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Like all college essays, the English paper requires essential thought and strong argumentation, but its focus on language and close textual evaluation makes it unique. We ship distinctive content material. Our writers do not plagiarize, rewrite, or paraphrase. They complete 100% original papers from scratch. Do not summarize the story or plot. You are supposed to research and present arguments to help your thesis statement.
Every body paragraph ought to deal with a different theme that's relevant to your matter. You will need to synthesise several of your reviewed readings into each paragraph, so that there is a clear connection between the various sources. You will have to critically analyse every source for how they contribute to the themes you are researching.
Maybe you have been shocked to see a personality act in a certain way, or maybe you didn't understand why the book ended the way it did. Complicated moments in a piece of literature are like a unfastened thread in a sweater: in the event you pull on it, you possibly walter's dream in a raisin in the sun can unravel the whole factor. Ask your self why the author selected to put in writing about that character or scene the best way he or she did and you would possibly tap into some vital insights in regards to the work as a whole.
From a common view, literal evaluation delves into the why and tries to know the apparent and hidden meanings that lurk beneath the principle plot. It causes one to not solely reflect on the story itself however to grasp the larger image of history, human situation etc. Reading analysis, however, is the act of studying to extract data.
Instantly after you may have acquired the topic to your future essay, concepts and images will start to come up in your head. Take a bit of paper and make notes of what comes to your mind. In a while, it is possible for you to to develop them into the entire essay.
Second, keep in mind that strong literary essays make opposite and stunning arguments. Try to think exterior the field. Within the 1984 instance above, it looks like the obvious reply can be no, the totalitarian society depicted in Orwell's novel isn't good for its citizens. But are you able to consider any arguments for the other facet? Even when your final assertion is that the novel depicts a cruel, repressive, and due to this fact dangerous society, acknowledging and responding to the counterargument will strengthen your overall case.
Clearly clarify how the ideas and ideas introduced in the body of the essay depict the theme. Merely put, your conclusion also needs to explain what message the creator was hoping to deliver about life and how it pertains to the examples you've got included in your evaluation.
As with the novel , essays existed in Japan a number of centuries earlier than they developed in Europe with a style of essays often called zuihitsu — loosely related essays and fragmented concepts. Zuihitsu have existed since virtually the beginnings of Japanese literature. Lots of the most famous early works of Japanese literature are on this genre. Notable examples embrace The Pillow E-book (c. 1000), by court lady Sei Shōnagon , and Tsurezuregusa (1330), by significantly renowned Japanese Buddhist monk Yoshida Kenkō Kenkō described his brief writings equally to Montaigne, referring to them as "nonsensical ideas" written in "idle hours". One other noteworthy distinction from Europe is that girls have traditionally written in Japan, though the extra formal, Chinese language-influenced writings of male writers had been extra prized on the time.
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Can I Learn from the Estate Planning Miscues of Celebs?
If you do not learn from your mistakes, you are doomed to repeat them. In estate planning, if you do not learn from other's mistakes, you are likely to repeat them. Mistakes in the estate planning of high-profile celebrities is one very good way to learn the lesson of what not to do. Here are eight celebrity estates, where the mistakes have been reported in the news over the years.


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USA Today Bestselling Author Heather Boyd believes every character she creates deserves their own happily-ever-after—no matter how much trouble she puts them through. With that goal in mind, she writes steamy romances that skirt the boundaries of propriety to keep readers enthralled until the wee hours of the morning.
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5. 'When you're in the moment everything you want is right' pretty much sums up her state of mind as she sits down to write. She goes with the flow.
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When did you know you wanted to be a writer?
I have always been a reader, but it wasn't until both my kids were in school that I put pen to paper. But the story just didn't go anywhere. I needed help. So I joined a writers group, got feedback and studied how to write better stories. The first time I was asked for the remaining chapters in the story being critiqued was pretty special. I don't write every day of the year, but its pretty close.
Take us through a typical writing day for you.
I work at my writing career full time, so after I gently guide the family out the door, I usually grab a coffee and settle in to write as many words as I can before midday. After lunch, words are often much slower to come by, but I persist until I finish the chapter or scene I'm working on. After that, I answer emails, read industry related blogs. I'm self-published, so there is always something new to discover and talk about with friends. Late afternoon is spent with my family. I don't like to write my stories late at night because I find it hard to switch off and go to sleep.
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Don't ever believe self-publishing is going to be easy or a quick way to make money. There are so many decisions you have to make that you just don't anticipate before you start. Having someone to talk to about it is a huge help. Also joining up with like-minded authors can fill any gaps or at least steer you in the right direction when panic is about to set in. Keep an open mind and prepare to pivot as the publishing industry grows and alters course. (It does that a lot!)
How would you describe the characters in your books?
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Entertainment! An escape from reality, a laugh, an urge to wake their partner in the middle of the night for the right reason, and to smile at the end of the story because it was time well spent.


