text:
OVERVIEW: What every practitioner needs to know
Are you sure your patient has disease due to rapidly growing nontuberculous mycobacteria? What should you expect to find?
Nontuberculous mycobacteria (NTM) can infect almost any organ in the body, thus, signs and symptoms will vary depending on the site of infection. In general, NTM cause four different clinical syndromes:
1) progressive pulmonary disease
2) skin and soft-tissue infection
3) lymphadenitis
4) disseminated disease
Rapidly growing mycobacteria (RGM) have a propensity to produce skin and soft-tissue infections.
Among the RGM, the three most clinically relevant species are M. abscessus, M. chelonae, and M. fortuitum. M. abscessus is the most pathogenic and most likely to produce pulmonary disease, causing approximately 80% of lung disease due to RGM. Another 15% of lung disease is caused by M. fortuitum, which also causes skin and soft-tissue infections, surgical wound infections, keratitis, and catheter-related infections. M. chelonae has been associated with disseminated disease, as well as skin and soft-tissue infections, but it is an uncommon cause of lung disease.
Pulmonary disease
The symptoms of pulmonary disease due to RGM are variable and nonspecific in nature. It is often difficult to determine if the symptoms are due to mycobacterial infection or the underlying lung disease, such as bronchiectasis, cystic fibrosis, or chronic obstructive pulmonary disease.
Chronic or recurring cough (70-90%), which may be productive (>90%), is one of the most common symptoms.
Other symptoms include:
Fatigue (>80%), malaise, low-grade fevers, night sweats, weight loss (<40%), chest pain, dyspnea (70%), and, occasionally, hemoptysis (<40%)
Skin, soft-tissue and bone disease
Patients may complain of localized drainage or abscess formation at the site of puncture wounds or open traumatic injuries.
Pain may be out of proportion to the apparent degree of inflammation.
Lymph node disease
Patients present with enlarged, unilateral, non-tender lymph nodes, most commonly in the cervical chain.
Disseminated disease
In patients with advanced HIV infection, the clinical manifestations are protean and may be confused with other diseases. RGM are uncommon causes of disseminated disease in HIV infected patients.
Classic symptoms include fever (>80%), night sweats (>35%), and weight loss (>25%).
Additional symptoms include abdominal pain and diarrhea.
In non-HIV infected immunocompromised patients, disseminated RGM disease may present as multiple cutaneous nodules or abscesses.
Physical findings
Pulmonary disease
Physical findings are nonspecific and often reflect the underlying pulmonary disease.
Nodular-bronchiectatic NTM disease tends to occur in post-menopausal women, many of whom have a characteristic morphotype with a thin body habitus, kyphoscoliosis, pectus excavatum, and mitral valve prolapse.
Fibro-cavitary disease typically occurs in patients with underlying chronic obstructive pulmonary disease, thus, ausculatory findings include distant breath sounds, wheezes, and rhonchi.
Skin, soft tissue and bone disease
Patients may complain of localized drainage and or abscess formation at the site of puncture wounds or open traumatic injuries.
Lesions may be mildly erythematous in appearance, mildly tender, and with serosanginous drainage.
Lymph node disease
Patients present with enlarged, unilateral, non-tender lymph nodes, most commonly in the cervical chain.
Disseminated Disease
Physical findings may include cutaneous nodules, abdominal tenderness, hepatosplenomegaly, and, occasionally, lymphadenopathy.
How did the patient develop disease due to rapidly growing nontuberculous mycobacteria? What was the primary source from which the infection spread?
Patients develop pulmonary disease due to RGM after inhaling contaminated aerosols or after aspiration of contaminated foods/liquids or gastric contents. Sources that have been associated with infection include natural and treated waters, as well as soil. In most instances, the actual source of infection is not documented.
Pulmonary disease due to RGM has been associated with esophageal disorders, such as gastroesophageal reflux and achalasia.
Exposure to water contaminated with RGM, such as in hot tubs, has been associated with hypersensitivity pneumonitis and pulmonary infection.
Soft-tissue infection usually follows a puncture wound or surgery.
Disseminated disease can result from entry of RGM into the blood stream via other primary sites of infection.
Which individuals are of greater risk of developing disease due to rapidly growing nontuberculous mycobacteria?
Specific conditions that predispose patients to infection with RGM
There are a number of medical conditions associated with infection due to RGM. These can be divided into those associated with chronic lung conditions, immunological defects, and exposures to high burdens of organisms.
Chronic lung conditions
Idiopathic bronchiectasis
Cystic fibrosis
Primary ciliary dyskinesia
Allergic bronchopulmonary aspergillosis
Chronic obstructive pulmonary diseases
Alpha-one antitrypsin deficiency
Interstitial lung disease (from any cause)
Chronic aspiration syndrome
Pulmonary alveolar proteinosis
Immunological defects
Human immunodeficiency virus (HIV)/AIDS
Immunosuppressive drugs, including those given post-transplant
Biological anti-inflammatory agents
Common variable immunoglobulin deficiency syndrome
Genetic defects in interferon-γ receptors or interleukin 12
Exposure to high burdens of mycobacteria
Indoor hot tubs
Nosocomial exposures
Beware: there are other diseases that can mimic disease due to rapidly growing nontluberculous mycobacteria:
Pulmonary disease
Fibrocavity disease due to RGM presents similarly to pulmonary tuberculosis
Other conditions that produce fibrocavitary disease include:
Histiocytosis X
Ankylosing spondylitis
Chronic hypersensitive pneumonitis
Nodular bronchiectasis is often misdiagnosed as asthma, chronic bronchitis, or chronic obstructive pulmonary disease.
Skin, soft-tissue and bone disease can be caused by tuberculosis or other bacterial infections, such as MRSA.
Lymph node enlargement can be due to tuberculosis, lymphoma, head and neck carcinoma, or metastatic carcinomas.
What laboratory studies should you order and what should you expect to find?
Results consistent with the diagnosis
There are no blood tests that are specific for the diagnosis of RGM infection.
Complete blood count (CBC): Patients may have anemia of chronic disease/or lymphopenia. Eosinophilia is usually related to underlying causes of bronchiectasis (e.g., allergic bronchopulmonary aspergillosis). Disseminated infection in patients with immunosuppression may present with severe anemia.
C-reactive protein or erythrocyte sedimentation rate (ESR): These tests are often elevated in patients with RGM disease and may normalize with therapy.
Comprehensive metabolic panel: Some patients with several diseases have low serum protein and albumin levels. Hyponatremia can also occur in this setting because of syndrome of inappropriate antidiuretic hormone (SIADH). In disseminated disease, the alkaline phosphatase is often elevated.
Serology: Because rheumatologic conditions can produce the underlying lung disease associated with the RGM infection, a serologic screen should be performed, including antinuclear antibody (ANA), rheumatoid factor (RF), and anti SSA/anti-SSB. For cavitary disease, anti-neutrophil cytoplasmic antibody (ANCAs) should be elevated.
Alpha-one antitrypsin levels: Some patients with alpha-one deficiency present with primarily bronchiectasis, as opposed to emphysema.
Cystic fibrosis screening: Patients should be considered for the possibility of cystic fibrosis (CF). A sweat chloride test and/or genetic screen should be considered.
Immunoglobulins: Common variable immunodeficiency (CVID) may be associated with recurrent sinopulmonary infections, including NTM pulmonary disease.
Lymphocyte enumeration: This should be performed in anyone with disseminated mycobacterial infection.
HIV: This should be performed on anyone with disseminated mycobacterial infection.
Sputum specimens should be obtained on at least three separate occasions for acid-fast smear and mycobacterial culture, as well as bacterial and fungal cultures. If patients are unable to produce sputum spontaneously, specimens should be obtained via induction with hypertonic saline (3-10%). Bronchoscopy with bronchoalveolar lavage may be necessary if adequate sputum specimens are not obtainable. A positive acid fast bacillus (AFB) smear may be due to NTM disease, however, tuberculosis should be considered as the first possible diagnosis.
Results that confirm the diagnosis
Pulmonary Disease
The diagnosis of RGM pulmonary disease requires culture of respiratory specimens, such as sputum or bronchoalveolar lavage (BAL) specimens. However, simply isolating NTM from a respiratory specimen does not necessarily indicate the organism is causing disease.
The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) have published criteria to distinguish disease from "colonization." Two positive sputum cultures are required to meet the criteria or, if sputum is not available, one positive bronchoscopy specimen culture or a biopsy with an accompanying positive culture (Table I).
Patients suspected of having NTM infection but do not meet the criteria in Table I should be followed closely, as disease will often progress.
Approximately 25-50% of patients who grow an RGM meet ATS/IDSA criteria.
Skin, soft-tissue and bone disease
Diagnosis is confirmed by culture and histopathological examination of biopsy tissue.
For RGM causing skin or soft-tissue infection, the incubation temperature of the culture should be lowered.
Disseminated disease
Blood cultures are positive in 90% of AIDS patients with disseminated Mycobacterium avium complex (MAC), a slowly growing NTM. However, the proportion of blood cultures that are positive with RGM is not known.
In non-HIV patients, diagnosis of disseminated disease can be made via blood culture, bone marrow culture, or biopsy of enlarged lymph nodes or skin nodules.
Definitive Diagnosis of infection due to RGM requires isolation of the specific species causing the infection. RGM can be differentiated from slowly growing mycobacteria based on their rate of growth in culture. RGM typically grow within 7 days of subculture.
Species identification is critical, as the need for therapy and treatment outcomes vary by species. Species identification can be performed with high pressure liquid chromatography (HPLC), biochemically, and with molecular methods. The latter are the most accurate ways to speciate RGM as other methods cannot reliably differentiate M. chelonae from M. abscessus and its subspecies.
Drug susceptibility testing can be performed by broth microdilution minimal inhibitory concentration (MIC) determination.
Table I.
|Pulmonary symptoms such as cough, weight loss, fever
|Nodular or cavitary opacities on chest radiograph or
|High resolution computed tomography that shows multifocal bronchiectasiswith centrilobular nodules
|Positive culture results from at least two sputum specimens or
|Positive culture results from a bronchoalveolar lavage/wash or
Transbronchial or other lung biopsy with compatible histopathologic featuresand positive culture or biopsy showing mycobacterial histopathologic featuresand one or more sputum or bronchial washings that are culture positive
What imaging studies will be helpful in making or excluding the diagnosis of disease due to rapidly growing nontuberculous mycobacteria?
Chest radiograph: This should be the first imaging study ordered when a patient is suspected of having RGM pulmonary disease. $
High resolution chest computed tomography (HRCT): This is the most important imaging study, as it is the most sensitive test for identifying underlying bronchiecstasis and centrilobular nodules suggestive of NTM disease. $$$
HRCT usually shows bronchiectasis and centrilobular nodules.
Cavitation has been reported in 14-44% of cases with M. abscessus.
For skin and soft-tissue infections, a CT scan or preferably an MRI scan should be obtained. $$$
($ = 125-500, $$ = 500-1,000, $$$ > 1,000)
What consult service or services would be helpful for making the diagnosis and assisting with treatment?
If you decide the patient has disease due to rapidly growing nontuberculous mycobacteria, what therapies should you initiate immediately?
Infectious disease: Consultation may be necessary if treatment is planned.
Pulmonary: Consultation may be necessary if diagnostic procedures, such as bronchoscopy, are required.
Respiratory care services: Such services are needed to address pulmonary hygiene and obtain sputum specimens, which are often induced after inhalation of hypertonic saline.
Immunology: Consultation may be needed if an immune defect or allergic bronchopulmonary aspergillosis is suspected.
Surgical consultation: Consultation may be necessary in selected patients with cutaneous, soft tissue, lymph node, or pulmonary disease.
Key principles of therapy
