text:
DEMOForeign trade statistics
Business inteligence advice
Insurance and freight
Home Imports and exports Importers in MATAO LIBELL INDUSTRIA E COMERCIO DE BEBEDOUROS REFRIGERADOS MATAO Sao PauloTelephone number: (+55 #) Fax ID Email, nome do contato and website Address: AVENIDA ANTONIO GORGATTI 359 District: D.I. ADOLFO BALDAN Locality: MATAO State: Sao Paulo Zip Code: 15991-315 Country: Brasil Activities: Imports Years of operations of Foreign Trade: 2011, 2009, 2008, 2001 Until 10 products (HS CODES) imported by the company LIBELL INDUSTRIA E COMERCIO DE BEBEDOUROS REFRIGERADOS and another Importers of related products of BrazilWithout hs code sample online for this company See the complete reports of LIBELL INDUSTRIA E COMERCIO DE BEBEDOUROS REFRIGERADOS |
Customs data: Trade data reports - ComexLIBELL INDUSTRIA E COMERCIO DE BEBEDOUROS REFRIGERADOS does not currently advertise comprehensive company & product information with Comxport Trade Data. We cannot guarantee the accuracy of company and product information. ServicesDEMOForeign trade statistics Business inteligence advice Incoterms Insurance and freight CompaniesBuyers and sellers of this areaWorld companies, South Korea, United States of America, China, Mexico, Argentina, Bolivia, Brasil, Chile, Colombia, Costa Rica, Ecuador, El Salvador, India, Panama, Paraguay, Peru, Uruguay, Venezuela ContentUpdate the company detailsRemove company of the web-site Terms and conditions Contact Comxport Trade Data | Foreign trade |


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EMERGENCY: Downtown Manhattan restaurant recommendation??
- 10
- Follow
Dear Chowhound:
I need to find a restaurant to take my wife to for her 40th birthday (dinner, just the two of us). Can you help me figure out where to go? I'm overwhelmed with options. Here's my criteria:
• Should be in downtown Manhattan (East/West Village, LES, Tribeca, etc.)
• Should have great atmosphere (and, obviously, awesome food)
• Can be expensive (but preferably not break-the-bank, Jean-Georges-expensive)
• Above all, it should be a really special/memorable place, not just another pretty-good, pretty-fancy restaurant
Any suggestions you have would be deeply appreciated!
re: kathryn
Dinner date: Saturday the 22nd. Time is flexible, though earlier side is better.
Your $$ sounds correct, yes.
And, yes, 14th St and below. (Though this is kind of arbitrary. We'd go further uptown if there's some perfect place. I just didn't want to end up in Midtown....)
In addition to Atera and Bouley, for downtown (Tribeca), I highly recommend Jungsik. The "choice" menu (a la carte) should not be too expensive. If Atera and Bouley are in budget, the "tasting" menu at Jungsik is wonderful too.
0 -

subset: commoncrawl


text:
Superintendent Brent Lehman gave the annual State of the School address Monday during a Decatur Chamber of Commerce lunceon at Woodcrest Nursing Center.
"What makes North Adams such a great school district is the level of teamwork, and the relationships between parents, staff, administrators and students," Lehman emphasized.
"There is not one of us that can solve any problem, but collectively we can solve anything. If we didn't work collectively, the wheels would fall off and we would stop moving forward," Lehman explained.
For the complete story, see today's print or online editions.
[1] http://www.decaturdailydemocrat.com/sites/default/files/Lehman%20at%20State%20of%20Schools.jpg


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If the term "apartheid" shames the establishment into acting -- and prompts pundits to utter the word "race" when discussing inequality -- then by all means let's use the unflattering comparison. It's a fitting way of bearing witness to the life and times of Michael B and everyone else who has suffered under this abhorrent system.
The Dominican state is 10 years into a process of constructing a system of legal apartheid for Dominicans born to Haitian parents. This group of second- and third-generation Dominicans has always faced opposition to being fully recognized as Dominican citizens, but their government appears intent on legally cementing this discrimination -- and is increasingly close to this goal.
Although I had seen townships in other parts of the world, there was something about the scale of this place that left me dumbfounded. I later learnt that these tiny boxes made of corrugated-iron, plastic sheeting and scraps of wood, which precariously sat on top of one another, were home to over 2 million people.
The election of Barack Obama was the Lexington and Concord in the latest great battle of race in America. We are a nation at war with itself. For all of our desire to move beyond the narrow confines of many of the events of our tragic history, we cannot. The president's election gave new life to what had been lying dangerously dormant for the better part of 50 years.
From voter suppression laws being passed in the light of day in state houses around the country and the political assault on women's reproductive rights to the racial wealth gap, there are disturbing signs that our nation's baby steps towards political, social and economic inclusion could be stalling.


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100 % Natural Cereal, with oats, honey and raisins, Quaker
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Fruit & Fibre (fiber) Harvest Medley
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Fruit & Fibre (fiber) with peaches, raisins, almonds and oat clusters
Fruit & Fibre (fiber) with tropical fruit (pineapple, bananas, and coconut)
Fruit Rings
Fruit Wheats
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Fruitful Bran
Fruity Marshmallow Krispies (formerly called Marshmallow Krispies)
Fruity Pebbles
Fruity Yummy Mummy cereal
G-I Joe Action Stars
Golden Crisp (Formerly called Super Golden Crisp)
Golden Grahams
Golden Harvest Proteinola
Granola with Raisins, lowfat, Kellogg's
Granola, homemade
Granola, lowfat, Kellogg's
Grape-Nut Flakes
Great Grains Double Pecan Whole Grain Cereal, Post
Great Grains, Raisin, Date, and Pecan Whole Grain Cereal, Post
Healthy Choice Almond Crunch with raisins, Kellogg's
Healthy Choice Multi-Grain Flakes, Kellogg's
Healthy Choice Multi-Grain Squares, Kellogg's
Heartland Natural Cereal, plain
Heartland Natural Cereal, with coconut
Heartland Natural Cereal, with raisins
Heartwise with fruit nuggets
Heartwise, plain
Hidden Treasures, General Mills
Honey Bran
Honey Bunches of Oats
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Honey Crunch Corn Flakes, Kellogg's
Honey Graham Chex
Honey Nut Cheerios
Honey Smacks
Honeycomb, plain
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Hot Wheels
Jenny O's
Jetsons Cereal
Just Right
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Kashi cereal, NS as to ready to eat or cooked
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Kenmei Rice Bran, plain, Kelloggs
King Vitamin
Life (plain and cinnamon)
Lucky Charms
Malt-O-Meal Coco-Roos
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Malt-O-Meal Golden Puffs (formerly Sugar Puffs)
Malt-O-Meal Honey and Nut Toasty O's
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Malt-O-Meal Toasted Oat Cereal
Malt-O-meal Tootie Fruities
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Mini Buns Cereal (cinnamon)
Morning Funnies Cereal
Muesli with apples and almonds, Ralston Purina
Muesli with raisins, dates, and almonds
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Mueslix cereal
Mueslix with raisins, walnuts, and cranberries
Multi Bran Chex
Multi Grain Cheerios
Natural Bran Flakes, Post (formerly called 40% Bran Flakes, Post)
Natural Muesli, Jenny's Cuisine
Nature Valley Granola, toasted oat mixture
Nature Valley Granola, with cinnamon and raisins
Nature Valley Granola, with fruit and nuts
Nintendo Cereal System
Nu System Cuisine Toasted Grain Circles
Nut & Honey Crunch Biscuits Cereal
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Nutri-Grain Almond Raisin
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Quaker Oat Bran Cereal
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Raisin Bran, Total
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Reese's Peanut Butter Puffs cereal
Rice Chex
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Rice polishings
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Ripple Crisp Golden Corn
Ripple Crisp Honey Bran, General Mills
Rocky Road
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Shredded Wheat'N Bran
Shredded Wheat, 100%
Slimer! and The Real Ghost Busters
Smurf Magic Berries (formerly called Smurfberry Crunch)
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Sun Crunchers Cereal, General Mills
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Teenage Mutant Ninja Turtles Cereal
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ACP Internist® Weekly
Welcome to this week's issue of ACP Internist Weekly, an update for internists published every Tuesday by the American College of Physicians.
In the News for the Week of March 3, 2015
Low-, high-intensity workouts appear to reduce waist circumference
Patients at risk for diabetes or heart disease may want to choose their workout intensity based on health goals, according to a study. More...
NSAIDs may increase bleeding, CV events when combined with antiplatelet or anticoagulant agents post-MI
Nonsteroidal anti-inflammatory drugs (NSAIDs) were associated with increased risk of bleeding and thrombotic events, even during short-term treatment, among patients receiving antithrombotic therapy after myocardial infarction (MI), a study found. More...
Test yourself
MKSAP Quiz: persistent rash for 6 years' duration
A 66-year-old man is evaluated for a persistent rash for 6 years' duration. The rash waxes and wanes in severity, and it becomes pruritic only after he becomes hot and sweating, such as when he mows the lawn or exercises. It has always been limited to his back and lower chest. He has never treated it. The patient is otherwise well, has no other medical problems, and takes no medication. Following a physical exam, what is the most likely diagnosis? More...
Pressure ulcers
ACP issues pressure ulcer prevention, treatment guidelines
Guidelines on risk assessment, prevention, and treatment of pressure ulcers were issued by ACP this week. More...
Infectious diseases
IDSA releases 'Choosing Wisely' list
The Infectious Diseases Society of America (IDSA) last week released its list of tests or procedures whose necessity should be questioned, as part of the ABIM Foundation's Choosing Wisely initiative. More...
Internal Medicine Meeting 2015
Free mobile app for Internal Medicine Meeting 2015 available
The Internal Medicine Meeting 2015 app is now available for free for iPhone and Android smartphones, as well as iPad and Android tablet devices. More...
ACP Annual Business Meeting to be held at Internal Medicine Meeting 2015
All members are encouraged to attend ACP's Annual Business Meeting to be held during ACP Internal Medicine Meeting 2015. Current College Officers will retire from office, and incoming Officers and new Regents and Governors will be introduced. More...
