text:
Kansas Hospitals Advance Economic Argument For Medicaid Expansion
By Jim McLean • Jan 12, 2015
Several red-state governors have dropped their opposition to Medicaid expansion in recent months and are pursuing ways to use federal dollars to fund their own more conservative plans.
Governors in the solidly red states of Wyoming, Montana, Tennessee and Utah are pursuing expansion options that seek to use billions in additional federal Medicaid dollars to help low-income adults purchase private coverage or create health savings accounts. Many of the proposals, which require federal approval, also include incentives aimed at helping recipients get better jobs so that they can purchase their own coverage without government assistance.
Last week, President Barack Obama said he would instruct the Centers for Medicare and Medicaid Services to work with states to expedite the approval process and find compromises on expansion proposals.
RELATED: Report: Medicaid Expansion In Missouri Would Yield Up To $100M In Annual Savings
Twenty-seven states and the District of Columbia have expanded Medicaid, according to the Kaiser Family Foundation. Another seven are considering it, while 16 states, including both Kansas and Missouri, are not actively discussing the issue.
Since his re-election in November, Kansas Gov. Sam Brownback has given no indication that he's preparing to follow the lead of his GOP colleagues. He and other members of his administration have been in discussions with the Kansas Hospital Association (KHA) on an expansion proposal aimed at winning over conservatives. But so far, neither he nor any of the Republican leaders in the Kansas House and Senate have indicated they're prepared to drop their opposition to expansion, which has prevented consideration of the issue the past two legislative sessions.
Still, Tom Bell, KHA's president and CEO, is optimistic that this year could be different.
"There has been progress made clearly since last session in terms of people understanding the issue better and people feeling that we really ought to take a hard look at it," Bell said.
Even so, he acknowledged, "I think it's still a heavy lift. It's still an uphill battle."
The KHA proposal
In the weeks leading up to the 2015 legislative session, Bell and CEOs from hospitals across the state have been briefing legislators on the KHA plan. Though still being tweaked, it closely resembles some of the proposals crafted in other red states.
Called KanCare2.0, the plan attempts to build on the privatized system installed by the Brownback administration in 2013, which made three for-profit insurance companies responsible for administering Medicaid under contracts with the state.
The aim of the proposal is to cover as many as 144,000 low-income adults who don't qualify for the state's existing Medicaid program. Many of them earn too much for Medicaid but too little to be eligible for ACA subsidies to help them purchase private insurance.
The KHA proposal would use federal dollars to help low-income adults purchase coverage if they have access to it through their employers. It also would give newly eligible beneficiaries the option of purchasing high-deductible plans or help them create health savings accounts and manage their own care.
It also would require some level of cost sharing from recipients who earn less than 100 percent of the federal poverty level – annually $11,600 for an individual and $23,850 for a family of four – and include incentives for job search and training.
"Those kinds of personal responsibility things are things that we think are important," Bell said.
Funding a big question
The Affordable Care Act promises to cover 100 percent of states' cost for expanding Medicaid for the first three years. Kansas already has missed out on year one and likely the second year as well at a cost of more than $700 million, according to a KHA study done last fall by Regional Economic Models Inc. and George Washington University.
After 2017, the federal share of expansion costs goes down gradually until by 2020 it reaches 90 percent, where the law says it will remain.
But even with the federal government paying 90 percent of the bill, the cost of expansion would substantially increase the state's Medicaid costs at a time when the governor and lawmakers are struggling to close a $280 million gap in the current year's budget and deal with a projected shortfall more than twice that big in next year's.
The hospital association estimates that expansion will cost the state an additional $312 million from 2016 through 2020. But it says jobs created by the infusion of federal Medicaid dollars and the increased tax revenue they generate would offset those costs with more than $35 million to spare.
"If Kansas were to move ahead with expansion, we actually create jobs … and bring more revenues to the state," Bell said. "I don't think you can say this program is just a cost to the state; I think you have to factor in a lot of other data."
That argument resonates with Rep. Barbara Bollier, a moderate Republican from Mission Hills and a retired physician.
"In light of our budget issues, it makes even more sense because states that have expanded are doing better economically," Bollier said. "We say we want to grow as a state and bring jobs in, yet the very thing that can do that we refuse to do. That makes no sense to me."
Rep. Tom Sloan, a moderate Republican from Lawrence and chairman of the House Vision 2020 Committee, recently told the Lawrence Journal-World that he planned to hold hearings early in the session on the "consequences" of not expanding Medicaid.
Many moderate Republicans and Democrats already support expansion. But between them they hold only about one-third of the seats in the House and are significantly outnumbered in the Senate as well. Conservative Republicans, who control both legislative chambers, remain skeptical.
Rep. Peggy Mast is the speaker pro-tem of the House. Like Brownback, the Republican from Emporia isn't convinced the federal government can or will keep its promise to foot 90 percent of the bill for Medicaid expansion.
"Looking down the road at the economic situation for the federal government as well as the state, we have to consider the implications of what could happen," Mast said.
Still, Mast said she's willing to listen to KHA and other advocates for expansion. And she credits the hospitals for doing their homework and crafting a proposal with conservatives in mind.
"I'm extremely impressed by their knowledge of the subject and how they're willing to come to the table and try to resolve an issue that we've been working on for some time," she said.
Urgent issue for hospitals
Hospitals are leading the charge for expansion for financial reasons. They were counting on expansion to help offset planned reimbursement reductions in that other federal health care program that starts with an "M" – Medicare.
"Medicare is in the neighborhood of 40 to 45 percent of our business, and we lost more than $100 million on that book of business last year," said Bob Page, president and CEO of the University of Kansas Hospital in Kansas City, Kan. "And if you look to the next five years, we've got another $95 million in Medicare cuts coming and we don't have Medicaid expansion in the offing. So, that puts a lot of pressure on us to come with that offset in a different fashion than was originally intended."
Rural hospitals also are struggling. Scott Taylor, president and CEO of St. Catherine Hospital in Garden City, said expansion would significantly reduce the number of uninsured patients whose inability to pay their medical bills has increased the hospital's uncompensated care costs by about $2 million.
"Medicaid expansion would allow us to treat more patients; particularly this group of individuals that are working hard but simply can't afford the high cost of health care and don't qualify for any other means of coverage," Taylor said.
Senate President Susan Wagle, a conservative Republican from Wichita, has been more open to expansion than other legislative leaders. She recently told the Wichita Eagle that she believes the state should pursue a "plan that brings in (more) federal dollars" to help ease the pressure on Kansas hospitals.
"I haven't pushed that on my Senate, but when people ask me, we need to keep our health care facilities as strong as other states and money needs to flow," Wagle said.
Opposition strong in Missouri
The Missouri Chamber lists Medicaid expansion as one of its legislative priorities. Democratic Gov. Jay Nixon also favors expansion. And Sen. Ryan Silvey, a Kansas City Republican, said he will once again introduce a proposal to both reform and expand Medicaid.
"It's going to be damaging to our hospitals if we don't do something," Silvey said last fall in an interview with KCUR.
But any expansion proposal will face entrenched opposition from Republican leaders, including Sen. Rob Schaaf, from St. Joseph, who took to Twitter in December to say: "Let me be crystal clear: We won't be expanding Medicaid."
A study published in August by the nonpartisan Urban Institute said that not expanding Medicaid would cost Kansas and Missouri hospitals more than $9 billion in federal funding over a 10-year period. Kansas hospitals would forgo $2.6 billion and Missouri hospitals would lose an estimated $6.8 billion from 2013 to 2022.
Jim McLean is executive editor of KHI News Service in Topeka, a partner in the Heartland Health Monitor team.
Kansas Hospitals Continue Push For Medicaid Expansion
By Jim McLean • Nov 20, 2014
The Kansas Hospital Association on Thursday continued its campaign for Medicaid expansion by reminding policymakers how much the state is losing by not claiming federal dollars to cover more low-income adults.
Why Kansas Democrats Shied Away From Medicaid Expansion Issue
By Andy Marso • Nov 21, 2014
Post-election soul-searching by Kansas Democrats includes disagreement over whether Medicaid expansion should have been a larger part of the party's strategy.
The Democrats lost all statewide races for the second straight time and lost another five House seats to drop their number in that chamber to 27. The defeats were part of a national wave of Republican election wins, but they have nonetheless led to talk within the Kansas Democratic Party about what could have been done differently.


I joined the Dannatt Trust some 12 years ago and currently serve as Treasurer. Now retired, my career was in education becoming Headteacher of a comprehensive school and then a Schools Inspector and teacher trainer. A first cousin (once removed!) to George, I and my wife Christine became increasingly close to George and Ann personally following a chance reunion at a Dannatt exhibition in 1994 – and have continued to admire George's work, knowledge and achievements ever since.


Instead of displaying all values, in some cases you may want to display only some values that respond to a criterion you set. Also, we were displaying the records in the order they appeared in the table. In some cases, you may want to re-arrange the order of records, following an arrangement of your choice. To perform these and other operations, you can use an object called a data view.
A data view is a technique of creating a particular view of the records of a table. In order to use a data view, you must specify a table that the view gets its values from, and then use that data view to specify how the records should be displayed.
To support data views, the .NET Framework provides a class called DataView. Because a data view is a control, there are two ways you can create it: visually or programmatically.
Click OK. This would add a DataView object to the Toolbox. From there, you can click the DataView button and click the form.
In order to play its role, a data view must know the table on which it would apply its operations. Therefore, when creating a data view, the first piece of information you should provide is the table. Of course, you must have previously created a table, such as one from a data set.
This property allows you to access a default directly from a table object.
dvwStudents.Sort = "LastName, FirstName, DateOfBirth ASC"
dvwStudents.Sort = "LastName DESC, FirstName"
So far, when displaying the records, we were showing all those that existed in the table of our choice. Data filtering consists of showing only some records, based on a condition, called a criterion, or more than one condition, in which case the plural is criteria.
dvwStudents.RowFilter = "LastName = 'Simms'"
dvwStudents.RowFilter = "DateOfBirth = #10/10/1994#"
dvwStudents.RowFilter = "DateOfBirth < #10/10/1994#"
dvwStudents.RowFilter = "(LastName = 'Simms') OR (LastName = 'Hamden')"
dvwStudents.RowFilter = "LastName LIKE '*on*'"
dvwStudents.RowFilter = "LastName IN ('Simms', 'Hamden')"
Besides the operators, you can also use some of the available functions.
Besides sorting and filtering records, another one of the most valuable actions you can perform using a data view consists of looking for a record. Finding a record consists of isolating one particular record based on a condition that can distinguish the intended record from the other records in the table. You have many options.
In our introduction, we saw that we could use a data view as an accessory to perform sorting or filtering operations on a table. You can in reverse create a temporary table using the results of a data view. You can create a table, add records to it, delete some records, or get the number of its records. The data view itself supports these minimal operations.
dvwStudents.RowFilter = "LastName = 'Thomas'"
The default value of this property is True, which indicates that new records can be added to the data view. To prevent new records on a data view, set this property to False.
The default value of this property is True, which indicates that the records of a data view can be changed. To prevent that the records be edited, you can set this property to False.
To edit a record, you can locate one or more of its values using the columns.
Its default value is True, which allows the records to be deleted. If you set it to False (programmatically or in the Properties window), no record can be deleted from the data view.


