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Annual CURO symposium highlihts undergraduate reserachers' year-long efforts
by walls-joelle
Annual CURO symposium highlights undergraduate researchers' year-long efforts
Athens, Ga. – The University of Georgia Honors Program is currently accepting applications from UGA undergraduate researchers who would like the opportunity to present their original research and creative works at the 2008 Center for Undergraduate Research Opportunities (CURO) spring symposium. The event will be held on March 31 at the Classic Center in downtown Athens.
"The CURO symposium has become the academic highlight for undergraduates at the University of Georgia," said Pamela Kleiber, associate director of the Honors Program. "We are fortunate that faculty from virtually every department, school and college at the university encourage their strongest and most experienced students to present their work at the symposium and also encourage their younger students to attend so they are inspired to take their turn in subsequent years. Faculty appreciate the importance of their students sharing their findings in the larger context of a university-wide symposium. We expect to top 200 undergraduate presentations this year."
Open to UGA undergraduates with a 3.4 minimum grade point average who engage in original, faculty-guided research endeavors in any discipline, the CURO symposium provides the forum in which students can showcase their creative and scholarly efforts to a larger audience.
For example, Lauren Kelly, a junior microbiology and Spanish double major at UGA, has been intrigued with conducting research since her freshman year when she studied the flight patterns of an Asian tiger mosquito and gave a presentation at UGA's Molecular Parasitology/Vector Biology symposium. With that first exposure to hands-on research, Kelly is now delving into more life-threatening infectious diseases issues, working under the guidance of Julie Moore, a professor of infectious diseases and a member of UGA's Center for Tropical and Emerging Global Diseases.
"Conducting scientific research as an undergraduate has expanded my mind and each day challenges me to think critically and analyze ideas, methods and information," said Kelly. "I believe every undergraduate student should be exposed to the stimulating environment of research. It bolsters continual learning and serves as a venue to harvest passions and to challenge oneself as an individual."
Kelly is one of a growing number of students pursuing research endeavors at the undergraduate level either through CURO or other research programs at UGA. The annual undergraduate research symposium is the cornerstone of CURO.
"The CURO symposium is often the first but seldom the last research presentation our students share. Many of these students go on to present at state, regional, national and, in some cases, international venues," said David S. Williams, director of the Honors Program. "The CURO symposium is valuable because students from all fields learn to discuss their research with experts and also with people who have only a lay person's knowledge of the content area. It is critically important for students to learn to communicate the significance of their research to various audiences."
Erica Holland, a sophomore public relations and speech communication major, had the opportunity to experience the CURO symposium as a high school senior when she was recognized as a CURO Promising Scholar and invited to the event. That visit sparked her interest in undergraduate research and led to her involvement with the CURO Apprentice Program where she received the Donald and Louise Hollowell Apprenticeship.
"I have learned so much about myself-my research interests and career interests-and I have definitely grown as a person through my research at UGA," said Holland, who is studying the history of the "n-word" and the implications of how it is used on a predominately white college campus with faculty mentor and history professor Robert Pratt.
"When you're doing research in a non-science area, it's a bit more challenging to come up with project ideas," she added, "but it's definitely rewarding because you make up your own lab, set your own guidelines, and from there, the sky's the limit."
UGA students interested in presenting at the 2008 CURO symposium must submit an application, an abstract of no more than 250 words describing the research project, and a supporting letter from the sponsoring faculty member via the CURO web site, www.uga.edu/honors/curo, no later than Jan. 18. All applicants will be notified by mid-Feb.
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Al Maimon
Al Maimon's father was born in Turkey and came to the United States in 1924 when his father, Avraham Maimon, became the rabbi of Sephardic Bikur Holim synagogue. Al attended Yeshiva University and met his wife, Jeanne, in New York. They lived in Israel when their children were young. His maternal grandfather, Reverend Moshe Scharhon, hazzan at Sephardic Bikur Holim, was born in Rhodes. With Rabbi Maimon, Al spent a lot of time at the synagogue growing up with the synagogue serving as the focal point in his life. He worked as a counselor at Sephardic Adventure Camp, which Rabbi Maimon started. He has participated in SeLaH - Sephardic Ladino Heritage - which sponsored events and created a newsletter. Al earned a master's degree in math and worked in operation research and large-scale information systems at The Boeing Co.
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A sugar free diet is very difficult to achieve but we can certainly reduce our sugar intake quite easily. And there are compelling reasons to do so.
Recent research suggests that sugar is as addictive as nicotine and that too much in our diet can lead to diabetes, kidney disease, cancer, heart disease, Alzheimer and premature ageing.
When sugar enters the blood stream the pancreas produces insulin to control the blood sugar levels. Excess sugar will be converted to fats which are then stored around your belly and certain organs. Fats known as triglycerides enter the bloodstream and can cause clogging of the arteries, leading to various diseases.
Food manufacturers are adding sugar to a huge range of products to increase their attractiveness so if you are eating ready made products, avoiding sugar is impossible.
Surprisingly savoury foods such as soups, pasta sauces, coleslaw and dressings all contain added sweeteners. While refined carbohydrates found in bread and pasta convert rapidly to sugars in our bodies.
The World Health Organisation has plans to reduce the recommended daily quota of sugar from 10 to 5 teaspoons (a teaspoon of sugar weighs 4 grams). So read the labels on packaging to see how much added sugar there is.
Although not all show how much sugar is contained in a portion; the amount may be per 100g or 100ml and even where portions are shown they may be smaller than would normally be eaten e.g. 30g for a portion of cereal which is probably half of what we would have for breakfast.


