text:
Number: 0780
Aetna considers the ADAMTS13 assay medically necessary for assessing prognosis in persons with thrombotic thrombocytopenic purpura (TTP).
Aetna considers the ADAMTS13 assay experimental and investigational for the following indications (not an all-inclusive list) because of insufficient evidence of its clinical utility for these indications:
ADAMTS13 (A Disintegrin-like And Metalloprotease with ThromboSpondin type 1 motif) is a multi-domain protease that limits platelet thrombogenesis through the cleavage of von Willebrand factor.
Retrospective studies of patients with thrombotic micro-angiopathies have shown that a deficient activity of ADAMTS13 in plasma is involved in thrombotic thrombocytopenic purpura (TTP) but not in hemolytic-uremic syndrome (HUS). It has been demonstrated that patients with inherited TTP have severe ADAMTS13 deficiency. However, patients with acquired TTP present with clinical and laboratory heterogeneity, and there are unequivocal cases of acquired TTP with measurable plasma levels of ADAMTS13. This heterogeneity poses a challenge for understanding the pathogenesis of TTP and selecting appropriate therapies (Mannucci and Peyvandi, 2007). The ADAMTS13 assay has been proposed by some to distinguish chronic recurring TTP (secondary to the presence of ADAMTS13 inhibitor) and HUS.
In a multi-center prospective cohort sutdy (n = 111), Veyradier et al (2001) reported that most patients diagnosed with HUS had normal plasma levels of ADAMTS13, even though a few of them (14 %) had reduced or even undetectable levels. However, the high diagnostic value of finding severe ADAMTS13 deficiency in TTP was subsequently challenged by other studies (Loof et al, 2001; Moore et al, 2001; Mori et al, 2002; Remuzzi et al, 2002; Coppo et al, 2004; Peyvandi et al, 2004); 2 of which involved prospectively recruited cohorts (Vesely et al, 2003; Zheng et al, 2004). Some of these studies also investigated patients with the form of HUS preceded by hemorrhagic colitis that occurs typically in children, or the atypical form that occurs more frequently in adults. Atypical HUS is sometime indistinguishable from TTP unless signs and symptoms of severe renal impairment are prominent (Mannucci and Peyvandi, 2007). The majority of these studies (Veyradier et al, 2001; Remuzzi et al, 2002; Vesely et al, 2003; Coppo et al, 2004) confirmed that ADAMTS13 is normal or only slightly decreased in typical colitis-associated HUS. However, in a few patients diagnosed with atypical HUS, ADAMTS13 was as severely deficient as in TTP (Loof et al, 2001; Veyradier et al, 2001; Remuzzi et al, 2002). Studies showing that protease activity was also reduced in plasma in an array of clinical conditions other than TTP (e.g., spanning from various thrombocytopenic disorders to disseminated intravascular coagulation, sepsis, the neonatal and post-operative period, liver cirrhosis and chronic inflammation) further challenge the paradigm that ADAMTS13 deficiency is a specific diagnostic beacon of TTP (Moore et al, 2001; Mannucci et al, 2001; Bianchi et al, 2002). In these conditions, however, ADAMTS13 deficiency was usually moderate or mild (10 % to 40 % of normal plasma value).
Mannucci and Peyvandi's (2007) reviewed the literature on ADAMTS13 and stated that it is not necessary to assay ADAMTS13 to diagnose TTP in the acute phase of the disease. Patients presenting with normal or moderately reduced ADAMTS13 can still be appropriately diagnosed with TTP. Furthermore, the authors stated, "[t]he decision to implement plasma therapy (infusion in patients with inherited disease, exchange in acquired disease) does not warrant the availability of ADAMTS13 values in real time. Clinicians need to identify patients who are more likely to relapse and develop chronic recurrent TTP. Patients who present with undetectable ADAMTS13 activity and detectable anti-ADAMTS13 during the acute episode and/or during first remission are more likely to experience other episodes. Therefore, ADAMTS13 testing appears to be more helpful as an index of relapse than as an index of short-term outcomes (remission and mortality rates), but larger confirmatory studies are warranted."
It has been posited that knowledge of the likelihood of relapse would be useful in avoiding stressors that can induce TTP. It has been observed that TTP can occur (or recur) after pregnancy, infection, pancreatitis, and surgery; acute stresses, resulting perhaps in the release of inflammatory cytokines or other prothrombotic mediators, can trigger an initial or recurrent episode, perhaps by altering the balance between levels of von Willebrand factor and ADAMTS13 activity in a susceptible patient.
van den Born et al (2008) stated that thrombotic microangiopathy (TMA) observed in malignant hypertension is similar to that of TTP, which is associated with a deficiency of ADAMTS13, a von Willebrand factor (VWF)-cleaving protease that cleaves large prothrombogenic multimers. These researchers hypothesized that ADAMTS13 is deficient in malignant hypertension and that the severity of TMA is associated with decreased ADAMTS13 activity. They included 20 patients with malignant and 20 patients with severe hypertension, and 20 matched normotensive individuals served as control subjects. Free hemoglobin, VWF, and active VWF were assessed to explore predictors of ADAMTS13 activity. Patients with malignant hypertension had lower ADAMTS13 activity (80 %; interquartile range [IQR]: 53 % to 130 %) compared with control subjects (99 % IQR: 82 % to 129 %; p < 0.01) but not compared with patients with severe hypertension (p = 0.14). ADAMTS13 activity negatively correlated with lactic dehydrogenase levels after logarithmic transformation (r = -0.65; p < 0.001) and was associated with platelet count (r = 0.34; p = 0.04) and the presence of schistocytes (r = -0.37; p = 0.02). Apart from the association with TMA, ADAMTS13 was inversely associated with creatinine (r = -0.42; p = 0.008). Increasing levels of VWF were associated with a decrease in ADAMTS13 activity (r = -0.34; p = 0.03). There was no significant association between ADAMTS13 activity and other parameters, including blood pressure. The authors concluded that ADAMTS13 is decreased in malignant hypertension and associated with the severity of TMA, likely because of the release of VWF after endothelium stimulation. A severe deficiency could not be demonstrated. They stated that more studies are needed to identify the role of ADAMTS13 in the TMA and ischemic complications of malignant hypertension.
Claus and colleagues (2009) measured VWF and related parameters as well as the protease activity regulating its biological activity in plasma of healthy controls and patients with different cause and severity of systemic inflammation to examine the effectiveness of the measures to detect highly prothrombotic states including TMA, one of the sequelae of sepsis. Plasma levels of VWF increased with increasing severity of systemic inflammation, probably due to activation of the endothelium. In parallel, the proteolytic activity of VWF inactivating protease, ADAMTS13, stepwise declined with the severity of inflammation, emphasizing the role of VWF-triggered platelet aggregation on the endothelium subsequently followed by development of TMA. As a consequence, the ratio of VWF antigen level and ADAMTS13 activity was significantly higher in patients with inflammation and sepsis, suggesting that this ratio might be more useful for the diagnosis of highly prothrombotic states including TMA than VWF multimer analysis alone. These findings suggested that ADAMTS13, VWF and related parameters, even in a combined approach, might be useful for the diagnosis and the therapeutic monitoring of patients with sepsis associated thrombotic microangiopathy.
In a case-control study, Molvarec et al (2009) examined if plasma ADAMTS13 activity is decreased in pre-eclampsia. A total of 67 pre-eclamptic patients, 70 healthy pregnant women and 59 healthy non-pregnant women were enrolled in this study. Plasma ADAMTS13 activity was determined with the FRETS-VWF73 assay, while VWF antigen (VWF:Ag) levels with an enzyme-linked immunosorbent assay. The multi-meric pattern of VWF was analyzed by SDS-agarose gel electrophoresis. There was no significant difference in plasma ADAMTS13 activity between the pre-eclamptic and the healthy pregnant and non-pregnant groups (median [25 to 75 %]: 98.8 [76.5 to 112.8] %, 96.3 [85.6 to 116.2] % and 91.6 [78.5 to 104.4] %, respectively; p > 0.05). However, plasma VWF:Ag levels were significantly higher in pre-eclamptic patients than in healthy pregnant and non-pregnant women (187.1 [145.6 to 243.1] % versus 129.3 [105.1 to 182.8] % and 70.0 [60.2 to 87.3] %, respectively; p < 0.001). The multi-meric pattern of VWF was normal in each group. Primi-paras had lower plasma ADAMTS13 activity than multi-paras (92.6 [75.8 to 110.6] % versus 104.2 [92.1 to 120.8] %; p = 0.011). No other relationship was found between clinical characteristics, laboratory parameters and plasma ADAMTS13 activity in either study group. The authors concluded that plasma ADAMTS13 activity is normal in pre-eclampsia despite the increased VWF:Ag levels. However, further studies are needed to determine whether a decrease in plasma ADAMTS13 activity could predispose pre-eclamptic patients to develop HELLP syndrome.
Uemura et al (2010) stated that ADAMTS13 is a metalloproteinase, produced exclusively in hepatic stellate cells, and specifically cleaves highly multi-meric VWF, which plays a pivotal role in hemostasis and thrombosis, and its function is dependent on its multimeric state. Deficiency of ADAMTS13 results in accumulation of unusually large VWF multimers (UL-VWFM) in plasma, in turn induces platelet clumping or thrombi under high shear stress, followed by microcirculatory disturbances. Considering that UL-VWFM, the substrate of ADAMTS13, is produced in transformed vascular endothelial cells at sites of liver injury, decreased ADAMTS13 activity may be involved in not only sinusoidal microcirculatory disturbances, but also subsequent progression of liver injuries, eventually leading to multi-organ failure. This concept can be applied to the development or aggravation of liver diseases, including liver cirrhosis, alcoholic hepatitis, veno-occlusive disease, and adverse events after liver transplantation. These results promise to bring further understanding of the pathophysiology of liver diseases, and offer new insight for development of therapeutic strategies.
