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1 Nov 2013: Legriel S, Schraub O, Azoulay E, Hantson P, Magalhaes E, et al. (2013) Correction: Determinants of Recovery from Severe Posterior Reversible Encephalopathy Syndrome. doi: info:doi/10.1371/annotation/2d87c752-042a-4c61-9254-9a3c73620bcd View correction
Few outcome data are available about posterior reversible encephalopathy syndrome (PRES). We studied 90-day functional outcomes and their determinants in patients with severe PRES.
70 patients with severe PRES admitted to 24 ICUs in 2001–2010 were included in a retrospective cohort study. The main outcome measure was a Glasgow Outcome Scale (GOS) of 5 (good recovery) on day 90.
Main Results
Consciousness impairment was the most common clinical sign, occurring in 66 (94%) patients. Clinical seizures occurred in 57 (81%) patients. Median mean arterial pressure was 122 (105–143) mmHg on scene. Cerebral imaging abnormalities were bilateral (93%) and predominated in the parietal (93%) and occipital (86%) white matter. Median number of brain areas involved was 4 (3–5). Imaging abnormalities resolved in 43 (88%) patients. Ischaemic and/or haemorrhagic complications occurred in 7 (14%) patients. The most common causes were drug toxicity (44%) and hypertensive encephalopathy (41%). On day 90, 11 (16%) patients had died, 26 (37%) had marked functional impairments (GOS, 2 to 4), and 33 (56%) had a good recovery (GOS, 5). Factors independently associated with GOS<5 were highest glycaemia on day 1 (OR, 1.22; 95%CI, 1.02–1.45, p = 0.03) and time to causative-factor control (OR, 3.3; 95%CI, 1.04–10.46, p = 0.04), whereas GOS = 5 was associated with toxaemia of pregnancy (preeclampsia/eclampsia) (OR, 0.06; 95%CI, 0.01–0.38, p = 0.003).
By day 90 after admission for severe PRES, 44% of survivors had severe functional impairments. Highest glycaemia on day 1 and time to causative-factor control were strong early predictors of outcomes, suggesting areas for improvement.
Citation: Legriel S, Schraub O, Azoulay E, Hantson P, Magalhaes E, Coquet I, et al. (2012) Determinants of Recovery from Severe Posterior Reversible Encephalopathy Syndrome. PLoS ONE 7(9): e44534. doi:10.1371/journal.pone.0044534
Editor: Giovanni Landoni, Università Vita-Salute San Raffaele, Italy
Received: May 9, 2012; Accepted: August 3, 2012; Published: September 14, 2012
Copyright: © Legriel et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This study was supported by the Hospital of Versailles. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic entity characterized by a variable combination of consciousness impairment, seizure activity, headaches, visual abnormalities, nausea/vomiting, and focal neurological signs. [1], [2], [3], [4], [5] Cerebral imaging abnormalities are often symmetric and predominate in the posterior white matter. Oedema is an occasional finding in the frontal and temporal lobes, basal ganglia, cerebellum, brainstem, and cortical grey matter. [4], [5], [6] Recognition of PRES is improving with the increasing availability of magnetic resonance imaging (MRI) and recent reappraisal of the imaging abnormality spectrum. [6].
The pathophysiology of PRES remains controversial, and the two main hypotheses contradict each other. One involves impaired cerebral autoregulation responsible for an increase in cerebral blood flow, whereas the other incriminates endothelial dysfunction with cerebral hypoperfusion. This hypoperfusion hypothesis may be most relevant to cases of PRES associated with cytotoxic therapy. Under both hypotheses, the cerebral blood perfusion abnormalities result in blood-brain barrier dysfunction with cerebral vasogenic oedema. [4], [5], [7] PRES can develop in association with a vast array of clinical conditions and is typically reversible once the cause is removed. [3], [8], [9] However, its reversible nature has been challenged based on reports of permanent neurological impairments and of mortality rates reaching 15% [8], [9]. No studies focusing specifically on patients with severe PRES requiring life-sustaining treatments [10], [11], [12], [13] have been published to date. Although the pathophysiological mechanisms may be the same as in less severe forms, knowledge of factors influencing the outcome of severe PRES might result in improved early management. [7].
Here, our objective was to identify predictors of functional outcome on day 90 in adults with severe PRES, with special attention to factors amenable to improvement. Thus, we thought to provide intensivists and other clinicians a realistic picture of severe PRES with useful management pathways in daily clinical practice. To this end, we conducted a multicentre retrospective cohort study.
The ethics committee of the French Society for Critical Care approved the constitution of this retrospective cohort of patients with severe PRES.
Patients admitted to one of the 24 participating ICUs (Appendix) between May 2001 and May 2010 and exhibiting clinical and neuroimaging features consistent with severe PRES, as defined below, were eligible for the study.
First selection of cases was performed by searching a patient's hospital claims data for the presence of certain International Statistical Classification of Diseases and Related Health Problems 10th Revision diagnosis and procedure codes among : Encephalopathy (G93.4), Hypertensive encephalopathy (I67.4), Toxic encephalopathy (G92), Gestational Hypertension (O14), Eclampsia (O15), Unspecified maternal hypertension (O16), Convulsions (R56), Epilepsy (G40), Status epilepticus (G41), Headache (G44), Visual disturbances (H53 and H54), Cerebral oedema (G93.6) and Abnormal findings on diagnostic imaging and in function studies, without diagnosis (R90–R94).
All neuroimaging documents were reviewed by two independent and certified neurologists with specialist stroke-experience and trained in MRI diagnosis of PRES and its pitfalls. Neuroimaging review was performed blinded to the clinical findings. Patients were included by consensus between two neurologists (FP and EM). Patients with no brain imaging studies available for review by the study neurologists were not included.
PRES was defined as a variable combination of acute neurologic clinical changes including consciousness impairment, seizure activity, headaches, visual abnormalities, nausea/vomiting, and focal neurological signs [4], [5] associated with neuroimaging findings consistent with PRES [4], including vasogenic oedema by MRI diffusion sequences (measurement of apparent diffusion coefficient (ADC)) or at least partial reversibility on follow-up imaging when diffusion sequences were not available. [6].
PRES was severe when associated with neurological failure defined by any neurological disorder of central origin among impairment of consciousness, seizure with or without status epilepticus, focal sign, encephalopathy, and meningeal symptoms, which required intensive care management for monitoring or life support management.
Coma was defined as the absence of arousal and consciousness with a Glasgow Coma Scale (GCS) score <9. [14], [15].
Visual abnormalities consisted of blurred vision, visual neglect, homonymous hemianopsia, visual hallucinations, and cortical blindness.
Focal neurological signs consisted of symptoms or signs related with damage to, or dysfunction of, a specific anatomic site in the central nervous system. [16] These signs were categorized as unifocal or multifocal, and as transient or persistent.
Convulsive status epilepticus was defined as continuous motor seizure activity for at least 5 minutes (continuous) or as more than two motor seizures without full recovery of consciousness in the interval (intermittent). [17], [18] Refractory status epilepticus was defined as continuous or intermittent seizures despite treatment with an intravenous benzodiazepine (clonazepam or diazepam) and intravenous phenytoin, fosphenytoin, or phenobarbital. [19] Electrical status epilepticus was diagnosed in comatose patients with or without subtle convulsive movements (rhythmic twitching of the arms, legs, trunk, or facial muscles; tonic eye deviation; or nystagmoid eye jerking) [20] but with generalized ictal discharges on the electroencephalogram (EEG). [21].
Seizure activity on the EEG was defined as continuous or recurrent rhythmic focal or generalized spikes; sharp waves; spike waves; or rhythmic waves changing in amplitude, frequency, and/or spatial distribution. [22].
Hypertension was defined according to the 2007 European guidelines for the management of arterial hypertension. Grade 1: mild hypertension (systolic blood pressure [SBP], 140–159 mmHg and/or diastolic blood pressure [DBP], 90–99 mmHg); Grade 2: moderate hypertension (SBP, 160–179 mmHg and/or DBP 100–109 mmHg); and Grade 3: severe hypertension (SBP≥180 mmHg and/or DBP≥110 mmHg). [23].
Diagnosis and Treatment
The management combined symptomatic life-supporting treatments and control of the factor causing PRES. [10], [11] Efforts were made to control systemic secondary brain insults and to limit effects of potential cranial hypertension Hypoglycemia was routinely checked and corrected. If glucose was given, 100 mg of thiamine was administered concomitantly, most notably when there was evidence of vitamin B1 deficiency. Patients were also routinely evaluated for hyperthermia, hyperglycemia, hypo- or hyper-carbia, anemia, metabolic disturbances, epileptic activity and aspiration pneumonia that may complicate the initial consciousness disorders and which required prompt correction. Patients with status epilepticus were managed as previously described. [24] Control of severe hypertension, if present, was an important part of the symptomatic management. Intravenous antihypertensive drugs including labetolol, nicardipine, or urapidil were given. [25].
A neurologist consultant was available for advice. Extensive diagnostic investigations were performed. CT was easier to obtain first. MRI was performed in most patients, as either the first or the second imaging study. Both local radiologists and neurologist consultants read the neuroimaging studies. In addition, a neuroradiologist was consulted if deemed necessary. Electroencephalography (EEG) was performed routinely to look for non-convulsive status epilepticus. Cerebrospinal fluid was examined in patients with a fever or clinical suspicion of meningitis and when deemed appropriate by the attending physicians. Laboratory tests were also obtained routinely. Plasma anticonvulsant drug assays, including magnesium assays, and qualitative tests for toxic agents or medications associated with seizures and other symptoms of PRES were performed at the discretion of the attending physicians.
Interventions to control identified causative factors were initiated promptly. These interventions included blood pressure control, withdrawal of cancer chemotherapy or immunosuppressive agents, caesarean section, and/or dialysis, as appropriate.
Data Collection
A standardized form was used to collect the variables listed in Tables 1–7 and Figure 1. Clinical features of PRES were collected retrospectively based on data in the pre-hospital notes, emergency-room chart, and ICU chart.
¥ Hypertension was defined according to the 2007 European guidelines for the management of arterial hypertension(16). Grade 1: mild hypertension (systolic blood pressure [SBP], 140–159 mmHg and/or diastolic blood pressure [DBP], 90–99 mmHg); Grade 2: moderate hypertension (SBP, 160–179 mmHg and/or DBP, 100–109 mmHg); Grade 3: severe hypertension (SBP≥180 mmHg and/or DBP≥110 mmHg) ‡ Mean arterial pressure (2/3 diastolic +1/3 systolic pressure) § Nine patients with haemorrhagic complications at first imaging: 3 with no follow-up imaging studies, 3 with persistent haemorrhagic abnormalities by follow-up imaging, and 3 with resolution of the haemorrhagic abnormalities Ψ According to the Logistic Organ Dysfunction (LOD) score [27] †The primary outcome measure was the score on the Glasgow Outcome Scale [39] (GOS) 90 days after onset of severe posterior reversible encephalopathy syndrome. A score of 1 indicates death; 2, a vegetative state (the patient is unable to interact with the environment); 3, severe disability (the patient is unable to live independently but can follow commands); 4, moderate disability (the patient is capable of living independently but unable to return to work or school); and 5, mild or no disability (the patient is able to return to work or school). A favourable outcome was defined as a score of 5 and an unfavourable outcome as a score lower than 5. The day-90 GOS score was known in all 70 patients.
