text:
Elevated Cardiac Troponin T Is Associated With Higher Mortality and Amputation Rates in Patients With Peripheral Arterial Disease
Author + information
- Received January 10, 2013
- Revision received April 18, 2013
- Accepted May 5, 2013
- Published online April 22, 2014.
Author Information
- Birgit Linnemann, MD∗,†∗ (Birgit.Linnemann{at}kgu.de),
- Thilo Sutter∗,
- Eva Herrmann, MD‡,
- Sebastian Sixt, MD∗,
- Aljoscha Rastan, MD∗,
- Uwe Schwarzwaelder, MD∗,
- Elias Noory, MD∗,
- Karlheinz Buergelin, MD∗,
- Ulrich Beschorner, MD∗ and
- Thomas Zeller, MD∗
- ∗Department of Angiology, University Heart Center Bad Krozingen, Bad Krozingen, Germany
- †Division of Vascular Medicine, Department of Internal Medicine, Goethe University Hospital Frankfurt/Main, Frankfurt/Main, Germany
- ‡Institute of Biostatistics and Math, Modeling, Faculty of Medicine, Goethe University Hospital Frankfurt/Main, Frankfurt/Main, Germany
- ↵∗Reprint requests and correspondence:
Dr. Birgit Linnemann, JW Goethe University Hospital Frankfurt/Main, Division of Vascular Medicine, Department of Internal Medicine, Theodor-Stern-Kai 7, D-60590 Frankfurt/Main, Germany.
Objectives The aim of the present study was to evaluate whether elevated cardiac troponin T (cTnT) was independently associated with an increased all-cause mortality or risk of cardiovascular events and amputation among patients with peripheral arterial disease (PAD).
Background PAD patients often have impaired renal function, and the blood concentration of cardiac troponin often increases with declining glomerular filtration rate.
Methods The cohort consisted of 1,041 consecutive PAD patients (653 males, 388 females, age 70.7 ± 10.8 years, Rutherford stages 2 to 5) undergoing endovascular peripheral revascularization.
Results At baseline, measurable cTnT levels (≥0.01 ng/ml) were detected in 21.3% of individuals. Compared with patients who had undetectable cTnT levels, those with cTnT levels ≥0.01 ng/ml had higher rates for mortality (31.7% vs. 3.9%, respectively; p < 0.001), myocardial infarction (4.1% vs. 1.1%, respectively; p = 0.003), and amputation (10.1% vs. 2.4%, respectively; p < 0.001) during a 1-year follow-up. In adjusted Cox regression models, cTnT levels ≥0.01 ng/ml were associated with increased total mortality (hazard ratio [HR]: 8.14; 95% confidence interval [CI]: 3.77 to 17.6; p < 0.001) and amputation rates (HR: 3.71; 95% CI: 1.33 to 10.3; p = 0.012).
Conclusions cTnT is frequently elevated in PAD patients and is associated with higher event rates in terms of total mortality and amputation. Even small cTnT elevations predict a markedly increased risk that is independent of an impaired renal function. (Troponin T as Risk Stratification Tool in Patients With Peripheral Arterial Occlusive Disease; NCT01087385)
Cardiac troponin T (cTnT) is a component of the contractile apparatus of cardiomyocytes and an established sensitive biomarker of myocardial cell injury. Therefore, testing for this biomarker is recommended for the diagnosis of myocardial infarction in the clinical setting of an acute coronary syndrome (ACS) (1). An elevated cTnT level is associated with an adverse outcome after ACS (2,3) in patients with chronic heart failure (4,5), acute pulmonary embolism (6), and end-stage renal disease (ESRD) (7,8) and in the general population (9–12). The clinical significance of detectable cTnT among patients with peripheral arterial occlusive disease (PAD) is unknown. Recently, some investigations have reported that elevated cTnT levels may also be of prognostic value in patients with acute limb ischemia (13,14). However, cardiac troponin levels often increase with a declining glomerular filtration rate, and many PAD patients have impaired renal function (15,16). There is evidence that chronic kidney disease itself is associated with an increased cardiovascular mortality (17,18). Elevated cTnT levels are also associated with other vascular risk factors, such as age, male sex, and diabetes (9,19,20). This study was performed to define the distribution and determinants of measurable cTnT among symptomatic PAD patients and to explore its prognostic impact on mortality, amputation rates, and cardiovascular outcomes during follow-up.
Study design and participants
This retrospective single-center study enrolled 1,065 consecutive symptomatic PAD patients at Rutherford stages 2 to 5 (Fontaine stages IIb to IV). Patients were admitted to our university teaching hospital between January 2007 and December 2007 for urgent or elective endovascular revascularization. The ankle-brachial index and diagnostic workup by a color-coded duplex scan were routinely used before angiography to confirm the diagnosis of PAD and to determine the therapeutic strategy. All patients were followed for a period of at least 12 months or until death. Most of the patients were regularly seen in the outpatient department for diagnostic follow-up and were asked to answer a standardized questionnaire. To obtain information about mortality and vascular morbidity, we reviewed medical records and contacted the patients and their general practitioners. Outcome data were available for 1,012 patients (95.0%) (Fig. 1). The protocol was approved by the local ethics committee and registered at ClinicalTrials.Gov (NCT01087385).
The exclusion criteria were all conditions that may acutely increase cTnT levels. Myocardial ischemia or clinical symptoms indicating unstable angina pectoris or ACS within the previous 14 days resulted in exclusion from analysis. Additional exclusion criteria were acute pulmonary embolism, aortic dissection, New York Heart Association functional class III or IV heart failure, cardiomyopathy, endocarditis/myocarditis, external electrical cardioversion for atrial fibrillation, and heart surgery within the previous 14 days. By contrast, chronic kidney disease (CKD) and impaired renal function were not exclusion criteria.
Laboratory assessment
Blood samples were collected upon hospital admission. cTnT was measured with the fourth-generation assay Elecsys troponin T using a Cobas 6000 e601 system (Roche Diagnostics, Mannheim, Germany) according to the recommendations of the manufacturer. The 99th percentile value for the reference population used by the manufacturer of the assay was 0.01 ng/ml, and the lowest level at which the coefficient of variation was <10% was 0.03 ng/ml (21). A cutoff value of 0.01 ng/ml, which corresponds to the 99th percentile of a reference population and the lowest level of detection, was chosen to define an elevated cTnT level (22). Measurement of cTnT was routinely performed in all PAD patients upon hospital admission. However, the cTnT values were missing for 7 patients, who were censored from further statistical analysis (Fig. 1).
In addition, laboratory testing included automated and standardized testing of serum creatinine levels. The estimated glomerular filtration rate (eGFR) was determined by the Cockcroft-Gault formula and classified using standards set forth by the National Kidney Foundation Disease Outcomes Quality Initiative (23). According to these standards, we defined an impaired renal function as an eGFR concentration of <60 ml/min.
Baseline characteristics, comorbidities, and medication
Assessment of atherosclerotic disease and cardiovascular risk factors was based on clinical history, clinical examination, and laboratory test results. Patients were interviewed about a history of coronary heart disease, ischemic cerebral infarction or transient ischemic attack, and PAD. Patients' smoking status, classified as currently smoking versus never or previously smoked combined, was obtained using a standardized questionnaire. Diabetes mellitus was diagnosed in accordance with the World Health Organization classification (24). Arterial hypertension was defined by a systolic blood pressure of more than 140 mm Hg, a diastolic blood pressure of more than 90 mm Hg, or both on at least 2 occasions or by the use of antihypertensive drugs (25). Hypercholesterolemia was defined as a fasting cholesterol level exceeding 200 mg/dl, a low-density lipoprotein cholesterol level of at least 130 mg/dl, or both on at least 2 occasions or by the use of lipid-lowering drugs (26). Finally, patient medications were also recorded.
Clinical evaluation and ECG registration
Seventeen patients in the initial cohort had had an ACS within the previous 14 days before study entry and were censored from further statistical analysis (Fig. 1). There was no clinical evidence of myocardial ischemia among the remaining patients. We analyzed the patients' electrocardiograms (ECG), which were performed simultaneously with blood sampling at the time of admission to the hospital. According to the consensus document of the Joint European Society of Cardiology (ESC), American College of Cardiology Foundation (ACCF), American Heart Association (AHA), World Heart Federation (WHF) Task Force for the Redefinition of Myocardial Infarction (1), we registered ECG changes that might be indicative of acute myocardial ischemia, for example: 1) ST-segment elevation at the J-point in 2 contiguous leads with the cut-off points of ≥0.2 mV in men or ≥0.15 mV in women in leads V2 to V3 and/or ≥0.1 mV in other leads; 2) horizontal or down-sloping ST-segment depression of ≥0.05 mV and/or T-wave inversion of ≥0.1 mV in 2 contiguous leads; and 3) the presence of left bundle branch block.
Patient outcomes
Differences between outcomes after 12 months were determined for patients with elevated and those with normal cTnT concentrations. The primary outcomes examined in this analysis included total mortality and amputation. Secondary outcomes included myocardial infarction, ACS, and target limb revascularization. ACS was defined as a non–ST-segment and ST-segment myocardial infarction or unstable angina resulting in admission to the hospital. All reported events were confirmed by a review of medical records.
Statistical analysis
If not stated otherwise, the statistical analysis was performed using Statistical Package for Social Sciences (SPSS Statistics version 20.0, IBM, Chicago, Illinois). The baseline characteristics are reported as percentages for categorical variables and mean ± SD for continuous variables. We used the chi-square test in cross-tabulations and the Mann-Whitney U test to compare metric variables. Differences in outcomes were compared between patients with elevated and those with normal cTnT concentrations. Cox proportional hazards models were used to examine the relationship between the cTnT levels determined at baseline and the outcome events. In these models, the cTnT level was examined as a categorical variable. The Cox models sequentially added age, eGFR, and the presence or absence of current smoking, diabetes, and critical limb ischemia (CLI). Age and eGFR were modeled as continuous variables. The final model also excluded all patients with ECG changes conformable with acute myocardial ischemia, according to the latest consensus document of the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction (1). All tests were 2-sided, and the criterion for statistical significance was a p value of <0.05.
Under conditions of competing risks, Cox regression models can produce misleading results, so a competing risk approach implemented in the software survival of R version 2.14.0 (R Development Team, R Foundation for Statistical Computing, Vienna, Austria) was used. We plotted the overall cumulative incidence of amputation outcomes and mortality (death before and after amputation) stratified by cTnT levels of <0.01 ng/ml and ≥0.01 ng/ml. Differences in curves were tested using the log-rank test. Furthermore, a reclassification analysis was performed using the Hmisc software package of R by Frank E. Harrell to quantify and compare the concordance of different predictors for mortality.
Baseline characteristics of the study cohort
The clinical characteristics and demographic information available for the definitive study cohort of 1,041 patients are summarized in Table 1. The mean age of patients was 70.7 (±10.8) years; and 62.7% were males, 44.9% were known to have coronary artery disease (CAD), and 12.0% had a history of cerebral infarction.
Determinants of elevated troponin T
cTnT was detectable (≥0.01 ng/ml) in 222 patients (21.3%). Patients with cTnT values ≥0.01 ng/ml were older, more likely to be male or diabetic, and less likely to have hypercholesterolemia or to be current smokers compared with patients with cTnT values <0.01 ng/ml. An elevated cTnT concentration was also associated with an impaired renal function (Fig. 2), cardio- and cerebrovascular comorbidities, and severe PAD. In patients with intermittent claudication (i.e., Rutherford stages 2 and 3), a cTnT of ≥0.01 ng/ml was present in 54 of 623 cases (8.7%) compared with 168 of 418 patients (40.2%) with CLI (i.e., Rutherford stages 4 and 5; p < 0.001). In addition, PAD was localized more distally among patients with a cTnT elevation. In 121 cases (54.5%), the revascularization procedure involved the tibial or peroneal arteries compared with 272 cases (33.2%) of patients with undetectable cTnT (p < 0.001) (Table 1).
One-year outcomes
During a 1-year follow-up, 106 patients died (9.7%). In 14 patients (1.4%), a major amputation was unavoidable, and 29 patients (2.9%) underwent minor amputation. The overall amputation rate was 4.1% (Table 2). Due to the progression of PAD, subsequent peripheral revascularization procedures were required, and target limb revascularization was performed in 24.3% of patients. Myocardial infarction occurred in 1.9% of patients during follow-up, and 4.6% of patients were hospitalized with an ACS.
Total mortality and amputation risk according to troponin T
Detectable cTnT levels ranged from 0.010 to 0.482 ng/ml. The distributions of cTnT by total mortality, cardiac events, and amputation are demonstrated in Figure 3. The mortality and amputation rates in patients with elevated cTnT (≥0.01 ng/ml) were increased compared with those with normal cTnT (Table 2), resulting in an unadjusted hazard ratio (HR) of 9.87 (95% confidence interval [CI]: 6.49 to 15.0) for total mortality and 4.92 (95% CI: 2.68 to 9.03) for amputation.
The cumulative incidence curves for amputation outcomes and mortality (death before and after amputation) stratified by cTnT <0.01 ng/ml and ≥0.01 ng/ml are demonstrated in Figure 4. Comparing 1-year outcomes between patients with cTnT values ≥0.01 ng/ml and those with <0.01 ng/ml, mortality risk was 32.9% vs. 4.0% (log-rank test, p < 0.001), respectively, and the risk of amputation was 9.9% vs. 2.4% (log-rank test, p < 0.001), respectively.
No differences were observed for the incidence of peripheral revascularization procedures. Regarding mortality, similar associations were observed in a subgroup analysis of patients with CLI (HR: 9.51; 95% CI: 3.94 to 23.0) and patients with intermittent claudication (HR: 5.01; 95% CI: 3.08 to 8.17). A corresponding subgroup analysis for amputation was not meaningful because only 2 amputations were performed in the subgroup of patients with intermittent claudication.
After adjusting for age, eGFR and the presence or absence of current smoking, diabetes, and CLI (Model 2), the mortality risk in the total cohort remained increased, with cTnT ≥0.01 ng/ml (HR: 4.64; 95% CI: 2.82 to 7.64; p < 0.001). However, in multivariate analysis, the amputation risk was no longer significant (HR: 1.86; 95% CI: 0.92 to 3.74; p = 0.083) (Table 3).
The introduction of cTnT improved the prognostic discrimination for mortality outcomes. The addition of cTnT to Model 2 (c-statistic: 0.802 ± 0.039) offered moderate improvement (c-statistic with cTnT: 0.835 ± 0.036). Quantifying and comparing Harrell's concordance, cTnT led to an improvement of risk reclassification (U-statistic: 0.30 ± 0.06).
No patient at baseline included in this analysis had clinical symptoms of unstable angina. Patients with an ACS within the previous 14 days before blood sampling had been excluded from the analysis. However, the interpretation of ECGs performed upon admission to hospital revealed significant differences in the frequencies of ECG criteria conformable with acute myocardial ischemia among patients with and without elevated cTnT (Table 4). Repeating the analysis after exclusion of all patients with any ECG changes suggestive of acute myocardial ischemia (Model 3), the HRs (and corresponding 95% CIs) were 8.14 (95% CI: 3.77 to 17.6; p < 0.001) for total mortality and 3.71 (95% CI: 1.33 to 10.3; p = 0.012) for amputation.
Troponin T and myocardial infarction
During the 1-year follow-up, we registered a total of 20 myocardial infarctions (1.9%). Unadjusted analysis revealed a risk of myocardial infarction for patients with cTnT values ≥0.01 ng/ml (HR: 3.75; 95% CI: 1.55 to 9.05) (Table 2). After adjusting for age and eGFR, the association remained significant (HR: 3.40; 95% CI: 1.23 to 9.45; p = 0.019) (Model 1). In the final model after exclusion of all patients with ECG changes that might indicate acute myocardial ischemia (Model 3), these associations were no longer significant (HR: 3.44; 95% CI: 0.86 to 13.7; p = 0.080).
In this study, we examined the associations between elevated cTnT with total mortality and vascular outcomes in PAD patients who underwent an angiographic workup and a primary endovascular therapeutic approach for disease stages 2 to 5 of the Rutherford classification. Importantly, we assessed patients without clinical evidence of acute myocardial ischemia, according to the latest version of the ESC/ACCF/AHA/WHF redefinition of myocardial infarction consensus document (1). Detectable cTnT levels (≥0.01 ng/ml) were observed in 21.3% of subjects in our cohort of symptomatic PAD patients. Elevated versus normal cTnT levels, as defined by the lower limit of detection using the conventional fourth-generation cTnT assay, was associated with several established vascular risk factors (i.e., age, male sex, diabetes, and CKD) and with an increased risk of death and amputation during follow-up. Adjusting for potential confounders such as age, eGFR and the presence or absence of current smoking, diabetes, and CLI did not impair this relationship. The cutoff level of ≥0.01 ng/ml revealed an 8.1-fold (95% CI: 3.8 to 17.6) increased mortality risk and a 3.7-fold (95% CI: 1.3 to 10.3) amputation risk among PAD patients.
Conversely, the associations between cTnT concentrations and myocardial infarction were not significant in our final model after adjusting for all potential confounding factors. A similar observation has been made by Omland et al. (27), who analyzed a cohort of 3,679 patients with stable CAD. In their study, cTnT levels measured with a high-sensitivity assay were detectable in 97.7% of CAD patients. Although increasing cTnT values were independently related to higher mortality and heart failure rates during a 5-year follow-up, no independent association was observed between cTnT and myocardial infarction (27). This finding is in contrast to observations in patients with ACS in whom cTnT concentrations are considered biomarkers of myocardial injury due to plaque rupture, intracoronary thrombosis, and myocardial ischemia and have been demonstrated to predict negative outcomes (2).
The plasma cTnT levels in healthy subjects are thought to result from a continuous microscopic loss of cardiomyocytes during normal life (28). There is evidence that detectable cTnT in subjects without clinical signs of acute myocardial ischemia indicates an increased risk for future cardiovascular events and unfavorable outcomes. The prevalence of cTnT values ≥0.01 ng/ml in 3,557 subjects of the population-based Dallas Heart Study was as low as 0.7% (9). That study investigated cTnT levels with a conventional fourth-generation cTnT assay, which was also used in our study. Detectable cTnT levels were typically associated with high-risk conditions, such as diabetes and advanced CKD. Moreover, elevated cTnT levels correlated with the presence of structural heart disease (e.g., left ventricular hypertrophy or dysfunction) and a subsequent risk of all-cause mortality (9,10,29).
Elevated concentrations of cardiac troponin are often observed in patients with advanced CKD, but without clinical signs of myocardial ischemia. In a large study that included 733 asymptomatic patients with ESRD, a high percentage of the patients had elevated concentrations of troponin (21). The authors of that study reported cTnT elevations in 82% of cases with a 0.01 ng/ml cutoff. In our study, elevated cTnT was prevalent in 21.3% of patients, and we also observed higher frequencies of elevated cTnT with declining renal function. Therefore, it is plausible that the association between cTnT levels and adverse outcomes is at least partly due to the presence of CKD, which by itself is indicative of an adverse outcome. However, our data reveal that cTnT levels ≥0.01 ng/ml remained an independent predictor of death and amputation even after adjusting for eGFR and other potentially confounding factors.
Only recently were cardiac troponin concentrations identified as a possible risk stratification tool in patients with acute or chronic CLI. Rittoo et al. (13) described a high prevalence of elevated cTnT among 39 patients with acute limb ischemia (44%). The cumulative survival rates after 7 days were 53% for cTnT-positive patients and 100% for cTnT-negative patients. However, the number of patients included in that study was small. A previous investigation of our study group highlighted the fact that an elevated cTnT was predictive of a worse in-hospital outcome in terms of mortality and amputation (HR: 3.4; 95% CI: 1.3 to 8.5) in patients with acute limb ischemia (14). Sarveswaran et al. (30) followed 152 patients with chronic CLI and without evidence of unstable CAD and discovered that elevated cardiac troponin I (cTnI) independently predicted mortality during a 2-year period (HR: 4.2; 95% CI: 1.3 to 12.7). In other investigations, Landesberg et al. (31) and Kertai et al. (32) demonstrated that low levels of asymptomatic troponin elevation during the perioperative period are associated with a poorer long-term outcome in patients undergoing major vascular surgery. To our knowledge, the present study is the first one that evaluated the prognostic value of cTnT in a large cohort of symptomatic PAD patients and provided strong evidence of an independent relationship between cTnT values ≥0.01 ng/ml and an increased mortality and amputation risk.
The mechanisms responsible for the release of cardiac troponin are most likely multifactorial and, in our patients, may include transient, clinically silent myocardial ischemia and small-vessel occlusions, myocardial strain, apoptosis of cardiomyocytes, impaired renal function, and inflammatory processes (33,34). Given the strong relationship between CAD and PAD as clinical manifestations of atherosclerosis, it is very likely that elevations in cTnT can result from transient and less-severe ischemia as a consequence of a mismatch between the oxygen supply and demand, and the exposure of myocardial cells to cytokines.
Furthermore, in the special situation of CLI, the increase in cardiac troponin appeared to be directly associated with skeletal muscle damage and rhabdomyolysis (35–37). It has been suggested that the release of necrotic muscle constituents into the circulation may have direct toxic effects on myocardial cells. However, Jaffe et al. (38) observed an increased cTnT quantified with a fourth-generation cTnT assay in 16 cases with skeletal muscle myopathy. The diagnosis of myopathy had been suggested by clinical history, examination, and increases of the creatine kinase and was confirmed by typical electromyographic changes and skeletal muscle biopsy. These results are in line with a previously published study reporting increased creatine kinase and cTnT, but not cTnI, levels among patients with idiopathic inflammatory myopathies (39). However, this issue of specificity is far from settled. There is some evidence that cTnI is also expressed in myopathic skeletal muscle tissue. Messner et al. (40) studied mRNA expression of cTnT and cTnI in the skeletal muscle and found that the mRNA of both cardiac troponin isoforms was expressed in the skeletal muscles of patients with myopathies (e.g., Duchenne muscular dystrophy). It has been suggested that re-expression of the fetal cTnT isoform in response to injury may contribute to the increase in cTnT levels (38,41). Another study investigated marathon runners and discovered cTnT to be undetectable before the race and to be elevated in 43% of the runners after the race. In this study, the elevations in cTnT were also related to higher inflammation markers (i.e., leukocyte and neutrophil counts, C-reactive protein, interleukin-6) (42).
Study limitations
The present study has some important limitations, which include the selection of patients included in this retrospective trial, the use of a conventional fourth-generation cTnT assay, and the fact that we did not perform serial cTnT testing and ECG recordings. Therefore, we cannot distinguish accurately between elevations due to acute silent myocardial ischemia and chronic disease, which is a major limitation in the interpretation of our results. However, the patients enrolled in this study were admitted to the hospital because of symptomatic PAD for angiography and endovascular revascularization, and they had no symptoms suggestive of ACS. In addition, our findings were not significantly attenuated after exclusion of patients with ECG changes that might be indicative of acute myocardial ischemia.
Previous studies have illustrated the fact that PAD patients have a substantially increased risk of cardiovascular morbidity and mortality (16,43,44). Among patients with symptomatic PAD and without clinical symptoms suggesting myocardial ischemia, an elevated cTnT is detectable in every fifth patient. According to our study, small elevations of cTnT (≥0.01 ng/ml) measured with a conventional cTnT assay predicted a markedly increased risk for death and amputation during the 1-year follow-up. A highly sensitive cTnT assay has recently been developed, allowing for the measurement of concentrations 10-fold lower than those measurable with conventional assays (45). These novel high-sensitivity cTnT assays clearly improve diagnostic performance in terms of an early and reliable diagnosis of acute myocardial infarction and have widely replaced the fourth-generation cTnT assay used in our study. However, the higher sensitivity of these novel assays is counterbalanced by a lower specificity. Thus, some of these assays allow the detection of cTnT even in up to 90% in the general population (45). Despite a number of trials providing evidence for the prognostic impact of higher hs-cTnT levels in patients with stable CAD, ACS, chronic heart failure, and ESRD (2,27,46,47), as well as in the general population (4,10,34), the optimal decision limit for the diagnosis of acute myocardial infarction and the optimal cutoff value for prognostic purposes remain to be determined (48).
Cardiac troponin T is frequently elevated in PAD patients and is associated with higher rates of events such as total mortality and amputation. Even small cTnT elevations predict a markedly increased risk that is independent of impaired renal function. However, further studies are needed to assess the prevalence, determinants, and prognostic implications of cTnT elevations measured by conventional or high-sensitivity assays in PAD patients.
Dr. Herrmann is a consultant for Roche Pharma and Novartis Pharmaceuticals. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- acute coronary syndrome(s)
- chronic heart disease
- chronic kidney disease
- critical limb ischemia
- cTnT
- cardiac troponin T
- eGFR
- estimated glomerular filtration rate
- end-stage renal disease
- peripheral arterial disease
- Received January 10, 2013.
- Revision received April 18, 2013.
- Accepted May 5, 2013.
- American College of Cardiology Foundation
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text:
Whilst on a rainy seaside holiday in North Holland, Dick Bruna entertained his young son by sketching a little bunny that kept hopping about the garden of his holiday house. Each evening he would make stories up about the bunny and soon Miffy was born.
Bruna is best known for his children's books, which he authored and illustrated - now numbering 124. Recurring characters include Boris the little boy bear and Barbara his girlfriend, Poppy the kind pig lady and Snuffy the dog. Additionally, Bruna has also created stories for characters such as Lottie, Farmer John, and Hettie Hedgehog. But it is Miffy (nijntje in the original Dutch), a small rabbit drawn with heavy graphic lines, simple shapes and primary colours, which has become his iconic figure, and one that has made him a household name the world over.
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subset: commoncrawl


