text:
Hypertension | |
Classification and external resources | |
Automated arm blood pressure meter showing arterial hypertension (shown a systolic blood pressure 158 mmHg, diastolic blood pressure 99 mmHg and heart rate of 80 beats per minute)
DiseasesDB | 6330 |
MedlinePlus | 000468 |
eMedicine | med/1106 ped/1097 emerg/267 |
MeSH | D006973 |
Hypertension (HTN) or high blood pressure, sometimes called arterial hypertension, is a chronic medical condition in which the blood pressure in the arteries is elevated. Blood pressure is summarised by two measurements, systolic and diastolic, which depend on whether the heart muscle is contracting (systole) or relaxed between beats (diastole). This equals the maximum and minimum pressure, respectively. Normal blood pressure at rest is within the range of 100-140mmHg systolic (top reading) and 60-90mmHg diastolic (bottom reading). High blood pressure is said to be present if it is often at or above 140/90 mmHg.
Hypertension is classified as either primary (essential) hypertension or secondary hypertension; about 90–95% of cases are categorized as "primary hypertension" which means high blood pressure with no obvious underlying medical cause.[1] The remaining 5–10% of cases (secondary hypertension) are caused by other conditions that affect the kidneys, arteries, heart or endocrine system.
Hypertension puts strain on the heart, leading to hypertensive heart disease and coronary artery disease if not treated. Hypertension is also a major risk factor for stroke, aneurysms of the arteries (e.g. aortic aneurysm), peripheral arterial disease and is a cause of chronic kidney disease. A moderately high arterial blood pressure is associated with a shortened life expectancy while mild elevation is not. Dietary and lifestyle changes can improve blood pressure control and decrease the risk of health complications, although drug treatment is still often necessary in people for whom lifestyle changes are not enough or not effective.
Signs and symptoms[edit]
Hypertension is rarely accompanied by any symptoms, and its identification is usually through screening, or when seeking healthcare for an unrelated problem. A proportion of people with high blood pressure report headaches (particularly at the back of the head and in the morning), as well as lightheadedness, vertigo, tinnitus (buzzing or hissing in the ears), altered vision or fainting episodes.[2] These symptoms, however, might be related to associated anxiety rather than the high blood pressure itself.[3]
On physical examination, hypertension may be suspected on the basis of the presence of hypertensive retinopathy detected by examination of the optic fundus found in the back of the eye using ophthalmoscopy.[4] Classically, the severity of the hypertensive retinopathy changes is graded from grade I–IV, although the milder types may be difficult to distinguish from each other.[4] Ophthalmoscopy findings may also give some indication as to how long a person has been hypertensive.[2]
Secondary hypertension[edit]
Some additional signs and symptoms may suggest secondary hypertension, i.e. hypertension due to an identifiable cause such as kidney diseases or endocrine diseases. For example, truncal obesity, glucose intolerance, moon face, a "buffalo hump" and purple stretch marks suggest Cushing's syndrome.[5] Thyroid disease and acromegaly can also cause hypertension and have characteristic symptoms and signs.[5] An abdominal bruit may be an indicator of renal artery stenosis (a narrowing of the arteries supplying the kidneys), while decreased blood pressure in the lower extremities and/or delayed or absent femoral arterial pulses may indicate aortic coarctation (a narrowing of the aorta shortly after it leaves the heart). Labile or paroxysmal hypertension accompanied by headache, palpitations, pallor, and perspiration should prompt suspicions of pheochromocytoma.[5]
Hypertensive crisis[edit]
Severely elevated blood pressure (equal to or greater than a systolic 180 or diastolic of 110 — sometimes termed malignant or accelerated hypertension) is referred to as a "hypertensive crisis", as blood pressures above these levels are known to confer a high risk of complications. People with blood pressures in this range may have no symptoms, but are more likely to report headaches (22% of cases)[6] and dizziness than the general population.[2] Other symptoms accompanying a hypertensive crisis may include visual deterioration or breathlessness due to heart failure or a general feeling of malaise due to renal failure.[5] Most people with a hypertensive crisis are known to have elevated blood pressure, but additional triggers may have led to a sudden rise.[7]
A "hypertensive emergency", previously "malignant hypertension", is diagnosed when there is evidence of direct damage to one or more organs as a result of the severely elevated blood pressure. This may include hypertensive encephalopathy, caused by brain swelling and dysfunction, and characterized by headaches and an altered level of consciousness (confusion or drowsiness). Retinal papilloedema and/or fundal hemorrhages and exudates are another sign of target organ damage. Chest pain may indicate heart muscle damage (which may progress to myocardial infarction) or sometimes aortic dissection, the tearing of the inner wall of the aorta. Breathlessness, cough, and the expectoration of blood-stained sputum are characteristic signs of pulmonary edema, the swelling of lung tissue due to left ventricular failure an inability of the left ventricle of the heart to adequately pump blood from the lungs into the arterial system.[7] Rapid deterioration of kidney function (acute kidney injury) and microangiopathic hemolytic anemia (destruction of blood cells) may also occur.[7] In these situations, rapid reduction of the blood pressure is mandated to stop ongoing organ damage.[7] In contrast there is no evidence that blood pressure needs to be lowered rapidly in hypertensive urgencies where there is no evidence of target organ damage and over aggressive reduction of blood pressure is not without risks.[5] Use of oral medications to lower the BP gradually over 24 to 48h is advocated in hypertensive urgencies.[7]
Hypertension occurs in approximately 8–10% of pregnancies.[5] Two blood pressure measurements six hours an apart of greater than 140/90 mm Hg is considered diagnostic of hypertension in pregnancy.[8] Most women with hypertension in pregnancy have pre-existing primary hypertension, but high blood pressure in pregnancy may be the first sign of pre-eclampsia, a serious condition of the second half of pregnancy and puerperium.[5] Pre-eclampsia is characterised by increased blood pressure and the presence of protein in the urine.[5] It occurs in about 5% of pregnancies and is responsible for approximately 16% of all maternal deaths globally.[5] Pre-eclampsia also doubles the risk of perinatal mortality.[5] Usually there are no symptoms in pre-eclampsia and it is detected by routine screening. When symptoms of pre-eclampsia occur the most common are headache, visual disturbance (often "flashing lights"), vomiting, epigastric pain, and edema. Pre-eclampsia can occasionally progress to a life-threatening condition called eclampsia, which is a hypertensive emergency and has several serious complications including vision loss, cerebral edema, seizures or convulsions, renal failure, pulmonary edema, and disseminated intravascular coagulation (a blood clotting disorder).[5][9]
Failure to thrive, seizures, irritability, lack of energy, and difficulty breathing[10] can be associated with hypertension in neonates and young infants. In older infants and children, hypertension can cause headache, unexplained irritability, fatigue, failure to thrive, blurred vision, nosebleeds, and facial paralysis.[10][11]
Primary hypertension[edit]
Primary (essential) hypertension is the most common form of hypertension, accounting for 90–95% of all cases of hypertension.[1] In almost all contemporary societies, blood pressure rises with aging and the risk of becoming hypertensive in later life is considerable.[12] Hypertension results from a complex interaction of genes and environmental factors. Numerous common genetic variants with small effects on blood pressure have been identified[13] as well as some rare genetic variants with large effects on blood pressure[14] but the genetic basis of hypertension is still poorly understood. Several environmental factors influence blood pressure. Lifestyle factors that lower blood pressure include reduced dietary salt intake,[15][16] increased consumption of fruits and low fat products (Dietary Approaches to Stop Hypertension (DASH diet)), exercise,[17] weight loss[18] and reduced alcohol intake.[19] Stress appears to play a minor role[3] with specific relaxation techniques not supported by the evidence.[20][21] The possible role of other factors such as caffeine consumption,[22] and vitamin D deficiency[23] are less clear cut. Insulin resistance, which is common in obesity and is a component of syndrome X (or the metabolic syndrome), is also thought to contribute to hypertension.[24] Recent studies have also implicated events in early life (for example low birth weight, maternal smoking and lack of breast feeding) as risk factors for adult essential hypertension,[25] although the mechanisms linking these exposures to adult hypertension remain obscure.[25]
Secondary hypertension[edit]
Secondary hypertension results from an identifiable cause. Renal disease is the most common secondary cause of hypertension.[5] Hypertension can also be caused by endocrine conditions, such as Cushing's syndrome, hyperthyroidism, hypothyroidism, acromegaly, Conn's syndrome or hyperaldosteronism, hyperparathyroidism and pheochromocytoma.[5][26] Other causes of secondary hypertension include obesity, sleep apnea, pregnancy, coarctation of the aorta, excessive liquorice consumption and certain prescription medicines, herbal remedies and illegal drugs.[5][27]
In most people with established essential (primary) hypertension, increased resistance to blood flow (total peripheral resistance) accounting for the high pressure while cardiac output remains normal.[28] There is evidence that some younger people with prehypertension or 'borderline hypertension' have high cardiac output, an elevated heart rate and normal peripheral resistance, termed hyperkinetic borderline hypertension.[29] These individuals develop the typical features of established essential hypertension in later life as their cardiac output falls and peripheral resistance rises with age.[29] Whether this pattern is typical of all people who ultimately develop hypertension is disputed.[30] The increased peripheral resistance in established hypertension is mainly attributable to structural narrowing of small arteries and arterioles,[31] although a reduction in the number or density of capillaries may also contribute.[32] Hypertension is also associated with decreased peripheral venous compliance[33] which may increase venous return, increase cardiac preload and, ultimately, cause diastolic dysfunction. Whether increased active vasoconstriction plays a role in established essential hypertension is unclear.[34]
Pulse pressure (the difference between systolic and diastolic blood pressure) is frequently increased in older people with hypertension. This can mean that systolic pressure is abnormally high, but diastolic pressure may be normal or low — a condition termed isolated systolic hypertension.[35] The high pulse pressure in elderly people with hypertension or isolated systolic hypertension is explained by increased arterial stiffness, which typically accompanies aging and may be exacerbated by high blood pressure.[36]
Many mechanisms have been proposed to account for the rise in peripheral resistance in hypertension. Most evidence implicates either disturbances in renal salt and water handling (particularly abnormalities in the intrarenal renin-angiotensin system)[37] and/or abnormalities of the sympathetic nervous system.[38] These mechanisms are not mutually exclusive and it is likely that both contribute to some extent in most cases of essential hypertension. It has also been suggested that endothelial dysfunction and vascular inflammation may also contribute to increased peripheral resistance and vascular damage in hypertension.[39][40]
System | Tests |
Renal | Microscopic urinalysis, proteinuria, BUN and/or creatinine |
Endocrine | Serum sodium, potassium, calcium, TSH |
Metabolic | Fasting blood glucose, HDL, LDL, and total cholesterol, triglycerides |
Other | Hematocrit, electrocardiogram, and chest radiograph |
Sources: Harrison's principles of internal medicine[41] others[42][43][44][45][46] |