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Keywords: Effectiveness, real world, safety, SGLT2i, type 2 diabetes
Gill HK, Kaur P, Mahendru S, Mithal A. Adverse effect profile and effectiveness of sodium glucose co-transporter 2 inhibitors (SGLT2i) - A prospective real-world setting study. Indian J Endocr Metab 2019;23:50-5
Gill HK, Kaur P, Mahendru S, Mithal A. Adverse effect profile and effectiveness of sodium glucose co-transporter 2 inhibitors (SGLT2i) - A prospective real-world setting study. Indian J Endocr Metab [serial online] 2019 [cited 2020 Jan 17];23:50-5. Available from: http://www.ijem.in/text.asp?2019/23/1/50/254457
Diabetes Mellitus has been a public health issue and more so for developing countries as they are still struggling with infectious diseases. Hence, developing countries are bearing the double brunt of persistent infectious diseases and rising noninfectious diseases. As per International Diabetes Federation (IDF) diabetes prevalence data, there were 425 million adults with diabetes worldwide in 2017, which is expected to rise to 629 million by 2045.[1] India is home to 72.9 million people with diabetes.[1] Patients with diabetes need to achieve good glycemic control to prevent or delay the complications related to diabetes.[1],[2] As far as the treatment is concerned, there are limited classes of drugs available for oral use in diabetes patients. Most importantly, the drugs used for glycemic control are either associated with weight gain or they are weight neutral.[3],[4] With the introduction of SGLT2i, diabetes treatment has taken a new turn. Not only these drugs lead to good glycaemic control, they have shown a benefit of weight reduction as well.
The Kidney plays a major role in regulation of glucose reabsorption and maintaining the overall metabolic balance in the body. Of ~180 g/day of filtered glucose in healthy kidneys, 99% gets reabsorbed. Glucose reabsorption in the kidney mainly occurs through two types of transporters—the facilitative glucose transporters (GLUTs) and by an active sodium-glucose co-transporters (SGLTs). Among the different types of SGLTs, SGLT2 is expressed primarily in the kidneys where it is found in the brush border membrane of the S1 segment of the proximal renal tubule, accounting for 90% of glucose reabsorption in kidneys. SGLT2i decrease the renal threshold for glucose reabsorption leading to urinary glucose excretion and net caloric loss, which leads to lowering of blood glucose level and weight loss.[5],[6],[7] SGLT2i lead to around 30–80 g of glucose loss in 24 h.[8],[9],[10]
Dapagliflozin, canagliflozin, and empagliflozin are three SGLT2i, which are FDA approved and are currently available for clinical use in India. They are recommended as options for treatment of patients with type 2 diabetes as monotherapy or in combination with other antidiabetic drugs.[11] There are many randomized trials and prospective trials to show good glycemic control and weight reduction benefits.[12],[13],[14] Genitourinary infection is the most commonly reported adverse effect with SGLT2i use in clinical trials.[15] People with diabetes are already at increased risk of genitourinary infections and use of SGLT2i might add significantly to this problem. Real-world data on SGLT2i use are very limited and have focussed mainly on effectiveness.[16],[17],[18] Real-world data are essential to ascertain if the safety and efficacy results of SGLT2i seen in clinical trials can be extrapolated to clinical practice. We designed this prospective observational study with the primary objective to evaluate the adverse effect profile of SGLT2i and secondary objective to see the effect on glycemic control and weight loss in patients with type 2 diabetes in real-world clinical practice.
This was an observational prospective longitudinal study, conducted in Outpatient Department of Endocrinology and Diabetes at a tertiary care center. All consecutive type 2 diabetes patients initiated on SGLT2i in outpatient department by a single consultant from 1 April 2015 to 31 March 2016, were included in the study. SGLT2i were prescribed to patients with type 2 diabetes who were obese (BMI >25 kg/m 2) and/or had suboptimal glycemic control (HbA1c >7%) on oral medications ± insulin. Additionally, obese type 2 diabetes patients with good glycemic control (HbA1c ≤7%), but were struggling to lose weight, were also prescribed SGLT2i. Patients with deranged renal function tests (RFTs), liver function tests, history of recurrent genitourinary tract infections, and pregnant and lactating women were excluded. As per routine protocol, every patient visited diabetes educator after getting final prescription and was instructed about maintaining hydration and good personal hygiene. Informed written consent was obtained from all the patients. Ethical clearance was obtained from institutional review board.
Follow-up data were collected at 0-, 1-, 3-, 6-, 9-, and 12-month follow-up. General physical examination and weight monitoring was done at each visit. Adverse effect profile was collected as per patient reporting and on positive questioning. All patients were encouraged to do self monitoring of blood glucose at home. HbA1c was done at 0, 3, 6, 9, and 12 months. HbA1c was analyzed by high-performance liquid chromatography method using Bio-Rad D10 analyzer. RFT was done at 0, 1, 6, and 12 months. Urine routine microscopy followed by culture sensitivity was done in patients with symptoms suggestive of urinary tract infection (UTI). Genital infections were diagnosed by patient reported symptoms and clinical examination. If patients did not come for follow-up for 6 months, they were contacted telephonically. Adverse effects were considered severe when clinical decision was taken to stop SGLT2i permanently, mild to moderate when SGLT2i were continued, or stopped temporarily. Patients were prescribed any one of the three available SGLT2i: Dapagliflozin, Empagliflozin, or Canagliflozin. We analyzed the efficacy and adverse effect profile as a class effect rather than individual drug effect.
Statistical analysis was done using SPSS window version 14.0. Continuous variables are expressed as mean ± standard deviation. Paired t-test was used to compare variables at different time intervals. Univariate logistic regression analysis used to test the effect of different variable on outcome. Significance level was set at P < 0.05.
In total, 486 patients were initiated on SGLT2i [Figure 1]. Overall, 319 patients came for at least one follow-up between 3 and 6 months. Out of 319 patients who came for follow-up, 7 patients did not start medicine (malignancy 1, Hepatitis 1, did not want to try new drug 5), so there were 312 patients for further follow-up. Out of 167 patients who did not come for follow-up, 89 patients gave information telephonically, whereas 78 could not be contacted. Out of 89 patients contacted telephonically, 13 patients did not start medicine. Therefore, there were total 388 patients for analysis at 6 months out of which 268 were males and 120 were females.
Figure 1: Patient flow diagram
Baseline characteristics are given in [Table 1]. Baseline antidiabetic drugs used in these patients is shown in [Table 2].
Table 1: Baseline characteristics (n=486)
Table 2: Baseline antidiabetic drugs (n=388)
Adverse effects: Adverse effects were analyzed at 6 months of follow-up (n = 388 patients) [Figure 2]. About 150 (38.6%) patients experienced adverse effects. Following adverse effects were noted:
Figure 2: Adverse effect profile (n = 388)
Genitourinary tract infections: This was the most common adverse effect seen [Table 3]. About 80 (20.6%) patients suffered at least one episode of genitourinary tract infection out of 388 patients. These were much higher in females (27.5%) as compared with males (17.5%). About 18.3% females suffered from vulvovaginitis, whereas 12.7% male patients suffered from balanoposthitis. About 10.83% females had UTI and all episodes were severe, leading to discontinuation of SGLT2i, whereas 0.7% males had mild to moderate and 4.1% had severe UTI. Mild-to-moderate infections were treated with topical or oral antibiotics.
Table 3: Genitourinary infections among males and females
Weakness and lethargy: This was the second most common adverse effect after genitourinary infection, reported by patients in absence of hypoglycemia or hypotension. Overall, 41 (10.5%) patients themselves came with the complaint and it led to discontinuation of SGLT2i in 13 (3.3%) patients.
Urinary symptoms: Twenty-one patients complained of disturbing urinary symptoms in the form of increase frequency of urination, nocturia, urinary urgency, and urge incontinence.
Alteration in RFT: Five patients had rise in blood urea and creatinine levels within 1 month of starting drug, where drug was discontinued (it was secondary to gastroenteritis and fever in two patients). Serum creatinine levels gradually increased in three more patients over 12 months. Serum creatinine (mg/dL) in these patients at 6 months was 0.99, 1.1, 1.18 and at 12 months was 1.7, 1.23, 1.4, respectively. One patient had rise in serum creatinine level from 1.0 to 1.6 mg/dL at 1 month, which persisted over next month leading to discontinuation of SGLT2i. So, there were total nine patients with alteration in renal function.
Falls: Falls were consequent to dizziness (n = 2), vertigo (n = 1), and one patient complained of reappearance of his childhood spells of transient loss of consciousness. But there was no injury.