From Sydney, Australia's largest and most famous city, to Perth, Western Australia's capital city, this tour through Australia—stopping first at the Great Barrier Reef (Cairns)—is a once-in-a-lifetime vacation. You'll spend three nights each in Cairns, Sydney, Melbourne, and Perth; two nights in Adelaide; and two nights aboard the historic Indian Pacific train traveling across Australia.
Other highlights of this Australia tour include an excursion to Kangaroo Island to see Australian sea lions, koalas, kangaroos, wallabies, and New Zealand fur seals in one of the world's last unspoiled habitats. In Adelaide, wander among kangaroos, wallabies, emus, and water birds at Cleland Wildlife Park. Explore Melbourne on a walking tour through the city's famous lanes and arcades—another unique experience Globus includes—and cruise on Sydney Harbour. In Cairns, take a high-speed catamaran to the Great Barrier Reef, one of the Seven Natural Wonders of the World. There's time to snorkel, take a semi-submersible watercraft tour, and attend a presentation by a marine biologist.


text:
Home » Decision Support in Medicine » Hospital Medicine
Lambert-Eaton Myasthenic Syndrome (Eaton-Lambert Syndrome)
Cara O'Brien
I. What every physician needs to know.
Lambert-Eaton Myasthenic Syndrome (LEMS) is a relatively rare disease of the neuromuscular junction that typically presents with gradually progressive, symmetric, proximal muscle weakness, most commonly in the lower extremities. Patients frequently present with difficulty walking, climbing steps or arising from a seated position. Rarely patients present with isolated facial weakness (most commonly ptosis), or respiratory failure. Autonomic complaints such as dry mouth or erectile dysfunction are common. Notably, there are no sensory deficits.
LEMS is associated with autoantibodies against voltage-gated calcium channels (VGCC). Binding of these autoantibodies to the VGCC in the presynaptic nerve terminal results in a decreased amount of calcium influx, and consequently less acetylcholine release into the synaptic junction and a reduced compound muscle action potential (CMAP). Electromyography (EMG) demonstrates a characteristic improvement in CMAP amplitude with either high frequency repetitive nerve stimulation or sustained isometric muscle contraction.
In about half the cases, LEMS is associated with an underlying malignancy, most commonly small cell lung cancer (SCLC). An exhaustive search for an underlying malignancy is therefore a focus of treatment for LEMS. Other treatment modalities focus on either increasing the amount of acetylcholine in the neuromuscular junction, or eliminating the VGCC autoantibodies with a goal of improving weakness.
II. Diagnostic Confirmation: Are you sure your patient has Lambert-Eaton Myasthenic Syndrome?
Diagnosis is typically based on clinical suspicion in the setting of a positive autoantibody screen for VGCC antibodies and a characteristic EMG.
85%–95% of patients with LEMS have antibodies against VGCC. However, antibodies against VGCC may exist in the absence of LEMS.
Patients with LEMS typically have a reduced resting CMAP amplitude on EMG. The amplitude of the CMAP increases with high frequency (10–50 Hz) nerve stimulation and this response to high frequency nerve stimulation is called post-activation facilitation. Because patients frequently have a difficult time tolerating high frequency nerve stimulation, an alternative finding is an increase in the amplitude of the CMAP after sustained (10 seconds) isometric muscle contraction, called post-exercise facilitation.
A. History Part I: Pattern Recognition:
LEMS typically presents in adults over the age of 40 and is most commonly associated with SCLC.
The most common finding in patients with LEMS is gradually progressive, symmetric, lower extremity, proximal muscle weakness, which patients will describe as a difficulty walking, standing from a seated position, or climbing stairs. Upper extremity (although not as common as lower extremity) proximal muscle weakness may also be present and will be described by patients as difficulty brushing teeth or hair, or lifting heavy objects. About one third of patients will describe a feeling of muscle aching or soreness.
Autonomic dysfunction may also be present with the most common symptom being dry mouth. In men, about 50% experience erectile dysfunction. Other autonomic symptoms that may be present are constipation, blurry vision and orthostasis.
About two-thirds of patients will have some cranial nerve finding with the most common symptoms being diplopia, or ptosis. However, the severity of ocular symptoms is mild, compared with myasthenia gravis.
Very rarely, patients will present with isolated respiratory failure.
LEMS associated with SCLC tends to have more severe muscle weakness and a more rapid progression.
B. History Part 2: Prevalence:
There is limited data regarding incidence and prevalence of LEMS. One study, from the Netherlands, found a prevalence of 2.3 per million and an annual incidence rate of 0.5 per million.
About 60% of LEMS cases are associated with an underlying malignancy. SCLC is the most commonly associated malignancy with about 50% of LEMS cases being associated with SCLC. Among patients with SCLC about 0.5%–3% have LEMS.
Patients with non-paraneoplastic LEMS often have other autoimmune diseases such as thyroid disease and type I diabetes.
C. History Part 3: Competing diagnoses that can mimic Lambert-Eaton Myasthenic Syndrome.
The differential diagnosis for LEMS includes any other disease that affects the neuromuscular junction such as myopathies, inflammatory myositis, polyneuropathies, and myasthenia gravis (MG).
LEMS is characterized by depressed or absent deep tendon reflexes which helps to distinguish it from the myopathies and myositis diseases in which deep tendon reflexes are typically preserved. The absence of sensory complaints and deficits helps to differentiate LEMS from the polyneuropathies.
The primary differential diagnosis is therefore MG. Patients with LEMS usually present with limb weakness as their initial symptom, whereas patients with MG typically present with extraocular muscle weakness (ptosis and/or double vision). In addition, the ocular symptoms of LEMS, once they develop, are typically less severe than in MG. On physical exam, reflexes are typically preserved in MG, but weak or absent in LEMS (including the pupillary reflex to light). Autonomic dysfunction including dry mouth, constipation and orthostasis are common in LEMS, but not in MG.
D. Physical Examination Findings.
Weakness of the proximal muscles is the most common physical exam finding, although the degree of weakness on exam may seem less than expected given the degree of functional impairment.
Hyporeflexia or areflexia is almost always present. Reflexes may temporarily improve after 10–15 seconds of sustained isometric contraction of the involved muscle (called post-exercise facilitation).
In the absence of a secondary polyneuropathy, sensation is intact in LEMS.
E. What diagnostic tests should be performed?
The diagnosis of LEMS requires a high index of suspicion, and is primarily supported by the clinical picture of proximal muscle weakness, autonomic dysfunction and hyporeflexia. The diagnosis is confirmed by serologic testing for antibodies to VGCC and by neurophysiologic testing.
1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?
All patients with suspected LEMS should have testing for antibodies against the P/Q-type VGCC. These antibodies are present in 85%–95% of patients with LEMS and less than 5% of patients with MG. However, it is important to note that these antibodies may be present in the absence of LEMS. VGCC antibody titers do not correlate with disease severity, but the levels of these antibodies may decrease substantially in patients being treated with immunotherapy. Therefore, the possibility of LEMS should not be excluded if a patient has a negative VGCC antibody screen, but is, for example, taking steroids.
Electrodiagnostic studies are also an important part of confirming the diagnosis of LEMS. In LEMS, the CMAP amplitude is reduced and with low frequency repetitive nerve stimulation (1–5 Hz) there is a further decrement in the amplitude of the CMAP. High frequency repetitive nerve stimulation at 20–50 Hz results in an increase in the CMAP amplitude usually by more than 100%. This finding is called post-activation facilitation.
Because patients do not tolerate high frequency nerve stimulation well, an alternative finding is a similar increase in the CMAP amplitude after 10–15 seconds of voluntary sustained isometric muscle contraction, called post-exercise facilitation. Because not all muscles will have an increase in CMAP amplitude of more than 100%, several muscles may need to be examined.
In patients with LEMS, additional testing for sex determining region Y-box protein 1 (SOX1) antibodies may help to determine if there is underlying SCLC. It is important to recognize that the sensitivity of SOX1 antibody testing is low (67%), meaning many LEMS patients with SCLC will not have SOX1 antibodies. However, the specificity of SOX1 antibodies for underlying SCLC is high (95%), and therefore LEMS patients with a positive SOX1 antibody screen are much more likely to have underlying SCLC.
2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?
The primary goal of imaging in LEMS is to detect underlying malignancy, most commonly SCLC. Computed tomography (CT) scan of the chest followed by a fluorodeoxyglucose-positron emission tomography (FDG-PET) scan, if the initial CT of the chest is negative, is recommended. These tests should be repeated every 3–6 months for 2 years after the diagnosis of LEMS.
F. Over-utilized or "wasted" diagnostic tests associated with this diagnosis.
III. Default Management.
Initial management of LEMS should focus on the search for an underlying malignancy using the screening imaging tests mentioned above. If an underlying malignancy is found, then treatment of LEMS depends on treatment of the underlying malignancy. Both the weakness and the EMG findings associated with LEMS often improve with treatment of the underlying cancer, and in some patients no further treatment is needed.
If no underlying malignancy is found, or if symptoms are persistent or severe despite management of an underlying cancer, then treatment is focused on improving weakness by increasing the amount of acetylcholine available at the neuromuscular junction, or by decreasing the concentration of VGCC antibodies using immunotherapy.
Since the goal of treatment is improvement in weakness, the initial choice of treatment depends on the severity of the underlying weakness. If the weakness is mild, then pyridostigmine at a dose of 30–120 mg every 3–6 hours may be tried initially. Pyridostigmine is an acetylcholinesterase inhibitor, which increases the amount of acetylcholine available to bind at the postsynaptic membrane. The primary side effects of pyridostigmine include nausea, abdominal cramping and diarrhea.
Acetylcholinesterase inhibitors used as monotherapy have rarely had significant effect on the symptoms of LEMS. Therefore, if the weakness persists despite a trial of pyridostigmine then a second agent may be added.
Guanidine, which increases the concentration of intracellular calcium in the presynaptic terminal and therefore augments the release of acetylcholine, was the first agent studied in the treatment of LEMS. It has been shown to improve weakness and the EMG findings of LEMS in multiple case reports. However, because of significant toxicity including bone marrow suppression and renal failure, guanidine has not been studied in a controlled trial. Guanidine may still be considered as an addition to pyridostigmine, but at a low total daily dose (maximum of 1000 mg/day).
The aminopyridines work in a similar manner to guanidine by increasing intracellular calcium in the presynaptic terminal and therefore leading to increased acetylcholine release. The most commonly studied aminopyridine is 3,4-diaminopyridine (3,4-DAP). Four placebo-controlled trials (with a total of less than 100 patients) have now demonstrated improvement in muscle strength and resting EMG findings in patients with LEMS treated with 3,4-DAP. It is recommended to start 3,4-DAP at 5 mg three times per day, and the dose may be increased up to 60 mg/day in 3–4 daily doses.
The side effects of 3,4-DAP are usually mild and most commonly consist of paresthesias of the perioral area and extremities, nausea and vomiting, and difficulty with sleep. However, serious side effects including seizures, myoclonus, chorea, and cardiovascular disorders have been reported, and the likelihood of serious adverse events appears to be dose-related. Because seizure is the most common serious adverse event, 3,4-DAP is contraindicated in patients with epilepsy. Due to concern for prolongation of the QTc, 3,4-DAP is also contraindicated in patients with congenital QT syndromes, and those taking other drugs known to prolong the QTc interval. Unfortunately, 3,4-DAP has limited availability in the United States.
