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February 25, 2005
Part I: Research Update
Part II:
There is no doubt that antiretroviral treatment today is simpler to take and has fewer toxicities than ever before. However, many of the people who began treatment years ago are still taking older regimens, many of which may have significant toxicities. Although clinicians have been wary of switching active drugs, an increasing number of studies have shown that this can be accomplished without adverse consequences and can improve a regimen's side effect profile, dosing frequency and pill burden. This year at the 12th Conference on Retroviruses and Opportunistic Infections (CROI) in Boston, there were several presentations addressing the topic of switching antiretroviral agents.
Switches in antiretroviral therapy have become quite common and are primarily considered in 3 circumstances:
This article will focus exclusively on treatment switches made for reasons of simplification or the management/prevention of antiretroviral-related toxicities.
With the development of additional antiretroviral agents that have favorable pharmacokinetic profiles for once-daily administration, it is not surprising that we continue to see studies designed to quantify the benefit of combining such agents in a once-daily regimen. Several of these regimens have become quite popular for the treatment of naive patients and are becoming increasingly more in demand by patients who have already begun therapy.
Another treatment approach that has grown more common involves the simplification of an antiretroviral treatment by switching to a FDC. Some studies have suggested that the convenience provided by these combined drugs will result in better adherence, without compromising long-term efficacy and safety.1 In addition, at the XV International AIDS Conference in Bangkok, Thailand, data were presented suggesting that the simplicity of once-daily therapy may translate into much improved clinical outcomes.2 More studies are needed to confirm this concept.
At this year's CROI, 2 studies presented data on switching in order to simplify treatment. The first one was a follow-up by Jean-Michel Molina et al of his previously presented French study: the ALIZE-ANRS 099 Trial.
The original study was a prospective, open-label, multicenter study in which 355 patients who were virologically controlled on a protease inhibitor (PI)-based regimen, were randomized to either continue their regimen (n=177) or to switch to a once-daily combination (n=178) of emtricitabine (FTC, Emtriva) + didanosine (ddI, Videx) + efavirenz (EFV, Sustiva, Stocrin). The previously presented data showed at 12 months that the once-daily arm was not inferior to the PI arm according to the virologic efficacy end-point.3
After the initial 12 months of this study, only the patients who had been in the once-daily arm were followed for an additional 2 years. Molina presented the results of the additional 2 years of follow-up for this once-daily arm.4
At the end of the additional 2 years of follow-up, of the initial 178 participants, 56 (32%) had discontinued the study for various reasons. The proportion of patients who had a plasma HIV RNA under 400 copies was 95% in an intent-to-treat analysis (ITT) and 96% in the as-treated population. The mean change in CD4+ cell count was modest (128 cells/mm3). In addition, 39% of the patients had at least one sign of lipodystrophy.
The investigators concluded that the substitution of a PI-based regimen with a simplified once-daily regimen of emtricitabine + didanosine + efavirenz was well tolerated and associated with long-term virologic suppression.
Another simplification study presented, known as the SEAL study (ESS30008), was sponsored by GlaxoSmithKline. It compared the combination pill known as Epzicom (Kivexa in Europe), which contains abacavir (ABC, Ziagen) and lamivudine (3TC, Epivir), to individual drugs in a treatment-experienced population that had controlled infection.5
The efficacy and safety of abacavir + lamivudine given either once or twice daily, or in a single pill as a FDC, have been extensively studied in antiretroviral-naive patients as part of non-nucleoside reverse transcriptase inhibitor (NNRTI) regimens.1,6
The SEAL study was a 48-week, phase III, randomized, open-label study that enrolled HIV-1- infected patients who had initiated treatment with twice-daily abacavir and twice-daily lamivudine, plus either a PI or an NNRTI. At the time of study entry, all trial participants had to have been on therapy for a minimum of 3 months, and had to have an HIV RNA of less than 400 copies/mL with a CD4+ cell count of more than 50 cells/mm3.
The 260 patients were randomized to either continue their abacavir + lamivudine regimen (twice-daily group), or switch to the abacavir/lamivudine FDC (once-daily group). They all continued their third drug, which, in two thirds of the patients, was an NNRTI. Because these patients were already on therapy, the rate of discontinuation after switching or continuing with their regimen was quite low (8% versus 10%, respectively).
In the once-daily FDC group, the proportion of patients who continued to respond (non-virologic failures) was 95% and 93% for the twice-daily group. These results did not change if the patients were stratified by the third drug (the PI or NNRTI) in their regimen.
The proportion of patients whose HIV-1 RNA fell to below 50 copies was 81% in the once-daily group and 82% for the twice-daily group in an ITT analysis. Participants' CD4+ cell counts, which were fairly high at baseline (median 554 cells), remained stable in both groups.
Overall, the combination of abacavir + lamivudine, either given as individual components or as a fixed-dose combination tablet, was extremely well tolerated. Only 2 subjects discontinued the study due to adverse events, which the researchers felt were not related to the study medications. As expected, no hypersensitivity to abacavir was reported in this abacavir treatment-experienced population.
During the 48 weeks of the study, 6 patients developed virologic failure: 4 of these patients were in the NNRTI group and 2 were in the PI group. For each of the 6 patients, the virologic failure was felt to be because of non-adherence. For this study, optimal adherence was considered to be above 95%, based on previous data. The proportion of patients achieving such a high level of adherence was 39% in the once-daily FDC group versus 31% in the twice-daily group.
The authors concluded that the fixed-dose combination of abacavir/lamivudine is associated with a potent and durable antiviral response, which was non-inferior to the response seen with abacavir + lamivudine when given as separate components twice daily.
Overall, these 2 simple studies provide more data corroborating what we have been learning over the past few years regarding the benefits of treatment simplifications, by either offering our patients once-daily antiretroviral treatment and/or by offering a treatment simplification with the use of a fixed-dose combination drug.
It is important to keep in mind though that the patients who were selected for participation in these studies had already had an excellent response to their first antiretroviral therapy regimen. It is highly unlikely that they had previously developed any underlying resistance while on therapy. So this bias in patient selection needs to be considered when extrapolating these study results to clinical practice. These treatment simplifications may not be an option for many patients who may have already developed partial resistance to some antiretroviral agents on prior regimens. In order to avoid adverse outcomes, it's vital to know what prior antiretrovirals your patients have been on and what their responses were before any such simplifications are made.
Determining the causative factors for metabolic complications is complex. These complications can be caused by different drug classes or by HIV itself.7 There are currently a multitude of ongoing trials attempting to address this issue.
There were several elegant presentations at this year's CROI addressing the management and the prevention of metabolic complications by changing therapy in patients who are already virologically controlled. Some studies focused on switches made from nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) to PIs for the improvement of lipoatrophy. In other studies, patients were switched off their PIs and onto a reverse transcriptase inhibitor in order to manage or prevent dyslipidemia and insulin resistance. A few other studies addressed specific complications such as anemia.
One of the most troubling side effects of long-term antiretroviral regimens is appendicular fat loss. Many studies have already documented the effects of nucleosides on the development of lipoatrophic changes (fat loss) in the trunk and extremities.8
It is important that these lipodystrophic side effects are addressed because they have been found to have a negative impact on both the physical and psychological well being of a patient. The weight loss in a patient's face, as well as in his or her arms and legs, often leads to stigmatization, decreased self-esteem and depression.
Several studies in the past, including the MITOX9 and the TARHEEL10 studies, have demonstrated that switching from a thymidine analog partially reversed lipoatrophy.
So, NRTI-sparing regimens are attractive potential alternatives to avoid the toxicities associated with NRTI therapy. In addition, mitochondrial dysfunction has been suggested as at least one potential underlying mechanism in the pathogenesis of peripheral lipoatrophy and dyslipidemia, which are associated with some thymidine analogs.
Robert Murphy, from Northwestern University Medical School, presented the results of the AIDS Clinical Trials Group (ACTG) study 5110, which was designed to assess lipoatrophy in patients switching to a thymidine analog-sparing or a nucleoside-sparing regimen.11
Patients who were receiving the thymidine analog of either stavudine (d4T, Zerit) or zidovudine (AZT, Retrovir), who had an HIV RNA equal to or less than 500 copies/mL and had clinical evidence of peripheral lipoatrophy, were randomized to:
To better evaluate changes in tissue fat, patients underwent centrally analyzed single-slide computerized tomography (CT) of their mid-thigh and abdominal fat. In addition, dual energy X-ray absorptiometry (DEXA) scans were obtained at baseline and week 24, along with other metabolic and immunologic parameters.
The group that had their switch delayed, began their intervention at week 24. Eleven patients were switched to abacavir and 13 patients were switched to lopinavir/ritonavir + nevirapine. All patients were followed for 48 weeks after their change in therapy.
The following slides summarize the median percentage changes at 24 weeks in abdominal SAT (subcutaneous adipose tissue) and VAT (visceral adipose tissue).
|Visceral adipose tissue (VAT)
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|Abdominal SQ adipose tissue
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|(Slides courtesy Robert Murphy; reprinted with permission. To download the full PowerPoint slide presentation, click here.)
At 24 weeks, subcutaneous thigh fat increased in the lopinavir/ritonavir + nevirapine group. There were significant SAT increases and significant VAT decreases for both interventions, and a decrease in VAT for the abacavir group. There were no significant changes seen in either glucose or insulin levels.
The lopinavir/ritonavir + nevirapine group had higher total cholesterol and triglyceride levels, but no changes in the high-density lipoprotein cholesterol (HDL-C). There were also no changes in bone mineral density (BMD). There was also a significant increase in CD4+ cell count for the lopinavir/ritonavir + nevirapine group.
This study clearly adds further evidence that switching patients off a thymidine analog is associated with significant improvements in some of the lipoatrophic manifestations clinically observed in some patients. The question, however, remains whether regimens omitting NRTIs altogether (not just a thymidine analog sparing regimen) will increase appendicular fat. It was Pablo Tebas, from the University of Pennsylvania, who endeavored to answer this question in his presentation of the ACTG 5125s study results.12
