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Prediabetes: Why Should We Care?
AshkanZand, MD; KarimIbrahim, MD; Bhargavi Patham, M.D., Ph.D.Houston Methodist Hospital, Houston, Texas
A clear link between cardiovascular disease and prediabetes has emerged over the past few years. Recent studies have shown that patients with prediabetes can suffer from coronary artery disease and diastolic heart failure even before progressing to overt diabetes. With this knowledge, physicians must identify prediabetes and take appropriate measures to optimize glycemic control. The pathophysiological defect seen in prediabetes can be managed with lifestyle modifications; thus, it is essential that physicians have a clear understanding of the current recommendations regarding diet and exercise. This review outlines the complications associated with prediabetes, presents an overview of the available pharmacological and surgical therapies that are effective in treating it, and provides a stepwise, multipronged approach for management.
The 2017 National Diabetes Statistics Report from the U.S. Centers for Disease Control and Prevention estimates that 33.9% of the adult U.S. population has prediabetes based on either fasting glucose or hemoglobin A1c (HbA1c) levels. The prevalence is higher in those aged 65 years and older, at 48.3%. Not surprisingly, only 11.6% of U.S. adults know they have prediabetes.1
Diagnosis of prediabetes is based on the presence of impaired fasting glucose, impaired glucose tolerance, and/or elevated HbA1c levels between 5.7% and 6.4%.2 Impaired glucose tolerance is defined as blood glucose levels of 140 to 199 mg/dL during a 75-gram oral glucose tolerance test (normal < 140 mg/dL), and impaired fasting glucose is defined as blood glucose levels of 100 to 125 mg/dL, although the World Health Organization has a narrower threshold of between 110 and 125 mg/dL).3 In multiple studies, prediabetes is shown to have a cause-effect relationship to cardiovascular disease and all-cause mortality. In a cohort meta-analysis by Huang et al., prediabetes was associated with an increased risk of coronary heart disease, stroke, and all-cause mortality.4
Focusing on lifestyle and medical management of prediabetes, this review highlights the systemic and, in particular, cardiac complications associated with prediabetes, with the goal of providing tools for healthcare providers to treat this patient population and provide secondary preventative measures.
The prediabetes state is not only a noteworthy risk factor for type 2 diabetes but is also a significant risk factor for macrovascular disease. Although some of the risk may be due to the progression to overt diabetes, an independent risk is still present in individuals who have not yet progressed to diabetes.5 A meta-analysis of 38 prospective studies in which cardiovascular disease (CVD) or mortality was the end point concluded that increasing glucose levels displayed a linear relationship with CVD risk.6
The macrovascular complications from prediabetes typically arise due to atherosclerosis. Because prediabetes and metabolic syndrome often coexist, the risk of developing an atheroma is high. In addition, strong evidence suggests that patients with prediabetes have an increase in fibrinogen and high-sensitivity C-reactive protein (hs-CRP)—both proatherogenic factors—compared with normoglycemic patients.7,8 This section focuses mainly on the macrovascular complications associated with prediabetes, specifically coronary artery disease and heart failure.
Coronary Artery Disease
While most recognize a direct link between diabetes and coronary artery disease, few physicians and patients acknowledge the potential risk associated with a prediabetes diagnosis. Sen et al. conducted a study on 62 acute coronary syndrome patients who were admitted to a tertiary facility in India to identify the proportion that had prediabetes; they discovered that 48.4% of this patient population had prediabetes and 25% had diabetes.9
In a study by the American Diabetes Association (ADA)10 on the impact of prediabetes on coronary artery atherosclerosis, 67 patients with established coronary artery disease (CAD) underwent angioscopic evaluation of multiple main trunk arteries. Per ADA guidelines, 16 of the patients were classified as nondiabetic, 28 were considered prediabetic, and 23 were diabetic. Yellow plaques identified by angioscopy are commonly considered the primary lesion in acute coronary syndromes, and the presence of two or more per vessel is considered to be a risk factor for future cardiac events. All groups were assessed for both the number of yellow plaques per vessel and intensity of yellow grade. The number and grade of yellow plaques were higher in the prediabetic patients than in nondiabetics (P = .02 and P = .04, respectively) but similar in both prediabetic and diabetic patients (P = .44 and P = .21, respectively). In multivariate logistic regression analysis, both diabetes and prediabetes were independent predictors of multiple yellow plaques.10 In a larger study done by Scicali et al., the impact of prediabetes on coronary artery calcium (CAC) scores and mean common carotid media thickness (IMT) was compared in prediabetic patients and nondiabetic patients. Of the 272 patients enrolled, both the CAC scores and mean IMT were significantly higher in the prediabetes group (P < .001 and P < .001, respectively).11 In conclusion, a prediabetes state could potentially have a similar impact as diabetes on coronary and peripheral atherosclerosis. Larger studies are needed in the prediabetes population to establish a direct link between prediabetes and CAD.
Diastolic Heart Failure
Although studies such as the Framingham Heart Study have established an epidemiologic link between diabetes and heart failure,12 there is no established pathophysiologic association between prediabetes and cardiac function in humans. In an experimental animal model, Koncsos et al. aimed to better define the relationship between prediabetes and diastolic heart failure by administering a single low dose of streptozotocin to Long Evans rats fed with high-fat chow. This treatment induced prediabetes as characterized by a slight elevation in fasting blood glucose, impaired glucose and insulin tolerance, and an increase in visceral adipose tissue. The cardiac consequence of a metabolic derangement such as prediabetes was assessed in this setting. Measurement of morphological and functional parameters of the hearts, as assessed by echocardiography, determined that left ventricular (LV) mass as well as LV anterior and posterior wall thickness were increased in prediabetes rats. Other cardiac dimensional parameters remained unchanged. The slope of the LV end-diastolic pressure–volume relationship, an early and sensitive indicator of diastolic dysfunction, was elevated in the prediabetes group. Pathological evaluation revealed increased oxidative mitochondrial stress and increased mitofusin-2 (MFN2) levels in vascular smooth muscle. Increased MFN2 is thought to induce apoptotic cell death in rat cardiomyocytes.13 Of note, in a previous study by Essop et al., cardiac mitochondrial oxidative stress in male Wistar rats was not seen even after 16 weeks, indicating that mitochondrial oxidative stress might not be present in all models and stages of prediabetes.14 Di Pino et al. studied the effects of prediabetes on diastolic function in 167 patients with HbA1c between 5.7% and 6.4%. In patients with prediabetes, they found a significantly lower peak mitral inflow in early diastole (E wave) to late diastolic atrial filling velocity (A wave) ratio (P < .05), a higher left atrium volume (LAV) (P < .05), and a higher sphericity index (SI) (P < .05) when compared to controls. The E/A ratio, LAV, and SI are all early signs of diastolic dysfunction.15
The combination of diet and exercise is arguably the single most important factor that could halt the progression towards type 2 diabetes in patients with prediabetes. Among the first studies to prove this was the Finnish Diabetes Prevention Study (DPS), a controlled randomized trial including 522 overweight subjects with impaired glucose tolerance who were randomized to either an intensive lifestyle intervention group or a standard-of-care control group.16 The intensive lifestyle intervention group received individualized dietary counseling and circuit-type resistance training and were advised to increase overall physical activity, whereas the control group received general counseling on diet and exercise along with an annual physical exam. The lifestyle intervention arm of the study was designed to be at a high intensity during the first year, followed by a maintenance period, with the goal of reducing both weight and dietary fat intake while increasing physical activity and dietary fiber. Weight reductions were measured after 1 year and at 3 years; the intervention group lost 4.5 kg and 3.5 kg while the control group lost 1.0 and 0.9 kg, respectively. Lipid and glycemic parameters showed more improvement in the intervention group, with a 58% reduction in the risk of developing diabetes compared to the control group. The subjects who were free of diabetes at the end of the intervention were followed up for an additional 3 years, and the incidence of diabetes, physical activity, and dietary intake of fiber and fat was measured. During the total 7-year follow-up period,17 the study concluded that the incidence of type 2 diabetes was 4.3 versus 7.4 per 100 person-years in the intervention and control group, respectively (log-rank test P = .0001), indicating a 36% reduction in relative risk.
Another large study that reproduced similar results was from the Diabetes Prevention Program (DPP), which was similar to the Finnish study in its design but included a group treated with metformin for comparison.18 A total of 3,234 high-risk adults were recruited; 1,079 participants underwent intensive lifestyle intervention, 924 were treated with metformin, and 932 were treated with a placebo. The lifestyle group achieved two important goals: loss of 7% of their initial body weight and a minimum of 150 min of physical activity per week (at an intensity similar to brisk walking). Diabetes incidence was reduced by 58% in the lifestyle group and by 31% with metformin compared to placebo. Analysis was by intention-to-treat, with one case of diabetes prevented for every 6.9 people. Further analysis of the lifestyle group showed a 16% reduction in diabetes risk for every kilogram of weight loss.19 After a 10-year follow-up, the study concluded that the effects of lifestyle modification on diabetes prevention were maintained.
Both the Finnish and DPP studies were successful in demonstrating that lifestyle intervention is a valuable key to managing prediabetes. However, the challenge still remains in implementing these methods in a community setting. Katula et al. applied the methods of the DPP study to the local community via key modifications to enhance efficiency and feasibility.20 Community healthcare workers with well-controlled diabetes and a history of a healthy lifestyle were recruited to deliver a group-based lifestyle weight loss (LWL) intervention through a partnership with a community-based diabetes educational program. The study recruited 301 obese volunteers who were prediabetic on at least two occasions. The LWL intervention had two valuable goals for their participants: a calorie intake between 1,200 and 1,800 kcal per day, and ≥ 180 min of physical activity per week. This approach is in agreement with parameters set by the American Diabetes Association, the North American Association for the Study of Obesity, and the American Society of Clinical Nutrition.21 Participants were present at 67.7% of all group intervention sessions. On an adjusted average of the 6- and 12-month means, LWL intervention participants had a net weight loss of 6.0% of their body weight and 5.0 cm in waist circumference compared to standard of care patients. There was also a 4.3 mg/dL decrease in fasting glucose in the LWL intervention participants versus a decrease of 0.4 mg/dL in the standard of care patients (P < .001).
There are currently four medications for treating the prediabetes subpopulation, including metformin, pioglitazone, acarbose, and liraglutide. In addition, the American Association of Clinical Endocrinologists (AACE) has also proposed three weight-loss therapies—including orlistat, lorcaserin, and phentermine/topiramate ER—to manage obesity with the goal of halting the progression of insulin resistance and type 2 diabetes (Figure 1).22 No data is available for naltrexone/bupropion. Table 1 provides an extensive review of the currently available pharmacological agents.23-40
In 2011, the American College of Surgeons Bariatric Surgery Center Network (ACS-BSCN) recognized bariatric surgery as a potential intervention for type 2 diabetes and prediabetes in addition to assisting in weight loss in morbidly obese patients. De la Cruz-Muñozand colleagues performed a retrospective analysis of 1,602 adults who underwent bariatric surgery; they were categorized into those with diagnosed type 2 diabetes, those with prediabetes, those with high fasting plasma glucose (FPG), and those with normal FPG. At 1- and 3-year follow-up post bariatric surgery, all four groups had normal FPG, but the prediabetes group had more significant weight loss (47 kg) than the diabetes population.41 Procedures such as the Roux-en-Y gastric bypass and the biliopancreatic diversion have been shown to be the most effective for patients with diabetes.42 Normalization of plasma glucose concentrations, HbA1c, and insulin levels were seen in 80% to 100% of patients within days post-surgery prior to any weight loss. The above findings could be attributed to reduced food intake, malabsorption of nutrients, and alterations in gastrointestinal anatomy that incite changes in the incretin system.
