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Kidney Artery Stenosis

Kidney Artery Stenosis Specialists
Your renal arteries carry oxygen and nutrient-rich blood from your heart to your kidneys. When one or more of those arteries become narrow or blocked, your kidneys don’t receive enough blood or oxygen to function properly. This renal vascular condition, called renal artery stenosis, can injure kidney tissue and increase blood pressure throughout your body. At Northeast Ohio Vascular Associates (NEOVA) in Willoughby, Ohio, Dr. David L. Rollins, Dr. Vikram K. Rao, and their team of clinicians offer comprehensive care for patients affected by kidney artery stenosis. They serve residents from communities in the Cleveland area.

Kidney Artery Stenosis Q& A

Northeast Ohio Vascular Associates

What causes renal artery stenosis?

The two main causes of renal artery stenosis, also known as kidney artery blockage, are:

Normal arteries are smooth and unobstructed inside. As you age, your arteries can become blocked by the buildup of plaque, a sticky substance made up of fat, cholesterol, calcium, and fibrous tissue. This process, which is known as atherosclerosis or hardening of the arteries, causes your arteries to narrow and stiffen. Atherosclerosis in one or more of your renal arteries can eventually reduce blood flow to your kidneys. This is the most common cause of kidney artery blockages.

Fibromuscular dysplasia
This less common condition causes artery walls to grow abnormally. In the renal artery, this can mean having several narrow sections of the artery in between wider sections, making it appear somewhat like beads on a string. Fibromuscular dysplasia, which affects women more often than men, can drastically impede blood flow to the kidneys.

Are there any symptoms?

Most people with kidney artery stenosis don’t experience any signs or symptoms of the condition until it reaches an advanced state. Signs that you may have an arterial blockage in your kidney include the sudden onset of high blood pressure, or high blood pressure that develops before the age of 30, or after the age of 55. Symptoms associated with advanced renal artery stenosis include:

  • High blood pressure that’s hard to treat
  • High protein levels in your urine or other signs of poor kidney function: Such as fluid overload or swelling in your body’s tissues
  • Declining kidney function during treatment for high blood pressure
  • Heart failure that doesn’t respond to treatment

Experiencing kidney discomfort (pain in your flanks) or blood in your urine may mean you have an aneurysm in your renal artery or inflammation of the arteries, also known as vasculitis.

What does renal artery treatment involve?

To keep high blood pressure under control, lifestyle modifications such as weight loss, increased physical activity, specific dietary changes, and smoking cessation can help. If your blood pressure is uncontrollable or your kidney function has progressively worsened, you may require an interventional procedure to restore blood flow. Procedures used to treat kidney artery stenosis include:

Angioplasty and stenting
During this procedure, the NEOVA team uses a small, inflatable balloon to place a stent, which allows the narrowed renal artery to open up to normal size.

Renal artery bypass surgery
This procedure requires placing a bridge or graft between the aorta and the blocked kidney artery to make a new route for the blood to reach the kidney. It’s rarely performed today because almost all blockages can be treated with balloons and stents.

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iPhone GSX Report, Apple iPhone IMEI Network Check, Policy Check
Apple iPhone GSX Network & Policy Check

Apple iPhone GSX Network & Policy Check

Obtain useful information about your Apple iPhone status including the current network status, policy ID and much more.

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This iPhone GSX report will provide an in-depth report of useful information about your iPhone. You’ll gain insights into the policy ID, unbrick status, unlock status, current network, serial number and much more.

Our Apple GSX Network & Policy Check is ideal if you need to find out whether your iPhone is locked and which network it is locked to. You may have recently bought a used iPhone and need to find out which network it is locked to.

Delivery times for our Apple GSX service is 1 – 2 days. Just click the buy now button and add your IMEI at the checkout.

Learn More About Netpal™ and the Services we Operate.

NetPal™ is a small, family run business that delivers a range of phone network solutions to customers and businesses around the world. As an internet based business that primarily delivers digital solutions we are firm believers is providing 1st class customer service.

Why was Netpal™ formed?

Netpal™ was set up by Mark Griffin after having a bad experience trying to unlock an iPhone, Mark went from unlock website to unlock website looking for a trusted supplier. After choosing a company Mark realised that the price he initially paid was not the final price & he had to pay more to finish the unlock.

On realising it was a scam Mark went to another website who assured him they would get him unlocked. This again turned out to be a scam. After doing some investigation it became clear that the unlock industry was rife with scam software and websites that just don't deliver.

What network services do Netpal™ provide?

As well as mobile phone unlocking Netpal™ provide a range of customer and business orientated mobile network solutions. Netpal™ is a provider of network solutions that cover all aspects mobile phone usage. Our network services cover:

  • Network checks
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In addition to a wide range of digitally delivered services Netpal™ also offer the latest SIM interposer chips for people looking for a low cost method of unlocking their iPhone.

The R-Sim range of SIM interposers are a cheaper alternative to IMEI factory unlocking are are generally suitable for customers who are visiting foreign countries for short periods.

Example report from our iPhone GSX check.

This report will contain the following information:

  • IMEI: 352017063311573
  • Serial Number: F18MH2KXFFGC
  • Initial Activation Policy ID: 270
  • Activation Policy Description: UK Vodafone
  • Applied Activation Policy ID: 270
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  • Bluetooth MAC Address:
  • First Unbrick Date: 06/13/14
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  • Unbricked: true
  • Unlocked: false
  • Unlock Date:

The NetPal™ Money Back Guarantee.

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Sometimes your unlock may fail. For example, if you pay for an unlock service that only has an 80% chance of successful completion your unlock may fail. In that instance we will provide you with a full refund.

We will also refund you if we tell you that you're unlocked but the unlock isn't working. Generally, if this happens we will conduct a GSX check or unlock code check which can take up to 48 hours to complete.

If the results of the check show you are not unlocked, we will provide you with a full refund or offer to re-submit your IMEI to an alternative unlock server.

Where we might charge you.

Sometimes a blocked or barred imei number is submitted that doesn’t get picked up by our Checkmend check. Additionally you may choose the wrong network or phone model. If for any reason your unlock fails because the IMEI number is blocked or barred or you've purchased the wrong unlock for your phone model or network we may charge you a fee of £4.50.

This is to cover the expense of administering and processing your failed unlock. Please ensure your IMEI is not from a phone reported stolen or possibly barred.

Where we cannot offer you a refund.

It's important you understand that we do not unlock your phone ourselves. All unlocks are processed by a global unlock server. We have to pay to enter your IMEI into the global unlock server and only make a few pounds for each customer we find.

It's because of this we cannot offer you a refund before your IMEI is fully processed by the unlock server. If your unlock fails we automatically refund you.

Additionally, you may believe you are not unlocked when our GSX check indicates that you are. This may be due to you not following the final steps to complete your unlock. If this happens we will provide full support until the issue is resolved.

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Choosing the Right Web Server Security Software

An accurate and automated web server security software is vital to the security of your web applications, because the web server itself also needs to be secured down.

Get a Demo

It seems like data breaches are always in the news. Websites, web applications, and also the web server and operating system they are hosted on are at constant risk of online attacks. So it's important to implement precautions to enhance the website and web server security. Malicious hackers are an increasing risk to the safety of business and users' sensitive information such as cardholder data, which includes financial and personal information.

To ensure web server security it is important to do more than just install the latest updates to address vulnerabilities and security flaws in the Microsoft Windows, Linux and Unix operating system. Also, web server security goes beyond simply deploying SSL/TLS and focus on web applications. You also need to focus on the security of your Microsoft IIS (Internet Information Services), Nginx, Apache HTTP server, and other similar software and network services running on your operating system to have a secure web server.

Web server administrators should follow web security best practices and test for misconfigurations on a regular basis. They should scan the Linux web server or Microsoft Windows server software to ensure the latest security patches are installed, file and directory permissions are correctly configured, server logs are safely stored and access to the web server (typically via SSH) and other server software is controlled via dedicated administrator accounts.

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text:
Obstetrics and Gynecology

Gestational Diabetes Mellitus

Gestational Diabetes Mellitus

1. What every clinician should know

Clinical features and incidence

Gestational diabetes mellitus (GDM) is carbohydrate intolerance, less severe than overt diabetes, diagnosed during the second half of pregnancy. During pregnancy, all women develop relative insulin resistance. This is most likely related to placental hormones. Most pregnant women increase their insulin production and maintain euglycemia in the face of insulin resistance. Those who cannot adequately increase insulin production, many of whose pregnancy-related insulin resistance is superimposed upon pre-existing insulin resistance and/or a beta cell defect, develop hyperglycemia which is diagnosed as gestational diabetes.

Such individuals are at increased risk for developing diabetes later in life; approximately 50% will have type 2 diabetes within 20 years of the index pregnancy.

