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Pain management is important for ensuring early mobilization after hip arthroplasty; however, the optimal components remain controversial. Recently, the quadratus lumborum block has been proposed as an analgesic option. The current study tested the hypothesis that the posterior quadratus lumborum block combined with multimodal analgesia decreases morphine consumption after hip arthroplasty.
This study was a prospective, randomized, double-blind, placebo-controlled trial. Before general anesthesia, 100 participating patients scheduled for elective total hip arthroplasty were randomly allocated to receive a 30-ml injection posterior to the quadratus lumborum muscle with either 0.33% ropivacaine (n = 50) or normal saline (n = 50). For all patients, multimodal analgesia included systematic administration of acetaminophen, ketoprofen, and a morphine intravenous patient-controlled analgesia. The primary outcome was total intravenous morphine consumption in the first 24 h. Secondary outcomes recorded intraoperative sufentanil consumption; morphine consumption in the postanesthesia care unit; pain scores at extubation and at 2, 6, 12, and 24 h; motor blockade; time to first standing and ambulation; hospital length of stay; and adverse events.
There was no significant difference in the 24-h total morphine consumption (ropivacaine group, median [interquartile range], 13 [7 to 21] versus saline group, 16 [9 to 21] mg; median difference, −1.5; 95% CI, −5 to 2; P = 0.337). Pain scores were not different between the groups (β = −0.4; 95% CI, −0.9 to 0.2; P = 0.199). There was no statistical difference between the two groups in intraoperative sufentanil consumption, morphine consumption in the postanesthesia care unit, motor blockade, times to first standing (median difference, 0.83 h; 95% CI, −1.7 to 3.4; P = 0.690) and ambulation (median difference, −1.85 h; 95% CI, −4.5 to 0.8; P = 0.173), hospital length of stay, and adverse events.
After elective hip arthroplasty, neither morphine consumption nor pain scores were reduced by the addition of a posterior quadratus lumborum block to a multimodal analgesia regimen.
Early mobilization after joint replacement surgery requires effective analgesia
Interfacial plane injections including quadratus lumborum block have been advocated for pain relief after hip joint replacement, but evidence for this approach is sparse
In the context of a multimodal postoperative analgesic strategy, providing a quadratus lumborum block using ropivacaine resulted in no less morphine consumption or pain in the first 24 postoperative hours compared to saline injection
Quadratus lumborum block also provided no advantages in terms of time to first standing, ambulation, or hospital stay
Early mobilization after total hip arthroplasty features as a strong recommendation in the enhanced recovery after surgery program.1 However, early physiotherapy is only possible with effective analgesia with few side effects. The optimal regimen with which to manage early postoperative pain after total hip arthroplasty remains controversial.2 Opioids, widely used for pain management, are responsible for adverse effects such as nausea, vomiting, dizziness, and urinary retention. Numerous techniques have been assessed to reduce morphine consumption after hip arthroplasty. Multimodal analgesia regimens, which include nonsteroidal anti-inflammatory drugs and acetaminophen, result in lower pain scores at rest and during mobilization, with a resultant reduced opioid consumption.1,3,4 Conversely, local anesthetic infiltration neither reduces morphine consumption nor improves postoperative rehabilitation.1,5 Although regional anesthesia techniques, such as the lumbar plexus block4,6 or the femoral nerve block,7 have opioid-sparing effects, they can result in significant muscle weakness and subsequent falls. Thus, other analgesic techniques, with few side effects, are needed for reducing morphine consumption. In recent years, several case reports have described the efficacy of the quadratus lumborum block in hip surgery.8–11 Ultrasound-guided quadratus lumborum block is an interfascial plane block of the posterior abdominal wall, first described as a posterior variant of the transversus abdominis plane block. There are three different approaches currently described, referring to the needle tip position with respect to the quadratus lumborum muscle: lateral to the muscle (termed quadratus lumborum block 1); posterior to the muscle (termed quadratus lumborum block 2); and anterior to the muscle (termed transmuscular block or quadratus lumborum block 3; fig. 1).12 The anterior quadratus lumborum block was recently shown to be effective for pain relief after total hip arthroplasty.13 This deep approach, however, can result in quadriceps muscle weakness due to spread of the local anesthetic to the lumbar plexus.14 In contrast, the posterior quadratus lumborum block approach is more superficial with less motor blockade than the anterior approach.14 In a magnetic resonance study, the dye spread is wider in the posterior approach compared to the lateral.15 Although this posterior approach has been reported as effective for analgesia after total hip arthroplasty in a retrospective cohort,16 randomized controlled studies are lacking. The extent of sensory blockade has moreover been minimally studied in clinical settings.
In the current study, we hypothesized that the posterior quadratus lumborum block (quadratus lumborum block 2), in combination with multimodal analgesia, decreases morphine consumption after elective total hip arthroplasty. Furthermore, we aimed to assess the spread of the solution in the interfascial space, the extent of the sensory blockade, the motor blockade, and the benefit in terms of early rehabilitation.
Materials and Methods
Study Design and Study Population
The Study of the QUadratus lumborum block in total hip ARthroplasty, Efficacy (SQUARE) was designed as a prospective, randomized, double-blind, placebo-controlled, single-center, superiority clinical trial using two parallel groups. The study was conducted at Lapeyronie University Hospital (Montpellier, France). In accordance with the Declaration of Helsinki, the trial was approved by the ethics committee (Comité de Protection des Personnes, Sud Méditerranée III, Montpellier-Nîmes, France, No. 2017.05.05 bis) and was prospectively registrated in ClinicalTrials.gov on June 16, 2017, with identifier NCT03189290, and principal investigator Philippe Biboulet. All patients provided written informed consent before inclusion.
Eligible patients for participation in the study were those scheduled for elective, unilateral primary total hip arthroplasty under general anesthesia, following an enhanced recovery after surgery pathway, aged 18 yr or older, affiliated with a medical insurance system, and with an American Society of Anesthesiologists (Schaumburg, Illinois) Physical Status I to III. Exclusion criteria included pregnancy, breastfeeding, cognitive impairment with difficulties in pain evaluation, allergy or intolerance to drugs relevant to the study, severe coagulopathy, and chronic kidney disease (estimated glomerular filtration rate inferior to 50 ml · min−1 · 1.73 m−2). Study exclusion also applied to patients with peripheral neuropathy or those receiving treatment for chronic non-hip pain.
Randomization and Blinding
The day before surgery, the participants were recruited by the study staff, and written informed consent was obtained. On the day of surgery, included patients were assigned randomly in a 1:1 ratio to either the ropivacaine or the saline group, using a computer-generated block randomization technique, with a block size of 10 patients. Randomization was performed by the Department of Medical Statistics, and the allocated sequence was concealed in sequentially numbered, opaque, sealed envelopes prepared by an investigator without clinical involvement in the trial. Before the patient's arrival to the operating room, an independent registered nurse anesthetist opened the envelope in the pharmacy of the operating room and prepared the allocated study drugs, ropivacaine or saline, in syringes labeled "SQUARE." After filling the syringes, the empty vials were returned to the central pharmacy. Then the study drugs, visually identical, were deposited in the patients' operating rooms. Blinding to group allocation applied for enrolled patients, anesthesiologists, physiotherapists, and the investigators performing follow-up visits. Enrollment ceased when the target sample size was obtained.
Intraoperative Management
Immediately before general anesthesia induction, the quadratus lumborum block was performed with the patient in the lateral decubitus position, with the block side and operative side nondependent. A curvilinear low-frequency ultrasound probe was placed transversely, transitioning laterally from the umbilicus to the posterior axillary line. The muscles of the lateral abdominal wall (external oblique, internal oblique, and transversus abdominis), of the posterior abdominal wall (latissimus dorsi, quadratus lumborum, and erector spinae), and anterior to the quadratus lumborum (psoas muscle) were visualized (fig. 1). The transducer was placed between the iliac crest and the twelfth rib and adjusted to visualize the shamrock sign (fig. 2).17 A 21-gauge 100-mm nerve block needle was inserted in-plane in a lateroposterior direction. The needle tip was advanced and positioned posterior to the quadratus lumborum muscle (fig. 1). Careful hydrolocalization technique, with the allocated blinded solution, was used to localize the needle tip and the correct point of injection. After negative aspiration, 30 ml of the solution, either 3.3 mg/ml (0.33%) ropivacaine (ropivacaine group) or normal saline (saline group), was injected in the interfascial plane posterior to the quadratus lumborum muscle, between the quadratus lumborum and the erector spinae muscles. The anesthesiologist recorded the final solution spread on an anatomical diagram, consistent with spread (1) posterior (quadratus lumborum block 2) to the quadratus lumborum muscle, (2) anterior (quadratus lumborum block 3) to the quadratus lumborum muscle, (3) back flowing toward the transversus abdominis (quadratus lumborum block 1), or (4) combination spread. The procedural duration, from sonography localization to the completion of injection, was recorded.
