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Tri-Hydroserpine Side Effects
Generic name: hydralazine / hydrochlorothiazide / reserpine
Medically reviewed by Drugs.com. Last updated on Feb 14, 2023.
Note: This document contains side effect information about hydralazine / hydrochlorothiazide / reserpine. Some dosage forms listed on this page may not apply to the brand name Tri-Hydroserpine.
Applies to hydralazine / hydrochlorothiazide / reserpine: oral tablet.
Because up to 20% of patients who receive 400 mg of hydralazine per day or more develop a systemic lupus erythematosus syndrome, some experts recommend checking a patient's acetylator status before giving higher doses. Up to 70% of "resistant" patients are fast acetylators, in whom the dose can be relatively safely increased.
Data suggest that hydralazine lupus may represent a unique hypersensitivity reaction in which antibodies to native DNA occur. These antibodies are believed to account for the clinical similarities between hydralazine-induced lupus and systemic lupus erythematosus.[Ref]
Immunologic side effects including a lupus-like syndrome have been reported. The lupus syndrome is more likely in patients who receive 400 mg or more of hydralazine per day, in female patients, or in patients who are slow acetylators. Of patients who receive less than 200 mg or 400 mg or more per day of hydralazine, 40% and 50%, respectively, develop a positive ANA titer, and up to 6% and 14%, respectively, develop a lupus-like syndrome.
The lupus syndrome may present as arthralgias (most common), myalgias, lethargy, malaise, a typical erythematous rash, weight loss, or dyspnea. It may also be found incidentally in asymptomatic patients by urinalysis (proteinuria, hematuria), blood chemistry (elevated ESR, antinuclear antibody), or chest X-ray (interstitial lung disease, rare). Hypocomplementemia is an extremely rare finding in hydralazine-induced lupus.
Alternative therapy is recommended for patients who develop the clinical appearance of a lupus syndrome, sustained rises in the antinuclear antibody titer, or the presence of LE cells. The syndrome is reversible, but may take months to years to resolve.
Immunologic side effects associated with reserpine are rare. A single case of angioimmunoblastic lymphadenopathy has been associated with reserpine. In one study of 231 patients, only one case of a lupus-like syndrome was recorded. The patient had previously received hydralazine.[Ref]
Since HCTZ may increase total serum cholesterol by 11%, LDL lipoprotein cholesterol by 12%, VLDL lipoprotein cholesterol levels by 50%, and may reduce insulin secretion, it should be used with caution in diabetic patients and in those with hypercholesterolemia.
Hyperuricemia may be an important consideration in patients with a history of gout. Hypophosphatemia and low serum magnesium concentrations may occur, but are usually clinically insignificant except in malnourished patients.[Ref]
Metabolic side effects are commonly associated with HCTZ, especially when doses greater than 50 mg per day are used. Mild hypokalemia (decrease of 0.5 mEq/L) occurs in up to 50%, and may predispose patients to cardiac arrhythmias. Metabolic alkalosis, hyponatremia, hypomagnesemia, hypercalcemia, hyperglycemia, and elevated serum uric acid levels are also relatively common. HCTZ may increase serum cholesterol.[Ref]
Nervous system
Nervous system side effects commonly associated with reserpine have included sedation, lethargy (different from the psychiatric syndrome of depression), drowsiness, weakness, vertigo, insomnia, or headache in approximately 1% to 5% of patients. Peripheral neuropathy has been associated with hydralazine. This problem is dose-related and is more common in slow acetylators. Headache or dizziness is reported in approximately 5% of patients who are taking hydralazine alone. Rare cases of cerebrovascular insufficiency have been associated with HCTZ-induced plasma volume contraction.[Ref]
Hydralazine-associated peripheral neuropathy usually first presents as paresthesias, numbness, and tingling in the extremities. It is probably the result of pyridoxine deficiency, perhaps because formation of a pyridoxal-hydralazine complex inactivates the coenzyme, and can, therefore, be treated by administration of pyridoxine.
While reserpine is used to treat tardive dyskinesia, extrapyramidal movements may worsen upon withdrawal of therapy. A case of CNS hypertension, believed to be due to cerebral edema, has been associated with reserpine. Increased parkinsonian movements upon reserpine withdrawal (as with neuroleptics) may be due to supersensitivity to dopamine as a result of increased dopamine receptors that developed during reserpine therapy.[Ref]
Hypersensitivity reactions to HCTZ, manifest as nausea, vomiting, diarrhea, and rash, are reported in less than 1% of patients. Cases of acute pulmonary edema, interstitial cystitis, interstitial nephritis, and anaphylaxis have been associated with HCTZ or other thiazide diuretics. Hypersensitivity reactions to hydralazine are rare, presenting as hepatitis, retroperitoneal fibrosis, or occupational asthma.[Ref]
A 44-year-old woman with hypertension and acute sinusitis developed acute renal failure, edema, and a generalized maculopapular erythematous rash during therapy with ampicillin, HCTZ, and hydralazine. A complete evaluation revealed bilateral hydronephrosis and hydroureters secondary to ureteral obstruction due to retroperitoneal fibrosis. Renal function returned to baseline after oral prednisone therapy. It is unclear whether this problem was due to one or more of her medications.
A 68-year-old man with a history of myocardial infarction (MI) developed dyspnea, chest tightness, a low grade fever, dizziness, sweating, and vomiting associated with cyanosis, a mild leukocytosis, radiographic evidence of pulmonary edema, clinical evidence of hypovolemia, and respiratory acidosis.
MI and infection were ruled out; the patient recovered after restoration of his intravascular volume with saline and albumin. The only precipitating factor per history was the ingestion of HCTZ, which the patient had taken without incident for two years. Rechallenge resulted in recurrent acute pulmonary edema. Other signs of hypersensitivity, such as rash or eosinophilia, were absent.[Ref]
Provocation of ischemia in patients with compromised left ventricular systolic function may be due to the inability of hydralazine to decrease preload or left ventricular filling pressures. Thus, in heart failure patients, hydralazine is often administered with a venous vasodilator such a nitrate.
The mechanism of increased pulmonary hypertension (PH) associated with hydralazine in patients with PH or COPD is a decrease of systemic vascular resistance accompanied by an increase in cardiac output without a fall in the pulmonary vascular resistance. Hydralazine-induced ventilation/perfusion mismatching with associated hypoxemia may also contribute to increased PH.
In case reports and small series of patients, the use of hydralazine in such patients resulted in palpitations, chest tightness, unchanged pulmonary vascular resistance, increased pulmonary artery pressure, decreased systemic vascular resistance, and increased heart rate and cardiac output. For this reason, if hydralazine must be used, many experts recommend hemodynamic monitoring during hydralazine therapy in such patients.
Rare cases of sinus pauses and profound hypotension during reserpine therapy have been reported. Reserpine is known to increase vagal tone and to deplete cardiac catecholamines.[Ref]
Cardiovascular side effects can occur as a result of all three drugs in this combination product, which makes it a poor choice for the treatment of hypertension in the elderly or in patients with angina pectoris. By causing peripheral vasodilation and reflex tachycardia, palpitations, flushing, edema, or chest pain have been reported in up to 5% of patients who are taking hydralazine alone. The risk of hypotension or orthostatic changes is increased with the addition of reserpine and HCTZ. Reflexive tachycardia may be blunted by reserpine, which can cause bradycardia (and rare cases of syncope with bradycardia) in 3% of patients. The use of hydralazine in patients with severe chronic heart failure has rarely been associated with ischemia, including episodes of myocardial infarction.
In patients with pulmonary hypertension (PH) and chronic obstructive pulmonary disease (COPD), hydralazine may increase pulmonary artery hypertension, especially during periods of hypoxia. The use of hydralazine in these patients may, on rare occasions, result in profound hypotension, tachycardia, and even death.
Rare cases of bradycardia or cardiac tamponade have been associated with hydralazine-induced lupus.
Cardiac arrhythmias, including ventricular ectopy and complete AV heart block, have been associated with HCTZ-induced hypokalemia and hyponatremia.[Ref]
The depressive syndrome associated with reserpine usually consists of melancholy, loss of self confidence, early morning awakening, loss of libido, and reduced appetite.
A case of reserpine withdrawal psychosis has been reported. This uncommon condition may be due to dopamine receptor supersensitivity, which may develop during reserpine therapy.[Ref]
Psychiatric problems related to reserpine therapy can be serious. Depression occurs in 2% to 28% of patients, is more likely when daily doses exceed 0.5 mg, and can present at any time during therapy. Suicidal ideation has been reported. Reserpine-induced depression is quickly reversible if therapy is withdrawn as soon as the syndrome is recognized, but can persist for several months after drug discontinuation if the syndrome fully develops. Reserpine withdrawal psychosis has been reported.[Ref]
Dermatologic reactions to HCTZ are rare, and include erythema annular centrifugum, acute eczematous dermatitis, and morbilliform and leukocytoclastic vasculitis. Thiazides may induce phototoxic dermatitis. In addition, a rare, distinct entity with clinical and laboratory features indistinguishable from those of subacute cutaneous lupus erythematosus has been associated with HCTZ. The hydralazine-induced lupus-like syndrome can include cutaneous vasculitis. A generalized, pruritic rash without evidence of lupus has also been associated with hydralazine. Two cases of Sweet's syndrome (neutrophilic dermatosis) have been associated with hydralazine.[Ref]
A 65-year-old man with ischemic cardiomyopathy developed a pruritic, erythematous, generalized rash within two months after beginning hydralazine (200 mg per day) therapy. There were no clinical or laboratory signs of lupus. The rash persisted upon gradual withdrawal of the patient's other medications, but cleared only after discontinuation of hydralazine. Rechallenge resulted in a recurrent pruritic rash.
A 67-year-old white woman with hypothyroidism, hypercalcemia, depression, and hypertension developed facial erythema, headaches, tremors, confusion, personality changes, and positive ANA and anti-nRNP titers while taking HCTZ, levothyroxine, and amitriptyline. A skin biopsy was consistent with lupus erythematosus. Her rash resolved upon discontinuation of HCTZ, but she later developed a higher ANA titer associated with symptomatic diffuse interstitial pulmonary infiltrates. She was successfully treated with corticosteroids.[Ref]
A 48-year-old woman with hypertension developed dyspnea, hemoptysis, pleurisy, proteinuria, and hematuria one year after beginning hydralazine (150 mg per day), polythiazide, and atenolol therapy. Other associated findings included an elevated ESR, antinuclear factor, anti-DNA titer, a positive LE test, and radiographic findings of diffuse interstitial lung disease. Two weeks after stopping hydralazine, the signs and symptoms of lupus with pulmonary involvement disappeared.
Rare reports of reserpine-induced bronchospasm are believed to be due to inactivation of beta-adrenergic receptors, which can result in a marked potentiation of the bronchoconstrictive effect of histamine.[Ref]
Respiratory system side effect have included nasal congestion, occurring in 3% to 8% of patients who are taking either reserpine or hydralazine. Rare cases of bronchospasm (reserpine), "hydralazine lung" (hydralazine-induced lupus), and acute noncardiogenic pulmonary edema (HCTZ) have been reported.[Ref]
Gastrointestinal side effects due to unopposed parasympathetic activity produced by catecholamine depletion may result in increased gastrointestinal motility and secretory activity. Because of this, new diarrhea or worsening of existing diarrhea or increased salivation have been reported in 2% of patients who were taking reserpine alone. Rare gastrointestinal complaints include increased appetite, abdominal pain, or vomiting. Rare cases of acute pancreatitis and acute cholecystitis have been associated with thiazide diuretics.[Ref]
Thiazide diuretics may increase serum cholesterol and triglycerides, resulting in increased risk of cholesterol gallstone formation. Reports of bowel strictures associated with thiazide ingestion have been reported in the 1960's, although these patients were on a combination HCTZ-potassium product.[Ref]
