text:
The Wheel of Time turns, and Ages come and pass leaving memories that become legend, then fade to myth, and are long forgot when that Age comes again. In one Age, called the Third Age by some, an Age yet to come, an Age long past, a wind rose from around the White Tower in Tar Varlon. The wind was not the beginning. There are neither beginnings nor endings to the turning of the Wheel of Time. But it was a beginning.
North and west the wind blew, through the city's newly risen towers, graceful bridges, and bustling marketplace. Out beyond the walls and across the city's surrounding farmland, and beyond to the trackless wilderness.
Almost ebbing away, a breeze from the south heading north meets up with the breeze, changing its direction northward, towards the Blight. Picking up speed, the wind begins to howl like a screech owl, warning farmers and merchants alike that death is on its way. Perhaps not today, or tomorrow, but soon it shall come to be. Shivering and holding cloaks tight about their shoulders, the people make warding gestures against evil, praying to the Light that all is well.
Picking up speed, and Moisture, the large mass rushes north, growing in size till it stretches from horizon to horizon. Lighting flickers and flashes in the clouds as it rolls, thunder crashing upon the ground so loudly that trees splinter from the viscious onslaught of noise and static discharge.
Rolling over a foothills, the wind, now a storm, flashes over the city of Barsine unloading its massed fury as it attemps to drive itself over the natural border. Rain hammers into the city; great drops of water, almost the size of buckets, fall from the sky. Lightning strikes the highest towers, great bolts connecting sky to ground, chanelled through metal rods towards the courtyards below. A brief moment later, thunderous roars of discharged air rattling 600 foot tall towers, shattering windows and shutters alike. More lightning strikes, more thunder, more damage.
The wind buffers the cloaks of those men standing guard upon the walls, pointedly ignoring the wind, the rain, the lightning of the storm. In a shorter tower, situated just beyond the northern gate of the grand city of Barsine, a man turns from the fury and focuses his attention onto those around him.
I do not belive this. This is utter folley The middle aged man with graying temples says simply as he limps back to the table, pulling free a map from amongst the large stack of paper work. Peering down, the man studies the map a moment longer, before looking up at the men sitting around the table.
My lord, these reports come from the Homeland Guard, whose honesty and bravery are reknowned throughout the land. They would not lie about this Another man, blonde of hair and heavy chested, grunts out in exasperation.
Holding his hand up, the graying man motions the guy to silence. I am not calling their sightings into question. Just the number. It is not possible. Perhaps they saw the same patrols... he mutters into silence, shaking his head.
The room is silent, the men stare at the leader. Coughs come from those that stand in the background, against the walls, and in the viewing chamber up above.
Shaking his head in resignation, the Lord speaks simply. As usual, General Greem, you are correct. The Homeland guard have served with honor since this city, nay, this land, was just a small village and fort. But 500,000 Trollocs?! The Lord shouts at the end, Quickly pulling his dagger out of its sheath and driving it home into the map, at a point on the map indicating a long narrow pass in the mountains.
What is our troop disposition? The lord asks, turning his gaze upon another man at the table.
My Lord Sneed, our troops number 75,000 infantry. There is a contingent of the Homeland guard, but they just number 300. The heavy and light calvary are out on maneuvers 7 days south of us with a contingent of light calvary from Aramelle. I believe that total is 35,000, my lord.The man says in a gruff force.
Sighing a long sigh, Lord Sneed turns once again and stares out the window at storm. Grunting, he smirks over his shoulder It appears that a storm is upon us, gentlemen. And I fear that this is only the beginning.
Standing upon a platform, General Greem addresses the assembled men and women on the Homeland Guard.
Ladies and Gentlemen. Barsinians, Guardians of the Homeland, Barsine needs you. This is the greatest need that the city and region has ever called upon you, and this is such the greatest need, of the most direst circumstances, that I cannot command. I can only ask. Walking across the platform he takes his time to stare at all the faces that look back at him.
There is A Trolloc Army in the hills, as some of you know. And you already know how many there are. 500,000 of the shadowspawn, descending upon this fair city. They march through Theomarkin's gap, a 60 mile gap cut by the Dark One himself in the mountains. We have used the pass innumerable times to enter the blight. Now, it seems that our access is used against us.
Again, pausing to stare at others, the general continues I leave tomorrow morning for Theomarkin's knee, the natural bowl in the gap. Here is where i plan to make my stand against the horde. I ask that you join me there, allowing our meager number a chance to stand against the horde. The Gap will funnel their forces down to just 15 wide, where the bowl will allow us to present 30 soldiers against them.
Sighing, the General draws his sword and raises it high. I go to Theomarkin's knee, to slay some Trolloc, who is with me?
Standing in a small room, a large sandbox dominates the room. The sandbox shows the area around Theomarkin's gap, with emphasis on the knee. Small lead figures, designed to look like trollocs and other shadowspawn are heaped at the northern most edge of the table. At the opposite edge, a couple human figures stand.
General Greem points at the human figures That is us. We are 3 days hard ride from the Knee. According to reports, the Horde is 4 days out, but at a marching speed. Should anything happen to our forces, the Trollocs will gain the Knee and we will be useless to slow them. They will roll over us.
Grunting to himself, and shaking his head, he continues I know I asked for volunteers before, but once again i must ask you this, because this is a suicide mission. I need a small group to go ahead of the main force and push past the Knee, and engage the Horde, in an effort to slow them down, for at least a day. There are numerous game trails and single foot paths that will allow a small group to range in the mountains, harass the enemy, and be able to lead them on a goose chase.
Pausing, he lets you all take a moment to let the idea sink in I dont ask this lightly; you all are some of the best that the Guard has, and I know that you all can do this. But as i said, this is a suicide mission. I think, with luck, only one of you may survive this. But the need for the city is so great that I ask you to carry out this plan.
Again, looking at everyone, Greem asks Will you do it?
|Tandem Arandell
Tandem scrutinizes the map for a moment, as if the extremely simple representation will provide him further insights, should he just stare at it long enough. In reality, he is looking past the display, deep in thought: Well, this is why I came back. To prove to myself that I'm not a coward. I can't turn the Guard down at their time of need.
Tandem looks up and says "General, I'll gladly lay my life down for the Guard. Though a thought occurs to me. Is it wise to send the sisters on this mission? Won't you need them at the primary battle?
Davor is looking at Greem. Why me you old fool? What good is a gleeman against trollocs? Shall i sing them to death? Bah! I might as well get on with it seeing how if i survive there will be a few songs from this. Pretty girls like heroes.
He looked around the room. His eyes immediately found the Aes Sedai. Blast, a pretty woman, but a Tar Valon witch. Ah, never mind. A woman is a woman always.
He lifted his hand and smiled through clenched teeth. More of a ruckus really. "I will go as well. Might as well do something useful except cheering the soldiers on".
|Niketsu Sedai
Niketsu Sedai, a dark skinned young looking woman of somewhat shorter height, steps forward and addresses Tandem and the assembled soldiers.
"Your concern is commendable, soldier, but think as well how much effect we might be able to have upon the enemy forces, strung out and vulnerable. Yes, we may die as well in this venture, robbing our companions of our skills at the Knee, however, our sacrifice may make it many times more likely that they will have time to reach the Knee in order to make that stand. General, I will go!."
Nodding to everyone as they speak, General Greem explains
These Aes Sedai are going because, frankly, 3 armsmen aren't going to do much against that horde. But, with Aes Sedai, they will provide the biggest distraction. And if you do this job well enough, you may be able to force a portion of this horde into another direction all together, lessening the potency of their surge.
Turning, Greem looks at the Gleeman, Davor. I appreciate the effort, son. I know you didnt sign up for the Guard, nor techinically are you a member of the Guard, but I specifically chose you for a specific reason. you are in charge of Morale. Nothing beats a squad than when morale is low. I charge you with keeping up morale amongst these fighters. Tell stories of the brave men and women of the earlier age, sing baudy songs about a lover who misses her man, but her mans hood even more. Distract them from this, because its easy to keep up morale here in the fortress, or out there in the knee, knowing your amongst peers and friends. But out beyond, all alone, It is hard to keep it up. hence your special skills
|Natalya Sedai
"Thank you for your concern, but it is the duty of the Green Ajah to battle darkspawn. If needs require us to travel beyond where safety lie to strike at this new threat then I will gladly go and buy the time necessary to rally our forces and stop them before they can threaten any innocents."
|Tandem Arandell
"Understood, General. I can certainly see the benefit of having the aid of the One Power on a mission like this," Tandem replies. Though it does get a bit difficult to breath when there are Aes Sedai around. I don't think they know I can channel, but they know more about these things than I do.
"And I will certainly be glad to have a couple of tried and true warders along."
|Warrick Gentara
The tall, lean man whom had earlier followed Niketsu Sedai into the room shifts from one leg to the other, his slate-colored eyes studying the intricate three dimensional map of the gap formed of sand as he commits the outline of the terrain to memory. As Niketsu speaks, giving her committal, indeed their committal to the mission, a small smile tightens his features.
His gaze travels over those assembled, briefly studying them before turning to Tandem. "Our role as Warders are to ensure the 'safety' of the Aes Sedai. That is our purpose. Indeed, that likely will be your purpose as well. They are the true weapon here. Without their talents,there is not much if anything the rest of us could do to slow this horde and this excursion doomed to pointlessness."
What resources do we have available to us, General?
btw, what season is it? WInter, Summer??
|Meridian Anterian
Silent behind Natalya, Meridian shifts slightly towards her indicating his agreement with her words.
|Davor Bodean
Good lad Greem says to Davor.
Reaching behind him, General Greem lifts a bag up from the table. The bag is small and nondiscript. Walking up to a table, he upturns the bag, and out falls 6 rings, making distint metallic clinking noises as they bounce off each other to the table. Upon making contact with the wood, the thump onto the wood. Where simple rings would bounce around, these fall and stop without movement.
Staring at the rings for long moments, General Greem motions you all around the table.
This is the greatest resource from the Guard that i can give you. And also its deadliest. For your enemies, and yourself. As you already surmise, these are ter'angreal. These rings are incredibly powerful. They negate your need for food, regenerate the most grevious of wounds, make you incredibly strong, incredibly fast.. Making a glance at the Aes Sedai, he grunts and continues and make you resistant to the One power. These rings have been in use since the founding of the Guard; only the most powerful, the most dedicated, the most true guardsmen got them for special, rare, deadly missions. The missions where the Guard isnt expected to survive, only to accomplish the mission.
Pausing a moment, the general walks to a side table and pours a glass of wine. taking a long pull, he continues. I am sure you want to know the down side. Its simple. In order to use these rings, you must be willing to sacrifice yourself. Once put on, these rings begin to drain the life force from you. Depending on your health, it may take up to 4 weeks before the ring consumes you, perhaps less, perhaps more. Either way, once on, the ring is a one way trip to accomplishing the mission, and thats all. I caution you, Do not put this ring on until the circumstance is dire enough for its need.
|Davor Bodean
Davor extends a hand, hovering over one of the rings. He pulls it back.
"So, once you put it on, you cannot take it off?" he looks the old man in the eyes for several moments, then grunts silently and picks up the most ornate one of the six. Shoving it in one of his coat pockets he looks at others and manages a smile. He hoped it seemed cheerful.
"Well, what are you waiting for?"
|Warrick Gentara
|Meridian Anterian
Stepping Forward, Meridian lifts two of the rings from the table. He slides one into his own pouch, and holds the other out to Natalya.
|Niketsu Sedai
Niketsu steps forward and picks up a ring. Her eyes meet Warrick's, acknowledging what they are both thinking; that if she uses it, she will essentially be killing them both.
She turns to the General, "I am curious to where these Ter'Angreal came from General, and why they were not turned over to the tower as is proper. However, as the times dictate practicality over justifications, I will take the ring. I however must say I have no intention of using it. Though you have called this a suicide mission, I have every intention of making it back alive - after completing our mission!"
|Warrick Gentara
Warrick holds Niketsu's gaze as she picks up the Ter'angreal and gives her a nod, knowing exactly the thoughts running through her mind. They were the same as those coursing in his own as he had stepped forward just before. Whether to use these or not would be a decision made together, for both would share the same fate in the end.
He nods again in agreement to her words. It may be likely we will not return as you say General, but Niketsu Sedai is right. We are not dead yet. Our ends have not yet been woven, and until that day, I intend to see as
many of us return to the Knee as able. The wheel weaves as it will. He allows himself a small smile. And besides, it will take a lot more than a few thousand trollocs or so to stop Niket once she has determined to do something.
|Meridian Anterian
Meridian's raspy voice comes quietly, I shall see Natalya Sedai safely through this, wheel willing or no. This will not be the first 'suicide mission' I have survived; not by a long shot.
Looking at Niketsu with a flat stare, General Greem says in an unperturbed voice Caraighan Maconar is said to have brought them here under the direct orders of the then current Amyriln Seat. If you have issue with it, Take it up with one of them.
Hearng Warricks statement, General Greem slaps the man on the back. I truely hope so, son. I hope to see you all in the Knee. Please, if you have no further questions, leave now. Horses have been readied for you to ride, and you are allowed to exchange your horses for fresh ones at the Gap tower. Good luck, and may the Light be upon you all.
|Natalya Sedai
Natalya begrudgingly takes the ring from Meridan and slips it snugly into a belt pouch muttering, "Desperation breeds more madness than insight but sometimes the two are the same."
Turning to the Greem, "We'll be there, just don't be late."
With that Natalya leaves and heads for her rooms to make the necessary preparations for the mission.
|Meridian Anterian
Meridian turns and follows Natalya out of the room. For a brief moment as he turns, his eyes meet those of Warrick and the grim determination is plain in Meridian's eyes.
|Tandem Arandell
|Warrick Gentara
Warrick glances at Meridian as the other warder moves past, determination locking both their gazes briefly.
I will go and gather our things as well, and perhaps a few extra besides. Warrick states to Niketsu. He gives a slight bow to Greem. "General." Turning on his heels, he heads to the door and out into the crisp air.
|Davor Bodean
Davor makes a flourishing bow, flashing as much of his cloak, nods to the assembly, turns on one heel and walks out of the chamber.
When he reaches the horses, he quickly finds his saddlebags, takes the many colored cloak off his back an puts on a plain dark green one he had in them. Then he hoists himself up on the horse and waits for others to join him.
|Natalya Sedai
Gathering her gear and changing into her armour. No matter how many times i put this on I never seem to get used to how heavy this is. But I must not show it, for the pride of the Green Ajah
She then waits for Meridian to finish their preparations and rejoin her.
|Warrick Gentara
Warrick leads the two warhorses to the party's meeting place, having saddled them and laden their packs with supplies. He nods to those present, takes out his pipe, and lights it as they await the rest of the party. A couple hard puffs and the blue-grey smoke rises lazily into the air. Well this should be an interesting trip. He grins to no one in particular and reaches down to give his horse's neck a pat.
|Meridian Anterian
Meridian follows Natalya to her rooms and collects her saddlebags and any equipment she is not personally carrying, then gathers his own equipment and heads for the stable. Once there he saddles their horses and ensures all is in readiness.
|Natalya Sedai
|Meridian Anterian
Meridian looks at Natalya Sedai for a moment. I have no intention that either one of us use that ring or fail to return from this mission. But I will fulfill my oath, Natalya Sedai.
Stepping out from the stables, you see your fellow guardsmen sitting upon their horses. Dressed in their uniforms, the horses and guardsmen sit at perfect attention. With a whisk of steel, the first ten pairs draw swords and raise them high, forming a steel arch for you all to ride under.
Taken aback for a moment, you quickly recognize the formation. This is the fallen heroes formation, one that is rarely given to those who fall in battle under the most honorable and deadliest of conditions. think medal of honor
At the far end, past all the pairs of guards, a lone figure stands, facing towards the gate, and beyond to the gap.
Mounting your horses, you slowly let your steeds march under the honor arch. As the center of the group passes, each pair of guard lower their swords, salute, and run the back of their left hand along the sharpened blade, drawing a slow but steady stream of blood.
starting with the first pair, and slowly following, these words flow over you, filling you with pride and purpose in your association with these brave veterans
While death is painful and sudden, the pain is nothing compared to the joy of having known these brave individuals
You cannot help but glance down at your own left hand, seeing a couple scars from having performed this same ritual for fallen comrades.
Slowly, the party rides up upon the lone figure, resolving into General Greem. Without looking at you, he walks with you to the gates.
His words spoken in a soft tone While i am in command, i will ensure that the living are provided for, taken care of, and lead properly. While i am in command, I shall escort the dead to their place of honor.
Looking down upon your general, you are suprised to see tears streaming down his face. A man whom you thought only had rage as an emotion, is crying. Coughing suddenly, he continues Go now, you walking dead. Join your brethren in the next life, where you find the next great honor
As he speaks the final words, you cross through the gateway, and your horses hooves clamor upon the stout wooden bridge. Rendering a final salute without looking at you, you know he will stay in that position until you are out of sight.
|Warrick Gentara
Warrick stares straight ahead as he rides beneath the arch. While his face is impassive, a torrent of emotions roil beneath the surface and along the bond; a mix of determination, resignation, anticipation, and concern for his companions, Niketsu primary among them.
Passing the last of the honor guard, he nudges his horse up beside Niketsu's and they ride side by side through the gate. Not until the horse's hooves pass from the bridge onto the path does he turn and look, first at her, then the others. Tapping out his pipe, and putting it away, he speaks. We have a lot of ground to cover. Press hard to the Gap tower and our remounts. Let's try and gain some ground on the shadowspawn, shall we?
|Davor Bodean
Davor looks at Warrick, and stays quiet for a while. He doesn't show it, but the show behind them did leave it's mark on his heart. I do be a fool perhaps he thinks but i do feel bolder now then i did be before we left
Turning towards Warrick, he speaks I do think that be a good idea, warder, but i no think that we should press the horses too hard. There be a lot of miles to cover to the gap, no need to kill the animals
|Warrick Gentara
|Niketsu Sedai
Resigned to the course necessity has led them to, Niketsu digs her heels into her mount. She pulls astride of Warrick and sets her horse's pace to match his.
I have no fear of death, and were I to die here, this would be a noble cause indeed. I have prepared myself my whole life to fight where needed, and when, whatever the cost. Why is it then that I feel that allowing myself to die on this mission would be a failure? Many great heroes have died on desperate missions like this, and such a death would probably set us amongst them; there would be no shame in it. Perhaps I lament for all the other battles I would never see, and for all the souls I could not save. Hmph. Folly.
|Tandem Arandell
Tandem gets on his mount, and anyone who knows him can see that he is uncomfortable. He is much better about horses than he once was, but he still doesn't like riding them. "Blast it all," he mutters as Warrick takes off at what seems to Tandem to be a break-neck speed.
|Davor Bodean
|Meridian Anterian
Meridian waits for Natalya to start moving then matches his horse to her speed.
|Natalya Sedai
Natalya solemnly rides through the procession careful not to look anywhere but straight ahead but nods to General Greem as she passes him.
Once outside and as the rest of the group speeds up and starts heading out she will follow quietly lost in her own thoughts.
sorry for some reason forums are still not letting me know when this campaign updates
|Natalya Sedai
my campaign tab. Sometimes it updates sometimes it doesnt . I could look at it one minute and nothing then post on another campaign then when I go back it says there are several updates and some are hours old. Maybe the forums don't like my browser or my browser doesn't like them.
natalya, we can further discuss this in the discussion page
At a pace that pushes the horses to cover mileage at a groudn churning rate, you fly through the countryside as you attempt to make up some distance and close the gap between yourselves and the oncoming horde.
As you ride, you pass farmers in fields, tending crops, little children herding cattle and sheep towards pastures, and women hanging laundry to dry. This idyllic scene seems to replicate itself over and over again as you speed through the developed farmland around Barsine. The urge to stop and warn people is strong, but you dare not, lest one stop causes you to be delayed further.
The sun seems to slowly inch across from horizon to its peak. At its peak, you all get off and walk the horses, eating food and stretching your legs. Stopping only long enough at a watering hole, you walk some more and then mount the horses once more, knowing that this last stretch will test the horses the greatest, for they have been galloping all morning.
ride check, everyone DC 15 to push the horses
|Meridian Anterian
Ride: 1d20 + 10 ⇒ (14) + 10 = 24.
|Warrick Gentara
|Niketsu Sedai
|Davor Bodean
|Natalya Sedai
|Tandem Arandell
forgot to answer this question. its mid fall. days get up to 65F, and at night it drops to mid 40s. Colder in the mountains
cresting a hill as you pass beyond the limits of human settlement, Natalya's horse suddenly drops back from the full gallop to cantor. A moment latter, both tandem and davor's horses pull up as well, sides heaving, slick with sweat.
Glancing about, you easily recognize where you are. You are about 3/4 of the way to the remount station. At your current speed, with horses spent, it will take you until nightfall to cover the ground. If not, you could get there just before supper time.
|Davor Bodean


