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Welcome to The Sunday Post, a weekly meme hosted by Kim the Caffeinated Book Reviewer. Grab a cuppa and let me bend your ear (eyes?) for a few minutes with my bookish news. This week I've calling reset time in my life.
Between My Sundays – what happened this week
Reset Time
I had an a-ha moment during the week, where I realised I just wasn't happy with myself. And it was a major call to reset my life. It's mostly related to my weight, for years I had it under control. But ever since I broke my humorous, the weight has piled on. Even though the injury is now a bad memory, and a low grade pain in my arm at times, it has continued to affect me.
Although in truth that break was literally the straw that broke the camels back. I had survived our heartbreaking miscarriage, which was our last chance to have a baby. Then my brother's death. And my Dad going blind. But breaking my humorous broke something within me.
During that time, to numb the horrendous pain, I comfort ate. Now that I was forced to sit, as I literally couldn't move for a few weeks, I had to finally grieve everything that had happened in the run up to that. So I comfort ate. Same all the way through physio, I pushed and pushed through the pain with great results. But I numbed the physical pain with food.
And then I was back in old patterns, and never stopped. Until now. I'm back, I feel strong, I feel ready to tackle that unwanted weight. I had been fooling myself that I was exercising loads, so those extra treats didn't matter. Deep down I knew better. But maybe it was what I had to do at that time. It's just weight, I know what I need to do. And no better woman to grit her teeth and go for it!
So it's reset time. And as my 50th birthday is next year, I've started Operation Fit Fab and Fifty. I plan to be in a much healthier body by the time that day rolls round. Somehow the time is right now, and I feel excited to bring myself back.
What happened on Between My Lines:
- [20 Apr] The Argument by Victoria Jenkins ★★½
- [20 Apr] End Game by Anna Smith ★★★★
- [20 Apr] Rewind by Catherine Ryan Howard ★★★★
- [21 Apr] Top Ten Tuesday : Titles That Would Make Good Band Names
What happened in the blogosphere:Check out some of my favourite #bookblogger posts this week, lots of lovely #bookdiscussions and bookish musings! Click To Tweet
- Of Wonderland displays her fab collection of Tarot Cards
- The Emerald City Book Review wonders Do you like books about fighting?
- Curiouser and Curiouser shares 5 Bad Reading Habits that she has.
Books I have received to review:
None this week. No harm. I've 18 NetGalleys to read and review, and some physical books too. I'm really looking forward to catching up with myself a bit.
Purchased Books
- I had to buy the final 2 book's in Katie McGarry's Thunder Road series, because once I started, I gobbled them up. What a fab romantic and edgy young adult series. Gossip Girl meets Sons of Anarchy!
- Conviction was 99p on Amazon and sounded great. What a tagline! Plus it's a Reese Witherspoon, Hello Sunshine bookclub pick, and I always enjoy those.
- I saw a great review for Up to the Pointe on a blog. Can't for the life of me remember where, but I love dance books. So I one-clicked straight away.
Library Haul:
No new library books this week.
Calling that a wrap on this week. Happy Reading to all.


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Bew Cocky Salsa
Tuesday September 29th, 2015 with Tim Anderson
Track 01 [Part 01]
Nothing starts an album off quite like a killer Track 01, and that's what tonight is all about! In part one of a two part series, Tim is bringing you some of his favourite opening tracks from some of his favourite albums. In step with the grey day we're having, Track 01 [Part 01] has a more chilled-out & subdued vibe, but worry not - if you're looking to tap your foot, nod your head, and bust a move or two, [Part 02] will be all about the upbeat tracks.
|Your Ex-Lover Is Dead
Stars - Set Yourself on Fire
|Caring is Creepy [Albequerque
The Shins - Oh, Inverted World
Kings of Leon - Only By the Night
|Everybody Knows It's Gonna Happen, Only Not Tonight
The Go Find - Everybody Knows It's Gonna Happen, Only Not Tonight
|Humble Peasants
The Most Serene Republic - Population
|Our Faces Split the Coast in Half
Broken Social Scene - Broken Social Scene
|Spit on a Stranger
Pavement - Terror Twilight
Feist - Let it Die
|Losin' You
Amy Milan - Honey From the Tombs
|Blowin' in the Wind
Bob Dylan - The Freewheelin' Bob Dylan
Laura Marling - Alas I Cannot Swim
|20 Years
The Civil Wars - Barton Hollow
|Wide Eyes
Hayden - Elk Lake Serenade
|Sigh No More
Mumford and Sons - Sigh No More
|Marching Bands of Manhattan
Death Cab for Cutie - Plans

subset: commoncrawl


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COMMON LAW Common law - is law developed by judges through their decisions in court. In other words, "judge-made" law. Common law is also known as CASE LAW or PRECEDENT. It is different from a statute, as statutes are passed and adopted through the legislative process (by the legislative branch).
The Superior Courts! The Supreme Court and the Court of Appeals are known as Superior Courts because the reasons for the decisions in the court cases that come before them are recorded for future reference. It is these courts which create common law.
Decisions, made by Higher Courts, will be binding on lower courts in the same hierarchy.
In other words, lower courts, in the same hierarchy, must apply the same reasons for decisions, when dealing with similar cases, as those applied by higher courts , in earlier decisions. This principle is called 'Stare Decisis' . This means literally 'to stand by what has been decided' and it is at the heart of the doctrine of precedent. In order for the doctrine of precedent to work there needs to be a court hierarchy (an order of importance) from the most superior to inferior courts.
YES! Judges and courts can only make law if: - a case is brought before them - If there is no previous binding decision already established by a higher court in the same hierarchy (novel case)
Role of the Courts in Law-making
Doctrine of Precedent
Doctrine of Precedent The judges look at past decisions to guide them; they look at the reasons behind the decision in past cases for guidance when deciding new cases. When a new situation arises and is decided on a precedent is created. What is a precedent? A precedent is the reasoning behind a court decision that establishes a principle or rule of law that must be followed by other courts lower in the same court hierarchy when deciding future cases that are similar.
The main reasons for applying precedent is to create consistency and predictability within the legal system, as like cases are decided in a like manner. This in turn gives us confidence in our legal system and we feel justice is being done.
Precedent is the reason for the decision.
Precedents can only be made when a judge alone is hearing a case. The Judge makes the decision and gives the reasons for that decision; the reason for the decision is then binding on lower courts in the same hierarchy. For this reason precedent is usually made by courts which hear appeals (as there is no jury – i.e. the Court of Appeal and the Supreme Court). A jury decision cannot create a precedent as juries do not give reasons for their decisions.
Lesson 2 Quick Revision of last lesson:
What does 'stare decisis' mean? What is precedent? Why do we need a hierarchy for precedent to exist? What are the advantages of precedent? What are the two ways that judges make law? Which Courts can make common law and why?
1. What does stare decisis mean?
Stare Decisis - literally means to stand by what has been decided; the process of lower courts following the decision of higher courts
2. What is precedent? Precedent is the reasoning behind a judge's decision that establishes a principle or rule of law that must be followed by other courts lower in the same court hierarchy when deciding future cases that are similar
3. Why do we need a hierarchy for precedent to exist?
So decisions of the Higher (superior) courts in the hierarchy, can be followed by lower (inferior) courts.
4. What are the advantages of precedent?
Precedent creates consistency and predictability within the legal system, as like cases are decided in a like manner. This in turn gives us confidence in our legal system and we feel justice is being done.
5. What are the two ways that judges make law?
When they are deciding on a new issue (novel case) brought before them or when a previous principle of law requires expansion to apply to a new situation. Statutory interpretation- interpreting the words in acts of parliament.
8. Which Courts can make common law and why?
The Supreme Court and Court of Appeal only can make law. These courts record the judgments of courts at the end of a case, and it is in the judgment that the ratio decidendi is stated.
Overruling a precedent
When a superior court decides not to follow an earlier precedent established by a lower court in a different case, but with similar material facts. The superior court will overrule the previous precedent. It can do this because it is not bound by precedents created in lower courts. When a precedent is overruled, the latest case becomes the precedent to follow in the future. New precedent is set. NO
Disapproving: Two different cases. When a court disapproves a precedent established by another court at the same level, then a new precedent is established. Both precedents remain in force until another case on the issue is taken to a higher court can overrule the previous decision and create a new precedent. In the case of a lower court disapproving of a precedent established by a higher court in the same hierarchy, then the original precedent is followed, but reluctantly. All the judge can do is apply the old precedent, but in their obiter comments explain their disapproval of the precedent.
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Sudan's annual inflation climbs to 68.64 pct in Sept. – statistics agency
Khartoum,October 13, 2018,(AltAfrica) – Sudan's inflation edged up to 68.64 percent in September year-on-year, from 66.82 percent in August, the state statistics agency said on Thursday.
Inflation jumped to more than 50 percent in January, when subsidy cuts triggered food price increases that kindled unrest. Since then inflation has continued to accelerates steadily despite attempts to slow price rises with strict limits on cash withdrawals.