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Our level of music-making is unparalleled in terms of precision, variety, complexity, energy, scope, and fun. We draw on a wide array of creative engagement approaches starting with percussion and song composition.
We draw on many different fields for both content and inspiration to create a truly original hybrid work. Besides the world of music, sources include neuroscience, chaos and systems theory, organization development, group dynamics, storytelling, leadership research, improvisational theatre, and aikido.
Programs are led by world-class facilitators, educators, musicians — artists who perform with musical luminaries including Sting, Santana, Bobby McFerrin, Huey Lewis and the News, and the Turtle Island String Quartet, at venues such as the Lincoln Center and Carnegie Hall.
We can employ the full range of musical experiences, including classical, rock and roll, world, and jazz. Each style imparts its own unique lessons about how to orchestrate, compose, collaborate, synchronize, and improvise effectively — distinctly different ways of leading, planning, partnering, implementing, and navigating change.
What makes us unique?
Assured successClients told us we surpassed their expectations for seven key criteria in 98 out of 100 program deliveries.
Credibility and experienceIn nearly three decades, we've wowed more than 100,000 leaders, managers, and individuals in organizations large and small.
Global outlookOur musicians and facilitators are culturally diverse global citizens; we've worked with organizations on four continents.
Originality and depth of designOur program originality and customization was rated as superior by discerning learning and development professionals and C-Suite executives at top companies such as Genentech, Electronic Arts, HopeLab, and Cisco.
Design and facilitation masteryWe've been recognized as master-level instructional designers by Duke Corporate Education, the Center for Creative Leadership, the Kennedy Center for the Performing Arts, the Society for Human Resource Management, the Organization Development Network, and the Association for Talent Development.
"Terrific ear-opening experience! What a dynamic metaphor for organizational harmony, integration, and wellness."
Dr. Bruce Blumberg, Physician-in-Chief, Kaiser San Francisco


