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The most common black red wedding invitations material is paper. Timeless Traditional Wedding Invitation Suite A stunning and somewhat mysterious tea length wedding invitation folder is closed with a classic red wax seal.
We love the modern lines and stripes and used the pattern to create these stunning black wedding invitations.
Red and black wedding invitation ideas. Enjoy the selection of professionally designed and customizable templates featuring burgundy color elegant floral decorations and unique calligraphy fonts. Most bridals have very determined colors of their weddings and while red is very popular. Shop for yours right now.
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This modern black and white damask wedding invitation has a red frame with a photo template area for you to add your own digital photo. Most bridals will choose this color as the main color of their wedding themes because of its passion vitality and romantic suggestions. Design ideas and inspiration.
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Black invitation ideas for your wedding or special event. The most popular color. All Wedding Party.
For further customization please click the Customize it button and use our design tool to modify this template. There are 8345 black red wedding invitations for sale on Etsy and they cost 859 on average. For modern yet classic style look no further than this black white and red color palette inspired by our Classic Urban wedding invitationsWere just loving the look of black and white with hints of red in this updated version of a classic theme.
Black White and Red Wedding Inspiration. See more ideas about damask wedding invitation black wedding invitations red damask wedding. More diy black white and red wedding invitations with so many requests for black white and red wedding stationery and other combinations of black and white with color i decided to add my suggestion for a diy and reasonable easy to make invite using one of our printable templates.
Black wedding invitations featuring rich jet black onyx and crisp white creating a sophisticated look. Opening these invitations is an experience in itself and will have your guests eager to celebrate your undoubtedly beautiful wedding day. Black Rose Wedding Collection.
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Most bridals will choose the red wedding invitations for their fall weddings or winter weddings. Black Rose Wedding Collection. Black tie wedding invitations maintains copyright of all the designs and photographs displayed on this website.
Budget Wedding Ideas Diy Invitations Weddings Red Black White Flamenco Red Black White Nulki Nulks Red And Black Wedding Invitations Up To 40 Off On Rustic. Jun 22 2013 – Explore Terrie Rauschers board Red N Black wedding followed by 427 people on Pinterest. All text style colors and sizes can be modified to fit your needs.
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Automatic miatas with this engine get a shorter final drive, but gearing remains the same for manual transmission cars. Up to an epaestimated 26 city35 highway mpg for 2019 mazda mx5 miata rf models with automatic transmission. With a spirited 181hp engine redlining at 7,500 rpm, the mx 5 miata was made to move youmind, body and spirit. In 1991 mazda unveiled the new mx6, commonly referred to as the second generation. If mazdas mx5 philosophy of jinba ittai horse and rider as one is to hold up with its roadster, you need the manual gearbox to create a more. Though many miata drivers will prefer the 6speed manual, the miata can come with a 6speed sport automatic transmission. Mazda miata sales data shows the manual is still the way to go. Mpg manual transmission city highway combined 26 34 29.
We test a 2020 mazda mx 5 miata rf with the optional automatic transmission. A few weeks ago a rep from mazda emailed me to ask if i wanted a 2014 mazda mx 5 miata for a week. The car is fine with the at but its almost not the same car compared to the mt. Complete manual transmissions for mazda miata for sale ebay. Mazda mx5 miata buyers still prefer the manual gearbox. Why an automatic mx5miata rf isnt a bad thing youtube. In the past almost 30 years, it has been one of the most loved sports cars by car enthusiasts. Assuming you have the manual transmission, the higher rpm during highway cruising is not a problem at all. The mazda mx5 miata is one of our favorite new cars on sale today and a veteran on our 10best cars roster. Come find a great deal on used 2019 mazda mx5 miatas in your area today.
Some cars are just made from the beginning with certain things in mind. For the mx5, a manual gearbox is one of those things. The mazda mx 5 nc is the third generation of the mazda mx 5 manufactured from 2005 to 2015. Search new and used cars, research vehicle models, and compare cars, all online at.
Should you buy a 2019 mazda mx5 miata rf with an automatic. Used 2017 mazda mx5 miata rf grand touring convertible. View detailed specs, features and options for the 2020 mazda mx 5 miata sport auto at u. For the mx 5, a manual gearbox is one of those things. Optional tech features include embedded navigation, a. Truecar has over 868,177 listings nationwide, updated daily. Complete auto transmissions for mazda mx5 miata for sale. Mazda mx 5 miata buyers still prefer the manual gearbox. How does the mazda mx5 miatas big horsepower increase for 2019 affect the powerfolding hardtop rf models performance.
Can you still have an awesome time in an automatic mazda miata. Its hard to do that in the automatic without actually flooring it, whereas in the manual, you can hold a gear at partial throttle, if you want. Learn more about mazda mx 5 miata mazda mx 5 miata overview if the rx7, introduced in 1979, was the car that put mazda on the map as far as u. Although the standard fourcylinder is small, it delivers just the right amount of muscle for the lightweight mx 5 miata. At its introduction in 2005, it won the car of the year japan award and made car and driver s 10best list from 2006 to 20.
A manual transmission seems to be the proper way to enjoy the miata. We drove 2017 mazda mx5 miata rf automatic and manual models during the pebble beach car week get the motor trend perspective right here. Although the automatic gearbox cannot live up to the extremely high standards set by the manual transmission, the powershift equipped mx5 remains a. The f56 5 4 mini cooper automatic is just a 6 speed auto slushy, but. There is only one engine available on the mx 5 miata, a 2.
Come find a great deal on used mazda mx5 miata convertibles in your area today. Mazda s flagship roadster with 3 decades of evolution, bringing excitement to millions of drivers at a very low price. Used mazda mx5 miata convertibles for sale truecar. Indeed, the 2016 mazda mx 5 miata does come available with an automatic transmission. Research, compare and save listings, or contact sellers directly from 100 2018 mx 5 miata models nationwide. Mazda mx5 miata transmission problems car forums at. Tradebit merchants are proud to offer auto service repair manuals for your mazda mx5 miata download your manual now. Used mazda mx 5 miata with automatic transmission for sale on.
Order your parts online or pick them up instore at your local advance auto parts. Used mazda mx5 miata with automatic transmission for sale. Theres nothing objectively wrong with the sixspeed automatic gearbox mazda has made available for its roadster, it works smoothly in other models. When tested at the track, the 2018 mazda mx5 miata recorded a competitive 060 time of 6. The mx 6 was produced with two transmission options, a fivespeed manual transmission or a fourspeed automatic with overdrive. It also helps that the miata has a fantastic manual gearbox. Information on the 2020 mazda mx 5 miata was unavailable as of this writing, but we are not expecting any major changes after the mild freshening and 17percent increase in horsepower the miata received for 2019. The clutch is a little vague in typical mazda fashion, but shifts are ultrashort, direct. It used the mazda g4ael 4 speed electronic shift automatic transmission. The sixspeed automatic in the miata rf is fine it shifts well enough, its quick in sport. Something along the lines of the vw gti however can go either way. The mazda miata has some big changes under the hood for 2019. The mx5 accelerates briskly and always seems to have power.
In this video i will show you why an automatic miata isnt necessarily a bad thing. The epa rates the miata at 26 mpg city34 highway with the manual transmission and 2635 with the automatic. Typically, small sporty cars are purpose built with that in mind. We drove 2017 mazda mx5 miata rf automatic and manual models during the pebble beach car week get the motor trend perspective. The new 2019 mx 5 miata rf is stylish and has a solid hard top. The mx5 is a car where revving the engine through its entire range is part of the joy of the car. The miata with an automatic has been a drivers car since the nc model. The nds manual mode has a very tight shiftzone that feels like a shortshift kit on a manual car. New listing transmission assembly manual 6 speed oem 0914 mazda mx 5 miata 2009 2014 club fits. I notice that more traditional automatics are being tuned to feel more like dsg. Its less a true automated manual and more an automatic where you request a gear, and if it.
So to mazda belgium for hooking me up with an rf for a. Although the automatic gearbox cannot live up to the extremely high standards set by the manual transmission, the powershift equipped mx 5 remains a massively entertaining car to drive. But were fans of continuous improvement and fully support mazdas updates to the miata. Compare 2006 mazda mx 5 miata repair manual vehicle brands.
When were talking 96kw and 150nm which, in fairness, isnt as modest as it sounds in a car weighing just over a tonne straightline speed is not something you want to give away easily. The mazda mx 5 miata marked a generation of the sports car industry when it came out in 1989. Frequency according to repairpal, mazda mx5 miata owners bring their vehicles into a repair shop for unscheduled repairs an average of 0. Its a sixspeed, torque converterbased automatic, no fancy dual clutch here, with paddles on the steering wheel and an updown shift function on the gear lever. The gear ratios are built that way and ultimately give the mx5 very responsive. Since 20, mazda has been building familiar automobiles such as the 20 mazda 5 4d s grand touring at and the 20 3 grand touring. Mazda tuned the freerevving engine to develop an entertaining 155 horsepower and 148 poundfeet of torque. The 2017 mazda mx5 miata rf retractable fastback is the second member of the current generation of miata roadster, which was redesigned just last year. The nc is the first mx 5 generation to feature a retractable hardtop variant, with its roof being able to fold and unfold in 12 seconds without sacrificing trunk space. Truecar has over 870,429 listings nationwide, updated daily. See hires pictures, prices and info on mazda mx5 miata rf cars for sale. Suitably, our automatic transmission test car arrived in the priciest, plushest of mx 5 trim levels, the grand touring. Modern mazdas generally deliver sportiness in an attractive package, and those two traits work well together in the 2017 mazda mx5 miata rf. We tested the manual miata in club spec, which brings performanceenhancing.1459 1335 330 1172 863 134 379 1506 1353 1187 1661 934 1653 15 716 855 1026 358 602 632 1519 1117 1516 1590 1104 816 1313 1661 399 1283 1189 897 812 129 106 1065 839 322 600 1301 1467 1116


