text:
- Contents
- Section 2: Testing and Assessment
- Initial History
- Initial Physical Examination
- Initial and Interim Laboratory and Other Tests
- Interim History and Physical Examination
- HIV Classification: CDC and WHO Staging Systems
- CD4 and Viral Load Monitoring
- Risk of HIV Progression/Indications for ART
- Early HIV Infection
- Expedited HIV Testing
- Resistance Testing
- Karnofsky Performance Scale
- Occupational Postexposure Prophylaxis
- Nonoccupational Postexposure Prophylaxis
- Preventing HIV Transmission/Prevention with Positives
- Immunizations for HIV-Infected Adults and Adolescents
- Preventing Exposure to Opportunistic and Other Infections
- Opportunistic Infection Prophylaxis
- Latent Tuberculosis Infection
- Smoking Cessation
- Nutrition
- Abnormalities of Body-Fat Distribution
- Dyslipidemia
- Insulin Resistance, Hyperglycemia, and Diabetes on Antiretroviral Therapy
- Coronary Heart Disease Risk
- Renal Disease
- Immune Reconstitution Inflammatory Syndrome
- Anal Dysplasia
- Candidiasis, Oral and Esophageal
- Candidiasis, Vulvovaginal
- Cervical Dysplasia
- Cryptococcal Disease
- Cryptosporidiosis
- Cytomegalovirus Disease
- Gonorrhea and Chlamydia
- Hepatitis B Infection
- Hepatitis C Infection
- Herpes Simplex, Mucocutaneous
- Herpes Zoster/Shingles
- Histoplasmosis
- Kaposi Sarcoma
- Molluscum Contagiosum
- Mycobacterium avium Complex Disease
- Mycobacterium tuberculosis
- Pelvic Inflammatory Disease
- Pneumocystis Pneumonia
- Progressive Multifocal Leukoencephalopathy
- Seborrheic Dermatitis
- Sinusitis
- Syphilis
- Toxoplasmosis
Renal Disease
Publish date: April 2014
Authored by: Alfredo Tiu, DO
The prevalence of renal complications among patients with HIV infection has increased as more patients with HIV are living longer as a result of effective antiretroviral therapy (ART) and opportunistic infection prophylaxis. More widespread access to and earlier initiation of ART has decreased the incidence of HIV-associated nephropathy (HIVAN), but other causes of renal disease persist, and in some cases are increasing in prevalence. These may be infections and other conditions related to HIV infection, other comorbidities (e.g., hypertension, diabetes), or medication adverse effects, including those caused by some antiretroviral (ARV) medications (see "Kidney disease associated with HIV infection" and Table 2, below).
Risk factors for renal disease in HIV-infected patients include the following:
- CD4 count <200 cells/µL
- HIV viremia, particularly RNA levels >4,000 copies/mL
- African-American race
- Family history of kidney disease
- Use of nephrotoxins (including medications; see Table 2, below)
- Comorbidities
- Diabetes mellitus
- Hypertension
- Hepatitis C
Renal disease in HIV-infected individuals can occur as a primary disease, as a secondary disease in the setting of other systemic illness, or as an adverse effect of medications. In the United States, the most common causes of end-stage renal disease in the general population are diabetes mellitus and hypertension. HIV-infected patients are at a fourfold higher risk of developing diabetes mellitus and a threefold higher risk of developing hypertension compared with seronegative individuals. Chronic hepatitis C, seen in 30-40% of HIV-infected individuals in the United States, is associated with several types of chronic kidney disease, including progressive secondary glomerulonephropathy, membranoproliferative glomerulonephropathy, and mixed cryoglobulinemia.
Note that ART should be given to HIV-infected individuals with renal disease, according to usual criteria for ART initiation; however, some ARVs must be avoided and some should be given at modified dosages according to the degree of renal dysfunction (see Table 3). Additionally, for patients with HIVAN, ART is the primary treatment.
Screening for kidney disease in HIV-infected persons is an important aspect of primary care, as patients typically have no symptoms until very late. High-risk patients (see list of risk factors, above) should be identified and monitored. Early identification of patients with renal dysfunction allows early intervention targeted at reversing the process of renal injury or slowing its progression. Current guidelines of the U.S. Department of Health and Human Services (HHS) and the Infectious Diseases Society of America recommend screening at entry to care, with subsequent screening as indicated by the patient's risk factors.
Screening consists of three tests:
Figure 1. Follow-Up for Patients with Normal Screening Test Results
Figure 1. Follow-Up for Patients with Normal Screening Test Results
Serum creatinine (Cr) and calculated estimate of renal function (eGFR); The eGFR usually is provided by the laboratory but may be calculated as follows:
eGFR by the Modification of Diet in Renal Disease (MDRD) equation:
GFR (mL/min/1.73 m2) = 186 x [serum Cr (mg/dL)]-1.154 x [age (years)]-0.203 x [0.742 if female] x [1.212 if African-American]
- Normal GFR: ≥90 mL/min/1.73 m2
- Chronic kidney disease (CKD): GFR <60 mL/min/1.73 m2
- The creatinine clearance (CrCl) can be used as a surrogate for eGFR but is considered to be less accurate. Note that CrCl is used in determining medication dosages.
CrCl (Cockroft-Gault equation):
(140 - age) x (weight in kilograms); multiply by 0.85 for females
72 x serum Cr (mg/dL)
- CrCl (Cockroft-Gault equation):
- eGFR by the Modification of Diet in Renal Disease (MDRD) equation:
- Urinalysis, for proteinuria, hematuria
Quantitative test for proteinuria (if eGFR <60 mL/min/1.73m2or ≥1+ protein on dipstick):
- Random urinary protein to urinary Cr ratio (U Pr/U Cr)
- This estimates 24-hour protein excretion and correlates well with grams per day of proteinuria; for example, a random U Pr/U Cr of 1.0 correlates with 1 g/day of proteinuria (normal is ≤0.2)
Suggested follow-up for patients with normal screening test results is shown in Figure 1; suggested follow-up of abnormal screening test results is shown in "Diagnostic Evaluation."
S: Subjective
As noted above, patients usually have no symptoms until late in the course of kidney disease and are diagnosed on the basis of laboratory abnormalities.
In symptomatic patients, presenting signs or symptoms are nonspecific. Patients with renal failure may present with fatigue, weakness, anorexia, nausea, pruritus, vomiting, edema, diminished urine output, discolored urine, altered mental status, and seizures. Those with renal disease associated with systemic illnesses may present with fever, arthralgias, respiratory symptoms, flank pain, abdominal pain, and diarrhea.
For patients with renal disease suspected on the basis of laboratory abnormalities (e.g., elevated serum Cr [azotemia], electrolyte disturbances, acid-base disorders, proteinuria, hematuria, and anemia), and for symptomatic patients with known kidney disease, ask about the risk factors and symptoms described above, and about the following:
- Systemic illness
- Night sweats, fever, weight loss
- Shortness of breath, cough, hemoptysis, nasal congestion, rhinorrhea
- Diarrhea, hematochezia, melena
- Dysuria, frequency, urgency, polyuria, decreased urine output, discoloration of urine
- Skin rash or skin lesions
- Edema, arthralgias, painful swollen joints, myalgias
- Family history of kidney disease, hyper-tension, diabetes mellitus
- Recent radiographic imaging with IV contrasts (including those containing gadolinium or iodinated agents)
Review the patient's medication list (see Table 1).
- Include over-the-counter medications, nonsteroidal antiinflammatory drugs, phosphate-containing enemas
O: Objective
Check blood pressure, temperature, and weight. Compare these with values from previous readings. Perform a physical examination, including evaluations of the following:
- Volume status (blood pressure, pulse, skin turgor, mucous membrane moistness, edema)
- Optic fundi (signs of retinopathy)
- Cardiovascular system (peripheral pulses, bruits), to assess for peripheral vascular disease
- Abdomen (auscultate for unilateral bruit [renal artery stenosis], distention, mass, organomegaly, tenderness)
- Musculoskeletal system (bruises, muscle pain, muscle weakness, swollen joints)
- Skin (rash to help evaluate for drug reaction, vasculitis)
- Rectum (enlarged prostate, if obstruction is suspected)
Review previous laboratory values (e.g., serum Cr, blood urea nitrogen [BUN], electrolytes, urinalysis) to determine whether the kidney disease is acute or chronic.
- Acute kidney injury (AKI) is assumed if there are no previous serum Cr values.
The presence of an abnormal GFR (≤60 mL/min for at least 3 months) suggests chronic kidney disease (CKD).
Review the CD4 cell count and HIV viral load.
A: Assessment
Once the duration of the elevated serum Cr is assessed, a differential diagnosis can be made.
The causes of renal failure are classified traditionally based on the area of the renal anatomy where the injury occurred: prerenal, renal, and postrenal (obstructive uropathy). Acute tubular necrosis (ATN) is the most common cause of acute kidney injury.
|Abbreviations: ACE = angiotensin-converting enzyme; HUS = hemolytic uremic syndrome; NSAID = nonsteroidal antiinflammatory drug; TTP = thrombotic thrombocytopenic purpura
|Laboratory Data
Imaging showing obstruction
|Partial Differential Diagnosis
Decreased renal perfusion
Vascular disease
Medication induced
Acute Tubular Necrosis
Ischemia leading to ATN
Endogenous toxins
Exogenous-induced ATN
Other intrarenal lesions
Prostate hypertrophy
Stones or crystal deposition
Kidney Disease Associated with HIV Infection
A discussion of glomerulonephropathy is beyond the scope of this chapter, but HIV and associated comorbidities (e.g., infections such as hepatitis C, hepatitis B, and cytomegalovirus, along with malignancies, heroin use, nephrotoxic medications, diabetes mellitus, and hypertension) are among the many causes of glomerulonephropathy. The condition most closely associated with HIV is HIVAN. This is a collapsing focal segmental glomerulosclerosis (FSGS) that usually occurs in persons of African heritage, and particularly those with a low CD4 count or high HIV RNA level. The clinical presentation includes the following:
- Nephrotic syndrome or nonnephrotic proteinuria
- Normal blood pressure
- Elevated Cr, often with rapid progression to end-stage renal disease (<6 months)
- Renal ultrasound usually reveals normal size or slightly enlarged echogenic kidneys
- Renal biopsy shows a collapsing FSGS
In addition, several conditions may be caused by ARV medications. Tenofovir may cause, though rarely, AKI with type 2 renal tubular acidosis (RTA) and Fanconi syndrome. Alternatively, it more commonly causes a gradual increase in serum Cr over a period of months or years; this appears to occur more frequently in persons concomitantly taking ritonavir-boosted PIs and perhaps also in those taking cobicistat. Patients who take tenofovir should have renal function monitored every 3-6 months. Indinavir can cause crystalluria, nephrolithiasis, and acute interstitial nephritis, and atazanavir can cause nephrolithiasis.
Some other medications commonly used in the treatment of patients with HIV infection and associated conditions may cause acute or chronic kidney injury. See Table 1, above, and Table 2, below.
It should be noted that several ARVs (including the NNRTI rilpivirine and the integrase inhibitor dolutegravir) as well as the pharmacokinetic inhibitor cobicistat (in the coformulation elvitegravir/cobicistat/tenofovir/emtricitabine, Stribild) may inhibit renal tubular secretion of creatinine and thus cause modest increases in serum Cr (in the range of 0.1-0.2 mg/dL) and modest decreases in eGFR. This does not result from kidney injury, and actual GFR remains stable. These creatinine increases occur in the initial weeks of treatment with one of these agents and remain stable afterward (if increases in Cr exceed what is expected for these drugs, it is important to conduct an evaluation for other causes).
|Acute Tubular Necrosis
|Acute Interstitial Nephritis
|Other Associated Abnormalities
|Antiretroviral Medications
Fanconi syndrome (hypokalemia, non-gap metabolic acidosis, hypophosphatemia, glycosuria)
May cause a slow increase in Cr
|Other Medications
|TMP-SMX (Bactrim, Septra)
|Hyperkalemia, crystalluria
|Aminoglycosides (e.g., streptomycin, gentamycin, amikacin)
|Overdose leads to high anion gap metabolic acidosis
|Papillary necrosis
|Amphotericin B
|Hypokalemia, hypernatremia (nephrogenic diabetes insipidus)
|Proteinuria, secondary minimal change disease, papillary necrosis
P: Plan
Diagnostic Evaluation
Figure 2. Workup of Abnormal Screening Test Results
Figure 2. Workup of Abnormal Screening Test Results
Determine whether the renal disease is acute or chronic, as above (see "O: Objective").
Perform a targeted laboratory evaluation, depending on results of initial tests, history, and physical examination.
- Urinalysis with microscopy and examination of urine sediment (e.g., hematuria, pyuria, casts) can help in identifying etiologies such as nephritic syndrome, ATN, or infection.
- Quantify the proteinuria by obtaining a random urine protein-to-urine creatinine ratio (U Pr/U Cr), if not done already; this correlates well with grams per day of proteinuria, as discussed above.
- Fractional excretion of sodium (FeNa) may be helpful in distinguishing causes of acute kidney injury.
- FeNa =
Urine sodium ÷ Serum sodium
Urine Cr ÷ Serum Cr
- FeNa <1 is highly suggestive of prerenal state
- FeNa >1 is suggestive of intrinsic renal injury
- FeNa =
- Urine culture, if urinary tract infection is suspected
Further workup will depend on the findings and the suspected cause.
Proteinuria can be present in patients with primary renal disease, and also in those with hypertension, diabetes mellitus, vascular disease, collagen vascular disease, malignancy, or certain infections. Proteinuria is not always pathologic and may be caused by transient conditions such as pregnancy, strenuous exercise, fever, seizure, or congestive heart failure; in some cases, it may be benign. However, proteinuria should be evaluated if it persists. If present with hematuria, proteinuria is highly suspicious for a glomerular disease.
The major classifications of persons with proteinuria are as follows:
Nephrotic syndrome:
- >3.5 g/day proteinuria
- "Bland" sediment, with no or few red or white blood cells
- Edema
- Hyperlipidemia
- Hypoalbuminemia
- Check serum complements (C3 and C4):
- Low complements: glomerulonephritis associated with subacute bacterial endocarditis, infection (postinfectious), lupus, membranoproliferative glomerulonephritis, and mixed cryoglobulinemia
- Proteinuria
- "Active" sediment, with white and red blood cells; may see red blood cell casts
- Further categorized into those with normal renal function and those with abnormal renal function
For asymptomatic isolated microscopic hematuria, obtain a follow-up urinalysis. If hematuria is persistent, obtain a renal and bladder ultrasound. If the result is normal, the eGFR is normal, and there are no other urine abnormalities, conduct routine follow-up with urinalysis and serum Cr testing. Refer patients aged ≥40 with persistent hematuria to a urologist for formal evaluation. Consider checking urine cytology, though that test is not sensitive enough to rule out genitourinary malignancy.
