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Kidney dysfunction, systemic inflammation and mental well-being in elderly post-myocardial infarction patients
Rick H. M. Heeres ORCID: orcid.org/0000-0002-0598-89731,
Ellen K. Hoogeveen2,
Johanna M. Geleijnse3,
Janette de Goede3,
Daan Kromhout3 &
Erik J. Giltay1
The aim was to investigate whether mild kidney dysfunction and low-grade inflammation in post-myocardial infarction patients are independently associated with markers of mental well-being (i.e. depressive and apathy symptoms, and dispositional optimism).
In post-myocardial infarction patients, kidney function was assessed by estimated glomerular filtration rate (eGFR) calculated from the combined CKD-EPI formula based on serum levels of both creatinine and cystatine C. Systemic inflammation was assessed using high sensitivity C-reactive protein (hs-CRP) levels. The 15-item Geriatric Depression Scale (GDS-15), the 3-item apathy subscale and the 4-item optimism questionnaire (4Q) were used to measure mental well-being and were analyzed using linear multivariable regression analysis.
Of the 2355 patients, mean age was 72.3 (range 63–84) years and 80.1% were men. After multivariable adjustment, a poorer kidney function was associated with more depressive symptoms (β = -0.084, p < 0.001), more apathy symptoms (β = -0.101, p < 0.001), and less dispositional optimism (β = 0.072, p = 0.002). Moreover, higher levels of hs-CRP were associated with more depressive symptoms (β = 0.051, p = 0.013), more apathy symptoms (β = 0.083, p < 0.001) and less dispositional optimism (β = -0.047 p = 0.024). Apathy showed the strongest independent relation with both low eGFR and high hs-CRP.
In post-myocardial infarction patients, impaired kidney function and systemic inflammation showed a stronger association with apathy than with depressive symptoms and dispositional optimism.
Depressive symptoms in coronary heart disease (CHD) patients are associated with an increase in cardiac morbidity and mortality [1]. The prevalence of major depressive disorder (MDD) in post-myocardial infarction patients is estimated at about 20% [2]. CHD is also associated with an increased occurrence of chronic kidney disease (CKD) [3], which may further contribute to the development of depressive symptoms [4–6]. It is well established that end-stage renal disease (ESRD) is associated with a poor quality of life and depressive symptoms, whereas this has not been thoroughly investigated for earlier stages of CKD. Patients with ESRD also have a prevalence of about 20% for MDD [7]. Moreover, as an inflammatory reaction is common in patients with ESRD, it is hypothesized that inflammation partly links ESRD to depressive symptoms [8, 9]. Systemic low-grade inflammation is present in patients with CKD, as well as in CHD, and may mediate the increased risk of depressive symptoms and apathy [10–13].
In three large cross-sectional studies, including 3700 to ≥ 28,000 patients [14–16], those with severe CKD (i.e. with an estimated glomerular filtration rate [eGFR] <30 ml/min/1.73 m2) had more depressive symptoms than those without CKD (eGFR ≥ 60 ml/min/1.73 m2). However, in only one of those studies (that included patients with diabetes) did the increased risk of depressive symptoms remain significant after adjustment for all relevant covariates [15]. Whether or not less severe forms of impaired kidney function (30 ml/min/1.73 m2 or higher) are associated with more depressive symptoms is still largely unknown. Moreover, the largest study that analyzed the continuous relation between eGFR and depressive symptoms found no significant associations [14]. Moreover, we are aware of only two studies on the association between CKD and depressive symptoms in cohorts of cardiac patients. In 374 patients suffering from congestive heart failure, Hedayati et al. found that those with severe CKD scored significantly higher on depressive symptoms [17]. In contrast, among 967 CHD patients, Odden et al. found no significant difference in depressive symptoms between patients with and without CKD [18].
A low-grade pro-inflammatory state is common in patients with CHD, exemplified by higher levels of serum C-reactive protein (CRP) [13]. A positive association between inflammatory markers and depressive symptoms is also well established in persons without somatic illness [19]. However, less is known about these associations in CHD patients. Among three studies that included from 71 to almost 1000 CHD patients [20–22], only the smaller study found a significantly increased CRP level in depressed CHD patients [22], whereas the two larger studies found no significant relation [20, 21]. In another study, when examining the linear relation between increasing CRP level and depressive symptoms, higher levels of CRP showed a significant association with more depressive symptoms; however, this association did not persist after adjustment for covariates [23].
The association between depressive symptoms and CHD has been called into question by recent cross-sectional and prospective studies in community-dwelling elderly [24–26]. Apathy, rather than depressive symptoms, was significantly associated with a higher incidence of CHD and other cardiovascular diseases. Apathy is a syndrome of primary motivational loss which manifests itself in a decrease in goal-directed cognition, emotion and behavior [27]. Two cross-sectional studies (including 1810 and 3534 subjects, respectively) also found that higher levels of CRP were significantly associated with more apathy [25, 26]. However, two longitudinal studies found no such association in 225 and 1015 elderly patients, respectively [28, 29].
The Alpha Omega Trial provided us with the opportunity to perform a cross-sectional analysis of mental well-being in post-myocardial infarction patients with a kidney function that ranged from normal to non-dialysis-dependent CKD stage 5. We aimed to investigate whether mild kidney dysfunction and low-grade inflammation were independently associated with markers of mental well-being i.e. depressive symptoms, apathy symptoms, and dispositional optimism. Dispositional optimism is defined as generalized positive outcome expectancies and a future orientation with trait-like mental properties [30].
Whereas previous studies used only creatinine levels to assess the eGFR, we included both creatinine and cystatin-C (CysC) levels to more accurately estimate kidney function [31], as well as high-sensitivity CRP (hs-CRP) as a measure of systemic inflammation.
The Alpha Omega Trial was a multicenter, double-blind, placebo-controlled trial conducted between 2002 and 2009 on the effect of low doses of n-3 fatty acids on cardiovascular events, described in detail elsewhere [32, 33]. The cohort consisted of 4837 free-living Dutch post-myocardial infarction patients aged 60–80 years, receiving state-of-the-art antihypertensive, antithrombotic and lipid-modifying drug treatment at baseline. Patients were randomly assigned to one of four trial margarines and were followed-up for 40 months (ClinicalTrials.gov no. NCT00127452). Blood samples were taken at baseline and after 40 months in patients randomized before August 2005 (i.e. 48% of the cohort, owing to financial constraints). Mental well-being questionnaires were administered at 40 months.
For the present cross-sectional study we used the 40-month follow-up data of 2355 (48.7% of 4837) patients who supplied blood samples and also completed the mental well-being questionnaires at 40 months [33].
Assessment of psychological measures
Depressive symptoms were assessed using the 15-item Geriatric Depression Scale (GDS-15) [34]. This self-administered questionnaire contains 15 yes/no questions and excludes certain somatic symptoms which might be due to medical illness. Higher scores (range 0–15) indicate more depressive symptoms during the past week. The GDS-15 is a reliable and well-validated measure of depressive symptoms in elderly medical patients [35]. For computation of the GDS-15 score, two missing items were allowed and were subsequently imputed with the mean of the remaining 13 or 14 items (n = 206 of 2355, 8.7%).
Apathy was assessed using the GDS apathy-3 subscale. This is a subscale of the GDS-15 which consists of the following three questions: "Have you dropped many of your activities and interests?", "Do you prefer to stay at home, rather than going out and doing new things?", and "Do you feel full of energy?" Compared with the 14-item apathy scale [36], the GDS apathy-3 subscale has a sensitivity of 69% and a specificity of 85% [24]. For computation of the GDS apathy-3 subscale, one missing item was allowed and was subsequently imputed with the mean of the remaining two items (n = 73 of 2355, 3.1%).
Dispositional optimism was assessed using the 4Q which centers around a focus on the future and is more closely related to life engagement, vitality, and feelings of having a purpose in life. In the Netherlands, the 4Q was used as part of a national 'life situation' survey by the Central Bureau of Statistics in 1976 and 1982. The 4Q consists of the following four items "I still expect much from life," "I do not look forward to the years to come," "My days seem to pass by slowly," and "I am still full of plans" (our translations). The response format was a 3-point scale of frequency: "fully in agreement" (score, 0), "partially in agreement" (score, 1), and "not in agreement" (score, 2). The additional answer category "do not know" was also coded as the midpoint (score, 1). The scores of two questions needed to be reverse coded, so that higher scores indicated greater optimism. Higher scores (range 0–8) indicated higher dispositional optimism. The 4Q shows moderate internal consistency and has clinical predictive value for cardiovascular mortality [37]. For computation of the 4Q score, one missing item was allowed and was subsequently imputed with the mean of the remaining 3 items (n = 21 of 2355, 0.9%).
Assessment of biological measures
Blood handling procedures for the Alpha Omega Trial are described in detail elsewhere [38]. In brief, blood samples were obtained at the patient's home or at the hospital, packaged in sealed envelopes and sent via standard postal service to a central laboratory.
Serum creatinine and CysC were measured from stored blood samples in a central laboratory [31]. Serum creatinine was measured by the modified kinetic Jaffé method (Dimension Vista 1500 Analyzer; Siemens). We calibrated directly to the standard supplied by the manufacturer from the National Institute of Standards and Technology Standard Reference Material, and a post-calibration correction factor was applied [31]. Intra- and inter-assay variations for low creatinine (mean = 0.8 mg/dl) were 1.8 and 2.9%, respectively, and for high creatinine (mean = 3.9 mg/dl) they were 0.8 and 2.2%, respectively. Serum creatinine values < 0.6 mg/dl were unreliable (owing to technical failure or analytical disturbance; n = 82) and, therefore, not reported in accordance with the Standard Operating Procedure of the central laboratory.
Serum CysC was measured by means of a particle-enhanced immune nephelometric assay (NLatex Cystatin C, Dimension Vista 1500 Analyzer; Siemens). We used calibrators and assays of the same lot code, which was stable (no downward drift). CysC was calibrated directly using the standard supplied by the manufacturer (traceable to the International Federation of Clinical Chemistry Working Group for Standardization of Serum Cystatin C) [39]. The analytical measurement range of CysC was 0.23–8.00 mg/L. Intra- and inter-assay variations for low CysC (mean = 1.00 mg/L) were 1.3 and 4.2%, respectively, and for high CysC (mean = 1.75 mg/L) they were 2.9 and 2.8%, respectively.
We estimated GFR using the combined creatinine-CysC-based Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation from 2012, taking into account age, sex, and race [31]. In addition, we used the CysC-based eGFR from the CKD-EPI equation from 2012 as well as the creatinine based eGFR from the CKD-EPI equation from 2009 separately [31].
Serum hs-CRP was measured in stored serum samples (Nephelometric, Deimension Vista 1500 analyzer, Siemens). Intra- and inter-assay variation for low hs-CRP (mean = 1.0 mg/l) was 2.1 and 1.6%, respectively, and for high hs-CRP (mean = 2.8 mg/l) this was 2.0 and 2.4%, respectively.
