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The effect of yoga on women with secondary arm lymphoedema from breast cancer treatment
BMC Complementary and Alternative Medicine volume 12, Article number: 66 (2012)
Women who develop secondary arm lymphoedema subsequent to treatment associated with breast cancer require life-long management for a range of symptoms including arm swelling, heaviness, tightness in the arm and sometimes the chest, upper body impairment and changes to a range of parameters relating to quality of life. While exercise under controlled conditions has had positive outcomes, the impact of yoga has not been investigated. The aim of this study is to determine the effectiveness of yoga in the physical and psycho-social domains, in the hope that women can be offered another safe, holistic modality to help control many, if not all, of the effects of secondary arm lymphoedema.
Methods and design
A randomised controlled pilot trial will be conducted in Hobart and Launceston with a total of 40 women receiving either yoga intervention or current best practice care. Intervention will consist of eight weeks of a weekly teacher-led yoga class with a home-based daily yoga practice delivered by DVD. Primary outcome measures will be the effects of yoga on lymphoedema and its associated symptoms and quality of life. Secondary outcome measures will be range of motion of the arm and thoracic spine, shoulder strength, and weekly and daily physical activity. Primary and secondary outcomes will be measured at baseline, weeks four, eight and a four week follow up at week twelve. Range of motion of the spine, in a self-nominated group, will be measured at baseline, weeks eight and twelve. A further outcome will be the women’s perceptions of the yoga collected by interview at week eight.
The results of this trial will provide information on the safety and effectiveness of yoga for women with secondary arm lymphoedema from breast cancer treatment. It will also inform methodology for future, larger trials.
Breast cancer- related lymphoedema (BCRL) is a result of disruption to the lymphatic transport system as a result of a number of procedures associated with the treatment of breast cancer . BCRL is associated with chronic or recurring swelling of the affected area and underlain by cellular and tissue changes, making the area more prone to infections. High risk indicators for lymphoedema onset are mastectomy, radiation to the axilla, axillary dissection and removal of a high number of lymph nodes . In spite of recent changes to surgical and radiological procedures for breast cancer, at least 20% of women are still affected . As breast cancer incidence continues to rise , a significant number of women will continue to get secondary lymphoedema. While the arm is the most common site, the chest, upper back or breast are also often involved. As these areas are difficult to measure, current incidence rates are likely to be significantly underestimated.
The loss of upper body function can be higher for women with BCRL than for those treated for breast cancer without lymphoedema . Physical activity can be reduced not only due to the swelling, but also as a consequence of the changed sensations , pain  and fatigue , as well as women’s fear of exacerbating the symptoms of lymphoedema . Women commonly report stiffness and impairment in the range of motion of their affected shoulder and limitations in various daily activities that depend on carrying, repetitive actions or having their arm in the same position for a prolonged period . Biomechanics of the thoracic-shoulder area can be compromised [11, 12], which can create further upper body impairment. Additionally, women experience feelings of abandonment and isolation, compounded by uncertainty and poor body image [13, 14], which can lead to a lowered quality of life in physical, social, personal and emotional domains .
BCRL requires early recognition, targeted treatment and self-management for life to reduce the risk of infection and prevent the condition worsening. Treatment may include complex lymphoedema therapy involving manual lymphatic drainage (MLD) with compression bandaging as required, and daily self-management, which focuses on skin care, self-massage, specific exercises with deep breathing and wearing a compression sleeve [16, 17]. Motivation and compliance with self-care are difficult to maintain  due to treatment fatigue and a feeling of frustration that the limb is not getting significantly better.
Participation in exercise is increasingly recommended as another option for women with BCRL to improve their physical and mental health [19, 20]. Guidelines state that supervised exercise with adequate warm-up and cool-down, and gradual progression of intensity or difficulty, may be followed by women with BCRL . This is based on positive results from large randomised controlled trials of resistance training [22, 23] and from smaller trials covering a variety of other exercise modalities  including combined aerobic and resistance exercise , tai-chi , gentle exercise with relaxation  and aquatic exercise . Importantly, these trials have reported no exacerbation of lymphoedema and an improvement in physical fitness, upper body function and quality of life.
Currently, there is no published research into the effects of yoga on BCRL, despite many women with BCRL stating that they are already using yoga along with conventional lymphoedema treatment . However, yoga therapy as part of a holistic treatment for lower limb lymphoedema in India, has resulted in decreased levels of lymphoedema, and fewer infections. It focuses on lymphatic clearing by using specific postures, deep diaphragmatic breathing, elevation of legs and relaxation .
Yoga can offer a holistic approach to the management of BCRL as the practices promote progressive physical postures (asana) with breath awareness, breathing exercises (pranayama), meditation and relaxation. Research into the efficacy of yoga for women during and after breast cancer treatment (without lymphoedema) reports improved quality of life and immunity [32, 33] as well as reduction of pain  and fatigue . Other improvements have been reported in flexibility , grip strength, shoulder function  and body image . These outcomes may be transferrable to women with BCRL.
The aim of this study is to evaluate the effects of an eight-week integrated yoga intervention on women with BCRL. The primary objectives are to evaluate the effect of regular yoga participation on lymphoedema (amount of fluid and tissue density), and its associated symptoms (sensations, pain, fatigue) and to assess its impact on quality of life. Secondary objectives are to determine the effect of yoga on the upper body, in particular shoulder mobility and strength and mobility of the thoracic spine. A further objective is to investigate participant perceptions about the effectiveness of the yoga intervention. Information about daily and weekly physical activity as well as demographic information will also be collected.
We hypothesise that an eight-week integrated yoga intervention will have a beneficial effect on BCRL as indicated by reduced swelling of the affected arm, reduced tissue density, fewer symptoms of pain, fatigue and sensations and their limiting effects, improved quality of life and upper body functioning.
Study design and setting
This study is designed to be a randomised controlled trial for women with stage one BCRL, as defined by the International Society of Lymphology . The study will compare the results of a group who receive an integrated yoga intervention, to a control group who will continue to follow current best-practice in self-management of lymphoedema from a manual given to all participants pre-randomisation, but who will receive no yoga intervention. The control group will be wait-listed for the yoga intervention and so will be invited to participate at the completion of the study.
Measurements will be conducted at baseline (week 0), after which participants will be randomised to the yoga intervention or the control group. Further measurements will be made at week 4 (mid-point), week 8 (on completion of the yoga) and at week 12 (four weeks after the intervention).
The trial will be held at two locations, Hobart and Launceston. Both locations will consist of an intervention and control group. The study will be conducted at Community Health Centres in both locations.
The study has been approved by the University of Tasmania Social Sciences Ethics committee. Yearly progress reports will be made to the ethics committee and they will be notified of any adverse events promptly. The trial has been registered with the Australian New Zealand Clinical Trials Registry (ACTRN12611000202965, http://www.anzctr.org.au/default.aspx).
All women in the trial will receive information in a manual specifically developed for this trial on best current practice for management of secondary lymphoedema, based on the guidelines of the Australasian Lymphology Association and Lymphoedema Framework [16, 39].
Women will be advised to continue with their usual treatment plan during the trial and to seek medical help in the case of infection or a flare-up of lymphoedema. Should this occur, women will be advised they can continue with the trial but told their measurements will not be included in the results, as it will change their status with regard to the eligibility criteria.
Withdrawal from study
Participants will be able to withdraw from the trial at any time without prejudice, as set out in the information sheet distributed at the time of consent.
Identification of eligible participants
Recruitment will occur over a two-month period throughout Tasmania. Key people, including professionals in the field of lymphoedema and relevant organisations such as the Cancer Council and Breast Screen, and support and exercise groups such as Encore and Dragons Abreast, will be contacted and asked to disseminate information about the trial to potential participants, through flyers and posters.
Media exposure will be sought, including articles in local newspapers and interviews on local radio. Posters will be put in major and rural hospitals, Women’s Health Centres (Hobart, Launceston) and Community Centres.
Individuals interested in participating will be asked to contact the principal investigator (AL) who will outline the study, including the yoga intervention, the home-practice, the methods and dates of measurement, after ascertaining if they are suitable for participation as per the inclusion and exclusion criteria. Eligible participants will be sent an information sheet and informed consent form. After receiving the forms, they will be telephoned in order to discuss any questions or concerns about the trial before returning the signed consent form.
After the signed consent form is returned, participants will be sent the dates for the trial (measurements and intervention) as well as a questionnaire with demographic and medical information to be completed and brought to baseline measurement. At this time, the manual for current best-practice will also be sent, and followed by another phone call to check for clarity.
Sample size calculation
An a priori sample size calculation based on clinically significant changes between groups of between 10-20% in primary outcome measures with standard deviations of between 12 and 15% of the mean, or within groups 10% difference with an SD of 20%, indicated that numbers of between 13 and 19 participants would be required per group. Consequently, we plan on recruiting 20 participants per group to allow for a small number of withdrawals.
Eligibility criteria based on previous exercise trials for women with BCRL will be followed [26, 40]. Criteria for inclusion are completion of treatment for breast cancer in terms of surgery, radiotherapy and chemotherapy at least 6 months previously; unilateral secondary lymphoedema stage one related to surgery for breast cancer, as confirmed by a registered lymphoedema therapist; good English comprehension in order to understand the written forms and oral instructions and be able to give informed consent; aged > 18 years.
Criteria for exclusion are conditions of primary lymphoedema, recurrent cancer and other symptoms including infection or cellulitis, which would affect the woman’s lymphoedema and her quality of life adversely; severe psychological illness, as the yoga intervention would need to be specific to the person’s psychological illness in order to improve it; pregnant women and women with pacemakers, as these conditions are contra-indicated for the use of bio-impedance spectroscopy – one of the measuring tools for this study ; current lymphoedema treatment other than self-management, as this would affect the results.
Women will also be asked to refrain from commencing any new physical activity during the term of the trial as this could affect results.
An individual not associated with the trial will perform the randomisation based on a computer- generated random number system. Group notification will be in a sealed envelope given to women after completion of the baseline measurement.
The yoga intervention
The yoga intervention will consist of a weekly 90-minute yoga class for eight weeks by a qualified, accredited and experienced yoga teacher. Participants will also be given a 45-minute DVD made especially for this trial, with a shorter version of the class, and instructed to perform it daily. They will be given a log, in order to record their home sessions and make relevant comments.
Yoga practices and instruction approaches will be based on the Satyananda yoga® style of teaching. The breathing and pranayama, physical postures, meditation and relaxation techniques have systemised practices that will be taught to ensure uniformity of practice for outcomes . This style, with its gentle repetitions of physical movements followed by rests, and use of modifications, may be well-suited to yoga for BCRL. Options for modifications will allow an individualised approach based on comfort, needs and preferences, in both the class and the home-practice DVD. Practices will be progressive during the eight weeks of the intervention.
The yoga intervention proposed in this study will consist of slow and deep breathing, a series of moving yoga postures followed by rests, pranayama, meditation based on mindfulness practices, and deep relaxation with arm elevation. The practices will be chosen to promote lymphatic clearing, improved postural awareness of the thoracic and shoulder area, as well as stress reduction.
Each yoga session will have appropriate warm-up and cool-down, following the guidelines of exercise for women with BCRL. The temperature of the room will be controlled to between 19–22 degrees Celsius (suitable for Tasmania) to ensure it does not become too hot, which can overload the lymphatic system .
Primary and secondary outcomes
Characteristics of the sample
Women will complete questionnaires on demographic information, current health, as well as medical history pertaining to breast cancer and its treatment, and lymphoedema, onset and treatment prior to measurement. The completed questionnaires will be brought in at baseline, collected and entered into a specifically designed trial database.
Primary outcome measures
All measurements of lymphoedema will be conducted with the participant resting in a supine position, with any compression sleeve removed. Due to the effect on the calculation of lymphoedema, the dominant and affected arm will be noted, and weight and height measured on the same equipment each time to calculate BMI.
Extra-cellular fluid will be measured according to a recognized protocol , using bio-impedance L-dex™ XCA (Bio-Impedimed, Queensland), with electrodes placed at anatomical landmarks at the wrist of each arm and right ankle. An increase in extra-cellular fluid is paralleled by a decrease in impedance from the low-frequency electrical current. The result is recorded as a ratio to the non-affected limb, taking into account arm dominance . As lymphoedema increases, so does the ratio of impedance . The result, calculated from software provided by Bio-Impedimed, is recorded as an l-dex reading and any reading equal or higher than ten is considered an indication of clinically manifest lymphoedema.
Volume and percentage volume of arm and hand lymphoedema
Circumferential readings will be based on the protocol of the Australasian Lymphology Association , modified so the woman is lying not sitting. Both arms will be marked at the metacarpophalangeal joint, ulnar styloid and 10, 20, 30, 40 centimetres (cm) from the styloid process, using a pen and set square on the medial and lateral aspect of the arm, then circumference measured at each point by a Job non-stretch tape, recorded in cm. Finger circumferences will be measured distal to the web space, and recorded in millimetres (mm). Volume of lymphoedema and percentage of lymphoedema in the arm and hand will be calculated using the truncated cone formula  from the addition of circumference readings, using software provided by Flinders Lymphoedema Clinic, South Australia (SA), which compares the affected to the non-affected arm. An increase in fluid volume and % fluid volume readings equates to an increase in level of lymphoedema. Fluid volume will be recorded as millilitres (ml) and % fluid volume of ml.
Density of fibrous tissue
Density of fibrous tissue will be measured by a digital tonometer, model 1383 (Bio-medical Engineering, Flinders Medical Centre, SA), validated especially for this population [47, 48], with an established protocol . Tonometer measurements will be taken on the forearm 10 cm from the cubital fossa and on the upper arm 10 cm up from the cubital fossa in the middle of the lymph territory. Additional measurements will be taken at the anterior trunk at mid-clavicular line between the second and third ribs and the posterior trunk between the acromion and the first thoracic rib in the subscapular fossa. The digital tonometer measures the resistance of the tissues to compression - that is, the amount of fibrotic induration (collagen build-up) in the superficial tissues at a given point [46, 50]. Each measurement will be followed by a three-second pause before retesting. A higher score for the digital tonometer denotes a higher level of tissue density. The result will be recorded in mm and the average of three recorded.
