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Stroke is the leading cause of disability in the United States and the third leading cause of death. Of long-term stroke survivors, 30% are dependent on others for help with activities of daily living and 15% require institutional care. Traditional care for patients with stroke has focused on treating complications and preventing recurrent strokes; the stroke itself was considered irreversible.
Recent trials of thrombolytic therapy, however, have engendered new hope for patients with acute ischemic stroke. Although studies of thrombolytic therapy for stroke were first published in 1958,1 only recent trials using computed tomography (CT) and shorter therapeutic time windows(defined as time from onset of stroke symptoms to treatment) have shown beneficial results. Moreover, the term brain attack defines the approach to patients with acute ischemic stroke, replacing the nihilism of an earlier era by identifying acute ischemic stroke as a medical emergency requiring urgent treatment. The impetus for this new approach has been the potential for thrombolytic therapy, but the hope is that all patients who experience stroke will benefit from more rapid assessment and initiation of treatment.
We review our understanding of the risks and benefits of thrombolytic therapy based on recent controlled trials. We also discuss evolving issues of patient selection, patient preferences for outcomes and risks, treatment outside of a controlled clinical trial, treatment by whom, and mode of delivery of treatment.
Before 1992, to our knowledge, there were 6 published, randomized, controlled trials using urokinase, streptokinase, or recombinant tissue plasminogen activator.1 Two of the trials did not have the benefits of pretreatment CT scanning, and the other 4 used therapeutic time windows ranging from 6 hours (2 studies) to 30 days. The time to treatment seems critical. Open-label studies show an increased rate of intracerebral hemorrhage (ICH) in patients whose time window extends beyond 6 hours.2 Now, most trials are performed with time windows of less than 6 hours.
In the early 1990s, the first 2 randomized, controlled trials of IV recombinant tissue plasminogen activator therapy were published (Table 1).3,4 To our knowledge, these studies were the first controlled studies to establish the potential safety and efficacy of recombinant tissue plasminogen activator in patients with acute ischemic stroke.
Patients in both studies underwent a cerebral angiogram identifying the site of arterial blockage and then were given either IV recombinant tissue plasminogen activator or IV placebo. A total of 129 patients were randomized within 6 hours of symptom onset to receive IV recombinant tissue plasminogen activator or placebo, with the study by Mori et al3 examining 2 separate doses of recombinant tissue plasminogen activator in addition to placebo. Both studies assessed recanalization rate, which is the ability to open the blocked artery, and clinical outcome using the hemispheric stroke scale, hemorrhagic complications, and mortality rate. Both studies found higher recanalization rates in the recombinant tissue plasminogen activator–treated group than in the placebo group. In addition, the recanalization rate for patients with isolated middle cerebral artery (MCA) occlusion was higher than that for those with internal carotid artery occlusion. Recanalization, regardless of treatment group, was associated with a better outcome. Patients receiving thrombolytic therapy had greater improvement on the hemispheric stroke scale score than those receiving placebo. Hemorrhagic infarctions occurred more frequently in the low-dose group of patients in the study by Mori et al, but this rate was similar to that of the placebo group in the study by Yamaguchi et al4(Table 1). At 1 month after stroke, mortality was similar in both treatment groups. The researchers concluded that thrombolytic therapy leads to higher recanalization rates and better outcomes, especially in patients with MCA and branch occlusions compared with internal carotid artery occlusions. The high recanalization rate seen in the placebo arms also reinforced the critical need for controlled clinical trials.
The largest and most recent randomized, controlled trials of IV recombinant tissue plasminogen activator included 2 studies conducted in Europe, the European Cooperative Acute Stroke Study (ECASS) I and II, and 2 in the United States, the National Institute of Neurological Disorders and Stroke (NINDS) recombinant tissue plasminogen activator trials, parts 1 and 2 (Table 2).5- 7
The ECASS I was a large, multicenter trial to evaluate the safety and efficacy of recombinant tissue plasminogen activator in patients with acute ischemic stroke.5 Patients were randomized within 6 hours of symptom onset to receive either IV recombinant tissue plasminogen activator or placebo. Primary outcomes assessed at 90 days were the Barthel Index (BI), a 10-item scale of activities of daily living, and the modified Rankin Scale (mRS), a 6-item scale of overall disability (Table 3). Secondary end points included the mortality rate at 30 days, the combined score of the BI and mRS at 90 days, and the stroke severity as measured by a 10-item Scandinavian Stroke Scale at 90 days. The trial did not show a statistically significant improvement in patients' ability to perform activities of daily living (P= .99) or their functional outcomes (P= .41), but there was a statistically significant (P= .003) difference in favor of the recombinant tissue plasminogen activator–treated group for the combined BI and mRS score. However, 109 patients (17.4% of the total enrolled) should not have been enrolled based on unintended departures from the protocol, such as patients who had an abnormal head CT scan result showing evidence of early infarction or the presence of blood. An analysis of the research cohort excluding these 109 patients showed recombinant tissue plasminogen activator–related improvements in the functional outcome of patients and in the Scandinavian Stroke Scale and the combined BI and mRS scores. There was a 3-fold higher rate of brain hemorrhage in the recombinant tissue plasminogen activator–treated group, and a significant (P= .02) increase in deaths due to ICH in this group. However, the overall mortality rate at 90 days was not significantly (P= .04) different between the recombinant tissue plasminogen activator and placebo groups (Table 2). The researchers concluded that recombinant tissue plasminogen activator was effective in patients with acute ischemic stroke when administered to those who do not have early radiographic signs of cerebral infarction or other significant departures from the protocol.
The NINDS recombinant tissue plasminogen activator trials compared IV recombinant tissue plasminogen activator, 0.9 mg/kg (maximum, 90 mg), with placebo administered within 3 hours of symptom onset.7 The NINDS study comprised 2 trials (n = 291 in part 1 and n = 333 in part 2); part 1 measured outcomes at 24 hours, and part 2 measured outcomes at 90 days. Because part 1 also measured outcome at 90 days, the overall results were combined by the investigators and are summarized in Table 2. The primary outcomes assessed for these trials were the BI and the mRS, the same as those for the ECASS I. In addition, 2 other outcomes were measured. The first was the National Institute of Health Stroke Scale (NIHSS) score, which is an 11-item (42-point) neurologic examination that tests cognition, level of consciousness, eye movements, visual fields, motor ability, sensation, and ataxia. It is most often used to grade the stroke severity at onset. Scores of 14 or higher are considered a moderate to large stroke.8 The initial NIHSS score is often compared with a follow-up score at 90 days to categorize improvement. An NIHSS score of 0 or 1 at follow-up is considered an excellent result. Another outcome measure was the Glasgow Outcome Scale, a 5-point global outcome scale with 1 representing death and 5 representing good recovery.
The primary efficacy outcome for part 1 was a 4-point improvement on the NIHSS score or the resolution of symptoms within 24 hours of stroke onset. The results demonstrated no significant (P= .21) improvement in the NIHSS score at 24 hours.
In part 2, the primary efficacy outcome was the percentage of patients with minimal or no deficit at 90 days measured by the 4 separate scales: the NIHSS, the BI, the mRS, and the Glasgow Outcome Scale. Because part 1 measured these 4 scales at 90 days as a secondary outcome, the results are often combined in the final report (n = 624). Patients treated with recombinant tissue plasminogen activator had a significantly (P= .008) better functional recovery at 90 days compared with the placebo group. Overall, there was an 11% to 13% absolute difference favoring recombinant tissue plasminogen activator in the number of patients with minimal or no deficits at 90 days. In other words, patients treated with recombinant tissue plasminogen activator were 30% more likely to have an excellent recovery than patients receiving placebo. The benefits of treatment with recombinant tissue plasminogen activator were sustained at 1 year.9
There were more patients with symptomatic hemorrhages and fatal ICHs in the recombinant tissue plasminogen activator–treated group than in the placebo group. However, there were no significant (P= .30) differences in early or 3-month mortality between groups (Table 2). This study showed that neurologic outcome was improved by the use of IV recombinant tissue plasminogen activator for patients with acute ischemic stroke.
Although there are case reports and nonrandomized trials that show the benefit of thrombolytic therapy, the NINDS study remains the only placebo-controlled, double-blind study to report a statistically significant (P= .008) benefit of IV thrombolytic therapy for acute ischemic stroke.10
Because of the excessive protocol departures in the ECASS I and the positive results of the NINDS trial, the ECASS II (n = 800) was designed using a lower dosage of recombinant tissue plasminogen activator and requiring stricter adherence to the protocol, especially exclusion of patients with early infarct signs on a CT scan, and the NINDS studies' guidelines for blood pressure control.6 The time window for treatment remained 6 hours. However, the ECASS II failed to demonstrate a significant (P = .28) difference between treatment groups in the primary outcome measure, minimal or no deficit (mRS score of 0 or 1) at 90 days (Table 2). When mRS scores were dichotomized for independence (mRS scores of 0, 1, or 2) and death or dependence (mRS score of ≥3), there was a significant (P= .02) benefit for recombinant tissue plasminogen activator–treated patients, with more patients having slight to no disability in the recombinant tissue plasminogen activator–treated arm (Table 2). The investigators found no treatment differences between patients treated within 3 hours and those treated from 3 to 6 hours after onset. Symptomatic ICH occurred more often in the recombinant tissue plasminogen activator– treated patients than in the placebo-treated patients, but mortality at 90 days was the same in both groups.
The lack of benefit of recombinant tissue plasminogen activator–treated patients in the ECASS II may be attributed to the observation that patients enrolled in the ECASS II had less severe strokes, as shown by the lower admission stroke severity scores and by the lower mortality rates in the placebo-treated group compared with mortality rates in other trials (Table 2). Thirty seven percent of the placebo-treated patients had a favorable outcome at 90 days, which is similar to the positive responses for the recombinant tissue plasminogen activator–treated patients in the ECASS I (36%) and in the NINDS (39%) trials. Also, the mortality rate in the ECASS II was roughly half that observed in the other 2 trials. Nevertheless, the researchers concluded that the trend supported a beneficial effect of recombinant tissue plasminogen activator, especially if the results were considered along with the positive results of the NINDS trial.
Several trials11- 13 of streptokinase for acute ischemic stroke were terminated prematurely due to excessive early mortality in the treatment groups. These trials administered 1.5 × 106U of IV streptokinase over 1 hour to patients who presented within 4 to 6 hours of symptom onset. Mortality rates for the streptokinase-treated patients ranged from 27% to 36% compared with 12% to 20% for the placebo group. Consequently, enthusiasm for thrombolytic treatment with streptokinase has waned. However, these trials were not preceded by dose escalation studies; streptokinase was often combined with aspirin; and doses of streptokinase used were those used for myocardial infarction and may have been too high. In addition, the researchers in one of the trials have noted that the mortality rates for patients treated within a 3-hour time window were no different between the treated and placebo groups. They suggest further studies are warranted.13
Intra-arterial thrombolysis is an alternative approach to the use of IV thrombolytic therapy involving a cerebral angiogram to identify the site of occlusion, and delivery of thrombolytic therapy directly into the clot. There have been 2 randomized, controlled trials of IA thrombolytic therapy for the treatment of stroke due to angiographically documented occlusion of the MCA. Both trials used recombinant prourokinase, a precursor of urokinase with high fibrin specificity (ie, "clot specific"), administered within 6 hours of symptom onset.
The Prolyse in Acute Cerebral Thromboembolism (PROACT) I trial assessed the safety and recanalization rates of IA administration of recombinant prourokinase compared with placebo.14 Forty-six patients were randomized on a 2:1 basis; for every 2 patients who received drug, 1 received placebo. All patients received heparin calcium. Six patients were excluded after randomization but before treatment: 2 because the time elapsed extended beyond 6 hours, 2 because there was no occlusion of the specified MCA, and 2 because of complications incurred before treatment with drug. Of the 40 patients treated, 26 received IA recombinant prourokinase (6 mg) and 14 received IA placebo. Both treatment arms initially received IV heparin, a 100-IU/kg bolus followed by a 1000-IU/h constant infusion for 4 hours (high-dose heparin). After 16 patients were treated, the heparin dose was decreased to a 2000-IU total bolus and a 500-IU/h infusion (low-dose heparin) on the recommendation of the safety and monitoring board of the study because of a high rate of symptomatic ICHs.
Overall, the recanalization rate was 58% in the treated patients vs 14% in the placebo group. There was an increase in symptomatic ICHs in treated patients at 24 hours (15% vs 7%); however, this difference narrowed to 15% vs 14% at 90 days. Mortality at 90 days was less in recombinant prourokinase–treated patients than in the placebo group; mortality due to ICH was 4% in the treated group and 7% in the placebo group. Recanalization was augmented by the concomitant use of heparin, with higher doses of heparin opening up more arteries but lower doses of heparin resulting in fewer hemorrhagic complications.