Okano et al (2010) evaluated changes of plasma ADAMTS13 activity and its clinical relevance in patients with hepatectomy. Plasma ADAMTS13 activity and its related parameters were sequentially determined after hepatectomy in 70 patients. ADAMTS13 activity significantly decreased from pre-operative 67.0 +/- 30.6 % to 48.1 +/- 24.6 % after hepatectomy (p < 0.0001). Pringle's maneuver for longer than 45 mins (p = 0.0007) and major hepatectomy (p = 0.0002) were significantly associated with the decrease of ADAMTS13 activity to less than 40 %. The decreased ADAMTS13 activity reflected post-operative thrombocytopenia (p = 0.0028) and hyper-bilirubinemia (p < 0.05). The authors concluded that plasma ADAMTS13 activity significantly decreased after hepatectomy due to ischemic injury together with liver mass reduction, reflecting a post-operative liver dysfunction. They stated that monitoring of ADAMTS13 activity may be useful to prevent further development of the liver failure after hepatectomy. Well-designed studies are needed to ascetain the clinical value of ADAMTS13 in monitoring liver diseases.
Choi et al (2011) examined ADAMTS13 activity as well as the ADAMTS13 gene mutation in children with hemolytic uremic syndrome (HUS). A total of 18 patients, including 6 diarrhea-negative (D-HUS) and 12 diarrhea-associated HUS (D+HUS) patients, were evaluated. The extent of VWF degradation was assayed by multimer analysis, and all exons of the ADAMTS13 gene were PCR-amplified using Taq DNA polymerase. The median and range for plasma activity of ADAMTS13 in 6 D-HUS and 12 D+HUS patients were 71.8 % (22.8 to 94.1 %) and 84.9 % (37.9 to 119.9 %), respectively, which were not statistically significantly different from the control group (86.4 %, 34.2 to 112.3 %) (p > 0.05). Five ADAMTS13 gene mutations, including 2 novel mutations [1584+2T>A, 3941C>T (S1314L)] and 3 polymorphisms (Q448E, P475S, S903L), were found in 2 D-HUS and 1 D+HUS patients, which were not associated with deficiency of ADAMTS13 activity. Whether these mutations without reduced ADAMTS13 activity are innocent bystanders or predisposing factors in HUS remains unanswered.
Ikeda et al (2011) noted that chronic liver injury evokes a wound healing response, promoting fibrosis and finally hepatocellular carcinoma (HCC), in which hepatic stellate cells play an important role. Although a blood marker of hepatic stellate cells is not known, those cells importantly contribute to the regulation of plasma ADAMTS13 activity. In this study, plasma ADAMTS13 activity was used to predict development of HCC in patients with chronic hepatitis B and CPrediction. Plasma ADAMTS13 was evaluated in chronic hepatitis B or C patients with or without HCC. Plasma ADAMTS13 activity significantly correlated with serum aspartate aminotransferase and alanine aminotransferase, liver stiffness value, and aspartate aminotransferase-to-platelet ratio index, irrespective of the presence of HCC, suggesting that it may reflect hepatocellular damage and subsequent wound healing and fibrosis as a result of hepatic stellate cell action. During the 3-year follow-up period for patients without HCC, it developed in 10 among 81 patients. Plasma ADAMTS13 activity was significantly higher in patients with HCC development than in those without and was a significant risk for HCC development by uni-variate and multi-variate analyses. Furthermore, during the 1-year follow-up period for patients with HCC treated with radiofrequency ablation, HCC recurred in 55 among 107 patients. Plasma ADAMTS13 activity or antigen level was significantly higher in patients with HCC recurrence than in those without and was retained as a significant risk for HCC recurrence by multi-variate analysis. The authors concluded that higher plasma ADAMTS13 activity and antigen level was a risk of HCC development in chronic liver disease. They stated that plasma ADAMTS13 as a potential marker of hepatic stellate cells may be useful in the prediction of hepatocarcinogenesis.
In an observational study, Freynhofer et al (2011) investigated the alterations of plasma VWF and ADAMTS13 following cardioversion (CV) and evaluated the predictive value of these parameters for recurrence of atrial fibrillation (AF). These researchers determined plasma levels of VWF and ADAMTS13 in 77 patients before and immediately after CV, as well as 24 hours and 6 weeks thereafter, by means of commercially available assays. The VWF/ADAMTS13-ratio was significantly elevated immediately after CV (p = 0.02) and 24 hours after CV (p = 0.002) as compared to baseline levels. ADAMTS13, 24 hours after CV, exhibited a significant association with recurrence of AF (hazard ratio [HR]: 0.97; p = 0.037). Accordingly, tertiles of ADAMTS13 showed a step-wise inverse correlation with the risk of recurrent AF (HR: 0.50; p = 0.009). After adjustment for confounders, ADAMTS13 remained significant as an independent predictor of recurrent AF (HR: 0.61; p = 0.047). Similarly, the VWF/ADAMTS13-ratio, 24 hours after CV, was associated with rhythm stability and remained an independent predictor of recurrent AF (HR: 1.88; p = 0.028). The regulation of VWF and its cleaving protease ADAMTS13 after CV might play a critical role in producing a pro-thrombotic milieu immediately following CV for AF. The authors concluded that since ADAMTS13 plasma concentration as well as the VWF/ADAMTS13-ratio are independently associated with rhythm stability, these indexes might be used for prediction of recurrence of AF. These findings need to be validated by well-designed studies.
Habe and co-workers (2012) noted that ADAMTS13, endothelial VWF and related proteins are involved in the pathogenesis of some life-threatening systemic thrombotic coagulopathies. Changes of plasma ADAMTS13 activity in TTP is well-known but is also involved in septic disseminated intravascular coagulation (DIC). These researchers investigated the ADAMTS13 activity, VWF and VWF pro-peptide (VWFpp) antigens in 69 patients with DIC, 143 with non-DIC, 21 with TTP and 23 with atypical HUS (aHUS) for diagnosis of DIC. The plasma ADAMTS13 activity was significantly low in patients with DIC, and the plasma levels of VWF and VWFpp antigens, were the highest in these patients, but there were no significant differences in the plasma VWFpp levels between the patients with DIC and those with aHUS. The difference in the plasma ADAMTS13 activity, the VWF and VWFpp antigens between DIC and non-DIC cases was significant in those with infectious and malignant diseases, but the difference in the VWFpp/ VWF ratio were significant only in subjects with infectious diseases. As an indicator for prognosis, the plasma levels of VWFpp were significantly higher in non-survivors than in survivors. Then, VWFpp/ VWF ratio and VWFpp/ADAMATS13 ratio will be potent informative indicators in DIC. The authors concluded that these findings suggested that ADAMTS13/VWF profiles may have important roles in the pathogenesis of DIC, and that ADAMTS13 and VWFpp are useful indicators for the diagnosis and prognosis of DIC. These findings need to be validated by well-designed studies.
Mazetto et al (2012) stated that increased levels of inflammatory markers and clotting factors have been related to the pathogenesis and prognosis of venous thromboembolism (VTE). In particular, the imbalance between VWF and ADAMTS13 has been described in patients with arterial thrombosis. In this study, a total of 77 patients with previous VTE and 77 matched controls were selected for the evaluation of the inflammatory markers, FVW, ADAMTS 13, and D-dimer. The presences of post-thrombotic syndrome (PTS) and residual vein obstruction (RVO) were also assessed in patients. Serum levels of tumor necrosis factor-alpha and interleukin-6 were significantly increased in patients compared to controls (median = 2.25 versus 1.59 pg/ml, p ≤ 0.001; 1.16 versus 0.98 pg/ml, p = 0.013, respectively). Plasma levels and activity of VWF (median = 150.25 versus 95.39 U/dL, p ≤ 0.001; 145.26 % versus 92.39 %, p ≤ 0.001) and ADAMTS 13 (median = 1088.84 versus 950.80 ng/ml, p ≤ 0.001; 96.03 versus 83.64 %, p ≤ 0.001) were also higher in patients. These investigators further analyzed the subgroups of patients with higher risk for VTE recurrence or VTE sequelae, defined as the presence of high D-dimer levels, RVO or PTS. All inflammatory markers were significantly higher in patients with increased D-dimer. The presence of PTS or RVO was not associated with higher inflammatory or coagulation parameters. The increased levels of inflammatory markers and VWF may suggest that there is a persistence of inflammatory activity in patients even at long periods after the VTE episode. In this context, it may be postulated that increased levels of ADAMTS13 could represent a compensatory mechanism against persistently increased levels of VWF. Moreover, increased inflammatory activity was associated with increased D-dimer levels, thus it is possible that this inflammatory activity may also be related to the risk of VTE recurrence.
Sonneveld et al (2014) stated that VWF plays an important role in hemostasis by mediating platelet adhesion and aggregation. Ultra-large VWF multimers are cleaved by ADAMTS13 in smaller, less pro-coagulant forms. An association between high VWF levels and cardiovascular disease has frequently been reported, and more recently also an association has been observed between low ADAMTS13 levels and arterial thrombosis. These investigators reviewed the current literature and performed meta-analyses on the relationship between both VWF and ADAMTS13 with arterial thrombosis. Most studies showed an association between high VWF levels and arterial thrombosis. It remains unclear whether ADAMTS13 is a causal independent risk factor because the association between low ADAMTS13 and arterial thrombosis is so far only shown in case-control studies. The authors concluded that prospective studies are awaited; a causal role for ADAMTS13 is supported by mice studies of cerebral infarction where the infusion of recombinant human ADAMTS13 reduced the infarct size.
Diagnosis of Acute Myelogenous Leukemia:
