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*From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH.
Correspondence to: Jonathan P. Parsons, MD, Division of Pulmonary and Critical Care Medicine, The Ohio State University, 201 HLRI, 473 W 12th Ave, Columbus, OH 43210; e-mail: firstname.lastname@example.com
Exercise-induced bronchoconstriction (EIB) describes airway narrowing that occurs in association with exercise. EIB occurs in up to 90% of asthmatic patients and is estimated to occur in > 10% of the general population. Recent reviews have identified asthma as a risk factor for sudden death and have reported many deaths that have been attributed directly to EIB. We present a review of the literature related to EIB in athletes including sections discussing its pathogenesis, diagnosis, and treatment, and which athletes are most at risk for experiencing EIB.
Exercise-induced bronchoconstriction (EIB) describes acute, transient airway narrowing that occurs during and most often after exercise. EIB objectively is defined as a ≥ 10% decline in FEV1 after appropriate exercise provocation.1Exercise is the most common trigger of bronchospasm in those who are known to be asthmatic, and 50 to 90% of all individuals with asthma have airways that are hyperreactive to exercise.2However, EIB also occurs in up to 10% of subjects who are not known to be atopic or asthmatic.3
The public health consequences of unrecognized or inadequately treated EIB are significant. In reviewing > 30 years of Israeli military recruit data, Amital et al4found that asthma was the single greatest risk factor for unexplained death. Becker et al5 identified 61 deaths over a 7-year period that met the criteria of an asthma death occurring in close association with a sporting event or physical activity. Of these deaths, 81% occurred in subjects who were younger than 21 years of age and 57% occurred in subjects who were considered to be elite or competitive. Strikingly, almost 10% of deaths in this review occurred in subjects with no known history of asthma or EIB. Results from these reviews suggest that all individuals involved in organized sports or physical activity should be cognizant of the risk of EIB. Coaches, trainers, and team physicians who care for competitive athletes who have asthma or EIB should be specifically trained in the recognition and treatment of EIB.
The prevalence rates of bronchospasm related to exercise in athletes range from 11 to 50%2 (Table 1
), and up to 90% of subjects with asthma will have EIB.,6Wilber at al7found that 18 to 26% of Olympic winter sport athletes and 50% of cross-country skiers were found to have EIB. Of the 50 elite summer athletes studied, with and without asthma, Holzer et al8found 50% to have EIB. Mannix et al9studied 124 elite figure skaters and tested them on an ice rink during their figure-skating routines. Thirty-five percent had a significant postexercise drop in their FEV1. The US Olympic Committee10 reported an 11.2% prevalence of EIB in all athletes who competed in the 1984 summer Olympics.
Despite numerous studies that have investigated the prevalence of EIB in athletes, most either included asthmatic patients in their data analysis or did not indicate what proportion were asthmatic prior to study enrollment, which makes it difficult to accurately estimate the prevalence of EIB in nonasthmatic athletes. Few studies have investigated the prevalence of EIB in cohorts of athletes without a known history of asthma or EIB. Rupp et al11evaluated 230 middle school and high school student athletes and, after excluding those with known EIB, found that 29% had a ≥ 15% reduction in their FEV1 after exercise challenge. Weiler et al12 found that 12% of college football players at the University of Iowa admitted to a history of asthma, 19% had respiratory symptoms postexercise, and 50% had evidence of bronchial hyperreactivity after bronchoprovocation. When members at an urban fitness center were studied, Mannix et al13 found that 41 of 212 subjects (19%), none of whom had previously received a diagnosis of asthma, had EIB. These studies suggested that EIB occurs frequently in subjects who are not known to be asthmatic and likely is underdiagnosed clinically.
The prevalence of EIB in athletes may be further underappreciated as patients with asthma and hyperreactive airways have been shown to be poor perceivers of symptoms of bronchospasm.14–16 Athletes, specifically, often experience a lack of awareness of symptoms that are suggestive of EIB.17–18 Athletes are generally fit and healthy, and the presence of a significant medical problem often is not considered. The athlete is often considered to be "out of shape," and vague symptoms of chest discomfort, breathlessness, and fatigue may not be interpreted as a manifestation of EIB. Athletes themselves are often not aware that they may have a physical problem. Furthermore, if they do recognize they have a medical problem, they often do not want to admit to health personnel that a problem exists.19
The pathogenesis of EIB is likely multifactorial and is not completely understood. The predominant hypothesis for the etiology of EIB is that breathing relatively dry air causes the airways to narrow by osmotic and thermal consequences of evaporative water loss from the airway surface.20These stimuli have been demonstrated to cause cough21and mucus production22independently in patients without predisposing respiratory conditions such as asthma. The hyperosmolar environment created by evaporative water loss may result in the release of mediators such as histamine, which is a potent bronchoconstrictor, from mast cell degranulation.23
During exercise, large volumes of air that are often colder than body temperature are exchanged. This large volume of air often overwhelms the ability of the upper airway to warm the air effectively, and, consequently, cool air reaches the distal airways. It has been suggested that cold air in the distal airways results in airway narrowing due to reactive hyperemia of the bronchial vasculature, and the subsequent increased hydrostatic pressures in the capillary bed lead to airway edema.24Kanazawa et al25 found that increased airway vascular permeability correlates with the severity of EIB in asthmatic patients. These data suggest that vascular responses in the distal capillaries are likely to be involved in the development of EIB.
Inflammation also plays an important role in the pathogenesis of EIB in asthmatic subjects. Asthma results from a chronic inflammatory cascade that ultimately results in airway inflammation, mucus production, smooth muscle hypertrophy, and bronchospasm.26A significant correlation has been reported between the severity of EIB and the degree of peripheral blood eosinophilia27and eosinophilic inflammation in induced sputum28 in asthmatic patients.
Although inflammation is a critical component of asthma and EIB that occurs in asthmatic patients, the role or significance of inflammation in the pathogenesis of EIB in subjects without asthma is unclear. The term exercise-induced asthma is often used interchangeably with EIB; however, EIB that occurs in athletes without a history of asthma who have normal lung function may be a distinct phenomenon from bronchospasm occurring as a manifestation of asthma. While the relationship between inflammation and airway hyperresponsiveness in nonasthmatic EIB patients is not well-understood, some evidence suggests that inflammation is increased in the airways of subjects without asthma after exercise or hyperventilation challenge. Karjalainen et al29measured mucosal inflammatory cell infiltration in the subepithelial basement membrane in endobronchial biopsy specimens of the proximal airways from 40 elite skiers without asthma. Biopsy specimens from the elite skiers were compared to biopsy specimens of 12 asthmatic subjects. The authors found that skiers had a greater degree of neutrophil infiltration, which is not typical in either atopic or nonatopic asthma. Furthermore, skiers had a lesser degree of infiltration with eosinophils, mast cells, and macrophages. These results suggest that the inflammatory process in these athletes may be different from that in asthmatic individuals. Larsson et al30found that a short exposure to cold air while running induced an increase in the number of granulocytes and macrophages in the BAL fluid of healthy subjects. Repetitive hyperpnea itself has been shown to recruit eosinophils to the airways and to promote the release of inflammatory cytokines.31 Although inflammatory cells have been documented in the airways of nonasthmatic subjects, whether they play a direct role in the development of airway hyperresponsiveness in nonasthmatic athletes that experience EIB is not known.
Exhaled nitric oxide (NO) is emerging as a new technique that may help to identify subjects with airway inflammation. EIB is currently thought to occur in part due to vasomotor changes related to relatively cool air in the distal airways. Because NO has profound effects on airway and vasomotor tone, it may be intimately involved in mediating the thermal consequences of exercise. Kotaru et al32 demonstrated that during hyperventilation asthmatic subjects generated approximately 55% more NO per minute than did healthy control subjects, even though their level of ventilation was approximately 66% lower. In contrast to healthy subjects, NO production in the asthmatic patients continued into the recovery period after the challenge stopped, and the fraction of exhaled NO rose temporally as the airflow limitation developed. These results suggest that NO plays a significant role in the development of airway obstruction that follows hyperventilation, and the quantification of exhaled NO may help to identify athletes who are at risk for experiencing EIB.
Although athletes who compete in high-ventilation or endurance sports (Table 2
) are more likely to experiences symptoms of EIB than those who participate in low-ventilation sports,33 EIB can occur in any setting.13 It is especially prevalent in endurance events such as cross-country skiing, swimming, and long-distance running33 in which ventilation is increased for long periods of time during training and competition, allowing for relatively more evaporative water loss and subsequent airway narrowing. There is also increased prevalence of EIB in winter sports athletes,7 which is thought to be due in part to the increased cooling of airways and the relative increase in reactive hyperemia in the pulmonary vasculature. It is important for athletes, coaches, and trainers supervising athletes in these "higher risk" sports to be aware of the increased incidence of EIB in these populations of athletes.
Athletes who participate in environments in which there may be environmental pollutants are at increased risk for the development of EIB. Chlorine compounds in swimming pools34and chemicals related to ice-resurfacing machinery in ice rinks35 may put certain populations of athletes at additional risk. Particulate matter and gases such as carbon monoxide and nitrogen dioxide, which are abundant in indoor ice arenas, and chlorine from swimming pools may act as allergic "triggers" and may exacerbate bronchospasm in athletes who are predisposed to EIB. Helenius and Haahtela34 showed a 96-fold greater risk of asthma in atopic swimmers when compared to nonatopic control subjects when atopy and swimming were included in multivariate statistical analysis. Leuppi et al36 found a 35% incidence of airway hyperresponsiveness in a group of ice-hockey players. In addition, figure skaters have been shown to have a high incidence of EIB.7,9
The clinical manifestations of EIB can range from mild impairment of performance to, less commonly, severe bronchospasm and respiratory failure. Common symptoms include coughing, wheezing, chest tightness, and dyspnea. More subtle evidence of EIB includes fatigue, symptoms that occur in specific environments (ie, ice rinks or swimming pools), poor performance for conditioning level, and avoidance of activity.
Generally, an exercise duration of 5 to 8 min at a workload representing at least 80% of the maximal predicted oxygen consumption is required to generate bronchospasm in most athletes.37Typically, athletes experience transient bronchodilation during exercise and experience symptoms of EIB shortly after exercise. Usually, symptoms peak 5 to 10 min after exercise ceases and can remain significant for 30 min if no bronchodilator therapy is provided.38 Even in the absence of intervention with bronchodilator therapy, many athletes will spontaneously recover to baseline airflow within 60 min.37 Athletes who experience symptoms for extended periods often perform at suboptimal levels for significant portions of their competitive or recreational activities.
The presence of EIB has been shown to be difficult to diagnose clinically as symptoms are often nonspecific.33 The lack of standard diagnostic methodology in the past is partly responsible for the large variability in the reported prevalence of EIB across different sports.2Figure 1
demonstrates our clinical approach to the diagnosis of EIB. A complete history should be taken and a complete physical examination should be performed on each athlete who has respiratory complaints associated with exercise. Other medical problems that can mimic EIB and that need to be considered in the initial evaluation of exertional dyspnea include vocal cord dysfunction, cardiac arrhythmias, and pulmonary or cardiac shunts. A comprehensive history and physical examination are recommended to help rule out these disorders; however, the examination findings are often normal in athletes with EIB. A history of specific symptoms in particular environments or during specific activities should be elicited. A thorough family and occupational history should also be obtained, as a family history of asthma increases the risk of a family member developing asthma.39
Despite the value of a comprehensive history of the athlete with exertional dyspnea, the diagnosis of EIB based on self-reported symptoms alone has been shown to be inaccurate. Rundell et al17 demonstrated that only 61% of EIB-positive athletes reported symptoms of EIB, while 45% of athletes with normal pulmonary function reported symptoms. Similarly, Hallstrand et al40 found that screening histories of identified subjects with symptoms or a previous diagnosis suggestive of EIB in 39.5% of the participants, but only 12.9% of these persons actually had EIB. Surprisingly, 7.8% of adolescents in that study with a globally negative review of symptoms of asthma or EIB actually had EIB. Holzer et al8 reported that only 60% of athletes with a positive result for an exercise challenge test reported symptoms. The lack of sensitivity and specificity of the history and physical examination in the evaluation of EIB requires the clinician to perform objective diagnostic testing when there is a suspicion of EIB.
Objective testing should begin with spirometry before and after inhaled bronchodilator therapy, which frequently will identify athletes who have abnormal baseline lung function. However, many athletes who are not asthmatic but who experience EIB will have will have normal baseline lung function.41In this cohort of athletes, spirometry alone is not adequate to diagnose EIB. Significant numbers of false-negative results may occur if adequate exercise and environmental stress is not provided in the evaluation for EIB. In athletes with normal findings on physical examination and spirometry, bronchoprovocation testing is recommended. A positive bronchoprovocation test result indicates a need for treatment for EIB. Objective change (usually a ≥ 10% decrease in FEV1) between pre-bronchoprovocation testing and post-bronchoprovocation testing values is necessary to confirm the diagnosis of EIB.42 If the athlete with persistent exercise-related symptoms has negative physical examination, spirometry, and bronchoprovocation testing results, we recommend reconsidering alternative diagnoses.
Various bronchoprovocation techniques exist; however, not all are equally valuable or accurate in assessing EIB in athletes. The International Olympic Committee adopted the eucapnic voluntary hyperventilation (EVH) challenge as the test recommended to document EIB in olympians.43EVH involves the hyperventilation of a gas mixture of 5% CO2 and 21% O2 at 85% of maximum voluntary ventilation for 6 min and the assessment of FEV1 at specified intervals after the test; this challenge test has been shown to have a high specificity44 for EIB. EVH has been shown to be more sensitive in some studies for detecting EIB than methacholine8 or field or laboratory-based exercise testing.44–45 The test is portable, relatively inexpensive, and there are protocols46that allow standardization between laboratories. Mannix et al47 used EVH to screen 79 high school athletes and found that 38% of them had EIB. EVH is an extremely valuable bronchoprovocation technique given its sensitivity and specificity, portability, and standardization of protocol. It is possible that the increased sensitivity of EVH for detecting EIB will demonstrate prevalence rates in athletes that are higher than those previously reported.
