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The epidemic of type 2 diabetes in the latter part of the 20th and in the early 21st century, and the recognition that achieving specific glycemic goals can substantially reduce morbidity, have made the effective treatment of hyperglycemia a top priority (1–3). While the management of hyperglycemia, the hallmark metabolic abnormality associated with type 2 diabetes, has historically had center stage in the treatment of diabetes, therapies directed at other coincident features, such as dyslipidemia, hypertension, hypercoagulability, obesity, and insulin resistance, have also been a major focus of research and therapy. Maintaining glycemic levels as close to the nondiabetic range as possible has been demonstrated to have a powerful beneficial impact on diabetes-specific complications, including retinopathy, nephropathy, and neuropathy in the setting of type 1 diabetes (4,5); in type 2 diabetes, more intensive treatment strategies have likewise been demonstrated to reduce complications (6–8). Intensive glycemic management resulting in lower HbA1c (A1C) levels has also been shown to have a beneficial effect on cardiovascular disease (CVD) complications in type 1 diabetes (9,10); however, the role of intensive diabetes therapy on CVD in type 2 diabetes remains under active investigation (11,12). Some therapies directed at lowering glucose levels have additional benefits with regard to CVD risk factors, while others lower glucose without additional benefits.
The development of new classes of blood glucose–lowering medications to supplement the older therapies, such as lifestyle-directed interventions, insulin, sulfonylureas, and metformin, has increased the treatment options for type 2 diabetes. Whether used alone or in combination with other blood glucose–lowering interventions, the availability of the newer agents has provided an increased number of choices for practitioners and patients and heightened uncertainty regarding the most appropriate means of treating this widespread disease. Although numerous reviews on the management of type 2 diabetes have been published in recent years (13–16), practitioners are often left without a clear pathway of therapy to follow. We developed the following consensus approach to the management of hyperglycemia in the nonpregnant adult to help guide health care providers in choosing the most appropriate interventions for their patients with type 2 diabetes.
The guidelines and algorithm that follow are based on clinical trials that have examined different modalities of therapy of type 2 diabetes and on the authors' clinical experience and judgment, keeping in mind the primary goal of achieving and maintaining glucose levels as close to the nondiabetic range as possible. The paucity of high-quality evidence in the form of clinical trials that directly compare different diabetes treatment regimens remains a major impediment to recommending one class of drugs, or a particular combination of therapies, over another. While the algorithm that we propose is likely to engender debate, we hope that the recommendations will help guide the therapy of type 2 diabetes and result in improved glycemic control and health status over time.
Glycemic goals of therapy
Controlled clinical trials, such as the Diabetes Control and Complications Trial (DCCT) (4) and the Stockholm Diabetes Intervention Study (5) in type 1 diabetes and the U.K. Prospective Diabetes Study (UKPDS) (6,7) and Kumamoto Study (8) in type 2 diabetes, have helped to establish the glycemic goals of therapy that result in improved long-term outcomes. Although the various clinical trials have had different designs, interventions, and measured outcomes, the trials, in concert with epidemiologic data (17,18), support decreasing glycemia as an effective means of reducing long-term microvascular and neuropathic complications. The most appropriate target levels for blood glucose, on a day-to-day basis, and A1C, as an index of chronic glycemia, have not been systematically studied. However, both the DCCT (4) and the UKPDS (6,7) had as their goals the achievement of glycemic levels in the nondiabetic range. Neither study was able to sustain A1C levels in the nondiabetic range in their intensive-treatment groups, achieving mean levels over time of ∼7%, 4 SDs above the nondiabetic mean.
The most recent glycemic goal recommended by the American Diabetes Association, selected on the basis of practicality and the projected reduction in complications over time, is "in general" an A1C level <7% (19). For "the individual patient," the A1C should be "as close to normal (<6%) as possible without significant hypoglycemia." The most recent glycemic goal set by the European Union–International Diabetes Federation is an A1C level <6.5%. The upper limit of the nondiabetic range is 6.1% (mean A1C of 5% + 2 SD) with the DCCT-standardized assay, which has been promulgated through the National Glycohemoglobin Standardization Program (NGSP) and adopted by the vast majority of commercially available assays (20). Our consensus is that an A1C of ≥7% should serve as a call to action to initiate or change therapy with the goal of achieving an A1C level as close to the nondiabetic range as possible or, at a minimum, decreasing the A1C to <7%. We are mindful that this goal is not appropriate or practical for some patients, and clinical judgment, based on the potential benefits and risks of a more intensified regimen, needs to be applied for every patient. Factors such as life expectancy and risk for hypoglycemia need to be considered for every patient before intensifying therapeutic regimens.
Assiduous attention to abnormalities other than hyperglycemia that accompany type 2 diabetes, such as hypertension and dyslipidemia, has been shown to improve microvascular and cardiovascular complications. Readers are referred to published guidelines for a discussion of the rationale and goals of therapy for the nonglycemic risk factors, as well as recommendations as to how to achieve them (1,21,22).
Principles in selecting antihyperglycemic interventions
Choosing specific antihyperglycemic agents is predicated on their effectiveness in lowering glucose, extraglycemic effects that may reduce long-term complications, safety profiles, tolerability, and expense.
Effectiveness in lowering glycemia.
Apart from their differential effects on glycemia, there are insufficient data at this time to support a recommendation of one class of glucose-lowering agents, or one combination of medications, over others with regard to effects on complications. In other words, the salutary effects of therapy on long-term complications appear to be predicated predominantly on the level of glycemic control achieved rather than on any other specific attributes of the intervention(s) used to achieve glycemic goals. The UKPDS compared three classes of glucose-lowering medications (sulfonylurea, metformin, or insulin) but was unable to demonstrate clear superiority of any one drug over the others with regard to complications (6,7). However, the different classes do have variable effectiveness in decreasing glycemic levels (Table 1), and the overarching principle in selecting a particular intervention will be its ability to achieve and maintain glycemic goals. In addition to the intention-to-treat analyses demonstrating the superiority of intensive versus conventional interventions, the DCCT and UKPDS demonstrated a strong correlation between mean A1C levels over time and the development and progression of retinopathy and nephropathy (23,24). Therefore, we think it is reasonable to judge and compare blood glucose–lowering medications, and the combinations of such agents, primarily on the basis of the A1C levels that are achieved and on their specific side effects, tolerability, and expense.
Nonglycemic effects of medications.
In addition to variable effects on glycemia, specific effects of individual therapies on CVD risk factors, such as hypertension or dyslipidemia, were also considered important. We also included the effects of interventions that may benefit or worsen the prospects for long-term glycemic control in our recommendations. Examples of these would be changes in body mass, insulin resistance, or insulin secretory capacity in type 2 diabetic patients.
Choosing specific diabetes interventions and their roles in treating type 2 diabetes
Numerous reviews have focused on the characteristics of the specific diabetes interventions listed below (25–33). The aim here is to provide enough information to justify the choices of medications, the order in which they are recommended, and the utility of combinations of therapies. Unfortunately, there is a dearth of high-quality studies that provide head-to-head comparisons of the ability of the medications to achieve the currently recommended glycemic levels. The authors highly recommend that such studies be conducted. However, even in the absence of rigorous, comprehensive studies that directly compare the efficacy of all available glucose-lowering treatments, and their combinations, we feel that there are enough data regarding the characteristics of the individual interventions to provide the guidelines below.
An important intervention that is likely to improve the probability that a patient will have better long-term control of diabetes is to make the diagnosis early, when the metabolic abnormalities of diabetes are usually less severe. Lower levels of glycemia at time of initial therapy are associated with lower A1C over time and decreased long-term complications (34).
Lifestyle interventions.
The major environmental factors that increase the risk of type 2 diabetes, presumably in the setting of genetic risk, are overnutrition and a sedentary lifestyle, with consequent overweight and obesity (35). Not surprisingly, interventions that reverse or improve these factors have been demonstrated to have a beneficial effect on control of glycemia in established type 2 diabetes (36). While there is still active debate regarding the most beneficial types of diet and exercise, weight loss almost always improves glycemic levels. Unfortunately, the high rate of weight regain has limited the role of lifestyle interventions as an effective means of controlling glycemia long term. The most convincing long-term data that weight loss effectively lowers glycemia have been generated in the follow-up of type 2 diabetic patients who have had bariatric surgery (37,38). In this setting, diabetes is virtually erased, with a mean sustained weight loss of >20 kg (37,38). Studies of the pharmacologic treatment of obesity have been characterized by high drop-out rates, low sustainability, and side effects; weight loss medications cannot be recommended as a primary therapy for diabetes at this time. In addition to the beneficial effects of weight loss on glycemia, weight loss and exercise improve coincident CVD risk factors, such as blood pressure and atherogenic lipid profiles, and ameliorate other consequences of obesity (37–40). There are few adverse consequences of such lifestyle interventions other than the difficulty in incorporating them into usual lifestyle and sustaining them and the usually minor musculoskeletal injuries and potential problems associated with neuropathy, such as foot trauma and ulcers, that may occur with increased activity. Theoretically, effective weight loss, with its pleiotropic benefits, safety profile, and low cost, should be the most cost-effective means of controlling diabetes, if it could be achieved and maintained long term.
Given these beneficial effects, a lifestyle intervention program to promote weight loss and increase activity levels should, with rare exceptions, be included as part of diabetes management. The beneficial effects of such programs are usually seen rapidly, within weeks to months, and often before there has been substantial weight loss (41). Weight loss of as little as 4 kg will often ameliorate hyperglycemia. However, the limited long-term success of lifestyle programs to maintain glycemic goals in patients with type 2 diabetes suggests that a large majority of patients will require the addition of medications over the course of their diabetes.
The characteristics of currently available antidiabetic interventions, when used as monotherapy, are summarized in Table 1. The glucose-lowering effectiveness of individual therapies and combinations demonstrated in clinical trials is predicated not only on the intrinsic characteristics of the intervention, but also on the baseline glycemia, duration of diabetes, previous therapy, and other factors. A major factor in selecting a class of drugs, or a specific medication within a class, to initiate therapy or when changing therapy, is the ambient level of glycemic control. When levels of glycemia are high (e.g., A1C >8.5%), classes with greater and more rapid glucose-lowering effectiveness, or potentially earlier initiation of combination therapy, are recommended; conversely, when glycemic levels are closer to the target levels (e.g., A1C <7.5%), medications with lesser potential to lower glycemia and/or a slower onset of action may be considered. Obviously, the choice of glycemic goals and the medications used to achieve them must be individualized for each patient, balancing the potential for lowering A1C and anticipated long-term benefit with specific safety issues, as well as other characteristics of regimens, including side effects, tolerability, patient burden and long-term adherence, expense, and the nonglycemic effects of the medications. Finally, type 2 diabetes is a progressive disease with worsening glycemia over time. Therefore, addition of medications is the rule, not the exception, if treatment goals are to be met over time.
