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The new translation available in electronic format for a new generation of scholars Now on CD-ROM, and with biblical-text links this fresh translation of The Book of Concord brings a new generation of scholarship and sensitivities to bear on the foundational texts of Lutheran identity. New scholarship, changes in the English language, new knowledge of the history and theology of these documents, and a more technology-driven populace dictated this new translation on CD-ROM. Translators: Charles Arand, Eric W. Gritsch, Scott H. Hendrix, Robert Kolb, William Russell, the late James Schaaf, Jane Strohl, and Timothy J. Wengert.
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text: Original Articles VOLUME 16 NUMBER 2 MARCH/APRIL 2003 Role of pleural fluid cholesterol in differentiating transudative from exudative pleural effusion: R. Guleria, S. R. Agarwal, Sanjeev Sinha, J. N. Pande, Anoop Misra ABSTRACT Background. Pleural fluid cholesterol has been reported to be useful in distinguishing between transudative and exudative pleural effusion. However, the difference in lipid profile between tubercular and non-tubercular pleural effusion has not been studied. Methods. The lipid profile of pleural fluid in 50 patients with exudative (25 tubercular and 25 non- tubercular) and 25 with transudative effusion was studied. The diagnosis was based on clinical criteria and/or a positive diagnosis from another site. Results. The criteria that best identified an exudative pleural effusion were pleural fluid cholesterol ³60 mg/dl, pleural fluid to serum cholesterol ratio ³0.4, pleural fluid triglyceride ³40 mg/dl and pleural fluid to serum triglyceride ratio ³0.3. Pleural fluid cholesterol had a sensitivity of 88% and a specificity of 100% for exudates with an accuracy of 92%. Pleural fluid to serum cholesterol ratio had a sensitivity of 98% and a specificity of 84%. These results were superior to the criteria proposed by Light et al. (sensitivity 98% and specificity 80%). Conclusion. Pleural fluid cholesterol estimation is an effective and cost-efficient method of differentiating exudative from transudative pleural effusion. The lipid profile does not help in diagnosing tubercular effusion. Natl Med J India 2003;16:64–9 INTRODUCTION Pleural effusion occurs in a number of pathological conditions and even exhaustive diagnostic tests fail to reveal the aetiology in as many as 15%–20% of cases.1–3 The classification of pleural effusion as transudative or exudative is the primary diagnostic step because, if the effusion is a transudate, no further diagnostic procedures are necessary and therapy is directed towards the underlying disease process. However, if the effusion is exudative a more extensive diagnostic work-up is required to distinguish between the many possible causes of exudative effusion. In India, tubercular effusion is common and may occur in a setting where the patient is predisposed to develop an effusion due to other causes. The various criteria that have been employed include pleural fluid specific gravity, protein levels and lactic dehydrogenase (LDH) levels. In 1972, Light et al.4 compared various criteria for differentiating between transudative and exudative pleural effusion and found none of them to be specific. They advocated the use of a combination of the following criteria to differentiate between transudative and exudative pleural effusion with nearly 100% sensitivity and specificity: pleural fluid protein to serum protein ratio >0.5; pleural fluid LDH >200 IU/L and pleural fluid LDH to serum LDH ratio >0.6. However, several prospective studies5–8 were unable to reproduce the results obtained by Light et al.4 In most of these studies, Light's criteria had a >95% sensitivity for exudates but the specificity was <78%. Various causes may be responsible for the presence of cholesterol in the pleural effusion.9–11 However, till recently, the cholesterol content of pleural fluid had been used along with the concentration of other lipid fractions to distinguish between chylothorax and pseudochylothorax.12,13 No systematic study had been done of the cholesterol level in pleural effusion due to various causes till recently. Few studies have now shown that pleural fluid cholesterol levels differ significantly in transudative and exudative pleural effusion.5,6,14–16 These studies have shown a high sensitivity and specificity for pleural fluid cholesterol levels to differentiate between transudative and exudative effusion. We aimed to use the criteria of pleural fluid cholesterol levels to distinguish between transudative and exudative pleural effusion and also to assess possible diagnostic differences in the lipid profile of effusion due to tubercular and other causes. PATIENTS AND METHODS Two gold standards were used for classifying a pleural effusion as transudative or exudative. One was Light's criteria, i.e. pleural fluid LDH >200 IU/L, pleural fluid to serum LDH ratio >0.6 and pleural fluid protein to serum protein ratio >0.5. The presence of any one of the three criteria established that the pleural fluid was exudative while the diagnosis of transudative effusion was made in the absence of all three criteria. The other gold standard was clinical criteria by which a patient was classified as having a transudative effusion if he had a clinical condition that could give rise to a transudative effusion such as congestive heart failure, cirrhosis of the liver or nephrotic syndrome, with a response to treatment of the underlying condition and absence of any other condition which could give rise to a pleural effusion. Patients were classified as having an exudative effusion if they fulfilled the criteria for diagnosis of tubercular, malignant or parapneumonic effusion. Patient selection Fifty patients with exudative (25 tubercular and 25 due to malignancy and other causes) and 25 with transudative pleural effusion were studied. All of them were outpatients or inpatients attending the Department of Medicine at our institution. A detailed history, physical examination and chest X-ray were done. The patients satisfying the following criteria were included in the study: age >15 years, clinically and radiologically demonstrable moderate-to-large pleural effusion, and willingness to participate in the study. The exclusion criteria were history of previous thoracocentesis and a bleeding diathesis. Patients on diuretics for their underlying disease in the group of transudative effusion were not excluded from the study. Diagnostic criteria Patients were divided into three groups: (i) tuberculous exudate, (ii) malignant exudate and exudate due to other causes; and (iii) transudate as in congestive heart failure, nephrotic syndrome, cirrhosis of the liver, etc. A tubercular effusion was diagnosed if all the following clinical criteria were present: 1. Fever, cough, pleuritic pain, malaise, anorexia, toxaemia, etc. compatible with a clinical diagnosis of tuberculous pleural effusion; 2. Exudative pleural effusion with predominantly lymphocytic pleocytosis and a few mesothelial cells; 3. Response to antitubercular therapy. Patients who had granulomas on pleural biopsy or those in whom mycobacteria were isolated from the pleural fluid, pleural biopsy or any other clinical specimen by smear and/or culture were diagnosed to have tuberculous pleural effusion even if they did not fulfil any of the clinical criteria outlined above. A malignant pleural effusion was diagnosed if one of the following criteria were fulfilled: 1. Demonstration of malignant cells on cytological examination of the pleural fluid; 2. Demonstration of malignant tissue in a pleural biopsy specimen; 3. Histologically proven primary malignancy with exclusion of any other cause known to be associated with pleural effusion. Congestive heart failure was diagnosed by an enlarged heart, pulmonary venous congestion on chest X-ray, peripheral oedema, response to treatment of heart failure and absence of malignancy or pulmonary infiltrate associated with an inflammatory process. Nephrotic syndrome was diagnosed when the patient had proteinuria >3.5 g/m2/day, hypoalbuminaemia and oedema. Cirrhosis of the liver was diagnosed if there was evidence of portal hypertension in the absence of heart failure, malignancy or pulmonary infiltrates, and response to diuretic treatment. Investigations A haemoglobin estimation, a total and differential leucocyte count, erythrocyte sedimentation rate (ESR) and a Mantoux test with 1 TU PPD were done for all patients. The Mantoux test was considered positive if the induration was >10 mm after 48–72 hours. Sputum was evaluated for mycobacteria by Ziehl–Neelsen staining and culture on Lowenstein–Jensen medium for 8 weeks whenever an acceptable sample could be obtained. In addition, a pleural biopsy was done wherever indicated and if consent was obtained. Samples of venous blood