officer , check his record) Why indeed would anyone give him any credability.
Crabby, read your paragraph #6. Did you find this ...counter service, no table waiting...quote in a hidden document? Do you think it could have been found by the persons wanting to open a restaurant? Why would this make the city liable? Again, if the oposing parties would have opened a dialog rather than hurling accusations, I think this could have worked out, but as it is, we all just need to move on and make the best of what is. It would have been nicer if the 15 had realized that they would make some quick enimies rather welcoming an opportunity to improve their own businesses, longterm, by starting a war, instead of opening a dialog, but the damage is done. It's time to move forward. While I feel that the departing business was responsable for not using due diligance, I will also feel less inclined to support the 15 who used bullying tactics, that was just bad behavior,on their part. Kinda makes you feel like you should keep your back against the wall with these folks....just not so neighborly....
There is another side to this sad story. As nice a person as Mrs. Mcmannus and her daughter are, they are business people who entered into a commercial lease. Under the law, they had the obligation of "due dilligance", in other words, an expectation and opportunity to examine all the conditions which would contribute to the success or lack there of for the planned business venture. This situation could have been avoided if they had actually performed an examination of the grant documents, looked at market projections, done feasability studies, or had employed their own attorney and or accountant to do so on their behalf. Often in order to save a couple of hundred dollars, this very important step is skipped. That is not a prudent business practice. And while I feel bad that these nice people will lose some money, I absolutely do not think that the City or any of the council persons are in any way liable for any part of the loss. The restrictions of the grant were not secret, as is evidanced by posters here who had no problem accessing it. Who among us has not impulsively rushed into a purchase or venture and found out later that we should have spent a little more time or money investigating the situation before taking the leap of faith. Unfortunately some well entrenched businesses, who have been successful for a long time have forgotten that moving to a new area may involve an entirely new set of challanges. I am also pretty sure that a "snack bar" set up can be very profitable. I have visited many such places and seen the potential. We need to remember that often to be successfull in a new venture it is not the best plan to offer what all the others are offering, but to offer something unique, not available elsewhere in the location. The other option to be successful is to offer the same product or service as others only significantly better quality or significantly lower priced. This business offered none of the above, so, perhaps out soon is in the end less costly. The loss might be considered tuition in business school. As for the 15 or so other businesses who objected to competition, I think they do not understand that the more business in their neighborhood, the more business there will be in their neighborhood. I have never met the person who NEVER visits more than one eatery, bar, store, etc. If not available here the customer will just leave the area to find variety.
The Bible says that there will be those pretending to be "men of God" who are not. It would seem that one who makes it his objective to spread intolerance, hate and malcontent may not be "a man of God", but perhaps a tool of the devil.
The real travisty is that some people who wish to influence others are spreading half truths and false information. Nothing good happens by wishing, it all takes hard work, planning, and yes, sometimes compromise. There is NO benefit to anyone in trying to make the public focus on the potential of negatives. No new project ever begun has come off without some glitches. Remember, the city will end up owning this property, which has been converted from a near condemable non taxpaying derielect property,to a functional structure with a future, at the expense of a private entity. You should make an effort to discover all the FACTS, rather than just the sour grapes.
My opinion may not be popular in some circles, but I just can't figure out why I was aware of this project years ago, and the people who are petitioning were not. Possibly they were not reading the local news, were more interested in reading their "home" newspapers, the Times, or Wall Street Journal. Maybe their main source of news is taken from CNN or FOX? I think the only way some folks find out what is happening locally is if a personal letter is sent to them. There were public notices, why didn't you see them? As my Father used to say, "were you waiting for your personal invitation?" The Channel is important. You accept and enjoy the benefit of a direct view, and access to the waterway, but apparently when it needs maintenance dredging, you would prefer that the material be placed in someone else's back yard. I might suggest that a special taxing district be established to save the taxpayers in general from bearing the burden of preserving your view while permiting the maintenance of one of your direct assets!!
Wouldn't it be nice if there were no profit in capturing wild animals. How could that happen? Maybe by raising them from the existing captive population. As to the value of zoo's, a beautiful day at a clean and well managed zoo is one of the best ways to teach children and adults to love the creatures of this earth.
Great letter. This has nothing to do with the child, and everything to do with the father. He is denying his child the most essential thing that kids want, and that is to just be like the other kids. If he has issues with freedom of choice, etc. he needs to address it without USING his child for his own purposes. The real world is filled with requirements that deny us our personal freedoms, appropriate dress is just one of them. A child has plenty of places to exercise his/her individuality. And I am sure that there will come a time in her life when her parents will also restrict what she wears even though she may prefer to ware things that they feel are not appropriate.
It boggles the mind that the suggestions offered would be taken with a chip on the shoulder. In these tough times we certainly do not need to be putting ourselves out there as amatures. If you'll spend $6,000 to promote, you should be promoting a product (this site) that is worthy of us, and will bring posative responses. My guess is that the intent is to not only get "clicks", but to generate some serious inquiries. Again, please do not go forward with this project until you've cleaned up the site. Spend some of your budget on producing a site that will bring something other than initial "click" and run responses. This comment is intended to give advice, not to critisize.
Please, Please, give this some more consideration. This is a really poor and amaturish site. The rediculously long sentencees,(have you never heard of bullit points?) terrible punctuation, and links that lead to municipal sites which, while they may inform, are not designed to "sell" the area. The box which leads you to "the research coast" is an example of a confused message. 7 minutes of mush is worse than a waste, it makes us look like Bumbletown. This is just a mess.
Why would anyone think that who you do or do not live with should be the concern of government?
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Visit Scripps blog on all things politics in the Sunshine State.
• Today's schedule • Admission, hours • Photo Gallery
Speeding PSL man tells cops he's 'on his way to kill his friend'.


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Viewing entries tagged with 'queensland rugby league'
Queensland Cup Preview - Round 14
PREVIEW notes for Round 14 of the Queensland Wizard Cup and details of memorial service for Dick
THE Gold Coast Vikings fly north to Mackay to take on Townsville in the state final of the Toyota Centenary Trophy on Saturday afternoon.
Gatton hosts QRL carnival
THE Queensland Rugby League A Grade Division Carnival continues to be a feature event on the annual representative match program.
Queensland Cup Round One Wrap
RESULTS and match reports from the opening round of the Queensland Cup.
Greater Brisbane Junior Rugby League - Sign-On Days 2008
AS RUGBY league in Australia celebrates its Centenary in 2008, the game
THE Queensland Rugby League today announced the eleven competing teams for the 2008 Queensland Wizard Cup season
QLD Cup on Ch 31 - 6.30pm Wednesdays
ONE of the more exciting advents in the history of the Queensland Wizard Cup occurs tomorrow evening, Wednesday August 29, with a brand new television show hitting the airwaves

subset: commoncrawl


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Daily Archives: September 3, 2011
GMG Tech Talk- Company Website Designers, Listen Up!