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Category Archives: Training
Worship Art 3/26/17: Comforter
I have been preparing for this for weeks. Drawing in my sermon notes book and researching. Also watching the many dove we have in our yard even though they aren't white. I also found some great tutorials on painting white … Continue reading
Days 9, 10, & 11: 30-n-30
I used the knowledge from the days 7 & 8 to work on the sky in my seascape: Soul Happy. I really like the way it is coming along. Discovering I needed to add a different blue, I wasn't quite … Continue reading
Days 7&8: 30-n-30
Days 5 & 6: Very busy days – Labor Day was a clean house like a madwoman day. We enjoyed dominoes with friends in my unfinished kitchen which meant, of course, that the clutter and dirt from traveling and remodeling … Continue reading
Marvelous Irid Grey!
During the September 30 in 30, I found in my playing with colors a wonderful grey to use on top of or instead of a black canvas background. It has sparked my imagination and I am definitely going to use … Continue reading
Day 26: Hookers Green Hue (Sep 2015)
I bought Golden's Hookers Green Hue because I had it in my watercolor palette but have not used it. Today's endeavors brought some delightful surprises. I'm definitely keeping this color. It has a very high tinting strength – a little … Continue reading
Day24: Pthalo and Magenta Play (Sep 2015)
This has taken a few days with a few cover ups with gessoed tinted with cadmium yellow light in the yellow band. It was fun.
Day22: Magenta Heart (Sep 2015)
My new favorite paint – up to now barely used- Golden's Quinacridone Magenta. Not quite finished with this one.
Day 21: Quinacridone Magenta (Sep 2015)
Some of the work in doing the audition sheets is becoming predictable but there is always a surprise. Today I worked with Golden's Quinacridone Magenta and was somewhat surprised when I realized that the colors I have worked with have … Continue reading
Day 18: Pthalo Paisley Heart (Sep 2015)
This little 4″ x 4″ x 1 1/2″ acrylic on canvas painting is inspired by my recent pen and ink attempts at paisley patterns. It was fun and I used the paint left over from my Pthalo Green (Blue Shade) … Continue reading
Day 17: Pthalo Green (Blue Shade) (Sep 2015)
Today's audition chart is with Pthalo Green (Blue Shade) by Golden. My surprise for today was that this color is almost exactly like the other Pthalo Green and Viridian that I have. Three tubes of paint nearly the same color. … Continue reading
Day 16: Cobalt Blue Hue (Sep 2015)
Today's audition chart is with Cobalt Blue Hue Heavy Body by Winsor & Newton. My surprises for today include learning the colors used to make the hue (Ultramarine Blue, Copper Pthalo, and Titanium White) and the shade that looks a … Continue reading
Day 12: Seahorse IV (Sep 2015)
I used some of the paint from the past two exercises to work on one of my aquarium paintings for day 12 on actually day 13. I hope to catch up this week or maybe I'll skip a day. Dentist … Continue reading
Day 11: Alizarin Crimson Hue (Sep 2015)
There are some colors on my palette I don't really understand. Since my goal for this 30 day challenge is to get to know my paints, I chose to do an audition chart for Alizarin Crimson Hue Heavy Body by … Continue reading
Day 9: Magnolia w/Cad Yellow Light Finished (Sep 2015)
Another day to paint. I finished my color study audition page and my magnolia painting. I am pleased with the results. Reference links: Winsor & Newton Galleria Acrylic Cadmium Yellow Pale Hue Color Mixology DVD by Gamblin Dick Blick
Day 7: Magnolia w/Cad Yellow Light (Sep 2015)
Happy to be working in paint today. My first color study is with Winsor & Newton Galleria Acrylic Cadmium Yellow Pale Hue. I would love to test their professional line but have not remembered to order a test tube. Maybe … Continue reading
Neon or Flouresent Paints: To Use or Not To Use
The use of neon and luminous paints have cropped up in several of the demonstrations I have attended recently. I was so excited to use them because of the vibrancy they added to a painting. I was happily adding … Continue reading
Scanning Pen & Ink Artwork II – Almost Finished!
Thanks to wikihow.com/Remove-Background-With-Photoshop-Elements I was able to remove fairly quickly the background of this image. I did the same process on a different letter (A) and found that the narrow strips of white were not able to be made transparent … Continue reading
Life Happens and Time Flies; Workshops and Websites
I can't believe it has been two months since the 30 day challenge. I think I will have to challenge myself for another 30 days to kick start my painting again. I have been busy – VERY busy though. So … Continue reading
DVD Review: How to Draw Comics the Marvel Way
How to Draw Comics the Marvel Way 1977 Although this instructional DVD was produced in 1977, it is very entertaining and educational. The set is simple and you can tell from the glasses and clothing Stan Lee and John Buscema … Continue reading
News from My Studio
You may have wondered where I've been. Well April and May have been very eventful. I have been on the road a lot! Many trips to my Mom's to help her recover from an illness. She is doing very well … Continue reading


