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The cerebellum plays an important role in mobility and cognition. However, it is unclear which regions of the cerebellum are associated with gait speed and information-processing ability in older adults without overt brain damage.
Cross-sectional associations between cerebellar gray matter volumes (GMV), gait speed, and information-processing ability were explored in 231 community-dwelling adults (mean age: 83 years, 48% black, 58% female). We measured gait speed on an automated walkway and information-processing ability on the Digit Symbol Substitution test (DSST). Total and regional cerebellar GMV was measured on 3T-magnetic resonance imaging. Lobar GMV of the cerebellum, obtained by an automated parcellation process, were aggregated based on the cognitive (lobules VI, VII, VIII and crus I, II), sensorimotor (lobules II, IV, V), and vestibular (lobules IX and X) functions ascribed to the cerebellar regions.
Larger cerebellar GMV correlated with faster gait speed and superior DSST scores (both p < .001) independent of age, gender, atrophy, and small vessel disease. After adjusting for age, gender, and atrophy, larger cognitive cerebellar GMV correlated with both faster gait speed (p = .04) and higher DSST scores (p < .001), larger sensorimotor cerebellar GMV correlated significantly with DSST alone (p = .02), and the vestibular cerebellar GMV with neither. The association between cognitive cerebellar GMV and gait speed was no longer significant after adjusting for DSST score in the linear regression models.
The relationship between gait speed and cerebellar GMV is influenced by information-processing ability, and this relationship is stronger in subregions ascribed to cognitive than vestibular or sensorimotor functions.
Gait; Brain aging; Cognition; Imaging.
Traumatic brain injury (TBI) is common in military personnel, and there is growing concern about the long-term effects of TBI on the brain; however, few studies have examined the association between TBI and risk of dementia in veterans.
We performed a retrospective cohort study of 188,764 US veterans aged 55 years or older who had at least one inpatient or outpatient visit during both the baseline (2000–2003) and follow-up (2003–2012) periods and did not have a dementia diagnosis at baseline. TBI and dementia diagnoses were determined using ICD-9 codes in electronic medical records. Fine-Gray proportional hazards models were used to determine whether TBI was associated with greater risk of incident dementia, accounting for the competing risk of death and adjusting for demographics, medical comorbidities, and psychiatric disorders.
Veterans were a mean age of 68 years at baseline. During the 9-year follow-up period, 16% of those with TBI developed dementia compared with 10% of those without TBI (adjusted hazard ratio, 1.57; 95% confidence interval: 1.35–1.83). There was evidence of an additive association between TBI and other conditions on risk of dementia.
TBI in older veterans was associated with a 60% increase in the risk of developing dementia over 9 years after accounting for competing risks and potential confounders. Our results suggest that TBI in older veterans may predispose toward development of symptomatic dementia and raise concern about the potential long-term consequences of TBI in younger veterans and civilians.
Cerebral white matter hyperintensities (WMHs) are involved in the evolution of impaired mobility and executive functions. Executive functions and mobility are also associated. Thus, WMHs may impair mobility directly, by disrupting mobility-related circuits, or indirectly, by disrupting circuits responsible for executive functions. Understanding the mechanisms underlying impaired mobility in late life will increase our capacity to develop effective interventions.
To identify regional WMHs most related to slower gait and to examine whether these regional WMHs directly impact mobility, or indirectly by executive functions.
Cross-sectional study. Twenty-one WMH variables (i.e., total WMH volume and WMHs in 20 tracts), gait speed, global cognition (Modified Mini-Mental State Examination; 3MS), and executive functions and processing speed (Digit-Symbol Substitution Test; DSST) were assessed. A L1–L2 regularized regression (i.e., Elastic Net model) identified the WMH variables most related to slower gait. Multivariable linear regression models quantified the association between these WMH variables and gait speed. Formal tests of mediation were also conducted.
253 adults (mean age: 83 years, 58% women, 41% black).
Main Outcome Measure
In older adults with average gait speed of 0.91 m/sec, total WMH volume, WMHs located in right anterior thalamic radiation (ATRR) and frontal corpus callosum (CCF) were most associated with slower gait. There was a >10% slower gait for each standard deviation of WMH in CCF, ATRR or total brain (standardized beta in m/sec [p value]: −0.11 [p=0.046], −0.15 [p=0.007] and −0.14 [p=0.010], respectively). These associations were substantially and significantly attenuated after adjustment for DSST. This effect was stronger for WMH in CCF than for ATRR or total WMH (standardized beta in m/sec [p value]: −0.07 [p=0.190], −0.12 [p=0.024] and −0.10 [p=0.049], respectively). Adjustment for 3MS did not change these associations. The mediation analyses also found that DSST significantly mediated the associations between WMHs and gait speed. Our models were adjusted for age, sex, BMI, quadriceps strength, years of education, standing height, and prevalent hypertension.
The impact, direct or indirect, of WMHs on gait speed depended on their location and was mediated by executive function. Thus, multi-faceted interventions targeting executive control functions as well as motor functions, such as balance and strength training, are candidates to the maintenance of mobility across the lifespan.
PMID: 24841418 CAMSID: cams4627
White Matter Hyperintensities; Mobility; Cognitive Function; Executive Function; Gait Speed; Mediation
Low literacy is common among the elderly and possibly more reflective of educational attainment than years of school completed. We examined the association between literacy and risk of likely dementia in older adults.
Participants were 2,458 black and white elders (aged 71–82) from the Health, Aging and Body Composition study, who completed the Rapid Estimate of Adult Literacy in Medicine and were followed for 8 years. Participants were free of dementia at baseline; incidence of likely dementia was defined by hospital records, prescription for dementia medication, or decline in Modified Mini-Mental State Examination score. We conducted Cox proportional hazard models to evaluate the association between literacy and incidence of likely dementia. Demographics, education, income, comorbidities, lifestyle variables, and apolipoprotein E (APOE) ε4 status were included in adjusted analyses.
Twenty-three percent of participants had limited literacy (<9th-grade level). Limited literacy, as opposed to adequate literacy (≥9th-grade level), was associated with greater incidence of likely dementia (25.5% vs17.0%; unadjusted hazard ratio [HR] = 1.75, 95% confidence interval 1.44–2.13); this association remained significant after adjustment. There was a trend for an interaction between literacy and APOE ε4 status (p = .07); the association between limited literacy and greater incidence of likely dementia was strong among ε4 noncarriers (unadjusted HR = 1.85) but nonsignificant among ε4 carriers (unadjusted HR = 1.25).
Limited literacy is an important risk factor for likely dementia, especially among APOE ε4-negative older adults, and may prove fruitful to target in interventions aimed at reducing dementia risk.
Cognitive aging; Risk factors; Epidemiology.
To evaluate race-related differences in depression onset and recovery in older persons, overall and by sex, and examine race-related differences in mortality according to depression.
Prospective cohort study.
General community in pre-designated zip code areas in Memphis, Tennessee, and Pittsburgh, Pennsylvania.
3,075 persons age 70-79 at baseline in the Health, Aging, and Body Composition study.
Depression was assessed at 8 time points over 10 years using the 10-item Center for Epidemiologic Studies – Depression (CES-D) scale; scores of <8 and ≥8 denoted nondepressed and depressed, respectively. We created variables for transitions across each 18-month time interval, namely, from nondepressed or depressed to nondepressed, depressed, or death, and determined the association between race and the average likelihood of these transitions over time.
A higher percentage of blacks than whites were depressed at nearly all time points. Adjusting for demographics, common chronic conditions, and body mass index, blacks had a higher likelihood of experiencing depression onset than whites (odds ratio, 1.22; 95% confidence interval, 1.03-1.43); among men, blacks were more likely to experience depression onset than whites (odds ratio, 1.44; 95% confidence interval, 1.24-2.89). Blacks also had a higher likelihood of transitioning from nondepressed to death (odds ratio, 1.79; 95% confidence interval, 1.30-2.46). Overall and in sex-stratified analyses, race was not associated with recovery from depression or with the transition from depression to death.
Our findings highlight race differences in depression in older persons and encourage further research on the course of depression in older blacks.
Aging; Depression; Depressive symptoms; Race differences; Epidemiology; Prospective studies
Worldwide, over 35 million people suffer from Alzheimer’s disease and related dementias. This number is expected to triple over the next 40 years. How can we improve the evidence supporting strategies to reduce the rate of dementia in future generations? The risk of dementia is likely influenced by modifiable factors such as exercise, cognitive activity, and the clinical management of diabetes and hypertension. However, the quality of evidence is limited and it remains unclear whether specific interventions to reduce these modifiable risk factors can, in turn, reduce the risk of dementia. Although randomized controlled trials are the gold-standard for causality, the majority of evidence for long-term dementia prevention derives from, and will likely continue to derive from, observational studies. Although observational research has some unavoidable limitations, its utility for dementia prevention might be improved by, for example, better distinction between confirmatory and exploratory research, higher reporting standards, investment in effectiveness research enabled by increased data-pooling, and standardized exposure and outcome measures. Informed decision-making by the general public on low-risk health choices that could have broad potential benefits could be enabled by internet-based tools and decision-aids to communicate the evidence, its quality, and the estimated magnitude of effect.
Alzheimer’s; primary prevention; non-randomized studies; low-risk; communication