The PROACT II trial was a safety and efficacy study comparing 6 mg of IA recombinant prourokinase with placebo; both treatment groups received heparin, a 2000-IU bolus and a 500 IU/h infusion for 4 hours.15 One hundred eighty patients were enrolled (121 received recombinant prourokinase and 59 received placebo). Patients were stratified by enrollment NIHSS score into 1 of 3 severity categories (4-10, mild; 11-20, moderate to severe; and 21-30, severe) to ensure a balance of stroke severity between the treated and placebo groups. The primary outcome measure was the mRS score at 90 days, with a favorable outcome defined as an mRS score of 2 or less. Secondary outcomes were percentage of patients with an NIHSS score of 1 or less at 90 days, recanalization rates, mortality, BI, and percentage of patients with a 50% decrease in NIHSS score.
Overall, patients treated with recombinant prourokinase had a significantly (P= .04) better functional recovery (mRS score of ≤2) at 90 days compared with the placebo group. Patients with an intermediate severity stroke with an NIHSS score between 11 and 20 had the greatest difference in functional outcome between the recombinant prourokinase–treated group and the placebo group (Table 4). In those patients with a mild stroke (NIHSS score, 4-10), there was no difference in the proportion attaining a good functional status. Across all 3 groups of stroke severity, there was a 15% absolute difference favoring treatment with IA recombinant prourokinase. Patients treated with recombinant prourokinase were 60% more likely to have slight or no significant disability compared with the placebo-treated group.
Recanalization rates were higher in the group treated with recombinant prourokinase but so were rates of symptomatic and asymptomatic hemorrhages. Despite the higher rate of early symptomatic hemorrhages in the recombinant prourokinase arm, mortality rates at 90 days were no different between the groups. Interestingly, 476 patients underwent angiography for possible participation in the PROACT II trial; 62% were excluded before treatment because they did not have an occlusion of the stem or first branch of the MCA. Of the 62% excluded, an internal carotid artery occlusion was found in 20%, no occlusion was identified in 19%, and 23% had either a more distal MCA occlusion or some other arterial occlusion.
Intra-arterial thrombolysis was efficacious in patients with an angiographically documented MCA occlusion of less than 6 hours' duration. Even when using a functional outcome score similar to that used in the NINDS trial (mRS score of ≤1), more patients receiving recombinant prourokinase had a favorable outcome compared with the placebo group (Table 5).
The results from the ECASS II and the PROACT II trial raise important questions. If some milder strokes improve without treatment, should we be treating such patients with thrombolytic agents? Half the patients enrolled into the ECASS II had a stroke severity score of less than 11 (relatively mild). Thirty seven percent of all patients had minimal to no deficit at 3 months without any thrombolytic treatment; we do not know if the improvement was seen only in those with milder stroke. In the PROACT II trial, there was no difference in outcome between drug- and placebo-treated patients with NIHSS scores between 4 and 10. Are these patients with low NIHSS scores (4-10) better candidates for IV recombinant tissue plasminogen activator therapy or should thrombolytic agents be avoided entirely? To answer these questions, we need more studies to assess the benefits and risks of treatment according to the initial stroke severity. Patients with milder strokes who may do well without thrombolytic treatment should be able to weigh the chance of increased improvement with treatment vs the risk of worsening or dying from ICH. On the other hand, patients with severe strokes who may have an increased risk of hemorrhage from recombinant tissue plasminogen activator therapy may consider risking treatment to lessen the chance of being permanently disabled or dependent on others. A recent trial of a heparinoid in patients with acute stroke by Adams and colleagues16 suggested that 46% of patients who present with a low NIHSS score between 7 and 10 will have an excellent outcome without any short-term therapy. Like this trial by Adams et al, most stroke trials should be designed to randomize patients according to their initial stroke severity to help address the relation between initial stroke severity and impact of therapy.
Another question raised by the results of the ECASS II and the PROACT II trial is how much improvement must occur following a stroke to be considered a meaningful outcome? Thrombolytic trials are considered "positive" if the patients have minimal to no deficit (mRS score of ≤1). Although the ECASS II found that significantly (P= .02) more patients treated with thrombolytic agents became functionally independent compared with placebo, it was not considered a successful trial because there were no treatment differences in patients for the primary outcome of minimal to no deficit. Being functionally independent is an excellent result for most patients with stroke who most fear their loss of independence. Whereas full recovery is a laudable outcome, we may be striving for too much. The PROACT II trial was considered positive because it chose as the primary outcome functional independence (mRS score of ≤2). Nevertheless, this was based on a small sample size insufficient for regulatory approval in the United States. Further work is needed to address patients' definition of quality of life so they can help us determine what outcome they most prefer. We advocate more outcome studies that address patient preferences, expanding on work done by Matchar and colleagues17 that showed patients would rather be dead than dependent on others, so the added benefit of moving from an mRS score of 3 to 2 may be worthwhile to the patient population we are treating.
Based on the results of the NINDS trials, the Food and Drug Administration approved the use of IV recombinant tissue plasminogen activator therapy for the treatment of acute ischemic stroke in June 1996. Several studies18 have since been published showing the safety and effectiveness of recombinant tissue plasminogen activator therapy in the community. The Standard Treatment with Alteplase to Reverse Stroke study19 prospectively collected data on 389 patients treated with recombinant tissue plasminogen activator from 24 academic and 33 community centers. All principal investigators in this study were neurologists who had experience in treating patients with stroke who received recombinant tissue plasminogen activator. The study reported a 30-day mortality rate of 13% and an ICH rate of 10% (3% symptomatic and 7% asymptomatic). Deviations from the NINDS protocol occurred in 27% of patients.19 The most common protocol violation was treatment beyond the 3-hour time window, and the next most common violations were treatment with anticoagulants within 24 hours of receiving a thrombolytic drug and an elevated blood pressure just before treatment. Tanne and colleagues18 performed a retrospective survey of hospitals that have organized stroke triage systems and experience giving recombinant tissue plasminogen activator. They found that symptomatic ICH occurred in 6% of treated patients. Deviations from the NINDS protocol occurred in 30% of patients.18 The Stroke Treatment in the Community project voluntarily collects data from 18 hospitals in Minnesota. So far, they have collected information on approximately half of all patients treated with recombinant tissue plasminogen activator and have a 10% combined symptomatic and asymptomatic ICH rate.20
Many of these reports published since approval of recombinant tissue plasminogen activator involved stroke centers experienced in the administration of thrombolytic agents. Many also used voluntary reporting of cases that may be biased.18,21 A citywide audit of 27 Cleveland, Ohio, area hospitals prospectively collected cases of patients treated with IV recombinant tissue plasminogen activator and compared the results with patients not treated with thrombolytic therapy.22 In this study, Katzan and colleagues found a higher symptomatic ICH rate (15.7%) and a higher mortality rate (15.7%) in the thrombolytic-treated group compared with those found in the NINDS trial. The researchers also found that 50% of patients treated with thrombolytic agents had deviations from national treatment guidelines.23 The most common deviations involved the use of antiplatelet agents or anticoagulants within 24 hours of recombinant tissue plasminogen activator administration and treatment beyond the 3-hour limit. The explanation for the higher rates of ICH and mortality is unknown. The researchers speculate that hospitals with less experience in the administration of recombinant tissue plasminogen activator may have had higher symptomatic hemorrhage rates. They also note that the high rate of departures from the national recommendations for treatment with recombinant tissue plasminogen activator may be a surrogate marker for lack of familiarity with thrombolysis and acute stroke management. Others18,24,25 have also found higher complication rates when strict adherence to the guidelines was not followed, although the Standard Treatment with Alteplase to Reverse Stroke study19 did not find a correlation.
These observations raise an important question of whether the community experience with recombinant tissue plasminogen activator can match that of a controlled trial run by experienced stroke investigators. The results of the ECASS I have shown us the perils of protocol violations. More prospective studies will be needed to follow the outcome of patients treated with thrombolytic therapy outside of a randomized, controlled trial. These studies may also provide insight into other questions regarding widespread use of thrombolytic therapy. For instance, what is the appropriate level of clinical expertise needed for administration of thrombolytic therapy? Does a neurologist need to be present or simply available by telephone? On a larger scale, should thrombolytic treatment be available in all emergency department settings? These answers can only be provided by ongoing surveillance of recombinant tissue plasminogen activator use and carefully planned surveillance studies. The Stroke Treatment in the Community project is still ongoing and, although this is a voluntary project with inherent biases, should provide important insights into the community experience with thrombolytic agents. Further analysis is under way to compare outcomes between patients treated at academic, metropolitan, and rural hospitals. Another ongoing study26 is a prospective comparison of the outcome of treatment with IV recombinant tissue plasminogen activator by emergency department physicians with telephone consultation of a neurologist vs treatment by a stroke neurologist. A preliminary report suggested there was no difference in outcomes, although there was an initial disparity between protocol violations among the emergency department physicians (33%) vs the neurologists (5%). An educational program was supplied and the disparity lessened, but further results are pending.26
Extensive diagnostic testing may limit the application of recombinant tissue plasminogen activator because a certain level of expertise would need to be quickly available in all emergency departments. Do we need to know the cause of stroke before we administer thrombolytic therapy? Since IV thrombolytic therapy must be administered within 3 hours of symptom onset, many patients receive treatment before the cause of stroke can be fully evaluated. The PROACT II trial has shown that 19% of patients who are thought to have a blood clot do not have an arterial occlusion by angiography. Caplan et al27 advocated using IV recombinant tissue plasminogen activator therapy only when arterial occlusive lesions can be demonstrated by vascular imaging studies. While this approach will treat only patients with ischemic stroke due to identifiable arterial blockage, it also delays treatment and limits thrombolytic intervention to specialized centers with readily available imaging technology. Conversely, James Grotta, MD, recommends more widespread use of IV recombinant tissue plasminogen activator therapy for patients with acute ischemic stroke in strict accordance with published guidelines, emphasizing reducing time to treatment over establishing a definitive diagnosis.27 In this approach, some patients with transient ischemic attacks or nonischemic conditions may receive thrombolytic therapy. Both viewpoints illustrate the need for ongoing research to better define the indications for thrombolysis and identify new ones.
There are no recent, large, randomized, controlled studies that directly compare thrombolytic agents in the treatment of acute ischemic stroke. In the United States, IV recombinant tissue plasminogen activator therapy is the only approved agent for this indication. Based on recent controlled trials, streptokinase cannot be recommended for the treatment of ischemic stroke. Recent studies have demonstrated that IA prourokinase may be a new thrombolytic option in selected patients with stroke. Although the recanalization rate for IA therapy is higher than that for IV administration, and recanalization is associated with improved outcome, until we have more conclusive evidence, we cannot recommend one route over the other.28 Location of clot, severity of stroke, and institutional and community capabilities may eventually dictate the most appropriate routes. Studies need to be done that compare IA with IV therapy in patients with acute ischemic stroke.
It is our opinion that IV recombinant tissue plasminogen activator therapy can at once be the standard of care for acute ischemic stroke and a source of comparison in prospective, randomized trials of new diagnostic and treatment alternatives. For example, these trials may investigate the role of imaging technologies, such as diffusion-weighted magnetic resonance imaging, magnetic resonance angiography, CT angiography, and transcranial Doppler ultrasonography, in identifying optimal candidates for thrombolysis. Prospective, randomized trials using IV recombinant tissue plasminogen activator therapy as the standard of care also provide the most powerful and efficient means of investigating new treatment alternatives, such as variations in thrombolytic delivery (dose, time window, mode of administration, and type of agent) and combination therapy with cytoprotective agents or platelet inhibitors.
In summary, thrombolytic therapy for ischemic stroke exemplifies the delicate balance between risk and benefit. Data from randomized, controlled trials have provided indications when the benefits of thrombolytic therapy clearly outweigh the risks. These trials also provide insight into clinical situations when the risk is too high for intervention. Unsettled issues requiring controlled investigation include the following: (1) identifying subgroups of patients based on initial stroke severity who will derive particular benefit or who are at special risk; (2) determining whether knowledge of site of occlusion should influence mode of delivery; (3) measuring health-related quality of life and patient preferences to determine what is the optimal outcome from the patients' perspective; and (4) assessing the effectiveness of thrombolytic therapy in the community.
Accepted for publication May 23, 2000.
Reprints: Judith A. Hinchey, MD, Strong Memorial Hospital, Box 681, 601 Elmwood Ave, Rochester, NY 14620 (e-mail: firstname.lastname@example.com).
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Use as a centerpiece for your baby shower, this Fillable Blue Baby Bottle can also make a great baby shower favor. You'll get six 3 inch by 1 1/2 inch blue baby bottles.
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, please contact our Customer Service Department at (firstname.lastname@example.com or 1-800-314-8794).

