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• No Need to Fast Before Lipid Measurements, Study Suggests
• Meta-Analysis: Probiotics Safely Reduce Risk for C. difficile–Associated Diarrhea
• Genetic Variation in Vitamin D Receptor Affects Health Outcomes
• Poor Physical Performance Associated with Dementia, Again
• Intensive and Standard BP Targets in Patients with Longstanding Type 2 Diabetes
• Widespread Screening for Type 2 Diabetes Might Not Lower 10-Year Mortality
• Mortality Increases as Renal Function Declines, Regardless of Comorbid Diabetes
or Hypertension
• CVS' PBM Plans to Stop Coverage of Certain Drugs
• FDA Investigating Reports of Deaths Tied to 5-Hour Energy Drink
• Black Women Have Higher Death Rates from Breast Cancer Than White Women
• Moderate Alcohol Consumption in Pregnancy Linked to Lower Childhood IQ,
Genotypying Study Suggests
• Like Girls, Boys Are Now Entering Puberty Earlier
• Diabetes Prevalence in the U.S. Nearly Doubles in 15 Years
• Obstet Gynecol 2012 Nov; 120:1085
• No Benefit of Multivitamins for Preventing Cardiovascular Disease in Men
• Presentation of Celiac Disease with Immunoglobulin A Deficiency
• Hypoglycemia Raises Risk for Death in Critically Ill Patients
• Alzheimer's Linked to Vitamin D Lack
MM: This is great news for those of us who cannot get that early appointment at the doctor's office for our yearly physicals. No longer must we ignore, "the most important meal of the day" just because we are going in for that battery of "standard" blood tests that will make us feel either wonderful or miserable about ourselves.
No Need to Fast Before Lipid Measurements, Study Suggests
A cross-sectional study in the Archives of Internal Medicine calls into question the need for fasting before lipid measurements, as current guidelines recommend.
Researchers in Canada used laboratory data to measure variations in lipid measurements according to the time since a patient's last meal (range, 1-16 hours). Nearly 210,000 individuals were included.
Overall, mean total and HDL cholesterol levels varied little, by less than 2%, with differing fasting times. LDL and triglyceride levels varied more, by less than 10% and 20%, respectively.
An editorialist concludes: "The incremental gain in information of a fasting profile is exceedingly small for total and HDL cholesterol values and likely does not offset the logistic impositions placed on our patients, the laboratories, and our ability to provide timely counseling to our patients. This, in my opinion, tips the balance toward relying on nonfasting lipid profiles as the preferred practice."
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MM: It's been over a decade that I have been recommending probiotics as a prophyactic measure when taking antibiotics. It makes me feel great when the peer-reviewed literature supports the actions of my integrative and restorative medicine colleagues and me.
Meta-Analysis: Probiotics Safely Reduce Risk for C. difficile–Associated Diarrhea
Probiotic therapy helps prevent Clostridium difficile–associated diarrhea (CDAD) in patients on antibiotics, according to a meta-analysis in the Annals of Internal Medicine.
Researchers analyzed 20 randomized trials that compared probiotics with placebo or no treatment in some 3800 children and adults who were taking antibiotics. The following probiotic species were included: Bifidobacterium, Lactobacilli, Saccharomyces, and Streptococcus. (Roughly half the studies excluded patients who were immunocompromised.)
Probiotics cut the risk for CDAD by 66%, with similar effects seen in both children and adults and with different probiotic species. Adverse events (e.g., nausea, fever) occurred in 13% of the control group and just 9% of the treated group.
The researchers conclude: "Moderate quality evidence supports a large protective effect of probiotics in preventing CDAD. Given the low cost of probiotics and the moderate quality evidence suggesting the absence of important adverse effects, there seems little reason not to encourage the use of probiotics in patients receiving antibiotics who are at appreciable risk of CDAD."
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MM: It seems that every time a new study comes out there are more questions that are raised than answers that are provided. When it comes to Vitamin D, I will continue to recommend 5000-10,000 IU daily to almost all of my adult patients. Irrespective of the small number that may benefit more from much ghigher doses than the general public, it is still important, in my opinion, to maintain 25-OH-D blood levels that are closer to the top of the 30-100ng/ml blood range than to the lower quadrant.
Genetic Variation in Vitamin D Receptor Affects Health Outcomes
Variations in the vitamin D receptor gene are associated with increased vulnerability to conditions such as hip fracture and myocardial infarction, according to a JAMA study.
Researchers identified small variations (called single nucleotide polymorphisms, or SNPs) in the gene governing the action of the vitamin D receptor in a cohort of adults aged 65 and older. In participants with low levels of 25-hydroxyvitamin D, the presence of one SNP in particular was associated with an increased hazard ratio for a composite outcome of hip fracture, MI, cancer, or death from any cause. Individuals with two copies of the SNP showed higher risks.
The researchers conclude that similar studies could "help pave the way toward identifying individual patients who may benefit most from vitamin D interventions."
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MM: The key appears to get mom and dad, Nana and Papa up and moving. Once again, irrespective of age, it appears that both aerobic and weight resistant exercise are potentially beneficial to both the body and the mind.
Arch Neurol 2012 Oct 22
Poor Physical Performance Associated with Dementia, Again
The "oldest old" are more likely to have dementia if they have physical impairments.
Poor physical performance and impaired cognition have been associated with each other in both cross-sectional and prospective analyses. This study adds support for the connection, focusing on a specific population aged 90 and older. The 629 participants (mean age, 94; 73% women; 74% with more than a high school education) in the main analysis were part of a cohort-based study of aging. Between 2003 and 2009, participants underwent assessment of physical performance, including objective measures of walking speed, ability to arise from the seated position, balance, and grip strength.
Dementia was diagnosed in 162 participants (25.8%) according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria using neurological evaluation, a cognitive screening test (Mini-Mental State Exam), and functional rating scales (Clinical Dementia Rating Scale and Functional Activities Questionnaire). Poor performance on each of the physical tasks was independently associated with an approximate doubling in the odds of all-cause dementia diagnosis. Secondary analyses that included 218 additional cohort members with partial physical performance datasets did not significantly affect the results.
Comment: Although these results are unique because of the age demographic of the participants, as the authors point out, the generalizability of the results may be challenged by the homogeneity of the study population of highly educated, Caucasian women aged 90 and older. Moreover, as with all cross-sectional studies, one cannot determine causation from these findings.
— Brandy R. Matthews, MD Published in Journal Watch Neurology November 13, 2012
CITATION(S): Bullain SS et al. Poor physical performance and dementia in the oldest old: The 90+ study. Arch Neurol 2012 Oct 22; [e-pub ahead of print].
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MM: The Synergy Blends line of nutritional, functional medicine products found at Mark Drugs are milder than most prescription alternatives while still having a similar net effect on blood pressure, cholesterol and blood sugar levels. This "softer, gentler" approach has proven itself to be effective and without adverse effects. Now the peer-reviewed literature seems to be supporting this gentler approach.
Arch Intern Med 2012 Sep 24; 172:1296
Intensive and Standard BP Targets in Patients with Longstanding Type 2 Diabetes
Intensive blood pressure control lowered stroke risk but not risk for myocardial infarctions.
The ACCORD blood pressure trial showed that intensive blood pressure control (target systolic BP, <120 mm Hg), compared with standard BP control (target SBP, <140 mm Hg), was not associated with lower risk for fatal and nonfatal cardiovascular events in patients with longstanding type 2 diabetes (JW Cardiol Mar 14 2010). In this meta-analysis, investigators evaluated outcomes of treating to intensive BP targets (SBP, 130 mm Hg; diastolic BP, 80 mm Hg) or to standard BP targets (upper limits: SBP, 140–160 mm Hg; DBP, 85–100 mm Hg) in such patients.
Five randomized trials that involved more than 7300 participants (mean ages, 53–62; mean duration of diabetes, 7–10 years) were included in the analysis. Achieved BPs in intensive-target groups were SBP, 118 to 140 mm Hg, and DBP, 64 to 81 mm Hg; achieved BPs in standard-target groups were SBP, 124 to 144 mm Hg, and DBP, 70 to 86 mm Hg. Overall, treating patients to intensive BP targets was not associated with fewer deaths or myocardial infarctions. Although treating to intensive BP targets was associated with a 35% lower relative risk for stroke, the absolute risk reduction was only 1%. Adverse effects were more common in the intensive-target groups (3.3%) than in the standard-target groups (1.7%).
Comment: A recent American Diabetes Association (ADA) guideline recommends that "most patients with diabetes" receive treatment to reach systolic BP of 130 mm Hg and diastolic BP of80 mm Hg (Diabetes Care 2012; 35 (Suppl 1):S11). The results of this meta-analysis, however, do not affirm this recommendation and suggest that treating to standard systolic and diastolic BP targets is sufficient. Notably, the ADA guideline does allow for "higher or lower" SBP targets based on patient characteristics (e.g., stroke risk).
— Paul S. Mueller, MD, MPH, FACP Published in Journal Watch General Medicine November 6, 2012
CITATION(S): McBrien K et al. Intensive and standard blood pressure targets in patients with type 2 diabetes mellitus: Systematic review and meta-analysis. Arch Intern Med 2012 Sep 24; 172:1296. (http://dx.doi.org/10.1001/archinternmed.2012.3147)
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Lancet 2012 Oct 4
Widespread Screening for Type 2 Diabetes Might Not Lower 10-Year Mortality
In a population-based U.K. study, screening all middle-aged high-risk patients did not help.
Early diagnosis of type 2 diabetes can improve clinical outcomes, and mathematical models have suggested that widespread screening might lower diabetes-related mortality. To test this hypothesis, researchers cluster-randomized 33 general practices in eastern England to offer either a single round of formal screening to all middle-aged patients (age range, 40–69) considered to be at high risk for diabetes according to specified clinical characteristics (28 practices with approximately 16,000 high-risk patients) or to continue diagnosing diabetes in such patients through routine clinical assessment (5 practices with approximately 4000 high-risk patients).
Overall, 73% of invited patients participated in screening, and 3% of patients in both groups received diabetes diagnoses. After a median 9.6 years of follow-up, overall mortality among high-risk patients was similar in the screening and no-screening practices (10.5 and 9.9 deaths per 1000 person-years, respectively). Rates of cardiovascular- and cancer-related mortality also were similar in the two groups.
Comment: The study population was of above-average socioeconomic status; these results might not be generalizable to less-affluent populations in which the prevalence of undiagnosed diabetes might be higher. In addition, multiple rounds of screening and longer follow-up might be necessary to detect mortality differences attributable to screening. Furthermore, important outcomes other than mortality might be modifiable by screening. Regardless, these data suggest that population screening for diabetes might be less effective than expected and should be evaluated carefully before widespread implementation.
— Bruce Soloway, MD Published in Journal Watch General Medicine October 23, 2012
CITATION(S): Simmons RK et al. Screening for type 2 diabetes and population mortality over 10 years (ADDITION-Cambridge): A cluster-randomised controlled trial. Lancet 2012 Oct 4; [e-pub ahead of print].
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Lancet 2012 Sep 24
Mortality Increases as Renal Function Declines, Regardless of Comorbid Diabetes or Hypertension
Kidney function is an important prognostic indicator.
Chronic kidney disease (CKD) is associated with mortality, cardiovascular disease, and end-stage renal disease (ESRD), but most studies on the prognostic implications of increasing albuminuria and decreasing estimated glomerular filtration rate (eGFR) are confounded by the high prevalence of hypertension and diabetes in populations with CKD. To determine the influence of hypertension and diabetes on risk estimates derived from CKD markers, researchers performed two parallel meta-analyses of combined data from 45 cohort studies that involved more than 1 million patients, each with baseline data on eGFR, albuminuria, and presence of diabetes or hypertension, and outcome data on mortality or ESRD.
Low eGFR and high albuminuria were associated strongly with higher risk for all-cause and cardiovascular-related death and ESRD, regardless of the presence or absence of hypertension or diabetes. Among patients with eGFR >75 mL/minute/1.73 m2, those with hypertension had slightly higher risk for death than those without hypertension, but, when eGFR fell below 60 mL/minute/1.73 m2, mortality risk was similar, regardless of hypertension status. Similarly, mortality risk was comparable in both groups when albumin–creatinine ratio (ACR) was <300 mg/g, but, above this level, mortality risk rose more rapidly in patients without hypertension. Risk for ESRD was similar for patients with and without hypertension at all levels of eGFR and ACR.
Risks for mortality and ESRD were significantly higher for patients with diabetes than without diabetes at all levels of baseline eGFR and albuminuria, and risk increased similarly for patients with and without diabetes as renal function declined.
Comment: The greater mortality risk associated with declining renal function among patients without hypertension compared with those with hypertension might reflect a higher prevalence of high-risk nonhypertensive renal diseases, presence of other cardiovascular disease (e.g., heart failure) masking hypertension, or a protective effect of antihypertensive medications. Although these meta-analyses are limited by the observational nature of the data, they clearly demonstrate the important prognostic risks associated with declining renal function, independent of the presence of diabetes or hypertension.
— Bruce Soloway, MD Published in Journal Watch General Medicine October 23, 2012
CITATION(S): Mahmoodi BK et al. Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without hypertension: A meta-analysis. Lancet 2012 Sep 24; [e-pub ahead of print].
Fox CS et al. Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without diabetes: A meta-analysis. Lancet 2012 Sep 24; [e-pub ahead of print].
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CVS' PBM Plans to Stop Coverage of Certain Drugs
CVS Caremark pharmacy-benefit business is targeting certain treatments for low testosterone and glaucoma, among other conditions, in its latest push to promote available alternatives to what it says are expensive drugs. It plans to block coverage for 17 more drugs starting January 1, 2013, including Abbott's testosterone treatment Androgel and Pfizer's overactive-bladder drug Detrol LA.
This move adds to its list of more than 30 drugs blocked for 2012—while also reinstating a few—in what industry consultants say was a particularly aggressive effort to secure pricing deals from drug makers. They will cover equally effective products with lower overall costs including many generics that remain available on the formulary.
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FDA Investigating Reports of Deaths Tied to 5-Hour Energy Drink
The FDA is investigating 13 reports of deaths after people consumed 5-Hour Energy drink, theNew York Times reports.
In the past 4 years, the agency has received 90 incident reports that cite 5-Hour Energy. Over 30 of these filings mentioned serious or life-threatening problems, such as myocardial infarctions, convulsions, and one spontaneous abortion. An FDA official told the Times that some of the reports may not contain enough information to determine whether the supplement played a role in the adverse event.
The drink, which comes as a 2-oz "shot," contains about 215 mg of caffeine, according toConsumer Reports. Eight ounces of coffee may contain about half that amount, depending on the preparation method.
Recently, the FDA also acknowledged that it had received five fatality reports involving Monster Energy drink
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Black Women Have Higher Death Rates from Breast Cancer Than White Women
Black women have a higher risk for death from breast cancer than white women, even though they have a lower incidence of the disease, according to an MMWR article.
Using data from population-based cancer registries and death certificates from 2005–2009, researchers calculated that black women had a lower incidence rate of breast cancer than white women (116.9 vs. 122.1 cases per 100,000). However, black women had a 41% higher risk for breast cancer mortality. Black women also were more likely than white women to be diagnosed at a regional or distant cancer stage (45% vs. 35%).
The authors note: "Black women experience inequities in breast cancer screening, follow-up, and treatment after diagnosis, leading to greater mortality. At the individual level, the maximal effectiveness of screening for breast cancer can only be achieved when all women have timely follow-up to breast cancer exams and state-of-the-art treatment."
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Moderate Alcohol Consumption in Pregnancy Linked to Lower Childhood IQ, Genotypying Study Suggests
A new study in PLoS One adds fuel to the debate on whether moderate alcohol consumption during pregnancy is linked to reduced cognition in offspring.
Nearly 4200 U.K. women reported their alcohol consumption twice during pregnancy, and their offspring had cognitive testing at age 8 years. Both mothers and children underwent genotyping for four genes that influence ethanol metabolism — genes encoding alcohol dehydrogenase (ADH) enzymes.
Researchers found that four ADH variants in children and one variant in mothers were associated with reduced childhood IQ — but only among children whose mothers drank moderately (up to 6 units weekly) during pregnancy.
The researchers say their finding "suggests that, even amongst women drinking moderate amounts of alcohol, subtle changes in exposure to alcohol due to an ability to metabolize the substrate may be important, and offers some support to the hypothesis that even small amounts of alcohol in utero have an effect on future cognitive outcomes."
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Pediatrics 2012 Nov 1; 130:e1058
Like Girls, Boys Are Now Entering Puberty Earlier
Depending on race and ethnicity, boys are entering puberty 6 to 24 months earlier than they were 40 years ago.
Data from three U.S. office-based research networks using standardized assessments of pubertal development demonstrated a trend toward earlier puberty in girls (Pediatrics1997; 99:505). Comparable data are now available for boys.
Researchers enrolled 5355 boys from 144 sites between 2005 and 2010. After excluding boys with missing data or who had medical conditions or medication histories that might affect pubertal development, 4131 boys (50% white) remained for analysis. Mean ages (and standard deviations) for reaching Tanner stage 2 genital development (e.g., thinning or reddening of the skin of the scrotum) and pubic hair development and testicular volume 3 mL are provided in the table.
Black boys reached stage 2 genital and pubic hair development significantly earlier than white or Hispanic boys. Boys with body-mass index (BMI) <15th percentile had later mean ages of genital and pubic hair development than boys with BMI >85th percentile. Mean age of pubertal events was 6 to 24 months earlier than the mean age of such events in Tanner's classic study of white institutionalized boys in England (Arch Dis Child1970; 45:13).
Comment: Like girls, boys now appear to be entering puberty at younger ages than in previous generations. Studies from Denmark, Sweden, Great Britain, Italy, and China indicate similar trends. The etiology of this phenomenon remains to be elucidated.
— Alain Joffe, MD, MPH, FAAP Published in Journal Watch Pediatrics and Adolescent MedicineNovember 14, 2012
CITATION(S): Herman-Giddens ME et al. Secondary sexual characteristics in boys: Data from the Pediatric Research in Office Settings network. Pediatrics 2012 Nov 1; 130:e1058.
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Diabetes Prevalence in the U.S. Nearly Doubles in 15 Years
