text:
Palo Alto, CA 94304
Facsímil: (650) 725-8375
Children's Hospital Boston, Boston, MA, 08/31/2003
Joslin Diabetes Center, Boston, MA, 06/30/2005
BACKGROUND: Diabetes devices such as insulin pumps and continuous glucose monitoring (CGM) are associated with improved health and quality of life in adults with type 1 diabetes (T1D). However, uptake remains low. The aim of this study was to develop different "personas" of adults with T1D in relation to readiness to adopt new diabetes technology.METHODS: Participants were 1498 T1D Exchange participants who completed surveys on barriers to uptake, technology attitudes, and other psychosocial variables. HbA1c data was available from the T1D Exchange for 30% of the sample. K-means cluster analyses grouped the sample by device barriers and attitudes. The authors assigned descriptive labels based on cluster characteristics. ANOVAs and chi-square tests assessed group differences by demographic and psychosocial variables (eg, diabetes duration, diabetes distress).RESULTS: Analyses yielded five distinct personas. The d-Embracers (54% of participants) endorsed few barriers to device use and had the highest rates of device use, lowest HbA1c, and were the least distressed. The Free Rangers (23%) had the most negative technology attitudes. The Data Minimalists (10%) used pumps but had lower CGM use and did not want more diabetes information. The Wary Wearers (11%) had lower overall device use, were younger, more distressed, endorsed many barriers, and had higher HbA1c. The High Distress (3%) group members were the youngest, had the shortest diabetes duration, reported the most barriers, and were the most distressed.CONCLUSION: These clinically meaningful personas of device readiness can inform tailored interventions targeting barriers and psychosocial needs to increase device uptake.
View details for PubMedID 30132692
OBJECTIVE: The aim is to report 1-year outcomes of the Supporting Teens Problem Solving (STePS) study, a randomized controlled trial comparing a distress and depression prevention program with a diabetes education program for adolescents with type 1 diabetes.RESEARCH DESIGN AND METHODS: With 264 adolescents in two locations (Chicago and San Francisco Bay Area), a randomized controlled trial was conducted comparing the Penn Resilience Program for type 1 diabetes (PRP T1D) to Advanced Diabetes Education. Interventions lasted 4.5 months, and assessments were conducted at baseline, and 4.5, 8, 12, and 16 months. Outcomes of interest were diabetes distress (DD), depressive symptoms, resilience, diabetes self-management, and glycemic control. Latent growth curve modeling was used to test between-group differences over time.RESULTS: Results indicate that there was acceptable randomization and exposure to interventions, and that exposure to PRP T1D was associated with substantial reductions in DD. In addition, stable glycemic control, resilience characteristics, and depressive symptoms were observed 1 year post-treatment. Diabetes management deteriorated in both groups.CONCLUSIONS: Intervening before symptoms of psychological distress start can prevent the development of the DD commonly seen in adolescents with type 1 diabetes. The STePS program represents a promising prevention program, and future reports on 2- and 3-year outcomes will explore benefits over longer periods of time.
View details for PubMedID 29921624
View details for PubMedID 29463672
View details for PubMedCentralID PMC5864144
Diabetes technology is a cornerstone of diabetes management in the 21st century, with advances in available devices over recent years playing a central role in the way that health care has progressed. Psychosocial interventions have been shown to have a positive impact on glycemic control, reduce psychological distress and reduce costs of health care. Addressing and improving psychosocial outcomes that complement biomedical improvements and looking to the future are crucial to enhance patient acceptance of artificial pancreas (AP) systems.To achieve closer collaboration and comparability across different AP research trials, a working group was established.Existing measures fail to adequately capture the extent to which human and psychological factors play a role in the uptake and efficient use of AP systems. Understanding these factors will ultimately lead to the most benefit for users. Reliable measures of the psychosocial impact of AP systems for users is crucial to ensure that (1) regulatory authorities are able to robustly consider these aspects as part of their approval process, (2) government and private payers are able to factor these aspects into their decisions regarding reimbursement, and (3) persons with diabetes maximize benefits in terms of both glycemic control and quality of life to minimize the burden of diabetes in everyday life.This working group will serve as a platform to foster exchange, identify research needs, and guide and initiate collaborative research laying the groundwork for optimal utilization of diabetes technology in clinical diabetes care. A close collaboration among all key stakeholders is crucial to ensure that devices are designed, trialed, approved, and provided with minimal user burden and maximum beneficial effect.
View details for DOI 10.1177/1932296815588332
View details for PubMedID 26085567
BACKGROUND: Hybrid closed loop (HCL) systems are designed to automate insulin delivery to improve type 1 diabetes (T1D) outcomes and reduce user burden and distress. Because the systems only automate some aspects of diabetes care, psychosocial and human factors remain an important consideration in their use. Thus, we examined whether psychosocial and human factors (i.e., distress related to diabetes management, fear of hypoglycemia, and technology attitudes) would (1) change after using the system and (2) predict glycemic outcomes during the trial.SUBJECTS AND METHODS: Fourteen adults and 15 adolescents with T1D participated in a multisite clinical trial of an investigational version of the MiniMed 670G system (Medtronic, Northridge, CA) over 4 to 5 days in a semisupervised outpatient setting. Users completed surveys assessing psychosocial and human factors before beginning the HCL system and at the conclusion of the study. t-Tests and regression analyses were conducted to examine whether these factors changed following trial exposure to the HCL system and predicted glycemic outcomes during the trial.RESULTS: Diabetes management distress decreased and diabetes technology attitudes became more positive over the trial period. Fear of hypoglycemia did not change over the trial period. There was a trend toward greater pretrial management distress predicting less time in range during the trial, controlling for time in range before the trial.CONCLUSIONS: Results suggest that this system is promising for enhancing technology attitudes and reducing management distress. Psychosocial factors, such as management distress, may negatively impact glycemic outcomes and should be a priority area for further investigation.
View details for PubMedID 30239219
View details for PubMedID 29934474
BACKGROUND: Background:Many people with type 1 diabetes (T1D) report barriers to using continuous glucose monitoring (CGM). Diabetes care providers may have their own barriers to promoting CGM uptake. The goal of this study was to develop clinician "personas" with regard to readiness to promote CGM uptake.METHODS: Diabetes care providers who treat people with T1D (N = 209) completed a survey on perceived patient barriers to device uptake, technology attitudes, and characteristics and barriers specific to their clinical practice. K-means cluster analyses grouped the sample by CGM barriers and attitudes. ANOVAs and chi-square tests assessed group differences on provider and patient characteristics. The authors assigned descriptive names for each persona.RESULTS: Analyses yielded three clinician personas regarding readiness to promote CGM uptake. Ready clinicians (20% of sample; 24% physicians, 38% certified diabetes educators/CDEs) had positive technology attitudes, had clinic time to work with patients using CGM, and found it easy to keep up with technology advances. In comparison, Cautious clinicians (41% of sample; 17% physicians, 53% CDEs) perceived that their patients had many barriers to adopting CGM and had less time than the Ready group to work with patients using CGM data. Not Yet Ready clinicians (40% of sample; 9% physicians; 79% CDEs) had negative technology attitudes and the least clinic time to work with CGM data. They found it difficult to keep up with technology advances.CONCLUSION: Some diabetes clinicians may benefit from tailored interventions and additional time and resources to empower them to help facilitate increased uptake of CGM technology.
View details for PubMedID 29991281
Integration of momentary contextual and psychosocial factors within self-management feedback may provide more specific, engaging, and personalized targets for problem solving.Forty-four youth ages 13-19 with type 1 diabetes (T1D) were provided a Bluetooth meter and completed the 30-day protocol. Participants were randomized to "app + meter" or "meter-only" groups. App + meter participants completed mealtime and bedtime assessment each day. Assessments focused on psychosocial and contextual information relevant for self-management. Graphical feedback integrated self-monitored blood glucose (SMBG), insulin, and Bluetooth-transmitted blood glucose data with the psychosocial and contextual data. App + meter participants completed an interview to identify data patterns.The median number of momentary assessments per participant was 80.0 (range 32-120) with 2.60 per day. By 2 weeks participants had an average of 40.77 (SD 12.23) assessments. Dose-response analyses indicated that the number of app assessments submitted were significantly related to higher mean daily SMBG (r=-0.44, P<0.05) and to lower% missed mealtime SMBG (r=-0.47, P<0.01). Number of feedback viewing sessions was also significantly related to a lower% missed mealtime SMBG (r=-0.44, P<0.05). Controlling for baseline variables, mixed-effects analyses did not indicate grouptime differences in mean daily SMBG. Engagement analyses resulted in three trajectory groups distinguished by assessment frequencies and rates of decline. Engagement group membership was significantly related to gender, mean daily SMBG, and HbA1c values.Momentary assessment combined with device data provided a feasible means to provide novel personalized biobehavioral feedback for adolescents with T1D. A 2-week protocol provided sufficient data for self-management problem identification. In addition to feedback, more intensive intervention may need to be integrated for those patients with the lowest self-management at baseline.
View details for PubMedID 29882677
This study adds to the literature on the psychometric properties of the Problem Areas in Diabetes-Teen (PAID-T) and Parent (P-PAID-T) Versions. It also aims to shorten the measures of diabetes-specific distress, determine construct validity, and establish cutoff scores.Data are from two independent studies (N=1,265). Adolescent-caregiver dyads completed measures of emotional distress, diabetes strengths, hemoglobin A1c, blood glucose checks, and average blood glucose. Exploratory and confirmatory factor analyses assessed factor structures for each measure. Correlational analyses provided support for concurrent validity. Receiver-operating characteristic curves identified cutoff scores based on clinically meaningful groups identified with latent profile analysis.Analyses supported a 14-item PAID-T and a 15-item P-PAID-T, with preliminary cutoff scores 44 and 54, respectively. Measures were associated with emotional and health outcomes as hypothesized.The PAID-T and P-PAID-T are valid, reliable, and useful measures of diabetes-specific distress for teenagers with type 1 diabetes and parents of teenagers.
View details for PubMedID 29267939
View details for Web of Science ID 000431185201234
View details for Web of Science ID 000431185202153
This study examines the hopes and expectations that children, adolescents, and adults with type 1 diabetes and their families have for new automated insulin delivery systems. The study also aims to examine how the automated insulin delivery system may impact family functioning and individual members' psychosocial adjustment.Forty-eight semistructured focus groups (n=195) and 89 individual interviews were conducted with children, adolescents, and adults with type 1 diabetes and parents and partners. Coders reviewed results in key themes most likely to contain references to the family system. Clusters were analyzed using thematic analysis to identify participants' salient hopes and expectations of how new technology may impact family relationships and individual psychosocial functioning.Three main themes emerged for participants' hopes and expectations for implementation of the automated insulin delivery system. First, there is an expectation that this diabetes technology will alleviate diabetes-specific worry and burden for the people with diabetes and other family members. Second, there is also hope that this system may reduce day-to-day stress and, third, improve family relationships.The unique perspective of a broad age group provides insight into how individuals and families creatively address the multiple tasks required in daily diabetes management. Study findings elucidate the very high hopes and expectations held by those managing type 1 diabetes and the impact this new technology may have on family relationships. Awareness of these hopes and expectations is important for developers and clinicians in addressing potential challenges to uptake and to ensure that expectations are set appropriately.
View details for PubMedID 29565721
View details for PubMedID 28656656
