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The present study characterized the TGR5 expression and the signaling pathways coupled to this receptor that mediates the relaxation of gastric smooth muscle. TGR5 was detected in gastric muscle cells by RT-PCR and Western blotting. Treatment of cells with the TGR5-selective ligand oleanolic acid (OA) activated Gαs, but not Gαq, Gαi1, Gαi2, or Gαi3, and increased cAMP levels. OA did not elicit contraction, but caused relaxation of carbachol-induced contraction of gastric muscle cells from wild-type mice, but not tgr5−/− mice. OA, but not a selective exchange protein activated by cAMP (Epac) ligand (8-pCPT-2′-O-Me-cAMP), caused phosphorylation of RhoA and the phosphorylation was blocked by the PKA inhibitor, myristoylated PKI, and by the expression of phosphorylation-deficient mutant RhoA (S188A). Both OA and Epac ligand stimulated Ras-related protein 1 (Rap1) and inhibited carbachol (CCh)-induced Rho kinase activity. Expression of RhoA (S188A) or PKI partly reversed the inhibition of Rho kinase activity by OA but had no effect on inhibition by Epac ligand. However, suppression of Rap1 with siRNA blocked the inhibition of Rho kinase by Epac ligand, and partly reversed the inhibition by OA; the residual inhibition was blocked by PKI. Muscle relaxation in response to OA, but not Epac ligand, was partly reversed by PKI. We conclude that activation of TGR5 causes relaxation of gastric smooth muscle and the relaxation is mediated through inhibition of RhoA/Rho kinase pathway via both cAMP/Epac-dependent stimulation of Rap1 and cAMP/PKA-dependent phosphorylation of RhoA at Ser188. TGR5 receptor activation on smooth muscle reveals a novel mechanism for the regulation of gut motility by bile acids.
- bile acids
- G protein-coupled receptor
- oleanolic acid
- smooth muscle relaxation
- TGR5 receptor
bile acids (BA), synthesized from cholesterol in liver and secreted into duodenum in response to food, play an important role in lipid digestion and absorption. Nearly 95% of BA are reabsorbed in the distal part of the ileum and colon and transported back to the liver via enterohepatic circulation. The primary bile acids, cholic acid (CA) and chenodeoxycholic acid (CDCA), are converted to their respective secondary bile acids deoxycholic acid (DCA) and lithocholic acid (LCA) by bacterial enzymes of the intestine. It is now very well established that BAs, in addition to their classic function in lipid digestion, act as signaling molecules with systemic endocrine functions such as regulation of bile acid, glucose and lipid metabolism, immune response, and cell proliferation and differentiation (5, 6, 32).
The endocrine function of bile acids is mediated through activation of nuclear and plasma membrane receptors, including the nuclear farnesol-X-receptor (FXRα, NR1H4) and plasma membrane-bound G protein-coupled receptor TGR5, also known as GPBAR1 (G protein-coupled bile acid receptor 1) (8, 15, 16, 23, 34). FXR expression is more abundant in liver and gut compared with other tissues and is more selectively activated by CDCA compared with other bile acids. FXRs function as sensors of metabolic signals and play an important role in the regulation of bile acid, glucose, and cholesterol homeostasis by controlling the expression of genes in specific metabolic pathways (15, 29). By downregulating the expression of CYP7α1, a key enzyme in BA biosynthesis, FXR exerts a negative-feedback control on BA biosynthesis (13). Activation of FXR increases glycogen biosynthesis in liver facilitating decrease in blood glucose levels (14, 36).
TGR5 expression is more abundant in liver, adipose tissue, and intestine compared with other tissues and is more selectively activated by LCA compared with other bile acids (8, 16). TGR5 participates in control of insulin release from pancreas, and this effect is mediated indirectly through release of glucagon-like peptide (GLP-1) and glucose-dependent insulinotropic peptide (GIP) from enteroendocrine cells and direct activation of β cells in the pancreas (7, 10). TGR5 is also highly expressed in the epithelium of gallbladder, where activation of TGR5 promotes gallbladder filling with bile (12). This is consistent with the fact that tgr5−/− mice are refractory to the formation of gallstones in response to the high-fat diet (33).
Activation of TGR5 also regulates gut motility. Luminal administration of bile acids inhibits gastric emptying and intestinal transit (25). This effect could be due to release of hormones such as GLP-1 and peptide YY (PYY) from enteroendocrine cells, release of nitric oxide from inhibitory motor neurons, and/or direct effect on smooth muscle of the gut. Studies by Poole et al. (25) demonstrated that the expression of TGR5 in inhibitory motor neurons of the enteric nervous system and addition of DCA to isolated segments of ileum and colon suppressed spontaneous phasic activity. Lavoie et al. (11) demonstrated that the expression of TGR5 in gallbladder smooth muscle and addition of LCA to isolated segments of gallbladder reduced spontaneous Ca2+ fluxes and caused membrane hyperpolarization. However, to date, there are no experimental data on the signal transduction pathways initiated by TGR5 receptors to modulate gastrointestinal smooth muscle function. In the present study, we demonstrated that in gastric smooth muscle, TGR5 receptors are coupled to Gαs/cAMP pathway and activation of these receptors leads to muscle relaxation via both PKA-dependent phosphorylation of RhoA at Ser188, and protein kinase A (PKA)-independent, exchange protein activated by cAMP (Epac)-dependent stimulation of Ras-related protein 1 (Rap1).
Oleanolic acid (OA) was obtained from Sigma-Aldrich (St. Louis, MO). Antibodies against TGR5, Rap1, and RhoA were obtained from Abcam (Cambridge, MA). [35S]GTPγS was obtained from NEN Life Sciences Products (Boston, MA). Western blotting and chromatography material were obtained from Bio-Rad Laboratories (Hercules, CA). Collagenase and soybean trypsin inhibitor were obtained from Worthington Biochemical (Freehold, NJ). All other reagents were obtained from Sigma (St. Louis, MO).
TGR5 knockout mice.
TGR5 knockout mice (tgr5−/−) were generated in a hybrid (129S3/SvlmJ×C57BL/6) background and were maintained in a temperature-controlled environment with a 12:12-h light/dark cycle and free access to food and water. Age- and sex-matched animals were used between 6 and 12 wk of age (31). Animals were killed by anesthetic overdose and bilateral thoracotomy. All experiments with animals were approved by Institutional Animal Care and Use Committees.
Preparation of dispersed and cultured gastric muscle cells.
Smooth muscle cells were isolated from the circular muscle layer of rabbit stomach by sequential enzymatic digestion, filtration, and centrifugation, as described (20, 21). The cells were resuspended in enzyme-free medium consisting of 120 mM NaCl, 4 mM KCl, 2.6 mM KH2PO4, 2 mM CaCl2, 0.6 mM MgCl2, 25 mM HEPES, 14 mM glucose, and 2.1% Eagles' essential amino acid mixture (pH 7.4). The partly digested tissues were washed with 50 ml of enzyme-free medium, and the muscle cells were allowed to disperse spontaneously for 30 min. The cells were harvested by filtration through 500-μm Nitex and centrifuged twice at 350 g for 10 min to eliminate cell debris. In some experiments, the muscle cells were cultured in DMEM containing 10% FBS until they attained confluence and were used in the first passage.
Detection of TGR5 in rabbit gastric muscle cells by conventional PCR.
Cultured gastric muscle cells were treated with the RNaqueous reagent (Ambion, Austin, TX) for total RNA extraction. The potentially contaminated genomic DNA was removed by treating 10 μg of the RNA sample at 37°C for 30 min with 1 μl of TURBO DNase (Ambion) followed by an extraction with phenol:chloroform:isoamylalcohol (25:24:1). RNA (2 μg) was used to synthesize cDNA using SuperScript II reverse transcriptase (Applied Biosystems, Foster, CA) with random hexanucleotide primers. Conventional PCR was performed on cDNA using the HotMaster Taq DNA polymerase kit (Epicentre Biotechnologies, Madison, WI). The primers for rabbit TGR5 (GenBank Accession no. NM_001082648) were forward 5′-CTG TCA CTG GCC CTG GCA AGC-3′ and reverse 5′-CGC CAC ATA GCG CTC CCC GTG-3′, generating a fragment of 282 bp.
Determination of TGR5 in dispersed smooth muscle by Western blotting.
Proteins (50 μg) were separated by SDS-PAGE and transferred to nitrocellulose membranes (Immobilon-FL, Millipore, Billerica, MA). The membrane was blocked, incubated with antibodies to TGR5 (Abcam, Cambridge, MA), and following washing incubated with secondary antibody conjugated to horseradish peroxidase (Santa Cruz biotechnology, Santa Cruz, CA). Immunolabeled proteins were detected by the ECL Plus enhanced chemiluminescence detection system (Amersham Life Science Buckinghamshire, UK).
Identification of TGR5 receptor-activated G proteins in smooth muscle membranes.
G proteins selectively activated by TGR5 ligands were identified by the method of Okamoto et al. (22). Ten milliliters of muscle cell suspension (2 × 106 cells/ml) was homogenized in 20 mM HEPES medium (pH 7.4) containing 2 mM MgCl2, 1 mM EDTA, and 2 mM dithiothreitol. After centrifugation at 27,000 g for 15 min, the crude membranes were solubilized for 60 min at 4°C in 20 mM HEPES medium (pH 7.4) containing 2 mM EDTA, 240 mM NaCl, and 0.5% solution containing 10 mM HEPES (pH 7.4), 100 μM EDTA, and 10 mM MgCl2 in the presence or absence of OA (10 μM). The reaction was stopped with 10 vol of 100 mM Tris-HCl medium (pH 8.0) containing 10 mM MgCl2, 100 mM NaCl, and 20 μM GTP, and the mixture was placed in wells precoated with specific G protein antibodies. Coating with G protein antibodies (1:1,000) was done after the wells were first coated with anti-rabbit IgG for 2 h on ice. After incubation for 2 h on ice, the wells were washed three times with phosphate buffer solution containing 0.05% Tween 20, and the radioactivity from each cell was counted by liquid scintillation (18).
cAMP generation.
cAMP was measured by ELISA (Arbor Assays, Ann Arbor, MI). OA (10 μM) was added to 0.5 ml of cell suspension (106 cells/ml) together with a threshold concentration of 3-isobutyl-1-methylxanthine (IBMX, 1 μM), and the reaction was terminated after 60 s with 6% cold trichloroacetic acid (vol/vol). The mixture was centrifuged at 2,000 g for 15 min at 4°C; the supernatant was extracted three times with 2 ml diethyl ether, and the samples were lyophilized. The samples were reconstituted for ELISA and acetylated with triethylamine/acetic anhydride (3:1 vol/vol) for 30 min. cAMP was measured in triplicate using 100-μl aliquots, and the measurements were expressed as percent increase above basal level.
cAMP-dependent PKA assay.