Among obese patients (body mass index > 40) who are candidates for bariatric surgery, prediabetes patients should be prioritized because they are at higher risk of diabetes and complications that can be prevented with surgery and the subsequent weight loss. This is supported by a post hoc analysis of 4,032 participants from the Swedish Obese Subjects study, half of whom had bariatric surgery and the other half receiving usual care. After 15 years of follow-up, patients in the diabetes, prediabetes, and normoglycemic groups who underwent bariatric surgery had a reduced incidence of macrovascular complications. Interestingly, the largest risk reduction for macrovascular complications was seen in the prediabetes group.43
The link between prediabetes and cardiovascular disease has been clearly established, and physicians should be aware of the implications for their patients. At this time, major organizations such as the AACE have publish written statements on the importance of diagnosing and treating the prediabetes population. Following these steps will help ensure that future complications in this subpopulation will not take a toll on our healthcare system.
The first step in managing patients with prediabetes is to encourage strict lifestyle modifications consisting of ≥ 180 min of physical activity per week and a calorie intake of 1,200 to 1,800 kcal per day. Providers can also refer their patients to ancillary providers, such as dieticians or weight management specialists, who can help them achieve their goals. In addition to lifestyle management, anti-obesity agents such as orlistat, lorcaserin, and phentermine/topiramate should be considered for obese patients with prediabetes.
Healthcare providers can also consider pharmacologic agents (metformin, pioglitazone, liraglutide, or acarbose) for management of prediabetes. Each of these drugs has a safe pharmacologic profile with regard to hypoglycemia. Metformin has a good track record of being a safe, tolerable drug with benefits such as modest weight loss and a potential cardioprotective effect. Pioglitazone (e.g., Actos) is another viable option due to its ability to increase insulin sensitivity and its known advantage in secondary prevention among stroke/myocardial infarction patients; however, it is also known to cause side effects such as weight gain and bone fractures in the osteoporotic population. If weight loss is a desired effect, providers can consider liraglutide, a weight-loss agent approved by the U.S. Food and Drug Administration that has been shown to improve glycemic control and HbA1c levels.
If medical management fails to achieve glycemic control, advanced measures such as bariatric surgery can be used with the goal of reversing prediabetes and helping obese patients lose weight. All surgical procedures are complex processes that require mental preparedness on the part of the patient and an in-depth understanding of how it will impact their lifestyle; thus, surgery should be reserved for those who are resistant to other forms of treatment. Providers should not be discouraged from sending patients who meet surgical criteria to bariatric surgical centers since studies have shown that surgery can control prediabetes and improve both lipid profiles and blood pressure.
In short, providers can help patients with prediabetes through multiple means and should use the above tools in their arsenal. Providers should also feel comfortable referring patients to an endocrinologist when the clinical picture is complex enough to require multidisciplinary care.
- Prediabetes is a growing concern as it affects roughly 33.9% of U.S. adults, with the majority of this population left untreated.
- Complications of prediabetes include macrovascular effects such as myocardial infraction, stroke, and peripheral vascular disease as well as microvascular changes such as retinopathy, neuropathy, and nephropathy.
- Healthcare providers should start screening for prediabetes and initiate treatment as soon as possible, starting with lifestyle interventions and progressing to pharmacologic therapies.
- Health providers should consider a multidisciplinary approach by involving a certified diabetes educator and/or nutritionist and recruiting additional support from an endocrinologist or bariatric surgeon as needed.
- Centers for Disease Control and Prevention [Internet]. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2017. National Diabetes Statistics Report, 2017; 2017 [cited 2018 Jul 2]. Available from: https://www.cdc.gov/diabetes/data/statistics-report/index.html.
- American Diabetes Association. Classification and Diagnosis of Diabetes. Diabetes Care. 2017 Jan;40(Suppl 1):S11-S24.
- World Health Organization [Internet]. Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia: report of a WHO/IDF consultation. Geneva, Switzerland: World Health Organization; 2006 [cited 2018 Aug 6]. Available from: http://www.who.int/diabetes/publications/Definition and diagnosis of diabetes_new.pdf.
- Huang Y, Cai X, Mai W, Li M, Hu Y. Association between prediabetes and risk of cardiovascular disease and all cause mortality: systematic review and meta-analysis. BMJ. 2016 Nov 23;355:i5953.
- Nasr G, Sliem H. Silent myocardial ischemia in prediabetics in relation to insulin resistance. J Cardiovasc Dis Res. 2010 Jul;1(3):116-21.
- Levitan EB, Song Y, Ford ES, Liu S. Is nondiabetic hyperglycemia a risk factor for cardiovascular disease? A meta-analysis of prospective studies. Arch Intern Med. 2004 Oct 25;164(19):2147-55.
- Isordia-Salas I, Galván-Plata ME, Leaños-Miranda A, et al. Proinflammatory and prothrombotic state in subjects with different glucose tolerance status before cardiovascular disease. J Diabetes Res. 2014;2014:631902.
- Bembde AS. A study of plasma fibrinogen level in type-2 diabetes mellitus and its relation to glycemic control. Indian J Hematol Blood Transfus. 2012 Jun;28(2):105-8.
- Sen K, Mukherjee AK, Dharchowdhury L, Chatterjee A. A study to find out the proportion of prediabetes in patients with acute coronary syndrome in a medical college of Kolkata. J Indian Med Assoc. 2008 Dec;106(12):776-8.
- Kurihara O, Takano M, Yamamoto M, et al. Impact of prediabetic status on coronary atherosclerosis: a multivessel angioscopic study. Diabetes Care. 2013 Mar;36(3):729-33.
- Scicali R, Giral P, Gallo A, et al. HbA1c increase is associated with higher coronary and peripheral atherosclerotic burden in non-diabetic patients. Atherosclerosis. 2016 Dec; 255:102-8.
- Mahmood SS, Wang TJ. The epidemiology of congestive heart failure: the Framingham Heart Study perspective. Glob Heart. 2013 Mar 1;8(1):77-82.
- Koncsos G, Varga ZV, Baranyai T, et al. Diastolic dysfunction in prediabetic male rats: Role of mitochondrial oxidative stress. Am J Physiol Heart Circ Physiol. 2016 Oct 1;311(4):H927-H943.
- Essop MF, Anna Chan WY, Valle A, García-Palmer FJ, Du Toit EF. Impaired contractile function and mitochondrial respiratory capacity in response to oxygen deprivation in a rat model of prediabetes. Acta Physiol (Oxf). 2009 Dec;197(4):289-96.
- Di Pino A, Mangiafico S, Urbano F, et al. HbA1c Identifies Subjects With Prediabetes and Subclinical Left Ventricular Diastolic Dysfunction. J Clin Endocrinol Metab. 2017 Oct 1;102(10):3756-64.
- Lindström J, Louheranta A, Mannelin M, et al.; Finnish Diabetes Prevention Study Group. The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care. 2003 Dec;26(12):3230-6.
- Lindström J, Ilanne-Parikka P, Peltonen M, et al.; Finnish Diabetes Prevention Study Group. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet. 2006 Nov 11;368(9548):1673-9.
- Diabetes Prevention Program (DPP) Research Group. The Diabetes Prevention Program (DPP): description of lifestyle intervention. Diabetes Care. 2002 Dec;25(12):2165-71.
- Hamman RF, Wing RR, Edelstein SL, et al. Effect of weight loss with lifestyle intervention on risk of diabetes. Diabetes Care. 2006 Sep;29(9):2102-7.
- Katula JA, Vitolins MZ, Rosenberger EL, et al. One-year results of a community-based translation of the Diabetes Prevention Program: Healthy-Living Partnerships to Prevent Diabetes (HELP PD) Project. Diabetes Care. 2011 Jul;34(7):1451-7.
- Klein S, Sheard NF, Pi-Sunyer X, et al.; American Diabetes Association; North American Association for the Study of Obesity; American Society for Clinical Nutrition. Weight management through lifestyle modification for the prevention and management of type 2 diabetes: rationale and strategies. A statement of the American Diabetes Association, the North American Association for the Study of Obesity, and the American Society for Clinical Nutrition. Am J Clin Nutr. 2004 Aug;80(2):257-63.
- Garber AJ, Abrahamson MJ, Barzilay JI, et al. CONSENSUS STATEMENT BY THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY ON THE COMPREHENSIVE TYPE 2 DIABETES MANAGEMENT ALGORITHM – 2018 EXECUTIVE SUMMARY. Endocr Pract. 2018 Jan;24(1):91-120.
- Rena G, Hardie DG, Pearson ER. The mechanisms of action of metformin. Diabetologia. 2017 Sep;60(9):1577-85.
- Salpeter SR, Buckley NS, Kahn JA, Salpeter EE. Meta-analysis: metformin treatment in persons at risk for diabetes mellitus. Am J Med. 2008 Feb;121(2):149-157.e2.
- Ramachandran A, Snehalatha C, Mary S, et al. The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia. 2006 Feb;49(2):289-97.
- Svensson E, Baggesen LM, Johnsen SP, et al. Early Glycemic Control and Magnitude of HbA1c Reduction Predict Cardiovascular Events and Mortality: Population-Based Cohort Study of 24,752 Metformin Initiators. Diabetes Care. 2017 Jun;40(6):800-7.
- Smith U. Pioglitazone: mechanism of action. Int J Clin Pract Suppl. 2001 Sep;(121):13-8.
- DeFronzo RA, Tripathy D, Schwenke DC, et al. Pioglitazone for diabetes prevention in impaired glucose tolerance. N Engl J Med. 2011 Mar 24;364(12):1104-15.
- Kernan WN, Viscoli CM, Furie KL, et al. Pioglitazone after Ischemic Stroke or Transient Ischemic Attack. N Engl J Med. 2016 Apr 7;374(14):1321-31.
- Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M; STOP-NIDDM Trail Research Group. Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial. Lancet. 2002 Jun 15;359(9323):2072-7.
- Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M; STOP-NIDDM Trial Research Group. Acarbose treatment and the risk of cardiovascular disease and hypertension in patients with impaired glucose tolerance: the STOP-NIDDM trial. JAMA. 2003 Jul 23;290(4):486-94.
- Russell-Jones D, Vaag A, Schmitz O, et al. Liraglutide vs insulin glargine and placebo in combination with metformin and sulfonylurea therapy in type 2 diabetes mellitus (LEAD-5 met+SU): a randomised controlled trial. Diabetologia. 2009 Oct;52(10):2046-55.
- le Roux CW, Astrup A, Fujioka K, et al.; SCALE Obesity Prediabetes NN8022-1839 Study Group. 3 years of liraglutide versus placebo for type 2 diabetes risk reduction and weight management in individuals with prediabetes: a randomised, double-blind trial. Lancet. 2017;389(10077):1399-1409.
- Marso SP, Daniels GH, Brown-Frandsen K, et al. Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med. 2016 Jul 28;375(4):311-22.
- Guerciolini R. Mode of action of orlistat. Int J Obes Relat Metab Disord. 1997 Jun;21 Suppl 3:S12-23.
- Torgerson JS, Hauptman J, Boldrin MN, Sjöström L. XENical in the prevention of diabetes in obese subjects (XENDOS) study: a randomized study of orlistat as an adjunct to lifestyle changes for the prevention of type 2 diabetes in obese patients. Diabetes Care. 2004 Jan;27(1):155-61.
- Lonneman DJ Jr, Rey JA, McKee BD. Phentermine/Topiramate extended-release capsules (qsymia) for weight loss. P T. 2013 Aug;38(8):446-52.
- Guo F, Garvey WT. Cardiometabolic Disease Staging Predicts Effectiveness of Weight-Loss Therapy to Prevent Type 2 Diabetes: Pooled Results From Phase III Clinical Trials Assessing Phentermine/Topiramate Extended Release. Diabetes Care. 2017 Jul;40(7):856-62.
- Gustafson A, King C, Rey JA. Lorcaserin (Belviq): A Selective Serotonin 5-HT2C Agonist In the Treatment of Obesity. P T. 2013 Sep;38(9):525-34.
- Nesto R, Fain R, Li Y, Shanahan W. Evaluation of lorcaserin on progression of prediabetes to type 2 diabetes and reversion to euglycemia. Postgrad Med. 2016 May;128(4):364-70.
- de la Cruz-Muñoz N, Messiah SE, Arheart KL, Lopez-Mitnik G, Lipshultz SE, Livingstone A. Bariatric surgery significantly decreases the prevalence of type 2 diabetes mellitus and prediabetes among morbidly obese multiethnic adults: long-term results. J Am Coll Surg. 2011 Apr;212(4):505-11; discussion 512-3.
- Keidar A. Bariatric surgery for type 2 diabetes reversal: the risks. Diabetes Care. 2011 May;34 Suppl 2:S361-266.
- Carlsson LMS, Sjöholm K, Karlsson C, et al. Long-term incidence of microvascular disease after bariatric surgery or usual care in patients with obesity, stratified by baseline glycaemic status: a post-hoc analysis of participants from the Swedish Obese Subjects study. Lancet Diabetes Endocrinol. 2017 Apr;5(4):271-9.


