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Antiretroviral therapy in human immunodeficiency virus (HIV)-positive patients can induce a lipodystrophy syndrome of peripheral fat wasting and central adiposity, dyslipidemia, and insulin resistance. To test whether in this syndrome insulin resistance is associated with abnormal muscle handling of fatty acids, 12 HIV-1 patients (8 females/4 males , age = 26 ± 2 yr, HIV duration = 8 ± 1 yr, body mass index = 22.0 ± 1.0 kg/m2, on protease inhibitors and nucleoside analog RT inhibitors) and 12 healthy subjects were studied. HIV-1 patients had a total body fat content (assessed by dual-energy X-ray absorptiometry) similar to that of controls (22 ± 1 vs. 23 ± 2%; P = 0.56), with a topographic fat redistribution characterized by reduced fat content in the legs (18 ± 2 vs. 32 ± 3%; P < 0.01) and increased fat content in the trunk (25 ± 2 vs. 19 ± 2%;P = 0.03). In HIV-positive patients, insulin sensitivity (assessed by QUICKI) was markedly impaired (0.341 ± 0.011 vs. 0.376 ± 0.007; P = 0.012). HIV-positive patients also had increased total plasma cholesterol (216 ± 20 vs. 174 ± 9 mg/dl; P = 0.05) and triglyceride (298 ± 96 vs. 87 ± 11 mg/dl; P = 0.03) concentrations. Muscular triglyceride content assessed by means of1H NMR spectroscopy was higher in HIV patients in soleus [92 ± 12 vs. 42 ± 5 arbitrary units (AU);P < 0.01] and tibialis anterior (26 ± 6 vs. 11 ± 3 AU; P = 0.04) muscles; in a stepwise regression analysis, it was strongly associated with QUICKI (R 2 = 0.27; P < 0.0093). Even if the basal metabolic rate (assessed by indirect calorimetry) was comparable to that of normal subjects, postabsorptive lipid oxidation was significantly impaired (0.30 ± 0.07 vs. 0.88 ± 0.09 mg · kg−1 · min−1;P < 0.01). In conclusion, lipodystrophy in HIV-1 patients in antiretroviral treatment is associated with intramuscular fat accumulation, which may mediate the development of the insulin resistance syndrome.
- human immunodeficiency virus
a syndrome characterized by lipodystrophy (peripheral lipoatrophy and truncal fat accumulation), hyperlipemia, and insulin resistance was recently described in human immunodeficiency virus (HIV)-1-infected patients (5). Although the clinical and biochemical picture is rather consistent, little is known about the pathogenic events leading to abnormal fat deposition and insulin resistance in HIV-1-infected patients. The first hypothesis, proposed by Carr et al. (6), suggested a major role of protease inhibitors (PIs) in the induction of hypertriglyceridemia (and insulin resistance), since they can interact with retinoic acid receptors at the liver site (6). This initial hypothesis was subsequently modified by the demonstration of the lipodystrophic syndrome in HIV-1-infected patients, either on other antiretroviral drugs [mainly nucleoside analog reverse transcriptase inhibitors (NRTI); see Refs.2 and 36] or naive to PIs (25). Thus it seems that both the viral infection per se or combined with different antiretroviral treatments plays a role in the pathogenesis of the lipodystrophic syndrome.
The abnormal fat distribution of HIV-1-infected patients is characterized by visceral and truncal obesity, adipose tissue atrophy of the limbs (mainly lower limbs), increment of adipose tissue in the mammary region, and "buffalo hump" (5). The metabolic alterations characterizing the insulin resistance syndrome include hyperlipemia (mainly hypertriglyceridemia), reduction of high-density lipoprotein (HDL) cholesterol, glucose intolerance, and hyperuricemia (5, 6). Among the most prominent hormone alterations, increased levels of insulin, C-peptide, prolactin, erithropoietin, and tumor necrosis factor (TNF)-α were described (9). An abnormal circadian cortisol pattern was also described (when this is the prevailing hormone alteration, the term "pseudo-Cushing" syndrome is used; see Ref. 34). A beneficial effect of growth hormone (GH) administration (indicated when an absolute or relative GH secretory defect is present) was suggested (44).
A clear-cut pathogenesis of HIV-1-related lipodystrophy is presently unknown. A disturbance of lipid metabolism (resulting from either the viral infection or the association virus-antiretroviral therapy-genetic background) seems to play a central role in the pathogenesis of the syndrome. The liver has been considered the main organ responsible for the defective lipid metabolism in lipodystrophic HIV-1-infected patients. The present study was undertaken to define a possible role of muscle in the pathogenesis of insulin resistance of HIV-1-related lipodystrophy. In particular, we asked the following questions:1) is the HIV-1-related lipodystrophy associated with an alteration of whole body energy metabolism and substrates oxidation rate; and 2) is there a metabolic alteration at the skeletal muscle site? Our data indicate an impaired whole body lipid oxidation in HIV-1-infected patients and a strong association between insulin resistance and intramyocellular lipid accumulation.
Twelve HIV-1-infected patients were selected in the population of over 600 patients at the Outpatient Clinic of Metabolic Diseases in the Division of Infectious Diseases of San Raffaele Hospital. Table1 represents the anthropometric parameters and the major clinical and biochemical data of the study patients. Twelve healthy volunteers, matched for major anthropometric parameters, were enrolled in the study and served as a control group. Antiretroviral therapy included both PIs and nucleoside analog reverse transcriptase inhibitors in all patients. Table2 outlines the major inclusion and exclusion criteria followed in the selection of the 12 HIV-1-infected patients. Only patients who were on a stable antiretroviral therapy for at least 1 yr (both PI and NRTI) and had constant blood CD4count and viral level for at least 4 mo were enrolled in the study. Patients who had a variation of body weight >10% of total body weight were excluded from the study. In all patients, fasting glucose and glycosylated Hb were assessed on day 1 (seeExperimental protocol for details) and were found to be normal. Previous normal blood glucose measured within 12 wk before the study allowed us to rule out diabetes mellitus. In addition, all HIV-1-infected patients received a standard 75-g oral glucose tolerance test (found normal) on a separate day within 2 wk of the study period. In all patients, 24-h urinary cortisol excretion was assessed in the 24-h urinary volume collected starting at 0800 of the day beforeday 1. Triglycerides and total cholesterol were higher in HIV-1-infected patients than in control patients. The finding of higher postabsorptive levels of insulin and C-peptide, indicating insulin resistance, completed the biochemical picture of the lipodystrophic syndrome. All patients could be classified as having a type III,grade 2 lipodystrophy according to the "ART-associated Lipodystrophy European Comparative Study" group (33). All patients had increased truncal adiposity, reduced or absent lower-extremity subcutaneous fat, and hypertriglyceridemia. Both HIV-1-infected patients and healthy controls were informed of the possible risks involved in the participation in the present study and gave their consent. The experimental protocol was approved by the Ethics Committee of San Raphael Scientific Institute, and written informed consent was obtained from all patients.
Experimental protocol.
All subjects involved in this protocol were studied on three separate days. The subjects assumed an isocaloric diet in the 4 wk preceding the study, and they did not modify their usual life style. On day 1, they were admitted to the Metabolic Unit of the Department of Medicine of San Raffaele Scientific Institute after an overnight fast (from 2200 of the day before study, only water was allowed). At 0800, a polyethylene catheter was inserted in the antecubital vein of one forearm, as previously described (23). At 0830, a basal blood sample for the measurements of hormones and metabolites was drawn. On day 2, all subjects were readmitted to San Raffaele Hospital at the Division of Diagnostic Radiology, where a1H NMR-spectroscopy scan was performed between 0700 and 0800 to assess the intramyocellular concentration of triglycerides, as previously described (30). On day 3, all subjects were admitted to the International Center for Assessment of Nutritional Status of the Universita' degli Studi di Milano to perform dual-energy X-ray absorption (DEXA) for the measurement of fat distribution in different body districts. The same day, respiratory gas exchange measurement by means of indirect calorimetry (model Vmax 29; Sensor Medics Italia, Milan, Italy) was started at 0830 after an overnight fast (9–11 h) and continued for ∼30 min. The three tests were performed in random order in no more than a 1-wk period in all subjects.