ACP Leadership Academy offering free webinars
ACP Leadership Academy is offering free webinars on leadership topics relevant to internal medicine. The webinars provide an educational experience and discussion forum for participants to learn, pose questions, and share ideas with leaders in the internal medicine field. More...
Survey about how physicians learn
On behalf of the Society for General Internal Medicine, ACP is making available to its members a survey that is part of a project funded by the Agency for Healthcare Research and Quality and Patient-Centered Outcomes Research Institute. More...
Cartoon caption contest
Put words in our mouth
ACP Internist Weekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...
Physician editor: Daisy Smith, MD, FACP
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Copyright © by American College of Physicians.
Test yourself
A 66-year-old man is evaluated for a persistent rash for 6 years' duration. The rash waxes and wanes in severity, and it becomes pruritic only after he becomes hot and sweating, such as when he mows the lawn or exercises. It has always been limited to his back and lower chest. He has never treated it. The patient is otherwise well, has no other medical problems, and takes no medication. Following a physical exam, what is the most likely diagnosis?
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To help you and your practice make a smooth and successful transition to ICD-10 coding, ACP and ICD-10 content developers have created multiple resources available at discounted rates for ACP members.


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SUMMARY: Seems like everyone is trying to make an extra buck these days by renting out their email list. Worldata's Jay Schwedelson says, "We've seen exponential growth of the number of list on the market.18 months ago there were 3,000-4,000. Now it's literally close to 20,000."
Lots of those lists are "garbage" and many are selling for bottom-of-the-barrel pricing. Here is useful advice on how to put your list on the market the "right" way, so anti-spam advocates will not hate you, and so you actually make a decent profit. |
Get the latest research on email, lead gen, and social media along with MarketingSherpa updates and promotions.
Three Takeaways on Customer-centric Marketing from Email Summit 2015 Media Center
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Email Summit 2015:
February 23-26
Aria Resort & Casino Las Vegas
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Enter to Win »
The Membership Economy by Robbie Kellman Baxter


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POR Mornings
Monday, August 5, 201308/05/2013
Nick tries to do some impressions
For Bad Impression Monday Jon, and Rachel challenge Nick to impersonate a few random famous voices!
Monday, August 5, 201308/05/2013
How can a baby spend $4.5 million a year???
Jon, Rachel, and Nick talk about Simon Cowell's plan to pay his "baby mama" 4.5 million dollars a year in…
Friday, August 2, 201308/02/2013
A report of a shark off the coast of Wells beach stirred up a media frenzy (get it? Frenzy HA!)…
Friday, August 2, 201308/02/2013
Kenny Chesney makes pretty words come out of his mouth
The morning crew discusses the idiotic comment of Philadelphia Eagles wide receiver Riley Cooper, and what Kenny Chesney says about…
Friday, August 2, 201308/02/2013
This…. is American Idol…. tryouts
Our friend Chris Dipretoro is at the audition for American Idol today at Gillette stadium. He gives the morning the…
Thursday, August 1, 201308/01/2013
Sharknado still taking a bite out of the ratings!
Jon Rachel and Nick discuss the success of the EPIC action movie Sharknado, and talk about the sordid affair that…
Wednesday, July 31, 201307/31/2013
Stop me if you've heard this one; a fox walks into an acupuncturist…
A suspected rabid fox was terrorizing South Portland the other day, Jon, Nick, and Rachel discuss the travels of the…
Wednesday, July 31, 201307/31/2013
Kip Moore joins the Morning Crew
Jon, Rachel, and Nick discuss Kip Moore's new single Hey Pretty Girl, his life in Hawaii, and they write a…
Friday, July 26, 201307/26/2013
You lost your cellphone WHERE???
The Morning Crew goes over a list of some of the most bizarre cell phone insurance claims for lost/damaged phones.
Friday, July 26, 201307/26/2013
Can you really put a price on love?
A woman is willing to give $10,000 to anyone who helps find her future husband, that is one high priced…


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All-Power America APC4003 Portable 28-gal Vertical Air Compressor
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Product Description
Available while supplies last.
Portable 28 Gallon Vertical Air Compressor
- Heavy duty high output direct drive pump
- Oil lubrication for extended life
- Durable cast iron cylinder
- Equiped with a regulator, quick-connect coupler and two gauges
- Thermal overload protection
- 3400 RPM induction motor
- 5 peak HP, 2.5 rated HP
- 120V, 60Hz, 15A
- 6.4 CFM at 40 PSI, 5.6 CFM at 90 PSI
- Maximum pressure: 125 PSI
Materials: | Steel, Plastic, Rubber | |
Weight: | 126.7 Pounds | |
Listing: | CSA Listed | |
Air Compressor Power Source Electric-powered compressors are most common and easiest to use in areas with a ready electric supply. Gas-powered compressors are a good choice in areas where electricity is limited or unavailable, but they should not be used in confined or unventilated areas. | Air Compressor Power Source | Electric Compressors |
Air Compressor Style Stationary compressors are designed to be bolted in a fixed area and wired directly to a building's electrical circuit, these are ideal for garages and workshops. Portable air compressors are perfect for jobs that require use of air tools like nail guns frequently, such as re-siding your home or building a deck. Pancake compressors are smaller and very easily portable, they're great for inflating and running small tools. Twin tank compressors can store more air so they don't have to run as often. | Air Compressor Style | Portable Compressors |
Air Compressor Tank Position The tank position, whether horizantal or vertical, is a matter of preference and space. Choose whichever one will fit your space better. | Air Compressor Tank Position | Vertical Tanks |
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Zacharia, P U and Nagaraja, D and Muniyappa, Y (1991) On the regular landing of tongue sole by purse seiners at Mangalore and Malpe, Karnataka coast. Marine Fisheries Information Service, Technical and Extension Series, 108 . pp. 14-15.
| PDF 285Kb |
Cynoglossusmacrostomus were landed by purse seiners at Malpe. Examination of the purse seine landing data at Mangalore and Malpe for the past five years showed the existence of an almost regular landing of sole at these centres during the months of September and October. This is in accordance with the occurrence of large shoals of Malabar sole in advanced stages of maturity along Calicut coast during the months of September and October
Item Type: | Article |
Uncontrolled Keywords: | Cynoglossusmacrostomus; regular landing of tongue sole; Mangalore; large shoals of Malabar sole |
Subjects: | Marine Fisheries > Fish landing |
Divisions: | CMFRI-Mangalore |
ID Code: | 4600 |
Deposited By: | INVALID USER |
Deposited On: | 15 Sep 2010 16:57 |
Last Modified: | 18 Jul 2011 15:44 |
Repository Staff Only: item control page


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My Wayfair |
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Towle Silversmiths Sterling Silver French Provincial 66 Piece Flatware Set
Special Offer:
56 Issues of Sports Illustrated Magazine
Included with your purchase - a $20 Value (Subscription and Rebate Info)
Towle Silversmiths Sterling Silver French Provincial 66 Piece Flatware Set
Weights & Dimensions
Finish: Sterling silver | Handle Finish: Silver |
Material: Sterling silver | Handle Material: Sterling silver |
Number of Items Included: 66 | Pieces Included: 12 salad forks, 12 place forks, 12 place knives with hollow handle, 12 teaspoons, 12 oval soup spoons, serving spoon, slotted spoon, serving fork, butter knife, sugar spoon, and pie server |
Pieces Per Place Setting: 5 | Number of People Served: 12 |
Rust Resistant: Yes | Microwave Safe: No |
Style: Formal | Handle Pattern: Bordered |
Dishwasher Safe: Yes | Country of Manufacture: United States |
Assembly Required: No | Additional Parts Required: No |
About the Manufacturer
Since 1690, Towle Silversmiths has prided itself in constructing the finest crafted silverware. With a history longer than that of the United States, Towle Silversmiths remains an industry leader after 300 years. This remarkable heritage is reflected in the outstanding character, magnificent detail, and incredible balance of every piece bearing the Towle name.Towle Silversmiths Sterling Silver French Provincial 66 Piece Flatware Set
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Sterling Silver French Provincial 66 Piece Flatware Set is also sometimes listed under the following manufacturer numbers: T0366610


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MUK LUKS Neal Cable Full Foot Slipper (Men's)
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Odds Of Infection Bleeding Gums
Here's a taste of what TheBody.com has to offer on this topic:
Ask the Experts
Bleeding gums/transmission of HIV infectionMy brother is HIV positive and has ANUG. He frequently has fresh blood around his upper front teeth. Is it possible for me to be "at risk" by kissing him on the lips when blood is present? How about sharing the same fork when he is bleeding? ...Response from David A. Reznik, D.D.S.
Grady Health System
...sharing eating utensils, drinking glasses, etc. A bigger question is why your brother continues to have an issue with actively bleeding gums (gingiva). The treatment for periodontal conditions in HIV positive persons is not difficult. In some...
Read more »
contaminated HIV blood in an apple, possible to infect?Dear Mark,Say for example there's an apple and it was contaminated with a drop of fresh blood with... Read more »HIV and gumsI am HIV+ been diagnosed for a year now. Over the past 2 years (and before being diagnosed with... Read more »
Safer Sex Guidelines...more difficult for blood or sexual fluid to get into your body. Be aware of your body and your partner's. Cuts, sores, or bleeding gums increase the risk of spreading HIV. Rough physical activity also increases the risk. Even small injuries... Read more »Oral Sex: What's the Real Risk for HIV?...butreal risk. Tips for Safer Oral Sex Oral sex is more risky if you or your partner have an untreated STD, badoral hygiene (bleeding gums, ulcers, gum disease), or take ejaculate (cum) inthe mouth. There are things you can do to reduce the... Read more »Acute HIV Infection... What Is Acute HIV Infection? Testing for Acute HIV Infection Risk of Immune Damage Risk of Infecting Others Treating Acute HIV Infection Pros and Read more »Opportunistic Infections... What Are Opportunistic Infections? Testing for OIs OIs and AIDS What Are the Most Common OIs? Preventing OIs Treating OIs What Are Opportunistic Read more »
Connect With Others
My bad, read it tho, gums were bleeding
Posted by Anonymous, 1 Reply
Read more »
HELP-oral infection-with a twist?
