text:
Cannabis Concentrate Callouts:
A Brief Look at Live Resin, Rosin, and the potency of concentrates
As the cannabis industry continues to shatter sales records and reach new heights, consumers are always searching for the next big thing. Recently, consumers have taken an interest in cannabis concentrates. Some forms of these concentrates include shatter, wax, crumble, or simply 'dabs.' However, consumers are becoming conscious of the cannabis concentrates that are rosin as well as live resin. So what exactly are these cannabis concentrates, and how do they differ from what is already available on the market today?
What is Rosin?
The term Rosin refers to a distinct extraction process that applies a combination of heat along with pressure to instantly force the substance or resin out of the bud of cannabis. Furthermore, the term rosin originated as a method of making a product used to create friction with bows used for musical instruments such as cellos and violas. With cannabis, this extraction method is amazingly versatile in that it can either be utilized with dry cannabis flowers or to clean up hash and kief into a hash oil. The result is often translucent, thick and can even appear similar to the cannabis concentrate shatter. If performed correctly, rosin can be implicative of the flavor, yield, and potency of other extraction products that utilize solvents.
Live Resin
Live resin is a form of Cannabis Concentrates that are prepared utilizing a technique that uses recently gathered cannabis and freezes it to extremely cool temperatures before and during the extraction process. Considering Cannabis Concentrates, Live resin is fairly new to the concentrate game. Its origins are often noted at some point between 2011 to 2013 with a handful of extractors as well as growers.
The History of Live Resin
When discussing the history of live resin, its creation is often accredited to two individuals. Additionally, this was done by creating a specific form of BHO (or Butane Hash Oil) extractor that has the ability to maintain the uncommonly low temperatures needed to produce live resin cannabis concentrates. The genius of the process was utilizing chilled, even frozen cannabis plant matter for the cannabis concentrate. By using frozen cannabis, the trichomes would become more susceptible to be being extracted into a cannabis concentrate. In unison, the two originators of live resin were able to create methods able to extract cannabis concentrates laden with extremely high levels of terpenes and trichomes.
How to Properly Identify Live Resin
In today's landscape of the cannabis market, most cannabis consumers can successfully identify concentrates such as wax, shatters, dabs, and others. Live Resin provides a slight difference from BHO extracts; one of these differences is the viscosity. Live Resin often appears to be runnier versus solidified shatter or thick-dripping dabs. Live Resin often appears in the same varying shades of gold and amber as most cannabis concentrates, but more stocky yet thin form. Moreover, due to the overwhelming terpene content found in Live Resin, the aroma will often be more intense versus other cannabis concentrates.
Why Consumers are Praising Rosin
The common cannabis consumer considers two primary values when making a cannabis-related purchase: 1) the level of organics possessed by the product, and 2) the overall potency of the product. With these insights in mind, it is evident why consumers are intrigued by concentrates such as rosin. This form of concentrate can be prepared in a solvent-less fashion. This means BHO does not have to be used to create rosin. The fewer chemicals associated with cannabis, the more likely consumers are to be drawn to it. At this rate, rosin may take over the hash market in a way the cannabis industry has not seen before.


text:
Introduction: Cuba's Postal History
The Island of Cuba, from an 1855 map published by J.H. Colton & Co., New York. (Private collection)
In the days before postage stamps were invented, people could send their letters either prepaid or unpaid. Most sent their letters unpaid, leaving it up to the recipient to pay the postage. Either way, generally, one had to take his letter to the post office for mailing. There were no mail collection boxes in most towns and villages.
If prepaid, the post office clerk determined the rate of postage by weight and distance, and one paid him across the counter. The clerk marked the letter "Paid" or "Franco," indicating prepayment, applied his town marking or datestamp and put it in the appropriate mail bag for its journey.
If unpaid, upon receipt, the clerk applied his town marking or datestamp and placed it in its appropriate mail bag. The letter would be rated for postage charges by a clerk in the receiving post office. When the addressee called at the receiving post office for his mail, he paid the postage due marked on the front of the letter.
This system began to change when Great Britain first issued postage stamps on May 1, 1840. Now people had an opportunity to prepay their postage with stamps. In those cities and towns with mail collection boxes, they could simply drop their stamped letters into a convenient mailbox, and would not have to travel to the post office to post a prepaid letter. Spain issued its first postage stamps on January 1, 1850. In Cuba, the first postage stamps were placed on sale on April 24, 1855.

subset: commoncrawl


text:
As families, there are plenty of games we can play to spend quality time together.
Sometimes it feels like there aren't enough hours in a day, and many of us wish we had more time—particularly to share with our family. Choosing fun, engaging activities and games to play with our little ones can make all the difference in taking full advantage of our precious family time.
At Lingokids, we offer you new games to play with your kids that are not only educational and entertaining, but can also help them learn important skills while you create fun memories together.
Discover how!
Why is it important to play games together as a family?
From outdoor to indoor options, board games to sports, there are many games for us to play together as a family.
Turning family time into quality time is key to helping build stronger relationships. It's an opportunity to share stories, come up with inside jokes, and create lifelong memories with our loved ones.
At Lingokids, we feel much the same about spending quality playtime with our kids—because great things happen when families play together! Choosing the "right" games and activities for your child might sound hard, but it doesn't have to be. Engaging them with creative activities that you both enjoy is a great start!
When we're having fun, the reward center of our brain is activated, and it just feels good. It's no surprise that this is the best way for kids to develop and learn (and why they spend so much time playing!)
Nurturing this state of play means saying "yes" to instant adventures or unexpected ideas—and inviting more fun into our everyday lives.
Reconnecting with Your Inner Child
For us grown-ups, no matter our age, wonderful things also happen when we play, like learning! When we tap into our inner child to play and discover new things with our little ones, we make the most of the amazing adventure that is growing up and raising a child.
Playing board games at home, building sandcastles on the beach, or eating ice cream together on a rainy day—it doesn't matter which activity we choose to do with our child, as long as we give them a piece of our heart and, more importantly, our time and attention.
After all, that's what they will remember most.
✔The Benefits of Playing Games Together as a Family
Your entire family can benefit from spending quality playtime together.
Here are just a few of the perks:
Family Bonding: Playing family games, sharing adventures, discussing strategies, and having fun together can help moms, dads, kids, grandparents, and other family members build stronger relationships.
Increased Communication: While playing games together, communication is key. Explaining the rules or what to do next, choosing which path to take, deciding which option to choose—these dynamics can impact and reflect your child's ability to listen and be heard.
Trust and Confidence: Relying on a partner is an important part of playing games. Trusting your game partner and, in return, feeling that you can be trusted, increases confidence and self-esteem. Playing games with your family can help you become a trusted figure to your child.
Decreased Behavioral Problems: To summarize the above, when you share a strong emotional bond with your child, establish trust, and improve communication within your family, you are likely to see an improvement in your child's behavior.
Introducing the New Lingokids "Play Together" Games
It's playtime! Try out these new Lingokids "play together" games with your kid.
After recognizing the many benefits that family games have to offer, we've designed some exciting new games you and your little ones will love!
Our new play together games are designed to encourage fun, educational parent-child playlearning™.
These games foster communication, collaboration, and strategic thinking while teaching vocabulary—fun for the whole family!
Check them out:
Collaborative Games
These funny games help build collaboration, communication, and strategy skills while helping your child learn new vocabulary for fruits and vegetables!
Two new collaborative games are available for you to play with your child:
– About: Help Lisa sail her boat through dangerous waters to pick up all the fruit, but be careful, there are water swirls everywhere!
– How to Play: On each side of the device you will find two arrows with the directions and on the other one the wheel. You'll need to synchronize and communicate with your child in order to navigate the boat and pick all the fruits Lisa needs!
Play Together! Tractor Driving Game
– About: Elliot needs some help collecting all the vegetables of his farm.
– How to Play: Direction commands are located on one side of your device, with the tractor's wheel on the other side. One of you will take care of either going forward or backward, and the other one will turn the tractor 360º!
How to Play the New Lingokids "Play Together" Games
I already have the Lingokids app!
If you already enjoy the Lingokids app, head to the "EXTRA CONTENT" section of the games area to find our full selection of games.
Please keep in mind that if you have Lingokids Basic, these family games are included in the three free games and activities you can enjoy per day. Remember: you can always upgrade your Lingokids account right from the app to enjoy all of our content without restrictions!
I'm new to Lingokids!
Oh, nice to meet you! Good news: click here to try out the app!
And don't forget to follow us on social media to get the best out of the Lingoworld and relevant tips on family games and parenthood!