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Skiarena Andermatt-SedrunClosed
Skiarena Andermatt-Sedrun Photos
Browse through our collection of Skiarena Andermatt-Sedrun photos to get acquainted with it before your ski trip or to relive great memories on the slopes. See all Skiarena Andermatt-Sedrun photos below.
Best Skiarena Andermatt-Sedrun Hotels
Latest News
Ski Switzerland despite the Franc
Tips from experts in the industry on how to make Swiss ski holidays more affordable.
Ski and snowboard enthusiasts from around the world:
We have been proud to provide you with free access to snow reports, resort guides and more, and we are beyond grateful for your readership and contributions to our community over the years.
Unfortunately given the changing media landscape, Mountain News Corporation has experienced financial declines in recent years. With additional economic challenges from the COVID-19 pandemic now facing our business, it is not financially viable to continue operating.
Mountain News Corporation and our OnTheSnow and Skiinfo websites will be shutting down. We will explore the possibility of selling, partnering, or contributing assets to another media outlet if there is an opportunity to allow for a consistent or enhanced online experience. For inquiries about Mountain News Corporation, please email email@example.com.
We want to thank our loyal employees for their tireless work over the years to bring great information to all of you. We take comfort knowing that our collective passion for the sport of skiing and snowboarding will certainly live on.
We'll see you on the mountain.
– Mountain News Corporation


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I am making a start today with this record of my diet and joint pain symptoms to see if there is any correlation. I will not record drinks, I drink black or herb/spice teas, no coffee while on the protocol : (
Breakfast – swede and onion hash with bacon (above)
Mid morning snack – a blood orange
Lunch – Leftover turkey with gravy, carrots, swede, butter nut squash and pork stuffing
Snack – pineapple and 4 dried apricots
Dinner – Thai yellow curry (home-made paste) with turkey, carrots, mange-tout and broccoli (above). I then ate a packet of coconut cream concentrate.
In the morning my foot pain was moderate and in the afternoon my knee pain started to increase a little. No pain in any other joints.


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We accept deposits in any currency. Player accounts are tracked in US dollars so deposits made in currencies other than US dollars will be converted at the current bank exchange rate. Deposit Methods for American & International Players:
1. Credit Cards
2. Prepaid Reloadable & Gift Cards
As deposit options are continually changing, be sure to check the casino cashier for a complete list of all available options.
1. NETELLER - PREFERRED METHOD (**) Not available for US, Canada, UK, Brazil and Australia.
Please click on any of the above deposit methods for additional information including benefits, how to register and use the method, and additional bonuses you are eligible for when using preferred methods.
For further assistance and information regarding any of our deposit methods, please contact our Deposit Options Department anytime by email [email protected], chat or toll free phone number.
Please expect withdrawals to take between 5-7 business days to process. It is very important to us that we meet or exceed your expectations. For this reason we need you to understand ahead of time that regulatory changes in the marketplace have limited the availability of deposit and withdrawal methods and have increased the time required to process withdrawals.
We value your business and will do everything we can to offer as many deposit and withdrawal options as possible and to keep the time it takes to process withdrawals to a minimum. Please expect withdrawals to take approximately 2 weeks to process.
It is very important that you add [email protected] , [email protected] and [email protected] to your safe list to ensure that you receive important email notifications regarding your account and any payouts being made to you. All correspondence from us will be sent from these email addresses to the email address that you have provided for your account. Thank you.
All of our transactions use SSL security layer for added security.
Please Take Note!
1. We reserve the right to request documentation prior to authorizing any withdrawal request, to verify the authenticity of the credit card information and/or the identification of the player. Any delays in providing documents will result in cashout delays. For further details on the documents that may be required please contact our Security Department at [email protected]
2. Minimum withdrawal amount is $150.00 and the maximum amount per withdrawal event is $2,000.00 per week unless otherwise stated for specific cases, depending on the player's class. This maximum withdrawal amount may also vary depending on the policies/limitations imposed by the third party payouts provider, through which payments are sent. Withdrawal requests are usually received within 48 hours, after which it takes a minimum of 5 to 7 business days to be evaluated. All payouts exceeding $2,000.00 will be paid out via installments not exceeding the maximum per week.
3. All payouts are in US Dollars. For your convenience, we offer the following methods for cashing out:
Neteller - Where available
ACH - for USA Players Only
Certified Money Orders - Worldwide except USA
Checks via Regular Mail or Courier - Worldwide.
|PlaYER CLASS
'Faxback Form' is an authorization form and is required in order to process your withdrawal.
Faxback Form PDF version
You are reminded to print out all transaction data, the rules of the game, the cancellation regulations, and the payment methods in order to avoid misconceptions and discussions at a later time.
Also take note that any player that deposits and requests a withdrawal without having wagered AT LEAST 5 times the amount deposited will be charged processing fees in accordance with the deposit method used. Fees vary depending on the deposit method and those methods that can not be electronically refunded by us will have delivery fees that also vary depending on destination and delivery method.
Please be aware that cancelled withdrawals do not apply towards promotional offers.
Also take note that any person that makes a deposit, and does not make any wagers with the deposit before requesting a withdrawal, will be subject to pay for the processing fees which will vary, depending on the deposit.
All pending withdrawals will be placed ON HOLD until every single deposit with clearance period that the player has used is switched to status cleared and verifiable via online back ends. These methods include, eCheck.
Please make sure your physical address is current and accurate at all times. Should you request to be paid via ACH then your banking details must also be current and accurate al all times. Please email the Finance Department should any of the above details require update prior to posting your withdrawal request.
Las Vegas USA strives to provide a safe environment for our players. We are GLI Certified to give players the best quality playing experience, and all transactions and activities are fully encrypted.
Las Vegas USA offers the players a secure gaming environment so they can enjoy the online casino experience without worrying about collecting rewards quickly and easily.
Las Vegas USA Casino offers 24/7 customer support, which means that any questions or concerns players have while playing on our online casino for can be answered and resolved ASAP.
With the best casino games on the web, out of this world online casino bonuses, a stellar VIP program and so much more, Las Vegas USA Casino is the ultimate online gaming experience.


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Thackeray blames it on 'influx of migrants' in maximum city
A day after 22 people were killed in a stampede at Elphinstone railway station
A day after 22 people were killed in a stampede at Elphinstone railway station, Maharashtra Navnirman Sena chief Raj Thackeray said that such incidents will continue to occur in Mumbai till hordes of migrants keep pouring into the city. He also warned that "not a single brick will be allowed to be placed for the bullet train in Mumbai" until the infrastructure of local railways was made better. The MNS leader, who has in the past stoked controversies with his anti-migrant rhetoric, told reporters at his residence Krishna Kunj in Dadar, "There has been a collapse of infrastructure facilities due to the migrant influx from other regions."
Saying that he travelled in Mumbai suburban trains for two years while studying arts at the Sir J J College in Mumbai, Mr. Thackeray said, "What you call the famed spirit of Mumbai which overcomes such tragedies is actually hopelessness in face of such calamities." On Friday, a stampede on a narrow foot overbridge at the Elphinstone railway station during the rush hour had led to deaths of at least 22 people and injuries to 30.


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2nd Assistant Production Accountant (Animation)
Accounting / Management control
Job description
Netflix is the world's leading streaming entertainment service with over 167 million paid memberships in over 190 countries enjoying TV series, documentaries and feature films across a wide variety of genres and languages. Members can watch as much as they want, anytime, anywhere, on any internet-connected screen. Members can play, pause and resume watching, all without commercials or commitments. The 2nd Assistant Production Accountant position for Feature Film and Series Animation will be based in our Hollywood Office and be a key strategic partner with the Production Accountant in the execution of the production plans and show budgets that represent the creative vision of the film makers. They will be instrumental in maintaining accurate accounting records and adhering to accepted procedures for all production payments.
· Responsible for all production crew set-up, including EP SmartTime, vendor set-up and invoice processing.
· Communicate between production, vendors, employees, corporate accounting and unions
· Support Production Accountant as needed to maintain the accuracy of the production's general ledge.
· Investigate and resolve open issues with payables, payroll, etc.


