Podcast appearances and mentions of jan jun

Join us for a lively discussion centered around the Jan - Jun 2024 Oasis/ULECx Investment Corp shareholder meeting. In this episode, we delve into a range of topics crucial to our corporation's journey and future aspirations.We dive deep into financial insights, exploring our corporation's return on investment, the impact of Jeff Randall Berte's transition from elder to equity shareholder, and crucial financial metrics such as book balance, total assets, and equity.We candidly discuss recent investments, including our ventures into real estate with two condominiums, highlighting our strategic approach to equity partnerships. Cost efficiency takes center stage as we explore relocating our office to a coworking space and providing furnished accommodations for traveling professionals.Martin passionately outlines our corporation's vision amidst the challenges faced in 2023, underscoring our unwavering commitment to integrity and virtuous business practices. The episode concludes with warm exchanges of encouragement and well wishes among participants, reinforcing our optimism for the corporation's long-term success.Tune in as we navigate the complexities of corporate stewardship and celebrate milestones in our journey together. Review the Oasis/ULECx Investment Corp January - June 2024 Financial Reports here. Join the conversation at oasis205.slack.com for ongoing discussions and insights. Stay tuned for more strategies for growth, empowerment, and community impact in next week's episode of IGNITE! Disclaimer: All opinions expressed on this podcast including the team and guests are solely their opinions. Host and guest may maintain positions in the companies and securities discussed.This podcast is for informational purposes only and should not be relied upon as specific investment advice for any individual or organization.

This episode of the Curious Case Vault has an admittedly grim premise--a patient who suffered two gunshot wounds to the head.  In this discussion, Alba leads us through a case of a young Brooklyn, NY man who, in the spring of 1888, sustained what could have been a devastating injury in any time in history.  In his case, we'll see how the neurosurgeon of the time treated this patient leading to an amazing if not inspiring outcome.  We'll talk about the evolution of this type of neurosurgical trauma care and form an appreciation for the resilience of the human brain to trauma of this sort.Case Link:This case comes to us from the archives of the Brooklyn Medical Journal and Retrospect of the Medical Sciences. Vol 1_1888 (Jan-Jun): 476-477. Sources:Modern Neurosurgical Overview for Gunshot Wounds to the Head from the AANS.Historic Overview of Neurosurgical Treatments for this injury at the turn of the 19th century available via this article by Agarwalla, et al.Support the showSponsor: Artery InkUse promo code HISTORYPOD at Artery Ink's website to save 10%* on your order of $35 or more and show support for our show as well as for a homegrown, wonderful local company. Artery Ink specializes in apparel and decor inspired by anatomy and the human body. Whether you're in the field of healthcare or not, Artery Ink has something that will definitely appeal to you so go and check them out! (*Discount code does not apply to subscription boxes)Submissions for Mike's Trivia Challenge Segment:-We invite our audience to submit medical history trivia questions (with or without a supporting article) to see if Mike happens to know the answer off the top of his head.-If Mike is wrong we'll award you your very own medical eponym so that you can join us in becoming a part of medical history.-Submit through our website, social media DMs, or via e-mail: poorhistorianspod@gmail.comPodcast Links:-Linktree (reviews/ratings/social media links): linktr.ee/poorhistorianspod

Dear Shareholders,I trust this message finds you in good health. On Monday, August 14th, ULECx Investment Corporation, the parent company of Oasis, convened the quarterly shareholders' meeting to discuss the financial performance of the first half of the year and to provide insight into our future strategies.During the meeting, we conducted an in-depth review of the financial results for the period January through June 2023. Our team presented a comprehensive analysis of key financial indicators, highlighting both achievements and areas of focus. This session allowed us to provide a transparent overview of our financial standing.Furthermore, we had the privilege of sharing our strategic plans for the upcoming quarters. Our leadership team elaborated on our vision, goals, and initiatives aimed at sustaining growth, optimizing operational efficiency, and enhancing shareholder value.For those who were unable to attend the meeting, the Jan - June 2023 Financial Reports are now available for your perusal. We encourage you to review these reports to gain a comprehensive understanding of our financial performance and strategic direction.Should you have any questions or require additional information, please do not hesitate to reach out to our Investor Relations team at [contact email/phone number]. Your insights and feedback are valuable to us as we continue to strive for excellence in our endeavors.We are committed to maintaining transparency, fostering growth, and delivering value to our esteemed shareholders. Thank you for your ongoing support.Sincerely,Martin A. BriggsExecutive Producer & Co-Founder ULECx Investment Corporation   We would love to hear from you! Contact us or follow us on Facebook, Twitter, Instagram, and LinkedIn! Disclaimer: All opinions expressed on this podcast including the team and guests are solely their opinions. Host and guest may maintain positions in the companies and securities discussed.This podcast is for informational purposes only and should not be relied upon as specific investment advice for any individual or organization.

Dominican Republic June 2023 Tourist Records. 5.3 Million Tourists Jan - Jun 2023. Investors are you paying attention?