A standardized form was used to collect the neuroimaging features of PRES: uni/bilateral involvement, grey/white matter involvement, lesion distribution (i.e., parietal and/or occipital and/or temporal and/or frontal lobes, ganglia, brainstem, cerebellum), presence of ischaemic and/or haemorrhagic complications, reversibility of lesions, and recurrences (Figure 1).
The primary cause of PRES was classified as hypertensive encephalopathy, exposure to a toxic agent, toxaemia of pregnancy (preeclampsia/eclampsia), autoimmune disease, or miscellaneous causes. Toxicity was considered when PRES occurred during or after a pharmacological treatment known to induce neurological toxicity (Table 3). Hypertensive encephalopathy was diagnosed in patients presenting the association of severe hypertension and signs of neurological failure [23], and absence of evidence of other etiologic category as described above.
The time from symptom onset to control of the causative factor was clocked (e.g., time to achieve blood pressure values within the normal range for hypertension, time to treatment discontinuation for toxicity, or time of C-section for toxaemia).
Severity and organ dysfunction at ICU admission were assessed using the Simplified Acute Physiology Score II (SAPS-II) [26] and the Logistic Organ Dysfunction (LOD) score. [27].
Assessment of Outcome
The primary evaluation criterion was the structured Glasgow Outcome Scale (GOS) score on day 90 (±7 days) after onset of PRES (Table 1). The GOS score reflects both mortality and morbidity. [28] Each surviving patient was interviewed for GOS score determination on day 90 and day 180 by a trained physician, when allowed by the time since inclusion. Otherwise, the GOS score was extracted from the hospital charts or determined by interviewing the patient's general practitioner or neurologist. For this study, we defined a favourable outcome as a GOS score of 5, that is, alive with good function enabling the return to former occupational or academic activities, with or without minor physical or mental deficits.
Statistical Analysis
Quantitative parameters are reported as median and interquartile range (IQR, 25th–75th percentile) and qualitative parameters as numbers and percentage. Categorical variables were compared using the χ2 test or Fisher's exact test, as appropriate. Continuous variables were compared using the Mann-Whitney U test or the Wilcoxon test, as appropriate. The day-90 GOS score was known for all study patients. Associations between patient characteristics and 90-day GOS score were assessed using a logistic regression model (Tables 5 and 6). Multivariable analysis was performed using stepwise forward selection to introduce variables whose P values were smaller than 0.20 by univariate analysis. The following variables were entered into the model: age (year), pre-existing co-morbidity (Y/N), epileptic seizure (Y/N), status epilepticus (Y/N), GCS score at ICU admission, headache (Y/N), acute hypertension (Y/N), mean arterial pressure on scene (mmHg), highest glycaemia value (mmol/L), LOD score, grey matter involvement (Y/N), brainstem involvement (Y/N), ganglia involvement (Y/N), total number of brain areas involved, haemorrhagic complication at first imaging (Y/N), time from PRES onset to causative-factor control (hours), SAPS II score, duration of mechanical ventilation (days), mechanical ventilation (Y/N), refractory status epilepticus (Y/N), length of ICU stay (days), length of hospital stay (days), toxaemia of pregnancy (Y/N), and exposure to toxic agent (Y/N). Then, the absence of a significant increase in the likelihood value after omission of each of the remaining variables was checked. Variables were tested for co-linearity and interactions before inclusion in the multivariable model. Goodness of fit was evaluated by the Hosmer-Lemeshow statistic. The area under the ROC curve was estimated by the c statistic (Association of Predicted Probabilities and Observed Responses). Odds ratios (ORs) and their 95% confidence intervals (95%CIs) were computed. Values of p less than 0.05 were considered statistically significant. Analyses were done using the SAS 9.1 software package (SAS Institute, Cary, NC, USA).
Patients (n = 70)
The patient flow chart is shown in Figure 1. Of the 86 patients admitted to the 24 study ICUs for possible PRES during the 9-year study period, 7 did not meet our inclusion criteria and 9 had no neuroimaging documents available for review, leaving 70 patients for the study.
Table 2 reports the main patient characteristics.
On-scene Clinical Presentation (Figure 1)
Consciousness impairment was the most common clinical feature, being present in all but 4 (94%) patients. Clinical seizures occurred in 57 (81%) patients. Median value of mean arterial pressure was 122 (105–143) mmHg on scene. Acute hypertension was noted in 62 (89%) patients.
Neuroimaging Features (Figure 1)
All patients underwent cerebral imaging. CT and MRI were performed in 12 (17%) and 58 (83%) patients, respectively. Among the 25 (36%) patients who underwent both CT and MRI, 4 (16%) had normal CT findings but had MRI evidence of PRES. Median time from ICU admission to brain imaging was 1 (0–4) day.
Median time from PRES onset to ICU admission was 0 (−2.5–0.5) hours. Mechanical ventilation was needed in 50 (71%) patients, for 5 (2–10) days. Median LOD score was 6 (IQR, 4–8), indicating a median of 3 (2–4) organ dysfunctions per patient. Organ involvements were as follows: neurologic, n = 54 (77%); respiratory, n = 50 (71%); renal, n = 44 (63%); haemodynamic, n = 22 (31%); hepatic, n = 12 (17%); and haematological, n = 15 (21%). Among patients with seizure activity, 31 (44%) had status epilepticus, including 7 (10%) refractory cases. EEG was performed in 59 (84%) patients and showed progression to electrical status epilepticus in 10 (17%). Overall, at least one cause of PRES was found in all 70 patients. The most common causes were toxicity (44%) and hypertensive encephalopathy (41%) (Table 3). Median time to control of the causative factor was 30 (7–86) hours. Systemic secondary brain insults on day 1 are reported in Table 4. Median lengths of ICU and hospital stays were 7 (IQR, 4–16) and 33 days (IQR, 15–62), respectively. ICU and hospital mortality rates were 10% (7 deaths) and 12.9% (9 deaths), respectively. During the 90-day follow-up period, 2 additional patients died, yielding an overall mortality rate of 16%. Among the 11 deaths, 4 were thought to be related to PRES, yielding a specific mortality rate of 5.7%. There was one case each of brain death related to cardiac arrest complicating the treatment of status epilepticus, refractory status epilepticus with multi-organ failure, cerebral haemorrhage with ventricular flooding, and brain death related to cerebral herniation complicating ischaemia. Among the 9 patients who died before hospital discharge, 6 died after decisions to forgo life-sustaining treatments.
Ninety-day Functional Outcome
The day-90 GOS score was known for all 70 patients. Among them, 33 (47.1%) were alive with a GOS score of 5 (Figure 1). Independent predictors of day-90 functional outcome are reported in Table 7. Among them, two factors increased the risk of an unfavourable functional outcome, namely, higher maximal glycaemia on day 1 (OR, 1.22; 95%CI, 1.02–1.45, P = 0.03) and longer time to control of the causative factor (OR, 3.3; 95%CI, 1.04–10.46, P = 0.04). Toxaemia of pregnancy as the cause decreased the risk of an unfavourable outcome (OR, 0.06; 95%CI, 0.01–0.38, p = 0.003).
In this retrospective multicentre study of 70 patients with severe PRES, 11 (16%) patients died before day 90 and only 33 (56%) survivors had a good recovery defined as a GOS score of 5. Both of the factors independently associated with a poor outcome (GOS<5) were directly linked to the early management, and both may offer hope for improving outcomes (Panel).
Patient characteristics were consistent with previous studies. PRES preferentially affects women and relatively young individuals with serious co-morbidities. [9] The main clinical manifestations were consciousness impairment (94%) and seizure activity (81%). Consciousness was often severely impaired, with a median Glasgow Coma Scale score of 9 (3–14) at ICU admission. The 44% prevalence of status epilepticus was considerably higher than in previous reports of unselected cases of PRES. [1], [9] The other clinical signs such as headaches, vision impairment, nausea/vomiting, and focal neurological signs at scene were in accordance with recent reports. [1], [6], [8], [9], [29] Acute hypertension was found on-scene in 83% of patients, with a median value of mean arterial pressure level of 122 (105–143) mmHg, in keeping with earlier data. [1], [3], [8], [9] The neuroimaging findings in our study were also consistent with current knowledge. Despite a marked predominance of posterior parietal-occipital lobe involvement, atypical patterns were seen in a substantial proportion of patients and included strictly unilateral lesion distribution and involvement of the grey matter, anterior lobes, basal ganglia, cerebellum, and brainstem. Thorough familiarity with these atypical patterns is crucial, especially when the clinical features are not suggestive [6].
All patients received early symptomatic management concomitantly with prompt and extensive investigations to identify the cause. The on-scene presentation was severe as evidenced by the high number of organ failures, and mechanical ventilation was required in 71% of patients. Antihypertensive drugs and anticonvulsants were given early, as necessary. At least one cerebral imaging study was performed, and 83% of patients had MRI, the reference standard for diagnosing PRES. [30] At least one cause was identified in all patients, allowing early etiological treatment. Median time from PRES onset to control of the cause was only 30 (7–86) hours. Exposure to toxic agents was the most common cause, with 44% of patients. The already long list of toxic agents associated with PRES is growing steadily. In our study, immunosuppressants such as anticalcineurin agents (cyclosporine A and tacrolimus FK506) were the most common toxic causes. Hypertensive encephalopathy was the second most common causative factor, with 41% of patients. Toxaemia of pregnancy and autoimmune diseases were identified in 23% and 11% of patients, respectively, potentially explaining the female predominance of the syndrome. Finally, other factors reported in association with PRES, sometimes only anecdotally, include hypomagnesaemia, sickle cell disease, and infection/sepsis/shock.