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Melvina 1839-
Ida 1870-1902
Emma 1872-1904
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Thank you for visiting the Nebraska Gravestone Photo Project. On this site you can upload gravestone photos, locate ancestors and perform genealogy research. If you have a relative buried in Nebraska, we encourage you to upload a digital image using our Submit a Photo page. Contributing to this genealogy archive helps family historians and genealogy researchers locate their relatives and complete their family tree.
Submitted: 11/26/12 • Approved: 11/26/12 • Last Updated: 2/17/13 • R237490-G237489-S3


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Top 10 Cures for Sciatica and Back Pain rocketed to the top 100 chart in sports medicine; and it has stayed on that best-selling list for seven months!
This book is not just for athletes though. All back sufferers are benefiting from the well written and concise tips for getting over back injury fast. The success of Top 10 Cures for Sciatica is because of the careful reviews of best products that provide pain relief. Many books on back pain talk about therapy, causes and doctors -- and this book covers those issues as well.
The true value of "Top 10 Cures For Sciatica" is the products evaluated. People are looking for immediate relief from back pain. Some of the items evaluated scientifically reduce back pain over 40% in studies.Continue reading


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Should my website be ADA compliant like my physical business location?
We have all seen or used them, from the ramp to get into a building, to the handicap bathroom in the back of the store. As a business owner, you know things like these are required by law. What you may not realize is that your website should have similar accessible features.
You may be asking yourself, "is this government mandated?", "Is this something I really need to be worried about?", or "Are the people that walk through my door really going to care?". I hope to try to answer these questions below.
Warning: What you need to know to avoid ADA and web-accessibility lawsuits
Let me start off with a brief history of the Americans With Disabilities Act (ADA). The ADA was signed into law by President George H. W. Bush back in 1990. The "too long; didn't read" (tl;dr) version is that the law eliminated unnecessary physical barriers to commercial and government buildings - think stairs and bathrooms. It also banned employment discrimination against the disabled. Fast forward to now, and as the saying goes, no good deed goes unpunished. The law has had some unintended consequences in the form of lawsuits and excessive costs for business owners to meet the ADA guidelines.
Four Reasons to Trust Your Website to Professionals
Entrepreneurs and small business owners are notorious do-it-yourselfers. Without the backing of major corporations, we need be able to create things and handle our own issues. However, there are some tasks to which we need to trust professionals.
7 Signs of a Great Municipal Government Website
City and town websites have very unique challenges. They must simultaneously serve a wide range of people with an even wider range of wants and needs. Unlike a retail or service business with a target audience, municipal government websites need to present information without overwhelming their citizens.
So what are signs of a great municipal government website?


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of all our most recent UK undergraduates are in employment or further study after six months
You'll join a friendly community of almost 19,000 staff and students
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UK and EU Christ Church alumni are eligible for a 20% discount on self-funded Postgraduate Taught Masters and Masters by Research.
Our MBA in Education Leadership and Management has been designed for experienced teachers, departmental heads, lecturers, managers, leaders and senior professionals working in education in the public, private and not-for-profit sectors in the UK and abroad. In an increasingly competitive environment, this course provides educational practitioners with an opportunity to develop your organisational, management and business skills as well as to enhance your professional practice.
This MBA is delivered through a partnership between the Business School and the Faculty of Education. Staff from the Business School combine excellence in their academic disciplines with considerable educational, managerial and business experience as well as active research in both the public and private sectors. Recognised nationally and internationally as a centre of excellence for teacher education and development, the Faculty of Education has also developed a reputation for being at the cutting edge of knowledge and training in education.
You will be able to access:
The programme is aimed at education sector professionals, these can be teachers, lecturers, heads, principals, office/business managers, specialists or other managers who are looking to enhance their qualifications and knowledge base. This often includes those who have been given, or are going to be given, responsibility for other staff and often for budgets too. This MBA is specially aimed at those with leadership and managerial roles within education.
The programme is comprised of the following modules, these being:
This module aims to provide you with an understanding of strategic concepts and in particular the importance of sustainable and competitive advantage in driving future strategy. The impact of the business environment and internal resources of organisations on strategic planning and choice will be critically examined in the context of achieving pragmatic strategic change.
This module introduces a range of analytical techniques to enable you to analyse and evaluate financial strategy and its alignment with corporate objectives, to critically appraise projects using a range of techniques and to evaluate risk and techniques for effective management. You will work in teams to develop business plans as part of their assessment.
This module will look at the practice and theory of leading and managing change and enable you to conduct research into a specific change within your area of interest.
This module will look at practice such as Project Management, Supervision, Evidence-Based Practice, Well-Being and others and you are expected to look at good practice and investigate its applicability to education.
The aim of this module is to provide you with a critical understanding of the theory and application of marketing and service management relevant to three distinct economic sectors, namely public, private and the not-for-profit.
The module will support you in developing inclusive policy and practice in your own unique and complex professional situations, through action research involving action planning, data gathering and analysis and systematic problem-solving to support change. It will do this with a particular emphasis on business processes.
This module will help you develop skills of research, critical enquiry and evaluation of a range of data including prior research and policy. Understanding and applying different approaches to conducting research and analysing data will be a key foundation for the course.
The aim of the dissertation is to enable you to analyse organisational structures, systems, processes and behaviour and subsequently make appropriate and costed recommendations for implementation of change, in order to improve business, management and/or service performance within a school, college, university of other educational organisation.
Depending on your route (part-time or full-time) the modules will be delivered across three terms in one year or two years. Six months will be allocated for completing the dissertation.
What will you gain from it?
Throughout the programme we place particular emphasis on:
Embarking on an MBA sends a clear message to current and prospective employers that you are strongly motivated to succeed and committed to your future career.
As well as taking forward your professional development and enhancing your professional practice, business and leadership skills, you will develop a rich understanding of existing and innovative practice in your chosen field. Additionally, you will become knowledgeable and skilled in relation to bringing about change and organisational improvement.
As well as enhancing your professional practice, managerial, business and leadership skills, you will develop a deeper understanding of existing and innovative practice in your chosen field.
The programme contains a mixture of lectures, IT informed learning, group discussion, case studies, experiential learning, project work, individual practical projects, leadership walks and organised visits to other organisations.
Progress is assessed on an ongoing basis, through assessments including written reports, group and individual presentations, and online submissions.
In total 180 Level 7 credits are required for the MBA, this includes the final dissertation.
Assessment is via coursework.
Alumni of Canterbury Christ Church University are eligible for a 20% discount on this course, subject to terms and conditions.
Students may self-fund their course or a sponsor may fund or part-fund. Bursaries, scholarships and fee discounts may also be available.
Although we aim to minimise any additional costs to students over and above the course tuition fee, there will be some additional costs which students are expected to meet.
The University's general principles policy for additional course fees are set out here
The following table sets out the general principles which apply to courses at Canterbury Christ Church University.
This varies depending on the Course - please refer to individual course webpages for further information about additional costs of travel and accommodation for placements.
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Candidates must normally provide evidence of a good honours degree in any subject (i.e. a 1st class honours or a 2.1 honours degree), managerial or professional experience in an education context.
Additionally, overseas students, in line with normal University procedures, must demonstrate:
a) entry qualifications equivalent to those above; and
b) an IELTS score of 6.5 overall, with no less than 6.0 in writing and no less than 5.5 in all other bands, or an equivalent score in an approved English Language test.
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Last edited: 27/11/2019 14:36:00