Zhang and colleagues (2014) examined the changes of VWF-cleaving protease (ADAMTS13) activity and VWF antigen (VWF: Ag) level in patients with acute myelogenous leukemia (AML) before and after treatment and evaluated their clinical significance. A total of 73 AML patients were enrolled in this study, the sodium citrate anti-coagulated plasma was collected before and after their induction chemotherapy. Fluorescence resonance energy transfer substrate VWF73 (FRETS-VWF73) assay was established to detect the plasma ADAMTS13 activity while VWF: Ag level was measured by ELISA. results showed that the ADAMTS13 activity in newly diagnosed patients with AML before induction therapy was obviously lower than that in normal controls (63.3 ± 25.5) % versus (105.1 ± 37.7)(p < 0.01), while the VWF: Ag level was higher than that in normal controls (226.6 ± 127.0) % versus (111.4 ± 39.7) % (p < 0.01). After standard induction chemotherapy, the ADAMTS13 activity of AML patients in complete remission period was higher than that in AML patients before therapy (p < 0.01), and was not significant difference with that in normal controls; the VWF: Ag was significantly lower than that in AML patients before therapy (p < 0.01), but it still was higher than that in controls (p < 0.05). The ADAMTS13 activity in newly diagnosed AML patients complicated with infection before therapy was obviously lower than that in AML patients without infection (52.2 ± 20.6) % versus (73.9 ± 24.7) % (p < 0.01), while the VWF: Ag level was significantly higher than that in AML patients without infection (262.2 ± 135.7) % versus (193.8 ± 110.2) % (p < 0.05). The ADAMTS13 activity in AML patients with disseminated intravascular coagulation (DIC) was significantly lower than that in AML patients without DIC (42.0 ± 14.5) % versus (73.4 ± 22.7) % (p < 0.01), while the VWF: Ag level was obviously higher that in AML patients without DIC (274.2 ± 140.0) % versus (204.7 ± 115.5) % (p < 0.01). The authors concluded that the ADAMTS13 activity in newly diagnosed AML patients before induction therapy has been confirmed to be lower and the VWF: Ag level to be higher, especially in AML patients with infection or DIC. They stated that the ADAMTS13 and VWF: Ag may play a role in the pathogenesis of AML and the formation of infection and DIC.
Furthermore, National Comprehensive Cancer Network's clinical practice guideline on "Acute myeloid leukemia" (Version 1.2015) does not mention ADAMST13 as a management tool.
Diagnosis of Cerebral Infarction:
Qu and colleagues (2016) noted that raised levels of VWF and reduced levels of ADAMTS13 activity are associated with thrombosis. These researchers investigated the relationships between plasma levels of VWF and ADAMTS13, their ratios, and the occurrence of cerebral infarction to understand the roles of VWF and ADAMTS13 in cerebral infarction. A total of 94 patients with cerebral infarction and 103 controls were analyzed. Plasma levels of VWF: Ag, VWF ristocetin cofactor activity (VWF: Rcof), and VWF collagen binding activity (VWF: CB) were measured by enzyme-linked immunosorbent assay (ELISA). The ADAMTS13 activity (ADAMTS13) was measured with FRETS-VWF73. The relationship between plasma levels and ratios of VWF and ADAMTS13 and the occurrence of cerebral infarction were analyzed. Patients with cerebral infarction displayed higher VWF: Ag and VWF: Rcof levels and lower ADAMTS13, VWF: CB/VWF: Ag, ADAMTS13/VWF: Ag, and ADAMTS13/VWF: Rcof levels compared to controls (p < 0.01). The highest quartiles of VWF: Ag (odds ratio [OR] = 5.11, 95 % confidence interval [CI]: 1.49 to 17.50) and VWF: Rcof (OR = 5.04, 95 % CI: 1.62 to 15.66) and the lowest quartiles of VWF: CB/VWF: Ag (OR = 5.91, 95 % CI: 1.95 to 17.93), ADAMTS13/VWF: Ag (OR = 9.11, 95 % CI: 2.49 to 33.33), and ADAMTS13/VWF: Rcof (OR = 3.73, 95 % CI: 1.39 to 10.03) are associated with cerebral infarction. The authors concluded that an association was found between reduced levels of VWF: CB/VWF: Ag, ADAMTS13/VWF: Ag, and ADAMTS13/VWF: Rcof ratios and cerebral infarction. They stated that these findings suggested that increased levels of VWF and reduced levels of ADAMTS13 activity may contribute to the pathogenesis of cerebral infarction.
Prediction of Excessive Post-Operative Drainage after Coronary Artery Bypass Grafting:
Mazur and associates (2014) stated that routine coagulation tests and bleed-scores fail to identify patients at risk of excessive post-operative drainage following coronary artery bypass grafting (CABG). These researchers examined if lower VWF and higher ADAMTS13 are associated with a high post-operative drainage after CABG. In the prospective cohort study, VWF: Ag, VWF:RCO, VWF:CB, ADAMTS13 antigen (ADAMTS13:Ag) and ADAMTS13 activity were measured on the day of elective on-pump CABG in 232 consecutive patients without a prior history of hemorrhagic diathesis, including von Willebrand disease (95 % discontinued aspirin pre-operatively). Post-operative drainage and blood product use were recorded. A comparison of extreme drainage quartiles (n = 56) showed that individuals with the highest drainage volumes have mean VWF: RCO lower by 19 % (p < 0.0001), median VWF: Ag lower by 19 % (p < 0.0001), ADAMTS13: Ag higher by 8 % (p = 0.0002), ADAMTS13 activity higher by 9 % (p = 0.01) and fibrinogen lower by 14 % (p = 0.03) than those with the lowest drainage. Linear regression analysis showed that pre-operative VWF: RCO (b = -4.83, p = 0.002) and fibrinogen (b = -61.52, p = 0.04) are the only independent predictors of post-operative drainage. Multi-variate logistic regression demonstrated that pre-operative VWF: RCO in the lowest quartile and ADAMTS13: Ag levels in the highest quartile increased the risk of high (greater than or equal to 1,000 ml) drainage (OR [95 % CI]: 4.88 [1.83 to 13.02], p = 0.001 and 3.77 [1.49 to 9.52], p = 0.005; respectively). The authors concluded that patients undergoing elective CABG with lower pre-operative VWF: RCO are at risk of having larger post-operative drainage, which suggests a novel contributor to increased peri-operative bleeding in cardiac surgery.
Prediction of Thrombotic Risk in Persons with Systemic Lupus Erythematosus:
Martin-Rodriguez et al (2015) noted that severe deficiency of ADAMTS13 activity leads to VWF ultra-large multimers with high affinity for platelets, causing TTP. Other pathological conditions with moderate ADAMTS13 activity exhibit a thrombotic risk. These researchers examined the ADAMTS13 activity in systemic lupus erythematosus (SLE) and its value as a thrombotic biomarker. ADAMTS13 activity, VWF: Ag and multimeric structure, and vascular cell adhesion molecule 1 (VCAM-1) were measured in plasma samples from 50 SLE patients and 50 healthy donors. Disease activity (SLE disease activity index [SLEDAI]) and organ damage (systemic lupus international collaborating clinics) scores, thrombotic events, anti-phospholipid syndrome (APS) and anti-phospholipid antibodies (aPLs) were registered. Patients with SLE showed decreased ADAMTS13 activity and high VWF levels compared with controls (66 ± 27 % versus 101 ± 8 %, p < 0.01, and 325 ± 151 % versus 81 ± 14 %, p < 0.001); VCAM-1 levels were higher in SLE patients (p < 0.05). Considering 3 groups of SLE patients depending on ADAMTS13 activity (greater than 60 %, 60 to 40 % and less than 40%), comparative analysis showed significant association between ADAMTS13 activity and SLEDAI (p < 0.05); as well as presence of aPLs (p < 0.001), APS (p < 0.01) and thrombotic events (p < 0.01). Reduced ADAMTS13 activity and increased VWF levels were especially notable in patients with active disease and with aPLs. The authors concluded that ADAMTS13 activity, in combination with other laboratory parameters, could constitute a potential prognostic biomarker of thrombotic risk in SLE.
Diagnosis and Monitoring of Diabetic Retinopathy:
Domingueti and colleagues (2016) evaluated the association between plasma levels of VWF, ADAMTS13 and d-Dimer, which consist on endothelial dysfunction and hypercoagulability biomarkers, and cystatin C with retinopathy in type 1 diabetic patients. Patients were classified according to presence (n = 55) or absence (n = 70) of retinopathy. Plasma levels of VWF, ADAMTS13, d-Dimer and cystatin C were evaluated by ELISA and ADAMTS13 activity was evaluated by FRET. Plasma levels of VWF (p = 0.033), ADAMTS13 activity (p = 0.014), d-Dimer (p = 0.002) and cystatin C (p < 0.001) were elevated in diabetic patients with retinopathy compared to those without this complication. The multivariate logistic regression analysis showed that ADAMTS13 activity (p = 0.031) d-Dimer (p = 0.015) and cystatin C (p = 0.001) remained associated with retinopathy after adjustment for age, diabetes duration, use of statin, use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin antagonist, use of acetylsalicylic acid and glomerular filtration rate. The authors concluded that ADAMTS13 activity, d-Dimer and cystatin C are associated with retinopathy in type 1 diabetic patients and are promising biomarkers for the diagnosis and monitoring of diabetic retinopathy.
Monitoring of Renal Function Following Kidney Transplantation:
Mota and associates (2015) stated that kidney transplantation is the key for patients with end-stage renal disease, improving quality of life and longer survival. However, kidney transplantation triggers an intense inflammatory response and alters the hemostatic system, but the pathophysiological mechanisms of these changes are not completely understood. In a cross-sectional, cohort study, these researchers investigated hemostatic biomarkers in Brazilian renal transplanted patients according to renal function and time after transplantation. A total of 159 renal transplanted patients were enrolled and D-Dimer (D-Di), thrombo-modulin (TM), VWF, and ADAMTS13 plasma levels were assessed by ELISA. An increase of D-Di was observed in patients with higher levels of creatinine. ADAMTS13 levels were associated with creatinine plasma levels and D-Di levels with glomerular filtration rate. The authors concluded that these results suggested that D-Di and ADAMTS13 can be promising markers to estimate renal function. They stated that ADAMTS13 should be investigated throughout the post-transplant time to clarify the participation of this enzyme in glomerular filtration and acceptance or rejection of the graft in Brazilian transplanted patients.
|CPT Codes / HCPCS Codes / ICD-10 Codes
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":
|CPT codes covered if selection criteria are met:
|Coagulation and fibrinolysis, functional activity, not otherwise specified (eg, ADAMTS-13), each analyte
|ICD-10 codes covered if selection criteria are met:
|Thrombotic microangiopathy [thrombotic thrombocytopenic purpura]
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
|A41.9 [reported with M31.1]
|Sepsis, unspecified [sepsis associated with thrombotic microangiopathy]
|Liver cell carcinoma
|Acute myeloid leukemia
|Hemolytic-uremic syndrome
|Diabetic retinopathy [diagnosis and monitoring of]
|Hypertensive diseases
|Acute coronary thrombosis not resulting in myocardial infarction
|Atrial fibrillation
|Cerebral infarction
|Occlusion and stenosis of precerebral and cerebral arteries
|Arterial embolism and thrombosis
|Other venous embolism and thrombosis [for prediction of recurrence of venous thromboembolism]
|Diseases of liver
|Systemic lupus erythematosus [prediction of thrombotic risk in persons with systemic lupus erythematosus]
|Hypertension, pre-eclampsia and eclampsia in pregnancy, childbirth and the puerperium
[reported with M31.1]
|Symptoms and signs specifically associated with systemic inflammation and infection [sepsis associated with thrombotic microangiopathy]
|Kidney transplant status [monitoring of renal function following kidney transplantation]
|Other specified postprocedural states [excessive post-operative drainage after coronary artery bypass grafting]


