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Post mortem human brain tissue is used for the study of many different brain diseases. A key factor in conducting postmortem research is the quality of the tissue. Unlike animal tissue, whose condition at death can be controlled and influenced, human tissue can only be collected naturalistically. This introduces potential confounds, based both on pre- and postmortem conditions, that may influence the quality of tissue and its ability to yield accurate results. The traditionally recognized confounds that reduce tissue quality are agonal factors (e.g., coma, hypoxia, hyperpyrexia at the time of death), and long postmortem interval (PMI). We measured tissue quality parameters in over 100 postmortem cases collected from different sources and correlated them with RNA quality (as indicated by the RNA Integrity Number (RIN)) and with protein quality (as measured by the level of representative proteins). Our results show that the most sensible indicator of tissue quality is RIN and that there is a good correlation between RIN and the pH. No correlation developed between protein levels and the aforementioned factors. Moreover, even when RNA was degraded, the protein levels remained stable. However, these correlations did not prove true under all circumstances (e.g. thawed tissue, surgical tissue), that yielded unexpected quality indicators. These data also suggest that cases whose source was a Medical Examiner's office represent high tissue quality.
Increasingly, human postmortem brain tissue is being used to quantify cellular and molecular markers of neural processes in the pursuit of understanding normal brain function and correlates of dysfunction in CNS illnesses (Casanova and Kleinman, 1990; Castensson et al., 2000; Harrison et al., 1994; Mirnics et al., 2001; Ravid et al., 1992; Torrey et al., 2000). Because of the inaccessibility of the human brain and its unavailability for biopsy, fresh tissue is rarely obtainable. Consequently, the translation of new findings from basic laboratory studies to human brain diseases relies heavily on the use of postmortem tissue. Although studies using human tissue have been done for decades (Johnson et al., 1986; Wester et al., 1985), the sensitivity and specificity required for today's molecular measures are greater, therefore calling for better tissue characteristics. This requires not only collecting better tissue than before, but also identifying measures of tissue quality and setting quality thresholds.
With this press for "high quality" tissue comes the need to determine the critical markers of quality for human postmortem tissue (Deep-Soboslay et al., 2005; Hargrove and Schmidt, 1989). Several laboratories have approached the evaluation of human postmortem brain cases with suggestions for markers of tissue quality (Lee et al., 2005; Preece and Cairns, 2003; Tomita et al., 2004). We have taken several of these newer measures of tissue quality and tested them in human postmortem tissue in a variety of situations to detect the relationship of the markers to the real quality of the postmortem tissue. Traditionally, a low postmortem interval (Barton et al., 1993; Ferrer-Alcon et al., 2003; Harrison et al., 1995; Lewis, 2002; Trotter et al., 2002) has been the hallmark of high tissue quality. More recently tissue pH (Hynd et al., 2003; Kingsbury et al., 1995; Li et al., 2004) has been used, and even more recently, specific markers of RNA quality have been introduced (Imbeaud et al., 2005; Johnston et al., 1997; Miller et al., 2004). In a cohort of human postmortem cases, we have determined these standard tissue quality measures, checked their collection correlates, and tested them for an association with RNA quality and with quantification of representative proteins. We have attempted to identify which are the most sensitive and reliable markers of tissue quality in human postmortem cases.
We analyzed postmortem human brain tissue collected at two sites, Dallas, TX and Baltimore, MD. Both tissue collections receive tissue from the local Medical Examiner's (ME) office; in addition, the Dallas collection also receives tissue from the Willed Body Program (WB) of the University of Texas Southwestern Medical Center and from its Transplant Service Center (TSC). Whole human brains are collected from recently deceased persons with psychiatric diagnoses and matched controls (persons with no psychiatric diagnosis and no evidence of a psychiatric diagnosis in first degree family members). For every case, we obtained next-of-kin (NOK) permission to collect the tissue for research; we gathered medical records from all relevant institutions and conducted a direct informant interview for each case with at least one family member or primary care person. At least 2 research psychiatrists reviewed each case and made an independent diagnosis based on all available clinical information and then developed a consensus diagnosis for each case (Deep-Soboslay et al., 2005). The collection of tissue in Dallas was approved by the UTSW Institutional Review Board; in Baltimore, collection of tissue was approved by the University Of Maryland School Of Medicine Institutional Review Board.
Tissue is collected at autopsy from cases with NOK permission for research donation. At the sites of collection, cases are kept cold (4 degree C) between death and autopsy for variable periods of time. At autopsy, the brain is removed in the usual fashion and put on ice as soon as possible, after which it is transported to the laboratory and dissected immediately using a customized dissection. The cerebellar hemispheres are removed and sliced and frozen. Collection and tissue management at each site is similar, varying in small details, except for the origin of cases.
An emphasis at all sites has always been placed on collecting high quality tissue; therefore, "low quality" cases for comparison are sparse. Characteristics of quality classically used for brain collections include the following: cases with a relatively young age (approx 20--50 years old), unexpected death, as few treatment years as possible, no co-morbid drug abuse (except alcohol and nicotine), low postmortem interval (<24 hours with an average of 10–14 hours), and high quality clinical diagnoses and clear treatment history.
Inclusion criteria for Dallas and Baltimore collection sites are: 1) any psychiatric diagnosis; 2) any cases in which psychiatric medication was used for Axis 1 diagnoses; 3) suicide, 4) all ages, genders, races; 5) any normal case with demographic and PMI characteristics matching a psychiatric case; 6) available NOK and NOK permission for collection. Exclusion criteria are: 1) traumatic injury to the head; 2) forensic or medical issues involving the brain; 3) > 24 hour PMI collected on a case-by-case basis; 4) documented history of an infectious disease.
A gross neuropathological exam was completed on each brain consisting of a macroscopic examination. A broad toxicological screen was done by the ME office for all of the common drugs of abuse and the common therapeutic drugs; these included approximately 500 medications and covers the common antipsychotic, antidepressant, mood stabilizers, and antiepileptic drugs.
For the tissue quality measurements we used cerebellar tissue, except where noted for regional comparison; the samples were obtained by punching the cerebellum slices with a 4 mm diameter dermal biopsy punch (Miltex, Inc.)
The surgical brain samples were obtained from the temporal neocortex of four patients who underwent anterior temporal lobectomy for medically intractable temporal lobe epilepsy at the Parkland Memorial Hospital. All four patients had MRI and pathologic evidence of mesial temporal sclerosis involving the hippocampus. The temporal neocortex was radiologically and histologically normal. Informed consent for research was obtained from the patients. The study was approved by the UTSW Institutional Review Board. The samples were dissected from the neocortex of the surgically resected specimen, carefully avoiding leptomeninges and white matter. Immediately, adjacent samples were submitted for routine histology. Microscopic examination of the adjacent samples verified that the samples contained only neocortex. The samples were placed in 1.5 ml microfuge tubes, frozen rapidly in a metal block at −80 C within 20 minutes of the time the samples were removed from the patient, stored at −80 C for 6–11 months, and used for total RNA isolation.
Because it is recognized that the manner of death (sudden versus prolonged death) impacts the quality of the tissue (Harrison et al., 1991), methods to record this have been developed. Tomita et al developed the Agonal Factor Score (AFS) to quantify the manner of death (Tomita et al., 2004). To calculate the AFS, several factors were rated: prolonged death (PD), coma, pyrexia, hypoxia, multiple organ failure (MOF), head injury (HI), neurotoxic substance ingestion. Each of these factors is scored with 1 (if present) or 0 (if absent). The overall AFS is calculated by summing all the individual scores.
Approximately 150 mg of frozen cerebellar tissue was homogenized in 1.5 ml of double deionized water (pH adjusted to 7.00), centrifuged for 3 minutes at 8000 g at 4 degree C. Tissue from other brain areas was used, where indicated. The pH of the supernatant was measured with a pH meter (Thermo – Electron Corporation) previously calibrated with 3 standards (pH = 4.00; pH = 7.00; pH = 10.00). For each sample, the determinations were made in duplicate.
Total RNA was isolated using Trizol (Invitrogen), according to the manufacturer's instructions. RNA purity was assessed using the A260/A280 ratio (A260 = absorbance at 260 nm; A280 = absorbance at 280 nm).
RNA integrity was analyzed first by 1.5% agarose gel electrophoresis. As a further step, the samples were run on an Agilent 2100 Bioanalyzer, which also automatically calculates the sample concentration, the 28S/18S ribosomal ratio, and the RNA Integrity Number (RIN).
Approximately 75 mg of frozen cerebellar tissue was homogenized with a Polytron homogenizer in 1.5 ml lysis buffer (0.05 M Tris, 10 mM EDTA, 0.5% Tween-20, 2μg/ml aprotinin, leupeptin and pepstatin, and 100μg/ml phenylmethane sulphonyl fluoride (PMSF)) and centrifuged for 15 minutes at 1000g at 4 degree Celsius. The protein concentration of the supernatant was determined using a BCA assay (Pierce). 30 micrograms of protein was mixed with 5X loading buffer (250 mM Tris HCl (pH 6.8), 10% SDS, 10%l Glycerol, 100 mM DTT and 0.2% bromphenol blue), resolved on a 12% SDS-PAGE gel, transferred to PVDF membrane (120 V, for 1.5 hours at 4 degree C), blocked in 5% milk in TBST (50 mM Tris, pH 7.4, 150 mM NaCl, 0.1% Tween-20), and incubated in primary antibody: synaptotagmin (St) (1:1500), Rab3A (R) (1:3000), Syntaxin1 (St) (1:4000), Munc18 (M) (1:1000), VCP (valosine containing protein) (1:2000) and GAPDH (G). The primary antibodies used in this study were a gift from Thomas Sudhof (UTSW), except for primary antibodies against GAPDH, where they were purchased from Santa Cruz Biotechnology. After washing with TBST, membranes were incubated in secondary antibody 125I (1:2000) and detected using a Storm phosphor imager. Valosin containing protein (VCP) was used as a loading control. All the protein levels were normalized to VCP.
All cases were first divided into 5 diagnostic groups: normal controls (NL), schizophrenia (SZ), bipolar disorder (BD), depression/suicide (D/S), and other diagnoses (O). The difference among the quality parameters was examined using one-way ANOVA followed by post hoc tests when indicated.
Secondly, all collection cases were divided by the 4 tissue sources: Dallas County Medical Examiner's Office (DME), Baltimore Medical Examiner's Office (BME), Transplant Service Center (TSC), and Willed Body Program (WB). The same parameters as above were compared between groups in a similar fashion.
We analyzed tissue samples taken from 114 individuals aged 15 years to 90 years, with the mean age of 45.3 * 17.9 years. The tissue came from two locations (Dallas, Texas and Baltimore, Maryland) and from three sources: Medical Examiner's Office (ME), Transplant Service Center (TSC) and Willed Body Program (WB). Neither Dallas nor Baltimore collections contained low quality tissue because of strict preexisting inclusion criteria.
The demographic characteristics of the cases and parameters used to assess case tissue quality are detailed by psychiatric diagnosis in Table 1. The average age range for each diagnostic group is: 16 – 77 years for normal controls (NL), 22 – 81 years for schizophrenia (SZ), 16 – 68 years for bipolar disorder (BD), 15 – 90 years for depression/suicide (D/S), and 17 – 57 for other diagnoses (O). This range covers the active illness years for most of the diagnoses. Tissue quality measures are generally high with relatively low PMIs (<24 hours), few agonal events at death (AFS = 0 or AFS = 1), good pHs (<6.4) and RINs (>7). ANOVA showed no difference among groups in terms of age (F(4, 109)=1.77, p=0.14)), PMI (F(4, 108)=0.94, p=0.44)), pH (F(4, 102)=0.28, p=0.89)), or RIN (F(4, 101)=1.01, p=0.40)).
To address the question of which tissue source provides high quality tissue, we contrasted the characteristics of tissue from ME, TSC and WB (Table 2). ANOVA indicated that there were age differences among locations (F(3, 110) = 7.02, p=0.0002)). The tissue from WB program had a significantly higher mean age as compared to DME (p< 0.001), BME (p = 0.002) and TSC (p= 0.0023). While it appeared that the WB tissue had a lower mean RIN value (RIN = 5.9 * 2.9) than the other tissue sources (RIN = 7.5 * 2.1 for DME; RIN = 7.5 * 1.7 for BME; RIN = 7.9 * 2.1 for TSC), the difference was not significant. Tissue quality measures from cases collected at both ME offices and TSC matched and were similarly good, with no differences in PMI (F(3, 109)=1.03, p=0.38)), pH (F(3, 108)=1.26, p=0.29)), or RIN (F(3, 102)=1.94, p=0.13)).
pH is one of the most widely used tissue quality measurements. We assessed pH levels in the whole collection and contrasted them by diagnosis and by the tissue source. The average pH is not significantly different across any of the diagnostic groups (Fig. 1) or the collection sites (Fig. 2). Although the average pH appears lower for the brains collected from WB program, it is not significantly lower.
It is possible that inner regions of the brain cool more slowly than the brain surface, therefore brain tissue in the deep areas could be of poorer quality, due to its prolonged exposure to higher temperatures. To address this question, we sampled several parts of the brain found at variable distances from the brain surface: dorsolateral prefrontal cortex (DLPFC), medial prefrontal cortex (MPFC) and the deep temporal cortex (TC). Moreover, inside any brain region, given the higher metabolic rate of the neurons as compared to the glia, we predicted that the neurons might be more susceptible to the factors that adversely influence the tissue quality. As the gray matter (GM) is composed mostly of neuronal soma and the white matter (WM) mainly of axons and glia, a comparison between the WM and GM could provide a crude estimate of how different tissue types in the brain are conserved. We measured pH from the regions described above and found that the marker was constant across all the sampled areas and that pH in all brain regions tested is well represented by the cerebellum pH (Table 3).
Intact total RNA consists mainly of two ribosomal species: 28S and 18S. Their corresponding bands should appear crisp and well delineated on a gel electrophoresis and the 28S band should be approximately twice as bright as the 18S band. As total RNA degrades, shorter fragments progressively accumulate and the ribosomal species become less abundant; consequently, the 28S and 18S bands fade or disappear and the smaller species migrate as a smear. Illustrations of this by RNA quality are given in Fig. 3a.
Agilent electrophoresis utilizes microcapillary electrophoresis, separating the molecules by size. The output is a diagram that displays fluorescence over time, with small molecules appearing at the left side of the graph. Illustrations of this by RNA quality are in Fig. 3b (high quality), Fig. 3c (medium quality), and Fig. 3d (low quality). With intact RNA, the baseline is flat, the two main peaks corresponding to the ribosomal species are sharp and clearly defined, and there is little noise between them (Fig. 3b). With progressive degradation of the total RNA, low molecular weight material can be visualized as supplementary peaks at the left side of the curve or as a shift in the baseline, and the ribosomal peaks are lower (Fig. 3c). Totally degraded RNA is made only of short fragments (Fig. 3d).