One milliliter of cell suspension was incubated in HEPES medium with OA (10 μM) or OA with protein kinase inhibitor, myristoylated PKI (1 μM), for 60 s at 31°C. The reaction was stopped by rapid centrifugation, and the pellet was rinsed with a medium containing (in mM) 50 Tris·HCl (pH 7.4), 10 EDTA, 0.5 IBMX, 10 2-mercaptoethanol, and 100 NaCl and homogenized in 0.5 ml of ice-cold medium. The mixture was centrifuged at 48,000 g for 15 min, and the supernatant was used as a source of protein kinase. The enzyme activity was measured by ELISA (Arbor Assays, Ann Arbor, MI).
Transfection of phosphorylation site-deficient RhoS188A in cultured smooth muscle cells.
RhoA mutant cDNA was subcloned into the multiple cloning sites (EcoRI) of the eukaryotic expression vector (pEXV), and a myc tag was incorporated into the NH2 terminus. Recombinant plasmid cDNAs (2 μg each) were transiently transfected into cultured smooth muscle cells using Lipofectamine plus Reagent. The cells were transfected with 1 μg of pGreen Lantern-1 DNA to monitor expression. Control cells were cotransfected with 2 μg of pEXV and 1 μg of pGreen Lantern-1 DNA. Transfection efficiency was monitored by the expression of green fluorescent protein using FITC filters. Expression was demonstrable in over 80% of the cells (21).
Phosphorylation of RhoA.
Phosphorylation of RhoA was measured from the amount of 32P incorporated after immunoprecipitation with specific RhoA antibody. Smooth muscle cell suspensions (10 ml; 3 × 106 cells/ml) were incubated with [32P]orthophosphate for 4 h at 31°C. One-milliliter samples were then incubated with OA (10 μM) in the presence or absence of myristoylated PKI (1 μM) or the cAMP analog (8-pCPT-2′-O-Me-cAMP, 10 μM) that selectively activates Epac for 10 min. The reaction was terminated with an equal volume of lysis buffer (final concentration in mM: 150 NaCl, 10 MgCl2, 1 PMSF, 10 EDTA, 10 Na2P2O7, 50 NaF, 0.2 Na3VO4, plus 1% Triton X-100, 0.5% SDS, 0.75% deoxycholate, 10 μg/ml leupeptin, and 100 μg/ml aprotinin). The cell lysates were separated by centrifugation at 13,000 g for 15 min at 4°C, and they were incubated with polyclonal RhoA antibody for 2 h at 4°C and with 40 μl of protein A-Sepharose for another 1 h. The immunoprecipitates were washed, extracted with Laemmli buffer, and separated by electrophoresis on 10% SDS-PAGE. After transfer to PVDF membranes, and 32P-labeled RhoA was visualized by autoradiography (21).
Assay for Rho kinase activity.
Rho kinase activity was determined in cell extracts by immunokinase assay as described previously (20). Cultured (after transfection) or freshly dispersed smooth muscle cells were solubilized with lysis buffer containing 50 mM Tris·HCl (pH 7.5), 0.1% SDS, 0.5% sodium deoxycholate, 1% Nonidet P-40, 150 mM NaCl, 1 mM PMSF, 10 μg/ml aprotinin, 10 μg/ml pepstatin A, and 10 μg/ml leupeptin. An equal amount of protein extract was incubated with Rho kinase antibody for 2 h, protein A/G agarose was added, and the samples were incubated at overnight at 4°C. The immunoprecipitates were washed twice in a medium containing 10 mM MgCl2, 40 mM HEPES (pH 7.4) and then incubated for 5 min on ice with 5 μg of myelin basic protein. The assay was initiated by the addition of 10 μCi of [γ-32P]ATP (3,000 Ci/mmol) and 20 μM ATP, followed by incubation for 10 min at 37°C. The 32P-labeled myelin basic protein was absorbed onto phosphocellulose disks, and free radioactivity was removed by repeated washing with 75 mM phosphoric acid. The amount of radioactivity on the disks was measured by liquid scintillation.
Activation of Rap1.
Freshly dispersed gastric smooth muscle cells were treated with OA (10 μM) in the presence or absence of myristoylated PKI (1 μM) for 10 min, and cells were solubilized with lysis buffer containing 50 mM Tris·HCl (pH 7.5), 0.1% SDS, 0.5% sodium deoxycholate, 1% Nonidet P-40, 150 mM NaCl, 1 mM PMSF, 10 μg/ml aprotinin, 10 μg/ml pepstatin A, and 10 μg/ml leupeptin. The lysates were incubated for 1 h with GST-fusion protein containing the Rap1 binding domain of Rap1GDS precoupled with glutathione-Sepharose to isolate activated GTP-bound Rap1. The Sepharose beads were washed with lysis buffer and suspended in Laemmli sample buffer; the samples were run on SDS-PAGE, transferred to nitrocellulose membranes, and blotted with Rap1 polyclonal antibody and the proteins were detected by the ECL Plus enhanced chemiluminescence detection system (Amersham Life Science Buckinghamshire, UK).
Measurement of relaxation in dispersed muscle cells.
Inhibition of contraction (i.e., relaxation) by OA was expressed as the decrease in maximal cell contraction induced by 0.1 μM CCh as described previously (18, 19). A 0.5-ml aliquot of cell suspension (104 cells/ml) was incubated for 10 min with 0.2 ml of medium containing test agents and the reaction terminated with 1% acrolein. In control experiments, 0.2 ml of medium was added without test agents. The length of the first 50 muscle cells encountered in successive fields was measured by scanning micrometry, and relaxation was measured in muscle cells maximally contracted with CCh (0.1 μM); the response was expressed as the decrease in maximal contraction. Basal muscle cell length was similar in different series of experiments and was 94 ± 5 μm.
Preparation of small interfering RNA.
Small interfering RNA (siRNA) oligonucleotides specific for rabbit TGR5 was obtained from Invitrogen (Carlsbad, CA). The sequence of TGR5 siRNA was as follows: forward 5′-CCC AAC UUC UCC UUC CUC UTT-3′ and reverse 5′-AGA GGA AGG AGA AGU UGG GTT-3′. Double-stranded RNA oligoribonucleotide NNGCGCGCUUUGUAGGAUUCA (5′-3′) was used as a control siRNA. Rap1 siRNA was as follows: CCT TTC CAC CAC GGT GAA A (5′-3′). Double-stranded RNA oligoribonucleotide NNGCGCGCUUUGUAGGAUUCA (5′-3′) was used as a negative control. Smooth muscle cells were seeded on 100-mm plates and allowed to adhere overnight. At the time of transfection, smooth muscle cells were 80–85% confluent and the siRNAs were transfected into smooth muscle cells at a final concentration of 20 μM by use of Lipofectamine 2000 reagent (Invitrogen, Carlsbad, CA) according to the manufacturer's instructions. Cells were kept for 24–48 h before IBMX and ligand treatment.
Statistical analysis.
The results are expressed as means ± SE of n experiments, and statistical significance was determined using Student's t-test for paired or unpaired values.
Expression of TGR5 in gastric smooth muscle cells.
TGR5 receptor was detected by RT-PCR on RNA extracted from cultured muscle cells from antrum and fundus of rabbit stomach in first passage using primers based on sequences of human, mouse, and rat cDNAs. A PCR product of the expected size was obtained using RNA isolated from fundus, antrum, and total gastric tissue (Fig. 1A). Western blot analysis using specific antibody to TGR5 demonstrated the presence of TGR5 receptor (35 kDa) in lysates derived from gastric muscle cells (Fig. 1B).
TGR5 receptors couple to Gs/cAMP/PKA pathway in gastric smooth muscle.
The TGR5 selective ligand, OA (10 μM), activated Gαs causing a significant increase in the binding of [35S]GTPγS to Gαs (259 ± 34% increase), but not to Gαi1 (2 ± 4%), Gαi2 (3 ± 4%), Gαi3 (6 ± 7%), or Gαq (3 ± 6%), in solubilized membranes derived from freshly dispersed smooth muscle cells (Fig. 2A). Consistent with the activation of Gαs, OA (10 μM) caused an increase in cAMP levels (46 ± 7% increase above basal levels) and stimulated cAMP-dependent protein kinase (PKA) (Fig. 2B). The selective PKA inhibitor myristoylated PKI (PKI, 1 μM) blocked the stimulation of PKA activity.
Specific involvement of TGR5 in OA-induced stimulation of cAMP was examined using cultured muscle cells transfected with TGR5-specific siRNA. Suppression of TGR5 expression with TGR5 siRNA abolished the OA (10 μM)-induced increase in cAMP levels (3 ± 4% increase above basal) compared with cells transfected with control siRNA (45 ± 4% increase above basal) (Fig. 3A). Similarly, the OA induced increase in cAMP levels (43 ± 2% increase) was abolished in muscle cells isolated from tgr5−/− mice (3 ± 5% increase) (Fig. 3B). These results provide conclusive evidence that OA-induced cAMP formation is mediated via TGR5 receptors.
Muscle relaxation in response to TGR5 activation.