In one study, rapidly progressive glomerulonephritis (RPGN) was described in 4 of 444 patients, all of whom were men who were treated for 5 to 11 years with daily hydralazine doses of 100 to 250 mg. In three of the four cases, biopsy revealed a focal and segmental glomerular necrosis with crescents and positive immunofluorescence. The antinuclear antibody titer became positive in three. Renal function improved in all but one after the withdrawal of hydralazine and institution of corticosteroid therapy. A number of other cases of RPGN have been reported. It appears to be far more common in patients who are slow acetylators.
Although HCTZ has been used to treat nephrogenic diabetes insipidus, a case in which the drug was believed to have caused this condition has been reported.[Ref]
Renal side effects including new or worsened renal insufficiency may occur due to HCTZ-induced intravascular volume depletion. Rare cases of interstitial nephritis have been associated with HCTZ. While renal side effects are common in idiopathic systemic lupus erythematosus, immune complex glomerulonephritis is rare in drug-induced lupus. Rare cases of rapidly progressive and focal glomerulonephritis associated with the hydralazine-induced lupus syndrome have often been accompanied by anemia, a positive anti-DNA antibody titer, and a positive ANA titer.[Ref]
There are rare case reports of HCTZ-induced immune hemolytic anemia. The following illustrates a fatal case:
A 53-year-old man with hypertension developed nausea, vomiting, diarrhea, and progressive anorexia and weakness associated with scleral icterus, anemia with spherocytosis, dark red urine with proteinuria, bilirubinuria, and hemoglobinuria, and elevated lactic dehydrogenase levels 18 months after beginning HCTZ and methyldopa. Haptoglobin was less than 50 mg per dl. Direct and indirect Coombs' tests were positive. The patient died suddenly; autopsy revealed left ventricular hypertrophy and mild coronary atherosclerosis, but no obvious cause of death.
A 71-year-old man with hypertension developed anorexia, weight loss, petechiae, and a microcytic anemia during therapy with hydralazine and oxprenolol. Evaluation for iron deficiency, hemolysis, or marrow depression was negative. The patient was found to have fecal blood loss, anti-DNA antibodies, decreased complement levels, a normal upper GI series, and biopsy-proven vasculitis. The syndrome resolved within two weeks after discontinuation of hydralazine.[Ref]
Hematologic abnormalities have been associated with the hydralazine-induced lupus-like syndrome. Anemia may be caused by one of at least four hydralazine-associated problems: hemolysis, the formation of a circulating anticoagulant, thrombocytopenia, and vasculitis. Rare cases of leukopenia and agranulocytosis have been associated with hydralazine, and rare cases of immune-complex hemolytic anemia, aplastic anemia, and thrombocytopenia have been associated with HCTZ.[Ref]
Genitourinary complaints have been limited to impotence, reported in approximately 5% of male patients.[Ref]
At least two cases of male impotence associated with hydralazine have been reported. The mechanism is unclear. There was no evidence of a neuropathy in either case.[Ref]
A prospective study of 34 patients who received oral thiazide diuretics for 14 years without interruption revealed an increased mean fasting blood glucose level after treatment. Withdrawal of thiazide therapy for 7 months in 10 of the patients resulted in mean reductions of 10% in fasting blood glucose and 25% in the 2-hour glucose tolerance test values. A control group was not reported.[Ref]
Endocrinologic problems associated with thiazide diuretics include glucose intolerance and a potentially deleterious effect on the lipid profile. This may be important in some patients with or who are at risk for diabetes or coronary artery disease. Reserpine can cause elevation of serum prolactin levels. This can result in gynecomastia in men or breast engorgement or pseudolactation in women.[Ref]
A 59-year-old woman with hypertension and cholecystic gallbladder disease developed abdominal pain, nausea, vomiting, and painful hepatomegaly associated with elevated serum transaminases, direct hyperbilirubinemia, and liver biopsy findings of subacute hepatitis (with bridging necrosis) within two days after hydralazine was added to her medical regimen. The signs and symptoms of hepatitis resolved after all medications were withheld, but returned upon rechallenge with hydralazine.[Ref]
Hepatic reactions are rare. Less than ten cases of hepatitis have been associated with hydralazine, many of which are believed to be due to hypersensitivity. Histologic findings include hepatocellular, cholestatic, mixed hepatocellular-cholestatic, and granulomatous patterns.[Ref]
Musculoskeletal cramps have occasionally been reported during HCTZ-induced diuresis.[Ref]
Oncologic concerns were raised after a large drug surveillance center in Boston reported an association between reserpine, a stimulator of prolactin, and breast cancer in 1974. These data were partially, but not completely, confirmed in two similar centers in Europe. A critical review of the these studies elucidated several design flaws. Subsequent, controlled studies failed to show an association between reserpine and an increased incidence of breast carcinoma.[Ref]
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94. Levay ID "Hydrochlorothiazide-induced pulmonary edema." Drug Intell Clin Pharm 18 (1984): 238-9
95. Goette DK, Beatrice E "Erythema annulare centrifugum caused by hydrochlorothiazide-induced interstitial nephritis." Int J Dermatol 27 (1988): 129-30
96. Alted E, Navarro M, Cantalapiedra JA, Alvarez JA, Blasco MA, Nunez A "Non-cardiogenic pulmonary edema after oral ingestion of hydrochlorothiazide ." Intensive Care Med 13 (1987): 364-5
97. Grunwald MH, Halevy S, Livni E "Allergic vasculitis induced by hydrochlorothiazide: confirmation by mast cell degranulation test." Isr J Med Sci 25 (1989): 572-4
98. Miller AJ, Abrams DL, Kaplan BM "Persistent reversal of severe systemic hypertension after prolonged toxic reaction to hydralazine." Cardiology 60 (1975): 251-6
99. Laslett LJ, DeMaria AN, Amsterdam EA, Mason DT "Hydralazine-induced tachycardia and sodium retention in heart failure: hemodynamic and symptomatic correlation by prazosin therapy." Arch Intern Med 138 (1978): 819-20
100. Wehner RJ, Romanauskas VS "An adverse reaction with hydralazine: a case study." AANA J June (1981): 274-5
101. Packer M, Meller J, Medina N, et al. "Provocation of myocardial ischemic events during initiation of vasodilator therapy for severe chronic heart failure." Am J Cardiol 48 (1981): 939-46
102. Packer M, Greenberg B, Massie B, Dash H "Deleterious effects of hydralazine in patients with pulmonary hypertension." N Engl J Med 306 (1982): 1326-31
103. Kronzon I, Cohen M, Winer HE "Adverse effect of hydralazine in patients with primary pulmonary hypertension." JAMA 247 (1982): 3112-4
104. Tuxen DV, Powles AC, Mathur PN, et al. "Detrimental effects of hydralazine in patients with chronic air-flow obstruction and pulmonary hypertension." Am Rev Respir Dis 129 (1984): 388-95
105. Keller CA, Shepard JW, Chun DS, et al. "Effects of hydralazine on hemodynamics, ventilation, and gas exchange in patients with chronic obstructive pulmonary disease and pulmonary hypertension." Am Rev Respir Dis 129 (1984): 606-11
106. Williams LL, Lopez LM, Thorman AD, et al. "Plasma lipid profiles and antihypertensive agents: effects of lisinopril, enalapril, nitrendipine, hydralazine, and hydrochlorothiazide." Drug Intell Clin Pharm 22 (1988): 546-50
107. Hammond TG, Mosesson MW "Fatal small-bowel necrosis and pulmonary hypertension in sickle cell disease." Arch Intern Med 149 (1989): 447-8
108. Lodeiro JG, Feinstein SJ, Lodeiro SB "Fetal premature atrial contractions associated with hydralazine." Am J Obstet Gynecol 160 (1989): 105-7
109. Aylward PE, Tonkin AM "Cardiac tamponade in hydrallazine-induced systemic lupus erythematosus." Aust N Z J Med 12 (1982): 546
110. Sharon E, Paolino JS, Kaplan D "Hematemesis after reserpine for Raynaud's phenomenon." Ann Intern Med 77 (1972): 479-80
111. Widmer RB "Reserpine: the maligned antihypertensive drug." J Fam Pract 20 (1985): 81-3
112. Combs RM "Unusual response to reserpine in paroxysmal atrial tachycardia with block unassociated with digitalis." South Med J 60 (1967): 839-42
113. Freis ED "Reserpine in hypertension: present status." Am Fam Physician 11 (1975): 120-2
114. Fleishman M "Letter: Reserpine, ECT, and depression." Am J Psychiatry 132 (1975): 1088
115. Lewis WH "Iatrogenic psychotic depressive reaction in hypertensive patients." Am J Psychiatry 127 (1971): 1416-7
116. Blumenthal M, Davis R, Doe RP "Carcinoid syndrome following reserpine therapy in thyrotoxicosis." Arch Intern Med 116 (1965): 819-23
117. Kent TA, Wilber RD "Reserpine withdrawal psychosis: the possible role of denervation supersensitivity of receptors." J Nerv Ment Dis 170 (1982): 502-4
118. Samuels AH, Taylor AJ "Reserpine withdrawal psychosis." Aust N Z J Psychiatry 23 (1989): 129-30
119. Ambrosino SV "Depressive reactions associated with reserpine." N Y State J Med 74 (1974): 860-4
120. Diffey BL, Langtry J "Phototoxic potential of thiazide diuretics in normal subjects." Arch Dermatol 125 (1989): 1355-8
121. Robinson HN, Morison WL, Hood AF "Thiazide diuretic therapy and chronic photosensitivity." Arch Dermatol 121 (1985): 522-4
122. Parodi A, Romagnoli M, Rebora A "Subacute cutaneous lupus erythematosus-like eruption caused by hydrochlorothiazide." Photodermatol 6 (1989): 100-2
123. Goodrich AL, Kohn SR "Hydrochlorothiazide-induced lupus erythematosus: a new variant?" J Am Acad Dermatol 28 (1993): 1001-2
124. Segal MS "Bronchospasm after reserpine." N Engl J Med 281 (1969): 1426-7
125. Atuk NO, Owen JA, Jr "Bronchospasm after reserpine." N Engl J Med 281 (1969): 908-9
126. Diamond L "Drug-induced bronchospasm." J Clin Pharmacol J New Drugs 10 (1970): 215-6
127. Dillon PT, Babe J, Meloni CR, Canary JJ "Reserpine in thyrotoxic crisis." N Engl J Med 283 (1970): 1020-3
128. Dietz MW "Iatrogenic jejunal ulcer." Am J Roentgenol Radium Ther Nucl Med 99 (1967): 136-8
129. Reinus FZ, Weinberger HA, Fischer WW "Medication-induced ulceration of the small bowel." Am J Surg 112 (1966): 97-101
130. Wagner W, Longerbeam JK, Smith LL, Feikes HL "Drug-induced ulcers of the small bowel causing intestinal obstruction or perforation." Am Surg 33 (1967): 7-11
131. Campbell JR, Knapp RW "Small bowel ulceration associated with thiazide and potassium therapy: review of 13 cases." Ann Surg 163 (1966): 291-6
132. Smith BL, Tedeschi A, Lane CD "Pancreatitis with a twist." Hosp Pract (Off Ed) 23 (1988): 150,
133. Holland GW "Stenosing ulcers of the small bowel associated with thiazide and potassium therapy." N Z Med J 64 (1965): 383-5
134. Delevett AF, Recalde M "Diuretic-induced renal colic." JAMA 225 (1973): 992
135. Orenstein AA, Yakulis V, Eipe J, Costea N "Immune hemolysis due to hydralazine." Ann Intern Med 86 (1977): 450-1
136. Widerlov E, Karlman I, Storsater J "Hydralazine-induced neonatal thrombocytopenia." N Engl J Med 303 (1980): 1235
137. Macleod WN "Anaemia in the hydrallazine-induced lupus syndrome." Scott Med J 28 (1983): 181-2
138. Garratty G, Houston M, Petz LD, Webb M "Acute immune intravascular hemolysis due to hydrochlorothiazide." Am J Clin Pathol 76 (1981): 73-8
139. Eisner EV, Crowell EB "Hydrochlorothiazide-dependent thrombocytopenia due to IgM antibody." JAMA 215 (1971): 480-2
140. Keidan H "Impotence during antihypertensive treatment." Can Med Assoc J 114 (1976): 874
141. Balizet L "Recurrent parathyroid adenoma. Association with prolonged thiazide administration." JAMA 225 (1973): 1238-9
142. Jori GP, Peschle C "Hydralazine disease associated with transient granulomas in the liver." Gastroenterology 64 (1973): 1163-7
143. Bartoli E, Massarelli G, Solinas A, et al. "Acute hepatitis with bridging necrosis due to hydralazine intake." Arch Intern Med 139 (1979): 698-9
144. Forster HS "Hepatitis from hydralazine." N Engl J Med 303 (1980): 1362
145. Itoh S, Yamaba Y, Ichinoe A, Tsukada Y "Hydralazine-induced liver injury." Dig Dis Sci 25 (1980): 884-7
146. Barnett DB, Hudson SA, Golightly PW "Hydralazine-induced hepatitis." Br Med J 05/10/80 (1980): 1165-6
147. Stewart GW, Peart WS, Boylston AW "Obstructive jaundice, pancytopenia and hydralazine." Lancet 05/30/81 (1981): 1207
148. Rice D, Burdick CO "Granulomatous hepatitis from hydralazine therapy." Arch Intern Med 143 (1983): 1077
149. Myers JL, Augur NA "Hydralazine-induced cholangitis." Gastroenterology 87 (1984): 1185-8
150. Mack TM, Henderson BE, Gerkins VR, et al. "Reserpine and breast cancer in a retirement community." N Engl J Med 292 (1975): 1366-71
151. Kodlin D, McCarthy N "Reserpine and breast cancer." Cancer 41 (1978): 761-8
152. Curb JD, Hardy RJ, Labarthe DR, Borhani NO, Taylor JO "Reserpine and breast cancer in the Hypertension Detection and Follow- Up Program." Hypertension 4 (1982): 307-11
153. Labarthe DR, O'Fallon WM "Reserpine and breast cancer. A community-based longitudinal study of 2,000 hypertensive women." JAMA 243 (1980): 2304-10
154. Jick H "Editorial: Reserpine and breast cancer: a perspective." JAMA 233 (1975): 896-7
155. Newball HH, Byar DP "Does reserpine increase prolactin and exacerbate cancer of prostate? Case control study." Urology 2 (1973): 525-9
Further information
Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.
Some side effects may not be reported. You may report them to the FDA.