Sharing personal information about type 1 diabetes (T1D) can help adolescents obtain social support, enhance social learning, and improve self-care. Diabetes technologies, online communities, and health interventions increasingly feature data-sharing components. This study examines factors underlying adolescents' willingness to share personal T1D information with peers.Participants were 134 adolescents (12-17 years of age; 56% female) who completed an online survey regarding experiences helping others with T1D, perceived social resources, beliefs about the value of sharing information and helping others, and willingness to share T1D information. Hemoglobin A1c values were obtained from medical records.Adolescents were more willing to share how they accomplished T1D tasks than how often they completed them, and least willing to share glucose control status. In multivariate analyses, sharing/helping beliefs (=0.26, P <.01) and glucose control (HbA1c value; =-0.26, P <.01) were related to greater willingness to share personal health information. Glucose control moderated relationships such that adolescents with worse A1c values had stronger relationships between sharing/helping beliefs and willingness to share (=0.18, P <.05) but weaker relationships between helping experience and willingness to share (=-0.22, P =.07).Many adolescents with T1D are willing to share personal health information, particularly if they have better diabetes health status and a stronger belief in the benefits of sharing.Social learning and social media components may improve intervention participation, engagement, and outcomes by boosting adolescents' beliefs about the benefits of sharing information and helping others.
View details for DOI 10.1093/jamia/ocx051
View details for PubMedID 28575462
Despite the challenges of managing type 1 diabetes, many adolescents achieve optimal outcomes. A validated measure of diabetes-specific strengths is needed to measure adaptive behaviors and attitudes associated with overcoming challenges and achieving "resilient" outcomes. Baseline data from 260 adolescents (age 14-18years, M =15.71.1, 60% female, 33% Non-Caucasian, M A1c=9.11.9%) and caregivers in a behavioral intervention trial were analyzed to evaluate psychometric properties of the 12-item self-report Diabetes Strengths and Resilience measure for adolescents (DSTAR-Teen). Reliability and validity were examined in relation to measures of related constructs, regimen adherence, and glycemic outcomes, and confirmatory factor analysis was conducted. Reliability was good (internal consistency: =.89; item-total correlations: r range=.55-.78). Significant correlations demonstrated construct and criterion validity. A two-factor structure reflecting intrapersonal and interpersonal processes fit the data better than a one-factor solution. The DSTAR-Teen has strong psychometric properties, captures adaptive aspects of adolescents' diabetes management (i.e., "strengths"), and is related to clinical outcomes.
View details for DOI 10.1093/jpepsy/jsx086
View details for PubMedID 28549160
Declining glycemic control in type 1 diabetes (T1D) during adolescence persists despite treatment advances. Non-adherence, peer relations, diabetes burnout, risk taking, transition to autonomy, family conflict, and poor quality of life (QOL) are recognized barriers. Shared medical appointments (SMAs) in adolescent T1D may offer benefits, but data are limited. Our objective was to determine whether SMAs, with multi-component interventions utilizing multidisciplinary teams, improve glycemic control and psychosocial outcomes in poorly controlled adolescent T1D.SMAs focused on self-management, communication skills, goal setting, glucose pattern recognition, and peer/diabetes team support. SMAs included: individual history and physical, labs, surveys, multidisciplinary educational ice breakers, group session, and individual wrap up. Outcomes were QOL, adherence, and retrospective and prospective glycemic control. Three to six subjects and families came to 3 SMAs and 1 individual appointment every 3 months over 9 months.A total of 37 English speaking subjects, ages 12-16yrs, with T1D 1 year, and hemoglobin A1c (HbA1c) 7.5-11% enrolled. Thirty-two subjects attended 75% of visits, meeting inclusion criteria.HbA1c worsened in the 9 months before study (HbA1c= 0.71.2; p<0.01), but remained stable during study (HbA1c=0.011.2; p>0.05). There were significant improvements in overall QOL (p=0.005), school function (p=0.006), psychosocial function (p=0.008), barriers (p=0.02), adherence (p=0.01), and communication (p=0.02). Improvements in school function and communication reached clinical significance.SMAs are feasible replacements to individual appointments in adolescent T1D, stabilizing glycemic control and improving QOL. Randomized controlled trials with optimizations are needed to further explore and refine this intervention.
View details for DOI 10.1111/pedi.12373
View details for Web of Science ID 000399353400005
Purpose The first hybrid closed loop (HCL) system, which automates insulin delivery but requires user inputs, was approved for treatment of type 1 diabetes (T1D) by the US Food and Drug Administration in September 2016. The purpose of this study was to explore the benefits, expectations, and attitudes of individuals with T1D following a clinical trial of an HCL system. Methods Thirty-two individuals with T1D (17 adults, 15 adolescents) participated in focus groups after 4 to 5 days of system use. Content analysis generated themes regarding perceived benefits, hassles, and limitations. Results Some participants felt misled by terms such as "closed loop" and "artificial pancreas," which seemed to imply a more "hands-off" experience. Perceived benefits were improved glycemic control, anticipated reduction of long-term complications, better quality of life, and reduced mental burden of diabetes. Hassles and limitations included unexpected tasks for the user, difficulties wearing the system, concerns about controlling highs, and being reminded of diabetes. Conclusion Users are willing to accept some hassles and limitations if they also perceive health and quality-of-life benefits beyond current self-management. It is important for clinicians to provide a balanced view of positives and negatives to help manage expectations.
View details for DOI 10.1177/0145721717697244
View details for PubMedID 28340542
View details for DOI 10.1037/hea0000445
View details for Web of Science ID 000396002500006
Adolescents with Type 1 diabetes (T1D) are vulnerable to diabetes-related distress and often struggle to complete self-management tasks needed to maintain blood glucose values in target range. One way that youth with T1D handle problems is through avoidant coping. The current study examined cross-time associations between avoidant coping style and diabetes outcomes and tested the possible mediating role of diabetes-related distress.Adolescents with T1D (N = 264) were assessed 4 times over 1 year to measure avoidant coping style, diabetes-related distress, adherence (on the basis of glucometer data and self-report), and glycemic control (hemoglobin A1c). Mediation and direct effects were tested across time using time-lagged autoregressive path models, making use of the repeated measurement of all constructs.The hypothesized mediation effect was found for all 3 diabetes outcomes. Higher levels of avoidant coping style were associated with greater diabetes-related distress at the subsequent time point, which was related in turn to fewer blood glucose checks, less frequent self-care behaviors, and poorer glycemic control (higher A1c) at the next assessment.In the context of diabetes, an avoidant coping style may contribute to greater diabetes-specific distress followed by deterioration in self-management and glycemic control over time. Maladaptive coping styles are modifiable factors that offer an entry point into intervention before further difficulties can take hold. (PsycINFO Database Record
View details for DOI 10.1037/hea0000445
View details for PubMedID 27808528
Diabetes devices (insulin pumps, continuous glucose monitors [CGMs]) are associated with benefits for glycemic control, yet uptake of these devices continues to be low. Some barriers to device uptake may be modifiable through psychosocial intervention, but little is known about which barriers and which patients to target.We surveyed 1,503 adult T1D Exchange participants (mean age 35.3 [SD 14.8] years, mean diagnosis duration 20.4 [SD 12.5] years) to investigate barriers to device uptake, understand profiles of device users versus nonusers, and explore differences by age and sex. Scales used were the Diabetes Distress Scale, Technology Use Attitudes (General and Diabetes-Specific), and Barriers to Device Use and Reasons for Discontinuing Devices.Most commonly endorsed modifiable barriers were related to the hassle of wearing devices (47%) and disliking devices on one's body (35%). CGM users (37%) were older than nonusers (mean 38.3 vs. 33.5 years), had diabetes for longer (22.9 vs. 18.8 years), had more positive technology attitudes (22.6-26.0 vs. 21.4-24.8), and reported fewer barriers to using diabetes technology than nonusers (3.3 vs. 4.3). The youngest age-group (18-25 years) had the lowest CGM (26% vs. 40-48%) and insulin pump (64% vs. 69-77%) uptake, highest diabetes distress (2.2 vs. 1.8-2.1), and highest HbA1c levels (8.3% [67 mmol/mol] vs. 7.2-7.4% [55-57 mmol/mol]).Efforts to increase device use need to target physical barriers to wearing devices. Because young adults had the lowest device uptake rates, highest distress, and highest HbA1c compared with older age-groups, they should be the focus of future interventions to increase device use.
View details for DOI 10.2337/dc16-1536
View details for PubMedID 27899489
In the past few years, the artificial pancreas-the commonly accepted term for closed-loop control (CLC) of blood glucose in diabetes-has become a hot topic in research and technology development. In the summer of 2014, we initiated a 6-month trial evaluating the safety of 24/7 CLC during free-living conditions.Following an initial 1-month Phase 1, 14 individuals (10 males/4 females) with type 1 diabetes at three clinical centers in the United States and one in Italy continued with a 5-month Phase 2, which included 24/7 CLC using the wireless portable Diabetes Assistant (DiAs) developed at the University of Virginia Center for Diabetes Technology. Median subject characteristics were age 45 years, duration of diabetes 27 years, total daily insulin 0.53U/kg/day, and baseline HbA1c 7.2% (55mmol/mol).Compared with the baseline observation period, the frequency of hypoglycemia below 3.9mmol/L during the last 3 months of CLC was lower: 4.1% versus 1.3%, P<0.001. This was accompanied by a downward trend in HbA1c from 7.2% (55mmol/mol) to 7.0% (53mmol/mol) at 6 months. HbA1c improvement was correlated with system use (Spearman r=0.55). The user experience was favorable with identified benefit particularly at night and overall trust in the system. There were no serious adverse events, severe hypoglycemia, or diabetic ketoacidosis.We conclude that CLC technology has matured and is safe for prolonged use in patients' natural environment. Based on these promising results, a large randomized trial is warranted to assess long-term CLC efficacy and safety.
View details for DOI 10.1089/dia.2016.0333
View details for Web of Science ID 000392822900005
View details for PubMedID 27982707
View details for DOI 10.1177/1932296816688010
Adolescents with chronic illness face greater risk of psychosocial difficulties, complicating disease management. Despite increased calls to screen for patient-reported outcomes, clinical implementation has lagged. Using quality improvement methods, this study aimed to investigate the feasibility of standardized screening for depression and assessment of global health and to determine recommended behavioral health follow-up, across three pediatric subspecialty clinics.A total of 109 patients aged 12-22years (median= 16.6) who were attending outpatient visits for treatment of diabetes (80% type 1), inflammatory bowel disease, or cystic fibrosis completed the 9-item Patient Health Questionnaire (PHQ-9) depression and Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Global Health measures on electronic tablets. Patients screening positive on the PHQ-9 received same-day behavioral health assessment and regular phone check-ins to facilitate necessary follow-up care.Overall, 89% of 122 identified patients completed screening during a 6-month window. Patients completed measures in a timely manner (within 3minutes) without disruption to clinic flow, and they rated the process as easy, comfortable, and valuable. Depression scores varied across disease type. Patients rated lower global health relative to a previously assessed validation cohort. Depression and global health related significantly to certain medical outcomes. Fifteen percent of patients screened positive on the PHQ-9, of whom 50% confirmed attending behavioral health appointments within 6months of screening.A standardized depression and global health assessment protocol implemented across pediatric subspecialties was feasible and effective. Universal behavioral health screening for adolescents and young adults living with chronic disease is necessary to meet programmatic needs in pediatric subspecialty clinics.
View details for PubMedID 28830798
The purpose of this phenomenological qualitative study was to examine the quality of life among college students living with Type 1 diabetes (T1D). Inclusion criteria included age 18 to 24, current college student, and a diagnosis of T1D for at least 1 year. Semi-structured interviews were conducted, in-person and by phone. During these interviews, college students shared stories of living with T1D and its impact on their quality of life. Three major themes emerged, which included "planning ahead," "thinking positive," and "seeking support." These findings provide a better understanding of the transitional experience of living with T1D and the impact on perceived quality of life while attending college. Techniques and strategies aimed at the enhancement of perceived quality of life for college students living with T1D were identified. These findings will provide valuable insight for professionals working with this population.
View details for PubMedID 27230752
View details for DOI 10.2337/dc16-2053
View details for Web of Science ID 000390785000017
View details for PubMedID 27879358
View details for PubMedCentralID PMC5127231