Midway through 2023 so no better reason to do a best of (so far).  This podcast pulls from the last six mixes Jan-Jun cherry picking the some of my favourites so far this year.  It's been a pretty good year for music so far, it wasn't easy choosing which tracks to play, although it was all done on the fly so it was dependent on the vibe and feel of the mix.The chatroom was packed, soooo grateful to the regulars that join every fortnight.  They absolutely influence the tracks I play.Not much more to say about the mix, I mean you've heard all the tracks before and hopefully most of your favourites made it into the mix.I'm off to Europe for the rest of July taking in nine cities in 17 days!  Can't wait to catch up with family and friends, some of whom I have seen for over 17 years.  One of the highlights of the trip is Suncebeat 14 which is confirmed as the last Croatia based Suncebeat.  It's always such an amazing experience, soulful househeads from all over the world coming together to enjoy the sun, sounds and great company.If you are going and you see me, come say hi.Tracklisting:1: Krywald, Farrer - He's The Chief2: Chaos In The CBD - Distorted Fields3: Dutchican Soul - Nine O Nine (Extended Mix)4: Prunk, Ruze - Incredible5: Joey Coco, Ralph Session - Bonafide (Ralph Session NYC Deep Mix)6: Honey Dijon, Cor-Ece - Stand (Club Mix)7: Dave Lee ZR, Omar - Starlight (Grant Nelson Extended Mix)8: Jaegerossa - Side of Soul9: Scott Diaz - Dancing Shoes10: Dick Johnson - Into The Groove (String Mix)11: Ralph Session, Mr V - Bounce To This (Underground Mix)12: Toman - Sunshine & Ravioli13: Byron The Aquarius - Get Up14: Krywald, Farrer - The People's Asafo15: Stefano Ranieri - It Could Happen16: Korie Minors - The Arrival17: Badbox - Zurna18: Nyaruach, Friday - Gatluak (LevyM Remix)19: Milton Jackson - 640020: The Vision, Ben Westbeach, Kon, Andreya Triana - Hallelujah In Heaven (Groove Assassin Extended Mix)21: Grant Nelson - Relentless22: DJ Dove - Bussit (Extended Mix)23: Vincent (FR) - How I Feel24: Pat Lok, Party Pupils - Alaska (Extended Mix)25: Cassimm - Son De Lo (Extended Mix)26: Austin Ato - Discolombo27: Zzama  - Underground Resistance (Colour Garage Side)Enjoy!

We thought we'd start sharing the first few minutes of our Patreon episodes here on the main feed to give everyone a taste of what you can expect if you join us at patreon.com/thefrankencast. This week over on Patreon, we're back with a free-flowing chat about the State of the Horror Union! We're discussing all the big releases from the first half of 2023 along with some upcoming stuff and a few things from 2022. And don't worry it's mostly spoiler-free!

In this episode I reveal how both White supremacists and decolonizing Latinos use the Black Legend narrative to justify their animosity towards Hispanic culture. References Giraudo, Laura, and Stephen E. Lewis. 2012. “Introduction: Pan-American Indigenismo (1940-1970): New Approaches to an Ongoing Debate.” Latin American Perspectives 39, no. 5 (September): 3-11. https://www.jstor.org/stable/41702280 Jackson, Robert H., ed. 1997. Liberals, the Church, and Indian Peasants: Corporate Lands and the Challenge of Reform in Nineteenth-century Spanish America. N.p.: University of New Mexico Press. Peck, Douglas T. 2001. “Revival of the Spanish "Black Legend": The American Repudiation of Their Spanish Heritage.” Revista de Historia de América, no. 28 (Jan-Jun), 25-39. https://www.jstor.org/stable/20140059 Zinn, Howard. 2003. A People's History of the United States: 1492-present. N.p.: Pearson Longman. --- Support this podcast: https://podcasters.spotify.com/pod/show/d-a-f-l-o-w/support

Mil anos em meia hora? Bora! Com tempinho pra criticar dessa visão de que só tinha cristianismo e europa na idade média! Separe trinta minutos do seu dia e aprenda com o professor Vítor Soares (@profvitorsoares) sobre a Idade Média. - Se você quiser ter acesso a episódios exclusivos e quiser ajudar o História em Meia Hora a continuar de pé, clique no link: www.apoia.se/historiaemmeiahora - Compre nossas camisas, moletons e muito mais coisas com temática História na Lolja! www.lolja.com.br/creators/historia-em-meia-hora/ - PIX e contato: historiaemmeiahora@gmail.com Apresentação: Prof. Vítor Soares. Roteiro: Prof. Vítor Soares, Prof. Victor Alexandre (@profvictoralexandre). Edição: Victor Portugal. REFERÊNCIAS USADAS REBOIRAS, Fernando, La España medieval, frontera de la Cristiandad. Revista Notandum 3, JAN-JUN,1999, pp. 25-48 LE GOFF, Jacques. As raízes medievais da Europa. Petrópolis. Rio de Janeiro. Editora Vozes, 2007.

This episode is about the trading between the Dutch of New Netherland, the English first of Plymouth and then of Massachusetts Bay Colony, and the Algonquian and Iroquoian tribes in the region during the 1620s and 1630s.  These relationships were important, both to the profitability of settlement for the Dutch and the English, and because they so destabilized the balance of power among the tribes and the Europeans that they would eventually lead to the very ugly Pequot War of 1636-38. The indigenous ceremonial currency, wampum, sat at the center of this trade, and we take a first look at its monetization by the Dutch and then the English. Twitter: @TheHistoryOfTh2 Facebook: The History of the Americans Podcast Selected references for this episode Mark Meuwese, "The Dutch Connection: New Netherland, the Pequots, and the Puritans in Southern New England, 1620—1638," Early American Studies, Spring 2011. Paul Otto, "Henry Hudson, the Munsees, and the Wampum Revolution," published in The Worlds of the Seventeenth-Century Hudson Valley, ed. Jaap Jacobs and Lou Roper. Albany: SUNY Press, 2014 D. I. Bushnell, Jr., "The Origin of Wampum," The Journal of the Anthropological Institute of Great Britain and Ireland, Jan - Jun 1906. Wampum (Wikipedia)

Starkast hosts Mirlyah (and Befuddled Panda's notes) in their follow up to episode #97: Anticipated SFF 2022 (Jan - Jun). This episode covers the second half of 2022. Here's a link to our 2022 anticipation list: https://docs.google.com/spreadsheets/d/12ITV5BVk4nN7CgHrRYtp77HUO0F7iEOl7Vb5c_AWj00/edit#gid=1972214995 Music is Galactic Damages by Jingle Punks. Considering supporting The Legendarium on Patreon: https://www.patreon.com/legendarium We can be found on The Legendarium Discord: https://discord.gg/FNcpuuA And on Reddit: https://www.reddit.com/r/thelegendarium/ Follow us on Twitter: @GreenteamPod