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Judith Richardson Bunney followed her in this work. Definition of chestnut in the Definitions.net dictionary. How to use chestnut in a sentence. We have twenty places available. In the citation below, the term is used humorously because the story has never happened, and so it couldn't be over-repeated. Since there is no walnut or pecan emoji, the Chestnut emoji gets around in all postings related to nuts (you know what that means). Chestnut is a centre for children aged 5-11 years, experiencing complex social, emotional and mental health difficulties. Chestnut definition is - any of a genus (Castanea) of trees or shrubs of the beech family; especially : an American tree (C. dentata) that was formerly a dominant or codominant member of many deciduous forests of the eastern U.S. but has now been largely eliminated by the chestnut blight and seldom grows beyond the shrub or sapling stage. In the 1880s, many American newspapers began using 'chestnut' in the way we do now, to refer to hoary, oft-repeated stories, and the term became established in the common lingo thereafter. English [] Etymology []. Information and translations of chestnut in the most comprehensive dictionary definitions resource on the web. Find more similar words at wordhippo.com! Actually, we should clarify: it is the only tree nut emoji. ... Chesnut, ches′nut, n. a nut or fruit enclosed in a prickly case: the tree that bears it: (slang) a stale joke or story. The name "chestnut" is derived from an earlier English term "chesten nut", which descends from the Old French word chastain (Modern French, châtaigne). "worn out") story. chestnut - WordReference English dictionary, questions, discussion and forums. old chestnut definition: 1. a subject, idea, or joke that has been discussed or repeated so often that it is not funny any…. The main aim of the centre is to support children to be able to move back into mainstream provision or to signpost them to a specialist provision that can meet their needs. old chestnut: [noun] an over-repeated (i.e. A peanut emoji does exist, but it's a different kind of nut that grows underground. The hospital was the site for a series of influential studies on the long-term treatment outcome for psychiatric conditions, known as the Chestnut Lodge studies. Citation from Austin Powers in Goldmember (2002 film) blacked out … What does chestnut mean? Originally as chestnut, with "old" for emphasis.Popularized US 1880s, particularly Northeast and Midwest, with various theories propounded. A possible source of the Greek word is the ancient town of Kastanea in Thessaly. An informal term that stands for or means something else than its literal meaning; a shorter way to say a word or phrase All Free. In the 1950s and 1960s, innovative dance therapist Marian Chace had regularly scheduled sessions with groups of patients. Learn more. Synonyms for chestnut include platitude, commonplace, banality, truism, bromide, shibboleth, trope, homily, groaner and cliche. The 'old' was added later as an intensifier. Meaning of chestnut. The French word in turn derives from Latin Castanea (also the scientific name of the tree), which traces to the Ancient Greek word κάστανον (sweet chestnut).
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North Texas is concluding yet another week of surging COVID-19 cases that are threatening to overwhelm the area's understaffed hospital systems.
At least 160 people were hospitalized with the coronavirus in the last 24 hours, bringing North Texas' total to 2,973, according to the Dallas-Fort Worth Hospital Council. Of those cases, 213 are at Parkland Health and Hospital System, up 26 patients from Thursday's total of 187.
Friday's COVID-19 hospitalization total is nearly four times greater than the total of 800 COVID-19 hospitalizations on Dec. 7.
The total hospital occupancy in North Texas during the last month increased from 92% to 93%, said Steve Love, president and CEO of the DFW Hospital Council. Looking at that metric alone, however, doesn't paint a complete picture of the strains hospitals are currently under, he said.
The critical difference between what hospitals are dealing with now compared to before the omicron-variant surge is the increasing percentage of patients positive for COVID-19 — and the number of available staff members to take care of them, he said.
Some facilities, like Parkland, the area's largest public hospital, have always operated at 100% capacity, even before the onset of the pandemic.
"Big hospitals like us … are 100% full every single day, so [the occupancy rate] doesn't change, with or without COVID," said Dr. Joseph Chang, Parkland's chief medical officer. "But occupancy rates can be helpful to understand smaller hospitals."
COVID-19 patients accounted for more than 34% of adult ICU patients in North Texas on Friday, Love said. That percentage is troubling, Love said, because of the additional resources required to care for COVID-19 patients.
Some COVID-19 patients — about 30% at Parkland — are positive for the virus but are primarily hospitalized for something else, Chang said. With previous variants, around 10% to 20% of hospitalized patients with COVID-19 fell in that category.
"It doesn't mean they don't have COVID or that COVID isn't making whatever they have worse," he said. "It just means their main diagnosis isn't COVID."
Regardless of whether they are hospitalized primarily for the virus, coronavirus patients often require more work from hospital staff than the average hospital admission. They have to be isolated, and health care staff have to safely don and remove extensive amounts of personal protective equipment.
Hospitalized COVID-19 patients can also require more medications and nurse assessments, Chang said. "A typical … COVID patient is about the same as any patient. But if the COVID patient is on higher levels of oxygen, then the workload doubles," he said. "If they go to the [intensive care unit], it's obviously even more than that."
Some areas of the health system are seeing more patients than others, including emergency departments, which are fielding sharp increases in the number of people coming to hospitals for COVID-19 testing, Love said.
"The good news is, we're treating some people in the emergency room and they're able to go home. They don't have to be admitted," he said. "But we're needing extra staff in that emergency room area to handle the surge of outpatient people."
Staffing shortages are amplifying the effects felt by increasing COVID-19 patient loads. Record numbers of nurses and other health care workers have left the field entirely because of the pandemic, and hospitals are struggling to fill those gaps.
And remaining health care workers aren't immune to the omicron variant, which is spreading at unprecedented levels.
The North Texas trauma service area, which encompasses 19 counties, is down about 15% in staff because of COVID-19 or other illnesses, Love said.
The area's hospitals anticipate roughly 1,000 state-supplied traveling nurses will arrive in the next week to offer some relief to the thin-stretched staffs. Still, that's likely not enough to cover all of the shortages across the entire trauma service area.
"It's going to be very helpful, and we're very appreciative, but it's not going to be enough to solve the entire staffing problem," Love said.
North Texas pediatric COVID-19 hospitalizations increased to 131 Friday, up five patients from the day before.
Cook Children's Medical Center in Fort Worth accounts for 39 of those patients, five of whom are in the pediatric ICU and one is in the neonatal ICU. Dallas-based pediatric hospital system Children's Health, which updates its COVID-19 hospitalization numbers weekly, reported 67 patients hospitalized with the virus on Tuesday.
While preliminary research shows that the omicron variant appears to be causing milder illness compared with the delta variant, pediatric hospitalization numbers are still rivaling those seen in previous surges.
The increase in pediatric hospitalizations could be explained by the relatively low vaccination rate among children ages 5 and older. About 90% of children ages 5 to 10 are not fully vaccinated against the virus.


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Office Space in International House – W5International House, High Street, Ealing Broadway, Ealing, London, W5, UK
Property Details
- Office Space: Managed Office, Serviced Office
- Office Size (Desks): 95
- Contract Terms: Minimum 12 Months
Property Description
Bright airy offices in Ealing Broadway with green gardens and an abundance of natural light.
Designed with your wellbeing in mind, International House is a bright open space with plenty of natural light and greenery. There's an impressive boardroom, to wow your clients. Lounges, where you can relax. Private phone booths, where you can make calls. And a lovely green garden, where you can unwind – or even work, with full wi-fi.
And for those who cycle to work or want to squeeze in a lunchtime workout, there are bike racks, showers and fresh towels to make your life easier.
With Ealing Broadway Centre next door, you've got 75 of the biggest names on the high street on your doorstep. The Broadway itself is full of independent cafes, restaurants and shops. The Town Square hosts pop-ups and festivals all year. And there's over 50 acres of local parkland to explore – including Ealing Common, Walpole Park and Pitzhanger Manor.
And with six different stations nearby, the transport connections couldn't be better. You can get to Heathrow or Canary Wharf in around half an hour. And when Crossrail opens, those journeys should be twice as fast.
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I am finally back on the road doing what I do best 'LIVE EVENTS'. My live shows begin again in Sept with several venues that I have previously demonstrated in, booking me again. (Thank you).
I also have several new venues coming up that I am honoured to be booked for.
I will once again be demonstrating in Ireland in November and can't wait for this..I've so missed my second home and the people.
The past eighteen months have been challenging for all of us in some way. I feel blessed to have been able to spend quality time with friends and family.
If you would like to book me for a live show then send me an email (email@example.com) or call to discuss.
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text: Gunnerkrigg Avatar thread. Apr 14, 2014 13:23:45 GMT Ophel likes this Quote Select PostDeselect PostLink to PostMemberGive GiftBack to Top Post by keef on Apr 14, 2014 13:23:45 GMT Apr 11, 2014 16:26:29 GMT Per said:If anyone wants an avatar:Time for a new avatar thread? I thought about necroing this one, but that was specifically about modifying the default Proboards avatar.Uploaded avatars are limited to 150x150 pixels, and they should obviously be related to the comic. Any requests?