Gastrointestinal upset: Six patients complained of nausea and vomiting initially after starting treatment.
Drug allergy: Drug was discontinued in two patients due to rash and itching over body.
Other adverse effects: Other problems reported by patients were paraesthesias, eye problems (burning, pain, and heaviness), body aches, and leg cramps. One patient had hypercalcemia, which could not be evaluated further. Two patients developed pancreatitis. None of the patients developed diabetic ketoacidosis or severe hypoglycemia.
Females had significantly higher UTI as compared with males (Chi-square value 4.5, P = 0.04; P = 0.02). Univariate analysis did not show any association between genitourinary infections and baseline HbA1c [odds ratio (OR) = 1.08, 95% confidence interval (CI): 0.9–1.2), age (OR = 0.99, 95% CI: 0.9–1.02), or duration of diabetes (OR = 0.99, 95% CI: 0.96–1.01). Similarly, multivariate analysis also did not reveal any association between genitourinary infections and baseline HbA1c (OR = 1.1 95% CI: 0.9–1.3), age (OR = 1.0, 95% CI: 0.9–1.05), or duration of diabetes (OR = 1.0, 95% CI: 0.96–1.09). Total 93/388 (23.9%) patients discontinued drug due to adverse effects [genitourinary infections (61), weakness (13), alteration in KFT (6), urinary symptoms (4), GI upset (2), drug allergy (2), falls (2), joint pains (1), night time hypoglycemia (1), and paraesthesia (1)].
HbA1c and weight data were available in 202 patients at 3–6 months and 104 patients at 9–12 months of follow-up. There was significant reduction in weight from baseline, with mean weight loss of 3.2 kg at 3–6 months and 3.9 kg at 9–12 months (P < 0.05). Mean reduction in HbA1c at 3–6 months was 1.26% and at 9–12 months was 1.27%, which was statistically significant for both the intervals (P < 0.05) [Table 4]. At baseline, only 9.6% patients had HbA1c ≤7.0% and 57.4% patients had HbA1c value ≥8.0%. On follow-up, 37.4% patients achieved HbA1c ≤7.0% and 79.3% achieved ≤8.0%. HbA1c and weight at 6 and 12 months were not correlated with baseline HbA1c, weight, age, and duration of diabetes.
Table 4: Effect of SGLT2i on HbA1c and weight
Achieving good glycemic control is an important step in diabetes management to prevent diabetes-associated complications. Metformin has been the first line drug for many years. DPP4i have become the second choice drug for physicians because of its weight neutral effect and less chances of hypoglycemia.[19] Our study also showed similar trend with DPP4i as the second most common drug used after metformin. When SGLT2i were introduced, they came as promising drugs particularly for obese people. The unique mechanism of action of SGLT2i, independent of impaired β-cell function and insulin resistance, effectively reduces HbA1c with reduced risk of hypoglycemia. Glycosuria leading to calorie loss, gives SGLT2 inhibitors the additional advantage of body weight reduction, contrary to most of the other antidiabetic agents. However, this glycosuric effect can also predispose patients to the risk of genitourinary infections. Genital tract infections (GTI), mainly mycotic balanitis and vulvovaginitis, are the most frequent reported adverse events of SGLTi use. In a meta-analysis, an increased incidence of GTIs with SGLT2i versus placebo (odds ratio = 3.50, 95% CI = 2.46–4.99]) and active comparators (OR = 5.06, 95% CI = 3.44–7.45]) was reported; no differences were demonstrated among SGLT2i.[13] The overall reported incidence of genital infections with SGLT2i use in clinical trials was 4%–6%, but these events were more common among women (with rates of approximately 7%–11%) than men.
About 18.3% females in our study developed genital infections, which is much higher as compared with other western population studies.[20],[21] Even males in our study had higher rate of genital infections (12.7%). These episodes were either recurrent or severe enough to discontinue drug in at least 6.3% males and 6.7% of females.
The reported incidence of UTIs in clinical trials ranged from 4% to 9%.[15] In our study, 10.8% females and 4.8% males suffered from UTIs. These UTIs were significantly more common in females. All UTIs in females were severe. In Leiter et al.'s study group, only one patient had severe UTI on 100-mg canagliflozin, mild UTI episodes were reported in 10.6%, and rate of mild genital infections was 9.5% and 13.9% in males and females, respectively.[20] Mathieu et al.'s study showed genital infection rate 5% and UTI <1% when dapagliflozin 10 mg/day added to saxagliptin plus metformin in patients with HbA1c 7%–10.5%.[21] Most of these studies have included patients with HbA1c below 10.5%–11.5%, whereas we had patients with all ranges of HbA1c. Reasons for higher incidence of genitourinary infections could be uncontrolled and long-standing diabetes. However, we did not find any significant correlation between genitourinary infections and baseline age, HbA1c, or duration of diabetes. Possible explanations for higher incidence of genitourinary infections reported in our study could be hot and humid weather in our country, which can precipitate genital infections. Recent posthoc analysis of canagliflozin also showed a trend toward higher rate of UTI in hot climate countries when compared with other areas (9.5% vs 4.6% at 26 weeks of placebo-controlled period, 22.3% v 7.4% at 104 weeks of active controlled period with canagliflozin 100 mg).[22]
Second most common complaint which we noticed was feeling of weakness and lethargy and importantly this led to discontinuation of drug in 3.3% of patients. This adverse effect, particularly in the absence of hypotension and hypoglycemia, has not been described in other studies. Osmotic diuresis has been described in more than 2%–3% patients and that too in few studies.[23],[24] Weakness, lethargy, and dizziness seen in our patients were likely due to osmotic diuresis, which could be exaggerated due to hot and humid weather observed in our country, causing dehydration. It was already starting of summer when SGLT2 inhibitors were introduced and temperatures usually cross 45°C here during summers.
HbA1c reduction seen in our study is comparable to other studies.[20],[25],[26] Mean reduction at the end of 12 months was 1.27% and 37.4% patient achieved HbA1c ≤7.0% in our study. Mean reduction in HbA1c was 0.82% and 0.93% at 52 weeks, when canagliflozin 100 and 300 mg, respectively, were added on metformin in Leiter et al.'s study.[20] Similarly, Schernthaner et al.'s study has shown HbA1c reduction of 1.03% when canagliflozin 300 mg added to combination of metformin and sulfonylurea in patients with HbA1c 7.0%–10.5%. About 47.6% patients achieved HbA1c <7%.[26] In Stephan et al.'s study, HbA1c reduction was 0.69% and 31.8% patients achieved HbA1c <7% when dapagliflozin 10 mg added to metformin sulfonylurea combination.[25]
Weight reduction noted in our study is also comparable to other studies. We found a mean weight loss of 3.2 kg at 3–6 months and 3.9 kg at 9–12 months. Rosenstock et al.'s study has shown weight loss in range of 2.3–2.9 kg, when SGLT2i was used as add on to metformin.[10] Similarly, weight loss of 2.7 kg was seen in Stephan et al.'s when SGLT2i was used as add on to metformin and sulfonylurea over 24 weeks.[25]
Our results demonstrate that the effectiveness is comparable but adverse effects associated with the use of SGLT2i in real-world practice are higher than those reported in clinical trials. Strengths of our study are as follows:
1) It is a real-world study. Clinical trials are often conducted with specific populations and in specialized environments that differ from the realities of clinical settings. We presented data of an observational study conducted in a specialist run diabetes clinic of a tertiary care center, where SGLT2 inhibitors are prescribed as first, second, third, or fourth choice, there are patients from different socioeconomic strata, different age groups, and duration of diabetes and good-to-poor glycemic control. Data on safety and effectiveness of a drug in such heterogeneous population seen in clinical practice add valuable information for understanding the risks and benefits of a new drug.
2) It is a prospective study of relatively longer duration (1 year) of follow-up, which is important to demonstrate the sustained effectiveness of any drug. Limitation of our study is that we did not have the control group. Another limitation is, we did not analyze the effect on other parameters such as blood pressure and lipid profile.
In light of the evidence that the SGLT2 inhibitors may reduce mortality in patients with diabetes and cardiovascular disease, these drugs are becoming increasingly popular among physicians. Therefore, patients and physicians need to be aware of the adverse effect profile of SGLT2i as well so that benefits of this promising class of drugs can be maximized by their vigilant use. Risk versus benefit should be assessed on a case-to-case basis. SGLT2i should be used cautiously in elderly, previous history or risk of UTI, patients already on diuretics and especially in countries with hot and humid weather. All patients should be educated about importance of maintaining adequate hydration and good genital hygiene.