Red blood cell casts
Red blood cell casts strongly suggest glomerulonephritis, which can progress rapidly.
ATN is the most common cause of AKI. A history of certain medication exposures, recent IV contrast, and concurrent illness may provide important clues to ATN. Laboratory findings that are consistent with ATN include increasing serum Cr and a characteristic urine sediment that shows "muddy brown" casts, which are casts that contain densely packed tubular cells.
During AIN, the classic triad of AKI, fever, and rash is not always present. Laboratory findings suggestive of AIN in the setting of AKI include sterile pyuria and eosinophiluria.
Sterile pyuria
Sterile pyuria also may occur in malignancy (e.g., renal, bladder), and in genitourinary tuberculosis. If tuberculosis is suspected, further testing usually requires three first-void urine specimens sent for acid-fast bacilli culture.
Crystalluria and nephrolithiasis
Usual causes of nephrolithiasis should be considered in patients with hematuria, particularly if symptoms consistent with nephrolithiasis are present. Other causes in persons with HIV infection include some medications, including the ARVs indinavir and (rarely) atazanavir; see Table 2 above.
Obtain radiographic imaging (see below) as part of the initial evaluation, and send the passed renal stone, if available, for analysis in order to provide more specific recommendations for management. If there is suspicion that the condition is caused by a medication, order specific chemical analysis (e.g., for atazanavir).
In patients with multiple renal stones, active renal stone formation, and recurrent kidney stones, a metabolic evaluation should be done. This includes a serum intact parathyroid hormone measurement and 24-hour urine collection for Cr, sodium, calcium, oxalate, uric acid, and citrate.
Radiographic imaging of the kidneys is important in the evaluation of renal disease. The size and echogenicity of the kidneys may help differentiate acute and chronic kidney disease. Small and echogenic kidneys are consistent with CKD, though HIV, diabetes, and some other chronic conditions are associated with normal size or large kidneys. Imaging also helps identify obstruction (though the absence of hydronephrosis does not completely rule that out), malignancy, and other conditions.
Both spiral computed tomography (CT) scan and renal ultrasound are acceptable radiographic imaging studies for nephrolithiasis. The advantage of spiral CT scan is its ability to localize stones and assess their size without the use of contrast. Gallium renal scan may be helpful in AIN.
Renal biopsy
Biopsy is not always indicated for patients with renal disease, but it can be very helpful in establishing some diagnoses and determining treatment options.
Patients with proteinuria will benefit from angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs). Follow the serum potassium and Cr during treatment with an ACEI or ARB (check 1 week after initiation, then periodically). Follow the JNC VII (Joint National Committee on Prevention, Detection, Evaluation and Treatment of Blood Pressure) guidelines for blood pressure control. For patients with hypertension and proteinuria, the target blood pressure is <125/80 mm Hg.
The cornerstone of HIVAN management is fully suppressive ART, and this should be quickly initiated or optimized in all patients, if possible. An ACEI or ARB also should be used to treat proteinuria. A trial of corticosteroids can be considered for patients with deteriorating kidney function while on effective ART plus an ACEI or ARB; consult with a specialist.
For ATN and AIN, discontinue the offending medications and provide supportive care, which may include gentle volume repletion, replacement of bicarbonate deficit, and management of electrolyte abnormalities (e.g., hyperkalemia); consult with a renal specialist.
Other modalities of treatment such as steroids or immunomodulators may be needed, depending on the specific glomerular disease diagnosed by renal biopsy.
Uncomplicated nephrolithiasis can be managed with hydration and pain control. Oral fluid intake should be titrated to produce ≥2 liters of urine output per day. Recommendations for dietary modifications should be based on the 24-hour urine metabolic evaluation. A low-calcium diet usually is not helpful for patients with normal serum calcium and may be detrimental to patients with oxalate renal stones. If the crystalluria is caused by medications, discontinue the offending medications, if possible (in the case of ARVs, make substitutions to maintain optimal virologic suppression).
Patients with complicated nephrolithiasis or pyelonephritis require urgent urologic evaluation.
- Acute kidney injury
- Monitor serum electrolytes, BUN and Cr
- After these normalize, perform routine follow-up
- Acute interstitial nephritis
- Avoid offending medications
- Chronic kidney disease
- Follow blood pressure closely
- If hypertensive, consider an ACEI or ARB as first-line medication, as above
- Target blood pressure is <130/80 mm Hg
- If evidence of nephropathy, target blood pressure is <125/75 mm Hg
- Follow blood pressure closely
- For patients with diabetes, optimize blood glucose control
- Address other risk factors for cardio-vascular disease (see chapter
Coronary Heart Disease Risk
- Dyslipidemia
- Cigarette smoking
- Obesity
- Physical inactivity
- Monitor serum electrolytes, BUN, Cr, and hemoglobin
- Risk of secondary hyperparathyroidism:
- Serum calcium <9.5 mg/dL
- Parathyroid hormone level >35 pg/mL
- Management:
- Low-phosphate diet
- Phosphate binders with meals
- Vitamin D supplement
- Anemia
- Consider recombinant human erythropoietin and iron supplement (consult with a nephrologist)
- Target hemoglobin 11-12 g/dL
- Avoid nephrotoxins, if possible
- Adjust medication dosages based on renal function (eGFR); see below
Patients with severe or chronic renal disease should be referred to Nephrology for further evaluation and assistance with the following:
- Management
- Education
- Evaluation for renal replacement therapy
- Peritoneal dialysis
- Hemodialysis
- Kidney transplant evaluation
Medication Dosage Adjustment
Dosages of many medications, including most nucleoside analogues (NRTIs), must be adjusted for patients with CKD, and for those on hemodialysis; see Table 3, below.
|Standard Dosage
|Dosing in Chronic Kidney Disease and Hemodialysis
|300 mg PO BID
|Dosage adjustment for CKD does not appear necessary
|Didanosine (enteric-coated capsules)
|250 mg to 400 mg PO QD, depending on weight
|CrCl (mL/min)
|Weight ≥60 kg
|Weight <60 kg
|400 mg QD
|250 mg QD
|200 mg QD
|125 mg QD
|125 mg QD
|125 mg QD
|125 mg QD
|Formulation not suitable
|125 mg QD
|Formulation not suitable
|200 mg PO QD
|CrCl (mL/min)
|200 mg QD
|200 mg Q48H
|200 mg Q72H
|200 mg Q96H
|200 mg Q96H, take after dialysis
|150 mg PO BID or 300 mg PO QD
|CrCl (mL/min)
|150 mg BID or 300 mg QD
|150 mg QD
|150 mg first dose, then 100 mg QD
|150 mg first dose, then 50 mg QD
|50 mg first dose, then 25 mg QD
|50 mg first dose, then 25 mg QD, take after dialysis
|20 mg to 40 mg PO BID, depending on weight
|CrCl (mL/min)
|Weight ≥60 kg
|Weight <60 kg
|40 mg BID
|30 mg BID
|20 mg BID
|15 mg BID
|20 mg QD
|15 mg QD
|20 mg QD, take after dialysis
|15 mg QD, take after dialysis
|300 mg PO QD
|Experience in patients with CrCl <60 mL/min is limited.
|CrCl (mL/min)
|300 mg QD
|300 mg Q48H
|300 mg BIW (i.e., Q 3-4 days)
|Not recommended
|300 mg once weekly, after dialysis
|300 mg PO BID
|CrCl (mL/min)
|100 mg TID (or 300 mg QD)
|100 mg TID (or 300 mg QD); take after dialysis
|Standard Dosage
|Dosing in Chronic Kidney Disease and Hemodialysis
Abbreviations: CrCl = creatinine clearance; HD = hemodialysis
Adapted from McNicholl I, Rodriguez R. Dosing of Antiretroviral Drugs in Adults with Chronic Kidney Disease and Hemodialysis . In: HIV InSite, Coffey S, Volberding P, eds. San Francisco: UCSF Center for HIV Information. Accessed December 1, 2013.
|Atripla (efavirenz/tenofovir/emtricitabine)
|1 tab PO QHS
|Substitute component drugs, adjusting dosage of each drug for CrCl
|Combivir (zidovudine/lamivudine)
|1 tab PO BID
|Substitute component drugs, adjusting dosage of each drug for CrCl
|Complera (rilpivirine/tenofovir/emtricitabine)
|1 tab PO QD
|Substitute component drugs, adjusting dosage of each drug for CrCl
|Epzicom or Kivexa (abacavir/lamivudine)
|1 tab PO QD
|Substitute component drugs, adjusting dosage of each drug for CrCl
|Trizivir (zidovudine/abacavir/lamivudine)
|1 tab PO BID
|Substitute component drugs, adjusting dosage of each drug for CrCl
|Stribild (elvitegravir/cobicistat/ tenofovir/emtricitabine)
|1 tab PO QD
|Do not initiate if CrCl <70 mg/mL; discontinue if CrCl <50 mg/mL
|Truvada (emtricitabine/tenofovir)
|1 tab PO QD
|CrCl (mL/min)
|1 tablet QD
|1 tablet Q48H
|Substitute component drugs, adjusting dosage of each drug for CrCl
Protease inhibitors (PIs) and nonnucleoside reverse transcriptase inhibitors (NNRTIs) do not appear to require dosage adjustment in persons with CKD. Some PIs and NNRTIs, however, do require changes in dosing strategy for patients on hemodialysis. (It should be noted that most PIs have not been studied in the setting of hemodialysis.) The CCR5 antagonist maraviroc should not be used for certain patients with CKD. Available recommendations for hemodialysis patients include the following:
- Unboosted atazanavir should not be used.
- Treatment-naive patients: atazanavir must be boosted by ritonavir.
- Treatment-experienced patients: atazanavir (boosted or unboosted) is not recommended.
- QD dosing should not be used.
- In patients with PI resistance, lopinavir/ritonavir levels may be subtherapeutic.
- CrCl <30 mL/min or on HD: not recommended with potent CYP3A inhibitors or inducers. Without potent CYP3A inhibitors or inducers: 300 mg BID (150 mg BID if postural hypotension occurs).
- An additional dose (200 mg) should be given after each dialysis session.
Patient Education
- Early diagnosis of kidney disease is important. Acute kidney injury usually is reversible but may take time and may require temporary hemodialysis support.
- Advise patients to report all the medications they take, including over-the-counter medications and herbs or supplements.
- Risk factors for kidney disease are uncontrolled HIV infection (viral load above 4,000 copies/mL and CD4 count <200 cells/µL), coexisting conditions (diabetes mellitus, hypertension, hepatitis C), and ethnicity (African-Americans, Hispanic Americans, Asians, Pacific Islanders, and American Indians). Advise patients that it is important to reduce any modifiable risks, including optimizing HIV control and diabetes mellitus or hypertension management.
- Advise patients that control of blood pressure is important in slowing the progression of renal disease. Hypertension control can be maximized by both lifestyle modifications (e.g., weight lost, exercise, avoiding excessive alcohol intake) and antihypertensive medications. ACEIs or ARBs are the drugs of choice for patients with hypertension and kidney disease. Target blood pressure is <125/75 mm Hg for patients with proteinuric kidney disease.
- Educate patients that management of chronic kidney disease helps avoid or control complications such as high blood pressure, weak bones (osteodystrophy), anemia, and nerve damage (neuropathy).
- When the kidney disease progresses to end-stage renal disease, several options can be explored. These are dialysis, kidney transplant, or palliative care. There are two modes of dialysis, hemodialysis and peritoneal dialysis. A nephrologist and the patient can decide which option is best. HIV control (suppressed viral load, optimal CD4) is required if kidney transplant is to be considered.
- Aberg JA, Gallant JE, Ghanem KG et al.; HIV Medicine Association of the Infectious Diseases Society of America. Primary care guidelines for the management of persons infected with human immunodeficiency virus: 2013 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jan;58(1):e1-e34.
- Atta MG, Gallant JE, Rahman H, et al. Antiretroviral therapy in the treatment of HIV-associated nephropathy. Nephrol Dial Transplant. 2006 Oct;21(10):2809-13.
- Berliner AR, Fine DM, Lucas GM, et al. Observations on a cohort of HIV-infected patients undergoing native renal biopsy. Am J Nephrol. 2008;28(3):478-86.
- Brown TT, Li X, Cole SR, et al. Cumulative exposure to nucleoside analogue reverse transcriptase inhibitors is associated with insulin resistance markers in the Multicenter AIDS Cohort Study. AIDS. 2005 Sep 2;19(13):1375-83.
- Campbell LJ, Ibrahim F, Fisher M, et al. Spectrum of chronic kidney disease in HIV-infected patients. HIV Med. 2009 Jul;10(6):329-36.
- Gupta SK, Eustace JA, Winston JA, et al. Guidelines for the management of chronic kidney disease in HIV-infected patients: recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2005 Jun 1;40(11):1559-85.
- McNicholl I, Rodriguez R. Dosing of Antiretroviral Drugs in Adults with Chronic Kidney Disease and Hemodialysis . In: HIV InSite, Coffey S, Volberding P, eds. San Francisco: UCSF Center for HIV Information. Accessed December 1, 2013.
- Mocroft A, Kirk O, Reiss P, et al.; EuroSIDA Study Group. Estimated glomerular filtration rate, chronic kidney disease and antiretroviral drug use in HIV-positive patients. AIDS. 2010 Jul 17;24(11):1667-78.
- National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease evaluation: evaluation, classification, and stratification. Am J Kidney Dis. 2002 Feb;39(2 Suppl 1):S1-266.
- Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents . Department of Health and Human Services. Accessed December 1, 2013.
- Post FA, Campbell LJ, Hamzah L, et al. Predictors of renal outcome in HIV-associated nephropathy. Clin Infect Dis. 2008 Apr 15;46(8):1282-9.
- Szczech LA, Gupta SK, Habash R, et al. The clinical epidemiology and course of the spectrum of renal diseases associated with HIV infection. Kidney Int. 2004 Sep;66(3):1145-52.
- Verdecchia P, Staessen J, Angeli F, et al. Usual versus tight control of systolic blood pressure in non-diabetic patients with hypertension (Cardio-Sis): an open-label randomized trial. Lancet. 2009 Aug 15;374(9689):525-33.
- U.S. Department of Veterans Affairs. Renal Disease . In: Ross D, Coffey S, eds. Primary Care of Veterans with HIV. Washington: U.S. Department of Veterans Affairs, Veterans Health Administration; April 2009;211-25.
- Zietse R, Zoutendijk R, Hoorn EJ. Fluid, electrolyte and acid-base disorders associated with antibiotic therapy. Nat Rev Nephrol. 2009 Apr;5(4):193-202.
Search the Clinical Guide
Related Resources
Abbreviations for Dosing Terminology
- twice daily
- twice weekly
- intramuscular (injection), intramuscularly
- intravenous (injection), intravenously
- oral, orally
- Q2H, Q4H, etc.
- every 2 hours, every 4 hours, etc.
- every morning
- once daily
- every hour
- every night at bedtime
- four times daily
- every other day
- every evening
- three times daily
- three times weekly


