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Peripheral neuropathy (PN) is a common complication occurring in HIV-infected patients. The estimated global prevalence of human immunodeficiency virus (HIV) infection was approximately 38.8 million in 2015. The estimated PN prevalence among this group is 19% to 42% worldwide[2–4] and it increases with age.[2,4,5] The HIV-associated PN (HIV-PN) predominantly affects sensory nerve fiber symmetrically. The main pathological features associated with HIV-PN are distal axonal degeneration, loss of neurons in the affected dorsal root ganglia, infiltration of inflammatory cells, and a decrease in epidermal nerve fiber density. The clinical symptoms vary from severe pain, hypoesthesia, and weakness to asymptomatic. These conditions contribute to impairment of patient's daily activity function, which significantly decreases the quality of life.
The social and economic burden of HIV-PN is huge. Therefore, early detection is important for prompt management to prevent complications. There are 2 main techniques used to detect PN: invasive (skin biopsy) and noninvasive (clinical screening/examination methods, nerve ultrasound, and electroneurographic examination).[6,7] Skin biopsy is an invasive method used to assess small nerve fiber condition by quantifying the epidermal nerve fiber density. This invasive method is considered a valuable diagnostic tool in various types of PN. However, this method is limited by special skill, tissue processing method, and optic equipment required to make a reliable result. Therefore, clinicians prefer to opt for noninvasive techniques for early detection of HIV-PN.
Some of the commonly used noninvasive techniques are skin vasoconstrictor reflex (SVCR), neuromuscular ultrasound, Sudoscan, nerve conduction study (NCS), and brief peripheral neuropathy screening (BPNS). In SVCR method, PN is detected by determining the reduction in blood flow using a Doppler device over the digit tip skin during an inspiratory gasp. The limitation of this technique is it requires a strict observation of a controlled standardized environment, inspiratory gasp practice and technique by the patients, and the availability of laser Doppler, which is often unavailable in many centers. Neuromuscular ultrasound is a noninvasive technique that uses a high-resolution ultrasonographic device to obtain the image of the nerves.[9,10] However, the weakness lies in its low-sensitivity, as past studies reported variations in the correlation between ultrasound findings and clinical findings.[9,10] Sudoscan, a simple and quick method based on electrochemical reaction between sweat chloride and stainless-steel electrodes or electrochemical skin conductance for detecting small fiber neuropathy, can also be applied to various neurology cases. Its reliability and reproducibility have been investigated in some cases such as diabetes and leprosy. However, this method is not widely available in Indonesia and still requires a specific software.[11–13] NCS is a well-known technique among clinical neurologist that uses an electroneurographic device to detect PN. Nonetheless, the sensitivity of NCS to detect small nerve fiber pathology is limited, while most early HIV-PN involves small nerve fibers. Furthermore, this method requires trained personnel and specialized equipment, which is not commonly available at provincial and district level hospitals. In these facilities, the frequently used method is BPNS. It is an affordable, fast, and easy test to screen HIV-PN, which is suitable for limited-resource settings. It uses a scoring system in assessing subjective and objective features of neuropathy to determine the likelihood of having PN in HIV patients. Yet, it is limited by low sensitivity (around 49%) to detect PN.
The other test method, stimulated skin wrinkling (SSW) to detect PN in HIV patient, which is yet not widely used, is the focus of this study. SSW refers to the reversible undulations of the surface skin occurring 5 to 30 minutes following water immersion or exposure to a eutectic mixture of local anesthetic (EMLA). Skin wrinkling occurs because of vasoconstriction in the glabrous skin, mediated by post-ganglionic sympathetic fibers.[16–18] EMLA affects the vasoconstriction by a passive diffusion to the digital pulp vasculature via the sweat glands. More recently, the use of SSW with EMLA (SSW-EMLA) has been reported in conditions with small fiber neuropathy. A study using SSW-EMLA for the detection of diabetic neuropathy found comparable sensitivity to other methods including NCS. Following receiver operating characteristic-analysis, at a cut-off point of <3 for an abnormal SSW-EMLA, sensitivity of SSW-EMLA for diagnosing diabetic neuropathy using NCS as a reference standard was 81.3%, and specificity was 67.0%.
As diabetic and HIV-PN has similar pathology, we hypothesized that this test can also be applied to HIV patients. Furthermore, the low cost and easy to use SSW-EMLA method might be useful for early detection of HIV-PN in resource-limited hospitals if it is shown to have a better performance for detecting early neuropathy. We explored SSW-EMLA test performance for the detection of HIV-PN compared with the current method of BPNS in HIV patients.
The study was conducted in the HIV/AIDS outpatient clinics at the Cipto Mangunkusumo Hospital, Jakarta between June 2014 and February 2015. HIV was confirmed by HIV-positive enzyme-linked immunosorbent assay (ELISA) test documented in patient's medical records. The study's ethical clearance was given by the Ethical Committee of the Cipto Mangunkusumo hospital No. 407/H2.F1/ETIK/2014.
2.1 Study participants
HIV-positive patients, aged between 18 and 60 years who provided written informed consent, were enrolled in the study. Among these patients, we set the exclusion criteria and conducted its screening through interviews and reviewed of the medical record. We excluded patients with a history of systematic illness that could cause neuropathy, history of repetitive activities using hands, congenital anomalies of the hands, fractures or other injuries to arm or hands, peripheral vascular diseases or responses such as Raynaud phenomenon, an open wound in the area where EMLA would be applied, and clinical symptoms of myelopathy or radiculopathy. We also excluded patients with other potential conditions that could cause PN such as anemia, diabetes, thyroid disease, renal disease/uremia, liver disease, and malignancies. Patients who had received chemotherapeutic drugs, statins, amiodarone, and/or tacrolimus for more than 7 days were also excluded from the study due to the same reason. Once eligibility was confirmed and the patients consented, they underwent physical, anthropometric [height, weight, and body mass index measurement (BMI)], and neurological examinations (visual acuity, cranial nerves functions, motor strength and tone, reflexes, and sensory functions). Their medical records were checked to obtain results of HIV status, complete blood count, CD4 count, and viral load. Antiretroviral drugs (ARV) history was obtained from the medication list found in the HIV/AIDS clinic database and treatment adherence was confirmed through interviews.
2.2 Test procedures
We conducted BPNS and SSW-EMLA test sequentially, first the BPNS followed by SSW-EMLA test. There was a 30-minute interval between these 2 tests.
The BPNS protocol was adapted from AIDS Clinical Trial Group (ACTG) protocol. There are 2 examination components for conducting this technique: subjective and objective. First, patients were examined for the subjective components. It included checking for any complaints of pain, aches, or burning sensation in their feet or legs, needle or nail piercing sensation in their feet or legs, or numbness sensation in their feet or legs. If the patient had no complaints, we asked if they ever experienced those symptoms before the outpatient visit when the test was conducted. If they answered yes, we asked them to rate the severity of each symptom from mild to severe, ranging from a scale of 01 to 10. If the patient never experienced any of those symptoms, we scored 11 (always normal). If the symptoms had been present in the past, but not since the last visit, we scored 00 (currently absent). Each hand was scored separately. The highest severity score was used to count the subjective sensory neuropathy scale. The subjective sensory neuropathy scale was as follows: scale 01 to 03 scored as grade 1; scale 04 to 06 was noted as grade 2; scale 07 to 10 noted as grade 3; and scale 11 and 00 scored as grade 0.