and pleural fluid were obtained at almost the same time. Pleural fluid obtained during thoracocentesis was sent for the following investigations: sugar, protein and LDH, red and white blood cell counts including differential leucocyte count, lipid profile including total cholesterol, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol and triglyceride levels. Pleural fluid was also investigated for mycobacteria by Ziehl–Neelsen staining and culture on Lowenstein– Jensen medium and, cytopathological examination for cell type and any malignant cells. Closed pleural biopsy was done by Cope's needle.17 Patients with tubercular pleural effusion were treated with standard chemotherapy and followed up regularly. Response to antitubercular treatment was defined as favourable if the chest X-ray showed complete resolution of the pleural effusion or residual pleural thickening and the patient felt better symptomatically. Patients with a pleural fluid cytology positive for malignancy were subsequently treated at the oncology centre. Statistical analysis The cut-off points for tests being evaluated as well as cut-off points for traditional tests that would best discriminate between transudative and exudative pleural effusion were chosen by drawing receiver operator characteristics (ROC) curves wherein the sensitivity was plotted against 1–specificity. The usefulness of each of the biochemical parameters for identifying exudates was evaluated using Bayesian methods to measure the following: sensitivity, specificity and diagnostic accuracy. As transudates and exudates are complementary for a given analytical parameter, the specificity for exudates corresponds to the sensitivity for transudates. Therefore, we used specificity and sensitivity in relation to the exudates in our study results. The statistical significance of differences between means was estimated by Student's t test and Wilcoxon rank-sum test. A p value <0.05 was considered significant. RESULTS The mean (SD) age of the patients with transudative effusion was 40 (15.9) years and of those with exudative pleural effusion was 43.5 (17.5) years. The difference in age was significant between the non- tubercular exudate and the 2 other groups, but not between those with transudative and exudative effusion. There were 19 men and 6 women with transudative effusion. Among the transudative effusions, 11 (44%) were bilateral, 11 (44%) right-sided and 3 (12%) left-sided. In patients with tubercular effusion, the effusion was right-sided in 16 patients (64%) and left-sided in 9 (36%). In the group with non-tubercular exudate the effusions were left-sided in 13 (52%) and right-sided in 12 patients (48%). Mantoux test was positive in 35% of patients with transudative effusion, 76% with tubercular effusion and 44% with non-tubercular exudative effusion. Pleural fluid cytology Two patients (8%) with tubercular effusion had haemorrhagic fluid compared to 19 of 22 (86.4%) with malignant pleural effusion. One patient with transudative effusion had haemorrhagic pleural fluid. Cytological evaluation detected a malignant effusion in 8 of 22 patients (36.4%). The mean leucocyte count in transudative effusion was 613 cells/cmm. The mean (SD) leucocyte count in patients with tubercular effusion was 2256 (1946) cells/cmm compared to 1597 (2072) cells/cmm in non-tubercular exudative effusion (p<0.001). Pleural biopsy A closed pleural biopsy was done in 13 of 25 patients with tubercular pleural effusion, and granulomas were demonstrated in 9 of these (69.3%). Other patients had non-specific changes, not diagnostic or suggestive of any particular disease state. A biopsy was also done in 12 of 25 patients with non-tubercular effusion, and a diagnosis was established in 10 (83.3%). No acid-fast bacilli (AFB) were demonstrated by Ziehl–Neelsen staining in the pleural fluid or biopsy specimens in any of the patients with tuberculous or non-tuberculous pleural effusion. Mycobacteria were not cultured from the pleural fluid or pleural biopsy specimen in any patient. Pleural fluid analysis Table I shows the results of the pleural fluid analysis and Table II shows the sensitivity, specificity and accuracy of these. Total leucocyte count of pleural fluid Using a cut-off of 1000 cells/cmm, 24 of 25 transudates were correctly classified (specificity 96%) while 24 of 50 exudative effusions were misclassified (sensitivity 52%). At a cut-off of 2500 cells/cmm, the specificity remained the same but sensitivity decreased to 28%. Pleural fluid protein Using a cut-off of 3 g/dl to separate transudates from exudates, 68 of 75 patients with pleural effusion were correctly classified (accuracy 90.7%), 5 of 50 exudates were misclassified (sensitivity 90%) and 2 of 25 transudates were misclassified (specificity 92%). Among the misclassified exudates, 1 was tubercular and 4 were malignant. Ratio of pleural fluid protein to serum protein Using 0.5 as the cut-off, 60 of 75 patients were correctly classified (accuracy 80%), 21 of 25 transudates were correctly classified (specificity 84%) and 11 of 50 exudates were misclassified (sensitivity 78%). Among the misclassified exudates, 6 were tubercular and 5 were malignant effusions. Pleural fluid LDH Using 200 IU as the cut-off, 64 of 75 patients were classified correctly (accuracy 85.3%). Only 1 of 25 transudates was misclassified (specificity 96%), while 10 of 50 exudates were misclassified (sensitivity 80%). Eight of the misclassified exudates were tubercular and 2 were malignant. Table I. Mean (SD) and range of tests done in different types of effusions Test Transudates (n=25) Exudates (n=50) Mean (SD) Range Mean (SD) Range Total leucocyte count (per 287.8 (612.6) 0–3000 1926.4 (2016.9) 10–8000 cmm) Pleural fluid protein (g/dl) 1.67 (1.25) 0.08–0.25 4.66 (1.2) 2.6–8.5 Pleural fluid to serum 0.28 (0.18) 0.01–0.6 0.66 (0.18) 0.35–1.27 protein ratio Pleural fluid LDH (IU/L) 63.2 (39.5) 12–208 396.38 (419.2) 138–2460 Pleural fluid to serum LDH 0.36 (0.3) 0.05–1.4 1.68 (1.7) 0.51–9 ratio Pleural fluid cholesterol 41.7 (13.2) 8–58 98.70 (31.8) 42–184 (mg/dl) Pleural fluid to serum 0.28 (0.1) 0.1–0.54 0.64 (0.2) 0.35–1.4 cholesterol ratio Pleural fluid triglyceride 15.52 (7.5) 5–35 54.36 (23.4) 15–120 (mg/dl) Pleural fluid to serum 0.14 (0.06) 0.14–0.06 0.45 (0.17) 0.11–0.8 triglyceride ratio LDH lactic dehydrogenase All the tests showed a statistically significant (p<0.001) difference between transudates and exudates Table II. Sensitivity, specificity, accuracy and area under the curve for tests studied, using clinical criteria as the gold standard Criteria Sensitivity (%) Specificity (%) Accuracy (%) Area under the curve Pleural fluid protein (g/dl)* 90 92 90.7 0.8488 Pleural fluid to serum protein ratio* 78 84 80 09116 Pleural fluid LDH (IU/L)* 80 96 85.3 09904 Pleural fluid to serum LDH ratio* 96 88 93.3 0.9744 Light's criteria 98 80 92 – Pleural fluid cholesterol (mg/dl)† 88 100 92 0.9752 Pleural fluid to serum cholesterol 98 84 93.3 0.9660 ratio† Pleural fluid triglycerides (mg/dl)† 84 96 88 0.9620 Pleural fluid to serum triglycerides 86 96 89.3 0.9560 ratio† LDH lactic dehydrogenase *classical cut-off †cut-off that gave the best discriminant value in this study Table III. Sensitivity, specificity and accuracy of different criteria used in combination Criteria Sensitivity Specificity Accuracy Pleural fluid cholesterol or pleural fluid protein 100 92 97.3 and pleural fluid protein 78 100 85.3 or pleural fluid to serum protein ratio 98 96 97.3 and pleural fluid to serum protein ratio 62 100 74.7 or pleural fluid LDH 88 96 97.3 and pleural fluid LDH 88 100 92.0 or pleural fluid to serum LDH ratio 100 96 98.7 and pleural fluid to serum LDH ratio 80 100 86.7 or pleural fluid to serum cholesterol ratio 98 84 93.3 and pleural fluid to serum cholesterol ratio 88 100 92.0 Pleural fluid to serum cholesterol ratio or pleural fluid protein 100 80 93.3 and pleural fluid protein 88 96 90.7 or pleural fluid to serum protein ratio 100 80 93.3 and pleural fluid to serum protein ratio 70 100 80.0 or pleural fluid LDH 100 80 93.3 and pleural fluid LDH 98 100 98.7 or pleural fluid to serum LDH ratio 100 80 93.3 and pleural fluid to serum LDH ratio 90 100 93.3 Pleural fluid protein or pleural fluid to serum protein ratio 90 80 86.7 and pleural fluid to serum protein ratio 72 96 80 or pleural fluid LDH 100 92 97.3 and pleural fluid LDH 90 100 93.3 or pleural fluid to serum LDH ratio 100 88 96 and pleural fluid to serum LDH ratio 82 100 88 Pleural fluid to serum protein ratio or pleural fluid LDH 100 92 97.3 and pleural fluid LDH 72 100 81.3 or pleural fluid to serum LDH ratio 98 92 96 and pleural fluid to serum LDH ratio 68 100 78.7 Pleural fluid LDH or pleural fluid to serum LDH ratio 100 96 98.7 and pleural fluid to serum LDH ratio 92 96 93.3 LDH lactic dehydrogenase All values are percentages Ratio of pleural fluid LDH to serum LDH Using a cut-off of 0.6 for pleural fluid to