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Likhitsathian, S.
Skulphan, S.
Benefits of Brief Group Cognitive Behavioral Therapy in Reducing Diabetes-Related Distress and HbA1c in Uncontrolled Type 2 Diabetes Mellitus Patients in Thailand
Kongprai Tunsuchart
Peerasak Lerttrakarnnon
2,* ,
Kriengkrai Srithanaviboonchai
1,3,
Surinporn Likhitsathian
4 and
Sombat Skulphan
Department of Community Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
Research Institute for Health Sciences, Chiang Mai University, Chiang Mai 50200, Thailand
Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
Department of Psychiatric Nursing, Faculty of Nursing, Chiang Mai University, Chiang Mai 50200, Thailand
Int. J. Environ. Res. Public Health 2020, 17(15), 5564; https://doi.org/10.3390/ijerph17155564
Received: 17 June 2020 / Revised: 23 July 2020 / Accepted: 30 July 2020 / Published: 1 August 2020
(This article belongs to the Special Issue Burden of Noncommunicable Diseases: From Individual to Society)
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This study evaluated the short-term efficacy of brief group cognitive behavioral therapy (BG-CBT) in reducing diabetes-related distress (DRD), lowering hemoglobin A1c (HbA1c), improving food consumption behavior, increasing physical activity, and improving medication adherence behavior. A quasi-experimental pretest/post-test design with follow-up assessments was used with an experimental and a control group. Participants were patients with uncontrolled type 2 diabetes mellitus (T2DM) and moderate or high diabetes-related distress recruited from the Diabetes Mellitus Clinic of Hang Dong Hospital, Chiang Mai, Thailand. Fifty-six eligible participants were purposively selected and enrolled, then randomly assigned to either the BG-CBT group or the control group. The BG-CBT group received six brief weekly sessions of cognitive behavioral group therapy, while the control group received conventional care. Baseline data were collected at week 0 (pretest) and at week 6 (post-test), including food consumption behavior, physical activity, and adherence to medication regimes, as well as a blood examination to determine levels of HbA1c at the week 12 follow-up. DRD was assessed using the Diabetes Distress Scale (DDS-17) and analyzed using descriptive statistics, including pair t-test and independence t-test results. The BG-CBT had a significant effect on the amelioration of diabetes distress, improvement of food consumption behavior, and reduction of HbA1c levels, demonstrating the effectiveness of BG-CBT in maintaining diabetes control in people with T2DM-related distress.
cognitive behavior therapy; diabetes-related distress; type 2 diabetes mellitus
Globally, diabetes mellitus is one of the most common metabolic disorders with a prevalence estimated to be 9.3% (463 million) and expected to rise to 10.9% (700 million) by 2045. The prevalence of impaired glucose tolerance is estimated to be 7.5% (374 million) in 2019 and is projected to reach 8.6% (548 millions) by 2045, with type 2 diabetes mellitus (T2DM) accounting for approximately 90% of that total [1]. In Thailand, the prevalence of T2DM is currently 9.9% of the adult population [2], higher than the global prevalence.
Many adults with T2DM experience a psychosocial burden and mental health problems associated with the disease [3]. The daily demands of people living with T2DM increase their risk of diabetes-related distress (DRD), a condition of stressful feelings associated with the challenges of managing diabetes and concerns related to diabetes complications [4].
DRD is a syndrome comprised of multidimensional components, including worry, conflict, frustration, and discouragement that can accompany living with diabetes [5]. The prevalence of DRD is reported to be 18–45%, with an incidence of 38–48% over 18 months [6]. High levels of diabetes distress can significantly impact medication adherence behavior and is linked to higher hemoglobin A1c (HbA1C) levels, lower self-efficacy, and poorer dietary and physical activity behaviors [7,8,9,10]. Previous studies have also reported that long-term DRD is associated with anxiety [11] and depression [12,13,14,15]. DRD has been shown to impact type 2 diabetes patients negatively through poor adherence to medication regimens and through reduced self-care [16,17]. A distinction has been drawn between DRD and depression, with research suggesting that DRD is more widespread [17]. The literature further suggests that DRD has a greater impact upon and is more closely associated with diabetes self-management and diabetes-related behavioral and biomedical outcomes than depression [8]. DRD is not a mental pathology or a common psychiatric disorder, which, when diagnosed, can be treated with medication [18]. Since DRD is linked to specific stressors, and much of diabetes distress is an expected reaction to a serious and chronic health-related stressor, it is viewed as part of the spectrum of diabetes, not as a separate clinical condition indicating psychopathology [17]. A primary goal is to reduce DRD in order to make it possible for patients to control their blood-sugar levels appropriately. However, to date no such programs have been developed for the management of DRD.
Cognitive behavior therapy (CBT) is a form of psychotherapy that can help reduce potentially detrimental emotions, behavior, and physiology physiological responses [19]. It is widely used to treat psychiatric disorders, psychological problems, medical problems with a psychological component, comorbid psychiatric disorders, difficulties in adjustment to illness, poor adherence to treatment and other illness-related behavioral problems [20]. CBT has been applied in diabetic patients with depression—e.g., Safren et al. [21] and Aguilera et al. [22]—including diabetic patients with DRD. Amsberg et al. [23] and Cummings et al. [24] report experimental studies of diabetic patients who could not control their blood-sugar level and who also had DRD found significant improvement in HbA1c levels and reduction of diabetes-related distress among the CBT intervention group compared with the control group. Similarly, Seyed et al. [25] conducted a quasi-experimental study of diabetic patients who could not control their blood-sugar levels and who had DRD. Their results indicated that CBT had significant effects on the amelioration of diabetes distress and on levels of HbA1c.
Although there is evidence that CBT can improve behavioral outcomes and may also improve HbA1c in patients with T2DM and DRD, including a number of studies using CBT in DRD therapy in patients with T2DM who could not control their blood-sugar levels, no such studies have been conducted in Thailand. The objective of this study was to develop and evaluate a Brief Group Cognitive Behavior Therapy (BG-CBT) program specifically aimed at reducing DRD, improving food consumption behavior, increasing physical activity, improving medication adherence, and controlling blood-sugar levels among Thai T2DM patients.
A quasi-experimental study design was used to test the efficacy of the BG-CBT intervention. The study compared a 6-session weekly brief group cognitive behavioral therapy with conventional care control (general counseling) using a pretest/post-test design with post treatment follow-up.
2.2. Participants
Participants were recruited from the DM clinic in Hang Dong Hospital, Chiang Mai Province, Thailand (Figure 1). Inclusion criteria were T2DM, age ≥ 18 years, HbA1c > 7, and DDS-17 score ≥ 2. Exclusion criteria were an established diagnosis of an advanced disease (e.g., advance heart failure, end stage renal disease, and metastatic cancer) or the presence of alcoholism, Alzheimer's disease, dementia, cognitive impairment, a major psychiatric or communication disorder, and inability to communicate in the Thai language.
The study was comprised of 56 participants. The generally accepted standard for a quasi-experimental study is a minimum of 30 individuals with 20–25 participants for each independent variable [26]. Twenty-eight of the participants were randomly assigned to the experimental group, and the other 28 were assigned to the control group. The groups were matched for gender, age, DDS-17 score and HbA1c level.
2.3. Brief Group Cognitive Behavior Therapy (BG-CBT) Intervention Program
The 6-session BG-CBT program was developed by the investigators and was based on Beck's (2011) work [19]. Each weekly session was 60–90 min long. The program was reviewed by a panel of three CBT experts: one psychiatrist and two psychiatric nurses. The objectives of the first session included building relationships and understanding the connections between stimuli, thoughts, emotions, behavior, and physiology. The second session focused on identifying stimuli that promote inappropriate behavior and methods to modify that behavior including finding ways to manage stimuli. The third session attempted to identify inappropriate behavior affecting emotions, thoughts, and physiology, as well as the influence of external stimuli, including searching for methods to change inappropriate behavior. The forth focused on negative automatic thoughts. In the fifth, negative automatic thoughts to be improved or modified were selected. In the sixth and final session, knowledge and understanding of what had been learned was summarized, including systems for monitoring achievement of the mutually established goals.