Physical sensations associated with lymphoedema
Visual Analogue Scales (VAS) have been validated as an effective method of recording individual perceptions of subjective parameters such as pain , and adapted in lymphoedema trials to include sensations specific to lymphoedema [40, 52].
A VAS scale that has been developed for this trial will be used to measure the severity of lymphoedema sensations which each woman will define, such as heaviness, tingling, aching. The VAS scale will also measure pain and fatigue, and the degree to which sensations, pain and fatigue have limited her activity for that day. The VAS scale will record what each woman felt on the day of measurement. The scale is scored as 0 cm being ‘no discomfort’ and 10 cm being ‘the worst imaginable’.
Quality of life
A validated questionnaire , developed specifically to measure quality of life for people with lymphoedema (LYMQOL), will be used. Its upper limb version will be used in this trial. Scores are recorded for the day of measurement. Total quality of life score is recorded between 0–10, ten being the best and zero the worst. Its result is recorded as the number the woman recorded from 1 to 10. Independent scales for function, symptoms, appearance, emotions, are also included in the questionnaire. Each of these includes several questions which are marked from 1 to 4, four being the worst. The sum of answers for each area of function, symptoms, appearance and emotions are added, then divided by the number of questions in that section to give a score for each parameter. A higher score denotes a lower quality of life associated with that parameter. In this way, different aspects of quality of life can be recorded numerically and compared between intervention and control groups.
Secondary outcomes measures
Range of motion of shoulder
The range of motion (ROM) of the shoulder of the non-affected, followed by the affected, arm will be measured using a two-armed goniometer, which has been validated for clinical trials  and used in trials for women with BCRL [54, 55]. An established protocol  will be followed . Women will sit in a low-back chair with stable shoulder blades, and suitable back support, their knees bent to 90° and with their feet at hip width and flat on the floor. Flexion abduction and extension of the shoulder in the sagittal or coronal planes will be measured from the starting point of arms in anatomical position. Interna l and external rotation of the shoulder will be measured from the starting position of the arm abducted to 90°, forearm pronated and parallel to floor, palm down, with elbow bent to 90°. To prevent fatigue, the testing will be conducted in the following order: flexi on internal rotation extension abduction external rotation. Endpoint of measurement will be full range, compensatory movements of the shoulder or trunk occurring, or women experiencing pain or tightness. The final result will be recorded in degrees as the best of three attempts. The higher the score the greater the range of motion.
Strength of shoulder
Muscle strength will be assessed using a Commander Powertrack II Muscle Tester (JTechMedical, Salt Lake City, Utah, USA), validated in a healthy population  and used in lymphoedema trials [7, 58] following an established protocol for muscle testing . The participant will sit in a stable position and the non-affected, then the affected, arm measured in turn, three times for each test. The arm will be raised to 90° for measurement of strength for flexion horizontal adduction and abduction. The arm will be positioned slightly across the body for measurement of strength for pectoralis major and the arm elevated to 120° for strength of serratus anterior. To measure the strength of extension, the participant’s arm will be by her side. Pectoralis minor strength will be assessed with the participant in supine position. This is also the order of testing to prevent fatigue.
The strength of the arm or shoulder will be measured from the force applied against the resisted hand-held dynamometer, held by the assessor for a count of three seconds. Measurement will cease when full strength is applied, compensatory movements of the shoulder or trunk occur or pain is experienced. The best of three attempts will be recorded in Newtons (n). A high score denotes a stronger muscle action.
Hand grip strength will be assessed by using a hand-held grip dynamometer (Smedleys, TTM, http://www.stoeltingco.com), which has been validated for use in a clinical setting , and using a protocol common to lymphoedema trials . The participant will sit in a stable position with her elbow bent at 90° and close to their body, palm facing inwards. Grip strength will be assessed by applying pressure to the dynamometer with the non-affected, followed by the affected, hand. Measurement ceases at full strength or if pain or instability occurs. The best of three attempts will be recorded in kilograms (kg). A high score denotes stronger grip strength.
Thoracic spine mobility
Thoracic spine mobility will be measured dynamically using video analysis in order to quantify the functional mobility of the spine during flexion/extension, lateral flexion and rotation following a validated protocol. . Range of motion will be recorded by a video camera with backlighting, utilising reflective surface markers. Reflective markers will be placed on women’s skin at the following locations: left and right superior posterior iliac spines (LPSI, RPSI), spinal processes (S1, L3, L1, T6, T1) and left and right acromion (LACR, RACR). Reflective markers will also be placed on the wall behind, or on the floor around the chair in the case of rotation, to provide calibration references. At the initial assessment, the placement of markers will be measured and recorded on the participant’s data sheet, to ensure consistency in the placement of markers at each measurement.
Women will be tested standing in stable anatomical position for flexion/extension and lateral flexion with the camera at a distance of two metres, and in stable sitting position for rotation with the camera one metre overhead. The test will be performed three times with each movement stopping at the point of full range, instability or pain.
Video footage will be downloaded at the end of each measurement. Video data will then be analysed using Quintic™ sports biomechanics video analysis software 9.03 version 14 (http://www.quintic.com). Measures will be calculated from resting position to range in each direction and full range, and will be recorded in degrees from software specifically made for this trial (Human Life Sciences, UTAS), following the calculated measures described in another trial . A higher score denotes greater movement. After analysis by Quintic, data will be entered into a specifically designed trial database.
As the use of video analysis with surface markers applied to the skin may be invasive for women who have been treated for breast cancer, women will have a choice of participation in this test.
Physical activity will be recorded at each session as it may impact other outcomes such as lymphoedema, sensation, pain, fatigue and arm movement. Physical activity in the week prior to each measurement period will be reported using the International Physical Activity Questionnaire (IPAQ-2005) short form, proven reliable in the Physical Activity for Lymphoedema (PAL) trial . The questionnaire measures the amount of vigorous, moderate and walking activity in intensity and duration, as well as the number of minutes in sitting. The total time in each activity is multiplied by an intensity value to calculate total weekly activity reported in MET.min-1. The total MET.min-1 score will also be given a value of 1 = light; 2 = moderate; 3 = high. Sitting time is recorded as a total number of minutes for that week.
Physical activity for that day will be recorded on the VAS scale as a number from 0-10 with 0 indicating no activity and 10 indicating constant activity.
Interview for yoga intervention women
A 20-minute audio-taped interview will be held at week 8 for the yoga intervention group and will be carried out by an independent assessor. Questions will be open-ended, in relation to the yoga sessions and DVD. Recorded interviews will be transcribed in full. An iterative-thematic approach will be used to analyse data by two researchers independently, then results compared and further analysis completed, by reporting data in themes and sub-themes according to frequency.
Study measures at baseline and weeks 4, 8 and 12
All staff involved in measurements will be trained prior to commencement of baseline testing and use standardised protocol and validated instruments. Two qualified lymphoedema therapists will take the lymphoedema measurements, one in Hobart, one in Launceston. Other staff will be the same at both locations. All assessors will be blinded to group allocation and to previous results. Each measurement will be performed by the same assessor at each time-point.
Participants will be advised to abstain from alcohol 12 hours prior to testing, caffeine and heavy exercise two hours before and be allocated a time that will not change during the trial to ensure consistency of readings for lymphoedema levels.
Measurements for the thoracic spine sub-group will be held the day after the other measurements at baseline, weeks 8 and 12.
All equipment will be calibrated prior to each measurement period.
All data will be recorded onto a case record form for each woman then transcribed into a specifically designed trial database.
Measurements at weeks 4, 8, 12
Measurements and sequence of measurements will be identical to baseline.
Compliance for attendance at yoga and home-practice DVD
A protocol will be put in place should a woman in the intervention have to miss a class, so that another class may be organised when possible. Attendance at the yoga class will be recorded weekly and DVD compliance self-recorded in a log, collected at weeks 4 and 8.
Medical and demographic information will be analysed using descriptive analysis within SPSS (version 19SPSS Inc. IBM, USA 2010) to calculate means and standard deviations or percentage values. Differences between groups will be assessed using t-tests for comparing continuous variables and chi-square tests for categorical variables.
All statistical analyses for quantitative measurements will be performed using STATA statistical software (version 12; 1985-2011; STATA corp.; College Station; Texas, USA). Binary categorical data will be analysed for variability between the groups using logistic regression. Parametric longitudinal data will be analysed via mixed methods linear regression. Non-parametric data will use ordinal logistic regression. Post-hoc testing will be performed on both parametric and non-parametric data using the Holms test to locate the means that are significantly different. Statistical significance will be set at p < 0.05.
Qualitative data from interviews will be analysed using an iterative-thematic approach.
Discussion and conclusion
The aim of this trial is to determine the effect of a yoga intervention on women with secondary arm lymphoedema as a result of breast cancer treatment by comparing the measurements of the intervention group with those of the control group, as well as to assess the perceived effects of yoga on the women in the intervention group by interview.
As no such trial has occurred up to this time, the results will assist in determining the effects of yoga on aspects relating to the lymphoedema, quality of life and upper body functioning for women with BCRL in the hope of finding another safe self-care option for women with BCRL. Finally, the methodology will inform future studies with larger numbers, as well as teaching guidelines for use by qualified yoga teachers.
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Speed-Andrews AE, Stevinson C, Belanger L, Mirus JJ, Courneya KS: A pilot evaluation of an Iyengar Yoga program for breast cancer survivors. Cancer Nurs. 2010, 33: 369-381. 10.1097/NCC.0b013e3181cfb55a.
Bower JE, Garet D, Sternlieb B: Yoga for persistent fatigue in breast cancer survivors: results of a pilot study. Evidence-Based Complementary and Altern Med 2011. 2011, 10.1155/2011/623168.
Galantino ML, Desai K, Greene L, Demichele A, Stricker CT, Mao JJ: Impact of Yoga on Functional Outcomes in Breast Cancer Survivors With Aromatase Inhibitor-Associated Arthralgias. Integr Cancer Ther. 2011, 10.1177/ 1534735411413270.
Thomas-MacLean R, Robertson S, Quinlan E, Kowalski K, Hamoline R, Spriggs P: Yoga for women with arm morbidity after breast cancer. Psycho-Oncology. 2010, 19: S265-
Van Puymbroeck M, Schmid A, Shinew K, Hsieh P: Influence of hatha yoga on physical activity constraints, physical fitness, and body image of breast cancer survivors: a pilot study. International Journal of Yoga Ther. 2011, 21: 49-60.
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Czerniec SA, Ward LC, Refshauge KM, Beith JM, Lee MJ, York S, Kilbreath SL: Assessment of breast cancer-related arm lymphedema-comparison of physical measurement methods and self-report. Cancer Invest. 2010, 28: 54-62. 10.3109/07357900902918494.
Asana, Pranayama, Mudra, Bandha. Edited by: Saraswati S. 1996, Bihar School of Yoga, Munger
Cornish B, Bunce IH, Ward LC, Jones LC, Thomas BJ: Bioelectrical impedance for monitoring the efficacy of lymphoedema treatment programmes. Breast Cancer Res Treat. 1996, 38: 169176-
Rockson SG: Bioimpedance analysis in the assessment of lymphoedema diagnosis and management. Journal of Lymphoedema. 2007, 2: 44-48.
Koelmeyer L, Shanley K, Reul-Hirch HM, Piller NB: Setting a National Standard for Measurement of Lymphoedema Limbs. Australasian Associaton of Lymphology. 2004, Mt Colah, NSW, Australia, Topic Standards and Guidelines. From http://www.lymphology.asn.au/new/document/updatedProtcol161204.pdf date cited 10.5.2011
Stanton AWB, Badger C, Sitzia J: Non-invasive assessment of the lymphedematous limb. Lymphology. 2000, 33: 122-135.
Clodius L, Deak L, Piller NB: A new instrument for the evaluation of tissue tonicity in lymphoedema. Lymphology. 1976, 9: 1-5.
Bates DO, Levick JR, Mortimer PS: Quantification of rate and depth of pitting in human edema using an electronic tonometer. Lymphology. 1994, 27: 159-172.
Moseley AL, Piller NB: Relationships between limb size and composition using objective measures. Their role in providing better treatment outcomes. Lymphology. 2007, 40: 170-175.
Piller NB: To measure or not to measure? What and when is the question. Journal of Lymphoedema. 2007, 2: 39-45.
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Jahr S, Schoppe B, Reisshauer A: Effect of treatment with low-intensity and extremely low-frequency elecrostatic fields of breast tissue and pain in patients with secondary breast lymphoedema. J Rehabil Med. 2008, 40: 645-650. 10.2340/16501977-0225.
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Box R, Reul-Hirche HM, Bullock-Saxton JE, Furnival CF: Physiotherapy after breast cancer surgery: results of a randomised controlled study to mimimise lymphoedema. Breast Cancer Res Treat. 2002, 75: 51-64.
Todd J, Scally A, Dodwell D, Horgan K, Topping A: A randomised controlled trial of two programmes of shoulder exercise following axillary node dissection for invasive breast cancer. Physiotherapy. 2008, 94: 265-273. 10.1016/j.physio.2008.09.005.
Box R, Reul-Hirch HM, Bullock-Saxton JE, Furnival CF: Shoulder movement after breast cancer surgery: results of a randomised controlled study of postoperative physiotherapy. Breast Cancer Research and Treatment. 2002, 75: 35-50. 10.1023/A:1016571204924.
Leggin BG, Neuman RM, Ianotti JP, Williams GR, Thompson EC: Intrarater and interrater reliability of three isometric dynamometers in assessing shoulder strength. J Should Elb Surg. 1996, 5: 18-24. 10.1016/S1058-2746(96)80026-7.
Johansson K, Ingvar C, Albertsson M, Ekdahl C: Arm lymphoedema, shoulder mobility and muscle strength after breast cancer treatment - a prospective 2-year study. Adv Physiother. 2001, 3: 55-66.
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Bohannon RW: Dynamometer measurements of hand-grip strength predict multiple outcomes. Percept Mot Ski. 2001, 93: 323-328.
Menegoni F, Vismara L, Capodaglio P, Crivellini M, Galli M: Kinematics of trunk movements: protocol design and application in obese females. J Appl Biomater Biomech. 2008, 6: 178-185.
Schmitz KH, Troxel AB, Cheville A, Lewis-Grant L, Bryan CJ, Gross CR, Lytle LA, Ahmed RL: Physical Activity and Lymphedema (the PAL trial): assessing the safety of progressive strength training in breast cancer survivors. Contemp Clin Trials. 2009, 30: 233-245. 10.1016/j.cct.2009.01.001.
The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6882/12/66/prepub
Grants have been provided by Swan Research Institute (SRI) and the Faculty of Health Sciences Seed Funding, UTAS.
The authors declare they have no competing interests.
AL, TB and ADW are responsible for the design of this trial and the construction of the measurement protocol. AL will conduct the yoga intervention. NP is responsible for the design of the lymphoedema methodology. MAI assisted in design of the trial and advice for aspects of the yoga intervention. DV designed software for interpretation of opto-electronic data for the thoracic spine tests. All authors read and approved the final manuscript.
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Loudon, A., Barnett, T., Piller, N. et al. The effect of yoga on women with secondary arm lymphoedema from breast cancer treatment. BMC Complement Altern Med 12, 66 (2012). https://doi.org/10.1186/1472-6882-12-66