Pharmacologic challenge tests, such as the methacholine or histamine challenge test, have been shown to have a lower sensitivity than EVH for the detection of EIB in elite athletes8 and are not recommended first-line tests for use in the evaluation of EIB in athletes. Holzer et al8 showed that of 42 elite athletes with respiratory symptoms, EVH detected 25 (60%) while methacholine challenge detected only 9 (21%).
A newer, promising technique involves the inhalation of mannitol in dry-powder form. Holzer et al48 studied 50 athletes and demonstrated that osmotic challenge testing with dry-powder mannitol challenge has both a high sensitivity and specificity for EIB. Mannitol had a sensitivity of 96% and a specificity of 92% to identify a positive response to EVH, and could be used as an alternative to EVH testing to identify EIB if EVH testing is not available. However, mannitol inhalation does not simulate exercise, and, currently, only one study has investigated its value in detecting EIB specifically in athletes.48
Pharmacologic therapy (Table 3
) for EIB has been studied extensively; however, most studies have included asthmatic athletes, and there are no guidelines currently available to guide pharmacotherapy in nonasthmatic EIB patients. It is not known whether the recommended therapy for EIB in asthmatic athletes is as efficacious in nonasthmatic athletes who experience EIB.
The most common therapeutic recommendation for minimizing or preventing symptoms in athletes who have EIB is the prophylactic use of short-acting bronchodilators (ie, β2-receptor agonists) such as albuterol shortly before exercise. β2-agonists are considered to be the most effective therapy for the prevention of symptoms of EIB in asthmatic patients.37,49Treatment with two puffs of a short-acting β2-receptor agonists shortly before (15 min) exercise will provide peak bronchodilation in 15 to 60 min and protection from EIB for at least 3 h in most patients.50 However, the overuse of β2-agonists has been shown to result in tachyphylaxis and to worsen symptoms of EIB and asthma.,49
Long-acting bronchodilators work in a pharmacologically similar manner as short-acting bronchodilators. The bronchoprotection afforded by long-acting β2-receptor agonists has been shown to last up to 12 h,51whereas the effect of albuterol is no longer significant by 4 h.52Ferrari et al53demonstrated that the inhalation of formoterol, a long-acting β2-receptor agonist, is effective in protecting asthmatic athletes as early as 15 min after dosing. Furthermore, Ferrari et al54 compared the effects of formoterol vs salmeterol in preventing EIB and again found that formoterol was effective 15 min after dosing, but that salmeterol was not effective that rapidly. Both medications were equally effective at 4 h. In a study comparing the average onset of action of formoterol vs salmeterol, Palmqvist et al55found that formoterol was effective in approximately 12 min while salmeterol was effective after 31 min. The results of these studies suggest that there are differences in the pharmacokinetics between salmeterol and formoterol, and that administration of salmeterol should occur significantly in advance of exercise for it to be optimally effective in preventing EIB. It is also important to stress the fact that long-acting β2-receptor agonists in general are not rescue medications and should not be used more than twice a day. Tachyphylaxis also has been shown to occur after repeated use of long-acting β2-receptor agonists56; thus, close follow-up is recommended when using these medications.
Inhaled corticosteroids are recommended as first-line therapy in terms of controller medications for athletes who have asthma and experience EIB.26 Airway inflammation is also often present in nonasthmatic athletes who have EIB,30,57and, therefore, inhaled corticosteroids may be an effective medicine for treatment; however, the efficacy of corticosteroids in this cohort has not been studied. Thio et al58showed that a single high dose of inhaled fluticasone propionate had an acute protective effect on the bronchial response to exercise in a substantial proportion of asthmatic patients enrolled in the study. Similarly, Jonasson59 concluded that patients with mild asthma, but with significant EIB, improved their exercise tolerance and symptom control after 3 months of treatment with a low dose of inhaled budesonide administered once or twice daily.
Leukotriene modifiers have been shown to be effective in controlling patients with EIB.60–64 Leukotriene modifiers have become an attractive therapy for EIB as a result of their efficacy, once-a-day dosing, and oral formulation. Leff et al65evaluated the ability of montelukast, a leukotriene-receptor antagonist, to protect patients against EIB. Montelukast therapy offered significantly greater protection against EIB than placebo therapy and was also associated with a significant improvement in the maximal decrease in FEV1 after exercise. In addition, tolerance to the medication and rebound worsening of lung function after the discontinuation of treatment were not seen. Rundell et al66 found that a single dose of montelukast provided reasonable protection in attenuating bronchoconstriction resulting from either exercise or EVH.
Leukotriene modifiers may be a more effective alternative in treating EIB than long-acting β2-receptor agonists. Villaran et al67evaluated 192 asthmatic patients with documented EIB and found that the effect of montelukast was greater than that of salmeterol in the long-term treatment of EIB over a period of 8 weeks in patients with mild asthma, as demonstrated by effect size, maintenance of the effect, and fewer respiratory clinical adverse events during the study period. Inhaled corticosteroids have been shown to be superior to leukotriene modifiers in managing chronic asthma.68 However, we are aware of no studies comparing these medications head-to-head in terms of their effectiveness in preventing EIB in athletes.
Mast cell stabilizers have been used extensively for the prophylaxis of EIB. These medications prevent mast cell degranulation and subsequent histamine release.69When a dose of either cromolyn or nedocromil has been administered to athletes 15 to 20 min prior to exercise, both agent have been shown to be effective in preventing EIB.70–71 In a metaanalysis72 of the prevention of EIB in asthmatic patients, nedocromil sodium was found to improve FEV1 by an average of 16% and to shorten the duration of EIB symptoms to < 10 min. While these agents are effective, they are often used as a second-line agent due to their cost, and the fact that their duration of action and efficacy is less than that of β-agonists.
Multiple pharmacologic approaches can be employed in the same patient if necessary. Combination inhalers (eg, fluticasone/salmeterol) have been become popular as a result of their effectiveness and convenience. Weiler et al73showed that long-term fluticasone/salmeterol therapy provided protection against exercise-induced bronchospasm in patients with persistent asthma. Woolley et al74 demonstrated that athletes in their cohort had a longer duration of protection from a combination of short-acting β2-receptor agonists and cromolyn compounds than from either medication used as monotherapy.
Other less commonly used inhaled pharmacologic agents that have been shown to prevent EIB include heparin75–76 and furosemide.77–78 However, the sample sizes in these studies were small, and the effects of these medications need to be validated in larger studies.
Many athletes find that a period of precompetition warm-up reduces the symptoms of EIB that occur during their competitive activity. Athletes often draw this conclusion without any guidance from health-care specialists. Symptoms of EIB usually occur after a few minutes of exercise, and some athletes find that warming up before exercise acts as prophylaxis against more significant episodes of EIB during exercise. It has been shown by investigators that this phenomenon of the "refractory period" does occur in some athletes with asthma and that athletes can be refractory to an exercise task performed within 2 h of an exercise warm-up.79–81 The refractory period is hypothesized to be secondary to the release of catecholamines such as epinephrine and norepinephrine, which are bronchodilators and to depletion of mast cell contents such as histamine which cause bronchoconstriction. However, the refractory period has not been consistently proven across different athletic populations and has not been well-documented in EIB-positive athletes who are not asthmatic.82
There are other nonpharmacologic strategies (Table 3) that athletes can employ to help reduce the frequency and severity of symptoms of EIB. Wearing a facemask during activity warms and humidifies inspired air when outdoor conditions are cold and dry, and is especially valuable to elite and recreational athletes who exercise in the winter.83Breathing through the nose rather than the mouth will also help to ameliorate EIB84 by warming, filtering, and humidifying the air, which subsequently reduces airway cooling and dehydration. In addition, athletes with knowledge of triggers (ie, freshly cut grass) should attempt to avoid them if possible.
In our experience, both pharmacologic and nonpharmacologic approaches are essential to minimizing the adverse effects of EIB. We recommend starting athletes that have clinical evidence of EIB on therapy with short-acting bronchodilators before exercise, and instructing them on the importance of adequate warm-up and avoidance of known triggers. This regimen will prevent significant EIB in > 80% of athletes.26 If symptoms persist, especially in athletes with asthma, inhaled corticosteroids should be added as maintenance therapy.26,58–59 While the efficacy of therapy with inhaled steroids in nonasthmatic athletes has not been extensively evaluated, we recommend using them in nonasthmatic athletes whose symptoms are not completely controlled with short-acting bronchodilators, as there is evidence of increased inflammation, although not typical of classic asthma, in the airways of subjects without known asthma as a result of hyperventilation and exercise.29–30 Alternatively, leukotriene modifiers65 or cromolyn compounds26,70–71 can be used in athletes whose asthma is inadequately controlled with β2-agonists.
EIB in athletes is a problem that is likely more prevalent than currently clinically recognized. The consequences of misdiagnosis or the failure to diagnose entirely can result in the impairment of performance and can be detrimental to health. The cohort of athletes who experience EIB but are not asthmatic needs further study. There are many unanswered questions about the pathogenesis of EIB in this cohort and whether therapy targeted at EIB in asthmatic patients is as effective in nonasthmatic athletes who experience EIB. Physicians and trainers must have a high index of suspicion when healthy athletes complain of symptoms during exercise. Most importantly, the education of both athletes and health-care providers, in terms of recognition of an impending or ongoing episode of EIB and appropriate treatment for such an episode, is paramount.
Abbreviations: EIB = exercise-induced bronchoconstriction; EVH = eucapnic voluntary hyperventilation; NO = nitric oxide
Learning objectives: 1) Identify the most common trigger of bronchospasms in individuals known to be asthmatic. 2) List the most common clinical manifestations of exercise-induced bronchoconstriction. 3) State the most established diagnostic indicator of exercise-induced bronchoconstriction. 4) Indicate preventative methods that should be considered by those individuals who participate in organized sports who are also known asthmatics.
The following authors have disclosed financial relationships with a commercial party. Grant information and company names appear as provided by the presenter: Jonathan P. Parsons, MD: GlaxoSmithKline: Speaker bureau; The CHEST Foundation: $10,000 grant (from sources other than industry). John G. Mastronarde, MD, FCCP: GlaxoSmithKline: Speaker bureau.
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Whether you began your search seeking for a counsellor, a psychotherapist or a homeopath, read on if you are interested in working with someone who offers something a little different, developed by way of over twenty-five years of experience.
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Q: My mother is declining and I'm afraid she has Alzheimer's, but my siblings don't believe me. I'm the one who takes care of her, so I'm resenting how they just don't get it. What should I do?
A: It can seem pretty isolating when you see your mom deteriorating while your brothers and sisters don't share your view. If they live farther away and don't see your mom as often as you do, then their view is going to be different because they simply don't see what you see.
They may be visiting with mom or talking to her on the phone during a short period of time when she acts perfectly normal. Some people in the early stages of Alzheimer's, especially if they have good social skills, can be very good at masking their deficits.
The best way to get all of you on the same page is to get to the heart of the matter and find out exactly what's going on with your mother. What may look like Alzheimer's to you, could be a side-effect from medication, signs of clinical depression, the results of a mini-stroke or even a B-12 deficiency.
Your mom would do well to receive a geriatric assessment that includes a battery of tests that could determine whether she is suffering from some form of dementia or another condition.
Once those tests are completed, it would be helpful if the results can be shared with you and your siblings by your mother's physician. For those who live out of town and can't make the appointment, then make arrangements with the doctor's office for a conference call.
If the office doesn't have that capacity, then at least have one other sibling attend with you. You could also bring a cell phone and call another sibling and place them on speaker while the doctor explains your mother's condition.
The objective is for at least one of your siblings to hear the same thing you hear from the doctor and for both of you to have the opportunity to ask questions. Following that session, you should share with each other what you heard the doctor say and then jot down notes of what you'll tell your other siblings.
By involving your brothers and sisters early in the diagnosis, they'll feel included and they won't have to second-guess whether your instincts are correct.
If it turns out to be Alzheimer's or any other serious illness that requires a good deal of caregiving on your part, then it will be important for all of you to understand the course of the disease and what to expect in terms of the care your mom will need.
The more the entire family understands how Alzheimer's progresses, then the more likely you'll be able to act as a team. No matter where each of you live, each of you could attend a support group offered by your local Alzheimer's Association or hospital.
One way for other family members to appreciate the caregiving needs of a loved one is to spend two to three days caring for them while the caregiver leaves for a short break.
It's also a good idea to keep a journal for a week describing the tasks you perform to take care of your mother. Giving her medications, taking her to doctor's appointments, preparing meals, taking her to adult day care, helping her with exercises, performing household chores, addressing her emotional needs, and keeping her safe are just some of the things you're likely doing all week long.
Share the list with your siblings and ask if any of them would like to volunteer to help with any of the items on the list. Even from a distance, someone can make arrangements for doctor's appointments, pay bills, look up information on medications, research medical conditions or make calls to Medicare and insurance carriers.
Everyone can pitch in to help pay for a housecleaning service to make your life easier or send some catered meals your way.
Reach out to your siblings — caring for mom is a family affair.
Contact Linda Rhodes at email@example.com.