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Brand Brand New California Financial Watchdog Would Just Just Take Aim At Predatory Lenders Amid Pandemic
Brand Brand New California Financial Watchdog Would Simply Take Aim At Predatory Lenders Amid Pandemic
California Assembly user Monique LimГіn (foreground) introduced a bill to produce a economic watchdog agency when it comes to state. Rich Pedroncelli/AP hide caption
California Assembly user Monique LimГіn (foreground) introduced a bill to produce a economic watchdog agency for the state.
Lawmakers in Ca are rushing to produce a brand new protection that is financial agency because of the finish associated with the thirty days. They do say it's needed because, beneath the Trump management, the key regulator that is federal been paralyzed.
Plus they state that throughout the pandemic that is leaving scores of Us citizens who will be in serious monetary straits more susceptible to predatory lenders, get-out-of-debt-scams as well as other wrongdoing.
One research this past year discovered that the federal Consumer Financial Protection Bureau's enforcement activity plunged by 80% from 2015. And cash returned to customers fallen by 96per cent.
CFPB Strips Some Consumer Protections For Payday Advances
«we have been now as states left doing the task ourselves,» states Ca Assembly user Monique LimГіn.
Along side Gov. Gavin Newsom, this woman is proposing to generate the brand new state watchdog agency, which will be called the Department of Financial Protection and Innovation. But a legislative due date means they must get it done by Aug. 31.
«customer defenses are a location where Ca really wants to show that individuals worry,» LimГіn claims. «since the economy that is fifth-largest the planet we believe that it's very important and it's really just the right move to make.»
The agency that is new supply the state wider energy and power to police aggressive loan companies, credit repair schemes, predatory loan providers as well as other shady monetary techniques.
Under Trump Appointee, Consumer Protection Agency Viewed Assisting Payday Lenders
LimГіn proposed the agency ahead of the pandemic. But she claims provided the fallout that is economic the need for more oversight is greater now.
«The timing from it is also more crucial,» she claims, noting that considering that the Covid outbreak, customer complaints about economic wrongdoing within the state are up 40 per cent. State officials state some of these complaints are about home loan organizations, signature loans, and organizations that promise to help individuals get free from financial obligation.
A list that is long of financing and customer security teams are backing the proposal. With well over 8 million individuals trying to get jobless in Ca alone, «many individuals are teetering regarding the brink of insolvency right right right here,» states Suzanne Martindale , whom works on policy problems for Consumer Reports.
» a negative loan, a high-risk payday item, an aggressive financial obligation collector, that will push some body throughout the side into poverty, into bankruptcy and homelessness in the worst feasible amount of time in the midst of a general general general public wellness crisis,» she claims. «So, the actual situation is also more powerful now.»
At a current legislative hearing, small company teams said they desire the newest agency to guard them from predatory economic methods too.
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Monetary businesses of program aren't frequently big fans of extra legislation. But Beth Mills using the California Bankers Association says she supports the brand new agency better policing some of this banking institutions' rivals.
She states many online loan providers for example face much looser laws compared to the banking institutions do.
«we might welcome greater legislation on them to be sure that we are running beneath the exact same guidelines,» Mills claims.
Nevertheless when it comes down towards the organizations that her group represents — which she claims are almost all of the big and little banking institutions and lenders when you look at the state, she claims, «we wish become exempt through the bill since the banking institutions and finance institutions that individuals represent are generally really greatly controlled at both their state and federal degree.»
California Rings Into The Brand New with A New Data Privacy Law year
And it also appears the firms that are financial the ear of some lawmakers. A team of moderate Democrats is pressuring Newsom allowing for big carve-outs for most economic businesses, a source near to the negotiations within the proposition informs NPR. And that could damage the brand new agency's capacity to pursue organizations whom make use of individuals.
Richard Cordray, a previous manager associated with the federal customer Financial Protection Bureau, says that could be a mistake that is big.
«I do not believe that the legislature should make it difficult for customers to obtain their funds straight right right back once they've been victimized by unjust, misleading and practices that are abusive» online payday loans Arizona no credit check says Cordray, that has been consulting in the bill.
Cordray claims, if it is done correctly, the new agency could be a model for any other states for how exactly to have a hardcore economic watchdog agency of one's own. In which he claims Congress envisioned that whenever it developed the federal CFPB beneath the Dodd-Frank monetary reform work.
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» The monetary reform legislation,» he claims, «had an implicit vow inside it that there is customer financial protection during the federal degree, but there would additionally be space for significant customer economic security in the state degree and that the two can perhaps work in partnership.»
It is said by him additionally envisioned that, «if one ended up being doing its work therefore the other ended up being pulling straight straight back, there nevertheless will be security for customers.» Cordray claims this agency that is new live away that vow.
But, a legislative due date means the balance has to get passed because of the finish regarding the thirty days in the event that agency will be developed this season. There is a vital hearing with lawmakers throughout the weekend.
Theoretically, the brand new agency would be developed by restructuring and expanding the dimensions and authority of a current agency called the Department of Business Oversight.


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Wittstadt-Lukianczuk Wedding 2020
Updated: Aug 27, 2020
Life as we know it changed March of 2020 - 3 months into the new decade. Lives were put on hold, plans were rescheduled, and masks became the new normal.
Marc and Courtney had their dream wedding planned out for quite some time scheduled fall of this historically insane year.
But as many couples to be wed in the year 2020 had gone through, chaos hit and a lot of changes were coming about. As life continues on, these two have gone through an enormous amount of diversity and obstacles and still somehow, through all the rubble, found a way to a happily ever after.
In front of their immediate family, I was so honored to capture and share this day with the new...
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Cheers y'all!


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DCMGA uses both Google Meet and Zoom for videoconferencing. Google Meet is excellent for small groups and meetings one hour or less. Zoom is for larger, longer meetings and requires at least two co-hosts.
Meetings on Google Meet can be initiated by anyone anytime, once they are set up in the DCMGA Google Suites for Nonprofits account or are willing to use their personal Google account. Meetings on Zoom require submission of a Zoom Meeting Scheduling Request and the presence of one of DCMGA's three Zoom administrators to open the meeting. After that, the Administrator will designate two co-hosts to handle the meeting.


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THE LAB ROOM Botanical Skin Infusion
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Shipping Weight: 250 g
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Shipping Weight: 250 g
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Rising Dragon
This elementally powerful 'wisdom' Dragon is depicted rising through typical Tibetan style clouds, which for this piece represent delusion.
Created to illustrate the narrative of a major documentary film on the epic escape of the Dalai Lama in 1959 called 'Never Forget Tibet' – 2022.
A study piece can also be seen here beautifully create in ink washes more typical of Chinese art.
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From our private database of 33,600+ case briefs...
In re Roberto d.B.
Court of Appeals of Maryland
923 A.2d 115 (Md. 2007)
Roberto d.B. (plaintiff) was a single man. He used his sperm to undergo the process of in vitro fertilization with an anonymous egg donor and an unrelated surrogate gestational host. The surrogate agreed she would relinquish all parental rights upon the birth of Roberto's child. The surrogate gave birth to Roberto's twins. The surrogate had no genetic connection to the children, but her name was printed on the children's birth certificates as their mother. The birth certificates correctly identified Roberto as the children's father. Roberto petitioned the Circuit Court for Montgomery County to remove the surrogate's name from the birth certificates. The surrogate joined Roberto's petition. The circuit court denied the petition, finding that the court did not have the power to order that the surrogate's name be removed from the birth certificates, and in any event, doing so was not in the best interests of the children. Roberto appealed.
Rule of Law
Holding and Reasoning (Bell, C.J.)
Dissent (Cathell, J.)
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Grand Palladium Lady Hamilton in Jamaica Junior Suite
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A London hotel in the North London providing decent comforts is the Hilton Islington. It has all the facilities that are provided in the Hilton chain. The rooms can be standard, Deluxe Suites or plain suites. Modern features like cooling, web gain access to have actually been offered the visitors. Those who don't want to miss their everyday exercise, there is a fitness club in this hotel in London.
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Alienation TCS F1 Folding Tire
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Save Liquid error (product-badge line 32): Computation results in '-Infinity'%
The Alienation TCS F1 Folding Tire-20x1.95" will not make your bike as fast as a 1000 hp open wheel race car, but it will make you faster than you and your worn-out, old, no-name tires. Featuring a directional tread pattern with a hard compound in the center and a softer outer tread. This tire is meant for use on the front of your BMX race bike. Designed to complement the Alienation TCS R1 rear tire.