Classically, the 28S/18S area ratio has been used to assess the total RNA quality. The 28S:18S rRNA ratio is calculated by dividing the areas under the 18S rRNA peak into the area under the 28S rRNA peak. When RNA is intact, the ratio should be approximately 2. However, looking only at 28S/18S ratio for RNA quality doesn't capture the magnitude of the degradation products in the estimation of RNA quality.
To solve this problem, Agilent developed an algorithm that analyzes the entire electropherogram without investigator bias and assigns a score from 1 to 10 based on the ribosomal peaks and the extent of RNA degradation products. This score is designated as RIN (RNA Integrity Number). A completely intact RNA will be attributed a RIN of 10. As more peaks different from 28S and 18S are encountered, RIN decreases accordingly to reflect the presence of the degraded material (Imbeaud et al., 2005).
Overall, there is a good correlation between pH and RIN (R2 = 0.64) (Fig. 4a). RIN and pH are highly correlated in the low RIN value range (RIN<7) (R2 = 0.8) (Fig. 4b). This correlation is not evident when looking only at higher RIN values (RIN>7) (R2 = 0.1), supporting the need for other tissue quality markers in addition to pH. Since most of the tissue we collected was of reasonably high quality, we may have had too few low quality cases to represent this correlation strongly.
Postmortem interval (PMI) as used here is the interval between the time of death and the time when the brain is frozen or fixed. When the exact time of death is unknown, we use the midpoint between the last time seen alive and the time when the body is discovered. Although traditionally thought to be a good marker of high tissue quality, with a PMI range of 6 to 40 hours, PMI does not correlate with the RNA quality (Fig. 4c). However, again, we may have lacked sufficiently long PMIs to demonstrate such a correlation.
Both PMI and pH have been previously used to indicate RNA quality assessment, but our data showed that there is no correlation between them, looked at independently (Fig. 4d). Again, a correlation might become evident in poor quality tissue.
Although VCP is not widely used as a loading control, we found it to have low variability across all tissue conditions. Out of 6 protein gels, we averaged the VCP values across all lanes and normalized VCP value in every lane to the average value. The changes relative to the mean were between 0.5% and 10%, even if we loaded tissue of different PMIs, RINs and agonal conditions. Specifically, we loaded 6 protein gels: the coefficients of VCP variability for each gel were as follows: 0.07, 0.06, 0.07, 0.06, 0.05, and 0.03. To begin to evaluate the effect of tissue quality markers on protein concentrations in the postmortem material, we measured protein concentrations in cerebellar tissue and correlated them with putative quality markers. Proteins of different sizes were chosen spanning different molecular weights (Rab 3A = 30 KDa; Syntaxin 1 = 35 KDa; Synaptotagmin 1 = 65 KDa; Munc-18 = 65 KDa) and from different cellular compartments (Rab 3A = 50% soluble, 50% synaptic vesicles; Syntaxin 1 = plasma membrane, Synaptotagmin 1 = synaptic vesicles, Munc-18 = 50% soluble, 50% plasma membrane) (Siew et al., 2004). These results were intended to be illustrative, not definitive. The relationship between the levels of these proteins and PMI, pH and RIN are shown in Fig. 5a, 5b, and 5c. Protein concentrations of these diverse illustrative proteins are stable across all of the tissue conditions available in the tissue collections we have analyzed. Neither PMI, pH, nor RIN impacts protein concentrations in the human tissue.
Accidentally, several pieces of cerebral tissue thawed and stayed at room temperature (in the −80 degree C freezer) for up to 24 hours. Fig. 6 illustrates the electropherograms for the 3 tissue samples before and after the thaw. The pH was practically unchanged across the before and after samples. However, the RNA quality was severely degraded, as indicated by the precipitous drop of RIN and by the electrophoretic migration pattern. Fig. 7 shows the before and after tissue values for both pH and RIN. Although the drop in pH was significant, the value is not informative for a quality marker, given the extensive overlap between "before" and "after" values. However, nearly all RIN values were in the "thawed" tissue were below 7. This example demonstrates a tissue condition where pH fails to signal the post - thaw change, whereas RIN easily discriminates the pre- and post-thaw states.
Some investigators have speculated that most of the degradation of RNA and protein in brain tissue happens early after death, perhaps within the first hour. To assess tissue with the shortest possible time after sampling, we procured and analyzed 4 surgical tissue samples. These were small pieces of medial temporal cortex collected during neurosurgery for epilepsy and frozen in less than 60 minutes. We predicted that our surgical samples would have an intact RNA and a pH close to the physiological pH of the living brain. Surprisingly, the range of pH values was similar to those found in postmortem brains; RIN values were generally lower, sometimes strikingly, than in the postmortem brain and the pH did not correlate with RIN (Table 3).
This study examined the characteristics of postmortem tissue quality in two human postmortem brain collections with the goal of identifying optimal tissue quality characteristics to use when selecting cases for human molecular studies. Furthermore, we examined the extent to which molecular measures from human postmortem tissue can be taken to represent such measures from fresh tissue and, therefore, the extent to which data from human postmortem brain tissue can represent the molecular conditions of the live brain. This study assumed optimal clinical diagnosis of cases, an essential feature of the process (Deep-Soboslay et al., 2005). The answers to these questions serve to suggest additional questions for the area of postmortem tissue quality and provide support for the use of postmortem brain tissue in studies of human brain research (Lewis, 2002; Tomita et al., 2004; Torrey et al., 2000).
These data show that chemical markers of tissue quality exist and suggest that they are useful in validating tissue quality. The traditional markers of tissue quality have been descriptive and included PMI, agonal condition, case age and health. In our hands, PMI was not predictive for RNA stability (within the limited quality range of our cases), confirming findings from a previous report (Trotter et al., 2002). Gradually, the field has acquired chemical markers of tissue quality, starting with pH and 28S/18S ratio, and now including direct measures of RNA quality, like RIN. The most useful human postmortem tissue quality marker in our hands is RIN. It correlates with the pH of the tissue and integrates the extent of RNA degradation with the presence of the 28S/18S peaks. However, caution is necessary: RIN is undoubtedly a sensitive indicator of total RNA integrity and a good predictor of overall mRNA integrity. However, since it has been shown that under certain circumstances some specific mRNA species are preferentially degraded (Barrachina et al., 2006; Buesa et al., 2004), it is advisable to verify individual mRNA integrity within an experiment. Our finding that RIN is the optimal marker for representing quality agrees with previously published studies that found RNA quality measures in assessing gene expression analysis (Colangelo et al., 2002; Jones et al., 2006; Ross et al., 1992).
pH appears to be a good marker of peri-mortem tissue quality, but does not appear to be sensitive to freezer degradation, as shown in our tissue-thaw illustration. Cerebellar tissue appears to be an adequate representative for other brain regions when testing for quality markers. Although we did not screen everywhere, we tested several representative regions from brain surface and from deep brain structures and saw pH values correlate highly. The data suggest that measures of tissue quality from a single brain region (like cerebellum) are likely to be representative of whole brain.
Overall, we found that the cases with the best tissue quality were more likely to come from the medical examiner's office than from other collection sources. It is reasonable to assume that cases where the cause of death is fast and unexpected might demonstrate good pre-mortem conditions with low agonal stress. It must be stressed, however, that before analyzing tissue quality for the collection cases, we had already screened and excluded many ME cases who failed to meet collection criteria (e.g., drug abuse, infectious diseases, head injury) so that the cases that qualified for our collection were already pre-screened for potentially confounding conditions. Therefore, we can only claim that it is for the subset of ME cases where case confounds have already been excluded, that tissue quality is high. In contrast, the tissue collected from the WB program was from cases with advanced age and anticipated deaths, where these and other confounds might have biased tissue quality.
Somewhat unexpectedly, in a preliminary analysis, we showed that postmortem tissue has tissue quality markers that are at least as good as surgical biopsy tissue. We are in the process of examining this question further to determine the source of RNA degradation in the surgical tissue. Several possibilities are reasonable: still active RNAases in the surgical tissue, the surgical anesthesia or exposure to air while fresh. However, these results provide preliminary support for a renewed confidence in molecular measures derived from postmortem tissue (Bahn et al., 2001; Leonard et al., 1993; Preece et al., 2003).
Furthermore, the results raise the possibility that variability in molecular outcomes across CNS regions and disease groups may more likely be the result of tissue heterogeneity than postmortem degradation.
The data shown here document remarkable stability of the protein we selected in postmortem tissue. However, until further data accrue, documentation of protein stability should still be individually demonstrated for specific experiments. Nonetheless, the proteins that we selected for analysis were varied by size and tissue compartment and are, to some extent, representative. However, others have found variable protein degradation in human and animal postmortem brain using immunoblotting and immunohistochemistry techniques (Irving et al., 1997; Li et al., 1996; Liu and Brun, 1995). Even so, in most cases, protein degradation occurred at high PMIs (> 40 hours). Moreover, we do not exclude the possibility of early degradation for specific proteins and we pursue the question of the stability of protein species using fresh human surgical tissue.
In conclusion, we find evidence for the proposal that human high quality postmortem tissue is a generally reliable laboratory resource for exploring molecular characteristics of healthy and diseased human brain. For any RNA or protein species, its degradation characteristics in human postmortem tissue still need to be documented. Nonetheless, case screening and tissue quality assessments (including RIN) are two indispensable tools to selecting postmortem cases representative of human brain tissue.
Drs. Couso-Bertalo and Sami Daoud participated in the dissections for the Maryland Brain Collection. Pengfei Cheng did the statistical analysis. This work was supported by a MH 60744 (RCR) and a MH 6223602 grant.
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Every day in my practice as a pain specialist I treat patients suffering from chronic pain, and every day California insurers deny my patients access to medications and procedures that I prescribe for the treatment of their painful, lifestyle limiting conditions.
California insurers are engaged in a very dangerous game that is potentially harmful to my patients. My patients go to a pharmacy to refill their prescriptions for medications that are already successfully treating their painful conditions and are told by their pharmacists that the prescriptions cannot be filled or that they should use a different type of medication. My patients leave the pharmacy without any medication, sometimes undergoing painful or possibly dangerous withdrawal, before I am told by the pharmacy what it has done. Meanwhile, I have to appeal the denial. Sometimes this process takes weeks to months, and despite medical evidence I provide, it is summarily denied.
In other cases, my patients are switched from effective drugs to cheaper, older, less effective drugs for their chronic and severe pain. This is frequently done without my consent and without the knowledge of the patient. And in some cases, the drugs the patients are forced to change to are not even the same type and have no evidence they are even effective for the condition being treated. Some of these older drugs have potentially dangerous side effects. Some patients must try and fail on up to five different medications before they are finally given the prescription that I originally prescribed.
This policy – sometimes called step therapy or "fail first" – can be dangerous to patient health and can actually increase the direct cost of health care in the long run due to unscheduled hospital stays, emergency rooms visits, loss of employment and a loss of productive quality of life.
For those patients who are the most vulnerable – low-income residents of San Diego County – step therapy is an even bigger challenge. Not only does the process jeopardize their health, but it also means that they must often arrange for extra child care and transportation to the doctor and pharmacist – an obstacle they are often not in the position financially to overcome. The extra expenses put some patients in the position of having to make the impossible choice between buying groceries or getting the medicine they need – medicine that their insurance should have paid for.
I believe in keeping costs down for my patients. I prescribe cheaper, older medicines that will work just as well for my patients when they are appropriate. But in some instances – because of patient history or reaction to these older medications – I choose newer medications that are proven more effective for their condition. Since I am a subspecialist, most of my patients have already been treated with cheaper, older medicines before the see me. It is a waste of time and money to have me have to repeat the same failed medical regimens again.
I know my patients. I am the one who treats them when they are in pain, who knows their medical histories and who knows what side-effects medications are likely to have on them. Health insurance companies do not know these things first hand. They have never examined my patients, yet are making significant medical decisions based on one motive only – increasing their shareholders' portfolios. In effect they are practicing medicine without license by replacing my prescription with their agenda.
The federal government has already taken steps to protect vulnerable patient communities from the prolonged pain of step therapy. The U.S. Centers for Medicare and Medicaid Services recently enacted a policy to prevent insurers from egregious step therapy requirements. Health insurers can no longer force Medicare patients to fail on more than two medications before covering what the doctor prescribed in the first place. San Diego County patients not covered by Medicare deserve the same protections.
Health insurers, as they often do when something threatens their bottom lines, are attempting to disingenuously change the debate to "cost containment" or "special interests" in an attempt to cloud the real issue. But making patients wait in pain for days and weeks or forcing them to choose between food and health is cruel and unethical. Helping patients in pain return to productive and healthy lives is not a special interest – it should be the only interest in our health care system.
It is time for this to stop. Assemblyman Jared Huffman, D-San Rafael, has introduced AB 1826, which was approved by the Senate Health Committee on Wednesday night. If passed by both houses of the Legislature, it will prevent California health insurers from denying patients in pain access to their lifesaving medication. For San Diego County residents suffering from chronic pain, help could finally be on the way.
Verdolin, a physician, is a pain specialist in Chula Vista.