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About Gloritone
Originally known as Vitamin, the guitar-based pop/rock trio Gloritone actively pursued post-grunge success in the late '90s. Vocalist/guitarist Tim Anthonise, bassist Nick Scropos, and drummer Dan Lancelot -- all veterans of the local club scene in Temple, AZ -- formed the band in September 1996. Vitamin had not yet performed 20 shows when a demo tape caught the interest of an RCA executive, and the band signed with the label's Kneeling Elephant subsidiary. A name change was suggested due to the strong likelihood of the existence of similarly named bands; after settling on Gloritone, the trio issued their debut album, Cup Runneth Over, in June 1998. Fainter Farther Still followed three years later, featuring a revised lineup with newcomer Scott Hessel on drums, but failed to make a significant dent in commercial radio. Faced with a lack of national support, the group quietly disbanded as its members went on to pursue projects with Roger Clyne & the Peacemakers (Scropos) and Let Go (Hessel). ~ Steve Huey & Andrew Leahey, Rovi

subset: commoncrawl


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Mud Lake Park is located six miles north of Dubuque along the beautiful bluff land scenery of the Mississippi River. This river access area offers excellent picnic and camping facilities with handicap accessible showers and restrooms. The boat ramp provides boater and fishing access to both Mud Lake and Mississippi River Pool No. 11. Marine fuel, food, and boating slips are available at the adjacent Hawkeye Marina.
Ice fishing is popular in the winter and this area provides access to the backwaters of the Mississippi. Mud Lake Park also serves as the site for the Osprey Reintroduction Program; a hacking tower is located in the SE corner of the park. Two picnic shelters are available for rental and for those interested in reserving a shelter for an event, please contact the park ranger with your information. A year-round Park Ranger is in residence at this site.
Only 30% of the campsites at Mud Lake Park campground can be reserved online. The other 70% are first come, first served. Reservable campsites that are not reserved can be used on a first come, first served basis. A list of campsites that are reserved will be posted every week in the campground kiosk.
Mud Lake Park
22312 Golf Lake Road
Dubuque, Iowa 52001


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|Message view
|« Date » · « Thread »
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|"Antonio Gallardo" <agalla...@agsoftware.dnsalias.com>
|Re: [Woody-binding] wb:repeater unique-path
|Thu, 06 Nov 2003 10:38:56 GMT
Bruno Dumon dijo: Hi Bruno: Thanks for the patch. I will try it right now. I stopped yesterday because of that. :-D > BTW, names like res_id and Auth_permission don't follow the java naming > conventions, better would be resId and AuthPermission. I am aware of that. Druid also generates the SQL script for the DB (I use PostgreSQL) and in PostgreSQL there are no diference between upper/lower cases. This is why we are using this nonstandard approach. But you are right. We will switch on the next app. Thanks for the comment. Best Regards, Antonio Gallardo
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Unique among reference books on the Bible, the volumes of the IVP Bible Dictionary Series bridge the gap between scholars and those pastors, teachers, students and lay people desiring in-depth treatment of select topics in an accessible and summary format. Articles cover traditional … more
Dr. Craig A. Evans is the Payzant Distinguished Professor of New Testament and director of the graduate program at Acadia Divinity College in Wolfville, Nova Scotia. He has received degrees from Claremont McKenna College, Western Baptist Seminary, and Claremont Graduate University.
Evans taught at Trinity Western University in British Columbia for 21 years, where he directed the graduate program in biblical studies and founded the Dead Sea Scrolls Institute. He has recently served on the advisory board for the Gospel of Judas for National Geographic Society and has appeared frequently as an expert commentator on network television programs.
Evans has written and edited extensively on the historical Jesus and the Jewish background of the New Testament era. His published works include From Prophecy to Testament, Jesus and the Ossuaries, Jesus: The Final Days, and Dictionary of New Testament Background.


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PEG 40 Hydrogenated Castor Oil is the polyethylene glycol derivatives of hydrogenated castor oil, and is an amber colored, slightly viscous liquid that has a naturally mildly fatty odor. It is used in cosmetics and beauty products as an emulsifier, surfactant, and fragrance ingredient, according to research.1 community members found this useful
PEG 40 Hydrogenated Castor Oil* An emulsifier and fragrance ingredient * Please read TIA's article on What Is It: PEGs
* An emulsifier and fragrance ingredient
* Please read TIA's article on What Is It: PEGs
PEG 40 Hydrogenated Castor Oil is the polyethylene glycol derivatives of hydrogenated castor oil, and is an amber colored, slightly viscous liquid that has a naturally mildly fatty odor. It is used in cosmetics and beauty products as an emulsifier, surfactant, and fragrance ingredient, according to research.
PEGs are not considered to be irritants or sensitizers, and are CIR and FDA approved for use, but not on broken skin. The CIR has found that PEG 40 Hydrogenated Castor Oil is safe for use in concentrations of up to 100% without causing irritation, although it has been shown to increase the sensitization potential of other ingredients. It's molecular weight of 40 means that it is minimally absorbed by the skin.
Despite the many fears regarding PEGs, they are seen as an ingredient in a large number of products because of their diverse properties. In a study published in the Toxicology journal in 2005, entitled "Safety assessment on polyethylene glycols (PEGs) and their derivatives as used in cosmetic products," it was concluded that: "Taking into consideration all available information from related compounds, as well as the mode and mechanism of action, no safety concern with regard to these endpoints could be identified. Based on the available data it is therefore concluded that PEGs of a wide molecular weight range (200 to over 10,000), their ethers (laureths, ceteths, ceteareths, steareths, and oleths), and fatty acid esters (laurates, dilaurates, stearates, distearates) are safe for use in cosmetics."
Safety Measures/Side Effects:
The Cosmetics Database found PEG 40 Hydrogenated Castor Oil to be a moderate hazard depending on use and notes contamination and toxicity concerns.
According to a study published in the International Journal of Toxicology, PEGs (including PEG 40 Hydrogenated Castor Oil) can contain harmful impurities, including: Ethylene Oxide, known to increase the incidences of uterine and breast cancers and of leukemia and brain cancer, according to experimental results reported by the National Toxicology Program; 1,4-dioxane, a known carcinogen; PAHs, known to increase the risk of breast cancer; lead; iron; and arsenic (source).
Products and formulas containing PEGs should not be used on broken or irritated skin. Although PEGs are considered safe for use topically on healthy skin, studies showed that patients suffering from severe burns were treated with PEG-based antimicrobial cream; this treatment resulted in kidney toxicity. "The PEG content of the antimicrobial cream was determined to be the causative agent. However, no evidence of systemic toxicity occurred in studies with intact skin. Because of the observation of kidney effects in burn patients, the CIR Expert Panel qualified their conclusion on the safety of the PEG ingredients to state that cosmetic formulations containing these ingredients should not be used on damaged skin" (CosmeticsInfo.org).
Recommended Products With PEG 40 Hydrogenated Castor Oil:
E'shee Clinical Esthetic Cellular Repair Serum ($179 in the shop), Skinfinite Platinum PM Cream 1% Retinol ($79 in the shop) and E'shee Clinical Esthetic Elixir of Life KI Therapy Serum ($189 in the shop).
As much as possible, products in the Truth In Aging shop are chosen for their safety profile as well as effectiveness.