Hypertension is diagnosed on the basis of a persistent high blood pressure. Traditionally,[47] this requires three separate sphygmomanometer measurements at one monthly intervals.[48] Initial assessment of the hypertensive people should include a complete history and physical examination. With the availability of 24-hour ambulatory blood pressure monitors and home blood pressure machines, the importance of not wrongly diagnosing those who have white coat hypertension has led to a change in protocols. In the United Kingdom, current best practice is to follow up a single raised clinic reading with ambulatory measurement, or less ideally with home blood pressure monitoring over the course of 7 days.[47] Pseudohypertension in the elderly or noncompressibility artery syndrome may also require consideration. This condition is believed to be due to calcification of the arteries resulting an abnormally high blood pressure readings with a blood pressure cuff while intra arterial measurements of blood pressure are normal.[49]
Once the diagnosis of hypertension has been made, physicians will attempt to identify the underlying cause based on risk factors and other symptoms, if present. Secondary hypertension is more common in preadolescent children, with most cases caused by renal disease. Primary or essential hypertension is more common in adolescents and has multiple risk factors, including obesity and a family history of hypertension.[50] Laboratory tests can also be performed to identify possible causes of secondary hypertension, and to determine whether hypertension has caused damage to the heart, eyes, and kidneys. Additional tests for diabetes and high cholesterol levels are usually performed because these conditions are additional risk factors for the development of heart disease and may require treatment.[1]
Serum creatinine is measured to assess for the presence of kidney disease, which can be either the cause or the result of hypertension. Serum creatinine alone may overestimate glomerular filtration rate and recent guidelines advocate the use of predictive equations such as the Modification of Diet in Renal Disease (MDRD) formula to estimate glomerular filtration rate (eGFR).[51] eGFR can also provides a baseline measurement of kidney function that can be used to monitor for side effects of certain antihypertensive drugs on kidney function. Additionally, testing of urine samples for protein is used as a secondary indicator of kidney disease. Electrocardiogram (EKG/ECG) testing is done to check for evidence that the heart is under strain from high blood pressure. It may also show whether there is thickening of the heart muscle (left ventricular hypertrophy) or whether the heart has experienced a prior minor disturbance such as a silent heart attack. A chest X-ray or an echocardiogram may also be performed to look for signs of heart enlargement or damage to the heart.[5]
Classification (JNC7)[51] | Systolic pressure | Diastolic pressure | ||
mmHg | kPa | mmHg | kPa | |
Normal | 90–119 | 12–15.9 | 60–79 | 8.0–10.5 |
High normal[52] or prehypertension | 120–139 | 16.0–18.5 | 80–89 | 10.7–11.9 |
Stage 1 hypertension | 140–159 | 18.7–21.2 | 90–99 | 12.0–13.2 |
Stage 2 hypertension | ≥160 | ≥21.3 | ≥100 | ≥13.3 |
Isolated systolic hypertension |
≥140 | ≥18.7 | <90 | <12.0 |
In people aged 18 years or older hypertension is defined as a systolic and/or a diastolic blood pressure measurement consistently higher than an accepted normal value (currently 139 mmHg systolic, 89 mmHg diastolic: see table —Classification (JNC7)). Lower thresholds are used (135 mmHg systolic or 85 mmHg diastolic) if measurements are derived from 24-hour ambulatory or home monitoring.[47] Recent international hypertension guidelines have also created categories below the hypertensive range to indicate a continuum of risk with higher blood pressures in the normal range. JNC7 (2003)[51] uses the term prehypertension for blood pressure in the range 120-139 mmHg systolic and/or 80-89 mmHg diastolic, while ESH-ESC Guidelines (2007)[53] and BHS IV (2004)[54] use optimal, normal and high normal categories to subdivide pressures below 140 mmHg systolic and 90 mmHg diastolic. Hypertension is also sub-classified: JNC7 distinguishes hypertension stage I, hypertension stage II, and isolated systolic hypertension. Isolated systolic hypertension refers to elevated systolic pressure with normal diastolic pressure and is common in the elderly.[51] The ESH-ESC Guidelines (2007)[53] and BHS IV (2004),[54] additionally define a third stage (stage III hypertension) for people with systolic blood pressure exceeding 179 mmHg or a diastolic pressure over 109 mmHg. Hypertension is classified as "resistant" if medications do not reduce blood pressure to normal levels.[51]
Hypertension in neonates is rare, occurring in around 0.2 to 3% of neonates, and blood pressure is not measured routinely in the healthy newborn.[11] Hypertension is more common in high risk newborns. A variety of factors, such as gestational age, postconceptional age and birth weight needs to be taken into account when deciding if a blood pressure is normal in a neonate.[11]
Hypertension occurs quite commonly in children over the age of 3 years and adolescents (2-9% depending on age, sex and ethnicity)[55] and is associated with long term risks of ill-health.[56] Blood pressure rises with age in childhood and, in children, hypertension is defined as an average systolic or diastolic blood pressure on three or more occasions equal or higher than the 95th percentile appropriate for the sex, age and height of the child. High blood pressure must be confirmed on repeated visits however before characterizing a child as having hypertension.[56] Prehypertension in children has been defined as average systolic or diastolic blood pressure that is greater than or equal to the 90th percentile, but less than the 95th percentile.[56] In adolescents, it has been proposed that hypertension and pre-hypertension are diagnosed and classified using the same criteria as in adults.[56]
The value of routine screening for hypertension in children over the age of 3 years is debated.[57] In 2004 the National High Blood Pressure Education Program recommended that children aged 3 years and older have blood pressure measurement at least once at every health care visit[56] and the National Heart, Lung, Blood Institute's and American Academy of Pediatrics made a similar recommendation.[58] However the American Academy of Family Physicians[59] support the view of the U.S. preventive Services Task Force that evidence is insufficient to determine the balance of benefits and harms of screening for hypertension in children and adolescents who do not have symptoms.[60]
Much of the disease burden of high blood pressure is experienced by people who are not labelled as hypertensive.[54] Consequently, population strategies are required to reduce the consequences of high blood pressure and reduce the need for antihypertensive drug therapy. Lifestyle changes are recommended to lower blood pressure, before starting drug therapy. The 2004 British Hypertension Society guidelines[54] proposed the following lifestyle changes consistent with those outlined by the US National High BP Education Program in 2002[61] for the primary prevention of hypertension:
- maintain normal body weight for adults (e.g. body mass index 20–25 kg/m2)
- reduce dietary sodium intake to <100 mmol/ day (<6 g of sodium chloride or <2.4 g of sodium per day)
- engage in regular aerobic physical activity such as brisk walking (≥30 min per day, most days of the week)
- limit alcohol consumption to no more than 3 units/day in men and no more than 2 units/day in women
- consume a diet rich in fruit and vegetables (e.g. at least five portions per day);
Effective lifestyle modification may lower blood pressure as much an individual antihypertensive drug. Combinations of two or more lifestyle modifications can achieve even better results.[54]
Lifestyle modifications[edit]
The first line of treatment for hypertension is identical to the recommended preventive lifestyle changes[62] and includes dietary changes,[63] physical exercise, and weight loss. These have all been shown to significantly reduce blood pressure in people with hypertension.[64] Their potential effectiveness is similar to using a single medication.[52] If hypertension is high enough to justify immediate use of medications, lifestyle changes are still recommended in conjunction with medication.
Dietary change such as a low sodium diet is beneficial. A long term (more than 4 weeks) low sodium diet in Caucasians is effective in reducing blood pressure, both in people with hypertension and in people with normal blood pressure.[65] Also, the DASH diet, a diet rich in nuts, whole grains, fish, poultry, fruits and vegetables lowers blood pressure. A major feature of the plan is limiting intake of sodium, although the diet is also rich in potassium, magnesium, calcium, as well as protein.[66] Different programs aimed to reduce psychological stress such a biofeedback, relaxation or transcendental meditation may be reasonable add-ons to other treatment to reduce hypertension.[67] However, overall efficacy is not greater than health education, with evidence being generally of low quality.[21][67][68]
Several classes of medications, collectively referred to as antihypertensive drugs, are currently available for treating hypertension. Use should take into account the person's cardiovascular risk (including risk of myocardial infarction and stroke) as well as blood pressure readings, in order to gain a more accurate picture of the person's cardiovascular profile.[69] Evidence in those with mild hypertension (SBP less than 160 mmHg and /or DBP less than 100 mmHg) and no other health problems does not support a reduction in the risk of death or rate of health complications from medication treatment.[70] Medications are not recommended for people with prehypertension or high normal blood pressure.[52]
If drug treatment is initiated the Joint National Committee on High Blood Pressure (JNC-7)[51] recommends that the physician not only monitor for response to treatment but should also assess for any side effects resulting from the medication. Reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34%, of ischaemic heart disease by 21%, and reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease.[71] For most people, recommendations are to reduce blood pressure to less than or equal to somewhere between 140/90 mmHg to 160/100 mmHg.[69][72] Attempting to achieve lower levels have not been shown to improve outcomes.[72] In those with diabetes or kidney disease some recommend levels below 120/80 mmHg;[69][73] however, these are not proven.[72] If the blood pressure goal is not met, a change in treatment should be made as therapeutic inertia is a clear impediment to blood pressure control.[74]
The best first line agent is disputed.[75] The Cochrane collaboration, World Health Organization and the United States guidelines supports low dose thiazide-based diuretic as first line treatment.[64][75][76][77] The UK guidelines emphasise calcium channel blockers (CCB) in preference for people over the age of 55 years or if of African or Caribbean family origin, with angiotensin converting enzyme inhibitors (ACE-I) used first line for younger people.[78] In Japan starting with any one of six classes of medications including: CCB, ACEI/ARB, thiazide diuretics, beta-blockers, and alpha-blockers is deemed reasonable, while in Canada and Europe all of these but alpha-blockers are recommended as options.[52][75]
Drug combinations[edit]
The majority of people require more than one drug to control their hypertension. In those with a systolic blood pressure greater than 160 mmHg or a diastolic blood pressure greater than 100 mmHg the American Heart Association recommends starting both a thiazide and an ACEI, ARB or CCB.[64] An ACEI and CCB combination can be used as well.[64]
Unacceptable combinations are non-dihydropyridine calcium blockers (such as verapamil or diltiazem) and beta-blockers, dual renin–angiotensin system blockade (e.g. angiotensin converting enzyme inhibitor + angiotensin receptor blocker), renin–angiotensin system blockers and beta-blockers, beta-blockers and centrally acting agents.[79] Combinations of an ACE-inhibitor or angiotensin II–receptor antagonist, a diuretic and an NSAID (including selective COX-2 inhibitors and non-prescribed drugs such as ibuprofen) should be avoided whenever possible due to a high documented risk of acute renal failure. The combination is known colloquially as a "triple whammy" in the Australian health industry.[62] Tablets containing fixed combinations of two classes of drugs are available and while convenient for the people, may be best reserved for those who have been established on the individual components.[80]