As shown previously, treatment of dispersed muscle cells with CCh (0.1 μM) for 10 min caused muscle contraction (26 ± 3% decrease in length from the basal cell length of 91 ± 3 μm). Treatment of cells with OA (10 μM) alone had no significant effect on muscle contraction (3 ± 5% decrease in cell length), but inhibited sustained contraction (i.e., caused muscle relaxation) induced by CCh. OA-induced muscle relaxation was abolished in muscle cell isolated from tgr5−/− mice (5 ± 4% relaxation) compared with muscle cells from wild-type mice (65 ± 4% relaxation), suggesting that OA-induced relaxation is mediated via TGR5 (Fig. 3C).
Treatment of cells with a cAMP analog, 8-pCPT-2′-O-Me-cAMP (10 μM, Epac ligand) that activates the exchange factor, Epac, but not PKA also caused inhibition of sustained contraction induced by CCh (0.1 μM). Relaxation in response to OA (10 μM), but not 8-pCPT-2′-O-Me-cAMP, however, was partly inhibited by myristoylated PKI (1 μM), suggesting that relaxation by OA was partly mediated by PKA (Fig. 3D).
Signaling mechanisms involved in OA-induced muscle relaxation.
Previous studies have shown that ACh-induced sustained contraction was mediated via activation of RhoA/Rho kinase pathway and relaxation of sustained contraction by agents that stimulate PKA or PKG was mediated by inhibition of Rho kinase activity via phosphorylation of RhoA (21). Consistent with the inhibition of CCh (0.1 μM)-induced sustained contraction, cotreatment of cells with OA (10 μM) inhibited (83 ± 6% inhibition) CCh (0.1 μM)-stimulated Rho kinase activity; the inhibition was partly suppressed (41 ± 5% inhibition) by myristoylated PKI (1 μM) (Fig. 4A). Partial inhibition of Rho kinase activity by PKI is consistent with the partial inhibition of OA-induced muscle relaxation by PKI.
Previous studies showed that inhibition of Rho kinase activity by PKA was mediated via phosphorylation of RhoA at Ser188 (21). Treatment of freshly dispersed smooth muscle cells with OA (10 μM) for 10 min caused phosphorylation of RhoA, and phosphorylation was inhibited by PKI (1 μM) (Fig. 4A). Treatment of cells with 8-pCPT-2′-O-Me-cAMP (10 μM) for 10 min had no effect on RhoA phosphorylation (Fig. 4A).
The role of RhoA in mediating the inhibitory effect of OA on Rho kinase activity was examined in cultured smooth muscle cells expressing RhoA (S188A), which lacks the PKA phosphorylation site. Phosphorylation of RhoA in response to OA (10 μM) was blocked in cells expressing RhoA (S188A) (Fig. 4B). Expression of RhoA (S188A) had no effect on CCh-induced Rho kinase activity, but partly blocked the inhibition of CCh-stimulated Rho kinase activity by OA. These results are consistent with the partial blockade of inhibition of CCh-induced Rho kinase activity by PKI, but in contrast with the blockade of OA-induced phosphorylation of RhoA (Fig. 4B). These results raise the possibility that inhibition of RhoA-mediated Rho kinase activity by OA involves PKA-independent mechanism(s). The possibility of a cAMP-dependent, PKA-independent Epac-mediated pathway was investigated using 8-pCPT-2′-O-Me-cAMP. Although 8-pCPT-2′-O-Me-cAMP had no effect on RhoA phosphorylation, it inhibited CCh-stimulated Rho kinase activity (42 ± 6% inhibition). Inhibition of CCh-stimulated Rho kinase activity by 8-pCPT-2′-O-Me-cAMP was not affected by PKI (39 ± 5% inhibition) (Fig. 4A). These results suggest that inhibition of Rho kinase activity by OA is mediated by a PKA-dependent mechanism via phosphorylation of RhoA and PKA-independent mechanism via activation of Epac.
Rap1 is one of the downstream targets of Epac that is shown to regulate Rho kinase activity (38). Treatment of cells with OA (10 μM) for 10 min stimulated Rap1 activity that was not affected by myristoylated PKI (1 μM) (Fig. 5A). In cell transfected with control siRNA, both OA (10 μM) and 8-pCPT-2′-O-Me-cAMP (10 μM) inhibited Rho kinase activity in response to CCh (0.1 μM). Myristoylated PKI partly blocked OA-, but not 8-pCPT-2′-O-Me-cAMP-induced inhibition of Rho kinase activity. Transfection of cells with Rap1 siRNA blocked the inhibition of Rho kinase activity by 8-pCPT-2′-O-Me-cAMP (10 μM), but only partly blocked the inhibition by OA (10 μM), and the residual inhibition was blocked by PKI (Fig. 5, B and C).
The present study presents novel data demonstrating the expression of G protein-coupled bile acid receptor TGR5 in gastric smooth muscle cells, and the signaling pathways coupled to TGR5 to mediate inhibition of agonist-induced muscle contraction (i.e., muscle relaxation). Both mRNA and protein expression of TGR5 was demonstrated in isolated gastric smooth muscle cells. Activation of TGR5 by OA, a potent TGR5 agonist that does not activate the farnesoid X receptor (27), stimulated Gαs activity, cAMP formation and PKA activity leading to muscle relaxation. In this respect, TGR5 receptors conformed to a pattern observed with other Gαs-coupled receptors in gastrointestinal smooth muscle, including vasoactive intestinal peptide/pituitary adenylyl cyclase activating peptide (VPAC2) receptors and β-adrenergic receptors, which stimulate Gαs/cAMP pathway to mediate muscle relaxation (18). Although several physiological functions of BAs are mediated via the nuclear receptor FXR and the membrane receptor TGR5, the suppression of OA-induced cAMP formation and muscle relaxation by TGR5 siRNA or tgr5−/− mice provided evidence for the selective activation of TGR5 in response to OA.
The present study also provided a detailed analysis of the signaling pathways initiated by TGR5 receptors to mediate relaxation of sustained contraction in smooth muscle. A model depicting these pathways is shown in Fig. 6. In gastrointestinal smooth muscle, Ca2+-independent sustained contraction by several contractile agonists is mediated via activation of Gq/G13 and the monomeric G protein, RhoA. Activation of RhoA leads to phosphorylation of MYPT1, a regulatory subunit of MLC phosphatase (MLCP), via Rho kinase, and CPI-17, an endogenous inhibitor of MLCP, via protein kinase C, resulting in the inhibition of MLCP activity and increase in MLC20 phosphorylation (9, 17, 21, 30). Agonists that stimulate the formation of cAMP and cGMP induce muscle relaxation by activating cAMP- and cGMP-dependent protein kinase, respectively. Both kinases stimulate MLCP activity via phosphorylation of RhoA at Ser188 leading to inhibition of RhoA and RhoA-dependent pathways (21). In permeabilized vascular muscle cells, contraction in response to geranylgeranylated RhoA, but not phosphorylation-deficient RhoA mutant (S188A), was inhibited by exogenous PKG, suggesting that phosphorylation of RhoA by PKG plays an important role in mediating muscle relaxation (28).
In gastric smooth muscle cells both PKA and PKG phosphorylate RhoA, stimulate its translocation back to the cytosol, and inhibit its activity and the activity of RhoA-dependent Rho kinase at the same time as they inhibit ACh-stimulated sustained MLC20 phosphorylation and sustained muscle contraction (21). Treatment of cells with OA also caused phosphorylation of RhoA, and phosphorylation was blocked in cells expressing RhoA (S188A) or by PKI. However, inhibition of CCh-induced Rho kinase activity by OA was only partly reversed in cells expressing RhoA (S188A) or by PKI, suggesting that PKA-independent mechanisms that do not involve RhoA phosphorylation in the suppression of Rho kinase activity. Our results showing inhibition of Rho kinase activity by the cAMP analog that selectively activate Epac or partial reversal of OA-induced inhibition by suppression of Rap1 suggest that inhibition of Rho kinase activity by OA involves both a PKA-dependent mechanism involving phosphorylation of RhoA and a PKA-independent mechanism involving activation of Epac/Rap1 pathway. Evidence in support of the latter pathway include the following: 1) OA-stimulated Rap1 activity was not affected by myristoylated PKI; 2) the selective Epac ligand inhibited CCh-stimulated Rho kinase activity and muscle contraction, and the effect of Epac ligand is PKA-independent as myristoylated PKI had no effect on inhibition of Rho kinase activity and muscle contraction in response to Epac ligand; and 3) Rap1 siRNA blocked the inhibition of Rho kinase activity in response to Epac ligand, and only partly suppressed the inhibition of CCh-stimulated Rho kinase activity in response to OA, and the residual inhibition was blocked by PKI.
cAMP, in addition to activating PKA, activates Epac, which belongs to a family of guanine nucleotide exchange factors (GEFs). Epacs are multidomain proteins with an NH2-terminal domain containing conserved cyclic nucleotide binding domain (CNBD) and a COOH-terminal catalytic domain. In the absence of cAMP, the regulatory domain interacts with the catalytic domain and inhibits the GEF activity, and this autoinhibition is relieved following the binding of cAMP to the CNBD and conformational change within the protein (2). The effects of PKA and Epac are antagonistic in cardiac fibroblasts with Epac being promigratory and PKA being antimigratory (37). Epac and PKA may act independently or in concert. The effects of Epac and PKA in airway smooth muscle, however, are additive. Both Epac and PKA induce muscle relaxation (26, 38). Understanding the mechanisms involved in PKA- vs. and Epac-mediated relaxation has revealed that one of the targets for Epac is Rap1.
Rap1 is a member of the Ras family of small GTPases, which upon activation serves as an important signaling molecule in several cellular responses (4). Studies in endothelial cells and neurons showed that Rap1 activation via cAMP leads to decrease in RhoA activation (3, 35). The GTPase-activating protein RhoGAP was identified as one of the targets of Rap1, and thus rapid inactivation of GTP-bound RhoA by RhoGAP could lead to inhibition of Rho kinase activity (35). These results suggest that inhibition of CCh-stimulated Rho kinase activity by OA could be due to inhibition of the upstream effector of RhoA in smooth muscle as well. The exact mechanism by which Rap1 inhibits RhoA/Rho kinase pathway in smooth muscle awaits further investigation.
