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Effect of variable heat transfer coefficient on tissue temperature next to a large vessel during radiofrequency tumor ablation
BioMedical Engineering OnLine volume 7, Article number: 21 (2008)
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One of the current shortcomings of radiofrequency (RF) tumor ablation is its limited performance in regions close to large blood vessels, resulting in high recurrence rates at these locations. Computer models have been used to determine tissue temperatures during tumor ablation procedures. To simulate large vessels, either constant wall temperature or constant convective heat transfer coefficient (h) have been assumed at the vessel surface to simulate convection. However, the actual distribution of the temperature on the vessel wall is non-uniform and time-varying, and this feature makes the convective coefficient variable.
This paper presents a realistic time-varying model in which h is a function of the temperature distribution at the vessel wall. The finite-element method (FEM) was employed in order to model RF hepatic ablation. Two geometrical configurations were investigated. The RF electrode was placed at distances of 1 and 5 mm from a large vessel (10 mm diameter).
When the ablation procedure takes longer than 1–2 min, the attained coagulation zone obtained with both time-varying h and constant h does not differ significantly. However, for short duration ablation (5–10 s) and when the electrode is 1 mm away from the vessel, the use of constant h can lead to errors as high as 20% in the estimation of the coagulation zone.
For tumor ablation procedures typically lasting at least 5 min, this study shows that modeling the heat sink effect of large vessels by applying constant h as a boundary condition will yield precise results while reducing computational complexity. However, for other thermal therapies with shorter treatment using a time-varying h may be necessary.
Radiofrequency (RF) tumor ablation is a treatment modality that uses radiofrequency electric current in an attempt to destroy cancer cells by localized heating of tumors. RF ablation is used for liver cancer, with increasing use in other organs such as kidney, lung, bone, and adrenal gland [1].
The heat due to RF heating causes tissue necrosis at predictable temperatures in relatively predictable volumes. During an RF ablation procedure, an active electrode is inserted percutaneously (i.e. through a small incision in the skin), during laparoscopy, or during open surgery with image-guidance into the tumors. Grounding pads are positioned at the patient's thighs or back muscles. RF energy is applied and current flows from the active electrode to the grounding pads. Thus, the patient becomes an element of the electrical circuit.
High RF current densities around the electrode results in resistive heating in surrounding tissue. While it takes several hours to induce cell necrosis at 43°C [2], at 50°C cell death occurs within 2–3 min [3]. The tissue adjacent to the electrode is rapidly heated, and the remainder of the tissue is heated by thermal conduction, which is a slow process. Typically, a single ablation takes 12 – 35 min depending on device type [4]. If the tissue temperature near the electrode is excessive, the tissue desiccates, and this process results in an electrically insulating layer preventing further energy deposition. As a result, the phenomenon limits the volume of the tissue that can be treated. A difference between tumor ablation and hyperthermia treatments (where lower temperatures of 43 – 45°C are used) is that during ablation most of the tissue volume that undergoes necrosis is at temperatures between 50 and 100°C. Therefore, the prevalent effect of cell death is coagulation necrosis conversely to hyperthermia treatments where a number of biologically complex mechanisms are in effect [5].
A shortcoming of current RF ablation devices is the limited performance adjacent to large blood vessels (diameter > 3 mm). When the active electrode is inserted near large vessels, the blood flow drags thermal energy away from the target tissue [6]. This is a heat sink effect that can change both the shape and maximum volume that can be treated. In fact, the distance of the blood vessels from the tumor determines the location of the maximal tissue temperature. As a result, tumors in the vicinities of large vessels are associated with high recurrence rates [7]. A considerable number of mathematical models have been suggested to describe heat transfer between tissue and vasculature [8–20] most of them are not directly applicable to liver tissue due to the specific blood supply of the liver. Most of the blood perfusing the liver (roughly 70%) is venous blood [21]; in addition, there are no counter-current vessels (i.e. venous and arterial vessels adjacent with opposing blood flow) in the liver as present in other tissues, and counter-current vessels are an integral assumption of most heat transfer models. As a result, most computational models of high-temperature tumor ablation simulate microvascular perfusion using the commonly used Pennes formulation [8], and model large vessels separately since the Pennes model does not describe large vessel perfusion accurately, similar to a previous study [22].
In order to estimate the heat sink effect of large vessels, many simulations performed hitherto assigned either constant temperature at the surface of the vessel [6, 23] or constant convective heat transfer coefficient, h, throughout the RF ablation procedure [24]. In order to estimate the value of h, the simulations performed implied that the flow in the vessel is laminar, the thermal boundary layer is fully-developed and h remains constant throughout the procedure. Other works support that hypothesis that the flow is laminar in large vessels [25, 26]. However, since the heated region during the procedure varies in time and the vessel heated length is small, the thermal boundary layer is not fully-developed. Thus, both the vessel wall temperature and h varies during the ablation procedure and cannot be considered constant [27]. Since the magnitude of h is a parameter that may significantly impact on the shape and size of the coagulation zone obtained during hepatic RF ablation, it is important to accurately model the time-varying behavior of h during the RF ablation of liver tumors in order to correctly determine the coagulation zone size. Thus, the overall objective of this work is to theoretically evaluate the impact of the time-varying h on the accuracy of the simulations of RF tumor ablation procedures.
Methods and models
We used the software FEMLAB (v. 3.2) to generate the finite element model. This software performs coupled electrical-thermal field analysis, and provides all the elements needed to build the model, solve the problem and post-process the results. The heating of tissue during RF ablation is modeled by the bioheat equation (1) [8].
where ρ, c and k are, respectively, the density (kg*m-3), the specific heat (J*kg-1*K-1) and the thermal conductivity (W*m-1 K-1) of the liver tissue. (A*m-2) and (V*m-1) are current density and the electric field intensity and can be calculated with Laplace's equation, using a quasi-static approximation. T is the temperature of the tissue, T bl is the temperature of the blood, ρ bl is the blood density, c bl is specific heat of the blood and w bl is blood perfusion (s-1). Q m (W*m-3) is the energy generated by metabolic processes and was neglected since it is small if compared to the other terms [28]. Microvascular perfusion was included in the model, considering the Pennes model [8]. Although the perfusion in normal and tumorous tissue can vary greatly, this paper focus on the temperature field close to large vessels and on the behavior of the time-varying h during RF ablation rather than simulating a clinical situation. The parameter w bl used in this model was 6.4.10-3 s-1 [29], which is in the range of the perfusion for cirrhotic human liver tissue [30]. Equation 1 states that RF current flowing through the tissue is converted into thermal energy, which in turn cause tissue injury.
The thermal and electrical properties for the various materials of interest are listed in Table 1[6, 31–33]. The vessel wall was not modeled separately since it has similar properties as normal liver tissue [34]. Since we are mainly concerned with the impact of h on the thermal ablation zone, this study does not model the temperature dependence of the thermal-electrical parameters of the tissue.
A three dimensional view of the model and its physical domain are shown in Figure 1(a). Figure 1(b) shows the top view of the model. We set the temperature on the boundary of the model to 37°C and the voltage at outer surfaces at 0 V. We modeled a multi-tine electrode (15 gauge, model-30, Rita Medical Systems, Inc., Fremont, CA).
The hepatic tissue where the electrode is embedded was modeled as a cylinder (100 mm diameter × 120 mm length). The initial temperature of tissue-electrode system and of the boundary of the model was set to 37°C. The voltages on the outer surfaces of the model were 0 V, assuming the Dirichlet boundary condition. The convective boundary condition was considered in the tissue-vessel interface. Thus, the heat sink effect of the blood flow inside the vessel was modeled by a convective boundary condition at the tissue-vessel interface. The value of convective coefficient was set in the model according to Equation 2, which assumes that the blood behaves as a Newtonian fluid in large vessels, the flow is laminar and the geometry of the vessel is linear [27]. Subsequently, with the use of Equation 2, the value of the convective coefficient is updated at each time step and is set as the new convective boundary condition on the vessel wall for the next step.
where h is the convective heat transfer coefficient (W*m-2 *K-1) and accounts for the large vessel perfusion, ρ is the density of the blood (kg*m-3), c is the specific heat of the blood (J*kg-1 *K-1), T 0 is the inlet blood temperature (37°C), T 1 is the temperature at the vessel outlet and T s is the maximum temperature of the heated region at the vessel wall. The parameters a and b are, respectively, the length of the heated region and the diameter of the vessel (Figure 2). u is the constant mean value of the blood velocity (0.2 m*s-1), considering the blood flow with laminar profile. Also, T m is 0:5·(T 0 + T 1). The temperatures T 0 and T 1 are set at 37 and 37.05°C when the temperature of the vessel wall is 50°C. This choice is based on both theoretical and experimental work performed by our group [27, 35]. For other vessel wall temperatures, we used linear interpolation to evaluate the temperature T 1. The temperature T 0 is kept constant at 37°C. The length of the heated region was calculated based on regions where the temperature in the vessel is above 37.01°C. Equation 2 considers the blood as a Newtonian fluid and one might be cautious about extending this equation to vessels smaller than 0.5 mm in diameter [27].
