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Hank Williams The Garden Spot Programs, 1950 has been nominated for Best Historical Album for the 57th Annual Grammy Awards! See the full list of nominations here. Congratulations to producers Colin Escott and Cheryl Pawelski, and to mastering engineer Michael Graves. Great work everyone, this was truly a labor ofContinue Reading
Happy Holidays indeed! The Posies Failure ranked in the top 10 reissues of 2014 by Rolling Stone. Number 8 to be exact, and in great company with the likes of Bob Dylan, The Beatles, andContinue Reading
Jaco Pastorius Modern American Music… Period! The Criteria Sessions named one of the Top 20 Historical Albums of the Year by Downbeat magazine'sContinue Reading
Omnivore Recordings celebrates Record Store Day Black Friday with three vinyl releases – all of which contain download cards! The classic, self-titled 1976 EP from Sneakers (featuring fellow future dB's members Chris Stamey and Will Rigby, with appearances from Let's Active's Mitch Easter and engineered by Don Dixon) is expanded by three tracks and available onContinue Reading
We now have the always-popular Big Star glow-in-the-dark Slip Mat back in stock! No turntable should be without one. Visit our Merch shop and get yourself one of these black and blue beauties now. Also available, the Omnivore SlipContinue Reading
100 releases, a bunch of Omnivorous artistes and five minutes = the Omnivore 100 video extravaganza!Continue Reading
What is Omnivore du Jour, you ask? Well, with the flurry of Omnivore activity on the horizon, and our ever growing catalog, it seemed a cool idea to give you a chance to help us celebrate special events, or just take advantage of some great bargains.Continue Reading
Rolling Stone has picked both Bob Mould's Workbook 25 and Hank Williams The Garden Spot Programs, 1950 as part of The Best Reissues of 2014. Read about all the picks here!Continue Reading
Here's a fascinating piece fromMichael Graves that pulls back the curtain on just what was involved in restoring the audio found on Hank Williams The Garden Spot Program, 1950.Continue Reading
Coming up today on NPR's Weekend Edition, Jett Williams and Colin Escott discuss tomorrow's release of Hank Williams The Garden Spot Programs, 1950.Continue Reading
Catch him while you can. Here are the remaining West Coast dates!Continue Reading
Check out this preview video to see what we have coming for Record Store Day!Continue Reading
Camper Van Beethoven reissues are coming! Check out the preview video here!Continue Reading
Sandra's career began early, and she experienced success as a songwriter, as well as a backing vocalist, performing on Al Green's classic Hi Records sides. Where's Your Love Been was released in 1972, and it never had a chance to find its fan base. That will change on March 18.Continue Reading
Welcome To 2014, Everyone!Continue Reading
Omnivore Recordings is proud to be involved in Iain Matthews' first U.S. release in fifteen years, The Art Of Obscurity! More than that, we're expanding our horizons, in working with Iain and Pledge Music, and making it even more special.Continue Reading
This year, Record Store Day Back to Black Friday is on November 29, so you can walk off the feast from the day before by heading to your local record store. We'll have three releases, all on vinyl!Continue Reading
Here's a video teaser for the upcoming Jellyfish album!Continue Reading
When Steve Marriott left the Small Faces (Rock and Roll Hall of Fame Class of 2012) to launch a new band in 1968, expectations were high. Marriott teamed with 18-year-old guitarist Peter Frampton, already a U.K. star through his work with The Herd, along with bassist Greg Ridley from Spooky Tooth, and 17-year-old drummer Jerry Shirley, who Steve Marriott had used as a session player for Andrew Loog Oldham's Immediate Record Label. Humble Pie recorded four albums and several singles before achieving its U.S. breakthrough with 1971's double-live set Performance: Rockin' the Fillmore.Continue Reading
We now have Stereo copies of the wonderful album Heartbreak by Bert Jansch available for now in our shop. Still on clear vinyl just like the Mono copies. Or get the CD with the bonus disc Live At McCabe's Guitar Shop! Either way, this record needs to be a part of your life!Continue Reading
We've got so many new releases coming in the fall, it's time to start sharing. Lots of folks have been asking about the Old 97′s & Waylon Jennings sold out Record Store Day double 7". So we're issuing it as a CD & Digital E.P., adding two more Old 97′s demos and letting it loose back out into the world! One of the added demos is a cover of the Magnetic Fields song, "Born On A Train!"Continue Reading
How does that song go? "Summertime, and the listenin' is easy?" Whatever the words are, we here at the Omnivore Head Table have made sure we've got you covered for every conceivable situation. June finds us in a power pop mode with the CD/Digital/Standard black vinyl release of our acclaimed Big Star documentary soundtrack, Nothing Can Hurt Me. We've even got a glow-in-the dark Big Star slipmat to put underneath! Add in The Three O'Clock's The Hidden World Revealed on CD/Digital and the paisley sun shines bright.Continue Reading
The story of Big Star will finally hit the big screen in the feature-length documentary Big Star: Nothing Can Hurt Me (for information on the film, please visit Magnolia Pictures). After years in the making, the movie will open in theaters, On Demand and on iTunes, July 3. A week before that, we'll be releasing the soundtrack featuring 22 tracks, all of which are previously unissued versions of classic Big Star songs! It will be available on CD, digital and a double-LP (standard weight, black vinyl). Pre-order now!Continue Reading
If the response to their recent reunion gigs (and anticipation for Coachella) weren't enough, we're proud to present the first ever collection by The Three O'Clock covering the years 1981-1986! Coming June 25, The Hidden World Revealed has everything a Three O'Clock fan could want; 20 tracks that include hits to demos to alternate mixes to fan-club singles.Continue Reading
There's a reason it's called RECORD Store Day. Yes, April 20th will be this year's Record Store Day, and we here at Omnivore are ready to deliver. Three titles in fact. Big Star, Old 97's with Waylon Jennings, and Three HIts.Continue Reading
Back by popular demand, Stack-a-Tracks, the two classic Jellyfish albums presented instrumentally for your enjoyment! Our Record Store Day first pressing was a limited-edition numbered gatefold 2-CD set that blew out so fast that we thought we should get it back out there as soon as possible for those who missed it. Available 3/12.Continue Reading
Here Tonight: The White Light Demos features never before heard solo demos from the 1970-1971 White Light era! 12 tracks including three songs previously unissued in any form. Liner notes by John Einarson, author of Mr. Tambourine Man: The Life And Legacy Of Gene Clark (Backbeat Books, 2005). Pre-order now!Continue Reading
Coming this February 12, Omnivore Recordings will release definitive compilations by three giants of country and rockabilly music; Wanda Jackson, Merle Haggard, and George Jones.Continue Reading
Check out the title track from the upcoming collection of unissued studio tracks and demos from Townes Van Zandt. 2-CD set available for Buy yours now in our shop!Continue Reading
We hope you're all healthy, happy and getting set for the holidays! At Omnivore, we've enlisted the help of a few thousand elves to help us get everything in order, they've been busy, we've been busy, so here we go!Continue Reading
Check out our collection of unissued Hee Haw recordings from Buck Owens, titled Honky Tonk Man: Buck Sings Country Classics.Continue Reading
Have we got plans for Record Store Day/Black Friday November 23? Oh yes we do! Rarities galore grace these four 10″ titles arriving in gorgeous picture sleeves!Continue Reading
Today on Noise Trade get a free digital 3-song E.P. in advance of the upcoming Old 97′s reissue of Too Far To Care. These three demos are exclusive to the E.P. and will not be on the 2-CD / 2-LP reissue. Nor will they be on the They Made A Monster: The Too Far To Care Demos LP/Digital release. So grab them from now Noise Trade and complete your collection!Continue Reading
Here's a first listen/viewing of "(Here On This) Lonely Night" from upcoming release by The Knack, Rock & Roll Is Good For You: The Fieger/Averre Demos. Doug and Berton shot this video back in '75, a real time-capsule video!Continue Reading
Indeed it is! On November 6, the world of Omnivore adds the great Bert Jansch to its roster with a beautiful reissue of his 1981 album Heartbreak. Long out of print, we're bringing it back for its 30th Anniversary in grand style as a limited-edition clear vinyl LP (first pressing of 1,500, black thereafter), a HD digital album and a double CD/double digital album. The second disc in the 2-CD package contains the previously unissued Live At McCabe's Guitar Shop, a full show from June, 1981. Buy yours here!Continue Reading
She did it all, from stage to screens big and small, but she never had a Christmas album! What?!? No holiday cheer? Do not fear, put on your Santa suit and shimmy down the chimney, as Omnivore Recordings is proud to announce The Edie Adams Christmas Album featuring Ernie Kovacs (1952). Our favorite track? Edie and Ernie duetting on "Silver Bells!" Buy now for everyone on your list who is cool enough to get it.Continue Reading
Let's just start with a quote from our friend Laurie Pepper, "Art hated the idea that people put jazz in a pigeonhole. He wanted to make people forget the categories and 'make them open up and listen.'"Continue Reading
Fifteen years have flown by since the Old 97's major label debut, Too Far To Care, first hit the shelves, and because this record is an Omnivore Recordings favorite, we decided to raise a ruckus for the anniversary in true Omnivore fashion. We expanded the original album to include four session outtakes to release as the first disc of the new 2-CD package. Then, when band gave us access to their pre-Too Far To Care demos, we put those all on Disc 2 of the new edition. Happy anniversary!Continue Reading
Today we're excited to announce that September 11 we release Rock & Roll Is Good For You: The Fieger/Averre Demos!Continue Reading
If you're a fan of mid-'70s funk/R&B/soul and jazz, then you're probably already hip to our Darondo and Two Things In One releases. Now, drawn from that same catalog, are three LP-only various artist compilations, each with a download card. The Music City Sessions, Volume 1: Richmond Experience is coming to your turntable August 14. Check out The Music City Sessions page for more details and info one the next two volumes!Continue Reading
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Chocolate Chess Pie was my grandmother Bobbie's signature fall and winter pie. It made appearances on every holiday table and was the one pie that made it onto everyone's dessert plate, along with a dollop of fresh whipped cream. Chess pie is a very southern concoction, the basic chess is sugar, eggs, and butter, with […]
Tag Archives: springpad
Feb 12 5 comments
Chocolate Chess Pie
Feb 09 4 comments
Ginger & Pear Pie
There is something about the combination of pear, ginger, and vanilla that makes me wild. It's sweet but also has this wonderful edge. I love pears, and pear pie is probably my favorite fruit pie these days, which is why I chose this pie as the first of February's sweet pies. Not to mention that […]
Feb 06 4 comments
Smokey Chicken Pie
If you follow me on twitter you'll know that I've been in kind of a slump lately. Part of it is that I've been sick a lot lately, it's that time of year where I have cold upon cold upon flu upon cold. Then there's the weather. It's been dreary, I don't want to do […]