On completion of the quadratus lumborum block procedure, general anesthesia induction, with the patient in a supine position, was performed using a standard protocol with target-controlled infusion of sufentanil (Geps model; plasma concentration, 0.3 to 0.4 ng/ml) and of propofol (Schnider model; plasma concentration, 4 to 6 µg/ml). In addition, 0.3 mg/kg ketamine and 0.15 mg/kg dexamethasone were infused. After endotracheal intubation, the sufentanil infusion was decreased to a target plasma concentration of 0.1 ng/ml, with intraoperative titration as required, at the discretion of the anesthesiologist. Total hip arthroplasty, with a posterior approach, was performed by the same surgical team. There was no local anesthetic infiltration in the surgical area. At 30 min before surgery completion, 1,000 mg of acetaminophen and 100 mg of ketoprofen were infused.
The patients were extubated in the postanesthesia care unit. Pain was assessed at rest and at 30-min intervals for 2 h, with a numeric rating scale from 0 to 10, with 0 signifying no pain and 10 signifying the worst possible pain. If the numeric rating scale was more than 3, a morphine titration of 2 mg every 5 min was administered. If the morphine dose exceeded 0.3 mg/kg, additional rescue medication, including 20 mg of nefopam, 1 µg/kg clonidine, and 10 mg of ketamine, was administered at the discretion of the anesthesiologist. Postoperative nausea and vomiting was treated with 4 mg of IV ondansetron. The extent of sensory blockade was assessed with a cold glass vial. The skin area where patients described a loss of cold sensation was graphically mapped on a representation of the hip divided into nine skin areas. At 2 h after extubation, the numeric rating scale at rest and during passive 90° hip flexion was evaluated in all patients. Motor weakness was assessed using the Bromage score,18 where 3 indicates unable to move feet, knee, or hip; 2 indicates able to move feet only; 1 indicates able to move feet and knee; and 0 indicates full flexion of feet, knee, and hip. A score of 2 or 3 is defined as significant motor weakness. Before discharge from the postanesthesia care unit, the maximal numeric rating scale experienced by the patients during their postanesthesia care unit stay was evaluated.
Postoperative Management
On the surgical ward, the patients systematically received 1,000 mg of acetaminophen IV at 6-h intervals and 100 mg of ketoprofen IV at 12-h intervals. A lightweight mobile infusion pump (Rythmic Evolution, Micrel Medical Devices, Greece) for IV patient-controlled analgesia was programmed with a bolus dose of 1 ml of morphine (1 mg/ml, with 100 µg/ml droperidol to reduce postoperative nausea and vomiting) and a lockout time of 7 min, without background infusion. The numeric rating scale was assessed at rest at 6, 12, and 24 h after extubation and on movement (passive 90° hip flexion) at 6 and 24 h after extubation. Motor blockade was assessed at 6 h after extubation using the Bromage score. At 24 h after extubation, the maximal numeric rating scale experienced by the patients during their surgical ward hospitalization was evaluated. Adverse events, including postoperative nausea and vomiting and urinary retention, were recorded during the first 24 h. These evaluations were performed by the anesthesiology team blinded to the study group. Early rehabilitation was facilitated by physiotherapists, with patients encouraged to first stand postoperatively on the day of surgery and to ambulate either on the day of surgery or the day after (depending on surgical ward admission time). Time to first standing, time to first ambulation, and the hospital length of stay were recorded.
Sample Size Estimation and Statistical Analysis
The primary outcome measure was the total cumulative IV morphine consumption at 24 h after extubation, inclusive of morphine administrated in the postanesthesia care unit and IV patient-controlled analgesia–administered morphine. Morphine consumption was chosen as the primary outcome, consistent with other studies on pain relief in total hip arthroplasty.4–6,13,16 Secondary outcomes included intraoperative sufentanil consumption; morphine consumption in the postanesthesia care unit; area of cutaneous sensory loss sensation; pain scores at rest at extubation time and 2, 6, 12, and 24 h after extubation; pain scores during passive 90° hip flexion at 2, 6, and 24 h after extubation; maximal pain score during the intervals between extubation time and 2 h after extubation and between 2 and 24 h after extubation; motor blockade at 2 and 6 h after extubation; time to first standing and ambulation; hospital length of stay; and adverse events including block-related side effects. The sample size has been estimated a priori with calculation based on the anticipated opioid consumption difference between study groups. We used the study of Minville et al.,19 which found that patients required 43 ± 16 mg (mean ± SD) of morphine in the first 24 h after a primary total hip replacement. Power calculation for a 25% difference in morphine consumption (10.7 mg), with an α probability level of 0.05 and a power of 0.90 (1 − β), yielded a sample size of 47 patients/group. The statistical analysis was carried out with intention to treat for a sample size of 100 patients. Categorical variables were expressed as a number and a percentage. Quantitative variables were expressed as the median and the interquartile range. The normality of the distribution of quantitative variables was determined using the Shapiro–Wilk test. The primary outcome was compared using Mann–Whitney test. For secondary outcomes, comparisons of quantitative variables between the two study groups were made using an unpaired two-tailed t test or a Mann–Whitney test. Comparisons of categorical variables were realized using a chi-square test or Fisher exact test, as appropriate. Pain scores at rest and on movement over the first 24 h after surgery were analyzed using a mixed model accounting for repeated measurements in the same patient. The numeric rating scale was the dependent variable. The randomization group, the mobilization, and the different measurement times were analyzed as fixed effects, with random intercept for the patient. The slope, the group, and the time interaction were tested. A model selection procedure (Bayesian Information Criterion, Bayesian Information Criterion minimization) was used to determine a final model. The group–time interaction was finally excluded in the final model. Estimates were reported using a 95% CI. To illustrate time to standing and time to ambulation, Kaplan–Meier curves and log-rank tests were used to explore the probability of patients being bedbound within each group. The data were right-censored 72 h postoperatively. A two-sided P value of less than 0.05 was considered statistically significant. Statistical analyses were performed with SAS Enterprise Guide version 7.1 (SAS Institute, USA).
From July 2017 to September 2018, 289 patients scheduled for elective total hip replacement were assessed for eligibility. After assessment, 100 patients were randomly assigned to one of the two groups, with 50 patients/group (fig. 3). All 100 patients were included in the analysis. Patient characteristics are described in table 1. There were no missing data.
Quadratus Lumborum Block
Details of the interfascial solution spread in the two groups during the quadratus lumborum block procedure are documented in table 2. Graphical mapping of cutaneous sensory loss in the ropivacaine group, for quadratus lumborum block 2 (n = 18), quadratus lumborum blocks 2 + 1 (n = 18), and quadratus lumborum blocks 2 + 1 + 3 (n = 10) is reported in figure 4. Detailed mapping of loss of cold sensation in all the patients of the ropivacaine group is available in the appendix. No patient had loss of cold sensation cephalad to the twelfth rib. Of 50 patients, 12 (24%) did not have loss of cold sensation in the hip area. Of those, four patients had only anesthetic spread posterior to the quadratus lumborum muscle (quadratus lumborum block 2), whereas eight had anesthetic spread both posterior and lateral to the quadratus lumborum muscle (quadratus lumborum block 2 + 1).
Morphine Consumption
During the first 24 h after surgery, the cumulative IV morphine consumption was 13 (7 to 21) mg in the ropivacaine group and 16 (9 to 21) mg in the saline group (median difference, −1.5; 95% CI, −5 to 2; P = 0.337). Intraoperative sufentanil consumption was 27 (20 to 35) µg in the ropivacaine group and 26 (18 to 34) µg in the saline group (median difference, 0; 95% CI, −5 to 5; P = 0.910). Morphine consumption in the postanesthesia care unit was 10 (4 to 13) mg in the ropivacaine group versus 10 (5 to 15) mg in the saline group (median difference, −1; 95% CI, −3 to 1; P = 0.448). Cumulative morphine consumption in the 12 patients without cutaneous sensory loss in the ropivacaine group was 9 (4 to 16) mg.
Pain Scores
Numeric rating scale results at extubation time and 2, 6, 12, and 24 h postoperatively are shown in figure 5. Comparisons, by analysis of repeated measures, revealed that pain scores during the first postoperative 24 h were not different between the two groups (β = −0.4; 95% CI, −0.9 to 0.2; P = 0.199). Numeric rating scale score decreased over time (β = −0.9 to −1.9) with respect to extubation time (P < 0.0001). Pain was higher during mobilization (β = 1.3; 95% CI, 1.1 to 1.5; P < 0.0001). In the postanesthesia care unit, between extubation time and 2 h after extubation, the maximal numeric rating scale was 7 (5 to 8) in the ropivacaine group and 7 (5 to 8) in the saline group (median difference, 0; 95% CI, −1 to 1; P = 0.696). In the postanesthesia care unit, 25 patients had insufficient analgesia despite morphine titration (13 patients in the ropivacaine group and 12 in the saline group; P = 0.771) and required additional rescue analgesia. On the surgical ward, between 2 and 24 h after extubation, the maximal numeric rating scale was 4 (3 to 5) in the ropivacaine group and 4.5 (2 to 7) in the saline group (median difference, −0.5; 95% CI, −2 to 1; P = 0.624).
Rehabilitation Outcomes
There was no significant difference between the ropivacaine and the saline groups for both (1) time to first standing, at 19.7 (5.1 to 24.4) versus 18.7 (5.6 to 23.2) h (median difference, 0.8; 95% CI, −1.7 to 3.4; P = 0.690) and (2) time to first ambulation, at 23.9 (20.5 to 28.1) versus 22.5 (19 to 25) h (median difference, −1.8; 95% CI, −4.5 to 0.8; P = 0.173). The Kaplan–Meier curves for time to first standing (P = 0.247) and time to first ambulation (P = 0.286) are presented in figure 6. Hospital length of stay was not different between the ropivacaine and the saline group: 4 (3 to 5) versus 4 (3 to 5) days, respectively (median difference, −0.5; 95% CI, −1 to 0; P = 0.227).
