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Advancing asthma care: the glass is only half full!!
Stanley J. Szefler, M.D.
Helen Wohlberg & Herman Lambert Chair in Pharmacokinetics, Divisions of Pediatric Clinical
Pharmacology and Allergyand Immunology, Department of Pediatrics, National Jewish Health;
Professor of Pediatrics and Pharmacology, University of Colorado School of Medicine, Denver,
Over the past 20 years there has been a concerted effort in the United States to reduce morbidity
related to chronic disease including asthma. Attention was initially directed towards asthma in
response to the recognition that asthma mortality was increasing and that the burden of disease
was significant. These efforts to address asthma mortality led to many new initiatives to develop
clinical practice guidelines, implement the asthma guidelines into clinical practice, conduct
research to fill the gaps in the guidelines, and to continuously revise the asthma guidelines as more
information became available. An assessment of our progress shows significant accomplishments
in relation to reducing asthma mortality and hospitalizations.
Consequently, we are now at a crossroads in asthma care. Although we have recognized some
remarkable accomplishments in reducing asthma mortality and morbidity, the availability of new
tools to monitor disease activity, including biomarkers and epigenetic markers, along with
information technology systems to monitor asthma control hold some promise in identifying gaps
in disease management. These advances should prompt the evolution of new strategies and new
treatments to further reduce disease burden. It now becomes imperative to continue a focus on
ways to further reduce the burden of asthma and prevent its onset.
Asthma; childhood asthma; asthma therapy; asthma statistics; asthma management; asthma
guidelines; asthma disease management; inhaled corticosteroids; long-acting β-adrenergic
agonists; leukotriene receptor antagonists; omalizumab; asthma surveillance; asthma mortality;
asthma hospitalizations; asthma exacerbations; asthma progression; personalized medicine; public
Over the past 20 years there has been a concerted effort in the United States to reduce
morbidity related to chronic disease including asthma. Attention was initially directed
towards asthma in response to the recognition that asthma mortality was increasing and that
the burden of disease was significant. These efforts to address asthma mortality led to many
new initiatives to develop management guidelines, implement the asthma guidelines into
clinical practice, conduct research to fill the gaps in the guidelines, and to continuously
revise the asthma guidelines as more information became available.
Corresponding author: Stanley J. Szefler, M.D., National Jewish Health, 1400 Jackson Street, Room J304 Molly Blank Building,
Denver, Colorado 80206, Phone: 303-398-1193 FAX: 303:270-2189 firstname.lastname@example.com.
NIH Public Access
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Published in final edited form as:
J Allergy Clin Immunol. 2011 September ; 128(3): 485–494. doi:10.1016/j.jaci.2011.07.010.
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The Journal has also participated in this effort to improve asthma care by publishing
numerous original articles, along with review articles and editorials to draw attention to the
advances in asthma research and to discuss current controversies. For the past 10 years, the
Journal has also published annual reviews on advances in childhood and adult asthma in
order to summarize the key publications from each year, especially from the Journal (1, 2).
Since the initial publication related to increased asthma mortality in New Zealand (3),
approximately 30 years ago, many changes have occurred to organize asthma care within
countries and globally. The first version of asthma guidelines in the United States was
introduced in 1991. Therefore, twenty years later is a good time to appraise where we are in
asthma care and what steps need to be taken to further improve asthma management in
children and adults. Indeed, an assessment of our progress shows significant
accomplishments and it now becomes imperative to continue a focus on ways to further
reduce the burden of asthma and prevent its onset.
Pathway to success
Reports in the early 1980s brought attention to increasing mortality and this was a wakeup
call to redirect asthma management (3). Over the next ten years, studies utilizing
bronchoscopy and biopsy indicated that asthma was more than acute inflammation
secondary to allergen exposure or simply bronchospasm related to asthma triggers, such as
an environmental irritant or exercise. These studies indicated that asthma was also a chronic
inflammatory disease. The approach to asthma management transitioned quickly from
treatment that utilized predominantly bronchodilator-based management (theophylline) to
one directed at anti-inflammatory (inhaled corticosteroid) therapy. National guidelines were
introduced in several countries in order to consolidate principles of asthma care and
transition the treatment approach to a base of anti-inflammatory therapy.
Asthma Guidelines
During the 1990s, a number of important developments occurred including the introduction
of asthma guidelines to translate research findings into clinical practice, more effective
medications, and the introduction of managed care. The first publication of asthma
guidelines from the National Asthma Education and Prevention Program (NAEPP) was
introduced in the United States in 1991 (4), followed by the development of International
Guidelines in 1992 (5), and consequently the Global Initiative for Asthma (GINA)
guidelines in 1995 (6). This was an attempt to unify treatment within countries and then to
collaborate on a uniform approach to asthma management in countries with a similar
socioeconomic base. The global guidelines took into account the varying economies and
access to medication. Since that time, there have been continuing revisions of the asthma
guidelines with the most recent version of the United States guidelines released in 2007 (7).
These revised guidelines emphasized asthma control and put forth two domains of control,
impairment to assess current symptoms and risk to assess potential for future exacerbations,
asthma progression and adverse medication effects (7).
New Medications
Many new medications for the management of asthma were introduced in the United States
during the 1990s. These medications included more potent inhaled corticosteroids
(budesonide, fluticasone), long-acting β-adrenergic agonists [LABA] (salmeterol,
formoterol), leukotriene modifiers (zafirlukast, zileuton, montelukast), and subsequently
combination therapy with inhaled corticosteroids (ICS) and LABA in a single delivery
device. The efficacy of these new medications was remarkable, especially combination ICS/
LABA therapy, and physicians increasingly recognized the ability of these new medications
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to reduce symptoms, exacerbations and systemic steroid requirements. Concern has been
raised regarding potential increased risk of severe asthma-related exacerbations with LABA
therapy and attempts have been made to limit use of LABA therapy (8). The only new
medication that has been introduced in the past 10 years has been omalizumab, anti-IgE.
This medication, although very effective in a proportion of patients with severe asthma, has
limited application due to high cost.
Ongoing Management
Along with the introduction of guidelines and new asthma medications, the concept of
asthma management consisting of a multi-faceted, ongoing approach to prevent
exacerbations was introduced and implemented during the 1990s and dramatically changed
the landscape for medical care. This period of time saw the merging of single physician
practices into multiple physician practices, and subsequently to multi-specialty clinics. A
major goal was to reduce inpatient care and thus to reduce hospital costs. In the past ten
years, increased attention has been placed on the management of asthma in children. This
was prompted by the recognition that inhaled corticosteroids as compared to as-needed
short-acting β-agonists had a significant effect on improving asthma control (9). In addition,
adverse effects of inhaled corticosteroids were limited to a small reduction in growth
velocity during the first year of treatment (10). This effect appears to be persistent but not
progressive (10). In regards to the efficacy of ICS in asthma management, they have been
shown to adequately control symptoms during the course of treatment but symptoms recur
when treatment is stopped. However, ICS did not significantly alter the course of the disease
based on this study (9).
With the recognition that management with asthma needs to be an ongoing rather than an
intermittent effort, support programs have been developed to assist patients in symptom
monitoring and to provide asthma education through various resources. The certification of
asthma educators has also established some consistency in information that is provided to
patients including features of environmental control. With the introduction of new
medications and new insights in disease development, efforts have now been enhanced to
increase awareness of asthma and provide asthma education for clinicians and patients.