serum LDH ratio, 70 of 75 patients were correctly classified (accuracy 93.3%), 3 of 25 transudates were misclassified as exudates (specificity 88%) and 2 of 50 exudates were misclassified and both were tubercular. The cut-off points which showed the best discriminant value in our study were: Pleural fluid protein 3 g/dl Pleural fluid to serum protein ratio 0.6 Pleural fluid LDH 135 IU/L Pleural fluid to serum LDH ratio 0.7 Pleural fluid cholesterol 60 mg/dl Pleural fluid to serum cholesterol ratio 0.4 Pleural fluid triglyceride 40 mg/dl Pleural fluid to serum triglyceride ratio 0.3 Using these cut-offs, the sensitivity and specificity of each parameter for exudates was the same as the sensitivity and specificity of different parameters using the cut-offs suggested by Light et al.4 Using a combination of our criteria and those of Light et al., an exudate could be classified either if one of the two criteria were met or if both criteria were fulfilled. The sensitivity and specificity for exudates, if the above-mentioned combinations were applied, are shown in Table III. Using Light's criteria as the gold standard for classifying pleural effusions into transudative and exudative, our study had 54 exudates and 21 transudates. The sensitivity, specificity and accuracy of lipid parameters, using Light's criteria as the gold standard, are shown in Table IV. DISCUSSION The first step in determining the aetiology of a pleural effusion should be to find out whether it is a transudate or an exudate. No single test or series of tests has yet proved to be completely reliable. Several criteria have been proposed5–8 and one of these—pleural fluid cholesterol—seems to have a higher diagnostic accuracy for identifying transudates. This study was designed to assess the utility of pleural fluid concentrations of cholesterol in comparison to the traditional criteria of Light et a1.4 and its individual parameters (pleural fluid LDH concentration, pleural fluid to serum LDH ratio, and pleural fluid to serum protein ratio) to distinguish between exudates and transudates. We also looked for differences in the lipid profile, if any, between tuberculous and non-tuberculous exudative effusions. Table IV. Sensitivity, specificity and accuracy of lipid parameters using Light's criteria as the gold standard Criteria Sensitivity Specificity Accuracy (%) (%) (%) Pleural fluid cholesterol 80.0 95.2 84.0 Pleural fluid to serum cholesterol ratio 92.6 80.9 89.3 Pleural fluid triglyceride 70.4 100 78.7 Pleural fluid to serum triglyceride 81.5 100 86.7 Light et a1.4 used pleural fluid and serum levels of protein and LDH to establish criteria for differentiating transudates from exudates with a sensitivity and specificity of near 100%. This high diagnostic accuracy made the criteria of Light et a1.4 the 'gold standard' for initial categorization of pleural effusion. However, Light's criteria require 4 biochemical estimations which, in developing countries such as India, may not be feasible in every patient due to economic constraints. Also, several prospective studies5–8 were unable to reproduce the results obtained by Light et al. In our study, Light's criteria had a sensitivity of 98% but the specificity for exudates was only 80%. For pleural fluid cholesterol, pleural fluid to serum cholesterol ratio, pleural fluid triglycerides, and pleural fluid to serum trigly-ceride ratio, we determined the level which best discriminated transudative from exudative pleural effusion. All transudates had pleural cholesterol levels <60 mg/dl, a cut-off which misclassified 16% of tubercular and 8% of non-tubercular exudates. Using this cut-off (60 mg/dl), pleural fluid cholesterol had a sensitivity of 88% and specificity of 100% for exudates, with an accuracy of 92%. The results of our study are comparable to the studies by Hamm et al.,5 Valdes et al.6 and Kalayci et al.18 We found that pleural fluid cholesterol, pleural fluid to serum cholesterol ratio, pleural fluid to serum LDH ratio and the criteria of Light et al.4 had almost the same accuracy, but pleural fluid cholesterol had the highest specificity. Pleural fluid LDH had the highest area under the curve followed by pleural fluid cholesterol. Therefore, in clinical settings with a high prevalence of transudative effusion or where patients clinically appear to have congestive heart failure (the criteria of Light et al.4 would classify these as exudates), the measurement of pleural fluid cholesterol can be useful. The use of pleural fluid to serum cholesterol ratio did not improve the accuracy of pleural fluid cholesterol estimation alone. Romero et al.19 found pleural fluid LDH to have the highest specificity (95%), being significantly higher than the Light criteria (p<0.05). They found the criteria of Light et al. and pleural fluid LDH-cholesterol to be equally effective in differentiating exudates from transudates. A similar finding has been reported by Costa et al.20 In previous studies, pleural fluid triglyceride has not been evaluated. The use of pleural fluid triglyceride and pleural fluid to serum triglyceride ratio in our study had a high specificity (96%) with an accuracy lower than that of pleural cholesterol. Given the variability of results from one laboratory to another, defining the cut-off levels for a particular laboratory may improve the specificity of the test without a loss in its sensitivity. This was the case in our study. It is evident from the comparative results of the classical and modified criteria depicted that the accuracy of pleural fluid to serum protein ratio and pleural fluid to serum LDH ratio remains the same but the specificity increased from 84% to 96%, and 88% to 96%, respectively. While the specificity remains the same by modifying the criteria of pleural fluid LDH, the sensitivity and accuracy improves significantly. Using Light's criteria with modified cut-off points yielded an accuracy of 97.3% with a specificity of 92% in comparison to an accuracy of 92% and specificity of 80% using the classical criteria. We also evaluated a combination of Light's criteria and our criteria in two ways: 1. Exudate is defined if any of the two criteria used in combination is fulfilled. 2. Exudate is defined if both criteria are fulfilled. The use of a combination of the two criteria gives a better sensitivity and specificity for exudates than either used alone. Using modified cut-off points, pleural fluid to serum cholesterol ratio and pleural fluid LDH used in combination, when both of them are required to define exudates, provide the best discrimination with an accuracy of 98.7% and specificity of 100% (Table III). Almost equivalent results with an accuracy of 98.7% and specificity of 96% are obtained on using either pleural fluid cholesterol and pleural fluid to serum LDH ratio in combination or pleural fluid LDH and pleural fluid to serum LDH ratio in combination when one of the two criteria is required to define an exudate. Therefore, in our study estimation of cholesterol and LDH in pleural fluid and serum gave an almost 100% sensitivity and specificity when used in various combinations, which is much higher than that obtained with the use of pleural fluid and serum protein and LDH as proposed by Light et al.4 Using Light's criteria4 as the gold standard, 54 patients were classified as having exudative effusion and 21 as having transudative effusion. Using a cut-off level of 60 mg/dl for pleural fluid cholesterol concentration, 84% of pleural effusions could be correctly classified with a specificity of 95.2% for exudates (Table IV). Use of pleural fluid to serum cholesterol ratio improved the accuracy to 89.3% but at the cost of lowering the specificity to 80.9%. Use of pleural fluid triglyceride and pleural fluid to serum triglyceride ratio yielded a specificity of 100% but accuracy of 78.7% and 86.7%, respectively. Therefore, among the lipid parameters, pleural fluid to serum triglyceride ratio appears to be the best with a specificity of 100% for exudates, misclassifying only 13% of pleural effusions. Using both pleural fluid cholesterol and pleural fluid to serum cholesterol ratio does not improve the discrimination significantly. Of the various combinations of lipid parameters, the use of pleural fluid cholesterol and pleural fluid to serum triglyceride ratio improves the accuracy to 90.7%, maintaining a specificity 95.2% for exudates (Table IV). REFERENCES 1. Storey DD, Dines DE, Coles DT. Pleural effusion: A diagnostic dilemma. JAMA 1976;236:2183–6. 2. Hirsch A, Ruffie P, Nebut M, Bignon J, Chretien J. Pleural effusion: Laboratory tests in 300 cases. Thorax 1979;34:106–12. 3. Chandrasekhar AJ, Palatao A, Dubin A, Lavine H. Pleural fluid lactic acid dehydrogenase activity and protein content—Value in diagnosis. Arch Intern Med 1969;123:48–50. 4. Light RW, MacGregor MI, Luchsinger PC, Ball WC Jr. Pleural effusions: The diagnostic separation of transudates and exudates. Ann Intern Med 1972;77:507–13. 