text:
Echocardiographic and biochemical evaluation of the development and progression of carcinoid heart disease
Author + information
- Received July 21, 1997
- Revision received May 18, 1998
- Accepted June 2, 1998
- Published online October 1, 1998.
Author Information
- William D Denney, MD∗,
- W.Evans Kemp Jr., MD∗,* (evans.kemp{at}mcmail.vanderbilt.edu),
- Lowell B Anthony, MD‡,
- John A Oates, MD† and
- Benjamin F Byrd III, MD, FACC∗
- ↵*Address for correspondence: Dr. W. Evans Kemp, Jr., 315 MRB II, 2220 Pierce Ave., Vanderbilt University Medical Center, Nashville, Tennessee 37232
Objectives. To study the applicability of a newly developed echocardiographic scoring system in the assessment of carcinoid valvular heart disease.
Background. We investigated prospectively the development, progression and regression of carcinoid valvular heart disease in patients with carcinoid syndrome by serial echocardiography, correlating these features with urinary 5-HIAA levels and clinical data collected during therapy with somatostatin analog.
Methods. Twenty-three patients with carcinoid syndrome underwent serial echocardiographic examinations. An echocardiographic carcinoid valvular heart disease (CVHD) % score was determined from points assigned for tricuspid and pulmonary valve structure and function.
Results. Fifteen patients had no CVHD at study entry (group 1), while 8 patients had findings of CVHD (group 2). Five patients in group 1 developed new CVHD (1B), while one demonstrated progression of CVHD (2B). The remaining patients did not develop (1A) or had no progression of CVHD (2B). Despite major declines in 5-HIAA levels during therapy in most patients, CVHD did not regress. There were significantly lower levels of median baseline 5-HIAA (98.8 vs. 256 mg/24 h), posttreatment 5-HIAA (50.3 vs. 324 mg/24 h) and posttreatment 5-HIAA time integral (37.3 vs. 192 g/24 h∗ days) in group A vs. B (p < 0.05). However, only posttreatment 5-HIAA levels independently predicted the development or progression of CVHD by multiple step-wise regression analysis (p < 0.005), with a threshold observed in the 100 mg/24 h range.
Conclusions. We designed a new echocardiographic scoring system to evaluate CVHD. Correlating echocardiographic scores with biochemical and clinical markers showed that only posttreatment 5-HIAA levels independently predicted the development or progression of CVHD. This study strengthens the association between serotonin secretion and CVHD, as well as introducing a new technique for serial follow-up of these patients.
Carcinoid tumors are uncommon and arise from the enterochromaffin cells of the gastrointestinal tract and bronchi. Carcinoid tumors may secrete large amounts of vasoactive substances, including 5-hydroxytyptamine (serotonin) which is subsequently metabolized to 5-HIAA by the endothelium of the pulmonary and hepatic vasculature. The carcinoid syndrome occurs in less than 4% of patients with carcinoid tumor (1,2)and is generally associated with hepatic metastases and elevated urinary 5-HIAA levels. Clinically, carcinoid syndrome is characterized by flushing, diarrhea, bronchoconstriction, telangiectasias and right heart disease.
Heart disease characteristic of carcinoid has been previously reported in 19% to 66% of patients with carcinoid syndrome (3–6). The characteristic cardiac lesion of carcinoid heart disease consists of fibrous plaques covering normal endothelium of the chambers and valves of the right heart (7). Left heart involvement is uncommon and is generally associated with bronchial carcinoid or right-to-left intracardiac shunting. Although the etiologic agent responsible for carcinoid heart disease has not been identified, several studies have implicated tumor secretory activity by demonstrating significantly higher urinary 5-HIAA levels in patients with carcinoid syndrome who have carcinoid heart disease (4,6).
Several analogs of the naturally occurring peptide somatostatin have been shown to improve diarrhea and flushing in patients with carcinoid syndrome while simultaneously lowering urinary 5-HIAA levels. However, the impact of treatment with these analogs on carcinoid tumor progression and cardiac involvement has yet to be determined.
The present study was designed to investigate prospectively the progression or regression of carcinoid heart disease in patients with carcinoid syndrome using serial 2-dimensional and Doppler echocardiograhpic studies employing a newly developed scoring system. To establish the association of carcinoid heart disease with urinary 5-HIAA levels, we correlated our results with serial urinary 5-HIAA levels and clinical data collected during therapy with somatostatin analog.
Study population
From November 1986 to August 1991, 23 patients with carcinoid syndrome were referred to Vanderbilt University for treatment with somatostatin analog. All 23 patients had histologically proven carcinoid, at least one of the typical symptoms of carcinoid syndrome (flushing, diarrhea or bronchoconstriction), and elevated urinary 5-HIAA levels. The mean age at entry was 59 ± 12 years (range 36 to 78 years). There were 14 men and 9 women. The age at entry, duration of carcinoid symptoms and extent of hepatic involvement with tumor were noted at the time of entry into the study. The extent of hepatic involvement with tumor was defined by abdominal computer tomography (CT) scan as no involvement, single hepatic metastasis or multiple hepatic metastases. All patients were begun on somatostatin analog using a protocol designed to determine the maximal tolerated dose. Doses were increased on a monthly basis to the maximal tolerated dose or a predetermined maximal dose (whichever was less). Twenty patients received octreotide while three received lantreotide.
Two-dimensional (2D) echocardiography, pulsed and continuous wave Doppler, and color flow Doppler studies were performed using standard techniques on each patient at entry into the study and serially approximately every 6 months. All studies were performed on Hewlett-Packard Sonos 500 or 1000 instruments and recorded on in videotape. A total of 126 echocardiographic studies were performed during the study.
To facilitate the detection of serial changes in carcinoid heart disease, we devised a scoring system (Fig. 1)which expressed the severity of carcinoid-induced valvular stenosis and insufficiency in the right heart by combined two-dimensional echocardiographic and Doppler criteria. This Carcinoid Valvular Heart Disease (CVHD) score was determined by 1) tricuspid valve appearance, 2) tricuspid regurgitation severity by either spectral pulsed wave or color Doppler flow mapping; 3) pulmonary stenosis severity by spectral pulsed or continuous wave Doppler, and 4) pulmonary insufficiency severity by color Doppler.
Tricuspid valve appearance was assigned 4 points and was graded on a 1 to 4 point scale as normal, mildly, moderately, or severely diseased. Grading was based upon qualitative assessment of leaflet thickness, leaflet mobility and leaflet retraction using all available echocardiographic views. Tricuspid valves with normal appearance received only 1 point while severely affected valves which were thickened, fixed and retracted received 4 points.
Tricuspid regurgitation was also assigned 4 points in the CVHD score and was graded based upon the color Doppler appearance of the regurgitant jet (or pulsed wave Doppler mapping in a few of the earliest studies) using a method similar to that reported by Suzuki (8). The severity of TR was graded from 1 to 4 by measuring the ratio of the color Doppler regurgitant jet "mosaic" area to the right atrial RA area in the apical 4 chamber view (TR/RA area ratio <10% = 1 point, 10–20% = 2 points, 20–40% = 3 points, and >40% = 4 points). When pulsed wave Doppler mapping was used, the severity of regurgitation was quantitated using the length of the regurgitant jet (8).
Pulmonic valve stenosis (PS) was assigned 4 points as well by measuring the peak Doppler velocity at the pulmonary valve. One point was scored for peak velocities <2 m/s (gradient <16 mm Hg), 2 points for 2–2.5 m/s (gradient 16–25 mm Hg). Higher severity scores were based on peak Doppler velocities and the severity of TR (see Fig. 1).
Pulmonic valve insufficiency (PI) was assigned only 2 points in the CVHD scoring system since no method for assessing its severity is well validated and its clinical significance in carcinoid heart disease is relatively small. PI was graded using a color Doppler method analogous to the one used for aortic insufficiency (9). Using the parasternal short axis view at the aortic valve level, we determined the ratio of the width of the regurgitant jet neck to the width of the pulmonary valve annulus. One point was scored for ratios less than 0.33, and for ratios greater than 0.33 2 points were scored.
The maximum number of possible points for any carcinoid heart disease echo study was thus 14. However, since some studies were inevitably too technically difficult to grade in one or two categories, the CVHD score was reported as a percentage of the points possible on that study. The CVHD% score thus equaled the total points scored divided by the points possible on that study, expressed as a percentage. The maximum normal score equaled 4 of 14 possible points (CVHD% score < 30), as in a patient with mild TR on color Doppler study, a structurally normal tricuspid valve, and a normal pulmonary valve.
All the echo studies were scored by a single observer unaware of the patients' previous echo scores or clinical and laboratory data. Fifteen randomly selected echo studies were rescored to determine the intraobserver variability. Based upon this result, a significant change in score was defined as greater than twice the standard deviation of the mean intraobserver variability. Patients were then grouped based upon the stability or progression of their carcinoid heart disease by comparing their CVHD% scores from initial and final echo studies.
Laboratory evaluation
Urinary 5-HIAA excretion was determined by an assay utilizing fluorescence polarization immunoassay technology (TDx Assay, Abbott Laboratories) on samples obtained before December 31, 1992 and by an assay utilizing high performance liquid chromatography on samples obtained after this date. Multiple 24-h urine collections were obtained on each patient as they were admitted for serial reevaluation of their response to treatment with somatostatin analog at a minimum of 6 month intervals. Mean pre- and posttreatment 24 h urinary 5-HIAA levels were determined for each patient. Mean posttreatment 5-HIAA values were determined as the sum of all 24-h urine values, obtained after therapy with somatostatin analog was initiated, divided by the number of days sampled. Mean pre- and posttreatment 24-h urinary 5-HIAA levels were expressed as mg/24 h. As a measure of cumulative exposure to serotonin for each patient, time-integrated urinary 5-HIAA levels were determined (Fig. 2)using the area under the curve of the multiple 24-h urinary 5-HIAA levels obtained over the period of follow up (result expressed in grams/24 h × days).
Statistical methods
Many of the variables were not normally distributed after grouping, so the median and interquartile ranges were used as measures of central tendency and variation. The Mann-Whitney rank sum Utest was used to compare the data from groups of patients who were either stable or progressed with respect to echocardiographic evidence of carcinoid valvular heart disease. Univariate and multiple step-wise regression analyses were used to determine the clinical and laboratory predictors of echocardiographic progression of carcinoid valvular heart disease. Statistical significance was determined at the p < 0.05 level.