subset: commoncrawl


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Photo Credit: Al Bello/Getty Images
I don't know about you, but I find all of this tedious waiting around for Beyonce to pop out that kid already to be exhausting. The mental anguish over "what ever will they name her?" (because if nothing else we're pretty sure it's a girl, right?) is enough to send me to bed for weeks.
Sure, rumors are swirling. According to the Huffington Post, Twitter is mostly to blame for bogus reports that Tiana May Carter had already made her debut. And then there's the whole lyrical proof argument to consider (Jay-Z in "Hello Brooklyn": "If I had a daughter guess what I'm a call her? Brooklyn Carter." Sort of hard to backpedal from that one).
But in case the expecting supernovas are still at a loss for the perfect handle for their Bey-B, I'd like to offer a few options. (And no, Bey-B isn't one of them.)
Houston -- It's B's hometown, dude. Why should your borough get all the love?
Derriere -- Because "Booty" (or even Fanny or Buns) would just be crass.
Kiwi -- The Carters are buddies with Gwyn and Chris, and how fun would it be to call Apple and Kiwi to dinner?
Jesus -- See #3 ("Jesus! Moses! Your hot dogs are ready!" Come on.).
Sasha -- For Bey's "fierce" alter ago, and also because it's presidential.
Halo -- It's angelic, it sounds like "hello" so the lyrical/cinematic options are endless ("You had me at Halo"), and it has a certain Demi-esque quality that's fairly irresistible. Am I right?
Xania -- Mama's character in The Pink Panther; perfect by Hollywood standards because it's wonderfully difficult to pronounce and impossible to spell.
Zenga -- The backward spelling of Beyonce's grandma Agnez Dereon (for whom B named her House of Dereon clothing line, so it's not that out there).
Eugenie -- Because sometimes not being cool is the coolest move of all. (See: Hazel, Phinnaeus)


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GasLog Ltd. Announces Date For 2013 Second Quarter Results
GasLog Ltd. (NYSE: GLOG), an international owner, operator and manager of LNG Carriers, today announced that it will release its financial results for the second quarter of 2013 before the market opens on Tuesday, August 20, 2013.
GasLog will host a conference call to discuss its results for the second quarter 2013 at 8:30 a.m. ET (1:30 p.m. London Time) on Tuesday, August 20, 2013. Paul Wogan, Chief Executive Officer and Simon Crowe, Chief Financial Officer, will review the Company's financial performance for the period. Management's presentation will be followed by a Q&A session.
The dial-in numbers for the conference call are as follows:
|1-646-254-3362 (New York, NY)
|+44 (0)203-427-1916 (London, UK)
|Passcode for the call is 6332240
A live webcast of the conference call will also be available on the investor relations page of the Company's website at http://www.gaslogltd.com/investor-relations. The press release announcing GasLog's second quarter 2013 results will also be available on this section of the website.
For those unable to participate in the conference call, a replay will also be available from 12:30 p.m. ET (5:30 p.m. London Time) on Tuesday, August 20, 2013 until 6:00 p.m. ET (11:00 p.m. London Time) on Tuesday, August 27, 2013.
The replay dial-in numbers are as follows:
|1-347-366-9565 (New York, NY)
|+44 (0)203-427-0598 (London, UK)
|Replay passcode is 6332240
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Conference Information
ABI has negotiated a special conference rate of $129 single/double per night at the Kansas City Marriott Downtown. Reservations are limited, and rooms are held on a first-come, first-served basis. Reservations may be made by individual attendees directly with the Marriott at (816) 421-6800, using group code AABAABA, or online at: Click Here for Direct Link to the Special Rate. ABI cannot guarantee registrants a room after February 4, 2013, or once the ABI room block is sold out.
Parking is available at the Kansas City Marriott Downtown.
Program Dates and Fees
The program will be held from Sunday, February 17 (attendance required at evening reception) through noon on Tuesday, February 19, 2013. The cost for participation is $499 for current ABI Members, or $645 for Non-members (includes 1-years membership in ABI). This fee includes all receptions, breakfast and luncheon functions, instruction, written materials, video services and flash drive.
Cancellation Policy
All fees, except a $75 handling fee, will be refunded if written notice of cancellation is received by January 25, 2013. No refunds will be granted after January 25, although substitutions will be allowed. After January 25, upon written request, a coupon for 20% off the registration fee (not including optional events) will be issued, which can be used (by the canceling registrant only) for any ABI educational program up to one year after this conference, or for this same conference next year.
About ACBPI
Advanced Consumer Bankruptcy Practice Institute
The Advanced Consumer Bankruptcy Practice Institute (ACBPI) is a Tennessee nonprofit Public Benefit Corporation classified as a Section 501(c)(3) organization by the IRS. ACBPI has been producing National Institute of Trial Advocacy (NITA)-style litigation skills training seminars for consumer bankruptcy attorneys since 2002. Using a small group modela student-to-faculty ratio never exceeding 8-to-1ACBPI has trained more than 475 consumer bankruptcy attorneys (representing creditors, debtors and trustees) at one-and-a-half day Institutes across the country.
Grants from the National Data Center, the National Association of Chapter 13 Trustees and from the American Bankruptcy Institute enabled ACBPI faculty to attend intensive training programs administered by the National Institute of Trial Advocacy. A grant from the National Conference of Bankruptcy Judges enabled ACBPI to begin acquiring the hardware, software and other equipment necessary to produce Institutes that include video reviews, PowerPoint presentations, online materials distribution and other Internet-based features.
ACBPI provides litigation skills training Institutes to any local or national nonprofit organization or institution that offers CLE to bankruptcy attorneys. ACBPI is an entirely voluntary organization. No officer, director or faculty member receives any compensation other than reimbursement of actual expenses for teaching at an Institute or attending faculty training sessions.
This program is currently SOLD OUT, but additional space may
become available. CLICK HERE to be notified via email.
Join the conversation at #ACBPIKC13
Copyright 2012 - The American Bankruptcy Institute