In this study, investigators wanted to demonstrate that a switch to a PI-containing/NRTI-sparing regimen would increase appendicular fat content and serum lipid levels without affecting glucose metabolism or BMD. ACTG 5125s is a metabolic sub-study of the larger trial A5116, which was conducted to determine the effects of a PI-containing, NRTI-sparing regimen on fat distribution and BMD by using whole body and regional DEXA, as well as other metabolic parameters.
Sixty-two subjects who initially had advanced HIV disease (nadir CD4+ cell counts of less than 200 cells/mm3), but were well controlled on their regimen at the time of study entry (HIV RNA equal to or less than 200 copies), were randomized to switch their initial successful antiretroviral regimen to open-label lopinavir/ritonavir + efavirenz (n=31) or switch to efavirenz + 2 NRTIs (n=31).
Patients were not allowed to enter the study if they were taking growth hormone, megestrol (Megace), anticytokine agents, ketoconazole (Nizoral), systemic glucocorticoids or treatment for osteoporosis.
There were no significant differences with regards to glucose metabolism, lipids, fat distribution and BMD between the 2 groups at baseline. The percentage of patients who had been taking stavudine at study entry was 19% for the lopinavir/ritonavir + efavirenz arm versus 25% for the NRTI arm.
At week 48, the median change in appendicular fat in the lopinavir/ritonavir + efavirenz arm was +562 grams (g) (-218 g to 1,186 g) versus a loss of -246 g (-631 g to 459 g) in the NRTI-containing arm (P = .097).
At the time of the last observation (n=46, median 104 weeks), a median gain of 782 g (an increase of 10%) of appendicular fat was noted in the non-NRTI arm versus a loss of -900 g (a decrease of 15%) in the NRTI-containing arm (P = .002).
|Appendicular fat change
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|(Slide courtesy Pablo Tebas; reprinted with permission. To download the full PDF slide presentation, click here.)
Patients had been taking different NRTIs at the time of study entry. These results provide additional evidence that the difference observed in the loss of appendicular fat was the result of the use of NRTIs in those patients. Unfortunately, the study was not large enough to determine differences between specific NRTIs, nor was it designed to determine the relative contribution of different NRTIs to lipoatrophy. Tebas pointed out that it was unlikely that stavudine might have driven the cumulative fat loss in the NRTI arm since less than 25% of the patients were taking stavudine in that arm.
At week 48, the lopinavir/ritonavir + efavirenz arm had greater increases in triglycerides (85 versus 11 mg/mL; P = .01) and in total cholesterol (+19 versus -7 mg/mL; P = .0008) compared with the NRTI arm. HDL-C were similar (+6 mg/mL for the lopinavir/ritonavir versus +2 for the NRTI arm). Trunk fat and BMD remained stable.
The findings in this study support previous observations noting that lopinavir/ritonavir has minimal effect on glucose metabolism, but that it is associated with greater increases in triglycerides and total cholesterol than the NRTI-containing regimen. These results also provide additional evidence that NRTIs are an important factor in the progressive appendicular fat that characterizes HIV lipoatrophy.
In another presentation, Graeme Moyle, from the Chelsea and Westminster Hospital in London, discussed the results of the RAVE Study.13
This study was conducted with the following assumptions:
Thus, with those things in mind, in this study, 105 mostly white, male, virologically-controlled patients (with HIV RNA of less than 50 copies) taking zidovudine or stavudine were equally randomized to change their thymidine analog to either abacavir or tenofovir, plus continue their other nucleoside and PI or NNRTI.
At study entry, all patients had moderate to severe lipoatrophy. The investigators then looked at the change in total limb fat mass by DEXA, the changes in lipids, VAT by CT-scan, BMD, body fat, CD4+ cell count and HIV RNA for a period of 48 weeks.
At baseline, there was a significant difference in the number of patients who had been taking stavudine. In the tenofovir group, 77% of the patients had originally been on stavudine while 23% had been on zidovudine. In the abacavir group, 59% of the patients had been taking stavudine while 41% had been taking zidovudine. Unfortunately, the investigators were unable to stratify the study results based on the prior use of stavudine versus zidovudine.
The most important findings of this study are summarized in the following 2 slides:
|Median changes at week 48 in limb fat by DEXA by baseline characteristics
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|Median change in metabolic outcomes to week 48
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|(Slides courtesy Graeme Moyle; reprinted with permission. To download the full PowerPoint slide presentation, click here.)
When switching from thymidine analogs, both tenofovir and abacavir allowed similar restoration of limb fat over 48 weeks. There was a trend toward more fat restoration on the tenofovir arm that was not statistically significant. Virologic suppression was similarly maintained in both groups and there were similar CD4+ cell count changes. The lipid changes did favor the tenofovir arm. There was also no significant BMD changes observed.
So the overwhelming weight of the data presented during this presentation indicates that switching from a thymidine analog to abacavir or tenofovir can lead to significant increases in limb fat, and that the use of thymidine NRTI-sparing regimens as initial treatment may help to prevent the development of this complication altogether.
Ana Milinkovic, from Barcelona, Spain, presented another interesting study aimed at answering the question of whether a reduction in the dose of stavudine could prevent and/or reduce the development of stavudine-associated metabolic complications.16
In her study, 58 virologically-controlled patients (HIV RNA of less than 200 copies) on stavudine 40 mg twice daily were randomized to:
More than two thirds of the patients in the study were taking an NNRTI-based regimen. Peripheral blood mononuclear cells (PBMCs) for mitochondrial analysis, DEXA scans and multiple other metabolic parameters were followed during the course of the study.
At 6 months, all patients but 1 in the stavudine 40-mg twice-daily group had plasma HIV RNA below 200 copies/mL. Significant changes in laboratory parameters, including mitochondrial function, were only detected in triglyceride and total cholesterol changes. In addition, mean changes in total peripheral fat and total lean mass were significantly different among the groups. (See slides below.)
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|Peripheral fat
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|Total lean mass
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|(Slides courtesy Ana Milinkovic; reprinted with permission. To download the full PowerPoint slide presentation, click here.)
The investigator found that switching from stavudine 40 mg twice daily to tenofovir was associated with significant improvement in triglycerides, total cholesterol and body fat at 6 months.
Interestingly, the reduction in the stavudine dose from 40 mg twice daily to 30 mg twice daily was associated with an improvement in triglycerides, total cholesterol and body fat at 6 months, although the differences did not reach statistical significance.
Another switch study that showed improvement of subcutaneous fat after patients were switched from stavudine to tenofovir was the LIPOTEST Study, which was presented by Esteban Ribera from Barcelona, Spain.17 The investigators attempted to prove that a switch from stavudine to tenofovir would result in an increase in mitochondrial DNA (mtDNA) in PBMCs that would then result in an improvement in a patient's lipid profile as well as his or her peripheral lipoatrophy.
Fifty-three patients with HIV RNA below 50 copies and objective evidence of lipoatrophy, on a stavudine-containing regimen, were enrolled in the study and switched to tenofovir. The rest of their regimen remained unchanged. The investigators measured the ratio between the mitochondrial DNA and nuclear DNA in PBMCs by real-time PCR assay. Fat mass and subcutaneous malar fat thickness were determined by bioelectrical impedance analysis and sonography, respectively.
Although not statistically significant, the authors were able to demonstrate that the mtDNA content in the participants' PBMCs increased from a baseline of 42 (32-63) to 66 (45-112) at 18 months. This increase was associated with statistically significant decreases in both lactate and triglyceride levels, as well as statistically significant increases in malar fat and thickness.
Overall, these presentations add to the extensive research implicating the use of thymidine analogs as a direct culprit in the pathophysiology of lipoatrophy. It also appears very clear that switching from a thymidine analog to a non-thymidine analog (specifically abacavir or tenofovir) can lead to significant increases in limb fat. Furthermore the use of thymidine NRTI-sparing regimens as initial therapy in naive patients may help to prevent the development of these complications in the first place.
Dyslipidemia, which simply refers to abnormal levels of fats in the blood, has become a common problem affecting HIV-infected patients, and it has been associated with a higher incidence of cardiovascular disease in HIV-infected patients.18 Several studies have established a relationship between the use of some PIs and NRTIs with alterations in total cholesterol and triglycerides.
In patients treated with PIs, researchers have observed a pattern of dyslipidemia that includes an elevation in total cholesterol levels, a high level of low-density lipoprotein cholesterol (LDL-C), a reduced level of HDL-C and elevated triglycerides.
The association of dyslipidemia with certain antiretroviral agents has led to the development of switching strategies that are designed to exchange the potentially offending component for a drug not known to cause dyslipidemia. Although most PIs have been associated with significant dyslipidemia, an exception to this is the more recently approved PI, atazanavir (ATV, Reyataz), which has not been associated with increases in total cholesterol, LDL-C and/or triglycerides.
But, for the most part, replacing a PI component with a drug from another class has usually resulted in an improvement in lipid parameters. Similarly, stavudine has been implicated in the development of hypertriglyceridemia -- a condition that improves once stavudine is replaced with a non-thymidine reverse transcriptase.
Several studies addressed the benefit of switching some antiretroviral drugs in order to manage dyslipidemia. This article has already discussed the results of 3 studies in which the change from a thymidine analog to tenofovir resulted in significant lipid improvements in the tenofovir arm.13,16,17
Michael Sension presented the preliminary 12-week results of the study AI424067.19 This study was designed to examine the effect on lipid parameters of a switch to atazanavir 400 mg once daily from another PI (boosted or not) in virologically-controlled patients. Patients (n=246) were randomized to either switch to atazanavir and continue their nucleosides, or continue with their current PI therapy. They then compared the percentage change from baseline in fasting total cholesterol, LDL-C, HDL-C, triglycerides, Apolipoprotein B and lipoprotein A.
The following graph shows the results of the mean fasting LDL-C and triglycerides from baseline through week 12 in this group.
|Mean fasting LDL cholesterol and TG from baseline through week 12 -- treated subjects
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|(Slide courtesy Emelio F. Ledesma; reprinted with permission. To download the complete PDF poster, click here.)
In the preliminary 12-week results of this 48-week study, the researchers were able to show significant reductions in participants' LDL-C after switching another PI to atazanavir, with no changes in efficacy between the arms. A statistically significant difference was observed in Grade 3-4 hyperbilirubinemia between the atazanavir and the continuation arms (22% versus less than 1%, respectively).
Another study, presented by Martinez from Barcelona, Spain, examined the effects of switching to ritonavir (RTV, Norvir)-boosted atazanavir on HIV-infected patients who were receiving antiretroviral therapy and experiencing hyperlipidemia.20 In this study, they analyzed data collected from 162 patients who received boosted atazanavir and who had evidence of hyperlipidemia at baseline (i.e., triglycerides greater than 500 mg/dL, and/or total cholesterol greater than 200 mg/dL, and/or LDL-C greater than 130 mg/dL).