text:
Above are some images from the Hart Island tour orientation slideshow.
NYCHS Hart Island/Harlem Jail Tour
Below are some images from the Harlem Courthouse jail web page.
|Three dozen New York historians, academicians, graduate students, genealogists and serious researchers participated in the first-ever history tour of Hart Island and the Harlem Courthouse jail Thursday, April 27.
Organized by the New York Correction History Society (NYCHS), the tour was conducted through the good offices of the New York City Dept. of Correction (NYC DOC) and in coordination with the City University of New York Americanist Group, a part of the New York Metro Chapter of the American Studies Association. NYCHS initiated the event to promote the academic community's interest in recovery and preservation of correction history in New York.
Helpful in arranging the Harlem jail portion of the tour were the New York City Department of Citywide Administrative Services, the New York State Office of Court Administration and the Harlem Community Justice Center whose offices are located there.
The all-day event began at 9 A.M. when participants gathered at NYC DOC hq in Manhattan's Tribeca section, received background information kits, viewed a 77-image orientation slideshow and then boarded the tour bus. At the City Island slip for the Hart Island ferry, they were greeted by Correction Captain Eugene Ruppert, veteran head of the Potter's Field burial detail; City Island historian and nautical museum curator Virgina Gallagher, and Correction Officers Samuel Perry and Thomas O'Connor, the only officers still with NYC DOC who worked on Hart Island when inmates were housed there. Both joined the Department in 1959.
On Hart, the tour group visited the Civil War Union soldiers and sailors' burial site and its 1877 monument as well as the site of the Army Nike Ajax missiles poised at the ready on the island during part of the Cold War. The visitors saw dozens of abandoned structures from the 19th century and later eras when the island housed various classifications of inmates and patients. The group viewed Potter's Field and the massive 30-foot high Peace monument build in 1948 by inmates for the unbefriended and unclaimed dead buried on the island.
Throughout the island tour, Capt. Ruppert, COs Perry and O'Connor and curator Gallager provided commentary and answered questions. On the return from Hart, she opened the doors of the City Island nautical museum (usually closed weekdays) so that the group could view the exhibits linking the histories of the two islands.
After a quick lunch at one of City Island's famed seaford restaurants, the group reboarded the bus that then headed to the Harlem jail where participants were greeted and escorted by David Bedrin, the Harlem Community Justice Center's facility and fiscal administrator. He led them on a tour of the 1892 courthouse's restored courtrooms (featuring partially restored WPA murals) and the unrestored 40-cell multi-tiered jail. One highlight of the visit was a peek at the recently discovered near-century old court and jail records bundled, shelved but damaged by dampness and pigeons in a long-forgotten attic storage area accessible only by ladder.
Before concluding the visit, tour members were thanked for their participation by Thomas McCarthy, NYCHS general secretary and NYC DOC director of historical services. He explained that the tour was just the latest in a series of activities set in motion by an initiative launched under the previous NYC Correction Commissioner, Michael P. Jacobson, and expanded under the current Commissioner, Bernard B. Kerik. The initiative seeks to recover, preserve and promote correction history in New York with the help and participation of the academic community. Professor Jacobson, now with John Jay College of Criminal Justice and the CUNY Graduate Center, is president of the New York Correction History Society; Commissioner Kerik, its board chairman.
Home Page
'About Us'
Starter Page
Photo Album Starter
Hart Island
Nike Base Story


text:
Press release
WASHINGTON, D.C. – In response to a request from Congressman Walter B. Jones (NC-3) and the Dare County Board of Commissioners, the federal Bureau of Ocean Energy Management (BOEM) has agreed to hold an additional public scoping meeting on the Outer Banks regarding the federal government's proposal to conduct an oil and gas lease sale off the coast of North Carolina between 2017 to 2022.
The meeting is expected to take place in mid-March, although a specific date, time and location have not yet been set.
Jones formally requested the meeting in a Feb. 5 letter to the director of the Bureau of Ocean Energy Management (BOEM), Abigail Ross Hopper.
The only public meeting that BOEM had previously scheduled in North Carolina took place Feb. 17 in Wilmington.
Jones and Dare County commissioners made the case that because Wilmington lies in the southeastern corner of the state, many citizens from the northern part of the coast who would like to attend the meeting would not be able to due to the geographic distance involved.
"It is vitally important for the federal government to receive the input of citizens who stand to be most impacted by this proposal," Jones said. "I am thankful to Director Hopper for granting this request so that those living in the northern part of the state can participate in this process."
Below is Jones' letter requesting a meeting in Dare County.


text:
Spagna Square
The Spanish Steps (Italian: Scalinata della Trinità dei Monti) are a set of steps in Rome, Italy, climbing a steep slope between the Piazza di Spagna at the base and Piazza Trinità dei Monti, dominated by the Trinità dei Monti church at the top.
The Scalinata is the widest staircase in Europe. The monumental stairway of 138 steps was built with French diplomat Étienne Gueffier's bequeathed funds of 20,000 scudi, in 1723–1725, linking the Bourbon Spanish Embassy, and the Trinità dei Monti church that was under the patronage of the Bourbon kings of France, both located above — to the Holy See in Palazzo Monaldeschi located below. The stairway was designed by architects Francesco de Sanctis and Alessandro Specchi.
from Wikipedia


text:
How to write a salon business plan?
Trend Setters is a full-service beauty salon dedicated to consistently providing high customer satisfaction by rendering exmobileent service, quality products, and furnishing an enjoyable atmosphere at an acceptable price/value relationship. We will also maintain a friendly, fair, and creative work environment, which respects diversity, ideas, and hard work.
Our Mission: to provide products and services that improve our consumers' appearance and psychological leisure.
Our Motto: "The Trend Begins Here!"
The time is suitable for starting this brand new venture. Patiently searching for six months for the perfect location, one had been eventually discovered. The need from the owner's customers, as well as the aspirations of the owner to a single time start her very own hair salon, while the procurement of highly professional and skilled beauticians to guide the salon, made this business certainly one of great potential.
Curley Comb, co-owner with Roller Comb, Jr., her husband, worked in a prestigious, upscale salon in MyTown, Texas when it comes to previous couple of years. Curley has created a large customer after through work and dedication. Curley, and her talented team of beauticians, has actually what must be done to produce this endeavor an incredibly successful one. We anticipate our growing reputation to lead to new business and beauticians to support our anticipated development.
To produce our goals, Trend Setters is pursuing additional loan financing. This loan are paid through the cashflow from business, and will also be collateralized by the possessions associated with organization, and backed by the character, experience, and private guarantees associated with the owners.
1.1 Keys to Triumph
The secrets to success within business tend to be:
- Area: offering an easily accessible location for consumers.
- Environment: offering an environment conducive to giving relaxing and professional solution.
- Ease: offering customers many services within one setting, and prolonged business hours.


text:
Marta Williamson was the low gross winner for the nine-hole ladies at the Alberni Golf Club last week, while LaDonna Knutson took home low gross in the same A Division.
Low putts went to Pennie Churchill.
In the B Division, it was: low gross – Lorraine Wilson; low net–Julie Swaney; low putts–Lorraine Wilson.
Chip-ins went to Marie Swain on No. 4, Katy Lekich on No. 7 and Churchill on No. 4 and No. 9.
Churchill also had a birdie on No. 9: way to go, Pennie.
LaDonna Knutson, Marta Williamson and Marie Swain shot par on No. 4, while Julie Swaney had a par on No. 8.
Welcome to Pennie Churchill, Cass Parker, Jan Charlesworth and Bonnie McIntyre for their first time out this year.
18 hole ladies
Low gross went to Anna Marie Krikke with an 87.
Low net went to Claudia Romaniuk with a 71.
In the ball sweep, golfers received 10 points for every fairway they hit and they had to subtract their putts from that.
Apparently some golfers are worse putters than others.
Gayle Rhodes won first prize for having the highest score and Evelyn Mee (our newest member) won second by only one point. Welcome, Evelyn.
Make sure all scores are in the computer, ladies from down south.
Anyone owing dues, they must be paid before you can participate in the Monthly Medal on Tuesday. Also we start at 8:30 a.m. on Tuesday.
*Kathy White pens Pitch'n'Putt.


text:
Campaign Objectives
Increase awareness of 8th Continent Soymilk Complete among mainstream consumers as the perfect food. Our focus was on promoting the product benefits: 100 percent cholesterol free, an excellent source of fiber and low in saturated fat, while removing the "yuck" factor by showcasing the product's award as "Best Tasting Soymilk in America."
Implementation of Campaign
We developed a series of media and sampling executions to meet the program objectives:
- Media
1) Utilized health and nutrition experts to deliver 8th Continent messages on local, regional and national levels
2) Developed "Easy Soy Cooking" media platform
3) Launched national media relations campaign featuring taste-centered applications of soymilk
4) Created 8th Continent Complete "5 Minute Breakfast national media tour as well as custom pitches around soy as a healthier, great-tasting alternative that wasn't just for breakfast, and as a tool in the fight against holiday weight gain. Our focus was on food and health editors, national women's and health magazines, and online influencers
5) Conducted local market tours with in-market Registered Dietitians
6) Conducted Satellite Media Tour with Elizabeth Somer, nationally-recognized Registered Dietitian.
- Sampling
1) Conducted sampling events for editors at Meredith Publications, with consumers in major markets at high-traffic locations
2) Conducted long-lead cooking event in New York, with entire menu made with Complete. Attendees included editors from Family Circle, Fitness, First for Women, Women's Day, Fit, Shape en Espanol, Men's Health, Good Housekeeping, Working Mother, etc.
3) Created an influencer sampling program targeting health conscious moms and adults motivated by health, environment and spirituality.
Campaign Results
Results included 153 million gross impressions, with 3.3 million print, 38 million broadcast, 60 million online, and 4.5 million Satellite Media Tour impressions. Media placements included Today Show," "View By the Bay," "Fox 4 Dallas," "NBC 4 Miami," Portland "AM Northwest," "San Diego Living," "NBC 4 Washington," "Fox 5 Nashville," "Good Day Dallas," ModernMom, Self, Denver Post, Dallas Morning News, Shape, LA Parent, Boston Globe, Supermarket News, Associated Press.
Reach out to learn how we can elevate your brand.