Those of us that use smartphones would like to let you know that when you try to make your client's website cute by displaying their telephone numbers with periods instead of dashes it makes smartphones unable to simply press that … Continue reading
Posted in GMG Tech Talk
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Did You Know? (Summer and Mug Ups Won't Last Forever)
If you've always said you want to catch Mug Up at Khan Studio and the Good Morning Gloucester on Madfish Wharf, but haven't yet (Jenn Cullen), summer is waning and there will only be a few more Mug Ups before … Continue reading
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Lisa Freed Has Some Nice Things To Say
I owe ya dude…. Years of coming up to Gloucester (I was part of the windsurfers at Niles) and watching the blog, I finally decided to hit Rocky Neck. Best dinner ever on the deck at The Rudder with my … Continue reading
Did You Know? (Dogtown Book Shop's 14th Anniversary)
August 2011 marked 14 the anniversary of Bob Ritchie's operation of Dogtown Book Shop in Gloucester. Congratulations Bob. Hope Dogtown Books is here for another 14 years. E.J. Lefavour
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Did You Know? (Schooner Adventure Flea)
Today until 2:00 there is a flea market going on at the Marine Railways featuring nautical stuff, tools and fleas – part of the proceeds benefit the Schooner Adventure. There are also tours all day into the evening of the … Continue reading
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James Montgomery and Friends Concert September 8th To benefit The Cape Ann vernal Pond Team
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ART by the Sea – Nantucket, Cape Ann, BVI, and Monhegan Island Closing reception of the John Caggiano, Five Islands Exhibition and 30th anniversary celebration of the John Caggiano Gallery
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Cape Ann Profiles show
On the next Cape Ann Profiles show host Rich Sagall interviews Art Thomas and Milt Lauenstein, two frequent letter writers to local newspapers. They discuss their motivations for writing letters, what they hope to achieve, and provide suggestions to other … Continue reading
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Video- 2011 Gloucester Schooner Festival Saturday Morning Live At The Heritage Center
Here's the scene 9:15AM at The Heritage Center
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Gloucester Has a Winner, by Connection
By Cathy (Frontiero) Spiro At the urging of my Aunts Mary Scola and Vincie (Scola) Gounaris, and my sister Josie (Frontiero) Palazola, I wrote this piece to express my thanks and appreciation to all the Cape Ann friends and … Continue reading
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Dave Jewell Aboard The Lady J Catches Rare Yellow Lobster
The lobster on the right obviously is the normal one. There are no bands on the yellow one because it was a female bearing eggs and only brought in to take pictures of.
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Andouille Smothered Beans
- 2 tablespoons vegetable oil
- 1/2 pound Andouille sausage, finely chopped
- 2 cups onions julienned
- 1/2 cup chopped celery
- Salt and cayenne
- 2 tablespoons chopped garlic
- 1 pound navy beans, rinsed, soaked overnight, and drained
- 2 bay leaves
- 8 to 10 cups water
- 1/4 cup chopped green onions
In a small stock pot, heat the vegetable oil. When the oil is hot, add the Andouille and render for 3 to 4 minutes. Stir in the onions and celery. Cook the vegetables for 2 to 3 minutes, or until the vegetables start to wilt. Season the vegetables with salt and cayenne. Stir in the garlic, beans, and bay leaves. Add the water and bring the liquid up to a boil. Reduce to a simmer and cook for 3 hours, uncovered, or until the beans are soft and creamy. Stir the mixture occasionally and check the seasonings for salt and cayenne. Stir in the green onions. Serve the beans with the pan-fried fish.
More Recipes and Ideas:
The Smoke Daddy Beans, Curried White Bean Dip, Two Bean Salad, Easy Dinner, Eggplant, Beans and Legumes, Easy Side Dish, Simmer, Meat Recipes


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Hey my sweet blogging friends! Some of you have probably
wondered where I've been…I assure you I'm still alive! :-)
I want to first start off by saying how much I appreciate
each and every one of you! Back in January I mentioned the thought of hanging up
my blogging hat for good, but decided not to do that...and I'm glad I did! But, I've found myself
overwhelmed with life yet again…nothing bad at all. As a matter of fact, it's great awesome, as a result...I've got a full plate(not that I'm complaining)!! The months of March, April and May
have always been busy months for our family, but this year…we've got many irons in the fire. For that reason, I just don't have the time to blog like I want to(I know, I know…some
of you are saying to yourselves…"but you
only blog once a week"! Haha! Hey for your information, that's A LOT for me! Lol!
And well, blogging doesn't JUST consist of blogging…but visiting other blogs,
keeping up with social media, etc., etc....ya know. And that y'all…can become a lot, well
at least for me…in this season.right now.where I am.
I've said all of that to say…I'll be taking a break from blogging
for the month of March. This is VERY BIG for me and I hope I don't lose any of
you as blogging friends as I cherish your friendship dearly! During my time off I'll be working on
revamping, finding ways to improve my blog, ways to engage more with my readers
through social media, etc. Basically,
more for you…the people I do this for – the people who make this blog go! With
that being said, I'll be coming back with a BANG! Lol! Of course, you can still connect with me via email, my personal FB page or Instagram.
The Bible tells us to whom much is given, much is required.
In this season, my family and I have been extremely blessed and given much from our wonderful Savior! Man, I tell you…He's faithful, great and greatly to
be praised! With great blessings come great responsibilities...ALL of which I'm so excited about!! Because of this, we as a family have always committed our lives full time and
still are, to His Kingdom and to spreading His gospel! Serving God has always been my first priority, then my family, and after that my ministry. And I consider this blog as one of my ministries...so I hold it and all of you who have supported me dear to my heart. I thank you for understanding during this time
and pray you'll join me back here…in this same spot ~ in April! As always, I love
and appreciate y'all so much!! I call you blessed!! And don't forget you not only ROCK my friends...but you ROCK HARD!! XOXO.


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Viewing entries tagged with 'wales'
NSW Origin I Team Announced!
THE New South Wales Rugby League has announced the side for the first State of Origin match against Queensland, to be played Wednesday 25 May 2011 at 8:00pm, Suncorp Stadium.
Legends of Origin raise almost $400,000 for Flood Victims
THE MMM Legends of Origin match has raised almost $400,000 for the victims of the Queensland Floods.
