Wednesday, November 15, 2017
An Unstill Life Tour and Giveaway!
An Unstill Life
by Kate Larkindale
Genre: YA Contemporary Romance
When your whole world is falling apart, what are the chances you’ll find love in the most unexpected of places?
Livvie feels like she’s losing everything: her two best friends have abandoned her for their boyfriends, her mother continues to ignore her, while her sister, Jules, is sick again and getting worse by the day. Add in the request Jules has made of her and Livvie feels like she’s losing her mind, too.
Her only escape is in the art room, where she discovers not only a refuge from her life, but also a kindred soul in Bianca, the school “freak”. Livvie’s always felt invisible, at school and at home, but with Bianca, she finally feels like someone sees the real Livvie. As the relationship deepens and it comes time to take the romance public, will Livvie be able to take that step?
Livvie’s about to find out if she has what it takes to make the tough decisions and stand up for herself—for the first time in her life.
Bianca pulled up in front of my house, which sat in darkness, not even the porch light on to guide me. I must be late. Mom always switched off the light at midnight, whether we were home or not, letting us know she was aware we’d missed curfew. I’d hear about it tomorrow. Or maybe not.
“Thanks for the ride,” I said. “And … thanks. Again. Like I said, you’re always rescuing me.”
“Maybe I think you’re worth saving.” Bianca wasn’t looking at me. Her eyes were turned to the open window. The words sounded simple, but they weren’t. They lay across the seat between us, pulsing in shades of pink and red.
“Thanks?” The word felt awkward in my mouth. Would she still think I was worth saving if she knew I was thinking of ways to kill my sister? I shoved the thought away as I climbed out of the car. “See you in school.”
“Yeah. See you.” Bianca turned, her eyes glittering under the streetlights. “Hey, Livvie?”
“Yeah?” I ducked my head back through the door.
“I really like your painting.”
I jerked back in surprise, knocking the back of my head on the door. “My painting? You mean the still life?”
She nodded. “Yeah. It’s really good. It’s like everyone else is painting the surface of the things, but you’re painting what’s underneath. The real apple. The real flowers. It’s got—” She stopped, searching around as if she’d find the word she was looking for hanging in the air, ripe for plucking. “Well, it sounds totally corny, but it’s got soul.”
My face grew warm. “Thanks,” I mumbled. “But yours is way better.”
She waved her hand in a dismissive gesture. “No. Mine’s clever. It’s thought out. But there’s no passion in it. Yours has that.”
I giggled. “Passion? For a bunch of fruit and flowers? I hope not.”
She smiled, too, the flicker of movement so small I could have missed it. “Well, yeah. It’s not the most exciting subject. But if you can inject that much life into something so stupid, just think what you could do with something you really care about. Like that thing you did with the song. That’s something special.”
I sank back into the seat, the springs wheezing beneath me. My ears blazed, and I knew my cheeks were just as red. No one had ever said anything like that to me before. Even Mrs. DeWinter dismissed my music pictures as irrelevant swirls of color, while Mom considered all painting and drawing to be a frivolous waste of time.
“Thanks.” I stammered again.
“No, thank you.” Bianca lit another cigarette, the fiery end punching a hole in the darkness.
“What for?” Smoke burned my eyes, making them tear. At least, I thought it was the smoke. I couldn’t remember the last time someone complimented me or made me feel special. I brushed at a wet spot on my cheek.
She took a long drag and turned to her open window before exhaling into the night. “I’ve always been the best at art. I never had to work hard to be the best either. Now I have something to work for.”
“Oh.” I admired the ease with which she admitted to being the best. “Okay.”
Silence filled the car, but it was a warm, comforting silence.
“I have to go.” The reluctance in my voice surprised me, and I realized I didn’t want to leave. And not just because Bianca’s words flattered me. I recognized the truth in them. “I have a curfew. And I’m late.”
“Sure. Wouldn’t want to get you in trouble.” She turned the key and let the engine struggle to life again.
I watched the way the light gleamed off her shiny red lips. Surprised, I realized I wanted to lean over and kiss them, wanted to see if she tasted of the raspberries I always tasted while in her presence. I scrambled out of the car, putting distance between us as fast as I could. My heart raced in my chest.
Having spent a lifetime travelling the globe, Kate Larkindale is currently residing in Wellington, New Zealand. A marketing executive, film reviewer and mother, she’s surprised she finds any time to write, but doesn’t sleep much. As a result, she can usually be found hanging out near the espresso machine.
Her short stories have appeared in Halfway Down The Stairs, A Fly in Amber, Daily Flash Anthology, The Barrier Islands Review, Everyday Fiction, Death Rattle, Drastic Measures, Cutlass & Musket and Residential Aliens, among others.
She has written fourteen contemporary YA novels, a few of which other people are allowed to see. She has also written one very bad historical romance. She is currently working on a new YA novel and ghostwriting an autobiography.
Follow the tour HERE for exclusive excerpts and a giveaway!
This post is part of a virtual book tour organized by Goddess Fish Promotions . The author will award a $25 Amazon/BN GC to a randomly draw...
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GUEST BLOG Fascinating Mid-19th Century Facts Sam Time readers will learn about Victorian customs in the U.S. The first time-travel chapter ...


Reducing Costs and Improving Outcomes
Research in Action, Issue 8
The question of which medicines work best at the lowest cost has become more and more important as costs have soared. The Agency for Healthcare Research and Quality (AHRQ) funds research about prescription medicine, and this synthesis shows the impact of that research.
Americans spent over $553 billion for health care in 1997.1 Over $200 billion was spent for hospitalizations, $180 billion for ambulatory care, and $72 billion for prescription medicine.1 Since 1991, prescription drug costs have soared, increasing faster than the inflation rate.2
The issue of prescription drug costs has captured the attention of legislators and policymakers, insurers, health care providers, and consumers asking the question: Which medicines work best at the lowest cost?
The Agency for Healthcare Research and Quality (AHRQ) has funded research that helps to answer questions about prescription medicine. AHRQ research has:
- Identified conditions for which drug therapy is not necessary.
- Discovered low-cost drug therapies that provide patients with the same quality of care as more expensive drugs.
- Revealed that sometimes the newest, most expensive drug therapy reduces costs overall because it keeps patients healthier and less likely to use other health care services.
- Investigated the cost effectiveness and safety of outpatient vs. inpatient services and the impact of preventive drug therapy.
Making a Difference
Prescription drug spending doubled from $60.8 billion in 1995 to $121.8 billion in 2000 and is expected to reach $160.9 billion in 2002.3 These increases can be attributed to the research and development of new drugs, as well as the availability of new, more expensive drugs that either replace older drugs or provide treatment for a condition that previously was not treatable.3,4 Consumers are also purchasing more prescription drugs.3 In 1993, 7 prescriptions were dispensed per person; by 2000, this number had increased to 10 prescriptions per person.3
AHRQ research projects have been funded to determine where the costs for treatment can be reduced without reducing the quality of care. The objective is to determine when older, less expensive drugs or no drug treatment can work just as well as newer, more expensive drugs.5-10 AHRQ has also funded research to determine whether limiting the use of certain drugs, such as antibiotics, can help to reduce the risk of developing antibiotic-resistant bacteria,11,12 thus decreasing costs related to hospitalization.
Although newer drugs are usually more expensive than older drugs, they are sometimes more effective than their older counterparts in reducing illness, hospitalization, or death,13 and the improvements in health care outcomes can justify the increased costs.14 Unfortunately, little information is available to doctors to determine which therapy works best,5 and very few studies have measured the cost benefits of new drugs.13
When better health outcomes involve increased costs, the burden of paying for treatment can have negative consequences. For example, because of cost issues, some patients may resort to drug mismanagement (not filling their prescriptions, taking less than the recommended dose, saving medications for future use, or taking a medicine belonging to another person).15,16 Increased prescription drug costs translate into higher costs for both insurers and patients and, ultimately, higher health insurance premiums for all consumers. Reimbursement strategies designed to save money may be detrimental to patients and may actually result in higher overall health care costs.17 For example, limiting reimbursements for drugs can reduce pharmaceutical costs but increase other costs, such as those for hospitalization.17
Impact of AHRQ Research
Expensive Antibiotics Do Not Always Have Better Outcomes
AHRQ research has found that antibiotics are not always necessary or effective and that less expensive antibiotics often work just as well as more expensive antibiotics. The cost of antibiotics varies widely.8,9 For example, antibiotics to treat middle ear inflammation in children or sinus infections and community-acquired pneumonia in adults cost anywhere from $2.00 to $113.00,6,8,10 resulting in expenses that exceed $4 billion annually.7,9 AHRQ research shows that several strategies work to reduce antibiotic expenses.
An AHRQ-funded study that evaluated randomized clinical trials conducted from 1968 through 1994 found that about 80 percent of children recover from middle ear inflammation without the use of antibiotics.12 More appropriate use of antibiotics would not only lower costs, but reduce the growing problem of antibiotic resistance.
