text:
P-Wave Morphology in Focal Atrial TachycardiaDevelopment of an Algorithm to Predict the Anatomic Site of Origin
Author + information
- Received December 9, 2005
- Revision received March 22, 2006
- Accepted March 28, 2006
- Published online September 5, 2006.
Author Information
- Peter M. Kistler, MBBS, PhD⁎,†,1,
- Kurt C. Roberts-Thomson, MBBS⁎,†,2,
- Haris M. Haqqani, MBBS⁎,†,
- Simon P. Fynn, MRCP⁎,†,
- Suresh Singarayar, MBBS, PhD⁎,†,
- Jitendra K. Vohra, MD⁎,†,
- Joseph B. Morton, MBBS, PhD⁎,†,
- Paul B. Sparks, MBBS, PhD⁎,† and
- Jonathan M. Kalman, MBBS, PhD⁎,†,⁎ (jon.kalman{at}mh.org.au)
- ↵⁎Reprint requests and correspondence:
Prof. Jonathan M. Kalman, Department of Cardiology, Royal Melbourne Hospital, Royal Parade, Parkville, Victoria 3050, Melbourne, Australia 3050.
Objectives The purpose of this study was to perform a detailed analysis of the P-wave morphology (PWM) in focal atrial tachycardia (AT) and construct and prospectively evaluate an algorithm for identification of the anatomic site of origin.
Background Although smaller studies have described the PWM from particular anatomic locations, a detailed algorithm characterizing the likely location of a tachycardia associated with a P-wave of unknown origin has been lacking.
Methods The PWMs for 126 consecutive patients undergoing successful radiofrequency ablation of 130 ATs are reported. P waves were included only when the onset was preceded by a discernible isoelectric segment. P waves were classified as positive (+), negative (−), isoelectric, or biphasic. Sensitivity, specificity, and predictive values were calculated. On the basis of these results, an algorithm was constructed and prospectively evaluated in 30 new consecutive ATs.
Results The distribution of ATs was right atrial (RA) in 82 of 130 (63%) and left atrial (LA) in 48 of 130 (37%). Right atrial sites included crista (n = 28), tricuspid annulus (n = 29), coronary sinus (CS) ostium (n = 14), perinodal (n = 7), right septum (n = 1), and RA appendage (n = 3). Left atrial sites included pulmonary veins (n = 32), mitral annulus (n = 8), CS body (n = 3), left septum (n = 3), and LA appendage (n = 2). In electrocardiographic lead V1, a negative or +/− P-wave demonstrated a specificity of 100% for a RA focus, and a + or −/+ P-wave demonstrated a sensitivity of 100% for a LA focus. A characteristic PWM was associated with high sensitivity and specificity at common atrial sites for tachycardia foci. A P-wave algorithm correctly identified the focus in 93%.
Conclusions Characteristic PWMs corresponding to known anatomic sites for focal AT are associated with high specificity and sensitivity. A P-wave algorithm correctly identified the site of tachycardia origin in 93%.
Focal atrial tachycardia (AT) is a relatively uncommon cause of supraventricular tachycardia and is difficult to treat medically. Fortunately, with the advent of radiofrequency ablation (RFA), this form of tachycardia can be treated with high long-term success (1,2). It is well-recognized that these foci do not occur randomly throughout the atria but tend to cluster at characteristic anatomic locations. In the right atrium (RA), these foci occur along the crista terminalis (CT) (1,3), the tricuspid annulus (TA) (4), the ostium of the coronary sinus (CS) (5), and the perinodal region. In the left atrium (LA), foci occur predominantly at the pulmonary vein (PV) ostia (6) and less commonly at the mitral annulus (MA) (7), the left atrial appendage (LAA), and the left-sided septum (8).
In recent years, mapping of these foci has evolved from the use of single- or double-catheter techniques with leap-frogging, through high-density multipolar mapping, to the use of sophisticated 3-dimensional mapping tools. Although contact and noncontact mapping systems (3) are effective in targeting ablation of AT, in the majority of labs they complement rather than replace conventional electrophysiologic techniques. However, although detailed and often expensive mapping techniques remain the cornerstone of identifying tachycardia origin and ablation success, it should not be forgotten that much initial information can be gleaned from a careful analysis of the P-wave. Although a variety of studies have described the P-wave morphology (PWM) from a particular anatomic location, a detailed algorithm characterizing the likely location of a tachycardia associated with a tachycardia P-wave of unknown origin has been lacking. We present a detailed analysis of the PWM according to anatomic site of tachycardia origin and use this to construct an algorithm to localize the tachycardia. We then apply this algorithm prospectively in order to evaluate its clinical utility.
Study population
The study population included a consecutive series of 186 patients (65% female, mean age 49 ± 17 years, range 9 to 85 years) undergoing RFA for focal origin of 196 ATs. All patients had clinically documented paroxysmal or incessant AT. Patients with multiple changing AT morphologies were excluded.
All patients underwent electrophysiological study after the provision of informed written consent. The study was approved by the Melbourne Health Research Ethics Committee. Patients were studied in the fasted awake state with minimal use of sedation. All antiarrhythmic drugs were ceased a minimum of 5 half-lives before the procedure.
Catheter positioning
Catheter positioning and the approach used in our laboratory for ablation of AT have been previously and extensively published (6). Standard electrophysiologic criteria were used to diagnose AT; these included the inability to demonstrate entrainment at 2 locations which are, "in the tachycardia circuit," 2 cm apart (9). Attempts at AT induction were made including atrial programmed extrastimulation and burst atrial pacing. If this was unsuccessful or when AT was not occurring spontaneously, isoproterenol was infused.
Mapping of AT
Anatomic localization of the atrial focus was performed during tachycardia or atrial ectopy by analysis of: 1) surface electrocardiogram PWM; and 2) RA endocardial activation sequence during tachycardia (1,4,7).
On the basis of the provisional findings from PWM and the right atrial endocardial sequence from standard catheters, point mapping to locate the site of earliest endocardial activation relative to surface P-wave onset was performed with a 4-mm-tip mapping/ablation catheter. A fiducial point on a stable intracardiac electrode, usually the CS catheter, relative to P-wave onset was defined to perform point mapping.
Anatomic definition
Anatomic definitions were as previously described for the CT (1), CS ostium (5), tricuspid (4) and mitral (7) annuli, and the PVs (6).
Earliest activation mapped to this region with 20-pole catheter positioned along the CT.
Defined as the region of the fossa ovalis and septum primum. Atrial tachycardia originating within Koch's triangle were separately classified as perinodal or arising from the CS ostium.
Earliest activation recorded in the proximal His bundle electrode; RFA successful within 1 cm of this region.
Definitions of AT arising from the CS ostium, MA and TA, and PVs have been previously published (4–7).
Surface 12-lead electrocardiographic PWM was assessed as previously described (10). Particular attention was given to assessment of an unencumbered P-wave by analysis during periods of atrioventricular block or after ventricular pacing. P waves were included for analysis only if an isoelectric interval was present and there was no fusion with the preceding QRS or T-wave. P waves were assessed at 0.3 mV and described on the basis of the deviation from baseline during the T–P interval as being: 1) positive (+); 2) negative (−); 3) isoelectric: arbitrarily defined when there was no P-wave deviation from a baseline of ≥0.05 mV (7); and 4) biphasic (+/− or −/+). Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPVs) were calculated for the most distinguishing features at each site.
Development of the P-wave algorithm
On the basis of the tabulated P-wave features for each anatomic location (Tables 1 to 3),⇓⇓an algorithm was developed to determine anatomic site of tachycardia origin. The algorithm was modified and tested against 20 P waves randomly selected from the original population until an accuracy of 95% was achieved. Anatomic structures that were within the known spatial limitations of PWM were grouped together.
Prospective application of the algorithm
The algorithm was subsequently prospectively applied, by 2 blinded observers, to a new population of 30 consecutive patients with focal AT who underwent successful RFA. An unencumbered tachycardia P-wave and a sinus P-wave selected from the successful electrophysiological study were assessed at 0.3 mV by each observer. The observer described the PWM as defined earlier and the algorithm was strictly followed.
Statistical analysis
All variables are expressed as mean ± SD. Comparisons between groups were performed with either an unpaired Student ttest or, where a normal distribution could not be assumed, the Mann-Whitney Utest. Categorical variables expressed as numbers and percentages were compared with a chi-square test. A p value <0.05 was considered statistically significant.
Tachycardia characteristics
Anatomic location
The anatomic distribution of 196 AT foci is presented in Figure 1.At the CT, the foci were superior in 47%, mid in 47%, and inferior in 6%. The distribution of tachycardia foci at the TA and MA are demonstrated in Figure 2.Tachycardia foci arising from the PVs were localized to the right superior pulmonary vein (RSPV) in 15, to the left superior pulmonary vein (LSPV) in 12, to the left inferior pulmonary vein (LIPV) in 5, to the right middle pulmonary vein in 1, and to the right inferior pulmonary vein (RIPV) in 2, and were ostial in 31 of 35 (89%).
One hundred twenty-six patients with 130 focal ATs were included for analysis, with 66 ATs excluded because of incomplete isolation of the tachycardia P-wave from the preceding T-wave (47) or because ablation was not successful (19). The putative sites of the ATs not included in the analysis of PWM were CT (n= 34), right perinodal (n = 15), TA (n = 9), CS ostium (n = 2), right septum (n = 2), PVs (n = 3), and LA roof (n = 1).
RA versus LA
The PWM for focal tachycardias arising in the right (Fig. 3)and left (Fig. 4)atria are presented in Tables 1 and 2, respectively. To assess the utility of the electrocardiogram (ECG) in differentiating left from right atrial origin of the tachycardia focus, we analyzed lead I, lead aVL, and lead V1, which have been previously considered to be most useful for this purpose (10).
A detailed analysis is shown in Table 3. Some of the critical observations were as follows:
Either a negative or a biphasic (+/−) P-wave in lead V1was associated with a specificity of 100% for a right atrial tachycardia (Table 3).
A positive or −/+ P-wave in lead V1was associated with a sensitivity of 100% for a left atrial tachycardia (Table 3). Predictive accuracy was reduced by foci arising at or close to the interatrial septum, such as the high CT (positive P-wave) or ostium of the CS (−/+ or isoelectric/+). Electrocardiographic leads aVL and I were less useful (Table 3).
Anatomic locations
The comparison of V1between tachycardia and sinus rhythm (SR) was useful in helping to distinguish a high CT location from an RSPV focus, although significant overlap in PWM persisted. Of the 7 CT ATs positive in lead V1, all 7 were positive in SR. All 14 RSPV foci were positive in V1during tachycardia. Of these, 9 were biphasic and 5 were positive in SR. Thus, in differentiating a superior CT focus from an RSPV focus, it was also helpful to look at the SR V1morphology (Table 3, Fig. 5).For CT foci, when V1was negative in tachycardia, the P-wave was also negative in SR (Table 3).
A PWM that included positive polarity in leads I and II, negative in aVR, and biphasic (positive-negative) in V1(and, if positive in V1in tachycardia, then also positive in SR) was associated with a sensitivity of 93%, a specificity of 95%, a PPV of 84%, and an NPV of 98% for foci at the CT.
In this study, we observed that ATs can arise from anywhere around the annulus. Despite this wide anatomic distribution, a PWM that included negative polarity in lead V1and positive or isoelectric in aVL was associated with a sensitivity of 83%, a specificity of 97%, a PPV of 89%, and an NPV of 95% for AT foci at the TA.
Of note, in lead V1, 23 of 29 TA ATs demonstrated a characteristically bifid negative morphology (Fig. 2). In general, the polarity of leads II and III was deeply negative for an inferoanterior location, and low amplitude, positive, or biphasic for a superior location (Fig. 2).
Tachycardia foci originating at the right atrial appendage (RAA) demonstrated a very similar PWM to the superior location of the TA (Table 1, Fig. 3).
CS ostium
A PWM that was −/+ or iso/+ in lead V1, negative in leads II, III, and aVF, and positive in aVL was associated with a sensitivity of 86%, a specificity of 98%, a PPV of 86%, and an NPV of 98%. Significant overlap was seen with AT foci at the left septum.
Body of CS
The P-wave was bifid positive in V1, deeply negative in leads II, III, and aVF, positive in aVL, and negative in aVR in 3 of 3 patients.
For right-sided PVs, a PWM that was positive in leads V1to V6and positive in lead I was associated with a sensitivity of 87%, a specificity of 94%, a PPV of 65%, and an NPV of 100%. Significant overlap was seen with CT foci. In addition, 2 RSPV foci demonstrated P-wave notching in leads II and V1, features generally associated with left-sided PVs. If criteria were added to include a change in lead V1from biphasic in SR to positive in tachycardia, the specificity improved to 100% but the sensitivity declined to 65%.
For left-sided PVs, a PWM that was isoelectric or negative in lead I and was bifid positive in lead II and/or V1was associated with a sensitivity of 82%, a specificity of 98%, a PPV of 88%, and an NPV of 97%. The exceptions were at the LAA, which resembled the LSPV location, and 3 LSPVs which were positive in lead I.
Some distinction between superior and inferior PVs could be made based on the P-wave amplitude in the inferior leads. In general, the P-wave for AT arising from inferior PVs was low-amplitude positive or negative (1 of 1 RIPV and 1 of 5 LIPVs).
For tachycardias arising from the LAA, PWM was similar to that of a left-sided PV. The presence of a deeply negative P-wave in lead I suggested an origin in the LAA.
Superior MA
A PWM that included a negative, then positive polarity in lead V1and was isoelectric or negative in aVL was associated with a sensitivity of 88%, a specificity of 99%, a PPV of 88%, and an NPV of 99%. The exceptions were 1 AT at the left septum and 1 superior MA focus that was isoelectric, and then positive in lead V1.
Perinodal region and interatrial septum
An isoelectric P-wave in lead V1was associated with a specificity and a PPV of 100% and an NPV of 97% for perinodal and right septal tachycardias, but the sensitivity was only 50% (Table 3).
A negative, then positive P-wave in V1was present in 3 of 3 left septal tachycardias and in 1 of 7 perinodal tachycardias. In the remaining ECG leads, there was significant overlap in PWM between perinodal and left septal sites.
P-wave algorithm
Based on the information presented in Tables 1 to 3, a P-wave algorithm was developed to allow prospective identification of the likely site of origin of a tachycardia according to PWM (Fig. 6).
Prospective application of the P-wave algorithm
This algorithm was subsequently prospectively applied to a new population of 30 consecutive patients with focal AT. Tachycardia locations for these 30 patients were: CT (n = 11); TA (n = 5); CS ostium (n = 3); RAA (n = 3); perinodal (n = 1); MA (n = 2); RSPV (n = 1); LSPV (n = 1); LIPV (n = 1); LAA (n = 1); and left septum (n = 1). The correct site of tachycardia origin (or 1 of 2 neighboring structures) was determined in 28 of 30 and 28 of 30 tachycardias, respectively (93%). For both observers, the algorithm incorrectly suggested a CS ostium location for a tachycardia originating on the TA immediately adjacent to the CS ostium and a LPV location for a tachycardia at the RSPV.
This study describes the PWM from a large consecutive group of patients with focal AT who underwent RFA. In this large series, we have observed that focal AT does have a particular anatomic distribution, as previously described (1,4–7). Importantly, we have shown that these anatomic locations have a signature PWM that provides a reasonably high predictive accuracy. Sites that demonstrated overlap in morphology were those in close anatomic proximity. In particular, these included the CT and RSPV, the left and right septal regions, and the LAA and LSPV.
Using the characteristic P-wave patterns, we were able to develop an algorithm to predict the likely anatomic site of tachycardia origin. The algorithm was then prospectively evaluated in an additional 30 patients and found to have a positive predictive accuracy of 93%. Until now, there has been no unifying attempt to match PWM to the particular anatomic locations from which ATs tend to arise and thereby develop an algorithm that may be applied prospectively.
RA versus LA foci
An important question to be addressed in an analysis of tachycardia PWM is the likely atrium of origin. In the current study of 130 tachycardia P waves, ECG lead V1was the most useful in distinguishing a right from a left atrial focus. A negative or biphasic (positive, then negative) P-wave in lead V1was associated with a 100% specificity and PPV for a tachycardia arising from the RA. A positive or biphasic (negative, then positive) P-wave in ECG lead V1was associated with a 100% sensitivity and NPV for tachycardia originating in the LA. Lead V1is located to the right and anteriorly in relation to the atria, which should be considered as right anterior and left posterior. Thus, for example, tachycardias originating from the tricuspid annulus were negative in V1because of the anterior and rightward location of this structure. The P-wave in V1is universally positive for tachycardias originating at the PVs, because of the posterior location of these structures.
Tang et al. (10) provided a detailed analysis of the utility of P-wave configuration in distinguishing right from left atrial tachycardia. In 31 patients, the most useful leads for distinguishing right from left atrial foci were V1and aVL. The major limitation in the use of a positive P-wave in lead V1to predict left atrial origin was in distinguishing foci at the superior CT from the RSPV. This is an important consideration given the relatively common occurrence of AT from both sites, which are known to be in close anatomic proximity. Tang et al. (10) made the important observation that RSPV foci showed a change in configuration from biphasic in SR to upright in AT, a change not observed for right-sided tachycardias. In the current study, a biphasic P-wave in SR becoming upright in tachycardia was observed in 9 of 14 RSPV tachycardias, but not in any cristal tachycardias. Although not described in the present study, foci arising from the superior vena cava (SVC), a neighboring anatomic structure, also produce a biphasic or upright P-wave in lead V1(11).
The predictive value of PWM for localizing the atrium of origin was more limited when tachycardia foci arose from the interatrial septum. Prior studies have also demonstrated that tachycardias arising from the interatrial septum are associated with variable PWM with considerable overlap for tachycardias located on the left and right side of the septum (8,12,13). Indeed, the known spatial limitations of P-wave analysis are highlighted when considering ATs that arise from the interatrial septum, and this at least in part contributes to the variable P-wave observations (14).
In an elegant study of focal AT using noncontact mapping, Higa et al. (3) described a preferential direction of activation and an atrial breakout point in the majority related to the anisotropic properties of the CT. Although an initial pathway of preferential conduction may potentially alter the PWM, the small differences in distance between successful ablation at the focus compared to the atrial break-out appear not to have a significant effect on PWM, perhaps because of the spatial resolution of the P-wave.
Study limitations
In keeping with the known spatial limitations of PWM, anatomic sites that were in close proximity, such as the high crista and RSPV and ostium of CS and left septum, could not always be separated. Knowledge of these overlapping sites is nonetheless important to the clinical electrophysiologist. The findings in the present study do not apply to tachycardias following extensive atrial linear ablation or patients with congenital heart disease or extensive scarring where atrial activation is frequently substantially altered. This series does not include uncommon but potential sites of focal AT such as the SVC and ligament of Marshall. Although the patient number for the prospective application of the P-wave algorithm is smaller than the total series, we believe this compares very favorably with prior publications (1,3,8,11,13).
P-wave morphology provides a useful guide to the localization of focal AT. Electrocardiographic lead V1was the most useful in identifying the likely anatomic site of origin for focal AT. A characteristic PWM was able to identify common anatomic locations with high sensitivity and specificity. A P-wave algorithm was constructed and prospectively identified the focus in 93%.
↵1 Dr. Kistler is the recipient of the Neil Hamilton Fairley Fellowship from the National Health and Medical Research Council (NHMRC) of Australia and the National Heart Foundation.
↵2 Dr. Roberts-Thomson is the recipient of the Medical Postgraduate Research Scholarship from the NHMRC of Australia.
This work is presented in part and is a recipient of the Eric and Bonny Prystowsky Heart Rhythm Society Fellows Clinical Research Award, New Orleans, Louisiana, 2005.
- Abbreviations and Acronyms
- atrial tachycardia
- coronary sinus
- crista terminalis
- electrocardiogram
- left atrium
- left atrial appendage
- left inferior pulmonary vein
- left superior pulmonary vein
- mitral annulus
- negative predictive value
- positive predictive value
- pulmonary vein
- P-wave morphology
- right atrium
- right atrial appendage
- radiofrequency ablation
- right inferior pulmonary vein
- right superior pulmonary vein
- sinus rhythm
- superior vena cava
- tricuspid annulus
- Received December 9, 2005.
- Revision received March 22, 2006.
- Accepted March 28, 2006.
- American College of Cardiology Foundation
- ↵
- Kalman J.M.,
- Olgin J.E.,
- Karch M.R.,
- Hamdan M.,
- Lee R.J.,
- Lesh M.D.
- Chen S.A.,
- Chiang C.E.,
- Yang C.J.,
- et al.
- ↵
- Higa S.,
- Tai C.T.,
- Lin Y.J.,
- et al.
- ↵
- ↵
- Kistler P.M.,
- Fynn S.P.,
- Haqqani H.,
- et al.
- ↵
- Kistler P.M.,
- Sanders P.,
- Fynn S.P.,
- et al.
- ↵
- Kistler P.M.,
- Sanders P.,
- Hussin A.,
- et al.
- ↵
- Marrouche N.F.,
- SippensGroenewegen A.,
- Yang Y.,
- Dibs S.,
- Scheinman M.M.
- ↵
- Saoudi N.,
- Cosio F.,
- Waldo A.,
- et al.
- ↵
- Tang C.W.,
- Scheinman M.M.,
- Van Hare G.F.,
- et al.
- ↵
- Frey B.,
- Kreiner G.,
- Gwechenberger M.,
- Gossinger H.D.
- ↵
- Man K.C.,
- Chan K.K.,
- Kovack P.,
- et al.


