text:
From the Department of Neurology, Beaumont Hospital (Drs Traynor, Forde, and Hardiman and Ms Corr), Department of Epidemiology and Biostatistics, Mater Misericordiae Hospital (Dr Codd), and Irish Motor Neuron Disease Association (Ms Frost), Dublin, Ireland.
This article was corrected | View correction
A correction has been published | View article
The El Escorial and the revised Airlie House diagnostic criteria for amyotrophic lateral sclerosis (ALS) classify patients into categories reflecting different levels of diagnostic certainty. We conducted a prospective, population-based study of the natural course of ALS in the Republic of Ireland during a 6-year period to examine the utility of these ALS diagnostic criteria.
Using data from the Irish ALS Register, we studied the clinical features of all patients diagnosed as having ALS in Ireland throughout their illness.
Between 1993 and 1998, 388 patients were diagnosed as having ALS. Forty percent of patients reported bulbar-onset symptoms. Disease progression occurred over time: at last follow-up, 75% of all patients had bulbar signs, compared with 59% at diagnosis. When the El Escorial criteria were applied, more than half of patients (218 [56%]) had definite or probable ALS at diagnosis. Of the 165 possible and suspected ALS cases at diagnosis (trial ineligible), 110 (67%) were trial eligible at last follow-up. Of the 254 patients who had died, 229 (90%) had definite or probable ALS, whereas 25 patients (10%) remained trial ineligible at death. El Escorial category at diagnosis was not a significant prognostic indicator. Use of the Airlie House criteria had no effect on the median time from symptom onset to trial eligibility (12.9 vs 12.8 months).
The El Escorial and Airlie House diagnostic criteria are excessively restrictive. Furthermore, levels of diagnostic certainty cannot be used as prognostic indicators.
AMYOTROPHIC lateral sclerosis (ALS) is a progressive degeneration of upper (UMN) and lower (LMN) motor neurons. Patients with findings suggestive of ALS are accorded different levels of diagnostic certainty (suspected, possible, probable, and definite ALS) by application of a set of defined diagnostic criteria. These criteria were established for research purposes in 1991 (El Escorial [EEC]1) and were revised in 1997 (Airlie House [AHC]2). To ensure uniformity within clinical trials, only patients exhibiting features of probable or definite ALS according to the EEC have been enrolled in recent clinical trials.3- 5
Despite the widespread use of EEC for clinical trial purposes, the majority of previously reported studies of the natural course of ALS have not adhered to these diagnostic criteria, and, more importantly, the outcome of the different diagnostic categories has never been formally evaluated. Furthermore, with the exception of prospective population-based studies from Scotland,6 the clinical course and survival of patients with ALS has been described almost exclusively from selected subgroups of the population.7,8
The purpose of this study, therefore, was 3-fold: to prospectively determine the natural course of ALS in a population-based cohort of patients with this condition; to compare survival in the population-based cohort with that in previously reported studies; and to ascertain the survival of patients according to their diagnostic category based on both the EEC and AHC.
The strength of this study lies in the existence of a complete register of all patients diagnosed as having ALS in Ireland. Details of this register have been published elsewhere.9 The vast majority of patients with ALS in Ireland are examined by a neurologist at some stage during their illness. Consequently, details of the medical care and clinical features provided to residents of the entire community are available for study, ensuring virtually complete case ascertainment of all cases of ALS occurring in this delineated population.
Diagnostic criteria for ALS were based on the EEC outlined by the World Federation of Neurology.1 These guidelines define 4 regions of the central nervous system, namely bulbar, cervical, thoracic, and lumbrosacral. A detailed attempt was made to exclude patients in whom symptoms are caused by conditions other than ALS (ie, ALS-mimic syndromes).10 Patients with suspected, possible, probable, and definite ALS according to the EEC were included in this study.
Once patients with ALS are enrolled in the register, details of their initial clinical features are obtained either by review of their complete medical records or, where possible, examination of the patient. All patients enrolled in the register are routinely followed up during the course of their illness at intervals of not less than 4 months. This is achieved by several methods: by telephone conversation with the patient, primary care physician, and primary care neurologist and by direct examination of the patient by our group. Particular attention is given to functional status at diagnosis and follow-up, progression of clinical features, potential risk factors, family history of ALS, and causes of death. For the purposes of this study, every patient was followed up to at least March 1999. Apart from those who died, follow-up was complete to that date for 96% of patients.
Data are stored on a computerized database (Microsoft Access, version 7.0; Microsoft Corporation, Seattle, Wash), allowing for organized retrieval of data. Statistical analyses are performed with SAS 6.11 statistical software.11 Survival was estimated by the Kaplan-Meier method,12 and differences in survival were measured by log-rank sum test. Survival was examined for the cohort as a whole and separately for those with bulbar vs spinal onset and by the central nervous system (CNS) region involved. An analysis of the risk for death associated with selected independent variables used the Cox proportional hazard model.13 Calculations were performed by using the date of symptom onset as day 0. Statistical significance implies P<.05 unless otherwise stated.
International comparison of survival in ALS was achieved by determining each data point on the survival curves for each study and displaying all the curves together by means of uniform axes.
Three hundred eighty-eight new cases of suspected, possible, probable, or definite ALS were diagnosed during the period from January 1, 1993, through December 31, 1998. Of these, 26 (7%) were familial ALS on the basis of detailed family history. Two hundred twenty (57%) of the incident cases were in men and 168 (43%) were in women. The median age at diagnosis was 63.3 years (range, 31.0-91.6 years) for men and 64.4 years (range, 19.7-92.1 years) for women. The median time from symptom onset to diagnosis was 8.0 months (range, 1.0-79.7 months). Follow-up accumulated 616.1 person-years, and median follow-up time was 15.0 months (range, 0.4-68.9 months). Of the 388 patients known to the Irish ALS Register, two thirds (n = 253) had died at the date of last follow-up. One patient had received long-term mechanical ventilation.
The site of symptom onset of the population is shown in Table 1. Seventy-six (45%) of women and 61 (28%) of men initially had purely bulbar-onset disease. The proportion of bulbar-onset symptoms increased with advancing age.
Table 2 shows the frequency of neurological signs for (1) the whole cohort at the time of diagnosis and (2) the total cohort at last follow-up, as well as (3) those alive at last follow-up and (4) those who had died. Seventy-five percent of patients at last follow-up had bulbar signs, representing an increase of 19% compared with the time of diagnosis. A comparison of neurological signs by CNS region between those who were alive at last follow-up and those who had died suggested that bulbar regional involvement was more common among those who died (83% vs 60%).
The nature of the neurological signs found in each region is outlined in Table 3. Combined UMN and LMN signs were present in nearly 90% of all cases at death.
The EEC categories of the entire cohort at time of diagnosis are shown in Table 4. One third of ALS cases fulfilled the EEC for definite ALS, whereas 87 (22%) had probable ALS, 136 (35%) had possible ALS, and 29 (7%) had suspected ALS. Data on 5 patients were incomplete. Only 40% of patients with familial ALS fell into the definite category at the time of diagnosis.
At the time of last follow-up, two thirds of the total cohort had died or had received long-term mechanical ventilation. Ninety percent of the patients had clinical features consistent with either definite or probable ALS before death; 9% were classified as having possible ALS and 1% of deceased patients had suspected ALS (Table 4). The follow-up time for deceased patients with suspected or possible ALS was shorter than that of patients with probable or definite ALS (10.6 vs 13.2 months), whereas the time between last outpatient review and death was marginally longer (5.9 vs 3.4 months).
The EEC category of the entire cohort at time of last follow-up demonstrated a similar progression of clinical features and disability: the clinical features of more than 85% of patients had advanced sufficiently to allow reclassification as either definite or probable ALS, compared with a minority (14%) of patients who remained in the possible and suspected ALS categories.
Patients with limb-onset disease were more likely to be categorized as having definite ALS at diagnosis, whereas bulbar-onset symptoms were most frequently categorized as possible ALS initially. A small number of patients (27 [7%]) initially had both bulbar and limb signs and met the criteria for probable or definite ALS.
The Kaplan-Meier survival curves of Irish patients with ALS grouped according to their EEC category at diagnosis are shown in Figure 1. The mortality rates of the 4 categories were similar (log rank test = 3.3; P = .51). Furthermore, the pattern of survival was similar in each diagnostic category. Median survival of patients in either the definite or probable category at diagnosis was 27 months, compared with 30 months for the possible category and 40 months for patients with suspected ALS. Multivariate analysis did not confirm EEC category at diagnosis as an independent predictor of prognosis.
Survival from onset among Irish patients with amyotrophic lateral sclerosis classified according to El Escorial category at diagnosis.
The EEC for definite or probable ALS have been applied for inclusion in clinical trials.2- 4 When the current practice was applied to the Irish cohort, the median time from symptom onset to trial eligibility was 13 months (Figure 2). Two hundred eighteen patients (56%) would have been considered trial eligible at the time of their diagnosis. Of the remaining 165 patients (136 possible, 29 suspected [43%]) who were trial ineligible at diagnosis, two thirds (110) became eligible during the follow-up period. The remaining 55 patients with ALS (14%) either had died of their neurological condition without being considered trial eligible (3 suspected, 22 possible) or had not changed diagnostic category from the time of diagnosis (6 suspected, 24 possible).
Time from symptom onset to trial eligibility among Irish population with amyotrophic lateral sclerosis according to the El Escorial and Airlie House criteria.
Potentially modifying factors were examined for their influence on trial eligibility under the EEC guidelines: bulbar-onset symptoms were associated with an earlier trial inclusion compared with limb-onset disease (11 vs 15 months; P = .001; Figure 2), whereas sex ratio, duration of follow-up, and median survival were statistically similar among trial-eligible and trial-ineligible patients.
When the AHC were applied, there was little difference in the number of patients considered eligible for clinical trials or the time for an individual patient to become suitable for inclusion. Only 3 patients, previously classified as having probable ALS under the EEC, were classified in the new clinically probable–laboratory supported category at the time of their diagnosis. Furthermore, the mean time from symptom onset to eligibility was almost identical when the revised guidelines were adopted (12.9 vs 12.8 months under the EEC).
This study is, to our knowledge, the second prospective population-based study of ALS survival6 and the first to identify all cases in an entire country during an extended period. Survival from diagnosis at 1, 3, and 5 years was 68%, 25%, and 17%, respectively, and there was evidence of disease progression both in the number of CNS regions involved and in the nature of involvement in each region. It is also the first epidemiological study of ALS, to our knowledge, to use the EEC for diagnosis and follow-up of patients, thus allowing for standardized comparison with future epidemiological and clinical studies.
More than 40% of the patients with ALS had bulbar or generalized symptoms at symptom onset, which is higher than some previously reported.14,15 However, other studies with complete case ascertainment have reported similar findings,16 suggesting that the high rate of bulbar-onset symptoms reflects the true disease distribution.
Our findings would suggest that cases with bulbar onset are first seen at an earlier stage in the disease process, before spread to other CNS regions has occurred. In the bulbar-onset population, dysarthria was 8 times more common than dysphagia as an initial symptom. This finding agrees with previous reports14 and may suggest that the glossal musculature is more vulnerable to the neurodegenerative process than the deglutition muscles. Alternatively, dysarthria may be reported more commonly by patients with ALS and their caregivers because slurred speech is easier to recognize than mild swallowing difficulties. This highlights the importance of obtaining an adequate intake history, including choking episodes; subtle changes in dietary consistency, such as avoidance of certain foods; duration of meals; and measurable weight loss.
The frequency of neurological signs in all 4 regions increased dramatically during the course of the illness. Our findings indicate that the majority of patients with ALS progress to have generalized involvement by the time of death.17 The pattern of UMN and LMN signs was similar in each region both at diagnosis and at death, ie, combined UMN and LMN signs accounted for the majority of cases, whereas solely UMN or LMN signs were comparatively uncommon. This supports the observation that corticospinal tract degeneration and anterior horn cell death may be linked and infrequently occur in isolation.18,19
Slightly more than half of Irish patients with ALS had either definite or probable ALS by EEC at the time of diagnosis and were eligible for clinical trial inclusion. There are few previous reports of the EEC categories of patients at time of diagnosis with which to compare our results. Although they did not strictly apply EEC, Haverkamp et al14 reported that 9% of 1200 patients attending a specialist ALS clinic had solely LMN signs (corresponding to suspected ALS), 3% had only UMN signs (ie, possible ALS), and 831 patients (69%) had "typical ALS." In a clinicopathological study of the EEC in 32 cases of ALS, only 10 patients (31%) carried a diagnosis of definite or probable ALS at initial examination.20
In our study, approximately 10% of those who died of their disease were still classified as having suspected or possible ALS at the time of their death and were thus considered ineligible for clinical trials.3- 5 The length of follow-up and the time from last review to death differed by only 2 months between the 25 trial-ineligible patients and the total cohort. Furthermore, the demographic characteristics of those who died did not differ significantly from those of the entire cohort, suggesting that their inability to travel was a function of their progressive disability. Although we were unable to have autopsies performed on our deceased patients, telephone and, often, personal contact between the patient and the ALS team was maintained until the time of death. We conclude, therefore, that those 25 patients died of ALS, albeit without reaching a stringently defined "certainty" with respect to their diagnosis.
Our findings have demonstrated that the EEC category of patients with ALS at diagnosis does not predict prognosis. One possible explanation for this unexpected finding may lie in the arbitrary and artificial definitions of the EEC categories and CNS regions.1,2 For example, a patient with subclinical electromyographic findings or fasciculations and mild weakness in a limb is considered to exhibit the same level of diagnostic certainty as another patient with profound weakness and atrophy in the same area, although the "disease burden" clearly differs between the 2 patients. Future diagnostic criteria for ALS that incorporate a role for quantitative muscle strength testing or neurophysiological estimation of spinal motor neuron number would be helpful to reflect the extent of disease.21,22
Currently, patients with ALS who have only LMN signs are excluded from clinical trials, and the suspected category has been deleted from the revised EEC.2 Our study demonstrates that patients with suspected ALS at diagnosis have a clinically similar course to patients in the other ALS categories: survival of the 29 patients with suspected ALS at diagnosis was statistically similar to patient survival in other EEC or AHC categories (Figure 1). As only 3 of the 254 deceased Irish patients with ALS had clinical features of primary lateral sclerosis at time of death, it is apparent that the majority of patients with only LMN signs at an early stage ultimately progress to other categories. Two of these cases proceeded to autopsy, of which one was an autopsy-proved case in a 74-year-old woman. The other was in a 54-year-old man without clinical UMN signs before death, but postmortem examination disclosed corticospinal involvement. The postmortem finding of ubiquinated neuronal inclusions, the pathological hallmark of ALS,23 in several cases of primary lateral sclerosis strengthens the view that the clinical diagnosis of primary lateral sclerosis represents ALS.18 Furthermore, patients with superoxide dismutase 1 mutations are known to initially manifest solely LMN findings16 and are included as having clinically definite familial, laboratory-supported ALS.24 Until the underlying pathogenic mechanisms of ALS are more fully understood, we believe that current evidence supports the inclusion of primary lateral sclerosis and suspected ALS that is clearly progressing in clinical trials.
Our findings indicate that use of the stringent EEC and AHC decreases the possibility of ALS misdiagnosis but also necessitates that patients have widespread disease to be considered eligible for trials. The difference in the time from disease onset to trial eligibility between the old EEC and the new AHC (median time, 12.8 vs 12.9 months) was small, and there was a greater than 99% agreement between the classification systems. This suggests that the revised guidelines did not succeed in their aim of shortening the time to trial eligibility. Therefore, the advantage of the EEC and AHC is that they prevent the inclusion of patients with ALS-mimic syndromes, who tend to have a better prognosis than patients with ALS. However, our previous findings demonstrate that patients with mimic syndromes can be excluded by appropriate prediagnostic investigations and by monitoring patients over time.10 The current criteria, which are based on the likelihood of a patient suffering from the disease by determining the extent of clinically apparent abnormal findings, have the great disadvantage of restricting clinical trials to patients with extensive burden of clinical disease.
We compared the survival curves of our population with those of 6 previous population-based studies judged to have the most complete case ascertainment (Figure 3).6,14,16,25- 27 The survival curves of the studies being compared were reproduced by manually plotting each individual data point and then displaying each of them with a uniform axis. The survival experience of patients in the 7 compared population-based studies was remarkably similar. A single curve can be constructed to summarize the data of these 7 studies (n = 1740). Such a composite curve may serve as a historical control population for future studies, perhaps allowing all patients with ALS enrolled in future trials to receive a potentially beneficial therapeutic agent.28 In addition, the survival of a placebo control group in a trial may be compared with this composite curve to confirm that the selection of the placebo group is representative and random.
Comparison of survival studies of amyotrophic lateral sclerosis.
In summary, this population-based study of the clinical features of ALS closely followed up an entire population of patients for a prolonged period. The high rate of bulbar-onset symptoms among the Irish and other studies with complete case ascertainment may reflect the true disease distribution and site of onset in this disease. Our study has shown that the established clinically based diagnostic systems are suitably specific for ALS. However, we have also shown that EEC and AHC lack sensitivity, particularly at the early stage of the illness, when patients would benefit most from therapeutic intervention. In the absence of a specific disease marker for ALS, we propose that the criteria for clinical trials be loosened to include patients with any clinical features of ALS, in whom progression has been identified, and in whom the common mimic syndromes have been excluded.
Accepted for publication February 4, 2000.
We gratefully acknowledge the assistance of all the consultant neurologists, neurophysiologists, and primary care physicians who collaborate in recruitment for the register. We also thank the Irish Motor Neuron Disease Association and the Irish Brain Research Foundation for their support.
Reprints: Orla M. Hardiman, MD, MRCPI, Department of Neurology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland (e-mail: email@example.com).
Thank you for submitting a comment on this article. It will be reviewed by JAMA Neurology editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers' bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Customize your page view by dragging & repositioning the boxes below.
More Listings atJAMACareerCenter.com >
Care at the Close of Life: Evidence and Experience
Palliative Care for Patients With Amyotrophic Lateral Sclerosis: "Prepare for the Worst and Hope for the Best"
All results at
JAMAevidence.com >
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Need assistance?
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.