5. Hamm H. Brohan U, Bohmer R, Missmahl HP. Cholesterol in pleural effusions: A diagnostic aid. Chest 1987;92:296–302. 6. Valdes L, Pose A, Suarez J, Gonzalez-Juanatey JR, Sarandeses A, San Jose E, et al. Cholesterol: A useful parameter for distinguishing between pleural exudates and transudates. Chest 1991;99:1097–102. 7. Roth BJ, O'Meara TF, Cragun WH. The serum-effusion albumin gradient in the evaluation of pleural effusions. Chest 1990;98:546–9. 8. Meisel S, Shamiss A, Thaler M, Nussinovitch N, Rosenthal T. Pleural fluid to serum bilirubin concentration ratio for the separation of transudates from exudates. Chest 1990;98:141–4. 9. Stein HM. Cholesterol thorax in tuberculosis (cholesterol pleurisy). Arch Intern Med 1932;49:421– 8. 10. Ferguson GC. Cholesterol pleural effusion in rheumatoid lung disease. Thorax 1966;21:577–82. 11. Coe JE, Aikawa JK. Cholesterol pleural effusion. Arch Intern Med 1961;108:163–74. 12. Staats BA, Ellefson RD, Budahn LL, Dines DE, Prakash UB, Offord K. The lipoprotein profile of chylous and nonchylous pleural effusions. Mayo Clin Proc 1980;55:700–4. 13. Sassoon CS, Light RW. Chylothorax and pseudochylothorax. Clin Chest Med 1985;6:163–71. 14. Vaz MA, Marchi E, Vargas FS. Cholesterol in the separation of transudates and exudates. Curr Opin Pulm Med 2001;7:183–6. 15. Jimenez Castro D, Diaz Nuevo G, Perez-Rodriguez E. Comparative analysis of Light's criteria and other biochemical parameters to distinguish exudates from transudates. Rev Clin Esp 2002;202:3– 6. 16. Gazquez I, Porcel JM, Vives M, Vicente de Vera MC, Rubio M, Rivas MC. Comparative analysis of Light's criteria and other biochemical parameters for distinguishing transudates from exudates. Respir Med 1998;92:762–5. 17. Cope C, Orange E. New pleural biopsy needle: A preliminary study. JAMA 1958; 167:1107–8. 18. Kalayci AG, Gurses N, Adam B, Albayrak D. Significance of pleural fluid cholesterol and beta-2 microglobulin levels for the differentiation of pleural effusions in childhood. Clin Pediatr (Phila) 1996;35:353–8. 19. Romero S, Martinez A, Hernandez L, Fernandez C, Espasa A, Candela A, et al. Light's criteria revisited: Consistency and comparison with new proposed alternative criteria for separating pleural transudates from exudates. Respiration 2000;67:18–23. 20. Costa M, Quiroga T, Cruz E. Measurement of pleural fluid cholesterol and lactate dehydrogenase. A simple and accurate set of indicators for separating exudates from transudates. Chest 1995;108:1260–3. All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India R. Guleria, S. R. Agarwal, Sanjeev Sinha, J. N. Pande, Anoop Misra Department of Medicine Correspondence to R. Guleria; firstname.lastname@example.com


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The results are out for the 'Nuker of the Year' contest which was running for over three weeks from 8 October to 5 November. The jury consisted of renowned names from the VFX industry namely: Jordan Thistlewood – Head of Creative Specialist at The Foundry; Amit Sharma – Head of Compositing at MPC Bangalore and Kyle McCulloch – Visual Effects Supervisor at Framestore. AnimationXpress.com had a chat with the winners of all the three categories, namely 'Nuker Team of the Year', … Read More
BENGALURU: Prime Focus Limited (PFL) reported 78.3 per cent growth in Income from Operations (TIO) in the quarter ended 30 September, 2015 (Q1-2015, current quarter) to Rs 350.17 crore from Rs 196.38 crore (quarter ended 30 September, 2013, or Q2-2014) and 76.6 per cent more than the Rs 199.5 crore in Q5-2014 (q-o-q). Notes:(1) 100,00,000 = 100 lakh = 10 million =1 crore (2) The company had filed results for a fifteen month period ended June 30, 2014, hence comparison … Read More
Looks like the Anil Ambani-owned Reliance MediaWorks (RMWL) is already taking precautionary steps at reducing it losses by getting rid of its loss-making cinema exhibition business, and transferring these assets to its subsidiary Reliance MediaVentures. The company has proposed the transfer of the exhibition business in order for a complete or partial sale of Big Cinemas. The exhibition business of RMWL operates the third largest cinema chains under the brand Big Cinemas, with approximately 250 screens across India. Incidentally, the … Read More
On 3 November, 1954 the original Godzilla film opened in Japan. Nearly 9.6 million movie-goers went to watch the film on opening night eager to see the monster come to life with the films revolutionary visual effects. Japan had a population of 88 million then. But it was a specific sound effect that would become one of the most famous moments in film history, Godzilla's emphatic roar…. Originally captured by using leather gloves and a double bass, recreating the iconic roar was one … Read More
Prasad Group, a pioneer in the Indian media and entertainment world over the last five decades, has worked on the VFX and DI for director Hari's latest Tamil hit, Poojai. It is an Action Masala movie that has been produced by Vishal Film Factory and cinematographed by Priyan. Yuvan Shankar Raja has composed the soundtrack and score for the film that stars Vishal and Shruti Hassan in the main lead. "We have worked on almost all the projects with Hari sir … Read More
Can you spot the difference between a real and a reel tiger? But we are certain after watching the movie 'Roar – Tigers of Sunderbans' you will be in a dilemma whether the tigers in the feature were real felines or just awesome CGI creatures, for this the credit goes to the founder of Anibrain Studio, Jesh Krishna Murthy and his team who have spent more than three years on their first Bollywood project. The film has been directed by … Read More
VFX is a very important tool in today's day and age and one of the most used software or tool is Nuke from the house of The Foundry. Well, in a very novel initiative the company is holding a nationwide contest christened 'Nuker Of The Year', which is open to students as well as professionals in India. Participants will need to submit a web link to a shot they have worked on including a VFX breakdown and the Nuke node … Read More
Not too long ago, on 2 October the Hindi film fanatics were treated with the release of two big budgeted and multi-cast films. One being the Hrithik Roshan and Katrina Kaif starrer 'Bang Bang' and the other being Vishal Bhardwaj's adaptation of 'Hamlet' starring Shahid Kapoor as Haider. Well, AnimationXpress.com got the opportunity to have an exclusive interaction with the VFX supervisor and Digikore Studios, who worked on giving 'Haider' the period look and also to help in creating the … Read More
Amsterdam based agency, Etcetera turned to PostPanic director Mischa Rozema to take on the challenge of its hugely ambitious Human Network script. Central to the integrated global campaign for TNT, is a stunning 50 second television spot highlighting the delivery giant's far-reaching network of dedicated couriers. With an accompanying TVC cutdown of 30 seconds, personalised video for TNT's existing clientbase and several key print visuals, PostPanic took on producing the main bulk of the integrated campaign followed by localising to … Read More
Prime Focus Technologies (PFT), the technology subsidiary of Prime Focus, the world's largest integrated media services powerhouse, has announced a deal with Crown Media Holdings, Inc. to deliver the cloud enabled DAX production workflow solution including the Emmy award-winning Digital Dailies and DAX Mobile, as well as Cuts and Video Watermarking for Crown Media Family Networks. Crown Media Family Networks is the parent company of Hallmark Channel and Hallmark Movies & Mysteries, the top destinations on cable for family friendly … Read More
Along with other Tamil block-busters, Prasad EFX continues to add expand its portfolio of work. This time it has worked on the VFX & DI for Sundar C's latest film, Aranmanai, a horror/comedy/thriller film produced by Vision I Media and Sri Thenandal Films. The movie has been distributed by Red Giant Movies and cinematographed by U.K. Senthil Kumar. "Having worked with Sundar sir before really helped us to understand his expectations and recreate that on screen. It was an extremely … Read More
Prime Focus Limited, the world's largest media services powerhouse will be launching its corporate social responsibility (CSR) arm 'Naresh Malhotra Foundation' in Mumbai on 2 October 2014, the occasion of founder and chairman Emeritus Naresh Malhotra's 70th Birthday. The initiative will be flagged off by Naresh Malhotra in the presence of staff, family and friends; Founder, Executive Chairman and Global CEO of Prime Focus, Namit Malhotra will be joining through a video conference. Naresh Malhotra has been the guiding force behind Prime Focus' stupendous … Read More


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The business cards as published in our February 2013 issue.