Prior to leading the BG-CBT sessions, the therapist participated in a three-day brief cognitive behavioral group therapy intervention training program and also received approximately six hours of guidance by instructors of the Faculty of Nursing, Chiang Mai University, who are experts in CBT. The guidance included observation and postsession feedback, as well as case conferences. In addition, members of the research study team randomly observed the interventionist therapists during one or more of the sessions.
2.4. Outcomes and Measurement
2.4.1. Primary Outcomes
Diabetes-related distress (DRD) was evaluated using the Diabetes Distress Scale (DDS-17) developed by Polonsky et al. [27], which had been translated into the Thai language by Kattika [5]. The questionnaire, which has an alpha coefficient of 0.95, is composed of 17 items and measures four critical dimensions of distress: emotional burden, regimen distress, interpersonal distress, and physician distress. Each item dimension is rated on a 6-point scale from 1 (no problem) to 6 (serious problems). Each dimension is interpreted as the mean score of each subcomponent: ˂2 = little or no distress, 2–2.9 = moderate distress, and ≥3 a high level of distress.
2.4.2. Secondary Outcome
Food Consumption Behavior, the survey of food consumption behavior questionnaire developed by the Bureau of Nutrition, Department of Health, Ministry of Public Health, Thailand was used to assess the food consumption behavior of the participants. The Cornbrash's alpha coefficient of the questionnaire is 0.75. The participation in each of the 14 survey items is divided into 3 frequency levels: daily (5–7 days per week—5 points), occasional (1–4 days per week—3 points), and never (0 points). The maximum total score is 100 points (very good habits), 80–99 (good habits), 60–79 (moderately good habits), <60 points (food consumption habits need improvement).
Physical activity was assessed using the Global Physical Activity Questionnaire (GPAQ) Version 2, developed by Armstrong et al. [28] and translated into the Thai language by Vanida [29] The questionnaire, with an alpha coefficient of 0.77, is composed of 16 items divided into 4 groups: group 1—occupational activities (6 items); group 2—activities related to traveling from one place to another (3 items); group 3—activities to do during free time for relaxation, resting, or recreation (6 items); and group 4—sitting and lying down behavior measured in metabolic equivalents (METs) (1 item).
Medication taking behavior evaluation of medication adherence behavior was measured using the Thai language Medication Taking Behavior Scale (MTB-Thai) [30]. The alpha coefficient of the questionnaire was 0.76. The questionnaire covered 6 areas: (1) forgetting to take medicines, (2) not taking medicines at the times prescribed, (3) stopping medicines because of adverse drug reactions, (4) stopping medicines because of getting better, (5) stopping medicines for other reasons, and (6) adjusting dosage regimens. Each item was rated on a scale of 1 to 4, then the ratings were combined. Scoring was as follows: high drug adherence = 24, medium drug adherence = 22–23, and low drug adherence ≤ 21.
Blood hemoglobin A1C (HbA1c) level was measured by ion-exchange High-Performance Liquid Chromatography (HPLC) at the Hang Dong Hospital Laboratory, Chiang Mai Province, Thailand.
All participants provided written informed consent prior to participation in the study. The study protocol was approved by the Research Ethics Committee of the Faculty of Medicine, Chiang Mai University, Thailand (no. 357/2016).
Demographic variables were analyzed using descriptive statistics; differences between groups were evaluated using the independent t-test. Differences within groups were analyzed using the paired t-test. Between-group comparisons were made using the independent t-test. p-Values < 0.05 were regarded as statistically significant.
The 56 participants in this study (experimental group = 28, control group = 28) had an average age of 56.04 years (±8.33). Most (58.9%) were female and most had comorbidities (73.2%) or DM complications (46.4%). The average duration of their T2DM was 8.87 ± 6.79 years. The mean HbA1c level, diabetes-related distress, food consumption behaviors, physical activity, and medication taking behaviors were 9.56 ± 1.86, 2.46 (± 0.44), 49.00 (± 8.04), 76.73 (± 76.85), and 21.75 (± 1.98), respectively. There were no statistically significant differences between the two groups in age, gender, DM complications, comorbidities, duration of diabetes, DDS-17 score, HbA1c level, physical activity level, or medication taking behavior score. There was, however, a significant difference in food consumption behavior at baseline (Table 1).
Paired t-test analysis of pretest and post-test results in the experimental group and control group found a statistically significant difference in DDS-17 scores (p = 0.00). T2DM patients with DRD in the experimental group had improved food consumption behavior scores (p = 0.00) and HbA1c levels (p = 0.00) after receiving BG-CBT. In the control group, there was no statistically significant change in DDS-17 scores, consumption behavior scores, physical activity scores, medication behavior scores or HbA1c levels between pretest and post-test. This may be because there were no significant differences in changes in physical activity or medication taking behavior between the groups (Table 2).
Table 3 shows the changes in the primary and secondary outcome measures between the experimental group and the control group from baseline to 6 weeks (3 months for HbA1c) after receiving BG-CBT. The primary outcome—reduction in DRD as measured by DDS-17 score in the experimental group compared to the control group—reached statistical significance. For the secondary outcomes—consumption behavior and HbA1c levels—there were significant differences between the groups (p = 0.003 and p = 0.009, respectively). There was no difference in the mean difference for physical activity or medication taking behavior score between the experimental group and the control group.
This first experimental study in Thailand found that BG-CBT could significantly reduce DDS scores (from 2.47 ± 0.41 to 2.08 ± 0.49) and HbA1c levels (from 9.44 ± 1.63 to 7.34 ± 1.10), as well as improve food consumption behavior scores (from 45.14 ± 7.37 to 50.21 ± 7.03) at the six-week follow-up (3 months for HbA1c levels) compared to the control group. There was improvement in the physical activity and medication taking behavior scores (from 69.90 ± 57.43 to 76.89 ± 61.39 and from 21.50 ± 2.03 to 21.89 ± 1.97, respectively), although the differences were not statistically significant. These results are consistent with a study by Seyed et al. [25], which reported on cognitive behavioral therapy (CBT) for diabetes patients and found that the pre-test to post-test changes in blood-sugar levels were significantly different in the two groups (experimental and control groups), and the level of diabetes distress in the experimental group before and after showed a difference, from 2.96 before therapy to 2.18 after therapy, which means that the level of diabetes distress decreased after therapy, which can significantly reduce blood-sugar levels and the degree of diabetes distress. There have been few studies explicitly comparing food consumption behavior before and after CBT in patients with type 2 diabetes, but research has found that using CBT results in improved dietary quality [31]. Most importantly, CBT has been shown to clarify misunderstandings that could lead to emotional distress and problem behavior [20].
This study shows that BG-CBT can reduce DRD, HbA1c levels, and improve food consumption behavior significantly compared to mean change of experimental group and control group conventional care alone. These results are consistent with a previous systematic review of randomized controlled trials of psychological interventions to improve glycemic control in people with type 2 diabetes. Eight of the twelve trials studies in that meta-analysis were involved in CBT and all eight reported improvement in long-term glycemic control and reduction of psychological distress in the CBT groups [32]. Similarly, several previous studies, e.g., Cummings et al. [24], evaluated the effect of cognitive behavioral therapy (CBT) plus lifestyle counseling in primary care on HbA1c levels in rural adult patients with T2DM with comorbid depressive and/or medication adherence behavior-related distress symptoms. The Cummings study found that patients in the intervention group showed significant improvement in HbA1c levels and greater improvement in DRD compared to the group receiving standard care. A study by Seyed et al. [25] on the effectiveness of combined group Cognitive Behavioral Therapy (CBT) in improving diabetes distress and glycemic control among 60 adults with type 2 diabetes found that reduced HbA1c levels were correlated with a reduction in DRD. That study found that the CBT had a significant effect on the amelioration of diabetes distress. Studies by Amsberg et al. [23] and Van et al. [33] of the effects of CBT on HbA1c and DRD in type 1 diabetic patients found significant differences in HbA1c and DRD between the experimental (CBT) group and the control group. In contrast, a randomized controlled trial by Welschen [34] on the effects of a cognitive behavioral treatment when added to managed care on consumption behavior in patients with type 2 diabetes found no statistically significant differences in eating behavior at three post-treatment time points. Similarly, a study of CBT by Yomogida et al. [35] found no statistically significant change in the diets of type 2 diabetes patients.