text:
For the use of our website it is necessary to use cookies.
What are cookies?
Cookies are small files that are downloaded to your terminal when you access certain web pages, allowing the latter to efficiently store and retrieve information about your configuration, browsing habits and other technical considerations through which this website can personalize your experience. on the web and adjust it to your preferences and features.
What do we use them for?
The cookies are used with the purpose of allowing and facilitating the user's interaction with it. In addition, the services of own or third-party statistics, used by the website.
There are two types of cookies, permanent and temporary (session cookies). Permanent cookies are stored as a file on your computer or mobile device for a period of time not exceeding 12 months. Session cookies are temporarily stored and disappear when you close your browser.
The applications that we use to obtain navigation information, measure and analyze the audience are:
Google Analytics (www.google.com/intl/en/analytics/)
This application has been developed by Google, which provides us with the analysis service of the audience of our page. This company can use this data to improve its own services and to offer services to other companies. You can know these other uses from the indicated links.
This tool does not obtain data of the names or surnames of the users or of the postal address from where they are connected. The information obtained is related, for example, to the number of pages visited, the language, the social network in which our news is published, the city to which the IP address from which the users are assigned is assigned, the number of users they visit us, the frequency and recidivism of the visits, the visit time, the browser they use, the operator or type of terminal from which the visit is made.
How can you eliminate cookies?
You can easily remove cookies from your computer or mobile device by using your browser. If you wish, you can configure your browser to be warned on the screen of the receipt of cookies, and to prevent the installation of cookies on your hard drive. Please consult the instructions and manuals of your browser for more information:
More information about Internet Explorer: windows.microsoft.com/es-419/windows7/how-to-manage-cookies-in-internet-explorer-9
More information about Mozilla Firefox: support.mozilla.org/es/products/firefox/cookies
More information about Chrome: support.google.com/chrome/answer/95647?hl=en
More information about Safari: support.apple.com/kb/PH5042
More information about opera: help.opera.com/Linux/10.60/es-ES/cookies.html
In none of the cases, "Adcshop.com" uses or accesses the 'cookies' for purposes other than those stated.


text:
Debra Bowen got her start in politics as the attorney for the Venice Town Council. When she was elected California Secretary of State in 2006, like any good Venetian, her first act was to ban electronic voting machines. This courageous act earned her the attention of the Kennedys. Both Ted and Caroline attended her award ceremony at the John F. Kennedy Library.
The Beachhead salutes Debra Bowen for keeping the faith!
"When a comprehensive review of California's new electronic voting machines revealed that election results could be altered on the new machines, Secretary of State Debra Bowen did not wait for things to go wrong on election night. . ." – Caroline Kennedy
"Her position was highly unpopular, but she didn't hesitate. She began the daunting task of ensuring fair and accurate voting. Last August, she courageously decided that she had to do something about it herself, and she de-certified three of the most widely used electronic voting systems in the state." – Sen. Ted Kennedy
Acceptance Speech by Debra Bowen
To the Kennedys, what a joy to be amidst your family. To the outstanding board and staff of the John F. Kennedy Library Foundation, the distinguished members of the John F. Kennedy Profile in Courage Award Committee, thank you for this most humbling honor.
You have caused me to think about the nature of courage, but not much has become clear.
There is one thing that I know though, and that is that courage is not the same thing as fearlessness. I am often introduced as being "fearless," but that is not true – and because I know that I have inspired at least a few young people, I feel a great responsibility to ensure that they know that fear is not a disqualifier for a life in public service.
For me, the equation is simple – I fear my own inner critic more than I fear the condemnation of others. I would rather be greeted with cynicism and criticism by the editorial board of a large newspaper than to live with the certain knowledge that my actions, or failure to act, did not come from a deep place of justice and integrity.
I know that sense of justice and fairness is what motivated me in junior high school to organize a sit-in outside the principal's office, over faculty censorship of the student newspaper.
It is why, in ninth grade, I orchestrated a protest over a school policy that did not allow girls to wear pants to school. My geometry teacher kicked me out of class for wearing pants, and I got a zero on the test. But I was not in trouble at home, because my parents had taught me that you do not have to accept the status quo if you think improvements can be made, and that standing up for what is right can never be wrong.
My family did not have a VW van with a bumper sticker that said, "Question authority." I grew up in the district of a courageous liberal Republican congressman, John B. Anderson of Illinois, whose integrity in office served as a role model for me. He continues to serve as a role model as the president of an organization called FairVote, which acts for universal access to participation in elections and majority rule with fair representation for all.
Despite my background of organizing protests at school, I am an accidental politician. I never set out to run for public office. I got involved with Neighborhood Watch in about 1987, working as a volunteer on local issues, and one thing led to another. I was simply too naïve to know that you didn't just run for a seat in the California Legislature, and so I did in 1992 and, as they say, the rest is history.
But I learned growing up that nothing happens by itself, that citizens must act if they desire change. During my three years at the University of Virginia law school, I became aware that democracy itself does not sustain itself – that, as Thomas Jefferson said, eternal vigilance is the price of liberty. And I am sure this is what John F. Kennedy meant in noting that democracy is not a "final achievement," but rather "a call to an untiring effort."
While democracy does not sustain itself, it is self-correcting over time.
As a nation, we are prepared to fight for our ideas, to vote, and then to accept the results, win or lose, knowing that the discourse will continue and that the next election will present another opportunity. And in trust of this, we have laid down arms, turning to ballots rather than to bullets to further the choice of leadership in our country.
But that only works if citizens believe that our elections are free, fair, and open, and if citizens can verify for themselves that the results are accurate.
My task as Secretary of State is to ensure that the fundamental tools of democracy – our voting systems – are up to that extraordinary responsibility.
That was the basis of the first-of-its-kind top-to-bottom review of voting systems that I commissioned in 2007. I wanted – on behalf of all voters – to know whether the systems we use to cast and tally our votes are secure, accurate, reliable, and accessible.
I invited the public to participate as fully as possible. I am grateful to all of those who criticized and commented, including elections officials in California, who helped me self-correct in the very design of the review.
The proprietary software itself poses a particular challenge. If people themselves are not allowed to analyze the computer code running the system, and 99% of people could not verify that the code accurately reflects the will of the people even if they could see it, how could I, as the chief elections officer of California, give them nothing more than a request to "trust me?"
Our democracy is not built on trust alone. The checks and balances – the mechanisms of self-correction – anticipate that errors in judgment will sometimes be made and that trust will sometimes be violated, but that the system will be tough enough to discover the truth and to recover its bearings.
With the scientific analysis of the top-to-bottom-review as my guide, I chose to favor the transparency of voter-marked paper ballots, which can readily be recounted, coupled with the accuracy and speed of the computer to do the tedious work of counting multiple races. I required strict post-election audits, to make sure that the scanners and all the computerized equipment have performed correctly, because that's something we cannot know simply by observation.
That meant sidelining some expensive equipment, but how do you argue that voters deserve less than the best we can provide?
Our work on California voting systems is only the beginning of my pledge to work for a system that moves us towards President Reagan's abiding principle: Trust, but verify. Play, but cut the cards.
It is up to each and every one of us to cut the cards as we continue the work first begun by our nation's founders over two centuries ago. Had our democracy not evolved, more than half of the people in this room and in this country, would not be voters – because you had to be white, male and, in most states, own land in order to vote. Of course, we have evolved to include all citizens in our electorate, and we must continue the quest for progress in all aspects of our government.
I have been inspired by the grassroots and the netroots who have pushed for a voting system worthy of our democracy. I would not have run for the office of Secretary of State without their encouragement, support, and hard work.
So I will accept this award on behalf of every person who believes that there is nothing partisan about ensuring that every eligible voter has the opportunity to vote, and that every ballot is counted as it was cast.
And I share this award with every voter who has had the courage to question our electoral process, and with everyone whose untiring effort protects the integrity of our democracy.