text:
You are here:
Archive Home > Bab
Ballads > The Story of Gentle Archibald
y children, once I knew a boy
(His name was Archibald Molloy),
Whose kind papa, one Christmas-time,
Took him to see a pantomime.
He was a mild, delightful boy,
Who hated jokes that caused annoy;
And none who knew him could complain
That Archy ever gave them pain.
But don't suppose he was a sad,
or serious, solemn kind of lad;
Indeed, he was a cheerful son,
Renowned for mild, respectful fun.
But, oh, it was a rueful day
When he was taken to the play;
The Christmas pantomime that night
Destroyed his gentle nature quite;
And as they walked along the road
That led to his papa's abode,
As on they trudged through muck and mire,
He said, "Papa, if you desire
My fondest hopes and joys to crown,
Allow me to become a clown!"
I will not here attempt to show
The bitter agony and woe,
The sorrow and depression dire
of Archy's old and feeble sire.
"Oh, Archibald," said he, "my boy,
My darling Archibald Molloy!
Attention for one moment lend —
You cannot seriously intend
To spend a roving life in town,
As vulgar, base, dishonest clown,
And leave your father in the lurch,
Who always meant you for the Church,
And nightly dreams he sees his boy
The Reverend Archibald Molloy?"
That night as Archy lay awake,
Thinking of all he'd break and take,
If he but had his heart's desire,
The room seemed filled with crimson fire;
The wall expanded by degrees,
Disclosing shells and golden trees,
Revolving round, and round, and round;
Red coral strewn upon the ground;
And on the trees, in tasty green,
The loveliest fairies ever seen;
But one more fair than all the rest
Came from a lovely golden nest,
And said to the astonished boy,
"Oh, Master Archibald Molloy,
I know the object of your heart—
To-morrow morning you shall start
Upon your rambles through the town
As merry, mischief-making clown!"
* * * * *
day, when Nurse Amelia called,
To wash and dress her Archibald,
She opened both her aged eyes,
With unmistakable surprise,
To find that Archy, in the night,
Had turned all red, and blue, and white,
Of healthy colour not a trace —
Red patches on his little face,
Black horsehair wig, round rolling eyes,
Short trousers of prodigious size,
White legs and arms, with spots of blue,
And spots upon his body too!-
Said she, "Why, what is this, my boy?
My gentle Archibald Molloy!
Your good papa I'll go and tell,
You must be dreadfully unwell,
Although I know of no disease
With any symptoms such as these."
The good old lady turned to go
And fetch his good papa, when lo!
With irresistible attack
He jumped upon her aged back,
Pulled off the poor old lady's front,
And thrashed her, while she tried to grunt,
"Oh, Archibald, what have you done?
Is this your mild, respectful fun,
You bad, ungentlemanly boy?
Fie on you, Archibald Molloy!"
Some dreadful power unseen, but near,
Still urged him on his wild career,
And made him burn, and steal, and kill,
Against his gentlemanly will.
The change had really turned his brain;
He boiled his little sister Jane;
He painted blue his aged mother;
Sat down upon his little brother;
Tripped up his cousins with his hoop;
Put pussy in his father's soup;
Placed beetles in his uncle's shoe;
Cut a policeman right in two;
Spread devastation round, — and, ah,
He red-hot pokered his papa!
Be sure, this highly reckless course
Brought Archibald sincere remorse.
He liked a joke, and loved a laugh,
But was too well-behaved by half —
With too much justice and good sense —
To laugh at other folks' expense.
The gentle boy could never sleep,
But used to lie awake and weep,
To think of all the ill he'd done.
"Is this," said he, "respectful fun?
Oh, fairy, fairy, I would fain
That you should change me back again;
Some dreadful power I can't resist
Directs my once respectful fist;
Change, and I'll never once complain,
Or wish to be a clown again!"
He spoke, and lo! the wretched boy
Once more was Archibald Molloy;
He gave a wild, delighted scream,
And woke — for, lo, it was a dream!
Archive Home | W. S. Gilbert | Bab Ballads
Page Created
29 July, 2011