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These cookies are required for basic site functionality and are therefore always enabled. These include cookies that allow you to be remembered as you explore the site within a single session or, if you request, from session to session. They help to make the bag and checkout process possible as well as assisting in security issues and conforming to regulations.
These cookies allow us to improve the site's functionality by tracking usage on the website. In some cases these cookies can improve the speed with which we can process your request as they allow us to remember site preferences that you've selected. De-selecting these cookies may result in poorly-tailored recommendations and slow site performance.
Social media cookies offer the possibility to connect you to your social networks and share content from our website through social media. Advertising cookies (of third parties) collect information to help better tailor advertising to your interests, both within and beyond Nike websites. In some cases, these cookies involve the processing of your personal data. For more information about this processing of personal data, check our Privacy & Cookie Policy. De-selecting these cookies may result in seeing advertising that is not as relevant to you or you not being able to link effectively with Facebook, Twitter, or other social networks and/or not allowing you to share content on social media.
A tech-inspired update to classic joggers, the Nike Sportswear Tech Fleece Trousers provide lightweight warmth and a relaxed fit for extra comfort.
A tech-inspired update to classic joggers, the Nike Sportswear Tech Fleece Trousers provide lightweight warmth and a relaxed fit for extra comfort.
Product Details
Free standard delivery on orders over SAR 900.
4.6 Stars
KaylaV557467534 - 22 Jul 2020
Very comfortable and stylish. Making a pair of grey sweats look good. High Waisted too, or maybe because I'm short. I am 5' 3" & 120LB, Athletic Build. I ordered a SMALL. I like the loose fit in my legs, thou I have a small waist, the waist band does fit loose. It has a drawstring so I can get by with tightening and tying the waistband. Maybe a XS would have fit, but I did not want my legs to feel like I was wearing tight fitted sweats. Other than that, these have become my favorite sweats to wear!
I like comfort
S H. - 15 Jul 2020
I purchased 2 pair and love them. I am 5'6" 185 and wear a medium. They are comfortable and run just right for me.
I love it
MarcellSM215634126 - 11 Jul 2020
Hello to everyone and I love my new Nike Sportswear Tech Fleece I buy the color grey and the size XS small I'm tall and very skinny legs,and it runs Big but it looks great I like the fit when when I'm traveling where is cold weather it perfect once again Thank you so much guys for all of my Orders I love them so much


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Thank you, my God!
I will celebrate your love forever.
How quickly the years of Love and Service, pass. I have many things to be thankful for – my Family, my Dominican Family, my many Relatives and countless Friends who have supported me all these years.
I was born January 9, 1927 in Española, New Mexico to Henry and Adelaide Salazar. I am the third oldest of eight children, four boys and four girls.
My education from grades one to twelve was in the Public School. I met Grand Rapids Dominican Sisters at Religious Education classes and this led me to decide to enter the convent when I was eighteen years old.
After attending Aquinas College I began my teaching ministry in Michigan and New Mexico. I spent 32 years teaching in grades K through 8. What means most to me in my Dominican vocation is the gift to be able to reach out and touch the hearts of the very young. My 29 years in pastoral work at Sacred Heart Parish in Grand Rapids brought out another gift of being present and sharing joy and faith with the elderly and ill of the parish.
I bask in the knowledge that I am personally and deeply loved by our God who fills me with great happiness and has given me tremendous energy to put my faith and love into practice.
Pray for religious vocations
Sister Marie Bernarde greets Grand Rapids Diocese Bishop Walkowiak during a visit at Aquinata Hall.
Sister Marie Bernarde thoughtfully contributes to Congregation business.


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Sign In
Water Curtain Booths
Established in 1992 , EXTREME MACHINE HIGH TECH (P) LTD. has made a name for itself in the list of top service providers of Coating Machine in India. EXTREME MACHINE HIGH TECH (P) LTD. is listed in Trade India's list of verified companies offering wide array of Water Curtain Booths, Powder Coating Machine, Optimum Performance Powder Coating Machines etc. Contact here for Coating Machine in Faridabad, Haryana.


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Mike and Jake talk about Breath of the Wild's minor pitfalls, and whether it serves as a good introduction to the rest of the Zelda series. by Jacob Dekker and Mike Mahardy on March 19, 2017. Upvote (3); Leave Blank. View Comments (2). Share. Log in or …
Who's the Ugliest NPC in Zelda: Breath of the Wild?Twinfinite
American designer credited in 'Breath of the wild' accomplished his decade-old dreamDigital Trends
How The World Of Hyrule In Breath of the Wild Has Changed Since The Game Awards 2014Siliconera
Game Rant -The Star Online -Kotaku Australia -GearNuke
all 68 news articles …read more
Is Breath of the Wild a Good Introduction to the Zelda Series? – Reboot Episode 2.5 – GameSpot


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Import:Mr. Vile
From Rare WikiJump to navigationJump to search
Mr. Vile is a red crocodile from Banjo-Kazooie and he proclaims himself to be the greediest crocodile of all. He lives in the belly of another, much larger crocodile, which can only be entered if Banjo turns himself into a crocodile with Mumbo Jumbo's magic and enters one of its nostrils. Vile challenges Banjo to three eating contests, with each one harder than the last. If Banjo wins all three, Vile will reward him with a Jiggy. But if Banjo loses one game, Vile will bite him and deplete one honeycomb. If Banjo will take a rematch after his win, he can win three Extra Lives or lose a life.


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Tuxedo Sequin Corset
0 reviews
Sequin tuxedo corset.
This item is proudly designed and manufactured by Leg Avenue.
- Item #1001134
- Sizes: Small, Medium, Large
- Colors: Black
- Designed by Leg Avenue
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Substantiating Feedback
An important emphasis of current evaluation practice is being able to "back up" or substantiate the ratings and feedback you provide.
How do I plan for substantiating evaluation feedback?
As you work through the SPEF-R©, customising the item examples, it is the perfect time to plan how to substantiate your evaluations. Consider the type of information you will need to support your evaluation of your student's performance.
Ask yourself
- What will I be looking for here?
- How could the student demonstrate this knowledge/behaviour/skill?
You may be able to
- observe the behaviour directly
- ask your student questions to gauge understanding/extent of knowledge/reflection-on-practice
- view written reflections
- read documentation
- request more formal presentation of information
Note ideas down so that you can let your student know what you will be looking for. If you have room record them on the evaluation form with your customised item examples. Alternatively record them on a separate piece of paper so that your student will be able to have a copy.
Develop a plan of how you will record specific examples of your student's practice. Many practice educators get into the habit of noting key examples in their diary or in a separate notebook. It is important to do this as soon after the event as you are able so that pertinent details are recorded accurately. Developing this practice can save you time when it comes to completing the evaluation as you will have all the information you need at your fingertips! It also underpins sound evaluation practice - You will have relevant information documented to corroborate the ratings and feedback you provide.


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Dui Sentences
THE FOLLOWING SENTENCES for driving under the influence of intoxicating liquor occurred during the period of June 13 to July 18. The listings include the offender's name, age, residence and charges. First offenders undergo a 14-hour alcohol abuse rehabilitation program, a substance abuse evaluation and a one-year license suspension with the ability to operate a vehicle if qualified for an ignition interlock device.
Wailuku District Court:
Kholby Akuna, 20, Wailuku; DUI, no insurance, driving without a license; 10-day jail term, $1,500 fine, $437 in fees.
Anthony Gilsog, 26, Kihei; DUI; five-day jail term, $500 fine, plus fees.
Jason Mendoza, 37, Wailuku; DUI; $150 fine, plus fees, 75 hours of community service.
Jeremy Tackett, 40, Wailuku; DUI; $250 fine, $437 in fees.
Jeffrey Takemoto, 58, Wailuku; DUI; $250 fine, plus fees.


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Catherine Tate's 'old dear' set to appear on the game show
Catherine Tate's Nan character is to make a guest appearance on Deal Or No Deal.
The OAP will face host Noel Edmonds in a sketch based on the hit Channel 4 show for Comic Relief.
A TV insider tells The Sun: 'The likeliest plot is that Nan will end up losing all the money with a rubbish box, before insulting Noel.
The presenter should expect a foul-mouthed tirade of abuse when that happens, then…


