text:
Exercise-induced right ventricular dysfunction is associated with ventricular arrhythmias in endurance athletes
Aims Intense exercise places disproportionate strain on the right ventricle (RV) which may promote pro-arrhythmic remodelling in some athletes. RV exercise imaging may enable early identification of athletes at risk of arrhythmias.
Methods and results Exercise imaging was performed in 17 athletes with RV ventricular arrhythmias (EA-VAs), of which eight (47%) had an implantable cardiac defibrillator (ICD), 10 healthy endurance athletes (EAs), and seven non-athletes (NAs). Echocardiographic measures included the RV end-systolic pressure–area ratio (ESPAR), RV fractional area change (RVFAC), and systolic tricuspid annular velocity (RV S′). Cardiac magnetic resonance (CMR) measures combined with invasive measurements of pulmonary and systemic artery pressures provided left-ventricular (LV) and RV end-systolic pressure–volume ratios (SP/ESV), biventricular volumes, and ejection fraction (EF) at rest and during intense exercise. Resting measures of cardiac function were similar in all groups, as was LV function during exercise. In contrast, exercise-induced increases in RVFAC, RV S′, and RVESPAR were attenuated in EA-VAs during exercise when compared with EAs and NAs (P < 0.0001 for interaction group × workload). During exercise-CMR, decreases in RVESV and augmentation of both RVEF and RV SP/ESV were significantly less in EA-VAs relative to EAs and NAs (P < 0.01 for the respective interactions). Receiver-operator characteristic curves demonstrated that RV exercise measures could accurately differentiate EA-VAs from subjects without arrhythmias [AUC for ΔRVESPAR = 0.96 (0.89–1.00), P < 0.0001].
Conclusion Among athletes with normal cardiac function at rest, exercise testing reveals RV contractile dysfunction among athletes with RV arrhythmias. RV stress testing shows promise as a non-invasive means of risk-stratifying athletes.
- Athletes
- Right ventricle
- Arrhythmias
- Sports cardiology
- Cardiac magnetic resonance imaging
- Exercise
- Arrhythmogenic Right ventricular cardiomyopathy
- Echocardiography
Among endurance athletes, ventricular arrhythmias most frequently arise from the RV. While these ventricular arrhythmias of RV origin are most often benign,1 a significant incidence of major arrhythmic and fatal events have been described in some cohorts of athletes in association with structural, functional, and electrical RV abnormalities.2–4 The accurate identification of those few athletes with a potential for life threatening arrhythmias remains a major clinical challenge.
We have developed evidence supporting a hypothesis that the RV may be an 'Achilles' heel' of the endurance athlete's heart. While the LV remains relatively unaffected, the RV has to withstand a disproportionate haemodynamic load during intense exercise5 resulting in transient exercise-induced RV dysfunction and chronic RV remodelling.5–11 In a pre-clinical model, this exercise-induced RV remodelling has been associated with a propensity to RV arrhythmias.12
Using novel exercise echocardiography and real-time cardiac magnetic resonance (CMR) measures to assess RV function during exercise, we hypothesized that exercise could promote RV dysfunction in endurance athletes with ventricular arrhythmias (EA-VAs). We compared EA-VAs with healthy endurance athletes (EAs) and non-athletic controls (NAs) with the aim of (i) validating the pathophysiological concept of exercise-induced pro-arrhythmic remodelling in humans and (ii) developing a non-invasive clinical tool for differentiating healthy athletes from those with a propensity to serious arrhythmias.
Endurance athletes with ventricular arrhythmias were recruited from an existing cohort at our institution in addition to new cases presenting over 36 months. The following inclusion criteria had to be fulfilled: (i) current or previous participation in competitive sport and an intensive exercise training regime (at least 3 × 2 h per week); (ii) RV arrhythmias excluding idiopathic RVOT-VT, required to have a monomorphic left bundle branch block morphology (a) sustained or (b) non-sustained for ≥3 beats at a rate of ≥120 b.p.m., or (c) frequent isolated premature ventricular beats ≥2000/day. Athletes were included if the heart appeared morphologically normal or had appearances consistent with 'athlete's heart', which was considered to include mild structural or functional abnormalities of the RV given that such changes have previously been described in healthy endurance athletes.5,7,11 Many of the athletes could be described by the syndrome 'exercise-induced'2,3 or 'gene-elusive'4 arrhythmogenic right-ventricular cardiomyopathy (ARVC), whereby there is: (i) mild structural and functional abnormalities sufficient to meet Task Force Criteria for a clinical diagnosis of ARVC,13 (ii) a protracted history of intense endurance exercise training, and (iii) no evidence of inherited disease. Thus, all athletes underwent comprehensive evaluation and were excluded from participation if a mutation or variant of uncertain significance was identified in any of the five desmosomal genes associated with ARVC, or if there was clinical evidence of disease inheritance.3 Athletes with moderate or severe RV abnormalities were excluded as this is not typical of an exercise-induced syndrome. Between 2011 and 2014, 25 athletes fulfilled the study inclusion criteria and 17 accepted to participate. Of these, eight athletes had an implantable defibrillator (ICD). Fifteen of 17 EA-VAs were treated with beta-blockers or non-dihydropyridine calcium-channel blockers alone or in combination with anti-arrhythmic medications. These medications were withheld for at least 24 h prior to exercise testing. All eligible volunteers were male and therefore only male subjects were recruited as control subjects.
The first 10 EAs responding to advertisements at local triathlon and cycling clubs who were competing in endurance sports and performing regular cycling and/or running training of >6 h/week were enrolled. Seven non-athletes (NAs) who were participating in recreational activity only (mild-to-moderate non-competitive exercise for <3 h/week) were included. No subjects met exclusion criteria of known cardiovascular disease or abnormalities on ECG or echocardiogram.
The study protocol conformed to the Declaration of Helsinki and was approved by the local Ethics Committee. All subjects provided informed consent.
Study design
Cardiopulmonary exercise testing was performed on an upright cycle ergometer (ER900 and Oxycon Alpha, Jaeger, Germany). Breath-by-breath analysis provided measures of oxygen consumption at peak exercise (VO2 peak), ventilatory equivalent for carbon dioxide (VE/VCO2 ratio), and maximal power output in Watts (Pmax). In those subjects with an ICD, the device was re-programmed such that all pacing and shocks were suspended during the exercise testing and none of the athletes with an ICD were paced. Having previously demonstrated that 66% of Pmax corresponded to the maximal sustainable exercise intensity in a supine position,14 we prescribed subsequent exercise efforts as: 25% ('low intensity'), 50% ('moderate intensity'), and 66% ('peak intensity') of Pmax.
After at least 3 h rest, echocardiography was performed at rest and during low-, moderate-, and peak-intensity exercise using a programmable semi-supine ergometer with left lateral tilt (Easystress, Ecogito Medical sprl, Liege, Belgium).
The following day, all subjects (except the eight EA-VAs with an ICD) underwent exercise CMR with simultaneous invasive pressure measurements. Prior to exercise, a 6 Fr pulmonary artery catheter was inserted under fluoroscopic guidance and a 20-gauge arterial catheter was placed in the radial artery. Pressure tracings were continuously acquired via a CMR compatible haemodynamic monitor (Maglife Serenity, Schiller AG, Baar, Switzerland).
Resting and real-time exercise images were acquired using a Vivid E9 ultrasound system (GE Vingmed Ultrasound AS, Horten, Norway) and analysed offline using EchoPAC (version 112; GE Vingmed Ultrasound AS). Resting measures, including atrial and ventricular dimensions, early diastolic myocardial velocities, and LVEF were acquired and analysed according to contemporary guidelines.15,16 Right-ventricular outflow tract dimension (RVOTd) was measured in a parasternal short-axis view from the RV free wall to the aortic valve annulus and the RV inflow dimension (RVITd) was measured at the level of the tricuspid valve from an apical acquisition.16 Two-dimensional global peak-systolic strain and strain rate (SRs) were quantified for the LV and RV on apical grey-scale images (60–90 frames/s) as described previously.17
During exercise, the following measures were obtained: (i) LVEF and RVFAC from a single-plane four-chamber view as described previously,17 (ii) RV free wall peak-systolic velocity (S′) by tissue Doppler imaging (frame rate, 120–160 frames/s), and (iii) systolic pulmonary artery pressure (PASP) from the maximal trans-tricuspid regurgitant velocities without addition of right atrial pressure estimates. Enhancement of the Doppler signal with agitated colloid enhancement was used in all subjects as described previously.17 As a surrogate of RV contractility, the RV end-systolic pressure–area relationship (RV ESPAR) was calculated as PASP divided by RV end-systolic area.17