Community programs have emerged to support health care advances including school
programs. In addition, efforts have been made to expand information related to work related
asthma (11, 12). Healthy People 2000 goals made asthma a national priority (13). The
objectives of Healthy People 2000 included: reduction in asthma hospitalizations (objective
11.1) and reduction to no more than 10% the proportion of people with asthma who
experience activity limitation (objective 17.4) (14). Asthma-specific Healthy People goals
for 2010 were expanded considerably to promote and track adoption of appropriate asthma
care as established in the NAEPP Expert Panel Report guidelines and self-management
education (15). The asthma objectives have been expanded and updated for the recently
released Healthy People 2020 goals
A major public health response has been directed to actions at the state and community level
to support patient- and community-level interventions and to assess the impact of the
environment on asthma (16 – 18) by the Centers for Disease Control and Prevention (CDC),
the National Heart, Lung and Blood Institute (NHLBI), and the Environmental Protection
Agency (EPA) and other federal agency partners. The CDC National Asthma Control
Program (NACP) was created in 1999 to implement evidence-based interventions at the
state and local level, forge partnerships between federal agencies, state health departments
and nongovernmental organizations to support asthma programs in multiple settings
(hospital systems, city health departments, school systems, and local chapters of national
asthma organizations), and to establish national and state asthma surveillance (19). In 2001,
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the Controlling Asthma in American Cities Project (CAACP) began and by 2009, the NACP
supported 34 states, Washington, DC and Puerto Rico with grants and technical assistance to
build and sustain programs that translate evidence-based practice into interventions. For
example, the NACP in partnership with the Task Force on Community Preventive Services
systematically reviewed the evidence of effectiveness of home-based multi-trigger multi-
component environmental interventions in improving asthma-related morbidity. Findings
indicated this approach is effective in improving overall quality of life and productivity in
children with asthma, and this home-based multifaceted approach is now being implemented
on the state and local level with planned evaluation of its impact.
The National Asthma Education and Prevention Program (NAEPP), sponsored by the
NHLBI not only develops the clinical practice guidelines, but also supports a number of
activities to enhance education of health care professionals, patients, and the public about
managing asthma. The NAEPP's National Asthma Control Initiative (NACI)
(http:://naci.nhlbi.nih.gov), launched last year, is an effort to accelerate adoption of the key
messages of the clinical practice guidelines in clinical practice, community settings, and
among government and private insurer programs. The NACI program sponsors
demonstration projects at the community level to develop educational tools, community
champions, and partnership programs with professional societies and lay organizations; the
website and newsletter gives up-to-date information about these projects.
The EPA supports a number of activities to enhance the integration of tailored
environmental interventions to reduce exposures that worsen asthma with comprehensive
medical care and community services for people who have asthma. Their website,
www.AsthmaCommunityNetwork.org <http://www.AsthmaCommunityNetwrok.org>,
offers community based asthma programs and health practitioners a forum for exchanging
information about and share resources for improving asthma care, including Internet tools to
facilitate collaboration, problem solving, and sharing program activities and news about
asthma-related events. The website is sponsored by EPA in partnership with Allies Against
Asthma and the Merck Childhood Asthma Network.
Population level surveillance has also developed in an attempt to identify trends in asthma
mortality and morbidity at both the national and local level. The national surveillance
program has also been created to systematically track prevalence, morbidity, health care use
and mortality. The first asthma surveillance summary was published in a Morbidity and
Mortality Weekly Report (MMWR) supplement series (20) in 1998. It brought together in
one publication existing national data on asthma prevalence, morbidity and mortality. At
that time there was no state level data on asthma and minimal national level data. State and
local level surveillance was initiated in 1999 (19).
In 1999, the Behavioral Risk Factor Surveillance System (BRFSS) added questions about
asthma control and medication use. In 2001 additional detail on adult asthma control
characteristics were obtained through a BRFSS optional module. Another BRFSS optional
module with child prevalence questions was introduced in 2005. The National Asthma
Survey (NAS), piloted in 2003 in four states and a national sample provided extensive
additional detail on asthma management. Use of the detailed NAS questionnaire has been
expanded through its implementation as a BRFSS Asthma Call-back Survey (ACBS) since
2005. The number of states conducting the ACBS has increased each year to 39 states in
2010. There has also been an increase in publications utilizing national and state
surveillance data. Two additional national surveillance summaries were published in 2003
and 2007.
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State level data is readily available on the NACI Program website
(http://www.cdc.gov/asthma/asthmadata.htm). Asthma surveillance data has also been
published in several journals (http://www.cdc.gov/asthma/links_data.html). These efforts are
intended to prompt a proactive approach to asthma management by monitoring population
level changes in asthma morbidity and mortality at the national, state and local level.
Asthma research
Asthma research expanded over the past 30 years to include several new areas of
investigation including, better methods to conduct clinical trials and to test interventions,
effectiveness research to understand real-world application of clinical trials information, and
pharmacogenetics discovery to identify new methods to individualize asthma management.
During the 1980s, studies related to asthma were mainly directed by pharmaceutical
industries and largely regulatory in nature. During the 1990s, there was a move towards
evidence-based medicine and the introduction of NIH asthma networks to address gaps in
asthma management including inner city asthma (21 – 28). With the emergence of key
asthma network studies, it was possible to identify comparative efficacy of medications,
explore variability in treatment response and obtain information on areas of need including,
inner city asthma, severe asthma, and early development of asthma (21 – 29). Also, studies
were reported that demonstrated the role of intermittent inhaled corticosteroid in place of
continuous daily dosing of this medication in order to minimize the risk of adverse effects
In addition, information from key asthma cohorts emerged to show the variable course of
asthma (33 – 40). Also, there is increasing recognition of the importance of comparative
effectiveness research to assess the benefits of medications in "real world" settings through
trials conducted outside the academic research setting and in the community settings, and to
evaluate the uptake and implementation of guideline-based care [41].
In summary, the recognition of increased asthma mortality in the early 1980s prompted an
ongoing effort to reduce mortality, reduce asthma exacerbations and improve overall asthma
control. In the 1990s there was a dramatic transition away from bronchodilator therapy as
core management to anti-inflammatory therapy as the preferred long-term controller.
National and global guidelines emerged to help consolidate information, change the focus of
management from episodic to ongoing disease management, and identify gaps in
management. Concerted efforts were developed to provide a mechanism to conduct
therapeutic research beyond the regulatory requirements for medication approval. Systems
were also developed to monitor asthma not only for asthma related mortality but also asthma
morbidity. This information also identified health disparities in mortality and morbidity. All
of this has paved the way for defining methods to improve health care by recognizing the
gaps in management and finding better interventions, especially for disadvantaged
Current status of asthma care
Overall, we can feel a sense of accomplishment in reducing asthma mortality and
hospitalizations due to asthma in the United States. Measurement of asthma prevalence
changed with the redesign of the National Health Interview Survey (NHIS) in 1997 [Figure
1]. There was a rapid increase from 1980 to 1996 of asthma 12-month period prevalence by
an average of 3.8% per year. After the redesign, the most comparable measure, current
asthma prevalence, was introduced in 2001 and still demonstrates increasing prevalence,
although at a lower rate, an average of 1.4% per year. The growing proportion of the U.S
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population with current asthma, 8.2% (24.6 million people) in 2009, presents a continuing
challenge to adapt and improve effective prevention and disease management strategies.
Coupled to this observation of increasing prevalence of asthma is the current estimate of
substantial costs related to asthma. Barnett and Nurmagambetov (42) evaluated data from
the Medical Expenditure Panel Survey and reported that over the years 2002–2007, the
incremental cost of asthma was $3,259 per person per year. For 2007, the total incremental
cost of asthma to society was $59 billion, with productivity losses due to morbidity
accounting for $3.8 billion and productivity losses due to mortality accounting for $2.1
Reductions in both asthma hospitalization and death rates have occurred over the past
decade despite the challenge of increasing prevalence [Figure 2]. However, racial disparities
in hospitalization and mortality remain a challenge. Asthma hospitalization rates among the
black population remain consistently higher than among the white population [Figure 3a]. In
2008, hospitalization rates were 3.6 times as high among black versus white populations, the
largest disparity during the period shown from 1980 to 2008.
While asthma death rates among the black population are also much higher, the relative
disparity has decreased from a high of 3.1 times higher death rates among black compared to
whites in 2004 to 2.8 in 2007 [Figure 3b]. These striking disparities post a challenge for
implementing effective asthma control measures among disparate populations with likely
different needs and obstacles.
