text:
Hearing Sense Recovery
There is an extensive literature on PLFs. Substantial data and confirmed observations in the peer-reviewed literature have already addressed topics considered controversial by some members of the otologic community. The clinical presentation of PLFs is clear, the various treatment options available have been well described, and the recent prospective histopathologic confirmation of PLFs has established a gold standard for diagnosis.1,2,48
It is the responsibility of otologists to become familiar with the extensive PLF literature. Scholarly discourse should be encouraged so that we may better care for patients whose lives and livelihood have been devastated by PLFs.
Black et al.—CHAPTER 55
1. Kohut RI, Hinojosa R, Budetti JA. Perilymphatic fistula: a histopathologic study. Ann Otol Rhinol Laryngol 1986;95: 466-471
2. Kohut RI, Hinojosa R, Ryu JH. Perilymphatic fistula: a single blind histopathological study. Adv Otol Rhinol Laryngol 1988;42:148-152
3. Dawes JD, Watson RT. Labyrinthine fistulae. J Laryngol Otol 1978;92(2):83-98
4. Sheehy JL, Brackmann DE. Cholesteatoma surgery: management of the labyrinthine fistula—a report of 97 cases. Laryngoscope 1979;89:78-87
5. Strohm M. Traumatic lesions of the round window membrane and perilymphatic fistulae. Adv Otolol Rhinol Laryngol 1986; 35:177-247
6. Parell GJ, Paige GD. Inner ear barotrauma in SCUBA divers. Arch Otolaryngol Head Neck Surg 1993;119:455-457
7. Edmonds C. Hearing loss with frequent diving (deaf divers). Undersea Biomed Res 1985;12:315-319
8. Molvaer OI, Natrud E. Ear damage due to diving. Acta Otolaryngol (Stockh) 1979;360(suppl):187-189
9. Caruso VG, Winkelmann PE, Correia MJ, et al. Otologic and otoneurologic injuries in divers: clinical studies on nine commercial and two sport divers. Laryngoscope 1977;4:508-521
10. Farmer JC. Diving injuries of the inner ear. Ann Otol Rhinol Laryngol 1977;86(suppl 36):1-20
11. Edmonds C, Freeman P, Tonkin J. Fistula of the round window in diving. Trans Am Acad Ophthalmol Otolaryngol 1974;78:444-447
12. Lundgren CEG. Alternobaric vertigo—a diving hazard. BMJ 1965;2:511-513
13. Head PW. Vertigo and barotrauma. In: Dix MR, Hood JD, eds. Vertigo. Bath, Avon, England: John Wiley & Sons Ltd; 1984:199-214
14. McNicoll WD. Traumatic perforation of the tympanic membrane with associated rupture of the round window membrane. J Laryngol 1978;92:895-903
15. Whinney DJD, Parikh AA, Brookes GB. Barotraumatic fracture of the stapes footplate. Am J Otol 1996;17:697-699
16. Miyazawa T, Ueda H, Yanagita N. Eustachian tube function and middle ear barotrauma associated with extremes in atmospheric pressure. Ann Otol Rhinol Laryngol 1996;105:887-892
17. Freeman P, Tonkin J, Edmonds C. Rupture of the round window membrane in inner ear barotrauma. Arch Otolaryngol 1974;99:437-442
18. Bruins WR. Blast injuries of the ear as a result of the Peterborough lorry explosion: 22 March 1989. J Laryngol Otol 1991;105:890-895
19. Konradsson KS, Carloborg BR, Farmer JC. Pressure gradients affecting the labyrinth during hypobaric pressure. Experimental study. Ann Otol Rhinol Laryngol 1997;106:495-502
20. Beuerlein M, Nelson RN, Welling B. Inner and midde ear hyperbaric oxygen-induced barotrauma. Laryngoscope 1997; 107:1350-1356
21. Guyot JP. Acoustic trauma caused by the telephone. OOtorhi-nolaryngology 1988;50:313-318
22. Schuknecht HF, Reisser C. The morphologic basis for perilymphatic gushers and oozers. Adv Otol Rhinol Laryngol 1988;39:1-12
23. Schepens YM, Schepens P. Complications which may be encountered in surgery for otospongiosis. Acta Otol Rhinol Laryngol Belg 1977;31:5-36
24. Glasscock ME. The stapes gusher. Arch Otolaryngol 1973; 98:82-91
25. Hemenway WG, Hildyard VH, Black FO. Post stapedectomy perilymph fistulas in the Rocky Mountain area: the importance of nystagmography and audiometry in diagnosis and early tympanotomy in prognosis. Laryngoscope 1968;78:1687-1715
26. House HP. The fistula problem in otosclerosis surgery. Laryngoscope 1967:1410-1426
27. Goodhill V. Sudden deafness and round window rupture. Laryngoscope 1971;81:1462-1474
28. Fee GA. Traumatic perilymphatic fistulas. Arch OOtolaryngol 1969;88:43-46
29. Glasscock ME, McKennan KX, Levine SC. Persistent traumatic perilymph fistulas. Laryngoscope 1987;97:860-863
30. Goodhill V. Traumatic fistulae. J Laryngol Otol 1980;94: 123-128
31. Sidi J, Tovi F. Traumatic labyrinthine fistulas. Isr J Med Sci 1979;15:156-158
32. Lehrer JF, Rubin RC, Poole DC, et al. Perilymphatic fistula— a definitive and curable cause of vertigo following head trauma. West J Med 1984;141:57-61
33. Hemenway WG, Black FO, Grimm RJ, Pesznecker SC. Traumatic perilymph fistula. In: Claussen CF, Kirtane MV, eds. Vertigo, Nausea, Tinnitus, and Hypoacusis Due to Head and Neck Trauma. Proceedings of the Seventh Scientific Meeting of the Neurotological and Equilibriometric Society. Amsterdam: Elsevier; 1991:167-170
34. Healy GB. Hearing loss and vertigo secondary to head injury. N Engl J Med 1982;306:1029-1031
35. Healy GB, Friedman JM, Strong MS. Vestibular and auditory findings of perilymphatic fistula: a review of 40 cases. Trans Am Acad Ophthalmol Otolaryngol 1976;82:44-49
36. Chester JB. Whiplash, postural control, and the inner ear. Spine 1991;16:716-720
37. Ferber-Viart C, Postec F, Duclaux R, Dubreuil C. Perilym-phatic fistula following airbag trauma. (Letter to the Editor.) Laryngoscope 1998;108:1255-1257
38. Huelke DF, Moore JL, Compton TW, Samuels J, Levine RS. Upper extremity injuries related to airbags deployments. J Trauma 1995;4:482-488
39. Thomas P, Bradford MO. The nature and source of the head injuries sustained by restrained front-seat car occupants in frontal collisions. Accident Anal Prev 1995;4:561-570
40. Duma SM, Kress TA, Porta DJ, et al. Airbag-induced eye injuries: a report of 25 cases. JTrauma 1996;41:114-119
41. Facer GW, Farrell KH, Cody DT. Spontaneous perilymph fistula. Mayo Clin Proc 1973;48:203-206
42. Althaus SR. Spontaneous and traumatic perilymph fistulas. Laryngoscope 1977;87:364-371
43. Shea JJ III. The myth of spontaneous perilymph fistula. Otolaryngol Head Neck Surg 1992;107:613-616
44. Cole GG. Validity of spontaneous perilymphatic fistula. Am J Otol 1995;16:815-819
45. Meyerhoff WL. Spontaneous perilymphatic fistula: myth or fact. Am J Otol 1993;14:478-481
46. Sando I, Takahara T, Ogawa A. Congenital anomalies of the inner ear. Ann Otol Rhinol Laryngol 1984;93:110-117
47. Reilly JS. Congenital perilymphatic fistula: a prospective study in infants and children. Laryngoscope 1989;99:393-397
48. Kohut RI, Hinojosa R, Ryu JH. The histologic characteristics of the core of the fissula ante fenestram. Acta Otolaryngol (Stockh) 1991;481(suppl):158-162
49. Dawes JD, Pearman K, Kochilas X. Patent fissula ante fenestram. J Laryngol Otol 1983;97:357-360
50. Jackler RK, Hwang PH. Enlargement of the cochlear aqueduct: fact or fiction? Otolaryngol Head Neck Surg 1993; 109:14-25
51. Griffith AJ, Arts HA, Downs C, et al. Familial large vestibular aqueduct syndrome. Laryngoscope 1996;106:960-965
52. Illum P. The Mondini type of cochlear malformation. Arch Otolaryngol 1972;96:305-311
53. Schuknecht HF. Mondini dysplasia: a clinical and pathological study. Ann Otol Rhinol Laryngol 1980;89(suppl 65):3-23
54. Kamerer DB, Sando I, Hirsch BE, Takagi A. Perilymph fistula resulting from microfissures. Am J Otol 1987;8:489-494
55. Harada T, Sando I, Myers EN. Microfissure in the oval window area. Ann Otol Rhinol Laryngol 1981;90:174-180
56. Weider DJ, Musiek FE. Bilateral congenital oval window microfistulae in a mother and son. Laryngoscope 1984;94: 1455-1458
57. Bluestone CD. Otitis media and congenital perilymphatic fistula as a cause of sensorineural hearing loss in children. Pedi-atr Infect Dis J 1988;7:141-145
58. Crook JP. Congenital fistula in the stapedial footplate. South Med J 1967;60:1168-1170
59. Guindi GM. Congenital labyrintho-tympanic fistula—a recently recognized entity in children. J Laryngol Otol 1981; 10:1:67-71
60. Healy GB, Friedman JM, DiTroia J. Ataxia and hearing loss secondary to perilymphatic fistula. Pediatrics 1978;61:238-241
61. Healy GB, Strong MS, Sampogna D. Ataxia, vertigo, and hearing loss. Arch OOtolaryngol 1991;100:130-135
62. Black FO, Pesznecker SC, Norton TL, et al. Surgical management of perilymph fistulas: a new technique. Arch Otolaryngol Head Neck Surg 1991;117:641-648
63. Black FO, Pesznecker SC. Surgical management of motion sickness in perilymph fistula patients. In: Twentieth Meeting of the International Barany Society. Würzburg, Germany; 1998
64. Grimm RJ, Hemenway WG, LeBray PR, Black FO. The perilymph fistula syndrome defined in mild head trauma. Acta Otolaryngol 1989;464(suppl):5-40
65. Erickson KR, DeWeese M, Simons A. A specific syndrome of memory impairment in patients with vestibular disorder: selective acquisition and retrieval deficits. International Conference: Perilymph fistula—a common cause of dizziness and dysequi-librium? September 6, 1990;Portland, Oregon. Am J Otol 1990:887-891
66. Kohut RI, Waldorf RA, Haenel JL, Thompson JN. Minute perilymph fistulas: vertigo and Hennebert's sign without hearing loss. Ann Otol Rhinol Laryngol 1979;88:153-159
67. Simmons FB. Fluid dynamics in sudden sensorineural hearing loss. Otolaryngol Clin North Am 1978;11:55-61
68. Simmons FB. Perilymph fistula: some diagnostic problems. Adv Otol Rhinol Laryngol 1982;28:68-72
69. Daspit CP, Churchill D, Linthicum FH. Diagnosis of perilymph fistula using ENG and impedance. Laryngoscope 1980; 90:217-223
70. Causse JR, Causse JB, Bel J. Tympanometry and fistula test. Audiology 1983;22:451-462
71. Black FO, Lilly DJ, Nashner LM, Peterka RJ, Pesznecker SC. Quantitative diagnostic test for perilymph fistula. Otolaryngol Head Neck Surg 1987;96:125-134
72. Black FO, Lilly DJ, Peterka RJ, et al. The dynamic posturo-graphic pressure test for the presumptive diagnosis of perilymph fistulas. Neurol Clin 1990;8:361-374
73. Nadol JB Jr. Positive Hennebert's sign in Meniere's disease. Arch Otolaryngol 1977;103:524-530
74. Arenberg IK, Ackley RS, Ferraro JA, Muchnik C. ECoG results in perilymphatic fistula: clinical and experimental studies. Otolaryngol Head Neck Surg 1988;99:435-443
75. Campbell KCM, Savage MM, Harker LA. Electrocochleogra-phy in the presence and absence of perilymphatic fistula. Ann Otol Rhinol Laryngol 1992;101:403-407
76. Black FO, Pesznecker SC. Perilymphatic fistula. The method of F. Owen Black. In: Gates GA, ed. Current Therapy in Otolaryngology Head and Neck Surgery. 6th Ed. St. Louis, MO: CV Mosby; 1998:71-78
77. Nomura Y. Otologic Significance of the Round Window. Munich: Karger-Basel; 1984