A clinical trial funded by AHRQ showed that amoxicillin performed no differently than a placebo in preventing middle ear inflammation in children. The proportion of children who remained free of inflammation after receiving amoxicillin twice a day (61 percent) was no different from the proportion for children who received amoxicillin once a day and a placebo once a day (64 percent) or children who received a placebo twice a day (63 percent).7
Researchers funded by AHRQ also found that more expensive antibiotics were not associated with better outcomes than less expensive antibiotics for treating middle ear inflammation in children ages 30 months to 13 years (Table 1). This retrospective study of children enrolled in Colorado's Medicaid program showed that the average rate at which a second dose was prescribed because the infection did not respond to the first dose of antibiotics was 11.6 percent for less expensive antibiotics and 13.2 percent for more expensive antibiotics.8
AHRQ-funded researchers more recently found that older antibiotics such as amoxicillin provide better treatment outcomes than newer antibiotics for children with middle ear inflammation. Researchers for the Center for Education and Research on Therapeutics (CERTs) at the University of North Carolina discovered that children covered by Medicaid in North Carolina who received older drugs had fewer return visits to their physicians than children who received newer, more expensive drugs. The average cost of drug therapy for older drugs such as amoxicillin was $12.00, while the newer drugs cost an average of $42.00.18
AHRQ funded an evaluation of randomized trials that showed 69 percent of patients with an uncomplicated sinus infection recovered without any antibiotic treatment at all. Researchers reviewed randomized clinical trials conducted from 1970 through 1998 that compared the use of older antibiotics (amoxicillin and folate inhibitors) with placebos and antibiotics that were newer and more expensive at the time of the studies (such as azithromycin, clarithromycin, and cefixime). Their analysis showed that two-thirds of the patients using placebos got well without any treatment, and the older antibiotics worked just as well as the newer antibiotics.5
The AHRQ Patient Outcomes Research Team (PORT) on pneumonia found that there were no differences in outcomes between outpatients with community-acquired pneumonia who were treated with less expensive antibiotics and those treated with more expensive antibiotics.9
In an observational study, patients who received treatment with antibiotics whose average daily costs were relatively inexpensive (ranging from .36 to $4.04) had outcomes similar to those of patients who were given more expensive antibiotics (ranging from $5.10 to $7.52 per day).9,10
A second observational study conducted by the AHRQ pneumonia PORT examined antibiotic costs and outcomes among outpatients with community-acquired pneumonia at five different medical institutions. The treatment site with the lowest antibiotic cost also had the lowest rates of subsequent hospital admissions, while the facility with the highest costs had the highest rate (Table 2).10
Finally, a clinical trial funded by AHRQ at Brigham and Women's Hospital, in Boston, found that costs could be reduced by decreasing prescription orders for the antibiotic vancomycin. Vancomycin was at one time the only antibiotic physicians could use to treat bacteria that had become resistant to all other antibiotics. It is prescribed primarily for patients who have a serious infection that is resistant to other antibiotics, who are allergic to other antibiotics, or who may have sepsis, and to prevent infection in patients who are about to undergo surgery. Overuse of vancomycin in the past 10 years, however, has resulted in the emergence of at least one strain of bacteria that is showing vancomycin resistance. Controlling the use of vancomycin would help to control development of new strains of antibiotic-resistant bacteria.11
All of the physicians studied used computerized order entry. The intervention group received computerized guidelines for ordering intravenous vancomycin; the control group of physicians did not. When compared with the control group of physicians, intervention physicians:
- Ordered 29 percent fewer initial courses of vancomycin.
- Wrote 36 percent fewer renewal orders.
- Had 32 percent fewer total orders for vancomycin.
- Prescribed vancomycin for 28 percent fewer patients.
- Prescribed vancomycin for 36 percent fewer days.11
The number of patients who received vancomycin during their hospitalization decreased by 15 percent (from 2,715 to 2,341) compared with 9 months before the study. This might have led to a cost savings of $90,000 per year. However, because many patients still required treatment for infection or to prevent infection, another antibiotic would have been prescribed instead of vancomycin. For example, physicians may have substituted cefazolin, which cost $9.00 per day compared with $12.00 per day for vancomycin. The hospital still saved $22,500 a year. Because of the impact the computerized guidelines had on physician ordering practices, at the study's conclusion these guidelines were made available to all users of the computerized order entry system.11
In some instances newer, more expensive drugs can lead to cost benefits. For example, new drugs could provide treatment for conditions such as HIV for which very few treatments had previously existed. In addition, newer drugs may be more effective, have fewer side effects, and represent better quality of care than older drugs. They also may lower costs overall by lessening the need for other health care services.4
An AHRQ-funded observational study done soon after the approval of the first protease inhibitors (drugs that keep HIV from reproducing) in the mid- and late 1990s showed that HIV-infected patients taking protease inhibitors had lower hospital inpatient costs, community care costs, and costs associated with the treatment of opportunistic illness. Researchers found that the average monthly Medicaid payments for pharmacy costs were higher for patients taking protease inhibitors. However, Medicaid patients who took protease inhibitors, when compared with Medicaid patients who did not, had:
- Significantly lower average monthly total payments for the sickest patients (those with low CD4a cell counts) in 1997 (Table 3).
- Significantly lower payments when hospitalized with an opportunistic illness both in 1996 and 1997 (Figure 1).19
a. CD4 cells are a type of white blood cell that helps the body fight off infections. HIV invades CD4 cells. Eventually, the body loses its ability to produce CD4 cells and therefore loses its ability to fight infection.
Outpatient Drug Treatment Can Be Effective and Reduce Costs
AHRQ research has demonstrated that some drug treatments offered on an outpatient basis have the same outcomes as those given on an inpatient basis at lower cost. For example, treating women with pelvic inflammatory disease (PID) as outpatients rather than inpatients could save as much as $500 million a year.20
PID, an infection and inflammation of organs in the pelvis, affects about 1.2 million women in the United States each year, resulting in infertility, chronic pelvic pain, and ectopic pregnancies. AHRQ funded the PID Evaluation and Clinical Health (PEACH) Study, which conducted a clinical trial to compare the effectiveness of inpatient and outpatient treatment. After 30 days, there were no significant differences in adverse outcomes between the outpatient and inpatient treatment groups, with the exception of phlebitis (inflammation of a vein) sometimes caused in inpatients by intravenous treatment with the antibiotic doxycycline (Figure 2). After an average followup period of 35 months, there were no differences in outcomes between outpatients and inpatients (Figure 3).20
AHRQ research has shown that using drugs to prevent opportunistic illnesses such as Pneumocystis carinii pneumonia (PCP) in HIV patients can lower costs. Drugs such as trimethoprim-sulfamethoxazole (TMP-SMZ), aerosol pentamidine, or dapsone can help prevent PCP, but many patients do not receive these medications.21-23
Researchers funded by AHRQ in the early 1990s examined past charts of HIV patients. They found that, among patients who developed PCP, those who took preventive drugs were less likely to require hospitalization or admission to the intensive care unit than those who did not take preventive drugs (Table 4). Patients who did not take preventive drugs accounted for 800 (85 percent) of 937 hospital days associated with this illness and were also more likely to die.21 More recent studies conducted by other researchers confirm that preventive drug therapy in HIV patients reduces the risk of PCP as well as other bacterial infections.22-24
Public Health Service guidelines today recommend that persons with CD4 counts less than 200 take drug therapy to prevent PCP, and treatment with TMP-SMX is covered under all of the Drug Assistance Programs funded by the Ryan White CARE Act.25
AHRQ continues to fund studies that investigate the costs and outcomes of pharmaceutical therapies.
Consequences of Drug Cost Sharing in the Elderly. Brigham and Women's Hospital, Boston, MA, Grant No. R01 HS10881-01. This study is examining the effects of differential cost sharing for pharmaceutical costs, an increasingly common strategy to discourage use of more expensive medications in many drug benefits plans. Specifically, researchers will assess the impact of differential cost sharing applied to angiotensin-converting enzyme inhibitors and calcium channel blockers on patterns of medication use and health care use.
Effect of Medicaid Drug Copayments on Outcomes and Costs. University of Minnesota, Grant No. R03 HS10791-01. This study is estimating the effect of Medicaid prescription drug copayments on the use of drugs and other types of health care and on total Medicaid expenditures.
Patient-Centered Care and Health Care Costs. University of Rochester, Grant No. R01 HS10610-01A1. This research study is examining the relationship between measures of physicians' patient-centeredness (a process where the physician incorporates the patient's experience of illness and shares decisionmaking) and patients' health care costs (total, inpatient, outpatient, testing, and medication), health status, and satisfaction. It will also characterize features of patient-physician communication that contribute to lower health care costs.
Centers for Education and Research on Therapeutics (CERTs). The CERTs demonstration program is a national initiative to conduct research and provide education that advances the optimal use of therapeutics (drugs, medical devices, and biological products). The program is administered as a cooperative agreement by AHRQ in consultation with the U.S. Food and Drug Administration. The research conducted by the CERTs program is intended to increase awareness of the uses and risks of new drugs and drug combinations, biological products, and devices as well as ways to improve their safe and effective use. The CERTs research will improve quality while reducing the cost of care by increasing the appropriate use of drugs, biological products, and devices and by preventing their adverse effects and consequences. The CERTs centers are:
- Duke University (HS10548): Therapies for disorders of the heart and blood vessels.
- HMO Research Network (HS10391): Usefulness of health maintenance organizations for studying drug use, safety, and effectiveness.
- University of Alabama-Birmingham (HS10389): Therapies for disorders of the joints and bones.
- University of Arizona (HS10385): Reduction of adverse drug interactions, especially in women.
- University of North Carolina (HS10397): Therapies for children.
- University of Pennsylvania (HS10399): Therapies for infection and antibiotic drug resistance.
- Vanderbilt University (HS10384): Prescription drug use in a Medicaid population.26
AHRQ-funded research helps identify drug therapies that can lower health care costs while maintaining quality of care. Less expensive drugs such as antibiotics can work just as effectively as more expensive drugs, lowering costs without compromising patients' health. However, some newer, more expensive drugs can also lower costs because they improve patients' health overall and reduce other medical expenses. More research needs to be conducted to identify those new drugs that have an advantage over older, existing drugs. AHRQ research has shown that some drug therapies can be provided on an outpatient basis, thus saving the costs of inpatient treatment. Finally, studies funded by AHRQ have helped lower costs by showing the benefit of providing preventive drug therapies.
For More Information
For more information about AHRQ research on pharmaceuticals, please contact Lynn Bosco, M.D., M.P.H., at (301) 427-1490 or Lynn.Bosco@ahrq.hhs.gov.
* 1. Agency for Healthcare Research and Quality, Center for Cost and Financing Studies. Health care expenses in the U.S. civilian noninstitutionalized population, 1997. Rockville (MD), 2001. AHRQ Pub. No. 01-R086. AHRQ Web site: http://meps.ahrq.gov/mepsweb/. Accessed April 14, 2008.
2. Kaiser Family Foundation, Williams C, Treloar J. Trends and indicators in the changing health care marketplace; 2002. Kaiser Family Foundation Web site: http://www.kff.org/. Accessed September 10, 2002.
4. Merlis M. Explaining the growth in prescription drug spending: a review of recent studies. Background paper for U.S. Department of Health and Human Services. Web site: http://www.aspe.hhs.gov/health/reports/drug-papers/merlis/merlis-final.htm. Accessed April 14, 2008.
* 5. De Ferranti SD, Ioannidis JP, Lau J, et al. Are amoxycillin and folate inhibitors as effective as other antibiotics for acute sinusitis? A meta-analysis. BMJ 1998; 317(7159):632-7.
* 6. Balk EM, Zucker DR, Engels EA, et al. Strategies for diagnosing and treating suspected acute bacterial sinusitis: a cost-effectiveness analysis. J Gen Intern Med 2001; 16(10):701-11.
* 8. Berman S, Byrns PJ, Bondy J, et al. Otitis media-related antibiotic prescribing patterns, outcomes, and expenditures in a pediatric Medicaid population. Pediatrics 1997; 100(4):585-92.
* 9. Gleason PP, Kapoor WN, Stone RA, et al. Medical outcomes and antimicrobial costs with the use of the American Thoracic Society Guidelines for outpatients with community-acquired pneumonia. JAMA 1997; 278(1):32-9.