text:
Now Playing
China's Economy Cools, Perhaps More Than Planned
The country's economy has not only been slowing down recently — it's been slowing faster than expected. That's due largely to overly effective efforts by Beijing to rein in earlier blistering, and unsustainable, growth. Many say the downshift will continue unless the economy undergoes serious reform.

subset: commoncrawl


text:
Church of the Annunciation Parish.
Are you new to The Parish? We welcome you and hope that you will find not only a parish but also a home here. For 65 years Church of the Annunciation Parish has proclaimed the gospel of Jesus Christ to the Catholic community of Bloomsbury and surrounding areas. We look forward to your presence as we gather to pray and worship as a community.
Are you a long time parishioner? You can browse through the Church of the Annunciation website and catch up on the latest news about the parish in general or a special ministry you are involved with. Or maybe after reading about a particular organization you will hear your own call to witness and serve Christ with them. Our parish and organizations have places for many different talents and gifts, yours are needed! However great or small the time you can devote to our parish, you do in His name, and we are grateful for your participation.
In order to recognize the Kingdom of God in our midst, we, the parish community, have as our mission to unite all members in God's name so as to live the Gospel of Jesus Christ!
We serve the needs of a growing faith community by expanding our ministries utilizing our time, talent and treasure!


text:
Meet and chat with Pools Harbor singles at Matchmaker.com, our Pools Harbor chat rooms contain thousands singles in your local area. Whether you are looking for serious relationships, friendship, or even marriage Matchmaker.com will help you find that special person. Chat with other members with a live video instant messenger or join on of our Pools Harbor chat site rooms and meet singles today!
Pools HarborJoin Now Free!
Pools Harbor Girls | Pools Harbor Men | Pools Harbor Gay | Pools Harbor Lesbians
More Pools Harbor Links:
Pools Harbor Dating | Pools Harbor Personals | Pools Harbor Speed Dating | Pools Harbor Singles | Pools Harbor Love
Senior Dating | Catholic Dating | Christian Dating | Muslim Dating
Black Singles | Asian Singles | Latin Dating
Matchmaker is a large and exciting online community where Pools Harbor chat discussions take place. Members are able to change text, style and color, add graphical smiles, and click usernames to bring up profile details. Pools Harbor chat rooms and users are organized intuitively on the left side of the interface where users are able to easily peek into rooms without joining, see who is inside, who'sbroadcasting audio and video, how long they've been in the Pools Harbor chat room and more. Clicking on the detail button or an individual username brings up expanded information on the Pools Harbor chat room.