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python3-apsw 3.24.0-r1-1 (arm64 binary) in ubuntu disco
APSW (Another Python SQLite Wrapper) is an SQLite 3 wrapper that
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Event schedule details
Sunday 30 June
Event location details
Expeditions Talks Programme, Flett Lecture Theatre
Natural History Museum
Speaker: Andrea Wulf
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Loaded Gun Storm Chasing
website of storm chaser Mikey Gribble
Links for Forecasting
Weather Company Toolbox
4km NMM WRF
SPC Mesoscale Analysis Page
Unisys Weather
Ensemble Forecasts
Oklahoma Mesonet
SPC Forecast Tools
This page is meant to be educational and will have a wide variety of tools, information and insights to storm
chasing and forecasting. Any feedback would be appreciated. Just go to the
Contact Me
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Links for Chasing
Storm Prediction
Links for Research
Severe Thunderstorm Events
Jon Davies
SPC Publications
I just got these Help Pages started, so
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"Help Pages" section. I will work on
them when I have time and eventually I
would like for it to be kind of an
overview on the topics that gives advice
and rules of thumb. I'm basically writing
down my notes and some of the things
I've learned over the years. If anybody
has any feedback or suggestions I
would be glad to hear it. Just go to the
contact me page
or email me at
About Chasing
New -
Hurricane Page
Help Pages
Beginner Level Surface Analysis
Miscellaneous Notes
Tornado Forecasting Notes
Winter Weather Forecasting
Severe Weather Forecasting
New Help Pages
I have had a lot of people ask me if chasing is anything like the movie Twister and the answer is no. 98% of
chasing is forecasting, driving, and seeing a whole lot of nothing.
these computers take initial atmospheric conditions, run thousands of equations, and produce atmospheric
these computers take initial atmospheric conditions, run thousands of equations, and produce atmospheric
conditions for later dates. There are several different models, but for forecasting severe weather in the plains I
primarily rely on the NAM, GFS, and RUC. I'll use other models too though, just not as much.
primarily rely on the NAM, GFS, and RUC. I'll use other models too though, just not as much.
For a typical spring tornado outbreak, the forecasting process will start about a week out. Synoptic scale (large
scale) forecasting is the primary focus at this point. What kind of airmass is over the Gulf of Mexico, is the
moisture fetch going to be adequate, what kind of tilt does the trough have, are the wind fields such that you
will have good directional shear, etc. As the chase day approaches and you get two or three days out you
begin to focus in on mesoscale (smaller scale) details and start to consider targets for your chase. What will be
the focusing boundaries for convection (warm front, cold front, dryline), where are these boundaries going to
be located when convection is anticipated, what convective mode is favored at each area of anticipated
convection, and so on until you narrow down the range of possible targets. Then on the last twenty four hours
leading up to an event you focus in on mesoscale features that could locally enhance the tornado potential,
such as outflow boundaries, mesolows, anomalies in the wind fields, and countless other slight differences
between different locations. Some time in the last day you pick a target. Basically you work on your forecast
daily and zoom in closer and closer on a target area as the chase day approaches. Of course there are
exceptions and this isn't always the way it works. Some times you know where you want to chase three days
out. The triple point may be the obvious target if the cap is going to be an issue. A warm front or surface low
may be the obvious target if it is the only location with sufficient low-level shear for tornadoes due to backed
surface winds. There are a million different scenarios and every chase is unique.
There is an art to targeting, especially in the earlier part of the season. The jet stream is stronger during the
winter than it is in the summer. As a result, the earlier months of storm season have stronger wind fields and
storm motions are much faster as a result (storms pretty much move at the mean wind speed throughout the
layer they are located in). Forecasted storm motions are a huge part of picking a target early in the season.
When storm motions are going to be >40kts, you need to setup down stream of where storms are going to
fire. When there is going to be fast storm motions I like to setup about 30-40 miles ahead of where I expect a
storm to form. That way the storm has a chance to mature before it gets to me and is hopefully going tornadic
about the time I get on it. Storms typically take at least an hour to mature and they don't start to put down
tornadoes until they have matured. There are exceptions. The fastest I have ever seen a storm tornado was
the Hallam, Nebraska storm in 2004. It produced the largest tornado ever recorded (a 2.5 mile wide F4). That
storm tornadoed about 30 minutes after it showed up on radar. That is fast. Anyways, the reason for setting
up ahead of where storms will form on fast storm motion days is because when a storm moves that fast you
can't keep up with it for long. If you get on a storm right after if forms (like you would with slower storm
motions) the storm will outrun you and you will loose it before it goes tornadic. Lots of chasers make this
mistake. I know I have several times. A storm may only be moving at 40kts, but that is as the crow flies, which
means you need to maintain an average speed of 60kts if you are driving on square mile grid roads, which is
usually the case in the plains. It is very stressful and difficult to keep up with fast moving storms and you need
to pick a target that is going to allow you to maximize your residence time on the storm during the most
optimal time for tornadogenesis.
Next comes the driving. I like to get to my target at least two or three hours before I expect storms to fire,
but this doesn't always happen. I am late a lot more often than I care to admit. I like to be at my target early
so that I can do last minute forecasting, which usually takes at least an hour, then fine tune my target and
move if necessary. You need that extra time to allow for flexibility in targeting. It is nothing to move a hundred
miles one way or another after you reach your original target. Storm chasers drive extreme distances to see
tornadoes. Most chases for me average over 600 miles.
Finally comes the storm. In twister they pretty much skip everything up to this point. In the movie they watch
radar and then haul ass after a storm when a hook echo forms. It doesn't work that way in real life. You have
to be there before it happens. That is why forecasting is so critical to being a good chaser. If you chase
warnings you are going to be too late the vast majority of the time.
Once I'm on a storm I like to position myself straight East of the updraft base, which is where tornadoes form.
Typically the storm is moving NE or E. This gives me the ability to put myself in front of the tornado when it is
forming so that I can get good up close video of the tornado as it approaches me. I typically stay about a mile
ahead of where a tornado would form and move in closer when I start to see rapid vertical motion and rotation,
which usually proceeds a tornado.
Very rarely do chasers get as close to tornadoes as they do in Twister. I like to get closer than most, but I still
have my limits. I will not put myself directly in front of a violent tornado (EF 4-5). If you do put yourself directly
in the path of a major tornado like that then you are in very serious trouble if your car gets stuck or breaks
down. Roads are usually muddy because the precipitation part of the storm has already passed through and
that needs to be considered. You can outrun a tornado, but not if the roads are in bad shape. The closest I like
to get to stronger tornadoes is about a quarter to a half mile away. In twister they get closer than that and
they do it on a regular basis. I don't think you would last long if you chased that way.
And finally, with all the forecasting, driving, and busts (days where you don't get a tornado) there is a whole lot
more boring times than exciting ones. You don't see nearly as many tornadoes as they show in the movie. I
like to think that I am a fairly good chaser and over the course of a season (April, May, and June) I consider
myself lucky if I see twenty plus tornadoes. I probably go on about 20-30 chases each year and drive about
20,000 miles. Early in the year, March and April, I will typically see a tornado on about 20-25% of the chases I
go on. In the peak of the season I get a tornado about 50-75% of the time. And then towards the end of the
season the percentage drops back down to 20-25%. Personally I think it is pretty damn good if you are hitting
about 50% of the time during peak season. Tornadoes are extremely rare and difficult to predict. You have to
earn them. I didn't get a tornado in my first two years of chasing and that mostly had to do with me not
knowing how to forecast. There is a huge learning curve with chasing if you are doing it on your own. It is a lot
of fun, but you have to work hard at it to be successful on a regular basis.
Q: Is storm chasing like the movie Twister?
troposphere and a sounding is the end result.
troposphere and a sounding is the end result.
A loaded gun sounding is a slang term for a sounding that is typical on tornado outbreak days in the plains.
With a loaded gun sounding there is extreme instability ready to be released, but it is being suppressed by a
cap. A cap is a temperature inversion in the atmosphere that works like a lid on boiling water. It allows
instability to build and build until finally it breaks the cap. When this happens explosive storms are usually the
result and with the right conditions in place tornadic supercells will form.
Q: What is "loaded gun" supposed to mean?