Patients were interviewed and physically examined by trained research nurses at home or in the hospital. Information on demographic variables (i.e., age, sex, ethnicity, educational level), lifestyle habits (i.e. smoking status, alcohol use, and physical activity), medication use and medical history (i.e., time since myocardial infarction, and history of stroke) were collected by self-administered questionnaires, as previously described in detail [33]. Medication was coded according to the Anatomical Therapeutic Chemical Classification System (ATC). Anthropometric measures were measured, body mass index (BMI) was computed (kg/m2) and blood pressure was measured. Diabetes mellitus was considered present in the case of a self-reported physician diagnosis, use of antidiabetic drugs, and/or elevated blood glucose.
Patients were divided according to eGFR ≤ 60 or ≥ 60 ml/min per 1.73 m2 and also divided according to the hs-CRP level (<3 mg/l and ≥3 mg/l) based on the clinical cut-off point of 3 mg/l. Patient characteristics are listed in Table 1; data are presented as median (interquartile range), mean (±SD), or number (percentage of the total), where appropriate.
Table 1 Characteristics of the cohort of 2355 post-myocardial infarction patients according to creatinine-cystatin C-based eGFR and serum CRP level
Four eGFR categories were defined based on eGFR; ≥ 90, 60–89, 30–59, and < 30 ml/min/1.73 m2, using the CKD classification as proposed by the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines [40]. Clinical cut-points of CRP for risk of future cardiovascular events were used; levels <1, 1–3, 3–5, and ≥5 mg/L represent very low, low, mildly increased, and moderately to severely increased levels, respectively [41].
Because plasma concentrations of hs-CRP showed a positively skewed distribution, levels were loge transformed before analyses to yield a normal distribution. Mean GDS-15 and 4Q scores ± standard error as well as median (25th and 75th percentiles [P25, P75]) were calculated per eGFR and hs-CRP category. The Pearson's correlation coefficient was used to assess the association between the 12-item GDS depression score (excluding the 3 apathy items) and the 3-item GDS apathy score, as well as the association between the total GDS total score and the 4Q optimism score. The Pearson's correlation coefficient was calculated between the original optimism score and an optimism score in which all items with a "don't know" answer were imputed with the mean of the remaining items. A correlation coefficient of 0.95 (P < 0.001) was found in the 463 participants with at least one "don't know" answer, suggesting that "don't know" coded as the midpoint was unlikely to have distorted the total optimism score. Analysis of covariance (ANCOVA) was used to determine significance for linear trend over the four categories of eGFR and CRP levels. All adjusted analyses were corrected for the 4 randomized groups (because, in the original trial, patients were treated during 40 months with either n-3 fatty acids or placebo) [33].
Models were specified for multivariable testing to adjust for possible confounders. Model 1 adjusted for age, sex, level of education, and the 4 randomized treatment groups; model 2 additionally adjusted for BMI, smoking status, alcohol use, antidepressant use, time since myocardial infarction, stroke and diabetes; model 3 was the full model and additionally adjusted for the other possible predictor variables (either creatinine-CysC-based eGFR or hs-CRP level) to determine the independent association of eGFR and hs-CRP with depressive and apathy symptoms, and dispositional optimism. Moreover, we included all three mental well-being parameters (12-item GDS depression score (excluding the 3 apathy items), 3-item GDS apathy score and the 4Q optimism score) into one statistical model as independent variables with eGFR or hs-CRP as the dependent variables. Linear associations were tested using univariate regression analysis. Analyses were stratified for gender, and gender × predictor interaction terms were added to the full model 3 to test whether associations showed a significant difference between women and men.
Two additional sensitivity analyses were performed in which, first, we excluded all 221 participants with any missing items on any of the mental well-being questionnaires and, second, we also excluded all 463 participants with a "don't know" answer on the 4Q as well as the 221 participants with any missing items, leaving 1723 participants available for the analyses.
All analyses were conducted using IBM SPSS statistics 20.0 (SPSS, Inc., Chicago, IL, USA).
In the total group of 2355 patients, mean age was 72.3 years; 80.1% were men and 99.8% were Caucasian. Of all patients, 1750 (74%) had an eGFR ≥ 60 ml/min/1.73 m2. The remaining 605 (26%) patients with an eGFR < 60 ml/min/1.73 m2 were more often female, less physically active, used less alcohol, more often had diabetes, and had a higher mean level of hs-CRP than those with an eGFR ≥ 60 ml/min/1.73 m2. There were 1564 (66%) patients with a low hs-CRP level of ≤ 3 mg/L; the 791 patients with a high hs-CRP level were more often female, more often smoked, and used less alcohol than those with low hs-CRP (Table 1).
The Pearson's correlation coefficient showed that the association between the apathy score and the 12-item GDS depression score (excluding the 3 apathy items) was only 0.42. The complete 15-item GDS total score and the 4Q optimism score were inversely associated with a correlation coefficient of -0.63.
Kidney function and mental well-being
In the fully adjusted model, categories with lower eGFR showed a significant association with more depressive symptoms. Patients with an eGFR < 60 ml/min/1.73 m2 had significantly more depressive symptoms (mean GDS-15 score 2.70) than patients with an eGFR ≥ 60 ml/min/1.73 m2 (mean GDS-15 score 1.80). Categories with lower eGFR showed a significant association with more apathy symptoms. Patients with an eGFR ≥ 90 ml/min/1.73 m2 showed significantly less apathy than patients with an eGFR of 60–89 ml/min/1.73 m2. Categories with lower eGFR were also significantly associated with less dispositional optimism (Table 2).
Table 2 Categories of creatinine-cystatin C-based eGFR and serum level CRP in relation to depressive and apathy symptoms, and dispositional optimism in 2355 post-myocardial infarction patients
Likewise, linear regression analyses showed that a lower level of eGFR was linearly associated with more depressive symptoms (β = -0.084, p < 0.001) and with less dispositional optimism (β = 0.072, p = 0.002; Table 3). The association between a lower level of eGFR and more apathy symptoms was stronger (β = -0.101; p < 0.001). All these associations persisted after additional adjustment for hsCRP. Interaction terms showed that relations were similar in women and men (p > 0.30, for all three interaction terms). When including all three mental well-being parameters into one statistical model as independent variables with eGFR as the dependent variable, apathy (β = -0.066, p = 0.001) was the only significant correlate, whereas dispositional optimism (p = 0.12) and the 12-item GDS depression score (p = 0.99) were no longer significant. Moreover, when we excluded the 48 participants with a eGFR < 30 ml/min/1.73 m2 from the analyses, the eGFR was still inversely associated with apathy (β = -0.054, p = 0.01), independently from CRP and all other covariates.
Table 3 Associations of creatinine-cystatin C-based eGFR and serum CRP level with depressive and apathy symptoms, and dispositional optimism in 2355 post-myocardial infarction patients
C-reactive protein and mental well-being
In the fully adjusted model, categories of higher hs-CRP serum level showed a significant association with more depressive symptoms, more apathy symptoms and less dispositional optimism (Table 2). Linear regression analysis also showed that a higher level of hs-CRP was significantly associated with more depressive symptoms (β = 0.051; p = 0.013) more apathy symptoms (β = 0.083; p < 0.001) and less dispositional optimism (β = -0.047; p = 0.024). However, after additional adjustment for the eGFR, only the association with apathy remained significant (β = -0.065; p = 0.002). In Fig. 1, the adjusted relationship with categories of hs-CRP seem to depict a threshold effect for the CRP level of ≥ 7. Moreover, when including all three mental well-being parameters into one statistical model as independent variables with the log-transformed CRP level as the dependent variable, apathy (β = 0.082, p < 0.001) was the only significant correlate, whereas dispositional optimism (p = 0.40) and the 12-item GDS depression score (p = 0.36) were not.
Associations of the creatinine-cystatin C-based eGFR and serum CRP levels with apathy in 2355 post-myocardial infarction patients. Mean serum eGFR and CRP levels are shown with error bars representing standard errors (SE), adjusted for age, sex, education, body mass index, smoking status, alcohol use, antidepressant use, statin use, time since myocardial infarction, stroke, and diabetes. The box sizes represent the relative number of patients
When testing for interaction, the interaction term for gender × hs-CRP was significant for depression (β = 0.129, p = 0.008), not significant for apathy (β = 0.076, p = 0.12), and of borderline significance for optimism (β = -0.088, p = 0.074). In subsequent stratified analyses, associations with depressive symptoms (β = 0.064, p = 0.007), apathy symptoms (β = 0.079, p = 0.001) and optimism (β = -0.059 p = 0.014) were stronger in men than in women.
Sensitivity analysis in 2134 and 1723 participants (i.e. excluding those with missing values and "don't know" answer category) showed that the relationship between eGFR and CRP on the one hand, and depressive/apathy symptoms and optimism on the other, were hardly affected. In particular, there was no attenuation as, in the adjusted model, the relationship with CRP increased in strength in the sample of 1723 participants.
The present results show that kidney dysfunction (reflected by a lower eGFR) and systemic inflammation (reflected by a higher hs-CRP level) were independently associated with apathy in post-myocardial infarction patients. The associations with depressive symptoms and dispositional optimism were less robust. Kidney dysfunction showed a linear and somewhat stronger association for apathy than for systemic inflammation, for which there seemed to be a threshold value of 7 mg/L.
We are not aware of previous studies that assessed the relation between kidney dysfunction and apathy symptoms in a large cohort. Nevertheless, our findings are in line with others reporting that patients with an eGFR < 30 ml/min/1.73 m2 had more depressive symptoms than patients with an eGFR ≥ 90 ml/min/1.73 m2 [14–16]. We extended these findings by showing that an increase in depressive symptoms was already present in patients with an eGFR < 60 ml/min/1.73 m2 compared to those with a better eGFR. Low apathy was found within the normal range of kidney function. On the other hand, our results are in contrast to those of the only other large study on CHD patients (n = 967) that did not find more depressive symptoms in patients with an eGFR < 60 ml/min/1.73 m2 compared to those with an eGFR of ≥ 60 ml/min/1.73 m2 [18]. However, this latter study dichotomized kidney function at < 60 ml/min/1.73 m2 which reduced the statistical power, and did not include CysC levels or apathy in their analyses. A study in a general population sample of over 28,000 individuals showed an inverse, linear trend relation between kidney function and depression, which did not persist in the multivariable model [14]; however, in that study depression was measured using the 4-item Center for Epidemiologic Studies Depression Scale during a telephone interview and, again, neither CysC levels nor apathy were assessed. We have extended these findings by showing a linear trend relation between eGFR and depressive symptoms, which was strongest for the apathy subscale.