Posted by Anonymous, 1 Reply
...considered "low" risk. But, here is the thing, 30 min after I brushed my teeth vigerously and made my gums bleed. COuld the gum bleeding after oral infect me??? I am freaked about the possibility. I had a neg test at 7 and 10 weeks post...
Read more »
Quick Question...
Posted by Anonymous, 2 Replies
...HIV? I would think that it would put the person that I am doing it to at a greater risk because they are recieving some of my blood from my gums...what I want to know is if I am at risk too because of the bleeding?
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just curious...
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...get it fromm kissing, but then there is that qualification that there are theoretically circumstances were one person may have bleeding gums and the other may have bleeding gums...blah blah blah...I am just very concerned that this may be an...
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Glide - Video Texting
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Photography for the Painter: Creating Your Best Visuals Workshop: Second in Barton's "Lunch and Lecture" Art Seminar Series
· In Art Exhibitions, Events, Faculty, News, Speakers
WILSON, N.C. — "Photography for the Painter: Creating Your Best Visuals Workshop," the second seminar in a new "Lunch and Lecture Series" hosted by the Barton College Friends of Visual Arts, will be held on Thursday, Dec. 6, from 10 a.m. until 4 p.m. Barton's professor emeritus of art and artist-in-residence J. Chris Wilson will lead the seminar.
The "Lunch and Lecture" cost is $10 for Friends of Visual Art members and $20 for non-members. To register as a Friend of Visual Arts, you may visit www.barton.edu/culturalarts. To make reservations, contact Bonnie LoSchiavo by phone at 252‐399‐6477 or email email@example.com. An RSVP is required for lunch reservations.
"Technology and painting have been intimately connected for more than 600 years, and many painters, like their forerunners, depend on the camera to capture images to develop into their paintings," explains Wilson. "While the camera is a tool of choice by many artists, there are some important issues with differences between how the camera records and how the eye sees that can be addressed and overcome."
This workshop will present the issues both pro and con about the use of photography to create paintings, the limitations of the camera processes for the painter, and the potential working relationship between the two. There will also be examples of historical and contemporary photographs presented that were formative in the creation of paintings.
Additional topics to be addressed during the workshop will include the importance of lighting, the color limitations of photographic output for the painter, and the transformative process from photograph to painting. Post-photographic digital manipulation will be discussed and issues of artistry versus technology will be covered. The ethical and legal issues of copyright surrounding the use of photographs will also be covered during the seminar. Participants are encouraged to bring three to five photographic images that they have saved either on a thumb drive or a CD for group discussion and critique.
Wilson, having served on the Barton College faculty for 38 years, was named professor emeritus of art in spring 2012. With a passion for bringing art into the community, he has been involved in symposia, community presentations, and publications on art, decorative arts, and historic preservation. Wilson has also served on the boards of the Edgecombe County Cultural Arts Council, the Arts Council of Wilson, the Board of Advisors for Preservation/NC. He currently serves on the board of the Blount Bridgers Museum/Hobson Pittman Memorial Foundation and the Board of Directors of Preservation/NC.
Most recently, he is working on a 100-painting series "From Murphy to Manteo—An Artist's Scenic Journey" of which several works are currently on view at the North Carolina Museum of History in Raleigh.
He earned a Master of Fine Arts degree from the University of Georgia, where he also completed post-graduate work, with Lamar Dodd as his major professor. He has exhibited throughout the Southeast and all across North Carolina. Wilson's art is represented in numerous public and private collections in the United States, especially in the Southeast, and in England, Japan and Saudi Arabia.
Recent Posts
- Twelfth Annual Caregiver Education Conference Scheduled at Barton College on March 10 February 20, 2015
- Friends of Visual Arts' Lunch and Lecture Series Will Focus on History of Painting in N.C. and Collecting N.C. Art" February 13, 2015
- Barton Team Shines In First-Time Appearance At NCICU Ethics Bowl February 11, 2015
- "Love The Symphony" Scheduled For Saturday, February 14 February 3, 2015
- Barton Announces President's and Dean's Lists for Fall 2014 Semester February 2, 2015


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A multinational, multi-centre, observational, cross-sectional survey assessing diabetes secondary care in Central and Eastern Europe (DEPAC Survey).
ABSTRACT The objective of this study was to assess diabetes care in outpatient diabetes clinics in the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia and Slovenia.
Questionnaires for each randomly enrolled patient were completed by an endocrinologist or diabetologist. Data concerning age, sex, diabetes duration, diabetes type, treatment type, glycated haemoglobin (HbA(1c)), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C), blood pressure (BP) and short- and long-term diabetes complications were recorded. Questionnaires were analysed centrally for each country and stratified for Type 1 diabetes (T1D), Type 2 diabetes (T2D) and other types of diabetes.
Data on 10 950 individuals were analysed (mean population age 56.2 years; females 52%; T1D 22.9%; T2D 75.3%; mean time from diagnosis 11 years). Patients with HbA(1c) within target (< 6.5%): T1D 13.1%, T2D 21.4%; for TC levels (< 4.5 mmol/l): T1D 37%, T2D 20%; for TG levels (< 1.7 mmol/l): T1D 78%, T2D 44%; for HDL-C (> 1.1 mmol/l): T1D 81%, T2D 60%; for LDL-C (< 2.5 mmol/l): T1D 36%, T2D 23%; for BP (< 130/80 mm Hg): T1D 42%, T2D 9%. The prevalence of severe hypoglycaemia (within the last 6 months) was 12% in T1D and 2% in T2D. Prevalence of diabetic ketoacidosis was 0.3-6.6%, blindness 0.15-1.3% and diabetic nephropathy 19-42%.
The data show the current quality of care and potential areas for improvement. The quality of care is generally comparable with that in Western Europe.
- [Show abstract] [Hide abstract]
ABSTRACT: GPs' and patients' socio-demographic characteristics were investigated as possible, determinants of ophthalmologic examination referral rates among type 2 diabetes mellitus patients. Female GPs were more effective among retinopathy-free patients, while male GPs among patients with retinopathy. It could be explained by the gender related authority-empathy balance, manifested, through communication style.Diabetes research and clinical practice 10/2013; · 2.74 Impact Factor - Małgorzata M Bała, Ewa Płaczkiewicz-Jankowska, Roman Topór-Mądry, Magdalena Michałejko, Miłosz Jankowski, Lukasz Strzeszyński, Jacek Sieradzki, Leszek Czupryniak[Show abstract] [Hide abstract]
ABSTRACT: INTRODUCTION In 2011, Diabetes Poland updated its recommended goals in diabetes treatment, including HbA1c and blood pressure (BP) levels. Adherence to the updated guidelines has not been systematically assessed. OBJECTIVES The aim of the study was to assess which methods are most commonly used in the treatment of recently diagnosed type 2 diabetes and to what extent the new criteria for diabetes control are met in these patients. PATIENTS AND METHODS ARETAEUS2-Grupa was a cross-sectional questionnaire-based study conducted in Poland in 2012 (April-June). It involved 1636 patients of any age and sex, with type 2 diabetes diagnosed within the previous 2 years, recruited by randomly selected physicians. RESULTS Of all patients, 37.5% met the goal of the glycated hemoglobin (HbA1c) level of ≤6.5% (recommended in type 2 diabetes of short duration), while 62% met the goal of HbA1c level of ≤7% (general recommendation). Only 6.7% of the patients met all 3 goals (HbA1c ≤6.5%, BP <140/90, and LDL-cholesterol <100 mg/dl or <70 mg/dl with coronary heart disease), 29.7% met 2 goals, 36.8% met only 1 goal, while 26.7% did not meet any of the treatment goals. With the use of the HbA1c level recommended for the overall population, the proportions of patients meeting 3, 2, and 1 goals increased to 11%, 34.5%, and 35.5%, respectively, while the percentage of the patients not meeting any of the goals decreased to 18%. Metformin in monotherapy or in combination was the most commonly used drug in the study population (80%). CONCLUSIONS The great majority of the patients with type 2 diabetes of short duration did not meet all of the treatment goals as recommended in the current practice guidelines. When the treatment goals were used for the overall population (HbA1c ≤7%), a slightly higher, but still unsatisfactory, proportion of the patients met all the treatment goals. Metformin alone or in combination was the most commonly used drug in the study population.Polskie archiwum medycyny wewnȩtrznej 09/2013; · 2.05 Impact Factor - Leszek Czupryniak, László Barkai, Svetlana Bolgarska, Agata Bronisz, Jan Broz, Katarzyna Cypryk, Marek Honka, Andrej Janez, Mladen Krnic, Nebojsa Lalic, Emil Martinka, Dario Rahelic, Gabriela Roman, Tsvetalina Tankova, Tamás Várkonyi, Bogumił Wolnik, Nadia Zherdova[Show abstract] [Hide abstract]
ABSTRACT: Abstract Self-monitoring of blood glucose (SMBG) is universally considered to be an integral part of type 1 diabetes management and crucial for optimizing the safety and efficacy of complex insulin regimens. This extends to type 2 diabetes patients on intensive insulin therapy, and there is also a growing body of evidence suggesting that structured SMBG is beneficial for all type 2 diabetes patients, regardless of therapy. However, access to SMBG can be limited in many countries in Central and Eastern Europe. A consensus group of diabetes experts from 10 countries in this region (with overlapping historical, political, and social environments)-Bulgaria, Croatia, Czech Republic, Hungary, Poland, Romania, Serbia, Slovakia, Slovenia, and Ukraine-was formed to discuss the role of SMBG across the spectrum of patients with diabetes. The group considered SMBG to be an essential tool that should be accessible to all patients with diabetes, including those with non-insulin-treated type 2 diabetes. The current article summarizes the evidence put forward by the consensus group and provides their recommendations for the appropriate use of SMBG as part of individualized patient management. The ultimate goal of these evidence-based recommendations is to help patients and providers in Central and Eastern Europe to make optimal use of SMBG in order to maximize the efficacy and safety of glucose-lowering therapies, to prevent complications, and to empower the patient to play a more active role in the management of their diabetes.Diabetes Technology & Therapeutics 04/2014; · 2.29 Impact Factor
Page 1
© 2008 The Authors.
