Objectives We sought to describe the early pediatric experience of transcatheter cryoablation, and identify whether specific arrhythmia substrates and/or ablation locations were particularly suited to cryoablation.
Background Radiofrequency (RF) ablation has become established therapy for pediatric tachyarrhythmias. However, challenges remain in terms of the safety and efficacy of RF ablation in specific locations; new methods may address these issues.
Methods Prospective data were available for 64 patients age 13 ± 4 (mean ± SD) years undergoing cryoablation at 14 centers participating in the Cryocath International Patient Registry. Dysrhythmia duration was 5.0 ± 4.2 years, with diagnoses of atrioventricular node re-entrant tachycardia (AVNRT) (n = 30), anteroseptal (n = 11), midseptal (n = 5), or other (n = 15) accessory pathway (AP) mediated AV re-entry, ventricular tachycardia (VT) (n = 3), and ectopic atrial tachycardia (EAT) (n = 2). Two patients had more than one arrhythmia substrate. Transcatheter cryoablation was offered by cardiologist preference after written informed procedural consent of each patient and/or legal guardian. Cryomapping was performed at −30°C and cryoablation was delivered with 4-min applications at −75°C.
Results Acute success was achieved in 45 of 65 (69%) cryoablation patients, with best success rates in AVNRT (83%) and right septal AP (75%), and lower success rates in other AP (43%), VT (66%), and EAT (0%). No device-related adverse events were reported. The success of radiofrequency (RF) ablation applied in 14 cryoablation failures was 4 of 4 for AVNRT patients, 1 of 1 for anteroseptal AP patients, 5 of 6 for other AP patients, 0 of 1 for VT patients, and 0 of 2 for EAT patients.
Conclusions Transcatheter cryoablation is a safe and well-tolerated alternative to RF ablation in pediatric patients on the basis of our initial experience. Success is highest in AVNRT and in substrates recognized as technically challenging or risky for RF ablation.
Radiofrequency (RF) ablation has become established therapy for pediatric tachyarrhythmias (1,2). However, challenges remain in terms of the safety and efficacy of RF ablation in specific locations, including the potential for injury to the coronary arteries, particularly when ablating within the coronary sinus and coronary veins (3–14). There continues to be a significant risk of ablation-induced atrioventricular (AV) block (15), particularly in right septal locations (16). The right AV groove may be a difficult location to achieve adequate catheter contact and stability, resulting in disappointing ablation results (17). Recently, transcatheter cryoablation delivery systems appropriate for pediatric use have been developed (18–23).
We sought to evaluate the safety and efficacy of early pediatric experience of transcatheter cryoablation as recorded in a prospective multicenter cryoablation procedure registry, as well as attempting to identify whether specific arrhythmia substrates and/or ablation locations were particularly suited to this new method.
Prospective data collection was performed for all patients <18 years of age undergoing a transcatheter cryoablation procedure using a Cryocath (Kirkland, Canada) system. There were 14 centers in 8 countries, all participating in the Cryocath International Patient Registry. Cryoablation was offered by physician preference, in most cases based on substrate location, with informed consent after local regulatory approval. Outcome measures were determined as for RF ablation.
After standard electrophysiologic assessment, a 7-F cryoablation catheter (Freezor 4 mm tip or Freezor Xtra 6 mm tip, CryoCath) was introduced via femoral (62 patients) and/or other (5 patients) venous and/or femoral arterial (1 patient) access. Cryomapping at −30°C for up to 60 s was performed and the arrhythmic substrate re-evaluated. Catheter adherence to the endocardium during the cryomap allowed for extrastimulus testing for inducibility, or in the case of atrioventricular nodal re-entrant tachycardia (AVNRT), assessment of slow pathway function. Cryoablation was performed at −75°C for a 4-min period.
There were 66 cryoablation attempts in 64 patients (36 males) age 1 to 18 years (mean ± SD, 13 ± 4 years). Two patients had dual substrates. One patient had congenital heart disease, with a previous repair of tetralogy of Fallot.
The distribution of arrhythmia substrates, as well as the procedural times and fluoroscopy times, stratified by substrate, are shown in Table 1.Procedural data were unavailable for one of the ectopic atrial tachycardia (EAT) cases. Thirty of the 66 cryoablations were for AVNRT. There were 30 cryoablations of accessory pathways (APs), one-half of which were right anteroseptal or midseptal.
The number of cryomaps and cryoablations, stratified by success and failure, is reported in Table 2.Although there appears to be a trend toward higher mean numbers of maps and ablations in failed attempts, the distributions are skewed and the medians are not dissimilar (p = NS by rank-sum test).
Best success rates (Table 1) were seen in AVNRT (83%) and right septal accessory pathways (75%), with lower success rates in other APs (43%) and ventricular tachycardia (VT) (66%). There were no reported successes in cryoablation of EAT, although the denominator is only two.
We evaluated the fate of failed cryoablation attempts (Table 1). Of the five failures of cryoablation in AVNRT, four were successfully treated by RF ablation. Of the four failed cryoablations of anteroseptal and midseptal APs, three were abandoned at the discretion of the clinician, and one anteroseptal AP was successfully RF ablated. Of the eight failed cryoablations for other APs, three were in the right posterior septum, two in the left posterior septum, one within the coronary sinus, and two on the left free wall. Two of these cases were abandoned, and five of the six remaining APs were successfully ablated with RF. All of the failed VT or EAT cryoablations also failed RF ablation.
From the patient's point of view in this series, the procedural success rate for ablation of AVNRT or AP, from any energy source, was 97% for AVNRT and 80% to 86% for APs, most of which were in right septal locations.
There were no complications of electrophysiologic (EP) study or cryoablation, specifically no cardiovascular injury and no permanent AV block. During cryomapping, transient observations of AV conduction abnormalities ranging from first degree AV delay to complete heart block were anecdotally observed, particularly in right septal locations; all of these were immediately reversed upon rewarming. One adverse event of "prolonged hospitalization due to prostatitis" was of uncertain relationship to the initial procedure. By way of comparison, a 3% to 4% overall complication rate for EP study and RF ablation has been shown in the Prospective Assessment after Pediatric Cardiac Ablation (PAPCA) study and its associated registry (17), whereas the reported incidence of AV block caused by RF ablation is 1.2% for AVNRT and 3.6% for all right septal pathways (24). In a review of a single center's experience of 145 septal APs, four cases of permanent AV block in 47 attempted anteroseptal and midseptal ablations were observed, for a site-specific AV block rate of 8.5% (16).
Three-month follow-up data were available for 28 of the 45 acutely successful cryoablations. There were four reported recurrences: two of AV node re-entry, one posteroseptal AP, and one VT. Depending on which denominator one uses, this may suggest somewhere between 9% and 14% recurrence rates. Because the follow-up data are incomplete, a selection bias to follow-up in the recurrence patients would be a reasonable assumption, and thus the recurrence rate may not be dissimilar from the PAPCA experience of 7% and 9% at two and six months, respectively (25).
This report represents the initial pediatric experience (as recorded in an international registry) of the use of a novel transcatheter cryoablation system. Acute success rates of 83% and 75% for AVNRT and right septal APs are similar to those of the early era of the pediatric RF ablation experience (1,26). Most impressively, there were no reports of injury to the normal conduction system, a finding similar to the larger adult experience with this form of ablation energy (27,28). Although the follow-up data in the Cryoablation Registry are incomplete, the recurrence rates are not dissimilar to those seen after RF ablations.