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Feb 10, 2015 Comics
Feb 21, 2014 Fashion
Things Get Weird at NYFW
Maybe we just don't get fashion? But what if we did? That's pretty trippy if you ask us. So naturally, when we had all this B-roll eye candy left over from our fashion week coverage, we got stoned and made this video.
Jan 21, 2013 Stuff
Make Sure You're Alive to Collect
It was Christmas of 1990 in my grandmother's house. My Aunt Debra reached behind her and pulled a bullet from a box on a nearby bookshelf. She held it between her thumb and forefinger, looked at my mother, and said, "Janna, this has your name on it."


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Results 1 to 7 of 7
04-22-2008, 09:29 AM #1Junior Guru
- Join Date
- Aug 2007
- Posts
- 184
Need some help and suggestions in advertising...
I was thinking of buying an ad space for one of our sites that is solely put up for a free printer promo we are affiliated with. I need some recommendations for other websites in which majority of the traffic are US and Canada based. I am more intersted in traffic that are business related as the promo would cater to business owners, small to medium corporations. organizations, etc.
The site - freeprinterpromo.com - would only accept ISP's from US and Canada. I have been getting good traffic on it from our own sites but would really want to market it more for greater reach. Would also be willing to spend a little on it.
Kindly give me some suggestions on sites or forum you have advertised before.
You may also PM me if you would like to recommend your own site - please provide your traffic stats, rate for banner or text ads, and other pertinent details.
Hope to hear from you
Not sure how much help you will get considering this is a SEM/SEO forumJaan Kanellis | iNET Interactive
04-24-2008, 01:31 PM #3Junior Guru
- Join Date
- Aug 2007
- Posts
- 184
And most web owners are also participating here - the reason why I posted this thread in this section. I want to know of other sites that offer sitewide links which have the traffic demographics I want to target.
Well I can tell you it is not a good idea to buy or sell links, especially Google.
Google is actively looking to demote and ban all those that buy and sell links for the purpose of manipulating search results.
Even if you are buying them just for traffic you could still be at risk.Jaan Kanellis | iNET Interactive
04-25-2008, 08:40 AM #5Newbie
- Join Date
- Apr 2008
- Posts
- 19
For purchase of references me google not to ban, but it is necessary to do all cautiously.
Many companies find direct mail to be highly effective.
04-25-2008, 01:57 PM #6Junior Guru
- Join Date
- Nov 2002
- Location
- Posts
- 211
It seems to me that if the links are of same interestCpwebhosting.net where the customer is first
Great Affiliate Program Call 321-205-9003
Earn on CPA up to $100.00 on Shared Hosting
04-25-2008, 03:54 PM #7Junior Guru
- Join Date
- Aug 2007
- Posts
- 184
I need the ad placement to be targeted so as to reach the right audience (as mentioned in my post). I am more geared towards conversion. Adsense is my second choice for this campaign. I am looking for a site that would render me the right traffic as I have other projects that I may want to advertise in that site if it would yield good results.


