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This paper aims to present an overview of screening and safety considerations for the treatment of clinical depressive disorders and make recommendations for safety monitoring.
Data were sourced by a literature search using MEDLINE and a manual search of scientific journals to identify relevant articles. Draft guidelines were prepared and serially revised in an iterative manner until all co-authors gave final approval of content.
Screening and monitoring can detect medical causes of depression. Specific adverse effects associated with antidepressant treatments may be reduced or identified earlier by baseline screening and agent-specific monitoring after commencing treatment.
The adoption of safety monitoring guidelines when treating clinical depression is likely to improve overall physical health status and treatment outcome. It is important to implement these guidelines in the routine management of clinical depression.
Major depressive disorder (MDD) afflicts an estimated 16% to 20% of the population during their lifetime [1-3]. In Australia 3.1% of men and 5.1% of women are affected in any 12-month period [4]. Current treatments include pharmacological, psychological and physical therapies. Antidepressants are amongst the most commonly prescribed classes of drugs [5] and their use continues to grow [6]. Adverse outcomes are part of the landscape in prescribing medications and therefore management of safety issues need to be an integral part of practice.
The adverse effects of antidepressants vary between individual drugs and drug classes and have been extensively documented [7-9]. In general tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are associated with more severe adverse effect profiles than the newer antidepressants. MAOIs interact with dietary tyramine necessitating patient counselling about dietary risks [10]. While there is substantial intra-variation in tolerability, MAOIs and TCAs retain an important place in the management of refractory depression [10] and the more putatively biological depressive disorders such as melancholia [11]. The selective serotonin reuptake inhibitors (SSRIs) and selective serotonin and noradrenaline reuptake inhibitors (SNRIs) broadly have lower toxicity than older agents [12], but have also been associated with significant adverse effects including cardiovascular effects, sexual dysfunction [8], weight gain [13], electrolyte disturbances, haematological effects [8] and hepatic damage [14]. A possible increase in suicidal thoughts and self-destructive behaviour in paediatric patients prescribed antidepressants has been documented [15] and regulatory warnings have been extended for young people up to the age of 25 years [16]. Most treatment guidelines recommend clinician vigilance for adverse symptoms or caution when administering antidepressants to people from high risk populations, including those with a prior history of medication sensitivity, the medically unwell [17], the elderly [18], adolescents [19] and pregnant or breastfeeding women [20]. Specific recommendations are, however, not widely available.
MDD is frequently comorbid with physical problems and illnesses including obesity [21], cardiovascular disease and diabetes mellitus [22], substance misuse and other mental disorders, reflecting both antecedent and consequence pathways [23]. This may affect the efficacy of treatments for MDD as well as increasing the vulnerability of patients to adverse effects and risk of harmful drug interactions.
Non-pharmacological treatments for MDD including psychotherapy [24] have also been associated with adverse events. Such adverse effects are, however, less frequently reported. Complementary and alternative treatments can be associated with adverse events [25] and pharmacological interactions. Even exercise, which has an established evidence base in depression treatment [26], may be associated with adverse effects in individuals with comorbid cardiovascular disease, prolonged QT interval or who attempt strenuous activity without a period of adjustment [27]. However, gradual exercise training for rehabilitation following a major cardiac event in depressed individuals is associated with 73% reduced mortality when compared to depressed individuals who did not participate in exercise training [28].
Guidelines exist for safety monitoring of treatments for schizophrenia [29], bipolar disorder [30] and for specific medications (e.g. clozapine) [31], but there are none for clinical depression. Previous Australian guidelines focus on treatment algorithms [32]. Guidelines for baseline screening and safety monitoring of antidepressant treatments may significantly reduce risks of adverse events.
Data were sourced by a literature search using MEDLINE and a manual search of scientific journals to identify relevant articles. Searches were conducted on multiple occasions by individual co-authors. Draft guidelines were prepared and serially revised in an iterative manner until all co-authors gave final approval of content. The process was completed over an 18 month period in 2010 and 2011.
The management of depression should include an appropriate diagnostic work up, especially to exclude organic or self-limiting determinants. A person's individual risk, prior treatment history and therapeutic preferences should be assessed prior to treatment selection.
Choice of treatment must carefully balance efficacy, potential harms and patient preference, facilitating an informed choice for patients to treatment that best matches their presentation [33]. The following sections will address evidence-based pre-treatment screening and monitoring of treatment of depression and are shown in Table 1. Baseline screening and monitoring recommendations for specific depression augmentation strategies (e.g. lithium [30], the atypical antipsychotics [29]) are reviewed extensively elsewhere and hence are not included below. Similarly, monitoring of psychological therapy is beyond the scope of this paper [24].
Obtaining a thorough patient history and examination prior to commencing treatment is important in order to (i) determine whether medical factors may be influencing the current presentation, (ii) determine and document any risk factors which may increase susceptibility to adverse outcomes, (iii) establish baseline measures of physical and mental health in order to monitor treatment efficacy and safety, and (iv) clarify depressive type and assist treatment selection.
Specific medical history information that can impact on monitoring and influence outcome includes substance use (e.g. alcohol [34], tobacco [35,36] and prescribed and illicit drugs), physical activity [37,38], life events, diet [39,40] and chronic and medical illness [41] as well as family history, history of illness and treatment history [42]. Personal or family history of thyroid, cardiac and cerebrovascular disease, hypertension, dyslipidaemia and/or diabetes mellitus should alert clinicians to increased risks associated with antidepressant treatments, and guide targeted baseline assessments.
Although uncommon, organic causes of depressive symptoms should be considered and evaluated before treatment is initiated. Organic causes include metabolic disorders, some vitamin deficiencies (e.g. vitamin D [43, 44], folate, B12, magnesium [45], zinc [46]), chronic pain, sleep apnoea, cancer, cerebrovascular disease, neurological disorders, traumatic brain injury, autoimmune disease (systemic lupus erythematosus), some infections (hepatitis and HIV) and endocrine disorders [47]. Thyroid disease is an occasional medical cause of depressive symptom onset or persistence whilst Cushing's and Addison's disease are rare causes [48].
Some organic causes of depressive symptoms can be detected through routine blood screening. The following tests may have a role in baseline screening prior to anti-depressant treatment.
Hyperthyroidism and hypothyroidism can be associated with mood disorders. Symptoms of hyperthyroidism include dysphoria, anxiety, restlessness, emotional lability and impaired concentration. Symptoms of hypothyroidism include psychomotor retardation, decreased appetite, fatigue and lethargy, which when severe mimics melancholic depression [48]. Subclinical and past thyroid dysfunction is a risk factor for depression and antidepressant non-response [49]. Identification of abnormal thyroid function in depressed patients should prompt correction of thyroid hormone levels (T3 and T4), and where necessary, referral to an endocrinologist for further investigation. Depressive symptoms may resolve with correction of thyroid hormone levels. However, for some patients depressive symptoms may persist and require additional treatment.
Full blood examination (FBE) can identify anaemia, potential underlying infections and blood dyscrasias that may contribute to depressive symptoms. Anaemia can induce fatigue and may be misinterpreted as, or contribute to, depressive symptoms. Alterations in leucocytes may alert to the presence of an underlying infection or other pathological process (e.g. cancer).
Diseases of the liver have been associated with depression [50], and some antidepressant treatments are associated with hepatotoxicity [14]. Impaired liver function at baseline should prompt further investigation to determine and treat any hepatic disease. High levels of GGT and AST may suggest comorbid alcohol abuse, especially if concurrent with an increased mean cell volume [51]. Intravenous drug use may result in hepatitis C and cause abnormal liver function tests (LFT).
Viral infections including human immunodeficiency virus (HIV) [52], hepatitis C [53], West Nile virus [54] and Epstein-Barr virus [55, 56] are associated with depression, albeit uncommonly. This may relate directly to the infection or be consequent to elevated levels of cytokines that may themselves be biomarkers of risk for depression [57]. Fatigue is common following acute infective illness [58] and may be mistakenly attributed as a depressive symptom. In addition, antiviral treatment, most notably PEGylated interferon, can cause episodes of depression [59]. Though uncommon in contemporary practice, non-viral infections such as syphilis [60] can also cause depressive symptoms. Fatigue and depressive symptoms may be a response to activation of the immune system [61], suggesting that broader associations between infections, treatments for infections and the manifestation of depressive symptoms may exist. Prior to commencing antidepressants, a detailed history of past infectious illness and treatments should be acquired, and supplemented with serological testing and testing of inflammatory markers (erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)) if current infection is suspected.
Alcohol abuse or dependence are causal factors contributing to depression [62]. Many other substances have also been associated with depression; however, the direction of causality has not been clearly determined. Smoking can increase the risk of depression [35], through direct neurotransmitter mechanisms and via pharmacokinetic drug interactions (e.g. tar components inducing hepatic isoenzymes CYP1A1, CYP1A2 and possibly CYP2E1) and pharmacodynamic drug interactions with nicotine [63]. Depressive symptoms may also emerge with smoking cessation [64]. Cannabis, amphetamine and cocaine use are also associated with depression, and intoxication or withdrawal can be confused with a mood disorder [65]. Furthermore, comorbid alcohol or substance abuse are associated with antidepressant treatment resistance and non-adherence [66]. Obtaining a detailed drug and alcohol history is essential in patients with depression, although clinicians should be cognisant of potential underreporting. Blood or urine screening may be useful in selective cases although such screening only identifies substances present at the time of the test. Collateral information from relatives and friends, as well as other health professionals is invaluable to fully explore substance and alcohol issues. Raised transaminases, elevated carbohydrate deficient transferrin and increased mean cell volume are a clue as to the presence of alcohol abuse.
Several medications are known to induce depressive symptoms. Interferon and other immune active agents (previously mentioned) may be directly causative of depressive episodes [59]. Benzodiazepine use may be associated with depression [67]. Opiates are frequently utilized agents especially in the context of chronic pain. Depression and chronic pain are commonly comorbid and iterative, and it is possible that chronic opiate use has a noxious effect on mood [68,69]. Other potential mood modifying agents include some steroidal and other hormonal treatments [70,71], cardiovascular drugs, cholesterol lowering agents, parkinsonian agents, antibiotic agents [72], antineoplastic agents [73], anticonvulsants [74], typical antipsychotics and analgesics [75-78]. If there is a temporal association of the onset of depression and the commencement of a medication, then an assumption of causality is practicable.
A high prevalence of vitamin D insufficiency is found in most western societies [79] particularly amongst the elderly [80-83]. Psychiatric cohorts appear to have even higher rates of Vitamin D insufficiency [43], with 58% of inpatients in one study having vitamin D insufficiency and 11 % showing deficiency. Low levels of vitamin D, which are common in winter, may contribute to seasonal affective disorder (SAD) [84,85] and a higher likelihood of developing a depressed mood [86,87]. There are some data, albeit inconsistent, that vitamin D supplementation may prevent or improve depressive symptoms [88,89]. While a comprehensive picture of the role of vitamin D in depression is yet to emerge, the high yield from screening and the simplicity of supplementation suggests that screening may be worthwhile. There is some evidence that folate, vitamin B12 magnesium and selenium, amongst other nutrients, are deficient in some individuals with depression, and inconsistent data that supplementation may be of value [45,90-92]. The absence of quality data limits evidence-based recommendations regarding screening, but this should be considered if indicated by history.
Depression often overlaps with dementia and mild cognitive impairment in elderly patients. Late onset depression may be a prodrome of cognitive decline [93] and depressive symptoms can be confused with dementia [94]. In patients with late-onset depression, diagnostic work up may require formal assessment of cognitive impairment. Late onset vascular depression has been associated with brain small vessel disease demonstrated by hyperintensities on MRI scans [95]. Patients with consistent symptoms should be assessed for vascular risk factors such as smoking, hypertension and diabetes.
Many antidepressants are associated with weight gain, but depression, particularly atypical depression, can cause weight gain independent of medication [21,96]. Metabolic syndrome is a cluster of risk factors which identify individuals at high risk for cardiovascular disease and type II diabetes mellitus [97]. The prevalence of metabolic syndrome in patients with current major depression was found to be 56% in a Finnish study [98] and 25% in a German study [99]. The relationship between depression and metabolic syndrome is bidirectional, with the syndrome also predictive of increased risk for depression [100]. A study of depressed inpatients recommended baseline metabolic screening for all hospitalized depressed patients and re-screening during remission [99].
Baseline measurements of height, weight (to calculate body mass index) and waist circumference should be undertaken. Patients should be questioned about risk factors for metabolic syndrome including smoking, personal or family history of diabetes, while observational analysis will also commonly suggest those at high risk or likelihood of the syndrome or its complications, such as sleep apnoea. Where appropriate, advice regarding smoking cessation should be given. Guidelines for reviewing risk factors for metabolic syndrome during antidepressant treatment are given in the section detailing ongoing monitoring.
People with depression are at an increased risk of developing cardiovascular disease [101]. In addition, some antidepressants (in particular TCAs) have associated adverse cardiovascular effects, although most of the newer antidepressants demonstrate low cardiotoxicity. TCAs may affect cardiac conduction and should be used with caution in patients with pre-existing cardiac disorders (especially in those with recent myocardial infarction and arrhythmias) [102]. Although rare, case reports of adverse cardiac events with newer antidepressants exist, including atrial fibrillation associated with fluoxetine treatment [102] and mild bradycardia with fluoxetine, fiuvoxamine and paroxetine [12]. Adverse cardiac events usually occur in patients with additional risk factors such as smoking [103]. An ECG is probably indicated at baseline and after attainment of therapeutic dosage in individuals with clinical risk factors who have been prescribed agents that can alter the ECG, particularly TCAs. Baseline monitoring of blood pressure and pulse is useful and particularly important if a MAOI or TCA is prescribed [104]. Venlafaxine can cause tachycardia and increased blood pressure, and this merits monitoring [105]. Postural hypotension is particularly common with the MAOIs early in the treatment course, although tolerance typically develops. Antidepressant treatment may cause changes in cardiac function that are not outside the clinically normal range [12], therefore baseline measurements will be required to detect these changes.
Hypercortisolaemia and hypocortisolaemia are both associated with depression, although patients typically present with different symptom clusters. Hypocortisolaemia may be more likely to be associated with 'atypical' depression, with symptoms including hypoarousal, hypersomnia, hyperphagia, lethargy, pain, fatigue and relative apathy, whereas hypercortisolaemia may be associated with 'typical' symptoms such as hyper-arousal, anxiety, insomnia and loss of appetite [106]. It is unclear whether hypothalamic-pituitary-adrenal (HPA) axis activation is causative of depression and consequently information about plasma cortisol is of limited clinical use. The exception is hypercortisolaemia associated with Cushing's syndrome, where depressive symptoms are common and may improve with treatment of the endocrine disorder [106]. Endocrine and cytokine dysfunction often co-occur [107], which may also influence mood disturbances. A cushin-goid appearance, impaired glucose tolerance and electrolyte disturbance may point to this diagnosis, and a 24-h urinary free cortisol measurement prior to commencing antidepressant therapy may be useful in this scenario.
Screening for pregnancy, including detailed history and consideration of a pregnancy test where indicated is important for women of childbearing age. Pregnancy can influence mood, especially when associated with psycho-social stressors such as an absent partner or when the pregnancy is unplanned [108]. Pregnancy also raises issues of potential drug-induced teratogenicity; hence knowledge of pregnancy status is important for guiding treatment choices [20,109,110].
Pharmacogenetics (genotype associations to medication response and tolerability) is an emerging area of promise in the safer and more effective prescription of various medications. Some pharmacogenetic tests are commercially available while others are still at an experimental stage. Typically, the tests either probe for polymorphisms of genes involved in neurotransmitter function or probe for polymorphisms of genes involved in drug metabolism [111]. Currently, the role of genotyping to predict antidepressant adverse effects remains unclear. While there is evidence that genotyping cytochrome P450 polymorphisms detects poor metabolisers and ultra-rapid metabolizers with some level of accuracy, their clinical utility in dose finding remains under investigation [112,113]. At present there is no evidence supporting the use of these genetic tests in routine clinical practice, particularly as there is no demonstrated relationship between blood concentrations of the SSRIs or other new antidepressants and clinical efficacy. The role of blood-brain barrier pump polymorphisms is also being explored [114]. There is limited evidence that certain genotypes are associated with higher rates of emergent suicidality while receiving an antidepressant, but results remain mixed [115]. At this stage, routine genetic testing of patients commencing antidepressants does not appear to have sufficient evidence to guide recommendations. In selected patients with a history of medication sensitivity or resistance, there may be a limited place for CYP450 genotyping. Should robust evidence of predicting pharmacogenetic response, tolerability and safety associations emerge there may be a greater place for such genotyping in the future.
