text:
Hey, hi, how's it going?
Say, this morning I got a Google news alert about a story on some of my packies in Eastern Oregon, so I clicked on it and read that there's good and bad news for them.
The good, of course, is that we're really recovering there — hurray, us!
(As if there was any doubt we would, silly humans.)
The bad was that — yikes — "It's getting a little bit easier for humans to kill" us.
Run away! Run away!
JK, we're not going anywhere.
Sounds like our population has reached some number or another in some big old management plan document that everybody agreed to in the distant past, and now, as you two-leggers like to say, the chickens are coming home to roost.
(Pro tip: Best served raw.)
Well, duh.
Look, thanks to the reintroduction of my great-great-great-great-great grandparents, Herkimer and Wilhelmina Wolf, into the Northern Rockies 20-whatever winters ago, and those federal and state protections, we're unstoppable.
The kid gloves you've been handling us with? Yeah, those can come off — and asap.
Honestly, that part of this whole thing has been way too embarrassing, for way too long.
Those sneaky little cameras on the trees and those collar thingies put around our necks apparently don't record their taunts, but the bears and cougars give us so much sh*t about being the "bios' little favorites" and stuff.
Even the coyotes laugh at us, and That's. Just. Not. Cool.
So, enough with that.
And this quote from the aforementioned story? "We're still in this very delicate phase when it comes to wolf recovery," said Arran Robertson of Oregon Wild.
Puh-lease, wolfy, never ever use the word "delicate" in reference to us again.
We're not delicate flowers, we're not delicate snowflakes, we're not delicate nothing.
Ahem, these fangs? The huge horkin' paws?
"If you had something like a disease outbreak, that could affect a huge chunk of the population," Robertson fretted, according to the article. "So we still want keep protections in place … because we could end up falling backwards very easily."
Trust me, we wouldn't feel the same way if a nice dose of the plague hit ya'll.
You're going to have to get used to what recovery brings with it.
I know that will be hard, but we're wolves here, damnit. Not unicorns. Not Bigfoot.
Not circus freaks or zoo exhibits.
We're regular animals. We've got day jobs, families, homes, we have fun little get-togethers, yeah OK sometimes we get in trouble with the neighbors.
(Pro tip: Best served raw.)
Speaking of, here's another thing: Quit reporting that people in the Middle Ages made up stories like Little Red Riding Hood.
You're killing our reputation, coyotes are laughing at us — we're talking libel suit here!
We can handle this, really. See what we've done in Idaho? Montana? Northeast Washington?
Nothin' different about Oregon; if anything this is even more fertile ground, even if it's further away from the 1.2 trillion cousins of ours up in Canada.
Sometimes we think you want us to fail, to always be just below some magic recovery number so we can't take our place in the animal kingdom, so that we can be your little pets for all eternity.
Not to bite the hand that feeds us …
(Yep, best served raw.)
… but let go, we got this.
Wolfy von Wolferstein IIIIX


text:
HOT Bikini Beach Parties UNCENSORED
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subset: commoncrawl


text:
If I close my eyes, I can almost smell it – musty, earthy, with a bit of sweat and dust. I can almost hear the hum of the combine, and hear the wheat being cut and harvested into the hopper. Other than spring, when life was reborn everywhere, harvest was one of my favourite seasons on the farm. It was like you finally got to reap from the months of sowing, spraying, checking on things, and praying for just the right amount of rain.
My Dad has farmed just over 50 crops, dutifully and painstakingly at times, watching and praying as the seasons changed. But what's the one thing you could always count on? There would be a harvest. Summer heat would eventually cool to the right temperature, allowing you to bring in the crop you'd waited months for.
God has a special affection for farmers, I think. What other job is there that so many elements are out of your control, determining your outcome?
I was reading in Isaiah this morning, using this study guide. It's thick, long and daunting, but helps me ask questions of the text when I read it, rather than just reading. After prophecies of judgement on the people for how they had disobeyed God and followed their own way, God speaks in Isaiah 28: 23-29 about how the farmer tends to his crops. For dill and cumin and wheat – how there are specifics the farmer knows and is led by God on how to harvest, "For he is rightly instructed, his God teaches him."
God basically says that you don't harvest forever. You don't "thresh it forever" (vs28). But in verse 29 we read the best part, "This also comes from the Lord of hosts, he is wonderful in counsel and excellent in wisdom."
As I stare out our livingroom window, fat white bunnies hide in the bushes in our backyard, foraging for bits of food. Daylight is starting to take form, and my heart longs for spring. How many more weeks? I am not a fan of winter. But winter forces rest, both on man and the land. And if we had a winter season of only two months, our Alberta land would not have the rest and hibernation it needs to produce the following year.
The seasons are the length they are for a reason, for what is needed to produce in the next.
And I am reminded… God is wonderful in counsel, excellent in wisdom. All seasons change, eventually. Always. And the tilling, and threshing, the sowing and the reaping – are all in his hands. My job? Is to be instructed of the Lord, and rest.
Whatever your season is today, trust that God has you in His hands, and will rightly instruct you.


text:
Gully, didn't clock LP meant low pass lol
gonna have a look through the good old photek perc folder for a nice clean bell sound that works with that
its a ...........Dånk? Dønk ? Dynk?
slæm dønk
obv you'll then need to make sure the two samples (the 808 kick and the bell) are in tune/in the same key
lemme upload some drum machine stuff
similar sound here
just waiting for this mediafire HO to upload the last one i have here
but its probably 2 sick for nna1
and im not sure the sound is in any of these packs lololol
nah nw, I heavily need more percussion/drum packs m8, so thank you
this is crazy - like circuit bent drum machine hits - 'fx-y' http://www.mediafire.com/download/sdsqar5uh6gczja/WAV+LOOPS.zip
i think maybe this on the way or part of the sound just at a lower pitch - http://www.mediafire.com/download/343im3zx6yqlkrf/5804+BUZ+BLP.wav
Scatta is the one
was it this by chance?
It feels like an lfo rate is like at 1/32 in the drop. Whenever I try it on any growl sound. Nothing happens. I even tried recording a sound and moving it to harmor and then speeding it up through there. Any ideas?
Sounds like it's been pitched up and downsampled/bitcrushed. Layered with a regular one for bass.
Does anybody know if he records his vox himself? They all sound kinda similar and all kinda sound like his interview voice.
posted this in dubs for feedback but realise i have way to many questions.
I've been attempting to analyse what i like about the old DMZ stuff so much, lets start with misty winter.
Seems like there is so much reverb, even on the kick? maybe all the kit is on a send?
I love the descending (square wave?) bass at 20 seconds, i can get the tone but its wobble is kind of weird, again, sounds super reverbed. I thought you werent supposed to put reverb on kicks, on basses etc, but alot of loefah stuff + the classic era seems to break all the rules in general.
Again this track rolls so much, and the beat doesnt seem to variate that much but somehow it keeps on rolling and doesnt get lame.
Heres my whack attempt at something similar.
to busy, doesnt roll, i know it must be about simplicity + sample selection + cultivating the right vibe but cant seem to get my head around it.
analysing these old tunes sends me down a rabbit hole, if i really think about the actual samples + sounds alot of it is pretty shit really, but it's so damn good!
Sorry for the essay lads, not sure if i was clear but i just want to learn abit more about these kinds of tunes if anyone has any pointers.
in misty winter the bass sounds like a pitch-bent down modulated sub going through distortion and reverb
in your track it sounds like one of your kicks (on 5) is late (or the previous one too early maybe) which might affect the roll factor, also the original mist winter beat has a swingy, groove quantize feel to it like the elements of the beat that fall on the off-beats are late by around a 64th
theres no reason not to put reverb on kicks and bass, it helps keep it powerful and punchy if u mono the low end of the reverb or just use a mono reverb.
how to sound of rainbows?
ah! will check later
Here's one to make some of you go "ugh really?" but the reason I want to know what you guys think is because I feel like I'm missing something...it's a sound that sounds like it should be one thing, but I tried that and it didn't work...so yeah, let's figure this out.
Ago's sub. He uses it in his own tracks and in a couple Numa Crew tracks. It's a sine-wave, obviously, and it has LFO modulation going on, but I can't tell if the LFO is modulating pitch or volume, or maybe both? I tried it both ways, and it doesn't have the sort of off-tune effect that his does. Am I missing something?
I don't want to ape the sound, really I just want to figure out how he's doing it lol.