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Intact femur radiographically +
- foot at contralateral mid-tibial level
- cruciate ligament deficiency
- coxa vara
- hypoplastic lateral femoral condyle with resulting valgus knee
- sclerosed lateral cortex
Amount of femoral shortening is variable patient to patient
Shapiro Type 1 growth disturbance
- i.e. LLD increases with time
Genu valgum
Fat thigh
High riding patella
Foot held externally rotated
Hypoplastic femur
Coxa vara
Lateral sclerosis
Simple femur hypoplasia
Femoral hypoplasia with coxa vara
Align early then lengthen in primary school years
1. Realignment may involve
Coxa vara
- proximal femoral valgising osteotomy
Valgus knee
- Supracondylar osteotomy / guided growth 8 plates
2. Lengthen tibia and femur
Caution for dislocated knee
- ACL deficient
3. Contralateral epiphysiodesis
Deficiency of bony elements on lateral side of lower limb
- characterised by hypoplastic or aplastic fibula
- abnormal foot
- normal foot
Most common congenital deformity of long bones
May be associated with PFFD
- tibial hemimelia can be inherited
- PFFD with type C / severe
- always slightly short femur
- cruciate deficiency
- hypoplastic LFC / valgus knee
- anteromedial bowing
- equino-valgus / ball and socket
- tarsal coalition
- small limb / foot
- absent lateral ray(s)
- lateral tarsal bones fused or absent
UL deficiency
Type 1: Short or partial proximal absence unilaterally
1A: Stable ankle joint ± ball & socket joint
1B: Unstable anklejoint / equinovalgus
Type 2: Complete absence unilaterally
- tibia short & bowed anteromedially, dimple at apex
- associated with lateral ray deformity & coalitions
Type 3: Bilateral
- severe
- associated with PFFD & upper limb deficiency
Fibular hemimelia / dysplasia is a spectrum
- child may have only gracile fibular and short leg in tibia and femur
- attributed to fibula hemimelia as no ACL, short femur etc
- can be pseudoarthrosis of tibia
- realise when tibia fractures and then doesn't heal
If less than 2 rays or unstable ankle
- cannot salvage
- symes / BKA
Indication for Syme's Amputation
- severe deficient foot that will not serve any useful purpose
- grossly unstable ankle
- associated tibial deficiency such that LLD & unstable AKJ preclude leg lengthening
- associated PFFD
Usually > 5 inches
- can predict based on difference at presentation
- can treat if have normal foot
Usual Options
- < 3cm shoe lift
- 3-5 epiphysiodesis
- 5-10 limb lengthening
- 10-16 limb lengthening + epiphysiodesis
- > 16 amputate
5cm at a time
Usually start when child 7-8, can understand reason for operations
Least important
- usually corrects
- most common
- high energy SH 2 / 1 i.e. distal femur
Thombotic / embolic
Ischaemia (arteritis)
1. Central
- tenting
- slows longitudinal growth +/- angulation
2. Peripheral
- can lead to rapidly progressive angular deformity
- especially small bar
3. Linear
- especially SH4
- effect depends on site and size
To assess deformity (angular and LLD)
To accurately map size and position of bar
- < 50% growth plate
- > 2 year growth
- healthy skin
Excision of bar and interposition graft (fat)
- excision with high speed burr
- via direct approach to growth plate
- more difficult
- via metaphyseal window (avoid damage to the perichondral ring)
- remove active part of growth plate
- prevent angular deformity
- use drill under II guidance
- 4.5 mm
- correct angulation post growth plate fusion / epiphysiodesis
Asymmetry between L and R side more than due to normal variation
Difficult to determine because no precise definition
Difficult to differentiate hemihypertrophy from normal variation
- enlargement soft tissues & bones also
- 1/13 000 combined
- 1/86 000 non-syndromic
Non syndromic hemihypertrophy associated with 4% incidence tumours
Non-syndromic is sporadic
Rarely apparent at birth
- thicker skin, more hair, accelerated bone age on involved side
- ipsilateral paired organs increased in size also
Non-syndromic hemihypertrophy
Inguinal hernias
- renal cysts
- cryptorchidism
- sponge kidney
- horseshoe kidney
- non-structural
- compensatory to pelvic obliquity
Syndromic hemihypertrophy
Associated with cutaneous and vascular lesions
- involvement of ipsilateral paired organs
- also divided as per extent of involvement
Classic hemi - UL & LL
Segmental - UL or LL
Facial - head and neck only
Crossed - opposite UL & LL
Normal population may differ up to 1-2 cm in length and circumference
Rush and Steiner 1946
- 1000 US army recruits
- 23% equal leg lengths
- 77% 0.75 cm
- 15% > 1 cm
1cm difference
- in adolescent within normal
- in infant in pathological range (4.2%)
Compare length of L and R tibia and femora with normal standards
- no association with tumours
Non-syndromic hemihypertrophy / Beckwith-Weidermann syndrome
- are at increased risk for intraabdominal tumors
1. Beckwith- Weidmann syndrome
3. Klippel-Trenaunay-Weber syndrome
4. Proteus syndrome
5. Malignant tumours
6. Olliers
7. Fibrous dysplasia
8. Poliomyelitis
9. Spastic hemiplegia of CP
10. Russell-Silver synd (short, cafe-au-lait spots, clinodactaly, hemiATROPHY)
11. JCA or haemophilia (secondary to hyperaemia)
13. Conradi-Hunnerman (chondrodysplasia punctata)
(5 - 13 may have contra-lateral shortened limb)
50% of hemihypertrophy will have syndrome
Pre / postnatal overgrowth, birth weight > 90 %
- neonatal hypoglycaemia
- macroglossia
- hemihypertrophy occurs in 13%
Predisposition for embryonal tumors (Wilms)
Genetic abnormality Chr 11 p15
- near gene for IGF -II
- AD transmission but most sporadic
Need abdominal US
BWS with hemihypertrophy c.f. BWS without hemihypertrophy
- risk embryonal tumour
- 27 V's 9%
NF1 may have overgrowth digit or limb
Characteristed by Hemihypertrophy + vascular malformations
- varicose veins
- port-wine nevi
- cutaneous and subcutaneous capillary haemangiomas
- cavernous haemangiomas
Name after Greek god who could change shape
Vascular + lymphatic malformations + lipomas
- haemangiomas
- lipomas
- lymphangiomas
- macrocephaly
- hyperostosis skull
- overgrowth long bones
Hemi-hypertrophy or atrophy
Klippel-Trenaunay-Weber syndrome
Proteus syndrome
Beckwith-Weiderman syndrome
Russel-Silver syndrome (atrophy)
Skeletal dysplasia
Chondrodysplasia punctata
Ollier's / Maffuci's
Multiple hereditary exostoses
Fibrous dysplasia
Closed HI
Spina bifida
Spinal dysraphism / tumor / injury
Peripheral nerve injury
Tumour / trauma / infection / radiotherapy physis
- Coxa vara
- Perthe's
- Tom Smith arthritis / post septic arthritis
- congenitally short femur
- fibula hemimelia
- tibial hemimelia
- bowing
Initially thought gives pain in back and contralateral knee and hip
- this may be debatable
1. Short leg gait
- increased energy expenditure is the only proven effect of LLD
2. Back
- pelvic tilt and secondary scoliosis
- initially compensatory
- can become fixed
- ? causes LBP - now thought no different from general population
- most children's spines adapt (not so with adults)
- up to 2 cm easily tolerated
3. Contralateral Hip
- uncovering of hip on long leg side in stance
- AKA long leg arthropathy
- ? increased OA
- no evidence
4. Contralateral Knee
- ? increased knee pain in athletes
2° Proliferative Zone chondrogenesis
Proximal Femur
- 3mm / year
- 15% leg
Distal Femur
- 9mm / year
- 37% leg
- 70% of femur
Proximal Tibia
- 6mm / year
- 28%
- 60% tibia
Distal Tibia
- 3mm / year
- 20%
14-15 Girls
16-17 Boys
LL vs Chronological Age
- steady growth occurs
- growth spurt in early adolescence
LL vs Skeletal Age
- Green & Anderson curves
- Growth vs Skeletal age
- shows no growth spurt
- because growth spurt & maturation spurt occur together
Skeletal Age & Chronological Age
- maturation can occur at different rates
- if early, are tall early & stop growing early
- can have spurt where mature more than age
- pass through skeletal ages more quickly
Determine cause
Determine deformity
1. Teleroentgenogram
- single exposure both legs
- long film with ruler
- Parallax errors
2. Orthoroentgengram
- same long Xray
- separate exposures hip, knee & AJ
- eliminates parallax error
- problem artefact
3. Scanogram
- similar separate exposures
- film moved between exposures
- smaller film
- multiple exposures
Software measures distances
- accurate to 0.2 mm
- legs must be in same position
- fast
1. Greulich- Pyle Atlas
Xray Left hand (non dominant)
- correlated with Green- Anderson table LL
- less accurate < 6
- improved accuracy by focusing on hand bones rather than carpal bones
2. Tanner- Whitehouse Atlas
- more refined
- 20 landmarks graded L Hand
- more accurate
- can't use as not correlated with LL
Note that all methods have an inherent error of 12 months
- gives accuracy to 1.5 cm
Need > 3 measures 4/12 apart for all methods
- If inadequate data wait till older or wait till skeletally mature
- If acquired event caused LLD, can plot onto graph
Less accurate
- based on chronological age
- only valid from age ten
- convenient / easy / simple
Basic rules
- girls stop growing at 14
- boys stop growing at 16
- distal femur 9 mm
- proximal tibia 6 mm
- distal tibia / proximal femur 3 mm
Calculate how much growth lost from fusion of physis / Predict effect of epiphysiodesis
- Effect = Physis rate x years of growth Left
Growth remaining method
- uses skeletal age
- requires graph
- estimates growth potential in distal femur and proximal tibia at various skeletal ages
- separate charts for girls and boys
Straight - Line Graph Method
- uses Green & Anderson data
- applied to a chart
At least 3 measurements each time
1. Length long leg
2. Length short leg
3. Skeletal age
Do so 3 times separated by 3-6 months
- accuracy improves with increased plotting
Plot the points for long and short leg on a vertical line for chronological age of either boy or girl
- create 2 lines for short and long leg over time
- line of best fit
- gives LLD at maturity at right of graph
- plot Long leg length on long leg line against skeletal age
- plot Short leg length on short leg line against skeletal age
- able with at least 3 measures to create line of best fit
- extend lines to maturity
- difference is LLD
Growth rate of each leg = slopes
- parallel or divergent
- AKA static or progressive
Then use Menelaus rule of thumb to determine appropriate age for epiphysiodesis
State of the art
- 2000
- take LLD for boy or girl
- multiplier for chronological or skeletal age
- predicts LLD at maturity
Adds to difficulty
- static
- progressive
- regressive
1982 5 developmental patterns
- 75% types I and II
I Increasing
- LLD increases at constant rate
- hemihypertrophy / atrophy
- tibial pseudoarthrosis
II Increasing plateau
- similar early, but annual rate of increase diminishes thereafter
- Perthes
III Plateau
- discrepancy increases, then stabilises
