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Sunday, January 6, 2013

Small Changes

Real food. Natural food. Gluten free. Grain free. GAPS. Dairy free. Vegan. Vegetarian. Wow, what a list! That's just quick off the top of my head on different diets or approaches that people take towards a more healthy approach to food and their health. I don't claim to be an expert in any particular way or want to spout off which way might be the right way. I can't even pin point what approach I'm steering our family at the moment! I think it's important to not get overwhelmed and not take on too much when adjusting to a new lifestyle of healthy choices. Most likely your family won't appreciate a sudden change and the new raw diet you chose! Currently I do make yogurt for our family, but I don't make my own bread. (I may start that again soon, but currently it would be too much for me to handle.) I make granola bars for our lunches, but the kids eat processed powdered covered pretzels after school. (Beyond gross IMO, and we take breaks from that favorite snack.) We buy raw milk, organic meats and cheeses, but still buy hotdogs and lunch meat. (Although I have seen recipes on how to make your own lunch meat, I'm intrigued but hate to experiment on good organic meat!) But do compromises make a difference? Does it need to be all or nothing? Certainly choosing healthy foods are always positive, made from scratch with real ingredients is better than the store processed with extra unpronounceable junk hidden in it. But will these small changes add up to a difference with your health? I think so. You don't have to be perfect, but one small healthy choice can lead to another. I totally believe what I choose for breakfast will set the tone for my food for the rest of the day. The more homemade items and home cooked meals you have, the sooner your tastes buds will sour to store bought confections. Candy bars are way to sweet and frankly a disappointment to me now. It tastes like wax to me, very sweet wax! The other day I bought my kids some "healthy" yogurt at the store, an attempt to let my 6 year old choose his own healthy snacks. I believe it was vanilla Activia yogurt. I tried some when one of the kids didn't finish the cup(hate to waste!) and I couldn't put my finger on the flavor- oh wait, frosting! It tasted like frosting! That's how my taste buds have changed. How do you start to make these changes? Most likely you already have made some changes so maybe I can share with you some truths I found in starting change. 1. Revert back to healthy choices you used to make. For example, swap your fake GMO processed flake of a cereal to oatmeal or eggs.... something that's normal for you and that you used to do at one point in time. It doesn't have to be something for every meal, just the easy adjustments you've made and liked before. 2. Make something from scratch - and go big. Let me explain, I don't mean run out and buy a bread maker with dreams to never buy a convenient loaf again. No, I mean make one simple homemade meal and make enough for leftovers. Make homemade soup and have that for lunch for the week. Make enough roasted vegetables for dinner and then add into your eggs or lunches the next few days. Make a crustless quiche for your breakfast all week. It doesn't have to be fancy, simple steps to make change easier. 3. Include the family in these changes. This can mean so many things, but I would think others would agree they could eat healthier, although resistance is normal. Small changes, some so subtle family members won't even notice, can get the ball rolling. Over the holidays I made my cheesy potato casserole but made it with 1/3 each of potatoes, cauliflower, and broccoli. Nobody baulked. Cauliflower lends nicely to the potato flavor, and cheese makes everything better. Just don't ignore your families habits and try to strong arm them into super healthy super fast, it won't be accepted. I'm sure there are other great ideas on starting change, please share what's worked for you. I'm always looking for ideas too.

Saturday, January 5, 2013

Yogurt Update

If you read my previous post for over a year ago(whoops!) not much has changed on the yogurt front. I still make yogurt regularly. I still sweeten it with honey. I love it with fresh or frozen berries and sometimes a bit of granola. I don't use it much in baking, but I have and did use it just the other day in my pancakes, I was short the proper amount of buttermilk and didn't want to just add thin milk. That's another story, I suppose. A few useful ideas with your yogurt to help trouble shoot and to incorporate it I to your kid's diet. First of all. Don't rush the process. If you try to cool it quickly in a sink of cold water you may easily get it too cool. It's certainly okay to warm it up on the stove, but too much fussing with the temperature will prevent the yogurt from thickening and setting up properly. I will still turn out, just won't be as thick as store brand. This is easily a problem for those with texture issues or who aren't that crazy about yogurt or especially *homemade* yogurt in the first place. Mental blocks can be hard to jump, let's make it easier! An easy way to incorporate it into your kid's diet is to add it to yogurt they already enjoy. Some kids cups of store bought yogurt has a bit of extra room, so add a table spoon or two and mix well. They won't notice and it will help them adjust to less sweetener I their yogurt. Soon you'll want to take it a step farther and divide the store bought yogurt in half then mix with your home made yogurt. You may need to save the store bought cups so they don't wise up too soon. You may also need to help your child adjust to your sweetener of choice. A lot of kids(mine) don't like honey by itself. My daughter has grown to like it in her yogurt, but refused it initially. And if all else fails, just tell your kids they don't like it. With my 7 year old it worked like a charm! We were talking about things that were healthy and not healthy at the dinner table(my kindergardener is obsessed about figuring this out lately) and I told her she didn't like an of the healthy things I made. - "Not true!" she claimed. So I listed off all the examples of homemade snacks she wouldn't eat. Well, to prove me wrong she said she did like those things, or at east needed to try them again. So now she'll eat my home made yogurt and granola bars, not all the time but definitely as an option.

Monday, September 5, 2011

Yogurt 101

Well, I've really jumped into this wholesome living way of life! I thought making my own bread was a huge step - but making my own yogurt is just crazy talk!!!

But yah know what - it was pretty easy and it was good! Well, once I added some honey - more on that later.

I'm not going to pretend to be an expert or certainly pretend to say I have my own recipe- if you want the exact great details - check out this blog:

She gives great directions and trouble shooting tips and puts your mind at ease through the whole process. If you think you messed up, probably not.

The first things you might want to know is how it turned out. It was tart, not something I would personally enjoy "as is". It was thick but got runny as soon as I started to stir it, so stir gently to protect the bacteria you worked so hard to cultivate. But it will still be thin. You could probably strain it a bit through cheese cloth for a thicker yogurt. I compared the taste to my starter, Stonyfield Plain Yogurt, and Stonyfield was much more tart. It was easy to flavor with a little experimentation, more below.

The process: Well, check out the website but honestly, it was very easy. You need to be home during the initial warming and cooling phase. Once you set it to incubate - all the pressure is off and you can potentially forget about it without harming it. Well, within reason. You probably have all the tools needed so there's not much prep. I've also found a slow cooker recipe here: which I might try at a future date.

My biggest concern was whether my family would like it, because honestly, they're the ones who eat the yogurt, not me. My husband eats a 6 oz yogurt every day with lunch. My two oldest kids eat a lot of frozen yogurt pops and my youngest eats a 6 oz yogurt for breakfast a few days a week.

We buy organic yogurt so this was costing us $10-$11 per week. It still had alot of sugar in it. So where does homemade yogurt stand in all this? Well, I think a half gallon of whole organic milk($3.69) will get us through each week. (although time will tell. They might not always get a full 6 oz serving, but I think they'll survive. That will save us about $30 each month! Cha-ching!!

But what about all that sugar? We like it sweet, not plain. I was definitely worried about this. Most people who make their own yogurt use very non-processed forms of sweeteners(honey & maple syrup). I enjoy those two things, but possibly not in my yogurt as a prominent flavor. Okay - I would, but would my picky husband and kids? I didn't really find any recipes that used table sugar. The other main method was whole fresh or frozen berries. A fine idea - but would everyone like chunks in their yogurt? That can be an issue depending on the phase.

So we tested.

I tested table sugar + vanilla extract, honey, and sweetened fresh strawberries(w/ dissolved table sugar). I tested them all first. Then I woke up my husband and let him taste them all. Then I had my oldest taste them. The results?

Honey is an awesome sweetener!!!! I was worried because my family does not LOVE honey. I LOOOVE me some honey and thought it was great. But my daughter detests it and my husband just thinks I'm crazy. But they both thought it was great. The table sugar was not so good because it was still grainy. The vanilla didn't do much for it either, but it was a cheap vanilla. (I'm considering making my own vanilla. ~Fun Fun!!)The strawberry was okay but needed the honey to give it the sweet punch we were used to. Later tried with with some chopped frozen berries and that was good too. So I don't think I'll continue making a sweeten berry mixture once its gone. Initially I measured the sweeteners, but then I just played around until I got the right amount of sweetness. I left the original batch a little less sweet so we could add berries. If need be, we'll add more honey.