In conclusion, in this real-world study, we found a significant proportion of patients experiencing adverse effects with SGLT2i use, genitourinary infections being the most common. Effectiveness in terms of HbA1c reduction and weight loss was comparable to that reported in clinical trials.
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Foroutan N, Muratov S, Levine M. Safety and efficacy of dipeptidyl peptidase-4 inhibitors vs sulfonylurea in metformin-based combination therapy for type 2 diabetes mellitus: Systematic review and meta-analysis. Clin Invest Med 2016;39:E48-62.
Gross JL, Kramer CK, Leitao CB, Hawkins N, Viana LV, Schaan BD, et al. Effect of antihyperglycemic agents added to metformin and a sulfonylurea on glycemic control and weight gain in type 2 diabetes: A network meta-analysis. Ann Intern Med 2011;154:672-9.
Bakris GL, Fonseca VA, Sharma K, Wright EM. Renal sodium-glucose transport: Role in diabetes mellitus and potential clinical implications. Kidney Int 2009;75:1272-7.
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Komoroski B, Vachharajani N, Boulton D, Kornhauser D, Geraldes M, Li L, et al. Dapagliflozin, a novel SGLT2 inhibitor, induces dose-dependent glucosuria in healthy subjects. Clin Pharmacol Ther 2009;85:520-6.
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Vasilakou D, Karagiannis T, Athanasiadou E, Mainou M, Liakos A, Bekiari E, et al. Sodium-glucose cotransporter 2 inhibitors for type 2 diabetes: A systematic review and meta-analysis. Ann Intern Med 2013;159:262-74.
Softeland E, Meier JJ, Vangen B, Toorawa R, Maldonado-Lutomirsky M, Broedl UC. Empagliflozin as add-on therapy in patients with type 2 diabetes inadequately controlled with linagliptin and metformin: A 24-week randomized, double-blind, parallel-group trial. Diabetes Care 2017;40:201-9.
Liu J, Li L, Li S, Jia P, Deng K, Chen W, et al. Effects of SGLT2 inhibitors on UTIs and genital infections in type 2 diabetes mellitus: A systematic review and meta-analysis. Sci Rep 2017;7:2824.
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Kosiborod M, Cavender MA, Fu AZ, Wilding JP, Khunti K, Holl RW, et al. Lower risk of heart failure and death in patients initiated on sodium-glucose cotransporter-2 inhibitors versus other glucose-lowering drugs: The CVD-REAL study (Comparative Effectiveness of Cardiovascular Outcomes in New Users of Sodium-Glucose Cotransporter-2 Inhibitors). Circulation 2017;136:249-59.
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Mathieu C, Ranetti AE, Li D, Ekholm E, Cook W, Hirshberg B, et al. Randomized, double-blind, phase 3 trial of triple therapy with dapagliflozin add-on to saxagliptin plus metformin in type 2 diabetes. Diabetes Care 2015;38:2009-17.
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Cefalu WT, Leiter LA, Yoon KH, Arias P, Niskanen L, Xie J, et al. Efficacy and safety of canagliflozin versus glimepiride in patients with type 2 diabetes inadequately controlled with metformin (CANTATA-SU): 52 week results from a randomised, double-blind, phase 3 non-inferiority trial. Lancet 2013;382:941-50.
Weir MR, Januszewicz A, Gilbert RE, Vijapurkar U, Kline I, Fung A, et al. Effect of canagliflozin on blood pressure and adverse events related to osmotic diuresis and reduced intravascular volume in patients with type 2 diabetes mellitus. J Clin Hypertens (Greenwich) 2014;16:875-82.
Matthaei S, Bowering K, Rohwedder K, Grohl A, Parikh S, Study G. Dapagliflozin improves glycemic control and reduces body weight as add-on therapy to metformin plus sulfonylurea: A 24-week randomized, double-blind clinical trial. Diabetes Care 2015;38:365-72.
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Rev. Kelly Dignan - September 1, 2019
Connecting to Our Roots
Sankofa is a mythological West African bird whose name means "go back and fetch it." The Akan people from Ghana believe that learning from the past ensures a strong future.
Related Topics: Inner Work | More Sermons from Rev. Kelly Dignan | Download Audio
From Series: "It's Personal"
More From "It's Personal"
Do You Know What I've Done?
Rev. Sean Neil-Barron - August 18, 2019
Water Communion Service
Revs. Gretchen & Sean & Kristen Psaki - August 25, 2019
I'm Too Busy... to Make It Personal
Rev. Kristen Psaki - September 8, 2019
Go Small
Rev. Gretchen Haley - September 15, 2019
We are located in the central west part of Fort Collins, off of Drake and just east of Taft Hill at:
1815 Yorktown Ave,
or by email at
hello@foothillsuu.org
While the church is bustling much of the time, our office is open Mon., Wed., and Thurs. 9 am to 4 pm. and Tues. 11 am to 4 pm. The office is closed Fridays.
Jennifer studied Social Communication and Journalism with a postgraduate program in Marketing at Universidad Santo Tomás in Bogota, Colombia. For two years, she did social service to help Transgender community of this city. Later, she worked as a journalist at Caracol Radio, which is one of the most important radio stations in her country. During the last 3 years, Jennifer has worked as an account executive in traditional marketing, digital marketing and public relations for different companies. Currently, she is visiting Fort Collins where she was looking for community service, meeting people and learning new things.
As a native New Yorker, Amy enjoys thinking big. She has a passion for community building and has previously worked for three local nonprofits as a database manager to help build systems that can assist with connecting people to their interests and to each other. You will often find her paddle-boarding at Horsetooth with her two kids, enjoying live music, or out walking her high-energy dog, Aspen.
About Kaley
Kaley is a sophomore Music Education Major at Colorado State University where she received a Music Scholarship for performance in Euphonium. Kaley has previously worked as a Nanny as well as being the older sister of a three-year-old sibling! Kaley hopes to be a middle school Band Director in the future.
About Betsy
Betsy is very excited to be the Family Ministry Assistant at Foothills Unitarian Church! Having grown up in Fort Collins, she knows the area and community well. Her background includes being a Youth Services Specialist at Platte Valley Juvenile Detention Center, where she supervised and provided support to incarcerated youth for the State of Colorado. She is also an avid volunteer for Partners Mentoring Youth and has worked with at-risk youth for many years. Prior to working for Platte Valley, Betsy worked at AT&T Mobility in sales. She is currently working towards getting a Master's Degree in Social Work so that she can become a counselor for at-risk youth. In her time off, Betsy enjoys reading non-fiction books and spending time with her pug mix, Igor. She also hikes on weekends and is very passionate about fitness. Betsy's always open to getting to know new people, so if you see her around please come say hi!
About Kara
Kara moved to Colorado in 2006 to study at Northern Colorado and Colorado State earning her Masters in Music Therapy. She works as a music therapist and music educator in the Fort Collins area. She joined Foothills in the Fall of 2017. While still new to Unitarian Universalism, the message of spreading courageous love is what resonated most with her. She enjoys furthering that message with families at Foothills through moving, playing instruments and singing. When not making music, she tries to spend time hiking, skiing, running or reading as many books as she can.
About Christopher
Nature, music and beloved community inform Christopher's budding ministry. A lifelong UU from Knoxville, Tennessee, he brings his experience in UU camps and conferences, hospital and university chaplaincy, and worship-crafting to serve Foothills. Christopher earned a Master's of Divinity from the Iliff School of Theology in 2017, and a BA in French from Middle Tennessee State University. He enjoys spending time outdoors and playing in his band Crispy Watkins and the Crack Willows.
About Dyane
Dyane Rogelstad is a Southern California native, but has adopted Colorado as her home. She grew up on an avocado ranch, loves the outdoors, and has three grown children and two grandchildren. Dyane's first love is music! She teaches music at her home studio and regularly performs as an accompanist-collaborator in the Northern Colorado area. She also serves as a Project Manager and Accountant at a locally-owned advertising firm in Fort Collins. Dyane is excited and grateful to be part of the Foothills community!
Lauren grew up in Maryland, DC, and Virginia, and moved to Colorado in 2014 with her husband Chris and their two children, Sylvia and Jack. She has worked as a consultant and educator in leadership and organizational development, communication, and diversity and inclusion. She loves bringing those skills together with her experience as a parent and partner to serve Unitarian Universalism and all the youth and families at Foothills. She believes in the power of our church to cast a wide circle of loving support around us as we navigate the tangled gorgeous chaos of our lives. Lauren likes to talk a lot, play word games, and dig in to great novels. She loves the Muppets. She is an ardent friend and focused parent; a gardener, yogurt maker, nature explorer, and dog lover; as passionately devoted to nurturing all those lives around her as she is to sometimes being blessedly alone. Lauren found her true home in Colorado but still feels the pull of the Atlantic Ocean, the Potomac River, and the Chesapeake Bay.