The present study found no significant differences in medication taking behavior or physical activity between the experimental group and control group, although medication taking behavior did improve in the experimental group. A study by Cummings et al. [24] found that patients receiving CBT intervention evidenced significantly greater improvements in medication adherence than those receiving the usual care. There may be other factors, however, that affect medication taking behavior. For example, in this study data were not collected on the patients' medication knowledge [36], education level, income, perceived treatment inefficacy, treatment complexity or on hypoglycemia [37]. This study did find increased physical activity in both the experimental group and the control group, but the difference between the groups was not significant. That finding is consistent with a previous study that also reported no statistically significant differences in physical activity between the CBT treatment group and the control group [35]. In contrast, a systematic review of research reports on cognitive therapies concluded that the therapies probably lead to a moderate increase in physical activity compared to no intervention or to usual care, suggesting that cognitive therapy may have a slight impact on physical activity [38].
An advantage of brief CBT is that, because it is a group intervention, i.e., it treats several people at one time, it is more cost-effective and, thus, potentially more accessible to a greater number of individuals in need of assistance. Additionally, patients enjoy rapid treatment gains, which may improve the credibility of the treatment and, as a consequence, increase their motivation for further change [39]. Brief CBT also provides an opportunity for patients to learn from the experiences and homework tasks of other group members—so-called vicarious learning. Additionally, groups can be less stigmatizing for some and any stigma that does arise can be reduced by the 'normalization effect' of meeting others with the same problem. CBT groups provide a ready 'audience', which can provide exposure and the opportunity for behavioral experiments. The views of other group members often carry more weight or are viewed as more 'neutral' than the views of the therapists, although the therapists' views are useful for cognitive challenging. CBT groups can also be beneficial for people who struggle with a one-to-one professional relationship, e.g., individuals who are likely to form a regressive and very dependent relationship with the therapist. Other patients who feel uncomfortable with a one-to-one professional relationship in therapy may prefer group work [40].
A limitation of this study was that it was not randomized, so results might have been affected by unknown confounding variables. There may also have been contamination of the sample (sampling bias), because the study involved a group of patients treated at the same diabetes clinic. A randomized control trial is warranted to confirm the effectiveness of a brief CBT program. Also, the results were monitored for only a short period of time, so the long term sustainability of the effects were not determined. The study has not collected data on the types of drugs that patients used to treat diabetes: some drugs (e.g., metformin) may affect cognitive deficit [41,42]. Therefore, future studies should collect data on medications used to treat diabetes. The effect of this intervention for older adults with T2DM has not been shown in this study and should be studied further.
BG-CBT is effective in reducing DRD, lowering HbA1c levels and improving food consumption behavior in Thai populations compared to standard treatment. The potential importance of the findings suggests that a larger-scale study be conducted, incorporating further methodological refinements, e.g., expanding the locations of sample collection, including a larger sample and conducting an extended follow-up assessment.
Conceptualization, K.T., P.L., K.S., S.L., and S.S.; methodology, K.T., P.L., K.S., S.L., and S.S.; software, K.T.; validation, K.T. and P.L.; formal analysis, K.T. and P.T.; resources, K.T., P.L., and S.S.; data curation, K.T., P.L., and S.S.; writing—original draft preparation, K.T. and P.L.; writing—review and editing, K.T., P.L., K.S., and S.S.; visualization, K.T. and P.L.; supervision, P.L. and S.S.; project administration, P.L.; funding acquisition, P.L. All authors have read and agreed to the published version of the manuscript.
The Faculty of Medicine, Chiang Mai University provided funding for this study (Grant No. 050/2017).
The authors would like to thank the Faculty of Medicine and the Faculty of Associated Medical Sciences, Chiang Mai University, Thailand for providing support. We would also like to thank all the participants in this study.
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Ahmad, N.S.; Ramli, A.; Islahudin, F.; Paraidathathu, T. Medication Adherence in Patients with Type 2 Diabetes Mellitus Treated at Primary Health Clinics in Malaysia. Patient Prefer. Adher. 2013, 7, 525. [Google Scholar]
Polonsky, W.H.; Henry, R.R. Poor Medication Adherence in Type 2 Diabetes: Recognizing the Scope of the Problem and its Key Contributors. Patient Prefer. Adher. 2016, 10, 1299. [Google Scholar] [CrossRef] [PubMed][Green Version]
Denison, E.; Underland, V.; Mosdøl, A.; Vist, G.E. Cognitive Therapies for Increasing Physical Activity. Knowledge Centre for the Health Services at the Norwegian Institute of Public Health (NIPH). 2016. Available online: https://fhi.brage.unit.no/fhi-xmlui/bitstream/handle/11250/2436234/Denison_2016_Cog.pdf?sequence=1 (accessed on 30 July 2020).
Bond, F.W.; Dryden, W. Handbook of Brief Cognitive Behaviour Therapy; Wiley: Hoboken, NJ, USA, 2002. [Google Scholar]
Whitfield, G. Group Cognitive–Behavioural Therapy for Anxiety and Depression. Adv. Psychiatr. Treat. 2010, 16, 219–227. [Google Scholar] [CrossRef]
Guo, M.; Mi, J.; Jiang, Q.-M.; Xu, J.-M.; Tang, Y.-Y.; Tian, G.; Wang, B. Metformin may Produce Antidepressant Effects through Improvement of Cognitive Function among Depressed Patients with Diabetes Mellitus. Clin. Exp. Pharmacol. Physiol. 2014, 41, 650–656. [Google Scholar] [CrossRef]
Zemdegs, J.; Martin, H.; Pintana, H.; Bullich, S.; Manta, S.; Marqués, M.A.; Moro, C.; Layé, S.; Ducrocq, F.; Chattipakorn, N.; et al. Metformin Promotes Anxiolytic and Antidepressant-Like Responses in Insulin-Resistant Mice by Decreasing Circulating Branched-Chain Amino Acids. J. Neurosci. 2019, 39, 5935–5948. [Google Scholar] [CrossRef][Green Version]
Figure 1. Flow chart of study procedure.
Table 1. Baseline characteristics of participants.
Experimental Group
Age (years) mean ± SD 58.18 ± 8.83 53.89 ± 7.34 56.04 ± 8.33 0.093
Gender (% female) 57.10% 60.70% 58.90% 0.813
DM complications (% present) 32.10% 60.70% 46.40% 0.326
Comorbidities (% present) 85.70% 60.70% 73.20% 0.713
Duration of diabetes (years) mean ± SD 10.34 ± 7.77 7.39 ± 5.40 8.87 ± 6.79 0.077
HbA1c% mean ± SD 9.44 ± 1.63 9.68 ± 2.09 9.56 ± 1.86 0.575
DDS-17 scores mean ± SD 2.46 ± 0.41 2.46 ± 0.47 2.46 ± 0.44 0.915
Physical activity mean ± SD 69.90 ± 57.43 83.56 ± 92.92 76.73 ± 76.85 0.511
Food consumption behavior score mean ± SD 45.14 ± 7.37 52.86 ± 6.81 49.00 ± 8.04 0.000
medication taking behavior score mean ± SD 21.50 ± 2.03 22.00 ± 1.94 21.75 ± 1.98 0.350
Table 2. Comparison of pretest and post-test within group means (paired t-test).
Experimental Group (n = 28), Mean (± SD)
Control Group (n = 28), Mean (± SD)
Post Intervention
DDS score 2.47 ± 0.41 2.08 ± 0.49 <0.001 2.46 ± 0.47 2.48 ± 0.80 0.817
Food consumption behaviors score 45.14 ± 7.37 50.21 ± 7.03 <0.001 52.86 ± 6.81 52.50 ± 5.07 0.777
Physical activity 69.90 ± 57.43 76.89 ± 61.39 0.176 83.56 ± 92.92 92.43 ± 109.88 0.372
Medication taking behaviors score 21.50 ± 2.03 21.89 ± 1.97 0.110 22.00 ± 1.94 21.46 ± 2.91 0.216
HbA1c% 9.44 ± 1.63 7.34 ± 1.10 <0.001 9.68 ± 2.09 8.97 ± 2.38 0.101
Table 3. Mean changes in outcomes from baseline to six-week follow-up (3 months for HbA1c levels).
Experimental Group (n = 28) Mean (± SD)
Control Group (n = 28) Mean (± SD)
p-Value Change
Mean Change
DDS score 2.47 ± 0.41 2.08 ± 0.49 −0.39 ± 0.47 2.46 ± 0.47 2.48 ± 0.80 +0.02 ± 0.62 0.006
Food consumption behaviors score 45.14 ± 7.37 50.21 ± 7.03 +5.07 ± 6.57 52.86 ± 6.81 52.50 ± 5.07 −0.36 ± 6.60 0.003
Physical Activity 69.90 ± 57.43 76.89 ± 61.39 +6.99 ± 26.64 83.56 ± 92.92 92.43 ± 109.88 +8.87 ± 51.67 0.865
Medication taking behaviors score 21.50 ± 2.03 21.89 ± 1.97 +0.39 ± 1.26 22.00 ± 1.94 21.46 ± 2.91 −0.54 ± 2.24 0.062
HbA1c% 9.44 ± 1.63 7.34 ± 1.10 −2.10 ± 1.53 9.68 ± 2.09 8.97 ± 2.38 −0.71 ± 2.21 0.009
Tunsuchart, K.; Lerttrakarnnon, P.; Srithanaviboonchai, K.; Likhitsathian, S.; Skulphan, S. Benefits of Brief Group Cognitive Behavioral Therapy in Reducing Diabetes-Related Distress and HbA1c in Uncontrolled Type 2 Diabetes Mellitus Patients in Thailand. Int. J. Environ. Res. Public Health 2020, 17, 5564. https://doi.org/10.3390/ijerph17155564
Tunsuchart K, Lerttrakarnnon P, Srithanaviboonchai K, Likhitsathian S, Skulphan S. Benefits of Brief Group Cognitive Behavioral Therapy in Reducing Diabetes-Related Distress and HbA1c in Uncontrolled Type 2 Diabetes Mellitus Patients in Thailand. International Journal of Environmental Research and Public Health. 2020; 17(15):5564. https://doi.org/10.3390/ijerph17155564
Tunsuchart, Kongprai, Peerasak Lerttrakarnnon, Kriengkrai Srithanaviboonchai, Surinporn Likhitsathian, and Sombat Skulphan. 2020. "Benefits of Brief Group Cognitive Behavioral Therapy in Reducing Diabetes-Related Distress and HbA1c in Uncontrolled Type 2 Diabetes Mellitus Patients in Thailand" International Journal of Environmental Research and Public Health 17, no. 15: 5564. https://doi.org/10.3390/ijerph17155564
Int. J. Environ. Res. Public Health, EISSN 1660-4601, Published by MDPI