text:
Where a vision becomes a possibility.
Scholarships are a gift. They change lives, allowing entry into a world of thought and exploration that would otherwise not be possible. We believe in their transformative power, and are always working to provide more. Information and application instructions are located through the links below.

subset: commoncrawl


text:
You are Here:
/ Pollinator Plants for Moist Sites
This fact sheet contains information about highly valued pollinator plants to consider when designing your landscapes and gardens. The plants include native flowers, shrubs, trees, grasses and herbs. An effective pollinator planting has at least three species blooming at one time, i.e.: 3-early, 3-mid and 3-late, during the growing season. This would include flowers, shrubs and trees. Bunch grasses are listed since they provide nesting habitat for bumble bees.
Native IL Prairie Flowers
*may be invasive
Native IL Shrubs
Native IL Trees
Native IL Prairie Bunch Grasses
Culinary Herbs
Referernce: NRCS Illinois Biology Technical Guide No. 23
Pollinator Biology and Habitat
Helping People Help the Land.
USDA is an equal opportunity provider and employer.
A Printed Version of this fact sheet is available in Adobe Acrobat.
Name Fact Sheet
PlantSeries-Moist.pdf (PDF, 378 kb)
NRCS Home | USDA.gov | Site Map | Civil Rights | FOIA | Plain Writing | Accessibility Statement
Privacy Policy| Non-Discrimination Statement | Information Quality | USA.gov | Whitehouse.gov


text:
What Happened in Prosecco?
As we start gearing up for the holidays and need a bottle or two of sparkling wine to enjoy, of course choices abound. You may already know that there are some very nice sparkling wines coming out of the Prosecco region in Italy that straddles Friuli a...Read more »


text: RSS Events Feeds Big Data Meetup Big Data and the Cloud at Microsoft Boulder 7/31/2013 6:00 PM - 7:00 PM Big Data and the Cloud at Microsoft, an IntroductionTell a friend ShareWednesday, July 31, 20136:00 PMBing Office1900 15th Street, Boulder, CO (map)Please join us for a fun evening at the Microsoft Boulder Office at 1900 15th Street. We will discuss how our product teams such as Bing, SQL Server, Windows Azure, Xbox, and Microsoft Research deal with Big Data. Our public Cloud business, Windows Azure is experiencing exponential growth with enterprise customers. We are preparing Windows Azure, and HDInsight (Hadoop as a Service) to help our customers work with Big Data in the Cloud. We will present some of the technical details of the work in progress.Agenda6:00 – 6:30 - Socialize over food and drink6:30 – 6:45 - Announcements, Upcoming Events6:45 – 8:30 - Big Data and the Cloud at Microsoft, an Introduction8:30 – ??? - Continued socializingAbout the SpeakerWenming YeAfter completing his graduate work at CU Boulder, Mr. Ye joined SRI International, where he focused on design and development of innovative wireless, handheld, and Web-based simulation tools and services. Mr. Ye returned to Boulder as a developer on the commercialization team at Tech-X Corp, where he developed and productized large-scale HPC software. Mr. Ye is currently a Senior Research Program Manager responsible for Cloud-based Big Data and Big Compute projects at Microsoft Research Connections. Learn More: Big Data Meetup Big Data and the Cloud at Microsoft Boulder


text:
Over 35 years of designing products makes for some extraordinarily well thought-out travel gear. Whether your travel gear is needed for your month long trip of a lifetime, or the everyday commute, Eagle Creek has the bag for you.
DenaliOutdoor.com features all the best outdoor gear Denali and Trailblazer stores have to offer. Located in Connecticut and Rhode Island and open 7 days a week, you will find a huge selection of The North Face, Patagonia, Merrell, UGG, Marmot, New Balance, Nike and more. Visit our locations page to find the Denali or Trailblazer near you!
866-451-3795 - Customer Service Hours: Mon-Fri 7:30am-3pm EST or email email@example.com


text:
Free Sample
This recent issue is free to all users to allow everyone the opportunity to see the full scope and typical content of JNIS.
View free sample issue >>
Access to JNIS
The Journal of NeuroInterventional Surgery forms part of the subscription to JNNP for both institutions and individuals. Individuals may subscribe separately to JNIS in print and/or Online: Subscribe here
SNIS members receive JNIS in print and can access the journal online via the members' area of the SNIS website
Don't forget to sign up for content alerts so you keep up to date with all the articles as they are published.


text:
In the past I've posted an article regarding the basic usage of grep, one of the commands that I use daily at work to search a text within multiple files, or a text string in the list of running process of a Linux server, but I've forgot to show you a small and useful option : How to colour the output that you get from
grep to highlight the text you were searching for in a long line.
This is a small option of this powerful command but can save your eyes when searching for a particular property of a Java process that is 4 or 5 lines long.
To be honest I've realised this thanks to an article of Alessio, posted recently on his nice blog: http://dark-linux.net and so the following is the translation by me of his article in Italian with some small addition in examples and explanations.


text:
This study is provided by ICPSR. ICPSR provides leadership and training in data access, curation, and methods of analysis for a diverse and expanding social science research community.
Prohibition Movement in the United States, 1801-1920 (ICPSR 8343)
Principal Investigator(s): Sechrist, Robert P.
These data were gathered for use in modeling the diffusion of prohibition in the United States throughout the nineteenth century. The study contains information on the prohibition status of counties from 1801 to 1920. For each county in the continental United States, the prohibition status is recorded annually starting with 1801. For those counties that were established after 1801, the prohibition status is recorded from the date the county was created. State-level prohibition status is also identified.
Access Notes
These data are available only to users at ICPSR member institutions. Because you are not logged in, we cannot verify that you will be able to download these data.
ASCII + SAS Setup SPSS Setup Stata Setup
Study Description
Sechrist, Robert P. Prohibition Movement in the United States, 1801-1920. ICPSR08343-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2012-10-26. http://doi.org/10.3886/ICPSR08343.v2
Persistent URL: http://doi.org/10.3886/ICPSR08343.v2
Export Citation:
- RIS (generic format for RefWorks, EndNote, etc.)
- EndNote XML (EndNote X4.0.1 or higher)
Scope of Study
Subject Terms: alcohol, alcohol consumption, counties, nineteenth century, political history, political movements, Prohibition era, social attitudes, social change, social history, twentieth century
Smallest Geographic Unit: county
Geographic Coverage: United States
Time Period:
- 1801--1920
Date of Collection:
- 1982-01--1983-11
Unit of Observation: county
Universe: Extant counties in the United States prior to 1920.
Data Types: administrative records data
Time Method: Time Series
Data Source:
historical literature and state archives
Extent of Processing: ICPSR data undergo a confidentiality review and are altered when necessary to limit the risk of disclosure. ICPSR also routinely creates ready-to-go data files along with setups in the major statistical software formats as well as standard codebooks to accompany the data. In addition to these procedures, ICPSR performed the following processing steps for this data collection:
- Created variable labels and/or value labels.
- Checked for undocumented or out-of-range codes.
Original ICPSR Release: 1985-05-24
Version History:
- 2012-10-26 SPSS, SAS, and Stata setup files, as well as SPSS and Stata system files and a SAS transport (CPORT) file have been added to this collection. The codebook has been updated.
Related Publications (?)
Export Options: RIS/EndNote
Export Options: RIS/EndNote
Metadata Exports
- Citations exports are provided above.
Export Study-level metadata (does not include variable-level metadata)
If you're looking for collection-level metadata rather than an individual metadata record, please visit our Metadata Records page.


text:
America's favorite license plates
Published On: Feb 20 2014 11:30:13 AM CST Updated On: Feb 21 2014 01:00:00 AM CST
Americans like Wyoming's license plate the most, according to a new survey. Find out the other favorites.
The views expressed are not those of this company or its affiliated companies. Please note by clicking on "Post" you acknowledge that you have read the Terms Of Service and the comment you are posting is in compliance with such terms.


text:
The Madison Metropolitan School District Board of Education finalized its 2012-2013 budget, and the final impact on residents' property tax bills is significantly less than the preliminary budget forecast.
The proposed budget indicated a 3 percent hike on the school portion of residents' tax bill. But after an increase in state aid, due in part to 4-year-old kindergarten numbers, the average home will only see school taxes go up about $8, or 1.75 percent.
"The board has been thoughtful and looking at a balance between responding to our community members by reducing what would have been the expected property tax levy and balancing that with really looking at our achievement gap needs," said Jane Belmore, interim superintendent for the Madison Metropolitan School District.
Belmore also said responsible one-time expenditures this year will add flexibility to next year's budget.


