text:
Coxibs and Heart DiseaseWhat We Have Learned and What Else We Need to Know
Author + information
- Received June 27, 2006
- Revision received July 31, 2006
- Accepted August 8, 2006
- Published online January 2, 2007.
Author Information
- Ignatius Gerardo E. Zarraga, MD⁎ and
- Ernst R. Schwarz, MD, PhD, FACC⁎,†,⁎ (Ernst.Schwarz{at}cshs.org)
- ↵⁎Reprint requests and correspondence:
Dr. Ernst R. Schwarz, Division of Cardiology, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Suite 6215, Los Angeles, California 90048.
Since their approval in 1998, the popularity of selective cyclooxygenase-2 (COX2) inhibitors has swung from a domination of drug sales to serious disputes about their cardiovascular safety. Despite the numerous studies on COX2 inhibitors that have emerged, drawing conclusions about their cardiovascular safety has been complicated by conflicting results, underpowered clinical trials, and the lack of a placebo group and use of post hoc analyses in many trials. Nonetheless, certain conclusions can be made with reasonable accuracy. This review addresses the controversy in 3 segments. It begins with a discussion of the several mechanisms proposed to explain how selective COX2 inhibition impacts the cardiovascular system. This is followed by a recount of the several clinical studies that delved into the cardiovascular outcomes associated with COX2 inhibitors. Finally, answers to key questions are provided to assist the clinician in devising a systematic approach to the risk-benefit analysis of COX2 inhibitors in actual practice.
The transformation of arachidonic acid to prostaglandin H2 (PGH2) is a step that commits arachidonic acid down the path of prostaglandin-thromboxane synthesis. This transformation is catalyzed by cytosolic prostaglandin G/H synthase, more commonly known as cyclooxygenase (COX). Prostaglandin H2 is an unstable intermediate and is further converted to one of many prostanoids, such as prostacyclin (PGI2) and thromboxane A2 (TXA2), by tissue-specific isomerases. As early as 1987, evidence emerged showing that the COX enzyme probably existed in 2 isoforms (1). Today it is well established that these isoforms, COX1 and COX2, exist and are encoded by separate genes on different chromosomes.
Cyclooxygenase inhibition formed the basis for the success of non-steroidal anti-inflammatory drugs (NSAIDs) in treating a variety of pain syndromes. The drawback, however, was that every year, 2% to 4% of patients taking NSAIDs suffered from symptomatic gastrointestinal ulcers and their complications (2). As the science behind the COX enzyme progressed, it became apparent that COX2 inhibition mediated the anti-inflammatory effects of NSAIDs, whereas COX1 inhibition was responsible for the adverse effects on the gastrointestinal tract. It therefore became reasonable to assume that inhibiting COX2 selectively would result in the same anti-inflammatory benefits that nonselective NSAIDs provided but with fewer gastrointestinal side effects. This rekindled the interest of pharmaceutical industries in manufacturing new analgesic and anti-inflammatory medications known as selective COX2 inhibitors or coxibs. In 1995, the first generation of coxibs, celecoxib (by Monsanto) and rofecoxib (by Merck), entered clinical trials. In 1998, celecoxib was approved by the U.S. Food and Drug Administration (FDA), followed by rofecoxib in 1999. These drugs soon dominated the prescription-drug market for NSAIDs. By October 2000, celecoxib and rofecoxib had sales exceeding $3 billion in the U.S. (3).
At the time that COX2 inhibitors were approved, randomized trials aimed at proving their gastrointestinal safety were still ongoing. It was not until 2000 that 2 large studies, CLASS (Celecoxib Long-Term Arthritis Safety Study) (2) and VIGOR (Vioxx Gastrointestinal Outcomes Research) (4), showed their superior gastrointestinal profile over conventional NSAIDs. Both studies, however, were not free of controversy. For the CLASS trial, the gastrointestinal superiority of celecoxib in its 6-month data became disputable when this superiority failed to manifest in its 12-month data (5). On the other hand, the VIGOR study raised concerns about the cardiovascular safety of rofecoxib. To amplify this concern, near the time of completion of the VIGOR study, preliminary evidence supporting the biologic plausibility of COX2-induced adverse cardiovascular events emerged. From hereon, the use of coxibs became plagued by safety concerns on the basis of both mechanistic and clinical data.
As a result of the evolving understanding of the potential risks of selective COX2 inhibition, in 1999, Merck introduced a standard operating procedure to evaluate and adjudicate cardiovascular events in all ongoing and future rofecoxib clinical trials (6). In 2002, the FDA also issued a new warning in the package insert of rofecoxib, stating that "… caution should be exercised when Vioxx is used in patients with a medical history of ischemic heart disease." This decision of the FDA to opt for a mere label change and not a more practice-changing intervention, such as compelling manufacturers to initiate trials on cardiovascular safety, has been highly criticized (7). As a matter of fact, for a good number of years after the VIGOR trial stirred controversy, no randomized controlled trial was initiated to address the cardiovascular toxicity of coxibs as a primary end point. Instead, more trials were designed to show the efficacy of coxibs for other indications, such as the prevention of recurrent colonic polyps, management of postoperative pain, and slowing down of the progression of Alzheimer's dementia. One such trial was the APPROVe (Adenomatous Polyp Prevention on Vioxx) study (8), which now stands among landmark clinical trials. It was prematurely terminated after investigators found an increased cardiovascular risk among patients taking rofecoxib, and served as the basis for the immediate worldwide withdrawal of rofecoxib by Merck on September 30, 2004. Thousands of lawsuits against Merck followed this event, because by this time an estimated 80 million people had already taken the drug (9).
Not too long thereafter, the results of 2 more randomized trials of coxibs were published and showed unfavorable cardiovascular outcomes as well. One was a celecoxib trial for colonic adenoma prevention (10), and the other was a valdecoxib/parecoxib trial for the management of postoperative pain after coronary artery bypass grafting (CABG) (11). In addition to being linked with a heightened cardiovascular risk, valdecoxib and parecoxib had previously been implicated in life-threatening hypersensitivity reactions, including anaphylaxis, angioedema, Stevens-Johnson syndrome, and toxic epidermal necrolysis (12). Consequently, on April 7, 2005, the FDA requested that Pfizer remove valdecoxib from the market. Furthermore, the FDA issued a cautionary note against the coxibs, and NSAIDs in general: "… an increased risk of serious adverse [cardiovascular] events appears to be a class effect of NSAIDs (excluding aspirin). The FDA has requested that the package insert for all NSAIDs, including Celebrex, be revised to include a boxed warning to highlight the potential increased risk of [cardiovascular] events and … to include a contraindication for use in patients immediately postoperative from CABG" (13).
In the following discussion, we highlight the several mechanisms that have emerged to explain how selective COX2 inhibition impacts the cardiovascular system. We then review the landmark clinical studies that delved into the cardiovascular outcomes associated with coxibs. Finally, we present a systematic approach to the risk-benefit analysis of coxibs in actual clinical practice.
Mechanisms Underlying the Cardiovascular Effects of Selective COX2 Inhibitors
Cyclooxygenase-1 is expressed constitutively in most cell types and is the only functioning COX in mature platelets. Cyclooxygenase-2, on the other hand, is an isoform with an expression that is induced by inflammatory stimuli such as bacterial endotoxin and cytokines. Induction of COX2 expression has also been demonstrated in atheromatous plaques (14,15) and neoplasms (16). This led to the hypothesis that COX2 inhibition might be useful in the treatment or prevention of atherosclerosis and various cancers. In fact, a few reports have suggested that COX2 inhibition might be cardioprotective. For example, Dinchuk et al. (17) have shown that COX2-knockout mice developed cardiac fibrosis. Two histologic studies, performed by Baker et al. (14) and Schonbeck et al. (15), showed the presence of COX2 in atherosclerotic lesions of native and transplanted coronary arteries, but not in normal coronary arteries. Furthermore, COX2 expression was localized to macrophages/foam cells, medial smooth muscle cells, and endothelial cells within the atherosclerotic plaque, all of which are established key players in atherogenesis. A similar study by Cipollone et al. (18) on carotid plaques showed a significantly higher concentration of COX2 in plaques associated with a recent transient ischemic attack or stroke compared with asymptomatic plaques. Cyclooxygenase 2 expression also appears to be induced by many of the same stimuli implicated in the development of atherosclerosis, including free radicals (19), tumor necrosis factor, interleukin-1 (20), platelet-derived growth factor (21), and increased arterial wall shear stress (22). Finally, because inflammation of the endothelium is known to diminish its capacity to produce nitric oxide, it has been suggested that COX2 inhibition can improve endothelial function in this setting. This was shown by 2 small, short-term studies (≤2 weeks in duration) in which celecoxib led to significant improvements in flow-mediated vasodilation compared with placebo in patients with hypertension or coronary artery disease (CAD) (23,24).
In reality, predicting the effect of COX2 inhibition on the cardiovascular system has not been straightforward. Although COX2 can be viewed as a "bad" player in the atherosclerotic process based on most of the aforementioned data, it can also be regarded as a "good" player if its up-regulation is thought of as a compensatory mechanism to help maintain vascular health. In addition, in 1998, it became apparent that the 2 COX isoforms affected the balance of vasoactive prostanoids differently. Several studies suggested that TXA2, a vasoconstrictor and promoter of platelet aggregation, was largely COX1-derived, whereas the synthesis of the vasodilator and potent inhibitor of platelet aggregation, PGI2, was linked to COX2 induction (25,26). Specifically, the up-regulation of COX2 (e.g., by interleukin-1β) shifted arachidonic acid metabolism from TXA2 synthesis to the preferential production of PGI2 (27). Furthermore, although nonselective COX inhibitors, such as aspirin and ibuprofen, suppressed TXA2 production in platelets, selective COX2 inhibitors did not (25,26). Altogether, a clear suggestion was made that COX2 inhibition could tip the vascular homeostasis into a prothrombotic state.
More investigations have since led to the unraveling of other mechanisms behind coxib-induced cardiovascular harm. For example, it has been suggested in animal models that COX2 mediates the cardioprotective effects of the late phase of ischemic preconditioning and that PGE2 and PGI2 are the likely effectors of such protection (28,29). Accordingly, COX2 inhibition can block the protective effect of late-phase preconditioning against myocardial stunning and infarction. In another study of mice models of atherosclerosis, antagonism of the TXA2 receptor was shown to retard atherogenesis, but the combination of selective COX2 inhibition and TXA2-receptor antagonism resulted in atherosclerotic lesions that lacked fibrotic caps, suggesting a destabilizing effect on these plaques (30). Wu et al. (31) also showed that when angiogenesis was induced by vascular endothelial growth factor, cell proliferation and the formation of vascular structures were increased in human umbilical vein endothelial cells that overexpressed COX2, whereas cell proliferation was significantly reduced when the endothelial cells were pretreated with a selective COX2 inhibitor. These findings suggest that COX2 may be cardioprotective, in part because of its role in angiogenesis. As will be discussed in later sections of this review, some COX2 inhibitors have been associated with hypertension and oxidative modification of lipids, providing yet another mechanism by which these drugs might produce adverse outcomes.
Risk of Ischemic Cardiovascular Events With Rofecoxib
The first major postmarketing multicenter trials on COX2 inhibitors were the CLASS and VIGOR trials (Tables 1 and 2)⇓(2,4). Although safety concerns were raised by the VIGOR trial, neither of these trials convinced the entire medical community of the increased cardiovascular risk of coxib use. The CLASS trial was a double-blind trial of 7,968 patients with osteoarthritis (OA) or rheumatoid arthritis (RA) who were randomized to high-dose celecoxib, ibuprofen, or diclofenac. Patients were allowed to take cardioprotective doses of aspirin. At the end of 6 months, there was no difference in the incidence of cardiovascular events between the celecoxib and nonselective NSAID groups, irrespective of aspirin use. The VIGOR study was a similar trial that randomized 8,076 patients with RA to either 50 mg rofecoxib daily or 500 mg naproxen twice daily. As in the CLASS trial, the coxib dose was over the maximum recommended dose for long-term administration, and was in keeping with the objective of the study, which was to rigorously assess the gastrointestinal safety of the drug even at supratherapeutic doses. Unlike the CLASS trial, patients in the VIGOR trial were prohibited from using aspirin. During a median follow-up of 9 months, the incidence of myocardial infarction (MI) was several-fold higher in the rofecoxib group: 4-fold higher as reported by the VIGOR study group; 5-fold higher as reported in the FDA files (32). Because the study lacked a placebo arm, it was unclear how much of the increased risk of MI was attributable to a harmful effect of high-dose rofecoxib, a protective effect of naproxen, chance (because of the small number of events), or a combination of these factors.