The age-adjusted prevalence of diagnosed diabetes in U.S. adults nearly doubled from 1995 to 2010, from 4.5% to 8.2%, according to an article in MMWR.
The report, based on data from the Behavioral Risk Factor Surveillance System, found that the prevalence of diabetes is 6% or higher in every state. At least 10% of the population has been diagnosed with diabetes in Alabama, Mississippi, Puerto Rico, South Carolina, Tennessee, Texas, and West Virginia.
The authors say that the dramatic increase is likely due to people living longer with diabetes in addition to an increase in incidence.
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Obstet Gynecol 2012 Nov; 120:1085
Obstructive Sleep Apnea, Obesity, and Obstetric Consequences
Preeclampsia, cesarean deliveries, and admissions to neonatal intensive care units were more common with maternal OSA.
Maternal obesity raises risk for cesarean delivery, anesthesia complications, venous thromboembolism, preterm birth, and fetal macrosomia. Obesity is also associated with obstructive sleep apnea (OSA), but the effects of OSA on obstetric outcomes are unclear. The Sleep Apnea in Pregnancy Screening Study was designed to identify risk factors and pregnancy outcomes in obese women with OSA. Pregnant obese women (body-mass index [BMI] 30 kg/m2) seen at an urban tertiary center were home-screened for OSA with portable polysomnography. OSA was defined as 5 instances hourly of airflow cessation for 10 seconds.
Prevalence of OSA among the 182 participants was 15.4%. Women with OSA had a median of 12.9 hypopneic episodes per hour of sleep and spent a mean of 6.5% of the night with oxygen saturation <90%. They were significantly older, had higher mean BMI, and were more likely to have asthma or chronic hypertension than women without OSA. Rates of pregestational diabetes were similar in both groups. The cesarean rate was 38% for the entire cohort and was higher in women with OSA (65% vs. 33%). Women with OSA also were more likely than non-OSA participants to have preeclampsia (42% vs.17%) and to have babies that required neonatal intensive care (46% vs. 18%).
Comment: In this cohort study, obstructive sleep apnea was associated with significantly higher rates of several comorbid conditions during pregnancy, as well as adverse neonatal outcomes. However, the women with OSA also had significantly higher mean body-mass index than those without OSA, so some of these results could be attributable to the effects of obesity. Nevertheless, these findings suggest that OSA presents additional obstetric challenges for obese women, and that pregnant patients who are obese probably should be screened for OSA.
— Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BC Published in Journal Watch Women's Health November 15, 2012
CITATION(S): Louis J et al. Perinatal outcomes associated with obstructive sleep apnea in obese pregnant women. Obstet Gynecol 2012 Nov; 120:1085.
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JAMA 2012 Nov 7; 308:1751
No Benefit of Multivitamins for Preventing Cardiovascular Disease in Men
A randomized, controlled trial showed that myocardial infarction, stroke, and death were not affected.
Observational studies of multivitamins for preventing cardiovascular disease (CVD) have yielded inconsistent and mostly negative results, as have randomized controlled trials of individual vitamins and minerals (including β-carotene, selenium, and vitamins B, C, and E). This randomized controlled trial that involved nearly 15,000 male physicians (mean age, 64) who were randomized to commercial daily multivitamins (Centrum Silver) or placebo is a companion analysis to a recently published study that showed a small benefit of multivitamin supplementation for preventing cancer (JW Gen Med Oct 25 2012). Follow-up continued for a median of 11 years.
No difference was found between the groups in risk for any major adverse CVD event, including myocardial infarction, stroke, or cardiac-related mortality. Multivitamin supplementation also was not beneficial in the small subgroup of men with histories of CVD at study entry (5% of participants).
Comment: These findings appear to disprove the suggestion (or hope) that vitamin supplementation prevents CVD, at least in men. The cardiovascular and cancer outcomes from this trial will help clinicians answer patients' questions about the value of multivitamins; additional results from this study (i.e., on preventing eye disease and cognitive decline) are forthcoming.
— Thomas L. Schwenk, MD Published in Journal Watch General Medicine November 15, 2012
Citation(s): Sesso HD et al. Multivitamins in the prevention of cardiovascular disease in men: The Physicians' Health Study II randomized controlled trial. JAMA 2012 Nov 7; 308:1751. (http://dx.doi.org/10.1001/jama.2012.14805)
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J Clin Gastroenterol 2012 Nov/Dec; 46:850
Presentation of Celiac Disease with Immunoglobulin A Deficiency
IgA deficiency in this patient group was associated with a higher rate of autoimmune disease.
Immunoglobulin A (IgA) antibodies, such as anti-tissue transglutaminase and anti-endomysial antibodies, are used to screen for and diagnose celiac disease. Approximately 2% to 3% of the general population is deficient in total serum IgA; therefore, when screening for celiac disease, it is common to measure both anti-tissue transglutaminase IgA as well as total serum IgA. Patients deficient in total serum IgA can be screened for celiac disease using immunoglobulin G (IgG) antibodies.
To characterize clinical features of celiac disease in patients with IgA deficiency, investigators conducted a single-center, retrospective cohort study of 1815 patients with celiac disease. Patients with IgA deficiency were more likely than those with normal IgA levels to have concomitant autoimmune diseases (29% vs. 12%; P=0.008). In addition, some patients with IgA deficiency and celiac disease had persistently positive IgG celiac serologies despite being on a gluten-free diet and having a normal repeat biopsy.
Comment: This study provides useful clinical information about the occasional patient with celiac disease who has IgA deficiency.
— Douglas K. Rex, MD Published in Journal Watch Gastroenterology November 16, 2012
CITATION(S): Chow MA et al. Immunoglobulin A deficiency in celiac disease. J Clin Gastroenterol 2012 Nov/Dec; 46:850.
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N Engl J Med 2012 Sep 20; 367:1108
Hypoglycemia Raises Risk for Death in Critically Ill Patients
Risk associated with hypoglycemia outweighs benefits of tight glucose control.
Hyperglycemia in critically ill patients is associated with morbidity and mortality. In light of this fact, investigators have spent more than a decade trying to determine the "right" blood glucose target for patients in intensive care units (ICUs). An initial trial suggested that intensive glucose control (target blood glucose, 80–110 mg/dL) lowered mortality in surgical ICU patients, but a subsequent large multicenter randomized trial (NICE-SUGAR) showed the opposite effect — tighter glucose control raised risk for death (JW Gen Med Mar 24 2009). Now researchers have analyzed data from 6026 NICE-SUGAR patients further to examine the relation between hypoglycemic events and mortality.
Moderate hypoglycemia (blood glucose level, 41–70 mg/dL) was significantly more common in the intensive-control group than in the conventional control group (74% vs. 16%). Almost all (93%) of the 223 patients who experienced severe hypoglycemia (blood glucose level <40 mg/dL) were in the intensive-control group. Hypoglycemia was associated with longer ICU stay, longer hospital stay, and mortality. Patients with worse outcomes included those who experienced more than one episode of hypoglycemia and those with severe hypoglycemia despite not having received insulin (reflecting that hypoglycemia can result from severe illness). The adjusted hazard ratios for death were 1.41 in patients with moderate hypoglycemia and 2.10 in patients with severe hypoglycemia.
Comment: These results support use of ICU protocols with target glucose levels of 140 to 180 mg/dL (i.e., the conventional glucose control group in NICE-SUGAR). Until we develop ways to monitor glucose levels more accurately and consistently, risks of hypoglycemia outweigh benefits of tight glucose control.
— Patricia Kritek, MD Published in Journal Watch Hospital Medicine October 22, 2012
CITATION(S): The NICE-SUGAR Study Investigators. Hypoglycemia and risk of death in critically ill patients. N Engl J Med 2012 Sep 20; 367:1108.
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Alzheimer's Linked to Vitamin D Lack
Dementia victims had low vitamin D blood levels vs. healthy people; levels seen a bit better in people on common AD drugs By Craig Weatherby
Vitamin D holds promise – yet unproven – as a deterrent to dementia. Epidemiological studies almost uniformly link low vitamin D levels to the presence of Alzheimer's … or greater risk of developing this common kind of dementia. And as French researchers noted, this apparent link is biologically plausible: "… vitamin D simultaneously targets several factors leading to neurodegeneration [and dementia] …" (Annweiler C et al. 2010) They cited the hormone-like vitamin's healthy influences on a variety of processes affecting brain health:
- Help avoid thyroid problems.
- Help maintain blood flow in the brain.
- Support the body's inflammation/oxidation control systems.
- Support growth and survival and maintenance of neurons (brain cells).
- Help maintain healthy levels of the key neurotransmitter called acetylcholine.
- Help clear the pro-inflammatory amyloid beta plaque associated with Alzheimer's disease.
For an overview of the relevant evidence, see "Vitamin D May Help Deter Alzheimer's", "Vitamin D Shows More Brain Protection Potential", "Vitamin D May Deter Dementia", and "Vitamin D May Diminish Risk of Alzheimer's and Depression".
For sure, we need clinical trials to test whether vitamin D supplements – or diets high in fatty fish, which are its only good food source – can reduce the risk of dementia. In the meantime, evidence linking lack of the "sunshine-and-seafood" vitamin to Alzheimer's disease (AD) continues to accumulate. Most recently, scientists from two British academic centers – Kingston University and Brighton and Sussex Medical School – uncovered more evidence linking Alzheimer's to a lack of vitamin D (Shah I et al. 2012).
British study links vitamin D lack to Alzheimer's
As lead researcher Declan Naughton said, his team came up with some novel findings about the different forms of vitamin D. "There are several different types of vitamin D that can be active in the body … a blood test, which we developed at Kingston University, was for the first time able to accurately measure which, if any, of the different variations of vitamin D were present in Alzheimer's patients." (KU 2012)
The Kingston-led scientists analyzed blood samples from three groups:
- Controls free of dementia
- Un-medicated Alzheimer's patients
- Medicated Alzheimer's patients taking standard AD drugs
They measured the participants' total vitamin D levels and the levels of the two forms of vitamin D obtainable from foods or supplements … vitamin D3 and vitamin D2:
- Vitamin D3 is made in the skin following exposure to sunlight (UVB) and fatty fish are the only good food sources (see our sidebar, "Fish fit the vitamin D bill").
- Vitamin D2 is even rarer in foods, with low levels found mostly in fungi (yeast and mushrooms), and higher levels (e.g., 100 IU per serving) added to some fortified foods (milk, yogurt, etc.).
As seen in other studies, the overall vitamin D levels and vitamin D3 levels in the Alzheimer's patients were lower than in the healthy controls. And the UK team found that the un-medicated Alzheimer's patients had very low levels of vitamin D2. As professor Naughton said, "The vitamin [D2] was either non-existent or in such low quantities that it could barely be measured. In comparison, people in the study who were either being treated with drugs to control their Alzheimer's or who didn't have the condition at all showed far higher levels." (KU 2012)
Vitamin D2 conversion seen as potential problem
As we said, there's ample if inconclusive evidence that lack of vitamin D might promote the development of Alzheimer's. However, according to professor Naughton, this was the first evidence of a possible link between Alzheimer's and failure to convert the D2 dietary form of this vitamin into the usable, storage form. The UK team's findings suggest that it may be unwise to use supplemental vitamin D2 as a dementia-deterrent. Clearly, more research is needed to confirm that hypothesis, but if confirmed, these findings could pave the way for a focus on the most effective way to maintain ample body levels of usable vitamin D. As Professor Naughton said, "Further investigations are now needed to determine whether simple dietary advice or giving a specific supplement could restore beneficial levels in Alzheimer's patients." (KU 2012)
How much "D" do we need?
A recent report by the Institute of Medicine recommended maintaining a blood level of 20 to 50 ng/mL. But many experts in the field say that people need a blood level of 30 to 100 ng/mL to achieve true vitamin D "sufficiency" … a conclusion embodied in the Endocrine Society's 2011 clinical practice guidelines (Holick MF et al. 2011; Heaney RP et al. 2011). If a doctor tests your vitamin D levels, make sure that he orders a 25-hydroxyvitamin D test. In addition, many doctors will call a result of 30 ng/mL (75 nmol/L) "sufficient", so ask to see your test results. Vitamin D3 is the "natural" form created when sunrays hit human skin, but it's abundant only in fatty fishy such as wild salmon (especially sockeye), albacore tuna, herring, mackerel, sablefish, and sardines … see our sidebar, "Fish fit the vitamin D bill". The body uses D3 more readily than D2, and D3 is more potent than D2 for producing the "storage" form of vitamin D (25-hydroxyvitamin D), which fulfills the body's vitamin D functions.
The Endocrine Society currently recommends the following vitamin D intakes, preferable vitamin D3 (Holick MF et al. 2011):
- Age 0 to 1 year: 400 to 1,000 IU/day
- Age 1 to 18 years: 600 to 1,000 IU/day
- All adults over age 18: 1,500 to 2,000 IU/day
- Pregnant or nursing women under age 18: 600 to 1,000 IU/day
- Pregnant or nursing women over age 18: 1,500 to 2,000 IU/day
There's also general agreement among expert researchers that vitamin D intakes of up to 4000 IU/day are safe. However, when it raised the vitamin D RDAs in 2010, the IOM only raised the upper intake limit to 2,000 IU. Frankly, we rely more on advice from the vitamin D and hormone experts at the Endocrine Society, but you must make your own judgment.
Sources: Annweiler C, Beauchet O. Vitamin D-mentia: randomized clinical trials should be the next step. Neuroepidemiology. 2011;37(3-4):249-58. Epub 2011 Dec 7. Annweiler C, Llewellyn DJ, Beauchet O. Low Serum Vitamin D Concentrations in Alzheimer's Disease: A Systematic Review and Meta-Analysis. J Alzheimers Dis. 2012 Oct 5. [Epub ahead of print]; Annweiler C, Rolland Y, Schott AM, Blain H, Vellas B, Herrmann FR, Beauchet O. Higher Vitamin D Dietary Intake Is Associated With Lower Risk of Alzheimer's Disease: A 7-Year Follow-up. J Gerontol A Biol Sci Med Sci. 2012 Apr 13. [Epub ahead of print]; Annweiler C, Schott AM, Allali G, Bridenbaugh SA, Kressig RW, Allain P, Herrmann FR, Beauchet O. Association of vitamin D deficiency with cognitive impairment in older women: cross-sectional study. Neurology. 2010 Jan 5;74(1):27-32. Epub 2009 Sep 30.; Annweiler C, Schott AM, Rolland Y, Blain H, Herrmann FR, Beauchet O. Dietary intake of vitamin D and cognition in older women: a large population-based study. Neurology. 2010 Nov 16;75(20):1810-6.; Balion C, Griffith LE, Strifler L, Henderson M, Patterson C, Heckman G, Llewellyn DJ, Raina P. Vitamin D, cognition, and dementia: A systematic review and meta-analysis. Neurology. 2012 Sep 25;79(13):1397-405.; Birks J. Cholinesterase inhibitors for Alzheimer's disease. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD005593. Review.; Buell JS, Dawson-Hughes B, Scott TM, Weiner DE, Dallal GE, Qui WQ, Bergethon P, Rosenberg IH, Folstein MF, Patz S, Bhadelia RA, Tucker KL. 25-Hydroxyvitamin D, dementia, and cerebrovascular pathology in elders receiving home services. Neurology. 2010 Jan 5;74(1):18-26. Epub 2009 Nov 25.; Buell JS, Scott TM, Dawson-Hughes B, Dallal GE, Rosenberg IH, Folstein MF, Tucker KL. Vitamin D is associated with cognitive function in elders receiving home health services. J Gerontol A Biol Sci Med Sci. 2009 Aug;64(8):888-95. Epub 2009 Apr 17.; Buell JS, Tucker KL. The value of physiologic vitamin D as a biomarker of dementia. Drugs Today (Barc). 2011 Mar;47(3):223-31. Review.; Constans T, Mondon K, Annweiler C, Hommet C. [Vitamin D and cognition in the elderly]. Psychol Neuropsychiatr Vieil. 2010 Dec;8(4):255-62. Review. French.; Dickens AP, Lang IA, Langa KM, Kos K, Llewellyn DJ. Vitamin D, cognitive dysfunction and dementia in older adults. CNS Drugs. 2011 Aug;25(8):629-39. doi: 10.2165/11593080-000000000-00000.; Gezen-Ak D, Dursun E, Bilgiç B, Hanagasi H, Ertan T, Gürvit H, Emre M, Eker E, Ulutin T, Uysal O, Yilmazer S. Vitamin d receptor gene haplotype is associated with late-onset Alzheimer's disease. Tohoku J Exp Med. 2012;228(3):189-96.; Heaney RP, Holick MF. Why the IOM recommendations for vitamin D are deficient. J Bone Miner Res. 2011 Mar;26(3):455-7. doi: 10.1002/jbmr.328.; Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, Murad MH, Weaver CM; Endocrine Society. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011 Jul;96(7):1911-30. Epub 2011 Jun 6. Erratum in: J Clin Endocrinol Metab. 2011 Dec;96(12):3908.; Kumar PT, Antony S, Nandhu MS, Sadanandan J, Naijil G, Paulose CS. Vitamin D3 restores altered cholinergic and insulin receptor expression in the cerebral cortex and muscarinic M3 receptor expression in pancreatic islets of streptozotocin induced diabetic rats. J Nutr Biochem. 2011 May;22(5):418-25. Epub 2010 Jul 23.; Shah I, Petroczi A, Tabet N, Klugman A, Isaac M, Naughton DP. Low 25OH vitamin D2 levels found in untreated Alzheimer's patients, compared to acetylcholinesterase-inhibitor treated and controls. Curr Alzheimer Res. 2012 Aug 8. [Epub ahead of print]
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Best Games for Kids
There are different types of games for children. Lots of the games are skill based, but there are a couple which are educational, but a lot of them are just downright fun for children to play. There are SpongeBob games there which are absolutely free to play and are extremely easy for children to get into. Thus, the games are important in the end since they help to teach skills that are not likely to be obtained from different sources. A number of the fast-paced games demand a good deal of attention. The babysitting games are incredibly common. The more popular games, targeted toward the severe gamer can be located on aggregate on-line websites.
Recommended game: zombs royale
A Improves vision It is normal to seek out parents discouraging children from watching too much TV as it isn't great for their eyes. You would not place your child loose in a city, then you did the dishes and ignore all types of individuals who could speak to them. Just because your son or daughter is sitting inside her room doesn't make them safe from predators on the web, verbal abuse or harmful habits. The winning child receives a prize.
Anyway, our kids really like to play, and it's an enjoyable game for children and grownups. Most kids attempt to keep away from books and education, which they feel an excessive amount of boring. Your children will thank you. Therefore, kids' who get a chance to take part in internet games have a tendency to forget their pains and as a consequence, they require less pain medication.
Internet has helped human beings for a lengthy time in many different cases and its most recent contribution to us is the site for children. The web is a superb resource for video games that you are able to pick up and play as long as you've got a browser. Again, you will find several free games online and they're available on a lot of sites. There are several flash-based strategy games on the internet that are totally free to play return man 3.
The Battle Over Best Games for Kids and How to Win It
For children, diner games are ideal for their basic gaming abilities. Both educational and recreational games can readily be found by doing an on-line search. Look beyond all the huge hardcore blockbusters, however, and you'll still find brilliant games that children will love playing, and that the entire family can get stuck into. On-line games have come to be the order of the day in the present world. Besides games for children, there are many baby games too.
If you don't like to purchase the game, it's possible to always devote a several minutes or a couple of hours playing with it online. Indeed, there's a strategy game that is only suitable for you. It is one that requires a set of techniques in order to complete it. Strategy games ought to be good for internet gamers as it gives them the exact same enjoyment minus the costs. Regardless of what type the game is, the games will stay educational and that's what really counts here. There are many games that is going to be among the best that you've ever played. There are many classic board unblocked games for kids to enter.