Treating moderate to severe hypertension decreases death rates and cardiovascular morbidity and mortality in people aged 60 and older.[81] There are limited studies of people over 80 years old but a recent review concluded that antihypertensive treatment reduced cardiovascular deaths and disease, but did not significantly reduce total death rates.[81] The recommended BP goal is advised as <150/90 mm Hg with thiazide diuretic, CCB, ACEI, or ARB being the first line medication in the United States,[82] and in the revised UK guidelines calcium-channel blockers are advocated as first line with targets of clinic readings <150/90, or <145/85 on ambulatory or home blood pressure monitoring.[78]
Resistant hypertension[edit]
Resistant hypertension is defined as hypertension that remains above goal blood pressure in spite of concurrent use of three antihypertensive agents belonging to different antihypertensive drug classes. Guidelines for treating resistant hypertension have been published in the UK[83] and US.[84] It has been proposed that a proportion of resistant hypertension may be the result of chronic high activity of the autonomic nervous system; this concept is known as "neurogenic hypertension".[85]
As of 2000, nearly one billion people or ~26% of the adult population of the world had hypertension.[87] It was common in both developed (333 million) and undeveloped (639 million) countries.[87] However rates vary markedly in different regions with rates as low as 3.4% (men) and 6.8% (women) in rural India and as high as 68.9% (men) and 72.5% (women) in Poland.[88] In Europe hypertension occurs in about 30-45% of people as of 2013.[52]
In 1995 it was estimated that 43 million people in the United States had hypertension or were taking antihypertensive medication, almost 24% of the adult United States population.[89] The prevalence of hypertension in the United States is increasing and reached 29% in 2004.[90][91] As of 2006 hypertension affects 76 million US adults (34% of the population) and African American adults have among the highest rates of hypertension in the world at 44%.[92] It is more common in blacks and native Americans and less in whites and Mexican Americans, rates increase with age, and is greater in the southeastern United States. Hypertension is more prevalent in men (though menopause tends to decrease this difference) and in those of low socioeconomic status.[1]
The prevalence of high blood pressure in the young is increasing.[93] Most childhood hypertension, particularly in preadolescents, is secondary to an underlying disorder. Aside from obesity, kidney disease is the most common (60–70%) cause of hypertension in children. Adolescents usually have primary or essential hypertension, which accounts for 85–95% of cases.[94]
Hypertension is the most important preventable risk factor for premature death worldwide.[95] It increases the risk of ischemic heart disease[96] strokes,[5] peripheral vascular disease,[97] and other cardiovascular diseases, including heart failure, aortic aneurysms, diffuse atherosclerosis, and pulmonary embolism.[5] Hypertension is also a risk factor for cognitive impairment and dementia, and chronic kidney disease.[5] Other complications include hypertensive retinopathy and hypertensive nephropathy.[51]
Modern understanding of the cardiovascular system began with the work of physician William Harvey (1578–1657), who described the circulation of blood in his book "De motu cordis". The English clergyman Stephen Hales made the first published measurement of blood pressure in 1733.[98][99] Descriptions of hypertension as a disease came among others from Thomas Young in 1808 and especially Richard Bright in 1836.[98] The first report of elevated blood pressure in a person without evidence of kidney disease was made by Frederick Akbar Mahomed (1849–1884).[100] However hypertension as a clinical entity came into being in 1896 with the invention of the cuff-based sphygmomanometer by Scipione Riva-Rocci in 1896.[101] This allowed the measurement of blood pressure in the clinic. In 1905, Nikolai Korotkoff improved the technique by describing the Korotkoff sounds that are heard when the artery is ausculated with a stethoscope while the sphygmomanometer cuff is deflated.[99]
Historically the treatment for what was called the "hard pulse disease" consisted in reducing the quantity of blood by bloodletting or the application of leeches.[98] This was advocated by The Yellow Emperor of China, Cornelius Celsus, Galen, and Hippocrates.[98] In the 19th and 20th centuries, before effective pharmacological treatment for hypertension became possible, three treatment modalities were used, all with numerous side-effects: strict sodium restriction (for example the rice diet[98]), sympathectomy (surgical ablation of parts of the sympathetic nervous system), and pyrogen therapy (injection of substances that caused a fever, indirectly reducing blood pressure).[98][102] The first chemical for hypertension, sodium thiocyanate, was used in 1900 but had many side effects and was unpopular.[98] Several other agents were developed after the Second World War, the most popular and reasonably effective of which were tetramethylammonium chloride and its derivative hexamethonium, hydralazine and reserpine (derived from the medicinal plant Rauwolfia serpentina). A major breakthrough was achieved with the discovery of the first well-tolerated orally available agents. The first was chlorothiazide, the first thiazide diuretic and developed from the antibiotic sulfanilamide, which became available in 1958.[98][103] Subsequently beta blockers, calcium channel blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers and renin inhibitors were developed as antihypertensive agents.
Society and culture[edit]
The World Health Organization has identified hypertension, or high blood pressure, as the leading cause of cardiovascular mortality. The World Hypertension League (WHL), an umbrella organization of 85 national hypertension societies and leagues, recognized that more than 50% of the hypertensive population worldwide are unaware of their condition.[104] To address this problem, the WHL initiated a global awareness campaign on hypertension in 2005 and dedicated May 17 of each year as World Hypertension Day (WHD). Over the past three years, more national societies have been engaging in WHD and have been innovative in their activities to get the message to the public. In 2007, there was record participation from 47 member countries of the WHL. During the week of WHD, all these countries – in partnership with their local governments, professional societies, nongovernmental organizations and private industries – promoted hypertension awareness among the public through several media and public rallies. Using mass media such as Internet and television, the message reached more than 250 million people. As the momentum picks up year after year, the WHL is confident that almost all the estimated 1.5 billion people affected by elevated blood pressure can be reached.[105]
High blood pressure is the most common chronic medical problem prompting visits to primary health care providers in USA. The American Heart Association estimated the direct and indirect costs of high blood pressure in 2010 as $76.6 billion.[92] In the US 80% of people with hypertension are aware of their condition, 71% take some antihypertensive medication, but only 48% of people aware that they have hypertension adequately control it.[92] Adequate management of hypertension can be hampered by inadequacies in the diagnosis, treatment, and/or control of high blood pressure.[106] Health care providers face many obstacles to achieving blood pressure control, including resistance to taking multiple medications to reach blood pressure goals. People also face the challenges of adhering to medicine schedules and making lifestyle changes. Nonetheless, the achievement of blood pressure goals is possible, and most importantly, lowering blood pressure significantly reduces the risk of death due to heart disease and stroke, the development of other debilitating conditions, and the cost associated with advanced medical care.[107][108]
Selective radiofrequency ablation of the nerves supplying the kidneys, which employs a catheter-based device to cause thermal injury to the nerves surrounding the renal artery without affecting other sympathetic nerves, may lower blood pressure.[109] So far, major side effects have been relatively infrequent, although cases of renal artery dissection, femoral artery pseudoaneurysm, excessive decreases in blood pressure and heart rate are among the reported adverse effects.[109] It has been suggested that renal nerve ablation may have a role in the management of resistant hypertension but its long term efficacy and safety have not been evaluated.[109] However, a 2014 trial failed to confirm a beneficial effect.[110]
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Further reading[edit]
- James, Paul A. (18 December 2013). "2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults". JAMA 311 (5): 507–20. doi:10.1001/jama.2013.284427. PMID 24352797.
External links[edit]
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Kevyn Orr requests formal appraisal of the DIA's collection
The eyes of the art world are trained on Woodward Avenue in Detroit, on the Detroit Institute of Arts.
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2012 Films I enjoyed:
- The Grey.
- Chronicle.
- 21 Jump Street - A pleasant surprise and a source of new-found fondness for Tatum.
- The Cabin in the Woods.
- The Raid: Redemption.
- Dredd - Well done, . And other people, I suppose.
Films that were merely 'okay':
- Haywire.
- Underworld: Awakening (eh, it's dumb fun and remains largely inoffensive)
- Project X - Moderation is a fatal thing. Nothing succeeds like excess.
- The Hunger Games - Is an all-round 'solid' film weakened by some poorly shot action sequences. But, hey, have to stay within the boundaries of the rating.
- Lawless.
- Looper - In all honesty, the film is hindered by a seemingly bizarre change of pace and direction, an uninspired milieu, and more paradoxes than... something with many paradoxes.
- The Innkeepers - Wait, what? A half-hearted crescendo superbly suits the anticlimactic finish. My main grievance lies with the pacing. It quite simply isn't comparable to the oddly polarizing The House of the Devil.
- The Awakening - Rebecca Hall is real pretty. Dominic West is also awful pretty.
Films that I did not enjoy:
- Coriolanus - I admittedly had high expectations, but this this film ended up more desiccated than the Great Sandy Desert. A really uncomfortable and generally stilted film.
- The Woman in Black - The acme of tepid horror commonality.
- Wanderlust - Insipid and crammed full with sentimentality.
- Jeff, Who Lives at Home - I really wanted to enjoy the film, but it turned out to be a rather flagrantly factory-like, generic performance.
- American Reunion - A rote and unimaginative experience.
- Battleship - An experience akin to being continuously struck in the face while in a raucous dance club.
- Men in Black 3 - Dull. Dull. Dull. Dull.
- Ted - Seth McFarlane is still Seth McFarlane.
- The Watch - A display of pleasant chemistry reminiscent of the initial Russian Roulette scene in The Deer Hunter.
- Total Recall - Totally devoid of all the elements that made the original likeable: Charming characters, a tongue-in-cheek approach, and action sequences striving to personalise themselves (in the standard Schwarzenegger fashion). Yo, DON'T BE SO SERIOUS, FILM!
- The Bourne Legacy - It just doesn't justify its own existence.
- The Campaign - What a waste of a commercially successful, comedically experienced cast. Poor writing is an effective way to kill a film.
- The Expendable 2 - This film is indeed more expendable.
Films that I acknowledge as having respectable merit but personally found wanting:
Again, I recognise that these films are of a high quality, but I personally felt were incomplete or misguided in some way.
- The Avengers - Tonally displeasing.
- Prometheus - A film diluted by too many threads and not enough questions, and swamped by a morass of characters that aren't worth a damn. Charlize Theron is real purdy, though.
- The Dark Knight Rises - An unrewarding ending is hardly recompense for such a lengthy--and at times tedious--build-up. Also, Catwoman is simply non-essential and Bane is short-changed. Michael Caine is great, though.