Metformin is the only biguanide available in most of the world. Its major effect is to decrease hepatic glucose output and lower fasting glycemia. Typically, metformin monotherapy will lower A1C by ∼1.5 percentage points (27,42). It is generally well tolerated, with the most common adverse effects being gastrointestinal. Although always a matter of concern because of its potentially fatal outcome, lactic acidosis is quite rare (<1 case per 100,000 treated patients) (43). Metformin monotherapy is usually not accompanied by hypoglycemia and has been used safely, without causing hypoglycemia, in patients with pre-diabetic hyperglycemia (44). The major nonglycemic effect of metformin is either weight stability or modest weight loss, in contrast to many of the other blood glucose–lowering medications. The UKPDS demonstrated a beneficial effect of metformin therapy on CVD outcomes that needs to be confirmed (7).
Sulfonylureas lower glycemia by enhancing insulin secretion. They appear to have an effect similar to metformin, and they lower A1C by ∼1.5 percentage points (26). The major adverse side effect is hypoglycemia, but severe episodes, characterized by need for assistance, coma, or seizure, are infrequent. However, such episodes are more frequent in the elderly. Episodes can be both prolonged and life threatening, although these are very rare. Several of the newer sulfonylureas have a relatively lower risk for hypoglycemia (Table 1) (45,46). In addition, weight gain of ∼2 kg is common with the initiation of sulfonylurea therapy. This may have an adverse impact on CVD risk, although it has not been established. Finally, sulfonylurea therapy was implicated as a potential cause of increased CVD mortality in the University Group Diabetes Program (47). Concerns raised by the University Group Diabetes Program study that sulfonylurea therapy may increase CVD mortality in type 2 diabetes were not substantiated by the UKPDS (6).
Like the sulfonylureas, the glinides stimulate insulin secretion, although they bind to a different site within the sulfonylurea receptor (28). They have a shorter circulating half-life than the sulfonylureas and must be administered more frequently. Of the two glinides currently available in the U.S., repaglinide is almost as effective as metformin or the sulfonylureas, decreasing A1C by ∼1.5 percentage points. Nateglinide is somewhat less effective in lowering A1C than repaglinide when used as monotherapy or in combination therapy (48,49). The glinides have a similar risk for weight gain as the sulfonylureas, but hypoglycemia may be less frequent, at least with nateglinide, than with some sulfonylureas (49,50).
α-Glucosidase inhibitors.
α-Glucosidase inhibitors reduce the rate of digestion of polysaccharides in the proximal small intestine, primarily lowering postprandial glucose levels without causing hypoglycemia. They are less effective in lowering glycemia than metformin or the sulfonylureas, reducing A1C by 0.5–0.8 percentage points (29). Since carbohydrate is absorbed more distally, malabsorption and weight loss do not occur; however, increased delivery of carbohydrate to the colon commonly results in increased gas production and gastrointestinal symptoms. This side effect has led to discontinuation of the α-glucosidase inhibitors by 25–45% of participants in clinical trials (29,51). One clinical trial examining acarbose as a means of preventing the development of diabetes in high-risk subjects with impaired glucose tolerance showed an unexpected reduction in severe CVD outcomes (51). This potential benefit of α-glucosidase inhibitors needs to be confirmed.
Thiazolidinediones (TZDs or glitazones) are peroxisome proliferator–activated receptor γ modulators; they increase the sensitivity of muscle, fat, and liver to endogenous and exogenous insulin ("insulin sensitizers") (31). The limited data regarding the blood glucose–lowering effectiveness of TZDs when used as monotherapy have demonstrated a 0.5–1.4% decrease in A1C. The most common adverse effects with TZDs are weight gain and fluid retention. There is an increase in adiposity, largely subcutaneous, with redistribution of fat from visceral deposits shown in some studies. The fluid retention usually manifests as peripheral edema, though new or worsened heart failure can occur. The TZDs either have a beneficial or neutral effect on atherogenic lipid profiles, with pioglitazone having a more beneficial effect than rosiglitazone (52,53). The PROactive (PROspective pioglitAzone Clinical Trial In macroVascular Events) study demonstrated no significant effects of pioglitazone compared with placebo on the primary CVD outcome (composite of all-cause mortality, nonfatal and silent myocardial infarction, stroke, major leg amputation, acute coronary syndrome, coronary artery bypass graft or percutaneous coronary intervention, and leg revascularization) after 3 years of follow-up, but a 16% reduction in death, myocardial infarction, and stroke, a secondary end point, was reported with marginal statistical significance (54).
Insulin is the oldest of the currently available medications and has the most clinical experience. Although initially developed to treat the insulin-deficient type 1 diabetic patient, in whom it is life saving, insulin was used early on to treat the insulin-resistant form of diabetes recognized by Himsworth and Kerr (55). Insulin is the most effective of diabetes medications in lowering glycemia. It can, when used in adequate doses, decrease any level of elevated A1C to, or close to, the therapeutic goal. Unlike the other blood glucose–lowering medications, there is no maximum dose of insulin beyond which a therapeutic effect will not occur. Relatively large doses of insulin (≥1 unit/kg), compared with those required to treat type 1 diabetes, may be necessary to overcome the insulin resistance of type 2 diabetes and lower A1C to goal. Although initial therapy is aimed at increasing basal insulin supply, usually with intermediate- or long-acting insulins, patients may also require prandial therapy with short- or rapid-acting insulins as well (Fig. 1). Insulin therapy has beneficial effects on triglyceride and HDL cholesterol levels (56) but is associated with weight gain of ∼2–4 kg, probably proportional to the correction of glycemia and owing predominantly to the reduction of glycosuria. As with sulfonylurea therapy, the weight gain may have an adverse effect on cardiovascular risk. Insulin therapy is also associated with hypoglycemia, albeit much less frequently than in type 1 diabetes. In clinical trials aimed at normoglycemia and achieving a mean A1C of ∼7%, severe hypoglycemic episodes (defined as requiring help from another person to treat) occurred at a rate of between 1 and 3 per 100 patient-years (8,56–59) compared with 61 per 100 patient-years in the DCCT intensive-therapy group (4). Insulin analogs with longer, nonpeaking profiles may decrease the risk of hypoglycemia compared with NPH, and analogs with very short durations of action may reduce the risk of hypoglycemia compared with regular insulin (60,61). Inhaled insulin was approved in the U.S. in 2006 for the treatment of type 2 diabetes. Published clinical studies to date have not demonstrated whether inhaled insulin, given as monotherapy (62,63) or in combination with an injection of long-acting insulin (64), can lower A1C to ≤7%.
Glucagon-like peptide 1 agonists (exenatide).
Glucagon-like peptide 1 (GLP-1) 7-37, a naturally occurring peptide produced by the L-cells of the small intestine, stimulates insulin secretion. Exendin-4 has homology with the human GLP-1 sequence but has a longer circulating half-life. It binds avidly to the GLP-1 receptor on the pancreatic β-cell and potentiates glucose-mediated insulin secretion (32). Synthetic exendin-4 (exenatide) was approved for use in the U.S. in 2005 and is administered twice per day by subcutaneous injection. Although there are far less published data on this new compound than the other blood glucose–lowering medications, exendin-4 appears to lower A1C by 0.5–1 percentage points, mainly by lowering postprandial blood glucose levels (65–68). Exenatide also suppresses glucagon secretion and slows gastric motility. It is not associated with hypoglycemia but has a relatively high frequency of gastrointestinal side effects, with 30–45% of treated patients experiencing one or more episodes of nausea, vomiting, or diarrhea (65–68). In published trials, exenatide is associated with an ∼2- to 3-kg weight loss over 6 months, some of which may be a result of its gastrointestinal side effects. Currently, exenatide is approved for use in the U.S. with sulfonylurea and/or metformin.
Amylin agonists (pramlintide).
Pramlintide is a synthetic analog of the β-cell hormone amylin. Currently, pramlintide is approved for use in the U.S. only as adjunctive therapy with insulin.
Pramlintide is administered subcutaneously before meals and slows gastric emptying, inhibits glucagon production in a glucose-dependent fashion, and predominantly decreases postprandial glucose excursions (33). In clinical studies, A1C has been decreased by 0.5–0.7 percentage points (69). The major clinical side effects of this drug, which is injected before meals, are gastrointestinal in nature. Approximately 30% of treated participants in the clinical trials have developed nausea. Weight loss associated with this medication is ∼1–1.5 kg over 6 months; as with exenatide, some of the weight loss may be the result of gastrointestinal side effects.
How to initiate diabetes therapy and advance interventions
Except in rare circumstances, such as patients who are extremely catabolic or hyperosmolar, who are unable to hydrate themselves adequately, or with diabetic ketoacidosis (see special considerations/patients below), hospitalization is not required to initiate or adjust therapy. The patient is the key player in the diabetes care team and should be trained and empowered to prevent and treat hypoglycemia, as well as to adjust medications with the guidance of health care providers to achieve glycemic goals. Many patients may be managed effectively with monotherapy; however, the progressive nature of the disease will require the use of combination therapy in many, if not most, patients over time to achieve and maintain glycemia in the target range.
The measures of glycemia that are initially targeted on a day-to-day basis are the fasting and preprandial glucose levels. Self-monitoring of blood glucose (SMBG) is an important element in adjusting or adding new interventions and, in particular, in titrating insulin doses. The need for and number of required SMBG measurements are not clear (70) but are dependent on the medications used. Oral hypoglycemic regimens that do not include sulfonylureas, and are therefore not likely to cause hypoglycemia, usually do not require SMBG. However, SMBG may be used to determine whether therapeutic blood glucose targets are being achieved and to adjust treatment regimens without requiring the patient to have laboratory-based blood glucose testing. A fasting glucose level measured several times per week generally correlates well with the A1C level. Insulin therapy requires more frequent monitoring.
The levels of plasma or capillary glucose (most meters that measure fingerstick capillary samples are adjusted to provide values equivalent to plasma glucose) that should result in long-term glycemia in the nondiabetic target range, as measured by A1C, are fasting and preprandial levels between 70 and 130 mg/dl (3.89 and 7.22 mmol/l). If these levels are not consistently achieved, or A1C remains above the desired target, postprandial levels, usually measured 90–120 min after a meal, may be checked. They should be less than 180 mg/dl (10 mmol/l) to achieve A1C levels in the target range.
Attempts to achieve target glycemic levels with regimens including sulfonylureas or insulin may be associated with modest hypoglycemia, with glucose levels in the 55- to 70-mg/dl (3.06- to 3.89-mmol) range. These episodes are generally well tolerated, easily treated with oral carbohydrate, such as glucose tablets or 4–6 oz (120–180 ml) juice or nondiet soda, and rarely progress to more severe hypoglycemia, including loss of consciousness or seizures.