Typical right heart carcinoid valvular abnormalities were observed in 8 patients (35%) on their initial 2D echocardiogram and Doppler study, while the remaining 15 patients showed no evidence of carcinoid heart disease. Those patients without carcinoid heart disease on the initial 2D echo were placed in group 1; those with carcinoid heart disease were placed in group 2. Since the intraobserver reproducibility study of 15 patients revealed a mean absolute difference in CVHD% score of 3.8 with a standard deviation of 4.7, a >10 point change in score was judged to be significant. As shown in Table 1, patients were thus further classified into those who demonstrated no echocardiographic progression or development of carcinoid heart disease (subgroup A) and those whose carcinoid heart disease progressed or developed (subgroup B).
Of the 15 patients who entered the study without evidence of carcinoid heart disease (group 1, median CVHD% score 29), 10 patients remained unaffected (group 1A, median absolute increase in CVHD% score of 0), while the other 5 developed new echocardiographic changes typical of carcinoid heart disease (group 1B, median absolute increase in CVHD% score of 28). Of the 8 patients demonstrating echocardiographic evidence of carcinoid heart disease at entry (group 2, median CVHD% score of 70), 7 patients remained stable (group 2A, median absolute increase in CVHD% score of 4) while 1 patient demonstrated progressive carcinoid heart disease (group 2B, median increase in CVHD% score of 15). Echocardiographic regression of carcinoid heart disease was not observed in any patient despite treatment with somatostatin analog. That is, an improvement in CVHD% score of 10 or more was never sustained on more than 2 serial echocardiograms.
Clinical data
Comparison of clinical variables at presentation in patients without echocardiographic evidence of carcinoid heart disease (group 1) and those with carcinoid heart disease (group 2) is summarized in Table 2. All but 2 patients showed either single or multiple hepatic metastases on abdominal CT scan. Although patients with carcinoid heart disease at entry tended to have carcinoid symptoms of greater duration, higher baseline urinary 5-HIAA levels and multiple metastases, these differences did not reach statistical significance.
Clinical variables from all patients who showed no significant echocardiographic evidence of progression/development of carcinoid valvular heart disease (group A) were then compared with those who demonstrated progression/development (group B). As shown in Figure 3, there were statistically significant differences in baseline urinary 5-HIAA levels (98.8 [59–186] vs. 256 [145–356] mg/24 h), posttreatment urinary 5-HIAA levels (50.3 [27–90] vs. 324 [103–458] mg/24 h), and posttreatment urinary 5-HIAA integral (37.3 [21–79.2] vs. 192 [59–703] g/24 h × days) (median [range]) (p < 0.05). There was no significant difference between these groups in the duration of carcinoid symptoms prior to entry, duration of treatment with somatostatin analogue, or percent change in urinary 5-HIAA levels (Table 3).
Table 4compares clinical variables from the subgroup of patients who entered the study without echocardiographic evidence of carcinoid heart disease and remained stable (group 1A) with those who developed new evidence of disease (group 1B). Patients from group 1B had significantly higher baseline urinary 5-HIAA levels (319 [193–356] vs. 77 [42–112] mg/24 h), post-treatment urinary 5-HIAA levels (442 [207–458] vs. 57.8 [20–90] mg/24 h), and posttreatment urinary 5-HIAA integrals (238 [59–703] vs. 34.2 [12–79] g/24 h∗ days) (median [range]) (p < 0.05) (Fig. 4). No statistically significant differences were shown in the duration of carcinoid symptoms prior to entry, percent change in urinary 5-HIAA levels, or duration of therapy with somatostatin analogue.
As shown in Table 5, three clinical variables were found to predict carcinoid valvular heart disease progression by univariate analysis. These were the posttreatment urinary 5-HIAA levels, the baseline urinary 5-HIAA levels and the 5-HIAA integral (p < 0.05). However, multiple step-wise regression analysis showed that only the posttreatment urinary 5-HIAA levels independently predicted the progression of carcinoid valvular heart disease (p < 0.005).
During the 6-year-study period, the mortality rates were 3/10 (30%) for group 1A, 3/5 (60%) for group 1B, 1/7 (14%) for group 2A and 1/1 (100%) for group 2B.
This prospective study used a new echocardiographic scoring system to document progression or regression of carcinoid valvular heart disease in serial studies. This CVHD scoring system is based upon the structure of the right heart valves as shown by 2D echocardiography, and upon their function as shown by Doppler echocardiography. In this study of patients with histologically proven metastatic carcinoid tumor, the 35% incidence of cardiac involvement on the initial echocardiogram is similar to that of previous studies (4–6). Although patients with cardiac involvement on their initial echocardiogram tended to have had symptoms of longer duration, higher baseline urinary 5-HIAA levels, and more frequent multiple hepatic metastases, none of these differences reached statistical significance. Pellikka et al. in an echocardiograhic study of 132 patients with carcinoid syndrome noted no difference in patients with carcinoid heart disease and those without carcinoid heart disease with regard to symptom duration, time from diagnosis or location of the primary tumor (10). However, they did note higher mean pretreatment 5-HIAA levels in patients with carcinoid heart disease than in those without carcinoid heart disease. The ranges of values were quite broad with moderate overlap between the 2 groups.
In this study, the development and progression of carcinoid heart disease during treatment with somatostatin analog were clearly linked to elevated urinary 5-HIAA levels. The 5 patients who developed carcinoid heart disease de novo during the study had significantly higher median urinary 5-HIAA levels and higher urinary 5-HIAA integrals than those who remained free of carcinoid heart disease. None of the other clinical variables, including duration of therapy, differed significantly between those who suffered progressive carcinoid heart disease and those who did not.
Our scoring system did not include mitral CVHD, which is only seen in 7% of cases (10). Only 1 patient in this study exhibited mitral valve disease with thickening and decreased excursion of the mitral valve leaflets (4%). This patient had a bronchial carcinoid tumor and simultaneously showed progression of pre-existing right heart involvement.
Stabilization or regression
Interestingly, regression of carcinoid disease (defined as a significant decrease in CVHD% score of >10 points on serial echocardiography) was not observed during treatment with somatostatin analog. Although the median posttreatment urinary 5-HIAA level was reduced to less than 50% of pretreatment level in 6 patients who entered the study with carcinoid heart disease, CVHD% score by echocardiography did not change significantly in these patients. There was a trend toward lower posttherapy 5-HIAA levels in the group with stable carcinoid heart disease when compared with the group with progressive or new carcinoid heart disease. Failure of this trend to reach statistical significance may be due to the small sample size as well as significant overlap of the ranges for percent change in 5-HIAA levels. Nevertheless, if more patients with pre-existing carcinoid heart disease can be followed after major reduction in urinary 5-HIAA levels, effective therapy may be shown to stabilize or even regress carcinoid disease.
Although it has been hypothesized that exposure of the endocardium to elevated levels of serotonin (4,6)or other secreted tachykinins such as neuropeptide K or substance P(4) might lead to fibroblast proliferation, the exact etiology of the fibrous plaques is obscure. Of the three clinical variables identified in the univariate analysis as predictors of progression of carcinoid heart disease (baseline urinary 5-HIAA levels, posttreatment urinary 5-HIAA levels, and the posttreatment urinary 5-HIAA time integral), only the posttreatment urinary 5-HIAA level was significant by multiple step-wise regression analysis. Failure of the posttreatment urinary 5-HIAA time integral to independently predict progression of carcinoid heart disease suggests that the absolute elevation in serotonin secretion is more important than cumulative exposure to serotonin. That is, there may be a threshold value of serotonin secretion above which fibroblast proliferation is activated. As shown in Figures 3 and 4, the threshold for urinary 5-HIAA values during therapy appears to be in the 100 mg/24 h range.
Morbidity and mortality
Since right heart failure contributes significantly to the morbidity and mortality associated with malignant carcinoid tumors, predictors of carcinoid heart disease development may be useful. Indeed, mortality in the patients who developed new (group 1B) or progressive (group 2B) CVHD was more than twice that of patients with no (group 1A) or stable (group 2A) carcinoid heart disease. Since persistent elevations in urinary 5-HIAA levels despite therapy (>100 mg/24 h) were independently associated with development or progression of carcinoid heart disease, aggressive attempts to reduce 5-HIAA levels below this threshold appear justified.
The CVHD% score provides a compilation of right heart pathology which can be used to monitor CVHD development and progression quantitatively. A larger study is needed to determine whether aggressive reduction of urinary 5-HIAA levels will reliably prevent or halt the progression of cardiac involvement. It has been suggested that a lower 5-HIAA level prior to valvular surgery correlates with improved postoperative survival (11). Surgical intervention with valvuloplasty or valve replacement remains the best means of improving right heart valvular function since regression of carcinoid valvular heart disease was not observed in this study during treatment with somatostatin analog.
Limitations and conclusions
One limiting feature of this study is the relatively small number of patients following during therapy for this relatively uncommon condition, metastatic carcinoid tumor. Although the differences in 5-HIAA levels were statistically significant, we still can only speculate on the role serotonin plays in carcinoid heart disease. Nevertheless, this prospective study demonstrated the usefulness of a new echocardiographicscoring system to evaluate the presence and severity of carcinoid heart disease by serial 2D and Doppler echocardiography. In those patients demonstrating echocardiographic progression of carcinoid heart disease, urinary 5-HIAA levels were significantly higher both before and during therapy with somatostatin analog. This study strengthens the association between serotonin secretion and carcinoid heart disease, and it also demonstrates the application of serial echocardiography in patients with malignant carcinoid tumors.
- Abbreviations
- 5-hydroxyindoleacetic acid
- carcinoid valvular heart disease
- computed tomography
- two-dimensional
- tricuspid regurgitation
- pulmonic valve insufficiency
- pulmonic valve stenosis
- right atrium
- Received July 21, 1997.
- Revision received May 18, 1998.
- Accepted June 2, 1998.
- American College of Cardiology
- ↵
- ↵
- ↵
- Lundin L,
- Norheim I,
- Landelius J,
- et al.
- ↵
- ↵
- Suzuki Y,
- Kambara H,
- Kadota K,
- et al.
- ↵
- Perry G.J,
- Helmcke F,
- Nanda N,
- et al.
- ↵
- Pellikka P.A,
- Tajik J.A,
- Khandheria B.K,
- et al.
- ↵
- Connoly H.M,
- Nishimura R.A,
- Smith H.C,
- et al.