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- Provenance
- Provenance information is currently unavailable
- Previous Owner(s)
Anne van Biema American, 1915 - 2004
- Label
Kan Shojo, the role played by Bando Mitsugoro IV (1800- 1863) according to the inscription on this print, represents the courtier Sugawara no Michizane (845-903). The famous play, Sugawara and the Secrets of Calligraphy (Sugawara denju tenarai kagami), which was performed both in kabuki and puppet theaters, has a complex plot based on the life of Michizane, who was exiled to Kyushu because of the actions of a rival at the imperial court. In this brilliant design by Kunisada, the actor raises the sleeve of his robe, which is decorated with a stylized plum-blossom motif that is associated with this role. To the right is an arrow hitting a bull's-eye, a symbol that was hung in the towers of kabuki theaters to indicate a "hit" play. This print commemorates a performance in the year that Mitsugoro inherited his adoptive father's name, under which he carried on a rivalry with Nakamura Utaemon IV (1796?-1852) that had begun between the actors' respective fathers.
- Published References
- Ann Yonemura with contributions by et al. Masterful Illusions: Japanese Prints from the Anne van Biema Collection. Seattle and Washington. cat. 38, pp. 128-129.
- Collection Area(s)
- Japanese Art
- Web Resources
- Google Cultural Institute
- Rights Statement
Copyright with museum