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Avani Gardens is a novel residential project developed by Avani Builders. This residential project is developed in 1.50 Acres. This residential project offers 2 and 3 BHK units. Total number of units available in this project is 115. There are 2 residential blocks in the project each towers of the blocks is well spaced so that each individual unit of the project will get best exposure to the natural sunlight and the breeze. The architecture of the residential blocks is designed such that residents can move around freely all over the campus. Avani Gardens, flaunting strategic location advantages can rightfully qualify as the next generation homes. Spread out amidst greenery and structured landscape, this complex comes equipped with some of the finest amenities and facilities that one can imagine of. This architectural marvel offers spacious and plush apartments that have well-appointed features that do not compromise with comfort. Away from the hustle-bustle of the city yet conveniently close to all social hot-spots, this residential township feels like a dream come true. Avani Gardens feels like a resort that is nestled in the lap of nature providing the much-needed calm and tranquility that one needs after a stressed day at work.
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High-Sensitivity Cardiac Troponin I Levels and Prediction of Heart FailureResults From the BiomarCaRE Consortium
Author + information
- Received September 10, 2019
- Revision received December 17, 2019
- Accepted December 17, 2019
- Published online April 27, 2020.
Article Versions
Author Information
- Isabell Yan, MDa,∗,
- Christin S. Börschel, MDa,b,∗,
- Johannes T. Neumann, MDa,b,
- Ngoc A. Sprünkera,
- Nataliya Makarovaa,b,
- Jukka Konttoc,
- Kari Kuulasmaa, PhDc,
- Veikko Salomaa, MD, PhDc,
- Christina Magnussen, MDa,b,
- Licia Iacoviello, MD, PhDd,e,
- Augusto Di Castelnuovo, PhD, MScf,
- Simona Costanzo, PhD, MScd,
- Allan Linneberg, MD, PhDg,h,
- Stefan Söderberg, MD, PhDi,
- Tanja Zeller, PhDa,b,
- Francisco M. Ojeda-Echevarria, PhDa,
- Stefan Blankenberg, MDa,b and
- Dirk Westermann, MDa,b,∗ (d.westermann{at}uke.de)
- aDepartment of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- bGerman Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
- cNational Institute for Health and Welfare, Helsinki, Finland
- dDepartment of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli, Italy
- eResearch Center in Epidemiology and Preventive Medicine, Department of Medicine and Surgery, University of Insubria, Varese, Italy
- fMediterranea Cardiocentro, Napoli, Italy
- gDepartment of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- hCenter for Clinical Research and Disease Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region, Copenhagen, Denmark
- iDepartment of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- ↵∗Address for correspondence:
Dr. Dirk Westermann, University Heart and Vascular Center Hamburg, Department of Cardiology, Martinistrasse 52, 20246 Hamburg, Germany.
Central Illustration
Objectives The aims of this study were to characterize the association of high-sensitivity cardiac troponin I (hs-cTnI) with heart failure (HF), to determine its predictive value beyond classical cardiovascular risk factors (CVRFs) and N-terminal pro–B-type natriuretic peptide, and to derive a relevant cutoff for potential clinical application.
Background HF is an important contributor to the overall burden of cardiovascular disease. Early identification of individuals at risk could be beneficial for preventive therapies.
Methods Based on the Biomarker for Cardiovascular Risk Assessment in Europe consortium, we analyzed individual-level data from 4 prospective population-based cohort studies including 48,455 individuals. Participants with myocardial infarction, HF, and stroke at baseline were excluded. We investigated the value of adding hs-cTnI to CVRFs and N-terminal pro–B-type natriuretic peptide using Cox proportional hazards survival models and for prediction by calculating C-statistics and Brier score.
Results The median age of the study population was 51 years, and the median follow-up time for occurrence of HF was 6.61 years. Cox regression models adjusted for age, sex, and CVRFs revealed a significant association of hs-cTnI with incident HF (hazard ratio: 1.42 per log [ng/l] unit change [95% confidence interval: 1.31 to 1.53]). The best predictive value was achieved in the model with CVRFs (base model) and both biomarkers (C-index = 0.862; 95% confidence interval: 0.841 to 0.882). Optimal hs-cTnI cutoff values of 2.6 ng/l for women and 4.2 ng/l for men were derived for selecting individuals at risk.
Conclusions In this large dataset from the general population, hs-cTnI could show its independence for the prognosis of HF.
- BiomarCaRE
- cardiovascular risk factors
- high-sensitivity cardiac troponin I
- N-terminal pro-B-type natriuretic peptide
- prediction of heart failure
Heart failure (HF) is one of the leading causes for morbidity and mortality in the Western population. The crude prevalence of HF is projected to increase by 25% over the next 20 years (1). Among middle-aged adults, the 10-year risk for new-onset HF is approximately 10% and even higher in older individuals (2). HF is diagnosed by its signs and symptoms, but imaging parameters are used to group patients in different HF subtypes based on ejection fraction (EF). Nevertheless, morbidity and mortality are similar for the different types (3). Treatment options for patients with reduced EF are improving, but in patients with only mildly reduced or preserved EF, no established therapy is available. This makes primary prevention of HF one of the unmet goals in HF research.
A biomarker-driven diagnostic approach could potentially allow early identification of individuals at risk for developing HF. To date, established markers for risk prediction of incident HF are limited and seldom used in clinical practice.
N-terminal pro–B-type natriuretic peptide (NT-proBNP) is widely applied in the diagnosis and prognosis assessment of HF (4). A potential use in the context of the prediction of incident HF has also been demonstrated (5). Besides NT-proBNP, troponin is the most established cardiac biomarker and is used as the gold standard to detect myocardial injury (6,7). Novel high-sensitivity cardiac troponin (hs-cTn) assays may even allow application as a prognostic biomarker because very low concentrations can be detected (8). There is first evidence that even these low hs-cTn concentrations show a graded and independent association with incident HF (9–11). Also, Evans et al. (12) showed the association in their study. However, the pathophysiology as well as the prognostic implications of increased hs-cTn concentrations are not yet completely understood. Besides, cutoff values have not been uniformly defined and are always assay specific.
To examine the association of high-sensitivity cardiac troponin I (hs-cTnI) with HF in the general population, we conducted an analysis of prospective cohort studies within the BiomarCaRE (Biomarkers for Cardiovascular Risk Assessment in Europe) consortium. The aims of this study were to characterize the association of hs-cTnI with incident HF, to determine its predictive value beyond classical cardiovascular risk factors (CVRFs) and NT-proBNP, and to derive a relevant cutoff for potential clinical application.
Study overview
The BiomarCaRE consortium is a European Union–funded consortium including 31 institutions. BiomarCaRE aims to determine the value of established and emerging biomarkers to improve risk prediction of cardiovascular disease in Europe. BiomarCaRE relies on large-scale epidemiological cohorts with long-term follow-up based on the population of the MORGAM (MONICA Risk, Genetics, Archiving and Monograph) project as well as several cardiovascular disease cohorts and clinical trials. All epidemiological and clinical phenotypes as well as disease outcomes have been harmonized in a database (13).
Study cohorts
Overall, the present analysis is based on the data of 4 population-based cohort studies from Denmark, Finland, Italy, and Sweden, in particular DanMONICA, FINRISK, Moli-sani, and Northern Sweden MONICA, comprising 48,455 individuals with 1,990 events of incident HF. The initial aim of the participating studies was to monitor risk factor levels in the population, keeping in mind that such health examination surveys would also create a valuable baseline for cohort studies.
In DanMONICA, 7,315 individuals were enrolled from 1982 to 1992 for examination with a median follow-up time of 24.06 years. A total of 7,702 participants from FINRISK were admitted in 1997 for examination with a median follow-up time of 13.84 years. Northern Sweden enrolled 10,259 individuals from 1986 to 2009 for examination with a median follow-up time of 12.85 years. At last, Moli-sani enrolled 23,179 individuals from 2005 to 2010 for examination with a median follow-up time of 4.3 years. All individuals included in this study were free of cardiovascular disease containing HF, myocardial infarction (MI), and stroke. Each study cohort is based on a well-defined population (Table 1). Cohort descriptions are provided in the Supplemental Appendix. All participating cohort studies were approved by local ethics committees; individuals provided written informed consent.
Definition of the endpoint
Each study center was asked to decide on the exact definition of HF for their cohorts. When routine clinical and death certificate diagnoses are used, the relevant International Classification of Diseases codes are usually as follows: International Classification of Diseases-8th Revision, 427.0, 427.1, and 428; International Classification of Diseases-9th Revision, 428; and International Classification of Diseases-10th Revision, I50 (HF), I11.0 (hypertensive heart disease with HF), I13.0 (hypertensive heart and renal disease with HF), and I13.2 (hypertensive heart and renal disease with both HF and renal failure), which were adjusted according to local coding practices. In all cohorts, the follow-up for HF was based on linkage with hospital stay and cause of death registers and in FINRISK also with the national drug reimbursement register. The codes actually used, often based on national modifications of International Classification of Diseases-Eighth Revision and International Classification of Diseases-9th Revision, are specified in the MORGAM e-publication (14).
Statistical methods
Missing data were handled by available case analyses; only those without missing values on the variables involved in that particular analysis were used. Continuous variables are presented as median (25th and 75th percentile) and binary variables as absolute and relative frequencies.
Survival curves for HF were computed according to the following pre-selected categories derived from the continuous hs-cTnI: low, <1.9 ng/l whereas 1.9 ng/l was the reported limit of detection of the Abbott assay; moderate, 1.9 ≤3.2 ng/l; and high, >3.2 ng/l whereas 3.2 ng/l divides participants with a hs-cTnI ≥1.9 ng/l into 2 equal-sized subgroups, respectively (15).
To examine the association of hs-cTnI with HF, sex- and cohort-stratified Cox proportional hazards survival models with MI during follow-up as a time-dependent covariate were used. The use of sex and cohort as stratification variables adjusts the models for sex and cohort by allowing for a different baseline hazard function for each level combination of these 2 variables (16). Because individuals with MI at baseline were excluded, at the beginning of the follow-up time, the binary MI variable used in the Cox models was coded as 0 for all individuals, and it stayed this way until an individual experienced an MI. At that time, the variable value was updated to 1.
For these analyses, the Cox models were additionally adjusted in the first model for classical CVRFs, body mass index, systolic blood pressure, diabetes, smoking status, antihypertensive medication, low-density lipoprotein (LDL) cholesterol, and kidney function (estimated glomerular filtration rate [eGFR]). These variables were used as time fixed covariates because they were only available at baseline. Age was used as the time scale in all models. Body mass index, systolic blood pressure, LDL cholesterol, and eGFR were used as continuous variables. The reference category for diabetes is the absence of diabetes. The reference category for smoking is nonsmoking. The reference category for antihypertensive medication is the absence of antihypertensive medication.
In the first model, we added hs-cTnI to CVRFs. In the second model, we added hs-cTnI to CVRFs and NT-proBNP. Additionally, in the third model, we studied the association of NT-proBNP with HF after adjustment for CVRFs.
The association of hs-cTnI with HF was studied with the same setting of variables for continuous and categoric versions of hs-cTnI. The categorization of hs-cTnI is described earlier. The categoric variable of NT-proBNP was derived from the continuous version as well defined as low, <30.91 ng/l; moderate, ≥30.91 to <68.26 ng/l; and high, ≥68.26 ng/l. For these analyses, both biomarkers were log transformed and winsorized. Hs-cTnI and NT-proBNP values above the 99.5th percentile (106.6 ng/l and 1,356.2 ng/l, respectively) were winsorized.
The proportional hazard assumption was examined graphically and with formal tests using the methods described by Grambsch and Therneau (17). No evidence of violations of this assumption was observed. Hazard ratios for continuous versions of hs-cTnI or NT-proBNP were reported per log (ng/l) unit change.
To examine the prognostic value of hs-cTnI and NT-proBNP, the C-index (18), the Brier score (19), and calibration plots (20) were used beyond that from a model including CVRFs (defined as the base model in this analysis). Additionally, we used the Akaike information criterion (AIC) to estimate the relative quality of our statistical models (21).
One aim of this work was the determination of a clinically relevant cutoff value for hs-cTnI. This was done using the method of Contal and O'Quigley (22). This technique uses the log-rank test statistic in order to estimate the cutoff value. The optimal cutoff was chosen to give the maximum separation between the groups below and above the cutoff. The equality of survival curves defined by the optimal cutoff was tested using the methods described in the aforementioned reference.
A 2-sided p value <0.05 was considered statistically significant. All statistical analyses were conducted with R statistical software version 3.5.1 (23). Data collection and biomarker measurement as well as additional statistical information are detailed in the Supplemental Appendix.
Study outcome
Of 51,190 individuals, prevalent HF, MI, and stroke cases (n = 2,735) were excluded from all analyses. There are 118 individuals with fatal MI and HF with tied event times. For these individuals, we assumed the event of HF to take place 1 day before death caused by MI. Under this assumption, these individuals could be included into the analysis. Additionally, there are 106 individuals who experienced nonfatal MI and HF at the same time. For these individuals, we assumed the event of nonfatal MI to take place 1 day before HF. The follow-up time of these 106 individuals ends at the time of experiencing MI. Sensitivity analyses underlying the reversed order of events for 106 individuals with tied event times provided similar conclusions.