Either dysphoria (sadness) or anhedonia (loss of interest in usually pleasurable activities) is required for a diagnosis of major depression. While major depression is a known risk factor for disability in older persons, few studies have examined the relationship between the 2 core symptoms of major depression and disability or mortality. Our objective was to examine the relationship between these two core symptoms and time to disability or death
Longitudinal cohort study
Setting and Participants
We used the nationally representative Health and Retirement Study to examine this relationship in 11,353 persons over the age of 62 (mean = 74) followed for up to 13 years.
Dysphoria and anhedonia were assessed with the Short Form Composite International Diagnostic Interview. Our outcome measure was time to either death or increased disability, defined as the new need for help in a basic activity of daily living. We adjusted for a validated disability risk index and other confounders.
Compared to subjects without either dysphoria or anhedonia, the risk for disability or death was not elevated in elders with dysphoria without anhedonia (adjusted HR = 1.11, 95%CI = 0.91–1.36). The risk was elevated in those with anhedonia without dysphoria (HR = 1.30, 95%CI = 1.06–1.60) and those with both anhedonia and dysphoria (HR = 1.28, 95%CI = 1.13–1.46).
Our results highlight the need for clinicians to learn whether patients have lost interest in usually pleasurable activities, even if they deny sadness.
Depression; anhedonia; activities of daily living; quality of life; health status
To compare depressive symptoms between caregivers to persons with dementia and other illnesses, and determine whether caregiver role captivity and care recipient disruptive behaviors mediate this association.
Prospective cohort study of older women in four U.S. communities followed from 1999 to 2009.
345 caregiving participants from the Caregiver-Study of Osteoporotic Fractures.
Caregiver status based on self-report of performing one or more instrumental or basic activities of daily living for care recipient. Depressive symptoms measured using the 20-item Center for Epidemiologic Studies Depression Scale. Scores of 16 or greater represented high depressive symptoms. Caregiver role captivity and care recipient problematic behaviors measured using validated instruments.
Approximately one-third of the caregivers cared for a person with dementia. High depressive symptoms were more common among dementia caregivers (22.8% vs. 11.2%, p <0.001), (unadjusted odds ratio [OR] 2.12, 95% CI 1.20-3.74). This association was completely mediated by caregiver role captivity and care recipient problematic behaviors. In adjusted results, high depressive symptoms was associated with middle and highest tertiles of role captivity (adjusted odds ratios [AOR] 5.01, 95% CI 2.31-11.05 and 9.41, 95% CI 3.95-22.40 for the middle and highest tertiles, respectively) and care recipient problematic behaviors (AOR 2.52 95% CI 1.02-6.19 and 5.26, 95% CI 2.00-13.8 for each tertile, respectively).
Older caregivers to persons with dementia are at increased risk of high depressive symptoms. Targeting problematic behaviors among dementia patients and addressing aspects of dementia care that result in role captivity may ameliorate caregiver depression.
caregiver burden; dementia; depression
Depressive symptoms and cognitive outcomes are strongly interrelated. Despite that rates of depressive symptoms fluctuate during late life, little is known about the impact of long-term cumulative depressive symptom burden on cognitive decline and dementia in older adults. This study examines the association of nearly 20 years of cumulative depressive symptoms with cognitive outcomes in a cohort of older women.
We assessed depressive symptoms in 7,240 women using the Geriatric Depression scale (GDS) at serial visits. We used a Poisson model with random slopes to estimate GDS trajectories for each participant from baseline to death or end of follow-up, and then characterized depressive symptom burden by quartile of the area under the curve. We assessed cognitive outcomes using repeated measures of the Mini-Mental State Examination (MMSE) and Trails B score over 20 years, Year-20 neuropsychological test battery, and adjudicated dementia and mild cognitive impairment (MCI).
Adjusting for potential confounders, compared with women in the lowest quartile of cumulative depressive symptoms burden, women in the highest quartile had 21% more MMSE errors over time (95% CI = 17%, 26%), 20% worse Trails B score over time (95% CI = 17%, 23%), worse scores on most of the Year-20 cognitive tests, and a twofold greater likelihood of developing dementia or MCI (95% CI = 1.48, 3.11).
Long-term cumulative depressive symptom burden was associated with cognitive decline and risk of dementia or MCI. Older adults with a history of depression should be closely monitored for recurrent episodes or unresolved depressive symptoms as well as any cognitive deficits.
Depression; Cognition; Alzheimer’s.
Step length variability (SLV) increases with age in those without overt neurologic disease, is higher in neurologic patients, is associated with falls, and predicts dementia. Whether higher SLV in older adults without neurologic disease indicates presence of neurologic abnormalities is unknown. Our objective was to identify whether SLV in older adults without overt disease is associated with findings from multimodal neuroimaging. A well-characterized cohort of 265 adults (79–90 years) was concurrently assessed by gait mat, magnetic resonance imaging with diffusion tensor, and neurological exam. Linear regression models adjusted for gait speed, demographic, health, and functional covariates assessed associations of MRI measures (grey matter volume, white matter hyperintensity volume, mean diffusivity, fractional anisotropy) with SLV. Regional distribution of associations was assessed by sparse partial least squares analyses. Higher SLV (mean: 8.4, SD: 3.3) was significantly associated with older age, slower gait speed, and poorer executive function and also with lower grey matter integrity measured by mean diffusivity (standardized beta=0.16; p=0.02). Associations between SLV and grey matter integrity were strongest for the hippocampus and anterior cingulate gyrus (both β=0.18) as compared to other regions. Associations of SLV with other neuroimaging markers were not significant. Lower integrity of normal-appearing grey matter may underlie higher SLV in older adults. Our results highlighted the hippocampus and anterior cingulate gyrus, regions involved in memory and executive function. These findings support previous research indicating a role for cognitive function in motor control. Higher SLV may indicate focal neuropathology in those without diagnosed neurologic disease.
gait disorders; diffusion tensor imaging; aging; brain
Little is known about the association of posttraumatic stress disorder (PTSD) with disability in late life. Most studies of late-life psychiatric disorders and function have focused on depression and generalized anxiety disorder (GAD).
To determine the association between PTSD and disability among older adults, and investigate if association differs by chronicity of PTSD.
The Collaborative Psychiatric Epidemiology Surveys (CPES 2001-2003) includes three aggregated, nationally representative studies (National Comorbidity Survey Replication, National Survey of American Life, and National Latino and Asian American Study or NLAAS) totaling 20,013 participants 18 years and older. Analyses used weights and complex design-corrected statistical tests to infer generalizability to US population.
Continental US; additionally Alaska and Hawaii for NLAAS.
We studied 3,287 CPES participants aged 55 years and older (mean (SD) age=66 (8.7) years, 60% female).
Main Outcome Measures
Disability was defined by 5 domains (out of role, self-care, mobility, cognition, and social) using the WHO-DAS.
3.7% of older adults had a history of PTSD defined by DSM-IV criteria. Of these, approximately half had persistent PTSD in later life (age of onset < 55 years as well as a recent diagnosis) (1.8%). Examining three PTSD groups, frequency of any disability was 79.7% for persistent PTSD, 69.6% for pre-late-life (age of onset < 55 years and age at last diagnosis < 55 years), and 36.9% for no PTSD (P <.001). In logistic regression analyses, adjusting for demographics, smoking, individual medical conditions, depression, GAD, and substance use disorders, respondents with persistent PTSD were three times more likely to have any disability than respondents with no PTSD (odds ratio [OR], 3.18; 95% CI, 1.32-7.64). Global disability results were non-significant for pre-late-life relative to no PTSD (OR, 1.99; 95% CI, 0.97-4.08). In addition, the results suggest that persistent PTSD relative to no PTSD has a strong association with all individual domains.
Conclusions and Relevance
Disability in older Americans is strongly associated with PTSD, particularly PTSD that persists into later life. These findings suggest that monitoring and treatment of PTSD is important over the long term.
To test the hypothesis that circulating endogenous estradiol is associated with stroke risk in older postmenopausal women. Stroke incidence increases after menopause, when endogenous estrogen levels fall, yet exogenous estrogen increases strokes in older postmenopausal women. The relation between endogenous estrogen and stroke is unclear.
Prospective case-control study.
Study of Osteoporotic Fractures.
Patients or Other Participants
Women at least age 65 years (99% follow-up) who were not taking estrogen at baseline.
Main Outcome Measures
Free estradiol index (FEI) was calculated by dividing total estradiol by sex hormone–binding globulin concentrations measured in banked baseline serum. Using logistic regression, odds ratios were estimated for a first-ever atherothrombotic stroke associated with endogenous FEI in 196 women who had a subsequent validated stroke (median follow-up, 8 years) compared with 219 randomly selected women who did not. Potential mediators were assessed in multivariable models.
The age-adjusted odds of atherothrombotic stroke increased with increasing FEI quartiles (Ptrend=.007). Women in the highest FEI quartile had an age-adjusted 2.31-fold (odds ratio, 2.31; 95% confidence interval, 1.28–4.17) higher odds than women in the lowest quartile. Women with greater central adiposity had a suggestively stronger association (P =.08). Atherogenic dyslipidemia, type 2 diabetes mellitus, and C-reactive protein level were potential mediators of this relation.
Endogenous estradiol level is an indicator of stroke risk in older postmenopausal women, especially in those with greater central adiposity. Potential mediators, including atherogenic dyslipidemia, insulin resistance, and inflammation, might underlie this association. Whether estradiol, independent of atherogenic adiposity, influences such mediators and stroke risk needs to be determined. Estrogen-altering agents might be harmful or beneficial depending on endogenous estradiol levels, especially in women with greater central adiposity.
To investigate whether greater cardiorespiratory fitness (CRF) is associated with better cognitive function 25 years later.