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Owners' comments
Already 95% sold! Immediate delivery!
Unit M1 : 3 bedrooms, 2 bathroom, 1570 ft2
Of an evolved luxury, Le Montcalm is an exception in a class of its own. The flashy is outdated; welcome to a world where aesthetics meets daily quality and comfort. If his elegance is a favorite, his class ensures an investment that lasts.
Luxurious condo located in Ville-Marie, close to downtown Montreal and the entertainment district, close to the Gamelins Gardens and Sainte-Catherine Street being the largest commercial artery in the city.
Access to the roof terrace and pool, gym, lounge, Nordic spa, sauna and garden. Incredible view of the Jacques-Cartier Bridge and the fireworks during the summer season.
Characteristics :
- 6 appliances included *
- Landscaping
- BBQ lifts on the roof
- Waste chute
- Individual air conditioning in each unit
- Lounge and dining area with rooftop BBQ
- Quartz counter
- Condos models to visit
- European-inspired kitchens
- Shower with ceramic walls and glass panel
- Storage space in the basement (optional)
- Interior space for bicycles in the basement
- Abundant windows
- Heated outdoor pool on the roof
- Ceilings 9 feet in height Training Room
- Splendid views of the metropolis on the roof
- Indoor parking (optional)
- Concrete structure
- Intercom system
- Shared rooftop terrace
- Private terrace or balcony for each unit
* Pictures are for information purpose only
Contact us and visit our website!
Property features
Equipment/Services Included:
- Central air
- Ceramic Shower
- Heated
- Outdoor
- Highway access
- Near park
- Public transportation
Near Commerce:
- Supermarket
- Drugstore
- Financial institution
- Restaurant


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This event has passed.
Curator's Tour
February 6 @ 10:00 am - 11:00 pm
Join Lightner Museum Curator Barry Myers as he takes you on a special tour highlighting treasures of Otto Lightner's collection from the gilded era. This informative tour is not to be missed! Tours are included in the price of admission and will begin in the front lobby of the museum at 10 am.


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SBI Capital Markets signs business alliance pact with two Japanese institutions: Media Report
Investment bank SBI Capital Markets signed a business alliance agreement with Japan's Mizuho Bank and Mizuho Securities, said a PTI news report. The pact relates to promotion of products and knowledge- sharing in areas of syndicate loans, project finance and debt capital markets.
The alliance will also help them to exchange expertise in equity capital markets, mergers and acquisitions advisory and private equity advisory, SBICaps said in a statement here.
Commenting on the tie-up, SBI Caps Managing Director and Chief Executive V G Kannan said, "the strategic alliance among the three institutions is a significant step towards synergising their strengths and supporting growing India-Japan relationship."
Mizuho Bank Managing Executive Officer/Head of Asia and Oceania, Hiroshi Suehiro, said, "India, being one of the BRICS countries and amongst the fastest developing economies in the Asia-Pacific region, makes for an attractive investment destination for Japanese companies."
This alliance will not only reinforce the relationship but also open an era of large-scale collaboration on strategic business and commercial alignment, the statement said.
Dion Global Solutions Ltd.


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LeMall To Introduce Special Shopping Day In India
Riding high on the success of LeEco's Superphones and accessories, LeEco is on the brink of creating yet another market disruption – this time through its own e-commerce marketplace, LeMall.com.
To meet the growing demand of the gadget-obsessed, the newly launched e-commerce marketplace of LeEco, LeMall.com, plans a one-day shopping celebration. The 'LeMall for All' Day will extend several exciting discounts and offers that will motivate buyers to purchase LeEco Superphones and exclusive audio and accessories at unmatched prices.
LeMall's special day – 'LeMall for All' is conceived as the answer to the globally popular Black Friday and Cyber Monday. Fortunately, Indian shoppers do not have to wait for a year to participate in 'LeMall for All', as it is planned on a periodical basis, when consumers can avail of numerous benefits and exciting offers through the day on LeEco's entire product line-up. The online marketplace will also be conducting lucky draws, wherein winners can get 100 per cent cashback and special LeMall coupons.
Apart from Superphones, LeMall in India also sells an exciting array of popular products, including gadgets and audio accessories with the latest state-of-the-art technology. For instance, the LeMe Bluetooth headphones come with a unique teardrop design and are available in five vibrant colors. Buyers can also purchase LeEco's Bluetooth speakers, all-metal earphones, Type-C Continual Digital Lossless Audio (CDLA) earphones and other LeEco gadgets and accessories.