text:
WEST JEFFERSON-A popular local artist was transported to Wake Forest Baptist Medical Center after she was hit near a crosswalk in downtown late Thursday night.
That news comes from West Jefferson Police Chief Jeff Rose and a report filed by WJPD Officer Josh Hodges.
According to police reports, Robert Dennis Hodges, 33, of West Jefferson, was traveling north on North Jefferson Avenue in a Scion SUV when he collided with Shannon W. Parrish, 53, who was attempting to cross the street near Rosebud Bakery. Parrish, who also goes by Talara, is the owner of the Barn Quilt Headquarters of the Blue Ridge above Hotel Tavern in West Jefferson.
The accident occurred shortly after 10 p.m. on May 12, as Parrish was crossing the street in a marked crosswalk, according to the report.
Rose confirmed that the report indicates Parrish did drink some alcohol prior to the accident but said he did not know how much.
The SUV's driver, Robert Hodges, told police he was heading toward Wilco when his dog barked at the crosswalk by Rosebud Bakery, apparently when he hit Parrish. Robert Hodges told police he never saw Parrish until he'd stopped his Scion.
Off-duty paramedic Nathaniel McCoy told police he saw the accident as it unfolded.
McCoy said he saw a female nearing the concrete bump out when she was "contacted by a dark colored Scion SUV," McCoy told police.
"I then noted the female 'lunge' forward and right before falling to ground where she came to rest on her right side near the concrete bump out," McCoy said. "I immediately pulled over and jumped from my vehicle and dialed 911."
McCoy said the Scion stopped and pulled into a parking space.
"(The SUV driver) came up behind me and asks, "Do I need to call 911?" I advised him that I was an off duty paramedic and that I had called already. I told him to 'Stand back and stay put,' until (law enforcement officers) arrived. I immediately began rendering aid to the patient," McCoy wrote.
McCoy told police the vehicle did not seem to be speeding at the time of the accident and said "the streets were poorly illuminated even with all the streetscape lights functioning."
Rose said Parrish was transported to Baptist and treated for head trauma, but said she is expected to recover. It's not immediately clear if charges have been filed in the case but the Jefferson Post will update the story as more details in the case are confirmed.
Reach Adam Orr at 336-489-3058.


text:
All are welcome to participate fully in the services at St. John's.
Below are some of the ministries that you may participate in if you feel called to do so:
Acolyte – The ministry of acolyting is open to all . Acolytes are responsible for lighting the candles prior to the service, carrying the torches in both the processional and the recessional, assisting in the set up of the altar for communion as well as assisting those members of the congregation that might need assistance leaving the communion rail and finally putting out the candles at the end of the service. Senior acolytes, carry the cross in the processional and recessional as well as receive the communion elements and plate offering from the ushers and assist the rector as needed in preparing the bread and wine for communion. Training is available and we welcome all young people to join this very special youth ministry. Please see Jim O'Neil.
Altar Guild – The Altar Guild's ministry is to prepare a place for worship. Members ensure that the church is always prepared for church services, baptisms, weddings and funerals. For more information, see Carol Hall.
Lay Assistant – A Eucharistic Minister is a lay person authorized to administer the element (wine) at a Celebration of Holy Eucharist. This ministry is appointed by the clergy and licensed by the Bishop for this ministry.
Licensed Lay Reader – A Licensed Lay Reader is a lay person who regularly leads public worship under the direction of the clergy of the parish.
Readings – Parishioners participate in services weekly reading the two lessons, psalm, and prayers of the people.
Usher – The usher is the first person the congregation sees as they enter the church. Duties include passing out bulletins, seating those in need, presenting the offerings, passing the plate, counting the attendance, and checking the pews for lost items.


text:
With so many available today, it is good to have a brand you can recognise. The Head Liquidmetal 8 Tennis Racket L1 is certainly that and will be a perfect purchase. For this great price, the Head Liquidmetal 8 Tennis Racket L1 comes widely respected and is a popular choice amongst lots of people.
Product Description
Characterictics: Composition: Liquidmetal. Beam: 28 mm. Head Size: 720 cm². Lenght: 69,50 cm. String Pattern: 16 - 19. Recommended String tension: 27 - 25 Kp. Weight (Unstrung): 265 g. Strung. Outlet model.


text:
If you do not specify a home page, the Webserver creates a default list that displays when a client logs onto the Web site. The default list displays the contents of the WebPages directory. You probably will not want to display this page on a regular basis. In fact, you can specify that this page never displays .
The default list looks similar to the following example.
Tip: The most efficient way for a user to move from one screen to another is to open one CimView screen and then overlay other CimView screens from that screen. In essence, the user will have opened CimView once and then will move from screen to screen within CimView.
In contrast, a default list is only a web page, not a CimView screen. Therefore, each time a user clicks on a CimView file in the default list, a new session of CimView has to open. Obviously, this is more time consuming than starting CimView once.
Step 2. Create a Home Web page.


text:
Distillation of solvent is a growing need of almost every industry. The advanced distillation column manufactured using the superior grade material and the advanced technology features provides a one stop solution to meet distillation need in various industrial and commercial sectors. Through our Distillation System you can easily filter impurities as in the context of salt from sea water and to refine the solution that is needed in beverage industries. Rufouz Hitek Engineers made Distillation System Suppliers is also widely used in other sectors beside crude oil extraction and you can also even filter air through this system. The advanced technology and the latest feature incorporated in the distillation system makes distillation easier and efficient. We are one of the leading Distillation System Exporter in India.
Holding an international presence we are counted as one of the leading exporters of industrial equipment used in chemical processing and other applications. With a strong clientele, we are not only confined to the Indian marketplace, but have extended our arm to the foreign countries of Europe, Asia, Africa, USA, etc. We carefully monitor all the aspects in the manufacturing unit to please our valued customers. Our clients always experience a sense of satisfaction from our service and this is followed by their repeated and regular orders. We have a strong control of the markets of:
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In our organization there is a team of experts who always inspect the quality of the manufactured products. From start to the last stage of packaging, they give their best efforts to meet the quality standards. Thus we ensure about the durability, energy efficiency and impulsive nature of our delivered products at all times..Read More
Rufouz Hitek Engineers Pvt. Ltd
Mr. Sunil B. Bhosale
A-61, Sumeru, SVP Nagar, Andheri-West,
Mumbai - 400053, Maharashtra.


text:
I think it's really fun to quantify things that aren't usually quantified, and I love to reminisce. With this in mind, I wanted to revisit the memories in my life so far and tabulate and depict them in a new way.
I wanted to explore how my memories are linked both to the places I've been and the people in my life.
As I worked, I reflected on this quote:
"In the end, it's not where you are or what you're doing, but who you're with that matters."
I think this is partially true. My memories are extremely dependent on people, and some of my strongest memories are from quite unexpected places (No offense, Gaylord, Michigan!). But the places I've lived and traveled in my life have led me to meet amazing people I otherwise never would've known, and so location has been essential in my creating memories so far, if only as a catalyst.
So, I spent a couple hours sipping hot apple cider with bourbon and inputting data about my memories into a spreadsheet. Before I explain the visualizations and how I made them, here's how I thought about my memories, and how I went about quantifying them.
I chose to focus on and visualize the intensity of my memories with people and places because I experience memory as a spectrum of intensity.
I represented memory intensity by assigning a number, 0-100, to each friendship or place, based on how strong my associated memories were. I was tempted to assign positive/negative values to the memories (are they "good memories" or "bad memories?"), but the more I thought about it, the more I felt like none of my strongest memories are all good or all bad. They're multi-dimensional, and without getting too nerdy, it would be beyond my knowledge or skill to visualize them in Euclidean n-space 🤓.
So I went with this definition of intensity, which I defined very unscientifically as the strength of the feeling I got in my stomach when I remembered them.
Here was my process for creating and visualizing the data:
People: "Who You're With"
- I downloaded a list of my Facebook friends and the date we became friends.
- I randomized the order of the list to eliminate any systematic bias in my remembering (I thought I might over-value the first memories I rated, and then under-value later ones as I became less sensitized. Because of this, I sorted the list by randomly-generated numbers in Excel.)
- I proceeded to go through the list, one by one, and read each name, and then input a number, 0 to 100, representing how intensely I perceived the memories I had with that person. So, a rating of 100 would mean I had the most intense memories possible, whereas 0 would be none (and there is one 0, and it went to someone who I honestly don't remember meeting. Oops).
I could have used more objective data to rank the memories I have with people. For example, the number of messages we've exchanged, or number of photos we've been tagged in together. In fact, Facebook does a pretty good job of determining who your "best" friends are. If you click on your friends list and scroll through, you'll notice that the people at the top are the people you're closest to.
However, I chose to make this data purely subjective, because that's what memory is: subjective. I would have been unhappy with any ranking Facebook came up with because it would have been wrong to me. It can't match how I remember the people in my life. So even though it took a while and it's harder to explain, I chose to subjectively quantify each memory, based purely on my perception and the feeling I got when I thought about each person.
To visualize the data, I put the spreadsheets into Tableau Public and played with different visualizations until I got some that I felt showed clearly how my relationships and memories are structured.
Places: "Where You Are"
I love working with geospatial data, so I thought it would be fun to plot my memories on a map and relive the trips that I've been exceedingly fortunate to have taken. I went back through Facebook and looked at all of my pictures and where they were taken, and thought back to every place I've spent significant amounts of time in my life. I entered all of these places in a spreadsheet — 103 in total. I did the same thing that I did with my Facebook friends: I assigned each a numerical value, 0-100, which represented how intense my memories of that place were.
Then I used Carto, a free tool for visualizing geospatial data, to depict the data on a map. I scaled each point based on the intensity of the memory. If you want to do something similar, you can create an account, upload a spreadsheet of your data, and have a visualization in less than 10 minutes.
People: "Who You're With"
I was curious to see how the intensity of memories would be distributed across the people in my life (using Facebook friends as a proxy). My hunch was that the distribution of memories would be intensely skewed towards a few people — perhaps 30 friends would account for 90% of the intensity. This ended up being pretty accurate, but I was surprised at just how many of my Facebook friends I, quite frankly, barely remember.
It's a little disheartening to actually see how little you think about people you're ostensibly "friends" with, but I don't think it's a bad thing. Humans aren't meant to be friends with more than 100 or so people, so there's nothing wrong with not thinking about a lot of people very often. There's also nothing wrong with staying connected with them in some way, and Facebook friendship is generally pretty costless.
The gender visualizations are about what I expected, too. I identify as a male and I'm interested in women, so I thought it made sense that memories with females were a little bit more intense than the others, on average.
Places: "Where You Are"
The map of my memories quite simply tells a story of my life. I was born in Santa Fe, though I moved when I was quite young and don't have a ton of memories there. I grew up in Cincinnati, (where everyone should live at least once!) and have had stints in St. Louis, Istanbul, Providence and Chicago, with lots of little jaunts thrown in that contribute some of my most intense memories.
This was an incredibly fun exercise and something I'd encourage everyone to do. It was awesome to travel in my mind to places far from this coffee shop in Cincinnati. As I did it, three big things jumped out at me:
- I am extremely privileged. This does feel kind of self-congratulatory, but oh well.
- Even though I think I'm pretty well-traveled for someone my age, looking at the map, I realize I have barely seen the world. It's relatively embarrassing that I've been to like 8 places in Switzerland and 0 in South America, Africa or Asia… or Antarctica.
- I love maps, mainly because every time I look at them I'm surprised by something. Did you know Berlin was that far East? Nor did I… nor did I.
Ideas for Next Time
There are tons more things I wish I could've done with this data. Seeing how my friends are linked to one another would be really cool, or showing where my most intense relationships are associated geographically. But this was a fun start and was interesting to think about.
If you'd like to do something similar with your Facebook or travel data (I really encourage you to! So fun.) and would like more insight into my methodology or access to the spreadsheets I used as a template, please don't hesitate to reach out to [email protected]. I'd love to help get you started.
Or if you buy me a coffee (I accept Venmo), I'll even do it for you. (The visualization process is really quick. It's the data creation that takes a while.)
You can view interactive versions of these data visualizations here (Facebook friends) and here (maps).
Happy remembering!