subset: commoncrawl


text:
My Nonprofit Reviews
Jon H.
Review for Outreach International, Independence, MO, USA
Outreach International is a unique nonprofit. Rather than being a "handout" organization, it is a "hand up." Outreach's philosophy is one about empowering people and communities to have skills that are self-sustaining, rather than being dependent on others for your livelihood. It is through their approach of helping members of these communities discern what they need and finding their own solutions that lives are truly changed. I can think of no other organization that has had the kind of impact on me that Outreach has. It has been an honor to be a part of such a powerful, life changing organization.
More Feedback
Would you volunteer for this group again?
For the time you spent, how much of an impact did you feel your work or activity had?
Did the organization use your time wisely?
Very Well
Would you recommend this group to a friend?
When was your last experience with this nonprofit?


text:
Voicemail for Mobile extends the benefits of eVoice to your mobile phone.You can read transcriptions of your mobile-phone voicemail, receive your voicemail in email, and more!
When activated, missed calls to your mobile phone go to your eVoice voicemail instead of your regular mobile voicemail. Callers hear your eVoice "unavailable" greeting, and all voicemail messages are stored in your eVoice account.
There is no additional cost to activate (or deactivate) Voicemail for Mobile. Standard eVoice usage fees apply. You may deactivate Voicemail for Mobile at any time to resume using your mobile carrier's voicemail system. However, additional costs for Voicemail-to-Text (i.e., delivering easy-to-read transcriptions of your voice messages directly to your inbox) may apply.
NOTE: Only one Voicemail for Mobile number may be used at a time.
Related Topics
© j2 Global, Inc. All rights reserved. eVoice® is a registered trademark of j2 Global, Inc.
6922 Hollywood Blvd, 5th Floor, Los Angeles, CA 90028


text:
Surround yourself in luxury. This wonderfully overstuffed pillow is created from high-end designer fabric in stylized medallion print. Expertly tailored with standard feather-down fill and zipper closure. The perfect accent for your bedroom, living room, or any room that needs a designer touch.
Estimated Ship Date: Made to order, but worth the wait! Ships in 1-2 weeks.
Delivery Method: Ships via Standard Ground Service. Please contact us for expedited shipping options.
Return/Exchange: This item is returnable for store credit within 30 days of the ship date (you will be responsible for return shipping). On the rare occasion that you receive a damaged or defective item, please contact us within 5 days of receiving your purchase, so that we may ship you a replacement.
©scenariohome 2013


text:
Ramdas Bhandarkar
Beautiful Life, Beautiful! - Poem by Ramdas Bhandarkar
Beautiful is life, beautiful,
So beautiful it will be,
With beloved share smile and laugh
When the one share his own,
Seeing and feeling not alone,
Not only sharing sorrow and happiness,
Everything they feel and think,
But also sharing everything they eat and drink!
Sharing the same cloth,
Sharing all weight and burden,
Sharing the same umbrella,
In hot Sun and rain!
Sharing the weight of bag and luggage,
Smiling together like kids of tender age!
Beautiful is life, beautiful,
When both stay together,
Lay together on Same cot,
Drink from same pot,
same room if they share,
Same eyes to look at things,
Same ears to listen to music,
Same taste in all and Everything,
Beautiful life, beautiful,
How beautiful mind is,
When heart sees
sweet heart,
we feel our beloved share
Everything with,
pain and sorrow,
But not the pain of heart,
as we are so feeble that,
we can't share his grief and sorrow
One day we will be with him and share his burden with ever lasting smile!
Beautiful life, beautiful will be,
Beautiful days will be
when I grow up to share his pain!
Comments about Beautiful Life, Beautiful! by Ramdas Bhandarkar
Read this poem in other languages
This poem has not been translated into any other language yet.
I would like to translate this poem »
Ramdas Bhandarkar's Other Poems
Famous Poems
Phenomenal Woman
Maya Angelou
Still I Rise
Maya Angelou
The Road Not Taken
Robert Frost
If You Forget Me
Pablo Neruda
Langston Hughes
Annabel Lee
Edgar Allan Poe
Caged Bird
Maya Angelou
Rudyard Kipling
Stopping By Woods On A Snowy Evening
Robert Frost
I Do Not Love You Except Because I Love You
Pablo Neruda


text:
Any couples who are not yet married and are only parties in domestic parternships, no matter what their sexual orientation, will not be given permission to move into Casa Di Amici Condo, according to WTSP-TV.
âI could not believe what I was reading. It basically says you have to be either a single person or a husband and wife to purchase a unit here,â realtor Julia Nowak, who rents one of the condos to her parents, told the station about a document she received from the association. ...
John Yurich USA wrote:No I am not wealthy. But I will be when I start my own Country Music/Country Gospel Band and get a recording contract and start making the big bucks.
Christopher000 wrote:Good luck with that and the rental properties not having stoves, fireplaces, and iceboxes in place of refrigerators. I can understand the ban on homosexuals and unwed couples, but that's not something you'll be able to include in the rental ad, and the rest, I think you are setting yourself up for failure.An enormous farm in Colorado and rental properties all over Kansas...you must be very wealthy!


text:
Quality of materials and elegance of the design: these are the keywords of our pendant. Finely-crafted pure, natural and A grade jade jadeite in Icy variety represents the quintessence of the craftsmanship expertise: this captivating pendant culminates in an auspicious statement in the donut style carving, thus became a lucky charm and at the same time an iconic symbol of fortune. Its design has an elegant, pure, and darling character, while the quality and appearance are exceptional. This Chinese round disc jade pendant is a fabulous pendant for any age group and every occasion.
Sleek, delicate and elegante. This fascinating pendant has oily luster in jello light green, snowflake white and brilliant translucence on sleek surface. Robust yet delicate. This pendant simply satisfies a desire for elegance.
Diameter: 24 mm
Depth: 4 mm
Depth: 4 mm
Matched Jewelry


text: Hello, I'm trying to upgrade findutils from the eecs.umich.edu mirror, and when dpkg installs, this is what happens: Preparing to replace findutils 4.1-31 (using findutils_4.1-32.deb) ... Unpacking replacement findutils ... dpkg: error processing findutils_4.1-32.deb (--unpack): error setting ownership of symlink `usr/doc/findutils/changelog.gz': Function not implemented dpkg-deb: subprocess paste killed by signal (Broken pipe) Errors were encountered while processing: findutils_4.1-32.deb E: Sub-process returned an error code I got a similar error about being unable to set ownership of symlinks while installing other packages. Any ideas about this? --James


text:
Milena Salvo
Milena Salvo graduated from the University of Turin, Turin, Italy, in chemistry (1992) and obtained his Ph.D. degree on Materials Engineering from Politecnico di Torino, Turin, Italy (1996), with a thesis concerning the joining of ceramic matrix composites for high temperature and thermonuclear fusion applications. In 1998, she became an Assistant Professor at Politecnico di Torino. She is now Associate Professor of materials science and technology and Lecturer of "materials science and technology" for energetic and mechanical engineering and "advanced ceramics" for material engineering at Politecnico di Torino. Salvo is a coauthor of more than 85 papers on international journals, conference proceedings, and 3 patents. Her research interests include the following: joining of advanced materials (ceramic and ceramic composite materials) for applications in the fields of thermonuclear fusion reactors and high temperature; coating of advanced materials for oxidation and wear protection; development, production, and characterisation of glass-ceramic and composite sealing materials for solid oxide fuel cells (SOFCs); vitrification and reuse of bottom ashes from the municipal solid waste incinerator(MSWI). The aim of this activity is the vitrification of bottom ashes from MSWIs and the reuse of the obtained glass as filler and aggregate in concrete and as raw material for glass-ceramic or composite materials.
Biography Updated on 14 April 2011


text:
Chicago St. Louis Game Ends in 5-4 Cardinals Victory - Recap
St. Louis used a 2-HR day from Albert Pujols on Saturday at Busch Stadium as the Cardinals defeated Chicago 5-4 in baseball action.
Bettors who backed the Cardinals were rewarded as -175 favorites at sportsbooks. Over-Under bettors saw the total score go OVER the closing total of 8.5.
Eduardo Sanchez earned the victory for the Cardinals, throwing 2 innings of work, striking out 2, walking 0, and allowing 0 hits and 0 earned runs. That effort was supported by 4 RBIs from Albert Pujols in the win.
Chicago's starting pitcher Randy Wells worked 5 2/3 innings, giving up 3 hits and 4 earned runs while striking out 0 in the loss. They got 3 hits from Kosuke Fukudome in a losing cause.
The battle of the bats favored Chicago as they had 12 hits, while St. Louis only had 9.


text:
Field maple
(Strassburg, 1580)
Author: BOCK, Hieronymus (1498–1554)
Artist: David Kandel
Hieronymus Bock is one of the three German Fathers of Botany.The first edition of his herbal was published in 1546 with 550 woodcuts by David Kandel. Kandel's hand-coloured woodcuts are both charming and informative, especially in the third part where the depictions of trees are enlivened by the introduction of genre scenes with animals and people, whose activities allude to the particular uses and character of the trees. Famous is the picture of the fig-tree, under which a boy with his trousers down drastically illustrates the purgative effect of figs.
Share this artwork:Twitter Pinterest Facebook Google Plus
Discover more:
TreesCherry treeOaktree
HerbalLime treeFig tree
CharmingOaktreeCherry tree
WoodcutTitle pageScrabrones
Or more:
Wunderkammer is a gallery of unique medical art from the Hagströmer Medico-Historical Library.
Wunderkammer is a gallery of unique medical art from the Hagströmer Medico-Historical Library.