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When it comes to cricket, no player can continue to be in the best of forms every single time they head out to the pitch for their team or franchise. A similar situation took place in the 2021 Indian Premier League on Tuesday for Rajasthan Royals hitter Riyan Parag, who was dismissed for just four runs in five deliveries.
However, such an understanding often goes over the head of some overzealous fans who do not see reason and lack patience. Thanks to the availability of direct contact between players and fans with the help of tools like Twitter and Instagram, showing their frustration towards these players has become extremely easy for common folk.
Legendary Sunil Gavaskar remembers Dhoni after Riyan Parag's failed helicopter shot. pic.twitter.com/u7NSiLDBEK— Shubham Shah (@Shubham41419985) September 22, 2021
Riyan Parag is big loser in royals squad. Just after bowling one legal delivery, trying fancy things as if RR in comfortable position in the game. In first innings, his fancy helicopter shot caused downfall of Rajasthan in the game !!— Mathmagician (@NaniPruthviraj) September 21, 2021
Riyan Parag ko helicopter shot try nahi karna tha, wo keval ek hi legend khel sakta hai, naam to suna hi hoga—     (@Extra__Cover) September 21, 2021
Another disappointing drawback of such a level of communication is that all the criticism is not only accessible to the players but also to their family members. While players sometimes respond to their critics and shut them up for good, their family members often refrain from doing so.
So after Parag had to walk back after an early dismissal, his Twitter handle was buzzing with trolls who were simply there to criticise him for getting out early, refusing to see the kind of hard work he has been putting into getting better at his craft every single day.
Bad day for Riyan Parag ?? Batting, Fielding ... #RRvsPBKS #IPL2021— Arun Jyoti Nath (@ArunJyotiNath2) September 21, 2021
Bad day for Riyan Parag— Mr. Nirlipta / Mr. ನಿರ್ಲಿಪ್ತ (@NkBlr) September 21, 2021
1st half me riyan parag bond ban raha catch ke bad selfie le rahe the ajj catch drop ki to kiya cameraman ne uski selfie https://t.co/0BkuAWWsCp— SHASHANK (@IBeingShashank) September 21, 2021
But it wasn't just Parag who saw the negative comments, it was his mother as well and she immediately knew that her little boy needed her support. Since Parag is in the United Arab Emirates, inside a completely sealed bio bubble, it was not possible for the mother and son to meet.
So, all she could do was send a simple message on WhatsApp, and based on the reaction Parag has had, it is safe to say that that message did its work just fine.
Maaaa. She knows. Always pic.twitter.com/BlTRJCOSgy— Riyan Parag (@ParagRiyan) September 23, 2021
"How are you doing baba? Don't stop believing in your abilities," she wrote in her text in the screenshot that was shared by the young cricketer on his Twitter handle. "Maaaa. She knows. Always," Parag wrote in the caption.
It didn't take long for the supporters to show up on his Twitter thread and compliment the mother-son duo for sharing such a heartwarming moment.
You can conquer the whole world, if she's just behind you. https://t.co/TwYrT4y1ns— KIRANKUMAR REDDY (@imkkreddy18) September 24, 2021
The only creature who cares https://t.co/tEkioUI0rq— Harsh Sharma (@wanted_munda_99) September 24, 2021
It's so cute how she has your profile pic. https://t.co/9eRiUPjyCw— ? ? ? ? ? ? (@ittnisibaathai) September 23, 2021
Oh my god. This is so beautiful. https://t.co/XjKXYUvrBw— TheRandomCricketPhotosGuy (@RandomCricketP1) September 23, 2021
Mothers are the BEST. https://t.co/zwyhkB3aie— Paridhi Srivastava 7 (@BeingKohlicious) September 23, 2021


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Indian Ocean Studies: Cultural, Social, and Political Perspectives (Routledge Indian Ocean Series) by Shanti Moorthy pdf epub fb2
Title: Indian Ocean Studies: Cultural, Social, and Political Perspectives (Routledge Indian Ocean Series)
Other Formats: azw docx lrf azw
Pages: 454 pages
Publisher: Routledge (November 11, 2009)
Language: English
Category: Other
Size PDF version: 1397 kb
Size EPUB version: 1590 kb
Subcategory: Humanities
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The Indian Ocean is famously referred to as the "cradle of globalization," as it facilitated cultural and economic exchanges between Africa, the Arab world, the Indian subcontinent, Southeast Asia, and China, for 5000 years prior to European presence in the region. As this ocean's significance has gained increasing attention from scholars in recent years, few have examined the 'human' dimensions in Indian Ocean exchanges. Including the work of historians, geographers, anthropologists and literary analysts, each essay in this volume addresses a specific human factor, such as the fate of the creole in the Bay of Bengal, creolization as a globalized phenomenon, migrancy and diaspora, the lives of seafarers then and now, and the lives of those who inhabit the ocean's littoral. This volume is a necessary addition to the field of Indian Ocean studies.


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By Takeru Yanagi
This ebook provides an research of our present wisdom at the starting place of the Earth's continental crust. There are elements to contemplate: tectonic and igneous procedures. Tectonic features contain sedimentary accretion, terrane accretion, and continental collision at continental margins, in organization with plate subduction. those techniques bring about the formation of huge mountain belts, the build up of which accurately grows the continents. notwithstanding, those tectonic points are involved in fabric recycling in the crust, and for that reason don't give a contribution to volumetric development of continental crust. Igneous approaches drawback separation of continental crust from the mantle and lead to the volumetric progress of continental crust. for that reason, the main target of this publication is to systematically study why and the way the Earth's continental crust types, through comparing magmatic strategies at island arcs the place new continental crust forms.
Read or Download Arc Volcano of Japan: Generation of Continental Crust from the Mantle (Lecture Notes in Earth Sciences) PDF
Best earth sciences books
The Biomarker Guide: Volume 1, Biomarkers and Isotopes in the Environment and Human History
The second one version of The Biomarker consultant is an absolutely up-to-date and improved model of this crucial reference. Now in volumes, it offers a finished account of the function that biomarker expertise performs either in petroleum exploration and in figuring out Earth background and tactics. Biomarkers and Isotopes within the setting and Human historical past information the origins of biomarkers and introduces uncomplicated chemical ideas proper to their research.
Empowering Metropolitan Regions Through New Forms of Cooperation: 0 (Euricur)
This insightful publication analyzes the advance of cross-border and cross-sector partnerships in a few ecu towns and areas. together with, among others, Copenhagen, Budapest, Helsinki, Munich and Catalonia, those case reports make clear the criteria deciding on the good fortune or failure of the coalition-forming method.
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The evolution of the Argentina Continental Margin in the course of the Quaternary and the stratigraphic and morphosedimentary configuration replied to climatic variability, oceanographic alterations, glacioeustatic fluctuations and tectono-isostatic strategies, which started to influence at the margin in the course of earlier geological sessions.
The Social Life of Maps in America, 1750-1860 (Published by the Omohundro Institute of Early American History and Culture and the University of North Carolina Press)
Within the age of MapQuest and GPS, we take cartographic literacy without any consideration. we must always now not; the facility to discover that means in maps is the fruit of an extended means of publicity and guideline. A "carto-coded" America--a kingdom within which maps are pervasive and meaningful--had to be created. The Social lifetime of Maps tracks American cartography's staggering upward thrust to its unheard of cultural effect.
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"May get hurt." Bella Hadid vs. Gigi and Leonardo DiCaprio's romance
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26-year-old American supermodel Bella Hadid spoke out against the new romance of her sister Gigi and Hollywood actor Leonardo DiCaprio. The Mirror writes about this.
According to insiders, the star of Palestinian origin convinces his sister not to meet with the legendary film actor. Bella believes that 27-year-old Gigi is not suitable for DiCaprio, because she is too good for him.
"Bella thinks that Gigi is too good for him. The fact that he, without thinking about his ex-girlfriend, met with Gigi, strains her. She is worried that her sister might get hurt," says an insider close to the star sisters .
On the eve of Leonardo DiCaprio broke up with 25-year-old model and actress Camilla Morrone. After that, the Internet began to actively joke about the young lovers of the American actor, because almost all of DiCaprio's girls were under 25 years old.
Immediately after the break of a 5-year relationship, celebrities attributed an affair with Ukrainian model Maria Beregova, but speculation was debunked , because the actor was spotted on a date with supermodel Gigi Hadid.