Several mechanisms could be involved in the relation between kidney dysfunction and apathy. For example, the vascular apathy hypothesis is suggested to underlie the relation between vascular disease and apathy symptoms [24]. Atherosclerosis may have caused renal vascular disease resulting in poorer eGFR as well as cerebrovascular disease causing brain ischemia which may result in apathy. The accumulation of uremic toxins causes encephalopathy in patients with kidney failure [42]. In patients with less severe kidney impairment, the neurotoxic effect of the accumulation of uremic toxins might have resulted in less extreme symptoms of apathy. Furthermore, anemia is a well-known complication of chronic kidney disease and could be part of the causal pathway to apathy. Also, apathy symptoms might overlap with other symptoms that occur in patients with kidney dysfunction. For example, fatigue shows some similarity with apathy and is one of the most frequently mentioned symptoms in patients with severe kidney dysfunction [43]. However, most studies on the relation between fatigue and psychological factors focused on depression and anxiety, but did not assess apathy. Finally, a third factor, related to aging, may underlie both apathy, inflammation and kidney dysfunction.
Earlier studies in CHD patients found no association between CRP levels and depressive symptoms [20, 23, 44]. However, the use of statins (and possibly beta-blockers and anti-depressants) may have reduced the inflammatory state [45–47] and thereby obscured the relation between CRP and depressive symptoms. In our study, however, an even higher proportion of patients used statins (87.7%) than in these latter studies; moreover, our study sample was larger than that of earlier studies [20, 23, 44]. Our findings are in line with the results of a large meta-analysis which also found that higher CRP levels were associated with more depressive symptoms in healthy individuals [19]. Also, for CRP levels we found that the strongest association was with the apathy subscale. Eurlings et al. found a concomitant relation between inflammation and apathy symptoms, and suggested that apathy symptoms may be part of sickness behavior, which can be described as a motivational state that reorganizes the organism's priorities to cope with systemic inflammation and infectious disease [29]. Kidney dysfunction may have caused a higher systemic inflammatory state [8] which, in turn, resulted in more apathy. However, this hypothesis was only partly supported by our results which show that the relation between eGFR and apathy symptoms is largely independent of CRP levels.
As opposed to depressive symptoms, optimism has been associated with better health outcomes (such as survival) in CHD patients and the general population [48–51]. Both behavioral (e.g. healthy diet, physical activity, and non-smoking) and biological pathways have been suggested as mechanistic explanations. In CHD patients we found a significant relation between eGFR and dispositional optimism, and an inverse relation between CRP levels and dispositional optimism. Other studies found no relation between CRP and optimism or other measures of positive affect, but did find an inverse relation with other markers of inflammation, such as interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-α) [52–54].
Some limitations of the present study need to be addressed. First, because psychological measures were assessed at 40 months only, we were unable to address potential temporal relations. Second, because our cohort consisted of post-myocardial infarction patients, the results cannot be extrapolated to other populations. Third, depressive symptoms were assessed using a questionnaire with 15 relatively crude 'yes/no' answer categories. Fourth, because we lacked information on proteinuria or hematuria we could not distinguish between the presence or absence of chronic kidney disease in patients with an eGFR of 60–89 ml/min/1.73 m2.
However, our study also has several strengths. The study had a large enough sample size to detect small but significant effects. Moreover, we used the combined creatinine-CysC-based CKD-EPI equation to estimate the eGFR, which is considered more accurate than creatinine-based eGFR [31]. Also, use of the GDS-15 to assess depressive symptoms excluded certain somatic symptoms which might be due to medical illness in elderly medical patients [35]. Finally, it has been shown in cardiac patients that, compared with the Beck Depression Inventory (BDI) I and II, the GDS was better able to differentiate between those who are depressed and those who are not depressed [55].
In conclusion, the present study shows a significant independent association between kidney dysfunction and apathy in post-myocardial infarction patients. This association was already apparent within the mild kidney dysfunction range. This implies that, at the population level, the impact of kidney dysfunction on mental well-being may be large, since we found that 26% of post-myocardial patients suffer from kidney dysfunction (eGFR <60 ml/min/1.73 m2).
4Q:
4-item Optimism Questionnaire
CHD:
CRP:
CysC:
Estimated glomerular filtration rate
GDS-15:
15-item Geriatric Depression Scale
hs-CRP:
High-sensitivity CRP
MDD:
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Van der Mast R, Vinkers D, Stek M, Bek M, Westendorp R, Gussekloo J, et al. Vascular disease and apathy in old age. The Leiden 85‐plus study. Int J Geriatr Psychiatry. 2008;23:266–71.
Ligthart SA, Richard E, Fransen NL, Eurelings LS, Beem L, Eikelenboom P, et al. Association of vascular factors with apathy in community-dwelling elderly individuals. Arch Gen Psychiatry. 2012;69:636–42.
Eurelings LS, Ligthart SA, Dalen JW, Moll van Charante EP, Gool WA, Richard E. Apathy is an independent risk factor for incident cardiovascular disease in the older individual: a population‐based cohort study. Int J Geriatr Psychiatry. 2014;29:454–63.
Marin RS. Apathy: a neuropsychiatric syndrome. J Neuropsychiatry Clin Neurosci. 1991;3:243–54.
Maas D, Van der Mast R, de Craen A. Increased c‐reactive protein is not associated with apathy: the Leiden 85‐plus study. Int J Geriatr Psychiatry. 2009;24:1177–84.
Eurelings LS, Richard E, Eikelenboom P, van Gool WA, Moll van Charante EP. Low-grade inflammation differentiates between symptoms of apathy and depression in community-dwelling older individuals. Int Psychogeriatr. 2015;27:639–47.
Scheier MF, Carver CS, Bridges MW. Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): a reevaluation of the life orientation test. JPersSoc Psychol. 1994;67:1063–78.
Inker LA, Schmid CH, Tighiouart H, Eckfeldt JH, Feldman HI, Greene T, et al. Estimating glomerular filtration rate from serum creatinine and cystatin c. N Engl J Med. 2012;367:20–9.
Geleijnse JM, Giltay EJ, Schouten EG, de Goede J, Griep LMO, Teitsma-Jansen AM, et al. Effect of low doses of n-3 fatty acids on cardiovascular diseases in 4,837 post-myocardial infarction patients: design and baseline characteristics of the alpha omega trial. Am Heart J. 2010;159:539–46.
Kromhout D, Giltay EJ, Geleijnse JM. N–3 fatty acids and cardiovascular events after myocardial infarction. N Engl J Med. 2010;363:2015–26.
D'ATH P, Katona P, Mullan E, Evans S, Katona C. Screening, detection and management of depression in elderly primary care attenders. I: The acceptability and performance of the 15 item geriatric depression scale (gds15) and the development of short versions. Fam Pract. 1994;11:260–6.
Pomeroy IM, Clark CR, Philp I. The effectiveness of very short scales for depression screening in elderly medical patients. Int J Geriatr Psychiatry. 2001;16:321–6.
Starkstein SE, Mayberg HS, Preziosi T, Andrezejewski P, Leiguarda R, Robinson R. Reliability, validity, and clinical correlates of apathy in parkinson's disease. J Neuropsychiatry Clin Neurosci. 1992;4:134–9.
Giltay EJ, Kamphuis MH, Kalmijn S, Zitman FG, Kromhout D. Dispositional optimism and the risk of cardiovascular death: the zutphen elderly study. Arch Intern Med. 2006;166:431–6.
Giltay EJ, Geleijnse JM, Schouten EG, Katan MB, Kromhout D. High stability of markers of cardiovascular risk in blood samples. Clin Chem. 2003;49:652–5.
Grubb A, Blirup-Jensen S, Lindström V, Schmidt C, Althaus H, Zegers I. First certified reference material for cystatin c in human serum erm-da471/ifcc. Eur J Clin Chem Clin Biochem. 2010;48:1619–21.
Levey AS, Coresh J, Balk E, Kausz AT, Levin A, Steffes MW, et al. National kidney foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med. 2003;139:137–47.
Ridker PM, Rifai N, Rose L, Buring JE, Cook NR. Comparison of c-reactive protein and low-density lipoprotein cholesterol levels in the prediction of first cardiovascular events. N Engl J Med. 2002;347:1557–65.
Seifter JL, Samuels MA. Uremic encephalopathy and other brain disorders associated with renal failure. Semin Neurol. 2011;31:139–43.
Curtin RB, Bultman DC, Thomas-Hawkins C, Walters BA, Schatell D. Hemodialysis patients' symptom experiences: effects on physical and mental functioning. ANNA J. 2002;29:562–74.
Steptoe A, Wikman A, Molloy GJ, Messerli-Bürgy N, Kaski J-C. Inflammation and symptoms of depression and anxiety in patients with acute coronary heart disease. Brain Behav Immun. 2013;31:183–8.
Ridker P. Should statin therapy be considered for patients with elevated c-reactive protein? the need for a definitive clinical trial. Eur Heart J. 2001;22:2135–7.
Kenis G, Maes M. Effects of antidepressants on the production of cytokines. Int J Neuropsychopharmacol. 2002;5:401–12.
Lanza GA, Pitocco D, Navarese EP, Sestito A, Sgueglia GA, Manto A, et al. Association between cardiac autonomic dysfunction and inflammation in type 1 diabetic patients: effect of beta-blockade. Eur Heart J. 2007;28:814–20.
Scheier MF, Matthews KA, Owens JF, Magovern GJ, Lefebvre RC, Abbott RA, et al. Dispositional optimism and recovery from coronary artery bypass surgery: the beneficial effects on physical and psychological well-being. J Pers Soc Psychol. 1989;57:1024–40.
Scheier MF, Matthews KA, Owens JF, Schulz R, Bridges MW, Magovern GJ, et al. Optimism and rehospitalization after coronary artery bypass graft surgery. Arch Intern Med. 1999;159:829–35.
Leedham B, Meyerowitz BE, Muirhead J, Frist WH. Positive expectations predict health after heart transplantation. Health Psychol. 1995;14:74–9.
Agarwal M, Dalal A, Agarwal D, Agarwal R. Positive life orientation and recovery from myocardial infarction. Soc Sci Med. 1995;40:125–30.
Roy B, Diez-Roux AV, Seeman T, Ranjit N, Shea S, Cushman M. The association of optimism and pessimism with inflammation and hemostasis in the multi-ethnic study of atherosclerosis (MESA). Psych Med. 2010;72:134–40.
Ikeda A, Schwartz J, Peters JL, Fang S, Spiro III A, Sparrow D, et al. Optimism in relation to inflammation and endothelial dysfunction in older men: the va normative aging study. Psych Med. 2011;73:664–71.
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Low GD, Hubley AM. Screening for depression after cardiac events using the beck depression inventory-ii and the geriatric depression scale. Soc Indic Res. 2007;82:527–43.
All data supporting the study are presented in the manuscript or are available on request from the corresponding author (R.H.M. Heeres).
Substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data: RHMH, EKH, JMG, JG, DK, EJG; drafting the manuscript or revising it critically for important intellectual content: RHMH, EKH, JMG, JG, DK, EJG; final approval of the version to be published: RHMH, EKH, JMG, JG, DK, EJG; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: RHMH, EKH, JMG, JG, DK, EJG. Each author participated sufficiently in the work to take public responsibility for appropriate portions of the content. All authors read and approved the final manuscript.
The Alpha Omega Trial was conducted in accordance with the Declaration of Helsinki and was approved by a central Medical Ethics Committee in the Netherlands (Haga Hospital, Leyenburg, The Hague, Netherlands, Office for Human Research Protections #IORG0004004) and by the committees of all participating hospitals. Written informed consent was obtained from all patients.
Department of Psychiatry, Leiden University Medical Center, Postbus 9600, 2300, RC, Leiden, Netherlands
Rick H. M. Heeres & Erik J. Giltay
Departments of Internal Medicine and Nephrology, Jeroen Bosch Hospital, Den Bosch, Netherlands
Ellen K. Hoogeveen
Division of Human Nutrition, Wageningen University, Wageningen, Netherlands
Johanna M. Geleijnse, Janette de Goede & Daan Kromhout
Rick H. M. Heeres
Johanna M. Geleijnse
Janette de Goede
Daan Kromhout
Erik J. Giltay
Correspondence to Rick H. M. Heeres.
Heeres, R.H.M., Hoogeveen, E.K., Geleijnse, J.M. et al. Kidney dysfunction, systemic inflammation and mental well-being in elderly post-myocardial infarction patients. BMC Psychol 5, 1 (2017). https://doi.org/10.1186/s40359-016-0170-z
Kidney dysfunction
Systemic inflammation
Depressive symptoms
Dispositional optimism