text:
By Tom Philpott: Guest Columnist
By July 26, Jennifer Flower had resigned from her civilian job at Fort Wainwright, Alaska. With her husband, Army SSgt. Brian Flower, expected home within days after a tough year in Mosul, Iraq, Jennifer planned to welcome him home and then to pack for reassignment to Fort Knox, Ky.
That morning, however, Jennifer heard a news report that shocked her. The 172nd Stryker Brigade Combat Team, Brian's unit, might see its year-long combat tour extended for up to 120 days.
Army Gen. George W. Casey, commander of Multi-National Forces-Iraq, ordered the 4,000-member brigade to Baghdad to help stop the violence between Sunnis and Shiites. In July alone, more than 1,800 Baghdad residents were killed, raising fears of a broader civil war if attacks continue.
In a video teleconference with the brigade's Family Readiness Group — spouse volunteers ready to pass along information and provide support to other families — Col. Michael Shields, brigade commander, confirmed the disappointing news.
"I was very upset. Angry. I was sad," said Jennifer, describing her initial reaction. "It was literally heartbreaking. To spend 12 months (apart) and to be within days of having your spouse back home, to find out that was going to be ripped away … was crushing."
That was three weeks ago. Families say they are bouncing back. They have returned to work, altered travel and vacation plans, arranged for ticket refunds and unpacked boxes. Some have taken their children on to new assignments, including to Europe, so they can settle in before school starts. Other children are surprised to be returning to Fairbanks schools.
"Just like anything else in the military, stuff happens unexpected. It is what it is. So you pick yourself up and you carry on," Jennifer said.
Spouses who are counseling spouses, through the readiness group, said most families have gotten over the shock. Soldiers and families are focusing on their new challenges. One is to ship back a lot of personal gear that soldiers already sent home. Also returning to Iraq will be 300 soldiers who had been sent home early to prepare for the full brigade's return.
Tricia Rambin, wife of the brigade's operations officer, Lt. Col. Mitchell Rambin, said her first concern on hearing of the extension was to be sure her sons, Matthew and William, got the information first from her not the media.
Eleven-year-old Matthew, she said, "cried for a few minutes, then pulled himself together and said, 'Well, that's OK. That's my dad's job.' My other son is taking it a little differently. He's 10 and can only absorb so much at one time. Every day there has been a new question."
The Rambin family immediately sent an e-mail to her husband, Tricia said, "to let him know that we were OK. That we actually felt bad for him that he wasn't coming home to us. And that we were doing fine. He needed to get back to work and not worry about us."
Courtney Bedoya, wife of Capt. Joey Bedoya, a transportation officer with the brigade's support battalion, said her husband was expected home in just 10 days when she learned of the extension.
"I was disappointed, of course. But it's part of what I married into," Courtney said.
Maj. Kirk Gohlke, spokesman for U.S. Army Alaska, said that in Baghdad the brigade will "assist the Iraqi security force with the sectarian violence. … It's the most critical mission over there right now."
The 172nd was chosen, he said, "because it has proven itself in combat (and) is the most experienced brigade over there."