text:
Legislators have been pushing the President to rethink a portion of his Affordable Care Act, which would add a 2.3 percent tax on all medical devices. Critics call the tax a job killer.
Pawn shops no longer are regarded as the last resort of the destitute. New customers are using the shops to raise loans.
Stuck at a plateau? Here are four things that could help your business reach new heights.
Most of the Sandy recovery money that's being offered by government agencies is loans. Grants that don't have to be repaid are preferred for most entrepreneurs. So what's the hold up?
Much is at stake for small businesses amid the deficit talks. A look at why Main Street is worried and why job creation isn't happening.
Borrowing by small businesses rose in October, as the central bank launched its latest round of monetary stimulus.
The office product company and online professional network have launched a digital forum offering networking, advice and content for small-business professionals.
How retailers can turn holiday shoppers into loyal year-round customers.
Meet KegSkins, a new way to keep beverages cold.
Time to take your business to the next level? Consider these tips for raising venture capital.
A new crop of alternative lenders such as Kabbage are using software—and sometimes Facebook activity—to gauge businesses and review loan requests within minutes. But the loans can come with hefty fees.
New online funding platforms are connecting entrepreneurs with potential financial backers. But for most upstarts that use crowdfunding websites to raise capital, the results can be more mixed.
What's so problematic about funding a start-up with a credit card?
Endeavor Global, a company that supports entrepreneurs in emerging markets, is focusing on Greece. Is the nonprofit crazy for jumping into the struggling nation?
A new study shows local bank managers have much leeway when distributing loans. But that discretion isn't always beneficial for local businesses. Learn more.
First-time franchise buyers are finding it more difficult to gather money needed to get their businesses off the ground. What's happening among lenders?
Yao Ming, the 31-year-old, 7-foot 6-inch former NBA star forced into early retirement from injuries, is now trying to make a splash as a venture capitalist in various projects in his home country.
Computer security specialists say "corporate account takeovers" have become increasingly common, and small businesses are especially easy prey because many lack firewalls and monitoring systems.
Choosing the right VC has become even more important in the wake of the Facebook IPO fallout.
A new survey by Citibank finds that 23 percent of small business owners have gone without pay for at least a year as they work to keep their businesses afloat in a tough economy.


text:
State Line Trail (A.K.A. Tuscarora Trail)
I would say this trail is somewhere between Intermediate and Advanced. You will also share this trail with hikers, ATV's, and 4-wheel drives. State Line Trail (AKA Tuscarora Trail, AKA County Line Trail) Background Originally constructed as a new route for the Appalachian Trail in response to development pressures in Northern Virginia, the 248-mile Tuscarora Trail became an extended side trail when the AT became a National Scenic Trail. The scenic trail designation made it possible for the Federal government to begin the process of acquiring land in a corridor around the trail thereby bringing permanent protection to the original AT route. While the Tuscarora was never used as a new trail for the AT, it's still a beautiful extended hiking route, leaving the AT to cut west across the Shenandoah Valley into the Shenandoah Mountains, then heading north into Pennsylvania where it reconnects with the Appalachian Trail. Until the mid-1990's, the south half of the trail from Shenandoah National Park to Hancock, Maryland was called "The Big Blue Trail" and was maintained by PATC. The north half was called "The Tuscarora" maintained by the Keystone Trails Association. In the early 90's, due to lack of attention, the Tuscarora section was rapidly disappearing back into the mountains. Thanks to the efforts of two District Trails Managers, PATC resurrected the trail and took over responsibility. At the urging of Elizabeth Johnston, PATC's then-Pennsylvania Chapter President, PATC then voted to rename the entire route "The Tuscarora". It now stands as a premiere hiking route with a singular name. Not as developed (there are only a few shelters along the route), not as public, not as long, and not as well-known at the Appalachian Trail, the Tuscarora offers something perhaps the AT doesn't - a better sense of wilderness and solitude. The Trail's connection point to the AT at its north and south terminus provides a hiking opportunity known as the "Tusca-lachian Loop". PATC is currently considering a patch to award to those who complete this enormous hiking circuit. From Potomac Appalachian Trail Club Store write up of trail guides and maps
post pictures of this trail >>
search for trail pictures >>
|Trail Directions
From I-81 in VA take Rt. 55 west past Star Tannery. At the top of the mountain and just before the WV state line there will be a road/trail on the left named Tuscarora Trail. You will see some limited parking area next to the high way or if you have a 4wd you can drive up the trail a couple hundred yards for more pull off areas.
|Trail Length
3.5 miles one way/ 6 round trip
|Trail Level
|Trail Type
Fire Roads
|Web Address
|Sort Reviews by: Latest Review | Best Rating
|Reviews 1 - 2 (2 Reviews Total)
Review Date
Overall Rating
Aerobic Difficulty
Technical Difficulty
Ridden Trail:
Reviewed by: srwings , Cross Country Rider
Recommended Route:
Other recommended trails in the same area:
Review Date
Overall Rating
Ridden Trail:
Reviewed by: Hopper Dale , from Stephens City, VA, USA
Recommended Route:
|Reviews 1 - 2 (2 Reviews Total)


text:
Run for the hills, those infernal conservatives are rewriting history. Or so one might gather from much of the coverage of Texas' latest textbook battle.
Well, maybe some books needed rewriting to wrestle them from previous biases. Everything truly is relative: If the textbooks are shifting right, is that a departure from accuracy or a move toward it?
Here's my offer. Next time the State Board of Education squabbles over hot-button issues, I'll settle it.
Before you jump to the conclusion that I would favor only my own political views, judge how I would rule as the Textbook Ref:
The founders: It should not be such an ordeal to teach that the people who founded this nation were deeply religious. In no way does that obligate any student to be equally religious, or religious at all. In fact, it is particularly noteworthy that while our founders were mindful of God, they created a nation where citizens may believe what they wish.
The Constitution: Our kids are constitutionally illiterate. I do not expect books to reflect my taste for strict constructionism, but I do expect kids to learn about the strong but very limited government the document outlines.
Separation of church and state: Those words do not appear verbatim in the Constitution, but it's clear the founders sought a distinction between matters of faith and governance. But not to the extent radical secularists would have you believe. Jefferson and Madison would not be shocked by a City Hall nativity scene; they would be shocked the ACLU wanted it yanked.
Kids should learn the value of religious neutrality, practiced by a government that prods us neither toward nor away from any belief we may hold dear. This is not violated by merely acknowledging the Judeo-Christian roots of our national values or the accommodation of a variety of religious imagery in the public square.
National leaders: I am less concerned with battles along the periphery - Phyllis Schlafly vs. Shirley Chisholm - and more with the big picture. John F. Kennedy and Martin Luther King Jr. properly earn big chunks of history book pages. But where is the salute to Ronald Reagan for bringing the Soviets to their knees?
As for other strata, I am fine with carving out room for Jerry Falwell and Cesar Chavez, the NRA and the NAACP. Why is this so hard?
Pop culture: The hip-hop argument drove me crazy. Those arguing against its inclusion as a cultural force pointed to its often crude lyrics, but I smell a different motivation: They hate it.
I don't have an iPod filled with Kanye West, but for 25 years, hip-hop and rap have dominated the charts as much as any other genre. Are many of the lyrics and messages inappropriate for kids? Of course, so that's what the book should say. Kids don't have to memorize violent or misogynistic lyrics to know about that controversy, as well as about artists who succeeded without resorting to them.
Multiculturalism: Heroes and trailblazers of every ethnicity should get their fair share of attention. If anyone of color has been given short shrift, that needs fixing. But let's not invent race-driven eminence. I'm sorry that Crockett, Bowie and Travis were not Hispanic, but lofting eight Tejano Alamo heroes to their status is simply not justified.
Evolution and intelligent design: Most scientists embrace Darwinian evolution, so texts should say so. Discrepancies with Genesis belong in comparative religion or social studies classes. But scientific skepticism - the growing number of scientists who believe there's empirical evidence that we are not here by cosmic accident - deserves examination, too, along with other substantive challenges to Darwin.
So there you have it. The Textbook Ref has ruled. I'm available next revision season at bargain rates.
Mark Davis is heard weekdays from 8:30 to 11 a.m. on WBAP News/Talk 820 AM and 96.7 FM. His e-mail address is email@example.com>.


text:
The roadway reconstruction work on South Dakota Avenue and Riggs Road continues in Northeast Washington. As part of that work, travelers will encounter temporary traffic patterns beginning on Thursday, according to the District Department of Transportation.
On Third Street, between Riggs Road and Second Street:
— The northbound lane will be reopened and traffic will remain on the west side.
— One lane per direction will remain open.
On Riggs Road between Chillum Place and First Street:
— Traffic will shift to the north side of Riggs Road.
— Two inbound lanes and one inbound lane will be kept open.
— The sidewalk on the south side of Riggs Road, between South Dakota Avenue and Chillum Place, will be closed.
On South Dakota Avenue between Riggs Road and Kennedy Street:
— Traffic will remain on the west side of South Dakota Avenue
— One southbound lane and two northbound lanes will remain open
— Drivers will be allowed to turn left onto Riggs Road from both northbound lanes.
There will be message signs in place to guide travelers through these new traffic patterns.


text:
Who: Eric Chan aka Pokeguyjai is your POC. I will be the SI instructor that will be running this group initially.
Where: In Easton, PA at the Easton Fish and Game Association (membership required). We have a 100 yd rifle range that is steel target friendly and a smallish handgun range that is movement friendly, but not exactly 360.
When: We mostly meet on Saturdays, more in the winter than in the summer since the Fudds are scarce in the winter.
Please let Eric know of your interest and we will post details as to fees, material, food, etc as the things get ironed out.
You must be an SI alumni to attend. No exceptions. This will be a skill building event, working on specific skillsets at each meeting.


text:
Bill Radke: Of course, Europe is asking those same kind of interest rate questions. Last week, the Bank of England held rates steady but made a surprise move to pour billions more dollars into the British economy. Today the U.K. paper, the Telegraph, says the bank is worried about deflation and prolonged stagnation. From London, here's Christopher Werth.
Christopher Werth: The U.K. had been abuzz with talk of "green shoots" lately. British manufacturing numbers are up, and consumer spending has been better than expected.
That's why it came us such a big surprise when the bank decided last week to increase its program to buy up nearly $300 billion in government and corporate bonds in order to increase the country's money supply. Conventional wisdom says adding more money to the economy risks inflation. But Vicky Redwood of Capital Economics says with such a lack of economic growth, prices actually risk going down, and that any recovery would be wiped out if deflation took hold.
VICKY REDWOOD: We've still got a significant risk of a W-shaped recession, or double-dip recession where the economy starts to grow again for a quarter a two, but then loses some of its momentum and slips back into recession further ahead.
Redwood says the same forces of spare capacity, where companies lower prices to compete for what little demand is out there, threatens pushing the U.S. into a similar deflationary spiral.
In London, I'm Christopher Werth for Marketplace.