text:
Article Text
Statistics from Altmetric.com
Request Permissions
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center's RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.
Introduction (Bruce Hamilton)
For practitioners working with elite athletes, the field of sports cardiology provides clinical, academic, administrative and fiscal challenges. These challenges are exemplified and reinforced by the lack of consistency and consensus both in the literature and academic presentations. Through the presentation of a series of clinical questions, this debate attempts to 'cut to the chase' on cardiovascular issues relevant to the clinician dealing with elite athletes. In so doing, we hope to crystallize some of the most important elements of the complex cardiological management of elite athletes, in a concise, readable format. Frequently over the last 10 years, many of the controversies in this field have been (rightly or wrongly) presented in a Europe versus USA paradigm. We have chosen to test whether there really are polarised views across the Atlantic, by deliberately pitting specialists from the USA against those from the UK. Professors Levine and Thompson are both internationally recognised sports cardiologists, with immense academic and clinical credibility, and who will represent the 'US approach'. Professor Whyte and Doctor Wilson are cardiac physiologists with a wealth of experience in the testing, evaluation and screening of elite athletes, and who have equally impressive academic credibility and for the purposes of this debate, they will be representing the 'European approach'. To initiate this process, each team was required to provide a concise answer (circa 200–300 words) to a series of five clinical conundrums. Subsequently, each team had the opportunity to provide a rebuttal to the opposing team's answers, and the following reflects the consolidation of those answers.
Question 1
A popular debate in the literature and the conference podium is the clinical utility of the ECG in the preparticipation screening of athletes. If one assumes that the overall cost:benefit of cardiac screening for athletes remains to be determined, is it now established that the ECG adds diagnostic value to the preparticipation cardiac screening of otherwise healthy athletes and should be a prerequisite for screening programmes?
PDT and BDL
Every debate must specify the topic for debate. Our side readily concedes that an ECG increases the diagnosis of multiple potentially fatal cardiac conditions including atrio-ventricular accessory pathways, right ventricular cardiomyopathy, Brugada's syndrome, long QT syndrome (LQTS) and hypertrophic cardiomyopathy (HCM). Indeed, taking any other position is foolish since the diagnosis of several of these conditions can only be made with an ECG. We are also not debating whether or not an ECG adds to the cost of screening. Of course it does and to argue otherwise would again be foolish. The only topic worthy of debate is whether or not the addition of an ECG to screening does more good than harm thereby justifying any required expenditures. Screening proponents rarely recognise the potential harm of a screening intervention, but such harms exist as discussed in a recent JAMA editorial on cancer screening titled 'The harms of screening'.1 The editorial correctly notes that the reason most position stands are cautious about recommending screening is because screening can result in iatrogenic disease. We have concerns that ECG screening will increase the number of athletes falsely diagnosed with disease (because the diagnosis of many of these conditions is imperfect) as well as the number of athletes correctly diagnosed with real disease who would never have experienced a cardiac event, but who will receive overly aggressive or inappropriate treatment. Until there is proof that such harm does not occur with ECG screening, there is absolutely no justification for routinely recommending or performing such treatment. This is also obvious because the primary rule of medicine is 'first, do no harm'.
GPW and MGW
There is consensus agreement from both the American College of Cardiology/American Heart Association and the European Cardiology Society that compelling justification exists for cardiovascular preparticipation screening on medical, ethical and legal grounds.2 ,3 While agreement on the implementation of screening may exist, there remains a difference in opinion regarding the methods employed to assess cardiovascular risk between the UK and USA. In line with the entire preparticipation screening debate, the North Americans base their exclusion of a resting ECG on a complete absence of empirical data, simply critiquing European data. This is puzzling to us, considering that some 30 years ago, data from the USA4 clearly demonstrated that in a cohort of 78 patients with HCM who had either died suddenly or had aborted cardiac arrest, where previous ECGs were available, 96% presented an abnormal ECG. The Italians further reported on 49 athletes identified as harbouring a disease associated with sudden cardiac death and demonstrated that only 14 (29%) presented cardiac symptoms before the time of death.5 Our own group reported on nine asymptomatic athletes from a cohort of 2720 young individuals (an incidence of 0.3% in line with current consensus) of whom none would have been identified without resting ECG.6 To avoid appearing Euro-centric, a recent study from Harvard provides strong support for an enhanced sensitivity and negative predictive accuracy with the (their words) 'mandatory' inclusion of ECG.7 It is clear that the resting ECG significantly improves the sensitivity of preparticipation screening, and despite the likely protestations of Professors Levine and Thompson, it is clear that some in the North American community believe it should be included as well.7–9 In summary, a preparticipation screening programme without a resting ECG is frankly a waste of time and money.
PDT and BDL Question 1 rebuttal
We agree with Professors Whyte and Wilson that ECG screening increases the sensitivity to detect HCM and the other potentially fatal conditions noted in our treatise, but that is not the point of this debate. The point of the debate is simple: Is there conclusive evidence that ECG screening does more good than harm? Such evidence is required before such testing is mandated for all athletes. Physicians should manage individual patients as appropriate for the clinical situation, and all concerned parents should be allowed to accept the risks as well as the benefit of ECG screening if they choose, but mandating testing for a population requires a higher level of justification. It is obvious that such evidence does not exist; if it did, there would be no debate. In the absence of conclusive data on the risks and benefits of screening, it is just as likely, and we believe more likely, that mandated screening would create more iatrogenic disease and deaths than lives saved. The onus is on Professors Whyte and Wilson to prove that this is not so.
GPW and MGW Question 1 rebuttal
Professors Thompson and Levine concede that the ECG improves the diagnosis of inherited cardiac conditions—this should be debate over! Yet to accuse us of failing to recognise the potential harm ECG screening may cause, is countered by their unwillingness to recognise that the fact that the downstream cascade of the US screening model consistently increases the number of false-positive athletes requiring further testing (harming the athlete and their healthcare system), and as we and others have demonstrated, increases the number of potential false-negative athletes provided with incorrect medical reassurance. To not engage in research to provide an answer to this conundrum is in direct opposition to their premise; 'do no harm'. Rarely has so much resistance been based on so little evidence!
Question 2
A frequently cited reason for cardiac screening of elite athletes is the negative effect that a Sudden Cardiac Death of a high-profile athlete may have on participation and therefore health of the population as a whole. However, limited evidence exists to support this hypothesis. Furthermore, the exact incidence of sudden cardiac death (SCD) is unknown. In light of the dearth of empirical evidence are we able to support or refute the mandating of cardiac screening in high-level athletes with confidence?
PDT and BDL
We agree that there is a dearth of empirical evidence on the risks of athletic participation. We are also unaware of evidence that the death of a high-profile athlete reduces athletic participation, particularly recreational activities that are used by the largest amount of the population to optimise health, but since Professors Whyte and Wilson are concerned enough about the risks of athletic competition to mandate ECGs for all athletes, they may consider any decrease in athletic participation as a life-saving intervention. It is this absence of data that is the core of our argument. Without data documenting that ECG screening saves more lives than it harms, the prudent approach is to 'do no harm'. So why do any screening at all, even the limited screening recommended by the American Heart Association? Again, there are no concrete data supporting that this approach works, but such screening can detect conditions such as aortic stenosis that were historical, but not current,10 frequent causes of exercise-related death, suggesting that athletes with this condition are somehow detected and excluded. Furthermore, the death rate among athletes in the USA achieved without mandated ECG screening approximates that of other locations where ECG screening is mandated,11 suggesting that the history and physical examination alone may be as effective as other approaches in identifying athletes who are most likely to die during sporting activities. A number of studies note the greater number of athletes with potentially fatal conditions detected by the ECG component of a screening programme. We are not convinced that all such athletes are helped and not hurt by this effort.
GPW and MGW
No negative 'measurable' effect on sporting participation rates for the general population following the SCD or aborted cardiac arrest of an elite athlete can be given. However, it is evident that for the 35 000 spectators and estimated 200 million TV viewers, watching the live (6 min!) cardiac resuscitation of the England Under-21 soccer captain during the recent Tottenham Hotspur versus Bolton Wanders FA cup clash, found it particularly disturbing. Debate surrounding the incidence of sudden cardiac death in young athletes has been the major impediment to progress in finding an international consensus on preparticipation screening.12 The central problem facing this debate is, with the exception of the Italians, the abject lack of systematic national registries (this includes the UK as well at the USA). However, particularly irksome in this debate is the perpetual diatribe from scientists who continue to publish their argument in highly reputable cardiology journals for a vanishingly small number of sudden cardiac deaths on newspaper reports and internet searches.13 This long-standing acrimonious debate was established by an early study from Van Camp et al,14 who postulated an incidence of sudden cardiac death in the USA of <20 per year. A more recent perusal of American newspapers has re-defined this number to 66 per year (0.6 deaths per 100 000 person-years)15; a figure similar to an earlier study from the same group examining sudden cardiac death in Minnesota (0.5 deaths per 100 000/year).16 Studies based on registries from the Italians suggest a rate of 2.1 deaths per 100 000/year;17 however, the introduction of screening reduced this number to a figure similar to that of the North Americans of 0.4 deaths per 100 000/year. Even the North Americans agree that the true incidence of sudden death in young athletes will only be achieved through mandatory centralised reporting.18 It is clearly time for an international embargo on guessing the incidence of sudden death and to recognise the fact that thumbing the sports pages does not replace registries! We should all focus our efforts on other, more important, areas of the debate.
PDT and BDL Question 2 rebuttal
We disagree with Professors Whyte and Wilson that 'debate surrounding the incidence of sudden cardiac death in young athletes has been the major impediment to progress in finding an international consensus on preparticipation screening'. The major impediment to consensus is the lack of data evaluating the benefits and harms of mandated screening. For reasons unclear to us, Professors Whyte and Wilson fail to discuss the potential harms of screening. Unnecessary atrioventricular nodal ablations resulting in heart block, cardiac perforation and tamponade, and unnecessary defibrillators placed for incorrect diagnoses, including a lifetime of generator changes, pocket infections, endocarditis and inappropriate shocks are not televised. If they were, there would be a robust cry against mandated screening, but neither side of the argument should be settled by anecdotes or emotion. It should be noted that the specific athlete cited by Professors Whyte and Wilson who unfortunately suffered a cardiac arrest on the field witnessed by stadium and TV crowds had been screened with an ECG at least three times prior to this episode. Moreover, we would suggest that it is equally disturbing to watch TV images of car crashes, natural disasters and the deaths of young people from any cause. Professor Whyte and Dr Wilson find it 'irksome' that 'scientists … publish their argument in highly reputable cardiology journals for a vanishingly small number of sudden cardiac deaths on newspaper reports and internet searches'. Others might find it irksome that scientists would recommend an expensive and potentially dangerous mandated screening programme without recognising the medical, psychological and financial risks of this recommendation. Still others might find it irksome that manuscripts published in 'highly reputable cardiology journals' after peer review are discounted so readily.
GPW and MGW Question 2 rebuttal
We repeat: it is simply not good enough to critique the Italian 'registry' of sudden deaths, and then provide counter evidence for not screening with ECG, based upon newspaper reports and internet search engines. This is exemplified by the use of reference 11 within which the US data are garnered from media reports. The absence of evidence argument is simply not a robust argument. It is clear that more evidence is required and centralised registries are the only answer: media reports do not replace registries!
Question 3
Many sporting federations are being encouraged to perform cardiac screening on their athletes prior to an international sporting event. However, it appears many individuals (trainers, physiotherapists, sports medicine physicians, nurses, etc) are involved in performing the initial cardiac screening evaluation. Do you believe that there is enough emphasis placed on this element of their training to allow for the safe first-line screening of athletes?
PDT and BDL
We would discourage sporting federations from performing such screenings and would suggest that they cease such activities before they hurt an athlete physically or injure an athlete's career unnecessarily. We are aware of a National Basketball Association player whose salary was markedly limited by the diagnosis of HCM, a diagnosis, made by well-trained experts, which remarkably disappeared after he stopped playing. We are also aware of a South American soccer player whose several million dollar salary was voided because of a markedly abnormal ECG, which never led to a conclusive diagnosis even when he was evaluated by exercise experts. Such events, albeit anecdotal, suggest that an athlete is at potential risk from screening regardless of who performs the screening. Who does the screening is a trivial and really moot point. What is important is whether or not there are data to justify such screening. There are not.
GPW and MGW
When debating the implementation and efficacy of preparticipation screening there is an important caveat; the inclusion of a resting ECG requires specialist sports cardiology expertise to optimise sensitivity. Indeed, this also applies to the administration of a family history and symptom questionnaire which requires specific training and expertise. While it may be undertaken by a specialist cardiac nurse, in our laboratories, it is always second checked by the attending sports cardiologist. This is the antithesis of the North American approach where questionnaires are sometimes performed by non-specialists without appropriate training including: physical therapists; nurses; and even coaches! The primary driving force of this non-specialist approach is cost-saving; however, given the pre-existing poor sensitivity of questionnaire and physical examination alone (established in answer 1 above), the use of non-specialists merely exacerbates the problem. Preparticipation cardiovascular screening of an elite athlete in the hands of a non-specialist is not only a waste of money but an unethical and immoral act of false reassurance. At present, there is little evidence for the provision of formal training in this area with only sporadic and unstructured educational opportunities for clinicians and healthcare workers to engage in the advancement of knowledge and skills (this includes ECG interpretation).19 Unless there is a significant emphasis placed on training and education, effective preparticipation screening is doomed to failure before it has begun.
PDT and BDL Question 3 rebuttal
We both see athletes with ECG 'abnormalities' detected on cardiac screening by competent physicians and admit that the diagnosis of what is normal versus what is abnormal is a challenge even after our combined 50 years of experience in clinical cardiology. The idea that education alone will eliminate false positives is simply naïve.
GPW and MGW Question 3 rebuttal