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Q: Funções privadas via ajax - Code Igniter Estou utilizando o Code Igniter para criar um sistema web e para que o usuário não atualize a página perdendo que já está aberto eu utilizo todas as chamadas via ajax dentro de "módulos". O problema é que, se eu coloco uma função em um controlador como público o usuário pode chutar a URL e acessar a função sem permissão e se eu uso as funções como privadas, não consigo acessá-las através de chamadas em Ajax.
Alguém ai tem uma boa solução?

A: Você pode usar $this->input->is_ajax_request() da classe input:
if (!$this->input->is_ajax_request()) {
   exit('No direct script access allowed');
}

redpajama_set_name: RedPajamaStackExchange


text:
Q: Pandas: Does pd.read_excel() need Excel to be installed for it to work? I was wondering if pd.read_excel() needs Microsoft Excel to be installed on the computer for it to work? I'm not sure if my customer will have Excel installed or not so I don't want the program to break down if it is not available.
Thanks!

A: pandas's pd.read_excel uses xlrd package to read excel file.
So it wont need Microsoft Excel.


Moderate rain (total 17mm) heaviest on Thu night, then becoming colder with a dusting of snow on Fri morning. Freeze-thaw conditions (max 7°C on Thu afternoon, min -2°C on Sat night). Wind will be generally light.
A dusting of snow on Sun afternoon. Freezing level rising with drizzle on Tue afternoon. Freeze-thaw conditions (max 7°C on Tue afternoon, min -3°C on Sun morning). Wind will be generally light.
This table gives the weather forecast for Dôme des Pichères at the specific elevation of 1500 m. Our advanced weather models allow us to provide distinct weather forecasts for several elevations of Dôme des Pichères. To see the weather forecasts for the other elevations, use the tab navigation above the table. For a wider overview of the weather, consult the Weather Map of France.