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Food Fix
Style Fix
Garden Fix
Décor Fix
Lucky Fix
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Use the contemporary combination of geometric patterns and pastel colours with touches of silver for your decorations
These decorations are ideal for a wreath or for your tree
What better gift to give than a pretty picnic basket? It has enough pockets and space to hold all the things you might need for the perfect picnic
Keep your picnic basket full of delicious surprises with basil, watercress and rocket – fresh from your own garden
A tart so easy and delicious
… in the river wild if you want to boost your libido and health
Sandals with gold trim black, Zoom (R250)
Amber dress multi-colour, Ruff Tung (R575)
Jelly sandals with bows neutral, Madison (R230)
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The snow reveals the secret traffic of my yard. The tracks of rabbits, deer, raccoons, birds, cats, dogs and humans make zig zag patterns through ice and drift. Such quiet crossings, blanketed by night right under my nose! The snow tells on the white emptiness of winter–it says: you are not alone here.
The snow came this year suddenly, all at once, without warning. We went out in it, before the sunset last night, and walked through the woods, marching with each footfall through the drifts and the heavy boughs of bushes weighted down by snow, decorated by the hard red berries no bird will eat, left behind like a beautiful, forgotten string from a holiday parcel.
Most amazing is how the snow illuminates the golden hues of sunlight; that interplay between snow and sun is magical.
There is whimsy in the woods, signs of human life beyond ourselves, beyond the crunch of our footfall. We walk through space and leave something of ourselves, intentionally or not. The earth can never forget us, we are ring pressed into her bark, but a moment in this evolving Universe.
We emerge from the woods as the sun falls, cold, ready for the warm mist of stew and heavy bread, and the quiet of a dark, snowy evening.
Walking in the woods, after the first snowfall of the year, may not thrill some. But it thrills me, because happiness is experienced in those seemingly insignificant spaces of nothingness. Peace comes not from winning all the wars, but from refusing to fight. Healing of trauma comes not from big excitement, but from nothing happening. Joy is glimpsed in the quiet posture of a tree accepting the weight and cold of snow upon its flesh.
Trauma is big, spectral, overwhelming. It squeezes itself into the whole frame, leaving no space for anything else. It's antidote is not something else that is big, but perceived as "good," something that crowds the whole mental and physical landscape. Space, nothingness, quietude–these are ordinary and abundant. But in that abundant, ordinaryness lies peace.


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Government Removal of VAT exemption
13 April 2012
They also think the most effective campaigning results from writing to local MPs with local examples, and a letter has been drafted for parishioners to personalise and sign should they wish, which can be downloaded here
A vigorous campaign will continue, but in these situations local pressure counts for a great deal.
Please have your voice heard by supporting the e-petition to put pressure on the Government to change their mind about the proposed imposition of VAT on alterations to Listed Places of Worship. Impact depends on speed, so please do encourage people to sign up as soon as possible.
The Government consultation ends on 4th May, so please sign before then.
Government Transitional Arrangements
Transitional arrangements are in place to mitigate the impact of the proposed introduction of VAT at 20% for works presently zero-rated. Works with a signed contract in place by 21st March 2012 will be exempted from the 20% rate of tax for works done by 20th March 2013. Works after this date will pay VAT at the standard rate. Works contracted after 21st March 2012 will incur VAT at the standard rate for the parts of the contract performed after 1st October 2012.
Special arrangements apply to works without a written contract that were started before 21st March 2012. When 10% of the works (by cost) was performed before 21st March 2012 and three-fifths (by reference to cost) would qualify for zero-rate under the present arrangements, the work performed after 1st October 2012 and before 20th March 2013 can be zero-rated.Please see the fuller wording in the consultation document for greater clarity, pages 26-27
Latest News from around the Diocese
Keep up to date with the latest news from around Winchester Diocese, using the links below.
Do you have a story for us? It could not be easier to tell us your news and spread the message across the Diocese. Simply click the button below.
Legislation on women bishops becomes law
The General Synod has enacted the measure enabling women to be ordained as Bishops in the Church of England.
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Debbie Thrower installed as an Honorary Canon
Debbie Thrower has been installed as an honorary lay Canon and member of Winchester Cathedral Chapter
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Bishop Tim Dakin's visit to East Africa
The Bishop of Winchester recently returned from an official visit to East Africa in his capacity as the Church of England's spokesperson on further and higher education.
Read More...
New Chair of the House of Clergy appointed
On Saturday 8 November Diocesan Synod appointed a new Chair of the House of Clergy
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Diocese welcomes changes to Reader Ministry
This summer, with the agreement of the Bishop's Council and in line with other dioceses, we have started to use the term 'Licensed Lay Minister' (LLM) rather than 'Reader' for all those exercising this important ministry.
Read More...
Bishops to mark Remembrance Sunday
Local Bishops will commemorate outbreak of World War One alongside communities in Winchester, Southampton and Basingstoke
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The Right Reverend Michael Scott-Joynt RIP
We are sorry to announce the death of the former Bishop of Winchester, the Right Reverend Michael Scott-Joynt.
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New Bishop of Basingstoke consecrated
The Reverend Canon David Williams consecrated by the Most Reverend Justin Welby , the Archbishop of Canterbury, at Winchester Cathedral
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New Archdeacon for Mission Development starts work
Rev Canon Dr Paul Moore joins Diocesan team
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Winchester Cathedral's Learning Centre Reopened
HM Lord-Lieutenant Open Winchester Cathedral's Refurbished Learning Centre
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You think retrospectives are the most boring meetings in Scrum and a waste of time? Or you are the ScrumMaster and you don't know how to spice up your retrospectives? Unfortunately, I sat in a lot of boring retrospectives, too. But IMHO retrospectives are the meetings with the biggest potential for a lot of fun. I've some spices in my suitcase that will turn any retrospective into a remarkable experience. Join me, to learn how to facilitate a retrospective your team will love.
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text: The LOVE Team View full-size image < previous next > Is this photo a winner? "Internal and external marketing campaign. " - http://www.mortgagereturns.com - The LOVE Team (Apr 04, 2013) Share this photo on: Twitter Facebook Pinterest Similar Photos: business services | happy | large group | professional | staff | marketing campaign Feeling inspired? Visit the CustomInk Design Lab to start your own group order. Design Your Own


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Find records of Huseyin Azerkan
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Huseyin Azerkan (1904 - 1994) was born on May 15, 1904. Huseyin was born into the Azerkan family.
Huseyin had no-known relationships. Huseyin died on February 6, 1994 at 89 years old.
Huseyin Azerkan's last known residence is at Atascadero, San Luis Obispo County, California.
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West Roxbury celebrates tomorrow today with its traditional Truman Rally in the municipal parking lot at Centre and Hastings streets (right across from the mural of James Michael Curley and Dapper... Read more
West Roxbury
Rox Diner, 1881 Centre St. in West Roxbury, goes before the Boston Licensing Board next Wednesday for permission to offer beer and wine.
Rox Diner, which grew out of a small breakfast-and-lunch place called Auntie Bea's, already serves beer and wine with dinner at its Newtonville location.
A power line came down on Powell Street in West Roxbury, off Spring, around 10 p.m., knocking out power in the area of Spring and Baker, as far south as the Deutsches Altenheim.
The NStar outage map is beginning to light up, although all of the outages so far are small (exactly one customer in Newton).... Read more
Christopher photographed the scene in the water aisle at the Waltham Shaw's on Saturday night.
