text:
One couple's story of hiking the Pacific Crest Trail from beginning to end
Photo courtesy Kristen Grund and Ville Jokinen
Nearing the finish of the Pacific Crest Trail, Ville Jokinen (left) and Kristen Grund sit together at sunset atop Washington's Blowout Mountain.
Photo courtesy Kristen Grund and Ville Jokinen
Kristen Grund (left) and Ville Jokinen pause for a moment while hiking through the snow-covered Sierra Nevada during their thru-hike of the Pacific Crest Trail.
But when 500 of those miles are covered in snow, what begins as a test of endurance can turn into a test of survival.
Kristen Grund, 30, and Ville Jokinen, 31, boyfriend and girlfriend who split their time between Bend and Finland, chose one of the toughest years in recent history to "thru-hike" (hike from end to end on a single journey) the Pacific Crest Trail -- but they made it.
On Sept. 29, five months after starting out at the United States-Mexico border town of Campo, Calif., Grund and Jokinen reached the trailhead in Manning Park, British Columbia.
Their longest break along the way was a three-day stay at Grund's parents' house in Bend.
According to Jokinen, estimates indicate that fewer than 80 of the 400 or so hikers who started out with the intention of thru-hiking the PCT in late April will finish this year. And more than half of the hikers who started out quit their journey before reaching or while in the snow-packed Sierra Nevada, as last winter and spring brought historically deep snowpacks to the American West.
Indeed, the toughest portion of the entire hike for Grund and Jokinen was Yosemite National Park in central California, which included 150 miles of extreme climbing through snow and dangerous high-river crossings as the snowpack began melting rapidly in July.
During some of the river crossings, the water was up to their necks.
"There were moments we could have been swept away," Jokinen said this week while recounting the journey. "The last river crossing in Yosemite was so intense. I was worrying about myself, and then worrying about (Grund), because she's shorter than me. I was thinking we might have to skip a section (of the trail). But that ended up being the worst. After that, it was just waist high or so."
Aside from crossing the rivers, trekking through snow is no easy task.
To find their way with no clear trail to follow, the hikers relied on topographic maps, compasses, GPS and occasionally even the footprints of hikers ahead.
"It would be trail, and then a giant snow heap, over and over," Grund recalled. "By the end of the day, I've never been so exhausted. We couldn't eat enough calories to keep (up with) what we were burning. We were skin and bones, and just starving."
Grund and Jokinen wore running shoes with Yaktrax (fitted devices placed over the soles of shoes for traction in snow) and used trekking poles.
On average, they covered 18 to 20 miles of trail per day. That average dropped to as few as 10 miles per day in the punishing Sierra Nevada, but it reached as many as 37 miles per day in Oregon.
After meeting 3� years ago on a scuba diving boat in Vietnam, Grund and Jokinen have maintained a long-distance relationship, embarking on several travel adventures together.
Per immigration rules,
Grund, who was born and raised in Bend, can stay 90 days in Jokinen's home country of Finland, but then must leave for at least 90 days.
Jokinen has a tourist visa for the United States, so he can stay in the U.S. for six months at a time, but then he must leave the country for at least the next six months.
Grund competed in soccer, swimming, basketball, track and cross-country at Bend's Mountain View High School, and Jokinen played professional soccer in Finland and Algeria.
The two have always stayed fit through running and hiking. They backpacked together through Southeast Asia, Central America and Mexico, and they sailed through the Caribbean.
They were driving across the U.S. on one trip when Jokinen noticed a PCT trailhead.
"She (Grund) started telling me more about it," Jokinen said. "She met some thru-hikers four years ago. I started getting more interested, and we started talking more about it. Last fall, we said, 'Let's do it next year.' "
The couple was living in Helsinki, Finland, last spring just before the start of their hike. Grund was working as a nanny and Jokinen in finance. They quit their jobs and returned to Bend to plan their adventure.
They made several REI and Costco trips for gear and food, packing resupply boxes that Grund's family would send to predesignated post offices along the way. The boxes were filled mainly with food, maps, batteries and toilet paper.
Grund and Jokinen traveled by air to San Diego, then hitched a ride from a friend to Campo, where they began their PCT trek on April 29.
They hiked from sunrise to sunset each day, camping each night in a tent with sleeping pads and a sleeping quilt.
After slogging through the torrid Mojave Desert of Southern California and encountering a number of rattlesnakes, the hikers entered the southern Sierra Nevada at Kennedy Meadows in mid-June. They used ice axes at times to traverse steep, icy slopes, and on June 23 they even took a side trip to climb to the summit of Mount Whitney -- at 14,497 feet, the highest peak in the continental U.S. The highest point along the Pacific Crest Trail is the Sierra Nevada's Forester Pass, at 13,153 feet.
The couple finally made it through most of the snow just north of Lake Tahoe at the end of July.
"Most people, if you ask them, their favorite section is the Sierras -- not us," Grund said. "We hit a pretty good depression after the snow. We all of a sudden realized how many miles we had to put in because we were two weeks behind (the planned schedule). We had to do 30 miles a day after doing 15 to 17 miles."
Grund and Jokinen needed only 14 days to cover the 458 miles of the PCT's Oregon section, averaging 34 miles per day. The 1,602-mile California stretch had taken 3� months.
After leaving Grund's parents' house in Bend, the hungry couple used the popular breakfast buffet at Mount Hood's Timberline Lodge as motivation for a series of 30-or-more-mile days. They made it from Santiam Pass to Timberline (100 miles) in just three days.
They reached the start of the 500-mile Washington section of the PCT in late August, hiking past Mount Rainier National Park and North Cascades National Park. During one river crossing in northern Washington, Jokinen recalled, a large black bear came within 30 feet of Grund just before she crossed a log spanning the river.
Grund never saw the bear, but Jokinen started cursing and shouting to warn her and it eventually walked away. It was one of six bears they saw along the PCT.
"I was stressed trying to cross that log," Grund said. "I didn't turn around."
Grund's parents picked the two weary hikers up last week in Manning Park, giving them a ride back to Bend after their walk of a lifetime.
Jokinen lost 28 pounds and only recently shaved the long beard he grew during the hike. Grund lost 15 pounds from her small frame.
They each went through five pairs of shoes, four backpacks, three sets of trekking poles and about 20 pairs of socks.
Jokinen looks at life challenges in a different light now.
"Finally, I have REAL problems," he said of their time on the trail. "I work in an office, so my problems are, like, 'Why is the Internet down?'
Or, 'My printer doesn't work.' (While out on the trail) I'm like, 'I don't have enough food. Or, we're running out of water.' "
Grund says her favorite sections of the trail were the Shasta Trinity National Forest in Northern California, the Three Sisters Wilderness in Central Oregon and the Goat Rocks Wilderness in Washington.
The emotions of finally completing their thru-hike of the PCT were hard to describe.
"I was crying, but I was so happy," Grund said of her feelings at trail's end. "Some of the most absolute amazing memories I will have in my life are on that trail … with him. We went through stuff that most couples never have to deal with."
The trail
The Pacific Crest Trail runs 2,650 miles from Campo, Calif., to Manning Park, British Columbia, covering the entire length of California, Oregon and Washington. The National Scenic Trail passes through the Mojave Desert, the Sierra Nevada, Yosemite National Park, Marble Mountain and the Russian Wilderness in Northern California, the volcanoes of the Cascades, Crater Lake, the Columbia River Gorge, Mount Rainier and the remote northern Cascades. The trail includes 750,000 feet of elevation gain.
Over the past decade the PCT has become a favorite of thru-hikers — the hardy souls who attempt to hike the entire trail in a single season.
Each year, an average of 300 hikers attempt to cover the full length of the PCT.
Most thru-hikers make planned stops in towns close to the trail (usually hitchhiking from highways crossed by the trail) to resupply with food and gear and pick up supply boxes that were mailed ahead by family or friends.
Source: www.pcta.org
On the web
For more information on Kristen Grund and Ville Jokinen's journey, visit dumbanddumberpct.blogspot.com.
Share your comments: Log in using your HeraldNet account or your Facebook, Twitter or Disqus profile. Comments that violate the rules are subject to removal. Please see our terms of use. Please note that you must verify your email address for your comments to appear.
You are logged in using your HeraldNet ID. Click here to update your profile. | Log out.
Our new comment system is not supported in IE 7. Please upgrade your browser here.


text:
Beyond Belief - Naturally Born
Filed Under: Music Videos, by DJ Z on Jan 31, 2012
Long-time DJBooth favorite Beyond Belief is back with a brand new weekly video series, entitled Breaking Beyond. The videos, which are written, performed, directed, and edited by Beyond Belief, will be available every Wednesday through this spring. For additional information on the log on to BeyondBeliefOnline.com.View more from:
Beyond Belief
Share This Page
DJBooth TV
Discover the best new songs, videos, and albums added to the Booth.

subset: commoncrawl


text:
Report: Broncos could trade Tebow
Tim Tebow will have performed his last Mile High Miracle if the Denver Broncos win the race to land Peyton Manning, Pro Football Network reported Sunday.
A source close to the team said Tebow stands to be traded upon the arrival of the four-time MVP.
The report claims the Jacksonville Jaguars are lining themselves up to acquire the unconventional quarterback, who led the Broncos on a sometimes-improbable run to the AFC West title last season.
Manning met with Broncos vice president of football operations John Elway and coach John Fox on Friday during a six-hour visit to the team's facility in Denver as the recently-released former Colt began the search for a new home after spending his entire pro career in Indianapolis.
Manning will meet with Cardinals bosses Sunday after arriving in Arizona on Saturday night, hoping to make a decision on his future within the next few days.
The Denver source claimed Tebow's starting spot would be safe should Manning snub the Broncos.
Tebow made no comment regarding his future in Denver while speaking with reporters at a fundraiser for a wounded war veteran in Tampa on Friday night.
Related Stories
Member Comments
Please note by clicking on "Post comment" you acknowledge that you have read the Terms of Use and the comment you are posting is in compliance with such terms. Be Polite. Inappropriate posts may be removed by the moderator.
NFL Headlines
NFL Insiders: Dolphins name Dennis Hickey new general manager
Carroll: Seahawks CB Richard Sherman sorry about postgame rant
Browns to interview Bills' Pettine with Broncos' Gase out of running
NFL talking to 49ers about sideline hit vs Seahawks in NFC title game
Falcons hire former Chiefs GM Pioli as assistant general manager