Initially, the profile temperature is uniform and there is no heated region in the vessel. Thus, the convective heat transfer coefficient is set initially at 0 W*m-2 *K-1. Temperature controlled RF ablations were simulated by varying the voltage applied to the electrodes during the procedure. The voltage was controlled in order to keep the maximum tissue temperature at 90°C. We performed temperature control by means of a proportional-integral controller as described previously [36]. The control algorithm for the finite element model is described by equations 3 and 4.
e = T s - T t
where T t is the electrode tip temperature, T s is the set temperature measured at the tip of the electrode where maximum temperatures occur, and K p and K i are control parameters of the PI controller. The control parameters determine the behavior of the algorithm, e.g., response time, overshoot, swinging. The parameters we used for the PI controller were K p = 0:4 and K i = 0:04. These values were obtained based on tests performed with the dynamic system. In order to implement the time integral of the temperature difference between the electrode tip and the set temperature (equations 3 and 4), we added an ordinary differential equation in Femlab.
In this study, the maximum hepatic tissue temperature was kept at 90°C and the maximum power applied during the procedure was 28 W. We used the 50°C-isotherm to determine the coagulation zone boundary as has been done in previous models of RF tumor ablation [6, 24, 28, 37]. We used the temperature at the tip of the electrode for convergence test. We refined the mesh and run the analysis again. We searched the optimal mesh size in order to keep the simulation fast while keeping the accuracy better than 0.01°C at the tip of the electrode. We tested 2 mesh sizes: 65,759 and 13,714. We concluded that the 13,714-element model satisfied our requirement. The time step size was chosen at 0.05 s, so that the maximum temperature change was smaller than 0.01°C during each step. The simulations were performed on a PC with a 2.4 GHz PENTIUM Celeron CPU, with 1 GB of RAM and 30 GB of hard disk space. For post processing, we employed the built-in module in FEMLAB and MATLAB. The computation time required for 10 min simulation was about 3 hours.
We placed the electrode in two different configurations: (a) 1 mm away from the vessel (shown in Figure 1) and (b) 5 mm away from the vessel. For each of these two configurations, we performed three studies.
The behavior of the convective heat coefficient on the vessel;
The evolution of the coagulation zone volume when the time-varying behavior of h is taken into account and when h is constant and equal to the value of the time-varying h at the end of the 10 minutes ablation;
The behavior of the maximum temperature at the vessel wall with both constant and time-varying h.
The behavior of the convective heat coefficient at the vessel wall
Figure 3(a) shows the evolution of the convective heat transfer coefficient at the vessel wall when the electrode is placed 1 mm away from the vessel. One can see in Figure 3(b) that h increases sharply at the beginning of the ablation procedure, followed by a sharp decrease within a second. The final value of h is indicated with a dotted line in Figure 3.
Figure 4(a) shows the evolution of the convective heat transfer coefficient on the vessel wall when the electrode is located 5 mm away from the vessel. Figure 4(b) shows that the maximum value of h occurs approximately at 0.5 s and decreases sharply thereafter. The final value of h is shown in Figure 4(a) and 4(b).
The evolution of the coagulation zone volume for varying h and for constant h cases
We analyzed the evolution of the coagulation zone volume (temperature greater than 50°C). First, we analyzed the coagulation zone development when varying h was taken into account. Second, we considered h as constant and equal to the final value of h in the first simulation. Figure 5(a) shows the coagulation zone volume development for both constant and time-varying h when the electrode is 1 mm away from the vessel. The absolute error is very small so that the curves are almost identical. Figure 5(b) shows the relative error (%) between the results obtained with the constant h and time-varying h. We also simulated the volume coagulation zone when the electrode is 5 mm away from the vessel. However, the differences in coagulation zones for constant h and time-varying h were below to 0.5% and therefore considered negligible.
The behavior of the maximum temperature at the vessel wall for varying h and for constant h
We analyzed the evolution of the temperature at the surface of the vessel. We determined the maximum temperature at the surface when the distance between the electrode and the vessel is 1 and 5 mm. Figure 6(a) shows the maximum temperature at the vessel wall when the electrode is 1 mm away from the vessel. Figure 6(b) shows the relative error (%). Figure 6(a) and 6(b) reveals that the difference in temperature is negligible after 80 s since the relative error approaches to 0%.
Figure 7(a) shows the temperature when the electrode is 5 mm from the vessel. Figure 7(b) shows the percentage error. One can see that the difference in temperature is nearly negligible during the whole procedure.
The aim of this study was to evaluate the impact of the time-varying behavior of the convective heat transfer coefficient h for the determination of the coagulation zone during RF tumor ablation procedures. We have simulated two different behaviors of the convective heat transfer coefficient: constant and variable. We also studied two configurations with the electrode either 1 mm, or 5 mm distant from a large vessel 10 mm in diameter [38]. When the electrode is 1 mm away from the vessel, h initially rapidly increases up to 6000 W*m-2 *K-1 followed by a sharp decrease to approximately 554 W*m-2 *K-1 within 60 s (Figure 3). When the electrode is 5 mm away from the vessel, the convective coefficient rapidly increases to approximately 7000 W*m-2 *K-1 and then rapidly decreases to 336 W*m-2 *K-1 (Figure 4). This behavior occurs because the thermal energy reaches the vessel rapidly due to close proximity to the electrode. Thus, h initially increases due to the increase in temperature on the vessel wall, and after a while the temperature increase extends along the vessel and the convective heat transfer coefficient decreases. Hence, the maximum value of h for the first case occurs around 0.2 s, and for the second case it occurs around 0.5 s after start of the ablation. This behavior becomes more obvious by observing Equation 2. Initially, the vessel wall is not heated yet, and h is 0 W*m-2 *K-1 because there is no heat transfer to the vessel. Then the temperature at the vessel starts to increase and also the heated length grows larger typically up to 11 cm. Initially the heated length is very small compared to the temperature difference T 1 - T 0, thus h sharply increases. After a few seconds, the length starts to increase faster than the difference (T 1 - T 0) and h starts to decrease until both (T 1 - T 0) and h show little change because equilibrium between heat loss and heating is reached. Recall that the thermal boundary layer is very small at the entrance region. Thus, h is very high [39]. It is noteworthy that if one wants to measure the dynamic behavior of the heat convection coefficient, the instrumentation must have a fast dynamic response and a very high static range as one can see from figures 3 and 4. We also analyzed the coagulation zone for the two cases of time-varying h and constant h. In the first few seconds and when the electrode is close to the vessel, the time-varying h has considerably higher values than the constant h and the relative error in coagulation zone volume due to the assumption of a constant h is very high (22%). For RF liver ablation this may not be important since initially the ablation volume is small (with a small absolute error), and the volume near the beginning of the treatment is not of high clinical value. As the time increases, the time-varying h sharply decreases, approaching its final value after 80 s for the 1 mm case and after 120 s for 5 mm case. Thus, the final coagulation zone volume is nearly identical in both cases. We also investigated the maximum temperature at the wall of the vessel, where tumor recurrence is possible due to insufficient temperatures. The maximum error in temperature is around 6% for the first 50–100 s, but then again is close to zero at the end of the ablation. Consequently, for tumor ablation procedures typically lasting at least 5 min, a very important result is the fact that modeling the heat sink effect of large vessels by applying constant h as a boundary condition will yield accurate results for RF ablation while reducing computational complexity. For other thermal therapies with shorter treatment times (e.g. 45 – 60 s long cardiac ablation close to coronary vessels) using a time-varying h might be required but needs to be further investigated.
Previous studies considered a constant heat transfer coefficient throughout the ablation procedure. In this work, simulations were performed using a more realistic, time-varying analytical expression of the convective heat transfer coefficient, which depends on the blood velocity and on the temperature distribution on the vessel wall. The simulations showed that the assumption of a constant convective coefficient leads to precise results when it is used for typical ablation procedures. Only during the first 1–2 min, a time-varying coefficient produces noticeable different results. However, this has no clinical impact for RF liver ablation procedure, which typically takes over 5 min.
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We would like to thank the University of Brasilia, CNPq, CAPES and FAPDF for providing support for this research. Part of this work was conducted in a facility constructed with support from the National Institutes of Health, Grant Number C06 RR018823 from the Extramural Research Facilities Program of the National Center for Research Resources.
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Authors' contributions
IS and AFR conceived the study; IS and CSP carried out the computer simulation; AFR and DH helped with the interpretation of the results and with the draft of the manuscript. All authors have read and approved the final manuscript.
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dos Santos, I., Haemmerich, D., Pinheiro, C.d.S. et al. Effect of variable heat transfer coefficient on tissue temperature next to a large vessel during radiofrequency tumor ablation. BioMed Eng OnLine 7, 21 (2008). https://doi.org/10.1186/1475-925X-7-21
DOI: https://doi.org/10.1186/1475-925X-7-21
- Thermal Boundary Layer
- Ablation Procedure
- Convective Heat Transfer Coefficient
- Tumor Ablation
- Heated Region