Blood Sugar Balance Supplement. Control Glucose, Insulin and Cholesterol.
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KEEP YOUR BLOOD SUGAR LEVELS BALANCED: One of the most important steps you can take for overall health and vitality. BioScience Nutrition's Blood Sugar Support correct these deficiencies and help restore normal metabolic activity. When you control your blood sugar, hunger pangs decrease and weight loss becomes easier.
Blood sugar balance is a natrual supplement formulared to enhance the healthy functioning of insulin.
Reduce the upward & downward fluctuation in the blood sugar levels & improves glucose metabolism.
❤ SUPPORT NORMAL BLOOD LEVELS WITH POWERFUL HERBS AND ANTIOXIDANTS: Contains a herbal blend of effective nutrients, vitamins, and antioxidants that are effective in supporting normal blood levels and help you to maintain overall health by fighting free radicals in your body.
❤ PROMOTES CARDIOVASCULAR HEALTH: Blood Sugar Balance is composed of natural herbs, vitamins, and minerals that support cardiovascular health. It aids in reducing cholesterol and supports well-balanced blood pressure. In promoting healthy insulin function by lowering blood glucose levels, this unique blend may assist in achieving natural weight loss.
❤ BLOOD SUGAR BALANCE: Is formulated to help the body maintain healthy blood sugar levels that are in the normal range. The key herbs include Cinnamon, Gymnema Sylvestre, Banaba, Bitter Melon, and Guggul. Also added are effective amounts of Chromium Picolinate, Vitamin C, and Vitamin E.
Vitamin C 50 mg, Vitamin E 15 IU, Biotin 300 mcg, Magnesium 125mg, Zinc 7.5mg, Manganese 1mg, Chromium 67mcg, Banaba Leaf (1% extract) 25mg, Guggul 50mg, Bitter Melon 50mg, Licorice Root Extract 50mg, Cinnamon Bark Powder 50mg, Gymnema Sylvestre Leaf Powder 50mg, Yarrow Flowers Powder 25mg, Cayenne Pepper Powder (40M HU/G) 10mg, Juniper Berry Powder 25mg, White Mulberry Leaf Powder 25mg, Vanadium 200mcg, Alpha Lipoic Acid 30 mg, L-Taurine 25mg.