The algorithm (Fig. 2) takes into account the characteristics of the individual interventions, their synergies, and expense. The goal is to achieve and maintain glycemic levels as close to the nondiabetic range as possible and to change interventions at as rapid a pace as titration of medications allows. Pramlintide, exenatide, α-glucosidase inhibitors, and the glinides are not included in this algorithm, owing to their generally lower overall glucose-lowering effectiveness, limited clinical data, and/or relative expense (Table 1). However, they may be appropriate choices in selected patients.
Step 1: lifestyle intervention and metformin.
Based on the numerous demonstrated short- and long-term benefits that accrue when weight loss and increased levels of activity are achieved and maintained, and the cost-effectiveness of lifestyle interventions when they succeed, the consensus is that lifestyle interventions should be initiated as the first step in treating new-onset type 2 diabetes (Fig. 2). These interventions should be implemented by health care professionals with appropriate training, usually registered dietitians with training in behavioral modification, and be sensitive to ethnic and cultural differences among populations. Moreover, lifestyle interventions to improve glucose, blood pressure, and lipids levels and to promote weight loss or at least avoid weight gain should remain an underlying theme throughout the management of type 2 diabetes, even after medications are used. For the 10–20% of patients with type 2 diabetes who are not obese or overweight, modification of dietary composition and activity levels may play a supporting role, but medications are generally required earlier (see special considerations/patients below).
The authors recognize that for most individuals with type 2 diabetes, lifestyle interventions fail to achieve or maintain metabolic goals, either because of failure to lose weight, weight regain, progressive disease or a combination of factors. Therefore, our consensus is that metformin therapy should be initiated concurrent with lifestyle intervention at diagnosis. Metformin is recommended as the initial pharmacologic therapy, in the absence of specific contraindications, for its effect on glycemia, absence of weight gain or hypoglycemia, generally low level of side effects, high level of acceptance, and relatively low cost. Metformin treatment should be titrated to its maximally effective dose over 1–2 months, as tolerated (Table 2). Rapid addition of other glucose-lowering medications should be considered in the setting of persistent symptomatic hyperglycemia.
Step 2: additional medications.
If lifestyle intervention and maximal tolerated dose of metformin fail to achieve or sustain glycemic goals, another medication should be added within 2–3 months of the initiation of therapy or at any time when A1C goal is not achieved. There was no strong consensus regarding the second medication added after metformin other than to choose among insulin, a sulfonylurea, or a TZD (Fig. 2). As discussed above, the A1C level will determine in part which agent is selected next, with consideration given to the more effective glycemia-lowering agent, insulin, for patients with A1C >8.5% or with symptoms secondary to hyperglycemia. Insulin can be initiated with a basal (intermediate- or long-acting) insulin (see Fig. 1 for suggested initial insulin regimens) (71). The relative increased cost of the newer agents that are only available as brand medications must be balanced against their relative benefits.
Step 3: further adjustments.
If lifestyle, metformin, and a second medication do not result in goal glycemia, the next step should be to start, or intensify, insulin therapy (Fig. 1). When A1C is close to goal (<8.0%), addition of a third oral agent could be considered; however, this approach is relatively more costly and potentially not as effective in lowering glycemia compared with adding or intensifying insulin (72). Intensification of insulin therapy usually consists of additional injections that might include a short- or rapid-acting insulin given before selected meals to reduce postprandial glucose excursions (Fig. 1). When prandial rapid- or very-rapid-acting insulin injections are started, insulin secretagogues (sulfonylurea or glinides) should be discontinued, or tapered and then discontinued, since they are not considered synergistic with administered insulin.
Rationale in selecting specific combinations
More than one medication will be necessary for the majority of patients over time. Selection of the individual agents should be made on the basis of their glucose-lowering effectiveness and other characteristics listed in Table 1. However, when adding second and potentially third antihyperglycemic medications, the synergy of particular combinations and other interactions should be considered. In general, antihyperglycemic drugs with different mechanisms of action will have the greatest synergy. Insulin plus metformin (73) and insulin plus a TZD (74) are particularly effective means of lowering glycemia. The increased risk of fluid retention with the latter combination must be considered. (TZD in combination with insulin is not currently approved in the European Union.) Although both TZDs and metformin effectively increase sensitivity to insulin, they have different target organs and have been shown to have modest additive effects, with addition of TZD to metformin lowering A1C by 0.3–0.8% (75,76).
Special considerations/patients
In the setting of severely uncontrolled diabetes with catabolism, defined as fasting plasma glucose levels >250 mg/dl (13.9 mmol/l), random glucose levels consistently >300 mg/dl (16.7 mmol/l), A1C >10%, or the presence of ketonuria, or as symptomatic diabetes with polyuria, polydipsia, and weight loss, insulin therapy in combination with lifestyle intervention is the treatment of choice. Some patients with these characteristics will have unrecognized type 1 diabetes; others will have type 2 diabetes but with severe insulin deficiency. Insulin can be titrated rapidly and is associated with the greatest likelihood of returning glucose levels rapidly to target levels. After symptoms are relieved, oral agents can often be added and it may be possible to withdraw insulin, if preferred.
Type 2 diabetes is epidemic. Its long-term consequences translate into enormous human suffering and economic costs. We now understand that much of the morbidity associated with long-term complications can be substantially reduced with interventions that achieve glucose levels close to the nondiabetic range. Although new classes of medications, and numerous combinations, have been demonstrated to lower glycemia, current-day management has failed to achieve and maintain the glycemic levels most likely to provide optimal health care status for people with diabetes.
The guidelines and treatment algorithm presented here emphasize
achievement and maintenance of normal glycemic goals;
initial therapy with lifestyle intervention and metformin;
rapid addition of medications, and transition to new regimens, when target glycemic goals are not achieved or sustained; and
early addition of insulin therapy in patients who do not meet target goals.
|Interventions .
|Expected decrease in A1C (%) .
|Advantages .
|Disadvantages .
|Step 1: initial
|Lifestyle to decrease weight and increase activity
|Low cost, many benefits
|Fails for most in 1st year
|Weight neutral, inexpensive
|GI side effects, rare lactic acidosis
|Step 2: additional therapy
|No dose limit, inexpensive, improved lipid profile
|Injections, monitoring, hypoglycemia, weight gain
|Weight gain, hypoglycemia*
|Improved lipid profile
|Fluid retention, weight gain, expensive
|Other drugs
|α-Glucosidase inhibitors
|Weight neutral
|Frequent GI side effects, three times/day dosing, expensive
|Weight loss
|Injections, frequent GI side effects, expensive, little experience
|Short duration
|Three times/day dosing, expensive
|Weight loss
|Injections, three times/day dosing, frequent GI side effects, expensive, little experience
|Interventions .
|Expected decrease in A1C (%) .
|Advantages .
|Disadvantages .
|Step 1: initial
|Lifestyle to decrease weight and increase activity
|Low cost, many benefits
|Fails for most in 1st year
|Weight neutral, inexpensive
|GI side effects, rare lactic acidosis
|Step 2: additional therapy
|No dose limit, inexpensive, improved lipid profile
|Injections, monitoring, hypoglycemia, weight gain
|Weight gain, hypoglycemia*
|Improved lipid profile
|Fluid retention, weight gain, expensive
|Other drugs
|α-Glucosidase inhibitors
|Weight neutral
|Frequent GI side effects, three times/day dosing, expensive
|Weight loss
|Injections, frequent GI side effects, expensive, little experience
|Short duration
|Three times/day dosing, expensive
|Weight loss
|Injections, three times/day dosing, frequent GI side effects, expensive, little experience
Severe hypoglycemia is relatively infrequent with sulfonylurea therapy. The longer-acting agents (e.g. chlorpropamide, glyburide [glibenclamide], and sustained-release glipizide) are more likely to cause hypoglycemia than glipizide, glimepiride, and gliclazide. †Repaglinide is more effective at lowering A1C than nateglinide. GI, gastrointestinal.
|1)Begin with low-dose metformin (500 mg) taken once or twice per day with meals (breakfast and/or dinner).
|2)After 5–7 days, if GI side effects have not occurred, advance dose to 850 or 1,000 mg before breakfast and dinner.
|3)If GI side effects appear as doses advanced, can decrease to previous lower dose and try to advance dose at a later time.
|4)The maximum effective dose is usually 850 mg twice per day, with modestly greater effectiveness with doses up to 3 g per day. GI side effects may limit the dose that can be used.
|5)Based on cost considerations, generic metformin is the first choice of therapy. A longer-acting formulation is available in some countries and can be given once per day.
|1)Begin with low-dose metformin (500 mg) taken once or twice per day with meals (breakfast and/or dinner).
|2)After 5–7 days, if GI side effects have not occurred, advance dose to 850 or 1,000 mg before breakfast and dinner.
|3)If GI side effects appear as doses advanced, can decrease to previous lower dose and try to advance dose at a later time.
|4)The maximum effective dose is usually 850 mg twice per day, with modestly greater effectiveness with doses up to 3 g per day. GI side effects may limit the dose that can be used.
|5)Based on cost considerations, generic metformin is the first choice of therapy. A longer-acting formulation is available in some countries and can be given once per day.
GI, gastrointestinal.
This document was reviewed and approved by the Professional Practice Committee of the American Diabetes Association and by an ad hoc committee of the European Association for the Study of Diabetes (Ulf Smith, Gothenburg, Sweden; Stefano Del Prato, Pisa, Italy; Clifford Bailey, Birmingham U.K.; and Bernard Charbonnel, Nantes, France).
D.M.N. has received research grants for investigator-initiated research from Aventis and Novo Nordisk. J.B.B. has conducted research and/or served on advisory boards under contract between the University of North Carolina and Amylin, Becton Dickinson, Bristol-Myers Squibb, Hoffman-LaRoche, Lilly, Novo Nordisk, Merck, Novartis, Pfizer, and Sanofi-Aventis. M.B.D. has received research support from Eli Lilly, Merck, and Pfizer; has served on advisory boards for Amylin, GlaxoSmithKline, Merck, Sanofi-Aventis; and has been on speakers bureaus for Amylin, Eli Lilly, GlaxoSmithKline, and Pfizer. R.J.H. has received research support from GlaxoSmithKline, Minimed-Medtronic, Novartis, and Novo Nordisk and has served on advisory boards for Amylin, Bristol-Myers Squibb, Merck, Novartis, Novo Nordisk, Pfizer, and Sanofi-Aventis. R.R.H. has received research support from Bristol-Myers Squibb, GlaxoSmithKline, Merck Santé, Novo Nordisk, Pfizer, and Pronova and has served on advisory boards and/or received honoraria for speaking engagements from Amylin, GlaxoSmithKline, Lilly, Merck Sharp & Dome, Novartis, and Sanofi-Aventis. R.S. has served on advisory boards for Amylin, Bristol-Myers Squibb, Eli Lilly, Merck, and Takeda. B.Z. has received research support from Eli Lilly, GlaxoSmithKline, Novartis, and Novo Nordisk and has been a member of scientific advisory boards and/or received honoraria for speaking engagements from Amylin, Eli Lilly, GlaxoSmithKline, Johnson & Johnson, Merck, Novartis, Pfizer, Sanofi-Aventis, and Smiths Medical.
Simultaneous publication: This article is being simultaneously published in 2006 in Diabetes Care and Diabetologia by the American Diabetes Association and the European Association for the Study of Diabetes.
Posted on the World Wide Web at http://care.diabetesjournals.org on 27 June 2006.
© 2006 by the American Diabetes Association, Inc., and Springer-Verlag. Copying with attribution allowed for any noncommercial use of the work.