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Doug Lance
Office: 517-596-8200
Cell: 517-917-4575
email: email@example.com
Janice Kitley
Office: 517-596-8400
email: firstname.lastname@example.com
Wendy Walz
Office: 517-596-8300
email: firstname.lastname@example.com
Lisa Morency
email: email@example.com
Joshua McAlister
email: email@example.com
**You may need to allow pop-ups in order to view meeting minutes.**
Information can be added, up to the Friday before the meeting, as it is submitted to the Township.
Waterloo Township Agenda
9773 Mt. Hope Road
Munith, MI 49259
Tuesday, June 23, 2020 6:30 p.m.
Public Hearing for Proposed Budget 2020-2021
1. Call to order at 6:30 p.m.
2. Pledge of Allegiance
3. Public Comment
4. Public Comment
5. Adjournment
Waterloo Township Board Agenda
Tuesday, June 23, 2020 7:00 p.m.
SPECIAL ORDER: Resolution Honoring Ted Beals
5. Correspondence
6. Old Business
a. Parks and Recreation Committee Update
7. New Business
a. Planning Commission
b. Aggregate Industries
c. Board meeting date change for July 2020
d. Budget Amendments for Current Budget
8. Other business that comes to the Board
9. Public Comment
10. Adjournment
Waterloo Township Board Meetings are held the fourth Wednesday of each month at 7:00pm at 9773 Mt Hope Rd. Munith, MI 49259
For information please call the Waterloo Township Offices during regular business hours at 517-596-8200.
All correspondence should be mailed to 9773 Mt. Hope Road Munith, MI 49259
Waterloo Township will have openings on the Zoning Board of Appeals due to current expiration of terms. Any interested persons who live in Waterloo Township should send a letter of interest and a resume'. Please mail to Clerk at Waterloo Township, 9773 Mt Hope Road, Munith, Mi 49259.


