text:
Infective endocarditis
|Infective endocarditis
|Classification and external resources
A mitral valve vegetation caused by bacterial endocarditis.
Infective endocarditis is a form of endocarditis, or inflammation, of the inner tissue of the heart (such as its valves) caused by infectious agents. The agents are usually bacterial, but other organisms can also be responsible.
The valves of the heart do not receive any dedicated blood supply. As a result, defensive immune mechanisms (such as white blood cells) cannot directly reach the valves via the bloodstream. If an organism (such as bacteria) attaches to a valve surface and forms a vegetation, the host immune response is blunted. The lack of blood supply to the valves also has implications for treatment, since drugs also have difficulty reaching the infected valve.
Normally, blood flows smoothly through these valves. If they have been damaged - from rheumatic fever, for example - the risk of bacterial attachment is increased.1
- 1 Classification
- 2 Signs and symptoms
- 3 Cause
- 4 Pathogenesis
- 5 Diagnosis
- 6 Prevention
- 7 Treatment
- 8 References
Historically, infective endocarditis has been clinically divided into acute and subacute1 presentations (because untreated patients tended to live longer with the subacute as opposed to the acute form). This classifies both the rate of progression and severity of disease.
- Subacute bacterial endocarditis (SBE) is often due to streptococci of low virulence and mild to moderate illness which progresses slowly over weeks and months and has low propensity to hematogenously seed extracardiac sites.
- Acute bacterial endocarditis (ABE) is a fulminant illness over days to weeks, and is more likely due to Staphylococcus aureus which has much greater virulence, or disease-producing capacity and frequently causes metastatic infection.1
This classification is now discouraged, because the ascribed associations (in terms of organism and prognosis) were not strong enough to be relied upon clinically. The terms short incubation (meaning less than about six weeks), and long incubation (greater than about six weeks) are preferred.2
Culture results
Infective endocarditis may also be classified as culture-positive or culture-negative. By far the most common cause of a "culture-negative" endocarditis is prior administration of antibiotics.
Sometimes micro-organisms can take a longer period of time to grow in the culture media, such organisms are said to be fastidious because they have demanding growth requirements. Some examples include pathogens like Aspergillus species, Brucella species, Coxiella burnetii, Chlamydia species, and HACEK bacteria. Due to delay in growth and identification in these cases, patients may be erroneously classified as "culture-negative" endocarditis.
Heart side
Endocarditis can also be classified by the side of the heart affected:
- Patients who inject narcotics or other drugs intravenously may introduce infection which will travel to the right side of the heart classically affecting the tricuspid valve, and most often caused by S. aureus.1
- In other patients without a history of intravenous exposure, endocarditis is more frequently left-sided.1
Infection setting
Another form of endocarditis is healthcare associated endocarditis when the infecting organism is believed to be transmitted in a health care setting like hospital, dialysis unit or a residential nursing home. Nosocomial endocarditis is a form of healthcare associated endocarditis in which the infective organism is acquired during stay in a hospital and it is usually secondary to presence of intravenous catheters, Total parenteral nutrition lines, pacemakers, etc.3
Valve type
Finally, the distinction between native-valve endocarditis and prosthetic-valve endocarditis is clinically important. Prosthetic valve endocarditis can be early (< 60 days of valvular surgery), intermediate (60 days to 1 year) or late (> 1 year following valvular surgery).
- Early prosthetic valve endocarditis is usually due to intraoperative contamination or a postoperative bacterial contamination which is usually nosocomial in nature.
- Late prosthetic valve endocarditis is usually due to community acquired microorganisms.3
Signs and symptoms
- Fever occurs in 97% of people; malaise and endurance fatigue in 90% of people.4
- A new or changing heart murmur, weight loss, and coughing occurs in 35% of people.4
- Vascular phenomena: septic embolism (causing thromboembolic problems such as stroke in the parietal lobe of the brain or gangrene of fingers), Janeway lesions (painless hemorrhagic cutaneous lesions on the palms and soles), intracranial hemorrhage, conjunctival hemorrhage, splinter hemorrhages, renal infarcts, and splenic infarcts.
- Immunologic phenomena: Glomerulonephritis which allows for blood and albumin to enter the urine,1 Osler's nodes (painful subcutaneous lesions in the distal fingers), Roth's spots on the retina, positive serum rheumatoid factor
- Other signs may include; night sweats, rigors, anemia, splenomegaly
A common mnemonic for the signs and symptoms of endocarditis is FROM JANE:
- Fever
- Roth's spots
- Osler's nodes
- Murmur
- Janeway lesions
- Anemia
- Nail hemorrhage (splinter hemorrhages)
- Emboli
- microscopic haematuria
- finger clubbing
Many microorganisms can cause infective endocarditis. These are generally isolated by blood culture, where the patient's blood is removed, and any growth is noted and identified. The term bacterial endocarditis (BE) commonly is used, reflecting the fact that most cases of IE are due to bacteria; however, Infective Endocarditis (IE) has become the preferred terms.
Staphylococcus aureus followed by Streptococci of the viridans group and Coagulase negative Staphylococci are the three most common organisms responsible for infective endocarditis. OtherStreptococci and Enterococci are also a frequent cause of infective endocarditis. HACEK group of micro-organisms and Fungi are seen less frequently.5
Viridans Alpha-hemolytic streptococci, that are present in the mouth are the most frequently isolated micro-organisms when the infection is acquired in a community setting. In contrast, Staphylococcus blood stream infections are frequently acquired in a health care setting where they can enter the blood stream through procedures that cause break in the integrity of skin like surgery, catheterisation or during access of long term indwelling catheters or secondary to intravenous injection of recreational drugs.
Enterococcus can enter the bloodstream as a consequence of abnormalities in the gastrointestinal or genitourinary tracts.
Some organisms, when isolated, give valuable clues to the cause, as they tend to be specific.
- Pseudomonas species, which are very resilient organisms that thrive in water, may contaminate street drugs that have been contaminated with drinking water. P. aeruginosa can infect a child through foot punctures, and can cause both endocarditis and septic arthritis.6
- S. bovis and Clostridium septicum, which are part of the natural flora of the bowel, are associated with colonic malignancies. When they present as the causative agent in endocarditis, it usually call for a concomitant colonoscopy due to concerns regarding hematogenous spread of bacteria from the colon due to the neoplasm breaking down the barrier between the gut lumen and the blood vessels which drain the bowel.78
- HACEK organisms are a group of bacteria that live on the dental gums, and can be seen with IV drug users who contaminate their needles with saliva. Patients may also have a history of poor dental hygiene, or pre-existing valvular disease.9
- Less commonly reported etiological bacteria are responsible for so called "culture negative endocarditis". Such bacteria can be identified by serology, culture of the excised valve tissue, sputum, pleural fluid, and emboli; and by polymerase chain reaction or and sequencing of bacterial 16S ribosomal RNA. Such bacteria include Bartonella, Chlamydia psittaci, and Coxiella.10
Multiple case reports of infective endocarditis caused by unusual organisms have been published in literature. Few examples include: Propionibacterium sp., which are normal skin flora, have been responsible for infective endocarditis sometimes leading to deaths due to the indolent course of this abscess producing infection.11Tropheryma whipplei has caused endocarditis without gastrointestinal involvement.12 Citrobacter koseri was found in an immunocompetent adult.13 Neisseria bacilliformis was found in a patient with a bicuspid aortic valve.14
Fungal and Viral
Candida albicans, a yeast, is associated with endocarditis in IV drug users and immunocompromised patients. Other fungi demonstrated to cause endocarditis are Histoplasma capsulatum and Aspergillus.10 Endocarditis with Tricosporon asahii has also been reported in a case report.15
Risk factors
In a healthy individual, a bacteremia (where bacteria get into the blood stream through a minor cut or wound) would normally be cleared quickly with no adverse consequences. If a heart valve is damaged and covered with a piece of blood clot, the valve provides a place for the bacteria to attach themselves and an infection can be established.
In the past, bacteremia caused by dental procedures (in most cases due to streptococci viridans, which reside in oral cavity), such as a cleaning or extraction of a tooth was thought to be more clinically significant than it actually was. However, it is important that a dentist or a dental hygienist be told of any heart problems before commencing treatment. Antibiotics are administered to patients with certain heart conditions as a precaution, although this practice has changed in the US, with new American Heart Association guidelines released in 2007,16 and in the UK as of March 2008 due to new NICE guidelines. Everyday tooth brushing and flossing will similarly cause bacteremia. Although there is little evidence to support antibiotic prophylaxis for dental treatment, the current American Heart Association guidelines are highly accepted by clinicians17 and patients.18
Other conditions that result in high number of bacteria entering into the bloodstream include colorectal cancer (mostly Streptococcus bovis),7 serious urinary tract infections (mostly enterococci), and drug injection (Staphylococcus aureus). With a large number of bacteria, even a normal heart valve may become infected.
A more virulent organism (such as Staphylococcus aureus) can cause infective endocarditis by infecting even a normal heart valve.
Intravenous drug users tend to get their right-sided heart valves infected because the veins that are injected drain into the right side of the heart. In rheumatic heart disease, infection occurs on the aortic and the mitral valves on the left side of the heart.
Other factors that increase the risk of developing infective endocarditis are low levels of white blood cells, immunodeficiency or immunosuppression, malignancy, diabetes, and alcohol abuse.1
As previously mentioned, altered blood flow around the valves contributes to development of endocarditis. The valves may be damaged congenitally, from surgery, by auto-immune mechanisms, or simply as a consequence of old age. The damaged part of a heart valve leads to formation of a local blood clot, a condition known as non-bacterial thrombotic endocarditis (NBTE). Altered blood flow, and thus infective endocarditis, are more likely in high pressure areas. Consequently, ventricular septal defects create more susceptibility than atrial septal defects. Damaged vascular endothelium will also promote platelet and fibrin deposition, upon which bacteria can take hold. Valvular lesions are a major cause of such damage, as are jet lesions resulting from ventricular septal defects or patent ductus arteriosus.
In general, the Duke criteria should be fulfilled in order to establish the diagnosis of endocarditis.19 The blood tests C reactive protein (CRP) and procalcitonin have not been found to be particularly useful in helping make or rule out the diagnosis.20
As the Duke criteria rely heavily on the results of echocardiography, research has addressed when to order an echocardiogram by using signs and symptoms to predict occult endocarditis among patients with intravenous drug abuse212223 and among non drug-abusing patients.2425 Unfortunately, this research is over 20 years old and it is possible that changes in the epidemiology of endocarditis and bacteria such as staphylococci make the following estimates incorrect.
The transthoracic echocardiogram has a sensitivity and specificity of approximately 65% and 95% if the echocardiographer believes there is 'probable' or 'almost certain' evidence of endocarditis.2627
Modified Duke criteria
Established in 1994 by the Duke Endocarditis Service and revised in 2000, the Duke criteria are a collection of major and minor criteria used to establish a diagnosis of endocarditis.1928 A definite diagnosis of infective endocarditis can be established if the following conditions are fulfilled: two major criteria, one major and three minor criteria, or five minor criteria. Diagnosis of infective endocarditis can only be said to be "possible" if only 1 major and 1 minor criteria are fulfilled or if only 3 minor criteria are fulfilled.
Major criteria include:
- Positive blood culture with typical IE microorganism, defined as one of the following:
- Typical microorganism consistent with IE from 2 separate blood cultures, as noted below:
- Viridans-group streptococci, or
- Streptococcus bovis including nutritional variant strains, or
- HACEK group, or
- Staphylococcus aureus, or
- Community-acquired Enterococci, in the absence of a primary focus
- Microorganisms consistent with IE from persistently positive blood cultures defined as:
- Two positive cultures of blood samples drawn >12 hours apart, or
- All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)
- Coxiella burnetii detected by at least one positive blood culture or antiphase I IgG antibody titer >1:800
- Typical microorganism consistent with IE from 2 separate blood cultures, as noted below:
- Evidence of endocardial involvement with positive echocardiogram defined as
- Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation, or
- Abscess, or
- New partial dehiscence of prosthetic valve or new valvular regurgitation (worsening or changing of preexisting murmur not sufficient)
Minor criteria include:
- Predisposing factor: known cardiac lesion, recreational drug injection
- Fever >38°C
- Evidence of embolism: arterial emboli, pulmonary infarcts, Janeway lesions, conjunctival hemorrhage
- Immunological problems: glomerulonephritis, Osler's nodes
- Positive blood culture (that doesn't meet a major criterion) or serologic evidence of infection with organism consistent with IE but not satisfying major criterion
Positive echocardiogram (that doesn't meet a major criterion)(this criterion has been removed from the modified Duke criteria)
Among people who do not use intravenous drugs and have a fever in the emergency room, there is a less than 5% chance of occult endocarditis. Mellors in 1987 found no cases of endocarditis nor of staphylococcal bacteremia among 135 febrile patients in the emergency room.25 The upper confidence interval for 0% of 135 is 5%, so for statistical reasons alone, there is up to a 5% chance of endocarditis among these patients. In contrast, Leibovici found that among 113 non-selected adults admitted to the hospital because of fever there were two cases (1.8% with 95%CI: 0% to 7%) of endocarditis.24
Among people who do use intravenous drugs and have a fever in the emergency room, there is about a 10% to 15% prevalence of endocarditis. This estimate is not substantially changed by whether the doctor believes the patient has a trivial explanation for their fever.23 Weisse found that 13% of 121 patients had endocarditis.21 Marantz also found a prevalence of endocarditis of 13% among such patients in the emergency room with fever.23 Samet found a 6% incidence among 283 such patients, but after excluding patients with initially apparent major illness to explain the fever (including 11 cases of manifest endocarditis), there was a 7% prevalence of endocarditis.22
Among people with staphylococcal bacteremia (SAB), one study found a 29% prevalence of endocarditis in community-acquired SAB versus 5% in nosocomial SAB.29 However, only 2% of strains were resistant to methicillin and so these numbers may be low in areas of higher resistance.
Not all people with heart disease require antibiotics to prevent infective endocarditis. Heart diseases have been classified into high, medium and low risk of developing IE. Those falling into high risk category require IE prophylaxis before endoscopies and urinary tract procedures. Diseases listed under high risk include
- Prior Endocarditis
- Unrepaired cyanotic congenital heart diseases
- Completely repaired congenital heart disease in their first 6 months
- Prosthetic heart valves
- Incompletely repaired congenital heart diseases
- Cardiac transplant valvulopathy
Following are the antibiotic regimens recommended by the American Heart Association for antibiotic prophylaxis:16
- Oral Amoxicillin 1 hour before the procedure
- Intravenous or intramuscular ampicillin 1 hour before the procedure
- In patients allergic to penicillins
- Azithromycin or clarithromycin orally 1 hour before the procedure
- Cephalexin orally 1 hour before the procedure
- Clindamycin orally 1 hour before the procedure
In the UK, NICE clinical guidelines no longer advise prophylaxis because there is no clinical evidence that it reduces the incidence of IE and there are negative effects (e.g. allergy and increased bacterial resistance) of taking antibiotics that may outweigh the benefits.30
Antibiotics were historically commonly recommended to prevent IE in those with heart problems undergoing dental procedures (known as dental antibiotic prophylaxis). They are less commonly recommended for this procedure.
High dose antibiotics are administered by the intravenous route to maximize diffusion of antibiotic molecules into vegetation(s) from the blood filling the chambers of the heart. This is necessary because neither the heart valves nor the vegetations adherent to them are supplied by blood vessels. Antibiotics are continued for a long time, typically two to six weeks depending on the characteristics of the infection and the causative micro-organisms.
In acute endocarditis, due to the fulminant inflammation empirical antibiotic therapy is started immediately after the blood has been drawn for culture. This usually includes vancomycin and ceftriaxone IV infusions until the microbial identification and susceptibility report with the minimum inhibitory concentration becomes available allowing for modification of the antimicrobial therapy to target the specific microorganism. It should be noted that the routine use of gentamicin to treat endocarditis has fallen out of favor due to the lack of evidence to support its use (except in infections caused by Enterococcus and nutritionally variant streptococci) and the high rate of complications.31
In subacute endocarditis, where patient's hemodynamic status is usually stable, antibiotic treatment can be delayed till the causative microorganism can be identified.
The most common organism responsible for infective endocarditis is Staphylococcus aureus,5 which is resistant to penicillin in most cases. High rates of resistant to oxacillin are also seen, in which cases treatment with vancomycin is required.
Viridans group streptococci and Streptococcus bovis are usually highly susceptible to penicillin and can be treated with penicillin or ceftriaxone.32
Relatively resistant strains of viridans group streptococci and Streptococcus bovis are treated with penicillin or ceftriaxone along with a shorter 2 week course of an aminoglycoside during the initial phase of treatment.32
Highly penicillin resistant strains of viridans group streptococci, nutritionally variant streptococci like Granulicatella sp., Gemella sp. and Abiotrophia defectiva, and Enterococci are usually treated with a combination therapy consisting of penicillin and an aminoglycoside for the entire duration of 4–6 weeks.32
Selected patients may be treated with a relatively shorter course of treatment32 (2 weeks) with benzyl penicillin IV if infection is caused by viridans group streptococci or Streptococcus bovis as long as the following conditions are met:
- Endocarditis of a native valve, not of a prosthetic valve
- An MIC ≤ 0.12 mg/l
- Complication such as heart failure, arrhythmia, and pulmonary embolism occur
- No evidence of extracardiac complication like septic thromboembolism
- No vegetations > 5mm in diameter conduction defects
- Rapid clinical response and clearance of blood stream infection
Additionally oxacillin susceptible Staphylococcus aureus native valve endocarditis of the right side can also be treated with a short 2 week course of beta lactam antibiotic like nafcillin with or without aminoglycosides
Surgical debridement of infected material and replacement of the valve with a mechanical or bioprosthetic artificial heart valve is necessary in certain situations:33
‣ Patients with significant valve stenosis or regurgitation causing heart failure ‣ Evidence of hemodynamic compromise in the form of elevated end diastolic left ventricular or left atrial pressure or moderate to severe pulmonary hypertension ‣ Presence of intracardiac complications like paravalvular abscess, conduction defects or destructive penetrating lesions ‣ Recurrent septic emboli despite appropriate antibiotic treatment ‣ Large vegetations (> 10 mm) ‣ Persistent positive blood cultures despite appropriate antibiotic treatment ‣ Prosthetic valve dehiscence ‣ Relapsing infection in the presence of a prosthetic valve ‣ Abscess formation ‣ Early closure of mitral valve ‣ Infection caused by Fungi or resistant Gram negative bacteria
Infective endocarditis is associated with 18% in-hospital mortality.5
- ^ a b c d e f g Mitchell RS, Kumar V, Robbins SL, Abbas AK, Fausto N (2007). Robbins Basic Pathology (8th ed.). Saunders/Elsevier. pp. 406–8. ISBN 1-4160-2973-7.
- ^ Morris AM (January 2006). "How best to deal with endocarditis". Curr Infect Dis Rep 8 (1): 14–22. doi:10.1007/s11908-006-0030-8. PMID 16448596.
- ^ a b Kasper DL, Brunwald E, Fauci AS, Hauser S, Longo DL, Jameson JL (May 2005). Harrison's Principles of Internal Medicine. McGraw-Hill. pp. 731–40. ISBN 0-07-139140-1. OCLC 54501403 56437106 56801936 56967424.
- ^ a b Amal Mattu; Deepi Goyal; Barrett, Jeffrey W.; Joshua Broder; DeAngelis, Michael; Peter Deblieux; Gus M. Garmel; Richard Harrigan; David Karras; Anita L'Italien; David Manthey (2007). Emergency medicine: avoiding the pitfalls and improving the outcomes. Malden, Mass: Blackwell Pub./BMJ Books. p. 63. ISBN 1-4051-4166-2.
- ^ a b c Murdoch, DR; et al. (9 March 2009). "Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study". Archives of Internal Medicine 169 (5): 463–73. doi:10.1001/archinternmed.2008.603. PMC 3625651. PMID 19273776.
- ^ Topics in Infectious Diseases Newsletter, August 2001, Pseudomonas aeruginosa.
- ^ a b Gold, JS; Bayar, S, Salem, RR (July 2004). "Association of Streptococcus bovis bacteremia with colonic neoplasia and extracolonic malignancy". Archives of surgery (Chicago, Ill. : 1960) 139 (7): 760–5. doi:10.1001/archsurg.139.7.760. PMID 15249410.
- ^ Chew SSB, Lubowski DZ (2001). "Clostridium septicum and malignancy". ANZ Journal of Surgery 71 (11): 647–649. doi:10.1046/j.1445-1433.2001.02231.x. PMID 11736823.
- ^ Mirabelle Kelly, MD (June 7, 2005). "HACEK Group Infections".
- ^ a b Lamas, CC; Eykyn, SJ (March 2003). "Blood culture negative endocarditis: analysis of 63 cases presenting over 25 years". Heart 89 (3): 258–262. doi:10.1136/heart.89.3.258. PMC 1767579. PMID 12591823.
- ^ Clayton, JJ; et al. (August 2006). "Endocarditis caused by Propionibacterium species: a report of three cases and a review of clinical features and diagnostic difficulties". Journal of Medical Microbiology 55 (8): 981–987. doi:10.1099/jmm.0.46613-0. PMID 16849716.
- ^ Dreier, J; et al. (2004). "Tropheryma whipplei Infection of an acellular porcine heart valve bioprosthesis in a patient who did not have intestinal Whipple's disease". Journal of Clinical Microbiology 42 (10): 4487–4493. doi:10.1128/JCM.42.10.4487-4493.2004. PMC 522317. PMID 15472298.
- ^ Dzeing-Ella, A; Szwebel, T. A.; Loubinoux, J.; Coignard, S.; Bouvet, A.; Le Jeunne, C.; Aslangul, E. (December 2009). "Infective endocarditis due to Citrobacter koseri in an immunocompetent adult". Journal of Clinical Microbiology 47 (12): 4185–4186. doi:10.1128/JCM.00957-09. PMC 2786675. PMID 19812281.
- ^ Masliah-Planchon, J; et al. (June 2009). "Endocarditis due to Neisseria bacilliformis in a patient with a bicuspid aortic valve". Journal of Clinical Microbiology 47 (6): 1973–1975. doi:10.1128/JCM.00026-09. PMC 2691068. PMID 19386832.
- ^ Izumi, K; et al. (October 2009). "A rare case of infective endocarditis complicated by Trichosporon asahii fungemia treated by surgery". Annals of Thoracic and Cardiovascular Surgery 15 (5): 350–353. PMID 19901894.
- ^ a b Wilson W, Taubert KA, Gewitz M, et al. (October 2007). "Prevention of infective endocarditis: guidelines from the American Heart Association". Circulation 116 (15): 1736–54. doi:10.1161/CIRCULATIONAHA.106.183095. PMID 17446442.
- ^ Zadik Y, Findler M, Livne S, et al. (December 2008). "Dentists' knowledge and implementation of the 2007 American Heart Association guidelines for prevention of infective endocarditis". Oral Surg Oral Med Oral Pathol Oral Radiol Endod 106 (6): e16–9. doi:10.1016/j.tripleo.2008.08.009. PMID 19000604.
- ^ Elad S, Binenfeld-Alon E, Zadik Y, Aharoni M, Findler M. (March 2011). of acceptance of the 2007 American Heart Association Guidelines for the prevention of infective endocarditis: A pilot study "Survey of acceptance of the 2007 American Heart Association guidelines for the prevention of infective endocarditis: a pilot study". Quintessence Int 42 (3): 243–51. PMID 21465012.
- ^ a b Durack D, Lukes A, Bright D (1994). "New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service". Am J Med 96 (3): 200–9. doi:10.1016/0002-9343(94)90143-0. PMID 8154507.
- ^ Yu, CW; Juan, LI; Hsu, SC; Chen, CK; Wu, CW; Lee, CC; Wu, JY (June 2013). "Role of procalcitonin in the diagnosis of infective endocarditis: a meta-analysis.". The American journal of emergency medicine 31 (6): 935–41. PMID 23601504.
- ^ a b Weisse A, Heller D, Schimenti R, Montgomery R, Kapila R (1993). "The febrile parenteral drug user: a prospective study in 121 patients". Am J Med 94 (3): 274–80. doi:10.1016/0002-9343(93)90059-X. PMID 8452151.
- ^ a b Samet J, Shevitz A, Fowle J, Singer D (1990). "Hospitalization decision in febrile intravenous drug users". Am J Med 89 (1): 53–7. doi:10.1016/0002-9343(90)90098-X. PMID 2368794.
- ^ a b c Marantz P, Linzer M, Feiner C, Feinstein S, Kozin A, Friedland G (1987). "Inability to predict diagnosis in febrile intravenous drug abusers". Annals of Internal Medicine 106 (6): 823–8. doi:10.7326/0003-4819-106-6-823. PMID 3579068.
- ^ a b Leibovici L, Cohen O, Wysenbeek A (1990). "Occult bacterial infection in adults with unexplained fever. Validation of a diagnostic index". Arch Intern Med 150 (6): 1270–2. doi:10.1001/archinte.150.6.1270. PMID 2353860.
- ^ a b Mellors J, Horwitz R, Harvey M, Horwitz S (1987). "A simple index to identify occult bacterial infection in adults with acute unexplained fever". Arch Intern Med 147 (4): 666–71. doi:10.1001/archinte.147.4.666. PMID 3827454.
- ^ Shively B, Gurule F, Roldan C, Leggett J, Schiller N (1991). "Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis". J Am Coll Cardiol 18 (2): 391–7. doi:10.1016/0735-1097(91)90591-V. PMID 1856406.
- ^ Erbel R, Rohmann S, Drexler M, et al. (1988). "Improved diagnostic value of echocardiography in patients with infective endocarditis by transoesophageal approach. A prospective study". Eur Heart J 9 (1): 43–53. PMID 3345769.
- ^ Li, J. S.; Sexton, D. J.; Mick, N.; Nettles, R.; Fowler, V. G.; Ryan, T.; Bashore, T.; Corey, G. R. (2000). "Proposed Modifications to the Duke Criteria for the Diagnosis of Infective Endocarditis". Clinical Infectious Diseases 30 (4): 633. doi:10.1086/313753. PMID 10770721.
- ^ Kaech C, Elzi L, Sendi P, et al. (2006). "Course and outcome of Staphylococcus aureus bacteraemia: a retrospective analysis of 308 episodes in a Swiss tertiary-care centre". Clin Microbiol Infect 12 (4): 345–52. doi:10.1111/j.1469-0691.2005.01359.x. PMID 16524411.
- ^ "Prophylaxis against infective endocarditis: Antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures". NICE Clinical Guidelines. National Institute for Health Care and Excellence (UK). March 2008. Retrieved 2013-04-30.
- ^ Cosgrove SE, Vigliani GA, Campion M, et al. (2009). "Initial low‐dose gentamicin for Staphylococcus aureus bacteremia and endocarditis is nephrotoxic". Clin Infect Dis 48 (6): 713–21. doi:10.1086/597031. PMID 19207079.
- ^ a b c d Baddour, LM; et al. (14 June 2005). "Infective Endocarditis Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: Endorsed by the Infectious Diseases Society of America". Circulation 111 (23): e394–e434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145.
- ^ Bonow, RO; et al. (23 September 2008). "2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Journal of American College of Cardiology 52 (13): e1–142. doi:10.1016/j.jacc.2008.05.007. PMID 18848134.
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Tea Rex
Molly Idle - Author
Hardcover | $16.99 | add to cart | view cart
ISBN 9780670014309 | 40 pages | 09 Apr 2013 | Viking Children's | 9.25 x 6.25in | 3 - 5 years
Summary of Tea Rex Summary of Tea Rex Reviews for Tea Rex An Excerpt from Tea Rex
Some tea parties are for grown-ups.
Some are for girls.
But this tea party is for a very special guest.
And it is important to follow some rules . . .
like providing comfortable chairs,
and good conversation,
and yummy food.
But sometimes that is not enough for special guests,
especially when their manners are more Cretaceous than gracious . . .
Introducing Tea Rex, a guest that just about any child would love to have to tea!
Praise for Tea Rex by Molly Idle:
"Sure to be enjoyed by tea-party enthusiasts, and even dino fans with no use for a teapot will find themselves drawn to this clever tale of a not-entirely-civilized beast of the past." —Kirkus
"…Idle has a gift for comic composition..." —Publishers Weekly
"The tension between the text and illustrations provides much to amuse the youngest tea-party hosts." —School Library Journal
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5110 Pendant
Pendant 5110 features a white, polished brass, satin steel, polished brass, polished copper, rosewood or a galvanized finish. One 100 watt, 120 volt, A19 medium base incandescent lamp not included. General light distribution. UL listed. 12 inch diameter x 7 inch height.
|Dimensions: 12"L x 7"H x 12"W
|Lamp Source: Incandescent
|Bulb: 1 x A19/Medium (E26)/72W/120V Incandescent
Bulb not included
|Dimmer: Incandescent
About Hilite
Hi-Lite Manufacturing Company was founded in 1958. Born of ingenuity and ambition, Hi-Lite achieved success through attention to detail and stubbornness to only manufacturer the highest quality product. Hi-Lite has built its reputation as a premier lighting manufacturer by using only the finest raw materials, inspirational designs, and unparalleled service. Hi-Lite welcomes you to enjoy our designs, service, and quality. Through all the years we have stayed true to our belief that American made quality combined with affordability still matters.