Although less dramatic, gender disparities also exist. In 2008, asthma hospitalizations were
1.5 times higher among females than males [Figure 4a]. The rise in asthma death rates in the
1980s was disproportionately borne among females with relative disparities reaching 1.4
times higher rates among females compared to males, a difference that has persisted despite
declining death rates during the last decade [Figure 4b].
Although this information has not been quantified in full publications, clinicians have
recognized a reduction in the number of patients receiving oral glucocorticoid therapy as
part of the maintenance schedule. This has significantly reduced the number of patients
suffering the consequences of adverse effects of systemic steroid therapy including
osteoporosis, cataracts, and growth suppression. This observation has been particularly
remarkable for children and has changed the spectrum of the disease. This has been largely
attributed to the introduction of new medications, organization of treatment into guidelines,
and better systems of management.
Currently, there is a focus on asthma control and emerging interest in prevention, initially on
preventing symptoms and then moving towards preventing progression. However, available
research and surveillance show a continued underutilization of evidence-based management
strategies to control asthma and thus there is room for improvement. This is an important
step for addressing disparities in health care. National data exists for persons with asthma
who report receiving components of self-management education and show that only a low to
moderate percentage have received the basic elements of asthma education [Table 1] (43).
Steps have been taken to achieve better monitoring systems for asthma including new tools
such as electronic medical records and health care provider surveillance systems. This level
of systematic monitoring also has practice level implications that strive to improve quality of
care by tracking outcomes.
Along with the changes in practice management, the concept of personalized medicine has
also emerged and early indicators suggest that this could significantly advance asthma
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management since there are variable responses to asthma treatment. While clinicians readily
use a personalized approach to selecting a medication, dose and delivery system to relieve
and prevent asthma symptoms, they do not currently use patient characteristics, biomarkers,
and genetics to select and adjust treatment. Generally, treatment is still based most often on
symptom presentation. Even basic tools, such as spirometry, are not readily incorporated in
assessing asthma control, monitoring the course of asthma, and adjusting therapy
accordingly. While spirometry is incorporated in asthma care conducted by most
subspecialists, it has not been readily adapted in the course of asthma management in
primary care.
There are several other interesting trends that will impact asthma management in the near
future. There are increasing public health concerns regarding the impact of the environment
on respiratory health and measures are being taken to institute control procedures and alert
the public to hazards, for example publication of pollen counts and to incorporate asthma
friendly environmental policies into public housing as well as school structure and
rehabilitation. Current targets have been set to reduce hospitalizations and urgent care
utilization by developing a systematic approach to managing chronic diseases including
asthma by health care providers. The concept of a medical home has been introduced in
order to help coordinate medical care, self-management education, and programs to link
families to the services they need to support the treatment plan.
Unfortunately, there are no new asthma medications on the horizon. However, observations
have been made regarding the beneficial effects of medications that were not directly
approved for asthma management, including vitamin D and tiotropium (44–46). Steps are
also being taken to obtain better insight on the origins of asthma, the natural history of
asthma, the relationship of genetics to the risk of developing asthma and to the variations in
response to treatment, and identification of easily measured biomarkers that can be used to
predict response to medications and monitor disease activity.
In summary, we are now at a crossroads in asthma care. We have recognized some
remarkable accomplishments in reducing asthma mortality and morbidity and closing some
gaps in health disparities with the introduction of new medications and management
systems. The availability of new tools to monitor disease activity, including biomarkers and
epigenetic markers, along with information technology systems to monitor asthma control
hold some promise in identifying gaps in disease management and should prompt the
evolution of new strategies and new treatments to further reduce disease burden.
Challenges for the next 10 years
How do we go beyond measures of asthma mortality and hospitalizations?
Efforts are now being made to provide precise definitions and methods for measuring key
asthma outcomes based on work of the NIH Asthma Outcomes Task Force held in 2010
(report in preparation). This will allow comparison across data in studies and facilitate
pooling of data for meta-analysis.
While it is important to continue monitoring critical asthma outcome measures, it would also
be useful to assess the impact of asthma on individual lives of all asthma patients. Some
health care systems are already taking steps to monitor asthma control in their patients and
prompt treatment adjustments to their clinicians. Indeed, disease severity is a combination of
the level of asthma control along with the number and dose of medications used to achieve
that control. Useful tools for health care providers to assess the impact of asthma and the
proportion of patients that are considered severe and systemic-steroid requiring will be
helpful. Identifying those patients that are significantly impacted by asthma and refractory to
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conventional treatment could direct them to studies that evaluate the efficacy of new
treatment strategies, such as immunomodulator therapy.
Will techniques of "personalized medicine" move from the bench to the clinic to the home
Currently, risk of disease is gauged by family history. Symptom expression is used to assess
asthma severity and control. Utilization of asthma action plans and education programs have
helped patients manage their own disease. The asthma self-management concept has
expanded. However, many patients with asthma still do not benefit from a comprehensive
management program and despite application of such a program there are still unpredictable
and severe exacerbations that lead to urgent care.
Combining a system of careful follow-up and communication through electronic medical
records along with periodic measurements of pulmonary function, there is the capability of
monitoring disease activity and the natural history of the disease in individual patients
including, remission, progression, and relapse (36, 38). However, these are still prominent
features of the disease and perhaps the identification of more subtle monitors of disease
activity, such as biomarkers and epigenetic markers, could prompt a more effective
treatment strategy to actually prevent exacerbations and progression. There is a continuing
debate on whether chronic obstructive pulmonary disease (COPD) might reflect the
evolution of a certain phenotype of asthma. Identifying these patients early in the course of
the disease, therefore, could theoretically lead to more effective early intervention strategies
to prevent COPD. The definition of asthma phenotypes and identification of specific
phenotype-related interventions will also be important.
To date, exhaled nitric oxide and sputum eosinophils have been prototype markers of
disease activity and targets of therapeutic intervention. Strategies to reduce sputum
eosinophils via methods to monitor and adjust glucocorticoid therapy have been shown to
significantly reduce asthma exacerbations (47). However, use of sputum eosinophils has
been limited to clinics with readily available procedures. Exhaled nitric oxide, on the other
hand, is easier to measure, although still requiring special training, equipment and
maintenance. It may be used in the clinic setting to obtain on-site results for clinical
decisions. The results of studies incorporating periodic measures of exhaled nitric oxide
have been less impressive in reducing exacerbations, as compared to sputum eosinophils
(48, 49).
Although, there is limited additional value of measurements of exhaled nitric oxide for
monitoring and adjusting therapy over a guidelines-based approach, measures of exhaled
nitric oxide can be used as a predictor of inhaled corticosteroid response in children, but not
necessarily in adults (50, 51). Furthermore, a recent study using a combination of urinary
leukotrienes and exhaled nitric oxide including the ratio of these two biomarkers, may help
direct the selection of either inhaled corticosteroid or leukotriene receptor antagonist therapy
for first-line long-term controller therapy in children (52). Exhaled nitric oxide might also be
used as a measure of medication adherence for inhaled corticosteroid therapy, although
further studies are needed, since exhaled nitric oxide might also be elevated due to other
exposures, such as allergens in sensitized patients.
To date, monitoring daily peak flows has not been sufficiently sensitive and specific to
identify impending asthma exacerbations (53), but still may be useful in assessing
variability, an important indicator of unstable asthma.
Furthermore, information is emerging that the Asthma Predictive Index, identified as part of
the Tucson Respiratory Study, can be useful in identifying young children with early
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respiratory tract illnesses suggestive of asthma or emerging asthma. A positive Asthma
Predictive Index may also be associated with a higher likelihood of beneficial effects from
inhaled corticosteroid therapy in young children with emerging asthma (31, 54). Further
refinement of these clinical tools and their application could help direct the selection and
monitoring of asthma therapy, especially in children.
Exploration of genetic markers continues in relation to clinical application for asthma
management. The most well studied genetic marker to date for asthma has been associated
with β-adrenergic polyporphisms. Early information suggested that the B16 Arg-Arg
polymorphism therapy was associated with declining pulmonary function in those treated
with regular short-acting β-agonists (55). Since this method of treatment, namely regular use
of short acting β-agonits, is now rarely used and the marker has not been associated with
deteriorating asthma control with combination ICS/LABA therapy, the clinical application
of this genetic marker is not an essential component of asthma care. However, emerging
information with filaggrin polymorphisms, suggests that this marker, when identified in
patients with atopic dermatitis, may carry a prognosis for higher risk of asthma (56, 57).
