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Systematic approach to problem solving for health care providers
|✅ Paper Type: Free Essay
|✅ Subject: Nursing
|✅ Wordcount: 2568 words
|✅ Published: 1st Jan 2015
Evidence-based in nursing is the practical, clinical application of the best research in patient care. Nursing Knowledge International translates the best evidence into the best nursing research, education, administration, policy and practice. Nursing Knowledge is committed to providing a comprehensive synthesis of the best nursing evidence, proven nursing expertise and practical clinical application that take into account individual patient, family and community values decision making, in order to provide the most consistent and best possible care to patients. Health care delivered in ignorance of available research evidence, misses important opportunities to benefit patients and may cause significant harm.
We are a group of four BSN-RN students, we assigned in this project to evaluate the nursing practice in clinical area if it evidence based or not and to identify the barriers and facilitators to the implementation of EPB into practice using different strategies to overcome the barriers.
Bed rest is recommended to patients with a diagnosis of acute myocardial infarction (AMI) upon initial hospitalization. Reasons for immobilization have included reduction in myocardial load, evidence of further malperfusion, and moderation of remodeling process. In last two decade, the influence of bed rest on patient outcomes following AMI has not been thoroughly investigated. In this project we investigate the practice of this issue in cardiac care unit at Salmaniya medical complex and compare it with the evidence based practice by review literatures, meta-analysis and clinical trials. We conclude to the final result and raise our recommendations. (Jacqueline K, 2004).
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Reason for choosing the topic:
From our experience as cardiac staff nurses we had faced a lot of difficulties to convince a patient with uncomplicated MI to be in complete bed rest especially after 12 hrs post hospitalization. ["Patients with uncomplicated MI: patients with ST elevation myocardial infarction who are free of recurrent ischemic discomfort, symptoms of heart failure, or serious disturbances of heart rhythm."(American Heart Association, 2004). As their chest pain has been relieved, they will try to convince themselves and others that they are in a good health, and can achieve their activities of daily living. Therefore, it is difficult to obligate them to be in complete bed rest. Usually the nurse will face a dilemma whether to mobilize the patient with uncomplicated MI or not as there is no clear protocol for the mobilization. In addition, if the nurse decides to mobilize the patient she/he will be in trouble, questionable, and accountable for any risk that might be happened for the patient. On the other hands, if the nurse doesn't mobilize the patient, the patient won't be satisfied and his psychological demands won't be met. Moreover, the cardiac nurses are aware about the significant impact of the psychological status of the MI patient on the heart workload, health, and efficiency. If the patient hasn't been satisfied, he would be anxious, nervous, and agitated which in turn will stimulate the sympathetic nervous system to release adrenalin and nor-adrenalin hormones that's lead to increase the heart rate, and vasoconstriction. Vasoconstriction will increase the venous return which means the increase of the pre load of the heart. In addition, the peripheral resistance will increase as a result of the vasoconstriction and that causes the increase of the after load of the heart. Both, increase of the preload and after load are dangerous as it will expose the MI patient for re-infarction, heart failure, and lethal arrhythmias.
Also, we have known that Mohammed Bin Khalifa cardiac center is mobilizing the patient with uncomplicated MI after 24hrs. As we aimed to try our best to standardize our care according to the accredited agencies, we have decided to find an evidence base about the mobilization of the patient with uncomplicated MI, and to apply it in our unit.
Title of our Topic:
Duration of Bed Rest for Uncomplicated Myocardial Infarction
PICO question:
Is prolong bed rest safer than early mobilization for uncomplicated MI patient?
Population: Uncomplicated MI patients.
*To keep a patient with uncomplicated MI at bed rest for more than 48hrs.
* To keep a patient with uncomplicated MI at bed rest for 12-24hrs
3. Comparison: comparing whether early mobilization of a patient with uncomplicated MI is safe as a mobilization after prolong bed rest.
4. Outcomes: Early mobilization (2-12 days) doesn't harm the patient and doesn't contribute with developing of any complication such as death, re-infarction, and arrhythmias. It is considered to be safe as prolonged bed rest.
Protocol used:
The used guidelines for mobilization of pts after an acute MI in SMC was stated in the management of acute ST segment elevation myocardial infarction (STEMI) included in " Evidence- Based Guideline for Management of Cardiac Cases in Secondary Case Settings in the kingdom of Bahrain" Which was developed by Dr. Anwer Jamsheer, Dr. Rashid Al Bannai and Dr. Tayseer Garadah (Consultants Cardiology) and was supervised and final reviewed by Dr. Abdul Hai Al awadi (Assistant Undersecretary for Hospitals).
It was mentioned in the above guidelines that "The patient is kept in bed rest until otherwise ordered by the physician" and the nurse should ask on daily bases about the allowed activity privileges for the pts (bed rest, bedside commode, sit out of the bed, walk around the bed, toilet bed side in the first two days and lastly the full mobilizing). It was suggested also that it is the responsibility of the nurse to ensure range of motion exercises (ROM), deep breathing and positioning while the patient is in the bed rest. Moreover, it was declared to explain to the patient the needed rest and to teach him the allowed exercises and help him, if needed. However, it was not mentioned who should do that. Guidelines explained in the "cardiac rehabilitation for patient with STEMI (phase I -in patient care)" the full carried out protocol for the mobilization of pt after an acute MI. This includes:
Full bed restrictions in the first 2 days, including bed side wash, shaving and bed pan.
Passive form of mobility for arms and foot ruling can be given at frequency of three times per day.
In uncomplicated cases the transfer to step down can be arranged on day three. With the mobilization around the bed and allow free toilet access under supervision.
On day four and five patient can walk in the corridor and allowed to go one flight or go for symptom limited exercise test.
It was noted that the source of information for these guidelines is the last literature review up to date / version 16.1: ACC and AHA, GHA pocket Guidelines and ECS2007, but actually there was no effective date rather than revision date mentioned.
This protocol was followed in most of cases but there were some exceptions. Extended bed rest was advised for pts who are unstable or had some complications after MI like lethal arrhythmias, heart failure or recurrent ischemia etc. Such cases were not mentioned specifically in the guidelines although it was mentioned in the original source of information after we have reviewed it.
The 1996 ACC/AHA Guidelines for the Management of Patients with Acute MI has found evidence on the continued practice of "coronary precautions" although it was advocated since 1960s that some of theses precautions are no longer applicable in the current practice. In the earlier years patients with STEMI were kept in bed rest for several weeks in order to decrease myocardial oxygen demand but then it was reveled that extended bed rest is more harm than good and it would delay the recovery. 2004 ACC/AHA Guidelines recommended that "Patients with STEMI who are free of recurrent ischemic discomfort, symptoms of heart failure, or serious disturbances of heart rhythm should not be on bed rest for more than 12 to 24 hours" In addition, it is mentioned that patients with hemodynamic instability or continued ischemia to have bedside commode privileges. Both practices are not seen in SMC as Pt with STEMI who described as stable will be in bed rest for 48 hours while unstable pt (complicated MI: patients who have recurrent ischemic discomfort, symptoms of heart failure, or serious rhythm disturbances) will be in bed rest for several days up to one week.
While searching for relevant data and protocol that could answer our PICO question and prove which is the safest and more beneficial for patient post uncomplicated myocardial infarction ,mobilization after 48 hours or less, we interviewed the experts in our institution (Salmaniya Medical Complex – SMC) who are consultant cardiologist in Coronary Care Unit(CCU) ,while interviewing Dr. Hayat Al-Mahroos, she stated that there is no clear protocol is being followed and mobilization depend on the patient condition, how ever the followed and common protocol is 48 hours post uncomplicated myocardial infarction which is not being reviewed long time back, although recent studies encourage early mobilization after 12 ours from bed to chair and after 24 hours pt can walk with the help of cardiac rehabilitation nurse ,in her management she stated still she is mobilizing the patient with in 48 hours because other cardiologist mobilizing the patient with in 48 hours and perhaps mobilizing the patient with in different durations may confuse the nurses ,in addition thrombolytic protocol is for 48 hours and nurses used to mobilize the patient once the protocol is finished ,so that if she asked to mobilize the patient with in 24 hours or to be shifted to step down the nurse will replay " patient still on protocol and didn't finish the 48 hours " she stated we don't discuses the issue as long there is no harm for the patient and we leave the patient till he finished the protocol to avoid confusion to the nurses ,more ever the setting of CCU doesn't encourage early mobilization ,the room of the patient has to have comfortable chair so that patient can be early mobilized ,the role of the cardiac rehabilitation should be extended to participate in mobilization of in patient ,early mobilization will definitely improve patient confidence and moral and will help in early discharge that will allow more vacancies for needed patient.
On other hand ,Dr. Rashid stated that post uncomplicated myocardial infarction , the patient will be on bed rest for 48 hours and that according to American college of cardiology and guidelines ,he stated that he agree with current protocol and going on line with American guidelines as it is the safest practice because this institution has always consciousness about health practice and has became a reference and source of evidence based practice on international level ,however he stated no enough trial were done on 24 hours bed rest.
In contrast, Dr. Tayseer stated that he is following the British guidelines that recommended 48 hour's protocol; he stated mobilizing the patient in the 24 hours may induce lethal arrhythmias which could be fetal.
