text:
Adolescent-onset metabolic syndrome
Natalie Ngu
Tuesday, September 1st, 2015
Fifth Year Medicine (Undergraduate) Monash University
Natalie is a fourth year medical student at Monash University with a particular interest in women's and children's health. She has spent some time researching which enabled her to realise that she would rather be on the ward than in the lab.
Obesity is a common cause of insulin resistance (metabolic syndrome) in adults, however in recent years this has extended into much younger age groups. Associated conditions including dyslipidaemia, type 2 diabetes mellitus, and cardiovascular complications are all major components of metabolic syndrome. This case report describes a sixteen-year-old with features typical of adult-onset metabolic syndrome. The patient described in this report did not receive adequate treatment for three years after her initial diagnosis, which highlights challenges in engaging with and managing this age group. This report discusses the use of a biopsychosocial approach in managing metabolic syndrome in the adolescent population.
DT is a sixteen-year-old female who was referred to the emergency department by her general practitioner (GP) after she was found to have a blood glucose level of 14.1mmol/L. She was commenced on intravenous saline and short-acting insulin, and transferred to the paediatric ward.
DT had been diagnosed with a cluster of health problems collectively known as the metabolic syndrome at 13 years of age, but subsequently ceased prescribed medication and failed to attend follow-up appointments. Her co-morbidities at the time included type 2 diabetes mellitus (T2DM), dyslipidaemia, obesity, and non-alcoholic fatty liver disease. She was also found to have obstructive sleep apnoea and polycystic ovarian syndrome.
She reported that most of her adult relatives were overweight, however denied any family history of T2DM or any hereditary conditions. She had never smoked, or participated in alcohol or recreational drug use.
Having emigrated from Samoa at age 11, DT said she had few friends, although she socialised within her church community. DT dealt with domestic violence in her immediate family, parental separation, and was responsible for the care of her seven siblings.
On examination, DT was severely obese with a body mass index (BMI) of 41.8kg/m2. Her vital signs were all within the normal ranges and she had no signs of diabetic ketoacidosis. Of significance was the presence of acanthosis nigricans on her neck, elbow creases, and axillae, indicating longstanding insulin resistance. She had a deep voice, but no other signs of hyperandrogenism.
DT's investigations revealed a HbA1c of 12.2% (reference range [RR]<6.5%), fasting glucose level of 14.1mmol/L (RR: 4.0-6.0), alanine transaminase of 56 mmol/L (RR <30), aspartate amino transferase of 44mmol/L (RR <30), and gamma-glutamyl transferase of 64 mmol/L (RR <30). Ketones, fasting lipid profile, and thyroid function tests were all within the normal ranges, and no insulin autoantibodies were present. Urinalysis demonstrated glycosuria but not ketonuria.
These results confirmed the previous diagnosis of T2DM. However, due to the resolution of dyslipidaemia and her normal blood pressure, DT no longer met the International Diabetes Federation criteria for metabolic syndrome. The deranged liver function tests were consistent with her previous diagnosis of non-alcoholic fatty liver disease.
DT was managed in a multidisciplinary setting involving a paediatrician, endocrinologist, diabetes educator, dietician, and a social worker. She received ongoing care from a local GP and the paediatric endocrinology hospital outpatient service. The GP initially checked her blood glucose level weekly and adjusted the metformin dosage (1 x 850mg mane, 2 x 850mg nocte) [1] as required. The allied health team provided her with a lifestyle plan to reduce her dietary energy intake, to include incidental exercise as part of a regular exercise regimen, and distraction strategies to address overeating. DT was also booked for appointments to monitor diabetes-related complications (ophthalmology, renal, and podiatry clinics). Due to difficulty locating an appropriate interpreter, DT's mother was not actively involved in discussions regarding her ongoing management. This made it incredibly difficult for the treating team to include DT's family in the management plan, despite family involvement being a crucial component of care of the adolescent.
DT was involved in many discussions around her extensive management plan, however she asked upon discharge, "What if I can't?" Her self-doubt demonstrates a normal, adolescent response to an overwhelming challenge and is worsened by a lack of family involvement in her care. It remains uncertain as to whether DT will attend any follow-up appointments.