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Coustou ko͞osto͞o´ [key], family of French sculptors.
Nicolas Coustou, 1658–1733, studied with his uncle, Antoine Coysevox, with whom he later collaborated on the decorations at Marly and at Versailles. He became rector and chancellor of the Académie royale. Among his best-known works are La Seine et la Marne (Tuileries Gardens) and the bas-relief, Passage du Rhin (Louvre). His brother, Guillaume Coustou, 1677–1746, also studied with Coysevox and in Rome. Returning to Paris, he worked at Versailles and at Marly. He is famous for his colossal group, The Ocean and the Mediterranean, at Marly, and above all for his exuberant Horses of Marly at the entrance of the Champs Élysées, Paris. His son Guillaume Coustou, the younger, 1716–77, was also a noted sculptor.
The Columbia Electronic Encyclopedia, 6th ed. Copyright © 2023, Columbia University Press. All rights reserved.
See more Encyclopedia articles on: European Art, 1600 to the Present: Biographies

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Rattlesnake Motodrome
Rattlesnake Motordrome is a 1/4 mile clay track in Rumney, NH. Operated in the past as Legion Speedway and The Pines Speedway, the track is now managed by Jason MacCalister and features a weekly show on Saturday nights with several classes of cars including visits from the Granite Sate Mini Sprinters and SCoNE sprint cars. Motor cycle and 4-wheeler events are also scheduled.Read More


