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014 Ketamine

Special K: Is Ketamine Really All That?

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Clinical use first reported in human medicine in 1965; approved for clinical use in 1970
First identified veterinary report: Glen JB. The use of ketamine (CI-581) in feline anaesthetic practice. Vet Rec 1973.

Unravelling story with respect to evidence-based medicine – in people and especially veterinary species. Less so regarding use in anaesthesia, more so regarding sedation and especially analgesia.

 “Ketamine may be the subject of misuse and, therefore, should be stored in the controlled drugs cabinet and its use recorded in an informal register.” (RCVS website, March 2015)

1. How does ketamine work? What does it do?

N-methyl-D-aspartate (NMDA) receptor antagonist:

  • Most widely reported and acknowledged mechanism; thought to be responsible for most clinical effects
  • But “nightmare of the pharmacologist” as myriad other proven/suggested mechanisms and receptors may be involved

2. Ketamine causes a continuum of central nervous system effects:

Dose-dependent CNS effects…with increasing doses: analgesia – sedation – partial dissociation – complete dissociation
Once complete dissociation reached, additional doses prolong duration of action without additional dissociation

Overlap between dose ranges for clinical effects; also depends on individual patient.

Low/sub-dissociative dose use for analgesia has gained increasing recognition and popularity in last 10 years or so
Analgesic uses include acute emergency pain but also perioperative pain management
Typically as infusion after initial loading dose for analgesia but intermittent bolus therapy also feasible
Analgesic effects both supra-spinal (brain) and spinal
Likely to have both more classically reported anti-sensitisation (“wind up”) CNS effects and direct analgesia

3. Is ketamine contraindicated with raised intracranial pressure?

Long-standing contraindication in veterinary references – seems to have been extrapolated from human references.
Long-standing contraindication in human references – based on small number of poor quality studies from 1970s.

Active on-going clinical research in humans with raised ICP of different causes (e.g. trauma vs. mass lesion vs. hydrocephalus) to test traditional contraindication
Increasing consensus at this time refuting this contraindication and supporting positive risk-benefit profile for ketamine use in general population of acute emergency human patients with suspected/proven raised ICP

Original contraindication reported in veterinary resources extrapolated from human medicine with no species-specific evidence. At this time it seems reasonable and legitimate to discard this ‘myth’ while keeping future evidence under review.

4. Ketamine is sympathomimetic:

Stimulates sympathetic nervous system (by preventing catecholamine reuptake and/or increasing secretion – seems unclear)
May therefore help to support patients with cardiovascular instability and existing sympathetic nervous system-driven compensation
If sympathetic response is blunted/exhausted, ketamine may depress cardiovascular system

5. What about ketamine in cats with hypertrophic cardiomyopathy (HCM)?

Meant to be relatively contraindicated in cats with HCM; sympathomimetic effect may cause a cat with sub-clinical cardiomyopathy to decompensate – especially if obstructive component to HCM.
Relative not absolute contraindication – risk-benefit profile as always
Undoubtedly many cats with sub-clinical HCM will have received ketamine and true significance/risk remains unclear

6. ‘Ketamine head’:

Ketamine emergence, dysphoria, mania, hyperexcitability, spackiness - “ketamine head” (Aoife O’Sullivan); especially cats
Emergence can range from entirely unremarkable to really quite spectacular neurological/neuromuscular signs
Prevention is key. Ensure other agents (e.g. opioid, α2-agonist) on board and active during emergence
Quiet room, minimal stimulation etc.
May require pharmacological intervention

7. Can ketamine be used as a sole agent?

Is it okay for a patient not to have already received another agent (e.g. opioid) that is on board and working at the time of ketamine administration? Or indeed not to at least have one with a rapid onset co-administered alongside the ketamine?

Sole use of ketamine reported in children and seems more recognised
Evidence in adult humans does not seem to support sole use
Suggest (anecdotally) never using ketamine as sole agent in veterinary species – especially due to increased risk of potentially spectacular “ketamine head”

8. Is ketamine contraindicated with raised intraocular pressure?

Another long-standing listed contraindication in human and veterinary medicine; again substantive evidence woefully lacking
Increasingly rebutted as a ‘myth’ in human medicine based on emerging evidence
No good quality clinically relevant canine/feline evidence identified
Author is comfortable to recommend use of ketamine in patients with raised IOP where potential benefits supersede this theoretical and unproven risk

9. Ketamine in caesarean section:

Can and indeed should you be including ketamine as part of your c-section protocol?
Used in women relatively commonly for this purpose; no evidence identified that poses increased risk to mum or baby
Paucity of veterinary evidence and certainly identified demonstrating increased risk
“Absence of evidence is not evidence of absence” but overall happy to recommend pre-, intra- and post-operative ketamine use for c-section
Provides multimodal analgesia. Dose-sparing for potentially more harmful drugs, especially inhalant anaesthetics

10. Other bits ‘n’ pieces:

Other things to highlight about ketamine:
Protective airway reflexes preserved

  • Cats’ eyes remain open – must keep well lubricated
  • Cats reportedly may salivate excessively – reported more in humans
  • Hepatic metabolism in most species; minimal in cats
  • Parent compound and metabolites renally excreted. Available evidence in people at this time does not suggest the need for dose reduction with hepatic or renal impairment.

Use in treatment of refractory status epilepticus reported in people; one published canine case report but actual unpublished clinical experience likely to be greater than this.

Also sometimes used in children with refractory status asthmaticus due to potential bronchodilatory effect from β2-adrenergic receptor stimulation. Unclear if effective in asthmatic cats refractory to standard therapies – very rare patient anyway?

Some papers that informed this episode:

Kovalcuka L, Birgele E, Bandere D, Williams DL. The effects of ketamine hydrochloride and diazepam on the intraocular pressure and pupil diameter of the dog’s eye. Vet Ophthal 2013. 16(1):29-34.

Pei-Yu Liao, Shi-Chieh Chang, Kuan-Sheng Chen, Hsien-Chi Wang. Decreased postoperative C-reactive protein production in dogs with pyometra through the use of low-dose ketamine. J Vet Emerg Crit Care 2014. 24(3):286-290.

Serrano S, Hughes D, Chandler K. Use of Ketamine for the Management of Refractory Status Epilepticus in a Dog. J Vet Int Med 2006. 20(1):194-197.

Wagner AE, Walton JA, Hellyer PW, et al. Use of low doses of ketamine administered by constant rate infusion as an adjunct for postoperative analgesia in dogs. J Am Vet Med Assoc 2002. 221(1):72-75.

Ahern TL, Herring AA, Stone MB, Frazee BW. Effective analgesia with low-dose ketamine and reduced dose hydromorphone in ED patients with severe pain. Am J Emerg Med 2013. 31(5):847-851.

Beaudoin FL, Lin C, Guan W, Merchant RC. Low-dose ketamine improves pain relief in patients receiving intravenous opioids for acute pain in the emergency department: results of a randomised, double-blinded, clinical trial. Acad Emerg Med 2014. 21(11):1193-1202.

Cohen L, Athaide V, Wickham ME, et al. The Effect of Ketamine on Intracranial and Cerebral Perfusion Pressure and Health Outcomes: A Systematic Review. Ann Emerg Med 2015. 65(1):43–51.

Drayna PC, Estrada C, Wang W, et al. Ketamine sedation is not associated with clinically meaningful elevation of intraocular pressure. Am J Em Med 2012. 30(7):1215-1218.

Green SM, Andolfatto G, Krauss BS. Ketamine and Intracranial Pressure: No Contraindication Except Hydrocephalus. Ann Emerg Med 2015. 65(1): 52-54.

Halstead SM, Deakyne Sj, Bajaj L, et al. The Effect of Ketamine on Intraocular Pressure in Pediatric Patients During Procedural Sedation. Acad Em Med 2012. 19(10):1145-1150.

Heesen M, Bohmer J, Brinck ECV, et al. Intravenous ketamine during spinal and general anaesthesia for caesarean section: systematic review and meta-analysis. Acta Anaes Scans 2015. 59(4):414-426.

Laskowski K, Stirling A, McKay WP, Lim HJ. A systematic review of intravenous ketamine for postoperative analgesia. Can J Anesth 2011. 58(10):911-923.

Anna Rosati, Manuela L’Erario, Lucrezia Ilvento. Rosati A, L’Erario M, Ilvento L. Efficacy and safety of ketamine in refractory status epilepticus in children. Neurol 2012. 79(24):2355-2358.

Terence L. Ahern, Andrew A. Herring, Erik S. Anderson, et al. The first 500: initial experience with widespread use of low-dose ketamine for acute pain management in the ED. Am J Emerg Med 2015. 33(2):197-201.

Tiwari A, Guglani V, Ram Jat K. Ketamine versus aminophylline for status asthmaticus in children: A randomized, controlled trial. Eur Resp J 2014. 44, Suppl 58 281.

Wadia S, Bhola R, Lorenz D, et al. Ketamine and Intraocular Pressure in Children. Ann Emerg Med 2014. 64(4):385-388.

Wang X, Ding X, Tong Y, et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth 2014. 28(6):821-827.

Zeiler FA, Teitelbaum J, West M, Gillman LM. The Ketamine Effect on ICP in Traumatic Brain Injury. Neurocrit Care 2014. 21(1):163-173.