Adolescent obesity
With obesity rates in Australians being very high, the public eye has long been focused on the health impacts of the modern lifestyle. The 2007 Australian National Children's Nutrition and Physical Activity Survey found that 17% of Australian children were overweight and 6% were obese. [2] Despite these figures, only a minority of Australian GPs routinely perform measurements such as height, weight, and calculation of body mass index in children, relying on visual inspection alone to assess weight. In addition, many GPs find it difficult to raise the issue of weight management with children and their families, resulting in delayed or lack of dietary control and lifestyle modification. [3]
Adolescence is a time when the ability to learn increases and new habits are adopted yet the ability to self-regulate is not fully developed. [4] Overweight adolescents may desire the improved body image and self-esteem that weight loss might entail but lack an understanding of the practical steps that need to be undertaken in order to achieve that goal. [5]
The Metabolic Syndrome in the Paediatric Population
The metabolic syndrome is a term used to describe the co-occurrence of a range of metabolic risk factors including abdominal obesity, hyperglycaemia, dyslipidaemia, and hypertension. [6] While the overt disease is rare in the paediatric population, adult cardiovascular disease is more common in those who exhibited metabolic syndrome traits as children compared to those who did not. [7]
The International Diabetes Federation requires the presence of central obesity as well as two other metabolic abnormalities to reach a diagnosis of metabolic syndrome (Table 1). [8] While DT did not meet the full diagnostic criteria for metabolic syndrome on her current presentation she previously fulfilled these criteria and has extensive metabolic derangements consistent with this syndrome, including cardiovascular disease, non-alcoholic fatty liver disease, chronic kidney disease, and diabetic retinopathy. [6] A New Zealand study of adolescents with a Pacific Island ethnicity (including Samoan) found that although rates of overweight and obesity were high (40% and 36%), only a small proportion had aberrant glucose metabolism. This is thought to be due to better insulin secretory reserves in these populations, and thus the fact that DT has T2DM is of particular concern given that she is at an extreme end of an already at-risk population. [9] Early onset T2DM is closely associated with hereditary risk factors such as increased BMI, lower threshold for insulin resistance, and dyslipidaemia. [6] Given the established heritability of these conditions it would be suitable to test DT's immediate family members for T2DM and dyslipidaemia.
Managing metabolic risk factors
Optimal management of co-morbidities reduces both the occurrence and severity of complications. Regular monitoring should be undertaken, including assessment of blood pressure, waist circumference, fasting lipid profile, fasting blood glucose, urinalysis and renal function, HbA1c, visual acuity, and pedal sensation. [6] First line management in individuals with obesity as well as obesity-associated complications includes weight loss, as well as lifestyle interventions such as diet and exercise modification, glycaemic control, and optimisation of lipid profile. Such monitoring may present a burden on both the patient and healthcare providers but is an important secondary prevention strategy to reduce the risk of major long term complications.
The identification of risk factors for metabolic complications is crucial in adolescents for two reasons: 1) many risk factors can be modified to reduce future disease burden; [6] 2) adolescents are more likely to misjudge their weight status and thus feel either overwhelmed or unable to recognise the need to make lifestyle adjustments. [10] Clinicians play an important role in providing support and initiating lifestyle changes.
Adolescent attitudes to chronic disease management
For DT, the prospect of dietary restriction, an exercise regime, daily medication, and multiple appointments may have appeared overwhelming. The transition from childhood to adolescence is marked by heightened social awareness and often a struggle to form an individual identity. [11] A study of adolescent females found that deviation from the BMI norm is associated with greater social anxiety, depression, and lower self-worth, all of which affect not only the mental health of the individual but also their engagement with healthcare professionals. [11] In DT, these factors may also impact on the day-to-day management of her health.
Another study investigating the experience of adolescents with T2DM, found that three main factors influence the maintenance of health and end-health outcomes: concept of illness, adjustment to diagnosis, and motivation to maintain good health. [12] The study suggests that the adolescent's beliefs about both the cause of the condition and the ability to adhere to advice are affected by motivation stemming from immediate and future consequences. If adolescents cannot yet fully understand the consequences, their motivation is sourced from family, health professionals, and their own perceptions of their health status. [10, 12] In DT's case, family dysfunction and lack of continuity of care due to emigration may have contributed to her apparent lack of motivation to comply with health recommendations.
What went wrong in DT's care?