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EMBL Courses and Conferences during the Coronavirus pandemic
With the onsite programme paused, many of our events are now being offered in virtual formats.
Registration is open as usual for many events, with back-up plans in place to move further courses and conferences online as necessary. Registration fees for any events affected by the COVID-19 disruption are fully refundable.
More information for participants of events at EMBL Heidelberg can be found here.
Accommodation and Transport
Accommodation is not included in the conference registration fee.
How can I book accommodation for the conference?
Which hotels can I book?
What type of room can I book?
Conference shuttle busses
Public transport to venue
How can I book accommodation for the conference?
Rooms have been reserved at our partner hotels, allowing participants to choose a suitable hotel at an EMBL discounted rate. Please contact one of our partner hotels before 22 July 2014 in order to ensure availability. Prices do vary according to season, therefore please quote the code CHB14-01 and confirm the exact price of the room with the hotel directly.
You can get in touch with other participants to arrange room-sharing on the Chemical Biology Facebook page.
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Which hotels can I book?
Please choose from one of our long standing partner hotels below.
View map showing our partner hotels and the nearest bus stops.
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What type of room can I book?*
- Single room - room with single bed for 1 person only
- Superior single room - larger single room or double room used as a single
- Double room - room with double bed ideally for a couple
- Twin room - room with 2 single beds for 2 persons
- Shared of twin room - the use of a single bed in a twin room (shared with another participant)
*Note: not all room types are available in every hotel.
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Conference Shuttles Buses
Conference shuttle buses are free of charge for participants, and depart from designated bus stops near the hotels to EMBL and back, mornings and evenings. The conference bus schedule is available here.
Please check the Google Map - Bus Stops and Hotels for details about bus stops and hotel locations.
Important info: Please note that NOT every bus stop will be used for every event. The bus stops for this conference are:
- Bus Station Main Train Station
- Bus Station Neckarmünzplatz
- Bus Station Peterskirche
- Bus Station Crowne Plaza
- Bus Station ISG Hotel
Further details
For further information visit Public Transportation to the Venue.
For information about accommodation and local transportation please refer to the FAQ page. Back to top