Risk factors

  • Overweight or obesity.

  • Family history of type 2 diabetes.

  • Racial/ethnic group with a high prevalence of diabetes.

  • Previous pregnancy with gestational diabetes.

  • Previous large baby.

  • Previous stillbirth.

  • First degree relative with diabetes.

  • Polycystic ovary syndrome (PCOS) or other conditions of insulin resistance.

  • Hypertension.

2. Diagnosis and differential diagnosis

Establishing the diagnosis

The American College of Obstetricians and Gynecologists (ACOG) currently recommends a two-step process for screening and diagnosis, starting with a 50 gram,1-hour glucose challenge and progressing to a 100 gram, 3-hour glucose tolerance test if the challenge is positive (Table I).

Table I.

ACOG two-step process for screening and diagnosis of gestational diabetes

Both ACOG and the American Diabetes Association (ADA) recommend that at the first prenatal visit patients with risk factors be tested for undiagnosed type 2 diabetes. Standard diagnostic criteria are utilized.

The ADA further recommends that pregnant women not known to have diabetes be tested for GDM at 24-28 weeks, preferably using a 75 gram, 2-hour oral glucose tolerance test (Table II) or by the two-step process recommended by ACOG.

Table II.

IADPSG recommendations for diagnosis of GDM on a 75 gram, 2-hour oral glucose tolerance test (OGTT)

The World Health Organization (WHO), the International Diabetes Federation (IDF), and the International Federation of Gynecology and Obstetrics (FIGO) recommend the one-step process (Table II) as well as testing for type 2 diabetes at the first prenatal visit for patients with risk factors.

Rationale for the new diagnostic criteria

The new criteria above, endorsed by ADA, the WHO and FIGO, were developed by the International Association of Diabetic Pregnancy Study Groups (IADPSG) with the goal of putting forth diagnostic criteria that would be accepted throughout the world.

  1. They are evidence-based, derived from data of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study, which demonstrated a significant, continuous direct relationship between each of the three OGTT values and each of four primary adverse outcomes as well as a number of secondary adverse outcomes.

  2. They use a 75 gram, 2-hour oral glucose tolerance test; this is standard throughout the world for nonpregnant individuals and should decrease confusion on the part of laboratories and caregivers.

  3. Having the same diagnostic criteria throughout the world will make comparisons among populations and outcomes possible.

The proposed criteria will identify an increased proportion of most populations as having gestational diabetes, likely in the range of 16-18% of pregnant women. If adopted, this will signal a major change in obstetric practice, and will require redesign of approaches to counseling, dietary prescription and management paradigms. It is somewhat reassuring that in two randomized trials of diagnosis and management of mild gestational diabetes, only 20% and 8% required treatment beyond dietary instructions.

Nevertheless, identification and management of mild gestational diabetes significantly reduced several important adverse outcomes in these pregnancies, including pre-eclampsia and macrosomia, without increasing the caesarean section rate compared to undiagnosed and untreated control patients with similar degrees of GDM.

We are in the midst of an epidemic of obesity and type 2 diabetes. As of 2015, 12.2% of adult Americans have diabetes (https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf) and another 34% have prediabetes meaning that nearly half of adult Americans currently have either diabetes or prediabetes. In light of these statistics, diagnosing gestational diabetes in 16-18% of pregnant women does not seem so surprising.

The IADPSG recommendations are currently being considered by professional groups and government agencies around the world. The NIH held a consensus conference in March 2013 to discuss the evidence for and against adopting these new criteria. The recommendation of the panel was to continue using the two-step process, with the 100 gram 3-hour OGTT until more definitive data become available regarding the benefits of diagnosing and treating an increased number of cases of GDM with the IADPSG criteria. The WHO and FIGO have recommended the use of the IADPSG recommendations.

Currently the American Diabetes Association recommends the one-step approach, but has endorsed either the one step (IADPSG) or two step approach, while ACOG continues to recommend the two-step approach.

3. Management

Maintenance of optimal circulating glucose levels

Recommendations for the management of gestational diabetes include prescription of medical nutrition therapy, determination of goals and appropriate timing of self-glucose monitoring, indications for initiation of pharmacologic treatment (either insulin or oral agents) and management of maternal glucose levels in labor.

Goals for glycemic control

Current recommendations from ACOG and ADA are that glucose levels be maintained below the targets in Table III. While these target levels have recently been challenged based on normative data from nondiabetic pregnant women suggesting that lower targets may be more appropriate, data from future randomized trials are needed to determine whether the use of such lower targets will improve outcomes.

Table III.

Current ACOG and ADA recommended targets

Self-glucose monitoring

Women with gestational diabetes are instructed on daily self-monitoring of blood glucose. Widely available reflectance meters and spring loaded devices for puncturing the skin of the finger or forearm have made obtaining capillary blood samples easy and measurement of glucose concentrations convenient at any time of day.

At one time these meters were quite variable as to whether the results were comparable to plasma or to whole blood glucose testing. Now most meters are designed to provide results from whole blood testing that are pre-converted to equivalent plasma glucose values. However, it should be kept in mind that capillary blood glucose values are somewhat higher than venous plasma values, especially after meals, since they include a mixture of arterial and venous blood.

While the use of reflectance meters is appropriate for metabolic management of patients with gestational diabetes, they are generally neither accurate nor precise enough for diagnostic testing.

Newer technology for continuous glucose measurement is not currently necessary for patients with gestational diabetes.

While many endocrinologists recommend only preprandial glucose testing in patients with diabetes who are not pregnant, there is Level 1 evidence that postprandial glucose testing in pregnant women with gestational diabetes improves fetal outcomes compared to preprandial testing.

While daily testing is commonly recommended, one randomized trial has demonstrated that women with milder gestational diabetes may be able to test less frequently. Once good metabolic control has been demonstrated on medical nutrition therapy, it should be possible to decrease testing frequency to every other day without an adverse effect on pregnancy outcome. It is expected that when the newer, lower diagnostic thresholds are in common use, more studies will be carried out to determine the safety and efficacy of such alternative, less costly, approaches to management.

It is not clear whether 1-hour or 2-hour post meal glucose testing is more effective for improving outcomes; comparative studies have yielded equivocal results. Either approach is acceptable.

Insulin treatment

Insulin is a large, highly charged molecule that usually does not cross the placenta. Antibody bound insulin has been demonstrated to cross the placenta in some studies, but high titers of insulin antibodies are no longer encountered with any frequency since recombinant human insulin has replaced beef and pork insulin for many years. Women with gestational diabetes who have not been previously exposed to exogenous insulin would also be highly unlikely to manifest insulin antibodies. Insulin appears to be safe and effective for managing gestational diabetes and has stood the test of time.

A number of different insulin preparations, with varying absorption, onset and duration of action are available. The human insulin preparations differ primarily by the vehicle in which they are suspended in terms of how they enhance or delay absorption from subcutaneous injection sites. The human insulin analogs differ generally by a single amino acid substitution. Table IV lists the different widely available insulins.

Table IV.

Widely available insulins

We generally initiate insulin treatment when at least one third of glucose values at a given time of day exceed goals over a week's interval. Various insulin regimens are used for treatment of gestational diabetes. Total doses will vary depending upon factors such as the patient's BMI and gestational age. One approach that we have found helpful, particularly in women whose BMI is below 30, or in more obese women with mild degrees of hyperglycemia, is outlined below:

  • When only postprandial values are elevated an arbitrary starting dose of 30 units before breakfast is divided into 20 units of an intermediate acting insulin such as NPH and 10 units of a short acting insulin such as lispro or aspart. These doses can then be increased as needed, depending upon the time of blood sugar elevations.

  • When post-dinner glucose is elevated, short acting insulin can be prescribed before dinner.

  • When only fasting glucose values are elevated intermediate acting insulin such as NPH can be prescribed either at bed time or before dinner.

  • When fasting and post dinner values are elevated the intermediate acting insulin can be combined with short acting insulin before dinner.

  • When elevated glucose values are encountered after this approach has been initiated, the appropriate component of the insulin regimen can be increased by 10-20%.

A weight-based insulin approach is especially useful in obese patients with GDM, particularly when glucose values are unequivocally elevated:

  • At the usual starting time of 26-36 weeks, multiply the current weight, in kg, by 0.9 units/kg to calculate the total daily dose.

  • Divide the dose as follows:

    • Morning dose (2/3 of the total daily dose) is twice the evening dose (1/3 of the total daily dose).

    • Morning dose is in the proportion of 2:1 (intermediate acting to short acting insulins).

    • Pre-dinner dose is in the proportion of 1:1 (intermediate acting to short acting insulins)

    • Individual components are then varied depending upon the blood glucose levels at the specific times of day.

