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Spicy coconut noodle soup
Nutrition and extra info
- Vegetarian
Nutrition: per serving
- kcal226
- fat17g
- saturates14g
- carbs15g
- sugars4g
- fibre1g
- protein4g
- salt0.45g
- 1 tbsp red curry paste
- 400g can coconut milk (use reduced-fat if you prefer)
- 100g pack mixed mushroom
The mushroom is a fungus which comes in a wide range of varieties that belong to two distinct…
- 1 block of wide rice noodles, soaked according to pack instructions
- 100g beansprout
- 1 fat green chilli, sliced into rings
- ½ bunch spring onions
Spring onionsp-ring un-yun
Also known as scallions or green onions, spring onions are in fact very young onions, harvested…
Heat a saucepan, then fry the curry paste for 1 min. Add the coconut milk and half a can of water, then bring to the boil. Simmer for 5 mins until slightly thickened.
Throw in the mushrooms and simmer for another 2 mins. Stir in the drained noodles, beansprouts and most of the chilli and spring onions, then heat for another min. Serve in deep bowls, scattered with the rest of the chilli and onions.
What's laska?
This recipe is based on laksa, a traditional Malaysian noodle soup. Laksa can be made with either rice or egg noodles – so if you already have egg noodles in the cupboard, just use those instead.
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Comments, questions and tips
Comments (5)
I make a soup similar to this. You begin by gently frying 2 teaspoons of green curry paste, a finely sliced red chilli, grated fresh ginger and garlic and then add about 500ml of chicken stock and simmer for 15 mins. After that you add the coconut milk (2 cans) and the mushrooms (which I always fry off first) as well as fresh coriander, fish sauce, lime juice, palm sugar and a splash of sesame oil to taste. I serve it with rice noodles and offer shredded poached chicken breast for anyone who wants it. It's wonderful.
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subset: commoncrawl


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Radio and television host Glenn Beck has experienced the rollercoaster of life like few others. From the suicide of his mother when he was just 13, to his eventual alcoholism, depression, divorce, unemployment, and health scares - Glenn has weathered life's darkest storms. Any one of those struggles could've ruined him, yet Glenn was able to keep moving forward. He saw past the darkness into the light; past his grief and addictions and into what his life could be.
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In Thrive, Arianna Huffington has written a passionate call to arms, looking to redefine what it means to be successful in today's world. Drawing on the latest groundbreaking research and scientific findings in the fields of psychology, sports, sleep, and physiology that show the profound and transformative effects of meditation, mindfulness, unplugging, and giving, Arianna shows us the way to a revolution in our culture, our thinking, our workplaces, and our lives.
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The best-selling author of The Wonder of Boys offers a holistic and uplifting look at how to celebrate life after 50. Written with Gurian's courageously optimistic outlook on life, The Wonder of Aging is a comprehensive and comforting road map of what to expect in the second half of your life - and how to celebrate it. The elder years can be a journey into something richer and deeper, full of hope and meaning rather than a sense of fate, and this audiobook gives you the tools to revel in them to the fullest.
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The Ultimate Valentine's Day Gift Guide
Whether you're shopping for him, her, the kids, or your single pals this Valentine's Day, we've got you covered. Check out 61 of the sweetest gift ideas for everyone on your list.
Just started datingGive them a subtle hint about how you're feeling with this ultra-cute (and incredibly useful) tote bag.
Je T'aime Tote Bag, $20.
Just started datingIn addition to the innuendo in this polish pack's name, this set is the perfect gift thanks to its selection of natural shades.
Deborah Lippman Undressed, $38.
Just started datingWhen you've only known each other for a couple of weeks but still want to show them you care, this cute yet funny card should do the trick.
Valentine's Day Card, $9.
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Wilfred Diamond Mosaic Blanket, $85.
Just started datingHave a music man on your hands? This super stylish bracelet supports MusiCounts, an educational organization helping to improve access to musical programs for Canadian children.
Rudsak MusiCounts Bracelet, $38.
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Figurative Animal Planters, $24-28
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For your new boyfriendHandmade in Canada, this classic tonic will help him feel sexy and refreshed—not just on Valentine's Day, but all year long.
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For your long-term girlfriendThis cute-as-a-button bag is the perfect accessory for your Valentine's Day dinner--or any dinner, for that matter.
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For your long-term girlfriendThere's a reason these ultra-comfortable skivvies have a cult following. Gift her a pair (or three) and she'll be yours forever.
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For your long-term girlfriendYou can bet she'll feel the love whenever she steps out in these new beauties.
Pink Lips Women's Classic Toms, $65.
For your long-term girlfriendThis flattering, floral chemise is really a present for both of you. Now that's what we call a win-win.
Wacoal Embrace Lace Chemise, $60.
For your long-term girlfriendIf she really hates accepting gifts, we've found the perfect item for her: with these darling silk bracelets, 20 per cent of the purchase price will be put towards lifesaving medication to pregnant moms living with HIV.
Alex and Ani Kindred Cord Heart Collection, $26 each.
For your long-term boyfriendThis isn't an inexpensive gift—but it's the perfect gift for the man who has everything.
Bridgewater Leather Weekend Bag, $660.
For your long-term boyfriendInspire your man to ditch those cheap drugstore products for something that's actually good for his skin. We love this face kit that's not only all-natural and organic, it's also produced in Canada!
Organic Skin Kit for Men, $50.
For your long-term boyfriendNo need to break the bank for a great wine this Valentine's Day. This aging accelerator takes any cheap wine/beer/whiskey and transforms it into something amazing.
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For your long-term boyfriendThis straight-out-of-Mexico eyewear brand is sure to be the talk of the town this summer. Your main man will feel like the coolest kid on the block when he owns a pair before everyone else.
Bamboo Life Holbox Sunglasses, $135.
For your long-term boyfriendYou can't put a price tag on health, and if you want your boyfriend to stick around for awhile (we assume you do), this is just as much a gift for you as it is for him.
FITBIT Charge HR Wireless Activity Wristband, $180.
For your fiancéStaying in to save money for the big day doesn't have to be boring. Show your sweetie your sensual side with this all-natural massage oil featuring spicy extracts like cinnamon and vanilla.
Vitruvi 'Do' Massage Oil, $40
For your fiancéBefore you get matching wedding bands, profess your love to your spouse-to-be with these matching pillow cases.
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For your fiancéWant to give your sweetie something sweet that doesn't come wrapped in pink foil and in the shape of a heart? We think we've found the perfect solution.
Mast Brothers Milk Chocolate Bars, $12.
For your fiancéHelp get his skin wedding-ready with this deep-cleansing sonic brush. (Bonus: it looks like something out of Star Trek, so even if he doesn't appreciate what it'll do for his skin, he'll get a kick out of using it.)
Foreo Luna for Men, $199.
For your fiancéWith so much to celebrate in the coming months, these stylish cocktail glasses will definitely come in handy.
Double Old Fashioned Fox + Top Hat Glasses, $24
For your fiancéeRemind your soon-to-be wifey just how sexy she is with this seductive yet surprisingly comfortable champagne-coloured bra and panty set.
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For your fiancéeYou already splurged on the ring, so keep things simple this Valentine's Day with a cute dish for her to store her bling in while she sleeps.
In the Right Place Small Heart Dish, $20.
For your fiancéeYou may have agreed to take it easy on pressies this year (with upcoming wedding expenses, we don't blame you!), but gift her this globe to show how excited you are for the honeymoon.
Banu Globe, $57.
For your fiancéeYou know that she's busy planning your upcoming nuptials, so treat her to the best gift of all: a time-saver. This meal delivery service will ship all ingredients (pre -measured) to your door so all you guys have to do is follow the instructions.
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For your fiancéeShe's not 'technically' married yet, so a little pre-wedding colouring fun à la Ryan Gosling isn't going to hurt anyone.
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For your husbandNothing quite says 'I love you' like a night out of the house, away from the kids. Our pick? The newly renovated W Montreal which boasts fun décor, superb room service and a fantastic spa, for an evening away he surely will not forget.
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For your husbandWith these gems, he'll literally be able to wear hearts on his sleeves: one yours, one his.
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For your husbandThis set has everything your main man needs to keep his skin in tip-top shape: sonic cleansing brush, face wash, aloe shave gel and anti-aging moisturizer.
Clinique Clean Skin Great Skin For Him Set, $115.
For your wifeIf your wife is also a mom, this glitter handprint will melt her heart.
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For your wifeIt's the little (pretty) things. Set the mood with these show-stopping candle holders and you can bet she'll be a happy camper.