Adverse Events and Safety
There were no complications or adverse events during the quadratus lumborum block procedure. At 2 h after extubation, significant motor weakness with a Bromage score of 2 or higher was observed in one patient in each group, which had regressed completely at 6 h after extubation in both patients. At 6 h after extubation, significant motor weakness was recorded only in one patient in the saline group (P = 0.489).
Postoperative nausea and vomiting occurred in 7 patients in the ropivacaine group and 12 patients in the saline group (P = 0.202). Urinary retention occurred in 2 patients in the ropivacaine group and in 4 patients in the saline group (P = 0.678).
In this study, the posterior quadratus lumborum block (quadratus lumborum block 2) did not reduce opioid consumption during the first 24 postoperative hours in patients undergoing elective total hip replacement treated systematically with a multimodal analgesia regimen. Neither did this block have an effect on pain scores, time to first standing, time to first ambulation, or hospital length of stay.
In the pathway of enhanced recovery after surgery, early mobilization is highly recommended. Although an approach using epidural and/or nerve blocks provides good analgesia, it can result in delayed ambulation.1 The search for optimal analgesia with less invasive techniques has made interfascial plane blocks increasingly popular.20,21 However, in addition to the numerous case reports published, there remains a strong need for rigorous assessment of these new interfascial plane approaches, including both their clinical effect and the underlying mechanism of action.
First, regarding the analgesic effect of the quadratus lumborum block in hip surgery, randomized controlled trials are scarce, and our results contrast with those of others studies. One randomized trial, comparing a lateral quadratus lumborum block (quadratus lumborum block 1) with a femoral nerve block, revealed the role of the quadratus lumborum block 1 in lowering pain scores and opioid consumption in patients undergoing hemiarthroplasty for femoral neck fracture.22 In this hip fracture context, where multimodal analgesia was not systematically utilized, the postoperative pain mechanisms may vary compared with the elective total hip arthroplasty context. In a retrospective comparative study, patients with a posterior quadratus lumborum block (quadratus lumborum block 2) also had lower pain scores and lower opioid requirements after elective total hip arthroplasty.16 However, in this study, total opioid consumption was expressed in oral morphine equivalents, and multimodal analgesia with nonsteroidal anti-inflammatory drugs and acetaminophen was not used. In a prospective randomized trial, after elective total hip arthroplasty, the anterior quadratus lumborum block (quadratus lumborum block 3) similarly led to lower pain scores and lower oral morphine equivalent consumption.13 The effect of the anterior quadratus lumborum block (quadratus lumborum block 3) has also been studied in a retrospective propensity-matched cohort study in which the anterior quadratus lumborum block was compared with the lumbar plexus block for total hip replacement.23 There was no difference between the two groups both in the IV morphine equivalent consumption and in pain scores. Because the lumbar plexus block is known to reduce pain after total hip replacement,2,4 this study demonstrates an impressively similar analgesic efficacy associated with the anterior quadratus lumborum block.
Second, there are few available data elucidating the underlying mechanism of action of these interfascial plane blocks. None of the studies referenced above have provided an assessment of the local anesthetic spread or of the sensory and motor blockade to explain the mechanism of action.13,16,22,23 The analgesic mechanism for the different quadratus lumborum block approaches thus remains poorly understood.24 Limited publications suggest that the effect of the anterior quadratus lumborum block (quadratus lumborum block 3) in hip surgery13,23 could be explained by local anesthetic spread to the lumbar plexus. In favor of this postulated mechanism, two cadaveric studies observed injectate spread to the upper lumbar plexus branches after an anterior quadratus lumborum block.25,26 Additionally, in one retrospective study, the incidence of quadriceps muscle weakness after an anterior quadratus lumborum block was 90%, suggesting a block of the lumbar plexus.14 With respect to the possible mechanism of action of the posterior quadratus lumborum block (quadratus lumborum block 2), this is even more debatable, but the results of our study provide the beginnings for further understanding. In our study, first, despite a rigorous control of the needle tip position, the solution injected between the quadratus lumborum and the erector spinae muscles had unpredictable spread, with local anesthetic visible at multiple varying locations around the quadratus lumborum muscle. It is possible that local anesthetic spread in these interfascial plane blocks primarily depends on tissue compliance rather than on the precise needle tip position within the thoracolumbar interfascial planes. Second, the cutaneous loss of cold sensation noted in our study was similar in all patients, irrespective of the individual local anesthetic spread pattern. This cutaneous anesthesia noted may be secondary to blockade of the subcostal, iliohypogastric, genitofemoral, and lateral femoral cutaneous nerves. This sensory block was demarcated at the inferior rib cage margin, with no spread in the cephalad direction beyond this margin. Similar observations with a limited sensory blockade have been published in several case reports.8–11 Finally, no motor blockade was reported after this posterior quadratus lumborum block. Innervation of the hip joint is complex and provided by branches of the lumbar and sacral plexus.27 Because nociceptors are mainly distributed on the anterior side of the joint capsule, the role of the obturator and femoral nerves in hip nociception is crucial.28 In our study, theses nerves were not blocked after the posterior quadratus lumborum block, possibly explaining the lack of analgesic effect of this block for total hip arthroplasty noted in our trial. Another commonly postulated mechanism of action is that local anesthetic spreads into the thoracic paravertebral space.29,30 However, as noted in our study and others, sensory blockade associated with this block is often patchy, not corresponding to a classic dermatomal distribution.8–11,29
This study has some limitations. First, this was a single-center trial, and external validity may be attenuated. However, total hip arthroplasty is a standardized procedure with similar patient care in most developed countries. Conversely, in this single-center study, all procedures were performed by the same surgical team, with the same surgical approach, and the administration of systematic multimodal analgesia is standardized across the nurse anesthetist team. Second, despite the a priori sample size calculation, the study was underpowered to detect a significant morphine consumption difference between the two groups, with a smaller difference obtained in our results compared to the study used for our sample size calculation.19 To detect a statistical difference between the two groups, 2,029 patients would have had to be included in each group, after a posteriori sample size calculation. However, would a 3-mg difference between the two groups, noted in this study, be clinically relevant? The low cumulative postoperative morphine consumption at 24 h after surgery suggests an effective IV multimodal analgesia regimen systematically used in all our patients.1–4 Notably, nonsteroidal anti-inflammatory agents have a significant intrinsic opioid-sparing effect in orthopedic surgery.1,2 In the same way, intraoperative use of ketamine and dexamethasone may have contributed to postoperative analgesia and therefore may have reduced the measured contribution of the quadratus lumborum block. Third, the optimal anesthesia choice, of general anesthesia versus spinal anesthesia, in total hip replacement can be debatable. In our institution, hip surgery is mainly performed under general anesthesia to optimize patient comfort. Within an enhanced recovery after surgery program, general anesthesia additionally seems to result in a more favorable recovery profile compared with spinal anesthesia.31 Fourth, because physiotherapist availability in our center was until 4 pm daily, the difference between groups in achieving early rehabilitation could have been underestimated. In some cases, we imagine that physiotherapist-accompanied rehabilitation would have been delayed until the following day for patients admitted late to the orthopedic ward after 4 pm. Finally, 12 patients in the ropivacaine group had low morphine consumption despite surprisingly no loss of cold sensation in the postanesthesia care unit. It is possible that there is a lack of correspondence between analgesia and loss of cold sensation or that there was inaccurate sensory blockade evaluation, for example because of patient drowsiness. In conclusion, we found the posterior quadratus lumborum block to have no clinically significant effect on morphine consumption and pain scores after total hip arthroplasty in the presence of a multimodal analgesia regimen.
The authors thank Guillaume Charon (International Product Manager at MICREL Medical Devices, Nice, France), for the allocation of three Rythmic Evolution infusion pumps; Laure Dega, C.R.N.A., and Martine Deschaises, C.R.N.A. (Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France), for their assistance; Aurelien Canon, M.D., Nathalie Bernard, M.D., Caroline Thuile, M.D., Thibault Loupec, M.D., Jules Gallais, M.D., Fanny Bauchy, M.D., Jibril Nouri, M.D., Maxime Varobieff, M.D., Sonia Tazerout, M.D., and Geoffrey Dagod, M.D. (Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France), for their enrollment of patients; and Bruno Souche, M.D. (Department of Anesthesiology and Critical Care Medicine, Saint Eloi University Hospital, Montpellier, France), for software adaptations to prescription protocols.
Research Support
Support was provided solely from institutional and/or departmental sources.
Competing Interests
The authors declare no competing interests.
Reproducible Science
Full protocol available at: firstname.lastname@example.com. Raw data available at: email@example.com.