BAs are released into the small intestine to facilitate lipid digestion and absorption. Active reabsorption in the terminal ileum by the apical sodium-dependent bile acid transporter (ASBT) is the main route for circulating bile acids (24). In addition to the systemic effect, more hydrophobic bile acids such as DCA and CDCA can also readily cross the apical and basolateral bilayers to reach the target cell and mediate muscle relaxation. The expression of TGR5 and inhibition of agonist-induced contraction by bile acids in smooth muscle cells has important functional implications. Increase in systemic BA concentration can regulate proximal gut motility by more than one mechanism. They can directly act on TGR5 receptors on smooth muscle to induce relaxation or act on inhibitory motor neurons to release VIP or NO, the main relaxant neurotransmitters in the gut (25). Additional mechanisms could involve membrane hyperpolarization via suppression of spontaneous Ca2+ fluxes (11). Recent work in our laboratory and by others has established that TGR5 receptors are expressed in enteroendocrine cells and activation of these receptors causes the release of GLP-1 and PYY (1, 7). Both GLP-1 and PYY are involved in the inhibition of proximal gut motility. Luminal administration of DCA also inhibited gastric emptying and intestinal transit in mice in vivo (25). Whether the inhibition of gastric function is mediated via muscle, neural, or enteroendocrine mediators requires further research, but identifying the physiological significance of TGR5 receptors in the muscle may prove significant. The results of the present study attain a greater significance in the light of evidence that ASBT expression is altered in motility disorders such as inflammatory bowel diseases.
In summary, the results of this study identify the expression of TGR5 in gastric muscle and a mechanism of TGR5-mediated smooth muscle relaxation. Our findings demonstrate that activation of Gαs-coupled TGR5 receptor causes gastric muscle relaxation via inhibition of RhoA/Rho kinase pathway leading to stimulation of MLCP activity and MLC20 dephosphorylation. Inhibition of Rho kinase activity was mediated by both PKA-dependent phosphorylation of RhoA at Ser188 and PKA-independent mechanism involving stimulation of Rap1 via Epac.
This work was supported by National Institute of Diabetes and Digestive and Kidney Diseases Grants (DK-28300, K. S. Murthy; DK-39957, N. W. Bunnett), the National Health and Medical Research Council (63303, 103188, N. W. Bunnett), and the Northern California Institute for Research and Education, Veterans Health Administration (C. U. Corvera).
No conflicts of interest, financial or otherwise, are declared by the author(s).
Author contributions: S.R., J.R.G., and K.S.M. conception and design of research; S.R. performed experiments; S.R. and K.S.M. analyzed data; S.R., J.R.G., and K.S.M. interpreted results of experiments; S.R. prepared figures; S.R. and K.S.M. drafted manuscript; S.R., J.R.G., and K.S.M. edited and revised manuscript; S.R., D.P.K., S.M., S.B., R.Z., C.C., N.W.B., J.R.G., and K.S.M. approved final version of manuscript.
We thank Drs. Johan Auwerx and Kristina Schoonjans, Univ. of Ecole Polytechnique Federale de Lausanne, Switzerland, for providing the tgr5−/− mice.
- Copyright © 2013 the American Physiological Society


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This study examined predictors of employment among substance-using men and women enrolled in welfare-to-work programs. Participants were 394 welfare applicants assigned to either coordinated care management or usual care for treatment services and job training and followed for one year to track employment outcomes. Common barriers to work were assessed at baseline in four key domains: disabilities, situational barriers, labor capital, and motivation. Results indicated substantial gender differences in the number and profile of work barriers. Among men, work experience and job motivation were the only significant predictors of employment; among women, multiple factors from each barrier domain predicted job acquisition even when controlling for all other significant predictors. Findings suggest that welfare-to-work programs should emphasize job training and job seeking during the early stages of welfare interventions for men and for many women.
A guiding supposition among substance use disorder (SUD) treatment professionals is that regular use of mood-altering substances is a primary work barrier among individuals with SUD, such that abstinence is a necessary first step towards gaining employment (SAMHSA, 2002). Alternatively, SUD may routinely co-occur with other kinds of employment barriers—for example, disabling physical or mental health conditions, housing instability, deficits in work skills or experience—that have greater impact on work acquisition than substance use and therefore represent a more logical target of interventions aimed at increasing employment (Schmidt et al., 2007). The current study examines how multiple barriers to employment predict self-reported days of work in the context of a practical clinical trial of case management services for male and female welfare-to-work participants with SUD.
Welfare reform and other legislation enacted during the 1990s dramatically altered the availability of social safety net benefits for individuals with SUD. The enactment of Temporary Assistance for Needy Families (TANF) legislation imposed time limits on benefits, dramatically reduced the availability of disability benefits for those with SUD by requiring certification of a co-occurring physical or mental health condition, and tied receipt of benefits to participation in work activities and eventual employment (Schmidt, Weisner, & Wiley, 1998). Because receipt of benefits is now temporary and contingent on progress towards employment, helping welfare clients with SUD obtain work in addition to resolving their substance use problems has taken on a greater priority (Morgenstern et al., 2003). This coincides with increased emphasis on employment within SUD treatment programs (Magura, Stains, Blankertz, & Madison, 2004) in accord with the chronic care model, which promotes maintenance of supportive relationships, stable physical and mental health, and productive employment (for those able to work) as important recovery goals (Betty Ford Institute Consensus Panel, 2007; McLellan, Lewis, O'Brien, & Kleber, 2000).
Substance use is one of several potential barriers to employability experienced by a large segment of the welfare-to-work population. Other prevalent work barriers include physical and mental health disabilities, housing and legal problems, limited work skills and experience (i.e., labor capital), and childcare duties (Corcoran, Danziger, & Tolman, 2003; Morgenstern et al., 2003; Morgenstern, Hogue, Dasaro, Kuerbis, & Dauber, 2008). Numerous studies have shown that experiencing a greater number of overall barriers is associated with lower rates of job acquisition and job stability (Danziger et al., 2000; Lee & Vinokur, 2007; Nam, 2005).
Welfare research on employment barriers and interventions has been conducted almost exclusively with female samples (Lee & Vinokur, 2007; Meara, 2006). Males also seek public assistance for a variety of reasons including medical coverage, housing and employment assistance, and basic individual and family needs (Morgenstern et al., 2008). Males who are primary caretakers for young children can qualify for TANF; otherwise, many states fund separate general assistance (GA) programs for needy men and women who are not TANF eligible. In order to set effective welfare-to-work policies for male recipients, it is critical to test whether existing barrier models aptly describe this important subgroup.
One potentially important and understudied factor for this population is motivation to work. Low work motivation is not typically counted as a barrier to employment. However, motivation to change is considered a key element of client readiness for treatment among substance users, for whom denial of addiction problems and ambivalence about treatment participation constitute major barriers to treatment success (Miller & Rollnick, 2002). Only a handful of studies have examined whether baseline motivation to work predicts later employment among participants in SUD treatment (e.g., Zanis, Coviello, Alterman, & Appling, 2001) or welfare-to-work programs (e.g., Lee & Vinokur, 2007). These few studies indicate that stronger initial motivation is associated with better employment outcomes. However, findings are limited by the absence of standardized methods to assess motivation to work. The current study adapted a well-validated measure of readiness to abstain from smoking (Biener & Abrams, 1991). It remains to be seen whether readiness to work is as important as disability, job skills deficits, and other barriers in predicting job acquisition.
Our group has conducted two clinical trials examining whether intensive case management leads to improved employment outcomes for substance-using welfare clients. The first trial compared intensive case management (ICM) versus simple referral to SUD treatment and welfare monitoring for TANF mothers who met SUD criteria but were not attending treatment. ICM yielded significantly higher levels of SUD treatment engagement as well as higher rates of abstinence and employment at 24 months following program entry (Morgenstern et al., 2006, in press).
The second trial generated the sample for the current study. Welfare applicants with SUD were selected to participate in one of two intervention conditions: coordinated care management (CCM), a continuity-of-care intervention focused on engaging clients in SUD treatment and ancillary services and fostering transition to employment, versus usual care (UC), a screen-and-refer intervention focused on assessing clients for substance use and related problems and referring needy clients to available community services. Findings indicated that among those not enrolled in methadone maintenance, CCM clients received more SUD treatment and ancillary services than UC clients and showed higher abstinence rates that emerged early in treatment and were sustained throughout one-year follow-up (Morgenstern, Hogue, Dauber, Dasaro, & McKay, 2009). Also, among women only, CCM increased rates of employment over time while UC remained stable at very low employment levels, with greater treatment attendance and abstinence levels during the first six months of CCM predicting greater employment at one year (Morgenstern, Hogue, Dauber, Dasaro, & McKay, in press).
The primary aim of this study was to examine predictors of employment among substance-using men and women participating in welfare-to-work programs. The study sample exhibited chronic substance use problems as well as a variety of work barriers related to mental and physical health, legal and housing problems, and child welfare involvement (Morgenstern et al., 2008). All participants were judged suitable for eventual employment by welfare assessors, required to attend SUD treatment, and monitored for progress toward self-sufficiency via job training, welfare-supported work experience programs, and job seeking activities. As described above, previous analyses of this sample revealed that care management was effective in improving abstinence rates for all non-methadone clients and employment rates for non-methadone women only. However, factors other than case management services, such as disability characteristics and socio-contextual factors, likely play a large role in determining who obtains work among hard-to-employ groups. Moreover, care management was not successful in promoting work among men in this sample (Morgenstern, Hogue, et al., in press).