text: Top 10 Innovations in Primary Care (in the Past Year) (Text Version) Slide presentation from the AHRQ 2011 conference. On September 20, 2011, Robert Dachs and Mark Graber made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (2.1 MB). .Slide 1Top 10 Innovations in Primary Care (in the past year)Robert Dachs, MD, FAAFPAssistant Director, Dept of Emergency MedicineEllis Hospital, Schenectady, NYClinical Associate ProfessorEllis Family Medicine Residency ProgramAlbany Medical CollegeMark Graber, MD, FACEPProfessor of Family and Emergency MedicineUniversity of Iowa Carver College of MedicineIowa City, IowaSlide 2Disclosure StatementDrs. Dachs and Graber have no affiliations with any product or pharmaceutical manufacturer.We are clinicians so you are about to hear what we think may be paradigm changers from this year's literature.We will run through "bonus" topics at the end: things we don't have time for but might tweak your interest.Slide 3I. Atrial Fibrillation ManagementDabigatran: Boon, Bust or Hype?Image: A graphic shows significant risk reduction of stroke (35%) using Pradaxa 150 MG twice daily versus warfarin.Slide 4Atrial Fibrillation ManagementWho gets anticoagulation?Who is at risk for hemorrhages?And is dabigatran (Pradaxa) everything its cracked up to be?Slide 5Atrial Fibrillation and StrokeWhy Do We Anticoagulate?Image: Bar chart shows the following data:<65 yrs: 4.9.65-75 yrs: 5.8.>75 yrs: 8.CVA rate (% per yr)The older the patient with atrial fibrillation, the higher the risk of cardioembolic stroke.Strokes due to Afib have higher mortality and morbidity.Warfarin decreases absolute annual risk from.4.5% → 1.4% (NNT=30).Slide 6Atrial Fibrillation: Who Gets Warfarin?ACC/AHA 2011 GuidelineRisk Category:No risk factors.One moderate risk factor.Any high-risk factor OR.≥2 moderate risk factors.Recommended Therapy:ASA 81-325mg q d.ASA or warfarin.Warfarin (INR 2.0-3.0).Moderate-risk factors:Age ≥75yrsHTNCHFLV ejection fraction <35%DMHigh-risk factors:Previous CVA, TIA, embolismMitral stenosisProsthetic heart valveSlide 7Atrial Fibrillation Management:1) Who Gets Anticoagulation?Last year: CHADS2.This year: CHA2DS2- Vasc.Slide 8Atrial Fibrillation: The CHADS2 ScoreCHADS2 Risk Criteria: Score:CHF: 1.HTN: 1.Age >75 yrs: 1.DM: 1.Prior Stroke or TIA: 2.Pts. (N=1733)CVA Rate (%/yr) (95%CI)CHADS2 Score1201.9 (1.2–3.0)04632.8 (2.0v3.8)15234.0 (3.1–5.1)23375.9 (4.6–7.3)32208.5 (6.3–11.1)46512.5 (8.2–17.5)5518.2 (10.5–27.4)6Risk Category:0: Low-risk (ASA)1: Moderate (ASA or warfarin)2+: High-risk (warfarin)Slide 9CHADS2 vs. CHA2DS2-VASc?CHADS2/Score/ScoreCHF / 1 / 1.HTN / 1 / 1.Age >75 yrs / 1 / 2.DM / 1 / 1.Prior Stroke or TIA / 2 / 2.CHA2DS2−VASc:CHFHTNAge >75 yrs.DMPrior Stroke or TIA.Vascular disease.Age 65-74 yrs.Female sex.N=1733 vs. N= 1,084 pts with afib, not on warfarin.1 year in Euro Heart study.Yip GB, et al. Chest 2010; 137:263-72.Gage BF, et al. JAMA 2001; 285:2864-70.Slide 10CHADS2 vs. CHA2DS2-VASc?CHADS2 / CVA Rate @ 1yr / CHA2DS2-VAScLow risk = 0 points - Low risk = 0 points 1.67% vs. 0.78%.Intermediate = 1 pt - Intermediate = 1 pt 4.75% vs. 2.0%.N = 73,538 pts with afib, not on warfarin.10 year period in Denmark.Olesen, JB, et al. BMJ 2011; 342:d124.A large external validation study—That's what we like to see…Slide 11Atrial Fibrillation: Anticoagulation Risks/BenefitsDecreases CVA by approx 3%/yr.Rate of ICH 0.1-0.6%. Increased with advanced age, HTN.Major bleeding rates: 1.2%/yr.2. So which patients need to avoid anticoagulation???Slide 12"But I Am Fearful of My Elderly Patient Falling (i.e., Subdural)"Using an analytic model…A patient over age 65 with Afib must sustain 295 falls in one year for the risk of subdural to outweigh benefit of stroke prevention.Man-Son-Hing, et al. Arch Intern Med 1999;159(7):677-85.Note 1: Patients on warfarin, spontaneous ICH more common than subdural.Note 2: Model uses assumptions—are they correct?That's last year—this year…Slide 13Previously…HEMORR2HAGES (2006): 1604 pts derived from NRAF database.10 variables—not all easy to obtain (eg "Genetic factors such as CYP 2C9 polymorphism).Shireman, et al. (2006): 26,345 pts from NRAF database.8 variables...but score too complicated!!!!!!!Risk Score = 0.49*Xage70+ + 0.32*Xfemale + 0.58*Xremote Bleed+ 0.62*XRecent Bleed + 0.71*Xalcohol/Drug Abuse ++ 0.86*Xanemia + 0.32*Xantiplatelet AgentThat's last year—this year…Slide 14Two New Scoring Systems: HAS-BLED and ATRIAA novel User-friendly Score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation. Pisters R, et al. Chest 2010; 138: 1093-1100.A new risk scheme to predict Warfarin-associated hemorrhage: The ATRIA study. Fang MC, et al. J AM Coll Card 2011; 58: 395-401.Slide 15Who Needs to Avoid Anticoagulation??HAS-BLEDPointsDefinition1HHypertensionSys BP >1601 or 2(1 pt each)AAbnormal Renal and/or liver functionDialysis/transplant cirrhosis/T. Bili 2x or AST/ALT 3x normal1SStroke 1BBleedingPrevious bleed/predisposition1LLabile INR<60% in therapeutic range1EElderly (>65 yrs) 1 or 2(1 pt each)DDrugs or alcohol excessAntiplatelet or NSAID'sA score of ≥3 is considered "high risk."ESC recommends "caution" using warfarin11 ESC Guidelines for the management of atrial fibrillation, 2011.Slide 16HAS-BLED: ResultsDerivation CohortValidation CohortScoren# of bleedsBleeds per 100 pt yrsn# of bleedsBleeds per 100 pt yrs0151790.5979891.1311589241.511286131.02221973.20744141.88341819.5118773.74414321.434648.70510-8112.506---2007------8------9------Major bleeds defined as any below:1) Bleeding requiring hospitalization.2) Require transfusion.3) Drop in Hgb>2 g/L.4) Hemorrhagic CVA.Slide 17ATRIA: ResultsDerived from 13,559 pts in Kaiser systemDerivation: Validation = 2:1 ratio ScoreAnemia: Hgb <13 male, <12 female3GFR <303Age >75 yrs2Any prior hemorrhage Dx1HTN1Risk category, pointsEvents/100 pt/yrsDerivationValidationLow risk (0-3)0.720.83Intermediate (4)2.712.41High (5-10)5.995.32One of my favorite Web sites: mdcalc.com.Slide 18Atrial Fibrillation ManagementDabigatran: Is it really 35% better?????Image: A graphic shows significant risk reduction of stroke (35%) using Pradaxa 150 MG twice daily versus warfarin.Slide 19What About Dabigatran (Pradaxa)?RE-LY trial: NEJM 2009; 361: 1139-51.Methods: 18,113 pts with afib, randomized to:followed for 2 years: dabigatran, 110mg BID; dabigatran, 150mg BID; warfarin.Results: OutcomeDabigatran, 110mg BIDDabigatran, 150mg BIDWarfarinCVA/embolism1.53%1.11%*1.69%Major bleeding/yr2.71%3.11%3.36%Mortality rate/yr3.75%3.64%4.13%NNT=172Cost: Pradexa = $230 per month, $2760 per year.Price accessed @ drugstore.com—3/25/11.Slide 20Pet Peeve............Benefits in: Relative RiskImage: A graphic shows significant risk reduction of stroke (35%) using Pradaxa 150 MG twice daily versus warfarin.......Harm in: Absolute numbersImage: A graphic shows the lower total bleed rate for Pradaxa versus warfarin.Slide 21And there will be more to come..Rivaroxaban (Xarelto): ROCKET-AF trial, non-inferior to warfarin: Published online, NEJM Aug 10, 2011.NEJM Sept 8, 2011.Apixaban (Eliquis): ARISTOTLE trial, non-inferior to warfarin: Presented at European Society of Cardiology, Aug 2011.NEJM; Sept 15, 2011Slide 22Reservations.....Cost: Even with INR monitoring, warfarin is cheaper. Shah SV, et al. Circulation 2011; 123: 2562-70.Efficacy vs. effectiveness (in the community).How about we do a better job with warfarin? Weekly home monitoring (vs. monthly outpt.).Improves therapeutic range from 50-60% to 85%.Decreases VTE events, mortality and hemorrhages!! Heneghan C, et al. Lancet 2006; 367:404-11. Cochrane Review, April 2010.Slide 23II. Calcium Intake: Heart Disease and Bone HealthBolland MJ et al. Calcium supplements with or without vitamin D and risk of cardiovascular events: Reanalysis of the Women's Health Initiative limited access dataset and meta-analysis. BMJ 2011 Apr 19; 342:d2040. (http://dx.doi.org/10.1136/bmj.d2040).andWarensjo E et al. Dietary calcium intake and risk of fracture and osteoporosis prospective longitudinal cohort study. BMJ 2011; 342:d1473 doi: 10.1136/bmj.d1473 (Published 24 May 2011).Slide 24First StudyReanalysis of Women's Health Initiative.Randomized 36,282 to placebo or calcium.1000mg/d and 400 IU daily of Vit. D.Primary endpoint was fracture.This is a second analysis of the randomized data looking for cardiac outcomes.Original study included serial EKGs.Slide 25What Did They Find?Hazard ratio for cardiovascular event (MI, CVA, Revascularization: 1.13-1.22 (significant p value) only in those not taking supplements already.In those taking supplements at randomization, overall mortality was less.NNH: 178, NNT: 302.Slide 26Second StudyCohort study of 61,433 women born 1914-1948.Randomized study started 1987 and was of fracture risk.Based on the Swedish Mammography Cohort.5022 in the sub-cohort that looked at Dexa scans.Followed for 19 years.Calcium intake as reported by patients.Slide 2724% of women had a fracture and 6% had a hip fracture.Calcium intake of 750 mg-882 mg/day (second quintile) was as good at preventing fractures and osteoporosis as were higher levels of calcium intake.In fact, highest quintile had Hazard ratio = 1.19 (95% CI 1.06-1.32) for hip Fx.Slide 28Conclusion?Cardiac disease: who knows?But, shoot for lower dose calcium supplementation.Slide 29III. HIV Update: This Will Be in the New Guidelines…http://www.nih.gov/news/health/may2011/niaid-12.htm(In press…)andThe HIV-CAUSAL Collaboration. When to initiate combined antiretroviral therapy to reduce mortality and AIDS-defining illness in HIV-infected persons in developed countries: An observational study. Ann Intern Med 2011 Apr 19; 154:509.Slide 30We Know Early Treatment Helps the PatientKitahata MM et al. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med 2009 Apr 1; [e-pub ahead of print]. (http://dx.doi.org/doi:10.1056/NEJMoa0807252).Sax PE and Baden LR. When to start antiretroviral therapy—Ready when you are? N Engl J Med 2009 Apr 1; [e-pub ahead of print]. (http://dx.doi.org/10.1056/NEJMe0902713).Slide 311,763 couples. 97% heterosexual.One HIV+ partner.Randomized to HAART immediately or after CD4<250 cells/mm3.Total cases: 39.28 cases from partner to partner transmission based on genetics.27 in the late HAART group.Early treatment prevents transmission.Slide 32Second Study8392 patients.Observational study.If started HAART at 350/mm3 instead of at 500/mm3 40% increase in AIDS-defining illness + death.NNT 48.Slide 33IV. Cancer Screening: One Step Up,____ Step Back?The National Lung Screening Trial.NEJM 2011; 365:395-409.Methods: 53,454 adults, age 55-74 yrs: 30+ pack yr smokers.Randomized to: 3 annual chest CT's vs. 1 Chest x-ray: Enrolled 2002-04, followed to 12/31/09.Slide 34The National Lung Screening Trial. NEJM 2011; 365: 395-409.Results:Chest CTChest x-rayDeaths per 100,000 Person/years247309Author's Conclusion:"…representing a relative risk reduction in mortality from lung cancer with low-dose CT screening of 20.0% (95%CI, 6.8-26.7) p=0.004"Slide 35The National Lung Screening Trial. NEJM 2011; 365: 395-409.Results:Chest CTChest x-rayDeaths per 100,000 Person/years247309Author's Conclusion:"…representing a relative risk reduction in mortality from lung cancer with low-dose CT screening of 20.0% (95%CI, 6.8 -26.7) P=0.004"When will we stop allowing RRR? (and insist on absolute risk reduction and NNT)Slide 36The National Lung Screening Trial NEJM 2011; 365:395-409.Results:Chest CTN=26,722Chest x-rayN=26,732Lung Ca Deaths356443Lung cancer deaths1.33%1.65%NNT312Slide 37The National Lung Screening Trial.NEJM 2011; 365: 395-409.Results:Chest CTN=26,722Chest x-rayN=26,732Deaths per 100,000 Person/years247309Lung cancer deaths1.33%1.65%NNT312NNH>1 in 3 false (+) CT scan.1 in 30 unnecessary surgery.1 in 161 with surgical complication.One of my favorite Web sites: TheNNT.comSlide 38Putting Those Risks Into Perspective....Chest CT group: 26,722: Any (+) test: 10,448 (39.1%).Lung CA confirmed: 649 (3.6%).False (+) rate = 96.5%.More CT's, bronchoscopy, needle biopsy, ect....Slide 39What Happens When You Go After Those "Nodules" With Needle Transthoracic (CT) Needle Biopsy?Methods: 15,865 pts with CT needle biopsy: From 2006 State Ambulatory Surgery Databases in California, NY, Michigan, FL.Results: Pneumothorax: 15.0%: Needing chest tube: 6.6% of all procedures.NNH = 6.6 and 15.Hemorrhage: 1.0%: Needing transfusion: 17% of "hemorrhages".Weiner RS, et al. Ann of Intern Med 2011; 155: 137-144.Slide 40Not Another Infectious Disease Guideline!Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months.Subcommittee on Quality Improvement and Steering Management Subcommittee on Urinary Tract Infection and Steering.Pediatrics; originally published online August 28, 2011;DOI: 10.1542/peds.2011-1330Slide 41What We Know?Treatment and diagnosis is all over the place.Workup after 1st episode?Workup after 2nd episode?And what workup should be done.Slide 42Some AnswersAnalysis of medical literature.UTI defined as pyuria and at least 50,000 cfu.Slide 43What Do They Recommend?US for all children after first febrile UTI (Level of evidence: C).No VCUG unless US shows scarring of kidneys, hydronephrosis, etc. (Level of evidence: B).Modelling: Only 1:100 will have grade V.No prophylactic antibiotics if grade I-IV reflux (Level of evidence: ??? But RCT).Slide 44VI. The Potential PE Patient…The problem: excessive CT utilization.The answer: Risk stratification.How to risk stratify?Last year: Well's Criteria.This year: PERC Rule.Slide 45CT Use in USA75 million in 2009.7% (5 million) in children.60% are womenImage: Line graph shows dramatic rise in use of CT scans from 1980 to 2005.Slide 46CT Scan and Radiation RisksChildren/young adults: greater Cancer risk: Tissues are more radiosensitive.More years of life to develop radiation induced cancer.Est. lifetime risk of cancer from one 64 slice Chest CT: 20 y/o female = 1 in 142.40 y/o female = 1 in 284.60 y/o female = 1 in 466.80 y/o female = 1 in 1338.Image: Line graph shows age of exposure decreasing for both colon and lung cancer per million patients exposed to radiation.Einstein AJ, et al. JAMA 2007; 298: 317-23.Slide 47Wells Clinical Prediction Rules for: PEClinical Symptoms of DVT: 3.Other diagnosis less likely that PE: 3.Pulse >100: 1.5.Immobilization or surgery within 4 weeks: 1.5.Previous DVT or PE: 1.5.Hemoptysis: 1.Malignancy (actively treated in past 6 mos): 1.High risk ≥678% PEModerate risk 2-627.8% PELow risk <23.4% PEWells PS, et al. Thromb Haemost 2000.Slide 48The PERC RuleLow clinical gestalt (<15% chance) with: Age <50—No hemoptysis.Pulse <100—No estrogen use.SaO2 ≥95%—No unilateral leg swelling.No previous VTE—No surgery/trauma requiring hospitalization in past 4 weeks.Derived from 3148 patients.Kline JA, et al. Jour Thromb Haemostasis 2004.Slide 49PERC Rule:Validation StudyMethods: 13 ED's, 8183 patients: 85% with CC of chest pain or dyspnea.Enrolled if study for PE was ordered.Measures: PE or death within 45 days.Results: 1666 pts. very low risk: PERC (-)neg: 15 with PE, 1 death = 1.0% (95%CI; 0.6—1.6%).Kline JA, et al. J Thromb Haemost May 2008; 6: 772-80.Slide 50How About a Community Hospital? Or "Why I Believe in PERC.."Methods: 308 pts with chest CT: 7/1/08—10/31/08, @ Ellis Hospital ED.213 (69%) to "R/O PE".2 reviewers applied PERC rule.Results: 48 (of the 213) met PERC rule.All 48 were negative for PE (100% sensitive)!(95% CI; 83.4—100%).Of the remaining 165 pts, 18 had (+) PE: Negative Predictive value = 100%(95% CI,93.8-100%).Dachs R, Kulkani D, Higgins, G., published ahead of print, Am J Emerg Med 2010.Slide 51VII. Antimicrobial UpdateKullar R et al. Impact of vancomycin exposure on outcomes in patients with methicillin-resistant Staphylococcus aureus bacteremia: Support for consensus guidelines suggested targets. Clin Infect Dis 2011 Apr 15; 52:975.Slide 52Previous LiteratureVancomycin vs. Traditional anti-Staph drug for MSSA (Beta-Lactam).Mortality: (37% vs. 11%; P=0.006).Kim S-H et al. Outcome of vancomycin treatment in patients with methicillin-susceptible Staphylococcus aureus bacteremia. Antimicrob Agents Chemother 2008 Jan; 52:192.Slide 53This StudyVanco has poor tissue penetration, slow bacteriocidal activity.Retrospective look at 320 patients treated with vancomycin for MRSA (2005-2010).52% failed using standard clinical criteria.Predictors: Endocarditis.Hospital acquired MRSA.Trough level <15 micrograms/ml.Value of area under curve vs. MIC <421.Slide 54Conclusion:Increase trough levels to 15-20 micrograms/ml.Area under curve of >400.Linezolid.Tigecycline.Change from Vanco if you have sensitivities of MSSA.But… companion piece points out that if MIC >2, high risk of renal injury if reach goals.Slide 55VIII. Decreasing Antibiotic Use and ClinicalTrials.govThe antibiotic pipeline is drying up.Strides (small) in decreasing antibiotic use are being made: Weiss K, et al. CID, published online 7/25/11.http://www.cdc.gov/nchs/ahcd.htm.Antibiotics rarely useful in otitis media: NNT = 16, NNH =24 (Cochrane Review, 2008).Use of "delayed"/"Back-up" prescriptions.Slide 56This Article Takes a Step Backwards (And Why Its Wrong)Treatment of Acute Otitis Media in Children under 2 Years of Age. Hoberman A, et al. NEJM 2011; 364:105-15.Methods: 291 children, ages 6 mos-2 yrs: With AOM (reasonable criteria).Randomized, double-blind to: amoxicillin-clavulanate vs. Placebo (90 mg/kg).Slide 57Antibiotics and AOM. Hoberman A, et al. NEJM 2011; 364:105-15.Results:Amoxicillin-clavulanate(n=144)vs.Placebo(n=147)1. Resolution of symptomsDay 235%vs.28%Day 461%vs.74%Day 780%vs.54%P = 0.142. 