The subjective component was followed by 2 objective components: vibratory sensation test on the distal interphalangeal (DIP) joints of the big toe using 128 Hz tuning fork; and deep tendon reflexes of the Achilles tendons test on both ankles using a reflex hammer.
For the vibratory sensation test, we vibrated a 128 Hz tuning fork and compressed the ends of the tuning fork just hard enough that the sides touched. The vibrating tuning fork was then placed on the bony prominence of the patient's wrist or hand to be sure that he/she could recognize the vibration or “buzzing” quality of the tuning fork. Again, we compressed the ends of the tuning fork just hard enough that the sides touched and immediately place the vibrating tuning fork gently, but firmly on the top of the DIP joint of one big toe and counted the seconds. We instructed the patient to tell us when the “buzzing” stopped. The time was recorded using a digital clock. The score was as follows: score 0 means the patient felt the vibration for >10 seconds (normal); score 1 was given if the patient felt the vibration for 6 to 10 seconds (mild loss); score 2 if the patient felt the vibration for ≤5 seconds (moderate loss); score 3 was given when the patient did not feel the vibration at all (severe loss); score 8 was given when the test is not done. We repeated the test on the other foot.
The deep tendon reflexes were tested on the Achilles tendons on each ankle. With the patient seated, we used 1 hand to press upward on the ball of the foot, dorsiflexed the patient's ankle to 90°. Using a reflex hammer, we then struck the Achilles tendon. The tendon reflex was felt by our hand as a plantar flexion of the foot, appearing after a slight delay from the time the Achilles tendon was hit. We used reinforcement by having the patient clench his/her fist before classifying the reflex as absent. The ACTG score was as follows: 0 – no reflex; 1 – hypoactive; 2 – normal; 3 – hyperactive; 4 – with clonus; and 8 when the test was not conducted.
The score for each BPNS test was summed up and interpreted as positive or negative for PN using the criteria described above. The BPNS result was considered positive for neuropathy if we found positive subjective component with at least 1 positive objective components.
2.2.2 SSW-EMLA test
We used a modified method of SSW-EMLA test described by Ng et al. First, both hands of the patient were washed using soap and water and dried. The examiner observed the initial appearance of the fingers and photographed them before EMLA 5% cream (lidocaine 2.5% and prilocaine 2.5%; AstraZeneca; Cambridge, United Kingdom) application. A thick covering of EMLA 5% cream was applied to the distal segment of the 2nd, 3rd, and 4th fingers of both right and left hands. Each finger was wrapped in a food grade plastic wrap and sealed using skin bandage. After the application of EMLA cream, the patients were asked to wait for 30 minutes and to keep the hands dry and clean. The patients were not allowed to drink coffee, tea, or smoke cigarettes during the waiting period. If the EMLA application was compromised, the patient waited for an extra hour and the whole procedure was repeated.
When 30 minutes were up, the examiner opened the bandages and examined the skin for wrinkling. The finger-tip appearances were compared with a special scale (Fig. 1) and scored. Wrinkling grades for digits 2, 3, and 4 were counted and average obtained. A difference of ≥3 points per hand (i.e., ≥1 point per digit) was taken as a cut-off or a different score. The SSW-EMLA test was considered abnormal if the total wrinkling score of each hand was <9.
2.3 Statistical analysis
Data were entered and analyzed using SPSS version 22 statistical software package (SPSS Inc., Chicago, IL). Categorical variables were analyzed and expressed as percentages. The SSW-EMLA test was compared with BPNS for neuropathy detection using sensitivity, specificity, positive, and negative predictive values. Univariate analysis was done using these following independent variables: gender, age, education, BMI, duration of ARV, adherence to ARV, lowest CD4+ count, history of stavudine therapy, history of zidovudine therapy, on stavudine therapy, and on zidovudine therapy with neuropathy as the dependent variable. To assess the significance of the differences between groups, we used the Chi-square test or Fisher exact test (for nonparametric variables). A P value of .05 was considered the threshold for statistical significance.
In total, 99 HIV confirmed patients participated in the study. Nearly two-thirds of them were male; one-third were <30 years (33%), with the majority in the age of group between 30 and 40 years; and 84% had BMI > 18.6. Education level with greater than 9 years of schooling was high (97.0%). The majority of participants adhered to ARV treatment (87.9%) and 80.8% had a usage of ARV between 3 and 56 weeks. We also found 57.6% participants, CD4+ count was less than 100 cells/mm3, and 42.4% 101 and 500 cells/mm3.
3.1 Detection of neuropathy with SSW-EMLA test and BPNS
The PN was defined by abnormal results of SSW-EMLA test (Fig. 2A) and BPNS was 36.4% (36/99) and 15.2% (15/99) (P = .04), respectively. The accuracy of SSW-EMLA test to detect PN compared with BPNS was 66.7% (the ability to differentiate PN taking into account the true positive and true negatives) with a sensitivity of 60.0% and 67.9% specificity (Table 1). There were 27 abnormal cases by SSW-EMLA test that were undetected by BPNS, with a 9.5% false negativity of SSW-EMLA test.
3.2 Variables associated with SSW-EMLA test and BPNS
Among the different variables studied, education was marginally associated with an abnormal SSW-EMLA test compared with patients with normal SSW-EMLA test (Table 2). Gender, age group, BMI, ARV duration, adherence to ARV, lowest CD4+ count, history of stavudine therapy, history of zidovudine therapy, currently on stavudine, and currently on zidovudine were not associated with abnormal SSW-EMLA test (P > .05). When analyzed for BPNS, age group >40 years has an association with abnormal BPNS (P = .02). There was no association with other variables and abnormal BPNS.
The performance of SSW-EMLA test was evaluated as a potential alternative to BPNS screening method to detect PN in HIV patients. We found SSW-EMLA test detected nearly 2 cases of PN for every case detected by BPNS, 36.4% and 15%, respectively. SSW-EMLA test picked up 27 cases that were considered normal by BPNS. We analyzed this finding correlated with the more objective characteristic of SSW-EMLA test and the nature of SSW that involve the small nerve fiber.
The correlation between small fiber neuropathy and SSW has been studied by some investigators and reviewed by Wilder-Smith. Compared with other commonly used indicator of small fiber neuropathy, the sympathetic skin response (SSR), SSW showed far superior results. Furthermore, when SSW was compared with Neuropads (a simple sweat test) in picking up small fiber neuropathy, SSW showed better sensitivity but lower specificity. The biological plausibility with EMLA is that it examines the autonomic nervous system signal transmission mediated by small nerve fibers. In chronic peripheral neuropathies (length-dependent), small nerve fibers are affected earlier than the larger fibers. In HIV patient, damage to the small fiber occurs as a result of the intake of nonreverse transcriptase inhibitors (NRTIs) drugs and neurotoxic effect of HIV as a result of glycoprotein 120 involvement.