Treatment for pulmonary NTM infections, including disease caused by RGM, varies depending on the particular species identified and the goals of therapy. RGM are typically resistant to many antimicrobials, so treatment outcomes are often poor.
Patients should be treated with a multidrug (≥2 drugs) regimen to prevent the emergence of resistance.
A combination of intravenous and oral antimicrobials is usually recommended for the initial phase of therapy.
Oral antibiotics (and inhaled antibiotics for pulmonary disease) should be used in the continuation phase of therapy of pulmonary disease.
Treatment regimens should be based on in vitro susceptibility results, although correlation with clinical outcomes is often suboptimal.
Mycobacterium abscessus ss. abscessus contain erm(41), which can induce macrolide resistance. Thus, although macrolides are currently recommended for treatment, it is likely they are not very active in vivo.
Mycobacterium abscessus ss. massiliense contains erm(41) with a deletion that makes it nonfunctional, thus, macrolide resistance is unlikely to be induced as with M. abscessus ss abscessus.
Clarithromycin has been shown to be a stronger inducer of erm(41) than azithromycin.
Mycobacterium fortuitum contains erm(39), which can induce macrolide resistance, thus, macrolides should not be used for treatment if other oral drugs are available.
Mycobacterium chelonae does not have an erm gene.
Surgical resection of the most involved lung segments or skin/soft tissue may be indicated in some patients, particularly those with focal disease who have failed medical therapy and/or acquired antimicrobial resistance.
Expert consultation should be obtained in most patients.
1. Anti-infective agents
If I am not sure what pathogen is causing the infection what anti-infective should I order?
Empiric therapies
Because there are many different RGM species, empiric therapy is not recommended.
In patients with severe or disseminated disease, a regimen including intravenous amikacin, imipenem, and a macrolide should be initiated and modified when precise speciation is known.
Ultimately, precise species identification is necessary to determine the most appropriate treatment regimen.
M. abscessus ss. abscessus and M. abscessus ss. bolletii should be treated with intravenous amikacin and imipenem (or cefoxitin) plus any oral antimicrobials with demonstrated in vitro activity. Unfortunately, there are few oral antibiotics that have in vitro activity. These include the macolides (azithromycin and clarithromycin), linezolid, clofazimine, and, rarely, the fluoroquinolones. M. abscessus ss. abscessus contains the erm(41) gene, which results in acquired macrolide resistance when the organism is incubated in vitro with clarithromycin. Whether this is important clinically is not clear; however, one study reported significant differences in treatment outcome based on the presence or absence of a functional erm gene.
M. abscessus ss.massiliense should be treated like M. abscessus ss.abscessus; however, because this organism does not contain a functional erm(41) gene, macrolides are likely to be effective.
M. chelonae should be treated with intravenous amikacin and imipenem (the organism is resistant to cefoxitin) plus any oral antimicrobials with demonstrated in vitro activity. M. chelonae does not contain an erm gene, so macrolides should be effective.
M. fortuitum should be treated with at least two antimicrobial drugs that have in vitro activity. M. fortuitum contains erm(39) so acquired macrolide resistance is likely. Fortunately, M. fortuitum typically has in vitro activity to several oral antibiotics.
See Table II for treatment options for RGM.
2. Next list other key therapeutic modalities.
Table II.
|M. abscessus, sp abscessus
|250 mg daily
|Cefoxitin 2-3 gms IV 3-4 times dailyTigecycline IV 50 mg once dailyLinezolid 600 mg once dailyMoxifloxacin 400 mg once dailyClofazimine 100 mg daily
|500-750 mg IV three times daily
|15 mg/kg/day given IV three times per week
|M. abscessus, sp massiliense
|Azithromycin (or clarithromycin)
|250 mg daily
|Cefoxitin 2-3 gms IV 3-4 times dailyTigecycline IV 50 mg once dailyLinezolid 600 mg once dailyMoxifloxacin 400 mg once dailyClofazimine 100 mg daily
|500-750 mg IV three times daily
|15 mg/kg/day given IV three times per week
|M. abscessus, sp bolletii
|250 mg daily
|Cefoxitin 2-3 gms IV 3-4 times dailyTigecycline IV 50 mg once dailyLinezolid 600 mg once dailyMoxifloxacin 400 mg once dailyClofazimine 100 mg daily
|500-750 mg IV three times daily
|15 mg/kg/day given IV three times per week
|M. chelonae
|Azithromycin (or clarithromycin)
|250 mg daily
|Tigecycline IV 50 mg once dailyLinezolid 600 mg once dailyMoxifloxacin 500 mg once dailyClofazimine 100 mg daily
|500-750 mg IV three times daily
|8 mg/kg/day given IV three times per week
|M. fortuitum
|400 mg daily
|Imipenem 500-750 mg IV three times dailyCefoxitin 2-3 gms IV 3-4 times dailyTigecycline IV 50 mg once dailyLinezolid 600 mg once dailyClofazimine 100 mg daily
|500-750 mg IV hree times daily
|Doxycycline (or minocycline)
|15 mg/kg/day given IV three times per week
Patients with underlying bronchiectasis should be trained in proper airway hygiene.
Airway hygiene should include, at minimum, the use of a flutter or positive expiratory pressure value.
Additional benefit may be obtained with use of a vibratory vest.
Inhaled hypertonic saline (7%) should be used.
Patients with gastroesophageal or swallowing disorders should have these addressed to prevent recurrent aspiration.
Controversial or evolving therapies
The use of immune adjuvants, such as interferon-gamma, remains controversial. Currently, interferon-gamma should be administered only when patients have documented immunological defects that would be expected to respond to treatment. Expert immunological consultation is advised.
What complications could arise as a consequence of disease due to rapidly growing nontuberculous mycobactiera?
What should you tell the family about the patient's prognosis?
Hemoptysis: Patients with RGM pulmonary infections may develop hemoptysis.
Concurrent or recurrent infections with other bacteria, such as Pseudomonas aeruginosa, are common.
Aspergillus: Similarly, colonization with Aspergillus species is common.
The expected treatment outcomes vary greatly depending on the site of infection, species causing disease, and underlying severity of disease. To date, there are no randomized clinical trials that have evaluated treatment outcomes in patients with disease due to RGM.
Pulmonary disease: In general, sustained culture conversion (≥12 months) has been reported to occur in 50-60% of patients with pulmonary disease due to M. abscessus. Three recent studies have described the treatment outcomes for pulmonary infections due to M. abscessus:
Jeon and colleagues reported treatment outcomes in 65 patients with pulmonary M. abscessus disease. Patients were treated with a standardized regimen that included 1 month of intravenous amikacin and cefoxitin (or imipenem) followed by clarithromycin, ciprofloxacin, or doxycycline for a total duration of 24 months. Treatment response rates were 83% for symptoms and 74% for HRCT. Sputum culture conversion was sustained for 12 months in 58% of the patients. Conversion was lower (17%) in those whose isolate demonstrated in vitro resistance to clarithromycin. Fourteen (22%) of the patients underwent surgical resection. Negative sputum culture conversion was achieved within a median duration of 1.5 months postoperatively and was maintained in 88% of patients with a preoperative positive culture. Toxicity was common. Neutropenia and thrombocytopenia associated with cefoxitin developed in 33 (51%) and 4 (6%), respectively. Drug-induced hepatoxicity occurred in 15% of patients. Ultimately, cefoxitin was discontinued in 60% of patients after a median of 22 days of treatment.
Koh and colleagues reported treatment outcomes for 64 patients with M. abscessus and 81 patients with M. massiliense lung disease. All patients were treated with the same regimen as described in the study published by Jeong and colleagues. Patients with M. massiliense lung disease were more likely to show symptomatic, radiographic, and microbiologic improvement than those with M. abscessus. Eighty-eight percent of patients with M. masiliense converted their sputum cultures to negative compared to 25% with M. abscessus.
Jarand and colleagues reported 107 patients with pulmonary M. abscessus infection. Patients were treated with individualized treatment regimens based on ATS/IDSA recommendations. Sixty-nine patients were followed for a mean of 34 months. Forty-eight percent remained culture negative for at least 12 months, 29% remained culture positive, 23% converted but relapsed, and 16% died. Twenty-two percent of the patients underwent surgical resection, and they were more likely to remain culture negative for at least 1 year (57% vs. 28%). Toxicity was common. At least one drug had to be stopped because of adverse reactions in 65% of patients. Cefoxitin and amikacin were most likely to cause adverse reactions.
Skin and Soft-tissue disease is usually cured, although surgical resection and removal of foreign bodies is often necessary.
Lymph node disease is usually cured, although surgical resection of the involved nodes may be necessary.
Disseminated NTM disease is associated with a poor prognosis. Treatment should be started as soon as disseminated disease is diagnosed.
Add what-if scenarios here:
What if the patient is asymptomatic?
Some patients with radiographic evidence of RGM disease have no symptoms at the time of diagnosis. The decision to treat or not treat varies based on a number of factors, such as the specific species isolated, presence of co-morbidities, extent of disease, and overall goals of therapy.
What if the patient suffers drug-related adverse reactions?
Adverse reactions are common with the multidrug regimens used to treat RGM infections. If a drug must be stopped, it is important to identify a substitute drug.
What if I have never heard of this species of RGM?
There are many different species of RGM. Most rarely, if ever, cause human disease. In such cases, it is strongly recommended that expert consultation be obtained.
How do you contract disease due to rapidly growing nontuberculous mycobacteria and how frequent is this disease?
NTM are widely distributed in the environment with high rates of isolation worldwide.
Organisms can be found in soil and water, including both natural and treated water sources.
Human disease is thought to occur by exposure to environmental sources, although the specific source is often not identified.
There have been several reports of isolation of the same species and genotype pattern in home water supplies (i.e., shower, hot tubs) as that isolated from the patient. A recent study evaluated the home water supplies of 37 patients with NTM pulmonary disease and reported isolation of the same species and genotype in 7 patients. Isolation of NTM was less common in residences in which the hot water temperature was greater than or equal to 125°F and there was a trend for lower isolation frequency in well water compared to treated water.
In most studies, M. avium complex is the most common cause of NTM related lung disease. The second most common cause varies from study to study with M. kansasii being reported to be the second most common cause of NTM lung disease in the United States. However, recent studies have reported that RGM are second to MAC causing 20% of all NTM related lung disease in the United States.
Organisms from the M. chelonae/abscessus group are the most common cause of lung disease due to a RGM. In the United States, the Southeastern United States from Florida to Texas appears to have the highest rate of isolation of M. abscessus.
Patients with pulmonary RGM infection are typically female, nonsmokers, and post-menopausal, although, in some areas, male patients are more common.
The incidence and prevalence of disease due to NTM have varied greatly from region to region. There are very few data that describe the incidence and prevalence due to RGM.
In a retrospective study of laboratory cultures in Oregon between 2005 and 2006, 933 patients were identified who had 1 or more NTM isolate. Approximately one-half of the patients met ATS criteria for disease, which gave an annualized prevalence of 7.2 cases per 100,000 persons. Pulmonary cases predominated with a rate of 5.6 cases/100,000 persons followed by skin/soft-tissue cases (0.9 cases per 100,000). Pulmonary disease prevalence was significantly higher in women than men (6.4 vs. 4.7 cases per 100,000 persons) and was highest in those 50 years of age or older (15.5/100,000 persons). Disease appeared to be more common in urban areas.
In a follow-up study, all Oregon residents with 1 or more NTM isolate were identified. From a population-based subset, clinical and radiographic information was obtained. Again, approximately 50% of the patients met ATS microbiologic criteria giving a 2-year period prevalence of 8.6/100,000 persons and 20.4/100,000 persons for those 50 years of age or older within the Portland, Oregon area.