2 successive days AOM-SOS score 0-1Day 220%vs.14%Day 441%vs.36%Day 767%vs.53%P=0.04, overallSlide 58Antibiotics and AOM. Hoberman A, et al. NEJM 2011; 364:105-15.Results:Amoxicillin-clavulanate(n=144)vs.Placebo(n=147)3. Severity of symptomsAOM-SOS scores (14 pt scale) @10-12 day visit1.59vs.2.46P=0.003, clinically insignificant4. Clinical failure (otoscopy)Day 4-54%vs.23%Day 10-1216%vs.51%P ≤0.001Slide 59Antibiotics and AOM. Hoberman A, et al. NEJM 2011; 364:105-15.Author's Conclusion:Antibiotics "…tended to reduce time to resolution of symptoms and reduced overall symptom burden and rate of persistent signs of acute infection on otoscopic examination."Really???Slide 60Antibiotics and AOM. Hoberman A, et al. NEJM 2011; 364:105-15.Problems with this study....You can't report out multiple (4) "primary outcomes": The more outcomes you look at, by chance alone one will be positive.Slide 61Antibiotics and AOM. Hoberman A, et al. NEJM 2011; 364:105-15.Problems with this study....You can't have 4 primary outcomes....Who cares what the TM looks like????4. Clinical failure (otoscopy)Amoxicillin- clavulanatePlaceboDay 4-54%23%Day 10-1216%51%P ≤0.001This is a "DOE" not a "POEM".Slide 62Antibiotics and AOM. Hoberman A, et al. NEJM 2011; 364:105-15.Problems with this study....You can't have 4 primary outcomes....Who cares what the TM looks like????You can't convert a secondary outcome into a primary outcome (just to create a positive study).Enter… ClinicalTrials.gov.Slide 63Images: Three line graphs show the first, second, and third recording of AOM-SOS Scores of 0 or 1 for children with continuing symptoms over a period of 7 days. Next to the first graph is a caption, "The "predefined" primary outcomes." Next to the second graph is a caption, "No clinical differences."Note: Figure 2. Resolution of Children's Symptoms during the First 7 Days of Follow-up. During the first 3 days, the Acute Otitis Media Severity of Symptoms (AOM-SOS) scale11,12 was administered twice daily; thereafter, it was administered once daily. Panels A and B show the proportion of children in whom symptoms had not resolved. Resolution of symptoms is defined in Panel A as the first recording of an AOM-SOS score of 0 or 1 and in Panel B as the second of two successive recordings of a score of 0 or 1. Panel C shows the mean scores on the AOM-SOS scale over the course of the first 7 days of the study treatment. Since multiple assessments were made on the first 3 study days, numbers on the x axis in all three panels indicate the end of a study day.Slide 64This Is the Primary EndpointImages: A graph shows the first recording of AOM-SOS Scores of 0 or 1 for children with continuing symptoms over a period of 7 days.Hoberman A et al. N Engl J Med 2011;364:105-115.Slide 65Why I Am Thankful For ClinicalTrials.gov"The primary objective of this study will be to compare time to resolution of symptoms in children receiving amoxicillin/clavulanate and children receiving placebo".You can't report a secondary outcome as a primary outcome!!! Otoscopy findings were predefined as a secondary outcome!!!It only allows for hypothesis generation.Especially when there are 21 secondary outcomes.Slide 66Antibiotics and AOM. Hoberman A, et al. NEJM 2011; 364:105-15.Other secondary outcomes—not reportedResults:Amoxicillin-clavulanate(n=143)vs.Placebo(n=146)Mean # of times analgesia0.37vs.0.43P=0.35Mean # of visits to office0.15vs.0.23P=0.20Mean # of ED visits0.07vs.0.07# of cases of family member missing work33vs.33Slide 67Antibiotics and AOM. Hoberman A, et al. NEJM 2011; 364:105-15.Other secondary outcomes—not reportedResults:Amoxicillin-clavulanate(n=143)vs.Placebo(n=146)Day 54.19vs.4.13P=0.71Day 114.40vs.4.12P=0.04Parental satisfaction:1 - Very dissatisfied.5 - Very satisfied.Slide 68Antibiotics and AOM. Hoberman A, et al. NEJM 2011; 364:105-15.Results:Amoxicillin-clavulanate(n=144)vs.Placebo(n=147)Clinical failure (otoscopy)Day 4-54%vs.23%Day 10-1216%vs.51%P≤0.001Side effectsDiarrhea24%vs.7%C. difficile6 casesvs.1Diaper dermatitis47%vs.16%Slide 69Antibiotics and AOM. Hoberman A, et al. NEJM 2011; 364:105-15.Author's Conclusion: Antibiotics "…tended to reduce time to resolution of symptoms and reduced overall symptom burden and rate of persistent signs of acute infection on otoscopic examination."Really??? Antibiotics "…provide no clinical benefit and increase the rate of diarrhea illness with potential harm." R. Dachs.Slide 70And Antibiotics in Children....Increasing rates of C. difficile infection in hospitalized children in US1: 3565 cases in 1997 → 7779 cases in 2006.Antibiotic use increases risk of CA-MRSA in children2 (and adults3).1 Nylund CM et al. Arch Pediatr Adolesc Med 2011; published online Jan 3, 2011. 2 Schneider-Lindner, et al. Arch Pediatr Adolesc Med 2011; published online Aug 1, 2011. 1 Schneider-Lindner, et al. Emerg Infect Dis 2007;13:994-1000Slide 71Skin Infections in 2000 = 13th PlaceSkin Infections in 2009 = 7th PlaceImage: A graph compares rate of discharges per 10,000 population for the most frequent conditions by body system for 2000-2009.Slide 72IX. Are the Millions of Dollars Spent on Alzheimer Meds and Antidepressants in Demented Elderly Worthwhile?Schneider LS et al. Lack of evidence for the efficacy of memantine in mild Alzheimer disease. Arch Neurol 2011 Apr 11 [e-pub ahead of print]. (http://dx.doi.org/10.1001/archneurol.2011.69 ).Slide 73Previous LiteratureNNT 12.No important positive outcomes (time to nursing home, ability to do ADLs, etc.).Donepezil not effective in minimal cognitive impairment.Cholinesterase inhibitors for patients with Alzheimer's disease: systematic review of randomized trials. BMJ 2005;331;321-327.Doody RS et al. Donepezil treatment of patients with MCI: A 48-week randomized, placebo-controlled trial. Neurology 2009 May 5; 72:1555.Slide 74This StudyWhy is this study important?Meta-analysis of 3 studies of patients with "mild" Alzheimer's disease.3 trials including 431 with mild disease (MMSE 20-23).Did not find any benefit in cognitive function, global functioning, ADL or behaviour.No difference in any scale between memantine and placebo.Slide 75ADAS-cog.CIBIC-plus.ADCS-ADL scale.Neuropsychiatric Inventory.Images: Four graphs compare Favors Memantine vs. Favors Placebo.Slide 76Conclusion: Memantine Doesn't Work For Mild Alzheimer's.Slide 77Sube B. et. Al. Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. Lancet 2011; 378: 403�11.Slide 78 Double blind, placebo controlled trial of those with "possible or probable" Alzheimers who were attending a geriatric psychiatry clinic (not shut-ins). Cornell score of depression of >8, had a care giver, not suicidal. (only 8 patient's were "possible").Slide 79Randomized to placebo, sertraline (Zoloft) (150mg), or mirtazapine (Remeron) (45mg).Outcome was 13 and 39 week Cornell Score.Used linear regression to control for which center patients were from (??), baseline Cornell scale of depression in dementia, time of participation (??).Slide 80111 controls.107 patients randomized to sertraline or mirtazapine.No differences between placebo and treatment arms. No difference between mirtazapine and sertraline arms.Side effects worse in treatment arms.Slide 81They changed power calculation from 507 to 339 once initial data was collected (?).Does not apply to shut-ins (but likely the same).Participation in a trial (someone caring about you, active interactions) works as well as drugs.Slide 82X. Guidelines Run Amok....Definition and Evaluation of Transient Ischemic Attack: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. Easton JD, et al. Stroke 2009; 40: 2276-2293.Slide 83AHA/ASA Definition and Evaluation of Transient Ischemic Attack: #1Now a "tissue-based" diagnosis.MRI needed within 24 hours of arrival: Class I, Level of Evidence B.Their explanation: You pick up more strokes.Response: And this improves outcomes???"For a guideline to be sound it should be linked on the basis of scientific evidence to the very health outcome that the guideline is designed to promote". Jt Comm J Qual Improv 1993 Jul;19(7):248-63.Slide 84AHA/ASA Definition and Evaluation of Transient Ischemic Attack: #2"It is reasonable to hospitalize patients with TIA if they present within 72 hours of the event and any of the following criteria are present:ABCD2 score of ≥3.ABCD2 score of 0-2 and uncertainty that diagnostic workup can be completed within 2 days as an outpatient.ABCD2 score of 0-2 and other evidence that indicates the patient's event was caused by focal ischemia."All Class IIa "reasonable", Level of evidence: C"GOBSAT"Slide 85ABCD2 Score: BackgroundCalifornia Score:1 pt for eachAge >60.DM.Duration >10 min.Motor weakness.Speech impairment.Johnson SC, et al. JAMA 2000. ABCD2 score.ABCD Score: 1 pt for each, except*Age >60.BP >140/90.Unilateral weakness: 2 pt: Speech only: 1 pt.Duration: >10min: →60 min: 2 pt.Rothwell PM, et al. Lancet 2005. ABCD2 score.Slide 86ABCD2 ScoreAge: greater than or equal to 60 (1 pt).Blood pressure: SBP≥140 or DBP≥90 (1 pt).Clinical Features: Focal weakness (2 pt) orSpeech impairment without focal weakness (1 pt).Duration of symptoms: ≥60minutes (2 pt) or≤59 minutes (1 pt).Diabetes (1 pt).Risk of CVA at 2 days:0-3 points = 1% risk.4-5 points = 4.1% risk.6-7 points = 8.1% risk.Johnson SC, et al. Lancet 2007;369:283-92.Slide 87Problems With ABCD2 Recommendation…Lack of ValidationRecommendation was made without any study examining the external validity of the score. Shah KH, et al. Ann Emerg Med 2009; 53: 662-73.You essentially admit everyone (> 2 score): Original Kaiser study: 92%.Sensitivity of 95%, but very poor specificity (12.5%).Perry JJ, et al. CMAJ 2011 Jul 12; 183(10):1137-45.Insurers now utilize (corrupted) these recommendations.....the cart before the horse...Slide 88Problems With ABCD2 Recommendation... And it Probably Does Not work!!!Methods: 637 pts. prospectively eval with TIA: At Mayo Clinic, 2001-2006.Results: 15 ischemic strokes at 90 days ABCD2 scoreCVA @7 daysCVA @90 daysLow (0-3)2/187 (1.06%)4/185 (2.12%)Intermediate (4-5)1/335 (0.30%)7/329 (2.08%)High (6-7)3/109 (2.68%)4/108 (3.57%)Stead LG, et al. Ann Emerg Med 2011; 57 (1): 46Slide 89Kudos to AHRQ… National Guideline Clearinghouse™The bad news: 2573 guidelines (as of 7/31/11).The Good news: You are aware of some of these issues…Promoting Transparent and Actionable Clinical Practice Guidelines: Viewpoint from the National Guideline Clearinghouse™/National Quality Measures Clearinghouse™ (NGC/NQMC) Editorial Board released Dec 20, 2010.Slide 90Promoting Transparent and Actionable Clinical Practice Guidelines: 2 NeedsA. Establishing "trustworthiness" of CPG.B. Promoting actionable CPG's to be used in CDS.#1 "…encourages CPG developers to describe their conflict of interest policies, to disclose potential conflicts of interest, and to describe all funding sources for the development of their CPGs".But who decides who sits at the table??#2 "…encourages CPG developers to formulate recommendation statements that are "actionable" and that employ active voice rather than passive voice.My plea: get rid of "consider" recommendation.Slide 91Promoting Transparent and Actionable Clinical Practice Guidelines: 2 NeedsA. Establishing "trustworthiness" of CPG.B. Promoting actionable CPG's to be used in CDS.#3 "avoiding vague or ambiguous recommendation statements (such as "Physicians may offer.." or "When possible..")Yes, and give clear drug/dosing recommendations.#4 "...encourages guideline developers to distinguish explicitly between factual statements and recommendations.Agree—but how about a step further... give the data NNT/NNH in the recommendation.Slide 92Kudos to U.S. Preventive Services Task Force (USPSTF) (AHRQ).... They Got the "Guideline Thing" RightAn excellent read....The Anatomy of a US Preventive Services Task Force Recommendation: Lipid Screening for Children and Adolescents. Grossman DC, et al. Arch Pediatric Adolesc Med 2011; 165 (3): 205-10.Slide 93Thank You for Time and Consideration!!!R. Dachs— Contact info: email@example.com. Graber—Contact info: firstname.lastname@example.com 94#1 Bonus Topic: Electronic Health Records (EHR)/Computerized Physician Order Entry (CPOE)And is being "electronic" really helping my patients?Image: A poster lauds Computerized Physician Order Entry (CPOE) as "Quality Care."Slide 95Bonus Topic: EHR/CPOEAnd is being "electronic" really helping my patients?Case #1: Electronic prescribing.Methods: 3,898 computer-generated Rx's: Obtained from outpt. Pharmacies, in 3 states.Results: 452 errors (11.6%) Range 5-37%: 275 (60.8%) were omissions (no big deal).163 (35%) were potential ADE's (a big deal).Errors associated with outpatient computerized prescribing systems. Nanji KC,et al. J Am Med Inform Assoc 2011 Jun 29 [Epub ahead of print].No difference in rates of ADE's in hand-written vs. computerized Rx's. Gandhi TK, et al. NEJM 2003; 348: 1556-64.Slide 96EHR: Case #2: Quality Indicators: OutpatientElectronic Health Records and Clinical Decision Support Systems. Romano MJ, et al. Arch Intern Med 2011 171: 897-903.Methods: NAMCS and NHAMCS 2005-07: 255,402 ambulatory visits.Analyzed 20 previously developed quality measures.Results: EHR used in 30% of 1.1 billion visits: Clinical Decision Support (CDS) in 57% of these: Only 1 of 20 indicators was greater in EHR with CDS visits (lack of routine EKG in low-risk pts).Slide 97EHR: Case #3: Quality Indicators: InpatientElectronic Health Record adoption and quality improvement in US Hospitals. Jones SS, et al. Am J Man Care 2010; 16: SP64Methods: Compared 2086 US hospitals: No EHR vs. Basic EHR vs. advanced EHR.On 17 performance measures (AMI, CHF, CAP).2003-2006.Results: No clear relationship between the use of EHR and improvement in quality measures.Slide 98EHR: Case #4: All Is Not Lost......Electronic Health Records and Quality of Diabetes Care. Cebul RD, et al. NEJM Sept 1, 2011; 365:825-33.Methods: Retrospective analysis 46 primary care sites in Cleveland area: Reviewed (4) diabetes care and (5) outcomes.24,547 EHR pts. vs. 2,660 paper-based practices.7/07-6/10.Results: EHR had greater adherence to DM care measures and improved outcomes: Note: the "outcomes" were intermediate (DOE's) endpoints, not firm clinical ones (POEM's).Slide 99 #2: Bonus Topic: Sepsis CareVasu TS et al. Norepinephrine or dopamine for septic shock: A systematic review of randomized clinical trials. J Intensive Care Med 2011 Mar 24 [e-pub ahead of print]. (http://dx.doi.org/10.1177/0885066610396312).Slide 100Previous LiteratureNot the best done study but norepinephrine was as good as dopamine overall and better in cardiogenic shock.De Backer D et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med 2010 Mar 4; 362:779.Slide 101This StudyMeta-analysis of 6 studies that compared norepinephrine with dopamine.995 randomized to norepinephrine.1048 randomized to dopamine.Endpoint: 28 day mortality.Mortality: 48% vs. 53%.Relative risk of arrhythmias 0.43.Slide 102#3 Bonus Topic: The Niacin IssueIn Press. NIH press release.http://www.nih.gov/news/health/may2011/nhlbi-26.htmSlide 1033414 patients with hx CAD taking a drug to reduce LDL.Randomized to niacin or no niacin (1,718, 1696) up to 2000mg/day.Trial stopped early. No difference in outcomes and increased incidence of stroke (??!).One problem is that 515 patients were on Zetia (ezetimibe) for HDL lowering.Slide 104Bonus Topic #4: TB Update(In Press…CDC release).http://www.cdc.gov/nchhstp/Newsroom/docs/PREVENT-TB-Factsheet.pdf Plugin Software HelpSlide 105Prior Literature6-9 months of Isoniazid.Slide 106This Study8,053 patients mostly from US and Canada (low prevalence area).Randomized to: INH self administered daily (69% finished).Rifampin + INH administered weekly by physician (82% finished).10 year follow-up.Results: 7 vs 15 cases (favoring rifampin + INH).But…low prevalence, observed, no HIV+ Page last reviewed October 2014 Internet Citation: Top 10 Innovations in Primary Care (in the Past Year) (Text Version). October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2011/dachs-graber/index.html