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Pentagon Federal Credit Union - Dulles, VA - Phone: (703) 661-6004
A credit union in Dulles is a cooperative financial institution that is owned and controlled by its members and operated for the purpose of promoting thrift, providing credit at competitive rates, and providing other financial services to its members. Many credit unions exist to further community development or sustainable international development on a local level. They are typically smaller than banks, and are generally not-for-profit cooperative institutions. Credit unions in Dulles have an unusual organizational structure, which attempts to solve the principal-agent problem by ensuring that the owners and the users of the institution are the same people. In any case, credit unions cannot accept donations and must be able to prosper in a competitive market economy.
PSEG Long Island Helps Customers Go Green and Save Green
Energy Efficiency Programs Save Customers Millions of Dollars (Long Island, NY) PSEG Long Island announced today that customers participating in energy efficiency programs in 2015 will save more than $60 million and 307,582,000 kilowatt hours (kWh) per year. The amount of energy saved is good for the environment, too, as it results in the elimination of the carbon dioxide..


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|Tourist Attractions
A. Takumi Butai Memorial Shrine
A monument in honor of Takumi Butai and Japanese soldiers who died here during the Second world War. Takumi was the Provincial Commander of the Japanese forces assigned in Cotabato City. Before he died, he requested that some of his ashes be buried in Cotabato City. This shrine was put up by the Lion's Club of Kyoto, Japan in cooperation with the City Government of Cotabato.
B. Tamontaka Church
Built in 1872 of Spanish architecture and design. It is the oldest church in the city , a relic of the living past.
A. PC Hill
A stone fort towering over the city with a height of 90 feet., now houses the Cotabato City Internal Defense Command. This is Cotabato City's famous landmark, this historic hill served as a watch tower for the natives in their defense drive to detect and repel assaults by enemies. From this hill, one can have a panoramic view of the city and the Rio Grande de Mindanao.
B. Kutang Bato Caves
The only cave in the country that is right in the heart of the
city. Its various entrances, all within traffic a rarity that can only be had in the
"Heart of Mindanao". These caves were also the source of the city's present name
for "KUTA" means FORT and "WATO" means STONE hence the name "Fort
of Stone" which later on became Cotabato. Its walls of white, beige and brownish
shade glitters in the dark and echoes a colorful past dating back to the days when no
foreign foot yet trampled upon its land. The caves had given sanctuary to the natives when
the Spaniards tried to convert them into the Castillan Faith and has served the purpose
when the Filipino guerillas fought the invading force of the Japanese Imperial Army during
the Second World War.
C. Rio Grande de Mindanao
The second largest river in the Philippines and the longest in Mindanao crisscrossing with its tributary the city's vast area. Estimated to be 182 kilometers long and 96 meters wide. Water Sports and boat racing are the popular attractions of the river, usually held to coincide with the Shariff Kabunsuan Festival and the Feast of Peñafrancia.
D. Timako Hill
The hill overlooks the Illana Bay and graced by the beach resorts of Linik, Kushiong and Tapian Point. A good resort considering its blue water and sandy white beach. Ideal for camping, boating, swimming and fishing.
B. Our Lady of Lourdes Grotto
A replica of Our Lady of Lourdes Grotto in France. The compound is equipped with ideal retreat house for recollection and seminars, a mini zoo and a children's park.
C. Autonomous Region in Muslim Mindanao (ARMM) Compound
Houses the Office of ARMM Regional Governor, Regional Legislative Assembly, Shariff Kabunsuan Cultural Center, the Regional Museum and almost all Regional Offices of Region XII and ARMM. The buildings in the compound showcase unique blend of modern and Muslim architecture.
D. Herbal Processing Plant
The first Herbal Processing Plant in the Philippines, inaugurated by former President Corazon C. Aquino in 1988. It processes herbal medicines like lagundi, sambong and tsaang gubat.