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Riverbend Center for Mental Health
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The main treatment approaches at this facility include Individual Addiction Counseling, Couples and Family Counseling, Group Addiction Therapy, Cognitive Behavior Therapy. The facility also offers its services in different environments, such as Outpatient Recovery.
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Silence is the root of everything. If you spiral into its void a hundred voices will thunder messages you long to hear. ~Rumi
"If you spiral into its void…" I am drawn to silence. And to spirals. I am drawing spirals. I see spirals everywhere. What is that all about?
Since listening is my passion, I image the ear as essentially a spiral in its outer shape. And delightfully, the inner ear, or chochlea, is a labyrinth-like spiral. There, the sound that drums on the ear tickles tiny vibrating hairs into messages of a frequency the resonates with the synapses of the brain.
Listening is not linear, but rather a winding of Wisdom. From inklings in the soul, Wisdom wanders from the vibrations of the vocal chords, through air to ear to brain to mind/heart/meaning.
The spiral listening we do in spiritual direction is part of a Great Spiral. John Baldock writes in The Essence of Rumi,
In Rumi's eyes, all creation is 'a great upward spiral of metamorphoses' (Lewis, Rumi, p. 416). In this upward, transformative spiral, the mineral realm becomes sustenance for plants, plants become food for animals, animals become food for humans, and humans have within them the potential to be transformed into a state in which they become one with the Divine Unity.
Rumi may not sound like standard Christian theology. Nor should he, since Rumi was Sufi/Muslim. And a mystic. Hence Rumi often sends me musing — "sounding out Wisdom."
Another voice, one of my most respected Christian teachers, Richard Rohr, perhaps says the same thing in a more biblical way:
Salvation is much more about at-one-ment from God's side than any needed atonement from our side. Jesus did not come to change the mind of God about humanity (it did not need changing)! Jesus came to change the mind of humanity about God! ~ Richard Rohr, Daily Meditations, January 21, 2018
Jesus saw us spiraling toward God. Toward learning to Love as One Beloved Universe. And I loop back to him again and again to recall the trajectory: Wisdom's DNA.
You will see spirals everywhere on my brochures and business cards for SOUNDING OUT WISDOM. This will give you a clue why.
What does a spiral signify to you? Or is there another essential shape, a circle, perhaps, that has currently captured your imagination?


text: Can't decide where to go for dinner – experience the cuisine of five of the city's finest chefs in one fantastic meal at Avila's Chefs to Watch Dinner. On Tuesday, February 24th, host chef Rodney Murillo welcomes colleagues Marc Orfaly of Pigalle and Marco, Tony Susi of Sage, Dante de Magistris of dante to collaborate on a five-course menu. Each chef takes a course from hors d'oeuvres to dessert (which will be taken care of by Davio's and Avila's pastry expert Tom Ponticelli) and each course will be paired with a wine plucked from Avila's impressive stores. The dinner, which costs $125 per person, begins at 7:00pm. To reserve your spot call 617.267.4810; tickets will also be available at the door – if there are any left.


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Thesaurus / formalFEEDBACK
synonyms for formal
synonyms for formal
- academic
- ceremonial
- explicit
- legal
- precise
- proper
- solemn
- strict
- express
- official
- regular
- ritual
- set
- approved
- ceremonialistic
- ceremonious
- confirmed
- conventional
- decorous
- directed
- fixed
- formalistic
- lawful
- methodical
- prescribed
- pro forma
- punctilious
- rigid
- ritualistic
- stately
- stereotyped
- stereotypical
- systematic
See also synonyms for: formalness
- polite
- precise
- nominal
- aloof
- by the numbers
- ceremonious
- conventional
- decorous
- distant
- exact
- playing the game
- prim
- punctilious
- reserved
- seemly
- sententious
- starched
- stilted
- straight arrow
- stuffy
- unbending
antonyms for formal
Roget's 21st Century Thesaurus, Third Edition Copyright © 2013 by the Philip Lief Group.
TRY USING formal
See how your sentence looks with different synonyms.
Quiz Yourself On These Adoption TermsSTART THE QUIZ
How to use formal in a sentence
Broadly, the war is between the formal linguists and the sociolinguists.TALKING IS THROWING FICTIONAL WORLDS AT ONE ANOTHER - ISSUE 89: THE DARK SIDEKEVIN BERGERSEPTEMBER 9, 2020NAUTILUS
Taking place after the 400-person formal dinner, it's geared specifically toward younger people and costs less than one-third of the spring benefit's entry-level ticket.HOW NONPROFITS ARE CATERING TO MILLENNIALS AND RETHINKING THE CHARITY GALA FOR YOUNGER GENERATIONSRACHEL KINGSEPTEMBER 7, 2020FORTUNE
No surprise, there's been a trend away from formal event–oriented wear, but other than that there hasn't been much change.THE CEO STRIVING TO MAKE VINTAGE, SECONDHAND CLOTHING AS POPULAR AS FAST FASHIONRACHEL KINGSEPTEMBER 6, 2020FORTUNE
Those interactions are less formal than what you get with video-conferencing services.TEEMYCO CREATES VIRTUAL OFFICES SO YOU CAN GRAB A ROOM AND TALK WITH COLLEAGUESROMAIN DILLETSEPTEMBER 4, 2020TECHCRUNCH
It's not as formal as perhaps a medical leave of absence where a third party is approving a leave request.HOW MANAGERS CAN RECOGNIZE BURNOUT REMOTELYKRISTINE GILLAUGUST 28, 2020FORTUNE
This tendency for informal learning to eclipse formal learning in terms of our behaviors is not limited to doctors or police officers.WHY SOME SENIOR OFFICERS ARE MAKING IT HARDER FOR POLICE DEPARTMENTS TO FIGHT RACISMMATTHEWHEIMERAUGUST 26, 2020FORTUNE
Since apartments are already allowed in the areas in which it applies, the city can adopt the measure without going through a formal "re-zoning" process, which would trigger state-mandated studies that could take years to complete.SINGLE-FAMILY ZONING'S CENTURY OF SUPREMACY IN SAN DIEGOANDREW KEATTSAUGUST 26, 2020VOICE OF SAN DIEGO
The hospital's chief nursing officer told investigators that there had been no formal meetings to implement the ZIP code list with staff and that no formal policy was developed regarding its use.FEDERAL INVESTIGATION FINDS HOSPITAL VIOLATED PATIENTS' RIGHTS BY PROFILING, SEPARATING NATIVE MOTHERS AND NEWBORNSBY BRYANT FURLOW, NEW MEXICO IN DEPTHAUGUST 22, 2020PROPUBLICA
The four researchers fed the Keller proof into a formal proof checker — a computer program that traced the logic of the argument — and confirmed it works.COMPUTER SEARCH SETTLES 90-YEAR-OLD MATH PROBLEMKEVIN HARTNETTAUGUST 19, 2020QUANTA MAGAZINE
Among the spaces Covid-19 has closed around the world are countless offices, nightclubs, and other habitats of formal footwear.STILETTO SALES ARE STUMBLING BECAUSE OF COVID-19MARC BAINJULY 13, 2020QUARTZ
- accepted
- accustomed
- commonplace
- correct
- current
- customary
- decorous
- everyday
- expected
- fashionable
- formal
- general
- habitual
- in established usage
- ordinary
- orthodox
- plain
- popular
- predominant
- prevailing
- prevalent
- proper
- regular
- ritual
- routine
- square
- standard
- stereotyped
- straight
- traditional
- tralatitious
- typical
- usual
- well-known
- wonted
Roget's 21st Century Thesaurus, Third Edition Copyright © 2013 by the Philip Lief Group.


