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We have uploaded a new version that fixes the problems some users with ATI/AMD cards had. If you are affected by these issues, uninstall your current version and update to version 220.127.116.11 or later.
Category Archives: Updates
Expiring versions
Important notice to users of the free version.
Version 126.96.36.199 of the simulator will expire on Monday, November 23, 2015.
All versions prior to 22.214.171.124 will expire on Monday, November 16, 2015.
Download and upgrade your version today to avoid interruptions.
Platinum Edition users can continue to run old versions but we encourage everyone to update to the latest one.
Version 2.0 is here!
The long awaited version 2.0 is finally here. Download today and enjoy tons of new features, fixes and improvements.
We have good and bad news for free users. In an intent to improve sales to cover increased costs for support staff, servers and developers, we have had to limit the free parts of the program. See our comparison table for details. The good news is that all users get a free trial period of 30 days with full Platinum Edition functionality before the program goes into the limited free mode.
Also please note that all previous versions will soon expire. Upgrade today to avoid interruptions.
Happy simulations!
New documentation
We have started to write tutorials for all the new features in Version 2.0. Head over to the CNC Academy for more (bottom of the page). More will follow…
Version 2.0 Beta is here!
We are excited to release the beta version of CNCSimulator Pro Ver 2.0. Make sure you download it and test out all new cool features.
Here are some of the new features the update brings:
- A new tool called "Gear Maker" for creating gears in SimCam.
- A new CNC Analysis tool for getting information about your CNC code.
- "3D Maker", a new tool for creating toolpaths from 3D STL files.
- Serial Terminal for direct communication with project boards like Arduino.
- New command $RotateWorkpiece to rotate the workpiece.
- Machine Info under "Machine Info and Codes".
- New G75 grooving cycle for lathes.
- Indicator in the editor that shows the last executed block.
- New feature: "Simulate from cursor" to allow to start simulation anywhere in the program.
- New machines, like for example a 4-axis milling machine.
- New commands to create lathe and milling tools on the fly.
- New $Color command to color surfaces in milling machines.
- Quick simulation, super fast simulation.
- Fanuc style U,V and W incremental code words.
- Improved G70 and G71 cycles in lathes.
- One-block G71 cycle.
- A function to save lathe workpieces as milling workpieces, so a project can be machined in both a lathe and a milling machine.
- A special function to easily create tutorials for trainers.
- $Cutting command in lathes to programmatically look inside the part.
- Arc Calculator to create G02/G03 arcs with ease.
- Polar Coordinates calculator.
- Corner fillet and chamfer calculator.
- Feeds and Speeds calculator.
- Snapshot function.
And much more…
Version 2.0 preview!
We are working on in-house beta testing of the new version 2.0. It is full of exciting new features! This video shows the most important ones.
No release date yet. But stay tuned for updates.
Documentation update
Phew! We have now updated the online help to reflect all new features and functions in the new version. If you find any errors or anything that is missing, please let us know and we will fix it as soon as we can. We want the online-help to be as complete and correct as possible. Next step will be to look over the tutorials at The CNC Academy so that they also we be up-to-date with the latest version. Thanks to all for your valuable feedback and for supporting our project!
The new version is here!
The new version is here!
Version 184.108.40.206 Stable
We are finally done with all the updates and testing of the new version.
A big thank you to all of you that have contributed with suggestions, issue reports and general beta testing. We would not have been able to do this without you.
It is great to have such a knowledgeable, active and engaged user group!
Main updates since last stable release are:
- Serial communications
- DXF Import and Export
- More SimCam features
- Customizable lathe tools in SimCam
- More cycles for lathe machines
- SimCam for lathe machines
- More virtual machines
- Scripting and plug-in capabilities
- Preview file dialogs
- Jog controller, physical interface as well as a virtual one
- Create prefabricated lathe workpieces from SimCam contours
- Flip and rotate workpieces for both milling and turning
- Dock the layers window in SimCam
For a complete list of updates, head over to:
Download your copy of the new version at:
We ask everyone for a bit of patience while we update the online-help and tutorials to match the new version.
And please let the suggestions and the feedback keep coming. We will never rest in our quest to create the most awesome CNC simulator possible!
New Product Video
Check out our latest product video for 2014.
New features shown in the video are coming soon.
More Jogging
In version 18.104.22.168 (coming soon) we have added support for the excellent ShuttleXpress Jog Shuttle from Contour Design.
The shuttle has different functions depending on if the jog enable switch is activated or not. See picture below.
You can get the device from this Amazon link.
And here is a link to a downloadable settings file so you will get the correct key mappings.
ShuttleXpress settings for CNCSimulator Pro
In the software for the ShuttleXpress, import the file to get the correct key mappings.
There is also a model called Shuttle Pro.
It has more programmable buttons and removable keycaps for easy labeling. It can be used with the CNCSimulator Pro as well, but you will have to map the keys yourself as we do not have a settings file for it yet.
These are the current keys used in the CNCSimulator Pro (from ver 184.108.40.206).
|Key name
|Jog Minus or Decrease Sim Speed
|Depends on the Jog Enable Switch
|Jog Plus or Increase Sim Speed
|Depends on the Jog Enable Switch
|Jog Mode STP or Start Simulation
|Depends on the Jog Enable Switch
|Jog Mode X or Pause Simulation
|Depends on the Jog Enable Switch
|Fast Forward
|Jog Mode Z or Fast Forw. Simulation
|Depends on the Jog Enable Switch
|Jog Mode Tool or Step Simulation
|Depends on the Jog Enable Switch
|Jog Mode Y or Stop Simulation
|Depends on the Jog Enable Switch
|Arrow right
|Pan Right
|3D view only
|Arrow left
|Pan Left
|3D view only
|Arrow up
|Pan up
|3D view only
|Arrow down
|Pan down
|3D view only
|Page up
|Zoom out
|3D view only
|Page down
|Zoom in
|3D view only
|Num keyb. center key
|Reset view
|3D view only
|Plus key
|Increase Sim speed
|Minus key
|Decrease Sim speed
|Toggle Fast Forward


text:
Big Bullet Trailer (1996)
25 June 1996 Action, Crime 87 mins
Hotheaded cop Bill Zhu (Lau Ching-wan) gets relegated to the Emergency Unit after a dustup with his inept boss. When the mob kills Zhu's pal and ex-colleague (Francis Ng) during a turf-war hit, he rounds up his motley department cohorts and embarks on a mission of revenge against the gangsters. The pursuit of the baddies culminates in a hair-raising showdown atop a hijacked transport plane in this action thriller.
Watch the official Big Bullet 1996 trailer in HD below or find more Big Bullet videos on Vidimovie.

subset: commoncrawl


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The entry level weekly benefit for Adult teams is £50, however it is vital that each team is aware of the importance of selecting the right level of cover as very often this doesn't come to light until an injured player needs to make a claim. Players who are self-employed need to seriously consider opting for the higher benefit levels or look at tailoring an individual policy suited for their circumstances. UKGLOBAL can assist with this.
Those weekly benefits start at £50 per week and increase at each cover level. It is therefore imperative that players are involved in the decision as to which weekly benefit level is opted for by the Club Secretary as this directly affects them.
Cover is purchased when you affiliate to the Association and full details are shown on the Affiliation form.
The 2017/18 Season will continue to provide a Limit of Indemnity of £10M. The cover provides general liability cover, protecting Clubs in respect of their legal liability to third parties for death, bodily injury or property damage arising from negligent acts. Claims examples include injury from goalposts/ cross-bars, player crushed by spectator seating, spectator facial injuries, glass & sharps, slipping & tripping, road traffic accidents from stray ball. The cover includes legal defence costs up to £250,000, to defend a player accused of negligently injuring another player.
For further details of the benefits and the minimal costs of topping cover up, please contact the Shropshire FA office.
Making a Claim:
For all claims, the club secretary must request a claim form from UKGlobal within 30 days of the incident in accorance with the policy wording. Please contact either Jerry, Natalie or Fiona using the details as follows:
Jerry Dungate Natalie Surridge Fiona Lavery
01883 333512 01883 333522 01252 734539
email@example.com firstname.lastname@example.com firstname.lastname@example.com
"Shropshire County FA Limited is an Appointed Representative of UKGlobal Risk Solutions who are authorised and regulated by the Financial Conduct Authority Reference number 460003"


text:
- Please select a date to see the proper prices!
Description of the Accommodation
Rooms, services La Quinta Inn & Suites Pearsall would be glad to host you for a memorable journey in Pearsall. The hotel is offering 66 tasfefully furnished, nice rooms for those looking for a place to stay at in Pearsall. Refreshing wellness services will be available on the spot, you may also use an indoor pool. The exact scope of services offered by La Quinta Inn & Suites Pearsall (including those for an extra fee) is available on the information sheet below.
Payment Depeding on the selected room, date and price, you may be asked to provide credit card guarantee or to pay by credit card in advance.
Arrival, opening hours The earliest time for arrival and check-in is 15:00, the latest time for departure and check-out is 12:00. The personnel can communicate with you in English.
La Quinta Inn & Suites Pearsall rooms Rooms
- Please select a date to see the proper prices!
Accommodation services
- Indoor pool
Pet friendly
Hairdryer, Fridge, Desk in the room, Microwave oven, Tea/coffee-maker


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In this chapter of the Dawn of Steam series, we join the Dame Fortuna crew once more in their journey after the Year of No Summer. With them, we travel to Japan, Australia, India, the deepest reaches of Africa before they return to England, completing their trip. However, it's not without great risk and sacrifice throughout the entire crew. By the time they can settle in at home, their actions have impact on events that are set to shape the world.
My Opinion:
Like the other books in this series, Dawn of Steam: Rising Suns was well-researched and well-written. While the story itself is an alternative timeline of events that happened in real life, Cook and Symonds use a lot of real information from history to create this saga. They also continue to use the journal and letter style of writing as the other books.
The action scenes and events that unfold have the reader held captive as each event unfolds. However, as well-written as this entire series is, it's not for the faint of heart. It's not a fast read. Each of these books is meant to be savored and enjoyed at a slow pace. However, none of them have failed to hold my attention across the several days each book takes to read.
Gaining an insight into the history of Japan, India, and Africa in this book was wonderful. It's like learning your world history in a much better way than a school could even think of teaching it. Throw in the fantastic idea of dirigibles and multi-shot weapons with moving battle suits, and it will keep many lovers of history and steampunk deep in the book while you learn something on the side.
I have recommended, and will continue to do so, this entire series to multiple people. While purists of historical fiction might not like the inclusion of random things that never happened, it's still a terrific read. The entire series is also a gentle introduction to the Steampunk genre. I know it has fueled my interest in this genre and I read as much of it as I can now. So, good job, Jeffrey Cook and Sarah Symonds! You have a winner here.
As of the writing of this post, this book is enrolled in the Kindle Unlimited program.