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Ander Herrera Says Man United Wasted Time In Contract Extension Talks
July 9, 2019 July 9, 2019 - by OLA - Leave a Comment
Ander Herrera has revealed what triggered his move from Manchester United to Paris Saint-Germain in a chat with Spanish newspaper Marca.
Herrera, who joined PSG on a five-year deal said he was happy at Old Trafford but lack of urgency from the club in contract negotiations as well as questions over his role in the side.
He said: "I do not like looking at the past very much, but there were differences regarding the project and my importance within it. I was very happy, I have a lot to thank the club and the fans for it and also to (Ole Gunnar) Solskjaer.
"He (Solskjaer) did a lot for me to stay, but things did not happen, they arrived late, and by then I had already made the decision to play in Paris."
TaggedAnder HerreraManchester UnitedOle Gunnar SolskjaerParis Saint-Germain
Juventus Completes De Ligt Move From Ajax
Atletico Madrid Signs Kieran Trippier From Tottenham
Harry Maguire Fee Still Not Been Met – Leicester City's Rodgers


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#Board Games
CMON announces chibified tabletop game Marvel United
Board game manufacturer CMON - in collaboration with Spin Master Games - has announced an upcoming Kickstarter campaign for an all-new tabletop title: Marvel United.Although there are very few images or details pertaining to the comic...
Contest: Get your game night on with one of three Funkoverse board games
In today's contest, we're giving away some Funkoverse board games featuring Batman, Harry Potter, and Rick and Morty characters! Remember board games? They're the best. My fiance and I spent a couple of heated hours going at it at Sorry! ov...
Rebellion announces new board game division, Rebellion Unplugged
British developer Rebellion, known for titles such as Sniper Elite, Strange Brigade and the Zombie Army series, has announced an exciting new board game division, Rebellion Unplugged.Headed up by Duncan Molloy, (formerly of Osprey Games), R...
Fallout Shelter is getting a board game adaptation
Fallout Shelter, which was surprise-revealed and released immediately during E3 2015, has been a smash hit for Bethesda. Originally arriving on iOS devices the game eventually made its way to Android, then PC, Xbox One, PS4 and Switch. It's...
Gloomhaven gets a well-needed tutorial in time for Asmodee's Steam sale
A while back, our own Darren Nakamura reviewed the Early Access release of Gloomhaven's digital adaptation. While he was excited with the prospect of a digital version of the game, he warned that newcomers should wait a bit as there was li...
The Binding of Isaac: Four Souls is now available at retail
The Binding of Isaac: Four Souls, the card game version of the popular Binding of Isaac series that had a wildly successful Kickstarter, is now available for purchase at Target stores nationwide. Available for $29.99, you'll get the full 34...
Gloomhaven on Early Access is a new way for veterans to play, but beginners beware
The digital adaptation of the current top-rated board game on BoardGameGeek Gloomhaven was announced about a year ago, and it is now available on Steam Early Access. For strategy gamers, it may seem like a no-brainer. If that many people li...
In your Black Heart is where you'll find the newest Carly Rae Jepsen TTRPG
A few months ago I did the Lord's work by reporting on a tabletop RPG based off of the music of Carly Rae Jepsen. I also shared a sad, sad story of remorse and regret regarding the immaculately poor decision to not go see her in concert. My...
Here's your first real look at the Gloomhaven PC adaptation
Although publisher Asmodee Digital has been teasing various bits of Gloomhaven PC gameplay on Twitch, the first actual trailer just dropped, and so far it looks promising if you're a fan of the tabletop game. This version will launch w...
Gloomhaven rules: Here's a tabletop primer before the digital edition arrives
Tabletop is taking over in ways it never has before. "Blame" Settlers of Catan or Dominion, but tabletop Kickstarters have been seeing a surge these past few years, taking up myriad spots on the all-time most funded Kickstarter list. W...
Contest: Save the kingdom in turn-based RPG For the King
What you you do for the king? Enter today's contest for a Switch or Xbox One copy of RPG For the King! Somewhere around the end of the PS2/beginning of PS3 era, RPGs turned their collective backs on the turn-based combat system, opting for ...
Elder Scrolls is getting a board game, with the ever-popular Skyrim kicking things off
We're in a resplendent era of RPG tabletop games, with Gloomhaven leading the charge. Over the past several years there's been a resurgence in the DragonStrike-esque D&D-lite genre, and many IPs, from Dark Souls to Fallout, ha...
We talked to the two minds behind the killer fan made Final Fantasy Tactics board game
One of the greatest things about Destructoid is its sense of community. I've made life-long friends here and meet folks who share the same passion as myself nearly every single day. Bartek Kubica, who resides in Poland, is one of those peop...
Bloodborne board game Kickstarter smashes the two million dollar mark
Last week we reported on an upcoming Kickstarter, hosted by board game makers CMON, which was hoping to raise funds to develop a tabletop game based on FromSoftware's grim RPG Bloodborne. The original goal was set at $200,000, and appears t...
Bloodborne board game coming to Kickstarter next week
FromSoft's grim adventure title Bloodborne is set to join the myriad of video games currently queuing up for a tabletop adaptation. A crowdfunding campaign to bring the RPG screaming into the real world will open next week, courtesy of boar...
Settlers of Catan is coming to the Switch in June
Everyone's favorite board game is coming to Nintendo Switch! Asmodee Digital, the king of digital board game publishing, will be releasing Settlers of Catan for Switch on June 20, 2019. For the few who may not be aware of Settlers of Catan,...
Steamforged Games has a Devil May Cry board game headed to Kickstarter
Those of you who haven't been directly injected with enough Devil May Cry in 2019 will be pleased to hear that there is currently a board game adaptation of the hip action series in the works, with a crowdfunding campaign set to start very ...
SNES prototype discovered for '90s video board game Atmosfear
A recently-discovered EEPROM has revealed that there was a SNES adaptation of creepy early '90s board game Atmosfear in the works, back during the heyday of the "video board game" craze.For those of you not approaching 40, Atmosfear (known ...
I haven't played Reversi in years, but Splatoon would probably drag me back in
My modern day board game routine of things like the Lord of the Rings card game, Scythe and Star Trek Ascendancy don't make much room for classics like Reversi, but this incredibly cute Splatoon-themed board would change my m...
Now that I found you, Carly Rae Jepsen tabletop game, I'm complete
I'm going to tell you a quick story of the biggest regret of my life. About three years ago now Carly Rae Jepsen rolled into town at a really cool local venue. Obviously, I was super excited because she's the greatest being alive. I went on...
This unofficial Final Fantasy Tactics board game is beautiful and highly complex
A self-proclaimed "psychofan" of Final Fantasy Tactics has unveiled their creation to the world by way of a Polish blog: a home brew Tactics board game. In the post the creator showcases rule sheets, the finished project and ...
Kingdom Hearts teams up with Talisman for a special tabletop edition of the RPG saga
I, personally, was never really into Talisman, the fantasy tabletop game that blew up huge during my formative years. I did take a stab at it several years back, in an evening that lasted a lifetime and ultimately ended with us designating ...
Phan-made Persona 5 tabletop game squeezes the RPG into 30 minutes of fun
Header Image: Box art commissioned from MangAsepTalented tabletop game designer Brother Ming has created a great looking new game based on Atlus smash-hit RPG Persona 5. The Unofficial Persona 5 Phan-Game includes characters and events from...
Metal Gear Solid board game brings the Shadow Moses incident to your dining room
Metal Gear Solid is the gift that keeps on giving. Having redefined a genre - and in many ways an industry - when released for PlayStation back in 1998, Hideo Kojima's stealth classic refuses to die, repeatedly popping up in re-releases, me...
Watch a live stream for the Assassin's Creed board game right now
Did you know there's an Assassin's Creed board game in the works? I didn't. It's being made by a team of ex-Ubisoft developers, and it looks like it's loosely based on the game V-Commandos, which has been compared to video games like Comman...