Zeiler FA, Teitelbaum J, West M, Goillman LM. The ketamine effect on intracranial pressure in nontraumatic neurological illness. J Crit Care 2014. 29(6): 1096–1106.

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Lisa Murphy DACVECC

Hypoadrenocorticism Refresher

By Lisa Murphy DACVECC

Primary hypoadrenocorticism (HA) is an uncommon disease in dogs and rare in cats.

Adrenal gland physiology

First, we’ll go over some basic adrenal gland physiology.

The adrenal cortex is primarily responsible for secreting several important hormones including cortisol and aldosterone. Cortisol has several functions including carbohydrate, lipid and protein metabolism, immune system modulation and proper catecholamine function. The amount of cortisol being released is determined by a negative feedback system:

  • The hypothalamus produces corticotropin releasing hormone (CRH) which stimulates the anterior pituitary to release adrenocorticotropic hormone (ACTH).

  • ACTH stimulates the zona fasiculata and reticularis of the adrenal cortex to produce and release cortisol.

  • Increased serum cortisol inhibits the release of CRH and ACTH.

Aldosterone is also released from the cortex; however its release is stimulated by hypovolaemia which is recognised by the kidney. In times of hypovolaemia.

  • Angiotensin II is released via a hormonal cascade and stimulates the zona glomerulosa to release aldosterone.

  • Aldosterone stimulates cells in the renal collecting duct to resorb sodium (leading to secondary water retention and restoration of the effective circulating volume) and excrete potassium.

Causes of HA

Primary HA is caused by adrenal gland dysfunction. Although much more rare, secondary HA can also occur; this is caused by hypothalamic or pituitary dysfunction. Most cases of primary HA involve concurrent cortisol and aldosterone deficiency although atypical HA can also occur where only cortisol is deficient.

The typical signalment for HA is young-to-middle aged dogs with females more likely to be affected. Average age of onset is 4 years old.

The most commonly affected breeds include Portuguese water dogs, Great Danes, Westies, Standard Poodle, Wheaton Terrier and Rottweilers.

In cats there is no known sex or breed predisposition.

The exact cause of primary HA is unknown but is believed to be immune-mediated destruction of the adrenal cortex. Less common causes of primary HA include trauma, infiltrative disease or iatrogenic destruction due to mitotane or trilostane therapy for hyperadrenocorticism. In one study evaluating 156 dogs on chronic trilostane treatment for hyperadrenocorticism, the relative risk of developing HA was 15% at 2 years and 26% by 4 years.

Clinical presentation

The clinical presentation of typical HA can be vague and non-specific. We will focus on the emergent Addisonian crisis:

Common clinical signs of a crisis include lethargy or collapse, hypothermia, hypovolaemic shock and bradycardia. Much of these signs occur secondary to the electrolyte changes induced by this disease (mainly hyperkalaemia and hyponatraemia).

On blood work, common findings include hyponatraemia, hyperkalaemia, azotaemia with a concurrent inappropriately low urine specific gravity (typically < 1.030) and possible lack of a stress leucogram.

Most of these patients (> 90% in some studies) will also have a low sodium/potassium ratio, typically less than 28. Other differentials of this include any disease which leads to severe dehydration including renal failure, severe gastrointestinal disease, and body cavity effusions among others.

Other less common blood work findings include hypoglycaemia and hypercalcaemia. Cortisol promotes gluconeogenesis and glucogenolysis and calciuresis leading to these respective electrolyte derangements.

In cases of severe hyperkalaemia, patients can experience significant bradycardia and/or dysrhythmias. Common ECG changes noted include:

  • Bradycardia

  • Diminished/absent P waves

  • Tented T waves

  • Wide/bizarre QRS complexes

  • Ventricular tachycardia/fibrillation

There are several ways to evaluate if a dog may have HA:

1. A screening test evaluating the resting cortisol can be performed initially with values less than 1 mcg/dl having excellent sensitivity (100%) and good specificity (98%) for HA in dogs.

Values < 2 mcg/dl were also 100% sensitive but only 78% specific for HA.

Dogs with values > 2 mcg/dl are very unlikely to have HA

2. A confirmatory ACTH stimulation test should be performed in all cases of suspected HA. This test is considered the gold standard.

The drug used in this test (cortisyn) is very expensive and recent studies have shown that the low dose ACTH (5 mcg/kg) stimulation test is as effective as the standard dose (using a 250 mcg vial in a dog or 125 mcg vial in a cat).

3. In cases where primary vs. secondary HA needs to be differentiated or to diagnose atypical HA, endogenous ACTH levels can be measured.

Animals with atypical HA (cortisol deficiency without concurrent aldosterone deficiency), should have normal electrolyte values and an elevated endogenous ACTH level.

4. Evaluation of a dog’s cortisol/ACTH ratio: in one study, all dogs with HA had ratios < 0.17 vs. healthy dogs who had values > 0.79 (reference range 1-1.26).

5. Urine sodium levels: in a recent study dogs with HA had significantly higher urine sodium levels when compared to dogs with non-adrenal illness

While there are several tests that may increase suspicion for HA, the ACTH stimulation is the gold standard confirmatory test.

It is important to note that most exogenous glucocorticoids can interfere with adrenal function tests; therefore tests should be delayed if the patient has recently received steroids. Of all types of glucocorticoids dexamethasone has the least effect on testing. In a true Addisonian crisis, fluid resuscitation is the most important first step so delaying steroid administration until after the ACTH stimulation test likely does not have a significant impact on survival.

Volume resuscitation:

Intravenous fluids are the mainstay of therapy in a crisis. Despite their potassium content, a balanced electrolyte solution is recommended over 0.9% sodium chloride solution. This is because the latter could increase the patient’s blood sodium levels too quickly which can cause neurological complications. Once the effective circulating volume is restored, kidney function and GFR will increase leading to kaliuresis; this negates the risk of using fluids with low potassium levels in a hyperkalaemic patient.

Patients who have life-threatening hyperkalaemia require rapid intervention.

In animals that are experiencing significant cardiotoxic effects, calcium gluconate can be administered. This will not lower potassium levels and its cardioprotectant effects last approximately 15-20 minutes so more definitive treatments need to be instituted following calcium administration.

Treatments to lower plasma potassium levels include fluid resuscitation as well as administration of substances which shift potassium from the extracellular compartment into the intracellular compartment:

  • The most commonly used is 50% glucose solution and regular (neutral, soluble) insulin (0.1 u/kg with concurrent glucose supplementation to avoid hypoglycaemia)

  • Sodium bicarbonate is used less commonly as this drug carries significant risks due to several possible side effects and should only be considered a last resort.

Following adrenal function testing, patients with typical HA can be started on mineralocorticoid and glucocorticoid supplementation:

  • Mineralocorticoids can be given daily in tablet form or as an injection given approximately every 25-30 days.

  • Glucocorticoids are typically administered intravenously to begin with and then per os. They are usually weaned off over time.

  • The timeline for clinical recovery is different for every patient although it can be anywhere from hours following supplementation to 3-5 days.

  • Animals with atypical HA (singular glucocorticoid deficiency) only require glucocorticoid supplementation.

  • Cats typically take longer to respond than dogs.

The prognosis for this disease is quite good, especially in those who survive the initial crisis. However they do require lifelong monitoring and treatment. This is typically long-term mineralocorticoid administration with intermittent glucocorticoid administration at times of physiological stress or illness.

Drowning Refresher

By Lisa Murphy DACVECC

Once the airway is below the surface of a liquid voluntary breath-holding occurs. This is then followed by involuntary laryngospasm as liquid enters the oropharynx and larynx. During both of these periods, the victim is not breathing gas and develops hypercapnia, hypoxaemia and acidosis. Once the arterial oxygen partial pressure drops sufficiently, laryngospasm stops and liquid is then actively aspirated. It is the hypoxaemia which leads to unconsciousness and apnea.

Once aspirated, water leads to several severe side effects:

  • One of the most significant is surfactant dysfunction and washout which reduces lung compliance and leads to atelectasis.
  • Water also interferes with the normal osmotic gradient in the alveolar-capillary membrane thus directly injuring the pulmonary epithelium. Damage to these cells has several effects including the release of inflammatory mediators and increased membrane permeability worsening fluid accumulation in the lung parenchyma.

It was once believed that the type of water (salt versus fresh water) was a more important determinant of outcome than the volume aspirated, however, more recent studies have found this to be untrue. This is because it’s the volume of water which affects surfactant function regardless of the type aspirated. Pool water is interesting because it typically contains agents to limit bacterial growth so secondary pneumonia is uncommon with this type of aspiration.

The temperature of the water aspirated can also play a role in survival. Cold water is associated with higher rates of survival. This is because it reduces cellular metabolism (and thus oxygen consumption) and activates the diving reflex (leading to bradycardia, hypertension, shunting of blood to the cerebral and coronary circulations).

The history of a drowning episode is usually known. Common tests performed in these cases include:

  • Blood gas analysis (ideally arterial) – most cases have a mixed respiratory and metabolic acidosis
  • Thoracic radiography:
    • Pulmonary oedema is likely
    • In some cases, where the volume of water aspirated wasn’t large but they suffered a choking-like episode, non-cardiogenic pulmonary oedema (NCPO) may be identified. This is suspected where the pulmonary oedema is predominantly in the caudodorsal lung field.
    • In cases which don’t go on to develop pneumonia, there is usually radiographic resolution of oedema within 7-10 days.