For patients with more severe symptoms or who fail to respond to a combination of pyridostigmine and either 3,4-DAP or low-dose guanidine, immunosuppressive therapy should be initiated. Unfortunately, there have been no randomized controlled trials of oral immunosuppressant drugs. So, the following recommendations are based on limited data. A typical starting regimen consists of oral prednisone at a dose of 1 mg/kg daily either alone or in combination with azathioprine at a starting dose of 50 mg twice per day.
Mycophenolate mofetil or cyclosporin may be substituted for azathrioprine in patients who are unable to tolerate azathioprine or do not have an adequate response. Rituximab has recently been reported to have some benefit in several patients with LEMS, but has not been more extensively studied.
In patients with the most severe presentation, such as respiratory failure, or who do not respond to the above treatment regimens, plasma exchange or intravenous immunoglobulin (IVIG) should be used. Plasma exchange has been shown to have benefit in several case series but only in the short term. IVIG has been shown in a single randomized controlled trial of 9 patients with LEMS to improve muscle strength, although the effect waned at 8 weeks. Therefore, both plasma exchange and IVIG should be used in combination with oral immunosuppressant therapy.
A. Immediate management.
In the absence of respiratory failure or severe weakness, no emergent therapy for LEMS is required. As mentioned above, with a severe LEMS flare, either IVIG or plasma exchange in combination with oral immunosuppressant therapy should be initiated.
B. Physical Examination Tips to Guide Management.
The need to alter therapy is dependent on symptomatic response and side effects. If a patient with LEMS continues to have weakness on physical exam, then additional therapy should be considered.
However, patients should be given an adequate trial of therapy prior to either increasing the dosage or changing therapy. In the case of pyridostigmine, guanidine, and 3,4-DAP the patient should be treated for several days prior to assessing for adequate response. In the case of oral immunosuppressants the patient may not see a benefit for several months.
C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.
For patients taking 3,4-DAP, periodic electrocardiograms should be obtained to monitor the QTc.
Due to its significant toxicity, patients taking guanidine should have serial blood counts to monitor for bone marrrow suppression, as well as renal and hepatic monitoring.
Measurement of VGCC titer is not recommended for following response to any therapy.
D. Long-term management.
The long-term management of LEMS is dependent on whether there is an underlying malignancy. In the presence of cancer, the prognosis of LEMS depends on the patient's response to cancer treatment. In the absence of underlying malignancy, most patients with LEMS require continued immunosuppressive medications.
E. Common Pitfalls and Side-Effects of Management.
In terms of side effects, patients taking pyridostigmine especially in combination with 3,4-DAP may experience nausea, vomiting, abdominal cramping and diarrhea. These symptoms may be lessened by decreasing the dose of pyridostigmine.
The most common serious adverse event with 3,4-DAP is seizure and the risk of seizure appears to be dose-dependent. Other common side effects with 3,4-DAP include insomnia, oral and extremity paresthesias, and gastrointestinal upset.
Patients taking guanidine may experience bone marrow toxicity, renal and hepatic failure.
IV. Management with Co-Morbidities.
Some antimicrobials should be used with caution in patients with LEMS as they can further impair neuromuscular transmission and therefore increase weakness. These include quinine and aminoglycoside antibiotics, particularly gentamicin, kanamycin, neomycin, and streptomycin. If it is necessary to use one of the aforementioned antibiotics, then a patient with LEMS should be carefully monitored for increased weakness.
Similarly, anesthetic agents should be used with caution in patients with LEMS. These include succinylcholine, d-tubocurarine, and other neuromuscular-blocking agents.
A. Renal Insufficiency.
Guanidine should be used with caution in cases of renal insufficiency.
B. Liver Insufficiency.
Guanidine should be used with caution in cases of hepatic disease.
C. Systolic and Diastolic Heart Failure.
Beta blockers, calcium channel blockers and certain antiarrhythmics including quinidine and procainamide affect neuromuscular transmission and therefore should be used with caution in patients with LEMS as they may significantly exacerbate weakness.
IVIG should be used with caution in the treatment of patients with LEMS and concurrent heart failure due to the large amount of volume required for administration.
D. Coronary Artery Disease or Peripheral Vascular Disease.
Similar caution applies as previously mentioned for the use of beta blockers and antiarrhythmics.
E. Diabetes or other Endocrine issues.
For patients with underlying diabetes, steroids should be used with caution as they may exacerbate hyperglycemia.
F. Malignancy.
As mentioned previously, symptoms of LEMS often improve with treatment of the underlying malignancy, and therefore effective treatment of the underlying malignancy is central to management of malignancy-associated LEMS.
G. Immunosuppression (HIV, chronic steroids, etc).
No change in standard management.
H. Primary Lung Disease (COPD, Asthma, ILD).
Due to reports of bronchial hypersensitivity, 3,4-DAP is contraindicated in patients with uncontrolled asthma.
I. Gastrointestinal or Nutrition Issues.
Patients treated with pyridostigmine and 3,4-DAP commonly experience gastrointestinal upset including nausea, vomiting, abdominal cramping and diarrhea. Patients with other coexistent gastrointestinal disease, may therefore have worsening symptoms if treated with pyridostigmine or 3,4-DAP.
J. Hematologic or Coagulation Issues.
Patients treated with guanidine must be monitored for bone marrow toxicity.
K. Dementia or Psychiatric Illness/Treatment.
V. Transitions of Care.
A. Sign-out considerations While Hospitalized.
The weakness of LEMS may worsen if the patient is febrile, or takes a hot shower or bath. Additionally, any coexisting illness may acutely exacerbate the symptoms of LEMS and should be treated aggressively.
In the setting of severe worsening of weakness including respiratory failure, immediate treatment would include plasma exchange and/or IVIG.
B. Anticipated Length of Stay.
In the absence of severe weakness or respiratory failure, patients with LEMS do not require hospitalization, and much of the evaluation and treatment of these patients can be performed in the outpatient setting.
C. When is the Patient Ready for Discharge.
In the absence of severe weakness or respiratory failure, patients with LEMS may be discharged home to complete much of their evaluation and treatment in the outpatient setting.
D. Arranging for Clinic Follow-up.
For patients with malignancy-associated LEMS, the most important follow up should be with oncology. Similarly, patients with underlying autoimmune disease should have follow up arranged with rheumatology. For management of symptoms related to LEMS, patients should be followed regularly by a neurologist.
1. When should clinic follow up be arranged and with whom.
Follow up with neurology should be arranged within 1–2 weeks of discharge depending on the severity of the underlying weakness. If malignancy was found during the hospitalization then follow up with oncology should ideally be arranged within 1 week.
2. What tests should be conducted prior to discharge to enable best clinic first visit.
For patients with newly diagnosed LEMS, it is helpful to have a CT of the chest and FDG-PET prior to discharge in order to determine appropriate follow up. A baseline EMG and serum titer of VGCC antibodies would also be useful.
3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.
If a patient with suspected LEMS did not undergo the above mentioned testing (CT chest, EMG, VGCC antibody screen), then these should be completed in the outpatient setting prior to the first clinic appointment.
If a patient was started on treatment during the hospitalization, then repeat EMG could be considered prior to clinic follow up to document response to treatment, although a decision to change treatment is primarily based on symptomatic response.
Any patient treated with guanidine should have a blood count, hepatic function panel and renal function panel on the day of clinic follow up.
E. Placement Considerations.
For patients who have severe weakness during their hospitalization, an assessment of their functional status by physical and occupational therapy should be obtained as soon as possible in order to assist with placement. Since many of the treatment options for LEMS are not effective immediately, patients with severe impairments are likely to require skilled nursing placement.
F. Prognosis and Patient Counseling.
Prognosis in the case of malignancy-associated LEMS is entirely dependent on the prognosis of the underlying cancer. In the case of non-paraneoplastic LEMS prognosis is quite good, although patients may require long term treatment with immunosuppressant medications.
VI. Patient Safety and Quality Measures.
A. Core Indicator Standards and Documentation.
B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.
For patients in whom long term steroid use is planned, patients should be started on calcium plus vitamin D and trimethoprim/sulfamethoxazole for PCP prophylaxis. Bisphosphonate may be considered.
VII. What's the Evidence?
Bain, PG, Motomura, M, Newsom-Davis, J, Misbah, SA, Chapel, HM, Lee, ML, Vincent, A, Lang, B. "Effects of intravenous immunoglobulin on muscle weakness and calcium-channel autoantibodies in the Lambert-Eaton myasthenic syndrome". Neurology. vol. 47. 1996. pp. 678-683.
Elmqvist, D, Lambert, EH. "Detailed analysis of neuromuscular transmission in a patient with the myasthenic syndrome sometimes associated with bronchogenic carcinoma". Mayo Clin Proc. vol. 43. 1968. pp. 689-713.
Gilhus, NE. "Lambert-Eaton myasthenic syndrome; pathogenesis, diagnosis, and therapy". Autoimmune Dis. vol. 2011. 2011. pp. 973808
Karam, C, Scelsa, SN. "Clinical reasoning: a 48-year-old woman with generalized weakness.". Neurology. vol. 74. 2010. pp. e76-e80.
Keogh, M, Sedehizadeh, S, Maddison, P. "Treatment for Lambert-Eaton myasthenic syndrome". Cochrane Database of Systematic Reviews. vol. 2. 2011. pp. CD003279
Lambert, EH, Eaton, LM, Rooke, ED. "Defect of neuromuscular conduction associated with malignant neoplasms". Am J Physiol. vol. 87. 1956. pp. 612-613.
Lambert, EH, Elmqvist, D. "Quantal components of end-plate potentials in the myasthenic syndrome. Ann N Y Acad Sci 183: 183-199, 1971Lang B, Pinto A, Giovannini F, Newsom-Davis J, Vincent A: Pathogenic autoantibodies in the Lambert-Eaton myasthenic syndrome". Ann N Y Acad Sci. vol. 998. 2003. pp. 187-195.
Lindquist, S, Stangel, M. "Update on treatment options for Lambert-Eaton myasthenic syndrome: focus on use of amifampridine". Neuropsychiatr Dis Treat. vol. 7. 2011. pp. 341-349.
Lorenzoni, PJ, Scola, RH, Kay, CS, Parolin, SF, Werneck, LC. "Non-paraneoplastic Lambert-Eaton myasthenic syndrome: a brief review of 10 cases". Arq Neuropsiquiatr. vol. 68. 2010. pp. 849-854.
Pellkofer, HL, Armbruster, L, Linke, R, Schumm, F, Voltz, R. "Managing non-paraneoplastic Lambert-Eaton myasthenic syndrome: clinical characteristics in 25 German patients". J Neuroimmunol. vol. 217. 2009. pp. 90-94.
Prommer, E. "Neuromuscular paraneoplastic syndromes: the Lambert-Eaton myasthenic syndrome". J Palliat Med. vol. 13. 2010. pp. 1159-1162.
Simon, JI, Herbison, GJ, Levy, G. "Case report: a case review of Lambert-Eaton myasthenic syndrome and low back pain". Curr Rev Musculoskelet Med. vol. 4. 2011. pp. 1-5.
Titulaer, MJ, Maddison, P, Sont, JK, Wirtz, PW, Hilton-Jones, D, Klooster, R, Willcox, N, Potman, M, Sillevis Smitt, PA, Kuks, JB, Roep, BO, Vincent, A, van der Maarel, SM, van Dijk, JG, Lang, B, Verschuuren, JJ. "Clinical Dutch-English Lambert-Eaton myasthenic syndrome (LEMS) tumor association prediction score accurately predicts small-cell lung cancer in the LEMS". J Clin Oncol. vol. 29. 2011. pp. 902-908.
Titulaer, MJ, Verschuuren, JJ. "Lambert-Eaton myasthenic syndrome: tumor versus nontumor forms". Ann N Y Acad Sci. vol. 1132. 2008. pp. 129-134.
Wirtz, PW, Nijnuis, MG, Sotodeh, M, Willems, LN, Brahim, JJ, Putter, H, Wintzen, AR, Verschuuren, JJ. "The epidemiology of myasthenia gravis, Lambert-Eaton myasthenic syndrome and their associated tumours in the northern part of the province of South Holland". J Neurol. vol. 250. 2003. pp. 698-701.
Copyright © 2017, 2013 Decision Support in Medicine, LLC. All rights reserved.
No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. The Licensed Content is the property of and copyrighted by DSM.
Powered By Decision Support in Medicine.
Next post in Hospital Medicine
Hypogonadism and Testosterone Treatment
Close more info about Lambert-Eaton Myasthenic Syndrome (Eaton-Lambert Syndrome)