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Interested in running with your dog? There are some simple dos and don'ts you should follow from the get-go. From having them wear a dog ID collar to maintaining control throughout your run, here are your key pointers to going on a safe, positive run together.
Table of Contents
Dos for Running with Your Dog
Get a health checkup
Before you start taking your dog out for runs, you should get their health checked out first. A simple veterinary examination will let your vet properly check your dog's physical condition. Consider it the sign off prior to exercising with your dog. Your vet will help you determine whether your dog has any underlying conditions that could make running a bad exercise for them, including arthritis, hip dysplasia, and other conditions.
Let them set the pace
Let your dog choose how fast you'll be running. Don't let them get worn out by setting a pace they can't meet. Instead, let them choose how hard they want to run.
Remain in control
Even though you're giving them control over pacing, remain in control of their leash and direction. Don't let your dog pull you around. You should still have control over your route.
Get them used to it
Don't rush into it. You didn't just start running five-mile runs out of nowhere. Your dog won't be prepared for it either. Slowly work your way up. Start by incorporating short runs into your daily walks, working up from there.
Use the right leash
The right leash will do you well while out running. Many runners prefer hands-free dog leashes as they make it easy to maintain healthy running form, keeping your hands free for water, food and good posture.
Pick up after your dog
You shouldn't keep running after your dog poops. Take the time to pick up after them first. Etiquette is always key when it comes to being a dog owner, remaining mindful of the societal norms a dog owner must follow. Picking up after your dog is always one of them.
Have them wear identification
You should also be sure that your dog wears an ID tag. Custom dog tags are your best option, as they'll allow you to create a customized ID tag for your dog. This is imperative for any owner who wants to guarantee their dog has some sort of protection if they were to ever run off.
Custom ID tags will allow you to add information such as your pet's name, your cell phone number, your name, any allergies your dog has and a simple statement such as, "I am loved."
Don'ts of Running with Your Dog
Not too old or too young
You should be mindful of your dog's age when deciding whether to take them running. Running with a puppy isn't a good idea, as they're not fully developed yet. Running can lead to irreversible tissue, tendon and skeletal damage. The same goes for older dogs, but for different reasons. Damage can be done to their skeletal and muscular system due to their age. Instead, stick to light exercising, like playing in the backyard or taking them for a short walk.
Don't run too hard
Don't overexert your dog, either. Too hard of a run can be bad for their health, particularly because you may push them to continue running harder than they're comfortable doing.
Don't run for too long
Similarly, don't stress your dog out by running for too long. Long mileage can be harmful to a dog, much the same as running them too hard because it's a level of exertion they may not be prepared for. Similarly, that increased mileage could do irreversible damage to their body.
Don't forget water at home
Your dog is bound to get tired after running for long enough. It's important you bring along water to keep them hydrated. Remember that signs of dehydration don't look the same as in humans. Signs your dog could use a water break include their tongue hanging out of the side of their mouth, reddened eyes, heavy panting, thick saliva and physical weakness.
Don't forget your treats
Similarly, you want to be sure you bring along treats to keep your dog's energy up, while also rewarding them for good behavior during your run. Consider bringing along a mix of treats. These include low-value treats and high-value treats. Low-value treats can be given to your dog when you come to red lights, stop signs, intersections and crosswalks. High-value treats should be given once your run is finished, as it will provide your dog with essential calories and protein, while also giving them positive reinforcement for their good behavior.
Don't let them be aggressive to others
Make sure your dog is on their best behavior while you're on the run, too. Your dog shouldn't be lunging at other runners, passersby and strangers' dogs. Rather, they should remain by your side throughout your run. Don't let them wander off whenever they want to, either. Keep them by your side from start to finish.
Don't forget to warm up
Remember that you can't just kick into a run, going from zero to 100 mph. Instead, you should move around before you start. This doesn't mean physically stretching your dog out! But it does mean getting your blood pumping. Hop around together, play over a toy and get them to chase after a treat. Anything that gets their heart rate up is a good way to start.
Don't run in bad weather
Lastly, be mindful of when you decide to go running. For instance, bad weather is never a good choice, especially if you're first starting out. It's good to work with good weather so you can have an enjoyable first run.
When running with your dog, take your time and remember not to rush. Your dog needs as much time getting used to running as you did. Ease them into it and help them learn the joys of running.