* 10. Gilbert K, Gleason PP, Singer DE, et al. Variations in antimicrobial use and cost in more than 2,000 patients with community-acquired pneumonia. Am J Med 1998, 104:17-27.
* 11. Shojania KG, Yokoe D, Platt R, et al. Reducing vancomycin use utilizing a computer guideline: results of a randomized controlled trial. J Am Med Inform Assoc 1998; 5(6):554-62.
* 12. Froom J, Culpepper L, Jacobs M, et al. Antimicrobials for acute otitis media? A review from the international primary care network. BMJ 1997; 315(7100):98-102.
* 14. Agency for Healthcare Research and Quality. Focus on cost-effectiveness analysis at the Agency for Healthcare Research and Quality. Rockville (MD), 2001. AHRQ Pub. No. 01-P023.
15. Mitchell J, Mathews HF, Hunt LM, et al. Mismanaging prescription medications among rural elders: the effects of socioeconomic status, health status, and medication profile indicators. Gerontologist 2001; 41(3):348-56.
* 17. Soumerai SB, McLaughlin TJ, Ross-Degnan D, et al. Effects of limiting Medicaid drug-reimbursement benefits on the use of psychotropic agents and acute mental health services by patients with schizophrenia. N Engl J Med 1994; 331:650-5.
* 18. Ringel-Kulka T, Tolleson-Rinehart S, Christensen DB. Antibiotic choice and treatment outcomes for acute otitis media. August 2002. Centers for Education and Research on Therapeutics Web site: http://www.certs.hhs.gov/whats_new/archive/2002/20020808_01.html. Accessed September 17, 2002.
* 19. Gebo KA, Chaisson RE, Folkemer JG, et al. Costs of HIV medical care in the era of highly active antiretroviral therapy. AIDS 1999; 13(8):963-9.
* 20. Ness RB, Soper DE, Holley RL, et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) randomized trial. Am J Obstet Gynecol 2002; 186(5):929-37.
* 21. Gallant JE, McAvinue SM, Moore RD, et al. The impact of prophylaxis on outcome and resource utilization in Pneumocystis carinii pneumonia. Chest 1995; 107:1018-23.
22. DiRienzo AG, van Der Horst C, Finkelstein DM, et al. Efficacy of trimethoprim-sulfamethoxazole for the prevention of bacterial infections in a randomized prophylaxis trial of patients with advanced HIV infection. AIDS Res Hum Retroviruses 2002; 18(2):89-94.
23. Dworkin MS, Williamson J, Jones JL, et al. Prophylaxis with trimethoprim-sulfamethoxazole for human immunodeficiency virus-infected patients: impact on risk for infectious diseases. Clin Infect Dis 2001; 33(3):393-8.
24. Effect of trimethoprim-sulfamethoxazole as Pneumocystis carinii pneumonia prophylaxis on bacterial illness, Pneumocystis carinii pneumonia, and death in persons with AIDS. J Acquir Immune Defic Syndr Hum Retrovirol 1999; 20(2):201-6
* 26. Agency for Healthcare Research and Quality. Centers for Education and Research on Therapeutics. Rockville, MD, 2002. AHRQ Pub. No. 02-P025. AHRQ Web site: http://certs.hhs.gov/about/certsovr.htm. Accessed September 12, 2002.


THE GUNSLINGER is the first volume in Stephen King's epic Dark Tower series. The Dark Tower is Soon to be a major motion picture starring Matthew McConaughey and Idris Elba, due in cinemas February 17, 2017. In this first novel in his epic fantasy masterpiece, Stephen King introduces readers to one of his most enigmatic heroes, Roland of Gilead, ...
THE GUNSLINGER is the first volume in Stephen King's epic Dark Tower series. The Dark Tower is Soon to be a major motion picture starring Matthew McConaughey and Idris Elba, due in cinemas February 17, 2017. In this first novel in his epic fantasy masterpiece, Stephen King introduces readers to one of his most enigmatic heroes, Roland of Gilead, the Last Gunslinger. He is a haunting figure, a loner, on a spellbinding journey into good and evil, in a desolate world which frighteningly echoes our own. In his first step towards the powerful and mysterious Dark Tower, Roland encounters an alluring woman named Alice, begins a friendship with Jake, a kid from New York, and faces an agonising choice between damnation and salvation as he pursues the Man in Black. Both grippingly realistic and eerily dreamlike, THE GUNSLINGER leaves readers eagerly awaiting the next chapter. And the Tower is closer...T HE DARK TOWER SERIES: THE DARK TOWER I: THE GUNSLINGER THE DARK TOWER II: THE DRAWING OF THE THREE THE DARK TOWER III: THE WASTE LANDS THE DARK TOWER IV: WIZARD AND GLASS THE DARK TOWER V: WOLVES OF THE CALLA THE DARK TOWER VI: SONG OF SUSANNAH THE DARK TOWER VII: THE DARK TOWER THE WIND THROUGH THE KEYHOLE: A DARK TOWER NOVEL
New in new dust jacket. Brand New books on affordable price. Shipping method: Standard & Expedite, Standard takes 7-8 and Expedited takes 4-6 working days. Due to the constantly changing USPS regulations regarding shipments to APO/FPO addresses we are not currently shipping to this type of address.
New in new dust jacket. International Edition. Brand New. Different ISBN number and Cover Page but contents similer to US edition. No CD/Access code with this. Legal to use despite any disclaimer on cover as per US courts. Choose Expedited shipping for 3-5 business days delivery. We can ship to PO Box Addresses. 100% Customer Satisfaction.
New in new dust jacket. International Edition, Brand New. ISBN and Cover Page differs, Contents similar to US edition. Access code or CD not available. Choose Expedited shipping for delivery in 3 to 5 business days. Legal to use despite any disclaimer on cover as per US courts. Shipping to PO Box Addresses available. Customer satisfaction guaranteed.
The Black Tower series is some of King's best writing.
The book came in excellent shape and in excellent timing.
Nothing but positive to say about the book, the shipping, and the story itself.
Nov 27, 2010
THIS WAS A GIFT TO A READER WHO LOVES TO READ I RECOMMEND IT TO A FRIEND CAUSE HE SAID IT WAS VERY GOOD AND WANTS ME TO GET THE OTHER BOOKS OF FOLLOW UP I THINK THERE ARE 8 BKS
Jan 21, 2010
The Begining of an Amazing Journey
This book is great for anyone with an apreciation for fantasy, western or typicall Stephen king style. The Gunslinger is only a mere introduction to the amazing adventures of Roland the Gunslinger and those he meets along the way on his quest for the Dark Tower. You will have more fun with this book if you pay attention to the little things such as songs (for example) that link Roland's world to our own. My best suggestion is that if you buy this book be prepared with the second Dark Tower book "The Drawing of Three" close at hand to avoid frustration.
Dec 25, 2009
An exeptional mind-twisting series
This is a good stand-alone book, but if you go on in the series and stick it out to the end your view of King - and of life and the world - will change, possibly in fundamental ways
Feb 24, 2009
The story begins..
It was 1970 when Stephen King, at his final year of university, received a gift: a stack of coloured paper. At this time, the King could not imagine how important that story would have been in his life as a writer, maybe. He spent 12 years to complete this first chapter of the most exciting and best-selling horror/fantasy saga,
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|Year : 2015 | Volume
| Issue : 1 | Page : 5-10
Lifestyle modifications and erectile dysfunction: what can be expected?
Maria Ida Maiorino1, Giuseppe Bellastella1, Katherine Esposito2
1 Department of Medical, Surgical, Neurological, Metabolic and Geriatric Science, Second University of Naples, Piazza L. Miraglia n° 2, Italy
2 Department of Clinical and Experimental Medicine, Second University of Naples, via Pansini n° 5, Naples, Italy
|Date of Submission||05-May-2014|
|Date of Decision||27-Jun-2014|
|Date of Acceptance||14-Jul-2014|
|Date of Web Publication||09-Sep-2014|
Department of Clinical and Experimental Medicine, Second University of Naples, via Pansini n° 5, Naples
Source of Support: None, Conflict of Interest: None
Erectile dysfunction (ED) is a common medical disorder whose prevalence is increasing worldwide. Modifiable risk factors for ED include smoking, lack of physical activity, wrong diets, overweight or obesity, metabolic syndrome, and excessive alcohol consumption. Quite interestingly, all these metabolic conditions are strongly associated with a pro-inflammatory state that results in endothelial dysfunction by decreasing the availability of nitric oxide (NO), which is the driving force of the blood genital flow. Lifestyle and nutrition have been recognized as central factors influencing both vascular NO production, testosterone levels, and erectile function. Moreover, it has also been suggested that lifestyle habits that decrease low-grade clinical inflammation may have a role in the improvement of erectile function. In clinical trials, lifestyle modifications were effective in ameliorating ED or restoring absent ED in people with obesity or metabolic syndrome. Therefore, promotion of healthful lifestyles would yield great benefits in reducing the burden of sexual dysfunction. Efforts, in order to implement educative strategies for healthy lifestyle, should be addressed.
Keywords: erectile dysfunction; lifestyle changes; physical activity; Mediterranean diet
|How to cite this article:|
Maiorino MI, Bellastella G, Esposito K. Lifestyle modifications and erectile dysfunction: what can be expected?. Asian J Androl 2015;17:5-10
|How to cite this URL:|
Maiorino MI, Bellastella G, Esposito K. Lifestyle modifications and erectile dysfunction: what can be expected?. Asian J Androl [serial online] 2015 [cited 2020 Jun 6];17:5-10. Available from: http://www.ajandrology.com/text.asp?2015/17/1/5/137687 - DOI: 10.4103/1008-682X.137687
| Introduction|| |
Erectile dysfunction (ED) is a common medical disorder which decreases quality of life in men. , It has been estimated that the worldwide prevalence of ED will be 322 million cases by the year 2025. Risk factor categories associated with ED include general health status of the individual, the presence of diabetes mellitus, and of cardiovascular disease (CVD), concurrence of other genitourinary disease, psychiatric/psychological disorders, and sociodemographic conditions.  Several cross-sectional and longitudinal studies showed an association between ED and most of the cardiovascular risk factors, such as diabetes, smoking, hypertension, hyperlipidemia, metabolic syndrome.  Moreover, ED is a marker of increased risk of CVD, and all-cause mortality. ,,
Cardiovascular diseases are the main cause of mortality in both sexes worldwide: , behavioral modifications that occurred in the last decades have led to the spreading of unhealthy lifestyles, which are believed to be one main cause of the burden of noncommunicable diseases worldwide.  Consequently, there has been a dramatic increase in the incidence of both type 2 diabetes mellitus and obesity, both in the Westernized and the developing countries. The increasing prevalence of obesity has brought about the rising prevalence of metabolic syndrome, a cluster of risk factors for CVD and type 2 diabetes mellitus, occurring together more often than could be attributed to chance alone. On the basis of the most recent epidemiological analysis using the National Cholesterol Education Program/Adult Treatment Panel III guidelines for cut-off values, slightly more than one-third of adults in the United States could be characterized as having the metabolic syndrome.  Quite interestingly, all these metabolic conditions are strongly associated with a pro-inflammatory state that results in endothelial dysfunction and decrease in the availability and activity of nitric oxide (NO). As NO is the driving force of the genital blood flow, it has been hypothesized and demonstrated that most cardiovascular risk factors are associated with ED in men.  Moreover, an inverse association between obesity and low-testosterone levels has been established in healthy men; the prevalence of low-testosterone levels in obesity may vary from 20% to 64% depending on the population and on whether total or free testosterone is used to make a diagnosis.  A higher prevalence of hypogonadotropic hypogonadism has been described in patients with type 2 diabetes mellitus  and referred to metabolic disorders causing hypothalamic-pituitary-gonadal axis regulation.  Testosterone regulates nearly every component of erectile function, and also modulates the timing of the erectile process, which occurs as a function of sexual desire, coordinating penile erection with sex.