Incidence and prevalence are increasing in some areas.
Ontario, Canada (2007): The isolation prevalence of all species (excluding Mycobacterium gordonae) was 19 per 100,000 population and increased 8.5% per year from 1997. The isolation prevalence of RGM varied from 1.2 to 2.3% but did not change significantly over the study period.
Four Integrated Health Care Delivery Systems in the United States (2004-2006): 28,687 samples from 7,940 patients were included in the analysis. Fifty percent were defined as possible cases (≤1 isolate) and 47% as definite cases (≥2 isolates). The average annual site-specific prevalence of NTM lung disease ranged from 1.4 to 6.6 per 100,000 persons. Prevalence was 1.1- to 1.6-fold higher among women than men. The prevalence of NTM lung disease was increasing significantly at the two sites at which trends were studied. 2.6% per year among women and 2.9% among men. Among persons 60 years of age or older, annual prevalence increased from 19.6 per 100,000 during 1994-1996 to 26.7 per 100,000 during 2004-2006.
U.S. Medicare Beneficiaries: A nationally representative 5% sample of Medicare Part B beneficiaries were analyzed between 1997 and 2007. The annual prevalence significantly increased from 20 to 47 per 100,000 persons or 8.2% per year. The period prevalence was 112 cases per 100,000 persons, although the prevalence was two-fold higher among Asian/Pacific Islanders than among whites. Western states had the highest prevalence of 149 cases per 100,000 with Hawaii having the highest prevalence of 396 per 100,000 persons. Other high prevalence areas included the Southeastern United States.
Hospitalized Persons in the United States (1998-2005): Records were reviewed of hospitalized patients who had a NTM International Classification of Disease Code of 031.0 in 11 states. Pulmonary NTM hospitalizations increased significantly with age among both genders. Annual prevalence increased significantly among men and women in Florida (3.2% and 6.5%) and among women in New York (4.6% per year).
RGM pulmonary disease occurs when a susceptible individual inhales contaminated aerosols or aspirates contaminated food/water or gastric contents.
Human disease is thought to occur by exposure to environmental sources, although the specific source is often not identified.
Transmission from human-to-human has not been demonstrated conclusively.
One study retrospectively analyzed 1,062 respiratory specimens from 214 patients with cystic fibrosis of whom 5 had 37 cultures positive for M.absessus. Pulsed field gel electrophoresis (PFGE) demonstrated that all 5 patients had unique genotype patterns documenting no transmission between patients.
Seventy-one isolates from 14 patients with cystic fibrosis, 3 non-CF patients with pulmonary disease, 1 patient with mastoiditis, 4 patients with infected wounds, and 6 environmental isolates underwent PFGE. Twenty-four patients had unique strains, whereas 4 patients had identical strains, 2 of whom were siblings with CF. They concluded that person-to-person transmission rarely occurs.
A recent report described possible interperson transmission of M.abscessus ss.massilinse in 5 patients at a CF center. Four of 5 patients had overlapping clinic visit days, but no other shared space was identified. Environmental studies of the clinic rooms, toilets, and spirometers performed 8 months after initial recovery were negative for M.abscessus.
RGM are not known to be spread from animal to human.
What pathogens are responsible for this disease?
By far, the most common RG to produce lung disease are those of the M.abscessus group followed by M.chelonae and M.fortuitum. The other RGM are rare causes of lung disease.
M. abscessus ss.abscessus
M. abscessus ss.massiliense
M. abscessus ss.bolletii
M. chelonae
M. fortuitum
M. alvei
M. boenickei
M. brumae
M. confluentis
M. elephantis
M. goodii
M. holsaticum
M. mucogenicum
M. peregrinum
M. phocaicum
M. speticum
M. thermoresistible
How do these pathogens cause disease?
NTM are environmental organisms, so exposure is common. However, progression to disease is relatively uncommon.
The pathogenicity of NTM varies widely with some species, such as M. mucogenicum, rarely causing disease and others, such as M. abscessus, frequently causing disease when isolated from a clinical specimen.
Among rapidly growing mycobacteia, the most pathogenic appear to be M. abscessus group followed by M. chelonae and M. fortuitum.
Pulmonary disease commonly occurs in the setting of underlying lung disease, such as cystic fibrosis, non-cystic fibrosis bronchiectasis, chronic obstructive lung disease, prior tuberculosis, pneumoconiosis, alveolar proteinosis, and esophageal disorders. NTM are inhaled or aspirated from the environment and presumably cause disease because of a lack of normal airway clearance mechanisms.
Women with nodular bronchiectasis and NTM pulmonary infections often have a specific morphotype characterized by lean body habitus, scoliosis, pectus excavatum, and mitral valve prolapse. Why these women develop bronchietasis and NTM infections is unknown. To date, no significant immunological defect has been described.
Skin and soft-tissue infections usually result after a puncture or other trauma. There are now numerous reports of nosocomial RGM infections occurring after surgical procedures.
HIV-infected patients develop disseminated NTM disease in the setting of advanced immunosuppression. For example, disseminated MAC typically occurs when the CD4 lymphocyte count is lower than 50 cells/ul.
Several immunological defects have been described in patients with disseminated disease. These include defects in interferon gamma and IL12 receptors.
What other clinical manifestations may help me to diagnose and manage disease due to rapidly growing nontuberculous mycobacteria?
RGM infections can involve any organ system, particularly in immunocompromised individuals. Patients' medical history and medications should be reviewed to determine if they are immunocompromised.
A history of lymph node enlargement, particularly cervical enlargement, may be due to RGM infection.
Complaints of cutaneous lesions, either singly or multiple, may be due to RGM cutaneous disease or disseminated disease. The patient should be questioned regarding recent trauma or invasive medical procedures.
Lymphadenopathy, particularly cervical lymphadenopathy, can be a manifestation of RGM disease.
Cutaneous lesions can be a result of focal infection due to a puncture in the skin or after an invasive procedure.
Multiple diffusely scattered cutaneous lesions may be a result of disseminated disease in an immunocompromised host.
What other additional laboratory findings may be ordered?
A serological assay that detects IgA antibody to glycopeptidolipid core antigen is currently available in Japan (Tauns). This assay was reported to have a sensitivity of 84.3% and specificity of 100% for detection of MAC pulmonary disease. M. abscessus is known to contain this antigen as well, but no studies have been published to date regarding the test performance for this RGM.
How can disease due to rapidly growing nontuberculous mycobacteria be prevented?
RGM are environmental organisms found in soil and water. To minimize exposure to potentially contaminated soil and water, an individual would need to:
Avoid hot tubs, particularly indoor tubs
Avoid swimming pools, particularly indoor pools
Avoid exposure to large amounts of dust and dirt
Vaccination with Bacillus Calmette-Guerin (BCG) has been associated with lower rates of NTM infection. However, BCG is not currently recommended to prevent NTM infection.
To avoid nosocomial infections, tap water should be avoided during medical procedures.
WHAT'S THE EVIDENCE for specific management and treatment recommendations?
Bange, FC, Brown, BA, Smaczny, C, Wallace Jr, RJ, Bottger, EC. "Lack of transmission of Mycobacterium abscessus among patients with cystic fibrosis attending a single clinic". Clin Infect Dis. vol. 32. 2011. pp. 1648-50. (This study reported no evidence of transmission of Mycobacterium abscessus within a single cystic fibrosis clinic. The authors used pulsed field gel electrophoresis to examine the spread of M. abcessus within the clinic, but they noted that all of the isolates were unique and, thus, transmission could not be documented.)
Choi, GE, Shin, SJ, Won, CJ. "Macrolide treatment for and infection and inducible resistance". Am J Respir Crit Care Med. 2012. (This study compared treatment efficacies of clarithromycin and azithromycin and determined the correlation between efficacy and induced erm (41) expression in experimental models of M. abscessus and M. massiliense. Clarithromycin induced greater erm(41) expression and, thus, higher macrolide resistance than azithromcyin.)
Griffith, DE, Aksamit, T, Brown-Elliott, B. "An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases". Am J Respir Crit Care Med. vol. 175. 2007. pp. 367-416. (This document represents the official recommendations of the ATS and IDSA.)
Jarand, J, Levin, A, Zhang, L, Huitt, G, Mitchell, JD, Daley, CL. "Clinical and microbiological outcomes in patients receiving treatment for pulmonary disease". Clin Infect Dis. vol. 52. 2011. pp. 565-71. (One hundred seven patients were treated with individualized regimens following ATS recommendations: 23% of the patients relapsed and 16% died. Of those who underwent surgical resection, 57% remained culture negative for at least 1 year.)
Jeon, K, Kwon, OJ, Lee, NY. "Antibiotic treatment of lung disease". Am J Respir Crit Care Med. vol. 180. 2009. pp. 896-902. (Sixty-five patients were treated with a 24-month standardized regimen, including clarithromycin, ciprofloxacin, doxycycline, plus 1 month of intravenous cefoxitin (or imipenem) and amikacin. Sputum conversion occurred in 58% of the patient. Drug induced toxicity was very common. Cefoxitin had to be discontinued in 60% of patients.)
Jonsson, BE, Gilljam, M, Lindblad, A, Ridell, M, Wold, AE, Welinder-Olsson, C. "Molecular epidemiology of Mycobacterium abscessus, with focus on cystic fibrosis". J Clin Microbiol. vol. 45. 2007. pp. 1497-504. (This study reported the possible person to person spread of Mycobacterium abscessus ssp massiliense in a cystic fibrosis clinic. Four out of five patients had overlapping clinic visits but no direct contact with each other. The environmental evaluation took place 8 months after the presumed transmission.)
Koh, WJ, Jeon, K, Lee, NY. "Clinical significance of differentiation of from ". Am J. Respir Crit Care Med. vol. 183. 2011. pp. 405-11. (This study compared treatment outcomes using a standardized regimen in patients with M. abscessus and M. massiliense. Patients with M. massiliense infection had higher rates of culture conversion than M. abscessus patients (88% vs. 25%). M. massiliense isolates had a deletion in the erm(41) gene making it nonfunctional.)
DRG CODES and expected length of stay
031.0 Pulmonary Mycobacteria, all species
031.1 Cutaneous Mycobacteria, all species
031.8 Other Spec. Mycobacteria
031.2 Disseminated Mycobacteria, all species
Copyright © 2017, 2013 Decision Support in Medicine, LLC. All rights reserved.
No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. The Licensed Content is the property of and copyrighted by DSM.
- OVERVIEW: What every practitioner needs to know
- Are you sure your patient has disease due to rapidly growing nontuberculous mycobacteria? What should you expect to find?
- How did the patient develop disease due to rapidly growing nontuberculous mycobacteria? What was the primary source from which the infection spread?
- Which individuals are of greater risk of developing disease due to rapidly growing nontuberculous mycobacteria?
- Beware: there are other diseases that can mimic disease due to rapidly growing nontluberculous mycobacteria:
- What laboratory studies should you order and what should you expect to find?
- What imaging studies will be helpful in making or excluding the diagnosis of disease due to rapidly growing nontuberculous mycobacteria?
- What consult service or services would be helpful for making the diagnosis and assisting with treatment?
- If I am not sure what pathogen is causing the infection what anti-infective should I order?
- What complications could arise as a consequence of disease due to rapidly growing nontuberculous mycobactiera?
- What should you tell the family about the patient's prognosis?
- Add what-if scenarios here:
- How do you contract disease due to rapidly growing nontuberculous mycobacteria and how frequent is this disease?
- What pathogens are responsible for this disease?
- How do these pathogens cause disease?
- What other clinical manifestations may help me to diagnose and manage disease due to rapidly growing nontuberculous mycobacteria?
- What other additional laboratory findings may be ordered?
- How can disease due to rapidly growing nontuberculous mycobacteria be prevented?
- WHAT'S THE EVIDENCE for specific management and treatment recommendations?
- DRG CODES and expected length of stay