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The Rights of Maritime Workers
Most countries are experiencing an increased demand for maritime workers. Some people fear to take training that will lead them to maritime jobs. Workers in the maritime industry are exposed to a large number of risks. Understanding the rights of the workers can help to reduce fear among learners to take out the maritime courses. Workers get to have peace of mind with a proper understanding of their rights within the maritime jobs. People can create interest with maritime jobs by reading maritime worker injuries to get a proper understanding of their rights enabling them to have peace of mind.
Individuals working in the maritime industry are protected certain laws. People injured within the workplace due to the negligence of other individuals are entitled to compensation according to Jones act. The workers should be compensated for medical expenses. Pain and suffering of the workers are among the issues that need to be compensated. Present and future loss of wages need to be compensated. The workers should visit maritime worker injuries learn about other losses which need to be compensated. Employers need to have proper understanding of the employee rights to avoid financial losses.
Employers are liable for ensuring the safety of the equipment and proper working conditions. Workers should be trained on the requirements for the given positions. The companies are liable in case of assault of the employees by their co-workers. Proper working conditions is a necessity for the maritime workers. The warning signs should be properly placed for visibility by the workers. Companies should consider maritime worker injuries to understand their responsibilities in ensuring employee safety. Overtime resulting in fatigue calls for compensation of the employees.
The cure and maintenance require employees to get compensation regardless of the incidents in which the accident occurred as long as it's within their duties. Rent and food of the injured are covered according to maintenance and cure. Marine workers dealing with navigable Waters are entitled to compensation according to the Longshore and harbor workers policies. In case of disabilities, the employees are entitled to compensation. In case of death the dependents such as spouses and children should be compensated according to maritime worker injuries.
In case of accidents the maritime workers should be aware of the right procedures to follow for their compensation. Experienced maritime attorneys are of great importance for the workers to achieve their compensation in case of accidents within their duties. Information regarding the right procedures for the maritime to get compensated can be acquired from maritime worker injuries. Employee should give priority to reputable maritime attorneys.


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An abundance of information about visitors to your site can be recorded with your Web server software. Even the simplest site logs track how many people (unique visitors) saw your site over a given time, how many pages were requested for viewing, and many other variables. By analyzing the server logs for your Web site you can develop quantitative data on the success of your site. The logs will tell you what pages were the most popular and what brands and versions of Web browser people used to view your site. Server logs can also give you information on the geographic location of your site readers. The usefulness of your site logs will depend on what you ask of the server and the people who maintain the server. Detailed logs are the key to quantifying the success of a Web site. Your Webmaster should archive all site logs for long-term analysis and should be prepared to add or change the information categories being logged as your needs and interests change.
A number of popular software packages are designed to produce easily readable site traffic reports, complete with data graphics and charts to aid
in data analysis. As a service to customers, site hosting companies often offer reports from popular site analysis programs like WebTrends, often
free of charge. Before contracting with an Internet Service Provider (ISP) for site hosting services, always ask about site analysis services. If your ISP or corporate Web site does not offer a good site traffic analysis package, ask whether the Webmaster can give you access to a monthly server log of your account. Basic versions of traffic analysis programs like WebTrends cost about three hundred dollars, and you can run them on a personal computer if you can gain access to the raw Web server log from your ISP or corporate Webmaster.
Don't abandon your site once the production "goes live" and the parties are over. The aesthetic and functional aspects of a large Web site need constant attention and grooming, particularly if a group of individuals shares responsibility for updating content. Someone will need to be responsible for coordinating and vetting the new content stream, maintaining the graphic and editorial standards, and assuring that the programming and linkages of all pages remain intact and functional. Links on the Web are perishable, and you'll need to check periodically that links to pages outside your immediate site are still working. Don't let your site go stale by starving it of resources just as you begin to develop an audience if you disappoint them by not following through it will be doubly difficult to attract them back.
The site editor should be sure that the Web site is regularly backed up onto a secure and reliable storage medium to ensure that a catastrophic hardware failure in your Web server does not wipe out your Web site. Most Web servers maintained by information technology professionals or commercial Web service providers are backed up at least once a day. If you don't know what your particular backup schedule is, ask your Webmaster or Web services vendor. Human error is the most common reason you may want quick access to a backup copy of your Web site. Unfortunately, it's easy to accidentally overwrite an old file (or a whole directory of files) over a newer version on the Web server, to delete something important in error, or to inadvertently wipe out someone else's work when updating a Web site. A recent backup (ideally no more than twenty-four hours old) can often be a lifesaver in correcting a mistake.
If your site is successful, it will quickly become an important record of your enterprise's work, your accomplishments, and a valuable record of the "state of things" as the site evolves over time. Unfortunately, too little attention is paid to this aspect of Web sites, and we are collectively losing huge pieces of our history because no one thinks about preserving permanent records of a Web site. Unless your Web site is prohibitively large, your Web site editor could arrange to collect and store the files of the site periodically or contract with your Web service provider to set aside a backup version at regular intervals so that it can be stored for long-term use. We take for granted the "paper trail" of history left by conventional business and work practices. Without a plan for preserving our digital works, our collective history may vanish without a trace.
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Empty lifeboat from missing vessel found in Mass.
Still no sign of the Foxy Lady II or its two-member crew from Maine
The Coast Guard says a lifeboat belonging to a missing Gloucester-based fishing vessel has been found in a marshy area of the Saugus River.
But there's still no sign of the Foxy Lady II or its two-member crew from Maine. The 45-foot scalloper set off on Saturday for a day trip and was scheduled to return that evening.
Officials say the empty rescue pod was noticed by a Saugus resident on Tuesday.
The Coast Guard has been searching an area covering 360 square miles off the Massachusetts coast since the girlfriend of the captain, Wally Gray, Jr., reported the vessel missing on Monday.
Gray and his crewmember, 50-year-old Wayne Young, are both from Deer Isle, Maine.
The Coast Guard says it did not receive a distress signal from the boat and plans to continue the search.