text:
Asphalt 7 apk android has been released yesterday, so here we will give you download link, review, and informations all about asphalt 7 android. Gameloft (developer of this game) is known as a developer that has great games. Asphalt is one of the game, this game has been developed until now. This app will invites you to race. Beat all the races and be become a winner. Asphalt 7 heat is available for iOS on June 21, but they say they will launch this for droids on June 25.
We can see on iOS Stores that this app is available for iPhone and iPad, but until now there isn't available on Google Play. So, be patient to wait it available. Maybe this will available on next day. In this version you will get new features, new cars, and new tracks. We think you will like the graphic because this app has great graphic and it will be increase in each series.
What will you get on this series?
New 60 cars with excellent design from many prestigious manufacturers will be yours and you can use it on your race. 15 tracks with excellent design and it's real from many cities on the world. The best feature is multiplayer mode. You can play with your friends up to 5 use local network or online. You can share your rank, your achievements and you can search new rivals. 6 game modes, 25 leagues, and 150 races will complete the game. We think you will never get bored.
We think this is the best racing game for gadgets. It has many users in previews series and today we get data that show how many people search this game. Watch the trailer, this application looks very attractive, with the look perfect graphic. But is it great on droid? We will give you the reviews after we get the app and will share for you all about this game. iPhone has ratina feature and this app is able to maximize the features on the iPhone retina. We get great graphics there. We think this is better than the previous series.
Well, next day we will give you info update about the game and share download link of asphalt 7 for droid.


text:
NOWELL-L ArchivesArchiver > NOWELL > 2001-11 > 1006357088
From: Diane Miles <>
Subject: Arthur Herbert NOWELL
Date: Wed, 21 Nov 2001 15:38:08 +0000
This is a Message Board Post that is gatewayed to this mailing list.
Classification: Query
Message Board URL:
Message Board Post:
I am looking for information on the above born in 1876 in Clifton, Bristol,
England. He was the eldest son of William and Kate nee Townsend and had
a brother Wesley b in 1880/81 and posibly a sister Edith Mary b 1878. He
qualified as a pharmacist in 1902 and came to South Africa where he died in
1928. Does anyone have any knowledge of the family?
Visit Ancestry.com for a FREE 14-Day Trial and enjoy access to the #1
Source for Family History Online. Go to:
This thread:
|Arthur Herbert NOWELL by Diane Miles <>


text:
El área de la sombra se refiere a la de un objeto cuadrado o rectangular.
This article lists several calculators for area of a quadrilateral
Calculation of azimuth and solar elevation angle by given the coordinates and time of observation. It's possible to input coordinates manually or by selecting from the directory of cities.
Can calculate area, arc length,chord length, height and perimeter of circular segment by radius and angle.
Calculates the distance between two point of the Earth specified geodesic (geographical) coordinates along the shortest path - the great circle (orthodrome). Calculates the initial and final course angles and azimuth at intermediate points between the two given.
This online calculator converts the value of an angle given in the form of the degrees-minutes-seconds to degrees, expressed in decimal fraction and back from decimal fraction to degrees-minutes-seconds.
Calculates the section flexure depth with pipe bender or bending machine to obtain given parameters.
This online calculator determines lengths of triangle sides given one side and two angles
Calculation of unknown parameters of projection using known parameters. Parameters are duration, maximum height, distance, initial velocity and angle.
Calculation of azimuth and elevation of the sun above the horizon for a given position and time. Table with one hour increments.
Calculator computes the diagonals of a parallelogram and adjancent angles from side lengths and angle.
This calculator computes triangle angles for given triangle sides using cosine law


text:
Im ready to order up a mod chip for my Wii and Im wondering if any of you folks out there have an say in which is the better chip. Im going to install it my self because it 4 or 5 solder points, so any one?
Best chip? WiiKey Vs. CycloWiz v.2
Ease of Install?
Andrew G.
theirs problems with burned games playing without the chip. unless you know a program that will do it?
im not sure. but let me warn you- I bought one for my xbox, didnt like it, and returned it. you will only get 1/2 your money back due to restocking fees. Also, make sure you COMPLETELY understand how to use and install it.
ps. y do u want to mod your wii? unless you will use it online
but still


text:
CONWAY - Despite making a strong run in the second half, the Russellville Cyclones could not overcome Conway's size advantage and shooting performance as the Wampus Cats held on for a 59-46 win Friday night.
The Cyclones (5-4) outscored Conway 19-12 in the third quarter, behind 12 points from Marcus Pillow, and trailed by only three (42-39) after the quarter ended. But the end result was the Wampus Cats pulling away for their third win in as many games against Russellville this season, thanks to holding a large lead early.
"We can't get behind that early in the game," Cyclone coach Joe Sitkowski said as Conway held the lead through most of the first half, with the largest being 11 points. "Conway is a great team and has great shooters, and we can't afford to go down early to a team like that."
Eric England drained a three-pointer at the buzzer in the second quarter to pull the Cyclones within 10 (30-20), and that shot seemed to give some much-need fuel for Russellville as it kept the momentum going. The run started when Pillow drove to the basket and scored on a layup at the 3:47 mark in the third quarter, setting up a 12-2 run the Cyclones went on to close the period. Alex Sarjahani and Pillow - who had eight points on the run - each drained a three-pointer during that stretch to help pace the scoring attack.
However, most of the time it seemed the Cyclones would get on a run, Conway (6-2) drained a big shot or came away with a strong defensive play to put an end to Russellville's run. Size also stood in the way of the Cyclones, as the home team found itself able to make points in the paint.
"They did a good job of getting the ball inside and getting some easy baskets," Sitkowski said. "Their guards can shoot too, and they really played well when the inside people weren't scoring."
The Cyclones got a couple breaks as the fourth quarter began with the Wampus Cat big men - 6-foot-6 Steven Stone and 6-7 Craig Amos - each missing free throws to keep the score 42-39. Pillow then drained a three-pointer at the 6:56 mark to give Russellville its first tie since the 4:02 mark in the first quarter. The Cyclones appeared to have the edge in momentum, but the home team quickly cooled off the hot-shooting Russellville team.
"The most disappointing thing to me was our shot selection," Sitkowski said of the Cyclones' shooting woes. "A lot of our problems had to do with their defense, but some had to do with our shot selection.
"Conway is a great team and have good players. They really gave us a lot of trouble."
Conway went on a 17-4 run thereafter to close the game and force the Cyclones into taking bad shots to prevent a comeback.
Eric England and Jeremy Hoard each hit on three-point shots and Pillow knocked down a free throw for Russellville's only scoring in the period.
Despite the outcome, the RHS coach was pleased with the continual hard effort the Cyclones showed.
"We got down and could have thrown in the towel," Sitkowski said. "I'm glad our kids didn't quit."
The beginning of the game is where the tone was really set, as Conway utilized their height advantage and perimeter shooting to take a 30-20 lead into halftime.
The Cyclones started slow in the first half, as they had trouble getting the offense going. After Pillow drained a three-pointer at the 4:02 mark in the first quarter to tie the score 6-6, Russellville was not able to either tie or take the lead the rest of the half.
The Wampus Cats ended the first quarter with a 7-3 run, including six unanswered points, to take a 13-9 lead into the second quarter.
Conway kept the Cyclones scoreless until the 5:01 mark when Matt Ewing's shot was called good after a goaltending call. Mackenzie Embry connected on a short jumper to make the score 13-19 at the 4:09 mark in the second quarter.
Quincy Maxfield answered with five straight points to prevent Russellville from gaining any momentum.
Ewing drained two free throws at the 2:53 mark to cut down on the Wampus Cat lead and make the score 24-15.
Maxfield and Ewing traded baskets again before Conway scored four unanswered points. The Cyclones did not get another basket until England drained a three-point shot at the buzzer to cut the lead down to 10.
Pillow led Russellville with 16 points. Maxfield led all scorers with 17 points, and Amos had 10. Anthony Connors paced Conway with 10 and Stone finished with eight.
The Cyclones will be back in action Dec. 28 in the Ozarks Classic in Harrison.


text:
HIGH NOON [1952] review
April 30, 2011
My only fear is that some day I will have run out of great old movies to watch and be left only with what the present produces. This thought occurred to me as I watched the first few minutes of HIGH NOON. Therefore, I savored every minute, not much unlike Marshal Will Kane (Gary Cooper) must have savored every minute before noon in this real-time Western and psychological masterpiece.
SOPHIE'S CHOICE [1982] review
April 22, 2011
SOPHIE'S CHOICE is a mesmerizing film, not at all what I expected. I had of course long heard of the movie, it's title bouncing deep in the back of my mind as some very difficult choice Meryl Streep had to make. I knew she had won the Oscar for the performance. I somehow thought the choice had to do with her children, which I was in fact right about, but not in the way I had thought at all. I thought SOPHIE'S CHOICE was going to be a concentrated drama, all taken place at one time in one circumstance, but what it is, is a epic stretching across continents with complexity of character revealed with powerful strokes.
NATIONAL VELVET [1944] review
April 17, 2011
If you are a dreamer, like me, and you feel your faith is diminishing, watch NATIONAL VELVET and feel renewed again in the power of dreams, in the faith of dreams. NATIONAL VELVET is a masterpiece and instantly one of my all-time favorite movies.
IN THE VALLEY OF ELAH [2007] review
April 8, 2011
Tommy Lee Jones is very good in movies where he plays a restrained investigator in a world that has moved past his own time. In fact, in 2007 he did it twice, first in NO COUNTRY FOR OLD MEN then in IN THE VALLEY OF ELAH. I watched the former twice when it was released and just watched the latter tonight. Jones played his character, the father of a missing soldier just returned from Iraq, with honor, respect and surprising capability. I think when you have a face as weathered as Jones' that that adds more character to a character than most actors under 40 can muster using everything at their disposal.
FOREIGN CORRESPONDENT [1940] review
April 3, 2011
My mini-Hitchcock marathon continues with FOREIGN CORRESPONDENT, as unclaustrophobic as a Hitchcock movie gets. There were scenes all over Europe, quite different than the single apartment in DIAL M FOR MURDER, which I watched last night. There was really no suspenseful moments at all and the mystery was revealed quickly. It seems the main point of this movie was just to show pre-World War II anxieties in Europe and America's distance from those concerns. It did not help that the main villain of the movie was allowed a final heroic act, thus neutering any final climatic moment and again allowing the wartime message to be the closing message of this film.
DIAL M FOR MURDER [1954] review
April 1, 2011
When one cleanses their palette by watching a movie like DIAL M FOR MURDER by Alfred Hitchcock (my favorite director), one realizes just how much unnecessary filler is layered upon modern movies just to make them slightly tolerably watchable. I was surprised to see the budget for making DIAL M was about $1.4 million. I guess most of that was paid to the actors and Hitchcock himself as there was basically only one set and zero special effects. Perhaps the most money should have gone to the writer Frederick Knott for adapting his play into such a suspenseful tale that produces emotions one just does not feel in movies made in this century. Oh, and Grace Kelly is a stunningly beautiful woman, which such class and presence, although she does play a woman who has an affair that drives her husband to murderous ideas.