Former Origin greats band together to help Queensland
A 'Legends of Origin' charity game is set to take place on January 27th at Parramatta Stadium to raise funds for Queensland's flood recovery. The match will feature league legends including Brad Fittler, Ricky Stuart, Mal Meninga and Gorden Tallis.
NSW 'Blues in Waiting' Camp
NSW Blues Coach Ricky Stuart has today announced a 51 man squad which will be invited to attend a 'Blues in Waiting' camp at Homebush in January.
NSW Blues name Ricky Stuart as Coach
THE Board of the New South Wales Rugby League today confirmed the appointment of Ricky Stuart as head coach of the NSW Blues.
Brian Canavan presents findings of Origin review
INDEPENDENT consultant, Brian Canavan, formally presented the findings from his extensive review of New South Wales Rugby League State of Origin to the Board of the New South Wales Rugby League today.
NSW Cup R25 and Bundaberg Red Cup R21 Results
THE weekend results from the penultimate round of NSW Cup action and the final round of Bundaberg Red Cup.
NSWRL Bundy Red Cup Teams - Round 21 (Final Round)
TEAMS and officials for Round 21 of the NSWRL Bundaberg Red Cup competition, the final weekend before the finals commence.
NSWRL Bundy Red Cup Teams - Round 20
FULL team lists for the 20th round of the 2010 NSWRL Bundaberg Red Cup competition. Referees to be confirmed.
NSW Cup Round 23 and Bundaberg Cup Round 19 results
ALL the results from the weekend's NSWRL action as the NSW and Bundy Red Cup competitions come nearer to the finals series.


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------ Choose a topic ------ Post Transplantation Cardiovascular Disease Cardiovascular Morbidity and Mortality Rates in Kidney Transplantation Cardiovascular Risk Factors Post Transplantation Hypertension Post Transplantation Dyslipidemia New Onset Diabetes Mellitus (NODM) After Transplantation Hyperhomocysteinemia Immunosuppressive Drugs and Cardiovascular Risk Immunosuppression and Post Transplantation Hypertension Immunosuppression and Hyperlipidemia Post Transplantation NODM in Transplantation Patients Management of Cardiovascular Risk Factors in Kidney Transplantation Modification of Immunosuppression Regimens Pharmacotherapy for CVD Risk Factors Anti-lipid therapy Treatment of NODM Summary Bibliography
Cardiovascular disease is epidemic in the dialysis and transplantation population. Despite improvements in immunosuppressive regimens and in both short and long term outcomes, graft and patient survival has been limited due to cardiovascular complications. As with dialysis patients, cardiovascular disease (CVD) is the leading cause of mortality among kidney transplantation recipients. Major risk factors for CVD include hypertension, dyslipidemia and diabetes mellitus. Additional risk factors such as the metabolic syndrome, hyperhomocysteinemia and microalbuminuria are being recognized. Careful risk assessment, early detection and initiation of appropriate interventions are critical to preventing post transplantation CVD and to prolonging patient and graft survival.
The risk of cardiovascular morbidity and mortality is higher in patients with chronic kidney disease (CKD). The rate of CVD is lower in kidney transplantation recipients than in dialysis patients, but still higher than the general population. Based on the United States Renal Data System (USRDS) the estimated prevalence of coronary artery disease (CAD) and left ventricular hypertrophy (LVH) in dialysis patients is 40% and 75% respectively.1 The prevalence of clinical or subclinical congestive heart failure (CHF) has also been estimated at 40% of the dialysis population. After stratifying by age, gender, ethnicity and presence of diabetes, CVD mortality is 10 to 20 times higher among peritoneal (PD) or hemodialysis (HD) patients compared to the general population. By comparison, the prevalence of CAD in kidney transplantation recipients is about 15% higher than the general population. Stated another way, the annual CVD mortality rate is about 9.0% in dialysis patients but only 0.54% in kidney transplantation recipients. As with the dialysis population, the rate of CVD mortality in kidney transplantation recipients is greatest in younger age groups and decreases with increasing age. For the general population between ages 26-34, the annual CVD mortality rate is <0.01%, whereas it is more than 10 fold higher (>0.1%) for kidney transplantation recipients of a similar age. The annual CVD mortality for the general population and for kidney transplantation patients equalizes only after age > 75 years.1
The elevated risk of CVD and mortality is probably due to a variety of factors. CKD is commonly associated with proteinuria, dyslipidemia, anemia and abnormal levels of thrombogenic factors, including elevated homocysteine. Uremia may be a risk factor for atherogenesis and cardiomyopathy. Additionally, there are post transplant factors that increase CVD risk. Many immunosuppressive drugs such as steroids and calcineurin phosphate inhibitors increase the risk of hypertension, dyslipidemia and diabetes mellitus. Progressive renal allograft dysfunction (failure) may worsen anemia, a risk factor for CHF, and promote hyperhomocysteinemia.2
The leading cause of late kidney graft loss is death with a functioning graft (DWFG), and most cases of DWFG are CVD related. According to data from the United Network for Organ Sharing (UNOS) Scientific Registry of Transplant Recipients (SRTR) combined with USRDS data (18,482 patients), death with a functioning graft accounted for 42.5% of all graft losses. DWFG as a cause of graft loss was 27.2% in the first month post transplantation, increased to 42.3% between months 2 and 12 and leveled to 39.9% between post transplant months 60 and 120. CVD and stroke were the primary factors accounting for 36.1% and 6.2% of the cases respectively.3 (Figure 1).
The American Heart Association (AHA) and American College of Cardiology (ACC) have identified hypertension, dyslipidemia, diabetes mellitus, cigarette smoking, family history of CAD and age (Men > 45 years; women > 55 years) as risk factors for CVD. The AHA has also identified obesity and physical inactivity as major risk factors. (Table 1).
• High blood cholesterol and lipoprotein levels• High blood pressure ( > 140/90 mmHg)• Diabetes mellitus• Metabolic syndrome• Tobacco use (smoking, chewing, environmental exposure)• Physical inactivity• Obesity/overweight (BMI ≥ 25 Kg/m)
Both the AHA and ACC recognize other factors that may modify cardiovascular risk including elevated levels of homocysteine, lipoprotein-a, fibrinogen and C-reactive protein (CRP).4 Additionally, microalbuminuria has been identified as an independent predictor of CVD and death especially in hypertensive individuals and in type II diabetics.5 Patients diagnosed with the metabolic syndrome are likely to develop diabetes mellitus and increased CVD risk. (Table 2).