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Daniel R. Mahanty (@danmahanty) is the director of the U.S. program at the Center for Civilians in Conflict (CIVIC). Prior to joining CIVIC, Dan spent 16 years at the U.S. Department of State. In 2012, he created and led the Office of Security and Human Rights in the Bureau of Democracy, Human Rights and Labor. In this role, he oversaw efforts to integrate human rights in U.S. security assistance and arms sales, advance the prevention of recruitment and use of child soldiers, and promote policies related to protecting civilians in conflict.
Dan holds a Masters from Georgetown in U.S. National Security Policy and a Bachelors in Economics from George Mason University. He is a Colin L. Powell Fellow, a term member of the Council on Foreign Relations, a Truman National Security Fellow, and served on the board of advisors for the NGO, "Women LEAD Nepal".
by Daniel R. Mahanty and Rita Siemion
May 7, 2020
by Daniel R. Mahanty
April 21, 2020
by Andrew Miller and Daniel R. Mahanty
April 14, 2020
by Daniel R. Mahanty and Benjamin Haas
December 17, 2019
by Rita Siemion and Daniel R. Mahanty
May 2, 2019
by Daniel R. Mahanty and Alex Moorehead
April 3, 2019


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Combine dry cake mix, egg and melted butter; press into a greased 13"x9" baking pan. Bake at 350 degrees for 10 to 12 minutes. Sprinkle marshmallows over baked crust; return to oven and bake for 3 additional minutes, or until marshmallow are melted. In a saucepan over medium heat, melt peanut butter chips, corn syrup, butter and vanilla. Stir until smooth; stir in nuts and cereal. Spread mixture over marshmallow layer. Chill briefly until firm; cut into squares. Makes 2-1/2 dozen.
Enjoy this recipe from 150 Recipes in a 13x9 Pan originally published 2/1/2017.