text:
Chamber is the 'Voice of Business'
The Chamber is actively engaged in issues advocacy and speaks out to influence public policy decisions at the local, state and federal levels.
Chris Turner is the Chair of the Chamber's Public & Government Affairs Committee, which constantly monitors legislative and regulatory issues.
"Government affairs is a primary focus for our Chamber," he said. He alerts the rest of the board to local, state and national government changes and initiatives.
A top priority at the state level is to preserve and protect the existing School Calendar Law…and maintain the uniform school start date," Brown said. "The health of our tourism-based economy depends on summer tourism revenues."
Each year, the Board of Directors develops a list of priorities – the issues that are most important to the small businesses that we represent.
The Chamber does not support or endorse any candidate for public office at any level, because we need to work with elected officials on both sides of the political aisle to foster a pro-business climate.
In coastal North Carolina, we are the "Voice of Business." Hear us loud and clear about that.
Mary Carlyle Brown and her husband, Steve Brown, are real estate brokers with Landmark Sotheby's International Realty.
Former Judge Doug McCullough of Atlantic Beach, who served on the North Carolina Court of Appeals (left), frequently attends Chamber events. He is shown with Chamber Board Member Bill Rogerson.
The Chamber has hosted Legislative Luncheons before and after session of the General Assembly. Shown are: Gus Tulloss of Gus H. Tulloss Insurance; Rep. Pat McElraft; and Sen. Norman Sanderson.