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Wessex FM News
Review into Cutting Police Station Hours in Dorset
8:04am 7th October 2013
Some of Dorset Police's desk enquiry offices are set to close and others are to reduce opening times.
The changes could save the force half a million pounds.
As part of a review of services it's found some enquiry offices get very few visits a day with most people using either either phone or the force website to make contact.
Now they're consulting about the details and are asking us to email our comments.
Chief constable Debbie Simpson say they're committed to providing the best possible service while giving value for money. She's also pledged it won't mean station closures and they'll retain what she calls 'a policing footprint' in every town in Dorset'
In a statement released this morning she goes on to say, "We are acutely aware that any changes to local policing, particularly those affecting station enquiry offices, are likely to generate considerable discussion. It is for this reason that Dorset Police will be in communication with key stakeholders over the coming weeks.
"I hope that this engagement will help to inform all of our communities of the rationale for change and also help to identify gaps in provision and how we can fill them.
"I would like to reassure members of the public that no final decisions have been made regarding station desk office provision in Dorset. However, we have to meet a very challenging budgetary situation and we are committed to providing the best possible service while reflecting true demand and value for money."
Members of the public wishing to provide feedback are encouraged to email firstname.lastname@example.com.
Police and Crime Commissioner Martyn Underhill said: "Dorset Police is the fourth lowest spending Force in England and Wales and there is no doubt that difficult choices need to be made. However, I am committed to ensuring that the Force makes the best use of reducing resources to deliver a service that reflects the needs of our communities.
"It is for this reason that the Chief and I recently agreed to make improvements to the 101 non-emergency service. This work has already led to improvements and, given that over three-quarters of the public prefer to contact Dorset Police by telephone, we will not be complacent.
"I am also working with the Force to introduce a Victims' Bureau, which enables Dorset Police to support victims of crime and ASB during their journey through the criminal justice system.
"Of course, it's important to me that we listen to all our communities as part of the engagement process and I'd urge anyone with suggestions or concerns to provide feedback. There are many ways to do this, including at the various public engagement forums that I hold across the county."
Sign up for the latest local news direct to your inbox


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Teacher in Multi-Skills, Tameside
Job details
|Tameside College
|£22,356 - £33,980 per annum
|Contract type
|Full Time
|Contract term
|Permanent Suitable for NQTs
|Closing date
|Applications are closed
Based in Ashton-under-Lyne, Greater Manchester, Tameside College is a further education college that offers a wide range of courses including Full-Time, Part-Time, Apprenticeships and University Level. We aim to give all our students an exceptional experience.
We believe in excellence and we back that up with high standards, real working environments and great teaching. We also believe that attending college is about more than achieving a qualification, important though that is. That is why we aim to give every person the opportunity to develop their full potential in a supportive and friendly environment.
We are now looking to recruit a Teacher in Multi Skills to join the faculty for Construction and Engineering Technologies.
Planning and delivering teaching/learning programmes using a flexible range of strategies and learning styles taking responsibility for the quality of own teaching and related curriculum development, you must develop learning resources / materials to meet individual learner needs and assist in the student enrolment and internal and external marketing activities of the College. Assessing student progress in College or on work experience, you must devise assessment processes against highly personalised progress targets and act as a personal tutor; providing student advice, support and induction.
We are looking to recruit an enthusiastic, innovative and highly motivated individual, with a relevant level 3 qualification or relevant NVQ (or equivalent) at Level 3 in Carpentry and Joinery, Bricklaying, Painting & Decorating or Plastering (preferably Carpentry & Joinery) coupled with a Level 4 teaching qualification (or a commitment to gaining this in a specified timescale).
With a successful track record of teaching using a wide range of teaching and learning methods and recent, relevant industrial / examining experience, you should have an up to date knowledge of your subject area and the ability to devise and deliver learning opportunities to meet group and individual learning needs.
To apply please visit: http://careers.tameside.ac.uk/Jobs/Index/1
Closing date for applications: noon, Wednesday 3rd May 2017
Interviews to take place w/c 22nd May 2017
About the employer
|Further Education
|Age range
|16+ years


text: Pii yer there NEW sytle rs6 reps and i love them i was exactly the same as you couldnt decided between these and the new shape s3 alloys !! Glad i went for these in the end cause there abit less common and look ace ! Now just to spend this months Overtime on more car parts


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My family has had several experiences with Dopkins, and all were very good, considering that funeral homes are not anyone's favorite place to go. They are friendly, helpful and k...
Check your contract for your arrangement plans. Not all things may be listed.
Cons: Will Not Make The Arrangements As Requested
From family friendly trips with kid friendly activities to local plumbers lawyers, spas, and contractors. Judy's Book has millions of listings and reviews for the best and not so great. Whether you're looking for a specific business or just trying to discover great places we make it easy. We're a family oriented site focusing on bringing trusted reviews and recommendations to moms and others. Green and Sustainable places are becoming more relevant to Judy's Book users, have a favorite place? Write a review and tell users why it's Green!


text:
Darrell's Firestone
ReScore Reviews™ (2)
98% Would Recommend
Latest Review 2 days ago
Review for Darrell's Firestone
DEBBIE M. on 08/03/2014
"Great service"
My PT Cruiser was towed to Darrell's Firestone due to an overheating problem. Had to leave keys and slip in lockbox since it was towed after hours. Car was ready next day in early afternoon & was reasonably priced!
Vehicle: Chrysler PT Cruiser
Service Date: 07/23/2014
Review Created: 08/03/2014 04:46 AM
Darrell a., Owner at Darrell's Firestone responded on 08/25/2014
Thanks for the business .


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reduction impact crushers
Impact Crusher,Roc Impact
An impact crusher is used for crushing of soft materials, limestone and shale, and for special uses such as recyclingRead More
I-130, Finlay
The ® Finlay I-130 tracked impact crusher has been specifically designed for ... with constant RPM for optimum separation even if feeder speed is reduced.Read More
Impact Crushers, Finlay
Overview. ® Finlay tracked mobile impact crushers are renown for their versatility and capabilities in the reduction and sizing of soft to medium natural granite and limestone and non-abrasive materials as well as recycling construction demolition waste.Read More
Reduction ratio of Cone crusher,impact breaker,roll crusher ...
Reduction ratio: The average number of pieces the raw feed rock is reduced into. Reduction ratio of Cone crusher. A crusher that breaks material by squeezing or compressing it between convex and concave shaped surfaces covered by manganese as the wear surface.Read More
Impact Crusher For Sale, Horizontal And Vertical Shaft Impact ...
impact crusher introduction. Zenith offers primary and secondary impact crushers for the crushing of soft and medium hard materials. These crushers have a very high reduction ratio, which normally results in a three-stage crushing plant becoming a two-stage plant, using the Zenith HSI and VSI ...Read More
Crusher,Wikipedia, the free encyclopedia
Impact crushers involve the use of impact rather than pressure to crush material. ... Ball mill for further reduction to powder; Car crusher; Compactor; Mill (grinding) Stamp mill; Jaques Limited Australian Jaw Crusher manufacturer; ReferencesRead More
impact crusher reduction ratio SAMAC,Coal Surface Mining
impact crusher reduction ratio Description : Size reduction & control Crushing of ore and minerals .com All crushers have a limited reduction ratio meaning that size reduction will takeRead More
what is the reduction ratio of an impact crusher,Mobile ...
Crusher Terminology, crushing type, and reduction ratio. Information on jaw crushers, including reduction ratios, and links to more information on jaw crushing. ...Read More
Size reduction impact crushers, Cage Mill, Hammer Mills
Stedman size reduction impactors, cage mill, pulverizers, hammer mill crushers and impact crushers reduce material sizes.Read More
feeding size of impact crusher,YouTube
Jan 18, 2014 ... installation. design and analysis of a horizontal shaft impact crusher,ethesis Crushers are one of the major size reduction equipment that is ...Read More
Lippmann Milwaukee, Inc.,Portable Impact Crushing Plants |
Lippmann custom engineers Portable Impact Crushing Plants mounted on heavy ... and large feed opening, this crusher is capable of high reduction ratios while ...Read More
Primary and Secondary Impact Crushers,McLanahan
New Holland Primary Impact Crushers. A reduction ratio of 20:1 allows the New Holland Primary Impact Crusher to reduce even the largest pieces of material to product size.Read More
Development of Mobile Impact Crusher BR480RG,Komatsu
Key Words: Mobile Crusher, Impact Crusher, Environmental Recycling, Concrete Debris, .... utilize the crusher capacity during crushing work and reduce the.Read More
® NP Series impact crushers,
This combination has proven revolutionary in improving capacity and product quality and in reducing operating and wear costs. NP Series impact crushers ...Read More
Secondary Impact Crushers,Stone Crushing Equipment,Grand ...
Material is sufficiently reduced in the primary chamber and passed by the front ... This impact crusher has a multi-turn breaker bar for extended life before change ...Read More
REMco RockMax,For masking the best cubical shaped in aggregate
The reason this is so is because it is the best way to transfer energy from the drive motors to the material being reduced. Impact crushers have fewer moving ...Read More
quarry and reduction equipment
Limestone quarry increases yearly production capacity up to 15 . Grand-Slam size reduction impact crushers at the new quarry, for limestone crushers History ofprevious equipment wasn39;t able to handle the agriculturalRead More
reduction ratios impact crushers
PB & PM Impact Crushers & Impact Mills,-Sonthofen. Impact Crushers and Impact Mills are a universal and, at the same time increase the size reduction ratio, improve the grain shape and enhance theRead More
What are the characteristics of jaw crusher versus an impact ...,Quora
Reduction ratio: typically, the reduction ratio of jaw crusher can range from 3/1 to 5/1. And that of impact crusher can reach 2/1 to 5/1 (for horizontal shaft ...Read More
Minimization of fines generation in size reduction of coals ...
In this work, various types of coals have been comminuted in an impact crusher. The size reduction process is characterized by four process parameters and relevant properties of the coal samples.Read More
Crusher Information,usedjawcrushers
Information on jaw crushers, including reduction ratios, and links to more information on jaw crushing. Specifications, capacities, and technical information on Kue Ken, Lippman, and jaw crushers. Also called chancadoras de quijadas.Read More
Next Post: Kerala Crushers Owners Association