Although there were less impressive acute success rates in posteroseptal and free wall locations, most of these pathways were subsequently successfully ablated using RF energy, suggesting that lesion size and delivery may have played a role in these locations (29,30). In contrast, the failure of RF ablation following attempted cryoablation of VT and EAT suggests that the ablation energy source and mode of delivery were not responsible in these cases.
The reversibility of cryomapping provides the opportunity for forgivable test lesions in locations known to be at high risk for heart block during empiric RF ablation. Accompanying this is the ability to formally retest AV nodal physiology as well as arrhythmia inducibility during both cryomapping and cryoablation (28). The intrinsic catheter stability related to cryoadhesion prevents dislodgement during ablation. All of these characteristics are expected to enhance both safety and efficacy (27,31,32).
The disappointing performance during this early cryoablation experience in the ablation of some APs is most likely related to the smaller lesion size with initial versions of the cryoablation catheter, leading to a smaller effective target area being ablated. The issue of convective heat loss during cryoablation on the atrial side of the left AV groove has been suggested as playing a role (30), with some centers reporting better success when using a retrograde approach in adults, although the safety and efficacy of a retrograde approach with the relatively stiff cryoablation catheter has not been evaluated in children (Dr. M. Dubuc, personal communication, March 2003). Newer cryoablation catheters with larger tip surface areas and/or modified coolant gas parameters may offer a benefit in these situations.
Similar to the early experience with RF ablation (26), it is reasonable to expect that a learning curve exists for the attainment of proficiency in utilizing cryoablation. Acute success rates as well as recurrence risks are currently acceptable, but should eventually approach those of established modalities. The established safety of cryoablation in high-risk locations should allow the effective ablation of arrhythmias that otherwise might be abandoned, or perhaps ablated with a requirement for permanent pacing (16).
Cryoablation is a safe and effective alternative to RF ablation and appears to offer unique advantages related to catheter stability during energy delivery, as well as the safety of reversible mapping lesions in high-risk locations.
The authors thank Peter Andrew for his assistance with statistical analysis.
Centers submitting pediatric cases to the Cryocath International Patient Registry: Allgemeines Krankenhaus St. Georg, Hamburg, Germany; Deutsches Herzzentrum, Munich, Germany; Elektrophysiologie Bremen, Bremen, Germany; Erasmus Medical Centre, Rotterdam, the Netherlands; Hopital Europeen Georges Pompidou, Paris, France; Hospital for Sick Children, Toronto, Canada; Illinois Masonic Medical Center, Chicago, Illinois; Institut de Cardiologie de Montreal, Montreal, Canada; Karolinska Hospital, Stockholm, Sweden; Kerchoff-Klink, Bad Nauheim, Germany; Mauriziano Hospital, Turin, Italy; Onassis Hospital, Athens, Greece; University Hospital, London, Canada; University of Insubria, Varese, Italy.
Drs. Kirsh and Hamilton have each received, in the past, both travel support and honoraria from Cryocath Inc. Dr. O'Connor is a former employee of Cryocath Inc.
Revision received October 14, 2004.
(1994) Radiofrequency catheter ablation for tachyarrhythmias in children and adolescents: The Pediatric Electrophysiology Society. N Engl J Med 330:1481–1487.
(1997) Radiofrequency catheter ablation for paroxysmal supraventricular tachycardia in children and adolescents without structural heart disease: Pediatric EP Society, Radiofrequency Catheter Ablation Registry. Am J Cardiol 80:1438–1443.
(2001) Coronary artery stenosis after radiofrequency catheter ablation of accessory atrioventricular pathways in children with Ebstein's malformation. Circulation 103:538–543.
(2000) Effects of intracardiac radiofrequency current application on coronary artery vessels in young pigs. J Cardiovasc Electrophysiol 11:565–571.
(1995) Acute coronary occlusion secondary to radiofrequency catheter ablation of a left lateral accessory pathway. Eur Heart J 16:859–861.
(2003) Mechanical reperfusion of acute right coronary artery occlusion after radiofrequency catheter ablation and long-term follow-up angiography. J Invasive Cardiol 15:173–175.
(2003) Surgical radiofrequency ablation induces coronary endothelial dysfunction in porcine coronary arteries. Eur J Cardiothorac Surg 23:277–282.
(2003) Left anterior descending coronary artery occlusion after left lateral free wall accessory pathway ablation: What is the possible mechanism? Europace 5:263–266.
(1995) Left main coronary thrombosis after radiofrequency ablation: successful treatment with percutaneous transluminal angioplasty. Am Heart J 129:1217–1219.
(1999) Right coronary artery occlusion as a complication of accessory pathway ablation in a 12-year-old treated with stenting. Cathet Cardiovasc Interv 46:59–61.
(2002) Acute coronary occlusion during radiofrequency catheter ablation of typical atrial flutter. J Cardiovasc Electrophysiol 13:1047–1049.
(1997) Chronic left main coronary artery occlusion: a complication of radiofrequency ablation of idiopathic left ventricular tachycardia. Pacing Clin Electrophysiol 20:1874–1876.
(2003) Coronary ischemia induced by radiofrequency ablation in the left atrium. J Cardiovasc Electrophysiol 14:186–190.
(2002) Can radiofrequency current isthmus ablation damage the right coronary artery? Histopathological findings following the use of a long (8 mm) tip electrode. Pacing Clin Electrophysiol 25:860–862.
(1996) Inadvertent atrioventricular block during radiofrequency catheter ablation: Results of the Pediatric Radiofrequency Ablation Registry. Pediatric Electrophysiology Society. Circulation 94:3214–3220.
(2003) Radiofrequency catheter ablation of septal accessory pathways in the pediatric age group. Am J Cardiol 92:947–950.
(2002) Pediatric radiofrequency catheter ablation registry success, fluoroscopy time, and complication rate for supraventricular tachycardia: comparison of early and recent eras. J Cardiovasc Electrophysiol 13:336–341.
(1994) Evaluation of possible application of cryo-catheter ablation. Rinsho Kyobu Geka 14:442–443.
(1998) Feasibility of cardiac cryoablation using a transvenous steerable electrode catheter. J Interv Card Electrophysiol 2:285–292.
(1999) Alternate energy sources for catheter ablation. Curr Cardiol Rep 1:165–171.
(1999) Transvenous catheter ice mapping and cryoablation of the atrioventricular node in dogs. Pacing Clin Electrophysiol 22:1488–1498.
(1999) Cryothermal ablation: mechanism of tissue injury and current experience in the treatment of tachyarrhythmias. Prog Cardiovasc Dis 41:481–498.
(2000) Catheter cryomapping and cryoablation of supraventricular tachycardia in man: preliminary results. Pacing Clin Electrophysiol 23:613.
(2004) Van Hare GF, Javitz H, Carmelli D, et al. Prospective assessment after pediatric cardiac ablation: demographics, medical profiles, and initial outcomes. J Cardiovasc Electrophysiol 15:759–770.
(1995) The learning curve for radiofrequency ablation of tachyarrhythmias in pediatric patients: Participating members of the Pediatric Electrophysiology Society. Am J Cardiol 75:587–590.
(2003) Catheter cryoablation is safer than RF in AVNRT ablation. Pacing Clin Electrophysiol 26:S141.
(2000) Cryothermal ablation of the slow pathway for the elimination of atrioventricular nodal re-entrant tachycardia. Circulation 102:2856–2860.
(2002) Catheter-based cryothermal versus radiofrequency ablation: morphometric lesion characteristics. Pacing Clin Electrophysiol 25:663.
(2001) Effect of blood flow and cooling rate on myocardial lesion during catheter cryoablation. Pacing Clin Electrophysiol 24:681.
(2004) Catheter cryoablation of supraventricular tachycardia: results of the multicenter prospective "FROSTY" trial. Heart Rhythm 1:129–138.
(2003) A trial of cryothermal and radiofrequency energy in Koch's triangle. Pacing Clin Electrophysiol 26:S39.