Literature review:
Early mobilisation for patients following acute myocardiac infarction:
A systematic review and meta-analysis of experimental studies
Olga L. Cortes, Juan C. Villar, P.J. Devereaux, Alba DiCenso ( 2009 )
Target studies included published and unpublished experimental, controlled studies in any language.
Systematic review and meta-analysis.
Patients defined as having uncomplicated AMI, except for Abraham et al. (1975), who enrolled patients with both complicated and uncomplicated AMI. Most studies included patients aged 55-65 years, with at least 70% male participants, except for one study that included only male participants (Messin and Demaret, 1982).
The experimental intervention was similar across studies (stand up, move to chair, and walk) with the only difference being how many days post-AMI their EM intervention was initiated.
Out of 385 potentially relevant studies, 14 met the eligibility criteria (13 published before 1983). There were 149 deaths (9.3% of 1607) and 82 non-fatal reinfarctions (5.2% of 1580) among post-AMI patients receiving EM, compared with 179 deaths (11.6% of 1541) and 80 non-fatal re-infarctions (5.3% of 1518) among AMI patients receiving control treatment (RR = 0.85, 95% CI 0.68, 1.05 and RR = 1.02, 95% CI 0.75, 1.39 respectively).
This systematic review of experimental data from studies conducted in the 1970s and 1980s showed a trend towards an increased survival of AMI patients receiving EM relative to those who do not.
There is uncertainty about early mobilisation and more research should be developed having into account all kind of differences among patients receiving treatment after AMI worldwide.
Short versus prolonged bed rest after uncomplicated acute myocardial infarction.
Systematic review and meta-analysis.
Hospitalized patients with uncomplicated myocardial infarction .
Early mobilization ( 2- 12 days)
Short versus prolonged bed rest after uncomplicated acute myocardial infarction.
Early mobilization (2-12 days) doesn't harm the patient and doesn't contribute with developing of any complication such as death, reinfarction, and arrhythmias. Its considered to be safe as prolonged bed rest.
Bed rest for acute uncomplicated myocardial infarction (Review)
Harald Herkner,Jasmin Arrich, Christof Havel, Marcus Mullner
Meta`analysis by:
Measuring the incidence of cardiac death
Measuring the incidence of reinfarction
Incidence of arrythemias
Thrmboembolic complication
patients post uncomplicated myocardial infarction
Incidence of cardiac death , There was no
evidence that bed rest duration has link or association with all cause
or cardiac death after uncomplicated myocardial infarction (RR
0.85, 95%CI 0.68 to 1.07, and RR 0.81, 95%CI 0.54 to 1.19, respectively).
Eleven papers reported on reinfarction ,ut still there was no association between the incidence of reinfarction and the
Bed rest duration (RR 1.07, 95%CI 0.79 to 1.44).
Arrhythmia was reported in seven studies There
was no effect of short or long term duration on arrhythmia rates .
Thromboembolic complications were reported in six studies.however the rate was lower in patients
with shorter duration of bed rest, but the figure was not significant statistically
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In war zones, the explosion of bombs, bullets, and other ammunition releases multiple neurotoxicants into the environment. The Middle East is currently the site of heavy environmental disruption by massive bombardments. A very large number of US military bases, which release highly toxic environmental contaminants, have also been erected since 2003. Current knowledge supports the hypothesis that war-created pollution is a major cause of rising birth defects and cancers in Iraq. We created elemental bio-imaging of trace elements in deciduous teeth of children with birth defects from Iraq. Healthy and naturally shed teeth from Lebanon and Iran were also analyzed for trace elements. Lead (Pb) was highest in teeth from children with birth defects who donated their teeth from Basra, Iraq (mean 0.73–16.74 208Pb/43Ca ppm, n = 3). Pb in healthy Lebanese and Iranian teeth were 0.038–0.382 208Pb/43Ca ppm (n = 4) and 0.041–0.31 208Pb/43Ca ppm (n = 2), respectively. Our hypothesis that increased war activity coincides with increased metal levels in deciduous teeth is confirmed by this research. Lead levels were similar in Lebanese and Iranian deciduous teeth. Deciduous teeth from Iraqi children with birth defects had remarkably higher levels of Pb. Two Iraqi teeth had four times more Pb, and one tooth had as much as 50 times more Pb than samples from Lebanon and Iran.
A pandemic of developmental neurotoxicity affects millions of children worldwide (Grandjean and Landrigan 2014). Prenatal exposures to industrial chemicals, particularly lead (Pb), are among known causes of this pandemic. Given the seriousness of this global health issue, accurate measurement of prenatal exposures has become a scientific priority. Deciduous teeth originate in fetal life and may prove useful in measuring prenatal metal exposures.
In war zones, the explosion of bombs, bullets, and other ammunition releases multiple neurotoxicants into the environment, adding to the burden of childhood exposures. Recent studies in Iraq indicate widespread public exposure to neurotoxic metals (Pb and mercury) accompanied by unprecedented increases in birth defects and cancers in a number of cities (Savabieasfahani 2013). Current knowledge supports the hypothesis that war-created pollution is a major factor in the rising numbers of birth defects and cancers in Iraq.
The Middle East has been the site of a massive environmental disruption by bombardments. In 2015 alone, the USA dropped over 23,000 bombs in the Middle East. Twenty-two thousand bombs were dropped on Iraq/Syria (Zenko 2016). US military bases also produce and release highly toxic environmental pollutants in the Middle East. Though our knowledge is limited, a recent report by Physicians for Social Responsibility (PSR) offers a conservative estimate of two million killed in the Middle East since the 2003 US invasion of Iraq. Around one million people have been killed in Iraq, 220,000 in Afghanistan, and 80,000 in Pakistan. A total of around 1.3 million, not included in this figure, have been killed in other recently created war zones such as Yemen and Syria (Physicians for Social Responsibility (PSR)).
It may seem callous to focus on the "long-term" effects of war while these horrific consequences of war are here and now. Nevertheless, long-term public health consequences of war need to be better examined if we are to prevent similar wars in the future (Weir 2015). To that end, here we report the results of our last samples from a growing war-zone.
Deciduous teeth of children from Iraq, Lebanon, and Iran can show a continuum of high to low war-related-exposures in children. Measurements of environmental samples in the areas of our interest are rare in the literature. Therefore, we deduce that a continuum of high to low war-related exposures can be detected in children of the selected areas based upon the knowledge of the number and length of wars fought in each country in modern times. We do know that Iraq continues to be the target of repeated bombings and military activity, that Lebanon has been the site for multiple wars, and that military activities have occurred in Lebanon intermittently up to 2016 (Haugbolle 2010). In contrast, Iran has been the site of only one war in modern times, which ended in 1988 (Hersh 1992). Our aim is to evaluate deciduous teeth for their suitability to serve as markers of prenatal exposures to neurotoxic heavy metals.
Metals are one of the main components of bombs, bullets, and other weaponry. Buncombe (2011) offers a historic account of the very large number of bombs and bullets that were dropped in the Middle East post-2003. Additionally, 1500 US military bases and facilities—with their associated toxic pollutants—have been erected in the Middle East since 2003 (Nazaryan 2014; Vine 2014). It has been suggested that US military bases are among the most polluting operations on earth (Nazaryan 2014; Broder 1990; Milmo 2014).
In Iraq, there are currently over 500 US military bases (Kennedy 2008; Vine 2014). Pollutants released from these bases have reportedly harmed human health (Institute of Medicine, IOM 2011). Metals are released in the environment in large quantities during and following wars, either by direct bombing or as a result of waste generated and released by military installations (IOM). Metals are persistent in the environment (Li et al. 2014), and their adverse effects on health—especially the health of sensitive populations (i.e., pregnant mothers, fetuses, growing children)—have been established (Parajuli et al. 2013; Grandjean and Landrigan 2014). Public exposure to war-related pollutants intensifies as wars become frequent and as the environmental release of waste associated with military bases increases. Metal exposures and toxicity are frequently reported in children, particularly those living in areas of protracted military attacks in the Middle East (Alsabbak et al. 2012; Jergovic et al. 2010; Savabieasfahani et al. 2015).
As prenatal exposures become more severe and common in war zones, the accurate measurement of those prenatal exposures becomes more urgent. The use of deciduous teeth, which originate in fetal life, as a biomarker of prenatal exposure, is worthwhile (Landrigan 2004) if we are to protect children from such exposures in the future. Teeth have been used as bio-indicators of environmental exposure to metals and to subsequent disease occurrence (Hare et al. 2011; Arora and Austin 2013). For example, Pb levels in primary teeth are accepted indicators of environmental Pb exposure in children and adolescents and have been linked to neurodevelopmental disorders (Arora et al. 2006).
Elemental bio-imaging with laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS) is a new method for imaging trace elements in tooth. Based on tooth LA-ICP-MS studies, deciduous teeth have been proposed as an effective past exposure biomarker that can objectively and precisely illustrate the intensity and timing of past exposures (Arora and Austin 2013). Fine-tuning of this method will significantly improve our ability to quantify children's exposures at different life stages and will enhance the quality of risk assessment studies for children.
War-related metal pollution occurs in varying degrees in Iraq, Lebanon, and Iran (Fig. 1). Children's deciduous teeth from these areas ought to bear the mark of these variable exposures.