The study showed that the median lipid changes from baseline to month 6 were: -18% in triglycerides (P<.0001), -12% in total cholesterol (P<.0001), -10% in LDL-C (P<.0001) and -3% in HDL-C (P>.05).
The proportion of patients with triglycerides greater than 500 mg/dL decreased from 33% to 10% (P<.0001), total cholesterol greater than 200 mg/dL from 90% to 51% (P<.0001), and LDL-C greater than 130 mg/dL from 65% to 36% (P<.0001).
In conclusion, this study found that in this patient population, switching to a ritonavir-boosted atazanavir was well tolerated, and was associated with significant improvements in plasma lipids, without an increased risk of virologic failure. There was also a significant reduction in the proportion of patients using concomitant lipid-lowering agents.
Calza et al, from the University of Bologna, Italy, presented the results of an interesting study in which patients with highly active antiretroviral therapy (HAART)-related dyslipidemia were either switched from a PI to an NNRTI or a lipid-lowering agent was added to their PI regimen.21
This study contained 142 randomized patients (130 patients were eligible for evaluation). Its purpose was to assess the efficacy on hyperlipidemia of a switch from a PI to nevirapine (n=29) or a switch to efavirenz (n=34), or the addition of pravastatin (Pravachol) (n=36) or bezafibrate (n=31) to their otherwise unchanged antiretroviral combination.
At baseline, all patients had a viral load below 50 copies, were taking a PI-containing regimen, were naive to NNRTIs and had for at least 6 months documented mixed hyperlipidemia (that had not responded previously with a diet intervention).
At the end of the 12-month follow-up, the reductions in mean triglycerides were 25.2%, 9.4%, 41.2% and 46.6%, and the reductions in total cholesterol were 27.1%, 10.2%, 45.8% and 37.6% for the nevirapine, efavirenz, pravastatin and bezafibrate groups, respectively.
So, as you can see, giving patients pravastatin and bezafibrate proved to be significantly more effective in the management of HAART-related hyperlipidemia than switching therapy from a PI to an NNRTI. Of note, however, is that pravastatin was found to be statistically more effective than bezafibrate, and nevirapine was found to be statistically more effective than efavirenz in reducing both plasma triglycerides and total cholesterol levels.
HIV-related anemia has been found in multiple studies to be multifactorial; however, one of the major culprits is the concomitant use of zidovudine, which is well known to be myelosuppressive. The importance of addressing anemia in HIV is clear, since a low hemoglobin level has been found to be an independent risk factor for progression to AIDS and death.22
In 2 recent trials that compared the use of zidovudine versus either abacavir6 or tenofovir1 (in combination with lamivudine or emtricitabine + efavirenz) in treatment-naive patients, the incidence of anemia leading to study discontinuation was found to be 4%-6% in the zidovudine arm. Therefore switching patients who had anemia and had been receiving zidovudine to either abacavir or tenofovir might be expected to result in hematologic improvements.
In another study, researchers assessed the hematologic benefits of switching from regimens containing a PI + zidovudine + lamivudine to efavirenz + didanosine + emtricitabine. This was a substudy of the French ALIZE ANRS 099 study.23
This open-label study was conducted for 48 weeks. Three hundred fifty-five patients were randomized to continue their PI regimen, or switch to an entire once-daily regimen. Of those patients, only 150 were taking zidovudine + lamivudine + a PI at baseline: 76 continued their baseline therapy and 74 were switched to emtricitabine + didanosine + efavirenz.
The mean change in hemoglobin from baseline to week 48, after switching to the once-daily regimen (and thus switching off of zidovudine), was +0.7 grams/dL versus -0.4 grams/dL (PI + zidovudine) (P<.01). There was also a statistically significant increase in the mean change of neutrophils (32% versus 6%). All of these patients were able to maintain virologic and immunologic control on their new regimen.
So, in conclusion, for HIV-infected patients who are just starting antiretroviral therapy, there are plenty of promising new options with a reduced potential for long-term metabolic complications.
For patients already on therapy with older drugs, there is compelling evidence that a switch off some of those older drugs may be appropriate in order to manage the emergence of an adverse event, such as dyslipidemia and lipoatrophy. In many instances, the switch is to a simpler regimen with easier once-daily scheduling and a low pill burden.
The results of these studies support the now common practice among many HIV providers: When patients experience toxicities and there are other options, providers switch medications. So, although switching to a less toxic antiretroviral therapy regimen is not new, having the clinical data to support that change and corroborate what we long suspected is extremely valuable.
Edwin DeJesus, M.D., is the medical director of Infectious Diseases Consultants Research Initiatives in Florida. In addition to treating HIV and hepatitis patients, he serves as the firm's principal investigator for several clinical trials. He is also a consultant for the Florida Department of Corrections, where he participated in the prototype HIV Prison Unit currently operating in central Florida.
Please read both the Research Update and the Case Studies sections of this article.
|Please note: Knowledge about HIV changes rapidly. Note the date of this summary's publication, and before treating patients or employing any therapies described in these materials, verify all information independently. If you are a patient, please consult a doctor or other medical professional before acting on any of the information presented in this summary. For a complete listing of our most recent conference coverage, click here.
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The man who will move into the 10-room papal residence inside the vaulted gates of the Holy See lives in a simple, austere apartment across from the Cathedral of Buenos Aires. In a city with a taste for luxury and status, he frequently prepares his own meals and abandoned the limousine of his high office to hop on el micro — Argentine slang for the bus.
A staunch conservative and devout Jesuit in Latin America's most socially progressive nation, Cardinal Jorge Mario Bergoglio, now Pope Francis, is the product of an almost Solomon-esque choice by the princes of the church.
The 76-year-old hails from a country and a continent where the once powerful voice of the church is increasingly falling flat, losing ground — as it is in Europe — to a tide of more permissive and pragmatic faiths and to fast-rising secularism. He gives voice to a church whose center of global gravity is shifting south.
But the first Latin American pope also represents a cultural bridge between two worlds — the son of Italian immigrants in a country regarded by some as the New World colony Italy never had. For many Italians, his heritage makes him the next best thing to the return of an Italian pope.
Bergoglio remains a fierce critic of socially progressive trends including gay marriage, representing a continuity of Benedict XVI's conservative doctrine.
Though questioned for some of his actions during Argentina's Dirty War, he may also be a target hard for progressives to hit. In recent decades, he has emerged as a champion of social justice and the poor who spoke out against the evils of globalization and has slammed the "demonic effects of the imperialism of money."
His papal name honors St. Francis of Assisi, the son of wealthy merchants who abandoned all for a life of poverty in the path of Jesus Christ.
At the same time, in the age of 24-hour news cycles and the cult of celebrity excess, he is described by some as so retro as to be something oddly new. He represents a flashback to an old-school view of the Catholic leaders as humble, soft-spoken clerics who walked among their flock and led by example — albeit also one who has used the Internet as a tool to reach lapsed Catholics.
"He knows how to take a municipal bus. … He has a sense of social justice, but he can be seen as quite conservative doctrinally," said the Rev. Robert Pelton, CSC, the director of Latin American Church Concerns at the University of Notre Dame.
"He's a simple person," Pelton said. "The fact is that he has a straightforwardness and simplicity that is quite unusual in public figures of our time."
It remains unclear whether even Latin Americans will respond with newfound energy to Bergoglio's ascension to the throne of St. Peter. Among many of its neighbors, Argentina is seen as a nation apart — a country that fancies itself more European than Latin American, with many likely to see the rise of an Italian-Argentine as largely unrepresentative of the region as a whole.
"Argentina is so secular today, a more euro-centric Latin country," said Joseph Palacios, specialist in religion and society in Latin American at Georgetown University. "They are catholic by culture, but not by practice. Geopolitically it makes sense in terms of bridging Europe to Latin America or the third world, but Argentines don't see themselves as being third world."
In his global introduction from the balcony of St. Peter's, he addressed the crowd in Italian, one of three languages he speaks fluently. He presented himself as soft and plain spoken, humble, even quaint — directing his comments seemingly to the citizens of his new city, Rome, more than to the 1.2 billion Catholics worldwide.
"And now let us begin this journey, the Bishop and people, this journey of the Church of Rome which presides in charity over all the Churches, a journey of brotherhood in love, of mutual trust," he said. "Let us always pray for one another. Let us pray for the whole world that there might be a great sense of brotherhood."
Born in Buenos Aires on December 17, 1936, Bergoglio was raised in a struggling middle class home of a railroad worker and housewife. Ordained a priest in 1969, his ascent toward higher office occurred during a time when the Catholic Church in Argentina stood accused of at best failing to speak out, and at worst being complicit, in the harsh right-wing dictatorships of the Dirty War that saw the disappearance of an estimated 30,000 dissidents between 1976 and 1983.
A book by the noted Argentine journalist Horacio Verbitsky, "The Silence," claims that Bergoglio, then a Jesuit leader, lifted church protection from two leftist priests of his order, effectively allowing them to be jailed for refusing to end their politically-charged ministry in Buenos Aires slums. Yet Bergoglio's supporters have cited a lack of evidence, countering that he endeavored to aid dissidents in danger during a dark period in Argentine history.
"History condemns him," Fortunato Mallimacci, the former dean of social sciences at the Universidad de Buenos Aires once said, according to Reuters. "It shows him to be opposed to all innovation in the Church and above all, during the dictatorship, it shows he was very cozy with the military."
One thing is certain, he rose fast. In 1992, John Paul II named him assistant bishop in Buenos Aires, then made him Archbishop five years later. He served on a number of Vatican commissions and in 2005 is widely believed to have come in second to Cardinal Joseph Ratzinger — now the pope emeritus — to succeed John Paul II.
But Bergoglio was mostly absent from the short lists for pope this time around, and has been largely seen as a Vatican outsider. That is seen as positive by reformers who are looking for a clean up of the Roman Curia, the Vatican City administration now battered by allegations of corruption and misconduct.
In recent years, Bergoglio became known for creating new parishes, reorganizing administrative offices spearheading a fiercely conservative social agenda. He has butted heads repeatedly with increasingly secular Argentine governments.
In 2006, he attacked a proposal to legalize abortion under certain circumstances by accusing the government of lacking respect for human life.
Varsity Maine
Boys' hockey players to watch
Monday's NFL roundup: Seahawks pull away to beat Vikings
Monday's NBA roundup: Embiid lifts 76ers past Pistons
Boys' basketball: Greely rises when needed
Hallowell awards 2 retail pot licenses, leaving existing operator out of the mix