Analytical determinations.
Aliquots of blood for the measurement of metabolite [glucose, triglycerides, total cholesterol, HDL, low-density lipoprotein (LDL), and uric acid] levels were placed in heparinized tubes, as previously described (30). Plasma glucose was measured with a Beckman glucose analyzer (glucose oxidase). Blood aliquots for insulin, C-peptide, prolactin, TNF-α, and GH were collected in tubes for serum separation. Plasma insulin was measured with a microparticle enzyme immunoassay technology with no cross-reactions with proinsulin, C-peptide, and glucagon (Imx Insulin assay; Abbott Laboratories, Rome, Italy; see Ref. 30). Free fatty acids (FFA; Table 1) were collected and measured as previously described (30). Urine collection (24 h) was performed to quantify cortisol excretion. Glycosylated Hb, uric acid, TNF-α, urinary cortisol, and insulin-like growth factor (IGF)-I were not measured in normal subjects. All blood samples were placed on ice until the plasma or serum was prepared by centrifugation at 4°C (within 1.5 h of sampling). All plasma and serum aliquots were frozen at −60°C until later analysis.
Indirect calorimetry.
Indirect calorimetry measurement was performed as previously described by means of a Vmax 29 Sensor Medics Instrumentation operated in the canopy/nutritional dilution mode (23). Respiratory exchanges were measured over a 30-min period with the patient resting in bed in a quiet room with an ambient room temperature ranging between 23 and 25°C. Only parameters obtained in steady-state conditions were used for final calculations (steady state defined as ≥3 min ofV˙o 2 within 10%, of respiratory quotient within 5%, and of air flow through the canopy system within 10%).
1H NMR spectroscopy.
1H NMR spectroscopy was performed on a Sigma 1.5 Tesla scanner (General Electric Medical Systems, Milwaukee, WI) using a conventional linear extremity coil. High-resolution, T1-weighted images of the right calf were obtained before spectroscopic acquisition to localize the voxel of interest for the1H spectroscopy study. Voxel shimming was executed to optimize the homogeneity of the magnetic field within the specific volume of interest. Two 1H spectra were collected from a 15 × 15 × 15 mm3 volume within the soleus and tibialis anterior muscles. A PRESS pulse sequence (repetition time = 2,000 ms and echo time = 60 ms) was used, and 128 averages were accumulated for each spectrum, with a final acquisition time of 4.5 min. The water signal was suppressed during the acquisition, since it would dominate the other metabolite's peak signals of interest. A third 1H spectrum of a triglyceride solution inside a glass sphere, positioned within the extremity coil next to the calf, was also obtained during the same session to have an external standard acquired in the same conditions as the subject's spectra. Postprocessing of the data, executed with the Sage/IDL software, consisted of high-pass filtering, spectra apodization, zerofilling, Fourier transformation, and phasing of the spectra. The integral of the area under the peak was calculated using a Marquardt fitting with Lorentzian functions of the peaks of interest. The integral of the methylene signal (−CH2) at 1.35 parts/million was used to calculate intramyocellular triglyceride content expressed in arbitrary units (AU) as the ratio to the integral of the peak of the external standard × 1,000 (30, 31).
DEXA was performed with a Lunar-DPX-IQ scanner (Lunar, Madison, WI). A different scan mode was chosen with respect to each subject's body size, as suggested by the manufacturer's operator manual. For regional analysis, three-compartment processing was performed in the arms, trunk, and legs (30). Fat content is expressed as kilograms of fat mass and as a percentage of tissues. Because all patients had truncal fat accumulation (rather than pure visceral obesity), the computed tomography scan of the abdomen was not performed.
Insulin action.
Insulin action was assessed using a quantitative insulin sensitivity check index (QUICKI) (18). QUICKI hinges on the measurement of fasting insulin and glucose concentrations. It takes both the logarithm and the reciprocal of the glucose-insulin product (a, b) where Gb (mg/dl) is the fasting glucose concentration and Ib (μU/ml) is the fasting insulin concentration and was found to be the best predictor of insulin sensitivity on the basis of fasting blood sampling.
Statistical analysis.
All data are expressed as means ± SE. Comparisons between the control and the HIV groups were performed with the Student'st-test for unpaired data when appropriate.
Body composition.
Table 3 presents data on absolute and percent fat composition in HIV-1-infected patients and in healthy volunteers in different body districts. No difference was observed in the absolute and percent fat content in the whole body and in the upper limbs between the two study groups. In contrast, both the absolute (P = 0.003) and percent (P = 0.002) fat content in the legs were markedly reduced with respect to the control group. The absolute (P = 0.02) and percent (P = 0.02) fat content of the trunk were higher in the HIV-1-infected patients with respect to controls.
Energy metabolism.
Resting energy expenditure (REE) in HIV-1-infected patients was not statistically different compared with healthy volunteers either in absolute terms (P = 0.47) or when calculated per kilogram body weight (P = 0.54) or kilogram lean body mass (P = 0.21). In contrast, the respiratory quotient, calculated by dividing the V˙co 2 by theV˙o 2, was markedly increased in HIV-1-infected patients (0.91 ± 0.02, P = 0.0001) with respect to healthy volunteers (0.81 ± 0.1), indicating an impaired lipid oxidation. Accordingly, whole body lipid oxidation (mg · kg−1 · min−1) was markedly impaired in HIV-1-infected patients with respect to controls (0.20 ± 0.06 vs. 0.88 ± 0.09, respectively,P = 0.00001). The reduction of lipid oxidation was matched by a complementary increment of glucose oxidation (mg · kg−1 · min−1) in HIV-1-infected patients (1.87 ± 0.21, P = 0.003) with respect to healthy subjects (1.03 ± 0.13; Fig.1 and Table 3).
Intramyocellular triglyceride concentration.
The intramyocellular triglyceride content of the soleus muscle was significantly increased in HIV-1-infected patients compared with healthy controls (101 ± 15 vs. 44 ± 5 AU, P= 0.001). Similarly, the triglyceride content of the tibialis anterior muscle was higher in HIV patients compared with controls (26 ± 6 vs. 11 ± 2 AU, respectively, P = 0.02; Fig.2).
Insulin action.
The QUICKI was lower (P = 0.012) in HIV-1-infected patients (0.341 ± 0.011) compared with healthy controls (0.376 ± 0.007). An inverse correlation between insulin action and intramyocellular triglyceride concentration was shown in the study subjects (Fig. 3). Gan et al. (11) found a similar correlation between insulin action assessed via the clamp and intramyocellular lipid content.