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How frustrating! I've finished the fifth of Charles Finch's very fun 1870s-set novels about Mr. Charles Lenox, MP and detective, and that's the last of them so far. I got to the end of this book while having supper in Clemson a few weeks ago and wanted to just growl aloud because I've caught up with the author, and now have to join his many fans in drumming my fingers impatiently waiting for more.
That's not to say that I couldn't quibble a little about this one if I wanted to. While on the one hand, I really have to applaud Finch on the amount of research that he did, I fear that he didn't spend nearly as much time establishing his killer's character. My understanding of sea life in the 1800s is limited to touring the Constitution and reading Chris Schweizer's first Crogan book, but Finch really made this location come to life, and brought home just how bad things could get for somebody who gets on the wrong side of a ship's captain at sea. By sending Lenox overseas on a top secret mission to Egypt for Her Majesty's Government, it looks at first like the amateur detective is going to start a new career as a secret agent, but a gruesome murder sees his expertise needed.
Locked room killings always have the potential for fun in detective fiction, but I've never run across one where the locked room is at sea. (Yes, I'm aware Christie wrote one; I don't like Christie.) It really is unthinkable that a naval lieutenant should be murdered in this way, and the captain, charged with getting Lenox to Egypt, is torn between his duty, his demands, and his disbelief. When somebody in the crew sends a harsh message warning of mutiny and then there is a second killing, the impossibility of the situation is driven home. This would be a mess on dry land in London; at sea, the events couldn't be more grim.
And yet the revelation of the killer and the depiction of his madness completely failed to gel with me. The villain couldn't have been drawn with broader strokes had he been played by the late, great Frank Gorshin, which makes the control that he had exercised prior to his unmasking completely unbelievable. There's also a disappointing reality of just the way this fiction can be expected to behave; when the killer gets away with a solid chunk of pages left to go, then it's obvious from space that the character will reappear while the hero is dealing with his spy mission. Fortunately, I found enough to enjoy with the material in Egypt that it never felt like marking time until the murder mystery was finally resolved.
The only real complaint that I have about Finch's universe is that Lenox seemed much happier when he was not torn between his loyalties to Parliament and his family and his desire to investigate. I appreciate the honest depiction that this would be the reality for a man in Lenox's position, caught between duty and devotion, but it's left him, despite the assurances that his marriage is a happy and strong one, simply feeling adrift and torn. I hope that the author can give his character's conflict some closure in the sixth book, A Death in the Small Hours, which is due to be published this November. Otherwise, give the man's protege John Dallington the lead time; he threatened to be more interesting than Lenox in the second and fourth books anyway and could certainly carry a novel of his own. Recommended with minor reservations.


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Monday: 4.7mi in 42 minutes, 9:01 pace, fartleks.
Tuesday: 4.35mi in 40 minutes, 9:17 pace, easy.
Wednesday: 3.33mi in 31 minutes, 9:22 pace, easy.
Pilates-Yoga class at the gym.
Thursday: 4mi in 37 minutes, 9:25 pace, easy run with the FNRC.
Friday: 9.53mi in 1:31, 9:33 pace. Wanted to get my long run in on Friday so my legs were rested for Sunday's 5K.
Saturday: 1600m in 48 minutes – swimming.
Sunday: 3.1mi in 22:16! New 5K PR! I also did a 0.15mi "warm up" which was really just running in the rain back to the race site after ditching my warm clothes in the car.
Total Miles: 30 (29 running, 1 swimming)
Total Time: 6hr, 15min
Thursday, Sunday
- Obviously the highlight of my week was the 5K PR.
- My next races are a very local 5K on Jan 20, and the F^3 Half Marathon on Jan 26. As long as it's not icy on raceday, I"m ready to kill it, "it" being my half marathon PR. As for the 5K … that's a short enough distance that I can race it and still race the half marathon six days later, right? Or should I just use the 5K as a tempo run? Help me, internets.
Also, I didn't take enough photos over the weekend to do a weekend shots post. Here is the one photo I took:
The Salt Creek Ballet performing the Nutcracker at the Center for Performing Arts at Governors State University.


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- Natural Living
- Cold Pressed
- Organically Grown
- First Choice
- Skin Care
Pure Safflower Oil is truly a versatile oil with numerous benefits from culinary to cosmetic.
It acts as a protection barrier to lubricate your skin while it moisturizes.
It helps soften dryness, smooth roughness, and soothe skin problems.
Cold pressed and food grade.


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At first glance, I was on board with the Mulberry Creased Patent Mitzy Hobo. I like big leather hobos, and I like Mulberry, so I didn't give the whole thing much of a second thought. But upon further consideration…I can't get behind this. Patent leather hobos are extremely hard to structure correctly – it's a shape that is supposed to slouch, by definition, and patent is a material that is much more conducive to creating structure than slouch. So, strike one. Because of the apparent lack of slouch, the handle isn't long enough. I don't think it would be comfortable to carry on my shoulder – I'm not a fan of having leather poke me in the arm pit. Strike Two. Then, the color. Oh, the color. Mulberry calls it "Lipstick," but I certainly don't have any lipstick in this shade, and I don't think I would want a bag this color, either. it's kind of salmon-y and a little too pastel for my taste, which is the same problem I had with the last Mulberry bag I reviewed. Pastels are hard to pull off and tend to make people look either washed-out or sallow, and I think this particular color might have both effects on my skin. So, strike three, it's out. Buy through Shop Bop for $695.
P.S. Please consider supporting our small, bag-loving team by clicking our links before shopping or checking out at your favorite online retailers like Amazon, Neiman Marcus, Nordstrom, or any of the listed partners on our shop page. We truly appreciate your support!


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My latest book, Prepping Strategies For Condos, Apartments, and Duplex Living: How to Prepare for Emergencies with Limited Space, is currently only $0.99 on Amazon Kindle for this week only!
Inside this book I'll show you how you can prepare yourself and your family with very little effort, minimal time, and sometimes for free… even in a small apartment or condominium.
So, if you're at all interested in grabbing a copy, right now is a great time to do it.
Here's What's Covered Inside:
- The 3 Biggest Problems With Apartments and Condos (why they're so much trouble and what you can do about each of them)
- 7 Sneaky Storage Solutions (so you can stockpile more supplies quickly and easily)
- 11 Small Space Prepping Solutions (each one is designed to maximize space usage without taking over your home)
- 7 Concerns Not to be Overlooked (condos and apartments have very specific problems that most single family homes do not)
- 9 Additional Supplies to Include (to ensure you have everything else that needs to be covered)
… and more.
Click here to discover more and get your Kindle copy on Amazon through the 27th only.


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Wednesday, May 9, 2018
By Marianne Cole
Tuesday, May 8, 2018
The most notable highlights of the meeting are as follows:
1. Presentation by Mona Crocker, Executive Director, Rocky Learning Council
Mona outlined various "asks" that council promote: reading to kids, advocacy for raising the age limit to 25 for people requiring GED or high school course improvements(currently the age limit is 19 and getting the additional creditation above that age is very costly), improved high speed internet in the rural area, and encouraging the use of the Rocky Learning Council for various local courses.
2. Attendance by Roger Smolnicky, Director of Recreation and Community Services, Town of Rocky Mr. Smolnicky outlined the capital funding strategy for the North Saskatchewan River Park which included a request that the county match the town's contribution of $200,000. The funds will be used to help over covered bleachers, water system, permanent washrooms, renos to the announcer and VIP boxes, a BMX track, and additional landscaping. The total value of these improvements would be $1, 200,000 to $1, 270, 000. The Rodeo Association and the Pro Chuckwagon Associations would contribute $150,000 in cash and $50,000 in donated materials, equipment, and labor. Then a matching CFEP grant for $600,000 would be applied for.
After discussion a motion was passed directing administration to write a letter of intent to the town that the county would provide $200,000 in the 2019 budget.
3. Leslieville/Condor Fire Halls
Regional Fire Chief, Steve Debienne, presented the results of the open house feedback surveys along with potential options/costs for either one facility or two. The survey comments indicated a slightly higher number of people favoring two facilities but many wanted more information on the potential costs of each option. 4 options with costs were presented to council:
Option 1: One Large Pre-engineered Station: Total cost $4, 200,000(***not including land purchase)
Option 2: Two smaller Pre-Engineered Stations: Total cost $6,000,000 ($3, 000,000 each)
Option 3: One Large Perma Column Station: Total cost $3, 200,000
Option 4: Two smaller Perma column Stations: Total cost $4, 600,000 ($2, 300,000 each)
Note: the pre-engineered structures use more steel in the structures while the perma column has more concrete and poles.
There was excellent, lengthy discussion as council brought up various concerns, points that need to be considered, and different options available. In the end a motion was passed unanimously, directing administration to obtain more specific information on costs for Option #4.
4. Tax Rate Bylaw
Council passed 3 readings to approve the tax rate bylaw that will see a 3% tax rate increase on residential properties and 6% on non-residential and farmland. It is noted in the agenda package that "the assessment base has increased overall, and therefore will show an increase in the overall tax collected for municipal purposes of $4.4 million." Further it states, "An increase in 2018 tax rates will remain for the most part offset by the decrease in the school requisition." (Note: The school requisition is set by the province.)
Broadband Public Engagement meetings:
Wednesday, May 23, 2018, 5:30-7:00PM, Nordegg Public Services Building
Monday, May 28, 2018, 5:30-7:00PM, Leslieville Community Hall
Tuesday, May 29, 2018, 5:30-7:00PM, Caroline HUB Community Hall
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Mistblower Cobra 10
All the functions of Cobra 10 Mistblower controlled by remote control. Cobra 10 mistblower gives excellent results at disinfection and insect controls. It is easy to set up on truck or small pickups easily.
|Honda 23HP - 12 KVA Starter Motor
|Spraying System
|Mistblower - ULV - Holder
|15 lt/ m , 50 Bar
|ULV Nozzle
|5+1 pcs
|ULV Cap moving system
|360 degree right-left 210 degree up-down
|Remote Control
|Joystick cap controlled , Formulation start-stop, lighting.
|Spraying Distance
|30-35 meter horizontal , 25 meter vertical
|Fuel Tank Capacity
|20 lt
|Fuel Consumption
|5.7 lt /hour
|Solution Tank Capacity
|200 lt fixed, 500 Liter optional.
|Solution consumption (ULV)
|100 Lt/h (15-60 µ)
|Solution Consumption (Larva)
|200 - 500 lt / h
|Solution Formulation
|Power Spray
|0 - 50 bar 50 m. hose
|280 kg
|98/125/150 cm
Mistblower Application Fields
- Mosquite, Fly, sandfly, acarid control
- Plant protection in field of crops and Forest, tree disinfections
- Grasslands, road sides, lake and river sides
- Fruit, vegetable gardens
- Sanitation and Disinfection pultry, barns, sheep folds
- Public Health (insect, mosquito control in Public places such as Parks, Lake sides, Underground sewage channels) in hotels, food production plants, private gardens and lawns.
- Food plants, depots, stocks, warehouses