redpajama_set_name: RedPajamaCommonCrawl


text:
Breach Notification , Business Email Compromise (BEC) , Fraud Management & Cybercrime
Clinic Notifies 212,500 About 2020 Breach Involving Fraud
Practice Says Compromised Email Accounts Were 'Voluminous' Marianne Kolbasuk McGee (HealthInfoSec) • January 4, 2022
A Florida-based gastroenterology practice is in the process of notifying more than 212,500 individuals of a December 2020 breach involving business email compromise and fraud.
Florida Digestive Health Specialists LLP on Dec. 27 reported to the state of Maine's attorney general office that an email breach discovered more than a year earlier involving wire fraud, has affected 212,509 individuals, including 11 Maine residents.
Lakewood Ranch, Florida-based FDHS has more than a dozen healthcare locations throughout the state.
"On Dec. 16, 2020, an employee noted suspicious activity within their FDHS email account that resulted in suspicious emails having been sent from their employee account," FDHS says in a Dec. 27 breach notification statement.
"Several days later, on Dec. 21, 2020, FDHS learned that funds had been misrouted to an unknown bank account."
'Voluminous' Email Accounts
FDHS says it immediately began an investigation and found that "a limited number" of FHS employee email accounts had been accessed by unauthorized users.
"That investigation was involved and, though access was confined to a limited number of FDHS email accounts, those accounts were voluminous," the breach notification statement says.
FDHS says it investigated to determine what information was contained in the compromised email accounts, assessing whether it constituted personal information, protected health information, or other confidential information, and to whom that information belonged.
"This process took a considerable amount of time and only concluded on Nov. 19, 2021," FDHS says.
The PHI contained in the affected email accounts include individuals' first and last names, address, date of birth, Social Security number, financial information, health insurance information, medical information, diagnosis, health insurance individual policy number, and Medicare/Medicaid information, FDHS says in its notification statement.
Breach Notification Duties
As of Tuesday, the FDHS incident had not yet been posted to the U.S. Department of Health and Human Services' HIPAA Breach Reporting Tool website listing health data breaches affecting 500 or more individuals.
Under the HIPAA breach notification rule, individual notifications must be provided without unreasonable delay and in no case later than 60 days following the discovery of a breach, according to HHS' Office for Civil Rights. Additionally, for PHI breaches affecting 500 or more individuals, covered entities must notify HHS no later than 60 days following a breach.
But aside from HIPAA, all 50 states, as well as Washington D.C., and Puerto Rico, have breach notification laws with varying reporting deadlines, experts note.
"Each state and regulatory body is potentially going to have their own reporting requirements. Often, variables, such as, the number of individuals affected, will determine the required course of action," says Benjamin Denkers, chief innovation officer at privacy and security consultancy CynergisTek.
Reducing Risk
FDHS is certainly not the first covered entity to report a major health data breach or to notify affected individuals many months past the general HIPAA breach notification 60-day deadline (see: Osteopathic Professional Group Reports Year-Old Breach).
In some recent data security incidents, including various ransomware attacks, authorities occasionally request an organization to delay breach notification, such as when a law enforcement official states it would impede a criminal investigation or cause damage to national security (see: Ransomware Roundup: Healthcare Sector's Latest Victims).
For instance, on Jan. 2, another Florida-based healthcare entity, Fort Lauderdale-based Broward Health, began notifying 1.3 million individuals of a data exfiltration breach discovered in October. Broward Health says the U.S. Department of Justice had requested that the entity "briefly delay" notification about the breach due to an ongoing law enforcement investigation into the incident.
FDHS Statement
A FDHS spokesman tells Information Security Media Group there is no evidence that any of the affected individuals' information has been used for malicious or fraudulent purposes. The wire fraud incident involved only affected FDHS, and not fraud committed against the entity's patients or employees, he says.
The incident was reported to law enforcement. FDHS continues to cooperate with that investigation, he adds.
So far, FDHS's investigation has not conclusively determined how the incident occurred. However, the forensic analysis has found no evidence that any other FDHS systems were impacted as part of this event, he says.
In its breach notification statement, FDHS says it is offering affected individuals complementary credit monitoring and identity restoration services for 12 months.
Additionally, FDHS says it has taken steps to bolster data security, including resetting passwords and strengthening password protocols, enabling multifactor authentication throughout its IT systems, and reconfiguring its firewall.
"I think anytime a malicious individual has sensitive information, it should be pause for concern. The question is what do you do about it?" Denkers says. "Credit monitoring, credit freezing, routinely changing passwords, and enabling multifactor authentication on everything are all ways victims can help minimize potential impact," he says.
"Attackers' tools, techniques and procedures are constantly evolving," Denkers says. "Organizations need to be continually validating that technical controls and safeguards in place are effective and working as designed."
When it comes to preventing business email compromises that lead to potential fraud, Denkers says aside from technical controls, organizations should also have business processes in place that validate financial transactions are legitimate.
"These types of processes can help catch when a business email compromise has happened, prior to funds being lost."
Microsoft Exchange Fixes Disruptive 'Y2K22' Bug
Microsoft: Log4j Exploit Attempts, Testing Remain Rampant
Frost & Sullivan Executive Brief: Beyond The Cloud
CISO Guide to Business Email Compromise - How to Stop the $1.8 Billion Problem
A Perfect Storm for Social Engineering: Anticipating the Human Factor in Post-Pandemic Cybersecurity
https://www.healthcareinfosecurity.com/clinic-notifies-212500-about-2020-breach-involving-fraud-a-18238


text:
Class of 2021: Inclusive Post-Secondary Education grads get set for life after university
Darius Leung, Siobhan Zobatar to attend virtual convocation June 10
Casey Blais, Student and Enrolment Services
Darius Leung, left, and Siobhan Zobatar.
The Inclusive Post-Secondary Education (IPSE) program at the University of Calgary will see two of its students graduate this year. After five years of study, Darius Leung and Siobhan Zobatar will each receive their Certificate of Completion during the university's virtual convocation ceremony on June 10.
The IPSE program provides individuals with developmental disabilities a university experience and support as they transition to employment. Students take two university courses each fall and winter semester for five years. An IPSE facilitator supports each student through their studies, but the students are empowered to work as much as they can on their own. The program is administered by the IPSE Society of Alberta who are housed in the Education Tower (rooms 051-054) and have been working with the University of Calgary since 1992 creating positive inclusive spaces in the community.
Darius Leung
Darius Leung.
By his own account, Leung really came into his own in the last two years of study. He said the more comfortable he became at the university, the more he learned.
"Sometimes for me, change isn't something I can deal with easily, but I'm willing to go for it," Leung says.
He found many challenges at university. He jokingly says that getting up early was a real challenge, but on a serious note, he found tests, essays, and assignments difficult, especially when he was not working one-on-one with his facilitator. However, sometimes he surprised himself.
"I had to write a 12-page essay in Latin American Studies," he says. "It was difficult, but I managed to get a B+ without facilitator help."
He says he enjoyed his university experience a lot and it was a far cry from the drama found in high school. He says he was able to make new friends at university, and people were more mature. He plans to start looking for work right away and says he would like to find something in customer service.
Favourite class: History 301
Typical university schedule: 9 a.m. – 5 p.m., Monday to Friday
Favourite student club: Pokémon Club
Commute: Bus
Advice for new students: University might be a bit big and you might get a bit lost, but you'll find your way eventually.
Siobhan Zobatar
Siobhan Zobatar.
University study helped Zobatar grow into a much more confident and independent woman. She illustrates just how much she has grown by pointing out that she learned to take transit on her own to university.
"Being a student, getting educated and learning made me feel excited and happy," says Zobatar. "My parents got to see me grow."
Zobatar says she put in a lot of hard work. She would go to class, then her facilitator would help her for an hour, and then she would work another hour or so on her own. She says her facilitator helped her with her speech, typing lessons and worksheets, in addition to course work.
It was not all hard work. While at university, she says she enjoyed participating in many activities offered through clubs like Zumba, and especially improv.
The pandemic was a huge challenge for her. She says she missed going to in-person classes and was especially tired of Zoom by the end of her studies.
"It's been so long and I missed my friends," Zobatar says.
Zobatar says she plans to continue her learning and development in the Graduate Support Services program run by the IPSE Society of Alberta. Through this program, she will undergo employment preparation, development of soft skills and have direct on-site support from a facilitator.
"Hopefully I get a job soon," says Zobatar. "I'd like to work in a bakery."
Favourite class: Geology 307
Typical university schedule: 4 – 5 hours per day, Monday to Thursday
Favourite student club: Improv Club
Advice for new students: Do not be too scared or nervous. It is not so bad.
Class of 2021: When the teacher becomes the student
Class of 2021: Love of country life leads new doctor to rural practice
students in profile


Mutual Fund investors in debt schemes are facing a scare as the asset management companies have started delaying redemption in many of the fixed maturity plans (FMPs), due to their exposure to Subhash Chandra-led Essel Group.
The FMPs of mutual fund industry, led by Aditya Birla Sun Life, have an estimated exposure of over Rs 7,500 crore to Essel Group debt papers. Around 55 close-ended FMPs have over Rs 1,700 crore maturing over the next three months. Aditya Birla Sun Life has over Rs 2,500 crore exposure in Essel Group.
The issue started with one of the Kotak Asset Management's fixed maturity plans (FMP), that matured on April 8, deferred the payment to investors. The delay in the repayment to the investors came on the back of the asset manager not able to collect payments from three stressed firms.
"We are working closely with the Essel Group for optimal recovery from Konti and Edisons for the benefit of our unit holders and believe that such recovery will take place albeit with some delay," Kotak spokesperson told DH.
The company also claimed that for IL&FS Transportation Networks, it has made a 100% provision for this investment as the company has been classified in the Red category where recovery is uncertain and will be dependent on the resolution plan.
The two FMP series – 187 and 127 – that are maturing this month has cumulative Assets under Management (AUM) of Rs 951 crore and exposure of Rs 186 crore to the Subhash Chandra-owned Zee Group.
Other than this, six FMPs of Kotak Mutual Fund with AUM of Rs 2,094 crore maturing in the next one month, have invested Rs 358 crore in the debt papers issued by the Zee Group.
A cross spectrum of market traders and Mutual Fund analysts that DH spoke to said that it was Chandra who is to blame for the mess. "He raised money from banks on personal name. How can we justify now that he's a willful defaulter or not," said a top executive of an AMC, wishing anonymity.
However, the banks, who have an exposure of almost Rs 13,000 crore to Essel Group, in late January, had stopped short from liquidation of the stake in the stressed companies, fearing a drop in the valuation.
A liquidation of about Rs 200 crore worth of Zee shares resulted in a drop of 3% in its value.