We identified three factors independently associated with the day-90 functional outcome. Among them, time to control of the causative factor provides the greatest room for improvement. Although a role for this variable was suggested previously [11], [31], our study is the first to demonstrate an independent association with the outcome. Patients may require blood pressure control, withdrawal of cancer chemotherapy or immunosuppressants, caesarean section, dialysis, or other interventions. Prompt control of the cause is crucial to decrease the risk of ischaemia or bleeding, thereby avoiding permanent disabilities or death. [1] Although control of the causative factor was achieved within a median of only 30 hours in our study, ischaemic and haemorrhagic complications occurred in 8% and 12% of patients, respectively. Moreover, reversibility of the imaging abnormalities was partial in 43% and complete in 45% of patients. Several studies have suggest that toxaemia of pregnancy may be associated with better outcomes. [32] In our study, toxaemia of pregnancy was independently associated with a higher likelihood of a favourable day-90 outcome (GOS = 5). Maternal mortality after eclampsia is only about 1%. However, extra-neurological complications (placental abruption and HELLP syndrome) and neurological complications (ischaemia and haemorrhage) can occur. Another risk after eclampsia is the development of post-traumatic stress disorder. Hyperglycaemia was the last factor independently associated with the 90-day outcome in our patients. Hyperglycaemia, a common occurrence in neurocritical care patients [33], was significantly associated in several studies with increased mortality and impaired functional outcomes after events such as stroke [34], [35], intracerebral haemorrhage [36], traumatic brain injury, [37] and spinal cord injury. [38] However, whether hyperglycaemia is an independent prognostic factor or a marker for brain injury severity remains unclear. [33].
None of the clinical or neuroimaging features evaluated in our study was independently associated with the day-90 outcome. The two independent risk factors for a poor day-90 outcome were related to early management. Our results support a goal-directed strategy combining prompt symptomatic treatment and control of the causative factor as soon as it is identified, regardless of on-scene severity of the clinicoradiologic presentation.
Previous studies provided limited data on the management and outcome of PRES. The mortality rate reached 15% [8], [9]. An assessment of functional impairment was reported in a single study, which found a median modified Rankin scale of 2.5 at discharge, indicating mild-to-moderate disability [8]. None of these studies focused on severe PRES. Moreover, the relative roles in fatal outcomes of the syndrome itself and of associated factors remained unclear. Our multicentre study accurately delineates the presentation, management, and determinants of functional outcomes in patients requiring ICU admission for severe forms of PRES.
Our study has several limitations. First, the extent to which our findings apply to the full spectrum of patients with PRES is unclear. Patients were included in 24 ICUs over a 10-year period, yielding a great variability in the radiologic technology used for diagnosis and follow-up. However the year of admission, as well as the center, were not determinants of functional outcome. However, despite the retrospective study design, the participation of 24 ICUs provided a broad picture of the management of severe PRES. Second, PRES was diagnosed based on a combination of clinical and neuroimaging features previously described as consistent with PRES. MRI was obtained in most of the patients, all neuroimaging studies were reviewed by two certified senior neurologists blinded to clinical data, and patients were included by consensus between the two neurologists. Consensus agreement between the two neurologists that performed independent blinded review of all available neuroimaging was strong with a value of 1 (considering a proportion of concordant classifications expected by chance of 0.05). Given the 7 cases discarded after neuroimaging expertise, kappa coefficient agreement between initial selection of cases and final enrolment was excellent with a value of 0.9 (considering a proportion of concordant classifications expected by chance of 0.05). Follow-up neuroimaging studies were lacking in 30% of patients, but this proportion was even higher in previous reports [6], [8]. Third, the GOS in its structured form has been found valid, practical, and reliable [39], but indirect GOS evaluation via charts or physician interviews has not been studied. Qualitative data from structured interviews may better assess the cognitive and emotional burden after PRES. Fourth, A GOS score of 4 may be viewed as a favorable outcome. A GOS score of 4 is "moderate disability" in a "patient capable of living independently but unable to return to work or school". This category is associated with functional impairments, as "some previous activities, either at work or in social life, are now no longer possible by reason of either physical or mental deficit". Thus, in keeping with other studies of outcomes of neurological conditions in critically ill patients, we defined a poor outcome as a GOS score smaller than 5. [40], [41] Fifth, even if global mortality rate was of 15.7%, assessment of direct imputability of PRES indicates a lower value of 5.7%. This interesting finding reinforces results of our multivariate analysis of factors associated with functional outcome in patients with severe PRES. Indeed, toxemia of pregnancy, as opposed to others causes, was associated with good outcome, underlying burden of co-morbidities in this syndrome. Moreover, reasons for death directly ascribable to PRES demonstrate the potential of aggravation in course of disease of patients presenting with severe PRES. Sixth, impact on 90-days functional outcome of other organ dysfunction than respiratory failure was not assessed during the whole ICU stay. Seventh, due to the retrospective design of the study, the GOS score was extracted from the hospital charts or determined by interviewing the patient's general practitioner or neurologist in 90% of patients. In the remaining 10% of patients (corresponding to latest inclusions), the GOS score was evaluated by the local investigator, who administered the scale directly to the patient during a phone interview. The day-90 GOS score was known for all study patients whereas the day-180 GOS score was known for 62 (88.6%) patients. Last, 90 days after ICU discharge may be too early to determine the final functional outcome. However, 90 days is the most widely used interval for assessing overall outcomes after brain injuries.
In conclusion, 90 days after severe PRES only 56% of survivors had achieved a good recovery and the outcome was predicted chiefly by factors available within a few hours after ICU admission. Among these factors, hyperglycaemia during the first 24 hours and delayed control of the cause may be amenable to improvement. These results should be confirmed in a large multicentre prospective study.
We thank A. Wolfe MD for helping to prepare the manuscript. All participating hospitals and intensive care units are listed in the appendix (contributors). Presentation at scientific conferences: Presented in part at the 39th congress of the French Society for Critical Care (January 2011), Paris, France. The following investigators participated in the study: Pierre Guezennec, Sybille Merceron, Matthieu Henry Lagarrigue, Benjamin Planquette, Pierrick Cronier (Medical-Surgical Intensive Care Unit, CH Versailles – Site André Mignot, Le Chesnay, France); Pierrick Cronier (Medical-Surgical Intensive Care Unit, CH Versailles – Site André Mignot, Le Chesnay, France); Virginie Laurent (Medical-Surgical Intensive Care Unit, CH Versailles – Site André Mignot, Le Chesnay, France); Julia Hilly-Ginoux (Medical-Surgical Intensive Care Unit, CH Versailles – Site André Mignot, Le Chesnay, France); Christian Hubert (Radiology Department, CH Versailles – Site André Mignot, Le Chesnay, France); Thierry Duprez (Neuro Radiology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium); Emmanuel Canet, Virginie Lemiale, Benoit Schlemmer (Medical Intensive Care Unit, CHU Saint-Louis, Paris, France); Jacques Frija (Radiology Department, CHU Saint-Louis, Paris, France); Charles Cerf (Medical-Surgical Intensive Care Unit, Hopital Foch, Suresnes, France); Antoine Scherrer (Radiology Department, Hopital Foch, Suresnes, France); Frederic Bourdain (Neurology Department, Hopital Foch, Suresnes); Marie-Laure Chadenat (Neurology Department and Stroke Center, CH Versailles - André Mignot, Le Chesnay, France); Chantal-Nifle (Neurology Department and Stroke Center, CH Versailles - André Mignot, Le Chesnay, France); Anne-Celine Zeghoudi (Neurology Department and Stroke Center, CH Versailles - André Mignot, Le Chesnay, France); Melissa Tir (Neurology Department and Stroke Center, CH Versailles - André Mignot, Le Chesnay, France); Manuela Vasile (Radiology Department, CHI de Créteil, Créteil, France); Christian Richard (Medical Intensive Care Unit, CHU de Bicêtre, Kremlin-Bicêtre, France); Denis Ducreux (Radiology Department, CHU de Bicêtre, Kremlin-Bicêtre, France); Frederic Baud (Medical Intensive Care Unit, CHU Lariboisière, Paris, France); Jean-Pierre Guichard (Neuro Radiology Department, CHU Lariboisière, Paris, France); Dominique Hervé (Neurology Department, CHU Lariboisière, Paris, France); Emmanuel Houdart (Neuro Radiology Department, CHU Lariboisière, Paris, France); Jean Mantz (Surgical Intensive Care Unit, CHU Beaujon, Clichy, France); Hervé Mentec (Medical-Surgical Intensive Care Unit, CH Victor Dupouy, Argenteuil, France); Jean-Paul Mira (Medical Intensive Care Unit, CHU Cochin, Paris, France); Franck Pilleul (Radiology Department, Hospices Civils de Lyon, Hôpital Edouard Herriot, France); Martin Cour (Medical Intensive Care Unit, Hospices Civils de Lyon, Hôpital Edouard Herriot, France); Michel Wolff (Medical Intensive Care Unit, CHU Bichat, Paris, France); Isabelle Klein (Neurology Department, CHU Bichat, Paris, France); Bertrand Guidet (Medical Intensive Care Unit, CHU Saint Antoine, Paris, France); Elisabeth Auffray-Calvier (Neuroradiology Department, CHU Nantes, Nantes); Hubert Desal (Neuroradiology Department, CHU Nantes, Nantes); Sandrine Wiertlewski (Neurology Department, CHU Nantes, Nantes); Benoit Guillon (Neurology Department, CHU Nantes, Nantes); Muriel Fartoukh (Medical Intensive Care Unit, CHU Tenon, Paris, France); Gerard Vermeulin (Radiology Department, CH Arpajon, Arpajon, France); Jean-Bernard D'Harcourt (Neuro Radiology Department, Cliniques du Sud-Luxembourg of Arlon, Luxembourg); François Blot (Medical-Surgical Intensive Care Unit, Institut Gustave Roussy, Villejuif, France); Clarisse Dromain (Radiology Department, Institut Gustave Roussy, Villejuif, France); Vincent Das (Medical-Surgical Intensive Care Unit, CH André Grégoire, Montreuil, France); Jean-Jacques Rouby (Surgical Intensive Care Unit, CHU Pitié-Salpêtrière, Paris, France); Damien Gallanaud (Neuro Radiology Department, CHU Pitié-Salpêtrière, Paris, France); Denis Lacroix (Neuro Radiology Department, CHU Pitié-Salpêtrière, Paris, France); Stephane Silvera (Radiology Department, CHU Cochin, Paris, France; Betty Marro, Neuro Radiology Department, CHU Tenon, Paris, France); Paul Muresan (Neurology Department, CHU Tenon, Paris, France); Sanaa El Mouhadi (Radiology Department, CHU Saint Antoine, Paris, France); Anne Liesse (Neurology Department, CH de Roubaix, Roubaix, France); Emmanuel Michelin (Neuro Radiology Department, CH de Roubaix, Roubaix, France).
Author Contributions
Conceived and designed the experiments: SL FP. Performed the experiments: SL OS EA PH EM IC CB OG NA B. Megarbane LB DS GP JC LA B. Mourvillier A. Galbois LCL MR FD A. Geffroy MS AS JLP CA MN OL GT FB YSC JPB FP. Analyzed the data: SL EA OS. Wrote the paper: SL OS EA PH EM IC CB OG NA B. Megarbane LB DS GP JC LA B. Mourvillier A. Galbois LCL MR FD A. Geffroy MS AS JLP CA MN OL GT FB YSC JPB FP.