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Steelton-Highspire School District's proposed balanced budget could mean fewer teachers and staff and reduced hours.
Susan Helms, district accountant, presented a preliminary 2013-14 budget to school board members Monday night of about $18.9 million, a 2 percent decrease from last year's nearly $19.7 million budget.
The proposed budget "will impact negatively some of our staff and some of our students, but with the understanding that it will at least provide this district with the ability to balance its budget and provide its major mission for the majority of our students," said Superintendent Audrey Utley.
As Helms outlined the preliminary budget, she ran down a list of proposed cuts to shave off about $759,500. The proposal also would increase the district's 24.837-mill property levy by 0.64 mils, bringing it to 25.477 mils.
The increase would mean the owner of a house assessed at $40,000 would pay $25 more a year, Helms said. The district's tax rate is one of the highest in Dauphin County schools — second only to Harrisburg School District.
Proposed cost-saving measures included:
- Cutting six Steelton-Highspire Education Association employees for a savings of about $340,000;
- Demoting four SHEA employees to part time to save about $133,000 and one American Federation of State, County and Municipal Employees secretary to part time for a savings of about $20,000;
- Reducing the summer days of five SHEA employees for a savings of about $14,000;
- Eliminating one ACT 93 position to save about $90,000, one business office position to save about $60,000, and five stipend positions, about $14,000;
- Eliminating nine para-professional positions to save about $80,000 and four coaching positions to save about $6,500.
- Discontinuing the drug-testing program for a savings of about $1,000;
- Reducing band transportation to competitions to save about $1,000.
ACT 93 positions are administrators in the district, Utley said.
Utley expected the district would get "firmer numbers" on costs and state funding, as it moved closer to May when it must pass a tentative budget.
"Every year, this is probably the most difficult thing that we also have to do," Utley said. "But we have no choice but to make sure that we are able to provide the educational programs that are needed and required and provide our students with the best education that we can afford."
Officials also are factoring into the 2013-14 budget a payment toward the district's negative fund balance, which currently is about $2.1 million, Utley said.
Judge Jeannine Turgeon on Monday approved the district's request for permission to borrow up to $2.5 million to pay off its deficit.
The district plans to pay off the deficit over a 10-year period at about $275,000 a year.


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Bill O'Reilly wants to rap with Jon Stewart.
The host of Fox News Channel's "The O'Reilly Factor" has invited the host of Comedy Central's "The Daily Show" as a guest Monday. Fox News said Friday that O'Reilly and Stewart will debate the invitation for Grammy Award-winning rapper Common to perform at a White House poetry night this week.
O'Reilly has criticized Common's presence at Wednesday's event. He says some of Common's lyrics celebrate violence.
Here's what one reader, lakergrad11, had to say about the story:
"I can't wait to see Stewart take on O'Reilly and show him who the better journalist is because Stewart wont back down to O'Reilly like so many of his other debaters."
» Read the entire story and see all the comments
» Become a public blogger on syracuse.com
» Connect with syracuse.com
» Read all the Your Comments


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Register for online non-medical counseling and health and wellness coaching.
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Other Resources
There's more to a military family than moving and deployments — take us along through each phase of your military life. And don't worry; we can help with the big stuff, too.
Keeping Your Kids Safe and Sound
Money matters can be tricky. We can help you make informed decisions on navigating legal and financial questions or point you to the resources that can help.
Retiring from the Guard or Reserves?
We've got your back. Protect yourself, and make health a priority with our support.
Good Relationships: Worth the Work
Attention all members of a military family: Take a peek at our cheat sheet for all things career and education-related.
Internships: A Place to Start
Let us help you make the most of your new assignment from planning each step of your move to confirming that your new commisary does — in fact — stock your favorite kind of cereal. What would a new place be without a little adventure.
Prepare Your Disaster Kit
The one constant of military life is that it changes — quickly. Be ready for the next chapter.
Deployment Childcare is Hard for All
Whether the death is of a parent who didn't return from war or a classmate killed in a car crash, teens are likely to feel emotions associated with grief very intensely, but they may lack the coping skills that adults have. Helping adolescents work through the loss of someone close can be especially difficult for family members and friends who are supporting them.
Grieving teenagers may respond to the loss with any combination of these feelings: sadness and depression, fear and anxiety, anger and irritability or confusion. You may notice that they are withdrawn, behaving recklessly, having difficulty sleeping, struggling at school or showing a new interest in death. As a parent, relative, or friend, your support and understanding will be needed, even if you're also grieving.
Adolescents can be difficult to relate to under normal circumstances. Their typical ways of interacting are likely to intensify when they're coping with a loss. Regardless of how they may be reacting, keep in mind that frequent interaction with family and friends during this period is an important part of their healing process. Here are some tips:
Accept the teen's expressions of grief, whatever they may be. It's not a good idea to try to tell teens what they should be feeling or when their pain will subside. The experience of grief is very individual.
Allow the teen to talk about the person who died as much and as often as he or she wants to. Be sure to do more listening than talking, and be patient if it becomes repetitive. It often takes time and a lot of talk to come to terms with what has happened. And don't hesitate to bring up the deceased person's name for fear that the teen will be reminded of his or her pain.
Don't be afraid to let your own feelings show. Allowing teens to see you cry or express your feelings in other ways may make it easier for them to express their own emotions.
Encourage the teen to be patient. Tell the teen to avoid imposing self-judgments about how they should be feeling or behaving. Reassure your teen that a large range of feelings, even feelings that may seem strange or unexpected, is actually normal.
Be very careful about how you explain the death. It's not a good idea to say that the person's death was God's will or to remind the teen if the person's behavior was to blame. Dwelling on why someone died is not likely to be helpful because it doesn't alleviate the pain of the loss.
Avoid placing new expectations on the teen too soon. For example, it's best not to tell your son that he's the man of the family after his father's death because it will impose additional pressure when he's already under stress.
Be alert to signs of acute mental health problems. Severe withdrawal, dangerous acting out or the warning signs of suicide are all reasons to seek professional help as soon as possible. Take your child to your primary health care provider or call Military OneSource at 800-342-9647 for assistance.
Grief counseling is often advised for individuals suffering from the loss of someone close. Most school systems are prepared to help students deal with losses. Make sure the teen's school knows about the loss and find out if they offer grief counseling services.
Many communities around the country have support groups and grief camps for young people coping with the death of a loved one. Some of these programs are specifically for kids who lost a loved one in the military. Military OneSource or your installation Family Service Center can help you find out about grief support programs available in your area.
The Tragedy Assistance Program for Survivors provides a grief camp for children. Each year several hundred children and siblings of deceased service members come together at Camp Good Grief with their counselors and mentors to share feelings and have fun. TAPS also provides many other services for survivors including online peer support groups, a hotline (800-959-8277), and information and resources for people coping with the loss of someone in the military.
Find programs and services at your local installation.
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Made in Cleveland Ohio-it works-does have some rust. Box in picture is the cover for it.It can be refurbished if wanted. Do have table that goes with it,treadle does work,but table in bad shape,mainly the table top. I am guessing at the shipping for the sewing machine it could be more or it could be less.always refund overpaid shipping. You can come and pick it up and there would be no shipping charge if picked up. Location New Bern,NC
Contact informations :
Seller Name: mandyboohorses
Sale Price: $35.00
Zip Code: 28560
Location: new bern, NC