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ELITEK (rasburicase) is a recombinant urate-oxidase enzyme produced by a genetically modified Saccharomyces cerevisiae strain. The cDNA coding for rasburicase was cloned from a strain of Aspergillus flavus .
Rasburicase is a tetrameric protein with identical subunits of a molecular mass of about 34 kDa. The molecular formula of the monomer is C 1523 H 2383 N 417 O 462 S 7 . The monomer, made up of a single 301 amino acid polypeptide chain, has no intra- or inter-disulfide bridges and is N-terminal acetylated. The drug product is a sterile, white to off-white, lyophilized powder intended for intravenous administration following reconstitution. ELITEK is supplied in 3-mL colorless, glass vials containing 1.5 mg rasburicase, 10.6 mg mannitol, 15.9 mg L-alanine, and between 12.6 and 14.3 mg of dibasic sodium phosphate.
The diluent solution for reconstitution, supplied in a 2 mL clear, glass ampule, is composed of 1.0 mL sterile Water for Injection, USP, and 1.0 mg Poloxamer 188. The product reconstituted with diluent is a clear, colorless solution.
In humans, uric acid is the final step in the catabolic pathway of purines. Rasburicase catalyzes enzymatic oxidation of uric acid into an inactive and soluble metabolite (allantoin). Rasburicase is only active at the end of the purine catabolic pathway.
Pharmacokinetics of rasburicase were evaluated in two studies that enrolled patients with lymphoid leukemia (B and T cell), non-Hodgkin's lymphoma (including Burkitt's lymphoma) or acute myelogenous leukemia. ELITEK exposure, as measured by AUC 0-24 hr and C max , tended to increase linearly with doses over a limited dose range (0.15 to 0.20 mg/kg). The overall elimination half-life was 18 hours. No accumulation of rasburicase was observed between days 1 and 5 of dosing. ELITEK mean volume of distribution was 110 to 127 mL/kg in pediatric patients. There are insufficient data to characterize pharmacokinetics in adult patients.
ELITEK was administered in three studies to 265 patients with acute leukemia or non-Hodgkin's lymphoma. The clinical studies were largely limited to pediatric patients (246 of 265). ELITEK was administered as a 30-minute infusion once (n=251) or twice (n=14) daily at a dose of 0.15 or 0.20 mg/kg/dose (total daily dose 0.20-0.40 mg/kg/day). ELITEK was administered prior to and concurrent with anti-tumor therapy, which consisted of either systemic chemotherapy (n=196) or steroids (n=69).
Study 1
Study 1 was a randomized, open-label, controlled study conducted at six institutions, in which 52 pediatric patients were randomized to receive either ELITEK (n=27) or allopurinol (n=25). 1 The dose of allopurinol varied according to local institutional practice. ELITEK was administered as an intravenous infusion over 30 minutes once (n=26) or twice (n=1) daily at a dose of 0.20 mg/kg/dose (total daily dose 0.20-0.40 mg/kg/day). Initiation of dosing was permitted at any time between 4 to 48 hours before the start of anti-tumor therapy and could be continued for 5 to 7 days after initiation of anti-tumor therapy. Patients were stratified at randomization on the basis of underlying malignant disease (leukemia or lymphoma) and baseline serum or plasma uric acid levels (<8.0 mg/dL and >/=8.0 mg/dL). The primary study objective was to demonstrate a greater reduction in uric acid concentration over 96 hours (AUC 0-96 hr ) in the ELITEK group as compared to the allopurinol group. Uric acid AUC 0-96 hr was defined as the area under the curve for plasma uric acid levels (mg·hr/dL), measured from the last value prior to the first dose of ELITEK until 96 hours after that first dose. Plasma uric acid levels were used for all uric acid AUC 0-96 hr calculations (see PRECAUTIONS , Laboratory Test Interactions ).
The demographics of the two study arms (ELITEK vs. allopurinol) were as follows: age <13 years (82% vs. 76%), males (59% vs. 72%), Caucasian (59% vs. 72%), ECOG performance status 0 (89% vs. 84%), and leukemia (74% vs. 76%). The median interval, in hours, between initiation of ELITEK and of anti-tumor treatment was 20 hours, with a range of 70 hours before to 10 hours after the initiation of anti-tumor treatment (n=24, data not reported for 3 patients).
The uric acid AUC 0-96 hr was significantly lower in the ELITEK group (128 ± s.e. 14 mg·hr/dL) as compared to the allopurinol group (328 ± s.e. 26 mg·hr/dL). All but one patient in the ELITEK arm had reduction and maintenance of uric acid levels to within or below the normal range during the treatment. The incidence of renal dysfunction was similar in the two study arms; one patient in the allopurinol arm developed acute renal failure.
Study 2
Study 2 was a multi-institutional, single-arm study conducted in 89 pediatric and 18 adult patients with hematologic malignancies. Patients received ELITEK at a dose of 0.15 mg/kg/day. The primary efficacy objective was determination of the proportion of patients with maintained plasma uric acid concentration at 48 hours where maintenance of uric acid concentration was defined as: 1) achievement of uric acid concentration </=6.5 mg/dL (patients <13 years) or </=7.5 mg/dL (patients >/=13 years) within a designated time point (48 hours) from initiation of ELITEK and maintained until 24 hours after the last administration of study drug; and 2) control of uric acid level without the need for allopurinol or other agents.
The study population demographics were: age <13 years (76%), males (61%), Caucasian (91%), ECOG performance status = 0 (92%), and leukemia (89%).
The proportion of patients with maintenance of uric acid concentration at 48 hours in Study 2 was 99% (106/107).
Study 3
Study 3 was a multi-institutional, single-arm study conducted in 130 pediatric patients and 1 adult patient with hematologic malignancies. 2 Patients received ELITEK at either a dose of 0.15 mg/kg/day (n=12) or 0.20 mg/kg/day (n=119). The primary efficacy objective was determination of the proportion of patients with maintained plasma uric acid concentration at 48 hours as defined for Study 2 above.
The study population demographics were: age <13 years (76%), Caucasian (83%), males (67%), ECOG = 0 (67%), and leukemia (88%).
The proportion of patients with maintenance of uric acid concentration at 48 hours in Study 3 was 92% in the 0.15 mg/kg group (n=12) and 95% in the 0.20 mg/kg group (n=119).
Pooled Analyses
For the pooled data set of the 3 clinical studies (n=265), total daily dosing for ELITEK ranged from 0.15 to 0.40 mg/kg/day with the majority receiving 0.20 mg/kg/day. The maximum daily doses received were 0.15 mg/kg/day in 116 patients, 0.20 mg/kg/day in 135 patients, 0.30 mg/kg/day (divided doses) in 3 patients, and 0.40 mg/kg/day (di-vided doses) in 11 patients. The safety and effectiveness of twice-daily dosing with ELITEK have not been established due to insufficient data (see DOSAGE AND ADMINISTRATION ).
Reduction of Uric Acid Levels
Data from the 3 studies (n=265) were pooled and analyzed according to the plasma uric acid levels over time. The pre-treatment plasma uric acid concentration was >/=8 mg/dL in 61 patients and was <8 mg/dL in 200 patients. The median uric acid concentration at baseline, at 4 hours following the first dose of ELITEK, and the per patient fall in plasma uric acid concentration from baseline to 4 hours were calculated in those patients with both pre-treatment and 4-hour post-treatment values. Among patients with pre-treatment uric acid >/=8.0 mg/dL [baseline median 10.6 mg/dL (range 8.1-36.4)], the median per-patient change in plasma uric acid concentration by 4 hours after the first dose was a decrease of 9.1 mg/dL (0.3-19.3 mg/dL). Among the patients with a pre-treatment plasma uric acid level < 8 mg/dL [baseline median 4.6 mg/dL (range 0.2-7.9 mg/dL)], the median per-patient change in plasma uric acid concentration by 4 hours after the first dose was a decrease of 4.1 mg/dL (0.1-7.6 mg/dL).
Figure 1 is a box and whisker plot of plasma uric acid levels inclusive of 261 of the 265 ELITEK treated patients from Studies 1, 2, and 3. Of the 261 evaluable patients, plasma uric acid concentration was maintained (see CLINICAL STUDIES , Study 2 , for the definition of uric acid concentration maintenance) by 4 hours for 92% of patients (240/261), by 24 hours for 93% of patients (245/261), by 48 hours for 97% of patients (254/261), by 72 hours for 99% of patients (260/261), and by 96 hours for 100% of patients (261/261). Of the subset of 61 patients whose plasma uric acid level was elevated at baseline (>/=8 mg/dL), plasma uric acid concentration was maintained by 4 hours for 72% of patients (44/61), by 24 hours for 80% of patients (49/61), by 48 hours for 92% of patients (56/61), by 72 hours for 98% of patients (60/61), and by 96 hours for 100% (61/61).
ELITEK (rasburicase) is indicated for the initial management of plasma uric acid levels in pediatric patients with leukemia, lymphoma, and solid tumor malignancies who are receiving anti-cancer therapy expected to result in tumor lysis and subsequent elevation of plasma uric acid.
ELITEK is contraindicated in individuals deficient in glucose-6-phosphate dehydrogenase (G6PD) (see BOXED WARNINGS , Hemolysis and WARNINGS , Hemolysis ).
ELITEK is contraindicated in patients with a known history of anaphylaxis or hypersensitivity reactions, hemolytic reactions or methemoglobinemia reactions to ELITEK or any of the excipients (see BOXED WARNINGS and WARNINGS ).
The safety and efficacy of ELITEK have been established only for a single course of treatment [once daily for 5 days (see DOSAGE AND ADMINISTRATION )].
ELITEK may cause severe allergic reactions including anaphylaxis. This can occur at any time during treatment including the first dose. Signs and symptoms of these reactions include bronchospasm, chest pain and tightness, dyspnea, hypoxia, hypotension, shock, and/or urticaria. ELITEK administration should be immediately and permanently discontinued in any patient developing clinical evidence of a serious hypersensitivity reaction (see BOXED WARNINGS , Anaphylaxis and ADVERSE REACTIONS , Immunogenicity ).
ELITEK is contraindicated in patients with G6PD deficiency because hydrogen peroxide is one of the major by-products of the conversion of uric acid to allantoin. In clinical studies, two patients developed severe hemolytic reactions [National Cancer Institute Common Toxicity Criteria 3 (NCI CTC) grade 3 and 4] within 2-4 days of the start of ELITEK. G6PD deficiency was subsequently identified in one of these patients. ELITEK administration should be immediately and permanently discontinued in any patient developing hemolysis, and appropriate patient monitoring and support measures initiated (e.g., transfusion support). It is recommended that patients at higher risk for G6PD deficiency (e.g., patients of African or Mediterranean ancestry) be screened prior to starting ELITEK therapy (see BOXED WARNINGS , Hemolysis and CONTRAINDICATIONS ).