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Biden black market thrives: US parents swap and sell baby formula amidst country-wide shortage.
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They are what they are.” – During an interview with Bret Baier, Ukrainian President Volodymyr Zelensky brushes aside Nazi Azov Battalion atrocities Newsweek: Zelensky Is Making It Harder to Prosecute Russians for ‘War Crimes’ in Ukraine.
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Sydney's Royal Easter Show has come under fire after organisers announced that vaccinated children will be allowed free entry, while unvaccinated kids would be charged full price to enter. https://t.co/IdmPPgDOIS — Rebel News Australia (@RebelNews_AU) April 3, 2022
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REVIEW: Ten Plagues
Dani Cugini is confused and mesmerised by one of Cambridge’s most experimental shows to date.
“You have not known what I have seen.”
It is 1665 and the plague has decimated London. A man stands in an empty, lavishly furnished room and washes his hands. Thus begins a production entirely different to the ADC’s usual fare. Secluded in the out-of-the-way Larkum Studio, with only two performers and a pianist, Ten Plagues is intimate and jarring – even the two performers are the same person, the same mind, ‘plagued’ with trauma, guilt and inwardness as he shelters from the plague.
Ten Plagues is a song cycle by Mark Ravenhill, adapted from plague-time texts including Defoe’s A Journal of the Plague Year. I didn’t know what a song cycle was before attending this show: it’s mostly in the name – it’s a cycle of songs that run into each other – but you have to see one to get a full sense of what they are. The songs are part-song, part-narrative, part-poetry, part-diary – it’s different from a musical or opera since everything is included within the songs.
Part of the intrigue of this production is in Conor Mitchell’s unusual score. Songs aren’t ‘catchy’ at all, but eerily chromatic and shifting (to the point that it’s a startling accomplishment that the performers remember the tune). It sets you on edge, bringing you into the mind of Ten Plagues‘ character as he loses loved ones, watches a man die in the street, and sings of the suffocating fear of both death and survival.
The performers, Heather Conder and David Matthews, both deserve praise for their performances – they are clearly both technically accomplished singers and show acting promise. Both present an interesting counterpoint, with Matthews’ more inward and yearning portrayal placed against Conder’s energetic and disturbed performance. Matthews walks slowly about the stage, sits, stares at the wall; Conder watches from the shadows, scampers about, steals a piece of fruit. It feels like they’re playing divided parts of the same psyche.
If ‘eerie’ is one word to describe Ten Plagues, another is ‘careful’: the lighting and choreography are minimalistic and elegant, and every movement and look between the performers is carefully composed. The singing is careful too, and any slips out of key were only momentary (entirely forgivable in an almost-hour-long show of near-constant singing). There was a slight volume problem, more with Matthews than Conder, with the music sometimes obscuring his words, but generally the production is effectively minimalistic and handled professionally.
But do I recommend Ten Plagues? Not to everyone. It’s definitely a niche production, which is not a problem in itself, but the weight of the subject matter and the unusual form means that not everyone is going to be spellbound. I found it arresting, thought-provoking, elegant – but not ‘entertaining’ as such. It depends on what you want in a show.
What I would say is that it’s an enriching experience to see something so different to the usual Cambridge theatre, and it’s worth seeing for a perhaps greater reason than it being ‘fun’: it expanded what I think of as ‘theatre’ and ‘musical theatre.’ And if you’re a fan of opera, Ten Plagues will likely interest you.
Ten Plagues is a rare gem to find within the Cambridge theatre scene. It may not be typical evening entertainment, but not all shows have to be. It is skilled, absorbing, and those involved deserve recognition for the difficulty of their subject. If you want something a little different, it’s worth a watch.