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Babies need vitamin D for healthy growth and development. Often formula contains the Vitamin D formula fed babies need. But breastmilk only contains about 10% of the recommended daily intake of vitamin D. I didn't realize that bones require vitamin D to help with the absorption of calcium. Vitamin D or sunshine during infancy is associated with the maintenance of good overall health according to recent studies. So of course like any mom I want the best for my baby. Recently I was offered the opportunity to try the Baby Ddrops Liquid Vitamin D. I was very interested in trying them.
The Baby Ddrops have eared the Parent Tested Parent Approved Seal of Approval for product excellence and is a Mom's Choice Award Gold Recipient. Baby Ddrops are available on Amazon direct from the manufacturer. Are you breastfeeding your baby? Has your doctor recommended Vitamin D for your baby? Do you want to win a bottle of Baby Ddrops Liquid Vitamin D for your little one? Well, here is your chance.
Buy it: Ddrops Baby Vitamin D 90 Drops
Win it: Two (2) Arizona Mama reader will win a bottle of Baby Ddrops Liquid Vitamin D.
Enter in the Rafflecopter form below! This giveaway will be open until 4/15 at 12:01AM (EST). Open to US and Canada.
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Lamb en Casserole
Wipe two slices of lamb cut one and one-fourth inches thick from centre of leg. Put in hot frying-pan, and turn frequently until seared and browned on both sides. Brush over with melted butter, season with salt and pepper, and bake in casserole dish twenty minutes or until tender. Parboil three-fourths cup carrot, cut in strips, fifteen minutes; drain, and sauté in one tablespoon bacon fat to which has been added one tablespoon finely chopped onion. Add to lamb, with one cup potato balls, two cups thin Brown Sauce, three tablespoons Sherry wine, and pepper to taste. Cook until potatoes are soft, then add twelve small onions cooked until soft, then drained and sauted in two tablespoons butter to which is added one tablespoon sugar. Onions need not be sauted unless they are desired glazed. Serve from casserole dish.
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text: It's the holiday season and we are just as excited as you are to sneak a peek at the fabulous new products we have coming your way for 2013! Over the next couple weeks, we will randomly post exclusive pictures of our newest products! Check back in later as we kick off 2013's VIP viewing.


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Crystal Palace had a fantastic season but unfortunately for club captain Paddy McCarthy he missed most of the campaign and will be hoping to make a big impact next season.
Injuries have really ruined his time at Palace but he has always been one of the most consistent performers in the Championship and the way he conducts himself has always been exemplary and it is no wonder he is an influential member of the squad even when he is not playing. Frustratingly though shoulder injuries have really slowed his career and he may have gone further and got international caps for Republic of Ireland.
McCarthy started his career at Manchester City but could not break into their first team and had to get some playing time by going on loan to Boston United where he played 12 league games and performed well enough for them to try and sign him permanently. This move didn't go through and before he left Manchester City, he had another loan spell away from the club, this time to Notts County.
In March 2005, Leicester City paid £100,000 for his services and he signed a three year contract with the club. He quickly became a fan favourite because of his no nonsense style and after just one season at the club he was named as their captain for the 2006-07. After more impressive performances, his season was ended because he dislocated his shoulder in February 2007. Despite being offered an extended contract he decided he wanted to leave the club before the start of the new season.
Charlton Athletic signed the central defender for £650,000 in July 2007 meaning that Leicester got some good service from him and also a profit which is always a sign of a good signing. But they won't have been happy with him when he scored his first goal for his new club against his former employers. Manager Alan Pardew said after the goal. "It was a good time for Paddy to score his first league goal for us. But football has these strange quirks. To be fair he has probably been our best player. He defended well and then topped it off with a goal."
This would be his only season at the club as he moved across South London to Crystal Palace in a deal that saw Mark Hudson move in the other direction and Neil Warnock was happy with this deal. "I've chased Paddy for about five years and I'm delighted to get him." In his first two seasons at the club he struggled with more shoulder problems and did not play as much as he would have liked. However, he was still showing that he was a reliable defender for any Championship team and proved that he could be a threat at the other end by scoring three goals in his first season.
Despite his injuries he was named club captain before the 2010-11 season and this was the start of two fantastic seasons where he played almost every game and in the 2011-12 season he played 50 times in all competitions, however he has not played much at all since then.
The final word can go to former Crystal Palace manager Ian Holloway. "He is a wonderful leader and wonderful servant and ambassador for this club. I can honestly say I have never seen anyone work as hard as him to get himself back."


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Enjoy the healing benefits of honey and natural botanicals. Organic jojoba and coconut moisturize; honey and maple syrup exfoliate. And a careful blend of floral essential oils provides an intoxicating aroma to create the ultimate botanical relaxation experience. Blending the art and science of aromatherapy, this premium product is handmade with the finest essential oils and organic and wild-crafted botanicals. Made in Vermont by Lunaroma®, exclusively for Gardener's Supply.


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Bob Reina is very humble in his role as the CEO and founder of Talk Fusion, but he is also very hungry. I don't mean hungry in the way we usually talk about someone being hungry. I mean he is hungry for more. In 2016, the company won two awards with one of them being the 2016 Communications Solutions Product of the Year Award. It was a great honor and it's something he was very proud of as it gained a lot of press for Talk Fusion. However, he is hungry to do even more with Talk Fusion and look for what is around the corner and what is next. Learn more: https://twitter.com/bobreina
It is that kind of excitement and that kind of joy that gets Bob Reina up in the morning and gets his creative juices flowing. It is the same kind of spirit and attitude he sees in a lot of the people that use Talk Fusion for all of their video needs. It is no secret that video is the wave of the present and the wave of the future. It is how people are interacting with one another these days. Bob Reina is also seeing that people are using it to make a living for themselves as well.
That is one of the greatest things, and it is why he remains hungry. The humble part is something that should not get lost in the shuffle, either. He is humble because even though the company has had success and he has been interviewed a lot because of it, he remains the same guy. You can watch an interview with him from years ago and watch one today, and he is the same exact person. He has changed, just like anyone else, but at his core, he is still a great guy with a big heart. That is the most important part that will never change. If anything, he will only become a better person in the future because he is committed to it.
Bob Reina is committed to everything he does, no matter how big the scope is at the end of the day. He wants to commit all he can to it and he wants to go all out for his customers and for his team over at Talk Fusion. He realizes they are really onto something special here, and he wants to keep riding that wave and keep moving the company in the right direction.
For the customers, they can't wait to see what Bob Reina is going to introduce next and what is going on with his IT team. They are known as the best in the industry and they are always working and tinkering with something.


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- José Mourinho was so enraged by Manchester United's loss to Manchester City he reportedly tried to barge into the opponent's dressing room after the game.
- Mourinho apparently swore at City goalkeeper Ederson and told the team to turn their music down, but was pelted with a one-pint carton of milk.
- Police reportedly had to separate a 20-man confrontation where "punches and bottles" were thrown.
- City assistant coach Mikel Arteta was reportedly left bloodied by the exchange.
Manchester City's 2-1 victory over local rivals Manchester United has been overshadowed by a 20-man confrontation that required police intervention.
Nicolás Otamendi and David Silva scored either side of the half, meaning Manchester City left Old Trafford with the victory, all three points, and had opened up an 11-point gap at the top of the Premier League table.
Though there were plenty of talking points during the game, the real drama occured after the final whistle.
United manager José Mourinho was so furious with the loss, he reportedly attempted to barge into City's changing room and swore at City goalkeeper Ederson, then had water and milk thrown at him.
Mourinho accused Ederson, shown celebrating below, of time-wasting and play-acting, according to The Guardian. He reportedly then screamed: "You f****** show respect. Who are you?"Embed from Getty Images
The BBC reported that the row did not end there. Mourinho had water and a "one pint carton of milk" thrown at him after telling City players to show respect, turn down their music, and quieten their victory celebrations.
The Guardian added that police had to "separate up to 20 players and staff members" as bottles and punches were thrown, reporting that Manchester City assistant coach Mikel Arteta was left bloodied as he suffered a gash above his eyebrow.
The Guardian's chief football writer, Daniel Taylor, tweeted that United striker Romelu Lukaku was "prominently involved" in the bloody skirmish.
—Daniel Taylor (@DTguardian) December 10, 2017
Players from both teams reportedly interacted normally after they had gotten changed.