subset: commoncrawl


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Integrated Accessibility Regulations
New accessible public spaces standards – What you need to know
Today, I'll review the Accessibility Standards for the Design of Public Spaces. Like the new accessible buildings standards, the standards for public spaces apply to new construction and extensive changes to existing spaces. They cover the following features…
New accessible buildings standards take effect in 2015
Since the passage of the Accessibility of Ontarians with Disabilities Act in 2005, Ontario has been steadily advancing its accessibility project with new and amended standards and regulations. The goal is an "accessible Ontario" by 2025, supporting all Ontarians in accessing goods, services, facilities, accommodation, employment, buildings, structures and premises. Two new regulations addressing the built environment will come into force in 2015.


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|This page documents the Official Policy of the GTA Myths Wiki. The Policy is to be followed by all users on the wiki.
Blocking is the method by which Bureaucrats and Administrators may prevent users from editing on the GTA Myths Wiki. Blocks are used to prevent damage or disruption to the wiki, not to punish users.
Any user may request another user to be blocked for violating rules, by simply going to the GTA Myths Wiki:Community Noticeboard, or by contacting a Bureaucrat or an Administrator and then reporting the rule violation. Blocked users can appeal the block by using their talk pages.
Something to keep in mind
No two situations are ever going to be exactly alike, and one of the hallmarks of a successful administrator is the ability to observe a situation where blocking might be in order and decide how harshly the offending user should be dealt with.
Except in the case of egregious vandalism, an administrator should observe the history of the offending editor's editing. If an editor seems to be trying hard, it may be safe to assume that the editor simply wasn't aware of the policy he/she was breaking, and a polite post to the talk page with a link to the violated policy should be sufficient. If a user has a talk page full of warnings or an editing history full of problem edits, the administrator should be stricter.
Blocking Policies
- Good faith will be extended to most users on the assumption they may not be familiar with wiki etiquette in general, and first instances will most likely be revered with a warning. However, administrators are free to use their discretion on whether to block or not based on the virulence of the vandalism.
- Block length should reflect the violation of rule. Blocks longer than one week should not be placed without prior discussion.
- If a user or an IP has been blocked before for vandalism, and continues vandalism in further edits, then that user will be recognised as a vandal only user or IP, and will be blocked indefinitely.
- The length of blocks is subject to discretion and the type of vandalism. Hate speech and advocation of illegal activities, for example, will result in longer blocks than the standard insertion of gibberish.
- When a user is blocked, it is required by policy for the Bureaucrat or Administrator issuing the block to leave a message on that user's talkpage explaining the block, and if possible a link to the specific 'dif' that warranted the block.
- Blocked users on their first block should not be blocked with talk page access disabled.
- Sometimes two admins will disagree on a block issued. Rather then change the block and end up in a wheel war, the admin who disagrees with a block is advised to discuss with the blocking admin on their talkpage.
Block Lengths
For repeat offending users, blocks should be of escalating length.
- First block should be between 1 day and 1 week.
- Second block should be between 3 days and 1 month.
- Infinite Blocks are to be issued only to vandals who have previously been blocked and warned.
If a sufficient amount of time has passed between unacceptable edits, an administrator may choose to block for a shorter duration, or even start off with a warning as opposed to a block. There is no hard set rule for dealing with this, administrators should use their best judgement, ask their fellow administrators or the community, or both.


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Follow RFF News on your cell phone. Text follow rff to 40404 you will receive txt messages with RFF News
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Still beyond me as to why Ciera did not try to pull this move off when she had the numbers last week... Did she just realise she was fourth?
Gervase is officially my least favourite Survivor this season, such a loud, delusional piece of thing. I LOVEDDDDD how the jury showed their displeasure by laughing loudly.Poor Katie, but it was worth the shot and she would have been next anyway. I bet she was tired with the game as well.
IKR, Ciera picking it would have been so hilarious considering she forced the situation.
Though, my favourite moments were Hayden randomly becoming a GREAT character out of nowhere, Ciera being Ciera and Katie getting knocked on the head with the ball multiple times in a row <3
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Being featured on Body By Baby! Head on over and subscribe to her page...great tips, fitness, and crafts. She can also be found on FB! Make sure you tell her I sent you!
Sunday, August 28, 2011
Down for the count...
Sorry I haven't posted anything recently, I have been in bed for over 72hrs now, two Doctor's visits, and 6 medications later..I am feeling half way normal. So please bear with me as I catch up on bucket and flower orders, lesson plans, grading, house work.. then get back on track with the blog. I have saved up some amazing freebies, so stay tuned! I will also talk about my "illness" to give some people insight as well as possibly help others. Thanks for understanding!
Wednesday, August 24, 2011
Family Photo Shoot
Monday, August 22, 2011
Meet the Teacher Monday
Hey y'all! Today I'm participating over at Blog Hoppin' for Meet the Teacher Monday.
Tell us a little something about you....
I am a 3rd grade teacher, mommy, wife, and crafter on the side.
How long have you been teaching?
I have been teaching for 10 years. I have taught 3rd grade in Georgia for most of them, 4th and 5th in California, and PreK in Florida.
You might not know...
That I can be pretty funny and scarcastic when I want to be! Even though I am a structured, organized teacher and person I love to have a good time.
What are you looking most forward to this school year?
Not having "that class" this year. I must admit I paid my dues last year and was promised a little relief this year, so here's hoping!
What do you need to improve?
This year a lot of our grading procedures and policies have changed. We, as a grade level, are pushing through and struggling together trying to "make it work for us"...it's been rough already.
What teaching supplies can you *not* live without?
Where do I begin??? Binders, labels, FONTS (I LOVE fonts), my mimio, anything to do with technology for that matter, my new AMAZING pencil sharpener, brand new sharpies, chisel tip Expo markers...I could go on and on!
So that's it for me...it's now your turn to go link up at Blog Hoppin' for Meet the Teacher Monday. Have fun!
Friday, August 19, 2011
Classroom Sign Tutorial
So as the second week of school comes to an end, with curriculum night behind me, and lesson plans for next week done...I begin to feel a slight bit of relief and then suddenly it's gone. I just washed a load of laundry for the third time, my husband informed me (after I started it) that he ran it for the second time when he came home from work, ugh! I have buckets to make (not complaining there, it's a lot like calming therapy for me) but also know my house could use a HUGE scrubbing! But I decided to take a few minutes and give you guys this tutorial and a freebie for Friday! Enjoy.
First coat entire canvas in the base color of your choice.
Once I had it coated I decided I wanted to add "depth" so I purchased these supplies:
I found some paper stencils on sale at WalMart, bought a shade darker paint, and some sponge stencil "brushes"
I did go over the stencil design with the lighter paint one more time, to mute them. When the paint was dry I simply cut the letters/sayings using my Cricut and stuck them on!
Here is your Friday Freebie, click to retrieve six Reader's/Writer's Workshop headers:
What you need:Background color of choice, sponge roller, canvas size of choice, Cricut and Vinyl letters of choice (or some way to put letters on canvas)
First coat entire canvas in the base color of your choice.
Once I had it coated I decided I wanted to add "depth" so I purchased these supplies:
I found some paper stencils on sale at WalMart, bought a shade darker paint, and some sponge stencil "brushes"
I did go over the stencil design with the lighter paint one more time, to mute them. When the paint was dry I simply cut the letters/sayings using my Cricut and stuck them on!
Here is your Friday Freebie, click to retrieve six Reader's/Writer's Workshop headers:
Monday, August 15, 2011
New Bucket and Desk Setup
Thought I would share my newest custom designed bucket, and believe it or not it is not for a teacher...for a little guys 1st birthday! Can't wait to see it in use.
Also as some of you teachers out there are still setting up classrooms, thinking of setting up your classroom, or already ready to change your seating arrangement around...here are a few pictures I took of seating arrangements around my school. I noticed that as I looked at different blogs and pictures I kept asking myself "where do the kids sit?". Hope it gives you a few ideas.
|I convinced her to change her boards...they came out cute! Also love this seating arrangement
|Another view of her room, the two other groups...this leaves a nice open space in the middle
|This is one of the smaller rooms, due to the movable wall, she also wanted more space in the front.
|This room also has extra desks behind the shelf with red boxes for possible push in students
|Younger classroom set up, this was during pre-planning so don't mind the supplies
|Special Ed. classroom. I like how she made the four desks like a kidney table (those are in high demand in our school)
Hope this helped or even inspired you! Happy Monday!
Saturday, August 13, 2011
Glass Stone Magnet Tutorial
For those of you that saw these on my classroom reveal blog, here is how I made them...super easy!
Materials needed:
For some reason blogger keeps rotating this picture...but you need Mod Podge, backing paper (cardstock), glass rocks (gems), circle punch, image/stickers/or paper of your choice, magnets
Take your stickers and place them on the cardstock, or use the cardstock you have chosen.
Using your circle punch (upside down so that you can see where you are punching) cut out the images or paper.
Mod Podge the front of the stickers or paper
Take the glass gems and place them, pressing lightly to secure them into place
I did cut plan circles and write on them, things such as No School, that is how I did the month letters in the top picture
Then flip them over and Mod Podge the back as well.
When dry, hot glue magnets to the back...I used larger ones because I wanted to be sure they didn't slip down my calendar as the year went on.
Enjoy and have fun!
Friday, August 12, 2011
Freebie Friday!
So I think a good way to celebrate the end to my first week of school is to have a Freebie Friday. I have grand plans to post a few tutorials this weekend ..that will be in between making a mimio lesson for next week, grading a few papers, spending time with my family, filling a few bucket orders, cleaning my house, doing laundry, and running errands. The weekend isn't long enough!
Here they are!
This is how I store my clipboards in my room. I love that they are easy for the students to access, yet are out of the way. Hint: buy the cheaper hooks (it doesn't seem to matter which ones I use, I end up having to hot glue them anyway)
Here they are!
This is how I store my clipboards in my room. I love that they are easy for the students to access, yet are out of the way. Hint: buy the cheaper hooks (it doesn't seem to matter which ones I use, I end up having to hot glue them anyway)
I could not find black with white polka dot calendar pieces (which is what I use to number ANYTHING in my room) so I made them...your lucky day!
Click Here to retrieve them!
Some of you read my behavior management blog, a little long...but it is working! Here is the label I used for the front of their folders, I included one with a piece of clipart so you wouldn't have to use stickers if you didn't want to.
Click Here to retrieve
And as a little bonus...some Reader's Workshop Headers
Click Here to retrieve!
And now it is time for this tired teacher to head to bed! (I hope my links and documents all work...this is my first time loading anything)
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Pushed some much-needed updates to llamajam.com — we've got some significant app improvements in the pipeline at the moment! #llamajam
Pushed some much-needed updates to llamajam.com — we've got some significant app improvements in the pipeline at the moment! #llamajam
Several #buzz gigs upcoming in the next couple of months! The first is on the , St. Mary's Church, Totnes @ 11:00 - , £5 on the door. The second is in early March in Kingskerswell, I'll keep you posted for details! Or email me at email@example.com to join the Buzz mailing list (we will never spam you).
"We have to start the cow paths for the world. The paved paths are for the privileged." (source) by inkpixelspaper
@thatemil RRRR yes, ambiguous date formats are so stupid, especially when they're on tickets (british rail, I'm looking at you)
Thoroughly enjoyed the #sfw hangout tonight, demonstrating #indieauth and learning about forkthelaw.org /cc @wardcunningham Aaron Parecki
Adventures in #pgsql, episode 1: Installed using aptitude. Went through create-new user dance. Figured out the template db is set to a useless encoding. Learnt how to regenerate the cluster using UTF-8.
Unhosted Adventures — a great guide to setting up your own #indieweb server /via Travis Wellman
Checked in to St. Mary's Church, Totnes for a #buzz rehearsal. Lots of nice tunes in our upcoming gig!
T1: Checking to see what's up with the weird note author thing
Just finished watching Star Wars: A New Hope Uncut. A fantastic project which was surprisingly easy to get lost in despite constant character gender and species changes (sometimes mid-sentence).
aral oh so you're suggesting it'd be a Boolean attr? That I could get behind – easy to polyfill too.
aral I disagree, "continue" is confusing compared to start. Start = start from a number, continue = what? Continue from a number? So the list should start from that number plus one? Or continue from another ol (perhaps by using an id reference)?
I don't feel emotionally intelligent enough to write anything which adequately sums up my anger at the sexism-in-tech situation.
Fortunately, @sazzy, rellyab and many others are, and have. Props to you all, keep going, I will support you however I can.
http://www.sazzy.co.uk/2013/02/speaking-up/ http://rel.ly/2013/02/also-speaking-up/ http://geekfeminism.wikia.com/wiki/Timeline_of_incidents
Booked my flight to Iceland and now submitting my first speaking proposal — this is an exciting evening! /cc @briansuda @digpen sophiedennis
Authentically Traditional by Robin Andrews is an interesting and welcome take on exactly what it means to be "authentic" in the context of #music /cc sophiedennis #bookmark #link
Watching Private Life of Plants, from the year I was born. It has aged well, and remains my favourite Attenborough series.
The value of #geo machine #tags and rev. geo coding: even though I don't yet have a fancy distance-queryable database, my notes can be queried by location. For example, notes I have posted in Devon.
Checked in at the Old Fort, Hembury whilst mapping the woods to help jwentomologist