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Morientes' agent hints at interest
Fernando Morientes' agent has intimated that Tottenham are keeping tabs on the Valencia striker.
By James Dall
Last Updated: 09/09/08 9:39am
Fernando Morientes' agent has intimated that Tottenham Hotspur are keeping tabs on the Valencia striker.
The former Liverpool forward has reportedly fallen down the pecking order at the Mestalla, and was an unused substitute in the club's opening game of the new Primera Liga season against Mallorca.
He recently admitted that this season is likely to be his last at Valencia due to his lack of starting opportunities.
Spurs boss Juande Ramos currently has just Fraizer Campbell, Darren Bent and Roman Pavlyuchenko at his attacking disposal and it is suggested in Tuesday's press that the Spanish coach could bid for Morientes in January in order to bolster his firepower.
Morientes' agent, Gines Carvajal, said in the Daily Mirror: "Tottenham know about Fernando from his time at Liverpool."
The 32-year-old scored eight goals in 41 Premier League appearances during his 16 months at Anfield.


text: The day after his wife disappeared in a kayaking accident off the coast of <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-comffice:smarttags" /><st1:State w:st="on"><st1lace w:st="on">Maine</st1lace></st1:State>, a man answered his door to find two grim-faced State Troopers. "We know it's late, sir, but we have some information about your wife," said one of the Troopers.<?xml:namespace prefix = o ns = "urn:schemas-microsoft-comfficeffice" /><o></o> "Tell me! Did you find her!?" the husband shouted.<o></o> <o> </o> The Troopers looked at each other. One said, "We have some bad news, some good news, and some really great news. Which do you want to hear first?" <o></o> <o> </o> Fearing the worst, the ashen husband said "Give me the bad news first."<o></o> The second Trooper said, "I'm sorry to tell you, sir, but this morning we found your wife's body in the bay." <o></o> "Oh my God!" exclaimed the husband. Swallowing hard, he asked, "What's the good news?" <o></o> The Trooper continued, "When we pulled her up, she had 6 twenty-five pound snow crabs and 12 good-size lobsters clinging to her." <o></o> <o> </o> Stunned, the husband demanded, "If that's the good news, what's the great news???" The Trooper answered, "We're gonna pull her up again tomorrow.<o></o>