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In the wake of last week’s terrorist activities, the U.S. legislature needs to wake up and to begin funding more ethanol plants.
For years, people in the agricultural community have recognized this vital renewable supplement to our fuel supply. The agriculture lobbyists’ efforts have often been overshadowed by big oil and other political interests.
Our economy and our way of life centers on energy – energy that is, more often than not, unreliable in its production and in its pricing. We will never be totally independent from our foreign oil needs, but a realistic goal of 20 percent will go along way toward less dependency on foreign oil.
The long-term results of a national plan to supplement oil with ethanol have many other benefits as well: employment directly linked to running the plants as well as the many support jobs such as transportation, warehousing, maintenance, and the increased revenue for farmers for the raw material.
Fewer American dollars exported out of this country and healthy farm revenues will drive more equipment purchases, leading to more manufacturing jobs.
If I painted a utopian picture with this scenario, I apologize. The constant unreliability of the present system with its daily, if not hourly, price fluctuations and the constant threat the Middle East imposes demands a new approach to this decades-old problem.
We have the tools already at our disposal. Now we need the commitment and resolve from our government and private industry to implement a program to start us on a new path towards less dependency on foreign oil.
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domain: news


text: You are a cat lover. You want your items to have the shape of cats. So, you will be instantly attracted by the lovely design of this Embroidered Cat Tote Bag. Let’s wear it lightly over your shoulder and store all of your essentials in the spacious compartment inside. Meanwhile, outside of the bag is classic color and a cute cat embroidered design which is suitable for daily. Perfect for a cat lover! Get it here.

domain: artistic


text:
Cottage Cheese Potatoes50 Reviews
- Prep: 15 min
- Cook: 40 min
- Ready In: 55 min
“This is a easy quick recipe. It is a favorite in my family. The blend of cottage and cheddar cheeses is spectacular.” - by Stephanie
Original recipe yields 5 servings
- Place potatoes in a large pot of water and boil until tender when pierced with a fork.
- Preheat oven to 350 degrees F (175 degrees C). Butter a 9x3 inch casserole dish.
- In a large mixing bowl, combine potatoes, onion, cottage cheese, and sour cream. Transfer mixture to the prepared casserole dish. Top with Cheddar cheese.
- Bake at 350 degrees F (175 degrees C) for 30 to 40 minutes.
Amount Per Serving (5 total)
- 421 cal
- 18.7 g
- 44.3 g
Based on a 2,000 calorie diet
Reviews (50)Rate This Recipe
"This recipe is very similar to one by Paula Deen on the Food Network. I sliced up my potatos and boiled them for a quicker cooking time and easier mashing. Used fat free cottage cheese and ommited t..." See morehe sour cream. Added a few pats of butter and folded in a sauteed chopped onion for rich flavor. Topped the mixture with Mexican cheese blend, salt and pepper. Baked in a 9 x 12 dish. I was terrified of failure when I scooped them out and they were runny (!) however they did set up nicely after sitting for a bit while my meatloaf rested. I suggest draining the cottage cheese. A good recipe when you want something tasty that will not be covered in gravy, but I am still searching for my all-time favorite potato recipe."
"This was a great recipe that wowed my wife when she arrived home from work.I did find that you might need to drain the cottage cheese over the sink before continuing.I added a little bit of garlic pow..." See moreder and some salt and pepper to liven it up a bit."
"This was really excellent. If you use fresh or frozen raw hashbrown cut potatoes you don't have to cook them first. Definitely salt and pepper the potatoes before adding the other ingredients. I us..." See moreed full-fat cottage cheese and then low fat cheddar and sour cream and it came out great. To avoid runniness: take the cottage cheese and the sour cream and blend in the blender till smooth. Line a colander with cheesecloth and put in a bowl. Turn the cheese mixture in and let it drain for a couple of hours before continuing on with the recipe. I also threw in some cheddar with the cottage cheese and sour cream. Comes out really great that way. Thank you, Stephanie!"
Cheese and Bacon Potato Rounds
Creamy Slow Cooker Potato Cheese Soup
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domain: food


text:
Yurizan Beltran (Yuri Luv) who is a Blacklisted adult actress, female adult performer, and a female adult entertainer is a mentally defective, highly evil, and a deeply wicked racist bigot whose racism and whose prejudice which is skin color based is targeted and projected towards African-American men or Black men especially whose skin color she hates with a great amount of racist hatred and which has also seriously hindered her from being in a serious intimate relationship with these African-American men or Black men. Therefore based upon these true statements, Yurizan Beltran (also known as Yuri Luv) must be Totally condemned, and Totally blacklisted to the greatest of all levels for being the wretched, corrupt, disgusting, despicable, mentally disturbed, malevolent, malicious, mentally poisoned, destructive, and deceptive bigoted racist garbage dump that she most certainly indeed is.
Additional Note: According to one site it says that her original name is Yurizan Beltran Lebanue and that she comes from the state of California (Long Beach). She has also used other aliases such as: Sweet Yurizan, Yuri Love, YuriLuv and Yurizan.
Written Accurately by one named “Truth”

domain: sociology


A road project most Lafayette residents likely had never heard of a year ago has been quickly gaining momentum to become the next crossing over the Vermilion River.
City-parish government is moving forward with a $350,000 engineering study to narrow down the possible routes for the extension of South City Parkway in south Lafayette and is considering buying 26 acres to secure much of the right-of-way for the road.
“This is pretty much the No. 1 bang-for-the-buck project in regards to reducing traffic,” said City-Parish Public Works Director Kevin Blanchard.
In terms of roadways, Lafayette is literally a city divided by the Vermilion River, and any new crossing has the potential to improve traffic, particularly for the congested arteries of south Lafayette.
“It’s one of those reminders that we are a river city, but we don’t always act like it. We need more bridges,” Blanchard said.
The most recent bridge across the Vermilion River was built in 2003 on Camellia Boulevard near River Ranch.
There has long been talk of the need for more river crossings, and the next bridge had been planned as part of project to extend South College Road.
Blanchard said the South College project is now expected to yield to the South City extension.
“I would say it’s on the longterm backburner,” he said.
Traffic studies show extending South College over the Vermilion River could make traffic worse in the absence of additional intersection upgrades and other projects in the area, Blanchard said.
The improvements from extending South City, on the other hand, would be dramatic, according to traffic projections by city-parish planners.
Ambassador Caffery Parkway is now the main corridor crossing the river in south Lafayette, and Ambassador Caffery is expected to be plagued with daily gridlock within 25 years if no new roads are built to relieve traffic, according to traffic models provided by city-parish government.
Extending South City from Robley Drive over the river to Verot School Road could keep daily traffic counts at the Ambassador Caffery bridge at present-day levels — roughly 57,000 — through 2040, according to the city-parish traffic models.
Those same models show that if nothing is done to relieve Ambassador Caffery, average daily traffic counts could climb to 69,000 at the Ambassador Caffery bridge by 2040, essentially year-round bumper-to-bumper traffic comparable to what’s seen at the height of the holiday shopping season.
Still, the South City project is by no means a sure thing, and some residents in the area where the road might be built have pushed back, complaining about the prospects of traffic and noise in an area that is now largely quiet and undeveloped.
City-Parish President Joey Durel said those issues will have to be dealt with eventually, but it’s too early to debate details of the possible impact before the completion of a $350,000 study starting this year to narrow down possible routes.
“This is the first stage of saying, ‘This is where the road should go,’ ” Durel said.
Most of the major decisions about the road will be made by someone other than Durel, who is serving the last year of his third and final term in office.
But Durel hopes to take a big step forward on the South City project before leaving, with the purchase of about 26 acres of land that takes in more than half of the general area being considered for the road.
A developer had begun work on the property but stopped earlier this year when serious talk began about the South City extension, and Durel estimated the property could be acquired for about $1 million. The cost, he said, is much cheaper than having to buy out businesses and homeowners if the road were cut through the middle of developed land.
There is no reliable estimate for building the road and bridge, but Blanchard said a very rough guess would put the project north of $50 million.
Durel said one option to pay the bill would be revenues from a temporary sales tax similar to what voters approved in December for building a new terminal at the Lafayette Regional Airport — a 1-cent tax with collections limited to eight months and restricted to paying for airport terminal improvements.
“Now we have a model of how a specific project could be paid for,” Durel said.