Other Uses for Yogurt:
The Kitchen Steward site gave some recommendations - and I'll just share a few of my favorites so far. I left one jar plain(until necessary) so I could use the yogurt plain if needed. I used it as a buttermilk substitute in my banana bread. This is awesome and I'm very excited that you can use this in place of buttermilk in recipes. I might actually attempt to make my own ranch dressing. I've always wanted to, because that is the one processed food item my family will not live without(Hidden Valley Ranch!) but I wasn't willing to mess around and try to make a suitable substitution unless I had organic buttermilk, which I have yet to find. And it would surely be expensive. But now it's not!

Tuesday, August 23, 2011

CAS: Community Supported Agriculture

Our First Basket

This is our first year to be apart of a CSA. I only learned about them months before we found this one - and it's purely by chance. A case of "who you know." There aren't many in our town - I've only heard of two others. And the one supported only 5 families!

It's been pretty cool! We started out with sugar snap peas, onions, and lettuce. Oh -and fresh cut flowers. But as the summer has gone on, we've had many of the typical summer produce - especially zucchini and cucumbers. I searched for some good recipes to use these plentiful ingredients - and I'll share those in another post. I'm in the process of deciding what to do with pattypan squash.

Mid Summer Basket

Due to the cool wet spring, we had a small crop of lettuce and the tomatoes were kinda stunted. So we're just starting to get tomatoes and I've had to supplement lettuce and a few other veggies. But for the most part I need to get my creative juices flowing and use what we get.

I know one concern is that you'll get veggies you don't like or know how to use. Um, yeah- very true! But I think it's a great opportunity to experiment or try veggies you wouldn't normally spend the money on from the store. Obviously we did pay for these veggies - so I did pay for the less desirable veggies, but it also encourages me to get the most out of what's given to me.

The only thing I totally didn't want or use was okra. I know some people love it, but I don't. I passed it on. I've also passed on alot of cucumbers. There were just too many. Last week I got 9 new cucumbers and I already had 5 or 6 and had just given away about a half dozen. It's hard because you can't cook with them - at least zucchini I can add it to recipes... but unless I start to pickle these babies - not sure what to do here!

Saturday, May 7, 2011

Planting Day!!

Today was our work day at our farm!

It was so great to meet the owner, Wendy, and to see how it all starts. She was more organized than previous years(or so I got the drift) because she had all the areas labeled. All thanks for the overly rainy season we're not used to!

So it was very relaxed. We got there around noon, much later than we planned, and she and her family were bringing out trays of food. All fresh veggies, fruit, fruit spreads, hard boiled eggs - it was a feast! Of course, we were there to work - so she got us started on some onions. We stayed for about 3 hours, while people came and went. IT was like family - she introduced us to everybody. The kids mostly played, but would dig in once in a while.

I'm a little nervous. She has so many variety of every kind of plant - we eat about 2 squash a year - let alone the nine different varieties she has!!! Plus not all these will keep like a squash will. It's also making me rethink what I'm going to plant in my own gardens.

It was a great day!! Everyone came home and took a nap - but not me. I went outside an got my own little plot of land ready. It's not much, but we don't get alot of sun. There was a hole in the middle from the last bush being pulled out last year - plus all the red rocks someone used for ground cover - my nemesis. I also tilled it and evened it out so it's ready to go!! I'll post the pic as soon as I upload pictures!

Thursday, April 21, 2011

Cleaning Supplies

Okay - I hate to keep revisiting the laundry soap, but I just made some and it obviously falls under approved topics for this blog!

So I'm desperately behind on laundry and just about out of soap. Fortunately I have everything I could need to make it. I was going to make a large batch, but I still don't have a 5 gallon bucket. Well, I forgot that it needs to sit overnight. Bummer. So I decided to make a batch of powder to have on hand in case the liquid runs up dry again.

I officially prefer the liquid laundry soap because it is cheaper - it's already melted and I feel confident that it will mix will with the cold water. The powder, although you use less, it uses more product and runs out faster. Plus I feel I need to use warm water so it melts and can clean properly. I did find a nifty way to store it though - in an old baby wipes container! With our new lifestyle I just don't have as much Tupperware available!

So onto other cleaning supplies. I have not taken the plunge on a vinegar based cleaning solution - although I am out of Lysol... and can't bring myself to buy more. I did find the Tea Tree Oil... but I didn't like the way it smelled! I'm not about to spend $6 on a little bottle to help the vinegar smell better - when it doesn't smell nice! Although I figure maybe the odor is strong enough to cut through the vinegar - and it's definitely better than vinegar! I looked at Jojoba oil too, and it smelled nice, but not quite as strong... would it cut through the vinegar? So I didn't buy anything. Ugh. Indecision has slowed me down many a times!

I do buy a few "green" cleaners from the store. The first is Method's fabric softener. It's a bit pricey, but I like it alot and I probably will use less(if any) during the summer. (I've not found a home remedy for this.) But for now, I still need a fabric softener. The other was Method's dishwasher soap. It comes in hard pellets, 1 per cycle. I know there are easy homemade dish washing cleaners out there - but even with traditional cleaners, we eventually get a buildup of residue on the dishes. That's when we breakout the (probably) horrible dishwasher cleaner and run that once or twice. So I'm afraid to use a homemade version that had reviews of residue. I suppose it doesn't hurt to try it though. It is expensive.

That's another topic of discussion soon to follow. Money is getting tight - what is going to get cut back with this new lifestyle?

Saturday, March 12, 2011

Defining Our Priorities + ramble at the end!

Food Priorities.

I think I was fairly vague about our food priorities in the beginning. Not intentionally - but because I'm not sure where the line is on certain Food Issues. But I am discovering our priorities. I will try to identify a few areas in food and eating that I've recognized and define how they apply to our family at this time. This is an evolution in our lifestyle and it's not happening overnight. So bear with me anyone with stricter food morals!

Raw Food = Best Food and Nutrition for Your Body/Health.
Um... I don't know that I disagree with that, but going all raw is too drastic for our family at this time. I've read and heard from several sources that highly recommend this manner of eating (also including freshly made fruit and veggie juices) to improve your health. Fortunately no one has any obvious health issues at the moment - so I'm not planning on changing our diet just yet. Although we have considered adding fruit and veggie juices to our diet - meaning buying our own juicer. Someone in the family does this - so we're planning on having dinner and trying some of their juice - to see if it's something we could do regularly.

Eliminating All Unprocessed Foods
I'm sure even those who attempt to do this allow some wiggle room, even if it's just in eating away from the home. Initially I thought we were striving for this, and we still are. But I'm learning more and more that although I'm finding organic alternatives to some of our eating habits, does not mean I am eliminating processed foods (Ex: Annie's Bunny Crackers). As a family I am striving for this, but it will take some work and time. I am attempting to develop new habits (ex: baking my own bread) but there are some products my family just loves - and I can't recreate them. I'm still trying to improve - I'm looking to make my own ranch dressing and ditching Hidden Valley for good... just need to gather all the ingredient (meaning, find organic buttermilk). Also trying to decide how crucial it is to remove sugar from our diet for good. I'm just comfortable baking with sugar!!

Eating Whole Unprocessed Foods Helps the Environment
I want to help the environment - but let me tell you a little secret about myself... ((I don't believe in global warming!!! Shhhhhh!)) I know - it's crazy! I do care about the environment and want to take care of it but frankly I'm a little more narrow minded at the moment. I can only change what I do and what I do for my family. I will continue to make wise eating choices for my family - and vote with my dollars and my actions. I will attempt to buy locally and organically and not be ignorant of the politics in the food industry. But bottom line, I'm worried about the extended health of my family and keeping as much crud out of our system as possible. And if this benefits the environment too - awesome.

Our Bottom Line
Like I said - my main goal is to keep as much crud out of our system as possible. I believe if we just consume food - and not the additives and hormones and chemicals that might tag along - that my family will lead long healthy lives. To do this, we must consume real food, raw or not, but as close to it's original state as possible. Yet we're a young family of five and I must be practical. As much as I love messing up a clean kitchen, trying something new or just making something from scratch - it can be exhausting and time consuming. I haven't decided if local is better than organic and exactly what veggies need to be organic. I still bake with sugar and I still buy backup (non organic) bread. I don't ever eat Doritos - EVER. And I wouldn't eat canned soup if you served it for dinner(homemade is just too awesome to go back to canned...) Frozen dinners are just gross and so are packaged cookies(although I allow them from time to time!) I'd like to say we're a pop free household - working on it. But I'm proud to say I'm switching over all our cleansers to a less toxic and cheaper alternative. Yes, my paper products are still bleached... sigh... It's such an evolving process!