text:
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redpajama_set_name: RedPajamaGithub


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text:
SARAH MARIE GRAYE
I'm Sarah Marie Graye…
…author of The Second Cup and The Victoria Lie.
I was born in South Manchester in 1975, to English Catholic parents as the second eldest of five daughters. (When people hear this they usually say "Your poor father!" – but he insists he never wanted sons.)
To the outside world, I seemed like a relatively normal kid. I would work hard in class but found myself easily bored. I was bullied and often retaliated, getting a name for being "lippy".
When I was diagnosed with depression aged nine, although it was initially a shock, it made a lot of sense to me. Having a label for why I was different was also helpful. (Although a few of my teachers dismissed mental health issues in someone so young, which was anything but helpful!)
it wasn't until after The Second Cup had been published, and following a breakdown, that I was diagnosed with ADHD – which has since been linked to a post-operative brain injury sustained in 2008.
While I don't think it's any surprise my debut novel is about mental health issues, I did feel that I'd cheated one of my characters out of closure: I'd accidentally given her ADHD.
So I decided to publish a new edition of my The Second Cup with character interviews – so my character could be diagnosed too. (This is the edition available on Amazon.)
In The Victoria Lie, I explore what it's like to receive a diagnosis of ADHD as an adult – particularly navigating the misinformation about the condition.
READ THE FIRST CHAPTER...
Read the first chapter of The Second Cup on Amazon for FREE.
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Read the Victoria Lie
PLEASE LEAVE A REVIEW
If you've read my books enjoyed them, I would love it if you'd review them on Amazon.
It's the best way to thank an author for writing a book – and it helps new readers find my book.
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redpajama_set_name: RedPajamaCommonCrawl


text:
Philippine football
Rappler Talk Sports: Mickey Ingles on Global FC player salary issues
Rappler talks to sports lawyer Mickey Ingles as he discusses legal issues behind the allegations against Global FC
Players and staff of Philippines Football League (PFL) club Global FC come forward with allegations that the club has not been compensating them for months.
This is an issue that resurfaced after some of the club's former players like Anton del Rosario and Milan Nikolic revealed their cases back in 2018.
As the league is set to meet with the club, Rappler talks to sports lawyer Mickey Ingles as he discusses legal issues surrounding the organization and what legal recourse affected players and staff can take. – Rappler.com
Ignatius Michael "Mickey" Ingles is an associate in The Law Firm of Ingles, Laurel and Calderon. He is also a full-time professor teaching Emerging Issues in Sports Law, Artificial Intelligence, Robots, and the Law, and Constitutional Law at the Ateneo Law School (ALS)
Ingles was the starting right winger of the Ateneo football team that won 3 straight UAAP men's football championship from 2004-2006. After graduating salutatorian in ALS, Ingles topped the Philippine Bar in 2012 and then obtained his L.L.M. from the Georgetown University Law Center in 2016. He is a licensed attorney in the Philippines and New York.
Marañon will always come home to the Philippines
Alen Stajcic says PH women's football 'best group I've been part of'
PH women's football team clinches record FIFA ranking
Azkals U23 winless in Asian Cup qualifiers with last-minute loss to Timor Leste
More on Philippine football