Baseline characteristics
Baseline characteristics for the overall study population and of each individual cohort are shown in Table 1. The median follow-up time for incident HF (95% confidence interval [CI]) was 6.61 (6.55 to 6.66) years. A total of 1,990 (4.1%) participants developed HF, and 1,965 (4.1%) experienced MI. The overall mortality was 9.6% (n = 4,648). In the subgroup of individuals with incident HF, MI and overall mortality were considerably increased after the diagnosis of HF (MI = 29.4%, overall mortality = 45.4%). The median age was 50.7 years; 51.9% (n = 25,134) were women, and 48.1% were men (n = 23,321). The incident HF subgroup was older with a median age of 61.2 years and was composed of more male individuals (57.2%). The median body mass index was 26.5 kg/m2; 43.8% were hypertensive, 4.6% were diagnosed with diabetes, and 24.2% were current smokers. The median LDL, high-density lipoprotein, and total cholesterol values were 3.3, 1.4, and 5.6 mmol/l, respectively. In the subgroup developing HF, all CVRFs including body mass index, systolic blood pressure, diabetes, smoking status, and blood lipids were more frequent (Supplemental Table 1). Missing information for individuals free of HF, MI, and stroke at baseline is shown in Supplemental Table 2.
Distribution of biomarkers
A total of 46,065 measurements of hs-cTnI and 41,140 measurements of NT-proBNP were available. The distributions of these 2 biomarkers are skewed to the right.
The median concentrations of hs-cTnI and NT-proBNP were 2.3 ng/l and 46.2 ng/l, respectively (Table 2). The distribution of hs-cTnI with cutoff values for women and men and the reference value are shown in Figure 1. In the subgroup developing HF, baseline hs-cTnI was 4.0 ng/l, and NT-proBNP was 102.5 ng/l (Supplemental Table 1).
hs-cTnI and association with HF
As illustrated in the unadjusted Kaplan-Meier survival analyses across the categories of hs-cTnI levels, the probability of HF rose with increasing hs-cTnI levels for women and men (Figure 2).
Hazard ratios (HRs) for continuous hs-cTnI after the addition to model 1 consisting of CVRF variables were 1.42 (95% CI: 1.31 to 1.53; p < 0.001) and 1.19 (95% CI: 1.09 to 1.30; p < 0.001) after the addition to model 2 with CVRFs and NT-proBNP.
Figure 3 displays adjusted (model 2) HRs of HF for the categories of hs-cTnI and NT-proBNP using the lowest categories as reference. We observed the highest association for HF among those individuals with hs-cTnI levels above 3.2 ng/l with HR of 1.63 (95% CI: 1.32 to 2.03; p < 0.001) and among those with NT-proBNP levels above 68.26 ng/l with HR of 2.48 (95% CI: 2.02 to 3.03; p < 0.001). Cox proportional hazard ratios for traditional cardiovascular risk factors is shown in Supplemental Table 3. Results from combining the hs-cTnI and NT-proBNP categories and showing event rates of new-onset HF are presented in Supplemental Table 4.
hs-cTnI and prediction of HF
The addition of hs-cTnI to the base model for the prediction of HF (C-index = 0.848; 95% CI: 0.828 to 0.869; Brier score = 0.01553) led to an increment in the C-index of 0.005 (95% CI: 0.003 to 0.008; p < 0.001). The addition of hs-cTnI and NT-proBNP to the base model yielded a C-index difference of 0.019 (95% CI: 0.013 to 0.026; p < 0.001) (Table 1). Further results of Brier score are also given in Tables 1 and 3, indicating the best results when adding both hs-cTnI and NT-proBNP to the base model. Additionally, when hs-cTnI was added to the base model, the AIC displayed a reduction from 12,081 (base model alone) to 11,998. The best predictive value with an AIC of 11,774 was found in the group with the base model, NT-proBNP and hs-cTnI (Table 1). The calibration plot is shown in Supplemental Figure 1.
Cutoff values of hs-cTnI for potential preventive therapies
After the application of the method used by Contal and O'Quigley (22), we calculated the cutoff value of hs-cTnI. To take into account possible sex-specific differences in hs-cTnI, we calculated 2 sex-specific cutoff values: 2.6 ng/l for women and 4.2 ng/l for men. Figure 4 shows the Kaplan-Meier curves for incident HF for 2 hs-cTnI categories divided by the cutoff values. In the follow-up time, participants in the category with hs-cTnI ≥2.6 (4.2) ng/l at baseline showed a significantly higher risk for incident HF compared with individuals with hs-cTnI under the cutoff values.
The main findings of this study based on harmonized data from large population-based cohorts are the following:
1. The 10-year event rate of HF with hs-cTnI (≥3.2 ng/l) and NT-proBNP (≥68.26 ng/l) was at 13.2%;
2. hs-cTnI levels were independently associated with incident HF;
3. The addition of hs-cTnI to a prognostic model consisting of CVRFs improved prediction of incident HF;
4. The best prediction value for incident HF was achieved by the combination of hs-cTnI and NT-proBNP into 1 model; and
5. Optimal hs-cTnI cutoff values of 2.6 ng/l for women and 4.2 ng/l for men were derived to select individuals at high risk (Central Illustration).
In the setting of pre-existing HF, scoring systems like the Meta-analysis Global Group in Chronic Heart Failure score (24) or the Seattle Heart Failure Model (10) have been developed to predict survival. A recent attempt to improve risk prediction by adding NT-proBNP has shown promising results (25). The addition of hs-cTnI to the established scoring systems may further improve prediction of HF and may allow tailored strategy for preventive therapies.
In this large population-based study, we focused on individuals with no prior history of HF to assess risk factors for possible prediction of incident HF. The rate of incident HF was about 4.1% in this population, and the median time to new-onset HF was 6.6 years. As expected, classical CVRFs could identify participants at risk to develop HF (Figure 3). Importantly, we show that hs-cTnI is associated with an increased incidence of HF in this large dataset and improved diagnostics on top of CVRFs. This is in agreement with earlier and smaller publications reporting an independent association of hs-cTn to incident HF (9,26). Recently, Myhre et al. (27) showed an association of troponin T and diastolic function in a cohort of older adults.
Levels of hs-cTnI were low (Figure 2) as expected when compared with patients with acute MI. Nevertheless, also slight increases of hs-cTn have been shown to be important for risk predication in the general population (9) and are associated with a poor outcome. In our study, hs-cTnI concentrations of 2.6 ng/l for women and 4.2 ng/l for men predicted incident HF. Currently, uncertainty remains about the pathophysiology behind the hs-cTnI elevation. Seliger et al. (28) showed that hs-cTnT levels are associated with replacement fibrosis and progressive changes in left ventricular structure in cardiovascular disease–free adults using cardiac magnetic resonance. In this study, we excluded individuals with prevalent HF, MI, and stroke, which could have been responsible for a subtle increase of troponin. However, the long median time of more than 6 years until diagnosis of incident HF implies that most of those individuals were at good health at the time of inclusion and no clinical HF was present. The idea of troponin release in the nonacute setting is also discussed by the fourth definition of MI (29) with the inclusion of acute and chronic myocardial injury. Similar mechanisms might be responsible for the results in this study. Irrespective of the exact cause of troponin release, these patients would possibly benefit from therapeutic intervention. Our results suggest that hs-cTnI may help to identify those individuals.
The association between NT-proBNP and the incidence of HF is already established. In a randomized controlled trial, Huelsmann et al. (30) demonstrated the possibility of prevention of HF in persons with elevated NT-proBNP measurement. In this trial, individuals with elevated NT-proBNP underwent targeted prevention, resulting in a lower incidence of HF compared with the control groups. In accordance, the addition of NT-proBNP to a model containing classical CVRFs in our analyses improved risk prediction of HF. Nevertheless, similar to hs-cTnI, the detected values were low and could also be the result of subclinical myocardial injury causing this elevation. Furthermore, soluble suppression of tumorigenesis 2 also plays an important role in predicting HF (31). However, soluble suppression of tumorigenesis 2 measurement was not available in most of the cohorts and thus could not be included in our analysis.
Importantly, even when hs-cTnI was added to CVRFs and NT-proBNP, there was an improvement of prediction, albeit this was modest. Furthermore, this might be important for understanding the pathophysiology of the development of HF because next to stress-induced elevation explained by NT-proBNP, other mechanisms causing myocardial injury seem to play an important cause at this disease stage already.
High cardiac troponin levels were associated with future major adverse events including all-cause mortality, MI, readmission for HF, and stroke in other papers (9). Consequently, considering the high prevalence in the general population, developing reasonable therapeutic strategies for patients with elevated hs-cTnI levels in ambulatory primary care could be very important. Therefore, the hs-cTnI cutoff values of 2.6 ng/l for women and 4.2 ng/l for men beyond the CVRFs and NT-proBNP derived in this study may serve as a basis for future studies evaluating respective primary preventive strategies.
Study strengths and limitations
An important strength of our study is the considerable size of the dataset with harmonized data from well-defined European population cohorts with 48,455 participants examining explicitly hs-cTnI as a risk marker for HF. Several limitations have to be taken into account. One of the major limitations is that we cannot provide information on HF subtypes (HF with preserved and reduced ejection fraction) because these were not consistently collected in the included cohorts. Moreover, whether subclinical HF might have been present at enrollment cannot safely be ruled out in this population study. Another limitation is data on valvular heart disease, a possible risk factor for HF, are not available in our cohorts.
In this large dataset of population cohort, hs-cTnI as a biomarker could independently predict incident HF. The best prediction value for HF was achieved after hs-cTnI was combined with NT-proBNP. The usage of both biomarkers for the diagnosis of HF could be essential for future clinical decision making.
COMPETENCY IN MEDICAL KNOWLEDGE: Elevation of serum hs-cTnI is associated with incident HF. hs-cTnI showed a marginal predictive value for HF.
TRANSLATIONAL OUTLOOK: Cutoff values of 2.6 ng/l for women and 4.2 ng/l for men were established. Further studies are needed to determine whether individuals with hs-cTnI > 2.6 ng/l/4.2 ng/l might benefit from specific preventive therapy.
The authors thank the participants and the staff of the cohorts for their contribution and efforts.
↵∗ Drs. Yan and Börschel contributed equally to this work.
The BiomarCaRE Project is funded by the European Union Seventh Framework Programme (FP7/2007-2013) under grant agreement no. HEALTH-F2-2011-278913. The activities of the MORGAM Data Centre have been sustained by recent funding from European Union FP 7 project CHANCES (HEALTH-F3-2010-242244). A part of the biomarker determinations in the population cohorts was funded by the Medical Research Council London (G0601463, identification no. 80983: Biomarkers in the MORGAM Populations). The DanMONICA cohorts at the Research Centre for Prevention and Health were established over a period of 10 years and have been funded by numerous sources. The FINRISK surveys were mainly funded by budgetary funds of the National Institute for Health and Welfare, Helsinki, Finland. Additional funding has been obtained from numerous nonprofit foundations. The Moli-sani project was partially supported by research grants from Pfizer Foundation (Rome, Italy), the Italian Ministry of University and Research (MIUR, Rome, Italy)–Programma Triennale di Ricerca, Decreto n.1588, and Instrumentation Laboratory, Milan, Italy. The Northern Sweden MONICA study was supported by Norrbotten and Västerbotten County Councils, the Swedish Research Council (2011_2395), the Swedish Research Council for Health, Working Life and Welfare, the Swedish Heart and Lung Foundation (20140799, 20120631, 20100635), and the Joint Committee of the County Councils in Northern Sweden. Dr. Blankenberg has received grants and personal fees from Abbott Diagnostics, Bayer, SIEMENS, and Thermo Fisher; grants from Singulex; and has received personal fees from AstraZeneca, AMGEN, Medtronic, Pfizer, Roche, Novartis, and SIEMENS Diagnostics outside the submitted work. Dr. Neumann has received personal fees from Abbott and Siemens; and has received grants from the German Heart Foundation/German Foundation of Heart Research and the Else Kröner Fresenius Stiftung outside the submitted work. Dr. Salomaa has received personal fees from Novo Nordisk; and has received grants from Bayer Ltd. outside the submitted work. Dr. Söderberg has participated in advisory boards for Actelion Ltd.; and has received speaker honoraria from Actelion Ltd. and Bayer Ltd. (unrelated to the present study). Dr. Kuulasmaa has received grants from the European Union and the Medical Research Council, during the conduct of the study. Dr. Westermann has received personal fees from Bayer, Boehringer Ingelheim, Berlin Chemie, AstraZeneca, Biotronik, and Novartis outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors' institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Heart Failure author instructions page.
- Abbreviations and Acronyms
- Akaike information criterion
- BiomarCaRE
- Biomarker for Cardiovascular Risk Assessment in Europe
- eGFR
- estimated glomerular filtration rate
- hs-cTn
- high sensitivity cardiac troponin
- hs-cTnI
- high-sensitivity cardiac troponin I
- hazard ratio
- low-density lipoprotein
- myocardial infarction
- NT-proBNP
- N-terminal pro–B-type natriuretic peptide
- Received September 10, 2019.
- Revision received December 17, 2019.
- Accepted December 17, 2019.
- 2020 The Authors
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Brian Kibler's Overload Shaman – June 2018
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Any substitute for Earth Elementals? Have everything but those two.
idk why you wouldn't toss hagatha for bogshaper. 'specially if you follow through on his possible changes and are fielding so many low cost spells.
Hagatha is for the long games. Kibler loves cards that provide long term value for single outcomes. Plus you'll ideally already have the giants in the later turns where you'll want to play the stones making the draw power from bogshaper not as impactful.
Kibler suggested removing one sandbinder for a zap after playing. he also said he might remove one lightning bolt for the 2nd zap.