In clinical studies, methemoglobinemia has been reported in 2 patients receiving ELITEK. Both patients developed serious hypoxemia requiring intervention with the appropriate medical support measures. It is not known whether patients with deficiency of cytochrome b5 reductase (formerly known as methemoglobin reductase) or of other enzymes with antioxidant activity are at increased risk for methemoglobinemia or hemolytic anemia. ELITEK administration should be immediately and permanently discontinued in any patient identified as having developed methemoglobinemia, and appropriate monitoring and support mea-sures (e.g., transfusion support, methylene-blue ad-ministration) implemented (see BOXED WARNINGS , Methemoglobinemia ).
Patients on ELITEK should receive intravenous hydration according to standard medical practice for the management of plasma uric acid in patients at risk for tumor lysis syndrome.
Drug Interactions
No studies of interactions with other drugs have been conducted in humans.
Rasburicase does not metabolize allopurinol, cytarabine, methylprednisolone, methotrexate, 6-mercaptopurine, thioguanine, etoposide, daunorubicin, cyclophosphamide or vincristine in vitro . No metabolic-based drug interactions are therefore anticipated with these agents in patients.
In preclinical in vivo studies, rasburicase did not affect the activity of isoenzymes CYP1A, CYP2A, CYP2B, CYP2C, CYP2E, and CYP3A, suggesting no induction nor inhibition potential. Clinically relevant P450-mediated drug-drug interactions are therefore not anticipated in patients treated with the recommended ELITEK dose and dosing schedule.
Laboratory Test Interactions
At room temperature, ELITEK causes enzymatic degradation of the uric acid in blood/plasma/serum samples potentially resulting in spuriously low plasma uric acid assay readings. The following special sample handling procedure must be followed to avoid ex vivo uric acid degradation.
Uric acid must be analyzed in plasma. Blood must be collected into prechilled tubes containing heparin anticoagulant. Samples must be immediately immersed in an ice water bath . Plasma samples must be prepared by centrifugation in a pre-cooled centrifuge (4°C). Finally, the plasma must be maintained in an ice water bath and analyzed for uric acid within four hours of collection (see BOXED WARNINGS , Interference with Uric Acid Measurement ).
Carcinogenesis, Mutagenesis, Impairment of Fertility
Long-term studies in animals to evaluate carcinogenic potential have not been performed.
ELITEK was non-genotoxic in the Ames, unscheduled DNA synthesis, chromosome analysis, mouse lymphoma, and micronucleus tests.
ELITEK did not affect reproductive performance or fertility in male or female rats at doses 8-fold higher than the human dose when corrected for differences in body surface area.
Pregnancy Category C
Animal reproduction studies have not been conducted with ELITEK. It is also not known whether ELITEK can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. ELITEK should be given to a pregnant woman only if clearly needed.
Nursing Mothers
It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants, a decision should be made whether to discontinue nursing or to discontinue ELITEK, taking into account the importance of the drug to the mother.
Pediatric Use
The efficacy and safety of ELITEK was studied in 246 pediatric patients ranging in age from 1 month to 17 years. There were an insufficient number of patients in the 0-6 months age group (n=7) to determine whether they respond differently from older children. These patients were pooled into the <2 years of age group (n=24). Children <2 years of age had a higher mean uric acid AUC 0-96 hr than those age 2-17 years (150 ± s.e. 16 mg·hr/dL vs. 108 ± s.e. 4 mg·hr/dL, respectively). In addition, the data suggest that children <2 years of age had a lower rate of success at achieving maintenance uric acid concentration by 48 hours [83% (95% CI of 62 to 95) vs. 93% (95% CI of 89 to 95), respectively]. Children <2 years old also experienced more toxicity. The following adverse events were observed more frequently in children less than 2 years of age compared to those age 2-17 years respectively: vomiting (75% vs. 55%), diarrhea (63% vs. 20%), fever (50% vs. 38%), and rash (38% vs. 10%).
Geriatric Use
Five of the 19 adults among the 265 patients enrolled in clinical studies of ELITEK, were age 65 or greater. Therefore, there are insufficient data to determine whether geriatric subjects, or adults in general, respond differently from pediatric subjects.
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The adverse reaction information from clinical trials does, however, provide a basis for identifying the adverse events that appear to be related to drug use and for approximating rates.
The data described below reflect exposure to ELITEK in 703 patients [63% male, 37% female; median age 10 years (range 10 days to 88 years); 73% Caucasian, 9% African, 4% Asian, 14% other/unknown]. ELITEK was studied for adverse reactions, regardless of severity, in 347 patients (265 pediatric and 82 adults) enrolled in one active-controlled trial (Study 1), two uncontrolled trials (Studies 2 and 3), and one uncontrolled safety trial (n=82). Additionally, an expanded access experience enrolled 356 patients, for whom reliably collected data were limited to serious adverse reactions.
Among the 703 patients for whom serious adverse reactions were assessed, the most serious adverse reactions caused by ELITEK were allergic reactions including anaphylaxis (<1%), rash (1%), hemolysis (<1%), and methemoglobinemia (<1%) (see BOXED WARNINGS and WARNINGS ). The commonly observed serious adverse reactions were fever (5%), neutropenia with fever (4%), respiratory distress (3%), sepsis (3%), neutropenia (2%), and mucositis (2%). The following additional serious adverse reactions were observed in </=1% of patients regardless of causality: acute renal failure, arrhythmia, cardiac failure, cardiac arrest, cellulitis, cerebrovascular disorder, chest pain, convulsions, cyanosis, diarrhea, dehydration, hot flushes, ileus, infection, intestinal obstruction, hemorrhage, myocardial infarction, paresthesia, pancytopenia, pneumonia, pulmonary edema, pulmonary hypertension, retinal hemorrhage, rigors, thrombosis, and thrombophlebitis.
Among the 347 patients for whom all adverse reactions regardless of severity were assessed, the most frequently observed adverse reactions (incidence >/=10%) were vomiting (50%), fever (46%), nausea (27%), headache (26%), abdominal pain (20%), constipation (20%), diarrhea (20%), mucositis (15%), and rash (13%). In Study 1, an active control study, the following adverse events occurred more frequently in ELITEK-treated subjects than allopurinol-treated subjects: vomiting, fever, nausea, diarrhea, and headache. Although the incidence of rash was similar in the two arms, severe rash (NCI CTC 3 , Grade 3 or 4) was reported only in one ELITEK-treated patient.
ELITEK is immunogenic in healthy volunteers, and can elicit antibodies that inhibit the activity of rasburicase in vitro (see BOXED WARNINGS , Anaphylaxis and WARNINGS , Anaphylaxis ).
In a study of 28 healthy volunteers, the incidence of antibody responses to either a single dose or to 5 daily doses was assessed. Binding antibodies to rasburicase were detected by ELISA in 17/28 (61%) volunteers and neutralizing antibodies were detected in 18/28 (64%) volunteers. Time to detection of antibodies ranged from 1 to 6 weeks after ELITEK exposure. In two subjects with extended follow-up, antibodies persisted for 333 and 494 days.
The incidence of antibody responses in patients with hematologic malignancy has not been adequately assessed. In clinical trials of patients with hematologic malignancies, 24 of the 218 patients tested (11%) developed antibodies by day 28 following ELITEK administration. However, this is not a reliable estimate of the true incidence of antibody responses in patients with hematologic malignancies, because the data from the healthy volunteer study indicate that antibody may not be detectable until some time point beyond day 28.
The incidence of antibody responses detected is highly dependent on the sensitivity and specificity of the assay, which have not been fully evaluated. Additionally, the observed incidence of antibody positivity in an assay may be influenced by several factors, including serum sampling, timing and methodology, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to ELITEK with the incidence of antibodies to other products may be misleading.
No cases of overdosage with ELITEK have been reported. The maximum dose of ELITEK that has been administered as a single dose is 0.20 mg/kg; the maximum daily dose that has been administered is 0.40 mg/kg/day. According to the mechanism of action of ELITEK, an overdose will lead to low or undetectable plasma uric acid concentration, which has no known clinical consequences. Patients suspected of receiving an overdose should be monitored, and general supportive measures should be initiated as no specific antidote for ELITEK has been identified.
The recommended dose and schedule of ELITEK is 0.15 or 0.20 mg/kg as a single daily dose for 5 days. Because the safety and effectiveness of other schedules have not been established, dosing beyond 5 days or administration of more than one course of ELITEK is not recommended. Chemotherapy should be initiated 4 to 24 hours after the first dose of ELITEK. DO NOT ADMINISTER AS A BOLUS INFUSION . ELITEK should be administered as an intravenous infusion over 30 minutes.
Reconstitution Procedure
Determine the number of vials of ELITEK needed to achieve the proper dosage, based on the individual patient's weight and the dose per kilogram. ELITEK must be reconstituted in the diluent provided. Add 1 mL of the provided reconstitution solution (diluent) to each vial of ELITEK and mix by swirling very gently. Do not shake or vortex . Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, and discarded if particulate matter is visible or if product is discolored.
Further Dilution and Administration
Using aseptic technique and syringes of appropriate volume, remove the predetermined dose of ELITEK from the reconstituted vials and inject into an infusion bag containing the appropriate volume of 0.9% sterile sodium chloride, to achieve a final total volume of 50 mL. This final solution for injection is to be infused over 30 minutes. No filters should be used for the infusion.
The reconstituted ELITEK contains no preservatives and must be administered within 24 hours of reconstitution. The reconstituted or diluted solution can be stored up to 24 hours at 2-8°C. Discard any unused product.
ELITEK should be infused through a different line than that used for the infusion of other concomitant medications. If use of a separate line is not possible, the line should be flushed with at least 15 mL of saline solution prior to and after infusion with ELITEK.
NDC 0024-5150-10: One carton containing 3 single-use vials each containing 1.5 mg of rasburicase and 3 ampules each containing 1.0 mL diluent.
Storage and Handling
The lyophilized drug product and the diluent for reconstitution should be stored at 2-8°C (36-46°F). Do not freeze. Protect from light.
Manufactured and distributed by Sanofi-Synthelabo Inc.
New York, NY 10016
U.S. License No. 1294
Printed in USA
Revised March 2005
Copyright, Sanofi-Synthelabo Inc. 2002, 2005 5631