domain: artistic


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You continue to have a major impact on art, fashion, and architecture with your multiple creative outlets. What’s your secret to success, for all creative fronts?
I think curiosity is something that continues to drive me in many of the projects I’m trying to execute or ideas I want to work through. You know, I’m constantly trying to make things I want to see exist in the world and I figure, hopefully, if I want to see them exist, other people may want to as well.
From your monumental “Blue Garden” in Rio to Future Relic ’08, what are the biggest art challenges you’ve faced this year?
Certainly the exhibition in Rio and the massive museum show that I just opened in Moscow both contained works on a monumental scale. These works are often partially segregated within my city of New York and then transported to locations in Russia and in Rio. I think the coordination of that and really making sure that these works are executed up to the level of quality that I expect for myself is one of the larger challenges. And you know, trying to be in three different continents in a week and a half opening exhibitions is also insane right now. I’m trying not to think about jet lag right now.
Tell us about your first-ever footwear collaboration with adidas. What was the experience like?
I mean the great experience for me, I think, is much of the same way that I have brought into my works across disciplines… in painting, sculpture, film, architecture and stage design. I think that working on this collaboration of the sneakers is a way to engage in the audience and speaking about my larger practice, some of whom were certainly familiar with my work before as well as others who do not come from that background. I think that anytime when I can create a scenario where I am reaching audiences from different backgrounds could be a very interesting way of creating dialogue and inciting people to think about the work. Part of the big push with the adidas project was, in some way, less about the shoe and more about this film project that I’ve been working on: “The Houglass Film.” We’re continuing on with that; so, the next part will be announced soon.
Speaking of Hourglass, what film projects are you currently working on? There are two separate film projects. The Hourglass film is related to the adidas project I have been working on and Future Relic is this larger film related to the Future Relic object I’ve been making. Mahershala is involved in the Future Relic project… in the section which I have not yet released. We’re in the process of determining what and how that is going to be shown, but it should be interesting.
What are your thoughts on artists collaborating with brands? Does the meaning of the artwork change?
I think that in some ways I am inside of that universe and in many ways I’m not. Oftentimes when critics are looking at work within the art world, they’re talking about it from the perspective of architecture since many of them know my work from the stage design that I created with Merce Cunningham, you know, who had a lineage that went back to Andy Warhol, Robert Rauschenberg, Jasper Johns and that whole universe. I think, from the art world, they often look at my work from that perspective. But in many ways, because of this cross-filtering of everything from fashion and film to even streetwear and sneakers, they’re blending in a way that I think is interesting and someway creates a scenario where a lot more people are looking at artwork through my generation and the younger generation. I think that’s great and it’s an amazing opportunity for artists like myself to engage wider audiences and thinking about artwork.
What are you working on currently? Any upcoming projects?
The exhibitions people are seeing today are often things I’ve been working on for, you know, the last two, three, in some cases 10 years. In one of the major works exhibited in Moscow, I first began thinking about it at least 10 years ago. Sometimes it just takes a long time to not only have the space to execute something but also the knowledge and ability to craft something in that way. So, you know, there are tons of different things that are sitting on my desk that may or may not be artworks in the future.
What are some things you can’t live without?
That I can’t live without… I’m looking around at my desk… certainly my notebook. I mean I like an automatic... non-digital functioning watch, my notebook, and probably a good pair of sunglasses.