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Unetbootin lets users set up almost any distribution on a bootable USB
Vampire hunter Van Helsing always has some holy water along for emergencies; Daywalker Blade relies on silver stakes. Experienced Linux users are more likely to resort to Linux on a USB stick to exorcise viruses from infected Windows computers. Thanks to Unetbootin, setting up an electronic emergency tool on a stick does not take much time. The installer lets you install various Linux distributions quickly and securely on an empty USB stick. Then you can use the stick to boot other computers. Unetbootin will roll out live versions as well as installation and netboot variants. If you are not happy with the default selection of distributions supported by Unetbootin, you can feed the tool an ISO file for your favorite distro. Timeconsuming workarounds necessitated by alternative tools such as Pendrivelinux are thus a thing of the past.
To install Unetbootin, copy unetbootin-linux-323 (from the DVD that came with this issue or from the website) to your home directory and make it executable:
$chmod u+x unetbootin-linux-323
The "Installing Unetbootin" box describes the steps for setting up Unetbootin in openSUSE 11.1 and Ubuntu 9.04. These steps should work for other distributions as well.
Preparing the USB Stick
Before you dive into Unetbootin, you might want to prepare your USB stick for installation by deleting the existing data and reformatting the stick. On open SUSE, type su root to become root; on Ubuntu, add sudo to the start of the command line.
To start, type sudo umount /dev/sdb1 to mount the stick, replacing /dev/sdb1 used in this example with the correct mount point. To discover the mount point ID, launch a terminal and type tail -f /var/log/messages shortly before unplugging the stick. The sdb: sdb1 line tells you that your system has assigned a device file of /dev/sdb to the stick, which has a partition called /dev/sdb1.
Now, working as root, type fdisk /dev/sdb to launch the Fdisk partitioning tool; the tool is controlled from the keyboard. Type P to discover how many partitions are on the stick. Then press D and type the partition number to delete the partitions. If the stick only contains one partition, you do not need to specify a number. After deleting the partitions, press N to create a new partition; it needs to be a primary partition (P). To use the first partition, select -1 then press Enter twice to use all the sectors on the stick. Pressing A and -1 enables the partition you created by setting the boot flag; now finish the preparation work by pressing W (for "write"). Fdisk now writes all the changes to the stick; you can cancel at any time before this. The next step is to format the empty – and still unmounted – partition with the ext3 filesystem. To do so, become root and type mkfs.ext3 -b 4096 /dev/sdb1, again replacing sdb with the device file for your USB stick. Linux will now write a fresh filesystem to the stick; this can take a couple of minutes. Linux writes blocks of 4KB (as defined by the –b 4096 option) to speed up the process. If you want to store Windows files on the stick, you need to run the mkfs.vfat -F 32 /dev/sdb1 command to create a FAT32 partition. The drawback to this option is that FAT32 does not support files of more than 4GB. After completing the format, unplug the stick, plug it back in to the USB port, and make sure the system mounts it again. In the file manager, you should now see a Lost+Found folder – but nothing else.
Installing Unetbootin
In openSUSE 11.1, make sure you have administrative privileges by typing su root, then type ./unetbootin-linux-323 to launch the file. For the sake of completeness, you might prefer running YaST and installing the p7zip package before you start, although the software will run without this dependency. On Ubuntu 9.04, working with a normal user account, type your administrative password after launching Unetbootin with the ./unetbootin-linux-323 command. Additionally, you can use Synaptic to install the p7zip-full package, which the software requires.
Unetbootin in Action
With the empty, mounted stick prepared, it is now time to launch Unetbootin. In the Distribution pull-down menu select your favorite distribution and the matching version number on the right. The small text box below this tells you something about your choice of distribution. At the bottom, select USB drive as the Type, and select the newly created sdb1 partition from the drop-down menu to the right. If you choose Show all drives, Unetbootin will list other drives – this is useful if you are not sure you have found your USB stick. Pressing OK launches Unetbootin – sink or swim time.
If everything goes as expected, the software will download an ISO from an FTP server, unpack the ISO, copy it to the stick, and generate a matching configuration file for the Syslinux bootloader. Unetbootin then finishes the transaction with a message and presents the buttons Reboot now and Finish. That's all there is to it. As your final trick, you can check to see whether the image really does boot properly from your stick.
Fast and Manual
Downloading the files can take some time. To speed up the process, pass in the ISO file manually. To do so quickly, download the ISO via BitTorrent and, in the Unetbootin GUI, specify the path to the ISO file as your Image. If you want, you can even specify the kernel and initrd file versions. This makes sense if you use a non-standard kernel with a specific feature or one that works better with your hardware. Often, it is quite useful to add a couple of Options to the boot process to make sure that Linux works with your hardware. Favorite kernel parameters in the case of hardware problems include ide=nodma (for problematic IDE drives) and acpi=off (to avoid trouble with nonfunctional or missing power management).
All told, Unetbootin is not just a convenient piece of software but a pretty mature one, too. However, nothing is perfect. For example, you still might not be able to install certain distributions. As a case in point, in our lab, we had trouble installing the SliTaz operating system, although Puppy Linux, Elive, and a KDE 4 Live version based on openSUSE worked fine. If the automated installation does not work, you can always try downloading the image manually from the web page and following the steps for the manual install.
Source of Information : Linux Pro Magazine August 2009