redpajama_set_name: RedPajamaCommonCrawl


text:
"G.S.D., FELLOW PROJECT, IMAGINARY AIRSHOW, & WILL GIBSON" show @ SLUGGOS. PENSACOLA, FL. 08/28/10
This year, Deadbroke Rekerds' recording artists, Fellow Project and Go Sell Drugs (Brooklyn) embarked on a Summer tour of the East Coast which landed them firmly on stage at Sluggo's Vegetarian Restaurant sharing a bill with Will Gibson and Imaginary Airshow.
The first act of the night was Will Gibson, a local musician, who set up the night with a mellow acoustic set highlighted by a song he wrote for his mother.
Following on stage, were the rhythmic pulses of Fellow Project from Long Island, New York. Ryan (drums) and Tia's (bass) driving rhythm section gets the balls of your feet locked and jumpin', while Joe's catchy single note phrases latch onto your brain and compels you to ping-ping your head around like the silver balls in the pinball machines I used to play as a kid. Ryan and Tia (married to each other) have a crazy musical chemistry onstage with his energy almost exploding to surface while she wields her bass (that is literally almost as tall as her) like a toothpick during their set. I only wish their set was longer.
Now, if you sat down on my couch and I told you to close your eyes and visualize true working class hardrock or punk, I bet you the boys of Go Sell Drugs would jump in your skull and burn a hole in your occipital cortex. GSD from Brooklyn, New York are for real. Lead singer and guitarist, Tony has all of the presence of tortured Social Distortion frontman, Mike Ness with the fire grilled vocals of Henry Rollins. Bassist, I-man and I talked about Wisconsin, Brett Favre, the high cost of living in New York, being hungry and life in general. Drummer, John even offered me his beer. One show away from the end of their summer tour and they are energized about life, their music and giving. This realness and ability to connect with people and the society surrounding us translates heavily in their music and show. Raw like demons trapped in hell for centuries, they don't try to pummel you outright, they have fun with the music, but there is always evident. the subtext and venom scratching at the skin. With song titles like "Sorry the feds broke up your Indian Summer" and "Where have all the East Villagers gone" you better come prepared for some energy at this show.
Closing out the night, were Imaginary Airshow (Pensacola, Fl.). Piloted by several of the area's hardest working musicians, this band knows how to invest all they have into their performance and connect musically with their audience. And when I say "connect" I don't mean in the pop punk, hip hop way of call and response banter between audience and artist. If Imaginary Airshow were a lover, they'd be the girl that wasn't needy and was so emotionally stable that she didn't need your feedback for validation. She's going to "do what she do" with or without you. Watching the band was almost a voyeuristic pleasure; craftsman in the dark, wearing black and their only occupation consisting of their tools and the energy they are creating.
The vocal lighthouse on this journey is Todd Vilardi whose moments of "breaking the fourth wall" are brief exchanges not to people in the audience, but the entire crowd as a collective listener/watcher. These short messages and moments are breathing while the lyrics take a break from dancing during the show. The weight of Todd's communication is made more powerful by the focused intent of fellow musicians Gio Lugo (bass), Aaron Finlay (guitar), Brandon Warren (drums) and Sean Peterson (keyboard) Their quiet devotion to the music they play is matched only by the intensity by which they execute it.
And ALL of this for only a $5 cover! Bargain, indeed.
Drink of the night: Bottled Water
Show Write-Ups
aaron finlay, bottled water, brandon warren, brett favre, deadbroke rekerds, FELLOW PROJECT, florida, gio lugo, GO SELL DRUGS, henry rollins, IMAGINARY AIRSHOW, mike ness, new york, pensacola, POST PUNK, punk, rock, sean peterson, sluggo's vegetarian restaurant, summer tour, todd vilardi, WILL GIBSON


text:
Thanks to a new service, debuted Monday by Amtrak, you can now surf the Internet while on Amtrak – for free. Traveling photographers can now upload their favorite photos to Flickr or Facebook. With a little luck, traveling photojournalists could now complete their stories and file them with their bureau before they ever get off the train.
Right now, the service is only available on the Acela Express trains, traveling between Boston and Washington. It's also available in six stations along that corridor. Stations offering the free service include:
- Washington Union Station
- Baltimore Penn Station
- Philadelphia 30th Street Station
- New York Penn Station
- Providence Station
- Boston's Route 128 Station
"AmtrakConnect" is available to every passenger on board Acela Express, both in Business and First class seating.
Listening to Lenetta McCampbell, senior director for on-board systems, it sounds like it will expand to other lines in other states as well. "This is only the first step for our AmtrakConnect program," says McCampbell. "Amtrak will continually improve the service as Wi-Fi technology evolves, and we are evaluating opportunities to expand AmtrakConnect to additional routes and stations throughout the country." AmtrakConnect was deployed on Acela Express by Virginia Beach-based GBS Group and its partner Nomad Digital.
This promises to be a welcome service for anyone who ever tried to stay connected using the likes of Verizon's mobile broadband card – which as this writer can attest, was a hit-or-miss proposition most of the time. "AmtrakConnect delivers the fast, reliable and consistent connectivity that our customers have been asking for," said Matt Hardison, chief, sales distribution and customer service.
Time will tell if it lives up to the promise and time will tell if it remains free. According to Amtrak's press release, the service will continue to be free during this introductory period and they will reassess the situation after they've had a chance to analyze its performance and acceptance by the traveling public.
Labels: Technology, Train travel, Travel


text:
Bruno Walter conducts Mozart [6 CD set]
2-6 weeks add to cart
Zino Francescatti (violin) Irmgard Seefried (soprano), Jennie Tourel (alto), Léopold Simoneau (tenor) & William Warfield (bass) / Columbia Symphony
[ Sony Classical Masters / 6 CD Box Set ]
Release Date: Thursday 1 September 2011
This item is currently out of stock. We expect to be able to supply it to you within 2 - 4 weeks from when you place your order.
Born in Berlin in 1876, Bruno Walter entered the Stern Conservatory at the age of eight, intending to become a concert pianist, and made his conducting debut in Cologne at 17. Following appointments in Pressburg (now Bratislava), Riga and Berlin, he went to Vienna as assistant to Mahler, whose works he later championed, giving the premieres of Das Lied von der Erde and the Ninth Symphony after the composer's death. Important positions in Munich and Berlin - as well as guest appearances in Salzburg, London, Amsterdam, Paris, New York, Moscow and elsewhere - brought him worldwide fame by the 1920s. After the Nazis drove him from Germany in 1933 and Austria in 1938, he settled in the United States, where he worked with several leading musical organisations, most notably the New York Philharmonic. He was, and through his many recordings still is, widely admired for his skilful use of rubato, sensitivity to structure and textural details, dramatic intensity and, perhaps most of all, the genial lyricism of his performances.
Symphony No. 35 in D major, K385 'Haffner'
Symphony No. 36 in C major, K425 'Linz'
Der Schauspieldirektor, K486: Overture
Così fan tutte, K588: Overture
Le nozze di Figaro, K492: Overture
Die Zauberflöte, K620: Overture
Symphony No. 38 in D major, K504 'Prague'
Symphony No. 39 in E flat major, K543
Serenade No. 13 in G major, K525 'Eine kleine Nachtmusik'
Symphony No. 40 in G minor, K550
Symphony No. 41 in C major, K551 'Jupiter'
Masonic Funeral Music in C minor, K477
Requiem in D minor, K626
(with Irmgard Seefried, soprano, Jennie Tourel, alto, Léopold Simoneau, tenor, & William Warfield, bass)
Violin Concerto No. 3 in G major, K216
Violin Concerto No. 4 in D major, K218
(with Zino Francescatti, violin)
Menuet KV599
German Dances (3), K605
Symphony No. 28 in C major, K200
Symphony No. 29 in A major, K201
Jascha Heifetz plays Great Violin Concertos [6 CD set]
Verdi: Requiem
Michala Petri plays Concertos & Sonatas
James Galway plays Flute Concertos [12 CD set]