text:
How to Grow the Penis?
If you are unhappy with the size of your penis and wish you knew how to make the penis bigger, here's some good news for you!
Many men like you would do anything possible to reverse the situation. They find a popular method that is talked about positively on the Web and decide that it must work, right? – Wrong!
Extenders, pills and surgery – oh, horrors! Aren't there risks with using such methods? And what if they don't work anyway?
In doing research on how to increase penis size, you will find 3 options – you can either add pills to your daily diet, use an extender or go under the knife.
Beginning with pills, these are basically growth hormone that enters the blood stream and causes the body to grow in all directions. People have indeed been able to increase penis size using pills but there are often side-effects that come along with this decision.
You will either find nothing happening and end up wasting your money, or a host of problems will come knocking on your door. You might be unable to walk without flinching with pain, and you still won't gain any penis size. Urination might become difficult after a certain period of time and you could feel nauseous after every meal.
Penis extenders are stretching devices that are attached to the penis to pull it and make it longer. The idea behind using such a contraption is that if you pull the organ for a long-enough period of time, the organ will gradually extend and hence increase penis size.
That might sound great but, how can it be? Yet, there are men who have used it, apparently with success.
Surgery is certainly the worst option because it involves going under the knife and there is obviously a huge risk involved. The procedure is very costly and the results are never guaranteed. If you do decide to choose this option, you will be put on bed rest for at least a month and during that time you will need assistance in going to the bathroom. Furthermore, if the surgery doesn't go as planned, you will not be able to go to the bathroom without crying out in pain every time.
Why would you expose yourself to that much stress and risk to increase penis size, especially when there is another method you can use that will add at least 3 inches to your length and 3.5 inches to your girth – without any pain or risk whatsoever? We call it bio-chemical penis enlargement.
How Biochemical Penis Enlargement Works to Increase Penis Size
Puberty is that bewildering time in our young lives when everything changes, our moods irritate us and – the worst part – our bodies look alien even to us! That's when a boy's penis starts growing – the growth hormone triggers the creation of a chain which extends through the body. This chain is made of nutrients and biochemicals which are active in the body. They make sure that the growth hormone does its job effectively.
After a certain point, when puberty comes to an end, some of these nutrients and biochemicals are removed from the chain; this basically means that they now are dormant in the bloodstream.
With the help of biochemical penis enlargement, these nutrients can be made active once again – hence you can increase penis size in the right manner.
What the 3 above-mentioned methods forget to mention is that unless and until the insides of your body agree with the external products, no change will take place. This is the reason behind this method's success and, because it makes perfect sense, you honestly can't go wrong with it! It keeps the external and internal resources in total harmony and makes sure that you increase penis size without the unnecessary stress and sleepless nights.
Do I need to Exercise to Make the Penis Bigger?
One thing you need to remember is that there are people out there who claim to have gained excellent results by using weights and penis pumps to increase penis size but, again, the chances are 50-50. However, once you have completed the biochemical penis enlargement treatment, you can carry out simple exercises, without the weights and pumps, to increase penis size. This will make sure that the said biochemicals remain active and that they remain where they are supposed to exist.
Once the level of nutrients and biochemicals in your body is high enough, you will be able to increase penis size – and it works speedily enough, so you can't argue on that point!
The best part about biochemical penis enlargement, apart from the obvious, is that once you have perfected the technique, there are no restrictions on the number of times you need to carry it out to get the results that you want. Surveys and studies show that men have been able to add 4 inches – but who's to say you can't be the one to break this record?
As long as you do everything you are told to and stick to the standard number of repetitions, you will be able to increase penis size in a very short time.
That said, it will take about 9 weeks to get the standard results but the wait shouldn't matter. All your hard work will pay off in the end and you will be able to strut around with at least a 9-inch-long penis soon enough. Inagine how it would feel when all the girls will want to date you and the guys will wonder what your secret is!


text:
On stage, Rose Tattoo look like nothing on earth but Rose Tattoo.
The band gives an impression of overwhelming masculinity, a totally urban, night time jungle maleness that if considered objectively, would be awe inspiring, making an audience afraid rather than irresistibly drawn to go along with the band. It has something to do with having more than a hint of humor. You get the feeling that if some rich dame accosted them in twenty yards of mink they´d look at her straight in the false eyelashed and say: "What mug shot all the rabbits for ya?".
All this, and nothing about their music yet. The music is what makes the looks work. If Rose Tattoo looked like that and didn´t deliver, they´d be ridiculous. As it is, they do deliver; in spades.
Their rock´n´roll pedigrees are excellent. Slide guitarist Peter Wellls spent time with Buffalo, a band of hardnosed rockers who missed out by being both just after and before their time. Ian Rilan played his Mack truck bass with Band Of Light. Singer Angry Anderson of the shaven head spent years with Buster Brown, as did drummer Dallas "Digger" Royal; the band was renowed for its maniacal intesity. Michael Cocks on second guitar is the youngest member, but in this context this youth means vitality rather that inexperience.
Together, they turn rose Tattoo into tough, hard driving, full on band that barely gives you time to breathe. Angry´s voice is a harsh roar capable of instant reversal into surprising sweetness. Ian Rilan´s bass and Digger´s drumming hurtle the sound along so fast and hard you expect to see steam rising from the bass. Sparks flying from the drumsticks. Michael Cocks guitar fills and runs are always more than just rhythm guitar; he provides the link in an already solid, complete three piece unit for Peter Wells to take off from, sending knife shrap slide slicing down your spine, creating that plummeting elevator sensation in your stomach. And Angry, standing with his legs spread wide, totally caught up, sings rage and fury in a voice like a clenched fist.
Rose Tattoo´s original material varies widely, from the realistic loving tang of "Sweet Rosetta" to the hard, life worn viciousness of "Astra Wally" and "Bad Boy for Love". They really shine covering the Stones´ "Streetfighter", sung a la Rose Tattoo: "What can a poor boy do `cept sing with Rose Tattoo". And it´s not just a bunch of nice middle class kids they´re convincing; Rose Tattoo have played in jails. The prisoners were impressed enough to ask them back; those guys aren´t going to take some naughty boy pose from a pack of phonies.
Rose Tattoo have a single together "Bad Boy for Love"/"Snow Queen" that´ll convince you better than any flat words on paper can. Rose Tattoo live will take you one higher - right out of your head.
|< Prev


text:
Al Qaeda group kills Defense Ministry aide in latest Yemen attacks
(Yemen Online)
2014-05-15 -
Retrieved at: 2014-05-14 23:16:00 GMT
May 14,2014More than 20 people have been killed in clashes in Yemen. The latest fighting came as the country's army had taken the offensive against al Qaeda-linked groups.
[source: Yemen Online]


text:
Cracking the Case against Hydraulic Fracturing
August 3, 2012
The debate over hydraulic fracturing ("fracking") has suffered from an enormous amount of misinformation and misdirection. Broad fears regarding the contamination of groundwater and an increased frequency of earthquakes have sent environmentalists into a frenzied campaign against the technology, but these fears lack merit, says Donovan D. Schafer, a research associate with the Independence Institute.
Regarding fracking's potential for the contamination of underground aquifers and other groundwater sources, the physics of the technological process immediately undermine this claim.
- In most cases, fracking takes place in formations many thousands of feet below sources of drinking water.
- Thus, the belief that fracking can directly cause contamination would requires fracking to create fractures extending thousands of feet upward, through many rock layers, and into freshwater aquifers.
- Fractures, however, have a natural bias to spread outward and not upward; for them to do so would defy well-documented natural tendencies.
The physics of the process illustrate that fracking is not inherently dangerous to groundwater sources. Cases of contamination, however, have been acknowledged as possible. This is because of improper drilling techniques and/or surface spills that are not inherent to the process. Thus, the demonization of fracking itself is misleading and misguided.
Similar criticism can be leveled at the accusation that fracking causes earthquakes.
- The ability of the fracking process to cause or contribute to the incidence of earthquakes is much more limited than many believe: the energy released during the fracking process is small and occurs slowly over time.
- Furthermore, other sources of energy such as hydroelectric dams and nuclear power plants have been shown to contribute to the frequency of earthquakes much more than fracking.
- Finally, the empirical evidence of cases in which fracking directly contributed to earthquakes emphasizes repeatedly that the events in question were extremely small and few in number.
Fracking's association with the causation of earthquakes actually stems from the disposal wells that hold waste material. Drilled with a completely different technique, these wells, yet again, are not inherent to the fracking process. Therefore, the negative consequences associated with disposal wells should not be assigned to fracking itself.
Source: Donovan D. Schafer, "Cracking the Case against Hydraulic Fracturing," Independence Institute, July 2012.
For text:
Browse more articles on Environment Issues


text:
Food takes a big bite out of our budgets. The average Canadian family spends more than $7,000 a year on food, according to a 2009 Statistics Canada survey. And most aren't spending $80 on a hot dog. But that isn't stopping chefs around the world from turning cheap eats into haute cuisine.
The trend of making blue-collar food with luxury ingredients - like caviar, truffles and Kobe beef - has created some uber-pricey class-bending pairings.
Here is a list of five foods that will make your jaw drop and mouth salivate all at once:
Hot dogs
A record for the most expensive hot dog was set last week in Brockton, Mass., when a Can-Am League baseball team, the Brockton Rox, sold two $80 "K-O Dogs," named in honour of the club's mascot, during a game. The sausage in these half-pound, all-beef, foot-long hot dogs was rolled in truffle oil and coated with finely crushed porcini mushrooms before a sprinkle of white truffle shavings was added. It was then nestled in a buckwheat blini roll from one of Cape Cod's most exclusive bakeries.
There seems to be an extreme-burger competition happening in Las Vegas. Le Burger Brasserie, which is housed in the Paris Las Vegas casino, threw down the gauntlet by offering the 777 Burger, which comes with Dom Pérignon Rosé Champagne and costs $777. The burger is more of a surf-and-turf smorgasbord of Kobe beef, Maine lobster, imported brie and prosciutto than a burger. But it pales in comparison with the luxe burger served at Fleur de Lys restaurant at the Mandalay Bay Resort and Casino. This Wagyu beef burger is garnished with foie gras and black truffles and is served with a bottle of 1995 Château Petrus in a pair of Ichendorf Brunello glasses, which the customers get to keep. It costs $5,000.
What could make breakfast expensive, beyond chowing down on hundred-dollar bills? A mountain of caviar served on top of an omelette, that's what. For $1,000, guests of Norma's, the restaurant in New York's Le Parker Meridien hotel, can order a Spanish-style omelette that includes lobster meat and 10 ounces of sevruga caviar, totalling more than 3,000 calories, making it one impressive petit déjeuner.
And everyone thought that bird's nest soup, the infamous Chinese delicacy, was expensive, with its usual price of $100. Well, it has nothing on a bowl of pho sold at House of An restaurants in California. At $5,000, this is no ordinary noodle soup. In fact, the noodles aren't really noodles at all but blue lobster flesh crafted into a noodle shape. Throw some A5 Wagyu beef, white Alba truffles and hand-raised bean sprouts into a foie gras broth and you've got yourself the legendary AnQi Pho. The one thing that helps a foodie swallow the price is that proceeds from the dish benefit the Children's Hospital of Los Angeles.
Not to be outdone by chefs, bartenders are pouring cocktails with outrageous price tags. One such drink is the mai tai served at the Merchant Hotel in Belfast, Ireland. A collective cheers is certainly in order when guests request it since the drink costs £750 (about $1,100). The special ingredient is 17-year-old J. Wray & Nephew Jamaican rum. It is alleged to come from the last remaining bottle of the kind of rum Victor J. (Trader Vic) Bergeron used when he created the mai tai in the mid-1940s.