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Wolf Run Apartments now home to its first residents
By Olivia Sundeen
Farmer Intern
With her pink hard hat and cheery smile, Katie Walters, property manager for Wolf Run Village, walks along the site of the Wolf Run Apartments reminding workers why this project is so important.
"There is nowhere else for these people to go," stated Walters of the housing made for teachers, law enforcement and city and county employees. "Once I tell the construction crew why this housing is being built, they understand why this project is so important."
Last week, the Wolf Run Village got its first tenants. The first to move in was a family new to town, originally from Wyoming. The second was Jeremy and Kristy Fowler, along with their kids, Dylan and Audrey, age 8. For the past year and four months, the Fowlers have lived in Watford City in a fifth wheel.
"We've learned so much living in a fifth wheel," stated Kristy Fowler, the administrative assistant for the McKenzie County Public School District No. 1.
The Fowlers have experienced quite an ordeal in their fifth wheel. In the winter, whenever the weather got into the negatives they would have to keep a de-icer inside because the door would get frozen shut.
"If you've done a winter in North Dakota in a fifth wheel," stated Jeremy, "you've really done something."
Walters, who has been overseeing this project since day one, feels it is so rewarding.
Rent for a two bedroom apartment is $875 a month and $726 for a one bedroom, making it affordable family housing.
"Sometimes it gets frustrating," stated Walters. "This project has been in the works for two years. To see the end result in sight and see the look of the tenants like the Fowlers when they first see their new home is so rewarding."
And that it was. Upon seeing the place they will now call home, the Folwers were ecstatic and most of all, grateful.
Lots of hugs, smiles and excited observations took place.
"Is this really ours?"
"We have a porch!"
"We have a real-sized fridge!"
"Mom, we have water pressure!"
"Wow, this is awesome!"
The ohs and awes continued in what seemed to be never-ending excitement."
"You don't know how much you take for granted until you have to move into something small," stated Jeremy.
To the Folwers, their new 1,000-square foot apartment seems like a mansion.
"I just want to say thank you McKenzie County," stated Jeremy. "This is awesome."
Walters was ecstatic with their reaction.
"It all came together," stated Walters. "I'm so happy the Folwers are happy."
New tenants will continue to move in from now until sometime in October.
"It is our hope to have all of the apartments done and people moved in by October," stated Walters. "As with every project, little things come up. But we are continuing to work hard and have no reason to think otherwise."
Not only is Walters excited to see the light at the end of the tunnel, so to speak, she couldn't contain her excitement in revealing that Wolf Run has been accepted for the Housing Grant. This will provide $1,483,231 with $845,441 coming from matches. Basically, this is a state tax credit.
"It's a way for us to tell the state we want this money to go right back to our community," stated Walters. "Every little bit helps.