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Soyu, Giriboy, and "No Mercy" Kihyun Collaborate on "Pillow"
Sistar's Soyu, rapper Giriboy, and Kihyun from the Mnet idol survival show "No Mercy" have released a digital single for their collaborative single "Pillow."
"Pillow" is the second single from "No Mercy." Previously, competing trainee Jooheon, chosen as the best rapper contestant on the show, released a single called "Coach Me" with Sistar's Hyorin and rapper San E.
The music video for "Pillow" is similar to that of "Coach Me," as the three artists sit in a room as they perform their single. Different from "Coach Me," "Pillow" is a much sweeter song with an acoustic sound. The song was composed by Duble Sidekick.
Kihyun was chosen as number one among the vocals on the survival show in the second round.
Watch the music video for "Pillow" below.


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Purple Day 2018 summary
Well, wasn't that a productive Purple Day? Here are just some of the highlights to which Young Epilepsy got involved with.
Purple Day celebrations started a day early for Young Epilepsy, as they hosted their annual Purple Plunge skydive at the GoSkyDive centre in Salisbury, Wiltshire. A total of eight skydivers jumped between 10,000 and 15,000 feet for the charity, with around an incredible £6,500 raised.
On Purple Day itself, there were plenty of towns and cities raising epilepsy awareness by turning purple for Young Epilepsy. These cities included Portsmouth, Liverpool, Brighton and Stoke-on-Trent.
In Lingfield, Surrey, all of the shops were decorated in purple with the incentive of winning a prize for the most embracive of Purple Day. Funeral directors Ballard and Shortall won the coveted competition, as judged by Lingfield Parish Chair, John Cole.
Meanwhile, 17-year-old Lewis Hine, famed for his viral epilepsy awareness video last year, which received public praise from the likes of Sir Elton John, Nick Grimshaw and Susanna Reid, helped light up Spinnaker Tower in Portsmouth. He recalls this opportunity as a 'proud moment' on his Twitter.
Young Epilepsy's fundraising and support groups in Staffordshire and North West pulled off some great coups in terms of getting big sites in their local areas lighting purple. The Byatts in Stoke-on-Trent got Hanley Town Hall raising epilepsy awareness, gaining support from the likes of local MP Jack Brereton. In Liverpool, the Mudge family got Liverpool Town Hall, Cunard Building and Bidston Lighthouse in purple for the night.
Across to Parliament, Young Epilepsy's chief executive Carol Long, along with Catherine Hodder and Lisa Thurston, attended an MP walk-in Purple Day session organised by the APPG (All Party Parliamentary Group) on Epilepsy.
Purple Day 2018 was a special one for Young Epilepsy's long term ambitions. The charity launched their 'In The Moment' campaign. It's a three year campaign that will begin by encouraging young people and their loved ones to tell their one 'moment' which changed their lives as a result of epilepsy. In doing this, Young Epilepsy has launched a new website with information and 'moments' accumulated, aimed to removing stigma and raising awareness.
Overall, it was a hugely successful day. The charity would like to thank fundraisers, supporters, schools, MPs and shops for raising much needed awareness of epilepsy and hopefully this enthusiasm will continue much further afield!
Explore the 'In The Moment' campaign


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|Up a level
Suma, HK and Kumar, Vadlapudi and Patel, Mohan Kumara and Srimany, Amitava and Ravikanth, G and Umapathy, Senthil Kumar and Vasudeva, R and Uma Shaanker, R (2017) Spatial and temporal distribution pattern of camptothecin in seeds and fruits of Pyrenacantha volubilis Hook.(Icacinaceae) during different fruit developmental stages. Current Science, 110 (5). pp. 1034-1038. ISSN 0011-3891
Singh, Shweta and Hima Bindu, J and Raghu, J and Suma, HK and Manjunatha, BL and Mohana Kumar, P and Ravikanth, G and Nataraja, KN and Ganeshaiah, KN and Uma Shaanker, R (2013) Isolation of endophytic bacteria producing the anti-cancer alkaloid camptothecine from Miquelia dentata Bedd. (Icacinaceae). Phytomedicine, 20 (10). pp. 913-917. ISSN 0944-7113
Ramesha, BT and Suma, HK and Senthilkumar, U and Priti, V and Ravikanth, G and Vasudeva, R and Santhosh Kumar, TR and Ganeshaiah, KN and Uma Shaanker, R (2013) New plant sources of the anti-cancer alkaloid, camptothecine from the Icacinaceae taxa, India. Phytomedicine, 20 (6). pp. 521-527. ISSN 0944-7113


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Wine & Comedy Night at Winery
|Sat, Jun 1, 2019
|7:00 PM to 10:00 PM
Doors open at 7:00, show starts at 8:00
John Knight
Reserve your spot now for this special evening of wine and comedy with John Knight. Featuring four performers including our very funny host Helene Angley, guests will enjoy a full evening of riotous entertainment with a full glass (or bottle) of wine in hand! Feel free to bring your own food.
Opener: Tiz Irie
Feature: Brett Druck
Host: Helene Angley
$25 Admission ($20 Vintner's Club)
Purchase Tickets
There are no walk-in tickets available for this event.