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- 2 / 2 The Cat Empire - Brighter Than Gold
The Cat Empire Announce World Tour
Posted on 22 Apr 2013
Multi-platinum selling The Cat Empire have today announced their biggest world tour to date. The tour will include the UK and Europe, USA, Canada, South America and Australia.
Melbourne's genre-busting group will play almost 70 shows across three continents in celebration of the release of their fifth studio album 'Steal The Light'.
The Cat Empire have toured all over the world, performing almost 950 shows including headlining some of the worlds most prestigious festivals, and playing on entertainment shows such as Letterman and Leno. Over the course of a decade, they have gained an incredible international reputation and established The Cat Empire as one of Australia's most unique musical exports.
With an outstanding new record and a live show to match, 2013 is set be another great year for The Cat Empire. Alberts writer Harry James Angus, vocalist, co-writer and trumpeter of The Cat Empire, says, "When we started out we were jazz musicians, but we wanted to play music that spoke to the whole world. I think with this record we've really come full circle, and we're really embracing that concept again."
The Steal The Light World Tour will get underway in North America in July, with the band headlining Canadian festivals and hitting the hot spots of the USA.
South America is in the bands sights this year for the first time following a huge online drive from fans in Rio, Sao Paulo and Buenes Aires who took it upon themselves to lobby the band for shows via pledge site Queremos. With over 500 fans pledging their attendance in less then one week, The Cat Empire re-routed their tour to respond to the demand, adding more cities each week as South Americans catch on and join the lobby group.
The band will be back in Australia in September to do a run through their favourite theatres, with The Empire Horns ( Alberts writer Roscoe James Irwin) and new addition to the entertainment troupe - Lenny and The Ela Dancers – 4 amazing dancers to get the rooms moving.
The Cat Empire will then head to Europe where they will be stepping up in venue sizes. London's Brixton Academy is set to sell out, and the band move on from multiple nights in Amsterdam's Paradiso to the famed Heineken Music Hall. The boys will finally get back to Barcelona for the first time since 2004.
The band's first single from the new album, "Brighter Than Gold," is already a crowd favourite, with high rotation on Triple J in Australia, "Mega Hit" status on 3FM in the Netherlands, heat building on it at radio in Germany and Belgium, and dipping into the Dutch iTunes chart in the top #20, peaking at #17 just two weeks after release.
"Brighter Than Gold" hints at great things to come on the new album, "Steal The Light", the bands first worldwide independent release. It arrives ten years after they crashed onto the recording scene with a self-titled debut album that was gold in Australia within weeks, platinum two months later, and double platinum a year on from that. Followed by a No. 1 chart entry for the sophomore album Two Shoes in 2005, and 2 more award winning albums after that, there is every indication that THE CAT EMPIRE have no intention of slowing down.
"In many ways this record is a return to our original aesthetic, a very simple thing; that the music is for dancing and feeling good. The record and the shows should make people smile, make people dance. That's all we want," muses Angus.
The Steal the Light World Tour goes on sale April 26. Dancing shoes essential.
The Cat Empire - STEAL THE WORLD TOUR 2013
Thurs 27 WASHINGTON DC – FILLMORE
Fri 28 PHILADELPHIA – WORLD LIVE CAFÉ
Sat 29 NEW YORK – BEST BUY THEATER
Sun 30 BOSTON – HOUSE OF BLUES
Thurs 4 OTTAWA – BLUESFEST
Fri 5 MONTREAL INTERNATIONAL FESITIVAL – THE METROPOLIS
Sun 7 TORONTO – GARRISON COMMON AT FORT YORK
Tues 9 CLEVELAND – BEACHLAND BALLROOM & TAVERN
Wed 10 CHICAGO – HOUSE OF BLUES
Thur 11 MINNEAPOLIS – CEDAR CULTURE CENTER
Fri 12 WINNIPEG FOLK FESTIVAL
Sat 13 WINNIPEG FOLK FESTIVAL
15/16/17 SAN FRAN, LA, SAN DIEGO to be confirmed
Fri 19 VICTORIA – PHILLIP'S BREWERY (Outdoors)
Sat 20 VANCOUVER – FOLK FESTIVAL
Sun 21 VANCOUVER – FOLK FESTIVAL
Tues 23 SEATTLE – NEUMOS
Wed 24 PORTLAND – DOUG FIR LOUNGE
Thurs 24 NELSON – THE HUME HOTEL
Fri 26 CALGARY – FOLK FESTIVAL
Sat 27 CALGARY – FOLK FESTIVAL
Sun 28 BAIE-SANT PAUL – LE FESTIF!
SOUTH AMERICA via pledge site Queremos
Thurs 1 FORTALEZA to be confirmed
Fri 2 RIO – CIRCO VOADOR
Sat 3 SAO PAULO - JOIA
Mon 5 BUENOS AIRES to be confirmed
Fri 6 ADELAIDE – THEBARTON pre-sale 24/25 april
Sat 7 PERTH – RED HILL pre-sale 24/25 april
Sun 8 DARWIN DISCOVERY
Thurs 12 MELBOURNE – FORUM pre-sale 24/25 april
Fri 13 MELBOURNE – FORUM pre-sale 24/25 april
Thurs 19 CANBERRA – UC REFECTORY pre-sale 24/25 april
Fri 20 SYDNEY – ENMORE pre-sale 24/25 april
Sat 21 SYDNEY – ENMORE pre-sale 24/25 april
Fri 27 BRISBANE – TIVOLI pre-sale 24/25 april
Sat 28 BRISBANE – TIVOLI pre-sale 24/25 april
4 - 6 Northern Qld to be confirmed
Thurs 17 UK, BIRMINGHAM – HMV INSTITUTE
Fri 18 UK, BOURNEMOUTH – O2 ACADEMY
Sun 20 UK, LONDON – BRIXTON ACADEMY
Tues 22 UK, BRISTOL – O2 ACADEMY
Wed 23 UK, OXFORD – O2 ACADEMY
Thurs 24 UK, MANCHESTER – RITZ
Sat 26 UK, GLASGOW – ABC
Sun 27 UK, SHEFFIELD – LEADMILL
Mon 28 UK, NORWICH – WATERFRONT
Wed 30 BELGIUM, BRUSSELS – AB
Sat 2 GERMANY, MUNICH – TOLHALLE
Sun 3 GERMANY, OFFENBACH – CAPITOL
Mon 4 GERMANY, BERLIN – COLUMBIAHALLE
Tues 5 GERMANY, HAMBURG – GROSSE FREIHEIT
Wed 6 GERMANY, COLOGNE – E-WERK
Fri 8 FRANCE, MARSEILLE – LE MOULIN
Sat 9 SPAIN, BARCELONA – APOLO – 2P
Sun 10 FRANCE, TOULOUSE – LE BIKINI
Mon 11 FRANCE, LYON – LE TRANSBORDEUR
Wed 13 HOLLAND, AMSTERDAM – HENEIKEN MUSIC HALL
Sat 16 FRANCE, PARIS – LE TRIANON
With more shows still to be added….


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This year's Champions League is headed into its latter stages, with Borussia Dortmund, Barcelona, Bayern Munich and Real Madrid the four sides left of the original 32. For the first time in what seems like an eternity, there is no English representation in the semi-final. The semi-finals will be held in Germany and Spain, with envious glances from London, Manchester and Paris in particular.
Though the lack of English representation is disappointing, it opens up an opportunity for fans of English football to support a foreign club with no feeling of guilt. Previously, many fans felt obliged to support a rival club on the mere pretence that they were English, and not supporting them would be to disrespect English football.
This article will attempt to rank the two German and Spanish clubs from a neutral fan's point of view.


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Volcafe - Our Coffee Business
Following the acquisition of the Volcafe group of companies in 2004, we are one of the leading coffee merchants in the world. We supply mainstream Arabica and Robusta coffees, as well as source and supply speciality gourmet coffees from a number of origins.
The head office of our coffee business is in Winterthur, Switzerland. We have operations in 14 of the top 20 coffee origins worldwide and sales offices in all the major consuming regions.
Volcafe Specialty Coffee is a subsidiary of Volcafe based in the USA. Volcafe Specialty is dedicated to sourcing and promoting the production of high quality and single origin coffees from smallholders, cooperatives and estates worldwide.