text:
Tax Havens/Bank Secrecy
Transnational Crime and Terrorist Financing
Need funds for the SDGs? Tackle trade fraud
GFI: Indonesia lost US$6.5 billion to Trade Misinvoicing in 2016; Revenue needed for SDGs
El Caso Odebrecht: El rol del movimiento social y del periodismo
The Odebrecht Case: The role of social mobilization and journalism
Tweets by @IllicitFlows
HomeBlogTax Havens/Bank Secrecy
Country/Region/Forum AfricaAlbaniaAngolaArgentinaAsiaAustraliaBangladeshBank for International SettlementsBelgiumBermudaBosnia-HerzegovinaBrazilBritish Virgin IslandsBulgariaBurmaCambodiaCameroonCanadaCayman IslandsChileChinaColombiaCongo, Democratic Republic ofCongo-BrazzavilleCroatiaCubaCyprusDenmarkDominican RepublicEgyptEquatorial GuineaEthiopiaEuropeFATFFinlandFranceG20G8 / G7GabonGermanyGhanaGreeceHondurasHong KongIndiaIndonesiaIranIrelandJerseyKenyaKosovoLatin AmericaLatviaLiechtensteinLuxembourgMacedoniaMalaysiaMexicoMiddle EastMontenegroMozambiqueMyanmarNamibiaNetherlandsNew ZealandNigeriaNorth AmericaNorwayOceaniaOECDPeruPhilippinesRomaniaRussiaSenegalSerbiaSingaporeSloveniaSouth AfricaSouth AmericaSpainSudanSwedenSwitzerlandSyriaTanzaniaTunisiaUgandaUkraineUnited KingdomUnited NationsUnited StatesVatican, TheVenezuelaWorld BankWorld Customs OrganizationZambia
Issue Illicit Financial FlowsTrade MisinvoicingMoney LaunderingAnonymous CompaniesTax Havens / Bank SecrecyTransnational Crime
Panama Papers Anniversary Is Opportunity to Underscore Severity of the Problem
By Tom Cardamone, April 3, 2017
Believe it or not, the Panama Papers scandal has an upside: it shed light on the dark corners of the international financial system. Prior to the revelation that one law firm helped establish over 200,000 anonymous companies, the casual observer knew tax evasion, corruption, and money laundering occur in the world but they didn't know quite how it works. Now the term "anonymous shell company" has some resonance and it is in the general lexicon — even if most people still can't explain how they work.
Implications of a Brexit: A U-turn in tackling global tax avoidance?
With just days remaining until Britain decides on its EU membership, the UK is at a crossroads. It has a historical choice to make, with various consequences attached to the decision on the 23rd of June on whether it becomes the first ever country to leave the EU. Those consequences could include undermining the leading role that Britain has taken in the global fight against corruption and transforming Britain into an even greater tax haven for multinationals.
Panama Papers Prove Law Enforcement Right on Beneficial Ownership
"ICE has long recognized the misuse of corporations and limited liability companies (LLCs) formed under State law as a serious threat to the ongoing effort to combat international criminal activities. The lack of corporate transparency has allowed...
FIFA: The Bribery Case with No Bribery Charge
By Heather Lowe, May 29, 2015
Corruption FIFA Sports
This was a very exciting week for lawyers who are sports enthusiasts – the Department of Justice indicted fourteen FIFA officials, alleging that they are part of what one could conclude from reading the indictment is a massive, multifaceted, bribery ring. Informal allegations have been made before, and the whispers that FIFA is synonymous with bribery and corruption have been growing louder over the years. But this week the Department of Justice shouted it from the mountain top (or, perhaps more accurately, in front of a lot of the international press corps, which was probably more effective).
There are a number of interesting facets to the case that is now before us. The first is that for a case about bribery, a charge of bribery seems to be conspicuously absent. The Defendants were indicted for a "pattern of racketeering activity," including charges of violating the Travel Act in aid of racketeering, money laundering, money laundering conspiracy, wire fraud, wire fraud conspiracy, and other charges that do not expressly include bribery. Why is that?
Settling Accounts: What Happens after SwissLeaks?
By Koen Roovers, February 18, 2015
HSBC SwissLeaks
The SwissLeaks Scandal around the HSBC Bank Subsidiary There Has Highlighted How Globalization Can Facilitate Tax-Dodgers. Only a Bright Spotlight of Information Can Deter Them.
A major leak of incriminating HSBC records last week resulted in print and television news coverage around the globe, trended on Twitter for several days and prompted several governments to start long-anticipated investigations. Through its Swiss entity, the British banking juggernaut helped customers from around the world to hide their money for tax evasion or other nefarious purposes without any questions asked. In fact, in several of the 'scripts' which accompany the accounts, banking personnel are seen to be very willing to accommodate dubious requests—from allowing cash withdrawals worth millions of dollars to setting up sham legal entities to obscure the ownership of the funds.
The 'Lagarde list', as the files have come to be known, has been around for a couple of years and so many have been asking: 'Why do we only see government action once a group of reporters put the spotlight on this?' Another frequent question has been whether the bank has really (as it claims) cleaned up its act.
Relatively few commentators have asked: how do we prevent this in the first place?
Checking up on the Banks: Yet More of the Same
By Joshua Simmons, November 10, 2014
Banks Enforcement Financial Crime Too Big to Jail
Until Global Financial Crime Punishments include Individual Prosecutions, Rogue Banks Will Continue to Do as They Please, Writes GFI's Joshua Simmons
After the recent spate of massive money-laundering, sanctions-busting, and tax-evasion scandals involving large international banks, sometimes it seems more difficult to name a single bank that has not been exposed for wrongdoing than list all those that have. One might think that, having worked their way through so many financial institutions, investigators and prosecutors would be at a loss for what to do next. The banks, though, seem more than willing to provide more work, with many either failing to meet their ends of their settlement agreements, continuing to move money for criminals and tax-evaders, or both.
Standard Chartered, which settled charges in mid-2012 related to its widespread activities violating U.S. sanctions on Iran, Burma, Libya, and Sudan, paid an additional fine this summer for failing to uphold its obligations under the settlement. The bank may now be in line for even more punishment, after new information seems to indicate additional transactions with Iranian entities that weren't disclosed or admitted in the original settlement. It's not presently clear whether Standard Chartered retained a relationship with Iranian customers after its settlement in 2012, but it certainly continued to take their money after the initial investigation began.
Messi and the International Impunity System
By Max Heywood, August 12, 2014
Anonymous Companies Lionel Messi Sports
Lionel Messi's Tax Troubles Should Increase Pressure on Politicians to Curb the Abuse of Anonymous Companies
The ongoing prosecution of football super star Lionel Messi for alleged tax evasion made global headlines last week. Messi and his father Jorge are accused of evading 4.2 million euros (US$5.6m) in tax on sponsorship earnings in court documents submitted by the prosecutor.
The alleged tax evasion scheme was based on using a web of anonymous shell companies registered in tax havens such as Belize and Uruguay, as highlighted by our colleagues at Global Witness. These shell companies were linked to other anonymous companies in what the prosecutor calls "convenience jurisdictions" such as the UK and Switzerland.
New Thomson Reuters Foundation Media Program to Investigate Illicit Finance, Tax Abuse
By Clark Gascoigne, July 17, 2014
Africa Journalism Thomson Reuters Foundation
Thomson Reuters Foundation Seeks Applications from African Media for Illicit Finance Training and Assistance Program by July 28th
Are you an ambitious journalist in Africa with an interest in probing illicit finance, money laundering, and tax related abuses? Or, perhaps, you represent an outstanding, independent media organization based in Africa with a desire and reputation for exposing financial crime and corruption?
Either way, the Thomson Reuters Foundation is launching a new three-year program assisting African media on the reporting of illicit finance and tax abuse, and they are hoping that you will apply. According to the TR Foundation:
African economies lose huge sums of money every year through practices such as tax evasion and avoidance, often carried out by large companies. However, this phenomenon receives little attention and is rarely the subject of in-depth investigation.
Thomson Reuters Foundation believes that African media has a vital role to play in bringing this issue to light and exposing tax abuse where it is taking place. We also believe that collaboration between journalists and media organisations across borders is essential when reporting on money flows between countries.
We are seeking outstanding journalists and ambitious, independent media organisations to join us in this new project.


text:
Cazinoul "Cassina" din Făget este un monument istoric aflat pe teritoriul orașului Făget.

Note

Monumente istorice din județul Timiș

redpajama_set_name: RedPajamaWikipedia


Issue: Some customers are reporting they are unable to upload images to the Blog, Calendar and Forums Apps on their site. After clicking the Image icon to upload an image, the Upload Image window spins and eventually displays an "Uh Oh" error message.
Status: This issue is being further investigated.
What to do: If you are affected, please comment with your site address.
UPDATE: This issue has been fixed. Customers who were affected can now upload new images to the App and it will automatically be placed into the App page.
Although this has been fixed, our Engineering team is continuing to work on resolving the issue of viewing previously uploaded files in Apps pages. As a temporary workaround, customers can take a saved copy of a previously uploaded image, rename the file, and upload it to the App page as a new image.
I cannot upload photos to my forum header settings.
Been like this since the start of the year. Keep getting support tickets closed and forum posts closed off because it's "resolved". It's not resolved and emailing Support is a waste of time because they do not respond.
Been having this issue all day. Very desperate to blog for my business.
Exactly my problem also, for about a month that I am aware of but could be much longer. I am loathe to pay my subs due now until there is some light at the end of the tunnel on this.
http://www.casadelporticato.com How long do we have to put up with this: for 2 months this is going on: unable to upload pictures to my BLOG: strange pictures that appear on my website....... AND REALY NOTHING SEEMS TO HAPPEN TO FIX THIS PROBLEM....... why don't you stop your activities as you cannot solve the problems....???? You will go out of business anyway if you continue this way..... and I will too if I stay with your company. ...... NOTHING is done to keep customers informed, nothing is done to communicate properly, nothing is done to compensate clients, nothing nothing absolutely nothing..... THERE IS SOOOOO MUCH FRUSTRATION WITH YOUR CLIENTS!!!
Still NOT fixed... been like this all year now so it's gotten beyond a joke. Other threads keep getting closed off as "resolved". This is NOT resolved. Early on I was told it was because half of Webs customers were migrated to a new server (which is why not all users are affected) and that it would be resolved quickly. That was more than a month ago and nothing. No updates on here, no replies to tickets logged, nothing.
MY ADVICE TO EVERYONE IS TO FIND A NEW HOST. WEBS ARE NOW THE WORST COMPANY GOING.
I don't even get the uh oh window. I get the window to select from my images, with the blue spinning wheel that never stops spinning. It's something new each week.
I have had this problem most of this year too. spellbookandcandles.co.uk please mend my blog! I am sick of the spinning then Uh Oh!!
Received contact from support via Omar who said the system is being upgraded and issues have occurred due to this.
I just hope for an update or info on how long this is estimated to take.
Very disappointed but making plans to fix my own business issues. This has come at the worst time as I'm finally releasing my first book but with no site to advert it as I can't upload pics.
It keeps saying uploading but nothing happens.
With all due respect, this has been going on for 10 days now. I needed to post an important blog entry last week, and couldn't. I'm paying a lot of money monthly for a pro site that doesn't work.
Can we please have an update and an ETA on when this will be fixed? This has been going on for 2 months now. I was initially told it was a problem caused by the server migration over the Christmas period and that the engineers were working on a fix. But that was almost 2 months ago. PLEASE can someone FIX this and update us? I think we've all been very patient and if it had taken a week or two, fine. But this has gone on way too long for paying customers.
Any update on when this will be fixed, please?
I did have some success just using direct links/URLs copied from the file manager but I really need to be able to use the file manager facility to locate and see the photos when I am inserting them into a blog post. It seems that the issue is well defined and known about and many people are suffering and yet no hint of a fix being found. A bit more information in layman's terms would be appreciated Webs.
Why hasn't anything been done regarding this issue?!
Could we please have an update? Online chat support just give a generic "we're working on it" response, email support doesn't even bother responding and we all seem to be ignored here.
As paying customers we expect better service than this.
This problem has been "investigated" for 13 days now. Are we to believe that someone(s) has come to work every day for two weeks and can't fix it? Or is nobody really working on it?
Still the same crap for 10 days now. Can't get pictures to upload to my blog. If it's not one thing it's another. Are you deliberately trying to get rid of us? Just let us know. That would be better than this slow torture.


text:
Румунска књижевност представља књижевност коју стварају румунски књижевници, иако се појам може користити да би означио сву књижевност написану на румунском језику.

Историја

Почеци

Најранији сачувани документ на румунском језику је Њаскуово писмо написано 1521. године судији и градоначелнику Брашова, Хансу Бенкнеру.

Румунска култура била је под јаким утицајем источне православне цркве, а званични став румунске цркве је да је православље у Румунију донео апостол Андреја. Према неким модерним румунским научницима, идеја ране христијанизације је неодржива, већ је била коришћена у пропагандне сврхе у тоталитарној ери као део идеологије протохронизма, који је тврдио да је православна црква била пратилац и бранитељ румунског народа током читаве његове историје. Најраније преведена књига на румунски језик били су старословенски религијски текстови из 15. века. Псалитр из Шкеија (Psaltirea Șcheiană) из 1482. године и Воронецки кодекс (Codicele Voronețean) представљају религијске текстове који су написани у Мармарошу.