All patients included in the study were lipodystrophic (Table 2). In particular, the total body weight and the total percentage of body fat mass were not statistically different from the control group. Interestingly, the arm fat percentages were also similar in HIV-1-infected patients and in healthy subjects, confirming that the body districts mainly involved are 1) the lower extremities, where the apoptotic process is prominent (1), and2) the trunk, where the fat accumulation is increased. Both the antiretroviral drugs and the virus itself have been hypothesized as possible causes of HIV-1-related lipodystrophy (25). The complete sequence of events by which PIs lead to insulin resistance, cause apoptosis, and eventually determine lipodystrophy is presently still unknown. PIs have two possible mechanisms by which they induce lipodystrophy and insulin resistance. First, PI drugs have a direct effect on the retinoic acid receptor (leading to apoptosis of adipocytes in specific body districts) and on the lipoprotein receptor-related protein; second, PIs have an indirect negative effect on insulin action by impairing triglyceride clearance (5, 6, 32). Because in the present work we did not measure the lipolytic rate of adipose tissue, we cannot draw any conclusion on a possible regional difference of PIs on lipolytic rate. In contrast, NRTI may, possibly, induce lipodystrophy via mitochondrial toxicity. In addition, non-virus-related mitochondrial toxic myopathies are known to induce lipid storage inside the skeletal muscle cells (10). Finally, the demonstration of lipodystrophy in patients naive for antiretroviral drugs (25) or in the very early stages of disease (4) may support the possibility that the retrovirus itself may induce the syndrome, without the concomitance of any drug treatment. Complex interactions are present among the retroviral infection, PIs, and NRTI drugs. Therefore, we selected patients on both classes of drugs (PI and NRTI for ≥1 yr), having the three known factors possibly involved in the pathogenesis of the lipodystrophy/insulin resistance syndrome (Table 2).
All patients were hypertriglyceridemic (Tables 1 and 3). No patient had hormone or metabolic factors that, per se, could induce or worsen an altered distribution of body fat or insulin resistance. First, diabetes mellitus was excluded, since hyperglycemia is known to induce insulin resistance. All HIV-1-infected patients had a normal urinary excretion of cortisol and plasma hormone levels in the normal range, excluding a major hormonal alteration leading to truncal adiposity. Interestingly, FFA concentration was not increased as in other forms of lipodystrophy, possibly because of the differential fat distribution between the abdomen (accumulation) and legs (atrophy; Table 1).
All patients were insulin resistant, with comparable glucose levels in the two groups. We made an effort to exclude a number of different diseases (diabetes mellitus, obesity, hyperuricemia, cancer, hereditary diseases, and sepsis) on the basis of known risk factors leading to a reduction of insulin action. We also ruled out a coexisting hyperuricemia by measuring the plasma uric acid concentration (normal in all subjects; Table 1). The normal hormone levels previously discussed excluded a hormonal cause of reduced insulin action, pointing to either the viral infection or the pharmacological interactions of antiretroviral drugs as isolated causes of insulin resistance. A possible mechanism of induction of insulin resistance by PIs was suggested by Murata et al. (27), who recently described a selective inhibition of GLUT4 activity by indinavir (a PI drug), with a normal phosphorylation of the tyrosine residues of insulin receptor and insulin receptor substrate-1.
REE is increased during sepsis (29) or in patients with advanced acquired immunodeficiency syndrome (37), leading eventually to cachexia. Our HIV-1-infected population does not show a significant increase in REE compared with the control group. Nonetheless, two previous reports demonstrate an increased REE in HIV-lipodystrophic patients on antiretroviral drug treatment (17,38). Possible causal links between increased metabolic rate and either higher TNF-α blood levels or resistance to antiretroviral drug treatment were previously suggested. Shevitz et al. (38) recently suggested that, although highly active antiretroviral therapy (HAART) may decrease the metabolic rate by lowering viral load, it increases the metabolic rate by a distinct, independent, and unknown mechanism. It is important to note that lipodystrophy itself (not associated with HIV infection, but with other diseases) may increase the metabolic rate. We (24) and others (20,21) have shown increased REE in diabetic patients with partial or total lipoatrophic diabetes mellitus. Nonetheless, REE was found to be increased in diseases associated with congenital/acquired, total/partial lipodystrophy, like Kobberling-Dunningan syndrome (42), Nasu-Hakola disease (8), and cystic angiomatosis (3).
It is noteworthy that our patients demonstrate a markedly reduced whole body lipid oxidation rate (and a complementary increase of carbohydrate oxidation) compared with the control group (Fig. 1 and Table4). This finding is somewhat expected in a cohort of patients hypertriglyceridemic, insulin resistant, and with an impaired clearance of plasma lipids, although it is most consistent in HIV-infected patients treated with antiretroviral drugs. In contrast, an early defect of lipid oxidation was shown in obese and postobese subjects (26, 35). Once obesity or type 2 diabetes is established, there is not necessarily a decreased lipid oxidation. A previous report of Hommes et al. (17) found the lipid oxidation normal to increased in HIV-infected patients not on HAART, underlining the importance of antiretroviral drugs in the development of the lipid oxidation defect. Korach et al. (22) recently showed that only after the institution of antiretroviral therapy did HIV patients develop a decrease in lipid oxidation.
Both the liver and the skeletal muscle are major sites of lipid oxidation. It is reasonable to postulate that an impairment of β-oxidation of fatty acids induces triglyceride accumulation at the organ sites. Liver steatosis (assessed by ultrasound echography) was detected in all HIV-1-infected patients included in this study (Table1; and is commonly present in most lipodystrophic patients; see Ref.16), although this finding might be indicative of a concomitant chronic hepatitis instead of primary hepatic lipid accumulation. For this reason, the report of a higher intramyocellular triglyceride concentration in the HIV-1-infected group is of crucial importance (Fig. 2). This is the first demonstration that HIV-1-infected patients with lipodystrophy have an increased level of lipids in the skeletal muscle cells. Because all HIV-1-infected patients were on both classes of drugs (PIs and nucleoside analog inverse transcriptase inhibitors), it is impossible to ascribe to one class of drug or to the other the increase of intramyocellular lipid content. Interestingly, many viral infections cause lipid (either cholesterol or triglyceride) accumulation in the liver parenchyma (7), heart (39), or skeletal muscle (15, 28). Therefore, the retroviral infection per se may be partially responsible for the higher triglyceride content in the skeletal muscle. Finally, intramyocellular triglyceride accumulation was described in other forms of lipodystrophy not characterized by cytokine production, either in rodent models (12) or in humans (40). Therefore, the lack of an HIV-nonlipodystrophic group does not allow us to dissect out the role of lipodystrophy and of viral infection itself in the development of intramuscular triglyceride accumulation.
In conclusion, the present data indicate a novel metabolic defect of HIV-1-infected patients treated with HAART, namely an intramyocellular accumulation of triglycerides associated with a reduced whole body lipid oxidation. The intramyocellular lipid concentration inversely correlates with insulin sensitivity. Probably, the retroviral infection in combination with HAART is responsible for the metabolic defect, which is associated with abnormal fat distribution. Recent publications point to a selective impairment of GLUT4 activity by PI drugs (27), and genetic manipulation of GLUT4 expression has shown a role of this protein in adipose tissue metabolism (13,19, 41). Therefore, on the basis of our results and on in vitro experimental evidence, the use of pharmacological agents selectively enhancing insulin action could be suggested in HIV-1-infected patients (14, 43).
This work was supported by Progetto Finalizzato del Ministero della Sanita', Italy, Grant no. R.F. 99 Unita' 03 and 04.
Address for reprint requests and other correspondence: L. Luzi, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milano, Italy (E-mail:luzi.livio{at}hsr.it).
The costs of publication of this article were defrayed in part by the payment of page charges. The article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
First published October 8, 2002;10.1152/ajpendo.00391.2001
- Copyright © 2003 the American Physiological Society