The current study advances research on employment barriers in SUD populations by identifying which specific barriers predicted one-year employment rates separately for men and women. Common barriers found in studies of predominantly female welfare samples include disability characteristics (e.g., physical health, mental health, substance use), situational barriers (e.g., housing instability, legal involvement), and labor capital deficits (e.g., work history, job skills). Motivation variables, such as readiness to abstain from substance use and readiness to work, are a promising but understudied domain. Arguably, different sets of factors are likely to serve as work barriers for men versus women. The current study tested the comparative strength of work barriers across four domains for each gender while controlling for demographics and intervention condition. Unique features of the study include a large subsample of men receiving benefits (67%), assessment of abstinence motivation and work motivation using a validated measurement approach, and one-year outcome data for on-the-books and off-the-books work. Also, the study used a multidimensional approach to assessing employment capital that included a standardized assessment of job aptitude and a measure of learning skills deficits.
Demographic, substance use, employment readiness, and sample characteristics at baseline (N = 394) are presented in Table 1 separately by gender: 67% men and 33% women. Across gender, participants were primarily African American (49%) or Hispanic (43%), averaged 39.8 years of age (SD = 8.5); most were unmarried (92%), and 54% graduated high school or received an equivalency diploma. Severity and chronicity of substance use were high across gender: At baseline participants reported using alcohol or drugs on more than half the days of each month, and they averaged 9.7 (SD = 11.1) years of regular heavy alcohol use and 10.4 (SD = 8.9) years of regular heroin or cocaine use. Almost all men (98%) and women (87%) reported having previously held a job, although many had not worked at all in the past three years, and most reported no days of work during the previous month. Despite these similarities, men reported significantly stronger work histories than women for every employment variable at baseline. Also, about 22% men and 17% women had unstable living conditions, and many (55% men, 30% women) were involved in the criminal justice system. The vast majority (76% men, 91% women) had received public assistance prior to their application for benefits at baseline; at baseline only 9% of men and 30% of women in this sample were TANF-eligible (i.e., pregnant or custodial guardian of dependent child under 18 years old), with the remainder eligible for General Assistance. Finally, only 25% of men and 25% of women had a child under the age of 18, and of these, 88% reported having a child living with a different caretaker. Hence childcare burden was an infrequent concern. As seen in Table 1, other than employment history variables, few gender differences were evident.
Data for the current study were collected from a representative sample of persons applying for welfare benefits in a large urban county that offers public assistance to eligible men and women (for a full description of study procedure see Morgenstern et al., 2009). A total of 1519 applicants completed a study eligibility screen in welfare field offices over two years; of these 543 (36%) met criteria designed to identify persons most likely to benefit from intensive case management: At least one day of illicit drug use or heavy drinking in past month, or one day of drug use/heavy drinking in past six months and currently motivated to attend treatment; Not hospitalized for mental health problems more than once in past year; Not currently experiencing psychotic symptoms or prescribed antipsychotic medication; Not residing on the streets, in shelters, or in imminent danger of being homeless; Not planning to move from the area for six months. Of 543 eligible applicants, 421 (78%) agreed to participate in the clinical trial; refusal rates did not significantly differ between the CCM versus UC conditions. Follow-up interviews were completed 1, 3, 6, and 12 months after baseline. Overall follow-up rates were 95% in CCM and 92% in UC and did not differ between conditions. N = 394 trial participants (94%) completed all measures necessary for inclusion in the current study.
For a complete description of treatment conditions and fidelity procedures see Morgenstern et al. (2009). Participants were randomly assigned to treatment condition via a computerized automated welfare management system. In both conditions, clients needing any level of SUD treatment were referred to a pre-approved treatment program and received either a partial or full temporary exemption from welfare-mandated job training activities. Clients were re-evaluated every 90 days and expected to transition in a timely manner from SUD treatment to participation in job training and eventually to self-sufficiency. The experimental condition, coordinated care management (CCM), featured an innovative care management approach focused on coordinating services among multiple providers to promote outcomes for individual clients. CCM case managers maintained caseloads of 30–35 clients, monitored program activities at 4–6 drug treatment sites via bimonthly site visits, and received ongoing training in substance use issues. The control condition, usual care (UC), assigned clients to welfare eligibility workers who maintained caseloads of 75–250 clients, made routine service referrals only during annual face-to-face meetings, and received no training in substance use issues.
Demographics (age, ethnicity, marital status, education), employment history, housing status, psychiatric history, drug treatment status (in drug-free program, in methadone maintenance program alone or in combination with drug-free treatment, no treatment), and welfare experience were obtained at baseline via structured interview procedures. Information on substance use chronicity and severity, prior SUD treatment episodes, and criminal justice involvement was obtained using the Addiction Severity Index (ASI, 5th edition: McLellan et al., 1992). Summary scores for physical heath status and mental health status were derived from the Short Form–12 Version 2 (SF-12; Ware, Kosinski, Turner-Bowker, & Gandek, 2002).
We adapted the Contemplation Ladder (Biener & Abrams, 1991; Rustin & Tate, 1993) to assess these constructs at baseline. The Contemplation Ladder is a measure of readiness to quit smoking based on the stages of change model that characterizes readiness to change as a progression through precontemplation, contemplation, action, and maintenance phases (Prochaska, DiClemente, & Norcross, 1992). We created two versions of the Contemplation Ladder to measure readiness to stop using alcohol and illegal drugs, respectively (described in Morgenstern et al., 2008). Participants completed the alcohol ladder if they reported having three or more drinks in one sitting in the past six months; they completed the drug ladder if they reported any illegal drug use in the past six months. All analyses used a combined ladder score, derived as follows: For participants who completed only one ladder, that score was used; for participants who completed both ladders, the ladder score corresponding to the more severe problem (based on the higher ASI Composite Score) was used. Response choices on the alcohol/drug ladder ranged from 1 (I do not have a problem with drinking [drugs], and I do not intend to cut down) to 7 (I have decided to quit drinking alcohol [using drugs] and plan never to drink [use drugs] again). A similar contemplation ladder was created for employment (also described in Morgenstern et al., 2008), in keeping with research demonstrating that intention to work predicts later job acquisition (Vinokur & Caplan, 1987; Vinokur & Schul, 2002; Zanis et al., 2001). Response choices on the employment ladder ranged from 1 (I am not interested in having a job, and I do not intend to look) to 6 (I would like to have a job now, and I have done something this past week to get one).
Due to baseline interview time constraints, data on employment skills were collected at the 1-month follow-up interview. The employment capital index was created based on responses to questions regarding learning skills, acquired job skills, and a standardized measure of employment aptitude. For learning skills assessment, participants were asked whether they had ever experienced any of 12 learning difficulties, including difficulty in working with numbers in a column, filling out forms, and taking notes. All responses of no difficulty were scored "1" and summed to create a total learning skills score. For acquired job skills, participants responded to 10 items asking about job skills that were required at their most recent job, such as talking with customers face to face, writing letters/memos, and working on a computer. Items were rated on a scale from 1 to 4, with higher numbers representing more job skills, and scores were averaged to create a total job skills score. For job aptitude, participants completed the Comprehensive Adult Student Assessment System Form 120, a 25-item timed standardized assessment of verbal ability specifically designed to appraise to employment competency (CASAS, 2002). Total scores on these three measures were standardized and averaged to create a total index score for employment capital.
Days of employment were assessed using a structured interview measuring the number of days worked since the previous assessment timepoint. The interview was used in the multisite Employment Retention and Advancement (ERA) evaluation of innovative welfare programs for hard-to-employ populations and is a state-of-the-art measure of employment outcomes in welfare-to-work evaluations (MDRC, 2008). At each follow-up (1, 3, 6, 12 months), participants were asked to recall how many days since the last interview they were paid for working on the books, off the books, in full-time jobs, or in part-time jobs. Specific dates of employment were logged, and a monthly timeline of days worked was constructed for each participant that combined on- and off-the-books work and also full- and part-time work. We decided not to tabulate job retention separately from total days of work because the difference between job retention versus job acquisition is muted in drug-using welfare populations, who have treatment participation mandates that typically delay or supercede employment requirements (Morgenstern et al., 2003). This was true in the current sample, which showed relatively little employment overall during one-year follow-up (see section 3.1).
Data were analyzed using Generalized Estimating Equations (GEE), an extension of the General Linear Model that permits a within-subject repeated measures examination of change over time as well as correction of variance estimates for correlated data within subject (Zeger & Liang, 1986; Zeger, Liang, & Albert, 1988). A series of GEE models were conducted to examine potential baseline predictors of employment through the one-year follow-up period. Employment was defined as the number of days employed within each month and was treated as a count variable. We first modeled the data as a poisson distribution. However, poor model fit parameters, along with large variances relative to the mean and examination of an employment data histogram, indicated over-dispersed data. In the case of overdispersed data, the poisson regression model underestimates variances and inflates the probability of Type I error; in such cases the negative binomial model provides better variance estimates and is more appropriate for inference testing (Gardner, Mulvey, & Shaw, 1995). Therefore, GEE models assumed a negative binomial distribution, logit link function, and exchangeable correlation matrix.
Potential baseline predictors of employment were examined in five domains: demographics, disability, situational barriers, labor capital, and motivation. Demographic variables included gender (0=female, 1=male), age in years, ethnicity (1=African American, 2=Hispanic, 3=Other), years of education, years spent on welfare, and also treatment condition (0=UC, 1=CCM). Disability variables included mental and physical health (higher scores indicate better health), alcohol and drug use (ASI composite scores), and number of prior substance use treatment episodes. Situational barriers included treatment status at baseline (1=drug free treatment, 2=methadone treatment, 3=no treatment), criminal justice history (0=any 1=none), and housing status (0=unstable housing, 1=stable housing). Labor capital variables included months employed in the past three years (0 = None, 1= 1–6 months, 2 = 7–12 months, 3 = 13–24 months, 4 = 24 months or more), and an employment capital index. Motivation variables included readiness to abstain from alcohol and drug use and readiness to work.
Predictors of employment were examined using a sequence of five GEE models conducted to test the set of variables in each domain independently of variables in all other domains. Following this initial examination of independent domains, a final cross-domain model was constructed including only predictors that were significant (p < .05) in each of the independent domain models. The set of demographic predictors (including treatment assignment) was also included in each model as control variables regardless of statistical significance. Due to the large familywise error rate resulting from multiple GEE analyses repeated for each gender, the criterion level for interpreting significance for the final domain model was set at p < .01 for both men and women.