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County projects may be broadcast
October 16, 2013
To showcase Lycoming County's current and future developments, the county commissioners are expected to approve an agreement not to exceed $20,000 with Pioneer Sports Production Thursday....
I guess i dont understand why were making a video, is this guy related to somebody, is that why were paying him 20k? Why do we need this video?
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This $20,000 of taxpayer money (no matter where they say it is coming from) would be much better utilized in infrastrucure imporovements vs. televising to county residents that won't watch in anyway. If they care they should come to your public meetings.
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Sarnen boasts a wide selection of accommodation options. Its range of simple inns and guest houses, comfortable hotels, private rooms and holiday apartments with lake and mountain views, and the campground on the shores of the lake itself, will entice you to prolong your stay. For seminars, group outings or school trips, Sarnen offers the ideal infrastructure and the perfect supporting programme.
Marvel at the scenery as you enjoy a leisurely cruise, take an exhilarating bike trip or go on a variety-filled hike. Sarnen's unique location also enables you to easily and quickly reach all the attractions of Central Switzerland.
Wintertime sees Sarnen transformed into a magical winter wonderland. The Langis, the sunny area above Sarnen, is an insider tip for cross-country skiers and winter hikers. Experience the magic of winter as you cross-country ski on 40 kilometres of groomed trails, go on a snowshoe tour or take a walk through the snowy pine forests.
The winter sports areas of Melchsee-Frutt, Mörlialp, the Panoramawelt Lungern, Engelberg and Meiringen-Hasliberg are less than an hour's drive away. While Sarnen itself is not right in a winter sports area, it is the perfect base from which to explore them all.


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Despite being viewed as strong and stable, the Canadian banking sector can still feel some short-term pain.
In this video, Motley Fool banking analysts Matt Koppenheffer and David Hanson discuss three Canadian banks that have been grabbing some recent headlines.
Solid companies selling at depressed prices have consistently helped generations of the world's most successful investors preserve capital, minimize risk, and achieve long-term, market-trampling returns. For one such company, read our free report: "The One REMARKABLE Stock to Own Now." Just click here to get started.


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Every December, people assemble from throughout the region and the state to re-enact and commemorate the military campaign and pivotal battles that many historians say turned the tide of the Revolutionary War.
Each spring, leaders of organizations whose funding has been slashed gather to ask state government officials to reconsider those cuts.
The Old Barracks Museum figures in both rituals.
Situated on the edge of a cobblestone street and surrounded by trees, it's easy to imagine it as the New Barracks, as it might have been called when it was built more than 250 years ago. As history has accumulated, the efforts of various groups over the years have preserved the barracks into its old age.
Constructed as a post during the French and Indian War in the mid-1700s, it survived the brief and famous occupation by British and Hessian troops during the Revolutionary War.
Through the 19th century, the stalwart barracks served as private homes, a school and a residence for widows and elderly women. The historic buildings were divided, decorated and deprived of their historic meaning until the Daughters of the American Revolution took matters into their hands in the early 20th century. Forming the Old Barracks Association, they determined to buy the remaining building and restore it as a living history museum long before anyone had coined that term.
Generations of schoolchildren and visitors to the capital have learned about 18th century military life with a tour of the facility and its museum. History becomes not a dusty, theoretical subject, but a vibrant, visceral story.
Now is not the time to desert that storyteller.
Yet that seems to be the fate awaiting the iconic building.
Richard Patterson, executive director of the Old Barracks Museum, appeared before the state Senate Budget Committee last week to seek restoration of the funds Gov. Chris Christie's proposed budget has eradicated. The museum was stripped of its $375,000 in state funding in Gov. Christie's budget for this year, but lawmakers found the necessary funding.
The governor eliminated the funding again for this budget; without it, the museum will have to declare bankruptcy because it does not have the funds to close and pay unemployment.
That would be a true shame, and much more than the loss of a quaint old building. It's a link to Trenton's past and the enormous role the city and the region played in the formation of the United States. Rather than force its closure, the state should capitalize on the singular and significant history of installations such as the Old Barracks.
Like the buried chapters unearthed at the Petty's Run archaeological site, the story of the Old Barracks is the grounding of the future. It's a foundation that ought to be treasured and maintained. We fear the consequences of the state turning its back on the museum.
We dread the day that it might become Ye Olde Barracks Sports Bar.
Follow the Times of Trenton on Twitter.


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By SACHIN KUMAR
Doha: Automobile loans taken by Qataris grew 32 percent to QR3.6m in December 2013 from QR2.7m in January 2013, which was double the growth seen in automobile loans taken by expatriates. Vehicle loans taken by expatriates rose 16.5 percent to QR1.9m in December from QR1.7m in January, according to Qatar Central Bank data.
The trend of citizens taking more vehicle loans continues in the current year. Automobile loans to Qataris in January 2014 went up to QR3.8m, while for expatriates the figure stood at QR2m. However, there was a slight slowdown in February with auto loans to Qataris remaining at QR3.8m while loans to expatriates stood at QR1.9m.
Every month more than 8,000 vehicles hit the roads in Qatar, of which more than 5,000 are private vehicles.
According to the Ministry of Development Planning and Statistics, 8,123 vehicles were registered with the Traffic Department in February, of which 5,250 were private vehicles, 1,980 vehicles were for private transportation, and 188 were private motorcycles. In January, 8,121 vehicles were registered with the Traffic Department, of which 5,318 were private vehicles, 1,811 were vehicles for private transportation, and 185 were private motorcycles.
Banks charge three to four percent per annum for car loans, which encourages customers to buy vehicles on loan.
In personal loans, non-Qataris have outpaced Qataris in growth. According to QCB data, personal loans taken by expatriates grew 36 percent to QR14.36m in December 2013 from QR10.6m in January 2013, whereas loans taken by Qataris rose nine percent to QR26.82m in December from QR24.5m in January.


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Your gift to the Vasculitis Foundation helps us fulfill our mission of supporting and empowering our community through our awareness, education, support and research programs.
You may designate your gift in honor or memory of someone special. The Vasculitis Foundation also accepts donations for birthdays, weddings, anniversaries, fundraising events and other special occasions. The Vasculitis Foundation will send a thank you note to the donor and an acknowledgement to the honoree or his / her family.
Thank you for your support.The Vasculitis Foundation is a registered 501 (c) (3) non-profit organization. All contributions are 100% tax-deductible.
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Top Definition
A Japanese fast food chain that has been imported to the Unites States (California). The food served here is not authentic. The meat and rice bowls comprise of thin portions of meat and plenty of rice.
Meet me at the Yoshinoya so we can chow down on some rice.
بواسطة luis18 أغسطس/آب 23, 2008
Trending Now
Can you define these popular missing words?
best chinese restaraunt.
cant go wrong with the teriyaki in yoshinoya...
بواسطة luis فبراير/شباط 6, 2004


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The Today show will take celebrity health-care advocacy to a new arena tomorrow when its popular host, Katie Couric, invites viewers to share her colonoscopy, a screening test for cancer.
It's a procedure few people want to talk about, much less undergo - and that, said Jeff Zucker, executive producer of the NBC morning show, is precisely the point.
"We're showing it to demonstrate that there's no reason people should be scared," Zucker said. "We try to do it with tremendous sensitivity. We don't show a lot of her colon. We're not going to gross anybody out."


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Maeve Hammond
Age 9, Michigan
Favorite Subject: Language Arts
Book: Dragon Rider by Cornelia Funke
Music: country
Extracurricular Activities: soccer, dance, and Ski Club
Hobbies: writing, reading, and bike riding
Maeve loves writing and hopes one day to be a journalist.
"I hope to learn in this experience what it really takes to succeed in journalism today," she said.
Maeve works really hard in school to be a good writer. She also created her own magazine outside of school.
In her free time, Maeve likes to ride her bike and write poems and short stories.
Maeve is in the fourth grade. She has two sisters and one brother.
History and Health in Michigan
The Great Lake State puts health first, especially in Battle Creek
By Maeve Hammond
Scholastic Kids Press Corps
Battle Creek, Michigan, is awesome because each season there is so much to do! Michigan has great weather in its upper and lower peninsulas. Michigan is the "Water Winter Wonderland" and the "Great Lake State." The name Michigan is Native American ("Michi-gama") meaning large lake. Michigan touches four of the five Great Lakes.
Battle Creek is special in the Great Lake State because it has been known as THE Health City (the San), THE Home for soldiers (the Percy Jones Hospital), and THE Cereal City (Kellogg's, Post, and Ralston's). People came to Battle Creek to "get healthy."
Battle Creek is also known for the special Michiganders who have lived here. (Maybe some day people will think of Battle Creek when they hear my name!) Some important people from Battle Creek are Erastus Hussey, Sojourner Truth, Ellen White, and Dr. John Harvey Kellogg—just to name a few.
Erastus Hussey made Battle Creek a "station" on the Underground Railroad. Sojourner Truth lived in Battle Creek after becoming a freed slave and then became a spokesperson for human rights. She is buried in our Oak Hill Cemetery.
Ellen White turned a small group of Seventh-day Adventists (SDA) into a large group with 200,000 members. Under her leadership, the SDA church grew from next to nothing in Battle Creek to one of the largest publishing houses in the world.
Dr. John Harvey Kellogg also made Battle Creek famous. His story is told in the movie "The Road to Wellville" about a Battle Creek Sanitarium Director. The "San" was famous for its nutritional treatments. It treated its poor and rich clients like kings, movie stars, and presidents. This success went from Battle Creek to your breakfast table as cereal!
Battle Creek is also special because it has looked after the Nation's wounded soldiers. After World War II Percy Jones had the biggest health care center for amputations, neurosurgery, and artificial eyes. Battle Creek was the first city to put in sidewalk wheelchair ramps in the U.S.! That makes me really proud to be in Battle Creek.
Today we still have the Veterans' Hospital taking care of those who fought for our country. Citizens of Battle Creek have a bright future, and a history of fighting for people's rights, and making life better for everyone.