78. Seltzer S, McCabe BF. Perilymph fistula: the Iowa experience. Laryngoscope 1986;94:37-49
79. Coats AC. The summating potential and Meniere's disease. Summating potential amplitude in Meniere's and non-Meniere's ears. Arch Otolaryngol Head Neck Surg 1979;107: 199-208
80. Coats AC. Electronystagmography. In: Bradford LJ, ed. Physiological Measures of the Audio-vestibular System. San Diego, CA: Academic Press, 1975:37-83
81. Coats A. On electrocochleographic electrode design. JAcoust Soc Am 1974;56:708-711
82. Arenberg IK, May M, Stroud MH. Perilymphatic fistula: an unusual cause of Meniere's syndrome in a prepubertal child. Laryngoscope 1974;84:243-246
83. Black FO. Vertigo: the method of F. Owen Black, M.D., F.A.C.S. In: Decker BC, ed. Current Therapy in Otolaryngology-Head and Neck Surgery. 1990:59-65
84. Epley JM. The canalith repositioning procedure: for management of benign paroxysmal positional vertigo. Otolaryngology Head Neck Surg 1992;107:399-404
85. Semont A. Curing the BPPV with a liberatory maneuver. In: Annual Meeting of the Barany Society, Marseille, France; 1987
86. Serafini G, Palmieri AMR, Simoncelli C. Benign paroxysmal positional vertigo of posterior semicircular canal: results in 160 cases treated with Semont's maneuver. Ann Otol Rhinol Laryngol 1996;105:770-775
87. Fisch U, Murata K, Hossli G. Measurement of oxygen tension in human perilymph. Acta Otolaryngol 1981;81:278-282
88. Nagahara K, Fisch U, Yagi N. Perilymph oxygenation in sudden and progressive sensorineural hearing loss. Acta Otolaryngol (Stockh) 1983;96:57-68
89. Fisch U. Management of sudden deafness. Otolaryngol Head Neck Surg 1983;91:3-8
90. Bhansali SA. Perilymph fistula. Ear Nose Throat J 1989; 68:11-27
91. Bennett RJ. On subarachnoid-tympanic fistulae: a report of two cases of the rare indirect type. J Laryngol Otol 1966;80: 1242-1252
92. Lingam S, Singh A. Recurrent meningitis due to labyrinthine fistula. J Neurol Neurosurg Psychiatry 1982;45:1168-1176
93. Grewal DS, Hiranandani NL, Pusalkar AG. Traumatic perilymph fistulae of the round and oval windows. J Laryngol Otol 1983;97:1149-1155
94. Schuknecht HF. Pathology of the Ear. 2nd Ed. Philadelphia: Lea & Febiger; 1993
Perilymph Fistulae
Richard R. Gacek
Since the description by Fee1 of perilymphatic fistula (PLF) to the middle ear space, there has been an explosion in the number of reports describing PLF. It is likely that PLF has been used to explain clinical cases of unexplained sensorineural hearing or vertigo, or both. The diagnostic criteria of PLF are not clearly defined and surgical exploration has been used as the principal approach to diagnosis as well as management. A major impediment to recognition of perilymph in the oval or round window niches (RWN) is the presence of tissue fluid produced by middle ear mucosa that reaccumulates when aspirated. An additional misconception responsible for reported round window membrane fistulae is the assumption that a fenestrated membrane, which often covers the entrance to the RWN, represents the RWM. Removal of the bony overhang of the RWN is necessary for exposure of the RWM. It is not surprising that PLF is overdiagnosed and overtreated. This has formed the basis for controversy regarding the issue of diagnosis, recognition, and treatment of PLF.
A perilymphatic fistula (PLF) may be defined as a communication of the perilymphatic space to the middle ear space. The volume of perilymph in the labyrinth is normally small, as it is derived as a transudate of the vasculature in the spiral ligament and, to a limited degree, the cerebrospinal fluid (CSF) space through the cochlear aqueduct. Therefore, perilymph loss in a PLF is small and reaccumulates slowly. A large volume of fluid from a fistula in the oval or round windows (surgical or traumatic) represents the flow of CSF through a congenital defect in the labyrinth that allows the subarachnoid space to communicate with the perilymphatic space. This form of CSF otorrhea will not be considered in this discussion of PLF, as its presence is easily recognized by its copious flow, and treatment is non-controversial. The PLF, which has attracted considerable controversy, is represented by a defect either in the ligamentous or bony structures of the oval or round windows in a normal labyrinth. It should also be pointed out that fistulization of the bony labyrinth (cochlea and semicircular canals) from chronic middle ear inflammation, particularly cholesteatoma, does not include communication into the perilymphatic compartment. The inflammatory response to bone erosion from cholesteatoma creates fibrosis of the endosteal membrane and variable degrees of labyrinthitis rather than a defect permitting perilymph loss. Issues of diagnosis and recognition of PLF at surgery form the main areas of disagreement.
Vast clinical experience is based on the signs and symptoms that result from a humanmade fistula in the oval window. This derives from the stapedectomy or stapedotomy procedure where either a large or small fenestra is fashioned in a fixed footplate and sealed with a tissue prosthesis to recon struct a sound transmission mechanism. Although the fenestra with PLF in this procedure is of short duration, as it is sealed with tissue and the healing response of the labyrinth and the middle ear, poststapedectomy symptoms reflect a controlled PLF. Both vestibular and auditory symptoms follow stapedectomy with the vestibular symptoms consisting of dizziness and dysequilibrium, occasionally accompanied by spontaneous nystagmus being the most troublesome. Auditory system effects appear as elevated bone conduction thresholds with some decrease in speech discrimination, which may require one or several weeks to return to normal levels. It is for this reason that the usual post stapedectomy auditory examination is obtained at 4 to 5 weeks. Animal research2 has demonstrated rapid healing of a defect in the oval window by regeneration of the endosteal membrane within 24 to 48 h, followed by regeneration of middle ear mucous membrane. This reparative response is more rapid with a small fenestra than with a large (total stapedectomy) fistula.
Clinical experience with the end result of an unhealed PLF comes from our experience with direct trauma to the tympanic membrane and ossicular chain as a result of the introduction of an instrument (toothpick, hairpin) into the external ear canal. When such an injury is accompanied by vestibular symptoms, it is axiomatic that immediate surgical exploration and removal of a subluxed or fractured stapes footplate with soft tissue seal of the PLF be performed.3'4 If such repair is not performed the PLF leads to irreversible sensorineural hearing loss with eventual resolution of vestibular symptoms as a result of central vestibular compensation. Early surgical repair of the oval window fistula insures recovery of auditory and vestibular deficits. Thus, surgical repair of PLF is capable of reversing the labyrinthine deficits caused by PLF.
Round window membrane ruptures can be produced in the laboratory animal (cat) by increasing subarachnoid pressure.5 However, the cochlear aqueduct is short and wide in the cat but is long, narrow, and filled with periotic duct tissue in humans. Therefore, this pathway usually will not permit transmitted CSF pressure in humans as in the laboratory animal, at least in the majority of temporal bones. Furthermore, the RWM is very thin with a reduced lamina propria in the laboratory animal (cat, guinea pig, chinchilla),6 whereas the human RWM has a thick lamina propria that will resist disruption by increased
Animal research has demonstrated that cochlear potentials do not change8,9 after RWM ruptures. Furthermore, RWM breaks, no matter how large, undergo spontaneous healing in 7 to 10 days.8 However, when such RWM ruptures are accompanied by intracochlear membrane breaks (Reissner's membrane, basilar membrane) there is a significant sensorineural hearing loss or change in cochlear potentials.10'11
These clinical and experimental observations indicate that a serous labyrinthitis occurs in PLF. The definition of serous labyrinthitis rests on the reversibility of auditory and vestibular dysfunction, implying that if function does not recover, a more advanced stage of labyrinthitis has been reached. Therefore, if the PLF does not heal either spontaneously or by repair, the serous labyrinthitis may progress to a serofibrinous labyrinthitis with irreversible loss of auditory and vestibular function. If the PLF is repaired while the stage of inflammation is serous, recovery of the function and reversibility of auditory and vestibular symptoms will occur.12 The time period beyond which repair will not prevent irreversible loss of function is unknown but probably has a duration of 1 to 2 weeks. This suggested time period is based on clinical experience with treatment of post-stapedectomy granuloma. Most ears with the granuloma removed within 2 weeks recover function completely, whereas those removed later than 2 weeks, or not at all, are associated with severe sensorineural hearing loss.
The main controversy centers around the diagnosis and management of PLF. In my opinion, history is an extremely important diagnostic criterion for spontaneous PLF. A traumatic event, either direct or indirect, to the tympanic membrane and ossicular chain must precede the onset of symptoms. This may occur after severe barotrauma, in which the patient feels sudden pressure change as a result of rapid ascent or descent. A similar force can be created in head injury without TB fracture, where a concussive force is delivered to the labyrinth and ossicular chain. The presence of auditory and vestibular symptoms after such an event may represent the diagnostic manifestations of PLF. These should be demonstrated with auditory and vestibular tests that include pneumatic otoscopy to exhibit a possible fistula.13-15
Marked displacement of the ossicular chain is more likely to produce a tear in the ligamentous structures of the oval window than the RWM because of the shearing force between the footplate and the margin of the oval window. This may produce disruption of the stapediovestibular ligament and the creation of PLF. This author has identified four PLFs in the oval window out of 20 surgically explored cases over a 25-year period. No PLFs were identified in the RWM. A higher incidence of PLF in the oval window than in the round window has also been reported by Singleton et al.13 It is possible that the thicker RWM in close proximity to a channel (cochlear aqueduct), which may decompress the pressure within the perilym-phatic compartment, is at least partially responsible for the infrequency of disruption at this area. Adequate exposure is necessary to precisely identify a tear in the RWM. Because the RWM is usually obscured by the bony overhang of the round window niche, exposure requires drilling off the overhang after the removal of the mucosal fold that is frequently draped over the aperture of the round window niche. This mucosal fold often has a small fenestra which may be mistaken for an RWM defect. This mucosal curtain may assume various positions in the RW niche that simulate the RWM.