text:
Shari Bolen, MD, MPH; Leonard Feldman, MD; Jason Vassy, MD, MPH; Lisa Wilson, BS, ScM; Hsin-Chieh Yeh, PhD; Spyridon Marinopoulos, MD, MBA; Crystal Wiley, MD, MPH; Elizabeth Selvin, PhD; Renee Wilson, MS; Eric B. Bass, MD, MPH; Frederick L. Brancati, MD, MHS
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or of the U.S. Department of Health and Human Services.
Acknowledgment: The authors thank Steven Fox for his help as the Task Order Officer.
Grant Support: This article is based on research conducted by the Johns Hopkins Evidence-based Practice Center under contract number 290-02-0018 with the Agency for Healthcare Research and Quality. Dr. Brancati was supported by a mid-career investigator award for patient-oriented research in diabetes from the National Institute of Diabetes and Digestive and Kidney Diseases (5 K24 DK062222-05).
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Shari Bolen, MD, MPH, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, 2024 East Monument Street, Suite 2-600, Room 2-615, Baltimore, MD 21205; e-mail, firstname.lastname@example.com.
Current Author Addresses: Drs. Bolen, Yeh, Selvin, and Brancati: Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, 2024 East Monument Street, Suite 2-600, Baltimore, MD 21205.
Dr. Feldman: Johns Hopkins University, Jefferson Building, 600 North Wolfe Street, Room 242, Baltimore, MD 21287.
Dr. Vassy: University of Pennsylvania Health System, 3400 Spruce Street, Philadelphia, PA 19104.
Ms. L. Wilson, Ms. R. Wilson, and Drs. Wiley and Bass: Johns Hopkins University, 1830 East Monument Street, Eighth Floor, Baltimore, MD 21287.
Dr. Marinopoulos: University Health Services, Johns Hopkins University, 401 North Caroline Street, Baltimore, MD 21231.
Bolen S, Feldman L, Vassy J, Wilson L, Yeh H, Marinopoulos S, et al. Systematic Review: Comparative Effectiveness and Safety of Oral Medications for Type 2 Diabetes Mellitus. Ann Intern Med. 2007;147:386-399. doi: 10.7326/0003-4819-147-6-200709180-00178
Download citation file:
© 2016
Published: Ann Intern Med. 2007;147(6):386-399.
As newer oral diabetes agents continue to emerge on the market, comparative evidence is urgently required to guide appropriate therapy.
To summarize the English-language literature on the benefits and harms of oral agents (second-generation sulfonylureas, biguanides, thiazolidinediones, meglitinides, and α-glucosidase inhibitors) in the treatment of adults with type 2 diabetes mellitus.
The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched from inception through January 2006 for original articles and through November 2005 for systematic reviews. Unpublished U.S. Food and Drug Administration and industry data were also searched.
216 controlled trials and cohort studies and 2 systematic reviews that addressed benefits and harms of oral diabetes drug classes available in the United States.
Using standardized protocols, 2 reviewers serially abstracted data for each article.
Evidence from clinical trials was inconclusive on major clinical end points, such as cardiovascular mortality. Therefore, the review was limited mainly to studies of intermediate end points. Most oral agents (thiazolidinediones, metformin, and repaglinide) improved glycemic control to the same degree as sulfonylureas (absolute decrease in hemoglobin A1c level of about 1 percentage point). Nateglinide and α-glucosidase inhibitors may have slightly weaker effects, on the basis of indirect comparisons of placebo-controlled trials. Thiazolidinediones were the only class that had a beneficial effect on high-density lipoprotein cholesterol levels (mean relative increase, 0.08 to 0.13 mmol/L [3 to 5 mg/dL]) but a harmful effect on low-density lipoprotein (LDL) cholesterol levels (mean relative increase, 0.26 mmol/L [10 mg/dL]) compared with other oral agents. Metformin decreased LDL cholesterol levels by about 0.26 mmol/L (10 mg/dL), whereas other oral agents had no obvious effects on LDL cholesterol levels. Most agents other than metformin increased body weight by 1 to 5 kg. Sulfonylureas and repaglinide were associated with greater risk for hypoglycemia, thiazolidinediones with greater risk for heart failure, and metformin with greater risk for gastrointestinal problems compared with other oral agents. Lactic acidosis was no more common in metformin recipients without comorbid conditions than in recipients of other oral diabetes agents.
Data on major clinical end points were limited. Studies inconsistently reported adverse events other than hypoglycemia, and definitions of adverse events varied across studies. Some harms not assessed in trials or observational studies may have been overlooked.
Compared with newer, more expensive agents (thiazolidinediones, α-glucosidase inhibitors, and meglitinides), older agents (second-generation sulfonylureas and metformin) have similar or superior effects on glycemic control, lipids, and other intermediate end points. Large, long-term comparative studies are needed to determine the comparative effects of oral diabetes agents on hard clinical end points.
The prevalence and morbidity associated with type 2 diabetes mellitus continue to increase in the United States and elsewhere (1, 2). Several studies of the treatment of type 2 diabetes suggest that improved glycemic control reduces microvascular risks (3–7). In contrast, the effects of treatment on macrovascular risk are more controversial (3, 4, 8, 9), and the comparative effects of oral diabetes agents on clinical outcomes are even less certain. As newer oral agents, such as thiazolidinediones and meglitinides, are increasingly marketed, clinicians and patients must decide whether they prefer these generally more costly medications over older agents, such as sulfonylureas and metformin.
Systematic reviews and meta-analyses of oral diabetes agents have attempted to fill this gap (10–19), but few have compared all agents with one another (18, 19). The few investigations that have compared all oral agents focused narrowly on individual outcomes, such as hemoglobin A1c level (18) or serum lipid levels (19). No systematic review has summarized all available head-to-head comparisons with regard to the full range of intermediate end points (including hemoglobin A1c level, lipid levels, and body weight) and other clinically important outcomes, such as adverse effects and macrovascular risks. Therefore, the Agency for Healthcare Research and Quality commissioned a systematic review to summarize the comparative benefits and harms of oral agents that are used to treat type 2 diabetes.
We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to January 2006 for original articles. We also searched these databases until November 2005 for systematic reviews. We reviewed reference lists of related reviews and original data articles, hand-searched recent issues of 15 medical journals, invited experts to provide additional citations, reviewed selected medications from the U.S. Food and Drug Administration (FDA) Web site, and reviewed unpublished data from several pharmaceutical companies and public registries of clinical trials. Our search strategy for the bibliographic databases combined terms for type 2 diabetes and oral diabetes agents and was limited to English-language articles and studies in adults. The search for systematic reviews was similar but included terms for study design as well.
We selected studies that included original data on adults with type 2 diabetes and assessed benefits or harms of FDA-approved oral diabetes agents that were available in the United States as of January 2006. To facilitate head-to-head comparisons of drug classes, we included drugs not on the U.S. market if members of their class were in use and had not been banned (voglibose, gliclazide, and glibenclamide). We also included studies of combinations of therapies that are commonly used, such as combinations of metformin, second-generation sulfonylureas, and thiazolidinediones. We excluded studies that evaluated combinations of 3 oral diabetes agents, and we also excluded first-generation sulfonylureas, because few clinicians prescribe these medications.
We sought studies that reported on major clinical outcomes (for example, all-cause mortality, cardiovascular morbidity and mortality, and microvascular outcomes) or any of the following intermediate end points or adverse events: hemoglobin A1c level, body weight, systolic and diastolic blood pressure, high-density lipoprotein (HDL) cholesterol level, low-density lipoprotein (LDL) cholesterol level, triglyceride level, hypoglycemia, gastrointestinal problems, congestive heart failure, edema or hypervolemia, lactic acidosis, elevated aminotransferase levels, liver failure, anemia, leukopenia, thrombocytopenia, allergic reactions requiring hospitalization or causing death, and other serious adverse events. For intermediate end points, we included only randomized, controlled trials, which were abundant. For major clinical end points and adverse events, we considered observational studies as well as trials, because fewer randomized trials assessed these end points. We excluded studies that followed patients for less than 3 months (the conventional threshold for determining effects on hemoglobin A1c) or had fewer than 40 patients. Figure 1 shows the search and selection process, and the full technical report (available at http://effectivehealthcare.ahrq.gov/repFiles/OralFullReport.pdf) provides a more detailed description of the study methods (20).
*Numbers add up to more than the number of abstracts or articles excluded because there may have been more than 1 reason for exclusion. †More than two thirds of the articles that were excluded for having fewer than 40 participants would have been excluded for other reasons as well. ‡The numbers of articles for intermediate outcomes, adverse events, microvascular and macrovascular outcomes, and mortality are not mutually exclusive.
One investigator used standardized forms to abstract data about study samples, interventions, designs, and outcomes, and a second investigator confirmed the abstracted data. Two investigators independently applied the Jadad scale to assess some aspects of the quality of randomized trials (21). We considered observational studies and nonrandomized trials to provide weaker evidence than randomized trials, and we did not use a standardized scoring system to assess their quality (22). We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) working group definitions to grade the overall strength of the evidence as high, moderate, low, very low, or insufficient (23).
We first performed a qualitative synthesis based on scientific rigor and type of end point. In general, we described the UKPDS (United Kingdom Prospective Diabetes Study) separately, because this large randomized, controlled trial differed from other trials in design, end points, and duration.
When data were sufficient (that is, obtained from at least 2 randomized, controlled trials) and studies were relatively homogeneous in sample characteristics, study duration, and drug dose, we conducted meta-analyses for the following intermediate outcomes and adverse effects: hemoglobin A1c level, weight, systolic blood pressure, LDL cholesterol level, HDL cholesterol level, triglyceride level, and hypoglycemia. For trials with more than 1 dosing group, we chose the dose that was most comparable with other trials and most clinically relevant. We combined drugs into drug classes only when similar results were found across individual drugs. We could not perform formal meta-analyses for microvascular or macrovascular outcomes, mortality, and adverse events other than hypoglycemia because of methodological diversity among the trials or insufficient numbers of trials.
We used a random-effects model with the DerSimonian and Laird formula to derive pooled estimates (posttreatment weighted mean differences for intermediate outcomes and posttreatment absolute risk differences for adverse events) (24). We tested for heterogeneity among the trials by using a chi-square test with α set to 0.10 or less and an I2 statistic greater than 50% (25). If heterogeneity was found, we conducted meta-regression analyses by using study-level characteristics of double-blinding, study duration, and dose ratio (calculated as the dose given in the study divided by the maximum approved dose of drug). The full report contains data on indirect comparisons, in which 2 interventions are compared through their relative effect against a common comparator (20). We tested for publication bias by using the tests of Begg and Mazumdar (26) and Egger and colleagues (27). All statistical analyses were done by using STATA Intercooled, version 8.0 (Stata, College Station, Texas).
The Agency for Healthcare Research and Quality suggested the initial questions and provided copyright release for this manuscript but did not participate in the literature search, data analysis, or interpretation of the results.
We found no definitive evidence about the comparative effectiveness of oral diabetes agents on all-cause mortality, cardiovascular mortality or morbidity, peripheral arterial disease, neuropathy, retinopathy, or nephropathy (Table 1). For each head-to-head comparison on specific outcomes, the number of randomized trials (≤3 trials) and the absolute number of events were small (20). The few observational studies were limited in quantity, consistency, and adjustment for key confounders.
Table 1.