text:
Commissioner Corner Message Board
New Point Settings Option Requested (Yahoo plz read!)
Does anyone think it would be great to add a scoring option for fantasy football where kickoff return yards only started netting points for returns that made it past the 20 yard line? It would also be great to be able to specify a difference in value between punt return yards and kickoff return yards, but I think this is less important.
Currently you have the option of scoring for return yards. However, there can be no customization between kickoffs and punt returns. However, every kickoff returner gets a lot more yards every season simply because of the yards received between the goal line and the 20 yard line. These yards, however, are only the result of the return man's decision to not take the touch back. If the return man runs the ball back to the 20 instead of taking a touchback, he really accomplishes nothing for his team. If he only gets to the 15, he actually loses 5 yards for his team. He only benefits his team in the case that he makes it past the 20. I think this should be reflected in scoring.
In contrast, punt returners are gaining very real yards for their team after catching a punt. These yards should all be scored, unlike the first 20 yards of a kickoff runback.
The problem with this situation is that you can't weigh return yards very heavily in the current system without largely skewing the value of return men. Kickoff returners gain way too many yards in the current system because of their first 20 yards each time after every kick. Thus, commissioners are forced to weigh return yards less heavily than any other gained yard (ie running/passing yards). This is counter-intuitive, as I believe every REAL yard gained for your team (not including QB passing yards) should be equal.
What do you think?Sort: Newest | Oldest | Most Replied Expand all replies
I understand what you are saying in terms of helping the team; however, I am not sure from a technology perspective how the system could determine that this kick off would have resulted in a touch back verses being downed at the 5. I have seen several kick offs this year where the returner was able to start somewhere between the 10 and the goal (not to mention the squib kicks used to avoid specific returners). If they let the ball go, there could be a chance that it would be downed. Under your setup, the first 10 yards of a kick off caught at the 10 would not count, yet every one of those yards could be helping his team.
What about those few times where a returner takes the kickoff a few yards in and sees the opening and taking it back for a large gain - should they be penalized?
I'm not sure from a technology standings how you could manage this; however, in a custom league you could aways have a league rule where the commish would manually adjust points based on some criteria set by the league. You could also set no points for return yards therefore it wouldn't matter and only true defensive actions provide defense team's points.
- 1 Reply to Coriwyn
I guess the point is that Kickoff returners are expected to get to the 20 at any level. Anything less is actually not really a positive thing in anyone's eyes. Even in the rare instance under the new kickoff rules where downing a ball in the end zone isn't possible, the rule would still make sense. A kickoff returner that reaches the 15 from a kickoff that only reaches the 10 is a disappointment and shouldn't get any points. The 20 yard line in kickoff returns is kinda the magic line where a coach determines if the return man has been effective.
That being said, I agree it may be a challenge from a tech perspective.
I don't have that much time, what did he say?lol j/k I give returners a point for every 20 yards. As far as Punt and Kick differences. Way over thinking things. Turn off the computer for a while.
Evil Chemist Evil Chemist Nov 19, 2012 10:35 AM Flag
I think you're crazy
Expert Fantasy Advice
Ranking Fantasy Hockey's top 50 players in preseason Big Board
The Big Board takes into consideration past returns, current performance and expected future gains in determining who should be included. … More »
Outfielder Shuffle Up: The ageless Carlos Beltran
There's plenty wrong with the Yankees offense this year, but Carlos Beltran is part of the solution. … More »
Freak Show Podcast: Cardinals pen, Strasburg and Giolito, Steven Wright
Brandon Funston and Scott Pianowski talk MLB news and happenings, starting in St. Louis. … More »
Daily Dime: Hanley Ramirez, Kershaw and Cueto, Coors Field
Hanley Ramirez's bat has come alive this week and he's cheaply priced for Sunday DFS. … More »
Mostly MLB Notes: Talking Encarnacion and a look around the league
Talking Edwin Encarnacion, a look around the league and other random nonsense. … More »


text:
He may be in the middle of a divorce, but Carey Hart has nothing but good things to say about estranged wife Pink.
"Above and beyond everything, we are the best of friends and she is the love
of my life," he told PEOPLE in Las Vegas Monday night, breaking his silence about their separation (announced last month). "We talk all the time."
The freestyle motocross star, speaking at the grand opening of Ago restaurant inside the Hard Rock Hotel, declined to comment further. Instead, the 32-year-old spent the remainder of the evening chatting with a small group of male friends inside he eatery, sipping red wine and taking a few pictures.
The hotel has become something of a safe haven for Hart, a Las Vegas native. This summer, he's slated to open a new bar, Wasted Space, inside the complex.
"It's about rock and roll decadence," he said. "It's everything a rock and roll bar should be – dark, gritty, comfortable with plenty of booze and a lot of loud, rocking-out music."
Hart met Pink at the 2001 X Games. They split for a time in 2003, but tied the knot with a non-denominational ceremony in Costa Rica in January 2006.
The singer, 28, has also been quick to defend her ex, calling him a "good man." She also insisted that their breakup is "not about cheating, anger or fighting."
Carey Hart: Pink Is the 'Love of My Life'
Rick Diamond/WireImage


text:
I Am Not A Lawyer, but I strongly suspect you're misreading Apache's
license. There really shouldn't be a problem with your making the DLL
available from your own website, as long as you do so under their
license (which should be easy; just make it a separate download from
your own code).
The standard Xerces binary distribution is available direct from Apache
and their shadows, though I can't vouch for whether that's as a DLL or
in some other form. See http://xml.apache.org/xerces-c/download.cgi


text:
The latest version of Adobe Flash Player is required to watch this video.
Please click on the link below to download the latest version. Thanks!
JERUSALEM, Israel -- The European Union should blacklist Israel's military, Sheikh Hassan Nassrallah said, in his first response to the European Union's unanimous decision earlier this week to brand Hezbollah's "military wing" as a terror organization.
"Why don't you classify the State of Israel as a terror state?" Hezbollah's spiritual leader said in a speech broadcast by video link from his hideout. Nasrallah almost never appears in public.
"Why don't you classify Israel's military wing, the IDF, as a terror organization if you recognize Israel is occupying Arab lands and refuses to implement international decisions for decades now?" he said, predicting the decision would benefit Israel far more than Europe.
"The Israelis clearly stated the decision was a result of their diplomatic efforts…These [European] countries have made themselves a full partner in responsibility for any Israeli aggression against Lebanon," he continued, saying the European Union had harmed its own interests more than "the resistance."
Nasrallah scoffed at the notion of freezing the terror group's funding or issuing travel bans against its operatives, warning the designation would reap "failure and disappointment."
The Syrian foreign ministry also blamed Israel for the European Union's decision, saying it would only affect Israeli "plots" in the Middle East.
EU Lists Hezbollah 'Military Wing' as Terror Group
Israel Vows to Prevent Weapons to Hezbollah
Trial in Cyprus Exposes Hezbollah Plots
Log in or create an account to post a comment.
Are you seeking answers in life? Are you hurting? Are you facing a difficult situation?
Find peace with God, discover more about God or send us your prayer request.
Call The 700 Club Prayer Center at 1 (800) 823-6053, 24 hours a day.
A caring friend will be there to pray with you in your time of need.
CBN News is a national/international, nonprofit news organization that provides programming by cable, satellite, and the Internet, 24-hours a day. Follow us on Facebook, Twitter, and Google+.
The Terrorists Funded by the WestBassam Tawil
The New Israel Fund and those who support it are helping terroristsRonn Torossian
Column one: Fighting fire with fireCaroline B. Glick
Op-Ed: There is no 'radical Islam' and there is no 'moderate Islam'Dr. Mordechai Kedar
'Narrow' escapesRuthie Blum
Why Palestinians Do Not Want Cameras on the Temple MountKhaled Abu Toameh
Social Media Killed My FatherYoni Kempinski and Ari Soffer
Iran's New Palestinian Terror Group: Al SabireenKhaled Abu Toameh


text:
The remaining six dancers took to the stage Wednesday and, following the show's new format, performed two numbers including the season's first disco and the first ever Tahitian and break-dance routines. "I was extremely nervous because I didn't want to offend who are really into Tahitian dancing or practice it their whole lives," Lauren Froderman told PEOPLE of her feathery performance. "But I just had fun. And I got lei'd!"
B-boy Jose Ruiz, on the other hand, had fewer nerves when it came to debuting the break-dance piece. While his Broadway routine danced with all star Courtney made his lack of formal training painfully obvious, he made sure to deliver in his second number. "That was for the b-boys," he said after the show. "A lot of us start off practicing in our garages. This shows them that we can do this too. We can make this an art form. We can make this amazing."
Contemporary dancer Robert Roldan's duet with all star Allison also hit home, not just for the dancers but for judge Mia Michaels. She was brought to tears by the performance, which was about coping with a loved one being sick, and said it reminded her of wanting to fix her mother before she passed away. "It was a gift. I related to it so much," said Roldan whose own mother battled breast cancer. "I still don't know how to react to what happened. Everything just clicked, it really hit me hard and I gave it all I got." And his hard work paid off tremendously as Adam Shankman, who was also in tears, declared it one of the performances of the season.
As for fallen favorite Wong, the contestants are only trying to move forward from his abrupt departure. "I feel like everything happens for a reason ... but he probably would have won," said fan favorite Kent Boyd, who, according to Nigel Lythgoe, now stands a fair chance in the competition since Wong has left.
Though his absence may have paved the way for a new standout none of the dancers are rejoicing. "I don't think anyone felt like 'Alex is gone, yay!' " Adechike Torbert said to PEOPLE. "It sucked. We just wish the best for everyone. I wish he was still here." --Mussarat Bata


text:
Office of the Superintendent
Youth Service Expedition program applications requestedTuesday, April 3, 2012, 1:51 pm
Montana Conservation Corps recently announced that it is seeking adventurous teens aged 15-17 years old for their 'Youth Service Expedition' program, a four-week summer service experience that combines outdoor adventure, education, job skills training and fun! Participants will receive a Service Award of $200 upon successful completion of program.
'Youth Service Expedition' crews will be based out of Kalispell, Missoula, Helena, Bozeman and Billings but youth from across the state, including rural areas, are encouraged to apply to participate.
To learn more, please visit Montana Conservation Corps website.
For more information, contact Jen Rusnak , 406-587-4475


text:
Margaret Toy, 92, who directed the country's first Meals on Wheels program, died Sunday at Riddle Memorial Hospital. She was a longtime resident of Drexel Hill.
Mrs. Toy helped give birth to what is now Meals on Wheels on a cold January day in 1954, when she organized a group of "platter angels" who piled into a car with hot meals they kept warm in newspaper-lined cardboard boxes.
That winter day, 10 needy people in Kensington ate warm suppers.
Since then, millions of people have been fed in communities across America.