subset: commoncrawl


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Police in Meredith, N.H., have charged a Worcester, Mass., man with seeking to distribute about 25 pounds of marijuana in the area.
Tuan Ngoc Le of Worcester, Mass., is accused of arranging to have two large parcels containing the marijuana delivered to a home he was renting in Meredith. He was being arraigned Friday.
Police learned of the pending delivery and intercepted it Thursday afternoon.
The Citizen reports officer posed as couriers and took the packages to Le's home. He was taken into custody after receiving them and charged with possession of marijuana with intent to distribute.
Police said they also seized thousands of dollars of cash from the home.


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AL Capsules
KANSAS CITY, Mo. (AP) — Salvador Perez drove in three runs and Mike Moustakas went 3 for 4 with a game-winning home run to lead the Kansas City Royals to a 6-5 victory over the Detroit Tigers and Justin Verlander on Saturday night.
Verlander (10-7) had not lost to the Royals since Sept. 9, 2009, but gave up six runs, five earned, on eight hits and four walks in 5 2-3 innings. It was the seventh time in 21 starts that Verlander failed to make it into the sixth inning.
Moustakas homered to right in the fifth to snap a 5-5 tie.
Perez drove in a run in the first with a sacrifice fly and stroked a two-run double in the third.
Jeremy Guthrie (9-7) picked up the victory, surrendering five runs on 10 hits and two walks in six innings.
Greg Holland worked the ninth to collect his 24th save in 26 chances.
HOUSTON (AP) — Michael Saunders got Seattle's only hit with a two RBI double with two outs in the seventh inning to lift the Mariners to a 4-2 win over the Houston Astros on Saturday night.
Erik Bedard (3-7) pitched 6 1-3 innings of no-hit ball before he was replaced by Jose Cisnero, who walked Mike Zunino with two outs before the double by Saunders put Seattle ahead 4-2.
The long fly ball sailed just out of reach of sprinting center fielder Brandon Barnes and landed at the top of Tal's Hill in straightaway center.
The Mariners, who extended their season-high winning streak to five games, tied it in a wacky sixth inning by scoring two runs thanks to a combination of passed balls, walks and a sacrifice fly.
Travis Blackley and Jose Veras each pitched a scoreless inning to complete the one-hitter.
BOSTON (AP) — Brett Gardner and Lyle Overbay each had three hits and drove in a run to back Hiroki Kuroda's seven strong innings, carrying New York Yankees past Boston.
The victory snapped a three-game losing streak for the injury-riddled Yankees, who hope to be bolstered soon by the return of captain Derek Jeter and Alex Rodriguez.
Mike Carp had three hits and scored a run for the Red Sox. It was just Boston's second loss in its last 11 games in Fenway Park.
Kuroda (9-6) and John Lackey (7-7) combined for just one walk — by Kuroda — and threw a high percentage of strikes.
All Star game MVP Mariano Rivera entered to a nice ovation and worked the ninth for his 31st save. Robinson Cano added two RBIs.
ANAHEIM, Calif. (AP) — C.J. Wilson outpitched Dan Straily, retiring 18 consecutive batters at one point, and Alberto Callaspo homered to help Los Angeles beat Oakland.
Wilson (10-6) gave up three hits in 8 1-3 innings. He struck out eight and walked two. Jed Lowrie's two-out double in the first and Nate Freiman's leadoff single in the second were the only hits off the left-hander until Lowrie's one-out single in the ninth on Wilson's 119th and final pitch. Wilson began his string of consecutive outs with three straight strikeouts on 10 pitches and didn't allow another baserunner until he walked Derek Norris on a full count leading off the eighth.
Ernesto Frieri got the final two outs for his 24th save in 26 chances, striking out pinch-hitter John Jaso with runners at first and second to end it.
TORONTO (AP) — Jeremy Hellickson won his fifth straight decision, Desmond Jennings reached base four times and Tampa Bay beat the Toronto for its 16th win in 18 games.
Rookie Wil Myers had two RBIs in his first career start as the cleanup hitter. Myers, who finished 2 for 4, has nine hits in his past 17 at bats.
Jennings went 3 for 4 with a walk and scored twice.
After starting the season 14-18, the Rays are a major league-best 43-23 since May 8.
Toronto's Jose Bautista homered for the second straight game but the last-place Blue Jays lost for the fifth time in six games.
Hellickson (9-3) allowed two runs and five hits in five innings, walked three and struck out three.
ARLINGTON, Texas (AP) — Adam Jones homered, every Baltimore starter had a hit, and Miguel Gonzalez pitched another solid game on the road in the victory over sliding Texas.
Rangers starter Ross Wolf (1-3) was done after the first four batters in the third reached base. They all scored to put Baltimore up 7-0. Wolf gave up nine hits to the 16 batters he faced, and his only two strikeouts ended the first with the bases loaded after the Orioles had already scored twice.
Gonzalez (8-3) scattered eight hits and allowed one run in 6 2-3 innings. He left after his 104th pitch, when Ian Kinsler had a sac fly for the first Texas run. Jim Johnson worked the ninth for his majors-best 35th save.
MINNEAPOLIS (AP) — Kevin Correia threw six sharp innings for his first win in a month, Joe Mauer and Justin Morneau each had two hits and a walk, and Minnesota beat Cleveland for its fourth-straight win.
Correia (7-6) allowed only three hits — one of them a two-run homer by Jason Kipnis — with one walk and three strikeouts.
The Indians led 2-0 after Kipnis' homer in the sixth. But Corey Kluber — who had pitched five shutout innings up to that point — left the game with tightness in his left hip, and the Twins pounced on a couple of Cleveland infield miscues to take the lead.
The Indians have lost two straight after heading into the All-Star break with a four-game winning streak.
CHICAGO (AP) — Alex Rios hit a grand slam and drove in five runs, and Jake Peavy pitched six solid innings in his return from the disabled list to lead Chicago over Atlanta.
Rios, who had been in a 2-for-20 slump, went 3 for 5 to help Chicago win for just the 10th time in 32 games.
Peavy (7-4), making his first start since June 4 because of a fracture rib, allowed seven hits in six innings, and just two of the four runs charged to him were earned.
Braves starter Paul Maholm (9-9) was forced out in the fourth inning because of a sprained left wrist. He was staked to a 4-0 lead but couldn't hold it. He allowed seven runs and seven hits in three-plus innings.