When this unexpected outcome from rofecoxib unfolded and mechanisms to explain its biologic plausibility emerged, several observational studies were published to help confirm the finding, but the results were conflicting (33–35). Pooled analyses of previous randomized trials likewise did not provide a clear answer to the issue. Three pooled analyses of trials before and after the marketing of rofecoxib, published from 2001 to 2003, supported the cardiovascular safety of rofecoxib (Table 1). These included the studies by Konstam et al. (6) and Reicin et al. (36), which found similar rates of thrombotic events and similar rates of the APTC (Anti-Platelet Trialists' Collaboration) end point (combined incidence of death from cardiovascular, hemorrhagic, or unknown cause; nonfatal MI; and nonfatal stroke) with rofecoxib, placebo, and comparator non-naproxen NSAIDs. The data evaluated by Konstam et al. (6) included the results of the VIGOR trial and indicated that naproxen was an outlier NSAID in that it was associated with a lower risk of cardiovascular events compared with rofecoxib. In an updated review, Weir et al. (37) reiterated in 2003 that rofecoxib was safe from a cardiovascular standpoint. In addition to the pooled analyses of Konstam et al. (6) and Reicin et al. (36), they included data from the Alzheimer's Disease and Mild Cognitive Impairment program, a composite of placebo-controlled trials that again showed similar rates of cardiovascular events in the rofecoxib and placebo groups.
In contrast to the above data, in 2001, Mukherjee et al. (38) published a review highlighting the cardiovascular risk associated with coxibs. In their analysis of the VIGOR study, the relative risk of an adjudicated cardiovascular thrombotic event with rofecoxib compared with naproxen was 2.38 (95% confidence interval [CI] 1.39 to 4.00). They then looked into the rate of similar events in a placebo group, which they derived from a meta-analysis of 4 aspirin primary prevention trials. Compared with this placebo group's annualized MI rate of 0.52%, the corresponding rates were higher in the rofecoxib group of the VIGOR trial (0.74%, p = 0.004) and the celecoxib group of the CLASS trial (0.80%, p = 0.02). This analysis, however, was criticized for comparing patients without rheumatoid arthritis (placebo group) with the patients of the VIGOR trial, all of whom had RA and were potentially at an increased risk for cardiovascular events (39).
After rofecoxib was withdrawn from the market based on the results of the APPROVe study, Jüni et al. (40) came out with a meta-analysis of 18 randomized controlled trials that compared rofecoxib with nonselective NSAIDs or placebo in patients with chronic musculoskeletal disorders (Table 1). After analyzing a total of 64 MI events in 21,432 patients, the relative risk of MI with rofecoxib vs. control was 2.24 (95% CI 1.24 to 4.02). Using cumulative meta-analysis, the investigators showed that this significantly increased risk should have become evident as early as 2000. Although estimates of the relative risk varied depending on whether rofecoxib was compared with placebo, a non-naproxen NSAID, or naproxen in the various trials, a test of interaction was not significant and it was concluded that the type of control had no important impact on the relative risk. Interestingly, the investigators showed that the only source of variation in risk of MI related to whether or not adverse events were examined by an external end point committee. In this light, they warned that data on adverse events from industry-sponsored randomized trials were trustworthy only if an independent end point committee was involved (41). To address the question of cardioprotection from naproxen, the investigators analyzed 11 observational studies that compared the cardiovascular risk of naproxen use with that of no NSAID use or use of a non-naproxen NSAID. The combined estimate of the relative risk of MI with naproxen use was 0.86 (95% CI 0.75 to 0.99). It therefore seemed that naproxen had only a small, if any, cardioprotective effect, and this effect alone could not have accounted for the higher MI rates in the rofecoxib arm of trials such as the VIGOR trial.
The verdict on the rofecoxib controversy was finally laid down by Merck when the results of the APPROVe trial came out (Table 1) (8). This trial was designed to test the hypothesis that 3 years of rofecoxib treatment will reduce the risk of recurrent adenomatous polyps in patients with a history of colorectal adenomas. At least 1,000 patients were randomized to 1 of 2 arms, 25 mg rofecoxib daily or placebo, and approximately 28% of the patients were designated as having a high cardiovascular risk profile. Patients were allowed to take low-dose aspirin for cardiovascular protection, although only about 20% actually took aspirin at some point in the study. On September 30, 2004, about 2 months before its planned completion date, the study was terminated after an interim review of the external safety monitoring board found a higher risk of thrombotic events, mainly MI and stroke, in the rofecoxib arm. Among those who took rofecoxib, this risk was especially high in those who had a history of symptomatic atherosclerotic cardiovascular disease or diabetes. Although the original article suggested that the excess risk surfaced only after 18 months of rofecoxib use, a correction to this claim was recently made; a re-analysis of the data did not suggest that a shorter course (<18 months) of rofecoxib was safe (42). Although the APPROVe trial was a relatively small trial that was not designed primarily to investigate cardiovascular outcomes, it brought forward a new dimension to the rofecoxib analysis by using placebo as the control and having a treatment and follow-up duration well beyond 24 months. Thereafter Merck could have accepted a black box warning, but it chose to pull the drug out of the world market immediately.
On May 11, 2006, Merck released their data on an off-drug extension of the APPROVe trial in which they followed up the over 2,500 patients for another year after discontinuation of the study drug (43). There continued to be more cardiovascular thrombotic events in those previously randomized to rofecoxib (28 events vs. 16 events in those previously randomized to placebo), with a relative risk of 1.64 (95% CI 0.89 to 3.04). When the off-drug extension data were combined with the 3-year on-drug data, the relative risk over 4 years was 1.74 (95% CI 1.19 to 2.55), hinting that the increased cardiovascular risk in those who took rofecoxib was slow to abate—in fact, more slowly than expected if the only mechanism invoked was a coxib-induced prothrombotic state. An in-depth analysis of the off-drug extension data is currently under way. In the meantime, continued follow-up of this cohort of patients will be valuable in understanding the long-term risks associated with rofecoxib.
Risk of Ischemic Cardiovascular Events With the Other Coxibs
Whether or not the cardiovascular risks of rofecoxib is a class effect of COX2 inhibitors is an issue that needs clarification. After all, the various COX2 inhibitors have important structural, pharmacodynamic, and pharmacokinetic differences, as listed in Table 3(44). Celecoxib, for example, is the least selective of the coxibs; with a COX1:COX2 half-maximal inhibitory concentration ratio of 30, it is only slightly more COX2-selective than diclofenac, which has a ratio of 20. In terms of metabolism, rofecoxib is the only one that it is inactivated by cytosolic reductases. The other coxibs are oxidized by cytochrome P450 enzymes, making them potentially more susceptible to drug-drug interactions. Furthermore, an in vitro study by Walter et al. (45) suggested that coxibs with a sulfone moiety, namely rofecoxib and etoricoxib, enhanced the susceptibility of lipids to oxidative modification through a process unrelated to their COX activity. This pro-oxidant property was not observed with other coxibs and nonselective NSAIDs. Inherent differences like these can potentially translate into differences in in vivo behaviors and clinical outcomes.
In fact, a few observational studies have suggested differences in cardiovascular risk between rofecoxib and celecoxib. In a case-control study by Kimmel et al. (46), the adjusted odds ratios for MI among celecoxib users and rofecoxib users compared with individuals who did not use NSAIDs were 0.43 (95% CI 0.23 to 0.79) and 1.16 (95% CI 0.70 to 1.93), respectively. In another case-control study using data from Kaiser Permanente, Graham et al. (47) showed that the odds ratio for an acute MI and sudden cardiac death among rofecoxib users compared with celecoxib users was 1.47 (95% CI 0.99 to 2.17) if the dose was ≤25 mg/day and 3.58 (95% CI 1.27 to 10.11) if the dose was >25 mg/day. Finally, in a study by Solomon et al. (48) that compared the rates of MI and ischemic stroke in users of nonselective NSAIDs or coxibs (including celecoxib, rofecoxib, and valdecoxib) with those in nonusers, rofecoxib was the only coxib that significantly increased the risk of cardiovascular events. Taken together, these studies suggested that the increased cardiovascular risk seen with COX2 inhibitors was most prominent with, and perhaps limited to, rofecoxib.
On the other hand, some randomized trials only strengthened the notion that adverse cardiovascular events were a class effect of COX2 inhibitors. The APC (Adenoma Prevention with Celecoxib) study was one such trial (10) (Table 2). It randomized 2,035 patients with a history of colorectal neoplasia to receive placebo or celecoxib, either 400 or 800 mg/day. During 3 years of follow-up, celecoxib was associated with a dose-related increase in the composite end point of cardiovascular death, nonfatal MI, stroke, and heart failure, and this effect was independent of concomitant use of aspirin or lipid-lowering medication. Notably, these findings contrasted with those of other studies, including CLASS (celecoxib vs. ibuprofen or diclofenac) and 3 unpublished studies, namely PreSAP (Prevention of Colorectal Sporadic Adenomatous Polyps; celecoxib vs. placebo), ADAPT (Alzheimer's Disease Anti-inflammatory Prevention Trial; celecoxib vs. naproxen or placebo), and SUCCESS-1 (the first Successive Celecoxib Efficacy and Safety Study; celecoxib vs. naproxen or diclofenac), all of which did not show any statistical difference in the risk of cardiovascular thrombotic events between celecoxib and a comparator nonselective NSAID and/or placebo (49) (Table 2). It should be emphasized, however, that like the APPROVe study, the strength of the APC trial lay in its use of a placebo as control and its treatment and follow-up duration of over 24 months. In a recent meta-analysis of randomized trials of celecoxib, Caldwell et al. (50) concluded that celecoxib significantly increased the risk of MI when compared with placebo (odds ratio 2.26, 95% CI 1.0 to 5.1) or when compared with placebo, diclofenac, ibuprofen, and paracetamol (odds ratio 1.88, 95% CI 1.15 to 3.08), but did not significantly increase the risk of other outcomes such as cardiovascular death and stroke.
Analogous to the results of the APPROVe and APC studies, 2 trials of valdecoxib and its pro-drug, parecoxib, for pain management after elective CABG questioned the safety of these drugs in high-risk patients (11,51) (Table 4).The larger of the 2 studies randomized 1,671 patients to one of three 10-day treatment arms: 1) intravenous parecoxib followed by oral valdecoxib; 2) intravenous placebo followed by oral valdecoxib; or 3) placebo. All patients received low-dose aspirin and were allowed to receive opiates postoperatively as needed. During only 30 days of follow-up, cardiovascular events, including MI, cardiac arrest, stroke, and pulmonary embolism, occurred more frequently in patients who received parecoxib and valdecoxib than in those who received placebo (2.0% vs. 0.5%, p = 0.03).
Lumiracoxib was evaluated in the TARGET (Therapeutic Arthritis Research and Gastrointestinal Event Trial) study (52) (Table 5).This was the first published study of coxibs in arthritis patients that prospectively evaluated predefined cardiovascular events along with gastrointestinal events. Over 18,000 patients were randomized to lumiracoxib (at doses 2 to 4 times higher than the recommended dose for OA), naproxen, or ibuprofen. Patients who were deemed high-risk for cardiovascular disease were started on low-dose aspirin before enrollment. After 1 year, the incidence of the APTC end point was slightly, but not significantly, higher in the lumiracoxib group compared with the nonselective NSAID group; this lack of statistical difference was not influenced by the use or nonuse of aspirin. Similarly, for MIs, no significant difference was found between lumiracoxib users and the combined nonselective NSAID group; however, there was an excess of events in the lumiracoxib arm, which became more prominent when naproxen was used as the comparator. Three points about this trial deserve mention. First, although it was a large trial, it was still insufficiently powered to detect significant differences in MI among non-aspirin users. Second, patients on low-dose aspirin had at least a 2-fold higher number of composite vascular events than did non–aspirin-treated patients, whether they were assigned to lumiracoxib or to nonselective NSAIDs. Counterintuitive as it may seem, this could reflect either an inability of aspirin to provide cardioprotection against lumiracoxib and NSAIDs, or the potentially higher baseline risk of those being treated with aspirin. Finally, there was an issue about hepatotoxicity. Transaminase elevations of more than 3-fold occurred in more patients on lumiracoxib than in those on the 2 nonselective NSAIDs (hazard ratio [HR] 3.97, 95% CI 2.96 to 5.32). Whether or not this was a dose-dependent phenomenon related to supratherapeutic doses of lumiracoxib remains unanswered. Nonetheless, on the basis of the above findings, it is difficult to justify the use of lumiracoxib at this time (53). For patients not taking aspirin, the absolute reduction of 0.72% in ulcer complications is offset by an excess of 2.0% of liver function test abnormalities and an excess of 0.17% of MI if naproxen is used as the comparator NSAID. For patients taking low-dose aspirin, it is even harder to justify lumiracoxib because the benefit of ulcer complication reduction is lost.
Etoricoxib and lumiracoxib are the 2 newest coxibs that have yet to be examined for approval by the FDA. Clinical trials of etoricoxib are ongoing and include EDGE II (Etoricoxib vs. Diclofenac Sodium Gastrointestinal Tolerability and Effectiveness Trial in Rheumatoid Arthritis Patients), which included 4,000 patients with RA, and MEDAL (Multinational Etoricoxib and Diclofenac Arthritis Long-term Study), which included 23,500 patients with RA and OA. The data from these 2 studies will be combined with those from the recently completed EDGE trial, another trial of etoricoxib involving 7,111 patients, and an analysis of predefined cardiovascular outcomes will be made. Together, the data from these trials will form the largest NSAID analysis ever designed (54) (Table 5).