- fracture femur
- Polio
IV Increasing- decreasing
- similar to III, then late increase at end of growth
- hemihypertrophy
V Decreasing
- Initial increase, steady, then decrease
Progression Rate = Change LLD / Time
Final LLD
- add Current LLD to Prog Rate x Time to Skeletal maturity
A. LL Equality
- components equal with no deformity
B. Components equal with bilateral symmetrical deformity
- eg bilateral varus knees
Uncompensated LLD
A. Fully Compensated LLD
- flexed contralateral knee
- equinus ipsilateral ankle
B. Sagittal deformity with ipsilateral sagittal compensation
- FFD knee with equinus & hip flex OR
- fixed equinus with flex knee & hip OR
- FFD hip with equinus & flex knee
C. Coronal deformity with contralateral coronal deformity
- valgus of knee & contralat varus of knee
A. Partly compensated LLD
- partly flexed contralateral knee
- partly equinus of ipsilateral ankle
B. Coronal hip deformity with sagittal compensation
- fixed hip adduction with contralateral knee flexion / ipsilateral equinus
- fixed hip abduction with ipsilateral knee flexion / contralat equinus
C. Sagittal deformity with coronal compensation
- FFD knee c ipsilateral hip abduction
- fixed equinus c ipsilateral hip ADD
- flexed knee
Signs hemihypertrophy
- haemangiomas / lipomas (Proteus, Klippel-Trenau-Weber, Beckwith)
- trauma, infection
Compensate well
- walk on toes short leg usually / equinus
- flexion long knee uncommon as energy++
Compensate less well
- walk with bilateral heel-toe gait
- vaults over long leg
- excess sagittal head motion
A. Functional LLD
- on blocks
- heels flat, nil knee FFD (if able)
- correct pelvic tilt
- should correct scoliosis
- if can make pelvis stable
- ASIS equal
- blocks are a quantitative measure of functional LLD
B. Apparent LLD
Lying on bed
- measure from xiphisternum to medial malleolus
- no correction for contractures
C. Real / True LLD
Must correct for deformity in coronal and sagittal plane
- hip adduction / abduction contracture
- hip FFD
- knee FFD
1. Hip FFD
- pillow under both thighs
2. Knee FFD
- pillow under both knees
3. Hip adduction contracture won't correct to neutral
- measure each leg crossed over the other
4. Hip abduction contracture won't correct to neutral
- place both legs in similar position
If there is a contracture, perform the above measures
- then meaure the intercalated segments
- from ASIS to medial joint line
- medial joint line to medial malleolus
- must not forget can have small foot / old calcaneal fracture / wasted buttock
- hips and knees flexed
- side by side
- look for tibial / femoral shortening
If shortening above knee, find out if shortened above greater trochanter
- i.e. hip deformity
Bryant's triangle
- line perpendicular to GT and ASIS
- distance between
- quantify in fingerbreadths
Nelaton's line
- line from ischial tuberosity to ASIS
- GT should be on or below line
Klisics line
- GT to ASIS
- should aim to umbilicus
- will be more parallel
Examine knee stability
- can have problems lengthening femur if ACL deficient
- i.e. fibula hemimelia
1. Equal leg lengths
- goal is mild to moderate isolated discrepancy
2. Unequal leg lengths
- goal with paralysis / equinus foot
- aim 1-2 cm short for clearance
3. Level Pelvis
- should use blocks to estimate functional correction
4. Vertical LS Spine
- vertical spine more important than level pelvis
5. Equalisation with Prosthesis
- goal with excessive LLD
- usually femur < 1/2 normal length or LLD >15cm
Correct coexisting deformity first
- can decrease discrepancy
May require correction of other problems first
- release of contractures
- correct angular deformity
- correct spinal deformity
- excision of bony bridge
- completion of partial arrest
0 - 2 cm
- no treatment, heel raise
2- 6 cm
- shoe lift, epiphysiodesis
- maximum subtalar joint can take
6 - 15 cm
- lengthening + epiphysiodesis
> 15 cm
- amputation
Shoe Lift / sole raise
Good treatment if 2-5 cm
- aim is to improve gait
- > 5 cm ankle sprains
- joint unable to cope
- need patten boot (steel reinforcements of STJ)
- 0 - 1.5cm heel raise
- 1.5 - 5cm heel and sole raise
- 5 - 12cm patten and boot
- 12 - 20cm patten and AFO / prosthesis
- 20+cm prosthesis
Often treatment of choice
- low morbidity
- accurate
- can shorten at level of deformity
Operate on normal leg
- get loss of height & proportions
Anticipated LLD 2-6 cm
If > 6 cm LLD
- excessive height loss
- knees at different level
Phemister Technique
Create bony bridge
- medial & lateral approaches
- access window removed
- physis excised with curette
Percutaneous Technique
Under II guidance
- percutaneous incision
- medial and lateral drilling into physis
- angle drill anterior and posterior
- entry points anterior, middle and posterior
- see white growth plate on drill
Continued longitudinal growth or angular deformity
- failure to eliminate growth plate
Maximum 2 - 6 for reasons above
Consider if
- too old, insufficient growth remaining
- can't predict LLD and wait til maturity
Usually performed over a nail
Max 3cm
Stimulate physis by hypervascularity 2° irritative
- insert vicryl into growth plate
- moderate success
See Limb Lengthening
Concept of distraction osteogenesis
Popularised by Ilizarov in the Soviet Union
- initially in the 1940's
- popularised in the 1980's
- also created the circular fixator
- low energy osteotomy
- attempt to minimise damage to blood supply and periosteum
- avoid use of saw
- minimise thermal necrosis
- gradual incremental distraction of a fracture callous after a latency period
- intramembranous ossification in zone of distraction
- type 1 collagen with osteoid laid on collagen
Maintains height & proportions
- Avoids operating on normal side
- steep learning curve
- complication rate 10 - 250%
General rules
- LLD 6-15 cm
- over 15 cm risks outweigh benefits
- < 20% limb
- 5cm in femur / 5 cm in tibia
Limitation is due to muscles / ligaments / nerves
- can repeat at staged procedures
- i.e. 5 cm per bone at any given time
Site of deformity best
Metaphyseal lengthening easiest
- large cancellous surface area
- thin cortex
- best blood supply
Mentally or medically unstable
- long and demanding process
- 12 months or more
Unstable joints
Associated neurology
- Weakness / Insensate
1. Osteotomy & Frame / Nail
2. Latency Period
3. Distraction Period
4. Consolidation Period
Maintaining blood supply via periosteum is the key
Open Corticotomy
Drill-holes & closed osteoclasis / Di Bastiani
Used in the femur
- percutaneous skin incision
- multiple drill holes first to weaken bone
- osteotome to complete
- apply force to complete fracture
Usually stablise initially with temporary external fixator
- perform osteotomy
- insert nail / ISKD
- remove frame
Tibial technique with Gigli saw
Proximal corticotomy in metaphyseal bone
- below tibial tuberosity
- frame on initially to stabilise
- incision lateral crest tibia, elevate periosteum lateral tibia
- incision medial border tibia, elevate periosteum medial tibia
- pass artery clip between periosteum and bone on one side
- pass wire on other side, retrieve with clip
- pass suture, then pass gigli saw
- perform subperiosteal corticotomy, periosteum intact
Wagner Osteotomy
Contra-indicated now
- osteotomy and acute resection
- distraction
- bone grafting and plating
- superceded by lizarov techniques
Need stable device or risk non-union with fibrocartilage
Uniplanar Device
- Wagner, Orthofix
- simple
- no angular correction
- "Cantilever Loading"
- problems with pin loosing
- often necessary in femur
- multiplanar correction
IM nail / ISKD
Self lengthening nail
- movement of leg induces lengthening mechanism
- maximum of 5 cm
- if only want 3 cm, lengthen 2cm before insertion
- all internal
- no pin site complications
- easier for patient
Runaway nail
- lengthens too quickly
- cause contractures and nerve injury
- nothing can be done about this
- incidence 5%
Jammed nail
- take to theatre to unblock
- may have to debride callus if lengthening too slow
Usually 1/52
- allow callus to form before distraction
- reduce latency period in child as may start to ossify
- increase latency period in diabetics / steroids
Rate / Regenerate
Optimum 1mm / day turning 4x / day
- balance premature union vs non union
- slower in adults / diabetics
- i.e. 2-3 x day
Stop if
- poor new bone formation
- nerve palsies
- joint subluxation
- joint contracture
1 month per cm or
Double the distraction period
Pin infection
- early oral antibiotics
- patient should have script at home
- take if pin site appears red or begins leaking fluid
- increase frequency of pin site cleaning
- tight well tensioned pins
- don't place pins throught muscle
Nerve injury
- demyelinate if lengthen > 6%
- muscle elongates poorly
- max 1mm / day
- congenital LLD more susceptible than acquired
- T achilles contracture in tibia
- FFD / adduction femur
- knee FFD
Device failure
- broken pins, loss of position
- inadequate consolidation before device removal
- 10 - 15% incidence
- can result in loss of length or angular deformity
Premature Consolidation
- unable to distract
- break pins / wires
Poor regenerate
- inadequate latency period
- too rapid distraction
- poor blood supply
Joint subluxation
- ligamentous insufficiency
Delayed or non union
- constant observation
Bone growth impairment
- damage to physis
- likely secondary to pressure
- best if delayed until after skeletal maturity
Psychological Stress
- tibial lengthening by distraction across physis
- similar results to metaphyseal lengthening
- need extra length in skeletally immature
Physeal injury risk
Chondrodiastasis if < 1mm / day
Paraxial deficiency of skeletal elements on medial aspect of lower limb
Only skeletal deficiency with a documented familial occurrence
1/ 1 000 000
Bilateral 30%
Leg short +++
Tibial Anterolateral Bowing
Foot fixed in severe varus
- can mimic CTEV
- sole facing perineum
- may be unstable
- no quads mechanism
Cleft hand
Reduplication of toes
MRI to assess extent of proximal failure
1. Unilateral Complete Type 1
No proximal tibial remnant
- usually foot abnormalities
- distal femur is hypoplastic & ossification delayed
- knee is featureless / unstable
- amputation early
- around 1 year before child gets attached to it
2. Unilateral Partial Type II
Well developed proximal tibia & knee joint
A. Knee
- proximal tibiofibular synostosis to prevent proximal migration
- fuse distal fibula to end of tibia
- then either symes or fuse fibula into calcaneus
B. Ankle foot
- distal tibial deficiencies
- get equinovarus deformity similar to club foot
- tibiofibular synostosis
- then either keep foot if good or Symes
3. Bilateral
A. Bilateral through knee amputation
B. Can try to make fibula into tibia and perform symes on one side
- Brown procedure
- need good quadriceps