- 1. Hinchey J, Chaves C, Appignani B, Breen J, Pao L, et al. (1996) A reversible posterior leukoencephalopathy syndrome. N Engl J Med 334: 494–500. doi: 10.1056/nejm199602223340803
- 2. Schwartz RB, Jones KM, Kalina P, Bajakian RL, Mantello MT, et al. (1992) Hypertensive encephalopathy: findings on CT, MR imaging, and SPECT imaging in 14 cases. AJR Am J Roentgenol 159: 379–383. doi: 10.2214/ajr.159.2.1632361
- 3. Schwartz RB, Bravo SM, Klufas RA, Hsu L, Barnes PD, et al. (1995) Cyclosporine neurotoxicity and its relationship to hypertensive encephalopathy: CT and MR findings in 16 cases. AJR Am J Roentgenol 165: 627–631. doi: 10.2214/ajr.165.3.7645483
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- 5. Bartynski WS (2008) Posterior reversible encephalopathy syndrome, part 2: controversies surrounding pathophysiology of vasogenic edema. AJNR Am J Neuroradiol 29: 1043–1049. doi: 10.3174/ajnr.a0929
- 6. Bartynski WS, Boardman JF (2007) Distinct imaging patterns and lesion distribution in posterior reversible encephalopathy syndrome. AJNR Am J Neuroradiol 28: 1320–1327. doi: 10.3174/ajnr.a0549
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Legriel S, Pico F, Azoulay E (2011) Understanding Posterior Reversible Encephalopathy Syndrome. In: Vincent J-L, editor. Annual Update in Intensive Care and Emergency Medicine 2011: Springer Berlin Heidelberg. 631–653.
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Burnett MM, Hess CP, Roberts JP, Bass NM, Douglas VC, et al.. (2010) Presentation of reversible posterior leukoencephalopathy syndrome in patients on calcineurin inhibitors. Clin Neurol Neurosurg.
- 9. Lee VH, Wijdicks EF, Manno EM, Rabinstein AA (2008) Clinical spectrum of reversible posterior leukoencephalopathy syndrome. Arch Neurol 65: 205–210. doi: 10.1001/archneurol.2007.46
- 10. Servillo G, Striano P, Striano S, Tortora F, Boccella P, et al. (2003) Posterior reversible encephalopathy syndrome (PRES) in critically ill obstetric patients. Intensive Care Med 29: 2323–2326. doi: 10.1007/s00134-003-1901-1
- 11. Kozak OS, Wijdicks EF, Manno EM, Miley JT, Rabinstein AA (2007) Status epilepticus as initial manifestation of posterior reversible encephalopathy syndrome. Neurology 69: 894–897. doi: 10.1212/01.wnl.0000269780.45472.16
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Legriel S, Merceron S, Pico F, Cordoliani YS, Bedos JP (2011) A rare cause of status epilepticus. Intensive Care Med.
- 13. Legriel S, Bruneel F, Spreux-Varoquaux O, Birenbaum A, Chadenat ML, et al. (2008) Lysergic acid amide-induced posterior reversible encephalopathy syndrome with status epilepticus. Neurocrit Care 9: 247–252. doi: 10.1007/s12028-008-9096-5
- 14. Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2: 81–84. doi: 10.1016/s0140-6736(74)91639-0
- 15. Bateman DE (2001) Neurological assessment of coma. J Neurol Neurosurg Psychiatry 71 Suppl 1i13–17.
- 16. Wippold FJ Jr (2008) Focal neurologic deficit. AJNR Am J Neuroradiol 29: 1998–2000.
- 17. Alldredge BK, Gelb AM, Isaacs SM, Corry MD, Allen F, et al. (2001) A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. N Engl J Med 345: 631–637. doi: 10.1056/nejmoa002141
- 18. Lowenstein DH, Bleck T, Macdonald RL (1999) It's time to revise the definition of status epilepticus. Epilepsia 40: 120–122. doi: 10.1111/j.1528-1157.1999.tb02000.x
- 19. Mayer SA, Claassen J, Lokin J, Mendelsohn F, Dennis LJ, et al. (2002) Refractory status epilepticus: frequency, risk factors, and impact on outcome. Arch Neurol 59: 205–210. doi: 10.1001/archneur.59.2.205
- 20. Treiman DM, Meyers PD, Walton NY, Collins JF, Colling C, et al. (1998) A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group. N Engl J Med 339: 792–798. doi: 10.1056/nejm199809173391202
- 21. Treiman DM, Walton NY, Kendrick C (1990) A progressive sequence of electroencephalographic changes during generalized convulsive status epilepticus. Epilepsy Res 5: 49–60. doi: 10.1016/0920-1211(90)90065-4
- 22. Kaplan PW (2006) The EEG of status epilepticus. J Clin Neurophysiol 23: 221–229. doi: 10.1097/01.wnp.0000220837.99490.66
- 23. Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, et al. (2007) 2007 Guidelines for the management of arterial hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 28: 1462–1536. doi: 10.1097/hjh.0b013e3281fc975a
- 24. Legriel S, Azoulay E, Resche-Rigon M, Lemiale V, Mourvillier B, et al. (2010) Functional outcome after convulsive status epilepticus. Crit Care Med 38: 2295–2303. doi: 10.1097/ccm.0b013e3181f859a6
- 25. Vaughan CJ, Delanty N (2000) Hypertensive emergencies. Lancet 356: 411–417. doi: 10.1016/s0140-6736(00)02539-3
- 26. Le GallJR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270: 2957–2963. doi: 10.1001/jama.270.24.2957
- 27. Le GallJR, Klar J, Lemeshow S, Saulnier F, Alberti C, et al. (1996) The Logistic Organ Dysfunction system. A new way to assess organ dysfunction in the intensive care unit. ICU Scoring Group. JAMA 276: 802–810. doi: 10.1001/jama.276.10.802
- 28. Jennett B, Teasdale G, Braakman R, Minderhoud J, Knill-Jones R (1976) Predicting outcome in individual patients after severe head injury. Lancet 1: 1031–1034. doi: 10.1016/s0140-6736(76)92215-7
- 29. McKinney AM, Short J, Truwit CL, McKinney ZJ, Kozak OS, et al. (2007) Posterior reversible encephalopathy syndrome: incidence of atypical regions of involvement and imaging findings. AJR Am J Roentgenol 189: 904–912. doi: 10.2214/ajr.07.2024
- 30. Casey SO, Sampaio RC, Michel E, Truwit CL (2000) Posterior reversible encephalopathy syndrome: utility of fluid-attenuated inversion recovery MR imaging in the detection of cortical and subcortical lesions. AJNR Am J Neuroradiol 21: 1199–1206.
- 31. Servillo G, Bifulco F, De Robertis E, Piazza O, Striano P, et al. (2007) Posterior reversible encephalopathy syndrome in intensive care medicine. Intensive Care Med 33: 230–236. doi: 10.1007/s00134-006-0459-0
- 32. Mueller-Mang C, Mang T, Pirker A, Klein K, Prchla C, et al. (2009) Posterior reversible encephalopathy syndrome: do predisposing risk factors make a difference in MRI appearance? Neuroradiology 51: 373–383. doi: 10.1007/s00234-009-0504-0
- 33. Godoy DA, Di Napoli M, Rabinstein AA (2010) Treating hyperglycemia in neurocritical patients: benefits and perils. Neurocrit Care 13: 425–438. doi: 10.1007/s12028-010-9404-8
- 34. Capes SE, Hunt D, Malmberg K, Pathak P, Gerstein HC (2001) Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke 32: 2426–2432. doi: 10.1161/hs1001.096194
- 35. Garg R, Chaudhuri A, Munschauer F, Dandona P (2006) Hyperglycemia, insulin, and acute ischemic stroke: a mechanistic justification for a trial of insulin infusion therapy. Stroke 37: 267–273. doi: 10.1161/01.str.0000195175.29487.30
- 36. Fogelholm R, Murros K, Rissanen A, Avikainen S (2005) Admission blood glucose and short term survival in primary intracerebral haemorrhage: a population based study. J Neurol Neurosurg Psychiatry 76: 349–353. doi: 10.1136/jnnp.2003.034819
- 37. Jeremitsky E, Omert LA, Dunham CM, Wilberger J, Rodriguez A (2005) The impact of hyperglycemia on patients with severe brain injury. J Trauma 58: 47–50. doi: 10.1097/01.ta.0000135158.42242.b1
- 38. Sala F, Menna G, Bricolo A, Young W (1999) Role of glycemia in acute spinal cord injury. Data from a rat experimental model and clinical experience. Ann N Y Acad Sci 890: 133–154. doi: 10.1111/j.1749-6632.1999.tb07989.x
- 39. Wilson JT, Pettigrew LE, Teasdale GM (1998) Structured interviews for the Glasgow Outcome Scale and the extended Glasgow Outcome Scale: guidelines for their use. J Neurotrauma 15: 573–585. doi: 10.1089/neu.1998.15.573
- 40. de Gans J, van de Beek D (2002) Dexamethasone in adults with bacterial meningitis. N Engl J Med 347: 1549–1556. doi: 10.1056/nejmoa021334
- 41. Todd MM, Hindman BJ, Clarke WR, Torner JC (2005) Mild intraoperative hypothermia during surgery for intracranial aneurysm. N Engl J Med 352: 135–145. doi: 10.1056/nejmoa040975


text:
Better, faster and always one step ahead has been our motto ever since the foundation of MAHE in 1993, and it still is today. As the original equipment manufacturer (OEM) of a wide range of products, we place great value on close contact with our customers regarding the development, production, and quality of our products. This collaboration is of the utmost importance.
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In the early years of the company, we incorporated sophisticated internal and external processes that now enable us to guarantee the best possible customer service. A wide range of products is proof of our expertise and motivation. Since 1993, our experienced production team has grown steadily to 110 employees. If you are not yet working with us, we invite you to challenge our flexibility, innovative craftsmanship and technical expertise with your custom projects. Our ISO 13485 certified and FDA-compliant manufacturing facility guarantees highest quality, shortest turnaround, and strictest confidentiality. Each of these important cornerstones ensure your and our competitive advantage in this highly competitive market. We aim to be your outsourcing partner of choice and would be delighted to personally meet with you to present our capabilities.

subset: commoncrawl


text:
Where good stories begin...
All the latest DFB news courtesy of Phil & Charlie.