Other Potential Adverse Cardiovascular Effects of Coxibs
Although nonselective NSAIDs have been associated with an increased risk of congestive heart failure (CHF) or worsening CHF (55,56), it is less clear whether COX2 inhibitors share the same risk. At least 2 observational studies have suggested that this risk is associated with rofecoxib but less so with celecoxib (57,58). One of them was a population-based cohort study that compared the rates of hospitalization for CHF among NSAID-naive elderly individuals who were started on rofecoxib (n = 14,583), celecoxib (n = 18,908), and nonselective NSAIDs (n = 5,391), and a randomly selected control group of non-NSAID users (n = 100,000). Compared with control patients and after adjustment for potential confounders, the relative risk (RR) of admission for CHF was significantly higher in those who received rofecoxib (RR 1.8, 95% CI 1.5 to 2.2) and nonselective NSAIDs (RR 1.4, 95% CI 1.0 to 1.9), but not in those who received celecoxib (RR 1.0, 95% CI 0.8 to 1.3). In the APPROVe study, CHF and pulmonary edema occurred earlier (about 5 months after starting the study drug) and at a higher rate in patients who took rofecoxib than in the control group (HR 4.61, 95% CI 1.50 to 18.83) (8).
Non-steroid anti-inflammatory drugs have also been associated with blood pressure elevation and lower extremity edema (59). Coxibs may share these risks, although once again, the greatest risk seems to be with rofecoxib. In a meta-analysis of 19 randomized trials involving 45,461 patients, the weighted mean difference in systolic blood pressure was +3.85/+1.06 mm Hg and +2.83/+1.34 mm Hg when coxibs were compared with placebo and nonselective NSAIDs, respectively (60). Among the different coxibs that were compared with placebo, the largest increase in systolic blood pressure was with rofecoxib (+5.66 mm Hg vs. +2.60 mm Hg with celecoxib). Rofecoxib also resulted in a statistically significant increase in the risk of hypertension compared with placebo (RR 2.63, 95% CI 1.42 to 4.85), whereas celecoxib (RR 0.81, 95% CI 0.13 to 5.21) and etoricoxib (RR 1.23, 95% CI 0.44 to 3.44) did not. Data from the CLASS and APPROVe trials suggested similar findings. In the CLASS trial, the incidence of hypertension was lower in the celecoxib group compared with the nonselective NSAID group (1.7% vs. 2.3%, p < 0.05), whereas the incidence of peripheral edema was comparable between the 2 groups (2). The APPROVe study, on the other hand, suggested an increased risk of hypertension and peripheral edema with rofecoxib compared with nonselective NSAIDs (8). Like celecoxib in the CLASS trial, lumiracoxib was not implicated in blood pressure elevation in the TARGET trial; in fact, nonselective NSAIDs were associated with significantly higher mean changes in systolic and diastolic blood pressure compared with lumiracoxib (systolic blood pressure: +2.1 mm Hg vs. +0.4 mm Hg, p < 0.0001; diastolic blood pressure: +0.5 mm Hg vs. −0.1 mm Hg, p < 0.0001) (52).
Drawing conclusions from the numerous studies on coxibs and their cardiovascular risk obviously has not been straightforward. Although it is understandable why clinical trials on arthritis patients would use nonselective NSAIDs as comparators, the lack of a placebo arm complicates the interpretation of the results, especially because NSAIDs may have cardiovascular effects themselves. In addition, most of the data we have on coxibs were derived from post hoc and non-prespecified analyses of randomized trials. We are still in need of randomized controlled trials that are purposely designed and adequately powered to examine the cardiovascular effects of these drugs. One such trial has been planned for celecoxib, PRECISION (Prospective Randomized Evaluation of Celecoxib Integrated Safety vs. Ibuprofen or Naproxen), which hopes to assess the relative safety of these drugs in about 21,000 patients with OA or RA and known CAD or multiple risk factors for CAD over a duration of 2 years (61).
Amidst the multitude of studies on coxibs, one thing we have learned is what specific questions to ask. Although the current data have their limitations, fortunately it is possible to draw a fair number of conclusions to answer some of these questions.
First, are all coxibs the same? We do not believe so. Although there are good data from randomized trials of rofecoxib, valdecoxib/parecoxib, and celecoxib to suggest that each of these drugs can result in adverse cardiovascular events (as though to suggest a class effect), there are likewise numerous studies that indicate different degrees of risk associated with different coxibs. The latter has been underscored by studies such as CLASS, PreSAP, ADAPT, and SUCCESS-1, which have shown no increased risk with celecoxib, and observational studies that have shown differences in risks between rofecoxib and celecoxib. That these differences are related to the COX2 selectivity of the drug or certain moieties within its chemical structure has been suggested but cannot fully account for the findings of the randomized trials. For example, of the various coxibs, lumiracoxib is the most COX2 selective, followed by rofecoxib and then celecoxib. The associated cardiovascular risks seen in the TARGET (lumiracoxib), VIGOR and APPROVe (rofecoxib), and CLASS and APC (celecoxib) trials, however, did not line up in quite the same order. Unfortunately, there are no clinical trials that have made head-to-head comparisons of the various coxibs on which we can substantiate this idea of a differential risk. It is also important to point out that as much as we have scrutinized the different coxibs, similar emphasis should be placed on the impact of different doses on outcomes. The APC trial showed quite clearly that the adverse events associated with celecoxib were dose-dependent. In this light, concerns about the safety of lumiracoxib in the TARGET trial, and most other coxibs for that matter, may be attenuated if lower doses are used.
Second, how should the cardiovascular risk profile of a patient affect our decision to use or not use a coxib? When the absolute risk increase in cardiovascular events is expected to be high with coxib use, as in a patient with CAD or multiple risk factors for CAD, it is but prudent to avoid a coxib. For the young, low-risk individual, the scenario is less clear. The absolute risk increase in events may be lower, but the relative risk increase can potentially be greater and still reach magnitudes of unacceptability. This is a specific issue that needs clarification by well-designed studies.
Third, is it beneficial to add aspirin when prescribing a coxib to a patient with an intermediate or high cardiovascular risk profile? Although the intuitive answer is yes, once again, the clinical trials do not provide us with a straightforward answer. The post hoc analysis of the APC data showed that patients who took aspirin did not have lower rates of cardiovascular events than those who did not take aspirin. Similarly, in the APPROVe trial, the increased cardiovascular risk experienced by the rofecoxib group did not seem to be influenced by baseline or subsequent use of aspirin. Findings such as these suggest that the adverse outcomes from coxib use might not be solely a consequence of COX2 inhibition (or a thromboxane-prostacyclin imbalance), and other mechanisms might be at play. What is perhaps clearer is the finding that when aspirin is taken together with a coxib, the gastrointestinal safety advantage of the coxib over a nonselective NSAID is lost. This was seen at least in the CLASS and TARGET trials.
Finally, is there still a place for coxibs in our scheme of managing patients with pain syndromes? Are there safer but equally efficacious alternatives? We believe that coxibs will continue to be clinically useful, although in a very select group of patients. These are the individuals who continue to require nonsteroidal anti-inflammatory treatment despite optimization of other modalities (e.g., disease-modifying drugs for RA and analgesics, physical therapy, and physical aids for OA), have a low cardiovascular risk profile, and have a relatively high gastrointestinal bleeding risk. Although the vast majority of trials that compared nonselective NSAIDs with coxibs for pain control did not show superiority of the latter, in clinical practice, the response to pain management varies from individual to individual, and it is not uncommon to have a patient who reports better pain relief with a coxib.
Currently, the impetus for avoiding coxibs is the potential to cause cardiovascular harm. Three important points arise from this statement. First, we actually lack definitive data about where the various nonselective NSAIDs, the presumed alternatives to coxibs, stand in terms of cardiovascular safety. This is because there has been no long-term placebo-controlled trial of conventional NSAIDs designed to evaluate cardiovascular outcomes. The vast majority of observational studies, however, have not shown any significant cardiovascular consequence from nonselective NSAID use, with the exception of naproxen, which has been implicated to be mildly cardioprotective by a few studies. A recent meta-analysis of placebo-controlled randomized trials also failed to show any significant cardiovascular effect of nonselective NSAIDs, including nabumetone, ibuprofen, indomethacin, diclofenac, and even naproxen, except possibly in trials of Alzheimer's disease, in which there was a nonsignificant trend toward increased events (62). Second, certain NSAIDs, such as ibuprofen, can blunt the antiplatelet effect of aspirin, presumably by binding to COX1 and blocking the channel that aspirin must traverse to bind COX1 (63). In view of this, it has been recommended that if aspirin and an NSAID are to be taken on a regular basis, the soluble form of aspirin should be ingested 2 hours before the NSAID (64). This type of interaction becomes essentially irrelevant when aspirin is combined with a coxib because COX2 is not expressed in mature platelets. Finally, if a decision is made to avoid a coxib, the combination of an NSAID with a proton pump inhibitor (PPI) may be just as safe for the upper gastrointestinal tract (65), but perhaps not so for the lower gastrointestinal tract, in which a PPI is not expected to provide any protection (67). A clear advantage of using a nonselective NSAID/PPI combination is its lower cost compared with a coxib, especially if over-the-counter equivalents (e.g., naproxen or ibuprofen plus omeprazole) are used. In patients with high cardiovascular risk who need to be on aspirin, more complex polypharmacy-type combinations such as coxib/aspirin/PPI and nonselective NSAID/aspirin/PPI have been suggested but have not been compared directly (66).
- Abbreviations and Acronyms
- coronary artery bypass grafting
- coronary artery disease
- congestive heart failure
- cyclooxygenase
- Food and Drug Administration
- hazard ratio
- myocardial infarction
- non-steroidal anti-inflammatory drug
- osteoarthritis
- prostaglandin
- proton pump inhibitor
- rheumatoid arthritis
- thromboxane
- Received June 27, 2006.
- Revision received July 31, 2006.
- Accepted August 8, 2006.
- American College of Cardiology Foundation
- ↵
- Tanaka Y.,
- Ward S.L.,
- Smith W.L.
- ↵
- Silverstein F.E.,
- Faich G.,
- Goldstein J.L.,
- et al.,
- Celecoxib Long-term Arthritis Safety Study
- ↵IMS Health. IMS Health reports Cox-2 drug sales in U.S. surge 137% in six month period. Westport, CT: IMS Health Inc., 2000. Available at: http://ww0.ne.imshealth.com/public/structure/dispcontent/1,2779,1341-1341-81004,00.html. Accessed February 8, 2006.
- ↵
- ↵
- ↵
- Konstam M.A.,
- Weir M.R.,
- Reicin A.,
- et al.
- ↵
- ↵
- ↵
- ↵
- ↵
- ↵U.S. Food and Drug Administration Talk Paper. Bextra label updated with boxed warning concerning severe skin reactions and warning regarding cardiovascular risk. Available at: http://www.fda.gov/bbs/topics/ANSWERS/2004/ANS01331.html. Accessed June 26, 2006.
- ↵U.S. Food and Drug Administration Alert for Practitioners. Celecoxib (Marketed as Celebrex). Available at: http://www.fda.gov/cder/drug/infopage/celebrex/celebrex-hcp.htm. Accessed June 26, 2006.
- ↵
- Baker C.S.,
- Hall R.J.,
- Evans T.J.,
- et al.
- ↵
- ↵
- ↵
- ↵
- Cipollone F.,
- Prontera C.,
- Pini B.,
- et al.
- ↵
- Adderley S.R.,
- Fitzgerald D.J.
- ↵
- Jones D.A.,
- Carlton D.P.,
- McIntyre T.M.,
- Zimmerman G.A.,
- Prescott S.M.
- ↵
- Xie W.,
- Herschman H.R.
- ↵
- Topper J.N.,
- Cai J.,
- Falb D.,
- Gimbrone M.A. Jr.
- ↵
- Chenevard R.,
- Hurlimann D.,
- Bechir M.,
- et al.
- ↵
- Cullen L.,
- Kelly L.,
- Connor S.O.,
- Fitzgerald D.J.
- McAdam B.F.,
- Catella-Lawson F.,
- Mardini I.A.,
- Kapoor S.,
- Lawson J.A.,
- FitzGerald G.A.
- ↵
- Caughey G.E.,
- Cleland L.G.,
- Penglis P.S.,
- Gamble J.R.,
- James M.J.
- ↵
- Shinmura K.,
- Tang X.L.,
- Wang Y.,
- et al.
- Birnbaum Y.,
- Ye Y.,
- Rosanio S.,
- et al.
- ↵
- Egan K.M.,
- Wang M.,
- Fries S.,
- et al.
- ↵
- Wu G.,
- Luo J.,
- Rana J.S.,
- Laham R.,
- Sellke F.W.,
- Li J.
- ↵Targum SL. Food and Drug Administration: cardiovascular safety review rofecoxib, 2001. Available at: http://www.fda.gov/ohrms/dockets/ac/01/briefing/3677b2_06_cardio.pdf. Accessed June 26, 2006.
- ↵
- Solomon D.H.,
- Schneeweiss S.,
- Glynn R.J.,
- et al.
- ↵
- Reicin A.S.,
- Shapiro D.,
- Sperling R.S.,
- Barr E.,
- Yu Q.
- ↵
- ↵
- ↵
- Lipani J.
- ↵
- ↵
- ↵
- ↵Merck. APPROVe Extension Statistical Package. Available at: http://www.merck.com/newsroom/vioxx_withdrawal/pdf/APPROVe_Extension_Statistical_Package.pdf. Accessed June 26, 2006.
- ↵
- ↵
- ↵
- ↵
- ↵
- ↵Advisory Committee Briefing Document: Celecoxib and Valdecoxib Cardiovascular Safety. Available at: http://www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4090B1_03_Pfizer-Celebrex-Bextra.pdf. Accessed June 26, 2006.
- ↵
- Caldwell B.,
- Aldington S.,
- Weatherall M.,
- Shirtcliffe P.,
- Beasley R.
- Ott E.,
- Nussmeier N.A.,
- Duke P.C.,
- et al.,
- Multicenter Study of Perioperative Ischemia (McSPI) Research Group,
- Ischemia Research and Education Foundation (IREF) Investigators
- ↵
- Farkouh M.E.,
- Kirshner H.,
- Harrington R.A.,
- et al.,
- TARGET Study Group
- ↵
- ↵Etoricoxib: FDA ACM Background Document. Available at: http://www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4090B2_01_Merck-Etoricoxib.pdf. Accessed June 26, 2006.
- ↵
- ↵
- Hudson M.,
- Richard H.,
- Pilote L.
- ↵
- ↵
- ↵
- Sullivan M.G.
- ↵
- ↵
- ↵
- ↵
- ↵
- ↵
- Reicin A.,
- DiBattiste P.,
- Mukhopadhyay S.,
- et al.