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skyhightree1 wrote:TennesseeTuxedo wrote:Thank you taking so much of your time posting such an educational thread as this.
ME THREE....GOOD WRITE UP...i HAVE HELPED IN QUITE A FEW BUT NEVER DONE ONE MYSELF....
skyhightree1 wrote:TennesseeTuxedo wrote:Thank you taking so much of your time posting such an educational thread as this.
milkmaid wrote:a good necropsy found that the calves needed dewormer, not antibiotic.
milkmaid wrote:I've seen plenty of posts by people perplexed why they had an animal die - especially the ones that appeared healthy the hour/day/week before. There's too many possibilities for any definitive diagnosis over the phone/internet/etc, especially with limited history and no pictures. Below is my attempt to help those type of posters narrow the possible differentials. Follow the instructions, take some good pictures, and you might be able to get an answer - or some good guesses - why your cow/calf/bull/etc died.
What do you need for a necropsy?
KNIFE - a sharp one! Most hunting knives and possibly some kitchen knives will work in a pinch. Mine is a 7" Jorgeson necropsy knife. The 5" blades will also work just fine, mine is a little excessive for calves.
GLOVES - please use!
CAMERA - pictures are essential
AX - you can cut through the ribs with a knife on anything up to about 18-24 months of age. Over that and you will need an ax (or massive set of bolt cutters/pruning shears) to get through the ribs.
TIME - I can do an 800lb calf alone in 7-12 minutes... but I did a couple a day for about 6 weeks to gain that competence. Plan on 45 minutes minimum with help, maybe an hour or two if alone or your first try at a necropsy. They're a little different than gutting a deer.
MISC - ruler if you need to describe something later, container(s) for specimens you're unsure about.
*Note: tissue samples go in the fridge, not freezer, and/or to your vet clinic ASAP*
STEP 1: The dead animal can be positioned with its right side up, left side up, or on its back. Doesn't really matter. I prefer right side up as I was trained on a feedlot and since pneumonia is one of the top causes of death in cattle - it tends to affect the first lung lobe on the right before the others. If I open the calf with its right side visible, sometimes I have my answer as to the cause of death right away. The vet school's necropsy floor prefers left side up (Lucky, I'm guessing you too?). I've traveled with a few veterinarians who preferred the calf on their back and splitting them down midline - my main complaint about that is it takes more than one person, a luxury I don't usually get.
STEP 2: Make a cut from the throat, down the neck, under the forelimb, and under the right hind limb. Lift the front leg and cut underneath it - there's just muscle and nerve attachments beneath it and it is fairly easy (dependent on size) to pick up and flip over. Depending on your size and strength - I've done some 1400 lb animals that I really did need an extra hand for leverage - or I've utilized chains, four wheelers, tractors, etc - use your head.
*Note: you can also make a cut along the hide up to the hip and skip cutting through the back leg as shown in the picture above - not quite as complete a necropsy and potentially more work later, but it is a valid option.
STEP 3: Getting through the ribs. Up to 18-24 months of age you can cut right through the costochondral junction with a knife.
I usually put a knife between each rib and separate them, then place my knife at the cartilage junction between ribs and sternum as shown in the pics above, and then just run my knife the length of the ribs. Younger animals its fairly simple, older animals can be incredibly frustrating if you don't get the knife set right. USE BOTH HANDS on the knife.
Here's your goal:
STEP 4: Look at the major organ systems and take pictures of all of them.
My minimum - lungs, heart, liver, kidney(s), rumen, omasum, reticulum, abomasum, esophagus, trachea, sometimes bladder, uterus, intestine, cecum, spleen depending on what I find up to that point/what the animal looked like prior to death. Always check the inside of the mouth for ulcerations (BVD can be the culprit).
*Note that in summer the mouth will often have white piles of fly eggs within a few hours after death - disgusting, but normal.
CUT ALL THE MAJOR ORGANS OPEN - don't just look at them. The interesting pathology is usually inside. This includes lungs, heart, liver, kidneys, esophagus, trachea as a bare minimum.
*Note: for the veterinarians on the board.... I do realize I'm describing a field necropsy and not a complete diagnostic laboratory one.
ABDOMEN: Evaluate the surface of the inside of the abdomen - this cow had peritonitis:
*Note that dragging a cow to a dead pile will occasionally cause some trauma that makes areas (on side close to ground) look bruised and sometimes look like peritonitis.
LUNGS: Look for adhesions between lungs and ribs as you break the ribs back.
Are they normal and pink or are there hard lobes, color changes, or abscesses in them?
Split the trachea down to the terminal bronchioles - this animal had lungworms:
Look for fluid (clear, red, white) in the chest as you open the thorax to get to the heart and lungs. Sometimes you'll have a fountain of yellow fluid come spraying out when you slice through the ribs in a chronic pneumonia case.
LIVER: Always cut slices (breadloaf style):
Look for spots that are inconsistent with the rest of the liver - this animal died of redwater following a necrotic area in the liver:
HEART: You can either cut it out with the lungs (remove the entire pluck with tongue, esophagus and trachea or just cut out heart and lungs together) or cut it out separately. This animal had a fascinating abscess attached to its heart (that's a normal looking bovine kidney next to it):
Always cut the heart open too. It has a right and left side - I usually split it top to bottom through each ventricle and up to the aorta and pulmonary arteries. Look for abscesses, color changes, surfaces that are not clean and shiny.
KIDNEYS: The left kidney is fairly easy to reach from this side and hides in the fat just behind the liver. It's lobed as can be seen in the picture above. Occasional problems with kidneys - 1) abscesses, 2) blocked (may be full of urine), or the interesting one below - she had a renal anurysm and bled out into the area surrounding the kidney.
ESOPHAGUS/TRACHEA: Some people take the tongue out as well, I'm not quite that motivated if I don't have a really good reason for it. I cut at the base of the tongue, peel the esophagus and trachea out together, slide my knife into the esophagus and split it (look VERY carefully for ulcerations not caused by your knife), then same for the trachea (BE CAREFUL - this is a good place to cut yourself). White foam is normal. I tend to make a short cut into the trachea, slide my knife between the rings to make a fingerhold, and then I can hold well enough to split the rest of the trachea.
Any ulcerations, surfaces that are not slick, thickened walls of the trachea, hemorrhage between tissues, etc are important and should be noted. Sometimes animals eat potatoes, onions, apples, or other food that can cause choking and death - be sure to check the length of the esophagus.
I'll get pictures at some point of this and add it to the post.
CALVES: Usually quicker and easier than adult animals, sometimes they have some really intriguing pathology.
LUNGS: If they're born dead, lungs tend to be dark pink/red and feel meaty. Born alive and they're pink and light. The ones below are normal.
This calf was born with a huge lung cyst - I don't recall the history well but believe it was born dead or died immediately after birth.
More normal ones on a 3 week old calf (note they are floating in water - good, normal lungs will float as pieces or in their entirety):
DOA - these lungs never inflated - if parts of lung on an adult animal look like this and feel thick/hard rather than light and squishy, think pneumonia.
Normal for a 3 week calf:
Curdled milk in a milk-fed calf:
LIVER: Normal
HEART: Normal
KIDNEY: Normal
SPLEEN: Normal - you'll find this on the left side of the animal.
UTERUS: Normal for a 3 week old calf (open) - and it'll look very similar in any open heifer.
#1: If you want answers, people need to be able to see context. Where is the item in the picture located in relation to other organs, how large is it, etc. It's better to take pictures a little too far away than too close.
#2: Either get the entire organ in the sun or get a shadow over it - it's difficult to tell actual color changes if half of it is covered by shadow.
#3: If it's covered in blood clots or dirt, it's incredibly hard to see whether its normal or not.
#1: Make sure you have a sharp knife.
#2: Cut them open ASAP after death - they'll decompose and organ systems won't look the same. 8 PM from death to 10 AM at necropsy is not ideal but dependent on cause of death, will usually still yield useful information. I did one of those just last week. 8 PM to 8 PM in the summer and you might be wasting your time. You might get 24 hours in the winter. Not in the summer.
#3: Cut EVERYTHING open. Feel free to post accompanying pictures of intact organs, but no lone pictures of an unscathed liver - breadloaf it so whatever is inside is visible. Same goes for lungs - cut a minimum of 3-4 slices into them - kidney, heart, etc. Some of my pictures are old and do not display this - just realize if you're posting pictures in search of answers it all needs to be cut if you want good responses.
#4: You'll miss more by not looking than by not knowing. Be curious and take more pictures than you think you'll need.
#5: If you have any concerns over diseases transmittable to humans - like anthrax in your area of the country - DO NOT open the animal.
#6: IF YOU PLAN TO HAVE DIAGNOSTIC TESTING DONE on the animal - e.g. you already know you have a disease outbreak, abortion storm, etc - let your veterinarian do the necropsy. Those types of testing may involve bacterial culture, something laboratories can't do when the same knife has been used to slice open the animal, digestive tract, affected organ(s), etc. This tutorial just covers curiosity.
QUESTIONS? - just ask. If you have something you know you're going to euthanize, feel free to ask here. If you're on the clock, your local vet clinic may be a much better option for immediate questions. Depending on your vet, most of the ones I've asked charge $75-100 to perform a necropsy and it may be helpful to watch one done once.
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Roundup: Bottle Chandeliers
Did you see those awesome new wine bottle chandeliers in the latest Pottery Barn catalogue? We love them (especially because we have box-fulls of green glass wine bottles left over from our wedding last year) so much that we set out to find a few more...
• 1 Pottery Barn's Wine Bottle Chandelier, $400
• 2 Via Moggit
• 3 Flickr member niallkennedy, licensed for use under Creative Commons
• 4 Via Supercozy
• 5 Apartment Therapy LA: Look! Bright Colored Adirondack Chairs


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Board your guided air-conditioned transportation and pass through Puntarenas and its surrounding mangroves. Then, proceed southward along the coast past the port of Caldera and small fishing villages, such as Mata de Limon. Next, head inland into the coastal range of mountains passing by small farming communities such as Tivies and Ceiba. Here, you'll have the opportunity to see typical Costa Rican rural life. Along the way, you may encounter different species of birds as well as sugar cane, bananas, coffee, mangos and other crops that are often exported to North America and Europe. Continue traveling south until you reach the Tarcoles River, where sightings of very large crocodiles are frequent.
This is where your Canopy Tour adventure will begin. Upon arrival, you'll be geared up with the necessary equipment and briefed on safety instructions. You'll be guided on a 15 to 20 minute walk through the tropical transition forest to the beginning of the tour. Once here, you'll proceed to the first horizontal traverse cable. The original Canopy tour consists of nine observation platforms, and eight horizontal traverse cables connected between the immense trees of this tropical paradise. Your journey through the trees will take approximately one hour. Here, you may see deer, monkeys and a variety of birds including the endangered scarlet macaw, orchids, bromeliads and mahogany trees. At the end of the tour you'll receive a complimentary bottle of water. Other beverages and souvenirs will be available for purchase once back at the reception area. After a few minutes of relaxation, you'll board your bus for the return journey to the pier.