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OBESITY-RELATED ILLNESSES are threatening the health of US children. It is now time to build a cohesive national policy that combats obesity in children and adolescents. In this article, we suggest principles for policy development based on barriers, precedents, knowledge available, and knowledge gaps.
Evidence repeatedly demonstrates the rising prevalence of obesity and obesity-related illnesses, with 30% of US children having a body mass index higher than the 85th percentile for their age.1- 5 Although comprehensive data are needed on the long-term effects of pediatric obesity on health, it is known that more than two thirds of obese children 10 years and older will become obese adults6 and that obesity in young adults causes on average 5 to 20 years of life lost.7 Obesity is also associated with a 36% increase in inpatient and outpatient spending and a 77% increase in medication use compared with expenditures for healthy-weight individuals.8 Some people have expressed reluctance to involve government or professional bodies in personal affairs pertaining to weight control.9 However, several facts combine to make pediatric obesity a public health priority that requires a concerted societal response. These include the magnitude of the problem, the fact that children cannot be fully responsible for their own health choices, and the recognition that obesity reflects a combination of genetic, behavioral, and environmental influences—together with society's special obligation to protect and care for children.
Thank you for submitting a comment on this article. It will be reviewed by JAMA Pediatrics editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
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I study how intricate forms in the natural world are
the organic result of simple physical law. Currently,
I am interested in the dynamics displayed by bacterial
communities in nutrient gradients. We have recently
developed a physical understanding of how certain
bacterial fronts spontaneously form bacterial waves
that pull nutrients to cells. My thesis considered
two examples of growth in a diffusion field: a network
of streams that grows by attracting groundwater and a
microbial community that grows by attracting
nutrients. In both cases, we combine mathematical
models with field observations and laboratory
experiments to predict the shape and scale of growing
features. Our results have provided insight into
diverse phenomena: from Martian valleys to
billion-year-old fossils.
Albert Libchaber
Daniel Rothman
Tanja Bosak
Olivier Devauchelle
Daniel Abrams
| Special thanks to
for designing this website.


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Barbara June Holland, 80, of Amarillo died Sunday, June 13, 2010.
Services will be at 10 a.m. Wednesday in Memorial Park Funeral Home Chapel of Memories, 6969 E. Interstate 40, with the Rev. Bradley Speer, pastor of Oasis Southwest Baptist Church, officiating. Burial will be in Memorial Park Cemetery.
Barbara was born Aug. 15, 1929, in Amarillo. She later married Garland Lonzo Holland Sr. on Nov. 16, 1945, in Amarillo. She was a dedicated and loving mother and grandmother. She loved to crochet and make clothing for her children, in which she took much pride and enjoyment.
She was preceded in death by her husband, Garland, in 1974.
Survivors include five daughters, Kittye Helfenbein, Phyllis Bell and Yvette Rains, all of Amarillo, Charlotte Holland of Washington state and Cherrie Horner of Panhandle; three sons, Garland Holland Jr. of Amarillo, Gregory Holland of Missouri and Carl Holland of West Virginia; 20 grandchildren; 32 great-grandchildren; and numerous nieces and nephews.
Leave online condolences at www.mememorialparkamarillo.com.
Amarillo Globe-News, June 15, 2010
© 2016. All Rights Reserved. | Contact Us


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Blogs Cliopatria When Was Genocide First Defined?May 21, 2004 8:54 pm
When Was Genocide First Defined?
Ian Johnston, in the scotsman.com (May 21, 2004):
THE term "genocide" was first used in an attempt to describe the organised extermination of six million Jews, gypsies and others by Nazi Germany.
In 1948, the United Nations adopted a formal convention against genocide - a word that combines the Greek genos, meaning tribe or race, with the Latin word for killing, cide - and defined it as an act that was designed to destroy or partially destroy a national, ethnic, racial or religious group.
This usually refers to killing people, but causing serious physical or mental harm, deliberately reducing conditions of life - such as cutting off food supplies - or stopping people having children or forcibly removing children from a group are also classed as genocide.
One of the worst recent cases took place in Rwanda in 1994, when an estimated million people were murdered as the extremist Hutu government tried to wipe out the rival Tutsi tribe as well as moderate Hutus during a 100-day massacre.
In the neighbouring Democratic Republic of Congo, six national armies, two rebel groups and numerous militias have been involved in a war that has resulted in the deaths of an estimated 2.5 million people, including many civilians, over six years.
The little-reported conflict, marked by sporadic outbreaks of fighting followed by ceasefires, has been called Africas own world war.
The outbreak of fighting following the collapse of Yugoslavia led to the worst slaughter in Europe since the Second World War. Some 100,000 civilians were killed and two million made homeless in Bosnia and Croatia in the 1990s.
The former Yugoslav president, Slobodan Milosevic, is being tried on charges of genocide and war crimes by Serb forces in those two now-independent countries, and Kosovo.
The massacre of 7,000 Muslim men and boys by Bosnian Serb forces when they over-ran the UN "safe area" of Srebrenica in July 1995 was the biggest single atrocity.
China has been accused of genocide in Tibet after its 1950 invasion when 1.2 million people - a fifth of the population - were killed.
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Posted May 4th, 2008 by Vicky+ in Chef, NewsComment (0)
Celebrity chef Paul Prudhomme was getting ready to cook at the PGA tour event held at a golf course when he was accidentally shot.
The .22-calibre bullet grazed his sleeve, before falling to the ground. He wasn't injured, but he got a hole in his coat. A couple of inches more and he could have been seriously hurt.
A true professional, Prudhomme continued cooking.
Posted May 1st, 2008 by Vicky+ in Chef, Television, Trivia
Looks like someone's really mad at celebrity chefs, from the looks of this video. You need a couple of anger management courses there. Or at least, a big slice of pie.
Comment (0)


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BRIEF-Goldman Sachs BDC prices $100 mln offering of convertible notes
* Goldman sachs bdc, inc. Prices $100 million offering of unsecured convertible notes
DUBLIN Nov 16 Ireland has turned the tale of its most reviled bank into an "Avenue Q"-style musical comedy because - as the show's tagline goes - "it only takes a few muppets to screw an entire country."
Featuring puppets of Irish Prime Ministers past and present and even one of German Chancellor Angel Merkel, "Anglo: The Musical" opened in Dublin this week, charting the rise and fall of the bank that has come to personify Ireland's boom and bust.
The bank is Anglo Irish Bank, the scandal-hit, failed lender that led a reckless credit splurge in the heady "Celtic Tiger" years and cost taxpayers a whopping 30 billion euros ($38.38 billion) during a capitulation that saw the country accept a humiliating financial bail out.
"When we had the idea about two years ago, we thought we've got to put this on in eight months or the Anglo story will be dead, but we were wrong about that," said Darren Smith, one of the show's producers and a co-author of the original story.
"Anglo has become part of the vernacular. They were the poster boys for the boom so appropriately they are the poster boys for the bust. The case could be made that we've made Celtic Tiger the musical but once you call it Anglo, things get noisy."
Smith's biting satire, brought to the stage by well-known Irish author Paul Howard, tells the story of a poor, young couple living on the fictional 'Inis Dull' (Dull Island), one of whom has their head turned when Anglo opens a local branch.
Urged to get on the property ladder before it's too late, they borrow 890 million euros to build a 40-storey apartment and retail unit beside their modest home, an exaggerated example of those who were gifted credit but now struggle pay mortgages.
The narrative switches between the west coast and Dublin where at Anglo's headquarters, the bank's chief executive approves multi-million euro loans while playing golf in his underpants.
"Put A Zero On The End, He's A Friend," the bankers sing.
An audience awaiting a sixth austerity budget in five years, partly as a result of the actions of banks like Anglo, know how it all ends, but judging from this week's opening performances, they are at least able to laugh about it.
"This whole thing of laughter is the best medicine... medicine is the best medicine but laughter can be a great release valve on the stresses of the situation," said Smith.
"It's not for us to tell people 'I know you've lost your house but really isn't it hysterical'. But for a lot of people, this a way of getting a little bit of relief."
* Goldman sachs bdc, inc. Prices $100 million offering of unsecured convertible notes
* Hopes dim for latest talks to reach oil production compromise
LIMA, Sept 27 Three companies have sued Peru at the World Bank's arbitration board for alleged breach of contract after the previous government did not make land available in a timely way, the transport minister said on Tuesday.