subset: commoncrawl


text:
On Sunday night, "60 Minutes" aired a damning report on Lumber Liquidators and what appeared to be intentional mislabeling of certain laminate flooring products made at a factory in China.
The company had warned the report was coming last week in an earnings call, but Piper Jaffray analysts wrote in a note to clients on Sunday night that the report was worse for the company than the firm had prepared for.
Piper said the report was worse than expected based on these three points:
- How specific the story was.
- The evidence provided by "60 Minutes."
- A poor on-camera interview by Lumber Liquidators founder Tom Sullivan, who conceded that the video evidence called into question the company's oversight of its suppliers.
The "60 Minutes" report outlined apparent violations by the company relating to the amount of formaldehyde contained in some laminate flooring products sold in California.
Specifically, "60 Minutes" went to factories in China that produce laminate flooring for Lumber Liquidators that the company says is "CARB 2" compliant, meaning it complies with California standards. The news program's undercover team spoke with factory managers who acknowledged that inventory being produced for Lumber Liquidators was labeled "CARB 2" compliant when it was not.
Early Monday after the "60 Minutes" piece, shares of Lumber Liquidators were down as much as 20%.
Piper added:
While the validity of 60 Minutes evidence and claims will likely be vigorously disputed by the company — and we are still in no position to determine if there has been any wrongdoing — the piece portrayed LL in a negative light and will likely leave the company guilty in the court of public opinion for the foreseeable future.
Piper also noted that the reaction on social media to the "60 Minutes" piece was "overwhelmingly negative," noting that, "Individuals noted they will be returning recently purchased product, asking how their floors could be tested, and commenting on the poor performance by LL's founder."


text:
Most Chinese epicures will assure you their country has eight great cuisines. At first glance, this way of delineating China's culinary cartography does seem to simplify an incredibly complex food culture. This concept is so ingrained in popular Chinese thought that few consider why only Shandong, Jiangsu, Zhejiang, Anhui, Fujian, Guangdong, Sichuan, and Hunan might measure up as the sole members of this elite club. Fewer still wrestle with whether these are the only provinces with bona fide grand culinary traditions, whether this notion has any factual basis, what it means both culturally and gastronomically to be excluded, who is left out in the cold and why, and what the rest of the country is enjoying for dinner.
To give these questions a bit of perspective, China has around 5,000 more years of history and an extra billion people when compared to the United States—it's enormous in every sense of the word. Moreover, it encompasses a wide variety of climates and almost every sort of geography possible—from endless deserts to deep jungles to frozen mountain ranges—and all of this is divided among 23 provinces, four municipalities, five autonomous regions, and two special administrative regions. The ethnic Han Chinese make up 92 percent of the population, and so they're responsible for most of their country's cultural identity and flavors, but China's foods have also been indelibly colored by a wide assortment of cultures and peoples.
So, does dividing China's food traditions into eight great cuisines make any sense at all?
After spending close to a decade dedicated to trying to comprehend the many components of this country's enigmatic gastronomy, I've found that this concept is, simply, nothing less than arbitrary. Even setting aside the culinary contributions of China's other ethnic groups and discounting the impact of such powerful forces as the dining habits of its rich and famous, its vibrant local street foods, its many religions, and a fascinating mixed bag of external influences, justifying the "eight great" way of thinking remains genuinely problematic, for it leaves out way more than it embraces.
The West tends to think of China as a mysterious place that is more or less monochromatic in terms of culture, language, and even food. But in some ways China is much like Europe, for they are almost the same size and contain a wide variety of cultures.
To a certain extent, yes, the "eight great" do represent some major Han Chinese gastronomic centers during the first half of the 20th century, for each of these provinces is home to a unique school (or three) of haute cuisine. But even if we take this into account, north and south China still end up getting short shrift, with only one representative each in the form of Shandong and Guangdong, respectively. The chili-loving provinces of Hunan and Sichuan embody China's center, while the rest all belong more or less to eastern China. That leaves more than three-quarters of the country unaccounted for.
Perhaps even more important, the "eight great" categorization is not in the least helpful. If, for instance, Beijing's foods are said to be covered by Shandong's mantle, what does that really mean? Was Shandong the sole or even the most important influence on the capital's way of dining? What about the imperial kitchens, the Muslims, the Manchurians, the Mongols, and the Silk Road traders? How about all those wars and migrations and foreign powers and revolutions? Did any of these come into play?
Of course they did. Beijing's foods are in many ways a crystallization of this capital's long history, its rich tapestry of immigrants and travelers, its place at the center of East Asian culture, and its role as the vortex into which ambitious chefs have been inexorably drawn. Beijing's cuisine is like no other. It certainly is connected to Shandong and many other northern foodways simply because they all share so many ingredients and lifestyles and ethnicities, as well as weather and geography. But the fact remains: Although they are both part of northern China, Shandong does not equal Beijing, nor does Beijing equal Shandong. Moreover, every other part of China can lay similar claim to a unique lineage, singular history, different set of influences and customs, and distinctive cuisine.
Historically, China has been much more practical in its approach toward categorizing its foods and cultures and people, for it merely divided them into north and south, using the Yangtze River as a general demarcation line. The earliest attempt to define each area's ingredients in the broadest way was made around 1,700 years ago, when Zhang Hua wrote: "The people of the southeast eat aquatic creatures, but in the northwest they eat land animals." And then, Shen Kuo noted about seven centuries later that "most southerners like the savory and northerners like the sweet." This theme continued with little variation until fairly recently. For example, it was only 200 years ago that Qian Yong noted: "Northerners enjoy that which is heavy and flavorful, while southerners want the fresh and light; northerners have lavish servings and greatly prefer numerous dishes, while southerners show skill at plating and greatly prize freshness in their fruits and ingredients." And so, far from being an authoritative take on China's food traditions, the concept of the "eight great cuisines" didn't even exist until a few decades ago. Nevertheless, this way of categorizing the nation's culinary styles is mysteriously accepted as gospel now, even though no one has been able to pinpoint when these groupings came about, who thought them up, or even why they were created.
It should be mentioned that China has one other popular way of viewing its foods, which is through the lens of the "four great cuisines." These probably predate the eight by no more than a few decades at the most. And yet, even these four lay claim to little more than vague beginnings—their earliest mention is found in a literary sketchbook from the early 1900s, with Shandong, the Jiangsu city of Suzhou, Guangdong, and Sichuan representing the cardinal points of the compass. This description is much more general than that of the eight. But then again, Xu Ke's relatively obscure book merely lumped all of the north together, mentioned the foods of the south and the east, chatted a bit about the spicy tendencies found in Yunnan, Guizhou, Hunan, and Sichuan, and talked in passing about the foods of Hubei and Fujian.
No monolithic Chinese cuisine exists. Instead, the country has given rise to a scintillating spectrum of unique gastronomies that reflect the local culture, history, climate, ingredients, and terrain.
Following that initial foray, no one managed to come up with a viable reason why Shandong, Suzhou, Guangdong, and Sichuan are so important to the exclusion of all others. The great Sichuanese chef Chen Kenmin (and father of Iron Chef's Chen Kenichi) offered four more wide-ranging categories back in 1980 when he suggested that the lands above the Yellow River are host to the northern cuisines as represented by Beijing, the upper reaches of the Yangtze are home to Sichuan and the western cuisines, the eastern cuisines encompass Shanghai and the lower reaches of the Yangtze, and the southern school centers around Guangdong and the Pearl River's environs. But even he qualified this by noting, "when it comes to defining China's cuisines, each province and each metropolis has its own unique style of cooking."
I was in the middle of writing a comprehensive Chinese cookbook called All Under Heaven: Recipes from the 35 Cuisines of China when it struck me that a new approach was in order. Over the preceding decades—and ever since I officially became an adult, for that matter—I had done little but eat and cook from China's enormous array of food traditions, and as a result, too many delicious hints as to the true nature of these interlocking puzzle parts were popping up for me to ignore.
For example, the preference for salt or soy sauce or some sort of fermented paste defined certain areas. A predilection for pork or chicken or lamb or fish or bean curd suggested specific landscapes and ethnicities. Rice fed the humid south, but to its north an assortment of hearty grains led by wheat and corn kept cold winters at bay. Vegan Mahayana Buddhists dwelling along the Yangtze gave rise to a brilliant meatless cuisine. Muslims changed the way the northern and western areas ate with their inventive pastas and breads. The esoteric Buddhists of Mongolia and Tibet somehow bridged their unique food traditions over the Muslim Uyghur expanse of Xinjiang. Chili peppers from the Americas bathed the central mountain ranges with their pungent heat, and the ancient food traditions of the Hakka people echoed the cooking techniques of the northern plains while seasoning the dishes of the coastal southeast.
Using clues like these to point the way, I mapped out all of China—including its vast and universally unsung western half—according to the main ingredients, climates, terrains, ethnic groups, religions, historical migratory patterns, and dialects. These food traditions then sifted down quite accommodatingly into five main culinary regions.
The West tends to think of China as a mysterious place that is more or less monochromatic in terms of culture, language, and even food. But in some ways China is much like Europe, for they are almost the same size and contain a wide variety of cultures. And we have to remember that when it comes to dining, the lion's share of Europe's culinary traditions fits into broad families centered in specific areas, and each of these is home to common ingredients and ethnicities, like the Mediterranean, Eastern Europe, Scandinavia, and so forth. From there, it's broken down further into distinctive food cultures such as French, and then into something more specific, such as Provençal or Lyonnais or Parisian.
And so, just as there really is no overarching European cuisine, no monolithic Chinese cuisine exists, either. Instead, the country has given rise to a scintillating spectrum of unique gastronomies that reflect the local culture, history, climate, ingredients, and terrain.
China's earliest inhabitants probably lived somewhere between the Yellow and Yangtze Rivers, but thousands of years ago the Han Chinese began setting out in search of new homes, spurred on by the familiar prods of overpopulation, war, famine, and unrest.
The majority, of course, settled in the fertile and temperate lands of the coast and the southeast, although many others traveled inland along its long river valleys, out along the Silk Roads to the west, and north into Mongolia and Manchuria. They intermingled with the indigenous occupants of tropical highlands and ice-covered steppes, were conquered by nomadic tribes who installed their own rulers on the Dragon Throne, and over time merged together into a country with a host of culinary influences. In short, the more I played with the moving parts, the more these five culinary regions shifted into sharp focus. Once that happened, one could even perceive the crisscrossing tendrils that accounted for 35 distinct cuisines in China.
The North and Northeast
Shandong, Beijing, Tianjin, and Hebei, as well as Liaoning, Jilin, and Heilongjiang in the northeast.
Nowhere does Han Chinese cooking combine so well with Hui Muslim, Mongolian, Manchurian, and even Slavic food traditions. This is where one finds such dishes as Russian soup made with oxtails and carrots, Tianjin's juicy pot stickers that sub-in the Chinese love for pork instead of the traditional halal beef, and consort's chicken wings seasoned with an improbable dash of red wine.
Vast deserts cover most of the northern half of China, with little more than the Great Wall serving to shield ancestral Han lands near the Yellow River, though it often proved ineffectual against the foreign tribes that swept down into the area with conquest on their minds. Some of these people liked what they saw and decided to set down roots, eventually becoming part of the Chinese family and bringing with them an unequivocal preference for lamb, beef, noodles, and bread. The other great external influences on this area's local foods were the spices and ingredients that traders introduced from the Levant and Central Asia, which is why cinnamon and fennel, as well as cucumbers and eggplant, are used here.
The Yangtze River Environs
The Huai Yang area, Jiangsu, Zhejiang, Shanghai, and Northern Fujian join together as its main branch, with the more inland provinces of Anhui, Henan, Hubei, and Jiangxi forming a sub-region.
If China's food culture were to have an epicenter, it would no doubt be located somewhere near the gastronomically sophisticated lower reaches of the Yangtze River, for inspiration from all over the country can be found here, from the most ancient cooking techniques of Henan and Shandong to the cutting-edge dishes of cosmopolitan Shanghai.
This is a place where the flaky crab shell pastries of upcountry Anhui find a welcome second home at the mouth of the Delta, gluten and bean curd reward Buddhist vegetarians with ingeniously meaty yet meat-free dishes, and Daokou poached chicken seasoned with a variety of gentle spices has entranced generations of devotees across a swath of provinces. The Yangtze is deep enough for seagoing vessels to sail a thousand miles upriver and, as a result, communities along this broad waterway have long been able to trade and interact. This is reflected in the shared interests of their cuisines: a pronounced love for freshwater fish and crustaceans, tender bamboo shoots, mild vinegars, rice wines, and excellent soy sauce.
The Coastal Southeast
The Hakka areas, Chaozhou, Southern Fujian, Taiwan, Taiwan's military families, and Hainan form the hearty northern half, while Guangdong and Southern Guangxi, the Pearl River Delta, Macau, and Hong Kong make up its more delicately flavored branch.
Refined seasonings hold sway in these warmer and wetter lands. Shaped by the enormous Pearl River, the ethereally light dishes of Guangdong's capital of Guangzhou, such as its deceptively simple steamed fish and poached chicken creations, trickled downstream throughout the Pearl River Delta to Hong Kong and Macau. But up in the area's craggy hills and along the rough coastlines that line the South China Sea, a more down-home style of cooking is shared by three major cuisines: Hakka, Chaozhou, and Southern Fujian. These are places where a dedicated love for the ancient cooking styles of the North China Plain combines with salty and fermented ingredients in hearty dishes like braised stuffed bean curd and Hakka "tamales" (zongzi); this common culinary heritage has in turn served as the main template for the foods on the islands of Taiwan and Hainan.
The Central Highlands
Sichuan, Hunan, Yunnan, Guizhou, and Northern Guangxi.
Chili peppers made their way from the Americas to China only a couple of hundred years ago, but in the Central Highlands they completely altered the way people eat. No matter whether they're raw, cooked, dried, pulverized, fermented in sauces, pickled in vinegar, or turned into crimson oils, the heat of chilies unifies the cuisines of this region. Dandan noodles and mapo doufu are just two of many amped up local dishes. Classic Han aesthetics run rampant in milder dishes, though, like Hunan's honey ham or the smoky camphor duck of Sichuan.
However, the flavorful aromatics of its many ethnic minorities—as in the Dai people's lemongrass chicken and Yunnan's cod with crispy bean sauce—are what set the food cultures of the Central Highlands completely apart from those of the rest of the country. Winding paths between the mountainous jungles along the southern edge of China allowed these indigenous people informal access into Burma, Laos, and Vietnam, introducing Southeast Asia's tropical seasonings into the local dishes.
The Arid Lands
Shaanxi, Shanxi, Gansu, the Northwest (namely Xinjiang, Qinghai, and Ningxia), Inner Mongolia, and Tibet.
Starting in the first millennium before Christ, the almost inconceivably rich and vibrant power of five dynasties—the Zhou, Qin, Han, Sui, and Tang—radiated out from Shaanxi Province and lured in the finest cooks and ingredients. Situated on the edge of the empire, almost half of China's landmass stretches out to the west of the imperial capital that is now Xi'an and is fed with dairy, meat, and wheat. Local ingredients like fresh lily bulbs and wolfberries (also known as goji berries) impart novel flavors and textures to the dishes of these desert domains.
Covered by the dry, sparsely populated expanses that stretch between the vast prairies of Mongolia, the shimmering sand dunes of Xinjiang, and the eternally frozen Himalayas, the Arid Lands are where salt usually supplants fermented sauces, fresh ingredients are favored over preserved foods, Indian spices spark the dishes of Tibet, and Han culinary traditions blend with the food cultures of Hui Muslims, Uyghurs, and Kazakhs in such dishes as cumin-scented lamb kebabs and pilaf, lotus patties perfumed with roses, and the vinegar-napped omelets called Buddha's hand rolls.
No matter how they're viewed, China's food traditions are far too complex to ever fit into eight or even four very limited categories. It's therefore high time that each place received the individual attention it deserves.
Even so, a lifetime will most likely never be enough to truly appreciate them and dine on all that they have to offer. No reason to stop trying, though.
Carolyn Phillips is a James Beard Award-nominated food writer, scholar, and artist. Her two fully illustrated books, All Under Heaven: Recipes from the 35 Cuisines of China (McSweeney's + Ten Speed) and The Dim Sum Field Guide: A Taxonomy of Dumplings, Buns, Meats, Sweets, and Other Specialties of the Chinese Teahouse (Ten Speed), were published in August 2016, and Heaven has made most of the "best cookbooks of 2016" lists. Her weekly blog is "Madame Huang's Kitchen" (MadameHuang.com), and she tweets as @madamehuang, but Instagrams as @therealmadamehuang.