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- SmartForm
- Altamonte Springs
- Apopka
- Casselberry
- Clermont
- College Park
- Heathrow
- Lake Mary
- Longwood
- Maitland
- Ocoee
- Oviedo
- Windermere
- Winter Garden
- Winter Park
- Winter Springs
- Gallery
Pay Bill
Lawn Care
- Dr. Jack's Difference
Pest Free Homes
Termite Free Zones
- Sentricon Always Active
Doctor's Resources
Dr. Jack's Story
Seasonal Alerts
- Subscribe Now
Bug of the Month
Request a Quote
Contact Dr Jack's
Altamonte Springs
College Park
Lake Mary
Winter Garden
Winter Park
Winter Springs
Pay Bill
Lawn Care
Dr. Jack's Difference
Pest Free Homes
Termite Free Zones
Sentricon Always Active
Doctor's Resources
Dr. Jack's Story
Seasonal Alerts
Subscribe Now
Bug of the Month
Request a Quote
Contact Dr Jack's
Local 407-422-3641
Toll Free (855) DRJACKS
You are here:
Lawn Care
Dr. Jack's Difference
Not all lawn care companies are the same
Dr. Jack's programs are designed to provide your landscape with all the recommended treatments you might need without any extra charges. Some of the differences we have found between our company and the competition include:
Dr. Jack's is a local, family-owned company in business since 1972 and not a branch of a large corporation. Our focus is on customer service and understand that serving our customers is our only priority. This philosophy seems to be lost with large corporations today that seem to focus only on the numbers.
Low employee turnover. Speak with the same people year after year that care about serving their customers. Our lawn technicians currently have (Dec 2015) an average of over 8 years of experience.
A+ rating with the Better Business Bureau of Central Florida
$25 credit for referring new customers (most of our new business is from referrals)
Lawn sales and customer service from graduate horticulturists or technicians only (no salesmen on commission that you will never see again once you begin receiving service)
Consistent fair pricing based on measured areas
No hidden charges for common treatments like chinch bug control, fungus, fire ants and dry fertilizer with potash
Lower annual cost with our bimonthly (every other month) lawn care service than competitors that charge less but service more frequently
EPA recommended IPM pest control program that helps protect the environment by reducing pesticide use
Our horticulturists are continuously researching and testing new products that keep us an industry leader in service quality
Some bilingual technicians and office staff
We do not require or try and sell unnecessary services like aeration in order to boost our profits
Our lawn trucks are custom designed for Dr. Jack's to provide both lawn and shrub care with the same visit
Turfgrass replacement guarantee for insect damage
Never a binding agreement for residential services (month to month)
When you add it all up, why use anyone else?
Our prices are competitive and when you add all the benefits included with our service, there is no better value or professional lawn care company than Dr. Jack's.
Contact us
right now
for your free quote and experience the Dr. Jack's difference!


text:
I live on the breaks between the Grande Ronde and Minam-Wallowa rivers. That is, I live there most nights and week-ends, and a little in the morning (before 7 am). I value the scraps of time that I am there.
Yesterday morning I heard elk bugling before getting in my car to drive into work. Correction, I heard the bugling of elk and the buzzing of a small private plane, the chattering of pygmy nuthatches and the rattling of a pick-up truck on the road, the clear heart-stabbing song of a meadowlark and a chainsaw starting up.
Life where I live is on the continuum of the wild and the human, as it is everywhere now. I'm beginning to understand that wildness extends into our cities, and we extend our influence into the wildest areas. I'm beginning to understand that every action of mine impacts the wild somehow, and the wild affects every part of my life. Often these are unintended consequences – most of which are unknown by me.
The windows of our house at night, bright with light in a dark world, concentrate the moths in our vicinity. The bats follow the moths, zipping around our porch. The pots of kitchen herbs and greens I keep watered on my back deck are assertively inhabited by the little frogs known as spring peepers – the only place I see them any more. Mule deer graze close by, knowing we do not have dogs or hunting rifles, knowing the coyotes keep a distance from our house.
We are neighbors – us and the coyotes and deer and rambling bear and occasional cougar and on and on. From not-so-wild turkeys to very wild grouse, owls to house mice, we live in each other's vicinity, some closer than others, some (like the house mice) too close for my comfort. They are part of my world, and for better or worse, I am part of theirs.
I mark my calendar as much by the birds I hear in the morning and the schedule of wildflowers blossoming, what stars are visible in the night sky, and the shape of the moon as by dates and months.
Now I have decided to move to town, aware that I will still be part of this continuum, aware that all my actions still will impact the wild around me, aware that I will still be struggling to learn how to be a better neighbor.
Warning to my human neighbors – I intend to plant native shrubs and wildflowers along my fence lines, tolerate any deer that wander by, put up bat boxes and bird boxes, and in every way I can imagine encourage the wild to continue co-habiting with me on this glorious, beautiful earth.
- Danae Yurgel, HCPC Office Administrator


text:
23 ha farm in Boekenhoutskloof and surrounds
Wayne Brownhill
Lew Geffen Sotheby's International Realty-Sandton
23 ha farm in Boekenhoutskloof and surrounds
R 6 500 000Can I afford this?
Farm For Sale in Dinokeng Big Five Game Reserve.
The Dinokeng Game Reserve is the first free-roaming Big 5 residential game reserve in Gauteng - and probably in the world - next to an urbanized area. It is a private/public initiative for which planning and development started in the early 2000's. It was officially opened on 22 September 2011 after the introduction of four of the Big 5. The last of the Big 5, the buffalo, were introduced in late 2012 and they have settled in well.
This magnificent, privately owned 'lodge' within this pristine reserve is designed to take full advantage of its surrounds and is an entertainers dream. Employing fine finishes and stacking doors that open to create an indoor/ outdoor feel it is a delight for the senses. You wont believe you are just over an hour away from the Sandton CDB. Traversing rights form part of the package. The 23 hectare property is protected by 'Elephant-proof' electric fencing so that you can sit back and relax on the pool-side loungers and watch the game go by. It has 2 boreholes that pump 15 000 litres per hour plus rights to 3 days water per month from the Canal.
It will be sold fully furnished including all Le Creuset kitchenware and crockery, cutlery, white goods, 2 sets of bed linen per bedroom suite and all bathroom accessories. Literally bring your supplies and settle in.
Accommodation has been thoughtfully planned with the floor plan divided into two separate sleeping quarters holding 4 en-suite bedrooms linked by expansive reception rooms including lounge & dining room with fireplace, fully fitted bar with pool table that all lead out to the winter/ summer patio. Further features include an exquisite custom-designed, separate out-door shower, fire-pit arena, braai area and viewing tower for the more adventurous, that sleeps 2.
Garaging for 3 vehicles (includes game viewing vehicle), separate staff accommodation, outbuildings with tractor and wood storage. Abundant vegetable garden and more. Not a cent has been spared to create a unique experience that will astound your guests and clients alike.
Make the call to secure your piece of heaven today.
Key Property Features
Email the Agent or request the agent Call You Back should you require any further details.
Share this Property
Need a Home Loan?
|Loan Value (Capital)
|Total Interest
|Total Repayment
23 ha farm in Boekenhoutskloof and surrounds
Need a Home Loan?
3D View
Video Tour
Apply for a Home Loan
Contact Agent