text:
Narrow your search
Big Red's latest Android is aimed at first-time smartphone buyers.
On the heels of Apple and Samsung, Facebook is plotting its first steps into the health-care industry.
The "Star Wars" universe has infiltrated every part of your life, so you might as well get the matching house keys, too.
Last year, LG launched the world's first OLED TV at $15,000. Now the the second-generation version goes on sale at Best Buy with a 75 percent price drop.
This basic dSLR doesn't stand out from the competition.
For less than $500, the Yoga 2 11 gets you Lenovo's excellent hybrid hinge but trades away some power and battery life.
The latest software updates reveal new features for the Apple TV, Apple's entry-level iMac should not be on your wishlist, and more iOS device rumors.
The Collins English Dictionary held a hotly contested vote for a geeky new-fangled word that would earn a spot in the book. We have a winner.
Kickstarter has relaxed its rules, making it easier for projects to be accepted on the crowdfunding website.
Now its most inexpensive interchangeable-lens model looks more sophisticated.


text:
Follow FEMA:
Sheriff's Office Annex
Main Content
Photo by Manuel Broussard - Jul 23, 2013
St Bernard Parish, La., July 24, 2013 -- To date, almost $5 million has been funded by FEMA for the Sheriff's Office Annex. FEMA has provided public assistance funding and grants to rebuild infrastructures destroyed by Hurricane Katrina. Gioan Nguyen/FEMA - Location: St Bernard Parish, LA


text:
- News
- Premium
- Lifestyle
- Tech
- Communities
- Video
- Multimedia
- More
Vietnam marks 'historic, golden' Dien Bien Phu victory
Published on May 7, 2014 1:06 PM
DIEN BIEN PHU , Vietnam (AFP) - War veterans, communist leaders and diplomats gathered in Vietnam's Dien Bien Phu town on Wednesday for an event to mark the 60th anniversary of the country's seminal victory over French colonial forces.
The bloody, 56-day battle in this remote, northwestern valley ended on May 7, 1954, precipitating both the collapse of France's colonial empire and Vietnam's emergence as an independent nation.
"Dien Bien Phu was a victory for all the people of Vietnam, Laos and Cambodia," as it ended French dominance in Indochina, said President Truong Tan Sang at a colourful ceremony featuring marching bands, flower-bedecked military floats and regiments of goose-stepping soldiers.
During the battle, artillery boomed across the valley and there was hand-to-hand fighting. Dien Bien Phu and its surrounding hills were filled with the rotting corpses of soldiers from both sides.
To continue reading, log in if you are a subscriber
Enjoy 2 weeks of unlimited digital access to The Straits Times. Get your free access now!