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Co. Cork → East Carbery (West Division) → Ross Civil Parish → Rosscarbery Electoral Division → Burgatia
Burgatia is in the Electoral Division of Rosscarbery, in Civil Parish of Ross, in the Barony of East Carbery (West Division), in the County of Cork
The Irish name for Burgatia is An Bhuirgéiseach
Burgatia is on Logainm.ie: Burgatia.
It is located at 51° 34' 40" N, 9° 0' 45" W.
Burgatia has an area of:
Nationwide, it is the 4996th largest townland that we know about
Within Co. Cork, it is the 375th largest townland
Burgatia borders the following other townlands:
We don't know about any subtownlands in Burgatia.
Curious to see who lived in Burgatia in the past? Maybe even seeing scans of their handwritten census returns?
Burgatia was added to OpenStreetMap on 26 Jan 2016 by Stephen_Co_Antrim.


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It's one thing to repeatedly warn against wearing racist costumes. But it's another thing entirely to understand why people wear them in the first place. We asked Kristina Olson, a cognitive psychologist who teaches at the University of Washington and whose work focuses on race, to shed some light on the thought process.
Every year around Halloween we see photos of people in racist costumes. As a cognitive psychologist, can you talk a little bit about what goes on in people's minds when they wear these get-ups?
I wish we could blame things like ignorance and people really not knowing the significance of things like blackface, but it's hard for me to imagine in 2013 that people could really be ignorant to the history of what things like blackface have represented. Given that this comes up every single year, sometimes multiple times per year, it's hard to say that it's ignorance.
As someone who studies race and is really interested in how people think about race, often we've moved into a place where a lot of race bias we see is a lot more implicit. But these kinds of events come up and I think we forget that there is still this pretty blatant kind of race-biased behavior. The people that seem to do it don't understand or are choosing to ignore the fact that this kind of racist humor not acceptable. One thing that I try to take from events like this is that part of the reason why they make the news is because not everyone thinks it's okay so when it goes happen, there's an outcry because so many of us realize how inappropriate it is.
One interesting thing that you sort of alluded to just now is that there seems to be this lack of empathy when people wear racist costumes. There was the story of the guys this year who dressed up like Trayvon Martin and George Zimmerman, for instance. The thing that people fall back on so often in this is, "But I'm not racist!" We have these ideas that racism has to be very explicit– and in these cases they definitely are — but people are able to distance themselves from their actions.
I guess it's the definitional issue of how one defines racism. But given the history of these kinds of blackface costumes, it becomes racism based on the context in which it happens. Had Trayvon Martin been any random person who had been killed, it would still be in bad taste to dress up as that person for Halloween. But the added element that the person is in blackface takes it from poor taste to this added element of being downright racist. You know the person was doing it to be provocative. It wasn't like they didn't realize that this was going to happen.
Can you talk a little bit about the impact on people of color who experience these costumes? Is there any research that you've done that talks about the cumulative stress of racism on individual people?
I don't have any particular research on this topic, but there's a lot of reason to think that the reason these things are impactful because it's often a person from a dominant group, a powerful group in society that's making fun of a group with less power. It's precisely because there's that power dynamic that the whole thing takes on even more significance. In this case, it's using your power to make a statement about just how powerful you are over another group.