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For your wifeEvery makeup lover knows the key to a perfect application is in the tools, so gifting your wife this expert set will make her life easier for years to come.
Sephora Deluxe Standing Easel Brush Set, $330.
For your wifeIf Valentine's Day is all about looking and feeling red hot, you can't go wrong with this hit of hot pink. Trust.
Ashley Graham Chemise, $95.
For your wifeThis DIY pedi kit is not only super thoughtful, it's also quite practical and can be put together in no time. All you need is some Epsom salts, cozy slippers and one (or both) of these amazing foot tools.
Amopé Pedi Perfect Electronic Nail Care System, $45-56.
For your wifeYou may not be around to pamper your leading lady every day, but this decadent set will give her all the tools she needs to pamper herself, including a luxe body wash, body cream and Jo Malone's famous cologne.
Jo Malone Nectarine and Honey Blossom Gift Set, $130.
For your kidsThese sweet-smelling pencils will brighten your kids' Valentine's Day, and every day after that.
Disney Princess Colored Smencil Set, $10.
For your kidsWrap your littlest one in a blanket full of love--or kisses and hugs to be exact.
Organic Cotton Muslin XO Swaddle Blanket, $36.
For your kidsThis heart-covered hat will remind them just how much you love them every time they put it on.
Girls Valentines Toque, $18.
For your kidsThis New York Times bestselling children's book is the perfect gift for your little ones. Its message of positivity and joy will make it a bedtime story staple.
I Wish You More, $21.
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Gap Awesome Graphic Tee, $23.
For your kidsRainy days just got a whole lot more fun thanks to these funky yet functional red rain boots.
Kids' First Gloss Rain Boots, $60.
For your single friendsIn their search for their prince, they've probably met (and kissed) quite a few frogs. They'll certainly get a kick out of this hilarious tank that says what they're so often thinking, "k bye."
K Bye Flowy Tank, $44.
For your single friendsWho says you need a partner to celebrate Valentine's Day? Throw a party for your girlfriends and bust out these beauties for a toast to those that missed out, and those you've yet to meet!
Copper Shovel Bottle Opener, $10.
For your single friendsIf your pal is still on the market, we're going to bet they're doing a lot of dating. Help them prep for all the hand-holding and kissing with this skin-and-lip-softening set.
L'Occitane Shea Butter Hugs & Kisses Hand and Lip Duo, $24.
For your single friendsThis empowering book features the work of Petra Collins along with other female artists shaping a generation of women. It's exactly what you want your best gal pal to be reading on February 14th!
Babe, $40.
For your single friendsWhether it's their first solo V-Day in years, or they're just a little bummed about still missing a plus one, this little token will brighten them up (as they crack one open).
Copper Shovel Bottle Opener, $10.
For your single friendsTreat their soles because really, your besties were your original soulmates.
Sticky Be Socks in Pink, $15.
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Last year Messi scored the most anyone has scored in a calendar year, 91, and is in unstoppable form already this year. He scored four last night against Osasuna.
"It is not my objective to break records," he told Argentine newspaper Clarin. "I just want to win everything possible with my club team and national team.
"We live to try and improve in every area of life – and I am no exception."
More about...
What is your opinion? Feel free to discuss the article under. You have to comment by using your Facebook profile. Be fair and have respect for other people and opinions!
Summer 2016 is set to be a very exciting time for football fans, as this is when the long awaited Euro 2016 tournament kicks off.
Since Guus Hiddink arrived at the helm, Chelsea have improved considerably after a tricky start to the campaign.


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Abuja comes alive for U-13 boys : The national finals of the 2013 NFF U-13 Football Championship will start in Abuja on Friday. It will last for five days. Organised on...
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West Bay Opera's Madama Butterfly: Puccini's Masterwork
* Additional fees apply. No coupon or promo codes necessary to enjoy the displayed discount price.
The last date listed for Madama Butterfly was Sunday May 29, 2016 / 2:00pm.
Currently at Lucie Stern Theatre
A Day in Hollywood / A Night in the Ukraine: Tony-Winning Tribute to Old Hollywood
- Full Price:
- $50
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Take a musical time machine back to Hollywood's golden age as Palo Alto Players bring A Day in… More
Venue Details
Reviews & Ratings
Featured review from Goldstar Member
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It was my first experience with the West Bay Opera. We decided on Tuesday to see Madama Butterfly on Friday, May 22...
It was wonderful. The cast was first rate - their performing skills matched operas I've seen in SF. The venue, Lucie Stern theater is small and the stage is small. The advantage - all seats are truly close to the stage. But there was nothing small about this production. The acoustics is good the orchestra(smaller) but great.
We left the house 30 minutes before the show. No hastle, no parking problems, no big expense... Great experience!
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Outstanding performance on Sunday afternoon; absolutely riveting. This is without question one of the finest small opera houses in the United States. The set, lighting, acoustics, and orchestra were all first-rate. Frankly, this was a better...continued
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An excellent production of Madama Butterfly with fantastic singing. All three of us were very impressed and enjoyed the performance very much.
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It was my first time attending the West Bay Opera. The performance and stage was top rate. I took my 18 yr. old daughter and we both enjoyed it very much. I would attend again.
This production is sung in Italian with English titles.


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Last updated: Feb 29, 2016
How I Conquered My Chronic Back Pain
Years after a car accident wrecked her back, Pat fought for and found relief Read more
More about low back pain
Chiropractors are often the go-to caregivers for back pain. In 2002, approximately 15 million Americans used chiropractic care, about 40 percent of them for low back pain. To become a Doctor of Chiropractic, students must complete four years of education and training at an accredited chiropractic college as well as a one-year internship. Be sure to choose a chiropractor who holds a board certification and is state licensed. Like osteopaths, chiropractors favor physical manipulation of the body, and chiropractic treatment focuses on manipulation of the spine. Be aware that some practitioners make greater claims about what they can cure than others. Choose a chiropractor who is honest about your chances of improvement.
Next Page: Osteopathic physiciansOsteopathic physicians
Osteopathic physicians hold Doctor of Osteopathic Medicine (DO) degrees and their training is similar to that of MDs, though osteopathy puts more emphasis on whole-body treatment and musculoskeletal manipulation. Like MDs, they can write prescriptions and perform surgery.
Physiatrists are MDs who specialize in physical medicine and rehabilitation. It's a fairly new specialty. "The field started in the 1940s out of returning vets from World War II and a lot of the injuries they sustained," says physiatrist Joel Press, MD, medical director of the Spine and Sports Rehabilitation Centers at the Rehabilitation Institute of Chicago. "A whole area of medicine evolved to evaluate and treat brain injury, spine injury, and amputees," says Press.
By definition, surgeons focus on more invasive treatments. Both neurosurgeons and orthopedic surgeons perform spine surgery. Most people think that neurosurgeons are "brain surgeons" but in fact they perform the majority of their operations on the spine. Becoming a neurosurgeon requires six to seven years in residency, as opposed to the four to five for orthopedists, and neurosurgeons tend to specialize in more delicate casesthat involve areas like the lining of the spinal canalthan orthopedic surgeons.
The wide array of back-pain treatment choices can be daunting, suggests Penney Cowan, executive director of the American Chronic Pain Association. "There is no road map that says turn left here and then turn right here," says Cowan.


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This is the October 7, 2012 news archive. View today's Jets rumors and news.