playing my first pure house set for two years! awesome house music!Dance Together (Original Mix) - Matt Caseli All Night (Tech Mix) - A.S.R, Redux Saints Swag House (Extended Mix) - Jose Nuñez, Antranig, El Gucci Burnin' Up Inside (Extended Mix) - Simon Ray Move (84bit Remix) - Animist, 84bit Push The Button (Original Mix) - Sanda Coupla Blues - Eyes Everywhere What Is This Sound (Archie Hamilton's Higher Repurpose Mix) - Peace Division, Archie Hamilton Yup (Amyelle Remix) - Fallon (UK), Amyelle Timeout (Original Mix) - GIORG, Santez Give It Up (Extended Mix) - Tough Love Bye Bye (Original Mix) - Caravaca Care Of What (Original Mix) - Noise Kidz Cabin Fever (Original Club Mix) - Dave Anthony Set U Free (Original Mix) - Jay Vegas We're Rollin' (Yes Baby! Remix) - Lisa Jane, Yes Baby! Intuition - JPA Party Time (Original) - Herald Club Rockin' (Original Mix) - Lebedev (RU) Feeling Close - Lauhaus, Mario Franca Foreign Policy (Original Mix) - Neil Smallridge Dragonfly (Original Mix) - Steffen Deux Slowly (Original Mix) - DiMO (BG) Make Up (bm edit) - Hot Since 82 Free Myself (Original Mix) - Yousef, Gorgon City, EVABEE In A Hurry (Sanda Remix) - Simon Shaw, Sanda Lost Messages - Miguel Migs Too Much Stress (Soledrifter Chill Remix) - Spennu, Soledrifter https://www.facebook.com/1djbm#djbm #House #TechHouse #Dance #DejavuFM #Radio #Quality

Join me today to drink in Our Heavenly Mother's messages from Heaven! As a Church, as a nation, as a world, we are very late in listening to our mother's pleas from Medjugorje. They are pleas for us to open ourselves to God in prayer, so that we can love, experience joy, happiness, and live in peace. These messages are dated from Jan-Jun 1986 and are 100% approved by the Church. Next week, we will meditate upon messages given during the second half of 1986. --- Support this podcast: https://anchor.fm/lisa9722/support

A new year is here and it's time to look forward to what the coming months in cinema hold. I go over the first half of 2022 and talk about the films that have caught my attention and have me excited.Follow & SubscribeAaronTwitterFacebookLetterboxdPatrickTwitterFeelin' FilmFacebookTwitterWebsiteEmail feelinfilm@gmail.comFeelin' Film on Apple PodcastsFeelin' Film on Google PlayFeelin' Film on StitcherFeelin' Film on TuneInFeelin' Film on OvercastFeelin' Film on SpotifyJoin the Facebook Discussion GroupMusic: Upbeat Party - Scott Holmes MusicRate/Review us on iTunes and on your podcast app of choice! It helps bring us exposure so that we can get more people involved in the conversation. Thank you!Support this podcast at — https://redcircle.com/feelin-film/donationsAdvertising Inquiries: https://redcircle.com/brands

Mirlyah hosts Starkast and Befuddled Panda to chat about their anticipated 2022 SFF releases for January through June. Did any of your anticipated releases get mentioned? If not, let us know what you're looking forward to in 2022. You can find us on Discord and on Twitter: https://discord.gg/FNcpuuA @GreenTeamPod List of releases mentioned: https://docs.google.com/spreadsheets/d/12ITV5BVk4nN7CgHrRYtp77HUO0F7iEOl7Vb5c_AWj00/edit?usp=sharing

Programação Jan-Jun ’22 da culturgest; Programação Jan/Fev ’22 do Theatro Circo; «Shine a Light», de Keep Razors Sharp.

Welcome to the 40th episode of The Bookcast Club, a book podcast for people who love to read and talk books. Sarah T and Jenny share their top new releases heading to a bookshop near you between January and June 2021.Support The Bookcast ClubYou can support the podcast on Patreon. Our tiers start at just $2 a month and rewards include, early access, bonus episodes and tailored book recommendations. Our aim, when we hit $75 a month, is to set up a fund to allow those with less money to buy books. If you are happy to donate for no reward you can do so on our website. A free way to show your support, and a very effective way of spreading the word, is to mention us on social media or review us on iTunes.Visit our Book ShopYou can buy all the books we mention on the podcast in our Book Shop. Bookshop.org is a great platform if you want easy book shopping without supporting the likes of Amazon. They support independent book shops and we earn a small commission on each sale, which helps with the running costs of this podcast. However, we would always encourage you to make the effort and shop with your local independent book shop. Many have gone to great efforts to develop an online presence and we're sure most, if not all, will take orders over the phone. They can order whatever book you want. You can find a list of independent bookshops to support on our website, many of which do home delivery. Books mentioned:The Art of Losing by Alice Zeniter 4/02/21Insatiable by Daisy Buchanan 11/02/21The End of the Road by Jack Cooke 18/02/21The Lamplighters by Emma Stonex 04/03/21The Manningtree Witches by A. K Blakemore 04/03/21The Lost Village by Camilla Sten 23/03/21My Phantoms by Gwendoline Riley 01/04/21Of Women and Salt by Gabriella Garcia 15/04/21Lonely Castle in the Mirror by Mizuki Tsujimura 22/04/21After the Storm by Emma Jane Unsworth 06/05/21The Divorce by César Aira 01/06/21The Other Black Girl by Zakiya Dalila Harris 10/06/21Wendy, Darling by A. C. Wise 15/06/21True Crime Story by Joseph KnoxThe Worst Street in London by Fiona RuleThe Five by Hallie RubenholdBlood and Sugar by Laura Shepherd-RobinsonThe Treeclimbers Guide by Jack CookeShia Labeouf by A. C. WiseThe Familiars by Stacey HallsSupper Club by Lara WilliamsHomegoing by Yaa GyasiWhere to find us:Instagram | Twitter | WebsiteSupport the show (https://www.patreon.com/bookcastclub)

Part 2 folks where we cover Asian Lit, middle-grade-YA, translated books and other notable literary fiction coming out in the first half of 2021. Enjoy!