There it sat for Andre Agassi, a short ball that bounced near the service line, the kind of ball he has put away in his sleep across a storied 18-year career.
But this was no ordinary matinee. After rain forced them to suspend play Wednesday, Agassi and Roger Federer resumed their quarterfinal match yesterday in the fourth set amid gale-force winds. Multiple times Federer went to toss his serve, only to stop as the ball blew astray.
Agassi, a noted wind player, was at home with this weather, but trying to hold serve late in the fifth set, he unleashed a forehand that might as well have hit the Globe in Flushing Meadows, as it landed several feet long and wide.
Federer, often freaked out by bad conditions in the past, outwitted Agassi on this day. With Agassi’s serve broken, Federer went up 5-3 and closed out the match on his serve. The 6-3, 2-6, 7-5, 3-6, 6-3 triumph left him soaring into his first Open semifinals tomorrow against Tim Henman.
Give Federer, the top seed who had never gotten past the Open’s fourth round, a ton of credit. He staved off the pro-Agassi crowd, an American tennis legend and the worst winds the Open has ever seen.
Afterwards, Agassi left open a chance that this could be his last Open, but don’t count on it. Not after taking the top-ranked player deep into a fifth set.
“This is as bad as it gets,” he said of the gusts. “I think anything more than this, there would have to be serious consideration into postponing matches.”
But then Agassi added: “The one element of tennis that is the most important still exists, which is two players have to compete against each other and find a way regardless of what the circumstances are. That’s what he did today.”
As yesterday’s play began, Agassi won the fourth set and Federer looked frustrated, the wind playing tricks with each shot.
He tried everything, even coming to the net three straight times. He whiffed at a couple of balls that unexpectedly took a turn from his racket when they got caught in the wind.
“It was warm-up tennis, just keep it in,” he said. “We couldn’t play our games. Usually we are guys who look for the winner, play aggressive.”
At 34 and the tour’s oldest player, Agassi would not guarantee he’d be back for another Open.
“What I’ve said for four years is if I’m out there forcing the best players in the world to play their best tennis.”
Agassi surely did that.
(p. 99 in metro and sports extra)


Lifelike fabric simulation and real-time display of processes by TEXION
The international textile and clothing market wants a wide range of products and high-end quality, at the same time, is governed by extreme cost constraints – a challenge that the software provider, TEXION, is assisting companies in this sector with its software solutions
Companies can tap into a huge potential when developing new products and by automating and optimising production – as long as they are using the right software. TEXION has, therefore, revamped and improved its ProCad range of CAD systems. With its new simulation software, this software specialist is also offering top quality 3D simulation that even the most discerning customers will accept when making their pre-selections. More drafts and fewer samples is just one of the advantages of this new system.
TEXION’s new software developments are also focusing on the machines that are used to produce this wide range of designs. The modern warp knitting machines used are state-of-the-art. ProFab’s role is to enable the performance potential of this technology to be fully utilised and to network the production machines into efficient processes. The Manufacturing Execution System (MES) is the link between the planning system and the production machine and is responsible for the automated sequences in accordance with Industry 4.0.
During production, both the ProCad and ProFab systems offer optimum integration and maximum benefits for the client. This performance is based on many years of close cooperation between TEXION and KARL MAYER, the leading manufacturer of warp knitting machines, on excellent customer relations, and on the proximity to the Technische Hochschule RWTH (RWTH Aachen University) in Aachen, where the company is based.
Pro-Fab – working with real-time data during textile production
ProFab is an efficient MES that supports every type and generation of warp knitting machine. This flexible TEXION product can be absorbed easily into existing infrastructures, and networks the machines to the planning system. Fully integrated into the machine control systems, ProFab can access all the machine data and all the planning data at the same time – an important pre-requisite for carrying out fully automatic sequences, and an effective process automation system. The guaranteed real-time networking of the machines into the Enterprise Resource Planning (ERP) systems provides an accurate view of the status of the machines at all times, the machine utilisation, the status of the job, as well as quality reports and analyses. Problems can be detected immediately and resource planning is simplified.
ProCad – a new dimension in 3D simulation
ProCad is the perfect tool for the design departments of textile producers. The high-end ProCad software developer enables multibar and jacquard raschel patterns to be developed and processed. The ProCad warpknit can handle warp-knitted spacer textiles, tricot and raschel fabrics. They can also be visualised as simulations – performance features that TEXION is expanding and optimising all the time.
The new 3D fabric simulation system was premiered at ITMA 2015. This innovative solution is available immediately for the ProCad developer, and alongside the 3D-Lab for the ProCad warpknit. It can produce 3D simulations of large lace, jacquard and tricot patterns extremely quickly and creates an extremely realistic image, which is based on two important new innovations – newly developed 3D algorithms and a wide range of new yarn models. The resulted surface structures look three-dimensional and sculptured, even at high magnifications. Reflective effects and light and shaded areas can be examined very closely on a microscopic level. Microscopically displaying the fabric enables yarn effects, such as shimmering yarns and deformations by integration in the stitch structure to be shown to full advantage.
According to Werner Modenbach, the goal that he set himself, i.e. to avoid the time-consuming and expensive production of sample collections in every area of warp knitting, has been achieved with 3D simulation. The feedback from clients, even in sensitive and critical areas, such as the car industry, is extremely positive. The users will recognise and accept the new simulation technology as a basis for making their pre-selections.
The ProCad developer and the ProCad warpknit are efficient design tools that make many more fabrics available for pre-selection than ever before for a much lower cost. Samples now only need to be produced of a few fabrics.
TEXION is the premium partner of Karl Mayer GMBH and Partner of LIBA. TEXION has supplied tailor-made systems for knitting machines, and it will continue to do so in the future. ProCad users thus can be sure that the ProCad package features perfect compatibility to all machines supplied by Karl Mayer and LIBA.
Since the market launch of ProCad in the eighties, we have continuously upgraded this software package in close cooperation with users so that ProCad always offers functions and optional features that meet the latest requirements.


text:
One unpleasant experience that will inevitably happen is having your turtle pee on you. There are a lot of myths on the internet surrounding turtle pee, so I want to dedicate an article to the topic.
What to do if Your Turtle Pees on You?
First off, if your turtle pees on you, there is no need to panic. Do not react in any way that could further scare your turtle.
This means no sudden jerking and certainly don’t drop the turtle. Gently place them back in their tank and then worry about cleaning up.
When it comes to cleaning up, the most important part is ensuring to keep the mess away from your eyes, mouth, and nose. If your skin was exposed make sure that area does not come in contact with your face. Quickly wash the impacted area with warm water and soap for at least 30 seconds.
My biggest concern in any scenario like the above is if young kids are involved. They should be trained beforehand before handling the turtle.
Because they often have a habit of putting their hands in their mouth, they should be monitored closely during and after handling the turtle. As soon as they are done, regardless of if you see turtle pee, you should make sure they keep their hands away from their face and then wash their hands.
Bacterial diseases can spread much more quickly with kids so keep a close eye on them! For example, your pet turtle can spread salmonella.
Why did my turtle pee on me?
More often than not, it is a defense mechanism and your turtle is reacting out of being scared. Make sure you do not surprise your turtle when you pick it up.
When you go to pick up your turtle, don’t do it from behind. Approach them from the front so that they can see your hand approaching them. Additionally, do not move them quickly when they are in your hands.
You should also not hold your turtle too tight. Remember that their shell is a form of their backbone, some pressing down on it can cause pain and cause them to pee on you.
If it becomes a common occurrence, I would recommend avoiding touching your turtle until it is more comfortable in its habitat. As it becomes more familiar with its tank and your company, you will have a much better shot at making it comfortable when you pick it up.
Just like humans, when they feel threatened, their biology can act in fascinating ways.
I will say that it is common for turtles to pee when you are transporting them. To help reduce their stress, you should check out my guide on how to transport a turtle.
Is turtle pee harmful to humans?
As long as the pee doesn’t get into your body, it should not be harmful!
On the other hand, if you somehow ingest the substance, it can be a cause of concern. This is because of the chemical urea (the waste product that helps breakdown proteins) that makes up a large concentration of urine.
The symptoms are similar to other bacterial infections but should never be fatal. They include:
If you do notice these symptoms after being around turtle pee, ingest as much water as possible and your body should naturally be able to flush out the toxins.
Common myths about turtle pee:
- It is a common misconception that turtle pee on the skin can cause warts. This is simply not the case! I have yet to read a scientific study proving this theory, and until that happens, I will stand firmly by this claim!
- Another common misconception is that turtle pee can cause brain damage. Again, this is simply not backed by any scientific evidence.
Do Turtles Pee in Their Shells?
Turtles do not pee in their shells. Rather, they have a small opening at the bottom of their shell and that is where they excrete waste. Turtles don’t have an anus, so this opening is where they excrete both urine and feces.
If you look closely at a turtle from underneath, you can see this opening, called the cloaca, at the bottom of their shell near the base of their tail. A related question I often get is, whether or not turtles can pee out of their mouths. In general, the answer is no!
However, there is one species of turtle, the Chinese soft-shelled turtle, that does mainly pee from it’s mouth. This is the only species known to man where this phenomenon is observed. Note that this is a saltwater turtle, and not a turtle known to commonly be in captivity.