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Prosecutors have filed lawsuits seeking to keep more than $3.4 million seized during police raids last fall at about two dozen Mexican restaurants across Indiana.
Civil forfeiture lawsuits have been filed in Tippecanoe and Marion counties, accusing the restaurant owners and others involved with the businesses of illegally obtaining the money.
The Tippecanoe County lawsuit accuses at least 25 restaurants of carrying out offenses including money laundering and falsifying tax documents. It doesn't detail the allegations.
No criminal charges have been filed stemming from the November raids and the investigation continues, Tippecanoe County Prosecutor Pat Harrington told the Journal & Courier.
The raids involved several El Rodeo restaurants in the Lafayette, Indianapolis and Richmond areas, along with restaurants under the El Jaripeo, Los Toros or La Carreta names around Indianapolis, northwestern Indiana and Vincennes in southwestern Indiana.
The Associated Press left a message Wednesday seeking comment from Richard Kiefer, an Indianapolis attorney for the restaurants.
Jose Bustos, manager of the El Rodeo restaurant in West Lafayette, is named as one of the individual defendants. He said he wasn't aware the lawsuits had been filed.
"I don't have any comments right now because our lawyers are still working on it. They don't tell us anything," Bustos told the Journal & Courier.
State Attorney General Greg Zoeller said that to win the civil forfeiture case, prosecutors must prove that the money was obtained illegally.
"The object of civil forfeiture is to take away the ill-gotten gains and put [the assets] into the criminal justice system," he said.
The lawsuit also asks that the defendants be ordered to give up any interests in the named restaurants and that the owners be prevented from reorganizing their businesses.
The suit seeks the revocation of any professional licenses the defendants obtained from the state.


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Don't have an account yet? Register yourself now and be a part of our community!
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Please enter the letters that are displayed in the picture below (letters are not case-sensitive). If you cannot identify the captcha even after reloading it, please contact the administrator.


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Yes! The only limitation is finding available time slots that work for both you and your trainer.
This varies from time to time depending on demand. You can see our class schedule here.
That depends on the type of membership you have. If you have a month-to-month type you can cancel at anytime. If you have a discounted annual commitment membership, you cannot cancel until your annual contract term expires.
Absolutely! We have superb nutrition and habit coaching systems that are unmatched.
We offer discounted memberships for children of our members.
No, we do not offer child care.
gave us astar review
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Best gym ever! Nicki always makes me feel so comfortable while I am there and is always more than helpful�
Never in a million years did I imagine myself enjoying a gym! I love the classes at the Pink Gym! The people, the instructors, the workouts! Starting a gym membership can me intimidating and scary, but rest assured the ladies in the Pink Gym will make you feel so comfortable! I'm a big girl, I've been going to the gym for almost two years. I have never felt ashamed, unwelcomed, or the worst….intimidated by others who are "skinny" or more fit than myself. If you're looking for a place to start, this is it!! You CAN do it and these ladies will help! 💖. I'm so thankful I started! I appreciate you guys more than you will EVER know!!!
the best gym ever! great equipment! clean and safe environment!
Love this ladies only gym! Love that I can go anytime I want~lots of exercise machines & free weights to use! And it's just down the street from me...so I can't walk down!���♀
the awesome atmosphere!!! the people are just sweet as can be plus you can go any time! I really can't say enough good things about the pink gym!
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The staff is very welcoming ! Love the workouts of the day!
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I love spin class and step class! Always a great workout!
if I want to have a good workout u want to come here the women there r so awesome and they help out each other this place is the best ever
So glad I got myself back in there! The new system they have is so awesome. You always know what level of training you're in. Love it!
Awesome gym with great equipment and it's LADIES only!
I love the way I feel every day I get to work out again. I'm not where I want to be but I'll get there again with the help of Nicki and my friends! ❤❤
The best gym in all of Arkansas. The trainers really know their stuff and will work with you to become familiar with the gym! I am so thankful that our...
Awesome ladies-only gym with a chic, pink aesthetic that's unlike anything you've ever seen!
Wonderful atmosphere and great staff members.
very energetic vibes, lots of machines to use, just a great atmosphere.
Im proud of my cousin for opening the gym and also im proud of the fact that olivia is involved also that is awsome and when i come home to vist i foraure what to check it out but you got to get a punching bag cant have a gym with out one lol
Everyone is very uplifting. They help you in any way needed. Nicki and crew motivate me and I love them for it!!!
Love this gym. Glad to be back.
All the women are very helpful and encouraging ‼
Amazing gym! Super clean, very nice new equipment. We love it!
Such a great atmosphere for ladies of all ages! Nicki and her entire team work so hard to make the Pink Gym a place where you WANT to come and be a part! �
Ladies, this gym has it all.. from top notch equipment to awesome class opportunities and encouraging, non-judgmental, welcoming staff AND members. Not only am I able to better myself here but I've also made some incredible friends.
Super friendly atmosphere with lots of different class options and workouts to chose from.
I absolutely love going to the Pink Gym! What an awesome workout facility for women of all ages!
Everyone is so friendly and helpful. It's a great place to work out!
Love that I can go whenever it's convenient for me
Love this gym! Was skeptical about going and put it off for months, but decided that I needed to do something and so glad I did.