subset: commoncrawl


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I remember standing at the altar, watching as she crossed the courtyard toward the church. I remember smiling so much my cheeks hurt; I remember the pride and appreciation I felt knowing I was about to be her husband; and I remember a momentary breeze lifting a stray strand of hair away from her face, like God's finger gently brushing it aside as she entered the chapel. As with any rare occasion when we don't enter a room together, our eyes found each other immediately. So much was said to each other during that long walk to the altar. Not in words, but spoken between our two hearts — in a language we had been fluent in from the moment we met…
Seven years ago today, I became the man I was meant to be by marrying the woman I was meant to be with. The moments we have shared since then are more than memories — they are carried within each pulse that beats from my heart; like a constant and steady flow of warmth and wonderment inspired by her presence. We came into each other's lives as parts of a fractured whole, survivors with scraped knuckles from time spent trying to repair broken marriages with parts from ourselves. Perhaps because of this it was easier to recognize one another when our hearts met for the first time. And perhaps because of our past experiences we were able to appreciate even more the rarity of what we felt.
Or perhaps what we felt was simply knowing we had arrived at a destination that had been set into motion long before we met.
The first year of our relationship was spent long distance, taking turns traveling the two hours between my home on the coast and hers in the valley. Though my divorce had been finalized, hers was still pending as her ex-husband bickered.
Today, as I sat down to write this, I happened upon an email I sent to her one morning. She was checking it frequently for word from her lawyer regarding the finalization of her divorce. I wanted this to be waitng for her instead…
Good morning, My Sweetheart.
I know you are checking your e-mail regularly — for reasons that I wish were different — so I thought I'd take take this opportunity to tell you a few things that I hope will bring a smile to your face and comfort to your heart…
Moving closer to daily life with you — whether in steps or leaps — is closer than I ever imagined I would get to the kind of Love I feel for you. As difficult as it gets at times having to wait for motion to build into momentum, I only have to stop and remind myself that regardless of the things I can't control when it comes to getting to the place I want to be with you, nothing can take away from the fact that we found each other… and that the Love we share carries us through each day.
Each packed box you send home with me; each time we tuck the kids into bed together; every morning we get the chance to wake up and look into each other's eyes or spend our first waking moments on the phone together… they are things we will look back on in the years ahead with smiles, with wonderment, and with appreciation for each other and the gift of our Love.
Sweetheart, I waited so very long to find You — the Love of My Life. The weeks or even months ahead are a small price to pay for a lifetime with you.
You are so worth the wait…
After seven years, I still can't help but smile whenever I see her; I am still in wonderment of what we have together; and I am filled with appreciation for being the man who wakes next to her each morning.
Here's why…
My sincere and heartfelt thanks to all of you for taking the time to share in the meaning of this day with us.


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Cleanup work after BP oil spill ending in Florida, 2 other states
NEW ORLEANS — BP PLC says cleanup work is ending in three of the states affected by the company's massive 2010 oil spill in the Gulf of Mexico.
The London-based oil giant said Monday that the Coast Guard is concluding "active cleanup operations" in Mississippi, Alabama and Florida, but the work continues along 84 miles of Louisiana's shoreline.
The Coast Guard will continue responding to reports of oil that washes up anywhere along the Gulf Coast. BP says it will take responsibility for removing any oil that came from its blown-out Macondo well.
BP says it has spent more than $14 billion on response and cleanup activities, with more than 48,000 people involved in those efforts at the height of the spill's aftermath.
Check back later for more details


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This is just another factual refutation of the mainline media's ideological propaganda.
Republicans have had bullets shot through their windows and bricks smashed through their windows. In fact, several bricks have been smashed through several Republican windows. And here we are now, with an article detailing the arrest of a man who made a death threat against a Republican "bitch" politician.
April 19, 2010
Arrest made in threat against Rep. Ginny Brown-Waite
A 66-year-old Hernando County man has been arrested in connection with a threatening voice mail message left at the district office of U.S. Rep. Ginny Brown-Waite, R-Brooksville. According to the FBI, agents arrested Erik Lawrence Pidrman at his home in Spring Hill without incident Sunday.
On March 25, Brown-Waite reported that someone left the following message: "Just wanna let you know I have 27 people that are going to make sure that this b**** does not live to see her next term. Good-bye."
The call came amid reports that a number of Congressional Democrats have gotten threats or had bricks thrown through their office windows following a contentious vote on health care legislation Sunday. It was not known Monday afternoon what allegedly caused Pidrman to make the call.
The integrity of the media has long-since been blown for all to see. The above story is about a Republican who was threatened with death. But the liberal bird cage liner otherwise known as the St. Petersburg Times just couldn't help but make the story about Democrats being the "real" victims.
The paper makes no attempt to mention the repeated acts of violence against Republicans, but instead deliberately makes it appear as though it is merely one rather insignificant isolated incident against a sea of acts of violence against Democrats. If anything, it is the other way around.
There's no mention of the crowd of leftist thugs hunting down and beating a Republican Bobby Jindal official and her boyfriend. There's no mention made about a lot of things.
Not that the left gives a damn about integrity. They are postmodernists who don't even believe in truth; so all that remains is rhetoric and demagoguery.
Bill Clinton just came out and directly compared the anger of the tea party movement to the climate that surrounded the bombing of the federal building in Oklahoma City. The media was all over that story, piling on to demonize the tea party movement, but only a tiny, tiny few have bothered to demand where the hell Bill Clinton was during the unhinged leftwing hatred during the Bush years.
Meanwhile, when Timothy McVeigh was asked why he did what he did, his answer wasn't "Rush Limbaugh," but rather something extremist and awful that the Clinton administration did: basically, massacre women and children during Clinton-era attacks on Waco and again at Ruby Ridge.
From Wikipedia:
Motivated by his hatred of the federal government and angered by what he perceived as its mishandling of the Waco Siege (1993) and the Ruby Ridge incident (1992), McVeigh timed his attack to coincide with the second anniversary of the deaths at Waco.[9][10]
You mean he didn't time his blowing up a building to honor Glenn Becks's birthday?
Maybe you should have blamed YOURSELF for the Alfred P. Murrah Federal Building bombing rather than a group that didn't even exist yet, you "it-depends-on-what-the-meaning-of-the-word-is-is" weasel. Maybe the mainstream media shouldn't trust a slimebag who forfeited his law license because of proven dishonesty. I'm just saying.
Basically, it all depends on what the meaning of "political demagogue" is, doesn't it, Slick Willy?
But don't worry, Democrats. Because the mainstream media is always there to tell big government Democrats, "Hi, I'm from the mainstream media, and I'm here to help."
The media constantly refers to the tea party movement as "anti-government." It's the heart of the Democrats' case that we're dangerous and could resort to violence. The fact that that isn't even remotely true is simply dismissed as entirely irrelevant.
The New York Times and the Associated Press just today used the identical same phrase: "This anti-government feeling has driven the tea party movement, reflected in fierce protests this past week." Without ever once reflecting on how biased that extremist label is. I have never ONCE seen an "anti-government" tea party protester. None of us want to abolish all government. "Anti-government" IS an accurate label to apply to extreme leftwing anarchist groups; but tea party protesters are PRO-limited government – and are most certainly NOT "ANTI government." But the incorrect and charged label that the media deliberately use creates an extremist and disturbing image. Which is exactly what these professional propagandists want.
Now, do you really want to see "anti-government" hate? Why don't you go to a liberal Democrat rally in which the crowd repeatedly chanted "FUCK THE USA!!!." Democrat Maxine Waters helped stoke the hate to furnace-levels that day.
Or how about Nancy Pelosi telling anti-Bush protesters, "I'm a fan of disruptors!" in 2006.
I might also point out that Barack Obama got his start in politics by benefiting from a fundraiser in William Ayers' – former terrorist bomber of the Weather Underground – living room. Obama then served on several boards of directors with said anti-government terrorist. And there's darned good reason to believe that that same anti-government terrorist helped him write his first book.
William Ayers – now an esteemed liberal professor and member of the liberal community in good standing – bombed several U.S. government buildings, and was responsible for the murders of innocent human beings. How the left must have cheered when he said, "I don't regret setting bombs," and added: "I feel we didn't do enough."
And do you want to know when he said those hateful words? On 9/11, the day that nearly 3,000 Americans were murdered by al Qaeda.
Mind you, that sentiment was basically shared by Obama's handpicked "reverend" of more than twenty years, as Jeremiah Wright said of 9/11: "America's chickens have come home to roost" following an anti-American diatribe.
If you really want to deal with anti-government hate, you maggot-souled liberal cockroaches, how about if you expose yourselves for once in your worthless lives?!?!?!
Pew just released a poll that demonstrates that 80% of Americans are anti-government rightwing extremists. Because 80% of Americans agree with the Tea Party and DISTRUST the Obama administration. And oh, isn't that exactly what the tea party has been saying for more than a year, now?
And this result is basically the lowest result in a half century. Which is to say, hey, lefties, the American people trusted George W. Bush MORE than they trust your damn big government socialist messiah.
And for damn good reason.


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Monday, February 6, 2012
Our World - Elephant Parade in Singapore
There were 162 elephants on display at well-known places for two glorious months starting from 11th November 2011 to 11th January 2012.
Here are some that caught my eye. Each of them is so cool and seems to have so much personality.
The objective of the Elephant Parade is to to raise public awareness for the conservation of Asian elephants. All of the elephants will be auctioned off and part of the proceeds will go towards The Asian Elephant Foundation and Wildlife Reserves Singapore Conservation Fund.
It's really sad when you hear that elephants are mercilessly hunted and killed for their tusks and their bodies left to rot. I hope the awareness campaign helps to prevent the extinction of elephants from their natural habitat.
Nature's great masterpiece, an elephant; the only harmless great thing.
- John Donne
Our World
20 comments:
These are lovely elephants, they're wonderful.ReplyDelete
- AnonymousMonday, February 06, 2012 7:14:00 PM
How cute. There are similar ones in zoos and amusement parks in our country.ReplyDelete
Such charming and magnificent animals!ReplyDelete
Wow! Those elephants are beautiful! : )ReplyDelete
These are cute elephants. I hope the auction raises a good amount for the charity and that Asian elephants can be saved. I think African elephants are in danger as well.ReplyDelete
Bonza photos, i especially like the Elephant in the 3rd photo depicting birds in full flight or just resting :-).ReplyDelete
Great series of shots of the elephants of this great initiative!ReplyDelete
How delightful! I love them and what a great objective! I do hope it helps save these magnificent animals! Your photos are terrific! Thanks for sharing! Enjoy your week!ReplyDelete
beautiful way to spread awareness!ReplyDelete
lovely captures!
These elephants are very cute.ReplyDelete
They are no longer around , being sold off in auction. Some of them do look cute.ReplyDelete
Magnificent sculptures. These elephants are true works of art, charming. Greetings.ReplyDelete
I hope they will have this same event if I visit SG again soon. Very colorful and educational event.ReplyDelete
Good idea, good campaign, and lovely street art! You mat be aware that you may see something similar in Europe but with cows (have you seen them in Vienna?)ReplyDelete
What a fun exhibit you got to see. I love animals, even the non real variety you have posted here.ReplyDelete
What a charming display. I love elephants!ReplyDelete
I seen it in the singapore zoo too, 3rd photo of elephant sculpture.ReplyDelete
Very nice photos of colorful elephants!!!!ReplyDelete
It's a very proper action to keep the balance in nature!
Many greetings and kisses
Oh wow! I love this! Elephants have always been my favorite... I would have loved to be there for this :)ReplyDelete
Stunning! I loved the Elephant Parade when it was in London and these Elephants will be all new as the London ones were auctioned off. They are so cute - thanks for sharing.ReplyDelete