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Dishing on Downton – Season 4, Episode 2

Whoah. This was a great episode, but I’m sick about Anna. Sick. WHHHHHYYYY?! What did you all think?

  • Jen

    January 14, 2014 at 11:30 pm

    SO upset by this episode. I feel like I now need to see spoilers before watching. This one felt over the top, gratuitous violence AND it’s Anna!!!! Gah

  • J.Mill

    January 15, 2014 at 12:31 pm

    I was super upset about Anna too. I thought that it was well produced, as you girls did, with the juxtaposition between the opera singer and the screams. I have an oddly impressionable memory when it comes to violence against women and that scene will probably never leave me.

    But something that I wondered about was the approach to sexual violence during this episode. I mean, Tom took some whiskey from Edna and told to go to bed. We are lead to believe that she may have taken advantage of him. I think that this, too, is possibly rape. If he can’t say no because he’s intoxicated, that’s still wrong.

    I don’t know if we’re supposed to take away from this that men are an assumed “yes” and women are blamed if they are a victim. Is this indicative of the time period? Of the class-ism? I don’t know. I just noticed the tandem events.

  • GreenInOC

    January 15, 2014 at 8:08 pm

    I got the impression that Mrs. Patmore faked her injury so Alfred could cook and wants to become a chef or something. When they are seated next to each other at the opera performance, they have this exchange:

    Alfred: I hope I didn’t let you down
    Mrs. P: I’m sure you didn’t; Mr. Carson said they gobbled it up like garnets/gannits/giants (like something that starts with a g!)
    Alfred: It’s what I want to do Mrs. Patmore
    Mrs. P: One step at a time…

    The storyline with Anna is distressing but I thought that it was shot beautifully (“shot” as in the way it was filmed, produced, edited, written). The fact that it wasn’t gratuitous nor focused visually but so haunting juxtaposed with the light, glittery, opera upstairs with the haunting, dark and screaming downstairs. It was so much more impactful than if it had been done with the more modern all-visual-all-the-time style of current visual entertainment.

    Of course Joanne Froggatt’s performance in the office with Mrs. Hughes was stunning. She conveyed such deep, desperate, and conflicting emotions in that scene it was incredible.

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Srtm to Nodes

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Data nodes from OpenStreetMap are defined by id, latitude and longitude, which is enough for painting 2D maps. Modern routing algorithms for example can also take advantage of elevation data.

As the elevation is not added to OpenStreetMap data directly, there exist some plugins that make use of Nasa SRTM data to obtain the elevation information. The osmosis-srtm-plugin (hosted at google code) is intended to be used as a plugin for Osmosis to process OSM-input files together with SRTM data in order to add a height tag to each node.


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Kalmykia in Russia.svg
Flag of Kalmykia.svg
Quick Facts
Capital Elista
Government Russian republic
Currency Russian ruble (RUB)
Area 76,100km²
Population 282,021(2014 estimate)
Language Russian, Kamylk
Religion Buddhism 37.6%, Russian Orthodox 18%, Athiest 13%, Non-Religious Spirituality 13%, Other 18.4%
Electricity 220V, 50Hz (European plug)
Time Zone UTC+4
A giant chess set in Kalmykia's capital, Elista

Kalmykia is a republic in Southern Russia and is most certainly the only Tibetan Buddhist "nation" of Europe. 20% of Kalmykia's land belongs to national reserves, parks and hunting plots.

  • Elista — the capital and Kalmykia's only "city"
  • Gorodovikovsk
  • Iki-Burul
  • Komsomolsky
  • Lagan — located near the Caspian Sea.
  • Tsagan Aman — located on the Volga River, Tsagan Aman is a popular fishing area and a fast developing spa-resort
  • Zundi Tolgi

Other destinations[edit]

  • Yashalta Salt Lake — located between Berezovoe and Solenoye villages of Yashalta district, it is known in Kalmykia for its therapeutic values. The administration of Yashalta district and republican authorities are planning to open a balneo-resort on Yashalta Salt Lake. Curiously, Yashalta was founded by Estonian settlers in 1877.
  • Chess-City — an administrative unit within Elista, it often serves as a venue for multiple international chess events. The Chess-City complex also hosts meetings of Russian state officials as well as Russian school olympiads.
  • "Black Lands" Biosphere Reserve — a nature reserve situated on the territory of Chernozemelsky and Yashkulsky districts. It is a refuge for ancient saiga antelopes.
  • Lola Horse Farm — situated not far from Elista in the quiet village of Lola — produces kumys (see Drink). During the Soviet era, this horse farm and adjoining clinic for respiratory treatment was very popular among communist party bosses, who travelled from Moscow, Saint Petersburg and from other far-way places in Soviet Union.
  • The Golden Abode of the Buddha Shakyamuni — a Buddhist Temple finished in 2005, located in the centre of Elista with the biggest statue of Buddha in Europe.
  • Syakyusn-Syume (Хурул «Сякюсн-сюме») — the second largest but oldest khurul in Kalmykia, located 6km north of the capital (closed for visitors most of time).
  • The Ergeni Hills are located in the northern part of Kalmykia. Different from the sandy dunes and steppe regions of central and eastern part, the Ergeni Hills are the only place to find some woods in the republic. Ergeni landscape area is filled with numerous heights, ravines, spring streams, and water-bearing sands. Popular for its mineral medicinal and fresh subsoil waters, the Ergeni Hills are also home to endangered fish species and Kalmyk medicinal plants. In addition, it is the highest point in the republic which rises to 218 metres above the sea level.
  • The Sarpa Lakes — right next to the Ergeni Hills, in the north-central part of Kalmykia freshwater lakes called the Sarpa are dispersed. The Sarpa Lakes include lake of Sarpa 42,6 sq.km, lake Barmanzak 25,8 sq.km, lake Tsagan-Nur 23,5 sq.km, and lake Batur-Mala 21,9 sq.km. Not only it is a picturesque wild scenery of Kalmyk flora and fauna, but also a perfect place for hunting and fishing.
  • Buddhist temples and monasteries , khuruls number is over 30 all over the republic. The smaller sacred memorials or stupa are dedicated to good events.
  • Bamb-TseTsg (Tulip) - National Nature Park. Founded in 1991 it includes over 500 hectares of grass and tulip fields of red (mostly), white, yellow and violet colour.

In ancient times, the region was home to nomadic tribes such as the Khazars, whose empire was broken by Kiev in 965. Later on it was the north-western corner of the mighty Mongol Empire and subsequently the Golden Horde. Kalmykia is a historical crossroads on the Silk Road.

The Western Mongol Kalmyk tribes, also called Oirats, migrated across Central Asia from an ancestral home around Xinjiang, China and southeastern Kazakhstan and eventually arrived in Southern Russia, displacing the Tatars of the Astrakhan Khanate. Originally an independent khanate, Kalmykia's independence was slowly chipped away and it was eventually assimilated into the Russian Empire.

As more than half of Kalmyks are followers of Tibetan Buddhism, the country is often referred to as the only Buddhist country in Europe. Sadly, nearly all of Kalmykia's beautiful khuruls (Kalmyk Buddhist temples) as well as all Christian churches were demolished under Stalin's massive campaign of cultural vandalism. Under German occupation all Jews of Elista were exterminated. Later in 1943 Stalin deported the entire population of Kalmyks to Kazakhstan and Siberia. The inappropriate agriculture along with previous collectivization caused erosion and desertification. Those Kalmyks who survived the brutal deportation and exile were finally allowed to return home in 1957, under Khruschev. But despite these hardships, Kalmykia's khuruls are being rebuilt, and the people remain, and merit a visit.

Present day Kalmykia garnered some press attention for the excesses of its former flamboyant and dictatorial president Ilyumzhinov. Ilyumzhinov, a former Kalmyk statesman in the USSR and president of the World Chess Federation, led Kalmykia since the break up of the Soviet Union, but failed to deliver on rather grandiose promises to turn Kalmykia into a "Caspian Kuwait" in which there would be "a cell phone for every shepherd." He, however, turned Elista into the claimed chess capital of the world by building a small district of Elista known as "City Chess" and by hosting successive chess championships in the capital.

Being one of Europe's poorest and most underdeveloped regions, Kalmykia now has one of the highest birthrates in Russia and growing private food production sector. Livestock raising and processing remains the main economic activity and there is also some fishing and arable farming. Oil-production contributed significantly to the economic revival. The official GDP growth in the republic was 2% in 2010.

Besides Buddhism and Orthodox Christianity believers there are smaller parts of Muslims, Christian Catholics and Protestants.