New York Jets
New York Jets News and Rumors
Myers: Tebow time is now, not later
nydailynews.com Updated Oct 7, 2012
What can the Jets possibly do before the game against the undefeated Texans that can help fans take their minds off what looks like a season that is about to go into an irreversible tailspin?Share Tweet
Gola's Playbook: Texans (4-0) at Jets (2-2)nydailynews.com Oct 7, 2012The Texans' Andre Johnson was stymied by Darrelle Revis in the past and while he should see more double coverage this time, he'll also have more opportunities to beat Antonio Cromartie, who, as good as he is, isn't Revis.Share Tweet
Sanchez, Jets offense face tall task in Texansnydailynews.com Oct 7, 2012For all the criticism and second-guessing that Mark Sanchez has endured through the years, his biggest challenge begins on a national stage Monday night with a no-name supporting cast.Share Tweet
Four things we learned about AFC EastESPN.com profootballtalk.com Oct 7, 2012Three games are in the books for Week 5 in the AFC East. The division went 2-1 on Sunday with the New York Jets still on the docket against the Houston Texans on "Monday Night Football." Here are four things we learned about the AFC East durin…Share Tweet
NFL Network Reports That Jets Have Unsold Tickets For Monday Night, So Naturally It's A Tebow Thingdeadspin.com ESPN.com profootballtalk.com Oct 7, 2012The backup quarterback is always more popular than the starter because he is an unknown quantity; he theoretically could be better than the starter. Tim Tebow is not an unknown quantity. We know exactly what his strengths and weaknesses are. His strengt…Share Tweet
Open Thread: Week 5 Sunday Gamesthejetsblog.com Oct 7, 2012With the Jets playing the Monday nighter, here's a chance for you to talk about the games you are watching unfold this afternoon. The battle for Pennsylvania resumes when Philly takes on Pittsburgh, the Atlanta-Washington game actually has promise andShare Tweet
BGA: The Expendables — Update #1thejetsblog.com Oct 7, 2012Every year, teams have to let some players go. Even though the Jets brought back Sione Po'uha, Bryan Thomas and Nick Folk, they chose not to bring everyone back. During preseason, I kept track of the progress on the guys who left so we could at least stShare Tweet
Sunday morning one-linersprofootballtalk.com Oct 7, 2012It's a homecoming day for Bills WR Stevie Johnson. Turnovers have been the biggest negative about Dolphins QB Ryan Tannehill's performance in his first four weeks. Patriots WR Brandon Lloyd is looking forward to his matchup with Champ Bailey. The JetsShare Tweet
J.J. Watt Ready For TebowOct 7Texans DE J.J. Watt sits down with Jon Gruden prior to facing the Jets on Monday Night.
Is Tebow Time Near?Oct 7Michael Smith breaks down the numbers to see if it's time for the Jets to turn to Tim Tebow.


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Emma Social recap: The In Like a Lion edition
Oh, hey March. What'd you do with our friend February?
This last week has been a busy one at Emma. We officially launched a new partnership with Bigstock by offering five stock images to every customer through March 31, hosted a whole slew of events at our Nashville office and (finally) recovered from all the Oscar hoopla.
If March also caught you by surprise, never fear. We've rounded up some of the best stuff from our social spaces this week.
Best practices
5 super-fast, easy ways to use images to up your email marketing
Are you giving people a reson to subscribe to your email?
Tips for keeping your open rate in the 50-70% range
Emma news
We're buying you stock images!
Jim Sherraden from Hatch Show Print visits Emma
B2C's blog says we're one of four marketing tools to help you grow
WorkIT Nashville interviewed our CEO, Clint Smith
Fun finds
The brands that got the Oscars all wrong this year
Instagram goes Polaroid on everyone in 2014
MySpace is back...and better than ever?
Our most popular tweet of the week
And lastly, a favorite find from our own Twitter feed
We'll be out at SXSW next week, partying it up. Let us know if you'll be there too. We'd love to connect. You know, IRL.


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Donald Trump will swear the oath for becoming United States president... More
Taliban murders at least 70 in attack on Christians at Easter
A group related to the Taliban has murdered at least 70 people in Pakistan as it targeted Christians celebrating Easter.
It's believed mostly Christians were murdered in the suicide bombing by the Jamaat-ul-Ahrar faction, which happened at a funfair in Gulshan-e-Iqbal park in the city of Lahore on Easter Sunday evening.
Women and children are among the dead.
Christians were at the funfair as part of Easter Sunday celebrations, when a suicide bomber blew himself up just metres from the entrance.
Prime Minister David Cameron said Britain would be helping any foreign nationals in Pakistan, and tweeted his condolences along with the Foreign Secretary Phillip Hammond:
I'm shocked by the terrorist attack in Lahore. My thoughts are with the families and friends of the victims. We will do what we can to help.— David Cameron (@David_Cameron) March 27, 2016
My thoughts are with victims of #LahoreBlast. UK utterly condemns senseless & shocking violence against innocent families.— Philip Hammond (@PHammondMP) March 27, 2016
Shehbaz Sharif, the chief minister of Punjab province in which the city of Lahore is located, tweeted his condolences:
Heart bleeds at loss of precious human lives in Lahore. Words cannot describe agony we are in to see our children's blood spilled by cowards— Shehbaz Sharif (@CMShehbaz) March 27, 2016
Wilson Chowdhry, Chairman of the British Pakistani Christian Association, told Premier:
"This recent attack is a clear targeting of Christians during their Easter celebrations.
"Families celebrating the resurrection of their Lord and Saviour have lost mothers and children as a consequence of this depraved violence.
"Pakistan is not safe for Christians as there is a genocide taking place there.
"Not a genocide that is state sponsored in it's entirety but a genocide nevertheless.
"Unless western governments wake up to this problem the death toll for Christians living there is set to rise exponentially."
The British Pakistani Association is helping to pay for the funerals of some of the victims, and has said hundreds of Christians are in need of support at this time.
Stay informed and inform others with up to the minute news from a Christian perspective.
Daily News email
RSS feeds
News Widgets
Copts in Egypt have been left terrified by the killing of a married... More
More than 100,000 people are alive today because the 1967 Abortion... More
Iraqi forces trying to drive Islamic State militants from a city... More
Authorities in Pakistan claim they've searched an interrogated... More
The Taliban has said it will commit more "devastating" attacks... More
The Syrian Army is pushing to try and recapture the Christian... More


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Showing Results: Most Recent
This review is from: Nanoxia NXDS5B Black Steel ATX Full Tower Computer Case
Pros: Excellent build quality, quiet, lots of hard drive cages, hard drive cages work with both 2.5" and 3.5" drives.
Be warned, this case is huge! and heavy! I checked the dimensions before I bought it and i thought it would be ok, but when I received it i had second thoughts on how huge it was, but i bought it for the ample HDD store space and still wanted it for that reason. Its quiet, holds a ton of HDDs so my server that i built it for runs nearly silently in my office and holds 14TB of movies and pictures.
Cons: The first one I ordered came damaged, the entire front panel, which is plastic, was shattered. The drive cages where all bent out of shape like diamonds. The 2nd one i received didn't have any damage, but the drive cages were again bent out of shape badly, but they were easily bent back into shape and operate and look fine now. The case is very heavy and it was likely dropped in shipment, though no external damage to the box, it probably broke inside the box because it didnt seem like enough packaging material to properly cushion such a heavy case. However, newegg paid return shipping and 2 weeks later i received a new case. It sucked having to wait about 2 weeks, but newegg was good about it.
Other Thoughts: Calling newegg for the first time i was worried i would have to wait on hold forever, but didn't have to wait at all. I got through to an american native English speaker immediately, they paid return shipping and sent the replacement item on 3 day shipping, but still had to make a trip to the UPS store and send the broken one back on slow, but free shipping, so it took a while to get the replacement.READ FULL REVIEW
This review is from: ViewSonic VA2249S Black 22" IPS Wide Viewing Angle LED Backlight LCD 16:9 Full HD 1080P Monitor, 1000:1, 250cd/m2, 178/178 Viewing Angles, DVI, D-Sub, VESA Mountable
Pros: Its an IPS monitor for a low price, at the perfect screen size for a desktop. $130 price couldn't be beat.
Cons: I bought this monitor because it was anti-glare, not a glossy monitor screen. If i buy an anti-glare monitor, then that means I don't want glare! So why did they make the bezel a practical mirror. The bezel is extremely reflective and distracting from the mirror like reflections. That is why i dropped an egg.
Other Thoughts: The screen is IPS and looks good for the most part. I am used to $800 IPS monitors at work but couldn't afford them at home, so I bought this, but you cant tell the screen isn't as good as those expensive monitors, but for $130 its good for the price. I lowered the default contrast and that made it better. The mirror like bezel is terrible and I almost wouldn't recommend this monitor simply because of it. The glares/reflections from the bezel are distracting and hard on the eyes. But this is also for my particular location in that I have some windows in the same room. Now knowing this, I wouldn't buy this monitor again and would search for an anti-glare IPS with a matching non-shiny bezel.READ FULL REVIEW


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1 review of Christo's Mediterranean Grill, first by Eliza80.
food poisoning
The hummus and Jackie O cake were good and our waiter was courteous but everything else was downhill from there.
The place looked like it hadn't been dusted in ten years nor the menus washed in that same amount of time, but since the hummus was good and they had vegetarian on the menu to suit my husband we decided to give it a try.
I ordered a cooked salmon dish topped with spinach, and I should have never touched it. I could smell it before I even saw the waiter. The spinach on the salmon was yellowed and funky like it had come out of a can or something and the rice tasted musky if you can imagine that. My husband ordered the vegetarian stuffed peppers which not only looked but tasted like they had been frozen and reheated at least once if not more than that.
Sure enough shortly after we left we had to cancel the rest of our plans for the evening so I could spend the rest of the night in our bathroom with a bottle of peptobysmol.