text:
Louis Leithold, (born Nov. 16, 1924, San Francisco, Calif.—found dead April 29, 2005, Los Angeles, Calif.), American mathematician and teacher who authored The Calculus, a classic textbook credited with having changed the methods for teaching calculus in American high schools and universities. The textbook was first published in 1968 and saw seven printings. Leithold received a doctorate in mathematics education from the University of California, Berkeley, and later taught at California State University; Phoenix (Ariz.) College; the Open University, Milton Keynes, Eng.; and Pepperdine University, Malibu, Calif. At the age of 72 the calculus guru began teaching high school in Malibu.
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text:
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text:
Alibaba opens US data center in new challenge to Amazon
Chinese online giant Alibaba will open a data center in Silicon Valley, it said Wednesday, challenging US rival Amazon in the field of cloud computing.
Chinese online giant Alibaba will open a data center in Silicon Valley, it said Wednesday, challenging US rival Amazon in the field of cloud computing.
NASA's Aqua satellite saw powerful, cold, high thunderstorms circling the center of strengthening Tropical Cyclone Lam as it appeared to cover most of the northern half of Australia's Gulf of Carpentaria.
(AP)—Utah state officials have seen what they describe as a sharp uptick in attempts to hack into state computers in the last two years, and they think it related to the NSA data center south of Salt Lake City.
No storm selfies, hookups, status updates. With Facebook and Instagram down for nearly an hour overnight, what were legions of users to do?
A team of NIST scientists has devised and demonstrated a novel nanoscale memory technology for superconducting computing that could hasten the advent of an urgently awaited, low-energy alternative to power-hungry conventional ...
The largest lithium battery factory in the world is getting a new neighbor at an industrial park east of Reno—the world's biggest data center.
Tropical Depression Mekkhala strengthened and organized on Jan. 14 and overnight into Jan. 15 when it reached tropical storm status. As the storm was consolidating, NASA's Global Precipitation Measurement (GPM) mission core ...
BlackBerry says it will use its expertise in secured messaging services to offer new ways for cars, home appliances and other devices to communicate with each other while keeping data secure and private.
A new data center in the United States is generating electricity for its servers entirely from renewable sources, converting biogas from a sewage treatment plant into electricity and water. Siemens implemented the pilot project, ...
Despite a bitter U.S. cold snap, the globe is rushing hell-bent toward its warmest year on record with last month setting the fifth monthly heat record of the year.


text:
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Letter(s) from Evgenia Zenina to Frank (Ireland)
Letter 1
Dear Sir.
as a request of your lady Eugenia we would like to announce you that she is not able to reply to your last letter as at the moment she doesn't have any possibility to pay for translation and Internet services, provided by our translation firm. She is sorry about it.
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we will be glad to answer all your questions.
We hope for our future cooperation.
Yours Faithfully,
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Alexandra Babochkina
Letter 2
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Cost of phone calls is not included in any service.
How it works:
This service works like this: you e-mail a letter to your lady,then we translate and print it for her. She replies to you, we translate and print this letter. We type and send it you to your address.
We will notify you if a letter is returned to us for any reason.
While your account is over we will send you a balance with detailed report of your expenses.
You can send the money through WESTERN UNION.
You should write in your document:
name of the receiver: Eugenia Zenina
address: 91000,Zhukova Block,5b
city: Lugansk
country: Ukraine.
You can use also your credit card to send payment through the Western Union service. You can do it on line on web site www.westernunion.com
Our contact number is: +3 8 050 959 06 11.
We are open for all your suggestions.
Sincerely Yours


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St. Joseph is a community of charming neighborhoods interlaced by a richly-wooded parkway system. Whatever your style, St. Joseph has a home to suit you. Grand, tree-lined avenues graced by traditional brick homes are popular spots with joggers and dog-walkers. A little apart from the business bustle are family-friendly neighborhoods of new construction. The young, the single and the empty-nesters find the vibrancy of downtown loft-living the ideal blend of comfort and convenience. For those with the vision to build, creating a custom home in the nearby country and scenic rural areas is an affordable dream.
Those seeking the convenience of renting also enjoy a variety of options with complexes, duplexes and condominiums available across all neighborhoods within the city.
Are you moving to St. Joseph? A New Resident Packet includes information about government officials, licenses, fees, utilities, etc. This information can be found in our printed Membership Directory (link to NPG flip book). To request a New Resident Packet to be mailed to you, contact the Chamber at 816-232-4461 or 1-800-748-7856 or send us an email.
Here are some useful links to help you get started:
- Electricity: KC P&L
- Gas: Missouri Gas Energy / LaClede Gas
- Telecommunications (phone, Internet, TV): AT&T and Suddenlink
- Water: Missouri-American Water
- Eagle Radio
- St. Joseph News-Press (daily newspaper)
Local Government:
Volunteer Opportunities:
Please visit the United Way Volunteer Center website to learn about volunteer opportunities available at more than 35 agencies throughout the community.
Real Estate:
Do you need help relocating? To see a list of Chamber member real estate companies that can help you find a rental or to purchase a home, please click here, or visit the St. Joseph Regional Association of REALTORS. For a list of property management companies, visit this page in our directory.


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Duplay Ultimate 2.0 12ft Trampoline with Ladder
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New and improved, back by popular demand, The Duplay ultimate 12ft trampoline 2.0 proves to be one of or best trampolines yet! Our ultimate trampoline provides the ultimate balance between quality, safety and price, meeting strict new EN71 safety standards our trampoline now has a 190cm high enclosure so you and your child can bounce even higher while having the time of your lives. Thew new spec 12ft ultimate trampoline provides extra 20mm foam padding around the springs for extra protection and comes with 72 hardwearing zinc coated springs. Bouncing has never been so much fun without over committing on price. The Ultimate 12ft trampoline comes with 4 support legs to support the main base of the trampoline.
You can buy this product from one of our carefully selected Approved Partners. The full list of options available are below. Simply add your chosen option to your basket and proceed to checkout when you're ready.
You can purchase products supplied by Halfords and selected other suppliers on halfords.com.
Checkout is always via halfords.com and all payment will be taken via halfords.com. In checkout the products will be split into separate deliveries for each supplier.Showing 1 - X of our buying options
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Matt Watson
Technical Lead at Make Do
Matt Watson is the co-founder and technical lead of WordPress agency Make Do. Matt loves writing and learning about code, and considers himself lucky to be doing what he loves for a living. Find out more about Matt, or get in touch to hire Matt for your project.
Latest posts by Matt Watson (see all)
- Reblog: Responsive Web Design (RWD) Background Images - July 28, 2017
- WordCamp Edinburgh July 2017 - July 26, 2017
- Changing your WordPress site language (locale) dynamically - June 16, 2017


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Fall 2004
Access to health care and health insurance is always a key issue in the presidential campaigns. Two federal programs that provide health insurance to millions of Americans are Medicare and Medicaid. What are they? Who is eligible? How do they differ? What is their future?

In this article, we examine Medicare, perhaps the better known of the two programs. Part two will examine Medicaid, which is coordinated through the states.

Congressional Action
Congress established both Medicare and Medicaid in 1965 as part of President Lyndon Johnson's social services programs. Medicare is a federal program specifically designed for Americans over age 65 and for some people under 65 who have disabilities.