Although the traditional language of the Kalmyk majority is Kalmyk (western Mongolian), it is mainly older people who speak it natively, while younger people usually speak Russian as their native language. Nowadays just a few villages are mainly Kalmyk-speaking by all generations. Russian is spoken and understood everywhere - although not by some of the very oldest Kalmyks.

Get in[edit]

The Republic of Kalmykia is a part of the Russian Federation. Therefore, when planning your trip to Kalmykia, you should apply for Russian visa.

By plane[edit]

The Elista airport is open for flights from Moscow by RusLine [1] and St. Petersburg by Ural Airlines [2].

By train[edit]

The Moscow-Elista train route goes through Stavropol. However, the most convenient way is travel to Volgograd by train then on to Elista by an express minibus (marshrutka), which are cheap.

By car[edit]

By bus[edit]

Several private companies operate a daily bus service between Moscow and Elista. The pickup points in Moscow are bus station close to subway stations: Orehovo, Teplyi Stan, Krasnogvardeiskaya.

By boat[edit]

Get around[edit]

See[edit][add listing]

In addition to the sights within the present reduced boundaries of the Republic of Kalmykia, worth visiting in Astrakhan oblast is one of the few remaining pre-revolutionary Buddhist Temples (under restoration but disused so far) (Хошеутовский хурул) in the village of Rechnoe on the left (east) bank of the Volga. It was founded in honour of Kalmyks fought against Napoleon and later was visited by novelist Alexander Dumas. To its north is Mount Bogdo (Great), revered by Buddhist Kalmyks, and with many fossils in its rocks. To its south the sacred lotus of the Buddhist Kalmyks can be seen growing in the waters of the Volga delta. These objects are inside the Nature reserve.

In Rostov oblast here are some settlements previously occupied mainly by the newer Buzaf clan of traditionally more russified and christianised Kalmyks who were also Cossacks. They were not allowed to reoccupy this area after their return from deportation.

In Stavropol krai to the south lies the spa resort of Yessentuki (Kalmyk: 'Ten Flags) in the foothills of the Caucasus Mountains, near Europe's highest peak, Mt Elbrus. In the European part of the Republic of Kazakhstan can be found the town of Kalmykovo, looking across the Ural River at Asia.

And if you cross Kazakhstan to its border with China, you can meet the Oirats, living in Dzhungaria, part of Xingjiang province. They are those Kalmyks who did not wish to remain in Kalmykia when it was incorporated into the Russian Empire, so they returned home. All these places occupy a small part of the former Kalmyk Empire that stretched from the Great Wall of China to the River Don in Europe, and from the forests of Siberia in the north to Tibet and the Himalayas in the south.

Do[edit][add listing]

  • The republic's national sport is (by the will of the former President Ilyumzhinov) chess and locals play throughout school. It is relatively easy to join a game in the parks.
  • Fishing, hunting (especially geese, apparently)
  • Attend a performance of traditional Kalmyk dance
  • Horseback riding
  • Tullip-watching lasts from the end of April till the first week of May, when the steppes is being covered with wild red flowers

Buy[edit][add listing]

Eat[edit][add listing]

  • Berk — Kalmyk traditional dumplings are larger and contain more meat than your average meat dumplings
  • Bortsg — Kalmyk traditional frybread
  • Makahan — Kalmyk dry horse meat sausage
  • Makhan sheltagan — Kalmyk traditional soup, contains a lot of meat and potato.
  • Kuyr
  • Dotur - lamb meat and haslet
  • Bortsoki - cookies

Drink[edit][add listing]

Traditional Kalmyk drinks bear some similarity to those found in Mongolia, but are unique to the region. Try:

  • Dzhomba — milk tea with salt (the so called Kalmyk tea served and drank in a certain ceremony)
  • Kumys — a sour horse milk that is considered a cure for respiratory diseases like tuberculosis, asthma, etc.
  • Araka — a milk vodka

Sleep[edit][add listing]

With tourism on the rise, travellers will have no difficulty finding good accommodation in Elista, although accommodations outside of the capital may be scarce or of lesser quality. It may be possible (and extremely rewarding) to arrange homestays in rural areas by asking around town or village centres.

Stay safe[edit]

Stay healthy[edit]

Kalmykia is known for its sunny weather and fresh air. However, visitors are advised not to drink tap water due to the high content of minerals and salt. Otherwise, Kalmykia offers a healthy environment, and delicious and fresh food — mutton and beef being specialties, also Caspian caviar, prized as far away as Moscow and Saint Petersburg.

  • From April till October stay sun-protected.
  • Swimming in the salt lake is prohibited for more than 20 min. because of the possible chemical burn.

This is a usable article. It gives a good overview of the region, its sights, and how to get in, as well as links to the main destinations, whose articles are similarly well developed. An adventurous person could use this article, but please plunge forward and help it grow!


WARC-Truncated: length

text:
Monday, March 17, 2014: A Classical St Patrick’s Day

March 17, 2014

Monday night at 7:00 on the "The Evening Concert" on WILL-FM it’s “A Classical St. Patrick’s Day” from IL Pub Media featuring the music of “Irish Classical Composers”. Vincent Trauth is the producer and host for two hours of “Irish classical music” by composers John Field, Charles Villiers Stanford, and others.

Monday March 17: Special: A Classical St. Patrick’s Day (from IL Public Media by VT)

TRAD. Arr. HARTY: “The Londonderry Air” [Ulster Orch./Thomson]

FIELD: Nocturne No. 5 in B-flat Major [Benjamin Frith, piano]

CHOPIN: Nocturne No. 5 in F-Sharp Major [Arthur Rubinstein, piano]

E.J. MOERAN: In the Mountain Country [Ulster Orch./Falletta]

Sir Hamilton HARTY: “An Irish Symphony” [National Sym. O. of Ireland/O’ Duinn]

TRAD. Arr. S.KANGA: My Love is Like a Red, Red Rose [T.Reilly, harmonica; S.Kanga, hp.]

TRAD. Arr. Overton: Danny Boy [James Galway, flute; London Mozart Players]

W.V. WALLACE: Celtic Fantasies on “Annie Laurie” and “The Last Rose of Summer”. [R. Tuck, p.]

STANFORD: O For A Closer Walk [Cambridge Singers/Rutter/W.Johnson, organ]

FIELD: Piano Concerto No. 3 in E-flat. [John O’Connor, p./ Scottish Chamber Orch./Mackerras]

TRAD. Arr GALWAY: Brian Boru’s March [Galway, flute; Harp Ensemble led by M.Robles]

TRAD. Arr GALWAY: Belfast Hornpipe [Galway, tinwhistle; Kevin Conneff, bodhran]

TRAD. Arr. GALWAY/MALONEY: Crowley’s Reel. [Galway, flute; The Chieftains; Nat. Phil. Orch.]

Classical 24 Music Playlist

WILL Highlights


text:
Health Sciences & Social Work

The WIU IESMA Student Chapter - The Emergency Management Student Organization

This page is the official web site of the Western Illinois University Student Organization - The WIU IESMA Student Chapter.

The WIU IESMA (Illinois Emergency Services Management Association) Student Chapter is the Emergency Management Student Organization for Western Illinois University.

The WIU IESMA Student Chapter holds the distinction of being the first university affiliate of Illinois Emergency Services Management Association (IESMA).  IESMA is Illinois' statewide non-governmental professional association for the emergency management community.

The goals of the WIU IESMA Student Chapter include:

A. To promote student interest in the profession of emergency management

B. To provide additional opportunities for interactions between students and faculty, and to facilitate off-campus networking opportunities

C. To support training and/or educational activities and professional development opportunities outside of the classroom

D. To provide a forum to represent emergency management student's interests within the IESMA organization

E. To provide a forum in which students can provide service to the emergency management profession, community, and university

Membership in the organization is open to all emergency management majors and minors, as well as other Western Illinois University students who are interested in the emergency management profession.