Basra City, in Iraq, is surrounded by military bases (Fig. 2), and it has been the site of numerous military attacks. Beirut, in Lebanon, has seen a civil war and intermittent bombings and military attacks. Isfahan, a south central city in Iran, has not witnessed any military attacks in recent history. We therefore expected to see high, medium, and low metal exposures in the deciduous teeth of children from Basra, Beirut, and Isfahan, respectively. Elemental bio-imaging of these selected deciduous teeth can improve our knowledge of prenatal exposures to toxic metals.
Material and methods
Tooth donation and sample preparation
In April 2013, deciduous teeth were collected in two public clinics, one in Isfahan, Iran (n = 2; 9, and 12 years old; mean age = 10.5), and the other in Basra, Iraq (n = 3; 5, 8, and 14 years old; mean age = 9). A private clinic in Beirut, Lebanon, also collected deciduous teeth for this study (n = 4; 11, 13, 6, and 6 years old; mean age = 9). Prior to tooth collection, parents of the potential tooth donors were informed about our research interest. Parents were made fully aware of the way the children's teeth will be used in this research. Samples of tooth used in this study were collected from children of those parents who gave their full consent to our proposed research. Parental consent forms were signed at the clinic in the presence of the licensed dentist. The children of Isfahan and Beirut were in good health but the deciduous teeth from Basra were donated by children who had survived various birth defects such as soft tissue anomalies and neural tube defects. They also lived in areas that had been bombed.
Iraqi children who donated teeth to this study confirmed that they lived in homes that were bombed (at least once) and also near a known bombed site. One of the Lebanese participants (the 12-year-old) lived in a home that was bombed and was also located near a known bombed site. Iranian children's dwellings were not bombed, and they did not live near a known bombed site.
Tooth samples were cleaned of saliva, blood, and other tissue debris. Then those samples were dried at room temperature and wrapped in clean medical gauze. Each tooth was then placed in a clean autoclaved paper envelope. After closing the envelopes, identification information was pasted on each envelope. Closed envelopes were mailed, in batches, from each country, to the corresponding author. Iranian and Lebanese teeth were in better condition upon arrival, compared to Iraqi samples.
Longitudinal sections were made of teeth after resin embedding for Basra and Isfahan teeth. Deciduous teeth from Beirut were not embedded in resin for sectioning. The sections were polished with 1-μm diamond paste and washed in Milli-Q water prior to analysis.
Image processing
Elemental images of 7Li, 25Mg, 43Ca, 52Cr, 55Mn, 66Zn, 88Sr, 138Ba, 208Pb, 232Th, and 238U in tooth were generated. Quantitative information is based on previously published single-point calibration (Hare et al. 2011).
Elemental maps were made of the sections using laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS). Elements scanned for were 7Li, 25Mg, 43Ca, 52Cr, 55Mn, 66Zn, 88Sr, 138Ba, 208Pb, 232Th, and 238U. 43Ca was used as an internal standard (all elements normalized to Ca). Laser parameters were chosen to yield pixel size of about 35 × 35 μm. The certified glass standard NIST 612 was used for semi-quantification of trace element levels in the samples.
Laser ablation-inductively coupled plasma-mass spectrometry
Operating conditions for the optimized LA-ICP-MS system, including variable parameters, plasma power, argon gas flow rates, sample depth (and thereby residence time of analytes in the plasma), lens voltages for ion beam focusing, and integration times for the mass spectrometer, have been reported earlier (Hare et al. 2011).
Results and discussion
Quantitative element maps of trace elements in deciduous teeth were created by the single-point calibration LA-ICP-MS method (Hare et al. 2011). Color index represents the range in metal levels from low (dark blue) to high (red) Fig. 3, Table 1.
Lead was consistently found in enamel and in dentine and in dentine-pulp junction (DPJ). Lead concentrations increase in the dentine when approaching the pulp cavity, and it remained high along DPJ. A narrow band of high Pb was evident on the surface of the enamel. The width of the band was variable. Lead appeared at similarly high levels in both the enamel surface and the DPJ. However, DPJ showed larger Pb deposits. Variation in Pb concentration was negligible across the band on the surface of the enamel and also in the DPJ. Maximum Pb levels were consistently detected in the Iraqi samples (1.9–48 ppm). The lowest Pb levels were found in the samples from Iran (0.039–0.19 ppm). Pb was highest in teeth from children with birth defects who donated their teeth from Basra, Iraq (mean 0.73–16.74 208Pb/43Ca ppm, n = 3). Pb in healthy Lebanese and Iranian teeth were 0.038–0.382 208Pb/43Ca ppm (n = 4), and 0.041–0.31 208Pb/43Ca ppm (n = 2), respectively. Lead levels were similar in Lebanese and Iranian deciduous teeth. Deciduous teeth from Iraqi children with birth defects had remarkably higher levels of Pb. Two Iraqi teeth had four times more Pb, and one tooth had as much as 50 times more Pb than samples from Lebanon and Iran.
Elemental magnesium (Mg) images were created only for samples from Iraq and Iran. Mg consistently appeared in the dentine. Magnesium concentration markedly increased in the dentine when approaching the pulp cavity. The highest Mg levels were found in samples from Isfahan, Iran (256–1664 25Mg/43Ca ppm).
Chromium (Cr) was highest in deciduous teeth from Iraq (1.03–5.2 52Cr/43Ca ppm), and it appeared along the enamel surface and in the dentine region of all teeth. Cr in dentine appears to increase when approaching the pulp cavity and then decrease again near DPJ. Cr was also evident along a vertical line that started from the tooth surface and continued through the dentine, reaching the pulp.
Manganese (Mn) was highest in teeth from Beirut, Lebanon (0.24–1.6 55Mn/43Ca ppm). Comparable levels of Mn existed in samples from Iraq and Iran. High Mn levels were detectable near the incisal tip in the region of the prenatally formed dentine. Mn was also evident in the form of a thin band on enamel surface, the width of the band varied.
Tooth zinc (Zn) levels were highest in Beirut, Lebanon. Maximum Zn concentration varied from 1.1–5.5 ppm to 8.0 to 400 ppm. In all samples, Zn concentrations in enamel were lower than in the dentine. Within the enamel, the highest Zn levels were seen at the outer edge with the inner enamel having very low concentrations. In the dentine, Zn was concentrated at the dentine-pulp margin and in the cervical dentine.
Uranium and thorium were not detected in any of the samples. Detection limits for U and Th are estimated to be in the ppb range for LA-ICP-MS analysis. Concentrations of U and Th in human teeth have been reported as <1 ppm.
Knowing that an estimated 1000 to 2000 metric tons of depleted uranium was fired during the 2003 war in Iraq (UNEP 2007 Annual Report), we had expected to detect uranium in deciduous teeth of children from Basra. However, surprisingly, U was undetectable in samples from Basra.
Our original hypothesis that increased war activity coincides with increased metal levels, including Pb, in deciduous teeth is confirmed by this research. Recent studies have used neonatal line as a reference point to determine prenatal or postnatal timing of exposure (Arora et al. 2014). Neonatal line is a histological feature formed in enamel and dentine at birth. Location of the prenatal line, which represented approximately 12–15 days of dentine deposition around birth, can provide a landmark to distinguish prenatally formed parts of teeth from those formed postnatally. Prenatal line appears as a distinct line in a light micrograph. The same study found that Pb levels in dentine formed at birth were significantly associated with cord blood Pb. This suggests that micro-spatial measurements of Pb in dentine can be used to show Pb exposure timing over the prenatal and early childhood periods and that secondary dentine has the potential to estimate long-term exposure up to the time the tooth is shed.
In Iraq today, an epidemic of birth defects is unfolding in many cities (Al-Sabbak et al. 2012). A variety of birth defects, some never seen before, are observed in hospitals routinely by researchers and physicians. Current knowledge is clear in that prenatal metal exposure can lead to birth defects. A comprehensive study of birth defects as related to the type of prenatal metal exposure (determined by the use of in deciduous teeth) can contribute to our understanding of how metals cause birth defects in humans. It may then become possible to answer questions regarding prenatal exposures to specific metals which are more frequently associated with certain birth defects.
Finally, it is important to mention that this current study concerns children's exposure to Pb during the military bombardment and occupation of Iraq. We present this article during an extraordinary period of public awareness concerning children's Pb poisoning in Flint, Michigan. This Pb poisoning in Flint occurred at a time when the elected city government was effectively deposed by emergency state administrators. They eliminated Flint's safe water source in favor of an inexpensive but hazardous water source. This has generated scholarly and mass media coverage, creating a global awareness of Pb poisoning and its dangers to the most vulnerable part of the population, namely children. An American Public Health association publication by Hanna-Attisha et al. clearly states the current knowledge about Pb poisoning in children and that Pb "… is a potent neurotoxin, and childhood Pb poisoning has an impact on many developmental and biological processes, most notably intelligence, behavior, and overall life achievement. With estimated societal costs in the billions, Pb poisoning has a disproportionate impact on low-income and minority children. When one considers the irreversible, life-altering, costly, and disparate impact of Pb exposure, primary prevention is necessary to eliminate exposure" (Hanna-Attisha et al. 2016).
Our previous work in Iraqi cities confirm that, as in Flint, Iraqi children have been exposed to comparable Pb, as well as other neurotoxic metals, many in utero (Alsabbak et al. 2012; Savabieasfahani et al. 2015). Cleanup and preventive measures are critically needed in Iraqi cities which have endured a huge burden of contamination created by war.