text:
I have a computer running XP 64bit that all of a sudden could not connect to the internet. I am using a router, and cable modem. I was using the computer yesterday, working fine, went to the store, came home, no internet. No one was in the house. I checked my network card (I assumed it died on me). It appeared to be ok. I installed a wireless card for testing purposes and ran in to the same issue. My network connection said it was sending packets but not receiving. I've spent since about 3pm yesterday afternoon working on this issue. The computer was not even contacting the router. I finally got it down to the computer can contact the router, but still get not get outside to the net. This is where the ip address change comes in. I have restarted the router, the modem, the computer, released, renewed, flushed dns until I was blue in the face. It keeps giving me an ip address of 192.168.1.113. Which was a static ip I was using in order for a game server to run on my computer. Of course I have already removed the static ip and set my settings to obtain automatically. I finally got to a point of desperation (and been wanting to do this anyway), and went and bought a new router. I plugged the router in, set up the software, plugged the computer back in. STILL giving me that ip address. I have no idea where it's getting the address from now. I even uninstalled my network card and reinstalled. I just don't understand where this address is being stored that it's getting it from. Once I changed it to obtain ip automatically it should be getting the address from the router (which is dhcp). Please, please help me get this thing to stop trying to use this address! Honestly, not even 100% sure it will work once I get it to stop using it, but at least it's a start.
Thank you for your time.


text:
Earlier today the Iowa caucuses results were officially classified as a tie, despite Rick Santorum coming in 34 votes ahead of oppoent Mitt Romney in final vote tallies. After Iowa GOP Chairman Matt Strawn took some heat for calling a Santorum lead of 34 votes a "tie" after he called a Romney lead of 8 votes a "win" the day after the caucuses, Strawn is officially declaring Santorum the winner.
Iowa GOP Chairman Matt Strawn says Rick Santorum is the winner of the Iowa Caucus. Period.
After the Republican Party of Iowa released the final certified results Thursday morning with eight missing precincts, Strawn released a statement saying he wanted to congratulate both "Senator Santorum and Governor Romney on a hard-fought effort during the closest contest in caucus history." The press release specifically did not state a specific winner of the Jan 3. Caucus, rather implying it was a tie.
But this afternoon, Strawn went on WHO Radio in Iowa and announced there should be no "ambiguity," that Santorum is, in fact, the winner.
"Certified results show Rick Santorum leading or won by 34 votes," Strawn told Jan Mickelson, noting that he needed to apologize to Santorum for any misunderstanding.
The switch of views comes just hours after a prominent Iowa Republican, Craig Robinson, called for Strawn's removal as chairman.
The announcement means the following:
Iowa winner: Santorum
New Hampshire Winner: Romney
South Carolina: To be determined Saturday
UPDATE: Romney called to concede.
|Katie Pavlich is the Editor at Townhall.com. Follow her on Twitter @katiepavlich. She is a New York Times Best Selling author. Her new book Assault and Flattery: The Truth About the Left and Their War on Women, will be published on July 8, 2014.
"Mamas, don't let your babies grow up to be brainwashed government dependents. Buy this book!" says Michelle Malkin.
"This is a thorough and gutsy book that should help set history straight." - Mark Levin
Buy Katie's book today and help us keep the pressure on the Left.
Author Photo credit: Jensen Sutta Photography
Former Speaker Dennis Hastert Indicted For Lying To The FBI, Evading Currency Transaction Reports | Matt Vespa
Fifteen Dollars an Hour for Thee, but Not for Me: California Unions Request Exemption from New Wage Law | Christine Rousselle
Comedian who plays wonderfully wooden Hillary on SNL finds actual Hill "resplendent" | Mary Katharine Ham