Face Tags
Accidents that work... http://www.davidficklingbooks.co.uk/blog/index.php/2012/06/07/sf-said-when-things-go-wrong/
Who's ready to sign up???? :) http://www.davidficklingbooks.co.uk/blog/index.php/2012/06/04/stranded/
Nickelodious Trumpery Ward is on the Storyblog! http://www.davidficklingbooks.co.uk/blog/
The brilliant writer, Eleanor Updale, is auctioning her self-portrait alongside other celebs!#childrenandarts
Mmm, treasure! http://www.davidficklingbooks.co.uk/blog/
Another COMIKET! Who's going? ComicaComiket#
For those who missed the launch of SOCKS... Happy Tuesday! And have a sockalicious evening!!
Curious about this cover? http://causticcovercritic.blogspot.com.au/2012/02/theres-no-way-theyll-ever-use-it.html.
I love this kind of feedback! @daveshelton @Education_RHCB
Great display in Oxford's Blackwell's..
Guess what just arrived at the DFB office?.. @conradwrites
Can you guess which DFB author this is, from the cake? First correct answer via DM gets a copy of the relevant book!
What do you think of our cover for A BOY AND A BEAR IN A BOAT? Crazy genius, or magnificent madness? Tell us! #boybearboat
We had a great time at the #nightcircus event last night! Thanks for the invite, @rebeccasbooks
Watch out for the SUPER ANIMAL ADVENTURE SQUAD, coming to a store near you in 2 weeks' time! @eruditebaboon
Guess what's out next month? BAGGAGE, by the brilliant Etherington Bros! Feast your eyes on this sneak preview...
Guess what's coming out next month? BAGGAGE by the brilliant Etherington Bros! Feast your eyes on this sneak preview
Who wants to see a sneak preview of SUPER ANIMAL ADVENTURE SQUAD, by the hilarious @eruditebaboon ? Out next month!
We all know that David loves his polka dot bow tie. But now Charlie Small has designed him a new one! #DFBowtie
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Howard Johnson Crozet properties are listed below. Search for cheap and discount Howard Johnson hotel rooms in Crozet, VA for your group or personal travels. We list the best Howard Johnson Crozet hotels & motels so you can review the Crozet Howard Johnson hotel list below to find the perfect place.
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VIA MyHoustonMagic
"Scandal" is one of the fall's hottest returning shows, and it makes sense–with a cast this good how can it not be a surefire hit?
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Join Olympia D and Old School 105.3 at Vibrations on Thursday for the Scandal watch party. Doors open at 8 p.m.
Meet The Cast of "Scandal" [PHOTOS]
7 photos Launch gallery


text:
Hotels near Al Qasba
Search hotels near Al Qasba in Sharjah
Last minute Sharjah deals
- Swiss-Belhotel Sharjahfrom $41
- Coral Beach Resort - Sharjahfrom $65
- Hilton Sharjahfrom $82$65
- The Ajman Palacefrom $102
- Fairmont Ajmanfrom $139$125
Trending now in Sharjah
Hotels within 0.5 miles of Al Qasba
- Most bookedHilton Sharjah
303 people looked at this hotel in the last hour
Most recent review
"Enjoyed the stay at Hilton Sharjah.Everything was near perfect except for the fact that the hotel does not cater to the need of Indians for India specific news ,entertainment and sports channels viz.,Times Now,India Today,News X,Zee,Sony Star Sports etc.,"
A Traveller, May 2016, IN
121 people looked at this hotel in the last hour
Most recent review
"I stayed for 3 nights,I stayed before at this hotel -Disadvantages: 1- Receptionist promised free in room Wifi, later asked for charges and after small fight gave for free. 2- Wifi so slow but solved next day. 3- Asked for charges for the complementary water bottles when asked for more in 3rd nig..."
A Traveller, Sep 2015, IE
25 people looked at this hotel in the last hour
Most recent review
"It was a great place to stay, beautiful Sharjah skyline. Nearby restaurants."
A Traveller, Dec 2015, AU
14 people looked at this hotel in the last hour
Most recent review
"Personnel was professional, helpful and kind. I would recommend this hotel to friends, especially since it is one metro stop from the Burj Khalifa and the largest shopping mall in the world. The food was outstanding as well."
A Traveller, Apr 2014, US
9 people looked at this hotel in the last hour
Hotels within 1 mile of Al Qasba
152 people looked at this hotel in the last hour
Most recent review
"Cool and nice place to stay for business travelers. Hassle free. Easy Accessibility all modes of travel, bus and taxis"
A Traveller, Apr 2016, IE
141 people looked at this hotel in the last hour
Most recent review
"A working short stay which was made comfortable and relaxing by the staff. Food was good and the overall cost was very reasonable. I would defiantly stop again. "
S, May 2016, GB
19 people looked at this hotel in the last hour
Most recent review
"Great Hotel for Family. Will atay again. Parking, Internet, Room Facilities, Kids area was very good. In short everything was very good. Receptionist Hanna was very helpful as well. Best place in Sharjah without getting stuck in Traffic."
A Traveller, Jan 2016, IE
Hotels within 2 miles of Al Qasba
15 people looked at this hotel in the last hour
Most recent review
"My stay was comftable and I appritiate every moment I was there, good service"
A Traveller, Feb 2016, IE
- Al Majaz Premiere Deluxe HotelNo Guest Reviews yet
Map of hotels near Al Qasba
- Sharjah City Centre
- University of Sharjah
- Sahara Centre
- American University of Sharjah
- Al Sharjah Sports Club
- Golf And Shooting Club Sharjah
- King Faisal Mosque
- Sharjah Corniche Hospital
- Sharjah Mega Mall
- Sharjah Ladies Club
- Sharjah Aquarium
- Al Tallah Camel Race Course
- Al Mahatta Museum
- Sharjah Calligraphy Museum
- Sharjah Archaeology Museum
- Sharjah Gold Souq
- Sharjah Art Museum
- Gulf Medical College
- Sharjah Heritage Museum
- Corniche Mosque
Hotels in Sharjah near Al Qasba
Are you looking for a cheap Al Qasba hotel, a 5 star Al Qasba hotel or a family friendly Al Qasba hotel? You just landed in the best site to find the best deals and offers on the most amazing accommodations for your stay.
When you search for hotels near Al Qasba with Hotels.com, you need to first check our online map and see the distance you will be from Al Qasba, United Arab Emirates.
Our maps are based on hotel search and display areas and neighborhoods of each hotel so you can see how close you are from Al Qasba and refine your search within Sharjah or United Arab Emirates based on closest public transportation, restaurants and entertainment so you can easily get around the city. All the hotels details page show an option for free or paid onsite parking.
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text:
Rent Wanda Hickey's Night of Golden Memories 1st edition today, or search our site for other textbooks by Jean Shepherd. Every textbook comes with a 21-day "Any Reason" guarantee. Published by Broadway Books.
Need help ASAP? We have you covered with 24/7 instant online tutoring. Connect with one of our tutors now.


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Cannondale Pro Cycling is back for the start of another year on the World Tour!
January 18th, marks the start of the 2016 World Tour Racing Season as the 2016 Cannondale boys toe the line on two continents; Australia and South America. The team is excited to get back to business and into the mix, young, hungry and determined - Fly the Green Flag this season and see why we are the most exciting team in the peloton.


text:
Join the 'Tambocor' group to help and get support from people like you.
Tambocor Questions
We found 11 questions associated with the 'Tambocor' topic.
Flecainide - Have been taking Tmbocor 50mg tabs 2 per day for 6 weeks?
I am having side effects after taking Tambocor 50mg Tabs twice a day, also on Minax Tabs 1 full one per day. Taking 2 per day Eliqus (Blood thinners) Have recently problem is Paroxysmal atrial ...
Posted 18 Mar 2016 • 0 answers
Does tambocor 100mg/flecainaide acetate affect resting heart rate?
will T.increase or slower the pulse?
Posted 21 Jan 2016 • 1 answer
On 50mg Tambocor& 10mg minax. Just went into AF took first dosage of the day.Do I take another?
... one or wait till next doage time?
Posted 2 Feb 2016 • 0 answers
Flecainide - Can Tambocor cause an unsafe increase in blood pressure?
My blood pressure has been between 106 and 125 over between 76 and 85 for the past year. I have a couple of episode of A-fib. After the first one I was taken off amlodopine and put on atenelol and ...
Posted 6 Dec 2014 • 1 answer
How do I get the name brand Tambocor?
The genetic does not work well for me
Posted 22 Jan 2015 • 1 answer
Atrial Fibrillation - Pill in pocket- what dosage do you take at onset of A Fib? Do you take?
... Tambocor when you are not in A Fib? I thought you only take it at start of episode but my script says take 50mg pill daily AND as needed. Confusing. Also taking 180mg of Diltiazem and very small ...
Posted 9 Apr 2012 • 1 answer
Tambocor - FROME WHERE CAN I BYE TAMBOCO ?
From any country can bye tambocor
Posted 9 Oct 2011 • 1 answer
My dr changed my Toprol XL 50mg to Tambocor 50mg with Norvasc 5mg, has anyone tried these?
My bp was controlled for many years, but I'm under a lot of stress lately and my bp is going crazy, some days is low, and some days is up. Also, I'm having a lot of palpitations and some ...
Posted 9 Jul 2011 • 1 answer
Atrial Fibrillation - does anyone experience waking up in the middle of the night with a racing?
... heart that lasts for a short time? I wil also feel anxiety and sometimes hand tremors. I am on tambocor. Is this drug related or just something to endured with afib?
Posted 28 Oct 2009 • 6 answers
Will miralax enterfere with my prescription meds(Tambocar)?
I take this med twice per day
Posted 7 Sep 2010 • 1 answer
Tambocor - where I can get TAMBCORE drug in india?
i want to buy the medicine tambcore drug
Posted 12 Sep 2009 • 1 answer
Ask a Question
Further Information
Related Condition Support Groups
Atrial Fibrillation, Atrial Flutter, Paroxysmal Supraventricular Tachycardia, Supraventricular Tachycardia, Ventricular Tachycardia, Wolff-Parkinson-White Syndrome


text:
Neonflames - draw your own nebula!
Neonflames is a tool to draw your own nebula!
Keywords: Advertising, Online Games, Humor, Computer Graphics
Neonflames is a tool to draw your own nebula!
Create your own generative art with Silk.
Procatinator is a blend of cat GIFs with music
The magic button — Make Everything OK
The sticky hands toys, perhaps the best toy 25 cents ever bought! See how you can re-live the joy of the flinging fun sticky hands with Coca-Cola.
A magical interactive artwork


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text:
School Resumes
Tuesday, September 6, 2016
Take a virtual tour of our school
Please take a moment to read the following letter and the service level chart.