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Sustainable Urban Mobility by WRI
EMBARQ catalyzes and helps implement environmentally, socially, and financially sustainable urban mobility solutions to improve quality of life in cities.
Founded in 2002 with the help of Shell Foundation, EMBARQ is now part of WRI Ross Center for Sustainable Cities, focusing on sustainable urban mobility as part of WRI's broader sustainable cities program.
EMBARQ has 12+ years of history making sustainable transport a reality in cities through continuous on the ground presence in Brazil, China, India, Mexico, Turkey, and the United States. Our sustainable urban mobility expertise lays in collaboration with local and national authorities, businesses, and civil society to reduce pollution, improve public health, and create safe, accessible, and attractive urban mobility solutions.


text: Robert G. Brown wrote: > > This is where Vista is a major screw up. Nobody cares about DRM > compliance but the DRM police. Nobody cares about multimedia systems, > and since functioning multimedia now fits in $500 telephones people are > understandably cynical about needing multicore multi GB systems to make > it work. What people DO care about, very much, is having a system that > happens NOW, click to keyboard, at their actual UI. Microsoft is in > deep trouble... > > rgb > I've missed a good RGB rant for awhile and this is a good one. It would be good even if I didn't agree with it. I wish that I thought that corporate IT would take the issues seriously. But, I don't. Too many people have their "Certifications," and I believe that there is so much entropy that real change will require even more than lack of usability. Thanks RGB, I needed that... Mike


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- News Releases
- Topics
- Podcasts
- Archive
- About
ROCHESTER, Minn. ― Jan. 21, 2014 ― Researchers at Mayo Clinic have found amplification of HER2, a known driver of some breast cancers, in a type of bladder cancer called micropapillary urothelial carcinoma (MPUC) and have shown that the presence of HER2 amplification is associated with particularly aggressive tumors. These findings suggest that administering trastuzumab to MPUC patients with HER2 amplification could improve outcomes, just as it has for breast cancer. The study is published in this month's Modern Pathology.
Journalists: B-roll of images and sound bites with Dr. Cheville are available in the downloads.
As with breast cancer, HER2 amplification in MPUC results in a faster growing form of cancer that spreads quickly and has a higher chance of recurrence. The hope is that combating this amplification with trastuzumab, a drug that is effective in HER2 positive breast cancers, will result in effective therapy against bladder cancer.
"These findings show it is critical for pathologists to recognize this type of bladder cancer and that providers should be aware of and order the appropriate tests," says John Cheville, M.D., a Mayo Clinic pathologist and lead author of the study. "This will be essential for any clinical trial examining the effectiveness of trastuzmab in treating MPUC."
The study identified HER2 amplification in 15 percent of patients with MPUC, compared to 9 percent of typical bladder cancers. Patients with HER2-amplified MPUC were more likely to have aggressive tumors than patients whose tumors did not have HER2 amplification, according to this study.
"Targeted treatments for HER2 positive breast cancer have led to markedly improved survival," says Dr. Cheville. "In one sense, what we are trying to do with HER2 positive bladder cancer is a relatively simple thing. We are trying to identify prognostic and therapeutic biomarkers, and ultimately match the most effective drug to the individual patient's tumor, rather than its location in the body."
HER2 is a very important target in breast cancer therapy, and gene amplification occurs in approximately 20–30 percent of cases, says Dr. Cheville. Using the latest molecular techniques, researchers in the Mayo Clinic Center for Individualized Medicine's Biomarker Discovery Program determined that some bladder cancers similarly show HER2 amplification and produce too much of the HER2 protein product, resulting in more rapid tumor growth and expansion.
This type of individualized therapy represents the future of cancer care, and findings like the one reported in Modern Pathology are only the beginning of many more to come, Dr. Cheville says. Last year, the Biomarker Discovery Program identified and validated 12 different molecular/genomic markers, most of them related to the diagnosis, treatment and prognosis of a variety of cancers.
About Mayo Clinic
Recognizing 150 years of serving humanity in 2014, Mayo Clinic is a nonprofit worldwide leader in medical care, research and education for people from all walks of life. For more information, visit 150years.mayoclinic.org, www.mayoclinic.org and newsnetwork.mayoclinic.org.
About the Mayo Clinic Center for Individualized Medicine
The Center for Individualized Medicine discovers and integrates the latest in genomic, molecular and clinical sciences into personalized care for each Mayo Clinic patient. Visit http://mayoresearch.mayo.edu/center-for-individualized-medicine for more information.
Sam Smith, Mayo Clinic Public Affairs, 507-284-5005, firstname.lastname@example.com
Shortly before Thanksgiving 2021, Jerry Haines, a part-time farmer and retired butter and cheesemaker, was helping another farmer with fall chores. He felt good but ...
May is Bladder Cancer Awareness Month, which makes this a good time to learn about the risk factors for bladder cancer and what you can do ...
May is Brain Cancer Awareness Month, which makes this a good time to learn about metastatic brain cancer. Overall, the chance that a person will develop ...


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The Rose Ball
An exclusive collaboration between Boris Van Dyck of IceBox Bar and Camille Key of Charleston After Dark, will be held on Wednesday, December 31, 2014, at the Johnson Hagood Stadium. Guests will enjoy a fashionably upscale New Years Eve Ball inside the Club Level & VIP patio from 9:00 pm until 2:00 am, with all-inclusive hors d'oeuvres and bar service, different genres of entertainment, visual and artistic production inside and outside on the football field, along with beautiful rooftop views of the entire city. Dress to impress in whatever makes you feel good, whether you feel like dressing up for a sophisticated ball or just a classy night out on the town. Indoor and outdoor access will be available throughout the night, with additional seating areas for all guests.
New Years Eve Dinner At Circa 1886
Circa 1886 restaurant celebrates the arrival of 2016 with a festive six-course prix fixe New Year's Eve dinner on Thursday, December 31. Enjoy a festive evening at Circa 1886 Restaurant on the grounds of the Wentworth Mansion.
Cost: $125.00 per person excluding gratuity and tax, and cost includes a complimentary glass of champagne. Other beverages are not included in the cost.
New Year's Eve Beach Bash
What better place to celebrate the New Year than Charleston's finest oceanfront venue at The Tides on Folly Beach! We have a fun-filled evening planned with amazing food, plentiful libations, live entertainment and a spectacular fireworks show!
Spend your last hours of 2012 on the dance floor. DJ C-Nile will be getting the party started downstairs, while Ntranze will be providing live music upstairs.
Open Bar
It wouldn't be a New Year's Eve Party with out an Open Bar. Please drink responsibly and remember, rooms packages are available!
Lavish Buffet
Replenish your energy spent on the dance floor and feast at the Buffet. Our lavish buffet includes shrimp, cheeses, and other foods.
Yorktown Countdown
Bring in the New Year with Charleston's largest annual New Year's Eve celebration! On Thursday, December 31st, 2015, the USS Yorktown Aircraft Carrier in Mount Pleasant, SC will not be occupied with the usual wanderers exploring a decommissioned ship. Instead, the venue will be transformed into the third annual Yorktown Countdown, Charleston's largest New Year's Celebration. Charleston's premier aircraft carrier ball drop party will provide two admission level options, great music, premium spirits, special appearances and entertainment, with magnificent views for the holiday festivities.
From 9:00 PM until 1:00 AM, guests of the event will see live bands and DJs from all genres imaginable, including funk, rock, dance, and Top 40 Billboard hits. Headlining acts include MVP, a high-energy dance band with members that have been a part of major accomplishments in the music business. The musicians and vocalists of MVP have recorded alongside or shared the stage with such greats as Patti Labelle, Trey Songz, James Brown, George Clinton and Parliament Funkadelic, Keith Sweat, Lil John, Widespread Panic and many more. The group specializes in a variety of different styles from Motown and beach to classic R&B and rock, 70s, 80s, hip-hop and contemporary dance. Case and point, once you experience them, you will know why they are called MVP.
Next up is SoulPlay, a diversified group of entertainers from Raleigh/Durham, NC who share a unique variation of talent from youthfulness to years of experience. This 7-piece super group will play classic, funk, disco, beach, and today's latest hits. Similarly speaking, Lectra Lust is one of Charleston newest and upcoming bands. The quartet describes their sound as "cerebral synth pop," offering listeners a new sensation, stimulated by a sleek layer of synth driven new wave overtones and warm accented vintage guitar textures, which are all commanded by rhythmic nu disco breakbeats and highlighted by driving bass lines. Finally, dj performances by Sparkbox and Kilgo, Clark Keagy on saxophone and Seth G on violin will create the high-energy icing on the cake as guests will be able to enjoy every remaining genre from the past 5 decades.
First Aboard (General Admission) and Captain (VIP) tickets go on sale October 1st and will offer guests a variety of options aboard the ship. First Aboard tickets will start at $100 per person and include an all-inclusive full service bar, light hors d'oeuvres, and access to the indoor airplane hangar as well as access the outdoor fantail area (on the same level). Captain tickets start at $150 per person and will give patrons the complete Yorktown Countdown experience offering everything under First Aboard, plus access to the Yorktown's rooftop flight deck (which will be tented and heated), a top-shelf all-inclusive bar, premium entertainment, big-screen ball drop, and much more.
New Years Eve Dinner Cruise
Celebrate the New Year with style aboard the SpiritLine Dinner Cruise. Our Executive Chef, Mason Mullock a graduate of the Culinary Institute of America in New York will prepare an exquisite four course dinner that is sure to delight, served by an attentive wait staff, eager to make your experience exceptional.
You will enjoy the best that Charleston has to offer while cruising aboard the elegantly decorated Spirit of Carolina. New this year will be a musical trio on both decks to enhance the evening with dancing and great live music!
Price per person is $95. Boarding time begins at 9:00pm. Cruise time is from 9:30pm to 12:30am
Whatever you do for New Year's Eve, be safe!