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Judge Paul L. Friedman of the U.S. District Court for the District of Columbia ruled on Wednesday in Halbig v. Sebelius that people who sign up for health insurance on federal exchanges in 34 states can get subsidies, disappointing those who thought that the courts would strike down the subsidies.
Despite the ruling, it seems clear that the Affordable Care Act is not working as intended. If the courts do not change it, it will surely need to be changed by Congress because of voter dissatisfaction. Enrollment is low, and only a quarter of enrollees are young people whose premiums are needed to subsidize the old and sick. When people get through on the website, many are finding that premiums and deductibles are higher than before, and that they do not have access to the doctors they saw previously.
The plaintiffs in Halbig v. Sebelius will no doubt appeal the ruling to the U.S. Court of Appeals for the D.C. Circuit. The verdict may well depend on which judges hear the case. In November, Senate Majority Leader Harry Reid and Senate Democrats eliminated filibusters for most judges and political appointees, allowing confirmation by a simple majority of 51 rather than 60 votes.
This allowed the Senate to confirm three new Obama appointees to the D.C. Circuit. Judges Patricia Millett and Cornelia Pillard were confirmed in December, and Robert Wilkins was confirmed on Monday.
Halbig v Sebelius was brought because under the letter of the Affordable Care Act, subsidies for insurance premiums are only available for state health insurance exchanges, not the 34 federal exchanges. But through regulation the Internal Revenue Service has extended subsidies to federal exchanges too.
Even though Halbig referred to 34 federally run exchanges, the final number this fall turned out to be 36, because several states could not fully qualify for administering their exchanges.
Judge Friedman sided with the government, ruling that Congress intended the subsidies to apply to federal exchanges, even though the letter of the law reads differently.
He writes, "In sum, while there is more than one plausible reading of the challenged phrase in Section 36B [i.e. the insurance subsidy on federal exchanges] when viewed in isolation, the cross-referenced sections, the surrounding provisions, and the ACA's structure and purpose all evince Congress's intent to make premium tax credits available on both state-run and federally-facilitated Exchanges."
Later this month, Judge James R. Spencer of the U.S. District Court for the Eastern Division of Virginia (Richmond) is expected to rule on the same challenge from another group of plaintiffs. Spencer's ruling, whoever wins, will also be appealed.
The implications of the case are immense. Since health insurance plans are costly, people on the federally run exchanges need subsidies to purchase them. If they do not qualify for subsidies, few will be able sign up.
Still, if the Affordable Care Act does not fail because of flaws in the law, it will likely be changed by Congress due to voter pressure. Already, the administration is delaying implementation of certain parts of the law because it is unworkable.
When Halbig v. Sebelius was filed in May 2013, the exchanges were not yet open for business. House Minority Leader Nancy Pelosi, then House Speaker, famously said in March 2010, "But we have to pass the bill so that you can find out what is in it." She was wrong: Americans have to experience Obamacare to know what is in it, and they do not appear to like what they are experiencing.
Implementation of the Affordable Care Act appears to have six major problems.
People are not signing up
A new report released this week showed that only 2.2 million people enrolled for plans in the exchanges in October through December, compared to a forecast of 7 million. Of those 2.2 million, 24% were younger Americans aged between 18 and 34. The administration had forecast that 7 million people would sign up, and that 38% of them would be young people.
Without more customers, especially more young people, whose health costs are low, insurance companies will suffer losses that will be paid for by the federal government, raising the costs of the program.
Numbers of uninsured will remain high
Even before the administration released its low enrollment figures, the Congressional Budget Office forecast that the Affordable Care Act was not going to achieve its goal of universal insurance.
In tables published in May 2013, CBO forecast that the number of uninsured non-elderly people would decline from 55 million in 2013 to 30 million in 2017 — and stay there until 2021, when it would rise to 31 million. The entire program, costing $1.4 trillion, is succeeding in insuring only another 25 million people.
Premiums are pricey
One reason that people are not signing up — after they get past the flawed websites — is that premiums are higher than expected. My Manhattan Institute colleagues Paul Howard, Yevgeniy Feyman, and Avik Roy have constructed an interactive map that shows differences in premiums before and after Obamacare by state.
Howard told me, ""Our analysis finds that, on average, Obamacare will increase underlying premiums by 41%, nationwide. Young men clearly fare the worst under Obamacare, with premiums rising 77% for the average 27-year-old. Older, and lower-income uninsured will find these increases offset by new federal subsidies, but it doesn't change the fact that Obamacare is increasing the underlying cost of coverage, not lowering it."
Deductibles are expensive
After enrollment, people find that deductibles are costly. For a bronze plan, the basic plan, deductibles can reach over $6,000 annually for singles and $12,700 for families. That means that to access the plan's benefits, after preventive care, families have to spend $12,700.
People cannot keep their plans
Although President Obama said on multiple occasions that "If you like your plan, you can keep it," this has not proved to be the case. Millions of plans have already been cancelled, and more cancellations are expected. On page 34,553 of the June 17, 2010 Federal Register, the administration forecast in a mid-range estimate that an average of 93 million people would lose their health plans in 2013. This includes 80 million people on employer plans and 13 million people with individual plans.
Since the employer mandate to provide health insurance was postponed until Jan. 1, 2015, employer cancellations have yet to come. But dissatisfaction with cancelled plans is likely to grow in 2014 as employers react to the mandate.
People cannot keep their doctors
President Obama also said on numerous occasions, such as a speech in Chicago on June 15, 2009, before the American Medical Association, "And that means that no matter how we reform health care, we will keep this promise: If you like your doctor, you will be able to keep your doctor. Period."
People are naturally unhappy that they cannot keep their doctors. In order to keep costs down, insurance companies are reducing the numbers of doctors on their insurance plans, and eliminating some of the more expensive hospitals in the networks.
What is clear is that irrespective of Halbig v. Sebelius, the Affordable Care Act is unsustainable. If the courts do not end it, then Congress will face mounting pressure from voters to repeal or reform it. The challenge will be to enable Americans to get affordable health care while allowing them to keep preferred plans and doctors, just as the architects of the Act promised.
More from MarketWatch:
How to cut health care costs in retirement
Not enough young people bought Obamacare


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10:08 AMAiseesoft Blu-ray Ripper v3.1.50
Aiseesoft Blu-ray Ripper v3.1.50 | 9 Mb
Aiseesoft Blu Ray Ripper is really an all-in-one Blu Ray Ripper to rip Blu ray Discs/m2ts video and common DVD discs to any other video/audio formats. This Blu Ray Disc Ripper can convert Blu Ray DVD and m2ts files to HD video including HD AVI, HD XviD/DivX, HD MP4, MOV, HD WMV files and all the common video formats MP4, AVI, WMV, MKV, FLV, SWF at a tremendous speed. This Blu Ray Ripper can also extract audio from DVD disc and convert it into MP3, AAC, M4A, etc.
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Rip Blu Ray Disc or Blu Ray video to any other video formats
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A lot has been made of the scene Wednesday night in Arlington where a couple caught a ball tossed into the stands by Mitch Moreland, seemingly stealing it from a little boy, who ended up in tears.
The couple has gone to the press to say that they didn't see the little boy. Someone from the Rangers dugout saw the crying kid and tossed him a ball, which seems to mean that everyone left happy, but it does bring up an interesting question:
Is there etiquette for baseballs that enter the stands?
It seems to be a general consensus that there's a difference between a ball tossed into the stands by a player and foul balls. Players usually target children when they soft-toss into the stands, meaning no adult should ever steal that away. Foul balls, however, are fair game.
But there are some that are saying any adult that catches any baseball in the stands should be handing it off to a child near them.
And frankly, that makes me a little angry.
I've never caught or been tossed a baseball and dammit, if I do, I'm keeping that sucker. Don't boo me, don't judge me – that ball means as much to me as it would to that kid. I'd put it in a place of honor in our (wo)man room. My parents didn't introduce me to baseball as a kid – I never got the opportunity to get a ball as a child. I'd be frickin' ecstatic over that ball and I'm not sure why I should have to give that up. Of course, that only accounts for the first ball. I'm not greedy. If I were ever lucky enough to get a second or third ball, those would, of course, go to kids around me.
Certainly I don't mean taking a ball from a child, or pushing, shoving or trampling anyone in order to get said ball. But if I'm lucky enough to catch one of those suckers, I shouldn't be shamed into giving it up.
The scene in Arlington is especially interesting because the child kind of had a tantrum both before and after he didn't receive the ball. There's an argument to be made that the kid shouldn't have gotten a ball just because he was crying – that's certainly not the type of behavior I'd want to reinforce in my children.
Is there also an argument to be made that at three years old, he'd never remember the incident and wouldn't be interested in the ball in a few weeks, whereas the couple was clearly thrilled and catching the ball was a highlight for them – they immediately started taking pictures with the ball?
So clearly I'm a selfish, no-kid having bastard, but what do you all think?