We studied 2,747 participants in the community-based Coronary Artery Risk Development in Young Adults Study of black and white men and women aged 18 to 30 years at recruitment in 1985–1986 (baseline year 0). Symptom-limited maximal treadmill test durations at years 0 and 20 provided measures of CRF. Cognitive tests at year 25 measured verbal memory (Rey Auditory Verbal Learning Test [RAVLT]), psychomotor speed (Digit Symbol Substitution Test [DSST]), and executive function (Stroop Test).
Per minute of baseline CRF, the RAVLT was 0.12 words recalled higher (standard error [SE] = 0.03, p < 0.0001), the DSST was 0.92 digits higher (SE = 0.13, p < 0.0001), and the Stroop Test score was 0.52 lower (better performance, SE = 0.11, p < 0.0001), after accounting for race, sex, age, education, and clinical center. Compared with the lowest quartile of CRF, each cognitive test was 21% to 34% of an SD better in the highest CRF quartile. Further adjustment for lifestyle and clinical measures attenuated coefficients for RAVLT and DSST slightly, while the coefficient predicting the Stroop Test lost more than half its value (p = 0.07). Analysis in the subset of 1,957 participants who also completed the year-20 treadmill test showed that 20-year change in CRF was positively associated only with DSST (p < 0.001).
Better verbal memory and faster psychomotor speed at ages 43 to 55 years were clearly associated with better CRF 25 years earlier.
Both traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) are common problems resulting from military service, and both have been associated with increased risk of cognitive decline and dementia resulting from Alzheimer’s disease (AD) or other causes. This study aims to use imaging techniques and biomarker analysis to determine whether traumatic brain injury (TBI) and/or PTSD resulting from combat or other traumas increase the risk for AD and decrease cognitive reserve in Veteran subjects, after accounting for age. Using military and Department of Veterans Affairs records, 65 Vietnam War veterans with a history of moderate or severe TBI with or without PTSD, 65 with ongoing PTSD without TBI, and 65 control subjects are being enrolled in this study at 19 sites. The study aims to select subject groups that are comparable in age, gender, ethnicity, and education. Subjects with mild cognitive impairment (MCI) or dementia are being excluded. However, a new study just beginning, and similar in size, will study subjects with TBI, subjects with PTSD, and control subjects with MCI. Baseline measurements of cognition, function, blood, and cerebrospinal fluid bio-markers; magnetic resonance images (structural, diffusion tensor, and resting state blood-level oxygen dependent (BOLD) functional magnetic resonance imaging); and amyloid positron emission tomographic (PET) images with florbetapir are being obtained. One-year follow-up measurements will be collected for most of the baseline procedures, with the exception of the lumbar puncture, the PET imaging, and apolipoprotein E genotyping. To date, 19 subjects with TBI only, 46 with PTSD only, and 15 with TBI and PTSD have been recruited and referred to 13 clinics to undergo the study protocol. It is expected that cohorts will be fully recruited by October 2014. This study is a first step toward the design and statistical powering of an AD prevention trial using at-risk veterans as subjects, and provides the basis for a larger, more comprehensive study of dementia risk factors in veterans.
Traumatic brain injury; Posttraumatic stress disorder; Alzheimer’s disease; Veterans; Neuroimaging
The use of potentially inappropriate medications in older adults can lead to known adverse drug events, but long-term effects are less clear. We therefore conducted a prospective cohort study of older women to determine whether PIM use is associated with risk of functional impairment or low cognitive performance.
We followed up 1,429 community-dwelling women (≥75 years) for a period of 5 years at four clinical sites in the United States. The primary predictor at baseline was PIM use based on 2003 Beers Criteria. We also assessed anticholinergic load using the Anticholinergic Cognitive Burden scale. Outcomes included scores on a battery of six cognitive tests at follow-up and having one or more incident impairments in instrumental activities of daily living. Regression models were adjusted for baseline age, race, education, smoking, physical activity, a modified Charlson Comorbidity Index, and cognitive score.
The mean ± SD age of women at baseline was 83.2 ± 3.3. In multivariate models, baseline PIM use and higher ACB scores were significantly associated with poorer performance in category fluency (PIM: p = .01; ACB: p = .02) and immediate (PIM: p = .04; ACB: p = .03) and delayed recall (PIM: p = .04). Both PIM use (odds ratio [OR]: 1.36 [1.05–1.75]) and higher ACB scores (OR: 1.11 [1.04–1.19]) were also strongly associated with incident functional impairment.
The results provide suggestive evidence that PIM use and increased anticholinergic load may be associated with risk of functional impairment and low cognitive performance. More cautious selection of medications in older adults may reduce these potential risks.
Dementia; Cognitive aging; Medication; Epidemiology; Physical function.
To examine the relationship between 25-hydroxyvitamin D (25(OH)D) levels and cognitive performance over time in older adults in the Health, Aging, and Body Composition (Health ABC) study.
Prospective cohort study
Community-dwelling participants in Pittsburgh, PA, and Memphis, TN
2,777 well-functioning adults aged 70–79 at baseline with serum 25(OH)D measured at the 12 month follow-up visit and cognitive function measured at baseline and 4-year follow-up visit.
Vitamin D status was categorized as 25(OH)D levels <20 ng/mL, 20 - <30 ng/mL, or ≥ 30ng/mL. Cognition was measured using the Modified Mini-Mental State Exam (3MS) and Digit Symbol Substitution Test (DSST). Linear regression models adjusting for multiple covariates, including age, education, sex, race, site, season, physical activity, and comorbidities were used in the analysis.
Sixty-eight percent of participants had 25(OH)D levels<30 ng/mL. Lower 25(OH)D levels were associated with lower baseline cognitive scores on the 3MS (adjusted means (95% CI): 89.9 (89.4–90.4), 90.8 (90.4–91.3), and 90.6 (90.2–91.1) for <20, 20-<30, and ≥30ng/mL, respectively; p trend =0.02) and the DSST (35.2 (34.5–36.0), 35.9 (35.2–36.6), and 37.0 (36.3–37.8), p trend =0.01). Participants with low 25(OH)D levels had greater declines in 3MS scores over 4 years than those with higher levels (LS mean change (95% CI): −1.0 (−1.5 to −0.6), −0.8 (−1.2 to −0.3), and −0.2 (−0.7 to 0.2) for <20, 20-<30, and ≥30ng/mL, respectively; p=0.05). There was no significant difference in DSST decline by 25(OH)D level.
Low 25(OH)D levels were associated with worse global cognitive function and greater decline over time as measured by the 3MS. Intervention trials are needed to determine if vitamin D supplementation can reduce cognitive decline.
Vitamin D; cognition; cognitive function; memory
To assess the burden of mortality attributable to Alzheimer disease (AD) dementia in the United States.
Data came from 2,566 persons aged 65 years and older (mean 78.1 years) without dementia at baseline from 2 cohort studies of aging with identical annual diagnostic assessments of dementia. Because both studies require organ donation, ascertainment of mortality was complete and dates of death accurate. Mortality hazard ratios (HRs) after incident AD dementia were estimated per 10-year age strata from proportional hazards models. Population attributable risk percentage was derived to estimate excess mortality after a diagnosis of AD dementia. The number of excess deaths attributable to AD dementia in the United States was then estimated.
Over an average of 8 years, 559 participants (21.8%) without dementia at baseline developed AD dementia and 1,090 (42.4%) died. Median time from AD dementia diagnosis to death was 3.8 years. The mortality HR for AD dementia was 4.30 (confidence interval = 3.33, 5.58) for ages 75–84 years and 2.77 (confidence interval = 2.37, 3.23) for ages 85 years and older (too few deaths after AD dementia in ages 65–74 were available to estimate HR). Population attributable risk percentage was 37.0% for ages 75–84 and 35.8% for ages 85 and older. An estimated 503,400 deaths in Americans aged 75 years and older were attributable to AD dementia in 2010.
A larger number of deaths are attributable to AD dementia in the United States each year than the number (<84,000 in 2010) reported on death certificates.
To compare the effects of different types of physical and mental activity on self-reported sleep quality over 12 weeks in older adults with cognitive and sleep complaints.
Randomized controlled trial.
Seventy-two inactive community-dwelling older adults with self-reported sleep and cognitive problems (mean age 73.3±6.1; 60% women).
Random allocation to four arms using a two-by-two factorial design: aerobic+cognitive training, aerobic+educational DVD, stretching+cognitive training, and stretching+educational DVD arms (60 min/d, 3 d/wk for physical and mental activity for 12 weeks).
Change in sleep quality using seven questions from the Sleep Disorders Questionnaire on the 2005–06 National Health and Nutrition Examination Survey (range 0–28, with higher scores reflecting worse sleep quality). Analyses used intention-to-treat methods.
Sleep quality scores did not differ at baseline, but there was a significant difference between the study arms in change in sleep quality over time (p<.005). Mean sleep quality scores improved significantly more in the stretching+educational DVD arm (5.1 points) than in the stretching+cognitive training (1.2 points), aerobic+educational DVD (1.1 points), or aerobic+cognitive training (0.25 points) arm (all p<.05, corrected for multiple comparisons). Differences between arms were strongest for waking at night (p=.02) and taking sleep medications (p=.004).
Self-reported sleep quality improved significantly more with low-intensity physical and mental activities than with moderate- or high-intensity activities in older adults with self-reported cognitive and sleep difficulties. Future longer-term studies with objective sleep measures are needed to corroborate these results.
physical activity; cognition; sleep; aging; intervention
Current dementia medications have small effect sizes, many adverse effects and do not change the disease course. Therefore, it is critically important to study alternative treatment strategies. The goal of this study was to pilot-test a novel, integrative group exercise program for individuals with mild-to-moderate dementia called Preventing Loss of Independence through Exercise (PLIÉ), which focuses on training procedural memory for basic functional movements (e.g., sit-to-stand) while increasing mindful body awareness and facilitating social connection.
We performed a 36-week cross-over pilot clinical trial to compare PLIÉ with usual care (UC) at an adult day program for individuals with dementia in San Francisco, CA. Assessments of physical performance, cognitive function, physical function, dementia-related behaviors, quality of life and caregiver burden were performed by blinded assessors at baseline, 18 weeks (cross-over) and 36 weeks. Our primary outcomes were effect sizes based on between-group comparisons of change from baseline to 18 weeks; secondary outcomes were within-group comparisons of change before and after cross-over.