Lifestyle and nutrition have been recognized as central factors influencing both vascular NO production and erectile function. Moreover, it has also been suggested that lifestyle habits that decrease low-grade clinical inflammation may have a role in reducing the burden of sexual dysfunction.  Both basic and clinical studies have shown that targeting several lifestyle factors commonly associated with ED, such as smoking, alcohol consumption, obesity, and limited physical activity can have significant effects on improvement of erectile function as well as testosterone levels ([Figure 1]). ,,,,, Therefore, there may be a role for lifestyle measures to prevent progression or even enhance the regression in the earliest manifestations of ED.  In this review, a comprehensive literary search was carried out in order to discuss the effects of lifestyle intervention strategies on erectile function, focusing on the potential mechanisms involved in increasing vascular NO production. We searched PubMed for papers published in English between 1990 and March 2014, using the key words "ED" and "lifestyle changes" "physical activity," "weight loss," "diet," "alcohol," "smoking;" we mainly focused on publications in the past 5 years. Other relevant articles identified by review of the reference lists of selected articles were also included.
|Figure 1: Behavioral risk factors and principal mechanisms involved in erectile dysfunction.|
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| Epidemiology and Risk Factors|| |
Erectile dysfunction is a frequent sexual problem that increases with age. According to a recent analysis of published works on the prevalence of sexual dysfunction by the International Consultation Committee for sexual medicine on definitions/epidemiology/risk factors for sexual dysfunction,  the prevalence of ED was 1%-10% in men younger than 40 years, 2%-9% among men between 40 and 49 years, and it increased to 20%-40% among men between 60 and 69 years, reaching the highest rate in men older than 70 years (50%-100%). Modifiable risk factors for ED include smoking, lack of physical activity, obesity, excessive alcohol consumption, recreational drug use.  In the Health Professional's Follow-up Study  several lifestyle factors, including physical activity and leanness, were associated with maintenance of good erectile function. On the other hand, diabetes mellitus is the most common risk factor for ED, as diabetic men showed a three-fold probability of having ED than men without diabetes.  Moreover, both cross-sectional and longitudinal studies have linked the development of ED to CVD, hypertension, hyperlipidemia, and metabolic syndrome, ,, all of which are largely preventable with an intervention strategy based on lifestyle changes.
| Effects of Lifestyle Changes on Erectile Dysfunction|| |
The association of modifiable behavioral factors with ED, primarily among men free of comorbidities, represents the rationale for intervention strategies addressed to prevent and potentially improve erectile function in patients with ED. As NO is a key factor for vascular health and ED is strongly associated with CVD, maximal attention should have to be paid on measures known to increase vascular NO production.
The only meta-analysis regarding exercise and ED showed that moderate and high physical activities were associated with a lower risk of ED, with odds ratios at 0.63 (95% confidence interval (CI): 0.43-0.93) and 0.42 (95% CI: 0.22-0.82), respectively.  Several prospective investigations indicate that the physical activity has a beneficial effect on prevention and/or improvements of ED. ,,
In hypertensive patients with ED, an 8-week exercise training for the duration of 45-60 min day−1 , improved ED compared with controls who remained sedentary during the same period.  A recent study evaluated the effect of a standard protocol of aerobic physical activity (150 min week−1 ) on quality of ED in middle-aged patients with arterial ED.  After 3 months, compared with controls, patients in the intervention group showed a significantly higher International Index of Erectile Function 5 (IIEF-5) score associated with a reduction of apoptotic circulating endothelial progenitor cells (EPCs) and endothelial microparticles. In a randomized, open-label study,  a total of 60 patients with ED were randomized to receive phosphodiesterase type 5 inhibitor (PDE5i) alone or PDE5i plus regular (≥3 h week−1 ), aerobic, nonagonistic physical activity. After 3 months, IIEF restoration of ED occurred in 77.8% (intervention group) versus 39.3% (control) (P < 0.004). Moreover, physical activity was the only independent variable for normal erection (P = 0.010), higher sexual satisfaction (P = 0.022) and normal total IIEF-15 score (P = 0.023), suggesting that lifestyle changes may significantly increase the benefits of medical ED therapy.
The mechanisms by which physical activity ameliorates ED include improved cardiovascular fitness and endothelial dysfunction,  increase in endothelial-derived NO,  decrease in oxidative stress,  and increase in regenerative EPCs.  Moreover, physical exercise showed beneficial effects on self-esteem and mental health,  with a positive impact on psychological issues associated with sexual dysfunction.
Both cross-sectional and prospective epidemiologic studies suggest that overweight, obesity and metabolic syndrome are associated with an increased risk of ED.  In particular, the largest population from the Health Professionals Follow-up Study in the United States, including 31 724 men free of ED at baseline, showed a 40% increased risk of developing ED with obesity.  Prospective studies ,, of variable duration from 5 to 25 years of follow-up reported that overweight or obese men had an increased probability (70%-96% higher) of developing ED compared with normal weight men.
Both short- and long-term weight-loss studies including only caloric modifications or restrictions demonstrated improvement of ED. In a study examining the effect of weight loss on quality of life among 37 men and women, after a follow-up of 28 days, the weight loss program seemed to have been beneficial on sexual life among men.  Khoo et al.  compared the effects of 8 weeks of a low-calorie diet (LCD) using meal replacements (KicStart) on insulin sensitivity, plasma testosterone levels, erectile function (IIEF-5), and sexual desire as measured by the Sexual Desire Inventory (SDI) in abdominally obese men with uncomplicated diabetes (n = 519) or without type 2 diabetes mellitus (n = 525) with a control group of nondiabetic men (n = 526) with similar body mass index (BMI) and waist circumference (WC). Weight loss of 10% was significantly associated with increased insulin sensitivity, plasma testosterone levels, and IIEF-5 and SDI scores in diabetic as well as nondiabetic men. The same group investigated the effects of diet-induced weight loss on sexual and endothelial function, lower urinary tract symptoms, and inflammatory markers in obese diabetic men.  Over 8 weeks, 31 abdominally obese type 2 diabetic men received either a meal replacement-based LCD ~1000 kcal day−1 (n = 19) or low-fat, high-protein (HP), reduced-carbohydrate diet (n = 12). Subjects continued on, or were switched to, the HP diet for another 44 weeks. Compared with patients with HP, men with LCD lost more weight (5% vs 10%). Moreover, both diets significantly improved plasma glucose, low-density lipoprotein, sex hormone-binding globulin, IIEF-5, SDI, and endothelial function (increased flow-mediated dilatation, reduced soluble E-selectin). At 52 weeks, reductions in weight, WC, and C-reactive protein were maintained, and IIEF-5, and SDI scores improved further. Similar results were obtained with bariatric surgery-induced weight loss. In a randomized controlled trial,  surgery-induced weight loss increased erectile function quality measured by IIEF-5, with increased total testosterone, free testosterone, follicle-stimulating hormone, and reduced prolactin levels. Moreover, significant improvements in all domains of the Brief Sexual Function Inventory, including erectile function, were also demonstrated in a 2 years study of bariatric surgery-induced weight loss.
Increased visceral adiposity and related risk factors are associated with a pro-inflammatory state that results in a decrease in the availability and activity of NO; the reduced testosterone levels associated with obesity and the metabolic syndrome may worsen both insulin resistance and endothelial function, thereby contributing to ED.  Moreover, body weight loss, obtained either by lifestyle or bariatric intervention, is associated with a decline in estrogen levels and a rise in gonadotropins and testosterone, which is greater in those who lose more body weight.
Dietary patterns with high content of whole grain foods and legumes and vegetables and fruits, and that limit red meat, full-fat dairy products, and food and beverages high in added sugars are associated with a reduced risk of ED.  The greater adherence to a Mediterranean-style diet, in particular, has been associated with a lower prevalence of ED in both diabetic and nondiabetic men. ,
Only few studies assessed the role or the effect of diet on ED. Esposito et al.  studied 65 men with the metabolic syndrome and ED; 35 out of them were assigned to the intervention diet and 30 to the control diet. Subjects in the intervention group were advised to consume at least 250-300 g of fruits, 125-150 g of vegetables, and 25-50 g of nuts per day; in addition, they were encouraged to consume 400 g of whole grains daily (legumes, rice, maize, and wheat) and to increase the consumption of olive oil. After 2 years, men on the Mediterranean diet consumed more fruits, vegetables, nuts, whole grain, and olive oil when compared with men on the control diet. IIEF score increased up to 22 in 13 and 2 men in the intervention group and control group, respectively (P = 0.015).
A substantial body of knowledge demonstrates that the abundant consumption of vegetables, fruit, and whole grain, and the dietary patterns rich in these foods produced a markedly lower risk of coronary disease.  The beneficial effect of the Mediterranean diet on atherosclerosis in general, and ED in particular can be mediated through multiple biological pathways, including a reduction of oxidative stress and subclinical inflammation, amelioration of endothelial dysfunction and insulin sensitivity, , which in turn may increase NO release in the penis arteries.