text:
Moon Donates Trees for Earth Day
To commemorate the 40th anniversary of Earth Day, Moon Travel Guides is partnering with American Forests to donate 1,000 trees to help offset Moon's carbon footprint, and to aid in creating healthy forest ecosystems for every community.
We would like to encourage all our readers to do something to help the earth this month. If you're interested in making a donation to American Forests, you can learn more about their program here. For every $1 you donate, one tree will be planted—and every donation, big or small, makes a huge difference in all of our communities.


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Zoroufy Stair Rods 158 Round Inspiration Stair Rod
Product Description
Round Inspiration Stair Rod
An inspired combination of fashion and affordability, Zoroufy's Inspiration™ Collection features the same standards of quality and design of their other lines - but at a dramatically reduced price.
An inspired combination of fashion and affordability, Zoroufy's Inspiration™ Collection features the same standards of quality and design of their other lines - but at a dramatically reduced price.
- Inspiration™ bracket accommodates runners up to 5/8" thick
- Price includes one rod and one pair of brackets and finials
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I alresdy had these rods on one set of steps and liked them. The carpet installers had no trouble installing them and the brass rods enhance the carpet on the steps. If you are looking for these carpet rods, this is the best site I have found and the prices are reasonable. They have the best selection.
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Applicability of FTA Circular 4220.1F
Third Party Procurement
Frequently Asked Questions
Q = Question; A = Answer
Q. As an MPO which receives FTA funds for planning purposes only, how detailed must our Procurement Policies & Procedures be in order to comply with Federal requirements?
Do Federal requirements dictate the entire organization's procurement processes and procedures? Or can there be separate processes for Federal funding?
A. The FTA Procurement Circular applies to all procurements that use FTA grant funds. If no FTA funds are used for a given procurement, then the Circular does not apply. FTA Circular 4220.1F (PDF), Chapter II 2.b. discusses the circumstances when the Circular is applicable to capital contracts and operations contracts.
You should also know that FTA has published a Grantee Procurement Self Assessment Guide that gives guidance as to the requirements for grantee procurement policy and procedures' manuals. (Posted: September, 2010)
Q. Our agency receives Section 5307 funds. We are an area over 200,000 and cannot use funding for operating assistance. So, does the County procurement process need to follow the FTA Third Party Procurement guidelines? If so, would you please direct me to the guidance to support your answer?
A. The FTA Procurement Circular (PDF), Chapter II, paragraph 2 (b), defines the circumstances under which the FTA procurement Circular would apply to grantee procurements. The rule is that only those contracts financed by FTA grant funds are subject to the Circular requirements. (Posted: October, 2010)
Q. Does 4220.1E apply to Transit Agencies procuring replacement parts for buses purchased using FTA funding? Are cities required to approve non OEM parts after testing of said parts have been completed and approved? Background: Replacement parts for Allison Transmissions have been submitted for testing and no failures have occurred in over three years but the city will not approve the manufacturer of replacement parts for purchase.
A. All grantee purchases using FTA funds are subject to the FTA Procurement Circular 4220.1F, vice .1E, which is available online. The Circular requires full and open competition unless the grantee processes a sole source justification through its management approval chain authorizing a non-competitive procurement. You might submit an inquiry to the grantee asking why these replacement parts are being procured without competition as required by FTA regulations. The grantee should have documented its rationale for the sole source award and this document should be available under the State's "Freedom of Information" statute. (Posted: November, 2010)
Q. Do we need to include federal clauses in a bid were we would only be using 18.5% of federal funds? For example a bid for auto parts where the funds are in our operating budget but only 18.5% is federal.
A. You must use Federal contract clauses for contracts that have any amount of Federal funding, and the procurement process to award those contracts must comply with the FTA Procurement Circular 4220.1F, which is available online. There is a contract clause matrix in Appendix D of the Circular. (Posted: November, 2010)
Q. Can an agency remove federal provisions after execution of contracts, if no federal funds are available?
A. If the contracts were awarded without federal funds and will be completely performed without federal funds, then FTA does not require federal clauses and you may negotiate these provisions out of the contract if you so choose. However, you must comply with the FTA Circular 4220.1F, Chapter II. 2. b. (2) (b) - "Operations Contracts Financed Entirely without FTA Assistance," regarding Disadvantaged Business Enterprise. If your agency is required by DOT to have a DBE program, you may not remove contracts from the DBE program by restructuring the funding so as to eliminate FTA funds. (Posted: June, 2011)
Q. We were recently awarded two grants with that are made up of New Freedom Funds. The question we have is that we are a non-profit agency and will be sub-contracting out a portion of our funds we receive from New Freedom to reimburse local other for-profit and non-profit contractors for trips they provide on our behalf through a mobility management coordinated service delivery model. We are not clear on the dollar thresholds and what FTA requirements should be included in our service contracts, and also what are the requirements for going out to bid and what FTA language must be included?
A. It is our understanding that your firm will be a third party contractor to the FTA New Freedom grant recipient (SANDAG). As such you are not required to follow FTA Procurement Circular 4220.1F since that circular applies only to recipients and sub recipients. You will have to comply with the terms of your third party contract and these terms will include certain third party contract clauses required by 4220.1F, Appendix D. Instructions for those clauses may be found in the Best Practices Procurement Manual (BPPM) Appendix A.1. Some of those clauses will have to flow-down to your subcontractors.
As far as requirements to compete your subcontracts, much depends on the type of contract you have with the FTA grant recipient. If that contract is firm fixed price, then the selection of subcontractors and the contractual risk associated with their performance is born by your firm, and thus the selection of those subcontractors should be entirely at your discretion. However, if the contract with SANDAG is a cost-reimbursement type, then the cost of the subcontract and the performance risk is passed on to the grantee, and we believe the subcontracts should be competed under these circumstances. In any event you should discuss this issue with the SANDAG Contracting Officer and obtain his/her concurrence with the subcontracting approach. (Posted: December, 2011)
Q. Are Circular 4220.1F requirements applicable to outside services that we procure as part of our operations that are partially funded by federal sources? I ask because we do not specifically apply the federal operating funds to these contracted services, but we do apply those federal funds to overall operations expenditures that include these contracted services. background = We are a mid-sized transit operator in a large UA. We receive 5307 and 5309 funding. The 5307 funding often includes operating funding for non-fixed route paratransit service as well as preventive maintenance that we apply to qualifying, vehicle maintenance and non-vehicle maintenance operating expenses as allowed. i.e. these funds are not applied to any specific project but to overall operating expenses. The operating expenses to which these funds are applied may include contractual arrangements such as administration of employee benefits plans, liability insurance or legal representation. Some of these may not be considered "micro-purchases" if one considers their longer term costs added up.
A. The current FTA Procurement Circular 4220.1F, discusses its applicability to grantee third party contracts in Chapter II. The Circular is available online.
Paragraph 2.b. (2) on page II-5 deals with Operations Contracts and applies the Circular to all operations contracts when the operations are financed with FTA assistance. If, however, the grantee can segregate its operations contracts to distinguish those financed with and without FTA funds, then the Circular may be applied only to those financed with FTA funds. If the contracts are not segregated as to FTA financing, then the Circular must be applied to all operations contracts.
Paragraph 2.b. (3) on page II-5 discusses the applicability of the Circular to Preventive Maintenance contracts, and the rules are similar. If the contracts are financed by with FTA assistance, then the Circular applies. If, however, FTA assistance is limited to specific contracts, which can be segregated from others not financed by FTA, then the Circular applies only to those contracts, and not to the others financed entirely without FTA assistance. (Posted: January, 2012)
Q. Would a grantee be precluded from utilizing preventative maintenance funds to support some or all preventative maintenance activities if the maintenance staff are management contract employees and the management contract is not FTA-funded?
background = The governing board for this grantee is insisting that the City bid the Transit Management Contract (Management Contract) for the Modern Streetcar outside of FTA Circular 4220.1F. They state that Management Contracts funded without FTA funds do not require adherence to the circular. I agree; management contracts funded without FTA funds are not subject to 4220.1F.
However, the grantee has always included the FTA boilerplate language in the Transit Management (Management Contracts), here is why:
- Someday, they may want/need to support this contract with FTA funds. Having the contract adhere to 4220.1F doesn't hurt and keeps the option open.
- The Transit Management contract for the fixed route service has the Management contractor managing the City's FTA-funded assets. In addition, a significant portion of preventative maintenance on those assets IS FTA-funded.
The grantee does NOT pay the Transit Management contractor directly with FTA funds. However, preventative maintenance IS funded with FTA funds.
A. As you note, FTA Circular 4220.1F, Chapter II 2. b. (3), "Preventive Maintenance Contracts," exempts all non-FTA-funded preventive maintenance contracts from the requirements of 4220.1F if such contracts are clearly segregated from FTA-funded maintenance contracts in the grantee's accounting system. However, we see no problem in the grantee adhering to the requirements of 4220.1F in competing and awarding this contract, if as you say, at some future time the grantee may wish to apply FTA funds to pay for the services of this contractor, and in this event having awarded the contract in accordance with FTA C 4220.1F would be required. We would also say that if the management contractor, as part of its management responsibilities in managing FTA funded assets, is required to expend FTA preventive maintenance funds in the "management" of those assets (e.g., repair, replacement, etc.), that those FTA funded expenditures will have to comply with 4220.1F. In fact, if it is the case that the management contractor will spend FTA funds in his management activities on the FTA funded assets, with the result that both local and FTA funds will be flowing from the grantee to the management contractor, although for different purposes, we would say that 4220.1F is required in the award of the contract. (Posted: June, 2012)