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Год издания: 2003
Количество страниц: 264
В продаже с 18.01.2012
Как только книга American Pictures станет доступна для заказа в одном из интернет-магазинов, Вам на e-mail будет отправлено уведомление.Укажите e-mail для связи:
Book Description In 1993, Jeff Dunas set out on the first of many trips crisscrossing the country to photograph scenes representative of small-town America in the 1950s, revisiting the country of his youth after spending the previous two decades in Paris. The stunning result is the American Pictures series documenting the architecture, landscape, and people simply living their American dream. "Visually speaking," Dunas observes, "the texture of this country has evolved from wood-and-brick buildings to glass structures that don't open. Air-conditioning runs in place of fresh air, which in itself is sometimes difficult to find. I wanted to take an archive of work from the last century into this century while I still could."

subset: commoncrawl


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Electorate and elites at one on Brexit dangers
A poll finds we are hostile to Brexit, and a study finds Ireland is among the least corrupt countries globally
Published 12/06/2016 | 02:30
Apart from a handful of people such as the indefatigable and long-term opponent of European integration Tony Coughlan, almost everyone in Ireland who has thought hard about Britain leaving the EU, or whose economic interests will be impacted, believes a Brexit would be bad for us. That "elite" opinion so heavily supports the Remain campaign in the UK referendum in 11 days' time is not surprising.
Any cold, rational calculation of Irish interests can only come down very strongly in favour of Remain. With the one possible upside (some jobs moving here from Britain) only partially mitigating the other economic and non-economic downsides, the case is open and shut from an Irish perspective at least. It is the proverbial no-brainer.
Despite a lot of talk in recent times about elites becoming disconnected from electorates, in this instance at least there is no such gap between the average voter and so-called elites in Ireland.
A new Millward Brown poll finds that the views of the Irish public closely reflect the views of the country's political class (including Sinn Fein), its economic interests, officialdom and - for what it is worth - we, the commentariat.
Fewer than one in 10 people polled here believes the Brits should quit. Of the eight other EU countries also polled, support for a British exit was lower only in Poland, unsurprising given that the almost one million Poles living in the UK could lose their automatic right of residence if Britain pulls out. (Also unsurprising, it might be added, is that the French were the most enthusiastic about getting rid of the Anglo Saxons, with more than one third backing Brexit.)
Asked if a similar in/out EU referendum should be held in Ireland, only one in eight wanted such a poll. In the other countries surveyed it was between twice and three times greater. While this is undoubtedly related to the fact that we, unlike any other EU member country, have voted on every change to the bloc's basic rules over decades, it also likely reflects a recovery in support for the integration of the continent.
The most recent EU-wide Eurobarometer opinion poll, conducted bi-annually on behalf of the European Commission, showed that we Irish had the third-most-favourable opinion of the union among its 28 members, with 57pc having a positive view. Only 14pc viewed it negatively. Although the positive/negative split has not returned to where it was pre-2008, it has moved sharply in that direction since the worst of the recession and euro crisis in 2012.
The comparatively high levels of support contrast with our nearest neighbour. The most recent Eurobarometer poll had Britons at the other end of the table in terms of how they view the EU. Fewer than one in three had a positive view, the fifth-lowest in the bloc.
It is extraordinary how differently two peoples who share so much can have such different views on our shared European system of government. One could write volumes on the issue, but a point that many make, particularly on the pro-EU side, seems to me to be very wrong.
That view is to attribute British hostility to a handful of Eurosceptic media moguls who manipulate the gullible masses. While the reporting as fact of many untruths and half-truths about Europe in some British papers is a disgrace to the profession of journalism, it seems to be more about playing to consumers' existing preferences and prejudices than creating them in the first place.
Nothing proves this like the Daily Mail. It has Irish and British editions. Comparing them on any given day is revealing. While a great deal of the non-political and human interest stories are carried in both editions, the more contested and political content is like chalk and cheese.
Hardly a day passes without the UK edition covering immigration. It is usually in a panicked tone that reinforces the views of many that Britain is being inundated with foreigners. Almost all stories on immigration focus on the negatives - pressures on public services, housing and the (in theory) wage-depressing effects for lower income earners. Membership of the EU is invariably portrayed as a reason for the migration phenomenon, if not the root cause.
If one read nothing other than the Daily Mail in the UK, it would be impossible to conclude that the move-ment of people across borders was anything but a disaster for British society and its economy. Much the same could be said for EU membership.
But if the Mail group of papers was so wedded editorially to these stances, why are there so few negative stories on the subjects in the Irish edition? The reason is because Irish people don't fret endlessly about either matter.
Despite Ireland having proportionately twice as many foreign-born people living here compared with the UK, Irish commentary on immigration is generally at the other extreme. I detect a degree of self-censorship, with people afraid to mention the downsides of immigration in any public forum for fear that they might be labelled a little Irelander, a bigot or even a racist.
Having said that, the almost complete absence of negative stories on immigration in the press here reflects the very different attitude of we Irish to immigration compared with the UK. The same could be said of the EU itself.
How corrupt is Ireland? There is no shortage of people in this country who believe we are little better than a banana republic. This view is not confined only to crazed conspiracy theorists. Those who hold the view point to very real examples of cronyism, palm-greasing and brown envelope-dispensing as evidence to support the banana republic belief.
There is, of course, corruption here, just as there are other forms of criminality. Human nature being what it is, corruption and crime exist everywhere at all times. But because there are abundant examples of all sorts of crimes being committed, it does not logically follow that Ireland is a nation of criminals.
In order to answer the question "How corrupt is Ireland?", one needs to make comparisons with other countries. Last week, the first attempt to compare cross-country levels of corruption was published (there is a long-standing measure of people's perceptions of corruption, but as the scholars who published the new study correctly stress, perceptions can often differ from reality).
The study is worth mentioning, not least because I could find no mention of it in any Irish media since its publication.
The Global Integrity Index, which can be accessed with the link at the end of this article, measures a range of things, from judicial independence to freedom of the press. Compiled by the European Research Centre for Anti-Corruption and State-Building in Berlin, it predictably put Nordic countries in the top three for probity across the world.
However, the index ranks Ireland as the eighth-cleanest country among the 105 it assessed, one place behind Sweden. That is not at all bad, and certainly does not support the banana republic thesis.
We have many problems in the way we govern ourselves - incompetence, inertia and short-sightedness to name a few. While new measures have been put in place in recent years to combat corruption, there is always more that could be done. However, as anyone who has seen a bit of the world knows, the extent of politicians and officials lining their pockets to live like kings in Ireland is limited.
To highlight that is not in any way to be complacent; saying that we are not the worst for everything in Ireland and that focusing attention (and anger) on the things we are genuinely bad at would make it more likely that the place is run better.
Sunday Independent


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The tough poetry of Karen Fisher's novel buoys this chronicle of Oregon migration along on an incantatory wave. It's 1847 and dour patriarch Israel Mitchell drags his reluctant wife, Lucy, and their children out to the Oregon Territory. Their paths cross with James MacLaren, a bereaved Scot trapper whose children have all died from smallpox and whose Nez Perce wife has run off. Each day the murderous landscape spools mercilessly ahead of the emigrants, and Fisher's depiction of a familiar-seeming journey that is not adventurous, as myth would have it, but a daily exercise in folly and survival, is astonishing. A Sudden Country requires a patient reader, but the spell it casts is transformative and rare. The heartbreaking first chapter alone is worth any number of lesser novels.
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SPOILERS: Batman #9
It's saying something when a LoSH character hanging out in Batman is hardly the most WTF moment of an issue.
SPOILERS: Nightwing #7
The circus is a strange place, evident by the endless Nightwing stories that come from it.
Stack Rundown, 10/16/2016
Man, I sure wish Damian showed up in Batman books too... you know, where it'd make total and complete sense?
SPOILERS: All-Star Batman #3
More mess is made. Lots more. I hope you weren't fond of the Royal Flush Gang.
Thursday, April 19, 2012
Batman #12 cover tease
This is supposed to be the issue about Harper Row, but lord knows what this is. Your guess is as good as mine.
(Source: Greg Capullo's Twitter)
Posted by Gotham Spoilers at 9:14 PM
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Found 863 tutors in Malden, MA 02148 – page 1 of 87.
Nahant 01908 · 7 miles from 02148 · $60/hour · teaches Computer Generated Music, Guitar
I have studied privately for over 25 years and have been teaching for 28 years. I have been a professional musician for over 30 years, toured most of the country as well as...Gold Apple rating, member for 8 years and 6 months
Boston 02119 · 8 miles from 02148 · $25/hour · teaches Chinese, Mandarin
* Bachelor's degree, qualified teacher, Beijing Language and Cultural University. I'm Dang Laoshi (Teacher Dang) and I'm from Shijiazhuang, China. I'Gold Apple rating, member for 6 years and 1 month
Malden 02148 · 0 miles from downtown · $65/hour · teaches Acting, Baritone, Computer
I was the artistic director of New York Opera Singers Association for three years and now am the director of Boston Opera Singers Association after moving to the Boston area.Green Apple rating, member for 8 years and 6 months
Medford 02155 · 3 miles from 02148 · $55/hour · teaches Biochemistry, Biotechnology
B.S. Biology from CSUF Ph.D. Molecular Cellular and Developmental Biology KU Postdoctoral Research Harvard University Over a decade of research and teaching experienceGreen Apple rating, member for 5 years and 1 month
Medford 02155 · 3 miles from 02148 · $30/hour · teaches Photography, Skating, Bicycling
I have been a freelance photographer for over 17 years. In addition to photography, I have spent many years in the retail camera business and have a complete understanding of...Green Apple rating, member for 8 years and 6 months
Boston 02108 · 5 miles from 02148 · teaches Accordion, Piano
I graduated from Boston University with a B.A. in music. I have performed a wide variety of music on cruise ships, in jazz bands, wedding and function bands...Green Apple rating, member for 1 year and 7 months
Boston 02108 · 5 miles from 02148 · $45/hour · teaches ACT, ADD-ADHD, Algebra, Algebra 1
6+ years of experience tutoring both excelling and struggling students all while maintaining a 4.0 GPA. I am also employed as a tutor on WyzAnt and , and I tutor full-time.Green Apple rating, member for 5 months
Boston 02110 · 5 miles from 02148 · $40/hour · teaches Chinese
Native Chinese speaker who grow up in China. I got my Bachelor degree in College of Communication a year ago. I'm a native Chinese Speaker. I'Green Apple rating, member for 4 years and 7 months
Boston 02108 · 5 miles from 02148 · $40/hour · teaches English as 2nd Language, Italian
Italian Language and Literature Donatella M. has a Masters from the Universita' Magistero di Bologna in Italy. She specializes in tutoring Italian and literature.Green Apple rating, member for 1 year and 12 months
Cambridge 02139 · 5 miles from 02148 · $30/hour · teaches Creative Writing, English
CELTA Certificate, Dublin Ireland 2011 Central Language Center is the perfect place for students looking for one-on-one attention in order to improve their skills in English such...Green Apple rating, member for 8 months