text:
Recent Posts
- Our Shelley Stocken
- Area shitbags boast of flouting airline mask mandates during Melbourne COVID outbreak
- Australian Vaccination-risks Network posts anti-vaccination billboard in Brisbane
- Unconscionable: Australian Vaccination-risks Network promotes convicted criminal
- The Drs. Wolfson – Incomprehensibly Cruel 2 – Light for Riley responds
Reasonable Hank Facebook
Subscribe to Blog via Email
- abuse
- Andrew Wakefield
- Anti-Vaccination Australia
- anti vaccination
- Australian Health Practitioner Regulation Agency
- Australian Spinal Research Foundation
- australian vaccination network
- Australian Vaccination Skeptics Network
- Australian Vaccination Skeptics Network - HCCC Public Health Warning
- AVsN
- Billy DeMoss
- Brian Martin
- Chiropractic Board of Australia
- Chiropractors' Association of Australia
- Chiropractors' Association of Australia Victoria
- conspiracy
- dishonesty
- Greg Beattie
- harassment
- Health Care Complaints Commission
- hypocrisy
- Jennifer Barham-Floreani
- Judy Wilyman
- meryl dorey
- Nurse
- Nursing and Midwifery Board of Australia
- registered nurse
- Sherri Tenpenny
- Simon Floreani
- Stephanie Messenger
- Tasha David
- Tim Shakespeare
- University of Wollongong
- Vaccine Free Australia
- Vaxxed
- vilification
- July 2021
- May 2021
- October 2018
- September 2018
- August 2018
- June 2018
- March 2018
- February 2018
- January 2018
- December 2017
- November 2017
- October 2017
- September 2017
- August 2017
- July 2017
- June 2017
- May 2017
- April 2017
- March 2017
- February 2017
- January 2017
- December 2016
- November 2016
- October 2016
- September 2016
- August 2016
- July 2016
- June 2016
- May 2016
- April 2016
- March 2016
- February 2016
- January 2016
- December 2015
- November 2015
- October 2015
- September 2015
- August 2015
- July 2015
- June 2015
- May 2015
- April 2015
- March 2015
- February 2015
- January 2015
- December 2014
- November 2014
- October 2014
- September 2014
- August 2014
- July 2014
- June 2014
- May 2014
- April 2014
- March 2014
- January 2014
- December 2013
- November 2013
- October 2013
- September 2013
- August 2013
- July 2013
- June 2013
- May 2013
- April 2013
- March 2013
- February 2013
- January 2013
- November 2012
- October 2012
- September 2012
- August 2012
- July 2012
- June 2012
- May 2012
- April 2012
- March 2012
- February 2012
- January 2012
- December 2011
- November 2011
- October 2011
Tag Archives: Megan Johnson
The mobbing of Riley Hughes' family by anti-vaccination thugs
Yesterday, Mamamia published an article which outlined the thuggery of the anti-vaccination movement towards Mia Freedman and the family of Riley Hughes. Riley Hughes passed away from whooping cough, in March 2015. Since then his parents, Catherine and Greg, and … Continue reading
Posted in abuse, anti-vaccination, anti-vaccination dishonesty, Anti-vaccine thugs, australian vaccination network, AVN, Brian Martin, Immunisation, Judy Wilyman, Light for Riley, meryl dorey, mobbing, public health, Public mobbing, skeptic, stop the australian vaccination network, University of Wollongong Tagged abuse, Adam Crabb, Adam G, Alicia Bennetts, Alicia Constable, Amanda Malsem, Amber Grace, Anna Patel, Anna Stancombe, anti vaccination, Anti-Vaccination Australia, Anti-vaccine thugs, australian vaccination network, Australian Vaccination Skeptics Network, Australian Vaccination Skeptics Network - HCCC Public Health Warning, Auti Rayne, AVN, AVsN, Bec Cameron, Belgin Colak, Belgin Sila Colak, Ben Grassham, Bernadette Harrison, Bev Pattenden, Breana Stanley, Brett Smith, Brett Smith Naturopath, Brian Martin, Brianandtracey Simpson, Brigette Petrovansky, Brittany Smith, Bronwyn Hancock, Cathie Murray, Cheryl King, Christine Phethean, Cindy Alchin, Courtney Hebberman, Danielle Breytenbach, Danielle Jupp, Dean Grant, Debbie Parsons, Dee Footman, dishonesty, Don Houston, Erin Anne, Erin Kingston, Fiona Nicholls, First Light Holistic, Gilly Bowyer-Braby, Giselle Kara Vles, Hannah Mueller, harassment, Hayley Van, Helen Solomon, hypocrisy, Jade Palmer, Jessica Kelly, Judy Cupper, Judy Wilyman, Julie Meadows-Shera, Jute Smith, Karalyn Sladka, Kathy Campbell, Kathy Matthew, Keira Jane, Kerry Baker, Kiata Hazell, Kim Sheppard, Kitty Mandala, Kym Kani, Leah Hudson, Louise Chamberlain, Luke E Lawless, Luke O'Hehir, Lynette Kennedy, Mary Manahan, Maryanna Winchester, Meg Rhiannon, Megan Johnson, Melanie Coburn-Battisson, Melanie Nolan, meryl dorey, Mjay Pascoe, mobbing, Morgan Jane, Nita King, Olivier Vles, Paula Bernadette, Persephone Rose, Pheebz Hill, Phoebe Hill, Public mobbing, Ramana Braye, Rebecca Wraight, Rebekah Julian, Rixta Francis, Robyn Langguth, Rudi Beattie, Ryan Thompson, Sam Pearson, Sarah Foskett, Sarah O'Reilly, Sensations Cafe Geographe WA, Serena Hohnke, Shari Smoker, Shari Zumba Smoker, Sharon Heilbronn, Steve Kefalinos, Suzanna Charis, Suzy Singleton, Tamara Nicdao, Taryn Matulj, The Crazz Files, Trent Wiseman, Trudy Bee, University of Wollongong, Unvaccinated Australia, Vaccine Free Australia, Vesna Peacock, vilification 21 Comments
Embedded in the hive-mind of the anti-vaccination 'cult'
Okay, it is not strictly accurate to call the anti-vaccination movement a "cult". One of the main features of a cult is the existence of a supreme leader; anti-vaccinationism is a many-headed beast, with many charismatic leaders – such as … Continue reading
Posted in abuse, anti-vaccination, anti-vaccination dishonesty, australian vaccination network, AVN, hypocrisy, Immunisation, meryl dorey, public health, skeptic, vaccination, Vitamin K Tagged abuse, Adam Crabb, Adam George Crabb, Aleena Noad, Allison Walker, Allona Lahn, Amber Borsotti, Amy Danec, Amy Daniels, Andrew Wakefield, anti vaccination, Anti-Vaccination Australia, australian vaccination network, Australian Vaccination Skeptics Network, Australian Vaccination Skeptics Network - HCCC Public Health Warning, AVN, AVsN, Ayla Mills, Bouamama Jazil, Bradley Dobson, Brianandtracey Simpson, Brittany Smith, Brittany-j Toretto, Bron McAllister, Caroline Duffy, Cat Wilson, Christine Phethean, Clair Berry, Clare Bailey, conspiracy, cult, Dan WF, Daniel Whitelock, Danielle Thompson, Debi Leeper, dishonesty, Dr Kevin Coleman, Emma Gibney, Emma Wiseman, Erica French, Erin Anne, Georgie Rush, Gloreen Andersen, Greg French, Greg Wilson, Hanan H Saleh, harassment, Health Care Complaints Commission, hypocrisy, Jason Wood, Jennifer Barham-Floreani, Joanna Mander, Julia Gilby, Kathy Matthew, Kayla D'Assumpcao, Kelli Hurley, Laura Leslie Murphy, Leisha Allen, Leisha Smith, Lina Minawiyeh, Lo Mong Bridge, Louisa Kenzig, Lucia Guzzardi, Lulu Langford, Lynette Kennedy, Lynne Hopewell, Marc Andrew Garibaldi, Margherita Ghezzi, Maria Murphy, Mark Krinkel, Mark Zuckerberg, Matthew Stewart, Meg Rhiannon, Megan Johnson, Melissa Grainey, meryl dorey, Miriam Baxt, Nikki Cornish, Nikki Louise Cole, Pavel Kalinov, Persephone De Kari, Persephone Rose, Ramana Braye, Refutations to Anti-Vaccine Memes, Renata Bialkowska, Rixta Francis, Robert Thompson, Rodolfo Plasencia, Sarah Foskett, Sarah O'Reilly, Sharon Heilbronn, Sissi-Rae O'Brien, Sophia Constantine, Sophie Krokos, Steph Brill, Stephen Exeter, Steve Kefalinos, Sue Davis, Suzie Connelly Robertson, Tami Perrin, Tara Brown, Tiana Theoharris, Tony Ciniglia, Trent Wiseman, Trevor Simons, Tristan Glenn, Tristan Wells, Unvaccinated Australia, Vaccine Free Australia, vilification, Wayne Baird, Zili Lau 12 Comments