Because its primary clientele are retirees, Medicare was originally managed by the Social Security Administration (SSA). Medicaid was managed by Social and Rehabilitation Service. Both were part of the Health, Education and Welfare (HEW) Department. In 1980, President Reagan split HEW into the Department of Education and the Department of Health and Human Services (HHS). In 2001, President Bush renamed HCFA the Centers for Medicare & Medicaid Services (CMS).

Background
Discussion about health and social services and the role of the government in health care is more than 100 years old. A national compulsory health insurance program was enacted in Germany in 1883 and the first Worker's Compensation law in the US was enacted in 1903 (and was later repealed).

Progressive Party Candidate Teddy Roosevelt ran for president in 1912 on a platform that included health insurance. And in 1918, the federal government provided its first grants to the states for health services.

In 1933, the first private hospital insurance was approved; it led to the establishment of Blue Cross. But the original Social Security Act of 1935 excluded health insurance. National health bills of one form or another were then introduced regularly. Then in 1956, government health insurance was provided for Armed Forces dependents.

Health insurance was a key issue for President Kennedy, who addressed the nation on the issue of Medicare in 1962. But it would be another three years before Medicare was signed into law by President Johnson.

In the intervening period, there has been a major change in the US population. Average life expectancy in 1890 was 47.9 years for men, 50.7 for women; by 1960 that had grown to 66.8/73.2 and in 2001 it was 74.4/79.8. This is an increase of about 50%. Thus percentage of the population over age 65 has grown from less than 10% in 1950 to 12.6% in 2000; it is projected to be 20.0% by 2030.

In 1965, when Medicare was enacted, just 56 percent of Americans over sixty-five had hospital insurance. Today almost all elderly Americans have hospital insurance through Medicare. And in 1965, about 29 percent of elderly Americans lived in poverty; by 1998, that had fallen to less than 11 percent.

What It Does
In 2003, Medicare covered about 40 million Americans. Enrollment is projected at 77 million by 2031, when the Baby Boomers are fully enrolled.

Original Medicare has two parts: Part A (hospital insurance) and Part B (coverage for doctor services, outpatient hospital care, and some medical services not covered by Part A). A controversial prescription drug coverage, HR 1, Medicare Prescription Drug, Improvement, and Modernization Act, was added in 2003; it takes effect in 2006.

Congress has also created a Medicare Advantage Plan which provides more choices but which is offered by private companies. Then there is Medigap (supplemental insurance).

Medicare Part A helps cover inpatient care in hospitals, critical access hospitals, or skilled nursing facilities. It also covers some home health care and hospice care. Most people don't have to pay a premium for Part A because they paid Medicare taxes while working.

Medicare Part B focuses on outpatient care but also covers some rehabilitation (physical and occupational therapy). The monthly premium for Medicare Part B was $66.60 in 2004.

Both Parts A and B have deductibles. In 1999, Medicare spent $128.8 billion on Part A benefits and $80.7 billion on Part B benefits.

How It Works
Doctors and supplies who agree to accept an "assignment" from Medicare must accept the proper Medicare deductible and coinsurance amounts. The doctor provides the service and agrees to request payment from Medicare.

Should a doctor or supplier not accept the Medicare "assignment," they may charge up to 15% more than Medicare's approved amount. However, they may ask the patient to pay the entire charge and let Medicare reimburse the patient instead of the doctor.

If a patient believes that Medicare should have paid for something that it failed to pay, he has 120 days to file an appeal.

Like most insurance programs, a small number of people account for most expenditures; about 75 percent of Medicare's outlays serve only 10 percent of those covered.As America's population ages, the federal budget will be under increasing pressure due to the cost of social programs like Medicare and Social Security.

Medicare Part A Hospital Insurance Trust Fund has been "broke" since 1992 -- that is, the annual operating costs have exceeded income. Part B faces the same fiscal challenge. But bankruptcy is not an option; gaps are met with general budget funding : in effect, a surcharge paid by all taxpayers.

Since 1970 real per-beneficiary Medicare spending has grown at the rate of about 5 percent per year. However, the Trustees made projections in 1999 based on this rate slowing to 1 percent; some believe this is extremely unrealistic.

In 1984, Medicare and Medicaid spending accounted for 9 percent of the federal budget; it was 20 percent of the 2004 budget.

In 1972, health expenditures accounted for less than 8 percent of Gross Domestic Product. In 2002 it jumped to 15 percent and should be about 18 percent by 2012 - long before the full impact of the Baby Boomers is felt.

Politicians on both sides of the aisle realize that the current social programs -- Medicare, Medicaid and Social Security -- are not sustainable. But the political will to do something about the problem is missing. There are basically three choices: reduce payments to providers, shift costs to retirees, or increase taxpayer fees.

Some questions leaders should be asking - and media should be reporting:

 How can Medicare and the health care system each be reformed to make them solvent and sustainable?

 Should programs like Medicare be reformed to make encourage citizens to work longer? If so, what kind of jobs will provide health insurance coverage?

 What are the consequences of employers that cease providing health care benefits to their retirees?


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In Congress, income inequality comes with breakfast, lunchMay 3, 2015
Photo: Jacquelyn Martin /Associated Press
WASHINGTON — Income inequality is more than a political sound bite to workers in the Capitol. It's their life.
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AP: Copyright 2014 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


text:
Legal aid firms look set for a turbulent sailing this year. Firms are still dazed by the speed of Lord Irvine's proposed reforms on legal aid and are anxiously awaiting the outcome of the current consultations.
Meanwhile proposed changes to the way professional partnerships are taxed have further nasty surprises in store for the profession.
In a surprising turn of events the Inland Revenue came up with a corker over Christmas which will have major implications for many, and will undoubtedly test the mettle of accounting systems across the country.
Not only have lawyers had to deal with the intricacies of self-assessment, they will now have to cope with a further change to their tax regime.
It is somewhat ironic that, at a time when the Government is calling on legal aid firms to gamble their own money on legal aid cases, these moves will reduce their cash flow.
In a further ironic twist, legal aid firms will suffer more than most due to the exceedingly long periods of time that it takes to get payment from the Government. Under the new regime of being taxed on work in progress, this will mean that they are being taxed on monies not yet received from the Government.
However, ensuring that firms are actually geared up to deal with these new changes is where the real problems lie. Most firms have computerised accounting systems at the moment. Under the new regulations, the systems will need to be centralised and firms will have to undergo full audits.
These new demands will inevitably impose further burdens on lawyers who must get to grips as never before with the business aspects of their practices. The legal profession has never had to be more business-minded and commercially-aware than it does today.


text:
The title of Friday's call was Small Computers vs. Big Phones, and the impetus was an issue of Mark Anderson's Strategic News Service by the same name. We talked about the coming "war" between smartphones and netbooks, computing in the cloud, and where the intersection between these devices might occur.
Many people expressed the opinion that we would likely be carrying multiple devices, depending on context, and thus were inclined to dismiss the idea that a war might be coming as hyperbole.
Nevertheless, there's certainly jockeying for position going on as TI prepares to ship 1W multi-core processors, operating system vendors duke it out, and the device manufacturers themselves battle for the hearts and minds of consumers.
Friday's conference call was recorded on Calliflower. In attendance: Tim Panton, Carl Ford, Jonathan Greene, Brad Jones, Bill Volk, Jim Courtney, Doug Renert, Kim Dushinski, Barlow Keener, Sheryl Breukrer, Ken Camp, Todd Spraggins, Sergio Meinardi, Misha Nossik, and Aga Magdolen.


text:
Get Yourself a Peoples Own QMobile
The fastest selling brand at jambo.pk QMobile surprises everyone. The sensation in online shopping, this user friendly brand is all set to blow our minds off. If there is one word that describes QMobile Tablets, it is FAMILIAR. In a very short span of time QMobile has generated a feel of people's own. The brand produces products in prices that are beyond the comprehension of competitors. QMobile Tablets are produced and marketed under the same philosophy. Keeping the price as low as possible and the technology as modern as any other tablet in the market, QMobile is offering ultimate benefits to the users.
Simplicity and decency, this is what defines the appearance of QMobile Tablets. The brand makes the unique price popular because of this simplicity in design. The same cost that is saved on design is contributed towards technology. This helps QMobile in coming up with some of the most advance Tablets. The range is classified under three different classes. The V, Q and X class. There is not any drastic of difference among the classes except for the price, which is because of added features.
This is just not all. Keeping up with their surprise packages, the QMobile Tablets are equipped with dual cameras and come with high resolution displays that help in improving user video and gaming experience. The best part of QMobile range is the screen size. Unlike other competitive brands, all of QMobile Tablets have larger screens. You no longer have to worry about the size while choosing among a wide range.