Neuroimaging has advanced substantially in the past three decades, with current technology permitting the assessment of neurochemical concentrations within the brain, more detailed appreciation of its structure and connections and an intriguing insight into its functionality. However, a lack of a consensus as regards diagnostic criteria and clinical phenotype of depression has meant that the emergence of characteristic neuroimaging features that have the necessary sensitivity and specificity at an individual level is yet to occur [116]. The only exception to this may be the use of MRI in cases of late onset depression to confirm the presence of underlying causative small vessel disease. Late onset depression may at times progress to dementia, and MRI will provide a baseline for future assessments.
In most jurisdictions, electroconvulsive therapy (ECT) is subject to specific legislative constraints and treatment needs to respect these limitations [117]. Patients should be assessed, including relevant investigations into their general physical health prior to receiving ECT. Acutely ill patients should only receive ECT as an inpatient, at least until their condition stabilizes, as suicide risk may increase in the early phase of treatment [118]. Investigations should be tailored to the individual patient depending on their history, physical examination and diagnosis. Screening for ECT overlaps considerably with pre-anaes-thetic screening and general recommendations in this document.
Uncontrolled hypertension and cerebral tumours are absolute contraindications to ECT. Blood pressure must be assessed. Cochlear implants are a contraindication, unless removed. Cardiac pacemakers are not a contraindication, but it is essential to know the underlying cardiac rhythm and to liaise with the patient's cardiologist on pacemaker management with ECT. Cardiologist opinion should also be sought with patients who have severe aortic stenosis. Anaesthetic monitoring includes ECG, pO2 and pCO2, and respiratory rate monitoring of pO2 and pCO2 as well as pulse, blood pressure, respirations, and conscious state are critical in the recovery area.
An emerging research area is that of biomarkers in depression. New data suggest certain biomarkers, including cytokines such as CRP [128] and leptin [129], may be indicative of risk of development of de-novo depression. Other biomarkers have demonstrated a cross-sectional association with depression, such as measures of oxidative stress and neurotrophins [130]. These markers are currently of research interest only, and while provisional evidence suggests potential roles they may shed light on clinical course and outcome [131], data are too preliminary to merit incorporation in routine clinical screening.
After initiating antidepressant treatment, patients should be monitored for suicide risk. A thorough review of suicide monitoring is beyond the scope of this review, however practice guideline are available elsewhere [119, 120].
Waist circumference and body mass index should be monitored, particularly in patients treated with antidepres-sants associated with weight gain [121]. It is unclear whether being overweight at baseline is associated with further weight increase with antidepressant exposure. Most studies have found no clear association between antidepressant-induced weight gain and baseline measures [122]. In some cases antidepressant treatment may reduce weight and abdominal fat by decreasing anxiety and regulating dietary patterns [123]. A naturalistic study found that weight gain in the first week of antidepressant treatment was a significant predictor of sustained weight gain [13]. There is limited evidence that ethnicity may influence weight increases with antidepressant treatment [124]. Early detection of weight gain and intervention to prevent sustained weight gain may have significant benefits. Monitoring of the metabolic profile may be prudent at 3, 6 and 12 months, then yearly, in all patients, not just in patients who are obese or overweight. While TCAs, MAOIs, mianserin and mirtazapine are most associated with weight gain [121], problems may arise with other newer antidepressants. Paroxetine may be more likely to cause weight gain than other SSRIs, and bupropion may be less likely than the SSRIs [125]. Particular attention should be given to those patients receiving augmentation or combination pharmacotherapy, especially with atypical antipsychotics [126].
Cardiovascular status may need monitoring during antidepressant treatment. Electrocardiography (ECG) is recommended for patients being treated with the older antidepressants, especially in those over 45 years of age and those with cardiovascular disorders [12]. ECG should be considered prior to initiation of a TCA, and at steady state, for monitoring the QTc interval and for development of arrhythmias [127]. It may also be considered prior to commencing treatment with an SNRI in high-risk individuals. QT prolongation is a common finding in the elderly. It can lead to Torsades de Pointes (a re-entrant tachycardia), resulting in ventricular fibrillation and sudden cardiac death. It is possible that such outcomes are under-reported. TCAs are known to cause QT prolongation by autonomic effects and effect on rapid outward potassium currents, resulting in delayed repolarization. Patients who have already been treated with a class I antiarrhythmic agent (Na+channel blocking) [12] and those who metabolize tricyclics more slowly (cytochrome CYP2D6 poor metabolizer phenotype) may be at increased risk [128]. Electrolyte disturbances, which can be a consequence of some antidepressants, increase the risk of arrhythmias [129].
SSRIs have also been rarely associated with cases of Torsades de Pointes. There were 20 such cases associated with fluoxetine, with one fatality, reported by WHO adverse drug effect monitoring between 1983 and 1999 [130]. Cases associated with SSRIs, however, remain infrequent, sporadic and often involve overdose or drug interactions. Overdose of tricyclics and SSRIs mimic the appearance of Brugada's syndrome with right bundle branch block and ST elevation [131], suggesting some drugs (including fiuoxetine and amitriptyline) may also block cardiac sodium channels. Baseline ECG is important in excluding familial long QT syndrome and to reveal T or U wave abnormalities. Repeat ECG monitoring of QT prolongation may be indicated when significant dose changes are made withTCAs. ECG monitoring with SSRI treatment may be useful in high risk cases, though this is usually unnecessary.
There are rare reports of blood dyscrasias with antide-pressant administration. Case reports have included mian-serin- or mirtazapine-induced neutropenia [132] and citalopram-induced thrombocytopenia [133]. Agranulo-cytosis induced by newer antidepressants is much less common than that which was reported with tricyclic or tetracyclic antidepressants [8]. Monitoring of the full blood examination in patients treated with antidepressants may be prudent when rechallenging patients with a history of a blood dyscrasia. With mirtazapine and mian-serin, one should be alert for emergent symptoms such as fever, sore throat, stomatitis or other signs of infections. If such symptoms occur, haematological investigations should be undertaken and the treatment stopped. Given the very low yield of screening for this very rare adverse event, routine haematological monitoring is not justified.
Numerous antidepressants have been found to affect the liver. The MAOIs and the TCAs are associated with an appreciable though infrequent risk of hepatotoxicity [134]. However, changes in hepatic enzyme levels have rarely been reported for SSRIs and other newer antidepressants including paroxetine [135-137], sertraline [138,139], fiuoxetine [140,141], mianserin [142], mirtazapine [143,144], bupropi on [145],trazodone [146,147], nefazodone [14], venlafaxine [146], duloxetine [148] and agomelatine [149]. Disentangling these rare reports from baseline-associated factors is difficult. Antidepressant-induced hepatotoxicity is usually an idiosyncratic adverse drug reaction of low prevalence characterized by elevated ALT and sometimes by jaundice. The consequences of antidepressant-induced changes in hepatic function can range from asymptomatic changes [144] to fatal outcomes [145]. It is unclear whether the use of antidepressants may aggravate existing hepatic disease. Pre-existing hepatic disease may alter the metabolic clearance of some antidepressants and may necessitate dose adjustment [134].
It does not appear that susceptibility to antidepressant-induced hepatotoxicity can be predicted by LFT or ALT before commencing antidepressant treatment. Therefore these tests are not used as a baseline screen to monitor risk for developing de-novo hepatic injury in response to antidepressant exposure [134]. However, they may be useful for detecting pre-existing hepatic injury and for establishing a baseline for patients before commencing antidepressant treatment and are required before commencing treatment with agomelatine. Antidepressant-induced hepatotoxicity typically occurs within the first few months of treatment.
Nefazodone has been withdrawn from the Australian market as a result of cases of fatal hepatotoxicity [150,151]. Elevations of serum transaminases are documented in clinical trials of agomelatine but these changes usually return to normal levels after discontinuation. The European Medicines Agency has recommended a liver function test for patients treated with agomelatine at the start of treatment and at 6, 12 and 24 weeks of treatment and when clinically indicated [152].
Lucena et al. [134] state that hepatotoxicity is an uncommon and unpredictable idiosyncratic reaction, and that there is no evidence that routine monitoring reduces the rate of hepatotoxicity with antidepressants in general.
After a hepatotoxic reaction, if an antidepressant rechallenge is indicated, monthly liver functions test for the first 6 months of treatment, with discontinuation of treatment if ALT values exceed (by three times) the upper limit of the normal range, if bilirubin levels rise, or if signs or symptoms of liver dysfunction are present, are recommended by the authors. If an individual develops increased serum transaminases, tests should be repeated within 48 h. After discontinuation, monitoring can be continued to ensure that liver function returns to the normal range. Rechallenge should be considered with caution, and only after careful consideration of risks and benefits. Adverse reactions to an antidepressant rechallenge are not uncommon [150] and sometimes a more severe antidepressant-induced hepatotoxic reaction may occur following antidepressant rechallenge [139,153].
SSRIs and some other antidepressants have been reported to cause hyponatraemia. The incidence rate in the elderly is 4.7 cases/1000 people treated/year [154,155], but is much lower in younger age groups. It should be suspected if an elderly patient becomes confused or develops a frank delirium after commencement of an antidepressant. It may be why a person's mood may inexplicably worsen. Deaths associated with hyponatraemia have been reported [156]. Liu et al. [157] reported on 736 cases between 1980 and 1995 associated with fiuoxetine, fluvoxamine, paroxetine and sertraline use. Hyponatraemia has also been reported for citalo-pram [158], escitalopram [159], duloxetine [160], mir-tazapine [161] and reboxetine [162]. It has been suggested that the risk may be greatest for patients who take fiuoxetine compared to other antidepressants [154]. SSRIs can induce isovolemic hyponatraemia through a syndrome of inappropriate anti-diuretic hormone (SIADH) secretion [159]. Hyponatraemia can resolve with antidepressant discontinuation and reoccur with rechallenge [160]. Baseline screening of patients should include an assessment of risk factors for antidepressant-induced hyponatraemia including advanced age (≥65 years) [157], previous history of antidepressant-induced hyponatraemia [160], low body weight [155], thiazide use [163], and the use of other agents that may cause hyponatraemia such as carbamazepine [164]. Anecdotally, female gender [163] may also be a risk factor. Most cases of hyponatraemia occur within the first 10 weeks of initiating antidepressant treatment, with 79% occurring in the first 3 weeks [154]. Regular monitoring of serum sodium in elderly patients has been recommended by some clinicians [154]. SIADH may also cause a worsening of depressive symptoms [154,159] and therefore should be sought and excluded. SIADH should be investigated if a person reports clinical deterioration, cognitive change or dizziness and fatigue after initiation of antidepressant treatment [159]. There is no current protocol for monitoring serum sodium in patients being treated with antidepressants; however, monitoring after 3-4 weeks of treatment should occur in individuals who match the high risk profile [155].
There are recent data indicating that SSRIs may reduce bone mineral density [165]. Serotonin has a key signalling role in bone cells and influences bone metabolism. Williams et al. showed a loss of 6.2% of bone mineral density (BMD) with SSRI treatment [166]. This magnitude of bone loss has the potential to lead to a 20% increased fracture risk. Bolton et al. described SSRI use in older adults being associated with an increased odds of osteoporotic fractures (OR = 1.45), as for other mono-amine antidepressants (OR =1.15), although the relationship was weaker [167]. These data are supported by a study showing that the risk of non-vertebral fracture for those over 55 years was two-fold for current users of SSRIs compared with non-users of antidepressants [168]. Preliminary data suggest intra-class differences [169], with citalopram seeming to have the lowest impact on osteoblast and osteoclast function. There are data indicating that, independent of treatment, people with depression have lower bone mineral density and a higher fracture risk, which is likely to be a compound result of lifestyle factors, disease state and iatrogenic treatment effects. These disease-related effects, combined with the effects on treatment, suggest that screening for bone mineral density should be considered in people on long-term SSRIs, and particularly in high risk groups such as the elderly, women and those with other risk factors such as fracture history, history of falls, low vitamin D, hypogonadism, hyperparathyroidism, thyroid dysfunction, systemic inflammatory disorders, and corticosteroid use. Physical inactivity, alcohol use and smoking are shared lifestyle risk factors for both depression and low BMD.
Antidepressant treatment is commonly associated with milder adverse effects. The Antidepressant Side-Effect Checklist itemizes 21 adverse events; nausea or vomiting, sexual dysfunction, increased appetite, decreased appetite, sweating, increased body temperature, weight gain, dry mouth, drowsiness, insomnia, blurred vision, headache, constipation, diarrhoea, problems with urination, palpitations, orthostatic dizziness, vertigo, tremor, disorientation, and yawning [9]. Such adverse effects are important causes of non-adherence to antidepressant treatment [9] and should therefore be routinely monitored.
Monitoring should take into account that antidepressants may interact with other medications and reduce the therapeutic effect or increase side-effects. Perhaps one of the most important differences between the newer antidepressants is their varying potential to cause drug-drug interactions through inhibition of cytochrome-P450 (CYP) enzymes [170]. Fluvoxamine, a potent inhibitor of CYP1A2 and CYP2C19, is a particular cause for concern with clinically relevant interactions reported with caffeine, clozapine, benzodiazepines, warfarin and other medications [170,171]. SSRIs such fluoxetine and paroxetine, which are potent inhibitors of CYP2D6, can also produce relevant interactions with other medications including beta-blockers, tricyclic antidepressants and antipsychotics such as perphenazine [172]. Special attention should be given to fluoxetine because inhibitory effects can persist for up to five weeks after discontinuation. Sertraline, citalopram and escitalopram seem to have less interaction potential than the other SSRIs [170,173]. Duloxetine andbupropion are moderate inhibitors of CYP2D6, while venlafaxine, mirtazapine and reboxetine are weak inhibitors and are less likely to interact with co-administered medications [173]. These factors should be taken into account when starting an antidepressant and in some cases may require dose adjustment.
Choosing a treatment that offers the optimal risk-benefit ratio for a given individual is typically complex. The balance between the patient's prior history of treatment response and tolerability, their current clinical profile and needs, their medical status and personal risks, and the differential tolerability profiles of the drug choices and their efficacy data need to be struck. Optimal safety monitoring is part of a system of care committed to a culture of patient safety. The treating clinician is primarily responsible for decisions regarding treatment choice, making these decisions on the basis of shared decision making, in the context of a collaborative alliance, and communicating the risks and benefits to the patient. In divergent settings, the monitoring arrangements need to vary. Computerized electronic medical records or checklists with reminder prompts may help with safety monitoring; however, systems for lines of communication, co-ordination of monitoring practices and for the interpretation of results need to be developed. If adverse events emerge, the re-balanced risk-benefit ratio needs to be evaluated on an individual basis. Decisions regarding further investigations, referrals to specialist care or the need for treatment changes will need to be made.
Safety monitoring guidelines are developed from indirect data, which are frequently limited and drawn from clinical trial data and surveillance monitoring. Almost no direct studies are available on the utility, cost-benefit ratios, yield or practical implementation of safety monitoring guidelines. The guidelines themselves are the product of an imperfect process of literature review moulded by consensus opinion. They therefore need to be used flexibly and should be moulded by clinical acumen. The recommendations should be adapted to the needs of individual patients, taking into account broad risk factors such as age, general health, comorbidity, polypharmacy, capacity for adherence to monitoring procedures, and clinical diagnosis. It needs to be stressed that these guidelines do not represent a fixed standard of care in a medico-legal context. The principal goal of these guidelines is to increase the probability of prompt detection and intervention for relatively insidious but clinically significant adverse events. They are likely to evolve with further research on risk, tolerability and safety of treatments.
This paper was completed under the auspices of the Australasian Society for Bipolar and Depressive Disorders. It was supported by an unrestricted grant from Servier Laboratories (Australia) Pty. Ltd. 8 Cato Street, Hawthorn VIC 3122, Australia to M.B and S.D. However, at no point in the process of planning, synthesis and writing was there any input or involvement from Servier. The authors alone are responsible for the content and writing of the paper.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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subset: commoncrawl