text:
5 Ways to Decorate with Wood Antiques
A frequent questions posed to many decorators is how to incorporate an inherited heirloom or a precious hand me down into a space design. Many struggle with how to live daily with those vintage or antique pieces in a way that celebrates their history but still proves useful in this modern century. The solution lies in how you go about it. There are many ways to decorate with wood antiques that preserve their character and still permit practical use.
First, you have permission to differentiate from the predictable and freely mix vintage pieces with more modern styles. A room that incorporates contemporary wallpapers or textiles in a modern palette will ensure a set of antique furnishings feels stylish rather than stodgy.
Glass front corner cabinets aren't destined for just the dining room, instead use them as a place to store books or as a cabinet of curiosities in the backdrop to your modern living room or any space with an empty corner.
Don't be limited by a piece's original intention or definition. A sideboard or buffet can be just as much at home in a sunroom as a formal dining room, just as a bureau or secretary can make itself useful in an entry instead of a bedroom or office.
Perhaps you've inherited or purchased an antique wood dresser with burled wood or carved detail. Consider placing it somewhere else other than the bedroom. Bring it into your living or dining room, style an elegant vignette above, and use the drawers to store linens or small decorative objects out of sight when not in use.
In a world where so many furniture pieces are mass produced, great antiques will stand the test of time and buck the trends. You can't go wrong when you place statement pieces where they belong, front and center. They'll bring originality and character to your home and become part of the memories created in your precious moments spent with family and friends.
Have you inherited or purchase any antiques for your home? How do you decorate with them practically or creatively in your spaces?
15 Responses to " 5 Ways to Decorate with Wood Antiques "
September 20, 2013 at 12:51 pm , by Meg
Love this article! We enjoy antiquing and using hand-me-downs (and my mom has a traditional style) but have more modern style, ourselves. So, we enjoy incorporating different styles and eras for a more eclectic effect. Break the rules!
September 21, 2013 at 8:47 pm , by Julia at Home on 129 Acres
Thanks for the tips. We recently bought a gorgeous antique dining table. Now I'm trying to figure out chairs and the other details to integrate it into our home. Any tips? My style is pretty traditional with a touch of country rustic.
March 13, 2014 at 8:49 am , by Stone Bridge Antiques
My boyfriend and I love the mix of old wood furniture and modern styles. So much so that several years ago we started our own antiques business selling solid oak furniture. I'm always looking for a unique piece to add to our collection. For so long we have heard people state that having solid wood furniture makes a room dark. Not so. When paired correctly, wood furniture brings a warmth and charm to any room. Thanks for helping to spread the word.
March 21, 2014 at 5:22 am , by Andy
I have worked with antique furniture for years and I have to agree that a mix of antique and modern pieces can work well together if incorporated correctly into the design. Your pictures illustrate that beautifully.
April 29, 2014 at 12:34 pm , by Deb
Actually a question more than a comment. I have lots of cool vintage furniture, all inherited but room is limited in living room. Loveseat is neutral with large storage ottoman (burlap look). Small easy chair w/ottoman (true burlap color). An antique small ottoman w/white, gray, light blue ikat. Large armoire in Lion's Mane. Dark secretary w/small chair in teal. Also mission table that folds w/ two sides. So when it's open it's oval. Also dark mahogany book w/4 shelves. Nice feet. One end table also folds and redone in crackle (aqua/lions mane). One w/ two shelves I think definitely needs done, currently in gloss maroon. I keep a a weaved cover over the top in a mushroom type cover. Another very large desk w/chair in dark wood also. Also small handmade birch table w/small black tiles. It is beautiful and getting ready to inherit another w/ wood top….Turquoise, teals, aquas are all my accent colors. But the walls a very much lighter version of Lion's Mane. Lots of art including black & white landscapes, to Mexican art including bright oranges, purple. Lots of plants. I also collect rocks and have them on display also. I would consider my style, vintage, eclectic. I want to know, if more of these dark pieces should be redone in something lighter.?Considering a mushroom type finish. bit mpt sure how to do that. Could you advise? Also trim work is dark wood, carpet is neutral w/spots of eggplant & blue. Wish I had hardwood floors, but not possible. Bamboo shades w/light blue sheers. Lighting consists of antique brass floor lamp and copper table lamp. Also wondering if turquoise stained glass hanging lamp would work over an end table? Please help! I love decorating but I'm afraid to do anything drastic. I am also considering updating my secretary desk with old burlap (coffee burlap bag) on the back for some contrast. Do you recommend? I also have considered removing mission table and replacing with old black sewing stand w/glass top. And also using a wicker (square) trunk w/ brass handles as a end table. I am sure this is mind boggling so I want to thank for your help in advance.
April 29, 2014 at 7:38 pm , by Roz
I have a antique sofa, about 7 ft long. upholstered in a cream fabric with very faint blue/coral pattern. My walls are minty-aqua. I find myself picking more items that are green & aqua hues but am unsure
how, where or what to add other colors. The room just does not feel inviting or comfortable.
May 20, 2014 at 4:36 pm , by The Butler & The Chef
Please visit our new website where you can find French Antique Furniture to decorate your interior! http://www.thebutlerandthechef.com
September 3, 2014 at 1:28 am , by Kellven Smith
I like your blog and the wooden furniture that you have shown in the dining area is mesmerizing. I am planning to get antiques for my newly constructed home. Your blog will be of great help. Thanks for the information and the fantastic pictures.
September 9, 2014 at 5:54 am , by safe Over the counter anti Inflammatory for dogs pain
It's a shame you don't have a donate button! I'd most certainly
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June 22, 2015 at 7:11 am , by Rare Finds
I love Antique Wooden Pieces and usually buy them but always in confusion how and where to use them. But, after read your article I've got so many ideas like idea of placing an antique wooden dresser at some place in your home except Bedroom and idea of buffet and side-board is good. I must say very useful and good article.
September 17, 2015 at 5:15 am , by Alice Paul
Antiques are best for home decor and they will give a classy and traditional look to our home. I like your ideas which are inspiring. I will definitely follow them.
January 29, 2016 at 1:14 pm , by becca
Please please – where is that wallpaper from in the top picture????
September 29, 2016 at 3:07 am , by Sowmya Iyer
Hi Kate!!
Lovely article. I can now tell different ways in which my customers can use the antiques and vintage furniture they purchase from our store!!


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Raina just wants to be a normal sixth grader. But one night after Girl Scouts she trips and falls, severely injuring her two front teeth, and what follows is a long and frustrating journey with on-again, off-again braces, surgery, embarrassing headgear, and even a retainer with fake teeth attached. And on top of all that, there's still more to deal with: a major earthquake, boy confusion, and friends who turn out to be not so friendly.
This coming-of-age true story is sure to resonate with anyone who has ever been in middle school, and especially those who have ever had a bit of their own dental drama.
…the real focus of Smile is Telgemeier's search for identity, a universal experience with which readers will readily identify. Her illustrations bear her trademark cartoonist touch, while the story's emotion is highlighted by the work of colorist Stephanie Yue.


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Are you ready to upgrade your career?
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Thursday 18 April 1968
It was Thursday, under the sign of Aries. The US president was Lyndon B. Johnson (Democratic).
Famous people born on this day include Derek Rydall and Mary Birdsong.
In that special week of April people in US were listening to Honey by Bobby Goldsboro.
In UK What A Wonderful World / Cabaret by Louis Armstrong was in the top 5 hits.
Yours, Mine and Ours, directed by Melville Shavelson, was one of the most viewed movies released in 1968
while Kennedy And Johnson by Evelyn Lincoln was one of the best selling books.
On TV people were watching Maratonci.
If you liked videogames you were probably playing Hamurabi or Hamurabi.
But much more happened that day: find out below..
You can also have a look at the whole 1968 or at April 18 across the years.
Old Newspapers
Have a look at the old newspapers from 18 April 1968 and get them!
TV Series
Which were the most popular TV series released in the last months ?
Which were the most popular movies released in the last 30 days ?
Find out your future
Get a FREE Numerology report based on the digits of 18 April 1968!
Wish him/her..
Historical Events
Which were the important events of 18 April 1968 ?
- Saint Galdino (d. 1176)
- Saint Perfecto (d. 850)
- Saint Agia (Aya) (d. 707)
- Saint Timon
- Saint Ursmarus (d. 713)
- Saint Werner (d. 1287)
- Blessed Idesbald van der Gracht (d. 1167), patron saint of fishermen and Flemish nobility
- Saint Eusebius (d. 526)
- Saint Apollonius (d. 185/6)
- Marie de l'Incarnation (1566 ? 1618)
- The Cheat's Cheatday on homestarrunner.com
- Zimbabwe ? Independence Day.
- Saint Emma
- Iran - Army Day
Famous Birthdays:
- Derek Rydall: American actor whose films include "Night Visitor," "Death Wish 4," and "Phantom of the Mall.
- Mary Birdsong: American actress singer and screenwriter.
- David Hewlett: English-Canadian actor director and screenwriter.
- 1st ABA basketball championship began
- 178,000 employees of US Bell Telephone System go on strike.
- Dutch Department of Amnesty International forms.
- London Bridge is sold to US oil company (to be erected in Arizona).
- San Francisco's Old Hall of Justice is demolished.
- US performs nuclear test at Nevada Test Site.
Featured Contents
Would you like to write an original contribution on a topic related to this specific date and get featured on Takemeback.to ? Send us your proposal!
Music Charts
Which were the top hits in that special week of April 1968 ?
Top #10 songs in the USA
- Bobby Goldsboro - Honey
- Union Gap - Young Girl
- The Box Tops - Cry Like A Baby
- The Beatles - Lady Madonna
- Aretha Franklin - (Sweet Sweet Baby) Since You've Been Gone
- Otis Redding - (Sittin' On) The Dock Of The Bay
- Georgie Fame - The Ballad Of Bonnie And Clyde
- Sly and the Family Stone - Dance To The Music
- James Brown - I Got The Feelin'
- Manfred Mann - Mighty Quinn (Quinn The Eskimo)
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...and if 18 April 1968 was your Birth Date then Join our Birthday Club!
Make this date unforgettable
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Magazine Covers
What news were making the headlines those days in April 1968?
- SportsIllustrated: Sports Illustrated: no.8071
- Life: Dr Martin Luther King Jr
- Time: TIME Magazine Cover: Lyndon B. Johnson -- Apr. 12, 1968
Which were the most popular books released in the last weeks ?
Remember when
What videogames would you be playing back in the days ?