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12511 Prosperity Dr.
Directions Silver Spring, MD 20904
Actual rating will vary with options, driving conditions, habits and vehicle condition.
Check out this gently-used 2013 Infiniti G37 x we recently got in.
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Added comfort with contemporary style is the leather interior to heighten the quality and craftsmanship for the Infiniti G37 x A vehicle as well-maintained as this Infiniti G37 x almost doesn't need a warranty, but you rest easier knowing it comes covered with the Infiniti factory warranty.
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okay she loves catnip and I put it on her stool because I want her to know its her stool well when I put it on there she loves all over the stool spins around on the stool on her side kind of and I bought her a scratchy thingy made of cardboard and it was pretreated with catnip and she loves on it she doesn't scratch it. why? and will the catnip hurt her
post #1 of 2
6/23/06 at 2:23pm
Thread Starter


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Epiphone Gothic Les Paul
This guitar is no longer for sale (sold on 2008-08-11)
Price : US $167.50
I am relisting this, please only bid if you plan to complete the transaction.
Up for bid is a Epiphone Gothic Les Paul. Satin black finish, Grover tuners, black hardware, Alnico V humbuckers and a set neck.
Body shows minimal wear. There are a few light scuffs here and there. Great action, plays nice.
Sorry no case but will pack very well. Please ask all questions before biding as all sales are final.
This guitar is sold (sold on 2008-08-11)
Post a comment on Epiphone Gothic Les Paul :


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Really, Tom Hicks? Really?
Seems Tom Hicks just don't get it. Because just two days after his Liverpool FC kicked its way into the Champions League semi-finals, the Texas Rangers and Dallas Stars' owner is demanding that Liverpool chief executive Rick Parry step down. Like, immediately. Hence, this story's use of such phrases as "boardroom turmoil" and "astonishing turn" and "shock move" (which shouldn't be confused with "shocker") and "embarrassing saga."
Why the letter demanding Parry's resignation? Something horrible? Something unforgivable? Not really: "Hicks was believed to have been enraged by Parry's interview recently on BBC Five Live in which the chief executive pleaded with both co-owners to end the war between them and come to an agreement that would allow the club to move forward." Coco, you bastard. --Robert Wilonsky
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text: My husband I went there to grab something to eat. Our waitress was poor and the food not that great. We ordered boneless wings. 10 boneless wings for $10.00. They looked like the chicken nuggets from McDonalds. Also $8.00 for a drink that consisted of mostly ice. The waitress was not attentive to our needs at all. We waited 25... 更多


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Laser Interceptor Dual, Laser Interceptor Quad, Valentine 1 & The Escort 8500 X50 - Blue, Uniden BC296D, GRE500, Lasershield, 2011 Kia Soul +, Yamaha FZ6, 2005 Black Dodge Neon SRT-4,
And they wonder why no one respects them. They are a joke.
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Welcome to Librarium Online!
Join our community of 80,000+ members and take part in the number one resource for Warhammer and Warhammer 40K discussion!
Registering gives you full access to take part in discussions, upload pictures, contact other members and search everything!
Does anyone know any sites that talk about these in depth?
Specifically, I want to know about the old Chaos god Malal, Squats fluff, Lizardmen in space, Minotaurs with guns, old miniatures/art, a real CD army book, etc...
I would appreciate it if any veterans of the old days could give me some info if there aren't any places I can find out first hand.
ph34r teh 1337 k0r34n 5p33x0r
Reading your post, it seems like you are interested in a whole gamut of information from the Wh40k Rogue Trader days. I wish there was a complete online copy of Rogue Trader, and there was a web project that was working to provide that, but unfortunately it has since closed down.
However, the following site has a number of transcripts taken from a number of sources, including Squats and a race called the Jokaero that were, I kid you not, super-intelligent orangutangs:
For pictures, there is an excellent website that scanned old Citadel miniature catalogues. There's some amazing stuff there, like the original prototypes of power armour (the current version most chapters use is either Mark 6 or Mark 7, the catalogue shows everthing from Mark 1 to 8). I also found an image of the Wh40k minotaurs, which has guns on its head instead of horns. You can find the site here:
My favourite sections, and the part I think are most meaningful to you, is 1991 Catalog 1. That catalogue came out when Wh40k really had an identity of its own rather than being merely a sci-fi version of Warhammer Fantasy; for example, by that time the Eldar were no longer called "Space Elves".
Regarding some of the specific things you mentioned, Ma'lal is the 5th Chaos power, a god that hates the other 4 Chaos powers. I remember there was a comic strip in the old, old version of White Dwarf magazine (before it covered only GW games). In it, Ma'lal gives some guy a mighty weapon to kill Chaos warriors in his name; I have a strong memory of it looking like a giant pick axe with an extra prong that kind of grabs the heads of evil people and sucks their soul out, but that sounds so ridiculous I myself think I'm confused. Ma'laal appears as a giant horned daemon, but his symbol is a skull that is half white and half black.
The Squats stuff is mentioned in the website above.
Regarding Space Lizardmen, I think they were referred to in Wh40k 1st edition Rogue Trader as the Slan or something, but had nothing to do with Slaanesh. They were an ancient dead race that's briefly described in blurbs, leaving some strange, mysterious monuments as a testiment to their power or something.
I remember Minotaurs with guns strapped to the head from the aforementioned catalogue, but I really don't remember their background, except to say that there were Beastmen in the Imperial Guard. There is a miniature of a Beastman with carapace armour with the Imperial eagle and a chainsword to prove that I'm not just plain senile. I felt Minotaurs and Beastmen were somewhat related, so I mentioned it in case you were interested. There is an interesting quote that sticks in my mind, where a Beastmen says something like, "We born different, we dirty. Emperor hates us. So we give him blood and skulls, ask for forgiveness. Say sorry."
Wow, this stuff you dug up is pretty cool. Its fun to see the whole evolution of the "Warhammer" work. Its gone from very sword and sorcery fantasy to a much more sinister "Gothic" look.
âCry âHavocâ and let slip the dogs of war!â? - Julius Caesar, Act III, Scene I