The focus should be on controlling the patient’s hypoxaemia.
The risk of pneumonia is low (estimated at 12% in humans) so empirical antibiotics are not recommended. In general, it is much more likely for these cases to develop pneumonia if they undergo mechanical ventilation.
Steroids also have not been shown to increase survival and their use is not recommended.

Similarly, there is little evidence supporting the use of diuretics in cases of NCPO. Diuretics are most useful for hydrostatic oedema which is associated with congestive heart failure. In cases of NCPO, the oedema is due to changes in pulmonary epithelium permeability (permeability oedema). Fluid can still leak into the parenchyma despite diuretic use. And since diuretics have systemic effects, they put patients at risk of dehydration and potential renal compromise.

There are several criteria that we can use to help identify those patients who could benefit from mechanical ventilation. The main indications are as follows:

  • Arterial partial pressure of carbon dioxide > 60 mmHg
  • Arterial partial pressure of oxygen < 60 mmHg despite non-invasive oxygen supplementation
  • Excessive respiratory effort with impending respiratory fatigue

Prognosis is not known in veterinary medicine. In general, animals showing more organ systems negatively affected and those requiring positive pressure ventilation have a worse prognosis.

Seizure Refresher

By Lisa Murphy DACVECC

Seizures are one of the most common neurological emergencies seen by small animal vets both in general practice and in emergency clinics. What follows is a brief discussion of seizures and some of the more commonly used anticonvulsive medications for management of these cases.

Idiopathic Epilepsy:

  • Most dogs suffering from idiopathic epilepsy are between 1-5 years old with genetic predilection in the beagles, the Keeshond, the dachshund, the Irish wolfhound, Labrador and Golden Retrievers and the English springer spaniel.
  • They can have any type of seizure (generalized/tonic-clonic, focal) but generalised is more common.
  • Predisposing factors are not known in animals but in people include stress, sleep deprivation, missed medications and concurrent illness.
  • Idiopathic epilepsy is less common in cats although also usually occurs around 1-5 years old.
  • In studies evaluating dogs > 5 years old, 35% had no identifiable cause of epilepsy, while the remainder were divided into those with neoplasia (52%) and those with other aetiologies (inflammatory, vascular, congenital). All dogs in the 8-10 year old group and in the over 15-years old group, and 80% of dogs in the 11-13 years old group, had neoplasia as the underlying cause.
  • When comparing the neurological exam to MRI findings, of those who had an abnormal neurological exam 79% went on to have a lesion on MRI. A properly performed neurological exam is considered to have 74% sensitivity and 62% specificity for diagnosing secondary epilepsy.

Metabolic and Toxic Causes:

Among the lesser studied causes of seizures in our patients are metabolic and toxin associated seizures, of which there are a number of potential culprits.

A retrospective study was performed on almost 100 dogs and found some very interesting findings. Intoxications were the most common cause with metaldehyde most likely (although this likely depends on geographic location). When evaluating metabolic causes alone, hypoglycaemia was most common. Interestingly, reactive seizures secondary to metabolic disorders or toxins had a 1.57x higher risk of a status epilepticus presentation as compared to idiopathic epilepsy.

Secondary Intracranial Hypertension:

While most seizures do not tend to be life-threatening, animals which have multiple seizures in a short period may be at risk for developing intracranial hypertension (ICH). Typically, intracranial pressure (ICP) is maintained within a narrow range secondary to several physiological processes. These can be disrupted as a result of seizure activity.

If left untreated, significant intracranial hypertension may lead to the Cushings response which is often fatal. Clinically it should be suspected in a seizuring patient with systemic hypertension and bradycardia.

Anticonvulsive Medications

Common first line anticonvulsive medications:

Thankfully, most patients presenting with seizures do not go on to develop such life-threatening complications and typically just require acute control of their seizures.

  • The most common medications employed to stop seizures are benzodiazepines. Diazepam and midazolam are typically given intravenously (0.5 mg/kg) or rectally (1 mg/kg) for rapid seizure control.
  • It is important to note however that they have a very short duration of action and animals may start having seizures again within 10 minutes of their administration.
  • These drugs also need to be used cautiously in patients with seizures due to hepatic encephalopathy as the drug’s metabolism will be reduced resulting in more significant sedation.
  • In some cases, a continuous infusion or repeated bolus administration must be used while waiting for the patient to respond to medications used for longer-term seizure control. Midazolam is recommended for this as it is water soluble and causes less thrombophlebitis; however, neither drug is superior to the other for seizure control.

  • Some patients are refractory to acute control with benzodiazepines and will continue to seizure. Recent case reports in veterinary patients have shown that ketamine and dexmedetomidine may be able to offer short-term seizure control in such cases.
  • In both cases, high doses are typically needed and patients require continuous monitoring for significant side effects.
  • Patients typically remain on an infusion until they are seizure free for at least 6-12 hours. The drug then needs to be slowly weaned over the next 6-12 hours.
  •  While the dog is on these infusions, a second medication for chronic seizure control must be started.

Common long-term anticonvulsive medications:

  • The most commonly used drug in veterinary patients.
  • Benefits include relatively low cost and, for most animals, being well tolerated long term.
  • Major disadvantages include the need to ‘load’ the drug as therapeutic levels can take several days to be attained during which time the animal would be at continued risk of further seizures. This involves the administration of a larger dose for the first 24 hours followed by a much lower maintenance dose. At high loading doses, most dogs will be very sedated. Their carers need to be warned that they can continue to be very sedated, and potentially ataxic, for the first few days of treatment.
  • Cats tend to show fewer side effects.
  • Phenobarbital also needs to be used cautiously in animals with an underlying hepatic disease as the drug will increase hepatic enzymes over time.

Potassium Bromide (KBr):

  • Can also be employed in dogs
  • It requires loading to attain therapeutic levels during which time the dog can be very sedated.
  • While it can offer excellent seizure control, some dogs develop significant side-effects (e.g. gastrointestinal, megaoesophagus, dysphagia) and treatment needs to be discontinued.
  • It is important to note that bromide competes with chloride ions in the renal tubule. Vets treating animals that are on chronic KBr treatment with intravenous fluids need to recognize that concurrent use of 0.9% sodium chloride will speed up renal clearance of KBr.

  • Has become more widely used in recent times
  • The exact mechanism of action is unknown
  • Major benefits of this drug include minimal side effects and that it attains therapeutic levels within 60 minutes of administration
  • While levetiracetam has excellent short-term effects, its use as long-term monotherapy for seizure control is controversial. It has been used in this was for idiopathic epilepsy but, after a ‘honeymoon’ period, an additional anticonvulsive medication may be needed.

  • A synthetic sulfonamide based drug
  • Takes a few days to achieve therapeutic levels
  • Tends to be well tolerated by most dogs
  • Advantages include generic drugs now available (so less cost) and the need for only twice daily dosing (so better compliance)
  • There are sparse case reports of dogs developing immune-mediated thrombocytopenia secondary to the sulpha component within the drug so this risk, while low, should be discussed with carers.
  • One caveat to its use is that concurrent use of phenobarbital increases the renal clearance of zonisamide so the dose may need to be increased.

There is not as much data available for the use of this drug in dogs. Studies that have been performed show that it can reduce seizure frequency by fifty per cent when used in dogs on chronic phenobarbital or potassium bromide therapy.

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Monday, December 31, 2018

Group of veterans dedicated to helping other veterans

South Bend, IN (December 31, 2018) — A local veteran is warm and safe inside his Hamlet trailer this holiday thanks to a dedicated group of Army veterans. The Army Riders, a non-profit motorcycle group, aims to serve those who served. They help veterans in need. Now, one of those veterans is saying thanks.

After falling on hard times, Tom Tharp found help and hope in the Army Riders.

The Army Riders Motorcycle Group

“We did this as a desperation thing,” says Tharp as he walks us around his Hamlet trailer, “I said I can fix it, I can fix that, but it was the unseen things that we ran into.”

Tom Tharp knew the trailer needed work when he bought it, but he didn't expect it would be this bad.
Moldy floors and walls, smoke detectors painted over, rotten floor boards, electricity issues, leaky pipes – that was just some of the issues that plagued his newly purchased trailer. Tom and his wife Debbie purchased the trailer after falling on hard times. Medical issues forced the couple to sell nearly everything they owned.

“Things were going really good and then they went down the tubes really quick,” says Tom. The past 3 years have been the hardest, he says.

Tom, who served in the Navy during Vietnam, tried to fix some of the issues himself. But, he knew he needed help.

The VA in Fort Wayne put him in contact with the Army Riders

“They came in stepped up and said what do you need done? We will do it,” says Debbie. The Army Riders are a group of veterans who are dedicated to helping other veterans.

“It doesn’t matter what branch they are in – it doesn’t have to be army – we help every branch if they area vet and need help we want to help them,” says Brandon “Gunn” Smith, the president of the Army Riders of Indiana.

Smith, or Gunn, has he likes to be called, served in Afghanistan. Now he is serving others through the Army Riders. Gunn is a welder and he combines his talents with the others in the group. Jeremy “Pipe” Gadsby was military police. Now he is a plumber.

“This is a family --every one of them. These guys will do anything for anybody. Especially anyone in the club,” says Gadsby, the Treasurer of the Army Riders of Indiana. The group has helped nearly a dozen vets this year, including the Tharps.