domain: biology


text:
To continue our theme of Sound of Music song titles…
I’ve been thinking recently about my own reading habits. As a child, I was a voracious reader. By the time I was ten, I was checking books out of the library ten at a time (that was the limit that the public library allowed for children), only to bring them back three days later. I often look back on those days with a mixture of nostalgia and humor, imagining the Matilda-like image of my young, insatiable self. Unfortunately, as I’ve aged, it has become harder and harder to maintain quite that speed of literary consumption. At my lowest point, back in 2013, I only managed to read 18 books in an entire year. But this year, as a semi-New Year’s resolution, I made myself a promise in two parts: 1) I was going to do a little bit of leisure reading every day and 2) I was finally going to finish all those books that had been sitting on my to-read shelf for years and years, collecting dust while I smothered under the weight of all my assigned reading. (Never let it be said that being an English major is a walk in the park.)
To begin this journey, I started with the books that I had filed under my “currently-reading” shelf on Goodreads. They were books that I had picked up at some point, then put down again for various reasons (schoolwork, only a limited number of books fit in my suitcase going abroad, etc.) and never finished, but couldn’t bring myself to put back on the to-read shelf, denying the progress I’d already made. Most of these books had been there for perhaps a year, maybe a bit more. But there was one outlier in all this, the dark shadow at the back of my bookshelf, lurking, waiting: Dune.
Dune and I have a long and storied history, one that begins more than four years ago. My junior year of high school, I had a good friend with whom I often exchanged book recommendations. I got him hooked on Brandon Sanderson. In turn, he gave me, as a Christmas present, one of his favorite books, and with the naive promises of youth, I told him that I would finish it over Christmas break and get back to him about what I thought.
Fast forward to four years later. I currently like to think of Dune as my literary Everest. I have started reading Dune no less than four times. Of those four times, I made it to about page 200 on three occasions, before I set it down, didn’t look at it for several months, and then, dripping with guilt, picked it up again only to realize that I had no idea where I’d left off, much less what on earth was going on.
To say I felt bad about the whole affair was a vast understatement. Not only was this a treasured book in the life of one of my good friends, Dune is a sci-fi literary classic. Every time I put it down, I asked myself if there was something I was missing. Was I just not getting it? Was there some hook I hadn’t gotten to yet? Was I, perhaps, just not as genre-savvy as I purported myself to be? But every time, months later, I found my interest slipping or other things calling for my attention, until I once again set it down, to be picked up again a year later.
I feel like we all have stories like this. Whether it be a piece of literature, a genre work, or even something more broad like a movie or TV show, we all find ourselves with these insurmountable Everests, looming in the distance, taunting us with their unclimbable slopes.
I am currently on page 456 of 489 of Dune. It is my fourth attempt and slowly but surely, I am getting through it. With any luck, I will have finished Dune by the end of February. So what does it mean to have reached the top of my literary Everest? I guess I’ll have to wait and see to find out.


The rise in Victorian land taxes, council fees and interest rates is forcing many investors to turn to Queensland and WA, which they say supply much better returns. City Council voted in favour of the 9.5% enhance to the residential property tax rate after they met on Wednesday to finalize the 2024 price range. Due to the creation of IT particular economic zones nearby, the existence of respected educational institutions, and the supply of different basic necessities, these micro-markets have skilled a constant influx of migrants from outdoors the town. However, it has made a fairly quick recovery in comparability to other real estate markets in the world, with demand gaining momentum.
- During the ’90s, for instance, it was usually referred to principally as PC software.
- Condo project has been ordered to pay more than $13 million in damages to dozens of people who made pre-sale purchases that by no means got here to fruition.
- The civic physique has surveyed a complete of 43,925 business properties to date within the ongoing survey.
- High property prices and mortgage charges have left extra investors claiming adverse gearing tax deductions, specialists say.
- The median U.S. sale worth reached $386,000 in June, a 24 % jump from the same time the earlier year, and the highest on report, according to the actual estate company Redfin.
Amid challenging financial conditions, an rising variety of Kenyans are facing defaults on their… read extra… The Kenya Revenue Authority is intensifying its efforts by concentrating on residential estates in… read more… Residents of the upscale Peponi View Apartments have been given per week Real Estate News to vacate their homes or… read extra… Individuals in Nairobi who personal residences in blocks and share common areas within their units will… read more…
The thought of built-in residing is shortly taking on within the residential sector as home patrons have begun to favor developments with state-of-the-art facilities, including workplace buildings, parks, schools, hospitals, and buying facilities with multiplexes. Make data-driven property choices with our easy-to-use free and paid instruments. The Edge Fair Value software lets users calculate the honest worth of a property, while the En Bloc Calculator helps to determine the chance of a Singapore project being put up for collective sale. Our complete new Research software supplies you knowledge on past transactions, value trends, and more for condos, HDBs, landed homes, industrial properties and industrial properties. This father-and-daughters staff with 50-plus years’ worth of mixed experience has amassed greater than $3 billion in residential real estate sales, many within the Hidden Hills and Calabasas markets.


Posted by: csheppard on Oct. 19, 2009
The Caravan of Thieves are Ashland Coffee & Tea's latest Artists in Residence.
The quartet, led by husband and wife team Fuzz and Carrie Sangiovanni, will be back in Ashland Wednesday, October 21.
I caught up with them on the phone from their hometown, Bridgeport, Connecticut.
Caravan of Thieves, despite being a relatively young band, has gotten off to a very promising start.
"Our very first show with Caravan was the Spring of 2008," says Carrie, who sings and plays guitar. "We've been playing together for about a year and a half."
The couple married in 2005.
"It was an intimate relationship before it became a musical one," says Fuzz, who also sings and plays guitar.
It's likely you've never experienced a show like theirs. Both Fuzz and Carrie say music has been a part of their lives since childhood.
"As a kid I was doing a lot of theater and Broadway," recalls Carrie. "I was classically trained on piano first and then started playing guitar in high school. My dad taught me."
"I started off as a kid playing guitar, Rock-n-Roll," says Fuzz. "I played my first show when I was 14. I just kind of got hooked on performing and playing in bands."
Fuzz went to school for classical music and arrangement and composition, played everything from blues to jazz to R&B to dance-pop, toured with Deep Banana Blackout and joined up with Tom Tom Club, which is the drummer and bass player from Talking Heads.
"When Fuzz and I met I was doing a solo singer-songwriter thing up in Burlington, Vermont,"