This combination of patient characteristics and genetics could prompt early intervention
strategies that would provide improved control and perhaps lead to disease remission.
What changes can be expected from the Public Health perspective?
Continued efforts are being made to follow the epidemiology and impact of asthma through
national, regional and local statistics. This information can be used to identify areas of need.
In particular, community statistics can be useful in identifying hot spots of asthma
prevalence or areas of increased asthma burden in order to focus resources or identify
impact factors, such as the environment, socioeconomics, or a combination thereof. This is
one of the direct effects of the CDC National Asthma Control Program that funds states for
surveillance, coalition building and interventions (19). Recent information from the websites
of the NHLBI NACI program and the EPA's Asthma Community Networks, in addition to
the CDC programs reveals increasing effort to coordinate federal programs to broaden their
reach to underserved communities and strengthen their ability to help clinicians and patients
improve asthma management.
With the development of a global approach to asthma care, there can be more
standardization of asthma management, however, various economic factors may lead to site-
and community- specific medication selections or intervention strategies. Once again,
statistical information to identify areas of high asthma prevalence and morbidity will be
important to channel knowledge and resolution.
On a broader scale, public health response to increased application of guideline-
recommended care, could further identify and address health disparities in asthma care.
There are ongoing challenges to implement a guidelines-based approach into clinical
practice and to increase public awareness of asthma control and for patients to work with
clinicians to achieve control. Continued health care policy changes should help to improve
reimbursement for physicians to provide this level of care and for patients to benefit from it.
A carefully integrated plan to understand and address emerging public health challenges,
e.g., increasing exposure to traffic pollutants, housing, climate change and pollutant/allergen
interactions, and reducing second hand tobacco smoke exposure, should also prove helpful
in reducing asthma burden.
Can we "cure" asthma by halting progression and preventing onset?
With the continued utilization and development of data bases for clinical outcomes,
biomarkers, genetics and environment to help understand disease origins and natural history,
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we will be able to successfully develop early intervention strategies for control and
prevention. Indeed, the Getting to Healthy People 2020 strategy places an emphasis on
disease prevention (58). To get to that point, it will be important to define genetic markers
and environmental factors that place individuals at risk for developing asthma. If certain
markers and environmental factors are associated with the development of asthma,
especially severe asthma, this will prompt consideration for the use of immunomodulators at
an earlier time point in management.
Methods to monitor disease activity, such as epigenetics and biomarkers, will be important
to assess the risk of disease persistence and progression. Information is also developing
related to potential effect of the microbiome on asthma development (59). However, it is not
clear whether the organisms identified are causative or perhaps commensal due to a defect in
the immune system related to asthma (60). This story will continue to develop.
Currently, our early intervention strategies center around the use of short-acting β-
adrenergic agonists to relieve symptoms and glucocorticoids to address airway
inflammation. However, some studies suggest that this strategy is not sufficient to alter the
course of the disease once glucocorticoid treatment is discontinued (61). If this is indeed
true, then more effective strategies are needed to prevent progression and to reduce the risk
of asthma exacerbations. We must continue to try to understand reasons for treatment failure
to shed light on potential new treatment strategies including new medications.
To date, the application of immunomodulator therapy in young children is viewed with great
concern due to potential effects on growth and development including the immune system
and the ability to maintain adequate host defense. However, a recent article related to
omalizumab therapy and the reduction of fall exacerbations in inner city children, prompts
questions related to the potential interaction of viral and allergen-induced inflammation (24,
62). Perhaps, strategies designed to target periods of allergic inflammation will also reduce
the risk of viral-induced asthma exacerbations. This area merits further study. Efforts to
define severe forms of asthma and identify phenotypes could also lead to a more directed
approach to management (26, 27, 63).
In regards to environmental control, it is apparent that airway inflammation and consequent
symptoms of airway obstruction due to inflammation can be related to allergy, virus, and air
pollutants. However, there are no specific biomarkers that can be used to identify the driving
force of the airway inflammation. Although exhaled nitric oxide and sputum eosinophils are
often associated with allergic airway inflammation, urinary leukotrienes with tobacco smoke
exposure and sputum neutrophils with infection or air pollution, it is not entirely clear on
how to use these specific markers to set a direction in treatment for individual patients. If
certain biomarkers could prove useful to differentiate the factors leading to airway
inflammation, perhaps they could channel environmental control strategies that are more
specific to the individual patient rather than generalized to all patients with asthma.
Can this effort extend to other national and global initiatives?
Indeed, asthma is considered a global public health problem. Concerted efforts within and
beyond countries can help shed light on the epidemiology and management of asthma. This
review has focused on information available in the United States but asthma and allergies
are being addressed in various worldwide efforts. As previously mentioned, the Global
Initiative for Asthma guidelines seek to address asthma management for developed and
developing countries. In addition, the World Allergy Organization is preparing a white book
that will address the rising prevalence of asthma and allergies to increase the visibility of
this problem and to propose recommendations to improve management.
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The Asthma series
This review is the first in a series of Journal articles on the current status of asthma. The
objective of this series is to highlight specific areas important to advancing asthma care.
Each review will summarize current status of the area and future needs to advance the field.
The next article in this series will focus on asthma pathophysiology. Dr. Stephen Holgate
will discuss the pathophysiology of asthma and the information that has developed
following the evaluation of new medications intended to interrupt various pathways of
inflammation. Dr. Wiliam Busse will then discuss the advantages and limitations of our
current tools and gaps that must be filled to improve on the diagnosis and treatment of
Next in this series, will be a discussion of the origins of asthma by Dr. Fernando Martinez.
Dr. Martinez will summarize current knowledge on the origins and natural history and the
need for further studies to define the various pathways of this disease, as it presents in
children and adults. This will be followed by a comprehensive discussion of the current state
of severe asthma.
Dr. Sebastian Johnston will follow with a topical review of asthma exacerbations. He will
discuss our knowledge regarding the etiology of asthma exacerbations and future steps that
could be taken to reduce the frequency and impact of these exacerbations or periodic loss of
Dr. Peter Barnes will analyze whether the pattern of severe asthma is changing and what
determines whether asthma is severe. He will also discuss our current treatment strategies
and the promise for new interventions.
Dr. Scott Weiss will conclude the series with a timely discussion of genetics and the
application of personalized medicine. He will identify steps that could be taken now to apply
these principles and steps that could be taken in the future to advance therapy and improve
the asthma guidelines.
We thank all of the invited experts for the time they took to evaluate their area for review
and for a comprehensive discussion of these topics. We hope that these summaries will
prompt further research that will lead to continuing advances in asthma care.
Supported in part by Public Health Services Research Grants HR-16048, HL64288, HL 51834, AI-25496,
HL081335, HL075416, and the Colorado Cancer, Cardiovascular and Pulmonary Disease Program. Supported in
part by Colorado CTSA grant 1 UL1 RR025780 from the National Institutes of Health (NIH) and National Center
for Research Resources (NCRR).
I would like to thank several colleagues for their assistance in preparing this review on the current status of asthma
management. I am grateful for the enthusiastic and thoughtful insights from Lara Akinbami, Jeanne Moorman and
Paul Garbe from the Centers for Disease Control, Virginia Taggart from the National Heart, Lung and Blood
Institute and my close friend and colleague, Harold Nelson. I would also like to thank the Editor-In-Chief, Donald
Leung, for encouraging the development of this series. I also thank Gretchen Hugen for assistance in the manuscript
Asthma Call-Back Survey
Behavioral Risk Factor Surveillance System
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Centers for Disease Control
chronic obstructive pulmonary disease
Environmental Protection Agency
Global Initiative for Asthma
inhaled corticosteroid
long-acting β-adrenergic agonists
Morbidity and Mortality Weekly Report
National Asthma Control Initiative
National Asthma Control Program
National Asthma Education and Prevention Program
National Asthma Survey
National Health Interview Survey
National Heart, Lung, and Blood Institute
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This fellow was enthusiastic, energetic, and quite theatrical in his efforts to get passersby to stop at his little booth on the marina in Cabo San Lucas.