… and secretly we are proud that our customers do not fit in the standard profile of our [downstream] network provider. To thank you for your active contribution [?? i did not even notice the whole thing] and in order to compensate you for your troubles we are sending you a unique t-shirt. It has been specially designed for this occasion and is produced in limited edition. we hope that you will wear this t-shirt with pride and that you will continue to download a lot with XS4ALL only.


text:
Home Brandon Monument Finds Home At Private Brandon Cemetery With Confederate Ties
Monument Finds Home At Private Brandon Cemetery With Confederate Ties
Photo Credit Nancy Nahas Memoria In Aeterna is a 106-year-old monument. The Confederate soldier (left) is facing south and the Union Soldier is facing north.
Photo Credit Nancy Nahas
Memoria In Aeterna is a 106-year-old monument. The Confederate soldier (left) is facing south and the Union Soldier is facing north.
The Brandon Family Cemetery, a quiet, privately-owned family cemetery, calling five generations of founding area families home, located on the corner of Brandon Blvd. and Lithia Pinecrest Rd., is the new home of a 107-year-old Confederate monument. Hillsborough County Commissioners voted 4-2 last summer to relocate it from the county courthouse after issues were raised about the statue being located on public county property.
According to County Commissioner Stacy White, the decision was made to move the monument to the Brandon Family Cemetery, where the founder of Brandon, John Brandon, and generations of family after him, is buried and members of the family, who served in the Confederate military forces, are buried there. There is also an existing Confederate memorial on the site.
According to White, this option was endorsed by key chapters of the United Daughters of the Confederacy as well as the Brandon family. The Brandon family has a track record of working with both the United Daughters of the Confederacy and the Sons of Confederate Veterans in their mission of remembering Confederate military personnel and history.
Some members of the commission stipulated that private funds must be used and had to be raised within 30 days to have the statue moved. The financial goal of $150,000 was met in just one day.
The statue was commissioned in 1911 by the United Daughters of the Confederacy and the Sons of Confederate Veterans. The Confederate Battle Flag is depicted on the front of the monument, and the dates 1861 to 1865 refer to the beginning and ending of the war between the states. The poem inscribed on the east side was written by Sister Esther Carlotta, a Roman Catholic nun.
According to the historical marker that accompanied the monument, the soldier facing north has been interpreted as the determined warrior facing the invader at the beginning of the war, while the soldier facing south is viewed as a young soldier returning home from conflict in a tattered uniform, wounded but not forgotten.
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Here's a product I thought I'd shared with you already , but searching the forum I see I haven't. I guess I was waiting for it to come in the mail.
This is an innovative product, that is versitile, portable, and truly brings good taste wherever you go.
My free sample ( go here to get yours!) came in the mail on Friday. I couldn't wait to try it, so today when having our Shabbat meal I decided to try out one on the sardines in our salads. The Sample includes two lemon, one orange and one lime. So I opened the little packet of one of the truelemons and sprinkled some on each of the sardines, and the rest I poured into my water glass. I added no sugar, but you could if you like sweet lemonade, but I prefer more refreshing.
The lemon on the sardines was subtle because there was only a bit on each one, but was dicernable, and a true lemon taste, which must come from the lemon oil in the ingredients.
So far I am thrilled and am dreaming up ways to use this.
You also will get a 40c coupon with your sample and where and how to find this at your local stores. As well as some hints and recipes. It is also available online.
Bonus, when you request a sample they also send some to our troops, is that great or what?
So, there it is, True Lemon, True Lime and True Orange.
I finally found this in my store and purchased the lemon and lime. Now I can stop hoarding the two packets I have left. I will give some to hubby to take to add to his water at work. Also I will keep some in the glove box so when I go out with my always bottle of water or that is the only thing I can buy to eat or drink at Borders, I have something to put in it to make it better tasting and not think I am being so deprived!
So have you sent for your free sample yet? Please do so, they are still sending 10 packets for each request, so please tell your friends to help out our soldiers. Right now you can also get a downloadable coupon for $1.00 and at around $2.59 a box that is a good bargain. The box I got has 32 packets in it for that price. I don't know of anything else GF that can give you so much flavor for so little a price.
Lets start making some recipes ideas for this great product. I can't always get lemons at the store because of the price or availability or just getting there so this is great, anytime you want to make something and add that special flavor of fresh lemon.
I am going to start a thread for us to post in the recipe forum to use this wonderful product!
Here's the link for the recipe ideas!


See new with free download links a list of the best WordPress testimonials plugins to show to your visitors what your site users or clients have to say about your company or your services.
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WordPress Testimonials plugins generally work by allowing you to add testimonials to your website in the form of custom post types — and give you a variety of ways to display your testimonials as widgets, full pages, slideshows, and more. Many of them also offer various ways to not only display testimonials, but also collect them, such as by adding a form to your website for visitors to fill in, or even gathering them for you via social media!
have some unique feature(s) to set them apart from the rest!
Hopefully you'll find this list extremely useful in helping you find the perfect testimonial plugin — and if, by chance, we happen to have missed your favorite plugin, let us know in the comments below!
Easy Testimonials is an easy-to-use, basic plugin that still packs a lot of features. It's also one of the most popular, with over 80,000 downloads and a rating of 4.6 stars! And I have to say, it's my favorite on this list — I've been using it on several of my sites for a quite while now.
With Easy Testimonials, you can display your testimonials as a customized widget, or add them to any post or page with a variety of shortcodes. You can also use the Settings menu to generate your own shortcodes with custom display options.
One of the best features of this plugin is the ability to control how the testimonials display. There are over 30 different display styles you can choose from, so you can customize the look without having to learn CSS. There's also a field in the settings menu to enter custom CSS if you want to fine-tune the display further.
The plugin is pretty self-explanatory and simple to use, but it also has extensive documentation if you get stuck. Many of the reviews also note that the developer is quick to help out with any issues.
There's also a Pro version that lets you collect testimonials on your website front end with a form, among other premium features.
…to list but four of many!
Testimonials Widget is one of the most popular testimonial plugins, and when you look at all the included features, it's easy to see why.
With this plugin, you're not just limited to testimonials, you can also use it to display portfolio projects and reviews. Each testimonial can include videos as well as images and text, and supports categories and tags, and review schema for rich snippets. Once created, the plugin lets you display each of these via shortcodes, widgets, or functions in your theme files.
…and ideal choice then, for a designer/developer wishing to display a range of different types of client testimonials on a portfolio website, for example.
There's also a premium version available that includes both support from the developer and a lot more features. Note: although the free version doesn't include direct support, it's worth mention that there's an available knowledge base that provides a certain level of community support.
Testimonial Basics is a simple and easy-to-use plugin that make it very easy to add testimonials without complicated options and configurations. There are styling options, including nine different fonts, so you can customize the look easily without having to know any CSS. Many of the reviews note how easy it is to configure and use — a great choice then perhaps, if you don't want to spend much time figuring things out or messing with any code.
There are input forms included, either as shortcodes or widgets, so you can collect testimonials from customers/clients directly on your website. You can also display your testimonials with shortcodes or widgets. Furthermore, this particular plugin is also available in French, Dutch, German, and Spanish.
HMS Testimonials is a little different because it includes absolutely zero styling out of the box. You'll have to know CSS in order to style your testimonials.
It does have some interesting features though, including a drag-and-drop editor for you to create your own page templates on which to display your testimonials. You can also add custom fields to your testimonials to display whatever additional information you'd like.
This is a basic, flexible plugin that's ideal for those who know their way around code but don't want to create a plugin from scratch. The developer is also very involved with the userbase and open to suggestions, and often incorporates new features to the plugin based on user suggestions.
Kudobuzz Testimonials is not as popular as the others on this list with just over 2,000 downloads, but it's highly rated and has some interesting features that set it apart from the other plugins on this list.
In addition to adding your own testimonials (or "kudos"), Kudobuzz also automatically gathers positive mentions of you on Facebook, Twitter, Google+, and blogs around the web.
In order to use this plugin, you'll have to create an account at Kudobuzz.com to use the plugin. Once you do, you can connect your social media accounts, and it'll start tracking your mentions for you. This is a really great, easy way to save complimentary mentions on social media. You can then use shortcodes to display your testimonials on a post or page.
This plugin seems to be very basic and doesn't have much documentation, but the functionality is very useful. Hopefully they'll develop it more and more as time goes on.
Do You Really Need a Plugin to Display Testimonials?
It's true that you could easily add testimonials to your website manually. In fact, I'd recommend doing just that if you happen to have both the coding skills and only a couple of simple testimonials to display — especially if you don't think you'll be updating or adding to them anytime soon.
All the Visualmodo WordPress themes already give you 2 premium WordPress plugins for free that have more options for testimonials style very easily.
If you're thinking to try using testimonials on your website in a big way, I'd absolutely recommend trying out one or more of the above-mentioned WordPress testimonial plugins!