Example: A 100 kg woman with GDM would start with a total daily dose of 90 units of insulin. She would take 60 units before breakfast and 30 units before dinner. Her morning dose would be 40 units of NPH insulin and 20 units of insulin lispro or insulin aspart. Her pre-dinner dose would be 14 units NPH and 14 units lispro or aspart.

When initiating this regimen, individual components may be omitted if hyperglycemia has not been occurring at the given time. For example, a 100-kg woman with GDM whose fasting and post-breakfast values are the only ones that are elevated may be started on 30 units of short acting insulin before breakfast and 14 units of NPH insulin before dinner or at bed time.

As needed, insulin dose is increased by 10-20%.

Remember that these formulas are only for calculating a starting dose of insulin. Once insulin therapy has been initiated, individual components are varied in response to glucose elevations at particular times of day.

An approach that we have found not to be helpful in most cases of GDM is the use of the sliding scale. This paradigm involves varying the insulin dose each day depending upon the patient's circulating glucose level. The problem is that insulin is best given in anticipation of its need, rather than after the fact. Since even rapid acting insulin takes time to act, responding retrospectively to elevated glucose levels may introduce more variability than would a more consistent regimen.

Thus, we respond to today's glucose values tomorrow - if today's post breakfast glucose is above target (and there is no obvious non-recurrent reason such as a dietary indiscretion), we anticipate that the patient's insulin need has risen, and increase tomorrow's pre-breakfast short acting insulin dose. The exception would be markedly elevated glucose levels, such as those exceeding 200 mg/dl, when we would sometimes recommend an extra dose of short acting insulin to bring the value down quickly. This situation rarely arises in patients with GDM; it is more often encountered with pre-existing diabetes.

The use of oral antidiabetic agents for GDM

Insulin has been the traditional "drug of choice" when treatment beyond diet is needed. However, insulin has a number of disadvantages:

  1. Insulin must be given as an injection.

  2. Multiple injections throughout the day are often necessary.

  3. Insulin can cause hypoglycemia.

Because of our patients' natural disinclination to inject themselves, much attention has been focused on the use of oral agents.

Glyburide: an insulin secretagogue

Glyburide, a sulfonylurea, binds to sulfonylurea receptors in pancreatic beta cells, stimulating insulin production and release regardless of the blood sugar level. It is only effective in patients with residual beta cell function, and therefore is not appropriate for the treatment of type 1 diabetes. The resultant insulin release lowers hepatic glucose production and enhances post meal insulin levels. Hypoglycemia is a potential side effect.

In a randomized trial glyburide (up to 20 mg/day) was compared to insulin for patients with gestational diabetes whose circulating glucose values were high enough to merit intervention. Outcomes, including macrosomia, neonatal hypoglycemia and reductions in hemoglobin A1c, were similar in the two groups, and only 5% of glyburide treated subjects required insulin. Glyburide was not detected in cord blood samples from exposed pregnancies. Ensuing case series' reported failure to achieve desired blood glucose levels in up to 20% of glyburide treated gravidas.

A subsequent study from the NICHD Obstetric-Fetal Pharmacology Research Units Network found that cord blood glyburide levels were 70% of simultaneously measured maternal levels. Although the absolute levels were low in both compartments, it appears that glyburide can cross to the fetus in significant amounts. A second study confirmed this finding in 2013.

In a systematic review and meta-analysis of RCTs comparing glyburide with insulin treatment of GDM, glyburide use was associated with a higher likelihood of macrosomia and neonatal hypoglycaemia than insulin. While no specific adverse effects on the fetus have been demonstrated when glyburide is used during pregnancy, the possibility remains of long term effects, particularly given the data regarding in utero programming of metabolism by various ambient exposures. When glyburide is prescribed for pregnant women, it is important to document that patients have been counseled regarding the lack of long-term studies on the offspring.

When glyburide is prescribed for GDM the usual starting dose is 2.5 mg po prior to breakfast or 2.5 mg po bid before breakfast and before dinner. The dose can be increased by 2.5 mg, then by 5 mg increments with the usual maximum dose being 10 mg po bid. However, pharmacokinetic studies have suggested that plasma concentrations are lower after a given dose of glyburide during pregnancy than in non-pregnant individuals, suggesting that higher doses may be needed.

Changes in dosage recommendations await further clinical studies of safety and efficacy. Current recommendations are to switch to insulin when glucose goals are not achieved at a dose of 20 mg glyburide per day. It can be anticipated that the need for insulin will arise in 5-20% of GDMs treated with glyburide.

Metformin: an insulin sensitizer

Metformin, a biguanide, enhances insulin action, stimulating glucose uptake in the liver and periphery, and suppressing hepatic glucose output. It only works when insulin is present, and it does not stimulate insulin secretion and release or cause hypoglycemia. This drug is commonly used to treat polycystic ovary syndrome (PCOS) and other forms of insulin resistance.

In the MiG trial, a randomized prospective trial comparing the use of metformin and insulin among GDMs requiring treatment, pregnancy outcomes were similar between the two groups. Among subjects assigned to metformin, 46% required the addition of insulin because the maximum metformin dose was not sufficient to achieve glucose goals. Subjects randomized to metformin treatment were more likely to express a preference for the same treatment in future pregnancies than were those using insulin.

Metformin has been shown to cross the placenta. In one study, cord arterial metformin levels were approximately twice maternal venous levels at the time of delivery. In a 2-year follow up study to the MiG trial, there were no differences between offspring exposed to metformin in utero and those exposed to insulin, other than greater subcutaneous fat in the former. In a systematic review and meta-analysis of RCTs comparing metformin and insulin use for GDM, metformin was associated with a lower risk of pregnancy related hypertension and less maternal weight gain, but a higher risk of preterm birth. On average, insulin was required in addition to maximal doses of metformin to achieve metabolic control in 34% of treated GDMs. While no specific adverse (or beneficial) effects of exposure to metformin have been reported, long-term human studies have not been conducted and animal data are sparse, such that caution must still be recommended.

The possibility of fetal programming for adult disease, including obesity and metabolic syndrome, is currently under study, suggesting that transgenerational effects of agents that reach the fetus be subjected to investigation. In the meantime, when metformin is prescribed during pregnancy, counseling regarding unknown negative or positive long term effects on the offspring should be documented.

Obstetrical management

Obstetrical management includes antepartum fetal testing, as well as the timing and mode of delivery.

Antepartum testing

While ultrasound estimates of fetal weight have not been shown to be more accurate than clinical estimation, monthly sonography may be a useful approach to assaying diabetic fetopathy. There has been a series of randomized trials that compared the use of U/S measurement of abdominal circumference between 29 and 33 weeks to guide initiation of insulin therapy to glycemia based management.

In GDMs whose fasting plasma glucose levels started at less than 105 mg/dl, similar proportions (40% U/S based management group, 30% glycemia based management) required insulin, and pregnancy outcomes were similar between the two groups. In a pilot study the use of U/S allowed 38% of "severe" GDMs to avoid insulin while outcomes were comparable. The randomized trials suggest that U/S measurement of abdominal circumference may be a useful indicator of evolving diabetic fetopathy.

If detection of evolving fetal macrosomia can allow a significant proportion of GDM patients to avoid insulin, this approach may be applicable to the milder GDMs diagnosed by the IADPSG criteria and may decrease the need for frequent self-glucose monitoring in those whose AC is not above the 70th percentile. However, since macrosomia is not the only adverse effect of GDM we should not let down our guard just because EFW is not excessive, especially when maternal glucose control does not meet goals. Ultrasound estimation of fetal weight may also be useful in guiding decision making as to mode of delivery (see below).

There is no level 1 evidence to guide recommendations for antepartum testing in women with GDM. ACOG notes: "There is no consensus regarding antepartum fetal testing among women with well-controlled GDM who are not medically treated".

Based on less than compelling evidence, in our center we perform weekly antepartum testing, generally a modified biophysical profile, beginning at 36 weeks in patients with diet treated GDM who are well controlled and have no other risk factors. Patients with GDM whose glucose levels are not well controlled and/or require insulin or oral antidiabetic agents, or who have other risk factors, are monitored by the twice-weekly testing paradigm applied to women with pre-existing diabetes, generally starting at 34 weeks or sooner, depending upon risk factors.

Timing of delivery

Gestational diabetes is not necessarily an indication for early delivery, but its complications may be. A 2011 workshop sponsored by NICHD and SMFM concluded that early delivery is not indicated when gestational diabetes is well controlled on diet or medication, but that timing of delivery should be individualized in GDMs whose glucose values were poorly controlled.