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HOBBS, N.M. {AP} Earlier this week the community of Hobbs came together to help a woman who said she had been robbed. Now Hobbs police have arrested the woman.
Georgia Barnett was arrested for improper sale, disposal, or concealing encumbered property property she had said was stolen by a stranger.
Barnett told police Monday, that her family had been robbed of a number of large items including a washer, dryer, gold earrings and a television.
Barnett painted a hard-luck picture when she said she had planned to sell some of the items, including prizes she had won from a local radio station, to pay to have the heater in her home repaired and the water turned on. She even said her Christmas gifts and ornaments had been stolen.
It appeared Barnett's luck was changing when a number of community members pitched in to replace some of the items. A relative loaned the family a television and a Hobbs business repaired the heater for free. And, another business repaired the window that Barnett said had been shattered by the burglar.
Since then, Barnett's neighbor, Ventura Benevides, contacted police and told them he was the one who was going to sell the merchandise for Barnett.
"With the information provided by Benevides and with his cooperation, detectives ran a sting operation against Barnett," said Captain Michael Emerson.
The woman has since told police she made up the robbery because she was behind on payments to the company where she rented a number of the appliances, Emerson said. She also said she made up the part about stolen Christmas presents and ornaments.
© 2017. All Rights Reserved. | Contact Us


text:
Gia Santos is a curvy girl who has always had a thing for shifters. Thankfully, she lives in a world where shifters are accepted by the population, and where she is able to join a dating site to specifically meet them.
Trey Cross is a bear shifter in a desperate situation. If he does not find a mate by the time he is 30 years old, he will lose his ability to ever take a mate. Currently he is 29.
Time is of the essence, and so Trey joins the same dating site in order to find a mate - and find one fast.
It is there that Gia and Trey meet, and sparks instantly begin to fly between the two of them. Only problem is, Trey feels he knows Gina from somewhere, and if he is right, then things could be about to get very, very dangerous for her....
©2015 SimplyShifters.com (P)2015 SimplyShifters.com
"Can't judge a bear by his cover!"
Enthusiasm, appropriate drama and feelings.
Their horseback ride.
The narrator did a good job of differentiating between her characters, yet did not make the voiced so extreme that sounded strange which for me ruins the story.
Over all enjoyable short story. There was not a huge amount of characterization due to the short length, however a back ground and history to keep them a part was created.
"Very light read"
Very light read with no cliffhangers or anything. No suspense just mostly romantic stuff with no good story behind it. It was quite boring but it's a fast read. Don't recommend it but if your in the mood for something lite here you go ...
"Typical bear shifter story pale bbw female wm bear"
Average shifter story searching for love. A rancher wm 30 y.o. bear shifter attracted to pale skinned dark hair curvy female that he meets at a male shifter to human female mixer. But, there is a female robbing shifter males who are too embrassed to report the mugging. is this worth a credit??? flip a coin. No diversity of different races or cultures involded with mixer or supporting characters surrounding the main characters.
Report Inappropriate Content
If you find this review inappropriate and think it should be removed from our site, let us know. This report will be reviewed by Audible and we will take appropriate action.


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Dwight Gooden MLB Baseball w/ "85 TC" Insc.
$174.98with case
$149.99without case
Dwight Gooden known to Mets fans as Doc or Dr. K epitomized the 'gotta believe' Mets in the mid- 80's. Throughout his career Doc was a fearless pitcher who helped lead the Mets to a World Series in 1986. He finished his career with the crosstown rival Yankees with a .634 winning percentage and 2293 strikeouts to his credit. And during the Yankees magical 1996 season Gooden pitched a no-hitter against the Mariners on May 14. The player who routinely hit 95 mph on the radar gun as a rookie in 1984 was back for one more fleeting moment. His fastball was back. Doc Gooden has hand signed this MLB baseball and inscribed it TC 85. A Steiner Sports Certificate of Authenticity is included.


text:
Derby roofing company safety tips
Weather can affect the dates of completion, but you can indeed help influence the severity of the impact. You can make sure there is an agreed upon no-later-than date set up between you and your Local DErbY RoOFINg COMpanY. Make it clear, and make it clear that the terms will be enforced. Once again, you …Read More Derby roofing company safety tips


text:
Finally Scoring This Ridiculous, Untouched Slab
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Nice, clean wave at Cotton's/Upper's/Trestles with a slight offshore breeze and hardly anyone out. Water temp: still cold enough for a 4:3
3rd January 2013
We found a monster.
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text: Ábalos+Sentkiewicz is an international architecture office settled in Madrid, Spain; Cambridge, U.S.; and Shanghai, China. It is directed by Iñaki Ábalos and Renata Sentkiewicz. Iñaki Ábalos and Renata Sentkiewicz have taught in prestigious universities such as ETSAM, Harvard University Graduate School of Design, Architectural Association, Columbia, Cornell, and Princeton, thereby combining academic, professional, and research activities. Iñaki Ábalos is Chaired Professor at ETSAM – Spain as well as Professor in Residence and Ex-Chair of the Department of Architecture at Harvard University Graduate School of Design. The work of Ábalos+Sentkiewicz is internationally recognized, having been the subject of fifteen individual exhibitions and many collective exhibitions in some of the most prestigious centers such as AA, London; Pavillon de l'Arsenale, Paris; MoMA, New York City; and the Biennale of Architecture of Venice. This prestige also reflects in the forty awards received in architecture competitions. Another forty-five awards have been given to different research and design activities, eighteen of them to built works by the firm.


text:
Log in
Log in
The Shulman Law Group
Atlantic States
973 345-1151
(201) 773-9240
Company DescriptionThe Shulman Law Group is based in New Jersey and have represented clients throughout the United States and worldwide, thus earning a national and international reputation as being the best immigration attorneys in business. Our lawyers travel to foreign embassies and consulates to directly handle problematic situations for clients. If you need a visa, wish to immigrate, or want to help bring a family member or employee to the United States, we can help. Firm founder Edward Shulman has more than 20 years of legal experience, and has also handled many high profile cases during that time. While an understanding of immigration law and procedure is necessary, our immigration attorneys know that consistent communication with our clients is crucial in all matters of immigration law.
PersonnelEdward Shulman, Owner
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VideoNo video provided


text:
Discussion in 'Studs, Stallions and Bulls Seeking' started by MrGrandeur, Sep 8, 2014.
Marion here
jenny here..
we were just there over thanksgiving! I'm from Dublin ... too bad we missed you. won't be back home for awhile
Columbus is a tough area, brah keep me posted if your lucky enough to find and meet anybody out here Fam.
we are down by Cincy sexy man
Good lord, all that ass...we should meet
yes we should
Separate names with a comma.