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Crossing the Unknown Sea
Work as a Pilgrimage of Identity
David Whyte - Author
Crossing the Unknown Sea shows how poetry and practicality, far from being mutually exclusive, reinforce each other to give every aspect of our lives meaning and direction. For anyone who wants to deepen their connection to their work-or find out what their life's work is-this book is essential to navigating the way.
"Readers who accept poet and Fortune 500 consultant Whyte's invitation to enter into 'an imaginative conversation about life and work' are likely to be challenged as well as delighted by the beauty of his writing and the expansiveness of his views. Gracefully using the metaphor of a sea voyage to depict the journey through the world of work, Whyte views work not only as a means of support, but as a means for interacting with the world and developing self-expression and identity...An abundance of provocative ideas... thoughtful readers will wholeheart-edly savor this book." (Publishers Weekly, starred review)
Mid Ocean
"Crossing the Unknown Sea is like a grail that reconfers dignity to what has been demeaned by our preoccupation with monetary wealth."Paul Hawken, author of The Ecology of Commerce
"Managers might do well to ditch wishy-washy motivational speakers and instead hire the fiery David Whyte to stir creativity and imagination in their employees."USA Today
"Keep this beautiful book with you and you will discover, as I have, a still point amid our slightly mad world."Peter Senge, author of the The Fifth Discipline and coauthor of Schools That Learn
To keep up-to-date, input your email address, and we will contact you on publication
Please alert me via email when:


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Kiplinger's Ranks UNC Asheville Among the Best Educational Values in Nation
Wed, 01/06/2010 - 11:25am
With the cost of college on the minds of many high school students and parents, a timely survey from Kiplinger's Personal Finance of the nation's 100 best values in public colleges was released this week. The annual list ranks four-year institutions that combine outstanding education with economic value.
The survey, published online and in the February print edition of Kiplinger's, ranks UNC Asheville 44th in the nation as a best value for in-state students and 50th in the nation as a best value for out-of-state students.
Selected from a pool of more than 500 public colleges and universities, Kiplinger's 100 best value colleges were ranked according to academic quality, retention rates, student-faculty ratios, graduation rates and cost and financial aid.
Other North Carolina schools to make the list include UNC Chapel Hill, North Carolina State University, Appalachian State, UNC Wilmington and North Carolina School of the Arts. The complete list is online.
Earlier this academic year, UNC Asheville received high marks from U.S. News & World Report's "America's Best Colleges" in several key categories, including for commitment to teaching, innovation, undergraduate research and affordability. In addition, the 2010 edition of the "Fiske Guide to Colleges," UNC Asheville landed a spot on the Best Buy list of American and Canadian colleges for the 16th consecutive year. The University was also among just 50 institutions nationwide named to the Princeton Review's "Best Value" Public Colleges list.