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An ornate tile material 02. Free to download!
UE4 Material – Tile 01
Another free asset for you! An ornate tile material.
UE4 Tips and Tricks: Ep #5
Check out the new episode of my quick tips and tricks for Unreal Engine 4.
In Episode 5:
– Pivot Points
– Auto Reimport
– Adding Lights
Static Mesh – Wooden Table
Wooden Table – A free Unreal Engine 4 asset.
UE4 Tips and Tricks: Ep #4
Hello everyone,
It's been a while since last episode, but here I come with the new one.
UE4 Tips and Tricks: Episode 4:
– Disable Auto-Exposure
– Lightmaps Preview
– Camera Bookmarks
Interactive Lights System
Interactive Lights System (ILS) allows you to quickly set-up an interactive connection between lights and light switches in Unreal Engine 4. It's a set of Advanced Blueprints to control when or how lights are switched on or switched off within certain area
Feature Walkthrough video:
Available on the UE Marketplace: Link
Use "iamfromblog" code on Gumroad, and get 15% off!
[UE4 Epic MegaJam] (R)evolution Jumpers (download)
The Mega Jam is now over and everyone is waiting for Epic to reveal the winner. Needless to say, we were extremely excited about participating in it. Seven days of hard work allowed us to create a tiny game, that we are really proud of and would like to show it to the world. This month's game jam theme was "Standing on the shoulders of giants". It's great how guys at Epic come up with topics with wide field for interpretation! Both literal and metaphoric 🙂
So what (R)evolution Jumper is all about? Go ahead and watch the gameplay video!
UE4 Material – Stone 02
Here's another stone material from my collection. Hope you like it!
UE4 Material – Stone 01
Hello UE world,
I always try to capture as many textures as possible while I'm on vacation so I can use them in Unreal Engine later on. Less selfies, more textures! Anyway, here's a freebie for you. A stone material with 2K textures.
Update: Advanced Glass Material Pack
My goal was to create an easy-to-use, high quality and customizable glass / transparent material pack for everyone. It doesn't matter if you are an architect, a game developer or a filmmaker, you should find this package useful.
Here's an overview video in 4K resolution at 60 FPS:


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Young and sexy fagot is satisfying his amateur daddy
Alright, I know you enjoyed seeing Kid Chocolate and Fabio together so we`re bringing them back for another update. You`ll find these guys in what looks like an abandoned building with Fabio on his knees giving Kid Chocolate a blowjob. He gets his turn to
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Oral is the order of the day to start them off and they sure put their white boy to work warming up those fat, horny dicks of theirs.
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Results 1 to 5 of 21
June 30th, 2013 06:33 PM #1
Our girls list. We need as much help as we can get!
Hi, this is my first post. I've been lurking for a while collecting names for my child who is due on July 24th. So after putting it off for a long time, I decided to make an account and ask for opinions/suggestions, considering we don't have long left at all now! (Approx 24 days which is nerve-racking and exciting at the same time!)
If it helps any, my name is Aimee and my husband's name is Win (Edwin). We also have an angel baby boy called Ignatius Evander Piet (peet)
Our girls list so far is:
Mietta (Me-Ett-Ah) - This is our top name right now.
Clementine - Too fruity?
Calina (Cal-Eye-Nah)
We have some middle name ideas (we'd also like 2 middle names for this baby, like Ignatius' name.) We have:
Mariposa (also as a middle)
Alba (& Albia)
Anyway, I'd love it if you could try and make some combos with these names as my husband and I seem to suck with making names flow, and we'd also appreciate any other thoughts and some suggestions!
June 30th, 2013 07:39 PM #3Senior Member
- Join Date
- Mar 2012
- Posts
- 832
Just commented on your boys list, so I figured I'd do the girls. Again, I'm bolding the ones I particularly like.
Mietta - there's nothing wrong with it. I find it too...airy for my tastes.
Cosima - I like the potential nn Cozy. Not bad, but feels...awkward
Mariposa - feels like a lot of name
Avalon - Aveline feels more name-ish.
Clementine - Yes, fruity. But still a lovely name, especially with Ignatius. Pronunciation of clem-en-teen will diminish fruit references
Calina - like a recliner?
Penna - seems too made up, especially compared to Ignatius
Milena - see Mietta. I think I like Mietta better.
Iona - make sure your last name isn't "pen" or "car" or some other inanimate object
Alethea - I love this name! I don't even usually like "al" names, but the Thea makes it pretty. Goes well with Ignatius Although, I'm not sure if I'm pronouncing it right (ah-lee-thee-ah?)
Leda - lead a what?
Mariposa - definitely better in the middle
Persephone - love this name! Just cause. I tend to like the Greek "e"
Bird - too blatant for my tastes. Although Clementine Bird sounds nice
Reverie - ditto
Hespera - The "h" is throwing me off. It's almost like Diaspora, but not...
Apolline - not sure how to pronounce this. If it's ap-oll-een, it's pretty, but Apple throws me off.
Seraphina - personal favorite But I agree on you with that it's middle name territory. Too frilly for the front.
Delphine - Okay, but I'm not a fan of the letter "d"
Willow - nice and soft sounding. Alethea Willow sounds nice. Now it just needs a strong second middle...let's see what we've got...
Phaedra - I like it! I guess I like Greek names
Alba (& Albia) - Not a fan of the letter b. Prefer Alma. Clementine Alma Bird. That sounds nice.
Juno - Okay. Prefer June. The o's are for the boys.
Avita - This sounds gorgeous, especially as Alethea Willow Avita or Clemetine Bird Avita.
Valentina - eh. I've heard it one too many times as a first, but a middle might be nice.
So, combos...
Clementine Bird Avita
Clementine Alma Bird
Alethea Willow Avita
Mietta Persephone Bird
Mietta Phaedra Clementine/Mietta Clementine Phaedra
Also, I accidentally typed Clementina once. How about Clementina? Less fruit connotation, same great sounds. Of course, that generates new combos, like...
Clementina Reverie June
Clementina Reverie Avalon
(I feel like it needs the -ee sound, and Reverie is shorter than Persephone, as Clementina is already super long)Proud author of Kissimmee, Orlando, Mary, Adam, Mississippi, Micah, Georgette, Evelyn, Diane, Millicent, Maybeline, Prudence, Margo, Jade, Matthew, Susan, Maura, Mil, Floss, Connor, David, and so many many more
June 30th, 2013 08:33 PM #5fiammetta Guest
Congratulations! I LOVE the name of your son, absolutely gorgeous.
Mietta - gorgeous, though I think it sounds mismatched next to Ignatius, not sure if that matters to you?
Cosima - love, love, love! Ignatius and Cosima are lovely!
Mariposa - so lovely, though I prefer this in the middle name spot.
Avalon - not my style.
Clementine - love this!!!! Also love the sound of Ignatius and Clementine.
Calina - quite nice. I think this will get mispronounced as cal-ee-nah however.
Penna - so cute! I'm not sure if this could work on an adult however.
Milena - love this, so sleek and elegant.
Iona - so lovely. Would love to meet a sibset of Ignatius and Iona.
Alethea - gorgeous and sophisticated.
Leda - love this, I have a friend named Leda.
Mariposa - see Mariposa above.
Persephone - absolutely love this!
Bird - I prefer Lark or Wren.
Reverie - not my style.
Hespera - so gorgeous.
Apolline - as above.
Seraphina - as above.
Delphine - nice enough, but I feel as though it's lacking something.
Willow - LOVE yhis!
Phaedra - so lovely.
Alba (& Albia) - I prefer Alba to Albia. A lovely name.
Juno - so gorgeous.
Avita - not my style.
Valentina - so so elegant.
You have some great names on these lists, I can't wait to see what you choose.
July 1st, 2013 01:23 AM #7
July 1st, 2013 02:11 AM #9Senior Member
- Join Date
- Jul 2013
- Posts
- 110
Good job jame1881, I have to say you stumbled upon a really great name, Clementina! <3
After reading through the options I have to give two thumbs up to your compilation:
Clementina Reverie Avalon


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Sports News
Champion Seahorses host Covenant Friday
CCS lost a load of standout players off last season's undefeated state championship team, but still return several key performers. The Seahorses open their season this Friday at home against Covenant School at 5 p.m. on Dischinger Field. Admission is free.
08.29.2012'She wants to be a football player and she's doing it'
Danielle Hill is Lyndsey's mother. When Lyndsey was asked if her mother encouraged her to play football, she responded, "No!" When asked about the toughness of the game, Lyndsey said, "I don't see it as being real tough. I can play with those boys."
08.29.2012Middlesex volleyball team to host W&L tonight
Middlesex High varsity volleyball coach Jennifer Harrow had a hard time picking a starting lineup this season. That's because there's so much talent on this year's Lady Chargers, she explained. "I'm very excited about this new year! There is a lot of depth to this team."
08.22.2012Middlesex Colts host powerful Grafton Tabb in opener Saturday
"Grafton Tabb is expected to bring over 700 fans to MHS for the games, and when added to our fans who will be there it could turn out to be one of the largest crowds ever to watch a football game at MHS," said a Middlesex Colts official this week.
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HR Directory
The HR Directory gives you a complete listing of the departments and staff within Human Resources.