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<img src="http://media2.onsugar.com/files/2013/11/02/897/n/1855103/fa72329eec1a7937_Fall.jpg" width="800" height="769" class="inline" style="border: none;/>
My readers and followers may have seen me reference Office 365 in a number of my posts or tweets over the past few weeks. I'm in the Office Champions program and you'll see me talking about a number of products that they have that I use and tomorrow, I will be in Seattle for a few days at the Microsoft campus! You can follow along by following me on Instagram and Twitter with the handle @AccessoryExpert as well as the hashtags #OfficeChamps and #ChampionsSummit (I will also use the hashtag #AccessoryExpertTravels if you're looking at how I am styling a chic look for rainy weather) to stay in the loop on the conversation, to ask questions and so much more (I'll be sharing via my Nokia Lumia 925 Windows Phone of course)!


text:
WALTHAM, Mass. -- Doc Rivers set the final sequence into motion, then stood as a helpless observer for maybe the seven most excruciating seconds of his career.
It was June 2, 1993, Game 5 of the Eastern Conference finals. Incensed by some of the New York tabloid headlines, Michael Jordan had just produced a 54-point performance a game earlier as the Chicago Bulls evened their series with the Knicks as the series shifted back to Madison Square Garden, where the Knicks hadn't lost since Jan. 28, a stretch of 27 games.
Down a point, Rivers put the ball in John Starks' hands on the right wing, then buried himself in the opposite corner. Starks' pick-and-roll with Patrick Ewing broke down, and the ball eventually ended up in the hands of Charles Smith as Rivers drifted toward the top of the key.
Four times Smith went up with a chance to move the Knicks a step closer to the NBA Finals. And four times he was thwarted. He was a split second too slow on the first attempt, allowing Horace Grant to deny him. Scottie Pippen provided the key block soon after, and the Bulls went the other way for a layup and a 97-94 triumph.
Rivers stood at midcourt and watched as Jordan leaped and pumped his fist wildly as the Bulls spilled off their bench in celebration. The top-seeded Knicks were eliminated two nights later in Chicago, and the Bulls went on to win their third consecutive world title.
Nearly two decades later, Rivers wishes he had a more endearing memory of Madison Square Garden, but admits that Game 5 remains the most vivid.
"I think it's tough for any player that never won it -- you really don't have a great memory," Rivers said. "I know that sounds bad in some ways, but it's very true. I really don't [have one positive moment at MSG]. I mean, I remember all the negative. I remember Game 5 against Chicago. That's not my greatest memory, but that's the memory I have."
It doesn't stop Rivers from openly gushing about MSG. He loves the arena and especially the history. He's downright excited for the frenzied atmosphere that surely awaits the first playoff game in that building in seven years when the Celtics meet the Knicks in Game 3 of an Eastern Conference quarterfinal series on Friday night.
"It's special to me because I played there. It's special to every single player because it's the only arena left," said Rivers. "There's no other arena in the NBA that has memories. All the others have been blown up and they've put up new ones.
"This is the one where Frazier-Ali happened. Not really, but this is the arena, the same land, at least. All this stuff that's happened, players know that. I have kids who, one of their dreams was to play in Madison Square Garden. They're not from New York. It's just the only building left. It used to be the [Los Angeles] Forum, the Boston Garden and Madison Square Garden. Now, it's just Madison Square Garden."
So, the Celtics are ready for MSG. Light up the marquee. Dust off the purple seats. Make sure Spike Lee is barking early and often. The Knicks haven't won a playoff game here since April 22, 2003, exactly a decade from Game 3. And the Celtics would like to extend that drought.
"Every player wants to play in Madison Square Garden," said Glen Davis, who has never shied from a big stage.
"I like the rims there. They've got good rims. It feels like you're shooting the ball real light when you play, but it is what it is. You've just got to play the game. Madison Square Garden is where everybody wants to play, and you just get up for those types of games."
Davis isn't the only one who likes MSG. Celtics captain Paul Pierce has already done two home run trots there this season, most notably after his game winner over Amare Stoudemire in the team's first meeting of the regular season there. After rallying from a double-digit hole to win at MSG again last month, Boston players took great pleasure in watching the arena empty out in the final moments.
Rivers admitted that his players typically thrive in a hostile environment, so he's hoping this trip will bring out the best in his troops. Rajon Rondo, for one, isn't allowing the moment to get bigger than him.
"I mean, hopefully a lot of cheers," Rondo quipped when asked what to expect at MSG. "Boston and New York are pretty close, so hopefully they give our Boston fans some tickets up there and we get a lot of supporters."
That's unlikely to happen. Just as it's unlikely that any amount of success at MSG will erase the bad memories that first leap to mind for Rivers when he thinks about the arena.
But a solid showing this weekend for the Celtics could send them into the next round with some much-needed momentum. And if the Celtics were to go on to win a world title, Rivers would surely remember MSG a bit more fondly as a steppingstone to that ultimate prize.
Chris Forsberg covers the Celtics for ESPNBoston.com.