text:
Tags: CEO, Email, email service, fail, Jeff Bonforte, mail, Marissa Mayer, Yahoo.
Posted 12/12/2013 at 12:37 PM
Posted 4 years ago
The October redesign had failed for Yahoo for technical reasons. Since November 25th, 2013 there has been a mass delivery failure of their service.
To add to Yahoo's woes, the promise to get the dormant Yahoo Mail service active again has failed to materialize with its promise. There is an unknown quantity of users who remain without email service, unable to even log in.
The head of Yahoo Mail, Jeff Bonforte has conceded finally that there is a problem raging on, yet here's a sample of how this guy spoke to staff in a meeting last Friday with them: Bonforte opined that the only way its customers would leave the service is if Yahoo kicked Mail users in the (testicles).
Mr. Bonforte who claims that all the problems stemming since Yahoo mail went missing on November 25th is in relation to a "hardware problem", wouldn't seem to be rectifying the problem by kicking Yahoo Mail/(male?) users in their hardware, would he?
I wonder what Yahoo President and CEO Marissa Mayer, who Fortune magazine ranked in the top ten of America's most powerful businesswomen, has to say about her company's out of control mail department.
You must be logged in to post a comment.


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I've been reading books on my iPad for a while now and want to write a little about what I've found regarding the iBooks vs Kindle apps on the iPad. This isn't a new topic (in fact, it may have been beaten to death), but I'm a fairly avid reader and a fairly avid iPad user, and it's my blog, and I can write about whatever I want. Today, I'm in a book mood. When iBooks was first announced, I was pretty excited because (a) I thought it was high time Amazon had some pricing competition and (b) the eBooks format was reputed to be more open than the locked-down Kindle format. It's been a few months and I haven't seen any price reduction, and although the format is still more open, it's still got DRM. I'm not seeing the DRM as a vote for or against either the Kindle or iBooks route because they both have it, and it's a serious drawback. I've already written about the case for e-books in general, so I won't rehash it.
I'll come to my point and state that I use the Kindle app far and away more than iBooks. The Amazon selection is far better, there are more options for buying books (iBooks limits you to going through the iBooks app, whereas on Amazon you can use the Web from anywhere and specify where you want the book sent), the most recent updates include the popup dictionary function I sorely missed in the early versions, and my notes and highlights are available from the Amazon Kindle Web portal. I can read my books from any of my devices (true for iBooks only if you have all Apple stuff, which I do, but not everyone does, yet). I also like the Kindle app setting that shows popular highlights; it's occasionally interesting to see what the general populace has seen fit to emphasize or remember.
I do use iBooks for PDFs and free books, of which there are a metric ton on Google Books and Project Gutenberg. It's possible but not as easy to get this stuff on a Kindle or into the Kindle app on an iPad. With iBooks, you just drag the thing you want to read onto iTunes and sync, and it looks good on the iPad when you're done. I can't remember the Kindle process, but it seemed more painful than that. iBooks has a little more eye candy, but it's not useful. You can, for example, choose what color your highlights should be, but you can get to them only through the app on your device. What good is that? With my Kindle-format books I have them all available online through Amazon, complete with my notes, highlights, and ratings.
Those are my thoughts du jour on the state of e-readery on the iPad. Here are some links and resources as a parting shot:
-Project Gutenberg -Amazon portal: this is where you access highlights and notes -How to save PDFs to iBooks (through print menu on Macs or through iTunes) -Kindlerama daily cheap/free Amazon deals -Amazon's Free Kindle Books page
Update, 9/6/10: I just found this timely article on Salon.com espousing an opposite view, and it's a pretty good read.