Amniocentesis is not considered helpful when early delivery is indicated because of poor metabolic control. We recommend that women with GDM not extend their pregnancies beyond the EDC. When dating is well documented and glucose is well controlled, we offer induction of labor (or repeat C/S if appropriate) between 39 completed weeks and the EDC. A population-based study of almost 200,000 GDMs reported that delivery at 39 weeks or 40 weeks was associated with a statistically significant lower risk of stillbirth and infant death than expectant management for another week. When glucose control is poor or undocumented we recommend earlier delivery.

Mode of delivery

Gestational diabetes is not an indication for caesarean section, but its complications may make caesarean section more likely. For example, hypertensive disorders of pregnancy occur with greater frequency in GDMs than in the general population. When such problems occur, early induction of labor may be necessary, which may make caesarean section more likely. Another scenario is fetal macrosomia, which can be associated with shoulder dystocia.

While the evidence is not unequivocal, ACOG recommends considering caesarean section without a trial of labor in diabetic patients when the estimated fetal weight is 4500 grams or more, and individualization based on the patient's history and the progress of labor when the EFW is 4,000-4,500 grams. A decision analysis concluded that, for women with diabetes whose estimated fetal weight is 4.5 kg or greater, it would require 443 caesarean sections at a cost of $930,000 (1996 dollars) to prevent one permanent brachial plexus injury. Projections of cost were similar when the estimated fetal weight was 4 kg or greater.

Management of GDM in labor

If the fetus has been exposed to hyperglycemia in utero, its pancreas may secrete and release insulin more readily in response to elevated glucose. Once delivery has taken place and the umbilical cord has been cut, the fetus is no longer receiving glucose from the mother. If fetal insulin secretion has been stimulated by hyperglycemia during labor, neonatal hypoglycemia is more likely to ensue. For this reason, it is important to maintain maternal euglycemia throughout the course of labor. Our current approach is as follows:

  1. If induction of labor or caesarean section is planned, and the patient has been in acceptable metabolic control, the usual diet and insulin dose (if the patient is insulin treated) is taken on the day prior to planned delivery. The patient is npo after midnight. Breakfast and insulin are withheld on the morning of induction or C/S.

  2. Rapid infusion of large amounts of glucose during labor has been associated with fetal and neonatal acidemia and should be avoided. However, the mother needs calories during the work of labor lest starvation ketosis develop. Therefore, we infuse 5% dextrose (usually in half normal saline) at a rate of 100-125 ml/hour. We monitor glucose levels at the bedside every 2 hours and aim for a glucose level between 80 and 120 mg/dl.

  3. If bedside glucose testing reveals values of 120 mg/dl or greater, we start an IV insulin infusion at 1 unit per hour; it generally takes 2-4 hours for maternal glucose to reach a steady state, so the dosage is adjusted accordingly.

Postpartum management

Once delivery of the placenta has occurred, maternal insulin resistance may be expected to rapidly diminish. Any insulin infusion used during labor should be discontinued. If anything, there is a tendency toward lower circulating glucose levels during the first day or so postpartum. If the patient with gestational diabetes has been treated with insulin or oral antidiabetic drugs during the pregnancy these should not be continued unless persistent diabetes is encountered.

While definitive testing for diabetes or prediabetes is best accomplished at a later date (see below), it is worthwhile to check a fasting glucose level once the patient is taking a normal diet to make certain that diabetes needing treatment has not persisted. At the time of discharge from the hospital the patient should be given an appointment for a 75 gram, two-hour oral glucose tolerance test at 4-8 weeks post-delivery.

Testing for diabetes and prediabetes

The American Diabetes Association and ACOG recommend testing between 4-12 weeks postpartum. The rationale for waiting is to allow the metabolic effects of pregnancy to completely dissipate. There are no data to determine the ideal interval before testing, and from a practical perspective if the test is delayed until after the postpartum visit there is a diminishing likelihood that the patient will actually undergo testing.

We find it most effective to send the patient home from her delivery with an appointment for her postpartum test scheduled for a date just prior to her postpartum visit so that the results will be available at that time, or testing can be rescheduled if the patient has not followed through.

As noted above, there are a number of different tests recommended to diagnose diabetes or prediabetes. However, women with gestational diabetes are, by definition, in the reproductive age group and are at risk for another pregnancy in the near future unless permanent sterilization has been carried out.

Should they develop diabetes before the next conception, their pregnancy will be at increased risk for congenital malformations and other problems. They will need preconception counseling, including help to achieve reasonable glycemic control prior to pregnancy in order to minimize these risks. Therefore, we recommend that the full 75 gram, 2-hour OGTT be performed. (See Table V for interpretation of this test.)

Table V.

Interpretation of a 75 gram, 2-hour oral glucose tolerance test (OGTT) in nonpregnant individuals

4. Complications

Gestational diabetes is characterized by maternal hyperglycemia. Because glucose is a relatively small molecule and crosses the placenta readily by a process of facilitated diffusion, maternal hyperglycemia leads directly to fetal hyperglycemia. The fetal pancreas responds by increasing production and release of insulin. Insulin is a relatively large molecule and does not cross the placenta, so the fetus cannot modify maternal glucose levels. Consequently, the fetus produces large amounts of insulin but remains hyperglycemic as long as the mother is hyperglycemic.

Fetal hyperinsulinemia is the most likely cause of all or most of the fetal and neonatal complications of GDM. Hyperinsulinemia in utero may also be responsible for long term adverse outcomes in the offspring of GDM pregnancies.

Maternal complications

Pre-eclampsia: hypertensive disorders of pregnancy occur with increased frequency in GDMs compared to controls. Chronic hypertension also appears to be more common in GDMs. There is increasing evidence relating hypertension to insulin resistance, so GDM and hypertensive disorders may have predisposing factors in common. The use of low dose aspirin (81 mg/day beginning by 16 weeks’ gestation) has been shown to be cost effective in preventing preeclampsia in patients at increased risk for this complication. While gestational diabetes confers an increased risk, it is usually not diagnosed until the late second or early third trimester, so the benefits of initiating this preventive measure so late in pregnancy are unknown. Risks and expense of low dose aspirin treatment are miniscule.

Caesarean section: Caesarean section delivery is more common in GDMs than in nondiabetic control patients. A number of contributing factors may be responsible:

  • Macrosomic fetuses are more likely to need delivery by caesarean section.

  • Pregnancy complications such as pre-eclampsia may lead to early induction of labor, which in the presence of an "unripe" cervix makes caesarean section more likely.

  • Antepartum testing commonly prescribed in GDM pregnancies may be positive, either true positive or false positive, leading to intervention.

  • One study has demonstrated that caregivers who are aware of the diagnosis of GDM are more likely to perform caesarean section compared to caregivers blinded to the diagnosis, even when the fetus is not macrosomic, presumably because of concern for possible adverse outcomes of vaginal birth such as shoulder dystocia.

Hydramnios: Excessive amniotic fluid occurs with increased frequency in both pre-existing diabetes and GDM. The common cause is likely fetal hyperglycemia with resultant osmotic diuresis when the diabetes is poorly controlled.

Fetal complications

Macrosomia: Fetal insulin acts as a "growth hormone" for the fetus; macrosomic or large for gestational age neonates are likely to result. There is evidence from randomized trials that treating gestational diabetes with the goal of normalizing circulating glucose levels can reduce the likelihood of macrosomia.

Stillbirth: Studies using hyperinsulinemic models in fetal primates and sheep have demonstrated an increase in stillbirths, possibly due to increased placental lactate production. Fetal death, while fortunately rare, is more likely as term approaches, and many caregivers induce labor at 39-40 weeks if spontaneous labor has not supervened by this time. This approach is supported by a population-based study showing a lower risk of stillbirth and infant death when delivery is accomplished at 39 weeks or 40 weeks.

Shoulder dystocia: In hyperinsulinemic fetuses of diabetic mothers, the shoulders grow disproportionally to the head so that shoulders may get "stuck" in the birth canal, causing injury such as fractured clavicle, and in some cases, brachial plexus injury which can be permanent in a small proportion of cases.

Neonatal complications

Neonatal complications of GDM are similar to those seen with pre-existing diabetes and relate to exposure to hyperglycemia in utero.

Neonatal hypoglycemia: Most likely this problem is secondary to fetal hyperinsulinemia which is stimulated by long term or intermittent maternal-fetal hyperglycemia. When the umbilical cord is clamped, the fetus is deprived of the maternal glucose supply. Particularly if the mother has been hyperglycemic during labor, the resulting fetal/neonatal hyperinsulinemia may cause neonatal hypoglycemia in the first few hours of life.

Neonatal plethora: Most likely fetal erythropoietin is increased due to chronic fetal hypoxemia. This raises fetal/neonatal hemoglobin levels and may lead to consequences such as neonatal renal vein thrombosis.