Patients managing type 1 diabetes have access to new technologies to assist in management. This manuscript has two aims: 1) to briefly review the literature on diabetes technology use and how this relates to psychological factors and 2) to present an example of human factors research using our data to examine psychological factors associated with technology use. Device/technology uptake and use has increased over the years and at present day is a common clinical practice. There are mixed results in terms of health and psychosocial outcomes, with specific subgroups doing better than others with technology. Our data demonstrated that patients have moderately elevated diabetes distress across differing types of technology used, from low-tech to high-tech options, possibly meaning that technology does not add or take away distress. In addition, users on multiple daily injections compared to all other technology groups have less positive attitudes about technology. Finally, we discuss implications for clinical practice and future research.
View details for DOI 10.1177/1932296816650900
View details for PubMedID 27234809
Adolescents with type 1 diabetes have an increased risk for a variety of emotional and behavioral challenges as well as negative diabetes outcomes. This study was designed to compare the effectiveness of a depression-prevention, resilience promotion program with an advanced diabetes education program. Each program consisted of 9 group-based sessions. There were 264 adolescents enrolled in this multi-site randomized clinical trial. The primary outcomes were depressive symptoms and glycemic control; secondary outcomes included resilience skills, diabetes management and adherence, and diabetes-specific distress. The goal of the present paper is to describe the study design, the intervention, and the baseline characteristics of the sample. Preliminary data suggests that enrollment, randomization and retention were successful. Longitudinal follow-up and examination of mechanisms of action as they relate to psychosocial and glycemic outcomes will be explored in the future.
View details for DOI 10.1016/j.cct.2016.05.006
View details for PubMedID 27267154
View details for PubMedCentralID PMC4969210
Health-related quality of life (HRQOL) is a critical diabetes outcome, yet differences between youth and parent-proxy ratings can make interpretation difficult. This study aims to explore potential differences between self- and parent-reports of Pediatric Quality of Life Inventory (PedsQL) scores from youth with type 1 (T1D) or type 2 diabetes (T2D) and to evaluate associations between discrepancies, PedsQL scores, and glycemic control (HbA1c).Youth and parents in the SEARCH for Diabetes in Youth Study (T1D: age 5-18, n = 3402; T2D: age 8-18, n = 353) completed the PedsQL Generic and Diabetes Modules, and youth provided a blood sample to assess HbA1c. Discrepancies (youth minus parent PedsQL ratings) were calculated and examined by age and diabetes type, and associations with youth PedsQL scores and HbA1c were evaluated.Discrepancies existed between youth and parent-proxy reports of generic and diabetes PedsQL scores in T1D and T2D (all p values < 0.01). Higher (more favorable) ratings were reported by youth except for those 5-7-years old, where parents' scores were higher. When parent-proxy scores were higher, discrepancies were largest when the child reported low PedsQL scores. Higher HbA1c was associated with larger discrepancies (youth scores higher) for adolescents with T1D.Discrepant PedsQL ratings suggest that parents may often underestimate youths' HRQOL except in the youngest children. Although examining both reports is optimal, the youth report should be prioritized, particularly for young children with T1D and for adolescents with either T1D or T2D.
View details for DOI 10.1007/s11136-015-1158-5
View details for Web of Science ID 000374866600004
View details for PubMedID 26466834
View details for PubMedCentralID PMC4936832
The INSPIRE study working group launched its initial workshop in February 2015 to facilitate collaboration among key stakeholders interested in automated insulin delivery (AID) systems and the psychosocial outcomes of individuals who may use these new technologies. Specifically, the INSPIRE team's goal is to facilitate measure development assessing the psychosocial factors associated with AID systems. A second working group was held to foster exchange among key stakeholders in AID system development. Patient, health care provider, engineering, industry, academic, regulatory and payer perspectives were presented. The INSPIRE working group will continue to serve as a platform to encourage open dialogue among all stakeholders with the aim of facilitating technology that offers minimal user burden and maximum benefit from both a psychological and physiologic perspective.
View details for DOI 10.1177/1932296815619637
View details for PubMedID 26645792
Declining glycemic control in type 1 diabetes (T1D) during adolescence persists despite treatment advances. Non-adherence, peer relations, diabetes burnout, risk taking, transition to autonomy, family conflict, and poor quality of life (QOL) are recognized barriers. Shared medical appointments (SMAs) in adolescent T1D may offer benefits, but data are limited. Our objective was to determine whether SMAs, with multi-component interventions utilizing multidisciplinary teams, improve glycemic control and psychosocial outcomes in poorly controlled adolescent T1D.SMAs focused on self-management, communication skills, goal setting, glucose pattern recognition, and peer/diabetes team support. SMAs included: individual history and physical, labs, surveys, multidisciplinary educational ice breakers, group session, and individual wrap up. Outcomes were QOL, adherence, and retrospective and prospective glycemic control. Three to six subjects and families came to 3 SMAs and 1 individual appointment every 3 months over 9 months.A total of 37 English speaking subjects, ages 12-16yrs, with T1D 1 year, and hemoglobin A1c (HbA1c) 7.5-11% enrolled. Thirty-two subjects attended 75% of visits, meeting inclusion criteria.HbA1c worsened in the 9 months before study (HbA1c= 0.71.2; p<0.01), but remained stable during study (HbA1c=0.011.2; p>0.05). There were significant improvements in overall QOL (p=0.005), school function (p=0.006), psychosocial function (p=0.008), barriers (p=0.02), adherence (p=0.01), and communication (p=0.02). Improvements in school function and communication reached clinical significance.SMAs are feasible replacements to individual appointments in adolescent T1D, stabilizing glycemic control and improving QOL. Randomized controlled trials with optimizations are needed to further explore and refine this intervention.
View details for DOI 10.1111/pedi.12373
View details for PubMedID 26919322
This special issue of the Journal of Pediatric Psychology showcases a growing area of research with a collection of 16 contemporary studies of resilience in youth with chronic medical or developmental conditions and their families. The research reported in this special issue covers a broad range of pediatric populations, including cancer, type 1 diabetes, and chronic pain, among others, ranging in age from early childhood through early adulthood. This introduction to the special issue reviews the various ways the articles' authors conceptualize and define risk and resilience; most analyze protective processes in relation to resilient outcomes, including both achievement of explicitly positive experiences and avoidance of dysfunction or disruption. Challenges with measurement of resilience-related constructs is reviewed. Finally, the special issue editors offer a definition of resilience in the context of pediatric and health psychology.
View details for DOI 10.1093/jpepsy/jsv072
View details for PubMedID 26275974
View details for PubMedCentralID PMC4592327
Diabetes impacts tens of millions of people in the United States of America and 9% of the worldwide population. Given the public health implications and economic burden of diabetes, the needs of people with diabetes must be addressed through strategic and effective advocacy efforts. Diabetes advocacy aims to increase public awareness about diabetes, raise funds for research and care, influence policy impacting people with diabetes, and promote optimal individual outcomes. We present a framework for diabetes advocacy activities by individuals and at the community, national, and international levels and identify challenges and gaps in current diabetes advocacy. Various groups have organized successful diabetes advocacy campaigns toward these goals, and lessons for further advancing diabetes advocacy can be learned from other health-related populations. Finally, we discuss the role of healthcare providers and mental/behavioral health professionals in advocacy efforts that can benefit their patients and the broader population of people with diabetes.
View details for DOI 10.1007/s11892-015-0636-z
View details for Web of Science ID 000377953300003
View details for PubMedID 26194156
View details for PubMedCentralID PMC4581582
The objective was to test whether Behavioral Family Systems Therapy for Diabetes (BFST-D), an evidence-based family therapy, produces individual changes in depressive symptoms for adolescents with type 1 diabetes in suboptimal glycemic control (HbA1c 9.0% [74.9 mmol/mol]).Data were from a randomized controlled trial (RCT) comparing two modes of BFST-D delivery: in clinic versus Internet videoconferencing. There were no significant differences between groups in the RCT, so groups were collapsed into a within-group prepost design for secondary analyses. A multiple regression analysis was performed to test for mediation of treatment outcomes by changes in family processes.Significant improvements in glycemic control, depressive symptoms, and family functioning were found from pre- to posttreatment. A multiple regression analysis for within-subject mediation indicated that improvements in depressive symptoms were partially mediated by improvements in parent-youth conflict; however, family process changes did not mediate diabetes health outcomes.In addition to improving treatment adherence and glycemic control, BFST-D has collateral benefits on depressive symptoms.
View details for DOI 10.2337/dc14-2519
View details for Web of Science ID 000358673200018
View details for PubMedID 26015558
Patients with diabetes increasingly have questions about diabetes alert dogs. This study evaluated perceptions about dogs trained professionally or otherwise to detect glucose levels.A link to a survey about glucose detecting dogs was announced on diabetes websites.135 persons responded, with 63 answering about their child with diabetes. Most respondents obtained their dog from a professional trainer (n=54) or trained it themselves (n=51). Owners of self- and professionally-trained dogs were very positive about dogs' abilities to alert them to low and high glucose levels, while owners of dogs that learned entirely on their own (n=15) reported lower frequencies of alerts and more missed hypoglycemic episodes, p<.01. Regardless of how dogs learned, perceptions about managing diabetes were improved during periods of dog ownership relative to times without, p<.001. Self-reported rates of diabetes-related hospitalizations, assistance from others for treating hypoglycemia, and accidents or near accidents while driving reduced during periods of dog ownership compared to periods without dogs, ps<.01.These data suggest potential effectiveness of and high satisfaction with glucose-detecting dogs. Clinicians can use these results to address pros and cons of dog ownership with patients who inquire about them.
View details for DOI 10.1016/j.diabres.2015.05.023
View details for Web of Science ID 000358554800026
This study examines technology use for problem solving in diabetes and its relationship to hemoglobin A1C (A1C).A sample of 112 adolescents with type 1 diabetes completed measures assessing use of technologies for diabetes problem solving, including mobile applications, social technologies, and glucose software. Hierarchical regression was performed to identify the contribution of a new nine-item Technology Use for Problem Solving in Type 1 Diabetes (TUPS) scale to A1C, considering known clinical contributors to A1C.Mean age for the sample was 14.5 (SD 1.7) years, mean A1C was 8.9% (SD 1.8%), 50% were female, and diabetes duration was 5.5 (SD 3.5) years. Cronbach's reliability for TUPS was 0.78. In regression analyses, variables significantly associated with A1C were the socioeconomic status (=-0.26, P<0.01), Diabetes Adolescent Problem Solving Questionnaire (=-0.26, P=0.01), and TUPS (=0.26, P=0.01). Aside from the Diabetes Self-Care Inventory-Revised, each block added significantly to the model R(2). The final model R(2) was 0.22 for modeling A1C (P<0.001).Results indicate a counterintuitive relationship between higher use of technologies for problem solving and higher A1C. Adolescents with poorer glycemic control may use technology in a reactive, as opposed to preventive, manner. Better understanding of the nature of technology use for self-management over time is needed to guide the development of technology-mediated problem solving tools for youth with type 1 diabetes.
View details for DOI 10.1089/dia.2014.0422
View details for Web of Science ID 000363943000004
View details for PubMedID 25826706
View details for PubMedCentralID PMC4504438
This study aimed to systematically review the evidence base for the use of existing psychological and psychosocial measures suitable for use in artificial pancreas (AP) research.This systematic review of published literature, gray literature, previous systematic reviews, and qualitative and economic studies was conducted using terms and abbreviations synonymous with diabetes, AP, and quality of life (QoL).Two hundred ninety-two abstracts were identified that reported psychosocial assessment of diabetes-related technologies. Of these, nine met the inclusion criteria and were included. Only four of 103 ongoing trials evaluated psychosocial aspects as an outcome in the trial. Of these, treatment satisfaction, acceptance and use intention of AP, fear of hypoglycemia episodes, satisfaction with AP, and an unspecified QoL measure were used.A better understanding of the psychosocial side of AP systems and the extent to which human factors play a role in the uptake and efficient use of these systems will ultimately lead to the most benefit for people with diabetes.
View details for DOI 10.1089/dia.2014.0305
View details for Web of Science ID 000351057300011
View details for PubMedID 25549042