Metabolic syndrome is present when three or more of the following abnormalities are present:
Given the prevalence of multiple CVD risk factors in most kidney transplant recipients and the high proportion of patients with pre-existing CVD, kidney transplantation patients should be considered high risk for CVD and treated accordingly.2, 6, 7 The National Cholesterol Education Program has stratified renal transplantation into three risk groups, which are as follows:
Risk Group A
(Low Risk)
Risk Group B
(High Risk)
Risk Group C
(Very High Risk)
0 to 1 risk factors
Multiple risk factors Hypertension/hyperlipidemia
With/without other risk factors
No target organ disease
Pre-existing CVD/CAD
No pre-existing CVD/CAD
Diabetes Mellitus
The majority of patients being evaluated for transplantation are in risk group B and C.
Comprehensive cardiovascular risk reduction for all three groups should include: 1) smoking cessation; 2) physical activity (30 minutes; 4 times per week); 3) weight management for patients > 120% of ideal body weight; 4) lipid management (total cholesterol < 200mg/dl, LDL < 100mg/dl, HDL > 40mg/dl for males, > 50mg/dl for females, triglycerides preferably < 150mg/dl); 5) blood pressures < 125/75 with proteinuria > 1g/day, < 130/80 with diabetes or chronic renal disease with < 1g/day proteinuria.2, 8
Hypertension is found in 90% of renal allograft recipients. The common causes include the following: native kidney disease, immunosuppressive agents including steroids and calcineurin inhibitors, the allograft itself (poor function or rejection) and transplant renal artery stenosis.
The seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC-7) has defined stage 1 hypertension as systolic blood pressure (SBP) 140-159 mmHg and diastolic blood pressure (DBP) as 90-99 mmHg. Stage 2 hypertension was defined as SBP > 160 mmHg and DBP > 100mmHg.8 Starting at a blood pressure of 115/75 mmHg, the risk of myocardial infarction, heart failure, stroke and kidney disease doubled for each 20 mmHg SBP/10 mmHg DBP above baseline, and for each 2 mmHg reduction in SBP the cardiovascular and stroke mortality risk was reduced by 7% and 10% respectively. For patients with chronic kidney disease or diabetes mellitus the American Diabetes Association (ADA) has set a goal of < 130/90 mmHg for reasonable control.9 Poor blood pressure control has a negative impact on renal allograft survival10 (Figure 2). The influence of blood pressure 1-year post transplantation was studied in almost 30,000 patients. Increases in SBP and DBP were associated with poorer graft survival at 3, 5 and 7 years. This was true even when graft failure or loss was censored for patient death. The negative impact of hypertension on graft survival was documented in patients whether or not they received anti-hypertensive therapy. SBP and DBP elevations were significantly associated with graft failure, albeit SBP appeared to be more important because increasing SBP was associated with declining graft survival at any level of DBP, including normal. An additional study suggested the impact of hypertension on long term graft function was even more pronounced in African Americans.11
Hyperlipidemia is not only a risk factor for cardiovascular disease post transplantation, but is an independent risk factor for kidney graft function loss in adult and pediatric patients. The National Cholesterol Education Program (NCEP) focused primarily on serum LDL cholesterol identifying optimal levels as < 100mg/dl.12 Serum LDL levels of 100-129 mg/dl are near optimal/above optimal, 139-159 mg/dl are borderline high, 160-189 mg/dl are high and > 190 mg/dl are very high. Serum cholesterol of < 200 mg/dl is desirable, 200-239 mg/dl is borderline high and > 240 mg/dl is very high. Desirable triglyceride levels are < 150 mg/dl whereas levels > 200 mg/dl are high and levels ≥ 500 mg/dl are very high.
Goals for treatment vary depending on the patients risk category. For low risk patients (< 1 risk factor), the goal is LDL < 160 mg/dl. For high risk patients (2 or more risk factors), the goal is LDL < 130 mg/dl. For very high risk patients, the goal is LDL < 100 mg/dl and, in fact, some experts would recommend an LDL < 70mg/dl.13
Hyperlipidemia may be an independent risk for kidney graft loss.14 In one study, patients with hypercholesterolemia (> 200 mg/dl ages 2-19 years and > 240 mg/dl age > 20 years) did not significantly lose kidney transplant function at 12, 36, 60 or 84 months post transplantation. However, the probability of doubling of serum creatinine at 12, 60 and 120 months post transplantation was significantly higher in patients with hypertriglyceridemia. Hypertriglyceridemia was described as serum triglycerides ≥ 100 mg/dl in patients < 10 years of age, > 130 mg/dl in patients 10-19 years of age and > 200 mg/dl in patients ≥ 20 years of age.
Patients with hypercholesterolemia and at least one episode of acute rejection may be at increased risk of late (10 year) allograft loss due to chronic rejection.15 Moreover, patients who rejected and had elevated serum cholesterol (≥ 250 mg/dl) had significantly higher graft loss than those patients who had normal cholesterol. At 10 years, there was no effect of hypercholesterolemia on graft loss in patients who did not reject their allografts. Additionally, there are other studies which suggest that hyperlipidemia may be a risk factor for chronic rejection or chronic allograft nephropathy.16, 17
The ADA has established criteria for diagnosing diabetes mellitus.9 Impaired glucose tolerance is present when the 2-hour post load glucose is 140 mg/dl to 199 mg/dl. Impaired fasting glucose is considered to be a fasting plasma glucose of 100 mg/dl to 125 mg/dl. Diabetes mellitus is present when one of the following is present: a random blood glucose level > 200 mg/dl, a fasting (no caloric intake for 8 hours) plasma glucose level ≥ 126 mg/dl or a 2-hour post load glucose ≥ 200 mg/dl during an oral glucose tolerance test. Presently there is no standardized definition for diabetes mellitus in the post transplantation population. Nevertheless, NODM is recognized as an important risk factor for post transplantation CVD, and it is associated with reduced graft and patient survival because of its association with increased CVD risk. Additionally, as obesity increases, so does the frequency of NODM.18 Pre-transplantation variables associated with increased risk of NODM are summarized in table 3.
Gaston RS, et al. Am J. Kidney Disease. 2004; 44-529-542.