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Additional security must be provided for vehicles three years and older.
All loans are subject to NCCU's Loan Policies and approval procedures
To find out details on what can be used as security click here.


text:
It seems an auspicious day to introduce my first collection of haiku to the world.
breath is the realisation of a project that has been rolling on and off my desk for about 2 years and I am pleased to record that it was home from the printer in November 2011. There's something about the death of loved friends that tends to focus the mind and I realised that I just needed to get on and do it and not look back later and be regretful.
Fortunately, this realisation coincided with what I felt to be a maturing and growth in my writing. I chose the poems for inclusion several times and believe that in the final selection each haiku carries its own weight.
The book contains poems largely dating from the past 5 years, although one or two are older than that. Among the haiku are several that have won awards in, for instance, the United States, Japan, Romania, Australia and New Zealand. There is also a good selection of poems that have been previously unpublished.
summer rain –
finding chocolate frogs
at the back of the shop
first published Daily Haiku, Cycle 11, 2011
breath has been arranged in the traditional way – by grouping poems under seasonal headings – with my own photographs of the seasons of the tree acting as separator illustrations.
From the start I wanted a book that would be a pleasant experience for the reader and Jane Smart at Kale Print in Tauranga and I carefully chose paper weight and type and cover material. I don't like too many haiku crammed on a page and/or in a small and "thin" font – so in this one there are two poems per A5 page, although a few have only one.
The vision I had for the cover (which popped into my head while driving home from the gym) has been enhanced and improved by Kale's graphic designer Michelle Reynolds. The book is perfect bound.
breath is self-published by necessity – if you think it's hard finding a publisher for a book of poetry, try hawking round a book of haiku! I chose the name Piwakawaka Press to celebrate the fantails (Rhipidura fuliginosa) that flit and hover outside my office window at home. The Maori name, piwakawaka, is derived from their squeaky call and the birds are believed to be messengers from the gods.
Choosing the photos for the book gave me a great deal of pleasure and when I realised that three of the four separators were showing trees, it took only a moment to realise that my subconscious was telling me something. All the photographs were taken in my home district, three of them in private gardens.
The separator for spring shows the blossom of the ornamental peach, Iceberg.
Summer shows a blowfly on Acer mikawaya tsabusa, a small maple that features overlapping leaves, something like the tiles on a roof.
A Liriodendron tulipifera (tulip tree) features in autumn, the photo taken at a large, country park near Tauranga.
Winter in this part of the world doesn't feature snow and ice, but is nonetheless relatively bleak, cold and wet.


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Whether your prized possessions are collectable coins or precious pieces
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text: Painting Ideas 2016 Door Color Trends (Favorite Paint Colors) By admin 1 year ago 204views0 1SHARES 0 I love this infographic from ThermaTru Doors. So many fun colors that would look amazing on an exterior door. source Related Stories Happy {exterior front door paint that doesn't fade} Painted Share this:SharerTweetAdd +1Related posts:Print Art On CanvasInterior House Paint Color IdeasBest Color To Paint A House


text:
- Please select a date to see the proper prices!
- Meal can be requested on the spot
Best offer
113.25 € / person / night, no meal
Description of the accommodation:
Rooms, services Travelling to Yarm and looking for accommodation? Take a look at what Crathorne Hall Hotel Yarm has to offer! The hotel is offering 37 tasfefully furnished, nice rooms for those looking for a place to stay at in Yarm. In case you'd like to have a meal or a drink on the spot, you will be provided freshly prepared dishes in the restaurant every day. Parking is availably nearby for those arriving by car. The bar can be an ideal place for a pleasant evening talk or a meeting. In case you'd bring your laptop along, you may go online via wireless Internet connection (WiFi) available at the hotel. If you wish to learn more about the exact scope of services provided by Crathorne Hall Hotel Yarm (including any available for an extra fee), you will find them on the information sheet below.
Payment Depeding on the selected room, date and price, you may be asked to provide credit card guarantee or to pay by credit card in advance.
Arrival, opening hours The earliest check-in time is 14:00, the latest check-out time is 11:00. You will be able to speak with the personnel in English.
Crathorne Hall Hotel Yarm rooms Rooms
- Please select a date to see the proper prices!
Accommodation services
Free WiFi in shared places
Garden, Bar
Own restaurant
Bathrobe, Hairdryer, Desk in the room, Mini-bar


text:
Pegasus probably be like "Oh you silly little boys, I'll leave you to your devices, unless, of course, you would let me join?" *Insert creepy little pedophile giggle*
Can I favourite this more than once? I feel like I should be allowed to favourite this more than once.
Haaa, that's so funny! On a second note, Bakura's hair is gorgeous!
yeah thats so typical for the both XD
Ha! You go, Pegasus!!! XD