Al-Sabbak, M., Sadik Ali, S., Savabi, O., Savabi, G., Dastgiri, S., & Savabieasfahani, M. (2012). Metal contamination and the epidemic of congenital birth defects in Iraqi cities. Bulletin of Environment Contamination and Toxicology, 89(5), 937–944.
Arora, M., Kennedy, B. J., Elhlou, S., Pearson, N. J., Walker, D. M., Bayl, P., & Chan, S. W. (2006). Spatial distribution of lead in human primary teeth as a biomarker of pre- and neonatal lead exposure. The Science of the Total Environment, 371(1–3), 55–62.
Arora, M., & Austin, C. (2013). Teeth as a biomarker of past chemical exposure. Current Opinion in Pediatrics, 25(2), 261–267.
Arora, M., Austin, C., Sarrafpour, B., Hernández-Ávila, M., Hu, H., Wright, R. O., & Tellez-Rojo, M. M. (2014). Determining prenatal, early childhood and cumulative long-term lead exposure using micro-spatial deciduous dentine levels. PloS One, 9(5), e97805. doi:10.1371/journal.pone.0097805.
Broder, J.M. (1990). U.S. military leaves toxic trail overseas. Loss Angeles Times, Accessed on 6/13/2016: http://articles.latimes.com/1990-06-18/news/mn-96_1_overseas-military-bases.
Buncombe, A. (2011). US forced to import bullets from Israel as troops use 250,000 for every rebel killed. Indep Lond. Accessed on 6/13/2016: http://www.belfasttelegraph.co.uk/news/world-news/us-forced-to-import-bullets-from-israel-as-troops-use-250000-for-every-rebel-killed-15050027.html.
Grandjean, P., & Landrigan, P. J. (2014). Neurobehavioural effects of developmental toxicity. Lancet Neurology, 13(3), 330–338.
Hanna-Attisha, M., LaChance, J., Sadler, R. C., & Champney, S. A. (2016). Elevated blood lead levels in children associated with the Flint drinking water crisis: a spatial analysis of risk and public health response. The American Journal of Public Health, 106(2), 283–290.
Hare, D., Austin, C., Doble, P., & Arora, M. (2011). Elemental bio-imaging of trace elements in teeth using laser ablation-inductively coupled plasma-mass spectrometry. Journal of Dentistry, 39(5), 397–403.
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Hersh, S. (1992). U.S. secretly gave aid to Iraq early in its war against Iran. New York Times.
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Jergovic, M., Miskulin, M., Puntaric, D., Gmajnic, R., Milas, J., & Sipos, L. (2010). Cross-sectional biomonitoring of metals in adult populations in post-war eastern Croatia: differences between areas of moderate and heavy combat. Croatian Medical Journal, 51(5), 451–460.
Kennedy, K. (2008) Report: army making toxic mess in war 608zones. Army Times. Accessed on 6/13/2016: http://www.armytimes.com/article/20081002/NEWS/810020318/Report-Army-making-toxic-mess-war-zones.
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Our sincere thanks to Dr. Manish Arora for the laboratory analysis and reporting. We also thank Ms. Yalda Hakim and Melanie Marshall of the BBC World News for the sample safekeeping, transport, and delivery.
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Savabieasfahani, M., Ali, S.S., Bacho, R. et al. Prenatal metal exposure in the Middle East: imprint of war in deciduous teeth of children. Environ Monit Assess 188, 505 (2016). https://doi.org/10.1007/s10661-016-5491-0
DOI: https://doi.org/10.1007/s10661-016-5491-0
- Metal exposure
- Deciduous teeth
- Lead
- Iraq
- Lebanon
- Iran
- War-related pollution


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Credit: MGN, Inc
Troopers with Kentucky State Police Post 13 in Hazard are investigating a crash that claimed the life of a Breathitt County woman the afternoon of Thursday, January 4, 2018. Troopers responded to the scene on Highway 15 near the Perry and Breahitt County line, in the Engle community of Perry County, after receiving a call advising of the crash at 2:35pm. It was initially determined that a 1992 Cadillac passenger car, driven by 46 year old Bruce Turner of Haddix, was traveling north on Highway 15, when he lost control of the vehicle and collided with a guardrail and overturned. The car rolled over an embankment where it struck a utility pole before coming to rest against a tree. A passenger in the car, 61-year-old Annmarie Nickell, was pronounced deceased at the scene by Perry County Deputy Coroner John Collett. Turner was transported to Hazard ARH for treatment of non-life threatening injuries. No autopsy will be performed and toxicology results from Turner are pending.


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Kansas State did not have a good resume building win coming into Saturday. Their best win was perhaps over Oklahoma, the team currently seventh in the Big 12 standings. But another opportunity arose Saturday evening for the Wildcats to earn that first resume building win with No. 7 West Virginia coming to Manhattan and the Wildcats didn't squander their big opportunity taking down the Mountaineers 79-75.
It was a very ugly game of basketball. There were 49 fouls and 39 turnovers between the two teams. K-State was able to deal with it best with the help of a few big runs, including one right out of the gate.
The Wildcats, full of energy, quickly pulled ahead 9-2 early on, feeding off the raucous, sold-out crowd in Bramlage Coliseum. K-State forced West Virginia to miss their first six shots and turn the ball over four times, which didn't allow the Mountaineers to set up their feisty press defense.
But things turned quickly. West Virginia started making baskets, which allowed them to set up their full-court pressure, and K-State was unable to cope.
Thanks to a multitude of Kansas State mistakes, including back-to-back five second violations, West Virginia was able to pull away from the Wildcats. The Mountaineers were up as much by as 12 in the first half.
"It takes a toll on you, mental and physical," head coach Bruce Weber said on West Virginia's press defense.
The lead wouldn't last long, however. K-State made a furious 10-0 run to close the gap to two before halftime. Sophomore guard Kamau Stokes' layup at the buzzer pulled the Wildcats within 36-38.
It was questionable if Stokes would even be able to play after injuring his ankle Wednesday night against Oklahoma State. But Stokes showed no signs of the injury as he led the Cats with 15 points on the night.
"I know it was going to be a big factor," sophomore guard Barry Brown said. "(Stokes) is a huge part of what we do and the team that we are. Just to have him on the court with us was big."
The Wildcats came out with the same energy they ended the half with and were able to pull ahead again. With the help of their crowd, K-State slowly pulled away from the Mountaineers, eventually taking a 65-55 lead with just 7:43 remaining.
But the momentum shifted again after senior forward Wesley Iwundu was called for a questionable flagrant foul. The Mountaineers would go on a quick 7-0 run to take the lead 66-65. But the Wildcats were able to force some turnovers and eventually pulled ahead and held on for the win. Head coach Bruce Weber said the Cats did well to deal with adversity late in the game.
"Give them credit, (West Virginia) made the run," Weber said. "(But) I think this is where we've matured as a team, we feel more confident that we can deal with adversity and go make plays."
K-State improved to 15-4 and 4-3 in Big 12 play with the win. They will head to Ames, Iowa on Tuesday night to take on Iowa State before heading to Knoxville, Tennessee to take on the Volunteers next Saturday.


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"Art means everything to us.
There is no Plan B"
Founder, Moto Art Show
Moto Art Show started as a response to a lack of art spaces to show motorcycle art in India. There are many amazingly talented motorists who are limited to showing their work in the online world and there is a clear need to bring them together to create exciting art experiences.
We promote artists and their work in the real world by curating art exhibitions in art galleries, as private and corporate events and through our online shop.
Moto Art Show is founded and curatoed by biker and motoartist Mallika Prakash. With roots in Delhi, Mallika started riding in San Francisco towards a self-propelled art career and has shown and sold her work in various galleries in and around San Francisco.
Mallika is committed to working with other motoartists from India and everywhere else to bring their work into the public eye. She believes that in person is the only way to experience the emotions and feelings these artworks ellicit.
"Moto Art Show is a revelation and a revolution in the Indian motorcycling scene. It is a clear picture of the evolving motorcycling culture and Mallika has created a brilliant platform for motoartists to showcase their work together."
Co-founder, The Bikerni


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Translated to English by Dafna O'NEILL
The romans conquered the Jewish state in 63BCE and thrned it into a vassal of Rome. The Jews revoted against Roman occupation in 66 CE (THE GREAT REVOLT), becuse of Rome's policy to replace the Jewish population and its culture by an Hellenist population and the Hellenist culture.
The role of the Hellenist population in the war against the Jews
The Distribution of the Urban Hellenist Population throughout the Land of Israel under Roman Occupation (63 BCE – 324 CE) / Dr.Rivka Shpak Lissak
Translated to English by Dafna O'neill
Rome turned the land of Israel into a Hellenist country by spreading 30 poleis and also military cities throughout the country. Under Roman occupation a network of poleis and military colonies was established and expanded throughout the Land of Israel, on the basis of a similar network built during the Hellenist occupation. Roman roads were laid to connect the cities and the military colonies to ensure that the Roman army could move around the country freely.
The Roman Policy of Colonizing and Hellenizing the Land of Israel / Dr.Rivka Shpak Lissak
Zeev Safrai and Gedalyahu Alon pointed out the significant growth in population and settlement and rapid urbanization during the Roman period. This urbanization process and population growth were not the result of a development policy, but rather resulted from a colonization policy and the increase in foreign settlement in the Land of Israel during the first and second centuries CE.