Post-transplantation factors influencing NODM, such as steroid dose and length of steroid exposure and the type of calcineurin inhibitor therapy, can potentially be controlled. In a study of cyclosporine (CSA) treated kidney transplantation recipients, the incidence of NODM clearly increased after 1995 when the formulation was changed to a microemulsion (CSA-ME, Neoral) which produced higher peak (C-max) concentration and a greater exposure (AUC) of CSA.19 Some studies have reported an increased NODM rate with tacrolimus (TAC) than with CSA. Higher TAC-related rates of NODM were reported in early trials using higher doses and accepting higher levels of TAC than are currently used. These trials also compare TAC with CSA rather than with CSA-ME therapy.20, 21 Early trials also used an azathioprine (AZA) TAC combination; whereas, TAC is now more commonly used in combination with mycophenolate. The latter combination allows lower trough levels of TAC, and the incidence of NODM is lower and often no different from that seen in CSA-ME based regimens.22, 23, 24
Mild to moderate hyperhomocysteinemia (> 14umol/L) is observed in 30% of the general population older than 67 years, 65% of adult kidney transplant recipients, 77% of pediatric transplant recipients and 85% of the dialysis population. It is an emerging risk factor for the development CVD and promotes hypercoagulability. It may be one factor which accounts for the disproportionate risk for cardiovascular morbidity and mortality in patients with chronic kidney disease and transplantation. The combined affect of hyperhomocysteinemia and hyperlipidemia appears to be additive.
Folate, vitamin B6 and vitamin B12 have been shown to reduce plasma homocysteine levels when used at supraphysiological doses. Treatment algorithms for patients recommend measurement of vitamin B12 levels and correction any deficiency. Following that, folic acid may be started as primary therapy at 2.5mg/day or at 10-20mg/day tapered to 3mg/day at 3 months. Homocysteine measurement should be done every 6 to 8 weeks. If homocysteine levels are inadequately controlled (> 24 umol/L) then vitamin B6 deficiency should be considered and a dose of 50mg/day should be started.
Immunosuppressive regimens used in kidney transplantation may add to CVD risk by promoting hypertension, hyperlipidemia, NODM, anemia and loss of renal function. Immunosuppressive agents differ with respect to their CVD risk profile contributions and the choice of individual agents and combinations of these agents can enhance or mitigate CVD risk.
As previously stated, over 90% of patients receiving a kidney transplantation become hypertensive. Both CSA and corticosteroids increase the risk while TAC, mycophenolate, and sirolimus (SRL) convey less risk. The pivotal phase 3 U.S. trial comparing TAC with CSA in kidney transplantation patients revealed that fewer patients treated with TAC vs. CSA were using antihypertensive drugs after 5 years.20 In this study all patients were on AZA and corticosteroids.25
A similar study by Margreiter reported a higher incidence of hypertension in patients on CSA-ME when compared to TAC after 6 months of treatment,26 and Gonwa et al.27 similarly reported a lower DBP in patients treated with TAC/mycophenolate instead of TAC/SRL, Immunosuppressive regimens of tacrolimus/mycophenolate without steroid seem to convey the least risk of hypertension.
As is the case with hypertension, CSA and corticosteroids increase the risk of hyperlipidemia. This is also true with SRL, whereas, TAC and mycophenolate do not. The previously mentioned pivotal U.S. trial comparing TAC/AZA/steroids to CSA/AZA/steroids revealed a significantly higher total serum cholesterol in the CSA vs. TAC arm (229.8 mg/dl vs. 193 mg/dl).20 Patients in the CSA arm also had higher LDL-cholesterol and triglyceride levels. Similar results were seen in a study where it was noted that more patients treated with CSA vs. TAC required lipid lowering therapy (58.8% CSA, 20% TAC).25 (Table 4)
P Value
Total cholesterol
210 mg/dl
LDL cholesterol
118 mg/dl
Patients on lipid
lowering therapy
The hyperlipidemic effects of SRL and CSA-ME are illustrated in a study Ciancio et al.22 After three months of therapy with CSA-ME/SRL, 27% of patients had a total serum cholesterol of >250mg/dl. Of the patients who were on TAC/SRL or TAC/mycophenolate, 16% and 2% had serum cholesterol >250mg/dl respectively.22 There had been no significant difference in lipid levels between the three groups at baseline. A significantly greater proportion of patients in the CSA-ME/SRL and TAC/SRL groups required anti-lipid therapy at 3, 6, and 12 month post transplantation when compared to the TAC/mycophenolate group. Gonwa et al27 reported a higher mean serum cholesterol, LDL cholesterol and triglyceride level in patients treated with TAC/SRL/steroids instead of TAC/mycophenolate/steroids. In the pivotal sirolimus trial, Kahan reported higher serum cholesterol and triglyceride levels with CSA-ME/SRL than with CSA-ME/AZA in kidney transplantation patients after 6 months of treatment.28 Again both patient groups received steroids.
These results demonstrate that CSA or CSA-ME and SRL are more likely to promote hyperlipidemia than TAC or mycophenolate. Corticosteroids further potentate hyperlipidemia regardless of the overall combination of immunosuppressive agents. It would appear that the combination of TAC and mycophenolate without steroid would be the least egregious regimen for promoting hyperlipidemia.
In the first year post transplantation, 6 percent of patients will have developed NODM, and by 15 years post transplantation approximately 30% of non-diabetic kidney transplantation recipients will have developed NODM.19 Early studies comparing TAC/AZA with CSA/AZA used higher doses and allowed higher levels of TAC than are currently used. Consequently NODM was reported in 19.9% of TAC/AZA treated patients vs. 4.0% of patients treated with CSA/AZA.22 Recent studies using TAC doses and levels more comparable to those used in current clinical practice and that combine TAC with mycophenolate instead of AZA resulted in a lower incidence of NODM which was no different from that seen with CSA-ME therapy.24, 27 Indeed, in one study, the rate of NODM was highest in the patient group taking CSA-ME/SRL vs. TAC/mycophenolate or TAC/SRL.22 Presently, the combination of TAC/mycophenolate without steroids is no more diabetegenic than CSA-ME based regimens.
Cardiovascular risk factors in kidney transplantation patients may be modified in two basic ways. If a risk factor such as hypertension or hyperlipidemia is associated with a particular immunosuppressive regimen, the agents may be changed. If immunosuppression cannot be changed, then lifestyle changes may be instituted and pharmacotherapy added.
If there is one drug which has profound effects on the three major risk factors, hypertension, hyperlipidemia and NODM, it is prednisone (corticosteroid administration). Elimination of corticosteroids from the overall immunosuppressive regimen is highly desirable. However, it has only been in the last few years that other anti-rejection drug combinations have had enough efficiency to allow steroid cessation. A clinical trail by Boots et.al.29 compared stopping prednisone 7 days post transplantation (STOP) against tapering steroids (TAP) in kidney allograft recipients on TAC immunosuppression. There were lower rates of NODM in the STOP group (8%) than in the TAP group (30.3%) at 31 months. No patients were using insulin in the STOP group compared to 21.2% in the TAP group. The median time to development of NODM was 631 days and 31 days in the STOP and TAP groups respectively. (Table 5)
(TAP n=34)
STOP @ 7 days
(STOP n=28)
Insulin Use
Time of onset in daysafter transplantation
< 0.001
An additional study revealed that prednisone for only 7 days after transplantation followed by TAC/mycophenolate immunosuppression without steroid resulted in a 3.5% incidence of NODM at 12 months. Clearly, steroid weaning and/or avoidance can have a beneficial effect on glucose tolerance.