text:
I get it. The words "strategic plan" have been so abused in the nonprofit sector that they elicit a whole spectrum of negative responses from the bored eye roll to the destructive desire to forgo strategy altogether. But I am a firm believer that charting a future direction for your nonprofit, whatever you want to call it, is absolutely fundamental to success.
A great strategy allows your nonprofit to:
- Connect mission and money
- Marshal ever-limited resources to their highest and best use
- Make board and staff more productive
- Articulate the value you provide your community
- Attract additional funding
- And, ultimately, create more social change
If you can't, as an organization, describe your strategy for the future, how will you build the momentum and resources needed to get there?
This month's Social Velocity webinar, The Value of a Great Nonprofit Strategy, will help you understand:
- Why strategy is so critical to building momentum and resources for your work
- What a great strategic planning process looks like
- How strategy can help you invest funders, engage your board, and make your staff more productive
- How to make your board more strategic
- The steps to get there
And remember, even if you can't make this date or time you can still register for the webinar and get access to the on demand recording, slides and ability to ask follow up questions. I hope you'll join us!
Photo Credit: jonrawlinson.com

subset: commoncrawl


text:
Both the College of Public Health and the University of Georgia provide a wide range of student resources to help you fulfill your potential and make the most of your time here as a student.
CPH Academics & Student Experience
UGA CPH offers a variety of undergraduate, master's, doctoral, and dual-degree programs within our four department and four institutes.
- Departments & Institutes
- Degrees
- Minors
- Certificates
- Dual Degree Programs
- Scholarships and Financial Aid
- Study Abroad
- Student Organizations
- Advising
- Academic Appeals Process | CPH Academic Appeals Process (PDF)
- Request for After Hours Access to Rhodes Hall
CPH News & Events
UGA CPH faculty, students and alumni are making an impact on public health in Georgia and around the world. View the latest stories or learn more about an upcoming event from the College of Public Health.
Today a career in public health positions you at the cutting edge of health sciences, public policy, research and business. UGA CPH graduates are making a difference around the globe.


text:
Ask a Mayor
A CityLab video series
What's the Most Surprising Thing You've Learned About Being a Mayor?
On becoming a waste management and parking policy expert.
Where Can You Go in Your City to Take a Break From Being Mayor?
Getting away from the job when you're always on the job.
What Ideas Have You Copied or Borrowed From Other Cities?
Stealing is encouraged among mayors.
What's the Most Frustrating Part of Your Job?
Mayors open up about the stuff that gets them down.
What Do People Tend to Get Wrong About Your City?
Mayors address their worst cultural stereotypes.
Why Has No Sitting Mayor Ever Become President of the United States?
A few have tried, but none have succeeded.
Outside of Your Staff, Who Do You Listen to the Most?
Mayors explain how friends and associates quickly become crucial advisers.
Who Runs Your Twitter Feed?
When it comes to social media at the municipal level, not everyone is a Cory Booker.
What's the Weirdest Place You've Ever Been Confronted by a Constituent?
There's no such thing as personal space when you're mayor.
What's the First Thing You Do When You Arrive at City Hall Each Day?
You asked. Mayors answered.
What Would You Ask If You Could Ask a Mayor Anything?
We're getting ready to interview a group of mayors from around the world. But we need your help!