At the Dedham Star, a manager went on the PA: "Attention shoppers, get all your power-outage needs at the front of the store." At the front of the store was a... Read more
West Roxbury Burger King has license suspended for two days for opening when its license was suspended for two days
The Boston Licensing Board today ordered the Burger King on VFW Parkway to shut for an additional two days after a police detective found it open on the first day it was supposed to be shut as two-day punishment for staying open late without permission.
Lt. Stephen Meade told the board at a hearing Tuesday that while the dining room was closed on Aug. 27... Read more
On a trip to the West Roxbury Shaw's this afternoon, Alex Jones noticed a rather precariously parked Jeep. Jones reports he happened to be there when the driver came out; guy explained, "it was just something I always wanted to do."
Copyright Alex Jones.... Read more
Timothy's on VFW Parkway recently shut down and took all its coffee with it. The table area's still open to customers from the neighboring Bruegger's, where a cashier said the Canadian-based Timothy's (which has nothing to do with Tim Horton's) was an experiment that just didn't bring in enough customers. It opened only a year ago.... Read more
Wicked Sharp (is that a good Boston name or what?) uses discarded ice from the Roche skating rink on VFW Parkway to create snowmen outside their store on Centre Street in West Roxbury.... Read more
Citizens Connect has several reports of tree damage from last night's storm, including this tree on wires on Ansonia Road in West Roxbury and this snapped tree on wires off Clarendon Street in the South End.... Read more
Among the press types who rushed to West Roxbury yesterday on word of a possibly bad crash involving a police cruiser was Alex Jones, a freelancer who specializes in "spot news" (i.e., things like car crashes). He tweets:
Had a @BostonPolice officer threaten to take my cameras for photographing in a public space today w/o his permission.
An alleged gun assault on an off-duty police officer on the VFW Parkway across from the West Roxbury Education Complex entrance this morning led to a massive police response followed a few minutes later by... Read more
We were headed south on the VFW Parkway the other day when, whoa, was that a coyote hanging out by the VA Hospital? We did a quick uey, pulled into the parking lot and discovered that, no, it was not a real coyote, just a plastic replica of one. Hokay.
Compare... Read more
Only since there aren't any overpasses there, the tractor-trailer took out a couple of telephone poles and wires near the Beethoven School around 2:15 p.m. Police blocked southbound traffic at West Boundary Road and northbound traffic at Grove Street until the situation could be cleared.
In Hyde Park, trucks get jammed between buildings, not under bridges.... Read more
It's at the Home Depot in West Roxbury.
Chris Casey spotted this sparkly new District A-1 Boston Police cruiser today on Centre Street in West Roxbury, wonders why BPD couldn't find a dealer closer than New York to buy them from.... Read more
West Roxbury Patch reports police had to be called after a man annoyed with his neighbor's retaining wall on Grove Street began digging a trench along the wall - on his neighbor's property.
Jenna Cramer, the assistant principal at the Joyce Kilmer, is now the principal, replacing Jerome Doherty, who remains in some sort of administrative limbo in which he has no position after being yanked from the Kilmer for reasons that have not been made public.... Read more
The Globe reports a teacher at the Joyce Kilmer School is under investigation by police and school and state child-protection officials for "inappropriate contact with students" and that the school's principal has been removed from his position.
The Globe says Superintendent Carol Johnson announced the news - along with news that the principal at the Frederick Middle School in Dorchester has been put on... Read more
Overheard in West Roxbury Y men's locker room among two retirement-age guys:
- 1: You still going to Egypt?
- 2: Yeah, sure.
- 1: I wouldn't go, even if it was free.
- 2: You're afraid of Egypt but you go to Dorchester?


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Zoe Saldana & Team Obtain Rights HELL OR HIGH WATER Novel
Zoe Saldana and producers Jane Startz and Aida Bernal have picked up the rights to Joy Castro's novel HELL OR HIGH WATER, Deadline reported this afternoon. At this time, Saldana and her sister Cisley's Saldana Productions are making a joint effort with Jane Startz Productions and Bernal's Spellbound Entertainment to adapt the acclaimed novel into either a TV series or a feature film.
HELL OR HIGH WATER is officially described as:
"Nola Céspedes, an ambitious young reporter at the Times-Picayune, finally catches a break: an assignment to write her first full-length feature. While investigating her story, she also becomes fixated on the search for a missing tourist in the French Quarter. As Nola's work leads her into a violent criminal underworld, she's forced to face disturbing truths from her own past and is confronted with the question: In the aftermath of devastation, who is responsible for rebuilding what's been broken?
Vividly rendered in razor-sharp prose, this haunting thriller is a riveting journey of trust betrayed—and the courageous struggle to rebuild. Fast-paced, atmospheric, and with a knockout twist, Hell or High Water features an unforgettable heroine as fascinating and multilayered as New Orleans itself."
Saldana is best known for her role in James Cameron's AVATAR, as well as J.J. Abrams' STAR TREK. She is set to reprise her role as 'Uhura' the next installment of the series, STAR TREK INTO DARKNESS.
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Source: http://llenrock.com/blog/top-10-real-estate-markets-to-watch-this-year/ Today's Top 10 comes to us from the most recent Jones Lang LaSalle (NYSE: JLL)Business of Cities report (PDF is here on ...Full Article
Purpose. Passion. Prosperity.
A thriving economy. Pro-business attitude. Talented workforce. Outstanding quality of life. This is Round Rock, Texas, recently named the second "best performing city" in the country by the Milken Institute. Discover why industry leaders such as Dell and Toppan Photomasks call Round Rock home. Why baseball legend Nolan Ryan chose us for his AAA baseball club, the Round Rock Express. And why Round Rock ranks at the top of every national study for our strong economy, relocation opportunities, safety and education and much more. Discover what Round Rock can offer you.
Recent Round Rock News
By: Amanda Dugan, KXAN Round Rock officials celebrated the beginning of construction on the area's first diverging diamond at Interstate 35 ...Full Article
Available Real Estate
Round Rock has a variety of commercial, industrial, and mixed-use buildings and sites available for your business' relocation or expansion.View All Real Estate
Round Rock's proximity to a labor pool of more than one million workers provides a growing pipeline of skilled labor and talented college graduates.View Workforce
Area Industry Map
View Area Industry Map
Invest in Momentum
If your business would like to be involved in shaping economic development in Round Rock, consider becoming a Momentum investor today!About Momentum


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Arm and leg warmers
Added: 5 years ago
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4 years ago
That's a very hot set! White is my favorite color for lycra warmers.
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4 years ago
This is one hot set Love the warmers and the blue gloves. especially love the plug up your ass. you nasty ****!!
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George R.R. Martin Wants to Put the "Craziest" ASoIaF Fan Theory to Rest Once and for All
All theories must die.
George R.R. Martin likes to play with his fans sometimes, but in this instance, he's ready to tell the truth.Read More
George R.R. Martin likes to play with his fans sometimes, but in this instance, he's ready to tell the truth.Read More
As we've previously learned, there is no end to the number of theories Game of Thrones fans have about George R.R. Martin's plans for the series.Read More
Strap in, book-reading nerds: there's another story arc we probably won't get this year. And don't worry, it's not Theon's—as far as we know, anyway. Spoilers for the summer children, so be warned.Read More
Last August we reported that Telltale Games had released a promotional image for their upcoming A Song of Ice and Fire-inspired game, but since then the developer has been incredibly tight-lipped about the point-and-click. Until last Friday, that is.Read More
Spoilers are coming, naturally.Read More
So far we've seen some good (Alexander Siddig as Doran Martell) and some bad (Sand Snakes with nipple armor) from Game of Thrones season five set pics. Now it's time for some "...the hell?" Warning, front and center. This post discusses major plot points for season five of Game of Thrones and A Dance with Dragons. Abandon spoilerphobia, all ye who enter here.Read More
Last time we journeyed to Braavos in Game of Thrones Season 4, all we saw was a giant interior space with Mycroft Holmes in it. With so many characters from the main cast descending on the free city at once, though, we're probably going to be spending a lot of time there when the show returns next year. Spoilers abound, of course!Read More
Ah, tinfoil theories. Ask anyone in any fandom about crazy fan theories and they'd be able to hit you with at least one. Game of Thrones has, well... substantially more than that.Read More
With Game of Thrones currently filming season 5 and GRRM coming out with a new book (but not the one we want *sob*) soon, things have been fairly quiet for fans of A Song of Ice and Fire. Luckily, we have fan theories to occupy us during the many hiatuses we're subject to. Here are some of the big ones—in next week's part two I'll be focusing on the more tinfoil-y options.Read More
Hodor actor Kristian Nairn might have let the Bran out of the backpack with this one. Potential spoiler alert for Game of Thrones season five, so read on at your own risk. Hodor.Read More


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Are you 'bingo' ready?