When the criteria for diagnosis of PLF are fulfilled, a conservative management is recommended initially. The following criteria are sufficient to support a diagnosis of PLF: (1) a history of trauma (barotrauma or head trauma), (2) sensorineural hearing loss and dysequilibrium, and (3) dissimilarity to other known labyrinth disorders. The presence of a positive fistula test is additional supporting evidence. Conservative management consists of a period of bed rest with head elevation for a period of 7 to 10 days to provide an opportunity for spontaneous healing of the defect by the endosteal membrane of the vestibular wall as well as the middle ear mucosa. Procedures that reduce subarachnoid pressure and possibly perilymphatic pressure are encouraged to assist healing. Should there be no improvement or should auditory or vestibular symptoms worsen, surgical exploration for PLF is indicated.
Exploration of the middle ear for PLF should be performed under local anesthesia with light sedation. Local rather than general anesthesia reduces the incidence of bleeding and fluid accumulation from manipulation of the middle ear mucosa. It also allows the patient to respond with a Valsalva maneuver when requested to enhance perilymph leakage. Complete control of bleeding is necessary before examination of the middle ear space is performed. Adequate exposure of the oval and round windows may require curettage of the posterior and superior ear canal wall. Both labyrinthine windows should be examined without manipulation of a mucosal surface since this maneuver may induce a serous transudate that can simulate per-ilymph. A sensitive and specific marker of perilymph would greatly facilitate identification of PLF. Attempts to find a marker using colorimetric markers such as fluorescein have not been successful. Chemical markers specific for CSF (b-2-trans-ferrin) have also not proven reliable as an indicator of perilymph in clinical studies.16 A recent report17 described detection of human apolipo-protein D using chemo- luminescent Western blot assay in human perilymph taken at surgery. A 75% positive identification rate for perilymph and no false-positive results among 15 controls (middle ear fluid) were recorded. Further confirmation of the use of such protein fractions specific for perilymph will aid the diagnosis of PLF.
A No. 24 aspirator tip is carefully used to examine the margins of the oval window with and without displacement of the ossicular chain. If no fluid accumulation is seen, the patient is asked to perform Valsalva maneuvers at least twice to determine whether an enhancement of subarachnoid pressure will produce perilymph flow. If the oval window examination is negative, the round window niche is examined initially without instrumentation following a Valsalva maneuver and ossicular manipulation. If no fluid has accumulated, the bony overhang of the round window niche is carefully removed with a microdrill to expose and examine the RWM while depressing the ossicular chain. If this examination is also negative, tissue augmentation of the membrane is not performed. I believe that repair in the absence of any visible evidence of PLF confuses the evaluation of the effectiveness of the procedure. A fistula small enough to escape detection by the preceding method of examination should have healed spontaneously.
If fluid has been detected in either of the labyrinthine windows, the precise location of the defect is revealed by use of a No. 24 aspirator and is prepared to receive a tissue graft by removal of mucosal membrane from adjacent bony surfaces. Small (1-mm) adipose tissue grafts are secured in place with gelfoam pledgets. The patient's activity postoperatively should be restricted for at least 1 week to 10 days to aid adequate fibrous healing of the PLF. Auditory function should be evaluated in 6 to 8 weeks postoperatively and at later periods if incomplete recovery is seen initially.
A reasonable statement of PLF incidence is that they do occur but are infrequent. The survey conducted by Hughes et al.18 of 167 surgeons of the American Otologic Society indicated that most (60%) performed three or fewer explorations for PLF per year. The average number of explorations for the group was less than five per year. The number of confirmed PLF was even smaller. If the diagnosis of PLF is based on strict criteria and surgical exploration carried out only after a conservative therapeutic trial has been offered, the number of confirmed PLFs will be very small.
Gacek—CHAPTER 56
1. Fee GA. Traumatic perilymphatic fistulas. Arch (Otolaryngol 1968;88:477-480
2. Hohmann A. Inner ear reactions to stapes surgery (animal experiments). In: Schunecht HF, ed. Otosclerosis. Boston: Little, Brown; 1962:305-317
3. Silverstein H. Penetrating wounds of the tympanic membrane and ossicular chain. Trans Am Acad Ophthalmol Otolaryngol 1973;77:125-135
4. Emmett JR, Shea JJ. Traumatic perilymph fistula. Laryngoscope 1980;90:1513-1520
5. Harker L, Norante JD, Ryu JH. Experimental rupture of the round window membrane. Trans Am Acad Ophthalmol Otolaryngol 1974;78:448-452
6. Richardson T, Ishiyama E, Keels E. Submicroscopic studies of the round window membrane. Acta Otolaryngol 1971;71:9-21
7. Kawabata I, Paparella M. Fine structures of the round window membrane. Ann Otol Rhinol Laryngol 1971;80:13-26
8. Simmons FB, Burton RD, Beatty D. Round window injury: auditory, behavioral and electrophysiological consequences in the cat. Trans Am Acad Ophthalmol Otolaryngol 1962;66:715
9. Weisskopf A, Murphy JT, Merzenich MM. Genesis of the round window rupture syndrome: some experimental observations. Laryngoscope 1978;88:389-397
10. Oshiro EM, Shelton C, Lusted HS. Role of perilymphatic fistula in sudden hearing loss: an animal model. Ann Otol Rhinol Laryngol 1989;98:491-495
11. Simmons FB. The double-membrane break syndrome in sudden hearing loss. Laryngoscope 1979;89:59-66
12. Arragg F, Paparella M. Traumatic fracture of the stapes. Laryngoscope 1964;74:1329
13. Singleton GT, Post KN, Karlan MS, Bock DG. Perilymph fistulas: diagnostic criteria and therapy. Ann Otol Rhinol Laryngol 1978;87:797-803
14. Simmons FB. Perilymph fistula: some diagnostic problems. Adv Otorhinolaryngol 1982;18:68-72
15. Love JT, Waguespack RD. Perilymphatic fistulas. Laryngoscope 1981;91:1118-1128
16. Buckman CA, Luxford WM, Hirsch BE, et al. Beta-2-trans-ferrin assay in the identification of perilymph. In: Abstracts of the One hundred thirty-first Meeting of the American Otologic Society; May 9-10, 1998
17. Telian SA, Disher MJ, Sun Q, Andrews PC. Biochemical markers for identification of human perilymph. In: Abstracts of the One hundred thirty-first Meeting, of the American Otologic Society; May 9-10, 1998
18. Hughes GB, Sismanis A, House J. Is there consensus in perilymph fistula management? Otolaryngol Head Neck Surg 1990; 102:111-117
Perilymph Fistulae
John F. Kveton
The diagnosis of perilymph fistula continues to be elusive, spawning both extremes of overdiagnosis and underdiagno-sis. In this situation, the otolaryngologist is confronted with the possibility of becoming either a charlatan for overdiag-nosing, and therefore overoperating on patients, or a therapeutic nihilist, and so failing to eliminate inner ear symptoms in one of the rare instances in which surgical intervention can remedy sensorineural impairment. The question of whether such a condition even exists has been raised by some investigators.1,2 By contrast, Goodhill's3 original descriptions of the pathophysiology of perilymphatic fistula and my personal experience with elimination of symptoms after surgical repair of obvious perilymph leaks would indicate that this condition does in fact exist. This chapter reviews my understanding of this entity and outlines my approach to arriving at the diagnosis and management of patients who present with the appropriate symptoms.
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• Surprising city break destination with a historical character
• Romantic city centre
• Majdanek museum
• Modern sports infrastructure
Tipps für Ihren Aufenthalt in Lublin
Eventful historyOne of the largest concentration and extermination camps was built in Lublin during World War II. The Majdanek camp was the second largest camp after Auschwitz. Now it is a museum and you can visit some barracks, gas chambers, the crematorium and several exhibitions. Discover the past now with a cheap flight to Lublin.
The old cityThe inner city of Lublin is one of the most beautiful in Poland and certainly worth a visit! With a flight to Lublin, you can visit the old gates, the cathedral, cheerful squares, cosy little streets and of course the Gothic castle that used to be a prison and now features a museum. You can even explore the city underground with the Lublin Underground Trail.
Sports and recreationZemborzycki Reservoir offers plenty of activities for old and young alike. A water park with several swimming pools and a pirate island for children, a beach at the lake, restaurants and bars ... Try one of the many water sports, go on a relaxing bike ride and enjoy the wonderful scenic environment. Furthermore, the city boasts state-of-the-art sports facilities for those who love swimming, athletics, soccer or even skiing and snowboarding. Book your flight to Lublin now and go exercise to your heart's content!
Cheap Tickets
* Preise pro Person, Hinflug, einschließlich der Flughafensteuern. Buchungen möglich vom 07/11/19 bis zum 08/11/20. Abreise möglich vom 07/11/19 bis zum 08/11/20. Die zu diesen Sonderpreisen angebotenen Flugtickets sind beschränkt erhältlich. Die Sonderaktion gilt nur, solange der Vorrat reicht. Diese Angebotsliste wird regelmässig aktualisiert. Den Zeitpunkt der letzten Aktualisiering finden Sie untenstehend neben 'zuletzt bearbeitet'. Tickets zu diesen Minimumpreisen sind daher immer begrenzt verfügbar und nur solange der Vorrat reicht. Danach können höhere Preise gelten.
Flüge nach Lublin an folgenden Tagen
Antwerpen (ANR) Lublin, Polen (LUZ)
|16/12/19 - 29/12/19
|30/12/19 - 05/01/20
|06/01/20 - 12/01/20