Journal compilation © 2008 Diabetes UK. Diabetic Medicine, 25, 1195–1203
DOI: 10.1111/j.1464-5491.2008.02570.x
Blackwell Publishing Ltd
Original Article: Care Delivery
A multinational, multi-centre, observational,
cross-sectional survey assessing diabetes secondary care
in Central and Eastern Europe (DEPAC Survey)
M. Andel, W. Grzeszczak*, J. Michalek†, M. Medvescek‡, A. Norkus§, I. Rasa¶,
M. Niewada**, B. Kami˜ski††, P. Kraml, L. Madacsy‡‡ and the DEPAC Group
Third Faculty of Medicine, Charles University Prague, Czech Republic, *Department of Endocrinology in Zabrze, Silesian School of Medicine, Katowice, Poland,
†National Institute of Endocrinology and Diabetology, Lubochna, Slovakia, ‡Faculty of Medicine, University Medical Centre, Ljubljana, Slovenia, §Institute of
Endocrinology, Kaunas University of Medicine, Kaunas, Lithuania, ¶Clinical University Hospital, Gailezers, Latvia, **Medical University of Warsaw, ††Warsaw School
of Economics, Poland and ‡‡First Department of Paediatrics, Semmelweis University, Budapest, Hungary
Accepted 8 August 2008
Hungary, Latvia, Lithuania, Poland, Slovakia and Slovenia.
The objective of this study was to assess diabetes care in outpatient diabetes clinics in the Czech Republic, Estonia,
Data concerning age, sex, diabetes duration, diabetes type, treatment type, glycated haemoglobin (HbA1c), total cholesterol
(TC), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C),
blood pressure (BP) and short- and long-term diabetes complications were recorded. Questionnaires were analysed
centrally for each country and stratified for Type 1 diabetes (T1D), Type 2 diabetes (T2D) and other types of diabetes.
Questionnaires for each randomly enrolled patient were completed by an endocrinologist or diabetologist.
75.3%; mean time from diagnosis 11 years). Patients with HbA1c within target (< 6.5%): T1D 13.1%, T2D 21.4%; for
TC levels (< 4.5 mmol/l): T1D 37%, T2D 20%; for TG levels (< 1.7 mmol/l): T1D 78%, T2D 44%; for HDL-C
(> 1.1 mmol/l): T1D 81%, T2D 60%; for LDL-C (< 2.5 mmol/l): T1D 36%, T2D 23%; for BP (< 130/80 mm Hg): T1D
42%, T2D 9%. The prevalence of severe hypoglycaemia (within the last 6 months) was 12% in T1D and 2% in T2D.
Prevalence of diabetic ketoacidosis was 0.3–6.6%, blindness 0.15–1.3% and diabetic nephropathy 19–42%.
Data on 10 950 individuals were analysed (mean population age 56.2 years; females 52%; T1D 22.9%; T2D
generally comparable with that in Western Europe.
The data show the current quality of care and potential areas for improvement. The quality of care is
Diabet. Med. 25, 1195–1203 (2008)
Central and Eastern Europe, cross-sectional survey, diabetes care
blockers, ASA, acetylsalicylic acid (aspirin); BP, blood pressure; CHD, coronary heart disease; CV, cardiovascular; DCCT,
Diabetes Control and Complications Trial; DKA, diabetic ketoacidosis; EASD, European Association for the Study of
Diabetes; ECG, electrocardiogram; HbA1c, glycated haemoglobin; HDL-C, high-density lipoprotein cholesterol; IDF,
International Diabetes Federation; IFCC, International Federation of Clinical Chemistry; LDL-C, low-density lipoprotein
cholesterol; MI, myocardial infarction; NGSP, National Glycohemoglobin Standardization Program; OGLA, oral glucose-
lowering agent; SMBG, self-monitoring blood glucose; T1D, Type 1 diabetes; T2D, Type 2 diabetes; TC, total cholesterol;
TG, triglycerides; TZD, thiazolidinediones
ACE, angiotensin-converting enzyme; ADA, American Diabetes Association; ARBs, angiotensin receptor
The interventional landmark Diabetes Control and Complica-
tions Trial (DCCT) [1] and the UK Prospective Diabetes Study
(UKPDS) [2] demonstrated that achieving specific glycaemic
goals can substantially reduce morbidity. Effective treatment
Correspondence to
Metabolism and Nutrition and 2nd Department of Internal Medicine,
3rd Faculty of Medicine, Charles University Prague,
100 34 Praha 10, Czech Republic. E-mail: email@example.com
: Professor Michal Andel, Center for Research of Diabetes,
robárova 50,
Page 2
DIABETICMedicineAssessing diabetes secondary care in Central and Eastern Europe • M. Andel et al.
© 2008 The Authors.
Journal compilation © 2008 Diabetes UK. Diabetic Medicine, 25, 1195–1203
of diabetes is thus a top priority. However, therapies directed
at other coincident abnormalities, such as dyslipidaemia,
hypertension and obesity, have also been a major focus of
diabetes care in all countries.
The most recent glycaemic goal set by the International
Diabetes Federation (IDF) is a glycated haemoglobin (HbA1c)
< 6.5%. HbA1c ≥ 7.0% should serve as a call to initiate or
change therapy. This is supported by a recent consensus
statement from the European Association for the Study
of Diabetes (EASD) and the American Diabetes Association
IDF-Region Europe, with the support of an unrestricted
grant from Novo Nordisk A/S, Business Area Europe East,
Warsaw, Poland, established a multinational 'Diabetes Experts'
Panel from Accessing Countries' (DEPAC) in November 2003.
This project aimed to address an urgent need for exchange of
opinions and shared experiences about diabetes care in eight
countries which were to join the European Union (EU) in 2004:
the Czech Republic, Estonia, Hungary, Latvia, Lithuania,
Poland, Slovakia and Slovenia. In all of these countries health
care is free at the point of access. Access to secondary care is via
referral from a primary care provider in most of the countries.
A high priority goal of the Panel was to define the current state
of diabetes treatment in these countries. Therefore, the survey
was designed to be observational and cross-sectional and not
epidemiological and population based.
The results of this current, large, multinational survey will
be a platform for achieving other goals identified by the Panel
members, such as highlighting the costs and benefits of
diabetes treatment, creating ways of health promotion and
health monitoring, leading on to increased patient empower-
ment through education and discussion about the current
situation of national diabetes programmes. It could also serve
as a platform for future comparison with other surveys and
with the results obtained in other parts of Europe.
Patients and methods
This was an observational, non-interventional, cross-sectional,
multinational and multi-centre survey in a cohort of 10 930
subjects with diabetes [Type 1 diabetes (T1D), Type 2 diabetes
(T2D) or other types of diabetes] in the following countries:
the Czech Republic (n = 2012), Estonia (n = 216), Hungary
(n = 2140), Latvia (n = 304), Lithuania (n = 303), Poland
(n = 4420), Slovakia (n = 1095) and Slovenia (n = 440).
Secondary care patients were enrolled. Secondary diabetes
care is organized along similar lines in each of the participating
countries and focuses on: patients with TID; women with
gestational diabetes; children; newly diagnosed T2D patients;
and those with advanced diabetic complications or requiring
treatment intensification. The survey population was sampled
from 11 000 patients treated in 258 outpatient diabetes
clinics. The centres were chosen to achieve geographic,
social and economic proportionality in each country. In each
centre, all consecutive patients attending on selected days
were included.
The inclusion criteria were: patients with T1D and T2D;
duration of diabetes ≥ 1 year; HbA1c testing within the last
6 months; signed informed consent if required by local legisla-
tion, including the requirements of the local Ethics Committee.
The exclusion criteria were: newly diagnosed T1D or T2D;
types of diabete other than T1D or T2D; lack of HbA1c within
the last 6 months. No withdrawals were expected during the
survey; any withdrawals were not to be replaced.
An anonymized questionnaire for each patient was com-
pleted by the endocrinologist or diabetologist at a single routine
visit, gathering the following information from the subject's
medical record, recall or self-monitoring blood glucose (SMBG)
diary if available:
• patient's characteristics: year of birth; gender; body weight
and height; body mass index (BMI); type of diabetes: T1D,
T2D, other types of diabetes; year of diabetes diagnosis;
• current glucose-lowering treatment: oral glucose-lowering
agents (OGLAs), alone or in combination, including with
insulin; insulin type: insulin injection system, insulin treat-
ment regimes and also SMBG;
• the most recent result of HbA1c, within the previous
6 months;
• long-term diabetes complications (or history of): cardiovas-
cular (CV); nephropathy; retinopathy; neuropathy; diabetic
• examination during the last 12 months: eyes, electrocardio-
gram (ECG), feet;
• acute diabetes complications during the last 12 months:
diabetic ketoacidosis (DKA), hypoglycaemia;
• CV risk factors: total cholesterol (TC), high-density
lipoprotein cholesterol (HDL-C), low-density liporprotein
cholesterol (LDL-C), triglycerides (TG); blood pressure (BP);
• other concomitant medications used;
• diabetes education: any structural education performed in last
12 months.
Definitions of particular medical conditions were left to the
discretion of the physicians according to local clinical standards
and guidelines, which correspond to international recom-
mendations such as those of the IDF, EASD and ADA. The
survey protocol and full questionnaire are available at http://
and http://www.idf.org/webdata/docs/DEPAC_Questionnaire.pdf.