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Reconstruction of St. Patrick's Church
Early Renovations
The financial prosperity and growth of the city of Toledo during the early 1920s, which was felt by most of the country as well, did not reach St. Patrick's. With decreased attendance came financial woes. At the same time, the church was also in need of repairs. Father Keyes decided that the best way to fund these repairs would be by selling the now abandoned St. Patrick's Cemetery, which had been replaced as the resting place for the parish by Cavalry Cemetery.
With this extra income, the renovation of St. Patrick's began. Changes included the marble floors that surround the altar and walls, new chandeliers and matching wall lights, and the addition of the signature shamrock inlays on the new terrazzo floors throughout the church. A new "Kilgen" organ was added to the choir loft, as well as new altar furniture. Outdoor improvements consisted of updating the front walkway, steps, and retaining walls. Other additions include the donated Stations of the Cross statues that adorn the church, which replaced pictorial representations.
In 1934, the church was the victim of vandalism. The vandals badly damaged the altar and stole various ornate gold objects. Most were recovered a few blocks away. Despite the vandalism, Mass was held the following Sunday.
In 1937, the last of the early renovations was completed as the cross on top of the spire was replaced due to damage. The new cross was made of wood and sheathed in copper and gold leaf. When completed, it was slightly smaller than the original galvanized steel cross that it replaced.
Renovation Projects, 1940s-2006
There were various projects between the 1937 steeple cross replacement and the current major renovation of the church that attempted to keep the aging building as well-maintained as possible.
In what would prove to be a tremendous bargain, Monsignor Schmit discovered three slabs of marble in a local junkyard. Schmit was able to purchase the three slabs for a mere $21.00. They would become the altar currently in use at St. Patrick's Church. The altar would not go unscathed, as in 1974 a scaffolding set up to make emergency repairs to glass high above the church came crashing down on the altar.
The 1980s found the church in financial crisis again. In 1984, the church created The Society for the Preservation of St. Patrick's Church in an attempt to bring back wayward parishioners and gain much-needed money for repairs. The society proved very adept at regaining lost parishioners, in addition to new members from Toledo's Irish and Catholic communities. One of the first major repairs was to the church's heating and cooling facilities, followed by the cleaning and restoration of the stained glass windows and updating of the nearly 100-year-old light fixtures. Later projects included remodeling the sacristy, removing pews at the rear of the church, restoring the louvers in the bell tower, and the construction of a new reconciliation room inside the church.
In 1972, the National Park Service added St. Patrick's Church to the National Register of Historic Places. In 1987, after years of controversy and various name changes, the name of St. Patrick's Church was officially changed to the Historic Church of St. Patrick. The name remains today. In 1991, the church was awarded a plaque of excellence by the Maumee Valley Historical Society for their continued efforts to maintain the church while "everything around it has been demolished or rebuilt."
History of the St. Patrick's Steeple
The Historic St. Patrick's Church was originally constructed with a galvanized steel spire and steeple. Due to the height of the church, as well as the metallic covering of the newer cross, the landmark topping of the church was prone to lightning strikes. There have been at least four strikes, with the last recorded instance occurring in 1998.
A lightning strike in 1954 shorted out the electric organ. The next strike would prove to be the most catastrophic. On September 9, 1980, the cross at the top of the steeple was hit. When the lightning struck, the copper sheathing around the wooden cross fused the copper to the cross and a fire ensued. Due to the height of the steeple, the local fire department was unable to put out the fire before the steeple was completely destroyed. The fire department was able to minimize the damage to the church, however, and most of the destruction was limited to the steeple and the roof. The organ also suffered water damage.
After the most recent lightning strike in 1998, the church was retrofitted with a lightning protection system.
Following the 1980 fire, St. Patrick's was without a steeple for almost a generation. In September of 2007, the steeple was re-attached to the church in a Skybreaking Gala.
2006-2007 Renovation Projects
After more than a century of service and ever-changing Toledo weather, St. Patrick's was beginning to show its age. Cracks were forming in the ceiling and on the walls, the brilliant stained glass windows were not as vibrant, and the many statues within the church were beginning to fade.
After discussion and debate in 2006, a full scale renovation of the church began. Almost every single aspect of the church, both inside and out, was to be renovated or improved. The majority of the funding was provided by the estate of Margaret Kennedy Hays Tank, a lifelong parishioner who passed away in 2006. A statue in her honor was placed in the Memorial Garden next to the church.
On June 10, 2007, a Mass of Thanksgiving was given to celebrate the restoration of the church. In September of that year, St. Patrick's held a Mass of Thanksgiving to commemorate the firefighters who fought the 1980 fire. Leonard Blair, Bishop of Toledo, presided over the Mass, which included a full choir; harpist (Denise Grupp-Verbon); the Academy Brass Quintet; the Church Organist (Terry Brassell); as well as Pipes and drums bagpipers from the Toledo Fire Fighters. A "skybreaking" was held on September 15 of that year to celebrate the return of the steeple to the historic church. The organ was blessed in a Mass held on October 21, and the inaugural organ concert was held on October 23.
Below are pictures of the renovations.
St. Patrick's had been without its signature steeple for almost 27 years when a replacement was set atop the church on September 6, 2007. It was built by Campbellsville Industries – the self-proclaimed "steeple people" – of Campbellsville, KY. The steeple measures more than 89 feet in height and weighs almost 12 tons. Including the cross at the top, the church is almost 250 feet tall and is easily recognizable from freeways, streets, and areas outside of the city.
The new steeple was given an "aged" finish so that it would not stand out from the 105-year-old monument built by Father Hannin. Most of the project was covered by funds donated to the church after the passing of Margaret Hays Tank, a lifelong member of St. Patrick's. A statue honoring Mrs. Tank sits in the Memorial Garden outside of the church. Other funds were collected through weekly tithes and church fundraisers.
Historic St. Patrick's Church, 2007
In 1987, after years of controversy and various name changes, the name of St. Patrick's Church was officially changed to the Historic Church of St. Patrick. The name remains today.
With the $3 million renovation nearly complete, the Historic Church of St. Patrick has almost returned to normal. On June 10, a Mass of Thanksgiving was given to celebrate the restoration of the church. Events held later in 2007 commemorated the firefighters who fought the fire that ensued after the steeple and spire were hit by lightning, a "Skybreaking Gala" was held on September 15 when the new steeple was placed on top of the church, the organ was blessed in a Mass on October 21, and the inaugural organ concert was held on October 23.
On June 10, 2007, a Mass of Thanksgiving for the Restoration of the Church, presided over by Bishop of Toledo Leonard Blair, occurred at the newly renovated church. The Mass included a full choir, harpist (Denise Grupp-Verbon), the Academy Brass Quintet, the Church Organist (Terry Brassell), as well as Pipes and drums bagpipers supplied to the church from the Toledo Fire Fighters.