Please revisit this page in the future for more information about the organization's current activities.


text:
Open Access

Symptomatic cardiac metastases of breast cancer 27 years after mastectomy: a case report with literature review - pathophysiology of molecular mechanisms and metastatic pathways, clinical aspects, diagnostic procedures and treatment modalities

  • Darko Katalinic1Email author,
  • Ranka Stern-Padovan2,
  • Irena Ivanac3,
  • Ivan Aleric4,
  • Damir Tentor5,
  • Nora Nikolac6,
  • Fedor Santek1,
  • Antonio Juretic1 and
  • Stjepko Plestina1
World Journal of Surgical Oncology201311:14

DOI: 10.1186/1477-7819-11-14

Received: 1 August 2012

Accepted: 13 January 2013

Published: 23 January 2013

Metastases to the heart and pericardium are rare but more common than primary cardiac tumours and are generally associated with a rather poor prognosis. Most cases are clinically silent and are undiagnosed in vivo until the autopsy. We present a female patient with a 27-year-old history of an operated primary breast cancer who was presented with dyspnoea, paroxysmal nocturnal dyspnoea and orthopnoea. The clinical signs and symptoms aroused suspicion of congestive heart failure. However, the cardiac metastases were detected during a routine cardiologic evaluation and confirmed with computed tomography imaging. Additionally, this paper outlines the pathophysiology of molecular and clinical mechanisms involved in the metastatic spreading, clinical presentation, diagnostic procedures and treatment of heart metastases. The present case demonstrates that a complete surgical resection and systemic chemotherapy may result in a favourable outcome for many years. However, a lifelong medical follow-up, with the purpose of a detection of metastases, is highly recommended. We strongly call the attention of clinicians to the fact that during the follow-up of all cancer patients, such heart failure may be a harbinger of the secondary heart involvement.

Heart metastases Breast cancer Pathophysiology Symptoms Treatment

Metastases to the heart assume greater diagnostic and therapeutic importance as the incidence of different cancer types rises. The condition was first described by Theophy Boneti in 1700 [1]. Primary tumours of the heart are rare, occurring at a frequency of <0.02% in different autopsy series [2]. However, secondary or metastatic tumours of the heart are more common than primary tumours [3] and patients may present with various cardiac symptoms. Common primary tumours to metastasise to the heart are mediastinal tumours, lung cancer, melanoma, breast cancer and esophageal cancer [4]. Intracavitary growth of secondary heart tumours, however, is quite unusual. Therefore, despite their frequency, metastases to the heart rarely gain clinical attention. The signs of cardiac involvement are often overlooked, since the symptoms of a metastatic disease prevail. We present a case of breast cancer with symptomatic heart metastases and heart chambers involvement 27 years after mastectomy and discuss the pathophysiology of molecular mechanisms of cardiac metastases, metastatic pathways, clinical manifestations, diagnostic procedures and treatment.

Case presentation

The patient’s past medical history was significant for a right-sided total mastectomy for carcinoma in 1984 (PHD: Adenocarcinoma of the breast) (Figure 1A and 1B). The patient was staged as T2N0M0. At that time, she had no radiation or chemotherapy. All lymph nodes were negative. In 1992, the patient was diagnosed with lung metastases and treated with CMF regimen (cyclophosphamide, methotrexate and fluorouracil), with a partial tumour regression. In 1995, she underwent the ablation of solitary metastasis in the left lung lobe (PHD: Metastatic adenocarcinoma of the breast). In 1999, a complete clinical re-evaluation was made since the hymoptysis and a solitary metastatic tumour in the distal left lung were diagnosed. She underwent a left-sided pulmectomy and mediastinal lymphadenectomy (PHD: Metastatic adenocarcinoma of the breast) with good clinical outcome and the disease was stabile for the following 6 years. In 2005, at regular oncologic follow-up, the patient was diagnosed with a tumour formation under the left scapula which was surgically removed (PHD: Metastatic adenocarcinoma of the breast, ER+, HER-2/neu +++) (Figure 1C and 1D). After that, she was treated with anastrosol and trastuzumab with regular medical follow-up and she felt quite well.
Figure 1

Histopathological evaluation. Hematoxylin and eosin (HE) histologic analysis revealed a highly cellular malignant tumour with solid clusters of atypical, polymorphic epithelial cells (image A, high-power photomicrograph, original magnification, ×400; HE stain). The tumour was partially necrotic (image B, low-power photomicrograph, original magnification, ×100; HE stain). Immunohistochemical study shows that the tumour cells stained positive for estrogene receptors (ER) (image C, low-power photomicrograph, original magnification, ×200) and HER-2/neu receptors (image D, low-power photomicrograph, original magnification, ×200) consistent with diagnosis of breast adenocarcinoma.

In 2011, 27 years after mastectomy, a 64-year-old white woman was admitted to our hospital with a 2-week history of shortness of breath, dyspnoea, paroxysmal nocturnal dyspnoea and orthopnoea without chest pain. The clinical presentation aroused suspicion of a congestive heart failure. The Karnofsky’s index of performance status (KPS) was 20% and the Eastern Cooperative Oncology Group Performance Status Scale (ECOG PS) was grade 4. On admission, the patient was afebrile and in a moderate degree of respiratory distress. There was no clinical or laboratory evidence for any kind of inflammation or pulmonary embolism. Her pulse was 140 beats per minute and regular, and her blood pressure was 130/90 mmHg. The heart sounds were distant and faint, there were no heart murmurs. Chest radiography revealed an increase in cardiac silhouette and the lung congestion. The electrocardiogram showed sinus tachycardia and low voltage without other abnormalities. All cardiac enzymes were negative. However, the high values of carbohydrate antigen 15–3 (Ca 15–3) (335.2 kIU/L, normal rate <25) and carcinoembryonic antigen (CEA) (380.8 μg/L, normal rate <3.4) suggested clinical relapse. Two-dimensional transthoracic echocardiography (2D-TTE) revealed cardiac involvement with metastatic tumour mass (Figure 2). A contrast-enhanced multislice computed tomography (MSCT) of the chest confirmed and demonstrated a large metastatic mass that involves predominantly the pericardium and the left ventricle with the extension into the left atrium (Figure 3A-3E). The patient was treated with corticosteroids, amynophilline, digitalis, beta-adrenergic antagonists, analgetics, low-molecular-weight heparin and oxygenation. The palliative radiation therapy was initiated, but because of patient’s severe general condition, a total dose of only 6 Gy/day was delivered as a palliative thoracic radiotherapy. Unfortunately, soon after hospital admission, the patient died. The immediate cause of death was cardiorespiratory arrest due to massive involvement of the heart by metastatic malignancy.
Figure 2

Echocardiographic evaluation. Four-chamber 2-dimensional transthoracic echocardiogram shows a large, irregular metastatic mass (2.3×1.1 cm), which infiltrated pericardium and myocardium (predominantly anteroapical and lateral walls of the left ventricle) with intracavitary propagation (arrows).
Figure 3

Radiological evaluation. Contrast-enhanced axial (Figures 3A-3C), coronal (Figure 3D) and sagittal (Figure 3E) multislice computed tomography scan of the chest revealed massive, predominantly necrotic metastatic tumour mass (13×10 cm in size on axial view) with pericardial and heart involvement (arrows). The tumour was partially necrotic and infiltrated the thoracic aorta and the pulmonary trunk with extension into the left atrium.

Malignant tumours metastasizing to the heart are one of the least investigated topics in clinical and experimental oncology. In the past, the low incidence of cancer to the heart has been explained on the theory that the heart was not receptive to tumour cells. Prichard mentioned the kneading action and metabolic peculiarity of the heart muscle, and the rapid blood flow as factors accounting for the low incidence [5]. Other authors considered that the low incidence was more likely the result of inadequate observation. Until the 1960s, primary and especially secondary cardiac tumours were merely a curiosity and the diagnosis was academic. Generally, they have devastating consequences given that they involve such an important organ and present in very subtle ways causing a subsequent delay in clinical diagnosis. In the past two decades, imaging has improved detection, with 2D-TTE, 2-dimensional transesophageal echocardiography (2D-TEE), computed tomography (CT) and magnetic resonance imaging (MRI) being the mainstay of clinical evaluation [6]. Because of its easy availability, 2D-TTE, 2D-TEE and radiology procedures such as CT or MRI are complementary techniques, and are all used in the evaluation of cardiac deposits. With the gradual improvement in surgery, chemotherapy, radiotherapy, biotherapy and molecular targeted therapy, life-threatening sites of metastases are more commonly receiving intensive local therapy for palliation. Such tumours are frequently highly responsive to radiotherapy or chemotherapy, and premortem diagnosis may be critical in the clinical management. Although no malignant tumours are known which diffuse preferentially to the heart, some do involve the heart more often than others, for instance lung cancer, breast and esophageal cancer, lymphoproliferative malignancies, as well as melanoma [5, 712]. Metastasis is cancer’s most deadly aspect and it is affected by several interconnected processes. Therefore, tumour’s ability to spread to the heart tissue depends on many different factors, not only the molecular, biological and pathophysiological characteristics of the primary tumour, but also the specific structural and functional characteristics of the heart [5].