subset: commoncrawl


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Iranian Police Chief Brigadier General Hossein Ashtari said on Saturday that the force will give a crushing response to the main figures behind the Chabahar terrorist attack.
The enemy is after undermining the security of the country but they should know that these blind attacks will not affect the determination of Armed Forces and Iranian people in the fight against terrorism, Ashtari said in a meeting with students of Amin Police University in Tehran.
He went on to say that police forces are undertaking their missions with more authority than ever.
Asked about the amount of explosives used in the terrorist attack, Ashtari said that investigations are still underway to discover its different aspects and details.
A terrorist suicide blast in Iran's southeastern port Chabahar near the Pakistani border on Thursday left at least two people dead and over 30 others injured.
In a relevant development on Thursday, Deputy Governor-General of Sistan and Balouchestan Province for Security and Law Enforcement Affairs Mohammad Hadi Mara'ashi told FNA that "a bomb blast was heard some minutes ago near a police station on a street in Chabahar city and security forces and aid groups were immediately deployed to the region".
He added that the bomb which was planted inside a car killed 2 people and wounded many others.
Local sources also said that at least 2 law enforcement police have been killed in the terrorist attack. The suicide bomber meant to open his path into the Law Enforcement command center, but was forced to stop where he blew up himself and the car.
Meantime, Caretaker of Chabahar city's Governor-General Office Bameri confirmed the death and injury of a number of people in the bomb blast, stressing that conditions are under control now.
He added that the bomb was planted inside a pickup truck near the Law Enforcement Police's station.
"A number of women, children and local business owners are among the wounded people who were transferred to Imam Ali (AS) hospital," Bameri said.
Latest reports by Chabahar medical officials said that wounded people were accepted to the city's hospitals, among them a pregnant woman and a 16-year-old adolescent.
Islamic Revolution Guards Corps (IRGC) Ground Force Commander Brigadier General Mohammad Pakpour underlined on Thursday that full security has been established in the Southeastern city of Chabahar after the Thursday morning terrorist attack.
Chabahar city is in full security and complete safety, General Pakpour said.
He added that a car with explosives tried to attack Police Headquarters in the city, noting that "unfortunately, a number of compatriots were martyred and injured by this blind terrorist operation", which had no achievements for terrorists.
The commander said the suicide car could not enter the police headquarters, adding that reports concerning martyrdom of the city's police commander are not correct.
General Pakpour visited the blast site on Thursday.
Also, the chief commander of Chabahar's Law Enforcement Police dismissed media claims that he was killed in the terrorist attack.
Foreign media reports said that Ansar al-Forqan terrorist group has claimed responsibility for the Thursday morning suicide blast in Iran's Southeastern city of Chabahar.


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Bachelor of Arts and Bachelor of Science in Economics
Why Study Economics at Cedarville?
Cedarville takes a broad, traditional economics program and integrates it with a biblical worldview to make it the ideal place to study.
Placement Success
We're proud of our successful graduates! 99% of 2018 graduates from the School of Business Administration were employed or in graduate school within six months of graduation.
What Can You Do With an Economics Degree?
From public policy to grad school, discover what you can do with an economics degree from Cedarville.
What is the Difference Between a BA and BS?
Consider your desired outcome first when choosing between a B.A. or B.S. in economics.
Why Are Free Markets Superior to Central Planning?
Learn how a free market economic perspective aligns with a Christian worldview, allowing individuals to flourish and maintain personal accountability.
Are Free Markets Biblical?
Examine how a free market economic perspective fits in with a biblical worldview.
Program Faculty
Jeffrey Haymond, Ph.D.
Dean, School of Business Administration; Professor of Economics
- 937-766-4442
Bert Wheeler, Ph.D.
Professor of Economics; Berry Chair for Free Enterprise
- 937-766-7714
Economics Program Curriculum
Building on your core liberal arts and Bible minor courses, you will take basic business courses laying the foundation for successful integration into management and general business positions. Your economics core includes basic principles that are then expanded on and enhanced in intermediate theory classes.
- Comparative Economic Systems
- Money and Financial Markets


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I can't clean the house in a quiet environment. I need company.
Today's cleaning adventure will be complete with Mr. Darcy.
My favorite version of Pride and Prejudice.
Today I'm infinitely grateful for the strength, and desire to clean my house. I'm also very grateful for a detailed, raucous, well done version of Pride and Prejudice. I love Mrs. Bennet, she's such a hoot living in her own rationalization.
Do you have a favorite?


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2 Corinthians 3:18, Bernard of Clarivaux, Bible Bowl, Cistercians, Faith in Action, James, Monasticism
One of the great dangers that every generation of the church has to deal with is the problem of "A Bible Bowl Faith;" A faith that is concerned with getting all of the correct answers but doesn't get expressed in daily life change.
Before everyone starts sending hate mail I want to make something clear: I am not completely against Bible Bowls. I do see the purpose in them. I was even once in a Bible Bowl, however, my team came in second place to a group that cheated (there's something really wrong about cheating in Bible Bowl.) That experience has only slightly skewed my thinking. While I must honestly admit that I'm not a huge proponent of Bible Bowls I do see the good that happens when we study the Bible together as a community and that Bible knowledge is a great foundation for faith.
However, I do think there is something wrong with Bible Bowl Faith. There is something wrong with believing that the most important thing is to get all the answers right. And I do wonder if we are slightly misguided when we encourage our children, and ourselves, to learn all the facts of the Bible but we fail to ever tell them what those facts mean or why they are important for life. I've recently started teaching a high school bible class and I am dealing with this same struggle. How do I help the students gain a passion for the Word while also making sure they are ready to take the test on Friday because I have to give them a grade. (Of course, all grades and tests are a result of the fall, but that is a completely different blog post.) What is most important is not that they can tell the facts of the Book of Hebrews and quote answers on a test, but that they understand the heart of the message, that God has done so much for them and they need to stay faithful to the end. We must make sure we convey the facts in a way that it leads to changed lives.
Bernard of Clarivaux lived during the 12th century and is credited with reforming monasticism. During this time the church was gaining more power in the greater culture and many monks and pastors were taking on leadership roles in the community. These public leadership roles though took away from their more important work attending to God in their own lives and encouraging the church. So Bernard led a group of monks, known as the Cistercians, to return to the ancient Rule of St. Benedict and focus on that which is most important. During one of his sermons, he said this:
"We must beware of this misstep so that we do not fall asleep in our faith. I warn you – do not become one of those who has a head full of "the right" Christian doctrines while failing to go on by working truth into everyday practice. For as the apostle James warned, faith that does not show itself in good deeds is not true Christian faith at all. For when we truly believe something, we give our whole self to it – not only our minds – and gradually all of our actions are changed." – Bernard of Clairvaux
Correct knowledge is important. Christians should always be striving to grow in knowledge of the Bible and more importantly of the God revealed in the Bible. Scripture knowledge is one thing that the Holy Spirit uses to help transform believers into the image of Christ. But, Biblical knowledge is not sufficient on its own. Correct knowledge must lead to transformed lives. As Bernard says, if we truly believe something that knowledge will gradually lead to a change of actions. And thus the problem with a Bible Bowl faith that leads to correct answers but not a changed life.
The goal is transformation into Christ likeness. Paul says it best when he says; "And all of us with unveiled faces, seeing the glory of the Lord as though reflected in a mirror, are being transformed into the same image from one degree of glory to another; for this comes from the Lord, the Spirit." (2 Corinthians 3:18) The goal is to become more like Christ, not just in knowledge but in action. All that we do as Christians, whether bible study, spiritual disciplines, attending Sunday Gatherings, should all be in an effort to grow in Christ likeness that leads to changed lifestyles. Bible Bowl Faith is not enough, we must always teach and learn for transformation. Or, as James says, faith without works is dead.


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Louis Daignault (ISN)
June 28, 2013, Ottawa, ON (ISN) – Japan has become the latest country to join the Global Drug Reference Online (Global DRO) network, providing more athletes than ever before with the opportunity to benefit from easily accessible and accurate information about the sport status of their medications.
Global DRO is an online tool originally created through a partnership between UK Anti-Doping (UKAD), the United States Anti-Doping Agency (USADA) and the Canadian Centre for Ethics in Sport (CCES) to allow athletes to check the prohibited status of licensed medications according to the latest World Anti-Doping Agency (WADA) Prohibited List. In 2012, there were more than 314,000 inquires between the web and mobile sites, proof of the popularity and effectiveness of the resource.
Now, athletes based in Japan can check the status of medications purchased in their home country as the Japan Anti-Doping Agency (JADA) has become part of the Global DRO system. The benefits of the new license extend to athletes and support personnel from the UK, USA or Canada, who now have four countries' brand data at their fingertips.
Athletes are advised to check Global DRO before taking any medication by simply searching the name of the product to find out whether it is prohibited, in or out of competition.
"As one of the founding partners, we are pleased to see Japan joining Global DRO and we encourage other national anti-doping agencies to join as well," says Paul Melia, President and CEO of the CCES. "As more countries' drugs are added to the database, there is an exponential benefit for athletes that train and compete internationally: a single, consistent source for this critical information."
The Canadian Centre for Ethics in Sport is an independent, national, not-for profit organization. We recognize that true sport can make a great difference for individuals, communities and our country. We are committed to working collaboratively to activate a values-based and principle-driven sport system; protecting the integrity of sport from the negative forces of doping and other unethical threats; and advocating for sport that is fair, safe and open to everyone.