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First, there's the matter of the film's title, Keanu, and the rumor that the film was in fact a parody of John Wick, an action feature starring the human version of Keanu, as in Reeves.
This one, simply titled Keanu, refers to a cat…that has been kidnapped…setting off a war between the cat's lawful owner (have I really just typed those words?) and a gang.
Yep. How could this movie be anything but a comedy? If you've seen the trailer, you'd know there's no room for doubt. Keanu pulls out all the stops.
The film stars Jordan Peele, Keegan-Michael Key, Method Man, Nia Long and Will Forte. Keanu is directed by Peter Atencio and written by Jordan Peele and Alex Rubens.
Early reviews are promising. RottenTomatoes weighs in with a score of
The film stars 75. Keanu runs 1 hour 40 minutes and is rated R.

subset: commoncrawl


text:
This week's restaurant nightmares: Beyond extreme
Blame it on Simone Biles and her fellow Olympians. Certainly, something inspired middling knuckleheads to reach higher this week in their efforts to complicate the lives of restaurateurs. Their nightmarish feats merit recognition—or maybe a dunking in a green diving pool.
Here's what we mean.
'And don't use the app, either'
A Florida prankster was legally banned from placing delivery orders after costing local pizzerias almost $700 in wasted pies. Randy Riddle was arrested earlier this month for calling the restaurants and requesting the delivery of a pie—usually to a vacant lot or an address that didn't exist.
This was no teenager's prank. Riddle is 49 years old and worked hard at his ruse. He used five different phone numbers to make his calls, and would often reach out afterward to the punked pizzerias to complain about the quality of their food. Similar behavior had led to an arrest eight years ago.
Riddle was charged this time with making obscene and harassing calls. He was released on $5,500 bail and the condition that he not place another delivery order.
Modern-day 'Jaws'
A manhunt for another extreme customer was stepped up this week in San Francisco, where legal authorities released a surveillance video of the man as he bit off a bartender's finger.
According to the police, the suspect was so determined to get back into the Silver Clouds Restaurant and Karaoke Bar after it closed that he broke a window and climbed inside, only to be confronted by a bartender. A fight ensued, and the unidentified bartender lost his finger in the brawl.
The police have asked the public to help identify the culprit and reveal his whereabouts.
From wrong to wronger
Sometimes transgressors come to their senses and try to right whatever wrong they've inflicted on a restaurant or its staff. That's not the case with this week's highest-profile nightmare, a story that reverberated far from its beginnings in Harrisonburg, Va.
In case you missed the social media eruption, an 18-year-old waitress of Hispanic descent was stiffed on her tip by a couple who ran up a charge of $26.11 at a restaurant called Jess's Downtown. Being shortchanged on a $4 gratuity wasn't as much of a slap as the insult that the couple scrawled on the check: "We only tip citizens."
The waitress, Sadie Elledge, is a U.S. citizen, born and raised in Harrisonburg.
Outraged, Elledge's grandfather blurted on Facebook that he'd gladly do jail time if he could just punch the bigots in the face. He later acknowledged that his post was intemperate and voiced regret for it.
Not so for the offending couple. The woman of the pair reportedly came back to Jess's and complained about the post and all the heat she's taking. The woman was so infuriated that the proprietor called the police.
'I only count 10 spices'
Presumably less trying was the situation dropped on KFC this week by yet another assertion the chain's top-secret chicken recipe had been found in the public domain. Headquarters was quick to dismiss the contention that a handwritten copy of Colonel Harland Sanders' recipe had been found in a scrapbook by a freelancer for the Chicago Tribune.
The twist this time is a plausible connection to the Colonel. The scrapbook was the former property of Claudia Ledington, the Colonel's second wife. It is now kept by her nephew, Joe Ledington, who showed it to freelancer Jay Jones, who was visiting the birthplace of KFC for a color story about the Colonel and his brainchild. Jones had asked Ledington to share some anecdotes of the famous Kentuckian. Leafing through the scrapbook together, they came upon the recipe, which lists 11 herbs and spices along with a key ingredient: white flour.
You can see it for yourself here.


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Although it's impossible to escape news of the opioid epidemic, we haven't heard the whole story.
At Progressive Care, I've met patients from all walks of life and witnessed firsthand the caustic consequences of opioid misuse and abuse. The opioid epidemic is a deeply emotional and complicated issue
In this three-part series, we'll explore the causes, obstacles, and solutions to the over-prescribing of opioid medications. If you missed it, start with Part 1: How Opioid Medication Became the Only Prescribed Pain Treatment.
Join us as Progressive Care, along with their wholly owned subsidiary, PharmCo, LLC, leads the charge to develop actionable solutions along with pain management alternatives to opioids.
Jane is suffering from an injury that resulted in surgical complications and has an incurable, pain-generating problem. For Jane, the pain is real, chronic, and severe. It is likely that she has developed a high tolerance, dependence, and addiction to opioids because of her medical condition.
If opiates are bad, then cutting them off would seem to be the logical solution.
However, cutting off opioid pain medication without an action plan in place typically results in life threatening withdrawal, as Jane's pain is amplified 1,000 times. Patients like Jane feel pain as well as abandonment, hopelessness, and despair.
Cutting opioid medication off completely can be cruel and harmful to the patient, due to dependency and addiction.
Opioid dependency and addiction are different concepts that go hand in hand. Dependency occurs when the patient lacks basic functionality without medication. Addiction is a mental and physical response where the patient "needs" the medication or substance, regardless of whether there is an underlying condition or not.
Taken by themselves, each state has relatively common solutions. Dependency would entail a managed withdrawal and introduction of effective medicinal alternatives. Addiction would require rehabilitation. However, dependence and addiction often exist at the same time. Most patients who are opioid dependent are also addicted, which is a much more difficult situation to solve.
Opioid addiction amplifies underlying pain during any withdrawal period, making it difficult to assess how much pain is derived from a medical condition versus the effects of addiction, or if the patient even needs ongoing pain management. Addiction also makes patients extremely resistant to alternatives as the brain craves the "high"-inducing effects of the opiate, which other forms of treatment will not provide.
To effectively manage pain for an addicted and dependent patient, the addiction must be addressed first. Removing an addiction is an excruciating process to start and a lengthy process to manage. For many patients, sobriety is a day-to-day situation as life events can trigger a return to addictive behavior.
More dedicated addiction treatment is necessary. Addiction can be treated in inpatient and outpatient settings. Counseling, support groups, medications, home health visits, and clinical services are all covered under the Affordable Care Act. It is important for these services to be more readily available and for the stigma of addiction to be removed. Addiction could happen to anyone and seeking treatment does not lessen the value of a person.
To come out on the other side of addiction, a person must be willing to endure the struggle and the pain that comes along with it. For this, support is imperative, and the medical community, doctors and pharmacies must prepare to provide support, and not simply reject patients because the addiction makes them difficult to manage.
Right now, many patients believe that opiates are their only option for pain relief. Opiates are not the only option and the alternatives may work even better over time.
Money is the biggest impediment to success against opioid addiction. Many patients lack addiction treatment coverage and even with coverage, out-of-pocket costs are significant. Many insurance carriers do not cover alternative pain therapies.
Alternative pain treatments are typically costlier than opiates. While opioid coverage continues, many alternative therapies are either denied initially by insurance companies or recouped after the fact during audit. This prevents many pharmacies and doctors from even attempting to try a more nuanced pain management approach.
Solutions require investment. The cost of putting an end to the country's opioid crisis will be extremely high. Insurance carriers, drug manufacturers, and government agencies must find a way to fund solutions that provide results. Doctors, rehab facilities, charitable organizations, support groups, and pharmacies will all need a commitment from the community and sources of capital to do the work and accomplish the mission.
There is still an uphill battle to be fought, as the country attempts to decrease health care costs overall. However, it must be said that alternative medicinal pain management solutions are significantly cheaper than hospital, rehab, and societal costs that result from patients who are not afforded effective options.
At Progressive Care and PharmCo, we're working on providing support to patients and doctors through our innovative services and new education program.