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Software-Services Description
AGSD Description of Software & Systems (Partial Listing)
Google Apps for Education (GAFE): GAFE is a suite of online productivity tools used to create documents, spreadsheets, presentations, forms, email and drawings via the secure Google domain '@myagsd.org'. The applications can be accessed from any device and saved locally or on the secure Google AGSD domain.
InfoSnap: InfoSnap is the online application used to collect and manage new student registrations and the annual submission of returning students' information. The data collected via InfoSnap is automatically and securely transferred to PowerSchool.
Official Payments: Official Payments is Avon Grove's secure payment portal for parents and taxpayers to remit online via credit card, debit card or check routing number. Bank fees may apply.
PowerSchool: The student information system (SIS) is the secure database that maintains all student information for accountability purposes such as: demographics, grades, attendance, discipline and class assignments/scheduling. PowerSchool creates official documents like report cards and transcripts as well as the required reportable data for the state and federal government. One username and password provides access, however, the features available are different depending on the school attended, i.e. the high school has more features available then the elementary school.
Schoology: The learning management system (LMS) is the secure online platform where students and teachers can interact, while at-school or at-home, synchronously or asynchronously. Like an online classroom, digital content is available in the form an integrated calendar, lessons, assignments, projects and other instructional content. Since Schoology is Avon Grove's unified online source for teaching and learning it provides access using one username and password.
School Messenger: School Messenger is the unified communication platform for email, text and voice messages, including emergency notifications. Notifications can be sent by the school or district manually or automatically based on type of message. Unsubscribing or blocking School Messenger notifications will also prevent the receipt of emergency notifications.