G'day Phil,
Encased by the products he sells this enthusastic vendor looks very much at home and you have photographed him very well in a great gesticulative pose and with a good composition, depth of field and focus.
Highlights and contrast have been well controlled and the colours are nicely natural.
The slight lens distortion works well here adding to the claustrophobic feel to the scene.
thanks so much dennis for taking the time to provide that feedback. Much appreciated!!!
– phil decocco
FANTASTIC ~~ LOVE THIS ~~Phil
thanks joe, this guy was a character! He saw my camera, put that sombreror on in a flash, and began his antics. When I showed him the shot, he had this deep, basso type laugh that rolled up from his belly.
brilliant capture of him in his domain!!
he was a hoot, playing to whatever audience got near.
Excellent capture, great composition and colours and the guy in the little shop looks like a real character!
robert, he was a one man band! Antics, gesticulations, and a booming voice!
15 years ago dad said he was just going out for some cigarettes, well look where he popped up! I'd know that mustache anywhere! Great Shot
well, dad was a million laughs and a great entrepreneurial whiz bang, center ring, barker.

subset: commoncrawl


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Genesis Health System in Davenport, Iowa, uses UnitedHealthcare's Heritage Premier Plan to help employees lose weight and address health risks. The program, through which employees can reduce their insurance premiums, is focused on health screenings, preventive care, and diet and exercise programs.
View Full Article in:Quad-City Times (Davenport, Iowa)
Published in Brief:


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Senior Taylor Collins and junior Anna Newton scored 14 points each while senior Haley Burke added 10 to lead Bulloch Academy to its 10th straight win Friday night as the Lady Gators pummeled Curtis Baptist 54-20.
The last couple of years has seen the Bulloch Academy wrestling team rise to prominence and even boast a few individual state champions. The Gators are off to another strong start in the 2011-12 season and are looking to take home the ultimate prize.
From the time she began her career at Claxton High School, Polly Murray has been a force to be reckoned with.
Southeast Bulloch is trying to regain its stride after a few down years and senior forward Blake Lundy is leading the charge.
After a pair of tough losses over the weekend, the Statesboro boys bounced back in style.
Portal beats Johnson County
KANSAS CITY, Mo. - Justin Houston cuts an imposing figure standing in front of his locker in the Chiefs' practice facility. The rookie linebacker is 6-foot-3, 270 pounds of muscle, his right eye a bloody red, a large scar on his chest and a tattoo inked across his right shoulder.
With the Statesboro girls expected to dominated their region once again this season, a lot of emphasis is being placed on the Lady Devils' performances against non-region competition.
The Bulloch Academy wrestling program will honor a former student by renaming its Battle of the 'Boro invitational tournament after him.
When Georgia high schools begin play in 2012-13, there are going to be some big changes in store.
Much is being made of Statesboro High School's girls basketball team this season. Six seniors are leading the Lady Blue Devils in their quest for a state championship, but it's a sophomore who is provided a good amount of firepower in each game.
Think of a wrestler - quick, efficient and light on his feet. Now think of an offensive lineman - tall, strong and lumbering. The two don't seem to go together, but when you mix them up, you get Bulloch Academy's Asa Johnson.
Bulloch Academy held its Fall Sports Awards ceremony for varsity student-athletes recently. Major award winners were (front row, l-r) Haley Burke (softball, rookie award), Corley Turner (competition cheerleading, coaches award), Danielle Atkinson (softball, most improved), Madelyn Vickery (softball, coaches award), Ashley Burke (cross country, best at state), JoBeth Hendrix (competition cheerleading, most improved), second row, l-r, Jaylen Evans (football, outstanding skill player), Bill Nguyen (cross country, coaches award), Clayton Rogers (football, team gator), Conner Fordham (football, outstanding lineman), Will Marsh (cross country, best at state) and Jake Hagan (football, most improved player). Not pictured: Jan Marie Page (competition cheerleading, best ...
Statesboro High will resume old rivalries, Southeast Bulloch will get some new ones and Portal stays pretty much the same in the new sports region alignments proposed Tuesday by the Georgia High School Association.
Bulloch Academy "brothers" Themba Twala and Jaylen Evans don't look anything alike, are not close in height nor do they have the same mother or father.
With just one region series left in the season, the Statesboro Blue Devils are not out of the region 3-AAAAA playoffs by a long shot. Statesboro High School's baseball team had a tough loss Tuesday in region play, losing to South Effingham 3-1, however SHS can still bounce back and finish the year strong.
Southeast Bulloch (5-4, 4-4 Region 1-AAA) battled for seven innings to defeat region foes Island High School in a 5-3 victory Tuesday night. The win not only gave the Yellow Jackets a much-needed region win, but extended the team's win streak to five games after starting the season 0-4.
Bulloch Academy claimed the top trophies in both the girls' and boys' meets of the 16th annual Gator Relays Saturday at the Georgia Southern University track and field complex.
Student-athletes from 16 independent schools will converge at the Georgia Southern University track and field complex this morning for the 16th annual Gator Relays.
Statesboro High School girls soccer coach Brian Thomas watched attentively as his team scrimmaged against each other one last time in the school's gymnasium before the team's big rematch against region foes Effingham County Monday afternoon.
Southeast Bulloch had a banner day on the track Wednesday as its boys ran away with a convincint victory while the girls notched a second place finish in a meet that included SEB, Bulloch Academy, South Effingham, Emanueld County Institute and Johnson of Savannah.
The Statesboro High School baseball team seems to be on a roll after a rocky 0-4 start to the season. The Blue Devils (5-4, 1-0 Region 3-AAAAA) are currently riding a five-game win streak and picked up the team's first region victory of the season after defeating Bradwell Institute 6-4 Monday night.
From basketball, to soccer, to track.
The Statesboro High School soccer team piled into the school's field house Thursday afternoon before practice to go over notes. Each player had their own personal blue envelope with a plan inside. However, these plans were not game notes from the night before or a strategy of how to score on the field. These notes were a part of a new program to help the young players in the room become men.
The Lady Gators didn't back down in their final game of the season. The team was tested all year after losing four seniors from last year's roster, but when it mattered most the Bulloch Academy girls basketball team cut down the nets while making school history in the process.
MACON – The Bulloch Academy girls won their second consecutive GISA Class AAA state basketball championship in rough-and-tumble fashion with a 45-41 victory over Gatewood Saturday night at Hawkins Arena on the campus of Mercer University.
This year's annual Statesboro High School Alumni baseball game is centered on helping a fellow teammate in need, and former SHS baseball coach Kenny Tucker could not be more proud.
It will be an all-Green and Gold, Lady Gator showdown in the championship game of the GISA Class AAA girls' state basketball championship today.
MACON, Ga. - Senior Pate Lomax muscled in a game-high 23 points to lead Bulloch Academy past Westwood 57-44 in the semifinals of the GISA Class AAA girls' basketball tournament Thursday at Hawkins Arena on the campus of Mercer University.
With just two games left before a state champion is crowned it's safe to say that the cream has risen to the top.
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Giving to Cru
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What was happening to Christ #AtThisTimeThis Easter, @CruTweets will be live-tweeting what Christ's week was like in the days and hours leading up to his execution and resurrection, using the hashtag #AtThisTime on Twitter.
Ten Ideas: Do You Have A Healthy Heart?The older I get, the more I realize that my heart needs daily examination.


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Red Carpet Inn Massillon
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Travel Blogs from Massillon
Still a Beautiful Place
... if you don't check the products, something you expect to have been hand made by a nice little Amish lady is in fact not! In one shop I found some nice hand made Amish dolls with hand made outfits on, authentic by having the Amish lady who makes them's signature on the doll. The dolls have no faces..... "Why No Faces? The Amish believe that the biblical reference in the Ten Commandments which speaks of a graven image is in reference to the image of a face. For this reason the Amish ...