text:
Everyone is in the same question. How can I reduce the sound/noise from this industrial design unit to mine bitcoin?
Stock - Fan Config:
Product Name: Fan Antminer
Size: 118x118mmx38mm
Color: Black
Material: Plastic
Connector: 4 Pin
Voltage: DC 12 v
Current: 1.4 A
Power: 16.8 W
Volume: 160 CFM
Wind pressure: 0.883 IN H2O
Noise: 56.5 d - BA
Speed: 5000RPM
Datasheet can be downloaded:
This question is in my head since they one - i order my miner unit.
I have some option that i will do, and let see which one is perfect for the Job
Option 1: Buy a silent type Fan. The problem here is - I can't find with similar rating.
Option 2: Put them into box. or StyroFoam cooler.
Option 3: Mineral Oil - i think this is messy and not maintenance friendly
Option 4: Silent Server Cabinet - a bit expensive - but for sure this will do the Job
Option 5: Refrigerator (Cooler) not the one with freezer - this could be the substitute to the Server cabinet.
Option 6: Put them outside. - not really a good Idea
Option 7: Buy Nordic 7000 - I already sent them mail and quoted me for 500 US dollar for 20 litters without shipping. They told me that i need to have an account with fedex or dhl. Hmmm-- let see! my company is happy to help me on this., But not for it right now. Maybe in the future. However the good thing with this liquid is that 100 percent sure you will not have any issued with your fan pwm and heat conductivity is very high too compare to oil - to be honest this is the best solution for liquid cooling as you don't need heatsink for your GPU or CPU / IC for asic machine
If you have guys a better option / solution - pm me/ comment. Thanks
How to reduce fan noise from Bitmain Antminer Machine? S5, S7, S9, V9 etc
Here we discuss tutorial, suggestion on Cryptocurrency like - Bitcoin, Litecoin, Dogecoin... and many more
1 post • Page 1 of 1
- dondon pramis
- Inventor
- Contact:
- Location: Philippines
1 post • Page 1 of 1


text:
/News/Responsively Yours: Rooted in Christ
Recently I have been reading deeply about the history of our movement of women in mission. Some of this has been prompted by the anniversaries we are celebrating; we are looking ahead to celebrating 150 years of mission service in 2019, and this year the church is recognizing the 130th anniversary of protestant mission work in Korea.
I am also aware of how little other people know about our history. As one way to share our history with others, United Methodist Women sponsored an interesting and provocative history conference at Methodist Theological School in Ohio, led by some leading United Methodist history and theology faculty. We heard fascinating papers from them and others who are working to find and tell stories about our predecessors.
From the beginning the women who were part of the mission societies and associations were touched by the needs of sisters in many places. (There are at least 14 predecessor organizations to United Methodist Women. A list is included in The Book of Discipline of The United Methodist Church 2012, ¶1322.) For many years they operated on the rubric of "women's work for women," and they formed direct bonds of mutual support with women — bonds not mediated by church or congregational structures. This included meeting immediate needs as well as sustained efforts to equip local women, establish schools and make it possible for women to obtain education in places where necessary education was not available.
A significant part of the organizations' work included welcoming and equipping local women around the world as Bible Women who reached out to other women far and wide, sharing the gospel and training them in literacy and basic health care.
From the very beginning, our Methodist and Evangelical United Brethren predecessors knew that this work was spiritual work. It was part of the call of God to them, as it is to us, to put our faith into action through prayer, giving, study and service. Then, as now, the women who joined the societies and associations wanted to be involved in something bigger than themselves. Many of their articles and prayers talk about their desire to "do something useful" — something that honored God and that made a difference for women, children and youth. This theme endures today.
For us and for our predecessors, doing something useful involved compassionate alignment with other women whose situations touch our hearts. Our commitment to justice impels us to speak out when we see people treated unfairly and to strategize to change hearts, minds and structures. Then as now, the women's mission movement did not see opening the soul to God as something separate from work for health, wholeness, peace and building of a society in which all can find their own flourishing. Being deeply connected to God through Jesus Christ is what impels and sustains our long commitment to direct service and advocacy for justice.
From footbinding, lynching and denying women the right to preach in the eras that precede us to mass incarceration, maternal health, wealth inequality and climate justice today, our rootedness in Christ takes us into engagement in the world. What a blessing it is to be "at home" in a movement that is bold enough to respond to the call of God!
Harriett Jane Olson
General Secretary
United Methodist Women
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Recently, TRX bands (or straps) has gained wide popularity. This is not surprising, the fitness industry does not stand still, every year there are all kinds of new training. So, what is TRX workout, what are its advantages and disadvantages? Can beginners effectively train with TRX?
TRX Workouts' Background
Not only lovers of bodybuilding can have problems with the place for training. That may well happen to anyone, for example, with military personnel. This is what happened to one of the officers of the army of the United States in the 1990s. During the planned exercises, he found that his subordinates did not use basic exercises enough.
However, training in real-life (field) conditions was not very simple. It was at that point that he had the idea to use bands for practicing, in that situation these bands were made of rubber. As a result, the soldiers had the opportunity to conduct solo training using for that purpose the weight of their bodies. This idea seemed attractive to many people, and TRX bands appeared quickly enough. It should be noted that Murph Crossfit has been also invented in field conditions. Today you have the opportunity to get acquainted with the most effective exercises with TRX bands.
The design of this sports equipment is extremely simple: two bands made of soft material and fixed to elastic cables. To perform a workout, you only need to attach the cables with the help of carbines to the bar, stairs, etc. In addition, TRX bands are equipped with a mechanism for adjusting the length. This is needed for performing different types of exercises, as well as for load displacement.
TRX Workout Plan: Features, Pros and Cons
Here are key points on TRX workout plan:
- Since a lot of muscle tissues are involved during the training, the calories are quickly burned and a person loses fat mass. Of course, during the training with the bands, virtually all the muscles of the body are actively working, but no set of exercises with TRX loops can eliminate the consequences of excessive consumption of calories. This is the reason that many quit TRX training, because they do not lose weight. You might be interested in what steroid burns fat.
- There are no isolating exercises with TRX bands (any pseudo-isolating exercise, even bicep curls, will involve several joints and muscle groups, therefore, it will be considered a compound exercise).
- There is no need to perform specific workouts for each muscular area (for example, as in the case of boulder shoulder workout in classic bodybuilding), taking into account the specificity of the load, all target muscle groups are usually involved in the work.
- Beginners without special training have the opportunity to develop only slow muscle fibers. Undoubtedly, performing complex movements, muscle growth would be much more powerful, but, unfortunately, it's very difficult to master them independently. Thus, gaining really large muscles can only be achieved by complex and high-intensity exercises.
- Working with TRX bands may be associated with the risk of getting injuries. If we compare training with TRX and CrossFit (you might like our article on steroids in CrossFit) or weightlifting workouts, then the TRX exercises are safer, but in terms of gaining weight they are inferior to properly organized bodybuilding sessions.
- It takes a lot of effort to maximize muscle loading. We have already said that it is necessary to master complex movements in order to quickly and effectively gain muscle mess. In turn, simple exercises are comparable in effectiveness with cardio loads, but not with strength training.
- Try to find YouTube video materials on TRX workouts. That videos will help you to learn proper technique of exercises' execution.
TRX Workouts for Beginners – How to Execute Them?
If you've just bought TRX bands, then, of course, you can immediately go to compound exercises, but this will not give good results. First, your muscles will not be ready for such a load, and secondly, you are unlikely to be able to perform a large number of repetitions. Because, you need to start your workouts with relatively simple exercises designed to train the chest, back, legs and muscles of the core (read more about beginner core workout, [link to article 47]).
Back row with TRX band is one of the most effective TRX exercises. It involves almost all muscles of the shoulder girdle, back, core (the necessary condition to keep the balance) and even the legs. Moreover, you can vary the load, making it more difficult or easier to perform by changing the angle of the body (this can be done by adjusting the setting of your feet).
The movement itself is very similar to any rows in the gym, but it is worth noting a number of mandatory conditions for the execution technique:
- Your body should be straight, representing one line.
- Your sight is to be directed only straight (to prevent the neck from bending forward).
- You need to strain the muscles of the back and shoulders, trying to exclude the work of the hands (the arms should intensively work only at the end of the amplitude, when you need to lift TRX bands to your chest).
- All movements must be slow and concentrated. Beginners are forbidden to make sharp movements, which can be traumatic.
TRX push-ups are another exercise adapted for TRX, which will be an excellent alternative and complement to barbell press and push-ups. The technique of doing this exercise is not very different from the usual push-ups, but you need to consider some features of TRX bands:
- Given the un-fixed and loose position of TRX, your body will include stabilizer muscles to maintain balance. Also in the first 2-3 weeks, you can feel a shiver in the muscles. This is considered a normal reaction, even for non-beginners.
- At first, you can reduce the amplitude to the one in which you can perform 10 repetitions (if you can do 10 repetitions at once, you may not follow this recommendation).
- Correctly adjust the length of the straps and select the right angle of the body when performing the exercise, this critically affects the technique.
- The arms should be straightened at the chest level.
TRX sit-ups are a good exercise for the legs. The basic technique is simple: you need to hold on to the straps (handles, if available) and perform squats. You can put your feet in any way, but it's important to make the back flat. You can slightly shift the axis of the load back to include different muscular areas.
The next step in the complication of the technique will be squats with the move of the leg back or forward. This is a direct way to learning how to do one-legged squat in the future (this exercise will create an impressive load and will allow you to train your legs well).
When performing any variation of squats, it is important to remember about the following points:
- your heel should not come off the floor;
- your back should be level;
- it is not recommended to pull the straps with your arms, helping yourself to get up, as this will significantly weaken the load and make the exercise less effective;
- you should not tilt your head, you have to look forward.
30-Minute TRX Workout (in Circuits)
It is performed for half an hour and involves all muscle groups. It is aimed at burning excess calories and fitting the body. Well, this 30-minute TRX workout consist of classic movements:
- TRX Sit-Ups;
- Plank;
- TRX Pull-Ups;
- TRX Push-Ups.
Each exercise should be done for several cycles of 15 repetitions.
As a result of training with TRX training loops, the following beneficial effects will definitely occur:
- increased endurance;
- better strength, perfect coordination and balance;
- improvement of the work of the respiratory system and cardiovascular system;
- increased muscle tone;
- muscle mass growth;
- better joint mobility.
Some people are wondering: "Are there any disadvantages of TRX workouts?" The main disadvantage is that for comfortable training with straps you need a free space from the suspension point: about 3-4 steps forward and around. In addition, you need to find that suspension point. But in general, TRX workouts for beginners are a good choice.
You might also be interested in TRX full body workout routine.