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It's Friday the 13th of October, the air is frosty and fresh, the trees are rustling in golden and the sun is low in the sky - blinding me as a drive home after a B E A UTIFUL day at Arnprior Farm's Pumpkin Patch. I have always wanted to visit a pumpkin patch! There … Continue reading Hello Pumpkin
55.864237 -4.251806


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I don't turn water into wine… (not in the miraculous Biblical sense "Christians" crave. If you want me to change water into wine… you'll need to bring mature fruit add a fermenting agent , flavor it with great extracts, wait for the process to work and then take the responsibility of letting the poisonous gasses out in a systematic manner. Trust me it works.
One day I'll write a tell all! Till then I'm simply a being trying to make a difference in my journey through this space and time.
There is no way around change… you have to do things you've never done before. take chances with new technology and have solid measurable goals and objectives.
My name is Bonnie Sandy and I am what a black female in tech looks like.
There are many who would try to change that but the fact that what I do works, That I understand this field and that of creative Industrialism and that i have tested many of my theories is solid. something that PR and greater agendas cannot change. You cannot manufacture" what i bring to the table… Or what I lack… It is the same for many who can make a serious difference in the fate of our people.
Instead what we have is a lack of support systems and "old thinking that stifles innovation and growth!
I am what "changing the ratio" or "challenging the divide' looks like. I am an excellent speaker but chances are you will not find me on the podium. I like working testing strategizing, affecting CHANGE!
A while back I made an effort to become more "social" and share my knowledge and expertise as well as learn from other so I joined several groups on Facebook and Google Plus. BTW as an Independent that formula needs to be streamlined. It occurred to me that i should"introduce myself" Sure i can easily cut and paste the short into at the top of my "about" page…
I'm a B.A.D.A.S.S.E Creative Ein-dustries advocate with an amazing track record is affecting the businesses of creatives..I design test and deploy tech enabled solutions for the art, marketing & business of makers! I also conduct seminars, workshops and projects around creativity, entrepreneurial strategy and technology. A fashion designer by training , I AM a black female cofounder and who now specializes in Product Development & Creative Industries Entrepreneurship.I'm not interested merely is building individual design entrepreneurs- I'm interested in building out larger, global ecosystem of Creative "EIN"dustrialist who build businesses that scale, trickle and affect the lives of others in other words I am committed to leveraging new media and emerging technologies to help mom & pops take their local businesses global & bring global businesses local and I"m Interested in all that connect, showcases, sells, inspires & celebrates the C's to Change :- creativity, culture, community, collaboration, corporations + commerce
But what do others, in my community say about me,
How do they introduce me.. I'd like you to meet,
Bonnie… she speaks tech
this is Ms Sandy she speaks tech
oh she's Yohane's mom … she speaks tech
She's a Mother , Woman, Black, Caribbean, Trinidadian, Caribbean, fashion designer … and She Speaks Tech"…
I'm from Trinidad where technology was introduced in high schools over 30 years ago, where the systems analyst and programmers in my fathers office were Blacks, some were women, 30 years ago. So why in The USA, In NY is my being a black female strange. Why do I still count the number of Black, females & Black females, in the room at tech events.
My father was a computer programmer, My brother and several other relatives not only code but have tech startups… i was certified in Cobol in 1986 (yes you read right LOL). I've been following NYtech scene since 2006/7. I was an instrumental part of the NY Fashion tech unconference in we started in 2009 (before I went rogue) … Save for barcamps I seldom get the time to attend tech events in NY.
The image used in the pic was taken (by Eliceo rodriquez) as I rested against the wall of a building in my community. I' purposely choose to be visible sitting in local cafes and lounges with my laptop so that I am accessible… eventually someone will walk up to me or more often than not introduce me as this is
These days In the Flatbush community I reside in there are few cafe's or lounges suitable for meetings. my clear can hold up to eight persons but as Burger King chose to cover their outlets it's the Mc Donalds'. I answer questions as simple as using saving (or finding) images Gmail or another Google feature , setting up Google voice as a phone service and of course help me, "I need to make money..".
I'm also equally comfortable in the NY tech scene… at hacks at Barcamps at coworking spaces.. I just do not have the time to attend them often. my Linkedin profile show endorsements for over 45 skills many were added by my network, what they recognized my expertise as, is in itself revealing.
So I'm owning IT!
My name is Bonnie "she who speaks tech" Sandy …
You can see a more detailed info on who I am and my experience and expertise at www.bonnieSandy.com, I suggest visiting the "ABOUT", "PRE-STARTUP" Tabs and their drop down menus My current focus is Designing A Creative Industrial Curriculum (and relative platforms) for a Converging Marketplace. https://www.bonniesandy.com/


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He walked into the house.
"You, my friend are living on borrowed time." She said
Shocked at the statement and unsure of what was wrong he went into the living room.
"What we had in the past was great, don't get me wrong, you did everything I needed you to but that has now ended. You are no longer reliable or fast, and I have had to restart you one too many times. And no it's definitely not me, it is without a doubt you."
"You really need to stop talking to inanimate objects love." He said with utter relief.
As part of the AtoZ challenge I am writing flash fiction of no more than 100 words. Today's prompt was…
Living on borrowed time
You can catch up with my other entries for this year's A to Z here.


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Last month, I had the pleasure of visiting Vinalhaven, Maine, a small island in Penobscot Bay. You have to take a ferry to get there. We had dense fog for the entire ferry trip, but it just made Vinalhaven seem like a magical land, hidden in the mists.
Round trip fare for a car or pick-up truck: $49.50. Round trip for a person: $17.50. Round trip for a bicycle: $16.50. Hmm, that doesn't really seem fair, does it? My bike weighs about 1 percent the weight of a car… Oh well, it's a beautiful island and it was definitely worth it to bring a bike. I mean, check this out:
What's that in the distance, you ask? Oh, it's just three electricity-generating windmills.
I'm sure there was some controversy before they were put up, people complaining about "ruining the view" and whatnot, but I'd say they improve the view – they are a sign of progress and a hope for a future full of renewable energy. Of course, back in the day, people probably thought that smokestacks were a sign of progress, modernization, and industrial strength.
One sign of progress completely absent from Vinalhaven: cell phone towers. I didn't mind so much, it was nice to be completely off the grid for a few days. It was nice to ride around the island, stopping here and there. I probably didn't even need to lock my bike (but I did, since I'm a city slicker).
I had a great, relaxing visit to the island, only slightly tarnished by the following interaction with the ferry worker who took my ticket: I was waiting to board the ferry to leave the island, chatting with my friends who were staying for a couple more days.
Ferry Worker: Do you have your tickets ready?
Me: [thinking she was asking for the tickets for me and my friends] Oh, it's just me going… Oh, you mean the ticket for my bike. I forgot that I bought a ticket for it too.
FW: Some people think we should encourage people to bring bikes to the island, but really it's the opposite, we should discourage them.
Me: Why's that?
FW: The roads are too narrow here, it's dangerous.
Me: [trying to remain upbeat] Oh, I found that everyone who passed me gave me plenty of room, I really didn't have any problems at all.
FW: Well sometimes, a car can be coming around a curve and you can't see them.
Me: Well, it's so nice and quiet on the island, I could hear the cars coming from quite a ways away, so if someone was about to overtake me and I could tell that it wasn't safe, I just stuck out my left hand and the car behind me would wait a couple seconds until it was safe to pass. I found that everyone was pretty patient and they only had to wait a couple of seconds.
FW: Oh no, these fishermen around here are some of the least patient people you'll ever meet.
Me: Well, I've biked many different places and I found everyone here to be very polite.
FW: I've talked to bikers from all over and they say that Maine drivers are the worst.
Me: [needing to board the ferry by this time] Well, that hasn't been my experience.
FW: People can get killed on these roads, you were lucky.
I was walking away by the time she said this. Of course, once I was in the middle of the bay, I thought of how I should have responded:
Me: Yeah I guess was lucky. Everyone I met on Vinalhaven was very polite, that is, everyone I met until just before I left.
So, thanks Vinalhaven Maine Ferry Service, part of the Maine Department of Transportation. Thank you for the great send-off.