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West Barnstable (GNIS FID: 615800) is a populated place located within the City of Barnstable Town, a minor civil division (MCD) of Barnstable County.
The elevation of West Barnstable is 52 feet. West Barnstable appears on the Hyannis U.S. Geological Survey Map. Barnstable County is in the Eastern Time Zone (UTC -5 hours).
Barnstable County: Subdivisions (MCDs) | Cities & Towns | ZIP Codes | Features (airports, churches, hospitals, etc.)Nearby Hotels | Driving Directions
BIG Map |
Driving Directions |
Terrain Map |
Satellite Map |
Data Source - USGS GNIS FID: 615800
BOUNDARY MAPS: Barnstable County
Barnstable Town city, MA
(2.7 miles SSE)
East Sandwich, MA (4.7 miles WNW)
Yarmouth Port, MA (6.4 miles E)
Forestdale, MA (6.6 miles W)
Sandwich, MA (7.2 miles WNW)
West Yarmouth, MA
(7.9 miles ESE)
Mashpee Neck, MA (8.1 miles SW)
Sagamore, MA (9.1 miles WNW)
Popponesset Island, MA (9.5 miles SSW)
Dennis, MA (9.6 miles ENE)
Pondsville, MA
(2.7 miles WSW)
Pond Village, MA (2.7 miles E)
Scorton Shores, MA (3.1 miles NW)
Farmersville, MA (3.6 miles WSW)
Barnstable, MA (3.9 miles E)
Camp Burgess, MA
(4.1 miles W)
Newtown, MA (4.1 miles SW)
Centerville, MA (4.1 miles SSE)
Marstons Mills, MA (4.1 miles SSW)
Plowed Neck, MA (4.3 miles NW)