The Population Composition During the First Century CE on the Eve of the Great Revolt (66 CE)/ DR.Rivka Shpak Lissak
Translated to English by Dafna O'NEILL
Before the establishment of the Hasmonaean Kingdom (140 BCE) the foreign population was the largest minority in the country. Under Hasmonaean rule Jews returned to became the majority.
THE POPULATION OF THE LAND OF ISRAEL ON THE EVE OF THE GREAT REVOLT (66 CE) / DR.Rivka Shpak Lissak
Translated to English by Dafna O'neill
The Jewish state (the Hasmonean kingdom) became a vassal of the Roman Empire in 63 BCE. From 6CE it came under direct rule of the Roman empire.In 66 CE the Jews revolted against the Roman occupation.
The Sophisticated Egyptian Deception Preceded to Yom Kippur War / Lt. Col. (Ret.) Shimon Mendes
24 Oct 2012
In order to understand the sophistication of the Egyptian deception that preceded the Yom Kippur War in 1973, it is essential to know that the Egyptian military doctrine was revolutionized in 1969. While the Israeli military thought remained stagnated.
The Fedayeen:The PALESTINE - ISRAEL CONFLICT / SHAUL BARTAL
Israeli Scholar, Veteran Pens Study of Palestinian Incursions
Tel-Aviv, Israel - Shaul Bartal's nonfiction The Fedayeen Emerge: The Palestine-Israel Conflict, 1949-1956 (published by AuthorHouse) describes each community's struggle in the 1950's as another stage in the conflict between Jews and Muslims from the British Mandate to the present. It shows how the Palestinians recovered from the Naqba - the catastrophe - of Israel's creation in 1948 and continued the struggle.
The Land of Israel Under Hellenistic Occupation / DR.Rivka Shpak Lissak
(Please refer to note No. 4 for references)
Hellenist treatment of conquered nations was cruel and included massacring the population and the sale of captured survivors into slavery. The purpose of this policy was to reduce the size of the local population, while colonising the Land of Israel and transforming it into a Greek-Macedonian colony. This policy destroyed the Jewish demographic majority in the Israel.
70 YEARS AGO: Riegner Telegram alerts world of Nazi Holocaust
08 August 2012
Seventy years ago, on 8 August 1942, the World Jewish Congress representative in Geneva, Gerhart M. Riegner, sent a telegram to British and American diplomats providing them with reliable information about Hitler's plans to annihilate millions of European Jews. The telegram was the first authoritative word that the Nazis actually had a coordinated extermination plan.
The Mandate For Palestine Still Matters 90 Years Later /Eli E. Hertz
July 24, 2012
Israelis and friends of the Jewish State alike are accustomed to the never-ending scorn the United Nations heaps on the Middle East's only free democracy, never mind its desire for peace with all of its Arab neighbors. It may seem unfathomable that the very same institution was ultimately responsible for the creation of Israel nearly 65 years ago.
Chapter 5 - Acculturation without Islamization under Arab- Muslim Occupation (640 – 1099)/ DR.Rivka Shpak Lissak
The Arab policy did not include forced Islamization (except for short periods),but mainly cultural Arabization.
Apocalypse, Hamaguedon,Gog Ou Magog, Fin Du Monde / I.Q.Rassooli
juin 10th, 2012
Translated to French by Dominique Kahtan
Chers Lecteurs, comme vous le savez ce site participatif propose du contenu très pragmatique et laissent peu de place aux errances de l'imagination. La situation nous amène à nous poser la question ! Apocalypse ? Armaguédon, Gog ou Magog,, 2012 fin du monde selon le calendrier des Mayas – il semble que ce soit bien plus simple que cela !
Par IQ al Rassooli traduit par Dominique Kahtan pour israel-flash
Arab Illegal Immigration to Palestine Under British Mandate:Part Two / Dr.Rivka Shpak Lissak
The Immigration of Egyptian Workers into the Land of Israel during the British Mandate Period
The Legacy of European Colonialism / Eli E.Hertz
April 18, 2012
Israel is often referred to as a colonial power responsible for much of the instability in the Middle East. The problem is that this labeling is a total fallacy. Unlike nation-states in Europe, modern Lebanese, Jordanian, Syrian, and Iraqi nationalities did not evolve; they were arbitrarily created by colonial powers.
Defending Jesus and Judaism / Alan Caruba
Jan.31 2012
As a book reviewer I receive countless requests to read books and, when I received one regarding "Kosher Jesus" by Rabbi Shmuley Boteach, I was intrigued by the title. In addition to fathering nine children, the rabbi has written 27 books, is a regular contributor to The Huffington Post and the profile on his website is filled with achievements and encomiums
Futile Efforts to Challenge the "Mandate for Palestine/ Eli Hertz
Futile Efforts to Challenge the
"Mandate for Palestine"
Myth: The "Mandate for Palestine" is a Class "A" Mandate
There is much to be gained by attributing Class "A" status to the "Mandate for
Palestine." If the inhabitants of Palestine were ready for independence under a
Class "A" mandate, then the Palestinian Arabs that made up the majority of the
inhabitants of Palestine in 192238 (589,177 Arabs vs. 83,790 Jews) could logically
claim that they were the intended beneficiaries of the "Mandate for Palestine"
provided one never reads the actual wording of the document:
The Legal Aspects of Jewish Rights to a National Home in Palestine : Part Two / Eli Hertz
Political Rights in Palestine Were Granted to Jews Only
The "Mandate for Palestine" clearly differentiates between political rights—
referring to Jewish self-determination as an emerging polity—and civil and
religious rights, referring to guarantees of equal personal freedoms to non-
Jewish residents as individuals and within select communities. Not once are
Arabs as a people mentioned in the "Mandate for Palestine." At no point in the
entire document is there any granting of political rights to non-Jewish entities
The Legal Aspects of Jewish Rights to a National Home in Palestine / Eli Hertz
The Two Most Significant Events in Modern History Leading to
the Creation of the Jewish National Home:
I. The Founding of Modern Zionism
Benjamin Ze'ev [Theodor] Herzl (May 2, 1860 – July 3, 1904)
After witnessing the spread of antisemitism around the world, Herzl felt
compelled to create a political movement with the goal of establishing a Jewish
National Home in Palestine. To this end, he assembled the first Zionist Congress
in Basel, Switzerland, in 1897. Herzl's insights and vision can be learned from
his writings:
The Goldstone Report "Reconsidered" - A Critical Analysis / Gerald M.Steinberg et al
The Goldstone Report "Reconsidered" – A Critical Analysis
Edited by Gerald M. Steinberg and Anne Herzberg NGO Monitor and Jerusalem Center for Public Affairs
To order a copy of this book, visit Amazon.com or contact [email protected].
Israel has been the subject of numerous controversial U.N. inquiries related to armed conflict and responses to terror attacks. But, the scope and impact of the Report of the United Nations Fact-Finding Mission on the Gaza Conflict, known as the Goldstone Report, were particularly extreme.
Chapter One - The Hellenist Colonization and Land Confiscation Policy in the Land of Israel (332 - 142 BCE) : Part Two / DR.Rivka Shpak Lissak
(Translated to English by Dafna O'neill)
http://www.rslissak.com/content/chapter-one-colonization-and-land-confis... Part One
(Please refer to note No. 4 for references)
Nov.29 1947 - UN Resolution:A JEWISH STATE
29 November 1947 - The UN Vote that Established Israel
November 29 2011
November 29 is a significant date in Jewish history. On November 29, 1947, the UN General Assembly voted in favor of a resolution, which adopted the plan for the partition of Palestine, recommended by the majority of the UN Special Committee on Palestine (UNSCOP). 33 states voted in favor of the resolution and 13 against. 10 states abstained.
UN Resolution 181 - The Partition Plan / Eli.E,Hertz
Nov.29 2011
A "Green Light" for Jewish Statehood - A 'Dead' Blueprint for Peace (November 29, 1947)
In 1947 the British put the future of western Palestine into the hands of the United Nations, the successor organization to the League of Nations which had established the Mandate for Palestine. A UN Commission recommended partitioning what was left of the original Mandate - western Palestine - into two new states, one Jewish and one Arab [Not a Palestinian state]. Jerusalem and its surrounding villages were to be temporarily classified as an international zone belonging to neither polity.
L'IMMIGRATION DES OUVRIERS EGYPTIENS EN ISRAEL PENDANT LE MANDAT BRITANNIQUE / DR.Rivka Shpak Lissak
Translated by Dominique Kahtan
Israel 1948; War for Independece
What Happened in 1948 during the Independece War
Chapter One - Colonization and Land Confisication Policy in the Land of Israel under Hellenist Occupation , Part One / DR.Rivka Shpak Lissak
Alexander the Great conquered the Land of Israel from the Persians in 332 BCE. His heirs, the Diadochi, established their Hellenist kingdoms: The Seleucid Empire in modern-day Syria, and the Ptolemaic Empire in Egypt. The Ptolemies ruled the Land of Israel from 301 to 198 BCE; the Seleucids from 198 to 142 BCE, at which time Judea regained independence.
From Alexander's time to the end of Hellenist rule in the Land of Israel, the Hellenist rulers employed a colonization policy throughout their empires, establishing some 350 Hellenist cities (Poleis).