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Deep Drawable Steels: Part One
Thermo-Mechanical Treatment (TMT) of Non-Ferrous Alloys: Part One
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Blast cleaning is the general term for the process of using mechanical energy to clean a range of material surfaces using numerous different materials and techniques.
Blasting abrasives which are fired under pressure at the surface, include wire clippings, silicon carbide, ice, walnut shells, glass, baking soda, sand, and steel grit depending on the surface to be cleaned.
Abrasive blast cleaning is a cleaning technique in which mechanical energy is used for the cleaning of surfaces by use of specific materials which are directed at a surface with a powerful blast and at high velocity. Air blasting is a very common blast cleaning technique used in many regions of the world, and there are other types of cleaning systems available as well. Some companies offer blast cleaning services, for a fee, and it is also possible to purchase or rent the equipment to perform this type of cleaning independently.
In blast cleaning, a variety of cleaning materials can be used, depending on the surface which needs to be cleaned. Some common options are wire clippings, silicon carbide, ice, walnut shells, glass, baking soda, sand, and steel grit. These materials are directed at a surface to be cleaned with the assistance of a jet of air, a rapidly moving wheel, or a similar system. The blast cleaning device usually provides the ability to adjust the focus and intensity for the purpose of controlling the cleaning very precisely.
The two main factors that can be varied in blast cleaning are the type of particle that is "blasted" and the pressure at which this is done.
Pressure: The pressure can normally be adjusted during the job to ensure that only the desired layers of material are removed. Using an overly high pressure is inefficient in that more energy is used than is necessary and also more particles will be used, therefore increasing cost and the amount of waste. A small test area, ideally somewhere discrete, is chosen and used to find the exact pressure required for the job. If the surface that is to be cleaned or treated is not uniform, the pressure may need to be adjusted as the work is carried out. This is a difficult task and requires a highly skilled and experienced person.
How is Blast Cleaning Used?
Aircraft: Cleaning and peening jet rotor blades and other precision parts. Cleaning welds, castings, manifolds, subassemblies, and parts before magna-fluxing or a heat treating. Cleaning carbon from exhaust stacks to prevent fire and carry out general aircraft maintenance.
Automotive: Removing corrosion, old paint and grime from bodies, fenders, and wheels. Cleaning indentations and other areas not accessible to hand sanders. Removing carbon, gum, and varnish deposits from internal engine parts.
Bicycle Manufacturers: Cleaning mil scale, flux and all foreign matter in preparation for new coating.
Cement & Cast Forms Manufacturers: Removing cement from pre-cast forms leaving the exposed aggregate. Cleaning residue from molds, forms, crushers, rolling stock, and for general plant maintenance.
Cylinder Repair: Removing old plant paint and grime from gas cylinders during required inspection and pressure testing periods.
Contractors: Removing heavy corrosion and old paint from equipment, steel and stone structures.
Circuit Boards: Light deburring and cleaning flux and solder splash.
Deburring: Removing light burrs from miscellaneous materials.
Electrical & Electronics: Cleaning transistor bodies and leads, and ceramic seals. Removing excess brazing and solder from wire guides.
Surface Preparation is used to remove existing paints / corrosion / oxidization / graffiti and to give the surface an etch to allow coating adhesion. In many cases Abrasive Blast Cleaning can provide the optimum method of surface preparation. Some of the advantages are detailed below:
Typical examples of Blasting methods and equipment are:
Blasting can be done via Open or Contained methods:
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I don't care how enticing radical, second-wave feminism's career oriented lifestyle sounds in college because whether on paper, or in person, it will end badly. And, despite the feminist's assurances of perpetual influence, youth and relevancy, everybody, especially women, gets old, haggard, out of touch and inconsequential. That is just how nature works.
Nobody gets out of this world alive. Everybody ages and eventually dies. But unlike humanity, businesses do go on and on and on, often by-passing and/or outlasting their
employees. And because companies cannot afford to fall behind in the marketplace, they must be in constant search for young employees to guide them into the uncertain future, and so, the dead wood must go. It's not a happy or pleasant thought. And, it's not personal. It's just the way businesses must function to survive.
Unlike businesses, most men and women are only in their prime for about 20 years, from age 25 to age 45. If you don't accomplish what you want to accomplish during those 20 years, you never will. At 45, old age begins its unrelenting assault and you eventually cannot hide or deny its effects. Despite radical feminism's rants to the contrary, "superwoman" does NOT exist and you will eventually get old and become expendable.
For a woman, those 20 prime years mean everything. Career choice not withstanding, the personal decisions made during those few short years will lead to joy or to regret. You will either end your life surrounded by children and grandchildren or you will end it virtually alone. My experience is that for women, there isn't a "career" on earth that's worth that trade-off. You will need your family when everything else is gone and if you denied yourself the happiness of marriage and children, in exchange for a 9 to 5 "career", you've been a fool, because your time will come too.
Your energy level will decline along with your sight and hearing. Unable to remain sharp-as-a-tack under the constant barrage of pertinent information on the job (the same information that used to thrill and challenge you), you will find yourself in retreat, rather than in attack mode. Through no fault of you own, career women fall out of grace sooner than men because they inevitably spend their lives burning the candle at both ends in an attempt to become feminist superwomen and in the end, they are simply not able to keep up.
So, before you jump off the deep end and focus your young life on career alone, remember it is a path that will eventually leave you single, sidelined, 60, and probably sick and sad. And trust me, it SUCKS!
The End It's the Women, Not the Men!


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You are currently browsing the tag archive for the 'holiday' tag.
A visibly harried Sir Ian has been forced from Barbados to deal with this nonsense.
This is a little something I wrote a couple of years ago about the ongoing assault on our most precious religious festival. Enjoy.
Yes, it's that time of year again. No sooner does an important traditional religious holiday roll around than the PC-brigade feel the need to strip-mine it of its original significance, just so's no-one's feelings get hurt. Fuck that.
For many years now, it's become unfashionable to talk of Geola, as Muslims, atheists, and Christians have all attacked our traditional holiday.
It is the Christians who have the most gall of all, daring to attach the name of some first-century Palestinian to a once-proud British festival. 'Yule' I can live with, despite its being a continental bastardisation of our British pronunciation 'Geola', but 'Christmas' is just wrong. You even have to mispronounce 'Christ' to say it.
It's important that we remember that Geola isn't just about family and friendship, it is also about the ritual human sacrifice of male slaves, once every nine years. When was the last time any of our loony local councils allowed this traditional practice? Once again the feminazis and Health and Safety Ceaucescus have stamped their grubby little Christian boots over our heritage.
Just think of what we have lost because of our spineless governing elites. Where once we swore fealty on the back of our best boar, loud enough for the god Freyr to hear, before slaughtering it and spending 12 days eating its carcass; now we have dried-up turkey and Iceland breaded prawns.
What is perhaps most disturbing is the way in which the Christian brigade have felt free to take the bits of our festival they liked (the decorated tree, the holly, the mistletoe, the Yule log, gammon), and pretend that our holiday has nothing to do with our traditional celebrations of the death of winter. They even crow about it!
When Pope Gregory wrote to St Mellitus as he came to convert the Britons, he instructed him not to change too many of the details of our festivities, but just the god they were worshipping. Such blatant contempt for our pagan heritage is, quite frankly, frightening, and yet another example of what happens when you let immigrants from the EU roam willy-nilly, preaching their message of hate.
The fact that our once proud Joulenpukki, who came to distribute presents to good children and devour the bones of bad ones has been forced in many government depictions to take off his robe of rotting goat hides and wear instead a red coat is surely shame enough.
Now, his belly shakes when he laughs like a bowl full of jelly, rather than rattling with the femurs of naughty children. Will we never learn?


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To promote the market expansion of Malaysian palm oil and its products by enhancing the image of palm oil and creating better acceptance of palm oil through awareness of various technological and economic advantages (techno-economic advantages) and environmental sustainability.OBJECTIVES
To enhance trade opportunities in the market place by identifying and meeting the latest opportunities in the market.
|To encourage product diversification by using Malaysian palm oil as the key ingredient, thus gaining a prominent role in new and reformulated products.
|To improve understanding of palm oil, enhancing its application and elucidating its numerous strengths and benefits.
To uphold the good name of Malaysian palm oil by closing the gap between the issues of perception, allegations and the realities of palm oil.
|To safeguard Malaysian palm oil as the most dominant vegetable oil in terms of market coverage, nutritional benefits, environmental sustainability and commercial success.
In delivering our services to the stakeholders and to the global masses, we at MPOC are shaped by a corporate identity that defines the organization as forward looking and insightful in its mission to promote the Malaysian palm oil industry. This shaping of MPOC's corporate identity can be found in the MPOC acronym where its identity is derived from the following:
M – Manpower development
The human resource growth in MPOC is not confined to the number of employees but is shaped by the development of individual employees where the right levels of expertise are the leading factors in reaching our objectives. With the right levels of expertise, MPOC becomes the reference point for the industry.
P – Planning & Promotional effectiveness
Objectives and goals can be achieved only with proper planning. The planning stages in MPOC are guided by the objectives in hand and with calculated planning, be it in programmes and activities organized by MPOC, the planning stages are crucial in the success of the activities. The new operational exercise puts in place a system that hones the planning of our activities.
The effectiveness of our promotional programmes and activities is vital in upholding the corporate identity. The promotional aspects of our programmes and activities are structured within the scope of manpower development, planning and operational efficiency. With the combination of this corporate identity, the vital promotional effectiveness can be carried through MPOC's promotional activities.
O – Operational efficiency
The programmes and activities that are featured under the new MPOC's approach will encompass the absolute necessary and practical methods in reaching our objectives. In MPOC's daily operations, the identity will assist the organization to efficiently operate within the context of its role and responsibilities. We focus on delivering results efficiently.
C – Commitment
Customer commitment is greatly emphasized in our operational strategy and MPOC's programmes are highly geared towards meeting and exceeding the expectations of the industry players. The level of customer commitment can be seen in MPOC's output in terms of its successful programmes and positive feedbacks from the industry
Malaysian Palm Oil Council (MPOC)
2nd. Floor, Wisma Sawit,
Lot 6, SS6, Jalan Perbandaran,
47301 Kelana Jaya,
Selangor Darul Ehsan, MALAYSIA. Tel : 603 – 7806 4097
Fax : 603 – 7806 2272 E-Mail : email@example.com