Прва књига штампана у Румунији била је старословенска религијска књига из 1508. године. Прва штампана књига на румунском језику била је Протестантски катекизам ђакона Коресија из 1559. године, коју је штампао Филип Молдовеанул. Други преводи грчких и старословенских књига штампани су касније током 16. века. Дософтеј, Молдавац који је објављивао у Пољској током 1673. године, био је први румунски метрички псалтир, који је написао најранију поезију писану на румунском језику.

Рани напори да се објави Библија на румунском језику почели су 1582. године, штампањем у малом граду Ораштијама књиге под називом Палија де ла Ораштије. Ова књига представља превод првих књига Старог завета, а штампали су је ђакон Шербан (син горепоменутог ђакона Коресија) и Маријен Дијакул. Палију је са латинског превео епископ Михаил Тордаш, а прецизност превода проверавана је помоћу мађарских превода Библије.

Цела Библија није била објављена на румунском језику све до краја 17. века, када су монаси у манастиру Снагов, близу Букурешта, превели и одштампали Букурештанску Библију (Biblia de la București) 1688. године.

Европски хуманизам дошао је у Молдавију током 17. века преко Пољске са представником Мироном Костином, који је писао хронику о историји Молдавије. Други хуманиста био је Димитрије Кантемир, који је писао о историјама Румуније и Молдавије.

Османска декаденција и фанариоти

Отоманско царство доминирало је румунским земљама током 18. века, које је одлучило да не дозволи румунске владаре у Влашкој и Молдавији и уместо тога владало преко грчких трговаца из Истанбула, званим фанариотима.

Сходно томе, грчка култура умногоме је утицала на развој румунске књижевности. На пример, један од највећих песника овог периода био је Алеку Вакареску, који је писао љубавне песме према традицији старогрчког песника Анакреонта. Његов отац, Јенакица, био је такође песник, али је написао и прву румунску граматику, док је његов син, Јанку, био вероватно један од највећих песника своје генерације. Људска комедија развијана је у анегдотама Антона Пана, који је покушао да илуструје мало балканског духа и фолклора који су Османлије донеле у румунске земље.

Ипак, наредна генерација румунских писаца се у потрагу за инспирацијом окренула ка европском илуминизму, међу њима и Георге Асачи, Јон Будаи Делеану и Динику Голеску.

Национално буђење
Како су се револуционарне идеје национализма шириле по Европи, оне су се такође појавиле и родиле међу Румунима, који су желели своју наицоналну државу, али су живели под страном влашћу. Многи румунски писци тог времена такође су били део националног покрета и учествовали у устанкама 1821. и 1848. године. Почело се расправљати о пореклу Румуна, а у Трансилванији се појавио латински покрет Şcoala Ardeleană, чији су чланови почели писати филолошке студије о романском пореклу Румуна и почели да отварају школе на румунском језику.

Румуни који су студирали у Француској, Италији и Немачкој, као и немачка филозофија и француска култура почели су да се интегришу у модерну румунску књижевност тог периода, временом смањујући утицај Античке Грчке и Оријента. Важна фигура књижевности тог доба у Влашкој био је писац Јон Хелиаде Радулеску, који је покренуо први часопис на румунском језику и прво Филхармонијско друштво, које је касније створило Национално позориште у Букурешту.

Најзначајнији писци друге половине овог века били су Василе Александри и касније Михај Еминеску. Александри је био плодан писац, доприносећи румунској књижевности са поезијом, прозом, неколико представа и збирком румунског фолклора. Еминескуа већина критичара сматра најзначајнијим и најутицајнијим румунским песником. Његова лирска поезија настала је под утицајем бројних румунских традиција, а такође су на њу утицале немачка филозофија и хиндуистичке традиције.

Књижевни круг Јунимеа који је, између осталих, основао Титу Мајорексу 1863. године и кроз који је прошао велики број румунских писаца, играо је веома важну улогу у румунској књижевности. Многи истакнути румунски писци, укључујући Јона Луку Карагиалеа, који је написао неке од најбољих румунских комедија; Јона Кренгеа, који је писао традиционалне румунске приче; и Барбуа Штефанескуа Делавранче, објављивали су своје радове у том периоду. Ђорђе Кошбук био је песник, преводилац, учитељ и новинар, најпознатији по својим стиховима који описују, величају и славе сеоски живот. Николаје Балческу, Димитрије Болининеану, Алеку Русо, Николаје Филимон, Богдан Петричеику Хасдеу, Александру Одобеску, Григоре Александреску, Константин Негруци, Александру Влахуца, Александру Македонски, Петре Испиреску, Дуилиу Замфиреску и Јоан Славичи представљали су такође важне књижевне личности тог доба.

Међуратна књижевност
Након постизања националног јединства 1918. године, румунска књижевност ушла је у оно што се може назвати златним добом, што је окарактерисано развојем румунског романа. Традиционално друштво и недавни политички догађаји утицали су на радове као што је роман Устанак (Răscoala) Ливиуа Ребреануа, објављен 1932. године, инспирисан румунским сељацима из 1907. годиен, као и дело Шума обешених (Pădurea Spânzuraţilor), објављено 1922. године и инспирисано учешћем Румуније у Првом светском рату. Почеци модерног романа могу се видети у делима Хортензије Пападат-Бенгеску (Concert din muzică de Bach - Бахов концерт), Камила Петрескуа (Ultima noapte de dragoste, întâia noapte de război - Последња ноћ љубави, прва ноћ рата). Георге Калинеску је још једна сложена личност румунске књижевности: романописац, драмски писац, песник, књижевни критичар и историчар, есејист, новинар. Објавио је ауторитативне монографије о Еминескуу и Кренгеу и монументалној (скоро 1.000 страница у четири тома) историји румунске књижевности од њеног настанка до времена писања (1941).

Важан реалистички писац био је Михаил Садовеану, који је писао углавном романе који су се одвијали у различита времена у историји Молдавије. Вероватно су најважнији писци тога доба били Тудор Аргези, Лучан Блага и Мирча Елиаде. Тудор Аргези је денео револуцију у румунској поезији 50 година након Еминескуа, стварајући нове стубове за модерну румунску песму. Лучан Блага, једна од најзначајнијих уметничких личности у земљи, кроз своје списе развио је комплексан филозофски систем, који и данас није савршено схваћен. Мирча Елиаде се данас сматра највећим историчарем у области религија. Његови романи откривају мистичну, претхришћанску симболику која отвара пут савременој румунској уметности.

Рођен у Румунији, Тристан Цара, песник и есејиста, главни је оснивач дадаистичког покрета, нихилистичког револуционарног покрета у уметности, и можда је био одговоран за његово име (румунски за "да да"). Касније је напустио нихилизам и препустио се надреализму и марксизму. По први пут у својој историји, румунска култура је била у потпуности повезана са западном културом, док је дадаизам први румунски уметнички и књижевни покрет који је постао интернационалан. Дадаизам и надреализам су основни делови авангарде, најреволуционарнијег облика модернизма. Румунску авангарду веома добро представљају Јон Минулеску, Герасим Лука, Урмуз, Перпесицијус, Тристан Цара, Григоре Куглер, Гео Богза, Барбу Фундоиану, Гелу Наум, Иларије Воронка и Јон Винеа. Макс Блехер је био песник чији су живот прекинули здравствени проблеми.

Георге Баковија био је песник симболиста. Док је у почетку припадао локалном симболистичком покрету, његова поезија се сматрала претходником румунског модернизма. Неке важне књижевне фигуре из овог периода биле су активне и у другим доменима. Василе Војкулеску је био румунски песник, писац кратке приче, драмски писац и лекар. Јон Барбу је био песник, као и важан математичар.

Цезар Петреску био је новинар, романописац и дечији писац. Посебно се памти по својој књизи за децу под називом Фрам, поларни медвед (Fram, ursul polar) - циркуски животињски лик је добио име по Фраму, броду који је Фритјоф Нансен користио на својим експедицијама). Елена Фараго је такође била дечји писац и песник.

Јон Агарбичану је био писац, као и политичар, теолог и гркокатолички свештеник. Гала Галактион је био други писац који је био и православни свештеник и теолог.

Друге књижевне личности из овог доба су Јонел Теодореану, Панаит Истрати, Гиб Михаеску, Отилија Чазимир, Георге Топорчеану.

Комунистичка ера

Марин Преда се често сматра најзначајнијим румунским писцем после Другог светског рата. Његов роман Породица Моромеци (novel Moromeţii) описује живот и потешкоће обичне сељачке породице у предратној Румунији, а касније и појаву комунизма у Румунији. Његова најважнија књига остаје Најдражи међу Земљанима (Cel mai iubit dintre pământeni), која представља окрутан опис комунистичког друштва. Захарија Станцу је 1948. године објавио свој први значајнији роман Босоноги (Desculț).

Неки од најважнијих песника овог периода су Никита Станеску, Марин Сореску, Ана Бландиана, Леонид Димов и Штефа Аугустин Доинаш. Важан романописац из ове ере био је Раду Тудоран.

Изван Румуније, Ежен Јонеско и Емил Чоран представљали су национални дух на највишем нивоу. Ежен Јонеско био је један од најистакнутијих писаца позоришта апсурда. Поред исмејавања најбаналнијих ситуација, Јонескови комади на опипљив начин приказују самоћу људи и безначајност њиховог постојања, док је Чоран био бриљантан писац и филозоф.

Савремена књижевност

Неки од познатијих савремених румунских књижевника су:

Хронологија (19 век—данас)
{{columns-list |colwidth=20em |
1812	Țiganiada				Јоан Будаи Делеану			(епска песма)
1883 Poezii Михај Еминеску			(поезија)
1884     O Scrisoare Pierdută                     Јон Лука Карагиале			(представа)
1920 Ion Liviu Rebreanu (роман)
1924	În Marea Trecere				Лучан Блага		(поезија)
1925     Danton         Камил Петреску               (представа)
1927	Concert din Muzică de Bach			Хортензија Пападат Бенгеску			(роман)
1927	Cuvinte Potrivite			Тудор Аргези		(поезија)
1929	Craii de Curtea-Veche				Матеиу Карагиале		(роман)
1930     Joc Secund         Јон Барбу               (поезија)
1933	Patul lui Procust			Камил Петреску		(роман)
1934	Ioana			Антон Холбан		(роман)
1936	Întâmplări în Irealitate Imediată		Макс Блечер		(роман)
1938	Enigma Otiliei			Ђорђе Калинеску		(роман)
1943 Panopticum Јон Карајон (поезија)
1945	Plantații			Констант Тонегару		(поезија)
1946	Stanțe Burgheze			Ђорђе Баковиа 			(поезија)
1946	Libertatea de a Trage cu Pușca			Ђео Думитреску			(поезија)
1947	Don Juana			Раду Станца		(представа)
1955 Moromeții Марин Преда (роман)
1956	Primele Iubiri			Николаје Лабис		(поезија)
1964	Ultimele sonete închipuite ale lui Shakespeare			Василе Воикулеску 			(поезија)
1965   Iarna Bărbaților Штефан Банулеску (кратка проза)
1966	Omul cu Compasul			Штефан Аугустин Доинаш 			(поезија)
1966	11 Elegii			Никита Станеску		(поезија)
1968     Iona    Марин Сореску   (представа)
1969	Carte de Vise			Леонид Димов		(поезија)
1969	Dicționar onomastic			Мирча Хориа Симионеску		(роман)
1970 Matei Iliescu Раду Петреску (роман)
1973	Vânătoarea Regală			Д. Р. Попеску		(роман)
1975	Lumea în Două Zile			Ђорђе Балајца		(роман)
1977	Cartea de la Metropolis			Штефан Банулеску			(роман)
1977	Bunavestire			Николаје Бребан		(роман)
1980	Faruri, Vitrine, Fotografii			Мирча Картареску			(поезија)
1983	Dimineață Pierdută	Габријела Адамештеану			(роман)
1983	Poeme de Amor	Мирча Картареску			(поезија)
1988	versuri vechi, nouă		Мирча Иванеску		(поезија)
1989	Și Ieri Va Fi o Zi			Мирча Неделчу			(кратка проза)
1990	Levantul			Мирча Картареску		(епска песма)
1993	Nostalgia			Мирча Картареску			(кратка проза)
1996	Amantul Colivaresei			Раду Алдулеску		(роман)
1996	Coaja lucrurilor, sau Dansând cu Jupuita			Адриан Оцоју		(роман)
1996	Orbitor. Aripa stângă			Мирча Картареску		(роман)
2004	Pupa Russa				Георге Кракиун			(роман)
2004	Proorocii Ierusalimului				Раду Алдулеску		(роман)
2006     ''Zogru       Доина Рушти   (роман)
2008     ''Fantoma din moră       Доина Рушти   (роман)
2009     ''Lizoanca la 11 ani       Доина Рушти   (роман)
2015     ''Manuscrisul fanariot       Доина Рушти   (роман)
2017     ''Mâța Vinerii       Доина Рушти   (роман)
2010     Rădăcina de Bucsau       О. Нимигеан   (роман)
2018     Armaghedon revelat       Грид Модорча (роман)
}}

 Литература

 George Călinescu, Istoria literaturii române de la origini până în prezent ("The History of Romanian Literature from its origins till present day"), 1941
 Nicolae Iorga, Istoria literaturii româneşti ("The History of Romanian Literature"), 1929
 Alex Ștefănescu, Istoria literaturii române contemporane, 1941-2000 ("The History of Contemporary Romanian Literature, 1941-2000"), 2005
 Dan C Mihăilescu, Literatura română în postceaușism, Vol II, Proza. Prezentul ca dezumanizare, Ed. Polirom, 2006 Vol II, Proza. Prezentul ca dezumanizare, Ed. Polirom, 2006 "Istoria literaturii românești", Nicolae Iorga, 1929
 "Istoria critică a literaturii române - 5 secole de literatură", Nicolae Manolescu, Editura Paralela 45, 2008 - recenzie
 "Literatura română postbelică. Lista lui Manolescu", Nicolae Manolescu, Editura Aula, 2001 - recenzie
 "Scurtă istorie a literaturii române", Dumitru Micu, Editura Iriana, 1994-1997
 "Istoria literaturii române: de la creația populară la postmodernism", Dumitru Micu, București, Editura Saeculum, 2000
 "De la Alexandru Macedonski la George Bacovia", Dumitru Micu, București, Editura Minerva, 1984
 "Istoria literaturii române în secolul XX", Dumitru Micu, București, Editura Fundației Culturale Române, 2000
 "Istoria literaturii române 1900 - 1918", Dumitru Micu, 2 volume, București, Editura Științifică și Pedagogică, 1964-1965
 "Literatura română la începutul secolului XX", Dumitru Micu, 1964
 "Istoria literaturii române contemporane (1941—2000)", Alex Ștefănescu, Editura Mașina de scris, București, 2005 - recenzie1 - recenzie2
 "Dicționarul literaturii române de la origini până la 1900", Stănuța Crețu, Gabriela Drăgoi, Florin Faifer, Ion Lăzărescu, Editura Academiei, București, 1979
 Dicționarul scriitorilor români (coordonatori Mircea Zaciu, Marian Papahagi, Aurel Sasu), Vol. I-IV, Editura Fundației Culturale Române, Editura Albatros, București, 1995-2002;
 Dicționarul esențial al scriitorilor români (coordonatori Mircea Zaciu, Marian Papahagi, Aurel Sasu), Editura Albatros, București, 2000;
 Dicționar general al literaturii române, București, Editura Univers Enciclopedic, 2006.
 Dicționarul Biografic al Literaturii Române, Vol I și II, București, Editura Paralela 45, 2006 - recenzie
 "Definițiile romanului. De la Dimitrie Cantemir la G. Călinescu", Șerban Axinte, Editura Timpul, 2013
 "Circulația în Moldova a cărții în limba română, tipărită în secolul al XVIII-lea", Ioana Panait-Cristache, în "Mitropolia Moldovei și Sucevei" nr. 5-6/1971
 Dicționar al presei literare românești (1790—1982), I. Hangiu, Editura științifică și Enciclopedică, 1987
 Dicționarul presei literare românești: 1790-1990, I. Hangiu, Editura Fundației Culturale Române, 1996
 Scriitori și reviste literare din perioada interbelică, Nae Antonescu, Editura Revistei Convorbiri Literare, 2001
 Presa literară românească: 1901-1948, I. Hangiu, Editura pentru Literatură, 1968
 Literatură română din Transilvania între preiluminsim și preromantism, Alin-Mihai Gherman, Editura Casa Cărții de Știință, 2004
 O istorie deschisă a literaturii române din Basarabia, Mihai Cimpoi, Editura Arc, 1996
 O istorie condensatǎ a literaturii române: 1880-2000, Volume 1, Henri Zalis, Editura Bibliotheca, 2005
 Explorări ín istoria literaturii Romåne, Alesandru Duțu, Editura Pentru Literatură, 1969
 Istoria cărții românești: De la începuturi pînă la 1918, Mircea Tomescu, Editura științifică, 1968

 Спољашње везе

 Romanian поезија
 Romanian literature
 Website of the Romanian Museum of Literature
 Lingua Romana, a journal on Romanian literature
 Poezie românească
 Literatura română - prezentare
 Muzeul Literaturii Române
 Dicționar de literatură română , Ecaterina Țarălungă
 Diaconul Coresi: "Să învețe rumânii cine-s creștinii", 17 aprilie 2009, Evenimentul zilei Romanul deceniului 2000-2010, 16 martie 2010, Dana G. Ionescu, Dan Boicea, Adevărul Prăpăstiile din literatura română, 24 februarie 2013, Andrei Crăciun, Adevărul "Să nădăjduim, totuși, că societatea românească va intra cândva în literatura universală", 13 decembrie 2009, Oana Rusu, Ziarul Lumina "Eminescu era slăbit, palid, neras; fața-i exprima o plictiseală de om necăjit", 14 iunie 2009, Oana Rusu, Ziarul Lumina Chemare la colaborare pentru Enciclopedia Literaturii Române Vechi, decembrie 2009, researchgate.net''


For the last month or so I've been thinking about fitness - or my lack thereof - and pondering what to do about it.
You see, when I was pregnant in the middle of last year, I put some weight on..and I haven't lost that weight. And I"ve not been too worried about it - until now.
Three years ago I hit the gym in a big way. I lost alot of weight, I looked and felt fantastic, I felt happy and I felt strong.
In fact, I'd never felt or looked better. We moved to the farm, away from the gym and I slowly stopped going.
I've had a couple of false starts along the way, but now I am ready to get serious! And I've been wondering how I could get that mindset back, as I struggle with motivation and need the support of others - and I need goals to help me achieve what I want to..
And now two things have happened. The first is the Aussie Bloggers Conference that I am attending in March. What a great goal to work towards..to lose weight and gain my fitness back to look trim and gorgeous! at the conference while meeting all of my new bloggy friends.
And the second thing has come in the form of my new friendship with Naomi from Seven Cherubs. We were chatting online the other day and as we have so much in common, we started talking about our weightloss and fitness goals and came up with the idea of a challenge.
We are challenging each other to lose 5 % of our body weight before the conference in 11 weeks. It's a realistic goal....and I am so happy and relieved that I have found a buddy to motivate and challenge me.
Naomi is truly amazing and I feel like I have known her forever. I can't wait to meet her in person at the conference where we both will be totally hot mamas!!!!
I've weighed myself today and my starting weight is 70.5 kg.
So my 5% goal is 66.9 kg. I am hoping to get down to 65 kg.
Naomi and I plan to share our journey with you, our challenge and our achievements.
Why not join in the fun..the more the merrier. Or in this case, the less is best!!!
And remember, we are looking at overall fitness and healthy eating - a lifestyle change for the better!
I'm in on the challenge! My clothes are all feeling a bit restrictive - time to shave off a few!
Oh, I read about this on Naomis blog. Very inspiring, how do you join up?
Oooh! Top idea! I shall be reading with interest!
Good Luck to you both! And don't forget to have fun alogn the way.
Okay ladies, Naomi and I have had some interest from lots of bloggers wishing to participate, thank you so much and we look forward to the challenge with you!
look forward to meeting you at the bloggers conference!
I'm having a private month of weight removal from holiday and Christmas... it must leave this body!
Count me in on the battle!
Hey there Farmer's Wifey -- I have posted my first Saturday BBB blog...can I link it here? Not sure how we'll all link up but I am looking forward to hearing about other bloggers' plans!


text:
Округ Чарльз Микс () располагается в штате Южная Дакота, США. Официально образован в 1862 году. По состоянию на 2010 год, численность населения составляла 9 129 человек.

География
По данным Бюро переписи США, общая площадь округа равняется 2 979,000 км2, из которых 2 843,000 км2 суша и 136,000 км2 или 4,570 % это водоемы.

Соседние округа

Население
По данным переписи населения 2000 года в округе проживает 9 350 жителей в составе 3 343 домашних хозяйств и 2 326 семей. Плотность населения составляет 3,00 человека на км2. На территории округа насчитывается 3 853 жилых строений, при плотности застройки около 1,00-го строения на км2. Расовый состав населения: белые — 69,65 %, афроамериканцы — 0,13 %, коренные американцы (индейцы) — 28,28 %, азиаты — 0,10 %, гавайцы — 0,01 %, представители других рас — 0,47 %, представители двух или более рас — 1,37 %. Испаноязычные составляли 1,89 % населения независимо от расы.

В составе 34,20 % из общего числа домашних хозяйств проживают дети в возрасте до 18 лет, 53,10 % домашних хозяйств представляют собой супружеские пары проживающие вместе, 11,70 % домашних хозяйств представляют собой одиноких женщин без супруга, 30,40 % домашних хозяйств не имеют отношения к семьям, 28,30 % домашних хозяйств состоят из одного человека, 15,10 % домашних хозяйств состоят из престарелых (65 лет и старше), проживающих в одиночестве. Средний размер домашнего хозяйства составляет 2,74 человека, и средний размер семьи 3,37 человека.

Возрастной состав округа: 32,00 % моложе 18 лет, 7,10 % от 18 до 24, 23,20 % от 25 до 44, 20,40 % от 45 до 64 и 20,40 % от 65 и старше. Средний возраст жителя округа 36 лет. На каждые 100 женщин приходится 96,60 мужчин. На каждые 100 женщин старше 18 лет приходится 94,10 мужчин.