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Tag: loss of consciousness
U.S. Navy Diving and Aviation Safety
Blood pressure is not the only silent medical killer. Hypoxia is also, and unlike chronically elevated blood pressure, it cripples within minutes, or seconds.
Hypoxia, a condition defined by lower than normal inspired oxygen levels, has killed divers during rebreather malfunctions, and it has killed pilots and passengers, as in the 1999 case of loss of cabin pressure in a Lear Jet that killed professional golfer Payne Stewart and his entourage and aircrew. Based on Air Traffic Control transcripts, that fatal decompression occurred somewhere between an altitude of 23,000 feet and 36,500 ft.
In most aircraft hypoxia incidents, onset is rapid, and no publically releasable record is left behind. The following recording is an exception, an audio recording of an hypoxia emergency during a Kalitta Air cargo flight.
Due to the seriousness of hypoxia in flight, military aircrew have to take recurrent hypoxia recognition training, often in a hypobaric (low pressure) chamber.
As the following video shows, hypoxia has the potential for quickly disabling you in the case of an airliner cabin depressurization.
Aircrew who must repeatedly take hypoxia recognition training are aware that such training comes with some element of risk. Rapid exposure to high altitude can produce painful and potentially dangerous decompression sickness (DCS) due to the formation of bubbles within the body's blood vessels.
In a seminal Navy Experimental Diving Unit (NEDU) report published in 1991, LCDR Bruce Slobodnik, LCDR Marie Wallick and LCDR Jim Chimiak, M.D. noted that the incidence of decompression sickness in altitude chamber runs from 1986 through 1989 was 0.16%, including both aviation physiology trainees and medical attendants at the Naval Aerospace Medical Institute. Navy-wide the DCS incidence "for all students participating in aviation physiology training for 1988 was 0.15%". If you were one of the 1 and a half students out of a thousand being treated for painful decompression sickness, you would treasure a way to receive the same hypoxia recognition training without risk of DCS.
With that in mind, and being aware of some preliminary studies (1-3), NEDU researchers performed a double blind study on twelve naïve subjects. A double-blind experimental design, where neither subject nor investigator knows which gas mixture is being provided for the test, is important in medical research to minimize investigator and subject bias. Slobodnik was a designated Naval Aerospace Physiologist, Wallick was a Navy Research Psychologist, and Chimiak was a Research Medical Officer. (Chimiak is currently the Medical Director at Divers Alert Network.)
Three hypoxic gas mixtures were tested (6.2% O2, 7.0% and 7.85% O2) for a planned total of 36 exposures. (Only 35 were completed due to non-test related problems in one subject.) Not surprisingly, average subject performance in a muscle-eye coordination test (two-dimensional compensatory tracking test) declined at the lower oxygen concentrations. [At the time of the testing (1990), the tracking test was a candidate for the Unified Triservice Cognitive Performance Assessment Battery (UTC-PAB)].
As a result of this 1990-1991 testing (4), NEDU proved a way of repeatedly inducing hypoxia without a vacuum chamber, and without the risk of DCS.
The Navy Aerospace Medical Research Laboratory built on that foundational research to build a device that safely produces hypoxia recognition training for aircrew. That device, a Reduced Oxygen Breathing Device is shown in this Navy photo.
Whidbey Island, Wash. (Feb 16, 2007) Lt. Cmdr. James McAllister, from San Diego, Calif. sits in the simulator during a test flight using the Reduced Oxygen Breathing Device (ROBD). The ROBD is a portable device that delivers a mixture of air, nitrogen and oxygen to aircrew, simulating any desired altitude. Combined with a flight simulator the ultimate effect replicates an altitude induced hypoxia event. McAllister is the Director of the Aviation Survival Training Center at Whidbey Island. U.S. Navy photo by Mass Communication Specialist 1st Class Bruce McVicar.
Although NEDU is best known for its pioneering work in deep sea and combat diving, it continues to provide support for the Air Force, Army and Marines in both altitude studies of life-saving equipment, and aircrew life support systems. Remarkably, the deepest diving complex in the world, certified for human occupancy, also has one of the highest altitude capabilities. It was certified to an altitude of 150,000 feet, and gets tested on occasion to altitudes near 100,000 feet. At 100,000 feet, there is only 1% of the oxygen available at sea level. Exposure to that altitude without a pressure suit and helmet would lead to almost instantaneous unconsciousness.
A test run to over 90,000 feet simulated altitude.
Herron DM. Hypobaric training of flight personnel without compromising quality of life. AGARD Conference Proceedings No. 396, p. 47-1-47-7.
Collins WE, Mertens HW. Age, alcohol, and simulated altitude: effects on performance and Breathalyzer scores. Aviat. Space Environ Med, 1988; 59:1026-33.
Baumgardner FW, Ernsting J, Holden R, Storm WF. Responses to hypoxia imposed by two methods. Preprints of the 1980 Annual Scientific Meeting of the Aerospace Medical Association, Anaheim, CA, p: 123.
Slobodnik B, Wallick MT, Chimiak, JM. Effectiveness of oxygen-nitrogen gas mixtures in inducing hypoxia at 1 ATA. Navy Experimental Diving Unit Technical Report 04-91, June 1981.
Author jclarke45Posted on July 27, 2016 August 17, 2016 Categories Aviation, Diving, Science and TechnologyTags altitude chambers, hypoxia, loss of consciousness, NAMI, NAMRL, NEDU, ROBDLeave a comment on U.S. Navy Diving and Aviation Safety
The Siren's Call of Rebreather Oxygen Sensors
Sirens Cove (contributed by Spanish Conqueror to Mythical Mania Wiki)
In Greek mythology irresistibly seductive female creatures were believed to use enchanted singing to beckon sailors to a watery grave.
Why this myth endured through the centuries is difficult to say. However, my theory is that it helped explain to grieving widows and mothers why ships sometimes inexplicably disappeared, taking their crew with them, never to be seen again. By the reasoning of the time, there must have been some sort of feminine magic involved.
The oxygen sensors in closed-circuit, electronically or computer-controlled rebreathers are a magic device of sorts. They enable a diver to stay underwater for hours, consuming the bare minimum of oxygen required. The only thing better than a rebreather using oxygen sensors would be gills. And in case you wondered, gills for humans are quite impractical, at least for the foreseeable future.
I have written, or helped write three diving accident reports where the final causal event in a rebreather accident chain proved to be faulty oxygen sensors. So for me, the Siren call of this almost magical sensor can, and has, lured divers to their seemingly blissful and quite unexpected death.
Those who use oxygen sensors know that if the sensor fails leading to a hypoxic (low oxygen) state, loss of consciousness comes without warning. If sensor failure results in a hyperoxic state (too high oxygen), seizures can occur, again leading to loss of consciousness, usually without warning. Unless a diver is using a full facemask, loss of consciousness for either reason quickly leads to drowning.
EX 19 rebreather (U.S. Navy photo)
Due to the life-critical nature of oxygen control with sensors, three sensors are typically used, and various "voting" algorithms are used to determine if all the sensors are reliable, or not. Unfortunately, this voting approach is not fail-proof, and the presence of three sensors does not guarantee "triple" redundancy.
In one rebreather accident occurring during the dawn of computer-controlled rebreathers, a Navy developed rebreather cut off the oxygen supply to a diver at the Navy Experimental Diving Unit, and all rebreather alarms failed. The diver went into full cardiopulmonary arrest caused by hypoxia. Fortunately, the NEDU medical staff saved the diver's life, aided in part by the fact that he was in only 15 feet of water, in a pool.
In two more recent accidents the rebreathers kept feeding oxygen to the diver without his knowledge. One case was fatal, and the other should have been but was not. Why it did not prove fatal can only be explained by the Grace of God.
The two cases were quite different. In one the diver broke a number of safety rules and began a dive with known defective equipment. He chose to assume that his oxygen sensors were in better shape than the rest of his rebreather. If he had been honest with himself, he would have realized they weren't. If he had been honest with himself, he would still be alive.
The other dive was being run by an organization with a reputation for being extremely safety conscious. Nevertheless, errors of omission were made regarding oxygen sensors which almost cost the experienced diver his life.
In the well-documented Navy case, water from condensation formed over the oxygen sensors, causing them to malfunction. The water barrier shielded the sensors from oxygen in the breathing loop, and as the trapped oxygen on the sensor face was consumed electrochemically the sensor would indicate a declining oxygen level in the rig, regardless of what was actually happening. Depending on how the sensor voting logic operated, and the number of sensors failing, various bad things could happen.
During its accident investigation, when NEDU used a computer simulation to analyze the alarm and sensor logic, it found that if two of the three sensors were to be blocked (locked) by condensed water, the rig could lose oxygen control in either a hypoxic or hyperoxic condition. Based on a random (Monte Carlo) sensor failure simulation, low diver work loads were more often associated with hypoxia than higher work rates, even with one sensor working normally.
We deduce from this result that "triple redundancy" really isn't.
The white circles at the top left of this scrubber canister housing are the three oxygen sensors used in an experimental U.S. Navy rebreather.
When the accident rig was tested in the prone (swimming) position at shallow depth, after 2 to 3 hours sensors started locking out, and the rig began adding oxygen continuously. The computer simulation showed that the odds of an alarm being signaled to the diver was only 50%. The diver therefore could not count on being alerted to a sensor problem.
Unfortunately in this near fatal case the rig stopped adding oxygen, the diver became hypoxic and the diver received no alarms at all.
After NEDU's investigation, the alarm logic was rewritten with a vast improvement in reliability. The orientation of the sensors was also changed to minimize problems with condensation.
Today what is being seen are divers who extend the use of their sensors beyond the recommended replacement date. Like batteries, oxygen sensors have a shelf-life, but they also have a life dependent on use. Heavily used sensors may well be expended long before their shelf-life has expired.
The Siren, by John Williams Waterhouse.
Presumably, the birthing pains of the relatively new underwater technology based on oxygen sensors have now passed. Nevertheless, those who use rebreathers should be intimately familiar with the many ways sensors, and their electronic circuitry, can lead divers ever so gently to their grave.
Like sailors of old, there are ways for divers to resist being lulled to their death by oxygen sensors. First among them is suspicion. When you expect to have a great day of diving, you should be suspicious that your rebreather may have different plans for you. Your responsibility to yourself, your dive buddies and your family is to make sure that the rebreather, like a Siren, does not succeed in ruining your day.
The best way to ward off sensor trouble is through education. To that end, Internet sites like the following are useful. Check with your rebreather manufacturer or instructor for additional reading material.
http://rebreathers.es/celulas%20o2/celulas%20o2.htm
http://www.rf30.org/
http://www.deeplife.co.uk/or_files/DV_O2_cell_study_E4_160415.pdf
Author jclarke45Posted on December 28, 2012 April 24, 2016 Categories Diving, Science and TechnologyTags diving, hyperoxia, hypoxia, loss of consciousness, oxygen, rebreathers, seizures, sensorsLeave a comment on The Siren's Call of Rebreather Oxygen Sensors

redpajama_set_name: RedPajamaCommonCrawl


A lovely lace yoke and split sleeves (hello, shoulder cutouts) update the retro-inspired silhouette of City Chic's plus size jumpsuit, styled with pleating at the waist and tapered legs.
Hits at ankle; approx. inseam: 30"


Changing car wrap is a very fast and attractive color change cars, and in the same way you protect existing paint cars. If you want to subsequently remove the foil, paint will remain the same as the day when the car stuck. Films that we use are Oracal (Germany), Avery (USA), Arlon (USA), 3M (USA). Average lifetime warranty on the foil is 5 years.
You can choose more than one hundred colors, ranging from bright, metallic, matte, 3D film, matte film with metallic crystals.
If the car has damage to paintwork such as dents, bad paint, corrosion, scratches, cracked plastic – everything has to be improved before starting work and it is possible to do everything at once in our room.