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Computational Linguistics and Intelligent Text Processing
Volume 6008 of the series Lecture Notes in Computer Science pp 199-211
A Case Study of Using Web Search Statistics: Case Restoration
- Silviu CucerzanAffiliated withMicrosoft Research
* Final gross prices may vary according to local VAT.Get Access
We investigate the use of Web search engine statistics for the task of case restoration. Because most engines are case insensitive, an approach based on search hit counts, as employed in previous work in natural language ambiguity resolution, is not applicable for this task. Consequently, we study the use of statistics computed from the snippets generated by a Web search engine, and we show that such statistics can achieve performance similar to corpus-based approaches. We also note that the top few results returned by a search engine may not the most representative for modeling phenomena in a language.
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- Title
- A Case Study of Using Web Search Statistics: Case Restoration
- Book Title
- Computational Linguistics and Intelligent Text Processing
- Book Subtitle
- 11th International Conference, CICLing 2010, Iaşi, Romania, March 21-27, 2010. Proceedings
- Pages
- pp 199-211
- Copyright
- 2010
- 10.1007/978-3-642-12116-6_17
- Print ISBN
- 978-3-642-12115-9
- Online ISBN
- 978-3-642-12116-6
- Series Title
- Lecture Notes in Computer Science
- Series Volume
- 6008
- Series ISSN
- 0302-9743
- Publisher
- Springer Berlin Heidelberg
- Copyright Holder
- Springer-Verlag Berlin Heidelberg
- Additional Links
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- Industry Sectors
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- Editors
- Alexander Gelbukh (16)
- Editor Affiliations
- 16. Center for Computing Research, National Polytechnic Institute
- Authors
- Silviu Cucerzan (17)
- Author Affiliations
- 17. Microsoft Research, 1 Microsoft Way, Redmond, WA, 98052, USA
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Comprehensive bioeconomic modelling of multiple harmful non-indigenous species
Harmful non-indigenous species (NIS) introductions lead to loss of biodiversity and serious economic impacts. Government agencies have to decide on the allocation of limited resources to manage the risk posed by multiple NIS. Bioeconomic modelling has focused on single species and little is known about the optimal management of multiple NIS using a common budget. A comprehensive bioeconomic model that considers the exclusion, detection and control of multiple NIS spreading by stratified dispersal and presenting Allee effects was developed and applied to manage the simultaneous risk posed by Colorado beetle, the bacterium causing potato ring rot and western corn rootworm in the UK. A genetic algorithm was used to study the optimal management under uncertainty. Optimal control methods were used to interpret and verify the genetic algorithm solutions. The results show that government agencies should allocate less exclusion and more control resources to NIS characterised by Allee effects, low rate of satellite colonies generation and that present low propagule pressure. The prioritisation of NIS representative of potential NIS assemblages increases management efficiency. The adoption of management measures based on the risk analysis of a single NIS might not correspond to the optimal allocation of resources when other NIS share a common limited budget. Comprehensive bioeconomic modelling of multiple NIS where Allee effects and stratified dispersal are considered leads to a more cost-effective allocation of limited resources for the management of NIS invasions.
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Volume (Year): 69 (2010)
Issue (Month): 6 (April)
Pages: 1303-1312
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References listed on IDEAS
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- Burnett, Kimberly & Kaiser, Brooks & Roumasset, James, 2007. "Economic lessons from control efforts for an invasive species: Miconia calvescens in Hawaii," Journal of Forest Economics, Elsevier, vol. 13(2-3), pages 151-167, August.
- Christopher Costello & Carol McAusland, 2003. "Protectionism, Trade, and Measures of Damage from Exotic Species Introductions," American Journal of Agricultural Economics, Agricultural and Applied Economics Association, vol. 85(4), pages 964-975.
- Leung, Brian & Finnoff, David & Shogren, Jason F. & Lodge, David, 2005. "Managing invasive species: Rules of thumb for rapid assessment," Ecological Economics, Elsevier, vol. 55(1), pages 24-36, October.
- Mark E. Eiswerth & G. Cornelis van Kooten, 2007.
"Dynamic Programming and Learning Models for Management of a Nonnative Species,"
Canadian Journal of Agricultural Economics/Revue canadienne d'agroeconomie,
Canadian Agricultural Economics Society/Societe canadienne d'agroeconomie, vol. 55(4), pages 485-498, December.
- Mark Eiswerth & G. Cornelis van Kooten & Jeff Lines & Alison Eagle, 2005. "Dynamic Programming and Learning Models for Management of a Nonnative Species," Working Papers 2005-07, University of Victoria, Department of Economics, Resource Economics and Policy Analysis Research Group.
- Lars J. Olson & Santanu Roy, 2002. "The Economics of Controlling a Stochastic Biological Invasion," American Journal of Agricultural Economics, Agricultural and Applied Economics Association, vol. 84(5), pages 1311-1316.
- Mark Eiswerth & Wayne Johnson, 2002. "Managing Nonindigenous Invasive Species: Insights from Dynamic Analysis," Environmental & Resource Economics, Springer;European Association of Environmental and Resource Economists, vol. 23(3), pages 319-342, November.
- Finnoff, David & Shogren, Jason F. & Leung, Brian & Lodge, David, 2007. "Take a risk: Preferring prevention over control of biological invaders," Ecological Economics, Elsevier, vol. 62(2), pages 216-222, April.
- Burnett, Kimberly M. & D'Evelyn, Sean & Kaiser, Brooks A. & Nantamanasikarn, Porntawee & Roumasset, James A., 2008.
"Beyond the lamppost: Optimal prevention and control of the Brown Tree Snake in Hawaii,"
Ecological Economics,
Elsevier, vol. 67(1), pages 66-74, August.
- Kimberly Burnett & Sean D'Evelyn & Brooks Kaiser & Porntawee Nantamanasikarn & James Roumasset, 2007. "Beyond the Lamppost: Optimal Prevention and Control of the Brown Treesnake in Hawaii," Working Papers 200714, University of Hawaii at Manoa, Department of Economics.
- Kim, C.S. & Lubowski, Ruben N. & Lewandrowski, Jan & Eiswerth, Mark E., 2006. "Prevention or Control: Optimal Government Policies for Invasive Species Management," Agricultural and Resource Economics Review, Northeastern Agricultural and Resource Economics Association, vol. 35(1), pages -, April.
- Buhle, Eric R. & Margolis, Michael & Ruesink, Jennifer L., 2005. "Bang for buck: cost-effective control of invasive species with different life histories," Ecological Economics, Elsevier, vol. 52(3), pages 355-366, February.
- Kim, C.S. & Lee, Donna J. & Schaible, Glenn D. & Vasavada, Utpal, 2007. "Multiregional Invasive Species Management: Theory and an Application to Florida's Exotic Plants," Journal of Agricultural and Applied Economics, Southern Agricultural Economics Association, vol. 39(October), October.
- Olson, Lars J., 2006. "The Economics of Terrestrial Invasive Species: A Review of the Literature," Agricultural and Resource Economics Review, Northeastern Agricultural and Resource Economics Association, vol. 35(1), pages -, April.
- Lars J. Olson & Santanu Roy, 2005.
"On Prevention and Control of an Uncertain Biological Invasion ,"
Review of Agricultural Economics,
Agricultural and Applied Economics Association, vol. 27(3), pages 491-497.
- Olson, Lars J. & Roy, Santanu, 2005. "On Prevention and Control of an Uncertain Biological Invasion," Working Papers 28595, University of Maryland, Department of Agricultural and Resource Economics.
- Richard D. Horan & Charles Perrings & Frank Lupi & Erwin H. Bulte, 2002. "Biological Pollution Prevention Strategies under Ignorance:The Case of Invasive Species," American Journal of Agricultural Economics, Agricultural and Applied Economics Association, vol. 84(5), pages 1303-1310.
- Perrings, Charles, 2005. "Mitigation and adaptation strategies for the control of biological invasions," Ecological Economics, Elsevier, vol. 52(3), pages 315-325, February.
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alyssajeanine05's review of Hard Candy Fox in a Box Spicy & Sweet
54 reviews
92% would repurchase
Package Quality: 4.1
Price: $$
Package Quality: 4.1
Price: $$
Age: 18 & Under
Skin: Dry, Medium, Not Sure
Hair: Brunette, Other, Other
Eyes: Brown
Before I start, lets just say that where I live, people must not be that into makeup because everyone says this product is so hard to find in Walmart, well there was plenty at mine. lol the packaging is adorable & the blush is very pigmented. The brush it comes with is okay, but I would rather use my MAC brushes with it. All in all, it's a great blush. I wish I would have known about this before I lent out $30 for a BeneFit boxed powder. (there the same. Except I would go with Hard Candy because it's cheaper.) (:
Read all 54 reviews of Fox in a Box Spicy & Sweet
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From the organizers of the protest:
Immediate Release
April 2013
Marriage Between Shale and Sustainability is a Fake
Penn. -- A coalition of Pennsylvania and Ohio students and residents staged a
mock wedding today at the EQT Plaza in downtown Pittsburgh to condemn the
misguided union of corporations and environmental nonprofits through the Center
for Sustainable Shale Development (CSSD). Oil and gas companies, such as Shell,
Chevron, and CONSOL Energy, and environmental nonprofits, such as the
Environmental Defense Fund (EDF), Pennsylvania Environmental Council (PEC), and
Group Against Smog and Pollution (GASP), began working together in March of 2013
in order to create a set of voluntary regulations for hydraulic fracturing or
"fracking." The demonstrators have asked all environmental nonprofits to divorce
themselves from CSSD due to irreconcilable differences.
central mission is to promote the idea of "sustainable shale," but fracking is
fundamentally unsustainable.
fossil fuels is the primary driver of climate destabilization and oil and gas
are finite resources. The gas industry is well aware of this, having admitted
that they can only provide gas for a limited amount of time. The concept of
sustainable shale is an oxymoron. The gas industry is using their partnership
with environmental nonprofits to co-opt the brand of sustainability and hide the
destruction caused by fracking.
is poised to greenwash fracking and congratulate companies for extraction that
is anything but sustainable. In our region, the boom and bust of the fossil fuel
industry has left landscapes poisoned and vacant. The last thing we need is the
false hope of sustainable shale development," said a Pittsburgh resident who
asked not to be named.
amounts of methane leak into the atmosphere during the life-cycle of gas
production, exacerbating climate change.# Fracking is economically unsustainable
as well; communities that focus on extraction experience boom-bust cycles and
are less prosperous in the long term.# There are also significant health
impacts associated with fracking. A recent study found that risks of cancer were
significantly elevated for people who live within half a mile of a fracking
Dorner, the bride at the mock wedding, said, "The
only future that we have is a sustainable one, and there is no room for fossil
fuels in it. We have to transition to renewable energy immediately, not just
move from one dirty fossil fuel to another."
Headwaters Economics, Fossil
Fuel Extraction as a County Economic Development Strategy: Are Energy-Focused
Counties Benefiting?,
revised 11 July 2009.
Chesapeake Energy Corp,the Oklahoma-based firm is the No. 1 driller in Ohio.
Rig Count Interactive Map by Baker Hughes, an energy services company.
Shale Sheet Fracking, a Youngstown Vindicator blog.
National Geographic's The Great Shale Rush.
The Ohio Environmental Council, a statewide eco-group based in Columbus.
Earthjustice, a national eco-group.
People's Oil and Gas Collaborative-Ohio, a grass-roots group in Northeast Ohio.
Concerned Citizens of Medina County, a grass-roots group.
No Frack Ohio, a Columbus-based grass-roots group.
Fracking: Gas Drilling's Environmental Threat by ProPublica, an online journalism site.
Pipeline, blog from Pittsburgh Post-Gazette on Marcellus shale drilling.
Allegheny Front, environmental public radio for Western Pennsylvania.


text:
Do you want to make Ohio.com your homepage?
By Jim Carney
Beacon Journal staff writer
Larry Modic talks about his experiences restoring his house on Manchester Road, in Akron, in this Dec. 19, 2012 file photo. (Michael Chritton/Akron Beacon Journal)
The recently boarded up home of Larry Modic at 1480 Manchester Road in Akron. (Mike Cardew/Akron Beacon Journal)
Click here to read or leave a comment(s) on this story.
Tony Swain torments the officers who have not found his killer.