It would appear that Professor Levine and Thompson are suggesting that if the experts get it wrong, then there is no value in undertaking screening because of the potential harm to the athlete. Apart from the Magalski paper on NFL players20 and Harmon et al21 paper on the incidence of SCD within the National Collegiate Athletic Association (NCAA), why has the world never seen any 'pooled' epidemiological screening data from the major US sporting federations National Football League (NFL), National Basketball Association (NBA), National Hockey League (NHL), Major League Baseball (MLB), Major League Soccer (MLS), etc). The world knows clubs in these leagues screen, as their insurance companies often mandate it before underwriting the player's salary. How many players were diagnosed, how many false positives, cost of the programme, number of problem cases, who performed the screening, etc… Let's work together and confirm the flaws in the system. Perhaps the North Americans should come off the fence and engage in research to assist in the provision of answers to these, and other, difficult questions.
Question 4
HCM presents in many guises. The diagnostic pathway now involves numerous investigations including ECG, echocardiography and cardiac MRI, substantially increasing our understanding of the pathophysiological staging of the disorder. Despite this, in some cases definitive diagnosis may be difficult to ascertain (ie, The 'Grey Zone') and/or stratifying individual risk absent thereby limiting the ability to make clear recommendations. On this basis, how confidently can we disqualify elite athletes with inherited cardiac disease from professional sports?
PDT and BDL
It is sometimes difficult to separate disease from the myocardial adaptations that occur with exercise training, but more vexing is being certain of the prognosis for an asymptomatic otherwise healthy athlete even with unequivocal HCM. Clinicians assume that an asymptomatic athlete with HCM is at risk for an exercise-related cardiac event. This assumption is based on the poor prognosis noted when HCM was first identified, and on the observation that HCM is the dominant cause of sports-related cardiac deaths in the USA. What is becoming increasingly clear, however, is that HCM may affect 1 in 500 individuals22 and that most of these individuals with HCM do not die suddenly during physical activity. Consequently, exercise risk for a person with HCM may not be related to HCM alone, but to accompanying conditions. For example, 9 of 15 runners dying with HCM had concomitant conditions that could have increased their risk of death.23 Also vexing is the possibility that exercise may positively influence the HCM genotype. In a murine model of HCM produced by inducing myosin heavy chain mutations, an exercise programme before HCM pathology appeared reduced fibrosis, myocyte disarray and markers of myocyte hypertrophy, whereas exercise after hypertrophy was established, reduced myocyte disarray, but not fibrosis.24 Both results, at least in a murine model, suggest that exercise may have some value in individuals with HCM. Whether or not this is true, is not the subject of this debate, and is used solely to reinforce the lesson that many tenets in medicine that appear clear and logical today will be proved foolish in the future. At present, we do not even know that restricting exercise in an HCM patient improves their prognosis.
GPW and MGW
The area of risk stratification is the most problematic and poorly understood area in the entire preparticipation screening debate. The risk stratification of non-athletic patients harbouring the common diseases associated with sudden cardiac death in sport is poorly described. Our understanding of risk is exacerbated when intense training and competition is imposed on a carrier. Guidelines from both the ACC 36th Bethesda Conference and European Society of Cardiology recommend that athletes with unequivocal or 'probable' cardiomyopathy abstain from competitive sport and vigorous training with the exception of low-intensity activities.25 ,26 However, in the absence of a definitive diagnosis, a conservative approach with education, close observation and regular (annual) follow-up is the approach adopted by most UK specialist sports cardiologists. We recognise that SCD related to HCM is rare27 and probably less than 1% per year. The risk is marginally higher in sporting individuals. An individual with HCM may therefore in fact have spent a lifetime participating in sport only to have the condition diagnosed later in life.28 In the case of the 'grey zone' athlete with mild abnormalities but not diagnostic of a cardiomyopathy, the sporting eligibility decision is always underpinned by the athletes family history of SCD and past or present personal symptoms, both of which are strong predictors of risk, abate derived from a diverse population of patients with cardiomyopathy; not athletes. Enhancing our understanding of risk stratification requires large-scale, multinational research programmes to help establish the natural history of these diseases and establish robust disqualification algorithms. Classically, those antagonistic to preparticipation screening use the area of risk and disqualification, alongside cost (both to the healthcare system and the athletes earnings), to justify their non-committal to screening; this, despite the absence of any empirical data to support their argument.
PDT and BDL Question 4 rebuttal
We are not 'antagonistic to preparticipation screening'. For example, we believe that screening underlies the decrease in deaths from aortic stenosis in young athletes. It also identifies athletes who have a family history of sudden death, report syncope during exercise, have neck, back or joint problems that have not been adequately addressed, manifest findings of Marfan syndrome or are being abused at home. In sum, there are many reasons to 'screen' athletes beyond the myopia of cardiologists. We will also not be 'antagonistic' to the use of the ECG in screening athletes once there are data to justify its use and to reassure us that the harm does not outweigh the benefit. The key issue is that the ECG identifies both more real and more spurious disease, exposing those athletes with falsely positive ECGs to additional tests, medical interventions and potential side effects. We are not concerned with the costs of ECG screening, but with its potential harm.
GPW and MGW Question 4 rebuttal
Data from our histopathology colleagues demonstrate that of 118 athletes referred for pathological assessment to ascertain the precise aetiology of SCD, 81% died either during or immediately after exercise;29 albeit small there is undeniably a link between phenotypic expression, continued intensive physical activity and sudden death. We also state that without a 'definitive' diagnosis, a conservative approach with education, close observation and regular follow-up is the optimal strategy. There is an alternative, North America approach; which is to 'bury one's head in the sand'. We anticipated that Professors Thompson and Levine would cite the Hippocratic oath; 'do no harm' in their defence to most of these conundrums. However, taking a lacklustre approach to active engagement in empirical research to seek answers to these and other difficult questions would appear to contravene this basic ethical tenant.
Question 5
Many international sporting bodies now provide guidelines for the screening of athletes. However, none of these sporting bodies provide guidelines as to how to manage a positive result. If an elite athlete is diagnosed as being gene positive for an inherited cardiac disease, but is asymptomatic, phenotype negative with a negative family history of sudden death, what is the medico-legal and ethical responsibility (and how may that differ from the attending cardiologist or International Federation Medical Committee) with regard to care for this athlete who has met the qualifying criteria for an event such as the Olympic Games?
PDT and BDL
We would argue that genetically screening athletes for cardiovascular disease in the absence of specific reasons and for any other reason than to facilitate a diagnosis is even more abhorrent than ECG screening. It is far too early in our understanding of cardiovascular genetics, epigenetics and post-translational gene modification to make recommendations to athletes regarding their eligibility for participation based on genetic testing alone. The medical-legal and ethical responsibility of any clinician dealing with an athlete with any positive screening test is to provide the best medical care available to that athlete. This includes explaining to the athlete that sometimes our diagnostic abilities exceed our ability to prognosticate. Medical decisions should be evidence based and when the evidence is lacking, the decision should be interpolated from the available evidence. The athlete's care should also be cognizant of the athlete's wishes. But in all dealings with athletes, the first injunction is to do no harm to that athlete's psychological state, career and health without concrete evidence that our recommendations provide more good than harm.
GPW and MGW
Currently no universal consensus exists to support recommendations for disqualification based on genotype positive–phenotype negative athletes, and thus we do not support a 'blanket approach' for genetic testing for all troublesome cases. It is true that for now, we do not know the natural history of those with myopathic ECGs or those who are genotype positive but demonstrate no phenotypic evidence of cardiomyopathy. Their risk of an adverse event relating to sport is likely considerably lower than those with phenotypic disease and hence very low (significantly less than 0.5% per year). To that end, the general consensus is (1) to allow full sporting participation in these cases unless there is a malignant family history or suspicious symptoms, that is, documented arrhythmia and/or syncope, and (2) to seek the expert opinion of a cardiologist with knowledge in sports cardiology and inherited cardiac disease 'before' genetic testing was undertaken. We have examples of asymptomatic elite athletes with negative family histories of SCD, who demonstrate abnormal ECGs suggestive of a cardiomyopathy, and are diagnosed with subtle and mild apical HCM. They have been cleared to compete in Olympic sport and have been event free for a number of athletic years thus far. Their event risk is ultralow based on all available long-term apical HCM follow-up. But it is worth noting that the genotype-positive diagnosis still carries the important message regarding family screening, as the same gene may manifest itself differently or more aggressively in other family members. From a medico-legal perspective the approach should be able to provide the athlete (parent/guardian where indicated) with the detailed results and highlight the absence of information in giving any recommendations. In addition to regular follow-up, full sporting participation should be accompanied by education of the athlete, their family and, where consent is granted, their sport. This later group is an area of much contention given the potential implications for contractual agreements and selection. In the absence of mandatory screening programmes, the results of clinical investigations remain confidential; it is this area which provides a major dilemma for attending cardiologists and team doctors who find themselves responsible to both the athlete and their club/sport. As with all other areas of this debate, the dearth of data can only be addressed through consensus agreement underpinned by research.
PDT and BDL Question 5 rebuttal
We disagree that 'the dearth of data can only be addressed through consensus agreement underpinned by research'. We suggest that data, and only data, can lead to consensus. Consequently, failure to reach consensus is due to insufficient data. In the absence of data, first do no harm.
GPW and MGW Question 5 rebuttal
We generally agree with all of what Professors Thompson and Levine state. At present screening is based on phenotype not genotype. No data exist to support disqualification on genotype alone. To compound this deficiency in genotype diagnosis, the provision of gene testing is sporadic, expensive and invariably a fishing exercise. At present, the list of disease-associated mutations is not complete and is unlikely to ever achieve 100% sensitivity. It is our belief, along with that of the Bethesda guidelines, that genes can be inherited but not expressed. Accordingly, genetic testing must not be approached lightly, and should always be undertaken after the consultation with a specialist cardiologist, and after the athlete has provided informed consent following extensive consultation with a specialist genetic counsellor.30
Conclusion (Bruce Hamilton)
Many years ago, from the sports physician perspective, it seemed we had sports cardiology pretty much 'sorted out'. However, over the last 10 years concern has been mounting, particularly with sports physicians working with elite athletes, at the lack of consensus within sports cardiology—which directly impacts upon our management of the elite athlete. Our hope in preparing this manuscript was that by posing relevant questions to appropriate specialists, we may short-circuit some of the complex academic arguments. As anticipated, this debate has again highlighted some of the many challenges that remain within the burgeoning field of sports cardiology.
We deliberately and provocatively titled this debate, 'USA versus European Approaches', but post hoc realised that we unwittingly confounded this underlying theme by pitting two physiologists against two clinical sports cardiologists. This confounder made itself abundantly clear in the first response of Professors Thompson and Levine, whereupon they highlighted the edict of 'first do no harm'. This statement will resound with clinicians reading this, and is an overlying principle upon which this discussion must, by necessity focus. Based on this medical/ethical message, a strong argument is presented that in the absence of appropriate evidence regarding the (suspected) negative consequences of mandated cardiac screening, either with or without electrocardiography, the application of both should be discarded. Unfortunately, it is clear that the data are not available to argue the relative merits of the opposing considerations of false positives (associated with cardiac screening) and the false negatives (associated with no screening or screening without an ECG) in an evidence-based manner. As a result, and appropriately, we must fall back on medical ethics as a guide. Paradoxically however, the fact that we lack the data (that realistically may only be generated via appropriate screening programmes) to provide consensus on this important issue may provide the imperative required to re-evaluate the application of 'first do no harm', with a view to the long-term benefits to future generations of athletes. As has been illustrated from review of breast cancer screening programmes, effective evaluation of the merits of the programme is only possible after sustained, long-term and careful evaluation of both positive and negative outcomes.31 It would be outrageous that if in 20 years time these same, currently unanswerable questions are similarly debated without adequate data.
It is clear from the discussion above, that (in a rare moment of harmony) all participants agree that any form of cardiac screening (if it were to happen) requires appropriately trained and skilled personnel. Somewhat surprisingly, it appears that even appropriate education, specialist training and years of experience does not prevent the inappropriate management of some athletes. While one must acknowledge the positive steps being undertaken by organisations such as the IOC medical commission in the provision of education in cardiac screening and ECG interpretation, the conclusion of our colleagues above is disconcerting when one considers the risks involved.
Unfortunately, it seems that we remain unable to adequately stratify the risk of sports participation, even for those athletes with the most common condition associated with sudden cardiac death in sport, HCM. While there are guidelines in place, it seems that these are based on pragmatic consensus, rather than cold hard facts. Furthermore, as outlined above, the application of specified guidelines depends on diagnostic determinations such as 'unequivocal', 'probable' or 'definitive' relying on the subjective interpretation of the same specialists, who were unfortunately condemned above. Reductionists among us may like the idea of utilising genomic studies to provide the answers we are lacking clinically, but our protagonists all seem to agree, that we are a long way from being able to appropriately utilise genetics to assist us. We all agree that appropriate cardiological evaluation of athletes is important. This debate between eminent and experienced specialists in this field has highlighted that there remains a divergent opinion regarding the merits and dangers of both mandated cardiac screening and the content thereof. There is however consensus that there are insufficient data to allow for an evidence-based answer to either this or other sports cardiology conundrums.
The questions presented to the debaters reflect the daily challenges faced by practitioners working with elite athletes. For sports medicine practitioners and policy creators, Professors Thompson and Levine present a strong argument for not mandating cardiac screening. However, for clinicians dealing with individual elite athletes upon whom they may be required to perform personalised screening evaluations, Professor Whyte and Doctor Wilson present a strong case for inclusion of the ECG. Ultimately, the question we must answer is, how do we appropriately create an evidence base which is able to answer these challenging issues, such that our next generation of colleagues are not repeating the same questions—and that the next generation of athletes are not subject to the same level of uncertainty?
Finally, Professors Levine, Thompson, Whyte and Dr Wilson are to be commended and thanked for the passionate and informed responses provided. While there are clearly differences in approach and emphasis which encouraged conflict, it was in the spirit of competition that the opposing teams took a combative approach to the others position. Indeed, it is worth noting that all the participants have the same end goal, are working together in research to achieve that goal, and importantly, remain friends!
Contributors Professor's Levine, Thompson, Whyte and Dr Wilson contributed equally in the production of this manuscript.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.