text:
07th Sep 2017
Bow Pasta With Basil Pesto & Prawns
Farfalle al pesto Genovese e gamberi?
This recipe was created during an argument between my boys: Rocco wanted pasta with garlic, prawns and rocket leaves and Luci wanted pesto. Here we are – basil pesto with prawns. It really works; we all absolutely loved it and I got to please both boys without turning my kitchen into a restaurant! Please make sure you only buy fresh basil to make the pesto as the flavour is so much better.
60g basil leaves
50g pine nuts
1 garlic clove, peeled
130ml extra virgin olive oil
30g freshly grated Parmesan cheese
150g cooked peeled large prawns
salt and black pepper, to taste
Bring 5 litres of water to the boil in a large saucepan with 1? tablespoons of fine salt. Put the basil, pine nuts and garlic in a food processor. Drizzle in the oil and blitz until smooth.
Transfer the basil mixture to a large serving bowl and fold in the Parmesan. Season with salt and pepper and fold in the prawns. Set aside.
Meanwhile, cook the pasta in the boiling water until al dente. To get the al dente perfect bite, cook the pasta for 1 minute less than instructed on the packet and always keep the pan uncovered. A good-quality dried pasta will take 8-10 minutes to cook.
Just before the pasta is ready to be drained, remove 4 tablespoons of the boiling water from the pan and add to the bowl with the pesto mixture.
Once the pasta is cooked, drain and tip it into the bowl with the pesto mixture.
Fold together for 30 seconds allowing the pesto to coat the pasta.
Extracted from Pronto! Let’s Cook Italian in 20 Minutes by Gino D?Acampo (Kyle Books, approx €18.50).
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A deal worth £1.2billion for a package of North Sea assets is reportedly being considered by Norwegian energy giant Equinor.
Norwegian publication Dagens Naeringsliv (DN) reports the state-owned energy business is considering whether to snap up oilfields held by Canadian company Suncor.
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Suncor currently holds a 29.9 per cent interest in the central North Sea’s Buzzard field, which is run by Chinese oil company Cnooc, which has a base in Aberdeen. The Buzzard field is reported to deliver more than 22,000 barrels per day net to the Canadians.
Sign up to Aberdeen Live's newsletter to get the latest stories and breaking news sent to your inbox
Suncor also has a 40 per cent stake in the Rosebank development - the biggest undeveloped oil and gas field in the North Sea, which Equinor is aiming to take a final investment decision (FID) on this year.
Additionally, Equinor has been tipped as a potential buyer for Cnooc’s UK’s North Sea assets, with the Chinese operator reportedly planning to pull its money out of the region.
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text:
It looks like Dracula will be getting the Sherlock treatment.Read More
What may seem like a whole new breed of leading male protagonist on TV, born from the widespread assimilation of nerd culture into the mainstream, is little more than your average alpha-male with an IQ upgrade.Read More
Turning Sherlock’s missing sibling into a woman was presumably writers Steven Moffat and Mark Gatiss’ way of giving women a more prominent role in the story, but why was Eurus, the only woman, the only sibling who used the family brilliance for evil instead of good?Read More
The end is nigh for Sherlock's fourth season and things aren't looking good for the world's foremost consulting detective.Read More
Cool manga, bro.
It looks like we're getting more Sherlock manga in 2017. Comic Book Resources reports that new ones are scheduled to arrive in February.Read More
Ancestry.com reports that Benedict Cumberbatch, who stars on the TV show Sherlock, is related to Sir Arthur Conan Doyle, the original creator of the Sherlock Holmes stories.Read More
It's not a game anymore.
Some big changes are coming to Sherlock once season 4 gets started in the new year. For one, Watson and Mary will try to figure out this whole parenting thing because raising a tiny human is no walk in the park.Read More
Things We Saw Today: Badass Body-Positive Cosplayer Shatters Expectations With Impeccable Costume Game
Rhapsody Artajo champions "being so comfortable in your own skin that you're inspiring other people to do the same."Read More
Sometimes you just have to laugh at the things and people you love.Read More
Wow it has been a long time since we've been able to write something like this, but it's finally happened: Sherlock season four is really coming, as evidenced by the fact that it now has a premiere date.Read More
As if it isn't bad enough that there aren't nearly enough episodes of Sherlock per season, or that we have to wait way too long between seasons, word from Benedict Cumberbatch, A.K.A. Sherlock himself, is that Season 4 may be its last.Read More
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Whether you're involved in the Sherlock fandom or not, it would be almost impossible for you to evade the question as to whether or not John Watson and Sherlock Holmes will end up in a romantic relationship together. It's not a new question when it comes to these two classic characters.Read More
It always takes forever with Sherlock doesn't it. Well, now fans of the hit BBC show can start getting excited! Sherlock has officially started production on Season Four! (Is it me, or does it feel like Sherlock's already been on for eleventy-jillion seasons because of their production schedule?)Read More
Paul McGuigan, who directed films like Lucky Number Slevin and Push as well as the pilot episode of Scandal and several episodes of BBC's Sherlock, tweeted yesterday that he also directed the first two episodes of Luke Cage.Read More
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Sherlock goes back in time! But not really.
The holiday special of BBC's Sherlock is a mix of what makes people love and hate the show.Read More
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The game is on! Or, it will be on January 1st when the BBC airs the Sherlock special "The Abominable Bride," in which Sherlock and John have a special, one-off adventure in the Victorian era. This new teaser, while only about 20 seconds long, gives us a great glimpse of the badassery of one Mr. John Watson. Check it out!Read More