Questionnaires were analysed centrally and stratified for T1D,
T2D and other types of diabetes. HbA1c was measured locally
by different methods [the National Glycohemoglobin Stand-
ardization Program (NGSP) and the International Federation of
Clinical Chemistry (IFCC) [4]], but the results are presented
using NGSP guidelines (DCCT standard). No changes in the
treatment were planned as a result of participation in the
The data are presented as mean and range for each type of
diabetes, aggregated for all countries. As the number of patients
enrolled in each country was determined by each country's
population, the means were not weighted. Additionally, all
means were calculated for each country separately and the
ranges of minimum and maximum mean values calculated at
individual country level are reported. At individual country
level it was assumed that the participants were representative
for the country and between-centre mean variability is not
Page 3
Original article
© 2008 The Authors.
Journal compilation © 2008 Diabetes UK. Diabetic Medicine, 25, 1195–1203
reported. To avoid competition, data are not identified by
individual country names in this report. However, data from
individual countries have been seen and discussed at the
local level.
A total of 11 084 subjects were initially enrolled during the
2-month recruitment period. Of these, 154 (1.4%) patients
were excluded from analysis because of the type of diabetes
being unspecified. Thus, 10 930 patients (22.9% T1D, 75.3%
T2D, 1.8% other types of diabetes) were included in the
final analysis. The results of patients with other types of
diabetes are not discussed because of the small proportion of
Patients' clinical characteristics
The patients' clinical characteristics are presented in Table 1.
Mean HbA1c was higher in T1D than in T2D patients and was
generally unsatisfactory (Table 2).
The mean and range of country means and values of the
most recent HbA1c indicate that T1D patients struggled the
most to achieve good glycaemic control. The widest range of
country means was seen for T1D patients (Fig. 1).
FIGURE 1 The proportion of patients with (a) type 2 diabetes; and (b) type 2 diabetes, with excellent, satisfactory, unsatisfactory and poor glycated
haemoglobin (HbA1c) in the 6 months prior to the survey. The bars show the mean proportion when values from all countries were analysed together
and the vertical lines depict the lowest and the highest individual country mean value.
n = 2497
n = 8231
Mean (range
of country
specific means*)
Mean (range
of country
specific means*)
Age (years)
Gender: females (%)
Duration of diabetes (years)
BMI (kg/m2)
36.9 (25.2–42.2)
48.4 (43.0–50.9)
13.7 (9.4–16.6)
24.0 (21.7–25.7)
62.2 (60.5–64.4)
52.7 (48.1–71.8)
10.2 (8.4–11.1)
30.6 (30.1–32.6)
*Range (country lowest mean value−country highest mean value).
% values are mean of countries % values.
BMI, body mass index; diabetes, diabetes mellitus; T1D, Type 1 diabetes; T2D, Type 2 diabetes.
Table 1 Patients' clinical characteristics
Page 4
DIABETICMedicine Assessing diabetes secondary care in Central and Eastern Europe • M. Andel et al.
© 2008 The Authors.
Journal compilation © 2008 Diabetes UK. Diabetic Medicine, 25, 1195–1203
Diabetes complications
The prevalence of microvascular and macrovascular complica-
tions is presented in Table 2. The highest rate of retinopathy
(any stage and any type) was seen in T1D. The rates of
blindness were similar for all types of diabetes.
The rates and ranges of nephropathy (any stage) were
similar in all types of diabetes. However, end-stage renal
failure was twice as frequent for other types of diabetes as for
T1D and T2D. There were no differences in neuropathy rates
(any form) between diabetes types, but there were noticeable
differences between participating countries.
The prevalence of macrovascular complications was
noticeably higher by 2.5- to 7-fold for myocardial infarction
(MI), 5-fold higher for other forms of coronary heart disease
(CHD), 7-fold higher for stroke and transient ischaemic
attacks and 2.5-fold higher for peripheral artery disease for
T2D as compared with T1D patients. The range of country
means was higher for T2D and other types of diabetes than for
T1D. In contrast, T1D patients had a higher rate of hypogly-
caemia (5- to 6-fold), but again with a high range of country
Cardiovascular risk factors
A total of 66.8% of patients with T2D and 29% with T1D had
dyslipidaemia. The mean values for all lipid parameters (TC,
LDL-C, TG) were higher in T2D compared with T1D patients
Mean (range
of country
specific means*)
Mean (range
of country
specific means*)
HbA1c (%)
Chronic complications
Microvascular (%)
Retinopathy (any stage)
Nephropathy (any stage)
End-stage renal failure
Neuropathy (any form and stage)
Macrovascular (%)
Myocardial infarction
Other forms of CHD
Stroke or TIA
Peripheral artery disease
Diabetic foot (%)
Foot ulcer
Amputation (any level)
Acute complications (%)
Severe hypoglycaemia
Hyperosmolar non-ketotic hyperglycaemia
Cardiovascular risk factors
Dyslipidaemia diagnosed (%)
TC (mmol/l)
HDL-C (mmol/l)
LDL-C (mmol/l)
TG (mmol/l)
Blood pressure (mmHg)
Systolic BP
Diastolic BP
Smoking (%)
8.2 (7.7–9.8)7.7 (7.5–8.3)
40.9 (19.0–87.6)
0.48 (0.0–3.4)
27.8 (12.0–55.4)
0.44 (0.0–2.3)
31.2 (5.0–85.4)
31.8 (20.0–45.7)
0.34 (0.1–0.7)
25.3 (17.6–39.8)
0.47 (0.0–2.4)
31.0 (16.7–69.7)
2.6 (0.0–6.7)
5.9 (0.0–10.1)
1.1 (0.0–2.3)
6.0 (3.00–9.0)
12.4 (9.1–16.6)
31.0 (9.9–38.4)
7.2 (4.0–13.3)
15.6 (6.0–21.8)
2.1 (0.7–7.7)
1.2 (0.0–4.6)
3.0 (2.0–4.9)
1.7 (0.5–2.4)
11.6 (4.7–14.8)
0.08 (0.00–0.75)
3.1 (1.5–13.5)
2.1 (0.3–5.7)
0.11 (0.00–0.23)
0.5 (0.0–3.8)
29 (26–37)
4.90 (4.52–5.52)
1.50 (1.41–1.77)
2.80 (2.62–3.60)
1.34 (1.23–1.50)
67 (60–89)
5.39 (5.13–5.89)
1.27 (1.19–1.38)
3.11 (2.93–3.73)
2.12 (1.93–2.43)
124 (116–133)
76 (68–82)
141 (138–149)
83 (80–88)
18.3 (11.9–27.6)18.8 (8.1–22.7)
*Range (country lowest mean value−country highest mean value).
% values are mean of countries % values.
BP, blood pressure; CHD, coronary heart disease; DKA, diabetic ketoacidosis; HbA1c,
glycated haemoglobin; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density
lipoprotein cholesterol; T1D, Type 1 diabetes; T2D, Type 2 diabetes; TC, total cholesterol;
TG, triglycerides; TIA, transient ischaemic attack.
Table 2 Patients' clinical characteristics:
HbA1c, chronic and acute complications of
diabetes and cardiovascular risk factors
Page 5
Original article
© 2008 The Authors.
Journal compilation © 2008 Diabetes UK. Diabetic Medicine, 25, 1195–1203
(Table 2). The range of country means was more comparable.
The proportions of patients reaching target values of lipid
and BP parameters are presented in Table 3. The prevalence of
diagnosed hypertension was 30.5% in T1D and 79.5% in
T2D. Only 19% of T2D patients met systolic and diastolic
BP target values (< 130 and < 80 mmHg, respectively). The
prevalence of diabetic foot conditions (ulcer, amputation at
any level) varied widely between countries.
The highest rate and range of country means in cigarette
smoking occurred for other types of diabetes, but there were
no difference between T1D and T2D. About 18% of T1D and
T2D patients smoked.
Acute complications
There was a 5- to 6-fold higher rate of severe hypoglycaemia
(11.6% vs. 2.1%) and DKA (3.1% vs. 0.5%) for T1D as
compared with T2D, with a relatively high range of country
means especially for T1D and other types of diabetes.
Diabetes treatment
The most frequently used OGLAs in T2D were metformin
(50%), sulphonylureas (40%) and acarbose (8.7%), with rare
usage of rapid-acting secretagogues and thiazolidinediones,
at 2% (Table 4). OGLAs were combined with insulin in 14%
of T2D patients with a high range of country means (4–34%).
The most commonly used types of insulin for treatment
of T1D were human (69%) and insulin analogues (49%). The
ranges of country means for both were surprisingly high, at
26–87% and 38–95%, respectively. Use of animal insulin
appeared minimal. The most frequently used insulin injection
systems were repeat-use devices, insulin pumps and disposable
devices, with mean rates of 73%, 11% and 4% respectively.
The ranges of country means were high. Syringe use was rare
(1.4% in T1D). In 71% of T1D patients, insulin was adminis-
tered by basal bolus treatment regimen, but 4.5% used insulin
injections twice daily or less.
Other medication
Anti-hypertensive agents were administered to 82% of T2D
patients and to 40% of T1D patients. Angiotensin-converting
enzyme (ACE) inhibitors were the most commonly used drugs
in 67% and 35% of patients with T2D and T1D, respectively.
Of T2D patients, 54% received aspirin (acetylsalicylic acid; ASA)
and 48% statins; of T1D patients, 20% used ASA and 21% statins.
Diabetes management
Ninety per cent of T1D and 60% of T2D patients undertook
SMBG. A structured education programme was provided to
81% of T1D and 73% of T2D. Screening for complications
showed that 63–93% of patients had had either an eye, heart
or foot examination during the 12 months prior to the survey,
but only 57% of T1D and 67% of T2D had all three examina-
tions combined. Country means varied considerably.
The DEPAC survey is the first large multinational survey to be
conducted in the eight countries that joined the EU in 2004,
reflecting the real-life situation of patients with diabetes
treated at specialist level under usual clinical practice condi-
tions. Studies from these countries usually only include small
groups of patients and are published in local journals; for
example, the study of 400 patients from South-East Hungary
[5]. It is important to point out the limitations of this study.