Letter to Parents
Service level Chart
Transportation Pre-registration
Dear Parents/Guardians
Please read this important letter from CBE Transportation Services. We are moving to a pre-registration system that will allow you to let us know if you plan to use yellow school bus services for the upcoming school year. Please complete a transportation pre-registration online as soon as possible so Transportation can begin planning and communicate routes by the end of July 2016. Your transportation pre-registration is due by Monday, June 6, 2016.
Pre-Registration for transportation can be completed online through your My CBE Account.
Thank you
Subscribe to RSS headline updates from: Powered by FeedBurner
Subscribe to Brentwood School RSS Feed by Email
Special Lunch Orders
Follow @ParentBrentwood


text:
Wynn graduates from air force basic training
Published: Thursday, September 11, 2008 at 12:16 p.m.
Last Modified: Thursday, September 11, 2008 at 12:16 p.m.
Airman Amanda B. Wynn has graduated from basic military training at Lackland Air Force Base in San Antonio, Texas.
During the six weeks of training, the airman studied the Air Force mission, organization, and military customs and courtesies; performed drill and ceremony marches and received physical training, field training and special training in human relations, and learned rifle marksmanship.
In addition, airmen who complete basic training earn credits toward an associate in applied science degree through the Community College of the Air Force.
She is the daughter of Janice and Leroy Wynn of Boiling Springs.
Wynn is a 2005 graduate of Boiling Springs High School.
Reader comments posted to this article may be published in our print edition. All rights reserved. This copyrighted material may not be re-published without permission. Links are encouraged.
Comments are currently unavailable on this article


text: I'm not saying that Scizor should be uber. But, it has had a huge affect on the metagame. Fast, fragile sweepers are destroyed by it, most walls take a decent hit from its CB attacks, and it checks many common OU Pokemon. However, I don't think that Scizor is metagame reliant. In fact, I think that it is one of the reasons for the current metagame.


text:
Apply Online
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Join the October LVC Photo Challenge on Instagram
Throughout the month of October, Lebanon Valley is inviting you to take a photo each day and share it with us via Instagram or Facebook using the hashtag #LVCChallenge.
Each day, Lebanon Valley College's official Instagram account, @lebanonvalleycollege, will introduce the theme for that day, allowing you to explore different activities on campus, show off your meal on Chicken Tender Thursday, snap a selfie, and much more!
For example, the opening theme on day one (Oct. 1) was "LVC Proud." Students, alumni, family, and community members posted photos all day exemplifying "LVC Proud," tagging each of them with #LVCChallenge. The best ones were reposted on the main LVC account and each gained that user one entry into end-of-the-month prizes.
• Winner ($50 Gift Certificate to the College Store)
• Runner-Up ($25 Gift Certificate to the College Store)
• Five Random Winners Throughout the Month ($10 Gift Certificate to the Dutchmen Den)
Each photo you post with the hashtag #LVCChallenge is equal to one entry into the contest. Feel free to participate multiple times on one day, but only one entry will be counted per day per user. At the end of the month, winners will be drawn randomly from all entries. The more days you participate, the better chance you'll have at winning!
Along with these drawings for the two College Store gift certificate, an added bonus will be surprise prizes given out three times throughout the month on random days. When a photo is posted, the winner will receive a comment saying "You're a Winner!" and will receive a $10 gift certificate to the Dutchmen Den. Again, the more you participate, the better chance you'll have at catching the random prize!
Click here to view the graphic explaining the themes for all 31 days of the challenge; jump in and snap away!
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Luke Kruger-Aimone '19 Dives into the Unknown with Newly Released Single
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Organ Students Gain World and Music Experience During Trip to Brazil
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Lebanon Valley College Announces Creation of Center for Political History
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LVC Completes Revitalization of Frederic K. Miller Chapel
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E.A.T. Research Students Present at International Conference
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Laura Gingerich '13 Shares Everyday Adventures Through Her Own Brand
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Service Spurs Local and International Travel for LVC Students
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Dr. Michael Fink Shares His PT Passion in Taiwan
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Alumna Dr. Sophia Lunt Receives AACR NextGen Grant for Transformative Cancer Research
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Math Addict: Pursuing a Career in Actuarial Science
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Diana Hoffman '17 Curates "Con Spirito: Emotions Through the Printed Image" Exhibit
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Students Invited to Visit During Discovery Days This Summer
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Collision Course—On Dr. James Glasbrenner's Career and Hobbies
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Leaving on a Jet Plane–Kems Sylvain's Global Experiences
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Harrisburg Symphony Orchestra to Perform Patriotic Concert at LVC
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Diverse Cultural Exposure: Students Reflect on Service Learning Trip to Peru
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Lebanon Valley College®
in Annville, Pa., welcomes 1,600 full-time undergraduates studying more than 30 majors, as well as self-designed majors. Founded in 1866, LVC has graduate programs in athletic training, business, music education, physical therapy, and science education. Annville is 15 minutes east of Hershey and 35 minutes east of Harrisburg; Philadelphia, Washington, D.C., and Baltimore are within two hours.
Lebanon Valley College
101 N. College Avenue
Annville, PA 17003-1400


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If you're looking for a peaceful 'away from it all' holiday where you can re-charge your batteries amongst beautiful countryside, County Durham is for you; providing untouched rural landscapes and a rich historical backdrop.
Any cottage holiday in County Durham would not be complete without a visit to the historic city of Durham. The city is renowned as one of the finest historical and cultural cities in the UK, with its magnificent cathedral and castle world heritage site. Enjoy its medieval architecture, cobbled winding streets, unique shops, pubs and restaurants.
The Durham Dales forms The North Pennines Area of Outstanding Natural Beauty, an area of open heather moorland, rivers and dales, wonderful wildlife and ancient stone villages; just perfect for days out walking and touring. Include a visit to High Force waterfall where you can combine a lovely woodland walk with the magnificent site of the waterfall where the River Tees falls over the falls in two stages, creating a wonderful natural, all-year round spectacle.
Head eastwards for days out at the Durham Coast, with a coastal path, quiet beaches and imposing headlands. A great way to unwind amongst nature as it was intended, with the wind in your hair and great uninterrupted view out across the North Sea.
For a the perfect family day out Beamish Museum fits the bill, where you can discover what the north east was like in times gone by. Set in 300 acres of countryside this is a working, living museum giving a real sense of what life was like all those years ago.
From riverside strolls to tackling parts of the Pennine Way and with quiet country roads to challenging off-road climbs, County Durham offers lots of opportunities to explore by foot or bike; suitable for both novices and experts alike!
Despite its rural character there's plenty to keep visitors fully occupied during their stay, with a wealth of things to do and places to see in this enchanting corner of England.
Take a look at our selection of holiday cottages in County Durham.
0 reviews
Peacefully set amidst rolling countryside on a 200-acre sheep farm, Ben's Hut is the perfect property for couples and families who enjoy an adventure. Simple yet perfectly formed, Ben's Hut offers cosy accommodation with a double bed and a shower room incorporated into the hut, so there's no need to traipse across a field every time you want to go to the bathroom! There is a small kitchen area with a fridge, microwave, kettle, toaster and a fold-away dining table with chairs. Every tiny detail has been thought of by the owner, even down to the wool-based insulation, which keeps the hut warm and welcoming at any time of year. Ben's Hut sits naturally amongst the grounds of this working sheep farm, and it has a private parking space and decking area with table and chairs. The tranquil location makes this the perfect place to relax and unwind, and there are many footpaths and cycle routes nearby with excellent views over the landscape. Situated on the Durham/Northumberland border, the property is ideally located for exploring the many attractions both counties have to offer. The historic city of Durham, with its boat trips and magnificent cathedral, and the market town of Barnard Castle, with its 12th-century castle, are both just a short drive away. The award-winning Beamish Open Air Museum is just 13 miles away, and is well worth a visit. Newcastle and Gateshead offer an array of museums and art galleries, along with excellent shopping, all just 18 miles away. The breathtaking scenery of the Northumberland National Park is within a half hour's drive, as is Hadrian's Wall. A little further afield, there's Alnwick Castle and Gardens, along with some glorious, unspoilt stretches of coastline about an hour's drive away. Shop, pub and restaurant 1 mile.
Step to entrance. All on the ground floor.Open plan living space.Living area: With 18" Freeview TV and DVD player.Dining area.Kitchen area: Galley-style with microwave and fridge (no cooker).Bedroom area: With double bed.Shower room: With shower cubicle and toilet.
Gas central heating, electricity, bed linen and towels included. Welcome pack. Decking area with garden furniture. Private parking for 1 car. No smoking. Please note: The property has a natural water supply from a spring.
5 reviews
Perfectly situated in the pretty Anglo-Saxon village of Witton-le-Wear, and commanding fabulous views across County Durham, the Dales and beyond, Witton Hall really is the perfect location for guests wishing to treat themselves to a holiday in magnificent surroundings. Witton Hall is one of the finest country houses to have ever been built in the north of England during the 20th century, and was once listed in The Times as one of the top 100 houses in the country. Detached South Lodge (ref MWC), located at the gates of Witton Hall, once served as the gate house and has its own hot tub and garden area. Suite Two (ref MWE), Suite Three (ref MWD) and Suite Four (ref MWF) are all apartments which are situated directly behind Witton Hall and surrounded by the grounds, gardens and a shared hot tub. Suite Four (ref MWF) is the largest of the properties and occupies a prime position within the grounds, with fabulous views over the garden, grounds and faraway hills and dales.Constructed from the finest sandstone, Witton Hall itself features classic Georgian elements including stone pillars, pediments, architraves, friezes and cornices. There are plenty of leisure facilities within the Hall, available from Monday to Saturday between the hours of 9am to 5pm, which can be booked for use via the owner (only available by prior agreement), including a gymnasium with weights and cardio vascular equipment and a sauna. The gymnasium looks out on to a dance floor with a sparkling ceiling consisting of hundreds of multi-coloured lights that sparkle and dazzle like the night sky. Guests can also find a heated swimming pool with wave system and wet bar. On a mezzanine level above the gymnasium, and overlooking the pool and dance floor, there is a games room with large screen TV, pool table, sound system and a refreshments area, which once again can be privately booked via the owner and are available between the hours of 9am to 5pm. Surrounding the Hall and leisure complex, there are 2½ acres of landscaped grounds which are home to a croquet lawn, tennis courts with outdoor barbecue and seating area, shared hot tub and also beauty parlour facilities where guests can book ahead and make an appointment for a professional sports or Thai massage. Guests may book and make use of a private chef, concierge service, airport pick up and beauty treatments by arrangement.For guests wanting to relax, unwind and really treat themselves, then there is no reason at all to even leave the grounds during their stay, but for those who wish to explore the local area and really get to know County Durham, the Durham Dales and Weardale Valley, then this is the perfect location from which to do so. Witton-le-Wear is an attractive, predominantly Victorian village and is situated on the northern banks of the River Wear. There are two pubs within walking distance of Witton Hall and also two churches, one of which dates back to Norman times. Perfect for walkers, cyclists and people who like to explore, there are numerous walks and public footpaths that cross directly through the village and through some of the most picturesque countryside that the county has to offer. There is also the opportunity to enjoy salmon and trout fishing at the nearby Witton Castle Lakes.Only a three mile walk away, visit the popular Hamsterley Forest which is a 2000-hectare site of walking trails, cycle trails and orienteering. The thriving market town of Barnard Castle is a 15-mile drive away and is often popular with visitors wanting to explore the weekly farmer's market or enjoy a meal in one of the many restaurants, pubs and local inns. Visit the historic city of Durham, 15 miles, a glorious city with fantastic heritage. Durham has many popular tourist attractions that include the Lumiere Festival, jazz festival, book festival, arts week, theatre, castle and c...