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I would like to start this with a short disclaimer: I am not an avid DC fan and I am just stating what, as a moviegoer, I would like to see in a DC cinematic universe. This comes with the release of 'Man of Steel' next year; a film which I believe has potential. It looks to depict the origin of Superman in a non-camp, OTT way- I would like that. Superman for me has always been an unlikable character, there are only so many places you can go with a character that is practically invincible but with a real world setting I can see this film succeeding. It could work as the first stepping stones of a movie universe.
Unfortunately I do not believe that they can reboot this universe, there is another hugely popular film franchise featuring one of DC's most popular characters- Batman. The Nolan trilogy have become some of the highest grossing films in the world to ignore them, for me, would be like blasphemy. These are amazing films and the only problem I can see is bridging the gap between this real world and the supernatural world. This problem however has an easy solution- do it Avengers style. In 'Iron Man' there were no superpowers just a genius with a suit and gadgets (just like batman) then in 'The Incredible Hulk' one small cameo at the end and WHAM! The possibilities became endless! With Man of Steel looking as gritty as it does why not drop in a cameo at the end, just the shadow of the iconic figure then in a gruff voice 'Clark, we need to talk' imagine that! What's so hard to do there? Why not step off the success of an incredibly successful series and use its Batman? I don't see any problems there.
There are however other problems. In the MCU each character had their own intro film exploring the character and their identities. From what I hear DC are going straight from 'Man of Steel' to 'Justice League' what the hell? So we will know two (possibly three) characters: Batman (new or old, he is a symbol and an icon) and Superman (maybe Green Lantern but let's not go there) so answer me this DC how are non-comic fans going to know who Wonder Woman and The Flash are? Actually now I think about it why not have Green Arrow form the show 'Arrow ' in it too at least we would know three characters! I think they should wait with 'Justice League' make a film setting up Wonder Woman and Flash, perhaps release JL in 2017 as opposed to 2015? And then make it a simple 'save the world' film.
These are my views. The Nolan Batman flicks left 'The Dark Knight rises' ready for a follow-up, take your opportunities you already have a universe ready for you DC, use it!
Gritty and Real
Gritty and Real... what is the problem!!???


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San Diego, CA (PRWEB) June 06, 2013
Resource4thePeople announced today that it is now providing consumers an information bank with updated information about litigation involving claims that patients who have had Bard IVC Filters implanted in their bodies have suffered alleged serious side effects.
Among the other related data on the site is a copy of the U.S. Food and Drug Administration's Aug. 9, 2010 health advisory* to physicians and consumers about the agency's concerns about health risks from the use of Inferior Vena Cava (IVC) filters.
"Although this warning was issued several years ago we have been receiving an increased number of inquiries from consumers about what legal rights they may have in cases in which they have suffered alleged serious health problems, some of which are life-threatening," said Resource4thePeople.
"We are in the process of responding to these inquiries by providing additions to the Bard IVC filters litigation page and will continue to do so as this litigation proceeds.
"The site also includes information about free consultations from our national network of attorneys that are being offered to consumers who want to know just what legal rights for which they may be eligible."
The side effects being investigated by Resource4thePeople attorneys are those outlined in the health warning by the FDA, including lower limb deep vein thrombosis (DVT), filter fracture, filter migration, filter embolization and IVC perforation.
"These are very serious side effects that are outlined by the FDA as well as being the subject of inquiries to us from consumers," said Resource4thePeople. "We are finding a growing interest in the details of the risks involved with IVC filters."
The site also contains detailed, simple-to-understand information about how the filters work and the problems that have been reported to the FDA in Adverse Event Reports. Here is part of the FDA warning:
"Since 2005, the FDA has received 921 device adverse event reports involving IVC filters, of which 328 involved device migration, 146 involved embolizations (detachment of device components), 70 involved perforation of the IVC, and 56 involved filter fracture. Some of these events led to adverse clinical outcomes in patients. These types of events may be related to a retrievable filter remaining in the body for long periods of time, beyond the time when the risk of pulmonary embolism (PE) has subsided.
"The FDA is concerned that these retrievable IVC filters, intended for short-term placement, are not always removed once a patient's risk for PE subsides. Known long term risks associated with IVC filters include but are not limited to lower limb deep vein thrombosis (DVT), filter fracture, filter migration, filter embolization and IVC perforation.
"FDA reviewed the literature and is conducting quantitative decision analysis modeling to evaluate the change in the risk/benefit profile after retrievable IVC filter implantation over time. More information about FDA's decision analysis model including risk/benefit implantation timeframe suggestions will be made available in an update to this communication as well as in a future publication in a peer-reviewed medical journal."
The most recent lawsuit update from Resource4thePeople involves the filing of a Bard IVC Filter lawsuit by a New York woman who is claiming in her lawsuit that the device was defectively designed, broke and caused her to suffer significant internal injuries.**
The woman, in her lawsuit, said the filter was implanted to prevent blood clots but the device broke apart with particles migrating through her body and damaging her internal organs.
"These allegations mirror the complaints that our national team of lawyers has been receiving inquiries about and we will continue to investigate these claims on behalf of the consumers that are contacting us," said Resource4thePeople.
Resource4thePeople also notes that a respected medical group has responded*** to concerns about the safety of IVC filters.
A professional peer group medical review is being launched by The Society of Interventional Radiology and Society for Vascular Surgery, which announced Feb. 13, 2013 that it will form a task force to measure the health risk of IVC filters to patients.
"The fact that a respected medical society and the FDA are both raising concerns about the safety of IVC filters has generated a great deal of patient concern and questions to us about the availability of legal advice," said Resource4thePeople.
IVC filters are medical devices designed to prevent blood clots in patients at risk for a pulmonary embolism in cases in which an anticoagulant is contraindicated or proven ineffective.
The FDA's health warning issued to health care professionals and consumers reports that serious health problems can occur on these spider-like devices when the legs that extend from it to block clots break off.
What can then occur, according to the FDA is that these broken parts from the filter may travel to other parts of the body and cause serious problems such as lower limb deep vein thrombosis (DVT), filter fracture, filter migration, filter embolization and IVC perforation.
Resource4thePeople also notes that another recent lawsuit*** filed by a patient who had a Bard IVC filters implant alleges the devices are prone to fracture and cause tears in body organs, including the heart.
The lawsuit also alleges that C.R. Bard is liable because company officials were aware of IVC filters problems but failed to adequately warn patients and health care professionals. The lawsuit claims that an estimated 100,000 of the devices have been implanted in patients in the United States.
**Case # 2:13-cv-2281, U.S. District Court, Eastern District of New York
****First Judicial District of Pennsylvania, In the Court of Common Pleas, Philadelphia County; Case ID120800814


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Francesca Le & Jillian Janson - Dirty Wives Club
Released: February 27, 2015
Francesca is toasting with Jillian about starting her new career. She knew she had to find a new job fast after fucking two of her students at the university she taught at. She landed an interview with her new boss Mr. Bailey where her oral qualifications got her the job. Jillian's sex life with her husband isn't exciting at all and Francesca knows who to call to get things a little more lively.


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Le Pavillon des Boulevards Send to Phone
OpenClosed 3 wks. Aug., 1 wk. Jan., Mon. lunch, Sat. lunch, Sun. Open until 10:00pm
- Air conditioning
- Dress code: Dressy
- Outdoor dining
* Click here for rating key
Text data on Le Pavillon des Boulevards to your phone, or a friend's cell phone.
Find out which restaurants and chefs top the list of GAYOT's 2016 Annual Restaurant Awards.


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Thinking about selling your car in the Leicester area? See how much you could get for your vehicle with webuyanycar.com, the UK's favourite online car buying service!
Located in the East Midlands of England, Leicester is a city and unitary authority, as well as the county town of Leicestershire. Situated on the River Soar on the edge of The National Forest, Leicester is home to over 330,000 residents.
Unfortunately, many of the 330,000 residents of Leicester face the same issues as the rest of us when it comes to selling cars the traditional way. Wasting countless valuable hours during evenings and weekends on tyre kickers and time wasters, only to result in an awkward bout of haggling in which neither party is happy with the outcome.
Selling a car in Leicester needn't be a hassle any longer, as webuyanycar.com now have branches in and around the city! Now you can sell your car in Leicester quickly and easily without entertaining a single time waster!
To find out how much you could get for your car, simply enter your reg number into the box below for your FREE and instant online car valuation!
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0116 216 6808
01162 161577
We have over 200 branches nationwide, with a 15 minute average drive time to a branch.
Free online car valuation
Book an appointment
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text:
What is JotForm?
JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
At JotForm, we want to make sure that you're getting the online form builder help that you need. Our friendly customer support team is available 24/7.
We believe that if one user has a question, there could be more users who may have the same question. This is why many of our support forum threads are public and available to be searched and viewed. If you'd like help immediately, feel free to search for a similar question, or submit your question or concern.
How to cahnge font size for Image Checkboxes widget?Asked by criterions on July 08, 2016 at 02:04 PM
Is there a way to control the label font size for the Image Checkboxes control? It's a great control, but I'd like to be able to reduce the font size if possible.
JotForm Support
Currently font size of Image Checkboxes widget is 15px. It is possible to change it with CSS. Inside of your Image Checkboxes widget Custom CSS field add this CSS code:
span {
font-size: 10px!important;
After that you form will look like this.
Here is my demo form: https://form.jotform.com/61896096449978
Feel free to clone it.
Hope this will help. Let us know if you need further assistance.
Perfect. That's exactly what I needed
JotForm Support
You're welcome.
Feel free to contact us if you have any other questions.