To ensure that selected work barriers were sufficiently independent from one another and would not present multicollinearity problems in predicting employment outcomes, we inspected bivariate correlations among all barriers from all domains separately for men and women. No correlation exceeded r = .37 in magnitude, indicating that the set of predictors contained non-redundant data. In both men and women, the strongest correlation was found between drug use and mental health (r = −.34 and −.37, respectively). Interestingly, neither alcohol use nor drug use severity was significantly correlated with employment skills or recent employment in either group.
We also inspected the level of work reported by men and women at each follow-up assessment, controlling for age, ethnicity, years education, years on welfare, and treatment condition. At every timepoint men worked more cumulative days than women: At 1 month, men averaged 3.9 (SD = 6.7) days and women 1.0 (3.7) days; (t (388.2) = −5.61, p < .001); at 3 months, men averaged 8.4 days (13.4) and women 2.5 (8.4) days (t (372.8) = −5.27, p < .001); at 6 months, men averaged 14.0 (20.7) days and women 3.7 (12.5) days (t (375.3) = −6.06, p < .001); and at 12 months, men averaged 28.9 (43.0) days and women 10.1 (26.5) days (t (365.6) = −5.23, p < .001). Note that a substantial number of participants obtained no jobs of any kind during follow-up: one-third of men and two-thirds of women reported no days of employment during the follow-up year.
Significant predictors of employment for men (n = 263) are presented below within each of the five independent domains (demographics plus four barrier domains), followed by a final model that includes the significant predictors identified in each domain. Incidence rate ratios and confidence intervals for each independent domain model and for the final model are shown in Table 2.
Significant demographic predictors of employment for men across follow-up included age and ethnicity. Specifically, younger participants were working more (IRR = .97; 95% CI = .96, .99; p < .01). African Americans showed lower rates of employment than those classified as "Other," who were mainly Caucasian (IRR = 1.78; 95% CI = 1.17, 2.71; p < .01).
Significant predictors within the disability domain included drug use, number of prior treatment episodes, and physical health status. Higher levels of employment were predicted by lower levels of drug use (IRR = .32; 95% CI = .12, .86; p < .05), fewer prior treatment episodes (IRR = .97; 95% CI = .95, .99; p < .01), and better physical health (IRR = 1.01; 95% CI = 1.00, 1.03; p < .05). Alcohol use and mental health did not predict work.
Housing status was a strong predictor, with men living in more stable conditions showing more employment gains (IRR = 1.48; 95% CI = 1.12, 1.94; p < .01). Criminal justice history and treatment status did not predict employment.
More months of employment in the past three years predicted greater employment across follow-up (IRR = 1.16; 95% CI = 1.06, 1.26; p < .01).
Participants reporting greater baseline readiness to obtain a job were working significantly more across the follow-up period (IRR = 1.44; 95% CI = 1.33, 1.56; p < .001).
The final model for men included all demographic variables and the following predictors that were significant in the independent domains analyses: drug use, prior treatment episodes, physical health, housing stability, work experience, and readiness to work. There were only two significant (p < .01) predictors of employment in the final model: more employment experience (IRR = 1.16; 95% CI = 1.06, 1.27; d = .08) and greater readiness to work (IRR = 1.41; 95% CI = 1.29, 1.54; d = .19). Effect sizes (Cohen's d; Cohen, 1988) were small for both predictors.
Significant predictors of employment for women (n = 131) are presented below within each of the five independent domains, followed by a final model that includes the significant predictors identified in each. Incidence rate ratios and confidence intervals for each independent domain model and the final model are shown in Table 3.
Significant demographic predictors of employment included age, ethnicity, years on welfare, and treatment condition. Specifically, older participants were working more (IRR = .1.03; 95% CI = 1.01, 1.04; p < .01), and Hispanics were working more than African Americans (IRR = 1.70; 95% CI = 1.18, 2.43; p < .01). Women with fewer years of welfare history obtained more work (IRR = .78; 95% CI = .66, .91; p < .01). As in our previous study with this sample (Morgenstern, Hogue, et al., in press), women in coordinated care management obtained more employment than those in a usual-care screen-and-refer program (IRR = 2.20; 95% CI = 1.56, 3.11; p < .001).
Women with better physical health at baseline reported more future employment (IRR = 1.04; 95% CI = 1.02, 1.06; p < .001). No significant effects on were found for alcohol use, drug use, prior SUD treatment, or mental health.
All three situational barriers predicted future employment. Women enrolled in drug-free treatment programs at baseline reported more work during follow-up than those enrolled in methadone maintenance programs (IRR = .17; 95% CI = .10, .28; p < .001) and those not enrolled in any SUD services (IRR = .52; 95% CI = .37, .74; p < .001). Contrary to expectations, women with more legal involvement (IRR = .54; 95% CI = .39, .74; p < .001) and less stable housing (IRR = .52; 95% CI = .36, .76; p < .001) reported more work over time.
More employment capital (IRR = 2.30; 95% CI = 1.71, 3.10; p < .001) and more work experience in the past three years (IRR = 1.49; 95% CI = 1.32, 1.68; p < .001) predicted greater employment across follow-up.
Participants reporting greater readiness to abstain worked more during follow-up (IRR = 1.40; 95% CI = 1.24, 1.58; p < .001). Also, those reporting greater baseline readiness to obtain a job were working more across the follow-up period (IRR = 1.93; 95% CI = 1.67, 2.21; p < .001).
The final model for women included all the demographic variables and the following predictors significant in the independent domains analyses: physical health, treatment status, criminal justice involvement, housing stability, employment capital, work experience, readiness to work, and readiness to abstain. Virtually every predictor that was significant in the independent domains analyses remained significant (p < .01) in the final model. Women who were older (IRR = 1.04; 95% CI = 1.02, 1.07; d = .02) and more educated (IRR = 1.26; 95% CI = 1.13, 1.42; d = .13) found more jobs, and Hispanics worked more than African Americans (IRR = 2.05; 95% CI = 1.28, 3.28; d = .40). As before, clients receiving coordinated care management worked more than those in usual care (IRR = 2.21; 95% CI = 1.44, 3.39; d = .44); however, opposite to what was found in the independent domains analyses, more employment was predicted by more previous years on welfare (IRR = 1.53; 95% CI = 1.23, 1.92; d = .24). Women with better physical health worked more (IRR = 1.04; 95% CI = 1.02, 1.06; d = .02), and those in drug-free treatment worked more than those in methadone maintenance (IRR = .11; 95% CI = .06, .21; d = 1.22) or those not enrolled in SUD services (IRR = .36; 95% CI = .23, .57; d = .56). As before, more employment was predicted by more legal involvement (IRR = .54; 95% CI = .36, .83; d = .34) and less stable housing (IRR = .46; 95% CI = .28, .77; d = .43). Finally, women with greater employment capital (IRR = 3.18; 95% CI = 2.27, 4.46; d = .64), work experience (IRR = 1.49; 95% CI = 1.32, 1.68; d = .22), motivation to abstain (IRR = 1.19; 95% CI = 1.05, 1.36; d = .10), and motivation to work (IRR = 1.79; 95% CI = 1.54, 2.08; d = .32) found more jobs over time. Effect sizes were small for age, education, physical health, and readiness to abstain; they were small-to-moderate for ethnicity, welfare tenure, treatment condition, not being in SUD treatment at baseline, legal involvement, housing stability, and motivation to work. A moderate-to-large effect was found for employment capital and a large effect for being in methadone treatment at baseline.
This study identified barriers to employability that predicted work outcomes in men and women on public assistance participating in welfare-to-work programs. Results indicated that there were substantial gender differences in the number and profile of work barriers. Among male recipients, work experience during the previous three years and motivation to obtain a job emerged as the only significant predictors of days worked over the course of a year. Among female recipients, multiple factors representing every barrier domain were uniquely related to job acquisition, even when controlling for all other demographics and barriers. Specifically, women worked more if they were older, Hispanic rather than African American, more educated, in drug-free treatment, in better physical health, more involved in criminal justice, less stably housed, more vested with employment capital and work experience, and more motivated to obtain work and abstain from substance use. Noteworthy among these findings are the following: (a) substance use severity, considered a major barrier to employability, did not predict job outcomes for either group; (b) motivation to work, though infrequently studied in welfare samples, was one of the strongest predictors in both groups.
For women, multiple work barriers in multiple domains related to future employment. This has been repeatedly shown in previous studies with female recipients (e.g., Danziger et al., 2000; Morgenstern et al., 2003) and confirms the suitability of the work barriers model for women on public assistance. The current study also found that assignment to care management benefited women even when controlling for a host of competing variables, strengthening confidence in similar results for the whole sample reported elsewhere (Morgenstern, Hogue, et al., in press) and in a similar study of intensive case management with TANF women (Morgenstern, Neighbors, et al., in press). The CCM model was designed to address multiple barriers to employability via intensive case management and direct coordination of services with providers (Morgenstern et al., 2009) and thus appears to be a good fit for substance-using women on welfare.
By the same token, findings cast further doubt on the suitability of the work barriers framework for male welfare recipients. As expected, men reported a stronger employment history and greater readiness to work than women at baseline, and over the course of follow-up they obtained more work. However, the usual roster of disability and situational barriers was not related to job acquisition, nor was assignment to care management. Instead, only two work-centered factors predicted future employment: work experience and work motivation. Thus male recipients exhibiting multiple barriers to employment were nevertheless more work-ready than women and evidently pursued alternate pathways to employment outside the mandated welfare-to-work system. A critical issue is whether work immersion approaches such as supported employment (Bond, 2004), which foster immediate work placements along with work training and case management for needed services, might be more effective for work-ready men.