text:
Hi guys,
I am trying to display two images next to one another (horizontally), but I am having no luck. They are being display underneath one another. There can be a maximum of 20 images that need to be displayed and I would like to display two per row. Does anyone
know how to do this?
Thanks in advance.
Answer 1
create a 2x10 table and put the images in there
then use expressions to hide or display rows based on whether there are any pictures in them


text:
Our smartphones, tablets, and other gadgets have turned us into junkies. Dependent on power, we're constantly looking for an outlet, so it stands to reason more and more devices need to be capable of powering our other devices. id America's L.E.D portable charger combines three bright white LEDs with a comparatively enormous rechargeable battery, so you can juice up your devices and shed some light on your life at the same time.
But Why?
I'll admit it; my fist question when I heard of the L.E.D was, "Where would I ever use that?" Portable power banks are one thing, but a battery powered light and a recharger in one? After spending a couple weeks with the L.E.D around my house, though, I now look at mere portable batteries and wonder why I was ever okay with just a one trick pony.
The L.E.D is not super portable, like some battery packs, but it definitely is movable. If you absolutely need an extra battery every day to keep your iPhone alive during extended use, it's not likely to be the battery pack you need. I found the L.E.D to be useful around the house or the office, where I could use it as a small, portable source of light: at my desk, in the garage, or the kitchen. Its magnetic back lets you mount it easily on kitchen appliances, desk furniture, and table legs. I require both light and an iDevice virtually everywhere I go, so a portable light that can also keep my iPhone's battery topped up makes more sense than I'd originally thought.
id America's put a great deal of thought into designing the L.E.D, and it's apparent from the moment you pick it up. The beveled edges and lightly textured metal casing just feel good in your hands, and the massive battery lends a weight that's reminiscent of the iPhone 4's heavier-than-expected heft. The internal battery is rated at 5,200 mAh, which is enough to charge your iPhone more than twice (current rumors point to a 2100 mAh battery for the iPhone 6, so this should even be able to handle future devices!).
The LED covers are white plastic, and the light is bluish, bright, and directional. There's an included docking station which lets you charge and stand the unit upright as a table lamp, though you can also plug a Micro USB cable directly into the bottom to charge. The base is a simple plastic affair that's a little finicky to plug into, so I found myself preferring the cable only method. A red light on the base of the L.E.D itself lights up while the battery is charging, and switches to blue when it's finished.
id America has built in some impressively robust and smart circuitry for charging, so the L.E.D portable charger is capable of outputting 5V/2 Amps, which provides you enough oomph to effectively charge an iPad rather than a mere trickle charge from lower-power batteries. With larger batteries, these devices will charge quickly but not fully. I was able to get from 2% to between 40-50% charge on my iPad Mini, which is enough to get me through a full 10 hours of Netflix watching at full brightness.
Tap Three Times
Speaking of those lights, one of the coolest things about the L.E.D is its touch sensitive light controller. Tap once on the top end for a dim white light, twice for a flashlight level, and three times for a small desk lamp level of light output. There's also a slider on-off switch that controls the light and charging output, so you can save the battery if you're packing the L.E.D away in a bag. Down on the bottom of the device is the Micro USB port and a full sized USB port for power input and output, respectively. Charging an iDevice is as simple as plugging in a USB cable.
Although id America's marketing material show the light in use for a romantic wine and cheese, the color and intensity don't really lend themselves to such a use. I found the light to be most useful in utility situations where being able to see is more important that subtle mood lighting. The light is bright enough for daily use as a desk lamp, and the large battery would also make it useful in an emergency situation. Light and iDevice recharging abilities make a pretty convenient combination.
As other reviewers have noted, the L.E.D portable charger does emit a slight high-pitched whine when used on the two lowest settings. I was only able to hear it when holding the unit right next to my head, so this shouldn't be a problem unless you're using it in close quarters.
At 5.4 oz. the L.E.D is hardly enormous, but if all you need is one extra charge to get you through the day on your iPhone, there are smaller and lighter external batteries and battery cases available. None of them, however, provide the same level of style and illumination. For the price, id America's L.E.D portable charger is a shining winner.
Appletell Rating:
Buy the id America L.E.D. portable charger
Provides: Dimmable LED lighting and portable battery for iDevices
Developer: id America
Minimum Requirements: Any USB-powered device, including iPhone, iPad, cameras, etc.
Price: $79.95
Availability: Now


text:
Windows 8 and Live ID
Microsoft is broadening the scope of Windows Live ID. Already it is used to view licensing keys and store OneNote data, as well as provide 5GB of free storage. Starting with Windows 8, the Live ID logon now will be a password and forms manager as well.
Because it is integrating the capabilities into the operating system, Microsoft can add features that standalone password managers cannot. For instance, with Windows 8 Microsoft is throwing in a lightweight environment manager that can save a wide range of settings such as your lock screen picture, desktop background, user tiles, and browser favorites and history, among many others. They automatically sync when you log into Live ID. Will this conflict with third-party environment managers such as Quest or AppSense? Windows 8 ships in October so we'll find out soon.
Additionally, Microsoft also lets you log into Outlook.com, Windows Messenger, and (formally known as) Metro apps without a password interface, and the setting and last-used state persist across all your Windows 8 PCs.


text:
IGOV Overview
Indigenous Governance programming is recognized worldwide for its relevance to Indigenous communities. Research and course content are informed by a deep respect for Indigenous knowledge and traditions as well as a thorough understanding of the current political realities of Indigenous communities.
Indigenous Governance follows an approach to learning that is characterized by personal dedication to Indigenous values and a commitment to community. IGOV supports the use of innovative teaching methods and aims to provide a sound and challenging educational experience. Our faculty, staff and students are held to very high standards of academic performance and ethical conduct, and our program of study integrates critical and intellectually challenging coursework, an Indigenous ethical framework for conducting research, and requires the establishment of long-term and mutually productive working relationships with Indigenous communities.
We currently offer;
Master of Arts in Indigenous Governance (MAIG)
Doctorate of Philosophy (PhD) by Special Arrangement


text:
Jill over at Breaking the Spine started this and I believe that it's awesome" This blog post is to alert those that visit about "the" book that we cannot wait to get our hands on.
OK! This book has been on my mind for a while. It has a smokin' hot cover and the synopsis...is out of this world. I like need to read it now, yaknowwhatImean? Nightshade has received some great props from other authors and I had to make it my WOW for this week. So what is your WOW?
Coming Soon to a Bookstore Near You:
NIGHTSHADE (October 19, 2010, Philomel)
While other teenage girls daydream about boys, Calla Tor imagines ripping out her enemies' throats. And she wouldn't have it any other way. Calla was born a warrior and on her eighteenth-birthday she'll become the alpha female of the next generation of Guardian wolves. But Calla's predestined path veers off course the moment she saves the life of a wayward hiker, a boy her own age. This human boy's secret will turn the young pack's world upside down and forever alter the outcome of the centuries-old Witches' War that surrounds them all. Click Here to visit the Nightshade website.


text:
IOC-UNESCO Calls for Proposals on Sea-Level Stations in the Caribbean
1 August 2012: The Intergovernmental Oceanographic Commission (IOC) of the UN Educational, Scientific and Cultural Organization (UNESCO) has issued a call for proposals regarding the acquisition, installation and maintenance/leveling visits of tide gauge equipment over a one-year period in the Caribbean. The call is issued as part of the IOC-UNESCO's mandate to coordinate implementation of the Tsunami and other Coastal Hazards Warning System for the Caribbean Sea and Adjacent Regions (CARIBE EWS).
Proposals should detail how maintenance visits will be carried out, and the proposed configuration of the sea level stations should be based on high-quality equipment that perform to the requirements and accuracy of the Global Sea Level Observing System (GLOSS). Proposals should be sent by 30 August 2012.
According to IOC, despite coastal populations being at less risk from tsunamis than in the past, at least 3,503 lives have been lost in the Caribbean Basin since 1842. [UNESCO Press Release] [Request for Proposals]


text:
1st NatWest One Day International: England v Australia
The 1st NatWest ODI between England and Australia is taking place on Friday 29th June 2012 at famous Lord's, home of cricket. Treat your guests to luxury hospitality in either The Captain's Lounge or Nursery Pavilion and catch all the action from the opening NatWest series ODI.
Lord's has long been seen as the 'Home of Cricket' and the game's spiritual 'headquarters'. But its importance is not merely historical. In practice it remains, to this day, perhaps the most important single place in the world of cricket. This is an outstanding venue to host your guests and enjoy England take on Australia.
Hospitality Packages
Nursery Pavilion
The Nursery Pavilion is an excellent restaurant which overlooks the picturesque Nursery Ground where you can see players from both teams warming up in the nets.
Here you can experience the finest hospitality throughout the day whilst enjoying world class cricket. The Nursery Pavilion is a superb restaurant offering a flexible space that can accommodate groups of all sizes to meet all your hospitality needs. Just minutes away are your reserved Mound Stand seats, perfectly located to enjoy the day's action.
Private tables available for groups of 8 - 12. Smaller parties are required to share a table.
- Lunchtime questions & answer session with a cricket legend
- Top Category seats in the Mound Stand
- Bacon roll on arrival
- Champagne reception
- Three course set lunch
- Complimentary bar throughout the day whilst in the Nursery Pavilion (excluding champagne)
- Afternoon tea
- Official Match Programme
- Scorecards
- Printed event documentation
Captains' Lounge
The Captains' Lounge is a unique dining experience with a past international captain.
This intimate setting provides the premium offer for hospitality at Lord's. Limited to only 120 guests, and with private tables of 2 to 10 available, your colleagues or clients will enjoy superb hospitality in the lounge and a prime view of the action from your reserved Mound Stand seats nearby.
Chatting with a past international captain hosting the lounge, as well as other cricketing personalities during the day, will ensure that you and your guests enjoy a memorable experience at the Home of Cricket.
- Hosted by a past international captain
- Top Category seats in the Mound Stand
- Full breakfast on arrival
- Champagne reception
- A la carte three course menu
- Complimentary bar throughout the day including fine wines and Champagne
- Afternoon tea
- Official Match Programme
- Scorecards
- Souvenir Gift
- Printed event documentation
|The Nursery Pavilion
|The Captains' Lounge
|Friday 29th June
Package and price subject to final confirmation and availability at time of booking
Prices are per person and subject to VAT
Optional Package Enhancements
- Executive transfers
- Overnight accommodation