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Glamourous brunette Missy Nicole masturbates in the gym
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I think it's fine. Already customizing HellKat now. Seems smooth.
---------- Post added at 09:35 AM ---------- Previous post was at 09:18 AM ----------
I just installed GravityBox Xposed Module. It does not sit well with the navigation bar, as it is always showing the nav bar, though it is fully disabled in the native settings and in gavitybox's.
I guess my problem is with GravityBox Module compatibility with the ROM. Anyways, not much of a problem. The ROM is very good. I like some features. Especially the build.prop and init.d mods. Can those mods be also added in MAHDI? I mean MAHDI is really perfect in every sense as for my preference, and adding those features would make it more awesome. Thanks!
---------- Post added at 11:39 AM ---------- Previous post was at 11:36 AM ----------
@ThatKawaiiGuy, do you have the modded kernel of xboxfanj? With all the OC, d2ws2w features? Thanks!
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The search will continue for 72 year old Mandy Thompson who left her home Friday morning and hasn't been seen since. The search and rescue teams will focus their search into Oro-Medonte Township. Police are now looking for a tow truck driver who may have seen her around 11am on Friday. The black truck was hooking up a vehicle on Penetanguishene Road near Napoleon Home Comfort.
Mandy is described as:
• 5'8
• Medium build
• Short red/brown hair
• Brown eyes
• Wearing a black knee length jacket, white sweater, jeans and white running shoes.


text:
Castle - For Want of a Nail
Castle - For Want of a Nail
Graphite on layout bond
Approx. Image size: 5" x 4.5"
Paper size: 6.5" x 8" - irregular
*Price reduced due to irregular paper shape
Add To Cart
Please click on each title below to see available drawings from Favorite Nursery Rhymes, along with size and price info. Thanks!


text:
Zion I
The Wormhole
2307 Bull Street
Savannah, GA, 31401
This event is 21 and over
Watch & Listen
The Sun Moon and Stars EP is the final link in the EP trinity from Zion I, which started with Masters of Ceremony, and Libations. The project captures the mounting tension of the ongoing clash between the police and the community, with Dreadlock and Unity. On the other side it features savvy storytelling over bass heavy ambience with Lost in Translation and Last Nite. Juggernaut serves as the street anthem, deftly balancing the extremes. The three modes convey the hunger of an artist steady honing his craft. Bear witness, to the Sun Moon and Stars.
The people said they needed a break from the sameness. There was no creativity. They had given up hope and fallen out of love with Hip-Hop. Then, along came KidSyc@Brandywine.
In early 2010, KidSyc recieved an e-mail with the subject line, "We respect your MC abilities...". This e-mail, sent by bassist Charles Hodge eventually ended KidSyc's year-long search for a live band and sparked what was soon to become an artistic force to be reckoned with.
With a pair of plaid pants and an undenialby magnetic sound, KidSyc@Brandywine captivated crowds at the 2010 Savannah Urban Arts Festival and broke the monotony of Savannah's Hip-Hop scene. Listing influences like Earth, WInd, and Fire, Radiohead, J. Dilla, Eminem, and Stevie Wonder, (to name a few), its no wonder a song like "Different" serves as a great snapshot of what these guys are all about.
If you take the thoughts, ideas, and emotions of your average misfit, sprinkle in some new-found confidence, and spread it all across a bold and adventurous soundtrack. What you will have is a KidSyc@Brandywine song...... and a new favorite rapper.
Upcoming Events
The Wormhole
Wed, November 22
Open Mic / Open Jam
Thu, November 23
Fri, December 8
Prohibition Repeal with The 9th Street Stompers
Fri, December 22
Dj Deekline
Sat, April 7
That 1 Guy