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Trainers Near You
Ashburn VA change location
Sharon Bourke
rockville, MD
Emmett Lewis Conner
burke, VA
Lisa Bucci
rockville, MD
ACE Fit Share
We have a wide selection of upper body workout routines and strength training exercises designed for all fitness levels. Target all areas of your body from your shoulders and upper arms to your thighs and lower abs with these full-body exercises. The American Council on Exercise is committed to helping all workout enthusiasts reach their fitness goals safely and efficiently. For full-body workouts featuring these exercises, visit our Workouts section.
Fit Life Articles
While most people associate February with Valentine's Day, it's also American Heart Month. This is a great time to think about ways to improve our heart health, which is so important given the high incidence of heart disease among Americans. So, while you're celebrating...
The list of benefits that come from high-intensity interval training (HIIT) is a long one—increased calorie burning, metabolism and endurance, to name just a few. Whether you're an experienced HIIT devotee or a newbie, incorporating these treadmill intervals into your...
To train the core the way it is designed to work, we need to get off of the floor and train the muscles from a standing position so they learn how to stabilize the body while working against the forces of gravity. Here are some great exercises to help you do just that.
ACE Pro Homepage
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4851 Paramount Drive, San Diego, California 92123 1 (888)-825-3636


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Welcome to UBS Funds
We offer a comprehensive range of investment and mutual funds. UBS Funds are the proprietary funds of UBS Global Asset Management and are available in the following countries.
Please select your country of residence:
Products and services in these webpages may not be available for residents of certain nations. Please consult the sales restrictions relating to the service in question for further information.
© UBS 1998 - 2014. All rights reserved.


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Lynette's surprise at seeing Preston and Porter pull into the driveway turns into a full panic attack once she realizes they have luggage with them. The boys were evicted from their apartment. They need a place to stay. Lynette tries to lock the doors, but the twins deftly play the "children of divorce" card to finally gain access to their new/old home. Later, they overhear Susan telling their mom about Julie's pregnancy.
Susan hears Julie making plans to meet the father of her baby at a coffee shop. She does a stakeout to learn that her baby's baby daddy is Porter Scavo! Susan is horrified until she realizes that he wants to keep the baby. If Julie doesn't want the kid, he'll raise her by himself. Susan offers Porter her full support. The first thing he'll need her to do is break the news to his mom.
Lynette takes the baby news in stride. Wait, no she doesn't. She completely freaks, especially when she learns Porter intends to raise the baby solo. Lynette tries to make her son understand that he's not ready to be a father. Porter doesn't disagree. But he vows to do whatever it takes for his daughter. He says, "She's not even born yet and I can't believe how much I'm dying to see her." In other words, he loves her. He really, really loves her.
Use a Facebook account to add a comment, subject to Facebook's Terms of Service and Privacy Policy. Your Facebook name, photo & other personal information you make public on Facebook will appear with your comment, and may be used on ABC's media platforms. Learn more.


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SUU Digital Library
The social institutions of the English people will be carefully considered, with a view of learning the lessons to be drawn, from the great social, religious and political changes in the History of England. The Norman conquest, the commonwealth and the revolution of 1688 mark epochs in this work about which cluster minor events preceding and following each. An attempt will be made to place these events into their logical groups.
European History. This course will cover the period from the commencement of the crusades to the First Hague Conference. A brief survey of the Hague Conference will be made.
The results of the religious enthusiasm and desire for adventure which were the main-springs of the crusades, will be classified and the ways by which the great Christian church developed its power and the means by which it maintained that power will unfold as the topics are developed. This is one of the most interesting periods of all history. Only mature students will be registered for this course.
Mr. Tollestrup.
Vocal Music. Instruction in the vocal music class will consist in reading the Scale, Sight-Reading to enable the student to read at sight any of the simpler musical compositions, writing from sound, Choral work, Choir singing and Church music.
Two hours per week.