Twelve individuals enrolled (7 PLIÉ, 5 UC) and 2 withdrew (1 PLIÉ, 18 weeks; 1 UC, 36 weeks). Participants were 82% women (mean age, 84 ± 4 years); caregivers were 82% daughters (mean age, 56 ± 13 years). Effect sizes were not statistically significant but suggested potentially clinically meaningful (≥0.25 SDs) improvement with PLIÉ versus UC for physical performance (Cohen’s D: 0.34 SDs), cognitive function (0.76 SDs) and quality of life (0.83 SDs) as well as for caregiver measures of participant’s quality of life (0.33 SDs) and caregiver burden (0.49 SDs). Results were similar when within-group comparisons were made before and after cross-over.
PLIÉ is a novel, integrative exercise program that shows promise for improving physical function, cognitive function, quality of life and caregiver burden in individuals with mild-to-moderate dementia. Larger randomized, controlled trials are warranted.
Cognitive decline and dementia are a major cause of disability and mortality among older adults. Cross-sectional evidence from observational studies suggests that greater arterial stiffness is associated with worse cognitive performance. These associations have been observed on measures of global cognition and across multiple domains of cognition. Epidemiologic evidence on the association between arterial stiffness and rate of cognitive decline has been less definitive, and very few studies have investigated the risk of developing dementia. This review summarizes the current research on arterial stiffness and cognition, issues around measurement and the effect that potential intervention might have on the course of cognitive aging. The evidence on pharmacological and non-pharmacological (exercise, nutrition, etc) interventions in older adults with arterial stiffness is promising. Yet there are no studies or trials that directly evaluate how interventions of arterial stiffness reduce or prevent cognitive impairment and risk of developing dementia. More research is needed to elucidate the causal link between arterial stiffness and cognitive decline and dementia, and to identify whether potential interventions to prevent or reduce arterial stiffness may benefit cognitive health of the elderly.
Aging; Arterial stiffness; Cognitive decline; Dementia; Epidemiology
To assess the prevalence of geriatric depression in Chinese American patients with cognitive impairment and to compare the prevalence to that of cognitively normal elderly Chinese Americans and Caucasians.
We compared rates of depressive symptomatology in elderly Chinese Americans to a matched group of Caucasians, with and without dementia, and assessed rates of treatment for depression across all groups.
Academic subspecialty referral clinic.
Participants included a total of 137 elderly, cognitively impaired and cognitively normal Chinese Americans and 140 Caucasians with and without cognitive impairment.
Demographic (e.g. age, education, race, language ability), cognitive (MMSE score), medical (e.g. cardiovascular morbidity) and functional (Clinical Dementia Rating Scale) risk factors were assessed for association with depressive symptomatology as measured by the Geriatric Depression Scale (GDS).
Depression (GDS score ≥ 6 out of 15) was significantly more common in cognitively impaired Chinese Americans (35%) versus cognitively impaired Caucasians (15%, χ2 = 33.8, p<0.05), and Chinese Americans were less likely to be on treatment for depression (12%) than Caucasians (37%, χ2 = 41, p<0.05). Cognitive and functional impairment, age and education were all independent predictors of GDS score. Rates of depression were not significantly different in cognitively normal Chinese American (6%) and Caucasian (0%) groups.
These findings indicate that elderly Chinese Americans with cognitive impairment are at significantly increased risk for unrecognized depression and that education, and/or other cultural factors associated with education may contribute to this risk.
geriatric depression; dementia; Chinese American
Mild cognitive impairment is often a precursor to dementia due to Alzheimer's disease, but many patients with mild cognitive impairment never develop dementia. New diagnostic criteria may lead to more patients receiving a diagnosis of mild cognitive impairment.
To develop a prediction index for the 3-year risk of progression from mild cognitive impairment to dementia relying only on information that can be readily obtained in most clinical settings.
Design and Participants
382 participants diagnosed with amnestic mild cognitive impairment enrolled in the Alzheimer's Disease Neuroimaging Initiative (ADNI), a multi-site, longitudinal, observational study.
Main Predictors Measures
Demographics, comorbid conditions, caregiver report of participant symptoms and function, and participant performance on individual items from basic neuropsychological scales.
Main Outcome Measure
Progression to probable Alzheimer's disease.
Subjects had a mean (SD) age of 75 (7) years and 43% progressed to probable Alzheimer's disease within 3 years. Important independent predictors of progression included being female, resisting help, becoming upset when separated from caregiver, difficulty shopping alone, forgetting appointments, number of words recalled from a 10-word list, orientation and difficulty drawing a clock. The final point score could range from 0 to 16 (mean [SD]: 4.2 [2.9]). The optimism-corrected Harrell's c-statistic was 0.71(95% CI: 0.68–0.75). Fourteen percent of subjects with low risk scores (0–2 points, n = 124) converted to probable Alzheimer's disease over 3 years, compared to 51% of those with moderate risk scores (3–8 points, n = 223) and 91% of those with high risk scores (9–16 points, n = 35).
An index using factors that can be obtained in most clinical settings can predict progression from amnestic mild cognitive impairment to probable Alzheimer's disease and may help clinicians differentiate between mild cognitive impairment patients at low vs. high risk of progression.
To determine if older, diabetic women have a greater longitudinal decline in physical performance and if these changes differ by insulin sensitizer use.
Prospective cohort study.
Baltimore, Minneapolis, Portland and the Monongahela valley in Pennsylvania, USA.
2864 community-dwelling women (mean age 78.5±3.6 years) enrolled in the Study of Osteoporotic Fractures in 1997–1998 and re-studied 4.9 ± 0.6 years later.
Women were categorized as having no diabetes (n=2680) or having diabetes (n=184). The prescription medication inventory was used to determine use of insulin sensitizers (metformin/thiazolidinedione). The outcomes were longitudinal changes in physical performance measures, including grip strength, usual walk speed, and rapid walk speed.
Estimates from fully adjusted models showed that diabetic women had greater declines in usual walk speed (−0.16 m/s [95%CI −0.19, −0.14]) and rapid walk speed (−0.21 m/s [95%CI −0.24, −0.17]) compared to non-diabetic women (usual: −0.11 m/s [95%CI −0.12, −0.11], rapid: −0.15 m/s [95% CI −0.16, −0.14]), p<0.01 for both comparisons. Diabetic women on insulin sensitizers had an attenuated decline in the loss of usual walk speed compared to those not on insulin sensitizers, p<0.05. Declines in grip strength did not differ significantly by diabetes status or insulin sensitizer use.
Older women with diabetes have a greater decline in walk speed, but not grip strength compared to older women without diabetes. Clinical studies in older adults to determine whether diabetes treatments like insulin sensitizers can prevent the loss in walk speed and mobility are needed.
elderly; diabetes; insulin sensitizer; physical performance; walk speed
Cardiovascular risk factors in middle-age are associated with cognitive impairment and dementia in older age. Less is known about the burden of calcified subclinical atherosclerosis and cognition, especially in midlife. We examined the association of coronary artery and abdominal aortic calcified plaque (CAC and AAC, respectively) with cognitive functioning in middle-aged adults.
This cross-sectional study included 2,510 black and white adults (age: 43–55 years) without heart disease or stroke who completed a year 25 follow-up exam (2010–11) as part of the Coronary Artery Risk Development in Young Adults Study. CAC and AAC were measured with non-contrast computed tomography. Cognition was assessed with the Digit Symbol Substitution Test (DSST) (psychomotor speed), Stroop Test (executive function), and Rey Auditory Verbal Learning Test (RAVLT) (verbal memory).
A greater amount of CAC and AAC was associated with worse performance on each test of cognitive function after adjustment for age, sex, race, education, and study center. Associations were attenuated, but remained significant for the DSST and RAVLT following additional adjustment for vascular risk factors, including adiposity, smoking, alcohol use, dyslipidemia, hypertension, and diabetes. Compared to participants without CAC or AAC, those with both CAC and AAC, but not CAC or AAC alone was associated with lower DSST scores (p<0.05).
In this community-based sample, greater subclinical atherosclerotic calcification was associated with worse psychomotor speed and memory in midlife. These findings underscore the importance of a life course approach to the study of cognitive impairment with aging.
atherosclerosis; heart disease; calcium score; cognition; subclinical disease; risk factors
To determine the association between interleukin-6 (IL-6), IL-6 soluble receptor (sR) and tumor necrosis factor soluble receptor-1 (STNF-R1) and cognitive status among oldest old women.
20-year longitudinal cohort study.
Four clinical sites in the United States.
905 women from the Study of Osteoporotic Fractures (mean age 88.3±2.8 years at cognitive status adjudication).
At Year 20, cognitive status was adjudicated as normal, mild cognitive impairment (MCI), or dementia. Inflammatory markers were measured from blood serum at Years 10 and 16 in a random sample of women.
Over 10 years, 199 (22.0%) developed MCI, and 145 (16.0%) dementia. There were no significant associations between IL-6 or STNF-R1 and cognitive status. High IL-6 sR (≥37401.36pg/ml, high tertile) at Year 16 was significantly associated with decreased risk for dementia (OR=0.54; 95% CI: 0.30, 0.97), compared to women with lower levels (<37401.36 pg/ml, lower two tertiles). Women with high IL-6 sR at both time points (OR=0.39; 95% CI: 0.17, 0.89) or who transitioned to a high level (OR=0.35; 95% CI: 0.14, 0.88) had reduced risk of dementia.
In this cohort of white, high functioning oldest old women, a consistently high or an increasing level of IL-6 sR is associated with reduced risk of dementia. Compared to other studies of younger old adults, this suggests the effect of inflammation on dementia may differ in younger old and oldest old. Understanding these differences will be crucial in interpreting results from ongoing clinical trials and in targeting therapeutic strategies to the oldest old.
Dementia; mild cognitive impairment; inflammation; oldest old