NFL Hall of Fame & Sammy's BDay party
... that has another two queen beds and a pool table, another larger bathroom with a corner spa bath. The cabin has a front door coming from where you park the car and a back door that lead to your own porch filled with chairs and Amish made rustic rocking chairs. There is an outdoor grill, park bench and a fire place outside. Didn't get a chance to take photos of the cabin and surrounds today, but I will add them tomorrow. I went for a little walk while everyone was ...
Chicago, Illinois to Berlin, Ohio
... and while driving everyone started looking for a bag cause we couldn't get of the road....... Someone found a bag, Cooper began to fill it,, sometimes getting in, sometimes missing, Mitch is holding the bag and dry retching, I had the window down trying to keep fresh air so I didn't follow.... Mitch tried to toss the bag but wasn't quite successful and it was running down the window..... Luckily a turn off to a Walmart appeared and we pulled in. ...
Welcome Home!
... just missed the hurricane coming in from the Pacific...we went from temps in the mid 90s and 90+ humidity to low 60s and low 40s last night...burr. Just what I expected for Ohio. Where'd summer go?
I know a ton of mail is awaiting for us and Richard will pick it up tomorrow. It was nice to be back in our own bed...but I sure miss those good cooks & our cabin steward! We are now back to ...
"Sunshine after the rain."
... a waterfall - he was very quick about it - and then the lads had a dip and the girls a paddle.
It was late morning before we mounted our steeds and headed back through unfamiliar scenery ... we could actually see beyond the roadside today. The sun was shining brightly and our spirits were high. The route was very picturesque and the road was superb, full of bends as it snaked up and down the mountains. We joined the interstate, a necessary evil when there ...
Other places to stay in Massillon
Hampton Inn Massillon44 First Street S.W., Massillon | 2 star hotelfrom $123


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DEAR ABBY: My husband is 56. His daughter, "Loreen," from his first marriage is 35. At times when he gives her a hug (as she's leaving from a visit) he will slap her on the butt. This makes me uncomfortable because it seems inappropriate at her age. I have told him how this makes me feel; he says it's something he has always done with both of his children. (He also has a son.)
GUANTANAMO BAY NAVAL BASE, Cuba - Somewhere amid the cactus-studded hills on this sprawling Navy base, separate from the cells where hundreds of men suspected of links to al-Qaida and the Taliban have been locked up for years, is a place even more closely guarded - a jailhouse so protected that its very location is top secret.
KANSAS CITY, Mo. - Two Chinese businesses and a U.S. company were indicted Wednesday in the tainted pet food incidents that killed potentially thousands of animals last year and raised worries about products made in China.
LONDON - Secretary of State Condoleezza Rice said Wednesday the fight in Afghanistan won't be won quickly and Defense Secretary Robert Gates scolded NATO countries who haven't committed combat troops ''willing to fight and die'' to defeat a resurgent Taliban.
JERUSALEM - Hamas militants fired a rocket into an Israeli border village, wounding two young sisters as they played outside their home. The attack followed Israel airstrikes against Gaza militants and threats of an ''all-front'' war on the Islamic group.
ATLANTA - When Barack Obama was declared the winner of Georgia's Democratic presidential primary, the Sweet Lowdown restaurant in midtown Atlanta echoed with whoops of glee as dozens of young, black professionals celebrated his win with raised martini glasses.
GSU press conference - Signing Day 2008
WASHINGTON - Hillary Rodham Clinton loaned her campaign $5 million late last month as Barack Obama outraised and outspent her in the Democratic presidential race.
QUITO, Ecuador - Ecuador's Tungurahua volcano shot columns of ash miles into the air on Wednesday, as officials ordered the evacuation of 3,000 villagers living near its slopes.
WASHINGTON - Worker productivity, the key factor in rising living standards, slowed sharply in the final three months of the year as overall economic activity weakened considerably while labor pressures increased.
(Note: All information included in this report is taken from law enforcement incident reports and arrest records, which are public records and available for review at any and all local law enforcement agencies. Not every arrest leads to a conviction. Guilt or innocence is determined by the court system.)
CHARLESTON, W.Va. - One of several white people charged in the suspected kidnapping, torture and sexual assault of a black woman has been indicted on a hate crime count, and two others have entered guilty pleas in the case.
ATLANTA - For the first time, health officials report that the AIDS virus can be spread by a mother pre-chewing her infant's food, a practice mainly seen in poor, developing countries.
WASHINGTON - It seemed reasonable. Since diabetes increases the risk of heart disease, aggressive efforts to lower blood sugar might help heart patients.
WASHINGTON - Politicians have finally found an issue they all can agree on: Telemarketers calling at dinnertime are a scourge that must be repulsed.
Bernard's Jewelers owners Pamela Anderson, Polly Reed Schuman and Pamela Reed have just returned from market and packed every inch of their beautiful little jewelry store "that service built."
Sherry Lynn's Farm Girl Miscellany and Sherry Lynn's Salon is located at 8 East Vine Street behind the Sea Island Bank's downtown drive thru.
Marc and Danielle Nauts are the owners of B&R Accounting & Taxes at 45 East Main Street. They share office space with their other company, B&R Treasures & Treats.
Renee Kalloniatis became the owner of Grace Gardens in June 2014.
When Bernard and Patricia Olliff opened Bernard's Jeweler's in Statesboro more than 40 years ago, they never dreamed their little jewelry store would become the success it is today.
B&R Treasures & Treats is a must see store in downtown Statesboro.
Sack Company Maintenance's dedication to extraordinary service is what sets them apart from their competition. They accomplish this through a unique combination of a highly trained workforce and superior equipment. Each SCM, Inc. technician is EPA certified and cross-trained in HVAC and refrigeration.
Forest Heights Pharmacy, located at 4439 Country Club Road, was founded by the late Joel Sikes in 2006. He was a long time Brooklet resident. Joel sold the business to Ben Ross in 2008 after he became ill. Ben is a second generation pharmacist/pharmacy owner who grew up working in his dad's pharmacy, Ross Drug, in Sylvania. Ben, his wife, Lauren and their two girls, Lanie and Lucy Kate, are active Bulloch County residents.
In 2006, Angie Hitchens and Brandon Blair founded 180 fitness. Angie had managed Gold's Gym for 10 years prior to its closing and Brandon was an employee of Gold's. Together they have a commitment at 180 to bring our community together through fitness and wellness.
Located in Statesboro, with over forty years of industry experience, since 1973, Bulloch County natives Lewis Spivey and Arthur Allen, Jr. own Southeastern Alarm & Technologies, Inc. Southeastern Alarm is the only full time locally owned and operated alarm company in Bulloch County.
For Dr. Al Mooney, Director of Addiction Medicine and Recovery at Willingway, one of the key factors that distinguishes this week's Addiction Update Conference is its "focus on the solutions rather than the problems."
Man of the Decade


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more wall
I am not sure how to post multiple pics in one message.
Here is a link that might be useful:
Beautiful wall! What are the approximate dimensions of the area? Also, what general effect do you want out of the planting (i.e.- multiseason color, low-evergreen, mixture of species, wildlife garden etc.) Have you had the soil tested or have a general feel for the soil (i.e. clay or sandy, acidic, etc.)? Has the soil been amended in any way in that area? I am sure "we" at Gardenweb could give you some very good suggestions. One other thing is how much maintenance are you willing to put in afterwards? For example, is there a sprinkler system and/or are you willing to water regularly the first year. Do you mind pruning and deadheading or do you wish the area to be as low maintenance as possible?
One other suggestion, if you still want a designer and have not found one. Contact Russell Gardens WHOLESALE in Churchville, Pa. They don't do design, but have one of the largest and best selection of perennials and ALL of the local designers use them. They may be able to recommend a name or two. Otherwise, let us Gardenwebers help!
We have basic clay type soil but it also has quite a bit of organic matter both what I added and also what is natural. It is acid I am fairly sure.