Cardiac magnetic resonance equipment, image acquisition, and analysis
Biventricular volumes were measured during supine cycling exercise using a real-time CMR method which we have previously validated against invasive standards.14 In brief, subjects performed supine exercise within the CMR bore using a cycle ergometer with adjustable electronic resistance (Lode, Groningen, The Netherlands). Images were acquired with a Philips Achieva 1.5 T CMR with a five-element phased-array coil (Philips Medical Systems, Best, The Netherlands). Steady-state free precession cine imaging was performed without cardiac gating. A stack of 13–18 contiguous 8 mm image slices was acquired in the short-axis plane and subsequently in the horizontal long-axis plane.
Simultaneous with the image acquisition, ECG and respiratory timing were retrospectively synchronized using an in-house developed software program (RightVol, Leuven, Belgium) such that contouring could be performed at the same point of the respiratory cycle for all slices.
Biventricular volumes were calculated from endocardial contours traced on the short-axis (SAX) image with simultaneous reference to the horizontal long-axis (HLA) plane thus enabling the analysers (GC and ALG) to confirm the position of the atrio-ventricular plane. Total pulmonary resistance (tPVR) was calculated as the ratio of mean pulmonary artery pressure (mPAP) to CO and total systemic vascular resistance (tSVR) as the ratio of mean systemic arterial pressure (mSAP) to CO. The end-systolic pressure–volume ratio (SP/ESV) was calculated as mPAP/RVESV for the RV and as (0.9 × systolic blood pressure)/LVESV for the LV, as previously described.18,19 NT-proBNP was analysed from venous blood samples.
Statistical analysis
Data were analysed using IBM SPSS statistics 22 software. Gaussian distribution of all continuous variables was confirmed using a Kolmogorov–Smirnov test and values are reported as mean ± SD or as median (25 and 75% percentile) as appropriate. For clinical characteristics, comparisons between groups for continuous variables were performed by one-way ANOVA, whereas the Fisher's Exact or χ2 test was used for categorical variables. A Mixed Linear Model with compound symmetric covariance matrix and the Bonferroni post-hoc test for multiple comparisons was performed to evaluate the LV and RV volume changes during exercise within and between groups. The interaction between group and workload was included to assess differences between groups. Receiver-operating characteristic (ROC) curves were constructed and area under the ROC curves calculated20 to identify the best echocardiographic and exercise CMR methods for distinguishing athletes with VA from healthy subjects (expressed as area and 95% confidence intervals). Resting, peak-exercise, and delta (Δ: change from rest to peak) values were assessed. The significance of differences in area under the curve of the correlated rest and peak exercise ROC curves was tested using the methodology described by Delong et al.21
Intra- and interobserver variability of echocardiographic measures were assessed at rest and during the three exercise stages in 15 subjects. The mean value of the two observations (x) and the absolute value of the difference between observations (e) ± SD were determined. Reproducibility was assessed by the coefficient of variation CV = (e/x) 100%, the intra-class correlation coefficient (two-way mixed and absolute agreement quoted). A P-value of <0.05 was considered statistically significant.
The demographic, clinical, and exercise echocardiographic characteristics of the four study groups are presented in Table 1. Athletes in each group were of similar age but athletes with arrhythmias had competed in sports for longer and had higher BMIs at the time of the study. Healthy EAs had a higher VO2peak compared with the other groups, consistent with the fact that the EA-VAs had been advised to de-train. Sixty-five percent of the EA-VAs fulfilled the diagnostic Task Force Criteria for ARVC but none had evidence of familial disease or RV abnormalities that were considered moderate or severe. As detailed in Table 2, the EA-VAs who met major arrhythmia criteria for ARVC were more likely to have been treated with an implantable ICD (P < 0.05) reflecting the likely influence that sustained ventricular arrhythmias of non-RVOT origin have on clinical decision making. The prevalence of other task force criteria abnormalities was similar between EA-VAs with and without ICDs. The putative risk factor of delayed enhancement on CMR (which is not a listed task force criterion) was observed in one ostensibly healthy EA and no more frequently in EA-VAs. Ventricular ectopy during cardiopulmonary exercise testing was less frequently observed in NAs but was similar in EAs and EA-VAs. Non-RVOT and variable morphology ectopics were similarly observed in all groups, while frequent ectopy and non-sustained VT were observed in EA-VAs without an ICD but not in those with an ICD (Table 2).
|Endurance athletes (n = 10)
|Non-athletes (n = 7)
|Endurance athletes with ventricular arrhythmias (n = 17)
|ANOVA P-value
|No ICD (n = 9)
|ICD (n = 8)
|Age (years)
|35 ± 6
|34 ± 16
|39 ± 8
|40 ± 9
|BMI (kg/m2)
|22.9 ± 1.5
|23.2 ± 1.7
|26.1 ± 3.0*
|26.0 ± 1.9*
|Years of endurance sports
|9 (6–17)
|0 (0–0)
|21 (12–34)§
|17 (8–20)§
|Hours per week
|11 (6–15)§
|0.6 (0–2)
|11 (7–14)§
|15 (14–21)§
|ARVC task force criteria
|Definite (2 major, 1 major and 2 minor, or 4 minor)
|Borderline (1 major and 1 minor or 3 minor)
|Possible (1 or 2 minor)
|RVOT ectopics only‡
|Calcium antagonists
|NT-proBNP (pg/mL)
|32 (12–43)
|24 (5–37)
|83 (21–294)
|132 (68–218)*§
|Cardiopulmonary testing
|VO2 peak (mL/min/kg)
|54.0 ± 9.7
|40.3 ± 3.7*
|38.8 ± 9.1*
|37.3 ± 6.3*
|Peak power (Watts)
|365 ± 68
|261 ± 48*
|328 ± 57
|291 ± 42
|Peak HR (b.p.m.)
|181 ± 7
|178 ± 16
|174 ± 25
|156 ± 14*
|VE/VCO2 (L/min)
|0.026 ± 0.003
|0.024 ± 0.004
|0.027 ± 0.003
|0.027 ± 0.004
Data presented as mean ± SD or median (25 and 75% percentile); P-values from ANOVA using Bonferroni post-hoc test for multiple comparisons.
*P < 0.05 for difference vs. EAs.
§P < 0.05 vs. controls.
‡In the absence of any other arrhythmias or structural abnormalities.
Bold text highlights significant comparisons (P < 0.05).
|EAs (n = 10)
|NAs (n = 7)
|EA-VAs (n = 17)
|No ICD (n = 9)
|ICD (n = 8)
|ARVC task force criteria details
|Global or regional dysfunction and structural RV alterations
|Repolarization abnormality
|Depolarization abnormality
|Family history
|Delayed enhancement on CMR
|Ectopy observed during exercise testing
|Any ectopics
|Non-RVOT morphology
|Multiple morphologies
|Frequent ectopy (>50 ectopics)
|Non-sustained VT
EAs, endurance athletes; NAs, non-athletes; EA-VAs, endurance athletes with ventricular arrhythmias; NA, not available: signal averaged ECGs were not performed in control subjects.
aDelayed enhancement on CMR is not a recognized task force criterion for ARVC.
*P-value calculated for comparison between EA-VAs with and without ICDs.
‡P-value calculated for comparison between all groups.
Bold text highlights significant comparisons (P < 0.05).
Echocardiography at rest and during exercise
There were few differences between the groups in resting cardiac measures (Table 3). As would be expected, cardiac volumes and dimensions were greater in the athletes, consistent with typical athletic cardiac remodelling. However, there were no significant differences in functional measures of LV, RV, or haemodynamic measures (LVEF, RVFAC, RV S′, and PASP) with the exception of RV strain rate which was reduced in EA-VAs when compared with healthy EAs and NAs (P = 0.002) and RV ESPAR which was reduced in EA-VAs when compared with NAs (P = 0.011). EA-VAs had larger RV outflow tract dimensions than healthy EAs and NAs while RV inflow dimensions and atrial areas were similar among the athlete groups but larger than NAs.
|Endurance athletes (n = 10)
|Non-athletes (n = 7)
|Endurance athletes with ventricular arrhythmias (n = 17)
|ANOVA P-value
|HR (b.p.m.)
|52 ± 8
|62 ± 12
|55 ± 9
|LV IVSd (mm)
|9.7 ± 3.4
|9.7 ± 0.7
|10.6 ± 1.1
|LV EDV (mL)
|142 ± 17
|110 ± 9*
|131 ± 24§
|LV ESV (mL)
|55 ± 10
|47 ± 5
|55 ± 17
|61.0 ± 4.5
|57.4 ± 5.9
|58.6 ± 7.0
|LV strain (%)
|19.7 ± 2.6
|17.7 ± 2.3
|18.1 ± 2.8
|LV systolic strain rate (-/s)
|1.14 ± 0.20
|1.13 ± 0.07
|1.0 ± 0.12
|LV s′ (cm/s)
|8.2 ± 1.4
|8.2 ± 1.3
|7.1 ± 1.9
|RV diastolic area (cm2)
|27.1 ± 3.4
|22.1 ± 2.1*
|30.5 ± 6.1§
|RV systolic area (cm2)
|14.7 ± 1.6
|11.6 ± 1.5
|18.1 ± 5.1*§
|45.2 ± 6.2
|47.5 ± 6.1
|41.1 ± 6.9
|RV strain (%)
|26.0 ± 2.5
|27.8 ± 2.0
|23.8 ± 4.6
|RV systolic strain rate (-/s)
|1.51 ± 0.22
|1.61 ± 0.19
|1.28 ± 0.22*§
|RV s′ (cm/s)
|11.5 ± 2.4
|11.5 ± 1.6
|10.0 ± 2.1
|TAPSE (mm)
|30 ± 5
|25 ± 4
|26 ± 4
|PASP (mmHg)
|25 ± 5
|21 ± 3
|23 ± 4
|RV ESPAR (mmHg/cm2)
|1.7 ± 0.4
|1.9 ± 0.4