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10/28/2015 A diner from New Kensington, PA tried it.
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Former US Senate candidate Gabriel Gomez is running up a mountain again.
But it's not the metaphorical one every Republican vying for statewide office faces in Democratic Massachusetts — it's an actual peak.
A year after Gomez lost the 2013 US Senate special election to Democrat Edward J. Markey, the former Navy SEAL is launching a new summit-racing business with three partners.
The company, O2X, will hold "eco-friendly obstacle-course summit challenge races" starting this September, Gomez said in a telephone interview. He described the summit challenges as the intersection between obstacle course racing and elite trail running. Read more…


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7 posts tagged with employee and boss.
Displaying 1 through 7 of 7. Subscribe:
Impossible work situation...
I had a friend hire me for a job, and quickly use her position over me to cut my hours and cause me undue stress. I'm at a loss as to what is actually going on, and how to proceed from this point on. [more inside]
Said something wrong in front of my boss
What should I do in this situation after saying something stupid in front of my boss? [more inside]
How can I do something nice for my boss?
What can I do for my boss that would be nice? I am trying to get back into her good graces and a suggestion was made that I do some one nice thing for her each week. I don't know what she is into. She's not into any of the things that I am. I do know that. Although, I don't necessarily think that matters. [more inside]
I have a staff member who is driving me up the wall. Please help me to understand what exactly it is that she is doing - and how to deal with it.
I have a staff member who is driving me up the wall. Please help me to understand what exactly it is that she is doing - and how to deal with it. Much more under the cut. [more inside]
Soupy Sales meets Fight Club
We are all so demoralized that if we don't get new jobs soon we're going to bring cream pies to work and run amuck throwing them at people as part of a massive collective nervous breakdown. [more inside]
Should I be less gregarious around my boss?
Should I be less gregarious around my boss? [more inside]
ManagerFilter: Improving Staff Morale
ManagerFilter:Need some easy, cost-effective tips for making the workday more fun and upbeat. [more inside]
Page: 1


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Between Okanogan and Spokane
Landscape is the weekly photo challenge, "typically displayed in a horizontal orientation" Cheri Lucas Rowlands
You can see I shot this landscape in a vertical orientation as well.
(August 2006 when visiting my brother in Washington)
Screen shots from online storage are not the best resolution. Have to dig out an external hard drive to hunt for 2006 landscapes original files from Washington trip.
and another favorite landscape is a cityscape of Pittsburgh at Night
Duquesne Incline at Night
Pittsburgh Skyline, Incline and Sea of Fog
Made the decision to turn right at the mouth of the Liberty Tunnel, go to Mount Washington and photograph the city in fog on the way to school this morning.
I thought the above shot was best with the gift of light on the incline car, as it prepared to head down the mountain. No tripod although there was a man with one. I stabilized my camera on the iron fence.
Of course, the light changes every moment as the sunrises in the east. All shots taken with 24-70 lens on the Canon 5D Mark ii
One vertical shot. Light and dark/ Cloud and shadow.
Trying to get the best view in the frame.
Being there. looking at the city in the fog, was a magnificent experience. The limits of photography.
It felt like being in a plane but you're standing on a concrete platform by the incline, looking at the city disappear in a foggy sea. Wasn't it just last week I was photographing the icy river and the barge lane? Today felt like early Spring.
Three young men agreed to let me capture their silhouettes. Thanks guys. I'll email them the blog post link today.
More in Depth
Still thinking about depth. A second gallery for the weekly challenge. What draws your eye into the picture.
Rolling Pins in Mathews Antiques, Ohio
Homestead Stacks through a rainy windshield
Duquesne Incline Tracks from Below
Looking down into the box of Bird Bath Birds at the Antique Store.
Two door windows.
City View from Incline Ride- The Monongahela River
The city is there, I swear
On the way to school, I drove up McArdle Roadway to Mount Washington.
This is shot from the Duquesne Incline Platform. A blanket of October 1st fog.
Almost a Wordless Wednesday.
Allegheny, Monongahela, and Ohio -Three Rivers
Threes. Many things come in threes. It's a strong number- a favorite number of many.
Still on the theme of three with a triptych story with the suggested 3 pictures will be coming in the near future……………
Thanks Mark for this thought on the Three Rivers even though the stadium by that name was demolished in 2001
(see implosion below)
Allegheny River on the left
Monongahela River on the right
Forming the Ohio River at the triangular point!
Incline in the Snow
I returned to the Duquesne Incline platform on Monday evening as I arrived from Ohio. Not quite as much snow as I thought there would be.
Taken just as the sun sank in the sky and the temperatures dropped. Will try again, a different winter day.
Couldn't wait any longer to shoot when the sky was darker as it was too windy and cold. You might have liked the night time version better.
Incline Operator
Meet Chuck Wise. He says his job has its "ups and downs." You can find him on youtube he told me! Thanks for the tour, Chuck. I was showing fellow blogger Vastly Curious around the Burgh Wednesday night, all the fine sights ( the city view on Grandview Avenue in Mount Washington)
Brrrr it was windy out on the platform.
Churck Wise (like the potato chip he reminded me so I'd spell his name right) has been operating the incline for about 15 years, just as his Great Grandfather did.
He graciously allowed me to photograph and blog him.. Thanks Chuck.
Length of Track: 794 feet
Duquesne Incline December Afternoon
To watch a 16 second stop action video of the incline – click the blue words- Duquesne Incline
Light Up Night 2011 Pittsburgh PA
On the way home from school I wound around and up Sycamore Street to Mount Washington. Parked and pulled out the sweater and blazer in the back of the car and layered as best I could. No tripod, no cable remote. Took this with the Self-Timer and propped the camera on an iron fence on the Duquesne Incline platform. Watched the sky grow dark. Met people from Dallas, Las Vegas, a couple of Pitt students and New York City and photographed them with the light up night behind them. An Art Institute Special Effects major was shooting a time lapse exposure and we chatted. Did I mention it was in the low thirties? With a wind chill factor that made it seem really chilly.
A week ago we were in the Columbus Athletic Club bowling and preparing for the wedding celebration. Didn't feel like driving right home after school and had stayed late to get ready for next week. An art room always needs attention.
My blog header is Light Up Night 2010 shot from the Monongahela Incline.
Full Moon Over Pittsburgh
Not Light Up Night tonight. My friend Ray called. Said there was a huge orange moon on the horizon but by the time I threw on my jeans, wool sweater, hat and scarf, drove up to Mt. Washington, the moon had risen and appeared off white. Clear, cold and windy, met two couples from Minneapolis on their way to the Macy's Parade in NYC. Ray told them how to drive off the mountain to Fathead's or Primanti's on Carson Street. The city lights looked brighter to me than Friday night. It was an impromptu shooting session but a lot of fun. Posting the Radio Tower on Shiloh Street tomorrow.


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BioLite PowerLight Lighting System
Ultimate portability with maximum functionality: charge and light with a device that fits in your pocket.
The anchor to the NanoGrid system. Warm, powerful lighting meets portable off-grid charging to create an energy hub in the palm of your hand.
Shareable Energy : The powerful 4,400 mAh Li-Ion battery can be recharged from any USB source (including BioLite products) and then share power to any of your USB chargeable gear Get There, Setup & Enjoy : 3-in-1 PowerLight helps you find your way, light your site, and enjoy your surroundings. Warm & Powerful : 450 lumens of broad spectrum light in your pocket. See colours in dark conditions while creating an inviting, home-like atmosphere that mimics daylight. Versatile Design : Rigid 360 S-Hook hangs on closed loops and angles light from almost anywhere
Specifications: Lumens 250 Lm torch; 200 Lm lantern Battery 4400 mAh lithium-ion16 Wh storage Burn Time NanoGrid burn times Dimensions 2.22 x 5.27 x 1.15 in (5.64 x 13.39 x 2.92 cm) Weight 7.05 oz (210 g) Outputs USB charge out; 2.5mm connector
Products are shipped by the individual Fruugo retailers, who are located across Europe and the rest of the world. The delivery times and shipping prices vary depending on the retailer's location, the destination country and the selected delivery method.
Fruugo offers two delivery options: Standard or Express. All retailers offer a standard delivery service, and some retailers also offer an express delivery service.
Although Fruugo retailers endeavour to deliver within these timescales, please note that the above timescales are estimated and not guaranteed.
The delivery timescales do not include any customs clearing times beyond Fruugo's control.
Please allow additional shipping time for deliveries to exceptional locations that are hard to reach, and also during busy periods such as Christmas.