domain: psychology


The University of Lagos (UNILAG) has postponed its post-UTME screening until further notice.
The institution made this announcement in a short statement posted on its website on Thursday morning.
UNILAG said, “new dates will be communicated as soon as possible,” for the screening which was to begin Monday, November 30.
The statement read: “The University wishes to inform all prospective candidates of the 2020/2021 Post-UTME Screening exercise earlier slated for Monday, November 30 to Saturday, December 12, 2020, that the screening has been postponed.
“New dates will be communicated as soon as possible. Any inconvenience occasioned by this postponement is highly regretted.”
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For 3 years, it ran in the Greeley Tribune. Since then, it has run in various subsidiaries of the Douglas County News Press. I still have most of my columns in digital format.
For many years, I only gave myself one rule: try to work the word "library" into every piece. My intent was to think in public about just what librarianship means at the end of the 20th century and beginning of the 21st.
There have been many advantages for me. I found that putting library plans out in front of the public, and getting feedback about them, helped me make better decisions. Sometimes, I found that it was very difficult for me to describe those plans or policies -- the kind of thing that makes me realize that they might not be good ideas after all. The weekly discipline of explaining my profession to the public keeps me more mindful, more honest. It also has provided steady visibility for the library and its issues.
November 22, 2000 - TatteredCover and Customer Privacy
I have long been an admirer of Joyce Meskis, owner of the Tattered Cover bookstore. I've even had the pleasure of working with her on several efforts to resist censorship.
Joyce doesn't just sell books, she really believes in the whole idea of an untrammeled world of ideas. She has lost customers by bringing in certain authors for book signings. This isn't an issue of left versus right, liberal versus conservative. Through her author invitations, she has offended both ends of the spectrum. Joyce believes that people have the right to think, speak, write, and read what they will. She literally puts her money where her mouth is.
Joyce is in the news again. She's seeking to block a subpoena forcing her to provide customer records to the police. Her notion -- almost quaint in an age of ever more invasive electronic attacks on privacy -- is that what you buy from a bookstore is a confidential transaction.
I'm not sure I can accurately summarize the police position. I believe they found a book at the scene of a crime, and that both involved the making of methamphetamine. A Tattered Cover invoice was also present at the scene. The police are seeking customer records from Tattered Cover to link the book to one of several persons under suspicion of the crime.
Joyce states that if her customers believe that business records about what books people purchase can be opened to governmental review, and that buying a book on a subject bespeaks an intent to commit a crime, this will have a "chilling effect" on her business. I think she's right.
I once faced a similar situation. I used to work in an Illinois library as the head of a large circulation department. The local police came to me with a library book, found at the place where arson was suspected. It was their only real lead. As in Colorado, I was forbidden to reveal this information UNLESS a subpoena were presented. First, though, I tried to verify that we had the information. I discovered that the book hadn't been checked out at all.
It should surprise no one to learn that somebody who steals a library book is capable of other crimes.
But Joyce has raised some troubling questions. Most people would grant that police work is important and difficult. Most of the time, cooperation with duly constituted authority is reasonable.
But for civil libertarians and others, alarm bells begin to sound when the government seeks to expand its ability to monitor not just what citizens DO, but what they are thinking about.
Have you ever read a book about something that was a crime? Or something that might one day be considered a crime?
Have you ever done a student report on drugs, or famous robberies? Have you, as a citizen, investigated charges of official corruption?
Just how eager should we be to start locking up people, or seeking to lock them up, on the basis of what strikes their curiosity? At what point does the attempt to catch crooks begin to make crooks of us all?


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ANTWERP—It’s one of the world’s busiest seaports, despite being 96 kilometres inland from the North Sea.
And the 15,000 freighters and cruise ships that arrive here annually sail past a small monument that salutes the 6,367 Canadians who died along this eclectic waterway liberating it from its Nazi occupiers during the Second World War.
The port of Antwerp in Belgium had been freed from German occupation by British paratroopers in September 1944. It was to be the principal supply depot for the final push by the Allies into Germany to end the war — but it might as well have been Moose Jaw if supply ships couldn’t reach the docks.
The Scheldt River and the Albert Canal through the river’s wide estuary, were tightly controlled by the Nazis. General Dwight Eisenhower, Allied commander in chief, turned to the 1st Canadian Army under the command of Lt.-General Guy Simonds to clean out the enemy and open the shipping lanes.
The notorious Battle of the Scheldt began 75 years ago on Sept. 2 and lasted three months. The Canadian troops, with Polish reinforcements, were thrown up against an enemy force nearly twice its size. It was the toughest fighting Canadians would face in the entire war, even though these same troops fought their way onto Normandy’s beaches three months earlier on D-Day.
The German’s had the high ground and busted all the area dams to flood the estuary forcing the Canadians to advance through mud and waist-high water towards the enemy.
And they did.
They killed 12,000 German troops and captured 41,043.
Hitler knew if the Allies got into Antwerp they were pounding on his front door. He unleashed all his might against the port and its estuary. German soldiers home on leave from the Eastern Front against Russia were quickly sent to Belgium.
Hitler’s terrifying V1 and V2 rocket bombs that had been raining down on London were all now directed at nearby Antwerp. That city suffered 10 times more V1 and V2 rocket attacks than did London during the war. They killed 30,000 civilians, but never halted shipping activity at the port
The Cathedral of Our Lady, one of Europe’s most impressive churches, played a major role in the defence of Antwerp.
Spotters were placed near the top of its 123-metre-high bell tower to watch for missile hits in the city and on the docks. They then phoned firefighting brigades to race to the site and extinguish the flames.
The 600-year-old cathedral was never hit and houses some of Belgium’s most famous works of art — many by local native Peter Paul Rubens — that have hung in the Cathedral for six centuries.
The huge Cathedral has 55 stained glass windows and 2,400 seats, but can accommodate 25,000 people. Visitors pay to enter as it costs 1.5 million Euros per year to maintain the cathedral, which is Antwerp’s most popular tourist attraction. So too is its old and new harbour.
The Second World War harbour opened up by the Canadians is now one of the liveliest neighbourhoods in Antwerp. The big warehouses that housed ammunition, tanks, sleeping bags, boots and food for the Allied troops have been converted to trendy condominiums with high ceilings. They now house young couples, singles and families. Instead of supply ships lining the piers, there’s a wide variety of restaurants, cafes and dance halls lining the piers.
Antwerp’s modern harbour has expanded further out on the Scheldt River. It employs 20,000 people and can accommodate ships weighing more than 400,000 tonnes. Tour boats prowl the working harbour to explain where the shipping goods are coming from, where they’re going and how they’re handled.
A stone fortress built 819 years ago on the east bank of the Scheldt River in the city core to control who gets to use the river is now undergoing a multimillion restoration. It’ll open in 2020 as Antwerp’s new cruise ship terminal.
More than 100,000 visitors arrive in Antwerp annually on cruise ships. And next year, passengers arriving via the stone fortress will see another salute to the Canadian troops for opening up the river to free passage.
The stone fortress used to house a museum depicting Antwerp’s 1,000 years of maritime trading, but that has moved into a spectacular new waterfront museum called MAS for short.
The new, 10-storey MAS museum has absorbed displays and artifacts from a dozen older museums in Antwerp that have since closed. The MAS was designed by the Dutch firm Neutelings Reidjik Architects.