Since our review, 2 high-profile comparative randomized trials with about 4 years of follow-up have been published, providing data on cardiovascular outcomes (28, 29). In ADOPT (A Diabetes Outcome Progression Trial) (28), the incidence of cardiovascular events was lower with glyburide than with rosiglitazone or metformin (1.8%, 3.4%, and 3.2%, respectively; P < 0.05). This effect was mainly driven by fewer congestive heart failure events and a lower rate of nonfatal myocardial infarction events in the glyburide group. Loss to follow-up was high (40%) and was disproportionate among the groups and therefore may account for some differences among groups.
The interim analysis of the RECORD (Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of Glycaemia in Diabetes) study reported that rosiglitazone plus metformin or a sulfonylurea compared with metformin plus a sulfonylurea had a hazard ratio of 1.08 (95% CI, 0.89 to 1.31) for the primary end point of hospitalization or death from cardiovascular disease (29). The hazard ratio was driven by more congestive heart failure in the rosiglitazone plus metformin or sulfonylurea group than in the control group of metformin plus sulfonylurea (absolute risk, 1.7% vs. 0.8%, respectively). In Kaplan–Meier curves, the risk for hospitalization or death from myocardial infarction was slightly lower in the control group than in the rosiglitazone group, but the difference was not statistically significant. A limitation of this interim analysis was the lack of power to detect differences, owing to fewer cardiovascular events than initially predicted.
The strength of evidence was moderate to high that most oral agents (thiazolidinediones, metformin, and repaglinide) improved glycemic control to the same degree as sulfonylureas (decrease in hemoglobin A1c level, about 1 absolute percentage point). Nateglinide and α-glucosidase inhibitors may have slightly weaker effects on hemoglobin A1c levels on the basis of indirect comparisons of placebo-controlled trials (low strength of evidence). The strength of evidence was moderate that, compared with most other oral agents, thiazolidinediones had a beneficial effect on HDL cholesterol levels (relative mean increase, 0.08 to 0.13 mmol/L [3 to 5 mg/dL]) but a harmful effect on LDL cholesterol levels (relative mean increase, 0.26 mmol/L [10 mg/dL]). Metformin decreased LDL cholesterol levels by about 0.26 mmol/L (10 mg/dL), whereas other oral agents had no obvious effect on LDL cholesterol levels. The strength of evidence was moderate that thiazolidinediones, second-generation sulfonylureas, and metformin had similarly minimal effects on systolic blood pressure. There was moderate evidence that most agents other than metformin increased body weight by about 1 to 5 kg. Metformin had no effect on body weight in placebo-controlled trials.
Table 1 shows evidence grades and a summary of the comparative conclusions. These studies applied primarily to patients with type 2 diabetes and no major comorbid conditions.
The full report (20) provides a list of references and detailed evidence tables. We found 136 randomized trials that addressed intermediate outcomes and a systematic review on acarbose versus other oral diabetes agents (20). Study duration ranged from 12 weeks to 10 years, but most studies lasted 24 weeks or less. Participants were mainly middle-aged, overweight or obese adults of European ancestry who had had diabetes for more than 2 years and no major comorbid conditions. Mean baseline hemoglobin A1c levels ranged from 6% to 12% but were typically between 7% and 9%. About two thirds of studies received pharmaceutical industry support. Only 22 (16%) trials described their randomization techniques, and 83 (61%) reported double-blinding. In 33 (24%) studies, losses to follow-up and reasons for withdrawals were not described.
Figure 2 shows the comparative effects of oral diabetes agents on hemoglobin A1c. Thiazolidinediones, second-generation sulfonylureas, and metformin produced similar reductions in hemoglobin A1c levels when used as monotherapy (absolute reduction, about 1 percentage point). Repaglinide produced similar reductions in hemoglobin A1c levels compared with sulfonylureas. Combination therapies had additive effects, producing an absolute reduction in hemoglobin A1c levels of about 1 percentage point more than monotherapy.
Error bars represent 95% CIs. To convert cholesterol and triglyceride values to mmol/L, multiply by 0.0259 and 0.0113, respectively. Glyb = glyburide; HDL = high-density lipoprotein; LDL = low-density lipoprotein; Met = metformin; Pio = pioglitazone; RCT = randomized, controlled trial; Repag = repaglinide; Rosi = rosiglitazone; SU = sulfonylurea; TZD = thiazolidinedione.
The results of these meta-analyses were generally consistent with results of the UKPDS, a multicenter randomized trial starting in 1977 that had minimal loss to follow-up (3). After 3 months of dietary intervention, participants were stratified by ideal body weight and randomly assigned to receive insulin, chlorpropamide, glibenclamide, or dietary intervention alone. Overweight participants were also randomly allocated to metformin. All agents had similar effects on hemoglobin A1c levels. After 10 years, glibenclamide and metformin had a statistically insignificant between-group absolute difference of 0.3 percentage point (3, 30–32).
Few head-to-head comparisons involved repaglinide, nateglinide, or α-glucosidase inhibitors. To evaluate these agents, we therefore relied on indirect comparisons with placebo controls. Repaglinide produced similar reductions in hemoglobin A1c levels (about 1 absolute percentage point) when compared indirectly with thiazolidinediones and metformin. In contrast, nateglinide and α-glucosidase inhibitors produced weaker reductions in hemoglobin A1c levels (about 0.5 absolute percentage point). Appendix Table 1 shows findings for placebo-controlled trials and the full report on indirect comparisons (20).
Figure 2 shows the comparative effects of oral diabetes agents on blood pressure. Thiazolidinediones, second-generation sulfonylureas, and metformin had similarly minimal effects on systolic blood pressure (mean decrease <5 mm Hg). The greatest contrast was between thiazolidinediones and sulfonylureas—the former agent produced a 3–mm Hg greater reduction—but this difference was not statistically significant. Too few comparisons of meglitinides and acarbose with other oral diabetes agents in terms of blood pressure were available to draw firm conclusions. Results were similar for diastolic blood pressure (data not shown) (20).
Figure 2 shows the comparative effects of oral diabetes agents on plasma lipid levels. Metformin decreased LDL cholesterol levels by about 0.26 mmol/L (10 mg/dL), whereas thiazolidinediones consistently increased LDL cholesterol levels by a relative mean of 0.26 mmol/L (10 mg/dL). Sulfonylureas had similar minimal effects on LDL cholesterol compared with acarbose or repaglinide (33, 34).
Thiazolidinediones increased HDL cholesterol levels by a mean of 0.08 to 0.13 mmol/L (3 to 5 mg/dL) compared with metformin or second-generation sulfonylureas; these latter agents had little effect on HDL cholesterol. Combination therapy with thiazolidinediones increased HDL cholesterol levels similarly to monotherapy with thiazolidinediones. Repaglinide and acarbose had little effect on HDL cholesterol compared with second-generation sulfonylureas.
Only rosiglitazone increased triglyceride levels, by a mean of 0.11 mmol/L (10 mg/dL) in placebo-controlled trials (data not shown). Pioglitazone decreased triglyceride levels more than metformin, by a mean of 0.29 mmol/L (26 mg/dL), and metformin decreased triglyceride levels more than second-generation sulfonylureas, by a mean of 0.11 mmol/L (10 mg/dL). Repaglinide and acarbose produced similar reductions in triglyceride levels, by a mean of 0.11 to 0.34 mmol/L (10 to 30 mg/dL) compared with second-generation sulfonylureas.
Data on nateglinide were too sparse to draw conclusions about its comparative effects on lipid levels.
Compared with sulfonylureas, thiazolidinediones and repaglinide produced similar gains in body weight (1 to 5 kg). Metformin produced no weight gain compared with most other oral agents or placebo (Figure 2 and Appendix Table 2), and acarbose produced no weight gain compared with placebo (Appendix Table 2).
Three UKPDS articles reported weight changes that were consistent with these results favoring metformin over sulfonylurea (mean relative decrease, 2 kg at 10 years of follow-up) (3, 30, 32). Most of the weight gain in the glibenclamide group occurred in the first 2 years, whereas the metformin group maintained body weight in the first 2 years and then experienced weight gain (3).
Several randomized, controlled trials and some observational studies consistently demonstrate that minor and major hypoglycemic episodes are more frequent in adults receiving second-generation sulfonylureas (especially glyburide) than in those receiving metformin or thiazolidinediones. Repaglinide and second-generation sulfonylureas conferred similar risks for hypoglycemia.
In many trials and a few observational studies, metformin was almost always associated with more gastrointestinal problems (flatus, nausea, vomiting, and abdominal pain) than were most other oral diabetes agents. However, rates of lactic acidosis were similar between metformin and other oral diabetes agents, according to a systematic review of 176 comparative trials (35).
In many randomized trials, thiazolidinediones were associated with higher risk for edema than were sulfonylureas or metformin (absolute risk difference, 2% to 21%). Other than edema and hypoglycemia, we had difficulty assessing harms associated with thiazolidinediones because there were few trials and events. In addition, cohort studies often did not adjust for key confounders. Thiazolidinediones appeared to confer a higher risk for congestive heart failure (although absolute risks were small—generally 1% to 3%) and higher risk for mild anemia yet produced similarly low rates of elevated aminotransferase levels (<1%) compared with sulfonylureas and metformin.
Few studies compared the effect of meglitinides with that of other oral diabetes agents for outcomes other than hypoglycemia. Most studies on adverse effects were applicable to persons without major cardiovascular, renal, or hepatic comorbid conditions.
Overall, 167 original articles and 2 Cochrane systematic reviews evaluated adverse events (the full report provides a list of references and detailed evidence tables) (20). About two thirds of the studies were randomized, controlled trials, and the rest were observational. Most were based in the United States or Europe and had industry support. Study duration varied from 3 months to more than 10 years. Most participants were middle-aged to older adults of European ancestry who were overweight or obese. The duration of diabetes ranged from 1 year to 15 years, and mean baseline hemoglobin A1c levels were typically between 7% and 9%. Most randomized, controlled trials excluded people with major cardiovascular, hepatic, or renal disease.
Eighty-five percent (105 of 123) of the randomized, controlled trials with data relevant to adverse events did not describe the randomization technique in sufficient detail to determine whether the randomization was appropriate. About two thirds (66%) of these trials were reported as double-blind. However, 90 (73%) of these trials did not describe the masking procedure. Twenty-two (18%) trials did not report on withdrawals or losses to follow-up.
Minor and major hypoglycemic episodes were more frequent in patients receiving second-generation sulfonylureas (especially glyburide) than in those receiving metformin or thiazolidinediones. Absolute risk differences between groups ranged from 4% to 9% when sulfonylureas were compared with metformin or thiazolidinediones in short-term randomized trials, although reported levels of hypoglycemic risk ranged widely across studies: 0% to 36% for second-generation sulfonylureas, 0% to 21% for metformin, and 0% to 24% for thiazolidinediones.
The 10-year follow-up from UKPDS reported the annual rates of minor and major hypoglycemia as 17.5% and 2.5%, respectively, in the glibenclamide group (obese and nonobese persons) and 4.2% and 0%, respectively, in the metformin group (obese persons only). Results from observational studies were consistent with those of the UKPDS.
Glyburide and glibenclamide conferred a slightly higher risk for hypoglycemia compared with other second-generation sulfonylureas (absolute risk difference, about 2% in trials of short duration). Repaglinide and second-generation sulfonylureas conferred similar risks for hypoglycemia. Comparative data on acarbose and nateglinide were sparse. The incidence of minor and major hypoglycemia was higher with combinations that included sulfonylureas compared with metformin or sulfonylurea monotherapy (absolute risk differences of 8% to 14% for short-duration trials) (Figure 3).
Error bars represent 95% CIs. Glyb = glyburide; Met = metformin; Repag = repaglinide; SU = sulfonylurea; TZD = thiazolidinedione.
Metformin produced more gastrointestinal symptoms (range, 2% to 63%) than most other oral diabetes agents (range, 0% to 36% for thiazolidinediones, 0% to 32% for second-generation sulfonylureas, and 8% to 11% for repaglinide). The absolute risk differences among groups ranged from 0% to 31%, although most were between 5% and 15%. Acarbose produced percentages of gastrointestinal symptoms (range, 15% to 30%) similar to those with metformin and higher than those with thiazolidinediones and sulfonylureas in a few trials (<3 trials for each comparison). Too few comparative studies were available on nateglinide to draw firm conclusions (Table 2).
Table 2.