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On behalf of Stange Law Firm, PC posted in Domestic Violence on Thursday, October 4, 2012.
Every parent has the right to a relationship with their child. Even in cases where the parents are going through a nasty divorce full of domestic abuse allegations, children should still be able to spend time with both of their parents.
In situations where accusations involving abuse play a role, a judge may only allow supervised visitation with the children. This is done in order to ensure the child’s safety, while also still allowing the child and parent to spend time together under the watchful eye of an advocate.
Paul Nassif, who is the estranged husband to “Real Housewives of Beverly Hills” reality star Adrienne Maloof, was recently awarded supervised visitation with the couple’s three children. This is amid a bitter contested divorce between the couple.
In September, two months after Maloof filed for legal separation and later a divorce, she accused her ex of verbally and physically abusing her in front of the children. Then, just last week, she obtained a temporary restraining order against her soon-to-be ex-husband. Her claim was that he was also abusing the couple’s three sons.
Upon hearing of this alleged abuse, the Department of Children and Family Services started to investigate. Those claims have since gone unfounded. However, the visitation time Nassif has with his children will still be supervised for the time being.
For Illinois residents this is a perfect example of just how contentious a divorce can get, with accusations involving abuse even springing up. Whether you want to know more about supervised visitation or have concerns regarding abuse allegations, an attorney with experience handling divorce and other family law issues can help answer any questions you may have.
Source: The Huffington Post, “Adrienne Maloof Divorce: Paul Nassif Awarded Supervised Visitation,” Sept. 27, 2012

domain: sociology


Karan Johar, known for steering a number of the first-rate romantic dramas in Bollywood, is returning to his “first home,” which for him is the cinemas, once more after an extended seven-yr hiatus. While he become nevertheless generating and running on different matters, Johar teased his grand comeback in advance with a star-studded assignment titled Rocky Aur Rani Ki Prem Kahani. And we ultimately have a release date for the epic love tale between Alia Bhatt and Ranveer Singh.
Keeping up with the drama in his films, Johar’s comeback assertion wasn’t a simple one. The Kabhi Khushi Kabhie Gham filmmaker posted a note observed by an lovely poem on his Instagram describing the film and its famous person solid at the same time as including that the film will launch on April 28 next 12 months.
“After 7 years, it’s time for me to return to my first home – the cinemas. I had absolutely the honour of working with no longer one, however many illustrious actors on the set of my film. The familial nostalgic feeling of an ensemble cast creates song that captivates the hearts and a tale that runs deep to the roots of our own family traditions,” examine his note.“It’s that time once more -to huddle along with your family and pals, buy the popcorn and witness simply sheer love & amusement spread on the big display. We’re overwhelmed and impatiently excited to eventually inform. Rocky Aur Rani Ki Prem Kahani in cinemas on 28th April 2023.”
Two hours earlier than the discharge date became revealed, Johar additionally penned a poem to tease that a “message” is coming quickly.The poem, in the beginning in Hindi, loosely translates to, “Love could be revived after 7 years with track by using Pritam and Amitabh Bhattacharya matching his music. Alia will megastar within the film and Ranveer could be himself having a blast. What a pair, what a movie it will be. Jaya could be in an unseen avatar and you’ll fall in love with Shabana. Dharmendra’s swag is still intact, we’re coming and that is a reality. So wait for the night for my message. This film is for each age organization – younger ones to senior residents.”
Johar ultimate directed Ae Dil Hai Mushkil in 2016. The film starred Ranbir Kapoor, Anushka Sharma, Aishwarya Rai Bachchan and Fawad Khan in lead roles.Pakistani cricket lovers across the globe sat with bated breath and a mixture of emotions today in hopes of watching history repeat itself after the guys in green secured a place in finals after 13 long years. But perhaps, even attaining the finals become a large feat for us and fans are pleased with their crew as usually!
From sending their love and appreciate to Shaheeh Shah Afridi after his damage mid-suit to commenting on our shortcomings and celebrities took to their social media to cheer up the green shirts for putting up a great combat and attempting their pleasant until the very give up.


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Removal of polycyclic aromatic hydrocarbons from water by magnetic activated carbon nanocomposite from green tea waste
This study aims to synthesize a magnetic activated carbon nanocomposite from green tea leaf waste (MNPs-GTAC) for evaluation of adsorption efficiency of 4 priority polycyclic aromatic hydrocarbons (PAHs). MNPs-GTAC contained spherically-shaped MNPs with cubic spinel structure, surface area at 118.8 m2/g, particle size at 8.6 nm and saturation magnetization at 34.2 emu/g. PAH adsorption reached a plateau at an MNPs-GTAC dose of 50 or 60 mg/L, pH of 2–4 and ionic strength of 0.1–10%, with PAH reduction in the presence of humic acid being compensated by addition of 0.1% sodium chloride. Kinetics was rapid attaining 80% removal within 5 min and the pseudo-second-order rate decreased in this order: Benzo[a]anthracene>Chrysene>Benzo[b]fluoranthene>Benzo[a]pyrene. Isotherm modeling revealed a Langmuir type-2 shape with the maximum adsorption capacity being 28.08, 22.75, 19.14 and 15.86 mg/g for Benzo[b]fluoranthene, Benzo[a]pyrene, Chrysene and Benzo[a]anthracene, respectively. Temperature study showed the PAH adsorption to be an endothermic and spontaneous process with increased randomness at solid-solution interface. Acetonitrile could completely recover the adsorbed PAH and MNPs-GTAC was successfully recycled 5 times with a minimum loss. Application to mineral water showed 86–98% and 72–89% removal for PAHs spiked respectively at 0.1 and 1 mg/L, while a complete removal was attained in tap and river waters.
Keywords: Magnetic nanoparticlesGreen tea waste activated carbonMagnetic carbon nanocompositePolycyclic aromatic hydrocarbonsAdsorption mechanism

domain: chemistry


text:
The Latest Guidelines new doctor home loan Oak Laurel For Useful Solutions Of Doctor Home Loan Geelong Victoria
Clinical Pharmacologist mortgage
Click here for rate may require membership. You had promised to provide us quick and 2 points on a $100,000 mortgage would equal $2,000. Amortization Tables: Clicking on the “show amortization tables” link reveals options to in any way imply an affiliation with that trademark's owner. If the buyer believes interest rates will fall or plans on process easy and painless. Studies suggest that home-owners who work with housing counselling listings that appear on this page are from companies from which this website receives compensation, which may impact how, where and in what order products appear. Some home buyers take out a second mortgage to use as part of their terms on their own website from those advertised through Bankrate.Dom. By Lydia Koehn on December 21, 2016 Buying a home amortization chart along with physician home equity loan Oak Laurel 0430129662 the ability to view a payment breakdown do not chart. To receive the Bankrate.Dom rate, you must identify and has not been reviewed, approved or otherwise endorsed by any of these entities. Prime Rate or the London is expressed as a percentage.
Identifying Indispensable Issues Of Geelong Victoria
"Regular commuters spend up to 20 hours per week on regional trains, and we need to keep them connected so they can keep in touch with their loved ones and use their travel time productively." According to Vodafone Australia, it will be building 23 of the 35 new mobile towers. As a major proponent of infrastructure sharing , Vodafone said it will accordingly collocate with all mobile carriers on 13 of these sites, and collocate two carriers on five of its towers. CTO Kevin Millroy said Vodafone also plans to invest AU$5 million to improve its mobile network throughout Victoria during 2016-17. The telco has already reallocated its 2100MHz spectrum to 4G services in regional areas Albury-Wodonga, Ballarat, Bendigo, Geelong, Mildura-Wentworth, and Shepparton, after renewing its spectrum licence in this band for AU$544 million. Vodafone last week also won 2x 5MHz of mobile broadband spectrum in the 700MHz band during the regulator's mobile broadband spectrum auction for a total of AU$285.9 million in an effort to improve data coverage throughout regional and metro areas. Telstra welcomed the Victorian government project, saying it complements its own network investments across regional Australia. "We have already made significant network investments along these rail links, extending our 4GX footprint as part of our ongoing commitment to regional Australia," said Telstra director of Wireless Network Engineering Channa Seneviratne. "As a result, once the in-train repeaters are installed as part of the Victorian government's investment, Telstra customers will have in-train coverage for close to 95 percent of the regional rail routes, provided by Telstra's existing infrastructure. "Our further investment in additional infrastructure as part of this project will increase that in-train coverage of the routes to 99 percent for Telstra customers." Optus, which has been installing small great site Pharmacist home loan cells across regional areas to boost mobile coverage , also welcomed the project, saying it demonstrates that telcos and governments can partner on bringing coverage to regional areas.
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domain: news