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- This event has passed.
Fremont Solstice Parade
June 20, 2020 @ 1:00 pm - 2:00 pm
The Fremont Solstice Parade is a family-friendly and a beloved Seattle event.
DETAILS: Streaming Live on Saturday, June 20th at 1 pm.
WHERE?: Facebook (https://www.facebook.com/FremontArtsCouncil/)
Youtube (https://www.youtube.com/channel/UCwHKpwGXzPGtpeBuZFV-Gug)
Videos and pictures of the PAST, PRESENT, and FUTURE of the Fremont Arts Council including our beloved Green Hat Presenters.
Celebrate with us on the longest day of the year with the Fremont Arts Council's most historic celebration art event! We have a new world view "stay at home scope", meaning limited human contact, a longing for love, small acts of kindness, and making art is our reality now.
In an optimistic effort to create a small fraction of the FSP, we have decided to go virtual. Thanks to the generous support of TPN & NASH (northwest arts streaming hub), offering us a packaged product that will be streamed via FAC Facebook and YouTube on June 20 at 1 pm (Pacific Time). FSP Virtual Event will be a compilation program of prerecorded content made of historical archives, ensembles, art, personal testimonies, and of course our Green Hat Go-Getters lead by Cheer Seattle and friends!
Our FSP Virtual Event theme for 2020 is Past, Present & Future. We are excited to announce our co-hosts Peter Toms, Harper, and Scarlet Parke! Join more than 60 dazzling community-based ensembles as they submit their art! All welcome; drag queens, giant puppets, stilt walkers, floats, dancers, musicians, Green Hat Go-Getters, and more! Together they will create a kaleidoscope of joyous human expression in our virtual program!
What (MADE) the Fremont Solstice Parade unique?
- EVERYONE CAN BE AN ARTIST. Full participation is completely open to the public.
- PEOPLE POWERED. No motorized vehicles are allowed
- ALL ABOUT THE ART. No printed words or logos are allowed. Participants relish the challenge of proclaiming their message through creative expression.
- FSP Virtual Event 2020 is now accepting submissions that include art cars, pets, words of inspiration and logos affiliated by non-profit organizations only.
Join the FAC Team!
Will YOU join the parade of friends who make community celebration art events happen? The FAC needs to grow our team of folks that are directly involved in event production, communications, fundraising, administration, and a myriad of other essential tasks year round. These awesome events are made possible by volunteers. Join the team!! …
Join the "FAC List" our Inner Circle Collaboration Group
The "FAC List" is a moderated discussion group for our inner circle of friends that want to stay in touch, learn about our current happenings, participate in event planning, share community art postings of interest, and help the FAC thrive. To join: visit faclist and click "apply for membership". Or, if you don't have a Google account: Subscribe to our Mailing List … – and check the "get more involved" option for "FAC List – Subscribe Me".
Support Community Art!
Want to keep the Fremont Arts Council in glitter and goo-gahs? We could not create our events and community art workshops without the support of our community. Donate or become a member …


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Office Space in an Iconic Building in the Chicago Skyline (Chicago, IL)
An iconic point in the Chicago skyline, this building overlooks Chicago's Millennium Park and provides gorgeous views of the Lake. It is surrounded by an eclectic mix of shops, bars, restaurants and other great attractions.
Located adjacent to the Chicago Underground Pedway and near all major CTA transportation lines, the easy access to this building makes it a premier office location in the East Loop; all one block from Lake Shore Drive.
Freshly renovated suite with full amenities, the 8th floor is relaxed and quiet, with plenty of space. Perfect for marketing teams, tech & software companies, and businesses with a mix of regular and partly-virtual employees; leasable team rooms are in abundance. Both free, private huddle rooms and 3 rentable conference rooms are available, including the Hancock room which incorporates moving desks for a variety of setup options. The design is inspired by the tranquility of coniferous forests. Eighth floor tenants also have access to our twenty-eighth floor conference rooms and the cognac room.
The first scene off the elevators, of a clean-lined reception desk and bright lake views through the glass windows of an impressive conference room, sets the stage for you and your client's experience on the 28th floor. The cafeteria is large and congenial, a large private co-working room is available as are 3 huddle rooms, all first come-first served, and two large conference rooms provide stunning displays of the city; the Buckingham room boasts floor to ceiling windows. Bright pops of color and curving white lines mimic the sails of the boats visible in the harbor.
Office Markets Served
IL - Chicago-North Michigan Ave., IL - Chicago-East Loop, IL - Chicago-Central Loop
Office Building information
We occupy 37,548 square feet of office space in the office building


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Spectacular studio apartment on the 29th floor in Charrington Tower, E14 offers unbeatable views of the City. The apartment offers 373 sqft of internal space and benefits from an open plan kitchen living room with built in wardrobes and stylish bathroom. Finished to a superb standard this property isn't one to be missed. Residents of Charrington Tower benefit from access to a number of onsite facilities including a fully equipped gym, swimming pool, a 43rd floor sky lounge and a 24hr concierge.
Charrington Tower is prominently placed with easy access to Canary Wharf by foot or local transport such as the DLR, travel will be further enhanced by the new Crossrail line.