subset: commoncrawl


text:
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text:
Quick show of hands – who here doesn't know that GMT watches are sort of my "thingâ€?  Ok, well, for the three of you, that's your notice – I'm into GMT watches.  Last year, I started doing a survey of some of the various GMT options out there.  At the advice and counsel of a buddy who is into higher-end stuff, he pointed me in some directions I would not normally have considered covering, and it's lead to some fun surprises.  The latest of these was when another friend from the watch world started working over in marketing at Panerai.  That was my door, and I stuck my foot in as quickly as I could.  I took some patience, but here we are today, and I was able to spend some time with the Panerai Luminor 1950 10 Days GMT.
In some ways, this review was also a way for me to be just a bit more like John, who likes his classic big brands, but prefers to go in slightly different directions with his picks (as we see with his own personal Panerai). Â That said, I was also being true to my own watch sensibilities. Â You see, the very first mechanical watch I ever had was a Panerai homage. Â That watch is long gone, but that one was where I really latched on to the loveliness of a sandwich dial, and that vintage look has stuck with me as a favorite ever since.
Of course, that lowly homage couldn't hold a candle to what I experienced with the Panerai Luminor 1950 10 Days GMT.  While I certainly don't have it to do a side-by-side, there's a reassuring heft that the real deal carries with it.  Some of this is it's real weight.  But there's more than a little that comes with the overall feel of a quality, sturdy build.  For example, the movement winds as smoothly as silk, and the crown protector flips out cleanly, the whole assembly sturdily affixed in place.  These are just a few impressions that hit quickly, and resonate as to how different this watch is from other look-a-likes you may have encountered in your own watch journey.
In general, I'd say that Panerai is more well known for their simpler time-only watches, either in a regular or California dial.  You know, the watches you call to mind when you think of Panerai.  But as I said, I'm channelling my inner John here, and we went in something that is off that "iconic†beaten path. Sure, the profile of the 44mm case is certainly identifiable, as is the tasty, tasty sandwich dial.  Once you get past that, though, the Panerai Luminor 1950 10 Days GMT brings a whole lot more to this Italian dinner.
Not that it's a surprise, all of it is hiding in plain sight in the name of the watch.  10 days?  That would refer to the power reserve that the movement offers.  Sure, ten days may be overkill for most folks, but to me it says "yeah, we can do it, we've got the room in the case, so we did it.  Take it or leave it.† And, yes please, I'll take it.  Not sure which side of the watch winder argument (do you need one?  or not?) to favor?  Well, a 10-day power reserve will certainly keep you from needing to worry about it.  The current level is indicated by a linear slider above the 6 o'clock position, and even brings some lume to the party.  For my time with the watch, I never saw the reserve drop below 9. Then again, I barely let the watch leave my wrist.
Next up for the Panerai Luminor 1950 10 Days GMT is the reason I initially asked for this watch on loan – the GMT.  Here, it's a bit more complicated than I normally encounter on my watches.  I mean, yes, you do have the secondary (arrow-tipped) hand that marks out the 24-hour time (and yes, I did have it set to GMT, thank you very much).  In a flip of how most folks would expect, the GMT hour hand is the one tied to the minute hand adjustment, and then the main hour hand can be advanced (forward or backwards) in one-hour clicks.  Again, this is the reverse of how most folks might expect, but I've come to understand (and appreciate) that this actually makes more sense for a traveller.  You keep the GMT time set to your home time zone, and then when you land in your new time zone, you do a quick 10-second adjustment to the main hour hand, and you're on local time.
Frankly, it just makes sense.  Which, when the movement in a watch (more on that in a second) is as complicated as we have here, well, that simplicity in operation is as welcome as it is a contrast to the movement's complexity.  That movement carries the label of calibre P.2003 (more on that here). Just that designation alone made Victor (once he realized what watch I was talking about) use some terminology that, well, made his thoughts (to the positive) known.  I just know it's an in-house movement for the brand, and enables all we see on this watch, including the sub-seconds and AM/PM indication over at 9 o'clock.
I also know that the movement is what makes the Panerai Luminor 1950 10 Days GMT appeal to me.  It adds elements to the watch that I simply like, as well as displaying some real technical chops.  And it does it in a way that isn't screaming it out at you.  It's there, quietly doing it's job, waiting for your to realize how superb it really is.  Or, you know, for your watch buddies to be struck just about speechless (as happened to one of my friends).
I do realize how funny it is to combine "Panerai†and "quietlyâ€, as it's larger-than-life sizing seems to be all about attention.  And sure, the 44mm case of the Panerai Luminor 1950 10 Days GMT is larger than I might personally prefer (fingers crossed we'll get to see that new 38mm case soon), I still found it eminently wearable.  I'd say my own wrists are on the edge of where this watch would be overbearing, but fortunately for me, it was on the correct edge.  Some of that is due to the curved lugs (I did have some overhang), and some of that is due to the strap that the watch comes on.
Stock straps are something that we generally don't give much attention to, I know.  But in the case of the Panerai Luminor 1950 10 Days GMT, it's worth calling out by itself.  This is more than just a little in part due to how many aftermarket "Panerai†straps there are out there, and I'm sure many of you have played with some of those.  Sometimes, it seems just throwing a Pre-V buckle on there is about all some makers do.  Others build out something that's more supple, and give the strap a luxurious look and feel.  Then, there's this one that I experienced, and it put all those others to shame.
On the Panerai Luminor 1950 10 Days GMT, the leather was extremely soft and supple, yet it felt plenty sturdy for taking the weight of the watch.  Surprisingly (again, this is my first time with a Panerai) it was also a padded strap.  It's a subtle gradation to the edges, but the padding in there, and helps build a profile as well as making the strap more comfortable.  This comfort is also assisted by the fact that the strap tapers to 22mm at the buckle, which helps reduce bulk under the wrist.  While I would not have minded a plain-old thumbnail buckle, I get that the Pre-V is a signature of the brand, and the slightly smaller size here, well, I'll let it slide.
As I mentioned, once I got the loaner of the Panerai Luminor 1950 10 Days GMT in, I rarely let it off my wrist.  That meant it went to the office, got paired up with a suit on a different day (pro tip:  make sure your French Cuffs have enough room to fit this case profile), and even headed out to the movies with the family (Paddington 2, for those curious, and it was quite enjoyable).  The overall size of the watch lends to a more casual feel, but the fully-polished case lets it sneak into that dressier scenarios as well.
Which, when you have a watch that commands a price tag of $13,400 – as the Panerai Luminor 1950 10 Days GMT does – you want something that is going to be versatile across a variety of situations.  Add in the fact that this is the sort of watch that is intended for continent-, if not globe-, trotting, and you all but need the versatility.  Yeah, there are other watches that can do this, but they likely won't have the technical chops that the Panerai Luminor 1950 10 Days GMT has.  Nor will it have that immediately-identifiable Panerai design DNA.  Which, in my book, is a good thing to see in the steel, and I'm certainly glad we got to spend some time with it.
I'm sure John and I can't be the only Panerai admirers amongst the WWR family of readers.  Sound off below (or over in our Slack channel) if there are any other Panerai models you'd like us to review.  I cannot say for sure that anything and everything is possible, but we'll certainly do our best to have a look at what you want to see.  Or who knows, perhaps you don't like these diversions into aspirational (read: save up for a while to get) sorts of watches – and if that's the case, let us know as well.  Unless you tell me otherwise, imma just assume you all are just as entranced by the Panerai Luminor 1950 10 Days GMT as I was.  panerai.com
Review Summary
- Brand & Model: Panerai Luminor 1950 10 Days GMT Â44mm (PNPAMS0533)
- Price: Â $13,400
- Who's it for?  The globe traveling sort of fellow who wants something sporty enough for town, but dressy enough for the board room
- Would I wear it? Would I ever!
- What I'd change:  If there was any way to keep all the complications, but shrink the overall case size, I would be all ears
- The best thing about it: Â How much is packed into what is, really, a fairly unassuming case and dial (at least on first glance)
- Movement
- Automatic mechanical, Panerai P.2003 calibre, executed entirely by Panerai
- 13¾ lignes, 8 mm thick, 25 jewels, Glucydur® balance, 28,800 alternations/hour.
- KIF Parechoc® anti-shock device.
- Power reserve 10 days, three barrels, seconds reset device.
- 296 components.
- Functions: Hours, Minutes, Small Seconds, Date, GMT, Power Reserve Indicator, Seconds Reset
- Case Diameter: 44 mm, AISI 316L Polished Steel
- Bezel: Â Polished Steel
- Back: Â See – through sapphire crystal
- Device protecting the crown: (Protected as a trademark) Brushed Steel
- Dial:
- Black with luminous Arabic numerals and hour markers.
- Date at 3 o'clock
- GMT indicator at 9 o'clock
- Linear power indicator at 6 o'clock.
- Crystal Sapphire crystal formed of corundum
- Water Resistance 10 bar (~100 metres)
- Strap: Â Calf Assolutamente, Dark brown, Beige, 24/22 MM Standard