text:
The easiest gluten free and vegan chocolate cake recipe. This delicious and simple cake is perfect for a birthday party, holiday, or any day that you want a sweet treat!
If you're new to gluten free and allergy friendly baking, one of the first things you need is a great cake recipe. Chocolate cake, to be exact. Because you may have a birthday coming up, or you might just want to bake one afternoon. You need an easy recipe that's no-fail and delicious. This is that chocolate cake recipe.
This gluten free and vegan chocolate cake uses basic ingredients and it is so easy to throw together. Mix it up and pop it in the oven, and 30 minutes later you have a fresh-baked chocolate cake ready to go. It can't get any easier than that.
Don't be afraid of this cake, non-vegan friends. The vinegar and the baking soda combine so nicely to give it a nice lift, you would never guess that this cake does not contain eggs. It is really, really marvelous. It is possible to bake a delicious chocolate cake without eggs or gluten.
And if don't need to be gluten free, go right ahead and use all-purpose flour! It works very well in this recipe – the cake will be a little lighter and less dense. Whatever flour you choose to use, this vegan chocolate cake will be a big hit.
You can use coconut oil or another oil if you prefer – you can even use melted vegan buttery spread. You can also make this in a round pan, or use this recipe to bake cupcakes. If you need to make a two-layer cake, just double the recipe.
FAQ about this gluten free and vegan chocolate cake:
Can I use coconut flour instead of gluten free flour?
No, that won't work – you generally need eggs in order for coconut flour to be light and fluffy. If you use it in this recipe, you will have a dense, flat cake.
How about using almond meal?
If you want to use some almond meal, you can try using half almond meal and half gluten free flour blend. The cake will be a bit denser, and possibly more moist. I would not recommend using ONLY almond meal.
Can I use maple syrup instead of sugar?
I haven't tried that. I would expect that the texture of the cake may change, and you would also need to use less water.
What can I use instead of vinegar?
Try a little lemon juice, that should work just as well as vinegar.
Where can I find gluten free baking powder?
Featherweight Baking Powder is gluten free and you can find it at Whole Foods, in some health food stores, and on Amazon (affiliate link).
My gluten free cakes usually sink in the middle? What am I doing wrong?
If your cakes sink in the middle, it's likely because the middle wasn't quite done baking. Stick a toothpick in the middle of the cake to see if it's done – it should come out clean or with just a few crumbs. It should not have wet batter on it.
My cakes always take less/more time to bake than the recipe suggests – why is this?
If you use a different gluten free flour blend, it could change the amount of time required for baking. You may also want to check your oven temperature to make sure that it's accurate.
The Easiest Gluten Free and Vegan Chocolate Cake.
- 1 ½ cups gluten free flour blend regular flour works in this recipe, if you are not GF
- 1 cups organic cane sugar
- ½ cup cocoa powder
- 1 teaspoon baking soda
- ½ teaspoon salt
- ⅓ cup organic canola oil
- 1 teaspoon vanilla
- 1 teaspoon white vinegar
- 1 cup cold water
- ¾ cup mini dairy free chocolate chips
- confectioner's sugar for dusting
- Preheat oven to 350 degrees.
- Sift together the dry ingredients. (This step is important, especially with gluten free flour. Otherwise you'll have lumps!)
- Add the organic canola oil, vanilla, vinegar and water. Mix together by hand, and don't overmix. Stir in the dairy free chocolate chips.
- Pour into an 8 inch square Pyrex dish and bake at 350 degrees for about 26-30 minutes, or until a toothpick inserted in the middle comes out clean.
- Dust the top with confectioner's sugar once cool.
adapted slightly from All Recipes.
Find tips, tricks, and easy recipes to help you with your allergy friendly and gluten free baking in my ebook:
This gluten free and vegan chocolate cake is:
- light and fluffy
- perfect for a party
- delicious with frosting or without