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Complete Heart Block Complicating Takotsubo Syndrome: Case Report and Literature Review
An 81-year-old woman presents with shortness of breath resulting in a diagnosis of picornavirus and complete heart block. Troponin was elevated and there was concern about acute coronary syndrome. The final diagnosis after echocardiogram and coronary angiogram was Takotsubo syndrome in addition to the heart block which required pacemaker insertion.
1. History of Presentation
An 81-year-old woman presented to a peripheral emergency department with a two-week history of shortness of breath. She had been commenced on oral antibiotics for a lower respiratory tract infection in the community.
1.1. Past Medical History
The patient has a history of hypertension, dyslipidaemia, osteoporosis, anxiety, and gastrooesophageal reflux disease.
1.2. Medications at Admission
Irbesartan 300 mg daily, hydrochlorothiazide 12.5 mg daily, thyroxine 50 mcg daily, rosuvastatin 10 mg daily, sertraline 25 mg daily, aspirin 100 mg daily, metoprolol 12.5 mg twice daily were the medications for the patients.
1.3. Clinical Course
On assessment in the emergency department, the patient was found to be in complete heart block (CHB) with a ventricular escape of 48 bpm (Figure 1). She denied chest pain on presentation or recently. High sensitivity troponin was found to be elevated at 525 ng/L (<16). The patient was transported to the local tertiary hospital for the management of acute coronary syndrome and complete heart block. A respiratory viral PCR swab was sent prior to transport. The swab later returned positive for picornavirus. B-type natriuretic peptide (BNP) was elevated at 1174 ng/L (<266) and subsequent troponins fell.
Echocardiogram after transfer revealed a large area of left ventricular apical hypokinesis, moderate atrial dilatation, and tricuspid regurgitation in the context of the known complete heart block (Figure 2 and supplementary figure 1).
Cardiac catheterisation was delayed secondary to inability to lie flat as a result of the respiratory infection, with cough fits and agitation without desaturation. This was performed on day 9 postpresentation. The coronary angiogram revealed nonobstructive coronary artery disease, with a focal 50% stenosis in the midleft circumflex coronary artery (supplemental figure 2). The left ventriculogram performed revealed near normalisation of the apical hypokinesis and an elevated end diastolic pressure of 20 mmHg (Figure 3). Laboratory findings are listed in Table 1.
1.4. Management
The complete heart block continued after cessation of the metoprolol. The patient was initially managed conservatively as the ventricular escape was greater than 40 bpm without hypotension. The patient did have exacerbations of coughing and agitation when lying flat, which could be attributed to either heart failure or respiratory tract infection. Chest X-ray on presentation was not consistent with heart failure despite the raised BNP. The picornavirus infection was managed conservatively. Nine days after presentation, once the patient was able to lie flat without incident, a dual chamber Biotronik pacemaker was implanted, DDD 60–130 (Figure 4). The patient was discharged on aspirin, irbesartan, rosuvastatin, and sertraline.
1.5. Follow-Up
Interrogation of the pacemaker 6 weeks postimplantation revealed underlying complete heart block with 100% ventricular pacing, no tachyarrhythmias, and satisfactory device parameters. The patient remains independent in the community 6 months following discharge.
2. Discussion
The patient had previously been referred to a cardiologist as an outpatient due to concerns regarding cardiomegaly on chest X-ray and resistant hypertension. Investigations completed 6 months prior to the patient's hospitalisation revealed normal left ventricular size and systolic function on an echocardiogram and right bundle branch block on an electrocardiogram.
It appears that the Takotsubo syndrome (TTS) in our patient's case was precipitated by the lower respiratory tract infection with picornavirus. This phenomenon of an emotional or physiological insult as a trigger for TTS has been well described. This case is unusual given the presence of complete heart block in association with TTS at time of presentation. It is unclear when the patient developed complete heart block as the ventricular escape was robust and was well tolerated hemodynamically. There was preexisting right bundle branch block, and the possibility of progressive conduction disease is high.
The alternative diagnoses for this case include acute coronary syndrome and viral-induced myocarditis. Picornavirus family has been associated with viral myocarditis in other cases and series [1]. Cardiac magnetic resonance imaging could help distinguish in cases were the diagnosis is unclear. We felt the characteristics of the echocardiogram and angiogram were consistent with TTS, and subsequently, cardiac magnetic resonance imaging and cardiac biopsy were not pursued.
Acute coronary syndrome was another possible diagnosis, with spontaneous recanalization. We felt this was unlikely given that the extensive wall motion abnormality was beyond a single coronary artery territory (the patient did not have a left anterior descending that wrapped around the apex) and was disproportionate to the peak troponin.
Several case reports of TTS and CHB exist [2–4]. The clinical challenges are twofold: firstly, determining which precipitates the other, and secondly, determining the need for a cardiac implantable electronic device (CIED). If the TTS is secondary to CHB, then pacing will be required; however, if the CHB is secondary to TTS, then there is the possibility of recovery and a CIED can be avoided. Cases of both scenarios have been reported in the literature [5, 6].
CIED implantation is not a benign procedure with recent research documenting a high complication rate of approximately 10% [7]. There are case reports of TTS occurring post CIED implantation [8]. Case reports of TTS and CHB have described implantation of dual chamber pacemakers, biventricular pacemakers, and defibrillator for the treatment of CHB [9–11]. One of the largest consecutive series of TTS reported a CHB prevalence of 2.2% [6]. Including our case, we were able to identify 24 reported cases of CHB complicating TTS. In four of the cases, a CIED was not implanted due to the resolution of the heart block. In further two cases, the AV block resolved postimplantation of the CIED (Table 2).
3. Conclusion
TTS is not a benign condition and presents a number of clinical challenges. An association with complete heart block is not uncommon and often requires CIED implantation.
Take-home messages and learning objectives are as follows: (i)Takotsubo syndrome can result in a wide range of dangerous arrhythmias, both brady and tachycardic(ii)Takotsubo syndrome can complicate other cardiovascular disease entities(iii)Most, but not all patients who have complete heart block and Takotsubo syndrome require a pacemaker
|Cardiac implantable electronic device
|Complete heart block (third-degree atrioventricular block)
|Takotsubo syndrome.
During the time of drafting, all authors were employed by Hunter New England Health. The employer had no role in drafting or reviewing the manuscript.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Supplementary Materials
Supplementary 1. Supplemental Figure 1: Transthoracic echocardiogram performed on presentation. Apical 2 chamber view, at end diastole (left) and end systolic (right) demonstrating left ventricular apical hypokinesis. Supplemental figure 2: Coronary angiography, with the left coronary artery (left) and the right coronary artery (right) demonstrating non-obstructive coronary artery disease.
Supplementary 2. Supplemental Videos: Video 1: Transthoracic echocardiogram performed on presentation. Apical 2 chamber view demonstrating apical hypokinesis with preserved basal function consistent with takotsubo syndrome. Video 2: Transthoracic echocardiogram performed on presentation. Apical 3 chamber view demonstrating apical hypokinesis with preserved basal function consistent with takotsubo syndrome. Video 3: Transthoracic echocardiogram performed on presentation. Apical 4 chamber view demonstrating apical hypokinesis with preserved basal function consistent with takotsubo syndrome. Video 4: Cardiac catheterisation performed on day 9, left ventriculogram demonstrating resolution of the apical hypokinesis.
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Author: NIKON
Brand: Nikon
Color: Black
- Full frame 243 megapixel CMOS image sensor and expeed 4 image processor
- Full HD 60/50/30/25/24p video
- Built in Wi-Fi connectivity and compatibility with the WT 5a plus UT 1 communication unit
- Shoot up to 65 fps at full resolution frame size (pixels): 1920 x 1080
- Pro video feature set including: Simultaneously record uncompressed and compressed, manually control ISO, shutter speed and aperture while recording even use power aperture control for smooth iris transitions and auto ISO for smooth exposure transitions
- Compact, lightweight and slim unibody (monocoque) body design with tilting Vari angle LCD display
Package Dimensions: 239x323x2722
Release Date: 23-09-2014
Details: From the Manufacturer Bring your vision to life with Nikon's first full-frame D-SLR to feature a tilting Vari-angle display and built-in Wi-Fi� connectivity. With pro-caliber video features inspired by the D810, the same autofocus and metering system used in the D4S and D810, a newly designed 24.3MP FX-format CMOS image sensor and EXPEED 4 image processor, the D750 delivers a feature set unlike D-SLRs its size. A monocoque design keeps the camera remarkably slim, compact and lightweight, and a control layout based on Nikon's flagship cameras makes for comfortable, intuitive handling. The D750 will deliver superb performance. Full-frame freedom, outstanding agility and the convenience of built-in Wi-Fi®.For those who find inspiration everywhere, who switch between stills and video without missing a beat, who want the look only a full-frame D-SLR can achieve and who love sharing their shots, the D750 is the tool to unleash your artistry. With features inspired by D4S and D810, the D750 brings dazzling image quality, cinematic video capabilities and pro-inspired handling in a nimble design with a tilting Vari-angle LCD and built-in Wi-Fi connectivity. Enthusiasts upgrading from a DX-format D-SLR will marvel at the D750's full-frame performance. Pros seeking a primary or secondary camera for fast-paced shoots will appreciate the D750's familiar handling and speed. And filmmakers looking for a compact D-SLR to bring a production to life or to capture B-Roll will find the D750 a perfect fit. The D750 is a thrilling centerpiece of an exceptional imaging system.Ignite your creative desiresA serious tool for serious shootersThe D750 has a feature set unlike full-frame D-SLRs its size. It uses the same autofocus and metering technology as the D4S and the D810—Nikon's powerful 51-point AF system with 15 cross-type sensors and 3D Color Matrix Metering III with a 91,000-pixel RGB sensor. It's fast and responsive; shoot 6.5 fps at full resolution. And it's endlessly versatile; shoot stills in multiple formats, video with enhanced definition, smooth time-lapse sequences up to 9,999 shots in-camera and more—all with stunning sharpness and rich tonality. Open new compositional possibilities with its 3.2-inch 1,229k dot tilting Vari-angle LCD display, or use a compatible smartphone or tablet as a remote monitor for Live View shooting.Take your passion to the next level24.3MP FX-format sensor and EXPEED 4Like every Nikon full-frame D-SLR, the D750 achieves a level of image quality few other manufacturers can match. Its newly designed 24.3MP FX-format CMOS image sensor is paired with EXPEED 4 image processing for fast frame rates, a low noise, wide ISO range of 100 to 12,800 (expandable up to ISO 51,200), Full HD video with enhanced definition and reduced noise at high ISO sensitivities, minimal moiré, jaggies and false colors and a Nikon first—autofocus performance down to -3EV. Paired with the versatile array of full-frame or DX-format NIKKOR lenses, the D750 is capable of telling any story you can imagine.Shoot cinematicallyCutting edge HD video capabilitiesWith professional video capabilities inspired by the D810 and an array of inputs and outputs, the D750 is as well-suited for recording daily life and events as it is for filmmaking and videography. Simultaneously record uncompressed and compressed Full HD 1080 footage at 60/50/30/25/24p. Manually control ISO, shutter speed and aperture while recording—even use Power Aperture control for smooth iris transitions and Auto ISO for smooth exposure transitions. Use Highlight Display with zebra stripes to confirm exposure, apply Flat Picture Control for easier color grading in post and record at low and high angles with the 3.2-inch tilting Vari-angle LCD.Stay connectedBuilt-in Wi-Fi sharing and remote controlSharing and transferring your favorite D750 photos is fast, easy and fun. Wirelessly connect to the D750 with a compatible smartphone or tablet, browse the camera's memory card, downlo