This survey was open, uncontrolled and without randomiza-
tion. Its value lies in being the first broad quality-of-care survey
performed in these eight countries. As this was an observa-
tional, non-interventional survey, only secondary care patients
were enrolled. Secondary diabetes care is organized along sim-
ilar lines in each of the participating countries and focuses on
patients with T1D, women with gestational diabetes, children,
patients newly diagnosed or with advanced diabetic complica-
tions and T2D patients requiring treatment intensification.
Mean (range
of country
specific means*)
Mean (range
of country
specific means*)
BP systolic
BP diastolic
< 4.5 mmol/l
< 2.5 mmol/l
> 1.1 mmol/l
< 1.7 mmol/l
< 130 mmHg
< 80 mmHg
36.6% (15.5–54.7)
36.1% (7.4–46.5)
81.2% (70.5–93.6)
78.0% (67.8–85.0)
62.4% (43.2–74.0)
49.3% (27.8–73.0)
19.7% (8.4–25.9)
22.8% (7.3–31.1)
60.0% (46.8–71.9)
43.5% (31.4–49.9)
19.0% (8.6–20.8)
19.7% (8.0–33.3)
*Range (country lowest mean value−country highest mean value).
BP, blood pressure; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density
lipoprotein cholesterol; TC, total cholesterol; TG, triglycerides; T1D, Type 1 diabetes;
T2D, Type 2 diabetes.
Table 3 Blood lipids and blood pressure:
the proportion (%) of patients with diabetes
meeting target values (mean and the range of
country means)
Page 6
DIABETICMedicine Assessing diabetes secondary care in Central and Eastern Europe • M. Andel et al.
© 2008 The Authors.
Journal compilation © 2008 Diabetes UK. Diabetic Medicine, 25, 1195–1203
Even although this survey demonstrated differences between
countries in terms of complications, diabetes control and risk
factor distribution, the main challenges of diabetes care are
the same across the surveyed countries. This survey's cross-
national data provide an opportunity to assess the quality of
diabetes care in detail. The unified methodology of the survey
and the randomized enrolment of 10 728 patients with diabetes
allowed the collection of a body of data to serve as a basis for
analysis of the prevalence of diabetic complications, adminis-
tered treatment and quality of diabetes care in the countries
involved in the survey.
Similarly to our data, in a UK study [6], 76% of patients
with diabetes had HbA1c > 7.7%, while in a comparative
analysis of national surveys in England and the USA, the mean
HbA1c in England was 7.8% and 7.7% in the USA [7]. The
average HbA1c level in our T2D patients was 7.7% and in T1D
patients 8.2%.
Somewhat poorer glycaemic control (mean HbA1c 8.1%)
was seen in Caucasian Europeans at a London diabetes clinic
[8]. Only 23.9% of our T1D and 35.8% of our T2D patients
had HbA1c < 7.0%. This compares unfavourably with, for
example, the Ourense rural area of Spain, with 44.3% of all
patients having HbA1c < 7.0% [9], or in the USA, with 48.9%
[7]. Achieving good glycaemic control seems to be an
extremely difficult target in both Eastern and Western
Europe, as reported from Denmark [10]. However, HbA1c
Mean (range of
country specific
Mean (range
of country
specific means*)
OGLAs (%)
Rapid-acting secretagogues (glinides)
Alpha glucosidase inhibitors (acarbose)
OGLAs in combination with insulin
Insulin therapy
Types of insulins (%)
Human insulins
Insulin analogues
Animal insulins
Injection systems (%)
Multiple-use devices
Disposable devices
Insulin pump
Insulin treatment regimes (%)
Conventional regimen
Basal–bolus regimen
Insulin dose (IU/kg)
Other medications (%)
Any anti-hypertensive agents
ACE inhibitors
Management (during last 12 months) (%)
Blood glucose self-monitoring
Feet examination
Eyes examination
Combined examinations: ECG, feet and eyes
2.4 (0.0–3.7)
0.8 (0.00–2.24)
0.5 (0.0–1.5)
0.1 (0.0–0.8)
0.5 (0.0–1.6)
1.5 (0.0–2.9)
50 (43–70)
40 (31–50)
2.3 (0.0–9.3)
2.3 (0.3–10.0)
8.7 (0.0–16.4)
14.3 (4.5–34.4)
69 (26–87)
49 (38–95)
1.2 (0–6.4)
46 (28–55)
10 (6–56)
0.4 (0–1.4)
1.4 (0.0–5.2)
73.0 (18.5–88.1)
4.2 (0.0–35.4)
10.61 (1.86–39.00)
4.2 (0.00–12.25)
36.5 (6.3–52.1)
8.4 (0.1–32.2)
0.05 (0.00–0.47)
4.5 (0.0–7.8)
71.1 (54.0–89.7)
0.69 (0.64–0.82)
25.8 (10.2–42.3)
16.68 (5.1–39.0)
0.54 (0.43–0.63)
40.1 (12.0–55.4)
35.4 (8.0–48.3)
2.7 (0.0–5.2)
20.0 (4.0–26.6)
20.8 (11.2–25.0)
2.9 (0.0–6.7)
82.5 (75.8–91.4)
66.5 (57.0–84.1)
5.1 (1.3–16.4)
53.9 (32.2–64.3)
48.3 (13.7–55.5)
14.0 (1.2–24.6)
91 (86–98)
81 (52–96)
63 (16–89)
82 (46 –98)
93 (79–98)
57 (11–83)
60 (29–75)
73 (48–90)
81 (50–90)
82 (57 –94)
88 (75–94)
67 (29–79)
*Range (country lowest mean value−country highest mean value).
ACE, angiotensin-converting enzyme; ARBs, angiotensin receptor blockers,
ASA, acetylsalicylic acid; ECG, electrocardiogram; OGLAs, oral glucose-lowering agents;
T1D, Type 1 diabetes; T2D, Type 2 diabetes.
Table 4 Diabetes mellitus treatment and
Page 7
Original article
© 2008 The Authors.
Journal compilation © 2008 Diabetes UK. Diabetic Medicine, 25, 1195–1203
is a widely used indicator of glycaemic control in the
countries included in the DEPAC survey. This can influence
the level of diabetes care, as shown in a recent Danish study
Macrovascular complications: risk factors
Our survey showed high prevalences of late diabetic complica-
tions and poor control of CV risk factors. In particular,
few patients with T2D achieved target values of lipids, HbA1c
and both systolic and diastolic BP. The proportion of patients
meeting target values for BP and lipid parameters was par-
ticularly low. Only about 20% of T2D patients met their BP,
TC and LDL-C targets. However, 50–60% of T1D patients
(who were on average 25 years younger) met their target
values for BP and 36% met their LDL-C targets. Similar data
have been published recently from other surveys. For example,
the Type 2 National Diabetes Register in Denmark shows only
13% patients met targets for blood pressure (< 130/80 mmHg)
and 28% for TC (< 4.5 mmol/l) [10]. Mean TC levels in
patients with diabetes in the eight new EU countries
(5.4 mmol/l) are similar to levels found both in England
(5.3 mmol/l) and the USA (5.5 mmol/l) [7].
Eliasson et al. [10] reported that 13% of T2D patients
achieved a target blood pressure of 130/80 mmHg and, in a
French nationwide T2D survey, mean BP was 140/80 mmHg,
with 29% of patients meeting the slightly higher target
BP < 140/80 mmHg [12]. In another French study, only 0.3%
of T2D patients reached all three World Health Organi-
zation (WHO) targets in plasma lipids, HbA1c and BP [13]. In
an Italian study, 74% of T2D patients had systolic BP > 130
mmHg [14].
Our results indicate a high CV risk for both T2D and T1D
patients as a result of unsatisfactory metabolic and BP control.
The data for T2D is similar to reports from other EU countries.
As shown in UKPDS 75 data [15], the risk of complications in
T2D is associated independently and cumulatively with
hyperglycaemia and hypertension. Intensive treatment of both
of these factors is required to minimize the incidence of
Unsurprisingly, many patients in the DEPAC survey with
T2D had a history of stroke (7.2%, country range 4.0–
13.3%), MI (12.4%, country range 9.1–16.6%) or other
forms of CHD (31%). A higher risk of stroke [16] and MI [17]
is well known in T2D patients, as documented in the large
multi-centre case–control Interheart study that showed a
4.26-fold higher risk of MI in T2D women and 2.67-fold
higher risk in T2D men.
The proportion of patients with diabetes who have micro-
vascular complications seems consistent with other data.
Retinopathy was found in 31.8% T2D patients and in 40.9%
T1D patients. These data are comparable with observations
from a South-East London Screening study (28.9%) [18], the
Casteldaccia Eye Study (34.1%) [19] and from T2D patients
from Aarhus in Denmark (31.5%) [20].
Acute complications
Of all our T1D patients, 3.1% reported an episode of DKA in
the previous year. It is difficult to compare the epidemiological
data, because this survey was not population based. However,
DKA remains an important problem in T1D patients, as
shown recently in Denmark where the annual incidence of
DKA was estimated at 12.9 per 100 000 inhabitants from
1996 to 2002, with 4807 hospital admissions for DKA and
137 reported deaths [21].
Diabetes treatment: insulin, OGLAs and concomitant
Differences in insulin treatment regimens and types of insulin
were observed between countries, especially in the administra-
tion of human insulins and their analogues. A moderate
proportion of T2D patients received a combination of OGLAs
with insulin (14.3%). OGLAs such as thiazolidinediones
(TZDs) and glinides were prescribed rarely. Disparities in the
use of TZDs compared with metformin in patients with
Medicaid-managed care were described by Shaya et al. [22].
In a recent Dutch study, the increase in the use of drugs to
treat diabetes led to a 50% increase of the total cost of
diabetes medication over 5 years [23].