|1.4 ± 0.4§
|RVOTd (mm)
|33 ± 4
|32 ± 6
|39 ± 8*§
|RVITd (mm)
|46 ± 6
|41 ± 6
|51 ± 4§
|Left atrial area (cm2)
|21.1 ± 3.6
|15.8 ± 2.5*
|20.3 ± 2.7§
|Right atrial area (cm2)
|21.1 ± 4.9
|16.7 ± 4.0
|22.5 ± 3.3§
|Peak exercise
|HR (b.p.m.)
|138 ± 10
|129 ± 8
|123 ± 20
|LV EDV (mL)
|127 ± 22
|102 ± 13
|122 ± 22
|LV ESV (mL)
|31 ± 16
|30 ± 3
|27 ± 22
|74.2 ± 5.9
|70.9 ± 2.3
|69.3 ± 8.5
|LV s′ (cm/s)
|13.5 ± 1.3
|13.6 ± 2.4
|10.9 ± 3.2
|LV e′ (cm/s)
|16.9 ± 2.8
|15.6 ± 2.8
|13.6 ± 3.7
|RV diastolic area (cm2)
|25.8 ± 2.2
|20.9 ± 1.9
|30.5 ± 6.2*§
|RV systolic area (cm2)
|11.1 ± 1.6
|8.9 ± 1.0
|17.4 ± 6.4*§
|57.1 ± 5.2
|57.0 ± 5.2
|44.1 ± 10.6*§
|RV s′ (cm/s)
|18.9 ± 1.2
|20.6 ± 2.9
|14.6 ± 3.4*§
|PASP (mmHg)
|61 ± 7
|49 ± 10*
|48 ± 9*
|RV ESPAR (mmHg/cm2)
|5.7 ± 1.1
|5.6 ± 1.5
|3.0 ± 1.2*§
P-values from ANOVA using Bonferroni post-hoc test for multiple comparisons.
*P < 0.05 for difference vs. EAs.
§P < 0.05 vs. NAs.
Bold text highlights significant comparisons (P < 0.05).
Echocardiographic measures were not obtainable in all subjects at peak exercise. Doppler myocardial velocities were obtained in all 34 subjects, LVEF and RVFAC in 32 subjects (94%), and RVESPAR in 24 subjects (71%). Despite this, peak exercise measures demonstrated significant impairment in RV reserve in EA-VAs, while LV measures were similar in all groups (Table 3). Right-ventricular areas were greater while RVFAC and RV S′ were reduced in EA-VAs relative to both EAs and NAs. These differences are more rigorously defined using repeated exercise measures (Figure 1). During exercise, LVEF augmentation was similar between all groups (interaction between within-subject changes during exercise vs. between-subject groups = 0.84, Figure 1A). In contrast, exercise-induced increases of RVFAC, RV S′, and RVESPAR were impaired in EA-VAs relative to EAs and NAs (P < 0.0001 for interaction exercise × group; Figure 1B–D). Within the group of EA-VAs, those with an ICD had lower RVFAC (36.0 ± 8.1 vs. 52.1 ± 5.3%; P < 0.0001) and RV S′ (12.6 ± 2.6 vs. 16.7 ± 2.9 cm/s; P < 0.0001) at peak exercise than those without ICD (P < 0.0001). An example of exercise echocardiography comparing RV function in an EA and EA-VA is provided in Figure 2 and Supplementary material online, Video S1.
NTproBNP did not correlate with resting LV strain (r = −0.31; P = 0.09), resting LVEF (r = −0.086, P = 0.6), or peak exercise LVEF (r = −0.026, P = 0.9). In contrast, NTproBNP correlated modestly with resting RVFAC (r = −0.42; P = 0.016), RV S′ (r = −0.44; P = 0.012), and RV strain (r = −0.57, P < 0.01) but a much stronger correlation was found between NTproBNP and peak exercise RVFAC and RV S′ (r = −0.78 and −0.71 respectively; P < 0.0001; see Supplementary material online, Figure S1).
Echocardiographic measures of RV function, pulmonary artery pressures, and cardiac output demonstrated excellent reproducibility. Intra-class correlation coefficients ranged between 0.93 and 0.997 for intraobserver variability and between 0.82 and 0.98 for interobserver variability (see Supplementary material online, Table S1).
Cardiac magnetic resonance-derived cardiac volumes and invasive haemodynamics during exercise
There were no differences in resting cardiac volumes between EAs and EA-VAs reflecting the fact that abnormalities in RV structure and function in the EA-VA group were, at most, mild. As expected, RV volumes in both groups were larger than NAs (P = 0.01 and P = 0.04, respectively). All resting haemodynamic measures were similar between groups (Table 4).
|Endurance athletes (n = 10)
|Non-athletes (n = 7)
|Endurance athletes with ventricular arrhythmias (n = 9)
|ANOVA P-value
|HR (b.p.m.)
|59 ± 8
|67 ± 7
|61 ± 12
|CO (L/min)
|8.1 ± 1.0
|7.4 ± 1.5
|7.7 ± 1.7
|LVEDV (mL)
|225 ± 18
|196 ± 23*
|229 ± 24§
|LVESV (mL)
|86 ± 10
|85 ± 17
|100 ± 32
|LVSV (mL)
|139 ± 14
|111 ± 17*
|129 ± 22
|61.8 ± 3.3
|56.6 ± 5.9
|56.8 ± 10.2
|RVEDV (mL)
|237 ± 28
|200 ± 22
|233 ± 34
|RVESV (mL)
|99 ± 13
|90 ± 14
|108 ± 31
|RVSV (mL)
|138 ± 19
|110 ± 13*
|125 ± 21
|58.0 ± 2.9
|55.1 ± 3.7
|54.1 ± 8.1
|mSAP (mmHg)
|96 ± 7
|89 ± 7
|93 ± 6
|mPAP (mmHg)
|14 ± 4
|11 ± 2
|15 ± 4
|964 ± 152
|984 ± 181
|1009 ± 248
|136 ± 38
|118 ± 27
|168 ± 78
|Peak exercise
|HR (b.p.m)
|161 ± 12
|151 ± 9
|149 ± 25
|CO (L/min)
|24.0 ± 2.6
|19.5 ± 3.6
|21.5 ± 5.1
|LVEDV (mL)
|218 ± 14
|186 ± 25*
|224 ± 19§
|LVESV (mL)
|65 ± 16
|57 ± 10
|79 ± 28
|LVSV (mL)
|153 ± 17
|129 ± 18
|145 ± 21
|70.1 ± 6.6
|69.5 ± 3.9
|65.2 ± 10.0
|RVEDV (mL)
|214 ± 28
|179 ± 22*
|237 ± 27§
|RVESV (mL)
|67 ± 19
|52 ± 10
|95 ± 30*§
|RVSV (mL)
|147 ± 22
|127 ± 17
|142 ± 24
|68.7 ± 6.9
|70.9 ± 4.1
|60.3 ± 10.4§
|mSAP (mmHg)
|129 ± 10
|116 ± 10
|126 ± 12
|mPAP (mmHg)
|28 ± 7
|23 ± 6
|30 ± 10
|435 ± 67
|489 ± 89
|492 ± 136
|94 ± 31
|98 ± 29
|121 ± 74
P-values from ANOVA using Bonferroni post-hoc test for multiple comparisons.
*P < 0.05 for difference vs. EAs.
§P < 0.05 vs. NAs.
Bold text highlights significant comparisons (P < 0.05).
During exercise, CMR measures were acquired in all subjects without ICDs. At peak exercise, RVEDV and RVESV were significantly larger and RVEF was reduced in EA-VAs relative to EAs and NAs (Table 4). When repeated exercise measures were assessed, there was a clear difference between the effect of exercise on RV and LV measures in EA-VAs (Figure 3). While LV function was similar between groups (Figure 3A, C, and E), RV function was reduced during exercise. Relative to EAs and NAs, the RV acutely dilated and failed to contract adequately, as demonstrated by a relative increase in RVEDV (interaction P = 0.013, Figure 3B) and an attenuated decrease in RVESV (interaction P < 0.0001, Figure 3D). As a result, RVEF augmentation was impaired in EA-VAs compared with healthy EAs and NAs (interaction P < 0.001; Figure 3F). An example of exercise CMR comparing RV function in an EA and EA-VA is provided in Figure 4 and Supplementary material online, Video S2.
Increases in SV, HR, mPAP, and SBP were similar between the different groups (Table 4). The mPAP/CO slope was similar in EAs, NAs, and EA-VAs (0.92 ± 0.42 vs. 1.11 ± 0.46 vs. 1.23 ± 1.1 mmHg/L/min; P = 0.64; Figure 5). On the other hand, the augmentation of RV SP/ESV was reduced in EA-VAs compared with EAs and NAs (P = 0.002 for interaction), again in contrast to the change in LV SP/ESV from rest to peak exercise that was similar between groups.
As illustrated in Supplementary material online, Figure S2, there was a strong correlation between echocardiography-derived RVESPAR and CMR-derived RV SP/ESV (r = 0.84; P < 0.0001).
Impaired right-ventricular contractile reserve as a means of identifying arrhythmic risk
Receiver operating characteristic curves demonstrated that the ability of RV measures to accurately differentiate EA-VAs from healthy subjects (EAs and NAs) was relatively modest at rest using echocardiography [AUC for RV ESPAR = 0.78 (0.61–0.95), RVFAC = 0.72 (0.54–0.90), and RV S′ = 0.71 (0.53–0.90), Figure 6A] but was impressive at peak exercise [AUC = 0.96 (0.89–1.00), 0.89 (0.78–1.00), and 0.90 (0.79–1.00), respectively, Figure 6B]. When compared with rest, this represented a significant improvement in AUC for RVESPAR (P = 0.02) and a trend for improvement in RVFAC (P = 0.052) and RV S′ (P = 0.054). In the cohort undergoing ex-CMR which excluded EA-VAs with an ICD, resting CMR measures did not differentiate athletes with arrhythmias [AUC for RVESV = 0.59 (0.33–0.85), RVEF = 0.55 (0.28–0.83), and RV SP/ESV = 0.47 (0.15–0.67), respectively, Figure 6C], whereas peak exercise measures did [AUC = 0.86 (0.70–1.00), 0.78 (0.55–1.00), and 0.88 (0.74–1.00) respectively, Figure 6D]. This represented a significant improvement in AUC for all CMR measures at exercise relative to rest (P < 0.05). An increase in RVESPAR < 3.09 mmHg/cm2 from rest to peak exercise had a sensitivity = 83% and specificity = 100%, while an increase in RV SP/ESV < 0.25 mmHg/mL had a sensitivity = 83% and specificity = 88% for identifying athletes with RV arrhythmias.
Consistent with our hypothesis that pro-arrhythmic remodelling predominantly affects the RV, we demonstrated that athletes with ventricular arrhythmias develop RV dysfunction during exercise while healthy subjects do not. Importantly, this was evident despite there being few abnormalities at rest. This is of considerable clinical significance given that routine clinical assessment of athletes with suspected arrhythmias comprises cardiac imaging at rest, often with a focus on the LV. Our alternative strategy of focusing on the RV during exercise proved far more accurate in identifying athletes with potentially serious arrhythmias and offers considerable promise as a non-invasive risk stratification tool.
Understanding the context of arrhythmias in athletes; the association with right-ventricular dysfunction