text:
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A doctrinally precise, intensely practical study of the first five chapters in Luke's Gospel. In this accessible and comprehensive commentary, MacArthur provides a verse-by-verse exposition of the text, accounts for its cultural and theological context, and addresses interpretive challenges and differing views while celebrating its unique treasures---including the fullest account of Christ's birth. 372 pages, hardcover from Moody.
Publishers Description
Luke 1-5 begins The MacArthur New Testament Commentary's look at the longest of the four gospels. The commentary provides a verse by verse and phrase by phrase exposition of the text, taking into account the cultural, theological, and Old Testament contexts of each passage. Interpretive challenges are fully dealt with, and differing views are fairly evaluated. The gospel of Luke is unique and provides valuable insight into Christ's life and ministry. For example, it gives the fullest account of Christ's birth and is the only gospel to record several of our Lord's parables, including the Good Samaritan and the Two Sons. Use this volume of The MacArthur New Testament Commentary series to assist you in your study of this cherished New Testament book.
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HipHarpAcademy.com Presents
Currently available for "At Your Own" Pace Learning
Already Registered for Hip Harp Academy? Log-In Here.
See the current schedule of guided classes at HipHarpAcademy.com
If you're already a FULL-Level member of "Hip Harp Academy" Log-in now at the link above and look for the "Strings of Passion" Badge. In you're not a full-member of the Academy or maybe not even a harpist – or a musician …READ ON!
What if you discovered there was an instrument inside you that resonates to your spirit the same way your instrument resonates outside you?
What if this inner instrument had strings like a harp and they resonated in your inner world – plucked by your creative expression in the outer world?
What if these two sets of strings resonated each other, so that, when you plucked the strings of one, the other resonated as well?
Those are your strings of passion
What if this is the beginning of the greatest creative adventure of your lifetime?
—Deborah Henson-Conant
Passion can be gentle and quiet – or bold and dramatic.
It can be like showing off, like revealing your inner Diva – or like holding something sacred and secret. It can be a whisper or a shout of joy.
Passion is connecting with your deepest artistic impulses – whatever they are – and expressing them with body, mind and soul.
If you're a musician it means letting your passion resonate through your instrument – your physical instrument that other people experience – and the strings of your inner instrument – your strings of passion.
(This photo is from the first live "Strings of Passion" retreat in 2011)
Finding your passion is about connecting to those strings.
I'm Deborah Henson-Conant – and the 7 Strings of Passion are the concepts that guide my own creative expression in every facet of my life: as a composer, a performer, as a creativity coach and as a lifelong beginner.
Like my instrument, each time these inner strings are touched, I resonate.
And like my music practice, my inner practice enhances my performance as myself – and that enriches how I engage as a musician
If you do nothing else for yourself in 2017 , discover YOUR strings of passion – the ones that resonate within you … and let them ring through your life and your creative expression.
As Featured In:
Strings of Passion is …
"Strings of Passion" is a 10-Week program of creative discovery to the heart of your inner resonance, your inner instrument. It's about learning to hear it, to feel it, to remember it.
It's also about developing of a personal creative practice – not practicING to get something 'right' – but a daily practice that connects your inner instrument and your outer instrument. I've shared these concepts around the world as a talk, a concert, retreat – and now I'm creating a 10-Week "Strings of Passion" online program just for the members of my Hip Harp Academy.
If you do nothing else for yourself in 2017 – discover YOUR strings of passion – the ones that resonate within you – and let them ring through your life and your instrument.
Join me in January 2017 – for Strings of Passion by registering for the yearlong Academy membership at HipHarpAcademy.com
If you do nothing else for yourself in 2017 – discover YOUR strings of passion
"You provide the most inspiring, amazing space for students to break through the challenges, let go, and feel free. It is so fascinating how you explore the emotional and spiritual aspects of music together.
I love how you keep it real and think out of the box all at the same time, and I love both the fun and profound sides of what you express and explore."
Tess Nurman (France)
What are the 7 Strings of Passion?
In this 10-week program I'll share the 7 strings of passion and how they resonate in your life and your music:
- IMPULSE: You'll reconnect with your first, your deepest, your secret creative impulses .
- STRUCTURE: You'll discover simple, beautiful musical structures that create a thread for your creativity to crystalize around.
- CHARACTER: You'll reveal the hidden richness of your own character to yourself and bring that character to your instrument
- ROLES: You will discover the power of roles to create freedom in your playing and in your own understanding. You'll discover the the subtle power of the followship role that allows you to follow your own passion – and you'll learn how following your passion becomes leadership.
- PRACTICE: You'll learn the flip side of practicing towards a specific goal: the developent of a creative practice that provides the rich groundwork for personal and musical expression
- DECONSTRUCTION: You'll discover the power of distillation and deconstruction, of moving beneath the details intothe deep power of simple forms that give you power to express spontaneously
- LIFT-OFF: You'll experience the moment of lift-off or fluency when you let go of the constructs and shoulds and rules of what you think self-expression should be and truly express yourSELF – the inner instrument that resonates in your own strings of passion.
"I just have to tell you how very excited I am about having signed up! I think this will affect not only my harp playing, but every aspect of my life!
I have always been a darn perfectionist and always felt like this trait paralyzed and limited my personal (and spiritual!) expression. So, I can't tell you how happy I am that you have created this course! I can't wait to work with you more! "
Amelia Gerlach (N.C.)
Feel the power of YOUR Creative Resonance in Your Hands
"Strings of Passion" is the first course in the 2017 "Hip Harp Academy" Curriculum To register, sign up for "Hip Harp Academy" "FULL" OR Register for "Strings of Passion" a la carte
Here's How:
OPTION #1: FOR HARPISTS ONLY: FULL "Hip Harp Academy" Yearlong Membership
Sign up for the Full/Core 'Hip Harp Academy' Year-Long Curriculum. 'Strings of Passion' is the first course of 2017, and the full curriculum INCLUDES "Strings of Passion" PLUS over 10 different programs including "Hip Harp Toolkit / Arrange Yourself," "Summer Harp Jam," "Hands on Harmony," "Blues Harp-Style" – you can see all the courses at HipHarpAcademy.com
Currently available for "At Your Own" Pace Learning
Next Guided Session planned for January 2018
Get on the First-to-Know List for Next Time
Pay in Full
($997 for the full yearlong "Hip Harp Academy" Curriculum with over 10 guided courses INCLUDING "Strings of Passion")
12-Month Payment Plan
($88 each month – about $2.75 a day)
For the full yearlong Curriculum with over 10 guided courses INCLUDING "Strings of Passion")
OPTION #2: FOR NON-HARPISTS "Strings of Passion" a la carte
If you're not a harpist, you can still sign up for "Strings of Passion" a la carte You'll be able to ask DHC how to adapt the program for your creative expression – plus you get a sneak peek into the international harp world. Choose Full pay or a 3-month payment plan.
- OPTION 1: Pay in Full ($797 for the 10-week "Strings of Passion" program)
- OPTION 2: Payment Plan (3 payments of $279)
"I love the simplicity! Yet it's very powerful and heartfelt" (S. W.)
"I love the idea of being physically involved in the music instead of the constraint that is taught in classical music." (J.H.)
"I love the idea that experimenting with a simple practice and letting go of what it sounds like – it helps to develop fluidity with the fingers, traversing "mistakes", and bring forth some amazing surprising results – Note to self: open yourself to DISCOVERY" (P.D.)
"Stories unfolding, ideas, blocks being tumbled down like kiddie structures…It feels like waking up to my own artist's soul after a very long sleep. The passion is the process!" [SJB]
"I am loving dipping into the Creativity Gym so far two days in a row! … it felt like an inkling of what it would be to play by resonating with the depths of my passion." (C.R.)
"The soundscapes – A and B – are really fun!…It is a relief to not feel responsible for lots of notes – but to listen for how one note resonates" (M.B.)
I am only FIVE minutes into watching the String of Passion chat replay, and already I feel like crying, I feel moved, I feel inspired and a longing and a yearning... Deborah, you are such a connector, an inspirer, such a teacher. [B.T]
What are the 7 Strings of Passion?
Each week we explore these 7 strings and how they enhance each other within you and in your playing.
Each week you get a audio file that you will play along with – not to develop proficiency, but to develop your INNER CREATIVE PRACTICE. You'll be playing – not to become better — but to reach deeper into your own passion. You'll be sharing as a community – with the choice to share anonymously – so that the resonance of each member of the group can support the others.
Each week you'll be writing, drawing and playing – and it will be completely irrelevant how 'good' you are at these things. You'll let go of being good, and do these things for the creative connection they give you with yourself. You'll learn to do these for yourSELF, not for others – not to reveal things to others, but to reveal you to yourself. And then I'll show you how you can connect with others using these same techniques.
==> In the weekly video lessons I'll take you through the individual strings and how they resonate together. You'll get prompts and heart-play to practice in both your life and with your harp.
==> In the "Strings of Passion" workbook you download you'll collect your creative discoveries.
==> The weekly Soundscape Audio files provide an enhancement for your practice. You'll download them on MP3 or listen in the online classroom and play along with simple musical prompts that allow each person play completely differently.
==> The Strings of Passion playbook includes the pieces I've composed specifically for this program – pieces you can just listen to – or, if you're a musicians, that you can play simply or expansively – playing from the inside out – and the outside in, as the strings of passion connect the inner and outer instruments. If you're a harpist, these are pieces you'll be able to add to your own repertoire as well as using them for your personal creative experience and for both concert and therapeutic playing you do for others.
==> In the closed "Hip Harp Academy" Facebook Group you can ask questions, share your musical discoveries and connect with the other members of the Core Level Academy.
==> In the weekly Q&A session with me you can ask anything – seriously … anything.
REGISTER NOW for "STRINGS OF PASSION"
"Strings of Passion" is the first course in the 2017 "Hip Harp Academy" Curriculum
To register, sign up for "Hip Harp Academy" "FULL" OR Register for "Strings of Passion" a la carte
A. HARPISTS ONLY: Register for the Full "Hip Harp Academy" ($997 for the full year – OR choose the 12-month payment plan). Core 'Hip Harp Academy' Curriculum is a yearlong program that INCLUDES "Strings of Passion" PLUS over 10 different programs including "Hip Harp Toolkit / Arrange Yourself," "Summer Harp Jam," "Hands on Harmony," "Blues Harp-Style" (see them all at HipHarpAcademy.com)
B. ANYONE: Register ONLY for the 10-Week "Strings of Passion" program a la carte ($797 for the 10-week "Strings of Passion" program – or choose the 3-month payment plan)
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© Deborah Henson-Conant / HipHarp.com


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An excerpt from www.HouseOfNames.com archives copyright © 2000 - 2017
Mapple Early Origins
Kirkcudbrightshire (Gaelic: Siorrachd Chille Chuithbheirt), part of the present day Council Area of Dumfries and Galloway, former county in Southwestern Scotland, where they held a family seat from early times and their first records appeared on the early census rolls taken by the early Kings of Britain to determine the rate of taxation of their subjects.
Mapple Spelling Variations
Mapple Spelling Variations
Spelling variations of this family name include: Mabbe, Mabee, Mabey, Mabie, Mabes and others.
Mapple Early History
Mapple Early History
This web page shows only a small excerpt of our Mapple research. Another 175 words (12 lines of text) covering the year 1200 is included under the topic Early Mapple History in all our PDF Extended History products and printed products wherever possible.
Mapple Early Notables (pre 1700)
Mapple Early Notables (pre 1700)
More information is included under the topic Early Mapple Notables in all our PDF Extended History products and printed products wherever possible.
The Great Migration
The Great Migration
Some of the first settlers of this family name or some of its variants were: Thomas Mabb, who arrived in Virginia in 1643; Arthur Mabb, who settled in Maryland in 1684; Martha, and Mettye Mabie settled in New York in 1685; W. F. Maybee settled in San Francisco in 1850..
Contemporary Notables of the name Mapple (post 1700)
Contemporary Notables of the name Mapple (post 1700)
Mapple Family Crest Products
Mapple Family Crest Products
See Also
See Also
Other References
The Mapple Family Crest was acquired from the Houseofnames.com archives. The Mapple Family Crest was drawn according to heraldic standards based on published blazons. We generally include the oldest published family crest once associated with each surname.
This page was last modified on 25 August 2015 at 09:01.
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People on the Move
Alex Price
Wealth Manager
Towry Limited
Role: Alex has joined the Towry team in Belfast as a Wealth Manager.
Track Record: With over 20 years experience Alex's role will see her work with a range of clients (in particular High New Worth Individuals and those with Personal Injury awards) to ensure they can meet their financial objectives through a range of financial planning and investment management solutions. Towry provides personal financial advice and investment management services to clients across the UK.


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Track Engineer / Project Engineer (Construction)
Riverdale Park, MD | Temp/Contract to Direct
Since 2001, RealStreet has connected management executives for the construction industry to contractors working on commercial and government projects. As the leading firm in the country which specializes entirely in senior level construction employment, we have cultivated long-term relationships with many of the industry's leading companies enabling us access to the top companies throughout the continental U.S.
We currently have a great assignment for a Track Engineer / Project Engineer (Construction) with one of our top clients. As a Track Engineer / Project Engineer (Construction), you will be supporting our client, one of the world's largest engineer, procurement, construction (EPC), maintenance and project management companies. The Track Engineer / Project Engineer (Construction) will join the project team supporting the construction of a large transit project.
Job Responsibilities
The Track Engineer / Project Engineer (Construction) will be responsible for ensuring that the tracks are constructed in accordance with the technical provisions and national and international railway group standards and will also work closely with the QA and Safety Certification managers during the drafting of the relevant safety certification documentation as relevant to the construction, operation and maintenance of the tracks:
- Providing technical oversight of the project rail design
- Providing technical oversight of project rail construction
- Coordinating the preparation and delivery of project deliverables and design documents
- Managing sub-consultants and contractors on a day-to-day basis
- Coordinating and managing the efforts of technical disciplines
- Supporting creation and coordination of overall project plans and schedules, and monitoring activities, progress and milestones against the plans
- Analyzing and making independent recommendations regarding solutions to problems with varying complexity in accordance with organization and project objectives and guidelines
- Organizing and prioritizing a variety of tasks in an effective and timely manner, setting priorities and meeting deadlines
- Planning and organizing own work assignments as well as carrying out tasks from management staff
Specific qualifications for the Track Engineer / Project Engineer (Construction) role include:
- Accredited four year degree or global equivalent in applicable field of study
- Minimum of fifteen years of work-related experience in the field of transit rail design and construction
- Extensive experience in rail design, construction, testing & commissioning of LRT (Light Rail Transit) and Metro systems
- Extensive experience in design, construction and testing & commissioning of different track systems including Ballast, Direct Fastening and Embedded Rail
- Experience working with MARC, WMATA and Amtrak is preferred
- Lump sum design-build rail experience is preferred
RealStreet offers a comprehensive benefit package which includes:
- Health, dental, vision, and prescription coverage
- Life insurance
- Long-term disability
- 401(k) with generous company match
- Paid time off
Build a better construction career with RealStreet and apply now!