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Aerial Images 2016 April - June
An index of aerial images taken with a DJI Phantom 2 Vision+ quadcopter
Aerial 2016 - 1
Aerial Pictures Home
Aerial 2016-3
ll pictures on this website are ©
Jon Wornham
May 14th
Flying from Onchan and Douglas Heads
Around Bradda Head
May 15th
This location is very close to Ronaldsway Airport so the flights were only undertaken after co-ordination with Ronaldsway Air Traffic Control.
May 22nd
Brandywell Road
May 24th
Whitestrand Beach & St German's
Peel Hill and Corrin's Tower
Peel Castle and Fenella Beach
May 29th
Ronaldsway Airport and on Langness. Due to the proximity of the airport all flights had to be co-ordinated with Air Traffic Control and particularly the first ones where the flight had to take place when there were no aircraft movements.
6th June
Lady Isabella - The Laxey Wheel, constructed in 1854 to drain water from the Laxey Mines and 72 feet 6 inches in diameter
Lady Evelyn - The Snaefell Mines wheel, a 50 foot waterwheel operated between 1865 and 1910 at the mine before being sold fo
further use in Cornwall. Returned to the island in 2003 and reconstructed by Pete Geddes and his team, turning again in 2006
Unless otherwise credited all pictures on this website are ©
Jon Wornham


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Trial Preparation
Sometimes presenting a jury with a mounted display is the best way to present your evidence. And sometimes you might want it projected to create a more dynamic and live experience for the jury. We're particularly adept at discussing your case's singular arcs and moments to help decide which is right for you. VisuaLegal's client-based philosophy involves developing a comprehensive story-telling feel to your demonstrative evidence. Initial consults and production meetings brainstorm your elements into their most creative realization. Afterwards, we offer the highest quality graphic reproductive services. Let us come to your office to give a short demonstration of what we can do to help you win.
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Mounted and laminated dispays of graphics and tutorials.
Expeditious and concise consultation and brainstorming.
All content on this site is property of Visualegal. Unauthorized duplication is a violation of applicable copyright laws and is strictly forbidden.


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CrazyTalk Animator provides an exciting new approach to traditional 2D animation with innovative new tools that allow users to apply 3D motions to 2D characters. New powerful tools have opened new possibilities for freely editing 2D motions and viewing them from any angle with a single click. Combined with functional features like facial puppet and auto lip-sync, it has become the most creative tool for 2D character animation.
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What's New Version 3.31
- Release notes were unavailable when this listing was updated.


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I want to quit. I do. I want to just be done. When you are leading a normal life, three months doesn't seem like it would be that long. BUT, when you are barely getting through the moment to moment, three months feels like an eternity. I have four more chemo rounds to do. FOUR MORE. The easy part is sitting through five hours of chemotherapy. That's easy. The hard part is when I turn into someone unrecognizable.
Roid rage, barfing and exhaustion. Perimenopause, hot flashes and hair loss. That's just an hour of my day. Every hour. I've been entered into a system in which this is normal. I'm watching big things just fall out of my life. I'm not working and it's hurting our family but, no one can be mad about it. I'm mad. I'm fucking PISSED OFF!
I have fought and survived things that many people wouldn't believe. My strength has already been tested. I have proven that I will prevail, so why do I have to do it again? I have rectified my spirit and payed it forward and received my karma. I have made amends, ended relationships, repaired relationships and started over. Why do I have to fucking do that AGAIN? It's great to hear and say things like, "cancer fucked with the wrong bitch" I love that stuff. But how much fight is one person supposed to have?
I am tough. Probably tougher than I should be. Thank god I was blessed with a little girl who came at a time that my heart needed to be softened. I don't want to have to become hard again. I don't want to fucking do this.
I was just arriving at a place in my life where I felt like a grown up. I have some accomplishments to be proud of. Those things can fade quickly if you can't be present to fight to keep them every day. There are people just waiting for me to fail so that they can scoop up my little piece wether consciously or subconsciously. My failure would and could be someone else's success.
Just know that this girl has been through some shit. But this battle is one that must be fought without armor. Why? Because cancer snatches it up. The layers of me are being thinned and it's up to my core to fight. I am hardcore and I will fight dirty. Watch me. If you think winning isn't everything, then you haven't fought cancer.