Although several of DT's health concerns were identified when she was thirteen years old a combination of factors, including emigration and family dysfunction, meant that DT did not have adequate support. These issues might be overwhelming to an adult, and are further amplified in an adolescent who does not yet have the understanding and motivation to adhere to treatment. She may have been prevented from 'falling through the gaps' if a treating team in Australia had been established by her New Zealand doctor before she emigrated. With a comprehensive handover, DT may have been better supported by a team who at least had some information about her history. The central problem however, is the family dysfunction meaning that her parents have had very little insight into her medical issues. Also considering that she has seven siblings and her parents are estranged, her health concerns are less likely to be managed outside of the hospital environment. This complex set of issues is difficult to address and may require support from a social worker and GP. Cultural issues including language, home life, and diet may be best evaluated with a home visit by a community nurse and the assistance of an interpreter. Cultural sensitivity is imperative to establishing rapport, so input from a Pacific Islander social worker may be beneficial.
The biospsychosocial approach
When addressing chronic disease, the biopsychosocial approach is appropriate for individuals of any age. This involves consideration of the medical aspects, which for DT includes medication and specialist reviews, as well as consideration of the psychological and social factors that influence attitudes and behaviours. Traditionally, the focus has been on addressing lifestyle factors in the individual, when there are perhaps better long-term outcomes by addressing wider, societal issues. [13] Family-centred models are the current mainstay of treatment and in DT's case, will require consideration of culturally appropriate ways to engage with her family such as with social workers, interpreters, ethnic health workers, and members of her church community.
By addressing her individual concerns, which may include self-esteem and self-confidence, and by improving communication with her healthcare providers, DT may be given a better chance at improving her long-term health outcomes. As mentioned previously, by improving self-efficacy, adolescents such as DT are given the confidence in their own ability to manage their health, and thus are more likely to be able to sustain a healthy lifestyle.
It is important to consider DT's Samoan origin, as factors such as family commitments, roles within the community, and societal expectations will influence her motivation and ability to improve her health. An investigation into the facilitators of healthy lifestyles in the Pacific Islands found that supportive role models and making physical activity more enjoyable were the most effective ways in which the health of communities could be improved. [14] These utilise the existing social structures of Pacific Island populations to provide motivation to make positive lifestyle choices and also support for long-term maintenance. Interventions should therefore focus on improving self-efficacy and providing realistic strategies. Motivational interviewing could be used by a GP to identify key goals for the individual patient to be achieved through a lifestyle plan. [4]
The increasing occurrence of typically adult-onset metabolic syndrome in children is a public health concern and DT is a prime example of the potential for patients to 'slip through the gaps'. While there are multiple public campaigns aimed at improving the modifiable risk factors in the paediatric population, the rates of obesity and associated complications remain high. Another concern involves the many challenges unique to adolescent medicine, as the patients are not only dealing with chronic health issues but the individual changes in body and mind that are characteristic of that stage of life. This case demonstrates that a multi-faceted approach aimed at engaging, motivating, and empowering adolescents is required to optimise health outcomes in this population.
Special thanks to Dr Datta Joshi – Consultant Paediatrician, Monash Health
Consent declaration
Informed consent was obtained from the patient and parent for publication of this case report
N Ngu: natalielyngu@gmail.com
[1] Metformin hydrochloride: Australian Government: Department of Health; 2014 [31/05/14]. Available from: http://www.pbs.gov.au/medicine/item/1801T.
[2] Health TDo. 2007 Australian national children's nutrition and physical activity survey – Key findings: Australian Government; 2007 [23/09/14]. Available from: http://www.health. gov.au/internet/main/publishing.nsf/Content/phd-nutrition-childrens-survey-keyfindings. [3] Cretikos MA, Valenti L, Britt HC, Baur LA. General practice management of overweight and obesity in children and adolescents in Australia. Med Care. 2008;46(11):1163-9.
[4] Fonesca H, Palmeira AL, Martins SC, Falcato L, Quaresma A. Managing paediatric obesity: a multidisciplinary intervention including peers in the therapeutic process. BMC Pediatr. 2014;14(89):1-8.
[5] Hardy LL, Hills AP, Timperio A, Cliff D, Lubans D, Morgan PJ, et al. A hitchhiker's guide to assessing sedentary behaviour among young people: deciding what method to use. J Sci Med Sport. 2013;16:28-35.