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Patients & Families
For Health Professionals
Meningitis can be a serious infection, and it can be contagious — which is why outbreaks make the news. However, it's also pretty rare.
Meningitis is inflammation of membranes around the brain and spinal cord called the meninges (pronounced: muh-NIN-jeez).
Most cases are caused by bacteria or viruses, but some can be due to certain medicines or illnesses.
Many of the bacteria and viruses that cause meningitis are fairly common and cause other routine illnesses. Both kinds of meningitis spread like most other common infections do — someone who's infected touches, kisses, or coughs or sneezes on someone who isn't infected.
Bacterial meningitis is rare, but is usually serious and can be life-threatening if not treated right away.
In some cases of bacterial meningitis, the bacteria spread to the meninges from a severe head trauma or a severe local infection, such as a serious ear infection or nasal sinus infection (sinusitis).
Viral meningitis (also called aseptic meningitis) is more common than bacterial meningitis and usually less serious.
Many of the viruses that cause meningitis are common, such as those that cause colds, diarrhea, cold sores, and the flu.
Meningitis symptoms vary, depending on the person's age and the cause of the infection. The first symptoms can come on quickly or start several days after someone has had a cold, diarrhea, vomiting, or other signs of an infection.
Common symptoms include:
Bacterial meningitis can be very serious. So if you see symptoms or think you could have meningitis, it's important to see the doctor right away.
If meningitis is suspected, the doctor will order tests, probably including a lumbar puncture (spinal tap) to collect a sample of spinal fluid. This test will show any signs of inflammation and whether the infection is due to a virus or bacteria.
Most cases of viral meningitis end within 7 to 10 days. Some people might need to be treated in the hospital, although most teens can recover at home if they're not too ill. Treatment to ease symptoms includes rest, fluids, and over-the-counter pain medicine.
If bacterial meningitis is diagnosed — or even suspected — doctors will start intravenous (IV) antibiotics as soon as possible. Fluids may be given to replace those lost to fever, sweating, vomiting, and poor appetite.
Complications of bacterial meningitis might need extra treatment. Someone with shock or low blood pressure might get more IV fluids and medicines to increase blood pressure. Some may need extra oxygen or mechanical ventilation if they have trouble breathing.
Bacterial meningitis complications can be severe and include neurological problems, such as hearing loss, visual impairment, seizures, and learning disabilities. Because impaired hearing is a common complication, those who've had bacterial meningitis should have a hearing test after they recover.
The heart, kidneys, and adrenal glands also might be affected, depending on the cause of the infection. Although some people develop long-lasting neurological problems, most who get a quick diagnosis and treatment recover fully.
Routine immunization can go a long way toward preventing meningitis. The Hib, measles, mumps, polio, and pneumococcal vaccines can protect against meningitis caused by those germs.
Although bacterial meningitis can seem scary, the chance of getting it is quite low. However, because it can be so serious, doctors now recommend that all teens get vaccinated against meningococcal meningitis. Many colleges actually require their students to get meningitis vaccines.
Wash your hands well and often, particularly before eating and after using the bathroom, and if you work closely with kids (as in a daycare). Avoid close contact with someone who's obviously ill and don't share food, drinks, or eating utensils.
In some cases, doctors may give antibiotics to anyone who has been in close contact with a person who has bacterial meningitis to help prevent infection.
Get medical care right away if you think that you could have meningitis or you have symptoms such as vomiting, headache, tiredness or confusion, neck stiffness, rash, and fever.
If you've been near someone who has meningitis, call your doctor to ask whether preventive medicine is recommended.


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It was a good day yesterday to visit the Hayward fault at the top of Chabot Road. The previous night's rain softened the ground and left the cut weeds smelling like fresh hay. This is the view north from the ground above the end of the road.
All of this land is suspect today, and the rocks cannot be trusted. The high ground I was standing on is the rubble pile built to support Route 24. The high ground on the right is an old excavation or rubble pile, I'm not sure which, supporting the loop linking Route 24 west and Route 13 south. The flat ground is the former roadbed of the Oakland & Antioch Railway. The trees in the distance are on a rocky slope that roughly marks the Hayward fault, but it may well have been quarried in the past. The nice thing about a fault, for producers of crushed rock aggregate, is that it pre-crushes the rocks. But the fault is somewhere in this view, although it's poorly mapped between the Claremont Resort and Montclair.
With that preamble, I feel free to speculate that the fault trace could possibly nip Chabot Road at its farthest end. We see displacement of the curbs, and at the farther joint we see evidence of compression. In both photos the near side would be west of the fault, moving leftward.
But just as likely, this trodden, retreaded land is shifting and settling all by itself. There may be slow landsliding involved. Also, heavy trucks and other vehicles could well have done this damage. The truth may come out after the next big earthquake ruptures the fault here. It's one place I want to check out in the aftermath, if I'm lucky enough.


text: Alexander Henry is a French and American fine artist living in Europe. After having studied fine arts at the Ecole des Beaux-Arts in Lyons, France, he worked for 15 years as a fashion photographer and art director in Paris and London. Alexander now focuses on art landscape photography, using his original motion-blur technique thus creating dreamy, impressionistic landscape images with the movement of his camera. He also creates stunning abstract digital paintings based on the pure emotion of color and shape using a kaleidoscope technique.


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I am truly speechless. It turns out that Janel Sterbentz, one of the organizers of last Friday's protest at the Fell/ Divisadero Arco station, and whose "Women who Ride" interview for the Bike NOPA blog was suppressed because she said that "cars leave destruction and unpleasantness in their path" has been forced to resign from her position as Bike to Work Day Coordinator at the Bay Area Bicycle Coalition (BABC), following SF Bicycle Coalition Program Manager Marc Caswell's condemnation of her comments made on this blog as well as her role helping to organize Friday's protest.
Many months ago, after being nearly knocked off her bike in front of the Arco station on Fell St., Janel asked the SFBC what was being done to improve safety along this critical thoroughfare. Marc told her that she should "take on a Fell street campaign because the SFBC 'doesn't have time' to work on it."
So she takes it on as a volunteer. After a year of rallying the neighborhood associations, speaking with the SFMTA and working with the SFBC, the city came up with a proposal and brought it before transportation engineers at a public hearing. Several residents in the neighborhood voiced their disapproval of removing a few parking spaces to make a left turn lane and the proposal was stalled. The SFMTA came back a month later with a watered down plan for a 7am to 7pm tow zone- a half measure that will not come close to fixing the dangerous condition at the Arco station.
Someone please explain to me why it is acceptable to sacrifice the safety of thousands of vulnerable road users every day so a handful of people can continue to enjoy city-subsidized free private vehicle storage along the public right of way. I just don't get it.
So, seeing that the system had totally failed, Janel plans to help mobilize a protest last Friday that captures widespread media attention and galvanizes the support of motorists and cyclists alike to finally close the dangerous gas station entrances on Fell, and what does she get? Fired from her bicycle advocacy job. You heard me right.
Now you might say- well the bicycle coalitions don't want to be associated with a direct action protest. But hold on just a second. It wasn't too long ago that the SFBC coordinated a series of direct actions in the Panhandle with their volunteer crossing guard program (started by yours truly when I was Program Director) that put pressure on the city and now- even though the intersection at Masonic and the Panhandle isn't perfect- we do have a dedicated phase for non-motorized traffic. It seems that the new SFBC staff has a very short memory.
Now, I don't expect the bike coalitions to participate in every protest (even though the public would never have known who Janel was employed by) but I do expect them not to undermine grassroots efforts by their members and off-duty employees to draw attention to one of the most dangerous stretches of roadway in the city for bicyclists.
As program director at the SFBC for almost three years, I understand the importance of public image. But this latest incident is a disturbing example of the coalition actually going against their base- acting in a way that undermines the very cause they are meant to be promoting. This is one of a series of recent events that is raising concern about the Coalition amongst longtime members.
Janel's general comments several weeks ago on my blog about environmental organizations are absolutely right on:
"@onthelevel: I agree, a sentiment often develops that the organizations who speak for and represent the movement are on top of the issues and are working in our best interest. That they know what they are doing so we don't need to get involved unless we are told what to do……"
These comments- made as a private individual- were seized upon by SFBC Program Manager Marc Caswell, who immediately sent an e-mail to Andrew Casteel, Executive Director of the BABC, essentially suggesting that Andrew reassess whether Janel should continue working at the BABC:
"As BABC Board, I'm a bit concerned by Janel's public comments criticizing, ostensibly, the SFBC. While I can understand the frustration regarding not having comments published– and don't really care to get involved in that discussion– the later blog comment by Janel is a direct criticism of not only an allied organization, but a member organization(!) of BABC."
Marc goes on to say:
"Of course, anyone is free to say what they want– but, as a BABC staff person, comments and public statements criticizing allies isn't a positive way to move the movement forward. And comments like this do, in fact, reflect upon the employer."
Nowhere did Janel indicate that she was talking about any specific organization. But that didn't stop Marc (who is also on the board of the BABC) from leaping to the conclusion that she was referring to the SFBC.
Marc also took issue with the fact that Janel helped organize the successful protest last Friday. Note that the SFBC has not breathed a word about the oil spill or why people should ride a bike in response to it in almost two months. A month ago, a number of people (including Marc) were invited by e-mail to take part in planning this protest. However, the SFBC refused to take part, instead choosing to target Janel for her role in organizing peaceful action at a location where cyclists' lives are daily put at risk and only half-measures have been supported by the Board of Supervisors.
Marc continues in his e-mail to Andrew:
"Beyond that smaller concern, I've been CC'ed on the email threads about the Fell Street Arco station protest in the coming month—and I've noticed that Janel is the *creator* of the event on Facebook…. as a Board member of the organization, my top job is to 'ensure the health' of the organization– and I think these recent public actions are undermining that. I'm not sure what we can do to fix it– but I want to at least express my concern as BABC Board with you both as staff. I'd welcome any further discussion on this topic and am available if you need me."
Andrew's response to Marc was:
"Janel has not run any of those blog posts or events by me for approval"
As if he controls every activity a part-time employee engages in outside of work. I'm sorry but that is the logic of the corporation, not of a grassroots bicycle advocacy organization.
So to try and put all of this into some perspective, you have Janel Sterbentz- a passionate and productive employee of the BABC– forced to resign because:
a) She made a general comment about the state of environmental organizations on a blog.
b) She helped to organize a protest against the Gulf Oil Spill, the worst environmental disaster in US history and against the continued obstruction of one of the most important bike lanes in San Francisco.
c) She made a (very reasonable and timely) documentary about the need for a bike path on the west span of the Bay Bridge and gave it to Senator Boxer's aid at the National Bike Summit as an individual constituent and got flack from her boss who said it was not appropriate to share the video without approval from her superiors in the California Bicycle Delegation.
It is indeed a sad state of affairs when a committed activist such as Sterbentz is terminated from her official role in bicycle advocacy for speaking out against car culture. And all that much worse because it came from a fellow colleague. This is not what I pay my membership dues for. And though I don't relish criticizing my friends at the SFBC, I do strongly suggest that if people are disturbed by this series of events, that they express their discontent to the acting ED Renee Rivera and the Bay Area Bicycle Coalition Board.
The region's bicycle coalitions need to seriously check themselves about this incident. There's a real world out here and people are getting hurt by car dependence. Silence is no longer an option.