Pathophysiology of cardiac metastases, metastatic pathways and cascades: from molecular to clinical aspects

Although primary cardiac tumours are extremely rare (different postmortem studies reported rates between 0.001% and 0.28%), secondary tumours are not, and the heart can be metastasised by any sort of malignancy [13, 14]. Only tumours of the central nervous system have not been proven to develop heart metastases. The exact incidence of cardiac metastases is unknown. Indeed, secondary deposits are considered rare, but when sought for, the incidence seems to be not as low as expected [15] and they exist usually in the setting of a widely disseminated disease [12]. Reflecting the age distribution, heart metastases predominantly occur in patients between the sixth and eighth decades of life and there is no gender preference. They were found in 1.23% of 12,485 consecutive autopsies, compared with a 0.056% prevalence of primary cardiac tumours [12]. In autopsies at which a malignant neoplasm was diagnosed, cardiac metastases were found in 9.7% to 10.7% of cases [4, 16, 17]. According to Bussani et al., the highest rates of heart metastasis were found in patients diagnosed with pleural mesothelioma (48.4%), melanoma (27.8%), lung cancer (21%) and breast cancer (15.5%). High rates have also been found in patients with ovarian cancer (10.3%) and lymphoproliferative malignancies (9.4%). About two-thirds of all heart metastases involved the pericardium and only one-third the epicardium or the myocardium [18]. Some tumours colonize a wide variety of organs and the first site encountered will be the most common site of metastatic formation. Others are more selective, they bypass some organs and selectively colonize specific distal tissues. Interestingly, for reasons which are not clear, melanoma has a particular predilection for metastasising to the heart and brain and a half of all cases of disseminated melanoma patients will have cardiac deposits at necropsy [19]. However, breast cancer primarily metastasizes to the bone, lungs, regional lymph nodes, liver and brain, with the most common site being the bone.

In 1889, Stephen Paget noticed that metastases in breast cancer were not random. He postulated ‘seed and soil’ hypothesis claiming that a metastatic cells arose from the proliferation of a few tumour cells (the seeds) in the favourable tissue environment provided by certain organs (the soil) [20]. According to the ‘seed and soil’ theory, it is difficult for cancer cells to survive outside their region of origin, so in order to metastasize they must find a location with similar characteristics [20]. For instance, melanoma spreads to the brain, presumably because neural tissue and melanocytes arise from the same cell line in the embryo. A few decades later, in 1928, opposite to Pageth’s opinion, James Ewing challenged the ‘seed and soil’ theory and proposed that metastasis occurs purely by anatomic and mechanical routes [21]. Today, it is widely known that both Paget and Ewing were right and that the two theories are not mutually exclusive. Additionally, organ-specific anatomic considerations also influence the metastatic process. These include blood-flow patterns from the primary tumour and the homing ability of cancer cells to certain tissues and organs. Typical environmental barriers in a metastatic event include physical (a basement membrane - BM), chemical (low pH, reactive oxygen species, hypoxia, and so on) and biological (immune surveillance, inhibitory cytokines and regulatory extra-cellular matrix peptides) components [22]. During tumour invasion, malignant cells penetrate a variety of extracellular matrices (ECM), including BMs and interstitial stroma through multiple steps in the metastatic cascade. To be completely successful, a tumour cell must invade and degrade connective host tissue (invasion of the primary tumour border - BM and the tissue surrounding the tumour by the cell) and subsequently intravasate (the bloodstream or lymph channels), survive the transit into the new environment, arrest in distant vascular bed, extravasate to a distant site (the tumour cell than invades into the BM of the targeted tissue interstitium), initiate a micrometastasis and proliferate to metastatic colony [21, 22]. The initial part of this cascade also known as ‘epithelial to mesenchymal transition’ (EMT) was first conceived by Krug et al. in 1987 and described by Hay in 1995 [23, 24]. It is defined as the switch from non-motile, polarized epithelial cells to motile, non-polarized mesenchymal cells, with the potential to migrate from primary tumour sites to distant tissues and organs, where they can proliferate [2325]. There are several EMT components, and the most important are E-cadherin, N-cadherin, and transforming growth factor-β (TGF-β) [26]. A ringleader of EMT is a process named the ‘cadherin switch’, defined by a decrease in E-cadherin, the component of adherent junctions, and a simultaneous increase of mesenchymal N-cadherin. This switch allows cells to lose adhesive affinity for other surrounding cells and become more migratory and invasive [2629]. Another most potent inducer of EMT is the TGF-β, a known pluripotent growth factor, able to induce EMT in mammary and other cell types [26, 30, 31]. As we know, the process of metastatic spreading is a complex series of different steps. Malignant cells break away from the primary tumour and degrade proteins that make up the surrounding ECM, which separates the tumour from adjoining tissue. Cell-ECM adhesion, motility, and localised proteolysis are mediated mainly by matrix metalloproteases (MMPs). The tumour cell develops structures called invadopodia, which are highly concentrated in several MMPs [32, 33]. Therefore, the degradation of ECM is facilitated by MMPs, and tumour cells can move across tissues into nearby stroma. ECM-tumour cell interactions play a critical role in each of the events of the metastatic cascade. Interactions of the breast cancer cells with integrins, fibronectin, tenascin C, laminins, collagens, endoglin, hyaluronan, heparanase and proteoglycans can contribute to the metastatic process. The ECM protein Tenascin C (TNC) is an adhesion-modulating extracellular matrix glycoprotein and it is upregulated in metastatic breast cancer. TNC is highly expressed in tumour stroma and stimulates tumour-cell proliferation. Endoglin is a cell-surface disulfide-linked homodimeric glycoprotein which binds to integrins and is a co-receptor for TGF-β. For instance, brain and heart-metastatic breast-tumour cells also express endoglin in large amounts [34, 35]. Heparanase expressed by breast cancer cells participates in angiogenesis and neovascularisation by degrading the polysaccharide scaffold of the endothelial BM, thereby releasing angiogenic growth factors from the ECM [36]. There are also several different cell types critical for tumour growth. Gao et al. and Nolan et al. demonstrated that endothelial progenitor cells are critical for metastasis and angiogenesis [37, 38]. Furthermore, the ablation of endothelial progenitor cells in the bone marrow leads to a significant decrease in tumour growth and vasculature development [39]. Metastatic spreading is also mediated by numerous growth factors and cytokines, operating through different cell signalling pathways. To initiate transcriptional responses, these signalling molecules must enter the nucleus through the nuclear pore complex (NPC). The NPCs are made of proteins named nucleoporins (Nups) and there are several Nups that are often abnormal in cancer patients. Some of them are Ribonucleic acid exports 1 (Rae1) linked to breast cancer pathophysiology [40] and Nup88 which is overexpressed in ovarian cancer [41] as well as in a broad spectrum of sarcomas, lymphomas and mesotheliomas [42, 43]. The transport of different cytokines, transcription factors (HER2, TGF-β, galectin-3, NF-κB and other), or metastasis activators across the nuclear envelope commonly requires transporters (karyopherins) that bring them to the nuclear pore. Finally, these molecules are translocated into the nucleus, where they can bind to target genes to initiate transcription and consequently cell migration and proliferation. For the metastasis to occur, all steps in the metastatic cascade must take place. Therefore, the blockade of any single step in the metastatic pathway should slow down metastasis progression [44].

Heart metastases are usually small and multiple; infrequently, single large tumour lesions are also observed. Clinically, they occur by four main routes: transcoelomic, lymphatic, haematogenous and thru implantation. Metastases may reach the heart via the hematogenous or lymphatic route, or by direct or transvenous extension. Lymphatic spread is most important and tends to give rise to pericardial metastases, while hematogenous spread preferentially gives rise to myocardial metastases. Tumours such as the breast cancer, which develop near the heart, may expand by direct extension into the heart tissue, but these tumours predominantly attain to the heart by the lymphatics. Via mediastinal lymph nodes, tumour cells intially invade the epicardial, and then the myocardial lymphatic system [45]. As in our case, secondary heart tumours that have partial or total intracavitary growth are rare; when they do occur, they are often accompanied by thrombosis [4651].