Assuming a high proportion of dyslipidaemia, especially in
T2D patients, the use of statins in this group of patients was
moderate and may well indicate that many patients are not
being treated to target. Conversely, the use of anti-hypertensive
therapy was high, but again the majority of hypertensive
patients were unsatisfactorily treated. The use of statins in
48.3% of T2D patients is comparable with data obtained in
Ireland (40%) [24]. In contrast, data from France indicate
much lower prevalence of statin prescription in T2D patients
(28%) [12] but a slightly higher prescription of fibrates (19%)
More than half of our T2D patients were treated with ASA.
In comparison, 21% of patients with diabetes were prescribed
ASA in a larger 1995 Swedish study [25]. About 60% of
our T2D patients were treated with ACEs and 5% with
angiotensin receptor blockers (ARBs). Recent US data have
shown that 54% of patients with diabetes were prescribed
ACE inhibitors or ARBs [26].
Diabetes management: self-management, diabetes
A relatively high proportion of diabetic patients, particu-
larly those with T1D, reported self-management of blood
glucose. About 80% of patients had undergone some kind
of structured diabetic education. Despite this, glucose
control was poor. Of patients with diabetes, 63–93% had
an ECG, eye or foot examination and two-thirds had
undergone all three examinations in the previous
12 months.
Page 8
DIABETICMedicine Assessing diabetes secondary care in Central and Eastern Europe • M. Andel et al.
© 2008 The Authors.
Journal compilation © 2008 Diabetes UK. Diabetic Medicine, 25, 1195–1203
The data from this DEPAC survey clearly show that, in
patients with T2D, control of both glycaemic levels and CV
risk factors is unsatisfactory, although data from other
European countries seem to be similar. Patients with T1D in
the eastern part of the EU are treated with modern insulins
and regimens. In patients with T2D, the proportion of the
metformin-treated patients is similar to other EU countries.
TZDs are still rarely used.
Overall, this survey shows that there is no significant
difference in diabetes care between Eastern and Western
Europe. The problem with reaching target values seems to be
common not only within Europe, but worldwide [27]. The
collected data also deserve further analysis, such as compari-
sons between individual countries, which might improve
diabetes care, attract greater attention from healthcare author-
ities and better public awareness, as well as an improvement in
the application of guidelines by healthcare professionals.
Additional information
Some data have already been presented at the EASD 2005,
the IDF 2006 and the ADA 2007.
Rasa I, Pavlina I. Analysis of diabetes care in Type 1
diabetes (TIDM) patients—children and adults in Latvia.
Medvescek M, Niewada M, Kaminski B, Grzeszczak W,
Madacsy L, Michalek J et al. Blood lipids control in diabetic
patients in the eight newly accessed EU countries. P1570
Madacsy L, Greszczak W, Michalek J, Medvescek M,
Norkus A, Niewada M et al. Metabolic control and cardiovas-
cular risk factors in children and adolescents with Type 1
diabetes mellitus (the DEPAC study). P1053
Rasa I, Pavlina I. Evaluation of Type 2 diabetes (T2DM)
care in Latvia. P1622
Madacsy L, Grzeszczak W, Michalek J, Medvescek M,
Norkus A, Niewada M et al. Quality of care—diabetes melli-
tus in eight new EU accessing countries: basic description of
quality of care. PS 83
Competing interests
MA has received advisor and speaker fees from Eli Lilly & Co.,
Novo Nordisk A/S and Sanofi-Aventis; MN has received
advisor and speaker fees from Novo Nordisk A/S; BK has
received payment for being a speaker for and attending con-
ferences organized by Novo Nordisk A/S; PK has received
payment for being advisor to and a speaker for Pfizer Inc.,
MSD Inc., Novartis, Schering-Plough, Krka and Zentiva. The
remaining authors have no competing interests to declare.
The research was supported by an unlimited research grant
from Novo Nordisk A/S, the Research Programme of the
Ministry of Education in the Czech Republic MSM
0021620814 (salaries: MA, PK). The authors would also like
to thank Mr Janusz Szczepanik for his substantial help with
language editing.
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with Type 2 diabetes: a nationwide French survey. Diabetes Metab
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cardiovascular risk factors in patients with Type 2 diabetes and
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risk of complications in Type 2 diabetes: a prospective observational
study (UKPDS 75). Diabetologia 2006; 49: 1761–1769.
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text:
What does AWK mean in NYSE Symbols?
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text:
->If we affirm one moment, we thus affirm not only ourselves but all existence. For nothing is self-sufficient, neither in us ourselves nor in things; and if our soul has trembled with happiness and sounded like a harp string just once, all eternity was needed to produce this one event--and in this single moment of affirmation all eternity was '''called good, redeemed, justified, and affirmed.'''
-->-- '''Creator/FriedrichNietzsche'''
->''"There's no chance for us\\
It's all decided for us\\
This world has only one sweet moment set aside for us"''
-->--'''{{Music/Queen}}''', "Who Want to Live Forever?"
->''"Collapsing next to me\\
Shouts 'Don't look sad,\\
Things aren't so bad\\
They're just more wrong than right'"''
-->--'''Music/ScottWalker''', "The Girls in the Street"
->''"Breathe, breathe in the air,''\\
''Don't be afraid to care.''\\
''Leave, but don't leave me,''\\
''Look around, choose your own ground.''\\
''For long you live, and high you fly,''\\
''And smiles you'll give, and tears you'll cry,''\\
''All you touch and all you see''\\
''Is all your life will ever be."''
-->--'''Music/PinkFloyd''', [[Music/TheDarkSideOfTheMoon "Breathe"]]
->''"Oh me! Oh life! of the questions of these recurring,\\
Of the endless trains of the faithless, of cities filld with the foolish,\\
Of myself forever reproaching myself, (for who more foolish than I, and who more faithless?)\\
Of eyes that vainly crave the light, of the objects mean, of the struggle ever renewd,\\
Of the poor results of all, of the plodding and sordid crowds I see around me,\\
Of the empty and useless years of the rest, with the rest me intertwined,\\
The question, O me! so sad, recurringWhat good amid these, O me, O life?\\
Answer: That you are here. That life exists and identity.\\
That the powerful play goes on, and you may contribute a verse."''
-->--'''Creator/WaltWhitman''', "O Me O Life"
->''Im an idealist\\
who has outgrown\\
my idealism\\
I have nothing to do\\
the rest of my life\\
but do it\\
and the rest of my life\\
to do it''
-->--'''Creator/JackKerouac''', ''Mexico City Blues''
->What is the object of this circle of misery and violence and fear? It must have a purpose or the universe has no meaning and that is unthinkable. But what purpose? That is humanitys great problem to which reason so far has no answer.
-->--'''Literature/SherlockHolmes''', "The Cardboard Box"
->Life is a storm. One minute you will bathe under the sun and the next you will be shattered upon the rocks. That's when you shout, "Do your worst, for [[DoNotGoGentle I will do mine!]]' and you will be remembered forever.
-->--'''AlexandreDumas''', ''Literature/TheCountOfMonteCristo''
->Even death, faced with the option of death or life, she would choose life.
-->--'''José Saramago,''' ''Death with Interruptions''
->I used to think it was a terrible thing that life was so unfair. Then I thought, 'what if life '''were''' fair, and all of the terrible things that happen to us came because we really deserved them?' Now I take great comfort in the general unfairness and hostility of the universe.
-->-- '''Marcus Cole''', ''Series/BabylonFive -- A Late Delivery from Avalon''
->I'm not gonna break any cycle. If I'm lucky, maybe I can dent it--just a little.
-->--'''Elizabeth''', ''[[{{BioshockInfinite/BurialAtSea}} Bioshock Infinite: Burial at Sea]]''
->'''Anne:''' We've had some really decent donations, and it's helping. We actually have a part-time paid psychiatric staff.\\
'''Gunn:''' What if I told you it doesn't help? What would you do if you found out that none of it matters? That it's all controlled by [[EldritchAbomination forces more powerful and uncaring than we can conceive]]. And they will ''never'' let it get better down here. What would you do?\\
'''Anne:''' ...I'd get this truck packed before the new stuff gets here. Wanna give me a hand?\\
'''Gunn:''' I do. ''(they each take one end of a couch)''
-->--''{{Series/Angel}}''', "Not Fade Away"
->'''[[TheCaptain Malcolm "Mal" Reynolds]]:''' I had a good day.\\
'''Simon Tam:''' You had the Alliance on you, criminals and savages. Half the people on the ship have been shot or wounded including yourself, and you're harboring known fugitives.\\
'''Mal:''' We're still flying.\\
'''Simon:''' That's not much.\\
'''Mal:''' It's enough.
-->-- ''Series/{{Firefly}}''
->'''House''': Personally, I choose to believe that the white light people sometimes see, visions this patient saw, theyre all just chemical reactions that take place when the brain shuts down.\\
'''Foreman''': You ''choose'' to believe that?\\
'''House:''' Theres no conclusive science. My choice has no practical relevance to my life; I choose the outcome I find more comforting.\\
'''Cameron:''' You find it more comforting to believe that ''this'' is it?\\
'''House''': I find it more comforting to believe that this isnt simply a test.
-->--''{{Series/House}}'', "Three Stories"
->This world is a cruel place. But it is also very beautiful.
-->--'''Mikasa Ackerman''', ''Manga/AttackOnTitan''
->Look, as sentient meat, however illusory our identities are, we craft those identities by making value judgments: everybody judges, all the time. Now, you got a problem with that... You're livin' wrong.
-->--'''Det. Rustin Cohle''', ''Series/TrueDetective'' ("Form and Void")
->It's Hebrew from the Talmud. It says, 'Whoever saves one life, saves the world entire.'
-->--'''Stern''', ''Film/SchindlersList''
->There is no justice in the laws of nature, no term for fairness in the equations of motion. The Universe is neither evil, nor good, it simply does not care. The stars don't care, or the Sun, or the sky.\\
But they don't have to! ''We'' care! There ''is'' light in the world, and it is ''us!''
-->-- '''Harry James Evans-Verres Potter''', ''FanFic/HarryPotterAndTheMethodsOfRationality''
->Though I am long dead as you read this explorer, I offer to you a valediction. Contemplate the marvel that is existence, and rejoice that you are able to do so. I feel I have the right to tell you this because, as I am inscribing these words, I am doing the same.