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San Francisco electro artist Moldover, like Beck before him, figured out a way to make physical music purchases superior to digital: Embrace the physical. In Moldover's case, that meant cramming an actual working theremin into the CD case.
Moldover really went all-out with this one. The CD case theremin features a headphone jack as well as a speaker, and the wiring on the theremin itself spells out the artist name, track names, and "album art," such as it is. He even includes a tiny pocket-sized version of the theremin so you're never without that odd organic screechy sound. The album costs $50, which actually seems pretty cheap considering it's packaged inside a musical instrument. [Denver Westword]


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By incorporating a three-step ladder that disappears into its front facade, this extra-tall shelf lets you maximize the storage space in your home, without requiring you to fetch a step ladder every time you need something off the top tier.
It was designed by Karen King and for $2,350 one can be yours in a choice of hickory, ash, or oak finishes. Not exactly cheap for what basically amounts to an extra few feet of storage space. But let's be honest, most people (namely me) will actually be buying it for that sweet, secret, swing-out ladder.
[Ideacious via Said the King]


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Hello everyone! This post is a bit difficult to write as I don't know how I want to formulate my words. For those who have been reading this blog frequently, you have no idea how much your support means to me. Forever Obsession started as a diary in 2012 with posts that documented my trip in Taiwan and took flight from there.
In 2013, I made the decision to begin actively blogging and as a result, chose to focus on book reviews and join the book community. I have had the privilege of watching Forever Obsession grow and while the reader count is small, it's become my outlet throughout my years in high school and will remain one of the most treasured memories in my heart.
If you guys have noticed recently, the amount of posts have been seriously lacking as I've struggled to come up with any source of inspiration and motivation to blog. There were moments when I wanted to write a huge rant about college or just a ramble post, but felt that it was out of place among the long history of book posts and for some strange reason, that became the reason I held back from posting.
With the new year, I'm determined more than ever to reconnect but while planning out new posts, I just had the desire to start a new chapter of my blogging life. Forever Obsession went through so many changes as I discovered what worked for me and how I wanted to grow as a blogger.
I think I made my decision to officially switch when I went back to Tumblr and made a new account under the name: Le Petit Photograph. After reconnecting on Tumblr, I found several really amazing lifestyle blogs and I guess that solidified the decision. That and a debate session with Claudia.
So today I sat down and did it - I made a new blog that shares the same name as my Tumblr and switched all of my social media links to fit that new blog. Forever Obsession will still be around, I debated whether I wanted to just change the name or private this one, but I decided to keep it up. I might post from time to time, but I plan on officially moving over to Le Petit Photograph with this being my last post.
This is both bittersweet and exciting as I'm pumped to explore the different paths I can take with the new blog, but I'm going to miss saying "Forever Obsession." Le Petit Photograph will still have book reviews, but I want to incorporate my life and thoughts as well. I hope that you guys are excited as well and please check out Le Petit Photograph by clicking the banner and following the next chapter of my adventure there!


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Would You Eat A Deep-Fried Full Christmas Dinner?
Imagine everything you normally eat for Christmas dinner — turkey, sausages, potatoes, stuffing, vegetables, pudding (!)…everything. Now imagine all of it coated in batter and deep-fried until crispy on the outside. Yes, someone does that. Just watch the video below and try not to gain 10 pounds:
Hollywood Fish Bar in Birmingham, England offers the fully battered Christmas dinner, which includes turkey, sausages, roast potatoes, stuffing, broccoli, carrots, Brussels sprouts and pudding or mince pies for dessert. Owner Chris Christoforou calls it 'Christmas Dinner in Batter' (while Louie Anderson just calls it a snack).
It's not clear how many calories are in this belly stuffer, but it's safe to say you may need to cut your belt off after consuming this batter-dipped Christmas meal. It might be the easiest way to clear out your annoying family after dinner, too.


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Today's blog post is by Christopher Cabrera, CEO of Xactly Corporation.
Note: hear Christopher Cabrera keynote on June 7 in London at the Sales & Marketing 2.0 Conference. Email email@example.com for more information.
Would you brush your teeth with a toothbrush duct-taped to a blender?
This is the question I posed to an audience of sales and marketing leaders last month at the Sales 2.0 Conference in San Francisco. I wasn't being flip.
While many of us are out there selling cutting-edge products, we still somehow justify motivating our teams with a tool from 1982 (Excel).
I'm not knocking Excel. It's a great tool. We use it at Xactly every day. But, Excel was not designed for managing the commission payments for a sales team, any more than a blender is meant to safely power your toothbrush.
You are creating real problems when you use Excel to motivate a sales team of any size. Gartner estimates that errors can amount to 10% of commissions. How much money is that for you—$10k a week? $100K?
The math is too big; the equations too complicated. The system is too slow to truly reward and actually encourages communication breakdowns. When you try to turn Excel into a sales motivator, you create real business problems.
Consider an example I shared at the conference: Back when I was a sales manager, I was mistakenly paid $80,000 instead of $8,000 in commissions. When I reported the mistake, my manager said to me: "Wow, Chris, do you realize we would have never caught that?" Turns out, my employer overpaid three of us $72,000 each and didn't realize it. Combined, that's more than $200,000!
And just imagine all of the incorrect payments they didn't catch over the years. These errors happen all the time. They cost companies millions. But this isn't the only cost. Salespeople who don't trust their paychecks aren't motivated to try for incentives. Why should they if their pay is essentially random? They may even waste time tracking their commissions.
But more and more companies are eliminating the sales roadblocks -- like errors -- created by running commissions in Excel. When they swap Excel for automation, they tap into the science of human psychology—the desire to compete and win.
Research from CSO Insights and the Aberdeen Group even shows that companies that use new incentive solutions sell more, more efficiently. Xactly's customers, for instance, see 146% revenue growth and 36% shorter sales cycles once they ditch manual compensation processes. What these leading companies understand that others don't (yet) is that the science of effective motivation can be built into incentive compensation tools.
To see what I mean, consider these not-so hypotheticals. Would your sales reps be more motivated (and capable) to outperform quota if they could:
- Track their performance against goals every minute of the day?
- Know exactly how much they'd get if they closed a potential deal?
- Trust the accuracy of their payments?
What about your sales managers? Would they be more effective if they could compare sales reps' performance by territory, product, and margin? All with the click of a button?
We all know the power of human motivation. When sales leaders ditch the thing that stands between incentive programs and real motivation -- Excel-driven errors -- they create a company culture that encourages top performance, healthy competition, and accelerated revenue. So why are you trying to force 30-year-old technology to do something that it was never meant to do?
Publisher's note: Join me on June 7 in London and hear Christopher Cabrera's keynote, "The Science of Sales Performance," at the Sales & Marketing 2.0 Conference.