text:
Sleep Apnea
Do you constantly feel fatigued and drowsy, no matter how much sleep you've had?
When you need a comprehensive dentist to evaluate and treat sleep apnea, please contact DC Smiles online or by telephone at Old Town Alexandria Office Phone Number 703-299-4614 to schedule an appointment with one of our Alexandria VA dentists on our team. We treat patients from across the Washington, DC Metropolitan area.
What is Sleep Apnea?
Sleep apnea is characterized by periodic breathing disruptions throughout the night that prevent restful and recuperative sleep.
Sleep apnea experts report that close to 10% of the population has sleep apnea, but up to 90% of those who have it are not diagnosed.
Do you sometimes wake up gasping for air, or find yourself with a dry mouth in the morning? These may be signs of a serious sleep disorder known as obstructive sleep apnea (OSA). People with sleep apnea cease breathing intermittently throughout the night. In order to force you to take a breath, your brain will wake you up, but this happens so quickly that most people are never become aware of it.
More Sleep Apnea Symptoms
Apart from fatigue, dry mouth, and waking up gasping for breath, people with obstructive sleep apnea can also suffer from the following symptoms:
- Chronic, loud snoring
- Frequent trips to the bathroom throughout the night
- Difficulty concentrating
- Short-term memory problems
- Mood swings associated with exhaustion
- High body mass index (thick neck)
- Insomnia or early wakefulness
If you are experiencing any of these symptoms, you may want to visit us to find out more about sleep apnea and potential treatment options. Our team can refer you for a sleep study through George Washington University or other fine sleep centers in the area.
We work with a team that includes cardiologists, ENT specialists, neurologists, and pulmonologists to develop your sleep apnea treatment plan. DC Smiles will regularly be in contact with this team of physicians to help you find relief from your sleep apnea.
For more information about Sleep Apnea or to schedule a consultation with us, call Alexandria, VA 703 299 4614.
Committed to Your Health and Well-Being
If sleep apnea is left untreated, it can lead to a host of health problems, including a heightened risk of heart attack and stroke. As part of our commitment to supporting the lifetime health of his patients, he offers comfortable sleep apnea therapy through custom orthotic devices, and in unique cases, may suggest orthognathic surgery, or corrective jaw surgery.


text:
|You can purchase this shirt created by famous Australian Vegan activist James Aspey here.
One year ago to this day, while I was down in Brisbane visiting my family, I made the life changing decision to never consume, use, or intentionally support the exploitation of another animal again in my life. It was on this day that I became Vegan.
I knew when making this decision that my life would be turned upside down. I fully expected friends, family, coworkers etc to bombard me with questions, lame jokes and criticisms. What I wasn't expecting was just how many people would support me in my decision, and who. Without naming names, some of the people I thought would support me didn't at first, but with time grew to accept my decision. Alternatively, those who I thought would never understand supported me from the get go and some even began to follow in my footsteps. I also stepped outside of my comfort zone and joined a local Vegan group that held weekly (turned monthly) potlucks, and made a whole circle of new friends. I cannot thank these people enough for supporting me in my decision, especially during those first few months.
Fast forward to today and it's as though I have been Vegan my entire life. What once seemed like such a daunting concept is now my every day way of life. The decision not to consume animals each day is no longer something I have to consciously think about, I simply listen to my body and eat whatever yummy plant based foods my body is craving at the time.. which can be anything from avocado and tomato on toast, to a completely raw salad dressed only with lemon juice (two meals I never would have eaten before going vegan!). I love my fruits and veggies so much more since cutting animal products out of my diet. It's like my tastebuds have completely changed. In fact, the smell and look of animal products completely turns me off now and actually makes me feel quite sick.. even cheese!
Never before have I been this interested in and excited about my health, cooking, eating out, supporting local businesses, getting involved in activism, keeping tabs on real world matters, etc. It's safe to say that Veganism has completely changed my life, 100% for the better. I have no idea what the future holds for me in regards to this new lifestyle change, but I am motivated and inspired to create more positive change in whatever way I can.
Watch this space! :)
bloglovin' ♥ facebook ♥ twitter ♥ instagram ♥ pinterest


text:
Scan at the box office and concession stand to earn points, unlock rewards and use your Movie Club credits.
Your web browser is blocking location sharing. Please enable location sharing through your browser settings, or search by ZIP code.
Limited August 09, 2019
Nationwide August 09, 2019
1 hr 39 mins
Aldis Hodge, Greg Kinnear, Sherri Shepherd, Melanie Liburd, Tiffany Dupont, Xosha Roquemore, Mystie Smith, Jose Miguel Vasquez, Dorian Missick, Monique Grant, Matt Battaglia, Michael Franti, Kevin Yamada, Thursday Farrar, Zeus Luby, David Clyde Carr
Tom Shadyac
The inspirational true story of Brian Banks, an all-American high school football star who finds his life upended when he's wrongly convicted of a crime he didn't commit. Despite the lack of evidence, Banks gets railroaded through a broken justice system and sentenced to a decade of prison and probation. Years later, with the support of Justin Brooks and the California Innocence Project, Banks fights to reclaim his life and fulfill his dreams of playing in the NFL.
Bleecker Street Media


text:
Blog – Insights by Stefan Willerstorfer
Acorde succeeds at D&AD
The London-based organisation D&AD (formerly known as British Design & Art Direction) has been celebrating outstanding work in design and advertising for almost 50 years. It was founded in 1962 by a group of designers and art directors including David Bailey, Terence Donovan and Alan Fletcher.
In D&AD's annual competition work is judged in 25 different award categories by 25 different specialist juries. Year after year the very best work is showcased in the renowned D&AD annual book. This year's typography section features Acorde among a handful of carefully chosen typefaces.The judging of the D&AD Awards in London.
Acorde wins the Grand Prize of Applied Typography 21
Applied Typography is an international design competition organised by Japan Typography Association, Tokyo. The design competition awards prizes in about a dozen different typographic design categories such as editorial design, visual identity and type design. While Best Work awards are given to several selected entries receiving high ratings in each category, the Grand Prize is awarded only to a single work or designer in the competition judged as particularly outstanding.
As you can imagine, I feel very honoured by receiving the Grand Prize for the type family Acorde. »Its intelligent and broad-brushed element is very beautiful and the readability and visibility are of high grade, which resulted in getting everyone's favour without reservations«, explains judging committee chairman Tsuyokatsu Kudo, about the jury's decision to award Acorde the Grand Prize of this year's design competition.Judging committee chairman Tsuyokatsu Kudo opens the ceremony of Applied Typography 21. The Grand Prize of Applied Typography 21 goes to the type family Acorde.
Yuki Nishimura reads out my written comment on winning the Grand Prize for Acorde.
Group photo of award winners and jury members of Applied Typography 21.
Chatting, eating and drinking at the party succeeding the official part of the ceremony.
Jury member Yoshimaru Takahashi states that »although the inclination to break with foundation is going around the present world of typography, the message of reconsidering its foundation to produce a high quality functional beauty can be seen in this work.« His colleague Toshiyasu Nanbu adds that Acorde is a typeface »that literally walks the royal road of typography.« I guess he is as curious as I am about where this road will further lead Acorde.
Acorde succeeds at the Tokyo TDC Annual Awards
The Tokyo Type Directors Club (TDC) was founded in 1987 and organises the annual Tokyo TDC Awards design competition. This year's winners are going to be published in the annual design book Tokyo TDC, Vol. 22. Among the winners is the type family Acorde which received the status Prize Nominee Work.
The winning entries can be seen in the travelling Tokyo TDC Exhibition 2011 which is being shown in Japan at Ginza Graphic Gallery in Tokyo from April 1 to April 25, at ddd Gallery in Osaka from May 10 to July 2 and in Korea at Samwon Paper Gallery in Seoul from September 3 to November 5.The Ginza Graphic Gallery in Tokyo hosts the TDC Exhibition 2011 from April 1 to April 25. Some impressions from the TDC Exhibition 2011 in Tokyo. From May 10 to July 2 the TDC Exhibition 2011 is shown at the ddd Gallery in Osaka.
Valentype 2011 – a love declaration to Acorde
On the occasion of Valentine's day, FontShop's Yves Peters asked the readers of his popular blog, The FontFeed, to declare their love to a type family of their choice. The readers designed images of declaration by using typographic, illustrative or photographic means. A jury consisting of Jürgen Siebert, Ivo Gabrowitsch, Stephen Coles, and Yves Peters selected five winners among the entries. The reward for every winner was a font package of four styles of the typeface they had declared their love to.
Just have a look at the gallery to see the winners, the various entries and the love declaration to Acorde.
Acorde wins Communication Arts Award of Excellence
Communication Arts has been publishing annuals showing the best in visual communications from around the world since 1959. But still 2011 marks a change. It is the first time – and certainly the beginning of a long tradition – of publishing a distinct annual specifically focused on typography.
The Communication Arts Typography Annual 1 presents the best work in various typographic categories such as books, periodicals, identity, packaging, and typeface design. It is a brilliant achievement that Acorde was among the first typefaces receiving the Communication Arts Award of Excellence in this category.The first Communication Arts Typography Annual.
Austrian publishing magazine Periodicum presents Acorde
Vielgesichtiges Schriftbild (multifaceted type) is the title of Christian Gutschi's article on the type family Acorde in the current issue of Periodicum (No. 2/2010), the bi-annual magazine by the corporate publishing company Egger & Lerch.
Gutschi emphasises Acorde's workhorse qualities and its applicability for various applications, conditions and sizes as the article's title already suggests. The article also gives information on the development process of the typeface and comments on various characteristics of Acorde.Cover of the publishing magazine Periodicum issue No. 2/2010. Pages showing the article inside the magazine.


text:
Weather forecast from Yr, delivered by the Norwegian Meteorological Institute and the NRK
Picture from our WEBCAM. Use the menu on the left side for pictures the last week.
Øyvegen 95, N-3853 Vrådal, Norway
Tel +47 35056183
Fax +47 35056220
E-mail: firstname.lastname@example.com nr: NO892963932MVA
This site usees cookies. Read more about cookies here.
Do not show this message again.


text:
I am trying to make dvd's of photo's stored on my laptop to play in a home dvd player...I have a file conversion program, but even that doesn't seem to work the way I need it to. Can anyone give me any pointers? Thanks....
Google for slideshow creator.
eg http://www.nchsoftware.com/slidesho...
This says it converts to dvd
Thank you...I will try it!
Ok, another question....I have tried the nchslideshow creator that you suggested and it is pretty simple to use. The question is, do I need to burn my file on a cd-r as a data disk or can it be a dvd-r or dvd-r/rw, cd-r/rw? Thanks for any help you can give...I am new at this, so please excuse my silly questions...
Not a data disk. Burn as a video dvd.
What program are you using?
Here are some free programs
A thank you would be nice, if I have helped.
I have 2 of them...Roxio Creator 2010 Plus and Corel Dvd Factory 2010... Thank you for all your help...
Sorry, I have never used those.
Burn the dvd as a video. You should end up with 2 folders
The audio will be empty, video will have files ending .VOB
A thank you would be nice, if I have helped.
Thank you so much....I will try it....