For your consideration we are offering for sale this Restored 1944 Parker 51 Double Jewel Fountain Pen in the Cordovan Color with 1/10 16K Cap. This fountain pen has been thoroughly taken apart, ultrasonically cleaned and put back together and is now in wonderful writing condition.
I have ultrasonically cleaned the NIB, feed, collector, breather tube, hood, cap, barrel and NIB. Replaced the old diaphragm with a new, properly sized one. Hand polished the 1/10 16K Gold Filled Cap & Gold Filled Arrow Diamond Clip, Clutch Ring, Blind Cap Tassel and 14K Parker NIB. Cleaned, Buffed, Polished and Waxed the barrel, blind cap and hood to bring back the vibrancy of fountain pen and to protect the celluloid. This Parker 51 measures 5 1/2" capped and 6 1/8" posted.
The fountain pen cap, barrel, blind cap and hood are in excellent condition with no chips, cracks or repairs. The 1/10 16K Gold Filled Cap has 9 line clusters with Deco Banding at the lip. The cap is clearly stamped with, "1/10 16K GOLD FILLED MADE IN U.S.A.". The cap is in excellent condition with no denting, there is a cartouche area with no monograming - an excellent overall cap . The Blind Cap and Cap have the plastic jewels that have been polished to high shine - the blind cap jewel displays a "honey" colored jewel. The barrel is stamped on two lines, "PARKER 51 MADE IN U.S.A. with date code 4, for 1944, in the third quarter". The clutch ring retains just a hint of gold plating in the center area. There are no monograms or personalizations to either the cap or barrel.
The actual writing portion of the 14K Parker NIB has a fine point measuring roughly .48mm when measured with digital calipers. When writing a sample with this NIB, it writes with a fine line. In the writing sample provided, the fine line measures at .37mm when measuring with digital calipers. The writing sample was done with the actual pen in the images that is listed for sale. The writing sample was used by dipping the NIB in Parker Quink Blue-Black Ink.
This vintage Parker 51 Vacumatic Fountain Pen is a gorgeous example from Parker. I would consider this Parker to easily grade Excellent Condition. It is ready to write or just add it to your writing arsenal collection.
NOTE: There is no blind cap / barrel / hood discoloration - the reflection off the camera body may give the appearance the color is not matching, but I will assure the color is matching across the pen hood, barrel and blind cap.


Well hello to you my reader chums! Today I thought I'd tell you about all the things I'm loving lately. Its obviously a bit too late to do a September favourites as we're nearing the end of October which is a crazy, its literally gone too fast! Therefore, I'm going to show you the things I've been reaching for and enjoying over these past two months.
The first product I'm going to tell you about is this Herbal Essences beautiful ends hair mask. This hair mask is specifically designed for split ends, and as I use heat quite a lot on my hair, I needed a something that was going to re-boot it and help the ends. I did get a trim which made it feel much healthier but I wanted to have a product which keeps it in a healthy condition. This mask has done wonders for my hair! Every time I use it, my hair feels silky, soft and appears in a lovely condition, especially the ends. I use it about twice a week to give my hair the little help it needs! It has such a beautiful scent as well, a scent that reminds me of all the products they use at the hairdressers if you get what I mean, its like a little treat on your hair, ahh I love it. Would totally recommend this mask to anyone who needs that bit of oomph to re-vamp the ends and add the shine/healthiness back to their hair.
The next product is from the Zoella beauty range and its the 'Soak opera'. Its designed for the bath or the shower and I've been using it as a shower cream. The thing I love most about this is the scent, like all of Zoe's range. It has a very similar scent to Daisy just not as sweet and has kind of a luxury feel, which I adore! It lathers up pretty well and as you get a lot of product in the bottle, I can tell it's going to last me a good while.
Another thing I've been loving which isn't to do with beauty, is this book called 'The twins' by Saskia Sarginson. I started to read this quite recently and I was hooked straight away, its such an insightful novel! I'm only half way in and I can't wait to see whats to come! As I'm a twin myself, it nice to read books to do with twins because it something I can relate to. For all you bookworms reading, I'd definitely check this one out.
A makeup brush I've been obsessed with lately is the Real techniques angled shadow brush from Nic's picks. I bought this set rather recently and have already got a lot of use out of it especially this brush. It is the softest brush ever and is just perfect for blending out eye shadows! I love how easy it is to blend with and the finish it helps achieve.
Another makeup product is this master precise eye liner by Maybelline. The thing I love about this eye liner is how easy it is to use and the amount of product given off. The pen is quite wet and gives off the ideal amount of product in order to make a defined clear wing.
The last makeup item is Rimmel lipstick from Kate's range in shade 107. I'm in love with this shade, it is the perfect berry/burgundy and I've been wearing it a lot recently. I like to wear it out on weekends, its such an autumnal colour and finishes the whole outfit off! It has a good lasting power and moisturises the lips as well. I find with some lipsticks they dry the lips out but not this one, its so creamy and pigmented!
Those were all my current favourite's, I do hope you enjoyed! Can't believe I'm nearly at 200 followers!
That Rimmel lipstick will forever be my favourite and I need to try Zoe's bubble bath as I'm loving the fizz bar!
I read The Twins recently. It was such a good book!
I love Zoella's bath range, and the body lotion is amazing. Leaves your skin so moisturised and soft. Totally did not expect it to be so good.
This hair mask looks lovely. I need a good one since I go swimming regularly.
Ooh I hope you give it a try!


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gave "parity payments" to farmers who agreed to limit production. The Act was designed to correct the imbalance between farm and nonfarm products and return purchasing power to pre-World War I levels. It met with only limited success. Production fell as intended (aided by the severe drought of 1933–36) and prices rose in consequence; but the AAA was of more value to big farmers than to small family farmers, who often could not meet their expenses if they restricted their output. Thus, even before the Supreme Court invalidated the AAA in 1936, on the ground that Congress had exceeded its power to regulate commerce, support for it had diminished. A second, more limited Agricultural Adjustment Act, 7 U.S.C. § 1281 et seq. (1938), similarly produced mixed results, tending to boost commercial farming at the expense of small farmers.
What made you want to look up Agricultural Adjustment Act? Please tell us where you read or heard it (including the quote, if possible).