text:
Women's Metallic Glam & Soul Infinity Ring
Thomas Sabo Ring from the Sterling Silver Collection. Ring in 925 Sterling silver, with white zirconia pavé. The filigree, with white pavé zirconia-embellished infinity symbol of the THE ETERNITY OF LOVE ring delicately envelops its wearer s finger, radiating for all eternity. Width: ca. 0.8 cm. Item number: TR2014-051-14. Rings. Rings. Silver plated. Cubic Zirconia. Boxed gift. Sterling Silver. Color: metallic


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|Elizabeth Joestar
|Erizabesu Jōsutā
|Lisa Lisa (リサリサ Risa Risa)
|December 1888
|175 cm
| George Joestar II (Husband)
Joseph Joestar (Son)
Holy Kujo (Granddaughter)
Josuke Higashikata (Grandson)
Jotaro Kujo (Great Grandson)
Jolyne Cujoh (Great Great Granddaughter)
|JoJo's Bizarre Adventure Volume #5 Chapter #43
| JoJo's Bizarre Adventure Episode 9 (baby)
Episode #16
|JoJo's Bizarre Adventure All-Star Battle
|Atsuko Tanaka (Anime, All-Star Battle)
Lisa Lisa is a character from the Battle Tendency Arc in JoJo's Bizarre Adventure
Ripple master Lisa Lisa resides in Italy with her servants Loggins and Messina, and her attendant Suzie Q. Caesar Zeppeli is one of her students. Tasked with protecting the Red Stone of Aja, she becomes Joseph Joestar's teacher after the awakening of The Pillar Men. Unknown to Joseph, she is Elizabeth Joestar, the baby that Erina Pendleton rescued on the boat at the end of Phantom Blood. She was adopted by Ripple master Straizo, and her mastery of the Ripple has allowed her to keep her youthful appearance. She married Jonathan and Erina's son George II, and gave birth to Joseph. George was later murdered by one of Dio's vampires who he discovered was masquerading as a higher-up in the British military, and Elizabeth became a fugitive after avenging her husband.
Lisa Lisa was created by Hirohiko Araki, the author and illustrator of series, as a major character of Jojo's Bizarre Adventure's second arc, Battle Tendency. The original manga series was originally serialized in Weekly Shonen Jump in 1987, until it was transferred to monthly Ultra Jump. Its first volume was released in August 10, 1987, published by Shueisha and still running for more than 100 volumes. It is one of the longest manga series running.
Her name is a reference to 1980's pop band Lisa Lisa And Cult Jam.
Despite her youthful appearance, Lisa Lisa is in fact a 50 year old woman even fooling Joseph who peeked on his mother without knowing her true identity. She's tall and a bit thicker than most women in the franchise due to her Hamon training. She's a beautiful woman with blue eyes, fair skin, and long black hair that reaches past her nape and shoulders. She usually wears dark red lipstick and two jade colored, hoop earrings. When going out, she usually wears sunglasses. She typically wears her scarf as a fashion statement as a weapon, see her power section below.
She has already experienced many hardships in her life. The death of her husband and having to throw her previous life away to become a fugitive has made her strong-willed. She faces any threats with a cool head and without faltering. As a teacher she is harsh and without mercy, but the results of her training earn her the respect of her students.
- Joseph - Even though she treats her son with a strict attitude during their Hamon training, she sacrifices a lot to make sure her son wouldn't get involved in the Joestar troubles, dealing with vampires. She wants to ensure her son had a normal life. However, fate has brought them together. It is demonstrated that she love her son during the funeral with all of Joseph's friends grieving for his death until Joseph proves them wrong.
Major Story Arc
Battle Tendency
After Joseph Joestar's defeat by Wamuu, Caesar and Joseph went to Italy to train under Caesar's master. Disguising herself as a gondolier, she attacks Joseph in Venice, showing him how little he knows about the Ripple. She forcibly puts a mask on him, which suffocates him unless he uses the specific Ripple breathing technique.
Taking Joseph as a disciple, she forcibly tasks him and Caesar with defeating the Hell Climb Pillar, a massive pillar covered in oil that can only be climbed using the Ripple.
After Esidisi's attack during Caesar's and Joseph's final Ripple exam and because of the Pillar Man's theft of the Red Stone, she travels to Switzerland with her students, where they discover Stroheim and his Nazi soldiers have possession of the Stone.
After recovering the Stone following Kars' attack on the Nazi's camp, Lisa Lisa and Joseph are abandoned by Caesar, who was desperate to attack the Pillar Men's stronghold. Her and Joseph, after deciding to follow after Caesar, unfortunately arrive too late, as Caesar had already encountered Wamuu and lost his life in battle. Lisa Lisa loses her composure, collapsing in tears upon finding Caesar's body.
After venturing deeper into Pillar Men's stronghold, the two Ripple users encounter Wired Beck, a vampire. Lisa Lisa casually defeats him, gaining access to Kars and Wamuu. Finding out that the Pillar Men had 100 minions ready to ambush them, she bluffs her way out by telling Kars that the Stone is hidden, and only she can disable the bomb that is attached to it, which will destroy the Stone should she be killed. Kars and Wamuu agree to a fair fight with Lisa Lisa and Joseph, at night at the nearby Colosseum.
After Wamuu's defeat at the hands of Joseph, Lisa Lisa prepares to take on Kars. Unfortunately, Kars tricks her by using a body double, and proceeds to stab her from behind. Lisa Lisa is left severely wounded and unconscious, held hostage by Kars. Rescued by Joseph and given to Speedwagon for emergency treatment, she misses Joseph's victory over the last Pillar Man and subsequent death.
She is next seen at Joseph's funeral, grieving over the apparent death of her only son, only to be surprised by the arrival of Joseph, who had actually survived, and his new wife Suzie Q.
After the events of Battle Tendency, she married a Hollywood screenwriter. Prior to the events of Stardust Crusaders, Joseph discusses the Joestar's star-shaped birthmark with her, but she does not formally appear.
Powers And Abilities
As a master of the Ripple, Lisa Lisa's breathing creates energy that she can use for various combat and non-combat techniques. As with all Ripple users, she is highly effective against vampires and zombies. She appears much younger than she truly is, due to the life energy of the Ripple. In combat, she uses a scarf woven from the bodies of the Satiporoja beetle, giving it excellent Ripple conducting abilities. She can use the scarf to send energy into her opponents, harden it, or use it as a sort of detection device, preventing sneak attacks.


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Last season was the first and only season to be able to attend all my grandson Matthew's practices and games. Now after a move from Louisiana to Tennessee to follow him to Tennessee he and his family moved back and we are 673 miles away from Pineville, Louisiana where he is playing his games. By the way that is Matthew's photo in my logo at ArmchairGM.
He called last week telling about his tryout which went very well. He said he had to dive to catch balls which were not hit directly to him. One of his former coaches told Matthew that he was impressive. The best thing about Matthew is that he is not afraid to get his uniform dirty to catch a ball and he is constantly smiling when he is on the field. I hope he never loses that enthusiasm. He turned 9 years old last Tuesday.
This season he finally gets away from using batting tees and pitching machines. He will be facing live pitching for the first time in his six years of playing youth baseball. The games will not go nearly as fast because there will be a lot more walks. I think he would make a good pitcher but that is up to his coaches.
Last year he played on a team managed by former major league pitcher Kevin McGehee. McGehee has been working with Greg Smith a former starter at LSU who was traded from Diamondbacks to Athletics this winter. Smith is on the brink of possibly being in the A's starting rotation. Smith is 31-14 in three minor league seasons with a 3.27 ERA. He couldn't have found a better team to break into the starting rotation except for teams like Rangers and Astros who have even more spots open.
Last year Matthew's team lost only one game during the regular season. The first thing anyone notices about Matthew is his love for the game and plays it the way it is meant to be played. When he is in dugout between innings he is focused on what is going on in the game not on the kids playing in the dugout.
It won't be easy this season being so far away from his games but will be getting reports from my daughter and her husband on how he is doing. I retired from youth baseball at the age of 13 after only four seasons and he is already in his sixth season at the age of 9 since he was 4 when he played his first game.
He is a Cardinals fan whose idol is Albert Pujols. He got to see Pujols homer in Minute Maid Park a couple of years ago which made his day.
Matthew, have a great season but most of all have fun.


text:
- Disconnect the negative battery cable.
- Loosen the drain plug (2) to drain the engine coolant into a suitable container.
- Disconnect oil cooler hose (1) on automatic transmission (A/T).
Disconnect radiator inlet hose and outlet hose from the engine.
Remove fan guide (1), clips (3) on both sides and the bottom lock, then remove fan guide lower (3) with fan shroud (4).
Disconnect the reserve tank hose (4) from radiator.
- Lift up and remove the radiator assembly with hose, taking care not to damage the radiator core with a fan blade.
- Remove rubber cushions on both sides at the bottom.
To install:
- Install rubber cushions on both sides of radiator bottom.
- Install radiator assembly with hose, taking care not to damage the radiator core with a fan blade.
- Connect the reserve tank hose (4).
- Install the lower fan guide (3).
- Attach the radiator inlet and outlet hoses to the engine.
- Connect the oil cooler hose (1) to automatic transmission.
- Connect the negative battery cable.
Pour engine coolant up to filler neck of radiator, and up to MAX mark of reserve tank. If the entire cooling system was drained, perform the following:
- Remove the radiator cap.
- Fill with engine coolant to the radiator filler neck.
- Fill with engine coolant to the "MAX" line on the reservoir.
- Start the engine with the radiator cap removed and bring to operating temperature by running engine at 2,500-3,000 rpm for 30 minutes.
- Check the coolant temperature gauge reading to make sure that the thermostat is open.
- If air bubbles come up to the radiator filler neck, replenish with coolant. Repeat until the coolant level does not drop any further. Install the radiator cap and stop the engine.
- Replenish coolant to the "MAX" line on the reservoir and leave as it is until the engine gets cool.
- After the engine gets cool, start the engine and make sure there is no water running noise heard from the heater core while the engine runs at 3000 rpm.
- Should water running noise be heard, repeat the engine coolant filling procedure from the beginning.