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*Awaits OTT Brenda explosion*
Brenda got a confessional!
Lol it was too early in the hour for someone to get voted out
O. M. G.He didn't find the HII?
Yeah but I would have dug anyway, or come back asap...
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Stefania di Petrillo's "Twigs & Brushwood" (Brins & Brindilles) Line
Re-invent... That's what Stefania Di Petrillo did when she designed her line. She re-invented the jewelry as we know it and she re-invented the wool and it's use. Her line is Fresh, original, elaborate. When you wear her Jewelry be ready to answer questions... at the party or in the street all the attention will be yours!


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Secret Santa Helpers: Fun Gifts Under $10
Ah, the dreaded office party Secret Santa shuffle. Depending on how friendly you are with your coworkers, this may be a tough one, as finding gifts for those we don't know well (even for those we do!) can sometimes be tricky.
If you draw an unfamiliar someone's name, here are a few ideas for great gifts under $10 to help you navigate Secret Santa holiday shopping within the price cap.
1. Corky "Toast It" Coasters for work or home from MOMA, $10
2. For a chuckle, Oliver Peppermint Stick appetizer plates from CB2, $2.95 each
3. For the chronically-late coworker, a MOMA 2012 Pocket Calendar, $8.99
4. Elegant glass vases from CB2, on sale $6.95 - $8.95
5. Give a gift for a good cause. Each of these special West Elm mugs benefits a different non-profit from Boy and Girls Club of America to the ASPCA, $10
6. Who turns down chocolate? Jme Chocolate Coin Willams-Sonoma, $7.95
7. A colorful Pantone Universe Pencil Tube, containing colored pencils. Buy from Hyatt's Online for $10.
8. Give a cup of cheer! The Republic of Tea Chai Tea Bags, $9.95
9. A tasty trio of popcorn seasonings from Crate & Barrel, $7.95
10. And last but not least, a mustache magnet from The Small Object to decorate family photos or silly post-it notes when work is dull, $6
Images: as linked above.