text: Share: Comments Print September 14, 2008 at 1:16 PM Sparks game thread Posted by Jayda Evans GAME OVER: Not sure what the Storm learned from this one, losing 65-48 to LA, but the point difference is about equal to what Bird and Griffith produce, so maybe Seattle will be alright in the postseason. Parker said she knows it's hardest to get out of the first round and Seattle knows that all too well, losing in the opening round the past three seasons. Regardless, it's going to be one of the most entertaining series of the postseason. Until then… MIMIC THAT: Well, Wright just picked Bobbitt's pocket and scored a layin, could you do that Burke (smile)? The score is 52-36 LA with 6:44 remaining. ANOTHER HATER?: Just got word that ESPN2 announcer Doris Burke thinks she could guard Wright and would be all in her grill, picking her pocket, especially if she was forced to go left. I don't know if it would be that simple for Burke, but Wright isn't the greatest ball-handler, we all know that. It's so tiring to even talk about it. She does what she does well and it works for the Storm, particularly when Bird is on the court with her. Maybe Burke could get Lauren Jackson the ball, but I could get Jackson the ball and my only basketball experience is being captain of the cheerleading squad that cheered for the teams for four years in high school. It's funny that Burke felt the need to go off. Guess she has to say something and there's not much to work with without the stars in the game. I know if I see one more shot of Bird, Leslie, Parker, and Jackson on the bench I'm going to vomit. (I'm watching on a screen while attending the game). Maybe the announcers should talk about the state of the league and how this is the largest crowd LA has had in a while. Or maybe ask Parker's fiance Sheldon Williams what he's texting throughout the game. I'd love to know that answer. HALFTIME: Couldn't hear Agler's halftime spiel aired on ESPN2, bet it had something to do with taking care or the ball and playing better defense. He still hasn't put Bird and Yo back in and why would he now that the second half has started? The Storm is down 42-18 and there's no need for Bird and Yo to try and rally the team back with it only helping a distant WNBA Finals home-court advantage dream. Reporters here are undecided about who'll win the series between the teams. A lot believe Seattle will if Swoopes and Cash are healthy because the Sparks are so inconsistent. Maybe this is where covering the Storm so long hurts me, but LA owns them in the postseason and I'm not certain this is the year it's broken. I do know home-court is a must for Seattle. KeyArena definitely plays a part in the Storm's play and they'll need serious backup, which Seattle did not have in 2002 and 2006. DYDEK CHECKS IN: She's still learning the system and Cooper said she's not in game playing shape, by Polish center Margo Dydek is in the game and made a basket in her first offensive possession to give the Sparks a 38-13 lead with 3:16 remaining before halftime. SPENCER FOR HIRE: Reserve Sidney Spencer is keeping the Sparks on pace with her shooting, she scored seven of her nine points in the second quarter to give LA a 32-11 lead. The Storm has 10 turnovers, which the Sparks converted into 11 points. Seattle is playing a little timid and needs to snap out of it. The game may mean little overall, but the reserves need to gain confidence by seeing their game work against the Sparks on the road. END OF FIRST: Woeful shooting is hurting the Storm, who is down 21-6 at the end of the opening quarter. Seattle is shooting 21.4 percent from the field while LA is shooting 42.9. F Shyra Ely is doing the best for the Storm, scoring four points. Kelly Santos has some tacky turnovers, but is being forceful inside along with Little. They just need the shots to drop. Before the game I thought the Storm's bench was better, but LA's is really playing well. It helps they have vets in Murriel Page and Marie Ferdinand-Harris on the court. BIRD, WRIGHT, GRIFFITH SIT: Don't know if it's for the remainder of the game, but Bird, Yo, and Wright are on the bench with their shooting shirts on. Is cold in Staples Center, but maybe Agler had seen enough. Leslie, Parker, and Brown are also on the bench chilling while their team builds a 17-6 lead with 1:54 remaining in the quarter. FIRST BUCKET: Little got the Storm on the board, hitting a nice turnaround jumper with 5:15 remaining to make the score 15-2. There could be a psycological drawback to this game no matter what Agler says. Who knows when Swin Cash (back) and Sheryl Swoopes (concussion) will really be able to return and getting beat down like this is not fun after all of the positive momentum the Storm bench created for themselves, hanging close to Sacramento and defeating Atlanta without all of their stars. TOO EASY: LA is the No. 1 shot-blocking team in the league and they're displaying that skill with ease to start the game ahead 4-0. Parker blocked KG at the three-point line while Leslie didn't even fully extend her arm to block Wright's layin. Griffith got a little payback, blocking Parker later. But the Storm is still down 6-0 with 7:22 remaining in the opening quarter. GRIFFITH STARTING: Yo is on the court ready to tip-off. She was fiddling with her leg during the national anthem, so I guess it was just a slight scare. GRIFFITH HURT?: Griffth crumpled to the court during layup drills, immediately grabbing for her right knee. The team froze and then surrounded her, apparently not knowing what happened. She seemed to slip, but I don't know. Agler and trainers helped peel her off the court and it's unknown whether she'll continue to start as planned. Tune in early if you want to see the stars from Los Angeles and Seattle. Storm mainstays Sue Bird and Yolanda Griffith will start along with the Sparks' normal starters, but both coaches said they'll take it easy on them since the postseason begins on Friday in LA. Sparks coach Michael Cooper said it's important for his team to play as usual, noting that in his former playing days, easing up on rotations did not help prepare for the playoffs. Storm coach Brian Agler is dealing with an injury-plagued team, so he said he's going to limit the minutes of Bird, Griffith, and Tanisha Wright. "We want to do the fundamental things — rebound well, make our free throws and play good solid defense," Cooper said of the matinee matchup. "Depending on where it's at the last quarter of the game, that's when we may start pulling our starters. But we're coimg out to play because in my experience, every time we've slacked off two or three games of the season, it does nothing good for you." Here are tonight's starters: STORM F Camille Little F Katie Gearlds C Yolanda Griffith G Tanisha Wright G Sue Bird SPARKS F DeLisha Milton-Jones F Candace Parker C Lisa Leslie G Keisha Brown G Shannon Bobbitt Tonight's officials are Denise Brooke-Clauser, Cameron Inouye, and Michael Price. Comments


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Fuel On The Fire: Trump Hikes Canadian Timber Tariffs In Retaliation For Milk Duty
With one taunting tweet, President Donald Trump threw wood on the fire of a skirmish with Canada that his administration insists is not war between two of the closest trade partners on the planet.
Trump announced he was imposing tariffs of up to 24 percent on imported softwood lumber, retaliation for what he said were increases in tariffs on U.S. dairy products sold in Canada.
"Canada has made business for our dairy farmers in Wisconsin and other border states very difficult. We will not stand for this. Watch!" Trump said on Twitter.
Canada has made business for our dairy farmers in Wisconsin and other border states very difficult. We will not stand for this. Watch!
— Donald J. Trump (@realDonaldTrump) April 25, 2017
The Canadian dollar fell to a four-month low after Trump's tweet. The Canadian dollar was trading at 0.7349 to the USD.
Canada Hits Back
A joint statement from Canadian Foreign Minister Chrystia Freeland and Natural Resources Minister Jim Carr called the Trump tariffs "unfair and punitive" measures that will hurt workers on both sides of the border. Canada "will vigorously defend the interests of the Canadian softwood lumber industry, including through litigation," the ministers said.
Speaking to Reuters by phone a day ahead of Tuesday's announcement, U.S. Commerce Secretary Wilbur Ross said that the duties would affect $5 billion worth of softwood lumber imports from Canada.
"It's about 31.5 percent of the total U.S. market, so it's a pretty big deal in terms of the Canadian relationship," he said.
Tariff Hike Part Of Long-Running Dispute
He said the Commerce Department took action because of because of unfair Canadian subsidies to the lumber industry. Much of Canadian lumber is grown on public lands, while most U.S. timber is on private property.
Ross said in an interview Tuesday on CNBC's "Squawk Box" that the new lumber tariff is the result of a long-running dispute and not the beginning of a trade war.
Ross said Trump was troubled by the plight of U.S. dairy farmers while traveling in Wisconsin last week.
Action Comes Ahead Of NAFTA Talks
Canada has long maintained a high tariffs on most dairy imports. The duty on milk is 270 percent. One exception was "ultrafiltered" milk and other protein-rich dairy ingredients used to make dairy products such as cheese and yogurt. North American free-trade rules do not cover these ingredients, so U.S. dairies have developed a big business selling such low-cost products to dairies in Canada.
That changed about a year ago, when Canadian dairy farmers persuaded regulators to create a new lower-priced class of industrial milk as an incentive to get dairies to produce protein substances in Canada, using Canadian milk. U.S. imports fell in 2016, and continue to decline.
Trump's tariffs come as the U.S., Canada and Mexico prepare to renegotiate NAFTA, the 1994 free trade agreement. Trump has directed almost all of his NAFTA criticism at Mexico, until now.
Related links:
Border Adjustment Tariff Has Ryan, Trudeau At Odds
Posted-In: News Emerging Markets Commodities Politics Forex Global Markets Media Best of Benzinga
© 2019 Benzinga.com. Benzinga does not provide investment advice. All rights reserved.


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Local artists will have an opportunity to feature their work in a group show at the Vineyard Haven Library this June. The show will be held from June 2nd through 14th, and will feature recent work by local artists. This year's show will be curated by Francine Kelly and coordinated by Jennifer Rapuano at the library. The event is sponsored by the Friends of the Vineyard Haven Public Library, who will host a reception for participating artists and the public on Tuesday June 3rd from 5:30 to 7:30pm.
Artists interested in participating may contact the library for details on submitting their work. The deadline for submissions will be May 1, 2014. Artwork submitted for consideration can be in any medium including photography, painting, drawing, ceramics, mixed media, jewelry, computer design, and collage. The Library can accommodate wall-mountable two-dimensional work or small three-dimensional pieces. Site-specific installations may also be proposed. We recommend that wall pieces should not be larger then 4 feet in length or width.
Submissions may be sent via email to firstname.lastname@example.com, or dropped off at the library during regular library hours. The curator will consider recent work (2012 and later) and submissions should include the artist's contact information, an artist statement, an image of the work, and information about the work including title, media, and dimensions. Multiple works may be submitted but due to space considerations not all submissions will be exhibited. Artists will be notified after May 15th if their work has been accepted.
For more information, visit the library website at www.vhlibrary.org/artshow.shtml or call Jennifer at the library at (508) 696-4210 x12. To contact curator Francine Kelly, email firstname.lastname@example.com.


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Our Fall semester starts the week of , on September 2, 2019 for private students (or as agreed), and the week of September 9, 2019 for groups. New students may join existing groups any time subject to an evaluation and space. Groups that are marked NEW, are planned for a start in September 2019, or as soon as there is sufficient enrollment (4-7 students for a group rate, smaller size group at modified rate). Please note that course fees will not be charged until a group has 4 or more students, unless otherwise agreed with each student.
Please register for programs by downloading a registration form from this website, and return it to us by email or mail, or call us with your information!
Our mailing address is:
LEARN, PO Box 255, Liberty Corner, NJ 07938
email: firstname.lastname@example.com,
telephone: 908 626 9655.