Neonatal hyperbilirubinemia: The normal transition from fetal to neonatal life, in which responsibility for oxygen delivery transfers from the placenta to the neonatal lungs, includes a decreased need for hemoglobin as oxygen levels increase. Hemolysis occurs, with the resulting bilirubin disposed of by the neonatal liver. When plethora is present (see above), the immature liver may be incapable of handling the resultant bilirubin load, leading to indirect hyperbilirubinemia and jaundice.

Respiratory distress: RDS is more common in premature infants of mothers with pre-existing diabetes whose metabolic control is poor or undocumented, presumably due to fetal hyperinsulinemia decreasing surfactant production. It would stand to reason that infants of gestational diabetic mothers similarly poorly controlled would be prone to similar problems.

Neonatal hypocalcemia: This is much more common in infants of mothers with poorly controlled pre-existing diabetes but remains a theoretic possibility when GDM is not well controlled.

Long term adverse outcomes in the offspring of GDM pregnancies

Obesity: Studies of the Pima population demonstrated that exposure to hyperglycemia in utero is associated with an increased likelihood of obesity into adult life.

Diabetes: Pima offspring were likely to develop diabetes in direct proportion to the height of maternal glucose levels during pregnancy glucose tolerance testing; female offspring who became pregnant were more likely to develop gestational diabetes if their own mothers had high blood glucose levels during pregnancy, even when they were compared to siblings born before their mothers developed hyperglycemia in pregnancy.

5. Prognosis and outcome

Prevention of subsequent diabetes

Gestational diabetes is a powerful predictor of subsequent diabetes, primarily type 2 diabetes but also type1 diabetes and genetically determined forms of diabetes. As noted above, approximately 50% of former GDMs will have diabetes within 20 years of the index pregnancy. While not all GDMs, or individuals with type 2 diabetes, are overweight or obese, much of the increase in diabetes in our population can be attributed to the epidemic of obesity and sedentary lifestyles.

While we generally do not recommend weight reduction during pregnancy, once delivery has occurred attainment of lower BMI can reduce the chance of developing diabetes in the future. Counseling of former GDMs should be initiated during prenatal visits and continued after the pregnancy. Recommendations should include:

  1. Adoption of a healthy lifestyle, including nutritional counseling and regular exercise.

  2. Weight loss if the patient is overweight or obese. Even modest weight reduction of 5-10% of body weight can ameliorate diabetes or prediabetes. In a randomized trial of lifestyle interventions versus metformin therapy versus placebo in patients at high risk for diabetes, weight loss averaging 2-4 kg was associated with a significant reduction in the development of diabetes, with lifestyle intervention being more effective than metformin. In a subanalysis limited to former GDMs metformin and lifestyle interventions were similarly effective, reducing risk of diabetes by approximately 50%.

  3. Patients diagnosed with diabetes should be referred to a caregiver expert in the management of this disorder; those with prediabetes should be referred and entered into a program to lower the risk of conversion to diabetes.

“What if” scenarios

What if the patient with GDM needs lots of insulin to achieve the goals for glucose control? Is there a limit to the amount of insulin that can be administered?

No, prescribe however much insulin is required to overcome the patient's insulin resistance and maintain glucose levels at the predetermined targets. Many patients with GDM, particularly those who are morbidly obese, require very large doses (100s of units per day).

Should metformin be added to reduce insulin resistance and allow lowering of the insulin dose?

This is often mentioned as an alternative. No data are available to address the benefits of such a regimen. Since metformin crosses the placenta and reaches the fetus and fetal effects are not clearly worked out, we prefer not to use this approach, although no harm has been demonstrated to date.

Insulin syringes only hold up to 1 cc (100 units of U-100 insulin). What can we do when this dose is exceeded?

While this phenomenon is much more common in patients with pre-existing type 2 diabetes than with GDM, it is occasionally encountered. One alternative is to have the patient take two injections. This is obviously more uncomfortable for the patient. An approach which we have found useful is the use of U-500 insulin in order to reduce the volume of the injection.

Unfortunately, only regular insulin comes as U-500. So, this requires that patients taking rapid acting insulin analogs switch to regular insulin (short acting). U-500 regular insulin also lasts longer, possibly as long as NPH insulin. For example, if a patient is injecting 70 units of short acting insulin and 30 units of NPH insulin in the morning prior to breakfast and it is necessary to increase her dose to 80 units of short acting insulin with 40 units of NPH insulin, the following steps can be taken:

  • Switch from rapid acting insulin to short acting (regular) insulin, which requires taking the injection 20-30 minutes before breakfast rather than just before the meal as with insulin lispro or insulin aspart.

  • Prescribe U-500 regular insulin.

  • To take 70 units of regular insulin, the patient draws up 0.14 cc of U-500 (which looks like she is drawing up 14 units) into a U-100 syringe. She then draws up 0.3 cc (30 units) of U-100 NPH insulin into the same syringe, for a total of 0.44 cc (looks like total of 44 "units").

  • Since U-100 1 cc syringes are marked in two unit increments, dosage increases in U-500 insulin must be made in 0.02 cc (10 units, but looks like 2 "units") increments. This is generally not a problem when patients are taking such large doses; a dose increase of 10 units is only 10% of 100 units!

It is critically important to give explicit written instructions and make sure the patient understands the plan lest she self-administer 5 times more insulin than is desired. We write down the dose in units, and then the dose in cc's, and make sure the patient demonstrates her knowledge of the difference.

Recently a concentrated form of the long-acting insulin analog, insulin glargine U-300, has come on the market. While this may be useful for pregnant patients with type 2 diabetes, it is quite expensive relative to other forms of insulin, and we generally do not find it necessary to prescribe long-acting insulin analogs for women with gestational diabetes.

How many elevated glucose measurements does it take before insulin is started or the dose is increased?

Our rule of thumb is that if 1/3 of the previous week's glucose measurements at a given time of day exceed our target we start insulin or increase the appropriate time's dose. We do take into account other factors, such as whether our dietitian believes that more can be accomplished through dietary modifications, particularly when the patient has just been diagnosed and only been on medical nutrition therapy for a week.

However, we bear in mind that the time for intervention with GDM is generally limited and we may ask the patient to come back sooner than a week if dietary modification is tried, or to call in her blood sugar values sooner than would otherwise be planned.

What about the patient who does not perform her self-glucose monitoring as often as is prescribed?

We take the results that are in her meter at face value and act accordingly. For example, if she has only done three post breakfast glucose tests in the previous week, and one 2-hour value is 130 mg/dl while the others are less than 120 mg/dl, we would increase her morning short acting insulin dose. We assume that the blood sugars on the days she did not test have not been lower than the values on days she tested. In our experience, it is unusual for patients with GDM to become hypoglycemic on insulin unless they take their insulin and then miss a meal.

How much is the insulin dose increased each time?

We increase the insulin dose by 10-20% depending upon the degree of hyperglycemia and the patient's body habitus (which generally reflects the degree of insulin resistance). Such increases are generally safe for patients with GDM and type 2 diabetes, but smaller increases are more appropriate for patients with type 1 diabetes who may be quite sensitive to 1 or 2 unit increments.

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Festive Gift Fair at Belsay Hall

Beat the Christmas rush and enjoy a far more leisurely and pleasurable Christmas shopping experience at Belsay Hall.

A great variety of specialist crafts and unique gifts will be on sale. You can also enjoy live music performances and craft workshops and there's even the chance for little ones to meet Father Christmas.

Guide Prices

Ticket TypeTicket Tariff
Adult£9.50 per person per day
Child£5.70 per person per day
Concession£8.60 per person per day
English Heritage MembersFree
Family£24.70 per person per day

English Heritage members Free
Adult £9.30
Child, 5-15 years £5.60
Concession £8.40
Family £24.20

Map & Directions

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    Vallum is a community of food producers who have gathered together on our family farm out...

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    Visit Close House and you will discover something a little different, something...

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    After the closure of the Clara Vale pit in 1966 nature reclaimed this site, which was...

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    Northumberlandia is a unique piece of public art set in a 46 acre community park with...

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    Located between the river Tyne and the attractive ‘old’ Ryton village, Ryton Willows...

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    Micro real ale brewery with pub attached, housed in re-built stone pumping station with...

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    With over 11 years experience North East Falconry offer a number of unique falconry...

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    Besides the A694 at Stargate roundabout, Stargate Ponds and Bewes Hills is an area of...

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Rotary Medowie Community Carols

6:30pm, Friday 2 December 2015
Ferodale Oval, Medowie.

Deck the halls! With fantastic entertainment and special guests, including Santa, Carols is sure to help you find your Christmas Spirit

Come join the Medowie community while students from four local Primary Schools Wirreanda Public, Medowie Public and Medowie Christian schools come together to entertain the crowds at Ferodale Oval, Medowie from 6.30pm.