The structure of the lymphatic system in the heart might explain the low incidence of secondary deposits in the heart compared with other tissues and organs [18]. As a particularity of lymphatics in the heart, the flow in the capillaries is high, determined by the effects of heart pressure. If lymphatics are obstructed by tumour cells, lymph will stagnate in the myocardial regions upstream of the obstruction, and endocardial to epicardial drainage by the lymphatics will be inhibited. This in turn leads to tissue damage due to lymph stasis, and favours an increased proliferation of neoplastic cells in undrained regions and retrograde lymph flow, which might disseminate malignant cells to the more internal parts. As a result of increased pressure, the lymphatic wall may also break, leading to interstitial tumour spread. The blockade of the common lymphatic node by neoplastic cells coming from metastasised mediastinum lymph nodes is a key event leading to the formation of metastases. The penetration into the myocardium is favoured by the stasis of the lymph flow, and most importantly by the damage to the epicardial plexus caused by the stasis in part, but also by the direct effect of the tumor cells [18, 52].

Interestingly, metastatic cell does not disseminate necessarily from the primary tumour. The first step in this process is metastasis to a ‘generalizing site’ such as lungs, liver, and so on (primary level of dissemination). This key disseminating site is the first filter encountered by blood-borne or lymph-borne metastases once they are released from the affected lymph nodes. For a given primary tumour, more than one such key metastatic site may exist. Dissemination of malignant cells then proceeds via secondary metastases from the generalising sites (secondary level of dissemination) [53].

Finally, more recent molecular studies have shown that some forms of malignant tumours, including breast cancer, arise from a small subset of cancer stem cells (CSCs), which are often marked by the cell surface antigens CD133, CD144 and CD24. These cells induce tumour formation and are often resistant to conventional anticancer treatments. The CSCs expresses specific repertoire of surface markers, which allows their differential purification, selectively endowed of tumorigenic capacity as opposed to all other subsets. They sustain the growth of heterogeneous cancer tissues, which recreate the full repertoire of tumour cell populations observed in the primary tumour, and most importantly, they display the main functional hallmarks: self-renewal and differentiation. However, the role of CSCs in multistage cancer progression, particularly with respect to metastasis, has not been well-defined and it has remained partially understood [5457]. Obviously, better understanding of CSCs as a fundamental component of the metastatic cascade may lead to novel therapeutic strategies [58].

Clinical manifestations and diagnostic procedures

There is no strong correlation between the extent of cardiac metastases and clinical symptomatology. Some tumours, even with extensive spreading to the heart, produce no symptoms and become evident by incidental findings. Usually, heart involvement is not noticed until after death. In some retrospective studies, only about 10% of patients who died of metastatic disease presented with symptoms or signs related with heart failure [9, 59]. The symptomatology and clinical presentation vary, depending more on location than on size and can be classified as extracardiac (constitutional and mechanical), cardiac (pericardial, myocardial and intracavitary) or combined. Constitutional symptoms of pyrexia, arthralgias, rash and so on are mostly caused as a result of cytokine release. Mechanical symptoms (dyspnea, orthopnoea and chest discomfort) result from compression of cardiac chambers or coronary arteries or from pericardial irritation or tamponade caused by growth or effusion/haemorrhage within the pericardium. Myocardial symptoms are caused by arrhythmias due to compression or encroachment on the conduction system. Intracavitary symptoms are caused due to secondary deposits that obstruct valvular function, blood flow or combined, or to tumours that cause tumour fragments to embolize into the systemic circulation or the lungs [18, 51]. Intracavitary symptoms may also vary with body position, which can alter haemodynamics. Most patients show symptoms of congestive heart failure, superior vena caval obstruction or embolization [60]. According to the anatomic location of the tumour, some special symptoms and physical findings can be grouped together with regard to pericardial, myocardial and endocardial/heart chamber involvement [6171].

Pericardial involvement may occur alone or may be associated with metastases elsewhere in the heart. Intrathoracic growths, usually carcinoma of the breast and lungs, may extend directly into the pericardium where the tumour may further invade other parts of the heart. The most feared complications are neoplastic pericardial effusions which can be serous, serosanguineous or bloody, and may lack haemodynamic compromise. They may be mild (and result in no symptoms; in cases of a slow increase in pericardial fluid, the pericardium may stretch and the pericardial effusion can remain asymptomatic for some time) but they are commonly symptomatic and often the first manifestation of a heart metastasis [61]. In all cases of a rapid increase in pericardial fluid, cardiac tamponade can result and necessitate immediate pericardiocentesis [4, 8]. Slater et al. even reported a case of constrictive pericarditis from metastatic breast cancer to the pericardium [62]. Hypotension, dyspnea, venous congestion, peripheral cyanosis, pulsus paradoxus and fall in QRS voltage are all hallmarks of diagnosis. Chest X-ray may reveal an increase in cardiac silhouette. The electrocardiogram (ECG) may be helpful in demonstrating pericarditis, but as Lamberta et al. concluded: ‘The electrocardiographic changes illustrative of pericarditis are minimal in subjects with malignancies of the pericardium unless there is suifficient involvement’ [63]. Tumour-induced pericardial effusion and pericardial masses can be best viewed by means of 2D-TTE and 2D-TEE imaging, CT scan, high resolution CT and MRI. Moreover, the pericardiocentesis specimen can be submitted to cytological analysis to typify the tumour cells and help identify the primary tumour origin.

Myocardial involvement may occur from encroachment on the pericardium, or conduction system by secondary deposits. Tumour tissue in the myocardial mass is usually asymptomatic and does not produce any characteristic ECG signs, but there are many exceptions. Generally, the clinical pattern is proportional to the degree of myocardial infiltration, or related to the wall infiltration site. Whenever the right heart is involved, the interventricular septum is likely to share in the process, and the conduction system may be compromised. Arrhythmias may occur, however, without septal invasion, and they are important for ante mortem diagnosis. Different ECG changes are extremely common in cardiac metastasis and ECG has been of some help [64, 65]. Typical presentation includes atrial flutter or fibrillation, premature beats and paroxismal supraventricular and ventricular arrhythmias (commonly tachycardias) conduction disturbances and atrioventricular blocks [64]. Tumour emboli occasionally plug a vessel and produce coronary insufficiency, symptoms of angina pectoris or myocardial infarction [3]. Association between tumour infiltration of the heart and cardiac rupture has been reported only in isolated cases. Metastases to the heart may affect the muscle sufficiently to produce congestive heart failure. Scott and Garvin concluded that the development of congestive failure without apparent cause in patients with malignant disease raises the possibility of cardiac metastases. [8]. Ceardic metastases may also cause T-wave changes, S-T deviations and Q waves [9]. Displacement of the RS-T segment, inverted T waves and isoelectric S-T segments in all leads may also be found [66, 67].

Heart chambers involvement is uncommon and the symptoms of venous and intracardiac involvement are often minimal in relation to the extensive involvement seen. Tumour emboli reaching the chambers may implant on the endocardium directly causing valvular stenosis, valvular insufficiency or heart failure. Murmurs typical of stenosis may be caused by metastatic deposits and may change with position. Syncope and sudden death have also been reported [47, 68]. Furthermore, intracavitary right-sided heart metastases can lead to pulmonary embolism, and left-sided heart metastases to systemic embolism [50,69,]. Most of the endocardial growths cause little disability and, like most metastatic deposits of the heart, are usually unexpected and incidental necropsy findings. Endocardial metastases may also mimic bacterial endocarditis which is relevant for differential diagnosis. Tumour cells that infiltrate the lumen of a great vein may initiate the deposition of fibrin upon them. The fibrin, in turn, serves as a framework for continued tumour growth. The thrombosis may also extend along the vein to the heart chambers, hindering blood flow and effective heart function. The left atrium may be invaded from the extension of tumour thrombosis of the pulmonary veins. 2D-TTE and 2D-TEE with CT or MRI are valuable in delineating the presence or absence of intracardiac tumour masses [6, 50, 69]. Nuclear medicine techniques previously employed to detect secondary heart deposits include blood pool imaging and gallium or thallium scintigraphy [70]. Positron-emission tomography computed tomography (18F] FDG-PET/CT) has already been proven be more accurate than CT in the evaluation of metastatic heart tumours, especially in the follow-up of patients previously treated with chemotherapy and/or radiotherapy [71]. 18F]FDG-PET/CT, positron-emission tomography MRI (PET-MRI) and 3-dimensional echocardiography may have the advantage of detecting the metastases in comparison with other conventional imaging modalities [7173].