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Animal Nation recently visited the Georgia Aquarium, where Bridget got to dive with whale sharks. They may be the largest fish in the ocean, but these sharks are gentle giants: filter feeders who rely on plankton and fish eggs to survive.
The Georgia Aquarium is the only place in the United States where you can see whale sharks in captivity. They're a part of the aquarium's Ocean Voyager exhibit, a football field-sized, 6.3 million gallon tank which features not only whale sharks, but manta rays, eagle rays, tiger sharks, sawfish, guitarfish, groupers and other tropical fish that are found in warm open ocean waters throughout the world.
Swimming with Whale SharksBy Bridget Marquardt | Animal Nation – Sat, Aug 18, 2012 12:08 AM EDT
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Hold onto it for the museum of primitive mechanical obnoxious devices after you tear it all out.
Looks like that primitive gear driven computer from about 1500bc that they dug out of the Aegean sea a few years back.
Eight years ago we purchased our home in Pflugerville (North of Austin TX) and it had this ancient-looking Rainsoft water softener installed and working fine. It always provided satisfactory service until a year or so ago when it started using less and less salt, and finally my wife is complaining about the taste of the water and the softener seems to use no salt. I went to poke at it and found that Rube Goldberg apparently started as a Rainsoft engineer and this thing has no manual and I'm no water softener guru.
The problem that really brought me here is the yellow transparent cylinder with a ball floating inside it. This looks like a check valve to me. It was covered with crazing and it started spraying like mad through all the cracks when I switched the valve to and from bypass. Broken, anonymous part, strike one.
It always screamed pretty loud during a regeneration cycle, and when I left it running a cycle the other day it stayed stuck screaming in the Brine 3 position for several hours before I left it in Bypass and went to bed. At one point as I was twiddling the dial it started letting water into the line to the salt tank, but I didn't dig out 3 feet of salt to see if it took the brine up again (yet). The thing sounds like a clock and does advance, but it doesn't advance all the way around the dial. Sticking mechanism, strike 2
I'm pretty sure the resin is at least 20 years old, and needs replacement - strike 3
It looks like a solenoid coil in there is corroding - strike 4, Something Must Be Done! The resin and salt tanks and plumbing seems like I should be able to re-use, and I'm not a fan of paying the same number of dollars for some chinese pile of junk from Sears, so here is where I think I stand:
- I'd like to repair this dinosaur if possible
- Couple hundred bucks for a new head made in this century
- Hundred or two for a fresh load of resin
- Can anyone tell me how this "Rainsoft Electronic Brain" is supposed to work, including what I should be able to see happening at what point in the cycle?
- Will a leaking check valve make it stop advancing on the cycle timer wheel programming whaziz?
- Is it rebuildable or is it too old? I have more time than money available - is there something likely wrong with this that I could fix?
- What is this leaking plastic cylinder thingy and where can I get another one?
- Will I need a new bypass valve assembly if I replace the timer/valve bits?
- Is there any place anyone can recommend for buying parts/supplies?
In all its glory:
Looks old, looks like a manual probably came with it.
Can I buy a vowel? Skip wheel knobs set like they mean it, time of day setting seems to set, big program knob rotates/clicks, switches all seem to "do something", regen time thing just spins with no resistance
Silicone & packing tape stopped the gross leaks, still drips pretty fast out from under the tape
Hold onto it for the museum of primitive mechanical obnoxious devices after you tear it all out.
Looks like that primitive gear driven computer from about 1500bc that they dug out of the Aegean sea a few years back.
I spend 13 years in the water business in Round Rock. The best person you can call is Tommy Dorsey Water in RR. He has been in the water treatment business for over 40 years and will give you a great price.
I'll look him up, thanks. Sorry about the delay my whole family came down with something nasty all yesterday.
So nobody knows much about the electromechanical wonder then? Oh well. I guess worst case I could try a manual regeneration (pour salty water in the tank and let sit) so the water isn't so nasty.
I know of two new timers, but with the rest of the valve the way it is and most likely in need of a rebuild... would it be worth replacing the timer and not rebuild the rest of the valve? The rest of the valve most likely does not have parts save for some one that has one on a shelf that is used but has not found its way the the dump...
The timer has the before micro switches...
Welcome to Terry's Forums David,
Any repair would be a waste of money, I think.
It was a good one in its day, but ballvalve is correct; "Hold onto it for the museum of primitive mechanical obnoxious devices after you tear it all out." , It was a work of art, Years ago, and did work. They also wasted salt, and made the water salty tasting.
Have a Great day.
Last edited by DonL; 06-03-2011 at 08:43 AM.
Theory only works perfect in a vacuum.
Cyber Security Protection for Windows C:\ > WWW.WinForce.Net
That is an OLD Rainsoft "70's". The part you have all goobered up is part of the brine assembly. There is a check ball in there that seats when the brine draw cycle is done.
The system will never work with all that goobered up. The PINS control when it regenerates, PIN OUT indicates day of regeneration.
It is time to replace the Dinosaur. Putting any money into this is pointless.


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Event Details
March for Life Rally
The annual March for Life Rally is from noon-1pm on Thursday, January 22, 2015 and as customary, will be on the National Mall. The March begins immediately after the Rally and follow its route up Constitution Avenue to the U.S. Supreme Court Building on Capitol Hill.
Download our Planning Guide with Checklist and Frequently Asked Questions:
Information on Hotel Reservations for the 2015 March for Life will be available later this year.
While you are in D.C.:
Rose Dinner
The Rose Dinner is held on the evening of the March for Life and begins with a cocktail hour at 6pm, followed by dinner at 7pm. Ryan Bomberger of the Radiance Foundation keynoted the 2014 Rose Dinner. Pictures coming soon.
Information about the 2015 Rose Dinner will be available later this year.
Exhibitor Show
The March for Life Exhibitor Show is open to the public and there is no charge to attend. The Exhibitor Show is an opportunity for pro-life organizations to share information about their organization and network with attendees of the March for Life and related events. The show is open the day before, and the day of the March for Life.
Information about the 2015 Exhibitor Show will be available later this year.
Youth Rally
The March for Life Youth Rally is held the day before the March for Life from 2:00 PM to 5:00 PM. Pictures will be available soon.
Information about the 2015 Youth Rally will be available later this year.
The Law Conference
The March for Life Law Conference, featuring the Law of Life Summit 4 and the Law Symposium, was held on Tuesday, January 21, 2014, at the Hyatt Regency hotel. This conference was co-sponsored by the March for Life Education and Defense Fund, Ave Maria School of Law and Americans United for Life.
Information about the 2015 Law Conference will be available later this year.
Nellie Gray 5K Run/Walk
The Second Annual Nellie Gray 5K, hosted by the National LIFE Runners Team, was unfortunately cancelled due to the extreme weather conditions. Information about a make-up date for the event will be made available as an opportunity arises.
Information about the 2015 Nellie Gray 5K will be available later this year.
March for Life Journal
The March for Life Journal, previously known as the Annual Report, is a publication available each January by the March for Life Education and Defense Fund. The Journal provides pro-life resources based on the theme of the March for Life, a history of the March, and also acts as a program for all official events of the annual March. The 2014 Journal will also include the Student Contest Winners and their winning entries.


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Going to Spellhold
Posted 18 July 2004 - 04:13 AM
<CamDawg> Yep. They're generally of the nature 'don't annoy Idobek.'
Posted 18 July 2004 - 04:29 AM
Seriously, though, Ido has a point.
<jcompton> Suggested plugs include "Click here so Compton doesn't ban me. http://www.pocketplane.net/ub"
The most reliable way to get hold of me is via email (button when viewing my profile).
Posted 18 July 2004 - 04:29 AM
Edited by khayman, 18 July 2004 - 04:31 AM.
Posted 18 July 2004 - 08:59 AM
Q: Is it going to be WeiDU?
A: No, it`s going to involve overwriting files in your override directory and will contain a custom DIALOG.TLK file. The player will also need to manually edit various 2DA files and scripts to make the mod running, it is only going to be compatible with The Darkest Day.
Oh man, you almost got me with that!!! You shouldn't do that to an old man...
Anyway, another mod I'm very much looking forward to!
Posted 18 July 2004 - 10:37 AM
because neeber said the underdark had cool stuff?
no really, just being able to own spellhold would be a good enough reason, i think...
hmmm...how about graft and corruption???
spell hold has a weekly maintainence of 2000 gp...this number is completely fabricated, the asylum only needs 500 gp to run...one of the hidden perks in the spellhold stronghold is skimming off the top, which compensates for being almost exiled if a cowles is chosen to be the director of spell hold...various documents near jon's notes tells you the details of the various scams previous directors used to get as much money as possible...of course you can turn in the documents to inspector brega at the gov district...
corruption..once a month, didi's (the shapeshifting girl) parents show up in spellhold, with a purse of 1000 gold to be spent on their little girl, to make her life better...you can either use the money for its purpose, get her cookies and milk and good food, keep the money, or when you find out her wealthy merchant family is moving to waterdeep, to move to the center of their trading empire, you can just send someone to fetch her, and you just smile as you push her into the arms of her mommy and daddy...
Posted 18 July 2004 - 07:17 PM
But if you're involved with the Cowled Wizards there must be several good reasons to head on out there. Are they sending you out there to discover why the director hasn't been checking in recently? Are they sending you out to escort a dangerous deviant into custody? Has Irenicus himself sent feelers back and, as the director, requested your presence? I'm sure all these work.
Click here to visit Aklon's G3 page.
Cam is on some kind of crack or something... either that, or it's the influence of Dr. Feelgood. - Icelus
The second confusing thing about Australia are the animals. They can be divided into three categories: Poisonous, Odd, and Sheep.
-Douglas Adams
Posted 18 July 2004 - 08:00 PM
Edited by BobTokyo, 18 July 2004 - 08:00 PM.
Posted 19 July 2004 - 11:14 AM
Posted 19 July 2004 - 11:25 AM
BobTokyo, on Jul 18 2004, 08:05 PM, said:
I understand that folks prefer code that works. -CamDawg, G3
Posted 19 July 2004 - 09:40 PM
Once there, the PC might of course, try to leave again - probably with Claire and Sanik's captain. The desharik would have to intervene at that point. He'd have been informed (by Saemon, I bet) that vampires had appeared in his town and would want the PC to take care of them. If the PC still refuses the desharik would probably start a fight with the party and lose it. However, the panic caused by the appearance of vampires and the demise of the desharik has caused the residents to load all they could onto every available ship and depart. This leaves the party stuck on Brynnlaw with no help and no place to go but Spellhold. If the party still won't go to Spellhold, vampire attacks every night and each time they try to rest indoors, should get the message across.
This is still a railroad solution of course but not so obviously so. Another tactic would simply be to have Bodhi and her minions attack whatever place the PC is in and plant the word among the civilians that the "PC's curse" is the reason for the Undead infestation. This would eventually mean that every NPC in the game would either attack the PC or run away. Plus, the vampires would also begin attacking the party. Eventually, the PC will can flat out be told (by one of the vampires) that Irenicus' enmity is behind all this and that Spellhold is the place to deal with it.
Edited by Hendryk, 19 July 2004 - 09:55 PM.
Posted 20 July 2004 - 03:59 AM
Posted 20 July 2004 - 04:33 AM
<jcompton> Suggested plugs include "Click here so Compton doesn't ban me. http://www.pocketplane.net/ub"
The most reliable way to get hold of me is via email (button when viewing my profile).
Posted 20 July 2004 - 06:28 AM
I like this one It's devious and sends the message accross.
I understand that folks prefer code that works. -CamDawg, G3
#14 Guest_Guest_*
Posted 23 July 2004 - 01:12 AM
Posted 25 July 2004 - 04:12 AM
Well, you see, I really dont give a damn about Imoen, and i dont care for power, just like Idobek. Thing is, if you are like this, you just HAVE to go to spellhold anyway to end the damned game. If i was truly rolaplaying i could say i'd live a really quiet SIMs life in Amn, but lets get real, i kill imoen in sight (then dump her body in the road) and i STILL have to pretend i care and go to spellhold to finish the game.
i like the idea, but why would a vampire... say, your enemies "the bad dude whos behind your downfall is irenicus and he's hiding in spellhold" like... it sounds like a james bond cliche, no? the bad guy telling you their exact plan while he thinks you are about to die?
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Above: Healthcare conference team.
The key challenge that healthcare enterprise leaders face is determining how to drive innovation while addressing problems of affordability, inefficiency and gaps in quality. This task is now complicated by strong economic headwinds that limit the resources available to attack these problems. Industry executives are also dealing with new sets of competitive and regulatory pressures on their efforts to drive business growth.
At Columbia Business School's 5th Annual Healthcare Conference held in New York City on November 21, over 500 students, alumni and other professionals heard more than 40 speakers and panelists discuss these issues.
The featured healthcare leaders said they are embracing change to develop creative solutions to the industry's growing problems and to provide attractive investment opportunities on a global basis. A career strategies panel of executive and corporate recruiters also presented their views on the skills and talents necessary for healthcare professionals to succeed in this dynamic environment. This was followed by a concluding career fair and networking reception with the conference's 17 corporate sponsors.
Ed Ludwig '75, chairman and CEO of BD (Becton, Dickinson), gave the opening keynote address. Ludwig said that a successful global healthcare company must use technology, scale, global reach and operational excellence to offer value-added products. These products should reduce costs, enhance the quality of patient care and generate sustainable earnings growth.
Following his remarks, four concurrent panels took place in the morning session on the topics of pharma and biotech, medical devices, diagnostics and payor/provider issues.
The pharma and biotech panel discussed the trend among companies to narrow their therapeutic priorities, focus on biologics, pursue licensing and target acquisitions and seek enhanced productivity and cost savings. Numerous early-stage biotechnology companies are turning to larger pharma and biotechnology firms to survive as they are unable to secure capital from the public market. Global medical device companies are seeking to introduce innovative and cost-effective products in a challenging regulatory and pricing/reimbursement environment and pursuing acquisitions and new markets to meet growth objectives. The consensus of the payor/ provider panel was that any healthcare reform in 2009 would likely be incremental due largely to economic and political headwinds, and that a key focus would be on information technology and expanding access to those without insurance coverage.
Robert Essner, former Chairman and CEO of Wyeth Pharmaceuticals and now executive-in-residence at Columbia Business School, provided the lunchtime keynote speech. He suggested that although the pharma industry faces significant challenges, the combination of new drugs, biologics and vaccines in key areas of unmet need (e.g. Alzheimer's, cancer, congestive heart failure) and the massive influx of informed baby boomers, who are demanding health solutions, provides favorable long-term growth prospects for innovative global pharmaceutical companies.
Three afternoon panels covered M&A, life science investments and emerging markets. It is anticipated that healthcare M&A will remain active across all sectors and that consolidation among Big Pharma companies appears inevitable. Early-stage life science companies and investors face a capital squeeze, which is threatening the viability of existing companies with lower levels of funds available for new investment. Emerging markets are an increasing focus for global pharmaceutical and medical device companies that are seeking new markets for their products.
The final panel of the day focused on the changing talent acquisition and development strategies of major healthcare enterprises. Panelists commented that successful leaders will need to have global and cross-functional experiences; that employees should be open to lateral moves that broaden their skills and experiences; and that healthcare companies considering new hires are seeking a broader "toolkit" of skills that reach beyond the traditional focus on healthcare backgrounds.
For more information about the conference and sponsors visit www.cbshealthcareconference.com.