text:
Well, it sounds to me like they are being deleted some how. Did your friend recently upgrade to Outlook 2003 from a previous version? Like maybe 2000? I would also check the deleted items folder and the "Recover Deleted Items" under the tools menu.
To get to the "Recover Deleted Items" folder you have to be in the "deleted items" folder, then just go up to "tools" – Recover Deleted Items.
Register Hereor login if you are already a member


text:
Black Lace Bodysuit
Fantasy Lingerie
This black lace bodysuit is fun and flirty. Made entirely of stretchy floral lace, this black lace bodysuit has a versatile open front that can be worn open or closed with the tassel ties. Stylish cap sleeves and classic open back shows off just enough skin to leave a little room for imagination. Cheeky see-through bottoms shows off those luscious cheeks. This provocative black lace bodysuit will show off those curves from every angle. Who doesn't want that?
- Black lace bodysuit
- Comfortable cap sleeves
- Flirty tassel ties
- Open front and back
- Cheeky lace bottoms


text:
FBI: 'virtual kidnapping' scam now targeting local doctors
SAN ANTONIO – The San Antonio office of the Federal Bureau of Investigation said Thursday that "virtual kidnappings" are on the rise with criminals shifting their focus to doctors in San Antonio and the surrounding areas.
"The hopes are that instead of investing time and trying to figure out whether or not it's a legitimate kidnapping, they might be willing just to pay to resolve the problem," said special agent Michelle Lee.
Lee said in the last few months the number of calls has doubled in the region from people who have received these calls, some of whom sent money via wire transfers.
"We're confident that there are a lot of other victims out there that may be a little embarrassed about what happened and are probably not contacting us," she said.
For dramatic effect, Lee said the callers often work with accomplices to increase the fear of the potential victims.
"They may have a woman in the background screaming and yelling for help or perhaps the sound of people being tortured," she said. "Anything that we could see in a haunted house that would sound awful are things they are using to try to scare their victims and terrorize them."
Even people who know they're being scammed still feel as someone's life might be in danger. One man received a call saying his daughter was kidnapped even though he didn't have one.
"Even though he didn't have a daughter, he was still afraid to hang up the phone," said Lee. "That is how much these individuals terrorize their victims when they are talking to them."
The FBI has reached out to local medical groups to inform all doctors in their regional service area about the scams. Lee said in the last year the local office investigated one kidnapping where a suspect was caught and prosecuted. Many of these calls are difficult to trace and are often placed from outside the United States. Lee said investigations are getting better as more people come forward.
To avoid falling victim, Lee suggests looking for the following possible indicators:
- Incoming calls made from an outside area code
- Multiple successive phone calls
- Calls do not come from the kidnapped victim's phone
- Callers go to great lengths to keep you on the phone
- Callers prevent you from calling or locating the "kidnapped" victim
- Ransom money is only accepted via wire transfer service
If you do receive a call from a possible kidnapper, the FBI says to consider the following to help determine whether it's legitimate.
- Stay calm
- Slow the situation down
- Avoid sharing information about you or your family during the call
- Listen carefully to the voice of the kidnapped victim
- Attempt to call or determine the location of the "kidnapped" victim
- Request to speak to the victim
- Ask questions only the victim would know
- Request the kidnapped victim call back from his/her cell phone
Anyone with questions about a possible kidnapping or extortion phone call can reach the local FBI office at 210-225-6741. Tips can also be sent anonymously at tips.fbi.gov.
Copyright 2014 by KSAT - All rights reserved.


text:
Represented Trinity Industries in its public offering of $400 million aggregate principal amount of investment grade 4.55 percent Senior Notes.
Sending an email will not establish an attorney-client relationship. You should not send us any information that you want treated confidentially. By clicking Accept you acknowledge that we may review and use any information you transmit to us.


text:
Digital crown may be seen on iPhones and iPads in future
Usually we get the feeling that the folks at Apple find nothing more enjoyable than filing a good patent application. They patent everything and anything they find even if it never finds a spot in a shipping product at the end.
Apple's patent applications happen to garner the most interest. The latest of such applications brought to the attention of 'Patently Apple' is the Apple Watch-Like Digital Crown. This will be able to be used on devices including the iPhone and iPad.
The crown is an interesting interface feature for the Apple Watch and will allow for new interactions on any device it appears on. In the latest applications 20160378187 and 20160378189 Apple has outlined why it thinks crown will be beneficial to owners of devices which usually do not feature mechanics of such kind.
The main aim is to provide feedback to interactions. Apple sees this as a great accessibility feature as well as an interface design. The applications are very wordy and complicated.
However in simple terms Apple is bringing a Digital Crown-like interface to the iPad and iPhone. Whether this idea is good enough may depend on the exposure to the Apple Watch but then we wonder if this will ever see the light of day or not as with Apple p'atent applications there is no guarantee if the product actually comes to work.


text:
How to Teach Your Child to Use Plurals
For awhile, a dimpled face can get away with the lisped, "I see two twee, Mommy." As much as you hate for your sweetheart to grow up and stop using those cute expressions, you also want her to succeed in the world around her. Help her accelerate her language development with an understanding of when to use a plural noun. Base the length of time you dedicate to practice on her age and attention span with a maximum of 10 or 20 minutes a day for a child under five. By staying positive in your tone and demeanor, you can help her form a positive approach to learning rather than being frustrated with her own mistakes.
Picture Flashcards
Make picture flashcards to represent single and plural objects in a sentence. Involve your child in finding and cutting pictures of objects from magazines. Assist him in gluing the pictures onto index cards. Place the finished flashcards in a pile on the table.
Use the flashcards to practice forming sentences with singular and plural nouns with your child 1. Model the correct ending for each flashcard he picks. For example, if he picks up the flashcard with one dog, have him say, "I have a dog." If he picks out a card with two dogs, have him practice a sentence such as "I have dogs."
Review the difference between singular and plural nouns with a flashcard matching game 1. Lay the flashcards out randomly on the table. Have him find matches, saying the words aloud. For example, he may say "tree" and "trees" as he picks up those cards.
Use traditional nursery rhymes and songs to sneak in more practice with plurals. Sing plural-rich songs like "One Elephant Came out to Play" and "The Ants go Marching." Point out the difference between "one elephant" or "one ant" and multiple elephants or ants.
Reinforce the songs "Hot Cross Buns" or "Sing a Song of Sixpence" with a picture of the plural items in the songs. Cut out circles for the buns and birds for "Sixpence" from colored construction paper. Have your child glue them onto craft paper and decorate them while you sing the songs.
Act out "Old McDonald," personalizing it to your child. Line up her collection of stuffed animals. Change the song to include her name and the names of her animal friends.
Take an adventure trip to the library or browse your own collection. Pick out picture books with repetitive plural nouns on each page 1. Choose from options like "Millions of Cats," "Green Eggs and Ham," "Spiders, Spiders Everywhere" or "Bears on Wheels."
Provide your child with a flood of plural nouns found in the books 1. This will help your child subconsciously learn to restructure her vocabulary. Ask him questions about what is on each page after you have read it. Prompt him to repeat the plural noun.
Practice the plural noun vocabulary after reading the books. Ask your child to tell you about his favorite part of the story. Have him make a picture with one of the plural nouns from the book 1.
Always monitor your child's use with safety scissors.
- The American Scholar: What Toddlers Know They Don't Know About Plurals
- Scholastic: Teaching with Books
- The Complete Resource Book for Preschoolers: An Early Childhood Curriculum With Over 2000 Activities and Ideas: Pam Schiller and Kay Hastings
- Always monitor your child's use with safety scissors.
- BananaStock/BananaStock/Getty Images


text:
Touch of London gay massageLocation: Central London, UK
Boutique gay massage agency offering Body to Body, Tantric and other types of male massage. Why not visit our website and see the profiles of our masseurs? Incalls and outcalls are available, short notice can be accommodated dependent on availability. A friendly and discreet service, qualified and experienced masseurs.Touch of London on Pink UK Touch of London gay massage website
Would you like your advert here?
Italy, Lombardy gay saunas
Gay bathhouses, also known as gay saunas are commercial spaces for men to have sex with other men. In gay slang in some regions these venues are also known colloquially
as "the baths", "the Sauna" or "the tubs," but they should not be confused with public bathing. Gay baths are for sex, not bathing.
Not all men who visit gay bathhouses consider themselves gay, regardless of their sexual behavior. Bathhouses for women are rare, though some men's bathhouses occasionally have "lesbian" or "women only" nights.
Saunas vary considerably in size and amenities-from small establishments with 10 or 20 rooms and a handful of lockers to multi-story saunas with a variety of room styles or sizes and several steam baths, Jacuzzi tubs, and sometimes swimming pools. Most have a steam room (or wet sauna), dry sauna, showers, lockers, and small private rooms.
states/regions in Italy that have gay saunasEmilia Romagna | Lombardy | Perugia | Piedmont | Rome | Sicily | Veneto |
Gay Saunas in Bergamo
Via della Clementina, 8, 24125
Bergamo, Italy
03 Jun 2019
More info on The City Sauna Club
Dean Morris Cards website
Gay Saunas in Desenzano del Garda
Via Faustinella, 1, 25015
Desenzano del Garda, Italy
03 Jun 2019
More info on Splash Club
Saucy Boutique website
Gay Saunas in Milan
Via Giovanni Schiaparelli, 1, 20125
Milan, Italy
06 May 2019
More info on Metro Club Milano
Other venues in Lombardy: Clubs | Places to Eat | Pubs | Saunas | Hotels


text:
Credibility Test for the Catholic in the Pew.
Tous les dimanches, Fr Voigt propose un résumé de son sermon en anglais. Dorénavant, nous publierons de temps en temps des textes en anglais que nous n'avons pas le temps de traduire mais qui peuvent faire du bien à ceux qui comprennent cette langue.
I will not believe unless I put my fingers into His wounded hands and my
hand into His wounded side. God bless Thomas for presenting the Catholic
Church at large with the only credibility test that matters - wounds. Wounded people need a wounded Savior. In our days more than ever before we must know the shepherds by their wounds. Are they ready to lay down their lives for the faith.
Martyr after martyr laid down their lives in horrific manners in order to protect the very details of our faith. Now we have leaders who practice a tolerance of any error known to man. Are they liberal? Certainly. Are they modern? Sure. Do they believe that you can be saved in any denomination? Of course. The Catholic Church is only one of the many
vehicles of salvation for the new leaders of the Church of the New Advent or
the Conciliar Church. There is no need to be martyred for believing in the
honoring of saints and their images. There is no need to belong to the
Catholic Church at all.
Universal salvation is yours for the taking simply because Jesus became man
as blessed John Paul II wrote in Redemptor Hominis. Why did those saints
seek to convert all those "heretics" when they just had to wait for the modern Church leaders to set them straight. Martyrdom and missionary efforts are useless expenditures of life and energy. We have come to the days of the global church and our leaders are men of greater vision than our
saintly forefathers. Why they know better than St. Peter that the Jews need
not recognize their error in crucifying the Lord of lords.
Our current Catholic wants no discomfort, no inconvenience and certainly no
conflict with the culture. It is those pesky "trads" that keep rocking the boat and saying that we must pass on what what handed down to us from
the apostles. Even if an angel came down from heaven with some new gospel let him be anathema. So why this credibility test?
One reason only: we have sinned and fallen short of the image of God and sin cries out for the wounds that bled for forgiveness. Hebrews 9:22 cries out that without the shedding of blood there is no forgiveness of sin. If there is no forgiveness then we are doomed to the dungeons of the demons.
Only through the wounds of the unique Son of God can we turn to a priest and confess: I have sinned but I believe that my Lord and Savior lives to cleanse and heal me.
This is the good news that the unique Bride of Christ offers us today and any day. Christ breathed upon them and uttered those immemorial words:
"Whose sin you shall forgive are forgiven; whose sins you shall retain are retained." Catholics believe and are healed. Can this happen outside the
Mystical Body of Christ? I think not.
In the hearts of Jesus, Mary and Joseph,
Fr. Richard Voigt