Steroid withdrawal also has a beneficial effect on hypertension. In by a study Itricik et.al., 30 of 44 high risk African American transplantation patients were weaned off steroids starting three months after transplantation. Two months after beginning steroid withdrawal both SBP and DBP were significantly reduced and SBP was still reduced 6 months after steroid withdrawal.31 During this 6 month period there was a concurrent reduction in anti-hypertensive medication in this population. Only 2 of 30 patients experienced acute rejection and 27 of 30 patients remained steroid free. Both serum total cholesterol and LDL cholesterol levels were reduced with steroid were stopped. This was an important finding since the maintenance immunosuppression consisted of TAC/SRL and the latter is particularly lipogenic.
A change in calcineurin inhibitor therapy from CSA or CSA-ME to TAC also results in improved blood pressure and lipid profiles. In one study Lightenberg et al32 used a crossover design to evaluate the effect of CSA or TAC on hypertension and blood lipids one year after kidney transplantation. Patients initially immunosuppressed with CSA were converted to tacrolimus and then retuned to CSA at 4 week intervals. Mean arterial pressure was monitored during the day and at night, significantly improved with conversion to TAC and worsened when patients were returned to CSA. (Figure 3)
MAP = Mean Arterial Pressure
Lightenberg, et al. J Am Soc Nephrol. 2001; 12:368-373.
A similar trend of improvement on TAC and worsening with CSA was seen with total and LDL cholesterol. Additionally, a study of 65 kidney transplantation recipients with serum cholesterol > 240mg/dl who were converted from CSA to TAC revealed a reduction of total cholesterol by 55mg/dl, LDL cholesterol by 48mg/dl and apolipoprotein B by 36mg/dl after 6 months.33 Improved lipid profiles, particularly with lower LDL cholesterol and improved HDL cholesterol have been shown in additional studies.34
An immunosuppressive regimen which uses TAC and mycophenolate without corticosteroids appears to have the advantage of lower total and LDL cholesterol, particularly the latter, and promotes less hypertension. The doses and levels of TAC used in current practice appear to convey no more risk of NODM than that seen with CSA-ME particularly when TAC is used with mycophenolate instead of AZA and when steroids can be avoided.
All major classes of antihypertensive medications have been used post transplantation and most patients will require two to four agents for adequate control as outlined by JNC VII guidelines.35-38 No single class is the clear choice, although diuretic therapy tends to be necessary in multiple dose anti-hypertensive regimens. Calcineurin inhibitor, (CSA and TAC) vasoconstrict the afferent renal arteriole promoting ischemia which reduces the glomerular filtration rate (GFR), activates the rennin-angiotensin-aldosterone system, promotes salt and water retention, and also stimulates transferring growth factor B1 (TGF-B1) promoting fibrosis. Approaches to treatment of hypertension in the kidney transplant patient include salt restriction, diuretic use and calcium channel blocker (CCB) therapy to promote afferent arteriolar vasodilation. In addition to reducing blood pressure CCB's do improve renal blood flow and GFR but have not been shown to be renoprotective. Indeed dihydropyridine CCB may accelerate the progression of renal disease if used without known renoprotective agents such as angiotensin receptor blockers (ARB) or angiotensin converting enzyme inhibitors (ACE-I). Finally many CCB such as diltazem or verapamil interact with cytochrome P450-3A4 and enhance blood levels of CSA or TAC. Constant monitoring and adjustment of the CSA or TAC dose is needed until a steady state is reached.
The use of ACE-I or ARB in kidney transplantation recipients was once avoided due to a fear of reduced blood flow to the allograft and loss of GFR. Now, however, there is an ample literature that these medications are renoprotective and can reduce microalbuminuria and proteinuria, markers for ongoing renal inflammation and damage.40 ARB's reduce plasma levels TGF-B, which has been associated with chronic allograft fibrosis and nephropathy. Potential side effects of ARB and ACE-I include hyperkalemia and anemia. The hyperkalemia can be potentiated by the concurrent administration of B-blockers, K sparing diuretics, the presence of diabetes mellitus, or declining renal function. Anemia results from a decrease in Angiotensin II type I receptor engagement which down regulates the production of erythropoietin. This interaction is useful in the case of post transplantation polycythemia (post transplantation erythropoesis) which can be treated with ARB or ACE-I therapy.
Historically, B-blockers have been useful antihypertensive agents and convey cardioprotection in post-MI patients and in other CVD patients. They are useful in CHF, particularly carvedilol. A recent met-analysis suggested that B-blockers have less beneficial effects on left ventricular mass reduction than ARB's, ACE-I, CCB's and diuretics.41 Untoward side effects of long term B-blocker therapy include insulin resistance and dyslipidemia, problems which may already exist in many kidney transplantation patients and which may be exacerbated by their immunosuppressive therapy. In a prospective study of 12,550 hypertensive adults who did not have diabetes mellitus, B-blocker treatment significantly increased the risk of subsequent diabetes mellitus compared to those patients treated with other hypertensive therapy.42
Diuretics may be used alone or with other agents to control hypertension. They are particularly effective in systolic hypertension and in patients exhibiting salt and water overload. Such is the case in patients on corticosteroids, CSA or TAC. Potential complications of diuretics include dyslipidemia, hypomagnesemia, hyperuricemia and gout, hypokalemia and insulin resistance, particularly if potassium is low. Thiazide diuretics impede urinary calcium loss and that effect may help combat bone loss. Loop diuretics are more useful in patients with hyperkalemia, hypercalcemia, edema and heart failure.
Currently HMG-CoA reductace inhibitors (statins) are the drugs of choice for most hyperlipidemic states, particularly in patients with pre-existing CVD.43, 44 These drugs show their greatest effects on total cholesterol and LDL-cholesterol and have been shown to reduce oxidative stress. There is a well documented risk of rhabdomyolysis or myopathy when statins are used with CSA because of CSA induced impairment of cytochrome P450-3A4 metabolism. This was first noted with lovostatin and is more common with the lipophilic HMGCoA reductase inhibitors. Statin exposure may be increased 8 fold by cyclosporine and may be increased by SRL as well.43 More hydrophilic statins such as pravastatin or fluvastatin (Lescol) have less propensity to produce rhabdomyolysis when used with CSA. Statin exposure is also much less in patients on TAC immunosuppression so rhabdomyolysis is much less likely to occur.