subset: commoncrawl


text:
Hewlett-Packard plans to sell the unlocked version of its Palm Pre 2 to small businesses as well as to mobile application developers.
The company disclosed plans for an unlocked Pre 2 for developers when it announced the phone on Oct. 19. Though the primary audience for the unlocked device will be developers of apps for the new WebOS 2.0 operating system, HP will also sell the Pre 2 through its small-business channel, according to spokeswoman Leslie Letts.
HP introduced the Pre 2 through French mobile operator SFR last month and said it would go on sale at Verizon Wireless and a Canadian carrier in the coming months. HP also said it would sell the handset directly to WebOS developers, with qualified developers getting a significant discount. The unlocked phone will work on UMTS (Universal Mobile Telecommunications System) networks, the 3G variant of GSM (Global System for Mobile Communications), used by AT&T and T-Mobile USA in the U.S.
In a YouTube video posted last week by Markguim.tv, HP Palm product manager Tim Pettitt said the company would offer an unlocked Pre 2 so that "if you're a GSM user that wants to have the device but don't want to have a carrier contract, then you can just buy it directly from HP.com."
The Pre 2 is the first major Palm product to come out since HP bought Palm earlier this year. It comes with a moderate hardware upgrade, with a 1GHz processor, 5-megapixel camera and other features, but more importantly runs the next-generation WebOS 2.0 operating system. Among other improvements, the new OS will be compatible with Adobe Flash 10.1 and QuickOffice Connect and will allow users to perform tasks immediately by typing on the physical keyboard.
With its acquisition by HP, the once independent Palm became part of a technology giant with well-developed channels into large enterprises and small and medium-size businesses as well as retail stores. It remains to be seen whether the larger company can make Palm products more competitive in a smartphone industry that has only become more cutthroat since the buyout deal was made in late April.
The Palm Pre, introduced last year by the independent Palm company, won praise from many observers for its slick slider design and multitasking WebOS software. That OS had been years in development and represented Palm's final bid to regain share in the smartphone business. But it failed to grab enough consumers' attention amid new iPhone, Android and BlackBerry rollouts, and by early this year Palm was still reporting big losses and carriers were slashing prices on the Pre and its smaller sibling, the Pixi.
Most mobile phones in the U.S. are sold by carriers and locked for use only on their networks and those of their roaming partners. Google sold its Nexus One handset on its own Website, including in an unlocked model, but stopped selling it in July after only a few months of sales.


text:
Our fascination with the differences between men and women has spawned countless TV shows, hit songs, and best-selling books. And now we're starting to understand how gender also influences social media use.
I began thinking about this while reading Porter Novelli's EuroPNstyles research, conducted among consumers in the UK and other European countries by my colleague Melissa Taylor, EVP of strategic planning and research. Drilling down into the facts and stats around social media, several clear trends emerged showing that the same preferences and behaviours are being played out in the digital space just as they are offline.
Of course both sexes are highly engaged in social media, but our data indicates that women are using social channels to reinforce existing social connections, and to interact with friends and family. By contrast men demonstrate a clear bias toward showing or sharing status, and promoting their opinions to the wider world. Never mind Men are from Mars, Women are from Venus – today it seems Men are from Foursquare, Women are from Facebook.
I pulled some of these trends into a presentation that I gave today as part of Social Media Week London, here are a few UK highlights:
- Women are more socially active than men: 65% of women access social media at least once a week, compared with just 51% of men
- Women are more likely to connect with people they know: 93% of women using social media do so to read posts and view pictures from friends or to comment on their friends' profiles. For men the numbers dropped to 89% and 84% respectively.
- UK women lead the rest of Europe in following brands to access deals and offers – this is the motivation for around 64% of women in social media, compared to a European average of just 52%, and 56% among UK men.
- Men are more likely to use social networks to display status and opinions. In the UK, 45% of men use social media to check into places compared with just 33% of women. Men are also happier to broadcast what they're saying to the world: 35% of socially-savvy men are Twitter users compared to 27% of women.
- Men are also more active in the blogosphere: 54% of digitally-active men say they seek out other people's blogs to read, compared with 46% of women. Men are more active bloggers than women too (34% vs 24%).
It's interesting to see that Forrester, the Wall Street Journal, comScore and even Facebook are all seeing similar trends, although brands and marketers are not always following suit. As Forrester's Tracy Stokes argues: "Women have the potential to drive a brand's reputation online because compared with men, they are more connected with each other and like to talk about brands and products, especially in social media. But marketers, particularly in more male-oriented categories like finance, are not making a digital connection with women."
It sounds simple but in this new era of communications, it's not enough to know how to "do digital" – we still need to understand people and what influences them, regardless of the medium. Those brands that manage to combine social media savvy with human insights will maximise their chance of success.
Note: EuroPNStyles is an annual study conducted by Porter Novelli among more than 10,000 European consumers in the UK, France, Germany, Spain, Portugal, Belgium and the Netherlands (UK sample = 1,700 people). It reflects our agency's belief that research uncovers insights which can trigger behavioural change.