domain: geography


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domain: health


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Brain Injuries: Headers harm women more than men
According to a new study, soccer headballs are significantly more dangerous for women than for men. The areas of damaged brain tissue are therefore five times more extensive in female athletes than in male athletes.
Dangerous head injuries
Head injuries in soccer or other “contact sports” are relatively common. Headballs in particular are dangerous, they can damage the brain. And that of women significantly more than that of men, as US scientists have now found out.
30 million women and girls kicking
According to FIFA, the international governing body of football associations, around 30 million women and girls play football worldwide. A header is much more dangerous for them than for male soccer players.
This is the result of a study by researchers led by Michael Lipton from the Albert Einstein College of Medicine in New York. The study published in the journal "Radiology" showed that brain damage caused by headballs is five times stronger in women than in men.
As a statement says, the results suggested that gender guidelines could be justified to prevent football-related head injuries.
Women feel worse after head injuries
"Researchers and clinicians have long known that women are worse off than men after a head injury," said study author Michael Lipton.
"But some believed that this was only because women were more willing to report symptoms," said the radiologist.
"Based on our study, which measured objective changes in brain tissue instead of self-reported symptoms, women seem more likely than men to suffer head trauma from brain injuries."
Special MRI procedure
In order to arrive at their results, the researchers examined 49 male and female amateur footballers between the ages of 18 and 50 who had completed approximately the same number of headers in the twelve months before the examination.
A special form of MRI, the so-called “diffusion tensor imaging” (DTI), was used.
The scientists found that the volume of white matter damage was five times greater in female soccer players than in male players.
It was also shown that eight brain regions were affected in women and only three in men.
"The results complement the growing body of evidence that men and women develop different biological responses to brain trauma," said lead author Todd G. Rubin.
Headers can't be forbidden
It is not clear why women are more sensitive to head injuries than men. The researchers suspect that, among other things, the differences in the neck muscles could play a role.
According to the study authors, the damage found in the study was only minor, but it is still a cause for concern.
In some cases, they could lead to further brain damage and serious functional disorders.
So should soccer players stop with the headers? "We have conducted several studies that show that most players can tolerate a certain amount of headers," said Dr. Lipton.
“Instead of banning headers altogether - which is probably not realistic - we'd rather find out how many headers are getting players into trouble. What is important about this study is that men and women may need to be viewed differently. ”(Ad)


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reviews & comments (39)
For all the comments about fat content,why not follow the recipe but instead of pan frying, spritz them with olive oil and bake on a sheet of parchment?
parmesan chicken, pan fried or baked, has always been a family favorite, it's elegant simplicity carries it from a weeknight family dinner to dinner with friends...the dry mustard was a nice, tasty twist tho...haven't used it before, but now i sure will ;0)
This is delicious and may be used with veal, chicken or pork cutlets. I used only half of oil suggested. I have also used capers because I love them.
Serendipity. I actually made this almost exact recipe last night. Only thing I did not do was the dry mustard. I pounded cutlets to 1/2 inch instead of 1/4 and added about 1/2 cup of yellow cornmeal to the breading mix for extra crunch. Great way to make cutlets!
This is a great recipe. By using cutlets the chicken cooks quickly without drying out. They weren't greasy and had a wonderful flavor. I served them over a baby spinach salad with just a simple red wine vinergarett. Will DEFINATELY make these again.
Substitute thin-cut, bone-in pork chops for the chicken. Even tastier. If you don't have mustard powder in your larder, just add some Dijon to the egg bath.
VERY TASTY and easy. My only gripe/concern is the "guilt-free" statement. This is still a lot of olive oil, even if most of it is for the frying. Ideally, and I thought things were going this way, "guilt-free" nuggets or any such treat would have a baked version, without all that oil. Also, bite-size vs full-size does not help the oil fat number; in fact, with more surface area to absorb the oil, quite the opposite. We love these recipes overall, but I would like to ask, again, that some nutrition information be provided---although I understand that is not easy (nor standardizable) for home-chef-developed recipes. Onward to good food and good health both!
Wonderful way to cook chicken - but use a real nice non-stick pan and reduce the oil used to cook them by at least half. As written the recipe calls for a whole days worth of oil for one person per serving.

domain: food


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I've been involved with commercial rafting and Zimbabwe Tour Operations for the past five years. While we've enjoyed great success with the regional coporate market in the experiential learning fields we have not seen much on the international leisure market.
Is the region considered safe?
Is info on the region accessible on the net?
Just how much "Bad press" does the region experience internationally?
Is the region perceived to be expensive?
Any answers / comments would be greatly appreciated.
Recent ActivityView all Africa & the Middle East activity »
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- 15 Southern Africa or Tanzania/Kenya for August 2018 Family Trip
- 16 Advise on Hotel stay and attractions visit in Casablanca
- 17 Experience of using Namibia Tracks and Trails
- 18 Transfer time at JNB Intl. airport
- 19 Sabi Sands areavs Motswari Timbavati area
- 20 Kilimanjaro Tour Operators
- 21 Egypt in 6 days itinerary - please advise
- 22 Going to Israel end of October. Maybe silly, but what shoes to bring?
- 23 Advice on private tour Morocco
- 24 Where are the best safaris in Africa?
- 25 Wilson airport transfer to NBO


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If John McCain is serious about school choice being a civil rights issue, perhaps he'd do well to revisit his party's longstanding efforts to ensure that public school districts remain segregated.
It was under the Nixon administration that the federal government fought busing programs and programs that made it possible for poor, minority, inner-city school kids to go to richer, whiter, suburban schools. The Nixon administration could have used its power to withhold Community Development Block Grant funds from municipalities, counties, and states that would not embrace affirmative measures. Instead they fought these measures and Republicans have made their resistance to regional, racial equality a hallmark of their policies ever since.
The Nixon administration even assisted with the fight against school integration in the (unfortunately) landmark case of Milliken v Bradley -- a direct attack on Brown v Board of Education.
Of course, this mentality has continued to today's Supreme Court in the recent school integration cases that included Justices Roberts and Alito -- the type of judges McCain says he wants on SCOTUS -- arguing against voluntary integration.
Here in the Chicago area, State Senator James Meeks used just this idea in his protest against unequal educational opportunities in the region.
The solution isn't to require poor people pay for private education while richer people get public education. It's to equalize the quality of education for everyone by removing the arbitrary barriers of school districts that perpetuate racial, ethnic, and income inequality.

domain: news


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The compliance work around data protection after the era of GDPR is a complex and challenging task. Some small business may get even confused about the existence of two pieces of legislation concerning the same subject – the GDPR and the Data Protection Act 2018.
So are they the same? Are they different? And which takes precedence over the other?
The simple answer is that these pieces of legislation are complimentary.
GDPR has been directly applicable in the UK since 25th May 2018. Most of the detailed legal provisions that all businesses must comply with are presented in the GDPR. However, it doesn’t cover everything that is needed to have a workable data protection regime so each EU country still has some of its own legislation to fill in the gaps – and this is why the new Data Protection Act (DPA) 2018 was adopted.
The creation of DPA 2018 serves three main functions:
- To Fill the legal gaps implemented into the GDPR and to give each member state the opportunity to develop the legislation in accordance with its internal rules and laws. The GDPR provides member states with limited opportunities to make provisions for its implementation and the DPA 2018 fills those gaps for the UK – for example: how to define ‘public authorities’.
- to further extend and clarify how data protection laws apply to certain broad areas that are excluded from the GDPR and are left to each member state, such as immigration, intelligence, and law enforcement.
- to set out the detailed provisions needed for the funding and functioning of the UK’s data protection regulator – the Information Commissioner’s Office (ICO). For instance, it covers the ICO’s duties, functions and powers, plus the enforcement provisions.
Another important function of the DPA 2018 is that it deals with some administrative points, such as repealing the old Data Protection Act 1998 and making the needed changes to deal with related legislation, like the Freedom of Information Act.
For comparison we’ve presented the most valuable information with a table:
Further, the DPA 2018 covers a few other areas, connected with data protection and privacy, though very specific to the UK. For example, the DPA 2018 has in its scope the criminal sanctions and fines for GDPR infringements (for example the introduction of an unlimited fine for the new offense of intentionally or recklessly re-identifying individuals from anonymised data). DPA 2018 clarifies areas such as processing relating to areas outside the scope of EU law (and the GDPR) such as national security and immigration; the role and powers of the UK’s independent authority (the ICO) in upholding information rights and freedoms; it decides the issues around the transposition of the EU Data Protection Directive 2016/680 (Law Enforcement Directive) into UK law.
In conclusion, the DPA 2018, therefore, sits alongside the GDPR. When considering your data protection duties, both the GDPR and the new DPA 2018 will have to be consulted.

domain: politics


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and ends on March 30 in Houston. You can view a complete list of tour dates below. Sunday is Kidz Rock Day starting at 11 a. m. to 5 p. m. The venue is situated at 220 N. Washington Street in Falls Society. More information on the venue positioned here. Disney's "N. B. More information about Imagine Dragons Concert Vivid Seats Group Sales February 2018.
For me, this will be the defining moment in how Genesis changed from a prog rock band to a American pop rock band with progressive influences. Depending on who you ask, its even the point where Genesis made its best or worst decision. Regardless, the band had never been sought-after. From this point on, every Genesis album went Platinum within U. S. Professor Louie & the Crowmatix been recently nominated for multiple Grammy Awards and will have back Levon Helm, Garth Hudson, and Rick Danko on solo albums when they were not touring utilizing Band. The award imagine dragons concert blends rock, blues, country and more into a splendid blend of unique Americana music. Many learn more information on this band at their website. Cry Cry Cry by Johnny Cash: His chorus of "Burn burn burn" from Ring of Fire is more well-known, but this three-peat brings the tears often accompanying classic country. The Cosmic Adventures of ManBoyis a four imagine dragons song EP provides a very classic rock sound onto it. The classic rock sound fits Mike Daly's voice nicely, that is better rather than the more pop sound he had previously gone for.
If you are looking for How To Get The Best Imagine Dragons Concert Tickets Online February, sports tickets and theater seats at the best prices click here.

domain: entertainment


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This is my favourite Roberta Flack album. It is filled with wonderful songs and that mesmeric, peerless voice that, for me, has never been matched. It only loses one star because I could not put 4 and a half, my only slight quibble being that some of the songs go on a little too long, but that should not put you off a most remarkable piece of work.
I have this on vinyl from the 70's and now as then, it is still the most sublime music and singing, ever. I think that Roberta Flack is overlooked today. The song, Killing Me Softly is attributed to the Fugees when it was Roberta's song and the best version obviously. Just love her!

domain: hobby


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News & Updates
February 8, 2017
It's a lot of money, but worth the cost.
SumoMe.com is now the former SumoMe.com. After six-plus years and 1.5 million cold hard dollars, we have finally rebranded as Sumo.com.
Yes, you read that right. It cost us $1,500,000 for that domain name. That ties Sumo.com with Russia.com for the 83rd most expensive domain purchase ever. But it’s not like we just c...