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Sodium transport is increased by vasopressin in the cortical collecting ducts of rats and rabbits. Here we investigate, by quantitative immunoblotting, the effects of vasopressin on abundances of the epithelial sodium channel (ENaC) subunits (α, β, and γ) in rat kidney. Seven-day infusion of 1-deamino-[8-d-arginine]-vasopressin (dDAVP) to Brattleboro rats markedly increased whole kidney abundances of β- and γ-ENaC (to 238% and 288% of vehicle, respectively), whereas α-ENaC was more modestly, yet significantly, increased (to 142% of vehicle). Similarly, 7-day water restriction in Sprague-Dawley rats resulted in significantly increased abundances of β- and γ- but no significant change in α-ENaC. Acute administration of dDAVP (2 nmol) to Brattleboro rats resulted in modest, but significant, increases in abundance for all ENaC subunits, within 1 h. In conclusion, all three subunits of ENaC are upregulated by vasopressin with temporal and regional differences. These changes are too slow to play a major role in the short-term action of vasopressin to stimulate sodium reabsorption in the collecting duct. Long-term increases in ENaC abundance should add to the short-term regulatory mechanisms (undefined in this study) to enhance sodium transport in the renal collecting duct.
- immunoblotting
- sodium transporters
- collecting duct
- Brattleboro rat
- aldosterone
the posterior-pituitary hormone, vasopressin, has been shown to increase both sodium (9, 18, 20, 40,41, 47, 51) and water reabsorption (19, 33) in the kidney collecting duct of rats and/or rabbits. Its role in water reabsorption has been well described. Briefly, vasopressin, acting through the vasopressin V2 receptor, can increase water permeability of the collecting duct both by acutely regulating trafficking of aquaporin-2 (22, 35) and, over a longer time frame, by increasing transcription and thus influencing the total number of aquaporin-2 (10, 23,36, 49) and aquaporin-3 (13,14, 49) water channel molecules in the principal cells of the collecting duct.
The role of vasopressin in the regulation of sodium balance is not as clear. Several investigators have shown, in acute studies, that in vitro application of vasopressin will increase sodium transport in perfused cortical collecting ducts (CCD) from rat (9,20, 40, 41, 45,51) or rabbit, (9, 18) as well as in primary rabbit CCD suspensions (7) and in several cell lines such as A6 cells (cultured toad kidney cells) (3, 52) and M-1 cells (derived from mouse CCD) (34). Furthermore, in perfused tubules the effect was additive to, and thus independent from, the increase in transport observed with aldosterone (9, 2,41). Furthermore, in several of the above perfused-tubule studies, it was shown that without pretreatment of animals with mineralocorticoids, sodium transport in response to vasopressin was nearly imperceptible in the CCDs (41, 51). Less work has been done examining the chronic effects of vasopressin on sodium transport in the kidney. Djelidi et al. (11) have reported that chronic exposure to vasopressin will increase22Na influx in RCCD1 (rat CCD) cells. However, the effects of chronically elevated vasopressin levels, in vivo, on sodium transport capacity in this segment have not been studied.
Sodium transport across the apical membrane of the cortical and outer medullary collecting duct occurs primarily through the amiloride-sensitive epithelial sodium channel (ENaC) (2 ). This channel, in the kidney, is a hetero-multimer made up of three distinct, yet homologous subunits: α, β and γ. Cloning of the three subunits from rat colon (6, 8) has made it possible to study the molecular regulation of these proteins. We, as well as others (11, 12, 42), have made antibodies against each of the subunits. Our antibodies are peptide-derived, polyclonal antibodies directed against a region in the carboxy tail of β- and γ-ENaC and against a region in the amino tail of α-ENaC (28). These antibodies are unique in that they are sufficiently sensitive to detect ENaC in native tissues by immunoblotting.
Vasopressin V2 receptor mRNA has been localized, by both in situ hybridization (38) and RT-PCR (19,25, 48), to the same tubule segments that express ENaC, that is, the connecting tubule and the collecting duct. The V2 receptor is coupled to adenylyl cyclase through Gsα activation in these cells. The long- and short-term antidiuretic actions of vasopressin are found to be primarily mediated by increased cellular cAMP levels. Chronic exposure to vasopressin is thought to lead to increased expression of aquaporin-2 protein via potentially multiple effects on regulatory motifs (or elements) in the 5′-flanking region of the gene. One such element is the CRE (cAMP regulatory element), which increases transcription rates for this protein (29). Interestingly, a CRE has also been found in the 5′-flanking region of γ-ENaC (50). Moreover, Djelidi et al. (11) have shown vasopressin-stimulated increases in transcription and translation of both γ- and β-ENaC in RCCD1 cells. Thus the purpose of these studies was to evaluate the effects of both acute and chronic elevation of circulating levels of vasopressin [or the V2-specific receptor agonist, 1-deamino-(8-d-arginine)-vasopressin (dDAVP)] on α-, β-, and γ-ENaC subunit abundances in the rat kidney by quantitative immunoblotting.
Animals and Study Design
For these experiments, four different groups of animals were studied. In the first, 12 male Brattleboro rats (250 g), under light methoxyflurane (Metofane, Schering-Plough Animal Health, Union, NJ) anesthesia, were implanted with osmotic mini-pumps (Alzet model 2001; Alza, Palo Alto, CA) to administer 20 ng/h dDAVP, the V2-receptor-selective agonist of vasopressin (n = 6) or saline vehicle (n = 6) for 7-days. In the second study, 205-g male Sprague-Dawley rats were water restricted for 7 days by offering a limited amount of water as a part of a slurry diet (23). "Restricted" rats (n = 6) were given 15 ml water · 200 g body wt−1 · day−1 mixed with 15 g of powdered food. Control rats (n = 6) were given 37 ml water · 200 g body wt−1 · day−1mixed with 15 g of powdered food. Rats in both groups consumed all of their diet daily and maintained weight throughout the 7-day period. In the third study, 12 male Brattleboro rats (250 g) were given a single acute intramuscular injection of 2 nmol of dDAVP dissolved in saline (n = 6) or saline alone (vehicle) (n = 6) and euthanized after 1 h. The fourth study was the same as the third study, but the rats were euthanized after only 30 min. In all studies, rats were euthanized by decapitation, and both kidneys were rapidly removed and either frozen on dry ice for later processing or immediately dissected and homogenized in a buffered isolation solution as described below.
Western Blotting
Preparation of samples.
Immediately after euthanasia (or after thawing), kidneys were placed in chilled-buffered isolation solution containing 250 mM sucrose, 10 mM triethanolamine (Calbiochem, La Jolla, CA), 1 μg/ml leupeptin (Bachem, Torrance, CA), and 0.1 mg/ml phenylmethylsulfonyl fluoride (US Biochemical, Toledo, OH) adjusted to pH 7.6. Whole right kidneys were homogenized using a tissue homogenizer (Omni 2000; Omni International, Warrenton, VA) fitted with a 10-mm micro-sawtooth generator in 10 ml isolation solution on ice. The left kidney was dissected into cortex and inner stripe of the outer medulla. Each region was separately homogenized in either 10 ml (cortex) or 1 ml (outer medulla) of isolation buffer while on ice.
Protein concentrations of the homogenates were measured by the Pierce BCA Protein Assay Reagent Kit (Pierce, Rockford, IL). All samples were then diluted with isolation solution to a protein concentration of between 1 and 3 μg/μl and solubilized at 60°C for 15 min in Laemmli sample buffer. Samples were stored at −80°C until ready to run on gels.
Electrophoresis and blotting of membranes.
Initially, "loading gels" were done on each sample set. Five micrograms of protein from each sample was loaded into an individual lane, and electrophoresed on 12% polyacrylamide gels (precast; Bio-Rad, Hercules, CA), and then stained with Coomassie blue dye (G-250, Bio-Rad; 0.04% solution made in 3.5% perchloric acid). Gels were then destained with water, and selected bands were scanned (Scan Jet 6100C; Hewlett-Packard, Palo Alto, CA) to determine density (NIH-Image software) and relative amounts of protein loaded in each lane. Finally, protein concentrations were "corrected" to reflect these measurements.
For immunoblotting, 10–30 μg of protein from each sample were loaded into individual lanes of precast minigels of 7, 10, or 12% polyacrylamide (Bio-Rad). The proteins were transferred from the gels electrophoretically to pure nitrocellulose membranes (Bio-Rad). After a 30-min, 5% milk block, membranes were probed overnight at 4°C with the desired affinity-purified polyclonal antibody. The production, purification, and characterization of the α- (L766), β- (L558), and γ- (L550) ENaC antibodies has been previously described in detail (28). Our anti-aquaporin-2 antibody (L414) was made to the same peptide as our previously used L127 antibody (10,13, 35, 36, 49) and gives a similar labeling pattern. Likewise, our anti-NHE3 antibody (L546) (18) and our anti-NCC antibody (L573) (24) have been previously characterized. For probing blots, all antibodies were diluted into a solution containing 150 mM NaCl, 50 mM sodium phosphate, 10 mg/dl sodium azide, 50 mg/dl Tween 20, and 0.1 g/dl bovine serum albumin (pH 7.5). The secondary antibody was goat anti-rabbit IgG conjugated to horseradish peroxidase (Kirkegaard and Perry Laboratories, Gaithersburg, MD) used at a concentration of 0.1 μg/ml. Sites of antibody-antigen reaction were visualized using luminol-based enhanced chemiluminescence (LumiGLO; Kirkegaard and Perry Laboratories) before exposure to X-ray film (Fujifilm; Fugi Medical Supplies, Stamford, CT).
Relative intensities of the resulting immunoblot band densities were determined by laser scanning (Scanjet 6100C) followed by analysis with NIH IMAGE software. The statistical significance of the effects of the various treatments on expression was determined by an unpairedt-test of densitometry values when standard deviations were equivalent, or by Welch's t-test when standard deviations were significantly different (Prism software; Graphpad, San Diego, CA).P < 0.05 was considered statistically significant.
Chronic dDAVP Infusion or Water Restriction Increases Aquaporin-2 Abundance
As a positive control, aquaporin-2 protein levels were examined in the whole kidney homogenates in the Brattleboro rats from the chronic dDAVP infusion study and from the water restriction study (Sprague-Dawley rats) (see methods). Previous studies (10, 36, 49) have shown an increase in this collecting duct protein with elevated vasopressin levels. In Fig. 1 A, an immunoblot is shown in which whole kidney homogenates from Brattleboro rats given an infusion for 7 days of either vehicle (n= 6) or dDAVP (20 ng/h) (n = 6) were probed with our anti-aquaporin-2 (L414) antibody. Each lane was loaded with a sample from a different rat. Preliminary Coomassie-stained gels were examined to assess equivalency of loading. Densitometry of the nonglycosylated form of aquaporin-2 (the 29-kDa band) and the glycosylated form of aquaporin-2 (the bands that fall between ∼36 and 47 kDa) was performed, and the values were summed. As we predicted, band density for aquaporin-2 was significantly increased (to 463% of the vehicle level) in the dDAVP-infused rats. Furthermore, water restriction of Sprague-Dawley rats also significantly increased band density for aquaporin-2 to 201% of the level observed in their control (water-replete) animals (Fig. 1 B).
Chronic dDAVP Infusion Increases α-, β-, and γ-ENaC Abundance
Figure 2,A–C, shows immunoblotting data derived from whole kidney homogenates for the three ENaC subunits in the Brattleboro rats that were either infused with vehicle or dDAVP for 7 days. Figure 2 D shows densitometric quantification of the immunoblots. As above, each lane was loaded with a sample from a different rat. In Fig. 2, A–C, the immunoblots were probed with anti-α- (L766), anti-β- (L558) or anti-γ-ENaC (L550) antibodies, respectively. In response to dDAVP infusion, β- and γ-ENaC were substantially increased (Fig. 2,B–D), whereas α-ENaC showed a more moderate, yet still significant, increase (Fig. 2, A and D). Average band density of α-ENaC in the dDAVP-infused rats was increased to 142% of the vehicle mean, whereas the average band densities for β- and γ-ENaC were increased to 238% and 288% of the vehicle mean, respectively (Fig. 2 D).
Water Restriction Increases β- and γ-ENaC Abundance
Water restriction to Sprague-Dawley rats causes a rise in endogenous levels of circulating vasopressin. Figure 3,A–C, shows immunoblots of whole kidney homogenates prepared from 12 rats that were either water replete (37 ml water · 200 g body wt−1 · day−1; "control") or "water restricted" (15 ml water · 200 g body wt−1 · day−1) for a total of 7 days. Figure 3 D shows densitometric quantification of the immunoblots. As above, each lane was loaded with a sample from a different rat. In response to water restriction, a similar pattern of expression was observed as seen with dDAVP infusion, although the increases in β- and γ-ENaC were smaller. In Fig. 3 A, the immunoblot was probed with polyclonal anti-α-ENaC antibody (L766). Although α-ENaC tended to be increased, band density was not significantly affected by water restriction. Average band density of α-ENaC in the water-restricted rats was 122 ± 12% of the control mean (P = 0.18). Figure 3 B shows an immunoblot loaded with whole kidney homogenates and probed with polyclonal anti-β-ENaC antibody (L558). Similar to the dDAVP infusion, β-ENaC abundance was significantly increased by water restriction. Band density was increased to 189 ± 14% of the control mean (P = 0.002) (Fig. 3 D). In Fig. 3 C, a similarly loaded immunoblot was probed with polyclonal anti-γ-ENaC antibody. The band density for the major band associated with γ-ENaC was likewise increased by water restriction [band density was 143 ± 13% of the control mean, P = 0.028 (Fig. 3 D)].