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Pharmaceutical interventions are addressed by a number of papers in this month's issue of the journal. Drug therapy is the major intervention offered by the NHS to enhance and sustain the health of the population. Medicines cost the NHS in excess of £10 billion annually, with the total cost and number of prescriptions steadily rising; the majority of prescribing occurs in general practice. Given this investment, together with the shift of chronic disease management to primary care, GPs need to ensure their prescribing is effective in maximising health gains while minimising risks to patients.
Polypharmacy is arguably one of the most pressing prescribing issues. There is no formally accepted definition, but it is usually considered as concurrent prescribing of at least four or five drugs. In a German study, over a quarter of older patients in primary care were found to be on five or more medicines,1 and a recent Italian study found that over 35% of older patients were exposed to polypharmacy.2 Data from the Swedish Prescribed Drug Register also show a prevalence of over 5% of patients in their 40s, and around 12% of those in their 50s who are taking multiple medicines.3 Rates are increasing in almost all ages, although more so in older people.3 And crucially, polypharmacy is associated with undesirable outcomes.4
In this issue of the Journal, linked prescription and survey data are used to demonstrate that multiple drug use in older patients is associated with overall worsening physical and psychological health.5 Larger studies are required to explore this in further detail, accounting for factors such as drug indication, comorbidities, medication interactions, and duration of treatment. Polypharmacy also has the potential to influence many aspects of safe prescribing, including adverse drug reactions, risk of medication interactions, and adherence. Furthermore, the appropriateness or efficacy of a drug given in combination with many other medications may be unclear. Human error is also likely to be exacerbated due to the complexity of patients' medication regimes. A lack of familiarity with some newer drugs, particularly those initiated in secondary care, may aggravate these issues still further.
Polypharmacy is associated with age, morbidity, and poor self-rated health.6 Also, older people are particularly prone to adverse consequences due to age-related physiological changes altering the pharmacokinetic and pharmacodynamic characteristics of many medicines.7 Given that life expectancy is increasing, and multiple morbidity is more common in older patients, the problem of polypharmacy is likely to become worse. Furthermore, our practice of evidence-based and protocol-driven medicine helps to drive the relentless increase in the number of pills a patient is asked to pop; guidelines are usually developed around single conditions and are poorly equipped to inform clinicians how to deal with patients already taking medicines for additional diverse clinical problems.
One way of helping patients to manage multiple medicines is the use of medication compliance aids. In a qualitative study, Lecouturier and colleagues found that such aids are perceived by patients to reduce disruption, improve adherence, and streamline medication taking.8 The study also suggests that GPs may be failing to ask patients about these issues, and that problems of communication with respect to polypharmacy occur at the primary–secondary care interface. It should be noted, however, that medication aids do not address the underlying problem of polypharmacy.
Polypharmacy is a difficult issue to address, requiring a rational and structured approach. We need to challenge the current culture of 'ratcheting up' numbers of medications, and to increase awareness of the consequences of polypharmacy. This can be addressed, in part, through continued medical education, and also through clinical guidelines, particularly for common conditions affecting older patients. In addition, tools need to be developed to identify individuals who are likely to be at particular risk from polypharmacy. These may be practice-based or pharmacy-based, and should take into account factors such as age, sex, clinical conditions, or deprivation.6 Furthermore, although it may be easier to apply such tools in a retrospective manner, prospective systems would be preferable, especially if they influence prescribing behaviour and prevent polypharmacy.
Polypharmacy is not synonymous with inappropriate prescribing, but the two are nevertheless strongly associated.9 Therefore, it would also be valuable to employ validated processes to identify inappropriate prescribing, such as the Screening Tool of Older Person's Prescriptions (STOPP).10 The development of prescribing safety indicators for UK general practice, derived from STOPP and other sources, will be published in a forthcoming issue of the BJGP.
Regular and thorough medication review is an essential intervention for addressing polypharmacy. It is important to assess whether patients are receiving therapeutic benefit from their medicines, whether there is ongoing clinical need, and whether potential benefits are outweighed by risks and side-effects. Wherever possible, patients' views should be ascertained; they should be fully involved in decisions about their medicines; the rationale behind any medication changes should be explained; and any concerns should be addressed. Reviews should be specifically arranged, rather than rushed impromptu additions to the end of a 10-minute consultation.
Managing patients with polypharmacy can be time consuming, with complex cases requiring careful balancing of competing clinical priorities and conflicting guidelines. Where GPs do not feel they have the time or skills to undertake a thorough medication review, they need to consider alternative approaches, such as employing clinical pharmacists or seeking advice from community geriatricians.
Polypharmacy is a major and growing public health issue. Proactively addressing the problem has significant potential to maximise quality of life for patients, help patients to manage their own medicines, reduce adverse effects, and encourage more rational and efficacious drug use. Further studies are needed to ascertain whether reducing polypharmacy results in better clinical outcomes.
Commissioned, not externally peer reviewed.
- © British Journal of General Practice, 2011


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Budding film makers scoop first prize at Welsh Film Awards
Congratulations to our Media Students who picked up two awards and five nominations at the recent Zoom film festival. The awards were:
Winner of best film 14-18 - This was awarded to Media students Jaynion Hampton, Jessica Morris, Morgan Rogers, Caitlin Roberts and Cameron Bash. Click here to see winning film.
Winner of Best Documentary 2015 - which was awarded to BTEC level 2 student Sarah Olivant.
Click here to see Sarah's winning documentary.
College re-openingView all latest news
If you are in Year 9,10,11 and are starting to think about college and your future? Why not sign up for our newsletter for all the latest information about college life, open days and events.Click on image to find out more


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The Guy At The Top Of The World
Did you see that guy sitting on top of the mountain overlooking Divorce beach on the front page of this rag? If not, pay attention! Go back, look at it and then come back for the story.
His name is Iker Algorri, a very unusual name and last name for a Mexican which originates from the separatist Basque province in Spain.
The pic was taken sometime in 1988 or 89, so he was in his early 20's at the time. The resort behind him is the now demolished Solmar resort, which came back to life as Grand Solmar, bigger and luxury-er.
Born in Mexico City, Iker arrived in Southern Baja (that's our state, Bunky) 36-years-ago. He remembers that waaay back he visited Todos Santos and thought, "I'd love to live down here in a little casita." But his job as a Mexican federal agent kept him busy in other parts of Mexico and in between, he traveled the world. He is an attorney with additional studies to become an English teacher, foreign commerce, customs, and chef.
He has traveled extensively as shown in his hundreds of selfies published on Facebook. He has been to the U.S., Canada, Cuba, Puerto Rico, Argentina, Egypt, Jordan, Israel, parts of Europe, the Virgin Islands, and one of his favorite places, Petra, in Jordan.
Iker has worked for the Mexican government at the federal gun registry, then as a customs warden, tax police, tax collector and interpreter for the justice department. At some point in his life, he followed his true vocation, which was eating, and decided to take some lessons to become a Chef. He worked for Café Brown in Fort Ware, B.C., Canada.
Later he made his dream come true. He moved to Todos Santos where he opened his own Café Brown in 2000 and served several celebrities, including his favorites, some Victoria´s Secret Angels. He is currently in charge of the kitchen at the Los Colibris Casitas in Todos Santos, where he also sporadically holds cooking classes.
His hobbies are music (he owns about 3,000 LP's, 2,000 cassettes and about 2,500 CD's), reading drawing, traveling, photography and … eating. He has two daughters and one son, named Asshanti Nic tehà , Andoni Younoem y Tahnee Danaè, and to this date remains single.