Intense endurance exercise has been associated with disproportionate RV wall stress and RV injury,5,7 and we have hypothesized that this may serve as a substrate for complex RV arrhythmias.22 Given that the haemodynamic load on the RV is minimal at rest and increases disproportionately with exercise intensity,5,23 it stands to reason that exercise offers an opportunity to identify early or subtle RV dysfunction. Consistent with this premise, there were few differences between EA-VAs and EAs using conventional echocardiographic and CMR measures performed at rest. Right-ventricular outflow tract dimensions were slightly greater while RV systolic strain rate and RVESPAR were slightly lower in EA-VAs when compared with EAs but these measures were of relatively poor predictive value on ROC analysis. On the other hand, every measure of RV function was reduced in EA-VAs during exercise and this was consistently demonstrated using both echocardiography and CMR. Exercise imaging also proved more useful than rhythm analysis given that ventricular ectopics were observed in healthy athletes and those with a predisposition to arrhythmias with equal frequency. Paradoxically, frequent ectopics and non-sustained VT occurred in those athletes who had been considered at lower risk of sustained arrhythmias and had not been treated with an ICD.
Real-time CMR performed during free breathing and strenuous exercise has been rigorously validated14 and has the advantage of providing simultaneous comparisons between LV and RV function. Thus, confidence can be placed in the divergence of ventricular function observed in EA-VAs during exercise. In the LV, augmentation of systolic function (reductions in LVESV and increases in LVEF) was similar between EA-VAs, EAs, and NAs (Figure 3). In contrast, the reduction in RVESV and the increase in RVEF were significantly attenuated in EA-VAs relative to EAs and NAs. Thus, it can be concluded that the RV is disproportionately affected by exercise and our validation of this concept in humans agrees with pre-clinical rodent models in which endurance exercise promotes pro-arrhythmic remodelling of the RV, while sparing the LV.12
Consistent with previous studies, we observed a near-linear relationship between pulmonary artery pressures and cardiac output (the so-called 'P/Q relationship').5,23 This current data represents the largest published description of invasively determined P/Q ratios in young healthy subjects and confirms that mean pulmonary artery pressures frequently exceed 25 mmHg at peak exercise (Figure 5). This represents a two- to three-fold increase in systolic load during exercise which is a far greater proportional increase than for the LV and could explain why the RV is most susceptible to exercise-induced dysfunction.
Exercise echocardiography or cardiac magnetic resonance?
Exercise-induced RV dysfunction in EA-VAs was consistently observed across imaging modalities. Furthermore, there was a strong inverse correlation between measures of RV function at peak exercise and NT-proBNP (see Supplementary material online, Figure S1) and also a strong correlation between RV contractility as determined by echocardiography and ex-CMR (see Supplementary material online, Figure S2). Thus, the question arises as to which imaging technique is better. Despite expectations of more accurate quantification of RV function with exercise CMR, it did not prove better than echocardiography at identifying athletes with subtle RV dysfunction and arrhythmias (Figure 6). Given the widespread availability and cost-effectiveness of echocardiography, this is an important finding. While a focus on RV measures is not commonly practiced, the measures employed in this study are relatively simple and could easily be included in clinical routine. During exercise, RVFAC and RV S′ were obtained in the majority of subjects and could accurately identify athletes with arrhythmias (Figure 6B). The strongest echocardiographic measure was RVESPAR but its clinical utility may be limited by the fact that it was measurable in only 71% of subjects. In contrast, high-quality images can be acquired by Ex-CMR in virtually all subjects but the technique remains expensive and confined to few specialized centres. Although the areas under the ex-CMR ROC curves seemed inferior to those of echocardiography, direct comparison is limited by the fact that athletes with an ICD had to be excluded from CMR assessment. Thus, the ex-CMR study group was smaller and those athletes with the most profound exercise-induced RV dysfunction on echocardiography were excluded. Device exclusions would not be an issue for new presentations in which risk assessment is required and ex-CMR may be an extremely useful adjunct to standard resting CMR performed to exclude structural pathology in athletes with arrhythmias.
Clinical utility of right-ventricular stress testing to identify athletes with arrhythmias
It can be extremely difficult to determine the significance of palpitations, isolated ventricular extra-systoles, or non-sustained VT in athletes, particularly when traditional cardiac imaging suggests that cardiac morphology and function are normal. From a population of 1644 screened athletes, Dello Russo et al.24 identified 17 athletes (1%) with frequent ventricular ectopy or non-sustained VT but normal cardiac structure and function by conventional measures. As a means of risk stratification, electro-anatomical mapping and a guided ventricular biopsy was performed revealing myocardial inflammation, fibrosis, and/or fatty infiltrates in 13 of 17 athletes. Right-ventricular angiography25 and inducibility during an electrophysiology study2 may also have some prognostic utility. However, ventricular arrhythmias may be identified in 1–3% of endurance athletes1,24 and the risks associated with these invasive techniques are not insignificant. There is clear need for a non-invasive means of differentiating healthy athletes from those with potentially serious ventricular arrhythmias. In this context, both exercise-CMR and echocardiographic RV stress testing show promise. Receiver operating characteristic curve analyses demonstrated that resting measures of RV function were poor at distinguishing athletes with complex arrhythmias from healthy subjects but that exercise measures were reasonably accurate (Figure 6).
Current clinical recommendations suggest that the absence of structural heart disease is a critical factor in determining the athlete's management and prognosis,26 but the manner in which structural heart disease should be excluded has not been established. Echocardiography and CMR are frequently used in these settings but emphasis tends to be placed on LV measures and imaging is performed at rest. Our current data suggest that this is a flawed practice with poor sensitivity for identifying athletes at risk of serious arrhythmias. We contend that exercise imaging with a focus on RV measures is a critical component of risk stratification in athletes in whom arrhythmias are suspected. Furthermore, there is considerable overlap between the subtle RV changes described here in athletes and those which occur in other cardiac pathologies such as ARVC. As far as we are aware, there are no studies investigating the utility of exercise imaging for ARVC but our data provide strong rationale for such investigations.
Our cohort was of modest size and comprised new cases of athletes with arrhythmias as well as cases previously assessed and managed at our institution. As a result, many of the athletes had received treatment including detraining, anti-arrhythmics, and ICDs. This introduces significant confounders in comparisons with the control subjects. However, anti-arrhythmic, beta-blocker, and calcium channel blocking medications were withheld for at least 24 h prior to exercise testing; a period sufficient to exclude any persisting pharmacodynamic effect. Two athletes were treated with low-dose Amiodarone which may have caused some negative chronotropic effect but would not have been expected to affect measures of biventricular function. As discussed previously, the exclusion of subjects with ICDs may have resulted in underestimation of the extent of RV dysfunction in the EA-VA cohort. Furthermore, there was significant heterogeneity among the cohort in terms of the burden and complexity of the arrhythmias, degree of RV remodelling, and the amount of prior athletic training. Nonetheless, this represents the largest comparison of athletes with and without ventricular arrhythmias to date, and the only study to investigate exercise measures in this setting.
In EAs, VAs are associated with RV dysfunction which is most appreciable under the haemodynamic stress of exercise. In athletes with ostensibly normal cardiac function at rest, echocardiographic and CMR measures of RV function performed during exercise show promise in being able to differentiate healthy athletes from those with a propensity to serious VAs.
Supplementary material
Supplementary material is available at European Heart Journal online.
This study was funded by a grant from the Fund for Scientific Research Flanders (FWO), Belgium. A.L.G. is supported by a Career Development Scholarship from the National Health and Medical Research Council (NHMRC-1089039) and a Future Leaders Fellowship from the National Heart Foundation (NHF-100409) of Australia.
Conflict of interest: none declared.
- Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: email@example.com.