[6] Meigs JB. The metabolic syndrome (insulin resistance syndrome or syndrome X) [Internet]. UpToDate. 2014. Available from: http://www.uptodate.com/contents/the- metabolic-syndrome-insulin-resistance-syndrome-or-syndrome-x
[7] Wake M, Clifford SA, Patton GC, Waters E, Williams J, Canterford L, et al. Morbidity patterns among the underweight, overweight and obese between 2 and 18 years: population-based cross-sectional analyses. Int J Obes. 2013;37:86-93.
[8] Van Grouw JM, Volpe SL. Childhood obesity in America. Curr Opin Endocrinol Diabetes Obes. 2013;20(5):396-400.
[9] Grant AM, Taungapeau FK, McAuley KA, Taylor RW, Williams SM, Waldron MA, et al. Body mass index status is effective in identifying metabolic syndrome components and insulin resistance in Pacific Island teenagers living in New Zealand. Metabolism. 2007;57:511-6.
[10] Fredrickson J, Kremer P, Swinburn B, de Silva-Sanigorski A, McCabe M. Biopsychosocial correlates of weight status perception in Australian adolescents. Body Image. 2013;10:552-7.
[11] Lanza HI, Echols L, Graham S. Deviating from the norm: body mass index (BMI) differences and psychosocial adjustment among early adolescent girls. J Pediatr Psychol. 2012;38(4):376-86.
[12] Salamon KS, Brouwer AM, Fox MM, Olson KA, Yelich-Koth SL, Fleischman KM, et Experiencing type 2 diabetes mellitus: quantitative analysis of adolescents' concept of illness, adjustment and motivation to engage in self-care behaviours. Diabetes Educ. 2012;38:543-51.
[13] Pratt KJ, Lamson AL, Lazorick S, Swanson MS, Cravens J, Collier DN. A biopsychosocial pilot study of overweight youth and care providers' perceptions of quality of life. Pediatr Nurs. 2011;26:61-8.
[14] Siefken K, Schofield G, Schulenkorf N. Laefstael Jenses: aAn investigation of barriers and facilitators for healthy lifestyles of women in an urban pacific island context. J Phys Act Health. 2014;11:30-7.
Posted in Case ReportsTagged adolescent, diabetes mellitus, dyslipidaemia, Metabolic Syndrome, obesity
Editor's welcome: healthcare leaders of tomorrow
Surgical hand ties: a student guide
Medical degrees being priced out of reach
Introducing JDocs, a competency framework for junior doctors
Bispectral analysis for intra-operative monitoring of the neurologically impaired: a literature review
Venous thromboembolism: a review for medical students and junior doctors
Glass micro-particulate contamination of intravenous drugs – should we be using filter needles?
Insights into the mechanism of 'chemobrain': deriving a multi-factorial model of pathogenesis
HIV/AIDS: let's see how far we've come
Complementary medicine and hypertension: garlic and its implications for patient centred care and clinical practice
Does increased geographical distance to a radiation therapy facility act as a barrier to seeking treatment?
Chronic obstructive pulmonary disease: extrapulmonary manifestations, pulmonary rehabilitation programs and the role of nutritional biomarkers on patient outcomes
Stroke prevention in non-valvular atrial fibrillation: advances in medical therapy
Pathogenesis of severe allergic asthma and the therapeutic use of anti- immunoglobulin E antibody
Efficacy of mirtazapine as adjunct therapy to antipsychotics in the treatment of chronic schizophrenia
English-speaking background and its relationship with length of stay in elderly patients admitted to a subacute setting: a retrospective study
Impact of socioeconomic status on the provision of surgical care
How do the specialty choices and rural intentions of medical students from Bond University (a full-fee paying, undergraduate-level medical program) compare with other (Commonwealth Supported Places) Australian medical students?
Health literacy and patient comprehension in the pre-anaesthetics consultation
General practitioner awareness of pharmacogenomic testing and drug metabolism activity status amongst the Black-African population in the Greater Western Sydney region
Adequacy of anticoagulation according to CHADS2 criteria in patients with atrial fibrillation in general practice – a retrospective cohort study
Personal reflection: how much do we really know?
The blind spot on Australia's PBS: review of anti-VEGF therapy for neovascular age-related macular degeneration
Trust me, I'm wearing my lanyard
Making the cut: a look at female genital mutilation
Managing complicated malaria in pregnancy: beating the odds
Ki-67: a review of utility in breast cancer
The role of general practice in cancer care


text:
Die Q.931-Empfehlung (Recommendation) der ITU-T (vormals CCITT) beschreibt Schicht 3 des Protokolls (ISDN user-network interface layer 3 specification for basic call control) und wird für die Signalisierung bei ISDN und H.323 verwendet.