We are trying to keep our shows concise folks so here is the first part of 2021 Anticipated Reads (January-June). In this first part we go into most anticipated books, a huge non-fiction list and speculative fiction to watch out for. We though we start off the year a little chilled, get you groovy on books coming out. Don't forget to listen into Part 2 coming out on Sunday. - - -Gymnopedie No. 1 by Kevin MacLeodLink: https://incompetech.filmmusic.io/song/3837-gymnopedie-no-1License: https://filmmusic.io/standard-licenseRussian DanceJoey Pecorarohttps://www.youtube.com/channel/UCXUbxtXlyp-urIb2hRlXRpQSneaky Adventure by Kevin MacLeodLink: https://incompetech.filmmusic.io/song/4383-sneaky-adventureLicense: https://filmmusic.io/standard-licenseLocal Elevator by Kevin MacLeod is licensed under a Creative Commons Attribution 4.0 licence. https://creativecommons.org/licenses/by/4.0/Source: http://incompetech.com/music/royalty-free/index.html?isrc=USUAN1300012Artist: http://incompetech.com/

Find out what each month has in store for your upcoming PERSONAL Year by the numbers. https://bit.ly/369vnBM --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app

In this episode of the Assault Forward podcast - lessons learned from the military, business, and entrepreneurship for life - we discuss After Action Reviews or debriefs. Taking a look at what was supposed to happen vs. what did happen and how your unit, business, or anything in life can improve for next time. Our Veteran Owned Business of the week is a non-profit that helps the Military Connected Community find the fastest route to entrepreneurial success, Bunker Labs. Check them out at https://bunkerlabs.org. Find them on social media, IG, FB @thebunkerlabs and apply today to the Veterans in Residence program (applications close on Oct. 15, 2020 for Cohort 21A, Jan-Jun 2021). Thanks for listening, please like and subscribe (and leave a 5 Star review!), send us DM's on all social media @AssaultFWD and visit our website https://assaultforward.us (and don't forget to use the discount code we mention in the show to save 15% off any order!!!) #Veterans #MadeinAmerica #AssaultForward #Business #Entrepreneurship #Military

In Trinidad and Tobago we have 3 seasons: Dry season (Jan-Jun),Wet season(Jul-Dec),and Silly season (every 5 years (Elelections). This year that date is 10th August and my birthday is 11th August. Any idea what I should do?!? Listen. Share. Inspire. Subscribe Social Media Links: Facebook: https://www.facebook.com/868andbeyond/ Instagram: https://www.instagram.com/868andbeyond/ Twitter: https://twitter.com/is868andbeyond Music Credit: https://www.youtube.com/channel/UCZrpJ8_rlwgdtd9WAikrkZA --- Send in a voice message: https://anchor.fm/868andbeyond/message

In Trinidad and Tobago we have 3 seasons: Dry season (Jan-Jun),Wet season(Jul-Dec),and Silly season (every 5 years (Elelections). This year that date is 10th August and my birthday is 11th August. Any idea what I should do?!? Listen. Share. Inspire. Subscribe Social Media Links: Facebook: https://www.facebook.com/868andbeyond/ Instagram: https://www.instagram.com/868andbeyond/ Twitter: https://twitter.com/is868andbeyond Music Credit: https://www.youtube.com/channel/UCZrpJ8_rlwgdtd9WAikrkZA

My absolute best of 2018 (Jan-Jun)

In this edition of the CLIMAS Southwest Climate Podcast - Mike Crimmins and Zack Guido sit down to discuss Southwestern weather & climate, including: The extended heat wave of June 2017 (and the near record heat for the first half of 2017 (Jan-Jun)) (1:00 - 15:00), The wildfires in the Southwest , and the role that a monsoon late arrival might have played (15:00-19:00) The Southwestern Monsoon - the components of the system, comparisons to other years, and what we might expect going forward (19:00-38:00) As a note: this was recorded on Jun 12, 2017, before most of the extended run of monsoon activity that hit southern Arizona Jun 10 - Jun 17 (and is ongoing!).  Mike and Zack will discuss more about this (amazing) week in the next edition of the podcast. Materials discussed in this podcast:     Monsoon Resources CLIMAS: www.climas.arizona.edu/sw-climate/monsoon Monsoon Summaries: https://cals.arizona.edu/climate/misc/monsoon/monsoon_summaries.html CSAP: Precipitation Maps of the Monsoon - Arizona and New Mexico  National Weather Service: www.wrh.noaa.gov/twc/monsoon/monsoon.php Bob Maddox's MadWeather Blog - https://madweather.blogspot.com/ Arizona WRF Discussion - https://arizonawrf.blogspot.com/   *122nd out of 123 - otherwise known as the 2nd warmest June on record (listen in for the details from Zack and Mike)

In this edition of the CLIMAS Southwest Climate Podcast - Mike Crimmins and Zack Guido sit down to discuss Southwestern weather & climate, including: The extended heat wave of June 2017 (and the near record heat for the first half of 2017 (Jan-Jun)) (1:00 - 15:00), The wildfires in the Southwest , and the role that a monsoon late arrival might have played (15:00-19:00) The Southwestern Monsoon - the components of the system, comparisons to other years, and what we might expect going forward (19:00-38:00) As a note: this was recorded on Jun 12, 2017, before most of the extended run of monsoon activity that hit southern Arizona Jun 10 - Jun 17 (and is ongoing!).  Mike and Zack will discuss more about this (amazing) week in the next edition of the podcast. Materials discussed in this podcast:     Monsoon Resources CLIMAS: www.climas.arizona.edu/sw-climate/monsoon Monsoon Summaries: https://cals.arizona.edu/climate/misc/monsoon/monsoon_summaries.html CSAP: Precipitation Maps of the Monsoon - Arizona and New Mexico  National Weather Service: www.wrh.noaa.gov/twc/monsoon/monsoon.php Bob Maddox's MadWeather Blog - https://madweather.blogspot.com/ Arizona WRF Discussion - https://arizonawrf.blogspot.com/   *122nd out of 123 - otherwise known as the 2nd warmest June on record (listen in for the details from Zack and Mike)