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Good Bye to Muck & Weeds!
LakeMat Pro
Muckmat Pro
BoatLift Mat
Sandmat Pro
Weeds Don't Grow With LakeMat Pro!
"Control 100% of your weeds, Guaranteed"
Chemical-free plus it is quick & easy to install
The LakeMat is an alternative to using chemicals, weed rakes or weed rollers to kill aquatic weeds in your lake front swimming area. The LakeMat is basically a large mat that you place over your swimming area to kill all aquatic weeds below it. The special material and distributed weight system is designed to fit to the bottom of the lake like a piece of carpet. The LakeMat immediately creates a aquatic weed free place to swim and play as it goes to work killing weeds. The material disproves the aquatic plants beneath of all sunlight, which kills all the aquatic vegetation below the mat. The plant will begin to decay and create gas. The LakeMat material is gas permeable, and you will see little gas bubbles coming through the mat. The LakeMat is meant to stay in the water all year long, so install and forget about it. And for your piece of mind, the LakeMat fabric is DEQ approved and guaranteed for five years against defects in materials and workmanship.
Large LakeMat
12.0' x 14.0'
Extra Large LakeMat
LakeMat Pro assembles and installs in just minutes — giving you a weed-free beach.
What you get — with LakeMat Pro
LakeMat Pro Gives You All These Benefits
Control 100% of your weeds, not just some of them — all of them!
Control only the lake weeds you want — exactly where you want
Leave other areas natural and untouched for fish & wildlife
Safe — No chemicals, fish kills, or water restrictions
Easy — No back-breaking raking and cutting
Quick — Less than 20 minutes to assemble & install
Low Maintenance — Leave it in year round (winter can't hurt it)
Can Be Moved — several times a year to control more weeds
Made in Grand Rapids, Michigan, USA!
Guaranteed to work — Because it does!
Want proof? Just Look at this photo...
The top half (where the weeds are) was professionally treated with herbicide — three times. The bottom half is where a LakeMat Pro sat — big difference, isn't it?
A simple idea. A remarkable product.
The simple part -- LakeMat Pro prevents your lake weeds from growing. It's basic science. No sun — no weeds. You'll also stop new seeds from sprouting. Pretty simple concept...
The remarkable part -- How it's done comes from years of research and testing — creating a superior design and materials — making LakeMat Pro the most effective weed control product you can buy.
Finding the right stuff.
Searching for the best fabric took well over a year. Trying several different types of materials, the first thing we learned was — what doesn't work.
(Tarps, plastic sheeting and tarp-like materials don't work — they're not gas permeable — they "bubble up." Landscape fabric screens, let in too much sunlight, weeds grow through after one season).
Fortunately, our search led to geotextiles — the same fabrics used in highway construction. We tested both woven and non-woven fabrics — of several weights and thicknesses.
LakeMat Pro fabric is made specifically for underwater use
LakeMat Pro fabric has several important properties for use in lakes and wetlands.
It's Water Permeable, lets 90 gallons of water to pass through per minute.
It's Gas Permeable. Gases from decaying biomass (lake weeds) pass directly through it.
It's Non-Woven. It takes 110 lbs of pressure at 3/8's of an inch to poke a hole in it.
It blocks 98 percent of available sunlight.
According to its U.S. manufacturers, the fabric lasts at least 20 years.
LakeMat Pro vs. Lily Pads Before and After
These photos show the dramatic difference after placing a LakeMat Pro over a patch of one of the toughest of all lake weed species: the White Water Lily.
These photos were taken one day apart.
If you look closely, you can see the edge of the LakeMat Pro in the bottom of the "After" picture.
You get the benefits of our research and testing
We didn't just slap fabric on a frame. Structural engineers, product design engineers, soil engineers, biologists, metallurgists and specialists in several fields were consultants.
The formula is — research, test, analyze, and repeat the process. This testing lead to improvements like gas-release ports patterning, a "perimeter" frame and improved connection points.
Simple, Safe — and Cost Effective
Today, LakeMat Pro is the most efficient, simple, safe and quick way to control your lake weeds. And I'd add — it's the most cost effective, too. For the average cost of one season's worth of aquatic chemicals, you can be weed-free, safely, for years to come.
If you're tired of fighting lake weeds — you've got the simple solution — LakeMat Pro.
LakeMat Pro — Be Weed Free — Guaranteed!
LakeMat FAQs
Are aquatic plants necessary?
Absolutely! They provide habitat and protection for fish and waterfowl, they're a food source, they recycle oxygen and carbon dioxide, they help prevent shoreline erosion and filter water particles. They become a problem when there is an overgrowth of aquatic weeds, especially on your beach front.
Can I leave my Mat in all year?
Yes, I leave mine in all year. You can take them out if you want to, but it's a lot of work and completely unnecessary.
Can the Mat be used on top of lily pads to get rid of them?
Yes, but lily pads are a tough customer. The best thing to do is cut them back and put one of our Mats over them as early in the season as possible. If they're on shore, you can use a black, plastic tarp to place over them. The idea is the deprive them of sunlight. But they are tenacious!
Do I have to put in the plastic stakes?
I would. The thing about muck is, it releases a lot of gases in the summer and it moves around easily. The more tension you create over the top of it, the better off you are. Some people don't use all the plastic stakes, but for best results, I'd use them all.
Do I need a DEQ permit to install a Mat?
It depends on what country, or state you're in, and sometimes, even what county or water body! If you speak with your regulatory agency, you'll want to tell them you're interested in installing a "seasonal benthic barrier." Most areas won't require a permit if it's something you put in and take out like a swim raft. If you're getting a MuckMat or BoatLift-Mat, it's primary purpose is to provide a "seasonal" platform to walk on. Most areas have no policy on lake bottom platforms.
Do I need to clean my Mat off?
It depends. If you have a lot of foot traffic, (boats, kids and dogs) that will keep sediment from building up. However, once a year or so (depending on how much sediment is floating in the water) you'll want to sweep it off, blow it off, or if you're really ambitious, take it out of the lake and wash it off. I don't suggest this last method, but it's up to you.
How are the mats affected by Zebra Mussels?
Zebra mussels like structure, like your dock, your boat, or you if you stand still long enough. Our Mats are flat, like the bottom and aren't really attractive to zebra mussels. They move across the Mats, but don't stay there. They'll be about as scarce on our Mats as they are on open, sandy areas.
Installation of the mat looks easy in shallow water. How does one isntall it in 8' to 10' depth water?
The only simple answer is use either a LakeMat Pro or a MuckMat Pro. The frame will keep it square and cause it to sink. I'd also suggest fastening some type of weights on the four corners to hold it in place until it settles on the bottom... yes, I'd leave the weights on it even after it settles.
Is there a risk of the mats ripping from fishing lures?
No. That said, if someone is dumb enough to be fishing in shallow, weedy water, with a non-weedless hook, and they're dumber still to let it sink to the bottom and the hook gets stuck in the Mat, they will break their line trying to get it out. Doesn't happen often. At my current cottage, I've had eight Mats in for four years. Over that time I've had one lure caught on one Mat. Just pull backwards, and the lure comes out easily. If you have a bumper crop of dumb fishers, you may have more lures to pull out, but it's not likely.
To cover a large area, can you attach more than 1 together to cover a wider/longer area?
Yes, it's especially easy to connect LakeMat and MuckMat simply by fastening the frames to each other. We had one guy who did 16 Mats! It's common for people to fasten two, three, and four together.
When installing, does the mat sink to the bottom or do you need to stand on it to sink?
LakeMat and MuckMat will sink by themselves fairly quickly. It may take a few minutes. You can help it along if you wish.
Does the LakeMat really work?
Yes, it prevents aquatic weed growth 100%, naturally, easily and inexpensively. LakeMat® provides a weed free area exactly where you want leaving other areas natural and undisturbed.
Does the LakeMat trap gases like a tarp?
No, your LakeMat® material is porous, it allows gases to escape. For example, a square foot of tarp lets zero gallons of water pass per minute. Another (non-approved) product we found lets through just four gallons per minute. LakeMat® lets through 90 gallons of water per minute. In addition, we include "gas release ports" to allow the gases to escape
How can a LakeMat® help with my soft lake bottom?
Aside from managing aquatic weeds, your LakeMat® also acts as a tension barrier. Think of it like a snowshoe over deep snow. By dispersing your weight, it holds you up. It may still feel a little soft, but you won't sink in up to your knees. And, you won't feel the muck and soft sediment on your feet. It feels something like walking on a felt carpet. (Note: We encountered one small lake where we put down a 20 foot pole and didn't reach any firm lake bottom. Although rare, such ponds are dangerous to walk in under any circumstances. We do not recommend LakeMat®, or anything other than avoiding them altogether).
How do I move my LakeMat®?
As long as you clean it off once a year or so, (sweep it or blow it off) it will last longer than you will. We guarantee the material for five years, but that's very conservative. The fabric manufacturers project if it received no UV light whatsoever, it will last 20,000 years. So if we go with just 1% of that, it should last much longer than we will.
LakeMat Testimonials
I was tired of raking weeds, now they're all gone, even the lilies. That's why we bought another one.
Carla P. located in Michigan
Compared to the traditional benthic barrier, we found that the LakeMats were much easier to assemble and install. By switching to LakeMats, we found that the assembly and installation steps only took a few hours, as opposed to a few days with the traditional barriers we used in previous years... In previous years, we had to use several cement blocks and rebar to keep the mats in place, which increased installation time and posed a safety hazard to anyone wading outside of the swimming area. We also noted that the LakeMats didn't require any gurgling during the season, as the porous fabric allowed the consistent aeration of gas bubbles.
Nate Parks & Recreation Program Assistant New York State Office of Parks, Recreation, & Historic Preservation Environmental Management Bureau- Water Quality Unit located in New York
I first of all want to say that I like your product. Secondly, your mats fit well into our WI laws on aquatic plant removal since a single riparian owner cannot remove more than a 30-foot width...and your mats are no more than 30 feet wide. We would appreciate a disclaimer on your website describing that Wisconsin requires a permit for Aquatic vegetation removal of more than 30' on a single owners property. I appreciate all efforts and time spent looking into this subject. Again I like your verbiage and product. Please feel free to contact me... Thank you for your time.
Timothy with the DNR located in Wisconsin
We walked them in 'lickity split' :) We did not stake the far end (24 ft out) as the depth of the water was about 5 ft deep. We put a couple large, but movable rocks in the centre of each mat. We did stake them at the shallow end. My husband, Rodney, says to let you know he was impressed at how quickly and easily we put all 4 into the lake. Now we plan to leave them in this first location until mid October, then move them to the other half of the lake shore (in front of our yard) that has this invasive weed growing. We will leave them there for the winter and a month or so after the ice goes off the lake next spring. The ice goes off usually the third week in April here. Will be interesting to see if the weed grows back right away in the area where we installed the mats yesterday.
Kevin & Rodney located in BC Canada
My wife Brenda and I own two 7-BR, 4,000 sq ft vacation rental lake houses on Stone Lake in Cassopolis, MI (SW Michigan) near the Indiana border. We take much pride in providing our Guests with an excellent experience in how well maintained we keep our two homes and our 50 acres of woods at Stone Lake. That said, until we discovered your Lake Mat Pro lake mats, the one area that seemed beyond our control was our two sandy beaches. Try as we might, including paying a great high school honor student $15 an hour to clean our beaches every Saturday between Guests, lake weeds were always an issue and virtually the only area where we felt we should have done better. And it was the one source of Guest complaints. This greatly distressed us. We felt helpless, despite weed pulling every Saturday between Guests and twice yearly chemical treatments approved by the Michigan Dept of Environmental Quality (maximum approved by the DEQ). That is until we discovered your Lake Mats...wow what a difference. We tried them out (2 per beach) in 2014, and it was the first summer ever we did not have one single complaint about water weeds all summer. Wow! This year, 2015, we bought 6 more so that literally all of our beachfront at both houses would have shallow water out to 25 feet that was 100% weed-free and muck-free -- and rock-free. Our Guests and their little ones love our beaches now - and rave about them! It has given us a competitive advantage (shhhh don't tell anyone) and we feel the investment has an excellent ROI.. Thank you for solving what had been seemingly a unsolvable problem. P.S. Since last summer, a number of our Stone Lake neighbors have purchased your Lake Mat Pro lake mats as they have seen how effective they are.
Ted & Brenda Gogol located in Cassopolis, Michigan
SandMat