In our study, there was no association between gender and PN and is similar to previous studies.[23,24] Likewise, we did not find an association with SSW-EMLA test in detecting PN in our study, although other studies have shown the incidence of HIV PN was associated with increased age. This is likely related to the poor immunological status found in our patients as shown in lower CD4+ finding. Decreased CD4+ count correlates with worsening immunological status, which is associated with neuropathy in HIV patients. All patients with abnormal SSW-EMLA test in our study had a CD4+ count of fewer than 500 cells/mm3 and 50% of them had CD4+ <100 cells/mm3. We also found no association between CD4+ count and PN. This can be explained by the nature of the research method (cross-sectional study) where the data were collected only at one point in time.
Our study is one of the first to use SSW-EMLA test to detect PN in HIV patients, and therefore, we could not compare it with other studies in HIV patients using the same method. However, 2 previous studies showed a higher sensitivity of SSW-EMLA test in detecting PN. First, a study on diabetic patients showed comparable sensitivity to other methods for detecting PN. Diabetic neuropathy and HIV PN have similarities, as both are affected by length-dependent neuropathy with early disruption of the axon and tendency to affect the small fibers first. Second, another study in Indonesia compared SSW-EMLA test and Sudoscan to detect autonomic neuropathy in multibacillary leprosy patients. The results revealed that SSW-EMLA test had higher sensitivity in comparison to Sudoscan, 64.3% and 32.9%, respectively. Like these studies, our study in HIV patients indicated a higher sensitivity of SSW-EMLA test in detecting PN in comparison to BPNS.
Our interest was to find a practical screening test that could be used in resource-constraint health facilities. Such a test should have an acceptable balance of easy usage, low false negative, and high accuracy. The SSW-EMLA test demonstrated these qualities comparable to our reference test, BPNS. The high NPV suggested that SSW-EMLA test correctly identified a patient who did not have a neuropathy.
The cross-sectional design limited us to assess associations of variables that change over time. In addition, we were unable to use a more sensitive test such as NCS. However, several studies have already validated SSW-EMLA test and shown it to be a reliable method for screening PN in conditions similar to HIV neuropathy. Our study was not designed to validate the SSW-EMLA test technique and therefore was limited to the use of 1 observer.
Compared with the BPNS, the SSW-EMLA test detected more cases and the detection of PN by the SSW-EMLA test was comparable to previous reports of HIV neuropathy by other methods. These findings indicated that SSW-EMLA test is a more objective and practical method than BPNS. Therefore, the method has potential as an alternative test for screening for HIV neuropathy in resource-constraint setting. Additional prospective studies are needed with more sensitive comparison tests to confirm the benefit of SSW-EMLA test for HIV neuropathy detection.
We thank Rukhsana Ahmed and Ralalicia Limato for reviewing the statistical analysis made in this research.
Conceptualization: Arthur H.P. Mawuntu, Darma Imran.
Data curation: Arthur H.P. Mawuntu, Corry N. Mahama.
Formal analysis: Arthur H.P. Mawuntu, Herlyani Khosama.
Investigation: Arthur H.P. Mawuntu, Herlyani Khosama.
Methodology: Arthur H.P. Mawuntu, Riwanti Estiasari.
Project administration: Corry N. Mahama.
Resources: Riwanti Estiasari.
Software: Arthur H.P. Mawuntu.
Supervision: Riwanti Estiasari, Darma Imran.
Validation: Riwanti Estiasari, Darma Imran.
Visualization: Arthur H.P. Mawuntu.
Writing – original draft: Arthur H.P. Mawuntu.
Writing – review & editing: Corry N. Mahama, Herlyani Khosama, Riwanti Estiasari, Darma Imran.
. Wang H, Wolock TM, Carter A, et al. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: the Global Burden of Disease Study 2015. Lancet HIV 2016;3:e361–87.
. Schütz SG, Robinson-Papp J. HIV-related neuropathy: current perspectives. HIV/AIDS (Auckl) 2013;5:243–51.
. Simpson DMM, Kitch DP, Evans SRP, et al. HIV neuropathy natural history cohort study: assessment measures and risk factors. Neurology 2006;66:1679–87.
. Cherry CL, Affandi JS, Imran D, et al. Age and height predict neuropathy risk in patients with HIV prescribed stavudine. Neurology 2009;73:315–20.
. Wu K, Bosch RJ, Mcarthur JC, et al. Peripheral neuropathy in HIV: prevalence and risk factors. AIDS 2012;25:919–28.
. Woldeamanuel YW, Kamerman PR, Veliotes DGA, et al. Development, validation, and field-testing of an instrument for clinical assessment of HIV-associated neuropathy and neuropathic pain in resource-restricted and large population study settings. PLoS One 2016;11:e0164994.
. Myers MI, Peltier AC. Uses of skin biopsy for sensory and autonomic nerve assessment topical collection on nerve and muscle. Curr Neurol Neurosci Rep 2013;13:323.
. Wilder-Smith EP, Fook-Chong S, Liurong L. Reflex vasoconstrictor responses of the healthy human fingertip skin. Normal range, repeatability, and influencing factors. Microvasc Res 2005;69:101–5.
. Merola A, Rosso M, Romagnolo A, et al. Peripheral nerve ultrasonography in chronic inflammatory demyelinating polyradiculoneuropathy and multifocal motor neuropathy: correlations with clinical and neurophysiological data. Neurol Res Int 2016;2016:9478593.
. Padua L, Granata G, Sabatelli M, et al. Heterogeneity of root and nerve ultrasound pattern in CIDP patients. Clin Neurophysiol 2014;125:160–5.
. He T, Wang C, Zuo A, et al. Electrochemical skin conductance may be used to screen for diabetic cardiac autonomic neuropathy in a chinese population with diabetes. J Diabetes Res 2017;2017:8289740.
. Selvarajah D, Cash T, Davies J, et al. Sudoscan: a simple, rapid, and objective method with potential for screening for diabetic peripheral neuropathy. PLoS One 2015;10:1.
. Casellini CM, Parson HK, Richardson MS, et al. Sudoscan a noninvasive tool for detecting diabetic small fiber neuropathy and autonomic dysfunction. Diabetes Technol Ther 2013;15:948–53.
. Ellis RJ, Evans SR, Clifford DB, et al. Clinical validation of the NeuroScreen. J Neurovirol 2005;11:503–11.
. Wilder-Smith E, Chow A. Water immersion and EMLA cause similar digit skin wrinkling and vasoconstriction. Microvasc Res 2003;66:68–72.
. Wilder-Smith EP. Water immersion wrinkling: physiology and use as an indicator of sympathetic function. Clin Auton Res 2004;14:125–31.
. Wilder-Smith EP, Guo Y, Chow A. Stimulated skin wrinkling for predicting intraepidermal nerve fibre density. Clin Neurophysiol 2009;120:953–8.
. Wilder-Smith EP. Stimulated skin wrinkling as an indicator of limb sympathetic function. Clin Neurophysiol 2015;126:10–6.
. Teoh HL, Chow A, Wilder-Smith EP. Skin wrinkling for diagnosing small fibre neuropathy: comparison with epidermal nerve density and sympathetic skin response. J Neurol Neurosurg Psychiatry 2008;79:835–7.
. Ng KWP, Ong JJY, Nyein TDN, et al. EMLA-induced skin wrinkling for the detection of diabetic neuropathy. Front Neurol 2013;4:126.
. Kokotis P, Schmelz M, Skopelitis EE, et al. Differential sensitivity of thick and thin fibers to HIV and therapy-induced neuropathy. Auton Neurosci Basic Clin 2007;136:90–5.
. Sharma H, Dubey T, Raghuvanshi S, et al. HIV neuropathy in pre-HAART patients and it′s correlation with risk factors in Central India. Neurol India 2013;61:478–80.
. Bansal D, Gudala K, Muthyala H, et al. Prevalence and risk factors of development of peripheral diabetic neuropathy in type 2 diabetes mellitus in a tertiary care setting. J Diabetes Investig 2014;5:714–21.
. Verawati V, Estiasari R, Imran D. Sensitivity and specificity of Stimulated Skin Winkle examination against Sudoscan to detect autonomic neuropathy in multibacillary leprosy. Depok: Universitas Indonesia; 2015.
Keywords:Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
brief peripheral neuropathy screening; eutectic mixture of local anesthetic; HIV peripheral neuropathy; Indonesia.; stimulated skin wrinkling test