Overall lifestyle changes
Lifestyle changes, such as increased physical activity, healthy diet, and reduced caloric intake, have been associated with the amelioration of erectile function in the general male population. Esposito et al.  conducted a randomized controlled trial involving 110 obese men with ED. Men assigned to the intervention group were entered in an intensive weight loss program, involving personalized dietary counseling and exercise advice, and regular meetings with a nutritionist and personal trainer. The dietary advice was tailored to each man on the basis of food records collected on three nonconsecutive days which had to be done the week before the meeting with a nutritionist. Men in the control group were given general oral and written information about healthy food choices and exercise at baseline and subsequent bimonthly visits, but no specific individualized programs were offered to them. After 2 years, men randomized to the intervention lost significantly more weight, increased their physical activity, experienced favorable changes in physiologic measures of endothelial dysfunction, and had significant improvement in their ED score compared with men in the control group. The same group used their database of subjects participating in randomized controlled trials to evaluate whether improvements in erectile function were related to success in achieving lifestyle changes.  After ranking men according to their success in achieving the goals of intervention (weight loss, low intake of saturated fat, high consumption of monounsaturated fat and fiber, and moderate physical activity), a strong correlation was observed between the success score and the restoration of erectile function. Moreover, at the 2 years examination point, the number of men without ED was significantly higher in the group randomized to intensive lifestyle changes compared with that of men in the control group. Wing et al.  evaluated 1 year changes in erectile function in 306 overweight men with type 2 diabetes mellitus participating in the Look Action for Health in Diabetes trial; from baseline to 1 year, 8% of men assigned to an intensive lifestyle intervention reported a worsening of erectile function compared to 22% of the control participants. Moreover, the overall IIEF score improved from 17.3 to 18.6 (P = 0.04 and P = 0.06, after adjusting for baseline differences) in the intervention group.
The suggested mechanisms by which weight loss, healthy diet, and physical exercise can improve erectile function include the amelioration of endothelial dysfunction, insulin-resistance, and low-grade inflammatory state associated with diabetes and metabolic diseases - all of which are risk factors for ED.  The resulting improved inflammatory status may help contribute to reduce the burden of sexual dysfunction in men.
Both the direct use of tobacco and second-hand exposure seem a consolidated risk factor for ED. , A recent meta-analysis of four prospective cohort studies and four case-control studies involving 28 586 participants showed that compared with nonsmokers, the overall odd ratio of ED in prospective cohort studies was 1.51 (95% CI: 1.34-1.71) for current smokers, and 1.29 (95% CI: 1.07-1.47) for former smokers.
Harte and Meston  investigated the association between smoking cessation and indices of physiological and subjective sexual health in men: smoking cessation significantly enhanced both physiological and self-reported indices of sexual health in long-term male smokers, irrespective of baseline erectile impairment. In a prospective study, Pourmand et al.  reported a beneficial effect on erectile function in men who ceased smoking. After 1 year the ED status improved in ≥25% of ex-smokers but in none of the current smokers; moreover, men who stopped smoking continued to have a significantly better ED status with long-term follow-up.
The moderate consumption of alcohol may exert a protective effect on ED in both the general population and in diabetic men. , In a recent study aimed at describing the incidence or remission and bio-psychosocial predictors of ED in 810 randomly selected Australian men aged 35-80, low-alcohol consumption was predictor of ED.  The data from a population-based cross-sectional study of men's health to assess the association between usual alcohol consumption and ED in Australia revealed that among current drinkers (n = 51 374), the odds were lowest for consumption between 1 and 20 standard drinks per week.  On further adjustment for CVD or cigarette smoking, age-adjusted odds of ED were reduced by 25%-30% among alcohol drinkers. In general, the overall findings are suggestive of alcohol consumption of a moderate quantity conferring the highest protection.  The beneficial effects of alcohol on erectile function may be due, in part, to the long-term benefits of alcohol on high-density lipoprotein cholesterol and other variables that increase the bioavailability of NO.
Experimental findings involving lifestyle modifications
Corroborating findings in the clinical studies, several experimental studies demonstrate beneficial effects of lifestyle-related factors (exercise, calories restriction, dietary factors, alcohol, smoking) on erectile function in animal models of ED. The most frequently reported models of ED used rodents as the predominant animal for investigating erectile function. Experimental animal models of ED include traumatic, metabolic (diabetes, hypercholesterolemia/lipidemia, and castration) and other organic models (smoking, hypertension, and chronic renal failure).  In male Sprague-Dawley rats, both erectile function and coronary artery erectile function (CAEF) were blunted in Western diet-fed rats who remained sedentary, but were preserved in those who started physical exercise (aerobic treadmill running) throughout the dietary intervention, suggesting that exercise training may be a practical strategy of preventing diet-induced ED.  A recent study in the same experimental model of rats demonstrated that the caloric restriction preserved both visceral adipose tissue (VAT) accumulation and erectile function; moreover, analysis of body composition showed that enhanced erectile response in calories-restricted rats was well correlated with the lower levels of VAT, indicating that the beneficial effect on erectile function may depend on decrease in adipose tissue.  Hannan et al.  showed that a combination of exercise and calories restriction may, in part, attenuated the age-related decline in apomorphine-induced erectile function in both normotensive and hypertensive rats, with an inverse correlation between the number of pharmacologically-induced erections and body weight. The role of dietary anti-oxidants on erectile function was investigated in a study of Zhang et al.:  rabbits with atherosclerosis-induced ED by balloon de-endothelialization of the iliac arteries were assigned to assumption of pomegranate extract as dietary anti-oxidant or tap water as placebo. Compared with rabbits receiving placebo, those who assumed pomegranate underwent improvement of intracavernosal blood flow, erectile activity, smooth-muscle relaxation and decrease in oxidative products, suggesting that dietary anti-oxidants may have an effect on molecular and ultra-structural alteration involved on ED. Ethanol may impair the endothelial function of corpus cavernosum producing endothelial damage, as it abolishes the endothelium-dependent relaxations induced by acetylcholine in mice.  Finally, chronic exposure to smoking decreases significantly both testosterone levels and the filling rate of corpora cavernosa in mice, when compared with a control group who was not exposed.
| Which role for Lifestyle Changes in Erectile Dysfunction?|| |
Erectile dysfunction is associated with smoking, excessive alcohol intake, physical inactivity, abdominal obesity, metabolic syndrome, diabetes, hypertension, and decreased anti-oxidant defenses, all of which reduce NO availability. Moreover, there has been increasing recognition of the many physiological causes of ED and of the potential for therapy to improve patient's quality of life, self-esteem, and ability to maintain intimate relationships.  Although epidemiological evidence seems to support a role for lifestyle factors, limited data are available suggesting that the treatment of underlying risk factors and coexisting illnesses - for example with diet, exercise, stress reduction, and smoking cessation - may improve ED.  It has been demonstrated that lifestyle-based intervention strategies improve endothelial function, NO bio-availability, and testosterone levels, producing benefits on erectile function. ,, The major limitation remains the paucity of intervention studies that have assessed the role of lifestyle changes on ED. Moreover, the studies reviewed are mainly limited to the exiguity of the study samples. However, the European Association of Urology recently stated that "lifestyle changes and risk factors modification must precede or accompany ED treatment" and classified the Level of Evidence as 1b with a Grade A.
None of the many available treatment options offers a complete response in all patients. Thus, as with many other medical diseases, prevention maybe the most effective approach to alleviate the consequences of ED. Despite the increasing evidence that unhealthy lifestyles lead to metabolic diseases, including sexual dysfunction, the majority of adults fail to meet physical activity and nutritional guidelines.  In particular, it is recommended that adults accumulate 30 min of moderate-intensity aerobic physical activity on most days of the week. Moreover, a weight loss of 5%-10% in overweight or obese nondiabetic or diabetic men can result in effective improvement in erectile function in a short period. The lack of food-based recommendations and actual dietary practice of the population could be an additional limitation. However, dietary pattern which is high in fruit, vegetables, nuts, whole grains, and fish but low in red and processed meat and refined grains are more represented in subjects without ED. Mediterranean diet has been proposed as a healthy dietary pattern based on evidence that greater adherence to this diet is associated with lower all-cause and disease-specific survival. In clinical trials, Mediterranean diet was more effective than a control diet in ameliorating ED or restoring absent ED in people with obesity or metabolic syndrome, so that the adoption of a Mediterranean diet may be associated with an improvement of ED.
| Conclusions|| |
Improvement of sexual (erectile) function in men should be added to the growing list of clinical benefits brought about by healthy lifestyles in human beings. Current recommendation that patients should observe to avoid or alleviate ED include increasing physical exercise, reducing weight (5%-10% or achieving a BMI ≤ 30 kg m−2 ), stopping smoking ([Table 1]).  When comorbidities, such as diabetes or hypertension, are present lifestyle modifications may be important in preventing or reducing sexual dysfunction.  From this point of view, promotion of healthful lifestyles for primary prevention among individuals at all ages would yield great benefits and reduce the burden of noncommunicable diseases, including sexual dysfunction. Efforts, in order to implement educative strategies for healthy lifestyle, have to be addressed.
|Table 1: Suggested recommendations on lifestyle changes to be observed in order to prevent/treat erectile dysfunction|
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| References|| |
Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA
1999; 281: 537-44.
De Berardis G, Franciosi M, Belfiglio M, Di Nardo B, Greenfield S, et al
. Erectile dysfunction and quality of life in type 2 diabetic patients: a serious problem too often overlooked. Diabetes Care
2002; 25: 284-91.
Lewis RW, Fugl-Meyer KS, Corona G, Hayes RD, Laumann EO, et al.
Definitions/epidemiology/risk factors for sexual dysfunction. J Sex Med
2010; 7: 1598-607.
Maiorino MI, Bellastella G, Esposito K. Diabetes and sexual dysfunction: current perspectives. Diabetes Metab Syndr Obes
2014; 7: 95-105.
Turek SJ, Hastings SM, Sun JK, King GL, Keenan HA. Sexual dysfunction as a marker of cardiovascular disease in males with 50 or more years of type 1 diabetes. Diabetes Care
2013; 36: 3222-6.
Dong JY, Zhang YH, Qin LQ. Erectile dysfunction and risk of cardiovascular disease: meta-analysis of prospective cohort studies. J Am Coll Cardiol
2011; 58: 1378-85.
Araujo AB, Travison TG, Ganz P, Chiu GR, Kupelian V, et al.
Erectile dysfunction and mortality. J Sex Med
2009; 6: 2445-54.
Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, et al.
Executive summary: heart disease and stroke statistics-2014 update: a report from the American Heart Association. Circulation
2014; 129: 399-410.
OECD. Mortality from heart disease and stroke, in Health at a Glance 2011: OECD Indicators, OECD Publishing; 2011. Available from: http://www.dx.doi.org/10.1787/health_glance-2011-6-en [last accessed on 2014 Jun 25].
Ezzati M, Riboli E. Behavioral and dietary risk factors for noncommunicable diseases. N Engl J Med
2013; 369: 954-64.