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Find best value and selection to your Large Female Monkey Surf Handcrafted Wood Art Wall Hanging Decor Hawaiian Hawaii search on eBay. As a true artist, it's essential to tweak the designs to incorporate your personal personal sense of artwork into your walls. Select a small patch of wall and practice time and again until you might be confident enough to get it proper on a bigger wall. They additionally make for nice gifts for anybody who has a house bar space, man cave, she shed, or another space that needs some wall artwork to be actually complete. Check out Make it Love It 's tips to create home state scrap wooden artwork to suit your home, wherever it could be. Pencils and Glue: A pencil will probably be used to mark out the essential blueprint on the wall. Etsy artist Shari of Modern Rustic Art presents this stunning DIY wooden artwork wall coat and/or hat rack.
Add some glamour to an otherwise bland vainness by creating wooden triangle art Paint the triangles in accordance with the room's coloration scheme and add a touch of glitter on one triangle for the diva-tastic look. The reason of taking average measurements is that your wall artwork would not look diagonal and asymmetrical. She reveals you exactly tips on how to make these eight foot lengthy wall art display ledges.
You don't necessarily have to stay to the motifs and designs that we went by. Reclaimed Barn Wood Sign- Grateful For This Day- Planked Typography Sign-one hundred yr old Barn Wood Wall Decor. You should keep in mind that the tribal wall artwork might be a comparatively everlasting fixture except you paint over it. If that is your first time making an attempt to paint one thing on a wall, select a small patch that may be repainted later. DIY wall art could be as simple and as quick to make because the artwork piece proven right here. This wood wall decor can be hung within the entryway of the home, or within the dining room for guests to admire. If you need a artistic way to display photographs, take into account crafting DIY photo clipboards.
Shown is a contemporary look to the wall artwork she created utilizing coloured electrical tape. Vintage – There isn't any scarcity of classic wooden wall artwork relating to well-liked wood designs. Take one ceiling medallion (the type meant to go on the ceiling and encompass the base of a lamp or ceiling fan), spray it bright red and tape some colourful artwork from a favorite music CD inside the middle. Include the annual camping journey or the child's first day of college, including a personal contact to an artwork piece. And numerous occasions, nothing matches the exact measurement of the surface space, and also you're left observing a blank wall. I actually have been wanting to purchase the wooden fork, knife, spoon and they are extraordinarily costly the furniture store.
Thanks so much for placing it all collectively in one place – makes it straightforward to select and select my next DIY artwork venture!! This DIY wall wine holder solely takes a few minutes to make, and looks incredibly sharp in the residence. I used easy pine wooden to make the above frame for the diy wall art for my son's school house several years in the past. Consider pottery display shelves The good accent to the kitchen or eating room, these wooden wall artwork items are simple to make and completely brag worthy. Reverse shade utilization of white paint on a black wall will only look good when there are no errors in your painting. This wood slice art is a simple and rustic approach to boost the dining room for company to get pleasure from. Just like an artist rigorously chooses a canvas, you will have to fastidiously select a portion of a wall that you just want to paint.


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The Used Car of Your Dream Awaits at Don Tester Ford-Lincoln Inc, Proudly Serving Drivers
If you've been searching for that right blend of comfort, performance and affordability, chances are you've looked at a wide range of used cars from all over the Norwalk, OH area. In a word, it can be tiresome. That's why the auto gurus at Don Tester Ford-Lincoln Inc, proudly serving the greater Milan OH, Sandusky OH, Huron OH and Monroeville OH areas, have handpicked the best pre-owned vehicles they can find in order to simplify your search as much as possible. Take a look below at our extensive inventory, and if you find one you like, contact us to arrange a test drive today.


text: IRS publishes identity theft information. The IRS warned that business identity theft is on the upswing. So far in 2017, the IRS has identified approximately 10,000 businesses as potential identity theft victims through June 1, compared to about 4,000 for 2016 and 350 for 2015. While the number of businesses affected was relatively low, the potential dollar amounts were significant: $137 million for 2017, $268 million for 2016, and $122 million for 2015. The IRS noted it'll add new questions to 2017 tax year preparation software for business-related returns.


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A handful of scripted reality show no-marks, a UKIP candidate and in Jeremy McConnell, the biggest nonentity in the series' history, the low-rent line-up of this year's Celebrity Big Brother didn't inspire much confidence.
And yet after a shaky start, it's provided wall-to-wall drama and the most brilliantly farcical CBB episode of all time. Here are ten moments which show why this 17th series can claim to be the best ever.
1. The house gets rid of Winston
The pointless boxed-up challenge very nearly killed the show before it had begun. But it finally exploded into life on Day 3 when a task revealed that Winston had previously described gay adoption as a form of child abuse.
The boxer-turned-politician claimed that he wasn't at all homophobic, but both his housemates and the public believed otherwise. And after adding 'sexism' to his list of deplorable behaviour by fondling Tiffany and perving over Nancy while in bed, he was thankfully booted out as the first evictee.
2. David's dead!
A farce of epic proportions, the misunderstanding over David Bowie's death couldn't have been scripted any better.
From the moment that his ex-wife Angie Bowie told Tiffany that 'David's dead,' a chain of events lined up perfectly – whether it was Tiffany's belief – and subsequent hysterics – that it was in fact their housemate David Gest that had passed away, or Darren Day slowly peeling away the bedcovers – where a sick Gest was taking a nap – expecting to find a lifeless body.
Big Brother's had many unforgettable moments over the years, but this mix of black comedy, tragedy and messy drama must rank as one of the all-time greatest.
3. Tiffany's 'old maiden shoe' rant
A virtual unknown at the start of the series, reality regular Tiffany has stolen the show from Gemma Collins with her unashamed horniness, diva-like reactions to being nominated and of course, her role in the above.
Her diary room entries have also always been consistently entertaining, and this foul-mouthed attack on her TOWIE housemate, and her 'old maiden shoes' in particular, was easily her most memorable.
4. Megan flips out
Apparently the ideal role model for Daniella Westbrook's daughter, relatively unknown Ex on the Beach star Megan made sure she grabbed plenty of screentime with this epic tantrum.
The 23-year-old almost came to blows with Tiffany before storming into the diary room where she launched into an aggressive rant, nearly sparking a racism row in the process. Incredibly, it wasn't the biggest meltdown of the series.
5. Nancy takes on Adele
Channel 5 producers appear to be obsessed with causing confrontation, but some of the best and most unexpected bits of CBB occur when they give the housemates the chance to have some fun.
The third former squeeze of Sven-Göran Eriksson to enter the CBB house, Nancy Dell'Olio, barely said boo to a goose during her short spell in the house. But she at least provided one golden moment with her wailing diva-like Lip Sync Battle performance of Adele's Hello.
6. John gets found out
The 'get whoever out' chants have become meaningless in the Channel 5 years, but it was still satisfying to see the smirk wiped from John Partridge's face after realising his do-gooder routine hadn't convinced the public.
The passive-aggressive ex-Eastender later tried to pretend as though he was enjoying his new-found villain status in a bizarre conversation with Tiffany, but sadly for him, he's just not that convincing an actor.
7. Stephanie's solitary confinement
Something tells us that Stephanie's dad was lying through his teeth when he told his daughter he was proud of her during the phone call task.
The sacked Hollyoaks actress went into CBB to change the public's perception of her, but in fact has done nothing but damage it further. This mother of all outbursts caused her to be virtually sectioned by CBB with an overnight stay in a ghostly spare room.
8. Gemma's obsessive need for screen time
She's calmed down a bit lately, but has any CBB contestant ever tried to shamelessly hog as much screentime as Gemma Collins?
Every hairdresser's worst nightmare spent most of her time wading in on every conversation within earshot and couldn't even peel a potato without being carted off to hospital.
9. The phone task
One of the few CBB tasks which didn't rely on pure bitchiness, the phone task allowed us to see the softer side of housemates as they were given the chance to speak to their loved ones within an allocated amount of talk time.
It also gave them the satisfying opportunity to regularly hang up on faeces-obsessed pseudo-psychologist Gillian McKeith.
10. Emma turns into Jeremy Paxman
Emma Willis certainly hasn't been holding back with this year's post-eviction interviews.
After barely concealing her contempt for Winston and his outdated views in the first week, she then gave Jeremy a grilling in the final week for his part in the love triangle – while also calling out the sheer hypocrisy of the audience for cheering him on yet booing Stephanie.
MORE: Celebrity Big Brother Final: 10 reasons Tiffany Pollard should win CBB 2016
MORE: Celebrity Big Brother final: 10 reasons Scotty T should win CBB 2016
MORE: Celebrity Big Brother Final: Why Darren Day should win CBB 2016