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The album definitely starts off meeting our expectations, the song Partner_Predator is carried by a heavy riff, Brandan's screaming vocals, and frantic drumming. The song's ending bridge and chorus show off more of the vocal range but it's mostly just warm and inviting, what we expect to hear from this group. It's a powerful song that works on so many levels. Bedburner and Fractional were songs that backers got to hear in their demo form. Both are mostly the same although some things have been slightly tweaked and adjusted for the better. The chorus of Bedburner for instance sounds larger than the demo version and the guitar on Fractional feels more pronounced. Last Apology is probably my favorite song still, it was released a few months back as a single for the album. I feel like it's the best blend of the heavier work, catchier sounds, and the more progressive and interesting style featured in other songs. Basically if I had to pick one song to show off the band it would be Last Apology, it's also catchy as hell.
Then there's the song December which blew me away when I heard it and is sure to catch you off guard. We're generally used to these musicians delivering heavier sounds with distorted guitars, loud basslines, and screaming. December throws that all away. It's not a soft song by any means but it's a more somber and methodical approach to music. The guitars seem to drift off into another realm, the same realm where the vocal work transports you to. This is easily the best Cory Brandan has every sounded, the song really shows off his range and the depth of his skills. For most of the song the vocals are sung and clean, yet there's no sign of awkward transitions or discomfort being in that range. He really owns it on this song. For that I would say while Last Apology is my favorite December is what I would call the best song on the whole album. It's trippy, it's dreamy, and it's different.
Hundred Suns delivered an album better than I could ever have imagined. I was absolutely expecting a stellar album, after all the pedigree behind this band is astounding, but The Prestaliis caught me off guard with just how diverse it really is. Every single second of every song is just jam packed with talent you could sit there and analyze each one for hours. You never know what to expect from a super group, often one member's sound takes over and it feels like a vanity project, yet there's none of that with Hundred Suns. Each member of this group shines bright on their own and yet when they are put together it's enough to light up the entire world. The band truly is greater than a sum on it's parts. If you have any interests in progressive metalcore or listen to bands like The Deftones and Night Verses do yourself a favor and listen to Hundred Suns. If you like any sort of rock, metal, hardcore, or heavy music in general you need to hear this album and embrace the sun.
Official Band Site


text: Honors Awarded to KODAK All-in-One Inkjet Printer and Two Digital CamerasROCHESTER, NY, Dec. 19 -- Eastman Kodak Company's (NYSE:EK) innovation was highlighted at the recent International Consumer Electronics Show Press Preview, where the company's products and services won three prestigious Innovations 2008 Design and Engineering Awards. The KODAK EASYSHARE 5300 All-in-One Printer was awarded an Innovation honor in the Computer Peripherals category, while the KODAK EASYSHARE V1253 garnered Innovations honors in the Digital Imaging category and the KODAK EASYSHARE ZD710 received accolades for its energy efficient design in the Eco-Design and Sustainable Technology category.The Innovations 2008 Design and Engineering Awards, sponsored by the Consumer Electronics Association and endorsed by the Industrial Designers Society of America, honors superior design and engineering among the year's most technologically advanced products. Chosen for the honor by a panel of independent industry designers, engineers and journalists, the KODAK Products will be on display at the 2008 International CES in Las Vegas from January 7-10, 2008 in the Kodak booth, Las Vegas Convention Center (Booth #31400/South Hall/3).About the Kodak Award WinnersThe KODAK EASYSHARE 5300 AiO Printer ($199.99 US MSRP) uses Kodak's premium, pigment-based ink, priced at $9.99 for a cartridge of black ink and $14.99 for a five-ink color cartridge (US MSRP), and can save consumers up to 50 percent on everything they print compared to similar consumer inkjet printers*. The KODAK EASYSHARE 5300 All-in-One Printer offers a 3-inch color LCD display that enables photo viewing and cropping directly from the printer. Memory card slots provide an additional quick and simple way to print digital pictures without a PC. Featuring print, scan and copy capabilities, the 5300 delivers high-quality documents and photos for users who enjoy printing without limitations. The 5300 can print and copy up to 32 pages per minute in black and 30 pages per minute in color, and print photos from PICTBRIDGE enabled cameras without involving a PC.The KODAK EASYSHARE V1253 Zoom Digital Camera ($279.95 US MSRP) allows consumers to capture HD still images (16:9 aspect ratio) and video (720p at 30fps), while offering a sleek design and simple-to-use controls. Equipped with 12MP resolution, a 3XSCHNEIDER-KREUZNACH optical zoom lens and KODAK PERFECT TOUCH Technology, the camera provides exceptional image quality for every shot. The V1253 boasts Face Detection Technology, which automatically adjusts the camera's settings for outstanding portrait shots, and Digital Image Stabilization to reduce blur caused by camera shake or subject movement. Images can be instantly viewed in 16:9 aspect ratio on the large 3.1-inch LCD screen of V1253. The 7-megapixel KODAK EASYSHARE ZD710 Zoom Digital Camera ($199.95 US MSRP) is a versatile, fully-automatic camera with 10x optical zoom and high ISO. The ZD710 is equipped with features that help consumers take consistently better shots, like Digital Image Stabilization and KODAK PERFECT TOUCH Technology.About Eastman Kodak CompanyKodak is the world's foremost imaging innovator. With sales of $10.7 billion in 2006, the company is committed to a digitally oriented growth strategy focused on helping people better use meaningful images and information in their life and work. Consumers use Kodak's system of digital and traditional products and services to take, print and share their pictures anytime, anywhere; Businesses effectively communicate with customers worldwide using Kodak solutions for prepress, conventional and digital printing and document imaging; and Creative Professionals rely on Kodak technology to uniquely tell their story through moving or still images.More information about Kodak (NYSE:EK) is available at www.kodak.com.#Editor's Note: Kodak corporate news releases are now offered via RSS feeds. Many RSS aggregators or readers, including my.Yahoo.com, NewsGator, and Google Reader, can be used to view these feeds. To subscribe, visit www.kodak.com/go/RSS and look for the RSS symbol. In addition, Kodak podcasts are viewable at www.kodak.com/go/podcasts. Podcasts may be downloaded for viewing on iTunes, Quicktime, or other PC-based media players. Users may also subscribe to Kodak podcasts via the iTunes store by typing "Kodak Close Up" in the search field at the top of the iTunes Store window.*Savings based on home printing of documents and photos, using average ink costs of comparable consumer inkjet printers. Actual results may vary. For more information visit www.kodak.com/go/inkdata for details.(Kodak, EasyShare, and Perfect Touch are trademarks of Eastman Kodak Company. Schneider-Kreuznach is a trademark of Jos. Schneider Optische Werke GmbH used under license by Kodak.)


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Semarang may not be as popular as other cities in Java Islands. However, the strategic position of Semarang has made the city a melting pot of Chinese, Indian Arab, and European cultures. Wander around the Chinese quarters and the Dutch commercial district, you will see the influences of different cultures everywhere. In the older part of the city near harbour named Kota Lama, or the Oudstadt, stroll around to explore the historic old buildings in what was once the European commercial district.
The one thing that you definitely must try in Semarang's Chinatown is the famous Lumpia (Springroll) Semarang. A dish that is similar to the springroll, the Lumpia has a sweet yet savoury taste and is filled with bamboo shoots, egg, chicken or shrimp. It can either be served in a soft wrap or deep fried, with a side of delicious thick brown sauce, freshly cut spring onions, birds eye chilli and lettuce.
The Karimunjawa archipelago, located in the Java Sea, north of the capital city of Semarang, has everything to offer sea lovers who enjoy trekking and snorkeling along a pristine beach. The Karimunjawa National Park (not to be confused with the Karimun Islands in Bintan, Riau) is one amongst seven marine national parks in Indonesia.
The pristine beaches and seas are home to healthy coral reefs that scatter in an 80 km wide area all the way to the coast of Jepara. Two protected biota species here are the black coral (Antiphates sp)and organ pipe coral (Tubipora musica). Others include the triton trumpet, the hornet helmet, and the pearly-chambered nautilus. Here are also hawksbill turtles, common green turtles, and on land are the red-breasted parakeet and other tropical bird species.
The archipelagic Karimunjawa, though not as known the Marine reserves near Ambon and Manado, has unexpectedly good beaches, reefs and lovely sea scopes. Corals seem to blossom into gardens, with an Amazing variety of form and color fishers and marine plants. Fringing reefs, atolls, wrecks and an excellent variety of different species make diving in Karimunjawa an unforgettable adventure.
Pick up from Semarang Airport and we will explore Semarang before check in to our hotel. Stay overnight in Semarang. Today's activities will be depending on the arrival time.
After breakfast, get ready to check out. We will take a flight to Karimunjawa (about 30 minutes). Reach Karimunjawa around noontime, check in to our homestay and rest while waiting for our lunch. At 2 pm, we will explore the island, go to Love Hill, and enjoy Tanjung Gelam Beach. Back to our homestay after sunset and have our dinner around 7 pm. Free time afterwards.
After breakfast, get your gears and suits ready. We will go snorkelling at Menjangan Kecil and Cemara Kecil. Lunch with grilled fish will be served while we are at Cemara Kecil Island. After lunch, we will go to Karang Gosong, a sandbar in the middle of the sea. Then we will see the baby shark and enjoy the sunset near Menjangan Kecil Island. Dinner at the homestay and free time afterwards.
After breakfast, free time until check out time at 10 am. We will take a flight back to Semarang.
*If necessary, the itinerary may subject to change depending on the situation on the day.
• 3 nights accommodation (twin-sharing)
* Single Supplement is available by request and whenever possible
– 2 nights homestay in Karimunjawa (AC)
– 1 night in Semarang
• Land transportation during the trip
• Meals as stated on the itinerary
• Snorkelling gears
• Wooden boat for island hopping
• Entrance fees, all necessary permits, retributions, and administrative requirements
• Tour Guide and/or Leader
• Mineral Water
• Flights
• Visa on Arrival (if applicable)
• Optional activities not included in the itinerary
• Personal expenses
• Gratuity for guides
• Travel insurance
By joining any of the trips organised by Indonesia Explorer (IDE) and partners, all participants are deemed to have agreed to the following terms and conditions:
• All deposits payment are not refundable once the trip is confirmed. However, you may look for a replacement.
• For payment made via Paypal, there will be an additional 4.4% Paypal fee from the total payment amount
• Organizers reserved the rights to prohibit participant for joining the outing if they find that the participant is not fit or suitable for the activities
• While Organizers try their best to organize all the trips, however, responsible for any unexpected issues arise prior/during the trips such as bad weather, cancellation or flight delayed, injuries, and other misfortune situations – are not held by the Organizers


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Our Revere project is located next to an active substation on Railroad Street. This substation has encountered loading issues, and thus our project is designed to help alleviate this excessive loading. In addition, this site will provide information about the effects of solar generation on a nearby substation's performance. The land is a former MGP site with very little reuse capability due to contamination, making it a prime site for solar power. The project is currently up and running.
Environmental Benefits
Construction of the project is estimated to save approximately 2,200 pounds of sulfur dioxide, 980 pounds of nitrous oxides, and 1.02 million pounds of carbon dioxide per year. This is equivalent to the emissions produced in generating electricity for 150 average homes.
This project is designed to generate 750 kW of DC power, accounting for approximately 887 MWh per year. This installation includes 2,640 panels spanning over 3 acres of land. The panels are mounted on the ground with a fixed inclination and position.