text:
Note: REQUIRES PRECERTIFICATION.*
Aetna considers Xofigo (radium (Ra)-223 dichloride) medically necessary for the treatment of men with symptomatic, metastatic, castration-resistant prostate cancer that has spread to bones but not to other organs (see Appendix).
Aetna considers the use of Xofigo for breast cancer, and for use in combination with docetaxel or any other chemotherapy experimental and investigational because its effectiveness for indications other than the one listed above has not been established.
Note: * Precertification of Xofigo is required of all Aetna participating providers and members in applicable plan designs. For precertification of Xofigo, call (866) 503-0857, or fax (866) 267-3277.
See also CPB 0361 - Radiopharmaceuticals Metastron® (Strontium-89) and Samarium-153 (Quadramet) for Metastatic Bone Pain, CPB 0802 - Prostate Cancer Vaccine, and CPB 0806 - Cabazitaxel (Jevtana).
Approximately 85 % to 90 % of patients with castration-resistant prostate cancer (CRPC) have radiological evidence of bone metastases, which are a major cause of decreased quality-of-life, disability, and death. To-date, however, treatments for bone metastases have been primarily palliative (Cheetham and Petrylak, 2012). Radiation-based treatments have been shown to provide palliative care in patients with advanced PC. Radium (Ra)-223, a well-tolerated alpha-emitter with a half-life of 11.4 days, is a calcium mimetic that naturally self-targets to areas of increased bone turnover in bone metastases. It emits high-energy alpha particles of short range (less than 100 um) that produce a potent and highly localized cytotoxic effect in the target areas. Recent studies have reported that Ra-223 has a favorable safety profile with minimal myelotoxicity in patients with bone metastases; thus, it may serve as a new therapeutic modality in patients with bone metastatic CRPC.
The Spanish Society of Clinical Oncology's clinical guidelines for the treatment of PC (Arranz Arija et al, 2012) noted that many patients with PC have prolonged survival and die of other diseases, so therapeutic decisions are often influenced by age and co-morbidities. The main procedure to diagnose PC is an ultrasound-guided core needle biopsy, which is indicated when a digital rectal examination finds nodularity or when prostate-specific antigen (PSA) is greater than 10 ng/ml, but is also recommended with PSA between 4.0 and 10 ng/ml. Depending on age, PSA, Gleason score and characteristics of the tumor, therapeutic options for localized PC are active surveillance, radical prostatectomy, and radiotherapy. Androgen deprivation treatment should be added to radiotherapy for men with intermediate- or high-risk PC. Androgen deprivation treatment is the current standard first-line treatment for metastatic PC. Several treatments such as Ra-223, sipuleucel-T, docetaxel-based chemotherapy, cabazitaxel or abiraterone plus prednisone, zoledronic and denosumab, are useful for CRPC.
Harrison et al (2013) discussed the clinical data currently available regarding the safety and effectiveness of Ra-223. Data from clinical trials including abstracts were collected and reviewed using the PubMed database, as well as the American Society of Clinical Oncology abstract database. Current bone-targeted therapies can be categorized into 2 main groups: (i) anti-resorptive agents (e.g., denosumab, zoledronic acid), which have been shown to delay skeletal-related events (SREs), and (ii) radiopharmaceuticals (e.g., samarium-153, strontium-89), which may have a role in pain palliation. Historically, neither anti-resorptive agents nor radiopharmaceuticals have shown definitive evidence of improved overall survival (OS) or other anti-tumor effects in metastatic CRPC. Radiopharmaceuticals are limited by myelosuppression, renal excretion, and thrombocytopenia. In a recently reported randomized phase III trial in men with symptomatic bone-metastatic CRPC who had received or were ineligible for docetaxel chemotherapy, Ra-223 treatment resulted in improved OS and delayed SRE. Toxicity consisted of minor gastro-intestinal side effects and mild neutropenia and thrombocytopenia that were rarely severe.
Nilsson and associates (2012) examined the dose-response relationship and pain-relieving effect of Ra-223. A total of 100 patients with CRPC and painful bone metastases were randomized to a single intravenous dose of 5, 25, 50 or 100 k Bq/kg of body weight Ra-223. The primary end-point was pain index (visual analog scale [VAS] and analgesic use); pain index was also used to classify patients as "responders" or "non-responders". A significant dose response for pain index was seen at week 2 (p = 0.035). At week 8 there were 40 %, 63 %, 56 % and 71 % pain responders (reduced pain and stable analgesic consumption) in the 5, 25, 50 and 100 k Bq/kg groups, respectively. On the daily VAS, at week 8, pain decreased by a mean of -30, -31, -27 and -28 mm, respectively (p = 0.008, p = 0.0005, p = 0.002, and p < 0.0001) in these responders (post-hoc analysis). There was also a significant improvement in the brief pain inventory functional index for all dose-groups (p = 0.04, 0.01, 0.002 and 0.02, Wilcoxon signed rank test). Furthermore, a decrease in bone alkaline phosphatase (a disease-related biomarker) in the highest dose-group was demonstrated (p = 0.0067). All doses were safe and well-tolerated. The authors concluded that pain response was seen in up to 71 % of the patients with a dose response observed 2 weeks after administration; and the highly tolerable side effect profile of Ra-223 previously reported was confirmed.
In a phase II, randomized, placebo-controlled study, Nilsson and colleagues (2013) evaluated the safety and effectiveness of Ra-223 in patients with CRPC and painful bone metastases. In this study, these researchers reported the 24-month OS and safety data from the period 12 to 24 months after the first injection of study medication. Patients with CRPC and bone pain were randomized 1:1 to receive 4 injections of Ra-223 (50 kBq/kg [n = 33]) or placebo [n = 31]) after external-beam radiotherapy; each injection was given every 4 weeks. End-points for this report were 24-month OS, long-term safety, and treatment-related adverse events (AEs) occurring in the 12- to 24-month period. After 24 months, 10 (30 %) patients were alive in the Ra-223 group compared with 4 patients (13 %) in the placebo group. Patients who received at least 1 dose of study medication had a median OS of 65 weeks in the Ra-223 group versus 46 weeks in the placebo group (log-rank p = 0.056). The hazard ratio (HR) for OS, adjusted for baseline co-variates, was 0.476 (95 % confidence interval [CI]: 0.258 to 0.877; Cox regression p = 0.017). The most frequent cause of death for both arms was disease progression. There were no reports of treatment-related AEs or long-term hematologic toxicity during the 12- to 24-month follow-up. The authors concluded that Ra-223 had a highly favorable safety profile, with no evidence of second malignancies at 24-month follow-up. The significant improvement in OS observed in patients receiving Ra-223 versus placebo suggested that treatment of bone disease with Ra-223 has survival benefits.
In a phase II, double-blind, multi-center clinical trial, Parker et al (2013a) prospectively evaluated the safety and effectiveness of 3 different doses of Ra-223 in patients with CRPC and bone metastases. A total of 122 patients were randomized to receive 3 injections of Ra-223 at 6-week intervals, at doses of 25 kBq/kg (n = 41), 50 kBq/kg (n = 39), or 80 kBq/kg (n = 42). The study compared the proportion of patients in each dose group who had a confirmed decrease of greater than or equal to 50 % in baseline PSA levels. Effectiveness was evaluated using blood samples to measure PSA and other tumor markers, recorded SREs, and pain assessments. Safety was evaluated using AEs, physical examination, and clinical laboratory tests. The Jonckheere-Terpstra test assessed trends between groups. The study met its primary end-point with a statistically significant dose-response relationship in confirmed greater than or equal to 50 % PSA declines for no patients (0 %) in the 25 kBq/kg dose group, 2 patients (6 %) in the 50 kBq/kg dose group, and 5 patients (13 %) in the 80 kBq/kg dose group (p = 0.0297). A greater than or equal to 50 % decrease in bone alkaline phosphatase levels was identified in 6 patients (16 %), 24 patients (67 %), and 25 patients (66 %) in the 25, 50, and 80 kBq/kg dose groups, respectively (p < 0.0001). The most common treatment-related AEs (greater than or equal to 10 %) occurring up to week 24 across all dose groups were diarrhea (21 %), nausea (16 %), and anemia (14 %). No difference in incidence of hematologic events was seen among dose groups. The authors concluded that Ra-223 had a dose-dependent effect on serum markers of CRPC activity, suggesting that control of bone disease with Ra-223 may affect cancer-related outcomes. They noted that Ra-223 was well-tolerated at all doses.
In a phase III clinical trial, Parker et al (2013b) assessed the safety and effectiveness of Ra-223 as compared with placebo, in addition to the best standard of care, in men with CRPC and bone metastases. These investigators randomly assigned 921 patients who had received, were not eligible to receive, or declined docetaxel, in a 2:1 ratio, to receive 6 injections of Ra-223 (at a dose of 50 kBq/kg intravenously) or matching placebo; 1 injection was administered every 4 weeks. In addition, all patients received the best standard of care. The primary end-point was OS. The main secondary efficacy end-points included time to the first symptomatic SREs and various biochemical end-points. A pre-specified interim analysis, conducted when 314 deaths had occurred, assessed the effect of Ra-223 versus placebo on survival. An updated analysis, when 528 deaths had occurred, was performed before cross-over from placebo to Ra-223. At the interim analysis, which involved 809 patients, Ra-223, as compared with placebo, significantly improved OS (median of 14.0 months versus 11.2 months; HR, 0.70; 95 % CI: 0.55 to 0.88; 2-sided p = 0.002). The updated analysis involving 921 patients confirmed the Ra-223 survival benefit (median of 14.9 months versus 11.3 months; HR, 0.70; 95 % CI: 0.58 to 0.83; p < 0.001). Assessments of all main secondary efficacy end-points also showed a benefit of Ra-233 as compared with placebo. Radium-223 was associated with low myelosuppression rates and fewer AEs. The authors concluded that in this study, which was terminated for efficacy at the pre-specified interim analysis, Ra-223 improved OS.
In an editorial that accompanied the afore-mentioned study, Vapiwala and Glatstein (2013) stated that Ra-223 is the first alpha emitter to undergo phase III testing and received FDA approval for clinical use in metastatic CRPC. They also noted that there is an active but not recruiting phase II clinical trial in the use of Ra-223 for breast cancer, and 2 open phase I-IIA studies in the use of Ra-223 in combination with docetaxel for metastatic CRPC.
In a review on "Emerging therapies in metastatic castration-sensitive and castration-resistant prostate cancer", MacVicar and Hussain (2013) stated that for chemotherapy-naive, metastatic CRPC, abiraterone is effective. Trials with additional agents targeting androgen receptor (AR) signaling, such as TAK-700 and enzalutamide, are ongoing. Other agents in development target the endothelin pathway, angiogenesis, AR chaperones, and immune mechanisms. Docetaxel with prednisone remains the standard first-line chemotherapeutic regimen as trials incorporating novel agents with docetaxel have been negative. Post-docetaxel, enzalutamide improves survival. Early results with cabozantinib are encouraging, and phase III studies are ongoing. Denosumab and Ra-223 reduce the risk of SREs, but only Ra-223 improves survival.
On May 15, 2013, the Food and Drug Administration (FDA) approved Xofigo (Ra-223 dichloride) for the treatment of men with symptomatic metastatic CRPC that has spread to bones but not to other organs. It is intended for men whose cancer has spread after receiving medical or surgical therapy to lower testosterone. The clinical trial supporting FDA's approval of Xofigo used 6 doses of Ra-223 every 4 weeks. The most common side effects reported during clinical trials in men receiving Xofigo were diarrhea, nausea, vomiting, as well as swelling of the leg, ankle or foot. The most common abnormalities detected during blood testing included anemia, leukopenia, lymphocytopenia, and neutropenia, and thrombocytopenia.
The National Comprehensive Cancer Network's clinical practice guideline on "Prostate cancer" (NCCN, 2013) recommends use of radium-223 as a first-line or second-line therapeutic option for symptomatic bone metastases. NCCN guidelines states that radium-223 is an alpha-emitting radiopharmaceutical that has been shown to extend survival in men who have castrate-resistant prostate cancer with symptomatic bone metastases, but no visceral metastases. The guidelines explain that radium-223 differs from beta-emitting agents, such as samarium-153 and strontium-89, which are palliative and have no survival advantage. Radium-223 causes double-strand DNA breaks and has a short radius of activity. The guidelines state that grade 3-4 hematologic toxicity (2% neutropenia, 3% thrombocytopenia, 6% anemia) occurs at a low risk.
The NCCN guidelines state:
Note on Xofigo dosing: The clinical trial supporting Food and Drug Administration's approval of Xofigo used 6 doses of Ra-223 (1 dose every 4 weeks). Third and subsequent doses of Xofigo should be discontinued if absolute neutrophil count does not return to greater than or equal to 1.0 x 10(9)/L, and platelet count does not return to greater than or equal to 50 x 10(9)/L 6 to 8 weeks after the administration of the second or last dose.


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Juicy Couture Jakarta
You are looking for Juicy Couture store locations in or around Jakarta? We provide you with the address, website, phone numbers and Juicy Couture opening hours to find your Juicy Couture store location for shopping in Jakarta.
Juicy Couture Jakarta address
MH.Thamrin 28-30, Plaza Indonesia level 3 no.91,
10350 Jakarta
Juicy Couture Jakarta store info
Flagship store: Yes
Phone: (62-21) 3199 6653
Website: http://www.juicycouture.com
Opening Hours
Unfortunately we can not provide you with the opening hours for Juicy Couture Jakarta. For more information please contact the Juicy Couture Jakarta store directly.