Frøkjaer-Jensen C, Davis MW, Hollopeter G, Taylor J, Harris TW, Nix P, Lofgren R, Prestgard-Duke M, Bastiani M, Moerman DG, Jorgensen EM.
We developed a method, MosDEL, to generate targeted knockouts of genes in Caenorhabditis elegans by injection. We generated a double-strand break by mobilizing a Mos1 transposon adjacent to the region to be deleted; the double-stranded break is repaired using injected DNA as a template. Repair can delete up to 25 kb of DNA and simultaneously insert a positive selection marker.


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Does Starbucks have sugar-free drinks? Yes, Starbucks offers a variety of sugar-free beverages. The best Starbucks sugar-free drinks are the Iced Vanilla Latte and the Iced Caramel Macchiato.
Both are great because they offer a very similar taste experience to their sugar-laden counterparts, which is why they are so popular and one of the best sugar-free drinks you can get at Starbucks.
With summer approaching, you may be wondering what to order at Starbucks. You may be looking for a sugar-free drink.
Here are the best sugar-free drinks at Starbucks:
1 Best Sugar-Free Drinks At Starbucks
1.1 1. Strawberry Acai Refresher
1.2 2. Passion Tango Tea Infusion
1.3 3. Iced Coffee with Milk and Sugar-Free Syrup of Choice
1.4 4. Cool Lime Starbucks Refreshing Limeade Beverage
2 Pros and Cons of Drinking Sugar-Free Drinks on a Regular Basis
3 How Starbucks Reduced the Calories in its Sodas and Teas?
4 How Do You Order Sugar Free at Starbucks?
5 What Can a Diabetic Drink at Starbucks?
6 Is Starbucks Sugar Free Syrup Really Sugar Free?
Best Sugar-Free Drinks At Starbucks
The most popular sugar-free drinks on the Starbucks menu:
1. Strawberry Acai Refresher
If you're looking for a healthy drink, strawberry acai soda is a perfect choice. It's sugar-free, vegan-friendly, and tastes amazing.
The flavor is refreshing thanks to its mango-based Acai base and it's also packed with vitamin C.
2. Passion Tango Tea Infusion
Passion Tango tea infusion is a sugar-free tea that can be enjoyed by people following a keto diet. It has coconut, pineapple, and peach flavors.
Passion Tango tea infusion contains only 25 calories per serving, which is perfect for the keto diet.
It also has no sweeteners or artificial flavors, making it ideal for keto dieters who want to avoid any added sugars in their diets.
3. Iced Coffee with Milk and Sugar-Free Syrup of Choice
Starbucks iced coffee with milk and sugar-free syrup is a delicious, caffeine-packed drink. It is a fairly sweet drink, so it may not be for everyone.
It contains about 54 grams of sugar per serving, which is quite high considering the recommended daily intake for an adult is about 36 grams.
4. Cool Lime Starbucks Refreshing Limeade Beverage
When Starbucks first introduced this drink, it was a hit. It was popular because of its unique taste and flavor and because it represented the company's goal of being "the third place" people go besides work and home.
The drink is made with a blend of fruits including mangoes, pineapples, oranges, tangerines, and limes. The drink is also fortified with calcium to help promote healthy bones and teeth.
Pros and Cons of Drinking Sugar-Free Drinks on a Regular Basis
Sugar-free drinks are becoming increasingly popular among people who want to lose weight. They are often used as a substitute for regular soft drinks.
However, there are some risks associated with the regular consumption of these drinks.
Weight loss is easier because the calories in the drink are much lower than those in regular soda.
The risk of developing type 2 diabetes is lower because there is no sugar or high fructose corn syrup in these drinks.
You can't feel the sweetness when you drink it, which means you have to consume more of it if you want to get that sweet taste like with regular soda.
Drinking too many sugary drinks can lead to weight gain and tooth decay, so making this change may be counterproductive for someone.
How Starbucks Reduced the Calories in its Sodas and Teas?
Starbucks took some bold steps to reduce the number of calories in its beverages. It eliminated cream and sugar from most of its iced teas and lemonades.
They also reduced the amount of liquid sugar they add to their iced coffee drinks, reducing the number of calories in each drink by 20%.
How Do You Order Sugar Free at Starbucks?
If you want to order a sugar-free drink at Starbucks you first need to know that Starbucks has 2 sugar-free syrups, which are Vanilla and Cinnamon Candy.
That means you may order a variety of drinks, such as hot coffee, teas, or lattes. You may also add sugar-free syrups to create your own unique combination.
Sugar-Free Snickerdoodle, for example, combines a sugar-free vanilla latte with a pump of sugar-free cinnamon candy syrup.
If all you want is an iced coffee drink, get a Sugar-Free Lattes over ice, which are a delicious and chilly drink.
It's worth noting that these sugar-free beverages aren't on the Starbucks menu, so you'll have to inform them about the aforementioned recipes.
What Can a Diabetic Drink at Starbucks?
Skinny Mocha Latte.
Cinnamon Dolce Latte.
Whole Milk Cappuccino.
Low-Carb London Fog.
Nitro Cold Brew.
Iced Green Tea.
Shaken Iced Passion Tango Tea.
Iced Peach Citrus White Tea.
Choose one of these delectable drinks the next time you order, or make your own by requesting fewer pumps of flavored syrup or sugar-free syrup in vanilla, mocha, or cinnamon dolce.
Is Starbucks Sugar Free Syrup Really Sugar Free?
They pointed out that Starbucks' sugar-free syrup includes sucralose, sometimes known as Splenda.
According to some studies, these alternatives may elevate blood sugar levels by modifying your gut flora, which would be detrimental to ketosis (the diet cuts back on carbs and sugar).
Jaclyn London registered dietitian, and director of nutrition at the Good Housekeeping Institute, states, "The notion that sucralose has a significant impact on blood sugar levels is absolutely FALSE.
Sucralose and stevia are both considered non-nutritive sweeteners, which means they have no carbohydrate calories and hence have no effect on glycemic response when ingested."
If you find yourself at a Starbucks, be sure to get a low-calorie, sugar-free beverage. Avoid using sugar, creamers, or lemonade additions in any of the beverages.
If you're not cautious, what seems to be a harmless trip to Starbucks for a basic breakfast and coffee might wind up being devastating to your waistline.
5 Bang Energy Drink Gas Station
Non Carbonated Energy Drinks [A Complete List]
What is the Strongest Energy Drinks You Can Find at a Gas Station?
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Caroline Constas y Miu Miu.
Faithfull the brand, Common Projects, Mother, Hermes y Boy y band of outsiders.
Miu Miu y Christian Dior.
Miu Miu, Cartier, Jimmy Choo y Hermes.
¿Qué modelito os gusta más?
Esta entrada fue publicada en Celebs y etiquetada balenciaga, band of outsiders, boy by band of outsiders, caroline constas, cartier, christian dior, common projects, diary, effy, faithfull the brand, giuseppe zanotti, graziela gems, gucci, hermes, inspiración, jimmy choo, miranda kerr, miu miu, moda, mother, reformation, sara weinstock. Guarda el enlace permanente.