text:
This IDC Survey Spotlight analyzes the results of the annual IDC Energy Insights Survey covering France, Germany, Italy, the Nordics (Denmark, Finland, Norway, and Sweden), Spain, and the U.K. Based on 120 interviews carried out between July and October 2015, it focuses on the utility industry.
The objective of this study is to analyze European energy suppliers' priorities for the next 12 months for communication channels — mobile apps, personalized info included in electronic bills, social media, call centers, personalized info included in paper bills, text messages/SMS, customer dedicated online portals, in-home displays — to increase customer awareness and engagement.
Note: A subset of the total respondent population answered the specific questions highlighted in this IDC Survey Spotlight.
IDC Energy Insights: Worldwide Utilities Customer Experience Strategies
App stores, Collaborative applications, Customer relationship management applications


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Search our Custom and Sold Galleries Here
This beautiful one of a kind ring is dripping with details!Inspired by the flora and vine motifs of the long ago Victorian era, this flower ring features many little details, including a milgrain edge , hand shaped claw like prongs, and a flower like settingThe opal is a stunning solid natural Australian opal. NOT a boulder opal, doublet or triplet. The fire is excellent on the front, but there is no fire on the back of the opalThe opal measures 10.4mm x 7mm x 3.8mm thickThe back of the setting is open so you can see the back of the opal.The ring is solid Sterling SilverThis is a unique ring, that is finished and ready to ship.Size 7.5The base of the band is plain to allow for the ring to be sized later if needed.Cheers,AustinIf you have any questions about the ring before ordering, please feel free to ask. I can also customize the ring with other stones or metals if you'd like to have one made just for you.
All jewelry is backed with a 100% satisfaction guarantee. If you receive an item and decide it is not what you had hoped, we will refund you your money if a request is made within 7 days of receiving the item.Pictures of items are not to scale.
You May View Our Polices Here You may view a list of link exchanges Here
Stone properties information is for reference only and is not to be used as medical advice. Properties are historic folklore only.


text:
Other name: None
Status: Ongoing
Viewed: 515
Summary: 1) Liar! Liar! Katana takes home a boy who has no recollection of his past or his name. However, Katana knows more than he's willing to share. 2) Impossible! What do these customers have up their sleeve? It just might be "impossible" to believe. 3) Kushami Graduated student still sees his sensei, but will they have continued relations? 4) Sweet Sickness Medicine, peaches, and special treatment 5) Don't Open Your Eyes 6) Hot Love 7) DOGS


text:
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Recipes Super Bowl and Sports Parties
Gluten-Free Brazilian Appetizer Pão de Queijo Recipe8:08 AMC Riches
Gluten-Free Brazilian Appetizer Pão de Queijo Recipe
Brazilian Pão de Queijo Recipe
Click here for more Brazilian & party recipe ideas!!
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Thank you for sharing this delicious recipe at the #RecipeSharingParty! I hope to see you next week. Pinned and Yummed. Please visit #OverTheMoon on Sunday or #ThursdayFavoriteThings for more sharing fun! Don't forget to Comment your link #'s so I can be sure to visit and you get a chance to be featured!ReplyDelete


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Get out and celebrate the 10th anniversary of Record Store Day this Saturday
This Saturday, record collectors and record stores alike will rejoice in celebration of the 10th annual Record Store Day.
Record Store Day started out to celebrate the vibrant culture surrounding independent record stores around the world. Since then, artists of varying popularity have put out exclusive content to get people to make a stop at their local record shop. This special day has led to all kinds of cool and highly anticipated records being put out every year, some so exciting and exclusive that people will show up long before opening hours and wait in line to be the first to get their hands on the new vinyl.
Some of the more anticipated releases for this year include live albums from Grateful Dead, moe. and Jimi Hendrix, a previously unreleased 15-minute recording from Pink Floyd and a 12-inch pressing of Spoon's latest single, "Hot Thoughts," which is limited to 2000 copies. Past years have seen a 10th anniversary edition of The White Stripes' "Elephant," a live recording from The Cramps, a picture disk of the soundtrack for "The Force Awakens" and even a compilation of Madonna's hits.
The holiday has received some criticism from collectors who get frustrated by constant reissues of albums on colored or shaped vinyl instead of just putting out new content. However, the creators of Record Store Day are encouraging artists to steer away from this trend, and that seems to be the case for this year's releases.
Despite the history of criticism, the holiday has almost single-handedly brought back the concept of buying and collecting records, breathing life into the once disappearing concept of the local record store. It has collected so much widespread attention that the day is tied with Christmas for accruing the biggest record sales of the year.
Record Store Day was started to specifically bring attention and support to independent record stores, as suggested by the title, but record labels are the ones that really benefit. The two concepts sort of go hand-in-hand, and Record Store Day helps to let both thrive. Media coverage surrounding the holiday tends to focus on the big-name releases to look forward to, but out of the steadily growing number of releases put out every year, three out of four of them are put out by indie labels.
Sales have thrived in indie record stores since the establishment of Record Store Day, but this is only exclusive to the holiday. Once it's over, the stores return to their normal sales and go back to struggling financially. Music stores need our business every day of the year to survive and be able to still exist and participate in Record Store Day every year.
I have worked at a music store, and I know firsthand that the employees are some of the most passionate people in the music industry. They are usually in touch with the local indie music scene, and will play independent bands' music in the store while people shop, as well as spread the word about them to anyone interested in discovering new music. Indie record stores are truly the lifeblood of the indie music scene.
This Saturday, if you take the time to visit a record store and capitalize on the exclusive releases, be sure to keep the store in mind for the future, and maybe pay them a casual visit every now and then. It really goes a long way, for the stores and artists alike.
Jenny Bourque is a freshman English and textual studies major. Her column appears weekly in Pulp. You can email her at email@example.com.
Published on April 18, 2017 at 9:23 pm


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Four Tips to Consider Before Getting a Gold Loan
Financial emergencies strike unannounced and you will be forced to liquidate all your investments, or borrow a loan. Personal loan are most sought options in the financial markets. However, they carry strict sanctioning procedures and stern credit checks such as very few end up getting it.
To fulfil the emergency credit requirements of needy individuals, banks like Axis bank have come up with a new form of loan. Banks are now offering loan against gold to individuals while keeping their gold belongings as collateral. As gold is held at collateral, gold loans are believed to be secured.
Before you go ahead to avail a gold loan, here are four basic tips that you should consider while getting the best deal.
1> Compare the interest rates
The interest rates levied on gold loans vary in the range of 12 to 15% as in case of banks. NBFCs charge higher interest rates which are up to 18%.
- Interest rate applied on the granted loans against gold vary directly according to the purity of the gold. Higher the purity, lower are the rates.
2> Credibility of lending body
Credibility issues arise when borrowing a loan from scheduled banks or NBFCs. Most banks grant loans only after assessing the repayment options of the borrower. Such loans may not be secure, and there are chances of your gold valuables getting tampered.Always choose established banks to avail a loan against gold as your valuables will always remain safe with them.
3> Valuation of Gold
Most of the NBFCs grant loan whose value is at times lower than the original gold value.Gold valuation is an important part of the loan sanctioning process. To get the best principal amount, always approach an established bank for an appropriate borrowing against gold.
4> Repayment and Defaulting Clauses
- Loan repayment tenures vary from 12 to 24 months on any given gold loan.
- Furthermore, many banks offer the option of repayment of total principal amount at the time of loan closure, while interest is to be paid on monthly basis.
- Select the repayment term as per your convenience.
- Similarly, in case of non-repayment, banks pre-intimate the borrowers before utilizing the gold assets. Ensure that such procedure is available with the lender in order to safeguard your valuables.


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"This post is part of a social shopper marketing insight campaign with Pollinate Media Group® and Weight Watchers, but all my opinions are my own. #pmedia #WWMarket http://my-disclosur.es/OBsstV"
The start of a new school year is here. It is hard to believe, but there is no mistaking the date circled on the calendar. It is especially hard because we just back from an amazing vacation that lasted 12 days. Not exactly the way you want to put an end to a glorious Summer. And, wouldn't you miss this view?
And with an amazing vacation, that means a LOT of not so healthy eating. Combined with the back-to-school blues, you can see that is a bad combination. So how do we cope? By combining a family movie night with Weight Watchers healthy snacks. Now you can enjoy snacks with your movie, without all the guilt!
Now, I will admit, I am one of those "mean" Moms. I don't let my boys play video games during the school week. They don't like it, but they grudgingly accept it. I understand that the first week of school can be extremely stressful, which is why I like to have a movie night during that first week.


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It's a long shot but Port Adelaide coach Ken Hinkley hasn't given up on the Power possibly making the AFL finals.
Port's 94-point thumping of hapless Brisbane at the Gabba on Saturday has lifted the Power above St Kilda to ninth on the ladder.
With four games to play eighth-placed North Melbourne hold all the aces with a 12-point margin, meaning one more win will almost certainly secure their finals spot.
But Hinkley is taking a where there's life, there's hope approach heading into next week's clash with Sydney at the SCG.
"It's still alive isn't it?," he said.
"It keeps us thinking, and dreaming, a little. We control what we control and that's next week."
The Power will be sweating on the fitness of Hamish Hartlett for the Swans clash after he injured a calf in the warm-up on Saturday.
Hinkley is hopeful the big win over the Lions will lift his team's confidence before taking on the fourth-placed Swans.
"We've gone up there and played well a few times so I look forward to that opportunity," he said.
"We've enjoyed the physical contest and we know Sydney will give us an opportunity to practice that against the absolute best."