All your family favourites will be performed and the evening will finish at 9.30pm.

Entry is free - although donations are encouraged by adults to help the organisers maintain the event for future years.


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Frenzy Animal Clinic

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Author Comments

Many pets get sick everyday, therefore Lisa wanted to work in the the local animal clinic. assist Lisa & specialist doctors to keep them happy and healthy. Reach daily goals, earn money, and unlock cool upgrades for your animal clinic.

Drag and drop the animals to the right order.

Log in / sign up to vote & review!

Newgrounds accounts are free and registered users see fewer ads!

Totally fine game for the site, no objectionable content and pretty fun gameplay. Five stars

wwggames responds:

Hi jakedrago1,

Thank you very much you like the game & dropping the 5 stars. :)

Decent but monotonous wasn't challenging. Maybe response time should impact score.

I'm probably not the target audience for this, so take my advice with a grain of salt.
1. I played through the first four levels, and everything felt the same. You match the animal to the table that has the same symbol on it. You wait for the vet to finish, then do the same thing in reverse.
2. The upgrades are all of two basic kinds: go faster or change the decor of the room a little. There's no real sense of achievement there. This exasperates problem 1.
3. The symbols are pretty small. It might be nice if they could be magnified when you hover over it.

Some possible changes: upgrades might make the clinic bigger, certain animals might need special handling, doctors could get in each others' way if you're not careful, you get to see a close-up of how happy and healthy the pet is after treatment.

wwggames responds:

Hey PieceOPi,

Thank you very much for your review & advice.

Day 6 has a huge difficulty spike that's quite jarring to go into.

It's not really a Tycoon but closer to a RTS.

I experienced a bug that made it so that I couldn't treat one of the animals and it made it impossible to complete a level.

You'll never have more than two animals so it's not really management but more click and wait 10 seconds for the same generic animation multiple times.

Some of the events(?) are weird. I.E. a fish had to get its teeth checked out. Sorry but goldfish don't have teeth.

Overall I would rate it at 2, as it's not terrible at what it does, but it's not good at it either.

wwggames responds:

Hi Avenger5998,

Thank you for your review. you've got a hard time, eh?

It's an okay game, Just a big too easy after about 2 levels.
I think it should get added.

wwggames responds:

Hi tabookodak5,

I think you mastered the game! thank you very much for dropping 4.5 stars.

Credits & Info

3.08 / 5.00

Jul 7, 2014
4:03 PM EDT
Simulation - Job


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CricketNext GET APP

Qais Ahmed, Chris Gayle Star as Balkh Legends win Afghanistan Premier League 2018

Cricketnext Staff | Updated: October 22, 2018, 7:25 PM IST
Qais Ahmed, Chris Gayle Star as Balkh Legends win Afghanistan Premier League 2018

Balkh Legends capped off an impressive season in the first edition of the Afghanistan Premier League (APL) 2018 by beating Kabul Zwanan by four wickets in the final in Sharjah on Sunday (October 21).

Zwanan opted to bat first on the big day but were pegged on the back foot early when their top performers in Luke Ronchi and Hazratullah Zazai were back in the hut with just 23 on the board.

Wayne Parnell and Colin Ingram scored 21 each and were rebuilding the innings with a decent partnership before Ravi Bopara took his only wicket of the night to have Ingram caught in the deep. It was the Ahmed show post that as he finished with figures of 4-0-18-5 to run through the Zwanans’ lower middle order to restrict them to 132 for 9 in 20 overs.

In reply, Legends lost both their openers Colin Munro and Darwish Rasooli in no time to Wayne Parnell but Chris Gayle struck a fine fifty to anchor the chase.

Ryan ten Doeschate fell to Muslim Musa but Gayle and Bopara took their side to safer shores with a 50-run stand before Rashid Khan got rid of the former for 56.

Parnell returned to take his third wicket when he dismissed Mohammad Nabi but Ravi Bopara’s unbeaten 32 saw the Balkh Legends over the line with 11 balls to spare.
First Published: October 22, 2018, 7:25 PM IST

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Four-month-old baby found alive at 'horror' crime scene

2018-06-03 19:01

Multimedia   ·   User Galleries   ·   News in Pictures Send us your pictures  ·  Send us your stories

A baby has been found at the scene of an apparent murder and suicide outside Groblersdal in Limpopo on Sunday morning, police said.

Provincial police spokesperson Colonel Moatshe Ngoepe said a passerby stumbled upon "the horrific" sight of the body of a man hanging from a tree.

Police were summoned and found the body of a 22-year-old woman with bruises around her neck, and a 37-year-old man hanging from a tree.

A four-month-old baby was found nearby as well, believed to be the child of either or both the deceased.

"The child is in good condition and he was taken to a safe place," Ngoepe said.

"The motive behind this incident is still unknown but domestic violence cannot be ruled out.

"Members of the community are still advised and encouraged that in case of any domestic related situation, they must consult their relevant local professionals for intervention rather than harming or taking the life of another."

Ngoepe said police investigations were ongoing.

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Two suspected poachers killed in Loskop Nature Reserve shootout

2018-07-16 11:18
(Julian Rademeyer, Beeld)

(Julian Rademeyer, Beeld)

Multimedia   ·   User Galleries   ·   News in Pictures Send us your pictures  ·  Send us your stories

Two suspected poachers have been killed and a policeman wounded at the Loskop Dam Nature Reserve in Mpumalanga at the weekend.

A shootout ensued on Saturday night during an intelligence-driven operation at the reserve.

Police spokesperson Brigadier Vishnu Naidoo said the team, which comprised of members of the SAPS Special Task Force and the local Stock Theft Unit, tracked down the two suspects when they came under fire shortly after 21:00.

Read: Lions eat 3 suspected poachers at Eastern Cape game reserve

A rifle, fitted with a silencer, was also recovered during the shootout.

"The team involved in Saturday night's incident must be praised for having put their lives on the line, as do many of our police officers on a daily basis to protect life and property," he said.

Naidoo said the police continued to call on communities to assist the police in their efforts to protect South Africa's natural resources.

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Daily news

21 June 2013

Wood is key ingredient in cheap rechargeable battery

From tree to battery
From tree to battery

(Image: Dr Jeremy Burgess/Science Photo Library)

A battery made from wood doesn’t exactly scream high-tech innovation – more like something cooked up round the campfire. But a device that exploits wood fibre could be the key to cheap, renewable power.

Lithium-based rechargeable batteries are too expensive to use on a large scale because there is so little lithium available. But sodium is abundant and cheap, so why not base a battery on a sodium electrolyte?

The problem is that sodium ions are many times larger than lithium ones, and they gradually damage a battery’s anode as they diffuse during charging and discharging. Another issue is that using a tin anode in such batteries would offer the highest power storage capacity, but this leads to the formation of a sodium-tin alloy that makes the battery swell, hastening what is known as “structural pulverisation”. The upshot is that a sodium-ion battery with a tin anode can only be charged and discharged around 20 times.

To get around this, Hongli Zhu and colleagues at the University of Maryland in College Park turned to a natural material they knew could more easily carry large ions: soft, porous wood fibre. These fibres include hollow elongated cells called tracheids, which have walls made of a tough material called lignin and which transport water and mineral salts around the organism.

Tin on wood

By depositing a 50-nanometre-thick layer of tin on 2500-nanometre-thick wood fibres, the researchers were able to create an anode that could be charged and discharged 400 times.

The relatively soft nature of the wood fibres effectively releases the mechanical stresses that would pulverise an ordinary tin anode, the team says, resulting in “unprecedented performance for a tin-anode sodium-ion battery”. And because wood fibre is easy to process, it should be possible to use it in the manufacture of low-cost batteries.

The team now wants to engineer bigger batteries for use in renewable storage applications.

Bingan Chen, a researcher specialising in novel battery materials at the University of Cambridge, UK, is impressed. “Using wood fibre as a substrate to lower their cost of sodium-ion batteries is a great, innovative idea,” he says. “But their challenge will be working out how to scale up the manufacturing process to make it commercially viable.”

Journal reference: Nano Letters, DOI: 10.1021/nl400998t

Print… and be charged

The 3D printing revolution has reached the world of batteries. Teams at Harvard University’s Wyss Institute and at the University of Illinois at Urbana-Champaign have jointly developed a technique for 3D-printing batteries the size of a grain of rice, for use in small medical implants and insect-sized drones.

Their idea was to 3D-print two comb-shaped elements that could be interlocked to create a stack of anodes and cathodes. Inks containing lithium metal oxide were then deposited on the comb teeth to create the electrodes. Finally, the assembly was filled with an electrolyte.

The technology already has a customer waiting: the US military wants such 3D printable batteries to reduce the amount of material it needs to ship to troops on the front line.