domain: health


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In times of war, there are always businesses that profit while the sons and, increasingly, daughters, of working people do the fighting and dying. Much the same applies in the case of trade wars, although in a less dramatic fashion.
The general definition of a trade war is based on the of fallacy that it arises because the free flow of trade between nation states and regions — claimed to be fair and beneficial to all — has been disrupted. So any country erecting financial barriers to imports — tariffs and other taxes — is said to be engaging in such a war.
But trade wars, at the level of constant skirmishing, are ongoing and have existed throughout modern history. The actions of US President Donald Trump in imposing tariffs on steel and aluminium and the reactions of China, Europe and other countries merely ratcheted up the tension.
In fact, the existence of competing cities, regions, nation states or, in this global economy, transnational corporations, means ongoing war. Because war is merely competition aimed at bettering the opposition.
And trade, for all the regulations and protestations of being free and fair, is neither. And, at times of cutthroat competition it is the workers who suffer. That, unfortunately, this is the reality.
So nation states that can afford it, subsidise their producers to enable them to export to other countries and so undercut domestic producers in the importing countries. There are plenty of examples in South Africa, ranging from the dumping of American and Brazilian poultry to biscuits from the Gulf states, Italian canned tomatoes and canned mealies (corn) from Thailand.
This is where the so-called free market — in fact an anarchic system that ensures increasing wealth going to a tiny minority — can be seen as part of what the labour movement terms the “race to the bottom” for working people; for those who have to sell their labour in order to survive.
I will explain by giving a simple example: major sportswear brands. They own no factories. They have small design facilities and they travel the world offering production contracts to whichever production facilities offer the lowest prices. Ever cheaper production costs are demanded and this means ever lower wages and worse conditions for workers. Or greater automation and mechanisation meaning greater joblessness.
Regulation also seldom works to really change anything. Might is all too often right. You can see that even with the International Criminal Court which the USA refuses to recognise. And international institutions such as the World Trade Organisation and the International Monetary Fund are part and parcel of the same system; they act in the interests of preserving the status quo.
Don’t forget that even “hot” wars have rules and regulation — the Geneva Convention and so on — that can simply be ignored. What is going on in Syria and Yemen are classic current examples.
So what can we, in South Africa do? Well, we could mount the moral high ground and — in line with a long time demand of the labour movement — trade only with those countries that observe at least the wages and working conditions that apply here. And we should block clearly subsidised dumping while, perhaps, giving greater support to local producers.
All of this would create jobs. And we should not forget that, nearly 20 years ago, a proposal was put forward by the Federation of Unions that all government infrastructure projects should be awarded only on a labour intensive basis.
These measures amount to moves away from the clearly dangerous and damaging economic dogma of neo-liberalism. But they would be steps in the right direction.
(First published in City Press, South Africa, November 18, 2018)

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The Scot's Pursuit
- Highland Swords, Book 3
- Narrated by: Paul Woodson
- Length: 7 hrs and 6 mins
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Alick Grant has never been the kind of man to do thing by halves. When he meets Branwen Denton, he’s instantly smitten - so much so that he asks for her hand in marriage.
But Branwen’s sire is a cruel man who delights in harming her, and he refuses the offer. Alick is determined to help her, and woo her...until someone kidnaps his mother.
Branwen’s life has been dark and lonely since her mother’s death. Alick Grant is a beacon of a brighter future. But her sire would never willingly allow her to be happy. He promises her to a much older man with six children, and with Alick distracted by his mother’s kidnapping and other dangers, he attempts to push her into the match.
Branwen must find and harness her inner strength in order to fight her father and secure her destiny. But can she and Alick hope to find happiness amidst such turmoil?
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- Sherry Tritt Holton
Alick is so intriguing. I really enjoyed his story. He is decisive and knows what he wants.
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Paul Woodson is one of my favorite narrators, he makes the characters breathe! His voice is so good, I can listen to him all day!
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The Scots Pursuit. Keira does it again. Paul Woodson is brilliant. I want more. ❤

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Barbiturates, often referred to as “downers”, are drugs that help a person sleep. These are sedative-hypnotics that decrease anxiety and produce sleep-inducing effects. Because they are sedatives, barbiturates can be incredibly dangerous, leading to coma or death. They are also highly addictive- just a small dose could cause someone to become addicted. Barbiturates were most commonly used in the 1970’s, and are not as heavily used now because they have been replaced with benzodiazepines, considered a safer group of sedative-hypnotics.
Barbiturates are addictive because they activate an inhibitory neurotransmitter in the brain called GABA. Increasing the activity of this chemical depresses the central nervous system leading the person to feel relaxed and sleepy. Barbiturates can be consumed via injection of the veins or muscles, but are most often taken in pill form. The effects of various barbiturates varies, as some last for a very short time and others last for up to 2 days after consumption. Some of the common barbiturates are: Luminal, Brevital, Seconal, Butisol, and Fiorinal. Many people who take these drugs take them to feel similar effects to that of alcohol. When taken, people often feel relaxed, happy, more talkative, and less inhibited.
Signs of intoxication are increased talkativeness, elation, impaired judgment, emotional fluctuations, sedation, slurred speech, lack of coordination, confusion, and more. There are many dangerous effects that barbiturate abuse and addiction can have on the body. Physical effects include changes in blood pressure, increased sensitivity to both pain and sound, breathing difficulties, increased risk of kidney failure, sexual dysfunction, and more. Mental health issues often consist of anxiety, restlessness, panic, emotional instability, insomnia, hallucinations, depression, and others. Overall, people who are addicted to this drug often lose interest in hobbies and responsibilities, have strained relationships, neglect self-care, and experience occupational issues or job loss.
Treatment for barbiturate addiction typically involves a form of detoxification, residential treatment, and aftercare. If you or a loved one is abusing or is addicted to barbiturates, please speak to a health care professional as soon as possible. A doctor can conduct a health assessment to determine your history, use of barbiturates, severity of addiction, and more. From there, they can recommend you to a treatment facility where you can receive round-the-clock support if needed. By seeking help, you can overcome your addiction and work through your key issues in a healthy manner. Psychotherapy is another great tool that you can use to begin working through your problems.
Recovery is yours when you start to do the work. At a treatment facility in the New Vista Behavioral Health family, you will be supported with staff and programming held to higher standards, providing exceptional care for better outcomes. Life is yours for living. Start making a change today by calling: 888-316-3665