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Gifts & Gift Cards
3.5 Inch Patch Holder Pages
$4.99For patches measuring up to 3 1/2 x 3 1/2 inches. Each plastic sheet holds six patches. Comes 6 sheets per package. Fits in any standard 3-ring binder. Check out Boy Scout and Cub Scout themed 3-ring binders 617638 and 617639. Learn More -
50 Miler Staff Shield
$5.99WARNING: Choking hazard. Small parts. Not for children under 3 years. Learn More -
50-Miler Domed Decal
$2.4950-Miler artwork is embossed on Mylar, printed in transparent inks, and capped with a polyurethane dome to create a beautiful 3-D effect. Measures 2 3/4" x 2 1/4". Learn More -
7-Ring Binder, CPD Logo
$29.99Leather planner with the CPD emblem debossed on front. Can use with the Frankline planner inserts. PVC cover, ID clear insert pouch. Pen loop, 50 lined page inserts. Measures 7" x 9.25" x 1". Learn More


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You can now get your free download of 'Fool For You ft Melanie Fiona' by signing up to the official Cee Lo Green mailing list below!
Posted: Mon 07 Feb 2011
Bring the love this Valentine's Day with THE LOVE EP! Featuring hits from Bruno Mars, Cee Lo Green, Trey Songz, Tank and Musiq Soulchild, THE LOVE EP will be available to download as of February 8th for $3.99. What's more, each artist will also have their own exclusive digital Valentine's Day card, allowing them to share the love with all their fans.
THE LOVE EP Tracklist Bruno Mars 'Our First Time' Musiq Soulchild 'So Beautiful' Tank 'You Mean That Much To Me' Cee Lo Green 'Fool For You' Trey Songz 'Make Love Tonight'
Posted: Tue 01 Feb 2011
Posted: Mon 31 Jan 2011
Cee Lo has just announced dates for his April European tour. Check below to see the dates and get your ticket now!
2 April: La Cigale, Paris - Buy Tickets 3 April: Trix, Antwerp - Buy Tickets 4 April: Melkweg, Amsterdam - Buy Tickets 6 April: Atelier, Luxembourg - Buy Tickets 8 April: Astra, Berlin - Buy Tickets 9 April: X-tra Club, Zurich - Buy Tickets 10 April: Muffathalle, Munich - Buy Tickets
Last week saw Cee Lo nominated for two Brit Awards for 'Best International Male Solo Artist' and 'Best International Album' for The Lady Killer. We can now announce that Cee Lo will be joining the likes of Take That, Rihanna and Plan B when he performs at the Brit Awards 2011 ceremony on February 15th at the O2! Make sure you tune in to ITV1 at 8pm on February 15th to watch the awards and see Cee Lo perform...you won't want to miss it!
Posted: Mon 24 Jan 2011
Cee Lo recently took Q Magazine through the records that have inspired his music and life, a collection that highlights his eclectic taste.
Click HERE to find out what made it into the list that includes everything from Dr Dre to The Stooges.
Cee Lo has unfortunately been forced to reschedule his imminent UK tour, due to scheduling difficulties.
The 5 date tour will now run as below:
March 26th – Glasgow, ABC March 27th – Manchester, Academy March 28th – Birmingham, O2 Academy March 29th – London, O2 Shepherd's Bush Empire March 31st – Bristol, O2 Academy
If you have already bought tickets to the show, these will still be valid. A few remaining tickets are still available to buy from the OFFICIAL STORE.
Posted: Fri 21 Jan 2011
Cee Lo Green goes uncensored in his latest interview with The Daily Beast, discussing his recent Grammy nominations, music he admires (Billy Joel, Iggy Pop), and music he does not (Maroon 5). Read the interview on The Daily Beast here.
Posted: Thu 20 Jan 2011
Cee Lo has been nominated for Best International Male Solo Artist and Best International Album for The Lady Killer at this years Brit Awards!
You can see who Cee Lo's up against in a full list of nominees here.
Posted: Fri 14 Jan 2011
Retrouvez Cee Lo Green dans l'émission Taratata ce vendredi 14 Janvier sur France 2 à 1h10!
Posted: Thu 13 Jan 2011
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RT @sxsw: Don't miss the SXSW interview w/ @CeeLoGreen this coming Saturday, March 15! http://t.co/nR7CDLD89e #sxswmusicMon, 10 Mar 2014 19:23:33 GMT
Check out my feature with @tmagazine for the "Take Two: A dual review of what's new" http://t.co/yxeW3FByhQSun, 09 Mar 2014 19:09:58 GMT
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Handicapped Travel Club, Inc. Get Out And Live! (G. O. A. L.) "Fun and Fellowship" is our motto. | ||
If there are things that you would like to see on the web site, any corrections that need to be made, or if you find broken links, please let me know by emailing me here: webmaster @ handicappedtravelclub.com (Please put 'HTC' at the beginning of the subject line.) Thanks, Brad Bartz |