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It's Called a Breakup Because It's Broken: The Smart Girl's Break-Up Buddyby Greg Behrendt
Synopses & Reviews
Publisher Comments:
Theres no doubt about it—breakups suck. But in the first few hours or days or weeks that follow, theres one important truth you need to recognize: Some things cant and shouldnt be fixed, especially that loser who dumped you or forced you to dump him. Its called a breakup because its broken, and starting right here, right now, its time to dry your tears, put down that pint of ice cream, log out of his e-mail, and open this book to Chapter One-and start turning your breakup into a breakover.
From Greg Behrendt, the co-author of the smash two-million copy bestseller Hes Just Not That Into You, comes Its Called a Breakup Because Its Broken--the ultimate survival guide to getting over Mr. Wrong and reclaiming your inner Superfox. From how to put yourself through "he-tox," to how to throw yourself a kick-ass pity party, Greg and his wife, Amiira, share their hilarious and helpful roadmap for getting past the heartache and back into the game. You will learn:
• Why you shouldnt call him—and what hes thinking when you do
• How to keep your friends and not lose your job
• How to avoid breakup pitfalls: IMing, stalking, having sex with your ex
• Reframing reality—seeing the relationship for what it was
• How to transform yourself into a hot, happening Superfox and get a jump on the better, brighter future that awaits
Complete with an essential workbook to help you put the crazy down on paper and not take it out into the world, Its Called a Breakup Because Its Broken is a must-have manual for finding your way back to an even more rocking you.
When Greg Behrendt-comedian and consultant to "Sex and the City-laid out the truth about men's "mixed signals" (the truth being that there's no such thing), millions of women found themselves liberated. But knowing a guy's not that into her doesn't mean a woman is not going to be hurt. Now, for every woman who's had her heart broken, Greg and his coauthor-wife, Amiira, offer "It's Called a Breakup Because It's Broken-a must-have survival guide for getting over Mr. Wrong and reclaiming your inner SuperFox.
This hilarious and helpful book covers everything from how to pull the plug on a relationship and make it stick, to proven remedies for uncontrollable crying, to how to act the first time you see him with another woman. Divided into two parts-Get Over It and Get On with It-chapters include:
- There Are No New Messages, so stop checking your
machine-and his!-every five minutes
- He's Not Hiding at the Bottom of That Pint of Ice Cream
- What's He Thinking? Who cares? But Greg and Amiira
respect the need to obsess, so here's a chapter of indulgence
- If It Was So Great, You'd Still Be Together: seeing the
reality for what it was
- Revenge Is a Dish Best Served HOT! So get out of your pajamas,
start taking care of yourself, and find your way back to an even
more rocking you
Plus: an essential workbook, so you can put the crazy stuff down
on paper instead of inflicting it on the world.
Before finding each other, Greg and Amiira had been there, too, and found their way out of the darkness. Now they've come back with a flashlight and a helping hand. "It's Called a Breakup Because It's Broken is more than the ultimatereference guide to the dissolution of a relationship. It's the voice of encouragement that you need to turn your breakup into a break-over, and get a jump on the brighter romantic future that awaits.
The authors of the #1 bestselling "He's Just Not That Into You" return with straight talk, humor, and tough love on how to get over him, now that he's gone.
About the Author
Comedian Greg Behrendt is the coauthor of the two-million-copy bestseller Hes Just Not That Into You. His acclaimed stand-up comedy has been seen on HBO, Comedy Central Presents . . . , The Tonight Showwith Jay Leno, Late Show with David Letterman, and Late Night with Conan OBrien. A former consultant on Sex and the City, he lives with his wife, Amiira Ruotola-Behrendt, in Los Angeles with their two children.
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Thank you so much for making our day so special and run so smoothly. We can't stop talking about it, it was such a memorable day.
Come and see Hestercombe dressed for a wedding at our Wedding Open Day on Sunday 11th May - 11am to 4pm. Click here for more information.
Hestercombe is a classical, romantic English garden, and is a perfect setting for your wedding. This breathtakingly beautiful garden covers over fifty acres of landscape and formal gardens, have been lovingly restored to their original splendour earning a place as one of Britan's best-loved gardens with international acclaim.
Hestercombe is licensed for civil ceremonies with the advantage of being able to hold your ceremony, drinks reception, wedding breakfast and evening party all at one magnificent and convenient location.
A Photographer's Dream
Lakes, cascades, temples, rills, shade-dappled pathways, romantic corners and views to take your breath away, create a spectacular backdrop to capture your memories.
Support and Expert Advice
Our dedicated Wedding Co-ordinator, Julie White, has many years experience in hospitality and wedding planning. Julie gives you a blank canvas with which to work offering advice and the opportunity to share ideas. And on the day, Julie together with an experienced Team, makes sure everything runs smoothly down to the last detail ..... even mopping tears of joy or nerves!
Your personal invitaion ...
Download our Wedding Pack or ring us for full information then, come and have your own tour of our facilities with Julie. We will be very happy to give you ideas and a quotation without obligation.


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I just hit refresh a bunch of times until I got to the Rio question.
I just had difficulty logging in so I tried to get my username sent to my email. I was fine until the 'random question' thing came up. Can I just know why you guys have this feature? Like for a non-regular member, how would they know what the name of the mod is or what is the second most used program in Japan, etc? If the question is to help stop bots then why not some normal arithmetic question? When a new user is trying to sign up for the forum, how will they know the answer to any of the questions? Then how will they register?
I was lucky because the question changed and asked for the founder's name, which I knew, so I could get access to my profile. But obviously you guys must be losing a lot of new members because of this.
I just hit refresh a bunch of times until I got to the Rio question.
Yeah but it's so dumb... like I'm using the forums for a game that's by the same forum provider... For their random question they have math questions which anyone can get... this is just ridiculous.
Maybe it's to keep people who will show up, make 4 or 5 posts and then leave from ever getting access. Maybe it's to make sure that only people who are dedicated and really want to be here by Googling or digging up some info on the site get on. Maybe.
Maybe stuffs to be made for deviants soon
It's partly because of spambots and partly because there aren't just spambots anymore. There are actual people who sign up (i.e. humans) and answering simple arithmetic questions will NOT dissuade those people from coming in to spam the board.
Anyways, I figure that if you're really interested in this place, you should at least a) know who the founder is b) know who the mods are here in the forum (Jubeh, Hayashida, GunZet, Psy, Cloudy, Kodos) and c) at least know that Paint Tool SAI is one of the most well-known and used programs outside of GIMP and Photoshop by those in the anime community which you can actually Google.
The answer is always there if you take the time to actually look around, google, or even ask. You may always contact me at any time without having to PM me or log into the forum if you have any questions or need help with anything as well.
With that said, I've made a few changes that hopefully will make it easier for new people to find out who's who here in the forum. :looks at shiny old badge:
FYI - I've decided to add several more questions and limited the questioning to registration only. A few are simple but there may be one that if you're a beginner, will require to either Google the answer for or if you're reading the site, you may find the answer if you dig around a bit.