When I learned of the Child Actor Blogathon at Comet Over Hollywood, I had two ideas for it almost right away: the Jackie Searl spotlight and this one. Not too long ago I argued for why the Juvenile Award should be re-instated. In this post I will follow up on that notion to augment my case. It's one thing to quickly cite who won while it was around and state it never should have left, it's quite another to show you who would have had they never gotten rid of it. Now I have decided to illustrate that in three ways, including some omissions found when it was instated (it'll make more sense when we get there, trust me). First, I will list the young actors who since the end of the award (after 1961) were nominated for an Academy Award.
These actors obviously, had there still been a Juvenile Award, would have won that. While on occasion they were awarded the prize, more often than not they didn't have a realistic chance. Regardless, their nomination was deemed prize enough it would seem, but I disagree and as you will see there have been plenty of instances where the Juvenile award could have been handed out either in addition to or in place of the nomination.
In 1996, when I was 15 and the young actors of the day where my contemporaries, I started making my own award lists. Being young myself at the time I wanted to recognize young actors where most awards excluded them more often than not. These selections reflect those that were my among my BAM award selections that were eligible and the Academy bypassed. Prior to 1996, I thought of significant performances that were worthy of noting and would've had a strong case for the Juvenile Award had it been around.
This one is highly unlikely as Kauwboy wasn't shortlisted for the Best Foreign Language Film prize. However, the fact that it was the official selection for The Netherlands did make it eligible.
My young actress choice last year, Sophie Nélisse, was a year off from the Oscar calendar but also a strong possibility for Monsieur Lazhar.
It figures that both the best young ensemble, and perhaps individual performance, of the past 25 years got overlooked. So they are all honored here.
2009 Bill Milner Is Anybody There?
A slight wrinkle here from my original selection. Since the Academy set precedent of awarding tandems, why not do so here as well?
My 2004 winner was one where I was awarding a film from 2003, due to my stand on release dates, which is different than the Academy's. Having said that I then had to factor in both my nominees and who the Academy would be more likely to pick and decided if they chose anyone it would have been Highmore.
2001 Haley Joel Osment Artificial Intelligence: A.I.
Here's another interesting case: my winner was in a TV film which the Academy would never honor. Then two more nominees were either shifted due to my interpretation of release date rules and one erroneously in my revisionist phase. That leaves two eligible: Dominic Zamprogna in The Boy's Club and Joseph Ashton in The Education of Little Tree. Some people besides me actually saw the latter so I'd put that one up as a winner.
Michelle was my actual winner in 1996. Sling Blade in my awards was shifted to 1997 due to its release date. It being an Oscar nominated film make it a more likely retrospective candidate.
This section marks personal selections prior to my picking extemporaneous year-end awards.
I recall watching E! and hearing there was some buzz being stirred by the cast/studio for Elijah. I knew it would never happen, but it was deserved buzz.
I have since expunged them but for a time I did backtrack BAM Award to back before they started. Some of these picks reflect those findings.
Say what you will, but you know if the award was around that this would have happened.
I honestly almost scrapped this section. However, looking back through young nominees I noticed the discrepancy that some young nominees did not get a Juvenile Award while there was one. So I figured while I was at it I'd list a few notable performances that didn't get recognized. Those that "didn't need one" since they were nominated as in their respective categories against adult competition have denoted those with an asterisk.
The Juvenile Award is such an interesting topic. I agree with Roddy McDowall deserving an award in How Green Was My Valley. That may be one of my favorite child performances-so much heart and love in his role.
And Patty McCormack in The Bad Seed. WOW. She's great and terrifying!
Though today I always cheer for the child actors at the Oscars but at the same time…hope they don't win. Knowing what we know now about child stars, I want them to have a normal life.
Thank you so much for participating not only with one but 2 posts!


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'It has to stop': Omar says Trump encourages violence, hate
WASHINGTON (AP) — Rep. Ilhan Omar says she's faced increased death threats since President Donald Trump spread around a video that purports to show her being dismissive of the 2001 terrorist attacks. "This is endangering lives," she said, accusing Trump of fomenting right-wing extremism. "It has to stop."
from Yahoo News - Latest News & Headlines https://yhoo.it/2Gks1xE