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Arosha Rosenberger-Timeless " Black and White" Collection
At Design Interviews
Interview with Arosha Rosenberger : Frank Scott: What is the main principle, idea and inspiration behind your design?. Arosha Rosenberger : The idea behind this Design is to Focus The Living Nature in 3 Dimensionion. .Frank Scott: What has been your main focus in designing this work? Especially what did you want to achieve?. Arosha Rosenberger : I wanted achieve by the 3 Dimension Designs to visualise the Nature/Living Woods in reality in clothes. .Frank Scott: What are your future plans for this award winning design?. Arosha Rosenberger : It all depends on my Success!!!! I am very optimistic but I will wait...... .Frank Scott: How long did it take you to design this particular concept?. Arosha Rosenberger : I am currently working on the Project. The Invitation for the A Fashion Award walked into my Door step unexpectedly..Only few Designs are completed. Atleast 3 to six months Design Work. .Frank Scott: Why did you design this particular concept? Was this design commissioned or did you decide to pursuit an inspiration?. Arosha Rosenberger : This was Collection was designed to persuit my Inspirations .Frank Scott: Is your design being produced or used by another company, or do you plan to sell or lease the production rights or do you intent to produce your work yourself?. Arosha Rosenberger : It all depends , on offers I recieve .Frank Scott: What made you design this particular type of work?. Arosha Rosenberger : To Visualise the Nature in Clothing .Frank Scott: Where there any other designs and/or designers that helped the influence the design of your work?. Arosha Rosenberger : No! This was my own Inspiraations used. .Frank Scott: Who is the target customer for his design?. Arosha Rosenberger : Business Couture / Eco-Couture .Frank Scott: What sets this design apart from other similar or resembling concepts?. Arosha Rosenberger : This Design Timeless Black & White t sets this design apart from other similar or resembling concepts because it is a Eco Friendly Collection. .Frank Scott: How did you come up with the name for this design? What does it mean?. Arosha Rosenberger : Timeless reminds me of been everlasting , endless. The Colours I Chose Black and White is endless which will never fade out. These two colours is a must in the Wardrobe. Also everlasting collection coz you can wear the Designs multifarios ways. eg From Business Event to Evening Cocktail..... .Frank Scott: Which design tools did you use when you were working on this project?. Arosha Rosenberger : Pattern Draping System .Frank Scott: What is the most unique aspect of your design?. Arosha Rosenberger : 3 Dimension .Frank Scott: Who did you collaborate with for this design? Did you work with people with technical / specialized skills?. Arosha Rosenberger : I worked with two proffesional Pattern Cutters and Seamstresses who are very well skilled in this Field. .Frank Scott: What is the role of technology in this particular design?. Arosha Rosenberger : 3D Technology in Clothing .Frank Scott: Is your design influenced by data or analytical research in any way? What kind of research did you conduct for making this design?. Arosha Rosenberger : I have done reasearch in Garment Design Techniques. .Frank Scott: What are some of the challenges you faced during the design/realization of your concept?. Arosha Rosenberger : The challengesare always to use the Correct Fabric with the Correct Design using relevent Colourscheme Fitting on the Mannequins etc..... .Frank Scott: How did you decide to submit your design to an international design competition?. Arosha Rosenberger : This is something what I always wanted to do.Imust agree this opprtunity came to unexpectedly. .Frank Scott: What did you learn or how did you improve yourself during the designing of this work?. Arosha Rosenberger : I improved my Fashion Design Development skills. .
Arosha Rosenberger-Timeless " Black and White" Collection Images:
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text: The Czech conductor and composer Jaroslav Krček was born in Bohemia in 1939 and studied composition and conducting at the Prague Conservatory. In 1962 he moved to Pilsen as a conductor and radio producer and in 1967 returned to Prague to work as a recording supervisor for Supraphon. In the capital he funded the Chorea Bohemica ensemble and in 1975 the chamber orchestra Musica Bohemica. In the Czech Republic he is well-known for his arrangements of Bohemian folk music, while his electro-acoustic opera Raab was awarded first prize at the International Composers' Competition in Geneva.


text: Parents take heed! Does your teen want a Nintendo DS for Christmas, but you worry about it distracting them from their schoolwork? Aspyr Media and the test prep wizards at Kaplan have your solution with futureU SAT Prep for the DS. First announced back in April, the 'game' is now hitting stores, just in time for Christmas. It might not be the console edutainment Crecente craves, but it'll do in a pinch. It features six mini-games across three categories that apparently represent everything Americans need to know in order to go to college; reading, writing, and math. It even tracks the player's progress, so you can tell early on if you need to hire a more intelligent doppleganger to take the test for you child. All this for only $29.99! No no parents, don't thank me. It's all part of my ongoing plan to ruin Christmas for children everywhere.Aspyr Media Ships New SAT Prep Video Game, futureU™, for Nintendo DS™ Interactive Test Prep Game Based on Study Material from Kaplan Test Prep and Admissions Designed for Studying While On The Go AUSTIN, TX - November 5, 2008 - Aspyr Media, in collaboration with Kaplan Test Prep and Admissions, announced today that futureU™, a first-of-its-kind SAT prep video game, has shipped to retail stores nationwide for Nintendo DS™. Following on the heels of the PC/Mac version of the same name, futureU represents a new medium for supplemental SAT prep by adapting test preparation material into a collection of fun interactive games. Utilizing the touch screen capabilities of DS, futureU offers a complete interactive experience unlike any standard test taking method to date. Designed for studying at home or on the go, the game consists of six distinctive mini-games that are divided into three main categories - Math, Reading and Writing. Developed as a complement to traditional SAT study methods, the game is grounded in Kaplan curriculum and features hundreds of questions and track-able player progress. futureU incorporates a wealth of in-game content that challenges and sharpens skills including: * Reading: Focuses on refining players' reading skills, vocabulary, main idea identification, themes and arguments, technique, and recognizing word meanings based on context. * Writing: Concentrates on improving players' writing skills by covering topics such as passive voice, run-on sentences, misplaced modifiers, parallelism, conjunctions, fragments, coordination and subordination, pronouns, subject-verb agreement, tenses, adverbs and adjectives, gerunds, idioms, wrong words, and double negatives. * Math: Enable players to practice critical math areas such as algebra, geometry, data, statistics, probability, polynomials, and sequences. futureU for Nintendo DS™ is rated "E" for Everyone by the ESRB and is available for an SRP of $29.99. For more information, please visit www.aspyr.com. futureU is the latest supplementary test prep offering from Kaplan which adapts test preparation content into a medium relevant for today's teens. Last year, Kaplan launched SAT prep for iTunes® and a score-raising graphic novel series.


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Listing ID: 115676
2451 Medel St., near Zamora St., Sta. Ana, Manila - 5 units
At Demonteverde Townhomes II your life will never be the same again. The prime location makes everything within reach. Work, schools, supermarkets, hospitals, banks, business centers, private offices and government institutions are all right at your doorstep! Live at the heart of it all.
This five-unit townhomes stands out in the community with its contemporary attractive design, refreshed interiors, practical and efficient features. Choose from 5 units now!
Completion Date October 1 2015


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Patrick Sarran-Ilok Removable Tables
At Design Interviews
Interview with Patrick Sarran : Frank Scott: What is the main principle, idea and inspiration behind your design?. Patrick Sarran : Tables are often not given the consideration they deserve, although they are probably the most important piece of furniture in a restaurant. As pointed out by my brother, Chef Michel Sarran, the daily task of setting up tables poses a serious practical problem and can even become a nightmare in the case of round tables which are very appreciated by guests as a symbol of conviviality. .Frank Scott: What has been your main focus in designing this work? Especially what did you want to achieve?. Patrick Sarran : I decided to solve this problem by designing a wooden table that is easy to manufacture and whose size and shape can be easily modified will. .Frank Scott: What are your future plans for this award winning design?. Patrick Sarran : I hope this design will continue to be successful. .Frank Scott: How long did it take you to design this particular concept?. Patrick Sarran : Six months. .Frank Scott: Why did you design this particular concept? Was this design commissioned or did you decide to pursuit an inspiration?. Patrick Sarran : I pursued my inspiration. I wanted something innovative for the trade fair Equip'hotel Paris 2014. .Frank Scott: Is your design being produced or used by another company, or do you plan to sell or lease the production rights or do you intent to produce your work yourself?. Patrick Sarran : iLOK design is used by QUISO, my own company; Maybe in the future I will need a partner. .Frank Scott: What made you design this particular type of work?. Patrick Sarran : Talking with restorers, I had identified an unsatisfied nee .Frank Scott: Where there any other designs and/or designers that helped the influence the design of your work?. Patrick Sarran : Following the designer Jean Prouvé, again I searched for simpler ways to get from function to form. There are some similar points in the approach as well as in the shapes. But I also remembered lost gestures of bending wood in some vernacular designs from the country side like old snowshoes or crutches. .Frank Scott: Who is the target customer for his design?. Patrick Sarran : Restaurants, meeting rooms and hotels. .Frank Scott: What sets this design apart from other similar or resembling concepts?. Patrick Sarran : Extending round tables has never been so simple. .Frank Scott: How did you come up with the name for this design? What does it mean?. Patrick Sarran : iLOK has no particular meaning .Frank Scott: Which design tools did you use when you were working on this project?. Patrick Sarran : I simultaneously use the software Shark and my cabinet maker workshop. .Frank Scott: What is the most unique aspect of your design?. Patrick Sarran : This unique design results from consideration of the end user's needs, as well as the possibilities offered by new woodworking processes. These designs have a simple exterior, as-well as conserving its technical interior. .Frank Scott: Who did you collaborate with for this design? Did you work with people with technical / specialized skills?. Patrick Sarran : I took the advise of the room director of Michel Sarran restaurant, Arnaud Ducroux. .Frank Scott: What is the role of technology in this particular design?. Patrick Sarran : I Moulded composite table tops under a vacuum, a technique derived from the aerospace manufacturing. I have worked out a process to inlay the female component of the bracket flush into the top. The brackets are cut using a laser machine and they are then folded using a digital press. .Frank Scott: Is your design influenced by data or analytical research in any way? What kind of research did you conduct for making this design?. Patrick Sarran : Moulding composite table tops under vacuum is a technique derived from the aerospace manufacturing. It enables the production of diameters up to 2.2m. I have worked out a process to inlay the female part of the bracket flush into the tops. The brackets are cut using a laser machine. They are then folded using a digital press. These modern techniques allow for small quantity production without investing in expensive stamping tools. I learned all these techniques through data research completed by experimentations in my workshop. For example the precise design mounting bracket had to be adapted to the capacities of the subcontractor that I finally chose, with the goal to minimise the cost. The piece exhibited at the MOOD of Como, in June 2016 used the second prototype of the mounting bracket, which it is not the final design .Frank Scott: What are some of the challenges you faced during the design/realization of your concept?. Patrick Sarran : It was a race against time. In June 2014 I had the main idea for the legs and table tops. I still had to invent a junction piece, both practical and affordable for small-scale production. In January I rented a stand for QUISO at Equip'hôtel fair. In July I was put forward for an Equip'innov award. The exhibition opened on 22nd November with a new challenge, to demonstrate the efficiency of the product within the restricted area of the stand. Patrick Sarran managed to successfully present four tables at the fair and to win the award. .Frank Scott: How did you decide to submit your design to an international design competition?. Patrick Sarran : One day, I found the proposal to participate to A'Design Award in my mail box. I did not know this competition. After I read the rules and the methodology of the contest, I told myself, why not? .Frank Scott: What did you learn or how did you improve yourself during the designing of this work?. Patrick Sarran : I improved my 3D design by using Shark software. I develop methods allowing me to mold large table tops of diameter up to 2,2 m and inlay mounting bracket flush to the top. .Frank Scott: Any other things you would like to cover that have not been covered in these questions?. Patrick Sarran : No .
Patrick Sarran-Ilok Removable Tables Images:
End of the article, click here to go back to previous page, or alternatively go back to Big Architects homepage.