Benny Morris: "The 1948 War Was An Islamic War"
Benny Morris: "The 1948 War Was an Islamic Holy War"
Amira Lamm interviews Benny Morris.
Chapter 6 - The Population's Composition During the Crusaders' Period (1099 - 1260 ) Part Two / DR.Rivka Shpak Lissak
Chapter 6 – The Population's Composition During the Crusaders Period (1099 – 1260) / DR.Rivka Shpak Lissak
Part Two
Settlement Distribution during the Crusader Period
Prof. Kedar (Jews and Samaritans in the Kingdom of Jerusalem) and Prof. Ellenblum (Frankish Rural Settlements in the Latin Kingdom of Jerusalem) charted the country's settlements during the Crusader period (1099-1260).
Chapter 3 - The Failure of Forced Conversion of Jews Under Christian - Byzantine Occupation (324 - 640 CE) DR.Rivka Shpak Lissak
Chapter 3: The Failure of Forced Conversion of Jews under Christian-Byzantine Occupation(324 – 640)
The Christian-Byzantine occupation's policy towards the Jews (395 – 640 A.D) included religious and economic decrees, pogroms, destruction of synagogues and a focused policy on the part of the government and the church to convert the Jews, along with other local non-Christians, into Christianity.
Chapter 7 - The Population's Composition During the Mamluk Period (1260 - 1516 ):Elimination of the Christian Majority Part One
Chapter 7. The Population's Composition during the Mamluk Period (1260 – 1516): Elimination of the Christian Majority
Part One
The Mamluks were Turkmen from Central Asia. When the Muslims conquered Central Asia, they enslaved Turkmen children, put them through military training and enlisted them as soldiers in their army. The Turkmen children were converted to Sunni Islam. As new Muslims they were known for their orthodoxy and religious fanaticism.
Jewish Bodies Found in Medieval Well in Norwich
23 June 2011
The remains of 17 bodies found at the bottom of a medieval well in England could have been victims of persecution, new evidence has suggested.
The most likely explanation is that those down the well were Jewish and were probably murdered or forced to commit suicide, according to scientists who used a combination of DNA analysis, carbon dating and bone chemical studies in their investigation.
The skeletons date back to the 12th or 13th Centuries at a time when Jewish people were facing persecution throughout Europe.


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"Urban mobility is going through a delicate transition moment towards electrification. Thanks to this consortium motorbikes will keep their key role," said Piaggio Chief of Strategy and Product, Mr. Michele Colaninno
Honda's Motorcycle Operations Chief Officer Yoshishige Nomura said, "The consortium's objectives aimed to make electric motorbikes more convenient for clients, as their "use on large scale can substantially contribute to the creation of a more sustainable society".
The four founding members of the consortium will also engage with various decision-makers, to help create an International set of technical standards for swappable battery systems and light electric vehicles. It will be a solution to the issues preventing widespread adoption of electric motorcycles as a more environmentally friendly and convenient form of mobility – the drive range and reduction of charging time.
This is a clear indication that MNC big shot scooter giants like Piaggio, Honda will launch electric scooters with batteries that can be swapped out easily. These companies have the resources to setup 20-30 battery swap stations in multiple cities. And with standardization, customer of a Piaggio electric scooter or a Honda electric scooter can visit these swap stations and change batteries which is good for the ecosystem. Standards are critical to the mass adoption of new technology. Lack of standards will result in disputes and slow adoption of technology. We have many examples in the past like DVD & BlueRay. We even see issues in our EV industry, where Tesla has their own charger network, where other vehicles cannot use them. Apparently Rivian is building their own charging infrastructure in the USA. We are seeing the same in India. The OLA Hyper charger network is another closed system, where no other electric scooter brand can use them.
Ultimately we will see standards coming up for charging too. But it is good to see this battery swapping standards being set by these giant MNC corporations.
While, we understand that battery swapping will be the main focus for these companies, but at the same time, they should give an option to charge batteries of two wheelers too. We hope they provide an option for users to charge at home or work. Charging at home or work is very easy, if we hope that option will be provided. If they don't, then we will understand that this entire battery swapping investment will be to ensure they remain in control, which is exactly EV owners don't want. Time will tell.


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Events - 29.03.2011 - 00:00
29 March 2011
"Eastern Switzerland – the best of"
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Begoña Basilica
It is built on the site of an old shrine where, legend has it, the Virgin Mary appeared at the beginning of the 16th century.
Bilbao residents have great devotion to the Virgin of this church, "La Amatxo". Work on this beautiful Gothic building began in 1519. The façade is in Renaissance style and has a large triumphal arch. Inside, special mention should be made of the Neo-Classical Main Altarpiece, where you can see the Camarín de la Virgen (Virgin's chamber). Its large, open belfry dates from the beginning of the 20th century.
Begoña Basilica
Virgen de Begoña 38
48006 Bilbao, Bizkaia (Basque Country)
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The "Why I Love Poker" Contest
1. PROMOTION DESCRIPTION: The "Why I Love Poker" Contest (the "Contest") consists of a submission phase (the "Submission Period") that begins on or about April 2, 2017 at 12:01 a.m. eastern time ("ET") and ends on or about 11:59 p.m. ET on April 29, 2017, followed by a voting phase (the "Voting Period") that begins on June 5, 2017 and ends on or about July 30, 2017 at 11:59 p.m. ET ("ET") (collectively ,the "Promotion Period"). During the Submission Period, entrants will have the opportunity to submit a story (each, a "Submission") explaining how poker changed their life and submit the story for consideration as more fully set forth below. At the end of the Promotion Period, one (1) Grand Prize winner will be selected as set forth below. By participating in the Contest, each entrant unconditionally accepts and agrees to comply with and abide by these Official Rules and the decisions of WPT Enterprises, Inc., 1920 Main Street, Suite 1150, Irvine, CA 92614 ("Sponsor"), which shall be final and binding in all respects.
2. ELIGIBILITY: This Contest is open only to individuals who are twenty one (21) years of age and the age of majority in their jurisdiction of primary residence at the time of entry. Residents of countries currently subject to the United States embargo or on the United States list of state sponsors of terrorism are not eligible to enter the Contest or win the Grand Prize. For a current list of countries currently subject to the United States embargo or on the United States list of state sponsors of terrorism, go to http://pmddtc.state.gov/embargoed_countries/index.html. Officers, directors and employees of Sponsor and its parents, subsidiaries, affiliates, members, distributors, sales representatives, advertising and promotion agencies (all such individuals and entities referred to collectively, the "Promotion Entities"), and each of their immediate family members and/or people living in the same household are NOT eligible to enter the Contest or win a prize.
3. HOW TO ENTER: To enter, visit the web site http://www.worldpokertour.com/stories (such URL and any site or microsite that such URL re-directs users to is referred to herein as, the "Submission Website") during the Submission Period and complete the submission form found on the Submission Website with the information requested, and follow the instructions to draft and submit your story. The Submission cannot be more than 2,000 characters and must meet the following "Submission Requirements": (i) the Submission must be the submitting entrant's original, previously unpublished work and not feature or focus on any material owned or controlled by third parties (including without limitation, third party copyrighted material); (ii) the entrant must provide upon request all appropriate clearances, permissions and releases for the Submission (in the event an entrant cannot provide all required releases, Sponsor reserves the right, in Sponsor's sole discretion, to disqualify the applicable Submission, or seek to secure the releases and clearances for Sponsor's benefit, or allow the applicable Submission to remain in Contest); and (iii) the Submission must not be obscene, libelous or otherwise objectionable. Any Submission that, in Sponsor's discretion, violates the Submission Requirements may be disqualified.
Personal information collected in connection with the Contest will be used in accordance with Sponsor's privacy policy located at http://www.worldpokertour.com/privacy-policy/. Entry must be made by the entrant, only through the Submission Website. Entries made by any other individual or any entity, and/or originating at any other web site or e-mail address, including but not limited to entering service sites, will be declared invalid and disqualified for this Contest. Tampering with the entry process or the operation of the Contest is prohibited and any entries deemed by Sponsor, in its sole discretion, to have been submitted in this manner will be void. In the event a dispute regarding the identity of the individual who actually submitted an entry cannot be resolved to Sponsor's satisfaction, the affected Submission will be deemed ineligible. The Promotion Entities shall not be responsible for incorrect or inaccurate entry information whether caused by Internet users or by any of the equipment or programming associated with or utilized in the Contest or by any technical or human error which may occur in the processing of the entries in the Contest. The Promotion Entities assume no responsibility or liability for any error, omission, interruption, deletion, theft or destruction, or unauthorized access to, or alteration of entries.
4. WINNER SELECTION AND NOTIFICATION: At the end of the Submission Period, a panel of judges selected by Sponsor in its sole discretion (the "Judging Panel") will select up to three (3) finalists (each, a "Finalist") based on the following criteria: (i) originality; (ii) theme; and (iii) connection to the game of poker. Decisions of the Judging Panel are final and not subject to appeal. Each Finalist must be verify that he or she is willing to participate in the WPT Main Event in the event the Finalist is selected as the Grand Prize winner and may be required to execute a "Finalist Release" in order to participate in the Voting Period phase of the Contest. In the event a Finalist declines such invitation, refuses to sign the Finalist Release or is unable to participate in the WPT Main Event on the dates specified by Sponsor, the opportunity will be forfeited and the Judging Panel will select the next highest scoring Submission. Once a Finalist is confirmed, Sponsor will, with reasonable input from the Finalist, create a whiteboard video based on the selected Finalist's Submission (each, a "Video"). Each Video will be uploaded to WPT.com and its affiliated social media website (such URL and any site or microsite that such URL re-directs users to is referred to herein as, the "Voting Website", and collectively with the Submission Website, the "Website"). During the Voting Period, people who visit the Voting Website will have the opportunity vote on the Video they like the best by liking the Video or sharing the Video. Votes for each Video may be tracked by the Website. Any posted rankings or vote counts are unofficial and should not be relied upon for any purpose. Any entrant offering or using, or attempting to use a "cheat," payment, or other incentive, or any other means to obtain votes may be disqualified and any votes earned by those means will be deemed void if Sponsor so elects in its sole discretion.