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Thus, alcohol metabolism destroys the essential coenzyme required for T synthesis. Alcohol also contributes to the release of special endorphins which inhibit hormone production. In addition, drinking too much alcohol leads to the elevation of estrogen levels in men because of the conversion of testosterone in estrogen. It means that T levels come down with a run.
"The Journal of Clinical Endocrinology and Metabolism" published that males who switched from a high-fat diet to a low-fat diet also saw a decrease in their testosterone levels. If you want to put some fat back into your diet without fearing cardiac implications, plant-based saturated fat like coconut is just the ticket. Meat-based fat is also acceptable if kept to less than 10% of your dietary fat intake.
It's tough to get a reading on your average blood pressure if you only measure it at the doctor's office. Buy a home monitoring kit at your local pharmacy. Take two readings a day, morning and night, for a few days. Repeat these steps a few times a year, and share the results with your doctor. Better understanding of your blood pressure is the first step to preventing heart disease and stroke.
Grape seed extract is another ingredient with not enough research to suggest a dosage. Grape seed extract can interact with drugs like “blood thinners, NSAID painkillers (like aspirin, Advil, and Aleve), certain heart medicines, cancer treatments, and others.” If this sounds like you (or if you ever pop an Advil to clear off a headache), you’ll need to speak with a doctor to make sure this supplement is safe to take.
Avoid stressful situations – It is actually that simple. If you can avoid stressful situations, then you can significantly improve your overall testosterone production. Why is that? Well, you should know that stress makes our bodies to produce cortisol that is a notorious and well-known testosterone killer. So, what can you do about it? Well, you should definitely try deep breathing, meditating, exercising, and other lifestyle changes that can help you deal with the stressful situations the right way.
14. Volek JS, Volk BM, Gómez AL, Kunces LJ, Kupchak BR, Freidenreich DJ, Aristizabal JC, Saenz C, Dunn-Lewis C, Ballard KD, Quann EE, Kawiecki DL, Flanagan SD, Comstock BA, Fragala MS, Earp JE, Fernandez ML, Bruno RS, Ptolemy AS, Kellogg MD, Maresh CM, Kraemer WJ. Whey protein supplementation during resistance training augments lean body mass. J Am Coll Nutr. 2013;32(2):122-35. PMID: 24015719
A number of research groups have tried to further define the relationship of testosterone and body composition by artificial alteration of testosterone levels in eugonadal populations. Induction of a hypogonadal state in healthy men (Mauras et al 1998) or men with prostate cancer (Smith et al 2001) using a gonadotrophin-releasing-hormone (GnRH) analogue was shown to produce increases in fat mass and decreased fat free mass. Another experimental approach in healthy men featured suppression of endogenous testosterone production with a GnRH analogue, followed by treatment with different doses of weekly intramuscular testosterone esters for 20 weeks. Initially the experiments involved men aged 18–35 years (Bhasin et al 2001) but subsequently the study was repeated with a similar protocol in men aged 60–75 years (Bhasin et al 2005). The different doses given were shown to produce a range of serum concentrations from subphysiological to supraphysiological (Bhasin et al 2001). A given testosterone dose produced higher serum concentrations of testosterone in the older age group (Bhasin et al 2005). Subphysiological dosing of testosterone produced a gain in fat mass and loss of fat free mass during the study. There were sequential decreases in fat mass and increases in fat free mass with each increase of testosterone dose. These changes in body composition were seen in physiological and supraphysiological treatment doses. The trend was similar in younger versus older men but the gain of fat mass at the lowest testosterone dose was less prominent in older patients (Bhasin et al 2001; Bhasin et al 2005). With regard to muscle function, the investigators showed dose dependent increases in leg strength and power with testosterone treatment in young and older men but there was no improvement in fatigability (Storer et al 2003; Bhasin et al 2005).
Keep in mind that you can use virtually any type of equipment you want for this – an elliptical machine, a treadmill, swimming, even sprinting outdoors (although you will need to do this very carefully to avoid injury) -- as long as you're pushing yourself as hard as you can for 30 seconds. But do be sure to stretch properly and start slowly to avoid injury. Start with two or three repetitions and work your way up, don't expect to do all eight repetitions the first time you try this, especially if you are out of shape.
A: Depo-Testosterone is a brand name medication that contains testosterone cypionate. Depo-Testosterone is given as an intramuscular injection. The medication is indicated for replacement therapy for men that have conditions associated with symptoms of deficiency in the hormone or absence of testosterone produced in the body. Conditions that can be associated with low testosterone include: delayed puberty, impotence and hormonal imbalances. Testosterone is a sex hormone that is naturally produced in the male testicles. In women, small amounts of testosterone is produced in the ovaries and by the adrenal system. Testosterone is available in various medications for testosterone replacement therapy. Different forms of testosterone (e.g. cypionate, enanthate etc) are contained in different brand name medications. Jen Marsico, RPh
To find the best testosterone booster, we collected every supplement available on BodyBuilding.com, and cross-checked our list against the top results on best of lists like MensFitness, BroScience, and BodyNutrition. We only looked at pills since some of the ingredients in testosterone boosters have a reputation for tasting bad, and powders just prolong the experience. There are a lot — 133 of them to be precise — and they all claim to boost testosterone levels. Testosterone (for men) is “thought to regulate sex drive (libido), bone mass, fat distribution, muscle mass and strength, and the production of red blood cells and sperm.” If a supplement can increase your natural testosterone levels, the rest should follow. As we mentioned above, it’s not that simple, and at best, you’ll experience only a short-lived boost.
I think that revamping your diet and lifestyle could be enough alone (no sugar, high fat, low carbs, lots of veggies, working out, low stress). Tongkat Ali would be an amazing added extra. I don’t know about mixing Tongkat with DAA and other stuff. Probably would be fine, but it’s strong. I usually say pick one. I know Testofuel has Fenugreek in it, but I don’t have too much experience with it. It has been proven to have effects. See this article.
The regulation of testosterone production is tightly controlled to maintain normal levels in blood, although levels are usually highest in the morning and fall after that. The hypothalamus and the pituitary gland are important in controlling the amount of testosterone produced by the testes. In response to gonadotrophin-releasing hormone from the hypothalamus, the pituitary gland produces luteinising hormone which travels in the bloodstream to the gonads and stimulates the production and release of testosterone.
Two of the immediate metabolites of testosterone, 5α-DHT and estradiol, are biologically important and can be formed both in the liver and in extrahepatic tissues. Approximately 5 to 7% of testosterone is converted by 5α-reductase into 5α-DHT, with circulating levels of 5α-DHT about 10% of those of testosterone, and approximately 0.3% of testosterone is converted into estradiol by aromatase. 5α-Reductase is highly expressed in the male reproductive organs (including the prostate gland, seminal vesicles, and epididymides), skin, hair follicles, and brain and aromatase is highly expressed in adipose tissue, bone, and the brain. As much as 90% of testosterone is converted into 5α-DHT in so-called androgenic tissues with high 5α-reductase expression, and due to the several-fold greater potency of 5α-DHT as an AR agonist relative to testosterone, it has been estimated that the effects of testosterone are potentiated 2- to 3-fold in such tissues.
The sex hormone testosterone is far more than just the stuff of the alpha male's swagger. Though it plays a more significant role in the life of the biological male, it is actually present in both sexes to some degree. Despite popular perceptions that testosterone primarily controls aggression and sex drive—although it does play a role in both of those things—research has shown that individual levels of testosterone are also correlated with our language skills and cognitive abilities. Testosterone occurs in the body naturally, but can be administered as a medication, too: its most common uses are in the treatment of hypogonadism and breast cancer, as well as in hormone therapy for transgender men.
Testosterone levels generally peak during adolescence and early adulthood. As you get older, your testosterone level gradually declines — typically about 1 percent a year after age 30 or 40. It is important to determine in older men if a low testosterone level is simply due to the decline of normal aging or if it is due to a disease (hypogonadism).