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New Algebraic Edition
Written by a young Grand Master, this introduction to chess strategy is aimed primarily at players for whom a game plan is utterly enigmatic. By isolating the basic elements and illustrating them through a selection of Master and Grand Master games, Simple Chess breaks down the mystique of strategy into plain, easy-to-understand ideas.
Essentially, Soltis advocates a 1 c4, 2 g3 sequence against virtually any set-up by Black. The rare exception is the response 2?d5 after either 1?e6 or 1?c6, when 3 b3 is recommended, although even here, the King?s Bishop does end up fianchettoed, but just a few moves later.The book maintains the same basic coverage as the second edition. It is divided into four sections: I ? c4 e5; II ? c4 c5; III ? c4 Nf6; and IV - c4, others. There are two basic systems presented in the book: The set-up credited to Botvinnik, with the KB fianchettoed, the QN on c3, pawns on c4, d3 and e4, and the KN on e2; and a variation of this, with the pawn on e3, with the d?pawn retaining the option of going to either d3 or d4, depending on circumstances.
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Mastering the Bishop Pair
This DVD is part of Roman's Getting the Winning Edge in the Middle Game series. In this volume Roman will help you recognize, exploit and capitalize on your opponents weakness. He will also help you to be able to avoid these mistakes in your own games.
ROMAN'S LAB - VOLUME 54 - Capitalizing on Your Opponent's Weakness Created in the Game
This wonderfully entertaining book also happens to be quite effective. Everything any child will need to know about chess strategy and more is here in this book, which is well laid out and easy to follow. Part of the fun factor for kids is that the book is replete with cartoon images of chess characters to help make the learning experience more exciting.
Winning Chess Exercises for Kids
f you are a beginner chess player that is struggling to progress in your game, controlling the center might be your problem. This basic principle is frequently overlooked as beginner chess players find it easy to become caught in a trap of not knowing what to study, and in what order to study it in!
Mastering Control of the Center - EMPIRE CHESS
Chess Strategy is the most difficult step in the road to improvement for beginners, requiring a deeper understanding of chess than simply tactics. You can think of combinations as math equations with a given, concrete result that you can prove. But strategy is more like describing the variables in this math problem and how changes will affect all aspects of the surrounding environment.
Winning Chess Strategy for Beginners - EMPIRE CHESS
Understanding positional chess is one of the most difficult concepts for beginner chess players because there are no concrete rules that apply to any given position. There are general guidelines, such as avoid placing your pawns on the same color as your bishop, however there are always exceptions and every position is different.
Play Positional Chess Like a Grandmaster - EMPIRE CHESS
An Omnibus of Chess Strategy
With Weapons of Chess, National Master and highly acclaimed teacher Bruce Pandolfini brings us the most accessible and easy-to-use chess strategy book ever.
Weapons of Chess
Comprehensive Chess Course - VOLUME 5
Chess Strategy for the Tournament Player is the fifth volume in Grandmaster Lev Alburt's Comprehensive Chess Course series. Endorsed by world champion Gary Kasparov as revealing "the once-secret Russian method of chess training," this new edition has material on the 2006 Absolute World Championship match between Kramnick and Topalov.
Chess Strategy for the Tournament Player
A supplement to the Chess player's handbook, containing all the most important modern improvements in the openings, illustrated by actual games; a revised code of chess laws; and a collection of Mr. Morphy's matches, &c., in England and France.
21st Century Edition
This book is Grandmaster Aron Nimzowitsch's companion volume to MY SYSTEM. This classic is one of the best selling and most instructive chess books of all time. Thousands of satisfied customers have used this book to improve their understanding of positional chess play.
In this valuable and entertaining book, Angus Dunnington arms the reader with all the necessary skills to be able to cope with vicious assaults on his or her king. Using illustrative games, Dunnington investigates in depth defensive ideas such as blockading, giving up material and the timely launch of counterattacks. Read this book and defend with confidence!
Starting Out - Defensive Play
"The foundation upon which any position is built is the board itself, that apparently simple space of sixty-four squares arranged in alternate light and dark colors..." That is how John Love introduces the sparkling world of positional play in chess.
Positional Ideas In Chess
One of the great theoretical works in chess, shows principles of action above and beyond moves. Acclaimed by Capablanca, Keres, etc.
33 Inspiration and Instructive Masterpieces
All chess-players love to play a smooth attacking game, flowing from start to finish, and sprinkled with spectacular ideas and sacrifices. However, few can do so regularly, and for most players, their collection of brilliancies missed far outweighs their creative successes. Innate talent plays an important role, but many of the skills needed for attacking chess can be learned by study and practice. Here, one of the world's most experienced annotators has selected 33 superb examples, and explained them in a way that strips away the mystery.
The Art of Attacking Chess
An Inspiring Guide for the Modern Attacker
Simon Williams, one of Britain's most dynamic and aggressive chess-players, has selected his favourite attacking games from the modern era, and annotated them with an infectious zeal that will inspire and instruct. He takes us inside the decision-making process, explaining how each stage in an attacking concept is formed, and shows how top players spot the signs that indicate it is time to stake everything on an all-out assault. We also get insights into the role of intuition and calculation in both attack and defence
How to Crush Your Chess Opponents
250 Puzzle Positions to Train Your King-Hunting Skills
Checkmating the enemy king is the ultimate goal in chess. In this book Simon Williams helps readers to practice and improve their skills in this vital area of practical chess. A mating attack typically involves a build-up of forces, followed by an opening of lines, often involving a sacrifice
Improve Your Attacking Chess
62 Masterpieces of Chess Strategy
Sixty-two masterly demonstrations of the basic strategies of winning at chess, featuring games by the greatest chess masters Capablanca, Tarrasch, Fischer, Alekhine, Lasker, Petrosian among them compiled and annotated by one of chess literature's most brilliant authors.
The Most Instructive Games of Chess Ever Played
495 Instructive Positions from Grandmaster Games
This complete guide, written by a grandmaster, can assist all players at every level in developing a more powerful strategic game. Spanning more than a century of chess, it presents examples on such themes as key squares, bad bishops, and pawn structures in ascending difficulty, with ample cross-references.
Positional Chess Handbook
The sequel to H.O.T. Chess. Grandmaster Motwani continues to explain his easy-to-use approach to chess thinking, and shows how Creative Original Opening Lines can bring astonishing over-the-board success. The many brilliant games in this book includes victories by Motwani over some of the world's leading players, whom he has outwitted in the early stages of the game.
The Road to Positional Advantage
In Chess Strategy for Club Players you will learn the basic elements of positional understanding, including pawn structures, piece placement, lead in development, open files, weaknesses, space advantage and king safety. You will master the art of converting a temporary plus into other, more permanent advantages. The author also explains what to do when, in a given position, the basic principles seem to point in different directions.
Chess Strategy for Club Players
How to Use Your Pawns to Fight for the Initiative and Central Control
This book tackles fundamental questions such as: 'How should pawns be used to fight for the centre?' and 'How does the central pawn formation affect planning for both sides?' These issues are central to understanding chess. Marovic discusses central pawn-structures and their impact on play both in the centre and on the wings.
Dynamic Pawn Play in Chess
This is a new edition of a classic work and will introduce a new generation of readers to the wonders of chess problems. The readers will find many of the best chess problems ever composed, chosen and investigated by John Rice, an International Master. The readers will find stories behind famous ideas.
Secrets from Scotland to Unlock Your Highly Original Thinking
The H.O.T. stands for Highly Original Thinking. The author's ideas extend beyond the situation on the board. He maximizes your strengths and exploits your opponent's weaknesses.
An Instructive and Entertaining Trip Through the Heritage of Chess
An algebraic expanded revision of Euwe's 1968 edition examining the contributions of great players throughout history. Nunn brings you up-to-date over the last 30 years with the eras of Fischer, Karpov, and Kasparov. They assess the contributions of each great players in the way chess is played and approached.
The Development of Chess Style
An Essential Guide to Pawn Structures
Study of this important book, with dozens of highly instructive and clearly explained games from the greats of chess, will enhance your middlegame skills and will let you understand why pawns are considered to be 'the souls of chess'.
Winning Chess Middlegames
Most chess books aim to guide and instruct by offering principles, rules, schemes and theories. Creative Chess, on the other hand, has a quite different and original approach. It firmly maintains that every chessplayer, whether amateur or master, is capable of creating something new in chess. After a discussion of the characteristics and processes of creativity, 10 central concepts, such as unusual positioning and functioning of pieces, alertness to subtle differences, absurd moves, and flexibility, are presented with a wealth of truly amazing examples to encourage the reader to broaden the horizons of his chess thinking.
75% Off Books (Shown in Cart)
The art of strategic planning is not easily acquired from most teaching materials, yet it is one of the most important aspects of practical play. In this book, positional factors have been approached, with examples showing how a certain specific weakness can be exploited by specific means. This book includes complete games where the strategic and positional factors are seen in the complex interplay of the middle game and end game.
Chess Strategy for Advanced Students
It is not always possible to win a game of chess by obtaining an advantage and then logically converting it into a win. In the games of average players the result is often in doubt until the last blunder and the more resourceful player will usually triumph.
Saving Lost Positions
Practical Lessons of a Junior World Champion
Mastering Positional Chess is a serious, but entertaining chess instruction book. Daniel started writing it when he realized that his lack of positional understanding was causing him to lose many games.
Mastering Positional Chess
Expanded and Updated
In the battle of chess ideas, the publication in 1991 of Dynamic Chess Strategy was a defining moment. Before Mihai Suba's exceptional book, chess writers had neglected one of the most important factors of a chess position: its dynamic potential. Suba demonstrated that the traditional concept of improving the position was often static and irrelevant, and that classical strategy, if applied dogmatically, can prevent you from finding the right plan and its subsequent moves.
Dynamic Chess Strategy
What Amateurs can Learn from Ulf Andersson's Positional Masterpieces
One of the most effective ways to improve your chess is to take a world class-player as your example. By collecting his games, studying his choices and examining his style, you will understand what made him rise to the very top. This is what Guido Kern and Jurgen Kaufeld have done with Swedish chess legend Ulf Andersson, a positional genius with a crystal-clear style, who rose to the number 4 spot of the FIDE world rankings.
Grandmaster Chess Strategy