subset: commoncrawl


text:
180pp., colour illus., paperback, Bologna, 2021
Published in conjunction with the exhibition, Halsey Institute of Contemporary Art, College of Charleston School of the Arts, Charleston, USA, 2021.
Introduction by Katie Hirsch and Bryan Granger. Essays by Joseph Gergel, Emmanuel Iduma and Dr. Mary Trent.
Features photography series made in South Africa, Guinea, Nigeria, Benin and Tahiti.
Art director and photograoher Namsa Leuba was born in 1982 in Switzerland to a Guinean mother and a Swiss father. She won First Prize at the Planches Contact Festival in 2010, the PhotoGlobal Prize at the Photography Festival in 2012, and the Magenta Foundation Flash Forward Festival in 2013. Leuba lives and works in Bordeaux.


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Bert Hellinger facts for kids
Quick facts for kids
Bert Hellinger
Born | 16 December 1925 |
Died | 19 September 2019 (aged 93) |
Spouse(s) | Maria Sophie Hellinger |
Anton Hellinger (16 December 1925 – 19 September 2019), known as Bert Hellinger, was a German psychotherapist associated with a therapeutic method best known as Family Constellations and Systemic Constellations. In recent years, his work evolved beyond these formats into what he called Movements of the Spirit-Mind. Several thousand professional practitioners worldwide, influenced by Hellinger, but not necessarily following him, continue to apply and adapt his original insights to a broad range of personal, organizational and political applications.
Anton Hellinger was born into a Catholic family in Leimen, Baden, Germany, in 1925. Hellinger stated that his parents' "particular form of Catholic faith provided the entire family with immunity against believing the distortions of National Socialism." At age 10, he left his family to attend a Catholic convent school run by the Order of the Jesuits in which he was later ordained and that sent him to South Africa as a missionary.
The local Hitler Youth Organization tried without success to recruit the teenage Bert Hellinger. This resulted in his being classified as 'Suspected of Being an Enemy of the People' In 1942, Hellinger was conscripted into the German army. He saw combat on the Western front. In 1945, he was captured and imprisoned in an Allied P.O.W. camp in Belgium. After escaping from the P.O.W. camp, Hellinger made his way back to Germany. Hellinger entered the Jesuits (Society of Jesus), a Catholic religious order, taking the religious name Suitbert, which is the source of his first name "Bert". He studied philosophy and theology at the University of Würzburg en route to his ordination as a priest. In the early 1950s, he was dispatched to South Africa where he was assigned to be a missionary to the Zulus. There he continued his studies at the University of Pietermaritzburg and the University of South Africa where he received a B.A. and a University Education Diploma, which entitled him to teach at public high schools.
Hellinger lived in South Africa for 16 years. During these years he served as a parish priest, teacher and, finally, as headmaster of a large school. He also had administrative responsibility for the entire diocesan district containing 150 schools. He became fluent in the Zulu language, participated in Zulu rituals, and gained an appreciation for the Zulu worldview.
His participation in a series of interracial, ecumenical training in group dynamics led by Anglican clergy in South Africa in the early 1960s laid the groundwork for his leaving the Catholic priesthood. From his point of view, the trainers worked from a phenomenological orientation -- they were concerned with recognizing what is essential out of all the diversity present, without intention, without fear, without preconceptions, relying purely on what appears. He was deeply impressed by the way their methods showed it was possible for opposites to become reconciled through mutual respect.
The beginning of his interest in phenomenology coincided with the unfolding dissolution of his vows to the priesthood. Hellinger told how one of the trainers asked the group, "What is more important to you, your ideals or people? Which would you sacrifice for the other?" This was not merely a philosophical riddle to him. He was acutely sensitive to how the Nazi regime sacrificed human beings in service of ideals. He said, "In a sense, the question changed my life. A fundamental orientation toward people has shaped all my work since."
After leaving the priesthood, he met his first wife, Herta, and was married, shortly after returning to Germany. He spent several years in the early 1970s in Vienna training in a classical course in psychoanalysis at the Wiener Arbeitskreis für Tiefenpsychologie (Viennese Association for Depth Psychology). He completed his training at the Münchner Arbeitsgemeinschaft für Psychoanalyse (Munich Psychoanalytic Training Institute) and was accepted as a practicing member of their professional association.
In 1973, he left Germany for a second time and traveled to the United States to be trained for 9 months by Arthur Janov. There were many important influences that shaped his approach. One of the most significant was Eric Berne and Transactional Analysis.
Nearing age 70, he had neither documented his insights and approach nor trained students to carry on his methods. He agreed for German psychiatrist Gunthard Weber to record and edit a series of workshop transcripts. Weber published the book himself in 1993 under the title Zweierlei Glück [Capricious Good Fortune; aka Second Chance]. In 2017 this book had its 18th edition.
As of 2018[update] Hellinger had published more than 90 books, 70 of them listed in the catalog of the German National Library (Deutsche National-Bibliothek, Leipzig). About half his publishing's are documentaries on his family constellation work, again as workshop transcripts. The other half presents his philosophy.
Hellinger traveled widely, delivering lectures, workshops, and training courses throughout Europe, the United States, Central, and South America, Russia, China, and Japan. Hellinger alienated some potential colleagues and supporters by his idiosyncratic behavior, such as making sweeping statements that reduced complex issues to single root causes or his manner of sometimes addressing clients in a caustic, authoritarian tone. Many practitioners distance themselves from the method's founding figure. Many others continued their association, integrating the further developments into their own practices.
Until his death on 19 September 2019, Hellinger operated the Hellinger School with his second wife, Maria Sophie Hellinger.
See also
In Spanish: Bert Hellinger para niños
- Family Constellations
Misty Copeland |
Raven Wilkinson |
Debra Austin |
Aesha Ash |


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The result of the Tiffany-Nike collaboration was briefly kept under wraps with the Nike Air Force 1 in black suede with Nike's signature comma in Tiffany Blue.
The shoe jewelry brand also got a square-shaped silver pendant placed on the heel of the sneaker and a blue box with a red interior. The shoes come with three extra pairs of laces.
Tiffany took to social media today to announce four silver accessories that are sold separately from the shoes. Items on display include a whistle, a toothbrush, a charm and a shoehorn. All items feature the Nike Swoosh and Tiffany & Co logos. and New York.
The $1 Nike & Tiffany Air Force 400 will go on sale March 7th.
Rating |


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Dr. Hennenfent is on Doximity
As a Doximity member you'll join over two million verified healthcare professionals in a private, secure network.
- Connect with other colleagues in the same hospital or clinic
- Search all U.S. specialist profiles and refer a patient
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Address not posted.
Sebring, FL 33870- Is this information wrong?
- Brad went to college at Northwestern University, medical school at the University of Illinois, and did his residency in Emergency Medicine at the University of Illinois Affiliated Hospitals Emergency Medicine Residency Program. Brad was previously the Director of Emergency Medicine at an inner city Chicago Emergency Department, and Regional Director for Emergency Consultants Inc.
Brad and his physician brother invented Treatment Scores which are a universal method to quantify the value of medical treatments for patients, using the individual patient's values and preferences. Treatment Scores create understandable treatment transparency, and enable evidence-based medicine, shared decision-making, and true informed consent. Treatment Scores put patients first while solving the 88% health illiteracy problem.
The Treatment Score = the net treatment benefit for the patient as summarized from the existing medical literature using evidence-based medicine guidelines. Treatment Scores are Sabermetrics (Moneyball, as in the Brad Pitt movie) for medicine.
When volunteering for a medical non-profit Dr. Brad Hennenfent helped get over $20 million in funding released by the federal government to the NIH for men's health research. Brad also helped get about $100,000 in grants in kind or donations for the medical foundation year after year.
Brad grew up in a basketball family and advocates for 4-on-4 full court basketball, because mathematically, 4-on-4 full court is superior to 5-on-5 for fast breaks, dunks, alley oops, and the run and gun style of basketball most fans love.
Brad is the author of several books:
"Surviving Prostate Cancer without Surgery"
"The Prostatitis Syndromes"
"Uncles and Etymology"
"Freedom is the Purpose of the People of the World"
"The American's Creed"
Education & Training
- University of Illinois College of Medicine at ChicagoResidency, Emergency Medicine, 1984 - 1987
- University of Illinois College of Medicine at ChicagoInternship, Preliminary Year, 1984 - 1985
- University of Illinois College of MedicineClass of 1984
Publications & Presentations
- 4 citationsRepetitive prostatic massage and drug therapy as an alternative to transurethral resection of the prostate.Bradley R. Hennenfent, Alfred R. Lazarte, Antonio Espinosa Feliciano> ;Medgenmed. 2006 Oct 25
- Responses from US readers to the Webcast video editorial entitled "American Healthcare is the best in the world if...".Narendra Bansal, Ed E Greif, Ronald Bosch, Jay D Holland, Tom Dixon, Scott D Cohen, Mayrene Hernandez, E M Reisman, David Burgio, Carol Peckham, Bradley Hennenfent, Ma...> ;Medgenmed. 2004 Sep 28
- Clinical Remission of Chronic Refractory Pelvic Symptoms in Three Men.Bradley R. Hennenfent, Antonio Espinosa Feliciano> ;Thescientificworldjournal. 2004 Jun 7
- Join now to see all
Press Mentions
- Treatment Scores: The Future of MedicineMarch 22nd, 2018
- 28: Quantifying the Science of Medicine with Dr. Bradley Hennenfent, Founder of Treatment Scores!October 19th, 2015
Other Languages
- Spanish
External Links
- Treatment Scores Bloghttp://TreatmentScoresBlog.com
- LinkedInhttps://www.linkedin.com/in/bradmd/
- Twitterhttps://twitter.com/BradMD
Viewing the full profile is available to verified healthcare professionals only.
Find your profile and take control of your online presence:


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Christianity's mission statement: A religious community to provide discussion, education, support, and happiness to people of similar Christian beliefs and people on their road of holy discovery.
Debates. A great way to discuss and debate various beliefs whether they come from inside denominations of Christianity or other religions.2.
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It's easy to think of the desktop CPU space as a duopoly: on the one hand you have Intel finally transitioning away from Skylake refresh after Skylake refresh with this year's 12th-gen Alder Lake parts. And on the other, you have a resurgent AMD that's delivered massive improvements to IPC and core count over successive Ryzen generations.
In the consumer CPU space, it's a two-sided fight. However, that doesn't mean that there aren't any other desktop CPUs in existence. Take a closer look and you'll quickly realize that the CPU space is a lot more diverse.
From high-performance Arm designs to specialized Russian government chips, there's a plethora of non-Intel and non-AMD chips out there powering full-size desktop PCs. In some cases, like the Zhaoxin Kaixian line of chips, you can even get your hands on them through the right channels. So, who are making these CPUs? What do they look like? How fast are they? And can you game on them? Let's take a look and find out.
Arm on PC: From mobile to the future of desktops
The prime example of Arm coming to challenge the status quo on the desktop. Last year, Apple released new MacBooks that on the outside look identical to the previous Intel generation, but inside Apple quietly kickstarted a revolution in the PC space. The M1 Macs feature a 5nm Apple SoC, featuring highly customized Arm cores. From an architectural standpoint, the M1 has more in common with the iPhone's A14 Bionic chip than either AMD or Intel's mobility-oriented x86 parts.
The M1 requires a Rosetta translation layer to convert x86 code into something the M1 can execute. Despite the overhead on legacy applications, the M1 can actually outperform Intel Comet Lake in some x86 workloads. Then in native apps it can demolish the competition.
Apple plans to phase out x86 chips in Macs over the next couple years. Globally, macOS has less than a 7 percent market share in the PC market. This means that Apple Silicon parts won't magically replace the likes of Tiger Lake U. However, Apple's move to the M1 will likely spur other manufacturers to take Arm on PC seriously.
As far back as 2012, Microsoft Surface RT featured an Arm SoC running a version of Windows. However, speed, app compatibility, and a host of other issues have kept Arm on PC out of the spotlight. The M1 could be a sign of things to come, with a wider range of products like the Qualcomm 8cx-equipped Samsung Galaxy Book S. Arm on PC is still in its early days. However, five years from now, non-Intel, non-AMD chips could be a common sight in desktops and laptops. And the vast majority of those would be Arm machines.
Zhaoxin: The Chinese x86 manufacturer about to break into the big leagues
Desktop and laptop Arm chips are set to become increasingly common. But what about alternatives in the x86 space? Only a handful of manufacturers: Intel, AMD, VIA, and DMP Electronics hold x86 licenses. Intel and AMD are known quantities. DMP is a Taiwanese fabless manufacturer responsible for the Vortex86 line of embedded chips, found in some set-top boxes and in the industrial sector.
That leaves VIA. In 2013, they launched Zhaoxin as a joint venture with Shanghai's municipal government, as part of China's efforts to reduce its reliance on foreign technology. VIA continues to own a minority stake in Zhaoxin and – critically – provides a x86 license, allowing Zhaoxin to create its own desktop CPUs.
Zhaoxin Kaixian CPUs are built on the 16nm process. The KaiXian-U6880A which is their top-end chip can actually be purchased and installed into a gaming system, assuming you live in China. It's an 8-core part that runs at a relatively low 3.0 GHz. The U6880A lacks hyperthreading, "boost" clocks, or an L3 cache. Benchmarks indicate that the U6880A performs more or less on par with the quad-core AMD A10-9700 APU, an evolution of AMD's older Bulldozer designs circa 2016.
The U6880A isn't exactly what we'd call a "good" gaming CPU: we're looking at a part that's frequently outperformed by the dual-core Athlon 200GE. Nevertheless, the Zhaoxin CPU is enough to deliver framerates north of 30 FPS in AAA titles like Hitman 3 and Far Cry 5.
Zhaoxin's next-generation KX-7000 series is supposedly built on the 7nm process node. This opens the door to higher clock speeds and greater efficiency. It remains to be seen how these parts will fare up against Alder Lake and Zen 4. However, raw performance leadership isn't exactly the point here. It's a commercially available homegrown Chinese x86 alternative that'll handle most ordinary workloads with ease.
Elbrus: The Russian government's server workhorse
Named after Mount Elbrus, the highest point in the Russian Federation, the Elbrus architecture is another attempt at tech self-sufficiency. Unlike Zhaoxin's chips however, Elbrus is designed solely to meet the Russian government's secure computing needs: you won't see any consumer-facing Elbrus parts in Moscow hardware stores.
The Russian government has two main uses for Elbrus: HPC servers for academia and research, and secure endpoint PCs for the military and other sensitive sectors.
MCST, a Russian semiconductor manufacturer spun off from the Soviet Union's premier computer science research team, has been building chips based on the Elbrus ISA for nearly 30 years. These aren't x86 chips. However, Elbrus features binary translation, much like the Apple M1. This allows Elbrus hardware to run x86 programs and OS environments like Windows.
Just a few months ago, MCST revealed the Elbrus 16S. This is a 16nm chip that runs at 2.0 GHz, delivering up to 1.5 TFLOPs of compute. Interestingly, the Elbrus-16S supports quad-socket implementations with up to 16TB of RAM - something that's not possible even on top-and AMD and Intel server hardware.
SHAKTI: An IoT and embedded platform made in India
Researchers at the Indian Institute of Technology unveiled this RISC-V -based platform in 2018. Indian silicon foundries are still in their infancy. As a result, the latest Shakti E series processors are built on the 180nm process and clock up to 100 MHz. These aren't chips built for mainstream workloads. Instead, Shakti's E series focuses on low power IoT and embedded use cases, such as sensors.
While the core Shakti IP was developed with government funding, a nascent Indian fab, InCore Semiconductors manufactures custom Shakti chips for a limited private sector clientele. It will definitely be a while before the Indian semiconductor industry catches up with the likes of Intel (or even Zhaoxin, for that matter). However, it's a step on the roadmap. In the here and now, Shakti chips can be deployed in a wide range of commercial and government-oriented IoT workloads. We're probably not going to see a Made in India desktop CPU for the next five years at least, but the groundwork has definitely been laid.
Wrap Up
Intel and AMD continue to have a commanding presence in the desktop CPU space. Unless you live in China or work for the Russian government, an Apple M1-powered device is the sole alternative that'll deliver competitive performance. However, between self-sufficiency efforts by governments across the world and the slow rise of Arm on PC, the desktop CPU space is about to get a whole lot more diverse.
What's the end of the decade look like? We reckon Intel and AMD parts will stay relevant. But you might just as likely be running an Arm desktop or something even more exotic.


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Being a solid poker player means not being rigid as the game progresses
Variance is not a bad thing to have in a game of poker; however, it can set your frustration to the edge if not handled properly. Playing Sit & Go (SnG) games comes with a lot of variances and, depending on the specific limits and type of game, SnG players are used to ranging their stack from 5-20 buys-ins on a regular basis. If you enjoy playing these types of tournaments, then it is important to invest some time understanding how variance can affect your game and how to act on any given situation, to keep frustration away.
Knowing how to play with a lot of variance comes in handy, especially because, typically speaking, the tournaments with the most variance usually have the highest returns. One of the lessons you can learn when playing SnGs is that the more risk you take, the more reward you can expect; of course, that depends if your move was successful. For being able to take some risks, the most important thing you need to focus on is your bankroll; that's the major aspect of being successful during one of these tournaments.
In addition to managing your bankroll properly, a little self-discipline is required to comfortably adjust your limits up and down when the game requires it. In addition, if you feel things are getting too stressful, you should know when you need to take a break and try another type of game. A common scenario in a SnG would be losing 10-20 buys-ins all in one hand and even more, especially when playing a heads-up SnG. The most important thing is to know this could happen and move on to another hand before letting the major loss affect you mentally.


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This is for new and potential members making their first character on the site. This quiz can help you develop some of the background for your character and gives you what we think is the most likely status for them - Commissioned, Enlisted, Civilian, or Cadet. The quiz results are a suggestion only.
Yes! They love it!
They would not necessarily mind it, but don't find it exciting either
Not at all. Space is a death trap.
They would keep trying until they did.
They would try another time or two, but if they still couldn't make it they would eventually realize it wasn't for them.
They would give up after the first time and try something else. SFA isn't the be all end all of the space careers.
They wouldn't even try the first time.
Yes, it wouldn't have been a problem.
Only if they earned a scholarship.
No, they couldn't or wouldn't have gone.
Yes, their IQ is impressive
Definitely above average
About average
Not really, but they get by
Yes, they are an expert at something(s) they learned elsewhere.
They have some skills they learned elsewhere.
No, they aren't particularly skilled.
They are skilled, but learned it from experience in Starfleet and/or the Academy.
Very ambitious
Pretty ambitious
Sort of ambitious
Not ambitious at all
Yes; you say jump and they don't ask questions!
Yes, within reason; you say jump and they ask how high
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Yes, they pushed them to go.
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They don't have family/family didn't care either way.
They are working on learning one
Become a leader!
Find a comfortable place
Stay where they are
Yes, they need wide open spaces and fresh air!
A little bit, but nothing serious.
Not at all. Recycled air is technically healthier anyway.
They are going to enroll
I haven't decided yet
Yes, absolutely
Probably. They'd have tried really hard
Probably not. They probably would have gotten discouraged and dropped out or failed out
They didn't go to the Academy! I keep telling you this! Why do you keep asking me about it?!
They would have tried, but failed to graduate from the Academy.
Here's an interesting quiz for you.