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oui, oui!
My days have been quiet of late but this week things will be a little different. Mark and I are heading to Québec City! I've never been there but have heard it is beautiful in every way - the St. Lawrence river, the glorious old Chateau Frontenac, cobblestone streets, and fabulous French food within slurping distance. I am prepared to dive head first into a plate of crêpes directly upon arrival. Everything will be profusely decked out for the Christmas holidays. But best of all we will be seeing Casse-Noisette aka The Nutcracker ballet performed at the Grand-Théâtre de Québec. I have wanted to see this all my life and have never had the chance. I cannot WAIT! (I promise, Mom, I will take you with me in my back pocket.) I'll be back soon to tell you all about it!


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I already have Spink catalog but I think that its prices are too conditioned by the fact that the same Spink is also an auction house that sells coins... and I'm interested also in mintage figures. Anyway many thanks for your answer.
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Wheeler, Raymond H.
FROM the dawn of science in ancient Greece to the present time, there have been geographers, students of climate, anthropologists, and historians, who have recognized some connection between human behavior and climate. Recently the problem has been revived, notably by ElIsworth Huntington, whose numerous studies on the history of civilization show that culture epochs in widely separated areas have come and gone on tides of climatic change. The more successful civilizations (as measured by modern standards) have evolved in temperate zones where climatic changes are frequent but not too extreme. An active climatic environment is conducive to cultural activity. Space does not permit a review of the vast literature relating to this field. The present account is a summary of a study now in its fifth year, the data of which have been assembled for a work of several volumes, the first one on the history of climate.