Ein Q.931-Rahmen setzt sich zusammen aus:
 Protocol discriminator (PD), Protokoll-Diskriminator
Im PD wird angegeben welches Signalisierungsprotokoll verwendet wird, zum Beispiel DSS1 oder FTZ 1 TR 6.
 Call reference value (CR), Verbindungserkennung
Mit dem CR-Wert werden unterschiedliche, gleichzeitig bestehende Verbindungen adressiert. Der CR-Wert bleibt für die Dauer einer Verbindung bestehen und ist nur lokal gültig.
 Message type (MT), Nachrichtentyp
Mit dem MT-Wert wird eine Angabe über den Inhalt der Nachricht, die Informationselemente, gemacht. Es gibt Message types für den Verbindungsaufbau, für den Verbindungsabbau und für die Steuerung von Dienstmerkmalen.
 Information elements (IE), Informationselemente
Mit den Information elements werden genaue Angaben zur übermittelten Nachricht gemacht. Der IE-Wert besteht aus den Teilen IE-Länge, IE-Name und IE-Inhalt.

Literatur
 Jonathan Davidson, James Peters: Voice over IP – Grundlagen. Markt + Technik Verlag, München 2000, ISBN 3-8272-5800-6.
 John G. van Bosse, Fabrizio U. Devetak: Signaling in Telecommunication Networks. Second Edition, A John Wiley & Sons Inc, New Jersey 2007, ISBN 978-0-471-66288-4.
 Bruce Hartpence: Packet Guide to Voice over IP. O'Reilly Media Inc, Sebastopol 2013, ISBN 978-1-449-33967-8.
 Wolf-Dieter Haaß: Handbuch der Kommunikationsnetze. Einführung in die Grundlagen und Methoden der Kommunikationsnetze, Springer Verlag Berlin Heidelberg, Berlin Heidelberg 1997, ISBN 978-3-642-63825-1.

Weblinks
 Q.931: ISDN Network Layer Protocol for Signaling (abgerufen am 10. Juli 2017)
 Integrated Services Digital Network (ISDN) (abgerufen am 10. Juli 2017)
 ISDN Switch Types, Codes, and Values (abgerufen am 10. Juli 2017)
 Zeichengabe im Euro-ISDN an der Benutzer-Netz-Schnittstelle (abgerufen am 10. Juli 2017)
 SERIES Q: SWITCHING AND SIGNALLING (abgerufen am 10. Juli 2017)

ISDN
Netzwerkprotokoll
Vermittlungstechnik
ITU-Empfehlung

redpajama_set_name: RedPajamaWikipedia


This 15 year young building contains 8 spacious units, each containing 2 charming bedrooms and 1 bath. You'll have access to a shared private terrace. It's also conveniently located only 1 block away from Fordham University's Rose Hill Campus, making this residence extremely student friendly.


text:
Water managers may have to 'spill' water from Lake Tahoe
rhoffman@tahoedailytribune.com
Given the amount of precipitation that has dumped into Lake Tahoe in the past handful of months, water officials may have to send "quite a bit" of water over the emergency spillway located in Tahoe City.
That statement from U.S. District Court Water Master Chad Blanchard on Tuesday comes with a caveat: Officials are waiting for an updated forecast that will take into account the impact of the most recent storms on spring runoff.
New information outstanding, the need to release, or spill, some water from the lake is looking likely. As of 2 p.m. Tuesday, Lake Tahoe was at 6,226.66 feet, according to provisional data from the United States Geological Survey. That number puts the lake 3.66 feet above its natural rim and within 2 ½ feet of the lake's "legal limit."
"This year it looks like we'll have to spill quite a bit of water," Blanchard said in an interview with the Tribune.
Use of the term "legal limit" in a Tribune story about the large rise in lake level between October and mid-February sparked curiosity from some readers who found the phrase unusual.
One reader asked: "What happens if the lake exceeds the limit? Does it get a ticket?"
The legal limit of 6,229.1 (6.1 feet above the lake's natural rim) and ensuing need to release water dates back roughly 100 years, Blanchard explained.
"It all dates back to 1907. We had another year like this [year], but 1906 had been a big year also, and we went into the winter full. … Then we had this type of winter that we're having now and the lake rose tremendously," Blanchard said.