In this edition of the CLIMAS Southwest Climate Podcast - Mike Crimmins and Zack Guido sit down to discuss Southwestern weather & climate, including: The extended heat wave of June 2017 (and the near record heat for the first half of 2017 (Jan-Jun)) (1:00 - 15:00), The wildfires in the Southwest , and the role that a monsoon late arrival might have played (15:00-19:00) The Southwestern Monsoon - the components of the system, comparisons to other years, and what we might expect going forward (19:00-38:00) As a note: this was recorded on Jun 12, 2017, before most of the extended run of monsoon activity that hit southern Arizona Jun 10 - Jun 17 (and is ongoing!).  Mike and Zack will discuss more about this (amazing) week in the next edition of the podcast. Materials discussed in this podcast:     Monsoon Resources CLIMAS: www.climas.arizona.edu/sw-climate/monsoon Monsoon Summaries: https://cals.arizona.edu/climate/misc/monsoon/monsoon_summaries.html CSAP: Precipitation Maps of the Monsoon - Arizona and New Mexico  National Weather Service: www.wrh.noaa.gov/twc/monsoon/monsoon.php Bob Maddox's MadWeather Blog - https://madweather.blogspot.com/ Arizona WRF Discussion - https://arizonawrf.blogspot.com/   *122nd out of 123 - otherwise known as the 2nd warmest June on record (listen in for the details from Zack and Mike)