text:
Toggle navigation
List Your Business
Sign In
Find a Venue
Wheat Ridge
Photographers near
Wheat Ridge,
Fast Response
Serving the Wheat Ridge, CO Area
You don't have to spend a fortune to get top level services for your wedding, party, or event! We are based in Florida and offer top level performances nationwide using local professional DJs, photographers, and videographers in budget friendly packages all over the country. We have done over 20,000
Crystaline Photography & Video
2.6 miles from Wheat Ridge, CO
The moment is only temporary, but the memory lasts forever! And this is the motto that we live by when capturing your event through still photography and/or video. As of 2021 we've been in business for 22 years serving all over Colorado. We offer full service coverage of weddings, parties, corporat
Rebeca Velie Photography
2.2 miles from Wheat Ridge, CO
I am an engagement and portrait photographer who is passionate about capturing the real you. My photos display my clients in a raw and authentic way that is truthful to who they are. My clients are my friends. I aim to make them feel comfortable throughout the entirety of the process. It's important
Professional Video and Photography - Photographer
4.5 miles from Wheat Ridge, CO
Your wedding is one of the most important events that will occur in your life. This is an intimate time that we share with our closest family and friends. Outside of the day itself, capturing the moments to be remembered and shared should be at the top of the priority list. The day of the event will
Blue Spruce Photography
5.5 miles from Wheat Ridge, CO
Just as the Blue Spruce tree digs its roots deep into Colorado, Blue Spruce Photography is here to help you plant your roots and create memories that your family will cherish for a lifetime. Capturing all of the important events, stunning details and spectrum of emotions is what we strive for with e
5.7 miles from Wheat Ridge, CO
"Wedding photographer based in Colorado and Worldwide who specializes in documentary style of imagery that are authentic and timeless! As a visual storyteller, I describe my work as in the moment, authentic, and natural. I approach every wedding and engagement session with a photo-journalistic style
pixil studio
6.8 miles from Wheat Ridge, CO
With over 25 years experience, hundreds of happy brides, thousands of past event and portrait clients and positive reviews all over the net, Pixil Studio is the perfect choice for all your Denver photography needs. Pixil Studio is based in Denver Colorado and serves all Front Range locations includi
Captured by Marcela
7.4 miles from Wheat Ridge, CO
Marcela Suter is a Colorado Elopement Photographer. She helps couples design the elopement day of their dreams, by kicking obligations to the curb, and crafting a unique, intimate experience. Marcela aims to create honest moments of intimacy and laughter so that her couples' images are filled with r
All Request Music Photo Booth
7.4 miles from Wheat Ridge, CO
Our Photobooth injects new energy and fun into special events. You can't believe the buzz it creates. People swarm it. They select the props and backgrounds that tickle their fancy and mug for the camera like they've never done before! They go home with pics of the best party they've ever attende
Rayna McGinnis Photography
7.6 miles from Wheat Ridge, CO
We offer hourly wedding photography at $225/hr and wedding collections that start at $2,200. All of our packages include two photographers, an online gallery and a DVD with your fully edited images. Event photography depends on the event and location.
Bergreen Photography
16 miles from Wheat Ridge, CO
Marc and Brenda Bergreen, a husband and wife photography team specializing in outdoor weddings, adventures, and lifestyle photography. They specialize in weddings for the adventurous couple. Whether you are planning a mountain wedding or a romantic elopement on a mountain top, Bergreen Photography h
Diana Sabreen Photography
16 miles from Wheat Ridge, CO
Creative and bold storytelling photography. Creating exceptional photos for all your wedding, portrait and event needs. Available for travel. Location: Golden, Jefferson County, Boulder County, Breckenridge, Keystone, Summit County, Colorado, Dillon, Frisco, Eagle County, Vail, Beaver Creek, Fron
16 miles from Wheat Ridge, CO
I am a member of the Professional Photographers of America (PPA) and Wedding & Portrait Photographers International (WPPI). My husband, Patric, who is both a Photographer and a Film Mixer, is my partner. We have a combined experience of over 40 years. We continually invest in our business yearly. We
Drive The Image
17 miles from Wheat Ridge, CO
In 2014 my dream became a reality when I opened Drive the Image. It took me over 25 years to make my dreams come true, but I wake up everyday feeling blessed that I am able to do what I love. My first wedding was in 2009 and done 300 weddings since. I love capturing love, a time in people's live th
Modern Moments Photography LLC
18 miles from Wheat Ridge, CO
Colorado Photographer specializing in engagements & weddings
GlamSpin Photo Booth Rentals
22 miles from Wheat Ridge, CO
We provide photo booth rentals for all events. These include 360 video booth and selfie booth services.
McBoat Photography
9.7 miles from Wheat Ridge, CO
McBoat Photography, led by owner/photographer Shameka McBoat, is a photography team that captures the story behind your images. We customize our journalistic style based on who you are and your vision for your event. We take the time to really get to know our clients and give you all the services yo
Laughing Eyes Photography LLC
19 miles from Wheat Ridge, CO
Metro Denver Colorado Traveling Photographer, your eyes tell a story, through photography we wish to capture your special moments. Photo Session: Senior Portraits, Newborn, Families, Kids, Engagements, Headshots, Modeling, Pets Wedding/Event Session: Weddings, Renewal Vow's, Anniversaries, Birt
Silent Expressions Photography
Wheat Ridge, CO
I have been photographing professionally since 2002 and have been doing weddings since 2005, I love what I do and I feel honored to be able to provide such a great service on such an important day. Silent Expressions Photography will customize a wedding photo package to fit ANY budget! Silent
Trabing Photography
3.6 miles from Wheat Ridge, CO
Creative and natural photography. Engagement, weddings, newborn, maternity, family, event and pet sessions.
Julie Harris Photography
4.0 miles from Wheat Ridge, CO
Julie Harris provides truly exceptional wedding photography and documentary lifestyle portraiture services for clients in Denver and across Colorado. Providing exceptional wedding and portrait photography services to clients in the Denver metro area since 2003.
Brett Amole Photography
4.1 miles from Wheat Ridge, CO
Professional photographer with extensive experience shooting assignments for newspapers and magazines specializing in photojournalism style event and wedding photography. Brett Amole Photography Weddings offers full digital image wedding packages. Your wedding will be captured on digital media so y
Bamboo Booth
4.1 miles from Wheat Ridge, CO
A modern update to the traditional photo booth experience located in Denver, Colorado. The bamboo booth is a great addition to any private or corporate event. Wedding receptions, charity events, holiday parties, corporate gatherings or retail promotions are great examples for the bamboo booth.
Sarah Roshan, Wedding Photographer
4.5 miles from Wheat Ridge, CO
The exclusive wedding photographer for carefree, romantic couples planning their outdoor wedding
DIRECT ENTERTAINMENT WEDDING Photography-Video DJ Denver CO Direct-Entertainment.com
5.1 miles from Wheat Ridge, CO
Visit Direct Entertainment. Choose your perfect wedding DJ, Photographer, Videographer and Photo Booth with an entertainment company and name you can trust, GUARANTEED. We are professional and fun as it gets, yet simple and AFFORDABLE. Let our team absorb your stress like a sponge! Since you'll be w
Colorado Bridal Shows, As Seen on TV! Denver's #1 Boutique Bridal Show
5.1 miles from Wheat Ridge, CO
Colorado Bridal Shows take place five times a year in the Denver area market in various locations. This Is the Bridal Show You've Heard About! Plan your wedding in one day at the #1 Boutique Bridal Show in Denver – Colorado Bridal Show, Sunday, Noon – 4pm. For current dates go to: www.ColoradoBr
Joseph Jestes Photography LLC
5.1 miles from Wheat Ridge, CO
Joseph Jestes is a Denver Colorado based photographer who specializes in capturing weddings and telling stories through lifestyle portraiture. With a degree in Photography, Joseph is a graduate of the Art Institute of Colorado and has been shooting for almost 10 years, and loves every minute of it.
DSmithImages Wedding Photography, Portraits, and Events - Denver
5.1 miles from Wheat Ridge, CO
DSmithImages is a Birmingham, Alabama wedding photographer who also provides portrait and event photography throughout the United States. No distance is too far for me to travel so I can provide you great photography!
Mountain View Photo, LLC - Denver
5.5 miles from Wheat Ridge, CO
Mountain View Photo offers beautifully posed and photojournalistic wedding photography at affordable prices. Wedding packages start at $875 and go up to $3,475 for all day coverage. Take 15% off January-March weddings. Digital Negatives are available on all packages with copyright release. Mount
Timothy Faust Photography - Denver
5.5 miles from Wheat Ridge, CO
Timothy Faust Photography is a full service studio based out of Colorado with worldwide avaialbilty. His weddings have been published in numerous bridal magazines. Timothy specializes in documentary style photography with creative modern portraiture. Each wedding includes a digital copy of your n
Gary Sheer Photography
5.6 miles from Wheat Ridge, CO
Welcome to Gary Sheer Photography. If you're looking for a photographer in Denver, Colorado, who can document your biggest moments, capture your essence, highlight your brand, or tell your story, you've come to the right place. I offer everything from event photos to headshots and portraits to real
Jamie Lee Creativity -Photography by Jamie Mathews - Denver
5.7 miles from Wheat Ridge, CO
Jamie Lee Creativity offers Full Service Wedding Photography. Located in Central Florida and available for travel. . Jamie takes a limited number of wedding each year to be able to best serve her clients and give them the amazing customer service experience her business has become known for. My p
Xposer Photography
5.9 miles from Wheat Ridge, CO
A variety of wedding packages and options are available to you. In addition, each wedding package may be customized to suit your overall desires and preferences. All wedding packages include Xposer Photography unique synthesis of artistic, photojournalistic and traditional photographic styles to cre
Rebecca Marie Photography
6.1 miles from Wheat Ridge, CO
International Fine Art photographer located in Denver but travels world wide
Gabriel Christus Photographer
6.3 miles from Wheat Ridge, CO
I am a photojournalist that specializes in catching moments and telling stories.
SocialLight Denver
6.5 miles from Wheat Ridge, CO
SocialLight Denver is the best Denver Photo Booth Company if you are looking for Photo Booth rental in Denver for your next events.
7.5 miles from Wheat Ridge, CO
Brosphoto - Denver CO. Two Wedding photographers for the price of one. Standard Package is $1400.
Kennedy Fotografik
7.6 miles from Wheat Ridge, CO
We are Josh and Elisa Kennedy, a husband and wife photography team. We live and work in gorgeous Denver, Colorado. We love living life together and laughing through every crazy moment. We like to think that we have a unique perspective on life that translates into our photographic art. We love get
Dancing Cloud Photography.com
7.6 miles from Wheat Ridge, CO
Photographer providing coverage for events (weddings etc.) senior and portraits, along with aerial, commercial, and interiors
Roger Williams Photographer
7.8 miles from Wheat Ridge, CO
Roger Williams is a portrait, wedding, commercial, and event photographer serving clients in the Denver area. Roger has spent the last two decades pushing creative boundaries with different types of photography and cinematography, but photographing weddings is his true love. He lives for capturing p
ACute Angle Photography
8.0 miles from Wheat Ridge, CO
Specializing in meaningful photojournalistic wedding photography. Multiple photographers will record the event with unlimited time and have available a mobile studio to photograph the guests at the special venue.
Nicole Nichols Photography
8.5 miles from Wheat Ridge, CO
My goal is to document your unique moments while also creating beautiful artistic pictures you will cherish forever! On your wedding day we are unobtrusive & focus on capturing the moment. However, we also like to get creative & if the bride & groom are up for it get lots of fun, funky, fashionabl
The Image Maker Photography
9.2 miles from Wheat Ridge, CO
In addition to commercial and fine art photography the IMAGE MAKER offers the wedding photography services of Marcia Ward. Marcia has been photographing weddings professionally since 1988. Marcia's rates are as reasonable as her her photography is artistic. Couples receive all photographs in a high
Cheeks Photography
9.7 miles from Wheat Ridge, CO
Welcome to Cheeks Photography, where every shot tells the story of "fascinating people doing fascinating things." Our Colorado-based company specializes in complete event coverage for parties and weddings, as well as creative portraiture for families, students and more. Our affordable prices and var
Brittany West Elopement Photography
11 miles from Wheat Ridge, CO
Brittany West offers stunning elopement wedding photography packages at reasonable prices. We make a difference by planning your elopements as never before and making your dreams turn into reality. You can customize or document your elopement packages according to your needs and budget. To know more
From The Hip Photo
11 miles from Wheat Ridge, CO
From The Hip Photo, Colorado's best-reviewed photographers, is a full-service, professional company specializing in a wide array of disciplines so we can step in and tackle all of your photography needs, both personally and professionally. We do it all, from engagements, weddings, and newborn sessio
Love In Media
13 miles from Wheat Ridge, CO
Love in Media provides top-notch photography services to the communities of Denver, Boulder, Broomfield, Westminster, Lafayette, and the surrounding areas in Colorado. We specialize in headshots that will set you apart. Jason Johnson is a professional photographer who can find the perfect angles, po
Jen Dz Photography
14 miles from Wheat Ridge, CO
I am a Colorado based elopement and microwedding photographer who helps awesome couples have unforgettable elopements in Colorado and throughout the Western U.S.
Ed Clemente Photography, LLC
14 miles from Wheat Ridge, CO
Are you wanting you're child's birthday photographed? How about you're wedding, maternity or even newborn? I am ready to photograph you! I am based out of Aurora Colorado and serving all of the Front Range.
Vow of the Wild
16 miles from Wheat Ridge, CO
Vow of the Wild is a cooperative endeavor between husband and wife team, Lisa Kingsbury and Alex Clem. Together they've spent almost a decade documenting couples' love stories in both photography and videography. Their specialization in elopements has taken them both across the United States as wel
Larsen Photo Co.
16 miles from Wheat Ridge, CO
Larsen Photo Co. is run by wedding and elopement photographer Nina Larsen Reed in Boulder, Colorado. Nina captures down to earth couples (and their dogs) across the Rocky Mountains, whether they're eloping alone on their favorite hiking trails, or celebrating with friends and family at a ski resort.
Fuse Photographic | Denver Wedding and Portrait Photography
17 miles from Wheat Ridge, CO
We are Travis and Laura, husband and wife, best friends, and wedding photography teammates. We live and work in beautiful Boulder, Colorado, where we love to quench our thirst for adventure and beauty in the outdoors. We are artists, and are passionate about seeking out a unique perspective to cap
11:11 Productions Photography
18 miles from Wheat Ridge, CO
With over 13 years of experience as a professional photographer, 11:11 Productions Photography delivers exceptional photographs with an abundance of energy and creativity. Specializing in couples photography, Barb Colombo and her team bring passion and enthusiasm to event photography, wedding photog
Artiste Photography
18 miles from Wheat Ridge, CO
Not just a photographer... an artist. Not just a photograph... a work of art.
We, The Light Photography
18 miles from Wheat Ridge, CO
As two born and raised Coloradans who have photographed over 200+ couples in 100+ locations across Colorado, we specialize in creating a different kind of wedding day that is just as adventurous as you are. When you choose us to guide you through the process, you get wayyyy more than just a photogr
In Love and Adventure
18 miles from Wheat Ridge, CO
In Love and Adventure is a husband and wife photography team that provides wedding photography for couples who want an adventure over tradition. Specializing in elopements and intentionally small weddings. Choose the adventure you've been craving, elope.
Heather Jackson Photography + Video
19 miles from Wheat Ridge, CO
Heather is an adventurous small wedding photographer in Colorado documenting love stories, lifestyle, and adventure for the sake of relishing what's best in life. Check out her beautiful, intimate elopement and wedding photography and consider her for your wedding.
Show More
There are
Photographers in and around Wheat Ridge at Eventective.com. Use the filter options to find your Perfect Wheat Ridge Photographer.