The pathophysiological and clinical aspects of cardiac metastases are intriguing, but, whatever the treatment, their clinical evolution is usually disappointing. In many cases, secondary deposits manifest in patients with advanced cancer disease, with the heart being involved in the generalised cancer spread. Most patients will already have undergone surgical treatment for the primary tumour, or chemotherapy and/or radiation therapy. The treatment of heart metastases depends on tumour origin and patient’s general condition (correlation with Karnofsky and ECOG performance scores), and may include different systemic chemotherapy or palliation [51]. However, the treatment is usually palliative because the prognosis is poor, but radiation therapy can successfully palliate cardiac metastases while preserving quality of life. In the specific cases where secondary cardiac involvement leads to the initial diagnosis of primary tumour, or is the first evidence of metastatic recurrence, aggressive management may result in long-term survival [18, 74]. Surgery would be only considered in patients whose primary tumour is under control and who have a significant disease-free interval. Surgery is also indicated in exceptional cases of solitary intracavitary growth, leading to obliteration of heart chambers or valve obstruction, and the patient appears to have a good prognosis [75]. However, in both cases, the postoperative mortality is significant [76, 77]. This poor prognosis points to the importance of selecting an appropriate mode of therapy, taking into consideration each patient individually [78].

Progress in cancer biology has expanded our understanding of the molecular and cellular mechanisms of cancer development, metastatic spreading to the heart and other tissues, as well as resistance of cancer cells to chemotherapy and radiotherapy. This manuscript has reviewed some of the key pathways that have been shown to play an important role in the process of breast cancer spreading to the heart and different diagnostic and treatment modalities. However, breast cancer and other malignant tumours, as a result of their genomic instability, have tremendous redundancy in their ability to maintain growth and to spread into surrounding tissues and distant organs. As such, this remarkable level of complexity makes successful treatment of breast cancer metastases all the more challenging. According to some reports, an average survival period after the diagnosis of cardiac metastases has been approximately 5.5 months [77]. Obviously, it is very important to know that in cancer patients with symptoms of heart failure, metastatic cardiac deposits must always be considered in the differential diagnosis, even in the subjects with a distant positive medical history. Clinicians should be alert to the possibility of cardiac metastasis in a patient with and even without clinical symptoms. 2D-TTE and 2D-TEE, which are easy, fast and sensitive techniques for detection of cardiac metastasis, and CT, MRI, 18F]FDG-PET/CT and PET-MRI as confirming methods should always be performed when any suspicion exists in order to exclude cardiac involvement during clinical follow-up [65, 67, 7173, 77]. This case also demonstrates that complete mastectomy and other oncological and surgical procedures may result in a favourable outcome for many years, but regular medical lifelong follow-up is mandatory.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

18F-fluorodeoxyglucose-positron-emission-tomography-computed tomography

Two-dimensional transesophageal echocardiography

Two-dimensional transthoracic echocardiography

Basement membrane

Ca 15–3:

Carbohydrate antigen 15–3

Carcinoembryonic antigen

Cluster of differentiation 133

Cluster of differentiation 144

Cluster of differentiation 24

Cyclophosphamide, methotrexate and fluorouracil

Cancer steam cells

Computed tomography

Extracellular matrices

Eastern cooperative cncology group performance status scale

Epithelial to mesenchymal transition

Estrogen receptor

Human epidermal growth factor receptor 2

Karnofsky’s index of performance status

Multislice computed tomography

Matrix metalloproteases

Magnetic resonance imaging

Nuclear factor kappa-light-chain-enhancer of activated B cells

Nuclear pore complex

Nucleoporin 88

Positron-emission tomography-magnetic resonance imaging

Pathohistological diagnosis

Ribonucleic acid export 1

Transforming growth factor-β

Tenascin C.

We wish to express our sincere gratitude to Dr. Kristijan Nikolic, Ph.D. for dedicated technical suggestions and artistic guidance in preparation of this manuscript.

Authors’ Affiliations

Department of Oncology, University Hospital Centre (KBC Zagreb), University of Zagreb School of Medicine
Department of Diagnostic and Interventional Radiology, University Hospital Centre (KBC Zagreb), University of Zagreb School of Medicine
Department of Cardiovascular Diseases, University Hospital Centre (KBC Zagreb), University of Zagreb School of Medicine
Department of Pulmonary Medicine, University Hospital Centre (KBC Zagreb), University of Zagreb School of Medicine
Department of Pathology and Cytology, University Hospital Centre (KBC Zagreb), University of Zagreb School of Medicine
Department of Clinical Chemistry, University Hospital Centre “Sisters of Charity”, University of Zagreb School of Medicine

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© Katalinic et al.; licensee BioMed Central Ltd. 2013

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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Current Sports #125 | November 25, 2013

Nov 25, 2013

The Michigan State men's soccer team advanced to the Sweet 16 on Sunday with a win over Louisville. Kevin Cope, a defenseman for the Spartan's, drops by the studio to discuss the game and their next game against Georgetown. Al and the crew will also talk Michigan State and Detroit Lions football.

Andrew Herr
Credit Matthew Michell


text:
Campbell knocked out of Districts

Campbell is knocked out the Division III District tournament, with a 46-43 loss to Canton Central Catholic.

The Red Devils were the #1 seed in the tournament, while the Crusaders were the #4 seed.

Campbell was led in scoring by Michael Williams.  He netted 13 points in the defeat, while Daron Clinkscale added 12.

Campbell finishes its season with a 15-8 record.

WKBN 27 First News provides commenting to allow for constructive discussion on the stories we cover. In order to comment here, you acknowledge you have read and agreed to our Terms of Service. Commenters who violate these terms, including use of vulgar language or racial slurs, will be banned. No links will be permitted. Please be respectful of the opinions of others. If you see an inappropriate comment, please flag it for our moderators to review.

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Two Truck Crashes in Two Days

This is an archived article and the information in the article may be outdated. Please look at the time stamp on the story to see when it was last updated.

STROUDSBURG -- For hours, the ramp for the Route 209 exit (304) off Interstate 80 West was closed as crews worked to clear an overturned tractor trailer.

The rig was carrying dry goods.

State police are investigating why it overturned.

It was the second major traffic tie-up in two days in the Stroudsburg area because of big rig crashes.

"I know they keep slowing the speeds, but no one slows down. They even have these big circles, you know, to keep distance, but it doesn't seem to help," said Carol Villoresi of Henryville.

On Tuesday, state police said a tractor-trailer driver lost control on Interstate 80, flipping on a concrete median, sliding and smashing into another tractor-trailer and another vehicle.

State police said the driver will be cited for speeding.

People who live in the Stroudsburg area said problems on the interstate mean bumper to bumper traffic where they live.

"As soon as there is an accident on either direction here, everybody gets pushed off here and you can't even move. You can't move in this town," said Fran Surma of Stroud Township.

Perry Surma is a truck driver and said tractor-trailer drivers get unfairly blamed for causing most of the wrecks on the highway in this area.

"When it comes to trucks, they are a whole different ball game," said Surma.

No one was injured in either crash.


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Contact Us

Chris Christie’s Popularity Versus Any Democrat [AUDIO]

Governor Chris Christie’s popularity in the aftermath of super-storm Sandy is off the charts and that’s got to be daunting for any Democrat thinking about challenging him next year.

Governor Chris Christie
Governor’s Office

Fairleigh Dickinson University political science professor Peter Woolley says through-the-roof poll numbers aren’t the only thing Christie has going for him.

Woolley says for a Democrat mulling the idea of tossing their hat into the ring, “It’s a tough time to make the announcement because all of the attention is focused on Christie. All of the attention is focused on his storm surge in the polls. It’s not a good time to announce although somebody’s got to get in the race.”

Woolley thinks any Democratic candidate knows Christie’s poll numbers will come back down to earth. The Governor acknowledged that last week too when he joked that he told his staffers to cut out the poll numbers and tape them to a wall so they can remember what a great poll looks like. Still, for Democrats the numbers are what they are right now.

“The challenge for Democrats is going to come as much from other Democrats as it will come from Christie because there are going to be a number of Democrats in the race and they’re going to be vying for the same campaign support and money that the other Democrats are vying for,” explains Woolley. “Christie’s in the catbird seat partly because his numbers are good, but also because he’s going to have nobody to compete with when he’s raising money. The Democrats are going to go hat-in-hand to a lot of the same people.”

In the latest statewide poll released yesterday, Christie gets a 67% approve to 21% disapprove job rating among all Garden State residents. With the all-important registered voters, his rating stands at 69% approve to 22% disapprove. In September, his job approval rating was in the mid-50s for both groups.

The 85% of Republicans who give the Governor a “thumbs up” are joined by 68% of independents and 57% of Democrats. Before to this survey, Christie had never broken the 40%-mark among Garden State Democrats. The no evidence of a gender gap which was apparent in past polls – 68% of men and 66% of women approve of the governor’s job performance. Christie also gets positive ratings from a majority (52%) of public worker households – the first time this has happened during his tenure.

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