text:
Helping Neighbors With Purposity
Purposity is changing lives, and you can be a part of it. Helping your neighbor, and your entire community, with just a few clicks.
If you knew your neighbor was in need, would you help them? Hear all the details, success stories, and feel inspired with this very special edition of All The Feels. Then follow the link below and join our team, and you can start helping people in your own neighborhood today!
"Purposity comes from the core belief that humanity finds purpose through generosity. Everywhere around us we see people in need. We also see people who want to help others but don't know how. We connect those dots through the power of text messaging and social media." Learn more by visiting purposity.com
Or follow the link below to join our team!
Join our team at http://www.purposity.com/jeffandjennshow?utm_source=Star%2094&utm_medium=Social&utm_campaign=star%2094%20launch


text:
The weekly round-up of news from the Nicolson Institute in Stornoway.
We hope that all staff, pupils and their families had a restful Easter break. Study leave for senior pupils starts on Tuesday, 2 May and the SQA examinations also start on that date. Senior pupils return to school on Monday, 5 June and the S6 Leavers' Ceremony will take place on Tuesday, 6 June.
This will be in the Town Hall, and tickets will be restricted to one per pupil.
The S1, S2 and S3 girls' netball teams travelled to Ullapool recently for a friendly tournament. The teams all played very well considering the less than favourable travelling conditions on the morning ferry crossing. The girls sported their new personalised sweatshirts (pictured above) which looked very smart.
The S1 and S2 netball club finished the term on a high this week with a visit to Eleven for dinner after the final week of netball. Miss Macmillan and Mrs Rogers would like to commend the girls on their dedication and commitment again this year. Netball club will resume in August.
Leis gu bheil Taghaidhean airson comhairlean ionadail air fàire, tha clasaichean AS1-3 Nuadh-Eòlas air a bhith a rannsachadh mar a tha taghaidhean airson comhairlean ionadail ag obair, an obair a bhitheas comhairlean ionadail a' dèanamh agus an siostam Bhòt Singilte Gluasadach.
In the run up to the local council elections S1-3 Modern Studies classes have been researching how local council elections work, the work local councils do and the Single Transferable Vote system.
Well done to the pupils who travelled to represent SRAC (Stornoway Running and Athletics Club) in the Scottish National Cross Country Championships. David Morrison (S2), Daniel Stewart (S3), Scott Maciver (S4) and Sophie Graham (S5) took part in the event which was held in Callendar Park, Falkirk. The students raced against hundreds of the best cross-country athletes in Scotland in very muddy conditions. Athletes now start their preparation for the summer track season.
Emma MacLeod (S1) and Josie Mansfield-Townsend (S5) were the winners of the school library's Pointless Book giveaway. Both entries were highly creative - Emma's was a very short story featuring a pink blue whale pet who must be fed on books, and Josie's entry was in the style of a blackmail letter which threatened harm to cute baby kittens if she did not win
Judge Adam Russell (Junior Librarian) and Ms B Morrison, librarian, decided not to take the risk and gave her a prize. Runners up received chocolate mini eggs.
On the last Friday of last term, a non-uniform day was organised to raise money for the School Fund. The total amount raised was £700.
The school would like to send its best wishes to Mrs C Macrury, maths teacher, who has given birth to a beautiful baby boy, Archie.


text:
Just another day at the Store, Renee had her All Occasion Card Class and I got to see some customers and chatted with lots of peeps! After work i went to see Heather. We split a chicken cutlet parmesan hero for dinner and watched Joy, well, the end of Joy. After that I came home and got Winston and settled in for a nice evening of TV. Sometimes I just need to be mindless and TV is the best escape! I need to mix it up a little, I think that I need a trip into the city soon! 😀
Today it's Paper Craft Crew Challenge day! This week we have a Tic-Tac-Toe for you…
I started my card by stamping the images from the Hero Arts Color Layering Seahorse Photopolymer Stamp Set in Orange Soda, Soft Apricot, Butter Bar, Soft Vanilla, Wet Cement and Tide Pool and cut them out with the Coordinating Frame Cuts. To make my background I stamped the Hero Arts Designer Woodgrain Background Stamp in Soft Brown directly onto my card base of Neenah Solar White 110lb Card Stock. My file folder is created with the Pretty Pink Posh Stitched Tabs Die and a piece of Putty, I added a piece of Seam Binding Ribbon along the bottom and it's adhered to the card with E-Z Runner. Next I die cut the Pretty Pink Posh Stitched Filmstrip Die from a piece of Tropical Sea and adhered it to the card with more E-Z Runner. The stamped images are then added with E-Z Runner and 3D Foam Squares. My greeting is from the Hero Arts Many Everyday Messages Photopolymer Stamp Set and is stamped in Soft Brown along the top edge of the filmstrip. Just a few Pretty Pink Posh Sparkling Clear and Marigold Sequins finish the card! Love the sea images against the woodgrain, you know me, I think that woodgrain goes with everything! LOL! I hope that you like my Design Team card for this week's Paper Craft Crew Tic-Tac-Toe challenge! Stop by the BLOG and see the rest of the Team's cards and let's see yours in the gallery! Thanks very much for your visit today! Have a wonderful Wednesday! 🙂
Products Used:
Stamp Sets: Color Layering Seahorse and Many Everyday Messages Photopolymer and Designer Woodgrain Background Wood Mount (Hero Arts)
Ink: Orange Soda, Soft Apricot, Butter Bar, Soft Vanilla, Wet Cement, Tide Pool and Soft Brown (Hero Arts)
Card Stock: Solar White 110lb and 80lb (Neenah), Putty and Tropical Sea (My Colors)
Dies: Color Layering Seahorse Frame Cuts (Hero Arts), Stitched Tabs and Stitched Filmstrip (Pretty Pink Posh)
Embellishments: Seam Binding Ribbon, Sparkling Clear and Marigold Sequins (Pretty Pink Posh)
Adhesives: E-Z Runner Ultra Strong and 3D Foam Squares (Scrapbook Adhesives) and Multi-Matte Medium (Ranger)
Tools: Big Shot
The links below take you to the Stamp, Ink, Paper Store where you can purchase the items used on today's project!


text:
Featured on Wigleaf's Top 50 Short Fiction Stories of 2013
Nominated for the Pushcart Prize for "The Fog" in The Quotable.
"Interview with Kawika Guillermo." Anak Sastra. January 31, 2014.
"Smoking with Kawika Guillermo." Interview by Brandon Wicks. Apr 2012
Reading of "What Fell Beneath the Tracks" by Brad Powers
"The Last of Its Kind" reviewed in Mothership: Tales from Afrofuturism and Beyond: "The last magician hunts the last dragon in the days of a decaying imperium. Sad, poignant tale."
"No Name Islands" review: "I think this story was the most visceral for me, despite how short it is. Here, too, we are in a speculative world of what might be with regard to ecology, this time with terraforming. The final image in this story will haunt me for a long time."
"No Name Islands review on The Star.


text:
Another video from the village of Nunney in Somerset. This time with empasis on the castle.
Nunney Castle, Somerset
July 10, 2009 at 4:00 am (Location, Video)
Tags: Nunney, Somerset
Nunney, All Saints
July 9, 2009 at 4:00 am (Location, Video)
Tags: Nunney, Somerset
Nunney in Somerset was home to many of my Starr ancestors.
Battle of Weymouth
February 24, 2009 at 4:00 am (History, Location, Video)
Tags: Crabchurch Conspiracy, Dorset, Weymouth
On Saturday 7th February 2009 a spectacular re-enactment took place in commemoration of the Battle of Weymouth and the Crabchurch Conspiracy of 1645.
Underground at Combe Down Mines
July 20, 2008 at 4:00 am (History, Location, Video)
Tags: Bath, Combe Down
Going underground in the silver tunnels at Combe Down Mines in Bath in this video from the Western Daily Press. The mines dates from the 17th and 18th Century and were used to extract Bath stone for the city of Bath, and have since been disused.


text:
Section No. 47
Southumbria Section Map
Forthcoming events for the Southumbria Section
Advertise your event free of charge
Risk Assessment for RSC events
A risk assessment form must be filled out for every event organised by the RSC. All forms are available for download along with examples of Red Risk Assessment Forms .
Downloadable Files
Annual Report 2016
Further information on events run by the Local Section committee
PDF (108k)
PDF files require Adobe Acrobat Reader
Contact and Further Information
Mr Jonathan W. Torne MRSC