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Full-Time Faculty | Adjunct Faculty
Professors Who Practice What They Teach
Quality education begins with quality teachers. The SSW faculty will help you prepare professionally because they are successful professionals themselves — and because they are dedicated to teaching and mentoring students.
SSW professors are actively engaged as clinicians, consultants, educators, researchers, and community leaders. Their research, scholarship, and experience cover a wide range of issues, including child welfare, pediatric chronic illness, gerontology, health care disparities, trauma, HIV/AIDS, refugees, family bereavement, racism and oppression, social work leadership, evidence-based practice, and social policy in the United States and around the world.
Highly Accessible
All faculty offices are located in the SSW building to provide students with direct and frequent contact with professors outside of the classroom.
"The Simmons faculty are very supportive and available. Whether it's by email, over the phone, or meeting on campus, they're there to help you."
—Melissa Sorrell-Kimble, '11 M.S.W.
Faculty Highlights
Professor Gary Bailey is the first African-American and the first American in 20 years to be elected president of the International Federation of Social Workers.
Professor Mary Gilfus has been investigating the effects of domestic violence for more than 30 years and works with Jane Doe Inc., the Massachusetts Coalition Against Sexual Assault and Domestic Violence. Her current research interests include social work practice and domestic violence services in Cuba.
Assistant Professor Dana Grossman Leeman serves on the Massachusetts chapter and international boards of the Association for the Advancement of Social Work with Groups.
Associate Professor and Hartford Faculty Scholar Peter Maramaldi is an expert in interdisciplinary approaches to health promotion and gerontology. He is also a clinical instructor at the Harvard School of Dental Medicine, where he works with interdisciplinary teams to improve the health and well-being of patients and families.
Professor Kathleen Millstein is on the Board of Advocates of Jewish Family and Children's Services and is a steering committee member of the Boston/ Haifa Project, where she collaborates with social service leaders from the two cities on projects related to children and families at risk. She also has conducted research in Israel.


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The former underground water reservoir, also called The Cisterns, offer unique exhibition spaces for art. It is located in Søndermarken across from Frederiksberg Palace.
Beneath Søndermarken's green grass you will find a huge underground space where the daylight never reaches. Here you will enter a dark, cold and damp world that resembles both forgotten cathedrals and gloomy catacombs.
Two refined glass pyramids mark the entrance to the museum. Natural daylight cannot enter these former water cisterns where 16 million litres of drinking water used to flow.
Urban stalactite cave
Today the cisterns are characterized as an urban stalactite cave - the only one in Denmark.
For years the cisterns were used as the Museum of Modern Glass Art. However, the exhibition space is no longer restricted to a particular artistic medium. Instead, it will be the Cisterns' distinctive architecture and unique climatic conditions that will determine which creative ideas and thoughts that take place under ground.
Exhibition by Christian Lemmerz
The exhibition Andante is created specifically for the cisterns by artist Christian Lemmerz. It appears as a large living sculpture - a sea of candles that illuminate and stage the site's dramatic appearance. For those who have followed Christian Lemmerz over the years, it will awaken glimmer of recognition, but at the same time the exhibition offers a decisive break from his former art pieces.
|Opening hours
|01/03/2014 - 30/11/2014
|Tuesday - Sunday
|11:00 - 17:00
|Admission Price
Admission - 50.00 DKK
Senior citizens
Admission - 40.00 DKK
Admission - 40.00 DKK
Children under 14 years
Free entrance
Last updated byWonderful Copenhagen email@example.com
CoordinatesLongtitude : 12.525071
Latitude : 55.67135
Bus4A, 6A, 18, 26
Distance to
Centre2,9 km.
Copenhagen Airport11,3 km.


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During the summer of 2012 I was groped by a member of the Full Body Cast, the group that performs the live Rocky Horror shows in Boston. This was a pretty upsetting experience for me for a lot of reasons—besides the whole non-consensual touching thing, I was also harassed by the cast for being a frigid bitch who should have expected that sort of thing.
What I ended up experiencing was a group of people who fronted themselves as a sex-positive community but who were really ill prepared to act as a voice for that movement.
Many people interpret the term "sex positive" as meaning "very comfortable with causal touching and sexual conversation topics." And yes, the term does have its roots in a conversation about being more open about sex and sexuality. But what is at the heart of being sex positive is the conversation. A lot of criticism that I received after I wrote about being groped was that I should have expected that kind of treatment because I went to a Rocky Horror show. Or as my groper so eloquently put it, I shouldn't go to the beach and complain because I got sand in my bikini.
This entire painful experience could have been completely avoided had there been some kind of conversation about the policy of cast-audience touching. At no time during the pre-show announcements did anyone mention that sitting in an aisle seat could result in being groped. Some people might like that, and I would have loved to change places with them.
But instead I was surprised by a hand roughly grabbing my breast and I spent the next several minutes in an anxiety attack.
My point is that people have different boundaries—and that's okay. The point of sex positivity is not to force everyone to be comfortable. The point of sex positivity is to be able to address these points in a constructive way. Some people are extremely comfortable with physical contact. Some people are like me and will find any number of ways to escape hugging. And still others are not interested in sex of any kind. Yes, that's a thing, and yes, it's okay.
It's a conversation that we should all be having. Sex positivity should be exciting, a chance make sure that you're not making people uncomfortable.
For someone like me, this extends past the conversations about actual intercourse and bleeds into a realm of comfort that I find endangered on a regular basis. I've been very clear about my need for personal space and I have turned many a friend away when they started in on a hug. And yet no matter how many times I've told some people that I don't like physical contact, they at times will insist upon it.
This is when I want to call on the real sex positivity. I shouldn't be made to feel bad about my boundaries and I shouldn't have to constantly explain that I don't want to be touched all the time by everyone. As it turns out, sex positivity isn't actually about sex; it's about the people who have it. Pushing the envelope means different things for different people.
It wouldn't hurt if we started to ask each other where that envelope is.


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Are you enthusiastic, full of energy and want to focus it on something worthwhile? Do you have unique skills you'd like to put to good use? Or perhaps you'd just like to try something new and get involved with Ambitious about Autism?
We are recruiting now for new volunteers to join our fantastic team. We have a range of fundraising projects for people of all ages and abilities, and in particular are looking for people to support Team Ambitious at the London Marathon and various other events. To find out more, contact us at email@example.com or 020 8815 5431.
There are currently no volunteering opportunities for working with our staff or pupils at TreeHouse School. New opportunities will be announced on this page.
To check out the latest internship opportunities at Ambitious about Autism, please see our Current vacancies.
Website developed by Enigma Interactive


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Last week, ace cornerback Richard Sherman, flush with adrenaline and testosterone after making a game-ending play, dissed his opponent in the post-game interview rather than, as is customary in the contemporary game, sticking to the script of "we played well" or "we could have played better." Arrogant braggadocio, ugly machismo, distraction from the team's accomplishment, or emotional honesty? None of the above.
To understand the flap, we have to acknowledge that gender is something we do, not something we are. Gender is a performance, whether of a girly-girl, a manly-man, or something in between. The performance is shaped by other people's expectations of how we are supposed to act given their guesses about what our genitals look like. First and foremost, people don't like having to guess, so we are supposed to let people know, via clothing and hairstyle, which set of expectations to impose on us. These expectations change over time and from place to place. In professional sports, Richard Sherman's long hair does not discredit his performance of masculinity any more than Samson's did. If anything, his impressive academic record is more likely to undermine his posture as a warrior.


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Cats know their popularity on the Internet is fleeting, so they're doing whatever they can to keep things interesting. These cats decided it was best to pay homage to the classics by imitating great centuries-old works of art. I think they're onto something. Take a look.
Cats reading, cats cuddling babies, they make sure to hit all their marks. Internet meme legitimacy is safe for one more day. Check out the gallery for more cats inspired by art, and the full gallery here. I'm in love with the cat in the fruit bowl.
Which one is your favorite?


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SAFE KIDS Oregon unites public and private organizations including emergency responders, law enforcement, health and safety professionals as well as interested citizens who work together to reduce unintentional preventable injury and death in Oregon's children ages 0 to 19.
For more information, visit the Safe Kids Oregon website.
Adobe Reader is required to view PDF files. Click the "Get Adobe Reader" image to get a free download of the reader from Adobe.


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Poolmaster Pro Action Water BBall Game
Be sure to select a color, size and quantity below
Item # 18658236
|Eligible for 25% Off A Single Item! (see promotion details)
|Eligible for Free Shipping, No Minimum! (see promotion details)
|Members of The League get 5% back when you spend $100! (see promotion details)
Product Details
The Poolmaster® Pro Action water basketball game delivers hours of fun for ages 8 and up! It features a strong frame, 3 separate foam bases for optimum stability, and a high-quality net that floats 23" above the water.
- Durable, lightweight frame
- 3 individual foam bases
- High-quality net
- Ball included
- Height: 23"
- Ages 8 and up
- One-year manufacturer's warranty against defects


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Select () or exclude () categories to narrow your recipe search.
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"Surprisingly tasty, filling. We made it on the hob and it cooked very quickly and I don't think the taste was compromised."
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"What a great recipe! Followed the recipe but added slightly more balsamic vinegar so that i could reduce it on the hob to sweeten it off. The in-laws loved the resulting dressing on the salad- many thanks!"
"Have just cooked this for all the family (including the in-laws!) Followed the recipe exactly...Tasted really good grilled with plain boiled potatos and salad. The chicken went down so well everyone left the chicken to the end of the meal to savour the taste."
"Very tasty! Delicate flavour."
"WHat a tasty recipe! really enjoyed the taste of this and the pickle really added to the flavour (Surprisingly)"
"Very tasty recipe! As some of the other reviews have stated, the spices really added to the flavour. Used Couscous and we really enjoyed the texture it. Many thanks for your guidance."
"The original Ramsay recipe is simpler and uses English Mustard. Tried this one anyway to see whether the flavour can be beaten, but when i followed the recipe exactly, felt that the taste was too strong and detracted from the pastry. The original recipe can be found at:http://www.bbcgoodfood.com/recipes/2538/beef-wellington"
"I followed the recipe exactly, although i must admit due to prefering a litle more spice, i added a quater teaspoon of Cumin and a quater teaspoon of fresh red chilli. Very flavoursome and ate with buttered toast. Thank you for the recipe!!!"
"An Excellent recipe! Very easy to follow, did not use the old bay seasoning, but the cakes were left with a delicate crab taste and remained flavoursome. Will certainly use this recipe again and look forward to using this now for entertaining guests as a starter."