text:
October 7, 2019
#1167: Live From The Cruise, Part 2
Adam and Drew discuss their experiences on the boat, and Adam shares his thoughts on cruise ships and how we've lost sight of the middle. The guys also take some audience questions and discuss Adam's latest documentary, No Safe Spaces.
Thanks to today's sponsors:


text:
January is a hopeful time of year. It's about new beginnings. Most of us are still going strong on our New Year's resolutions, the weather in Palm Pay, Florida is about as good as it's going to get, and the kids are finally heading back to school. Along with all this good news, now is the perfect time to plane for your best year yet!
We're talking about pulling out the calendar, looking over the seasons, making plans, and setting goals. Sadly, resolutions, and a lack of motivation to keep them up, have become more of an inspiration for humor than success. So we're suggesting a different approach in 2019.
Instead of giving yourself a loose goal, like simply trying to read more this year or learn a new talent, it's time that you set M.A.D goals instead.
It's time to leave loose and abstract goals in 2018. Ideas like doing more of this, or having a better attitude about that aren't going to bear fruit unless you wrap it in language that can easily be put to action. Instead, be specific. How many books do you want to read this year? What specific room or dresser are you going to clean out?
Once you've nailed down precisely WHAT you want to do, it's time to decide if you CAN do it. Is it within reason? And is it in line with your starting point. This isn't about lowering your expectation. It's simply about being honest with yourself. Your highest aspirations are certainly within reach, but sometimes it's good to approach things less like a sprint and more like a marathon.
What's your timetable? When is this happening? And how are you breaking things down? Chances are, if your goal encompasses a period of two months, you might be underestimating that mid-year drag when the summer hits. Instead, try breaking up your biggest life projects into monthly tasks. If you want to garden more, try putting in 1-2 new plants a month, until you have a selection of produce to make a big green giant jealous.
And as you look over your 2019 plans, it's always good to keep self-care in mind, including your flossing and brushing habits and planning your dental appointments according as needed. When was the last time you stopped by for a visit? Every six months is recommended. Better to mark that in your calendar earlier than later!
From everyone at River Oak, enjoy a happy and healthy new year!


text:
Surface mines rely on continued safe operation of equipment to maintain profitability. Equipment failure can lead to profit loss due to lack of product leaving the mine as well as repair. Traditionally, conventional Non-destructive methods have been applied to ascertain component health, and monitor damage mechanisms. Many of the critical inspection areas on surface mine equipment components are hard to access, are in close proximity to other components, and must be performed with minimal down time associated with removing components for improved NDT inspection. In the last few years many large scale and small scale surface mining operations are finding that improvements in phased array technology have allowed for improved NDT inspections to be performed on mining heavy equipment. Success stories of surface operations implementation of phased array technology with application details will be discussed based on field work, training and implementation by the author including dragline inspections. Improvements in phased array equipment and software easing the implementation will be highlighted.
Total Views
56 Page Views
Total Shares
0 Tweets
0 PDF Downloads
0 Facebook Shares
|Total Usage


text:
The Dark Knight
The Dark _night is a famous night in 24th August 6000 B.C, when there was no electricity and the moon wasn't shining. It turned out to be a really horrible Dark _night. Proper description of that night was not found in any history or mythology due to the lack of light. Because of being so dark it is called The Dark _night!
Description (Not proper)[edit]
Firstly, the fact has to be concerned that as there was no light nobody could see what happened. The description here is based on the cave writings of the historian Tyranosaurates. It is mainly from the sounds that were heard.
On that night two dinosaurs and many cavemen were having sex. It was not possible to see in the darkness if actually only two dinosaurs were there, or there were three in a group. Tyranosaurates wrote this hearing sounds like "Rrwwaahh!" "WHOOH!" etc. The use of goat skin condoms was prevalent at that time. Several people were severely injured due to not being able to see anything in the darkness on the dark _night. Many forests were destroyed and many animals died due to the irresponsible sexual attitude of the dinosaurs. And scary creatures like werewolves.... wait, there was no moon shining, so no werewolf. Tyranosaurates's description concluded saying the darkness of the night was beyond description.
Oh, Did you mean The Dark Knight ?[edit]
The authority apologizes for the inconvenience as the system could not scan your request properly. More possibly Evil Microsoft blocked something and made it stop work. The Dark Knight is the title of the first dark or black African person (from Uganda) to become a knight as a reward of defeating a group of lesbians and sex opposers in a British war. When King Charles XXXVI was defeated six times in a war with them, at last they hired the dark guy who was actually famous for having the largest penis in the world (8.7 feet). He instantly defeated all of them and attained knighthood. From then he is known as "The Dark Knight".
While the Dark Knight is famous all over Uganda for being a pride of the country, Evil Wikipedia says that The Dark Knight is a movie about some creature which is a cross between a human and a vampire bat, or a vampire that had a terrible weakness of not being able to drink blood. So, his whole life he fucked around. He was the black sheep of his family. Thus he concealed his identity wearing a mask. This is just Wikipedia's evil conspiracy to raise confusion in the mind of knowledge seekers.
UnMovie:The Dark Knight Rises[edit]
The Dark Knight rises is an UnMovie directed by Fuck Norris based on the story written by William Sexpear. The movie is about a war between the real Dark Knight and Wikipedia's Vampire Dark Knight.
At the beginning the Vampire guy starts to claim that he is the real dark knight. The dark knight knows about this and starts a war. Then the vampire guy steals a military duplication ray from Russia's weapon base and makes many duplicates of him to win the war. At that time the real Dark Knight who had the 8 feet 7 inches long penis, finally exposes his penis. Thus it the Dark Knight rises his penis and defeats the full vampire force in one strike (This makes the name of the movie so). Thus the dark knight wins the war and people all over England and Africa rejoice to their hearts.
- Rowan Atkinson as The Dark Knight
- Katy Perry as The Vampire Guy