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The Orange Houses
ISBN 9780142419823 | 176 pages | 01 Sep 2011 | Speak | 8.26 x 5.23in | 14 - AND UP years
Summary of The Orange Houses
Summary of The Orange Houses
Reviews for The Orange Houses
An Excerpt from The Orange Houses
Tamika Sykes, AKA Mik, is hearing impaired and way too smart for her West Bronx high school. She copes by reading lips and selling homework answers, and looks forward to the time each day when she can be alone in her room drawing. She's a tough girl who mostly keeps to herself and can shut anyone out with the click of her hearing aid. But then she meets Fatima, a teenage refugee who sells newspapers, and Jimmi, a homeless vet who is shunned by the rest of the community, and her life takes an unexpected turn.
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Eric Allen Ravotti
Position: LB
Height: 6-3 Weight: 250 lbs.
Born: March 16, 1971 in Freeport, PA
College: Penn St. (school history)
Drafted by the Pittsburgh Steelers in the 6th round (180th overall) of the 1994 NFL Draft.
Weighted Career AV (100-95-...): 3 (10215th overall since 1950)
Sponsor this page for $5 and help Pro-Football-Reference.com provide this service. Your message will replace this ad.


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Please Note: By clicking a link to any resource listed on this page, you will be leaving the TeensHealth site.
American Academy of Pediatrics (AAP)
The AAP is committed to the health and well-being of infants, adolescents, and young adults. The website offers news articles and tips on health for families.
Go Ask Alice!
Go Ask Alice! is Columbia University's health question and answer service. It offers open and frank discussions of sensitive topics.