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Martinez joins 4-H in Imperial County
Anita Martinez
Anita Martinez has joined UCCE as a new 4-H program representative overseeing the 4-H Youth Development Program in Imperial County.
She started her role on Jan 2, 2020, focusing on outreach to underserved populations in Imperial County and on working with the business community for partnership opportunities.
Before joining UCCE, Martinez was employed as the chief executive officer at the Holtville Chamber of Commerce, where she successfully redesigned and organized the 2018 and 2019 Carrot Festival.
During her career, she has served in various roles, such as marketing supervisor for a casino, marketing director for an agriculture company and off-road race team, and marketing director for two major credit unions.
Martinez is a life-long Imperial Valley resident with roots in Heber, where she attended grade school before graduating from Southwest High School in El Centro. As a former 4-H member, she remained a strong advocate of the 4-H Youth Development Program and was a project volunteer until she decided to start a new club in her hometown of Heber. Dogwood 4-H Club, named after the road that links most major Imperial Valley cities, was proudly founded in 2013 with only 12 members. Since then, it has grown to over 18 families, serving as many as 34 members.
As the new 4-H representative, Martinez is excited to share her knowledge and help expand the program to new families and members who can enjoy the benefits of the program. She is looking forward to helping 4-H leaders expand on youth/adult partnerships and opportunities and to attract new adult leadership to the program.
She graduated with a Bachelor of Science in business management with an emphasis in marketing at University of Phoenix.
Martinez is based in Holtville and can be reached at (442) 265-7711 and ammart@ucanr.edu.
Ritz joins ANR as disability management services coordinator
David Ritz
David Ritz joined UC ANR in November 2019 as the disability management services coordinator. This new position in ANR's Human Resources is funded by UC Office of the President. An experienced, certified rehabilitation counselor, Ritz served in a similar role on the UC Davis campus since 2007. As disability management services coordinator, he provides technical consultation, counseling and training to managers, supervisors, academics and staff on the California Fair Employment and Housing Act, California Labor Code, Americans with Disability Act, UC Policy and Collective Bargaining Agreements related to the interactive process, reasonable accommodation and medical separations.
He will also assist in developing and expanding wellness programs and activities for UC ANR employees, and increasing accessibility for the disabled at UC ANR events and programs. Prior to joining UC Davis, he spent 27 years in private practice as a vocational rehabilitation counselor, creating rehabilitation and career development plans, providing early intervention counseling for Department of Corrections employees, and developing reasonable accommodations and job modifications for disabled workers.
Ritz has a Master of Arts in education and is a Certified Rehabilitation Counselor by the Commission on Rehabilitation Counseling.
Ritz is based at the ANR building in Davis and can be reached at (530) 750-1317 and daritz@ucanr.edu.
Urrea joins Human Resources
Angela Urrea joined UC ANR in January 2020 as a Human Resource generalist. In this role, she will provide assistance with staff employment efforts, including classification, compensation and recruitment.
Urrea is an experienced HR professional with a background in recruitment, leaves of absence, workers compensation, disability, payroll and safety. Her most recent role was with UC Davis where she provided human resources assistance and support to our fellow university faculty members.
She is based in the ANR building in Davis and can be reached at aurrea@ucanr.edu.
Reiter wins award for best Twitter feed
Maggie Reiter, UC Cooperative Extension turfgrass and weeds advisor for Fresno County, won a 2020 Super Social Media Award for "Best Twitter Feed" from Golf Course Industry magazine. Winners for each category were chosen from industry people on social media nominated by Golf Course Industry readers, followers and listeners.
Follow @maggie_reiter on Twitter to see photos and descriptions of her research.
Super Social Media Award winners will be honored during #GCITweetUp20 inOrlando on Jan. 29.
Maggie Reiter uses her Twitter feed to inform the public of the research she is conducting.
Posted on Monday, January 27, 2020 at 10:52 AM
Author: Pamela Kan-Rice
Tags: Angela Urrea, Anita Martinez, David Ritz, January 2020, Maggie Reiter
UC ANR is Smoke & Tobacco-Free
Webmaster Email: jewarnert@ucanr.edu


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UK to start COVID-19 vaccinations on Tuesday – Health Chief
by The Eagle Online
in Featured, R&D Health
The first doses of the Pfizer/BioNTech vaccine against COVID-19 would be administered in the UK on Tuesday, Chris Hopson, head of NHS Provider, a membership organization for the National Health Service trusts in England, announced on Friday.
"There are 50 hospital hubs and we know the vaccine will reach those to enable people start vaccinating on Tuesday," the NHS official told the BBC broadcaster.
The United Kingdom on Wednesday became the first country in the world to give emergency use approval to a candidate vaccine developed by US pharmaceutical giant Pfizer and German company BioNTech.
The companies had earlier announced that their vaccine had shown to be roughly 95 per cent effective at preventing infection during clinical trial.
UK health minister Matt Hancock said on Wednesday that the first 800,000 doses of the 40 million doses the UK had secured with Pfizer/BioNTech would be available next week.
Local media reported on Thursday that the first batch had entered the country via the Eurotunnel.
Asked if there was any target for the number of vaccines to be administered on Tuesday, Hopson said "as many as possible", but stressed that the bulk of the immunisation programme would be carried out from January to March, 2021.
"It's a marathon, it's not a sprint," he said.
UK Business Minister Alok Sharma also confirmed that the plan is to start the vaccination programme next week.
Sharma said he was confident that all the 800,000 doses would be available by then.
Other countries, including Russia, have also developed vaccines.
Russian President Vladimir Putin also on Wednesday ordered his government to begin a large-scale vaccination campaign next week.
Sputnik/NAN.
Tags: Chris HopsonCOVID-19National Health ServicePfizer/BioNTech vaccine
Kwara records 46 new cases of COVID-19


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Joan Burkett was a young girl during the war and lived with her family near the Surrey Docks. Remaining in London for the duration of the war, Joan was looked after by her grandparents as her father, serving in the Merchant Navy, was killed at the beginning of the war and her mother had to begin work at the Woolwich Arsenal in order to support the family.
Joan recalls her schooling being interrupted by the war as schools closed and many were destroyed in air raids. During the war, Joan only attended school for two years. The bombing was heavy in the area around Surrey Docks. It was not long before the family's house was destroyed by a bomb. Rendered homeless, the family lived in a shelter until they were relocated by the council to a requisitioned house. The bomb had destroyed most of the family's belongings and Joan recalls the Red Cross supplying them with clothes. Other voluntary services visited the shelter twice daily to feed the homeless families residing in the shelter.
The shelter in which they stayed after being bombed out was 'well organised'. Joan recalls, 'They even had a first aid place in the shelter and a little place where the children could go to learn a little bit because as I said no schools was open'.