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      <ReturnValue>
        <ReturnType>Mono.Unix.Native.Signum</ReturnType>
      </ReturnValue>
      <Docs>
        User-defined signal 2.
      </Docs>
    </Member>
    <Member MemberName="SIGVTALRM">
      <MemberSignature Language="C#" Value="SIGVTALRM" />
      <MemberSignature Language="ILAsm" Value=".field public static literal valuetype Mono.Unix.Native.Signum SIGVTALRM = int32(26)" />
      <MemberType>Field</MemberType>
      <AssemblyInfo>
        <AssemblyVersion>1.0.5000.0</AssemblyVersion>
        <AssemblyVersion>2.0.0.0</AssemblyVersion>
        <AssemblyVersion>4.0.0.0</AssemblyVersion>
      </AssemblyInfo>
      <ReturnValue>
        <ReturnType>Mono.Unix.Native.Signum</ReturnType>
      </ReturnValue>
      <Docs>
        Virtual alarm clock (4.2 BSD).
      </Docs>
    </Member>
    <Member MemberName="SIGWINCH">
      <MemberSignature Language="C#" Value="SIGWINCH" />
      <MemberSignature Language="ILAsm" Value=".field public static literal valuetype Mono.Unix.Native.Signum SIGWINCH = int32(28)" />
      <MemberType>Field</MemberType>
      <AssemblyInfo>
        <AssemblyVersion>1.0.5000.0</AssemblyVersion>
        <AssemblyVersion>2.0.0.0</AssemblyVersion>
        <AssemblyVersion>4.0.0.0</AssemblyVersion>
      </AssemblyInfo>
      <ReturnValue>
        <ReturnType>Mono.Unix.Native.Signum</ReturnType>
      </ReturnValue>
      <Docs>
        Window resize signal (4.3 BSD, Sun).
      </Docs>
    </Member>
    <Member MemberName="SIGXCPU">
      <MemberSignature Language="C#" Value="SIGXCPU" />
      <MemberSignature Language="ILAsm" Value=".field public static literal valuetype Mono.Unix.Native.Signum SIGXCPU = int32(24)" />
      <MemberType>Field</MemberType>
      <AssemblyInfo>
        <AssemblyVersion>1.0.5000.0</AssemblyVersion>
        <AssemblyVersion>2.0.0.0</AssemblyVersion>
        <AssemblyVersion>4.0.0.0</AssemblyVersion>
      </AssemblyInfo>
      <ReturnValue>
        <ReturnType>Mono.Unix.Native.Signum</ReturnType>
      </ReturnValue>
      <Docs>
        CPU time limit exceeded (4.2 BSD).
      </Docs>
    </Member>
    <Member MemberName="SIGXFSZ">
      <MemberSignature Language="C#" Value="SIGXFSZ" />
      <MemberSignature Language="ILAsm" Value=".field public static literal valuetype Mono.Unix.Native.Signum SIGXFSZ = int32(25)" />
      <MemberType>Field</MemberType>
      <AssemblyInfo>
        <AssemblyVersion>1.0.5000.0</AssemblyVersion>
        <AssemblyVersion>2.0.0.0</AssemblyVersion>
        <AssemblyVersion>4.0.0.0</AssemblyVersion>
      </AssemblyInfo>
      <ReturnValue>
        <ReturnType>Mono.Unix.Native.Signum</ReturnType>
      </ReturnValue>
      <Docs>
        File size limit exceeded (4.2 BSD).
      </Docs>
    </Member>
  </Members>
</Type>

redpajama_set_name: RedPajamaGithub


Over 50000 pages are listed in this category provide FREE listing in a user friendly and search engine friendly way. If you want to list your company on the top listing of the page gallatin web designers click on GET LISTED NOW for paid listing.
Gallatin Tennessess's hometown web design and industrial Wonderware programming for businesses and industry.


The students will be responsible for doing daily service, changing sheets, operating a vacuum, greeting guests of the hotel .
Need to have a clean appearance all the time. Need to bring black belt and black shoes.
housing in the hotel students need to share a room.


Transcriptional corepressor (PubMed:20812024). Mediates the transcriptional repression activity of some nuclear receptors by promoting chromatin condensation, thus preventing access of the basal transcription. Isoform 1 and isoform 4 have different affinities for different nuclear receptors. Involved in the regulation BCL6-dependent of the germinal center (GC) reactions, mainly through the control of the GC B-cells proliferation and survival. Recruited by ZBTB7A to the androgen response elements/ARE on target genes, negatively regulates androgen receptor signaling and androgen-induced cell proliferation (PubMed:20812024). Forms a large corepressor complex that contains SIN3A/B and histone deacetylases HDAC1 and HDAC2. This complex associates with the thyroid (TR) and the retinoid acid receptors (RAR) in the absence of ligand, and may stabilize their interaction with TFIIB. Interacts directly with RARA in the absence of ligand; the interaction represses RARA activity. Interacts (isoform SMRT) with HDAC10. Interacts with MINT. Component of the N-Cor repressor complex, at least composed of NCOR1, NCOR2, HDAC3, TBL1X, TBL1R, CORO2A and GPS2 (PubMed:10809664, PubMed:10944117, PubMed:11931768, PubMed:19858209, PubMed:21240272). Interacts with CBFA2T3 and ATXN1L. Interacts with RARB; the interaction is weak and does not repress RARB transactivational activity. Interacts with HDAC7 and C1D. Interacts with NR4A2; this interaction increases in the absence of PITX3. Interacts with BCL6 (via the BTB domain), required for BCL6 transcriptional repressor activity on a subset of target genes. Forms ternary complexes with BCOR and BCL6 on target gene promoters but, on enhancer elements, interacts with BCL6 and HDAC3 to repress proximal gene expression. May interact with DEAF1. Interacts with RXRA. Interacts with MECP2 (By similarity). Interacts with ZBTB7A (PubMed:20812024). Interacts with AR (PubMed:20812024).
DISCOVERY OF THE SECOND GENERATION ROR GAMMA INHIBITORS COMPOSED OF AN AZOLE SCAFFOLD.
UniProt: NCOR2 is active in the following subcellular-locations: nucleus.
GO terms: NCOR2 is active in the following subcellular-locations: histone deacetylase complex, membrane, nuclear body, nuclear chromatin, nuclear matrix, nucleoplasm, nucleus, transcriptional repressor complex.


For once, RINGO STARR is the hottest Beatle. We caught him here reading an UNIDENTIFIED BOOK on an aeroplane trip with George Harrison and others. 99% of the reason that previous sentence exists is so we could use the word "aeroplane." Oh look, we did it again!
While I can't comment on the book, they're on a Vickers Viscount aeroplane (the windows are distinctive) and the camera that George is holding is a Asahi Pentax SV with clip-on light meter. Nifty.