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Segway Obstacle Experience£16 instead of £49 for a 1-hour Segway obstacle experience for 1, or £29 for 2 people at Madrenaline, Heaton - save up to 67%
FOR ONE: A 1-hour Segway obstacle experience for 1 at Madrenaline, Heaton (was £49) OR redeem towards another Wowcher deal.You save 67% (£33)
FOR TWO: A 1-hour Segway obstacle experience for 2 at Madrenaline, Heaton (was £98) OR redeem towards another Wowcher deal.You save 70% (£69)
Save 67%
Time left to purchase
- Get to grips with a Segway obstacle course.
- Features seesaw and rope bridge.
- Includes all equipment, training and safety briefings.
- Valid Mon-Sun, 10am-4pm.
- Tea and coffee included.
- Based 35 minutes outside of Manchester.
The Fine Print
- One per person or per pair.
- May buy multiples as gifts.
- Voucher valid until 26th Apr 2014.
- £10pp surcharge at weekends.
- Must be aged 11 or over. Under-16s must be accompanied by an adult.
- Max. weight 18st.
- Not suitable if pregnant, have high blood pressure or joint/mobility problems.
- Subject to availability.
Full Details
'You can reach me by railway / You can reach me by Segway / I don't care how you get here / Just get here if you can.' Those aren't quite the lyrics, but that's what you're getting with today's deal…
We're offering you a one-hour Segway obstacle experience for 1 person for just £16, or for 2 people for £29, saving you up to 67% off Madrenaline's prices.
Based just 35 minutes outside of Manchester, the lovely people at Madrenaline have what we think is the perfect treat for any friend or loved one who's after an adrenaline-pumping experience with a difference! Kitted out with all the necessary safety gear, your one-hour experience will see your expert instructor take you through the basics of riding a Segway. You'll learn how to move, stop, reverse, turn, accelerate, mount and dismount. You'll then take part in three off-road challenges; an exciting obstacle course with humps and bumps, the slalom and the relay rally. If you need any further convincing, check out the video below.
How to Redeem
- When the deal ends we'll send you your unique wowcher code.
- Head to Madrenaline's site to book using the link we send you.
- Enter your wowcher code when prompted.
Once purchased, you can redeem this wowcher towards another wowcher or claim a Wowcher Wallet Credit. Click here for more info.


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Job Overview
This position is in the Senior Executive Service, a small elite group of top government leaders. SES members possess a diverse portfolio of experiences including strong skills to lead across organizations. As an executive, you will influence the direction of innovation and transformation of the federal government and lead the next generation of public servants.
This position represents the top technical and management authority in the Department of the Navy in matters principally relating to Naval Facilities Public Works Management, to include: facilities maintenance; facilities services; base support services; energy and utilities management; installation environmental compliance; and base support vehicles and equipment. As such, the incumbent is: (1) principal advisor to the Commander and Executive Director of Naval Facilities Engineering Command (Echelon 2); the Secretary of the Navy; and (2) the normal point of liaison between the Navy, the other military agencies, and industry partners.
Primary duties include executive leadership for more than 8,000 NAVFAC employees who provide Public Works products and services at more than 100 locations world-wide in support of DON installation operations. Responsible for planning, programming, budgeting and executing more than $4 billion annually, including $3 billion/year Navy Working Capital fund account. Responsible for establishing best business practices and processes for more than 50 separate products and services, for community management and professional development of 8,000 employees, for resource management and IT support across the Public Works Business Line, and for program management of four major product and service lines within NAVFAC. Responsible for the technical authority and engineering decisions related to the NAVFAC Public Works functions, including life cycle sustainment, life safety, and environmental compliance.
Travel Required
- Occasional Travel
- May be required


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Finding out how much your car is worth is easy with our free valuation tool below. All you have to do is enter your registration number to start a new valuation.
Our dealership operates from three locations in the Beckenham area, and is part of the Masters Group, a family-owned and run company established for over 60 years operating in Kent, Surrey & South London
For unbeatable deals and offers on the Citroën range of cars and vans including the vastly popular Citroen DS3 and DS3 Cabrio in Kent, contact us at our Penge Showroom on 020 8659 0909.
For service, repair, parts and accessories or just friendly advice, our expert After Sales team is available at Copers Cope Road, Beckenham on 020 8650 5046.
Finally, our manufacturer and insurance approved body repair centre is there to help when things go wrong, and able to get you on the road again quickly and with the minimum of fuss. Call 020 8650 5046 for an estimate. At Masters Citroën, we know you have a choice so we are professional, helpful, friendly and courteous as well as extremely competitive in all departments. Put our claim to the test today and you are sure to be delighted.


text:
La Cucina Italiana magazine offers these simple, authentic dishes of the Italian countryside. From fettunta, the quintessential way to savor new olive oil, to schiacciata alla Fiorentina, Tuscany's timeless sweet flatbread, the flavor of new olive oil shines through. Each recipe serves 8.
Drain the beans. Process half of the beans with the scallions, herbs, pepper, and olive oil. Pour into a heavy saucepan and add the vegetable broth. Bring to a boil and simmer, covered, 20 minutes. Stir in the remaining beans; simmer 10 minutes. Meanwhile, toast the bread and rub it with the garlic. Place the bread on the bottom of eight soup bowls and pour the soup over the bread. Drizzle with olive oil and serve hot.
This page modified February 2007
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text:
101 Airborne iOS
- Publisher: Robocat
- Release Date: Sep 26, 2012
- Critic score
- Publication
- By date
Sep 27, 2012The stunning graphics will just suck you right into the action, and it's definitely a fun challenge.
Oct 3, 2012On the whole 101 Airborne is a solid topscroller action game. Aiming takes a little while to get used to, but overall the controls are good. Also, the 3D graphics are superb and the soundtrack is very appropriate. There are plenty of upgrades and levels, so it is definitely a justified purchase if it sounds appealing.
There are no user reviews yet.


text:
North Olmsted, OH Maid Service
Maid With Care
Maid With Care provides professional residential cleaning services to North Olmsted, OH and the surrounding areas. Locally owned and operated since 1985, we are an established company that offers quality and reliable services at affordable prices. From washing floors to cleaning light fixtures, our fully trained professionals are prepared to exceed your expectations.
Learn More About Maid With Care:
We also serve Cuyahoga County - Rocky River, Lakewood, Fairview Park, North Olmsted, Westlake, Bay Village, Olmsted Falls, Berea, Middleburg Heights, Strongsville, Parma Heights, and Brookpark, as well as Lorain County - Avon, Avon Lake, North Ridgeville. If outside of these areas, a travel fee will be applied to your order.
Contact Maid With Care today at 440-779-4410 for a free estimate.
Contact Information
Hours of Business:
Tuesday to Friday: 8:00 am to 5:00 pm
Methods of Payment:
Cash and Checks


text:
By Larry Lage, AP Sports Writer
ANN ARBOR, Mich. Lloyd Carr's lasting legacy as the Michigan football coach will be better than the one he has now.
If his name was mentioned Monday, when he announced his retirement, the response might've included a joke about him losing to second-tier Appalachian State or to the Jim Tressel-led Ohio State Buckeyes six times in seven years.
That's fair, because what happened recently is what people remember.
It's also unfortunate, because Carr was much more than that as a coach and a person.
It might shock some to see his .752 winning percentage sandwiched between Florida State's Bobby Bowden and South Carolina's Steve Spurrier among active coaches.
Perhaps it would surprise others to learn Carr's 1997 national championship was Michigan's first in 49 years, well before Bo Schembechler came to Ann Arbor, or that he was the first coach in school history to win four straight bowls.
Carr is one of eight Big Ten coaches with five conference titles and he won almost twice as many games as he lost against top-10 teams.
"History will be more kind to Lloyd Carr than the present perception about him as a coach," said Big Ten Network analyst Gerry DiNardo, who coached at LSU, Vanderbilt and Indiana. "It's natural for people to bring up what happened this season, but his critics should also point out his national championship, winning percentage, Big Ten titles and record against top-10 teams.
"And what's really remarkable is he did it without the hint of NCAA violations."
Carr suddenly became Michigan's interim coach in 1995, when Gary Moeller resigned, and he grew into the high-pressure job. The Wolverines dropped the interim tag during his first season and, two years later, he validated the decision by leading them to a national championship.
Along the way, Carr developed players that turned into NFL stars such as New England quarterback Tom Brady and Green Bay cornerback Charles Woodson.
On the Mount Rushmore of coaching at Michigan, Carr has earned a spot next to Schembechler and Fielding Yost. Among coaches with a decade of experience in the Big Ten, Carr ranks behind the late great Michigan coaches with a .779 winning percentage in conference games.
"I feel extremely privileged to have played for one of the most respected and passionate coaches in the history of Michigan football," Brady said.
Carr was tough on his players at times, suspending them or kicking them off the team for misdeeds.
Yet they respected him because of his work ethic and for thinking about them as people in ways such as forcing them look up a word in the dictionary outside his office before coming in to talk.
Players, assistants and those he let close to him also got a kick out of his sneaky humor and teasing ways. That's another unfortunate aspect of Carr's legacy.
On TV, he often came across as dry, boring or combative during news conferences. Away from the spotlight, he was a pleasure. And he was a generous benefactor. Carr helped raise more than $2 million for the school's Children's Hospital, cancer and urology centers by promoting the sale of wristbands, hosting a car wash and a radiothon.
The former high school English teacher would talk about world leaders such as Theodore Roosevelt and Benjamin Disraeli and how their leadership principles guided his life.
When Carr announced he is retiring after the Wolverines play their bowl game, he shared his inspiration from poet Pakenham Beatty.
"He said, 'By your own soul learn to live,'" Carr said Monday at a news conference in which he went back and forth between tears and laughter. "'If some men force, you take no heed. If some men hate, you have no care. Sing your song, dream your dream, hope your hope and pray your prayer.'
"And that's what I've tried to do."
Carr knew some people would go searching to find out something about Beatty.
Perhaps that was fitting; teaching right to the end.
Copyright 2007 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


text:
In the College of Human Sciences and Humanities you'll learn, work and grow alongside
those who are curious about all facets of the human experience. Our goal is to transform
lives and communities through scholarship and practice in disciplines as diverse as
the world around us. Choose from among 15 undergraduate majors and 19 minors and 17
graduate programs including our newest, the Doctor of Psychology degree in Health
Service Psychology. We invite you to meet our exceptional faculty and friendly staff
who can help you find your place here in UHCL's College of Human Sciences and Humanities.
Contact us today to get more information or to schedule a campus visit. We can't wait
to meet you!