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Grilled Vegetables with Sun Dried Tomato Vinaigrette
- 4 sundried tomatoes, in oil, chopped
- 1/4 cup red wine vinegar
- 3 garlic cloves, smashed
- 2 tablespoons basil chiffonade
- 1/2 cup olive oil
- Salt and freshly ground pepper
- 2 portobello mushrooms, cleaned and stems removed
- 1 small head fennel, quartered
- 4 artichokes, cleaned and quartered
- 1 yellow zucchini, quartered
- 1 green zucchini, quartered
- 1/4 cup olive oil
- Salt and freshly ground pepper
Place tomatoes, vinegar, garlic and basil in a blender and blend until smooth. Slowly add the olive oil until emulsified. Season with salt and pepper to taste. Preheat grill. Brush the vegetables with olive oil and season with salt and pepper to taste. Grill until cooked through. Arrange on a platter and drizzle with tomato vinaigrette. Turn each slice over, sprinkle with parsley and grill an additional 20 seconds
Recipe courtesy of Bobby Flay

subset: commoncrawl


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The Farm on Adderley
Brooklyn, NY 11218
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Malted and Mashed: Finger Lakes Distilling at The Farm on Adderley
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On Tuesday night, Ditmas Park's The Farm on Adderley (1108 Cortelyou Road, Brooklyn, 718-287-3101) hosted Brian McKenzie of Finger Lakes Distilling for a cocktail-paired dinner featuring the upstate distillery's refined hooch as par...
Get My Goat Party in Photos
Monday, October 28, 2013 at 3:30 p.m. by Fork in the Road
In an effort to entice more Americans into eating goat, Heritage Foods declared October "Goatober," and it teamed up with the Farm on Adderley (1108 Cortelyou Road, 718-287-3101) to throw a party celebrating this animal, a popular m...
Get My Goat: Celebrate Goatober at The Farm on Adderley
Thursday, October 24, 2013 at 11 a.m. by Deena Shanker
If you thought beer was the only consumable thing celebrated in October, we've got news for you: The month has also been dubbed Goatober by the fine people at Heritage Foods, and Ditmas Park restaurant The Farm on Adderley (1108 Cor...
Ditmas Park Celebrates Neighborhood Eats During "Cortelyou at Twilight" [PHOTOS]
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1. Seton Hall and Cincinnati have as legitimate a shot to finish second in the Big East as any other teams. Both are veteran squads and are making winning plays late in games. The schedule is also kind. Nothing is a given, but the Hall doesn't play Syracuse again (lost at Carrier Dome), won't go to West Virginia (won at home) or Georgetown (Feb. 21 at home). A trip to UConn on Feb. 4 still remains. Cincinnati gets Syracuse once – at home (as well as the Hall). A trip to UConn and West Virginia Jan. 18-21 looms large. The rise is a credit to both the Hall and UC, but it also shows how the Big East is sagging with key programs (Louisville, Pitt, Villanova) suddenly down.
2. Michigan State has had so much drama the past few seasons that's eerily quiet now with the Spartans. The only issue was in the offseason when Delvon Roe had to retire due to injuries. Tom Izzo has a leader in top big man Draymond Green, guards that get along in Brandon Wood and Keith Appling, freshmen who contribute without a problem and more frontcourt depth than any other Big Ten team. The Spartans are now winning handily the games they should and have the karma going in their favor for a run at the Big Ten title.
3. Frank Martin's honesty is so refreshing whether Kansas State is winning or losing, if it's an off day, game day or in the aftermath of a tough loss. He is a tremendous character who is great for the game and of course for those of us in the media. There is nothing vanilla about Martin. He wasn't pleased with the defense in the loss to Baylor on Tuesday and he didn't hold back. Kansas State went 1-2 against the toughest three-game stretch of any team in a major conference (losing at Kansas, beating Missouri and losing to Baylor).


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7 posts tagged with bicycle and sanfrancisco.
Displaying 1 through 7 of 7. Subscribe:
San Francisco bike questions
I'll be travelling to San Francisco for a conference the last week of May and I'd like to rent a bicycle and bike around a bit. Any bike-related stuff going on then? This and other bike questions inside. [more inside]
How do I stop being so paranoid about my bike being stolen?
I live in San Francisco and just started biking. Whenever I bike somewhere and lock up out of sight, I start worrying about my bike being stolen. I know it won't actually suck that much when it happens (I'll be pissed, then get a new bike). How do I stop thinking of my bike as "that expensive popular-to-steal thing I just left outside oh no?" [more inside]
Going to San Francisco and Portland; what am I doing?
Planes and Trains and Bikes, oh my! or, Going to San Francisco and Portland for a week and a half; what should I do and see and eat? [more inside]
I have foolish dreams of pedaling to used bookstores and coffeeshops on June afternoons
Is there anywhere in the SF Bay Area where I could rent a bicycle long term? [more inside]
Neither co-optin nor hatin.
Looking for a commuting bike for San Francisco. I have about $1000 to spend and am considering a single speed. Details on that, plus my commute, inside. (And yes, I have seen this and this. [more inside]
Mama's tired after her run-in with the law, children.
SFBikeLawFilter: I got pulled over and ticketed on my bike for starting against a red light. I am not planning on contesting the ticket, but I'm having trouble finding out what to expect in terms of traffic court and fine. The Bike Coalition's info is sort of outdated and Google isn't turning up much that's solid. YANAL and/or YANML but I'd appreciate some help. [more inside]
Help a first time bike courier
Help me be a bike / bicycle messenger / courier in San Francisco [more inside]
Page: 1


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Takata's remaining two bidders to seek court-led turnaround in Japan, report says
Takata's two remaining bidders plan to propose a court-mediated turnaround for the Japanese operations of the troubled airbag supplier, the Nikkei business daily reported.
EPA nominee Pruitt to review vehicle emissions rules
Oklahoma Attorney General Scott Pruitt, President-elect Donald Trump's choice to lead the EPA, said he will review the Obama administration's recent decision to lock in fuel efficiency rules.
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This is a summary. To read the whole story subscribe to BostonGlobe.com
Thousands of property owners in Essex County and across the Bay State could be affected by FEMA's nationwide redrawing of flood maps, many of which haven't been updated since the 1970s.
The move is aimed at shoring up the troubled federal flood insurance program, which is nearly $24 billion in debt.
Under the Flood Insurance Reform Act of 2012, passed by Congress last summer, FEMA is required to redraw the boundaries and phase out decades-old insurance subsidies for owners of homes that were built in high-risk flood zones before the original federal flood zone maps were created, among a litany of other changes.
But many homeowners now find themselves in flood zones for the first time, facing the likelihood of having to pay hundreds or even thousands of dollars in premiums for flood insurance or see rates increase by more than 25 percent.


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Prices are being cut on groceries, electrical items and furniture, with stores suggesting the offers will last throughout January and beyond.
Experts said the cuts were part of a deliberate move by supermarket chains in preparation for a "shock wave" which could see a slump in sales following strong trading during Christmas.
They suggested stores were "nervous" about a sharp slowdown in customer spending in the New Year due to the rise in VAT.
Value Added Tax was cut last year from 17.5 per cent to 15 per cent but has since returned to its former level.
VAT is not charged on essential food items, such as bread and cheese. However, a rate of 17.5 per cent is charged on luxury items such as alcohol and crisps.
Mark Guymer, head of shopping at price comparison website Moneysupermarket.com, said: "Stores are preparing for a shock wave, with VAT rising and customers returning to a more cautious approach.
"Stores are nervous and it is part of a well thought out strategy to grow their customers base during what they anticipate will be a tough January."
In addition to Tesco and Asda, Sainsbury's has more lines reduced and at half price than ever before, with its sale lasting until February 10.
Deals include all bedroom furniture and upholstered sofa's and chairs within Sainsbury's range at half price.
It is the breadth of Asda's price cuts which are making the discounts the biggest for a decade, with the store cutting one in five products.
It means the price of 3,600 essential items – including potatoes, carrots, grapes, bananas, milk, nappies, rice, bread, cheese and yogurt – will fall throughout January.
The prices of bananas are being cut from 98p to 77p per kilo, while the cost of seedless white grapes is being reduced from £4.47 to £1.77 per kilo.
A spokesman for Asda said: "Some customers also told us they were worried about prices going up due to VAT but as these cuts show our pricing plans for 2010 already far exceed the impact of any VAT increases."
Tesco is offering special deals on 12,000 groceries, saving a typical shopper £7.56 on a basket of everyday items, including bananas, tea, beer, meat and fish, compared to a year ago.
Savings will also be available on non food lines such as an Acer 4GB, 15.6 inch laptop, which was £497, now £397, and a Garmin Sat Nav, 215W, which was £149.97, now £99.97.
Richard Brasher, Tesco's commercial and marketing director, said: "The cost of shopping is as important to customers as we move into 2010 as it has ever been."
- Asda:
Bananas were 98p, now 77p per kilo
Seedless white grapes were £4.47, now £1.77 per kilo
Hovis White Bread Mix was 74p, now 54p
Milk 4 pints was £1.53, now £1.23
- Tesco:
Baking Potatoes 2.5kg were £1.92, now £1
Ripen at Home Nectarines were £2.99, now £1.49
Danepak Maple Cure Back Bacon 220g was £3.00, now £1.50
Princes Tuna Chunks In Brine 4 x 185g was £5.39, now £2.69
- Sainsbury's:
JS Butchers Choice large pork sausages were £1.99, now 99p
JS British honey roasted ham joint was £10.99, now £5.49