“Oh man, it was just amazing. It took so much pressure off both of us. It was just like, wow. This is unbelievable,” says Tom.

For Tom, the Army Riders fixed the plumbing and electricity, replaced the fridge, patched up and fixed the heating, and are in the process of replacing the front door. “It is not about me, it is about these guys. They are number one. They are my heroes,” says Tom.

The Army Riders are looking for people who need help or people who want to help.

You can contact them on their website:

Tuesday, December 11, 2018

Veterans Court helps Navy veteran involved in Fight

Indianapolis, IN (December 11, 2018) — All of us have had those moments when we are not at our best, when we do something we regret. For Rebecca Mills, that moment went viral.

Most people won't recognize her by name, but they probably remember the YouTube video — the one where two women traded punches at a Beech Grove Walmart.

Mills, 42, is the woman in the pink shoes who got out of a scooter and wrestled with another woman in the shampoo aisle. The other woman can be heard telling a little boy to punch Mills in the face. The boy punched Mills.

Rebecca Mills delivering the keynote speech at Indianapolis Veterans Court Photo: Vic Ryckaert

That’s a kind of low few people hit. And it's been viewed by millions of people since June 2015.
But this story isn't about Mills' greatest embarrassments and biggest failures.

This is a story about a woman who crawled from the depths of addiction and isolation with the help of allies in a special corner of the justice system.

A slow descent
Years before she bottomed out in the shampoo aisle, Mills served nine honorable years in the Navy, from 1994-2003. She was an operations specialist, with the rank of second class petty officer. Mills served her country on three ships, including a tour in the Mediterranean.

 She left the Navy and stayed home to raise her three sons. After her husband retired from the Navy in 2006, they moved to Indianapolis. But things here didn't work out as Mills hoped.

It was a slow descent that landed her in the legal system. Her marriage was starting to fall apart. She and her husband would divorce in 2014. "I was at complete rock bottom with no foreseen hope," Mills said.

She battled depression and migraine headaches for years. She was in constant pain, and doctors couldn't tell her why. She underwent years of testing before in 2012 she was diagnosed with fibromyalgia, a nervous system disorder that causes severe body pain and fatigue. That's why she was in a scooter in that infamous video.

She relied on pills for migraines, depression, and to help her sleep. Mills said they helped her avoid facing her many failures. "I became dependent on my medicine," Mills said. "I was no longer being held accountable for my life."

After Walmart
Mills recognizes now that she was struggling with addiction. Poor choices, she said, led to that Walmart aisle.

The fight earned Mills a night in jail and a misdemeanor conviction for disorderly conduct. A first-time offender, Mills was sentenced to 40 hours community service and handed a $183 fine. In the three-and-a-half years since the Walmart video went viral, it's been posted and reposted many times with added commentary and music.

There's the video posted last year in which Indianapolis sports radio host Dan Dakich calls boxing match-style play by play, making fun of Mills' looks and weight. The audio comes from a segment Dakich aired on his radio show to mark the two-year anniversary of the fight.

Rebecca Mills at Indianapolis Veterans Court. Photo: Vic Ryckaert

Once a proud veteran, Mills became a punchline.

"I started asking myself, 'How can one be humble if they've never really truly been humiliated,'" Mills said. After the Walmart fight, Mills said she became a recluse, withdrawing from friends and loved ones. She said she was abusing her prescription pills and smoking marijuana heavily.

Then, just 10 months later, things got worse.

She still can't explain exactly what was going on in her head that night. She was sleep-deprived, numbed by pills and pot. She was under intense stress, she said, after the death of her dog, a break-up with her then-fiance and a suicide attempt by her son. "They could write a country song about this," Mills told IndyStar during a February 2017 interview.

Late in the evening on April 17, 2016, Mills entered the south-side home of a stranger who lived not far from her. Dogs barked loudly as she tore through the home and woke the owner. She poked her head into the bedroom and said "sorry," the man told police.

She took random items from the home, sunglasses, suntan lotion and a gun holster, according to a probable cause affidavit. Then she stood on the porch and screamed: "People are going to burn!"

Police arrested Mills about an hour later. She asked officers to contact country singer Tim McGraw. He was her boyfriend, she told the officers, and she wanted them to tell him she was going to jail.

This time Mills was facing a felony.

She needed help, but she didn't realize it.

"I look at getting arrested as a blessing in disguise," Mills said. "I was a sick person who needed and wanted to get well."

Redemption for veterans
Mills' felony case, the one where she broke into her neighbor's home and ranted about Tim McGraw, was assigned to the Indianapolis Veterans Court, a treatment program for military veterans facing misdemeanors and low-level felonies.

The court helps "veterans in crisis recover their sense of mission and accomplishment," said Judge David Certo, who has presided over the court since it launched in October 2015.

Modeled after the success of drugs courts, Veterans Court helps veterans and current service members grapple with the substance abuse and mental health problems that keep so many recycling through the legal system.

About 400,000 veterans live in Indiana, according to the U.S. Census Bureau. Many struggle with mental health issues. The suicide rate for veterans in Indiana is nearly twice the rate for Hoosiers as a whole, according to the U.S. Department of Veterans Affairs.

Each week, about 25 veterans are arrested in Marion County. This year, 62 have been assigned to Veterans Court. Fifteen graduated in 2018; 16 more have graduated since the court started hearing cases.

Anyone who has served in the military and has addiction or mental health problems that could benefit from treatment may be offered the opportunity to have their cases heard in Veterans Court.

It's a voluntary program, Certo said. The supervision and requirements are often more intense than a sentence in the regular court system.

Mills entered the program in 2016. She stood before the judge facing charges of felony residential entry and misdemeanor theft.

Certo, on the bench, looked over her record of nine honorable years of Naval service and reminded Mills that she was successful once. She could be again.

The court set her up with a mentor and required her to attend counseling sessions.

With the help of counseling and support from other veterans, Mills said she stopped abusing drugs and started going to church. Mills said she started focusing on herself and began doing what it took to straighten out. She dumped the people who supported her bad habits, replacing them with friends who wanted her to succeed. For Mills, the road back wasn't anything special. Wake up. Go to work. Get there on time. Be someone others can count on. Do it every day.

'They believed in me'
Mills graduated the Veterans Court in 2017. The charges against her were dismissed — the big reward for all who complete the program.

She has a job she enjoys as a field technician testing construction materials for Patriot Engineering and Environmental. She's rebuilt relationships with her three sons, one of whom now lives with her.

She has put the Walmart fight in her past. It happened, but it doesn't define her.

"I never thought I'd get to this point where I could talk about that and not get mad, or cry, or feel guilt or shame," Mills said. "I hope that story encourages other people to get the help they need."

On Nov. 30, the court welcomed her back to its most recent graduation ceremony. This time, as the keynote speaker. "Veterans Court was my second chance," she told an audience of more than 100 in the auditorium at the Indiana War Memorial. "It provided me with a safe, nurturing treatment program. It met me where I was and accepted me with all my flaws.

"They believed in me when I didn't believe in myself." Tears ran down her cheeks as Mills finished her speech.

The audience clapped and cheered, rewarding Mills with a long, enthusiastic standing ovation.

SOURCE: Indy Star
STORY:  Vic Ryckaert

Tuesday, December 4, 2018

Veterans Job Fair

Indianapolis, IN (December 4, 2018) — Around 75 companies will be at Lucas Oil Stadium on Thursday, December 13 for a job fair for veterans. The job fair runs from 11 a.m. to 3 p.m. The 75 companies that will be at the job fair are from several different industries.

Recruiters from Spectrum, Eli Lilly and Company, Farmers Insurance, Allstate and many others will be at the job fair. DAV or Disabled American Veterans and RecruitMilitary are the organizations running the job fair. They estimate the companies will have about 250 to 300 jobs to offer. The job fair is open to veterans, those transitioning out of the military, national guard and reserve members and spouses.

Organizers expect about half of the people who attend to get some kind of offer or job interview. And if anything, they say it's a good opportunity for veterans to recruiters who understand how valuable veterans are.

 "These events are the last true place to network. We say how much networking is so important, but they really don't tell you where or how to do that. I think this is one of the last real time places that you can come and network and have a really organic conversation with a recruiter that's likely a veteran as well and if not - really understands the veteran talent space, so it's good to see even if you're gainfully employed now, it's good to see where you could go," said Chris Cravens with RecruitMilitary.

The job fair is free. Parking in the South Lot at Lucas Oil Stadium is also free. More information, at:


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20th Century Fox Creates Indie Game Support Fund

The independent scene of gaming continues attracting several companies and game developers. In fact, 20th Century Fox has actually revealed that they will help boost this scene as well. Furthermore, this will be achieved by creating a fund designed to help independent game studios who have ambitious projects. The first game to benefit from this fund will be Etherborn.

20th Century Fox Creates Fund for Indie Game Developers

Etherborn is the first game to be taking benefit from the 20th Century Fox fund

20th Century Fox’s games development and publishing division FoxNext Games has announced the establishment of a development fund for independent creators. Furthermore, this fund aims to help the developers who are looking to “take creative risks”. Additionally, the very first person to take benefit from this fund will be Alfred Matter with his game: Etherborn.

“As passionate creators of games, we’ve been searching for like-minded developers focused on innovation, experimentation and a certain amount of creative risk.” Says FoxNext VP of external development TQ Jefferson in an announcement. “We’re partnering with inspiring game makers, providing the support they need to develop the best version of their games and ultimately connect with the widest audience possible.”