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We help you search for a Paignton cornet tutor. Cornet tuition are a great way to start a stimulating new hobby, acquire a new skill and gain confidence with cornet. Use our service to search for Paignton cornet teachers and select which matches your requirements so you can begin your cornet tuition in Paignton immediately!
First Tutors: Music is the best place to locate Paignton cornet teachers in the UK, helping you discover Paignton cornet tuition in your area and Paignton teachers to help with any instrument, for example, piano, violin or guitar. We can help you find Paignton cornet lessons or a one-to-one Paignton cornet tutor to prepare for cornet exams and develop your cornet skills! We order Paignton cornet teachers near you according to their hourly prices and distance from you.
If you are a cornet teacher and would like to offer your cornet lessons in Paignton or throughout the UK, please register with First Tutors: Music or find out more about us here. Becoming a Paignton cornet teacher is a wonderful way to re-affirm your own knowledge by giving cornet tuition while assisting someone else, all in the Paignton area!


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It's not all the time that you discover you need a replacement Blower Motor Regulator Resistor to fix your automobile. Land Rover vehicle owners have become used to a certain level of versatility when driving their Discovery around town. When your Land Rover Discovery was born, it was destined for a driver who prioritizes British engineering in their automobile. Your Land Rover dealership isn't the only place to locate the highest quality repair parts to fix your Discovery.
It would be unusual for you to get into a car or truck and not be able to change the speed of your heater blower.. A heater blower resistor gives you the ability to control the level, volume, and speed of the heat and A/C that comes from the vents. Because it is connected directly to the heater switch, your Land Rover Discovery blower motor resistor modulates the resistance applied to the circuit that handles the load of the blower motor. When the Land Rover Discovery heater switch is set to "Max", there is less resistance in the circuit so more amps go to the blower. Conversely, at the lowest blower setting the circuit is running high resistance so fewer amps go to the blower motor.
When your Land Rover needs a top quality replacement Blower Motor Regulator Resistor, there's no need to go somewhere besides the authority, Car Parts Discount. Ordering new Land Rover parts from www.carpartsdiscount.com means you are paying the lowest prices for the most superior original and aftermarket replacement Discovery parts on the internet. Given all the hassles associated with repairing damage to your car or truck, let www.carpartsdiscount.com be the first place you go to make purchasing it easy. Need 2004, 2003, 2002, 2001, 2000, 1999 Land Rover Discovery Blower Motor Regulator Resistor parts? We've got them right here.


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Bossa Woven Top Red
This top is simply stunning: georgeous print, cut and fabric! A very cool feather print on an elegant viscose-cotton fabric and a classy yet easy to wear style. The pin tuck detail with a subtle gathering in the front and back and fabric covered buttons at the cuffs and back are lovely details enriching this special and colorful piece.
Detail & Fit >
True to size. Relaxed fit.
Material & Care >
62% Viscose, 38% Cotton. Machine wash cold.
About maan >
The belgium label maan is a particular gem in the world of kidswear. Their collection is loved for its exquistite mix of prints, unusual yet co-ordinating colours, fabrics and fine details. Creating a look which is classy but unexpected and with a certain edge. The quality of their garnments is superb and the attention they put to details outstanding. But maan is not only a label for fashion savy parents. Children love wearing Maan's clothes because they are bright with original prints, soft to touch, comfortable and easy to wear.


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NP231 Oil Seal Slip Yoke Eliminator Housing
This oil seal from Rugged Ridge fits NP231 transfer cases with a slip yoke eliminator .
Pricing: $3.99
For use with 18676.60 only. Direct OE replacement Jeep parts and accessories built to the original specifications by Omix-ADA. Limited five year Manufacturer's warranty.
- 18676.62
- 18676.62
- 804314123925
- Rugged Ridge
- New
Shipping Information
- Item Requires Shipping
- 0.1 lbs.
- W3.0000" x H0.5000" x L3.0000"
Customer Reviews
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Dog-friendly Linkinhorne Cottages & Ground Floor Facilities
Tucked away in a little known and quite idyllic location in Cornwall, just a few miles from the town of Callington nestling in the valley below Bodmin Moor, is the village of Linkinhorne. A little rural piece of paradise hidden off the tourist routes. Primrose and Snowdrop have been superbly converted from old stone…
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What is JotForm?
JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
At JotForm, we want to make sure that you're getting the online form builder help that you need. Our friendly customer support team is available 24/7.
We believe that if one user has a question, there could be more users who may have the same question. This is why many of our support forum threads are public and available to be searched and viewed. If you'd like help immediately, feel free to search for a similar question, or submit your question or concern.
JotForm Support
Merhaba Hakan Bey,
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Iyi günler.


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Advanced Search
Thirteen-year-old Montgomery doesn't believe in magic. But then, he'd have said people don't live hundreds of meters below London, yet here they are! And in the Underworld city of Lundarien, they have EIGHT kinds of magic - the 'Magic Circles'. Here Montgomery meets Jarfin and others, who show him around the vast city caverns and even take him hunting in the Hanging Forest, and he soon feels more at home in the Underworld than back in his apartment on the Surface.
I'm got a great reader and my concentration is poor, but I listened to the full 6 hours of this book in a single sitting! <br/>I loved the twists a..Show More »nd turns of Montgomery's adventures in Lundarien and the conflict with his 'normal' life in London. If only so many chapters didn't end on cliffhangers I might have spread the listening out over a few days. I'll just have to listen to it again instead.« Show Less


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Blog Posts by Harjit
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Aug 05 2010 (15:41)
Harjit 1 blog posts
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I travelled in Japan's bullet train and our Amritsar Swarna shatabdi is far better than that. Our food quality is much better than there bullet train.
Aug 05 2010 (15:47)
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Guest: 83f2b007 show all posts
Are you rating it just by the food quality? What about the other parameters like Speed , Timeliness, Cleaniness ... ?
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Enayet Shameem 157 blog posts 50 correct pred (72% accurate)
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As an Indian and Punjabi you must like Indian cuisine than pure Japanese
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Ask about the over 50 other support services that are available! Are you travelling and need a boardroom? As a Telsec Business Centres client you can take advatage of over eight hours of free boardroom space and facilities per month in any of over 500 Business Centre locations in 40 countries.
Telsec also has many services that may be of interest as well.
Locations Home >> EE >> Tallinn >>
Office Space and Virtual Offices
Located in: Tallinn,
Lootsa 2,
Location Details:
The environment at this business centre is inspirational to say the least. Perfect for innovative companies, our Ülemiste City centre is in the heart of it all. Strategically located in Nordics' most modern seat of innovation, this centre is energy-aware and environmentally-friendly. Its inspired approach to the creation of a contemporary working environment will leave you and your clients impressed.
Office Space Services: Featuring furnished offices, meeting rooms and more with business center services.
Virtual Office Services: Featuring live telephone answering, advanced telecommunications and business address mail receipt.


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Lockgate Dairy is set in a peaceful location and offers en suite bed and breakfast accommodation, free Wi-Fi and free guest parking. Chichester city centre and the Blue Flag sandy beach at West Wittering are only 10 minutes' drive away.
You can check in between 16:00 - 23:00. You can check out between 06:00 - 11:00.


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Berlin Nightlife
Mark and I got back from Prague by lunch time. I had yet another Doner. I simply cant get enough of these! We spent the rest of the day relaxing and drinking the Belgium beer Mark brought home. I tried a Framboise which was infused with rasberries and I have to admit...I actually enjoyed it! lol. That night Alex and Olli invited us over for dinner at their apt.
Olli made everyone fresh strawberry daquaris before dinner and then she prepared delicious steak salads with baguettes and brie that Mark and I brought along. For desert we had Proseco/energy drink cocktails, (quite an interesting combination), and then she brought out Lindt bars! I tried a square each of blueberry, cayanne pepper and mango!! It was a lovely get together and Olli even hand rolled each of us cigarettes for afterwards!
After a few more cocktails we headed out to a club which was extremely underground! It was filled with German punks and was quite an interesting scene. Drinks were cheap so I was happy and the music was great. When we left at 5AM there was a huge snowstorm going on outside and we all threw snowballs at each other on the way to the S-bahn. What a great tonight! I headed back to Mark's apt to finish packing my suitcase and then I was off to the airport for my 9AM flight...cant wait to SLEEP!
Posted by veranoamor 08:56


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Reception (July, 30)
A reception will follow the conference opening ceremony. Both will take place at Teatro Municipal, the city's Opera House. All conference participants are welcome.
Conference Dinner (August, 2) - SOLD OUT
Conference dinner will take place at one of the most famous barbecue restaurants in town, Porcão Rio's. Various kinds of meat will be served continuously, the so called "rodízio" system. A wide variety of salads, sea food and drinks will also be served. Music and dance will follow. Several Brazilian rhythms will be performed by the famous dancer Carlinhos de Jesus and his group. Dinner tickets cost R$ 140,00 (approx USD 60) per participant. The same applies to accompanying persons. Payment should be made simultaneously with that of the conference registration. A limited number of dinner tickets are available and will be sold on a first come, first served basis.
Spouse's program
Spouses / accompanying persons are offered a number of activities during the symposium. Detailed information and reservations are available on the official tour operator website.