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Town officials say they'll ask the state to look at tweaking a traffic light at the intersection of Main and Cherry Streets to ease traffic flow.
Eastbound motorists approaching the intersection (down from St. A's, library on the right) often have to wait two to three light cycles to make a left onto Main, according to Tiger Mann, assistant director of public works and senior engineer with the New Canaan Department of Public Works.
"We can ask the state to see," Mann said at a meeting of the Traffic Calming Work Group, held Tuesday at the New Canaan Police Department. "You can never make the turn. It takes two cycles, sometimes three. I know that South and Cherry is very tight on timing and Main and Cherry is the same thing."
One solution may be to reduce the westbound traffic at the intersection by giving those trying to turn left/north onto Main Street a green arrow (similar to turning left from Elm Street onto Park).
Work Group members Jim Cole, who is chairman of the Police Commission, and police Capt. David Bender, also were in attendance.
Bender said he recently received a complaint from a resident about the intersection, whose corners include a parking lot, library and bank.
Cole offered that motorists who have trouble with the intersection may consider turning onto Main further south, such as at Church Street or Harrison Road. However, Bender noted, many motorists may be coming from areas such as Pine Street, leaving the only viable detour to come through Morse Court—itself accessible by another difficult left, onto South Avenue from Cherry.
Two state roads—Rte. 106 and 124—run concurrently where Main and Cherry intersect downtown, meaning Connecticut Department of Transportation approval is needed to change the traffic light.


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Washington, D.C. – Democratic Leader Nancy Pelosi released the following statement today on the passing of Common Cause President and former Congressman Bob Edgar:
"Today, our country lost one of its most ardent, passionate, and effective voices of a more open and honest democracy. Whether in the Capitol or at Common Cause, Congressman Bob Edgar dedicated his life to ensuring our government lived up to the values it was formed to protect.
"A proud son of Pennsylvania, Bob spent 12 years in Congress focused on advancing and strengthening the health, security, and prosperity of the American people. An extraordinary patriot, he secured support for veterans suffering from the sacrifices they made in the Vietnam War. A man of deep faith, he led the National Council of Churches in its work to combat poverty, foster interfaith understanding, and build international peace. A dedicated champion of transparency and fairness, he picked up the mantle of reform to protect and preserve a government determined by the votes of the people, not the pocketbooks of the privileged few.
"Congressman Edgar is an extraordinary example of how the strength of one voice can empower millions to call for change. His memory and legacy will inspire his colleagues and everyone who seeks a more open, just, and perfect union. We only hope it is a comfort to his wife Merle, his sons, Andrew, David, and Rob, and their families that so many mourn their loss at this sad time."


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I was happy to see a record number of people turn out for last Wednesday's KOTO board meeting. Based on the sign-up sheet that was passed around the room, I'm guessing there were around fifty-sixty hard-core KOTO fans. The majority of those who spoke made it clear they were upset about the way the board and new ED have treated Janice. The excuse given by the board that there is too much risk in doing events was refuted by several long-time KOTO organizers and volunteers. Aura Jones provided numbers that further put into question the board's assertions.
The issue of whether or not board members violated KOTO bylaws by holding secret meetings and not properly noticing other meetings was not resolved, as the board said they needed to research their records. Getting to the truth here would make a good investigative story for the local media. The meetings in question are: March 13, June 5, August 6, December 11, and January 6.
Jerry Green spoke about how the original shapers of KOTO strove to make democracy an important part of KOTO operations and culture. Following him, a woman commented that we elect board members and that constitutes democracy, and now we should stand back and let the board do its job. I want to disabuse her and anyone else who believes such tripe. Democracy is a participatory form of government. Electing representatives is where democracy begins. It is up to us, the people, to make sure elected ones represent the people and not special interests. Democracy requires constant vigilance. It is our duty to speak up when problems arise.
KOTO has been struggling for some time. We seem to be an organization trying to find our balance and place in a rapidly changing world. We do not want to live in the past, but that's all we know so we cling to it. In the meantime, we tread water, waiting for some big swell to carry us to our proper place.
There is a current pulling KOTO toward a more corporate philosophy. This means we have to make the bottom line KOTO's highest value. It means the news will be filtered and replaced with public relations narrative, and the real news suppressed. It means people will be expendable and treated without respect, as Janice was. It means we will sacrifice our authenticity. It means we will be robbed of our voice, our spirit and soul. The corporate direction will kill us. We don't need no corporatization.
Right now we need a slate of good, solid candidate for the upcoming election of five board members. We need both young ones to share their energy, perspective and vision, and older ones to share their experience and wisdom. We need candidates whose only agenda will be to help KOTO fulfill its potential as the voice of the community.
Thank you, Janice, for all the dedication, hard work and love you have given to KOTO and the community. You brought us fun and laughter, much needed funding, and many fond memories. KOTO will not be the same without you.
– Eileen McGinley


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That was some odd type of article in my opinion.. "Fallen Angel?"
I really like the part about "If your lookin' for trouble-look right in my face."
Disagree completely with Elvis studying Tom Jones moves? Say what?
If we take notice of Elvis' performances and films, he (except for an edit error) was never seen the way Tom Jones liked to reveal himself on stage.
Elvis was way to big a name to ever play Vegas...no wonder he hated it.
And the necklaces of a different religion worn at the same time, is cute. It also shows no disrespect for anyone.


text: Discover how to bring balance to your mind, body and soul and walk through life as a fully conscious being, bringing light, peace and beauty to everyone around you. Explore Shamanic body-mind medicine. Learn how to shed your past and its worn out stories, break free from the grip of fear and unfavorable heritages, drop your limiting roles and beliefs and discover the original wounds that derailed your destiny.


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Running a business doesn't stop until the business stops. You can start a company faster and easier in the United States than almost anywhere in the world, but getting it right takes a plan. You'll need to consider whether you need a business loan, temporary or permanent staffing, whether you're going to use a public relations company to get word out about who you are, business insurances, data backup, where are your customers coming from? Will you need to contract with a lead generation service? And this is just the very tip of the iceberg.
For many small business owners, choosing the right tools and technology to support their company can seem like a daunting and expensive task. However, its no longer necessary for small companies to pay big prices for IT.
What do you really need to know about building a Web site, and what should it cost? The short answer, if you want it to actually help your business, is "more than you think it probably should." But we have some tips to help you know what to look for.


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6 Things: Our National ParksTuesday, October 19th, 2010
There's hardly an American tradition more venerable than a long, hot road trip to one of our national parks. Families have been experiencing the wonders of the natural world this way since Yosemite was designated as the world's first national park in 1906. Since the weather's getting a bit cool for hiking in the mountains, today we'll take an armchair tour of our nation's natural treasures.
Read: How people are working to preserve the natural soundscapes in our national parks, from Smithsonian Magazine.
Hear: American Favorite Ballads, including Shenandoah, Home on the Range, and This Land is Your Land,performed by Pete Seeger, from Smithsonian Folkways.
Watch: Excerpts from the new Ken Burns documentary – The National Parks: America's Best Idea. From PBS.
Eat and Drink: Did you know that you can bring your own picnic to the National Zoological Park? BTW, no feeding the animals!
Check out: Excavations by geologists in our national parks (and elsewhere) have unearthed much about prehistoric climate change. Our interactive online program teaches you how to use 55 million-year-old leaves to gauge temperature change, from Smithsonian Education.
Go: Now is a great time to book a journey to our National Parks, including our new America's National Parks tour, a journey through 5 breathtaking National Parks in one phenomenal vacation.
What's your favorite National Park? Please share.


text:
Originally Posted by BennyTheBall
Your anus, K2. Ring is a euphemism for anus.
We all judge others even if it isn't our place to judge, but supposedly at the end we are all judged by one!!!
Wrestling, women and money who could ask for more???
Reserved for when Arsenal lift the FA Cup
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text:
Recoverable Gas news and technical articles from Oil & Gas Journal. Search Recoverable Gas latest and archived news and articles
Fayetteville study include: Original free gas in place of 80 tcf for the 2,737-sq mile study area. Technically recoverable gas resources of about 38 tcf. Base-case total field estimated ultimate recovery (EUR) of 18.2 tcf, which includes
production (Q), and future recoverable gas (G fr ). The multicyclic model ..... ultimate recovery G pau , future recoverable gas , G fr , can be obtained. After ..... be 9,215 tcf, and remaining recoverable gas should be around 6,686 tcf
of Apalachicola (Fig. 1), recoverable gas -condensate and light to medium ..... reservoirs. The chance of discovering recoverable gas -condensate and light to medium ..... waters probably 800 million bbl of recoverable gas -condensate and light to medium
mean value) of undeveloped recoverable gas resource for the Barnett shale ..... resource estimates for technically recoverable gas resources for the Barnett shale ..... input data, the technically recoverable gas resources in the Barnett shale
oil and more than half the estimated economically recoverable gas . The plan will allow for access to oil and gas resources ..... economically recoverable oil and 8.7 tcf of economically recoverable gas , BLM indicated. 'Areas locked up' Moriarty said AOGA and its
development project. At the time, the 18,543 acres of the airport were estimated to hold 470 bcf of technically recoverable gas resources (TRR), and the ratio of the CAPEX and the TRR suggested an all-in development cost of $1.98/Mcf
of the traditional oil-producing area. OMV estimated 60-160 million bbl of recoverable oil and 10-40 bcf of recoverable gas from its discovery. The 7324/8-1 Wisting Central vertical rank wildcat on PL 537 proved OMV's exploration concept
Berantai RSC and Balai RSC. Berantai field, which went on production in 2012, achieved a 15% increase in estimated recoverable gas resources compared with 2011 as a result of development efforts. And predevelopment work at the Balai Cluster has
basin, contains the Prosperidade and Golfinho-Atum natural gas complexes that hold an estimated 35-65 tcf of recoverable gas . In cooperation with Mozambique's government and others, Anadarko said it will continue developing an LNG park
estimate assumes Tajikistan's actual economically recoverable gas resource at 23 tcf—20% of the total gas reserves ..... reports that for its LNG projects, 3.8 tcf of recoverable gas reserves can support 450 MMcfd of gas production over