All carriers deliver during normal business working hours and may require a signature on receipt, so please ensure your order is delivered to an address where someone will be available to accept it.
We do our best to ensure that the products that you order are delivered to you in full and according to your specifications. However, should you receive an incomplete order, or items different from the ones you ordered, or there is some other reason why you are not satisfied with the order, you may return the order, or any products included in the order, and receive a full refund for the items.
Certain products purchased at Fruugo cannot be returned. They fall in the following categories:
Please take reasonable care of the goods whilst in your care. Any goods returned must be in a resaleable condition. They must be unworn/unused with original tags attached and in original packaging. It is your responsibility to ensure that the goods are appropriately packaged to ensure they are not damaged in return transit.
Notifying us of a return
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Shipping products back to retailers
Goods must be returned without undue delay and in any event not later than 14 days after notifying us of your cancellation.
If you are returning products to several retailers, you should distribute the products accordingly and send the products to those retailers who shipped them to you initially.
We strongly recommend that you use registered mail (and insure any high-value packages), since neither Fruugo nor the retailer take responsibility for shipments that are lost or damaged during return transportation.
Please ensure you retain a proof of postage receipt so in the unlikely event your parcel goes missing, you will have proof you sent it.
You will be refunded within 14 days of the retailer receiving back the goods. We will notify you by e-mail once the products reach the retailer and are accepted for return. Where a retailer has offered to collect the goods, you will be refunded within 14 days of cancelling your contract.
Unless a product or products you wish to return arrived to you damaged or faulty, you are responsible for the return transportation costs.
Providing you are returning all the products from a specific retailer, we will refund the standard shipping costs you paid for the original delivery. If you chose to pay for a non-standard delivery, we will only refund the cost of our least expensive, standard delivery.
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We will generally instruct you to ship the damaged product back to the retailer. As soon as it reaches the retailer, they will send you a replacement product. If the replacement can't be made, or if you wish to cancel the order, you will be refunded in full. You will also be reimbursed for reasonable returns postage costs for damaged or faulty goods once we have received your postage receipt.
If the outer packaging of your order is clearly damaged on arrival, and you are suspecting that the products are damaged as well, you can either reject the delivery or accept the goods and sign for them as damaged. In both instances, please notify Fruugo customer care as soon as possible.
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This bus stop is served by route 46b. http://images.ratemyarea.com.s3.amazonaws.com/assets/0062/8528/dublin_bus.jpg?picture=628528 Bus Stop http://www.dublinbus.ie Ireland Mount Merrion Co. Dublin (South) North Avenue 53.294083 -6.21065 cash
Bus Stop
53.294083, -6.21065
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Factitious Biochemical Measurements Resulting From Hematologic Conditions
Factitious laboratory results often lead to unnecessary testing or treatment. This brief review of factitious biochemical results due to preexisting hematologic conditions focuses on the mechanisms underlying the factitious results and suggests ways to prevent them. An observant pathologist identifies these errors, intervenes in a timely fashion, investigates the sources of error diligently, and institutes measures to prevent their recurrence.
- Artifact
- Factitious
- Hyperkalemia
- Myeloma
- Paraprotein
A significant number of laboratory results and reports are factitious1–4 or misinterpreted by clinicians and other laboratory clients.5 Such mishaps may lead to unnecessary diagnostic evaluation6 and/or unwarranted therapeutic interventions.6–9 On the other hand, an astute observer may identify the factitious nature of a result and investigate it to diagnose an underlying serious condition.10–12
The sources of factitious laboratory results may be preanalytical, analytical, or postanalytical factors. The preanalytical factors are in vivo causes, such as preexisting disease conditions and medications, and in vitro causes, such as problems with sample collection, type of sample tube, anticoagulant and ambient conditions, and duration of storage and transport.13,14 Recent fiscally driven efforts at centralization of laboratory facilities mean longer transportation times, while the batching of laboratory tests leads to longer storage times. The analytical factors are instrument and method-related issues, specifically the advanced automation of clinical laboratories and the lack of human intervention before the results are released. Lastly, the postanalytical factors are human errors in transcription of results and comprehension5 and interpretation of reports.
Larger clinical laboratories are conventionally subdivided into hematology, chemistry, microbiology, anatomic pathology, and so on. The testing is done by specialized technologists who are competent in identifying and correcting errors in their own subspecialties but not outside their field of expertise. This article bridges that gap by reviewing the factitious biochemical measurements that arise as a result of hematologic conditions and factors Table 1. The artifacts are classified by hematologic conditions and their mechanisms and prevention are discussed.
Paraproteins and Polyclonal Hyperimmunoglobulinemias
Paraproteins can interfere with many laboratory measurements (Table 1)3,6,8,10,11,14–88 such as glucose,10 bilirubin,15,16 high-density lipoprotein (HDL),11,16,17 sodium,32,33 chloride,32 phosphate,16,18–31 calcium,6,34 urate,35 thyroxine,40 C-reactive protein (CRP),12,23 antistreptolysin-O (ASO),23 urea,38,39 creatinine,37 and albumin.83 As a general rule, all laboratory results in a patient with a paraprotein should be reviewed for possible error, especially results that are clinically inconsistent. The immunoglobulins associated with factitious results are usually monoclonal but can be polyclonal.84 Among the paraproteins, IgM is more often the culprit because its higher molecular weight yields heavier precipitates and causes more interference. In some cases, investigation of clinically "out of place" factitious biochemical results leads to identification of a paraprotein and subsequent diagnosis of an underlying lymphoplasmacytic neoplasm.10,11
The frequency of immunoglobulin-induced laboratory errors is variable and probably underreported. The testing for up to half of patients with monoclonal immunoglobulinemia showed interference in phosphate assay.19 Large reviews of patients with paraproteinemia show that the immunoglobulin concentration in patients with factitious results did not differ from patients without the interference.19 When the interference occurred, however, the degree of interference was proportional to the immunoglobulin levels.
Immunoglobulins can induce factitious results in one or more of the following ways: (1) Immunoglobulins may precipitate or flocculate due to chemical interaction with the test reagents or to their inherent chemical structure, eg, cryoglobulinemia. The opaque precipitates interfere with automated nephelometric, turbidimetric, colorimetric, and light-scatter–based autoanalyzers.6,11,16,19–24,35,39,85 (2) Immunoglobulins may chemically inactivate the test reagents. (3) Immunoglobulins increase the colloid phase of plasma and relatively decrease the aqueous phase, thereby reducing the amount of water-soluble molecules.33,81,82 (4) Immunoglobulins may act as antigens and bind to reagents or the analyte and interfere with immunologic measurements.23,37
The paraprotein interference in laboratory testing is intermittent; it is seen in some patients and not others and at one time in a patient and not at another time. Also, since the reagents are frequently modified by the manufacturers, these laboratory errors are difficult to anticipate.
Paraprotein-associated factitious results can be minimized or avoided by one or more of the following measures: (1) diluting the sample to reduce the precipitates; (2) "deproteination" of the sample to eliminate the paraprotein; (3) using a saline or water blank instead of plasma (IgM, but not IgG or IgA, interferes with the reading of blank cuvettes in some instruments, eg, Olympus AU80035 [Olympus, Center Valley, PA] instruments using the Trinder method to measure hydrogen peroxide. This can be avoided by replacing saline with water.); and (4) setting up manual flags that identify higher baseline absorbance16 or a sudden change in absorbance when the interacting reagent is added15,16; such manual flags are, however, discouraged by instrument manufacturers.
Factitious Hyperbilirubinemia
Total and indirect bilirubin15,16 levels of more than 30 mg/dL (513.1 μmol/L), but normal levels of direct bilirubin, may be seen in patients with paraproteins. These factitious results are seen in serum and plasma. They are seen with the liquid end point chromogenic Roche assay using the Hitachi 917 analyzer (Roche Diagnostics, Indianapolis, IN) but not with the Vitros 950 (Johnson & Johnson, Langhorne, PA).15,16 However, this artifact is unlikely to be restricted to this platform because most automated analyzers use similar routines.16 The interference is rare, and the testing for 100 patients with paraproteins and 13 with polyclonal hypergammaglobulinemia did not show any interference. Dilution of the sample only partially corrected the artifact. The samples consistently produced a spike in absorbance when reagent 2 (Roche Diagnostics) was added, and designing a flag for this spike identified the factitious result consistently, without any false-positive results.