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Martin Luther King.
Extracts from this document...
Chapter II Martin Luther King In 1940s, the Civil Rights Movement appeared as a challenge to end up racial discrimination and segregation as a system that tended to separate blacks from all aspects of life. Though granted their freedom, blacks were still treated as some subordinate species to the white race: they were denied the chance to be promoted in their jobs and most of them suffered from a low income compared with white workers. Blacks had to live in separate neighborhoods under appalling conditions and were "confined to the central city and notably dirty and unpaved slums".1 Martin Luther King (1929-1968) was born in Atlanta Georgia to grow up and become one of the greatest heroes of American history. As a boy, Martin was always taught to respect people and to settle disagreements with love, not hate. Martin's best friend was a white boy whose mother did not allow him to play any longer with Martin who was so astonished and bewildered that he ran to his mother and asked for an explanation. His mother told him that this was because he was black. He became very upset and could not understand how the color of someone's skin could make all the difference. Martin's mother laid him in her lap and said" you must never feel that you are less than anybody else. You must always feel that you are somebody"2. From that time on, Martin never forgot what his mother had told him and grew up determined that he would make the difference. Indeed, Martin Luther King became one of the principle leaders of Civil Rights Movement and the symbol of nonviolent protest in the struggle for racial justice (exemplified in the boycotts and sit-ins that he organized). King's view towards racism symbolized the voice of a generation and of a human being who saw in slavery an end to man's humanity: I refuse to accept the view that mankind is so tragically bound to the starless midnight of racism and war that the bright daybreak of peace and brotherhood can never become a reality. ...read more.
King called that "the madness must cease"; war is not the answer to solving man's problems because violence breeds violence and destruction: Through violence, you may murder the liar, but you cannot murder the lie, nor establish the truth. Through violence, you murder the hater, but you don't murder the hate...Returning violence for violence multiplies violence, adding deeper darkness to the night...Darkness cannot drive out darkness; only light can do that. In his book Stride towards Freedom, King explained how Christian love and peaceful tactics were the motto of the civil rights movement. Nonviolent tactics, he believed was a moral necessity that helped man establish a sense of the self and to help defeat the white ego by making him feel ashamed of all his misdoings and mistreatment of a fellow human being. Though King urged his people to advocate passive resistance, he abhorred "silence" and called all the nations to awaken from their deep slumber and march on to struggle for a new world, a new reality that would establish man's identity as a fully blooded human being who is endowed with due respect and dignity. Martin believed that it is high time that people should open up their eyes and see the world around them, the world that promised them freedom and equality but gave them nothing but pain and misery. He called all the citizens of America to wipe away their tears and to start believing that "tomorrow is another day" not another yesterday. King demanded that all the blacks and the suppressed break the shackles of silence and raise their voices so that they can be heard calling for their legitimate rights: We must move on...but we must speak. We must speak with all the humility that is appropriate to our limited vision, but we must speak. I have moved to break the betrayal of my own silences and to speak from the burnings of my own heart...17 King's message of breaking the silence through peaceful protests was carried out by almost all negroes all over America. ...read more.
The prize was the motive, he continued, that inspired millions of people and incited them to work harder determined to make the dream- the American dream- come true. On April 3, 1986, he travelled to Memphis and delivered his last speech in which, it seemed, he predicted his own end: I have seen the Promised Land. I may not get there with you. But I want you to know tonight that we as a people will get to the promised land. And I am happy...Mine eyes have seen the glory of the coming of the Lord. Martin Luther King was assassinated in 1968. His death did not mean the end: King lit up the candle for the coming generations who were handed over the torch to continue their struggle against racism and discrimination. It was their fight now: King had died, but he did not leave them stumbling in a vacuum; they were well prepared for the next battle because King had taught them how "to destroy the barries of fear and insecurity that had been hundreds of years in the making". He had taught them how to endure the bitter maltreatment of the white race with smiling faces that challenged the white ego and exposed his brutality and savagery. King had showed his people the way and they had followed his lead because they knew he was the one- the chosen one who is going to take them through "thousands midnights...dreary with low- hovering clouds" into the light of the morning...the new morning of salvation and freedom. Even now whenever you pass by his grave, there you will see an inscription on his tombstone: "Free at last, Free at last, Thank God Almighty I am free at last..." We may not win tomorrow... but we won't quit, we won't give up...sure we have not realized all our ambitions; certainly we have a long way to go. But the important thing is that we were on the way. ...read more.
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The answer to this question has changed dramatically over the years for me, but every time my 88 year old grandmother complains that she never ate organic food as she is perfectly healthy I try and gently remind her that when she was growing up on the East Coast, in the 1930s there were no genetically modified crops or chickens. Farmers didn't inject hormones into animals to make them develop quicker and they didn't know about the ill effects of pesticides.
The other night when I visited a very close "sister – like" friend, I was reminded about how much my household has changed over the last several years and hers too. We chatted about rSBT free products from Trader Joe's while we laughed about our college years. I had taken a course at an organic farm after spending a week at Rancho La Puerta and learned so much. The farmer had gotten nerve damage as a child from pesticide spraying at the third generation farm he grew up in. Some financially savvy tips included always buying certain things that are either organic or hormone free – milks, eggs, and poultry are especially important to eat organically. The next would be berries and grapes. For people like me on a restricted budget, there are some places he said it was ok to "cheat". Buying regular bananas, avocados and other fruit with thick skins are ok to buy regular since the pesticides can be peeled off. Some other tips are to buy the generic organic brand of stores like Whole Foods and others.
In my house, I use organic cleansers, I have organic bug spray, I buy local, organic produce, I have organic milk and eggs delivered to my house by an old fashioned delivery man. When I remodeled, I used low VOC paints and non toxic stains. My cancer came back anyways.
But the other morning as I stepped on a white pillowy bath mat at my friend's house and used a fresh smelling thick white towel I remembered that fabric softener has also been kicked out of my house too. Will this keep cancer from coming back again? I don't know but I feel better about my choices and the impact these things have on the environment and that's all that counts for me. I must admit though that I do miss fluffy towels.


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Today's recipe is a super versatile and delicious make shift quiche! This recipe is my take on a quiche, I didn't make a crust but I used cast iron pans when I baked them so they formed a crispy crust. I hope you try this one out and let's get started!
- 1 yellow onion
- 2 cups of diced red potatoes (I used around 12 red potatoes)
- 10 oz container of cherry tomatoes
- 1 green bell pepper
- 1 1/2 cup chopped white mushroom
- 1 block of firm tofu (I used a 19 oz package)
- 3 cloves of fresh garlic
- 1 cup of chopped fresh basil
- 2 cups of Garbanzo Bean Flour
- 4 tablespoons of Nutritional Yeast
- 2 "eggs" using your favorite egg replacer, mine is this one
- 1 teaspoon of baking powder
- 2 cups vegan cheddar cheese (I used Daiya)
- 1/4 teaspoon of paprika
- 1/4 teaspoon of chili powder
- 1/4 teaspoon of turmeric
- 2 tablespoons of olive oil for sautéing
- salt and pepper to taste
- Start by preheating your oven to 450 degrees F.
- To make this recipe we are going to begin by chopping up our ingredients that need to be cooked down before adding them into the batter. Chop your onion, potatoes, bell pepper, mushroom and around three quarters of your tomatoes (set aside the rest, we will use a couple of them to color the batter). Once your veggies are chopped place them in a large skillet to sauté with your olive oil. Let the veggies cook down at medium to high heat and stir every few minutes.
- While your veggies are cooking down we are going to make the batter to hold the quiche together. In a food processor blend together your tofu, garlic, garbanzo bean flour, nutritional yeast, baking powder, vegan cheese, and all your seasonings. Once that mixture is well combined add in the rest of your tomatoes and your vegan eggs (make sure to follow the directions on your egg replacer first). Pulse together and your batter is ready.
- Chop up your basil roughly and add it into your veggies, remove the skillet from the heat.
- Next, pour your batter into the pan and mix until all your veggies are incorporated into the batter.
- Pour your quiche batter into a baking dish, I prefer using cast iron for a dish like this so I lightly oil my cast iron pan and pour my batter into the pan, making sure it is even. I ended up using one medium pan and one smaller size pan.
- Place the quiches in the oven for 20-35 minutes or until they are golden brown. It is important to check them every ten minutes or so because they can burn quickly, you want them to be a golden brown and firm.
- When your quiches are done pull them out of the oven and let them cool for ten minutes and serve! Garnish with fresh herbs and/or your favorite sauce!
Servings: This recipe makes 6-8 servings
Prep/Cook Time: 1 hour
*This post contains affiliate links, which means I receive a small commission if you make a purchase using this link.
I hope you enjoy this recipe, it is a fun one!


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Vanessa Hudgens shocked her fans with her new look as the actress decided to ditch her long tresses in favor of a short crop. Check out her new 'do and find out what was the reason for her hairstyle transformation next!
High School Musical star and ex-girlfriend of heartthrob Zac
Efron, Vanessa Hudgens shocked everyone
with her new look as she appeared sporting a short crop. Vanessa
Hudgens's new short hairstyle look wasn't a
personal decision, but rather required by a job as she has
transformed her look for her new acting role as a pregnant runaway
teenager in the upcoming movie Gimme Shelter.
Vanessa Hudgens has always attracted a generous amount of attention due to her natural beauty, bohemian fashion style as well as glossy long black locks that just enhanced every bit of her femininity. The new look Vanessa Hudgens opted for is quite shocking as she went for a short crop, a look that reveals greatly her facial features, but still, a look that suits her incredibly well.
The hairstyle transformation that
she had to go along with for her movie Gimme Shelter isn't exactly
all Vanessa ever wanted as she told Access Hollywood in an
exclusive interview, but she's not shy about it. Going from a long
'do to a short crop isn't exactly easy, but Vanessa makes this
change look effortless. She told Access Hollywood that she misses
her hair, but there's nothing she can do about it. When asked if
she misses her long locks she says:
"I miss it; believe me, I do, but there is nothing that I can do about it. My sister is like my best friend and she naturally has like the longest hair, so whenever I'm around her I'm like giving her the evil eye."
When asked about hair extensions, if she's going to turn towards their help to get her length back, Vanessa says that her hair is too short for extensions.
"I think that it's too short, like in the back...Yeah, I don't know, I'm kind of stuck; but it's okay, it's good. Whatever. I'm free, I'm not hiding from the world."
But Vanessa looks hot and confident as she proves on the red carpet at the premiere of Captain America: The First Avenger. Vanessa wore her hair tousled and bushed back, which helped her create a super youthful, classy, yet fresh look, perfect for a diva.
Cut longer on the top and shorter on the sides, the look can be quite versatile, so we bet we'll see some surprising short hairstyle ideas from Vanessa.
What do you think about Vanessa's new look?
Photos courtesy of Getty Images


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During the 2013 season, outside linebacker Willie Jefferson was among a trio of players cut by the Texans for breaking team rules at a team hotel, reportedly by smoking pot. After that, Jefferson couldn't find another NFL team willing to give him a shot.
But after two years in the Canadian Football League, Jefferson is back in the NFL, as Washington signed Jefferson to a contract today.
Jefferson played well over the last two years, recording 10 sacks for the Edmonton Eskimos. He's a talented pass rusher and probably has a better chance of making Washington's 53-man roster than most players picked up at this time of year.
At least he does if he can stay out of trouble. Jefferson was arrested for marijuana possession during his time at Baylor after he was found passed out in the driver's seat of his car at a Taco Bell drive-through. His Baylor teammate Josh Gordon was a passenger in his car and was arrested with him. Jefferson was later kicked off the team at Baylor.
Perhaps two years of exile in the CFL was enough to give Jefferson a wake-up call. If so, Washington may benefit with a talented young pass rusher on the roster.