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Religion, Ethnicity, and Community Mental Health: Service Provision and Identity Politics in an Unplanned Egyptian Community
Elizabeth M. Coker
affiliation not provided to SSRN
Community Development Journal, Vol. 43, Issue 1, pp. 79-92, 2008
Successful community mental health programs depend on strong social networks and cooperation between resource providers, both of which are complex products of local culture and history. The results of an ethnographic study of an unplanned urban neighborhood in Cairo, Egypt emphasize the importance of the political, social and historical context to community service development. The informal nature of the community, characterized by migrants from different ethnic and religious groups and a relative lack of governmental services, produced a culture of service provision that indirectly serves to accentuate religious and ethnic tensions. The findings are relevant not only to the developing world, but also to community program development in large, multicultural urban centers anywhere.
Date posted: June 30, 2008
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Paula Deen is fighting back against a lawsuit filed on Monday by a former employee of a restaurant she co-owns with her brother.
Lisa Jackson – who worked for five years as the general manager of Uncle Bubba's Seafood and Oyster House in Savannah, Ga. – claims in legal papers that she was regularly subjected to sexual harassment by Deen's brother Earl W. "Bubba" Hiers and that Deen, 66, made racist comments.
In a statement released Tuesday, Deen's attorneys at law firm Oliver Maner refute the allegations made in Jackson's filing, saying in a statement, "We investigated those claims and attempted unsuccessfully to address those claims with her."
Calling Jackson's assertions "baseless, inflammatory allegations," the statement goes on to say that the lawsuit is an attempt to "ruin Paula Deen's reputation."
The statement continues, "We look forward to our day in court."
Paula Deen's Lawyers Hit Back at Harassment Lawsuit
Vallery Jean/WireImage


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Baby Name Poll Results
Hannah Margaret vs. Olivia Margaret vs. Clara Margaret
Down to our final 3. Four year old twin brothers are Jacob Nicholas and Benjamin Cooper. Thank you! Leah, Dylan, Jacob and Benjamin
The Top Baby Name is...
|Hannah margaret
|45% (18 votes)
|Olivia margaret
|28% (11 votes)
|Clara margaret
|28% (11 votes)
Voted for Hannah. However you can't go wrong with any of them!
posted by guest :: 2013-12-05 18:22:53 | report
Hannah is my favorite Clara I don't like and olivia is WAY to popular Hannah gets my vote!!
posted by guest :: 2013-12-05 18:24:05 | report
Clara is beautiful! You cant go wrong!!
posted by guest :: 2013-12-05 18:41:49 | report
Clara. Hannah and Olivia are way too popular
posted by guest :: 2013-12-05 18:51:59 | report
posted by guest :: 2013-12-05 18:59:54 | report
Hannah's really not that popular depending on where you live,
posted by guest :: 2013-12-05 19:22:38 | report
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MOBILE, Alabama -- Three weeks since being relocated, students at the tornado-struck Murphy High said they're adjusting to attending classes at a middle school across town, mostly in portables.
The students practiced a tornado drill Tuesday, during which they walked from the nearly 60 portable classrooms they are occupying behind Clark-Shaw magnet school in west Mobile into the gymnasium.
And churches, the Drug Education Council and other groups have donated ponchos to help the students move between classes on rainy days such as today.
"We've finally worked out most of the glitches, and the students seem to be happy," Principal William Smith said one recent day, as he directed the mammoth operation of loading all 2,250 students onto 54 buses after school.
The students are expected to finish out this school year at Clark-Shaw, and to return to Murphy - damaged badly in a Christmas Day tornado - in August.
The students are not allowed to drive to Clark-Shaw, located in the Alpine Hills neighborhood, or be dropped off by their parents. Instead, they are being shuttled to and from Murphy, a distance of about 8 miles.
Several students who have been interviewed by the Press-Register and al.com said they're not to keen on having to take the buses. It makes for a long day, as they leave Murphy at 7:30 a.m., and board the buses at 3:30 p.m. to head back.
During a recent visit to the school, students were grouping together and talking to their friends as they made their way between classes. Members of the school's ROTC were practicing on the practice football field. The band crammed into a double-wide portable for practice.
"The teachers are doing an outstanding job," Smith said. "We're asking them to do things they've never done before, like bus duty. But we've all come together."
The Murphy students have the portables as well as a two-story building known as the "back building." They are separated from the 700 Clark-Shaw middle schoolers by a fence. Their arrival and dismissal times are an hour apart, so there's no mingling, and Murphy's students don't start their lunch waves until Clark-Shaw is done.
"It's been kind of different," said sophomore Ferdinand Amanor. "I'm not used to things being so strict. But I don't think it's so bad anymore."
Amanor said the buses are crowded and that it's difficult to make it all the way from one of his classes upstairs in the back building to one of the portables on the eastern edge of campus.
"I miss Murphy, definitely," Amanor said, "the freedom that we had."
Added Shane Ellison, a senior, "It was tragic to see our school completely devastated like that, but I'm thankful for Clark-Shaw's hospitality. I'm glad we were given a second chance."
Ellison said he's missing out on some of the fun he would have had at Murphy, during his senior year. But officials have said they'll find a way to fit those activities in.
"It's my senior year, and my school turns up destroyed," he said. "But it's going to get rebuilt and it's going to be stronger for future students."
Meanwhile, it looks as if the insurance company is going to cover about $11 million worth of damage. School officials met with local legislators Tuesday to talk about seeking tens of millions of dollars more in state funding to renovate or restore the historic campus, which was built in the 1920s.
Rep. Randy Davis, R-Daphne, a former band director at Murphy, congratulated school system officials for getting Murphy set up at Clark-Shaw. Davis said he has invited Gov. Robert Bentley, who visited Murphy in December, to come see for himself how the two schools are operating together, but separately.