In July 1907, the lake level was at 6,231.26 feet — an elevation that led to a great deal of erosion. With no way at the time of forecasting how the winter weather could impact lake level come spring, and with fear of possible damage to homes around the lake, talks about limiting Lake Tahoe's level started ramping up around that time, Blanchard said.
Going above the eventually established legal limit was common in the early 20th century. The lake exceeded the legal limit by at least ½ a foot in 1906, 1907, 1914, 1916 and 1917.
There was legal action at some point, and around 1917 was when 6,229.1 feet was established as the upper, or legal, limit of the lake. The number eventually found its way into the Truckee River Agreement of 1935, and it has remained the legal limit since.
There have been instances, such as in 1997, when the lake went slightly above the limit. Only so much water can be released, and in some instances the outflow cannot keep pace with the inflow, Blanchard said. In 1997, the lake exceeded the limit by "a couple tenths of a foot" before dropping back down, he added.
As for this year, the decision on whether to release water (and if so, how much) in order to make room for runoff will need to be made in the near future.
Currently, 50 cubic-feet-per-second — the minimum amount required to be released from Lake Tahoe at this time of year — is running out of the lake. Blanchard noted that even if officials decide to spill water, the amount pales in comparison to that lost to evaporation each year. That number averages 40 inches, he said.
If the lake does manage to fill this year, it will mark a physical increase of 6 ½ feet — a new record. The previous record of 6 feet came in 1995.
"We'll have to wait for a new forecast. … We very well could be required to start some precautionary release from Tahoe," Blanchard said.
Correction: The original version of this story used the incorrect unit of measurement when describing the lake's height above the natural rim. It is feet, not inches.

redpajama_set_name: RedPajamaCommonCrawl


Seldom do we sit down for a nice meal without a well-suited beverage. Most of the time that beverage is wine, although occasionally a well-selected beer complements a hearty German dish or a perfectly grilled bratwurst. When wine is preferred, there are many choices, so the question is always which wine is appropriate for the meal. Most important, select a wine you enjoy drinking. It would be a mistake to choose a wine you don't like merely because convention suggests it should be served with certain foods. Granted, a big cabernet is a perfect companion to a prime cut of beef, but if you don't like the character of a cab, the meal won't be what it should be. Let your taste dictate your selection.
Another way to enjoy wines with food is to incorporate the wine into the cooking process. This can be done in several ways, from marinating to braising, flamb�ing and finishing. One of the characteristics of wine that makes it unique is the alcohol, which acts as a solvent to release certain flavors in food. Don't worry about getting intoxicated; most of the alcohol is released through evaporation while cooking. While the alcohol dissipates, other characteristics of the wine can contribute astringency - through tannins - acidity, and oak or vanilla-like flavors.
So, which wine should you use in cooking? Never choose a wine you wouldn't want to drink. So-called "cooking wines" are closer to vinegar than wine. Conversely, don't waste a premium wine in cooking, as the subtle nuances that make the wine so great will be lost in the cooking process. Generally, choose a red wine for beef, veal and pork and white wines for seafood and poultry. There are some exceptions to this, such as the French classic coq au vin. Select a wine for its particular qualities: pinot noir for earthiness, zinfandel for spiciness, sauvignon blanc for tartness and acidity, Riesling for sweetness, etc. Whichever you choose, make sure it is a well-balanced representation of the variety.
Wine can be used in the kitchen to flavor components in marinades along with aromatics and oil. It can also be used for deglazing pans for sauces and gravies. When using this technique, make sure to reduce the wine by half before thickening, or the sauce will taste of alcohol. Incorporating wine in a braising liquid or in a soup or stew brings out the complexities of the other ingredients. Sweet dessert wines can be used to macerate fruits or as a component in sorbets or sabayon sauces.
Cooking with wine isn't difficult and can lend wonderful flavors to otherwise common dishes. Here's an example: the French classic coq au vin.
Fry bacon until just crisp; remove from pan. Coat chicken pieces in flour, salt and pepper. Brown chicken on both sides in hot bacon fat. Add vegetables, saut� until wilted. Remove pan from heat, pour in cognac, put pan back on the flame. Flamb� carefully. When the flames die down, gradually stir in the wine and broth; add the herbs. Cover and simmer for 1 hour. Remove cover and continue to simmer for 15 minutes to allow the sauce to reduce a bit.