Factitious Hypolipidemia and Normolipidemia
Falsely low or undetectable levels of HDL by the homogeneous colorimetric Roche HDL-C Plus assay (Roche Diagnostics) may be seen in up to 25% of patients with paraproteins.11,16 Reanalysis on other instruments such as the Vitros and Beckman LX-20 (Beckman-Coulter, Fullerton, CA) instruments yielded normal results. Unlike the late interference with reagent 2 in the Roche bilirubin assay, the interference in Roche HDL-C assay is at an early stage owing to precipitation of the paraprotein by reagent 1 (Roche Diagnostics) and can be flagged by monitoring for high baseline absorbance.11 Another report described similar artifacts using a liquid-based enzymatic reaction, but a non–liquid-based technique provided normal levels.17
Factitious Hyperphosphatemia and Hypophosphatemia
Paraproteins exert biphasic interference on serum phosphate levels, usually resulting in factitious hyperphosphatemia3,16,18–30 but occasionally in hypophosphatemia.31 Pseudohyperphosphatemia may be seen in patients with IgM, IgA, or IgG paraproteins and results in unwarranted investigations of renal dysfunction and changes in treatment plans. In addition, hypophosphatemic patients showing falsely "high" levels of phosphate may be labeled as pseudonormophosphatemic, and this may be just as clinically relevant as pseudohyperphosphatemia. This interference is seen with the liquid colorimetric assay on the Bayer Advia 1650 (Bayer, Pittsburgh, PA) but not with slide-based, solid-state colorimetric assays on the Vitros 950.18 In a prospective study, only 1 of 27 samples with paraprotein had clinically significant pseudohyperphosphatemia.18 Deproteination completely corrected this artifact, suggesting the causative role of precipitation of paraprotein in an acid pH or binding to the inorganic phosphorus.
On the other hand, pseudohypophosphatemia was seen in 2 patients with monoclonal gammopathy of undetermined significance and multiple myeloma, respectively,31 using non-deproteinized samples but not in deproteinized samples.
Factitious Hyponatremia/Hypochloridemia
Pseudohyponatremia, pseudohypochloridemia, and reduced anion gap were seen in a patient when using the indirect ion-specific electrode method, Hitachi 917, but not with the direct electrode method, ABL 725 (Radiometer, Westlake, OH).32,33 Serum potassium was normal with both methods. This artifact is due to a water exclusion effect, ie, increased colloid phase decreases the aqueous phase per volume of sample, and, thus, the plasma has lower levels of electrolytes per volume of sample.33 Pseudohyponatremia is seen with the indirect method because it involves dilution of the sample, which exaggerates this aqueous phase deficit. There is no dilution step in the direct method. The patient described had recently received 40 g of intravenous immunoglobulin, which may have further increased the serum protein levels.
Factitious Hypercalcemia
Pseudohypercalcemia due to an IgM paraprotein was seen in 2 patients when using the Arsenazo dye method on the Beckman CX7 analyzer (Beckman-Coulter).6 The precipitation and turbidity interfered with reading the test. In both cases, this interference led to extensive diagnostic evaluation for parathyroid function and other causes, and parathyroid surgery was considered for 1 patient as well. Measurement using atomic absorption spectrometry and O-cresolphthalein complexone assay provided the correct readings.
Factitious Hypoglycemia
Consistent pseudohypoglycemia in hexokinase methods, but not in glucose oxidase methods, was seen in a diabetic patient.10 Subsequent investigations revealed an IgM-κ para-protein. In another patient, a low level IgM paraprotein (60 mg/dL [600 mg/L]) in a patient with small lymphocytic lymphoma/chronic lymphocytic leukemia was associated with extremely low blood glucose measurements by the hexokinase method (Roche/Hitachi), while the glucose dehydrogenase strips (glucometer) consistently showed expected levels. This was possibly due to antibody activity of the monoclonal protein against an antigen in the hexokinase reagents.
Factitious Hypouricemia and Normouricemia
Increased IgM, but not increased IgA or IgG, led to a marked underestimation of uric acid levels by the Trinder reaction in the Olympus AU800.35 This phenomenon is likely due to high absorbance in the blank cuvette owing to protein precipitation but was not corrected by deproteination with 20% trichloroacetic acid. Replacing the saline with water in the blank position completely corrected the anomalous results without affecting the results in patients without myeloma.
Factitious Hypoalbuminemia
Artifactually low serum albumin levels were seen in 1 of 16 patients with an IgM paraprotein.83 The paraprotein interfered with albumin measurements by slowing the bromocresol green reaction so that the 10 second reading was artifactually low. The interference was not immunological, ie, the IgM did not act as antialbumin.
Factitiously High CRP Levels
Artifactually high levels of CRP have been described in a patient who was subsequently diagnosed to have low level IgM-λ monoclonal gammopathy of undetermined significance,37 in another patient with an IgM-κ paraprotein,23 and 1 with polyclonal increase in IgM.84 There was no clinical suspicion of systemic inflammation in either patient. The phenomenon was ascribed to binding of the paraprotein to anti-CRP–antibody coated latex particles in a Behring II nephelometer (Siemens, Deerfield, IL) and was abolished by deproteination of the sample or using a manual kit method.23
Falsely High Ferritin Levels
When a latex-enhanced immunoassay was used, spuriously high serum ferritin levels were seen in a patient with polyclonal IgM hypergammaglobulinemia in absence of clinical infection or malignancy.84 Methods not using latex enhancement provided normal results.
Falsely High ASO Levels
Artifactually high levels of the ASO titer were seen in a patient with an IgM-κ paraprotein23 due to coating of the ASO antigen–laden latex particles by the paraprotein in a Behring II nephelometer. The ASO titer was normal using the Rantz-Randall method that uses human group O erythrocytes.
Falsely Low Urea Levels
Falsely low blood urea levels and discordance with creatinine levels may be seen in patients with an IgM paraprotein when using the o-phthalaldehyde method or the Astra 8 (Beckman-Coulter) or Synchron CX3 analyzer (Beckman-Coulter).38,39 The creatinine levels are unaffected by the paraprotein, truly reflecting the renal status. It seems that the paraprotein coats the sensing electrode and interferes with the reading. Using an enzymatic method with Olympus AU5000 analyzer (Olympus) avoids the artifact.39
Falsely Low Creatinine Levels
Of 18 patients with IgG myeloma, 3 showed artifactually low levels of serum creatinine37 on several instruments that determine creatinine by the Jaffe reaction but expected results using an enzymatic method. Acid precipitation or dithiothreitol preincubation abolished the artifact.
Falsely Low Thyroxine Levels
Three patients with myeloma had undetectable levels of thyroxine by a homogeneous enzyme immunoassay (EMIT) but normal results with competitive protein-binding radioassay on small, reusable Sephadex columns.40 The interference was due to turbidity of the paraproteins in the EMIT reaction mixture, resulting in an increased absorbance and a marked underestimation of hormone concentration.
Increased Blood Cell Counts
Factitious biochemical results that can be seen in patients with increased numbers of WBCs, RBCs, or platelets include pseudohyperkalemia,3,8,36,41–50 pseudo-hypokalemia,51 pseudohypoglycemia,3,52,60 pseudohypoxemia,3,53–59,86 and falsely increased serum cobalamin levels.3 These artifacts are due to release of cellular constituents during clotting or storage, eg, potassium, or to the metabolic activity of the cells consuming nutrients and oxygen from plasma before the sample is analyzed.
Factitious Hyperkalemia and Hypokalemia
Hyperkalemia is a common and often life-threatening condition, seen most often in patients with renal failure and sometimes in patients taking drugs such as angiotensin converting-enzyme inhibitors, potassium-sparing diuretics, laxatives, trimethoprim, corticosteroids, β-blockers, and non-steroidal anti-inflammatory agents. Pseudohyperkalemia is a common laboratory artifact3,8,36,41–50 and may lead to unnecessary treatment8 or emergency referral and hospital admission.46 The artifact is due to leaching of potassium from the cytosol during clotting or prolonged storage of the sample.42 It is usually seen in serum but not plasma,43 a fact that can be gainfully used in the differentiation of true hyperkalemia from pseudohyperkalemia. The potassium levels in serum are, on average, 0.36 mEq/L (0.36 mmol/L) higher than the levels in plasma49 in samples with normal numbers of blood cells.