text:
Definition of "cautionary" - Learner's Dictionary
(Definition of "cautionary" from the Cambridge Learner's Dictionary © Cambridge University Press)
Get a quick, free translation!
- causeway noun
- caustic adjective
- caution noun
- caution verb
- cautionary adjective
- cautious adjective
- cavalier adjective
- cave in
- cave noun
Create and share your own word lists and quizzes for free!
Word of the Day
in a manner of speaking
used for saying that something is partly true


text:
- Öffnungszeiten: Open 24 hours per day.
- Bus-Frequenz: 4 Minutes
- Abstand vom Hafen: 8.3 Miles
- Behalten Sie während Ihrer Reise Ihre Autoschlüssel
ÜberblickThe Parking Spot 2 servicing Dallas Fort Worth Airport offers free car side transport to and from the airport terminal 24 hours a day. FREE transportation from your car to/from all airport terminals is provided 24 hours per day.
Warum sollten Sie diesen Parkplatz buchen?
- Self Park secure parking near Dallas Fort Worth Airport
- Exterior Fence - Free Newspaper
- Average Shuttle Wait Time 4 Minutes
- Distance From Airport 8.3 Miles
- Open 24 hours per day.
Informationen für Menschen mit Behinderungen
Keine Angaben
Weitere Informationen
Bei AnkunftPlease arrive to park 20 minutes before you want to be at your terminal.
Bei RückkehrAfter retrieving your luggage, please call for pick-up. Please wait in the off-airport shuttle area.
Adresse für Navigationssysteme
5100 John W. Carpenter Fwy,
From Downtown Dallas: Take the 114 West (John Carpenter Freeway) to Freeport Pkwy. Exit and make a U-turn on the service road heading back east. The Parking Spot 2 (Formerly FASTTRACK) is on your right.
From North Dallas: Take the 635 West (LBJ Freeway) to the Freeport Parkway exit. Cross over the freeway and go south 1.3 miles. Go under the 114 freeway and turn left on the service road.The Parking Spot 2 (Formerly FASTTRACK) is on your right.
From Plano, Flower Mound area: Go south on the 121 to the north end of the airport. Take 114 East and go 1 mile, exit Freeport Parkway. Go through the light and The Parking Spot 2 (Formerly FASTTRACK) is on your right.
From Ft. Worth, Arlington: Take either 121 or 369 North to 114 East. Go east on the 114 freeway for ¾ of a mile past the north entrance of the airport. Take the Freeport exit and go through the light.The Parking Spot 2 (Formerly FASTTRACK) is on your right.


text:
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Receive the latest in Footwear, Fashion, Music and Creativity in our newsletters.
A purveyor of affordable fusion Taiwanese cuisine, the Lower East Side's Baohaus and founder Eddie Huang welcome Fool's Gold's Ninjasonik into the kitchen for a quick lesson. A Baohaus-adapted version of Hawaii's classic loco moco is on the top of the menu as Huang puts the Ninjasonik crew through their paces.


text:
NBR Trifecta residential project on Sarjapur-Baglur is a great investment opportunity in southwestern Bangalore. Developed by NBR Group, NBR Trifecta is situated in the midst of greenery, encircled by Premiere educational institutions and top MNCs. The grand new NBR Trifecta plots are developed to offer all category people aspiring to build their dream home. Plots cost Rs. 1350/- per sq. ft, one can purchase it only for Rs. 1100/- per sq. ft. as a pre-launch offer. NBR Trifecta is DTCP approved and HNDTA converted. Loan facility is available from many premiere banks. For support and documentation details, call 8088678678.
Key Features of NBR Trifecta Gymnasium and swimming pool Over 100 acres township Underground sewage system Near to Infosys campus and Chikka Tirupathi Temple Avenue plantation Kids play area Ready for registration
Browse http://www.nbrdevelopers.com/nbr-trifecta/ for more details about NBR Trifecta.


text:
- 1(psychology) a mental image of somebody as being perfect that you do not realize you have and that influences your behaviour
- 2(pl. imagos, imagines BrE BrE//ɪˈmeɪdʒɪniːz//; NAmE NAmE//ɪˈmeɪdʒɪniːz//; BrE BrE//ɪˈmɑːdʒɪniːz//; NAmE NAmE//ɪˈmɑːdʒɪniːz//) the final and fully developed adult stage of an insect, especially one with wings Word Origin late 18th cent. (in sense (2)): modern Latin use of Latin imago
BrE BrE//ɪˈmeɪɡəʊ//; NAmE NAmE//ɪˈmeɪɡoʊ//; BrE BrE//ɪˈmɑːɡəʊ//; NAmE NAmE//ɪˈmɑːɡoʊ//
Check pronunciation: imago


text:
Vodka "Russian Standard" Gold, Box, 700 ml
- Region:
- Producer:
- Brand:
- Volume: 700 ml
- Type:
- Class:
Vintages and volumes
Reviews of purchase "Russian Standard" Gold, Box, 700 ml
Tasting Notes
Has a velvety, smooth taste, which felt a light creamy tone. The finish is warm, warming.
Due to the multi-stage cleaning has a soft rounded aroma with a light vanilla note.
Perfectly suited to the hodgepodge, ear, hot and cold dishes of meat and fish. Fish is best served salmon, pink salmon, salmon, herring and salmon and sturgeon. Blends perfectly with caviar, pickled mushrooms and cucumbers, as well as stuffed pancakes and grilled vegetables.
Interesting Facts
For its production using the best winter wheat and pure glacial water of Lake Ladoga. Thanks to a four-filtration using charcoal filters, vodka "Russian Standard Gold" has a pure and mild flavor and ginseng extract gives its tonic properties and makes any holiday brighter and happier.
Luxury gift box with embossed gold ornaments, made in the style of the palace is a spectacular frame of vodka "Russian Standard Gold" and embodies the traditions of Russian generosity and hospitality. This gift will be appreciated at its true worth culprit celebration and decorate any festive meal.


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Local Food Directory
Enclose phrases in double quotes ("").
LifeCycles Good Food Directory
Welcome to the Good Food Directory!
Welcome to the the Vancouver Island Good Food directory. The purpose of this website is two fold. The first is the help people on Vancouver Island connect with local farmers, producers, and prossesors of local food. The second purpose of this website is to educate people about the distance supermarket food travels and the environmental and economic impact these imported foods have along their travels. To get started, make a selection below on how you would like to browse this directory.
Why Buy Local?
Taste, freshness, nutrition, supporting local growers, environmental health--there are many reasons to buy local! Some of the less-obvious reasons to buy local include reducing emissions of greenhouse gases and other pollutants, helping to stregnthen the local and global economy, and to improve everyone's health. When browing different products you'll notice a section that describes the average distance this food travels and highlights the impacts you will have on the environment and the economy by buying local. If you find yourself interested in this type of information you can do custom calculations and keep track of your personal impacts by clicking Calculate Food Miles on the lefthand menu.
If you are interested in learning how we built this directory and some of the models that were used in determining our statistics, you can check out our Food Miles Tutorial
Do you operate a small farm or business that provides local food? You can add yourself to the directory. If you have any questions or comments regarding the directory, or need your listing updated, please email email@example.com.
Dairy Products
The islands are a rich source of a broad variety of dairy products. Smaller producers can list their product(s) in specific categories such as Cheese or Goat Milk. Commercial dairies may produce many more products than those listed in our directory.
Click the links provided to view listings of local beverage producers and processors. Resources include micro-breweries and vineyards, as well as non-alcoholic drink processors.
Many varieties of poultry eggs are available on the islands. Listings can include farming practices used in raising the poultry such as free-range or organic.
Fresh Produce
This directory attempts to list as many resources as possible, from the commercial supplier to small producers who sell a few items at markets or by special order. Farmers' Markets are linked to this page.
Fruits and Berries
The islands are rich in seasonal fruits and berries. Since imported fruit tends to come from very far-away locations such as New Zealand and South America, purchasing locally when in season helps greatly reduce global production of CO2 and other air pollutants contributing to climate change.
Grains and Bread
Included are local producers of grains, those who process grain into flour and flour into bread and pastries, and resources who incorporate locally-grown produce in their baked goods. Locations where these goods are sold are also listed.
A thriving bee community is a vital part of a healthy growing environment. Fortunately, while pollinating our plants and trees, bees also provide us with tasty honey. There are many island resources who keep bees and harvest honey for our consumption.
Just as our climate is ideal for growing produce, so do our island habitats support a thriving livestock agriculture. Check here to find the diverse range of locally farmed meat products available.
While often categorized with fruits, nuts are provided their own category in this directory for clarity. To further confuse the issue, we have chosen to categorize filberts under the other name they commonly are referred to in Canada - the hazelnut.
Prepared Meals
This category serves to represent the products restaurants and caterers create out of the variety of items grown or processed on the islands. Several restaurants now recognize the benefit of supporting local farmers and using ingredients in season when menu planning.
Here you will find all things harvested naturally from the sea. Wild fish, shellfish and sea vegetables such as kelp are harvested around Vancouver Island and processed for local consumption.
Soy Products
Resources that create, sell or use locally produced soy products are welcome to link their contact information to this category. It is also the location to research producers of gluten and alternative protein products in general.
All candy makers listed in this directory create their products locally and some utilize local products as ingredients. This supports our goal of decreasing greenhouse gas emissions by preventing or diminishing the requirement to ship candy products to the island from distant locations.
Craft vinegars are created from scratch at local breweries and vineyards. Other products listed include vinegars infused with locally grown herbs, and fresh local produce pickled in vinegars.