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Aug 25, 2019
Swears, Spoilers and the ever growing list of Dorian Gray's fetishes.
Whoops! I cut off a bit of episode 1.
So here is the rest of episode 1 and then Episodes 2 & 3.
Courtney from Cult of Domesticity and Morgan wander through the very gothic alleyways and opium dens of Penny Dreadful (the tv show).


text: I have delurked and have a few q's for ya'll. 1. I want to buy a Minidisc recorder for my son. I love my Sharp that I got a couple of yrs ago but am not sure what brand has the most bang for the buck now. the new Sharp MDSR60 looks pretty good specially for the price. 180$. i am not a wealthy man btw. 2.I need a road case for my rack gear w/ a mixer. did I mention that I am not a wealthy man yet? Musicians Friend has some Cadence that are in my range 200$ w/ a top angled seperate mixer rack, 8 & 12 space same price. Any advice? 3.A power conditioner for the rack. they are wide and varied in price and I don't know much about them. I am in the 2-300$ range. ouch this is adding up. i like the looks of the Furman PM-Pro Power Conditioner, 280$ from Musicians Friend. i am gonna start playing out again , ahh spring fever and G.A.S. what a combo. I am also going to start typing all lowercase I give up! Did I mention that I use will use all of this stuf for Looping? thank you all for now ahead of time and for all that i have learned and unlearned from this list over the years. jd, aka echo17 http://members.nbci.com/echo17/tbl.html http://artists.mp3s.com/artists/185/echo_17.html my much more famous sons jd jrs.site http://www.krimson-news.com/


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A new build of R-Studio 5.1 is available for download:
- Possible bugs in processing very large volumes (4TB+).
- Drive View didn't display HDD serial number.
- Default incorrect sorting in DriveView (partitions, logical disks, and empty spaces were sorted separately.
- Some possible crashes.
R-Studio v5.1 Build 130010
A forum on data recovery using the professional data recovery software R-STUDIO.
Post Reply
1 post • Page 1 of 1
Post Reply
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Privacy Policy
CarFriend.me does not distribute your personal information to other parties. The information you provide us with stays with us. We will take reasonable measures to ensure your email address does not get spammed. We may place cookies on your computer to improve the functionality of the site. These cookies will not store personal information about you and will not be used in a malacious way.


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Recovery Ministries: A Place of Trust and Safety
It happens everywhere. Drug and alcohol abuse, domestic violence, and child sexual abuse exist in every social class, ethnic group, and age. The incidents are often silenced, hidden under a veil of guilt and shame. Recovery ministries seek to provide a sanctuary for victims to find safety, counsel and healing. For those called to this ministry, there are several issues Northeastern Seminary students and graduates have found essential as they are equipped to help others.
"The biggest issue recovery ministers deal with is that of paying attention to the critical need for anonymity and confidentiality," says Greg Brotzman, M.Div. '06, of Celebrate Recovery, a program at Northgate Free Methodist Church in Batavia, N.Y. The ministry deals predominantly with alcohol and drug abuse and is led by a team of volunteer leaders. Brotzman has found that recovery occurs when people feel they are in a safe environment. This stems from a place where trust has been established and out of that trust people begin to release the pain that is behind their addictions. Consequently, "listening well is a critical skill necessary for ministry to those in recovery," he states. The Seminary's personal spiritual formation curriculum uniquely fosters these skills as a key element of the faith sharing experience.
In addition to listening, recovery takes time. One must be prepared to "be there for the long term, ready to listen and care, and [provide] a safe place where people can feel valued and respected," counsels Brotzman. It can take years for recovery to actually take place in a life. During this time, there is often a "struggle with feelings of being used and abused after addiction gets the better of the one [you] are working with and [they] become disheartened and distant from helping," shares Geri Metcalfe, MATL C24, who worked with Cornerstone Manor Women's and Children's Shelter and Men's Center. "When walking alongside persons suffering from addiction, a readying of the heart is critical," she advises. She also encourages, "we must remember we do not do the heart work; God does!"
Heart work occurs, to be sure. Many working in recovery ministry have themselves "been victimized as children in domestic violence and child sexual abuse," shares D.J. Robinson, M.Div. C23, an ordained elder at Elim who founded T.A.M.A.R., Theological Awareness Ministry for Abuse Recovery. She started the ministry during her field education at the Seminary, to equip pastors and laity with preventative care training to effectively address and respond to victims and survivors of domestic violence and child sexual abuse. Among the people she has worked with, she has found it common for victims who have found healing to want to help others.
"God is God of the oppressed," emphasizes Robinson and this work of hearing, listening, encouraging, and defending is the work of recovery ministries.


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Aquamarine and diamond cocktail ring. Set with a central rectangular emerald-cut natural aquamarine in an open back claw setting with an approximate total weight of 2.00 carats, flanked by twenty round old cut diamonds in open back grain settings with an approximate total weight of 0.80 carats, to a heavy set scrolling form with rounded shoulders, and a closed scalloped gallery with pierced backholing, tapering down to a solid flat shank. Marked 18 carat yellow gold and platinum, French, circa 1940.


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Pearl Abyss is celebrating this week as the Black Desert Online has passed the 10M player mark.
They have confirmed today that they are going to celebrate hitting the major milestone with in-game celebratory events and giveaways that will reward adventurers for their continued support.
The event "Celebrating Millions" is comprised of three sub-events that will start after this week's maintenance and will run for the following three weeks.
The first "Choice of 10 Million" event will reward players with the newly added Cliff's Weapons. These can be exchanged into Gold Bars, the value of which will vary depending on the level of enhancement. More events of great benefits will follow in the upcoming weeks.
In addition to the playable event, players who log in can also look forward to rewards including Shakatu's Luxury Box, Artisan's Memory (x5), and Advice of Valks (+50).
For players who have yet to play Pear Abyss' MMORPG, Black Desert Online is available for 50% off up until 1st November 2018 at 17:00 UTC.
For more information on Black Desert Online and to register for a 7-day free trial, visit blackdesertonline.com


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SPECIAL OFFER: Save up to 35% on tickets to see Rock of Ages at the Shaftesbury Theatre in London
The smash-hit Broadway musical Rock of Ages is rocking London at the Shaftesbury Theatre.
Enjoy a special offer on tickets to see the big new West End musical Rock of Ages.
Rock of Ages celebrates (glam)rock music of the 80's, featuring hit songs by Bon Jovi, Journey, Whitesnake, Poison, Pat Benatar and many more. Set in 1987 on the Sunset Strip in Los Angeles, a small town girl meets a big city rocker in LA's most famous rock club and they fall in love, set against the greatest songs of the 80s. This arena-rock love story is told through a succession of rock hits including I Wanna Rock, We're Not Gonna Take It, Come on Feel the Noize, Hit Me With Your Best Shot, Don't Stop Believin', Dead or Alive, We Built This City, I Wanna Know What Love Is and The Final Countdown.
The musical features a book by Chris D'Arienzo, and a Hollywood movie version is currently in production starring Tom Cruise, Russell Brand and Paul Giamatti.
SPECIAL OFFER: Save up to 35% on selected performances to see Rock of Ages at the Shaftesbury Theatre in London


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Architects: Rogers Stirk Harbour + Partners
- Year: 2018
Photographs:Joe Woolhead
Manufacturers: GKD Metal Fabrics, SEFAR Architecture, Sherwin-Williams, Atlas Schindler, FastLane, Interpane, Josef Gartner, Permasteelisa
Architect of Record: Adamson Associates
- Land Owner: Port Authority of New York & New Jersey
- Owner / Developer: World Trade Center Properties, LLC An affiliate of Silverstein Properties, Inc.
- Structural Engineers: WSP
- Security Consultant: Ducibella Venter & Santore
- Exterior Wall Consultant: Vidaris
- Height: 1,079 feet tall, 80 floors
- City: New York
- Country: United States
Text description provided by the architects. 3 World Trade Center is the third building in the WTC Master Plan, developed by architect Daniel Libeskind.
The tower is defined by the structure's steel exterior, clad in a unique load-sharing system of k-shaped bracing. This accentuates the central volume of the building and creates a more slender appearance in its primary elevations. The k-bracing is located on the outside of the building to give a human scale of grain and texture to the external façade. The structural steel is over-clad with stainless steel panels to protect the steel elements from the external environment.
The façade consists of a linen-finish stainless steel and glass curtain wall, with annealed glass panels complete with a laminated interlayer and coating to reflect surrounding scenery. On the west-facing elevation, this façade experiences the afternoon setting sun where there is a fantastic interplay of light and shadow off the stainless-steel cladding, as well as reflecting the orange glow of the sun. Therefore, the building's mood changes in appearance with a change in façade coloration throughout the day.
All corners of the tower are column-free and utilize an exterior bracing system to ensure that occupants of the office levels have unimpeded 360 degree panoramic views of New York.
The tower form is articulated all the way down to grade in order to enhance the vertical and graceful aesthetic of the structure. A podium extension at the base of the tower acts to reinforce the continuation of the re-established Greenwich Street, and provides the larger floor plates for retail and office floor functions.
The building's 60-foot tall lobby is enclosed by a three-sided cable net wall façade which lines the Greenwich Street frontage and captures the junctions of the lobby on the corner of Cortland Way and Dey Street. The cable net wall is composed of laminated glass units, 5 feet wide by 10 feet high.
A 43-foot high Zimbabwe black granite-clad wall lines the western face of the lobby, and mirror-backed glass panels with woven metallic mesh fabric flank the walls of the elevator lobbies. Sardinian Gray granite lines the floor.
3 World Trade Center offers a strong interface with the public realm along Cortlandt Way and Dey Street which have been redeveloped into pedestrian areas. This, in turn, will improve the accessibility of the retail space in the building, as well as helping it to integrate more completely with the WTC Transportation Hub to the north of Dey Street.