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A Love Story E guide Excerpt
Our functions give attention to the enjoyment of taking part in basketball in an organized setting, in addition to basic coaching via the drills essential to correctly develop. Girls and boys who dwell inside the Sylvania College District and are at current enrolled in grades Ok-twelfth are eligible. See specific program information below.
Lewis, the 13th-ranked participant in ESPN's highschool recruiting rankings, is probably going one of the extraordinarily regarded prospects in his class. He has NBA potential as a two-technique participant, and his bodily functionality and defensive prowess had everybody within the nation coming after him, nevertheless solely two schools stay now.
Rebecca Lobo (1999 WNBA All-Star): I am in eighth grade, and I'm already 6-foot-2. You go to highschool dances, and no boy is asking the 6-foot-2 girl with the big perm hair to gradual dance. But after I performed basketball, I liked being tall. Basketball was the place the place I felt good about myself.
Step up your sport with breakthrough basketball gear.
The Blue Ribbon School Basketball Yearbook has named their preseason High 25 and the UCLA basketball workforce is available in at #14 of their rankings. Basketball is a group sport. Two teams of five players each try to score by shooting a ball by a hoop elevated 10 feet above the bottom. The sport is performed on an oblong ground known as the court docket docket, and there is a hoop at each end. The courtroom is cut up into two principal sections by the mid-court docket line. If the offensive staff places the ball into play behind the mid-court docket line, it has ten seconds to get the ball over the mid-court docket docket line. If it doesn't, then the protection will get the ball. As soon because the offensive crew will get the ball over the mid-courtroom line, it could possibly not have possession of the ball within the space in again of the highway. If it does, the protection is awarded the ball.
Males's Basketball standout Joel Johnson was named the male recipient of the NAIA's Emil S. Liston Scholarship Award. The latest: Hurt may want been the busiest recruit throughout the country at first of the fall period, hosting Calipari, Mike Krzyzewski, Roy Williams, Invoice Self, Jay Wright and Richard Pitino throughout the first two days alone Penny Hardaway was in Minnesota to see the 6-9 forward two days later, and Indiana is among the many different colleges involved. Hurt has not but launched his schedule of official visits, though UK will get one and a go to to Enormous Blue Insanity next month remains a possibility.
If it would not, then the protection will get the ball.
Basketball was invented in December 1891 by Canadian James W. Naismith. An instructor at the YMCA Coaching College in Massachusetts, he sought a suitable indoor sport to maintain his school students fit and warm by means of the chilly New England winters. He formulated 13 rules, most of which nonetheless apply at the moment. In 1893, the primary ladies's recreation was carried out on the Smith School, in Northampton, Massachusetts, USA.
Reply 2. No explicit part. Give consideration to your entire rim. It is too arduous to have a look at a spot on the entrance or once more of the rim. Think about the rim as a whole particularly for distance after which your thoughts dictates to your index finger to shoot the ball straight and additionally it is a big part of the sensitivity and get in touch with that helps make the shot go straight. Crooked footage not often go in. Judging the distance is loads easier than taking pictures the ball straight since about seventy eight% of photographs are crooked.
He can also play the wing, a position UConn has lacked at in current times. August 21 2018 – Penny Hardaway, coach of the Memphis males's basketball workforce, throughout an appearance at the Memphis Rebounders annual preseason banquet at the Laurie-Walton Household Basketball Center. Nevertheless the coach famous he has endured plenty of basketball grinds.


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Gold Coast Top Companies 2018 | 21-30
24 October 2018, Written by Nick Nichols, Camilla Jansen, Matt Ogg, Paris Faint
While business development and negotiations for new opportunites are often slow burn exercises, the pay-offs can prove massive if you make the right decisions at critical inflection points in a company's evolution.
Fortunes are made quickly when the going gets good, but not everyone is always so lucky. Companies that fall on hard times may fall into obscurity and sometimes they resurface, but often the trick is making the right choices to stay in the game for the long haul.
The dramatic change that occurs in the corporate world has been evident in the Gold Coast Top Companies 2018 list so far.
Out of today's 21-30 section only three companies - Supercars, Morris International and Digga Australia - are in a similar boat rank-wise to what they were in our 2016 list.
National Veterinary Care (ASX:NVL) was only a year old when that list came out and naturally did not make the cut, but now the group has cracked the Top 30 and its founder Tomas Steenackers won the Gold Coast Young Entrepreneur of the Year Award 2018 a couple of weeks ago.
From a rebounding marine sector to travel to wine, today's companies are as inspiring as they are competitive as we edge closer towards the final countdown.
21. Palm Lake Group
Established: 1977
22. Supercars
Established: 1997
23. Morris International
Established: 1973
While he still has direct-marketing interests servicing national and international clients, the group also counts manufacturing, information technology, tourism, hotels and venture capital in its business portfolio with other groups including Norwell Motorplex, Pronto Direct and TEMA Property Services.
Sirromet Wines, a business born from Morris's interest in wine, has established itself as Queensland's dominant wine brand.
24. Midway Metals
Established: 1975
The Yatala-based Midway Metals is Australia's largest independent stainless-steel distributor and manufacturer. It has operations Australia-wide as well as in New Zealand, Singapore and Vietnam.
25. Ignite Travel Group
Established: 2005
In a time-poor world, Ignite Travel Group has managed to beat the naysayers who have little faith in the longevity of traditional travel agents and it has become a major player in the Australian holiday market.
26. National Veterinary Care
Established: 2015
27. Langs Building Supplies
Established: 1976
From what began as a small backyard business in the 1970s, family company Langs Building Supplies now has three sites in South East Queensland with customers ranging from DIY home handymen through to major construction companies.
"I believe our Yatala headquarters to be the largest Queensland-owned building and fabrication centre in Queensland," says founder Bob Lang.
"Our fabrication operations have the capacity to fabricate the equivalent of 20 house lots of roof trusses and wall frames daily."
The group describes itself as a "trade-focused" building supplier with specialist knowledge and a large range of landscaping and structural timber as well as up-to-date and extensive hardware and plumbing supplies.
Bob Lang says emphasises the importance of ongoing staff training to be able to deliver quality goods and service to valued customers.
"We work closely with local schools, presenting at career days and offering both school based traineeships as well as fully accredited courses to school leavers," he says.
"It is not uncommon for us to have up to ten trainees at any one time in our company.
"We have an in-house training facility which offers young people who are prepared to work hard the chance to learn a valuable skill. In addition, we are constantly training and adding to the skills our current staff."
28. Telwater
Established: 1999
The leisure marine market has bounced back in recent years, so it's no surprise that Telwater, Australia's largest manufacturer of aluminium boats and trailers, has shared the ride.
Telwater was established by Paul Phelan and Bruce Shepherd in 1999, some 11 years after the business partners bought Quintrex, a brand that has been a part of the Australian landscape since 1945.
29. Maritimo
Established: 2003
Maritimo entered its 15th year of operation with an appetite for expansion on the Gold Coast, buoyed by strong domestic and international markets for its luxury motor yachts.
"Most overseas residents look at Australia as being somewhat isolated and in a rugged part of the world with a dramatic and sometimes challenging coastline.
30. Digga Australia
Established: 1981
The countdown in is on. Don't miss when we reveal which other companies made the list throughout the week.
Click here to read


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Banana-Pineapple Breakfast Shake – Makes 4 Servings
- 490g plain yogurt
- 225g tinned crushed pineapple in juice, undrained
- 1 banana
- 120g ice cubes
- 2 tablespoons sugar
- 1 teaspoon vanilla extract
- 1⁄8 teaspoon ground nutmeg
Place yogurt, pineapple, banana, ice cubes, sugar, vanilla and nutmeg in pitcher of KitchenAid Magnetic Drive Blender. Cover and blend on Icy Drinks/Smoothies setting.
Pour into four glasses; serve immediately.


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With Thanksgiving right around the corner we started to do some fun turkey crafts, the first one is a fun Coffee filter turkey made into a magnet.
You can paint, color, or use daubers to make your turkey's feathers. We used our daubers.
Coffee filter
Brown construction paper for the face(head) cut out a circle
Red, orange and yellow for the turkey feathers (paint, crayons, markers, or daubers)
Goggle eyes
Yellow construction paper for the turkey's nose
Glue magnet strip
Small popsicle sticks to glue on the back of the turkey to keep it firm
You can get all the supplies at the Dollar Tree except the magnet strips and small popsicle sticks(those can be bought at Wal-Mart)
Really fun, inexpensive and easy craft to make with kids.
Be sure to check out the other fun Thanksgiving crafts we have done. Thanksgiving tile keepsake and Terra Cotta Turkey
Thanks for stopping by to see what fun stuff we are doing. If you like what you see please come and follow us over on FB and Pinterest, would love to have you. Also, please feel free to share the fun things you are doing with us.
Friday, November 16, 2012
Coffee filter turkey magnet
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Hi!The reasons for this may depend on the age of your daughter. Here are some videos I have found useful on dealing with moody girls. Check them out! http://www.kidsinthehouse.com/video/helping-tweens-self-regulate-when-they-feel-moodyhttp://www.kidsinthehouse.com/video/tips-dealing-your-daughters-moodinesshttp://www.kidsinthehouse.com/video/preventative-measures-tween-mood-swings
I agree with the teachers. These emotions eventually gets transferred into passion for work, life, career path, hobbies, etc. down the line. I wouldn't worry too much.
I think that sometimes people grow up too fast before they realize how they can convey their feelings. Turns into an "me vs. the world" mentality. Need to stress that is NOT what is happening.
Perhaps your daughter feels that her relationships with her peers that make her "popular" are shallow and that's why she craves attention and love that is more profound. Do you have a good relationship with your daughter? Perhaps more attention from you will make her feel like she isn't taken for granted! Just a tip :)
While this may be normal, I would still keep a close eye on your daughter. If she feels the need to physically hurt herself now, that may manifest itself into something more dangerous down the line.
I'm with Hayden, it might be harmless now but the more attention that you pay to it, the better.
I highly recommend a book called, Best Friends, Worst Enemies. By far the best book I have found that covers childrens social lives from preschooler on up through high school. Every parent should have a copy!
Oh I am definitely going to check this book out.
I just started a thread yesterday about some mild but difficult issues with friends in kindergarted. Thanks for sharing this resource!
How old is she? I would like to know because it makes a difference. Some of the things you describe seem normal to me like her fighting with her sister over silly things. I know many kids especially younger ones who are close in age who do that. I swear my boys could fight over an empty gum wrapper when they want. Other times they are each other's biggest supporter.You say she hits herself. Has she been evaluated for any type of sensory disorders? I would take her to a developmental pediatrician and let her see the school counselor at least.Good luck.
If she's older I would have an expert check her out. It could be depression & she doesn't need to suffer needlessly.
How old is she? I know my son is 12 and he is much moodier than he was when he was younger...