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Classic Gold Filled Bangle
This beautiful and simple Classic Gold Filled Bangle is a perfect everyday companion and ads some glamour to your wrist. It looks nice on its own but also stacked with a watch or other bracelets such as the Skinny Gold Bangle. The width of the hand forged, soldered and textured bangle is 2.6 mm. Choose between three finishes (zoom in on second and third picture for close-ups).
This bangle is available in a lot of different sizes, please refer to the last picture that explains how to measure yourself to find your right size. If you have very flexible joints you could go a size smaller than you measured in case you would like it to fit tight. M is the standard bangle size and will fit most.
Gold-fill is the highest quality of gold plating. Gold fill is not to be confused with gold plating as filled literally has 100% more gold than gold plating. Gold filled is much more valuable and tarnish resistant. Gold Fill jewellery looks like solid gold jewellery and will last a lifetime if you take care of your it. 90% of people react to it just as they do to 14ct solid gold.
14ct Gold Fill Wire
14ct Solid Gold Solder


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Carlos Antonio Rios/Houston Chronicle file
The last batch of Texas Wheat was brewed Monday, as Saint Arnold has decided to discontinue the beer.
Saint Arnold Brewing Co. is dropping Texas Wheat, one of its original lineup of beers, and replacing it with a variation of its best-selling Fancy Lawnmower.
The last batch of Texas Wheat was brewed Monday and should be ready for packaging in about two weeks, bringing to close a nearly 17-year run for a beer that was called Kristall Weizen until it got a new name and a tweaked recipe in August 2005.
The first kegs of Weedwacker, a Kolsch-style beer fermented with a Bavarian hefeweizen yeast, will start to appear around May 15. Saint Arnold founder Brock Wagner said the draft version is being rushed to market to fill a looming but temporary void in Summer Pils caused by unexpectedly strong sales of the popular seasonal.
Early June will bring the release of 12-ounce bottles featuring the familiar Lawnmower labels but with weeds sprouting across the manicured lawn in the background and "Weedwacker" slapped over the original name.
Weedwacker debuted last summer as the first in Saint Arnold's Movable Yeast series, in which the brewery takes familiar beers and ferments them with different yeasts to highlight the difference in taste made by this often unheralded ingredient.
It got a "big, big response" from consumers, Wagner said.
"Everybody loves it," he said. "We loved it when we brewed it. … Weedwacker will be in my fridge."
The move comes as Saint Arnold continues to grow at a blistering pace following its move into a new brewery near downtown a year ago. Sales set a record last month, up 75 percent over March 2010, Wagner said. That followed growth spurts of 40 percent in both January and February over the same months last year.
Sales of Texas Wheat had grown the past four years, but nowhere near as rapidly as the Houston brewery's other beers. In 2010, for example, its total production of 771 barrels was less than half the amount of increase in Lawnmower production. The beer never made up more than 5 percent of sales, a brewery spokesman said.
Brown Ale, with production levels similar to Texas Wheat, will remain. Wagner explained that the company makes nothing comparable to Brown, while the addition of Weedwacker would mean a crowd of relatively lighter-bodied beers, such as Lawnmower, Summer Pils and Amber Ale.
Wagner was not sentimental about the demise of Texas Wheat, never a personal favorite.
"It was the one time we came up with something we thought would sell rather than a beer that I just wanted to make," he said.
Still, it was not a decision made lightly. The last time Saint Arnold tweaked its core lineup of year-round beers was in March 2004, when it introduced Elissa India Pale Ale.
Join Beer, TX on Facebook at facebook.com/rcrocker.beertx or follow me on Twitter: @rcrocker


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24 March 2012
AKB48's Tokyo Dome Concert Announced!
At the beginning of yesterday's AKB48 [Gyoumu Renraku] concert in Saitama Super Arena, it was announced that AKB48 will hold a concert in Tokyo Dome.
Video: http://www.youtube.com/watch?v=xV5LU0UuZSw
The announcement VTR started with the numbers "1830M", and Takahashi Minami, the de facto leader of AKB48, was shown walking out of the Don Quixote building that houses the AKB48 Theater.
As the number counted down, important scenes of AKB48's history were shown. The first AKB48 performance, AKB48's big break with RIVER, the senbatsu elections, the team shuffle, their Kouhaku performance, the janken tournaments, just to name a few.
Takamina continued walking.
The counter stopped for a while at '1', and Takamina was shown letting out a tear while smiling. Slowly the Tokyo Dome came into view and the counter finally reached '0'. Takamina was standing outside the Tokyo Dome. The "1830M" was the distance from the AKB48 Theater to Tokyo Dome, 1,830 meters.
Flashed on screen were the words "AKB48 Tokyo Dome Concert decided" "distance between 'AKB Theater' and 'The place we've dreamed about' ". The dates of their Tokyo Dome concert has not been revealed at this time.
Tokyo Dome is the goal of AKB48, A goal that took 7 years to reach since December 8th, 2005. The AKB48 Official Blog is titled "~AKB48 TOKYO DOME made no Kiseki~", or "AKB48's Miraculous Path to Tokyo Dome". However, officials have stressed that "Tokyo Dome is not the final goal for AKB48, just a passing point". which makes us wonder what Akimoto Yasushi has in store for the group after the concert.
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As we've expected the purging of federal websites to remove hints of international co-operation on mythical climate change has begun. The EPA is no longer explaining efforts at curbing greenhouse gases.
I checked some other agencies and the other websites I mentioned in earlier blogs still survive. I will be checking them occasionally to see who lasts last. I'm betting on the Department of Defense. Trump is properly afraid of the military and I think Bannon is focused on getting to his dreams of world war and racial purity so he needs the military on his side at all costs.


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BFFs, Are You Psyched? The Third Batman Movie Is Coming Out July 2012!
Will you be the first in line to catch the follow-up to The Dark Knight?
We don't know what it's going to be about, or who's going to be in it, but we DO know that the next installment in Christopher Nolan's Batman franchise is heading to theaters July 20, 2012. Warner Bros. released the information yesterday, sending fans into a frenzy! BFFs, who do YOU want to see in the next Batman movie? Angelina Jolie as Catwoman? Johnny Depp as the Mad Hatter (again?) Drop us a comment and tell us who you'd love to see go head-to-head with Christian Bale!


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Quick Links
Hiking Mount Washington
Check out "The Ultimate Beginners Guide to Hiking" by Hobby Help to start your voyage up Mount Washington!
Hiking Mt. Washington is NOT an easy task. Please make sure you are well prepared and educated about what is in store for you. There is the option of taking a One Way Cog Railway Train Ride down or up the mountain in the months that we are operating.
There are two main trails for hiking Mount Washington on the west side of the mountain – the Jewell Trail (easier, but longer) and the Ammonoosuc Ravine Trail (harder, but shorter). Each trail takes the average hiker around 5 hours one way to hike up or hike down Mount Washington. Remember, you are hiking at your own risk, so BE PREPARED! Trail maps, guide books & other hiking essentials are available for sale in our Marshfield Station Gift Shop.
For expert Skiers, there is the option of skiing Mount Washington in the winter months. A lengthy hike is required to get to a point of being able to descend, so prepare for winter hiking along with making sure you have the skills and ability to ski down the mountain. There is no first aid or other services available for skiers. There is more information on our Skiing the Cog Railway page!
Hiker One Way Train Rides
For people who choose to hike Mount Washington (and if you do, please make sure you are WELL EDUCATED and have all the required gear), we do offer the ability to take a One-Way Up or a One-Way Down on the Mount Washington Cog Railway. Pricing information can be found on the Schedule & Tickets page. If you plan to take a One Way Down, make sure you return to the correct side of the mountain!
These One Way Downs are NOT a guarantee. Upon purchase you will be put in stand by and will fill in available seats on each departure after round trip passengers have boarded. This may mean that your party is split between seats/trains/hours and you may have to wait additional time to board the train.
One Way Up's can be purchased ahead of time by visiting "Buy Tickets Now", or calling us 24/7 at 603-278-5404.
Why Can't I Buy a One Way Down in Advance?
Believe us, we'd love to sell you one in advance, but we choose not to for a few factors:
- It's never a guarantee the train makes it to the Summit. Inclement weather can happen at any time, and the last thing we want to do is leave you stuck up top! Always be prepared to hike back down just in case!
- Trains stick to a strict departure schedule. If you are not on the top when the train departs, we still have to leave, and can't promise there will be room on the next available trains
Hiker & Skier Parking at the Mount Washington Cog Railway Base Station
We offer the ability to park your car in a safe, monitored location right next to the trail heads. Payment accepted is cash only and cars without a permit may be towed.
Hiker / Skier Land Use Permit
- Plowed and maintained parking lot
- Park right at the trailheads for the Ammonoosuc Ravine and Jewell Trails.
- One Way riders will receive a credit towards the price of a ticket.
Please purchase these permits with a Hiker Parking Representative at the entrance to Marshfield Base Station, or at the Drop Box. Hikers who come on weekends when our hiker parking attendant is issuing the parking passes are eligible to receive a coupon to offset the price of parking. It will be valid for $10 off per ticket on one-way trips only. The coupon MUST be presented at time of purchase at base or summit to qualify for the discount. If it is left in the car/pack/etc, it can NOT be applied retroactively.
Additional information about lodging, activities, restaurants and more when staying in the Mount Washington Area can be found on ExploreMountWashington.Com