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TOP FOOD BLOGDropbox
One of my favorite online services is Dropbox. This service allows me to seamlessly synchronize files between computers with 2 GB of online storage. And the beauty of all this... is that it's FREE! Click the link below to get started (and to get an extra 250 MB of online storage). DropboxFind me on Facebook!
All content on this blog is copyrighted and licensed under the Creative Commons Attribution-NoDerivs 3.0 Unported License. In layman's terms, if you want to use all or part of any blog posts, please contact me and ask. Chances are good that I'll be happy to let you use content in your own works in return for a link back to this blog.
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Tag Archives: American Royal
Jesse Black's "My American Royal"
Last weekend one of the most prestigious sets of BBQ competitions took place – the American Royal Invitational and Open contests. Going to this contest has been on my BBQ bucket list ever since getting into the world of BBQ. Until I get to do so, I'll just have to live vicariously through others. Big Al of Canadian Bakin' BBQ Team wrote about his experiences competing at the contest last week. Today I'm absolutely thrilled to present a new perspective about the American Royal experience. Let's check out "My American Royal" by Jesse Black of Thermoworks.


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Things to see and do - Schwäbisch Gmünd
Leaving for Germany
Where to sleep?
Schwäbisch Gmünd Hotel tips
Hotel Pelikan from62 €
Book -
Hotel Fortuna from75 €
Book -
Hotel Einhorn from69 €
Schwäbisch Gmünd Travel guide
Schwäbisch Gmünd : Michelin's recommendations
This former imperial city lies in the Rems Valley, a popular destination for day trippers. The Roman colony of Gamundia, first mentioned in 782, was granted its town charter by Konrad III (1138-1152) of the Hohenstaufen dynasty. Traditionally, Swäbisch Gmünd is a centre for the working of precious metals. Today the «city of gold and silver» numbers some 70 gold- and silversmiths. Their cutlery, dishes and chandeliers grace the finest tables.
Tourist attractions Schwäbisch Gmünd : Things to see and do
Holy Cross Cathedral, Schwäbisch Gmünd
D - 73525 Schwäbisch Gmünd
We are surprised by the absence of towers in this 14C cathedral. The interior is a perfect hall with the chancel easily distinguishable from the nave by virtue of its more intricately worked ribbed vaulting. The edifice houses many masterpieces.The c..
D - 73525 Schwäbisch Gmünd
The decidedly Baroque character of this square is further emphasized by the prosperous-looking houses overlooking it and the fountain dedicated to the Virgin. Several half-timbered houses, the hospital and the «Gräth» (the old town hall) nevertheless..
Hotels Schwäbisch Gmünd
Hotel Pelikan
Türlensteg 9 D - 73525 Schwäbisch Gmünd
Offering cosy rooms and free wireless internet access, this hotel is located directly on Schwäbisch Gmünd's historic market square. The Hotel Pelikan provides spacious, brightly furnished rooms in the heart of the old quarter. All rooms have free Wi..
Hotel Einhorn
Rinderbachergasse 10 D - 73525 Schwäbisch Gmünd
Set in a a historic, 12th-century building, this boutique hotel offers elegant rooms with free Wi-Fi. It is located in the Old Town district of Schwäbish-Gmünd, just 100 metres from the Market Square. The Baroque-style rooms at the Hotel Einhorn inc..
Hotel Fortuna
Hauberweg 4 D - 73525 Schwäbisch Gmünd
This hotel is situated near to the River Rems and provides a spacious spa area. In just a few minutes from here you can reach the historical square, which is the historical centre of the town Schwäbisch Gmünd.
Restaurants Schwäbisch Gmünd
Münstergasse 2 D - 73525 Schwäbisch Gmünd
Both the setting and the cuisine at Fuggerei are perfect. The first thanks to the beautiful old vaulted ceiling, the second as a result of Armin Wiedmann's delicious food. Whether you go for one of the various roast joints or the 10-course 'Amuse Gue..


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Decorate for your Derby Day party with our 17" foil horseshoe. Each 17" gold foil horseshoe is printed on both sides and sold by the piece. Please order in increments of 1 piece.
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Catalogue entry
[from] Nos. 487–500: Sketches of Coast and other Scenes, c. 1840–5?
THESE fourteen sketches on millboard were discovered in the early 1960s in a parcel among the works from the Turner Bequest transferred from the Tate Gallery to the British Museum in 1931; they had not been numbered or included in Finberg's 1909 Inventory. They fall into three groups according to size, approx. 10 1/2 × 12 in., 9 3/4 × 13 1/2 in. and 12 × 19 in., but form a homogeneous group technically and stylistically. Two further sketches from the same parcel are distinct in style, technique and the type of millboard used (see Nos. 485 [D36676] and 486 [D36680]). Ship in a Storm (No. 489 [D36682]) is close in composition to Snow Storm—Steam-Boat off a Harbour Mouth, exhibited in 1842 (see No… (read more)


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- Musician's Friend Best Selection, Price & Service. Guaranteed.
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Private Reserve Guitars 866-926-1923
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MIDI switcher with eight programmable loops for multiple applications.
The Rocktron Patchmate Loop 8 is a MIDI Switcher that comes with 8 programmable loops you can configure for multiple applications. Popular uses are amp channel switching, effects loops, guitar routing and realtime control of guitar effects.
The Patchmate Loop 8 is easy to set up and program with realtime user controls. Store patches using the front panel loop buttons. Using MIDI gives you unlimited control possibilities, by using continuous controller messages from the Rocktron All Access foot controller.
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A buffered analog input with front and rear feed thru is standard. The Patchmate Loop 8 may be set to any midi channel and contains 128 presets for use with any MIDI foot controller. The unit has MIDI in/out and thru capabilities.
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Comments about Rocktron Patchmate Loop 8 MIDI Switcher:
Quite simply the best in it's price range for a looper with midi switching capabilities. It is easier to program than most and is quite cheap for all that it doesReally impressed with the quality etc,I don't really know what else to say except if you are in the market for one of these things this is a very easy to use and simple unit that will get any job done quietly and of course awesomelythnaks!
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Today Only: Free Slurpees!
Sorry, this deal is expired.
The best deals can go quickly and don't always last as long as we first thought. Prices and inventory can be very fluid. There are many great deals that are still active.
See more active 7-Eleven Deals or deals filed under:
Today Only: Free Slurpees!
Today only, select 7-11 Stores will be giving out free 7.11oz Slurpees. This is in honor of what 7-11 is deeming "Purple Friday". There is no coupon necessary so you can just head on over to a participating store. The offer is only valid today so use their store locator to find a participating store near you!