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text:
Cost of primers and powder
Ammunition, Gear, and Firearm Help
Handloading and Reloading
> Cost of primers and powder
Steve H
March 15, 2008, 08:26 PM
Does the cost of shipping hazardous materials stop you from buying primers and powder thru the internet, do you find the bottom line to be less if you buy at a local store?
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March 15, 2008, 08:29 PM
I still get primers from a guy at the gun shows around here. I would have to buy 10K instead of the 4 to 6K I usually get from him to even out and I would rather buy from him. If he has what I want as far as powder I will get it from him as well. I can get powder about the same over the internet, but have to buy at least 4 pounds to spread out the haz mat fee.
March 15, 2008, 09:23 PM
If you only need a few of something, the local store is THE way to go.
However, if you are a volume kind of person, the Internet works wonders. Example: 1lb fffg black powder locally=$17.50 (last time I bought some...last year). Just had a box of black delivered from Graffs @ $12.70 lb. Substantial savings buying in bulk online for sure.
March 15, 2008, 09:28 PM
I get mine local, the Hazmat fees are too high.
March 15, 2008, 09:39 PM
local gun shops or gun shows only.
March 15, 2008, 09:41 PM
It is more than just the Haz-Mat Fee that keeps me from buying powder and primers via the internet. Let us keep that "Shipping and Handling" charge in mind as well. I can usually find primers within $1 or so of the "net Pricing" at local outlets. Same with powder. Add $20 for Haz-Mat to the $10-15 S&H that the Internet Dealer charges and the Local Dealer's prices are very close. The way I see it is that $20 is being added to my order for no appreciable benefit to me.
Don't hesitate to buy bullets over the net though as my favorite supplier (Montana Gold) pays the shipping. Sure makes the mailman unhappy though.
March 15, 2008, 10:18 PM
Unless the price is really good and I'm ready to buy a large quantity, the HazMat shipping fee kills the benefits of online shopping. I usually find primers and powder at local gun shows for about the same price as on-line, and sales tax is way less than HazMAt and shipping costs.
Bullets I usually get on line as the gun show guys I was buying from no longer are there :(
March 15, 2008, 10:50 PM
The above pretty much covered it. Unless buying in large volume, or no local source, the shipping & Hazmat fees make it not worth buying online.
March 15, 2008, 11:20 PM
Lasy year I made a big order with Powder Valley (http://www.powdervalleyinc.com/). I don't remember exactly how much I ordered but I think it was 10,000 Primers and ~10lb/12lb of powders. With an order like that of 20 plus pieces that adds less than a Dollar to each item. The $20 hazmat fee doesn't hurt with an order of that size. That was the only time I ordered powder and primer online though. Everything after that has been local shops and shows.
March 15, 2008, 11:24 PM
I stockpile this stuff to last me into tight times like today.
Last time I purchased primers 1000 primers cost about 10 bucks.
XD-40 Shooter
March 16, 2008, 12:19 AM
Gun show's is where I buy, winchester small pistol primers are $22.95/1000 and plated 40 S&W bullets are $100/1000. I can't come close to that on the internet, especially with the hazmat on primers.
March 16, 2008, 12:25 AM
I buy both local and mail order. When I need a pound or two of powder or a one box of bullets I buy local. If I need a bunch of powder and primers I buy from Powder Valley. When I order several hundred bullets I get them from Shooters Pro Shop.
March 16, 2008, 12:37 AM
I buy local....Unfortunately I don't(the wife won't let me) shoot enough to require Hi volume buying. Trying to talk her into stockpiling bullets and brass however cuz of these prices lately
evan price
March 16, 2008, 01:52 AM
I buy online, usually from Powder Valley, $90/5K Wolf primers is the best deal out there today.
As far as hazmat & shipping goes, group buys, baby. Team up with the local reloaders and stock your selves up. If you get 50,000 primers in one order that's only pennies per sleeve in hazmat. Add in a few 8# kegs of powder and it's practically a nonissue.
March 16, 2008, 01:58 AM
cost of fed match primers at powder valley are around 30/k. at carters here in the Houston area they are 37/k. If you order enough of them with some powder you can easily make up the diff in haz mat cost and shipping. shipping is just like the tax anyways. the more you buy the less the cost on the shipping anyways. I just got 58lbs of primers and powder shipped to me for 19 dollars and that was with insurance. The cost of the order was 800 dollars. tax on that here would have been in excess of 64 dollars. buy getting it online and paying for the hazmat and shipping, I still saved over the tax I would have had to pay. that does not ever include the savings on the products. 8lbs of varget/benchmark from powder valley was 116.75. The same from Carters which is one of the only places here in Houston that I know to get it from was 21/lb. they did not sell it in 8lb jugs. When I asked them to order it for me it was 150 dollars for the 8lb jug plus they wanted me to pay the haz mat on it also. That is a rediculous price and I will not buy much from them in the future. RG
March 16, 2008, 03:27 AM
I use to buy local until Varget ran me $23 and Accurate Arms products were over $20 per pound :rolleyes:
Now I save my pennies and order from Powder Valley. It really doesn't take much of an order to get my savings back. I also get the benefit of a great selection and they almost always have my primers. They are a first class operation to say the least. Great Service & Great Prices.
If I need a pistol powder I will buy a pound locally if really needed. However, bulk loading of rifle calibers mandates buying the 8 pounders to save money. Those are not really available near me. Factor in a 20 mile drive each way and the cost for gas must also be considered.
All this talk of reloading supplies makes me realize I need to take an inventory.
March 16, 2008, 07:50 AM
The hazmat fee is $20. I find the "locals" charge somewhere between $8 and $10 more than on-line retailers for a pound of powder. The gun shows are $5 to $6 more. There is also a price differential in primers, but it doesn't seem to be as grea maybe $4 to $5 per thousand. The math is simple. I try to keep adequate stocks of the components I use on hand so that I won't run out and have to pay for the local merchant's next vacation. I also have several buddies who reload and we all have been known to borrow a pound of this or some quantity of primers. Typically, any combination of 4 items, be it powder or a brick of 1000 primers covers the Hazmat fee. Anything above 4 = savings.
Rollis R. Karvellis
March 16, 2008, 08:12 AM
The locale guy here is a good freind, so I try to send as much bussness to as I can, but when a good deal comes up I, jump.
XD-40 Shooter
March 16, 2008, 03:12 PM
I buy 8lb keg's of Unique for $104 at Sportsmans Warehouse, out the door.
March 16, 2008, 03:56 PM
Its about 108 out the door at the SW in Austin. I buy here because the SW sells winchester primers for about 25 per k and mag tech for about 20. Their 1lb for alliant pistols powders in about 16 plus tax. Their close enough to powder valley and such I would have to buy a whole lot to off set the price. I am going to have to order some black powder sometime soon. I will have to see if there is anyone is Austin using it and get together on a group buy. Either that or I will just be sitting on 25 lbs of black powder.
March 16, 2008, 06:10 PM
I buy powder and primers on line. It is a lot cheaper for me that way. Primers local for me are in the high twenties per thousand and after hazmat and shipping I can get them for $18 to $19 per thousand. Same with powder, when it's all done it cost me around $12 per pound.
Well Regulated
March 16, 2008, 08:49 PM
It all depends on where you live in relation to a retail store. The closest retail store to me would cost about $20+ in gas at today's prices so, there is no real savings in driving there.
evan price
March 16, 2008, 09:07 PM
Here in Central Ohio I have seen primers up in the $36/thousand range and powder is up in the $24/lb range for the most common stuff like W231 or 4895. There are still shops selling primers for $26/k but you have to look and see what little they have, usually not much inventory.
March 16, 2008, 10:28 PM
I am surprised that no one has mentioned not having to pay sales tax if you order online. Where I live buying local can't even come close to the prices I get online. My local dealer wants $141/8lbs Varget. Powder Valley wants $116. Just buying that one item alone more than covers the cost of the hazmat fee. Anything else you buy is just icing on the cake. I maxed out the 48lb limit on hazmat on my last PV order. Probably saved over $400 compared to local.
March 17, 2008, 12:33 AM
As a Kansas resident, I do not "escape" the state sales tax by buying from Powder Valley. (I am envious of you folks who can order from out of state.)
I have bought small quantities of powder and primers from my "local" (35 mile round trip) gun shop, but found Graf & Sons prices to be substantially lower. Their S/H fee is a flat $4.50, regardless of how much or how little you are ordering. If I order several pounds of powder and/or several thousand primers, even with the $20 HazMat fee I come out ahead compared to buying locally.
March 17, 2008, 12:46 AM
I buy most of my powder and primers from Powder Valley, but I also buy from the local gun shop. The savings on one keg of powder is enough to break even on the hazmat, then I save money on the rest of the order.
But if I just need 1000 primers (or 100) or want to try a pound of a new powder, I drive over to Dale's Gun Shop.
March 17, 2008, 07:35 AM
I try and buy from my local dealer unless he happens to be way off in price from the web dealers. I'd like him to stay in business for when I need something and don't want to wait for it to come by UPS.
March 17, 2008, 04:23 PM
I used to buy a pound or two from my local shop but when I had some loads worked out and wanted several pounds of the same lot powder (2400, H4198, Unique) dude offered to order me the kegs and charge me a Haz-Mat. Wouldn't even check for same lot 1lb. containers in their stock for me. I didn't feel like begging them to take my money so now me & two buddies go in on a big Powder Valley buy a time or two a year.
March 17, 2008, 05:37 PM
Usually order gun powder shipped in. Generally 32 lb order. Primers, best prices have been at gun shows.
March 18, 2008, 08:49 AM
I figured that to get past the $20 hazmat fee and the $10 s&h of powder valley, you need to order about $140 of primers/powder to make it worth while. Last time I figured it, I bought 5 lbs of powder and 3000 primers. It was $170 from powdervalley (with hazmat/shipping/handling) vs. $200 (with tax) at my local store.
March 18, 2008, 05:45 PM
I just ordered 25k Wolf Primers and 2 8# jugs of Ramshot Xterminator from Wideners today. Price came to $687 after shipping and hazmat. That puts the primers at about $95 per 5k and the powder at $107 per 8#. I also ordered 4 8# jugs of 844 from Pat's today. Should be around $410 after shipping. He pays the hazmat if you buy enough jugs.
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Rain returned to Western Massachusetts this evening, with some scattered showers still working their way through the region as of 10 p.m. Most of this rain is rather light, and will be moving out of the area shortly after midnight. Skies clear out by tomorrow morning.
High temperatures today reached the upper-60s despite the cloud cover. Mostly sunny skies will return tomorrow, and help push our highs into the lower-70s in Springfield.
A warm front will start moving through the Northeast for the beginning of next week. Sunday and Monday will feature a mix of clouds and sun (Monday is expected to be the sunnier of the two) with highs still reaching the low to mid-70s.
Showers and thunderstorms come back to Western Massachusetts for Tuesday. Some of the rain will be heavy at times, especially late Tuesday afternoon. Temperatures return to the 50s for the second-half of the week.
Tonight: Scattered showers before 2 a.m., clearing skies late, low 39.
Saturday: Mostly sunny, high 71.
Sunday: Partly sunny, breezy, high 71.
Monday: Mostly sunny, breezy, high 74.


text:
In order to capture contested elections across the Southeast, particularly Deep South states like Alabama and Mississippi, the Democratic party needs to lure voters who have not historically gone to the polls, party leaders said at a Southern caucus meeting Friday in Mobile.
Pointing to reports that show Democratic presumptive nominee Barack Obama's appeal among
They called it the "down ballot effect."
"The turnout in most of your states with the African-American voter is going to be incredible. And that's going to get us a couple points," said campaign consultant Mike Henry, who is running the U.S. Senate campaign in Virginia for that state's former Gov. Mark R. Warner.
Other party leaders agreed they needed to attract minority voters.
"The issue of race is one that, particularly here in the South, we ought not run from," said South Carolina State Rep. Gilda Cobb-Hunter. "It's the 800-pound gorilla in the room. And if we don't deal with it, God knows no one outside this region will. I just hope we can have a real frank discussion. We can't be scared about it."
About 40 party leaders from Virginia to Texas gathered Friday at the Riverview Plaza Hotel for the two-day caucus. The event is the last such gathering before the party's national convention, though it was not officially recognized by the Democratic National Committee.
In a roughly hour-long speech, Henry, who resigned as deputy campaign manager for Hillary Clinton in February's presidential primary races, pointed to a Virginia gubernatorial race where he organized a successful bid for Tim Kaine.
Henry said the office was captured because Kaine ran an "aggressive but not negative" race that focused on the "fast growing" suburban areas.
"They have a lot in common with the economy. And you can't lose sight of that," Henry said. "Try to focus on quality of life, and what, as Democrats, we can do for them."
In the Virginia race, Kaine even picked up points with voters who were NASCAR fans and those who supported the death penalty, Henry said.
"We can work the South back into our column by simply thinking about how we approach these fast-growing communities," he said. "It's really coming alive."
Though Northrop Grumman Corp. sponsored the event, there was only a subtle mention of the Government Accountability Office's decision to sustain a protest from rival Boeing Co. over the $40 billion Air Force tanker contract.
Gerald Johnson, with Capital Research Center, showed a poll in which 48 percent of Alabamians said they were satisfied with the condition of the state, though 74 percent of them were dissatisfied with the status of the country. He linked that to a Democratic majority in state politics.
Johnson said Mobile had a "little setback" this week, but "other than that it has been a positive two or three years" for the state.
Mobile Mayor Sam Jones, a Democrat expected to attend a lunch panel meeting today, spoke briefly at the start of the meeting and then left. He had a parade to prepare for in the evening.
"This is our celebrate Mobile weekend," Jones said.