Chronic dDAVP Infusion, but not Water Restriction, Increases the Abundance of the Thiazide-Sensitive NaCl Cotransporter
We also assessed the effects of chronically elevated vasopressin levels on two additional sodium transporters: NCC, the thiazide-sensitive, apically located NaCl cotransporter found in the distal convoluted tubule; and NHE3, the sodium/hydrogen exchanger (type III) found in proximal tubules and the thick ascending limb. Figure4 A shows an immunoblot of whole kidney homogenates from the dDAVP-infused Brattleboro rats and their vehicle controls probed with our anti-NCC antibody (L573) (24). NCC abundance was increased significantly (band density was 241% of vehicle mean) by the dDAVP infusion. Figure4 B shows an immunoblot of whole kidney homogenates from control (water-replete) Sprague-Dawley rats and water-restricted rats. With this treatment, there was no change in NCC abundance (mean band density for water-restricted group = 93% of control mean). Figure4, C and D, shows similar blots that were probed with our anti-NHE3 antibody (L546) (16). NHE3 abundance was not affected in either study.
Acute Exposure to dDAVP Results in Increased Abundance of Cortical ENaC Subunits
In studies designed to examine acute (30–60 min) effects of vasopressin on ENaC abundance, modest, yet significant, increases in ENaC subunit abundances were observed. However, this rapid response was only observed in the cortex homogenates. Figure5 shows a bar graph summarizing the changes in α-, β-, and γ-ENaC expression in the cortex (Fig.5 A) and the outer medulla (Fig. 5 B) of the dDAVP-treated Brattleboro rats after 30 or 60 min of exposure to dDAVP (values have been normalized to their vehicle controls = 100%). In the cortex, both α- and β-ENaC abundances were significantly increased after 30 min, and β- and γ-ENaC abundances were increased after 60 min (Fig. 5 A). In contrast, in the outer medulla no significant effects of dDAVP were observed in this short time frame (Fig. 5 B).
Vasopressin has been shown by several investigators (9, 18, 20, 40,41, 45, 51) to acutely increase sodium transport in the CCD of rats and/or rabbits. This transport has been shown to be amiloride sensitive in many of these experiments, suggesting enhanced transport through the apically located amiloride-sensitive ENaC, which is the principal port of sodium entry into these cells (2). With recent cloning of the three subunits of ENaC, α, β, and γ, from the rat colon (7, 9), we are now able to study potential molecular mechanisms responsible for ENaC regulation. Nevertheless, it is important to note that in contrast to the above acute studies, the regulation of sodium transport in the collecting duct by chronically elevated blood vasopressin levels has not yet been adequately studied. It may well be that, like many other proteins, e.g., aquaporin-2, chronic and acute regulation are accomplished by different mechanisms (10, 22, 35, 36). In these studies, we examined the effects of elevated blood vasopressin levels on ENaC subunit abundance after both chronic (7-day infusion of dDAVP, or water restriction) or acute (single injection of dDAVP) exposure. Our principal finding was that all three ENaC subunits, α, β, and γ, are increased by vasopressin, with the increases in β and γ being most pronounced. We show increased whole kidney abundance of α-, β-, and γ-ENaC after a 7-day infusion of dDAVP to Brattleboro rats and an increase in whole kidney β and γ abundance after 7-day water restriction to Sprague-Dawley rats. Furthermore, in Brattleboro rats exposed acutely to dDAVP, increased abundances of cortical α- and β-ENaC at 30 min and cortical β- and γ-ENaC at 60 min were apparent. In contrast, the abundances of ENaC subunits in the outer medullary collecting duct were more resistant to change in response to dDAVP exposure; no changes were apparent in the acute studies, and only β-ENaC was increased after chronic dDAVP.
Chronic Vasopressin Increases α-, β-, and γ-ENaC Abundance In Vivo
Our findings are consistent with those of Djelidi et al. (11), who recently reported vasopressin-stimulated increases in β and γ transcription rates and ENaC activity in the rat cortical collecting duct cell line, RCCD1. In the studies of Djelidi et al. (11) in vitro incubation of the cells with vasopressin resulted in a rapid and sustained (up to 10 h) increase in amiloride-sensitive short-circuit current and22Na transport. The RNase protection assay showed a rapid (within 1–3 h) increase in γ-ENaC mRNA, with no change in α-ENaC mRNA. Furthermore, in situ hybridization showed an increase in β-ENaC mRNA within 24 h. Treatment with actinomycin D blocked these changes in mRNA, suggesting that increased transcription was responsible for the changes in β and γ rather than decreased degradation of the mRNA. These studies also showed an increase in the rate of protein synthesis of both β- and γ-ENaC, but not α-ENaC, as assessed by immunoprecipitation of 35S-labeled proteins. When transcription was blocked by actinomycin D, the vasopressin-induced increase in short-circuit current was no longer apparent, suggesting a potentially important role for changes in ENaC subunit abundance to regulate sodium transport capacity of the cells.
Our results are similar in that β- and γ-ENaC expression is increased, but somewhat in contrast with the above studies, we observed an increase in α-ENaC abundance after 30 min and 7 days of dDAVP infusion. These differences could be a result of α-ENaC being increased by a mechanism other than transcriptional or translational regulation in our studies. For example, the rate of degradation of α-ENaC protein might be retarded with high circulating vasopressin levels. Alternatively, it is possible that chronic administration of dDAVP to Brattleboro rats corrected the relative aldosterone deficiency that is normally apparent in untreated Brattleboro rats (4, 31, 32). Although Brattleboro rats have normal or elevated plasma renin activity and angiotensin II (ANG II) levels, their aldosterone levels are approximately twofold lower than their parent strain, the Long-Evans rat (4, 31, 32). The defect in the Brattleboro rat has been proposed to be due to several possible mechanisms. First, these rats may have a decreased secretion of adrenocorticotropic hormone (ACTH) from the pituitary (5). In vitro studies have shown that dDAVP is also a potent V1Bvasopressin receptor agonist (43), and Sakai et al. (44) revealed that dDAVP directly stimulates ACTH release from corticotropic adenoma cells through V1B vasopressin receptors. Second, the defect could be at the level of the adrenal, i.e., depressed adrenal responsiveness as result of decreased ANG II (46) or ACTH receptors on the adrenal gland or post-receptor-mediated events (4, 27). Thus the increase in α-ENaC expression after chronic dDAVP might, in part, result from increased circulating aldosterone, as it has been reported by several investigators that α-ENaC mRNA (1,15, 37) or protein abundance (28) is markedly increased by increases in circulating aldosterone levels. In support of this mechanism, we also found that expression of whole kidney NCC, the NaCl cotransporter of the distal convoluted tubule, was significantly increased by the dDAVP infusion, relative to vehicle infusion (Fig. 4) even though the distal convoluted tubule is believed to lack V2 receptors. NCC abundance has recently been reported (24) to be increased by high circulating levels of aldosterone in Sprague-Dawley rats either infused with aldosterone or fed a low-salt diet. Finally, we observed that, like α-ENaC, NCC abundance was not upregulated by water restriction. Therefore, it is possible that α-ENaC and NCC may have been increased with chronic dDAVP infusion due to a vasopressin-mediated restoration of normal circulating aldosterone levels. Nevertheless, increased aldosterone levels would not likely explain our observation of increased cortical α-ENaC abundance after only 30-min exposure to dDAVP. Furthermore, it is possible that NCC abundance is regulated differently in response to elevated vasopressin in Brattleboro rats (the strain in which the dDAVP-infusion studies were performed) than it is in Sprague-Dawley rats (the strain in which the water restriction studies were performed). Additional studies will need to be done to sort out specific mechanisms.
Is α-ENaC Abundance Rate Limiting for Sodium Transport?
Independent regulation of the three subunits of ENaC is apparent from this work and others (1, 15,28, 37, 47). The implication of changes in abundance of one or two subunits and not the other(s) on sodium transport capacity is not known. α-ENaC appears to be the only subunit of the three that has been reported to be transcriptionally regulated by aldosterone (1, 15,37, 47), a hormone which clearly upregulates sodium reabsorption in the collecting duct. May et al. (30) have postulated that α-ENaC abundance is rate limiting for assembly of the multimeric ENaC complex; thus sodium transport might be expected to be proportional to α-ENaC abundance. Therefore, increased β- and γ-ENaC abundance (as we have observed here) with little concurrent change in α-ENaC abundance might be predicted to have little impact on net NaCl absorption. However, the physiological benefit of having increased β- and γ-ENaC expression might become significant, in so far as NaCl reabsorption is concerned, if α-ENaC is upregulated and no longer rate limiting, for instance, by high aldosterone levels. This might occur, for example, during volume depletion, when vasopressin and aldosterone would be predicted to work synergistically to increase NaCl reabsorption. Further studies will be required to assess the impact of differential regulation and subunit stoichiometry on sodium transport.
Potential Role in Acute Upregulation of Sodium Transport
The rapid time frame in which increases in abundance of ENaC subunits occur (30–60 min) would suggest that these abundance changes might be an important component of the acute stimulation of sodium transport in perfused CCDs when vasopressin is added to the bath. Reif et al. (40, 41), Tomita et al. (51), Frindt and Burg (18), and others have observed increased sodium transport that occurs within 20 min, in perfused tubules from rats and/or rabbits. The fact that vasopressin increases β- and α-ENaC abundance (and possibly also γ-ENaC) in the 30-min time frame, might partly explain why vasopressin's action to increase sodium transport appears to be additive to that of mineralocorticoids (20, 41), as their mechanisms for activating ENaC may be distinct. However, the relative magnitude of the increase in transport observed when vasopressin is applied to the bath in perfused tubule studies (about 3- to 4-fold) would suggest that mechanisms in addition to increased subunit abundance most likely are responsible for increased sodium absorption in the CCD. For instance, trafficking or phosphorylation of any of the ENaC subunits may be an important component of regulation of ENaC activity. Protein kinase A has been reported to increase patch-clamp current in A6 cells (39), and Kleyman et al. (26) have evidence suggesting that ENaC is redistributed to the apical plasma membrane with arginine vasopressin stimulation in A6 cells.
Cortical Collecting Duct Appears Most Sensitive to Vasopressin
Another interesting finding from our acute studies was that the vasopressin-mediated changes in ENaC abundance were mainly, and almost exclusively, observed in the cortical homogenates (CCD) compared with the outer medullary homogenates (outer medullary collecting duct). The reason for this striking difference is unclear. The interstitial environment of the medulla is quite different from that in the cortex, particularly with regard to the increase in osmolality. Furthermore, different paracrine factors may be present, such as prostaglandins. Additionally, although vasopressin V2 receptors have clearly been localized to all regions of the collecting duct (17, 25, 38, 48), the number of active binding sites or post-receptor intracellular signaling may be different along the length of the collecting duct.
In conclusion, we find a marked increase in whole kidney abundances of β- and γ-ENaC with chronic exposure to vasopressin in rats. Furthermore, α-ENaC abundance is also increased, but much more modestly, and only after dDAVP infusion. Increased subunit abundances might be expected to result in increased amiloride-sensitive sodium transport capacity of the collecting duct. In addition, we find rapid (within 30–60 min) increases in abundances of all three subunits in response to vasopressin. These changes could be predicted to play some role in the increased transport of sodium observed in perfused CCDs when vasopressin is added to the bath, although additional mechanisms are likely to be involved. These combined results therefore suggest that vasopressin is involved in both salt and water conservation, through regulation of ENaC abundance, during water-deprived states, or during states of acutely elevated blood vasopressin, such as hemorrhage.
This work was supported by National Institute of Diabetes and Digestive and Kidney Diseases Grants DK-38094 and K01-DK-02672-01 to Georgetown University (to C. A. Ecelbarger and J. G. Verbalis) and by the intramural budget of the National Heart, Lung, and Blood Institute (to C. A. Ecelbarger, G-H. Kim, J. Terris, S. Masilamani, C. Mitchell, I. Reyes, and M. A. Knepper).
Address for reprint requests and other correspondence: C. A. Ecelbarger, Bldg D, Rm 232, Georgetown Univ., 4000 Reservoir Rd NW, Washington, DC 20007 (E-mail: ecelbarc{at}gunet.georgetown.edu).
The costs of publication of this article were defrayed in part by the payment of page charges. The article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C. §1734 solely to indicate this fact.
- Copyright © 2000 the American Physiological Society