Ervin RB. Prevalence of metabolic syndrome among adults 20 years of age and over, by sex, age, race and ethnicity, and body mass index: United States, 2003-2006. Natl Health Stat Report
2009; 5: 1-7.
Meldrum DR, Gambone JC, Morris MA, Meldrum DA, Esposito K, et al
. The link between erectile and cardiovascular health: the canary in the coal mine. Am J Cardiol
2011; 108: 599-606.
Kalyani RR, Dobs AS. Androgen deficiency, diabetes, and the metabolic syndrome in men. Curr Opin Endocrinol Diabetes Obes
2007; 14: 226-34.
Dandona P, Dhindsa S. Update: hypogonadotropic hypogonadism in type 2 diabetes and obesity. J Clin Endocrinol Metab
2011; 96: 2643-51.
Bellastella G, Maiorino MI, Olita L, De Bellis A, Giugliano D, et al
. Anti-pituitary antibodies and hypogonadotropic hypogonadism in type 2 diabetes: in search of a role. Diabetes Care
. 2013; 36: e116-117.
Esposito K, Giugliano F, Di Palo C, Giugliano G, Marfella R, et al.
Effect of lifestyle changes on erectile dysfunction in obese men: a randomized controlled trial. JAMA
2004; 291: 2978-84.
Hannan JL, Maio MT, Komolova M, Adams MA. Beneficial impact of exercise and obesity interventions on erectile function and its risk factors. J Sex Med
2009; 6 Suppl 3: 254-61.
Horasanli K, Boylu U, Kendirci M, Miroglu C. Do lifestyle changes work for improving erectile dysfunction? Asian J Androl
2008; 10: 28-35.
Chew KK, Bremner A, Stuckey B, Earle C, Jamrozik K. Alcohol consumption and male erectile dysfunction: an unfounded reputation for risk? J Sex Med
2009; 6: 1386-94.
Esposito K, Ciotola M, Giugliano F, Maiorino MI, Autorino R, et al.
Effects of intensive lifestyle changes on erectile dysfunction in men. J Sex Med
2009; 6: 243-50.
Håkonsen LB, Thulstrup AM, Aggerholm AS, Olsen J, Bonde JP, et al.
Does weight loss improve semen quality and reproductive hormones? Results from a cohort of severely obese men. Reprod Health
2011; 8: 24.
Khoo J, Piantadosi C, Worthley S, Wittert GA. Effects of a low-energy diet on sexual function and lower urinary tract symptoms in obese men. Int J Obes (Lond)
2010; 34: 1396-403.
Esposito K, Giugliano F, Maiorino MI, Giugliano D. Dietary factors, Mediterranean diet and erectile dysfunction. J Sex Med
2010; 7: 2338-45.
Shamloul R, Ghanem H. Erectile dysfunction. Lancet
2013; 381: 153-65.
Bacon CG, Mittleman MA, Kawachi I, Giovannucci E, Glasser DB, et al
. Sexual function in men older than 50 years of age: results from the health professionals follow-up study. Ann Intern Med
2003; 139: 161-8.
Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol
1994; 151: 54-61.
Thompson IM, Tangen CM, Goodman PJ, Probstfield JL, Moinpour CM, et al
. Erectile dysfunction and subsequent cardiovascular disease. JAMA
2005; 294: 2996-3002.
Giuliano FA, Leriche A, Jaudinot EO, de Gendre AS. Prevalence of erectile dysfunction among 7689 patients with diabetes or hypertension, or both. Urology
2004; 64: 1196-201.
Esposito K, Giugliano F, Martedì E, Feola G, Marfella R, et al.
High proportions of erectile dysfunction in men with the metabolic syndrome. Diabetes Care
2005; 28: 1201-3.
Cheng JY, Ng EM, Ko JS, Chen RY. Physical activity and erectile dysfunction: meta-analysis of population-based studies. Int J Impot Res
2007; 19: 245-52.
Feldman HA, Johannes CB, Derby CA, Kleinman KP, Mohr BA, et al.
Erectile dysfunction and coronary risk factors: prospective results from the Massachusetts male aging study. Prev Med
2000; 30: 328-38.
Bacon CG, Mittleman MA, Kawachi I, Giovannucci E, Glasser DB, et al
. A prospective study of risk factors for erectile dysfunction. J Urol
2006; 176: 217-21.
Ponholzer A, Temml C, Mock K, Marszalek M, Obermayr R, et al
. Prevalence and risk factors for erectile dysfunction in 2869 men using a validated questionnaire. Eur Urol
2005; 47: 80-5.
Lamina S, Okoye CG, Dagogo TT. Therapeutic effect of an interval exercise training program in the management of erectile dysfunction in hypertensive patients. J Clin Hypertens (Greenwich)
2009; 11: 125-9.
La Vignera S, Condorelli R, Vicari E, D'Agata R, Calogero A. Aerobic physical activity improves endothelial function in the middle-aged patients with erectile dysfunction. Aging Male
2011; 14: 265-72.
Maio G, Saraeb S, Marchiori A. Physical activity and PDE5 inhibitors in the treatment of erectile dysfunction: results of a randomized controlled study. J Sex Med
2010; 7: 2201-8.
Meldrum DR, Gambone JC, Morris MA, Esposito K, Giugliano D, et al
. Lifestyle and metabolic approaches to maximizing erectile and vascular health. Int J Impot Res
2012; 24: 61-8.
Meldrum DR, Burnett AL, Dorey G, Esposito K, Ignarro LJ. Erectile hydraulics: maximizing inflow while minimizing outflow. J Sex Med
2014; 11: 1208-20.
van Craenenbroeck EM, Conraads VM. Endothelial progenitor cells in vascular health: focus on lifestyle. Microvasc Res
2010; 79: 184-92.
Cooney GM, Dwan K, Greig CA, Lawlor DA, Rimer J, et al
. Exercise for depression. Cochrane Database Syst Rev
2013; 9: CD004366. doi: 10.1002/14651858.
Larsen SH, Wagner G, Heitmann BL. Sexual function and obesity. Int J Obes (Lond)
2007; 31: 1189-98.
Shiri R, Koskimäki J, Hakama M, Häkkinen J, Huhtala H, et al.
Effect of life-style factors on incidence of erectile dysfunction. Int J Impot Res
2004; 16: 389-94.
Fung MM, Bettencourt R, Barrett-Connor E. Heart disease risk factors predict erectile dysfunction 25 years later: the Rancho Bernardo Study. J Am Coll Cardiol
2004; 43: 1405-11.
Kolotkin RL, Head S, Hamilton M, Tse CK. Assessing impact of weight on quality of life. Obes Res
1995; 3: 49-56.
Khoo J, Piantadosi C, Duncan R, Worthley SG, Jenkins A, et al.
Comparing effects of a low-energy diet and a high-protein low-fat diet on sexual and endothelial function, urinary tract symptoms, and inflammation in obese diabetic men. J Sex Med
2011; 8: 2868-75.
Reis LO, Favaro WJ, Barreiro GC, de Oliveira LC, Chaim EA, et al.
Erectile dysfunction and hormonal imbalance in morbidly obese male is reversed after gastric bypass surgery: a prospective randomized controlled trial. Int J Androl
2010; 33: 736-44.
Dallal RM, Chernoff A, O'Leary MP, Smith JA, Braverman JD, et al
. Sexual dysfunction is common in the morbidly obese male and improves after gastric bypass surgery. J Am Coll Surg
2008; 207: 859-64.
Esposito K, Giugliano D. Obesity, the metabolic syndrome, and sexual dysfunction in men. Clin Pharmacol Ther
2011; 90: 169-73.
Corona G, Rastrelli G, Monami M, Saad F, Luconi M, et al.
Body weight loss reverts obesity-associated hypogonadotropic hypogonadism: a systematic review and meta-analysis. Eur J Endocrinol
2013; 168: 829-43.
Wang F, Dai S, Wang M, Morrison H. Erectile dysfunction and fruit/vegetable consumption among diabetic Canadian men. Urology
2013; 82: 1330-5.
Giugliano F, Maiorino MI, Bellastella G, Autorino R, De Sio M, et al.
Adherence to Mediterranean diet and erectile dysfunction in men with type 2 diabetes. J Sex Med
2010; 7: 1911-7.
Esposito K, Giugliano F, De Sio M, Carleo D, Di Palo C, et al.
Dietary factors in erectile dysfunction. Int J Impot Res
2006; 18: 370-4.
Esposito K, Ciotola M, Giugliano F, De Sio M, Giugliano G, et al.
Mediterranean diet improves erectile function in subjects with the metabolic syndrome. Int J Impot Res
2006; 18: 405-10.
Hu FB, Willett WC. Optimal diets for prevention of coronary heart disease. JAMA
2002; 288: 2569-78.
Lopez-Garcia E, Hu FB. Nutrition and the endothelium. Curr Diab Rep
2004; 4: 253-9.
Esposito K, Giugliano D. Diet and inflammation: a link to metabolic and cardiovascular diseases. Eur Heart J
2006; 27: 15-20.
Wing RR, Rosen RC, Fava JL, Bahnson J, Brancati F, et al.
Effects of weight loss intervention on erectile function in older men with type 2 diabetes in the Look AHEAD trial. J Sex Med
2010; 7: 156-65.
Esposito K, Giugliano D. Lifestyle/dietary recommendations for erectile dysfunction and female sexual dysfunction. Urol Clin North Am
2011; 38: 293-301.
Polsky JY, Aronson KJ, Heaton JP, Adams MA. Smoking and other lifestyle factors in relation to erectile dysfunction. BJU Int
2005; 96: 1355-9.
Kupelian V, Link CL, McKinlay JB. Association between smoking, passive smoking, and erectile dysfunction: results from the Boston Area Community Health (BACH) Survey. Eur Urol
2007; 52: 416-22.
Cao S, Yin X, Wang Y, Zhou H, Song F, et al
. Smoking and risk of erectile dysfunction: systematic review of observational studies with meta-analysis. PLoS One
2013; 8: e60443.
Harte CB, Meston CM. Association between smoking cessation and sexual health in men. BJU Int
2012; 109: 888-96.
Pourmand G, Alidaee MR, Rasuli S, Maleki A, Mehrsai A. Do cigarette smokers with erectile dysfunction benefit from stopping? A prospective study. BJU Int
2004; 94: 1310-3.
Kalter-Leibovici O, Wainstein J, Ziv A, Harman-Bohem I, Murad H, et al.
Clinical, socioeconomic, and lifestyle parameters associated with erectile dysfunction among diabetic men. Diabetes Care
2005; 28: 1739-44.