text:
Epson Stylus Pro 9900 44 Large Format Printer (Black and Gray)Epson
- Product #:
- Manufacturer #:
- 44" Wide Format - Gallery Quality Printing - UltraChrome HDR Pigment Inks - 11 Individual Ink Tanks - Long Life Prints - Easy-to-Use Menu System - Network Capable - Spindle-Free Roll Media Loading - Rotary Cutting System
- Maximum Resolution:
- 2880 x 1440 dpi
- Maximum Resolution:
- The maximum size of a print with optimum quality.
- Maximum Printable Area:
- This is the maximum printing area of a type of paper.
- Paper Type:
- All 2 and 3"" Core Inkjet-compatible Roll Papers up to 44"" wide All Inkjet-compatible Cut-sheets between 8.3 x 11"" and 44 x 36""
- Paper Type:
- This is the paper type.
- Optical Resolution:
- Cyan, Orange, Yellow, Light Cyan, Matte Black, Photo Black, Vivid Magenta, Light Black, Green, Light Light Black, Vivid Light Magenta
- Optical Resolution:
- Number of pixels per inch recorded by the scanner's image sensor.
Our Next Generation
For more than a decade, Epson has set the standard by which all other photographic printing technologies are judged. So, when we decided to develop an entirely new generation of photographic printing technology, the significance of this effort inspired our engineers to rethink everything.
Introducing the all-new Epson Stylus Pro 7900 and 9900 printers
Representing our next generation, the Epson Stylus Pro 7900 (24-inch) and Epson Stylus Pro 9900 (44-inch), incorporate our latest achievements in photographic ink jet technology. By combining the precision of our MicroPiezo TFP print head with the extraordinary performance of Epson UltraChrome HDR ink, our newest generation of Epson Stylus Pro printers continues to represent a level of technology unprecedented in Epson's history.
Epson UltraChrome HDR represents our latest generation of pigment ink technology. Now utilizing ten colors - including an all-new Orange and Green - Epson UltraChrome HDR ink produces the widest color gamut ever from an Epson Stylus Pro printer. Even more remarkable, combining Epson UltraChrome HDR ink with our new Epson AccuPhoto HDR screening technology dramatically raises the level of print quality and once again sets a new benchmark standard for photographic reproduction.
Our advanced Epson MicroPiezo TFP print head is capable of producing higher quality prints, at speeds almost twice as fast as our previous generation. And, with our latest ink-repelling coating and auto nozzle verification technologies, clogged nozzles are virtually eliminated.
Developed in partnership with X-Rite, Epson has incorporated an optional, high-performance, in-line spectrophotometer. When driven by the latest front-end RIPs, Epson SpectroProofer can automate any color management process in your commercial or flexographic proofing workflow.
With printers capable of handling virtually any media type, in roll or cut sheet, up to 24 or 44 inches wide, Epson sets the standard for professional media use. Whether producing sellable color or black-and-white photography, fine art reproduction, or producing color accurate commercial and flexographic proofs for client approvals, never before have Creative Professionals had such powerful tools, allowing them to produce their vision without compromise.
With every introduction of a new Epson Stylus Pro printer, we continue to innovate and refine the overall printing experience. With the introduction of our latest Epson Stylus Pro 7900 and 9900 printers, Epson is once again redefining what's possible from photographic ink jet printing.
High-Precision Ten-Channel Epson MicroPiezo TFP Print Head
- Thin Film Piezo (TFP) print head design capable of handling ten separate ink channels
- One-inch wide high-performance print head with 360 nozzles per channel
- Auto-sharing black ink channel technology
- Low vibration meniscus control for highly accurate dot shape and placement
- All-new ink repelling coating to dramatically reduce nozzle clogging
- Produces variable-sized droplets as small as 3.5 picoliter to greatly decrease print times while optimizing photographic quality
Epson AccuPhoto HDR Screening
- Advanced ten-color screening algorithm resulting in prints with superior color and clarity
- Maximum resolution of 2880 x 1440 dpi for incredibly sharp text and line art
- Produces extremely fine blends and photographic transitions
- Extremely accurate highlight-to-shadow detail
- No visible photographic graininess due to the printing process*
- Ensures consistent color balance regardless of the viewing light source
- When combined with the precise dot placement accuracy of the Epson MicroPiezo TFP print head, overall photographic print quality is dramatically improved
Epson PreciseColor Manufacturing
- Unique production technology to ensure printer-to-printer color consistency
- Colorimetric calibration is performed during the manufacturing process
- This process automatically evaluates and adjusts the color performance of each printer produced
- The result is extreme color repeatability for demanding color performance over time
- Completely eliminates the need for internal printer calibration devices or procedures
Automatic Nozzle Verification and Cleaning
- Embedded sensors quickly verify nozzle status without using media
- System automatically performs a head cleaning if required
- Nozzle verification is performed in under 30 seconds
- Nozzle verification process consumes less than 1 ml of ink
- Can be set to automatically perform check before each job; periodically; or can be turned off
Automatic Print Head Alignment
- Built-in sensor performs highly precise alignments of all color channels
- Aligns both single and bi-directional print modes
Epson UltraChrome HDR Ink Technology
- Next-Generation Ten-Color Pigment-Based Ink System
- Unique High Dynamic Range (HDR) pigments for an extremely wide color gamut
- Ten-color printing system including all-new orange and green inks
- Designed to work with Epson AccuPhoto HDR screening technology
- Professional print permanence ratings
- Outstanding short-term color stability for mission critical proofing applications
- Improved Microcrystal Encapsulation Technology for reduced gloss differential
- Exceptional black density up to 2.6 with an L* value ~3.0
Three-Level Black Ink Technology
- Simultaneously uses Black, Light Black, and Light Light Black inks
- Significantly improves the gray balance while eliminating colorcasts
- Outstanding highlight-to-shadow grayscale accuracy for a smoother tonal range
- Virtually eliminates any bronzing of the basic pigment chemistry
- Enhances the ICC profiling process for ColorSync and ICM workflows
Automatic Black Ink Mode Switching
- With both Photo and Matte Black ink cartridges installed simultaneously, the Epson Stylus Pro 900 series printers automatically utilize the optimal black ink mode, delivering maximum black density for the chosen media. Taking advantage of the Epson MicroPiezo TFP auto-sharing black ink channel ensures a fast and efficient switch. And to further reduce switching errors, the user can choose to confirm the switching process from the front control panel.
- The standard Photo Black ink mode can be used for any media type with professional results. However, for certain Epson media types such as Velvet Fine Art, Enhanced Matte, and UltraSmooth Fine Art, using the optional Matte Black ink mode instead, will dramatically increase your black optical density for even better print quality.
Professional Media Handling
- Compatible with virtually any media type, in roll or cut sheet, up to 24 or 44 inches wide
- Accurate loading of cut-sheet media up to 1.5mm thick posterboard
- All media is front-loaded via a unique straight-through media path
- Printer and driver based media identification and synchronization system for virtually error-free media use
- Media bin safely captures multiple prints up to 24" x 36" or 44" x 36"
- Optional Automatic Take-up Reel System for unattended production of large print runs (SP9900 only)
Epson ePlaten Media Loading Technology
- Accurate automatic media loading, movement, and tracking
- Electronically controlled roll media rewind and take-up
- Automatic roll media rewind upon media release
- Simplifies the overall roll and cut-sheet media loading process
Spindle-Free Roll Media Loading
- User-adjustable roll media adapters accepts either 2- or 3-inch media cores
- Simple tension lever ensures quick and secure media core loading
- Designed with Epson ePlaten Technology for highly-accurate roll media usage
- Additional media adapter pairs available as an accessory for efficient roll media switching
Roll Media Length Tracking and Identification System
- Real-time automatic remaining roll media length counter
- Automatic bar code tagging of remaining roll media information for faster reloading
- Very useful for tracking partially used media rolls
High Performance Rotary Cutting System
- Durable rotary cutter, designed to be virtually maintenance free
- High performance cutting speeds - cuts 24" to 44" wide rolls in under two seconds
- Off-carriage cutting system eliminates media dust within critical components
- Capable of cutting virtually any media type, including most canvas and fine art papers
High Performance Print Engine Speeds
- Utilizing our latest print head technology, the Epson Stylus Pro 900 series printers are among the fastest wide-format printers in the industry.
Advanced Black-and-White Printing Technology
- Unique driver technology takes full advantage of our three-level black system to produce professional black-and-white prints from color or grayscale image files
- Produces a truly consistent print with no color crossover or color cast
- Some of the world's greatest black-and-white photography has been printed using this technology
Epson Intelligent High-Capacity Ink System
- Pressurized ink cartridge technology ensures reliable ink delivery at all print speeds, while dramatically reducing the physical size of the ink cartridges
- Eleven individual ink cartridges; available in 150ml, 350ml, and 700ml fill capacities
- On-the-fly ink cartridge replacement for increased productivity
- Mix and match across all three ink cartridge sizes
Easy-to-Use Front Control Panel
- High-resolution 2.5" color LCD for improved viewing of printer status
- Simple button layout for all navigation and basic printer functions
Epson SpectroProofer - Powered by X-Rite
- Optional 24- or 44-inch wide spectrophotometer developed jointly with X-Rite
- Simple installation fits cleanly into the front of the Epson Stylus Pro 7900 and 9900
- Incorporates a high-performance X-Rite ILS20 spectrophotometer for extreme measurement accuracy below 0.5 dE94
- UV-cut and non-UV-cut versions available at time of purchase
- Both black or white interchangeable backing plates included
- Built-in print dryer to accelerate the dry-down and reading process
- When driven by the latest software RIP front-ends, Epson SpectroProofer can automate virtually any color management process in your workflow
Superior Connectivity
- Standard connectivity includes one USB 2.0 and one 10/100 BaseT Ethernet port
- Professional Epson Photographic Drivers for Macintosh and Windows
- Fully supported by most leading third party RIPs and workflows
Apple Macintosh 16-bit Printer Drivers
- Enhanced 16-bit data support for Macintosh users
- Takes full advantage of 16-bit data files from compatible application software
- Depending upon the file being printed, you may see a more accurate print
- Advanced web-based printer information and management system
- Automatically tracks printer consumables usage and print job information regardless of location
- Provides real-time cost-per-print estimates and print-job-run information
- Create various reports using actual print job information
- Provides remote printer monitoring and alert capability
- Secure information management using the latest encryption technologies
- True web-based fleet-wide printer management via secure web-based account
World Class Service and Support
- Includes one-year of limited coverage under the Epson Preferred Protection Plan with toll-free telephone support available Monday through Friday and usually next-business-day on-site service
- Optional one- or two-year Epson Preferred Plus service plans available
Product Reviews
There are no reviews for this product.
|Epson - Epson
|Power Requirements & Consumption
|Stand-by Consumption:
|Less than 5 W
|Approximate Consumption:
|Approx. 55 W or less
|Rated Frequency:
|50 - 60 Hz
|Printing Method Data
|Printer Technology:
|Advanced MicroPiezo TFP print head, with ink repelling coating technology
|Number Of Nozzles:
|Color and Monochrome 360 nozzles x 9
|Maximum Resolution:
|2880 x 1440 dpi
|Roll Paper and Specialty Heavyweight Media
|Print Longevity/Archival:
|Up to 200 years
|Nozzle Pitch:
|Ink Cartridge Configuration:
|11-cartridge (C, Lc, VM, VLm, Y, O, G, LK, LLK, + PK or MK)
|Minimum Ink Droplet Size:
|3.5 picoliters
|Physical Specifications
|Paper Handling
|Maximum Printable Area:
|Paper Size:
|Cut Sheets: 8.3 x 11"" up to 44 x 36"" Roll Paper (2"" Core): Up to 44"" x 147.6' Roll Paper (3"" Core): Up to 44"" x 662.7'
|Borderless Paper Sizes:
|10"", 13"", 16"", 17"", 24"", 36"", 44""
|Maximum Paper Thickness:
|1.5mm Cut-sheets 0.5mm Roll Paper
|Paper Capacity / Feed:
|2"" Core Inkjet-compatible Rolls with a Diameter of 4"" 3"" Core Inkjet-compatible Rolls with a Diameter of 6""
|Paper Type:
|All 2 and 3"" Core Inkjet-compatible Roll Papers up to 44"" wide All Inkjet-compatible Cut-sheets between 8.3 x 11"" and 44 x 36""
|Hardware & Software Data
|Interface & Connectivity:
|one Hi-Speed USB 2.0 (1.1 compatible) and one Ethernet Port (10/100Base-T)
|Memory Card Capability:
|Image Preview Screen:
|Environmental Conditions:
|Operating 50 to 95F (10 to 35C) Storage -4 to 104F (-20 to 40C)
|Sound/Noise Level:
|Approximately 50 dB(A) according to ISO 7779
|Postscript Support:
|Yes: RIP Software Required (sold separately)
|Operating Systems & Requirements:
|Macintosh Leopard 10.5 or Higher (16bit) Windows Vista and XP (Both 32 and 64-bit supported)
|Direct Print Capability:
|Printer Language:
|Epson ESC/P2 raster photographic drivers standard Includes PANTONE licensed and SWOP certified PostScript Language Level 3 compatible RIP by ColorBurst
|Scanner Data
|Optical Resolution:
|Cyan, Orange, Yellow, Light Cyan, Matte Black, Photo Black, Vivid Magenta, Light Black, Green, Light Light Black, Vivid Light Magenta
In The Box
Epson Stylus Pro 9900 Printer
Power Cord
Printer Stand
Paper Basket
Starter Ink Set: Cyan, Orange, Yellow, Light Cyan, Matte Black, Photo Black, Vivid Magenta, Light Black, Green, Light Light Black, Vivid Light Magenta
Epson Software CD-ROM
You may also like
You May Also Like
Photo Paper
Kodak Premium Glossy Photo Paper Roll 42x100
Product #: EKD1393768
Manufacturer #: 1393768Our Price: $109.95
Earn 1100 U-REWARDS Loyalty Points
Kodak Pro Luster 10x100 Inkjet Paper
Product #: EKD1650969
Manufacturer #: 1650969Our Price: $52.00
Earn 520 U-REWARDS Loyalty Points
Epson Stylus Pro 7900 24in Large Format Printer (Black and Gray)
Product #: EPD1819
Manufacturer #: SP7900HDROur Price: $3,699.00
Earn 36990 U-REWARDS Loyalty Points
Epson Stylus Pro 9890 Designer Edition Printer (Black and Gray)
Product #: EPD1828
Manufacturer #: SP9890DESOur Price: $5,495.00
Earn 54950 U-REWARDS Loyalty Points
Epson Stylus Pro 4900 Inkjet Printer (Black and Gray)
Product #: EPD1793
Manufacturer #: SP4900HDROur Price: $1,895.00
Earn 18950 U-REWARDS Loyalty Points
Epson Stylus Pro 9890 44 Large Format Printer (Gray)
Product #: EPD1827
Manufacturer #: SP9890K3Price: $4,995.00 Add to cart for more details
Earn 35990 U-REWARDS Loyalty Points
Printer Accessories
Epson C12C890191 Replacement Ink Maintenance Tank for Epson Stylus Pro 9900
Product #: EPD9042
Manufacturer #: C12C890191Our Price: $34.95
Earn 350 U-REWARDS Loyalty Points
Epson Replacement Cutter Blade for 4000, 7600, 9600, and 4800
Product #: EPD9005
Manufacturer #: C12C815291Our Price: $89.95
Earn 900 U-REWARDS Loyalty Points
Warranty and Service
Epson 1 Year Additional Preferred Plus Service Warranty For 7900/9900
Product #: EPD9916
Manufacturer #: EPP900B1Our Price: $724.95
Earn 7250 U-REWARDS Loyalty Points
Epson 2 Year Additional Preferred Plus Service Warranty For 7900/9900
Product #: EPD9915
Manufacturer #: EPP900B2Our Price: $1,286.50
Earn 12865 U-REWARDS Loyalty Points
Epson Ink
Epson T642200 Ultrachrome HDR Cyan Ink Cartridge 150 ml
Product #: EPD4677
Manufacturer #: T642200
Epson T642100 Ultrachrome HDR Photo Black Ink Cartridge 150 ml
Product #: EPD4676
Manufacturer #: T642100
Epson T642300 Ultrachrome HDR Vivid Magenta Ink Cartridge 150 ml
Product #: EPD4678
Manufacturer #: T642300
Epson T642400 Ultrachrome HDR Yellow Ink Cartridge 150 ml
Product #: EPD4679
Manufacturer #: T642400
Epson T642500 Ultrachrome HDR Light Cyan Ink Cartridge 150 ml
Product #: EPD4680
Manufacturer #: T642500
Epson T642600 Ultrachrome HDR Vivid Light Magenta Ink Cartridge 150 ml
Product #: EPD4681
Manufacturer #: T642600Our Price: $84.50
Epson T642700 Ultrachrome HDR Light Black Ink Cartridge 150 ml
Product #: EPD4682
Manufacturer #: T642700
Epson T642800 Ultrachrome HDR Matte Black Ink Cartridge 150 ml
Product #: EPD4683
Manufacturer #: T642800
Epson T642900 Ultrachrome HDR Light Light Black Ink Cartridge 150 ml
Product #: EPD4684
Manufacturer #: T642900
Epson T642A00 Ultrachrome HDR Orange Ink Cartridge 150 ml
Product #: EPD4685
Manufacturer #: T642A00
Epson Green 150ML HDR Cart for 7900 and 9900
Product #: EPD4686
Manufacturer #: T642B00
Epson Photo Black 350ML HDR Cart for 7900 / 9900 / 7700
Product #: EPD4687
Manufacturer #: T596100
Epson Cyan 350ML HDR Cart for 7900 / 9900 /7700
Product #: EPD4688
Manufacturer #: T596200
Epson Vivid Magenta 350ML HDR Cart for 7900 / 9900 /7700
Product #: EPD4689
Manufacturer #: T596300
Epson Yellow 350ML HDR Cart for 7900 / 9900 /7700
Product #: EPD4690
Manufacturer #: T596400
Epson Light Cyan 350ML HDR Cart for 7900 and 9900
Product #: EPD4691
Manufacturer #: T596500
Epson Vivid Light Magenta 350ML HDR Cart for 7900 and 9900
Product #: EPD4692
Manufacturer #: T596600
Epson Light Black 350ML HDR Cart for 7900 and 9900
Product #: EPD4693
Manufacturer #: T596700
Epson Matte Black 350ML HDR Cart for 7900 / 9900 / 7700
Product #: EPD4694
Manufacturer #: T596800
Epson Light Light Black 350ML HDR Cart for 7900 and 9900
Product #: EPD4695
Manufacturer #: T596900
Epson Orange 350ML HDR Cart for 7900 and 9900
Product #: EPD4696
Manufacturer #: T596A00
Epson Green 350ML HDR Cart for 7900 and 9900
Product #: EPD4697
Manufacturer #: T596B00
Epson Photo Black 700ML HDR Cart for 7900 / 9900 /7700
Product #: EPD4698A
Manufacturer #: T636100
Epson Cyan 700ML HDR Cart for 7900 /9900 /7700
Product #: EPD4698B
Manufacturer #: T636200
Epson Vivid Magenta 700ML HDR Cart for 7900 / 9900 / 7700
Product #: EPD4698C
Manufacturer #: T636300
Epson Yellow 700ML HDR Cart for 7900 / 9900 / 7700
Product #: EPD4698D
Manufacturer #: T636400
Epson Light Cyan 700ML HDR Cart for 7900 and 9900
Product #: EPD4698E
Manufacturer #: T636500
Epson Vivd Light Magenta 700ML HDR Cart for 7900 and 9900
Product #: EPD4698F
Manufacturer #: T636600
Epson Light Black 700ML HDR Cart for 7900 and 9900
Product #: EPD4698G
Manufacturer #: T636700
Epson Matte Black 700ML HDR Cart for 7900 / 9900 / 7700
Product #: EPD4698H
Manufacturer #: T636800
Epson Light Light Black 700ML HDR Cart for 7900 and 9900
Product #: EPD4698I
Manufacturer #: T636900
Epson Orange 700ML HDR Cart for 7900 and 9900
Product #: EPD4698J
Manufacturer #: T636A00
Epson Green 700ML HDR Cart for 7900 and 9900
Product #: EPD4698K
Manufacturer #: T636B00
Epson 36 In. x 100 Ft. Premium Luster Photo Paper (Roll)
Product #: EPD8605
Manufacturer #: S042082Our Price: $124.99
Earn 1250 U-REWARDS Loyalty Points
Epson 13 x 19 Semi Matte SWOP3 Standard Proofing Paper (100 Sheets)
Product #: EPD7122
Manufacturer #: S045157Our Price: $109.00
Earn 1090 U-REWARDS Loyalty Points
Epson 36 In. x 100 Ft. Premium Semi-Matte Paper (Roll)
Product #: EPD86109
Manufacturer #: S042151Price: $195.00 Add to cart for more details
Epson 24 In. x 100 Ft. Semi-Matte White Proofing Paper (Roll)
Product #: EPD8416
Manufacturer #: S042004Price: $135.00 Add to cart for more details
Earn 950 U-REWARDS Loyalty Points
Epson 36 In. x 100 Ft. Enhanced Matte Paper (Roll)
Product #: EPD8607
Manufacturer #: S041596Our Price: $79.95
Earn 800 U-REWARDS Loyalty Points
Epson 8.5 x 11 In. Ultra Presentation/Enhanced Matte Paper (250)
Product #: EPD6616
Manufacturer #: S041914Our Price: $49.10
Earn 491 U-REWARDS Loyalty Points
Epson 44x131.7 Matt Single Weight for Inkjet (Roll)
Product #: EPD8902
Manufacturer #: S041855Our Price: $109.24
Earn 1093 U-REWARDS Loyalty Points
Epson 17 x 100 Semi Matte SWOP3 Standard Proofing Paper (Roll)
Product #: EPD8017
Manufacturer #: S045154Our Price: $109.00
Earn 848 U-REWARDS Loyalty Points
Epson 16.5X100 Semi Glossy Paper (Roll)
Product #: EPD8903
Manufacturer #: S042075Our Price: $60.08
Earn 601 U-REWARDS Loyalty Points
Epson 44 x 100 Semi Matte SWOP3 Standard Proofing Paper (Roll)
Product #: EPD8836
Manufacturer #: S045156Our Price: $279.00
Earn 2000 U-REWARDS Loyalty Points
Epson 24 x 100 Semi Matte SWOP3 Standard Proofing Paper (Roll)
Product #: EPD8437
Manufacturer #: S045155Our Price: $149.00
Earn 1140 U-REWARDS Loyalty Points
Epson 24 In. x 131.7 Ft. Single Weight Matte Paper (Roll)
Product #: EPD8415
Manufacturer #: S041853Our Price: $51.99
Earn 520 U-REWARDS Loyalty Points
Epson 24 In. x 100 Ft. Semi Gloss Photo Paper (Roll)
Product #: EPD8411
Manufacturer #: S041393Our Price: $79.99
Earn 800 U-REWARDS Loyalty Points
Epson 36 In. x 82 Ft. Double Weight Matte Paper (Roll)
Product #: EPD8600
Manufacturer #: S041386Our Price: $59.00
Earn 590 U-REWARDS Loyalty Points
Epson 24 In. x 50 Ft. Ultra Smooth Fine Art Paper (Roll)
Product #: EPD8419
Manufacturer #: S041782Price: $175.00 Add to cart for more details
Earn 1290 U-REWARDS Loyalty Points
Epson 24 In. x 82 Ft. Double WT Matte Paper (Roll)
Product #: EPD8418
Manufacturer #: S041385Our Price: $39.95
Earn 400 U-REWARDS Loyalty Points
Epson 36 In. x 100 Ft. Premium Glossy Paper (Roll)
Product #: EPD8409
Manufacturer #: S041391Our Price: $113.99
Earn 1140 U-REWARDS Loyalty Points
Epson 44X100 Premium Glossy Paper (Roll)
Product #: EPD8806
Manufacturer #: S041640Our Price: $149.14
Earn 1492 U-REWARDS Loyalty Points
Epson 44 In. x 50 Ft. Ultra Smooth Fine Art Matte Paper (Roll)
Product #: EPD8800
Manufacturer #: S041783Price: $325.00 Add to cart for more details
Earn 2200 U-REWARDS Loyalty Points