At the end of the Voting Period, the Judging Panel will select one (1) Grand Prize winner based on the Judging Criteria, the number of votes the Finalist's Video receives, and social sharing metrics. The Grand Prize winner will be subject to verification and compliance with these Official Rules. The Grand Prize winner will be notified by telephone, e-mail, and/or mail using the contact information provided at the time of entry after the end of the Voting Period. Sponsor shall have no liability for any winner notification that is lost, intercepted or not received by the potential winner for any reason. If any potential winner does not respond within the time required by Sponsor, or if the winner notification is returned as unclaimed or undeliverable to any potential winner, such potential winner will forfeit his or her prize and an alternate winner may be selected. If any potential winner is found to be ineligible, or if he or she has not complied with these Official Rules or declines the prize for any reason, such potential winner will be disqualified and the prize may be awarded an alternate winner.
5. GRAND PRIZE: One (1) Grand Prize is available. The Grand Prize consists of (i) the opportunity to participate in the WPT Main Event at the Borgata Poker Open (the "WPT Main Event"), currently scheduled to take place ; and (ii) $US 1,000 for use toward travel to attend the WPT Main Event (the "Travel Stipend").
In the event that the WPT Main Event listed in the prize description do not or cannot take place as scheduled or at all, for reasons included but not limited to scheduling conflicts, cancellations, postponement, an event of "Force Majeure" (defined below), or for any other reason, then in lieu of receiving the prize element associated with the applicable poker tournament, prize winner will receive a substitute prize of comparable value, which shall constitute full satisfaction of Sponsor's prize obligation to the prize winner, and no other or additional compensation will be awarded. For clarification and the removal of doubt, the Grand Prize winner is responsible for organizing the following: (i) transportation for the prize winner to the WPT Main Event; (ii) accommodations in connection with the WPT Main Event; and (iii) ground transportation and any other incidental expenses incurred in connection with attending the WPT Main Event (the "Travel Costs"). The Grand Prize winner shall be responsible for any Travel Costs that exceed the Travel Stipend. The Grand Prize winner must possess all required travel documents, including visas and valid passports, if and as applicable in order to participate in the Grand Prize. In the event the event a prize winner is unable to travel to the WPT Main Event, the prize will be forfeited in its entirety.
6. GENERAL PRIZE CONDITIONS: Except as set forth herein, no cash alternative or substitution of prizes will be allowed, except Sponsor reserves the right in its sole discretion to substitute prizes of comparable value if any prize listed is unavailable, in whole or in part, for any reason. Prizes will be awarded only if the potential prize winner fully complies with these Official Rules. All portions of the prize(s) are non-assignable and non-transferable. Any prizes pictured in point-of-sale, online, television and print advertising, promotional packaging, and other Contest materials are for illustrative purposes only. The actual prize may vary. In the event there is a discrepancy or inconsistency between guidelines, disclosures or other statements contained in any such promotional materials and the terms and conditions of these Official Rules, these Official Rules shall prevail, govern and control. All details and other restrictions of the prize(s) not specified in these Official Rules will be determined by Sponsor in its sole discretion. Each prize winner shall be solely responsible for all federal, state and/or local taxes, and the reporting consequences thereof, and for any other fees or costs associated with the applicable prize. If required by law, Sponsor reserves the right to withhold and remit to the appropriate taxing authorities the amount of any tax or taxes due. Each potential winner may be required to execute an Affidavit of Eligibility, a Liability Release and where imposing such condition is legal, a Publicity Release (collectively, the "Prize Claim Documents"). If a potential winner (or a minor potential winner's parent or legal guardian) fails or refuses to sign and return all the Prize Claim Documents within ten (10) days after being notified that he or she has been selected as the potential winner (or a shorter time if required by exigencies), the potential winner may be disqualified and an alternate winner may be selected.
Sponsor makes no warranties, and hereby disclaims any and all warranties, express or implied, concerning any prize furnished in connection with the Contest. WITHOUT LIMITING THE GENERALITY OF THE FOREGOING, SUCH PRIZES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND, EITHER EXPRESS OR IMPLIED, AND SPONSOR HEREBY DISCLAIMS ALL SUCH WARRANTIES, INCLUDING BUT NOT LIMITED TO, THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE AND/OR NON-INFRINGEMENT.
7. REPRESENTATIONS AND WARRANTIES/INDEMNIFICATION: Each person who enters this Contest (and any minor entrant's parent or legal guardian) represents and warrants as follows: (i) the Submission is the original work of the entrant; (ii) the Submission does not contain any computer virus (as applicable) and is otherwise uncorrupted,(iii) the Submission is not the subject of any actual or threatened litigation or claim; (iv) the Submission does not and will not violate or infringe upon the intellectual property rights or other rights of any third party; and (v) the Submission does not and will not violate any applicable laws. Each entrant hereby agrees to indemnify and hold the Promotion Entities harmless from and against any and all third party claims, actions or proceedings of any kind and from any and all damages, liabilities, costs and expenses relating to or arising out of any breach or alleged breach of any of the warranties, representations, covenants, obligations or agreements of entrant hereunder.
8. GRANT OF RIGHTS: For good and valuable consideration, the receipt and legal sufficiency of which is hereby acknowledged, each entrant into the Contest (and his or her parent or legal guardian, if the entrant is a minor) hereby irrevocably grants Sponsor, its successors and assigns, a non-exclusive license (but not the obligation) to reproduce, publicly perform, stream, exploit and otherwise use the Submission (as his or her performance and appearance therein) throughout the universe, in perpetuity, in connection with the advertising, marketing, publicity, promotion and exploitation of the Contest and the Video, without further notice to, consent by, or payment to entrant. Without in any way limiting the foregoing, Sponsor shall have the right, in its sole discretion, to edit, composite, morph, scan, duplicate, or alter the Submission for any purpose which Sponsor deems necessary or desirable, and each entrant irrevocably waives any and all so-called moral rights they may have therein. Sponsor shall have the right to freely assign its rights hereunder, in whole or in part, to any person or entity. Sponsor shall retain the rights granted in each Submission even if the Submission is disqualified or fails to meet the Submission Requirements.
9. PUBLICITY RELEASE: By participating in the Contest, in addition to any other grants which may be granted in any other agreement entered into between Sponsor and any entrant in and/or winner of the Contest, each entrant irrevocably grants the Promotion Entities and their respective successors, assigns and licensees, the right to use such entrant's name, photograph, likeness, statements, biographical information, and any other personal characteristics, in any and all media in connection with the Contest, the Video and the advertising and promotion thereof and each entrant and/or prize winner hereby release the Promotion Entities from any liability with respect thereto.
10. GENERAL LIABILITY RELEASE/FORCE MAJEURE: Entrants agree that the Promotion Entities (A) shall not be responsible or liable for, and are hereby released from, any and all costs, injuries, losses or damages of any kind, including, without limitation, death and bodily injury, due in whole or in part, directly or indirectly, to participation in the Contest or any Contest-related activity, or from entrants' acceptance, receipt, possession and/or use or misuse of any prize, and (B) have not made any warranty, representation or guarantee express or implied, in fact or in law, with respect to any prize, including, without limitation, to such prize's quality or fitness for a particular purpose. Sponsor assumes no responsibility for any damage to an entrant's, or any other person's, computer system which is occasioned by accessing the Website or otherwise participating in the Contest, or for any computer system, phone line, hardware, software or program malfunctions, or other errors, failures, delayed computer transmissions or network connections that are human or technical in nature. Without limiting the generality of the foregoing, Sponsor is not responsible for incomplete, illegible, misdirected, misprinted, late, lost, damaged, stolen, or postage-due prize notifications; or for lost, interrupted, inaccessible or unavailable networks, servers, satellites, Internet service providers, websites, or other connections; or for miscommunications, failed, jumbled, scrambled, delayed, or misdirected computer, telephone or cable transmissions; or for any technical malfunctions, failures, difficulties or other errors of any kind or nature; or for the incorrect or inaccurate capture of information, or the failure to capture any information. Sponsor reserves the right in its sole discretion to disqualify any individual who is found to be tampering with the entry process or the operation of the Contest or the Website, to be acting in violation of these Official Rules, or to be acting in an unsportsmanlike or disruptive manner, or with the intent to disrupt or undermine the legitimate operation of the Contest, or to annoy, abuse, threaten or harass any other person, and Sponsor reserves the right to seek damages and other remedies from any such person to the fullest extent permitted by law. No mechanically reproduced, illegible, incomplete, forged, software-generated or other automated multiple entries will be accepted. Sponsor reserves the right to modify, extend, suspend, or terminate the Contest if it determines, in its sole discretion, that the Contest is technically impaired or corrupted or that fraud or technical problems, failures or malfunctions or other causes beyond Sponsor's control have destroyed or severely undermined or to any degree impaired the integrity, administration, security, proper play and/or feasibility of the Contest as contemplated herein. In the event an insufficient number of eligible entries are received and/or Sponsor is prevented from awarding prizes or continuing with the Contest as contemplated herein by any event beyond its control, including but not limited to fire, flood, natural or man-made epidemic of health of other means, earthquake, explosion, labor dispute or strike, act of God or public enemy, satellite or equipment failure, riot or civil disturbance, terrorist threat or activity, war (declared or undeclared) or any federal state or local government law, order, or regulation, public health crisis, order of any court or jurisdiction, or other cause not reasonably within Sponsor's control (each a "Force Majeure" event or occurrence), then subject to any governmental approval which may be required, Sponsor shall have the right to modify, suspend, extend or terminate the Contest. If the Contest is terminated before the designated end date, Sponsor will (if possible) select the winner in a random drawing from all eligible, non-suspect entries received as of the date of the event giving rise to the termination. Inclusion in such drawing shall be each entrant's sole and exclusive remedy under such circumstances. Only the type and quantity of prizes described in these Official Rules will be awarded. These Official Rules cannot be modified or amended in any way except in a written document issued in accordance with law by a duly authorized representative of Sponsor. The invalidity or unenforceability of any provision of these rules shall not affect the validity or enforceability of any other provision. In the event that any provision in these Official Rules is determined to be invalid or otherwise unenforceable or illegal, these rules shall otherwise remain in effect and shall be construed in accordance with their terms as if the invalid or illegal provision were not contained herein.