Martin SA, Atlantis E, Lange K, Taylor AW, O'Loughlin P, et al.
Predictors of sexual dysfunction incidence and remission in men. J Sex Med
2014; 11: 1136-47.
Cheng JY, Ng EM, Chen RY, Ko JS. Alcohol consumption and erectile dysfunction: meta-analysis of population-based studies. Int J Impot Res
2007; 19: 343-52.
Chung E, De Young L, Brock GB. Investigative models in erectile dysfunction: a state-of-the-art review of current animal models. J Sex Med
2011; 8: 3291-305.
La Favor JD, Anderson EJ, Dawkins JT, Hickner RC, Wingard CJ. Exercise prevents Western diet-associated erectile dysfunction and coronary artery endothelial dysfunction: response to acute apocynin and sepiapterin treatment. Am J Physiol Regul Integr Comp Physiol
2013; 305: R423-34.
Maio MT, Hannan JL, Komolova M, Adams MA. Caloric restriction prevents visceral adipose tissue accumulation and maintains erectile function in aging rats. J Sex Med
2012; 9: 2273-83.
Hannan JL, Heaton JP, Adams MA. Recovery of erectile function in aging hypertensive and normotensive rats using exercise and caloric restriction. J Sex Med
2007; 4: 886-97.
Zhang Q, Radisavljevic ZM, Siroky MB, Azadzoi KM. Dietary antioxidants improve arteriogenic erectile dysfunction. Int J Androl
2011; 34: 225-35.
Aydinoglu F, Yilmaz SN, Coskun B, Daglioglu N, Ogulener N. Effects of ethanol treatment on the neurogenic and endothelium-dependent relaxation of corpus cavernosum smooth muscle in the mouse. Pharmacol Rep
2008; 60: 725-34.
Park MG, Ko KW, Oh MM, Bae JH, Kim JJ, et al
. Effects of smoking on plasma testosterone level and erectile function in rats. J Sex Med
2012; 9: 472-81.
O'Leary MP, Althof SE, Cappelleri JC, Crowley A, Sherman N, et al.
Self-esteem, confidence and relationship satisfaction of men with erectile dysfunction treated with sildenafil citrate: a multicenter, randomized, parallel group, double-blind, placebo controlled study in the United States. J Urol
2006; 175: 1058-62.
Hatzimouratidis K, Amar E, Eardley I, Giuliano F, Hatzichristou D, et al.
Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. Eur Urol
2010; 57: 804-14.
Esposito K, Giugliano D. Healthy lifestyle for metabolic health: no more excuse! Endocrine
2014; 46: 176-8.
Moyad MA, Park K. What do most erectile dysfunction guidelines have in common? No evidence-based discussion or recommendation of heart-healthy lifestyle changes and/or Panax ginseng. Asian J Androl
2012; 14: 830-41.
|This article has been cited by|
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|[Pubmed] | [DOI]|
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|[Pubmed] | [DOI]|
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|[Pubmed] | [DOI]|
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| ||Current Opinion in Endocrine and Metabolic Research. 2019; |
|[Pubmed] | [DOI]|
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| ||International Journal of Impotence Research. 2018; |
|[Pubmed] | [DOI]|
||From inflammation to sexual dysfunctions: a journey through diabetes, obesity, and metabolic syndrome
| ||M. I. Maiorino,G. Bellastella,D. Giugliano,K. Esposito |
| ||Journal of Endocrinological Investigation. 2018; |
|[Pubmed] | [DOI]|
||Exercise training causes a partial improvement through increasing testosterone and eNOS for erectile function in middle-aged rats
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| ||Experimental Gerontology. 2018; 108: 131 |
|[Pubmed] | [DOI]|
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| ||Reproductive Biology and Endocrinology. 2018; 16(1) |
|[Pubmed] | [DOI]|
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| ||Mahmoud ElJalby,Dominique Thomas,Dean Elterman,Bilal Chughtai |
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|[Pubmed] | [DOI]|
||Calorie restriction reverses age-related alteration of cavernous neurovascular structure in the rat
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|[Pubmed] | [DOI]|
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| ||Bioscience Reports. 2017; 37(4) |
|[Pubmed] | [DOI]|
| ||Faysal A. Yafi,Lawrence Jenkins,Maarten Albersen,Giovanni Corona,Andrea M. Isidori,Shari Goldfarb,Mario Maggi,Christian J. Nelson,Sharon Parish,Andrea Salonia,Ronny Tan,John P. Mulhall,Wayne J. G. Hellstrom |
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|[Pubmed] | [DOI]|
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| ||The Journal of Sexual Medicine. 2015; 12(6): 1319 |
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||Cardiovascular disease and male sexual dysfunction
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| ||Asian Journal of Andrology. 2015; 17(1): 3 |
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A beautifully illustrated story.An environmentally important book.
Tree's Song (for Jenni)
A moving story about the lifelong love between a girl and an apple tree.
"Tree's Song (for Jenni) has the makings of a classic, both for the simple, moving story and the timelessness of the illustrations."
Patricia Lowry, former Pittsburgh Post-Gazette
"Tree's Song (for Jenni) is a wonderful coming of age story that explores our bond with nature throughout the seasons of our lives. Beautifully written and illustrated, it will captivate readers both young and old.
"As a boy, I would read in the big tree in my parents' front yard during the summer. Tree's Song took me back to those days and helped me recall good memories of sitting in our tree."
Chris G., Librarian
“I am truly impressed with the story and Illustrations in Tree's Song (for Jenni). For one who has spent a lifetime among the apple trees, Tree’s Song resonates with the recurring need and delight in establishing a bond with trees, especially fruit trees that provide nourishment for the body as well as the spirit. From the child’s first joy of discovery to the wrinkled hand cradling its precious fruit, this bond is a commitment and an understanding about our natural world. Jenni spoke to her tree without uttering a single word.”
Tom Burford, "Professor Apple"
Orchard consultant, lecturer, and author of Apples of North
America, Timber Press, 2013
"An uplifting book - beautiful in story, illustration, and environmental message."
Sharon G. Flake, Award-winning author of The Skin I'm In
Tree's Song (for Jenni) is a picture book for nature lovers of all ages, especially those who love trees.
It tells a sweet story, perfect for children and for parents and grandparents to share with children.
It is also enjoyed by adults who care about trees because it provides a touching reminder of the importance a tree can play in our lives.
Tree's Song captures with beautiful illustrations many significant life events and stages:
being young, growing up, going away to college, getting married, having a baby, and growing older.
Tree's Song makes a beautiful gift for wedding and baby showers. It is also a great way for parents and grandparents to pass on their love of nature to their
children and grandchildren.
Environmentally Important - Tree's Song (for Jenni) portrays a healthy, happy relationship between human beings and nature with Tree and Jenni as BFF.
Tree's Song (for Jenni) is a hardcover book (8-3/8" x 9-1/2") of 40 pages, printed in the United States on 100% recycled paper.
janet jai is a nonfiction writer and poet-artist who loves trees. She has been published and has exhibited nationally and internationally. She is the author of Saving Our Public Libraries: Why We Should. How We Can. She is also the creator of poemART, an intimate blend of poetry and colorful abstract art. A limited-edition book of her early poemART is in the collection of the National Museum of Women in the Arts. In 1996, jai opened her own firm, Vision and Values, which is dedicated to "Communications That Make a Difference."
Maria Cherkasskaya is an artist and illustrator, originally from Ukraine. For almost 20 years, she was a Production Designer at Ukranimafilm, a renowned animation studio in Kiev. There she created characters, storyboards and backgrounds for animation films, many of which received national and international awards. Since 1994, Maria has lived in Pittsburgh. Her illustrations have appeared in numerous children’s books and magazines.


Her sigh filled the garden. “I really do have to go. I’m a business woman, and I have to be up early.”
She stood. “This was nice. Thanks.”
He took both her hands in his. She swayed toward him, started to kiss his cheek.
“No.” He met her lips with his. Hunger, raw and deep, ripped through him. He tasted the same emotion on her lips, in her. One kiss led to another and another.
Breathing hard, she broke away, running her fingers through her hair to push it off her face. “I can’t do this. It was never a question of chemistry. We had that in spades.”
“We still do.” His voice was husky and ragged.
“I can’t and won’t deny that.”
“Come upstairs with me. Stay the night.” He trailed kisses along her neck, her collarbone. She shivered, and he knew she was close.
But she put her hands on his arms and pushed away. “I can’t.”
“I know I handled things badly, but how can you hold it against me so long?”
She didn’t answer. Simply turned to walk away.
He grabbed her hand and kissed it before she melted into the night, leaving him standing in the dark, wanting more. So much more.


Khan, Hasham (2009) Power Quality Improvement of Distribution system with Dispersed Generation using Novel Algorithem for Islanding Control and Detection Processes. PhD thesis, University of Engineering & Technology, Taxila .
Distribution engineers investigate economical and technical feasibility of new capacity expansion alternatives. Distributed generation (DG) can be used effectively to support the customer’s power quality requirements. DG is an imperative tool that can partially replace the need to erect new generating stations in order to cope with the increasing load demands.However, numerous complexities arise like parallel operation of DG within existing system, phenomena of islanding and its detection, micro grid operation, monitoring and control etc. Several techniques have been developed for the effective detection of islanding.These techniques have numerous deficiencies.First of all, a majority of these islanding detection techniques have been developed only for balanced three phase load.No single-phase load and unbalanced three phase loads have been considered. Secondly, successful transfer into autonomous micro grid operation requires islanding detection and a subsequent change in control strategy of micro grid DG units.Thirdly, this operation causes large amount of current flow out of the micro grid into the fault, resulting in severely depressed micro grid bus voltage. In this research work, the emphasis is to improve these problems and overcome the drawbacks of existing techniques.The aims and objectives of this study are to develop a novel islanding detection technique, reliable, effective and efficient operation of DG in coordination with main utility network as well as power quality improvement for essential load. In order to improve the power quality of distribution network and to detect the islanding phenomena with DG, innovative techniques are required to implement the solution and mitigate the problems effectively. In this research study, using an analytical approach, two algorithms have been designed; a comprehensive algorithm for the implementation of distributed generation (IDG) by finding the optimal size and location of DG for power quality improvement and a new islanding detection algorithm (NIDA) for islanding detection under multiple distributed generation scenarios. The proposed algorithms can be utilized effectively to enhance the feeder performance having randomly distributed loads.The algorithms have been designed in “C language” and are based upon the power quality improvement of distribution feeder in terms of node voltage profile enhancement, power loss reduction and islanding detection in multi-DG scenario.The newly designed algorithms outperform the conventional approaches, which encounter numerous complexities during their implementation.The designed algorithms have the capabilities to operate under uniform and non-uniform loads with low power factor for both single DG and multi-DG scenario.The suggested algorithms have been implemented on different feeders including, 11kV feeder, 12.5kV feeder and IEEE 34 bus feeder.The feeders have been simulated in “C-language” and the results have been verified. The simulation results show that the algorithms can be implemented efficiently to detect the islanding phenomena and enhance the distribution system performance in terms of node voltage profile improvement and power loss reduction.
|Item Type:||Thesis (PhD)|
|Uncontrolled Keywords:||Feeders, Power, Technique, Distribution, Unbalanced, Quality, Micro, Processes, Feasibility, Improvement, Control, Algorithms, Generation, Dispersed, Islanding, Improvement|
|Subjects:||Engineering & Technology (e) > Engineering(e1) > Electrical engineering (e1.16)|
|Deposited By:||Mr. Javed Memon|
|Deposited On:||28 Dec 2011 09:23|
|Last Modified:||28 Dec 2011 09:23|
Repository Staff Only: item control page


But the fruit of the Spirit is love, joy, peace, patience, kindness, goodness, faithfulness, gentleness, self-control; against such things there is no law. And those who belong to Christ Jesus have crucified the flesh with its passions and desires. If we live by the Spirit, let us also keep in step with the Spirit. Let us not become conceited, provoking one another, envying one another.