domain: entertainment


text:
Comments on the 2016 ESC Guidelines for the Management of Atrial Fibrillation
Rev Esp Cardiol. 2017;70:50
Full text - PDF
In line with the methodology recommended by the Guidelines Committee of the Spanish Society of Cardiology,1 the present article discusses the innovations and most controversial aspects of the recent guidelines for atrial fibrillation (AF).2 Notably, of 154 recommendations, only 23 (15%) have a level of evidence A and 80 (52%) a level of evidence B, confirming the need for further clinical research into this condition.
Some of the most novel or relevant aspects of the guidelines are summarized in Table, in conjunction with some critical comments.EPIDEMIOLOGY
The guidelines report interesting data on the high incidence and prevalence of AF: 1 in every 4 middle-aged adults in Europe and the United States will develop AF during their lifetime. The estimated prevalence of AF in individuals older than 20 years is 3%, in line with data from the Spanish OFRECE study,3 which showed an AF prevalence of 4.4% in the general population older than 40 years.PATHOPHYSIOLOGICAL AND GENETIC ASPECTS THAT GUIDE THE MANAGEMENT OF ATRIAL FIBRILLATION
The hypothesis that there are different types of AF with distinct pathophysiological bases is somewhat daring. Although the etiological factors can differ, the pathophysiological consequences are probably similar, and there is no evidence for the hypothesized ¿distinct pathophysiological mechanisms¿ and ¿different types of AF¿, except in very specific disease and clinical situations. The attempts of the guidelines to link distinct etiological factors with specific pathophysiological mechanisms are somewhat speculative but nonetheless interesting because this approach might suggest future lines of research to better understand the pathophysiology of AF.DIAGNOSIS AND TIMELY DETECTION OF ATRIAL FIBRILLATION
The use of pulse palpation or electrocardiography for any reason as part of opportunistic screening of at-risk patients can detect about 3% of patients older than 65 years with asymptomatic AF. Asymptomatic AF episodes can also be detected in patients with implanted devices, which can record atrial high rate episodes (AHREs). Such episodes have been associated with a higher risk of embolic events, and it is hypothesized that anticoagulants might effectively prevent stroke. Implantable devices should be interrogated to identify AHREs, and patients with AHRE should undergo AF screening and embolic risk stratification.
A considerable percentage of strokes (about 6.5%) might be due to undetected AF episodes. The prevalence of asymptomatic AF is even higher in selected populations with cryptogenic stroke. There is no clear consensus on the optimal monitoring method or whether it needs to be invasive or not. Continuous monitoring is recommended for 72 hours after an ischemic stroke (class of recommendation I, level of evidence B) and, subsequently, ambulatory monitoring with noninvasive systems or implantable loop recorders for all patients who have had an ischemic stroke (IIa B).CLASSIFICATION OF ATRIAL FIBRILLATION
The new guidelines classify AF episodes that are cardioverted within 7 days as paroxysmal; in previous guidelines, all episodes requiring cardioversion were considered persistent, even those lasting less than 7 days. This criteria change might be confusing and it remains to be seen whether these definitions will also be adopted by the guidelines of other scientific societies. A new type of AF is introduced¿long-standing paroxysmal¿but is insufficiently explained.
The classification of AF based on etiology no longer seems to be relevant from the therapeutic perspective.
The classification is now based on AHRE symptoms, with class 2 subdivided into 2a¿mild symptoms¿and 2b¿severe symptoms. Thus, patients in class 2b could benefit from adequate rhythm control.
New and Important Aspects
|For patients with TIA or ischemic stroke, screening for AF should be performed using short-term ECG followed by continuous electrocardiographic monitoring for at least 72 hours||I B|
|Pacemakers and ICDs should be regularly interrogated to identify AHREs. Patients with AHRE should also be monitored using ECG to document AF before its treatment is initiated||I B||Identification of AHRE justifies screening studies for AF and embolic risk stratification|
|For patients with stroke, physicians should consider additional continuous electrocardiographic monitoring using noninvasive ECG monitors or loop recorders to document silent AF||IIa B||Particularly applicable to cryptogenic stroke|
|Definition of paroxysmal AF: self-limiting, typically within 48 hours. Some paroxysmal AF episodes can last up to 7 days. AF episodes that are cardioverted within 7 days are considered paroxysmal||Appropriate reorganization, although the recommendation may generate temporary confusion and obligate reinterpretation of previous studies|
|Weight loss should be considered in obese patients with AF, as well as treatment of other risk factors to reduce AF burden and symptoms||IIa B|
|Obstructive sleep apnea treatment should be optimized to reduce AF recurrence and improve the effects of its treatment||IIa B|
|Integrated management with a structured approach should be considered for all patients with AF to improve adherence to guideline recommendations and reduce hospitalizations and mortality||IIa B||Complicated implementation. Lack of evidence for the recommendation|
|For patients of both sexes with AF with no other stroke risk factors, anticoagulant or antiplatelet therapy is not recommended to prevent stroke||III B, harm|
|Anticoagulant therapy should be considered to prevent thromboembolisms in male patients with AF and a CHA2DS2-VASc score of 1, bearing in mind patients¿ individual characteristics and preferences||IIa B|
|Anticoagulant therapy should be considered to prevent thromboembolisms in female patients with AF and a CHA2DS2-VASc score of 2, bearing in mind patients¿ individual characteristics and preferences||IIa B|
|To improve stroke and bleeding risk estimation in patients with AF, measurement should be considered of levels of biomarkers, such as high-sensitivity troponin and natriuretic peptide||IIb B||Not clearly shown to reflect thromboembolic or bleeding risk|
|When patients receive VKA therapy, the TTR should be as high as possible and regularly checked||I A||Lack of definition of TTR level. Recommendable use of the SAMe-TT2R2 scale|
|When oral anticoagulation is initiated in patients with AF who are candidates for NOAC therapy (apixaban, dabigatran, edoxaban, or rivaroxaban), this treatment is preferable to a VKA||I A|
|Patients with AF receiving VKA therapy should be considered for a NOAC if the TTR is poorly controlled despite good adherence or if it is preferred by the patient, as long as there are no NOAC contraindications (eg, a prosthetic valve)||IIb A||The recommendation level has been decreased without a clear reason|
|Antiplatelet monotherapy is not recommended for stroke prevention in patients with AF, independently of stroke risk||III A, harm|
|Combination oral anticoagulants and antiplatelet agents increase bleeding risk and should be avoided in patients with AF with no other indication for platelet inhibition||III B, harm|
|LAA occlusion can be considered to prevent stroke in patients with AF and contraindications to long-term anticoagulant therapy (eg, patients who have had potentially fatal bleeding without a reversible cause)||IIb B||Class of recommendation inexplicably low|
|Anticoagulation with heparin or LMWH is not recommended in patients with AF immediately after an ischemic stroke||III A, harm|
|NOAC therapy is recommended in patients with AF and previous stroke instead of VKAs or aspirin||I B|
|Combined treatment with an OAC and antiplatelet agent is not recommended after a TIA or stroke||III B, harm|
|For patients who have had a stroke, aspirin should be considered for secondary stroke prevention until initiation or resumption of oral anticoagulation||IIa B||Slight disagreement due to bleeding risk|
|Beta-blockers, digoxin, diltiazem, or verapamil are recommended for heart rate control in patients with AF and LVEF ¿ 40%||IB||Removal of the recommendation to avoid digitalis in patients with paroxysmal AF. The use of digitalis drugs as isolated blocking agents is strengthened, without a solid rationale|
|Catheter ablation of AF should be considered as first-line treatment to prevent AF recurrence and improve symptoms in selected patients with paroxysmal AF as an alternative to antiarrhythmic drug therapy, considering the risks, benefits, and preferences of the patient||IIa B|
|When physicians are planning catheter ablation of AF, they should consider maintaining oral anticoagulation with a VKA (IIa B) or NOAC (IIa C) during the procedure to maintain adequate anticoagulation||IIb B/C|
|Catheter ablation should try to isolate the pulmonary veins via radiofrequency or cryoballoon ablation||IIa B|
|Ablation of the AF should be considered to avoid pacemaker implantation in patients with AF-related bradycardia||IIa C|
AF, atrial fibrillation; AHRE, atrial high rate episode; ICD, implantable cardioverter defibrillator; LAA, left atrial appendage; LMWH, low-molecular-weight heparin; LVEF, left ventricular ejection fraction; NOAC, new oral anticoagulant; TIA, transient ischemic attack; TTR, time in therapeutic range; VKA, vitamin K antagonist.
The guidelines highlight the risk factors and comorbidities associated with AF and quantify their effect on AF risk. In addition to the usual risk factors, particular emphasis is given to obesity, alcohol consumption, smoking, and regular vigorous exercise.
Some drugs used in the treatment of AF in heart failure patients decrease AF risk (angiotensin-converting enzyme inhibitors, beta-blockers [BBs], and eplerenone), but not others (angiotensin II receptor blockers and neprilysin inhibitors). To reduce recurrence, weight loss is recommended (IIa B) for obese patients, whether via AF ablation or other strategies. For patients with chronic obstructive pulmonary disease, hypoxemia and acidosis correction is recommended in acute episodes (IIa C), as well as obstructive sleep apnea treatment (IIa B). A useful addition would be discussion of the relationship of reduced alcohol consumption and vigorous exercise with AF risk reduction.
A novel recommendation is to abandon the term ¿nonvalvular AF¿ and to refer to the specific underlying condition. Although up to 30% of patients with AF have some type of valve involvement, only mechanical heart valve prostheses or rheumatic mitral stenosis impact stroke risk.INTEGRATED MANAGEMENT OF PATIENTS WITH ATRIAL FIBRILLATION
The guidelines propose (IIa B) the establishment of specific integrated multidisciplinary management programs for patients with AF to increase adherence to the guidelines¿ recommendations and improve prognosis. This recommendation is supported by 2 randomized studies that compared this strategy with usual care in tertiary centers, although one of these studies found only a marginal benefit. Various observational studies have also found fewer events with these programs. Although this strategy probably improves the prognosis and treatment of patients with AF, we believe that the current evidence is insufficient.STROKE PREVENTION
A controversial aspect is the use of biomarkers (high-sensitivity troponin and N-terminal pro¿B-type natriuretic peptide) to stratify thromboembolic risk, although the recommendation is IIb B. The diagnostic and prognostic usefulness of these biomarkers has been shown in other cardiovascular diseases but confirmation is required of their additional prognostic value in clinical risk scales. The studies contributing to the inclusion of these biomarkers in the guidelines were performed in patients enrolled in large trials comparing vitamin K antagonists (VKAs) with new oral anticoagulants (NOACs). Accordingly, the role of biomarkers is controversial because all patients were anticoagulated. Their use in low-risk patients has not been validated and their role in patients without anticoagulation remains to be studied.
The guidelines strengthen the usefulness of the CHA2DS2-VASc score for predicting thromboembolic risk. Anticoagulation is not recommended in patients with a CHA2DS2-VASc score of 0, even women (III B). However, anticoagulation is assigned a IIa B recommendation in men and women with a single stroke risk factor and a I A recommendation for men with 2 or more risk factors and women with at least 3. Thus, the female sex is no longer considered an independent risk factor when the anticoagulation indication is being assessed. Men with 1 point and women with 2 points are combined in a special section and the recommendation is for an individual risk evaluation. A recent meta-analysis4 showed that the embolic risk with a CHA2DS2-VASc score of 1 is below the estimated net-benefit threshold for VKAs (1.7% per year), whereas the net-benefit threshold would be lower for NOACs (0.9% per year).
A list of modifiable risk factors for bleeding is proposed but no bleeding risk scale is explicitly recommended. Estimation of bleeding risk was a landmark in the treatment of patients with AF. The HAS-BLED score identifies modifiable risk factors for bleeding, such as the use of antiplatelet agents, uncontrolled hypertension, and poor control of VKA therapy. New bleeding risk scales, such as ATRIA, ORBIT, and ABC,5, 6 have replaced the HAS-BLED score with a table of bleeding risk factors grouped into modifiable, potentially modifiable, and nonmodifiable. Another surprising change is the inclusion of biomarkers that are not used in daily clinical practice, such as GDF-15.
VKAs are the sole therapeutic option for patients with rheumatic mitral valve disease or a mechanical heart valve prosthesis. The guidelines note the importance of adequate VKA therapy in anticoagulation control, estimated by the time in therapeutic range (TTR). These antagonists continue to have a I A recommendation when the TTR is adequate. Notably, no cutoff point has been established for the TTR in this section or in the recommendation box. In recent years, a new score, the SAMe-TT2R2, has been shown to be useful in identifying patients failing to achieve optimal anticoagulation control.7 This scale has been validated in a Spanish population.8 Its use would increase the percentage of patients considered suitable for these drugs who are not predicted to achieve stable anticoagulation¿exceeding 40% of patients in different series¿and would also avoid the 6-month transition period for VKAs mandated by current Spanish regulations.9
A clear preference is expressed for NOACs over VKAs for nonvalvular AF (I A recommendation). However, it seems illogical to reduce the recommendation for a change to a NOAC when inadequate control of the international normalized ratio (INR) is achieved with VKAs: this recommendation was I B in 2012 and is now IIb A. In addition, the bleeding risk associated with NOACs is similar to that of aspirin10 and they show a greater ability to reduce embolic events.11
A conclusive recommendation is made to avoid the use of aspirin to prevent stroke, independently of patients¿ embolic risk (III A). The use of antithrombotics is also discouraged if there is no specific indication for antiplatelet therapy.
The guidelines incorporate edoxaban and present a ¿per-protocol on-treatment analysis¿, which favors the drug. We believe that it would have been pertinent to discuss the main analysis in more detail. Table 13 shows discrepancies in dosage with the summary of product characteristics of edoxaban. The authors of the guideline have expressly chosen the criteria used in the clinical studies, given the international setting of the guidelines and possible differences in labeling between countries.
Two interesting differences with previous guidelines are the clear declaration of the safety of anticoagulation with NOACs in patients with mild-to-moderate chronic kidney disease and the recommendation to monitor renal function to enable anticoagulant dose modification and risk redefinition.
We must remember that no important clinical trial has validated the utility of acenocoumarol, the most widely used VKA in Spain. Acenocoumarol has a plasma half-life of 8 to 11 hours, similar to that of NOACs. Warfarin has a more prolonged half-life, which stabilizes the anticoagulation level.
Spain is not likely to be able to apply these recommendations on the use of NOACs, largely due to a lack of public funding.
Due to the results of a meta-analysis, surgical closure of the atrial appendage has gone from being supported by expert consensus opinion to having a level of evidence B. Similarly, the guidelines add the possibility of atrial appendage exclusion with thoracoscopy with the same recommendation level. However, despite the reduced embolic risk, the guidelines recommend that oral anticoagulation therapy be maintained after surgical exclusion of the atrial appendage. Percutaneous occlusion of the atrial appendage as an alternative due to contraindication to oral anticoagulation continues to be only a IIb B recommendation, despite recent evidence showing a high success rate and low complication rate (< 5%) with this procedure.Secondary Stroke Prevention
Another new development is a special section containing a useful management scheme for anticoagulant resumption. Heparin is not recommended after a stroke or transient ischemic attack (III A) because it increases the risk of intracranial hemorrhage without reducing the risk of stroke. An interesting innovation is the preferred indication (I B) of NOACs over VKAs and aspirin and the contraindication of combined antiplatelet agents and anticoagulants in secondary prevention (III B). A possible weak point is that the flowchart is based on expert consensus.
The recommended use of fibrinolytics in anticoagulated patients with AF who have had a stroke is limited to patients under treatment with a VKA and with an INR < 1.7 or under treatment with dabigatran if the activated partial thromboplastin time is within the normal range and the last dose has not been administered within the last 48 hours. The safety and effectiveness of anticoagulation reversal for fibrinolysis are unknown.