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In a recent article, I described the Greek parliament's upcoming vote on 13.5 billion euros in new spending cuts and tax increases as a "make or break" type event for the market. Although I have attempted to explain why the coming weeks are absolutely critical for Greece, Greek Prime Minister Antonis Samaras' characterization of the two alternatives facing the country in the event of either a negative or positive vote make my portrayal seem rather meek. Recall that last week, Samaras said:
" ..The problem is not whether we [introduce] this measure or that measure. On the contrary, it is what we would do if no agreement is reached and the country is led into chaos." (emphasis mine)
So chaos awaits if parliament votes 'no' (a contention I actually agree with although I'm not sure it will happen as quickly as Samaras seems to be suggesting). Now consider what the Prime Minister predicts will happen should the new package and budget get parliamentary approval:
As soon as the new measures are passed and we get the critical aid tranche, liquidity will start again to feed businesses and households, uncertainty will end, sentiment will change... the fear of a return to the drachma will disappear...[and] all this (talk of Greece exiting the euro) will end irreversibly.
Now that is the definition of make or break. Of course it is also profoundly unrealistic. Greece will not revert to a state of nature immediately should the vote not pass and a rainbow will probably not appear over the Athens Parliament House to give the "all clear" in the event the vote passes. The fact is that no matter what the outcome, Greece will remain mired in a deep recession for years and the specter of a 'Grexit' will hang over the Parthenon for quite some time.
Take it from Angela Merkel who, in stark contrast to the hopeful tone struck Sunday by Samaras, told her Christian Democratic Party Saturday that
...whoever thinks [the debt crisis] can be fixed in one or two years is wrong.
Specifically, Merkel predicts the crisis will drag on at least until 2018.
The new projections for Greece's debt revealed last Tuesday showed that instead of topping out near 170% of GDP, the country's debt will now likely hit 192% of GDP in 2014. It is difficult to imagine that no one will be talking about a 'Grexit' past next week as Samaras predicts in the event the votes are positive.
To some, all of this talk about a Greek exit and a subsequent reverberation through the world's financial system is just scare tactics. This is easy to say from the cozy confines of a country not struggling under 25% unemployment and social and political upheaval.
In fact, according to the CIA World Fact Book, as of 2009 (so you can probably go ahead and assume the stats have gotten far worse since then), more people lived below the poverty line in Greece than in Bosnia and Herzegovina in 2007, Iran in 2007, Jamaica in 2009, and the West Bank in 2010. This point was originally raised on ZeroHedge, but it bears repeating here because the dates for the comparison countries' estimates weren't listed in their post, so it didn't paint the clearest picture as to exactly what was being compared to what. The real question here is what the figure is now for Greece if it was 20% in 2009 and 20% in 2010. If the figure has risen by just 5%, the same number of people would be living under the poverty line in Greece as in Iraq in 2008 and Uganda in 2009.
Now given this, investors should ask themselves if this situation is likely to get better or worse going forward given the new estimates for Greek debt-to-GDP. It would seem that doubts about the country's ability to remain in the euro will undoubtedly persist and while there may well be a general consensus that it would be better for the stability of the worldwide financial system if Greece did not leave the euro, there simply is no agreement as to who will foot the bill for keeping it in the currency union. As the Wall Street Journal so eloquently explains:
All creditors agree that Greece's debt is unsustainable. They also agree that someone will have to take a loss. They all insist that the said someone is someone else.
So this brings me back to the point I raised previously. Private holders of Greek debt say they will never be asked to take another haircut because the portion of Greek debt held in private hands is inconsequential as a result of the original PSI, therefore buying Greek bonds is a good idea. Eurozone governments say they can't take a writedown because it may be illegal, therefore people assert there is no reason to worry about a domino effect. The ECB says it can't take a writedown because to do so would be monetary financing, therefore the assertion is that the ECB's balance sheet is safe. Finally, the IMF is senior so it can't take a haircut - period. Nonetheless everyone seems to think that Greece will not be allowed to exit the euro.
All of these scenarios simply cannot coexist. Someone has to take a loss here - that's all there is to it. Either private creditors get hit again, eurozone governments get hit, the ECB gets hit, or Greece exits and everyone gets hit. Anyway you slice it, this isn't going to end well. Those who think the fate of Greece will have only a negligible effect on the U.S. financial system (and by extension U.S. equities) are, in my opinion, exhibiting a misplaced sense of American exceptionalism which, if they don't protect their portfolios with put options or long positions in volatility, will prove detrimental to their financial well-being. As strange as it may sound, "so goes Greece, so goes Spain and Italy." And that, readers, is where the real damage will be done.
Disclosure: I have no positions in any stocks mentioned, and no plans to initiate any positions within the next 72 hours. I wrote this article myself, and it expresses my own opinions. I am not receiving compensation for it (other than from Seeking Alpha). I have no business relationship with any company whose stock is mentioned in this article.


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10 Years Ago: Bob Seger Gets Back on the Road After a Decade Away
After becoming one of the most popular touring acts in the world, Bob Seger stayed away from the stage for an entire decade.
After becoming one of the most popular touring acts in the world, Bob Seger stayed away from the stage for an entire decade.
After five years away and some personal turmoil, Bob Seger released 'The Fire Inside' on Aug. 27, 1991.
Bob Seger sports one of the most mysterious catalogs of any major rock star, but have no fear we've sorted it all out for you.
The 1976 double-album Live Bullet captures Bob Seger precisely at the midpoint of his transformation from rock 'n' roll journeyman to arena-rocking celebrity.
Bob Seger achieved full-fledged rock stardom with 1976's Night Moves, but while his raspy howl may have been new to a generation of fans, he'd actually been chipping away at mainstream success for many years.
Glenn Frey's recent death has left Bob Seger mourning the untimely loss of a lifelong friend.
Just a little more than a year after releasing his most recent album, Ride Out, Bob Seger is already gearing up for a new release and another tour.
Stephen Colbert showed up on a Michigan public access cable show that included a chat with Eminem, who found himself on the receiving end of a Bob Seger pop quiz.
Bob Seger's new 'Ride Out' album is a Top 5 hit in the U.S., but it looks like it won't even have a chance to top the Australian charts.
The extensive series of tour dates Bob Seger has lined up in support of his new hit record 'Ride Out' won't begin until late November, which means he'll be home to enjoy Halloween with his family.


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Losing the Thread: Joyful Wit and Wisdom for Today's WomanAlie Stibbe
Here is a wealth of diverse quotations, mostly by women, to illuminate the world of Christian women. Funny, shrewd, compassionate, and penetrating, the quotations and anecdotes are carefully laid out so that the book serves both as a resource and as a handsome gift. This is ... Read More
More From: Alie Stibbe
"The older I get the greater power I seem to have to help the world; I am like a snowball . . . the further I am rolled the more I gain." -Susan B Anthony
"I never go out unless I look like Joan Crawford the movie star. If you want to see the girl next door, go next door." -Joan Crawford
"Even I don't wake up looking like Cindy Crawford." -Cindy Crawford
- Product type: Book
- Format: Book
- Release Date: Jan 31, 2010
- Height: 0.50
- Width: 6.70
- Length: 9.10
- Volumes/Discs: 1
- Pages: 240
- Publish Date: Jan 1, 2010
- Language: English
- Audience Age Maximum: 100
- Audience Age Minimum: 18
- Audience Gender: Female
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We are engaged in internationally leading materials processing and forming research addressing some of the global healthcare and manufacturing challenges. Research sponsors include the UK Research Councils (mainly EPSRC), Orthopaedic Research UK, The Royal Society, The Wolfson Foundation, The Leverhulme Trust, The Islamic Development Bank, The Danish Agency for Science, Technology & Innovation, The Worshipful Company of Armourers and Brasiers and several industries. We enjoy close ties with the UCL School of Pharmacy (https://www.ucl.ac.uk/pharmacy). Clinical work is carried out in conjunction with the Eastman Dental Insititute, the Division of Medicine and hospitals affiliated with UCL.
5) We are also working on another set of projects with clinicians in Moorfields Eye Hospital and Professor Anthony Harker ( http://www.ucl.ac.uk/~ucapahh ) on blepharoptosis, with Professor Yiannis Ventikos - http://www.ucl.ac.uk/mecheng/people/academic-staff/yiannis-ventikos (on modelling our processes and inventing related but new approaches) and the TopInstitutes of Food & Nutrition in Holland (new food material microstructures for preventive healthcare).
2) To exploit the patented process of depositing textured bioactive islands supported by JRI Ltd.:
6) Currently, we are also developing a patented new mobile electrohydrodynamic gun-device to deposit wound dressings and drug delivery vehicles/patches.
It is also being exploited commericially to treat urinary tract infections.
featured on a journal front-cover and attracted an exceptional altmetric score of 10.
1) To explore the patented pressurised gyration process which can manufacture fine fibres:
which was awarded a 2013 Royal Society Brian Mercer Feasibility (Innovation) Award. See:
4) We have just initiated an EPSRC supported network:
This included 10 industrial partners and 12 academic partners and aim to promote pharmaceutical electrohydrodynamic technology.
Biomaterials Processing Laboratory
Professor Mohan Edirisinghe