domain: library


text:
This study is a product of research on aging in place in the rural2 Midwest. Here we take the perspective of social demography to investigate long-term trends of aging in rural Kansas. Using county level historical statistics and in-depth analysis of the 2000 Census, we put these trends into the context of aging in the United States, and present a statistical analysis of aging and economic development. The data for this study come from various sources at the U.S. Census Bureau and the Economic Research Service (E.R.S.) division of the U.S.D.A. We also address the community development challenges posed by aging in place. This latter subject will be presented as an overview since our current research activity is conducting case studies addressing community development issues in greater depth.
Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.
Kulcsár, László J. and Bolender, Ben
"Home on the Range: Aging in Place in Rural Kansas,"
Online Journal of Rural Research & Policy:
1. This research was supported by the Fall 2005 Kansas State University Small Research Grant program. We'd like to acknowledge the help of the Kansas Population Center in hosting this research project.
2. It has to be noted that there are two parallel urban-rural classification systems in the US. The Census Bureau uses a place-based system, differentiating between urban and rural places. The Office of Management and Budget uses a county-based system, differentiating between metropolitan and non-metropolitan counties. This latter scheme is used by most researchers, however in many publications researchers use the term “rural” as a synonym for non-metropolitan. In this study, the terms rural and non-metropolitan are used interchangeably.
3. The U.S. Census Bureau considers the following states to be part of the West North Central Division: South Dakota, North Dakota, Nebraska, Missouri, Minnesota, Kansas, and Iowa.
4. Peter Laslett, "Necessary Knowledge: Age and Aging in the Societies of the Past" Pages 4-79 In: Aging in the Past: Demography, Society and Old Age by D. Kertzner and P. Laslett (eds.). Berkeley: University of California Press, 1995.
5. Glenn Fuguitt, David L. Brown, and Calvin Beale, Rural and Small Town America. (New York: Russell Sage Foundation, 1989).
6. Kenneth Johnson and Calvin Beale, "Nonmetro Recreation Counties. Their Identification and Rapid Growth" Rural America 17 (2002):12-19.
7. Nina Glasgow and David L. Brown “Social Integration Among Older In-Migrants in Nonmetropolitan Retirement Destination Counties: Establishing New Ties.” Pages 177-196 In: Population Change and Rural Society by William Kandel and David L. Brown (eds.). Dordrecht: Springer, 2005.
8. Richard Rathge, and Paula Highman, "Population Change in the Great Plains. A History of Prolonged Decline." Rural Development Perspectives 13 (1996).
9. Lisa Hetzel and Anetta Smith, "The 65 Years and Over Population: 2000". Census 2000 Brief, Washington DC: US Census Bureau, 2001.
10. Donald Adamchak, Len Bloomquist, Kent Bausman and Rashida Qureshi, "Retail/Wholesale Trade Employment Directly Related to Population Change in the Nonmetro Great Plains." Rural Development Perspectives 13 (1998): 46-51.
11. K. S. Markides, D. M. Timbers and J.S. Osberg, "Aging and health: A longitudinal study. Archives of Gerontology and Geriatrics 3 (1984): 33-49.
12. Donald Cowgill, "Aging and Modernization: A Revision of the Theory" Pages 123-146 In: Late Life: Communities and Environmental Policy by J. Gubrium (ed.). Springfield: Charles Thomas, 1979.
13. Nina Glasgow, "Older Rural Families" Pages 86-96 In: Challenges for Rural America in the Twenty-First Century by David L. Brown and Louis E. Swanson (eds.). The Pennsylvania State University Press, University Park, 2003.
14. W. Leutz, R Abrahams and J. Capitman, "Administration of eligibility for community long-term care" The Gerontologist 33 (1993): 92-104.
15. J. H. Schulz, The economics of aging. (Westport: Auburn House, 2001).
16. S. E. Rix, "The labor market for older workers." Generations 26 (2002): 25-30.
17. J. A. Kutpers and V. L. Bengston, "Social breakdown and competence: A model of normal aging" Human Development 16 (1973): 181-201.
18. Glasgow, 2003, Ibid.
19. R. T. Coward, "Aging in the rural United States." Pages 161-178 In: North American elders: United States and Canadian perspectives by E. Rathborne-McCuan and B. Havens (eds.). New York: Greenwood, 1988.
20. Kenneth Johnson and Richard Lathge, “Agricultural dependence and changing population in the Great Plains.” Pages 197-218 In Population Change and Rural Society, by William A. Kandel and David L. Brown (eds.). Dodrecht: Springer, 2006.
21. See Calvin L. Beale, The revival of population growth in nonmetropolitan America (Washington DC: U.S. Department of Agriculture, Economic Research Service, 1975).
22. In this table, the rural and urban terms refer to the Census Bureau definition.
23. By 2006, due to changes in the classification system, the number of metropolitan counties increased to 17.
24. This is only one aspect of this complex change. Employment in the meat processing industry is increasingly based on minority labor, mostly Hispanics (see William Kandel and Emilio Parrado. “Restructuring of the US Meat-processing Industry and New Hispanic Migrant Destinations.” Population and Development Review 31 (2005): 447-471.). This has important implications in community development in these places.

domain: geography


text:
Fog, then a sunny afternoon, in store for Central Texas Sunday
Central Texans off to an early start Sunday morning may see some fog along and east of Interstate 35, but it should clear by this afternoon, the National Weather Service said.
The fog could reduce visibility to as low as one mile (during a dense fog advisory, visibility is one-quarter mile or less). Forecasters reminded drivers to use low beam headlights and keep extra distance from the next car ahead.
Later today, temperatures could climb as high as the low 90s. This evening, expect partly cloudy skies and a less than 20 percent chance of rain.
The forecast for Monday looks much the same. The morning should be cloudy, but temperatures may be as high as 90 degrees during the mostly sunny afternoon.