Currently marketed thiazolidinediones, second-generation sulfonylureas, and metformin had similarly low rates (generally <1%) of clinically significant elevated aminotransferase levels (>1.5 to 2 times the upper limit of normal). An insufficient number of studies evaluated or reported on the effects of meglitinides on serum aminotransferase levels, but they appeared to be similar to the effects of other oral diabetes agents (Table 2). Liver failure was so rare that agents could not be compared for this outcome by using these data.
Risk for congestive heart failure was greater with thiazolidinediones as monotherapy or combination therapy than with metformin or sulfonylureas (range of absolute risk differences, 0.7% to 2.2% in head-to-head, short-duration randomized trials). The absolute risk for congestive heart failure in the trials ranged from 0.8% to 3.6% for thiazolidinediones and 0% to 2.6% for nonthiazolidinediones. In contrast, neither metformin nor second-generation sulfonylureas were associated with congestive heart failure risk in 2 of 3 observational studies and 2 of 2 placebo-controlled trials. Congestive heart failure was reported mostly in cohort studies that did not adjust for key confounders, such as duration of diabetes, hemoglobin A1c level, blood pressure, and medication adherence. However, the cohort studies were consistent with one another and with limited data from randomized trials (Table 2).
Edema was more frequent in patients receiving thiazolidinediones as monotherapy or combination therapy (range, 0% to 26%) than in patients receiving second-generation sulfonylureas (range, 0% to 8%) or metformin (range, 0% to 4%). The absolute risk differences ranged from 2% to 21% in head-to-head randomized trials (Table 2).
We found a systematic review that reported similar rates of lactic acidosis between metformin and other oral diabetes agents (35). In this review, pooled data from 176 comparative trials and cohort studies totaling 35 619 patient-years revealed no cases of fatal or nonfatal lactic acidosis in any medication group. The estimated hypothetical upper limit of the underlying incidence of lactic acidosis was 8.4 cases per 100 000 patient-years in the metformin group and 9 cases per 100 000 patient-years in the nonmetformin group (35). We found 8 additional studies with data on lactic acidosis (3 randomized trials and 5 cohort studies). All showed little or no elevated risk for lactic acidosis in metformin recipients (Table 2).
Six head-to-head randomized trials, 7 placebo-controlled randomized trials, and 1 cohort study evaluated anemia as an outcome. Thiazolidinediones may be associated with an increased risk for anemia compared with other oral diabetes agents (posttreatment absolute risk differences, 1% to 5%). The mean decrease in hemoglobin level was small (≤1 g/dL). Only 1 study reported an adverse event of thrombocytopenia and leukopenia.
No study reported an allergic reaction to oral diabetes medications that led to hospitalization or death.
In addition to data published in peer-reviewed journals, we reviewed data from the FDA, unpublished trials conducted by industry, and clinical trial registries. The only new finding was that pioglitazone was associated with an increased risk for hospitalization for acute cholecystitis (12 patients) compared with placebo (1 patient) in a pooled analysis of 1526 patients (20). Otherwise, unpublished data were consistent with those from the published literature.
We did not find strong evidence of possible publication bias. Only 2 drug comparisons, from studies of hypoglycemia, had statistically significant results for publication bias (P < 0.05) according to the less conservative test of Egger and colleagues (27): metformin versus second-generation sulfonylureas (8 studies; P = 0.04) and repaglinide versus placebo (3 studies; P = 0.035). The 3 largest studies in the comparison of metformin with sulfonylureas had smaller absolute risk differences than the smaller studies; however, all studies showed that metformin is associated with less hypoglycemia than sulfonylureas. There were too few studies in the comparison of repaglinide versus placebo to draw conclusions about publication bias. For all other comparisons, the funnel plots appeared to be roughly symmetrical, and results of the tests of Begg and Mazumdar (26) and Egger and colleagues (27) were not statistically significant.
Ideally, oral diabetes agents should improve microvascular and macrovascular outcomes and mortality. We found no definitive comparative evidence on these outcomes. Because of this uncertainty, we evaluated medication effects on intermediate outcomes and other adverse events. By these criteria, we found that metformin was similar to, or better than, other currently available oral agents. Second-generation sulfonylureas also fared well against other agents, apart from the increased risk for hypoglycemia. Compared with newer agents, metformin and second-generation sulfonylureas share 3 additional advantages: lower cost, longer use in practice, and more intensive scrutiny in long-term trials with clinically relevant end points. Thiazolidinediones, although they pose a lower risk for hypoglycemia and a slight beneficial effect on HDL cholesterol level, showed no advantage in glucose-lowering effect and were associated with adverse effects on LDL cholesterol level, body weight, and risk for congestive heart failure.
These findings support the current American Diabetes Association and International Diabetes Federation recommendations that favor metformin as initial pharmacotherapy for type 2 diabetes (36, 37). They are also consistent with the 2007 American College of Endocrinology guidelines that suggest choosing an oral diabetes agent on the basis of the individual patient's burden of comorbid conditions (38). Of course, optimal glycemic control often requires multidrug therapy. Our review confirms that a second agent is additive both in terms of improved glycemic control and increased risk for adverse events, unless both agents are used at lower doses. Although they are not clearly superior to newer agents, sulfonylureas remain a reasonable alternative as second-line therapy, especially if cost is an issue.
Our findings are generally consistent with those of previous reviews of the effects of oral diabetes agents on intermediate outcomes, such as hemoglobin A1c level, lipid levels, and body weight (10, 12, 14, 16, 18, 19, 39, 40). Inzucchi (18) conducted a systematic review of the effect of oral diabetes agents and placebo on hemoglobin A1c and drew conclusions similar to ours. Our study adds to this research by including more recent articles, comparisons involving meglitinides, and meta-analyses of head-to-head comparisons. In a 2002 systematic review (without quantitative meta-analyses) on the lipid effects of oral diabetes medications, Buse and coworkers (19) reported findings similar to ours. Our investigation updates their review and adds more detail on differences between drugs from formal meta-analyses. The main contribution of our review is its comprehensiveness: We included a broad range of clinically relevant outcomes and adverse effects across all available drug classes.
Nissen and Wolski (11) recently reported results of a meta-analysis suggesting a relationship between use of rosiglitazone and risk for myocardial infarction. When they analyzed specific drug–drug or drug–placebo comparisons, however, their results were not statistically significant. Likewise, we found no statistically significant differences between specific oral diabetes medications in terms of cardiovascular outcomes other than congestive heart failure. Limitations of Nissen and Wolski's study included the small number of largely unadjudicated events and the fact that cardiovascular events were not the primary outcome. An additional limitation that influenced their conclusions was the decision to include studies with 2 diverse patient samples: nondiabetic persons, in whom the risk-to-benefit ratio of an oral diabetes agent may differ greatly from that in their diabetic counterparts, and diabetic persons with congestive heart failure, for whom rosiglitazone is contraindicated. The decision to include these studies may have biased the meta-analysis toward showing harm. Finally, exclusion of studies with no cardiovascular events in either group introduced a small bias against finding no difference in cardiovascular risk. Given the limitations of Nissen and Wolski's analysis, the effects of rosiglitazone on cardiovascular mortality and myocardial infarction are still uncertain. A recently published interim analysis from the RECORD study showed no statistically significant elevation in cardiovascular risk (besides congestive heart failure) related to rosiglitazone compared with metformin and sulfonylureas (20). Overall, these recent findings are consistent with ours: We found no conclusive evidence of worse cardiovascular morbidity or mortality with oral diabetes agents, other than the higher risk for congestive heart failure with thiazolidinediones than with other oral medications.
Several adverse events merit further discussion. First, because of concerns about lactic acidosis, metformin is contraindicated in patients with impaired renal function or congestive heart failure. However, neither our review nor that of Salpeter and colleagues (35) found evidence of an elevated risk for lactic acidosis in patients taking metformin compared with other oral diabetes agents. The evidence for metformin-induced lactic acidosis stems mainly from about 300 case reports. We did not consider case reports in our review because they pose problems in determining causality and provide no clear denominator for risk estimation. Underlying comorbid conditions, such as chronic kidney disease or myocardial infarction, are well-established risk factors for lactic acidosis; therefore, attributing lactic acidosis to metformin use versus an underlying comorbid condition is often difficult. Most reported cases of metformin-related lactic acidosis were associated with severe underlying illnesses (41, 42). Because of lingering fears about biguanides (phenformin was unequivocally related to risk for lactic acidosis), we suspect that apparent cases of "metformin-induced lactic acidosis" may have been overreported. However, we could not rule out the possibility that metformin conferred additional risk in the presence of severe underlying cardiac or renal disease, because these conditions were excluded in most randomized trials and were too uncommon in cohort studies to allow assessment.
Second, macular edema has been mentioned as an adverse event related to use of rosiglitazone only in case reports (43), which we excluded from our review. Third, the ADOPT study (published after our review was completed) reported an increase in fracture risk in women taking rosiglitazone compared with metformin or sulfonylureas (28). No cases were reported in the studies from our review, but this will need further investigation. Finally, repaglinide may be associated with less serious hypoglycemia compared with second-generation sulfonylureas, as was seen in 1 study of elderly persons (44), and in patients who skip meals, as was seen in 1 randomized trial not included in our review (because it was <3 months in duration) (45).
Our study has limitations. First, most of the trials, especially those of newer agents, were short-term trials, generally lasting less than 1 year. Ideally, therapeutic decision making should be based on long-term effectiveness. Second, head-to-head data were limited in many instances. This was especially true for multidrug regimens now in common use and for some of the newer agents, such as rosiglitazone, nateglinide, and miglitol. Third, although almost all studies reported the incidence of hypoglycemia, reporting of other adverse events was inconsistent, and the definitions of adverse events varied across studies. For instance, gastrointestinal events could include nausea, vomiting, abdominal pain, flatulence, or a combination of these events, making comparisons across studies difficult. Few trials reported data on elevated liver aminotransferase levels, congestive heart failure, anemia, and allergic reactions; therefore, we relied on cohort studies for many of these outcomes. The available cohort studies, however, were limited by their ability to adjust for key confounding factors, such as hemoglobin A1c level, blood pressure, duration of diabetes, adherence to medications, and medication dose. Finally, we focused on safety issues by making an a priori hypothesis of potential harm, and we may have missed harms reported only in case reports or those that were not assessed in trials or observational studies.
Compared with newer, more expensive agents (thiazolidinediones, α-glucosidase inhibitors, and meglitinides), older agents (second-generation sulfonylureas and metformin) have similar or superior effects on glycemic control and other cardiovascular risk factors (blood pressure, lipid levels, and body weight). Each oral diabetes agent is associated with adverse events that counterbalance its benefits. Overall, metformin seemed to have the best profile of benefit to risk. Large, long-term comparative studies on major clinical end points, such as myocardial infarction, chronic kidney disease, and cardiovascular mortality, are needed to determine definitively the comparative effects of the oral diabetes agents, especially in light of recent controversy regarding rosiglitazone.
Appendix Table 1.
Appendix Table 2.
Terms of Use
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Audio summary
Other Audio Options: Download MP3
Cardiology, Endocrine and Metabolism, Diabetes, High Value Care, Coronary Risk Factors.
Results provided by:
Copyright © 2016 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Privacy Policy
Conditions of Use
This PDF is available to Subscribers Only