Notably, aspirin can be considered after a stroke in patients with AF until (re)initiation of anticoagulant therapy is possible (IIa B). It seems that this recommendation fails to consider the bleeding risk of the drug (which is mentioned in various sections of the guidelines). Previous editions of North American guidelines for the prevention of recurrent stroke indicate that aspirin has a net clinical benefit.
An algorithm is proposed for the management of oral anticoagulant therapy after an intracranial hemorrhage. If anticoagulation is reinitiated, the anticoagulant should have a lower bleeding profile, although no specific agent is specified. Atrial appendage occlusion is recommended if anticoagulation is contraindicated (IIb C).
Finally, the established levels of evidence can be confusing regarding parenteral anticoagulation after a stroke (level A) and the preference for NOACs in this setting (level B), given the characteristics of the studies addressing these issues.
A specific section of the document summarizes the various factors increasing bleeding risk. This section includes a cutoff point for a labile INR, and the guidelines recommend that patients be switched to a NOAC when an adequate TTR (¿ 70%) cannot be maintained. Falls and dementia do not increase intracranial hemorrhage risk. Interruptions to anticoagulant therapy for surgical operations and minor procedures should be avoided, as well as the use of bridging therapy because it increases bleeding risk. However, NOACs are not mentioned in this context.
A surprising recommendation is to use fresh frozen plasma in patients with a bleeding event and anticoagulated with VKAs. Most guidelines recommend the use of prothrombin complex concentrate, given the lack of efficacy of fresh frozen plasma and its difficult administration (requiring thawing and a large volume) and associated secondary effects.12 Idarucizumab is recommended as an antidote to dabigatran, as recently shown.
One noteworthy contradiction: the guidelines mentions that the greater risk of gastrointestinal bleeding associated with dabigatran 150 mg, rivaroxaban 20 mg and edoxaban 60 mg vs VKAs, dabigatran 110 mg and apixaban 5 mg has not been reproduced in subsequent registries, but then explicitly recommend that these drugs not be used in patients with a high risk of gastrointestinal bleeding.
Regarding combination anticoagulant and antiplatelet therapy, the guidelines reproduce the latest expert consensus of the European Heart Rhythm Association (EHRA). Thrombotic and ischemic risks should be estimated and the clinical situation evaluated, particularly elective coronary stenting for acute coronary syndrome. Triple antithrombotic therapy is recommended in most patients; the duration should be as short as possible (IIa B or IIa C) and followed by dual therapy (oral anticoagulation plus a single antiplatelet agent). When a NOAC is used, the consensus is to use the lowest effective dose to prevent stroke in AF. However, the combination of aspirin, clopidogrel, and low-dose rivaroxaban (2.5 mg twice daily) is not recommended for stroke prevention in patients with AF. The use of prasugrel or ticagrelor as part of triple therapy should be avoided unless there is a clear need for these agents (eg, for stent thrombosis in patients under treatment with aspirin plus clopidogrel).RATE CONTROL THERAPY IN ATRIAL FIBRILLATION
No major changes have been made to these recommendations. For acute rate control, the guidelines continue to preferentially recommend BBs and nondihydropyridine calcium antagonists (CAs) over digitalis. For long-term rate control, the same strength of recommendation is given to these 3 types of drugs (I B); specific drug selection should be based on patient characteristics. The guidelines have removed the recommendation not to use digitalis drugs as the only agents for heart rate control in patients with paroxysmal AF. This advice contrasts with North American guidelines, which only consider BBs and CAs for long-term heart rate control and restrict the use of digitalis to patients with heart failure.13 Digitalis drugs have few negative dromotropic effects in adrenergic states, as usually occur during paroxysmal AF episodes. The data from the FANTASIIA registry14 show that the most widely used drugs for heart rate control in AF patients in Spain are BBs in most patients (60.2%), followed by digoxin (19.5%) and, to a lesser extent, CAs (10.7%). The guidelines recommend the combination of BBs or CAs with digitalis. However, these drug combinations are controversial because the results published on these combinations are discordant.
The guidelines barely consider combined heart rate and rhythm control, despite the possible effects of drug interactions. Combinations of some of these drugs can enhance their negative chronotropic effects. This is the case for the combined use of BBs and the type C antiarrhythmic drugs flecainide and propafenone because both types of drugs profoundly affect sinus node function. They should thus be used with caution in elderly patients or patients with suspected sinus node dysfunction. Recent publications discourage the combination of dronedarone with any agents that depress atrioventricular conduction, such as digoxin, given that the PALLAS trial15 linked their combined use with increased mortality (relative risk up to 7.3 times higher than digoxin or dronedarone in monotherapy). This combination is even discouraged in the European data sheet for dronedarone and it is striking that it has not been reflected in the new guidelines.
Atrioventricular node ablation and pacemaker implantation is one way to achieve heart rate control after drug therapy failure. However, the guidelines have largely ignored the type of cardiac resynchronization device, whether single-chamber, dual-chamber, or triple-chamber.RHYTHM CONTROL THERAPY IN ATRIAL FIBRILLATION
The first major comment of the guidelines in this area is that the benefits of rhythm control therapy are limited to symptom improvement. Because there are no data on reduced mortality, there are no guidelines for asymptomatic patients. The publication of new studies such as the CABANA (Ablation Versus Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial) trial (NCT00911508) are eagerly awaited.
There are no changes in the indication or in the usual cardioversion procedure in patients with new-onset AF. Antiarrhythmic drug selection is based on their safety profile in the different heart diseases. The guidelines note that the new drugs, such as vernakalant, do not significantly improve efficacy and recommend which agents are suitable for each disease.
An alternative option is ablation, which is awarded a IIa recommendation. This class of recommendation might be a source of controversy due to the considerable number of randomized studies showing that ablation is superior to antiarrhythmics in patients without previous antiarrhythmic therapy. Because most recurrences are observed in the first months after vascular surgery, the guidelines comment that amiodarone reduces recurrence for 4 weeks, but not for longer times. Intermittent amiodarone use after vascular surgery is associated with greater mortality and more hospitalizations vs continuous use. The effectiveness of new drugs such as ranolazine or combinations of antiarrhythmic drugs such as dronedarone and ranolazine is called into question due to recent publications.
The guidelines affirm that ablation is clearly superior to antiarrhythmic drugs when one of these drugs has previously failed. Although studies comparing ablation and antiarrhythmic drugs in untreated patients are mentioned, the findings are not collected in a specific comment.
The guidelines note that, apart from antrum isolation, no technique has been shown to be superior to catheter ablation for either paroxysmal or persistent FA. The usefulness of certain interesting techniques, such as rotor ablation, remains to be shown in clinical trials. However, cryoablation is not inferior to conventional point-to-point ablation. Although experts indicate that cavotricuspid isthmus ablation should be performed in patients with AF and atrial flutter, there are no conclusive data supporting the effectiveness of this approach.
Surprisingly, despite the recent position document of the EHRA with other societies on periprocedural antithrombotic management,16 this article has not been cited. Due to recent evidence, the guidelines state that patients treated with VKAs should maintain this treatment during the procedure. However, the guidelines fail to note whether the benefit observed in patients with AF is long-lasting. Thus, there are doubts about the general suitability of anticoagulant maintenance, whether VKAs or NOACs, during ablation procedures (IIb).
Because AF and ventricular dysfunction frequently coexist and worsen each other's symptoms, it is important to define the value of ablation in these patients. The guidelines fail to cite any study showing that ablation boosts ventricular function recovery in patients with either adequate or inadequate ventricular heart rate control17 and that the main determinant of ventricular function recovery failure is the presence of myocardial infarction. No convincing evidence is put forward showing that ablation is superior to strict control of ventricular heart rate with node ablation and subsequent resynchronization device implantation. However, the guidelines do state that ablation is superior to amiodarone in patients with ventricular dysfunction and an implantable device.SURGERY AND ATRIAL FIBRILLATION
The most notable contribution in this area concerns ablation that is not combined with another type of surgery. The development of videothoracoscopy and bipolar radiofrequency ablation with cryothermy has simplified the procedure and has reduced complications to such an extent that it can be considered another surgical option for the treatment of AF. Effectiveness rates ranging between 70% and 90% justify its use in patients who have undergone failed percutaneous procedures.HYBRID THERAPY
The guidelines discuss 2 aspects of hybrid rhythm control therapy involving antiarrhythmic drugs: their combined use with either catheter ablation or pacemakers. Regarding the first approach, although the guidelines establish that it appears to be common knowledge to use antiarrhythmic drugs in patients with AF recurrence after an ablation procedure, no guidelines or strength of recommendation are established for its use, despite various studies showing a lower incidence of AF and fewer hospitalizations after ablation.18 The guidelines mention the possible use of cavotricuspid isthmus ablation and continued antiarrhythmic drug therapy¿mainly with type IC antiarrhythmic drugs¿in patients with AF and organized atrial flutter, but no strength of recommendation is provided. In the European and North American guidelines for supraventricular tachycardia treatment, a strong recommendation (I and IIa) is awarded to this approach.
The guidelines also mention combination hybrid therapy involving a pacemaker and antiarrhythmic drugs, largely due to the negative chronotropic effects of these drugs. Pacemakers permit the use of higher doses of these drugs. However, catheter ablation can sometimes obviate the need for antiarrhythmic drugs and pacemakers. Some of these patients have reverse remodeling of the sinus node, which can return after AF termination with ablation.19 However, early sinus node dysfunction can be unmasked by the antiarrhythmic drugs and would require monitoring.SPECIFIC SITUATIONS
This section has been reorganized to remove the brief comments of previous guidelines on hyperthyroidism and pulmonary disease.
The guidelines stress the need to use medical records and other tests to evaluate the presence of channelopathies and other cardiomyopathies in young patients without apparent structural heart disease but with AF; systematic genetic studies are not considered necessary. The section on sport and AF is well supported, although it might be imprecise, even confusing, regarding the effects of detraining.
Another development is that the pertinent information on AF (and other atrial arrhythmias) in adult patients with congenital heart disease is organized in a separate section. However, the recommendations are level C only, except for those referring to atrial flutter.AREAS WITH GAPS IN EVIDENCE
The guidelines highlight 9 specific situations requiring appropriately powered randomized trials to robustly establish an adequate recommendation level. Some of these are especially relevant, such as anticoagulation in patients with AF and severe chronic kidney disease, anticoagulation after a bleeding or stroke event, the optimal timing of cardioversion for new-onset AF without anticoagulation, and atrial appendage occlusion for stroke prevention.
There is a lack of scientific evidence in diverse areas of knowledge supporting some of the recommendations or preventing their implementation. Examples include AHREs, the role of anticoagulation in biological prostheses and rheumatic mitral valve disease, and the role of ablation in persistent AF. Questions remain regarding atrial appendage closure/occlusion, because the indications included in the clinical guidelines are different from those evaluated in the main clinical studies, and the need to maintain anticoagulation after device implantation.CONCLUSIONS
Although the guidelines have a strong clinical focus and have incorporated the relevant available evidence, it is patently clear that many of the situations considered require greater scientific support.
A notable inclusion is the integrated management of AF because this approach recognizes the epidemiological importance of the disease, its relationship with other risk factors, the need for early detection, its multidisciplinary treatment, and the role played by the patient.
The largest section deals with anticoagulant therapy and considers various related factors such as the correct indication, bleeding risk, and its combination with antiplatelet agents or atrial appendage exclusion. All of these factors interact and have distinct effects due to differences in clinical situations.
The guidelines consider heart rate and rhythm control therapies, with few changes, and lack definitions in specific situations, such as certain hybrid therapies or the role of ablation. However, the surgical setting is considered.
Special situations are defined, and areas lacking clarity are recognized.
There are some important changes concerning the classifications of paroxysmal and persistent AF, the role of female sex as an embolic risk factor, and the abandonment of the HAS-BLED stratification scale of bleeding risk, among others, which could lead to some confusion upon their incorporation into clinical practice.
These guidelines are welcome for persuasively arguing for a need for systematic care in patients with AF.CONFLICTS OF INTERESTS
However, the following authors declare financial relationships with entities that may have interests in certain aspects of the article: F. Arribas: consulting (Boheringer-Ingelheim, Daiichi Sankyo, Lina Nova), presentations (Boston Scientific, Bayer), educational presentations (Medtronic, Boston Scientific, Biosense), attendance at meetings (Medtronic, Lisa Nova, Boston Scientific). I. Roldán: presentations (AstraZeneca). J. L. Merino: board member (Daichii Sankyo, Biosense, Sanofi), consulting (Biotronik, Cardiome, Daichii Sankyo, Medtronic, Sanofi, Sorin), presentations (Biotronik, Boston Scientific, Medtronic, St. Jude, Sanofi), educational presentations (St. Jude), attendance at meetings (Biotronik, Boston Scientific, Medtronic, St. Jude, Sanofi), symposium sponsorship (Bayer, Boheringer-Ingelheim, Pfizer, Cardiome, Boston, Equipamiento Scientific, Medtronic, St. Jude, Sorin, Microport). R. Ruiz: consulting (Medtronic, Boston Scientific), presentations (Medtronic, Boston Scientific, St. Jude). L. Mont: consulting (St. Jude Medical, Boston Scientific, Johnson & Johnson, Medtronic Boehringer), expert testimony (St. Jude, Boston Scientific, Johnson & Johnson, Medtronic, Boheringer-Ingelheim), presentations (St. Jude, Boston Scientific, Johnson & Johnson, Medtronic, Boehringer), educational presentations (Johnson & Johnson). F. Marín: consulting (Daiichi Sankyo, Bayer), attendance at meetings (Daiichi Sankyo, Bayer), presentations (AstraZeneca), research project (Pfizer/BMS, Boehringer-Ingelheim). V. Barrios: member of the board of directors (Bayer, Boheringer-Ingelheim and Daiichi Sankyo), consulting (Bayer, Boehringer Ingelheim, Daiichi Sankyo), presentations (Bayer, Boheringer-Ingelheim, Daiichi Sankyo, Pfizer). G. Barón: consulting (Bayer, Boheringer-Ingelheim, Daiichi Sankyo, Pfizer), expert testimony (Bayer, Boheringer-Ingelheim, Daiichi Sankyo, Pfizer), presentations, manuscript preparation (Bayer), attendance at meetings (Bayer, Pfizer). E. Díaz: consulting (Medtronic, Boston Scientific), presentations (Medtronic, Boston Scientific, St. Jude Medical, Biotronik), educational presentations (Medtronic, Boston Scientific, St. Jude, Biotronik), attendance at meetings (Medtronic, St. Jude). J. L. Ferreiro: presentations (Daiichi Sankyo, Pfizer). N. Pérez-Castellano: consulting (Medtronic, Boston Scientific, St. Jude Medical, Livanova), presentations (Medtronic, Boston Scientific, St. Jude Medical, Livanova), manuscript preparation (Boston Scientific), attendance at meetings (Boston Scientific). A. Tello: grants (Astra Zeneca), presentations (Amgen, Astra Zeneca, Merk, Biosensors), attendance at meetings (Daichii Sankyo). F. Alfonso: attendance at meetings. I. Ferreira-González: presentations (Bayer, Pfizer, Boheringer-Ingelheim), educational presentations (Bayer, Pfizer, Boehringer, Abbott), consulting (Bayer). L. Rodríguez-Padial: presentations (MSD, Pfizer, Rovi, Daiichi Sankyo, Amgen, Sanofi), attendance at meetings (Menarini, Servier, Sanofi).
¿ SEC Working Group for the 2016 ESC Guidelines for the Management of Atrial Fibrillation, Expert Reviewers for the 2016 ESC Guidelines for the Management of Atrial Fibrillation, and the SEC Guidelines Committee.
The names of all of the authors of this article are listed in the Appendix.
Corresponding author: email@example.com
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domain: literature