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Ascension er en britisk ø i Sydatlanten, cirka 1300 kilometer nordvest for Sankt Helena. Den tilhører det britiske oversøiske territorium Saint Helena, Ascension and Tristan da Cunha, tidligere kendt som Saint Helena and Dependencies.

Øen har et areal på omkring 88 km² og cirka 1100 indbyggere. Den største by er Georgetown på vestkysten, med 560 indbyggere (2003).

Natur
Øen er vulkansk og gold, næsten helt uden vegetation, bortset fra et mindre område omkring toppen af Green Mountain (859 meter over havet). Årsnedbøren varierer fra 150 mm ved kysten til 635 mm i bjergene. Mange havskildpadder besøger øen mellem januar og maj for at lægge æg.

Næringsliv
Ascension er et vigtigt kommunikationscenter, og den har en britisk jordstation til satellitkommunikation samt en radiosender (BBC). På øen er der den britisk-amerikanske Wideawake-flybase. I apartheidtiden i Sydafrika anvendte South African Airways denne flyveplads til mellemlanding på ruten London–Johannesburg, da de ikke kunne få overflyvningstilladelser til det afrikanske kontinent. Wideawake havde en central rolle i Operation Black Buck under Falklandskrigen i 1982.

Derudover har ESA en sporingsstation til Ariane-opsendelserne fra Kourou.

Det dyrkes frugt og grøntsager på øen. Sportfiskerturisme forekommer.

Historie
Øen blev opdaget d. 25. marts 1501 af den portugisiske kaptajn João da Nova, og fik navnet Ascension fordi den blev opdaget Kristi himmelfartsdag. Den er siden 1815 en britisk koloni. Da Napoleon kom til Sankt Helena efterlod man en britisk garnison i Georgetown. Øen kom i 1922 under Saint Helena and Dependencies-området.

Kilder

Eksterne links

 Ascension Island Government

Sankt Helena, Ascension og Tristan da Cunha
Øer i Atlanterhavet
Britiske imperium

redpajama_set_name: RedPajamaWikipedia


The wheels are only 2 months old. Two of them are mint and the other two have some curb rash, but can be easily fixed. I want to get rotiforms so I wanna get rid of these. I wrapped the center caps black if u want I can take them off.


text:
Idaho TV weatherman charged with rape
By Crimesider Staff
February 2, 2016 / 11:07 AM / CBS News/AP
TWIN FALLS, Idaho -- A south-central Idaho TV weatherman has been charged with felony rape.
Twenty-three-year-old John William Holland appeared in Twin Falls County Magistrate Court on Monday where a judge set bond at $10,000.
Police say that a woman met with the KMVT-TV weatherman at a local restaurant on Friday and went with him back to his home.
Police say the woman reported that Holland initiated sex but that the woman declined three times, but that Holland refused to stop.
Police say the woman contacted authorities who obtained a search warrant and recovered physical evidence from Holland's residence.
KMVT, a CBS affiliate, says the station is reviewing the matter and Holland is currently on leave.
"We are reviewing the information provided to us by the court about Mr. Holland's arrest and charge," the station's general manager said in a statement obtained by KBOI."We take the allegations seriously, and we will follow this situation and report on it as we would any similar case."
It's not clear if Holland has an attorney.
First published on February 2, 2016 / 11:07 AM
CBS News/AP


text:
Comparison of silatrane, phosphonic acid, and carboxylic acid functional groups for attachment of porphyrin sensitizers to TiO2 in photoelectrochemical cells
Bradley J. Brennan, Manuel J. Llansola Portolés, Paul A. Liddell, Thomas A Moore, Ana L Moore, John Devens Gust
A tetra-arylporphyrin dye was functionalized with three different anchoring groups used to attach molecules to metal oxide surfaces. The physical, photophysical and electrochemical properties of the derivatized porphyrins were studied, and the dyes were then linked to mesoporous TiO2. The anchoring groups were β-vinyl groups bearing either a carboxylate, a phosphonate or a siloxy moiety. The siloxy linkages were made by treatment of the metal oxide with a silatrane derivative of the porphyrin. The surface binding and lability of the anchored molecules were studied, and dye performance was compared in a dye-sensitized solar cell (DSSC). Transient absorption spectroscopy was used to study charge recombination processes. At comparable surface concentration, the porphyrin showed comparable performance in the DSSC, regardless of the linker. However, the total surface coverage achievable with the carboxylate was about twice that obtainable with the other two linkers, and this led to higher current densities for the carboxylate DSSC. On the other hand, the carboxylate-linked dyes were readily leached from the metal oxide surface under alkaline conditions. The phosphonates were considerably less labile, and the siloxy-linked porphyrins were most resistant to leaching from the surface. The use of silatrane proved to be a practical and convenient way to introduce the siloxy linkages, which can confer greatly increased stability on dye-sensitized electrodes with photoelectrochemical performance comparable to that of the other linkers.
https://doi.org/10.1039/c3cp52156g
Photoelectrochemical cells
Carboxylic Acids
carboxylates
Organophosphonates
metal oxides
Brennan, B. J., Llansola Portolés, M. J., Liddell, P. A., Moore, T. A., Moore, A. L., & Gust, J. D. (2013). Comparison of silatrane, phosphonic acid, and carboxylic acid functional groups for attachment of porphyrin sensitizers to TiO2 in photoelectrochemical cells. Physical Chemistry Chemical Physics, 15(39), 16605-16614. https://doi.org/10.1039/c3cp52156g
Comparison of silatrane, phosphonic acid, and carboxylic acid functional groups for attachment of porphyrin sensitizers to TiO2 in photoelectrochemical cells. / Brennan, Bradley J.; Llansola Portolés, Manuel J.; Liddell, Paul A.; Moore, Thomas A; Moore, Ana L; Gust, John Devens.
In: Physical Chemistry Chemical Physics, Vol. 15, No. 39, 21.10.2013, p. 16605-16614.
Brennan, BJ, Llansola Portolés, MJ, Liddell, PA, Moore, TA, Moore, AL & Gust, JD 2013, 'Comparison of silatrane, phosphonic acid, and carboxylic acid functional groups for attachment of porphyrin sensitizers to TiO2 in photoelectrochemical cells', Physical Chemistry Chemical Physics, vol. 15, no. 39, pp. 16605-16614. https://doi.org/10.1039/c3cp52156g
Brennan BJ, Llansola Portolés MJ, Liddell PA, Moore TA, Moore AL, Gust JD. Comparison of silatrane, phosphonic acid, and carboxylic acid functional groups for attachment of porphyrin sensitizers to TiO2 in photoelectrochemical cells. Physical Chemistry Chemical Physics. 2013 Oct 21;15(39):16605-16614. https://doi.org/10.1039/c3cp52156g
Brennan, Bradley J. ; Llansola Portolés, Manuel J. ; Liddell, Paul A. ; Moore, Thomas A ; Moore, Ana L ; Gust, John Devens. / Comparison of silatrane, phosphonic acid, and carboxylic acid functional groups for attachment of porphyrin sensitizers to TiO2 in photoelectrochemical cells. In: Physical Chemistry Chemical Physics. 2013 ; Vol. 15, No. 39. pp. 16605-16614.
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title = "Comparison of silatrane, phosphonic acid, and carboxylic acid functional groups for attachment of porphyrin sensitizers to TiO2 in photoelectrochemical cells",
abstract = "A tetra-arylporphyrin dye was functionalized with three different anchoring groups used to attach molecules to metal oxide surfaces. The physical, photophysical and electrochemical properties of the derivatized porphyrins were studied, and the dyes were then linked to mesoporous TiO2. The anchoring groups were β-vinyl groups bearing either a carboxylate, a phosphonate or a siloxy moiety. The siloxy linkages were made by treatment of the metal oxide with a silatrane derivative of the porphyrin. The surface binding and lability of the anchored molecules were studied, and dye performance was compared in a dye-sensitized solar cell (DSSC). Transient absorption spectroscopy was used to study charge recombination processes. At comparable surface concentration, the porphyrin showed comparable performance in the DSSC, regardless of the linker. However, the total surface coverage achievable with the carboxylate was about twice that obtainable with the other two linkers, and this led to higher current densities for the carboxylate DSSC. On the other hand, the carboxylate-linked dyes were readily leached from the metal oxide surface under alkaline conditions. The phosphonates were considerably less labile, and the siloxy-linked porphyrins were most resistant to leaching from the surface. The use of silatrane proved to be a practical and convenient way to introduce the siloxy linkages, which can confer greatly increased stability on dye-sensitized electrodes with photoelectrochemical performance comparable to that of the other linkers.",
author = "Brennan, {Bradley J.} and {Llansola Portol{\'e}s}, {Manuel J.} and Liddell, {Paul A.} and Moore, {Thomas A} and Moore, {Ana L} and Gust, {John Devens}",
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publisher = "Royal Society of Chemistry",
T1 - Comparison of silatrane, phosphonic acid, and carboxylic acid functional groups for attachment of porphyrin sensitizers to TiO2 in photoelectrochemical cells
AU - Brennan, Bradley J.
AU - Llansola Portolés, Manuel J.
AU - Liddell, Paul A.
AU - Moore, Thomas A
AU - Moore, Ana L
AU - Gust, John Devens
N2 - A tetra-arylporphyrin dye was functionalized with three different anchoring groups used to attach molecules to metal oxide surfaces. The physical, photophysical and electrochemical properties of the derivatized porphyrins were studied, and the dyes were then linked to mesoporous TiO2. The anchoring groups were β-vinyl groups bearing either a carboxylate, a phosphonate or a siloxy moiety. The siloxy linkages were made by treatment of the metal oxide with a silatrane derivative of the porphyrin. The surface binding and lability of the anchored molecules were studied, and dye performance was compared in a dye-sensitized solar cell (DSSC). Transient absorption spectroscopy was used to study charge recombination processes. At comparable surface concentration, the porphyrin showed comparable performance in the DSSC, regardless of the linker. However, the total surface coverage achievable with the carboxylate was about twice that obtainable with the other two linkers, and this led to higher current densities for the carboxylate DSSC. On the other hand, the carboxylate-linked dyes were readily leached from the metal oxide surface under alkaline conditions. The phosphonates were considerably less labile, and the siloxy-linked porphyrins were most resistant to leaching from the surface. The use of silatrane proved to be a practical and convenient way to introduce the siloxy linkages, which can confer greatly increased stability on dye-sensitized electrodes with photoelectrochemical performance comparable to that of the other linkers.
AB - A tetra-arylporphyrin dye was functionalized with three different anchoring groups used to attach molecules to metal oxide surfaces. The physical, photophysical and electrochemical properties of the derivatized porphyrins were studied, and the dyes were then linked to mesoporous TiO2. The anchoring groups were β-vinyl groups bearing either a carboxylate, a phosphonate or a siloxy moiety. The siloxy linkages were made by treatment of the metal oxide with a silatrane derivative of the porphyrin. The surface binding and lability of the anchored molecules were studied, and dye performance was compared in a dye-sensitized solar cell (DSSC). Transient absorption spectroscopy was used to study charge recombination processes. At comparable surface concentration, the porphyrin showed comparable performance in the DSSC, regardless of the linker. However, the total surface coverage achievable with the carboxylate was about twice that obtainable with the other two linkers, and this led to higher current densities for the carboxylate DSSC. On the other hand, the carboxylate-linked dyes were readily leached from the metal oxide surface under alkaline conditions. The phosphonates were considerably less labile, and the siloxy-linked porphyrins were most resistant to leaching from the surface. The use of silatrane proved to be a practical and convenient way to introduce the siloxy linkages, which can confer greatly increased stability on dye-sensitized electrodes with photoelectrochemical performance comparable to that of the other linkers.
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10.1039/c3cp52156g