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Are you building a home or planning to install new flooring this year?
There are so many flooring options that it's easy to get overwhelmed by your choices.
If new flooring is in your future this year, this list of the top flooring trends for 2018 is for you. Check out what's trendy this year and see what would look great in your home.
1. Bleached and Blanched Woods
Bleached floors add a softness to your home. This is a great choice for those who don't like the look of dark floors.
2. Distressed Flooring
Distressed style has been around for a while and doesn't seem to be going anywhere. To give the distressed look, the wood undergoes artificial aging to get the desired look.
3. Textured Tiles
If you want a textured look, consider textured tiles. Textured tiles are designed to look like other materials like wood or natural stone. Aside from looking like these other materials, they also feel like them.
4. Black and White
Black and white tiles are making a big comeback among the 2018 flooring trends. This trend combines vintage and contemporary. Black and white tiles will add a beautiful and unique twist to your home.
5. Chevron Pattern
This year's new flooring trends include fun patterns. Chevron and herringbone can add a lot of personality to your home. Get creative and use different plank widths.
6. Terrazzo Tile
Terrazzo tile is a flooring material made by exposing marble chips on concrete and then polishing until it's smooth. This type of flooring dates back to the Egyptians and is having a major comeback today.
7. Reclaimed Barn Wood Tiles
The reclaimed barn wood look is still very popular. Thanks to the wonders of technology, you can now get this distressed look on tiles. Some people may love the look of barn wood but prefer the functionality of tile. For those people, this is a great solution.
8. Bamboo
Bamboo flooring can provide a beautiful, woody look to your home without the actual wood. Bamboo is a type of grass that is used for flooring. If you decide on this look, it's important to understand that bamboo is very sensitive to moisture and can swell easily.
9. Porcelain Planks
Porcelain planks are a great option in floor trends if you are wanting to add the look of wood to rooms that are prone to moisture and dampness like bathrooms and kitchens. They are very durable and attractive.
10. Carpet Tiles
Carpet tiles are one of the great flooring trends if you want an alternative to traditional carpeting. They take the feel of carpet with the look of tile. Carpet tiles are easy to install and can add style and texture to your home.
Picking Your Favorite Flooring Trends for 2018
Picking your favorite flooring trends for 2018 can be exciting. Installing new flooring is a great way to update your home. There are lots of flooring ideas to choose from, so you can find the perfect look for your home.
If you are ready to install new floors, we would love to help you. Contact us today for a free in-home (or at work) estimate.


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Meet our February issue winner
PICTURED HERE: Lily Kinnamon, age 6
PARENTS: Heidi Kinnamon and Matt Dicks
SUBMITTED BY: Her mother
THE BACKSTORY FROM HEIDI: "This picture was taken at Oakland Nursery while waiting to see Santa. As Daddy held our spot in line, Lily and I walked among the Christmas trees and other decorations. … Our annual tradition is to go to Oakland Nursery."
Enter photos for Kid Pic of the Month by sending the photo (at least 1 MB in size) as an email attachment to firstname.lastname@example.com. For all the rules and guidelines, go to ColumbusParent.com/kidpic.


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This EIU report seeks to examine the potential business opportunities, and risks, involved in adapting to anticipated changes in the global climate, and examines new emerging markets for goods and services as businesses seek to adapt to the realities of an uncertain climate.
Key Findings:
- Although most businesses are aware of the need to respond to climate change, few are yet actively adjusting.
- Around nine in every ten firms have suffered climate impacts in the past three years.
- While risks abound, executives see greater opportunity.
- Much work is already underway in terms of developing relevant new products and services.
- Emerging markets are viewed as the primary business growth opportunity, especially within Asia.
- Limited awareness about adaptation and a shortage of skills are the main obstacles hindering further development.
Read more on


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Live & Kicking Sports Bars in Belize
Any vacation in beautiful Belize will undoubtedly provide tourists with plenty to fill their travel itinerary, whether diving into the amazing azure waters, through the gorgeous green jungles, or delving into the rich local culture and history. However, despite having more than enough to keep them occupied here, whenever avid sports fans are away from home for any length of time, it's often hard for them to forget what's going on back home; especially if their favorite team has a game, or there's a popular sporting event they don't want to miss.
Thankfully, there's a great selection of lively sports bars to be found amongst the most popular destinations in Belize, where cool beers are on tap and live sporting events are available on-screen, beamed from around the world. These are three of the most popular in key resort areas around the country.
Pedro's Sports Pub
Seagrape Drive, San Pedro, Ambergris Caye
Located at Pedro's Hotel, Pedro's Sports Pub and Pizzeria is a popular venue amongst locals and tourists alike, especially those who are keen on keeping in touch with the latest sporting action from around the world. In the fully air-conditioned main bar, there are 52' and 62' big screen TV's where fans can watch the latest American sports, including NFL, NBA, MLB and NHL games live and direct. It's also easy to find, just south of the San Pedro Airport runway, and they also boast the best pizzas in Latin America.
Image Source: @PedrosHotel via Facebook
A glance through the Twitter account of Pedro's Hotel would also suggest the owners are big fans of English sports and especially Premier League soccer team, Arsenal. Don't be surprised to see plenty of other live sports from Britain, which is handy to know for anyone visiting in April and keeping a keen eye on the latest pre-race details at Oddschecker for the 2019 Grand National, which is sure to fill the bar with punters when the horses start charging around the famous Aintree circuit in Liverpool. It is, after all, the most famous horse race in the world.
Riverside Tavern
2 Mapp St, Belize City
The highest rated amongst 98 restaurants reviewed at TripAdvisor and winner of the Certificate of Excellence at the travel website, every year between 2015 and 2018, the Riverside Tavern has an established reputation as one of the most popular dining locations in the capital of Belize. As the name of the venue would suggest, Riverside Tavern is located alongside the Haulover Creek in the heart of downtown Belize City, with outdoor patios to enjoy the views while sipping on a cool beer or cocktail.
Image Source: @riversidetavernbelize via Facebook
If that's not the kind of view you had in mind, head inside to the bar and that's where the views of a sporting persuasion will be found. Although it's mostly American sports that are shown live, the staff pride themselves on offering excellent customer service, which means they'll find the sports you want to watch and on one of the many TV screens, wherever it's being broadcast from around the world.
Barrier Reef Sports Bar & Grill
Playa Asuncion, Caye Caulker
Just because visitors are staying on one of the most picturesque little islands Belize has to offer, doesn't mean they have to miss out on their favorite sports. Whenever there's a game on, the Barrier Reef Sports Bar and Grill is usually where locals, ex-pats and tourists will flock to see the live action; whether it's their favorite European soccer teams, the latest big-fight boxing, or live American sporting events.
Image Source: @belizesportsbar via Facebook
Just one look at all the pennants, flags, banners and other sporting memorabilia covering the walls and ceilings around the bar, visitors will know the owners and staff are just as crazy about sports as they are. What's more, even watching your favorite team lose isn't all that bad here, because stepping back outside with another beer, all your sorrows are washed away by the idyllic beach setting and the melodic reggae music you'll probably hear playing. Watching sports in this part of paradise certainly has welcome benefits.
Enjoying Live Sports in Belize
The three sports bars featured in this article are amongst the most popular, found in three key tourist destinations. Also, they all offer free WiFi, which is handy for anyone betting on sporting events, or keen to follow up to the moment statistics on the sports they're watching, using their mobile, tablet or laptop.
Of course, these aren't the only places where visitors can watch international sports live. Most hotel resorts have access to live international sports, which you can watch in your room or at their bars. However, nothing quite beats sharing the enjoyment of an event with sports-mad fellow tourists and locals, in venues such as those mentioned.