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Recently I was speaking with Aaron Tomlinson, a police trainer at Fox Valley Technical College in Appleton, Wisconsin. He gave me permission to share with you an analogy he uses to prepare his recruits to stay alert on the contacts they will make in their future career.
To paraphrase, Aaron tells them that the day-to-day contacts an officer makes on the street are much like the game of Bingo.
Each number called out is like a call for service answered, leading them toward "bingo" — the inevitable confrontation that lies ahead.
Poised Like a Panther
This gray-haired granny knows that if she gets lackadaisical, zones out, or just plain snoozes she loses. She stays alert, and pays attention because the next number called might be a "Bingo!"
Bingo Ready
Ask yourself, "Am I bingo-ready throughout every contact? Am I at least as alert as a 78-year-old Grandma playing 'Bingo'?"
You should be — your life depends on it.
Remember, confrontation for you is as inevitable on the street as "bingo" in the game of that same name. Unlike Bingo it is not a game that you are playing. Like Bingo, however there is no second place on the street.
You have to be — at all times — bingo-ready.
Got the message?
You did?
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10 Used French Military Suspenders, Olive Drab
Item # WX2-206158
- Google+
This item is shipped directly from the factory. To see the expected shipping date, please add to your Shopping Cart. Sorry, no express shipping available. We are unable to ship factory direct items to Alaska, Hawaii, Puerto Rico or APO or FPO addresses.
- Details & Specs
10 "vet" French Military Suspenders.
Tired of hitching up your pants? Keep your squad's pants riding high with these pre-tested Suspenders. Sure to pass inspection!
- Cotton material
- Button attachment to pants
- Fully adjustable.
- Made in France.
Condition: used, in very good shape.
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- Reviews
10 Used French Military Suspenders, Olive Drab is rated out of 5 by 4.Rated 4 out of 5 by Trapper 56 from Lightweight and cool It was time to replace the one's I've used for years. They are comfortable and lightweight, making them practical for use in the summer. Made for short folks (I'm 6-2') you can ignore the buckles on the front and simply pin them to the proper length with a brass safety pin. I get army surplus buttons to sew on the inside of pants for attachment.Date published: 2014-10-09Rated 4 out of 5 by RICHARD from good price and productDate published: 2013-10-28Rated 5 out of 5 by DIANA from they are thin and you don't feel any pooling thought they hold, good mach for the Belgian overpans...Date published: 2013-10-21Rated 3 out of 5 by BEN HUGH from I'm 6'01", and they're kinda short.Date published: 2012-08-23
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Mayday Bar: An elegant runway for take-off or landing
New: Bar Food International - at the Mayday Bar
Whether you're looking to meet friends in a comfortable and stylish atmosphere or enjoy a romantic evening for two: the Mayday Bar at Hangar-7 will spoil you with its international cocktails and delicious bar food.
You don't need a plane to find your way to the Mayday Bar – just take the lift! The second floor of
Hangar-7 offers a stylish environment to let your hair down and forget the daily grind for a few hours – at any time from noon till midnight (1.00 a.m. on Fridays and Saturdays).
The historical aircraft on show inside Hangar-7 can be admired from a bird's eye view at the Mayday Bar. And the menu is just as spectacular, offering a large choice of exquisite cocktails from all around the world and an equally international range of culinary delights. This comes as no surprise, considering that the bar food dishes are specially created for the Mayday Bar by the chefs of the Ikarus Team, who incorporate their experiences from working with more than 130 top international chefs as part of the guest chef concept over the past ten years.
Expect to be spoiled with unique compositions of classic or unusual ingredients, brought together using a wide variety of cooking styles, techniques and philosophies.
So, in addition to spending a couple of hours in comfort and style, you'll also find the perfect dish to treat your taste buds at the Mayday Bar!
Weekly menu
Spaghetti "aglio e olio"
with vongole and spinach
Beiried "Strindberg"
with rosemary potato and cabbage
Pickled salmon with roesti,
field salad and horseradish
Braised goose
with potato dumpling and baked apple
Orecchiette with tuna
and ratatouille vegetables
Risotto with calamari,
olives and tomatoes
Stilt of veal
with sauce Hollandaise and fries
Today´s lunch specials are on offer daily from 12:00 – 02:00 pm.
Bar Food International
"Spider roll"
with baked softshell crab and spicy mayonnaise
Honoka Japan : Carpe Diem Kombucha Classic, green tea, passionfruit, yuzu
Yellow curry
with braised chicken leg and steamed rice
T-Hailand: coconut rum, pineapple, lime, lemongras
Tapas con jamón y queso
"Sanchez" : cherry liqueur, vermouth, blackberry liqueur,
Carpe Diem Kombucha Quince, lime
Toasted rye bread with spinach, raclette and truffle
"Alm Tee": tea of hay, ricola, crue de cacao
Köttbullar of reindeer with cranberries, cream sauce and red cabbage salad
Frozen Princess: cranberry, marzipan, milk, vanilla
Prawn-Tacos with guacamole, salad and salsa
"Heisenberg in Mexiko": tomato, lime, chilli, salt
Tiramisu with chestnuts and oranges
Eclair filled with cream cheese, vanilla ice cream and berries
Further information
Opening hours Hangar-7 Mayday Bar
Sunday to Thursday from 12:00 midday to 12:00 midnight
Friday and Saturday from 12:00 midday to 1:00 am
Bar Food International daily from 12:00 midday to 10:00 pm
Dish of the day served daily from 12:00 midday to 2:00 pm
Bar Food
Bar Food at the Mayday Bar /en/day-night/mayday-bar/bar-food/
Carpe Diem Lounge-Café
Relax, pause a while and enjoy /en/day-night/carpe-diem-lounge-cafe/
Mayday BarCocktails &
Bar Food /en/day-night/mayday-bar/
Threesixty BarRelax in fabulous style /en/day-night/threesixty-bar/
Hangar-7 Summer Feeling
Hangar-7 Outdoor Lounge /en/day-night/outdoor-lounge/
The Long Night of Museums
Saturday, 4 October 2014 /en/day-night/events/the-long-night-of-museums/


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The 4-star Hôtel Meriem is an attractive option in Marrakech. This is an excellent option for those who require a larger selection of rooms to choose from. The distance between Menara International Airport and this accommodation is 3.6 km (2.2 miles). Public transport is facilitated by nearby Marrakech Station. Not only Town Square Jemaa I-Fna, but also Setti Fatma Falls and Ourika Valley, are a pleasant walk's distance from here. Dar Si Said Museum and Museum of Islamic Art are museums in Marrakech not to be missed. Centre Football Kawkab Marrakech is one of the stadiums in the proximity of this accommodation.
Hôtel Meriem has 2 restaurants where you can have a meal. The hotel does not charge guests for breakfast. There are common areas here for guests' use, with a garden and a coffee shop/café among them. You can find an outdoor swimming pool here, as well as a children's swimming pool and a swimming pool. The hotel's health and wellness facilities include a sauna, a spa/wellness center and a steam room. Forgot something at home? A gift shop that is located on site could provide a solution. A concierge service is a service here, along with a late check-out option and an express check-in/out service. Total rooms: 181. Your parking options here include paid self service parking at limited hours.
Hôtel Meriem is appointed with air conditioning. A housekeeping service is provided in each of the welcoming rooms here. Facilities in the bathroom include a bidet and a complimentary toiletries set in addition to a deep soaking bath.
Show reviews
|From 13:00 Check-out: Until 12:00
|Wi-Fi Internet at additional cost in general areas only (lobby/reception etc.)
|Paid Parking (Self-service)
|Pet policy:
|Pets are not allowed.
|General facilities:
|Extra common areas:
|Wellness facilities:
|Swimming Facilities:
|Note: It is the responsibility of the hotel chain and/or the individual property to ensure the accuracy of the photos displayed. We are not responsible for any inaccuracies in the photos.