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Who should the focus be on in DOFP??
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High Evolutionary
Join Date: Nov 2003
Location: Genosha
Posts: 14,037
Re: Who should the focus be on in DOFP??
Well, perhaps they could use SOME of the original trilogy characters to bring in mainstream interest and provide support for the newer, unfamiliar characters.
Of all the First Class characters, I'm interested in Magneto, Emma Frost, Havok, Banshee and Xavier.
I don't know how on earth they are going to make Jennifer Lawrence's Mystique grow into Rebecca's version; it's going to need several films to make that transition from insecurity to being a cold, hard, kick-ass reptile. And I don't think they will ever give us the luxury of several films focusing on the First Class cast.
While I would like to see the First Class series give us young versions of Scott, Jean and Storm and the introduction of Polaris, I don't know if they will bother with that.
Batman v Superman 6/10, Captain America: Civil War 7.5/10, Deadpool 8/10, X-Men: Apocalypse 8/10, X-Men: Days of Future Past 9/10
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This full website whois and analysis report on Frederictonchamber.ca was ran on January, 20, 2017.
We include detailed information like the server IP Address which is 22.214.171.124. Frederictonchamber.ca resides at Cloud Communications, LLC in Arlington Heights, IL, United States.
The official title of Frederictonchamber.ca is: Fredericton Chamber of Commerce - The Voice of Business - Home
The official description of Frederictonchamber.ca is:
custom description for seo
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Craryville NY Real Estate & Land for Sale
1 Properties Found
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Pumpkin Hollow Rd North Craryville, NY 12523
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text:
J and E Hall Gold Medal
Deadline for nominations extended to 4th November 2016
Download the nomination pack here
This internationally respected award recognises the most noteworthy practical contribution to the field of refrigeration. The award, which has been sponsored by J&E Hall International consistently for 39 years with a prize award of £5,000, is open to individuals or teams with recent outstanding achievements in one or more of the following areas:
The 2015 award was made to Ian Tansley, Chief Technical Officer of SureChill Company Limited. Ian is a leading figure in the renewable energy industry where he is addressing the issue of providing reliable cooling with an intermittent or erratic power supply. His vaccine refrigerator operates without the need for a constant power source and avoids the use of costly and unreliable solar rechargable batteries using water based cooling technology. The World Health Organisation has approved medical refrigerators using this technologyand it is already having a major impact on child health worldwide, helping to save lives in some of the most difficult environments on earth. Ian will give a paper detailing the technology and its potential for commercial application in a paper to members next year.
Previous Award Winners
2014 - REINARD RADERMACHER whose work has pushed the research frontiers by exploring new technologies and developing them for real life applications. He is a world authority on energy efficiency and environmentally sustainable thermal systems research. The simulation packages developed under his direction are used by more than 60 organisations worldwide and have helped to enable researchers, policy makers and designers to analyse life cycle estimate of natural and low GWP refrigerants.
2013 - RUZHU WANG received the award for his work in research and application of heat pumps using low grade heat sources. The award was given in recognition that his work provided the widest range of practical innovations for heating and cooling for both buildings and other applications. It provides a method of using solar heating to drive adsorption - thus propelling the feasibility of solar powered cooling for the future.
2012 - ROBERT HADFIELD for his work in the advancement of the practical application of infrared single-photon detector technology in closed-cycle refrigerator systems, eliminating the need for liquid cryogens, and for the work to commercialise this technology for use in the National Physical Laboratory and in commercial companies in medical diagnostics. This is a unique development that will support the advancement of physics and medical science in a vast range of applications and is an example of refrigeration technology advancements supporting the development of other practical sciences
2011 - PEGA HRNJAK for his work on the practical application of innovation as the Director of their Air-Conditioning and Refrigeration Centre at the University of Illinois and a private commercial research facility which focuses on thermal systems ranging from nano-technology to large industrial equipment.
2010 -DONALD CLELAND for his achievements in For his achievements in technology transfer related to food refrigeration and efficiency research. Examples of his original contributions include predicting the effect of shape on rates of food heating and cooling; determining moisture sorption characteristics of food packaging, measuring air infiltration into refrigerated spaces and quantifying latent heat loads in refrigerated facilities. Recently his work has expanded to cover fluorocarbon replacement by hydrocarbons in farm milk cooling vats and the development of industrial heat pumps using carbon dioxide.
2009 – JURGEN SEUSS for his achievements in carbon dioxide compressor development and application in light commercial refrigeration. This includes the development of the TN Compressor which has a matching control device – a technology which has achieved significant practical application in bottle coolers, vending machines, display ccases and high efficiency domestic hot water heat pumps.
2008 - RON CONRY designed from scratch a compressor that would meet all of the industries needs for the future - high efficiency, operating at high speed, oil free, light weight, quiet, without vibration, and fully integrated and cost competitive. To date over 10,000 Turbocor compressors are now in operation worldwide and he continues to develop this technology to achieve even further efficiencies and new models. The Judges made this award to Ron Conry of Turbocor for his achievement in seeing this vision through to realisation of the Turbocor compressor.
2007 - PROF JOHN THOME of the Laboratory of Heat and Mass Transfer, Swiss Federal Institute of Technology in Lausanne, Switzerland.The 2008 award went to an individual who has carried out wide ranging work on two-phase flow and heat transfer of refrigerants as well as original work on the development of micro evaporation cooling systems, which have practical applications in low
2006 - Dr ANDY PEARSON of Star Refrigeration for his work on the practical development of safe and relatively uncomplicated application of carbon dioxide to both commercial and industrial systems, enhanced through detailed examination of supercritical heat transfer behaviour, plate heat exchanger design, system component application and system design specific to carbon dioxide.
2005 - PROF IAN EAMES for his work on for his work on the application of jet pump cycle technology to substantially improve the performance of standard absorption refrigeration methods leading to enhanced COPs and reduced system costs and resulting in commercial manufacturing acceptance
2004 - PROF CLARK BULLARD As a Professor at the University of Illinois, USA, Dr Bullard has carried out wide ranging, original work using simulation models to develop improved systems for refrigeration and air conditioning, influencing the design of heat exchangers, evaporators, condensers, accumulators and compressors.
2003 - DR RAKESH AGRAWAL Dr Agrawal has carried out outstanding work in the field of cryogenic air separation technology for gas liquefaction systems. He is the holder or co-holder of 116 US Patents, (102 of them in Cryogenics) and over 300 foreign patents. He has made truly extraordinary contributions to the development of gas liquefaction and cryogenic separation technologies.
2002 - PROF ALBERTO CAVALLINI Throughout his career, the research of Dr Cavellini has always been broad, ranging over several topics related to heat transfer, refrigerants and AC&R equipment, engineering thermodynamics and applied acoustics. However his work on condensation heat transfer and pressure drop with refrigerants has been his core research activity.
Previous winners - 2001 - DR D DIDION; 2000 - DR AC CLELAND; 1999 - MR M LAWRENCE; 1998 - DR R RADEBAUGH; 1997 - NORMALAIR-GARRETT LTD, UK; 1996 - MR S SUNDARESAN; 1995 - DR J PAUL AND MR E JAHN; 1994 - DR A FUTAKAWA; 1993 - DR F FRANKS; 1992 - PROFESSOR K. WATANABE; 1991 - DR S.F. PEARSON; 1990 - PROFESSOR K. STEPHAN; 1989 - PROFESSOR P.O.FANGER; 1988 - PROFESSOR R.L. WEBB; 1987 - DR C. BAILEY; 1986 - DR W.R. MALEWSKI; 1985 - PROFESSOR W.F. STOECKER; 1984 - PROFESSOR G. LORENTZEN; 1983 - PROFESSOR G. GLEW; 1981 - MRS M.M. DOYLE; 1979 - DR H. SIXSMITH; 1978 - DR A.D. APPLETON; 1977 - B. ZIMMERN;
Award rules and how to nominate
1. The J&E Hall Gold Medal was initiated by Hall-Thermotank Ltd in 1977 as the Hall-Thermotank Gold Medal to mark the centenary of the company's involvement (originally as J&E Hall Ltd) in the field of refrigeration in 1877.
2. The Institute of Refrigeration will award the Gold Medal annually to the person considered to have made the most noteworthy contribution to the advancement of refrigeration and related technologies.
3. The Institute shall have the authority to withhold the award in any year if it considers that none of the nominations is of a sufficiently high standard.
4. The winner of the award each year will be presented by the sponsor with:
5. The award will be international and nominations will be accepted from all parts of the world.
6. Nominations may be made by any organisation or individual, with the permission of the nominee. Individuals may nominate themselves but such nominations must be authenticated by another responsible person with sufficient knowledge to do so. Nominations for work carried out by more than one person will be accepted but no more than two people will receive the award each year.
7. Each nomination must be supported by evidence of the contribution or achievement on which the nomination is based. This should take the form of a statement, in English, not exceeding 1,000 words with such supporting documentation and illustrations as may be necessary. The volume of evidence should be kept to the minimum necessary. The panel shall be empowered to call for additional evidence if they so wish.
8. All nominations received by the due date will be considered by a Panel chaired by the President of the Institute of Refrigeration, or his appointee and comprising four other members chosen annually by the Institute.
9. The Panel shall be empowered to call on specialist advice if it so wishes.
10. In considering the nominations, the Panel will pay special regard to the practical nature of the contribution on which the nomination is based and to its originality. Work of a theoretical nature may be accepted provided its practical viability can be clearly demonstrated.
11. The contribution cited in the nomination need not necessarily have been made within the preceding year. Work carried out over an extended period will be admissible but there should be some evidence to indicate that it has reached its culmination, or that its significance has become apparent relatively recently.
12. The Panel will bear in mind that the purpose of the award is to encourage progress rather than to acknowledge past achievement.
13. The Gold Medal will not be awarded to the same person for two years in succession.
14. The winner will normally be expected to attend a presentation ceremony in London. He or she may be asked as a condition of acceptance to present a paper to the Institute of Refrigeration.
15. The decision of the Panel on any matter will be final.
16. Nominations should be addressed to The Secretary, at the Institute of Refrigeration.
17. Nominations must reach the Secretary of the Institute not later than the date specified on the nomination form each year. An announcement of the award will be made on the occasion of the Institute's Annual Dinner.
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iHerb Customer Reviews
Savings of: $0.55 (16% off)
Great product!
Posted by 5598399106105531991 on Aug 02, 2016
I love Preserve containers: great quality, the screw top is really convenient, the shape is great and so is the colour. They're so easy to clean (they are dishwasher safe, but you won't need a dishwasher to clean them: the interior is so smooth you can literally just rinse them with water), odourless and without a scratch after months of everyday use. I have 8 of them (not kidding!) and I keep buying more for my friends. :)
food storage
Posted by Reviewer4you on Jun 29, 2012
Happy with it. Size is enough for small taken lunch to work. No problems with the lid. Nice design and color.
Está muy bien
Posted by rocioes on Jun 09, 2015
No sabía que había este tipo de envases ecológicos, en España no son fáciles de encontrar. Me gusta bastante aunque el precio es un poquito elevado. El material es bastante resistente
Very good quality
Posted by MariaDeleva on Feb 18, 2016
The cup is of very good quality plastic - I like it.
Small food storage
Posted by 5244912328962143881 on Apr 08, 2014
Very handy! Great to bring small lunches and snacks!
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I use it all the time! good for everything small. I recommend you to buy the large one good quality US product.
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Nice quality!
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Nice box