text:
What's in this article?
What is Alzheimer's Disease?
According to the Center for Disease Control, Alzheimer's disease is a common cause of dementia causing as many as 50 to 70% of all dementia cases. In fact, Alzheimer's is a very specific form of dementia. Symptoms of Alzheimer's include impaired thought, impaired speech, and confusion. Doctors use a variety of screenings to determine the cause of dementia including blood tests, mental status evaluations and brain scans.
Symptoms of Alzheimer's
The symptoms of Alzheimer's disease are generally mild to start with, but they get worse over time and start to interfere with daily life.
There are some common symptoms of Alzheimer's disease, but it is important to remember that everyone is unique. Two people with Alzheimer's are unlikely to experience the condition in exactly the same way.
For most people with Alzheimer's, the earliest symptoms are memory lapses. In particular, they may have difficulty recalling recent events and learning new information. These symptoms occur because the early damage in Alzheimer's is usually to a part of the brain called the hippocampus, which has a central role in day-to-day memory. Memory for life events that happened a long time ago is often unaffected in the early stages of the disease.
Memory loss due to Alzheimer's disease increasingly interferes with daily life as the condition progresses. The person may:
- lose items (eg keys, glasses) around the house
- struggle to find the right word in a conversation or forget someone's name
- forget about recent conversations or events
- get lost in a familiar place or on a familiar journey
- forget appointments or anniversaries.
Although memory difficulties are usually the earliest symptoms of Alzheimer's, someone with the disease will also have or go on to develop problems with other aspects of thinking, reasoning, perception or communication. They might have difficulties with:
- language: struggling to follow a conversation or repeating themselves
- visuospatial skills: problems judging distance or seeing objects in three dimensions; navigating stairs or parking the car become much harder
- concentrating, planning or organising: difficulties making decisions, solving problems or carrying out a sequence of tasks (eg cooking a meal)
- orientation: becoming confused or losing track of the day or date.
A person in the earlier stages of Alzheimer's will often have changes in their mood. They may become anxious, irritable or depressed. Many people become withdrawn and lose interest in activities and hobbies.
Causes of Alzheimer's
Like all types of dementia, Alzheimer's is caused by brain cell death. It is a neurodegenerative disease, which means there is progressive brain cell death that happens over a course of time.
The total brain size shrinks with Alzheimer's – the tissue has progressively fewer nerve cells and connections.
How common is Alzheimer's disease?
In the US, the most recent census has enabled researchers to give estimates of how many people have Alzheimer's disease. In 2010, some 4.7 million people of 65 years of age and older were living with Alzheimer's disease in the US.1
The 2013 statistical report from the Alzheimer's Association gives a proportion of the population affected – just over a tenth of people in the over-65 age group have the disease in the US. In the over-85s, the proportion goes up to about a third.2
As our dementia page outlines, there is a handful of different types, but Alzheimer's disease is the problem behind most cases of memory loss and cognitive decline:2
- The Alzheimer's Association says it accounts for between 60% and 80% of all cases of dementia.
Vascular dementia, which is caused by stroke not Alzheimer's, is the second most common type of dementia.
Who is affected Alzheimer's disease?
Alzheimer's disease is most common in people over the age of 65, and affects slightly more women than men.
The risk of Alzheimer's disease and other types of dementia increases with age, affecting an estimated 1 in 14 people over the age of 65 and 1 in every 6 people over the age of 80.
However, around 1 in every 20 cases of Alzheimer's disease affects people aged 40 to 65.
What is Dementia?
Dementia is not a single disease in itself, but a general term to describe symptoms such as impairments to memory, communication, and thinking.
While the likelihood of having dementia increases with age, it is not a normal part of aging.
Light cognitive impairments, such as poorer short-term memory, can happen as a normal part of aging. This is known as age-related cognitive decline rather than dementia because it does not cause significant problems.
Dementia describes two or more types of symptom that are severe enough to affect daily activities.
An analysis of the most recent census estimates that 4.7 million people aged 65 years or older in the United States were living with Alzheimer's disease in 2010. The Alzheimer's Association estimates that:
- Just over a tenth of people aged 65 years or more have Alzheimer's disease
- This proportion rises to about a third of people aged 85 and older
- Alzheimer's accounts for 60-80 percent of all cases of dementia
Causes of Dementia
Dementia usually occurs in older age. It is rare in people under age 60. The risk of dementia increases as a person gets older.
Most types of dementia are nonreversible (degenerative). Nonreversible means the changes in the brain that are causing the dementia cannot be stopped or turned back. Alzheimer disease is the most common type of dementia.
Another common type of dementia is vascular dementia. It is caused by many small strokes.
Lewy body disease is a common cause of dementia in the elderly. People with this condition have abnormal protein structures in certain areas of the brain.
The following medical conditions can also lead to dementia:
- Huntington disease
- Brain injury
- Multiple sclerosis
- Infections such as HIV/AIDS, syphilis, and Lyme disease
- Parkinson disease
- Pick disease
- Progressive supranuclear palsy
Some causes of dementia may be stopped or reversed if they are found soon enough, including:
- Brain injury
- Brain tumors
- Chronic alcohol abuse
- Changes in blood sugar, sodium, and calcium levels (dementia due to metabolic causes)
- Low vitamin B12 level
- Normal pressure hydrocephalus
- Use of certain medicines, including cimetidine and some cholesterol drugs
Symptoms of Dementia
Dementia symptoms vary depending on the cause, but common signs and symptoms include:
Cognitive changes
- Memory loss, which is usually noticed by a spouse or someone else
- Difficulty communicating or finding words
- Difficulty reasoning or problem-solving
- Difficulty handling complex tasks
- Difficulty with planning and organizing
- Difficulty with coordination and motor functions
- Confusion and disorientation
Psychological changes
- Personality changes
- Depression
- Anxiety
- Inappropriate behavior
- Paranoia
- Agitation
- Hallucinations
How common is Dementia?
According to the Alzheimer's Society there are around 800,000 people in the UK with dementia. One in three people over 65 will develop dementia, and two-thirds of people with dementia are women.
The number of people with dementia is increasing because people are living longer. It is estimated that by 2021, the number of people with dementia in the UK will have increased to around 1 million.
Difference Between Alzheimer's and Dementia
When a person is diagnosed with dementia, they are being diagnosed with a set of symptoms. This is similar to someone who has a sore throat. Their throat is sore but it is not known what is causing that particular symptom. It could be allergies, strep throat, or a common cold. Similarly, when someone has dementia they are experiencing symptoms without being told what is causing those symptoms.
Another major difference between the two is that Alzheimer's is not a reversible disease. It is degenerative and incurable at this time. Some forms of dementia, such as a drug interaction or a vitamin deficiency, are actually reversible or temporary.
Once a cause of dementia is found appropriate treatment and counseling can begin. Until a proper diagnosis is made, the best approach to any dementia is engagement, communication and loving care.


text:
NBA: Top Five Power Forwards of All Time
There are many NBA debates that are always discussed. Who is the best shooting guard of all time? Who is the best small forward of all time, and, of course, who is the GOAT (greatest of all time)? However, there is one debate that seems to always be overshadowed. That being who the greatest power forward of all time is in NBA history. Well, that is what we are discussing for this list. We will be taking into account personal accolades, team success, and individual stats and there impact throughout the player's career. Without further adieu, here are the top five greatest power forwards of all-time.
NBA: Top Five Power Forwards of All Time
Power Forward #5: Kevin Garnett
Kevin Garnett was an absolute bully on the court. He brought the intensity night in and night out. The Big Ticket was a force on both ends of the floor and helped the Minnesota Timberwolves find a lot of success in the early 2000s. He was eventually traded to the Boston Celtics where he joined forces with Ray Allen and Paul Pierce and would eventually earn his first championship ring. For his career, Garnett averaged 17.8 points per game to go along with 10 rebounds per game.
This means he averaged a double-double for his career. Not to mention, he also blocked 1.4 shots per game coupled with an impressive defensive rating of 99. Garnett also has an impressive resume. He was a 15-time All-Star, one time NBA champ, nine-time All-NBA Team member, a four-time rebounding champion, and was a 12-time All-Defensive Team member. Garnett was a force to be reckoned with during his prime and is bound for the Hall of Fame in the future.
Power Forward #4: Charles Barkley
Say what you want to say about Charles Barkley as an analyst, but he was great in his prime. What is funny is that he now seems to be underrated and somewhat forgotten in some ways as a player, partly due to his colorful TV personality. If the Phoenix Suns did not run into a Chicago Bulls team led by Michael Jordan and Scottie Pippen, then Barkley may have some NBA jewelry to this day. However, he still had an impressive resume for his career.
Barkley made the All-Star Team 11 times and also made the All-NBA Team 11 times as well. Barkley is also a former MVP to go along with the 1990-91 All-Star Game MVP. Barkley's numbers are also impressive. Throughout his career, he averaged 22.1 points per game coupled with 11.7 rebounds per game. Barkley was also deceptively adept at ball-hawking. He averaged 1.5 steals per game for his career and finished with a career defensive rating of 105.
Power Forward #3: Kevin McHale
Kevin McHale helped form one of the first deadly "big threes," in NBA history with the Boston Celtics. The trio of him, Larry Bird, and Robert Parish were the winningest trio for a long time. McHale was one of the craftiest low-post players in NBA history. As a result, he averaged 17.9 points per game. Not to mention, he also tallied 7.3 total rebounds per game to go along with an offensive rating of 118. McHale is also overlooked as a defender. He nearly averaged two blocks per game (1.7) and also finished with a career defensive rating of 106.
McHale possesses a great resume being a member of the Celtics in the 1980s. Much of his accomplishments were due to his ability as a player. He is a three-time champ, but he also made the All-Star Team seven times to go along with making the All-Defensive Team six times throughout his career. Not to mention, he is a two-time Sixth Man of the Year winner. McHale was not just one of the best power forwards, he is also one of the best low-post players in NBA history.
Power Forward #2: Karl Malone
Karl Malone's resume speaks for itself. The Mail Man was part of a deadly duo with the legendary John Stockton. It seemed like no one could stop the pick and roll chemistry Malone had with Stockton. The end result? Being top five in points scored in NBA history along with being considered one of the greatest power forwards of all time. Malone averaged 25 points per game for his career (the best scoring average out of everyone on this list) and even tallied 10.1 rebounds per game.
Not to mention, Malone averaged 1.4 steals per game which included a season where he had almost two steals per game. He finished his career with a defensive rating of 101. He even tallied an impressive defensive rating of 98 in his last year in the league. Of course, we cannot forget his accomplishments either. Malone is a two-time MVP, 14-time All-Star, made the All-Defensive Team four times, and also made the All-NBA Team an impressive 14 times in his career. Malone truly has a strong argument for being the great power forward of all time, but there is one player who does surpass him by a bit.
The GOAT of Power Forwards: Tim Duncan
Tim Duncan, also known as the Big Fundamental, was one of the most fun players in NBA history to watch. Especially if you truly love the game and love fundamentals. No one has scored on more bank shots than Duncan and the man helped make the Spurs relevant again. He helped the great David Robinson get over the hump in terms of getting a ring and also was a great mentor to young players. Honestly, how can anyone hate this man? Duncan is as humble and classy as they come. In his prime, Duncan was a monster on both ends of the floor. He averaged 19 points per game for his career on 50.6 percent shooting.
Duncan also possesses a total rebounding average of 10.8 per game coupled with a block average of 2.2 per game. Duncan would finish with a career defensive rating of 96! An extremely impressive rating in this department. Of course, we cannot bring up Tim Duncan without talking about the myriad of accolades. He is a five-time champion, 15-time All-Star, 15-time All-NBA Team member, and a two-time MVP. On top of this, Duncan has also has won the Finals MVP three times, been the MVP of the All-Star Game, and won the Rookie of the Year Award. When you take into account all of this, it is easy to see why the great Tim Duncan is the greatest power forward of all time.