I don't mind watering as needed initially and am OK with some pruning and deadheading. Mostly I want a natural look but not an out of control look. I would really like to get some height because that side of the house is bland. It is a southern exposure. The problem with putting a tall tree in is that the utilities including the septic tank (not field) is right there. However I do have some space. I was thinking maybe some sort of trellis up the side of the house.
I am not familiar with Russell Gardens. My husband just gave me a Kales Nursery gift certificate. Does anyone have any experience with Kales?
Thanks for the feedback.


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MSU Ceremony
The Registrar's Office provides details for commencement ceremonies, including the College of Letters and Science, on their website at: www.montana.edu/commencement/.
College of Letters & Science Spring 2015 Commencement Ceremony
College of Letters and Science graduates will participate in the afternoon commencement ceremony, which starts at 1:30 p.m. with the processional beginning at 1:10 p.m.
Colleges participating in the afternoon ceremony include:
- Arts and Architecture
- Letters and Science
- Nursing
- Gallatin College
College of Letters & Science Spring 2015 Commencement Celebration
The College of Letters and Science will hold a commencement celebration on Saturday, May 9th, immediately following the afternoon commencement ceremony. The celebration will be held in the Gaines Hall Foyer (just north of the Field House). Treats and refreshments will be served. Friends and family are welcome. No RSVP needed. Contact Jennifer Storment in the Dean's Office of Letters and Science for more information at (406) 994-4288 or firstname.lastname@example.com.


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Good values on homes are still available, as the number of homes listed for sale is greater than the number of homes being sold. Great deals can be found by determined buyers.
Rental property is in high demand and availability is low. Rent prices have decreased by 8% over the past 3 months. This is 25% lower than the state average of $1,356 and 118% lower than the country average of $2,358.
Trend data coming soon.
|For Sale: 136
|New: 17
|Recently Sold: 42
|Reduced: 52
|Average Home Price
|Average Sold Price
|Property Records: 3,599
|Foreclosed: N/A
The average home price in 30536 is $276,436, which is 105.2% higher than the average sold price in 30536 ($134,695) . The average home price per square foot in 30536 is $108 and about 1% of all homes in 30536 sold in the last 6 months. For 30536 home values, real estate prices, and city market trends, research the 3,599 property records or search our 42 recently sold or 136 homes for sale listings. The listings and properties in 30536 are only a part of the 3,144,466 properties and 67,834 homes for sale in Georgia. Because of this, the average home price and average home value of 30536 also influence the average home price $107,765 and average sale price $221,158 of Georgia. Listing counts, 30536 home prices and home values in 30536 are sourced daily from listing and property data on realtor.com®, which is the most up-to-date and accurate aggregation of real estate listings in the industry and includes approximately 800 regional MLSs and is the official website of the National Association of Realtors®.
|Median Age
|Median Household Income


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SPRINGFIELD, Ore. — A Springfield woman is sharing her story about a group of firefighters who went beyond the call of duty. Susan Breedlove was moving from Eugene to Springfield last Saturday when things took a bad turn. Her brother had a heart attack while helping her load the truck with her belongings. Susan and … Continue reading »
Firefighter Fitness Challenge
EUGENE, Ore. — They work every day to save lives and for the next three months, a group of firefighters are working to improve their health, along with their families. Hundreds of Lane County firefighters, that includes volunteer and paid, have signed up to be a part of this fitness challenge. Organizers say the "Lane … Continue reading »
Electrical Problem Causes Apartment Fire
EUGENE, Ore. — The Eugene-Springfield Fire Department says an electrical issue is to blame for a fire that destroyed four apartment units on South Willamette Street. Firefighters say an electrical malfunction in the ceiling of the second story unit started the fire. Two firefighters were hurt battling the fire. They were both released from the … Continue reading »
Fires Burn Near I-5, Threaten Homes
DOUGLAS COUNTY, Ore. — Firefighters are closely watching fires that flared up right next to I-5 Thursday evening. The Douglas Forest Protection Association says the fires spanned 60 acres flames got dangerously close to homes and cars driving by on I-5. Five fires up and down 1-5 from the Myrtle Creek exit to Clarks Branch … Continue reading »
Santa Clara Fire Dept. Chicken BBQ
EUGENE, Ore — Santa Clara volunteer firefighters are preparing for the 57th annual chicken barbecue. Forty volunteer firefighters provide emergency service in the Santa Clara area and this fundraiser generates one third of their budget. The money goes directly to the volunteer association for community events and education programs. Organizers say every year they sell … Continue reading »
Firefighters Fight Muscular Dystrophy
SPRINGFIELD, Ore. — Local firefighters are using their fire boots Saturday, not to battle fires but to fight muscular dystrophy. This fundraising effort by firefighters is called Fill the Boot and it started Friday. All proceeds are going to the Muscular Dystrophy Association and participants say they couldn't be happier to help the cause. Firefighters … Continue reading »
Report Released on Big Windy Fatal Crash
NEAR GLENDALE, Ore. — An investigative report shows what led to the deadly crash of a fire crew member last summer in Southern Oregon. 19-year-old Jesse Trader of Albany was killed last August while fighting the Big Windy Fire In the report, investigators say he was on his first assignment driving the truck only about … Continue reading »
Firefighters Being Called on Crime Duty
CAVE JUNCTION, Ore. – As budget concerns continue to stifle Josephine County law enforcement, residents are beginning to look elsewhere. Now fire departments say they're getting calls from people who see them as the only ones who will respond to crimes. Last week the Illinois Valley Fire District responded to a call for medical aid, … Continue reading »
Firefighters Helping the Homeless
EUGENE, Ore. — Local firefighters traded in the hoses and hydrants for the hammers and nails Monday to build transitional housing at Opportunity Village. Monday they built the bungalows from the ground up, using charity money collected throughout the year to pay for supplies. The group built two bungalows in Opportunity Village. Firefighters and paramedics … Continue reading »
Walden Addresses Volunteer Fire Crisis
WHITE CITY, Ore. — Representative Greg Walden met with fire chiefs from Jackson County to discuss the classification of volunteer firefighters on Saturday. The congressman and fire officials were addressing a bill introduced to U.S. House of Representatives Ways and Means Committee back in December. Under the Affordable Care Act, anyone working thirty hours or … Continue reading »


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Publisher's Description+
MetaX is a Windows movie tagging program for MP4, M4V, WMV, MKV and AVI files. You can search TVDB, TMDB, iTunes,, Amazon and IMDB with the click of a mouse and then write that information into the file so that it is displays in your Media Player.
What's new in this version:
Autotagging, iTunes support, improved country ratings and language support and XBMC support.


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The shortlist for this year's Man Booker Prize was announced earlier today. Looks like a decent enough list, although I'm pretty surprised that the David Mitchell book didn't make it . . . Anyway, here's the full list, and I'm sure over the next few days there will be tons of articles and posts analyzing this list. (Seeing that I haven't read a single one of these books—although I am looking forward to C and the Emma Donoghue book sounds kinda creepy—I don't really have anything to say . . . )
Peter Carey, Parrot and Olivier in America
Emma Donoghue, Room
Damon Galgut, In a Strange Room
Howard Jacobson, The Finkler Question
Andrea Levy, The Long Song
Tom McCarthy, C
Pedro Zarraluki's The History of Silence (trans. Nick Caistor and Lorenza García) begins with the narrator and his wife, Irene, setting out to write a book about silence, itself called The History of Silence: "This is the story of how. . .
There are plenty of reasons you can fail to find the rhythm of a book. Sometimes it's a matter of discarding initial assumptions or impressions, sometimes of resetting oneself. Zigmunds Skujiņš's Flesh-Coloured Dominoes was a defining experience in the necessity. . .
In a culture that privileges prose, reviewing poetry is fairly pointless. And I've long since stopped caring about what the world reads and dropped the crusade to get Americans to read more poems. Part of the fault, as I've suggested. . .