text:
Note to editors: The following press information has been released by Nissan Motor Company Ltd. with images showing the 2013 model year Japanese market GT-R. Specifications of the U.S. market 2014 model year GT-R will be announced at a later date.
YOKOHAMA, Japan – Nissan Motor Co., Ltd. today announced the launch of the 2013 model year Nissan GT-R, which goes on sale in Japan on November 19 at Nissan dealers nationwide.
The 2013 model year Japanese market Nissan GT-R features enhancements throughout the vehicle for increased performance, improved ride and handling, and greater customization.
Already considered a legendary supercar, the 2013 GT-R received evolutionary design and engineering enhancements based on feedback acquired from competing in the 24-Hours of Nürburgring race earlier this year. Notable modifications include improved engine response in both the mid- and upper-rpm rev range, increased body rigidity, and specification changes to the shock absorbers, springs and front stabilizer. As a result, the vehicle's overall performance is dramatically increased, high-speed stability improved and ride quality is more refined. Additionally, a Premium Edition version will be offered that features rich semi aniline leather and custom-colored interior as fashionable interior package, further enhancing the sense of quality within the cabin.
The 2013 GT-R model will also be available in North America, Europe, and then subsequently to other regions from January 2013 onwards.
2013 MY NISSAN GT-R Overview
1. Mechanical Features
Sharper mid-range engine response and improved high-end acceleration.
- The incorporation of high-output injectors that more precisely control fuel injection improve mid-range engine response and acceleration at higher rpms.
- Specially-developed orifice to the relief valve have been added to the turbocharger bypass; these suppress the rapid decrease of the forced injection pressure, helping to sustain acceleration at high rpms.
- By adding a specially-designed baffle plate to the oil pan, oil pressure is better stabilized while rotational friction within the oil pan is reduced, especially during high-performance driving.
- Motul Competition Oil is offered as an engine oil option at Nissan dealers due to the many requests from GT-R customers who frequently drive their cars at circuit.
Glued-to-the-ground handling and rock-solid stability at super high speeds.
- After meticulously measuring the roll center of a GT-R while in motion, Nissan engineers lowered the vehicle's center of gravity in accordance with the deflection of the suspension bushings and tires. The specifications of the shock absorbers and front stabilizer have also been modified.
- Cam bolts have been installed on the front suspension to improve camber accuracy and maintainability of alignment settings.
- The torque from the driveshaft to the hub bearings was increased to improve reliability in high-stress situations, such as competition(track) driving.
Improved driving stability and steering response.
- Reinforcements were added at two locations in the dash panel bar and instrument panel member , resulting in improved suspension performance and increased body rigidity.
2. Interior
Pure Edition
- The quality level of the interior has been improved by changing the color of the stitching and adopting a thicker seam on the instrument panel and door trim.
Black Edition
- An attractive red-and-black color combination steering wheel increases the car's sporty flair.
- RECARO carbon bucket seats are available as a factory installed option.
Premium Edition
- A new two-tone interior color of Amber Red and Black adds style to the interior as option for fashionable interior package.
- Hand-stitched genuine semi-aniline leather front seats have been added.
3. Specifications/ equipment
- Carbon-fiber rear spoiler and lightweight aluminum-alloy forged RAYS® wheels are available as a factory installed option (Black Edition).
- Rear View Monitor comes as standard equipment on the Black and Premium edition models.
- Convenient "side knobs" on the left and right sides of both front seats improve usability when seatbacks are pushed forward (all models).
# # #
For more information, contact:
Nissan Motor Co., Ltd. (Japan)
Global Communications Div.
Tel:+81-(0)45-523-5552 (Corporate)
Tel:+81-(0)45-523-5549 (Product)
Tel:+81-(0)50-3804-7182 (IR)
http://www.nissan-newsroom.com/EN/ (For media)
http://www.nissan-global.com/EN/IR/ (For IR)


text:
Obviously I don't have a crib to stage this in...especially considering the fact that I don't have children! But here is a look at all of the custom bedding I made for Kelly. The box-pleated crib skirt completes the set, made of Nicey Jane Slim Dandy.
Kelly's goal was to have bedding that was modern, sophisticated, and not too matchy matchy. All of the different graphic prints in coordinating colors accomplish her goals rather nicely I think. Hopefully she'll share pictures of the finished nursery with us soon!
14 all together now.
Share |
Posted by holly | bijou lovely at 11:03 PM
Labels: lovely designs
14 comments:
I love it Holly. Love it, love it, love it. :)ReplyDelete
Oh that is gorgeous. I would say it definately meets her goal. That is so darling, I love it.ReplyDelete
So cute! You are so talented.ReplyDelete
Beyond adorable! You did such an amazing job.ReplyDelete
Seriously adorable! You are so awesome ;)ReplyDelete
This looks great. If I ever get around to having kids, I'm calling you!ReplyDelete
I love it! It all looks great, Holly!ReplyDelete
You did a great job!ReplyDelete
Hehe... I'm all giddy. Can't wait to put it in the nursery. And for SURE I will share pics. :)ReplyDelete
wowza. fantatstic job! can't wait to commission you (uh, in about 3 years when we're ready to have kids!)ReplyDelete
Great job Holly! Beautiful!!!ReplyDelete
This looks amazing!! You did a great job!ReplyDelete
Ridiculously cute!ReplyDelete
Subscribe to: Post Comments (Atom)


text:
Railay Beach
The Railay Beach peninsula near Krabi in southern Thailand is known amongst rock climbers and adventure travelers for the stunning cliffs and serene, isolated beaches. There are no roads to Railay. To get there, you must take a longboat around the steep cliffs from a nearby town.Read More
All photos © 2015 Sascha Faun Winter. Photos licensed Creative Commons BY-NC-ND 4.0 unless otherwise stated. Please email or tweet with any questions.