11. NATURE OF RELATIONSHIP/WAIVER OF EQUITABLE RELIEF: Each entrant hereby acknowledges and agrees that the relationship between the entrant and the Promotion Entities is not a confidential, fiduciary, or other special relationship, and that the entrant's decision to provide the entrant's Submission to Sponsor for purposes of the Contest does not place the Promotion Entities in a position that is any different from the position held by members of the general public with regard to elements of the entrant's Submission. Each entrant understands and acknowledges that the Promotion Entities have wide access to ideas, stories, designs, and other literary materials, and that new ideas are constantly being submitted to it or being developed by their own employees. Each entrant also acknowledges that many ideas or stories may be competitive with, similar or identical to the Submission and/or each other in theme, idea, plot, format or other respects. Each entrant acknowledges and agrees that such entrant will not be entitled to any compensation as a result of any Promotion Entity's use of any such similar or identical material. Each entrant acknowledges and agrees that the Promotion Entities do not now and shall not have in the future any duty or liability, direct or indirect, vicarious, contributory, or otherwise, with respect to the infringement or protection of the copyright in and to the Submission. Finally, each entrant acknowledges that, with respect to any claim by entrant relating to or arising out of a Promotion Entity's actual or alleged exploitation or use of any Submission or other material submitted in connection with the Contest, the damage, if any, thereby caused to the applicable entrant will not be irreparable or otherwise sufficient to entitle such entrant to seek injunctive or other equitable relief, and entrant's rights and remedies in any such event shall be strictly limited to the right to recover damages, if any, in an action at law.
12. NO OBLIGATION TO USE: Sponsor shall have no obligation (express or implied) to use any Submission or to otherwise exploit any Submission, or, if commenced, to continue the distribution or exploitation thereof, and Sponsor may at any time abandon the use of the Submission for any reason, with or without legal justification or excuse, and entrants shall not be entitled to any damages or other relief by reason thereof.
13. DATES & DEADLINES/ANTICIPATED NUMBER OF CONTESTANTS: Because of the unique nature and scope of the Contest, Sponsor reserves the right, in addition to those other rights reserved herein, to modify any date(s) or deadline(s) set forth in these Official Rules or otherwise governing the Contest. Sponsor cannot accurately predict the number of entrants who will participate in the Contest.
14. FURTHER DOCUMENTATION: If Sponsor shall desire to secure additional assignments, certificates of engagement for the Submission or other documents as Sponsor may reasonably require in order to evidence or effectuate the rights granted in these Official Rules, then each entrant agrees to sign, authenticate and deliver the same upon Sponsor's request therefor.
16. ARBITRATION PROVISION: By participating in this Contest, each entrant (and any minor entrant's parent or legal guardian) agrees: (i) that any and all disputes the entrant may have with, or claims entrant may have against, the Promotion Entities relating to, arising out of or connected in any way with (a) the Contest, (b) the awarding or redemption of any prize, and/or (c) the determination of the scope or applicability of this agreement to arbitrate, will be resolved exclusively by final and binding arbitration administered by JAMS and conducted before a sole arbitrator in accordance with the rules of JAMS; (ii) this arbitration agreement is made pursuant to a transaction involving interstate commerce, and shall be governed by the Federal Arbitration Act ("FAA"), 9 U.S.C. §§ 1-16; (iii) the arbitration shall be held in Los Angeles, California; (iv) the arbitrator's decision shall be controlled by the terms and conditions of these Official Rules and any of the other agreements referenced herein that the applicable entrant may have entered into in connection with the Contest; (v) the arbitrator shall apply California law consistent with the FAA and applicable statutes of limitations, and shall honor claims of privilege recognized at law; (vi) there shall be no authority for any claims to be arbitrated on a class or representative basis, arbitration can decide only entrant's and/or Sponsor's individual claims; the arbitrator may not consolidate or join the claims of other persons or parties who may be similarly situated; (vii) the arbitrator shall not have the power to award punitive damages against the entrant or Sponsor; (viii) in the event that the administrative fees and deposits that must be paid to initiate arbitration against Sponsor exceed $125 USD, and entrant is unable (or not required under the rules of JAMS) to pay any fees and deposits that exceed this amount, Sponsor agrees to pay them and/or forward them on entrant's behalf, subject to ultimate allocation by the arbitrator; (ix) if the entrant is able to demonstrate that the costs of arbitration will be prohibitive as compared to the costs of litigation, Sponsor will pay as much of entrant's filing and hearing fees in connection with the arbitration as the arbitrator deems necessary to prevent the arbitration from being cost-prohibitive; and (x) with the exception of subpart (vi) above, if any part of this arbitration provision is deemed to be invalid, unenforceable or illegal, or otherwise conflicts with the rules of JAMS, then the balance of this arbitration provision shall remain in effect and shall be construed in accordance with its terms as if the invalid, unenforceable, illegal or conflicting provision were not contained herein. If, however, subpart (vi) is found to be invalid, unenforceable or illegal, then the entirety of this arbitration provision shall be null and void, and neither entrant nor Sponsor shall be entitled to arbitrate their dispute. For more information on JAMS and/or the rules of JAMS, visit their website at https://www.jamsadr.com.
17. WINNERS LIST/OFFICIAL RULES: To obtain a copy of any legally-required winners list, send a self-addressed stamped envelope to The "Why I Love Poker" Contest Winners List, c/o WPT Enterprises, Inc., 1920 Main Street, Suite 1150, Irvine, CA 92614. All such requests must be received within six (6) weeks following the end of the Promotion Period.
© WPT Enterprises, Inc. All Rights Reserved.


text:
14K Château Marquise Ring
- Precio normal
- Precio de venta
- Precio normal
- Precio unitario
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Free shipping on US domestic orders, and international orders over $200
Our 14K Château Marquise ring features three marquises. A ring band to make you feel like royalty. Perfect to wear alone or paired with other rings. Handcrafted in 14K yellow gold, rose gold and white gold with cz or natural white diamonds.
Create the ultimate stack by pairing this with our Pixie Cluster ring, and Venice Pear Marquise Ring.
**This item is specially made for you . Please allow 1-2 week lead time.
Domestic: Free standard shipping within the U.S.
International: Free standard shipping for orders over $200
- Interested in customizing this item? See our special order page here to start.
- Not sure what your ring size is? See our conversion chart here.
*For custom size, simply indicate your ring size during checkout. Reach us here, or email us at email@example.com if unsure.
Online Return Policy
All pieces are made-to-order with precious metals and gemstones, and cannot be exchanged or returned for change of mind. If a wrong size is ordered, you can send the ring back for resizing. You will be responsible for the return shipping and will be subject to a resizing fee. Please contact us at email@example.com before proceeding.


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This week is a huge week for golf in Orlando as the Tavistock Cup and the Arnold Palmer Bay Hill tournaments are set to start. We'll be following all the action as the leading players in the world hit the fairways and greens.
Today is the start of the two day Tavistock Cup in which 24 players compete for a purse of $2,150,000. The winning team receives $600,000, second place $480,000, third $360,000 and fourth place $300,000. The Tavistock Cup is also an event that has seen more than $7 million generated for charity over its short nine year history.
The Tavistock Cup was established in 2004 and began simply as a friendly interclub match between Isleworth and Lake Nona's golf professional members. Today, the tournament encompasses four teams as Albany and Queenwood were added in 2010 and is recognised as the World Golf and Country Club Championship.
Today sees Round 1 and that will start at 10.50am. We'll be giving updates from time to time now that the players have arrived on the course….some of whom have arrived in grand style by helicopter!
Here's some photos from the players arriving and you'll find more on Facebook.com/FloridaLeisure