I would like to pose the argument that it is rare for one to ever come across a truly passive protagonist in a novel. The protagonist (perhaps) of Three Light-Years, Claudio Viberti, is just that—a shy internist who lives in. . .
The last five days of the eleventh-century Icelandic politician, writer of sagas, and famous murder victim Snorri Sturleleson (the Norwegian spelling, Snorre, is preserved in the book) make up Thorvald Steen's most recently translated historical fiction, The Little Horse. Murdered. . .
We all know Paris, or at least we think we know it. The Eiffel Tower. The Latin Quarter. The Champs-Élysées. The touristy stuff. In Dominique Fabre's novel, Guys Like Me, we're shown a different side of Paris: a gray, decaying. . .
One hundred pages into Birth of a Bridge, the prize-winning novel from French writer Maylis de Kerangal, the narrator describes how starting in November, birds come to nest in the wetlands of the fictional city of Coca, California, for three. . .


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La Sapiniere
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TripAdvisor Reviews La Sapiniere Saint Omer
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Back to English-type weather and the BBC
... Channel it became really murky and misty. just like being at home.
It was getting quite dark by the time we got to Wissant and there were only 2 other MH's there. At least we could listen to Radio 2 while we prepared our evening meal.
Week Eight. Wragby- Calais - Antwerp.
Monday February 2nd - Friday February 6th
Left Derbyshire and returned back to Amanda's Mum and Alf's while the car was fixed.
The car dealer rang to tell us the good news that our car was ready midday Tuesday, instead of rushing over to Sheffield to pick it up we decided to chill out and pick it up Wednesday.
Picked up the car, it goes brum brum when you press the accelerator, and moves forward ...
Almost at the end
Today we drove over 3.5 hours towards St. Omer and found the vet's place. The campsite which is about 1 mile away seemed very busy and expensive, so we found another one about half an hour away. This campsite is lovely with a small nice pool which is just like it would be in a hotel. It also has plenty to do for the big and small and has a restaurant. We will probably visit Dunkerque tomorrow and find another campsite for the ...
Day One :D
... now...'. The heart wins without fail, and embarrassment ensues as neither person understands what the other is saying. And that is exactly what happened today. Following that slight hiccup, our meal ran smoothly and was very tasty. I have sampled many a steak haché, believe me, and I can safely say that Flunch's was the best :) The journey back to the motel was one of the highlights of today: we all sang Bohemian Rhapsody and Another One Bites The Dust very, very loudly ...
The learning curves continue!
... 13.13 metres deep. There were tie on places in stages going up the side like a ladder, but only enough to get our middle line on as we can't reach any others. Isi then spotted a bollard on a slider so John put the line on that. It certainly made life a lot easier as we now realised it was a lock and not a lift, so as we rose up, this slid up with us. There was quite violent water movement from the middle of the lock but we sat quite nicely with the one line on and the ...


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Football players get dream opportunity in NFL
After the 2011 football season ended, Marist seniors Jaquan Bryant, Kevin Fitzpatrick and Ryan Dinnebeil came together with a simple yet challenging goal: make the NFL.
Now, two of them have been given an opportunity to make that dream a reality.
As NFL teams look to fill up their rosters after last week's draft, many undrafted free agents are signed by teams and given the opportunity to try out for the team. For the first time in program history, a Marist player has signed with an NFL team in April.
Cornerback Jaquan Bryant has signed with the Oakland Raiders, while wide receiver Kevin Fitzpatrick has been picked up by the Buffalo Bills.
"They had a dream," Marist head coach Jim Parady said. "They came together at the end of the season and did everything they could to prepare. After the end of their college careers they continued to train to reach get to another level."
Bryant led the Red Foxes with 41 solo tackles and four interceptions playing in all 11 games of the 2011 season. The 6-foot-1 St. Albans, N.Y. native was named first team All-Pioneer Football League this past season as well as the second team in 2009 and honorable mention in 2010. Bryant also served as the team's primary punt returner, averaging 8.1 yards in 23 returns.
Fitzpatrick was the leading receiver on the 2011 Marist squad with 601 yards on 49 receptions. He was tied for the team lead with five receiving touchdowns and was third on the team averaging 54.6 total yards per game. The 6-foot-3 wide receiver out of Columbia, Md. did not miss a game in his career, which was highlighted by the game-winning touchdown catch on a Hail Mary with seven seconds to play against Jacksonville in 2009.
Bryant and Fitzpatrick, along with fellow senior running back Ryan Dinnebeil, worked out in front of NFL scouts at Fordham University's Pro-Day in February.
"They opened some eyes for some people at the All-Star game and at the Fordham Pro-Day," Parady said. "They've caught the attention of the right people."
According to Parady, although Dinnebeil has not received that phone call yet, his agent had indicated last week that he thought there was a good chance someone would be interested in picking up the fourth all-time leading touchdown scorer in Marist football history.
Bryant and Fitzpatrick will report to short minicamps for their teams in mid-May to show off their skills and attempt to make the first round of cuts.
"All it takes for a guy at our level is an opportunity, and now they have one," Parady said.
Parady said that it is difficult for anyone at the Football Championship Subdivision to make that impression pre-draft, but once given that opportunity, anything can happen. The coach also mentioned how this will help the program going into the future.
"For the recruiting part, guys will see that guys here are getting looks," Parady said. "It'll be a tremendous asset in that respect."
For the players, getting the call was a dream come true, but there is still work to be done.
"It's awesome," Fitzpatrick said, "but there's still a long way to go. It's a big step to come out of the Pioneer League and a small school like Marist."
"It definitely is [a dream come true] to get this opportunity," Bryant said. "I've been playing football my whole life. Now I just have to go out there and do what I do."
Fitzpatrick will go to Buffalo minicamp on May 10. Bryant is still waiting to hear when he will depart for the Raiders' minicamp.
"We're very excited for these guys," Parady said. I think they'll do great out there. They are realizing a dream right now, which not many athletes say they can do."
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Mullingar Pewter
Quality pewter gifts skillfully hand crafted in Ireland from the internationally renowned Mullingar Pewter company
The craft of pewter making was revived in Ireland in the 1970's by Mullingar Pewter.
Over the years they have developed an extensive range of gifts such as pewter glasses, tankards, pewter hand crafted sports plaques to name but a few of the products from their extensive range.
Large Heart Claddagh Jewelry Box with legsBy Mullingar Pewter
St Patrick SuncatcherMullingar Pewter
Claddagh Cead Mile Fáilte Wall Plaqueby Mullingar Pewter
Price: $ 49.50
Price: $ 45.00
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Jameson Whiskey Measureby Mullingar Pewter
Book of Kells Goblet 12ozMullingar Pewter
Ardagh Chalice Inspired replicaMullingar Pewter
Price: $ 24.50
Price: $ 69.95
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Claddagh Heart Shaped Jewellery BoxBy Mullingar Pewter Jewelry
Celtic Whiskey Measureby Mullingar Pewter
Irish Shamrock Door KnockerMullingar Pewter
Price: $ 37.50
Price: $ 24.50
Fáilte Irish Welcome Door KnockerMullingar Pewter
Celtic Irish Door KnockerMullingar Pewter
Teachers Scottish Whisky Measureby Mullingar Pewter
Price: $ 29.50
Irish Claddagh Jewelry Box by Mullingar Pewter3 Sizes Available
Claddagh Door KnockerMullingar Pewter
Price: $ 29.99


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Greg Abbott flush with cash in last week of governor campaign
With 8 days left until the election, GOP governor candidate Greg Abbott has reported raising $4.2 million over the last four weeks.
In the latest disclosure report for Sept. 26-Oct. 25, Abbott showed late money is pouring in at a pace of $1 million a week.
He also indicated he's been on a spending spree with $13 million left in the bank, down from $30 million just four weeks ago.
In all Abbott reports having raised $45 million in his governor's campaign.
"The incredible support our campaign has received from tens of thousands of Texans is a direct reflection of the enthusiasm Greg Abbott has inspired among Texas voters for his vision to build a better, brighter future for our great state," said campaign finance director Sarah Whitley.