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Wendy Davis is kicking ass.
Austin tends to be home to lots of non-Texans who move here for its undeniable "cool factor" and thriving economy. A lot of my acquaintances who fall under this category tend to look on the rest of my beloved Texas as a sea of ignorance. As a young and progressive woman, I've been on the wrong side of the whole "good ol' boy" thing too many times, but my state is so much more than that. Regardless of politics, Texans exemplify strength and tenacity, and Wendy Davis is the embodiment of both as she filibusters this bill.
Go her–I will never understand how the people who think merely registering their guns is an infringement on the second amendment can also think it's okay to ACTUALLY infringe on the rights of other people to get married or make decisions about their own baby-growing organs.


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1. Order uniforms for the Princess for school next year. This is my first time with a child in a uniform school. How much do we order? Five of everything?
2. Order books for aforementioned child. So much for the fun of the back to school and going to the bookstore to get a stack of new books. We've already ordered most of her eBooks and downloaded them onto her iPad. Now I have to order the workbooks that she will need for next year.
3. Read the books that the Princess has on her summer reading list. There are only three, and I know that if I am familiar with them, it will be a help during the inevitable August meltdown before her summer reading journal is due.
4. Check out the local art center where the youngest will be taking art classes after camp this summer. We started off small, one six week class, but if he likes it, he may take more classes during the school year or next summer. They have adult classes, too, so you never know. . .
5. See the Princess performing after three weeks at a summer ballet intensive. It's going to be her longest time away from home, and it's going to be a lot of work, so I'm excited and nervous to discover how she and her dancing will have changed during those three weeks.
6. Vans Warped Tour, on Lughnasa, of all days. I guess that is a bit apropos.
7. Meeting Pj in person! We've know each other for many years via blogs and the internet, but it looks like we will get to meet in person this summer.
8. Going to my first ever ComicCon, with the youngest. He says he might wear a cape. That ups the ante on whatever I decide to wear, doesn't it?
9. Checking out the upcoming The Science Behind Pixar exhibit at the Museum of Science. We will be taking the boys while the Princess is away at dance.
10. Start another Whole 30 on July 1st. This is a big, nationwide Whole 30, so join along! I will talk a little bit more about my Whole 30 experience below.
So, on May 4th, I started the Whole30. Coincidentally, Melissa Hartwig, one of the authors of the Whole30, stopped by at a local cross fit gym on her book tour for the book. Even more coincidentally, Melissa Joulwan of The Clothes Make the Girl (whose Chocolate Chili is the one and only reason why I survived on the Whole 30) was also speaking with her. EVEN MORE COINCIDENTALLY, I bumped into Teresa there. I was still in the beginning of my Whole 30 experience and was feeling a tiny bit crappy, crappy enough that I almost stayed home. (Okay, my introverted tendencies may have also played a big part in this.) But I am SO glad that I went. I had an awesome time on all levels.
I'm not going to go into the Whole30 in too much detail. There's a ton of stuff about it online and there's so much stuff that you could even do the Whole30 without buying either the Whole 30 or the prior book by the Hartwigs, It Starts With Food. Suffice it to say that it's 30 days of not eating stuff that's probably not great for you (dairy, grains, legumes, sugar, etc). It's got a lot in common with paleo eating, except it doesn't go for all the weird fake food you can make while you are doing paleo - it's about eating whole foods, not making bastardized versions of comfort foods with paleo ingredients. You can have caffeine and unsweetened (i.e., baking) chocolate, and potatoes - what's not to like about the Whole 30? Well, from experience, I can say all those eggs and all that meat.
Did the Whole 30 work for me? I would have to say yes. I definitely look and feel better. For the first time in my entire life, my manicurist tells me I have such nice strong nails. I thought she was being sarcastic at first, because I am known for having terrible, weak nails. The dark circles under my eyes have gone (though severe allergies can bring them back). Lots of people noticed that I was thinner, and I am - I lost 12 (I think) pounds on the Whole30. And that it awesome in itself, because no amount of changing my diet or my exercise over the past few years has made one tiny bit of difference in that. It's possible I have a thyroid issue, but my doctor, after being all excited about it, never followed up. Right now, I don't even care about that. I've taken control and I'm making things happen.
Technically, I could leave the Whole30 now. That's easier said than done. Every time I have reintroduced something, I've gotten sick. I had a baked potato with butter and sour cream with my dinner on Friday night and I spent the next 44 hours sick, with sleep my only relief from the pain. I had been hoping to work my way up to eating some grains, particularly flour, as I have a birthday coming up and, dammit, I wanted to have my cake and eat it, too. But right now it looks like birthday excitement is going to be some gluten and wheat free granola with unsweetened coconut milk. I live on the wild side!
As crappy as my reintroduction to other foods has been, I'm still sticking with my plan to do another Whole30 starting July 1st. Anyone want to join me?


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April 20, 2016
Every Premier League club ranked by total average number of goals per game – most entertaining teams this season
Which club has proved best value this season, in terms of entertainment?
Leicester City and Tottenham Hotspur have been in formidable form at the top of the Premier League table, but they might struggle to pip their rivals in the goals per game charts.
Check out the total goals per game for each side – ranked from least to most – this season by viewing the slideshow above.
Stats correct up to 20 April, 2016.


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Gov. Sam Brownback will deliver a "very practical" State of the State address, his top lieutenant said Tuesday.
Brownback will give the speech at 5 p.m. Lt. Gov. Jeff Colyer told reporters to expect an address that will discuss both challenges and accomplishments.
"He's very straightforward with people. Tomorrow the detailed budget will be out and in the budget you'll see that it's a structurally-balanced budget and we've got a tough task to get there and there's a reasonable balance he's put together," Colyer said.
Colyer declined to discuss specifics.
The state faces a $350 million budget shortfall in the current fiscal year, and a gap of more than $500 million next year.


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Album Review (From Hello Asia)
Check out my album review of this album for Hello Asia here: http://www.helloasia.com.au/reviews/albums/jj-lin-from-m-e-to-myself-album-review-taiwan-2015/
Track Listings
1. 序曲:調音 Tuning Up
2. 不爲誰而作的歌 Twilight
3. 序曲:中場休息 Intermission
4. 關鍵詞(Horae Beauté 韓媞形象主題曲) The Key ("Horae Beauté" Theme Song)
5. 只要有你的地方(晚安版) By Your Side (Bedtime)
6. 彈唱 A Song for You Till the End of Time
7. 有夢不難 Adolescent
8. 序曲:Welcome to the Livehouse
9. Too Bad
10. 你,有沒有過(Livehouse版) Roll On (Livehouse)
11. 序曲:12年前 12 Years
12. 現在的我和她 No Longer Us
13. 序曲:海邊 初 The Beach Arrival
14. Lier and Accuser
15. 獨舞 The Lone Ranger
16. 序曲:海邊 終 The Beach Departure
17. 你,有沒有過(電影《破風》主題曲) Roll On ("To The Fore" Theme Song)
18. 只要有你的地方(電影《消失的愛人》主題曲) By Your Side ("The Secret" Theme Song)
Bonus CD:全面開戰(《部落衝突Clash of Clans》主題曲) Clan Wars ("Clash of Clans" Theme Song)
Album Information
Mandopop ballad prince JJ Lin is back again this year with his experimental album "From M.E. to myself", and not only include 18 songs, but also a documentary including interview clips with JJ himself that allow him to share a more intimate side to his personality.
"One year ago I started an entirely new journey, and I decided to tear away from the packaging of popular music, and start anew in categorising myself and my music. I asked myself a question: in the production of music, what else is there I haven't tried?
So I began this project. I hope that through exploring the depths of my heart and unspeakable emotions, using the sound of instruments, melodies, using my own voice I can express these feelings. I hope these actions will allow me to see a side of myself I had never seen before, talking and interacting with those parts of me that had always been hidden beneath the surface"
These were the thoughts going through JJ's head that led to the conception of this album.
Going even further to describe this album as a milestone for the Chinese pop music industry, I am increasingly intrigued by this concept, given me always having wanted to see the true inner part of JJ Lin that I had never experienced.
Lin also used the 'Dummy Head' recording technique for this album in order to create an intimate atmosphere between himself and listeners, similar to that of a live house full of audience members.
Although a consistently popular artist, I've always yearned to see what was underneath the surface with JJ. As talented a singer-songwriter he may be, writing good ballads does not a standout point make. I've always found that his music although nice lacked flavour and uniqueness, something that truly stood out to me as JJ's inner voice.
However it he is able to push through and deliver on this album, not only will it be his best one yet; it will also be a turning point in his career, and growth in character for the boyish singer.
Taken from: http://asianpopweekly.weebly.com/news-nuggets/jj-lin-releases-experimental-new-album-from-me-to-myself-on-25th-december
September 2016


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Currency Displayed in
The BL20 is a super compact, lightweight, high performance speed controller for your racing multi-rotor. Pre-flashed with BLheli and ready to use with Oneshot (aka oneshot125 / PWMsync) mode via compatible flight controllers running Cleanflight or similar. Pick up the USB programmer to changes settings via BLhelisuite.
These ESCs do not have a BEC (battery eliminator circuit) - you will need to supply 5v power to your flight controller (and onto your radio reciever) with a UBEC or stepdown voltage regulator.
Note: Our BL20 ESC is the same model as the Favourite (FVT) Little Bee 20A ESC
Posted by Miller on 29th Mar 2016
Been using these escs for awhile and they have never failed me. Plenty of power and great customer service. A+
Posted by Unknown on 14th Mar 2016
I love the size
Posted by CoRNDoGRR6_fpv on 12th Mar 2016
The footprint of this ESC is very small and can fit anywhere. Provides the punch needed for your quad. Great ESC at a great price.
Posted by sean krantz on 18th Oct 2015
Smooth, responsive, tiny, and best part.... more power!! Great ECS's buy now!!!!!!!!!
All prices are in USD.