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While the name "Benson," was dropped when Faegre & Benson merged with Baker & Daniels in 2012 to become Faegre Baker Daniels, "Benson" lives on as the name of the firm's intranet service. Andrew Humphrey explained to the Star Tribune that the idea to name the intranet service after the late John Benson, who joined the firm in 1914 and founded Minneapolis Legal Aid, came from new colleagues at merger partner Baker & Daniels. "Several of them felt bad about [Benson] being left out as we had to consolidate for brevity," said Humphrey. "We have also retained the Benson name for our firm pro bono award. This is a big deal in our firm," Humphrey added.
Media Mentions
January 28, 2013


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The sad spectacle of US election campaigns has been substituted for real news in the One Percent's mainstream media. This is the periodic spectacle that they try to frame as being the essence of "democracy". This independent journalist and author who is an expert on the Bush clan (he wrote Family of Secrets) explains how the Republican party primary election campaign has left the current crop of contenders for their party's nominee for President looking so bad that they may be forced to turn to another candidate who might have some credibility.
Okay, I hear you screaming that you couldn't stand another Bush in the White House! Don't worry. This is all about appearances. The One Percent really loves Obama. As Baker writes:
My hunch is that the Bushes and the real establishment (that's not the Tea Party, not the Santoriacs or the Gingrichites, folks) just love how bad the GOP field is. Obama is almost certain to be reelected. Which is just fine. Like Clinton, he's played ball on all the big issues that really matter to the One Percent of One Percent—foreign intervention, oil, Wall Street bailouts.