. . . 2008 Bishnu Ghosh Cup, the Bikram yoga championship. This annual event will take place in Los Angeles at the LAX Westin on February 1-3. Regional finishers will compete for the U.S. title, and there will be an international competition on the last day. For more information, visit www.bikramyoga.com.


Review: Trap Door Brewing, Vancouver, WA On Friday, March 3rd, we hit one of the up-in-comming breweries in downtown Vancouver, Trap Door Brewing. Opened in 2015, Trap Door has gone through some evolution in their beer quality and they have made some improvements to their location, adding in more food carts and a refined patio space. The great part about the craft beer industry, is that there's room for everyone. I've had the conversation with many beer-geek friends and while you may not have the best product, the greatest location, or the most awesome food, there's room for you if you're doing it right. Their location in downtown Vancouver is quickly becoming a craft beer destination with a few taprooms and other smaller microbreweries opening up tasting rooms nearby.
Trap Door fits into the Vancouver brewing scene as having a line up of beers that can hold their own and are appealing to their audience that are quickly learning that craft beer is worth the trip to find. I must say that Vancouver's scene is just starting out (compared to Portlands) and we need to give them room to grow and should allow them to improve over time. For breweries to succeed in Vancouver, they need to provide something unique and a step up from commercially produced crap that's at most bars. Trap Door is doing this with effeciency and success. Their taproom/brewery location provides a friendly space to both learn about and enjoy their beers. Props to the bartenders that are well versed and willing to help you explore their lineup. They have a larger bar to sit at, small two top and larger tables/booths that you can easily find a spot at, unless it's a Thurs, Fri. or Saturday night. They tend to be packed on those nights.
I appreciate their model in not having to deal with the complications that come with running a restaurant with your brewery, they are focused on what they do, and they do it pretty well. The availablility of food carts with a range of awesome Thai and Mexican food, and a great patio outside gives equal opportunity to draw in more foot traffic and provide a place for people to enjoy the excellent food and great beer in one spot. The one issue that I might have with their location is that they do allow kids in the front part of the seating area (they even have play mats and games for them). There's been a few times we've stopped by and had a bunch of kids running around and being loud. I know it's cutting off a sector of the public to not allow kids inside, but is it worth alienating those that don't want to listen to screaming kids while you try to sip on a beer?
With all that said, I've been fortunate enough to have sampled their beers right after they opened, and subsequently every few months since then. They had a couple of really good recipes that have maintained since then (IPA and Pilsner), and they've expanded to other varieites and are doing a bunch of one-off seasonals that both hit and miss depending on your preferences in beer. This time around my favorite was the Bourbon Barrel Aged Uptown Brown and El Sobrante Milk Stout (Nitro). The reviews below are pictured starting at the left, and going clockwise around the tray. I'd definately recommend giving them a try if you're in downtown Vancouver, or if you can find their beer on tap at a local bar/restaurant.
Appearance: Orange/golden, clear draft with a slight foamy white head, minimal lacing and no retention.
Smell/Aroma: Has a ton of fruit juices, acidic citrus from grapefruit to apple/mango/pineapple, mild wet leaves.
Taste: Thin malts (crackery), with plenty of pine and hop vegital resins, a bit of citrus zest sharpness on the mid.
Mouthfeel: Medium-bodied, some tingling on the back of the tongue from the good amount of carbonation.
Overall: This is a great wet-hop Pale Ale, with tons of fresh grapefruit juice on the mouth with the sharp acidity one would expect with zest.
Appearance: Hazy pale yellow, opaic with a shallow foamy head, minimal retention that dropped quickly, some spider lacing on the rim.
Smell/Aroma: Yeasty and bright citrus and sweet fruits.
Taste: Bitterness from the front to back, shallow yeast and low crackery malt profile. Citrus and grapefruits show up, lemon, dries out on the back.
Mouthfeel: Great presence with lots of carbonation, mild chalky tongue.
Overall: Great NE style IPA, tons of bitters, tons of fruit, lots of lingering aftertaste.
Appearance: Dark brown/black, solid small bubbly tan head with great retention and lots of large lacing clumps.
Smell/Aroma: Toffee, roasted coffee, some hints of ash, burned sugars.
Taste: Flavors are sweet and lighter for the style. The roasted grains really shine, almost like a schwartzbier. Minimal ash and burned flavors, minor bitterness and low aftertaste.
Mouthfeel: Thin bodied, lots of creamy head and presence on the tongue.
Overall: This is a great brown, shows off the complexity of the grainbuild, and has enough sweet to counter the burned grain vibe.
Appearance: Jet black, reddish hues on the edges. Little to no head, minimal retention.
Smell/Aroma: Old wet coffee grounds, acidic, dry.
Taste: Super coffee, ashy, roasted grains, and lots of solid earthiness on the back.
Mouthfeel: Thin to medium bodied, low carbonation and little alcohol on the front.
Overall: Super duper coffee stout, if you love espresso, you'll love this.
Appearance: Dark black opaic draft with minimal head and some large bubbly lacing.
Smell/Aroma: Sweet cocoa, charred bread crust with soft back florals.
Taste: Sweet cocoa and bitter coffee grounds on the front, some great roasted and charring on the mid to balance the sweet. The vanilla and cocoanut don't really show up much on the back.
Mouthfeel: Chewy but thin on the back, plenty of carbonation and prickly on the tongue.
Overall: Great Imperial stout with lots of great flavors that mix into a savory dance on the tongue.
Appearance: Dark black/brown with light red hues against the light. Minor off-white head with delicate small lacing.
Smell/Aroma: Sweet molasses and crusty bread, alcohol (whisky) and slight hints of dried fruits.
Taste: Strong alcohol forward, sweet brown sugars, hints of wood (oak) and some rounded floral from the vanilla. Finnishes dry and with some alcoholic hits.
Mouthfeel: Thin, shallow carbonation, leaves a sweetness and dry finish on the back.
Overall: Solid imperial brown, lots of alcohol on this one, great if you like whisky.
Appearance: Orange/copper hued draft, bright white foamy head, decent lacing, minor retention.
Smell/Aroma: Fruits ranging from pineapple to grapefruit zest, some hints of sharp pine needles and earthiness.
Taste: Citrus and pine bitters, bright flavors, resins coat the tongue. Mild sweetness helps hold the bitters back, but the overall vibe is more citrus than not.
Mouthfeel: Great amount of carbonation makes the mid-bodied draft pleasing.
Overall: Classic NW style IPA, plenty of bitters and citrus vibes.
Appearance: Lighter yellow/straw hues, bright white foamy head, minor retention and spidery lacing.
Smell/Aroma: Pine and yeasty notes followed by peppercorns and melon sweetness.
Taste: This is a thin and hop forward pilsener. Pine, hits of dried leafs, cracker malts are hidden on the back.
Mouthfeel: Low carbonation, lighter bodied, some coating on the tongue.
Overall: Nice bitterness lets this pils shine. Great session beer.
Taste: Stronger cocoa hints on the nitro draft, sweet and savory with lots of bitters on the back.
Overall: Great Imperial stout on nitro with lots of great flavors that mix into a savory dance on the tongue.
Appearance: Bright orange/red, clear and zero head.
Taste: Sweet sugars, bright orange peels, zesty acidic notes.
Mouthfeel: Bubbly on the tongue, thin bodied, some minor driness on the back.
Overall: Great cider for those that aren't beer fans.
Beer, brewery, review, Trap Door, Vancouver, Washington. Bookmark.