text:
|Home | About | Journals | Submit | Contact Us | Français
Patients with diabetes mellitus (DM) are prone to a diffuse and rapidly progressive form of atherosclerosis, which increases their likelihood of requiring revascularization. However, the unique pathophysiology of atherosclerosis in patients with DM modifies the response to arterial injury, with profound clinical consequences for patients undergoing percutaneous coronary intervention (PCI). Multiple studies have shown that DM is a strong risk factor for restenosis following successful balloon angioplasty or coronary stenting, with greater need for repeat revascularization and inferior clinical outcomes. Early data suggest that drug eluting stents reduce restenosis rates and the need for repeat revascularization irrespective of the diabetic state and with no significant reduction in hard clinical endpoints such as myocardial infarction and mortality. For many patients with 1- or 2-vessel coronary artery disease, there is little prognostic benefit from any intervention over optimal medical therapy. PCI with drug-eluting or bare metal stents is appropriate for patients who remain symptomatic with medical therapy. However, selection of the optimal myocardial revascularization strategy for patients with DM and multivessel coronary artery disease is crucial. Randomized trials comparing multivessel PCI with balloon angioplasty or bare metal stents to coronary artery bypass grafting (CABG) consistently demonstrated the superiority of CABG in patients with treated DM. In the setting of diabetes CABG had greater survival, fewer recurrent infarctions or need for re-intervention. Limited data suggests that CABG is superior to multivessel PCI even when drug-eluting stents are used. Several ongoing randomized trials are evaluating the long-term comparative efficacy of PCI with drug-eluting stents and CABG in patients with DM. Only further study will continue to unravel the mechanisms at play and optimal therapy in the face of the profoundly virulent atherosclerotic potential that accompanies diabetes mellitus.
Diabetes mellitus (DM) is associated with a 2 to 4-fold increased risk of coronary artery disease, and ischemic coronary artery disease is responsible for three-quarters of diabetes-related deaths [1]. The adverse macrovascular consequences of DM are well recognized, as is the accompanying accelerated rate of atherosclerosis that predisposes patients to occlusive coronary artery disease, myocardial infarction and death. Patients with DM are prone to a diffuse and rapidly progressive form of atherosclerosis, which increases their likelihood of requiring revascularization [1, 6]. In the United States, approximately one third of all percutaneous coronary intervention (PCI) procedures are performed on patients with DM. As the prevalence of DM increases, the number of patients with diabetes requiring revascularization for advanced coronary artery disease will escalate. The unique pathophysiology of atherosclerosis in DM modifies the response to arterial injury, with profound clinical consequences to patients with diabetes undergoing PCI. Although there has been considerable improvement in the management of patients with coronary artery disease, coronary event rates remain heightened [2, 3], and mortality greater among patients with diabetes [4, 5].
Selection of the optimal myocardial revascularization strategy for patients with diabetes and multivessel coronary artery disease (CAD) is crucial to improving the outcome of these high-risk patients. The following review summarizes current evidence regarding the effectiveness of various revascularization methods in patients with diabetes.
The patient with diabetes presents challenges to all revascularization procedures and the technology is itself slower to adapt and optimize. At least three epochs can be defined in interventional approaches to coronary disease—early, mid and modern. The earliest tracking of patient well-being soon after the advent of angioplasty revealed the unique biology of diabetic vascular disease [7–10]. Kip and associates described the short- and long-term outcomes of percutaneous transluminal coronary angioplasty (PTCA) in 2114 consecutive patients including 281 patients with diabetes from the National Heart Lung and Blood Institute (NHLBI) 1985 to 1986 Registry [7]. There was then no difference in rates of procedural angiographic success and completeness of revascularization. However, combined in-hospital complication including death, myocardial infarction, and need for emergency surgery were almost two-fold higher, and inhospital death was more than 6-fold more prevalent in patients with DM [7]. In the middle period of interventional approaches, the differences in patients with and without diabetes fell as the technology of interventional cardiology progressed even as sicker patients were intervened upon. Angiographic success was achieved more frequently in patients with diabetes in the 1997–2001 NHLBI Dynamic Registry, where stenting was used in nearly 90% of patients. Whereas procedures were successful in 77% of patients with diabetes in the 1985–1986 cohort, success increased to 96% in the four years that followed. Abrupt closure fell more than two-fold from 2.2% to 0.9%, and the hard end points were all similarly reduced, including inhospital mortality (1.9% vs. 4.3%), myocardial infarction (1.0% vs. 7.4%), and in-hospital CABG surgery (0.8% vs. 6.2%) [11].
The refinement of interventional technology has propelled us into a third epoch, the late or modern period. Methodological and technical advances have solved many of the hurdles that had limited initial success. Yet, even in the face of similar procedural success and procedural related complications, in-hospital mortality amongst patients with diabetes was far higher than all others undergoing coronary stenting [12]. Patients with diabetes tolerate multivessel intervention and acute ischemic complications of angioplasty poorly [13].
The incidence of restenosis, the need to reintervene after angioplasty, has dropped significantly with the progression of interventional methods and technology except in the face of DM. Numerous studies have shown that patients with diabetes experience a greater need for repeat revascularization after intervention, and much of the difference in the interventional risk associated with DM occurs within the first 6 months, corresponding to the period in which restenosis is most active. The initial report from the 1985 NHLBI Angioplasty Registry indicated that the angiographic restenosis rate in patients with diabetes was 47%, as compared to 32% in patients without diabetes [14]. In the ensuing 25 years restenosis rates have spanned to an even higher 71% when DM is present [15–18]. In a study of 485 consecutive patients with DM undergoing balloon angioplasty without stenting, at least one vessel with restenosis was found in 68% of patients [19]. Even with stents, patients with diabetes have higher restenosis rates compared with patients without diabetes [20–22], and greater need for repeat revascularization. Data from 5 studies with over 4800 patients document the increased angiographic restenosis rates in patients with diabetes with an absolute overall 10% difference between patients with and without the disease [23].
The restenotic process is more virulent in patients with diabetes—more often leading to total vessel occlusion after coronary stenting [24–26], and resulting in myocardial infarction, reduced left ventricular function, heart failure [19] and long-term mortality [7, 9, 23, 25]. In a consecutive series of patients with successful stent placement (715 with DM and 2,839 without DM), the 1-year cardiac mortality rate was almost twice as high in patients with diabetes (5.7 vs. 2.9%, p<0.001). The incidence of the composite endpoint of cardiac death and nonfatal myocardial infarction was significantly and commensurately higher as well (8.0 vs. 4.6%) [25].
Since the earliest reports of differences in the DM population question has been raised as to whether these differences reflect an extreme of the biologic processes that affect all patients or a different set of pathologic events all together. The clinical manifestations are different and may be part of the diabetic process. The defective anginal warning system (DAWS) the plagues patients with diabetes and ischemic heart disease may be evident here as well, as many of restenotic events were clinically silent, with no angina in 36% and stable angina in 33% of patients. Progression of native disease is far more prevalent in patients with diabetes as the majority of angioplasty procedures performed more than 1 year after the index intervention are at a site different from the initially treated lesion. Patients with diabetes require more frequent revascularization with either surgery or angioplasty after the first year of the initial angioplasty, indicating that patients with diabetes are more prone to progression of coronary disease [9].
A large number of clinical, anatomical, and procedural variables have been associated with restenosis in various studies. Patient-related variables include demographics, concomitant medical diseases, serologic markers, and genetic polymorphism. However, the most consistent patient-related risk factors associated with restenosis is DM [27]. In a pooled analysis of several major stent trials, Cutlip et al. found DM to be the strongest clinical predictor for restenosis, with an almost 50% increased risk for target lesion revascularization at one-year follow-up [28]. In a series of patients enrolled in 16 PCI studies with 6-months angiographic follow-up, 31.1% of patients with diabetes developed restenosis. Smaller vessel reference diameter before the procedure and greater stented length of the vessel were independent predictors of restenosis in patients with diabetes [29]. The higher risk for restenosis exists in patients with diabetes throughout the vessel size range [25].
Restenosis is a characteristic response to mechanical vessel injury. Endothelial denudation and dysfunction enables and promotes local thrombosis, superficial and then deep inflammation, which trigger smooth muscle cell proliferation [30, 31], and eventually matrix remodeling and extracellular matrix deposition. Each of these events can be exacerbated by hyperglycemia, hyperinsulinemia, insulin [32, 33] or frank diabetes [34]. Hyperglycemia promotes inflammation [35, 36], induces the production of growth factors that promote restenosis [27] and increases matrix gene transcriptions [37]. Advanced glycosylation end products (AGEs) accumulate in vascular tissues with normal aging and at an accelerated rate in DM. AGE formation is accelerated in correlation with glucose concentration and time of exposure to hyperglycemia. AGEs interact with specific receptors (RAGE) present on all cells relevant to the restenosis process including inflammatory cells and smooth muscle cells. AGEs–RAGE interaction in vessel wall may lead to inflammation, smooth muscle cell proliferation, and extracellular matrix production, culminating in exaggerated intimal hyperplasia and restenosis [27, 34]. Enhanced intimal proliferation was found in patients with diabetes at the site of angioplasty-induced arterial injury, particularly in restenotic lesions [38]. Animal models of restenosis implicate RAGE in promoting the mononuclear phagocytes and smooth muscle cell response to arterial injury [39, 40].
Corpus et al. [41] assessed the effect of glycemic control on target vessel revascularization at the time of coronary intervention in 179 patients with diabetes as compared with 60 controls. Patients who had optimal diabetic control, defined as HbA1C≤7%, had a target vessel revascularization rate of 15%, compared with 34% among counterparts with an HbA1C >7%. By multivariate analysis, poor glycemic control, HbA1C >7%, was a major independent predictor for target vessel revascularization with an odds ratio of 2.87. Similar repeat revascularization rates were observed among patients with diabetes and optimal glycemic control and patients without diabetes.
Insulin has several biological actions, which may be related to the process of restenosis. Insulin can potentiate proliferation and migration of smooth muscle cells, most likely through the action of insulin-like growth factor [42] or other stimulatory factors. There are suggestive data in humans that insulin-resistance is associated with restenosis among patients without diabetes [43–45].
The risk of restenosis may also be dictated by the anti-diabetic drugs used. Thiazolidinediones (TZDs) are anti-diabetic agents that increase insulin sensitivity and are currently used to treat patients with type 2 DM. Beyond their metabolic action, TZDs exhibit anti-inflammatory and anti-atherogenic effects in vascular cells in vitro and limit lesion development in various animal models of arteriosclerosis. Several studies have shown that TZD treatment reduces restenosis and neointima formation after coronary stenting in patients with type 2 DM [46, 47] and in patients without diabetes [48], independent on the glucose-lowering properties of these agents.