text:
Support the Expansion of the Mt Elphinstone Park - Save the Clack Creek Gallery Forest (A93884) Status - Critical. It is part of the proposed expanded Mt. Elphinstone Park and provides critical connectivity between the existing 'island' parks #2 and #3. Only by preventing this logging do we get to keep an intact ecosystem in place. The province has agreed to undertake an Elphinstone Land Use Plan with the shíshálh Nation and the SCRD yet the Ministry of Forests says: "Resource management and use are expected to continue during modernized land use planning, including forest development …" 'Forest development' means LOGGING and specifically the Clack Creek Forest (A93884). The contentious forest blocks (one of which is the Clack Creek Forest) that triggered this Land Use Plan are the very ones that the province, through BC Timber Sales, are targeting for logging before planning has even begun! The SCRD supports protection of Clack Creek Gallery Forest (A93884), here's why you should as well...
Protect the Dakota Bowl Bear Sanctuary
Home to some of the oldest trees in Canada. This forest is a 'time capsule' of natural and cultural features including at least 33 Culturally Modified trees. Logging these forests will destroy one of the best bear habitats on the Coast.
On the slopes rising above Dakota Creek (lower Sunshine Coast) a population of black bears (Ursus americanus) has found a sanctuary – safe from human disturbance. However, BC Timbers Sales (BCTS) is planning on logging 50.4Ha, or 124.5 acres of this forest, where dozens of bear den sites would be destroyed. Loss of this special habitat will displace these bears and drive them into human-conflict zones. Logging these old-growth forests would be a tragic loss to the Sunshine Coast. Dakota Bowl Bear Sanctuary is on traditional Squamish 1st Nation territory. The Sunshine Coast Regional District opposes logging in The Dakota Bowl Community Watershed. Find out more...
Save 'the Chanterelle Forest' (LOST January 2018)
'The Chanterelle Forest', in the already heavily logged Wilson Creek Watershed, is threatened with clear-cut logging by Sunshine Coast Community Forest (SCCF), Block EW028. SCCF is a logging company owned and operated by the Town of Sechelt. This low-elevation forest is currently surrounded by Falling Boundary Tape setting the stage for its destruction. Logging would wipe out another easily accessible mushroom harvesting site on the Sunshine Coast. This natural forest system features Old-Growth Douglas-fir 'vets', elk and bear trails, wildlife trees, and ideal growing conditions for a variety of fungi and lichen, including Chanterelles, Pines and Coastal Reindeer lichen. This forest supports mushroom pickers with a seasonal cash crop. It lies within the traditional territory of the shishalh Nation, and portions of it within the proposed Mt. Elphinstone Prov. Park expansion area. 'Take Action' Today - Click Here
Help Protect 'The Twist and Shout Forest' (LOST - October 2016)
A key section of the the Mt. Elphinstone Provincial Park expansion zone is under threat to clearcut logging. BC Timber Sales Blk A87125 threatens to log an intact, multi-story forest between two existing former cutblocks, thus adding to fragmentation across this fragile landscape. The forest type is recorded as Blue-Listed on the Provincial Endangered Species (Flora) List, and yet does not obtain any special considerations for protection. Take a walk along the ELF trail that meanders through this older forest, and you'll feel like you're in Stanley Park as you walk under the towering Douglas-Fir trees. Please, 'Take Action' today by contacting the BCTS decision-makers found on the campaign page. This forest is on traditional Skwxwu7mesh (Squamish) lands. (Photo Credit - Thanks to Shel Neufeld)
'Take Action' Today - Click Here
A Conservation Review Of The Elphinstone Prov. Park Expansion Proposal
Wayne McCrory – one of Canada's leading conservation-biologists, has completed an ecological review of the 2,000Ha lower Elphinstone forests that is the subject of a park expansion & protection area. Wayne conducted field studies, compiled and analysed existing data and has now completed a break-through report on our Elphinstone forest. He makes a compelling case for protection of this lower elevation, emerging old-growth forest. To avoid creating 'islands of extinction' due to having 3 isolated park zones as is the present case, McCrory's recommendation is to secure a 2,000Ha zone that will provide adequate buffer zones for the 3 park parcels, and in doing so help to maintain the viability of this blue-listed ecosystem.
Protect Roberts Creek Headwaters Ancient Forest (SAVED - October 2013)
On the northwest slopes of Mt. Elphinstone, in Squamish Nation's traditional lands, this forest lies between 2 Wildlife Habitat Areas (WHA) and is the home of 1000+ year old endangered 'Ancient' yellow cedar trees, the endangered Marbled Murrelet, the black bear and countless other animals and species. In addition to destroying these highly prized values, clearcut logging now scheduled, would split this WHA in half and pose a high risk to downstream fisheries and water users on the lower reaches of Roberts Creek. Sunshine Coast residents and all concerned citizens must now act quickly to save this forest before it is too late. Home of many of the 'Oldest Trees in Canada' these forests are truly living monuments to the past, present and future and therefore should go into a special category of 'Ancient Forests' and be preserved forever.
Press Release – AJB/SURESPAN CONTINUES LOGGING IN THE CHAPMAN DRINKING WATERSHED
AJB/SURESPAN CONTINUES LOGGING IN THE CHAPMAN DRINKING WATERSHED ELF Press Release Chapman Watershed Logging Continues April '18 Click below for Background and Campaign Page: http://www.loggingfocus.org/protect-the-chapman-creek-drinking-watershed/
The Day Road Forest is Threatened – AGAIN
Neighbourhoods of Roberts Creek are once again faced with the awful prospect of clear-cut logging adjacent to their properties. Residents living in the Locker, Grauman and Day Rd areas have been embattled with large swaths of forests emptied out of their trees by Island Timberlands (IT) based in Nanaimo. Now, it appears that IT is […]
FPB Report – ELF Press Release – Elphinstone Plant Communities at Risk From Logging
ELF Press Release FPB report on Elphinstone (sent to Ministers) (1) Read the full report at the link below: IRC212-Elphinstone See also the Twist and Shout Campaign Campaign page located under Campaigns. http://www.loggingfocus.org/campaigns/protect-the-twist-and-shout-forest/
FPB Report concludes that 'The Twist Shout Forest' should have been protected
Forest Practices Board Report – Managing At-Risk Plant Communities Near Mount Elphinstone Park concludes that 'The Twist Shout Forest' (BCTS Timber Sale Block A87125) should have been protected. Read the full report at the link below: IRC212-Elphinstone See also the Twist and Shout Campaign Campaign page located under Campaigns. http://www.loggingfocus.org/campaigns/protect-the-twist-and-shout-forest/
CBC News – Logging injunction to be lifted
Logging injunction to be lifted in forest popular with mushroom pickers Work in Sunshine Coast cut block will be permitted as of Jan. 25, anti-logging activist says By Bethany Lindsay, CBC News Posted: Jan 18, 2018 1:02 PM PT Last Updated: Jan 18, 2018 1:12 PM PT http://www.cbc.ca/news/canada/british-columbia/logging-injunction-to-be-lifted-in-forest-popular-with-mushroom-pickers-1.4493656 To view the Campaign page for full details Click Here: Protect […]
Injunction Lifted -Letter to DoS REQUEST FOR STOP WORK EW28
Injunction Lifted January 15, 2018 Letter to DoS REQUEST FOR STOP WORK EW28
BECOME AN ELF "FOREST DEFENDER" TODAY BY DONATING EVERY MONTH! WHEN YOU CONTRIBUTE MONTHLY THEN ELF CAN SECURE A YEARLY BUDGET. CONTRIBUTE AS LOW AS $10/PER MONTH. SUGGESTED ONE-TIME DONATIONS OF $50-$100.>>>>>Should you have a larger gift you would like to discuss, please contact us at: email@example.com <<<<<
Help Protect the Last of the Old Growth and Natural Mt. Elphinstone Forests!
Sign up today to get the latest News and Updates.
Recent Posts
- BC Timber Sales logging of Schmidt Creek old-growth imperils orca habitat
- Video – 1000 Hearts for Clack Creek Forest
- BC Timber Sales Preparing Dakota Valley for Extensive Old-Growth Logging
- ELF 2018 End of Year Report
- Letter to the SCRD Chapman Drinking Watershed slash burn (video clip)
- Elphinstone Park Expansion Campaign Continues
- ELF Alert News: Community Forests Engagement Process (July 9 &10)
- What's wrong with the Sunshine Coast Community Forest?
- A Community Forest for the Community
- Sample Letter to BCTS Opposing Blk A93884 ( Clack Creek Gallery Forest) Auction
- Press Release – AJB/SURESPAN CONTINUES LOGGING IN THE CHAPMAN DRINKING WATERSHED
- The Day Road Forest is Threatened – AGAIN
- FPB Report – ELF Press Release – Elphinstone Plant Communities at Risk From Logging


text:
Video: Rivalry heats up between former team mates Ainslie and Spithill
by Philip Reynolds
In a story that is as old as sport itself, the closest of team-mates are now the greatest of rivals.
This will certainly be the case in the seas off Hampshire next week as British Olympic hero Sir Ben Ainslie and his home-based Land Rover BAR team start the long journey to win the America's Cup for Britain for the first time in its history when they line up against Jimmy Spithill and his Oracle Team USA.
Australian Spithill has led Oracle Team USA to two consecutive cup victories, most famously including a n amazing comeback against Emirates Team New Zealand in 2013 in San Francisco Bay with Ainslie as a team-mate.
Now, one week ahead of the first races of the Louis Vuitton America's Cup World Series –the 35th America's Cup cycle - the two fierce competitors are squaring up and rivalries are being stoked.
Spithill, whilst acknowledging Ainslie's sailing pedigree, said that his winning track record was all as a single-handed sailor. "Playing the skipper in a big team; that's a big challenge for him."
However, he welcomed the challenge, describing it as "awesome competition" and saying: "It is about time there has been a team from the UK. And what better time for Ben and the team he has assembled than now?"
Ainslie dismissed Spithill's single-handed gibe saying that he had spent a large part of his career being part of America's Cup teams and knew how to build a successful team.
Despite the rivalry the mutual respect is also evident.
Spithill said: "Ben is a really good guy. You meet him on the shore and he's very courteous, well mannered. On the water though, you flick a switch. He becomes very, very aggressive and he gets the results."
Ainslie is equally full of admiration for Spithill describing him as "a machine".
"I sailed with him in the last cup and I was incredibly impressed with how he dealt with being on the back foot, never dropping his head, always believing he could win."
A seam of determination runs through both men but Ainslie has been clear in his determination to bring the cup to Britain.
"The America's Cup started here in 1851. We've had a few shots over the past 164 years but we've never come that close to winning. It's important to us to get that job done now…
"We want to beat Oracle Team USA. No doubt they're going to be right up there and very, very tough to beat. But we think we have a good shot at it and we'll have a bit of home crowd advantage."
Amidst all this talk of the UK-US rivalry, it should not be forgotten that there are four other teams taking part that may well have a say in proceedings.
Emirates Team New Zealand has turned over its race crew to a younger generation, with Peter Burling taking the helm. The first winner of the Red Bull Youth America's Cup is on fire with an unprecedented string of victories in the 49er class as he simultaneously campaigns for the 2016 Olympic Games.
The man he replaced, Dean Barker, didn't sit on the sidelines for long. Barker bounced back as the CEO and skipper of SoftBank Team Japan, making its America's Cup debut in Portsmouth.
Artemis Racing will be led by Nathan Outteridge, who turned heads in the last America's Cup for his ability to coolly step into his first America's Cup campaign and assume a leadership role. An Olympic gold medallist, Outteridge is far from unique on an Artemis Racing team stocked with medal-winning sailors.
And Groupama Team France will be flying with Franck Cammas, the French multihull veteran who has won every race, and broken every record, he has set his mind to. Will the America's Cup be next?


text:
Vision, Mission & Values
Our associates understand that our corporate values are more than just words in print. As an organization, we strive to make sure every experience you have with us aligns with our vision, mission and values.
To become the preeminent risk management organization in the areas of property, casualty and health through heroic customer service.
To provide holistic service to clients and community to improve and protect people's lives.
To employ great people and provide them the opportunity to actualize their individual potential.
- Provide heroic customer service
- Act with integrity and ethics
- Question things constructively
- Be an empowered thinker
- Be passionate about your life and your work
- Be a great listener and be responsive
- Put a smile on someone's face
- Celebrate accomplishments
- Demonstrate compassion for others
- Own it
- Help someone else succeed
"Working with Poms has been an awesome experience. They have saved me and my employer time and money with their prompt response, strategic marketing of our needs to plan providers, ease of transition to new providers and excellent customer service."
Sherri Paniagua
Human Resources Manager, Las Virgenes Municipal Water District, Calabasas, CA
The 5 Pillars of Risk Control
Whatever kind of business you run, there are bound to be at least a few risks involved. Learning how to control those risks not only keeps customers and employees safe, but also benefits your bottom line.
Learn five techniques for controlling risk in your company by downloading your free copy of "The 5 Pillars of Risk Control" today.


text:
Lena Reynolds
Lena Guerrero Reynolds is working on a Masters in Museum and Exhibition Studies at UIC, with concentrations in Gender & Women's Studies and History. She developed a passion for history growing up in Chicago, exploring the rich stories of every neighborhood block. After a bachelors in history from Urbana, and a study abroad adventure to Paris, she returned to Chicago in 2010. She volunteered at the Chicago History Museum for two years, doing activities with elementary students and engaging with visitors in the groundbreaking Out in Chicago exhibit. Moving to the Jane Addams Hull-House Museum, she worked as a Museum Educator for two years, creating unique programming for all ages and establishing the museum's Gender and Sexuality Tour. Starting school in fall of 2014, Lena became a Graduate Assistant for the Latino Cultual Center on campus. She's enjoyed building tours and programs around the monumental indoor mural, El Despertar de las Americas by Hector Duarte, and igniting cross-cultural understanding through civic dialogue. She believes in the power of cultural spaces to entertain, educate, and challenge our communities to build a more just society.
Courses Taught