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FREE SHIPPING! on All Orders $50 or More. *Limited to domestic US orders only.
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RECIPE BOX // SHOPPING CART 0 items - $0.00 // CHECKOUT // SHOPPING LIST // ORDER STATUSWilton's strict testing standards ensure the highest quality disposable bags you can buy. Our proprietary blend of materials helps Wilton bags feel more comfortable and outperform competitive bags. They can be used with or without a coupler and work great for microwave-melting and piping of Candy Melts. Fits standard tips and couplers. Just use, then toss! Instructions included.
Now in a convenient Value Pack! These dispenser boxes makes it easy to pull out one bag at a time, so you can keep your decorating space uncluttered.


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A marijuana grow was uncovered inside a Puyallup home Wednesday morning after the house caught fire.
Someone renting the home in the 800 block of 5th Street Southeast called 911 about 8:25 a.m. to report seeing smoke coming from the roof. Fire crews were able to quickly knock down the blaze.
No one was injured. Investigators haven't determined what started the fire, but it is believed to be accidental, Central Pierce Fire & Rescue Assistant Chief Randy Stephens said.
Puyallup police are handling the marijuana investigation.
Police Capt. Scott Engle said a number of plants were being grown in one of the bedrooms.
Evidence of the marijuana grow was seized from the house, and a report will be sent to Pierce County prosecutors for consideration of criminal charges, Engle said.


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More copies of this ISBNThis title in other editionsOther titles in the Miles Vorkosigan Adventures series:Cordelia's Honor (Hugo Winners)by Lois M Bujold
Synopses & ReviewsPublisher Comments:When Enemies Become More than Friends — THEY WIN
In her first trial by fire, Cordelia Naismith captained a throwaway ship of the Betan Expeditionary Force on a mission to destroy an enemy armada. Discovering deception within deception, treachery within treachery, she was forced into a separate peace with her chief opponent, Lord Aral Vorkosigan — he who was called "The Butcher of Komarr" — and would consequently become an outcast on her own planet and the Lady Vorkosigan on his.
Sick of combat and betrayal, she was ready to settle down to a quiet life, interrupted only by the occasional ceremonial appearances required of the Lady Vorkosigan. But when the Emperor died, Aral became guardian of the infant heir to the imperial throne of Barrayar — and the target of high-tech assassins in a dynastic civil war that was reminiscent of Earth's Middle Ages, but fought with up-to-the minute biowar technology. Neither Aral nor Cordelia guessed the part that their cell-damaged unborn would play in Barrayari's bloody legacy.
Table of ContentsShards of honor — Barrayar.
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AHS Boys Soccer at Chisholm Trail; JV-7:30 P.M. V-5:30 P.M.
The Community News • P.O. Box 1031 • 203 Pecan Dr. • Aledo, TX 76008 • 817-441-7661 • FAX: 817-441-5419
The Bearcat/Ladycat Soccer Camp Session III: Bearcats/Ladycats grades 6 through incoming freshmen will be from 9 to 11:30 a.m. Week 1 is June 4 through 7 and Week 2 is June 11 through 14 at the Aledo High School. Cost is $85. Receive a $10 discount if siblings sign up together. Receive a $20 discount if you register for both weeks of camp (only one discount per family). For more information call Coach Derek Vierling at 817-312-8540 or Coach Bryan Johnson at 817-528-6291.
Attachment | Size |
AISD Soccer Camp.pdf | 169.17 KB |
AHS Boys Soccer at Chisholm Trail; JV-7:30 P.M. V-5:30 P.M.
AHS Girls Soccer at Chisholm trail; V-7:30
Aledo Varsity Tennis hosts the Aledo Tournament
Aledo Varsity Track & Field will compete at the Aledo Track & Field Meet.
Aledo Girls Varsity Golf is competing in the Arlington Heights Invitational at Pecan Valley
Aledo Varsity Track & Field will compete at the Saginaw Track & Field Meet.
Aledo Varsity Tennis at the Crowley Tournament
Aledo Boys Varsity Golf is competing in the Tiger Cup at Walnut Creek in Mansfield (Power)
Aledo Varsity Track & Field (QUALIFIERS ONLY) will compete at Texas Relays.
Aledo Varsity Tennis competes in the District Tournament at TCU


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Last updated on 03/13/14 UTC
Albemarle Overview
Coldwell Banker Helps You Learn More About Albemarle, North Carolina Real Estate
Albemarle, North Carolina is located in Stanly. Nearby cities and towns include Aquadale, Badin, Millingport, New London and Richfield. Albemarle is a suburban community with a population of 16,258. The median household income in Albemarle is $37,933. 58% of residents are married and families with children reside in 30% of Albemarle households. Half the population of Albemarle commutes 14 minutes or more to work, with 77% of residents holding white collar jobs and 23% residents holding blue collar jobs.
The median age of homes in Albemarle, NC is 38 years, with 51% of those homes owned, 34% rented and 14% not occupied. In the previous year, 0 Albemarle properties were sold. The median sale price of a home in Albemarle in the previous year was $79,000. Find a Coldwell Banker real estate agent in Albemarle, North Carolina today.
Homes for Sale around Albemarle
1214 Ridge St
Albemarle, NC 28001
3 Beds, 2 Baths -
Albemarle, NC 28001
4 Beds, 2 Baths -
807 Pee Dee Avenue
Albemarle, NC 28001
4 Beds, 2 Baths -
612 E Cannon Avenue
Albemarle, NC 28001
2 Beds, 2 Baths -
1005 Avondale Ave
Albemarle, NC 28001
3 Beds, 1 Baths -
230 N. 6th Street
Albemarle, NC 28001
3 Beds, 1 Baths -
403 Park Ridge Road
Albemarle, NC 28001
3 Beds, 3 Baths -
342 Park Road
Albemarle, NC 28001
2 Beds, 1 Baths
North Carolina Demographics Data
Albemarle Demographics Data
North Carolina Real Estate Statistics
Albemarle Real Estate Statistics
Albemarle Real Estate Offices
Real Estate Careers Near Albemarle
Sales Associate,
Coldwell Banker Triad, Realtors |
High Point, NC
Coldwell Banker Triad, Realtors, located in High Point, NC A career in real estate can be exciting and very rewarding both personally and financially. To test drive a career in real estate, visit our website at http:...
Real Estate Sales Associate,
Coldwell Banker United, Realtors |
Indian Trail, NC
Coldwell Banker United, Realtors, located in Indian Trail, NC We are looking for serious, career-minded individuals that are self-motivated to learn the real estate business. We are looking for individuals that enjoy wor...
Albemarle Real Estate Agents


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Published March 16, 2013, 12:00 AM
Discovery of stink bug in Duluth may mean problems for Northland homes, crops
Its name is no joke. The brown marmorated stink bug really does give off a stink when disturbed. Even more disturbing: It's been discovered in St. Louis County for the first time.By: Jana Hollingsworth, Duluth News Tribune