text:
Download citation file:
From Memorial University Medical Center, Savannah, GA 31404.
Requests for Single Reprints: J. David Baxter, MD, Memorial University Medical Center, 1101 Lexington Avenue, Savannah, GA 31404; e-mail, email@example.com.
What is the difference between air and water? One costs more and takes more sustained effort to deliver, but both are medical interventions with risks and benefits. When death is upon us, why do we easily withdraw or withhold one but struggle with withholding or terminating another?
Please read the other comments before posting. Contributors must reveal any conflict
of interest.
Comments are moderated and will appear on the site at the discretion of The American
College of Physicians editorial staff. Please be sure your email address is
updated in your account, otherwise the American College of Physicians will not be
able to contact you about your comment.
Anyone can submit a comment any time after publication, but only those submitted within 4 weeks of an article's publication will be considered for print publication. One month after publication, editors review all posted comments and select some for publication in the Letters section of the print version of Annals. (Not peer reviewed)
Authors: No more than 5
Text: Word Limit 400 (excludes references), 5 references, no figures or tables
* = Required Field
Disclosure of Any Conflicts of Interest*
(applies to the past 5 years and foreseeable future) Indicate any potential conflicts
of interest of each author below, including specific financial interests and relationships
and affiliations relevant to the subject matter or materials discussed in the manuscript
(eg, employment/affiliation, grants or funding, consultancies, honoraria, speakers
bureau, stock ownership or options, expert testimony, royalties, donation of medical
equipment, or patents filed, received, or pending). If all authors have none, check
"No potential conflicts or relevant financial interests" in the box below. Please
also indicate any funding received in support of this work. The information will
be posted with your response.
Dr Baxter, in struggling with his mother in law's treatment options for advanced Alzheimers disease, notes: 'I didn't think she would want to have a tube placed in her abdominal wall just so she could be kept alive.'
This factual comment about the efficacy of feeding tubes in improving survival should be referenced.
In a widely cited analysis of evidence about feeding tubes Finucane et al (1) note that there is no evidence that feeding tubes increase survival, or improve any other clinically important outcome.
(1) Finucane T, Christmas C, Travis K. Tube Feeding in patients with advanced dementia: A Review of the evidence JAMA. 1999;282(14):1365-1370.
None declared
Terms of Use
The In the Clinic® slide sets are owned and copyrighted by the American College
of Physicians (ACP). All text, graphics, trademarks, and other intellectual property
incorporated into the slide sets remain the sole and exclusive property of the ACP.
The slide sets may be used only by the person who downloads or purchases them and
only for the purpose of presenting them during not-for-profit educational activities.
Users may incorporate the entire slide set or selected individual slides into their
own teaching presentations but may not alter the content of the slides in any way
or remove the ACP copyright notice. Users may make print copies for use as hand-outs
for the audience the user is personally addressing but may not otherwise reproduce
or distribute the slides by any means or media, including but not limited to sending
them as e-mail attachments, posting them on Internet or Intranet sites, publishing
them in meeting proceedings, or making them available for sale or distribution in
any unauthorized form, without the express written permission of the ACP. Unauthorized
use of the In the Clinic slide sets will constitute copyright infringement.
to gain full access to the content and tools.
Learn more about subscription options


text:
Give your guests a chill when you hand them a Frozen Wonderland Personalized Mod Frame!
Mod Frame features:
Please allow ample time for delivery. Our ship date for this product is noted in your shopping cart. Many items are shipped separately, so please allow extra time for these items to arrive. Shipping charges are based on the value of the merchandise and not the number of shipments. For additional shipping information, contact our Customer Service Department at (firstname.lastname@example.com or 1-800-227-2789).


text:
LANSING, MI -- Within just hours of AAA Michigan's report of a 4-cent drop from the previous week, gas prices in and around the Capital City spiked Monday afternoon.
The price of a gallon of regular unleaded gasoline averaged out to $3.49 throughout the greater Lansing area Monday morning, but by mid-afternoon prices were encroaching on $3.70 at some local stations.
The average price in the area Tuesday stands at $3.65, according to AAA. GasBuddy.com, a website that monitors gas prices across the country, reports the sudden price surge has affected most of the upper Midwest and attributes it to refinery issues.
"Great Lakes region saw prices for immediate gasoline delivery jump 10-cents per gallon early Monday morning and are the highest in the nation, beating out the West Coast for the dubious title of 'most expensive wholesale gasoline prices' in the nation," GasBuddy Senior Petroleum Analyst Patrick DeHaan blogged.
"This coming on the heels of reports of a downed coker at BP's massive Northwest Indiana refinery, and weekend reports of issues at Citgo's Lemont, IL refinery, as well as Phillips 66's refinery in Wood River, IL. Combined, these facilities have the capacity to refine nearly one million barrels of crude oil per day, or nearly 15 million gallons of gasoline per day."
Michigan's statewide average price jumped 9 cents from $3.61 Monday to $3.70 Tuesday. Nationally, gas prices rose an average about 1 cent to $3.50 on Tuesday.
Click here to subscribe to MLive Lansing's newsletter.
Follow Brandon Howell on Twitter: @BHowellMLive. Email him at email@example.com or call him at 517-908-0711.


text:
Scale the intersection of women, entrepreneurship and technology through thought-provoking, inspirational and education webinars. With these web-based seminars, we will expose the diversity among employees, entrepreneurs and investors in technology by bringing them together and creating a forum for them to share knowledge, interact and be inspired.
Do you have comments or suggestions for future webcasts? Do you want to be a speaker for one of our future webcasts? If so please fill out this form. We look forward to hearing from you.
Webcast #2 [08/22/14] – How to Transform Your Ideas into Software Products with Poornima Vijayashanker
Webcast #1 [07/10/14] – PITCH Perfect : How to pitch your startup with Dave Kochbeck


text:
Top Definition
"oh no, the computer broke, i ejaculated all over the keyboard"
от Anonymous 22 февруари 2003
Trending Now
Can you define these popular missing words?
Photos & Videos
What you are on now
You are on the computer now
от Charlie Mulligan 05 март 2004
The most useful and most frustrating thing any human being will ever work with.
The computer crashed again. I lost three thousand lines of code.
от Mystery Man 28 януари 2003
If you're looking up this word, kill yourself.
To use the internet, one must have at least a vague idea of what a computer is.
от ddt 21 ноември 2004
a very, very expensive punching bag
Work with me! *Crack* stupid computer! Gonna punch the life out of you!
от gusto5 29 май 2004
A tool that is supposed to save time but intead wastes time.
1. Viruses
2. Bugs
3. Crashes
4. Spyware
5. Urbandictionary.com :)
2. Bugs
3. Crashes
4. Spyware
5. Urbandictionary.com :)
от Why do I keep coming here? 24 септември 2003
The most boring and frustrating thing in the world-however, I keep coming back.
the computer isnt playing my cd! piece of shit! Oh there we go-computer i love you!
от elvis on the toilet. would you like a sandwhich? 18 февруари 2004