text: July 19, 2007: Dust and debris parade in an extremely misshapen ring around the young star, HD 15115. The disk, seen edge-on with NASA's Hubble Space Telescope, is the dense blue line extending from the star to the upper right and lower left of the image. The disk appears thicker at upper right than at lower left, evidence of its lopsided structure. Astronomers think the disk's needle-like look is caused by dust particles following a highly elliptical orbit around the star. The lopsidedness may have been caused by planets sweeping up debris in the disk or by the gravity of a nearby star. An occulting mask on Hubble's Advanced Camera for Surveys was used to block out the bright starlight in order to see the dim disk. The occulting masks can be seen in the image as the dark circle in the center and the dark bar on the left. The star is behind the central mask. The Hubble image was taken on July 17, 2006. Follow-up observations in 2006 and 2007 with the W.M. Keck Observatory investigated the odd disk further.See the rest:


text:
Wildfire could cause air quality issues
Special notice issued Wednesday
Department of Natural Resources officials say there could be air quality problems downwind of a northwestern Wisconsin wildfire.
The DNR issued an Air Quality Special Notice on Wednesday.
Agency spokesman Kevin Harter says they haven't had any reports of problems but residents in Bayfield and Douglas counties, where the fire has been burning, or counties directly to the south should be cautious.
The fire started Tuesday afternoon and has destroyed nearly 50 structures and forced dozens from their homes. Firefighters have stopped most of the fire from spreading as of Wednesday afternoon.
The DNR says people should monitor their symptoms and consult a physician if they have concerns about smoke exposure.
Symptoms include irritation of eyes, nose and throat, or breathing discomfort. Smoke can aggravate chronic lung or cardiovascular disease.
Copyright 2013 by The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


text:
A Hubble WFPC2 image of the core of M31. Astronomers believe the two bright objects are a ring of red stars and a disk of blue stars.
Object Names: M31, Andromeda Galaxy, NGC 224
Image Type: Astronomical
Credit: NASA, ESA and T. Lauer (NOAO/AURA/NSF)
To access available information and downloadable versions of images in this news release, click on any of the images below:


text:
This tasty dish provides a healthy array of vegetables and can be used for breakfast, brunch, or any meal! Serve with fresh fruit salad and a dinner roll.
Nutrition Facts
Serving Size 1/5 of omelet
Calories 242
Total Fat 9 g
Total Carbohydrate 18 g
Protein 19 g
Ingredients and Preparation
Ingredients Measures
Small potatoes, peeled and sliced 5
Olive oil or vegetable cooking spray 1 tablespoon
Medium onion, minced ½
Small zucchini, sliced 1
Green/red peppers, sliced thin 1½ cups
Medium mushrooms, sliced 5
Whole eggs, beaten 3
Egg whites, beaten 5
Pepper and garlic salt with herbs to taste
Shredded part-skim mozzarella cheese 3 ounces
Parmesan cheese 1 tablespoon
- Preheat oven to 375°F.
- Cook potatoes in boiling water until tender.
- In a nonstick pan, add oil or vegetable spray and warm at medium heat.
- Add the onion and sauté until brown. Add vegetables and sauté until tender but not brown.
- In a medium mixing bowl, slightly beat the eggs and egg whites, pepper, garlic salt, and mozzarella cheese. Stir egg-cheese mixture into the cooked vegetables.
- Oil or spray a 10-inch pie pan or ovenproof skillet. Transfer potatoes and eggs mixture to pan. Spread with parmesan cheese and bake omelet until firm and brown on top, about 20-30 minutes.