Wine Pairing: Evesham Wood Willamette Valley Pinot Noir. Drink this one. Retails for $18.99.


If you want to understand and even manage your hair loss, you need to educate yourself about it. The prospect of the loss of hair can be hard to handle. Here's some tips to deal with this problem.
Taking care of your physical health is vitally important if you have any type of illness of disease. If you don't take care of it by doing or taking what you were advised, your body may go into "overdrive" trying to stay alive and repair itself. Because your body is having to use lots of energy in order to mend itself, it won't have the ability to use this energy on maintaining your hair follicles. Blading will occur, as a result.
Use products meant to repair some of the damage you do by styling your hair. Avoid pulling hair too tight, and do not keep it tied in rubber bands or other holders for long amounts of time. Shampoo and other hair products may also be damaging your hair, even if not as much as they used to. Ponytails that have been pulled too tight can damage the hair shaft and this can lead to hair follicle damage also.
You may not believe it, but one way to combat the loss of your hair is to move to an area that has low air pollution. Studies have proven that men who live in areas that are polluted have more the loss of hair. This is because the pollutants can get into the bloodstream and cause damage to hair, making it fall out.
For men afflicted with alopecia, a possible treatment is the use of liquid saw palmetto. The natural extracts prevent growth of DHT, the male hormone responsible for the loss of hair. This method is easy to use. Just get the juices from the fruit and spread them around your hair.
Do your homework about blading treatment techniques, so that you can be mindful of what they involve. What you learn could help you decide whether or not a product is worth the extra cost.
Your hair should be as thick and full as possible before being cut. Cutting your hair when it is very short weakens it, so you need to let it grow a little longer.
Some people believe in the success of aloe vera preventing hair thinning, this may be something you would want to try. The treatment is to rub the Aloe Vera into the scalp before bed. Your scalp will be stimulated and the minerals from the aloe vera might strengthen your hair.
Blading can trigger many emotions inside a person, which are quite negative. Now that you are aware of some new strategies to help you deal with your hair loss, you are better equipped to have a happy life, whether or not you are able to halt your thinning hair. Use these tips to benefit your daily life.


text:
PFC "Elias 'Eli' Benjamin" (Eleazar Benevidez)
MP eyewitness to alien bodies at base hangar and hospital
Chester Barton | Eli Benjamin | Frederick Benthal | Glenn Dennis | Oliver Henderson | Walter Haut | Chester Lytle | Milton Sprouse | B-29 Crate Flight | Strange Debris | Main Page
Alien body eyewitness Eli Benjamin was in the 2007 Witness to Roswell by Tom Carey and Don Schmitt, though first introduced in November 2006 on (Sci Fi Investigates--Roswell --at YouTube). According to Carey and Schmitt, Benjamin and his wife visited the International UFO Museum in Roswell in 2002. Against her husband's wishes, Mrs. Benjamin spoke to museum director Julie Shuster (also daughter of 1947 base public information officer Walter Haut, who put out press release of a captured flying saucer, and who also said he saw alien bodies), saying that her husband had seen the bodies at the base hospital (a story he first told her in 1949 when they were married). Benjamin, however, refused to tell his story until 2005, and according to Carey and Schmitt, was very emotional about it, several times breaking down in tears. His wife said he still had nightmares about the events.
Benjamin is pictured in the 1947 base yearbook, providing support to his story that he was there at the time, but the name is a pseudonym. His name was kept anonymous at his request, and a number of researchers kept it so, including myself, even though we knew his true name. "Benjamin" indicated he was made to sign a nondisclosure statement in 1947 and was fearful of government reprisal for going public, particularly losing his pension.
Nevertheless, Benjamin briefly appeared in two more documentaries in early 2015, one about Roswell in general ("UFOs Declassified", S01E05, "UFO Crash Sites"--see 10:29 into video), which, among things, shows his yearbook photo enabling easy identification. The other was a short teaser in Feb. 2015 about the so-called "Roswell slides," supposedly depicting an alien body ("Kodachrome" by SlideBoxMedia--see 2:39 into video). Here he states upon viewing a slide, that the being, or whatever, closely resembled what he saw back in 1947.