text:
Inflammation, Sepsis, Epigenetics, miRNAs
Mohamed Elgazzar, PhD
Assistant Professor
Research Interests:
The general theme of my research is basic molecular processes that can be translated to the field of inflammation, with a focus on severe systemic inflammatory processes like sepsis. My specific contributions and emphasis are epigenetic and microRNA based regulation that generates reprogramming of genes linked to inflammation, and posttranscriptional control of inflammatory genes through differential expression and activities of microRNAs.
Current Research:
The general theme of my research is basic molecular processes that can be translated to the field of inflammation, with a focus on severe systemic inflammatory processes like sepsis. My specific contributions and emphasis are epigenetic regulation that generates reprogramming of genes linked to inflammation, and post-transcriptional control of inflammatory genes through differential expression and activities of microRNAs.
Gene reprogramming through epigenetic processes:
Epigenetic gene reprogramming is an emerging concept relevant to human diseases. The general objective of my research is to investigate epigenetics of severe systemic inflammation (SSI), specifically the epigenetic processes that differentially regulate gene transcription in SSI and sepsis. We discovered that SSI blood and tissue leukocytes show gene-specific reprogramming with repressed transcription of acute proinflammatory genes like TNFa, IL-6 and IL-1b and activated transcription of other sets of genes like IkBa, antimicrobial peptides, and anti-inflammatory cytokines. These findings may have clinical relevance since improved outcomes in SSI follow reversal of gene reprogramming. Expression of proinflammatory genes is required for priming and activation of innate immunity cells in order to mount an antimicrobial response. We found that TNFa transcription repression is due to a ''histone code'' shift to histone H3 lysine 9 dimethylation (H3K9me2), H3 serine 10 dephosphorylation (H3S10phos). These results support that epigenetic mechanisms participate in repressing acute inflammatory genes and sustaining often lethal immunosuppression observed in septic patients.
Regulation of posttranscriptional processes by microRNAs in the SSIphenotype:
A second area of my research addresses an unexpected and novel observation that gene-specific regulatory processes for protein production are dissociated from those that regulate the process of transcription. MicroRNAs (miRNAs) appear responsible for gene-specific modifications of mRNA metabolism and translation, which together define protein synthesis. MicroRNAs are an abundant class of endogenous non-coding RNAs of approximately 22-nucleotides in length that regulate gene expression post-transcriptionally by inducing degradation and/or translation repression of target mRNAs. Several hundred miRNAs have been identified in mammals. Bioinformatic predictions indicate that mammalian miRNAs can regulate ~30% of all protein-coding genes. Recent studies have implicated miRNAs in regulating a number of biological pathways, including proliferation, differentiation, apoptosis, and signal transduction, and they suggest that aberrant miRNA expression is a common feature in human diseases such as cancer and some developmental disorders. Our recent work indicates that miRNA expression is differentially regulated in the SSI phenotype. We found that limiting expression of gene-specific miRNAs (miR-221, miR-125b and miR-579) reverses the translational repression of proinflammatory genes like TNF during endotoxin tolerance. This tolerance or hyporesponsiveness to further stimulation with bacterial endotoxin is associated with the immunosuppression that follows SSI.
Innate immunity cell reprogramming in chronic sepsis:
Evidence supports that the pathophysiology of sepsis varies as it moves from an initiating acute hyperinflammatory phase (or SSI) to a chronic hypoinflammatory and immunosuppression phase that sustains chronic infection. Using a mouse model of chronic sepsis, we found that this inflammatory phenotypic switch is initiated in the bone marrow due to inflammatory signals and results in reprogramming of innate cell differentiation and maturation leading to a state of hyporesponsiveness. With this model, we also are studying how miRNAs support the innate immunity cell phenotypic switch to sustain chronic inflammation.
Current Funding:
1 R15 GM100322-01 (PI: Elgazzar), 12/01/11–11/30/14, NIH/NIGMS TLR-dependent reprogramming of translation regulates acute systemic inflammation This proposal seeks to identify the posttranscriptional molecular processes that selectively regulate protein synthesis in the severe systemic inflammation phenotype.
Past Funding:
R01 AI065791-01A1 (PI: McCall) 02/01/06-01/31/11, NIH/NIAID NF-κB and Chromatin Changes in Human Sepsis This proposal tests that increased expression of RelB acts as a negative feedback mechanism for gene transcription repression in severe systemic inflammation. Role: Co-Investigator
Selected Publications:
El Mezayen R, El Gazzar M, Seeds MC, McCall CE, Dreskin SC, and Nicolls MR. Endogenous signals released from necrotic cells augment inflammatory responses to bacterial endotoxin. Biochim Biophys Acta 2007; 111:36-44.
El Gazzar M, Yoza B, Hu J, Cousart S, and McCall CE. Epigenetic Silencing of TNFα During Endotoxin Tolerance. J Biol Chem 2007; 282:26857-64.
El Gazzar M, Yoza B, Chen X, Hu J, Hawkins G, and McCall CE. G9a and HP1 couple histone and DNA methylation to TNF transcription silencing during endotoxin tolerance. J Biol Chem 2008; 283:32198-208.
Chen X, Yoza B, El Gazzar M, Hu J, Cousart S, and McCall CE. RelB sustains IkB expression during endotoxin tolerance. Clin Vaccine Immunol 2009; 16:104-10.
El Gazzar M, Yoza B, Chen X, Garcia BA, Young NL, and McCall CE. Chromatin-specific remodeling by HMGB1 and linker histone H1 silence proinflammatory genes during endotoxin tolerance. Mol Cell Biol 2009; 29: 1959-71.
El Mezayen R, El Gazzar M, Rebecca Myer R, and High KP. Aging-dependent upregulation of the IL-23p19 gene expression in dendritic cells is associated with differential transcription factor binding and histone modifications. Aging Cell 2009; 8:553-65.
Chen X, El Gazzar M, Yoza B, and McCall CE. The NF-kappaB factor RelB and histone H3 lysine methyltransferase G9a directly interact to generate epigenetic silencing in endotoxin tolerance. J Biol Chem 2009; 284:27857-65.
El Gazzar M, Liu T, Yoza B, and McCall CE. Dynamic and selective nucleosome repositioning during endotoxin tolerance. J Biol Chem 2010; 285:1259-71.
El Gazzar M and McCall CE. MicroRNAs distinguish translational from transcriptional silencing during endotoxin tolerance. J Biol Chem 2010; 285:20940-51.
McCall CE, Yoza B , Tiefu L, and El Gazzar M. Gene-specific epigenetic regulation in serious infections with systemic inflammation. J Innate Immun 2010; 2:395-405.
Vachharajani V, Wang S, Mishra N, El Gazzar M, Yoza B, and McCall CE. Curcumin modulates leukocyte and platelet adhesion in murine sepsis. Microcirculation 2010; 17:407-16.
Liu T, Yoza BK, El Gazzar M, Vachharajani VT, and McCall CE.NAD +-dependent SIRT1 deacetylase participates in epigenetic reprogramming during endotoxin tolerance. J Biol Chem 2010; 286:9856-64.
El Gazzar, M., Church, A. & McCall, C.E. MiR-146a regulates both transcription silencing and translation disruption during TLR4-induced gene reprogramming. J Leukoc Biol 2011; 90:509-19.
McCall CE, El Gazzar M, Liu T, Vaccharajani V & Yoza BK. Epigenetics, microRNAs, and bioenergy shifts coordinate gene-specific reprogramming during acute systemic inflammation. J Leukoc Biol 2011; 90: 439-46.
El Gazzar M & McCall CE. MicroRNAs and transcription factor regulatory networks in hematopoietic lineage commitment and differentiation: regulators of the regulators. Immunol Cell Biol (Review) 2011; (in press).
Brudecki L, Yin D, Ferguson DA, McCall CE & El Gazzar M. Hematopoietic stem-progenitor cells restore immunoreactivity and improve survival in chronic sepsis. Infect Immun 2011; (submitted).


text:
Popular Searches
Fort Wayne, Ind., native Cornelius Bowick knows all about dealing with hardships growing up in a city with one of the higher crime rates in the United States.
Last season he experienced his first trying football season with the Maryvale team winning just one game after finishing 7-3 in 2010, his first year at the helm.
"I knew we had a lot of holes in our program with being young and inexperienced," Bowick said. "20-plus seniors when we went 7-3 to just 12 last season."
The Panthers will begin the 2012 campaign with more than 20 seniors who will all see playing time and a large junior class that Bowick feels will have several student-athletes play on the Division I level.
The coaching staff has refined the offense and defense so 2011 won't occur again and purchased several iPads so the players can see where they're making mistakes in order to improve on their game.
Fundamentals hurt Maryvale the most last season, missing blocks and missing tackles week in and week out. The younger kids have to get acclimated to wrapping up offensive players because they play flag football on the middle-school level.
"At the point of contact we have to make sure we get better there," Bowick said. "If we can increase tackling, individually and as a team, and blocking on the O-line, we will be better. We've been working on those things since January."
The entire offensive and defensive lines have been working out and lifting since January to make sure they are ready for the opening game Aug. 24 at Tolleson.
Bowick pulls double duty at Maryvale as the head track-and-field coach, giving him the ability to stay in contact with the players year-round and improve their speed, acceleration and change of direction in the spring.
The former Ball State hybrid linebacker from 1997-2001 hopes for a better outcome this year with a senior-laden team that hasn't seen the playoffs since the 2009-10 campaign.
"Sometimes you have to be able to take the lumps and stand up and fight," Bowick said about last season's performance. "We teach our kids those things because of lot of those kids don't have that upbringing.
"You have to learn how to fight and learn how to take care of yourself. I expect us to be real successful this year."
Aug. 24 at Tolleson
Aug. 31 at Chandler
Sept. 7 vs. Westview
Sept. 14 vs. Carl Hayden
Sept. 21 at Alhambra
Sept. 28 vs. Central
Oct. 5 vs. St. Mary's (at Phoenix College)
Oct. 12 vs. North
Oct. 19 at Trevor Browne
Oct. 26 vs. Basha
Popular Searches
Phoenix Maryvale head coach Cornelius Bowick believes his team is better than the one win season his team had in 2011.
View subscription options


text:
In February 2011, Shermere Lyons witnessed a fatal shooting as she walked out of a Camden convenience store.
She was pulled to safety by the store owner, who quickly closed the door behind them and called her father, she recalled. That night, Shermere lost her appetite, and over the next week, the images of the shooting replayed in her mind when she slept.
"It was weird to see somebody get shot in front of you," said Shermere, now 16, a LEAP Academy University Charter School junior who has aspirations of becoming a pediatrician.
With three months of the year still left, 48 homicides have been recorded in Camden - 10 short of the record 58 set in 1995, authorities said.


text:
By The Associated Press
STARKVILLE, Miss. (AP) — In November, the Starkville Police Department was looking for a couple of good men for a new assignment.
Candidates could be assured of being miserably hot in the summer, chilled to the bone in the winter and drenched in rainy weather. In addition, the candidates were assured of performing a tedious, thankless job. Oh, and the job is potentially dangerous.
Not surprisingly, the sign-up sheet was not filled with names. In fact, only three officers offered their services. Ultimately, officers Andy Round and Taylor Wells were chosen.
The two officers this month became the SPD's first motorcycle unit, since the mid-1970s, and neither seemed daunted by the unique challenges the job presents.
Both are long-time motorcycle enthusiasts. Round, 30, said he started riding, at age 7, on a little Honda 50 motorcycle.
Wells, 34, has been riding 11 years, including some time competing in motocross competitions.
"The way we look at it, when we are off-duty we are riding, whether it's hot or cold," Wells said. "We both just love to ride. So when the opportunity came up for us to ride and get paid for it, we jumped at the chance."
Although both men are veteran riders, the officers needed special instruction for the job and training on the massive Harley Davidson motorcycles they will use when on duty.
The officers spent two weeks in specialized training in Gulfport.
"That's 80 hours of training," Wells noted. "I rode 212 miles and never left the parking lot."
The first lesson?
"Laying the bike down," Round said. "This is a big bike. And sooner or later, you're going to go down. Just getting the bike back up is something you have to learn."
Police Chief David Lindley said the motorcycles will be used primarily for traffic control, where maneuverability of a motorcycle is an asset.
"As Starkville has grown, so too has the traffic congestion," Lindley said. "It has become a real problem sometimes just getting an officer from Point A to Point B. The motorcycles are really excellent in those situations."
"Oh, yeah," Round said. "Even with a bike this big, you can turn it around in one lane. In a patrol (car), you have to go to the next block or wait for traffic to clear to turn around. And when the traffic is heavy, that can take some time."
Although Lindley recognized the value of motorcycles, he did have reservations about adding them to his fleet. There is, after all, an inherent danger in riding motorcycles, where there is little between the rider and objects with which he might collide.
Although neither officer had any reservations, they did encounter some resistance at home.
"At first, I got a little push back," said Round, who is married with two children. "They were afraid it would be dangerous. But I took the motorcycle to the bus stop where my kids wait for the bus to school. When all of the other kids got there and started talking about how cool it was, my kids thought it was cool, too. So we're good."
Taylor said his girlfriend expressed the same reservations.
"I just told her, 'Hey, you don't think twice about it when it's the weekend and you're jumping on the back of my bike,'" he said. "So I guess she's OK with it."