Etherborn is a puzzle-platformer game created by Alfred Matter which will make its debut on Xbox One, PC, Switch, and PS4. It’s a game that brings challenges in the form of gravity-based gameplay. You can take a look at the game’s trailer below:

This fund certainly will help a lot of creative game developers to achieve their wildest dreams. However, no other game besides Etherborn is currently taking benefit from FoxNext’s fund. On the other hand, FoxNext announced that other games will be taking advantage of the fund later this year.

What do you think about the move made by 20th Century Fox? Do you think FoxNext will actually help indie devs who take risks in the industry? Do you look forward to Etherborn’s release? Let us know your thoughts on the VGR Forums.


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Ballet Flats Women Gray, charcoal

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As seen on the runways for several years, the ballet flat design is still as hot as ever! Dior, Dolce & Gabbana, Chanel, and even Christian Louboutin are some big fashion hitters to be found at, and always at unbeatable prices! Fashion-hunters will love the collectible red-sole models. For undeniable chic, search for Dior or Chanel for their minimalist ballet flats. At, our premise is simple: to give everyone the chance to sell their ballet flats, whether private or professional sellers. From trendy to vintage to collector, new or used, this is a great choice of shoes that simply cannot be found elsewhere. We check the condition of every posted article, so you have nothing to worry about! What are you waiting for? Start browsing now!


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Trump praises China’s Xi for extending presidency for life

U.S. President Donald Trump with China's President Xi Jinping at the Great Hall of the People in Beijing, China, Nov. 9, 2017. REUTERS/Damir Sagolj

United States President Donald Trump expressed approval of China’s decision to remove the two-term limit for the presidency, saying “we’ll have to give that a shot someday.”

Attending a closed-door fundraiser Saturday, the president commended the move of ruling Communist party in China that effectively allows President Xi Jinping to stay in power indefinitely. “He’s now president for life, president for life. And he’s great,” said Trump. “And look, he was able to do that. I think it’s great. Maybe we’ll have to give that a shot someday.”

It was not clear whether or not the president made the remarks about extending presidency in jest. However, his supporters at the fundraising, which was held at the ballroom of his Mar-a-Lago estate, received his comments with cheers and applause.

Democrat Representative Ro Khanna, commented about Trump’s statements on Twitter, saying, “[W]hether this was a joke or not, talking about being President for life like Xi Jinping is the most unAmerican sentiment expressed by an American President…George Washington would roll over in his grave.”

U.S. Presidents served a maximum of two four-year terms by tradition until President Franklin Roosevelt was elected a record four times, beginning in 1932. In 1951, the U.S. Constitution was amended to limit the presidency to two terms.

Trump also made remarks about other American political figures, including former presidential rival Hilary Clinton and former president George W. Bush during the fundraising event.

He pondered on whether Clinton is a happy person. “Is Hillary a happy person? Do you think she’s happy?” he said. “When she goes home at night, does she say, ‘What a great life?’ I don’t think so. You never know. I hope she’s happy.”

On the other hand, he made sarcastic comments about Bush’s decision to invade Iraq over faulty intelligence about its possession of weapons of mass destruction. “That was Bush. Another real genius. That was Bush,” Trump said. “That turned out to be wonderful intelligence. You know? Great intelligence agency there.”


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Mobile Security Officers

VIP mobile security officer service is the ideal solution for a cost-effective and efficient visible deterrent.  Our trained and SIA licensed uniformed guards will patrol and inspect your premises at agreed frequencies, checking for damage or intrusion.

The Service we Provide to you.

We provide a ‘walk and check’ service, as well as a vehicle patrolling service covering the areas of Essex and East London.  All our vehicles can be fitted with specialist equipment such as cameras and satellite navigation and tracking systems supported by our 24 hour control room

VIP rapid response security services offer you 24/7 peace of mind, when you are not at your premises.  Our mobile patrol service is fully accountable, easy and hassle free to implement.

Benefits of Using a Mobile Security Service

As part of the mobile patrol services, we protect you and your staff from exposure to any risks by offering a secure locking and unlocking service also available 24/7.  At designated times our fully licensed and insured guard will attend your location and check if the building is clear of staff or visitors before securing it.  This is a time-saving and cost effective alternative for your site together with the risks to you and your staff being eliminated.

Further Support we can Provide you With.

We also provide a full range of other support services to compliment our mobile patrol service.  For example, security guards can be hired for additional protection and monitoring of goods and equipment and our key holding and alarm service is available to deal with emergency access to the site and alarm activations.

We are an accredited ISO 9001:2008 Quality management company.

Enquire Today

Our motto here at VIP is “Working With You”


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Sauvignon blanc, which means “wild white,” is one of the world’s most highly acclaimed white grapes. Keeping pace with the Sauvignon blancs of the Loire Valley and Bordeaux, Virginia brings its own expression to this wonderful white, showcasing classic aromas of fresh herbs and hay balanced with sharp acidity. When Sauvignon Blanc vines grow in the limestone-rich soil of some Virginia sites, the resulting wine can also have the smoky aroma of flint. Try Sauvignon blanc with oysters at one of Virginia’s oyster festivals, or pair with shrimp, salmon, or poultry.
France (Loire Valley, Bordeaux)
Vitis vinifera
Ideal Soil
Clay and limestone soils.


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Stainless Steel Gold & Silver Heart Cremation Pendant

Stainless Steel Gold & Silver Heart Cremation Pendant

  • Length:    20 inches
  • Metal:      316L Stainless Steel

This Gold And Silver Heart With Blue Stone pendant opens to allow you to place a small amount of cremated remains inside. It can also be used to hold crushed flowers, a wisp of hair, dirt or sand from a memorable location, or any other tiny object you want to keep close to your heart.

Ships within 24 hours from our GA warehouse. If this is an "at need" item, please call us for assistance.

Why are there no prices on your urns or jewelry? In order to access pricing, you must contact Vision Medical customer service to receive a login.

Do you charge sales tax? We do not charge sales tax except in our home state of Georgia. We are obligated to charge both county and state taxes.

What forms of payment do you accept? We accept Visa, Mastercard, Discover, American Express and Paypal.

When can I expect my order? Generally speaking, standard FedEx shipping takes 1 to 5 business days in the contiguous 48 states.

Can I get overnight or second day delivery? Yes, but orders must be placed before 12:00 pm EST.

Do you ship outside the US? No, only the contiguous 48 states.

How do you ship? We ship exclusively with FedEx.

Do you offer engraving on cremation urns? Yes, we offer personalization on certain urns. Urns that can be engraved are so marked. Standard engraving is 2-3 lines. Call customer service for pricing.

How long does engraving take? Please allow at least 3-4 business days for approval of proof of engraving.

We offer a 100% satisfaction guarantee policy. If within 14 days of receiving your product you are not completely satisfied for any reason, we will replace the product or refund your money.

  • Please inspect all merchandise upon arrival for possible damage
  • Keep all original packaging as you received it for at least 14 days
  • You must contact Vision Medical within 14 days of receiving your order at
  • Our team of customer service professionals will work with you to satisfy your business needs

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• Summary
  • Venue

Make a crafty cart inspired by our colourful Scillian carretta!

Carts are used to transport goods and people all over the world. They can take all shapes and sizes. The Sicilian carretta at Streetlife Museum is brightly coloured and was used to transport fruit. The carts were passed down through generations and each added to the decoration! What kind of cart will you craft? Colourful or plain? Two wheels or four?

Children must be accompanied and supervised by an adult at all time. Please arrive early to avoid disappointment, as  some activities can be busy.

Free, drop-in.

High Street
01482 300300

If you have purchased a ticket for an event/activity at this venue through hull2017.co.uk, please do not contact the venue direct with enquiries for that purchase as they will be unable to help.

Social Channels

Venue Access

  • Accessible Information Points
  • Accessible Toilets
  • Assistance Dogs
  • Baby Changing
  • Blue-Badge Parking
  • Level Access
  • Wheelchair Access

Opening times

Monday 10am - 4:30pm
Tuesday 10am - 4:30pm
Wednesday 10am - 4:30pm
Thursday 10am - 4:30pm
Friday 10am - 4:30pm
Saturday 10am - 4:30pm
Sunday 11am-4pm

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Searenity Margate

Sunlight-flooded 1-bedroom beach-front Victorian penthouse – Searenity is perfect for a romantic getaway, a creative break or just some ‘me’ space.

The flat is incredibly bright and warm, offering far-reaching sea views from nearly every single window in the lounge, kitchen and even the bedroom. Bed linen, fluffy Egyptian cotton towels, toiletries included. Lots of freebies for guests including FREE bottle of wine and a pint of milk on arrival, FREE Nespresso coffee, tea, spices and condiments, Wi-Fi access and even a FREE Netflix subscription – to give guests a pampered experience.

Watch the stunning sunsets from the elegant dinner table situated in a bright turreted dining area. Margate Old Town, Turner Contemporary and the famous cycle route Viking Trail are within easy reach, while the flat is within walking distance from Margate station.