Substance use and mental health status, two commonly cited work barriers (Danziger et al., 2000), had no observed relation to employment outcomes despite the severity of these problems in this sample (see Morgenstern et al., 2008). Note that all study participants were referred for SUD treatment after baseline, and men and women in both conditions showed improved abstinence rates during follow-up (Morgenstern et al., 2009). Programmatic interventions for substance use over time may have confounded the relation between baseline substance use and later employment. It is also possible that substance use and co-occurring mental health barriers exerted combined or interactive effects on employment that were unobserved at the individual predictor level. A previous study (Morgenstern et al., 2008) documented the high degree of co-occurring problems in this sample. Even so, current findings argue that removing or modulating disability barriers is insufficient for promoting job acquisition for either men or women. Instead, work readiness needs to be systematically addressed in order to move hard-to-employ SUD welfare recipients toward sustainable employment (Meara, 2006; Schmidt et al., 2007). Because work motivation and experience are potentially more malleable than disability characteristics, realigning welfare interventions to emphasize job training and job seeking during the early stages of welfare management appears to be a promising strategy for this population (Morgenstern, Hogue, et al., in press).
As expected, being enrolled in methadone maintenance was a significant barrier to employment for women. This corresponds to prior studies showing that methadone clients have modest to poor work outcomes even when their drug use is reduced (e.g., French, Dennis, McDougal, Karuntzos, & Hubbard, 1992; Zanis et al., 2001). But it was surprising that among women, housing instability and criminal justice involvement were related to more employment. One explanation is that women benefited to some degree from structured monitoring by the legal system and various housing assistance agencies, perhaps participating in mandated programs with employment requirements. Note that truly homeless persons—those residing on the streets or in temporary shelters—were excluded from study participation. The counterintuitive finding that more years on welfare predicted greater employment in the final model for women was offset by the opposite finding in the independent domains analyses, wherein more welfare history predicted less employment; the final model result may be a proxy or suppressor effect stemming from unidentified correlations with a third variable.
Important strengths of the current study include the large subsample of male welfare recipients, assessment of a comprehensive profile of work barriers including understudied personal motivation and labor capital factors, and timeline-based retrospective collection of daily employment data for documented and undocumented work. An important limitation is lack of a formal test for differential barrier effects in men versus women because the sample size limited power to detect gender interactions or evaluate competing path models. Most participants were heavy substance users, constituting a restricted high range of severity that may have attenuated the correlation between substance use and work. Persons reporting recent psychiatric hospitalization or antipsychotic medication—evidence of acute psychiatric problems—were excluded from the study. It is well established that severe and persistent mental illness is a significant barrier to employability (Lehman et al., 2002); our study utilized a normative measure of mental health not intended to assess severe mental illness. The study selection criteria—no acute psychiatric problems, not homeless, not intending to leave the area for six months—were designed to increase the study's internal validity, that is, the fit between the study sample and the experimental intervention. But in so doing, selection criteria decreased external validity by excluding persons with significant transience and mental health problems that commonly occur in substance-using welfare populations.
Note that data for this study were collected over a three-year period [2004–2006] during which a particular historical set of labor market factors affected work acquisition in both study conditions; similar studies need to be completed in future markets to evaluate the robustness of findings. Employment data are based on self-report only. Findings are limited to a 12-month outcome period; longer follow-up periods are needed to investigate the possibility of more gradual or delayed employment effects. Longer follow-up would also permit examination of reciprocal influences between employment and work barriers, including the degree to which finding and keeping a job subsequently impacts disability and motivational characteristics over time (Atkinson et al., 2003).
Study results indicate that work readiness factors rather than disability characteristics are strong predictors of future employment for substance-using men and women on public assistance. Thus there may be large benefits to revising the focus of welfare interventions for SUD populations, which currently emphasize treatment referral and disabilities management, to include substantial emphasis on employment planning during the earliest stages of care. Gender differences were also pronounced. Job acquisition by men was related exclusively to work experience and motivation, with little evidence that services in other domains improved job outcomes. In contrast, multiple barriers impeded work success for women, and intensive management of these barriers facilitated job acquisition. However, despite their participation in welfare-to-work programs, women achieved low levels of employment overall (see also Morgenstern, Hogue, et al., in press). Additional research is needed to determine whether some female recipients are too disabled to meet current work mandates and thereby require alternative services more consistent with a disabled population.
This study was supported by the National Institute on Alcohol Abuse and Alcoholism (R01 AA13873), with supplemental funding from the National Institute on Drug Abuse, the Administration on Children, Youth, and Families; the Children's Bureau of the Administration for Children and Families; the Substance Abuse and Mental Health Services Administration; and the Office of the Assistant Secretary for Planning and Evaluation. The study was completed in partnership with MDRC and the Human Resources Administration of New York City.
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.

subset: commoncrawl


text:
Darius Build Guide by iluu3160
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Darius Build
Ability Sequence
Not Updated For Current Season
The masteries shown here are not yet updated for the current season, the guide author needs to set up the new masteries. As such, they will be different than the masteries you see in-game.
I like to play Darius as a tanky champion. His playing style is almost like Pantheon, aggresive. This build will help you initiate fights and stay in them for most of the duration. It will also help you do major damage and quite possibly 4-hit a squishy champ at mid-game.
I like to use [Ionian boots of Lucidity] since my build already makes [Darius] tanky, and i can run from any danger, but [Mercury's Treads] are also highly recommended if your enemies have a lot of CC.
Why Trinity Force AND Frozen Mallet?
I use [trinity force] and [Frozen mallet] because [frozen mallet] gives me enough health to withstand damage from initiating team fights and [trinity force] gives me the speed too escape from danger or catch someone on low hp and gives extra damage to do that pull and spin combo which deals a ton of damage.
Last Whisper, Bloodthirster, or Infinity Edge?
I love using [Last Whisper] because it just adds to that major armor penetration you already have. It's also good since Darius already does major damage. Bloodthirster is also a good choice since it helps you sustain health while in a team fight. Infinity edge is a good item but i wouldn't consider using it since you're not really going to deal crits.
This is always my final build when i get all my items.
Skill Sequence
This is a possible alternative for the skill sequence I use.
Runes are totally up to you and your playing style. I like to stay in fights so i always have health quintessences and seals. Armor penetration Marks and Physical Damage Glyphs are a must have in my opinion. I might also consider movement speed runes since Darius can't really escape from danger unless flash is up.
Team Work
If your team doesn't have a tank, be the one to initiate a team fight or a gank. Darius's pull and slow (e+w) combo works really well when initiating. whatever you do don't stop fighting and only back out when you need to. Wait for the enemies to get low on hp and mop the floor with your ult.
I know I didn't write much, but i will update and get into more detail soon. What I have talked about should be enough for you to start off with. Thank you and leave your opinions about the build below.


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I spent six months in Heritage Park and even though I was glad to finally go home, I was actually sad to leave. As in all large facilities there were occasional problems, but they were quickly and efficiently resolved by the staff when I mentioned them. The food, although institutional style food, was actually quite good. Everyone I dealt with was courteous and efficient. There were,of course, some exceptional employees but to avoid hurt feelings, I won't name them. I will, however, mention the director, Troy T., who had an open door policy that I took full advantage of. Sometimes just to talk for a free minutes. Even though he was very busy and constantly going here and there keeping the place running smoothly, he was never too busy to listen. One other person I have to mention is Raygene. She worked for therapy and also weighed everyone every week. She also either kept me company, walking or pedaling the NuStep, Monday through Friday. She was great company and we developed a friendship over the months. I will actually miss them all. The nurses and CNAs were all very kind. Some of them were extra special and they know who they are because I made it a point to tell them on a regular basis. If you're looking for a place to take your loved one, I would recommend Heritage Park highly.
Heritage Park Center
Reviews of Heritage Park Center
Overview of Ratings
April 07, 2017
I am/was a resident of this facility
May 19, 2015
I am a friend or relative of resident
This place did wonders with my husband--he fell and broke his hip and was at another location and they did not get him out of bed. I brought him to Song and they got him out of bed the same day of admission and he walked out less than a month later and is doing well. I couldnt thank the staff enough!
March 08, 2015
I am a friend or relative of a resident
We just moved my mother over to Heritage Park. It's very clean, it's very nice place to visit, and it has big hallways. They have a little center where you can watch movies or have dinner with your family. The rooms are a little small. The staff are very nice and very helpful. She doesn't participate in a lot of the activities except for cards.
February 19, 2014
I am a friend or relative of resident
I don't know what to say? One minute it was okay and the next I didn't understand? But when the medicare ran out all of a sudden she was well and able to go home? And the MRSA became a insect bite? The lab couldn't tell the difference??? What kind of lab is that?? And couldn't tell what kind of insect bite? She was contagious but yet she could be checked out? But only for three hours?? They never did sign off on the log book. It is funny what money can and no money can't do? The food was questionable, but the staff was great.
September 14, 2013
I am a friend or relative of resident
Over the last few months, I have LOVED this place. The staff have been very helpful. The social worker seems to know a lot about other facilities and community programs. Their new director of nursing has been heavily involved in the care of everyone there that I have seen. The administrator always calls me back when I have questions and leave a message. I have had nothing but a good experience with Heritage Park since I started visiting it. I would recommend this place to anyone!!
September 09, 2013
I am a friend or relative of resident
I have checked the other nursing homes in the area(Ogden) this one is much larger, alot of sunshine and everyone is very kind. The building is older but NO SMELL!!! Alos they have just put a new director of nursing and she is GREAT! Alot of changes and from what I can see all FOR THE BETTER....great care and staff that care!
July 11, 2013
I am a friend or relative of a resident
My husband was in Heritage for five days before I got him out. It's older and doesn't have a lock down unit. The place is okay and clean when you walk in. It's got a lot of wings but they were understaffed and could not keep on top of their patients. I never did eat there but my neighbour had hers in there and her dad and she wouldn't recommend it. They put my husband with another person and that made it rough and hard on my husband who had Alzheimer's.