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- Adult Adventure
- Some Body Parts
- Tools and Tapers
- Accessories
- Straight Barbells
- Curved Barbells
- Replacement Parts
- 14k Gold Only
- Captive Bead Rings
- Earlets & Tunnels
- Segment & Seamless Rings
- Ear Plugs
- Hide Your Piercing
- Genuine Diamond Jewelry
- Organics
- Spirals & Claws
- Screwball Rings
- Charms
- Fixed Bead Rings
- Circular Barbells
The Sleek & Hollow Penis Plug is a beautifully designed toy made for beginners and more experienced users alike. It will give your penis that striking look of a pierced member even if you don't have any piercings. Even more, it will provide deep stimulation for your urethra and hit all the right spots.
This plug is made of 316L Surgical Grade Steel, so it's durable, smooth, elegant and completely body-friendly.
The plug is about 2 inches long and it features a special design that makes the insertion both easy and very enjoyable. The diameter at the largest point is your choice between 7 and 16 mm. It was previously available only in 10 mm but we added the other sizes upon your request.
This sleek & hollow penis plug will make you feel better for not having a Prince Albert piercing, because your penis will look pierced with elegant jewelry. This plug is a great option for those who don't want to get pierced but love the look of a pierced penis. It is the best way to add some shine to your penis without pain.
Product Questions
What is the "standard" LENGTH of the SLEEL & HOLLOW penis plug? Is a longer length possible? How can that be ordered?
Customer Reviews
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(Posted on 9/10/18)
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felling is assume wish I ordered a size larger but good felling
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Just a bit of an update. I ordered the 8mm plug initially, and in time it was slipping out, so I went to a 9mm. It was a little hard inserting and removing it, but now, it is no problem. I can wear it without discomfort. Think I may be ready for the next larger size. I agree with some comments about the shaft. Mine tend to extend about 1/8 to 1/4 inch, especially after I had pee through it. I like the look of the ring right against the pee hole.
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(Posted on 8/27/14)
- A very good product Review by Mike
I am an amateur to the use of penis plugs. I ordered the 7mm which was to small it would not stay in while urinating or walking around with it in. Cumming through it, the hole was so small that it just oozed out. I ordered the 8mm and the 9mm because I did not know what size I needed. The 8mm was perfect fit. The only problem was the length of the neck with the ring was to long. It did not give the appearance of having a piercing. I took and trimmed the neck and add ring that I had from a 10mm plug that makes the plug look as though I am pierced. I can pee through it with no problem and cum through it with great squirting distance. My girlfriend really loves the plug and playing with it with her mouth and tongue. Putting the plug in was not very hard to get in with some silicon lube and a little pressure. It is however a little harder to get out and usually requires a few drinks to get it out. I have worn it for 24 hrs several times. I am now enjoying my plug for the first time longer than 24 hrs and plan on keeping it in for the rest of this week.
With much enjoyment,
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After a couple tries with different sizes I finally have one that fits for the most part. Ended up with an 8mm and the largest part fits perfect it's the smaller end towards the ring that tends to want to slide out about 1/4". A little uncomfortable at first insertion but that went away after a few hours. Can't wait to piss and cum through this. Hoping that after a while I will be able to upgrade to the 9mm plug that I ordered first but is really tight.
(Posted on 2/1/14)
- Great quality, but much too small Review by bling
Your measurements are in European comparisons. You need to add the same sizes in 1/16 inches so the customer can make valid comparisons in length, diameter and/or circumference. As it is now, we have to keep trying until we get the right size or try another product.
Glad that you were pleased with it otherwise.
There is a conversion chart on our size and gauge page but we are always happy to help you just ask. If you are the type that does not want to ask, just use a ruler, it has both mms and inches, you can draw a line on a piece of paper in mms and then measure it in inches.
(Posted on 10/22/13)
- My first order. Review by Noel
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(Posted on 7/24/13)
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I bought this plug maybe 3 years ago, never have I been able to get it in my dick. I thought it was too wide, I've bought several plugs since in a 5/16 size, they go in no problem. While I was playing tonight I got out this plug and omygosh!!! I witnested the POP that I've have been reading about. It's in finialy in, and I love it! I'm sucking down lots of beer so I can piss thru it, then I'll cum thru it. Is there a link to send pics wearing your jewelry?
(Posted on 7/2/13)
- GREAT Review by RONNIE
First time user,glad I did. A little lube and in it went no problem felt great. What a feeling when you come for the first time a long stream of juice any woman would love. No discomfort wearing it in but does tend to come out a little, so the next step is a 10mm beaded plug. As they say size is the secret so try something in your dick before ordering to get the correct size for you. Had mine in all morning no problem at all but will take it out for cleaning. Thanks chain gang for your help and a top product.
(Posted on 6/5/13)
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New to this. First time I had something up my urethra, except for the one time when I was catheterized. Thought I would give it a try. Ordered the 8mm plug and it seems to fit without popping out. About a quarter of an inch does pop out, but that's all. A little uncomfortable for now on first wearing, but I hope that will decrease as I get accustomed to it. Would have been nice if the ring on the end was about 6 gauge. In all, a nice piece of penis jewelry. Doubt if I'll wear it 24/7 – yet.
A caveat – before you try to pee through the plug, be sure that the tube is clear. Mine came with some crud in it.
(Posted on 4/15/13)
- An interesting piece of penis jewelry Review by Dan
This is my first time with inserting something up the urethra - outside of being catheterized once. First of all, I got the 8mm, and it seems to fit fine. Didn't pop out, although it seems to come out about a quarter of a inch after wearing. Was a little painful on insertion and some discomfort on wearing. Have worn it about half and hour on the first try. I hope the discomfort will subside on subsequent wearing. I like the idea, and would have like the ring on the end to be of larger gauge.
(Posted on 4/15/13)
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Size does matter when purchasing this . As I am an amateur in this new exploration , I decided to start small with this plug and work my way up to larger sizes . Unfortunately I started too small . The 7mm fell right out as soon as I put it in . So I thought maybe I used too much lube . Not the case . It's just too small . I will be jumping up to a 9-10 mm size on the next purchase and hope not to work down instead . As far as Quality ? It's top notch and shipping was very fast . Thank You Chain Gang .
I cant blame Chain Gang for my experience with this product . Fantastic quality again .
But Please note future purchasers : Do attempt to see what size urethra you have in order to purchase the correct size to ensure the best experience at the least amount of expense .
(Posted on 3/22/13)
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I found this to be an excellent piece and the stainless steel gives it good heft. Quality construction, well worth the price.
(Posted on 3/15/13)
- 7mm was this right size for me Review by foboz
After trying a 6mm of a different style (too small) and coming to the conclusion that the 8mm was too big, I anted-up one more time for the 7mm. Getting it in the first time was very uncomfortable - even slightly painful. I thought I was in for trouble as the plug was even more difficult to get out. After a few deep breaths and a little wincing I did manage to get it out; surprisingly there was very little irritation and what there was passed within the hour. The second time around there was a little resistance, a very slight discomfort and then it just "popped" in. I've had it in for a couple of hours now; hopefully getting it out will be a bit easier this time too.
I feel that the "shoulder" length is too long as I find I need to push it back in all the time. Urinating was OK - just expect some "leakage" around the plug; haven't tried cumming with it in yet.
(Posted on 12/21/12)
- Good Product Review by TheNazz59
This is a very stimulaiting product, I love the feel of it in my cock, once you get past the little bit of the uncomfortable feeling its fine. Inserting it is fine and again stimulating, the cum through is also good. The only problem when I have tried to wear this for longer lengths of time and it usualy slips out when you are flacid. The feeling of the ring at the end is also very stimulating, feels very sexy. My lady loves to suck my cock with it in me and tongue the ring at the end, the end results are great!!!
(Posted on 12/9/12)
- First Class Product Review by Robert
Very solid construction. Even the ring is solid. You cannot see where it is joined together to form a ring. I order the 7 mm. size. My wife slid it into my penis easily with the help of the surgical lubricant. However, my penis started pulsating and it started to slide out. She kept having to gently tap it back in. No problem. Perhaps if the plug were an inch longer.
(Posted on 9/2/12)
- Great Product Review by Woofy
First ordered a 9 mm but it was too small and would slide out on its own. Just received the 10 mm and it is just perfect. It takes soem effort to get it in but will stay all day and night if you want...Love wearing it at work, reminds me how sexual I am...Great product...
(Posted on 8/17/12)
- Untitled Review by Guest
This item is high quality and arrived in a timely manner. It would be better for me if the area that widens was closer to the ring end. maybe a 1/4 to 3/8 inch closer to the ring end. That change would help the piece stay in place better.
(Posted on 2/29/12)
- Untitled Review by Guest
Great item. I was concerned about the size and being able to use it. I received it and it slipped right in. Liked it so much ordered a larger one right away
(Posted on 2/29/12)
- Untitled Review by Dan
Found this plug very exciting to wear. Felt wonderful while wearing and with a little added weight is was very exciting. My only issue was when I tried to remove it. It seemed to hangup, I think the backside taper should be sloped more. It was a tight fit going in, but that is to be assumed as I had the 9mm unit. But I'm vewry well pleased with my plug.
(Posted on 2/29/12)
- Untitled Review by Robert
I have to use a gland ring to keep it in but besides that it works great
(Posted on 2/29/12)
- Untitled Review by Guest
Quality material, quick delivery and great service
(Posted on 2/29/12)
- Untitled Review by Dan
Fantastic!!! Very good quality, exactly as it was described and OH SO MUCH FUN! Felt so good the first time in I nearly passed out!!! I can't wait to be able to wear it for extended times and am really looking forward to f**king my wife with it too!
(Posted on 2/29/12)
- Untitled Review by Guest
This is a well made product and as with the rest of the items ordered from TCG everything went as expected. Make sure that you get your size right or this will be a bad purchase for you.
(Posted on 2/29/12)
- Untitled Review by Duyane
An easy fit until I get used to the 8mm plug. And polished to a mirror finish with no sharp edges!
(Posted on 2/29/12)
- Untitled Review by Guest
very nice piece ordered the largest got it in on day three.shipping was fast also and discreet. now i wanna try it out then i will try a bigger one.the wife seems excited!!!!!!!!!!!!!!!!!!!!
(Posted on 2/29/12)
- Untitled Review by Michael
I purchased this item for a little more excitement in my life... but unfortunately it really doesn't stay in place for me.... even though I purchased the largest size... it MAY be because I DO use sounds at times, and have widen my Urethra to a point where if I DO wear it, and I CUM... it pops right out...LOL... wouldn't even try to use it while peeing...LOLI could only use it with no lube...as THEN it doesn;t even stay in place... only a little spit will do...LOL
I just need to order a larger size is all since I have stretched so much, but Awesome Quality on the plug
(Posted on 2/29/12)
- Untitled Review by Guest
bought the 8mm size, slips in easy but slips out all the time. cannot keep it in
(Posted on 2/29/12)
- Untitled Review by Guest
What a product went in the first time and don't want to take it out in the erected stage the ring stands out and ad pleasure when having sex . Every girl i had showed it to wanted to feel it inside them . So for me one hell of a product .
(Posted on 2/29/12)
- Untitled Review by Guest
it is to small and slides out very easy ( and i have a small penis) great for a first time user but should skip this and just go to a larger size
(Posted on 2/29/12)
- Untitled Review by Ron Kersh
My sleek and hollow penis plug 9mm may betoo small because it will not stay in place. I need a glan's ring with a short chain or loop to hold the plug in
(Posted on 2/29/12)
- Untitled Review by Kersh Ron
I like theplug but i can't keep it in. 9mm is too small.I made a glans ring and tied the plug to it.
(Posted on 2/29/12)
- Untitled Review by J R RATTS
TOO LONG, Other than that great.
(Posted on 2/29/12)
- Untitled Review by easyrider
After reading other reviews of this product, I decided to try it. This is the first item of this nature that I've purchased. With that in mind, I of coarse ordered to small. The items slips right out, i am very disapointed to have to wait for a larger size,i have 8mm not sure if i should get 9 or 10mm, i dont want to get it wrong twice, So far I am very happy with the design and concept. Looking forward to the right size.
(Posted on 2/29/12)
- Untitled Review by mike
sleek and compact I need a bigger size to be able to wear it on it's own, fortunately I have a PA and I can insert the plug, then the ring through the piercing and the gauge of the PA ring will prevent the shoulder of the plug from passing past it, for a deeper penetration I loop the plug's ring over the PA ring prior to closing the circle of the PA with a captive beed. That keeps the plug snugly and completely inserted.
(Posted on 2/29/12)
- Untitled Review by Guest
Fun little device, well made. It stands up to every statement made about it. I am very pleased!
(Posted on 2/29/12)
- Untitled Review by Cordeiro Mauricio
Very nice piece. I was confused by the different diameters, and got one a bit larger, so it's difficult to remove it. For my anatomy it would be better if the internal angle was less sharp.
(Posted on 2/29/12)
- Untitled Review by Guest
nice product except for the shoulder which has too abrupt an angle on it for comfortable removal ( i SUPPOSE THT IS THE POINT OF THE PLUG THOUGH) - the bore size of teh thru hole is nice an beg which allows one to urinate more easily.
(Posted on 2/29/12)
- Untitled Review by Baron Awl
The Sleek & Hollow plug is an extremely well-made item which is exactly as described on the web-site. Mine arrived in about a week in a discreet brown envelope, well-padded for protection. I ordered an 8mm flange, which, unfortunately, is way too small for my needs. If I'd checked myself prior to ordering (with a knitting needle, crochet hook, or stainless-steel chopstick), I would've known to order the largest size possible. Live n' learn-next time I'll look for something with a larger diameter and a sharper stop, in hopes it won't pop right back out after insertion. But none of this is the fault of the manufacturer-the piece itself is attractive and flawlessly made-I'll just hang mine on my key chain and tell people it's a dog whistle.
(Posted on 2/29/12)
- Untitled Review by Guest
After reading other reviews of this product, I decided to try it. This is the first item of this nature that I've purchased. With that in mind, I of coarse ordered to small. The items slips right out, I will order another one, larger and try again. So far I am very happy with the design and concept. Looking forward to the right size.
(Posted on 2/29/12)
- Untitled Review by Dave
The quality is first rate. The back end was too blunt for comfortable withdrawl so I remachined the countour to provide for a more gentle taper. Actually, I reduced the diameter of the body to .386 and the fit is still painfully tight on instertion but nothing I can't put up with.
(Posted on 2/29/12)
- Untitled Review by Guest
Awesome little piece!!
(Posted on 2/29/12)
- Untitled Review by Guest
It's hollow, but not so sleek. Widest diameter is approximately 3/8 inch. Will take some acclimation time to fit some people.
Finish is good, price is good.
(Posted on 2/29/12)
- Untitled Review by Peter Pee
I love wearing it but occasionally it pops out. Maybe it should be a little bit longer or is there some way to keep it snugly in? Let me hear from other users.
(Posted on 2/29/12)
- Untitled Review by Guest
A softer curve to the base of the plug would aid removal and a thicker end so the ring isn't the only thing keeping it from sliding in further would have been nice.
Overall the build quality is decent and it functions as advertised.
(Posted on 2/29/12)
- Untitled Review by Nice Quality
It's just a little too thick for my hole although I'm still stretching and using 7% benzocaine to make it feel a little less stressful.
(Posted on 2/29/12)
- Untitled Review by Toy
This is the second Penis Plug I have received. The first one was from another company and not the same quality. Chain Gang products are 100% better and the shipping time was very short, only 4 days total. The plug was well crafted and very highly polished. No sharp edges with which to get cut. The only problem I have now is the diameter is 10 mil., which for me is about 1 mil to much. It would be nice if the plug could be ordered in 9 mil, 9.5 mil and of course the 10 mil. I use it all the time, even during intercourse with no problems. The sinsations are very pleasurable. My wife loves the visual too. This little plug will keep your penis stimulated for quite some time. Maybe your partner too.
(Posted on 2/29/12)