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Im 19 years old and I'm on the bigger side; I have not gotten my period in 5 months, when ever I take a home pregnancy test they instantly come back negative. Since I started missing my period I have gained weight, I feel nauseous EVERYDAY and I feel like I'm sleeping more than usual. If I'm not pregnant what other reasons are causing my delayed period?
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Before and After Gallery
What are Black Triangles?
Black Triangles (otherwise known as open gingival embrasures) are spaces that are present between the teeth and the gum line. Unfortunately, they can attract unwanted attention when an individual is smiling. In particular, they occur as we age and they occur more frequently in those with gum/periodontal disease and smokers.
Not only can they make an individual look older but they can also serve as food traps and can harvest plaque, tartar, food and stains. This can potentially lead to gum disease and tooth decay. These triangles can sometimes even effect your speech or result in some patients 'spitting,' when talking.
There can be several causes or possible even a combination of the following:
- Recession of gums due to gum disease.
- Recession of gums due to thin tissue biotype.
- Orthodontic movement of teeth
- Natural shape and position of teeth
We can help reduce the chances of these triangles developing by carrying out good oral hygiene. Using a soft small brush head and gently massaging the teeth and gums is advised. Daily interdental cleaning as instructed by your dentist/ hygienist is recommended too.
A regular dental check-up will allow the dentist to pick up on these triangles early on.
Treatment options
- Do nothing – If the gum disease is not active, triangles are being kept clean and they are not an aesthetic concern to the patient.
- Gum Surgery – If the patient is suitable a surgical approach can be taken to restore these triangles, learn about the revolutionary pinhole technique here.
- Crowns/ Veneers – A more traditional and expensive approach.
- Orthodontic treatment – If suitable teeth can gently be reshaped and re aligned to eliminate/reduce black triangles.
- Aesthetic bonding using conventional techniques – A relatively painless procedure in which the teeth are built up by a skilled practitioner freehand to eliminate/reduce the black triangles using composite resin.
- Bioclear matrix technique – This is aesthetic bonding using injection moulding of composite resin, similar to the option above but a more contemporary technique allowing us to produce aesthetically superior, more predictable and longer lasting In lower teeth this may be the only long lasting option. See the Bioclear matrix technique below
Book an examination/consultation today to discuss the above if you have black triangles.
Bioclear Matrix Technique
Dr Krishen and Dr Kotecha are fully certified to provide treatments using the Bioclear matrix technique.
Bioclear is a special technique which uses a set of anterior matrices to mould and shape composite to close black triangles. It results in smooth, well contoured restorations that are aesthetic and durable. The cost of Bioclear Matrix system is substantial for the practice as it requires a large investment in equipment and materials. It is technique sensitive to ensure there are no overhangs (which can cause gum disease) and therefore is only carried out by certified practitioners.
This treatment takes approximately 60 minutes and comes with 5 year guarantee. The cost starts from £250
- Please click here for our fees guide.
- Please click here for examples of our work
- For further details of our techniques, materials and techniques please click here.
- Please click here for our guide to maintaining your oral hygiene.
- Interest free payment options are available
- Return to the top of the page
St Johns Wood