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Paperback review

6 March 2004

Squirm factor

How to levitate: walk barefoot on a muddy river bank and step on an eel. Some countries think them good to eat, while others think they are disgusting. To scientists, eels are irritatingly mysterious. We know that European and American eels breed in the Sargasso Sea but no one has succeeded in breeding them in captivity. People have hung them with jewellery, worshipped them as gods, and even fed human slaves to prized captive eels. Richard Schweid’s Consider the Eel (Da Capo Press/Perseus, $16.95/£13.50) mixes slippery tales with fabulous recipes. First catch your eel…

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Long IslandNassau

Westbury school district

6 a.m. to 9 p.m. at Dryden Street School, Park Avenue School, Drexel Avenue School and Westbury Middle School.

The district proposes a $130,178,342 budget for 2015-16, a 5.22 percent increase from the current $123,715,746. The local tax levy would rise 1.85 percent, from $75,741,151 to $77,142,183.

The increase is equal to the state's tax cap of 1.85 percent, so a simple majority vote will be required to approve the budget. School taxes on the average single-family home would decrease 2.52 percent, from $9,473.24 to $9,234.50.

The budget funds a contractual increase of 1.5 percent for teachers and a 3.2 average step increase. The budget does not include any cuts in programs or services.

District website:

Incumbents Pless Dickerson and John E. Simpkins and challenger Larry D. Wornum are running for two at-large seats. Terms are three years.

Pless Dickerson

BACKGROUND: Dickerson, 66, has lived in the district 40 years. He has served on the school board for two terms, from 2006 to present. Dickerson holds several degrees, including a doctorate from the Educational Leadership Program at Teachers College, Columbia University. He is a former superintendent of the Wyandanch school district.

ISSUES: Dickerson said the greatest challenge the district faces is the constant increase in student enrollment. The student population is at 5,200 and growing. This number includes the recent arrival of unaccompanied children from Latin America. "Our responsibility is to educate all students who reside within our school district boundaries," he said. "This presents a great number of challenges." The major challenge is overcrowding with buildings at capacity, class sizes increasing and a student-to-teacher ratio that is less than ideal, he said. He plans to seek additional funding from the state as well as grants and partnerships to provide such resources.

John E. Simpkins

BACKGROUND: Simpkins, 50, is a director of talent acquisition and special projects for Henry Schein, and is seeking his second term on the board. He has three children who all attend private schools. He is a graduate of St. John's University. He has lived in the district for 21 years.

ISSUES: Simpkins said the Westbury school system is facing unprecedented challenges. The explosive enrollment growth requires firm and responsible governance to ensure that district money is being utilized effectively to bring about the best academic experience for children, he said. "I have demonstrated responsible governance working alongside my fellow board members, yet my work individually and collaboratively is far from over. I am running to continue to lend a voice to all constituents: public and private school parents, residents and business owner," he said.

Larry D. Wornum

BACKGROUND: Wornum, 63, is retired from the U.S. Department of the Treasury and has lived in the district for 27 years. He holds a bachelor's degree in criminal justice from Northeastern University. His three adult children graduated from district public schools. He had served on the board from 2007 to 2010.

ISSUES: He said that while the test scores, ranking and graduation rates are poor, the school budget has continued to increase and the "fault is clearly at the door of the school board," he said. He said he would not support building a new school and would instead reconfigure the school schedule and use portable classrooms. He said he would work to increase participation by parents, non-parents and especially retirees. He also questioned the timing of board meetings, saying they start at 7:30 p.m. and typically last until after midnight when votes are taken. "I would end this practice," he said.

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NY Criminal Defense & New York Penal Law 265.03 – Criminal Possession of a Weapon in the Second Degree

Criminal Possession of a Weapon in the Second Degree, pursuant to New York Penal Law 265.03, is unquestionably one of the most serious criminal charges that an individual can face in NYC or anywhere in New York. That is right. Even if you have a permit in Colorado, Georgia or Alabama, if you possess than firearm in a hotel room in Manhattan or at JFK or LaGuardia Airports, the crime has still been committed if you do not have a permit in New York. The New York criminal defense attorneys at Crotty Saland PC, have not only successfully represented clients charged with possessing loaded guns, but prosecuted individuals charged with this crime as Assistant District Attorneys under Robert Morgenthau. The following is a “primer” for those not familiar with this offense and the strict liability it seems to impose on the accused.

A person is guilty of Criminal Possession of a Weapon in the Second Degree (NY PL 265.03) when:

(1) with the intent or purpose to use the firearm (handgun, pistol, revolver, etc.) you possess a (a) machine gun, (b) loaded firearm (loaded has a much more liberal legal definition than bullets physically in a gun) or (c) a disguised gun; or

(2) you possess more than five firearms (it can be different types such as revolver, pistol, etc.)

(3) you possess a firearm that is loaded (intent to use unlawfully not required!!). Generally, there is no felony if the possession is in your home or place of business. New York Criminal Possession of a Weapon in the Second Degree is a C violent felony punishable by a minimum of three and on half years and up to fifteen years in state prison.

Make no mistake, a conviction for this offense will land you behind bars for at least a few years to well over a decade. While intent to use the firearm unlawfully is an element of NY PL 265.03(1), it is not an element or requirement under NY PL 265,03(3). In other words…just having the loaded firearm (the law does not actually require the bullets to be in the chamber/cartridge/cylinder) without a permit outside your home or place of business without the slightest malicious intent is punishable by at least three and one half years.

Although the statute is very clear and prosecutors are often unsympathetic to people carrying guns without permits, there still may be a defense that you can set forth. Did the police search you properly? Was the gun legally “loaded?” Is the possession based on a legal presumption? Are there mitigating circumstances? Did you possess the firearm in an area airport and properly checked it?

As stated above, Crotty Saland PC has had tremendous success representing clients charged with possessing loaded firearms. Our clients have not only benefited from our experience, but we have been legal analysts and quoted on gun crimes in the national, regional and local media from Sports Illustrated Online to the New Jersey Star-Ledger and the AM-NY. If you are accused of a crime involving weapons, no attorney can guarantee a particular outcome, but we will unquestionably fight to protect your rights and freedom.

The New York criminal defense lawyers and former Manhattan prosecutors at Crotty Saland PC represent clients throughout New York City and the region.


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Why the War Over Health Care Isn’t Over

The Trump era has conditioned us to brace for chaos, upheaval, and the next story. On Tuesday, after Mitch McConnell, the Senate Majority Leader, decided not to schedule a vote on a last-ditch Obamacare-repeal bill put forward by Senators Lindsey Graham and Bill Cassidy, it took only a few hours for the political world and much of the news media to move on to the next item on the White House’s agenda: tax reform. But, before running forward into this new legislative battle, it’s worth dwelling on what we’ve learned over the past few months, as successive G.O.P. health-care bills have faltered. Some of the lessons are encouraging, and some aren’t. Let’s start with the uplifting stuff.

Seven and a half years after Congress passed the Affordable Care Act, the central value it enshrines—that affordable health care should be available to everyone, regardless of age, income, or medical history—is now widely accepted. Opinion polls show almost universal support for this proposition. Donald Trump says he supports it, and so do Republican leaders such as House Speaker Paul Ryan (although they tend to use weasel words like “accessible” rather than “affordable”). That is why the Republicans got into such political trouble when—after years of promising to repeal Obamacare—they finally had to release details of their plans for doing so. It turned out that their ideas would lead to millions of poorer Americans losing coverage, while many seniors and sick people would see their out-of-pocket costs soar. The Party’s hypocrisy was exposed.

Another progressive idea included in the A.C.A. that has proven durable is the notion that expanding health-care coverage is important enough to justify higher taxes on the wealthy. When Donald Trump took office, Republicans were determined to repeal two Obamacare tax increases that had hit households earning more than a quarter of a million dollars a year: a 0.9-per-cent surcharge on Medicare taxes and a 3.8-per-cent investment tax. These increases had helped pay for the law’s insurance subsidies and its big expansion of Medicaid. Yet going after these tax increases left Republicans open to the accusation that their real motivation was to help the Party’s wealthy donors. After McConnell’s Better Care Reconciliation Act died, in mid-July, Republicans quietly stopped pushing to get rid of these taxes. McConnell’s so-called “skinny repeal,” which was voted down in the early hours of July 27th, and the Graham-Cassidy bill both would have left these taxes in place. For a Republican Party that views cutting taxes on the rich as one of its central missions, that was a big retreat.

The general point is that the enactment of Obamacare, despite all the criticisms it has received, has permanently shifted the political debate. It is no longer enough for Republicans to argue that America can’t afford a decent health-care system, or that the way to fix things is to simply repeal the A.C.A. and leave the rest to the market. Having seen the pluses and minuses of Obamacare, most Americans aren’t willing to junk it in exchange for vague promises. Any potential replacement must be able to withstand some detailed comparison shopping. Thus far, no Republican plan has been able to meet that challenge.