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COVID-19 update
First of all, from all of us at Lovechock we'd like to send you all our love and positive energy; and above all good health during these challenging times.
Our factory in the Netherlands is still producing with the maximum of care, continuing to make our delicious vegan raw chocolates. This means that we are currently despatching and delivering orders within our normal timeframes. We truly appreciate the extraordinary work that is being done in the wholesale and retail, offline and online, so you can still enjoy the power of our raw chocolate.
Thank you all very much for your loyalty and the love you are sharing with us. Please take care and stay safe.
With Lovechock, from the team.Where to buy Lovechock online
Our chocolate bars are handcrafted with superfood ingredients.
Our chocolate tablets are a tasty combination of raw cacao and superfoods.
Our lovestory
Love for your body. Love for the farmer. Love for the planet. When Lovechock started as first European manufacturer of raw chocolate in 2009, the Amsterdam based company didn't only want to create the most yummy and healthy cacao experience, but also conscious chocolate with a sustainable way of production.
Raw Cacao
Cacao is naturally rich in many nutrients such as vitamins, minerals, flavonoids (polyphenols), and last but not least mood enhancers or "love chemicals" as we call them such as Tryptophan and Anandamide; also known as the bliss chemical. We process our cacao at low-temperatures, cutting out many of the conventional chocolate making techniques to keep our cacao as close to nature.
100% Organic
We use only the best natural ingredients for our products. Therefore, all ingredients are organic (SKAL certification 1249180). On top of this, we use the heirloom Arriba Nacionale cacao bean from Ecuador. Lovechock obtains its cacao beans, directly from small farmers, who often grow other fruits besides cacao and do not use any pesticides.
Direct Trade
The cacao that Lovechock uses is produced in an honest way that is in compliance to the fair wage for the farmers. Lovechock buys its cacao directly from the farmers' cooperatives in Ecuador, without any middle man. In this way we avoid that the margin goes to third parties such as intermediaries and make sure that the involved farmers receive a fair wage and are treated respectfully.
Natural sweeteners
Lovechock doesn't add refined sugar. Our chocolate is sweetened with natural sweeteners like e.g. dates or the dried nectar of Javanese coconut palm tree blossom. Of course, like all ingredients, also these natural sweeteners are 100% organic.
Plastic free
Lovechock wants to take care of the planet. Out of love for our earth all products are packed plastic-free and completely biodegradable. And this already since 2011.
From the start all our products are vegan. We want to honor the planet that supplies our ingredients. And we know we can make our raw chocolate taste delicious without any animal products.
Palm oil free
Lovechock chocolate is palm oil free. We do not only process the cacao as minimal as possible, we also add as many ingredients as necessary. And when we add something, we add exquisite ingredients like superfoods - and no cheap fat.
Our chocolate contains no traces of wheat or gluten. Those suffering from gluten intolerance no longer have to do without chocolate and can indulge too.
Check out our Instagram @lovechock_official or share your creations with #lovechock.


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Supponor, the virtual replacement specialists, whose technology integrates with perimeter LED displays, have recently launched a crowd-funding campaign to help drive their next wave of development.
They've just reached the halfway point on their drive to raise £1 million of investment so we thought it would be interesting for our readers to understand a little more about the campaign following some recent high profile contract wins.
A little about Supponor
Supponor has been working in the augmented reality (AR) space for over a decade. In that time we've been developing – and deploying – virtual replacement advertising in sport. The team is split primarily between our R&D facility in Finland, and our operational and commercial arm in London.
At the heart of our proposition is our patented DBR Live technology, which enables us to digitally replace the advertising content that typically frames the pitch/court/field in major sports events. This means that media rights owners using Supponor's technology can deliver different brand messages into individual viewing territories – essentially commercialising their highest profile media space multiple times over.
DBR Live combines advanced camera optics with intelligent object masking and powerful software. This enables us to produce multiple broadcast feeds of a single event (e.g. a football match), in which the perimeter advertising content that frames the pitch can be changed for different international audiences.
We've got some pretty cool customers
Some of the world's biggest leagues, brands, clubs and federations trust our technology. DBR Live has already been used in a number of major sports leagues and we continue to seek approval with other key sports properties. The table below demonstrates the markets in which we are operating/undertaking notable trials.
The latest version of the technology, which integrates with ADI's LED perimeter boards, has been approved for use by the DFL in Germany's Bundesliga, and will be fully deployed from the beginning of the 2018/19 season. Facilitating a major new contract, together with ADI, we'll be providing multiple virtual feeds for Borussia Dortmund matches, as well as a selection of other high profile games.
According to Nielsen Sports, virtual replacement advertising technology is forecast to have a €60m incremental impact on club revenues in Germany's Bundesliga when Supponor's AR platform launches next season.
A previous version of Supponor's DBR Live technology has been deployed in Spain's LaLiga for over four years. Here Supponor's technology has been used to deliver up to nine customised international feeds for over 160 Real Madrid and Barcelona matches. Other football leagues in which the technology has been either been approved or trialled include Serie A, the Premier League, and EFL.
A major breakthrough in North America saw deployment of virtual replacement advertising in the NHL's World Cup of Hockey, which utilised the tech in the 2016 finals. The deployment transformed the static dashboards into a dynamic digital canvas for TV viewers, allowing brands to more effectively activate their partnerships.
Why the time is right
Whilst Supponor has been working in the virtual advertising space for over a decade, it feels like the market and the technology have finally caught up with one another. One stumbling block for the wider adoption of our technology in sports such as football has been the fact it wasn't previously compatible with LED advertising boards. The latest innovation, however, combines the ability to deliver visible LED in the stadium with the ability to virtually overlay the content for viewing audiences.
The timing of the launch of the new LED hybrid system feels like it couldn't be better. Sports clubs and federations are increasingly 'internationalising' their brands. You only need look around Europe and see how the major clubs and leagues are developing international strategies. As the Premier League's Richard Scudamore puts it "If you are going to sell global you better be able to localise."
Outside of soccer, major US sports are attempting to extend their reach too, with MLB following the lead of the NBA and NFL in staging international matches in London.
So why are leagues and teams seeking to extend their international reach? The answer seems obvious to us… Brands demand more value, and one way to deliver this is by growing ones audience. But brands won't be satisfied with this alone – they need to be able to tailor their message for each individual audience in order for it to be effective.
Hyper-targeted future
Whilst we feel the next 12 months will be a breakthrough year for our virtual replacement advertising technology, the future is even more exciting. Ultimately, the time will come when in game perimeter advertising will be hyper-targeted; matching brands and individual viewers so they see brand content most relevant to them.
We're already able to serve different brand messages to individual broadcast regions, which is a huge step, but we can also target viewers by device, meaning that fans watching the same game on a mobile or tablet can be served different brand content to those watching on TV. The future vision for our platform means we'll be able to help brands reach sports fans based on their individual preferences and interests.
But what about the immediate future?
This latest investment drive is key helping us accelerate our short term growth which will help us position as the leading provider of such virtual replacement technology.
Our strategy is focused around gaining approval of virtual replacement advertising from a wider range of sports federations and governing bodies – all of which has considerable operational costs – and by dramatically increasing the scalability of the technology in order to satisfy this rising demand.
Critically, we'll use new funding to complete the next generation of our optics technology (allowing more broadcasters to integrate the technology into everyday operations).
Summary of objectives:
– Increase in the number of games being virtualised (for existing and new customers)
– Commence roll out of next generation optics technology at scale
– Gain approval for virtual replacement by more leagues/federations – currently La Liga, Bundesliga, NHL
– License the technology to more partners
– Increase in the media value of the virtual inventory
– Adding additional products (for example virtual goal mats) for existing deployments
– Increase in fees when renewing contracts as media value is better established
Find out more by visiting the Supponor pitch page here.
The feature above was originally published on crowdcube.com
As with all investments of this nature, capital is at risk. Please Invest Aware.