text:
Why should home care be the theme on Understanding and Remembrance Day for Severe ME on August 8? Helen Brownlie of the 25% ME Group has written an explanation for Phoenix Rising ...
Discuss the article on the Forums.
William Switzer - CDC looking for XMRV and MLV in lab workers!
Discussion in 'XMRV Research and Replication Studies' started by CBS, Mar 4, 2011.
Page 5 of 9
Page 5 of 9


text:
More Nikon D800 Details Leaked
It has been more than three years since the release of the 12-megapixel Nikon D700 full-frame DSLR camera. Following the leaked specs of the rumored D800, the first product pictures of the purported D700 successor have now surfaced on Nikon Rumors.
According to the rumor website, the D800 would be smaller and lighter than the D700, has a 36-megapixel sensor, 51-point AF system, USB 3.0 support, and does 1080p30/25/24 video recording. Judging from the dedicated live view button and still/video switch at the rear of the camera, it's natural to assume that video recording is going to be a key feature of this camera.
D700 users, maybe it's time to save up?
Source: Nikon Rumors
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When this season kicked off nine months ago in neighboring Bahrain, we knew it was going to be a close one. Ferrari had a two-time champion at the helm and a hungry wingman to match. McLaren had the reigning champions from the past two years in what was dubbed a "super team." Brawn GP was bought by Mercedes-Benz, which then brought the most successful driver in F1 history out of retirement. Meanwhile, Red Bull was riding the crest of a fairy-tale ascension that only narrowly failed to materialize the year before. Yes, we knew it'd be close, but not this close.
Heading in to the season finale this weekend in Abu Dhabi, the constructors' championship had just been decided, but the drivers' title was still up for grabs. And for the first time in sixty years of Formula One history, it was down to an unprecedented four drivers. Fernando Alonso looked poised to take his third title, but both Mark Webber and Sebastian Vettel were still well in contention for their first, while Lewis Hamilton looked at slim – but still possible – chances at claiming his second. It was down to the line, and for all the marbles. Follow the jump to find out who was crowned champion, and how.


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Horror in Connecticut
Latest update: December 16th, 2012
On Friday, Adam Lanza (20) stormed into Sandy Hook Elementary School in Connecticut and killed 20 children.
He began his day fighting with his mother, who he shot in the face with a gun she had legally bought. He then headed over to the kindergarten where his mother taught. It was initially thought that Lanza was allowed into the school because they recognized him, but investigators are now saying they think he forced his way in.
He then shot the the school principal, a school psychologist and three other teachers who were holding a meeting, killing them all and wounding one other person.
After that he walked into a kindergarten class and opened fire killing 18 children and their teacher. Two additional children died in the hospital.
A school custodian ran through the school warning about the shooter, and someone else managed to get on the PA system letting the rest of the school know something was wrong.
Lanza then shot himself in the head.
Lanza was described as shy, disturbed, and autistic, but also brilliant.
Prime Minister Netanyahu, President Shimon Peres and other world leaders sent their condolences to President Obama following this senseless massacre.
Jewish Press News Briefs
About the Author: JewishPress.com brings you the latest in Jewish news from around the world. Stay up to date by following up on Facebook and Twitter. Do you have something noteworthy to report? Submit your news story to us here.
If you don't see your comment after publishing it, refresh the page.
Our comments section is intended for meaningful responses and debates in a civilized manner. We ask that you respect the fact that we are a religious Jewish website and avoid inappropriate language at all cost.
If you promote any foreign religions, gods or messiahs, lies about Israel, anti-Semitism, or advocate violence (except against terrorists), your permission to comment may be revoked.
Imported and Older Comments:
Instead of crying crocodile tears, Obama should have spoken in support of the poor brother, Ryan Lanza who was handcuffed, photographed, misreported by the hysterical press, and will now suffer trauma as a result. For several hours, Ryan's photo was plastered all over the media instead of the psycho murdering brother. Mistaken identity = a ruined life. WHo's addressing this?
Has anyone considered that he might have been taking anti-depressants? There's a black box suicide warning on them and they have been linked to violence. Many school shootings were done by people on these drugs. Just one of many articles on the subject. http://www.psychologytoday.com/blog/mad-in-america/201101/psychiatric-drugs-and-violence-review-fda-data-finds-link


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Great Green North
Seven items to have at the ready:
1. Rubbermaids 75-quart DuraChill Cooler, which keeps beer cold for almost a week ($43; rubbermaid). 2. Sweat- and waterproof K2 Endurance Sunblock ($13; k2suncare.com). 3. Patagonias wrinkle-free Vitaliti polo shirt, which looks better at dinner after youve worn it hiking ($55; patagonia.com).4. Smiths gold-rimmed Bellaire sunglasses ($100; smithoptics.com). 5. Hi-Tecs V-Lite Radar II eVent light hikers, which can double as trail runners, since theyre built onrunning lasts ($120; frameworkfitness.com). Drive west an hour to Baddeck and set up camp at the Chanterelle Country Inn, a solar-heated B&B where the organic dinners mean wild mushrooms, fresh mussels from the harbor out back, and, until July 15, lobster; for the rest of the month you're stuck with the snow crab (doubles, US$158, including breakfast; chanterelleinn.com). Then load up your bike and drive out to 200-year-old Acadian villages, through Highlands National Park, and, if 18 percent grades don't dissuade you, to the majestic north end, where you can take a guided sea-kayak tour through pilot whale feed zones (US$100; kayakingcapebreton.ca). Before leaving Baddeck, unwind at a ceilidh, the old Celtic precursor to the rave, with fiddles, tin whistles, and (in place of ecstasy) the island's own single-malt whiskies.


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Fare Forward, Voyagers...
George Santayana (1863-1952) lived in Boston for 40 years and taught philosophy at Harvard for 23 of those years. He had, however, been born in Spain, never gave up his Spanish citizenship and spent the last four decades of his life in Oxford and Rome.
Books and Culture
In September 1943, after the downfall of Mussolini and the occupation of Italy by the Germans, the Allies landed forces at Salerno, 160 m
An outspoken critic of the Bush administration (and the Catholic Church), James Carroll is a former priest who is becoming a redoubtable
In this brief but compelling little book, Joseph Kelly, professor of religious studies at John Carroll University in Cleveland, Ohio, off


text:
Jims Club House
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+1 42 5417 1534
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text:
This is your resource to discuss support topics with your peers, and learn from each other.
Hi, I'm glad to be part of the community!
Here are my first impressions on App World.
• Clean and slick design and animation
• promo apps section
• Like that I can slide up to view more apps
• Like the header navigation (featured - apps - games - my world)
• ...standard features
Cons or Feature Requests
• When you do a search there is no back button
• The sub sections (newest - top free - top paid - recent updates) only show 25 titles. I would expect to be able to see more results through a paging system or continual populate as you scroll down
• No way to set the results per page in the sections or in the search results (10 - 25 - 50 or 100, etc)
• Apps you already have installed are included in the apps search or section results (I would expect them to be excluded or marked as already installed)
• On the app detail page I would expect to see download or install count. In a way this may be only of interest if it is significant or possibly as a developer preference.
• I would expect to be able to click on the app author / developer and see what other apps they have
• The description on the app detail page needs to have the linebreaks removed (replace the double line breaks with a single line break)
• On the app detail page I'd expect to be able to zoom in to the screen shots
• On the support pop up I'd expect to be able to email the developer through a form or at least for now be able to copy the email address to the clipboard
• When installing a new app sometimes it shows the green busy indicator / downloading bar but never finishes. Restarts don't seem to help. Disabling and enabling the wifi might have been the solution.
• I would expect to be able to see more than 1 initial reviewer comments and more than 5 when expanded.
• Not trying to be picky but the background alpha of the tile list should be more opaque to focus more on the apps. The image behind it is too pretty (distracting in my opinion).
• When you click on the top sections (Apps - Games) you are shown sub sections like business - education - finance, etc. You are then shown more sub sections and more sub sections before you get to see any apps. I would expect to click on the main category, for example, "Business" and then see all apps in that category. Then if you want to filter down that category you'd be able to select "Business Tools", "Data Collection", etc. Or simply add an "All" sub category.
• Add a send [app details] to friend (email, sms, etc) on the app detail page
• In the my world section there is a installed and uninstalled views. In the uninstalled views it shows two programs that I've uninstalled but can reinstall. I would expect to be able to be able to remove them completely.
Thanks for listening if you've read this far


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Check in from 14h / Check out prior to 11h
Posada De Las Flores Resort Punta Chivato: Find photos, reviews, information, amenities and compare prices for 5 stars hotels in Punta Chivato, Mexico.
Located in Punta Chivato, Posada De Las Flores Resort Punta Chivato offers 5-star accommodation, as well as free Wi-Fi, an outdoor pool and a swimming pool. It also features a terrace, a tour desk and an airport shuttle.
Hotel description
Guests of the resort have access to its wide range of outdoor activities, including snorkeling and fishing. It also has a safe and a shuttle service.
Rooms at Posada De Las Flores Resort Punta Chivato provide a stylish space to relax, complete with a mini bar.
The resort provides a daily breakfast, and has a bar where guests can unwind with a drink. Each evening, guests are invited to wind down in the comfortable lounge bar.
Hotel features
Restaurant, Bar / Lounge, Air Conditioned, Mini Bar, Hair Dryer, TV
Safe-Deposit Box
Swimming pool, Tour Desk, Water Activities, Fishing, Pool Outdoor
High-speed Internet, Internet Connection (wireless)
Airport shuttle
Availability and Prices
Booking Site
Room Type
Per room
Per night
Per night
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