text:
Hello again! I've not posted much for a while as frankly there's not been much to say on "local" issues. However with our summer camp now over and batteries recharged I thought I'd resurface! This years summer camp was "short haul" after longer trips the last two years. We did a cycle tour round the local area. The centre piece was the scouts doing their aeronautics badge and taking control of a glider. Leaders got a go as well and frankly I found it terrifying! I'm quite happy with my feet firmly on terra firma. Anyway with flying being the centre piece there was only one Hollywood blockbuster we could possibly shoot a nod towards for this years musical montage. https://m.youtube.co...h?v=Zacn3fE4760 Full photo gallery here http://12thcambridge...e-tour-de-cams/ Enjoy!
Summer camp 2014 "Reach for the skies"
Started By Cambridgeskip , Aug 23 2014 12:07 PM
2 replies to this topic
Posted 23 August 2014 - 12:07 PM
- 0
Posted 27 August 2014 - 07:16 PM
Wow. Very neat trip. A traveling summer camp. How was this organized? Who did the bulk of the itinerary and schedule? And I notice (BSA take note) the uniform of the day seems to be a tshirt and a necker! And we can't get Scouts to wear the necker and make slides/woggles.
- 0
Posted 28 August 2014 - 01:12 AM
Wow. Very neat trip. A traveling summer camp. How was this organized? Who did the bulk of the itinerary and schedule?
And I notice (BSA take note) the uniform of the day seems to be a tshirt and a necker! And we can't get Scouts to wear the necker and make slides/woggles.
In terms of organisation and planning, basically we did it! We sat down with the PLs and talked about what was available within cycling distance and what they wanted to do. From then on it was a case of getting on the phone and asking the various venues when they could have us. It took a bit of juggling in order to get them arranged in an order that made for a reasonable cycling route. Most places are very scout friendly and were willing to pretty much bend over backwards for us!
As for uniform it's pretty much standard on camp to wear any old t-shirt and a necker. A lot of kids prefer a friendship knot to a woggle when on camp (partly because it makes the woggle harder to lose). We were asked to wear uniform shirts during the gliding at the request of the airfield so they can pick out guests from gliding club members.
The kids actually quite like the neckers. I don't know how it works your side of the atlantic but in any given district each group has its own colours for its necker. So it starts to become a little bit tribal, particularly at district and county events. Kids take real pride in their group colours! There was talk of getting rid of the necker around the millennium when the uniform was revamped but there was near insurrection from the kids. There is also real pride from those who get to wear the red, white and blue national necker because they have either done an international trip, been selected for the world jamboree or various other reasons. You can see a couple of them in bther video.....
- 0
0 user(s) are reading this topic
0 members, 0 guests, 0 anonymous users


text:
Reforming the Technical & Vocational Education Sector
lThe main providers of the Technical and Vocational Education and Training (TVET) sector in Iraq are the General Directorate of Vocational Education (GDVE) in the Ministry of Education, the Foundation of Technical Education, and Ministry of Labor and Social Affairs (MoLSA).
GDVE is responsible for 250 vocational schools offering training and equipment to secondary schools (grade 12). These schools accommodate about 25,000 full time students annually. Overall, more than 95% of all technical and vocational training in Iraq is provided by public schools. The Foundation of Technical Education of the Ministry of Higher Education and Scientific Research is in charge of technical education at higher level.
The Directorate of Employment and Training of MoLSA has the political mandate to carry out the training and further education of unemployed youth and adults and redundant soldiers. It has access to a total of 16 Skill Centres for the purpose of training the above-mentioned target groups. These Skill Centres offer non-formal trainings beyond the formal educational system under the Ministry of Education. As such, the qualification needs of disadvantaged persons can be fulfilled very flexibly. Cooperation with the MoLSA guarantees appropriate access of the target groups. The "Employment" division, which is affiliated with the MoLSA, has the exclusive task of finding employment for graduates.
A major problem of the current Technical and Vocational Education environment is its fragmentation and the uncoordinated management and administration of each sub-system. There is a lack of an institutional framework to organize, articulate, integrate, regulate and ensure the quality of training interventions and programs. This often leads to unnecessary duplication of efforts, and ineffective use of scarce training resources. In addition, the centralized decision-making structure in the Vocational Education System, coupled with generally weak management capacity at school level, contributes to the inefficient use of resources.
The TVET Programme, which is jointly implemented by UNESCO, ILO, and UNHABITAT, was designed to support the rehabilitation and modernization of the Technical and Vocational Education and Training sub-sector in Iraq by re-orienting and improving the TVET system so that it prepares young people effectively for wage and self-employment in the industrial, construction and service sectors of the economy.
Major components of the programme, on which UNESCO is currently working, include the following:
- Design of a TVET policy document aiming at guiding the TVET sector reform and streamlining the TVET sub-sector in light of the labour market requirements.
- Development and adoption of organizational reform plans for individual TVET schools, institutes, colleges and training centers to facilitate the implementation of the changes in the TVET system.
- Development of a TVET programme Review and Renewal plan.
- Implementation of a short-cycle modular training "Skills for Work" programme consisting of modular training in selected vocational skills that are in high demand in the labour market, in order to achieve quick impact in terms of youth employment and self-employment.
- Establishment of contract training centres (CTCs) in three pilot governorates as pilot Business Units within the Foundation of Technical Education (FTE) in order to capture industries' needs.
- Introduction of an apprenticeship vocational system for 6 selected disciplines at 6 pilot schools in order to demonstrate best practice-based approaches.
- Upgrading of the quality and relevance of vocational programmes in pilot MOE schools, FTE/ MOHESR colleges and MoLSA centres.
- Improvement of TVET equipment and ICT infrastructure through procurement of workshop equipment and computer labs.
To date, UNESCO implemented a three phase Governance programme which resulted in designing a new governance model for Iraq and an action plan to ensure that the new model is endorsed by the Iraqi Government and implemented. The main focus was on four main components; namely Governance, Organizational Framework, Quality Assurance, and Performance Assessment.
One of the TVET programme's objectives is to have the Organizational Reform Plans developed and adopted in individual TVET schools, institutes, colleges and training centers by training senior Iraqi National Experts in the three ministries. This will facilitate the implementation of the changes in the TVET system. The TVET programme also aims to design a Program for Review and Renewal Framework and to produce a Manual for the Development of the TVET System in Iraq.
Vocational and Technical skills provision is being enhanced in all TVET public structures by conducting a short-cycle modular training "Skills for Work" programme, consisting of modular training in selected vocational skills that are in high demand in the labour market, in order to achieve quick impact in terms of youth employment and self-employment. Three contract training centres (CTCs) were established as pilot business units within the Foundation of Technical Education (FTE) in order to capture industries' needs.
UNESCO is also working to upgrade equipment in all three ministries according to needs of the stakeholders.


text:
OTTAWA — Prime Minister Stephen Harper is hinting that the key Conservative campaign plank from the 2011 federal election that earned him a majority may not be pitched overboard after all.
Income-splitting for couples with children under 18 was a $2.5-billion pledge during the last election — a Conservative promise that would kick in as soon as the government balanced the federal budget.
But Finance Minister Jim Flaherty began publicly questioning the policy even before his Feb. 11 budget that effectively balanced the books this year and projected a surplus for 2015.
"I think income-splitting needs a long, hard analytical look … to see who it affects and to what degree, because I'm not sure that overall, it benefits our society," Mr. Flaherty told the Ottawa Chamber of Commerce during a televised post-budget interview.
Under questioning in the House of Commons, Mr. Harper refused to repeat his 2011 income-splitting pledge after budget day. Government sources, meanwhile, spread word that the Prime Minister and his Finance Minister were of one mind on the matter.
However, following a week-long break in the Commons schedule, Mr. Harper rose in the House on Tuesday to strike another note.
"Income splitting has been a good policy for seniors in Canada, and it will also be a good policy for Canadian families," the Prime Minister said in French in response to Liberal goading about broken election promises.
Mr. Harper did not repeat the statement in English.
'Income splitting has been a good policy for seniors in Canada, and it will also be a good policy for Canadian families'
His comment came the same day Mr. Flaherty told a Reuters news service interviewer in Australia that he has not decided whether he'll run again in 2015.
"We'll see. I haven't decided," Mr. Flaherty the 64-year-old Finance Minister said in an interview in Melbourne, where he is attending the G20 finance ministers' meeting and a business forum.
In November, Mr. Flaherty said "Yes" when a reporter asked him whether he plans to run again in the next election.
"Nothing has changed. I have work to do. I've got to balance the budget. I said I would," he said at the time.
Meanwhile Tuesday, the Prime Minister's Office repeated the emphatic defence of income splitting.
"It is a good policy," Jason MacDonald, Mr. Harper's director of communications, said in an email.
"It has been good for seniors and it would be good for families but, as the Prime Minister has said, we aren't in a position to talk about additional tax relief until we have the fiscal room to do so. That means balancing the budget and creating a surplus before we talk about additional relief."
Seniors have been allowed to split pension income to reduce their tax burden since 2007.
Studies by respected think-tanks such as the C.D. Howe Institute have found that family income-splitting would benefit only about 15% of Canadian families and the benefits would disproportionately go to the wealthiest, single-income households.
Nonetheless, a number of Conservative MPs — including some high-profile cabinet ministers — appeared to be caught flat-footed when Mr. Flaherty questioned the soundness of income-splitting as a policy, and there was some grumbling about how Conservative voters would react to any policy shift.
The Conservative party in 2011 made several tax relief promises, including the $2.5-billion pledge to allow two-parent households with children under age 18 to split up to $50,000 in income for tax purposes to the lower-income partner.
"This measure will be implemented when the federal budget is balanced within our next full term of office," stated the party platform.
The Canadian Press, with files from Postmedia News