Drug-eluting stents (DES) reduce angiographic restenosis and need for repeat revascularization procedures amongst all patients. The benefit in diabetes appears to be similar. Initial results from subgroup analysis of patients with diabetes from a number of randomized controlled trials (including the SIRIUS and TAXUS IV) have been encouraging, demonstrating significant reductions in rates of restenosis, TLR and/or MACE in patients receiving a DES [49, 50]. Sirolimus-eluting stents (SES) reduced the relative incidence of in-lesion angiographic restenosis from 59.5% to 17.6% in patients with DM (65% reduction) and from 30.7% to 6.1% in patients without DM (80% reduction) [51]. In both patients with and without DM, SES transformed restenosis from a diffuse to a focal pattern. However, the absolute late loss and restenosis remain higher in patients with DM receiving SES, and DM remained an independent predictor of TLR (OR 1.65, p=0.03). Furthermore, in insulin-requiring patients, the angiographic in-segment restenosis rate was 35% in the SES arm and 50% in the BMS arm [51]. Similarly, in the small (n=160) DIABETES Trial, target-lesion revascularization at 9-months was significantly lower in the SES group as compared with the BMS group (6.3% versus 31.3%) [52]. The TAXUS-IV randomized trial compared paclitaxel-eluting stents (PES), to their bare-metal counterpart. PES reduced the rate of 9-month binary angiographic restenosis (i.e. >50% diameter stenosis of treated segment at follow-up) by 81% (6.4% vs. 34.5%), and 12-month rates of target lesion revascularization by 65% (7.4% vs. 20.9%). Moreover, diffuse in-stent restenosis was reduced by more than 90% in patients with DM receiving the paclitaxel-eluting stent, such that when angiographic restenosis did occur, it was predominantly focal in nature [53].
As restenosis was the major limitation of BMS use in patients with diabetes, DES are considered by many to be the standard of care for patients with diabetes undergoing stent placement. However, the most complex patients with DM (e.g. those with multivessel and diffuse disease) were excluded from enrollment in the DES trials, and only future studies will confirm if the effects of DES are lasting in diabetes.
Although the magnitude of restenosis reduction achieved with DES is impressive, it is important to recognize that these trials mandated an angiographic follow-up. Revascularization was therefore driven not only by clinical necessity but also by the angiographic appearance of narrowing within the treated segment even in patients who did not have documented ischemia [54]. Although DES are effective in reducing the need for repeat revascularization, most of the current information has been obtained by studying selected patient populations in selected medical centers. In real world practice, the benefit of DES in patients with DM might be less impressive [55]. For example, in the Swedish Coronary Angiography and Angioplasty Registry, the numbers needed to treat patients with diabetes with DES to avoid one additional restenosis per year with BMS ranged from 21 to 47 lesions in patients treated with one stent and 11 to 27 in patients with multiple stents [56].
Equally critical is to consider is whether a reduction in restenosis will result in improvement in the hard end points of myocardial infarction and death, which are considerably higher in patients with diabetes. As several randomized trials and meta-analyses [57–59] have shown no significant reduction in rates of death and myocardial infarction with DES, as compared with BMS, it seems unlikely that greater use of DES in the diabetic population can meaningfully alter the outcome of these patients.
A collaborative network meta-analysis of 35 trials including 3852 patients with DM and 10,947 patients without DM demonstrated that compared with BMS, TLR rates are strongly decreased by use of SES and PES in patients with DM. It was determined that only 6 patients with diabetes would need to be treated before one revascularization event would be circumvented in the four years after intervention, in contrast to the 8 needed in patients without DM [60]. However, in trials with dual anti-platelet therapy (DAT) with aspirin and a thienopyridine for less than six months, the risk of death associated with SES in patients with diabetes was more than twice the risk associated with BMS. These results imply that one death will arise over four years for every seven with intervention. Conversely, trials with dual anti-platelet therapy for six months or more showed no increase in risk from using SES compared with BMS [60]. The duration of DAT modified the safety profile of drug eluting stents mainly in patients with DM. In an analysis of patients with diabetes in the Swedish Coronary Angiography and Angioplasty Registry, DES significantly reduced restenosis to half the rate seen with BMS. However, there was no difference in the combined outcome of death or myocardial infarction in patients with diabetes treated with DES (n=4754) or BMS (n=4956) with up to 4 years of follow-up [56].
The ISAR-DIABETES trial compared SES and PES in patients with diabetes. PES were associated with a higher rate of in-segment late luminal loss as well as an increased risk of angiographic restenosis. However, the study was not powered to demonstrate clinically important differences between the two groups [61]. Jensen et al. performed a randomized multicentre IVUS study comparing neointimal hyperplasia formation and distribution within stents in patients with diabetes treated SES and PES [62]. The neointimal response differed between patients treated with SES and PES as the latter generated greater and more diffuse neointimal hyperplasia than the former. Although angiographic late loss might differ from one DES to another, it is still unknown whether this surrogate end point will translate into a clinical end point of efficacy such as restenosis [55].
The possibility of increased rates of stent thrombosis (ST) after DES has been a matter of concern and can be particularly pertinent to patients with diabetes. ST is classified based on the time of the adverse event relative to the index procedure. Early ST refers to the first 30 days after stent implantation and is further stratified into acute (<24 hours) and subacute (24 h to 30 days). Late ST defines the time interval between 1 month and 1 year after stent implantation; very late ST includes any event beyond 1 year [63]. After DES implantation, late ST occurs at a relatively constant rate over time up to at least 4 years after stent implantation [64]. Delayed healing and impaired endothelialization (i.e., incomplete endothelial coverage of stent vascular segments associated with persistence of fibrin deposits) are common features of late and very late ST, and combine with chronic inflammation and hypersensitivity reactions to promote local clot [65]. Increased inflammation, hypersensitivity, and outward remodeling might prolong the window of vulnerability to stent thrombosis and at all times [63, 66]. The definitive diagnosis of ST requires either angiographic or postmortem evidence of thrombotic stent occlusion. Probable ST encompasses any unexplained death within 30 days of stent implantation or any myocardial infarction in the territory of the implanted stent regardless of time [67]. Though ST is multifactorial [63] several studies confirmed higher rates in patients with diabetes especially for patients on insulin therapy [68–70].
In the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial, insulin-requiring DM was a significant independent predictor of definite or probable ST occurring within 30 days (odds ratio, 2.35; 95% CI, 1.36 to 4.07) [71]. In the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel–Thrombolysis in Myocardial Infarction 38 (TRITON-TIMI 38), patients with DM and acute coronary syndrome (n=3146) had a two fold higher rate of stent thrombosis than those without DM (2.8% versus 1.4%), with highest rates among subjects treated with insulin (3.7%) [72]. In a large 2-Institutional Cohort Study of 8,146 patients who underwent percutaneous coronary intervention with a SES (n=3,823) or PES (n=4,323) and were followed up to 4 years after stent implantation, DM was an independent predictor of overall, early, and late definite ST [73], and the only predictor of early ST. Similarly, in the Swedish Coronary Angiography and Angioplasty Registry (n=73 798 DES and BMS), insulin-treated DM was an independent predictor of ST (1.8-fold increase) [74]. Finally, in the e-Cypher registry (n=15157), insulin-dependent DM was an independent predictor of ST at 1-year (2.8-fold risk increase) [68].
The increased risk of patients with diabetes for ST might be related to the more diffuse nature of atherosclerosis, accompanied by longer lesion lengths, smaller vessel size, and greater plaque burden, which might impose less optimal procedural results. Previous studies have identified both vessel size and lesion length as predictors of stent thrombosis [64], which may explain in part the predisposition of people with DM to this adverse event in the absence of adequate anti-platelet therapy. Additionally, the detrimental effects of DM on endothelial function [75] and platelet function [76] may also promote the development of ST. Further analyses are needed to assess the optimal duration of dual anti-platelet therapy after implantation of a DES, particularly in the diabetic population. However, because patients with diabetes appear to be at higher risk for ST, longer use of dual anti-platelet therapy beyond 1 year may is reasonable [77], and any cessation of anti-platelet therapy should be avoided.
When other medical procedures requiring interruption of aspirin and clopidogrel are scheduled, stent thrombosis becomes a matter of concern. Until more data are available, physicians should be aware of the potentially high risk of stent thrombosis when interrupting anti-platelet agent regimens in patients with DM, particularly if other risk factors for ST are present (e.g. renal insufficiency, bifurcation lesions) [55]. Thus, given the importance of a 1-year course of dual anti-platelet therapy, it is recommended that elective surgery be postponed for 1 year [77], and among those patients for whom surgery cannot be deferred, aspirin therapy should be considered during the perioperative period.
The Bypass Angioplasty Revascularization Investigation (BARI) study enrolled 1829 patients with angiographically-documented multivessel CAD and either clinically severe angina or objective evidence of marked myocardial ischemia requiring revascularization. At 5-years there was a near doubling of mortality among patients with diabetes on insulin or oral hypoglycemic therapy assigned to multi-vessel angioplasty compared with those assigned to surgery (35% vs. 19%). In contrast, mortality was an identical 9% in both revascularization strategies if no drugs were required to control the diabetic state [78]. The 5.4-year cardiac mortality was 3.5-fold higher in the PTCA group (20.6 % vs. 5.8%) [10]. The survival benefit of CABG was limited to the 81% of patients with diabetes receiving an internal mammary graft. Cardiac mortality was 2.9% when an internal mammary graft were used and rose 6-fold to 18.2% when only vein grafts were employed. The latter rate was similar to patients receiving PTCA (20.6%) [10]. The BARI investigators recently reported that the survival benefit of CABG persisted at 10 years [79]. The 10-year survival in the overall study population was 71.0% for PTCA and 73.5% for CABG. However, in the subgroup with treated DM, patients randomized to CABG had higher survival than those randomized to PTCA (PTCA 45.5% vs. CABG 57.8%, P=0.025). Today these results pose a virtual black-box warning pushing clinicians to propose CABG for patients with diabetes and multi-vessel disease.
The results of other randomized trials comparing multi-vessel angioplasty to CABG are consistent with the BARI findings. Long-term follow-up of patients participating in the Emory Angioplasty versus Surgery Trial (EAST) demonstrated an improved survival in patients with diabetes randomized to CABG (75.5% vs. 60.1% with PTCA at 8 years). The angioplasty patients with DM had a worse survival than patients without DM by eight years (without 82.6%, and with DM 60.1%) [80].
The BARI trial provided important insights that increased our understanding of the benefit of revascularization techniques in DM. However, the initial cardiac revascularization procedures in BARI were performed between 1988 and 1991, before the introduction of coronary stents and other technical refinements in angioplasty and surgery. The Arterial Revascularization Therapy Study (ARTS) compared stenting and CABG for the treatment of patients with multivessel coronary disease. Patients with diabetes treated with stenting had reduced event-free survival at 1 year as compared with those treated with CABG (63% vs. 84%, P<0.001) and compared with patients without diabetes treated with stents (76%, P=0.04); differences were driven primarily by an increased need for repeat revascularization [81]. At 5-years, the major adverse cardiac and cerebrovascular events (MACCE) in patients with diabetes treated with stents was 55%, versus 39% in those without diabetes, again largely attributable to the higher rate of repeat revascularization (43% vs. 28%). Conversely, there was no significant difference in the five-year MACCE rate between patients with and without diabetes treated with CABG (25% vs. 21%) [82].