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As if taking part in one of the biggest rock tours of the summer wasn't enough, Def Leppard is following it up with a fall tour with another legendary band.
Just weeks after the stadium tour with Mötley Crüe, Poison and Joan Jett ends, the "Rock of Ages" band will hit the road with ZZ Top. The 16-date Vision Tour will hit mid-sized cities that the stadium tour missed. The trek begins September 21st in Albany, NY and runs through October 18th in Spokane, WA. You can buy tickets here after they go on sale February 21st.
"What a year this is going to be!" frontman Joe Elliott exclaimed. "First, sold out stadiums, then we go on tour with the mighty ZZ Top! Having been an admirer of the band for a lifetime it's gonna be a real pleasure to finally do some shows together. Maybe some of us will get to go for a spin with Billy (Gibbons) in one of those fancy cars."
The 2020 Vision Tour brings together two Rock & Roll Hall of Fame bands. Def Leppard was inducted in 2019, while ZZ Top was enshrined in 2004 on the strength of blues-based hits like "Cheap Sunglasses" and "Sharp Dressed Man."
"We're excited about hitting the road with Def Leppard this fall; we've been fans of theirs since forever," Gibbons said. "We've been at this for 50 years now and the forthcoming run with them underscores that the good times are really just beginning. Joe Elliott is always welcome to ride shotgun with us and we won't even ask him to pay for the gas."
9/21 - Albany, NY - Times Union Center
9/23 - Virginia Beach, VA - Veterans United Home Loans Amphitheater
9/25 - Knoxville, TN - Thompson-Boiling Arena
9/26 - Brandon, MS - Brandon Amphitheater
9/28 - Orange Beach, AL - The Wharf Amphitheater
9/30 - Bossier City, LA - Centurylink Center
10/2 - Little Rock, AR - Verizon Arena
10/3 - Tulsa, OK - BOK Center
10/5 - Wichita, KS - Intrust Bank Arena
10/7 - Lincoln, NE - Pinnacle Bank Arena
10/9 - Grand Rapids, MI - Van Andel Arena
10/10 - Des Moines, IA - Wells Fargo Arena
10/12 - Grand Forks, ND - Alerus Center
10/15 - Salt Lake City, UT - Vivint Smart Home Arena
10/17 - Portland, OR - Moda Center
10/18 - Spokane, WA - Spokane Arena
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The objective is to scout reasonable east / west routes across Columbia Heights from Old Soldier's Home to Rock Creek Park. We will be accompanied by a representative from the District Department of Transportation, who will help answer your questions. Please remember to bring a helmet and installed front and rear bike lights.
For those on the list who ride that area frequently have suggested routes or if you have questions about the ride, please contact Jeanie Osburn (email@example.com), chair of this committee.


text: When performing outdoors at Fetes and Shows it is often useful to have some means of attracting a crowd, or something to amuse a small audience while you wait for the crowd to build. I often use a marionette dancing among the kids, sitting on their knees, sharing a high five etc. I decided for this year I wanted a bigger puppet than the one I have been using. I wanted a gentle, non-frightening little boy character. He's coming along. He's about 70cm or 28 inches in old money.


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Shoe Sorter Conveyor
Sliding shoe sorter conveyors are high throughput positive divert sortation systems capable of gently sorting a wide variety of product sizes, shapes and weights. Contact us to learn more about how we can integrate these into your material handling and automation systems.
Gentle Sorting And Reliable Tracking With Shoe Sortation Systems
Sliding shoe sorter conveyors are a great option for a system when conveyed products are fragile or easily damaged as the system provides smooth sorting along with reliable tracking.
Shoe sorters can sort at a rate of 75 to 225 cartons per minute, making them an excellent sortation tool for distribution centers. If needed, special units can sort at rates higher than 300 cartons per minute.
Shoes sorters are ideal for both distribution and manufacturing to the versatility of the system. Industries that can benefit from this solution include:
Hytrol ProSort Sliding Shoe Sorter
High speed sortation solution
Sliding shoe sorters are a high-speed solution for a variety of products, including those found in e-commerce, warehousing, and parcel industries. Shoe sorters comprise a bed of aluminum slats with shoes attached. These types of solutions boast high throughputs with accurate movement and gentle handling of product.


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Beware the roads that lead to this national treasures are very bumpy and windy.
If you're looking for a party stay at the luscious Zephyr lodge. They've got great jungle views and a big pool to chill in. It's conveniently located near the bus stops in lanquin but you won't be walking distance from Semuc.
If you want a chilled backpackers experience Green Go's might be the place for you. They offer cute little tree house to stay in and they are very conveniently located 15min walk away from Semuc.
If you want a 'hippy' experience stay at Utopia. The hostel is set in a cacao plantation so if you're staying there don't miss the chocolate making workshop! You get to make and take all the delicious chocolate treats with you too. I did like the communal space there which has stunning views over the jungle. Only downside I would say is, the lack of internet, you'll have to walk up a hill to a lightless internet spot. The so called 'Nooks' are also just by the dorms with no real separations so you'll hear everything! Also you must be a morning person as they love to blast some music from 7am onwards.
Semuc champey...
It's pretty easy here, the main attraction is semuc champey a collection of crystal blue ponds with chilling areas and jumping ropes. I'd recommend spending the day there and don't miss the walk up to the mirador where you'll get the infamous picture of all the ponds.
Back on the tube. Every hostel will organise a tube excursion. If you're staying at Utopia, you tube all the way back home. They arrange to take our bags and we just made our way down empty handed. You won't have to worry about being thirsty too as There's also lots of locals selling beer there too. There's a few rapids so make sure to hold on to your beers.
The caves...
Go explore some caves with candle light. Just by the Semuc champey ponds you can take a stroll into Mayan's history. Worth the detour!


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Aloe Vera Juices & Gel
Natural, Kosher and Organic
Natural High has produced superior quality kosher and organic Aloe Vera gels and juices for more than 30 years. We grow our nutrient-rich Aloe Barbadensis Miller plants without pesticides or herbicides, exceeding Texas Organic Standards Act & Certification requirements. The leaves of mature plants are hand filleted and cold processed without chemicals to exacting standards, to eliminate bitter elements of aloe while preserving naturally occurring vitamins, minerals, amino acids, and enzymes.
Liquid Aminos
Essential Amino Acids
Amino acids are the "building blocks" of the body. Vital components of the human enzyme and hormonal systems, aminos form proteins to create new cells, repair tissue, and form antibodies to combat viruses and bacteria. Liquid Aminos by Natural High is a superior quality blend of 16 essential amino acids, including: Alanine, Arginine, Aspartic Acid, Glutamic Acid, Glycine, Histidine, Iso-Leucine, Lysine, Leucine, Methionine, Phenylalanine, Proline, Serine, Threonine, Tyrosine, and Valine. Effective and easily absorbed, our Liquid Aminos are made from non-GMO soybeans and purified water -- no alcohol, gelatins, artificial fillers, or preservatives.
Liquid Aminos
|Nutrition Info
|Natural High
|Liquid Aminos
|Natural High
|Liquid Aminos
|Natural High
|Liquid Aminos
|4/1 gal.
Smoothie Drink Mixes
Natural High Smoothie Drink Mixes
Natural High Smoothie Drink Mixes are a satisfying, refreshing drink. These mixes are convenient for storage, as no refrigeration is needed. Boost Natural High Brand Smoothies by adding nutritional supplements, or mix with fruit or frozen yogurt for an on the go meal replacement. Try our traditional favorite – Horchata Supreme Smoothie Mix. Perfect for any celebration!


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Coronavirus Update: Two Non Gambians Currently Being Tested At MRC
The Director of Health Promotion and Education at the Ministry of Health, Modou Njai has confirmed to The Chronicle that two Indonesian nationals are currently being tested at MRC hospital in Fajara as suspects of Coronavirus infection.
"We've two suspects who are currently at the MRC and they're Indonesian nationals and we're waiting for the results. They're young ones and the samples were collected yesterday," he told The Chronicle on Tuesday morning.
This medium understands that the two suspects are boys who were living in Gambia until recently when they visited their country. According to information, their parents who already contracted the virus had to quickly send them back to avoid the infection.
Arriving in Gambia through Senegal, the boys were showing symptoms which led to them being quarantined, according to a source in the medical field. They were taken to Bundung Maternal and Child Health Hospital, formally Jammeh Foundation for Peace Hospital before they were referred to MRC for further examination.
The Chronicle will keep following these cases and report it accordingly.
Meanwhile, The Gambian president Adama Barrow is expected to address the nation on the state of affairs regarding the pandemic.