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Explore the City of Arts and Sciences with a passionate local guide and find out how the futuristic architectural masterpiece came to be. The tour operator will meet you at the doorway of Barcelo hotel to start the tour and will take you to Calatrava's modernistic complex to learn the stories and the history behind the buildings. Then, admire Valencia from the city's highest rooftop terrace and get an incomparable panoramic view of the city. Here you will be free to relax and indulge in a 10-course tasting menu of local products accompanied by a comprehensive wine-tasting of prize-winning regional wines.
Walking tours
Valencia City of Arts and Sciences tour with rooftop wine and tapas
based on 1 review
Free cancellation
Language: English
Availability: Every day
Mobile voucher accepted
Duration: up to 4 hours
Instant confirmation
Guided Tour
Meal Included
Do this because
- Take part in a guided tour of the City of Arts and Sciences and discover the modern face of the city
- Reach the highest terrace in Valencia and get a spectacular view over the entire city
- Conclude your experience tasting local food and wine in an intimate and relaxed atmosphere
- Enjoy a small-group experience including local guide, typical meal and drop-off service
What to expect
Read more
What's included
- Guided walking tour around the City of Arts and Sciences
- Lunch or dinner with tapas and wines with spectacular views from the highest terrace
- Private drop-off service back to your accommodation at the end of the tour
What's not included
- Pick-up service from your accommodation
Reduced price
- For children (0-5 years) this event is for free
Av. de França, 11, 46023 València
Meeting point:
At the doorway of Barcelo Valencia.
What to remember
- The tour is subject to favorable weather conditions
- The tour will host a minimum of 1 and a maximum of 10 participants
- The tour is not wheelchair accessible
Read more
Every day:
- Morning tour (including lunch): 11.00am
- Afternoon tour (including dinner): from 4.30pm to 6.30pm, depending on the season
Read more
Sea Saffron
Booking fee
Good news! No extra fees are applied to this booking.
Cancellation policy
Receive a 100% refund if you cancel up to 7 days before the activity begins. If you cancel up to 3 days before, you can still receive a 50% refund.
What people say about this experience
based on 1 review
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The guys from Original Plumbing, the magazine about trans men, are celebrating their mothers' plumbing today, and the fact that at one point in time, they took a ride through it. At Your Mom, attendees are encouraged to bring their moms, or at least come dressed like them (there'll be a costume contest, too). DJs Roze Royce and Delbert Betts D.D.S. spin into the night, backed by "mom-centric visuals." And San Francisco–based photographer and OP editor Amos Mac will be setting up a baby-bump photo booth to fulfill every guy's secret wish to look like Arnold Schwarzenegger in Junior.
Sun., May 8, 4 p.m., 2011
This article from the Village Voice Archive was posted on April 27, 2011


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When they were released in April 2015, the Galaxy S6 and S6 Edge ran on Android 5.02 Lollipop and T-Mobile started rolling out the Android 6.0.1 Marshmallow at the end of May. Now, this carrier is pushing out a new update to these two flagships and the file weighs in at 250MB, containing the Android security patch for the month of June.
Galaxy S6 and S6 Edge owners who opted for T-Mobile's services are upgrading their devices' software version to G920TUVU4EPF1 and G925TUVU3EPD1, and it's important to install this update because it comes with bug fixes and improvements to anti-theft functionality. The update is rolled out via OTA, which means that it will take a few days until it will reach all users, but if you're impatient, you can manually attempt to force it by going to the Settings menu and tapping on About Device, then on System Updates.
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text:
%0 Government Document %D 2011 %T Waswanipi Food Security Workshop Report %A Noreen Dianne Willows %X
This report summarizes the food security workshop held in Waswanipi on April 12 and 15, 2011. It is one part of the research for a project titled First Nations Food Security: Piloting the Promising Practices tool and understanding community perceptions of food security. Dr. Noreen Willows from the University of Alberta is the lead investigator of the project. The research is supported by the Cree Nation of Waswanipi and the Cree Board of Health and Social Services of James Bay (Quebec). Funding was provided by the First Nation and Inuit Health of Health Canada and the Cree Health Board.%G eng


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I didn't know it was World Water Day yesterday until I read yesterday's paper today. Regrets.
It's not so bad as one I had when I came home one day and found my faucet running. Forgetfullness caused me accidental, unintentional neglect. I wasted water. I was guilty. From then on, I became more cautious to make sure all taps and even power consumers are off when we leave home. Resolve. We find ways to solve our problems and avoid new ones.
World Water Days aren't holidays of funfare. They are there to remind us of our responsibilities.We SHOULD and we, actually, CAN do something.
The UN cites a few examples of what we can do: "follow a healthier, sustainable diet; consume less water-intensive products; reduce the scandalous food wastage: 30% of the food produced worldwide is never eaten and the water used to produce it is definitively lost!produce more food, of better quality, with less water."
Learn more about the world's water situation, visit the United Nation's Website:
View pictures as contributed by the Guardian, click:
World Water Day Photos from the Guardian
A green earth cannot be possible without water. Learn Green. Love Green. Live Green.
Surely God is my salvation; I will trust and not be afraid. The LORD, the LORD himself, is my strength and my defense; he has become my salvation." With joy you will draw water from the wells of salvation.
Isaiah 12:2-3


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Pasadena, TX – Enchanted Florist – Your Houston Flower Shop, a distinguished flower shop in Pasadena, TX is proudly announcing the celebration of their 38 years in the flower business. Their company is owned by Debbie Wright, AAF, TMFA, who is a past president of Texas State Florists' Association and still active. She has also been committed to the industry of education.
Enchanted Florist – Your Houston Flower Shop is an authentic full-service flower shop that was launched in 1982 on Burke and Southmore, six years later they moved to the Strawberry location where they spent over 25 years. Then in January of 2014, they relocated to their present facility in Fairmont.
"Our florists are artists who know how to take advantage of the wide variety of fresh-cut flowers from all over the globe including Ecuador, California, and Holland," explained the spokesperson for Enchanted Florist – Your Houston Flower Shop, regarding the skills of their well-selected florists.
Enchanted Florist – Your Houston Flower Shop carries a large selection of flowers for all special occasions including Happy Birthday flowers, get well flowers, anniversary flowers, thank you flowers, I'm sorry flowers, and sympathy flowers. The wedding florist team from Enchanted Florist – Your Houston Flower Shop offers custom arrangements for one and only moments. They also offer wedding packages, wedding delivery, even if it is a small wedding, they will be glad to share their expertise to create a pleasant memory.
At the Enchanted Florist – Your Houston Flower Shop, customers enjoy a varied selection of prime-cut fresh flowers including Ecuadorian red and pink roses, daisies, and tulips, set individually or in elegant bouquets. As an added value, they also offer a Floral Rewards Point system, through which they seek to continue creating more ways for their loyal customers to save and obtain even more value with every redeem.
As a locally, woman-owned Pasadena company, Enchanted Florist – Your Houston Flower Shop prides itself on being the Best Florist in Pasadena TX, producing excellent quality in flower arrangements that go hand-in-hand with great customer service for their last 4 generations of women. Their prestigious flower shop is famous for its great professionalism and responsibility. As through their years in business, their expert florists have strived to offer world-class services in a timely manner, whether for pre-schedule orders or even on the same day. Their local flower delivery is available in Pasadena, Deer Park, Houston, and the surrounding areas.
"Excellent florist! I moved away from Houston but still have family in the area. I needed a sympathy funeral flower arrangement delivered the next day. You were able to come through in a pinch. The beautiful display was delivered ahead of schedule and looked just like the picture I had picked out," said a satisfied customer, regarding her most recent experience contracting Enchanted Florist – Your Houston Flower Shop.
Enchanted Florist – Your Houston Flower Shop is located at 4416 Fairmont Pkwy #104, Pasadena, TX 77504. To schedule flower delivery or request same-day delivery service, contact their team via phone at 832-850-7677 or send online inquiries via email to [email protected] Connect with them on social media to view their portfolio or for additional information regarding their services or to get a free wedding consultation, visit their website.
Media ContactCompany Name: Enchanted Florist – Your Houston Flower ShopContact Person: Debbie Wright, AAF, TMFAEmail: Send EmailPhone: 832-850-7677Address:4416 Fairmont Pkwy #104 City: PasadenaState: TXCountry: United StatesWebsite: http://enchantedfloristpasadena.com