July 07, 2013
I am a friend or relative of resident
This place was awful! They did not come when my moth used the call button, they lied about her having been given medication. They left her paperwork out on the counter for anyone to read (and I saw the family members of other patients reading it while it sat there so I looked to see what they were reading and it was my moms info) I asked them to put it away and they said they would tell the nurse and no one ever moved it. They forgot to bring her meals and to shower her. She sat in pain for hours pushing the call button and on one ever came. I had to call and call for anyone to answer the phone. I live very close and visited my mom several times a day. Each and very time I was there I had to ask them to DO THEY'ER JOB. This place is horrible please do not leave your loved ones there. The last thing I said to the nurses it that my mom was getting worse and they needed to contact the doctor and get some tests done do to her severe cramping. The next morning I got a call telling me that mom was not responding and it looked like she had had a stroke. She was taken to the hospital where she later died. It was not a stroke but the ammonia level had gotten so high she was in a coma and she was severlly dehydrated (thus the cramping). Best I can tell they never called the doctor as I had asked. They did not kill my mom but of they had done as I asked I may have had more time with her.
June 07, 2013
I am a friend or relative of a resident
We chose Heritage Park Center because I was familiar with the facility and it was close to my location. I also knew the level of care they provided since my parents were there before. My husband's stay there was more on rehabilitation for about three months and I really liked their therapy. The facility was very clean and the rooms were spacious. The staff were very caring and the food was excellent. It was a very good experience.
March 15, 2013
I am a friend or relative of resident
Staff shortage made disabled residents wait for a long time to get help. Not enough exercise equipments for residents. Second smoking is everywhere and cigratte butts can be found in the back yard everywhere.
December 16, 2012
I visited this facility
Thy were very kind and friendly!
July 24, 2012
I am a current client of this provider
It's a skilled facility where it's just a mile away from my home. They weren't that good but they weren't bad. There were better facilities rated higher but I think some things are inherent and I need to be close by the mom so I can see her everyday. Overall I can say that I am satisfied with their service. There's a couple of staff that are satisfactory. I don't know if it's because of staff shortages or whatever but sometimes my mother won't be changed like in 6-8 hours. It bothers me but I don't know if you could stop that anywhere. My mother has medicare so she is in a semi-private room. Her room is fine and food there is doable but it's nothing fantastic.
September 30, 2011
I am a friend or relative of a resident
This place was the bottom of the barrel. My father in law contracted scabies at this facility. They never helped him. It was crowded and dirty and poorly staffed. We got him out as fast as we could.
Features of Heritage Park Center
Medicare (ratings last updated: 06/16/17)
- Health:
- Overall:
- Quality:
- Staff:
- Medicare Provider Number: 465003
- Ownership Type: For Profit Corporation
- Date Certified: 05/01/2017
- Resident Capacity: 176
About Heritage Park Center
Heritage Park Center is a nursing home in Roy, UT that provides patients with skilled nursing care as well as private or shared accommodations. Contact Heritage Park Center for more details on housing, services, and rates.
Map of Heritage Park Center
Request Info


text:
After the Audio launch of Ra One in Tamil at Chennai, Sharukh Khan as promised during the audio lanch was seen at Rajini's Poes Garden.
SRK while questioned during the audio launch function press meet on whether he would meet the super star had replied, "I'm a Rajini fanatic,he is the biggest star with a universal appeal. I will definitely pay him a visit at home on my next trip to Chennai."


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Terms Of Use
You can use the site as much as you want, ill update this page later. Just dont upload anything that is illegal, under age or is not something you filmed yourself. You cannot upload videos from other companies to this site, this is only for you to upload YOUR videos from your spanking company or from your webcam of you being spanked or giving spankings. You can also upload from home video cameras and cell phones as long as the quality is good and it has to do with spanking. No underage video or you will be reported.
Producers, if you see your videos here and want them removed please click support and contact us, we will remove them immediately or you are free to open a free account here and we can transfer your video(s) to it and give proper credit and traffic.


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Paper industry faces key decision on GM technology
A strategic decision whether to support the development of genetically modified (GM) trees must be made soon by the pulp and paper industry, according to a report by consultants 3C Associates. 1 Development of the technology is being led by US paper companies, with one expecting to have commercial levels of GM seedlings within six years. But by encouraging substantial investment in GM products before consumer acceptance has been won outside North America, they risk repeating the mistakes made by US grain exporters.
Sorry you do not have access to this article. Please contact Customer Support at
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Birth Plans As Conversation Fodder
What do you do and say when not only do many people inquire about your birth plan, but then those same busybodies try to change your mind?
What do you do and say when not only do many people inquire about your birth plan, but then those same busybodies try to change your mind?
We're discussing Wendy Mogel's "The Blessing of a Skinned Knee" parenting book in our monthly book club. Have you read it yet?
A new baby is on the way and the parents have different opinions if their young toddler should give us his crib to the new baby and move to a toddler bed or stay in his current crib.
Whether your kids are already back-to-school or you are winding down your summer vacations, we knew you could use some back to school humor and wisdom (okay, more humor than actual wisdom) and enjoy our back-to-school truths.
Every school year, there are certain items that kids are just DYING for – the must-haves of the back-to-school season. We polled family and friends to find out what is hot right now. Take a look and also – tell us what your kids are loving this season.
Beyond the important decisions of your children's welfare and estate, there's nothing like writing your will to give a heavy dose of parenting perspective.
A mom needs help with her husband and his shaming of their sensitive toddler son for his recent and many crying bouts.
Teenage Mutant Ninja Turtles are everywhere. Here's how to throw a fun and easy-to-execute TMNT party for your kids whether it's for a birthday or back-to-school.
A mom can't shake the feeling of sadness and regret over a tubal ligation. What should she do?
Even though some kids are back to school already, summer is not over yet. This craft is way to repurpose your pool noodles. It's super simple to make.
A mom needs encouragement to confront her family about its aggressive dog being around her young children.
Easy back-to-school teacher's gift idea. Cute and useful! Print our free gift tag to go along with your teacher's gift.
We surveyed our regular contributors– scattered around the country– about their favorite retail stores for Back-to-School clothes shopping. Here are our favorite retailers for kids' clothing and why.
A reader asked how to tell her kids about the divorce. Single Mom Kristen Chase shares her 5 tips on how to have that difficult conversation.
Asynchronous development can be worrisome and/or baffling, but it's simply a difference that brings its own challenges and even joys.
Mom needs help finalizing potty-training her kid who only will poop on the floor.
A mom needs help and support for herself as she comes to terms with her son's varied special needs diagnoses.
Have a child at home who loves the Teenage Mutant Ninja Turtles? Here's a tutorial for a great and fun TMNT sandwich design for your bento box or parties.
Honesty is the best policy, but I routine lie to my teenagers on one very important point… and I'm going to keep doing it, too.
Why are your cloth diapers deteriorating at an alarming rate? Could it be how you wash them?


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Fred Phelps – Quietly Into the Night
In the very near future, Fred Phelps – the founder of the Westboro Baptist Church, will be dead.
The church is famous for it's anti-gay and anti-abortion sentiments…
as well as picketing military funerals with hateful signs.
Phelps, who was reportedly excommunicated from his own church in 2013 has recently entered a hospice facility and is presumably "on the edge of death". What celebrations will ensue? That remains to be seen. There has been much talk about protesting his funeral in fair return, though it is unlikely there will be one since Westboro church does not believe in commemorating the dead.
Will the world be a better place without him?
I say yes…
but I still hope the sounds of rejoicing at his passing will be low.
I understand thinking that it would be right to cheer the death of such hate…
to offensively picket his funeral like he did for so many others…
but I also know that I am not the arm of justice.
I know that if a child throws sand in my son's face, he need not throw it back. If everyone is blind with sand, no one can move forward.
I know that I cannot condemn his behavior while mirroring it.
I know that hate occupies space in the heart…
and that our hearts can be better occupied than with the likes of Fred Phelps.
I think he should go quietly into the night…
and I will curb my urge to rejoice.
I hope we can observe a quiet respect for the dying…
without the uproar he so loved to create…
without the fury and the hate he fed off of…
and perhaps with pity or forgiveness…
but most of all, with a great sadness for a life so tragically ill-spent.
8 responses to "Fred Phelps – Quietly Into the Night"
I love this, Jenni. It reminds me of that famous MLK Jr. quote: Darkness can not drive out darkness, only light can do that. Hate can not drive out hate, only love can do that.
I would rather fill my heart with love and hope. When his passing happens, I will consider it a non-event, and quietly breathe a sigh of relief, and be done with it.
How about this for weird?
Thank you for this post. As a Kansan and someone who lives just a couple of towns away from him, it will be a quiet relief when he is gone. Unfortunately, his family will continue to carry on with the hate they so strongly cling to. I completely agree that his death should not be celebrated, two wrongs do not make a right, and protesting his funeral (if there is one) is just lowering oneself to their level. Why can't we all just get along?!
Extremely well said, Jenni.
"Just want to have a little peace to die
And a friend or two I love at hand…
Take a look at poor Peter, he's lying in pain
Now let's come run and see"
–Robert Hunter/Jerry Garcia
Well said Jenni! I agree.


text:
BESSEMER, Ala. (WIAT) — Calvin Tart was convicted of sexual abuse in Jefferson County. He was released from jail and moved to Bessemer in November, but when officers went to his home, he wasn't there. They discovered he moved out without notifying the Sheriff's Office.
"We try to gather as much information as we can," Sheriff Mike Hale said. "We work with the Marshall Service and our other sister agencies to locate the offenders."
Tart is wanted on a $15,000 bond. If you see him, call the Jefferson County Sexual Predator Hotline.


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Made Chuma Mbao Earrings
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Colour: Gold
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Composition: 100% Brass
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Killer Instinct with Chris Hansen
Murder on Highway 23
Season 2 Episode 1
In California's Simi Valley, 20-year-old Megan Barroso is heading home from a July 4th party when she disappears. Her car is found stranded on Highway 23 - riddled by bullets from an AK47. Chris unfolds the harrowing tale of a truly evil predator.
- 43 min
- Premiered 07/25/2016


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