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What is it? An update to Mercedes's entry-level sedan in the United States, the new C-Class comes in four models, with several different engine sizes. There's the C250, a new four-cylinder offering with a 201-hp, 1.8-liter turbocharged inline four-cylinder; the C300 4Matic, with last year's 228-hp, 3.0-liter V6 and all-wheel-drive; and the rear-wheel-drive C350 with a new 302-hp, 3.5-liter V6. Mercedes claims the new engines improve fuel efficiency by 15 percent across the board.
The new C-class will be available in sedan and coupe body styles, but the CLK name for the coupe has been dropped. What hasn't been dropped from the coupe is the C63 AMG model, which moves to the coupe from the sedan body in the new car.
What's new or notable? The C250 has the first four-cylinder engine in a C-Class since the C230 Kompressor hatchback flopped in the United States market in 2004.
When will it be available? September 2011


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Three out of four college students hold at least a part-time job throughout college, and yet, according to the Department of Education, the average student still graduates with more than $13,500 in student-loan debt.
I recently read an article in the Aid for Education Report that noted a dramatic increase in federal financial assistance in the last decade. What the article didn't report was that close to 60 percent of the $68 billion in total federal aid was doled out in the form of student loans - loans that seem to inhibit graduates from taking jobs in the public sector, where salaries are often lower than in the private sector. Moreover, the prospect of such debt is causing many potential first-generation college students to avoid higher education altogether.
In May 2000, I achieved a lifelong dream: As a first-generation college student, I graduated and took a job in the public sector. Thanks in large part to the generous men and women who continue to establish scholarships with West Texas A&M University Foundation, I graduated debt free.
I now call myself a "broker of dreams." Officially, I develop and manage scholarships for the WT Foundation. But through my job, I enable three different groups to make their dreams a reality: The men and women who have a dream of helping tomorrow's future today by providing scholarships to deserving students; the students who have a dream of becoming tomorrow's future by preparing at our university today; and, finally, my dream of helping students attain a college education at a quality university, and communicating to donors the significance and lasting impact of their gifts.
More than 800 students a year attend WT on scholarship. Without private support, provided through the WT Foundation, many of these students could never achieve their dreams. Private support makes a tremendous difference at WT:
It allows WT to recruit top students and provide them the extra support and time they need to excel;
It provides faculty and program development to ensure that students receive the highest caliber of education, preparing them to lead us all to a brighter future; and
It ensures that financial assistance will be available to future generations of WT students.
With competition for state funding becoming more intense, private gifts will play an even more important role in financing the university's progress and ensuring that the needs of a growing number of students are met.
The mission of the WT Foundation is to support the university and its students by seeking, receiving and administering gifts and grants for scholarships and institutional support.
I am glad to work for an organization where funding futures and fulfilling dreams is part of my everyday responsibility. Thanks to continued support from many generous men, women, businesses, corporations and foundations, many more WT graduates will start their futures without the burden of student loans.
Salem Silvey works in the Office of Development and is a former president of the student body at West Texas A&M University. She can be contacted at 651-2647.
© 2016. All Rights Reserved. | Contact Us


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We may have found a good purpose for Hackers. Before you go into shock, read on…
The company called Wickr, (for those of you that aren't familiar with it, it's a secure messaging app), has reached out to hackers and offered them a reward for doing what they do on a daily basis.
That's right, hackers are being offered $100,000 to uncover and, here's the important part, 'responsibly disclose' any and all critical security flaws in the company's app.
Point-of-sale (PoS) Hacks
Posted by Steve Bell
Just before Christmas last year the mother of all hacks took place in the US. Target, a retailer which sells everything from kid's swings and outdoor flooring to curling irons and razor sharp HD smart TVs had its point of sales (PoS) systems hacked.
Information from up to 40 million customer's credit and debit cards was lifted by hackers. Within days, this information started appearing on underground web sites which specialize in this type of information. Some of the credit card details were going for about $20 each. So worried were the banks that some of them even dived into the deep web and bought up the credit/debit card information to protect their reputation and their customer's bank accounts.


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CLEVELAND, Ohio – A Cuyahoga County grand jury Tuesday indicted a founding member of the Heartless Felons on gang and intimidation charges as part of a continued crackdown on the Cleveland street gang that has doled out violence on the streets and in prisons for years.
The grand jury charged Donte Ferguson, 28, of Cleveland with participating in a criminal gang, intimidation, retaliation and resisting arrest. Prosecutors said Ferguson threatened a member of the Cleveland police's gang unit after encountering him in a public place.
"Today's indictments represent another step in our continuing efforts to disable both the adult and the juvenile wings of the Heartless Felons," said Duane Deskins, the first assistant in the county prosecutor's office, in a statement.
"Mr. Ferguson is going to answer for his violent gang activities – and he is going to learn that we take threats against police officers very seriously."
If convicted, Ferguson could face more than 10 years in prison. His attorney in previous cases, Kevin Spellacy, could not be reached for comment.
In May, a county grand jury accused five other members of the Heartless Felons with gang-related charges. The charges include murder, robbery and weapons violations.
In June, county prosecutors accused more than 40 teenage members of the gang on charges that stem from violent attacks at the Juvenile Detention Center. Prosecutors have sought to have the youths charged as adults.
Prosecutors said Ferguson is one of the founding members of the Heartless Felons. His criminal record dates back to when he was 19, and court records show that his cases were assigned to the mental-health docket.
Cleveland police arrested him last week on charges of possessing firearms, a violation of his probation. He is being held in the county jail.
The Heartless Felons has its roots in Cleveland, where members worked to gain control of facilities in the Ohio Department of Youth Services in the 2000s, according to interviews and state records.
The gang then grew up in state prisons, becoming the second largest in the adult prison system with about 600, said D.J. Norris, a gang expert for the state prison system. It is second behind white supremacists.
Juvenile court officials said the gang began recruiting new members at the Detention Center, where new members were forced to pummel other youths to gain respect.
In recent years, the gang has spilled out into the city's streets, using guns and violence to bolster its pattern of extortion, authorities said.