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In the latest sign that some U.S. cities are barely making ends meet, the city of Oakland, California Thursday priced a $211 million taxable bond which will help it cover pension obligations. Yes, borrowing money to cover retiree pay.
Moody's Investor Service has proposed adjusting its U.S. public sector pension data to put the unfunded liabilities at $2.2 trillion, nearly triple what they were two years ago.
While market reaction to San Bernardino's pending bankruptcy has been "much calmer than expected," Envision Capital's Marilyn Cohen added, "people are asking 'Is Riverside next?'" referring to the other major city in California's Inland Empire.
The heat from three California bankruptcies in two weeks is fanning out like a late summer brushfire. Los Angeles County officials have ordered a review comparing their financial practices to now-bankrupt Stockton.
Compton's auditors just quit and refuse to sign off on the city's financial reports.
"I wouldn't be surprised if there were more (bankruptcies) in California or around the country," said Amy Laskey, managing director for tax-supported public finance for Fitch Ratings. "But I don't think it has implications for another filing every week. I don't think that's going to happen."
Some analysts point to reports that municipal bond defaults are slowing, despite the headlines. The Bond Buyer says a healthy $7.1 in muni debt is coming to the market this week.
But everyone wonders, who's next?
"We have not even looked into or discussed bankruptcy," said Dan Romero, Mayor of Hercules, a small city just nine miles from Vallejo, California, which infamously kicked off the current round of municipal bankruptcies in 2008. Hercules has been struggling, and the state controller reportedly called its financial records the worst he's seen.
"I understand that we're sort of the banner child for what not to do as an RDA (redevelopment agency)," Mayor Romero said, "but we're turning those things around."
Hercules has renegotiated debt payments, slashed staff and pay, and voters approved a half cent sales tax increase.
"What we've been doing for the last couple of months is selling our assets so that we can pay off our debts," Romero said.
The city of North Las Vegas, Nevada, has declared a fiscal emergency in hopes of avoiding bankruptcy, which in Nevada can only be done with the legislature's approval.
"We currently are current on all of our indebtedness," City Manager Tim Hacker said.
He said the city is also making payroll and pension obligations. The fiscal emergency allowed the city to avoid contracted raises after efforts to get more union concessions failed. Hacker feels the city can avoid Chapter 9, but he's not so sure about his neighbors in the west.
"We believe that what has maybe been the tip of the iceberg is really going to start to unfold here in the next few years," he said.
Maybe not. The new wave of bankruptcies is bringing all sides together in many cities to hammer out concessions. Voters and San Jose and San Diego approved cuts to current pay and benefits, decisions that may end up in court. And then there's the economy.
"We are starting to see some growth in non-property tax revenues, and I think some of the spending cuts that have been done in the past couple of fiscal years will bear more fruit going forward," Fitch's Amy Laskey said. "I wouldn't think that there is going to be a massive Chapter 9 filing situation."
— By CNBC's Jane Wells


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Taking a shot at Iowa is in vogue these days.
The trend started this summer when a fashion critic for Elle magazine made a snotty swipe at what folks wear during ...
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Howard Bach (USA)
Born in Saigon, Howard Bach now represents the USA and is the doubles partner to the legendary Tony Gunawan.
The pair won the IBF World Championships; the first American success in the competition. He has a degree in finance and speaks Cantonese and Mandarin as well as English.
|Career Highlights
Singapore Open Super Series Winner


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First impressions: T-Mobile G1 (three years later)
Exactly three years ago, those who pre-ordered began receiving their T-Mobile G1′s, the little phone that started it all. I was lucky enough to be in that group. After spending several hours with the bronze-colored geegaw on October 20, 2008, I wrote up my breathless, geeked-out thoughts for my personal blog. It's cute, I was ... Read More »


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Did you, or have you read any of Pinky's posts ? He specifically details (as does Swiss Pauli) how the club would have funded the transfer dealings, not with the money that the owners put in, but in the form of loans. Fair enough, we don't expect them to be out of pocket, it is a business.
So in this event then, they actually never did put anything in then, in the form of loans or not, because to your figures we paid all of the fees over the terms of the contract.
What of the 10M that you spoke of in the post I quoted ? Or that bristol's 4.5 M that you dismiss as a myth ? So you go from a 10M couple of deals to less than nothing. No problem with that, but let's call it what it is ?
So actually we ain't got a pot to pi$$ in as alluded to by Pinky et al ?
Your defence of the owners is fine mate, it is honestly. But I don't understand you telling me I don't understand the point when all I have said is we never had the money to pay for Sordell or Rhodes or Jelavic or any others then, which is maybe why we didn't land any of them. And now you seem to be saying that I am pretty well correct.
Go back over your posts mate:
Trap1 wrote:The £4 million pound myth is going to be exposed for sure!!
Totaaly bonkers when you consider we have made two offers over that figure plus two official offers that had they been accepted would have busted the £10 million.
There is no budget, G&S will buy something they believe to be good value - after all, it's their own money.
Trap1 wrote:BTW we have just put in a third bid for Jordan Rhodes as per the Daily Mirror.
This appears to be a WHUFC last throw of the dice...
New Jordan Rhodes and Richard Snodgrass offer now in.
Trap1 wrote:Wormley,
Sure. two offers for Jordan Rhodes (yes, I disagree with Alan Nixon on the figure), plus one for Marvin Sordell of which Watford have decided to sit on.
Ultimately Sam wants Rhodes and the cash is going on him or another striker Sordell still being a possible. The club will unveil Edgar Costa (loan) tomorrow.
You certainly seem to indicate that we have money to spend..or am I wrong ?? And all these bids are, like suggested, peanuts up front knowing that they more than likely wouldn't be accepted but looked good in print.
Great P.R.


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Having been a regular worshiper at a Quaker church for a few years while in college, I would say that the Quaker rejection of water baptism reflects a dualism between matter and spirit that is quite foreign to Orthodox sacramental spirituality.
Quote from: PeterTheAleut on November 04, 2012, 05:56:59 PMHaving been a regular worshiper at a Quaker church for a few years while in college, I would say that the Quaker rejection of water baptism reflects a dualism between matter and spirit that is quite foreign to Orthodox sacramental spirituality.Peter,Oh, I don't know - I think Orthodox also distinguish the two, but they value both - for example, there is resurrection of the physical body and the spiritual soul. I think all the sacraments have both a spiritual and physical aspect.Besides that, I think the last several posts in this thread have given verses distinguishing the baptism with water from the baptism or coming on of the Holy Spirit. eg. I think Ashman made a good point of St Paul's words in Acts 10, where Paul encouraged baptism with "water" "in the name of Jesus" for some people who already had received the Spirit.Two problems I have with the Quaker view are that:1) Christ told the disciples to baptise all nations "in the name of" the Trinity, and Acts 10 suggests this means an act of water baptism that uses its name. And the example of the apostles shows they understood it as an act they performed. So I see water baptism as following His instruction, even if it can be rationalized away.2) Even if one accepts the Quaker view that water baptism is actually unnecessary and the spirit's baptism is what counts in Christ's instruction, the Quakers aren't even really following that because they themselves do not do acts of spirit baptism. They do not directly pray for other individuals to get the spirit, which would mean this kind of baptising others in the spirit. Admittedly some Quakers may do this from time to time as a coincidence, but their teaching does not give this as a general instruction.But Peter, it sounds like an interesting story you have. Have you written on the internet about coming to Orthodoxy, or perhaps you were visiting the Meeting while Orthodox because of the depth of Quaker spirituality, which admittedly has overlap with Orthodoxy?Be good.
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All News Releases By Date
Public invited to comment on proposed lead-based paint rule
Release Date: 03/31/2006
Contact Information: Mark Merchant 415-947-4297, Enesta Jones 202-564-7873
SAN FRANCISCO, Calif-March 31, 2006 – The U.S. Environmental Protection Agency will hold a public meeting Thursday, April 6 from 1:00 PM to 5:00 PM (Pacific Standard Time) to receive comments from the public on a proposed federal rule for handling lead-based paint.
The meeting on the proposed Lead Renovation, Repair and Painting Program Rule will be held in the Phillip Burton Federal Building & U.S. Courthouse, Nevada/California Conference Rooms, 450 Golden Gate Ave., San Francisco, Calif. 94102.
The San Francisco meeting is one of five scheduled around the country during the comment period ending April 10. Other cities hosting the EPA meetings include: Washington, D.C.; New York City; Atlanta and Chicago.
The EPA is proposing some simple but effective work practices that can reduce potential exposure to dangerous levels of lead for residents, especially children. These work practice standards and training and certification requirements would apply to persons engaged in renovation, repair and painting activities that disturb lead-based paint in housing built before 1978.
The new proposal is one component of a comprehensive program that will also include training and an education and outreach campaign to promote lead-safe work practices. It will help to meet the goal of eliminating childhood lead poisoning as a major health concern by the year 2010.
Persons interested in scheduling a presentation (limit 10 minutes) can contact Mike Wilson at email@example.com or 202/566-0521.
The proposed rule and background information are available on EPA's Web site at: https://www.epa.gov/lead
Search this collection of releases | or search all news releases
View selected historical press releases from 1970 to 1998 in the EPA History website.


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The Upper Canada District School Board cares about the health and well-being of all of our students. We make sure to demonstrate it through our programs and our values in the UCDSB. We strive to ensure that our students feel safe, included, and ready to learn every time they come to school.
We hope you'll take a look through the pages on the left and learn more about how we're making our students' well-being a priority in our schools every day.


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Cool blue crystals adorn this lovely wind chime with its fairy-like sound.
If windchimes were made in a magic land at the end of the rainbow, they would probably look something like our Woodstock Gem Drop Chimes. A delight to the eyes and ears, they are delectable little treats for the home and garden. What's more, they all sound great together so you can collect the whole set!This chime is designed to hang from a string loop, rather than an o-ring.