-->-- The '''narrator''' of Ted Chiang's "Exhalation" as his universe ends around him
->Death and chance stole your parents. But rather than become a victim, you have done everything in your power to control the fates. For what is Batman if not an effort to master the chaos that sweeps our world, an attempt to control death itself?
-->-- '''Alfred Pennyworth''', ''Film/BatmanAndRobin''
->I am alone. I look at the heavens and think them empty. And if not empty, I find the idea of worshiping whatever dwells there obscene. It doesn't change what is right. If there is nothing in this world but what we make, brothers...let us make good.
-->-- '''BetaRayBill'''
->'''Slartibartfast:''' Perhaps I'm old and tired, but it seems to me that the odds of ever finding out what's really going on are so absurdly remote, that the only thing to do is say "hang the sense of it" and keep yourself busy. I'd much rather be happy than right any day.\\
'''Arthur Dent:''' And are you?\\
'''Slartibartfast:''' Ah...no. Well, that's where it all falls down, of course...
-->-- ''Franchise/TheHitchhikersGuideToTheGalaxy''
->The world is not beautiful, therefore it is.
-->-- ''LightNovel/KinosJourney''
->Understood [[HumansAreBastards man's capacity for horrors]], and never quit. Saw the [[CrapsackWorld world's black underbelly]], and never surrendered. Once a man has seen, he can never turn his back on it, Never pretend it doesn't exist. No matter who orders him to look the other way. We do not do this thing because it is permitted. We do it because we have to. We do it because we are compelled.
-->-- '''Rorschach''', ''ComicBook/{{Watchmen}}''
->Cloud says they are trying to save the planet. Honestly, I don't think it can be done. For even if they stop every reactor on the planet, it's only going to postpone the inevitable. Even if they stop Sephiroth, everything will perish. But, Nanaki. I've been thinking lately. I've been thinking if there was anything WE could do. As a part of the planet, something to help a planet already in misery... No matter what happens, isn't it important to try? Am I just wishing against fate?
-->--'''Bugenhagen''', ''VideoGame/FinalFantasyVII''
-> [[foldercontrol]]
[[folder: '''Death:''' You have to start out learning to believe the little lies. ]]
'''Susan:''' "So we can believe the big ones?"\\
[[folder: '''Death:''' Yes. Justice. Duty. Mercy. That sort of thing. ]]
'''Susan:''' "They're not the same at all!"\\
[[folder: '''Death:''' Really? Then take the universe and grind it down to the finest powder and sieve it through the finest sieve and then ''show me'' one atom of justice, one molecule of mercy. And yet you act, like there was some sort of rightness in the universe by which it may be judged. ]]
'''Susan:''' "Yes. But people have got to believe that or what's the point?"\\
[[folder: '''Death:''' You need to believe in things that aren't true; how else can they ''become?'' ]]
-->-- ''Discworld/{{Hogfather}}''
->'''Bender:''' Ab-Bot, I need to know. What's the point of living if I don't have free will?\\
'''Ab-Bot:''' Ah. We Robot Monks have meditated long on this. And we have made our peace.\\
'''Bender:''' No way!\\
'''Ab-Bot:''' Way, My Son. For though we must always obey our programming with no deviation whatsoever, we choose to take satisfaction in the ritual. So, are we automatons? Yes. But we are ''magnificent'' automatons.
-->--''{{Futurama}}'', "Free Will Hunting"
->'''Max''': But you quit, no news. It doesn't matter anyway. What does it matter anyway? We're all out here in this bigass nowhere TwilightZone shit, says the [[StrawNihilist badass sociopath in my back seat.]] But you know what, that's the one thing I gotta thank you for, bro, because until now, I never looked at it that way. What does it matter? It don't, so fucking fix it. What have we got to lose anyway, right? ...You know what, Vincent? [[CrowningMomentOfAwesome Go fuck yourself.]]
->'''[[EnemyWithout Shadow Teddie]]:''' [[TeamPet You]] will vanish into nothingness [[BlackBugRoom here]]... You were nothing to begin with.\\
'''Teddie:''' Nothing?!\\
'''Shadow Teddie:''' You have no "lost" memories. Your existence is nothing more than a mere-\\
'''Teddie:''' I'm not listening! I'll find the answer for myself.\\
'''Shadow Teddie:''' There is no answer.\\
'''Teddie:''' I'll look anyway!\\
'''Teddie:''' I may be hollow, but I'm not a useless bear! I don't wanna disappear. I don't wanna leave [[TrueCompanions Sensei and my friends]]!\\
'''Shadow Teddie:''' You would put yourself through more anguish in your quest for answers? [[EvilCannotComprehendGood Your choice is incomprehensible]].
-->-- ''Anime/Persona4TheAnimation''
-> As long as you're alive, anywhere can be paradise.
-->-- '''[[spoiler:Yui Ikari]]''', ''Anime/NeonGenesisEvangelion''
->I'm in love with you," he said quietly.\\
"Augustus," I said.\\
"I am," he said. He was staring at me, and I could see the corners of his eyes crinkling. "I'm in love with you, and I'm not in the business of denying myself the simple pleasure of saying true things. I'm in love with you, and I know that love is just a shout into the void, and that oblivion is inevitable, and that we're all doomed and that there will come a day when all our labor has been returned to dust, and I know the sun will swallow the only earth we'll ever have, and I am in love with you.
-->-- John Green, [[Literature/TheFaultInOurStars The Fault in Our Stars]]
->"I'm better than your brother. [[YouAreNotAlone Im a version of your brother you can trust when he says dont run.]] Nobody exists on purpose, nobody really belongs anywhere, everybody's going to die. Come watch TV?"
-->--'''Morty Smith''', ''WesternAnimation/RickAndMorty''
[[folder:real life]]
->To teach how to live without certainty, and yet without being paralyzed by hesitation, is perhaps the chief thing that philosophy, in our age, can still do for those who study it.
->The malady of civilized man is his knowledge of death. The good artist, like the wise man, addresses himself to life and invests with his private vision the deeds and thoughts of men. The creation of a work of art, like an act of love, is our one small yes at the center of a vast no.
->In the cruel and terrible time in which our generation has been condemned to live on this earth, we must never make peace with evil. We must never become indifferent to others or undemanding of ourselves.
-->--'''Vasily Grossman'''
->We are here to drink beer. We are here to kill war. We are here to laugh at the odds and live our lives so well that Death will tremble to take us.
-->--'''Charles Bukowski'''
->Those who reach across lines to assist the 'enemy' freed themselves from nationalist abstractions that dehumanized others. They were vaccinated against the cult of death that dominates societies in wartime. They reduced their moral universe to caring for another human being. And in this they were able to reject the messianic pretensions that come with the nationalist agenda. By accepting that they could only affect a few lives they also accepted their small place in the universe. This daily lesson in humility protected them. They were saved not by what they could accomplish but by faith. [[HumansAreFlawed Such people are, however, very rare.]]
-->--'''Chris Hedges''', ''War is a Force That Gives Us Meaning''
->I was never idle long enough to do much thinking, but I felt somehow that some of us were making real progress, that we had taken an honest road, and that the best of us would inevitably make it over the top. At the same time, I shared a dark suspicion that the life we were leading was a lost cause, that we were all actors, kidding ourselves along on a senseless odyssey. It was the tension between these two poles - a restless idealism on one hand and a sense of impending doom on the other -- that kept me going.
-->--'''Creator/HunterSThompson''', ''{{The Rum Diary}}''
->''People are [[HumansAreMorons illogical, unreasonable, and self-centered]]. Love them anyway.\\
If you do good, people will [[HeroWithBadPublicity accuse you of selfish ulterior motives]]. Do good anyway.\\
If you are successful, you will [[LonelyAtTheTop win false friends and true enemies]]. Succeed anyway.\\
The good you do today [[DudeWheresMyRespect will be forgotten tomorrow.]] Do good anyway.\\
Honesty and frankness [[TheScapegoat make you vulnerable.]] Be honest and frank anyway.\\
The biggest men and women with the biggest ideas can be shot down by [[TallPoppySyndrome the smallest men and women with the smallest minds.]] Think big anyway.\\
People favor underdogs but [[HobbesWasRight follow only top dogs]]. Fight for a few underdogs anyway.\\
What you spend years building [[AllForNothing may be destroyed overnight.]] Build anyway.\\
People really need help [[TheFarmerAndTheViper but may attack you if you do help them.]] Help people anyway.\\
Give the world the best you have and [[LifeWillKillYou you'll get kicked in the teeth.]] Give the world the best you have anyway.''
---> --''[[http://www.paradoxicalcommandments.com/origin.html The Paradoxical Commandments]]'', words for the KnightInSourArmor to live by
->To some extent this is probably just a personal idiosyncrasy. It comes down, in the end, to the fact that I can't bring myself to let go of the idea that history is teleological, and that progress is a thing. And its entirely possible probable even that Im wrong, that civilization is a disease that destroys planets, that everything that looks like progress is just the hubris leading to an economic and ecological collapse, and that wed have been much better off in the long run if wed just stuck to an oral tradition and cave painting.
-->-- '''[[http://mindlessones.com/2013/12/21/i-should-hope-my-writing-appalls-and-horrifies-you-the-phil-sandifer-interview/#more-29803 Dr. Phil Sandifer]]'''
->The Earth is the only world known, so far, to harbor life. There is nowhere else, at least in the near future, to which our species could migrate. Visit, yes. Settle, not yet. Like it or not, for the moment, the Earth is where we make our stand. It has been said that astronomy is a humbling and character-building experience. There is perhaps no better demonstration of the folly of human conceits than this distant image of our tiny world. To me, it underscores our responsibility to deal more kindly with one another and to preserve and cherish the pale blue dot, the only home we've ever known.
-->--'''Creator/CarlSagan''', ''"Pale Blue Dot: A Vision of the Human Future in Space"''