text:
All my "hero" cars are **** boxes from the 50's-early90's, so it's more of an issue of how much space I have to huck my pile of heaps out in the yard.
All my "hero" cars are **** boxes from the 50's-early90's, so it's more of an issue of how much space I have to huck my pile of heaps out in the yard.
'07 997.1 TT 6MT: Arctic Silver / Sea Blue. AWE exhaust, PTF custom 93/E85, BBS CH-R in widebody fitment, 5.9 60-130 E85, platform record
'15 F80 M3 6MT: Alpine White / Sakhir: Exec pkg, LEDs, carbon roof, Harman Kardon, black 19s, etc
Past: 300 hp B5 A4, 500 hp Evo 8, 2 450 hp E92 335s, 520hp C6 Z06, and a 750 hp CBA GT-R
I dont think ill ever own an f40
Maybe ill one day have a red Quattro
Full time manual transmission elitist
Part time arm chair CEO
My Hero car is a 550 Maranello and I'm currently busting my ass to make sure I own one before I turn 40...I have 119 days to go, but who's counting
It's a proper, proper thing!
I drove a Rolls Royce Ghost a couple weeks ago (one of the benefits of owning a Lambo, they thought I was important enough at the Rolls dealer to email me and offer a test drive of the Ghost) and I had the same impression. It didn't drive that much better than any other large luxury sedan, and the interior wasn't THAT much nicer than something like an S Class (or the 7-Series it's based on) but it costs as much as 3 S Classes. I'm FAR from a dashstroker, but seeing pieces made of plastic in the Rolls was shocking to me, for that price the interior should be made out of solid gold
"When you need to get somewhere quickly, I'd rather get there the fastest I can, looking the best I can"-Rutledge Wood
Yes, Corrado SLC. I am glad to have owned it and enjoy driving it. Now keeping it running on the other hand... LAWD HELP ME!
Yes and no. I dont really have any 'dream' cars, just ones I really, really like.
- I bought an '05 Audi allroad. Loved it since I first set my eyes on it. Finally got my hands on it and daily drove it and it was a wallet raiding nightmare. When it worked, it was oh so nice. The rest of the time, it wasnt. I sold it and still miss it when I see others on the road.
- Had a built up Land Rover Discovery for a bit. Fun truck but 8 mpg and constantly acting up electrics. Sold it and miss it dearly.
- Replaced the Disco with a diesel 60 series. Holy grail, right? Great truck yes but no where near as fun, or capable, as the Disco. Sold it when I moved to England. If I hadnt moved, I wouldve sold it anyway.
- 1972 MGB GT. That I want back and want it back BIG time. I would take that one back before I take my 1958 MGA.
- I will eventually buy another GT and find a pre 1988 Range Rover.
Looking for a car event on the East Coast? Check here
Our Lady of Blessed Acceleration, don't fail me now.
from 19-22 i definitely drove some hero cars. i daily drove a fully modded STI from 19-21, while have a basically new gsx-r600 at the same time. then when i left the army i had a mint S4 for a while. that was pretty sweet. also the period of my life where i not only could afford to screw around with cars, i cared to. i don't care nor can i afford to now as a full-time student. haha.
fun times were had. i still have a very nice car for my age and in school, so no complaints.
Garmin Is My Pilot.
I am confident you are wrong, but instead of illustrating why, I will just make disparaging remarks about your reading comprehension.
2000, got a MKIII 2.0 ABA VW (upgrading from parents hand me down '86 Olds wagon... my main goal was 70mph uphill)
2011, got a Forester XT limited 5spd. Needs some work to make it entertaining to drive, but for its purpose its great (70mph, in the snow, never need chains for snowboarding runs)
Shutup and drive yo cah'!
It's a proper, proper thing!
Not quite there yet.. the Mustang is fun, but i'm not done with it yet to make it my hero car.
Hero cars that are attainable:
- 78 Triumph TR-6
- 73 Porsche 911
Something something darkside..
I used to own my hero...fvckin' exwife...
I do own my now sort-of hero:
And I'm not talking about a modded GTR vs a stock 458 or similar. I'm talking stock vs stock. I'd have a hard time taking a GTR over say a 997 GT2, even if the GTR was faster and easier to drive.
"When you need to get somewhere quickly, I'd rather get there the fastest I can, looking the best I can"-Rutledge Wood
The 2004-2005 STi has been one of my hero cars since Jr. High. When I was finally able to own one, I was ecstatic. It was pretty much everything that I thought it would be.
Hopefully I'll get to own a C10 Nissan Skyline or an E30 M3 one of these days.
Some sort of air-cooled 911 is my hero.
I'd love to see it in the next 10 years. Even next 5 years maybe if prices start to drop enough on SCs and 3.2s that a well maintained one reaches the prices that turds reach now.
flickr | Follow me on instagram: @ginger_reporter
Looking for a car event on the East Coast? Check here
Our Lady of Blessed Acceleration, don't fail me now.
I guess the closest I came to this was my 2 Corvettes and they definitely lived up to my expectations.
At this point in my life I would love to be in a position to own any of the sports cars I had on the list but never got around to owning. Just isn't practical living where i do and not having a garage. So I guess I could count the Elise, NSX and C6ZO6 as the heroes I never got around to owning?
Not yet.
Still working on it.
Free 1SICKLEX
goes out the garage..........yup
I would never again spend the stupid money I paid for the 750iL, let alone what a Maybach cost. I was 36 in '88 and driving a powerful, pretty exclusive, luxomobile was pretty important to me. I'm way past that. What I've saved in not flipping daily drivers has allowed me to have my other toys.
The car marked a very high point in my financial life, but also a high point for stress. I'm glad I got it, but I'm also glad I pared back those kind of expenses.
Garmin Is My Pilot.
I am confident you are wrong, but instead of illustrating why, I will just make disparaging remarks about your reading comprehension.
no, probably never.
but maybe one day, I'll be able to afford to buy and maintain one of these
Finally got my WRX, base model and all it is my hero car.
No, I usually only get to test sit the exotics at shows.
Garmin Is My Pilot.
I am confident you are wrong, but instead of illustrating why, I will just make disparaging remarks about your reading comprehension.
edit now that I thought about it a bit, cars I heart. S15 Silvia, fell in love with them ever since I saw a brand new one in Australia in 2000. Datsun 510's, 240Z, STI, ur-quattro, R32, R33, R34GTR's, when I was younger I had lusted for 16V Scirocco's (had 2 8V though).
Last edited by VWVan; 10-02-2012 at 11:26 PM.
I guess a hero car is a car you really look up too and would love to drive, let alone own?
No, I don't think I will ever be able to afford a Underground Racing Lamborghini.
Since 2001
We're talking paper forks now
We're talking bacon cuts now
We're talking turkey talking, turkey walking
My 914 was my hero car. i've owned it for 5 years and have only driven it for 1 year. i was disappointed in the power so i pulled the motor and saw it was running on three cylinders. I have just finished the project and built the motor up a little. The handling is awesome but now that i have the 911 the power is disappointing even with me bilding the motor up. So i think ill need to sell it.
Last edited by flytech78; 10-02-2012 at 11:35 PM.
1 1 2 3 5 8 13 21 34 55
Good bye and thanx for all the fish!
Yes i do, after soo long of waiting and wanting.
Used to drive this (not my pic):
I really wanted an E30 325is when I got it, but couldn't find it and "settled" for an E36, which I wasn't really a fan of at the time. As I owned it, it grew on me a lot, and ever since I've sold it, I've realized that that car does everything I want. Agressive but classic looks, fairly luxurious and comfortable, practical, and incredible to drive. I just wish I could comfortable afford it (I was making a lot of money in high school which allowed me to afford the purchase, but then in college my income mostly stopped, so I didn't feel I could comfortably afford to maintain it). I need another one when I graduate .