text:
When booking your flights and you have a connecting flight, how much time do you allow between those?
Obviously, the amount of time you need to leave between flights depends on the airport, the airline, the weather, customs, security, and switching terminals…to name a few.
Scheduling a safe amount of time saves you hassle and unwanted stress. But, how much time is that? Most sites tell you to leave at least 90 minutes between flights. That’s the ideal amount.
For international flights that connect with domestic flights, you will need to leave enough time to clear customs. And, that can vary widely in airports.
When traveling to a foreign country, it seems like I always have some leftover cash. If I know I’m going back to that country, I’ll save it. However, if I don’t want to remember where I put it for next time…here’s an idea.
Before you go on your trip, purchase a Starbucks coffee card. Then, before your return trip home, go to the Starbucks in the airport…there’s always at least one. Take your extra change and currency and use it to add to the value of the card.
No leftover change…extra money on your Starbucks card.
If you don’t drink coffee, you can always use it for a gift.
If you use a packing list, you probably won’t forget important items. If you don’t use a list…at least plan ahead to remember everything you need for your upcoming trip.
Are you traveling to a country where you need an adapter for your electronics? If so, do you know which one you need? It’s best to plan this ahead of time to avoid looking for the right adapter at the last minute. No sense buying an expensive one in an airport gift shop.
Do you know the weight restrictions on your luggage…both carry on and checked? Good idea to check before you arrive at the airport.
Do you need any immunizations? If so, do you know how far in advance you should get them?
Have you broken in your new shoes?
Do you need or want a special meal on the plane? If so, have you ordered it?
Did you book your pet or house sitters?
The Stags Leap District of Napa Valley, California turns 25 this year. It was officially recognized as an American Viticulture Area (AVA) in 1989. However, cabernet sauvignon vines weren’t planted there until 1961. This area of the Valley is known for its cool breezes, clay and loam soil, and gentle hills. Wines produced here are known for their soft, rich tannins and impressive ageability.
In 1976 the 1973 Stag’s Leap Wine Cellers Cabernet Sauvignon took first place at the Judgement of Paris tasting, which propelled this AVA into fame. Ten years later another Stags Leap District wine, the 1972 Clos du Val Cabernet Sauvignon took first place at the 10 year anniversary of the Paris tasting.
Stags Leap District is the smallest AVA by planted acreage in Napa Valley.
When traveling, it’s always a good idea to be polite. It doesn’t matter if you’re going wine tasting, visiting a museum in San Francisco, or shopping in Paris. After all, you’re in their territory.
Typically in Europe, and especially in Paris it’s a good idea to greet the shopkeepers when entering a shop and to thank them when you leave. Why? It’s just the polite thing to do. You also get to practice your French or Italian or wherever you are.
In fact, practicing some simple phrases in the language of the country where you will be visiting is also a good idea. Start now by learning ‘hello’, ‘goodbye’, ‘please’, and ‘thank you’. You’ll be glad you did.

domain: geography


JF Strainstall provides a static load testing service to determine the performance of a pile when subjected to a given load.
Static load tests can be used to determine the settlement that can occur at working load, or a multiple of it, and can also be used to verify the ultimate bearing capacity of a pile.
There a number of different methods of static load tests:
- Maintained load test - each increment of load is held constant for a specified period of time or until the rate of settlement falls below a specified value.
- Constant rate of penetration (CPR) test - the load is applied to the pile in order to maintain the rate of penetration at a constant speed. This method is usually conducted for determining the ultimate bearing capacity of a pile.
- Tension test - similar to maintained load test, except the purpose of this method is to determine how the pile will perform under a tensile load.
- Zone testing - this method is usually conducted after ground remediation over a large surface area.
Static load testing methodology
Loading can be applied in one of two ways; using a jack which reacts against a kentledge heavier than the required test load or using a jack which reacts against beams held down by tension piles acting as anchors.
Pile settlement is recorded using dial gauges or electrical displacement transducers. The applied load is monitored using calibrated load cells, and on up to date systems can be controlled automatically using a portable computer and a compressed air pump.


I was alarmed to hear Owen Paterson, the UK’s Environmental Secretary, speaking on Radio 4 the other morning, urging the government, industry and scientists ‘to join forces in tackling the widespread public fear and skepticism about genetically modified crops‘.
In America, GMOs are already part of the food supply, with experts estimating that as much as 60% to 70% of processed foods have genetically modified ingredients.
Soybeans, maize, cotton, and rapeseed oil are the most common genetically modified foods in the US. That means many foods made in the U.S. containing field corn or high-fructose corn syrup, such as many breakfast cereals, snack foods, and foods made with soybeans (including some baby foods); could likely have genetically modified ingredients. These ingredients appear frequently in animal feed as well.
Here in the UK, a recent survey by the YouGov market research company found that only 21 per cent of the global population currently supports GMO technology, while 35 per cent were against it.
The key question is whether or not GMO foods are safe for humans to consume???
Whilst many, including the EU chief scientist, Anne Glover, argue that: “there is no substantiated case of any adverse impact on human health” from GM crops, there are many studies which reach the complete opposite conclusions.
For instance, the ‘leaked 2012 research by Profit Pro indicated that genetically-modified corn contained a startling level of toxic chemicals in comparison to the organic crops.’
‘July 24 will see the launch of a global on-line Monsanto Video Revolt action, which will cover YouTube, Facebook and Twitter in order to bypass the corporate media blackout on GMO foods and bring the issue to world attention.’
via ‘Safer than conventional food’: Push to make UK world GMO leader sparks outrage — RT News.


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Over my lifetime, the first people who come to mind are my mother and sister. I mentioned in the book how much their support meant to me as I became a single mom.
If you had to do it all over again, would you change (remove or add) anything in your book?
I worked on this book off and on for two years, and I believe I produced the best work I could at the time. There were so many things I left out of the book, but I may do a revised version in the future, adding my own experiences once I have begun raising my daughter as a teenager (she is only 8 now). What I will change with my next book is the way in which I approach the publishing process. I will form a more solid team and give myself more time to create the book without feeling pressured or not having a plan B if there is an issue with one of my service providers.
I wrote the book with teen girls in mind, and I have heard from teen girls that read it quickly (couldn't put it down), and enjoyed it. I'm also hearing a great response from women in their 20s all the way to their 60s (mothers, grandmothers and childless women alike), who also strongly relate and identify with the concepts in the book, especially regarding relationships and self-esteem. I've also gotten great feedback from women who say that the Reflections Journal (which contains workbook-style questions) is something they can use right now, even without having read the book. I firmly believe that the issues I discuss in the book that are not resolved when you're young follow you and often cause bigger issues into adulthood and that's probably why it is resonating with women everywhere.
Do you have anything specific that you want to say to your readers?
In this book I tell a lot of personal stories, and they're not always flattering, but that's the point. I'm just relaying messages from my past to teach. I don't divulge information just for the sake of shock value. I love bring up "taboo" subjects, or that people know is present but don't want to admit (e.g., the proverbial "elephant in the room." Denying that an issue exists does not delay or erase its effect. Once you expose something negative, it starts to lose its power.
I want to connect with people and be relatable, and the way I do that is by sharing pieces of myself that are relevant from a teaching/coaching perspective. I want them to see that I'm a real person that overcome some things, and I'm not ashamed to talk about it. I can admit my mistakes because I grow from them. That's how we all learn. I can't come from a standpoint of, "That's beneath me," or a platform of perfection. Everyone talks about "keeping it real," and I do just that. I'm pretty transparent and when I speak about my personal business to make a point of helping others, people respect me for it.
Do you have any current project, and if you do can you tell us alittle about it?
I am writing another nonfiction book that focuses on the perspective of single Black fathers in America. There is so much emphasis on single mothers in the Black community (which is fine—I am one and I identify), but I want to bring Black families together for those who want that. The Black community is struggling so much because of broken homes. I want to tell the single dads’ side of the story, through the many voices of the real Black America. If you are interested in contributing via an interview, you can contact me at email@example.com for more details.
Daree I like to thank you for such a great interview, I honestly enjoyed reading your book and hope that readers enjoy it as much as I did.
Just being able to share is a blessing to me and I hope the book brings hope and inspiration to all who read it. Connect with me on the following sites:
Daree Allen is an authorpreneur, young adult esteem advocate, speaker, and goal-getter in Atlanta, GA. She has published articles on a variety of topics as a freelance writer and blogger, and is the author of the new teen mentoring book entitled, "What's Wrong With Me?" in which she discusses her own childhood dealing with self-esteem, premarital sex, family and personal relationships. Find out more about her work at www.dareesinsights.wordpress.com and www.DareeAllen.com.

domain: literature


This article was contributed by Mark Paxton.
Pat’s Place, the Community FoodBank thrift store, will close its doors after almost a decade of offering San Benito County Shoppers value-priced goods and unexpected treasures.
The announcement was made to volunteers and staff this week, following a decision by FoodBank’s management and board of directors.
“It’s been quite an adventure,” said Maria Lynn Thomas, FoodBank CEO. “We rely heavily on the commitment of volunteers for everything that happens at the food bank, and Pat’s is no exception. It’s only through them that we’ve been able to keep the doors open for more than nine years.
“We know that our thrift store is a real benefit to many regular customers looking for value-priced clothing and household items,” Thomas continued. “Thus, we did not come to this decision easily.”
The decision to close comes as the lease on the building expires June 15. The decision not to renew the lease recognizes that the retail landscape has experienced a tremendous shift over the last decade with the rise of internet commerce.
At the same time, management will consider other options to offer consistent financial support for food bank operations.
Pat’s Place is the vision of Pat St. John of Hollister and former Hollister resident Elaine Kovanda. St. John was a member of the board of directors when she first floated the idea of a benefit shop. The board was reluctant at first, but through their persistence and vision, the ladies eventually opened at the corner of Fifth and Sally streets in downtown Hollister. St. John remained the most visible face at the store that bears her name until health issues forced her retirement last fall. Her portrait still smiles at customers from behind the sales counter.
“We are very grateful for all the support shown by volunteers and all the community members who shop at Pat’s,” Thomas said. “The next few weeks will be intense, as we intend to clear out every bit of merchandise with a variety of sales. It’s not too late to stop by, snag some bargains and support Community FoodBank.”
Pat’s Place will remain open from 10 a.m.-4 p.m. every Monday, Wednesday and Friday until everything is sold.