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Deputy Permanent Secretary of Labour Mr. Singhadet Chu-umnart assigned the Bureau of Inspection and Evaluation's expert Mrs. Rasee Benjatikul to welcome Major General Preecha Saipetch and committee from the Defense Mobilisation Department on visit to observe command practice exercisies (CPX) and military preparation for 2017 at the Executive Operation room. The Ministry of Labour presented plans on preparing its workforce, coupled with a preparation training center in support of military and defense working teams. The training was a collaborative effort through the Defense Mobilisation Department Eoc web system, implemented once a year. On the 24th of May, the Ministry of Labour joined the National Security Council in launching the CPX for military preparation this year, through video teleconference (VTC) at the Ministry of Labour's Networking and Regional Support division.
The plan to gather resources for the nation's defense is assigned to various units in order to efficiently provide the nation with any defense measures it may need. The plan involved 10 dimensions including manpower, food, water, transportation, communication, public health and medics, industry and production factors, fuel and energy, information dispersion and other facilitations.
Source: Ministry of Labour


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Looking for the next best asphyxiation device? Look no further! Grab a Cru tie and make your boring black formal choker a thing of the past!
Tokyo Crusaders Rugby Football Club
Team website for Tokyo Crusaders RFC International Rugby club in Kanto, Japan
Certainly not a clip-on.
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The private equity firm Centerbridge Partners LP walked away from its tentative deal to buy LightSquared out of bankruptcy at a court hearing Tuesday. Read More »
Dec 17, 2013
In trying to execute a complex attempt to acquire assets from LightSquared Inc., Dish Network Corp.’s distaste for the independent committee that approved its bid could end up getting in its way. Read More »
A group of LightSquared’s lenders on Tuesday filed a plan to reorganize the wireless-satellite company based largely on Dish Network Corp. Chairman Charlie Ergen’s $2.2 billion bid for the company’s spectrum assets. Read More »
Content engaging our readers now, with additional prominence accorded if the story is rapidly gaining attention. Our WSJ algorithm comprises 30% page views, 20% Facebook, 20% Twitter, 20% email shares and 10% comments.

domain: economics


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Concept Development and Performance: Mihran Tomasyan – Saro Usta
Lighting Design for Stage: Cem Yılmazer
Lighting Design for Livestream: Yasin Gültepe
Lighting Technician: Yasin Gültepe
Sound Technician: Berkant ‘Doktor’ Kılıçkap
Livestream Directorial Support: Muhtar Pattabanoğlu, Melih Kıraç
Teaser: Muhtar Pattabanoğlu
Photo: Engin İriz
Poster Design: Alican Tezer
SAR is a performance by two friends who grew up together with the same culture in the neighbourhood of Kurtuluş in Istanbul. Wednesday, February 24, at 21:00 Turkish time, 19:00 Central European time SAR will be streamed “live from the stage” by Moda Sahnesi and will be your guest at home. Using music, movement and paper, they assemble and reassemble their memories and observations, forged by a feeling of common identity and tell a “mountain story” which we are not so unfamiliar with.
You chose your seedling, decided on a good place for it, prepared its soil, watered it for the first time, turned your back and walked away, days passed, perhaps weeks, the rains came, and then snow, winds blew, every now and then you came and checked, it had grown to your height, it had held up well, its roots could sink as deep as eternity, then came spring and then came summer, the sun rose, the moon set, Venus came up, you were already dead, who knows where your grandchildren woke up, some had departed, those who arrived had departed from other places, it didn’t work out, some things went wrong, the tree grew, there used to be one house in the distance, then there were three, then five, then five hundred, murders took place in its shade, and of course, some kissed, too, some never realized it stood there, and some gave it water.
Then they chopped it down.
And thank goodness for that because the pavement needed widening.
This performance was constructed upon a misunderstanding of the world, humanity, mountains, the earth and the sky. It has absolutely nothing to do with the tree mentioned above. The performance is interested in knowing where the grandchildren wake up.
Enjoy the performance, from wherever you are watching…

domain: artistic


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Did you know 19.5% of 19-24 year olds experience a mental health disorder? This is according to a report published by the RCSI in 2013.
It is so hard to believe that even in this day and age there is still so much stigma around mental health. With anxiety being one of the most common mental health disorders, it’s time to look at the facts of it.
According to Oxford Dictionaries, anxiety is a feeling of worry, nervousness, or unease about something with an uncertain outcome. Or a nervous disorder marked by excessive uneasiness and apprehension, typically with compulsive behaviour or panic attacks.
Everyone will suffer with anxiety at some point in their lives but 11% of young people between the ages of 19-24 experience an anxiety disorder at any given time. So for the purpose of anxiety disorders we will be working from the second definition.
Anxiety can often leave people feeling hopeless and fretting over something that is not exactly rational but to them it is the most rational thing in the world.
There are many types of anxiety disorders, Generalized Anxiety Disorder, Panic Disorder, Phobias, Post-Traumatic Stress Disorder and Obsessive-Compulsive Disorder to name just a few.
Each anxiety disorder has its own rage of symptoms, but many of the symptoms they have in common include;
- Unshakable feelings of dread/irrational fears
- Digestive discomfort/problems
- Difficulty breathing/hyperventilating
- Heart Palpitations
- Chills and hot flashes
Anxiety disorders can completely take over someone’s life and lead them to take panic attacks. A panic attack is, a sudden overwhelming feeling of acute and disabling anxiety and is often an experience which leaves a person feeling like they are going to die.
The best way to describe a panic attack, is this overwhelming feeling of panic, which may make you feel like you are burning up, you begin to find it hard to breathe and feel like you can’t catch your breath, this leads you to feel dizzy, which in turn makes you feel like you are going to pass out. Then comes the chest pains and the heart palpitations and you convince yourself you are going to die.
Yet people don’t seem to understand how this feels and affects a person when they have not experienced it themselves. A lot of people just do not understand, they don’t realise the damage they are doing when they say things like, ‘It is mind over matter’ or ‘You just need to relax’. Why would someone come to you about a problem with their mental health if you are going to demean them?
Another relatively shocking statistic is that 62% of people would not want others to know if they were suffering with their mental health. With so much judgement still surrounding the concept of mental health, can you honestly say you wouldn’t mind if everyone knew you were suffering with yours? This stigma needs to be addressed and by educating people on mental health issues you are helping to fight this battle.
If you or someone you know suffers from an anxiety disorder there is help and treatment available. Some of the treatments available include;
- Medication: Tablets used to reduce the symptoms of anxiety disorders include anti-depressants and anxiety-reducing tablets.
- Counselling: This is a process in which trained mental health professionals help people by talking through strategies for understanding and dealing with your anxiety disorder.
Changing things like your diet and lifestyle can help, by doing things like eliminating or reducing your intake of coffee and exercising. Exercise helps as it gives you an outlet for stress and worry and by doing things like meditation and yoga you are learning to relax.
One thing I wish to ask of all of you is to never judge someone because of something like their mental health. You don’t know what it is like to walk in their shoes. If a friend or family member is suffering from an anxiety disorder or any kind of mental health issue be there for them.
Don’t make them feel like there is nothing wrong with them or that they are attention seeking and say something stupid like: “It is mind over matter.” You are not helping and they will not thank you for it.
If you are effected by anxiety, here are just some of the organisations which you can go to for support:
Alternatively, check out some of the many free support services offered by your college services and welfare officer on your college website.