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NAI Tri-Cities has many agents and professionals at your service. If you know the party you are looking for, please use the form on the right to enter the person's name to retrieve their contact information and profile.
The NAI Tri-Cities team has 60+ years of collective real estate experience making us a trusted and respected member of the local business community and global marketplace. NAI Tri-Cities is the only globally managed commercial real estate firm in Benton and Franklin Counties, offering an array of services to local and incoming businesses.
Our team is comprised of five highly skilled Principals as well as other key staff that exemplify excellence in the real estate sector. Our team members have been involved in every aspect of Industrial Brokerage, Retail Brokerage, Office Brokerage, Corporate Services, Consulting Services, and Investment Sales & Acquisitions in southeastern Washington.
Please use the following contact information:
NAI Tri-Cities
89 Gage Blvd
Richland Washington 99352
United States
Tel +1 509 943 5200
Fax +1 509 943 5244
We offer several ways to approach your real estate in a holistic manner: either from your perspective as a Client or addressing your specific Property type.
We invite you to browse our services in relation to your specific real estate needs. Please select your Client type or Property type, depending on the focus of your current requirement.
Our team members have been involved in every aspect of Industrial Brokerage, Retail Brokerage, Office Brokerage, Corporate Services, Consulting Services, and Investment Sales & Acquisitions in southeastern Washington.
Jazz Bains brings over 8 years of experience in the hospitality industry and thrives in customer satisfaction. He was born and raised a Seattle native and brings a fresh and innovative approach to the Tri-Cities. He moved to the area in 2012 in order to invest in his own commercial properties and now successfully heads his own hotel investments. His dedication, outgoing nature, and true passion for his business has helped Jazz's reputation as a professional realtor rapidly rise. With robust networks and relationships across Washington state, he's thrilled to assist future clientele with all their real estate endeavors.
Jazz's career began to take off in 2012 when he became the owner and manager of Kennewick Suites. As the owner and manager, his essential duties included overseeing staff and maintaining hotel operations. This bank owned property with low revenue became a booming hotel as the occupancy rose from 40% to 94% within the first year. After a major $300,000 renovation, the hotel was put up for sale at an increased rate of 154% from the initial buying price, selling for a total of $2,800,000 million.
While dealing with the Kennewick Suites, Jazz grasped a new opportunity by identifying the Guest House Inn as an underestimated property with extreme potential. Alongside his partner, they collectively worked on cultivating a better work environment by focusing on team building exercises and training programs. Creating a dynamic team stimulated growth in occupancy rates from 54% to 89% under their management. Moving forward with a renovation of $400,000 allowed for the property to be converted into a Red Lion Inn and Suites. By amplifying sales initiatives within the first year of management from $730,000 to $1,200,000, Jazz was able to achieve a maximized appraisal of $6,000,000 million after purchasing the property for $2,700,000.
Jazz's latest endeavor has been orchestrating efforts behind the construction of a Best Western Plus Hotel in Boardman, OR. He currently partners with contractors, architects, civil engineers, and consultants to discuss site development, and operational objectives. He is strategically designing the hotel in order to ensure an aesthetically pleasing atmosphere to enhance the experience of future guests.


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Presentations: New Music/New Places
Soyeon Kate Lee, piano
Soyeon Kate Lee performs solo works for piano.
Alexander Scriabin:
Sonata-fantasie in G-sharp Minor
Impromptu alla Mazurka Op. 2, No. 3
Impromptu in B-flat Minor Op. 12, No. 2
Lera Auerbach (1973— ):
Suite (9 preludes from Op. 41) for Piano, Op. 41a (1999)
Alexander Scriabin:
Feuillet d'album, Op. 45
Fantasy in B Minor, Op. 28
Miguel Roig-Francoli (1953— ):
Six Preludes after Chopin (world premiere, 2015)
Dmitri Shostakovich:
From 24 Prelude and Fugues, Op. 87 –
No. 14 in E-flat Minor
No. 15 in D-flat Major
Claude Debussy:
From Preludes Book I –
La fille aux cheveux de lin
Ce qu'a vu le vent d'ouest
Claude Debussy:
L'isle joyeuse
Co-presented with ChamberMusicNY.
CAG is a presenter partner of Composers Now.


text: I recently gave my old rig to my wife to replace her laptop. Specs are in the sig. This box has been running primarily wired but the Wifi is failing me now. I have tried to enable my wireless connection but its greyed out. I have tried updating drivers with the right click method. I even tried the WLAN Auto Config fix and still no dice. Any other suggestions or maybe its time for an I7 NUC for the MRS.


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prosoftassociatesMember since Feb 2, 2018Articles: 26Location: n/aFollowersprosoftassociates don't have any followers yet
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Showing Collections: 1 - 10 of 24
Albert Charles Jacobs Papers
Identifier: U321
Overview Contains papers relating to Chancellor Albert Charles Jacobs and his time at the University of Denver.
Dates: 1949-1955
Alton Barbour Papers
Identifier: M107
Dates: Other: 1912-1998
Alvin Goldberg Papers
Identifier: M338
Dates: Other: Date Not Yet Determined
Bin Ramke Papers
Identifier: M381
Overview Collection contains personal papers of University of Denver English Professor Bin Ramke. Contains photographs, manuscript and poem drafts, research materials, essays, clippings, publications, personal journals and notebooks, Macintosh Powerbook G4, Macbook Air, course materials; primarily photocopies of primary materials.
Dates: 1973-2013
Carol Metsker Papers
Identifier: M426
Overview This collection consists of the papers and objects of Carol Metsker, a former Unversity of Denver faculty member.
Dates: 1966-1980
College of Liberal Arts Records
Identifier: U014
Overview Collection contains meeting minutes from the Liberal Arts Faculty dated 1931-1937 and 1938-1941, the itinerary and study questions related to the Study Tour of England in 1989, and the college Circular dated 1899.
Dates: 1899 - 1989
Debbie Gale Mitchell Papers
Identifier: M420
Overview Debbie Gale Mitchell graduated with a Doctorate from the University of Denver (DU) in 2013. She is currently a member of the faculty at DU.
Dates: 2017
Deborah Howard's Holocaust Portraits and Papers
Identifier: B398
Overview Deborah Howard is an Associate Professor and Head of Painting Program at the University of Denver. After a discussion on racial stereotypes and aging in a Figure Painting course Howard was teaching, she began to develop her Portraits of Child Holocaust Survivors project and settled on drawing as the media for the project. Howard has drawn and painted twenty-five people who escaped, hid or survived concentration camps during the Jewish Holocaust of WWII. Four portraits from the project are in...
Dates: 1949-2019
Donald Stedman Papers
Identifier: M318
Dates: Other: 1930-2009
Dwight Smith Papers
Identifier: U322
Overview This collection contains materials relating to Dwight Smith and his time as Chancellor at the University of Denver.
Dates: 1984-1989
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NEW YORK — What's the fate of the "Furious"? Possibly the biggest global opening in movie history.
"The Fate of the Furious," the eighth installment of the popular "Fast and Furious" series, opens in the U.S. and 63 international markets, including China, the U.K. and Mexico, this weekend.
It's on track to gross more than $530 million worldwide, according to producer Universal Pictures.
That would break the global box office record held by Disney's "Star Wars: The Force Awakens," which brought in $529 million globally in 2015. (Yet, to be fair to the galaxy far, far away, "Force Awakens" didn't open in the world's second largest market, China, until a month after it was released.)
So far the film, which opened Thursday night in North America, has brought in $194.8 million worldwide, including $45.6 million on opening day in the United States. The early totals have pushed the 16-year-old series above the $4 billion mark overall.
It's no shock that the film is a hit with international audiences. For the first seven films in the franchise, 67% of ticket sales came from abroad, especially China. In that market, it took 2015's "Furious 7" only eight days to gross $250 million.
The latest film, which stars Vin Diesel and Dwayne "The Rock" Johnson, is already breaking records in China. "Fate" has nabbed the country's record for biggest single day ever and is projected to have the biggest three-day opening of all time in China as well.
"Once again, the 'Furious' franchise has come off the line faster than ever before," said Shawn Robbins, chief analyst at Boxoffice.com.
Time will tell if "Fate" crosses the finish line on Sunday with a new global record, but so far the film is driving in the right direction.


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How to Hack the New Facebook Update
You may have heard recently that Facebook made a BIG change to the News Feed. In case you haven't heard, or you're not sure what it's all about, I'll give you a quick rundown. Facebook has reworked its algorithm, or filter, that decides what you see and don't see in your feed. Mark Zuckerberg, the…Read More
The Fine Art of Auburn, CA
Auburn, the beautiful town I call home, was recently featured in an article naming it The Best Town in Northern California and I couldn't agree more! Auburn Post Office Flickr/ Jim Gaither via onlyinyourstate.com For those who may not know, Auburn is a small (but not too small!) town located in the heart of Gold Country,…Read More
The Fine Art of…
My sister called me the other day saying she stumbled on a few things from our younger modeling days and that I just had to see them. It was a kick taking a trip down memory lane…check out this magazine cover from 1983 with my mom and sister and this oh-so-dramatic headshot: Man, I miss those…Read More
My Top 10 Intentions for 2017
"Every journey begins with the first step of articulating the intentions, and then becoming the intention." ― Bryant McGill, Voice of Reason I've put together my top 10 intentions for 2017 – I hope they bring you a little inspiration and help encourage you to find your intentions. Here's to a new year, new beginnings, and new…Read More
Why Selling During the Holidays Isn't the Worst
People tend to ask me the same question around this time of year – "Should I put my home on the market in winter?" It's understandable why you wouldn't want to – decorating, holiday shopping and parties can take up a LOT of time. Plus you may have to go easier on the glitter elves…Read More


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We are in a stable good place. With the right new owner that loves fitness and this business. It will take this to a new level. We want to find the right buyer to finish a turn key studio to new heights.
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