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The Ease of an Electric Range
by Guest on Mar 29, 2011
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The first major benefit of using an electric range is that it can efficiently heat up to specific temperatures. Because of how the electric range is designed, the cookware you use to cook the food in will absorb more of the heat than other stoves. This means that less heat is lost out into the kitchen or surrounding rooms. The ability for the electric range to insulate the heat can help with your utility bills and it will also help the kitchen to stay at a constant temperature and not get uncomfortable to work in.
The next advantage that an electric range has is the fact that it can put out consistent heat. The electric range is designed to distribute the heat evenly across the board so that you don't have to worry about overcooking one half of the meal and undercooking the other half. This can help if you are cooking eggs, omelets, crepes, pancakes, or other evenly distributed food items. Not only that, the heating options on an electric range are also very easy to use. The temperature is easier to control so that you can make sure that the heat is set to a specific level. This will help you to cook meals at the exact temperature at which they need to be cooked at.
Another great benefit of an electric range is how safe and convenient it is to use. The first reason why they are so safe is because you don't have to worry about an igniter or a pilot light. Also, the fuel source that you will be using is electricity which is very safe as long as the outlet is properly grounded. All you need to do is make sure that the electric range is plugged into the electrical outlet and that it is placed in its proper position. Another feature that most electric range models offer to help out with safety is the "hot surface" light. This light will stay on as long as the surface of the electric range is still emitting any heat. You can avoid putting any objects on the electric range that could possibly start on fire or become a hazard.
With all of the benefits that have been listed about the electric range, it is easy to see why this could be a great addition to your home. Ease of use, safety, convenience and cooking capabilities are just a few of the many advantages that an electric range has over other units. Do your research and find the electric range that is right for you.
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System needs to endJuly 12,2014
System needs to end
Sixteen-year-old Mohammad Abu Khdeir was found dead after having been burned alive in East Jerusalem, an apparent victim of a revenge attack following the killing of three Israeli teenagers on the West Bank. He was the 10th Palestinian killed by the Israeli military or right-wing extremists in the last two weeks.
We mourn all lost lives. To honor them all, we need to think about how to change the conditions that make such unthinkable violence possible. The ongoing Israeli occupation is at the heart of this crisis.
While we mourn the three Israeli teenagers killed in the West Bank, we should also mourn the 1,384 Palestinian children killed by the Israeli military since 2000, according to the Israeli human-rights group BTselem. Thats one Palestinian child killed by the Israeli military every three to four days. These deaths are virtually ignored by the mainstream media.
We cannot ignore the huge power difference between Israelis and Palestinians or pretend it is just a cycle of violence with no root cause or context. These horrific incidents are happening in the context of an ongoing colonial occupation, itself a system of daily violence.
That system, which by its very nature puts the lives and human rights of all in jeopardy, needs to end.
Crystal Zevon
BarreMORE IN LettersAs a member of the Berlin school Renovation Committee, I want Berlin voters to know that the... Full StoryI am writing to express my support for State Sen. Full StoryIn 2014, Milne entered the governors race late when he sensed an opportunity to challenge the... Full Story
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BRIDGEPORT - Bridgeport Mayor Bill Finch assured residents today that they are safe following the arrest of Times Square bomb suspect Faisal Shahzad.
FBI agents served search warrants today on Shahzad?s home on Sheridan Street. Twelve surrounding homes were evacuated for approximately two hours during the raid.
Finch says he has been in close contact with Gov. Jodi Rell and New York City Mayor Michael Bloomberg. He says he also received information that the suspect attended the University of Bridgeport at one time.
Mayor Finch says he plans to visit members of the city?s faith-based communities tomorrow.


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Apple-China Mobile Pact a Good Deal Long Term: Yang
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|By PR Newswire
Article Rating:
|August 14, 2014 02:00 PM EDT
PRINCETON, N.J., Aug. 14, 2014 /PRNewswire-USNewswire/ -- Educational Testing Service (ETS) is releasing the second annual report on TOEIC® test takers worldwide for the TOEIC® Listening and Reading (L&R) assessment.
The TOEIC® Listening and Reading Report on Test Takers Worldwide is based on the information gathered from all test takers who completed the TOEIC® Background Questionnaire administered in 2013. The report presents information about TOEIC test-takers' average Listening and Reading scores, educational background, work experience, English language study and use, and the TOEIC test-taking experience.
ETS is making this data available to enable users to learn more about the backgrounds of people who took the test and some of the factors that impacted their TOEIC scores and related improvement in English proficiency. Organizations can look at the data to set score benchmarks and goals; however, because the response rates varied across different background questions, special care should be taken in making inferences based on this data.
"As the English language continues to grow globally, it is critical that score users understand more about who takes the TOEIC test," says Feng Yu, Executive Director of the TOEIC Program. "And because the questionnaire is so in-depth and the testing process is standardized, test takers of any background and location can be compared fairly by score users."
Relying on this data and TOEIC scores, organizations can build a more diverse and qualified labor pool to make informed decisions around placing, developing and promoting employees from and within any country or region. Additionally, the growing acceptance of the TOEIC tests around the world means test takers can advance their careers at a wider range of organizations.
Report highlights include:
- Description of TOEIC L&R test-takers in 2013
- Average TOEIC scores across native countries, industries, etc.
- Relationships among L&R scores
- Test-taker demographics
TOEIC assessments are fair, reliable and valid measures of a test-taker's ability to use English in the workplace. Used by nearly 14,000 organizations in 150 countries, the TOEIC tests are the international standard for assessing an individual's English-language proficiency level and measuring how well potential employees can apply their English-language skills in a work environment.
While organizations use TOEIC scores and surveys to build a stronger employee base, job seekers trust the TOEIC Program to differentiate themselves in a competitive job market. TOEIC assessments measure all four language skills and provide descriptions of test-takers' strengths and weaknesses that can be used to inform critical hiring, placement and training decisions.
To download the report, visit www.ets.org/toeic/publications. For more information about the TOEIC program, please visit www.ets.org/toeic.
About the TOEIC Test
For more than 30 years, the TOEIC test has been the global standard for measuring workplace English-language communication skills. The TOEIC assessment family, including the TOEIC Listening and Reading test, the TOEIC Speaking and Writing tests and the TOEIC Bridge™ test are used by nearly 14,000 businesses, organizations, and government agencies in 150 countries. In 2012, almost seven million TOEIC tests were administered worldwide, solidifying the TOEIC Program as the largest and most widely used English-language assessment for the workplace. For more information on the TOEIC tests and other services provided by the TOEIC Program, visit www.ets.org/toeic.
About ETS
At ETS, we advance quality and equity in education for people worldwide by creating assessments based on rigorous research. ETS serves individuals, educational institutions and government agencies by providing customized solutions for teacher certification, English language learning, and elementary, secondary and postsecondary education, and by conducting education research, analysis and policy studies. Founded as a nonprofit in 1947, ETS develops, administers and scores more than 50 million tests annually — including theTOEFL® and TOEIC® tests, the GRE® tests and The Praxis Series® assessments — in more than 180 countries, at over 9,000 locations worldwide. www.ets.org.
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DevOps is being widely accepted (if not fully adopted) as essential in enterprise IT. But as Enterprise DevOps gains maturity, expands scope, and increases velocity, the need for data-driven decisions across teams becomes more acute. DevOps teams in any modern business must wrangle the 'digital exhaust' from the delivery toolchain, "pervasive" and "cognitive" computing, APIs and services, mobile devices and applications, the Internet of Things, and now even blockchain. In this power panel at @...
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The Quantified Economy represents the total global addressable market (TAM) for IoT that, according to a recent IDC report, will grow to an unprecedented $1.3 trillion by 2019. With this the third wave of the Internet-global proliferation of connected devices, appliances and sensors is poised to take off in 2016. In his session at @ThingsExpo, David McLauchlan, CEO and co-founder of Buddy Platform, discussed how the ability to access and analyze the massive volume of streaming data from millio...
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In the 21st century, security on the Internet has become one of the most important issues. We hear more and more about cyber-attacks on the websites of large corporations, banks and even small businesses. When online we're concerned not only for our own safety but also our privacy. We have to know that hackers usually start their preparation by investigating the private information of admins – the habits, interests, visited websites and so on. On the other hand, our own security is in danger bec...
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Regulatory requirements exist to promote the controlled sharing of information, while protecting the privacy and/or security of the information. Regulations for each type of information have their own set of rules, policies, and guidelines. Cloud Service Providers (CSP) are faced with increasing demand for services at decreasing prices. Demonstrating and maintaining compliance with regulations is a nontrivial task and doing so against numerous sets of regulatory requirements can be daunting task...
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@DevOpsSummit has been named the 'Top DevOps Influencer' by iTrend. iTrend processes millions of conversations, tweets, interactions, news articles, press releases, blog posts - and extract meaning form them and analyzes mobile and desktop software platforms used to communicate, various metadata (such as geo location), and automation tools. In overall placement, @DevOpsSummit ranked as the number one 'DevOps Influencer' followed by @CloudExpo at third, and @MicroservicesE at 24th.
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Enterprises have been using both Big Data and virtualization for years. Until recently, however, most enterprises have not combined the two. Big Data's demands for higher levels of performance, the ability to control quality-of-service (QoS), and the ability to adhere to SLAs have kept it on bare metal, apart from the modern data center cloud. With recent technology innovations, we've seen the advantages of bare metal erode to such a degree that the enhanced flexibility and reduced costs that cl...
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"Media Sponsor" of SYS-CON's 19th International Cloud Expo, which will take place on November 1–3, 2016, at the Santa Clara Convention Center in Santa Clara, CA. CloudBerry Backup is a leading cross-platform cloud backup and disaster recovery solution integrated with major public cloud services, such as Amazon Web Services, Microsoft Azure and Google Cloud Platform.
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In the next forty months – just over three years – businesses will undergo extraordinary changes. The exponential growth of digitization and machine learning will see a step function change in how businesses create value, satisfy customers, and outperform their competition. In the next forty months companies will take the actions that will see them get to the next level of the game called Capitalism. Or they won't – game over. The winners of today and tomorrow think differently, follow different...
Oct. 28, 2016 04:15 AM EDT Reads: 1,152
According to Forrester Research, every business will become either a digital predator or digital prey by 2020. To avoid demise, organizations must rapidly create new sources of value in their end-to-end customer experiences. True digital predators also must break down information and process silos and extend digital transformation initiatives to empower employees with the digital resources needed to win, serve, and retain customers.
Oct. 28, 2016 02:45 AM EDT Reads: 1,788
SYS-CON Events announced today that SoftNet Solutions will exhibit at the 19th International Cloud Expo, which will take place on November 1–3, 2016, at the Santa Clara Convention Center in Santa Clara, CA. SoftNet Solutions specializes in Enterprise Solutions for Hadoop and Big Data. It offers customers the most open, robust, and value-conscious portfolio of solutions, services, and tools for the shortest route to success with Big Data. The unique differentiator is the ability to architect and ...
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You think you know what's in your data. But do you? Most organizations are now aware of the business intelligence represented by their data. Data science stands to take this to a level you never thought of – literally. The techniques of data science, when used with the capabilities of Big Data technologies, can make connections you had not yet imagined, helping you discover new insights and ask new questions of your data. In his session at @ThingsExpo, Sarbjit Sarkaria, data science team lead ...
Oct. 28, 2016 02:00 AM EDT Reads: 4,396