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21 January 2022 - 5:30 PM
Cirque du Soleil's TORUK – The First Flight
Photo: Youssef Shoufan; Costumes: Kym Barrett © 2015 Cirque du Soleil
How well do you remember James Cameron's Avatar? I'm sure you remember the look of the film- the groundbreaking visuals, the swooping excitement, the one time the headache you always get from 3D somehow seemed worth it. It's the #1 highest grossing film of all time (unless The Force Awakens makes another 1.2 billion before leaving theatres) and shockingly only falls as far as #2 when you adjust for inflation (after Gone With the Wind). But do you remember the story at all? Do you remember it making you feel anything or invest in it beyond your general sense of wonder at the technical feats on display? I'll jog your memory- Avatar is a pretty vacant film; a refried mishmash of familiar narratives painted blue and presented prettily. It looks cooler than almost anything else has ever looked, but that's all.
TORUK- The First Flight, the Cirque du Soleil piece that's inspired by the film and swinging into town for a one-weekend engagement at the ACC, is just like that. It starts with some glorious projection work and is highlighted by a few feats of acrobatic wonder- the first, and arguably the most extraordinary, involving a see-saw-like bone structure and the second (pictured) a collection of motorized poles- but the skeleton on which these beautiful things are hung is ultimately not noteworthy.
A classic Cirque show is more like last year's KURIOS, a series of extraordinary physical feat after extraordinary physical feat unified by a strong aesthetic. I'm not opposed to adapting that format to become more story-based, in fact I welcome that ambition, but TORUK focuses too much on a weak, predictable story at the expense of the bread and butter of Cirque du Soleil- the cirque. The effect is almost confusingly dull with too many characters wandering around miming the distress of a specific plot point rather than moving on to their next display of superhumanity. Set in the world of Avatar but with none of the film's characters or story elements, TORUK is a basic coming-of-age tale with a dash of Into the Woods-style "gather 5 things" hijinks, some impressive puppet monster roadblocks and a big final saving of the day that doesn't feel particularly earned.
It's somehow fitting that the Avatar Cirque show has the same fundamental flaws as its inspiration. Both the film and the show are so very lovely to look at and there are technicians (in the lighting booth, in the design department and in the ensemble) who are working at the top of their game but the writers haven't given them material worthy of their efforts.
TORUK – The First Flight performs at the Air Canada Centre from Thursday, January 7 through Sunday January 10.
Written by: Kelly Bedard
Published: Friday, 2016/01/08 - 6:05
Highlights from Corona Cold Reads
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If you're wanting to decorate your garden with large, conspicuous, brilliantly colored blooms, look no further than our gorgeous selection of Hibiscus. Whether you choose a Rose of Sharon (the shrub form of Hibiscus) or a Rose Mallow (the perennial form), you'll enjoy eye-catching crepe-papery flowers in shades of pink, red, blue, and purple, to name a few! Tolerant of heat and humidity, attractive to hummingbirds and butterflies, and ignored by deer, Hibiscus are a must-have for the sunny garden.


If you're travelling on a domestic Seat only, Seat + Bag, Tasman and Pacific Island Seat or Seat + Bag fares you can purchase a Standard Seat in advance using paid Seat Select.
Seat Select offers great value options to secure a bit extra, so check out the pricing below. Prices displayed are one-way per journey sector and are in Chinese Yuan.


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Former El Slavador president heads to trial in $310 Million Corruption scandal
Category : Crime, Human Interest, Legal
A judge in El Salvador decided Wednesday to send former President Elías Antonio Saca (2004-2009) and six collaborators to trial, to answer for the deviation of 301 million dollars during his administration, the Prosecutor's Office said.
"The Fourth Court of Instruction of San Salvador sends to trial former President Elías Antonio Saca, 3 former employees and 3 former employees of the Presidential House," the Attorney General of the Republic (FGR) recorded in his Twitter account.
Prosecutor Mario Huezo said that if Saca is guilty, he could receive up to 25 years in prison.
READ MORE:https://www.prensa.com/mundo/Justicia-salvadorena-juicio-expresidente-Saca_0_5031996775.html
JAMES BRYSON DID NOT WRITE THIS ARTICLE; this is merely an ENGLISH TRANSLATION OF "LA CRITICA" https://www.critica.com.pa/nacional/denuncia-red-frog-sigue-vendiendo-fincas-propiedad-de-tres-cruces-de-oro-606475 La Crítica 6/22/2021 The Tres Cruces de Oro group, a subsidiary of Six Diamonds Resorts International, denounced the fact that the Red Frog Beach group continues to sell lots and …
https://translate.googleusercontent.com/translate_c?depth=1&hl=en&prev=search&pto=aue&rurl=translate.google.com&sl=es&sp=nmt4&u=http://elsiglo.com.pa/internacional/segunda-pandemia-vuelve-hundir-demanda-aerea-70/24169140&usg=ALkJrhhLWtpQ3uqzZgzNgj7QguFkVMRvgA International flights were the most affected, with a drop of 87.8% compared to that registered in October last year Total demand for air travel fell 70.6% in October compared to the same month last year, a sign of how "desperately slow" the sector's recovery is going to be due …


Successful applicants for the NDP 2013 ticket balloting may collect their tickets from June 7 to 16. They would have already been notified of their successful application by the organisers.
Tickets are available for pick up from 10am to 10pm at the Float@Marina Bay which is at 20 Raffles Avenue.
To pick up their tickets, applicants must bring along a photo identification card. They may also authorise someone to pick it up on their behalf. A letter of authorisation may be downloaded from the NDP website.


Carmin has been a licensed loan originator for many years. Carmin's diverse background provides the knowledge needed to provide you excellent service. He makes it easy and explains each phase of the loan process so that you understand and have a smooth closing.
His experience and professionalism are priceless tools for a mortgage originator.
Carmin is dedicated to make sure that his clients experience the best customer service possible. He has been an active member of the community for many years and really values every client that entrusts him with their financing needs.


Home / Frequently asked questions / Developer Services / Can I build over a water main?
No, you are not permitted to build within 3 metres of a public water main as we must have unrestricted access to repair, maintain or renew our main when required.
There are further details of an alternative process (water main diversion) within our Guidance notes.