There is one good lipid lowering trial in transplantation patients; that is The Assessment of Lescol in Renal Transplantation (ALERT). ALERT was a multicenter randomized double-blind placebo-controlled 5 year trial that examined the impact of fluvastatin on cardiac and renal endpoints in kidney transplantation patients.45 Although, fluvastatin significantly lowered LDL cholesterol compared to placebo, it was not associated with significant risk reduction for the primary endpoint i.e. cardiac death, non fatal MI or coronary intervention procedures. However, fluvastatin therapy was associated with significantly reduced risk of cardiac death:
(RR 0.62; p = 0.03) definite non fatal MI (RR 0.68; p = 0.05) and cardiac death or definite non fatal MI (RR 0.65; p = 0.005).
For patients with predominantly hypertriglyceridemia, fibric acid derivatives (fibrates) are the agents of choice.43, 46 When used with HMGCoA reductase inhibitors there is a risk for rhabdomyolysis, and this may be augmented if concurrently given with calcineurin inhibitors. There have been reports of acute renal failure in transplanted patients using fibrates; however, there were no such reports with gemfibrozil. It is the preferred fibrate in kidney transplantation recipients with hypertriglyceridemia. Finally, omega 3 fish oil has significant triglyceride lowering effects and is indicated for patients with triglycerides > 500 mg/dl and HDL cholesterols <40mg/dl in men and <50mg/dl in women. There are no reported drug interactions with statins. (Table 6)
Side Effects
Interactions with Immunosuppression
Bile acid resins
Bloating constipation
Interfere with CSA and TAC absorption
Glucose intolerance
Increased liver enzymes
Use with CSA, TAC, steroids may exacerbate glucose intolerance
GI upset
Increased risk of myositis/rhabdo when used with statins, CSA, TAC
Reductase inhibitors)
Myositic/rhabdomyolysis Increased liver enzymes
Increased risk of myositis/rhabdomyolysis when used with fibrates, CSA and TAC
Omega 3 Fatty Acid
Fishy eructation
None presently known
Development of diabetes after transplantation requires life style modifications to help achieve glycemic control. Diet, weight loss and exercise are all critically important; but usually pharmacotherapy will be required. If the fasting glucose is > 300mg/dl, regardless of whether the patient is type 1 or type 2 diabetic, insulin will be required. For those patients who cannot achieve adequate control with insulin, metformin or a thiazolidinedione may be added. A sulforylurea or insulin secretagogue would have no benefit in this setting. Patients with type 2 diabetes may initiate therapy with an oral hypoglycemic agent such as a sulfonylurea or an insulin sensitizing thiazolidinedione.
Metformin is considered a second line agent due to concerns of lactic acidosis, if serum creatinine is > 1.4 mg/dl. Most patients will require treatment with more than one agent. (Figure 4 and 5)
A more complete discussion of NODM and its treatment will occur in the section on post transplantation diabetes to follow.
Cardiovascular risk factors are prevalent in chronic renal failure patients. The major risk factors, hypertension, hyperlipidemia and diabetes mellitus can be exacerbated or mitigated immunosuppression choices. The current literature suggests that immunosuppression with a combination of tacrolimus and a formulation of mycophenolic acid without steroids may have the least effect on cardiovascular risk in kidney transplantation patients. (Table 7)
+ +
+ + +
+ + + +
1. Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis. 1998; 32(suppl 3); S112-S119.
2. Danovitch GM. The epidemic of cardiovascular disease in chronic renal disease: a challenge to the transplant physician. Graft. 1999; 2(suppl 11); S108-S112.
3. Ojo AO, Hanson JA, Wolfe RA, et al. Long-term survival in renal transplant recipients with graft function. Kidney Int. 2000; 57:307-313.
4.. Grundy SM, Pasternak R, Greenland P, Smith S. Fuster V. Circulation. 1999; 100:1481-1492.
5. Klausen K, Borch-Johnsen K, Feldt-Rasmussen B, et al. Very low levels of microalbuminuria are associated with increased risk of coronary heart disease and death independently of renal function, hypertension, and diabetes. Circulation. 2004; 110:32-35.
6. Ponticelli C, Villa M. Role of anaemia in cardiovascular mortality and morbidity in transplant patients. Nephrol Dial Transplant. 2002; 17 (suppl 1):41-46.
7. Ducloux D, Kazory A, Chalopin J-M. Predicting coronary heart disease in renal transplant recipients: a prospective study. Kidney Int. 2004; 66:441-447.
8. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. US Dept of Health and Human Services. National Institutes of Health. Bethesda, Md. 2003. Available at: http://www.nhlbi.nih.gov/guidelines/hypertension Accessed March 15, 2005.
9.American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2005; 28(suppl 1):S4-S36.
10. Opelz G, Wujciak T, Ritz E. Association of chronic kidney graft failure with recipient blood pressure. Kidney Int. 1998; 53:217-222.
11. Cosio FG, Dillon JJ, Falkenhain ME, et al. Racial differences in renal allograft survival: the role of systemic hypertension. Kidney Int. 1995; 47:1136-1141.
12. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood cholesterol in Adults (Adult Treatment Panel III). US Dept of Health and Human Services. National Institutes of Health. Bethesda, Md. May 2001. Available at: http://www.nhlbi.nih.gov/guidelines/cholesterol. Accessed March 15, 2005.
13. Update on cholesterol guidelines: more-intensive treatment options for higher risk patients. NIH News. US Dept of Health and Human Services. National Institutes of Health. Bethesda, Md. 2004. Available at: http://www.nhlbi.nih.gov. Accessed February 20, 2005.
14. Carvalho MFC, Soares V. Hyperlipidemia as a risk factor of renal allograft function impairment. Clin Transplant. 2001; 15: 48-52.
15. Wissing KM, Abramowicz D, Broeders N, Vercerstraeten P. Hypercholesterolemia is associated with increased kidney graft loss caused by chronic rejection in male patients with previous acute rejection. Transplantation. 2000; 70:464-472.
16. Castello IB. Hyperlipidemia: a risk factor for chronic allograft dysfunction. Kidney Int. 2002; 61 (suppl 80): S73-S77.
17. Guijarro C, Massy ZA, Kasiske BL. Clinical correlation between renal allograft failure and hyperlipidemia. Kidney Int. Suppl. 1995; 52:S56-S59.
18. Gaston RS, Basadonna G, Cosio FG, et al. Transplantation in the diabetic patient with advanced chronic kidney disease: a task force report. Am J Kidney Dis. 2004; 44:529-542.
19. Cosio FG, Pesavento TE, Osei K, Henry ML, Ferguson RM. Post-transplant diabetes mellitus: increasing incidence in renal allograft recipients transplanted in recent years. Kidney Int. 2001; 59:732-737.