"I got myself ready, got my gun, and reported to the big hangar, as ordered... While looking at my OIC [officer in charge] to get instructions for duties at the hangar, I came upon a commotion at the main entrance to the hangar. Some MPS were trying to subdue an out-of-control officer, who among other things, appeared to be drunk as a skunk. I found out later that the officer in question was from my squadron and was the very officer--whose name I cannot now recall--was to have overseen the transfer of several 'Top Secret items' from the big hangar to the base hospital, and I was there to help escort the transfer. I was told later that he had been to the crash site and had seen the ship. When this officer reported to the hangar and saw the small bodies, it was apparently too much for him to handle, and he just lost it.
"... a Major or Lt. Colonel came out of the hangar, looked over the situation, and pointed at me. 'You! come over here,' he said. 'You're now in charge of this detail. Get these over to the base hospital!' He then pointed to three or four gurneys inside the hangar, each of which had something on it that was covered by a sheet. On one of the gurneys, whatever was under the sheet appeared to be moving. I...instructed the rest of the men in the detail to load the gurneys with their payload into the back of a truck that had just arrived for the purpose. ...As the men were loading the truck, one of the gurneys slipped during the handoff, and the sheet covering fell away, revealing the grayish face and swollen, hairless head of a species that I realized was not human.
"My orders were to deliver these to the base hospital's emergency room and remain there until relieved. Upon arriving at the emergency room ramp, we proceeded to unload. I went in with the first gurney and stood aside near the doorway as the medical people took control of the gurney. A half-dozen or so medical and nonmedical officers quickly removed the covering sheet. I couldn't see too well from where I was standing because of the number of officers gathered around the gurney, but I could see well enough to make out that a very small person with an egg-shaped head that was oversized for its body was lying on the gurney. The only facial features that stick out in my mind now are that it had slanted eyes, two holes where its nose should have been, and a small slit where its mouth should have been. I think it was alive. The medical people were mostly just staring at it...
"After the rest of the gurneys were brought into the room, I was dismissed and told to return to my squadron, which I did. There, I was debriefed and made to sign a nondisclosure statement regarding what had just taken place. I was told that if I ever spoke out about it, something bad would happen, not only to me, but also to my family. I heard later that the one species that was still alive was apparently taken to Alamogordo, then shipped to Texas or Ohio.
The yearbook identifies Benjamin/Benevidez as a private first class in the 390th Air Service Squadron at Roswell, a security unit. He possessed a Top Secret clearance, guarded the B-29s that carried A-bombs, and was a recovery specialist, being called out during plane crashes. (Another controversy concerned his rank, since the Kodachrome documentary identified him as a lieutenant in 1947 instead of a PFC. This may simply have been a misunderstanding between his discharge rank years later vs. his rank in 1947)
Below is an exerpt of Benevidezs' account from the Carey & Schmitt book. In his Sci-Fi program appearance there were some details not present in the book. He mentioned there being a terrible smell at the base hospital, confirming the account of mortician Glenn Dennis & some others of a horrific stench being associated with the alien bodies. He noted seeing a very slight protrusion for a nose instead of just two holes, and seeing the live alien at the base hospital moving slowly from side to side. He estimated he was about 20 feet away at the time. He was quite certain it wasn't human. At the hangar he saw a lot of crash wreckage, which he noted wasn't like normal airplane crash wreckage in that it wasn't burned. This confirms other accounts of crash wreckage also being taken to the same hangar as the bodies.
In the second documenary ("UFOs Declassified"), he says simply the bodies had a smaller form than ours and they had a very unusual smell, one that made you want to vomit.
Carey & Schmitt relate that Benjamin had been on guard duty all night on the flight line and was just returning to his barracks on the morning of Tuesday, July 8. He noticed unusual activity at base headquarters, where base commander Col. William Blanchard regularly held his weekly staff meetings on Tuesday morning, and thought that something was going on. When he got to his barracks, he was assigned to "special duty," told to grab his gun and report to Hangar P-3 (Hangar 84). Benjamin then gave the following account:
Enormous controversy then erupted and his real identity was outed by debunkers as Eleazar Benevidez. Since it is now so public, I am including it here in March 2014. He is pictured at right in the 1947 Roswell base yearbook.
PFC Eleazar Benevidez,
MP, 390th Air Service Squadron
Roswell base yearbook, 1947, p. 93
This page was last updated: March 8, 2015


Download free paintings by Annibale Carracci (1560-1609) from PaintingsAlley.com. Available in jpeg format for your arts collection. PaintingsAlley.com has the biggest searchable collections of paintings by world famous artist Annibale Carracci (1560-1609).