Informational meeting set for Tuesday for Nanticoke Road span replacement.
The planned replacement of a small bridge between Bivalve and Nanticoke next year could change residents' daily travel plans over a period estimated to last 10 to 12 weeks.
The bridge over Windsor Creek on Nanticoke Road will close to traffic, forcing drivers to take a detour on Jesterville and Oak Grove Church roads for the duration.
Basile said she normally takes Jesterville Road anyway because it is a more direct route to her house, but she takes the route over the bridge on Nanticoke Road in the dark and at dusk to avoid a large deer herd that lives along Jesterville Road.
But the bridge — which overlooks the marsh and the Nanticoke River — often floods in storms, making it impassable.
"I think it's long overdue," Basile said of the bridge replacement.
Built in 1931, the bridge is considered safe but is nearing the end of its useful service life, according to the State Highway Administration. If the deterioration continues, weight restrictions would need to be posted.
The new bridge will have wider shoulders to improve safety. Construction is scheduled to begin on the $3.1 million project in fall 2016 and would be completed in spring 2017.
Residents will be able to learn more about the bridge at an informational meeting from 5:30-7 p.m. Tuesday at the Westside Fire Department.
While bridge repairs and replacements can cause headaches for motorists, the work is the "No. 1 priority" for the State Highway Administration, said district engineer Donnie Drewer.
The state inspects older bridges each year, while newer ones are checked every two years, Drewer said. Engineers also inspect bridges after they have been damaged in vehicle collisions or by other catastrophic events.
The Nanticoke Road bridge is just one of several Lower Shore bridge projects on SHA's books for the next couple of years. The state will also replace a small wooden bridge over Mockingbird Creek on Delmar Road next year and a bridge over Kings Creek on southbound Route 13 near Princess Anne in 2017.
The largest bridge project currently is the Pocomoke River Bridge —which is actually two side-by-side spans on Route 13 linking Somerset and Worcester counties — which started in winter 2013 and is expected to be completed in spring 2016.
The $18.7 million project has caused traffic to be rerouted with two-way traffic on one span at a time.
"One is done and now we're working on the other," Drewer said.
The SHA also is beginning preliminary work on several other bridge projects, although the agency does not yet have funding for them.
Drewer said next up will be work on 11 bridges on the Route 13 Bypass that span Route 13, railroad tracks, Old Ocean City Road, Parker Pond and Mount Hermon Road. Design work has begun and the administration will seek funding for them in either 2016 or 2017, he said.
The work will involve replacing the decks on all of the structures, which isn't difficult work, but it will create challenges for the highway administration.
"The difficult part is trying to maintain traffic," he said.
State officials have also started thinking about replacing the Route 50 bridge in Ocean City, which is now 67 years old.
A preliminary study done a few years ago looked at options for the new bridge's location, Drewer said. State officials decided it should be built on the north side of the existing bridge. The new structure will also be a drawbridge, but it will sit up higher so it won't need to be opened for smaller boats.


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Cardioversion is a medical procedure by which an abnormally fast heart rate (tachycardia) or other cardiac arrhythmia is converted to a normal rhythm using electricity or drugs. Synchronized electrical cardioversion uses a therapeutic dose of electric current to the heart at a specific moment in the cardiac cycle, restoring the activity of the electrical conduction system of the heart. (Defibrillation uses a therapeutic dose of electric current to the heart at a random moment in the cardiac cycle, and is the most effective resuscitation measure for cardiac arrest associated with ventricular fibrillation and pulseless ventricular tachycardia.) Pharmacologic cardioversion, also called chemical cardioversion,  uses antiarrhythmia medication instead of an electrical shock.

Electrical
To perform synchronized electrical cardioversion, two electrode pads are used (or, alternatively, the traditional hand-held "paddles"), each comprising a metallic plate which is faced with a saline based conductive gel.  The pads are placed on the chest of the patient, or one is placed on the chest and one on the back.  These are connected by cables to a machine which has the combined functions of an ECG display screen and the electrical function of a defibrillator. A synchronizing function (either manually operated or automatic) allows the cardioverter to deliver a reversion shock, by way of the pads, of a selected amount of electric current over a predefined number of milliseconds at the optimal moment in the cardiac cycle which corresponds to the R wave of the QRS complex on the ECG. Timing the shock to the R wave prevents the delivery of the shock during the vulnerable period (or relative refractory period) of the cardiac cycle, which could induce ventricular fibrillation.  If the patient is conscious, various drugs are often used to help sedate the patient and make the procedure more tolerable.  However, if the patient is hemodynamically unstable or unconscious, the shock is given immediately upon confirmation of the arrhythmia. When synchronized electrical cardioversion is performed as an elective procedure, the shocks can be performed in conjunction with drug therapy until sinus rhythm is attained. After the procedure, the patient is monitored to ensure stability of the sinus rhythm.