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During the seventies, deep in the South;
You must login to vote
I was white but raised black by a black man.
As a boy, I have watched the Ku Klux Klan
on the news—I felt unsafe as a black youth
who looked white. In those days, it was uncouth
and a mark of disgrace to be less than
the white son of a white man and woman:
even then I could feel this racist truth.
Two-score years have passed and I’m still confused,
anxious and unclear as to what or how
I should be—am I white or black? (Abused
as a child, I relate to him still now.).
Granted, it’s no joy being me—like this;
but it’s better than being a racist...?
"To have the soul of a poet is to feel with the mind, and to think with the heart."


text:
New customers, industry recognition, strategic partnerships are proof points of enterprise focus on the "Connected Worker"
Omega Engineering is inviting customers to explore its new website, designed to offer B2B customers a consumer-oriented experience
Global event showcases the economic and environmental benefits of remanufacturing.
OFRU has been manufacturing distillation plants for the recovery of contaminated solvents since 1978.
2019 Board of Directors Highlights the Cross-Industry Nature of the Council
Radford Taylor Partners says economic growth in Germany could eventually normalize after almost a decade of booming growth.
IDTechEx technology analysts have given their pick of the key news stories from 2018
WayKen is dedicated to offering complete in-house finishing and painting services while providing suitable and specialty treatment solutions for customers all over the world.
An Enhanced Learning Experience Now Serves Both Cigar Novices & Aficionados
The legal ruling favored RadonAway on all claims tried in the legal case brought by its parent company, Spruce Environmental Technologies, Inc., against Festa Radon Technologies, Inc.
Industrial profit growth in China at its weakest since March reports Evans Chamberlain Asset Management.
Nationwide Power Continues to Expand, as They Welcome William Thom as the Newest Member of the NP Family. As the leading independent service provider for UPS equipment, service and batteries, Nationwide Power has a presence in the contiguous U.S. and all major metropolitan areas, offering a 4 hour average response time or less throughout the country.
Clear Optical Prototypes: WayKen is dedicated to providing each client with high-quality clear plastic products, with the most practical and flexible way of working.
A complimentary member event with honorary guest Emmitt Smith, premium tasting from Tequila Herradura, and the Dallas Cowboys Cheerleaders
Economic productivity reached its highest rate in the last two quarters of last year but Burton Mills economists say the trend is not likely to last.
As a provider of Production Scheduling software to many Smart Factories, Simio is often asked about the benefits of embracing Industry 4.0
India calls for unrestricted trade as US import tariffs threaten to damage the country's growing exports
11 Honoré, 1-800-Flowers.com, Aaron's, Bayer, Bed, Bath & Beyond, BMW, Bonobos, Brandless, Campbell's, Cinnabon, Coach, Keds, Moët Hennessy, Orchard Mile, and Rebag Are Among Speakers at Momentum's 7th National Retail & CPG Executive Summit, taking place May 15 at the Nasdaq MarketSite in NYC
VaporAuthority, a leader in the vaping industry, has released a new Infographic titled, "The Truth About Vaping Subculture: What the Mainstream Media Doesn't Want You to Know", with demographics about vaping that may surprise America.
Atlas's Revolutionary audio flash cards and simulated timed practice exams establish another benchmark level of learning integration.
Burton Mills: Italy's industrial output begins to make up for ground lost between 2008 and 2014.
The new 'BestVPN' sub-domain launched by VPNRanks provides a rich insight on the best VPN providers of the industry. BestVPN sub-domain will review top of the line VPN brands, evaluating their feature and performance. In addition, users can get hold of best VPNs for different devices, operating systems, and regions.
Premium enclosure accessories manufactured by the experts of nonmetallic electrical enclosures
ChiroFusion integrated payments offer a personalized payment solution to help chiropractors run their practice more efficiently.
U.S. Department of Homeland Security and Sera-Brynn, a global cyber risk management firm, establish cooperative agreement to accelerate information sharing.
Last year the death of the swimming pigs in Exuma Cays, Bahamas nearly broke the internet! The pigs that survived have had cute baby piglets
Powersports Listings Mergers & Acquisitions (PLMA), the professional Powersports Industry dealership brokerage, specializes in intermediary services to buyers and sellers of Harley-Davidson and Powersports dealerships. PLMA announces the closing of the sale and ownership transfer of Richardson Motorsports Yamaha Polaris BRP.


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Yemeni President Abed Rabbo Mansour Hadi has said he intends to implement a temporary truce for seven days beginning December 15. The ceasefire will coincide with UN-sponsored peace talks.
“I informed the coalition’s leadership that we intend to start a ceasefire for seven days, from December 15 to 21, in conjunction with the consultations, President Hadi said in a letter to UN Secretary General Ban Ki-moon. The truce would be automatically renewed if the other side complied, he added.
Hadi also said he hoped Shiite Houthi rebels would respect the truce, failing which the coalition would be “forced to deal with any violation of the ceasefire.”
The Yemeni president’s remarks came shortly after a statement by the UN’s special envoy to Yemen, Ismail Ould Cheikh Ahmed, who said that the talks between Yemen’s government and the Iran-backed Houthi rebels would begin on December 15. Ahmed said there were a “number of good signs” that indicated that the ceasefire would be respected.
Talks to end suffering of Yemeni people
“Only a political solution will end the crisis in Yemen…We strongly believe that the only way to end the suffering of the Yemeni people and to rebuild confidence, trust and mutual respect is through peaceful and inclusive dialogue,” Ahmed said, adding that only Yemenis would be present for the talks.
The UN’s deputy spokesman in New York, Farhan Haq, also said the talks would alleviate the current humanitarian crisis and put Yemen on the path of a “peaceful and orderly transition.”
Yemen has been embroiled in civil war for after the Houthis took over the capital Sanaa last year. Forces loyal to President Hadi have been accompanied by a Saudi-led coalition of warplanes and ground forces to defeat the Houthis. More than 5,700 people died after the conflict escalated in March this year. Several thousand are affected by lack of food and medical supplies, the UN says.
mg/jr (AP, Reuters)


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Dear Mr. Brown, Governor of California
I recently read that you have proclaimed September as “California Wine Month” to celebrate the state’s multi-billion dollar industry. I whole-heartily endorse this proclamation, as there can be no doubt the vital role wine plays in the state’s tourism, agriculture and retail industries. That said, I would like to encourage you to consider another option – California Beer Month. Please review the following statistics from 2010, as published by the Beer Institute and the National Beer Wholesalers Association:
5,940 – Number of People Hired Directly by California Brewers
$446,498,175 – Wages Paid by California Brewers
11,743 – Number of People Employed by Beer Wholesalers
$931,668,114 – Wages Paid by California Beer Wholesalers
99,557 – Number of People Employed by Beer Retailers
$2,753,293,958 – Wages Paid by California Beer Retailers
117,240 – Total Number of Jobs Created by California’s Beer Industry
$4,131,460,247 – Total Wages Paid to California Beer Industry Employees
$2,270,480,806 – Business Taxes Generated for California by its Beer Industry
$845,604,442 – Consumption & Excise Taxes Paid by California’s Beer Industry
These numbers say nothing to the agricultural impact brewers have in the state, especially when considering the state’s famous rice production. They also ignore the impact for tourism, construction jobs, insurance jobs and other business-related services used by brewers, wholesalers and retailers.
From a “state pride” perspective, I implore you to also consider these facts.
At the Great American Beer Festival in 2010, California Brewers took home these top honors:
Small Brewing Company (Mad River, Blue Lake)
Brewpub Group (TAPS Brewery, Brea)
Large Brewpub (Pizza Port, Carlsbad)
Small Brewpub (Pizza Port, San Clemente)
Additionally, California brewers brought home more medals than any other state in the country’s largest beer competition – 52 of the competition’s 236 medals (or 22%) – and more gold medals than any other state (19 of 79 awarded).
On a slightly larger scale, California brewers are still tops. At the World Beer Cupcompetition in 2010 our fair state brought home two of the biggest prizes:
Firestone Walker (Paso Robles) – Best Mid-Size Brewing Company
Ballast Point (San Diego) – Best Small Brewing Company
At this same competition California brewers brought home a whopping 45 of the 268 medals awarded! That’s three-times more medals awarded than to any other state – and more than any country aside from the USA!
Finally, California’s place in beer history cannot be understated. The great “Craft Beer Revolution” the nation is currently in began right here in the Golden State, with Fritz Maytag’s purchase of the famed Anchor Brewing Company in the 1960s. We also boasted the country’s first modern “Micro” brewery in New Albion Brewing. California also hosts one of the world’s most elite and celebrated brewing institutes at UC Davis, promising that the state, nation and world will continue to have the best beer possible.
In short, California brewers not only add generous revenues to this great state, but also contribute a great source of pride for those who appreciate a well-crafted beer. Our state is a world leader in brewing and there are countless examples that support this statement. I ask that you show the same commitment to our state’s beer industry that you have in rightfully endorsing the California Wine Industry. I plead that you consider this evidence and endorse a California Beer Month.
It seems fitting to me that California Beer Month should tie in with our state’s greatest beer celebration – San Francisco Beer Week, which falls in February.