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175 Practices and 600,000 Patients: Celebrating the Successes of the Patient Centered Medical Home Pilot and the Medical Homes Model in Maine
On the final day of 2016, the sun will set on the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration, a national health care transformation initiative that supported the Patient Centered Medical Home (PCMH) Pilot in Maine. MAPCP and the Maine PCMH Pilot have led to marked and positive change in the way primary care is delivered, ushering in more patient-focused and team-based care that is now enjoyed by more than 600,000 Maine patients.
To recognize the accomplishments of the initiative over the last six years, Conveners of the Patient Centered Medical Home Pilot (MaineCare, Maine Quality Forum, Maine Quality Counts, and the Maine Health Management Coalition) brought together participating primary care practice team members from across the State. The event, held earlier this month at Maple Hill Farms in Hallowell, included both on-site and virtual participants celebrating their hard work and dedication to improving the delivery and quality of care. While thanking the practices during the intimate gathering at Maple Hill, the conveners also ensured that each practice received broad public recognition in half-page ads that appeared in the Portland Press Herald and the Bangor Daily News.
The MAPCP Demonstration began in 2011 with eight states participating: Maine, Michigan, Minnesota, New York, North Carolina, Pennsylvania, Rhode Island and Vermont. Each project was conducted and coordinated by the participating State and included Medicaid and substantial participation by private health insurers. The demonstration was initially planned to last for three years in each state. In early 2014 a decision was made to extend the initiative through the end of 2014, and in September 2014 CMS announced that it would continue the demonstration through 2016. Now, at the close of 2016, the pilot is finally wrapping up in Maine, after bringing over $35 million in supplemental payments directly to Maine primary care providers.
Lisa Letourneau, MD, MPH began the day's activities by celebrating the incredible accomplishments of the 175 practices that participated, bringing innovative care to 677,000 patients.
Sharing from the national perspective, guest speaker Lisa Dulsky Watkins, MD, Director, of the Multi-State Collaborative at the Milbank Memorial Fund, offered the national context and recognized the contributions of the Maine practices and the PCMH Pilot. Following Lisa's presentation was a lively panel discussion from experts Gay De Hart from Mingle Analytics, Kim Gardner from Maine Quality Counts from Lee Umphrey, Harrington Family Health Center, and Sheila Hanley from the Centers for Medicare and Medicaid Services. They discussed potential new Medicare reimbursement options emerging from passage of the recent MACRA legislation, including the encouraging new Comprehensive Primary Care Plus alternative payment model – a model that may become available in Maine beginning in 2017 or 2018.
Marie Brown, MD, Associate Professor, Department of Internal Medicine at Rush Medical Center, invigorated the crowd with practical tips on streamlining patient care while improving quality and reducing cost. Taking the time to do pre-visit planning, and re-configuring traditional medication adherence protocols, would pay significant dividends in both time and savings, she suggested. She pointed to online toolkits from the American Medical Association's Steps Forward program as a great source of how-to info on both pre-visit planning and medication adherence.
Wrapping up the day, a number of providers reflected on the impact the PCMH and Health Home initiatives had on their practice.
"This work translated into enhanced satisfaction for the whole (care) team," said Inland's Gavin Ducker, MD. "introduction of TeamSTEPPS had the largest impact," he added, referencing the team-based communication training offered by Maine Quality Counts.
Susan Cheff, MD, of the Helen Hunt Health Center, also appreciated the initiative's emphasis on team-based care. "What we define as a team is so different now. It's expanded to include more disciplines. Now, the integrated team has become what we do, who we are." She also stressed the kind of freedom that teams bring to individual members. "When it comes to patient care, I can do what I'm best at. And I know that my team members are taking the initiative to do what they're best at."
To learn more about the MAPCP, and the PCMH and Health Home initiatives in Maine, please visit the Maine Quality Counts website.