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I know why they freed Ai Wei Wei.
Now, just my conspiracy theory: China knows that the International Human Rights Community has been kept unduly busy over Ai, and feels bad about it. It's like wasting police resources over a petty thief while the big robber goes berserk bombing, torturing, murdering and looting unnoticed. Now that China has let Ai go, perhaps the force of righteousness could be redirected at Guatanamo? Iraq? Afghanistan? Libya and . . . ? Sorry sorry, Libya doesn't count. It's a humanitarian mission aimed at protecting the Libyans; the Central Bank was just a sideline job, my apologies. But the rest is valid nonetheless, and a lot more is coming.
It's a pity that Ai's going to miss his Nobel Prize though. For a while, I suspected that he was a Chinese trick to overwhelm the Nobel Prize with 60m mud squeezing artists and a few hundred thousand chanting monks, year after year after year. Evidently, I was being too cynical as usual . . .
中国政府知道艾未未一事,令到国际人权分子忙不过来,所以没有时间监察美国在本土,"关塌哪妈",伊拉克,阿富汗, 利比亚 。 。 。 等等等等 的人权状况。呃,等多一等,利比亚不算数。利比亚属于人道行为,因为 "噢斑马" 说过,去利比亚是为了拯救利国人民;第一时间搞了间 "美资利比亚中央银行" 只不过是附带任务,纯属巧合。反正我认为中国是觉得由于艾未未一个肥佬,搞到全世界团团转,有如浪费警力:试想,众家丁为了追个小扒手,任由汪洋大盗杀人放火抢劫兼强奸,无法无天,实在说不过去。所以良心发现,把老艾放了。
我本来希望中国会发动五六千万个会写新诗或捏泥公仔的同胞,和几十万不大会诵经的密宗和尚,把未来五十年的诺贝尔奖都由炎黄子孙承包下来,让挪威全国的空凳,通通派上用场。这个壮举,在当今国际形势之下,本来是大有成功希望的。无奈北京好像没有这份闲情和野心 。 。 。可惜,可惜。


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Approval for Quayside North omniplex project
A major development planned for Douglas town centre has been approved by the planning authority.
Island-based developer Kane Limited is behind the £25 million proposal, which would see a seven-screen cinema 'omniplex' created on Lord Street.
In Murray House this morning, the planning committee made the recommendation to grant the firm permission to go ahead with the build, which is now subject to a legal agreement.
'Quayside North'
Plans for the former bus station site, which has been a car park for the last 17 years, were submitted in August 2018.
A multi-storey car park with space for more than 200 vehicles is included.
It also proposes an 80-bed Travelodge Hotel, along with 20 residential apartments.
Seven units are also included for retail and restaurant use.
Councillor Richie McNicoll, who is of head of Douglas Council's environment committee, raised concerns over access on Chapel Road, something the owner of the Albert Hotel, Geoff Joughin, originally objected to.
This issue has since been addressed by the developers.
However, the pub owner's main concern now is from a business point of view.
"We're going to be drowned" he told Manx Radio. "My whole building will be in the dark."
With regard to the full complex, Mr Joughin believes the committee has allowed 'overkill' and compared it to 'putting a quart into a pint pot.'
During the announcement of the application last year, Chief Minister Howard Quayle said it would be a 'great asset to Douglas town centre', believing it would offer diversity in terms of entertainment.
It will also create up to 100 jobs.
Today's decision will now undergo a three-week period of appeal, during which those with Interested Person Status may come forward.


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My constituents of Calwell are everyday Australians looking for a 'fair go'. The budget's across the board tax increases to fund Medicare and NDIS and its $65 billion dollar corporate tax cuts at the expense of cuts to education through a 22 billion dollar cut to schools, hikes in university fees and cuts to TAFE and apprenticeships is hardly a vote of confidence for the ordinary people in my electorate.
By choosing to deliver to big business and choosing multinationals at the expense of middle and working class, and the risky assumption that company taxes will translate into jobs growth and wages growth shows this government is putting its eggs in one basket at the therefore failing to secure better days for the people in my electorate.


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The Ouse
The Ouse is the river of York . It cuts a path through the town before ultimately finishing in the Humber Estuary.
The reason for visit, The Ouse is a scenic delight. There are riverside roads to walk along that are ideal for post-luncheon strolls. You will see some of local wonders of York from the Millenium bridge to Clifford's Tower. Then make sure to walk through Rowntree Park, next to the canal. But the best way to really grasp the river, have one of the typical boat tours or cruises. Have the early eve cruise and you will be witnessed to dazzling sunset views which will give you breathing space for thought. The boat sets up with a totally stocked bar should you elegant an evening liquor and It has lively on board commentary. So you know absolutely what you are looking at.
York Minster
Things to do in York – It's the cathedral of the York and one of the most astonishing in the country.
The reason for visit, With its antique stained-glass windows, sparkling artefacts, stone buttresses, York Minster is a miracle and must for anyone touring the city. Down in the underground cells, we can study more about the Christian history of the area. That backdates to Roman Empire times. If you have got the energy, walk to the central tower clearing 275 step ups, that leads to the highest point in York. Local history students are the most of tour guides.
It means they know what it's like to be affected with excessive info, So they will be sure to give you in on the most impressive bits.
York City Walls
Things to do in York – It is ancient fortified walls which once defended the city from outsiders.
The reason for visit, The Romans have done a lot for UK. Roads were built by them, hot-water baths and they left York with the longest antique barrier in the country. Walking the entire length of York's city walls will take a few hours, especially if you stop to read the different plaque. Alternatively, you can admit the help of a guide to save a few of brain work. Tailored tours assure you only have the juicy tidbits, At the same time private tours extract any possibility of stragglers.
Things to do in York – York Tourist Information …
The Jorvik Viking Centre
It's a journey back in time to the days of York which was under Danish rule and a place for historical education.
The reason for visit, This is a opportunity to delve into York's Scandinavian past – and no, we are not discussing hygge here. In 866 the York city surrendered to Danish attack. this attraction provides a snapshot of Viking life and how it would have been like. Its moving carriages, life size dioramas also ancient artefacts – along with a fossilized Viking poo – it's a real journey back in time
Clifford's Tower
York Tourist Information – It is the ruined Norman keep at the middle of York Castle.
The reason for visit, the name of this tower based on an incident of history. Roger de Clifford was hanged. It was for treason in 1322. But it gives some pretty amazing views. If you brace yourself and step up to the summit of the hill, you will be rewarded with views of York Minster and the city which are unparalleled. We can see as far as the North York Moors national park on a clear day.
York Dungeon
It's a thrilling, mesmerizing trip through the grizzly and dark parts of York's past.
York torture chamber delves into the dark side of history. With a boatload of horrify actors, special effects, live shows and sets that conjure as much fright as history, that's not for the sensitive ones. As you fearlessly shuffle through the torture chamber you will meet face to face with some of York's most blatant characters (counting criminals) earlier heading to the bar to calm your nerves.
The Shambles
It's a winding, narrow, old fashioned street in the historical quarter of York. That brings visitors in their droves. The Shambles is an Old English word for slaughterhouse. It's the perfect example of how well preserved York is. Many buildings date back to the fourteenth century in this street and still there are butchers' hook s out front. At first view, you might think which idiot erected these rickety, finest heavy timber framed buildings,but the overhang indeed had a practical desire: to protect the 'wattle and daub' walls down and stop the meat of butcher from going off in the sunshine. Brainy stuff.
Things to do in York – York Tourist Information …
The National Railway Museum
It's the ideal excuse to get your trainspotter on and freak out.
Anybody with an intensity for period dramas, design or history, will revel in a journey to the National Railway Museum which is the largest railway museum in the UK. There are a million pieces of memorabilia, counting real life trains which have long been out of service. Mocked up stations and perfectly restored carriages, All of them are open to explore. We can also have a miniature railway ride outside.
York Cold War Bunker
It's a relic of York history since the days of the ever ticking Doomsday Clock and the Iron Curtain.
If you are bored of learning about Vikings and Romans, then lose yourself in one more chapter of history. The semi-subterranean Cold War Bunker of York was built in case of a nuclear attack by Soviets. With its doors which are blast proof, decontamination areas and perspex maps are expressed by English Heritage as "the most modern & spine chilling" of their properties.Tours are managed by helpful guides who know their things and also tours begin each one hour on the hour, so time your appearance right to avoid stick around.
Comedy shows at the Grand Opera House
It's a Grade II theatre which was passionately restored in the 1980s for a massive £4 million.
York Tourist Information – Along with all its historical attractions, York boasts some refreshing live entertainment venues too. Following its '80s rejuvenation which saw the design of the theatre returned to its original style – fulfil with period features – Now the Grand Opera House plays to a cheerful program of live music, musicals and comedy to keep punters coming. With some of the finest names in the business presenting here, you are guaranteed a wonderful night out and a fairly familiar one to boot, as the theatre has a best capacity of just less than 1Hous Stay In a Hotel
Stay in a top hotel
Its lots of lovely, elegantly preserved hotels for all desire and budgets.Need a roof over head while you are in this city? The city has some eye catching places to stay – from exceptional Victorian behemoths to 900 years old boutique hotels also even a cosy convent.
Whether you are after budget friendly choices or looking for luxury, you are able to refer and compare all the details are given below.And if you are moving this far north from London, it makes sense to stay someplace really gorgeous, Isn't it?


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Place links here to publications and web resources which are substantial compediums of information regarding water resources, their use and environmental issues.
- Smart Water Report Smart Water Report at www.westernresources.org Western Resource Advocates
- Water 2025 Water 2025 Preventing Crises and Conflict in the West United States Department of the Interior
- The Water Encyclopedia
- "U.S. Intelligence Report Warns of Global Water Tensions" article by Steven Lee Myers in The New York Times March 22, 2012
- "Global Water Security" Intelligence Community Assessment, ICA 2012-08, 2 February 2012 Unclassified version of an intelligence assessment prepared by the United States intelligence community for the State Department.
- OpenWater wiki 'a site that provides a platform for water quality scientists, researchers and practitioners to discuss analytical methods that are "tried, but maybe not true."'
Position papersEdit
- Facing Our Future: A Balanced Water Solution for Colorado at www.westernresources.org Western Resource Advocates
International resourcesEdit
- CSD Water Action and Networking Database (CSD WAND) CSD WAND – Water Action Network Database, a site created by the UN Department of Economic and Social Affairs.
- Water Information System for Europe WISE (Multi-lingual portal WISE
Business organizationsEdit
Community content is available under CC-BY-SA unless otherwise noted.