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The following is an opinion of The Flint Journal Editorial Board.
The Genesee County Parks & Recreation Commission is to be commended for putting together an ambitious new five-year plan that will continue to add polish to some of the county's many gems.
With warm weather arriving, the county's parks system plays an important role in the quality of life for area residents. Our parks and their amenities also help attract visitors, and their discretionary spending, to Genesee County. A win for everyone.
For instance, more than 26,000 runners signed up for 2013's Warrior Dash at the E.A. Cummings Center in Genesee Township.
The wildly popular event -- which is part race and part obstacle course with a touch of costume party thrown in -- is returning for a fourth time this summer. If the parks aren't kept in good condition, however, they won't be able to attract and keep events such as this one. That's why a long-term strategy for park maintenance and improvement is so important.
The $30-million list of projects now heads to the county Board of Commissions for final approval later this month. We urge the board to give the blueprint the green light so that some of the 51 projects listed can get under way.
Everything from nuts-and-bolts maintenance to adding new sports fields at Linden Park and a splash pad at Flushing Park are on the list. If fully funded, it's not surprising that the lion's share of dollars would go to Crossroads Village ($7.05 million), with $3.1 million earmarked for the Huckleberry Railroad. It would be unwise to let these stellar attractions go without needed repairs and improvements.
The priorities, however, are flexible and projects are apt to change over the life of the plan. What is set in stone, however, is the need for the County Board's approval in order for the park system to qualify for state Department of Natural Resource grants.
So, pass the plan, go after the grants and other funding sources that are available, and do whatever it takes to keep Genesee County's parks among the best in the state.
Members of The Flint Journal Editorial Board are Editor Marjory Raymer, Audience Solutions Manager Jason Christie, Community Engagement Specialist Kristin Longley, Managing Producer Clark Hughes and Managing Producer Bryn Mickle. Find out more about the editorial board here.


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Yankees vs. Orioles Cake Competition
Charm City Cakes is hosting a Yankees vs. Orioles cake competition in Baltimore on July 13.
Join decorator Mary Smith as she hosts a cake class and competition in honor of the baseball rivalry. Mary will give a short demonstration at the begining of the class of how to fondant a cake, and different decorating methods. Students will then use those tips to design and create their very own masterpiece. At the end of the class participants will be able to submit their cake for a competition.
The Orioles have generously donated 2 pairs of tickets, and field passes for the batting practice to the 8:05 matchup that night to the first and second place winner.
A portion of the proceeds will be donated to the Young Adult Institute: National Institute for People with Disabilities.
The cost is $150 per participant, ages 14 and up, and you can register here.


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Jason William Bradwell, 20, admitted that he posed as a recruiter for the DEA and persuaded an Irvington woman to fill out a 30-plus page "application" containing detailed personal information. The next step was to be a "home inspection."
Mobile police found the application at the Salvation Army, where Bradwell was staying.
Earlier this year, a Mobile police officer said that the woman feared for her safety.
But defense lawyer Andrew Jones said last week, "There was no such kidnapping plan." He said that Bradwell "certainly doesn't present a danger to the public."
Under an estimate of advisory sentencing guidelines, Bradwell faces a prison range of two to 10 months. Jones said that he would ask the judge to let his client out of jail until the sentencing date on Oct. 27.
"He'll have done most, if not all, of the time under his sentencing guidelines," he said.


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Receiver Calvin Johnson, after missing one day with a thigh injury, returned to practice on Thursday and will start Sunday against the Tampa Bay Buccaneers. Receiver Mike Furrey, who was sidelined last week after suffering a concussion against Jacksonville, went through some individual drills but it's unlikely he'll play.
Center Dominic Raiola didn't work out on Wednesday but was ruled out for Sunday's game. Raiola (broken right thumb) is waiting for a special cast that might allow him to play and snap with his right hand. Defensive end Dewayne White (calf) did not practice and isn't expected to play.