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Facilities (Learning Spaces)
Educational institutions face mounting risks from mold, asbestos and hidden underground environmental issues.
The essential elements of IAQ management
Decisions need to be made that are based on more than looks.
A few things to consider when selecting new flooring.
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30 Things I Can't Wait To Tell My Kid About The Day They Were Born
My 10-year-old daughter is old enough to have already heard literally every possible story about her birth. From the first snowfall of the season, to how she didn't cry the moment the nurse laid her on my chest, she's well-informed about the day she came into the world. My son, on the other hand, is too young to have re-lived all the glory of his special day. Of all the things I can't wait to tell my kid about the day he was born, the most important is how unbelievably happy I was to finally meet him.
My sweet boy was birthed over three long days and after an unplanned induction to keep me from losing more amniotic fluid. The two of us already had quite the thrill ride, thanks to what the doctors labeled as a "threatened abortion" and ultimately high-risk pregnancy. After suffering two miscarriages before I became pregnant with my son, I hoped with all that I had that he'd make it to term so I could thank him for being the rainbow baby I had dreamt of meeting.
While I know most mothers say the following about their children, and we're all biased about the babies we bring into the world, I can unequivocally say that my son was (and is) perfect. In fact, he's so damn perfect he made all the heartache and the frustration leading up to his birth, more than worth it. With that, here are some other things I can't wait to tell him about the magical day he came into my life.
I Didn't Expect To Be Induced That Day
When I went in for my mandatory bi-weekly appointment, I wasn't due just yet. However, my doctor had run some tests after discovering I'd been leaking amniotic fluid. I didn't leave the hospital again until after labor and delivery.
I Had To Wear A Fetal Monitor
Part of having a high-risk pregnancy means continuous concern over your baby's (and your own) health. My son's heartbeat would either rapidly rise or slow to a near stop. Due to his irregular heartbeat, I had to go through most of labor on my left side to keep him steady. The monitor was bulky and uncomfortable but, at that point, I'd have worn a truck if it meant he'd come out healthy.
He Took His Time Coming Out
I was admitted Monday morning and delivered Wednesday evening. Wednesday, you guys. It was a long, hellish week (as a lot of women's deliveries are) that I'm happy to have behind me.
I Was Almost Scheduled For A C-Section
The labor part of giving birth felt infinite. I wasn't dilating or progressing as I "should" have been and in order for my son to travel through the birth canal. You'd think after all my son went through he'd want to vacate STAT, but it wasn't the case. Instead, I was one check away from a C-section before things went horribly awry.
My Pain Medication Didn't Take
The funny thing about epidurals is, well, they don't always work. The epidural I had in order to birth my daughter didn't take and, unfortunately the epidural I had for my son didn't take, either. All it did was numb parts of my leg enough to keep me pinned to the bed with a pinching catheter in place.
I've Never Been In So Much Pain Before
My first labor and delivery was painful because I didn't have anything to compare it to. With my son, it was another level of pain with absolutely no relief. The contractions were worse and, no matter what I was given, I felt every single second of it.
My Hospital Gown Kept Flying Open
When you're in a hospital gown and in labor, it's hard to care about anything other than the pain you're currently experiencing. Even with the different family members breezing in and out of the room, I couldn't have cared less about what they did or didn't see. I just wanted my boy out of my body.
His Sister Wanted To Meet Him
My daughter turned 5 years old the day I gave birth, and she anticipated this baby more than anyone. While I don't think she completely understood that we would take that baby home with us forever, there was no present we could've given her that would have possibly outdone her baby brother. I still remember her anxiously awaiting his arrival with her little hands folded in her lap just as she was escorted into the waiting area while I pushed.
He Was Born On His Sister's Birthday
When I went in for my checkup that morning, I hoped they wouldn't admit me so not to ruin my daughter's special day. We'd planned to take cookies to her preschool class to celebrate and, well, my induction ruined it. Thankfully, by the time Wednesday rolled around (her actual birthday), she wasn't upset with me for "missing" her birthday. Instead, she was so happy she'd have a brother to share it with.
I Wasn't Dilated Enough When It Came Time To Push
Because of the slow progression and possible c-section, the doctors kept checking my dilation. When my body wanted me to push, I wasn't where they needed me to be and I was told to wait it out. It was the most pain I've ever been in (and yes, I still remember it all too clearly).
I Had To Switch Positions To Keep My Son's Heart Rate Up
While I was told to mostly lay on my left side, there came a point when I simply couldn't. I mean, hours upon hours in excrutiating pain is a lot time to stay in one place, especially when a baby is trying to move (slowly) out of your body. Every slight variation of movement put my son at risk, as his heart beat would drop and they'd tell me to go back to the same position. It was extremely frustrating.
I Pushed For An Hour
One nurse checked me and said I wasn't dilated enough (though it felt like it). About 20 minutes of hell later, another doctor checked and said I could try to push if I wanted, so I did. I thought for sure the baby would come right out but, yet again, he took his time. That hour was the longest hour of my life.
My Son's Heartbeat Stopped With Every Push
Just like with moving positions, every push almost killed my son. The contractions made it hard not to push but, when I did, they'd yell at me to stop because it put him in danger. Eventually, they adjusted my body into a weird tilted angle that didn't feel comfortable or natural, but it was to make sure the heart rate stayed the same through pushing.
My Mom & Husband Held My Legs
Also in the room was my mother-in-law. At this point, who cares who sees what?
I Cried Through Most Of It
OK, so I cried through all of it. It hurt!
I Nearly Lost Consciousness
It was hot in the room and after I started pushing, I got dizzy and almost passed out. They put an oxygen mask on me to help but this is where things get fuzzy.
My Son's Entrance Is A Blur...
I know at some point I pushed my son out (I think). Honestly, though, it all happened quickly. One minute I was pushign, and the next minute he was in the world.
...Until The Chaos Over The Cord
Once they told me he was out, and I was finished with my part, there was confusion and buzz surrounding the umbilical cord that snapped upon my son's entrance. It's the reason he was blue, and quiet, when I looked across the room.
Doctors Rushed In From Other Rooms
Because of the state I was in, I thought maybe the cord had just been around his neck but that, ultimately, he was fine. Honestly, the entire situation felt like a dream. Then multiple doctors and nurses rushed in the room to inspect the gory scene down by my feet, and the reality of the situation was undeniable.
Doctors Took My Son Away From Me
For an unknown length of time, I didn't see my baby while the doctors and nurses worked to get him to breathe. There was so much going on, I wasn't sure if I was awake or actually dreaming.
For A Moment In Time, I Had No Idea What Was Going On
My husband pushed the oxygen mask back onto my face. I remember looking up at the ceiling until my son's first cries bellowed.
His Birth Was More Serious Than I Imagined
Those little blips of scene I saw earlier were finally in my full view once I had enough oxygen. Fully alert, they explained how the cord was indeed wrapped around my son and had been done so in a way that was on the verge of rupturing in utero. Instead, it snapped the moment I pushed him out. Had this happened while pregnant, I'd have bled out. Doctors continued to examine the scene, flummoxed by the events, but all I could focus on was holding my boy.
Waiting To Hold Him Was Worth It
That very moment they placed my baby into my arms, I didn't care about a single thing I'd gone through to meet him. None of it mattered.
He Stopped Crying The Moment I Held Him
What can I say? He was beautiful.
My Daughter Was The First To Really Hold Him...
My daughter was technically the first person to hold my son for any length of time, thinking he was her actual birthday present. She didn't say much, but stared lovingly at him while we all watched on.
...And She Wouldn't Give Him Back
She refused to let any of us hold the baby because she loved him so much. If only that were still true today!
We Lit The Birthday Candles & Sang
My father-in-law brought in a cake for the birthday babies. We lit the candles and sang as a family.
Everyone In Our Family Couldn't Get Enough Of Him
Once my daughter saw the cake, she wasn't interested in holding the baby anymore. We passed my boy around, thankful he'd made it (and that I had, too).
There Was No Snow This October Day...
On the day of my daughter's birth, there had been snow, but on this day, the sun shined through the windows as if the weather was hinting at how different the two kids would be.
...But There Was A Rainbow
After two miscarriages, infertility issues, and ovarian cysts, it didn't matter what I'd gone through to have my son — my rainbow baby. I'd do it all over again. When the time comes, this is the thing I can't wait to tell him the most.


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He's been buying little cylinders of fizz tablets - Swisse he thinks, but the last little while has seen us coming up empty. We have tried everywhere to get 'em and the reasons for the lack of 'em have made us laugh and sometimes get a little cross and finally we were dumbfounded at the chemist at Australia Fair on the weekend, when we were told that it was the Chinese, that it was their fault, that they buy 'em all up as soon as they come onto the shelves. Seriously blaming a whole nationality on the lack of a vitamin, and she was straight faced too.
As he's felt better, he figured he wanted to continue as he had begun, but as the fizzers were unavailable he settled for some powder stuff, which tastes less than fab - fucking horrible he said, so after the first try, he's left it alone.
Not only is that not good value cos he's gonna let it go hard in the tub before finally throwing it away, I discovered that the packaging is appallingly, ridiculously misleading. Why is it necessary to put a teaspoon of stuff into a cement mixer size tub and con buyers into thinking they have a big bunch of the stuff only to be disappointed, in this case twice, once by the tiny bit of goo and secondly by the shit taste. All very ho hum.
This is how very full the tub was when we opened it.
And it's a bit like going to the bakery today for a stick of bread. I have been going to this bakery for years and have bought literally hunderds of French sticks, so today when I went and bought one and it was the size of a long bread roll, well yeh I noticed! I asked the bloke - the owner, if they were making the sticks smaller, and of course he denied it. More Ho Hum. Making 'em smaller is stupid! If they want more money for 'em, put the price up, be honest about it. It just gives me the shits when people lie and try and treat their punters like fools. Either the bags are now 4 inches longer than they used to be or the bloody stick is smaller! He carried on about some bollocks that maybe they were rolled differently, seems honesty is beyond him.
Here's my French stick from Horners Bakery.