Myocardial infarction (MI) in children is uncommon, but underdiagnosed.  This is due to two main factors: the etiologies are varied; and the presenting symptoms are “atypical”. We need a mental metal detector!  Case examples Congenital Two main presentations of MI due to congenital lesions: novel and known.  The novel presentation is at risk for underdiagnosis, due to its uncommonness and vague, atypical symptoms.  There are usually some red flags with a careful H&P.  The known presentation is a child with a history of congenital heart disease, addressed by corrective or palliative surgery.  This child is at risk for expected complications, as well as overdiagnosis and iatrogenia.  Risk stratify, collaborate with specialists. The fussy, sweaty feeder: ALCAPA Anomalous Left Coronary Artery from the Pulmonary Artery (ALCAPA) is an example of what can go wrong during fetal development: any abnormality in the number, origin, course, or morphology of the coronary arteries can present as a neonate with sweating during feeds (steal syndrome), an infant in CHF, or an older child with failure to thrive or poor exercise tolerance. The stable child with chest pain: myocardial bridge Normal coronary arteries run along the epicardial surface of the heart, with projections into the myocardium.  If part of the artery’s course runs within the myocardium (i.e. the artery weaves into and/or out of the myocardium), then there is a myocardial bridge of the coronary artery.  With every systolic contraction, the artery is occluded.  Although a myocardial bridge may not cause symptoms (especially at distal portions), the area it supplies is at risk. With any minor trauma or exertion, demand may outpace supply, resulting in ischemia.  Diagnosis is made on coronary angiography. The unwell child post-cardiac surgery: Fontan problems The child with single ventricle physiology may have a Norwood procedure at birth (creation of a neoaorta, atrial septectomy, and Blalock-Taussig shunt), a Bidirectional Glenn procedure at 3-6 months (shunt removed, superior vena cava connected to pulmonary arteries), and a Fontan procedure at about 2-3 years of age (inferior vena cava blood flow is shunted into the pulmonary arteries). These children depend on their preload to run blood passively into the pulmonary circuit; afterload reduction is also important to compensate for a poor left ejection fraction, as well as to avoid the development of pulmonary hypertension.  They are typically on an anticoagulant (often aspirin), a diuretic (e.g. furosemide), and an afterload reduction agent (e.g. enalapril).  Any disturbance in volume status (hyper- or hypovolemia), anticoagulation, or afterload may cause myocardial strain or infarction.  Take the child s/p Fontan seriously and involve his specialists early with any concerns. Autoimmune The body’s inflammatory-mediated reaction to a real or perceived insult can cause short- and long-term cardiac sequelae.  Find out how well the underlying disease is controlled, and what complications the child has had in the past. The red, hot, crispy, flaky child: acute Kawasaki disease Kawasaki disease (KD) is an acute systemic vasculitis, diagnosed by the presence of fever for five or more days accompanied by four or more criteria:  bilateral conjunctival injection, mucositis, cervical lymphadenopathy, polymorphous rash, and palmar or sole desquamation.  The criteria may occur (and disappear) at any time during the illness. Infants are under double jeopardy with Kawasaki Disease.  They are more likely to have incomplete KD (i.e. not fulfill strict criteria) and if they have KD, they are more likely to suffer the dangerous consequences of aneurysm formation (chiefly coronary arteries, but also brain, kidney).  Have a low threshold for investigation. Treatment includes 2 g/kg/day IVIG and high-dose aspirin (30-50 mg/kg/day) acutely, then low-dose aspirin (5 mg/kg/day) for weeks to months.  Regular and long-term follow-up with Cardiology is required. The aftermath: sequelae of Kawasaki disease The family and child with a history of KD may have psychological trauma and continuous anxiety about the child’s risk of MI.  Approximately 4.7% of children who were promptly diagnosed and correctly treated will go on to have cardiac sequelae. Children who have no detected cardiac sequelae by 8 weeks, typically continue to be asymptomatic up to 20 years later.  Smaller aneurysms tend to regress over time, especially those < 6 mm. Thrombi may calcify, or the lumen may become stenotic due to myofibroblast proliferation.  Children with any coronary artery dilatation from KD should be followed indefinitely. Giant aneurysms (≥8 mm) connote the highest risk for MI.  Parents often are concerned about recurrence, and any subsequent fever can be distressing.  There is a low rate of recurrence for KD: approximately 2%.  Infants who have coronary aneurysms are at the highest risk for recurrence. The older child with vague chest complaints and hypercoagulability: Systemic Lupus Erythematosus and Anti-Phospholipid Syndrome Up to 15% of cases of SLE begin in childhood.  Adult criteria are used, with the caveat that the diagnosis of SLE in children can be challenging; many children only manifest a few of the criteria initially before going on to develop further systemic involvement. The Systemic Lupus International Collaborating Clinics (SLICC) revised the criteria in 2012.  The patient should have ≥4/17 clinical and/or immunologic criteria.  The clinical criteria are: acute cutaneous (malar); chronic cutaneous (discoid); oral; alopecia; synovitis; serositis; renal; neurologic; hemolytic anemia; leukopenia; or thrombocytopenia.  The immunologic criteria are: ANA; anti-dsDNA; anti-Sm; antiphospholipid; low complement; and/or Direct Coombs (in absence of hemolytic anemia).  At least one criterion should be clinical, and at least one should be immunologic.  Children with antiphospholipid syndrome (APS) may occur with or without SLE.  Patients are at risk for venous and arterial thrombi formation.  APS may also cause structural damage, such as valvular thickening and valvular nodes (Libman-Sacks endocarditis).  Mitral and aortic valves are at the highest risk. Although most children with chest pain will not have MI, those with comorbidities should be investigated carefully. Trauma Direct, blunt trauma to the chest can cause myocardial stunning, dysrhythmias, or an asymptomatic rise in Troponin I.  However, some children are at risk for disproportionate harm due to a previously unknown risk factor.  Clinically significant cardiac injury occurs in up to 20% of patients with non-penetrating thoracic trauma. The motor vehicle collision: blunt myocardial injury Direct trauma (steering wheel, airbag, seatbelt), especially in fast acceleration-deceleration injury, may cause compression of the heart between the sternum and the thoracic spine. Electrocardiography (ECG) should be performed on any patient with significant blunt chest injury.  A negative ECG is highly consistent with no significant blunt myocardial injury. Any patient with a new abnormality on ECG (dysrhythmia, heart block, or signs of ischemia) should be admitted for continuous ECG monitoring. Elevation in troponin is common, but not predicted.  A solitary elevated troponin without ECG abnormality is of unclear significance.  Author’s advice: obtain troponin testing if there is an abnormal ECG, more than fleeting suspicion of BCI, and/or the child will be admitted for monitoring. Hemodynamically labile children should be resuscitated and a stat transesophageal echocardiogram obtained. The high-velocity object: coronary artery dissection or thrombus Direct trauma (e.g. MVC, baseball, high-velocity soccer ball) may cause damage to the left anterior descending artery or left circumflex artery, at the highest risk due to their proximity to the chest wall.  Thrombosis and/or dissection may result, often presenting in a focal pattern of ischemia on the ECG. Echocardiography may reveal valvular damage related to the injury, as well as effusion and ejection fraction.  