text:
Ms. Julie Mueller
Director of Experiential Learning and Career Placement
Email: email@example.com
Phone: 859-344-3386
Fax: 859-344-4042
Office Location: Main Campus Administration Building - 2nd Floor
Welcome to the Career Planning Center! Please feel free to contact me if you are interested in career counseling or taking a personal career assessment. I'm also happy to help you with choosing/switching a college major. I'm here to assist you with your resume, cover letter, interviewing skills, seeking an internship or co-op, job searching, professionalism in the workplace, or any other occupational needs. My role is to assist you throughout all stages of your career, and my goal is that you are confident, prepared, and excited about your career! You are welcome to call, e-mail, or stop by my office. My office is located in the Student Life Hallway.


text:
Local teacher is no fan of Tomblin's education bill
On March 13 there was an editorial that supported Governor Tomblin's education bill. I am greatly disappointed in the comments made in that editorial.
I have been a teacher in West Virginia for over 20 years and believe that the system needs to change. However the system needs to change from the top up and that is what the audit reflected also. I have responses below for each paragraph.
What Mountain State residents talking with their legislators must accept is that for all the good qualities on display at some schools, the state's public education system is a wreck. Our children's performance on standardized tests ranks behind almost every other state. About one-fourth of students who enter school do not graduate. Of those students who do graduate, around one-third require remediation if they go to college.
And this is all the teacher's fault? Does poor parenting or unenforced laws about compulsory school attendance share in this formula? I recently gave a homework assignment to a class of 20 students and told them I was taking a grade on it. Five students returned the assignment, and what was the assignment? It was a permission slip so that students, who are minors, had permission to submit work for an art competition!
Those students who do not graduate generally have some type of attendance issue. How is that the teacher's fault that the student is not present in class? I send a letter to parents when a student has missed five days of my class. Usually I get no response from parents.
If one-third need remediation for college level classes, maybe they should have been told that at an earlier age. I frequently tell students, "If you are going to college and don't want to pay for classes that won't count toward your major you need to improve your math and English skills." Many students do not take college prep courses but say they are going to college. They take such classes as teacher assistant, tutoring, office assistant during their senior year and, therefore, go to college unprepared. Somehow that becomes the teacher's fault that they are unprepared.
The sad truth is that the stereotype of uneducated "hillbillies" has some basis in fact. We can resent that all we want, but defensiveness will not do our children any good.
I have had an opportunity to visit schools in other states. I have found that those students were no different, or "smarter," than our students here. They just do a better job of teaching to the test than we do.
Yes, there are sections of the governor's bill we wish could be altered. Some changes already have been made. But a concerted effort is under way to weaken some of the most critical proposals in the bill. There is a very real possibility that the bill could be gutted before it reaches Tomblin's desk to be signed into law.
The bill needs to be gutted. Start at the top. The cap is removed for the salary of the state superintendent, but more pressure/responsibility/total success of student achievement is placed on the backs of teachers in the state. There is nothing in this bill that addresses poor performance of principals, superintendents, county boards, state department individuals, and/or parents who have as much to do with a kid's education as we do.
So let us be clear: One of the most important opportunities for education reform in years, perhaps even decades, is upon us. If we throw it away, shame on us.
Yes, shame on you for demanding more from a group of professionals who are ranked 50th in the nation in pay, but you want them to do more than they are already doing.
Do you know what we do? We work our eight-hour teaching day, do fundraisers, work some evenings and or weekends doing lesson plans, grading papers or preparing lessons. We take students on field trips on weekends and summers where we are responsible for them 24 hours a day with no pay. We go in before school starts to prepare our rooms and go in after school is out to finalize everything, etc. Teachers are learning new technology on their own time and attending conferences that they do not get paid for and/or is out of their school day.
Shame on us for working our butts off for the lowest pay in the nation. We should just work our eight hours and let the kids suffer because that seems to be what is important here. We get paid for two to three snow days that are not able to be made up, and that is just terrible that we are getting paid for days we don't work. Did I mention that many of us do go to school during those snow days to do school work or do other work at home?
Included in Tomblin's proposal is that more attention is given to early childhood education, ensuring that students can read adequately before they leave third grade, emphasizing training in a career or vocation, focusing on the critical middle school years, and testing 11th grade students to ensure they are ready for college.
So the issue is we are spending too much money on education. The cost of adding early childhood education to the system is a cost of approximately $10,000 per child. What is read adequately by third grade – first, second, third grade level? How will this be measured? What about a student that has some type of disability? Additional emphasis on career and vocational and focusing on middle school are good concepts, but are those things clearly defined? An 11th grade test to ensure students are ready for college is a good concept, but who takes it? All students whether they have had college prep courses? Only those that have had college prep? Who decides? How do we measure if a student is ready for the work force?
There is much, much more in the bill to improve schools in ways great and small. Again, the bill is not perfect. But it is a start, and West Virginians need to insist our legislators not bow to pressure and maintain the status quo.
Yes, please do not bow to the opinion of teachers who have been in the system for 20 plus years. We are lazy, no account individuals who have done little work to help educate the youth of our state. That is the attitude I have after reading and hearing the support from others for this bill. It is all the teacher's fault yet again!
Denise Stalnaker


text:
Egyptians Not Happy With Muslim Brotherhood's Mohammed Morsi
Yes, the same Morsi who is the president of Egypt
(Telegraph) Demonstators burned down a headquarters block of the Brotherhood's political front, the Freedom and Justice Party, in Alexandria.
And there were also heavy clashes in cities with a record of protest against the former regime of ex-President Hosni Mubarak like Suez and Port Said.
In Cairo, the biggest demonstrations for months filled Tahrir Square, reviving the spirit and chants of last year's revolution.
An array of liberal and secular groups, including activists at the forefront of the protest movement that forced Hosni Mubarak from power marched on the Square to demonstrate against what they were calling Morsi becoming the "new pharaoh".
What's happening is that Morsi ended judicial independence so that his decrees would be unchallengeable by law. So, the upshot is that a "dictator", Mubarek, who kept the peace, tried to protect Coptic Christians in Egypt and work with Israel, was deposed and replace with….the makings of a dictatorship based along Muslim Brotherhood and theocratic lines. Gee, if only someone had been concerned that something like this could happen /sic
The Islamist president assumed sweeping powers on Thursday in a decree read out by his spokesman Yasser Ali on state television.
"The president can issue any decision or measure to protect the revolution," it said.
"The constitutional declarations, decisions and laws issued by the president are final and not subject to appeal."
And once he starts issuing "declarations, decisions, and laws" based on Sharia Law and the Koran, I wonder how those who were saying Mubarek had to go will feel? Will there be concern over the treatment of women and gays? Or will we get the same idiocy of multiculturalism and tolerance?
Also see...
Even though my father, brother, uncles and grandfather were in the military, I seldom handled guns growing up. That's because unlike many of the other people in my family, I've...Read More
William Teach
Related Articles
19 Cross-dressers Flogged Under Sharia Law
No matter what one might think of gays and/or cross-dressers, approve or disapprove, nowhere in human compassion should something like
Iran Ready To Execute 18 Year Old Under Fake Sodomy Charges
For all you liberal dhimmi's out there, as you ignore the threat from radical Islam and the calls for Sharia
Ad With Burning WTC Opposing Ground Zero Mosque Approved For NYC Buses
Well, this certainly won't build the kind of dialogue that the WTC Imam wants. Oh, well, face it, liberals, Islam


text:
At what age can they safely space their feedings out more? My DD is 2 weeks old and is going from an every 2 hour feeding schedule to an every 3 or 4 hour feeding schedule. I was told at the hospital to wake her during the night if she hadn't nursed in 3 hours (and same thing during the day).
Is this normal for her age, or, at 2 weeks should she still be nursing every 2 to 3 hours?
FYI, she's very content between feedings, and pee/poo seems normal.


text:
Re: Danica finished 14th
Schmoopy1000 wrote:My take on her race, & yes I watched her entire race with her car cam.
She struggled when in a ton of traffic at restarts. Once the cars got strung out some with a lot of help from her spotter, who I think did great. She would get in a rhythm & start getting better times. Spotter wouldnt be afraid to tell her when she was overdriving or not hard enough. At one time the spotter yelled at her to stop looking in her mirror & get back to the bottom of the track (she was overdriving at the time) that he would tell her when to worry about what is behind her. & honestly once she got back in rhythm, drove away from the 11 car.
Now as far as shes a girl people racing her in certain ways. I will have to call BS on that (at this race atleast)
When she was being passed, she was being passed cleanly
When she was passing cars it was very common she would rough them up with her bumper. Sometimes on purpose sometimes I think she gets excited & drives in to hard. She even sideslammed her teammate at one time. Dont know if she has an issue with the 81 car or not, but I swear she hit him everytime she was passing him. Then when she worked her way into a top ten & had a nice rhythm going. I thought the race would end under green & she would have "earned" her top ten. But then she overdrove the car again when she was around another car (the 81 again) & slid up into the 81 & spun herself out. So she still has learning to do with car control, but her fans (I dont think she is claiming this) that other drivers are racing her differently than others.
Blaming the competition for her mistakes is weak quite honestly. So I hope she hasnt said the same things I am hearing from some of her fans.
100% Danica's fault..
81 car - Bowles was blocking her whole race in Bristol and half race in Texas..