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GLIMMER TRAIN: FALL 1998, Issue 28.
Edition: First appearance in print of these works.
Portland, OR: Glimmer Train Press, 1998. First edition - Includes stories by Steve Adams, Lin Enger, Susan Engberg, John Griesemer, Jenny Drake McPhee, Sally Bingham, Bruce Machart, and Christine Byl. Interview with A. J. Verdelle, and an article in the 'silenced voices' series on the Mexican writer Jose Francisco Gallardo Rodriguez by Siobhan Dowd. Each story is preceded by a picture of the author as a child, brief autobiographical comments, and a printed signature. Several authors in each issue also contribute to the comments and photographs found in the "Last Pages" at the end of each issue. A rather idiosyncratic journal, edited by two sisters, but one which consistently publishes excellent fiction. 168 pp. We specialize in literary journals, and have many others - including many not yet catalogued and listed on line. ISBN: 1880966-271.
Condition: Fine in glossy illustrated wrappers. Laid in is a bookmark and the first issue of a newsletter called "Writers Ask" on the craft of writing.


text:
One dead after fire in Southwest Middlesex
One person is dead after a fire at a property west of London.
Around 10:20 a.m. Tuesday, fire crews and police were called to a property on Melbourne Road in Southwest Middlesex Township. Members of the Middlesex County Ontario Provincial Police, the Strathroy-Caradoc Fire Department, the Chippewas of the Thames First Nation Fire Department, and Middlesex-London EMS were called to the scene.
One person was found and pronounced dead by the Coroner.
The identity of the deceased is not being released until next of kin can be notified.
Middlesex OPP are assiting the Office of the Fire Marshal to determine the cause of the blaze.
Read original story from London Ontario – BlackburnNews.com


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Donald Trump, the former president of the United States, is known for using social media as a way to share his views with the public. Barack Obama, however, was the first candidate for president to use social media. It became clear that this could be a powerful tool in a presidential campaign. This fact was confirmed in 2016, when Trump's team began to use carefully crafted messages on various platforms.
It is unclear if social media will still have an impact on the 2020 election. Twitter is a platform that has been used by both sides of the political spectrum for decades. Does it still hold any influence?
Aubrey Jewett, Associate Professor and Assistant School Director within the School of Politics, Security, and International Affairs of Central Florida University, stated that "Social Media will play an essential role in 2024's presidential election."
Jewett pointed out that for many Americans social media is an important news source. He cited the Pew Research report that showed that over 70% of Americans get their news via social media.
Jewett added, "Candidates and campaigns will use social media advertising to target their messages precisely to those who are most responsive." Disinformation campaigns are spreading through social media, despite attempts to stop. They may have an important impact. People often use social media to talk about politics and policies.
Social media can be a powerful tool to motivate voters, to ensure they cast their ballots, and both campaigns are likely going spend a large amount of money in these outreach efforts.
What about the spread of misinformation?
A danger is that the social media platforms could be used to "fool everyone, always," at least through the spreading of misinformation.
Craig Barkacs, professor of business law and ethics in the MBA programs at the Knauss School of Business at the University of San Diego, warned that social media has become a prime pollutant in today's political landscape, which is so littered with lies, deception, conspiracy theories, misinformation, and, even worse, disinformation – even as nearly three-quarters of Americans turn to it for a source of news.
Barkacs explained that headline-itis is a mental disorder whereby Americans are prone to glancing quickly at the shiny objects and moving onto the next one. The average article is read for 15 seconds and a video maybe 10 or less seconds, according to research. Pew Research Center also found in a study that people who rely on social media for their news are less politically aware and engaged than those who use other sources.
Even though minds can be changed
It is unlikely that those who are most involved in "flame-wars" online on Twitter or other platforms will change their mind, since the people who throw the fuel have already made their decision. It is still possible for opinions to change on controversial issues.
Some people might claim, "Hey! If you look at the vicious arguments that go back and forth on social media sites, nobody ever changes their mind." This may hold true for both sides, but not for anyone who watches the arguments. If one side only appears, and is not challenged by anyone else, then the viewers will never be exposed to a counterargument.
It could be even more important to check the facts of statements by politicians before next year's elections. Even more so, it could be important to prevent a campaign of disinformation that supporters of one candidate could mount to undercut the opposition.
The lies, conspiracy theories, and deception that are spread on social media need to be fought against. Disinformation and propaganda cannot be ignored. Barkacs said that vigilance is important and that the game of "whack-a-mole" cannot be stopped, no matter how frustrating it might be. Thomas Jefferson once said, "An informed electorate must be a pre-requisite to democracy." Even though the social media is used often to spread misinformation, they can still be utilized to provide accurate information.
Social Media's Changing Role
It should also be noted that both sides use social media to good success – so it is likely its role as a tool to reach voters in an election will only continue to evolve.
Jewett said that when social media became popular, Democrats seemed to have an edge because young voters were much more likely to be using new technologies like social media. Also, younger voters tend to lean Democratic. As time passed, however, the use of social media grew, with many boomers, seniors, and middle-aged people using it. In 2016, when Donald Trump was at the height of his popularity, he effectively used Twitter to market and recruit Republican voters.
It's not yet clear which side has the advantage of social media in 2024.
Biden, who is older, hasn't had a huge impact on social media. However, Democrats and Biden's campaign are likely to increase their social media marketing. Biden will be able to use social media effectively to discredit his opponents and generate excitement if he faces Trump again, as it is highly likely.
We can also expect social media to play a part if a different GOP candidate wins the nomination. It could also include Florida Governor Ron DeSantis. He may need to make up lost ground.
Jewett added that "he will need to show that he is a social media expert, which has been largely absent from his tenure as governor. However, his team of campaigners will include many social media experts who worked in his past campaigns and governor's offices."
Attention Artificial Intelligence
The biggest question is not whether there will be another match between Biden & Trump but how AI could be used next year.
Jewett said that artificial intelligence would help to microtarget voters and respond faster to social media events.
He warned that the biggest impact could be the use of AI to present misinformation in unprecedented ways – both in terms of quality and quantity of advertisements as well as via faux news pieces.
The AI technology allows even those with only basic computer knowledge to easily create fake videos, pictures and audio that fools the general public and can be difficult to detect by digital experts. It's scary to think that, in an election that is close, there may be clever 'deepfakes' which can damage one candidate or give their election opponent," Jewett added.
Social media and AI could create messages that are more targeted than ever before.
Barkacs said that social media had infected politics whether they liked it or not.
SME Paid Under


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I've seen it far more times than I can count: a kid walks onto campus, picks a tough STEM major like Engineering, then, after seeing he can't cut it there, switches over to something less challenging (but still hard) like Chemistry or Pre-Med. Then after flunking those classes, changes major again and again, until finally […] … learn more→
Tag Archives: majors
Study: Students leave hard majors. No kidding!
WIU: African and Women's Studies OUT
It's so rare to see a glimmer of sanity in higher education, I feel the need to highlight it when it sparkles a little. Even within this little flash of light, there is darkness, however…but first the good news: Administrators recommended that majors in African-American studies, philosophy, religious studies and women's studies all be cut […] … learn more→