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Chemistry is a fundamental science that impacts all aspects of one's life. A bachelor's degree in Chemistry is an excellent preparation for many careers in science, industry, government, or commerce. Chemistry majors will prepare for pre-professional programs such as graduate, pharmacy, medical, dental, or veterinary schools. A student that graduates with a bachelor's degree in Chemistry will have developed practical, analytical, problem-solving, presentation, and communication skills. This exciting and challenging field can lead to a successful future.
Dr. Jerry Easdon
Organic Chemistry
Professor of Chemistry and Nettie Marie Jones Chair of Chemistry
Dr. Kenny Garrison
Analytical Chemistry
Professor of Chemistry
Dr. Carol Breaux
Physical Chemistry
Associate Professor of Chemistry
The knowledge gained through the study of chemistry opens many career pathways. The following is a list of some career options that could be considered with a chemistry degree.
The Chemistry major at College of the Ozarks culminates in three semesters of research during the student's junior and senior years.
Topics of current research include:
Students often report their research results at national and regional chemistry meetings.
Chemistry majors and minors have the opportunity to work in the Chemistry department. This is an excellent source of on-the-job training as students have the opportunity to serve by assisting and preparing labs, tutoring students, grading papers, managing hazardous waste, and promoting lab safety.
The Chemistry department occupies the third floor of the Pfeiffer Science building. The department has three fully equipped laboratories, including a general chemistry lab, an analytical lab, and an organic lab. The laboratories house a gas chromatograph and a gas chromatograph/mass spectrometer, an infrared spectrometer, a high pressure liquid chromatograph, gel electrophoresis and capillary electrophoresis instruments, a bomb calorimeter, a fluorometer, two ultra-violet/visual scanning spectrometers, an electrochemical detector, two rotary evaporators, an atomic absorbance spectrometer, a defractometer, and a nuclear magnetic resonance spectrometer. All three laboratories have proper safety equipment.
Also available in the Chemistry department is a computer lounge. Available software allows three dimensional and computational modeling of compounds and the ability to predict experimental results. Data from the lab can be processed and interpreted by the computers.
Chemistry Club is a very active club on campus that participates in homecoming activities, chemistry shows, graduate school visits, chemistry tutoring, highway cleanup, and other activities throughout the school year.
Sigma Zeta is an honor society for mathematics and science students.
Students participating in undergraduate research attend and present their research at American Chemical Society regional and national meetings and the Missouri Academy of Science. Research students in the Chemistry department at College of the Ozarks have consistently won awards at the annual Missouri Academy of Science.
Chemistry students and professors participated in the Silver Dollar City annual Science Day.
© 2020 College of the Ozarks®
100 Opportunity Ave.
Point Lookout, MO 65726
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Lab School (K-12)
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Friday, May 29, 2020 3:20 PM
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The New York Times on Sunday outlined legal methods used by Cupertino, California-based Apple to avoid paying billions of dollars in federal and state taxes.
One approach highlighted in the report: Even though the company is based in California, Apple has set up a small office in Reno, Nevada, to collect and invest its profits. The corporate tax rate in Nevada is zero. In California, it's 8.84 percent.
While many major corporations try to reduce their tax bills, technology companies like Apple, Google Inc., Microsoft Corp. and others have more options to do so.
And what have we seen as a result of Apple
Otherwise, we have nothing. And that's the problem here. Big corporations come here to Nevada to avoid paying taxes, and we have nothing to gain from it.
Yet as Apple hides its corporate profits in Reno, it actually hires people in Cupertino. And there's a reason for that. It's because Silicon Valley is full of top notch schools that are full of inquisitive students, tech companies there always have a rich pool of highly skilled workers to dip into and hire.
While UNR and Washoe County are trying to create the same kind of synergy in Reno, their possibilities are more limited simply because UNR hasn't been allowed to grow into another Stanford or UC Berkley. Instead, we've had to argue over how much to cut from both K-12 and higher education.
We clearly suffer went we don't invest in the basics, like public education. And Nevada has clearly suffered as the result of underfunding our schools. There are just certain benefits that good education provides and unfair tax codes can not... You know, benefits like jobs and stable communities.
Perhaps Silicon Valley tech giants like to hide their corporate profits here in Nevada, but we're not really reaping any rewards from their tax evasion. Rather, we continue to deny ourselves a chance to create our own version of Silicon Valley by denying our state the revenue we need to properly fund public education. While it's nice to know Apple has an office in Northern Nevada, it would be nicer if we had the kinds of well paying high tech jobs that continue to go elsewhere.


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Keefe Jackson Quartet – Seeing You See (CF 176)
Keefe Jackson, a saxophonist and clarinetist, seems to fit in well in his adopted hometown of Chicago, Ill. He's even recorded several albums for that town's landmark jazz label, Delmark. And Seeing You See, his first for the Portuguese label Clean Feed, has a crisp, nimble sensibility that touches on two of the Windy City's most elegant exports.
First, there's a hint of Clifford Jordan-esque hard-bop in Jackson's melodies, which he plays in unison with trombonist Jeb Bishop ("Maker"). Second—and most important—is the aesthetic connection that Jackson makes with Chicago's free-jazz tradition. Jackson is a more conservative player than, say, Roscoe Mitchell or Anthony Braxton—two of the city's most intrepid saxophonists—but his improvisational efforts display a well-organized logic that owes a lot to the Chicago school ("How-a-low").
In between heads, the Jackson quartet, which also features bassist Jason Roebke and Noritaka Tanaka, goes out without going too far out. Jackson has a tone that, while occasionally crackling with un-tethered energy, is well rounded and seldom squawky. He is an excellent complement to Bishop, for whom a muted growl is as extreme as it gets. Underlying the brass interplay—which manages to be both bluesy and pointillistic—is a rhythm section that gives the feeling of swing even when unconnected to a regular time signature ("If You Were"). These guys do what seems to come naturally to Chicago-based outfits: They make freedom sound friendly.


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Whetstone Inn
...Not the least of Vermont's blessings is that it may refresh urbanized senses, renewing enjoyment of the whole experience of living.
There is a magic about Vermont by which just being there is a most precious occupation. But that need not be the only activity to commend either the state or the Whetstone to you.
Marlboro itself is a Vermont idyll, nearly atop the Green Mountains as they rise to the west of the Connecticut River Valley.
The village is the tiny centerpiece of a hilly countryside which blazes forth each fall; turns soft emerald in spring; and is the winter wonderland of verse and lore when the snow comes.
Down the road apiece from the Inn and the village lies Marlboro College, quickening country life. On its campus, the internationally celebrated "music from Marlboro" originated, and each year continues on, sweetening the summer weeks.
From Marlboro — to the north, west or south — many of New England's attractive villages are within easy driving distances of the Whetstone, making it a convenient hub for exploring much of southern Vermont.
In minute and mile, especially as these are measured in the open spaces of America, these locales are but moments apart, though each may enchant away hours for a leisurely traveler. While their appeal may often be redundant, each village is yet singular in radiating a special something about the American experience — past and present.
Treasured by those for whom Vermont is as much a state of mind as a state in the Union, these are locales which should not be missed by those becoming acquainted with the state.