text:
After three seasons, ABC is moving on. The network has cancelled Suburagatory.
Suburgatory continues the story of single dad George Altman (Jeremy Sisto) and his teenage daughter (Jane Levy) after they move from the city an overly wholesome community in the suburbs. This season, the rest of the cast includes Cheryl Hines, Allie Grant, Ana Gasteyer, Chris Parnell, and Carly Chaikin.
The show premiered in September 2011 to a very strong 3.3 rating in the 18-49 demographic with 9.8 million viewers. The numbers dwindled downward over the course of the season but the network renewed it for season two anyway.
Season two started off well but once again, the ratings dwindled downward. This time, ABC gave Suburgatory a limited 13 episode renewal.
In season three, the ratings started pretty low and stayed there. The current season has averaged a 1.6 demo rating with 5.44 million viewers. It's down 27% in the demo when compared to season two's average.
The network has now decided to call it quits after 57 episodes. The season (now series) finale of Suburgatory will air next Wednesday, May 14th.
What do you think? Are you sorry that this show has been cancelled? Should it have been renewed for season four? Would you watch it on another channel?


text:
Great SoundCloud support in blogging tool Posterous
It's nice to see how smoothly the smart (micro)-blogging tool Posterous integrates with SoundCloud. If you're on a SoundCloud track page (or any other page with SoundCloud tracks embedded for that matter) you can use the Posterous bookmarklet so post SoundCloud tracks on your blog in literally one click!
Here's how it looks when you click the bookmarklet on a SoundCloud track page:
And then after clicking "Post" the track is immediately published on your blog:
Very slick, we like! Great for all you music bloggers out there!


text:
Update your browser to view this website correctly.Update my browser now
The search engine lets you find the ideal vehicle depending on your search and your destination, including in Turkmenistan. Since the listings are very diverse, you'll have a choice between different types of vehicles: compact, luxury sedan, family vehicle, etc.
Spend your time as you wish and admire the landscape without worrying about organizing or time!
Compare thousands of cars in Turkmenistan. Select every small detail of the car of your dreams.


text:
CRS: Border and Transportation Security: Selected Programs and Policies, March 29, 2005
From WikiLeaks
About this CRS report
This document was obtained by Wikileaks from the United States Congressional Research Service.
The CRS is a Congressional "think tank" with a staff of around 700. Reports are commissioned by members of Congress on topics relevant to current political events. Despite CRS costs to the tax payer of over $100M a year, its electronic archives are, as a matter of policy, not made available to the public.
Individual members of Congress will release specific CRS reports if they believe it to assist them politically, but CRS archives as a whole are firewalled from public access.
This report was obtained by Wikileaks staff from CRS computers accessible only from Congressional offices.
For other CRS information see: Congressional Research Service.
For press enquiries, consult our media kit.
If you have other confidential material let us know!.
For previous editions of this report, try OpenCRS.
Wikileaks release: February 2, 2009
Publisher: United States Congressional Research Service
Title: Border and Transportation Security: Selected Programs and Policies
CRS report number: RL32840
Author(s): Lisa M. Seghetti, Jennifer E. Lake, and William H. Robinson, Domestic Social Policy Division
Date: March 29, 2005
- Abstract
- Border and Transportation Security (BTS) is a pivotal function in protecting the American people from terrorists and their instruments of destruction. This report addresses selected programs and policies now in place that seek to attain higher levels of BTS. It is the second in a three-part series of CRS reports that make use of analytical frameworks to better understand complex phenomena and cast them in terms that facilitate consideration of alternative policies and practices. (The first report in the series, CRS Report RL32839, Border and Transportation Security: The Complexity of the Challenge, analyzes the reasons why BTS is so difficult to attain. This report is the second in the series. The final report is CRS Report RL32841, Border and Transportation Security: Possible New Directions and Policy Options.)
- Download


text:
Flight1 Aviation Technologies has released a free software plug-in for Lockheed Martin Prepar3D and Microsoft Flight Simulator X that sends GPS, AHRS, and Traffic data from the simulator to ForeFlight Mobile on an iPad or iPhone.
"Pilots know that the more closely they re-create the mental experience they have in the airplane, the more valuable their training in a simulator can be," says Flight1 Aviation Technologies President Jim Rhoads.
"Many of our customers use ForeFlight Mobile on an iPad or an iPhone when they fly, connected to an external GPS or ADS-B device," he explains.
"While they can certainly use ForeFlight as a stand-alone Electronic Flight Bag to plan their flights, view charts, view weather, and get airport information when they simulate flying, we wanted them to be able to have the same connected experience they have in the air."
ForeFlight connects to the simulator via a WiFi connection to the same network, then uses the data from the simulator just as it would use data coming from a real GPS or ADS-B device. Pilots can use ForeFlight Mobile with the simulator just like they would in the airplane, including the GPS, ADS-B Traffic, and Attitude Indicator features.
"We think it's so valuable for pilots to use sims with the same tools they use in the airplane that we're giving the ForeFlight Plug-in to anyone who requests it. We know it will enhance their experience using our avionics simulations."
Pilots can learn more at:
Flight1 Aviation Technologies was launched in 2004 to focus on delivering PC-based simulation solutions to aviation customers. With a unique history that has followed the simulation and training industry's appropriation of game-based technologies, the company is changing the way pilots train and stay proficient. To learn more about their tools for flight training and pilot proficiency, visit flight1tech.com.
Jim Rhoads


text:
HISTORIC DREAM SPEECH—Dr. Martin Luther King Jr., head of the Southern Christian Leadership Conference, addresses marchers during his "I Have a Dream" speech at the Lincoln Memorial in Washington Aug. 28, 1963. (AP Photo)
by Freddie Allen
For New Pittsburgh Courier
WASHINGTON (NNPA)—The hoopla surrounding the observance the 50th anniversary of the March on Washington for Jobs and Freedom often ignores that lack of progress made since 1963 on tough issues such as persistent unemployment and wage disparities, according a newly-issued report.
In the report titled "The Unfinished March: An Overview," Algernon Austin, director of the Program on Race, Ethnicity and the Economy at the Economic Policy Institute, described the "forgotten history of the march" and outlined a number of goals that remain unmet.
"Our contemporary understanding of the march and of the Civil Rights Movement, more generally, is quite limited," said Austin, the author of the report. He said Blacks often celebrate the accomplishments of the march, such as the Civil Rights Act of 1964 and the Voting Rights Act of 1965, but ignore the intransigent economic issues, including housing, employment, and wage disparities, that were raised by the national demonstration.
"Historians have focused on the successes and they were tremendous successes when you consider how long and how deep Jim Crow was in American society," explained Austin. "There were significant advances that deserved to be celebrated, but we probably celebrated those advances a little too much."
The EPI report stated that: "The organizers of the March on Washington for Jobs and Freedom also demanded decent housing, adequate and integrated education, a federal jobs program for full employment, and a national minimum wage of over $13.00 an hour in today's dollars."
James Clingman, author of "Blackonomics," a weekly NNPA syndicated column, said that Dr. Martin Luther King Jr., despite history's focus on his civil rights success, also recognized the economic crisis that the Black community faced and often advocated for Black workers.
Many of the civil rights leaders and the organizers of the march understood that gaining civil rights without addressing the economic disparities would leave Blacks unable to fully enjoy those rights.
"We have no future in a society in which 6 million Black and White people are unemployed and millions more live in poverty. Nor is the goal of our civil rights revolution merely the passage of civil rights legislation," said A. Philip Randolph, president of the Negro American Labor Council, during his speech at the march in 1963.
"Yes, we want all public accommodations open to all citizens, but those accommodations will mean little to those who cannot afford to use them."


text:
waxed canvas harness (charbon)
strong? yes. sustainable? yes. casually stylish? absolutely.
waxed canvas harnesses get even better with age. they develop the look of distressed leather and can be re-waxed if needed to stay water-resistant. they are handmade with a strong, sustainable, cotton canvas permeated with a non-toxic wax. the aluminum, quick release buckle along with the solid brass hardware add to the style and strength of our harnesses.
want your stitching to be a different color? just let us know in the order notes which color you'd like. choose from any of our waxed canvas or cork colors.
- non-toxic, waxed canvas fabric
- quick release, aluminum buckle
- solid brass hardware with a matte nickel finish
- water-resistant, easy to clean
- handcrafted in the USA


text:
Commercial Whipped Cream Dispensers
iSi of Austria is the leader in the technology of nitrous propelled whip cream and foams. We try to offer a complete selection of their products along with support. Although many of their products are manufactured in China, each whipper is inspected in Austria. You can rely on their products for reliability and quality. All products displayed are 100% compatible with the N2O chargers offered on our web store.
|Home > Commercial Whipped Cream Dispensers


text:
This isn't the first time Nate Diaz has flipped off an opponent in the middle of a match, nor the first time he's shown his propensity for flipping people off—that's what Nate and his brother Nick do. Those guys just love flipping the bird. Nonetheless, Fox was caught off-guard, unless the contingency plan all along was "cut to silent prematch footage of an empty octagon," in which case, plan well executed. It made for a weird broadcast, but these things are expensive, so cut to whatever b-roll footage you've got.
It didn't work entirely, though—our own Tim Burke was able to capture this wonderful screencap, which means that our nation's children were exposed to the middle finger (in the midst of this bout between men beating each other half to death) for long enough to be permanently scarred. Do your worst, FCC. These monsters have to learn somehow.
Henderson won by unanimous decision.