Sea View Terrace


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Swan Lake Campground

  • National Forest Campground
Swan Lake Campground located across the highway from Swan Lake has 35 campsites and encompasses an area of 2 acres at an elevation of 2,500 feet. The area is wooded with birch and fir trees and the Swan Mountain Range borders to the east. Water and restrooms with handicapped facilities are located along paved loops. Access to the Swan Lake Day Use Area is included in the nightly fee. The Swan Lake Campground is also a great place for bicyclists to stop and spend the night. The campground features bike lanes and a first-come first-serve fully featured campsite for bicyclists. A boat launch is also conveniently located there. Fishing, swimming, and boating are popular activities at the lake.

There are also scenic trails for hiking. Pets are welcome on a leash. Groceries, a cafe, laundry facilities and showers are within one mile of the site. The maximum recommended trailer length for the area is 50 feet.

Please limit stay to 14 days. A fee is required for the use of this campground. Reservations can be made at
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Mailing Address
Flathead National Forest
200 Ranger Station Road
Bigfork, MT 59911
Alternate Phone
Toll Free
5/15 - 9/30
Special direction map

Special Directions

Located just 1 mile northwest of Swan Lake on Montana Highway 83.


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Travel Etiquettes

This guide introduces etiquettes and customs in Okinawa you are advised to know before your trip. Please check them before departure so that you can travel comfortably just like a local.

Walking the streets

・In Okinawa, litter should not be dropped on the street. It should be separated into cans, bottles, burnable and non-burnable garbage.

・Do not spit on the road, or drop used chewing gum.

・Okinawans generally talk quietly in public places, on buses and the monorail.

・Smoking is prohibited in many places. Please smoke in designated smoking areas. Smoking on the street is prohibited in the Kokusui Street and Okiei Street in Naha City. Violation may lead to fines.

・It’s unusual to go shirtless in Okinawa. Wearing swimwear and going shirtless except at the beach is frowned on.

・When eating buffet-style, avoid leaving food uneaten. You may be charged extra if you leave food uneaten. Also, do not take drinks and so on away with you.

・Please do not bring your own food and beverages. The table is strictly reserved for orders from the menu. Fruit peelings, fish bones and other waste should be left on your plate and not dropped on the floor.

・Some restaurants serve water and provide small towels for cleaning your hands. They’re free of charge and you can ask for more. However, you can’t take them away with you.

・Many izakaya restaurants serve a small dish of food that you haven’t ordered. This is an appetizer, and it’s included in the table charge. About 200 to 500 yen is added to the bill for this. This depends on the restaurant. If it bothers you, ask when you enter a restaurant.

・You may be asked to take off your shoes before entering the building, or change into indoor slippers.

・There is no need to pay tips when shopping, at bars and restaurants, in hotels or taxis. Just saying “Arigato” is enough.

・Japanese toilettes consist largely of western style toilettes and Japanese style toilettes. Bear in mind the next person to use the toilet, and use it properly.

How to use the toilet

For those of you who want more tips and useful information about the trip

Safety Guide for Visitors to Okinawa (PDF)

Restrictions on carry-on baggage (PDF)

Simple Communication Sheet for Disasters (PDF)

Typhoon Preparedness Manual (PDF)


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The Richmond Region Tourism Foundation is a 501(c)(3) entity organized to conduct and support activities that promote the advancement and further the charitable and educational activities within the purpose of the Richmond Region Tourism. Specific Foundation activities include supporting the I am Tourism Ambassador training program and funding an annual scholarship. The $1,000 scholarship is awarded at the Richmond Region Open Golf Tournament and is made possible through proceeds from the tournament.

Financial support for the Foundation comes from the Foundation's annual golf tournament, as well as individual and corporate contributions and gifts. To make a tax-deductible donation to Richmond Region Tourism's Foundation, contact Tamera Wilkins Harris at or (804) 783-7410.

Makaela Stillworth
Aspires to one day be an event planner
School: VSU Department of Hospitality Management
Graduation Date: May 2016
Makaela recently completed an internship at the Hyatt Regency Hotel & Spa in Monterey, CA, in which she was able to acquire first-hand knowledge about event execution from beginning to end. Her academic honors and awards include induction into Eta Sigma Delta National Hospitality Honor Society where she serves as vice president. She is also a member of the National Society of Minorities in Hospitality where she serves as the membership director.

Past Scholarship Recipients
Caleb Ugworji
Aspires to one day open a sports bar
School: VSU Department of Hospitality Management
Graduation Date: May 2015
He has worked with both ARAMARK and Marriott Vacation Clubs. His experience also includes a trip to China to participate in an educational program focused on sustainable agriculture tourism.


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The leafy suburb of Manuka in the heart of Canberra is a fine place to live and find love, but in these days of stressful, busy lives, it can be a challenge to find the time and energy to seriously look for a lifelong partner. Dating for single men can be difficult because it’s hard to know where to look and where your ideal partner may be hanging out. Of course, you can spend endless hours trawling through unchecked and unvetted profiles in online dating sites, but if you want to find an ideal partner for a long-term relationship, the search can be frustrating and fruitless. Dating for single women can be just as difficult or even more so, because you may have to cope with the many predators in bars and online dating sites wanting to take advantage of women looking for long-term love. Even those who are genuinely looking for their ideal partner are unlikely to be compatible.

If you’ve been searching for your ideal man or woman for a lifetime partnership you may be reaching the end of your patience, and your optimism may be waning after a chain of meetings with hopelessly mismatched dates. You may even be thinking of giving up and reconciling yourself to a life without true love. But don’t give up! We can help you as we have helped thousands of others over our last three decades as a leading introduction agency in Canberra.

Our services are completely confidential and don’t stop at finding you your first date. We are always available to give advice and listen to your needs. Your first consultation is free, but best of all is the fact that you can be assured any date you have is with a person whose profile matches that of your perfect match. Forget blind dates or hit-and-miss introductions — with us, you are in complete control at all times. If you don’t find the love of your life on your first date, we will continue to find matches for you until you do.

Finding love in Canberra may be difficult, but it is not impossible. Who knows? Your perfect match may live close by in Manuka.


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Enerex The Friendly Trio, 90 Capsules

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Enerex The Friendly Trio Details

The Friendly Trio supplies 2 billion CFU of three strains of beneficial probiotic bacteria that are powerful and vigorous in their abilities to aid and maintain healthy digestion. They also undertake positive action with our immune system to keep us protected, and harmful organisms in check. These essential living micro-organisms also help us digest our food, produce some B vitamins, protect our gut lining, and assist with elimination.

These probiotics are specifically chosen for their effectiveness and broad spectrum abilities to maintain a healthy gut flora balance. Coupled with the convenience of not requiring refrigeration, they provide value second to none.

Enerex The Friendly Trio Features

Enerex’s The Friendly Trio contains 2 billion live cultures of potent bacteria strains called Lactobacillus acidophilus KS-13, Bifidobacterium bifidum G9-1 and Bifidobacterium longum MM-2.

Enerex chose these three types of bacteria because they have been researched to be optimum for a balanced intestinal environment. The Friendly Trio® are obtained from living human micro-organisms, perfected through decades of laboratory culturing. These have been processed to retain viability at room temperature, meaning unlike many other probiotics supplements, they do no need to be refrigerated. These particular strains are used in over 30,000 hospitals and clinics worldwide.

Lactic bacteria are your body’s companions

Lactic bacteria include Acidophilus, which lives in the upper and lower part of your small intestine, and Bifidobacterium, which lives from the lower small intestine to the large intestine (colon). These bacteria (which transform sugar into lactic acid) decrease the pH level of the intestines. This increases acidity and produces substances that suppress bad bacteria.

A gut reaction?

Recent studies have shown that probiotics can help to relieve inflammatory bowel disease (IBS), reduce inflammation in ulcerative colitis, prevent and lessen diarrhea, prevent and manage skin diseases (including eczema), reduce infections including Candida albicans yeast, and decrease constipation.

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*Review Disclaimer: Not everyone has these results. Product experiences vary from person to person. Please use these reviews for information only as they have not been reviewed by a medical professional. Do not substitute the informatioin in the reviews for advice from your physician or other health care professional or any information contained on or in any product label or packaging.

Suggested Use

Adults, Adolescents, Children (1 year and older): Take 1 Enerex The Friendly Trio capsule 3 times daily with meals or as directed by a health care practitioner.

Nutrition Facts
Serving Size: 1 Vegetarian Capsule
Servings per Container: 90
Amount Per Serving
% Daily Value
Lactobacillus acidophilus (KS-13) 1.6 billion
Bifidobacterium bifidum (G9-1) 0.2 billion
Bifidobacterium longum (MM-2) 0.2 billion
FOS (fructo-oligosaccharides) Chicory 100 mg
* Percent daily values are based on a 2000 calorie diet
  † Daily Value not established
Note: Serving Sizes are rounded to the nearest whole serving

Additional Ingredients: Hypromellose (vegetarian cellulose-complex capsule)

Allergy Information: na

Warning: Do not use if you are experiencing nausea, fever, vomiting, bloody diarrhoea or severe abdominal pain, or if you have an immune-compromised condition (e.g. AIDS, lymphoma, patients undergoing long-term corticosteroid treatment). Consult a health care practitioner prior to use if you are pregnant or breastfeeding. Discontinue use and consult a health care practitioner if symptoms of digestive upset (e.g. diarrhoea) occur, worsen, or persist beyond 3 days.
Store in a cool, dry place. Keep out of reach of children.