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CCleaner v2.27.1070
- Added support to Wipe MFT Free Space.
- Added cleaning for Windows Explorer breadcrumb bar.
- Added cleaning for Opera beta versions.
- Added option to turn off CCleaner jumplist tasks on Windows 7.
- Added menu option to Registry Cleaner to add key to exclude list.
- Improved support for SeaMonkey 2.0.
- Improved Windows 7 Taskbar progress accuracy.
- Improved minimize to system tray functionality across all platforms.
- Improved Opera cleaning by including opcache and temporary_downloads folder.
- Improved performance of Compact database routines.
- Improved Wipe Free Space code to avoid locks.
- Improved security when deleting files.
- Minor GUI and interface improvements.
- Minor bug fixes.
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Bloomberg – Hedge funds cut bets on a commodity rally to a four-year low on signs of surplus supply in everything from coffee to zinc before Goldman Sachs Group Inc. said prices had fallen too far and investors should buy.
Speculators reduced net-long positions across 18 U.S. futures and options in the week ended March 5 by 9.2 percent to 405,885 contracts, the lowest since March 2009, U.S. Commodity Futures Trading Commission data show. They are the most bearish on copper in four years, and are also betting on declines for coffee, hogs, sugar, soybean oil, wheat and natural gas.


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Baby naps can be a restful time for you and your little one — but the process of getting your baby to sleep during the day can be just the opposite. Understand the basics of baby naps.
It takes awhile for newborns to develop a sleep schedule. During the first month, babies usually sleep and wake round-the-clock, with relatively equal periods of sleep between feedings.
As babies get older, baby nap times typically lengthen and become more predictable. For example:
Remember, however, that every baby is different and baby nap schedules can vary considerably.
To ease your baby into nap time:
It's common for babies to cry when put down for sleep, but most will quiet themselves if left alone for a few minutes. If the crying lasts longer than a few minutes, check on your baby and offer comforting words. Then give him or her time to settle again.
If your baby wakes shortly after you put him or her down for a nap and isn't wet, hungry or ill, try to be patient and encourage self-settling. You might gently pat your baby, offer a massage or breast-feed for a short time.
Also, keep in mind that babies are often active during sleep — twitching their arms and legs, smiling, sucking, and generally appearing restless. It's easy to mistake a baby's stirrings as a sign that he or she is waking up or needs to eat. Instead of picking up your baby right away, wait a few minutes to see if your baby falls back to sleep.
It depends on how well your baby is sleeping at night.
Some babies confuse their days and nights — sleeping more during the day than at night. One way to set your baby straight is to limit daytime naps — especially those in the late afternoon — to no more than three or four hours each. If your baby is napping for too long at the end of the day, it can make it harder for him or her to fall asleep at bedtime.
Some babies and older children go through periods during which they refuse to nap — even though they still need the rest. If this happens, try adjusting your baby's bedtime. Making bedtime a little earlier or later can sometimes help a baby nap better during the day.
Helping your baby get the right amount of daytime sleep isn't always easy. Don't feel bad if some days are more challenging than others. Remember to look and listen for the signs that your baby is tired and try to keep his or her nap routine consistent.
If you have questions or concerns about your baby's napping schedule, talk to his or her doctor.
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Colombia's Congress approved a new peace deal with FARC rebels late on Wednesday, despite objections from former President and now Senator Alvaro Uribe, who said it was still too lenient on the insurgents who have battled the government for 52 years, NBC News reported.
The agreement was approved in the lower house by 130-0, a day after the Senate ratified it 75-0. Lawmakers from Uribe's Democratic Center party left the floors of both houses in protest just before voting began.
The new agreement to end Latin America's longest insurgency was put together in just over a month after the original pact — which allowed the rebels to hold public office and skip jail — was narrowly and unexpectedly defeated in an Oct. 2 referendum.
U.S. & World
Stories that affect your life across the U.S. and around the world.
The government and FARC worked together in Cuba for four years to negotiate an end to the region's longest-running conflict that has killed more than 220,000 and displaced millions in the Andean nation.


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I've yet to see any proof that we actually need a remake of Carrie. Yes, interesting people like Boys Don't Cry director Kimberly Peirce and Julianne Moore are involved, and sure, the original Brian de Palma film is nearly 40 years old, and horrible teenage girls have only gotten more horrible in the last few decades. But every trailer and TV ad and motion poster for the movie seems hellbent on only showing off the most famous scenes from the first film-- the blood-soaked prom, the religious chanting, the crazy-eyed Carrie (this time played by Chloe Moretz) taking her revenge. Even if you've never seen the original, you're familiar with all this stuff. So what's new?
I haven't seen the actual movie yet, but I'll tell you one thing that's new in trying to sell this thing: viral marketing. The above video, posted to YouTube yesterday, reveals an elaborate prank that went down in a West Village coffee shop, in which a little bit of special effects magic made a lot of innocent coffee drinkers believe a young woman had lost her telekinetic shit in the middle of her morning latte. Unlike many viral efforts that try to pass themselves off as real, this one is upfront about being a coordinated studio effort, but the fun is in watching the surprised victims who had no idea they were part of a viral effort. Obviously these people were debriefed afterwards and signed a release form for their faces to appear here, but the look of surprise on their faces-- for everyone from the construction worker to the sheepdog-- is genuine and priceless.
Will this make anyone go see Carrie when it comes to theaters next Friday? Probably not. There's a big difference between seeing the same story about the world's most famous telekinetic teen and encountering another one, completely by accident, in your local coffee shop. But kudos to Carrie distributor Screen Gems, or whoever was responsible for cooking up this stunt, for finding a way to do movie viral marketing that perfectly toes the line between mystery and straight-up obnoxious.
Here's the actual, more traditional trailer for Carrie below, pig's blood included.


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Evening dress with floral patternItem #: 660245
Evening dress with floral pattern
Super Chic 50s Dress by Living Dead Souls London!
The beautiful pinup dress is a top fashion rockabilly dress for various Rock n Roll events or elegant evening events.The summer dress missed any Rockabella an exceptional figure and a stunning appearance.
The evening dress is a form-fitting Pencil dress in black with a red floral print top which is in the center, decorated with a pretty trim, made of fabric covered buttons.The super chic pin-up dress goes up over the knee and thus underlines the elegant style.Next to it is a slight gathering that gives the rockabilly dress an extravagant look.The stretchy size evening dress features adjustable straps and a trendy fabric belt.On the back is a zip.
You can combine the pencil dress with Inamagura Block Heel Brogues and the Poizen Industries Gothic Bag Black .
Material: 97% Cotton, 3% Elastane


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This time of year sees an increase in swimming pool usage, as many find ways to beat the summer heat. The increased use of pool and spas means paying closer attention to the quality of water that you are using. Pool and spa water is often vulnerable to environmental conditions and can require regular maintenance. During the month of August, Filtersfast.com is offering customers an additional 10% off of our already low price on any Filbur Pool and Spa filter. Filbur Manufacturing produces pool and spa filters that are number one in construction and quality. According to Joe Marcotte, National Sales Manager for Filbur:
"Our filters are produced to exact OEM specifications because we are the industry's leading OEM cartridge supplier. We maintain strict specifications on all replacement cartridges and grids. We use industry proven Reemay Media with the proven Microban Antimicrobial technology. This prevents harmful bacteria from growing on the cartridge. Less bacteria results in a reduction of foul odors, algae, black mold and other harmful contaminants which foul a cartridge."
Filbur filters are easier to clean than any other filter in the marketplace. They also feature Filbur Freedom™ Antimicrobial Pool and Spa Filter Cartridges that prevents harmful bacteria from growing on the cartridge. The Antimicrobial Protection lasts as long as the cartridge filters.
For a complete list of Filbur products available on Filtersfast.com, visit our Filbur category page. Take advantage of this exciting offer today. Filbur pool and spa filters ensure better water quality in your pool and spa.


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For the 2016 *fiscal year, Judge Maryann Lunderman has disposed 2 cases at the Office of Disability Adjudication and Review (ODAR) in Albuquerque, New Mexico. Out of those 2 dispostions, 0 were dismissed, 0 were approved and 2 were denied. This means that the percentage of dispositions that Judge Lunderman has approved in Albuquerque for the 2016 fiscal year is 0%. The information below for Judge Maryann Lunderman was last updated on 6/11/2019.
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A 45-year-old man from Texas was rescued in darkness Thursday night following a fall while hiking near the Gem Lake Trail, in the Lumpy Ridge portion of Rocky Mountain National Park just north of Estes Park.
Rangers say they were contacted about the man having fallen and reached him at 10:30 p.m. about a mile up the trail from the Gem Lake trailhead. They said he was off trail in a difficult area to access. He had fallen about 15 feet and had numerous injuries, including a serious lower leg injury.
It took 10 park staff to extricate the man from the steep, rocky formation where they found him. They then wheeled the man down the trail on a litter and reached the trailhead about 3 a.m. Friday.
The man was then transported by ambulance to Estes Park Medical Center.