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Trip Planner : South Pacific / Australia / New South Wales / Port Macquarie / Breweries / Black Duck Brewery
Black Duck Brewery, Port Macquarie
Categories: Breweries, Food & Drink
Black Duck Brewery is located in Port Macquarie. By using our Port Macquarie itinerary maker, you can arrange your visit to Black Duck Brewery and other attractions in Port Macquarie.
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It's a bit unexpected to pull up in an industrial area and finding a cool little brewery with a great vibe and even better beer but the Black Duck is just that! We stopped by and tasted a paddle of lo... read more »
John K
This place has got all the ingredients of a great chill and chat place. Don't let its location in an industrial estate put you off. Good selection of beers, nice finger food and great pizzas. On holid... read more »
A tasting tray of 4 for $5 Great flavours very easy drinking Try the Black beer for an unexpected treat . Pizza available for $15 coffees ciders wines great place for an easy afternoon
Alexei Watson
Delicious range of local beers, fun location. Murphy the Great Dane always soaking up attention too.
Chris Sonn
Lovely place to have a beer, great red ale, and lovely people. Give it a go
Philip Pollock
Create selection of own brewed beer, not just the usual Australian and American pale ale. Check out the IPA. Good pizzas as well
Alex Fagan
Awesome food, brilliant bees! Recommend the near lovers pizza with golden goose APA ;)
Ehh heh heh
As far as breweries go, it's one of the best I've been to. Tasty, cheap and the staff are friendly. A must if you are in or passing through Port Macquarie.
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Grapes from the heralded appellations of Walla Walla, Yakima and Columbia Valley can be found in tasting rooms throughout the city. The region's family-run wineries embrace a hands-on vintning process, and knowledgeable servers can explain each red and white's journey from grape to bottle.
Wine enthusiasts in downtown Spokane can visit a number of tasting rooms and wineries all within close proximity of one another. In addition to award-winning wine, Barrister Winery hosts tours by appointment and art events. Nectar Tasting Room is shared by five wineries and features a rotating "Food Flight" menu. And across from the historic Davenport Hotel, Patit Creek Cellars sells premier Walla Walla wines paired with locally-sourced, light cuisines.
Just minutes east of downtown Spokane local vintners at Arbor Crest, Nodland Cellars and Latah Creek offer award-winning wines and a friendly, educational tasting atmosphere. To really take in the Spokane Valley, visit Arbor Crest's magnificent Cliff House. Perched atop a 450 ft. cliff, this historic building provides panoramic views of the Valley to accompany their array of rich reds and crisp whites.
Weekly tasting events on Thursday evenings - sometimes wine, sometimes beer. Check out the website to see what's coming up!
One of the state's oldest wineries producing award-winning Washington wines. Named one of "50 Great Producers Every Wine Lover Should Know" by Wine Spectator. The Cliff House Tasting Room, located on
Nectar Tasting Room is shared by five Washington wineries in the heart of downtown Spokane providing over 50 wines in one location. Visitors can enjoy wine from Anelare Winery, Coyote Canyon Winery,
Latah Creek offers guests the opportunity to visit one of the most picturesque small wineries in the area. Latah Creek's award winning wines may be sampled at your leisure while you tour the adjoining
We leave the wine flights up to you; choose to create your own adventure or let us be your guide. Try a gourmet cheese plate to pair with one of our elegant reds or refreshing whites and visit us on
Nestled among rows of vines on the Columbia River in Goldendale, Washington, Maryhill is a popular destination with an adjacent 4,000-seat outdoor amphitheater that hosts a world-class summer concert
At Townshend Cellar we are dedicated to producing quality wines from the state of Washington. Our wines derive their distinctive flavors from extensive oak aging in small French and American oak
The Craftsman name is inspired by our winemaker, Greg Shelman. Greg became intrigued with wine after taking a tour of the Napa wine country in 1966. Years after earning a Pharmacy degree from
Over the last fifteen years the Wylie family has been working their estate vineyards in Walla Walla, WA to bring our friends the beauty of Va Piano. Justin & Liz, along with their 3 children:
Nestled in an old fire station in the Historic Warehouse District, Robert Karl Cellars is a boutique winery dedicated to producing world class wines with grapes grown in Washington's new appellation,