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Call us today
Just over 20 million adults in the United States struggled with addiction in 2016, according to the National Survey on Drug Use and Health (NSDUH). As addiction is a highly personal disease, there are many different types of treatment and care options to manage it. The National Institute on Drug Abuse (NIDA) publishes that there are over 14,000 dedicated addiction treatment facilities in the United States.
Orange County drug rehabs offer treatment through both public and private providers. Public providers are overseen through the regional provider, the Orange County Health Care Agency (HCA). Behavioral health services, which includes drug rehab, are managed through the Behavioral Health Services (BHS) division. The 2016 Community Health Needs Assessment (CHNA) Kaiser Foundation Hospital Anaheim & Irvine reports that in Orange County, there are 122.7 mental health providers per every 100,000 residents, which is lower than the state average of 157 per 100,000 people.
Approximately 34 percent of the residents of Orange County residents have reported using illicit drugs at least once, and 6 percent have misused a prescription drug at some point in their lifetime. According to the Drug and Alcohol Morbidity and Mortality in Orange County 2017 report, there were 3,876 hospitalizations in the OC related to drug or alcohol dependence, with alcohol being most common and opioid drugs being the second most involved substances.
Drug rehab can take many forms, and it is offered through a variety of treatment settings and environments. This drug rehab guide for Orange County can help residents understand the ins and outs of addiction treatment and how to find relevant and local care.
There are many different formats to choose from when it comes to drug rehab. The two main types of drug rehab are outpatient and inpatient. Outpatient services are provided at a facility at specific times, and the individual will return home each evening. Outpatient services can vary in structure and intensity. For example, intensive outpatient programs (IOPs) are similar in structure to a residential, or inpatient program. IOPs, at the minimum, offer programming three hours a day at least three days a week for a total of nine hours. Many IOPs offer more hours more days a week as needed. The journal Psychiatric Services publishes that in 2011 nearly half of all addiction treatment providers offered IOPs; there were over 6,000 programs throughout the United States that year. An IOP can be a step down from a residential program or an option for someone who needs more intense services than traditional outpatient programs can provide; however, the person may not require inpatient around-the-clock care.
Another intensive and short-term form of outpatient drug rehab is a partial hospitalization program (PHP). These programs are a step down from a residential program, offering services for most of the day with individuals mainly returning home just to sleep in the evenings and then coming back again the next day. A PHP is often followed up by additional outpatient drug rehab services and may serve as a transition into traditional outpatient rehab.
A residential program can offer the highest level of comprehensive care with extremely structured programming and constant supervision 24 hours a day, seven days a week. An inpatient drug rehab program can provide a safe and secure environment for individuals to learn new life skills and coping mechanisms while forming healthy habits and relapse prevention tools. Nutrition and physical health can be attended to as well as emotional wellbeing. The National Institute on Drug Abuse (NIDA) reports that both outpatient and inpatient drug addiction treatment services should continue for at least 90 days.
Both outpatient and inpatient drug rehab programs may require detox services first. Detox programs allow drugs to process safely out of the body. In the case of significant drug dependence, a medical detox program that uses medications as well as supportive care in a medically monitored setting is optimal. Detox typically lasts between five and seven days on average, and it may be provided through outpatient or inpatient means, depending on a person's individual needs. Detox should always be followed up with a complete drug rehab program.
Both outpatient and inpatient drug rehab centers in orange county will include some of the following types of services:
Supporting individuals in recovery is an important aspect of drug rehab, as addiction is a chronic and relapsing disease. Support groups are a form of outpatient support that individuals can join during rehab and continue attending well into recovery. Participating in an orange county recovery support group can improve abstinence rates, as the Journal of Addictive Disorders publishes that individuals who participated in Alcoholics Anonymous (AA) were twice as likely to remain sober over those who didn't. A self-help group like AA offers peer support through a 12-Step faith-based program that focuses on complete sobriety and offers members anonymity, confidentiality, and encouragement in recovery. Other types of support groups exist for recovery support, such as SMART (Self-Management and Recovery Training) Recovery.
Support groups are a form of recovery services that can augment a drug rehab program and sustain long-term recovery. These groups are usually free to join and don't require any kind of preregistration. Meetings are generally open to anyone in recovery wishing to remain sober.
There are typically two main types of providers: those offering public treatment services and those providing private care. Public providers often receive funding through the state and/or federal government, and they may have specific eligibility requirements and length-of-stay maximums. Public treatment beds are often waitlisted, and it can take longer to get into a program.
In California, public healthcare needs are managed through the California Department of Health Care Services (DHCS) and then regionally managed through each specific county healthcare office, such as the OC Health Care Agency. All residents of the OC who are also US citizens can seek public drug rehab services; however, priority is given to pregnant women, those in crisis, and individuals demonstrating financial hardship.
Public providers generally accept Medi-Cal, which is free or low-cost health insurance coverage for low-income adults and children in California as well as those without health insurance. Public providers offer drug rehab services for free, at a low cost, or on a sliding scale depending on what families and/or individuals can afford.
Private drug rehab providers often accept health insurance as a form of payment, and they offer payment plans and loan opportunities for payment. Private drug rehab programs can generally offer more private accommodations, a wider variety of amenities, and quicker access to care with fewer restrictions than public rehab programs.
Private programs and providers will differ on cost depending on the type of services required. For example, residential treatment programs will cost more than outpatient services on average, and the longer a person stays, the more it can cost. Luxury accommodations obviously cost more.
Drug addiction treatment may seem expensive with average costs around $15,000 or more; however, NIDA reports that rehab can actually save families and society money in the long run when you factor in the costs of lost workplace production, healthcare expenses, and criminal justice costs. Most drug rehab providers have counselors on hand to work with families on budgeting and finding the best financial means to pay for treatment services.
When looking into drug rehab, it is important to prioritize your own individual needs. Everyone is different, and programs can benefit each person differently. Understanding what kinds of rehab programs in orange county are out there and educating yourself on local drug rehab options is essential in order to make an informed decision. Important things to consider include:
Families should sit down and prioritize their needs before choosing a treatment program in order to ensure that it will be the right fit. Come up with a budget and determine how to pay for treatment as well as what type of services will be the most beneficial. Will a residential program where a person can focus completely on healing and recovery be optimal, for example? If a person does not suffer from significant drug dependence or co-occurring disorders and family, work, and/or school obligations need to be attended to then perhaps an outpatient treatment program will work best. Often, treatment providers can perform detailed assessments and evaluations to help determine what level of care will be best.
Talk to your insurance company as well to identify available options and what may be necessary for coverage before enrolling in a program. Some providers will want a referral from a primary care provider (PCP), for instance, while others will require policyholders to choose an in-network provider.
Decide how important privacy and anonymity are. Private providers may offer the highest level of discretion, and it may even be beneficial for peace of mind to enroll in a facility that is set in a secluded location. For others, being close to family during rehab may be a higher priority as family and loved ones can play a major role in treatment and recovery. Make a list of prioritized needs before choosing a drug rehab program or provider.
Once the priorities for care are determined, there are questions that families and individuals can ask providers before enrollment to ensure that all needs are being met. These include:
A 2018 report on substance use in California found that:
To find a drug rehab center in Orange County, the Orange County Social Services Agency (OC SSA) provides a local listing of substance abuse services. The OC Health Services Agency offers a Behavioral Health Services Navigation resource tool. The OC Links Information and Referral Line can also provide online and telephone support for residents seeking public drug rehab services.
The Coalition of Orange County Community Health Care Centers (COCCC) provides information on low-cost and free medical services for residents of Orange County. To find state-regulated treatment services in any area, individuals can input their local zip code and the type of service requested through the Behavioral Health Treatment Services Locator operated by the Substance Abuse and Mental Health Services Administration (SAMHSA). Primary care providers as well as medical and mental health providers also often provide resources for drug rehab services in local communities.
Preventative and recovery support organizations are often community-based and provided by nonprofit organizations and agencies. These organizations support local communities and strive to ensure healthy societies by educating the public on drug abuse, providing preventative campaigns and measures, offering resources for treatment, and providing general information for families and individuals in recovery.
The National Council on Alcoholism and Drug Dependence- Orange County (NCADD-OC) is a nonprofit organization that offers educational and drug and alcohol abuse prevention services to the local Orange County community. Another community preventative resource is the Garden Grove Drug-Free Coalition (GGDFC), which strives to minimize alcohol and drug use by area youth.
The Orange County Sheriff's Department (OC SD) provides information on area drug education and other community resources. The nonprofit Project PATH runs the Alcohol and Other Drug (AOD) Impaired Driving Prevention Project to help reduce impaired driving in Orange County. Recovery support organizations, such as Orange County- Alcoholics Anonymous (OC-AA) and the Orange County Area of Narcotics Anonymous (NA), offer continuing support in recovery with local meetings and fellowship opportunities.
Knights of Columbus Hall 130 W. Main St., Tustin.
Daily: 6 a.m. and noon
Mondays: 7:30 p.m., men's group
Tuesdays: 7:30 p.m.
Fridays: 8 p.m.
Church of the Foothills 19211 Dodge Ave., Santa Ana.
Mondays: 7 p.m.
Mariposa Women's Center812 Town & Country Road, Room 16, Orange.
Mondays: 7:30-9 p.m.
Daily meetings countywide. Call to find a meeting at (714) 556-4555.
Daily meetings countywide. Call (714) 776-8581 or visit https://www.todayna.org/ for information.
Mariposa Women's Center812 W. Town & Country Road, Room 16, Orange
Sundays: 7:30 p.m.
Daily meetings countywide. Call (714) 573-0174 for meeting locations and times.
Weekly support groups open to those who struggle with depression or bipolar disorder. Call (714) 744-8718 for information.
Fullerton, Huntington Beach
Laguna Beach, Orange
Open to those who struggle with co-occurring disorders.
Church of the Foothills19211 Dodge Ave., Santa Ana.
Fridays: 7:30-9 p.m.
343 W. Valencia Drive, room HFullerton.
Saturdays: 10 a.m.


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Cumbria health boss John Ashton defends NHS reform letter
Cumbria's director of public health has defended his right to speak out on the government's planned health reforms.
Prof John Ashton co-signed a letter in a newspaper earlier this month. It defended the Royal College of GPs' chair, who oppose reform.
He was then summoned to a meeting with regional health bosses after being told his actions were "inappropriate".
He has now demanded an apology from Health Secretary Andrew Lansley saying he felt he had been bullied.
NHS Cumbria said in a letter to Prof Ashton that he should not express his personal views and told him to attend a meeting planned for Friday.
He claims the Department of Health is behind moves to "gag" him and has demanded an apology.
He said: "Trying to gag me at this stage in my career won't have an effect.
"As a public health director and as the advisor for public health to the county of Cumbria... I have the freedom to speak out on matters of interest.
"I am not acting politically, I am acting professionally, drawing on the evidence of what will happen if we go down the road to private health insurance.
"The PCT was told to do this from the Secretary of State's office and I want an apology for that because I feel bullied.
"To get a letter like that, delivered to your house out of the blue, is unacceptable."
A spokesman for the Department of Health said all decisions about Prof Ashton had been made by his employers.
He added: "Therefore, there is no need for Andrew Lansley to apologise because he has not been involved."
Prof Ashton was one of a number of signatories of the letter in The Independent newspaper talking about widespread opposition among health professionals to the bill.
Proposals in the Health and Social Care Bill include giving GPs control of much of the NHS budget and opening up the health service to greater competition from the private and voluntary sectors.
In a statement, NHS Cumbria said NHS organisations must always remain non-political but added the planned meeting was not disciplinary.
An NHS Cumbria spokesperson said: "NHS clinicians are always free to express their opinions as individuals and NHS Cumbria has never stood in the way of anyone expressing a personal view.
"Every senior manager in the health service has to nonetheless be mindful of expressing their views on political issues as individuals, and not on behalf of the NHS organisations for which they work."


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