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The products and the claims made about specific products on or through this site have not been evaluated by or the Canadian Food and Drug Administration and are not approved to diagnose, treat, cure or prevent disease. The information provided on this site is for informational purposes only and is not intended as a substitute for advice from your physician or other health care professional or any information contained on or in any product label or packaging. You should consult with a healthcare professional before starting any diet, exercise or supplementation program, before taking any medication, or if you have or suspect you might have a health problem. is not responsible for any statements or claims that various manufacturers make about their products or the general information provided for each product on this website. We cannot be held responsible for typographical errors or product formulation changes. Please consult with your own physician or health care practitioner regarding the suggestions and recommendations made at and especially before using any product sold on this website.


text: If taking an ongoing case does not fit into your schedule, VLP offers many short-term pro bono opportunities that allow you to volunteer for a discrete block of time on a particular day. Your commitment does not extend beyond that day.  For some of the Lawyer for the Day projects and Court Clinics, you may need to be certified for Limited Assistance Representation. For more information about our pro bono projects, please contact Pro Bono Manager Miranda Black at mblack@vlpnet.org


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Friday, October 27, 2006

Zegin drugstore demolished in Bitola

A drugstore belonging to Zegin company, housing pharmaceutical laboratory of the Public Health Facility, has been demolished late Wednesday, Makfax's correspondent reported.

Marija Litoska, the manager of the drugstore, confirmed the incident took place at 23:00 hrs, adding that the perpetrators did not took a thing, but merely committed the act of vandalism.

She also said that the security agency "Protect" that was supposed to guard the drugstore, informed her about the incident as late as at 6 a.m., because, according to the agency, the contract with Zegin had been expired.

The Police conducted inspection at the site and the operation for tracking down the vandals is under way.

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Accessibility links

Breaking News

Syrian Kurds Could Tip Scales of Syrian Conflict

Ciwan, who would only give his first name because he has family still in Syria, escaped with his son from his hometown Idlib, Yayladagi, Turkey, March 22 , 2012.

A tent city among the ruins of a former tobacco factory along the Turkish-Syrian border is home to Syrian refugee Ciwan and his four-year-old son. The Yayladagi camp is swarming with Syrians fleeing the bloodshed of their homeland. But for Ciwan, a Syrian Kurd, it's unfamiliar living among the predominantly Arab population.

"Over there I lived mostly with my people, but here I am with them, it’s not very easy but slowly I am getting used to it,” he said.

His unease defines the struggle of Syria’s largest ethnic minority, the Kurds. The violent year-long political and social upheaval in Syria has left the country's estimated two million Kurds reeling.

Lodged between decades of oppression and the uncertainty of a future Syria ruled by the Arab-Sunni majority, Kurds have approached the uprising with caution.

They say they want to see President Bashar al-Assad's brutal reign end, but they also see this as an opportunity to reverse their suffering under the hand of an Arab nationalist regime. The Kurds fear a post-Assad, Sunni majority government might enact conservative Muslim policies curtailing a secular state.

As Syria’s largest ethnic minority, Kurdish leaders and some experts believe the Kurds have the power to tip the scales of the conflict and help an emerging opposition bring down Mr. Assad.

A haunting past

The Kurds are a non-Arab population native to the central Middle East. Oppression of culture, language and their national identity has defined life for the Kurds in Syria, Turkey, Iran and Iraq to varying degrees over the last half century and longer.

In 1962, the Syrian government stripped the citizenship of more than 100,000 Kurds, after holding a census in the Kurdish region. With this data, the government claimed these Kurds had illegally crossed the border into Syria. Today that number has grown to nearly 300,000, with the descendents of these Kurds unable to claim Syrian citizenship.

Even in peaceful times, Ciwan, who asked that his last name be withheld, had to protect his son from the Syrian state’s oppression of the Kurdish population.

"They did horrible things to us, they changed our villages' names into Arabic," he said. "They brought Arab people from other parts of Syria to our land, and they now live in our land. They don’t let us give Kurdish names to our children. My child’s name is Sexubun, but I have to give him an Arabic name too."

At the start of the government crackdown in April 2011, in an attempt to appease the ethnic minority, the Assad government granted citizenship to about 200,000 of the stateless Syrian Kurds.

Still, Kurds were not safe as anti-government protests spread nationwide.

Ciwan says he escaped the violence in his hometown of Idlib, after seeing Kurds killed in the unrest.

Haunted by their past, the Kurdish consensus seems to be it is time for Mr. Assad to step down.

"We as Kurds envision [see] our rights in this revolution and in toppling this Assad regime with all its symbols," said Radwan Hussein, a Syrian Kurd, as he protested outside an Arab League meeting in Cairo.

But for the Kurds, the challenges would not end with the downfall of President Assad.

"The regime is illegitimate," said Dr. Abdulhakim Bashar, secretary-general of the Kurdish Democratic Party of Syria. "We’re done with that already. But we need to think of a post-Assad era now."

Kurds seek parity

As the former head of the Kurdish National Council, a unified bloc of Kurdish parties, Bashar outlined the Kurdish demands to join the Syrian National Council, Syria’s opposition umbrella group.

They are seeking constitutional recognition, human rights initiatives, compensation for suffering, and participation in a nationwide democratic process. They promote the idea of a decentralized government, a decision to be made by Syrians through a referendum vote. And they want to drop the word "Arab" from the country's official name.

"Arab nationalists need to understand that Syria doesn’t only belong to them," Bashar said. "They shouldn’t hijack the revolution for their own agendas."

This stance has left them at odds with opposition groups.

The Kurdish delegation walked out of a meeting of Syrian opposition figures in Istanbul this week. In protest, the Kurds refused to sign on to a declaration naming the opposition Syrian National Council as the "formal interlocutor and formal representative of the Syrian people."

The SNC is emerging as the main political group backed by the West and Arab nations as the replacement for the Assad government.

Tipping the scales

Michael Weiss of the London-based Henry Jackson Society said the Kurds are the "decisive minority group" in Syria playing a "savvy game" with the opposition to ensure their rights.

"It’s hard to imagine the revolution succeeding without their full participation in it," he said.

Mona Yacoubian, a senior adviser for the Middle East at the Stimson Center, says Kurdish support for the opposition would force a tougher hand on Kurds by the Assad government.

The Assad government has minimized its assault on Kurdish areas in what analysts see as an attempt to keep the Kurds from rising up.

"The eastern part of Syria has been relatively quiet," Yacoubian said. "If the Kurds decide they want to throw their lot in with the opposition, I think that could change things significantly."

But Robert Lowe, manager of the Middle East Center at the London School of Economics, says he believes the opposition can succeed without the Kurds.

"I think some of them are watching and waiting to see which way it might swing," he said. "And if it was swinging in favor of the overthrow of Bashar al-Assad’s regime, I think the Kurds would very quickly become a part of it. But I don’t think their involvement is absolutely essential."

Back at the refugee camp on the Turkish-Syrian border, Ciwan wants to bring his son home to a Syria free of the Assad government where he could live freely as a Kurd.

"All we want is to have our rights," he said.

Henry Ridgwell in Turkey, Elizabeth Arrott in Cairo and Sirwan Kajjo in Washington contributed to this report.

Join the conversation on our social journalism site - Middle East Voices. Follow our Middle East reports on Twitter and discuss them on our Facebook page.

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Bridal nail polish goes bold and bright

Bridal nail polish goes bold and bright

Manicure options for a bride's big day

A bride’s hands are undoubtedly haute property on her wedding day. All the more reason to ensure neatly filed nails sport the right polish. “Traditionally brides have chosen pale soft pink lacquer shades for their wedding mainly due to the fact that they want to feel feminine, pretty and princess-like,” Karon McKendrick-Taylor, OPI’s Educator and Trainer tells us.

Yet some trend-setting brides are steering clear of creamy nudes and sea-shell pinks in favour of shades with more punch. “There has been a trend towards bolder and deeper lacquer shades worn by brides. Adding a bit of colour makes a more of a statement and looks great in photographs,” Karon adds.

OPI’s biggest trend prediction for bridal nail colour? “More passionate colours such as red for romance.” Whichever shade you decide for your day start with our pick of these wedding-worthy manicure essentials.

What nail polish colour did you wear on your wedding day?

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Mark Your Calendars: AUSU Annual General Meeting

AUSU will hold its Annual General Meeting on Wednesday, April 10, at 5:30 pm MST. The meeting is free and will be held via teleconference; all currently active undergraduate students may attend.

If You’re interested in issues affecting AU students, you won’t want to miss the teleconference. The meeting will review AUSU’s financial statements for 2012 and the budget for 2013, and will ?also discuss new service offerings and have a session for members to ask questions.? For more information or for copies of relevant documents, visit the AUSU website or email

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By Neal Ford

Screen Shot 2014-11-18 at 12.05.54The following is an extract from “Functional Thinking: Functional Programming using Java, Clojure and Scala”, published by OReilly.

Why Functional?

Let’s say for a moment that you are a lumberjack. You have the best axe in the forest, which makes you the most productive lumberjack in the camp. Then one day someone shows up and extols the virtues of a new tree-cutting paradigm, the chainsaw. The sales guy is persuasive, so you buy a chainsaw, but you don’t know how it works. Demonstrating your expertise with the previous tree-cutting paradigm, you swing it vigorously at a tree—without cranking it. You quickly conclude that this newfangled chainsaw is a fad, and you return to your axe. Then, someone appears and shows you how to crank the chainsaw.