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Simple Matters - One4Review
Simple Matters is a clown group of 5 performers, 2 guys and 3 girls. They perform a number of routines some funny, others tasteless.
Given their early afternoon timing when a family audience is likely to be interested, one of the male performer's routines was not funny and indeed caused offence. On one of his forays into the audience, he aggressively messed up the hair of a girl in her early 20's, all for the sake of a cheap laugh but to her obvious distaste. Shortly after, her and her male companion walked out.
In addition, there was a routine extracting items during the act of childbirth, which was then followed by him disappearing into the womb. This left the audience non-plussed from what I could see around me. (Believe me I am no prude. I can take late night adult humour and whether I laugh or not will depend on the personality, presence and timing of the performer.)
Cut this performer's contribution out and what remains would be a more than acceptable show. For me, circus humour should be about clever stunts with the timing looking easy when it can actually be difficult and physically demanding. Fair enough a bit of rude humour but restraint is necessary.
As the show stands, the audience numbers will continue to be tiny.
Reviewed by Ben
Gilded Balloon Teviot; 14
3 to 27 August 2012 (not 7, 14 & 20)
13.30 – 14.45
Fringe Programme Page Number: 319


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Account Executive
- Employer
- Creative Circle
- Location
- Bethesda, MD, Maryland
- Salary
- competitive
- Posted
- Jun 13, 2019
- Function
- Operations & Strategy
- Specialty
- Account Management, Client Services, Operations
- Metro Area
- Other
- Duration
- Full Time
Position: Account Executive
Location: Bethesda/Chevy Chase, MD
Status: Freelance
Estimated Duration: Ongoing
Starts: Within a Couple Weeks
Rate: Up to $42/hr DOE
Job Description:
A client in Bethesda, MD is looking for an Account Executive to join their team on a long term contract, ONSITE.
- The Account Executive will work in an internal agency.
- Be the main, day-to-day point of contact for client partners.
- Act as a strategic partner and extension of the client while ensuring that all project deliverables are executed on strategy.
- Be the liaison between the client and the creative team
- Master assigned lines of business, brand(s)
- Work with clients to develop integrated communications strategies
- Manage and guide project workflows to execute client campaigns, marketing collateral and customer-facing content
- Expertise in strategy and execution in the development and delivery of content, social and/or digital marketing
- Lead all project initiatives by working with the creative team to scope and shape concepts and executions
- Work with Account Supervisor to prepare and pitch business and campaign proposals
- Partner with clients to develop complete and comprehensive creative briefs.
- Identify opportunities for expanded work or new projects within assigned business units.
- Responsible for strategic project consultation and creating integrated project proposals
- Work with Project Manager in monitoring budgets for active projects and specific project deliverables.
- Work with PM on project estimating and scheduling.
- Communicate regularly with the client and provide the client with project status reports
- Partner with the creative team to present deliverables and obtain, consolidate, and translate client feedback.
- Oversee full project scope including PM on inputting tasks, alerts and change requests into Advantage.
- 4+ years of experience as an account executive strongly preferred.
- Ability to partner with clients to develop relevant, effective marketing communications strategies.
- Understanding of design and copy and experience developing creative communications across multiple media and social channels.
- Experience leading a multi-functional project team in both traditional and digital marketing (including creative, social, content, digital, production, distribution, print production, fulfillment, and managing external vendors).
- Understanding of brand design including strategy development, defining visual identity and tone of voice.
- Demonstrated success in managing 360 marketing campaigns.
- Proven understanding of project estimating, scheduling and project management.
- Ability to succeed under pressure, working independently to managing multiple concurrent projects while shifting priorities and responding to changing business/client needs.
- Exceptional attention to detail and excellent written, verbal, communication and presentation skills.
- Strong relationship building and client management skills.
- Expertise with Microsoft Office (Word, Excel and PowerPoint).
If you feel you are qualified for this position please send your resume (and samples if applicable) to:
View additional job opportunities at www.creativecircle.com
Creative Circle is an Equal Employment Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by law. Creative Circle will consider qualified applicants with criminal histories in a manner consistent with the requirements of applicable law. If you need a reasonable accommodation in the application process, please contact your Recruiter (the person you'll be interviewing with) or a member of our Human Resources team to make arrangements.
Similar jobs


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Make Up Brush Cleaning Pad
Regular price $ 7.90
$ 0.00
The CosMat Make-Up Brush Cleaning Pad allows you to easily clean your cosmetic make-up brushes. With an easy to hold handle, the CosMat slips on and stays secure. The seven various texture zones can clean and refine any size of make-up brush. Keeping your make-up brushes clean will help extend brush life and will prevent brush-related breakouts. The hygienic silicon is durable and easily cleaned.


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Blended Learning Kurse TEST
New York
Your goal
Do you want to learn German and have high standards and expectations, but only have a limited amount of time? Are you used to learning on a computer, but don't want to miss out on the advantages of a face-to-face classroom environment? Would you like to have greater flexibility to choose learning times that work for you?
See what our students have to say:
I took several blended classes at the Goethe-Institut because like most New Yorkers, I can't commit to a 3 hour class every week. So instead, I'd come 1.5h in person and get to exchange with my classmates in class once a week and also get useful explanations from the teacher about grammar or conjugation points etc. At home, I'd continue with my German learning, online, through the Goethe-Institut platform. The online platform is great because it gives you the flexibility to work from home or at the office, at a convenient time. Also it is very interactive and the online phase always offers opportunities to interact with other classmates. - Edith, B1.2, Winter 2019
The format of the blended classes are excellent. I really like how we learn some new material on our own before class, and then review what we've done at home at the beginning of the next class. It makes for really effective learning, and really efficient too -- everyone comes somewhat prepared, so that we can practice speaking a lot more! - A1.3 Student, Winter 2019
What does BLENDED LEARNING offer?Our BLENDED LEARNING courses combine the best of both worlds: intense face-to-face instruction and flexible online German lessons. Since this learning format is especially efficient, you will make major progress within just a short period of time. We offer BLENDED LEARNING courses for levels A1 through C1. Depending on the course, you can decide whether you would like to continue with the Blended Learning format or would prefer to switch to a traditional face-to-face course or a completely online course.
Blended Learning is an ideal option if you want to learn German quickly, but don't have the time to come to a face-to-face course twice a week. It is also perfect for people who live far away from the Goethe-Institut, but don't just want to learn online.
Course description for BLENDED LEARNING
- For face-to-face lessons you only have to come to the Goethe-Institut once a week. You will learn in a group of 6 to 16 students.
- During the online units, you will work on your computer using the Goethe-Institut's interactive learning platform. You can individually and flexibly decide when and where you want to learn. With the help of professional, multimedia exercises and the latest learning methods, you will practice your reading, writing, and listening comprehension skills in German.
- You will work on individual and group assignments. You can personally interact with other students in the course via chat or in forums.
- The scope and content of the curriculum corresponds to that of our face-to-face courses. The 40 lesson units are divided into 20 face-to-face classes and 20 online learning units. The course lasts 10 weeks. A German instructor will personally support you for the entire duration of the course. This instructor will give you new assignments and regular feedback on your progress.


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I co-taught a graduate/undergraduate course on codesign, where consultants and groups' collaboration is such a transformative experience that it blurs the line of who is learning from whom.
I advised the CMS.862 group working with NeighborMedia, a citizen journalism platform in Cambridge, MA.
(Regarding the poster, I used a laser cutter to cut out the edges. Originally, the pieces were meant to be perforated so students could tear off and pocket information. After the first test, however, I realized that the cutting process would take hours per poster, so I abandoned it)
N+N was meant to give Grand Rapidians the opportunity to connect with one another across class, nationalities and ethnicities by telling their own stories and connections to age-old recipes, fast-food favorites, etc. After all, we all eat.
Food: the most delicious embodiment of memories and storytelling. We all eat, and we all have stories, from whipping up family classics to the corner eatery serving up comfort in a bowl. Nibs + Noms is a platform and resource for Grand Rapidians to interpret ways of collecting, making and eating food, and a chance to explore food curiosities. Nibs is a collaborative, themed zine that will be published on a quarterly basis and Noms is a site for Grand Rapidians to share sustenance-related content that catches their whimsy.
For complicated reasons, the project didn't launch, but it had much community buy-in, from contributors to institutions offering their support and resources. You can read more about the life of N+N here.
When I was at MIT, I took full advantage of the Media Lab shop to learn lasercutting, vinyl cutting, the water jet, and other digital fabrication tools. I learned how to make stencils, cut and etch wood and other materials, but my favorite tool by far was the vinyl cutter. Above, I made a map for my phone of all the U.S. states I lived in, tiles for the Bopscotch project (BW image on top, followed by example of prepped file), and a decal for my computer.
I have been making my own personal business cards for years, always designing them and usually printing and making them. When I began my independent consulting business, I sent my design to a letterpress shop for production. The business card is a smoke gray, with copper hot foil stamping.
Upon being accepted to MIT, Comparative Media students must pull together a creative piece to introduce themselves to the cohort and rest of the department. I created a foldable zine with a website component. Details below:
Do you ever get bored with describing yourself in the same ways? I do. I start concocting different narratives: A sketchbook of inventions I dream up. An art book with blue prints of every room I've called my own. My life told in flavors of hummus. Most recently, a smear campaign.
It came to me as I was watching Law & Order, season five. This time, a prominent and gay NYC politician has been murdered. The courthouse morphs into a political arena, and the murderer (another politician) is exonerated. The things coming out of his mouth! How the crowd cheered! I can't believe this was a mere 15 years ago!
It got me thinking, as I watched Media Scrutiny Theater (OTM's riff on Mystery Science Theater 3000), what would my smear campaign look like? I'm into neighborhoods. I care most about impacting people I could meet. Hell, if I got into MIT, maybe I can be president after all!
But media is prey to spin, and a prepared politician I must be. So before I start soliciting for my war chest, voilà!: my exercise in potential smears.
And for the accompanying Media Scrutiny (and instructions to refold the zine), go to: helloDenise.com/smear
A gentlewomen's agreement among friends to eat at least two kale-based meals per week—one raw and one cooked—till the spring equinox (March 20).
Team Brooklyn: Emily and Denise
Team Midwest: Heather
Pictured (full album available here):
Kale kimchee
Kale wonton
Kale salad dressed in pistachio
Kale musubi
Kale dolmas
In 2011, a friend and I decided to challenge ourselves to try the vegan diet. He was a vegequarin, and I was a curious omnivore. We agreed to go vegan two months a year—one month during a season of abundance and other during scarcity. We have since continued this tradition, bringing many more friends on board.
2012 archives
2011 archives