Pseudohyperkalemia is seen in patients with acute leukemia; chronic myeloproliferative disorders such as chronic myeloid leukemia, polycythemia vera,41,48 and essential thrombocythemia44,48,50; chronic lymphocytic leukemia45; and in some patients with reactive thrombocytosis.36,43,48 In 1 review of the data for 435 patients with a reactive or neoplastic increase in blood cell counts, thrombocytosis was associated with higher levels of pseudohyperkalemia, erythrocytosis was associated with a mild increase in potassium levels, but no pseudohyperkalemia was seen with isolated leukocytosis.43 Approximately 75% of patients with essential thrombocythemia and polycythemia had factitious elevation of the serum potassium level above the reference range compared with a third of patients with reactive thrombocytosis.48 There is only a weak correlation between the degree of pseudohyperkalemia and the platelet count. In 1 study, the serum potassium level was found to increase at the rate of 0.07 to 0.15 mEq/L (0.07–0.15 mmol/L) for every 100 × 103/ μL (100 × 109/L) increase in the platelet count.42,50 However, the authors concluded that the correlation was very weak, a finding later confirmed by others.48
Preanalytical conditions that induce in vitro hemolysis8,42 or clotting of the sample result in pseudohyperkalemia or exacerbate the pseudohyperkalemia due to increased numbers of blood cells. Conditions that induce in vitro hemolysis include fist clenching during phlebotomy, blood drawing into an evacuated tube,45 use of small-gauge needles, use of tourniquets, cold storage, delay in sample processing, and the mechanical trauma during shaking or hard centrifugation of the sample or pneumatic tube transport. A leukemic patient with pseudohyperkalemia in serum and plasma due to traumatic cell lysis during pneumatic tube transport8 was treated with unnecessary dialysis until its artifactual nature was suspected following the failure of normalization of serum potassium levels when dialyzed against a potassium-free dialysate. A similar phenomenon was not seen in samples with a normal WBC count.
Factitious hyperkalemia can be minimized by prompt analysis of the sample. However, astute clinical determination of absence of symptoms of hyperkalemia is the only way to avoid unnecessary diagnostic workup or treatment.
Factitious hypokalemia may be seen in patients with a high WBC count (>100,000/μL [100 × 109/L]) in acute leukemia when the blood samples have been allowed to stand at room temperature.51 This phenomenon is related to transcellular potassium shift into the leukemic cells. Pseudohypokalemia should not be confused with true hypokalemia, which may be seen in patients with acute myeloid leukemia, especially with monocytic differentiation. The mechanism in this case is related to lysozymuria, which promotes renal tubular excretion of potassium.89
Factitious Hypoxemia
Pseudohypoxemia3,53–59,86 is seen in patients with marked leukocytosis, thrombocytosis, and, very rarely, in patients with reticulocytosis. Pseudohypoxemia can lead to suspicion of serious clinical conditions such as pulmonary leukostasis, pulmonary embolism, or pneumonia. It is more pronounced in patients with immature leukocytes and higher leukocyte counts.55,59 It disappears as the leukemic burden diminishes with treatment. Pseudohypoxemia is seen only in arterial blood samples used in conventional arterial blood gas analyzers and not in the capillary blood samples used in pulse oximeters.54,55 Pseudohypoxemia is due to rapid consumption of the oxygen dissolved in the plasma by a large number of metabolically active cells. Another possible mechanism is coating of the sensing electrode by large numbers of leukemic cells that interfere with the reading.57 However, that does not explain why pseudohypoxemia is more pronounced with blasts than with mature cells.
Pseudohypoxemia can be prevented or minimized by running the sample without delay, eg, by using continuous arterial blood gas sampling,56 by placing the sample immediately on ice, by adding potassium cyanide58 or sodium fluoride, or by using plasma instead of whole blood.57 However, most of these methods are expensive,56 and the results are not consistent. The only way to consistently prevent factitious hypoxemia due to increased numbers of blood cells is to use pulse oximetry,59 which measures capillary oxygen tension.
Factitious Hypoglycemia
Pseudohypoglycemia has been reported with leukemias with high WBC counts,3,52 in myeloproliferative disorders, and in patients receiving hematopoietic cytokines with rapidly rising counts.60 The artifact is due to glucose consumption by the metabolically active cells and can be prevented by using anticoagulants containing sodium fluoride or potassium oxalate.
Factitiously High Cobalamin Levels
Factitiously high levels of cobalamin have been seen in patients with myeloproliferative disorders with high leukocyte counts.3 A true cobalamin deficiency can be masked. A similar artifact has also been seen with plasma cell neoplasms.
Hemolysis can occur in vivo and in vitro. In vitro hemolysis can occur during sample collection owing to a difficult venipuncture; sampling through narrow-gauge needles or intravenous catheters (especially in small infants),61 extreme tourniquet pressure and prolonged fist clenching, and during transport and storage owing to extremely high or low temperatures. In vivo hemolysis is seen in hemolytic anemia. In vitro hemolysis results in factitiously high levels of serum potassium and folate, whereas in vivo hemolysis results in masking of glucose-6-phosphate dehydrogenase (G6PD) deficiency and in low levels of hemoglobin (Hb)A1c.
Factitious Hyperkalemia
In vitro hemolysis results in pseudohyperkalemia42,43,61 due to potassium release from erythrocyte cytosol. The increase in potassium levels is directly proportional to the plasma Hb concentration, and a correction factor of 0.00319 × plasma Hb (mg/dL) has been devised to derive the actual potassium level.61
Misleadingly Low HbA1c Levels
Because of the shortened RBC life span, in vivo hemolytic conditions, eg, hereditary spherocytosis, lead to an estimated glycated hemoglobin, or HbA1c, that is correct but clinically misleading.62–64 In HIV+ patients, HbA1c underestimated the glucose levels by 12.3% compared with the 3-month average fasting blood glucose levels.64 The authors also found that the patients had low haptoglobin levels, indicating hemolysis, probably induced by nucleoside analog drugs. The mechanism for lowered HbA1c in hemolysis is that the HbA1c levels increase during the life of erythrocytes, and determination of its reference range presumes a normal erythrocyte lifespan of 120 days. In conditions of hemolysis, and following massive hemorrhage, the average age of erythrocytes is less than 120 days, and, consequently, HbA1c levels are factitiously low. HbA1c estimations are also correct but clinically misleading in patients who have had a recent blood transfusion.
Misleading Normalization of G6PD
G6PD levels may be increased to normal and clinically misleading shortly after a hemolytic crisis.65 The younger erythrocytes and reticulocytes replacing the older RBCs have higher levels of G6PD, which may mask a hemizygous G6PD deficiency.
Factitiously High Serum Folate Levels
Falsely higher levels of serum folate may be seen in hemolyzed samples owing to the release of large amounts of folate from erythrocyte cytosol.3
Erythrocyte Membrane Abnormalities
Certain rare, dominantly transmitted hereditary abnormalities of erythrocyte cell membranes result in pseudohy-perkalemia.42,43,66–69 This group has been termed hereditary stomatocytosis and related disorders and includes hereditary dehydrated stomatocytosis (also known as xerocytosis), hereditary overhydrated stomatocytosis, hereditary cryohydrocytosis, and familial hyperkalemia. The presence of stomatocyte morphologic features is a sensitive marker but not specific for this group of conditions. Stomatocytes are frequently seen in liver disease, in which there is no cation leak across the membrane and no pseudohyperkalemia. Also, some cases of frank stomatocytic hemolytic anemias do not show pseudohyperkalemia.68
The cation leak in hereditary stomatocytosis is due to an abnormality of temperature-dependent membrane electrolyte pumps. The pseudohyperkalemia develops on cooling of the sample and can be seen as soon as 1 hour after collection. The plasma and serum values are abnormal. The artifact can be prevented by keeping the sample at 37°C and by analyzing promptly after collection.
Abnormal Hemoglobins
HbA1c values reflect long-term glycemic control in patients with diabetes. However, HbA1c measurement by high-performance liquid chromatography (HPLC)-based assays is inaccurate in the presence of some structurally abnormal hemoglobins.63,70,71,77–79,87,88 The extent of interference varies with the specific commercial HPLC method used and the type of abnormal hemoglobin.
Some hemoglobin variants result in underestimation of HbA1c, eg, Hb Takamatsu, HbG Szuhu,71 HbC, HbS, HbO Padova,72 HbJ Meerut,73 Hb Riyadh,74 HbJ Baltimore, Hb Camden, HbJ Lome, Hb Ube-2, Hb Etobicoke,75 Hb Görwihl,76 and Hb Rambam.70 Other variants result in overestimation of HbA1c, eg, Hb Raleigh,80 Hb Okayama,70 Hb Graz,63 HbK Woolwich,77 Hb Osu-Christiansborg,78 Hb Sherwood Forest, Hb South Florida, and Hb Niigata. Increased HbF, eg, in hereditary persistence of fetal hemoglobin or the rise of HbF during pregnancy may also yield factitiously higher results for HbA1c because of coelution.79
Hb variants interfere with the measurement of HbA1c in a variety of ways. HbA1c overestimation is due to coelution of the native Hb variant with HbA1c,88 or its separation from HbA so that the denominator is small. HbA1c underestimation is due to separation of the glycated hemoglobin variant from HbA1c so that it is not considered in the HbA1c calculations.