text:
US Air Force Launches Advanced Communications Satellite
By Mike Gruss 18 September 2013
A United Launch Alliance Atlas 5 rocket carrying the third Advanced Extremely High Frequency (AEHF-3) satellite for the United States Air Force lifts off from Cape Canaveral Air Force Station on Sept. 18, 2013. The AEHF constellation will provide survivable, global, secure, protected and jam-resistant communications for high-priority military ground, sea and air assets.
(Image: © ULA)
WASHINGTON — The third in a series of highly secure U.S. military communications satellites successfully launched in the early morning hours of Sept. 18 aboard a United Launch Alliance (ULA) Atlas 5 rocket from Cape Canaveral Air Force Station, Fla.
The rocket launched at 4:10 a.m. local time and the Advanced Extremely High Frequency (AEHF)-3 satellite separated from the vehicle about 51 minutes later. AEHF-3 faces 110 days of orbit-raising operations and 60 days of testing, according to a U.S. Air Force press release.
Lockheed Martin Space Systems of Sunnyvale, Calif., is building a total of six AEHF satellites under a contract worth an estimated $9 billion or more, including associated ground systems. When fully deployed, the AEHF constellation will consist of four satellites in geostationary orbit and secure communications payloads hosted aboard classified satellites in polar orbit. [Gallery: Declassified US Spy Satellite Photos & Designs]
"AEHF is functioning well in tests, and allies are connecting to the system for the first time. It shows that our product is meeting mission needs, and we have room to expand capacity for both tactical and strategic users in the future," Mark Calassa, vice president of protected communication systems at Lockheed Martin, said in a statement.
Northrop Grumman Aerospace Systems of Redondo Beach, Calif., provides the satellites' communications payloads.
"The sophistication of this payload will provide users with literally millions of options for countering various enemy electronic, cyber and physical threats," said Stuart Linsky, vice president of communication programs for Northrop Grumman Aerospace Systems.
The first satellite in the constellation, AEHF-1, was launched in August 2010 but took more than a year to reach its operational orbit due to a propulsion glitch. AEHF-2 joined AEHF-1 in orbit in May 2012.
The satellites are designed to provide assured and highly secure communications links under all conditions, including a nuclear war. One AEHF satellite provides more capacity than the entire legacy Milstar constellation. Currently, the satellites are used by Canada and the Netherlands in addition to the United States.
The fourth AEHF satellite is expected to launch in 2016 or 2017, Air Force officials have said. Satellites four, five and six are on schedule, according to a Sept. 18 press release from Lockheed Martin.
The Atlas 5 configuration used in the launch featured a 5-meter payload fairing supplied by Ruag Space of Europe and three solid-fueled strap-on boosters provided by Aerojet Rocketdyne of Sacramento, Calif. The Atlas 5, one of two rockets built by Denver-based ULA, is used primarily for U.S. government missions but launches the occasional commercial satellite.
"Today's successful launch was the 75th since ULA was formed nearly seven years ago, the 40th Atlas 5 mission, and the fourth ULA launch in the last six months," Jim Sponnick, ULA vice president of Atlas and Delta programs, said in a prepared statement. ULA is a Boeing-Lockheed Martin joint venture.
This story was provided by Space News, dedicated to covering all aspects of the space industry.


Waytoplay Highway 24 pcs – Rockabilly Jr.
You can take these roads anywhere; from the beach to the bathtub, the living room to the backyard, the grandparents place or on a camping trip.
The road parts are made for little hand's from age 2 and up, and they are super easy to connect. Any combination of straights and curves, roundabouts and crossings means endless durable play, they are also interchangeable, so you can collect more pieces to add to your collection.
The highway includes 24 road parts.
Waytoplay can also be washed up in the kitchen sink after a hard day's driving.
A toy for all ages, the possibilities are endless, watch your little one's creative imagination flourish with these rubber road systems.


EVERFI empowers educators to bring real-world learning into the classroom and equip students with the skills they need for success–now and in the future. Thanks to partners who share this mission, EVERFI's online resources for teachers are available at no cost.
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EVERFI's digital curriculums empower teachers to bring critical skills education into their classrooms. Our interactive, game-based lessons help prepare students for success in the real world.
Students and Teachers are at the heart of our work. EVERFI's programs offer enrichment opportunities for both professional and student learning.
Learn more about how schools are using EVERFI to activate their education initiatives.
"As a teacher, it is amazing that there are sponsors who make this wonderful tool free for us to use! EVERFI offers quality resources with real-life scenarios for students to make deeper connections. I love that it connects directly to our standards and that there are additional lesson ideas to expand and deepen the learning."
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Join more than 50,000+ educators across North America teaching critical skills.


Our CREATURES CONSTRUCTION KIT offers you an extremely wide range of source sounds to create your own unique creatures. Included are more than 7.600 royalty free sound effects in over 1000 files, reaching from huge to tiny, low to high and soft to hard. This great collection of pre-edited source recordings contains basically everything you need to create any creature you have in mind. As a bonus, we included great movement sounds for the category "tiny".
Recorded and edited in 192kHz, provided in 96kHz, 24-bit, the possibilities to further pitch, stretch and process are vast. No matter if you want to create slobbery insects, ferocious orcs or giant dragons, you will find it in this library.
Huge and rumbling beasts, tiny and nasty insects, brutal and slippery zombies: The CREATURES DESIGNED edition offers more than 300 royalty-free & ready-to-use sounds in 76 files. The collection consists of numerous sets of outstandingly evil creatures, with various different moods in each set.
The effects are provided in various sets of individual creatures, each including numerous states like calm, attack, hurt, tense, die. That makes it very easy for you to quickly pick the right sound for your scene.
We invited vocal and voice artists into our studio and pushed them to the max to create some really outstanding and interesting creature sounds. All artists were recorded in 192kHz with high-frequency microphones to guarantee enough sample data for some heavy pitching and processing.
We recorded more than 1.000 different files to cover an incredible bandwidth of different source sounds, perfect to mix and blend them to construct any amount of really unique creature sounds.
The "Creatures" library has lots of good wet close proximity sounds that are often difficult to get from real animal recordings. I typically have to record myself to get those, so this is a welcome addition to my library. Nice work and nice price!
The L Word, The Prophet, The Gambler, the Girl and the Gunslinger etc.
I knew before I even started I would have to pick up the CREATURES Construction Kit. There is such a large variety of sounds to choose from, all with high sample rates, it is simply an essential tool for the scary and fantastic fantasy creatures! I'm designing the sound of a massive sea monster, and some huge vicious wolves. BOOM Library is sending chills down my spine, and hopefully the viewers too!
Total War: Warhammer, ANNO 1404, The Elder Scrolls Online etc.
For the Total War: WARHAMMER release trailer we loved using the CREATURES Construction Kit to spice up our own vocal recordings. Generally speaking, whenever we are missing certain sound effects we know that they will be available in one of the many Construction Kits. They are absolutely irreplaceable.


The Muse Poet is a collection of poems I've written over the course of several years. They reflect my happy moments, lustful desires, deepest secrets, and darkest thoughts…these words are the essence of me; they are my soul.
Many of the poems have been inspired by the words of my muse, Shelby James. She is the voice inside of me that puts the words to my emotions. Within these pages, you will find some poems that were included in my debut novel – I am ShelbyJames.
No matter the journey I've taken or the roads I've traveled, words have always been my release. They are my truth… my peace…my Beauty in the Darkness.