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Once again last week we saw the spectre of Tasmania's most hated project dominating the public discourse and once again we saw (Matthew Groom – Listen here, http://blogs.abc.net.au/tasmania/2012/02/the-pulp-mill-investment-and-political-tension.html ) Will Hodgman's Liberal opposition attempting to use the issue to drive a wedge between Labor and the Greens.
Hissy fits by Matt Groom and Peter Gutwein with calls for Lara Giddings to sack Greens leader Nick Mckim from cabinet were classic political grandstanding and left Will Hodgman's party looking too much like hypocrites. The Liberals' calls came after Nick Mckim urged (Here: http://www.abc.net.au/news/2012-02-09/gunns-pulp-mill-warning/3819840?section=business) new Gunns main man Richard Chandler to steer clear of the Tamar Valley Pulp Mill project.
Will & Lara's lynch mob
Only a few months ago two of Australia's most successful entrepeneurs, Jan Cameron and Graeme Wood bought up the dilapidated, unprofitable and unsaleable Triabunna Woodchip Mill ($10M investment) on Tasmania's East Coast from Gunns Ltd with plans for a slow phase-out of woodchip operations and long term plans to develop the site into a tourist hub.
To say the $10M investment in the struggling East Coast Town was not welcomed by either of the big political parties in Tasmania is an understatement.
Shadow Treasurer Peter Gutwein led the Liberals' trashing of the investment, screaming blue murder and making the utterly ridiculous demand that the Tasmanian Government compulsorily acquire the Triabunna site from its rightful and legal owners.
It was the Tasmanian Liberal Party who led the charge, whipping up a hate campaign against Cameron and Wood's $10M investment in Tasmania. They were of course cheered on by a hypertensive looking Robert Wallace and the TCCI.
As Premier Lara Giddings, in my view, who could barely conceal her contempt for the two successful entrepeneurs led an ugly public campaign against Cameron and Wood, Will Hodgman raised no objection about a $10M dollar investment being talked down, rather unleashing the Liberals' attack dogs and cheering on the Premier.
The knives were out for Jan Cameron & Graeme Wood. It was an unedifying spectacle particularly from the Premier of Tasmania.
It's this aspect that particularly exposes the Liberals' claims that Mckim's sacking is warranted because of his senior role as a goverment minister.
Indeed Will Hodgman's Liberals cheered on as Tasmania's most senior minister – The Premier, publicly trashed a $10M private investment in a struggling Tasmanian town. Yet Mr Mckim apparently should be sacked for continuing the Greens' long standing public campaign against the proposed Tamar Valley Pulp Mill.
No-one should be under the illusion that Will Hodgman's Liberals wouldn't have monstered Cameron &Wood if the Libs had the reigns of Government. Nor doubt that a Hodgman Government led by greenie hatin' Bass MHA Peter Gutwein, would have pushed ahead with its call to compulsorily acquire the Triabunna Mill from its rightful owners and in doing so confused & scared potential investors as governance in Tasmania were taken to new lows.
Imagine the wonderful publicity as Tasmania (and the public purse) was dragged through an ugly high profile legal battle with two of Australia's most successful and forward thinking business people.
The Liberal and Labor parties clearly prefer to back a failing company like Gunns who would almost certainly be dead now without its major asset – a large plantation estate which was acquired with large thanks to MIS taxpayer-assisted help.
The Liberals' concerns appear less about investment in Tasmania per se; rather their own love affair with polluting, volatile & unprofitable industries like woodchipping and pulp.
The Shadow Treasurer's cycnical call for the Giddings government to compulsorily acquire the Triabunna Mill shows the Liberals' woodchip & pulp mill bondage even overrides the Libs' so called belief in the free market economy.
Couple this with the Liberals' nod & a wink to the most corrupt legislation ever to pass through the Tasmanian Parliament (The Pulp Mill assessment act 2007) and the Libs' willingness to turn a blind eye to the abuses of process that kept the project alive and one has to be fairly pessimistic about a prospective Hodgman government's commitment to Tasmania's statutory planning processes and ethical governance.
• Download Gunns and FSC …
14 Comments
#13, I'd expect the increase in on-line comments is part of FIAT's (perhaps via TCT) lobbying campaign of the MLCs…just a few angry ants.
John O'Shea, #8:
What breath of fresh air? It would be the same air we've always had. Why would the Liberal party act any different to how Labor has been? There are certainly differences at the Federal level but here in Tasmania there are none.
How do you figure the Greens set the agenda? What they have achieved has been either ignored or of little consequence to most. The budget woes are not of the Greens making, nor is the response to them. Saying it again and again (like Will and his friends at the TCCI) doesn't make it so.
Looking back at history Labor and Liberal in Tasmania have never really acted differently, have never talked differently and have never really been any different, with the sole exception being the colour of their flags.
Judging from the hysterical anti-Green slavering on The Mercury online comments to almost any political article these days, quite a few Tasmanians are quick to forget history.
The hospital is not only publicly owned, it is an essential service (though in the mind of Lara and Will possibly not as essential as woodchip processing plants and big shiny pulp mills).
VOS hypothetical is so nonsensical that……..hold on…..the Libs might just go for it!
6; Good try VOS but the metaphor is flawed. The hospital is a State owned asset and is an entirely different matter to a privately owned wood chip facility.
You might do better with something like a privately owned power station, or perhaps a munitions factory? Something owned privately but essential to the country. Of course, you might open up all sorts of discussion re the comparison!
For all the common-sense, 'yep, that's the way to go', sounds good & sensible – I read in the comments pages of this paper…none of it appears through the looking-glass in day-to-day Tasmanian life…none.
Tasmania will be, and always has been…some surreal Frank Capra film detailing the woe of the average man/woman in a 'corrupt' state.
Dig it up, shear it off or cut it down.
What is so hard in this state about accepting the reality that (I'm 47) nothing has ever been any different here…and returning after 30 years in VIC & NSW, nothing has ever changed.
Where does the leader that breaks the mold and sacrifices person gain for historical kudos come from – surely there must be a truly great three term leader here somewhere?
Someone with the Jeff Kennett will of steel, the Don Dunstan social vision and the…get ready, Rex Connor:
Give me men to match my mountains,
Give me men to match my plains,
Men with freedom in their visions
And creation in their veins
dream that Australians should have control over their mineral, agricultural and oceanic gifts.
I read letters from those that posses those gifts, so they are not mutually exclusive. Are we so lost in Tasmania that it is better to live as a lamb for a lifetime, than as a lion for a voting-day.
You wouldn't read about the Libs in the most savage satire.
With a Government on a 17% approval rating substantially due to their support of one of the most inefficient resource extraction industries in the world, we have an opposition vowing a full-bore resumption of that industry, despite the virtual disappearance of their increasingly disreputable market.
Even more bizarrely, they don't bother to address any of the vast illogic in their position.
In the Third World, all this would be readily ascribed to brazen corruption. In Tas, the "C" word isn't officially acknowledged to exist.
John Hayward
The Libs would be a breath of fresh air after the pathetic performance of this Labor/Fringe Dwelling government. The Labor party seem so intent on clinging to power that they are prepared to overlook the job destroying and ultimate whiteanting of their fringe dwelling collaborators.
It is well past the time that the Greens were permitted to set the agenda for governance of this state.
J. O'Shea Launceston.
#6 "I'd like to by (sic) the Royal Hobart Hospital and turn it into a casino". Where's the flaw in this argument? The RHH is not for sale. Triabunna was……..and buyers were pretty thin on the ground until Cameron and Wood came along with cold, hard cash.
I've got a spare billion dollars. I'd like to by the Royal Hobart Hospital and turn it into a casino. Wouldn't it be unethical, corrupt, and take governance in Tasmania to new lows if the Giddings government tabled legislation to block me and keep it functioning as a hospital – outrageous!
This is competent work from Pilkington. Endlessly defining the problem is not enough I feel. We have two actual coalitions operating in Tasmania for some time with Labor in both of them. Johnd's comment(2) is correct. The only change at the next election appears to be the Greens will no longer be in any coalition. Unless you include Nick McKim as 'shadow education minister' as part of a 'coalition opposition'. Who cares anyway? Back to the problem. The solution in my view is to reduce the power of all of them, and increase the power of responsible Tasmanians who are outside of the washing machine political process.
People who cannot be bought or swayed by any of the parties. In the Tasmanian situation it is party allegiance that is the problem not the lack of it.
Gutwein is attack dog to Will Hodgman as Lennon was to Bacon. And when Will goes, as Will surely will, we'll have a Lennon style premier only with the TCCI urging him on instead of the CFMEU. As Phoebe once famously said on TT: "Same shit, different arse." This pattern of dysfunctional and profoundly undemocratic government must be broken. As Peter Henning says ("Thrilled" today's lead article
) no wonder reasonable federal politicians like Plibersek hold the Tasmanian government in such contempt. How can change take place is the question. I'd like to see the structure changed completely: abolish the two party system and have a committee system legislating issue by issue, but I can't see that happening yet. A feasible step in the right direction would be to revert to a 35 seat House.Despite what Nigel Burch said about increasing the number of seats (http://oldtt.pixelkey.biz/index.php?/article/are-35-fools-more-talented-than-25-jimbo-linzo/) at least 35 members means new faces. As for his argument that we'd get more of the same, I'd rather use the statistical argument of regression towards the mean: it's so bad now amongst the major parties that any new blood is likely to be better — particularly if we have more Greens and independents in that mix.
It is a worry that the two major parties are so much in lock step with each other when it comes to the chip and pulp industry. When election time comes around it doesn't give us any hope of having a fair and economically run gov't as they both promise the same old same old. Why do they bicker so when they could form the one party and be agreeable? Unfortunately the Greens don't stand a chance of holding gov't in their own right.
This is what is so depressing. The Giddings train-wreck will be voted out at the next election, but is this what we have to look forward to?
This story is a prime example of why we need to get rid of the two-party system.
The Libs and TCCI are a fairly close family. I have noted before the TCCI is quite vocal on high levels of business taxation and wasted government expenditure until it comes to forestry. All of a sudden they support wasted government expenditure. Why? One does not have to look beyond their membership where some have suckled at the public teat for years. Look no further than road and bridge building, gravel supplies and heavy machinery and you will find the motivators.
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Buzz is strong that Salman Khan and Katrina Kaif may start shooting for the third installment of 'Tiger' franchise in February.August 12, 2020, 8:42 pm explore: Movies
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April 24th, 2006
Saw this "Mallard Fillmore" comic in the paper last week and it got me thinking. My mother may be far from a shining example, but she had me reading by age three… I kid you not! To this day I can remember our "play time" with phonics and flashcards. Those early years set the stage for a life-long love of learning.
These days, so many parents don't view their children's education as a personal responsibility. Either they feel ill-equipped, uninterested, or too busy. Of course, there are plenty of exceptions… My aunt and uncle are among them. They homeschooled my six cousins, the oldest of whom recently graduated from UCLA.
I was always a little jealous of their personalized education because I was always so bored! In both private and public schools, I had the same experience of waiting for the slowest moron in class to catch up so that we could finally move on and learn something new. The whole process was terribly painful for a bright girl with A.D.D.
Maybe some day I'll have a family and face decisions about education. I wonder if I'll have the option to home school, or if economic conditions will force me to subject my children to the boredom I once endured.
Entry Filed under: Carrie's Rants
9 Comments
1. Jason Rohrblogger | April 25th, 2006 at 3:15 pm
Welcome back! Missed you…
2. deletedsoul | April 26th, 2006 at 3:36 am
Welcome back!
On the subject of homeschooling, I can vouch for there being advantages to this. I was homeschooled from 3rd to 12th grade. Not being distracted by peer pressure, learning at your own pace, and being able to have one on one contact with your teacher is invalueable.
The downside? A lot of times (even in my case) the parent doesn't have the patience or the time to devote to the child. There's always the social interaction aspect, but most towns have homeschool groups that have gym classes, outings, etc.
There are even schools that offer advanced satellite plans to help the family with the administrative and grading side of things, so they can focus on teaching.
Homeschooling is not just for religious nuts or backwoods scary people anymore. Its a viable option for those wanting the best education possible for the child.
3. deletedsoul | April 26th, 2006 at 3:40 am
One last thing…the monetary concerns are often without cause whem considering homeschooling. My school offered a complete plan for 350.00 per year, less than the average public schooled child spends on clothes, lunches and books.
4. Grins | April 26th, 2006 at 4:42 am
My mom didn't homeschool but she did have us VERY prepped for school at an early age. She is responsible for my love of reading without a doubt.
And as for the economic stuff, it works out. I somehow manage to scrimp and save so my son can go to private school in high school. Which reminds me, the tuition is due again. Eeek.
5. Joefish | April 26th, 2006 at 6:56 am
Nice to see you again.
I don't think I ever had ADD, but I was certainly bored to tears in public school. Or lazy. Bored or lazy, one or the other.
6. Nihility | April 26th, 2006 at 10:35 am
Heh, now I guess I have to update my blog too 😀
In Israel there is no such thing as home schooling at those ages. We have a law enforcing free, mandatory education, up to 10th grade I believe. Our education system has been under a lot of scrutiny for quite a while. Ther are just so many funds you can divert to education when you are constantly at war. We're confronted with rising violence and dropping grades.
You do have the option of sending your kids to private school, though this can be expensive, and after tenth grade your kids are no longer obligated to go to school, though most will complete their education. The way I see it, in order for homeschooling to work you have to have a committed, educated parent, and if you are that type of person you might as well get a job and send your kids to private school.
7. LlamaKing | April 26th, 2006 at 11:30 am
Only flaw in your assumption, Nihility, is that being committed and educated doesn't always provide enough income to afford the essentials, let alone private school.
8. Nihility | April 26th, 2006 at 1:49 pm
So, you can't even afford the essentials and yet you don't even get the low paying job in order to home school your kid? Who then, in return, will be educated but won't be able to find a job? So what's the point?
Look around you. Most people are lazy as hell. They find a routine and stick to it. If you are energetic, enthusiastic (and yes, committed) you will find a job and move up in the ranks (unless you happen to be some unhappy minority, but that's a whole different issue)… If you aren't, you have no business home schooling in the first place!
9. Paul G. | April 26th, 2006 at 3:00 pm
"Look around you. Most people are lazy as hell."
There's a negative outlook if I ever saw one! Most people will work like hell to avoid what they thin of as work. They'll work even harder than they would if they had been doing the work. Lazy? Nope. Misdirected? Yes. The average person works 80 times harder than they have to.
On a direct note to the original rant. My parents took a direct interest in my education and I too was reading long before entering school. Because eventually not only would I get bored out of my skull waiting on the slowest kid in the class [usually a very nice person], it end up with teachers, professors and instructors that were slower than the slowest student in the class… And then came the idiot "decider" bosses.