The property is situated only a short drive from Bishop Auckland which plays host to the magical Kynren Eleven Arches spectacular from July-September 2016. Kynren - an epic tale of England - promises to be a historical extravaganza with a cast of over 1,000 people set over 7.5 acres of County Durham. There'll be 14 action packed and movie-like performances of colossal and dazzling proportions. The shows will incorporate a full size lake with pyrotechnics, stunning lighting and water effects making it a true spectacle in every sense of the word!
Spacious living room. Spacious dining room. Large bespoke kitchen with travertine marble floor. Double bedroom with 5ft bed and TV. Shower room with double shower cubicle and toilet.
Situated in the popular market town of Barnard Castle, the properties at 10 Newgate are the ideal base from which to explore the local and surrounding areas. Perfect for business guests, families, friends, couples and single guests, there is an ample choice of accommodation to suit each guest and fulfil their requirements. Each property at 10 Newgate offers good quality, comfortable and practical accommodation. There is a choice of property depending on the guest's requirements. All named after local attractions and historic buildings, there are many personal touches throughout, making Newgate a real home from home. Raby (ref 31097) and High Force (ref 31098) are both 2-bedroomed apartments that sleep 4 people. Each have 2 double bedrooms, as well as a comfortable living room and well-equipped kitchen with good quality appliances. Hamsterley (ref 31101) is a 1-bedroomed property with a double bedroom. Fully self contained, there is a small kitchen, living room and family bathroom with ample space for 2 guests. The Market Cross (ref 31099) is a quirky property which is an 'upside down' building with the 2 double bedrooms on the ground floor and a large living room and kitchen on the first floor. Once again there are good quality bathroom facilities and many personal touches. Both The Museum (ref 31096) and The Castle (ref 31100) are perfect for guests who want to enjoy comfortable, practical accommodation. The space has been well used to provide a comfortable sleeping area that has been cleverly screened off from the living room and kitchen area by the careful placement of the furniture and wardrobe. These two studio apartments are perfect for guests who would like a little more space and facilities than a standard hotel room in the area. 10 Newgate is located behind a local pub at the heart of Barnard Castle, and guests will be able to leave their car behind to take a leisurely stroll into the town centre, with many top class pubs, restaurants, inns and cafés that line the old fashioned high street. There is also a weekly farmers market that provides local produce, arts, crafts, food and drink, and several boutique and gift shops that are scattered throughout the town. At the end of Galgate is Scar Top and the ruins of the stone castle date back to 1125 and gives the town its name. The castle also overlooks the River Tees and offers magnificent views over the surrounding areas. A little further afield but still within only a few miles distance, guests will find the pretty picture-postcard village of Staindrop, which is set in a dedicated Area of Outstanding Natural Beauty and is definitely worth the short trip out to visit. Perfect for walkers, cyclists and nature enthusiasts, Barnard Castle is set amongst some of the most magnificent countryside that the county has to offer. There are many public footpaths, established walks and cycle paths that lead through the town, alongside the River Tees and out into rolling countryside and beyond, towards places and attractions including Binchester Roman Fort and Raby Castle, as well as many National Trust houses and sites. The cathedral city of Durham is only a 30-minute drive away and is perfect for guests wanting to include a theatre break into their stay, a romantic boat ride along the River Wear, a meal out in one of the bistros and restaurants, boutique shopping or the opportunity to visit the famous cathedral and Durham Castle, which is steeped in history and tradition. Durham is a city that is thriving all year round and offers free on street entertainment on a regular basis including the annual book week, Lumiere Festival, jazz festival, art festival, miners gala and many more. For those wanting to travel a little further afield, guests will find all the majesty and beauty of both High Force and Low Force waterfalls or be able to explore the ...
All on ground floor: Living room with double bed/kitchen. Shower room with toilet.
All properties: Gas central heating, electricity, bed linen and towels included. Travel cot. High chair. 42" Freeview TV. iPod dock. Electric cooker. Microwave. Public car park (permit provided for weekly bookings, short breaks £1.50 per day).
7 reviews
Nestled away in the quiet and peaceful village of Middlestone, one of a pair and adjacent to the owner's home, Laburnum Cottage really is a hidden gem. The absolute perfect location for guests wanting to enjoy a luxurious romantic break, the cottage has been renovated to the highest of standards. With far-reaching views across open countryside and right out towards the North York Moors in the distance, guests will find themselves mesmerised by the splendour of the local scenery. Perfect for walkers, ramblers and cyclists, as well as those just wanting to enjoy a well-earned rest, Laburnum Cottage is perfectly placed for exploring and getting to know the area. Middlestone village is a sought after spot with a great local pub that serves excellent food and drink, so for those guests who want to really treat themselves then they can just walk directly across the road to the Inn, which was listed as a 'Durham CAMRA Rural Pub of the year' in 2014. For those guests who enjoy travelling a little further afield, there are many established walks, public footpaths, cycle paths and bridleways that travel through the area and beyond, through nearby villages and towns such as Coundon, Spennymoor and Kirk Merrington. The popular cathedral city of Durham is only an 8½-mile drive away and offers guests year-round attractions. Durham is one of the most historic cities in England and offers guests a plethora of attractions to visit and explore. The famous Durham Cathedral and Castle are historic buildings and definitely worth a visit. There is also the Gala Theatre located in the centre of the city, making this the perfect spot for guests wanting to enjoy a theatre trip as part of their break. Packed with top-quality restaurants, bistros, cafés and bars, Durham is a thriving city. Guests have the opportunity to enjoy the annual Lumiere Festival, annual book week, jazz festival, arts festival, miners gala and many more free attractions, as well as the weekly farmer's market and pavement artists that line the streets and market place. Should guests wish to enjoy a little retail therapy, then they will find some beautiful boutiques along with many high street names and designers. Barnard Castle is another popular town that lies only 17 miles away and offers guests quaint tea shops to visit, as well as many small cafés and restaurants for those couples who enjoy eating out. A little further afield, but still within easy driving distance, guests will be able to enjoy a day trip to the magnificent Yorkshire Dales and North York Moors, the Northumberland Dales and Hadrian's Wall, or visit one of the many smaller villages in County Durham and the Durham Dales. There is also the opportunity to visit the Angel of the North statue or shop till you drop at the Metrocentre, both only a 35-minute drive away. Shop 1 mile, pub and restaurant 20 yards.
Large living room with wood-burning stove, stable door to decking area and wooden floor. Small kitchen with tiled floor. Bathroom with over-bath shower and toilet. Lower ground floor: Sitting room. First floor: Double bedroom with 6ft four poster bed and wood-burning stove.
6 reviews
Set in the quiet village of Stainton and dating from 1870, this former granary enjoys beautiful views across the dales and open countryside. The Old Granary has retained much of its original charm including exposed beams and it has been furnished to a good standard with the bathroom having the benefit of a power shower, the property is well-presented to offer a relaxing and comfortable accommodation for two people from which to explore the delights of this fascinating area. In a tranquil setting with walks from the doorstep, it is a haven for bird watching and nature lovers with an abundance of wildlife in the area. Outside is a sheltered patio and visitors can enjoy use of a large garden, ideal for unwinding after a day walking or touring, or for dining al fresco on warmer days. For lovers of the outdoors a leisurely stroll can be enjoyed across the meadows from the property into the historic market town of Barnard Castle, 5 miles, which has fishing on the RIver Tees (permit required), a golf course, swimming pool, good choice of shops, tea rooms and restaurants, with several good country inns in the surrounding villages. The area is steeped in history and rich in culture with a range of attractions, including the famous Bowes Museum, Raby Castle, High Force waterfall and the beautiful gardens at Eggleston Hall, with woodland walks, cycle routes (hire available) and picnic areas at nearby Hamsterley Forest. The Yorkshire Dales National Park is just 5 miles away whilst the city of Durham, Beamish and the Lakes are all within an hour's drive. Golf nearby. Shop, pub and restaurant 2 miles.
12 stone steps to entrance. All on first floor: Living room with beams/ dining room/kitchen. 1 double bedroom. Bathroom with shower over bath and toilet.
Gas central heating, electricity, bed linen and towels included. Freeview TV. DVD. Electric cooker. Microwave. Washing machine. Fridge/freezer. Wi-fi. Sitting-out area and furniture. Shared garden. Parking (1 car). Welcome pack. No smoking.
5 reviews
Nestled away behind the quaint village green of Staindrop and facing Langley Beck, this semi-detached, single-storey holiday cottage is ideal for couples wanting to get away from it all, relax and spoil themselves in a well-furnished cottage that is packed with charm, character and original features. The comfortable living room boasts an original stone floor and a gas woodburner-style fire that heats up quickly and gives character and warmth to the room. There is also a small courtyard to the rear of the property which looks out on to the beck and borders the Raby Castle estate. Famous for its history, architecture and fabulous garden and grounds, Raby Castle is only a short walk away from The Snuggery and really is worth a visit for guests of all ages, if only to catch a glimpse of over 200 deer which wander the grounds. Staindrop is set in a dedicated Area of Outstanding Natural Beauty and is home to a wonderful mix of glorious countryside, stunning views, historic towns and villages, as well as High Force, England's highest waterfall. Perfect for walkers, Staindrop is the ideal base from which to explore the many and varied faces of the county, starting with the network of public footpaths that run in and around the village. A coffee shop/bistro, tea room, shop, local family butcher, pub and post office serve the everyday needs of residents and visitors alike. Only five miles away is the thriving market town of Barnard Castle which offers a weekly market and more local pubs, shops and restaurants to enjoy. The cathedral city of Durham is a mere 30-minute drive away and is perfect for a romantic boat ride along the River Wear, a meal out in one of the many bistros and restaurants, some boutique shopping or the opportunity to visit the famous cathedral and Durham Castle, both of which are steeped in history and tradition. Beamish, the living museum of the north, is a must-see attraction for all visitors to the area while the Metrocentre and Newcastle upon Tyne can be reached in just over an hour's drive. For guests wanting to explore even more of what the northern counties have to offer, Cumbria (and the Lake District), the Yorkshire Dales, the North Pennines and Northumberland are all within a 2-hour drive away. Shop 120 yards, pub 430 yards.