Please provide this reference number to our customer service center representative on request, so we can help you better


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With a stay at Hôtel Pavillon Opéra, you'll be centrally located in Paris, steps from Grand Rex Cinema and minutes from Porte Saint-Denis. This 4-star hotel is close to Louvre Museum and Notre Dame Cathedral. Read More About Hôtel Pavillon Opéra
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text:
WASHINGTON (AP) - House Republicans announced Tuesday they will recommend dispatching the National Guard to South Texas and speeding Central American youths back home as their response to the immigration crisis that's engulfing the border and testing Washington's ability to respond.
DENVER (AP) - Adam Campbell heard a huge cracking sound, saw a flash of light and said he was knocked to the ground as he ran across one of Colorado's tallest peaks during a 100-mile endurance race.
BURLINGTON, Vt. (AP) - A Vermont man who told police he urged his girlfriend to jump off a cliff in a drug-induced haze because of an imagined bear attack was being held on $100,000 bail on charges including attempted murder and arson.
ELMWOOD PARK, N.J. (AP) - Four teenagers are facing charges in what authorities say was the sexual assault of a highly intoxicated 15-year-old girl that was videotaped on a cellphone.
CUPERTINO (AP) - Apple is teaming up with former nemesis IBM in an attempt to sell more iPhones and iPads to corporate customers and government agencies.
SANTA CLARA (AP) - Intel's earnings jumped 40 percent in the latest quarter, beating expectations, as companies picked up the pace of office PC replacement.
SUNNYVALE (AP) - Yahoo Inc. said Tuesday that its second-quarter earnings and revenue declined, as the company struggled again with display advertising sales.
PHILADELPHIA (AP) - Cable and Internet giant Comcast is apologizing after a tech-savvy California customer posted eight minutes of telephone conversation online in which he tried repeatedly to get a customer service representative to disconnect his service.
PALO ALTO (AP) - Hewlett-Packard's interim chairman, Ralph Whitworth, has resigned from the company's board to concentrate on personal health issues.
PORTLAND, Ore. (AP) - A Southern Oregon wildfire destroyed six homes and 14 other buildings, and dozens of additional blazes ignited after thousands of lightning strikes lashed the state.
WASHINGTON (AP) - Two Texas lawmakers announced legislation Monday to speed removals of tens of thousands of Central American kids from the U.S.-Mexico border, as Washington searched for a solution to the growing crisis.
LOS ANGELES (AP) - Inspectors at Los Angeles International Airport seized an unusually slimy package - 67 live giant African snails that are a popular delicacy across West Africa.
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COLORADO SPRINGS, Colo. (AP) - A marijuana giveaway for veterans attracted about 1,000 people to a Colorado hotel.


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text: I guess it is always a warning sign if you go into a restaurant at 7:30pm and you are the only customers. The setting was both good and bad -- overlooking the hotel pool, which was nice, but perhaps someone might have turned some lights on as it was tricky even to see the menu by starlight. The wooden seats... More


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Follow FEMA:
No. 2 Stuart Creek Fire Smoke Plume
Main Content
Photo by Adam DuBrowa - Jul 06, 2013
Census Area, Alaska, July 7, 2013 -- Black Smoke Billows in the distance from the Stuart Creek Fire no. 2, firefighters are fighting the fast burning blaze on the ground as FEMA task force teams fly above en route to flooding inspections along the Yukon river. Adam DuBrowa/FEMA


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Foolish Naivete: Sen. Coburn 'Believes' Obama Will Become Entitlement Reformer in 2nd Term
Republican Senator Tom Coburn has just completed his transformation into a laughing stock. In an interview with the Washington Post's Ezra Klein, Coburn claimed that he fully believes that President Obama will become an "entitlement reformer" in his second term.
At the end of Klein's first part of the interview he asks Coburn if Republicans will do any better to "compromise" with Obama if Obama wins a second term. Here is Coburn's absurd reply:
We've had conversations where he's told me he'll go much further than anyone believes he'll go to solve the entitlement problem if he can get the compromise. And I believe him. I believe he would.
This is the single dumbest thing I've ever seen a Republican say. The naivete and stupidity of this naïf is the most gobsmackingly stupid I've ever seen.
Obama a "reformer"? If Coburn really does believe this he reveals a startling lack of good sense. Obama has made an entire career out of gladhanding his opponents and in private one-on-one talks telling them exactly what they want to hear. He is soothing, assuring, even tempered. And he always, always lies through his teeth.
Even when he was in the Illinois Senate he did this. He'd seems so reasonable and good natured in his interactions. He always seemed to be willing to compromise. And in every vote he'd vote the hard-line, left-wing way.
Obama is not a compromiser but he is a hard-line leftist, a big government guy. The thought that he'll do anything to reform entitlements, the supporting pillar of the Democrat Party, is absurd. If anything he'll look to keep the status quo, but he is more likely to want to enlarge such programs.
Further, President Obama has shown not a single sign that he's interested in any actual reform of practically anything much less entitlements. He's a government hog, not a reformer.
Lastly, you must realize that once re-elected, Obama will have even less reason to compromise with Republicans. He'll be wholly unbounded by the need to cater to voters and will use his second term for "legacy" issues, items that he wants to push forward at all costs — costs that won't include worrying about voters.
That Coburn "believes" in Obama calls the Senator's intelligence, maybe even his sanity, seriously into question.
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Warner Todd Huston is a Chicago-based freelance writer, has been writing opinion editorials and social criticism since early 2001 and is featured on many websites such as Andrew Breitbart's BigGovernment.com, BigJournalsim.com and all Breitbart News' other sites, RightWingNews.com, CanadaFreePress.com, and many, many others. Additionally, he has been a frequent guest on talk-radio programs across the country to discuss his opinion editorials and current events as well as appearing on TV networks such as CNN, Fox News, Fox Business Network, and various Chicago-based news programs. He has also written for several history magazines and appears in the book "Americans on Politics, Policy and Pop Culture" which can be purchased on amazon.com. He is also the owner and operator of PubliusForum.com. Feel free to contact him with any comments or questions : EMAIL Warner Todd Huston and follow him on Twitter, on Google Plus , and Facebook.
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67, Florissant, COI have been teaching for 47 years and enjoy it. I'm active in coaching and school projects. The summers are interesting as a ranger, meeting a variety of people from around th...
36, Woodland Park, COHi there! I am a third generation Denver native but I currently live in the mountains and work in Colorado Springs. I can usually be found at a sporting event or concert on th...
44, Woodland Park, COABOUT ME: As a person I like to think of myself as confident but not rude. Im a fairly humble man, have a great sense of humor and am fun to be around. I have been there fo...
28, Woodland Park, COOccupation: Medical / Health Services; Height: 6' 0"; Eye Color: Blue; Hair Color: Blonde; Political Vi...
55, Florissant, COI am fairly new to Colorado, and so far I love living here. There's always an outdoor activity no matter what the season. I would like to find a great guy to travel with and e...
45, Woodland Park, COOccupation: Education / Teacher / Academic Research; Height: 5' 11"; Eye Color: Green; Hair Color: Red;  ...
48, Florissant, COHello,I am John. I enjoy outdoor activities,volleyball, country dancing, rodeos, and movies. I am honest,caring, and would like to meet someone who shares the same desire to g...
44, Woodland Park, COI thank God each day for the many blessings in my life. I feel that I'm very fortunate in so many aspects but I'm missing someone to share this journey. Sadly, I find mysel...
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We threw a surprise rave birthday party for someone at the Funny Or Die office on Monday. Best. Monday. Ever.
Office Mates episode 1
Office mates indulge in a little small talk.
Office Mates episode 3
These office mates share a laugh.
Another Angle on Office Worker Goes CRAZY
What the hell happened at this office?!
Office Mates episode 5
Everyone loves girl scout cookies, including these 2 office mates.
Catching Sand
It's a Pod Cast
Angry Billy
In honor of the Solar Eclipse on 10/23
Magnificent Kaaboom!!! Official Selection Horrorvision Film Festival
Magnificent Kaaboom!!! Official Selection Horrorvision Film Festival Spanish Horror Trash Film Fest
Knowledge with Colin Quinn
Knowledge with Colin Quinn