domain: medical


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In most cases, individuals who serve as public officials are government employees. Therefore, the government entity is responsible for withholding and paying Federal income tax, social security and Medicare taxes. They must also issue a Form W-2, Wage and Tax Statement, to a public official.
Do politicians get taxed?
FACT: This information is completely false. Members of Congress pay income taxes just like every other American. The U.S. tax code states that everyone who receives revenue must pay an income tax, including Representatives and Senators.
Do governments pay taxes?
We pay taxes because the federal, state, and municipal governments enact tax laws. That tax revenue pays for a variety of government services. The federal government collects about the same as the state and local governments combined.
Who is exempt from paying taxes?
If you’re over the age of 65, single and have a gross income of $14,050 or less, you don’t have to pay taxes. Or if you’re married and filing jointly, and you and your spouse are over 65, you can earn up to $27,400 before paying taxes [source: IRS].
Do federal employees pay federal taxes?
As mentioned above, federal workers pay taxes. Under the Federal Employee Retirement System (FERS), all federal employees hired in 1984 or later pay Social Security and Medicare Taxes, including all public officials.
How much do federal politicians get paid?
Introduction. Senators and members receive an annual allowance by way of basic salary—$211,250 from 1 July 2019.
How much do politicians get paid?
|Executive, Legislative, and Judicial Officers||114/1|
|Speaker of the House…………………………||$223,500|
|House Majority & Minority Leaders…………||$193,400|
|House/Senate Members & Delegates………..||$174,000|
What are the 5 major sources of revenue for the government?
Sources of Government Revenue: 9 Sources | Economics
- Source # 1. Tax: …
- Source # 2. Rates: …
- Source # 3. Fees: …
- Source # 4. Licence fee: …
- Source # 5. Surplus of the public sector units: …
- Source # 6. Fine and penalties: …
- Source # 7. Gifts and grants: …
- Source # 8. Printing of paper money:
How much money does the government have 2020?
In 2020, the federal government spent $6.55 trillion.
How does government make money?
How does the government get money? … Most government money comes from: Collecting taxes, or revenue, from people and businesses. Borrowing it by selling Treasury securities (savings bonds, notes, and Treasury bills)
How can I legally not pay taxes?
- Qualify For Tax Credits. …
- Take Itemized Deductions. …
- Enroll In College. …
- Drunken Driver Turns DUI Into Tax Deduction. …
- Cats Can Be Worth Big Money. …
- Exotic Dancer’s Breast Implants Pay For Themselves. …
- Even Drug Dealers Get Tax Deductions. …
- Bribes Can Be a Business Write-Off.
How much money can you make without paying taxes?
The minimum income amount depends on your filing status and age. In 2020, for example, the minimum for single filing status if under age 65 is $12,400. If your income is below that threshold, you generally do not need to file a federal tax return.
Do the rich not pay taxes?
A report from ProPublica illustrated how wealthy people in the U.S. are able to avoid income taxes by keeping the bulk of their wealth in investments that have little or no taxes.
What is a 59 minute rule in federal government?
Generally, outside of command instructions there is no specific rule or regulation regarding supervisor’s authority to allow 59 minutes early departure from work without charging it as leave or loss of pay. However, it is a common practice, and the basis is derived from several different documents.
How much do federal employees pay for healthcare?
Your federal agency will cover the majority of the health care costs, usually between 70 and 75 percent. A flexible spending account allows you to put aside some of your pre-tax salary to pay for common out-of-pocket expenses.
Do federal employees get a pension and Social Security?
In 1984, the federal government introduced a second retirement system, known as the Federal Employees Retirement System, or FERS. … Employment under the FERS system is covered by Social Security, so that when you retire you will receive both a federal pension and a Social Security benefit.


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This week’s conviction of Sinaloa Cartel kingpin Joaquin ‘El Chapo’ Guzman heralds a major victory in raising awareness of the pure evil involved in Mexican drug smuggling through our porous borders. But it also reveals something about disgraced former FBI Director James Comey . . .
From "El Chapo" sexually abusing 13-year-old girls as “vitamins” to boost his libido to employing a hitman who used a tiled “kill room” made inside a house in border-city Juarez, the trial demonstrated the obvious dangers of sharing an open border with a country burdened by near-complete lawlessness.
In El Chapo’s trial, a witness alleged that the corruption of Mexican government officials reached up to the President of Mexico at the time, Enrique Pina Nieto, who allegedly received $100 million in bribes from the cartel.
Left out of El Chapo’s trial was the cartel’s financial connections to key law enforcement players inside the Obama administration.
In 2012, the Justice Department accused the El Chapo-led Sinaloa Cartel of moving over $7 billion through HSBC bank locations inside Mexico. The bank’s Mexican locations allowed huge cash deposits (sometimes hundreds of thousands of dollars in a single transaction), which were then accessible to the cartel at HSBC bank locations inside the United States.
Despite playing a key role in establishing the cartels inside the US, the DOJ gave HSBC a slap on the wrist–a deferred prosecution agreement–under which the bank would not be prosecuted for laundering billions of dollars in cash for the Sinaloa Cartel, as long as the bank rehabilitated its practices and stayed out of trouble for five years.
Overruling career prosecutors– who wanted to prosecute the bank–US Attorney Loretta Lynch and Attorney General Eric Holder let the bank off the hook with a $1.9 billion “record fine,” which made up a small fraction of one year’s profits.
It is unknown whether then-FBI Director Robert Mueller aggressively investigated the executives and employees involved. Given the lack of convictions, and his failure to speak out against the agreement, it’s unlikely that Mueller engaged in any pre-dawn raids or SWAT-style arrests.
Ironically, Jerome Corsi, one of Mueller’s current perjury-trap targets, was one of the journalists who exposed the HSBC scandal in 2012. Now, as many of you know, Corsi is under Indictment by . . . Special Counsel Robert Mueller . . .
A month after the deferred prosecution agreement was finalized, future FBI Director James Comey took a 97% pay cut from his job as general counsel at Bridgewater Associates hedge fund to join Britain-based HSBC as director of the money laundering vulnerabilities sector. The move reduced his jaw-dropping income from $6,632,616 per year to under $200,000, per financial disclosures.
With former Deputy Attorney General Comey at the helm of the troubled bank’s money laundering compliance efforts, HSBC could reassure its investors that the troubles in 2012 were over. However, Comey apparently missed the Russian money laundering that was taking place while he oversaw the vulnerabilities sector.
Less than six months after Comey took the HSBC job, President Obama nominated him to replace Robert Mueller as FBI Director. In 2014, Obama nominated Loretta Lynch to replace Eric Holder as Attorney General.
See how all of that worked? All the same players in top US Law Enforcement, shuffled around to make certain that the gigantic cash from the Sinaloa Drug Cartel, was all dealt with by the exact same people . . . . WHY? To keep a lid on who ELSE was getting massive bribes????
HSBC clients donated $81 million to the Clinton Foundation. Gee. What a coincidence.


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After significant collaborative work among many stakeholders in the spinal muscular atrophy (SMA) community, we are pleased to share that the Secretary of Health and Human Services (HHS), Dr. Alex Azar, has accepted the recommendation to add SMA to the Recommended Uniform Screening Panel (RUSP) for newborns. This is a landmark decision for the SMA . . .
MDA has announced the award of 13 new grants totaling $2.6 million as part of its continued commitment to finding treatments and cures for the diseases in its program. Each of the 13 new grants funds a project that aims to increase our understanding of the causes or underlying mechanisms of neuromuscular disease or potential . . .
The Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC), a federal committee that oversees newborn screening, voted today to add spinal muscular atrophy (SMA) to the national list of disorders recommended for screening at birth. Following today’s vote, the Secretary of Health and Human Services (HHS) will make a final decision on whether . . .
PTC Therapeutics reported today the U.S. Food and Drug Administration’s Office of Drug Evaluation is unable to approve the company’s New Drug Application for ataluren (brand name Translarna) for the treatment of Duchenne muscular dystrophy (DMD) caused by a premature stop codon, or nonsense mutation, in its current form.
“It truly feels as if my entire career path has been leading me to this role,” said Vos. “I am excited to bring my passion for patient care and advocacy, as well as my success using new technology to build new, innovative communication approaches, to lead MDA in the fast-changing world of research and patient care.”
After the news of MDA champion Jerry Lewis’s passing broke Sunday, scores of admirers took to social media to remember the comedian and philanthropist. Here are just a few of the thousands of tweets sent by some of the entertainment business’ brightest stars — and some of MDA’s staunchest partners. Want to add your remembrance to the chorus? Visit our Tributes page, where we are collecting memories for Jerry’s family.


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I love this game, its simplicity and playability make it loads of fun, better than #2 (as many have already said). The only thing i find odd is the fact that when i jump on other players, it takes quite a few seconds for the jump to take effect and make them smaller and whatnot. I really don't know why. Also, when other players seemingly fly to the end of the level, before it has even begun lol, are these people cheating in some way or is my computer just mucking up. Anyway, this is an awesome game. (By the way, im Shiny (: )
The ball kept getting stuck off the screen! SO annoying! Although if you fixed a few things like that, i could see this being pretty good. Also, you should stop people from just picking up the ball and holding somewhere and "de-structing" stuff. Ruins the game. And get some music! I don't care what! I hate games that leave you in silence!
Finally! A multiplayer game that is easy to pick up play, slightly difficult to master, and great to waste 10 minutes! Good job!
A nice step up from the last one, although some of the nights lasted AGES, but i just couldn't stop playing! By the way, i missed the deadline by like 1 day ):
newgrounds.com — Your #1 online entertainment & artist community! All your base are belong to us.

domain: game


4GUNE is the Basque Cluster for University Training in Engineering, Science and Technology.
It is led and promoted by the Basque Government’s Department of Education and embraces 11 Centres from the Basque University System, the Basque Industry 4.0 Steering Group, the Basque Innovation Agency – Innobasque, the Basque Business Confederation – Confebask and their partners, Adegi, Cebek and SEA, SPRI and the Automotive Intelligence Center (AIC).
The presentation session will take place on February 3rd at IMH- Campus of Advanced and Digital Manufacturing
The results of the project "Identification of the future competencies needed by the industrial professionals to achieve the sustainability of European Industry 4.0" has been published in a high impact scientific journal.4Gune
The scientific journal Recycling has published the mentioned article, authored by the student Patricia del Val, along with the researchers Tugce Akyazi, Aitor Oyarbide and Aitor Goti.
In the 2021/2022 academic year, the University will continue to bring Business closer by fostering practical collaboration through business challenges


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476 North Dakotans are reported to have died with the coronavirus. To put that number in perspective, that’s more than the population of a number of small cities across the state.
On Tuesday, nine deaths were reported in Ward County. Over the last seven months, there have been a total of 43 deaths in the county.
The executive officer from First District Health Unit says community spread has continued to bring COVID-19 inside the area’s long-term care facilities and she says it’s getting there through employees.
“So, it’s difficult when you have the amount of community spread that we do to keep them out of assisted-living facilities or any of the high-risk population,” said Lisa Clute, executive officer at FDHU.
Clute could not say provide specifics on where the spike in deaths came from.