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This is a guest post by Anne Galivan. Anne talks to us about looking younger at any age.
By Anne Galivan
We've all seen the pictures: celebrities with so much Botox or collagen injections that they can't even smile…or they look like chipmunks…or their lips look liked they've been stung by bees. I totally get wanting to stay young-looking. One of my philosophies of life is that I may have to get older, but I'm not going down without a fight! I do not look my age, I do not dress my age, and whether I act my age, I'll leave that to others to decide!
I am a 49-year old mother of four – ages 26, 22, 17, and 8 and have been home-schooling for over 20 years. I own a business with my husband that I do the book-keeping for (under protest; I am a great administrator but I hate paperwork!) and I am also a part-time college student. If it sounds like I don't have a lot of time for myself, you are right. Precious little time, in fact.
But, I believe in taking care of myself, keeping fit, and pampering myself even if that just means playing with the makeup I buy from Sephora.com. Below are my tips for looking youthful in your 40's and beyond:
• First of all, I want to acknowledge that genetics do play a role in our lives: everything from when our hair goes gray to whether you struggle to keep your weight under control or will have dark under-eye circles (like I do). But genetics do not have to dictate how we look and there are innumerable ways to work with or downplay our genetics.
• For instance, my father passed away from cancer in August 2008 at the age of 74. Until the disease really started to take a serious toll, however, he always looked at least 10 years younger than his age. Part of that was due to the fact that his hair never went gray! I have been blessed to share his genes.
• But if you are going gray there are so many fun things you can do with your hair in terms of coloring or highlighting. As a matter of fact, even though I don't have a gray hair in my head, I opted three years ago to go with blondish highlights in my hair and the result was fantastic. It took years off of my look! I actually had people I hadn't seen in awhile not recognize me!
• I strongly recommend that you don't go it alone when it comes to coloring/highlighting your hair. Invest the money to pay a great stylist to color and cut your hair. This is one of the areas where I have made the conscious decision to splurge a little because, quite frankly, hair is possibly the most critical component of our look as women.
• Secondly, just because you are getting older doesn't mean you have to shop in the "old ladies" section of the department store. The clothes you shop for should reflect your body type, personality, and career. I shop mainly in the juniors section because I am petite, I like to keep my look up-to-date and as a full-time mom I wear jeans almost all the time. Not "mommy jeans" but low-rise junior jeans. And while some of you might be thinking that junior jeans can only look ridiculous on a 49-year old woman, I have to disagree. They actually complement my figure the best. I am so glad that I finally stopped trying on women's jeans a few years ago and tried on a pair of low-rise jeans…they just fit so much better!
• My point is that you need to change your mindset of where you are "supposed to be shopping" for your clothes. Those distinctions in the department store: juniors, women's, petites, etc. make it convenient for the store but they have nothing to do with what fits best on your body.
• I will point out that I don't shop only in the junior section. For instance, graphic tees just aren't going to pass muster. I roam and browse the different departments and different types of clothing stores to put together a stylish look that looks cute/sharp/hot without looking like I'm trying to re-live my high school years (which I wouldn't want to do anyway!)
• Thirdly, I have to bring up the subject of weight. I know, I know – we are bombarded with stories about weight loss everywhere we turn. And if you are struggling with your weight that can be incredibly depressing . However, keeping our weight at a healthy level will have a huge impact on how youthful we look.
• Believe me, I know what it is like to struggle with weight. Over ten years ago I developed a chronic illness. At one point (it was in 2001) I went on a steroid to try to treat it and gained 25 pounds in five months. Shortly after coming off the steroid I became pregnant with my fourth child and gained another 35 pounds. I had my little bundle of joy at the age of 40. And I had gained 60 pounds in just 14 months.
• If you are age 40 or over you know that trying to lose weight at that stage of life is challenging. On top of that I was still battling a chronic illness and was nursing a baby. Exercising was out of the question and I could only do so much with my diet. Within a year I had lost about 30 pounds (part of that was delivering an 8 pound 7 ounce baby!) Over the next few years I managed to lose another 15 pounds. But was still at least 20 pounds heavier than I wanted to be and nothing seemed to be budging the scale. I had started working out at home with hand weights using "The Firm" DVD's (highly recommended!) and that HAD helped me to change my body shape a little. But I needed to start moving the scale. A friend on Twitter recommended The Diet Doc's Guide to Permanent Weight Loss. I learned from reading this that I, like most Americans, was eating way too many carbohydrates and not near enough protein. This is not a "no-carb" plan like Atkins it is rather a "controlled-carb" plan (or at least that's how I look at it). I started following the Diet Doc's plan in February 2010 and lost about 15 pounds in four months. I was thrilled. I hit a plateau after that (which will happen) so after awhile I started getting a little stricter with myself and tracking my carbs, fat, and protein again, and promptly began dropping weight again. I truly believe anyone can have success on this plan and if nothing else, it's worth a try.
• Before I move on I want to say something again about exercise. You need to do it. No matter what fitness level you are at, unless you have a real disability, you can do something. In addition, keep in mind that whatever exercise program you choose to begin with, don't stop there. Our bodies will adapt to our level of activity so you need to keep challenging yourself. If you start out walking, after awhile maybe you should add some weight training or swimming or biking to your exercise repertoire. I prefer using DVD's to exercise at home because that fits my lifestyle. My health issue does not allow me to do cardio, but I can work out with hand weights which tone, strengthen, and help to prevent osteoporosis. I am developing some killer muscles!
• The last item I want to address is caring for your skin and using make-up. I think one of the funnest parts of being a girl is playing with make-up! And it doesn't have to take a lot of time to add a good skincare regimen to your life. I will admit I am not as faithful with my facial products as I'd like to be, but I do keep at it. And I am constantly trying new things with foundation or blush in order to keep things interesting. I even started using eye shadow recently! I used to use it all the time when I was young but had gotten out of the habit…thought it would take too much time but guess what? It doesn't! And it adds so much to my look!
• The first thing you must do, however, is take care of your skin and any problem areas. One of the things I love about Sephora.com is that I can go on the website, plug in a skin concern and get dozens of products recommended. I then go to the customer reviews to find out what real people say about these products. Sephora has a 100% satisfaction guarantee so I have nothing to lose by trying something new. And I have returned a couple of under-eye creams in my quest to find something that will diminish my dark under-eye circles. I have never had any problem with returning a product to them.
My final thought: the real secret to looking younger at any age is deciding whether or not you are worth the investment of time, energy and money. Women are by nature nurturers and we will often spend money and time on our families that we would never consider spending on ourselves. And to an extent, there is nothing wrong with that! I believe a life of self-sacrifice brings more satisfaction and fulfillment. But at the same time, neglecting ourselves does not necessarily make us better people. Feeling good about ourselves because we have invested time, money, and energy into looking nice will help our general attitude towards life and that can only benefit those in our lives as well. Give yourself permission to look younger at any age…today!
Anne has four children aged 25, 22, 16, and 8. She is a writer, a blogger, owns and runs a business with her husband, is a part-time college student. Her passion is home-schooling which she has been doing for 20 years now and launched Homeschooling 911 with resources to help those educating or interested in educating their children at home.
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4 Comments
I'm okay with looking my age – as long as it's an attractive & healthy look! I'm too frugal (cheap?!) to spend money on hair color (I turned mostly gray in my early thirties, so can you imagine the accumlative cost over the years??). I have a modern style which complements my hair, and I am amazed at how many women comment on how much they like my hair. It's kind of crazy that you have to be "courageous" not to dye your hair.
Anne Galivan
Twitter: homeschool911
December 31st, 2010 at 7:56 pm
I am glad that you have been able to get by with not coloring your hair – but the truth is most women do not have the facial structure to make going gray look good.
Your point that you are okay with looking your age "as long as it's an attractive and healthy look" is well-taken. I don't think that women who choose to color are necessarily any less confident – they just feel that they look better that way…and isn't that the point?
Some women can pull off gray and some can't. I don't need to color (I don't have a single gray hair in my head and I'm 49!) but highlighting my hair took years off my look and I love it.
Probably the most important thing women can do to stay young-looking comes down to nutrition and exercise – which fits right in with your "healhty look" perspective. There is perhaps nothing that will age a woman faster than carrying excess weight.
Thanks for taking the time to comment!
Anne Galivan recently posted..Where I Thank My Readers and other stuff
Great post. I have been fortunate to have looked younger than my age most all of my life. However, I'm now at a point where I want to stay that way but, it is requiring that I do things I never used to have to do. But, I will continue to do them because although I believe feeling good inside is what matters most and it definitely exudes on the outside; there are physical aspects of myself that if kept looking good also contribute to my inner happiness. I'm not going to fight aging but, I'm going to do my best to stay healthy and look good on the outside for as long as possible.
Kim recently posted..A Memorable Christmas Hug
Anne Galivan
Twitter: homeschool911
December 12th, 2010 at 8:32 pm
I also find that when you feel good about yourself and how you look, you are not thinking so much about yourself and you can focus on others. So I try to make sure I look good at a social gathering not to "impress" but so that I can feel comfortable interacting with others.
Thanks for the comment!
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TUSCALOOSA, Alabama -- As she crumpled to the turf and pain shot through her left knee, Ryan Iamurri thought she might be in the clear.
The first time Iamurri, Alabama's 4-foot-10 senior utility infielder, tore an ACL in one of her knees, it didn't hurt at all. The pain was minimal when she injured her right knee while playing soccer during her sophomore year of high school, but it was significant enough to sideline her for all but two softball games.
"This one hurt really, really bad," Iamurri said. "So I was like, 'Maybe that's a good sign.'"
It wasn't.
After colliding with teammate Andrea Hawkins during a mid-week practice in March, Iamurri was left with a torn ACL and MCL. It was too late into her final season to redshirt, but she was promptly presented with two options after a meeting with Alabama team doctor, Dr. Lyle Cain.
When an athlete is playing in his or her final season and doesn't plan to pursue the sport any further, a torn ACL is manageable in certain situations. For Iamurri, who no longer plays in the field and receives a pinch-runner any time she reaches base, it's certainly an inconvenience, but it's one she's embraced.
"It was either try the rehab, do the brace and see what happens or put on street clothes and sit in the dugout," Alabama softball coach Patrick Murphy said. "She wasn't going to do that."
Three weeks to the day of the injury, Murphy called on Iamurri to pinch-hit in the sixth inning of a close game against South Alabama. She worked the count to two balls and two strikes before she slapped a groundout to third.
It wasn't what she wanted, but the experience solidified that she'd made the right decision. A little more than a week later, she picked up her first hit since the injury, an opposite-field single that allowed her to jog with ease to first base.
If she's called to pinch-hit tonight in Alabama's Super Regional showdown with Nebraska (8 p.m./ESPN), Iamurri will hope to do the same.
"I was thinking, 'Man, I'm just going to try to find holes so I don't have to run that hard to first,'" she said. "Once I realized I could do everything I could do for this team prior to tearing my ACL, I knew it was going to be OK."
Iamurri has carried that mindset ever since Alabama offered her a scholarship. A high school teammate of star pitcher Jaclyn Traina in Naples, Fla., Iamurri committed on the spot.
In her four years at Alabama, she's started in 40 games and averaged a little more than 40 at-bats per season. She's been the definition of a role player, as she's played behind the likes of Danae Hays and Kaila Hunt at second base and maintained the smile on her face from start to finish.
"Just getting the opportunity to play here was very cool," Iamurri said. "When I came here, I knew I wanted to win, not play. To get to contribute as much as I have is enough for me. Yes, everyone wants to be the starting shortstop batting in the three-hole, but it is what it is.
"Role players are what makes the difference between the good chemistry and the bad chemistry."
Murphy often uses Iamurri as a pinch-hitter "any time there's a kid up that can't get a bunt down." The injury hasn't affected his decision-making.
"I would put my salary on her getting a bunt down," Murphy said. "If I put a Coca-Cola can out in center field and I tell her to hit it with the ball, she probably could do it."
Iamurri's upbeat attitude throughout this bit of adversity has been symbolic for an Alabama team that enters its Super Regional matchup with much more confidence than it did last year at Tennessee. The Crimson Tide is looking to return to the Women's College World Series for the first time since 2012, when it won the whole thing.
Iamurri's surgery is scheduled for June 10 or 12 -- just a few days after the championship final. No matter where her final game is played, she'll finish her career in an Alabama uniform, not street clothes.
"People like Ryan and Jordan (Patterson) have to set the tone for the rest of the team that aren't playing and they've done it," Murphy said. "She's done it better than anybody we've ever had in our history here."


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New Eagle mother found guilty of starving twinsUPDATED 4:14 AM EDT Jul 16, 2013
Roxanne Taylor, 26, of New Eagle was found guilty of starving her children.Video Transcript
WE HAVE TO GET TO THIS--- A STORY JUST IN RIGHT NOW-- AS A LOCAL MOTHER HAS BEEN FOUND áGUILTYá OF STRAVING HER CHILDREN. ROXANNE TAYLOR TOOK THE STAND TODAY IN HER OWN DEFENSE AFTER POLICE SAY THEY FOUND ONE OF THE CHILDREN LAST YEAR SEVERELY UNDERWEIGHT. ON THE STAND TAYLOR CLAIMED THE CHILDREN WERE FINE HER CAR--- SAYING SHE MIGHT NOT BE PERFECT-- BUT SHE IS A GOOD MOTHER. TAYLOR WILL FACE SENTENCING SEPTEMBER 13TH. 3
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The Vermilion City Guru
Spoiler Alert!
Originally Posted by Neosquid
one of these days I'll manage to stop being an obnoxious fanboy...
Originally Posted by Mr. MR
Maybe I should do a couple of PotW
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|ANE 588 - Individual Directed Study
|(1 cr.) This course permits first-year students to study a particular problem or area of emphasis in anesthesiology that is not covered in-depth in the program curriculum, under the direction of a faculty member. This may be used for student research. Every Year, All
|This course is currently not being offered. Please try again next session.