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Dr. Obretenova of Washington University School of Medicine has no relevant financial relationships to disclose.)
Dr. Culebras of SUNY Upstate Medical University at Syracuse received an honorarium from Jazz Pharmaceuticals for a speaking engagement.)
Inadequate sleep hygiene entails the behaviors, practices, rituals, and habits that result in sleep onset or maintenance difficulties and unrefreshing sleep. It is prevalent across all age groups from young children to the elderly. Consensus statements have been published by the American Academy of Sleep Medicine and Centers for Disease Control regarding recommended duration of sleep for both the pediatric and adult populations (Consensus Conference Panel et al 2015; Paruthi et al 2016). In our present society, we embrace a culture of taking liberties with our sleep in order to improve academic performance and productivity or to fulfill social or official obligations. This leads to behaviors and habits that then make it difficult to fall asleep or stay asleep through the night. This can result in chronic sleep complaints as well as daytime fatigue and sleepiness. In addition, poor sleep hygiene has been shown to worsen other comorbid psychiatric and neurologic disorders. Electronic device use before or during bedtime, especially in young adults, is becoming more common and has been associated with higher risk of poor sleep. Recognition, counseling, and therapeutic strategies can result in increased sleep quantity, improved sleep quality, and improved daytime functioning. In this article, the authors discuss the presentation, impact, and treatment of inadequate sleep hygiene.
Key points
• Staying in bed for longer than 20 minutes or trying to force sleep may increase latency to sleep.
• Exposure to light (such as from screens associated with televisions, computers, mobile phones, handheld video games, or tablet devices) prolongs latency to sleep.
• Frequent daytime napping or napping late in the evening often results in sleep-onset difficulties.
• As the components of sleep hygiene, including bedtime routine, bed time, and wake up times, are individual-specific, it is important to keep in mind that the treatment for inadequate sleep hygiene must also be individually tailored.
Historical note and terminology
The concept of sleep hygiene has been referenced as far back as 1864 by Italian neurologist Paolo Mantegazza (Gigli and Valente 2013). Inadequate sleep hygiene was formerly recognized as a subtype of chronic insomnia; however, this classification was abandoned in the 2014 revision of the International Classification of Sleep Disorders (ICSD-3) due to the ubiquity of poor sleep practices across various forms of insomnia and other sleep disorders. Inadequate sleep hygiene can be construed as behaviors that result from or are sustained by daily living activities that are inconsistent with the maintenance of good-quality sleep and normal daytime alertness. Patients have ongoing sleep/wake difficulties as a function of practices such as daytime napping, maintaining a highly variable sleep/wake schedule, routinely using sleep-disruptive products (caffeine, tobacco, alcohol, and illicit substances) too close to bedtime, engaging in mentally or physically activating or emotionally upsetting activities too close to bedtime, routinely using the bed and bedroom for activities other than sleep, or failing to maintain a comfortable environment for sleep.
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text:
Say Hello to Zorro by Carter Goodrich
Published: 2011 by Simon & Schuster Books for Young Readers
Reasons why I liked this book, and chose it as Book of the Week:
From the end papers readers will be able to tell the kinds of personalities the two main characters – Mr. Bud and Zorro – have. One's fiesty (Zorro) the other is more chill (Mr. Bud).
I love how this book shows that opposites really do attract.
It shows that all living things – human or animal – have their own unique schedules. Showing we are all set in our ways and don't always love change.
This book gives non-dog owners a glimpse into the life of a dog. Which according to Mr. Bud is sleeping, going out for walks, eating, waiting for greet and fuss time, and of course sleeping some more. Oh, the life!
Zorro looks like on ticked off pug when we first meet him.
Mr. Bud does NOT like his routine interrupted. But really, who does?!
I love how this book shows how sometime one dog may get more attention than the other, but that doesn't mean that one dog is loved more than the other.
Zorro is a bit of a toy hog.
Mr. Bud may be older, but he certainly has no problem standing up for himself.
I think this book illustrates the importance of compromising and the importance of sharing.
Friends can come in all shapes, sizes, and dispositions. And this book shows that friends can be made anywhere, and at the most unexpected time.
Sometimes doing something with a friend is just more fun … like going for long walks.
This book shows the importance of acceptance. And than we shouldn't judge someone superficially.
Even though Mr. Bud and Zorro or friends, they still squabble. It's a realistic portrayal of relationships.
Dog lovers will fall in love with this book.
There's a follow-up to Say Hello to Zorro.
The writing is simple. But really makes a statement.
The illustrations are soft, alluring, and makes the writing pop!
This was a really fun book to read. It confirms I'm a dog kind of person.
The front of the book features an illustration of both Mr. Bud and Zorro, front view, while the back shows the two characters from the back! I think that attention to detail makes this an awesome read that both children and adults will love.
Mr. Bud and Zorro made me laugh a lot.


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Day 820 (Tajikistan Day 9)
Thought for the day (barely audible through loud frustrated swearing): 'There are worse places I could be feeling horrible in'. The day started out okay. I woke feeling very exhausted and was quite slow-moving as I packed up my camp in the company of donkeys and cows feeding on the grass around me. It was an easy downhill to the military post, where I stopped at the gate and waiting for a minute for someone to appear before squeezing under the metal bar and continuing on my way. From here the day deteriorated. Bad roads (loose, rocky, sandy) combined with a strong headwind made the going so tough that my average speed was lower than yesterday, despite the fact I had no mountain pass to cross. I soon realised my hopes of reaching Langar today were dashed. I ate the last of my proper lunch stuff yesterday (bread, tomatoes and cucumbers), so I was left with just oat bars and mixed fruit and almonds to keep me going. Despite having food in my belly, my energy levels continued to decline. I looked forward to making camp and getting a hot meal in me, but today became one of those days that I couldn't get my stove going, no matter what I did. I even took the whole thing apart and cleaned it. I have absolutely no idea why it sometimes works and sometimes doesn't. When I admitted defeat, I swore loudly and threw my bag of pasta in the tent in a moment of rage. The bag burst open and sprayed penne everywhere. The wind is picking up and blasting dust under the fly and into the tent. I ate the last of my oats for dinner, so unless I get my stove going in the morning and cook some pasta, then I have very little food to get me through tomorrow. To make things even worse, somehow my phone has deleted all the Maps.me maps I had downloaded, so now I can't navigate as well as I would like. It will be some days yet before I have a chance to get the maps back. As I lay in bed, I can't help but feel that my body is very nearly beaten. But, as I said, there are worse places to be feeling horrible in.
|Distance ridden today
|Average cycling speed
|Total distance ridden


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Metallic One Shoulder Short Sequined Prom Party dress. Beading is done in different sizes of metallic gold & silver sequins in rays like pattern coming from the side of the dress. Side zipper closure. built-in cups. Imported.
Strapless Short Prom Party Dress with Artistic Sequined pattern. Gold & silver sequins in horizontal & diagonal direction gives the dress an artistic pattern. Mini dress has built-in cups with back zipper closure also. Imported.
Strapless Short Geometric Sequins Pattern Party Prom Dress. Sequins in silver & light gold make different geometric designs at bust, waist & skirt. Sweetheart neck dress is padded at bust with back zipper closure. Imported.
V-neck Short dress has an asymmetrical hemline with hanging beads, short sleeves with hanging beads, shoulder padded and a closed back with zipper closure. The wrap around style hemline dress has hectagon shaped beading pattern all over the dress. Natural silk (100%) chiffon hand-beaded dress with Polyester Lining. The color shown is Aqua.
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text:
Josephine F. Glass - Nursing Sister WW1
From London.
RG 150, Accession 1992-93/166, Box 3577 - 60
Attestation for Can overseas expeditionary Force
Born in Tillsonburg Jul 3 1886
Parents Mr & Mrs. ?. F. Class now in London Jct. On.
Graduate nurse
May 11 1915
28 years 10 months
5'5", fair complexion Blue eyes, dark brown hair, scar on left cheek
Declared Fit same day in London England to CAMC
Chronological Order of Service
Note that the publishing date of the newspapers could be out as much as month from the actual date of the event.
April 22, 1915 Tillsonburg Observer
Miss Josephine F. Glass, daughter of S. Frank Glass, MP for East Middlesex. She has been for a year and a half on the staff of nurses of the Toronto Board of Education has volunteered her services to the department of militia for service in the overseas contingent,, and has been accepted. She will be a nursing sister, with rank of lieutenant, and with some 50 other Canadian girls will likely leave for the front as quickly as their equipment can be made ready. Miss Glass graduated from the Clifton Springs NY Training School of Nurses in 1910
May 11 enlists in England - Goes to France and at Rouen and Etaples but we don't know what unit or dates
1916 - Still in France and at Rouen and Etaples but we don't know what unit or dates
1917 - On Furlough in Canada, presume she goes back to same units?
Jan 4, 1917
NS Josephine Glass, daughter of S. Frank Glass, MP of London has returned home on furlough after serving with the CAMC for 21 months, a great portion of the time being in the hospitals at Etaples and Rouen. France.


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Kohl Corporation and Dillard's Inc
| 2006| 2007|
| Kohl's| Dillard's| Kohl's| Dillard's|
Total assets turnover| 1.72| 1.40| 1.68| 1.34|
Fixed assets turnover| 3.13| 2.43| 2.78| 2.27|
Inventory turnover| 4.12| 2.82| 3.85| 2.70|
Average holding period| 88.58days| 129.64days| 94.84days| 135.40days| Payables turnover| 11.25| 6.08| 11.82| 6.17|
Average time to turnover| 32.45days| 60.05days| 30.89days| 59.14days| Cash conversion cycle| 56.13days| 69.59days| 63.95days| 76.26days| PS: There's no amount in accounts receivable in Kohl's Balance sheet, so we cannot analyze the receivables turnover between two companies. |
Kohl's total assets ration and fixed assets ratio are higher than Dillard's, indicating that Kohl's uses its total assets (including its fixed assets) more effectively than Dillard's, and also indicating that Kohl's is generating more volume of business given its total asset investment. As Kohl's some assets increased and Dillard's sales decreased in 2007, total asset ratio and fixed assets ration of two companies have decreased.
Kohl's inventory turnover in 2006 and 2007 are higher than Dillard's, indicating that Kohl's has a better management of inventory than Dillard's. The inventory improved because of an increase in the COGS, which indicates more sales, and a decrease in the average inventories. Therefore, Kohl's higher inventory turnover might be due to its more effective marketing strategies. What's more, these two companies experienced a decrease in inventory turnover in 2007, indicating an increase in inventory and less effective management of inventory in that period. Kohl's number of day's sales in inventory decreased from 88.6 days to 94.8 days during 2007, and Dillard's almost experienced a little higher decrease (in percentage) than Kohl's. They are the major decreases in managing inventory.
Kohl's payable turnover is higher than Dillard's, indicating that Kohl's is paying for its suppliers at a...
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