Interference of Hb variants with HbA1c measurements can often be eliminated by changing the assay method. Failing that, regular blood glucose monitoring by a point-of-care device should be advised.
Sudden massive hemorrhage and subsequent large-scale inflow of reticulocytes from the bone marrow reduce the average age of erythrocytes and artifactually decrease the HbA1c values.
Transfusion of Blood Products
Therapeutic hypergammaglobulinemia produced by infusion of intravenous immunoglobulins can lead to pseudohy-ponatremia.33,81,82 This artifact results from increased colloid (immunoglobulin) phase in plasma, reducing the sodium-carrying aqueous phase. This is an in vivo artifact that, unlike pseudohyperkalemia, produces clinical symptoms, eg, neurologic deterioration,33 and may even lead to death.82
Misleading Normalization of G6PD
G6PD levels may be higher after transfusion of 1 or more units of packed RBCs,65 masking a hemizygous G6PD deficiency. Repeated testing after 8 to 12 weeks provides correct values.
Misleading Normal RBC Folate and Serum Cobalamin
RBC folate and serum cobalamin levels may be misleadingly normal after transfusion due to correction by transfused RBCs and plasma. Repeated testing after 12 weeks provides correct values.
Factitious laboratory results often lead to unnecessary testing or treatment. This brief review of factitious biochemical results due to preexistent hematologic conditions focuses on the mechanisms underlying the factitious results and suggests ways to prevent them. Observant pathologists identify these errors, intervene in a timely manner, investigate the sources of error diligently, and institute measures to prevent their recurrence.
We thank Professor Barbara Bain for guidance and critical review.
Upon completion of this activity you will be able to:
list the biochemical artifacts associated with various hematologic conditions.
analyze the mechanisms causing these artifacts.
predict the artifactual results in various hematologic disorders.
prevent the occurrence of artifacts as much as possible.
The ASCP is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The ASCP designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™ per article. This activity qualifies as an American Board of Pathology Maintenance of Certification Part II Self-Assessment Module.
The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose.
Questions appear on p 284. Exam is located at www.ascp.org/ajcpcme.
- © American Society for Clinical Pathology
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text:
District 3 AA Tournament action begins today
Staff Report
BAYOU VISTA — Local youth baseball district all-star action will begin today when the District 3 AA (8U) Tournament kicks off at the Bayou Vista Civic Center.
Six teams will participate in the tournament: Morgan City, Franklin, Patterson, Thibodaux National, Thibodaux American and St. Mary Central.
Action will be played on two fields.
Today's action begins with a 5:30 p.m. contest between Morgan City and Franklin on field 1 and the contest between St. Mary Central and Thibodaux American begins at the same time on field 2.
At 7 p.m. Patterson will play Thibodaux National on field 1.
Action will continue Thursday when Thibodaux National will meet St. Mary Central at 5:30 p.m. on field 1, while at the same time on field 2 Patterson will play Franklin.
At 7 p.m. Thursday, Thibodaux American will play Morgan City on field 1.
On Friday, Thibodaux American will meet Thibodaux National at 5:30 p.m. on field 1, while at the same time on field 2 Morgan City will face Patterson.
At 7 p.m. on field 1, St. Mary Central will play Franklin.
Saturday's action includes games on field 1 at 10 a.m. featuring Patterson and St. Mary Central, at noon between Thibodaux National and Franklin and at 2 p.m. between Patterson and Thibodaux American.
On field 2 Saturday, Thibodaux American and Franklin will meet at 10 a.m., while Morgan City and St. Mary Central will play at noon and Thibodaux National and Morgan City will meet at 2 p.m.
MC 9s, 11s begin play Thursday
The Morgan City 9- and 11-year-old All-Stars will begin play in their District 3 tournaments Thursday at Peltier Park in Thibodaux.
In 9-year-old action, Morgan City will begin play at 6 p.m. against Thibodaux, while on Friday, Thibodaux and Franklin will meet at 6 p.m.
On Saturday, Morgan City and Franklin will play at 10 a.m.
Action will continue Sunday in the double-elimination tournament with the tournament champ crowned either Sunday morning in a 10 a.m. contest or in an if-necessary contest at 2 p.m.
In 11-year-old action, Morgan City and Thibodaux will kick off tournament action Thursday with an 8 p.m. contest, while on Friday, Thibodaux and Franklin will meet at 8 p.m.
On Saturday, Franklin and Morgan City will play at noon.
Action will continue Sunday in the double-elimination tournament with the tournament champ crowned either Sunday morning in a noon contest or in an if-necessary contest at 4 p.m.
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text:
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text: Home Leisure and community History and heritage Green Plaque Awards Scheme You voted for your favourite Leicestershire people and places to be honoured with a Green Plaque, here are your final six. Chapel Street, BarwellSite of the Barwell MeteoriteOn Christmas Eve 1965, one of the largest meteorites recorded in British history landed on the quiet and unsuspecting village of Barwell. Its flaming arrival was followed by a sonic boom as the 4.5 billion-year-old rock exploded into thousands of pieces.Nominated by Barwell Parish Council William CottonInventor and manufacturer of Cottons Patent Knitting MachinesBorn in Sileby in 1819, William spent most of his adult life living and working in Loughborough. A hosiery manufacturer, he developed a powered knitting machine and other ingenious innovations that changed the way knitted fabrics were produced forever.Nominated by Dennis Powdrill of Loughborough Lady Florence DixieAuthor and campaigner for women's rightsLady Florence Dixie was a renaissance woman ahead of her time. In 1875, she came to live at Bosworth Hall. She was appointed war correspondent for the 'Morning Post' of London to cover the Anglo-Zulu War and also wrote a feminist novel in which she prophesised that by 1999 the nation would be peacefully led by a woman! She also played a key role in the development of women's football.Nominated by the Market Bosworth Society PalitoyToy CompanyThe original toy factory on Owen Street in Coalville manufactured some of the most popular toys in Britain, including Action Man, Tiny Tears, Pippa, Tressy, Mainline Model Railways, Merlin, Star Wars figures and the Care Bears.Nominated by Robert Brechin of Church Gresley Sir Frank WhittleInventor of the Jet EngineBorn in 1907, Sir Frank Whittle was a pioneering aeronautical engineer whose invention – the jet engine - created a revolution in air travel. He worked with Power Jets Ltd at Lutterworth from 1938-1948 to develop the turbojet engine.Nominated by Geoff Smith of Broughton Astley Wicklow LodgeMilitary Hospital during WWILocated in Melton Mowbray, Wicklow Lodge served as a military hospital in WWI treating over 1,400 sick and wounded soldiers from January 1915 - April 1919. It was originally a private house given free of charge by the owner, and was fully supported and funded by the people of Melton Mowbray.Nominated by Derek Simmonds of Melton Mowbray The next stage involves us organising the installation of the successful six green plaques. Information on when those events will take place will be avalible on twitter, by folowing: @LeicsCountyHall. Opens new windowOpens new windo Grow your own food and help local peopleBecome a volunteer master gardener Help us improve this page Hide content Was this page helpful? Yes It was helpful, but Please select a reasonthere's a broken link it's hard to understand it's incorrect it's outdated it's too long Other No Please select a reasonit didn't answer my question it's not detailed enough it's hard to understand it's incorrect it's outdated it's too long Other Details


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iHerb Customer Reviews
Savings of: $12.15 (38% off)
Review of results from using Enzymatic Therapy Tablets
Posted by Reviewer2524928 on Oct 15, 2009
after taking these tables for four days now, I am finding that the arthritic pain in my knees and hip have almost totally disappeared.
Relief from aching muscles
Posted by Reviewer1151993 on Feb 17, 2012
Very helpful, especially if I've been working hard in the garden. After taking it for almost a year I find I don't need it all the time anymore.
I'm new to enzymes
Posted by Reviewer3218974 on Jan 05, 2011
and I have not used this long enough to know what the results will be....
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I just received a very nice book review on my newest novel, A Birth at Dawn. I thought I'd post it for those who have't been to my blog lately.
A Birth at Dawn by Christie Silvers is an exciting vampire and were/vampire romance that continues you through it on the edge of your seat waiting for the next piece of action to occur. Vampire families do exist if you believe. If you are a true vampire romance fan this is a must read and I look forward to the next book in the series and so should you!
Mind Fog Reviews ~ Anastasia Cassella-Young