text:
See All
My Communities
My Discussions
My Email Digests
Spotlight: Member Stories
I am a Stay at Home Mom of 2 kids, Melly-Bean who is 2 and Devin-Monkey who is 6. We live in rural Northern Maine in a small town of 2,000 or so peopl...More
More Members
Helpful Tips
I read almost all of Dr. B. Nazario's articles and one item I see missing is what is known as "Pulldown Burns" among the medical and ... More
Thank you for voting!
1 of 1 found this helpful
Helpful Resources
Related News
Report Problems With Your Medications to the FDA
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit the FDA MedWatch website or call 1-800-FDA-1088.


text:
- News
- Premium
- Lifestyle
- Tech
- Communities
- Video
- Multimedia
- More
Iran's top clergy back President Rouhani's softer nuclear approach
Published on Feb 2, 2014 12:51 AM
DUBAI (REUTERS) - President Hassan Rouhani has secured the backing of senior conservative clerics against hardliners opposed to a nuclear deal reached with major powers, Iran's official news agency Irna said on Saturday.
His first vice-president, Mr Eshaq Jahangiri, visited clerics in the Shi'ite Muslim holy city of Qom to explain the deal and seek their blessing over "complex foreign policy issues" ahead of talks next month on a long-term accord, Irna said.
An interim deal between Iran and the five permanent members of the UN Security Council plus Germany was reached in November in Geneva, aimed at persuading Iran to curb parts of its nuclear work, in return for a limited easing of sanctions.
Hardline clerics close to Iranian Supreme Leader Ali Khamenei, Revolutionary Guards commanders and the intelligence services have attacked the temporary concessions Mr Rouhani has made, although Mr Khamenei has so far backed the president. Mr Khamenei has the final say on all state matters, including the nuclear issue.
To continue reading, log in if you are a subscriber
Enjoy 2 weeks of unlimited digital access to The Straits Times. Get your free access now!


text:
"I put my daughter's picture and all of the information in and it looked great on screen! Usually when it looks great on screen it doesn't turn out like that when it prints. I was so shocked at how nice the picture came out and the invitation as a whole. Will definitely order more from here!"
"The colors are bold and well, colorful, without being neon or cartoonish. The invitation was an excellent choice for a 50th birthday. Like always, Tinyprints printed and shipped quickly. I am never disappointed."
"It only took a couple of minutes to personize these cards and they turned out very professional looking. I was suprised to recieve them so quickly, well ahead of the stated expected shipment date."
"I used this card for a Thank-you card for my husband's golf theme 60th birthday party. I used a picture of him showing up for the surprise party after completing a golf game. I put 60 on the flag and included his name on the side and wrote a thank-you note across the bottom instead of using it as an invite. The product is once again of high quality and so I was thrilled to send them out. Quite a few of our friends and relatives have commented on the great thank-you card they had received and a few have asked where I got them from, which again I share Tiny Prints information."
"I ordered these cards for my 5 year olds birthday! They are so cute and easy to design! Everyone that got one has commented about them and asked where I got them. The delivery was expensive but I got 2 day rush. Overall I loved them!!"


text:
Alabama Hurricane Dennis (DR-1593)
Incident period: July 10, 2005 to July 16, 2005
Major Disaster Declaration declared on July 10, 2005
Updates and Articles, Blogs, and News Releases
April 26, 2006
News Release
ORLANDO, Fla. ? Flooding is America's most common natural disaster. Even though hurricanes are the main cause of flooding in Florida, we must be prepared at all times. Officials from the State of Florida Emergency Response Team (SERT) and the Department of Homeland Security's Federal Emergency Management Agency (FEMA) urge Floridians to take action now and buy flood insurance before heavy rains and late spring floods begin.
April 19, 2006
News Release
ORLANDO, Fla. -- In the six months since Hurricane Wilma hit South Florida, more than $760 million in Public Assistance funds has been dispersed throughout communities affected by that storm, contributing to a total of $1 billion in Public Assistance funds that has reached city, county and state applicants for recovery from the 2005 storms, officials from the Department of Homeland Security's Federal Emergency Management Agency (FEMA) and Florida's State Emergency Response Team (SERT) announced today.
August 19, 2005
News Release
MONTGOMERY, Ala. -- More that $4 million is disaster payments have been provided to aid applicants following Hurricane Dennis on July 10. Federal and state disaster officials have received over 11,000 applications for disaster assistance, which includes housing assistance and payments for losses from the storm. Persons who were affected by Hurricane Dennis in Baldwin, Escambia and Mobile counties can still call and apply for disaster aid via FEMA's toll-free telephone line 1-800-621-FEMA (3362). Applicants have until September 8 to apply for assistance.
August 19, 2005
News Release
MONTGOMERY, Al. -- Free legal services through the Alabama Bar Association is available to eligible residents of Mobile, Baldwin and Escambia counties affected by Hurricane Dennis. Disaster officials say that this free service often goes unnoticed after a disaster but could be very helpful as residents clean up after the hurricane and try to get their lives back in order.
August 5, 2005
News Release
MONTGOMERY, Ala. -- In the month since the President declared three Alabama counties eligible for Individual Assistance, more than $3.5 million in disaster assistance has been approved to help those affected by Hurricane Dennis, state and federal officials announced today.
August 5, 2005
News Release
MONTGOMERY, Ala. -- Alabama's disaster victims have 30 days remaining in which to register with the Federal Emergency Management Agency (FEMA) for state and federal assistance in recovering from damage suffered during Hurricane Dennis. The application deadline is Thursday, September 8. "Any resident of a declared county who suffered uninsured losses should register to ensure the possibility of assistance," said Michael Bolch, the official in charge of federal recovery operations. "Those who plan to register, but have delayed, need be alert to the deadline."
Main Content
State/Tribal Government:


text:
Teen Holiday Comedy Too Many Tamales
Full Price
$10.00 - $15.00
Our Price
$4.00 - $7.50*
The day begins with a festive start as Maria's making tamales for the Christmas party, but panic ensues hours later when she realizes her mother's wedding ring, which she slipped on her finger earlier, is missing. Now, all of her cousins must eat through dozens of tamales to find the ring. Based on Gary Soto's beloved picture book and featuring puppets and lively Mexican music, Marsh Youth Theater's Bay Area premiere of Too Many Tamales will be performed by its Teen Troupe.
* Additional fees apply. No coupon or promo codes necessary to enjoy the displayed discount price.
All offers for Too Many Tamales have expired.
The last date listed for Too Many Tamales was Saturday January 4, 2014 / 2:00pm.
Currently at The Marsh Upstairs Studio Theater
One-Woman Comedy Analyzes Love & Race: Black Virgins Are Not For Hipsters
- Full Price:
- $20.00
- Our Price:
Echo is about to lose her virginity to a good-looking white hipster that she met on Craigslist. This… More
Venue Details
Parking garage on 21st Street is convenient to the theater.star this tip starred
Go to the 5 pm show and eat out afterwards. We had cocktails afterward at Piattini on Mission. The incredible bartender continued our education in bar culture and mixed some wonderful drinks.star this tip starred
Reviews & Ratings
Featured review from Goldstar Member
view more less of this review
There is just something about watching young people perform that makes me tear up. A sweet production by great people.
More Information
Based on the book by Gary Soto
A play by Margarita Galban and Lina Montalvo


text:
Kimura, Y.; (2010) Measurement of glutathione synthesis by isotope ratio mass spectrometry in systemic inflammation. Doctoral thesis, UCL (University College London).
|PDF - Requires a PDF viewer such as GSview, Xpdf or Adobe Acrobat Reader
During sepsis and critical illness, a systemic inflammatory response can significantly produce reactive oxygen and nitrogen species, which can damage host tissues. Usually, several different antioxidant defences protect host cells from these reactive species. One of the important antioxidant defences is glutathione, a tripeptide synthesised from the precursor amino acids cysteine, glutamate and glycine. The aim of this study was to measure glutathione synthesis in vivo, using deuterated glycine as a tracer. Firstly, a new method for analysis of glutathione and glycine using both gas chromatography-mass spectrometry (GC-MS) and gas chromatography-isotope ratio mass spectrometry (GC-IRMS) was developed. The derivatives of both compounds were measured in a single chromatographic analysis, and the method was compatible with both GC-MS and GC-IRMS, and capable of measuring low carbon-13 or deuterium enrichment of glutathione in 50μl of erythrocytes. Erythrocyte glutathione synthesis was measured, using GC-IRMS, in critically ill infants and children who had been infused with deuterated glycine. Glutathione fractional synthesis rate (FSR) was not statistically different between septic and non-septic patients. In order to determine whether glutamine is able to increase GSH synthesis by acting as a glutamate precursor, erythrocyte GSH synthesis was measured using GC-IRMS in septic infants and children randomised to receive glutamine dipeptide or placebo. There was no significant difference in glutathione FSR between those given glutamine and those given placebo. Intestinal glutathione depletion is known to occur following intestinal ischaemia-reperfusion injury. I measured glutathione synthesis in a rat model of intestinal ischaemia-reperfusion injury, and found that hypothermic rats with ischaemia-reperfusion injury had a higher intestinal glutathione synthesis than normothermic rats, providing a potential mechanism by which hypothermia may maintain intestinal glutathione levels. In conclusion, the newly developed method of glutathione analysis using GC-IRMS was useful for compound specific isotope analysis of biological samples.
|Thesis (Doctoral)
|Measurement of glutathione synthesis by isotope ratio mass spectrometry in systemic inflammation
|Open access status:
|An open access version is available from UCL Discovery
|UCL classification:
|UCL > School of Life and Medical Sciences > Faculty of Population Health Sciences > Institute of Child Health
View download statistics for this item
Activity - last month
Activity - last 12 months
Archive Staff Only: edit this record


text:
TheSpread is Pleased to Welcome GTBets as Our Newest Sportsbook Sponsor!
Limited Time Offer - Free $20 Bet Just for Signing Up! Don't Miss Out on Free Money, This Offer Will Expire Soon Click Here to Get Your Free $20 Bet
- Index
- » Baseball Discussion
- » Former commissioner Kuhn dead at 80
Former commissioner Kuhn dead at 80
Former commissioner Kuhn dead at 80
Former commissioner Kuhn dead at 80
Associated Press
PONTE VEDRA BEACH, Fla. (AP) - Bowie Kuhn, whose 15 tumultuous years as baseball commissioner coincided with free agency and multimillion-dollar salaries, died Thursday. He was 80.
Kuhn died at St. Luke's Hospital following a short illness, his spokesman Bob Wirz said.
When Kuhn took over as commissioner from William Eckert on Feb. 4, 1969, baseball just had completed its final season as a tradition-bound 20-team sport with no playoffs, a reserve clause and an average salary of about $19,000.
During his tenure, the sport battled the rise of the NFL and a combative players' union that attacked him with lawsuits, grievances and work stoppages.
"I want it to be remembered that I was commissioner during a time of tremendous growth in the popularity of the game," he said, "and that it was a time in which no one could question the integrity of the game."
People did question several of his major decisions. He didn't attend the game in 1974 when Hank Aaron hit his 715th home run to break Babe Ruth's career record. And he banned Hall of Famers Willie Mays and Mickey Mantle from association with their teams because of their liaisons with gambling casinos — Mays in 1979 and Mantle in 1983.
Many fans also remember him for his questionable choice to watch World Series games played at night in frigid weather without an overcoat.
Kuhn feuded with colorful personalities: owners Charlie Finley, Ted Turner, George Steinbrenner and Ray Kroc; former star players Mays, Mantle and Curt Flood; union head Marvin Miller. He presided over a 50-day strike that split the 1981 season in half.
Finley once called Kuhn "the village idiot." A prim and proper lawyer who stood ramrod erect, Kuhn was thought of as a stuffed shirt by some.
"You've got to develop a sense of humor," Kuhn once said in an interview. "You have to be able to stand back and laugh. That's invaluable, or you're apt to go slightly balmy."
- Index
- » Baseball Discussion
- » Former commissioner Kuhn dead at 80
Board Info
- Board Stats:
- Total Topics:
- 47596
- Total Polls:
- 2
- Total Posts:
- 304169
- Average Posts Per Hour:
- 3.8
- User Info:
- Total Users:
- 3992
- Newest User:
- Ryan moore
- Members Online:
- 1
- Guests Online:
- 2203
- Online:
- Blade
Forum Legend:
- Topic
- New
- Locked
- Sticky
- Active
- New/Locked
- Sticky/Locked