Synchronized electrical cardioversion is used to treat hemodynamically unstable supraventricular (or narrow complex) tachycardias, including atrial fibrillation and atrial flutter. It is also used in the emergent treatment of wide complex tachycardias, including ventricular tachycardia, when a pulse is present. Pulseless ventricular tachycardia and ventricular fibrillation are treated with unsynchronized shocks referred to as defibrillation. Electrical therapy is inappropriate for sinus tachycardia, which should always be a part of the differential diagnosis.

Medication
Various antiarrhythmic agents can be used to return the heart to normal sinus rhythm. Pharmacological cardioversion is an especially good option in patients with atrial fibrillation of recent onset. Drugs that are effective at maintaining normal rhythm after electric cardioversion can also be used for pharmacological cardioversion. Drugs like amiodarone, diltiazem, verapamil and metoprolol are frequently given before electrical cardioversion to decrease the heart rate, stabilize the patient and increase the chance that cardioversion is successful. There are various classes of agents that are most effective for pharmacological cardioversion.

Class I agents are sodium (Na) channel blockers (which slow conduction by blocking the Na+ channel) and are divided into 3 subclasses a, b and c. Class Ia slows phase 0 depolarization in the ventricles and increases the absolute refractory period. Procainamide, quinidine and disopyramide are Class Ia agents. Class 1b drugs lengthen phase 3 repolarization. They include lidocaine, mexiletine and phenytoin. Class Ic greatly slow phase 0 depolarization in the ventricles (however unlike 1a have no effect on the refractory period).  Flecainide, moricizine and propafenone are Class Ic agents.

Class II agents are beta blockers which inhibit SA and AV node depolarization and slow heart rate. They also decrease cardiac oxygen demand and can prevent cardiac remodeling. Not all beta blockers are the same; some are cardio selective (affecting only beta 1 receptors) while others are non-selective (affecting beta 1 and 2 receptors). Beta blockers that target the beta-1 receptor are called cardio selective because beta-1 is responsible for increasing heart rate; hence a beta blocker will slow the heart rate.

Class III agents (prolong repolarization by blocking outward K+ current): amiodarone and sotalol are effective class III agents. Ibutilide is another Class III agent but has a different mechanism of action (acts to promote influx of sodium through slow-sodium channels). It has been shown to be effective in acute cardioversion of recent-onset atrial fibrillation and atrial flutter.

Class IV drugs are calcium (Ca) channel blockers. They work by inhibiting the action potential of the SA and AV nodes.

If the patient is stable, adenosine may be used for restoration of sinus rhythm in patients with macro-reentrant supraventricular tachycardias. It causes a short-lived cessation of conduction through the atrio-ventricular node breaking the circus movement through the node and the macro-reentrant pathway restoring sinus rhythm.

Procedure

Preparation

Cardioversion for restoration of sinus rhythm from an atrial rhythm is largely a scheduled procedure. In addition to cardiology, anesthesiology is also usually involved to ensure comfort of the patient for the duration of the shock therapy. The presence of registered nurses, physician associates, or other medical personnel may also be helpful during the procedure.

Before starting the procedure, the patient's chest and back will be prepped for electrode placement. The skin should be free of any oily substances (e.g., lotions) and hair which may otherwise interfere with adhesion of the pads. Once this is complete, the medical team will adhere the pads to the patient using a rolling motion to ensure the absence of air pockets. (see details on pad placement below). The anesthesiology team will then administer a general anesthetic (e.g., Propofol) in order to ensure patient comfort and amnesia during the procedure. Opioid analgesics (e.g., Fentanyl) may be combined with Propofol, although anesthesiology must weight the benefits against adverse effects including apnea. Bite blocks and extremity restraints are then utilized to prevent self-injury during cardioversion. Once these medications are administered, the glabellar reflex or eyelash reflex may be used to determine the patient's level of consciousness.

The pads are connected to a machine that can interpret the patient's cardiac rate and rhythm and deliver a shock at the appropriate time. The machine should synchronize ('sync') with the R wave of the rhythm strip. Although uncommon, sometimes the machine will unintentionally sync to high amplitude T waves, so it is important to ensure that the machine is synced appropriately to R waves. Interpretation of the patient's rhythm is imperative when using cardioversion to restore sinus rhythm from less emergent arrhythmias where a pulse is present (e.g., atrial flutter, atrial fibrillation). However, if a patient is confirmed to be in pulseless ventricular tachycardia "v-tach" or ventricular fibrillation "v-fib", then a shock is delivered immediately upon connection of the pads. In this application, electrical cardioversion is more properly termed defibrillation.

Cardioversion

Once the machine is synced with the patient's cardiac rhythm, the machine must be charged. To determine the amount of charge (measured in joules "J") the patient requires, many factors are considered. As a general rule of thumb, recent-onset atrial arrhythmias require less energy compared to persistent atrial arrhythmias. If the cardiologist suspects that the patient may be less respondent to cardioversion, a higher energy may be utilized. Once the machine is synced and charged, a shock can be delivered to the patient.

Recommended Energy Levels
 Atrial Flutter and SVT: 50-100 J for biphasic devices; 100 J for monophasic devices
 Atrial Fibrillation: 120-200 J for biphasic devices; 200 J for monophasic devices
 Ventricular Tachycardia (with a pulse): 100 J for biphasic devices; 200 J for monophasic devices
 Pulseless Ventricular Tachycardia and Ventricular Fibrillation: 120-200 J for biphasic devices; 360 J for monophasic devices

After cardioversion

Following electrical cardioversion, the cardiologist will determine if sinus rhythm has been restored. To confirm sinus rhythm, a distinct P wave should be seen preceding each QRS complex. Additionally, each R-R interval should be evenly spaced. If sinus rhythm is restored, the pads may be disconnected, and any other medical equipment is removed from the patients (e.g., bite blocks, restraints, etc.). The patient will regain consciousness soon thereafter (the effects of Propofol generally last for only 3-8 minutes). However, if the arrhythmia is persistent, the machine may be re-charged to a higher energy level, and the cardioversion attempt may be repeated. It is recommended to wait 60 seconds between subsequent cardioversion attempts, but this amount of time may be adjusted based on the patient and/or provider.

Electrode pad placement
Pad placement for electrical cardioversion a cardiac arrhythmia may be either anterior-posterior or anterior-lateral. In an anterior-posterior setup one pad is placed on the chest and the other pad pad is placed on the back. In an anterior-lateral setup, one pad is placed on the chest and the other pad is placed along the left midaxillary line. Choosing the right pad placement can be an important aspect when measuring the success of electrical cardioversion. For example, the anterior-posterior pad positioning is commonly used when attempting to restore an atrial arrhythmia as the vector between the pads predominately runs through the atria. The anterior-lateral pad positioning may be used when attempting to restore pulseless ventricular tachycardia or ventricular fibrillation as there may not be enough time or strength to apply an electrode the patient's back.

Anterior-Posterior pad placement

The anterior pad should be placed inferior to the right clavicle while also being vertically centered over at the level of the right 4th intercostal space. The posterior pad should be placed just lateral to the left side of the spine and vertically centered at the level of T7. The inferior angle of the scapula can be used as a reference for the level of T7.

Anterior-Lateral pad placement

The anterior pad should be placed inferior to the right clavicle while also being vertically centered over at the level of the right 4th intercostal space. The lateral pad should be placed along the left midaxillary line at the level of the left 5th intercostal space. The left nipple can be used as a reference for the level of the left 4th intercostal space. From here, the midaxillary 5th intercostal space is identified by moving inferiorly one intercostal space and laterally towards the midaxillary line.

See also
 Implantable cardioverter-defibrillator (ICD)
 Transcutaneous pacing
 Automated external defibrillator
 Cardiopulmonary resuscitation (CPR)

References

External links
 Cardioversion from the National Institutes of Health
 Pharmacological Cardioversion from the American Academy of Family Physicians (1998)
 Synchronized Electrical Cardioversion from eMedicine Online
 Cardioversion from the Heart Rhythm Society

Cardiac procedures

es:Desfibrilación y Cardioversión eléctrica