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A new Commonwealth Fund report finds that Medicaid managed care plans that are owned by publicly traded for-profit companies whose primary line of business is managing Medicaid enrollees spent an average of 14 percent of premiums on administrative costs, compared with an average of only 10 percent spent by non-publicly traded plans owned by groups of health care providers, health systems, community health centers, or clinics.
Sampling health plans with at least 5,000 enrollees resulted in an initial sample of 225 Medicaid managed care plans representing 23.8 million enrollees. The numbers of plans reporting quality of care measures was limited and varied by measure. Only 27 percent of the publicly traded Medicaid-only plans reported quality measures and scored lower on these measures compared to non-publicly traded plans; they scored 13 percentage points lower when it came to managing chronic illness, and 11 percentage points lower on a composite score measuring preventive care.
"Managed care plans represent a large piece of Medicaid's future, and plans owned by publicly traded companies will likely be a growing share of this market," said lead author Michael McCue, a professor at Virginia Commonwealth University. "In order to assure that Medicaid provides high quality, efficient health care, it will be crucial that state Medicaid directors responsible for managed care contracts take into account publicly traded plans' commitment to Medicaid and whether they are striking the right balance between providing high quality care to patients and increasing earnings."
According to the report, Assessing the Financial Health of Medicaid Managed Care Plans and the Quality of Patient Care They Provide, enrollment in Medicaid managed care is on the rise, and the authors anticipate that rise will continue as most people newly eligible for Medicaid under the Affordable Care Act will likely join managed care plans. In 2009, CMS reported 72 percent of Medicaid enrollees were fully or partially covered by a managed care plan, up from only 55 percent in 2000. From this study sample, the number of enrollees in managed care plans owned by publicly traded companies jumped significantly—from 5.6 million to 9.8 million between 2004 and 2009.
"This report shows us that it is possible for health plans to keep administrative costs down and quality high for Medicaid beneficiaries," said Commonwealth Fund President Karen Davis. "Millions of people are already covered by managed care plans and millions more will be added to their ranks when Medicaid is expanded in 2014 under the Affordable Care Act. Now is the time to ensure performance of private contractors to assure that scarce resources are used wisely and patients get the high quality health care they deserve."
Key Report Findings:
Quality of care data were reported by only one out of four publicly traded Medicaid-only plans. This limited number of plans performed significantly worse than non-publicly traded plans on clinical quality composite measures of preventive care (11 percentage points lower), including childhood immunization status, and adolescent and child well-care visits, and chronic illness care (13 percentage points lower), including diabetes care and appropriate use of medications for asthma for children and adults.
Provider-sponsored health plans had the lowest administrative cost ratio overall, 8%, compared to 12% for non-provider sponsored plans.
When looking at measures of patients' experience with their health care plan, non-publicly traded plans scored seven percent higher in overall patient satisfaction than the Medicaid-only publicly traded plans.
Health plans sponsored by health care providers reported higher quality than non-provider sponsored plans—scoring eight percentage points higher when it comes to managing chronic illness and eight percentage points higher when it come to managing preventive care.
More than 50 percent of Medicaid enrollees in Delaware, Florida, Georgia, Illinois, Indiana, Maryland, Missouri, Nebraska, Nevada, Tennessee, Texas, Washington state, West Virginia, and Wisconsin are enrolled in health care plans managed by publicly traded companies.
The full report will be available on June 15, 2011 at http://www.commonwealthfund.org/Content/Publications/Issue-Briefs/2011/Jun/Financial-Health-Medicaid-Managed-Care.aspx
Mary Mahon | EurekAlert!
Further information:
Further reports about: > Commonwealth > care providers > chronic illness > health care > health care providers
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Researchers from the Institute for Quantum Computing (IQC) at the University of Waterloo led the development of a new extensible wiring technique capable of controlling superconducting quantum bits, representing a significant step towards to the realization of a scalable quantum computer.
"The quantum socket is a wiring method that uses three-dimensional wires based on spring-loaded pins to address individual qubits," said Jeremy Béjanin, a PhD...
In a paper in Scientific Reports, a research team at Worcester Polytechnic Institute describes a novel light-activated phenomenon that could become the basis for applications as diverse as microscopic robotic grippers and more efficient solar cells.
A research team at Worcester Polytechnic Institute (WPI) has developed a revolutionary, light-activated semiconductor nanocomposite material that can be used...
By forcefully embedding two silicon atoms in a diamond matrix, Sandia researchers have demonstrated for the first time on a single chip all the components needed to create a quantum bridge to link quantum computers together.
"People have already built small quantum computers," says Sandia researcher Ryan Camacho. "Maybe the first useful one won't be a single giant quantum computer...
COMPAMED has become the leading international marketplace for suppliers of medical manufacturing. The trade fair, which takes place every November and is co-located to MEDICA in Dusseldorf, has been steadily growing over the past years and shows that medical technology remains a rapidly growing market.
In 2016, the joint pavilion by the IVAM Microtechnology Network, the Product Market "High-tech for Medical Devices", will be located in Hall 8a again and will...
'Ferroelectric' materials can switch between different states of electrical polarization in response to an external electric field. This flexibility means they show promise for many applications, for example in electronic devices and computer memory. Current ferroelectric materials are highly valued for their thermal and chemical stability and rapid electro-mechanical responses, but creating a material that is scalable down to the tiny sizes needed for technologies like silicon-based semiconductors (Si-based CMOS) has proven challenging.
Now, Hiroshi Funakubo and co-workers at the Tokyo Institute of Technology, in collaboration with researchers across Japan, have conducted experiments to...
#IC2S2: When Social Science meets Computer Science - GESIS will host the IC2S2 conference 2017
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World Health Summit – Day Three: A Call to Action
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21.10.2016 | Health and Medicine
Stanford researchers create new special-purpose computer that may someday save us billions
21.10.2016 | Information Technology
From ancient fossils to future cars
21.10.2016 | Materials Sciences


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Image Copyright © The Institution of Mechanical Engineers / Mary Evans
Media ID 5081795 from Prints Online
Watermarking and Website Address do not appear on finished products
Creation Date: 23rd May 2011
1795, automobile, boiler, boilers, boulton, company, engine, grimshaw, hills, making, motor, motoring, plant, rope, scar, steam, transport, transportation, watt, webster
Service was so efficient I shall not hesitate to use them again.
reviewed by Mrs Peter Pan
9th June 2016
Arrived packed well as described very good seller
reviewed by susan smith
17th May 2016
Fast delivery. Would buy from this seller again
reviewed by Glamrock
16th June 2016
Iam very happy with the mugs and I will buy again off the seller thanks emma
reviewed by Emma S
25th April 2016
arrived early, very well packaged, as always media storehouse are very good people to buy from, the picture of dame maggie smith is excellent. But like everything that she is in she is fantastic and very beautiful. thankyou.
reviewed by amanda smith
8th June 2016
Print arrived well within Estimated Delivery Date, very well packaged, excellent condition and as described, thanks.
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23rd July 2016


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Foam Roofs in Hallsville, TX
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The former Victorian Premier has called for performance bonuses of CEOs to be linked to the mental well-being of employees
In the past five years more than half of Australian working women have experienced gender inequality
Registrations are open for the Employment Law for HR Professionals Masterclass, which is heading to Perth in February 2013.
Following sell-out seminars in Sydney, Melbourne and Brisbane over the past few months, we have brought together a new line-up of leading workplace relations lawyers to present a valuable program that focuses on the employment law issues affecting Western Australia.
From recent adverse action cases to social media policies, the latest in WHS laws and ways to manage ill and injured workers, the Employment Law for HR Professionals Masterclass is a valuable event for any HR practitioner or people manager.
For more information about the program and to register click here. Super Saver discounts apply until next Friday 21st December.
Having chaired the Brisbane event I would recommend it to any HR practitioner who wants to learn more about the Specialist IR field.
The government's plans to crackdown on paid parental leave has been met with some stinging criticism
Staff in Victoria and New South Wales have the best chance of getting a pay rise, claims new research


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The Rev. Quentin Chin, pastor of First Congregational Church, UCC, at 514 Main St., has announced the church's Christmas Eve services.
A family worship will be held at 4 p.m. Thursday in the Sanctuary and a candlelight service of lessons and carols will be celebrated at 8 p.m. in the Chapel.
All are welcome to attend.


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- Nursing students to prep for disasterbradenton.com
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Powershot S60
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Visitors of Steves can visit the stores below for real-time pricing and availability. You can also find hot, soon to expire online offers on a variety of cameras and accessories at our very own Camera Deals page.
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