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Oct 4, 2013
The Office of Governor Bob McDonnell issues an executive directive calling for the creation of an Anti-Human Trafficking Coordinating Committee to expand Virginia's fight against human trafficking.
The Coordinating Committee's role will be to be to follow-up on recommendations put forward by an informal workgroup and to develop new recommendations and strategies for strengthening the state's response to human trafficking.
McDonnell made the announcement on Friday at the first-ever Governor's Summit on Human Trafficking in Richmond. The summit was attended by more than 200 people representing government agencies, law enforcement and prosecution, victim service programs, social service and mental health agencies and schools. Advocacy groups and other private nonprofit organizations were also represented.
Speaking at the summit, Governor McDonnell remarked, "Human trafficking is one of the fastest growing criminal enterprises in the world. This horrible crime generates billions of dollars in profits by victimizing people through control and exploitation. We have worked over the last three years to strengthen Virginia's laws against human trafficking, but there is more to be done to combat this growing crime."
McDonnell also said that he will consider including in the upcoming budget funding for a pilot programs designed to reduce prostitution and provide services for the female victims of trafficking who are coerced into the crime.
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text: Stone has some pretty strict philosophies when it comes to food. We stand by local and organically cultivated ingredients because we know they're better for the environment, and they taste pretty darn good, too. You can get amazing items prepared with truly farm-to-table ingredients every day at our three Stone Brewing World Bistro & Gardens locations, but there are a few nights out of the year where we take it to the next level of freshitude—Fresh Dinners. These feasts are made solely from ingredients procured the very same day, and some of those ingredients come from our very own Stone Farms.


text:
- SHOW ME ANOTHER:Love and Family Prayer of the Day
- SHOW ME ANOTHER:Prayer of the Day
- SHOW ME ANOTHER:Parenting Prayer of the Day
- SHOW ME ANOTHER:Christian Prayer of the Day
Graduation Blessing
Hear, O children, the instruction of a parent,
And give attention that you may gain understanding,
For I give you sound teaching;
Do not abandon my instruction.
Acquire wisdom! Acquire understanding!
Do not forget nor turn away from the words of my mouth.
Do not forsake her, and she will guard you;
Love her, and she will watch over you.
I have directed you in the way of wisdom;
I have led you in upright paths.
When you walk, your steps will not be impeded;
And if you run, you will not stumble.
Take hold of instruction; do not let go.
Guard her, for she is your life.
Source: Adapted from The New American Bible
Top Rated Prayers


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Multiple Choice
Cooper-Hewitt: Multiple Choice - Marketing Design in the Twenty-first Century
Join modern design firms Maharam, Design Within Reach and Tricycle as they share their companies' approaches for marketing design. Held in conjunction with the exhibition Multiple Choice: From Sample to Product, this panel will explore current marketing trends such as consumer customization and online outreach.
Multiple Choice, Exhibition, sample, product, marketing, trends, 21st century, modern design, Maharam, Design Within Reach, Tricycle, customization, outreach, online, panel, talk, long, public program
Cooper-Hewitt: Cloak and Dagger - Design Espionage
In past centuries sample books served to record patterns and motifs used in decorative arts and were carefully guarded by manufacturers against espionage attempts from competitors. In this panel, held in conjunction with Multiple Choice: From Sample to Product. Cooper-Hewitt invites you to join intellectual property lawyer Harley Lewin, and Susan Posen, CEO of Zac Posen, in a conversation with Eric Wilson of The New York Times on how designers strive to protect their work in a knock-off culture.
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Multiple Choice: From Sample to Product
This exhibition will examine sample books and other sampling formats as tools for marketing or recording designs and techniques in a wide variety of media. Drawn from the Museum's collection, exhibition objects will include sample books of wallcoverings; woven and printed textiles; ribbons, lace and embroidery; sample plates; and drawings and prints showing design alternatives.
Multiple Choice, Multiple Choice: From Sample to Product, exhibitions, sample books, permanent collection, wall coverings, textiles, sewing equipment, drawings, prints, ch:exhibition=35350753
Sustainable Sampling
At the end of the introduction to the Multiple Choice exhibition, the curator reflects that, "as contemporary design industries move to open-sourcing and electronic formats for the marketing of their products, physical samples may soon become obsolete."
Multiple Choice, Exhibition, physical, samplers, material, sampling, obsolete, conversion, alternative, virtual, electronic, digital, formats, ephemera, rare, elimination, waste, economical, sustainable, process, event, Multiple Choice Marketing Design in the Twenty-first Century, ecological, marketing, approaches, Tricycle, interior design, prototype, innovative, methods, Michael Hendrix, Chief Brand Officer, mission, reduction, technology, environment-friendly, benefits, experiences, upside, encourage, mass, adoption, color shift, metamerism, challenge, dematerialized
Behind the Scenes of Multiple Choice: from Sample to Product
Exhibitions are hard work. At Cooper-Hewitt they are planned years in advance and involve several departments cooperating towards a common goal of creating the best exhibition possible
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Dance the night away with other young travellers in Old Havana, mingle with the locals at overnight homestays, sample the local rum and cigars, connect to the salsa culture on the dance floor, move those hips to incredible live music, explore colonial Havana's alleyways, laze under the Caribbean sun.
Use promo code: G14PLUSAIR100+see offer terms and conditions
That's right. Book your airfare when you book your G Adventures trip and we'll slice $100 off the price for you. Simply enter promo code G14PLUSAIR100 when prompted and we'll do the rest.
Offer valid for new bookings only with international air travel originating in North America added to a land booking. Not valid with any other discount, offer or promotion. Subject to availability. Must book by June 1, 2014, for travel by February 1, 2015. Subject to airline regulations and restrictions.
For too many people, Cuba is nothing more than a beach resort. That's crazy; the island practically buzzes with energy and you should do likewise—get moving. Journey through the culture-soaked streets of Trinidad and Old Havana for your fill of drinking and dancing. The music here pours out of open windows. Hit the beach and explore the outdoors then connect with the locals in homestays and make friends for life as you hit the sites with other young people like yourself. Boring? Impossible!
Arrive at any time.
Stop by Santa Clara en route to Trinidad and visit important historical sites, including the famous Che monument. Orientation walk of Trinidad's beautiful centre. Learn some moves during a salsa dancing lesson and take in some live music at an evening out at the Casa de la Trova. Enjoy a home-cooked local group dinner hosted by one of the homestay families. With nearby national parks, a beach, bikes and more, there's plenty to keep you busy!
See sugarcane and tabacco plantations in this rich agricultural town. Have a cigar, do a rum tasting and take a day trip to the island of Cayo Levisa. Practice some Spanish while staying in a local homestay.
Stop at lush Las Terrazas en route back to Havana. Discover Old Havana on a short walking tour.
Depart at any time.
Find dates, prices, and more trip options.Book Now


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The Carousel Designs Factory Outlet Store is now only available on our website!
Due to space constraints, the outlet store located inside our factory has been moved entirely online. Many of the deeply discounted baby bedding products available exclusively in our outlet store can now be found in the clearance section of our website.
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The teenagers survived mainly on coconuts and rainwater
WELLINGTON, New Zealand — Three teenagers survived 50 days adrift in a tiny boat in the South Pacific by drinking rainwater and eating raw fish and a seagull before being rescued by a passing trawler, a senior crewman on the fishing vessel said.
The trio – Samuel Pelesa and Filo Filo, both 15, and Edward Nasau, 14 – had been given up for dead on their coral atoll in the Tokelau islands, where a memorial service was held for them after extensive searches failed to find them.
The boys set off on Oct. 5 in their aluminum dinghy from their home island to one nearby. It's not known how they went missing, but the outboard motor on their boat may have broken down at sea.
Worried family members reported them missing and the New Zealand air force launched a sea search. No sign of the tiny boat was found.
On Wednesday, the tuna boat San Nikuna spotted a small dinghy bobbing in the open sea northeast of Fiji, with three people aboard waving frantically, said first mate Tai Fredricsen. They had drifted 800 miles (1,300 kilometers) from where they set out.
"We saw a small vessel, a little speedboat on our bows, and we knew it was a little weird," Fredricsen said.
The fishing boat pulled up alongside the smaller vessel and asked the teenagers if they needed any help, to which they readily replied that they did.
"All they could say was 'thank you very much for stopping," Fredricsen told New Zealand's National Radio on Thursday by phone from the ship. "In a physical sense, they look very physically depleted, but mentally – very high."
The teens and their boat were hauled aboard the fishing trawler, which was on its way to Fiji Friday where it would deliver the trio into medical care.
Source: Huffington Post