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Guess what guys.
No really, you gotta guess.
Okay FINE, I'll just tell you.
Remember how last year we had an advent calendar with lots of fun tutorials, surprises, and giveaways?
We're not doing that again.
Don't get mad.
Let me finish. Sheesh.
We're doing something different.
For the next 12 days, we're doing DevaCurl giveaways on DevaCurl.com.
That's 12 days, aka 12 chances to win.
And while the prizes start out super small, they get bigger, and BIGGER, and BIGGER every day.
Aka you should be pretty excited.
Want your chance to win? Sign up here.
Each day, you'll
But what if you don't win?!
Don't fret, there's a special sale each day for anyone who doesn't win. Aka at the very least, you're guaranteed access to a special Deva Deal.
Get. In. On. This. People.
Oh that's not enough?
Sorry, not sorry. Because um. We teamed up with 97 curly girls, to give away our brand new Miracle Kits. Keep your eyes peeled on the hashtag #DevaMiracle across Twitter and Instagram and you might just catch one.
To find the giveaways, simply search for the #DevaMiracle hashtag on social platforms. Right now, on Insta there's three hiding in the top posts.
But keep your eyes peeled, new ones are launching every day!
Yeah, we figured you were.
Sign up for 12 Days of Deva right here! And don't forget to continue to watch out for #DevaMiracle on Instagram here and on Twitter here.
Team Deva


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IT'S FINALLY OCTOBER! October is my favorite month by far. I've mostly lived places that are very summery year round, and while that might sound great to some of you, for me summer weather = death.
I get hot so easily and sometimes even get headaches from the heat and it makes me not even want to venture outside and UGH. But in lovely October the weather starts getting cooler (well, in theory) so you can pull out cozy sweater and boots, seasonal treats like "pumpkin spice this" and "peppermint that" come back, and most importantly, HALLOWEEN IS NIGH. Halloween is my absolute favorite holiday and I like to stretch it as long as I can, which means my apartment was decorated yesterday and all this month I'll be doing fun Halloween-themed nails.
I'm not a huge fan of super literal nail art like Frankenstein's monster patchwork or stamps of bats and witches' hats – I don't hate that stuff, and will on occasion even do them myself, but in general it's not my jam. I more prefer playing with traditional holiday colors/themes instead of straight images. Also, GLITTER. Soooo much glitter in the coming weeks (actually, for the next few months, because holidays = glitter to me). Get excited! Anyway, to kick off the month I have a skittles mani:
I used a shitload of polishes for this mani, as you can see.
Finger by finger:
Thumb: Wet'n'Wild Black Creme + Sephora by OPI Traffic Stopper Copper (which I now realize I forgot to include in the bottle photo ahhh!). I liked pairing copper instead of a true orange with black, it's still Halloween-y but more chic or something. This is one coat of Black Creme and one coat of TSC, believe it or not.
Index: China Glaze I'm With the Lifeguard + Cirque Debris, Wet'n'Wild Tangled in My Web. First on my left hand I used Debris, a chunkier glitter, but thought it was too similar to the size of TSC on my thumb, so on my right hand I used Tangled and I think the tiny black glitter is a better contrast.
Middle: Sinful Colors Let's Talk + W'n'W Black Creme, Girly Bits' Into the Night. Let's Talk is almost impossible to photograph correctly – it's a true, royal purple, and if you don't own it you need it because it's beautiful. I've never done the drippy style before, but I think it looks pretty good for being my first try! I added Into the Night on top of the black drips on my left hand but thought that made it harder to see so I left it off my right hand (I really should've used another color but I liked making black the color that tied all the nails together).
Ring: Oh man, I LOVE the striped ring finger, despite how long it took to do. I used tweezers to painstakingly place five or six striping tape pieces on my nails. I had to re-do each placement a few times to get it perfect, because I wanted all the stripes to be the same width as the striping tape and even though I was just eyeballing it I think it came out really great! It reminds me of Jack Skellingston's suit.
Pinkie: CG Orange Marmalade + OPI Black Shatter. I put some tape at a diagonal and globbed on my poor, semi-dried-out Black Shatter. It's gotten so gross and didn't even crackle that well. I remember when this polish first came out there were a lot of issues with it drying out quickly, and I guess I have had mine for a few years now. :(
A lot of work but I really love this mani! A fun way to kickoff the Halloween countdown.
I decided that I was going to list a favorite Halloween/horror movie of mine with each manicure. This is not a list of "best Halloween movies" or anything, just some of my personal faves. First up is a movie that I already included a gif of that's beloved by everyone who was a child in the 90s:
Hocus Pocus, y'all! If I did have to choose one halloween movie, it would be this one by a mile. Maybe I only think this because I grew up with it, but Hocus Pocus is a rare PG (?) movie that can actually be enjoyed as an adult, too. The story is fun, the setting of Salem is perfect (and lovely in all its autumn glory), and every single character is enjoyable and well-acted, even the kids and the minor characters (it's especially fun to see a pre-Sex and the City Sarah Jessica Parker be absolutely ridiculous).
It's still funny even though I've seen it a million times since I was a kid. I can quote the whole movie (sometimes I just text my sister "Max. Fat chance.") but that doesn't stop me from enjoying the shit out of this movie every time I see it. It's really just a classic, and if you've never seen it, you should definitely check it out on one of ABC Family or the Disney Channel's inevitable airings, if only for the scene where Bette Midler sings. I'm not exaggerating when I say it's one of the most amazing things in this world.
Do you get excited for fall (or in my case, "fall") too? Do you love Halloween or Hocus Pocus as much as I do? What did you think of this mani?
I hope you enjoyed this post! See you next time! A x


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Current Articles
Should we increase our minimum wage?
An expert on Seattle's experience will address 2 Hawaii events
From Grassroot Institute
HONOLULU, Feb. 23, 2020 >> Proposals to increase Hawaii's minimum wage are back on the docket at the state Legislature, in an effort to make our state more affordable. And who doesn't want that? It's an attractive idea, but what could go wrong?
To help answer that question, the Grassroot Institute of Hawaii is sponsoring two luncheons in March at which Jacob Vigdor, a professor of public policy and governance at the University of Washington, will talk about what resulted in Seattle after 2014 when it became the first big city in the United States to start raising its minimum wage over a period of several years to $15 an hour.
Vigdor and his colleagues conducted a comprehensive analysis of the city's new wage structure and found that the costs outweighed the benefits.
If you would like to hear more about how minimum-wage legislation harms the very people it is meant to help, and what Hawaii lawmakers could be recommending instead to bring down Hawaii's high cost of living, please join us for these two important events. Both will be moderated by Keli'i Akina, president and CEO of the Grassroot Institute of Hawaii.
The first of the two luncheons is scheduled for Monday, March 23, at Cafe Julia in the Honolulu YWCA, 1040 Richards St. Admission is $25 and includes a luncheon buffet. Paid parking will be available at Ali'i Place.
The second is on Tuesday, March 24, at the Maui Country Club in Paia. Admission is $10 and includes a luncheon buffet and parking.
For more information, please call 808-591-9193 or email firstname.lastname@example.com.
* * * * *
UPDATE: Jacob Vigdor presentations will be via teleconference
HONOLULU, March 8, 2020 >> Out of an abundance of caution due to the coronavirus, the Grassroot Institute of Hawaii has decided to use teleconference technology for its two luncheon presentations in Hawaii this month by minimum-wage expert Jacob Vigdor.
The University of Washington professor of public policy and governance will talk about what resulted in Seattle after it started in 2014 to raise its minimum wage over a period of several years to $15 an hour, and those in attendance will still be able to interact with him in real time, thanks to the wonders of modern technology.
A similar event in February, featuring economist Dan Mitchell from Washington, D.C., was converted to a teleconference for the same reason, and it turned out to be quite successful.
The two events featuring Vigdor will still take place on the same dates and at the same venues as originally planned:
>> Monday, March 23 at Cafe Julia in the Honolulu YWCA, 1040 Richards St.
>> Tuesday, March 24, at the Maui Country Club in Paia.
Keli'i Akina, president and CEO of the Grassroot Institute of Hawaii, will be moderator of the two events, and Vigdor's presentations are still expected to be exciting and informative.
The Grassroot Institute of Hawaii is an independent 501(c)(3) nonprofit research and educational institution that seeks to lower the cost of living and increase opportunities in Hawaii by promoting individual liberty, economic freedom and limited, accountable government.
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text: How to Keep Your Rock Hill Home Comfortable This Winter Posted March 15, 2017 If you want to keep warm during the Rock Hill winter, your furnace will requite some maintenance to make sure it's working at its best. If you've already arranged your annual tune-up with US Air Heating and Cooling, you're right on schedule. Don't panic if you haven't, there's still time! Give us a call at [[phonenumber]] to schedule your appointment. Between professional maintenance, there are quite a few things you can do to keep your furnace working at its peak performance. Try these maintenance ideas to keep your furnace healthy:To make sure your system is operating correctly, test your thermostat frequently. Turn it on and gradually increase the temperature setting until you hear your furnace start. If you don't hear anything, read our blog post on furnace repair for thermostat troubleshooting or give us a call.Check your filters regularly and clean or change them when recommended. We can't emphasize this enough. It's a an efficient way to boost the airflow through your furnace and maintain peak efficiency.Keep all your vents and cool air returns clear of interference. This includes keeping the ventilation outside of your home clear.Look in to having your air ducts professionally cleaned if you see dust accumulating around your cool air returns or noticeable debris in your ducts. To find out more about duct cleaning and the signals it's time to hire someone, refer to our blog on duct cleaning. It's important to us that you stay comfortable this winter. If you want to learn more about furnace maintenance or would like to book a service with one of our technicians, call US Air Heating and Cooling at [[phonenumber]] or make an appointment online.


text:
Victron Energy
Price: £280.00
(£336.00 inc. VAT)
Product Code: SDFI0000110
Group Code: VE
The Filax has been designed to switch critical or sensitive loads, such as computers, industrial controls or modern entertainment equipment from one AC source to another. The priority source typically is the mains, a generator or shore power. The alternate source typically is an inverter. With its switching time of less than 20 milliseconds sensitive loads will continue to operate without disruption. The Filax is not intended to supply high power household equipment like washing machines, or electric motors


text: Kate Moran goes out for a new movie premiere and she puts on an elegant black dress that covers very little when it comes to her tits. We are able to see her nipples poking through the transparent fabric as the reporters flash their cameras. The babe looks like she likes the attention that she is getting from all the guys watching her.