text:
Overcome Pain and Illness
If there were no withdrawal symptoms to worry about, addicts would be far more willing to enter addiction rehab and would experience a lot more success. Because of the intense pain and discomfort involved, the experience of withdrawal symptoms is one of the largest challenges to a successful drug and alcohol rehab.
What’s more, a powerful craving for drugs – largely due to how a substance alters the body’s production of the hormone dopamine – can make one’s attempt to recover in rehab especially difficult. Certain drugs release chemicals into the body that produce endorphins, which then release dopamine. Dopamine is the body’s “pleasure hormone,” and the desire or lack of dopamine in one’s body can often influence one to continue their behaviors that lead to a sensation of reward (“pleasure”), like substance abuse. Medication assisted therapy is a technique that allows the doctors at Behavioral Health of the Palm Beaches to limit the release of these chemicals and keep cravings in check.
Control Cravings and Get Results
If it has been determined that you are a good candidate for medication assisted therapy, the standard course of treatment includes a medically supervised injection of Vivitrol®, which is the brand name version of Naltrexone. The drug is administered immediately following the initiation of detox and has proven highly effective in the treatment of many other medical conditions.
Medication assisted therapy is not meant to be used over a prolonged period of time, nor is it intended to be the only addiction treatment received at our facility. We use medication to ease the detox process, and offer activities, spiritual exploration, psychotherapy and other methods to achieve long-lasting results.

domain: psychology