text: Funduscopy is one of the most commonly used diagnostic tools in the ophthalmic practice, allowing for a ready assessment of pathological changes in the retinal vasculature and the outer retina. This non-invasive technique has so far been rarely used in animal model for ophthalmic diseases, albeit its potential as a screening assay in genetic screens. The zebrafish (Danio rerio) is well suited for such genetic screens for ocular alterations. Therefore we developed funduscopy in adult zebrafish and employed it as a screening tool to find alterations in the anterior segment and the fundus of the eye of genetically modified adult animals.A stereomicroscope with coaxial reflected light illumination was used to obtain fundus color images of the zebrafish. In order to find lens and retinal alterations, a pilot screen of 299 families of the F3 generation of ENU-treated adult zebrafish was carried out.Images of the fundus of the eye and the anterior segment can be rapidly obtained and be used to identify alterations in genetically modified animals. A number of putative mutants with cataracts, defects in the cornea, eye pigmentation, ocular vessels and retina were identified. This easily implemented method can also be used to obtain fundus images from rodent retinas.In summary, we present funduscopy as a valuable tool to analyse ocular abnormalities in adult zebrafish and other small animal models. A proof of principle screen identified a number of putative mutants, making funduscopy based screens in zebrafish feasible.

domain: biology


text:
So from the outset, ON benchmarked the taste and mixibility against the best protein powders on the market. ... Optimum Nutrition Platinum Hydro Whey Review (Chocolate & Vanilla) By ZB126 in forum Product Reviews - Help Out! Replies: 10 Last Post: 10-09-2009, 05:15 PM. 3.9 out of 5 stars 2,576 ratings | 68 answered questions 10 Days Returnable Currently unavailable. Hydro whey is the most effective protein on the market and produced by the optimum nutrition, it's the highest in quality for mixing and packed with 30grams of protein 15.5grams of essential amino acids and also 8.8grams of bcaa's, will never use anything else as I get the results with fast recovery. Replies: 29 Last Post: 06-04-2012, 08:53 AM. Isolates are the purest form of whey protein with no excess fat, cholesterol, or lactose. Platinum Hydrowhey is the fastest, purest, most advanced whey protein Optimum's ever developed. Optimum Nutrition Platinum HydroWhey 3.5 / Velocity Vanilla - LE 1,600.00 3.5 / Turbo Chocolate - LE 1,600.00 Optimum Nutrition, Platinum Hydro Whey, Velocity Vanilla, 3.5 lbs (1.59 kg) - 2.09 Pound (950 g),Vanilla Shake The only way to reap the results of Platinum Hydrowhey is to drink it. Optimum Nutrition (ON) Platinum Hydro Whey Protein Isolate - 1.75 lbs, 795 g (Velocity Vanilla) by OPTIMUM NUTRITION. Regardless of whether you choose Turbo Chocolate or Velocity Vanilla, Platinum Hydrowhey® tastes as great as it works and dissolves easily in water, milk, or juice. By History in Effect in forum Product Reviews - Help Out! So from the outset, ON benchmarked the taste and mixibility against the best protein powders on the market. We don't know when or if this item will be back in stock. Regardless of whether you choose Turbo Chocolate or Velocity Vanilla, Platinum Hydrowhey tastes as great as it works and dissolves easily in water, milk, or juice. The only way to reap the results of Platinum Hydrowhey® is to drink it. Optimum Nutrition Platinum Whey - Velocity Vanilla So I got a free sample from my last BB.com order and it was some platinum hydro whey Mixability: 10 ... HIE on Optimum Nutrition Platinum Hydro Whey:Velocity Vanilla. Platinum Hydrowhey contains a single-source protein composed entirely of hydrolysed whey protein isolates. Optimum Nutrition Platinum Hydrowhey Home / Protein Powder / Whey Protein / Hydrolysates / Optimum Nutrition Platinum Hydrowhey. Bookmarks. Hydro Whey - Velocity Vanilla I mixed the 1/2 serving sample with 8oz of coffee. Optimum Nutrition Plat.
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Pluribus learned the nuances of Texas Hold ‘Em by playing trillions of hands against itself. After each hand was done, it would evaluate each decision, determining whether a different choice would have produced a better result.
Mr. Brown called this process “counterfactual regret minimization,” and compared it to the way humans learn the game. “One player will ask another, What would you have done if I had raised here instead of called?”
Unlike systems that can master three-dimensional video games like Dota and StarCraft — systems that need weeks or even months to train to play against humans — Pluribus trained for only about eight days on a fairly ordinary computer at a cost of about $150. The hard part was creating the detailed algorithm that analyzed the results of each decision. “We’re not using much computing power,” Mr. Brown said. “We can cope with hidden information in a very particular way.”
In the end, Pluribus learned to apply complex strategies, including bluffing and random behavior, in real time. Then, when playing against human opponents, it would refine these strategies by looking ahead to possible outcomes, as a chess player might. This spring, the researchers tested the system in games in which a single human professional played against five separate instances of Pluribus.
In that format, Mr. Elias was unimpressed. “You could find holes in the way it played,” he said; among other bad habits, Pluribus tended to bluff too often. But after taking suggestions from him and other players, the researchers modified and retrained the system. In subsequent games against top professionals, Mr. Elias said, the system seemed to have reached superhuman levels.
The system did not play for real money. But if the chips had been valued at a dollar apiece, Pluribus would have won about $1,000 an hour against its elite opponents. “At this point, you couldn’t find any holes,” Mr. Elias said.
All the matches were played online, so the system was not deciphering the emotions or physical “tells” of its human opponents. The success of Pluribus showed that poker can be boiled down to nothing but math, Mr. Elias said: “Pure numbers and percentages. It is solving the game itself.”


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Looking to save a little cash? Here’s a suggestion you won’t hear every day: Move to Hawaii.
The state with a notoriously high cost of living unexpectedly offers you the best deal on property taxes, according to a recent analysis from WalletHub.
As part of the analysis, WalletHub ranked every U.S. state and the District of Columbia by their real-estate property tax rates, which the website based on the median real-estate tax payment and median home price for each state.
The 10 states with the lowest real-estate property tax burdens are:
- Hawaii: 0.27 percent effective real-estate tax rate
- Alabama: 0.42 percent
- Louisiana: 0.52 percent
- Colorado: 0.55 percent
- District of Columbia: 0.55 percent
- Delaware: 0.56 percent
- South Carolina: 0.57 percent
- West Virginia: 0.59 percent
- Wyoming: 0.61 percent
- Arkansas: 0.63 percent
The state with the highest rate is New Jersey (2.44 percent), followed by Illinois (2.31 percent) and New Hampshire (2.20 percent).
As WalletHub points out, property taxes actually impact us all, homeowners and renters alike:
“We all pay property taxes, whether directly or indirectly, as they impact the rent we pay as well as the finances of state and local governments.”
How to trim your property tax bill
Nobody likes paying property taxes, but being told to pony up for more than is justified is even worse.
Sometimes, a homeowner can have the sneaking suspicion that taxing authorities have appraised a property value beyond the home’s true worth. If you appeal this verdict, you can get your local board of assessment to change its mind and lower your tax costs.
Sound impossible? Not according to Money Talks News founder Stacy Johnson, who has successfully appealed his property taxes in two states. To learn about a two-step appeal process that might save you a bundle, check out “Ask Stacy: How Can I Fight My Property Taxes?”
If property taxes are crushing you and you are of a certain age, you might be able to put off the day of reckoning. For more, check out “12 States Where Older Homeowners Can Defer Property Taxes.”
How do you feel about your state’s property taxes? Sound off in comments below or on our Facebook page.