text:
Submit Your Own Review!
Submit Product
Horse Tack Review
English Tack Reviews
Dressage Saddles (543)
Jumping Saddles (286)
Close Contact Saddles (424)
All Purpose Saddles (377)
English Saddle Fittings/Pads (479)
English Bridles (439)
English Bridle Accessories (136)
English Show Apparel (201)
English Casual Apparel (321)
English Chaps/Boots/Helmets (551)
English Miscellaneous (90)
Western Tack Reviews
Barrel Saddles (204)
Reining Saddles (84)
Roping Saddles (108)
Show Saddles (80)
Trail Saddles (780)
Western Saddle Fittings/Pads (279)
Western Bridles (81)
Western Bridle Accessories (73)
Western Show Apparel (19)
Western Casual Apparel (25)
Western Chaps/Boots/Hats (68)
Western Miscellaneous (33)
Horse Gear Reviews
Horse Boots and Wraps (348)
Halters/Ropes/Leads (152)
Horse Health and Well Being (282)
Horsewear (485)
Horse Treats (125)
Horse Miscellaneous (74)
Barn & Stable Reviews
Fly Control (222)
Gifts/Books/Videos (95)
Grooming Equipment (332)
Stable Accessories (44)
Tack Room (90)
Training Equipment (49)
Barn and Stable Misc (97)
Animal Legends First Aid Kit for Horses
Horse Tack - Horse First Aid
A First Aid kit is very important to have on hand in any stable and in your trailer. Animal Lengends has put together a convenient yet inexpensive kit for all to you. The Animal Lengends First Aid Kit includes: Tea Tree-ADE ointment and spray, a large disposable cold pack, a 3 oz bottle of DMSO roll-on, a pint of hydrogen peroxide, alcohol prep packets, antiseptic towelettes and 4"x4" gauze sponges. Comes in a durable water-resistant vinyl tote bag.
Tea Tree ADE Veterinary Skin Care Ointment Treats minor cuts, major wounds, ring worm, thrush, burns(including sunburn), saddle sores, stall rubs, scratches, bites and stings, and most other skin disorders. Contains Tea Tree Oil(Melaleuca Alternifolia)
Tea Tree ADE Veterinary Skin Care Spray 8oz Same effective ingredients as Tea Tree ADE Skin Care Ointment. Convenient, easy to use spray solution.
DMSO (Dimethyl Sulfoxide) Roll-On is to be used as a solvent only. DMSO is a colorless liquid derived from lignin, the natural material that bonds together the cells of trees. It is extracted during the manufacturing of pulp and then processed. It is an organic non-synthesized product.
The cold pack provides relief in an instant! Simply squeeze, shake and apply. Stores at room temperature.
Animal Legends - It's What Your Horse Would Buy! Animal Legends is the manufacturer of: LeucaLather Equine Shampoo, LeucaLather II Pet Shampoo, Tea Tree-ADE Veterinary Ointment, Tea Tree-ADE Veterinary Spray, Equine Hoof Dressing, Electrolytes, Poultice, Silks Shampoo, Silks II Shampoo, Silks BLUE Shampoo, Tea Tree Oil Pure


text:
Photos: 100 years of the Adolphus Hotel, from the days of 20-cent beers to now
Photo: Louis DeLuca/Staff Photographer
An ornate nameplate greets arrivals at the front of the Adolphus Hotel on Commerce Street in downtown Dallas.
To post a comment, log into your chosen social network and then add your comment below. Your comments are subject to our Terms of Service and the privacy policy and terms of service of your social network. If you do not want to comment with a social network, please consider writing a letter to the editor.


text:
The Patent Crisis and How Courts Can Solve It
Dan L. Burk
University of California, Irvine School of Law
Mark A. Lemley
Stanford Law School
February 26, 2009
UC Irvine School of Law Research Working Paper No. 2009-8
Stanford Law and Economics Olin Working No. 370
Stanford Public Law Working Paper No. 1349950
Patent law is crucial to encourage technological innovation. But as the patent system currently stands, diverse industries from pharmaceuticals to software to semiconductors are all governed by the same rules even though they innovate very differently. The result is a crisis in the patent system, where patents calibrated to the needs of prescription drugs wreak havoc on information technologies and vice versa. According to Dan L. Burk and Mark A. Lemley in this book from the University of Chicago Press, courts should use the tools the patent system already gives them to treat patents in different industries differently. Industry tailoring is the only way to provide an appropriate level of incentive for each industry.
Number of Pages in PDF File: 7
Date posted: February 26, 2009 ; Last revised: May 14, 2014
Suggested Citation
© 2016 Social Science Electronic Publishing, Inc. All Rights Reserved.
Terms of Use
Privacy Policy
Contact Us
This page was processed by apollobot1 in 2.484 seconds


text:
I'm sure I'll probably get killed here by my metal brethren, but I actually like Godsmack. Certainly, I realize they are a more metal version of Nickelback; a band whose sole goal is to create three or four radio hits on each album, sell a good amount of music and concert tickets, and basically be a key cog in the radio rock syndicate. I get it - it's less about the art of music than the business of music with them. That said, they have been consistently solid with their albums...so much so that most say they are the modern day AC/DC where there's NO difference from record to record. For Godsmack, all a new album means to most people is that they will be invading radio with the sames songs as always...but with different words attached to them.
Another thing I've learned about Godsmack though is that their consistency does not stop in the recording studio. Having seen them 3 times, they are consistently boring on stage. I saw them once before they were big, and twice after they made it. They killed it before they were big. They were very dull live after they hit. LIVE & INSPIRED pretty much captures the successful live Godsmack experience. They bring all the energy of the corpse in the first minute of an episode of LAW & ORDER: SVU. Each member of the band (sans drummer Shannon Larkin, who's drums are booming throughout) puts forth a remarkably drab performance here that is boring to painful to get through. Songs like "Straight Out Of Line" are greatly diminished without the studio enhancements added to the vocals of Sully Erna. That song is still decent, but it gets worse as things move on. "Moon Baby" is simply painful to listen to as Erna drones on and on through a megaphone or some other voice altering device. The band drone on and on throughout this show; playing all of their hits and making you wish that you had just decided to listen to one of their studio albums instead.
Also included on this release are four newly recorded cover songs - Joe Walsh's "Rocky Mountain Way", The Beatles "Come Together", Pink Floyd's "Time" and Metallica's "Nothing Else Matters". In short, four unnecessary versions of these songs that really no one needed to hear. In fairness, the reworking of "Come Together" is interesting and pretty good. As for "Rocky Mountain Way" and "Time", both are pretty much standard re-recordings of the work that lack what the originals had. As for "Nothing Else Matters", I think that speaks for itself.
PITRIFF RATING - 34/100 - Boring, uninspired and featuring about as much life as Whitney Houston's bath water, LIVE & INSPIRED is certainly one of the least necessary releases to come along in awhile. Just buy the studio albums - they are a whole lot better. On a side note, since Oracle came out we've had a Sully solo album, a greatest hits and now a live record. Is this band about to call it a day?
Chris Akin


text:
GROUP HOSTS HAUNTED SCHOOL HOUSE: The Students of the Monroe Center in conjunction with the Fine Arts Council Ghost Walk will hold a Haunted School House from 6:30 to 9 p.m. Saturday at 261 Monroe St., Warren. The event will include pumpkin crafts, face painting and refreshments.
ASSOCIATION TO HEAR FROM COMMITTEE: The Southeast Side Community Association will meet at 6 p.m. Thursday at the St. James White Hall, Milton Street and Willard Avenue in Warren. Representatives from the committee will discuss activities for children.
DANCE PLANNED AT TOWN HALL: The North Bloomfield Historical Society will hold a square dance and line dancing from 7 to 10 p.m. Friday at the town hall, state Routes 87 and 45. Cost is $5 for kids 10 and older and $4 for kids younger than 10. For more information, call 440-685-4582.
STUDENTS TO ATTEND MEETING: Junior government students at John F. Kennedy Catholic School in Warren will observe today's Trumbull County Commissioners meeting at 9 a.m. hosted at the school. Kennedy Upper Campus students in grades seven to 12 will also go to the online polls this Friday as part of the National Student Mock Election project.
JUNIOR LEAGUE PLANS SHOW: The Junior League of Youngstown is holding its bi-annual fall fashion show, "Make It Work!," from 6 to 8 p.m. Thursday at the Holiday Inn, 7140 South Ave., Boardman. All proceeds will support the Junior League of Youngstown community projects and the new issue-based community impact model. For tickets, call 330-743-3200.
CLOTHING COLLECTION HELD: The Champion Pride Council will be opening its annual Community Clothing Center from 9 to 11 a.m. Saturday at Champion Central Elementary School gym. New and nearly new winter clothing for children and teenagers will be available at no cost. Members of the Champion Pride Council will be available to help find sizes and collect selections.
Celebrate Recovery 101, 6 to 8 p.m., for help with depression, divorce, addictions and life issues. First United Methodist Church, Park Avenue, Warren, 330-392-6276 or 330-553-2644.
Cortland Community band, 7 p.m., band room, Lakeview Middle School on Wakefield Drive. www.cortlandcommuni-tyband.org or 330-652-2424.
Families Anonymous Warren, newcomers 6:45 p.m., meeting 7 p.m., Neil Kennedy Recovery Clinic, 160 Clifton Drive, Warren, 330-307-8182.
Niles Al-Anon, 8 p.m., New Hope United Methodist Church, 21 Fairview Ave., Niles.
TOPS Ohio 1262, McDonald, weigh in 8:45 a.m., meeting at 9:30 a.m., McDonald Community Center, Ohio Avenue.
Knights of Columbus Council 7491, 7 p.m., St. William Church rectory.
Here and Now, 6 p.m., Sahara Club II D, 2345 Youngstown Road, Warren.
God Walked In, 5 p.m., 5 Memorial Drive, Greenville, Pa.
Champion Kiwanis Club, 7 a.m., Wayside Restaurant, 825 State Road N.W.
Mended Hearts Support Group, 7 p.m., Finnegan Auditorium, St. Elizabeth Health Center, 330-793-2531.
Wednesday Morning Recovery, Narcotics Anonymous, 10 a.m. closed discussion, former unemployment office, 684 N. Park Ave., Warren.
Warren Rotary Club, noon, Enzo's Restaurant, Elm Road N.E.
TOPS 1350, Cortland, weigh-in, 9:15 a.m., Bazetta Township Hall, 3372 state Route 5.
TOPS 1859, 5:30 p.m. for weigh-in and meeting 6 p.m. at Champion Christian Church, 151 Center St.
Wednesday Night Serenity Hall AA meeting, 7:30 p.m., Badger Hall, First Presbyterian Church, Mahoning Avenue, Warren.
Niles Kiwanis, noon, Hometown Buffet.