20. Pirsch JD, Miller J, Deierhoi MH, Vincenti F, Filo RS. A comparison of tacrolimus (FK506) and cyclosporine for immunosuppression after cadaveric renal transplantation. Transplantation. 1997; 63:977-983.
21. Mayer AD, Dmitrewski J, Squifflet J-P, et al. Multicenter randomized trial comparing tacrolimus (FK506) and cyclosporine in the prevention of renal allograft rejection. Transplantation. 1997; 64:436.
22. Ciancio G, Burke GW. Gaynor JJ, et al. A randomized long-term trial of tacrolimus/sirolimus versus tacrolimus/mycophenolate mofetil versus cyclosporine (Neoral)/sirolimus in renal transplantation. II. Survival, function, and protocol compliance at 1 year. Transplantation. 2004; 77: 252-258.
23. First MR, Gerber DA, Hariharan S, Kaufman DB, Shapiro R. Posttransplant diabetes mellitus in kidney allograft recipients: incidence, risk factors, and management. Transplantation. 2002; 73:379-386.
24. Johnson C, Ahsan N, Gonwa T, et al. Randomized trial of tacrolimus (Prograf) in combination with azathioprine or mycophenolate mofetil versus cyclosporine (Neoral) with mycophenolate mofetil after cadaveric kidney transplantation. Transplantation. 2000; 69:834-841.
25. Vincenti F, Jensik SC, Filo RS, Miller J, Pirsch J. A long-term comparison of tacrolimus (FK506) and cyclosporine in kidney transplantation: evidence for improved allograft survival at five years. Transplantation. 2002; 73:775-782.
26. Margreiter R. Efficacy and safety of tacrolimus compared with ciclosporin microemulsion in renal transplantation: a randomized multicenter study. Lancet. 2002; 359:741-746.
27. Gonwa T, Mendez R, Yang HC, et al. Randomized trial of tacrolimus in combination with sirolimus or mycophenolate mofetil in kidney transplantation: results at 6 months. Transplantation. 2003; 75:1213-1220.
28. Kahan BD. Efficacy of sirolimus compared with azathioprine for reduction of acute renal allograft rejection: a randomized multicenter study. Lancet. 2000; 356:194-202.
29. Boots JMM, Christiaans MHL, van Duijnhoven EM, van Suylen R-J, van Hooff JP. Early steroid withdrawal in renal transplantation with tacrolimus dual therapy: a pilot study. Transplantation. 2002; 74:1703-1709.
30. Borrows R, Loucaidou M, Van Tromp J, et al. Steroid sparing with tacrolimus and mycophenolate mofetil in renal transplantation. Am J Transplant. 2004; 4:1845-1851.
31. Hricik DF, Knauss TC, Bodziak KA, et al. Withdrawal of steroid therapy in African American kidney transplant recipients receiving sirolimus and tacrolimus. Transplantation. 2003; 76:938-942.
32. Ligtenberg G, Hene RJ, Blankestijn PJ, Koomans HA. Cardiovascular risk factors in renal transplant patients: cyclosporine A versus tacrolimus. J Am Soc Nephrol. 2001; 12:368-373.
33. McCune TR, Thacker LR II, Peters TG, et al. Effects of tacrolimus on hyperlipidemia after successful renal transplantation: a Southeastern Organ Procurement Foundation multicenter clinical study. Transplantation. 1998; 65:87-92.
34. Baid-Agrawal S, Delmonico FL, Tolkoff-Rubin NE, et al. Cardiovascular risk profile after conversion from cyclosporine A to tacrolimus in stable renal transplant recipients. Transplantation. 2004; 77:1199-1202.
35. Baroletti SA, Gabardi S, Magee CC, Milfrod EL. Calcium channel blockers as the treatment of choice for hypertension in renal transplant recipients: fact or fiction. Pharmacotherapy. 2003; 23:788-801.
36. Zhang R, Leslie B, Boudreaux JP, Frey D, Reisin E. Hypertension after kidney transplantation: impact, pathogenesis and therapy. Am J Med Sci. 2003:325:202-208.
37. Midtvedt K, Hartmann A. Hypertension after kidney transplantation: are treatment guidelines emerging? Nephrol Dial Transplant. 2002; 17:1166-1169.
38. Schwenger V, Zeier M, Ritz E. Hypertension after renal transplantation. Am Transpl. 2001; 6:25-30.
39. Eisenberg MJ, Brox A, Bestawros AN. Calcium channel blockers: an update. Am J Med. 2004; 116:35-43.
40. El-Agroudy AE, Hassan NA, Foda MA, et al. Effect of angiotensin II receptor blocker on plasma levels of TGF-β1 and interstitial fibrosis in hypertensive kidney transplant recipients. Am J Nephrol. 2003; 23:300-306.
41. Klingbeil AU, Schneider M, Martus P, et al. A meta-analysis of the effects of treatment on left ventricular mass in essential hypertension. Am J Med. 2003; 115:41-46.
42. Gress TW, Nieto FJ, Shahar E, Wofford MR, Brancati FL. Hypertension and antihypertensive therapy as risk factors for type 2 diabetes mellitus. N Engl J Med. 2000; 342:905-912.
43. Abtahi P, Zand MS. Management of hyperlipidemia in the stable solid organ transplant recipient. Graft. 2001; 4:266-274.
44. Massy ZA, Kasiske BL. Post-transplant hyperlipidemia: mechanism and management. J Am Soc Nephrol. 1996; 7:971-977.
45. Holdaas H, Fellstrom, Jardine AG, et al. Effect of fluvastatin on cardiac outcomes in renal transplant recipients: a multicenter, randomized, placebo-controlled trial. Lancet. 2003; 361: 2024-2031.
46. Rosas S, Szapary P, Rader DJ. Management of selected lipid abnormalities: hypertriglyceridemia isolated low HDL-cholesterol, lipoprotein (a), and lipid abnormalities in renal diseases and following solid organ transplantation. Cardiol Clin. 2003; 21:377-392.
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Home » News » Crime
December 14. 2012 12:05AM
Reports of gunshots in Nashua, followed by a crash on Everett Turnpike
NASHUA — Police were investigating reports of gunshots late Thursday.
Police received reports of shots fired in the city about 11:30 p.m. Thursday, followed by a report of an accident near exit 2 of the F.E. Everett Turnpike in which the car's occupants ran away from the scene of the accident on foot.
Sgt. John Harvey said the two incidents "are apparently connected," but said he didn't have more information on the incidents.
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UPDATED: Rochester man shot multiple times as police attempted arrest
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