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Education & Outreach Volunteer
44.860794, -93.3877)
Cause Areas
WhenIt's flexible! We'll work with your schedule.
Where7900 West 78th St., Suite 100Edina, MN 55439
We are searching for a volunteer to support our Education and Outreach department.
Volunteer expereince will include:
- Assembly of education training folders and outreach materials
- Maintenance of resources files
Some of this work could be done from home.
Volunteer should have a professional, family and/or educational background related to Alzheimer's disease.
- Data Entry
- Program Management
- Healthcare
- Administrative Support
- Customer Service
- Community Outreach
Good Match For
Requirements & Commitment
- Once a week for a couple hours.
More opportunities with Alzheimer's Association Minnesota-North Dakota
- Support Group Facilitator in...
- Community Education in Fargo
- Longest Day Planning Committee
- Early Stage Social Engagement...
- Community Education Volunteer in...
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- Education & Outreach Volunteer
- Data Entry Assistant
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- Young Champions in the Twin Ports
- Community Education in Fergus...
- Office Reception Assistance in...
- Community Education in Bismarck
- Community Education in Minot
- Community Education Volunteer in...
- Office Assistants


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|Reviews for Boys Before Flowers
| ChoppingBoard chapter 8 . 11/3
Ughh why is Yama so stubborn?
| Scripturiens chapter 7 . 11/7/2014
I love the whole "jumping out of the building" business. Effortlessly funny.
I really enjoyed this chapter, although I understand nothing of this "war". Good writing though.
| Guest chapter 6 . 11/20/2013
ACDC is one of the greatest bands ever created.
| Tagny chapter 4 . 11/20/2013
Awww romance is heating up between Mimi and Yamato :3
| Guest chapter 3 . 11/20/2013
I keep thinking they're going to sleep with each other but it doesn't happen. It makes me laugh non a less.
| Tagny chapter 2 . 11/20/2013
Awwe a karaoke contest! Awesome choice of challenge! Haha can't wait to read the next chapter.
| Tagny chapter 1 . 11/20/2013
I love this story! Can't wait to read on!
| aisacchan chapter 9 . 3/28/2012
good story.. i really like it
| SnowLion no Miko chapter 9 . 1/16/2011
I really loved this fanfic! The concept was wonderful, and you did a great job pulling it off. Keep up the awesome work!
| kidimpulse213 chapter 9 . 1/20/2009
I loved everything about this story. I love this so much that i read it all in one sitting (except for a break for dinner after which i took my desert to my computer and ate it while reading XD)
I loved every scene that concerned the see-saw, the pond and the fish Yamato won for Mimi.
I loved Yamato's band, and the various cameos of the digi-destined - that was just love to me, they were fleshed out and in character even if they were obviously not the main point of the story i loved taichi scratching his nose all the time )) and adored how considerate joe was, how bashful ken was and how boyish takeru was.
I loved how authentic this fic felt - it's so well-researched that it really feels like Japan - Yamato and Mimi's Japan.
my favorite scene of the story (out of the many many scenes that were just gorgeous) was when Yamato went to his mother's house and they drank tea together and yamato just spilled his guts out. It was both heart-warming and heart-wrenching at the same time and i thought it as sort of a turning point
I also can't describe how much I adore Sora calling Taichi Tai-yo and all the Takeru and Hikari moments snuck in between the story (they're my otp after all )
You just write brilliantly *_* this was just... AWESOME! There is something about the way you describe things that is both concise and just *filled* with meaning I totally TOTALLY admire your writing
| Tagny chapter 9 . 7/20/2008
AW, what a cute story! I love the ending! And the fcat that you made Matt wear a tiara! Cute fic!
| Little Lost Penny chapter 9 . 1/4/2008
Simply awesome *w* I loved it, goes to favourites astraifth ahead!
Write more of this couple *w* your stories are the best!
| hikanoko chapter 9 . 11/15/2007
Great story. I started it and couldn't stop until the end. You write really well.
| amazonian rush chapter 9 . 8/27/2006
I rarely says that, I used to hate those times that I says them, but I'm not ashamed to say: I love your work. There's a lot of information about the Japanese culture, you got their chemistry right... I just loved it. Maybe many have said this to you, but I don't care.
| Small Tuesday chapter 9 . 7/4/2006
This is brilliant. Pure brilliance. I have never seen a better written story. EVER. The plotline was so intriguing, and everything - as twisted and unrelated as it was in the beginning - tied together to make a wonderful story. This is incredible. So funny, so sweet. You should PUBLISH it.
Gawd - the things I'd pay to write something like this.
Genius, I tell you. GENIUS.


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- Please select a date to see the proper prices!
- Meal can be requested on the spot
Best offer
34.40 € / person / night, no meal
Description of the Accommodation
Rooms, services Keys Hotel Bengaluru Hosur Road Bengaluru is offering 159 comfortable rooms to guests looking for accommodation in Bangalore. The hotel is offering you freshly prepared fine local meals in its restaurant every day. If you are curious to discover the highlights of the area, you may also rent a car nearby. You can secure your valuables in the safe. You can browse the Internet via wireless connection (WiFi) available at the hotel. An exact and detailed list of equipment in the rooms and of the services provided by Keys Hotel Bengaluru Hosur Road Bengaluru you will find on the information sheet below, including any applicable additional fees.
Payment Advance bank card payment or credit card guarantee may be required for the reservation, depending on the chosen date, room and price.
Arrival, opening hours The earliest time to check in at the hotel is 12:00, the latest time to check out is 12:00. English is spoken by the personnel.
Keys Hotel Bengaluru Hosur Road Bengaluru rooms Rooms
- Please select a date to see the proper prices!
Accommodation services
Free WiFi in shared places
Car rental nearby
Elevator, Safe deposit box
Own restaurant
Fridge, Desk in the room, Tea/coffee-maker


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The University of Connecticut expands beyond just the Storrs campus. With four regional campuses around the state, access to UConn is readily available throughout Connecticut. Small classes, access to talented faculty, and exclusive internships and majors provide unique opportunities while benefitting from of a quality education. The Regional Campuses – Avery Point, Hartford, Stamford, and Waterbury – provide Connecticut's citizens with diversified educational programs: master's degrees, four-year undergraduate degrees, two-year general education programs for Storrs-bound students, and, for returning adult students, a bachelor of general studies degree and non-credit courses. Each regional campus has a specific mission based on the strengths and needs of its community and region, but all have faculty with active research programs and all take pride in individualized student support services. Faculty, students, and courses meet the same criteria as those at Storrs, and are also linked to Storrs and to each other through the latest technology for distance learning.
Avery Point
Joseph Madaus, Ph.D., Interim Director
The Avery Point campus in Groton is a center of excellence for marine and maritime studies. Overlooking Long Island Sound, the Avery Point campus is home to the Connecticut Sea Grant College Program, Project Oceanology, the National Undersea Research Center, and the Long Island Sound Resource Center. Bachelor's degrees in American Studies, English, General Studies, Marine Sciences, and Maritime Studies are offered.
Nina Rovinelli Heller, Ph.D., Interim Director
Through ongoing partnerships with schools, businesses, government, and national and neighborhood organizations, the Hartford campus provides hands-on learning and serves as a model of community service, opportunity, and success. This vision will be further realized in fall 2017, when the campus will move to downtown Hartford. Hartford offers Bachelor's degrees in Business Administration, Business Data Analytics, English, General Studies, Human Development and Family Studies, Psychology, and Urban and Community Studies in partnership with the Waterbury campus.
Terrence Chang, M.F.A., Director
Stamford's campus located downtown provides access to internships, field placements and jobs with Fortune 500 companies and non-profit organizations, as well as performing arts centers, restaurants, and shops.
Stamford offers Bachelor's degrees in American Studies, Business Administration, Business Data Analytics, Digital Media and Design, Digital Marketing and Analytics, Economics, English, General Studies, History, Human Development and Family Studies, and Psychology.
William A. Pizzuto, Ph.D., Director
For more than 60 years, UConn's Waterbury campus has opened doors to educational access and excellence to thousands of Connecticut residents, many of whom have distinguished themselves in community service, business, education, law, and politics. Waterbury offers Bachelor's degrees in Business Administration, Business Data Analytics, English, General Studies, Human Development and Family Studies, Psychology, and Urban and Community Studies in partnership with the Hartford campus.