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Add Hugh Freeze and Bo Pelini to the growing number of major college football coaches engaging in a war of words through the media.
The Ole Miss coach responded Friday to accusations of shady recruiting tactics regarding Washington transfer wide receiver Damore'ea Stringfellow his Nebraska colleague made during Big Ten Media Day earlier this week. On Tuesday, Pelini told reporters to "read between the lines" as to why Stringfellow had first committed to the Cornhuskers before signing with the Rebels.
"I think we all know what happened in that situation," Pelini said.
Pelini also referred to Stringfellow's mother, Kahlilah Levine, as a "clueless parent." In a June 25 Omaha World-Herald report, Levine denied message-board rumors that plane tickets for her to accompany her son on recruiting trips to Ole Miss and Alabama had been paid for by someone else.
On Friday during his press conference to open fall camp, Freeze said he had tried to contact Pelini about the situation, but had been unsuccessful. He also got in a dig at Pelini, according to the (Jackson) Clarion-Ledger's Hugh Kellenberger:
Hugh Freeze on Bo Pelini's comments: "I think it's bad form ... we're colleagues and in this together."
-- Hugh Kellenberger (@HKellenbergerCL) August 1, 2014
"I reached out to him, actually, and said, 'If you have something I don't know, please call me." Pelini did not respond, Freeze said.
-- Hugh Kellenberger (@HKellenbergerCL) August 1, 2014
Hugh Freeze: "We're glad we have String ... and his mom."
-- Hugh Kellenberger (@HKellenbergerCL) August 1, 2014
Stringfellow was a four-star recruit and top 100 overall prospect out of a California high school in 2013, and played in 12 games with three starts at Washington last season. He ended the year with 20 receptions for 259 yards and a touchdown, but was suspended indefinitely and eventually left the team after an altercation with Seattle Seahawks fans on the night of the Super Bowl.
He first committed to Nebraska, but then changed his mind to Ole Miss. Stringfellow will sit out this season under NCAA transfer rules, but will have three years of eligibility beginning with the 2015 season.


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Four Seasons Hotel Baku Open June 15
April 19, 2012
By: Christopher Roney
The wonderful new Four Seasons property in Baku is a little bit off the beaten path, but we're certainly looking forward to its opening. Coming up on June 15, 2012, Four Seasons is bringing its signature style to the Caucasus region. The Beaux-Arts hotel is the perfect stop for the business traveler or tourist looking to experience the vibrant social scene. The Penthouse Spa is the ultimate destination for relaxation. Take a load off after a rough day of business by loosening your muscles through proven Turkish and Persian treatments. A two-story atrium with heated swimming pool is your spot for a relaxing float. Book now for the summertime at the Four Seasons Baku.
Photo via Four Seasons Baku.
New Luxury Hotels Opening in 2012: Four Seasons Hotel Baku, Azerbaijan
April 19, 2012
By: Oksana Balytsky
We at Five Star Alliance are all about the best and most luxurious hotels. We certainly keep up with the happenings in the luxury travel world and take pride in bringing our clients the latest luxury travel news. Keep up with our newest blog series where we'll be featuring luxury hotels opening in 2012 to stay on top of the trends and make your reservations at the newest hotspots.
The Four Seasons Hotel Baku is opening mid-2012, and they are currently accepting reservations for arrivals from June 15th, 2012! Located in Azerbaijan's capital on the Caspian Sea, the Four Seasons presents a beautiful luxury hotel on the waterfront promenade, just steps from the Old City. Its 142 classic yet modern guest rooms and 29 luxurious suites almost all open to a balcony with stunning views of the city or of the Caspian Sea. Explore the city of Baku, swim in the glass-roofed atrium, or relax in the penthouse spa. Be sure to visit this up-and-coming area and be one of the first to experience everything the Four Seasons Hotel Baku has to offer!
By: Oksana Balytsky


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A school district in Arkansas has trained 20 teachers in handgun use. The teachers, all volunteers, have been certified as guards and given $1,100 to purchase their own 9mm handgun.
The newly trained teachers will be sent into the new school year as an extra line of security against potential armed attackers. The schools will post signs declaring the presence of an armed teacher, but it will not say which specific instructors are armed and trained.
Arkansas has joined several other states which have armed staff in schools.
Readers responded with their thoughts on arming teachers in the comments sections. Here's a sampling of what they had to say:
From NYTaxedToDeath: This is a very smart idea. This act alone has likely reduced their chances of an armed invader significantly, because they are no longer a gun free zone. Now they are no longer an easy target.
If only others would consider this very responsible position on weapons in the school, I think we would see less occurrence of Sandy Hook like violence.
From spantchr: This is a recipe for tragedy. Just wait until the first student is killed by one of these pistol packing teachers.
From Ripper MrsRipper: Sounds like a good idea. Teachers should be properly trained, they are after all the only people that stand between our children and want to be terrorist.
From FrankGrimes23: I hope nothing bad happens, but I guarantee if it does the pro-gun lobby will blame the individual and not the idea again. However when you constantly push for more guns you increase the number of irresponsible individuals as well.
From chocura: A teacher is responsible for keeping the students safe. Safety plans call for the teachers to get the students to a safe setting as soon as possible, not to be a vigilante with a handgun.
What do you think about armed teachers in schools? Leave a comment below.


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A nationwide group of Hispanic pastors is urging illegal immigrants to boycott the 2010 U.S. census, amid calls by Gov. Jon Corzine calling for all immigrants to be counted.
The National Coalition of Latino Clergy and Christian Leaders said illegal immigrants should not agree to be counted unless Congress first passes immigration reform.
Every ten years, the census seeks to count everyone in the United States.
The group said census numbers have been used to target and repress the undocumented. They said the nation's estimated 12 million illegal immigrants need a path to legalization before they agree to have their numbers count toward state funding and congressional seats.
The proposed boycott comes as several national Latino organizations are urging every immigrant, regardless of status, be counted.
The governor and other officials stressed the importance of counting immigrants, including those who do not speak English or are undocumented.
Corzine has said hundreds of billions of federal dollars for education, housing, health care, and transit are allocated to states based on the count.
Some officials have also raised concerns that outmigration of residents to the South and the West will cost New Jersey one of its 13 seats in the U.S. House of Representatives.


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This video is stolen content from my website. Please remove this immediately.
Поглазел я на все эти совокупления и даже как-то бодрее стало на душе. Вот такая квинтэссенция.
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NEW YORK (MainStreet)Hiring a realtor to sell your house typically involves signing a four-month contract with the real estate agency.
Also see: 5 Questions to Ask Your Realtor Before Hiring
Even though the housing market is heating up in many areas across the country, selling homes isn't an overnight process, hence the extended contract.
At the end of the four months, if your home hasn't sold, should you renew with the same realtor or hire a new one?
As the contract expiration date approaches, rest assured you'll be approached by competitor real estate firms trying to persuade you to sign with them.
Having your house sit on the market for four months is frustrating for you and the realtor, since he or she is spending money on advertising and not seeing any return.
Also see: New Mortgage Lending Rule Intended to Protect Borrowers May Hurt Self-Employed
If there was tension between you and your realtor, you might decide not to renew for that reason alone. But there are plenty of reasons why a house fails to sell, from a slow market to an exorbitant asking price to bad luck.First, assess how well the realtor marketed your house, based off of what he or she initially promised you when you signed with the agency.
"The agent may have listed the home via the traditional online and print outlets, but was there a property-specific website created?" says real estate agent Paul Santucci of Boston Lofts. "Think about what set the agent's marketing efforts apart from other listings."
When it comes to open houses, it's common for the agent to send a junior broker to conduct the open house. "If you weren't aware that the agent you hired at the initial contract signing wasn't the agent that would be actually showing your open house, that's a problem," Santucci adds.


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Poultry Science
Graduate Program
Why UGA?
Students who undertake graduate work in Poultry Science at the University of Georgia have excellent opportunities for strong course background, broad research experience and practical exposure to the dynamic poultry industry.
The UGA Poultry Science Department offers specialized training in physiology, genetics, nutrition, products technology, parasitology, toxicology, microbiology and molecular biology leading to the M.S. or Ph.D. degrees in Poultry Science.
Close Knit Student Group
The Poultry Science Graduate Student Organization promotes career development and social activities that make the graduate student experience more than just academics and research. Our students enjoy their graduate experience and will look back upon their graduate school days as the most rewarding, stimulating and interesting of their lives.
Outstanding Faculty
Our faculty have won nearly every major research, teaching and extension faculty award offered by the College of Agricultural and Environmental Sciences and by the Poultry Science Association. The department is recognized worldwide.
About Athens
UGA is located in Athens, Georgia, a vibrant college town with a population of 100,000. Athens has repeatedly been voted one of the best college towns in the US and has a #1 Rolling Stone rated music scene. Athens in one hour from Atlanta and only a few hours from the Appalachian mountains and the Georgia coast. UGA has a lively campus with great cultural opportunities


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Welcome to Noise Candy, al.com's stereophonic sketch of the week ahead in music along the Gulf Coast.
In this week's edition, BW Correspondent Luke Buckley speaks with Kishi Bashi about his show tonight at the Alabama Music Box, raising money to payback his credit card debts and his relationship with one of Athens Georgia's most fabulous freaks, Kevin Barnes.
K Ishibashi bares all about squeezing out a living in the music industry, what keeps Regina Spektor on the road and why he spent the last year locked in an attic.
All that and more on this episode of Noise Candy.
Click on the player below to listen to this week's edition on your computer. Or click here to download it or play it on your iPhone or iPad.
Kishi Bashi.mp3


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