Since there is often a need to investigate the coronary anatomy, percutaneous coronary intervention (PCI) is recommended. The minor trauma with disproportionate complaint: myocardial bridge As mentioned in the congenital section (above), a known variation of a coronary artery’s course involves weaving in and out of the myocardium, creating a baseline risk for ischemia.  Even minor trauma in a child with a myocardial bridge may cause acute thrombus, or slow stenosis from resulting edema.  Unfortunately, the presence of myocardial bridging is often unknown at the time of injury.  Approximately 25% of the population may have myocardial bridging, based on autopsy studies. Take the child seriously who has disproportionate symptoms to what should be a minor injury. Hematologic Coagulopathic and thrombophilic states may predispose children to focal cardiac ischemia.  The best documented cormorbidity is sickle cell disease, although other pro-thrombotic conditions also put the child at risk. The child with sickle cell disease and chest pain: when it’s not acute chest syndrome Sickle cell disease (SCD) can affect any organ system, although the heart is traditionally considered a lower-risk target organ for direct sickling and ischemia.  The major cardiac morbidity in sickle cell is from strain, high-output failure and multiple, serial increases in myocardial demand, causing left ventricular hypertrophy and congestive heart failure. However, there is mounting evidence that acute myocardial ischemia in sickle cell disease may be underappreciated and/or attributed to other causes of chest pain. Other cardiac sequelae from SCD include pulmonary hypertension, left ventricular dysfunction, right ventricular dysfunction, and chronic iron overload. Evidence of myocardial ischemia/infarction in children with SCD has been demonstrated on single-photon emission computed tomography (SPECT) scan. The puffy faced child with chest pain: nephrotic syndrome hypercoagulability Children who suffer from nephrotic syndrome lose proteins that contribute to the coagulation cascade.  In addition, lipoprotein profiles are altered: there is a rise in the very low-density lipoproteins (LDL), contributing to accelerated atherosclerosis.  Typically nephrotic patients have normal levels of high-density lipoproteins (HDL), unless there is profuse proteinuria. Children with difficult-to-control nephrotic syndrome (typically steroid-resistant) may form accelerated plaques that rupture, causing focal MI, as early as school age. The previously well child now decompensated: undiagnosed thrombophilia Asymptomatic patent foramen ovale (PFO) is the cause of some cases of cryptogenic vascular disease, such as stroke and MI.  However, the presence of PFO alone does not connote higher risk.  When paired with an inherited or acquired thrombogenic condition, the venous thrombus may travel from the right-sided circulation to the left, causing distal ischemia.  Many of these cases are unknown until a complication arises. The chronically worried, now with a reason: hypercholesterolemia A family history of adult-onset hypercholesterolemia is not necessarily a risk factor for early complications in children, provided the child does not have the same acquired risk factors as adults (e.g. obesity, sedentary lifestyle, smoking, etc).  Parents may seek help in the ED for children with chest pain and no risk factors, but adult parents who have poor cholesterol profiles. The exception is the child with familial hypercholesterolemia, who is at risk for accelerated atherosclerosis and MI. Infectious Myocarditis has varied etiologies, including infectious, medications (chemotherapy agents), immunologic (rheumatologic, transplant rejection), toxins (arsenic, carbon monoxide, heavy metals such as iron or copper), or physical stress (electrical injury, heat illness, radiation). In children, the most common cause of myocarditis is infectious (viruses, protozoa, bacteria, fungal, parasites).  Of these, viral causes are the most common (adenovirus, enterovirus, echovirus, rubella, HHV6). The verbal child may complain of typical chest complaints, or may come in with flu-like illness and tachycardia or ill appearance out of proportion to presumed viral illness. The most common presenting features in children with myocarditis are: shortness of breath, vomiting, poor feeding, hepatomegaly, respiratory distress, and fever. The infant in shock after a ‘cold’: myocarditis Beware of the poor feeding, tachycardic, ill appearing infant who “has a cold” because everyone else around him has a ‘cold’.  That may very well be true, but any virus can be invasive with myocardial involvement.  Infants are only able to increase their cardiac output through increasing their heart rate; they cannot respond to increased demands through ionotropy.  Look for signs of acute heart failure, such as hepatomegaly, respiratory distress, and sacral edema. The child with tachycardia out of proportion to complaint: myocarditis The previously healthy child with “a bad flu” may simply be very symptomatic from influenza-like illness, or he may be developing myocarditis.  Look for chest pain and tachycardia out of proportion to presumed illness, and constant chest pain, not just associated with cough. The “pneumonia” with suspicious chest x-ray: myocarditis Acute heart failure may mimic viral pneumonia.  Look for disproportionate signs and symptoms. Toxins Younger children may get into others’ medications, be given dangerous home remedies, take drugs recreationally, have environmental exposures (heavy metals), suffer from a consequence of a comorbidity (iron or copper overload) or have adverse events from generally safe medications. The hyperactive boy with a hyperactive precordium: methylphenidate Attention deficit hyperactivity disorder (ADHD) is growing in rate of diagnosis and use of medications.  As the only medical diagnosis based on self-reported criteria, many children are given stimulants regardless of actual neurologic disorder; with a higher proportion of children exposed to stimulants, adverse effects are seen more commonly. Methylphenidate is related to amphetamine, and they both are dopaminergic drugs.  Their mechanisms of action are different, however.  Methylphenidate increases neuronal firing rate.  Methamphetamine reduces neuronal firing rate; cardiovascular sequelae such as MI and CHF are more common in chronic methamphetamine use. Although methylphenidate is typically well tolerated, risks include dysrhythmias such as ventricular tachycardia. The child with seizure disorder and chest pain: anti-epileptics Some anti-epileptic agents, such as carbamazepine, promote a poor lipid profile, leading to atherosclerosis and early MI.  Case reports include school-aged children on carbamazepine who have foamy cells in the coronary arteries, aorta, and vasa vasorum on autopsy.  It is unclear whether this is a strong association. The spice trader: synthetic cannabinoids Synthetic cannabinoids are notoriously difficult to regulate and study, as the manufacturers label them as “not for human consumption”.  Once reports surface of abuse of a certain compound, the formula is altered slightly and repackaged, often in a colorful or mysterious way that is attractive to teenagers. The misperceptions are: are a) synthetics are related to marijuana and therefore safe and b) marijuana is inherently “safe”. Both tend to steer unwitting teens to take these unknown entities.  Some suffer MI as a result. Exposure to tetrahydrocannabinol (THC) in high-potency marijuana has been linked to myocardial ischemia, ventricular tachycardia, and ventricular fibrillation.  Marijuana can increase the heart rate from 20-100%, depending on the amount ingested. K2 (“kush 2.0”) or Spice (Zohai, Genie, K3, Bliss, Nice, Black Mamba, fake weed, etc) is a mixture of plant leaves doused in synthetic chemicals, including cannabinoids and fertilizer (JWH-108), none of which are tested or safe for human consumption.  