Средний доход на домохозяйство в округе составлял 26 060 USD, на семью — 30 688 USD. Среднестатистический заработок мужчины был 24 747 USD против 19 688 USD для женщины. Доход на душу населения составлял 11 502 USD. Около 20,80 % семей и 26,90 % общего населения находились ниже черты бедности, в том числе — 35,50 % молодежи (тех, кому ещё не исполнилось 18 лет) и 21,00 % тех, кому было уже больше 65 лет.

Примечания

Ссылки
 Официальный сайт правительства округа Чарльз Микс, штат Южная Дакота
 Национальная ассоциация округов США

Округа Южной Дакоты


We are a Vancouver based company offering tailor-made immigration services to our clients worldwide.
Square One Study Permit Centre is a registered member of the Immigration Consultants of Canada Regulatory Council (ICCRC). We are also the authorized consultant serving VGC International College. At Square One Study Permit Centre, we specialise in Study Permit applications as well as Permanent Residence applications including Express Entry, Family Sponsorship, Provincial Nomination Categories. We also advise you on the Labour Market Impact Assessment and provide support and an assessment for employers on how to hire temporary foreign workers.


Alcohol | Is it vegan?
Below is some information about the different types of alcohol commonly found in Japan. Please note that some 'beauty' drinks, usually found in izakayas, contain collagen and are therefore not vegan. Look for コラーゲン (korāgen).
As well as regular beer, there is also 'happoshu' (low malt beer) and 'third beer' (no malt beer made from wheat, soy or other ingredients) in Japan.
According to Barnivore the following Japanese beer is vegan: Kirin, Asahi, Sapporo and Baird Beer (craft beer). Almost all the Kiuchi Hitachino Nest beer is vegan too (the Sweet Stout contains lactose). Unfortunately there is no listing on Barnivore for Suntory.
Per an article in LiveKindly in November 2018, Kirin Holdings Co., Ltd., the second-largest alcoholic-beverage manufacturer in Japan, has agreed to join Asahi Group Holdings, Ltd., Suntory Holdings, Ltd., and Sapporo Holdings Ltd. to stop animal testing that is not required by law.
Kyoto Brewing Company stated that they don't use any animal products such as isinglass to filter their beer. The only clarifying agent they use is called Koppakleer, which is derived from carrageenan, a seaweed.
Unfortunately we only received a response from Kikkoman, informing us that they are unable to provide any information about whether Manns Wines are vegan.
So if you're looking for wine, it may be better to search Barnivore for information on imported wine.
Like wine and beer, sake may or may not be vegan depending on the manufacturing process.
""Q30. Vegetarian Sake. As a sake lover and a new vegan, I need to find sakes that do not use any animal product in their brewing and refining. Can you give me any information on how to double check a sake as "vegan-friendly?" Most sake does not use gelatine finings, although we cannot determine what does and what does not, and there is no way to know from the label. Powdered active charcoal is used for fining of most Japanese sake. This is made from (as far as we know) wood and plants, but we cannot be sure about all stuff at all places. Sake called "muroka" is unfiltered and unfined so that would be a safe bet." – see the FAQ section of his website.
So in short, look for unfiltered and unfined sake if you want to be sure it is vegan.
The Sake Brewery Nanbu Bijin in Ninohe, Iwate, which exports to 38 countries and regions around the world, obtained the world's first vegan sake certificate on January 25th, 2019 from Vege Project Japan. Read more about their products and awards here.
There are at least two major differences between sake and shōchū. First, sake is only made from rice, whereas shōchū can be made from a number of different ingredients, including rice, sweet potatoes, wheat, buckwheat, sugar and corn. Second, sake is fermented (like beer) whereas shōchū is distilled (like whisky, vodka, gin and other liquors).
Awamori is the Okinawan version of shōchū. Shōchū and soda (often fruit flavoured) is sold in cans as 'chūhai' and as a 'sour' in restaurants/bars. Chūhai is a shortening of 'shōchū highball'. Umeshu is a liquor made by steeping unripe plums and sugar in shōchū. Similarly, yuzushu and momoshu are made with yuzu fruit or peaches and either shōchū or sake.
Like other liquors, shōchū is likely to be vegan, although this will ultimately depend on the manufacturer (and whether the shōchū is flavoured with animal products like honey). Unfortunately it is difficult to find information about whether particular brands of Japanese shōchū are vegan. There are a couple of shōchū manufacturers listed on Barnivore, but they are in America and Canada. We contacted Choya Umeshu Co Ltd and asked whether their products are vegan, but we did not receive a reply.


text:
Donor Support | Contact Us
Country Offices
Leadership Supporters
Legacy Leaders
Approach & Areas of Focus
Food Security Projects
RESULT – Ghana
MILEAR – Ethiopia
CHANGE – Ghana
Women Deliver Mobilization
In Memorium & Tribute Gifts
Charity Gift Catalogue
#FeedChildren Campaign
First Nations Nutrition
Donating Stocks & Shares
Donating RRIFs & RRSPs
The Feed (CFTC Blog)
Donor Publications
thrive!
Your Impact Report
Transformations 2018
Dream Season Comic
Youth on the move in Africa
Kelsuma, with her second oldest son, on her farm in the Cheffa Valley, Ethiopia.
The movement of people inside and across borders of all kinds is an intrinsic and natural feature of human life. Children have always migrated on their own, often safely and with their families' approval (think for instance about children emigrating to study abroad).
Youth migration is a problem only when
children are driven from their homes by hardship
the safety of migrant children is compromised
migrant children are exploited and trafficked in transit and at the place of destination.
Kelsuma: Ethiopia can be like Saudi Arabia
Ethiopia is seeing a lot of its children and young people migrate to the Arab countries to seek employment. According to the International Labour Organization, "In Ethiopia, youth employment presents both an opportunity and a challenge considering 71% of the population is under the age of 30." (ILO, 2016).
While CFTC does not address migration directly, we are always gratified to see that the core development work we support has a wider impact.
Kelsuma Abdu got married when she was a young teen and she and her husband went on to have five children. When the MILEAR project started in 2012, their relationship was on the rocks. Her husband had become a heavy consumer of khat, had started being violent and would leave the family with no food. The couple was among the first to be selected by CFTC's local partner, ORDA, for MILEAR's gender training. The experience was transformative for Kelsuma.
Gender training encouraged Kelsuma to work for better conditions in her marriage. She stuck it out for two years, until it was clear things were not working out. After their divorce, Kelsuma put into practice the agricultural training also provided through MILEAR. Her position as a divorced woman and a farm owner was unusual in the village, but gender training had confirmed in her a spirit of independence that was always there, and given her permission to act on it.
Kelsuma got a loan and with it bought an ox and an irrigation pump. She collaborated with friends and they managed to survive the severe drought of 2015/16.
Her farm, which she also works with some of her children including her oldest son, was so successful that she became a role model for the community. The last time we talked to Kelsuma, her oldest son wanted to move to Saudi Arabia. With two years of farming success under her belt, Kelsuma is now thinking about buying land and building a house for him. She wants him to stay. Hers is a success story and her son does not need to make the perilous journey to a foreign country where he might be exploited. In spite of the social pressure to go, Kelsuma has real persuading power to keep her son on what can very well become his own farm. She told us: "if you work hard, Ethiopia can be like going to the Arab countries. Look at us, in two years we turned our lives around from being poor to being well-off."
CFTC doesn't target child migration or migration in general as a central focus in our work. Through our local partners, however, we put ourselves at the service of communities so that they may empower themselves. It was a real joy for us to see how gender training, a relatively simple process done very respectfully by our local partners, rippled out to affect financial self-reliance, female livelihoods and social status, and reduced the risks of child migration for this Ethiopian family.
Fatima: I see myself as a role model
Fatima, second from left, sits with her mother and younger sister and with Augustine N-Yokuni, CFTC's Country Director (Ghana).
In Ghana, migration occurs more frequently within the country than to other countries (80% of migrants in Ghana move internally). While the impoverished northern regions where CFTC and its local partners work produce only 10% of Ghana's overall internal migration (see Internal migration in Ghana: Determinants and welfare impacts), the conditions from which northern youth are fleeing are more severe and the profile of those migrating tends to be younger and less educated, meaning that their prospects at the other end of their journey aren't as positive.
Fatima, now 21, had struggled for years to stay in school despite economic hardships. She had been involved in CFTC's sponsorship program through our local partner, RAINS, since 2003. Despite this support, she and her six siblings faced many difficulties.
"I nearly dropped out of school in 2017. I could not afford to pay my fees because farming was bad for my parents that year and my father was very ill," Fatima said.
She once dreamed of becoming a nurse, but she came to believe – as so many adolescent girls do – that her only option was, as she said, "to migrate to the south for Kayaye" (a menial job where she would be at risk of violence, early pregnancy, and worse).
Fortunately, Fatima, along with other girls in her school, had learned about the dangers of child marriage and other forms of gender-based violence. She spoke to her head teacher and a representative from RAINS. They were able to provide her with the support she needed to complete school.
Fatima is proud that she has been able to complete high school: "I see myself as a role model to younger children, especially girls," she said. While she awaits her final grades, Fatima has enrolled in a beautician course to help fund the next phase of her education.
"Your support was a 'stitch in time' to me. I know that without it, I would have been given out for marriage or ended up on the streets of Accra," Fatima said.
There is still a good chance that Fatima will decide to pursue higher education and employment outside of her home community. However, she is now more empowered and has options that put her in the driver's seat, whatever decision she chooses to make.
These stories of young people, one from Ghana and one from Ethiopia, illustrate that that the close connections and collaborative work between CFTC's local partners, local school and community authorities, families, and the youth themselves can make all the difference in the trajectory of a young person's life.
There are immense pressures on families to alleviate their economic burdens by sending their oldest children away from home for marriage or work. Even when the young person is involved in the decision-making and eager to go, this can compromise their educations and possibly their safety. And, there is a tremendous lure for young people to seek better fortunes elsewhere. While this can sometimes be a positive experience, the risks are high, especially for girls and young women.
With attention to the core principles of community-based development – in Fatima's case, child sponsorship and educational supports; in Kelsuma's family, support for women's livelihoods, agricultural training, and gender equality – families can stay together, feed and educate their children, and capitalize on all the benefits of creating an educated, energized and employed youth population while reducing the perils of need-driven youth migration.
CLASSROOM BASICS – $55
A desk, chair, chalk boards, maps and other essentials make learning possible. Your gift lets kids explore the world from within a well-equipped classroom.
FARMING COMBO – $115
This farming combo provides a sustainable source of food and income, with garden tools, seeds and training to start a home garden.
Give monthly to help children every day.
9 Reasons Why We Love You
Why I Give: Blake
Jordan's magical pig
EthiopiaGhanaMigrationYouthYouth Migration
6 Lansing Square, Suite 123
Toronto, ON M2J 1T5 Canada
Best Gift Ever
The Standards Program Trustmark is a mark of Imagine Canada used under licence by Canadian Feed The Children.
© 2020 Canadian Feed The Children
Canadian Feed The Children is a Canadian Registered Charity. Charitable Registration Number 118830983 RR0001
New Email Subscribers
New Child Sponsors
New BGE
New Everyday Heroes
New Mass Single Gift
Transformations Welcome Series - Library Event
Transformations Welcome Series - Website