The incidence of 5-year mortality in patients with DM assigned to multivessel stenting was 5.1% higher (13.4% compared with 8.3% in the surgical group), although the study was not powered to show mortality differences between patients with and without diabetes. Within the stent group, patients with diabetes had a significantly higher mortality rate than patients without diabetes (13.4% vs. 6.8%). The SYNTAX (SYNergy Between PCI With TAXus and Cardiac Surgery) study was the first to compare coronary artery bypass graft surgery (CABG) and the TAXUS Express PES in patients with and without diabetes and with complex left main and/or 3-vessel disease (452 with medically treated DM; 71% were treated for 3-vessel disease and 29% for left main disease). In patients with diabetes, the 1-year composite MACCE rate was significantly higher after PES treatment compared with CABG treatment (RR 1.83). The relative risk of repeat revascularization of PES over CABG was 3.18 in patients with diabetes compared with 1.94 in patients without diabetes [83]. Compared with CABG, mortality was higher after PES use for patients with diabetes with highly complex lesions (4.1% vs. 13.5%). Revascularization with PES resulted in higher repeat revascularization for both patients without diabetes (5.7% vs. 11.1%) and patients with diabetes (6.4% vs. 20.3%) [83]. Importantly, follow-up at 1 year may not yet reflect the true long-term differences between CABG and PES treatments of patients with diabetes because previous reports demonstrated reduced long-term mortality in CABG compared with PCI [79, 84].
Hlatky and colleagues recently analyzed pooled individual patient data from 10 randomized trials comparing the effectiveness of CABG with PCI (n=7812). During a median follow-up of 5.9 years, mortality in patients with diabetes (CABG, n=615; PCI, n=618) was 30% lower in the CABG group than in the PCI group. In contrast, mortality was similar between groups in patients without DM. The beneficial effect of CABG compared with PCI on survival did not differ between balloon angioplasty (n=6) and bare-metal stent (n=4) trials [84].
The CARDia (Coronary Artery Revascularization in Diabetes) trial enrolled patients with diabetes with either multivessel CAD or complex single-vessel CAD (ostial or proximal left anterior descending artery disease) in whom coronary revascularization was recommended on clinical grounds. Patients were randomized only if an experienced interventional cardiologist and cardiac surgeon agreed that there was reasonable equipoise in the risks and benefits of PCI and CABG. The primary end point was a composite of death, MI, and stroke assessed at 1 year after randomization with a major secondary end point of the composite of the primary outcome and repeat revascularization. The primary comparison used a noninferiority method with the upper boundary of the 95% CI not to exceed 1.3 to declare PCI noninferior. The study enrolled 510 patients with diabetes, with 69% of patients in the PCI arm receiving SES. The combined rate of death, MI, and stroke in the CABG group was 10.5% compared with 13.0% in the PCI group (HR: 1.25, 95% CI: 0.75–2.09). Thus, the noninferiority margin of 1.3 was exceeded by the upper limit of the CI for the primary end point, indicating that the study results could not demonstrate that PCI is noninferior to CABG. The rates of death, MI, stroke, or repeat revascularization were 11.3% and 19.3% in the CABG and PCI groups, respectively [85].
The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI-2D) trial tested the hypothesis that in patients with both DM and stable coronary disease, prompt revascularization, surgical or catheter-based, would reduce long-term rates of death and cardiovascular events as compared with medical therapy alone. A second hypothesis, that insulin sensitization would be superior to insulin provision will not be discussed here. Coronary artery disease was documented on angiography (≥50% stenosis of a major epicardial coronary artery associated with a positive stress test or ≥70% stenosis of a major epicardial coronary artery and classic angina) before randomization. All patients had to be appropriate candidates for both elective PCI or CABG. Patients were randomized to undergo either prompt coronary revascularization or medical therapy. The appropriate method of revascularization for each patient (PCI or CABG) was determined a priori by the responsible physician. Approximately one third of patients in the PCI stratum who were assigned to undergo revascularization received a drug eluting stent. The primary end point was death from any cause, and the secondary end point was a composite of death, myocardial infarction, or stroke.
The rates of death from any cause did not differ significantly between the revascularization group and the medical-therapy group. The 5-year survival rate was 88% among patients in the revascularization and medical-therapy groups, with no statistical difference in rates of major cardiovascular events or death. The initial selection process of patients for the CABG stratum resulted in a population of patients with a much greater atherosclerotic burden and more lesions than in the PCI stratum. These patients had more 3-vessel disease (52% versus 20%), more total occlusions (61% versus 32%), more proximal left anterior descending stenosis ≥50% (19% versus 10%), a greater number of nonobstructive and obstructive atherosclerotic and class C lesions [86]. Prompt revascularization significantly reduced major cardiovascular events, as compared with intensive medical therapy, among patients who were selected to undergo CABG largely because of a reduction in MI events, but not among those who were selected to undergo PCI (P=0.002 for the interaction between study-group assignment and intended method of revascularization) [86, 87]. Of the patients who were assigned to receive medical therapy, 42% had changes in their clinical course that led to coronary revascularization during the 5 years of follow up. The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial also showed that percutaneous intervention with optimal medical therapy was no better than optimal medical therapy alone for patients with stable CAD in general and for a subgroup of patients with DM (34% of patients enrolled) [88].
The BARI investigators have identified two mechanisms for the protective effect of CABG in DM. First, there appears to be a strong protective effect with respect to survival in the group of patients with diabetes who sustained a myocardial infarction. The striking reduction in the risk of death after spontaneous Q-wave myocardial infarction in the patients with DM (relative risk, 0.09; 95 percent confidence interval, 0.03–0.29) accounted for about 50% of the overall reduction in mortality attributable to CABG. Second, there was a moderate but constant reduction in mortality throughout follow-up that occurred in the majority of patients with diabetes who remained free of myocardial infarction. These protective effects of CABG may be related to the increased restenosis rates following angioplasty in DM and incomplete revascularization associated with multivessel angioplasty [89, 90]. In the BARI study population, 3.1 grafts were placed per patient undergoing CABG, whereas the mean number of successfully treated lesions in the PTCA group was 2.0 [10]. Together with the high restenosis rate among patients with diabetes, it is likely that a higher proportion of the myocardium remains unprotected and unrevascularized in patients with DM, and a greater proportion of the myocardium becomes ischemic during an acute spontaneous myocardial infarction. The impact of incomplete revascularization may be even more severe owing to new arterial narrowings and coronary artery disease progression [91], more diffuse and distal coronary disease and micro-circulatory dysfunction in DM.
The amount of jeopardized myocardium decreases initially following revascularization and increases subsequently with target lesion restenosis, graft failure, or the development of new narrowings in native vessels. Follow-up angiographic analysis of the BARI patients at years 1 and 5 revealed that the total percentage of jeopardized myocardium, defined as the overall percentage of the coronary perfusion territory compromised by stenoses ≥50%, was higher in patients with diabetes [92]. The mean percentage increase in total jeopardized myocardium was significantly greater in patients with diabetes compared with patients without diabetes at 1-year protocol-directed angiography (42% versus 24%) and on the first clinically performed (unscheduled) angiogram within 30 months (63% versus 50%) but not at 5-year protocol-directed angiography (34% versus 26%). In contrast, among CABG patients, DM was not associated with an increase in jeopardized myocardium at any angiographic follow-up interval. In this context, DM does not seem to affect the patency of internal mammary grafts, or the accelerated atherosclerotic process that characterizes vein grafts [93, 94]. The lower rate of nonfatal myocardial infarction with surgical revascularization observed in BARI-2D [87] is consistent with the hypothesis that, bypass grafts to the mid-coronary vessel treat the culprit lesion and prophylaxes against new proximal disease, progression of proximal narrowing or plaque rupture occurring proximal to a patent graft insertion. Proximal coronary arterial stents, bare metal and drug-eluting, cannot protect against new disease.
Efforts to prevent myocardial infarction and improve long-term survival in patients with diabetes with established CAD should focus primarily on reducing the incidence of acute thrombotic events and the development of ventricular dysfunction. The BARI 2D trial demonstrated that for many patients with DM and CAD, optimal medical therapy rather than any intervention is an excellent first-line strategy, particularly for those with less severe disease. Revascularization can be applied later if drug therapy does not adequately control symptoms without incurring an increased risk of MI or cardiac death [86, 95]. For patients with diabetes with less severe CAD, single-vessel or two-vessel CAD not involving the proximal left anterior descending artery and normal left ventricular function, there is little prognostic benefit from any intervention over optimum medical therapy. In such patients who require intervention after optimization of medical therapy there is no obvious survival advantage for either PCI or CABG, but there is a significantly higher risk of repeat revascularizations with PCI. Although DES reduce restenosis in comparison with bare-metal stents in patients with diabetes [60], DES studies have consistently shown higher repeat revascularization rates after PCI compared with surgical revascularization [83, 96]. Notwithstanding, PCI with DES or BMS is a reasonable approach in these patients (Fig. 1).
The effectiveness of PCI for treated patients with diabetes with asymptomatic ischemia or CCS class I or II angina who have 2- or 3-vessel CAD with significant proximal LAD who are otherwise eligible for CABG is not well established [97, 98]. CABG is superior in terms of survival, recurrent infarctions and freedom from re-intervention for patients with treated DM with moderate to severe symptoms and multivessel CAD in the setting of significant proximal left anterior descending artery involvement, and patients with diabetes with a significant stenosis (≥50%) of the left main coronary artery, [86, 95, 97] (Fig. 1). However, the clinician's judgment on the revascularization strategy remains an important factor.
The clinical management of patients with diabetes and asymptomatic CAD in the face of silent ischemia and the value of coronary revascularization are not clear. Revascularization has not proven beneficial at reducing mortality or major cardiac events for patients with asymptomatic or stable CAD. Indeed, there can be no benefit from relief of angina in asymptomatic patients. Furthermore, in the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study, a prospective randomized trial evaluating outcomes after screening for asymptomatic CAD in type 2 patients with diabetes, cardiac event rates were not significantly reduced by myocardial perfusion imaging screening for myocardial ischemia over 4.8 years [99]. Even moderate or large defects had a cardiac event rate of 2.4% per year and a positive predictive value of just 12% for cardiac events. Finally, the results of on-going randomized trials including FREEDOM [100] and long-term results of the SYNTAX and CARDia trials are awaited to inform us on the long-term comparative efficacy of PCI with DES and CABG in patients with DM.
Insulin therapy converted the acute devastating process that is diabetes mellitus into a chronic disease. Vicissitudes of glucose levels and insulin exposure expose vascular tissues to extremes that exaggerate potent injurious signals and impede repair. The patient with diabetes and CAD is confronted with multiple risks, challenges, and issues as yet unresolved. Angioplasty is less well tolerated and less definitive in patients with diabetes, and full-blown bypass grafting is likely superior to balloon and stent intervention in the face of multi-vessel disease. The benefit and risk of DES in patients with diabetes is not fully defined but likely similarly presents evidence of a potential safety concern. Future studies will define more rigorously the interplay of diabetes mellitus, control of disease and choice of intervention and therapy. Time and scientific investigation will determine if diabetes represents an extreme form of the normal response to vascular intervention or a unique set of processes of its own. For now we must be satisfied in more assiduous control of the endocrinologic abnormalities and more precise vascular intervention.
Elazer R. Edelman is supported in part by a grant from the USA National Institutes of Health (GM 49039).
Doron Aronson, Department of Cardiology, Rambam Medical Center and the Rappaport Research Institute, Technion, Israel Institute of Technology, Haifa, Israel.
Elazer R. Edelman, Harvard–MIT Division of Health Sciences and Technology, and Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Massachusetts Institute of Technology, Cambridge, MA, USA.
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.


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