All on ground floor: Living room with beams and stone floor. Kitchen. 1 double (5ft) bedroom with beams. Shower room with toilet.
Gas woodburner in living room included. Gas central heating, gas, electricity, bed linen and towels included. 40" Freeview TV. DVD. Stereo/CD. Gas hob. Electric oven. Microwave. Washing machine. Fridge/freezer. Wi-fi. Small enclosed patio and furniture. On road parking. Cycle store (in nearby garage). Welcome pack. No smoking.
15 reviews
Converted from an 18th-century detached barn, this romantic studio style accommodation is a perfect getaway for couples wanting to explore the spectacular North Pennine countryside. Set in a traditional Weardale village and beside the owner's home, Cromer House Barn has its own private patio for enjoying the tranquillity of this designated Area of Outstanding Natural Beauty. The property is in an ideal location for walking, cycling and sightseeing, while Kilhope Lead Mining Museum, Bowes Museum and Hamsterley Forest are all nearby. The historic city of Durham, Beamish Museum, Hadrian's Wall and the Eden Valley are all under an hour's drive. Shop and pub serving food within 300 yards.
Ground floor: Dining area/kitchen. Wet room with toilet. Mezzanine: Living room/bedroom area with double bed.
Woodburner in living room included. Solid fuel central heating, electricity, bed linen and towels included. Travel cot. High chair. Freesat TV. DVD. CD. Microwave. Washing machine in outbuilding. Fridge/freezer. Patio and furniture. Parking. Cycle store. No smoking.
12 reviews
South View Mews is a delightful, detached, small barn conversion in the heart of Teesdale's rolling countryside, the location of TV's 'More Creatures Great and Small'. Set in the renowned and award-winning classical English village of Romaldkirk, set around three village greens, just 5 miles from the historic town of Barnard Castle, South View Mews is an excellent base for walking and exploring the North Pennines, High Force (Britain's highest waterfall) and the Upper Tees Valley.If you enjoy eating out then the local pub is but 10 yards from the cottage and has a range of hand pulled ales and multi award-winning dining. In the next village there is another excellent pub with great food set in a casual dining environment. There are also a number of very good pubs in Middleton in Teesdale, Holwick and Cotherstone just a stones throw away. You could also visit the local farm shop and cafe just along the road.There is extensive walking with the Pennine Way passing just 3 miles away and at the nearby reservoirs you can stroll to High Birk Hatt, the rural home of Hannah Hauxwell, the lady of the Dales made famous by the television documentaries in the 1970s.Riding can be arranged in the village with a number of liveries and golf can be enjoyed at Barnard Castle Golf Club or at a number of high quality courses from Rockliffe Hall at Hurworth to Slaley Hall or a lovely 9 hole course at Headlam Hall just a few miles away.Barnard Castle lies just 5 miles to the east with regular and reliable buses just 50 yards from South View Mews and offers a typical market town feel with a range of antique shops. There is a good range of butchers, bakeries and a smattering of high street stores with cafes, pubs, restaurants and a large supermarket. There are farmers markets at Middleton-in-Teesdale.Further afield, the delightful town of Durham with its magnificent cathedral, Beamish Museum, Auckland Castle, former home of the Prince Bishops, and the north east coastline, with its many harbour and ports. The Metro Shopping Centre is but 50 minutes to the north. Shop 1 mile, pub and restaurant 10 yards.
Ground floor: Living/dining room/kitchen. Separate toilet. First floor: 1 double (5ft, zip and link) bedroom. Shower room with toilet.
Gas central heating, electricity, bed linen and towels included. Satellite TV. DVD. CD. Electric cooker. Microwave. Washing machine. Dishwasher. Freezer. Sitting-out area and furniture. Parking (1 car). Cycle store. No smoking.
4 reviews
This superb, romantic, 17th-century holiday cottage, perfect for couples, is nestled in a select site on a small, tranquil, leafy lane just off the heart of the very historical conservation village of Ebchester. Adjoining another property, it boasts expansive countryside views to the rear which houses horses, wildlife and sometimes red kites. A Roman fort lies beneath the fields and the area is peppered with Roman ruins and artefacts. Try the Derwent Walk, or visit the Pennines for more walks, cycling and breathtaking scenery in an AONB. The delights of Durham city with its cathedral, castle, fine shops and galleries are close by. There are several beaches, shops, nightlife, rowing, hot air ballooning and paintballing available locally. Only 40 minutes from the Heritage Northumbrian coastline. Attention to detail throughout the cottage is superb from these very caring owners. The friendly local pub and an award-winning restaurant are close by. Shop/P.O. 200 yards.
The property is situated only a short drive from Bishop Auckland which plays host to the magical Kynren Eleven Arches spectacular from July-September 2016. Kynren - an epic tale of England - promises to be a historical extravaganza with a case of over 1,000 people set over 7.5 acres of County Durham. There'll be 14 action packed and movie-like performances of colossal and dazzling proportions. The shows will incorporate a full size lake with pyrotechnics, stunning lighting and water effects making it a true spectacle in every sense of the word!
Spacious living room with gas 'coal-effect' fire in feature inglenook and rugs on oak floor. Open-plan kitchen/dining room. First floor: Double bedroom. Bathroom with Victorian claw bath, shower attachment and toilet.
3 reviews
Set amidst rolling countryside and enjoying peace and tranquillity on the owners' 200 acre farm, where you can enjoy its many footpaths and cycleways, these renovated cottages provide excellent accommodation. Lying down a sleepy country lane, these stone-built cottages were converted from farm barns and have been tastefully and thoughtfully furnished giving the perfect base that's both relaxing and ideal for exploring the diverse attractions this region has to offer. Only 20 minutes from the many attractions of Newcastle and Gateshead - home to the Sage music venue, Baltic contemporary art gallery and excellent shopping. The renowned Beamish Open Air Museum that vividly recreates life in the North of England in the late 1800s and early 1900s is just 3 miles away and is an essential day out. The historic city of Durham, with its magnificent cathedral, which is regarded as the finest Norman building in Europe, is a mere 10 miles away. Durham is one the most beautiful cities in England, with spectacular architecture, tree-lined river bank walks and winding streets. Durham Cricket ground, which hosts many international matches is just 10 minutes away. The Durham Dales with wonderful scenery, great hill walking and cycling is only a 20 minute drive, while further afield you can discover Hadrian's Wall, Alnwick Gardens and the castles and gloriously unspoilt coastline of Northumberland – all under an hours' drive. Lapwing Cottage and Beamish Cottage (refs E5028 and E5029) can be interlinked to sleep 4 guests. Shop and pub serving food 2 miles.
All on ground floor: Living/dining room/kitchen. 1 double (6ft zip and link, can be twin) bedroom. Bathroom with bath, shower cubicle and toilet.
Use of shared freezer. Shared garden and furniture.
Lapwing Cottage and Beamish Cottage (refs E5028 and E5029) can be interlinked to sleep 4 guests. Pig Run Barn and Millers Barn (refs E5343 and E5344) can be interlinked to sleep 9 guests.
All properties: Oil central heating, electricity, bed linen and towels included. Travel cot. High chair. Two Freeview TVs. DVD. CD/iPod dock. Microwave. Washer/dryer. Dishwasher. Wi-fi available at £10 per stay. Private parking for 2 cars. No smoking.
2 reviews
This detached former miner's cottage dates back to 1865 and is situated in a quiet location on the edge of Middleton-in-Teesdale. It retains many original features, with its beamed ceilings, original stone fireplace with open fire and lovely coordinating soft furnishings. This property offers comfortable holiday accommodation with lots of character and will appeal to couples seeking either a romantic break or simply to explore the surrounding countryside. The village offers a variety of shops, country pubs serving good food and tea rooms. The popular High Force Waterfall is nearby and a short drive takes you to the Bowes Museum and the market town of Barnard Castle. This cosy little cottage is well cared for by the owners and makes an ideal base for touring and walking the Northern Dales and the Yorkshire Dales. Shop and restaurant 200 yards, pub ¼ mile.
Ground floor: Living room with tiled floor/kitchen with dining area. Beams throughout. Steep, open at one side stairs to first floor: 1 double bedroom with wooden floor. Bathroom with bath, shower cubicle and toilet.
Open fire in living room (initial fuel included). Economy 7 central heating, electricity, bed linen and towels included. Freesat TV. DVD. CD. Electric cooker. Microwave. Shared garden with patio, sitting-out area and furniture. On road parking. No smoking.
12 reviews
This charming, detached former Hemel, close to the owners' home, lies just 1½ miles from the historic village of Lanchester and only 10 miles from Durham. Lanchester is steeped in history dating back to the 12th century and it has a large village green which sits in the middle of some charming properties, with 3 village inns and eateries to hand. Cyclists will be eager to explore the quiet country roads or take the Derwent Valley Railway Path east to the outskirts of Durham, or west to join the Waskerly Way and on to Weardale. A walk can be taken along these footpaths, the section just south of Lancaster skirting the river Browney being a particular highlight. Corbridge is a mere 15 miles away with super pubs, tea rooms and shops, then carry on to Hadrian's Wall to visit the Roman forts or a little further to Hexham, with its beautiful abbey. Enjoy Durham with its river walks, fine cathedral, bijou wine bars, traditional pubs and plenty of retail therapy. Alnwick Castle where part of the Harry Potter films were made takes approximately 1 hour, where you can visit the enchanting water gardens and treehouse, and stroll along the cobbled streets. Drive a little further north and follow the Heritage Coastal Route to come across Seahouses and Bamburgh, and the enchanting Holy Island or Lindasfarne, making a great day trip. Come back and relax at this holiday cottage, admiring the views outside after a day's exploring. Consett 3 miles. Children's play area 1½ miles. Shop and pub 1½ miles, restaurant ½ mile.
Ground floor: Living/dining room/kitchen. First floor: Galleried area with double bed and Velux. Shower room with toilet.
Biomass central heating, electricity, bed linen and towels included. Freeview TV. DVD. Electric hob. Combi microwave/oven/grill. Washing machine. Dishwasher. Freezer. Wi-fi. Large decked area and furniture. Parking (2 cars). No smoking.
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cottages.com is the new home of cottages4you (Cottages for You).
cottages.com is a trading name of Wyndham Vacation Rentals (UK) Ltd. Registered in England and Wales.
Registered Office: Spring Mill, Stoney Bank Road, Earby, Lancashire,BB94 0AA, UK
Company Registration Number 00965389. VAT Registration Number: GB 598 22 99 77