The ubiquity of the Internet has played a role here. As the action on Capitol Hill proceeded, practically everybody had access to the latest health-care analyses from independent institutions like the Congressional Budget Office, the Kaiser Family Foundation, and the Commonwealth Fund. Most people didn’t actually read the studies these organizations produced, of course. But the news media helped transmit the key findings, and so did the round-the-clock social-media efforts of experts including Kaiser’s Larry Levitt, the former Obama Administration official Andy Slavitt, and the Center for American Progress’s Topher Spiro. The C.B.O.’s studies, which showed that the G.O.P.’s plans would lead to big drops in coverage and much higher premiums for people older than fifty-five and those with preëxisting conditions, were arguably the single biggest factor in public opinion turning against McConnell and Ryan’s efforts. This month, when the Republicans tried to rush through the Graham-Cassidy bill, they scheduled things so that the C.B.O. wouldn’t have enough time to do a proper scoring. But this tactic rebounded: it was widely, and rightly, seen as subterfuge.

For once, real news and real analysis won out over fake news, and democratic activism defeated procedural stunts on Capitol Hill. On Tuesday, I noted that health-care-advocacy groups and Democratic activists had for months pursued Senator Susan Collins, of Maine, putting pressure on her to vote against her Party’s bills.

Of course, Collins might have decided to oppose the Republican repeal bills even without the protests. (And, as I noted, the nation owes her its thanks.) But there can be no doubt that the activism had an effect. Think back to what happened during April and May in the House of Representatives, when Paul Ryan, trying to pass his American Health Care Act, faced defections from moderate Republicans who represent places such as New York, New Jersey, and Pennsylvania, and who were being subjected to regular protests in their home districts. Ryan ultimately got his plan through the House, but the wider repeal effort never really recovered its momentum.

On the other side of the ledger, it must be acknowledged that, as the Duke of Wellington is reputed to have said of the Battle of Waterloo, it was a damn close-run thing. Had Collins, Lisa Murkowski, or John McCain voted the other way on the “skinny repeal,” back in July, the legislation would have proceeded to a House-Senate conference, where it would probably have been broadened and passed. We don’t know for sure how many Republicans would have supported the Graham-Cassidy bill if it had come to an actual vote, but it surely would have been close, too. Republicans have comprehensively lost the intellectual arguments: they can’t cite a single reputable study showing that their bills would preserve affordable coverage for the old, the sick, and the poor. But that doesn’t appear to be enough to sway most G.O.P. senators. Either because they feared primary challenges from the right or because they had trotted out the anti-Obamacare patter for so long that they had come to believe it, the vast majority of them toed the Party line. Especially after Tuesday’s Senate primary result in Alabama—where the insurgent Roy Moore defeated the Party favorite Luther Strange—there is no reason to expect this attitude to change. And there’s also no reason to believe that the Republican Party won’t, at some point, launch yet another repeal effort. In fact, it is only a question of when.

On Wednesday, Lindsey Graham, who had just watched his bill die, said that the Party would return to health care immediately after passing tax reform. But a legislative window for pushing through a health-care measure with just fifty votes is closing, and, going forward, the Republicans will need sixty votes to break a Democratic filibuster. Unless, of course, they pass another budget-reconciliation bill, which would give them another chance at a fifty-vote victory. Or they could get rid of the filibuster altogether, a step which Donald Trump urged them to do on Wednesday.

For now, it looks like the next repeal effort will have to wait until after the 2018 midterms. But another thing we’ve learned in the past few months is that you should never underestimate the determination of the Republicans, and of their wealthy donors, to dismantle Obamacare, or their eagerness to embrace practically any tactic that might help them achieve their goal. “Bottom line is the ACA is not remotely safe between now & 2018 election,” Andy Slavitt tweeted on Wednesday. The forces of enlightenment and progress have won another big battle. But the war isn’t over.

The Risk of Nuclear War with North Korea

On the ground in Pyongyang: Could Kim Jong Un and Donald Trump goad each other into a devastating confrontation?


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Judith Orloff, MD

Judith Orloff, MD, is a UCLA psychiatrist in private practice in Los Angeles who synthesizes the pearls of traditional medicine with cutting-edge knowledge of intuition, spirituality and energy medicine. Her latest book, Emotional Freedom: Liberate Yourself from Negative Emotions and Transform Your Life (Three Rivers Press, 2011), is a New York Times best-seller.

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The Official Site of the New Jersey Devils

Devils deal for Trent Hunter

by Staff Writer / New Jersey Devils
Trent Hunter headed for the Garden State.

Newark, NJ – The Devils today acquired forward Trent Hunter from the New York Islanders in exchange for forward Brian Rolston. The announcement was made by Devils’ President/CEO/GM Lou Lamoriello.

Hunter, 31, joins the Devils after spending nine seasons with the Islanders’ organization. His career totals show 99 goals and 130 assists for 229 points and 201 penalty minutes in 459 career NHL contests. The 6-3, 210-lb. forward has also appeared in 14 career playoff games, posting four goals and one assist for five points and six penalty minutes. He had career highs of 25 goals, 26 assists and 51 points and was named to the NHL’s All-Rookie Team in 2003-04. Hunter saw action with the Islanders and Bridgeport (AHL) in both 2001-02 and 2002-03.

He made his regular-season NHL debut in 2002-03, after appearing in four games during the 2002 Stanley Cup Playoffs vs. Toronto. Born July 5, 1980 in Red Deer, Alta., he made his professional debut with Springfield (AHL) in 2000-01. He was acquired by the NY Islanders from Anaheim on May 23, 2000. Hunter was the Mighty Ducks’ fourth choice (sixth round) and 150th overall selection in the 1998 NHL Entry Draft. He played three seasons of junior hockey for Prince George (WHL).

Rolston, 38, recorded 14 goals and 20 assists for 34 points and 34 penalty minutes in 65 games last season. He was one of 20 players to be re-acquired and play for New Jersey.
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NEW HAVEN — Injuries have become a weekly obstacle for the Yale football team. Replacing key starters on the shelf is now merely part of the game-planning for coach Tony Reno and his staff.

Already without the league’s best running back, Zane Dudek, limited by injury all season, the Bulldogs’ latest casualty, quarterback Kurt Rawlings, will miss the rest of the season after suffering multiple fractures in his leg last Friday at Penn.

Jimmy Check, a sophomore with limited experience, will run the Yale offense for the remaining four games.

At least the Bulldogs can take solace knowing other teams are dealing with the same problems, perhaps none more strapped than Columbia, which is expected to use its fourth-string quarterback when the team’s meet Saturday at Wien Stadium (1 p.m., ESPN+).

The Lions (3-3, 0-3) have yet to make it through an entire game with one quarterback. Against Dartmouth last weekend they lost quarterbacks Josh Bean and Ty Lenart, leaving signal-calling duties to senior Ryan Suitt, who in four years hadn’t completed a pass in his college career.

Columbia also lost running back Dante Miller to a broken leg, further stretching an offense already without receiver Josh Wainwright and linebacker Justin Woodley, both gone for the season with injury.

Yale (4-2, 2-1), looking to keep its Ivy League championship hopes alive with a victory, has managed to dig into its depth chart with far more success.

“If you want to be an elite team you have to play like an elite team,” Reno said. “We’re playing better than we have. But we’re not even close to where we need to be yet.”

At this time a year ago, Columbia was the story of the Ivy League, undefeated in league play under new coach and East Haven native Al Bagnoli, who’d retired after a distinguished career at Penn only to be snapped up by a program looking to finally have a football impact.

Yet while the Lions breezed through a non-conference slate of Central Connecticut State, Georgetown and Marists, they’ve yet to win an Ivy game this fall, losing to front-runners Princeton and Dartmouth as well as Penn.

Yale’s depth has allowed it to deal with its own plague of injuries far more efficiently.

Dudek, the first freshman to lead the Ivy League in rushing, was the star of last season’s victory over Columbia, rolling off 173 yards rushing to put an end to the Lions’ dreams of an undefeated campaign.

Alan Lamar, a star freshman who missed his entire sophomore year due to a knee injury, has kept the Bulldogs’ run game sharp. He’s topped 100 yards the past two weeks, including 179 and two touchdowns in the win over Penn. Freshman Spencer Alston averaged over six yards on his eight carries against the Quakers.

Expect Check to rely heavily on receivers J.P. Shohfi and Reed Klubnik, who’ve emerged as two of the league’s best pass-catching threats.

“We believe in playing a lot of people; four backs, three tight ends, six or seven receivers in a game,” Reno said. “Our offensive line’s been a rock. They haven’t played their best game yet.”