domain: law


text:
Heartburn causes a mild to severe burning sensation in your throat or your chest. Additional minerals and vitamins such as vitamin D may contribute to treating. Since heartburn is not usually an emergency medical situation, it can be easily.
Mar 14, 2012. When taken inappropriately, these meds can trigger a lot of health. My regular doctor then said gastroesophageal reflux disease (GERD) was causing my. a multivitamin and a calcium supplement with vitamin D. Two days.
However, it can also cause heartburn. The oil – not the fish – appears to be responsible for gastrointestinal side effects. Fish itself is low in fat and high in protein.
next year you will be talking about vitamin c toxicity, then a year after that it will be vitamin e toxicity, do you see a pattern here? Matt, your early books on bizarre eating behaviors already explain vitamin a,c,d,e and k disruptions.
Many people have a passing case of indigestion from time to time. But when it occurs frequently, it could be indicative of a more serious condition called gastroesophageal reflux disease, or GERD.
World Gastroenterology Organisation Global Guidelines. GERD Global Perspective on Gastroesophageal Reflux Disease. Update October 2015. Review team
Sep 18, 2017. Find how Vitamin D can help in providing relief from GERD. spilling acidic contents of the stomach into the esophagus causing heartburn.
This is the final article of a four part series on acid reflux and GERD. Read the first article on the underlying cause, the second article on the myths of H. pylori and low stomach acid being the major causes and the third article on the main stream medical treatments.
You can get symptoms of indigestion from taking ANYTHING- even water or a. And by the way, you say that you heard on this site that Vitamin D can cause.
Jun 7, 2018. The danger of untreated GERD is that it can cause health problems. of calcium and vitamin D that also will help prevent GERD symptoms.
Indigestion Lightheadedness Upset stomach, or indigestion, is usually no cause for concern. It is often possible to treat the symptoms using home remedies. In this article, we look at 21 of the
But not all IBS is the same. There are four types: (2) IBS-D may involve loose stool, an urgent need to go to the toilet, cramps, and stomach pain. IBS-C may cause an inability to move the bowels.
Jul 9, 2017. 47 yrs old Female asked about Vitamin d deficiency & acid reflux, Coold their be a common cause?. I can understand your concern well.
Sep 30, 2015. While doctors can't say for sure that a lack of Vitamin D causes these. She claims it can lead to acid reflux, poor stomach emptying, bloating.
Kotyczka C, Boettler U, Lang R, et al. Dark roast coffee is more effective than light roast coffee in reducing body weight, and in restoring red blood cell vitamin E and glutathione concentrations in.
Diabetes Medications Do NOT Protect You Print this article: Standard medical therapy for type 2 diabetes won’t protect you from heart disease, stroke, amputations, blindness, or anything else.
It's too early to say whether too little vitamin D causes high blood pressure — or whether vitamin D supplements may have any role in the treatment of high blood.
Angina (angina pectoris) describes the pain, discomfort, ache, or other associated symptoms that occur when blood flow to heart muscle cells is not enough to meet its energy needs.
Best Treatment for Achieving Remission of Inflammatory Bowel Diseases. Absolute Truth Exposed – Volume 1 is a book that covers eight topics that are vitally important to everyone.
Feb 26, 2017. Vitamin D is very important for your health, but it is possible to get too. Although only extremely large doses can cause toxicity so rapidly, even.
Aug 6, 2018. In my experience, yes. GERD is caused when the lower esophageal sphincter tone is low enough to allow the stomach contents to come back up the esophagus.
Gerd Wuttke Guido Ulrich Buchwald (born 24 January 1961) is a German former professional football player, Throughout his career he played as a defender. He is currently director of football of Stuttgarter
Millions of Americans can’t digest a certain sugar in milk and milk products called lactose. If you’re one of them, you have lactose intolerance.
Dec 19, 2015. Find out which supplements can cause or worsen acid reflux, nausea and GERD, including vitamin B6, arginine, and CoQ10. ConsumerLab's.
Apr 20, 2015. Q: I've been taking an over-the-counter med (Prilosec) for heartburn every day for. day to control the production of heartburn-causing stomach acid, believing they. And there can be toxicity from too much vitamin D-2 or D-3.
Sep 7, 2011. Dr. Cannell discusses vitamin D and acid reflux with a reader. I am happy to report that I am off meds and can enjoy foods I had not been able.
According to a scientific study which measured the effect of dietary changes on GERD, the following foods should help with acid reflux: whole grains, beans, vegetables (except onions, and tomatoes), lean fish, lean chicken, and more.
Q: After breakfast I take a multivitamin, and about a half hour later I get heartburn. If I forget to take my pill, I feel fine. Is it possible my vitamin is the problem? Will.
Taking large doses of vitamins may cause harmful side effects. For example, large doses of vitamin A can lead to nausea, headaches, or joint pain. Your body.


text:
Imagine a news organization that provides you with information about the elections and candidates running for office, without telling you what to think or how to vote. It may be hard to imagine, especially in light of recent polls showing fewer Americans than ever trust information provided by the news media. Enter FloridaWins.org, a non-partisan news and information service designed to help employers communicate with employees about the upcoming elections and the candidates running for office.
Recognizing Floridians are fed up with partisan politics, FloridaWins.org set out on a mission in 2014 to provide only one thing: the facts. FloridaWins.org does not endorse candidates and does not promote one party over another – it simply provides the facts to Floridians and lets each person decide where they stand.
In 2016, FloridaWins.org has stepped up its efforts to educate Floridians about the issues and elections. In addition to regular articles and animated videos covering the issues, the website staff interviewed candidates running for election to the Florida House and Senate and asked them questions about jobs, healthcare and education. The result? More than 100 candidates have a video posted on FloridaWins.org that allows voters to compare their answers to the questions, side-by-side.
More than 20 regional chambers of commerce have partnered with FloridaWins.org to help the business community engage its employees in non-partisan voter education efforts. Although many business leaders have responded, more are needed. To help make elections easier for your employees and their friends and family members, contact Greg Blosé at email@example.com or call 850-521-1243 to get your free copy of the FloridaWins.org voter engagement toolkit. The toolkit will provide you with the dates, messaging and other tools you need to help educate your employees about the upcoming election.
When your employees are educated and involved, Florida Wins.

domain: politics


text:
- Border Collie
- 1 years 8 months
All our unwanted and abandoned pets want is a warm home with a loving family. If you’re looking for a new pet, why not consider rehoming from us?Please rehome Rocco 2
By sponsoring a pet like me, you’ll be helping my friends to find loving homes. Why not give a gift that will change a life?Sponsor a pet
Hi, my name is Rocco 2 and I am a 3 year old male American Bull Dog.
I am a great big softy and I love to spend time with people having fun playing and going out on nice walks to explore!
I could potentially live with another social doggy friend as long as we are able to meet and make friends at the centre first.
I could also potentially live with children who have had experience around big boys like me and would also really like it if we can meet and make fiends at the centre first.
If you feel that I would be a good match for you, please complete an online application form for me today and I will look forward to meeting you.
Lots of love Rocco xx
Read the pet’s profile to make sure that they are suitable for your circumstances.
We want to be fair to everyone who applies for a pet so applications are dealt with in the order that we receive them.
Please be patient while we process your application. If you are successful we will contact you to go through next steps.
I'd like to say I have a lot to give to my new owner and that I think I deserve a warm and loving home. Can you help me out? I think Blue Cross would be much appreciative!

domain: pet


text:
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Is this south central Colorado or the Sahara? It’s not always easy to tell at this unique park where the continent’s tallest sand dunes join the rugged Sangre de Cristo mountains.
Wander, sled or sand-ski among the dunes, or, even better, backpack out to camp in the sand.
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