(Galatians 5:22-26 ESV)
Passions are powerful. Love has built kingdoms and lust has torn them down. Ambition has built industrial empires and greed has bankrupted them.
We’ve all known someone who consistently allowed their passions to lead them into bad decisions. I had a friend who went from relationship to relationship–even if relationship wasn’t always the right word–and made major purchases that he couldn’t afford the moment he got his head above the financial water. He wasn’t a bad guy; he was a good friend who was there when I needed him. Unfortunately, his passions made all of his major decisions for him. He rarely considered how his actions today would impact his life ten years in the future. Most of his decisions were only about right now.
Much like Esau.
Esau’s birth name means “hairy”, which conveys a bit of his rough character, but I think his other name, Edom, is even more apropos. It means “red” like the earth or like the fire of his anger, ambition, and lust. He wasn’t a farmer like his father, Isaac, nor a shepherd like his brother, Jacob. He was a hunter. He started quarrels, married impulsively, made bad deals in desperation and then promptly forgot about them.
Esau was a sort of reverse spiritual alchemist, turning the gold inheritance of his fabulously wealthy father into the lead of struggle and broken relationships. The inevitable end of the exceedingly passionate, those people who see what they want and go after what they see, is to be consumed by their urges.
Passion is a good and powerful force when checked by the Spirit, but when it is allowed to run free, it is crippling. The words Esau spoke at his father’s bedside when he finally realized what he had done in selling his birthright to Jacob are heartbreaking, but hardly unexpected:
As soon as Esau heard the words of his father, he cried out with an exceedingly great and bitter cry and said to his father, “Bless me, even me also, O my father!”
Solomon described Esau’s state of mind in Proverbs 11:3: “His heart rages against the LORD.” The passionate fool rarely directs his rage where it belongs. He lashes out at anyone nearby–which is why Rebekah was wise to send Jacob away to Laban before Esau could catch him–and against God when no more convenient target is available, but his ruin was his own doing. Whatever conspiring Jacob and Rebekah did, only Esau was in a position to sell his birthright. Nobody tricked him. Nobody forced him. He lusted after what was before him in the moment and didn’t value at all those things that he couldn’t see and taste.
Esau, enslaved to his passions, spent decades learning just a small portion of the peace and prosperity that he could have attained in his youth by submitting desire and passion to a higher calling in his father’s house. Although he learned to master his passions enough to reconcile with Jacob and build a legacy of his own, but his passed his anger and envy on to his descendants whose uneasy relationship with Israel simmered for more than a thousand years. His grandchildren and great grandchildren carried on his pattern of willful and ignorant self-immolation for many generations.
Concerning appropriate behavior of spiritual brothers toward one another, Paul wrote:
Do not be slothful in zeal, be fervent in spirit, serve the Lord. Rejoice in hope, be patient in tribulation, be constant in prayer.
In other words, be passionate about things that are not immediate and for which the ultimate rewards are more spiritual than physical, and restrain your passions concerning things that are physical. Be zealous, but not hasty; be passionate, but not vengeful.
Hunger will pass. God’s Word won’t, and neither will hell.
God can help you master your passions through prayer, study, and consistent practice. It’s not easy, but it can be done, and the earlier you start, the better. Your grandchildren will thank you.


My heart has been broken so many times lately. It breaks when I log on FB and see friends talking about horrible things happening around the world. It breaks at things happening in our own home. It breaks at things happening in my own mind and heart. Good. Let our hearts to be broken and stay broken. Let our expectations about the way life "was supposed to be" be shattered by the reality of the life which actually is. I keep waiting for things to "go back to normal". But we can't wait for our hearts to heal before living life - it'll never happen and we'll spend our lives waiting instead of living.
Copy & share: https://nathanpeterson.net/live-broken-hearted/
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A number of local writers and playwrights got the opportunity of a lifetime when they sat in a workshop with now international playwright Katori Hall.
Hall, the writer of “The Mountaintop” – a fictitious play showcasing the last night of Martin Luther King’s Jr’s life, was in Barbados, compliments the US Embassy, for the Caribbean Premier of the play which played to enthralled audiences at the Frank Collymore Hall during April. She shared some of her experiences with participants on the eve of the premier.
“Write in your tongue,” Ms. Hall told the participants. “Only you can do them in a way that is authentic, true and loving. Write your tongue! When I write about the South a lot of people can be dismissive of it. They say ‘why don’t you write about New York City or LA,‘ but this is the where I come from, this is the way I walk in this world. It’s very important for you to be that [writer] it’s a lot of responsibility but because you are there and the cadences and rhythms are there in your blood and in your memory your writing is the only way we will get an authentic portrayal of those stories.”
She further explained “Plays are stories of witness. Unlike film or reading short stories the audience completes this art form. Movies can be distributed like a piece of music that can be recorded. Plays are different every night, they are never the same because the audience’s reactions may change, or the actor’s performance changes. That is not to say that films are better or worse, they are just different to live theatre.”
Two well known Barbadian writers who attended the Republic Bank sponsored workshop commented:
“The experience tonight was – I keep thinking refreshing not sure that is the right word but that fits. It was my intention to take whatever I got today and learned for my writing in all areas and I definitely learned quite a bit that I can take to enhance my writing. Also [these tools] may reignite the writing a play at this stage of my life” stated Sandra Sealy.
Winston Farrell, who read an excerpt from his play House of Landship, said “I felt good about having the group read this work in progress. Katori and the others helped bring up some issues in the work which I can continue to think about and work on.”


The Cat Sitter's Pajamas
A Dixie Hemingway Mystery
By Blaize Clement
(Minotaur Books, Hardcover, 9780312643133, 272pp.)
Publication Date: January 3, 2012
Enter your zip code below to find indies closest to you.
Author Blaize Clement has thrilled readers everywhere with the first six books in her pet-sitting mystery series. Now Blaize’s beloved heroine Dixie Hemingway is back for another adventure, and she has her hands full when the worlds of celebrity hijinks, counterfeit fashion, and naughty cats collide.
Dixie Hemingway, no relation to you-know-who, accepts a job taking care of famous linebacker Cupcake Trillin’s cats, Elvis and Lucy, while he’s away. But what seems like an easy job turns scary when Dixie finds a celebrity fashion model in Cupcake’s house. The woman refuses to leave AND she also claims to be Cupcake’s wife. But Dixie has met Cupcake’s wife, and this woman certainly isn’t her.
Soon, Dixie is spun into the world of counterfeit high fashion. When a valuable list of fake merchandise sellers goes missing, the criminals go after Dixie. Once again, what started as a simple cat-sitting job has turned into a mess that only Dixie can solve.
BLAIZE CLEMENT is the author of Curiosity Killed the Cat Sitter, Duplicity Dogged the Dachshund, Even Cat Sitters Get the Blues, Cat Sitter on a Hot Tin Roof, Raining Cat Sitters and Dogs, and Cat Sitter Among the Pigeons.


Longtime readers of the site may remember a post from a couple of years ago in which we swapped a few words with Jo Brown about her fantastic Nature Journal project. We’re delighted to learn that Jo’s journal has now been adapted into her very first book Secrets of a Devon Wood — an exact replica of her original Moleskine journal, and a rich illustrated document of the flora and fauna to be found in the garden of her Devon cottage and the nearby woods. See pages extracted from the book below…
Secrets of a Devon Wood is published tomorrow by Short Books. You can order a copy (£12.99) through your local independent bookshop.
You can also follow Jo on Instagram.


"I loved everything about Dragon Mine, from the scorching first chapter to the epic worldbuilding. It's my new favorite Donna Grant novel! All hail Donna Grant, the Dragon Queen!" - New York Times bestselling author Larissa Ione
Walk with New York Times and USA Today bestselling author Donna Grant through the doorway into the next engaging installment of her captivating new Dragon Kings series...
I am hers, and she is mine...
Vaughn has spent eons searching for the woman who captured his heart, only to be disappointed time and again. Sure, he sees her in his dreams. May get to touch and hold her. But it's not the same. As the emptiness inside him grows, he jumps at the chance for a distraction. Setting his eyes on the dragons again in Zora is a balm, but it can't compare to once again coming face-to-face with the gorgeous beauty who holds a piece of his soul.
With responsibilities comes sacrifice...
Eurwen has never known anything but the burden and joy of ruling the dragons. But unlike her twin, she's always been curious about Earth and the Kings and felt as if something were missing from her life. When her reunion with her parents brings an unexpected surprise, she can't help but give in to the pleasure that Vaughn offers. Still, her loyalty lies with her realm, and the hurdles in their way to happiness seem insurmountable-especially with a new and unknown foe seeking to destroy them.
Trust doesn't come easily, but love conquers all. And no amount of time or space can keep those who belong together apart.
"I love fantasy romance and Donna Grant is one of the best at writing it. Dragon Mine defines what it means to have a true soulmate. I was captivated by this sexy love affair that was eons in the making." - New York Times bestselling author, Sawyer Bennett
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About the Author
Virginia DeBerry and Donna Grant are the bestelling authors of Far from the Tree and Tryin' to Sleep in the Bed You Made, which won an Honor Award for Fiction from the Black Caucus of the American Library Association, the Book of the Year Award from Blackboard, and the New Author of the year Award from the Go on Girl! Book Club. The authors met while working as models, and what should have been a rivalry ended up a decades-long friendship.