Synthetic cannabinoids have a higher affinity to cannabinoid receptors, conferring higher potency, and therefore worse adverse effects.  They are thought to be 100 to 800 times more potent as marijuana. Bath salts (Purple Wave, Zoom, Cloud Nine, etc) can be ingested, snorted, or injected.  They typically include some form of cathinone, such as mephedrone, similar to the substance found in the naturally occurring khat plant. Hallucinations, palpitations, tachycardia, MI, and dysrhythmias have been reported from their use as a recreational drug. Chest pain with marijuana, synthetic cannabinoid, or bath salt ingestion should be investigated and/or monitored. Riding that train: high on cocaine Cocaine is a well-known cause of acute MI in young people.  In addition to the direct stimulant causes acutely, such as hypertension, tachycardia, and impaired judgement (coingestions, risky behavior), chronic cocaine use has long-term sequelae.  Cocaine causes accelerated atherosclerosis.  That, in conjunction with arterial vasospasm and platelet activation, is a recipe for acute MI in the young. Cranky: methamphetamine Methamphetamine is a highly addictive stimulant that is relatively inexpensive and widely available.  Repeated use causes multiple psychiatric, personality, and neurologic changes.  Risky behavior, violence, and motor vehicle accidents are all linked to this drug.  Like cocaine, methamphetamine may cause fatal dysrhythmias, acute MI from demand ischemia, and long-term sequelae such as congestive heart failure. Summary Acute MI is a challenging presentation in children: Easily missed: uncommon and atypical Varied etiology Respect vague symptoms with a non-reassuring H&P Try to detect it: CATH IT! References Congenital AboulHosn JA et al. Fontan Operation and the Single Ventricle. Congenit Heart Dis. 2007; 2:2-11. Aliku TO et al. A case of anomalous origin of the left coronary artery presenting with acute myocardial infarction and cardiovascular collapse. African Health Sci. 2014; 14(1): 23-227. Andrews RE et al. Acute myocardial infarction as a cause of death in palliated hypoplastic left heart syndrome. Heart. 2004; 90:e17. Canale LS et al. Surgical treatment of anomalous coronary artery arising from the pulmonary artery. Interactive Cardiovascaulr and Thoracic Surgery. 2009; 8:67-69. Güvenç O et al. Correctable Cause of Dilated Cardiomyopathy in an Infant with Heart Failure: ALCAPA Syndrome. J Curr Pediatr. 2017; 15:47-50. Hastings RS et al. Embolic Myocardial Infarction in a Patient with a Fontan Circulation. World Journal for Pediatric Congenital Heart Surgery. 2014; 5(4)L631-634. Hoffman JIE et al. Electrocardiogram of Anomalous Left Coronary Artery From the Pulmonary Artery in Infants. Pediatr Cardiol. 2013; 34(3):489-491. Kei et al. Rare Case of Myocardial Infarction in a 19-Year-Old Caused by a Paradoxical Coronary Artery Embolism. Perm J.2015; 19(2):e107-e109. Liu Y, Miller BW. ALCAPA Presents in an Adult with Exercise Inlerance but Preserved Cardiac Function. Case Reports Cardiol. 2012; AID 471759. Möhlenkamp S et al. Update on Myocardial Bridging.Circulation. 2002;106:2616-2622. Murgan SJ et al. Acute myocardial infraction n the neonatal period. Cardiol Young. 2002; 12:411-413. Sieweke JT et al. Myocardial infarction in grown up patients with congenital heart disease: an emergening high-risk combination. International Journal of Cardiology. 2016; 203:138-140. Schwerzmann M et al. Anomalous Origin of the Left Coronary Artery From the Main Pulmonary Artery in Adults. Circulation. 2004; 110:e511-e513. Tomkewicz-Pajak L et al. Arterial stiffness in adult patients after Fontan procedure. Cardiovasculr Ultrasound. 2014; 12:15. Varghese MJ et al. The caveats in the diagnosis of anomalous origin of left coronary artery from pulmonary artery (ALCAPA). Images Paediatr Cardiol. 2010; 12(3): 3–8. Autoimmune Ayala et al. Acute Myocardial Infarction in a Child with Systemic Lupus Erythematosus and Antiphospholipid Syndrome. Turk J Rheumatol. 2009; 24:156-8. Nakano H et al. Clinical characteristics of myocardial infarction following Kawasaki disease: Report of 11 cases. J Pediatr. 1986; 108(2):198-203. Pongratz G et al. Myocardial infarction in an adult resulting from coronary aneurysms previously documented in childhood after an acute episode of Kawasaki’s disease. European Heart J. 1994. 15:1002-1004. Newburger JW et al.  Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease. A Statement for Health Professionals From the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Circulation. 2004;110:2747-2771. Son MB et al. Kawaski Disease. Pediatr Rev. 2013; 34(4). Yuan S. Cardiac surgical procedures for the coronary sequelae of Kawasaki disease. Libyan J Med. 2012; 7:19796. Trauma Abdolrahim SA et al. Acute Myocardial Infarction Following Blunt Chest Trauma and Coronary Artery Dissection. J Clin Diagnost Res. 2016; 10(6):14-15. Galiuto L et al. Post-traumatic myocardial infarction with hemorrhage and microvascular damage in a child with myocardial bridge: is coronary anatomy actor or bystander. Signa Vitae. 2013; 8(2):61-63. Janella BL et al. Acute Myocardial Infarction related to Blunt Thoracic Trauma. Arq Bras Cardiol. 2006; 87:e168-e171. Liu X et al. 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Acute myocardial infarction in young adults: causes and management. Postgrad Med J. 2002; 78:27-30. Silva JMP et al. Premature acute myocardial infarction in a child with nephrotic syndrome. Pediatr Nephrol. 2002; 17:169-172. Suryawanshi SP. Myocardial infarction in children: Two interesting cases. Ann Pediatr Cardiol. 2011 Jan-Jun; 4(1): 81–83. Infectious Cunningham R et al. Viral myocarditis Presenting with Seizure and Electrocardiographic Findings of Acute Myocardial Infarction in a 14-Month-Old Child. Ann Emerg Med. 2000; 35(6):618-622. De Vettten L et al. Neonatal Myocardial Infarction or Myocarditis? Pediatr Cardiol. 2011; 32:492-497. Durani Y et al. Pediatric myocarditis: presenting clinical characteristics. Am J Emerg Med. 2009; 27:942-947. Erden I et al. Acute myocarditis mimicking acute myocardial infarction associated with pandemic 2009 (H1N1) influenza virus. Cardiol J. 2011; 552-555. Hover MH et al. Acute Myocarditis Simulating Myocardial Infarction in a Child. Pediatr. 1191; 87(2):250-252. Lachant D et al. Meningococcemia Presenting as a Myocardial Infarction. Case Reports in Critical Care. 2015; AID 953826. Laissy JP et al. Differentating Myocardial Infarction from Myocarditis. Radiology. 2005; 237(1):75-82. Miranda CH et al. Evaluation of Cardiac Involvement During Dengue Viral Infection. CID. 2013; 57:812-819. Rettig JS et al. Myocarditis in Children Requiring Critical Care Transport. In:  "Diagnosis and Treatment of Myocarditis", Milei J, Ambrosio G (Eds). DOI: 10.5772/56177. Toxins De Chadarévian JP et al. Epilepsy, Atherosclerosis, Myocardial Infarction, and Carbamazepine. J Child Neurol. 2003; 18(2):150-151. McIlroy G et al. Acute myocardial infarction, associated with the use of a synthetic adamantly-canabinoid: a case report. BMC Pharmacology and Toxicology. 2016; 17:2. Mir A et al. Myocardial Infarction Associated with Use of the Synthetic Cannabinoid K2. Pediatr. 2011; 128(6):1-6 Munk K et al. Cardiac Arrest following a Myocardial Infarction in a Child Treated with Methylphenidate. Case Reports Pediatr. 2015; AID 905097. Rezkalla SH et al. Cocaine-Induced Acte Mycardial Infarction. Clin Med Res. 2007; 5(3):172-176. Schelleman H et al. Methylphenidate and risk of serious cardiovascular events in adults. Am J Psychiatry. 2012 Feb;169(2):178-85. Sheridan J et al. Injury associated with methamphetamine use: a review of the literature. Harm Reduction Journal, 2006; 3(14):1-18. Stiefel G et al. Cardiovascular effects of methylphenidate, amphetamines and atomoxetine in the treatment of attention-deficit hyperactivity disorder. Drug Saf. 2010 Oct 1;33(10):821-42.   This post and podcast are dedicated to Edwin Leap, MD for his sanity and humanity in the practice of Emergency Medicine.  Thank you, Dr Leap for all that you do.

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