The problem with a completely new programming paradigm isn’t learning a new language.  After all, everyone reading this has learned numerous computer languages— language syntax is merely details. The tricky part is learning to think in a different way.

Even if you don’t care about Scala or Clojure, and are happy coding in your current language for the rest of your career, your language will change underneath you, looking more functional all the time. Now is the time to learn functional paradigms, so that you can leverage them when (not if) they appear in your everyday language. Let’s take a look at the reasons why all languages are gradually becoming more functional.

Shifting Paradigms

Computer science often advances in fits and starts, with good ideas appearing decades before they suddenly become part of the mainstream. For example, Simula 67, created in 1967, is the first object-oriented language, yet object orientation didn’t really become mainstream until after the popularization of C++, which first appeared in 1983. Often, good ideas await foundation technologies to catch up. In its early years, Java was regularly considered too slow and expansive in memory usage for high-performance applications, but shifts in the hardware market made it an attractive choice.

Functional programming follows the same conceptual trajectory as object orientation: developed in academia over the last few decades, it has slowly crept into all modern programming languages. Yet just adding new syntax to a language doesn’t inform developers of the best way to leverage this new way of thinking.

I start with a contrast between the traditional programming style (imperative loops) and a more functional way of solving the same problem. For the problem to solve, I dip into a famous event in computer science history, a challenge issued from Jon Bentley, the writer of a regular column in Communications of the ACM called “Programming Pearls,” to Donald Knuth, an early computer science pioneer. The challenge is common to anyone who has written text-manipulation code: read a file of text, determine the most frequently used words, and print out a sorted list of those words along with their frequencies. Just tackling the word-frequency portion, I write a solution in “traditional” Java, shown in Example 1-1.

Example 1-1. Word frequencies in Java

public class Words {
private Set<String> NON_WORDS = new HashSet<String>() {{
￼2 |
    add("the"); add("and"); add("of"); add("to"); add("a");
    add("i"); add("it"); add("in"); add("or"); add("is");
    add("d"); add("s"); add("as"); add("so"); add("but");
    add("be"); }};
public Map wordFreq(String words) {
TreeMap<String, Integer> wordMap = new TreeMap<String, Integer>(); Matcher m = Pattern.compile("w+").matcher(words);
while (m.find()) {
String word =; if (! NON_WORDS.contains(word)) {
if (wordMap.get(word) == null) { wordMap.put(word, 1);
} else {
                wordMap.put(word, wordMap.get(word) + 1);
} }
return wordMap; Chapter 1: Why
} }

In Example 1-1, I create a set of nonwords (articles and other “glue” words), then create the wordFreq() method. In it, I build a Map to hold the key/value pairs, then create a regular expression to allow me to determine words. The bulk of this listing iterates over the found words, ensuring that the actual word is either added the first time to the map or its occurrence is incremented. This style of coding is quite common in languages that encourage you to work through collections (such as regular expression matches) piecemeal.

Consider the updated version that takes advantage of the Stream API and the support for higher-order functions via lambda blocks in Java 8 (all discussed in more detail later), shown in Example 1-2.

Example 1-2. Word frequency in Java 8

private List<String> regexToList(String words, String regex) { List wordList = new ArrayList<>();
Matcher m = Pattern.compile(regex).matcher(words);
while (m.find())
return wordList; }
public Map wordFreq(String words) {
TreeMap<String, Integer> wordMap = new TreeMap<>(); regexToList(words, "w+").stream()
            .map(w -> w.toLowerCase())
            .filter(w -> !NON_WORDS.contains(w))
            .forEach(w -> wordMap.put(w, wordMap.getOrDefault(w, 0) + 1));
return wordMap; }

In Example 1-2, I convert the results of the regular expression match to a stream, which allows me to perform discrete operations: make all the entries lowercase, filter out the nonwords, and count the frequencies of the remaining words. By converting the iterator returned via find() to a stream in the regexToList() method, I can perform the re‐ quired operations one after the other, in the same way that I think about the problem. Although I could do that in the imperative version in Example 1-1 by looping over the collection three times (once to make each word lowercase, once to filter nonwords, and once to count occurrences), I know not to do that because it would be terribly inefficient. By performing all three operations within the iterator block in Example 1-1, I’m trading clarity for performance. Although this is a common trade-off, it’s one I’d rather not make.

In his “Simple Made Easy” keynote at the Strange Loop conference, Rich Hickey, the creator of Clojure, reintroduced an arcane word, complect: to join by weaving or twining together; to interweave. Imperative programming often forces you to complect your tasks so that you can fit them all within a single loop, for efficiency. Functional programming via higher-order functions such as map() and filter() allows you to elevate your level of abstraction, seeing problems with better clarity. I show many examples of functional thinking as a powerful antidote to incidental complecting.

Aligning with Language Trends

If you look at the changes coming to all major languages, they all add functional extensions. Groovy has been adding functional capabilities for a while, including advanced features such as memoization (the ability for the runtime to cache function return values automatically). Even Java itself will finally grow more functional extensions, as lambda blocks (i.e., higher-order functions) finally appear in Java 8, and arguably the most widely used language, JavaScript, has numerous functional features. Even the venerable C++ added lambda blocks in the language’s 2011 standard, and has generally shown more functional programming interest, including intriguing libraries such as the Boost.Phoenix library.

Learning these paradigms now allows you to utilize the features as soon as they appear, either in your use of a new language such as Clojure or in the language you use every day.

Neal Ford on Shifting to Functional Thinking

About The Author

1 Comment

  • Marcel Weiher

    It looks like the “functional” example is missing the word list, which accounts for 6 of the 18 lines in the “traditional” code. If you take that into account, the difference is 1 line of code ( 11 vs. 12). Not exactly overwhelming.

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  • Situated in Laugharne on the River Taf estuary, Brown's is surrounded by beautiful coastline, and near to pretty seaside towns such as Tenby.
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Famous as the home of acclaimed Welsh poet and author Dylan Thomas, Laugharne stands on the Taf River Estuary in South Wales. A small but bustling town, there is plenty going on here to keep you entertained for a few days - estuary walks, a magnificent castle, the quirky Tin Shed Museum, the Dylan Thomas Boathouse, cafes and shops.

The Carmarthenshire coast has numerous stunning beaches to explore - wild and windswept or sunny and sandy, a trip to the beach is a must in any season - try nearby Pendine Sands.

Or, you could or head to picturesque seaside town of Tenby - just a 30 minute drive away. A delightful little harbour town, Tenby is home to many restaurants, shops, cafes and pubs all linked by cobbled streets. The colourful houses and hotels overlook some of Pembrokeshire's most beautiful beaches - walk along South Beach toward Giltar Point for fantastic views of Caldey Island.

Local attractions

  • Tenby - 32 km
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The former drinking den of Dylan Thomas, Brown’s Hotel – aka 'The Browns' – is a canny combination of upmarket local, artsy meeting space and posh (for the area) boutique b&b.

Chris Moss
The Telegraph

Your Hotel

Originally built in 1752, Brown's is an historic and iconic address which gained fame as Dylan Thomas' favourite haunt when he lived in Laugharne. He even famously gave the pub's phone number as his own! And it's no wonder he loved it so much - inside it has the feel of someone's living room - small, cheerful and full of eclectic locals.

Refurbished in 2012 to include 15 quirky bedrooms, the B&B has gained worldwide acclaim since its re-opening, being featured in The Telegraph, The Guardian, Tatler and The New York Times.

As well as being an iconic literary address, Brown's is also the social hub of Laugharne - live music is played in the bar every Sunday afternoon and regualr Poems & Pints night are popular too.

  • 15 bedrooms
  • Buffet breakfast
  • Bar
  • Free parking
  • Pets welcome
  • Wifi

Some services may incur additional charges, payable locally.

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This offer is based on a bed and breakfast stay.

Enjoy a full cooked breakfast is served each morning, and the bar serves light snacks alongside its locally brewed ales, quality wines and Penderyn whisky.

Brown's managers also run the Three Mariners pub next door which offers a full menu. If it's fine dining you're after, head to The Cors - an acclaimed restaurant open Thursdays - Sundays. (2 minutes walk away)

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Stag Head Wall Sticker

Bring a bit of nature into your room with the bold, majestic appearance of this stags head. A great statement wall decal for any home!

Size; 65cm (H) x 45cm (W)

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Florida Probate Lawyers and Estate Administration Attorneys — Pompano Beach, Fort Lauderdale, Jacksonville

From law offices in Broward County (Pompano Beach) and Jacksonville, our attorneys assist families whose loved one has died with or without estate planning documents such as a will or trust. Probate is the legal procedure known as the “Administration” of a deceased person’s estate, either in accordance with the desires of the deceased person as expressed in his or her will; or in accordance with Florida Law if he or she did not have a will. When a person dies with certain assets in his or her name only, the assets must be probated to pass to the person’s heirs or beneficiaries.

Our probate attorneys are experienced in probate matters and can help probate a deceased person’s estate so that his or her estate is properly distributed to heirs, beneficiaries, personal representatives, executors, and other interested parties. Our goal is to help families and personal representatives (executors) navigate the probate process, locate and gather assets; pay creditors, and distribute remaining assets or property according to the will.

In the event a person dies without a will, which is called “intestate” or “intestacy”, Florida law determines who the heirs, beneficiaries are and other interested parties are; and how the estate is distributed.

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