text:
Upstate News
Darryl Geddes 315 464-4828
University Hospital pediatric heart surgeon honored for role in Rotary's Gift of Life program
George Alfieris, M.D., a pediatric cardiac surgeon at University Hospital, has received one of Rotary International's highest honors—the Paul Harris Award—for performing life-saving open heart surgery on needy children from abroad during a ceremony held today (Nov.12) at University Hospital.
Alfieris received the award from the president of Rotary International Bhichai Rattakul, who has served as foreign minister and deputy prime minister of Thailand.
University Hospital and its surgeons are partners in the Rotary's Gift of Life program, which brings children from overseas who are in need of life-saving heart surgery to University Hospital. In most cases the life-saving surgery that is available at University Hospital is not available to these children in their homeland. Since 1990, University Hospital physicians have performed heart surgery on 34 children from a variety of countries, including the Ukraine, Jamaica and El Salvador.
Rattakul and Alfieris visited the most recent Gift of Life child, three-year-old Diomar Castillo of the Dominican Republic. Castillo was operated on Oct. 29 to repair a hole in his heart and to correct a condition called pulmonary stenosis.
Considered one of the region's foremost pediatric heart surgeons, Alfieris performs nearly 200 open heart surgeries on children from across New York state each year. He has performed numerous surgeries for children who have been brought to the United States for life-saving heart procedures by Rotary International's Gift of Life program. In addition to his appointment at SUNY Upstate and University Hospital, Alfieris also performs surgery at Strong Memorial Hospital in Rochester.
The Paul Harris Award, named for the founder of Rotary, recognizes outstanding service and dedication to Rotary programs and initiatives.
There are more than 1,600 Rotarians in the District 7150, which includes Central New York.
Search Upstate News
Upstate in the News
- Prostate Cancer Survivor to Men: 'Get Checked Out Promptly and Get Checked Out Often
Time Warner Cable News Central NY
- Your questions on skincare answered
WTVH CBS5 Syracuse
- Upstate Medical nursing students get new home on campus
Syracuse Post Standard
- New York Teen Donates Kidney to Younger Brother: 'This Was My Chance to Save Him'
- Syracuse teen receives kidney transplant from older brother
WTVH CBS5 Syracuse
- Inside the Mind of the Munich Mass Killer
Psychology Today


text:
? Place an order in the next
Hours Minutes . Overweight charges may apply to some items.
Not the correct shipping zip code? Update your information below.
Enter a valid zip code
Please select options for this product
Estimated Delivery for
Change Shipping Destination
(based on 78 reviews)
of respondents would recommend this to a friend.
Ratings Distribution
5 Stars
4 Stars
3 Stars
2 Stars
1 Stars
Best Uses
Feels full size too small
Feels half size too small
Feels true to size
94% (64 reviews)
(64 reviews)
Feels half size too big
Feels full size too big
Reviewed by 78 customers
Displaying reviews 1-10
Back to top
Previous | Next »
Great Helmet and Good Value
By Rapman59
from Minneapolis, MN
About Me Avid Cyclist
Comments about Bell Delirium Mountain Helmet - Nashbar Exclusive:
I've had a number of helmets and the ones from Bell with huge events are my favorites. Of course, everyone at Nashbar is always awesome. Help when I need it and everything arrives exactly when promised! Thanks!
Bottom Line Yes, I would recommend this to a friend
Was this review helpful? Yes / No
- You may also flag this review
Comment on this review
great price,perfect fit
By Schwinn Homegrown
from Albany NY
Came sized perfectly out of the box. I'm a 7 1/4 hat size and medium Bell has always fit great. The straps were pre-adjusted perfectly. Bell and Nashbar do it right.
Great Helmet!
By DFMenez
from Anoka, MN
Great Helmet for the price... Very easy to adjust and fits extremely well. Could not have made a better purchase!
What a great helmet!
By TLT
from Maine
About Me Casual/ Recreational
See all my reviews
Helmet fits very comfortably. The adjustments allow for a perfect fit.
Saved my noggin!
By GAC
from Parkville, MO
Did it's job perfectly well. So well that I am replacing it with the exact model, different color, as red not in stock--I'm not a fashion queen, color is irrelevant. Replacing it < 6 months after I got it, as I took a nasty spill at 15-20 MPH on a downhill section at Slaughter Pen Trail in ARK. Right hip took 90+% of the fall. Checked helmet, as small cut from my glasses by my lefft eye. Sure enough, took a hard blow to the parieto-occipital area of the helmet, foam cracked. Worked as designed! Thanks, Bell
Good helmet for all-around use
By TequilaSheriff
from Kentucky
This is my third Bell Delerium helmet--I guess that it is the ideal product at my price point. The retention system and straps are pretty easy to adjust (I adjust them once out of the box and then pretty much never again for the life of the helmet). I like the visor as a bit of shade and protection. I can't say that this helmet is any better than any other helmet, but it works just fine for me.
Good value
By Michael
from Rochester, NY
Based on the sizing guidelines provided, I was a small. This did not surprise me as I have a small head (I wear youth size baseball caps). However, even on the largest setting, I had to squeeze into this helmet. It was way too small. My measurement was just below the minimum measurement for a medium and I exchanged it for a medium, which fits fine. Unless you are well within the small range, then I suggest you go up to a medium.
Great fit
By Phineas JW
from Bellingham, WA
The adjustable strap pinches my ear. I haven't played around with adjusting the strap by reweaving it. The helmet fits, feels and looks great otherwise.
Quality at a sensible price
By PCruz
from Enterprise, Al
Bell quality at a reasonable price. I've owned several Bell helmets and have not been disappointed by any of them.
Great for road biking too.
By Albert
from Mountain View, CA
This helmet fits much better than my old Bell helmets ever did, thanks to the gear driven adjustable inner sizing band. Instead of just sitting on the top of my head, the helmet feels like it wraps around the back much more. The visor seems minimal; they should have made it an inch longer.
Item No. »
We Make Shopping Safe, Secure and Easy
© 2016 Nashbar. All Rights Reserved.
Return to Mobile


text:
A major snowstorm will hit Hunterdon and the rest of north and central Jersey, bringing 4 to 8 inches of snow, possibly more, to the region.
The National Weather Service office in Mount Holly has already issued a Winter
Storm Watch, likely to be upgraded later to a Warning, in effect from Thursday evening through Friday morning.
There will be blowing and drifting snow and dangerous cold, NWS said.
The heaviest snow will be Thursday night, with rates of an inch or more an hour possible. And it will get much colder than it's been, with Friday morning temperatures predicted to be 11 in the Flemington area.
Just as the snow gets heaviest Thursday night, winds will be increasing with gusts over 30 mph. "Near- blizzard-conditions are likely. Wind chills will be falling into the single digit as this is occurring," NWS said.
Snow is forecast to develop from northwest to southeast during Thursday afternoon, then widespread snow is expected Thursday night and Friday morning.
This will be an increasingly fluffy snow and as winds increase Thursday night, blowing and drifting snow should make travel even more hazardous, NWS said. "Road plowing operations would be greatly affected by the blowing and drifting snow, it noted.
More Hunterdon County news: NJ.com/hunterdon • Facebook • Twitter


text:
Legit argument, but Detroit was 1 goal away from being tied with the best scoring team in the league last season. To me, scoring depth is more important than top heavy teams. Problem DRWs had was everyone (not named Lidstrom) went cold at the same time. Its hockey, it happens.
What those teams have in high end scoring, they lack in offensive or defensive depth. Wings had a ton of guys last season with 10 or more goals, and its really nice to know that any line can score. Its nice having 40 or 50 goal guys but not at the expense of depth.


text:
What are you looking for? A story maybe? Why don't you tell me yours? Tell me your life story. Go on. You know you want to... Look down below here, there is a comment box. Just write it all down. Don't be shy. Maybe someday, somebody will read it and just be absolutely amazed. They will say, "fuck, that guy was so cool". So go ahead. Tell me your life story. I'm genuinely interested. I swear.
The statistics above update daily and provide insight into how well articles, files, videos, images and other content you post is affecting the popularity of your member. If you wish to track these statistics on your homepage, blog, facebook or even in news and forum posts here, please use the following embed code:
Click for a text link | Click for an icon | Click for a button | More »
We recommend you link to your member profile on your homepage, blog, forum and other communities you are a member of like Facebook and Twitter. To help you do this you can copy and paste any of the code options on your right, or check out our mediakit.
All content linked with your profile including archived downloads, news etc is still being tracked and included on the above graph even if it isn't mentioned.


text:
Five Democrats vying for the nomination to take on Gov. Corbett in November raised $27.2 million last year, and as of Dec. 31 had $25.6 million on hand to spend against each other, according to campaign finance reports filed Friday.
Corbett started the year with $7.5 million in his campaign coffers after raising $6.8 million in 2013. The take was lower than his campaign, and some leading Republicans, had hoped, but the incumbent has the luxury of watching a Democratic demolition derby while continuing to raise money.


text:
Hurricane Isaac batters the Mississippi coast Wednesday.
No email address was supplied by
To complete your registration on this site, please supply an address.
Please confirm or modify the email address to which you will have subscription offers sent.
For a more personalized experience, please supply the following optional information.


text:
By kidfishing
By DancingGenes
By DancingGenes
By Joy
By cocoajuno
By cocoajuno
|August Blooms 2016
|Your Best Daylily Parents
|Alphabet of Daylily Terms...Let's Talk About "P's"
|june seedlings
|Favorite patterned daylilies?
|Seedlings June 2013
|Blooming in June 2013
|The eyes have it.
|Debra's Seedlings
|Name this daylily 2011 #2
|Adding Actions:
» Upload a photo
Editing Actions:
» Edit data details
« Add a new plant to the database
» Search the Daylilies Database: by characteristics or by cultivar name
« See the general plant entry for Daylilies (Hemerocallis)
» Read our note about daylily rust scores
« The Daylilies Database Front Page


text:
by julie | Posted: 13/01/09
Play all? / 7 songs
1.Song: All Downhill From Here
by Jim O'Rourke from Insignificance
2.Song: Palace Music - Horses
by Palace Music
4.Song: Beast For Thee
by Matt Sweeney and Bonnie 'Prince' Billy from Superwolf
5.Song: Just As You Are
by Robert Wyatt from Comicopera and Different Every Time - EX MACHINA / BENIGN DICTATORSHIPS
6.Song: Merman
by Max Tundra from Mastered By Guy At The Exchange
Get the Flash Player to see this movie.
Night And Day
by Hot Chip
by Hot Chip
by The Magnetic Fields
by The Magnetic Fields
Gun Has No Trigger
by Dirty Projectors
by Dirty Projectors
Do Your Thing
by Lightships
by Lightships
Exactly Nothing
by Real Estate
by Real Estate
City Kiss
by Fránçois & the Atlas Mountains
by Fránçois & the Atlas Mountains
Third Swan
by King Creosote and Jon Hopkins
by King Creosote and Jon Hopkins
Into Giants
by Patrick Watson
by Patrick Watson