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SCRATCH SLEEVES Scratch Mitts - "Oatmeal"
We have run out of stock for this item.
Essential for babies & kids with eczema or other sensitive skin conditions that cause rash or itch. Prevents them tearing skin through scratching.
Cream body and mitts with OATMEAL piping. Natural silk mitts & 100% cotton sleeves. Machine washable at 40 degrees using non-biological detergent. Can be tumble-dried.
3-6M Wingspan 60-65 cm | 6-9M Wingspan 65-70 cm
For other sizes not available on our webstore, please email email@example.com to order. Scratch Sleeves make scratch mitts for 0 months to 8 years.


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As WTI crude went above $50 last year, Kosar noticed that the Commitments of Traders (COT) data was showing a record net-short position among smart money hedgers in the crude oil futures market. Now that crude is in excess of $60 a barrel, these hedgers have dug in and increased their short position even more, Kosar noted. Thus, we have a large 'smart money' net-short position that's losing money. "Here's why that bothers me," he said. "I don't like to fade the smart money, but when oil prices got up to $120 a barrel years ago, the same thing happened. At about $60 or $70 a barrel, these hedgers were really short, and the market kept going up." At that level, hedgers had to start buying back their short hedges. This short covering forced buying, which is a big part of what fueled oil's move to $120. Normally, Kosar prefers to avoid splashy calls, but when he sees a group or entity this leaning this heavily to one side, it bears mention. "That's an outlier," he said. "That's not something I would bet on, but it is something I'm watching now because these smart money hedgers are under the gun right now. Every time oil goes up a dollar, these guys are feeling more pain."
Striving to further the profession with diverse opportunities in continuing education, advocacy, ethics awareness, and networking.
25 Broadway Suite 10-036 New York, NY, 10004 firstname.lastname@example.com (+1) 646-652-3300


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For more quotes from U.S. presidents and other famous people, check out the Quotes section here on YourDictionary.
It is better to offer no excuse than a bad one.
It is infinitely better to have a few good men than many indifferent ones.
Every post is honorable in which a man can serve his country.
Jefferson's life quotes are good examples of his interests:
Good wine is a necessity of life for me.
I believe . . . that every human mind feels pleasure in doing good to another.
A little rebellion now and then is a good thing.
In matters of style, swim with the current: in matters of principle, stand like a rock.
Lincoln's life quotes reflect his theories on life, happiness and friendships:
The better part of one's life consists of his friendships.
I do not like that man. I must get to know him better.
You can fool some of the people some of the time, and some of the people all of the time, but you cannot fool all of the people all of the time.
I am a slow walker, but I never walk back.
Grant's quote on labor reflects his feelings about the working man:
Labor disgraces no man; unfortunately you occasionally find men disgrace labor.
Roosevelt's life quotes reflect his beliefs in how to manage your life:
Happiness lies not in the mere possession of money; it lies in the joy of achievement, in the thrill of creative effort.
Repetition does not transform a lie into a truth.
If you treat people right they will treat you right ninety percent of the time.
Kennedy's life quotes reflect his theory on how to achieve success:
We must use time as a tool, not as a couch.
Let us never negotiate out of fear. But let us never fear to negotiate.
Things don't just happen, they are made to happen.
We celebrate the past the awaken the future.
Ask not what your country can do for you, but what you can do for your country.
Reagan's life quotes reflect his wide range of interests and his down-to-Earth approach to life:
All great change in America begins at the dinner table.
Preservation of our environment is not a liberal or conservative challenge, it's common sense.
Believe what you are doing is important, even if you are only grubbing for worms in the back yard.
Clinton's life quotes reflect his philosophy of decision-making:
Strength and wisdom are not opposing values.
Promising too much can be as cruel as caring too little.
Yesterday is yesterday. If we try to recapture it, we will only lose tomorrow.
Obama's life quotes reflect his philosophical approach:
Don't shortchange the future, because of fear in the present.
Anything that holds women back holds back the entire country.
Vote! Voting's the best revenge.
For more quotes from U.S. presidents and other famous people, check out the Quotes section here on YourDictionary.
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The temperature has dropped (at least for now), and it's officially that time again: the holiday season. According to the ever-abundant, holiday themed commercials this time of year, this season is all about laughing with your family members, shopping, and having no worries whatsoever. This is partly true. However, there is a side to this time that no one advertises. Amidst all of the laughing and cooking and shopping, Americans gain an average of a pound a person over the holidays. If you're already overweight, the news just gets worse.
But never fear! ProHealth is here with 5 healthy tips to help you make it through the season.
1) One common mistake people make during the holidays is skipping meals. The justification is logical: if I don't eat breakfast, I can eat whatever I want for dinner, right? Wrong. Skipping meals, especially breakfast, is one of the least healthy things you can do. Aside from depriving your brain from crucial fuel to help you think through the day, you're kicking your body into starvation mode. This means that when you finally do eat (turkey, dressing, pie, oh my!), your body will take all those extra calories and store them up for another day rather than just burning through them. It's just like putting gas in your car: you can't run on E today just to over fill the tank tomorrow. So rather than skipping out on your normal meals, eat small, healthy meals during the day so you can splurge on a piece of pie at dinner.
2) This leads us to our next point: over indulging. We all know how this happens. Aunt Sally brings pie, Uncle Jim makes his famous eggnog, and Bob's new wife made an incredible spread of candies. We resist at first, then as everyone else digs in, we think, "Oh why not. It's Christmas after all. Calories don't count at Christmas!" The next thing you know, you've gorged yourself on sweet treats and you're in a sugar coma in the recliner, regretting every bite. You're not alone, and there are tricks to help you resist the sweet tooth this year. The best way to treat a problem is to prevent it, so on that note, prepare for those temptations ahead of time. Make up your mind to only eat when you're hungry, no matter how tasty everyone says the cookies are. If you aren't hungry, your body doesn't need any food. It's that simple. If you want to indulge a little, moderate yourself. Have one cookie instead of three. Split a piece of pie with someone and you'll be doing both of you a favor. Also, eat healthy snacks and early meals (fruit for breakfast, salad for lunch) so you start the day on the right foot. If you kick your body off with the right stuff, you're much less likely to crave the junk later.
3) On that note, there are even ways to avoid being bombarded with desserts and candies for six weeks. Remember when you and your grandma would spend the day in the kitchen baking and making memories? You can still make the memories, without all the junk food. Instead of baking cakes and cookies, make wreaths and ornaments. If you're feeling charitable, write cards to soldiers overseas or fill shoeboxes for those less fortunate. Bonus: charity work makes our minds AND our bodies feel good.
4) Another thing we forget, or ignore, during the holiday season is to keep track of ourselves. Don't fall into the mindset that Christmas doesn't count. Your body doesn't know it's Christmas. It's going to process what you eat and how you exercise just like any other day of the year. Don't stop exercising, weigh yourself, and keep putting on those pants that fit perfectly in October so you'll know what's going on with your body. Ignoring it doesn't make it go away, so you might as well stay in the loop!
5) Since we can't avoid cooking copious quantities of cuisine during the last six weeks of the year, here are some ways to make all those delicious dishes less devastating.
- Gravy: We've all see the crust on the day-after gravy, but did you know that scraping off that layer will save you about 56 grams of fat per cup of gravy? So simple, and so effective! Do this before your meals and your body will thank you.
- Dressing: Think less bread, more veggies. Honestly, that's where dressing gets all of its flavor anyway. Add in more onions, garlic, and celery. If you're into fruit in your dressing, replace some of those crumbs with extra cranberries and apples. Moisten your dressing with low fat, low sodium chicken or vegetable broth, or even applesauce.
- Turkey: Removing the skin from your bird will cut out an average of 11 grams of fat per 3 ounce serving.
- Mashed potatoes: When you're whipping and mashing up this popular side dish, use skim milk, low fat chicken broth, garlic, and parmesan instead of butter and whole milk. Still tasty, but better for you!
- Desserts: Cut the crust, use egg whites instead of whole eggs, replace heavy cream with evaporated skim milk, and top cakes with fruit and powdered sugar instead of frosting.
As always, remember that ProHealth is here to take care of your health. Walk-ins are welcome and wait times are short so people can go back to enjoying time with their families. From wellness checks to minor emergencies, ProHealth is here to keep you happy and healthy this holiday season!
For more tips on how to stay healthy this holiday season, visit our sources: RealSimple.com, Health.com, MayoClinic.com, HumanKinetics.com, NYTimes.com. Photo courtesy of FreeDigitalPhotos.net.


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Game information
- Game title: Mr Ray The Missing Colors
- Category: Puzzle Games
- Game ID on Flash Game: 3650
- Game author: Mrray Music
- Total hits of the game: 7334 times
- Best screen resolution: 700 x 400 pixels
- Game instructions for Mr Ray The Missing Colors:
One day, Mr. Ray found two friends landing in his garden, and they have lost all the colors through the space travel. So Mr. Ray decides to help them find back all the colors. In Mr. Ray The Missing Colors, an arcade game on www.flash-game.net, you can help Mr. Ray finish his mission. There are actions at the bottom of the screen, such as "look at", "talk to", "walk to" and "pick up". You need to use these commands to help the character find and return all the colors. There are hints on the left upper corner, use them if necessary. Good luck!