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English description about our JUG
by badr on mar, 07/19/2011 - 22:43
The Morocco JUG (Java User Group in Morocco) aims to provide a platform for all Java enthusiasts to network, exchange ideas, share knowledge and help each other in order to strengthen the Java community in Morocco. We also help engineering school and univerity in defining good java courses and worshops. Our members come from Morocco's considerable high tech community and multiple universities. We encourage anybody from beginner to expert interested in Java and related technologies to join us.
MoroccoJUG is led by :
- Badr ElHouary: firstname.lastname@example.com
- Faissal Boutaounte: email@example.com


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Ethan Garrison
Ht.: 6-0
Hometown: Concord, NC
Previous School: Cox Mill HS
Eligibility: So. Major: Sports Medicine
Ethan Garrison enters his second season at Pfeiffer.
Personal: Son of Tammy & Earl Garrison…Born on October 22nd, 1994…Majoring in Sports Medicine.
Pfeiffer University Academic and Swimming Highlights:
Freshman Year: Queens University of Charlotte- top 5 finishes in 100m back
High School Swimming Highlights:
Selected all-regional and all-conference as well as the MVP (sophomore-senior year).
High School Awards and Honors:
A/B honor roll all four years.


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Credits & Info
- Uploaded
- Dec 18, 2012 | 11:20 AM EST
Author Comments
When Tony Stark was in high school, he was gifted with all the powers of an iron. Now, as the Amazing Iron-Man, he must battle adversaries as fearsome as the Crease and his own chafing buttocks, with abilities as diverse and captivating as Resemble an Iron and Emit Steam.
If you want to collab on something, please don't hesitate to contact me!
Animation and voices by Blitzgerald
Music by Jack Kerrigan
Sound effects from freesfx.com and other similarly shite places
Rated 5 / 5 stars November 7, 2013
At first I was going to say what is this crud....BUT this is REALLY AWESOME THEN MY CRUD ...
I never thought of an amalgamate character like spider-man meets iron man together would be so great and funny and in a comedic way too... WOW spot on
Rated 5 / 5 stars December 19, 2012
This is one of the funniest parodies I have seen in a long time on here. So well done sir, well done ! 5 all the way
Rated 5 / 5 stars December 19, 2012
XD, that was random/epic.
I loved the intro.
Your video, is saved!
5 stars/5 score.
"The Audiophile".
Rated 5 / 5 stars December 19, 2012
Yup! This is how it really happened! Nice animation!!!
Rated 5 / 5 stars December 18, 2012
That was a hilarious Iron Man parody. And I have to say I havent seen one done like this. Props for being original and funny.. . One thing bugs me though..So what IS the difference between gingers and redheads?? :3


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Apple's white iPhone 4 is available beginning April 28 from Apple's online store, at Apple's retail stores, AT&T and Verizon Wireless stores and select Apple Authorized Resellers.
White iPone 4 is available in the US for a suggested retail price of US$199 for the 16GB model and US$299 for the 32GB model.
The long-awaited device is available now in Austria, Australia, Belgium, Canada, China, Czech Republic, Denmark, Finland, France, Germany, Hong Kong, Ireland, Italy, Japan, Luxembourg, Macau, Netherlands, New Zealand, Norway, Singapore, South Korea, Spain, Switzerland, Sweden, Taiwan, Thailand and the UK.
- Trends in the upstream LED equipment and materials industries, 2H13
This report examines the outlook for upstream, which includes MOCVD equipment, rare earth materials and sapphire substrates, is also particularly significant as an indicator of trends in the LED industry as a whole over the next year.
- Global AMOLED market analysis and forecast, 2011-2015
This report analyzes the current state of development and strategies of the two largest AMOLED panel makers, Samsung and LG Display, examines the potential of the AMOLED handset panel and OLED TV markets, and takes an in-depth look at the competitiveness of S. Korea in the AMOLED sector.


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Lynn Hall Memorial Park is located on Fort Myers Beach, just north of the foot of Matanzas Pass Bridge, next to "Times Square" in the heart of downtown.
This lively gulf front park is conveniently located adjacent to shopping and restaurants. It features a licensed fishing pier with bait/gift shop, shelters with grills for picnicking (available on a first come first serve basis only), a ship shaped playground for the youngsters, outdoor freshwater rinse off showers and restrooms with changing facilities. There are more than 100, first-come first-serve, park, pay & display parking spaces available within the park at $2 per hour. Time is sold in increments of one hour up to the maximum time allowed, no partial hours. Payment accepted in nickels, dimes, quarters, one dollar coins and $1 and $5 bills, however NO change is given or provided. Maximum vehicle length 20 feet, no trailer parking permitted.Location
More Details
Restrooms | Picnic Area | Concessions | Grills | Showers |
Fishing | Trails | Shelling | Rentals | Parking Fee |
Sunday | Monday | Tuesday | Wednesday | Thursday | Friday | Saturday | |
Opens | 6AM | 6AM | 6AM | 6AM | 6AM | 6AM | 6AM |
Closes | 11PM | 11PM | 11PM | 11PM | 11PM | 11PM | 11PM |
- Andy Rosse Lane Park
- Barefoot Beach
- Bluebill Beach
- Boca Grande Beach
- Bonita Beach
- Bowditch Point Recreational Park
- Bowman's Beach
- Bunche Beach
- Cape Romano/Kice Island
- Captiva
- Clam Pass
- Conner Park
- Delnor-Wiggins Pass State Park
- Dog Beach
- Estero Island Beach
- Fort Myers Beach (Lynn Hall Memorial Park)
- Gulf Shore Beach
- Gulfside City Park - Sanibel
- Keewaydin Island
- Lovers Key State Park
- Lowdermilk Beach Park
- Lynn Hall Park
- Naples Beach
- Residents Beach
- Sanibel
- Sanibel Causeway Islands
- South Marco Beach
- Tigertail Beach
- Turner Beach
- Vanderbilt Beach
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David McCord poetA prolific poet of children's verse, McCord wrote or edited more than 40 books, including One at a Time, On Occasion and What Cheer. Born: 1897Died: 1997 Information Please® Database, © 2007 Pearson Education, Inc. All rights reserved.
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March 11, 2014
Four wheeler accidents have killed three dozen people in West Virginia this year! Do you know what to look for before buying a used four wheeler? Here is some advice to help keep your family safe.
Last year 40 people were killed on four-wheelers in West Virginia. It's an all-time record.
If you factor in the deaths with the population West Virginia has the highest death rate with four wheelers in the country.
Ryan Atkins is replacing the tires on his buddy's used four wheeler giving it the once over before it's back in service.
Ryan talks about what to look for, "You'll check the brakes when you replace the tires. Anytime you have the wheels off you tend to look at those things and make sure. You know, everyone wants to stop."
It's state law every year your car gets inspected for possible problems. Not the case with four wheelers. Once it leaves the lot, it's anybody's guess.
Dwayne Maynard says, "The biggest mistake people make is buying a used four wheeler with their heart and not their head."
Too often, simple maintenance is ignored and problems go undetected.
What are some of the things they should look for just to make sure it is safe?
Dwayne, "Cracked frames, see if handle bars been bent to see if it's been rolled. It could have weakened the weld on anything on it."
Ryan Atkins says, "Check your brake fluid."
A few hours up on a lift can make the all the difference between whether your ride is safe or an accident waiting to happen.


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