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Rock City Connect is the best first step toward getting plugged in at Rock City. It's how you move from "attender" to actively engaged team member. At Connect, we help you connect your passion to God's purpose for your life. You'll hear the story and vision of Rock City, get to know the team and a ton of people who are on the same journey as you. You'll also learn about all the ways you can get plugged in to what God is doing at Rock City.
Connects are held for two Sunday evenings, bi-monthly at the Rock City offices located at 5000 Arlington Centre Blvd in Columbus.


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Home : : Costa Rica Vacations
Independent Package Includes
Special Features
▲ Kindly plan your arrival flight into San Jose on Day 1 no later than 9:00 pm in order to connect with your transfer to the hotel
SUV Mini Manual - Suzuki Jimny or similar
SUV Compact Manual - Daihatsu BeGo or similar
SUV Intermediate Automatic - Hyundai Tucson or similar
SUV Standard Automatic - Mitsubishi Nativa or similar
DAY 1, Thursday - Depart for Costa RicaDepart for Costa Rica. Arrive in San Jose, the capital of Costa Rica, which is surrounded by lush green mountains and valleys. After clearing customs, transfer to your hotel. The remainder of the day is at leisureOvernight: San Jose
DAY 2, Friday - Travel to TortugueroDepart early this morning for the Caribbean Coast. In the company of a bilingual guide, drive by Braulio Carrillo National Park and Banana Plantations to the port of La Pavona or Cano Blanco to board a motor launch, which will travel along canals through the heart of the Costa Rican jungle to Tortuguero. Enjoy lunch on arrival, and afterwards, attend an orientation with the guide who will explain the day's activities. In the afternoon, visit Tortuguero Village. Return to the lodge around dinnertime and spend the remainder of the evening at leisureOvernight: TortugueroMeals: Breakfast, Lunch, Dinner
DAY 3, Saturday - Full Day in TortugueroThe morning is at leisure. In the afternoon, enjoy a boat tour along the canals, where you are likely to see turtles, caimans, monkeys, and many tropical birds thriving in the wild. Please note: the afternoon boat ride is subject to weather conditions and may be replaced by another hike along hotel trails. Enjoy the remainder of the day at leisureOvernight: TortugueroMeals: Breakfast, Lunch, Dinner
DAY 4, Sunday - Transfer to Guapiles, Drive to ArenalThis morning, travel by motor launch and motor coach to Guapiles, where your car will be dropped off to you. Continue to the Arenal area, famous for its volcano, lake and hot springs. You may choose to visit one of the many hot springs facilities that offer visitors an ideal way to relax. Stay for dinner as well, as many of these facilities offer several restaurantsDrive Time: 3-4 hours*Distance: 95 miles*Overnight: ArenalMeals: Breakfast, Lunch
DAY 5, Monday - Full Day in Arenal Spend a full day at leisure in Arenal in the midst of an unspoiled setting. You may choose to spend half the day hiking to Arenal National Park, enjoying the natural hot springs throughout the area, or spend the morning or afternoon enjoying a horseback ride through both pastures and rainforest to La Fortuna Waterfall. For extraordinary views of the Arenal Volcano and Lake Arenal, the Sky Tram gondolas soar smoothly through the rainforest to an observation deck. You can ride the tram down the same route that you ascended or take a fast-paced Sky Trek zip line tour to the bottomOvernight: ArenalMeals: Breakfast
DAY 6, Tuesday - Drive to MonteverdeDepart for Monteverde Cloud Forest area. The road system in Costa Rica has improved over recent years, but be aware that those in and out of Monteverde can be bumpy and unpaved. Visit the charming small town of St. Elena, founded by Quaker settlers in the fifties and filled with tasty restaurants and folksy artisan shops. Then, explore the Monteverde Cloud Forest Reserve, which is dedicated to the conservation of many species of flora and fauna, and has over 8 miles of trails available to explore on your own or with a guide. Set atop the spine of Costa Rica's continental divide, Monteverde is a world above the coastal towns that dot the country's famous shoreline. You can explore the internationally recognized environment along trails, trams, canopy tours or inside museumsDrive Time: 3-4 hours*Distance: 70 miles*Overnight: MonteverdeMeals: Breakfast
DAY 7, Wednesday - Full Day in MonteverdeEnjoy a full day to explore the Monteverde Cloud Forest on your own. Boasting 120 reptile and amphibian species, 130 mammal species, and 500 bird species, the Reserve represents an outstanding example of biodiversity. You may choose to visit the Selvatura Adventure Park, where you can experience a canopy or treetop walkway tour. The canopy (zip line) tour allows tour takers to feel truly immersed within the forested environment. There are 15 cables and 18 viewing platforms that stretch over 2 miles -- the longest cable length of any canopy tour in Costa Rica. The Treetop Walkway guides visitors both through and above the rainforest with a birds-eye view of the rainforest canopy on a series of suspension bridges connected by trails. Alternatively, you may choose to trot out onto the trails around Monteverde on horseback or learn about coffee production and Costa Rican folklore at the Don Juan coffee plantationOptionals: Selvatura Canopy Tour (AM)Optionals: Selvatura Canopy & Hanging Bridges Tour (AM)Optionals: Selvatura Hanging Bridges Tour (AM)Overnight: MonteverdeMeals: Breakfast
DAY 8, Thursday - Drive back to San JoseDrive back to San Jose. Consider a stop at Poas Volcano National Park, one of the most visited sites in Costa Rica, which features short easy trails for hiking. A short trip from San Jose, the Poas Volcano contains one of the world's largest volcanic lakes, Lake Botos, which fills an inactive crater and is surrounded by a cloud forest. Or, head to Costa Rica's highest active volcano, Irazu, and on the way back visit the colonial Orosi Valley which is famous for having the oldest church in Costa Rica. If you are not interested in visiting volcanoes, there is plenty to do in San Jose. Visit one of the museums or head to Mercado Central, a very old and unique bustling food marketDrive Time: 5 hours*Distance: 90 miles*Overnight: San JoseMeals: Breakfast
DAY 9, Friday - Depart Costa RicaReturn your vehicle at the Car Rental Facility at the San Jose International Airport prior to your departure flight homeMeals: Breakfast
*Please consider that the driving times and distances are estimated and that they can vary because of many circumstances, such as, specific route taken, hotel location, traffic, weather, road conditions, etc.
This first class hotel is located opposite the tranquil La Sabana Park and close to the tourist and cultural districts.
Hotel Details
This tourist class hotel is located nearby Tortuguero National Park.
This superior tourist class hotel is located between La Fortuna de San Carlos and the Arenal Lake.
This tourist class hotel is located near the beautiful protected rainforest of the Monteverde Cloud Forest Preserve.
This first class hotel is located near the famous Monteverde Cloud Forest Reserve for exploration of outstanding wildlife and natural beauty.
This superior first class hotel is located in the city of San Jose and is a short walk away from Park la Sabana.
This superior tourist class resort is located 4 miles west of La Fortuna with spectacular views of Arenal Volcano. Ideally situated for relaxation, comfort, and exploration of nearby Arenal Volcano National Park. Experience the lush tropical gardens and a typical Costa Rican dairy farm, Finca Manoa.
This first class hotel is famous around the world for its rich flora and fauna, where six different ecological systems converge. El Establo is a Quaker / Costa Rican family owned lodge, situated on 150 acres of tropical forest.
Book your Optional Tours before you travel and see more, save time, save money, and protect your investment. Tours purchased while traveling may cost an extra 10% or even more! Tours often sell out - avoid disappointment! Save your cash - many countries do not accept credit cards. Travel insurance only covers services purchased prior to departure.
Also Available
*Not Included:Car Rental Fees of up to $120.
Additional Information:
Land only price does not include arrival transfer.
Kindly plan your arrival flight into San Jose on Day 1 no later than 9:00 pm in order to connect with your transfer to the hotel.
Please plan your departure flight out of San Jose on Day 9 for no earlier than 8:00 am to allow time to drop off your rental car in the morning.
Please note the minimum age for drivers is 23.
A GPS system for your vehicle is highly recommended. Reserve in advance for an additional cost of $9 per day. Reservations may be made via Vacation Builder.
Entry Requirements:
Passengers traveling abroad require a passport valid for six months beyond their travel dates. All travelers are responsible to check if a visa is required for all countries on their itinerary. For visa information,
check our Visas page.
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©2014 Virgin Vacations | CST# 2017407-20


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Case in 18K white gold, set with 60 brilliant-cut diamonds (~ 1 carat).
Matte black dial set with 5 brilliant-cut diamonds (~ 0.11 carat) and 5 navette-cut yellow sapphires (~ 0.09 carat).
Camella motif in 23K gold, hand engraved and polished.
Self-winding mechanical movement.
42 hour power reserve.
Onyx cabochon crown.
Black satin strap with ardillon buckle in 18K white gold set with 80 brilliant-cut diamonds (~ 0.49 carat).
Water-resistance: 30 meters.
Diameter: 37.5 mm.
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For more information, click here Suggested retail price - Actual price may vary. For more information, click here Price


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Anyone for singles or doubles (3.0-3.5) Wednesday at 6pm? We could decide where to play later.
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|Jet Ski & Waverunner
|Includes trailer, towing
accessories, toys and life vests
|All San Diego Jet Ski and Waverunners are available for Rent in Mission Bay,
San Diego Bay or to take to any lake or river.
|2007 Yamaha Waverunner FX Cruiser High Output
|Need more info on local Jet Sking?
Below are summaries of local and distant Jet Ski areas.
|-160 Horsepower -3 Passenger -4 Stroke Power -No Oil Mixing -Tow Capable -Reverse -Digital Gauges
-Remote Control (Training Mode)
The FX160 is very reliable and has a sturdy feel. The large hull provides a comfortable ride in rough water or
long distance journeys. Think BMW Touring Motorcycle.
|Operating Hours 9:00am - 9:00pm 7 days a week
Text Message: (949) 338-8747 for Reservations 24/7
Location: 4275 Mission Bay Drive San Diego, CA 92109