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How to set up proxy server in Nox App Player. Though Nox does not support VPN apps, but if you are using proxy servers to connect to the internet on the hosting machine, you could still config Nox to use the same proxy server as well. Here are the steps: 1. Go to Android settings >> Wi-Fi >> Long press WiredSSID. 2. Click Modify Network. 3.
Jul 19, 2020 How To Setup Your Proxy in Windows 10 - BestProxyAndVPN.com Open Network & Internet settings Step 3: Select Proxy from the right side of the window. Click on Proxy Step 4: Scroll to Manual proxy setup and toggle the switch to On. Insert below your proxy IP address and port. These are available to you in your account's Control Panel. Click Save. And that's it. Toggle the switch to on and insert your IP How to set up proxy server in Nox App Player – NoxPlayer
To set up a proxy on Windows 10, simply head to your Settings screen and open the Network and Internet section. From there, click on the Proxy tab and choose from the list of available proxy settings.
To disable the proxy, follow the same steps and, at Step 4, set the Use Setup Script switch to Off. Set up a proxy manually. Another way to set a proxy is to manually enter its IP address and port number. The address of a proxy server is similar to that of any computer on the network, and it could be something like: 192.168.1.211. Feb 15, 2017 · How to set up a proxy in Edge. Launch Edge from your Start menu, desktop or taskbar. Click the More button in the top-right corner of the window. (It looks like three dots.) Click Settings. How to set up a proxy server in Windows. Here's how to set up your Windows PC to use a proxy server on Windows 8 or Windows 10: Press the Windows + I keys simultaneously to access the Windows Settings menu. On Windows 10, click Settings > Network & Internet > Proxy. On Windows 8, click Settings > Network Proxy.
Dec 07, 2019 · The proxy provides many functions like anonymous navigation, access to geographically restricted content, or filter some content. Well basically a proxy server is a computer that acts as an intermediate between your PC and the internet and all the traffic looks like the Proxy server did it.
Aug 21, 2017 · Five steps to set up an HTTPS proxy server. Once you've gathered what you'll need to create your HTTPS proxy server (and made sure your server is suitably prepared), the final step is performing the actual setup. Fortunately, this process should be simple for most web professionals. 1. Set up a subdomain with SSL Smart DNS Proxy can be set up on numerous pieces of equipment including PC/Mac desktop computers and laptops, iOS/Android powered mobile devices (smartphones, tablets or e-book readers), smart TV sets, set-top boxes and game consoles. You may also set up the whole network using our simple guidelines for routers. Jul 06, 2017 · To enter manual proxy settings, enable "Use a proxy server" under Manual proxy setup. Enter the address of the proxy server and the port it uses in the "Address" and "Port" box. Your organization or proxy service provider will provide you with the network address and port number the proxy requires. Jul 26, 2020 · set up proxy on android,change proxy on android,how to proxy on android,proxy server on android phone,use proxy on android,set up Socks5 on android,proxy server,free proxy list,proxy server,proxy Nov 09, 2019 · Enter the proxy server address and port. The address and port both have their own boxes under the "Proxy server" header. If you need to specify different addresses and ports for different services (e.g., you have a separate proxy for FTP connections), click the Advanced button to enter your additional info. Note: you don't have to set up a proxy if you are already using NordVPN app. For Socks5 use port 1080, for HTTP use port 80. Here is a tutorial on how to set up a proxy on uTorrent: 1. Open your uTorrent client. 2. Click on Options and then press Preferences. 3. A new window pops up. Click on Connection. 4. Mar 26, 2020 · If your home or office network is behind a proxy server, then you will need to setup proxy in order to browse the Internet. In this tutorial, we will show you several ways to configure proxy settings in Ubuntu desktop. Setting Up Proxy with Ubuntu Desktop GUI. You can setup the proxy in Ubuntu Desktop by following the below steps: 1.


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Agriculture & Husbandry. Tull (Jethro) & Cobbett (William), The Horse-Hoeing Husbandry, London: Published by William Cobbett, 1829, original publisher's boards, repaired, 8vo, Donaldson (Professor J.), British Agriculture, London: Atchley & Co., 1860, repaired, original green cloth, some movement, 4to, Davis (Hewitt), Farming Essays, London: James Ridgway, 1848, stained and toned, original cloth, 8vo, Rham (The Rev. W.L.), The Dictionary of the Farm, second edition, London: Charles Knight & Co., 1845, printed in double-columns, in-text illustrations, original cloth, repaired, 8vo, etc., (7).
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Featured Scholar: Barbara Flynn, DBA
Richard M. and Myra Louise Buskirk Professor of Manufacturing Management, IU Kelley School of Business
Director, IU Center for International Business Education and Research
Barbara Flynn has a global outlook. Her large-scale research project collects data from manufacturers in 12 countries. It allows plant managers to compare the practices and performance of their plants with other plants in their industry, both in their country and with their global competitors. The data includes practices and performance related to accounting, quality management, technology management, human resource management, strategy, shop floor control and a variety of other areas. Data has been collected from some of the best plants in the U.S., Japan, China, Germany and other countries. It has been used as the foundation for many individual studies that address topics of interest to managers.
Through the provision of detailed feedback reports, participating managers are able to benchmark their practices and performance with that of other plants in their industry, both in their country and in the world. Dr. Flynn believes the best research is based on solving real world problems. Her translational research combines a rigorous methodology and strong theoretical foundation with examination of practical problems that are important to the U.S. economy.
Professor Flynn's global research efforts have a positive impact on the U.S. manufacturing practices and performance and is another example of how IUPUI's faculty members are TRANSLATING their RESEARCH INTO PRACTICE.
Selected Publications in IUPUI ScholarWorks
With several research works contributed to IUPUI's free, open access repository, Professor Flynn has made translational research knowledge available to professionals, researchers, students, and communities around the world.
Flynn, B., Pagell, M., & Fugate, B. (2018). Editorial: Survey Research Design in Supply Chain Management: The Need for Evolution in Our Expectations. Journal of Supply Chain Management, 54(1), 1–15. http://hdl.handle.net/1805/17991
Guilherme Zamur, Ely Laureano Paiva, and Barbara B. Flynn. Suppliers' non-compliance with sustainability standards: a new perspective based on discrete-choice experiments. International Journal of Production Research. (2017). http://hdl.handle.net/1805/17194
Hu, H., Djebarni, R., Zhao, X., Xiao, L., & Flynn, B. (2017). Effect of different food recall strategies on consumers' reaction to different recall norms: A comparative study. Industrial Management & Data Systems, 117(9), 2045–2063. http://hdl.handle.net/1805/15834
Flynn, B., Pagell, M. and Fugate, B. (2017), Survey research design in supply chain management: the need for evolution in our expectations. J Supply Chain Manag. Accepted Author Manuscript. http://hdl.handle.net/1805/14917
Janaina Siegler, Andre Ravara, Susana Pereira, Fundação Getulio Vargas, and Barbara B. Flynn. The Samarco Accident in Brazil: Industry and Supply Chain Impacts. (2016). http://hdl.handle.net/1805/17200
Ni, J. Z., Ni, J. Z., Melnyk, S. A., Melnyk, S. A., Ritchie, W. J., Ritchie, W. J., ... & Flynn, B. F. (2016). Why be first if it doesn't pay? The case of early adopters of C-TPAT supply chain security certification. International Journal of Operations & Production Management, 36(10), 1161-1181. http://hdl.handle.net/1805/12880
Barbara B. Flynn, Janaina Siegler, Marcelo Bradaschia, Fundacao Getulio Vargas, and Sao Paulo. Comparative Analysis of Resilience by Supply Network Structure. (2015). http://hdl.handle.net/1805/17201
Xiande Zhao, Yina Li, and Barbara B. Flynn. The financial impact of product recall announcements in China. International Journal of Production Economics. (2013). http://hdl.handle.net/1805/17243
Barbara B. Flynn, Xiande Zhao, Xiaowen Huang, and Jiang Wei. Special Topic Forum on Supply Chain Management in Emerging Markets: Critical Research Issues. Journal of Supply Chain Management; Wheat Ridge. (2013). http://hdl.handle.net/1805/17240
Sarah Jinhui Wu, Steven A. Melnyk, and Barbara B. Flynn. Operational Capabilities: The Secret Ingredient. Decision Science. (2010). http://hdl.handle.net/1805/17285
Shanshan Hu, Qing Ye, Wei Chi, and Barbara B. Flynn. Supply Chain Structure, Inventory Turnover, and Financial Performance: Evidence from Manufacturing Companies in China. SSRN Electronic Journal. (2010). http://hdl.handle.net/1805/17286
Barbara B. Flynn. Introduction to the Special Topic Forum on Global Supply Chain Management. Journal of Supply Chain Management. (2010). http://hdl.handle.net/1805/17287
Barbara B. Flynn, Baofeng Huo, and Xiande Zhao. The impact of supply chain integration on performance: A contingency and configuration approach. Journal of Operations Management. (2010). http://hdl.handle.net/1805/17289
Xiande Zhao, Yina Lee, Stephen Ng, and Barbara B. Flynn. The Impact of Product Recall Announcements on Stock Market Reaction: a Study of Chinese Listed Companies. (2009). http://hdl.handle.net/1805/17290
Cecil C. Bozarth, Donald P. Warsing, Barbara B. Flynn, and James E. Flynn. The impact of supply chain complexity on manufacturing plant performance. Journal of Operations Management. (2009). http://hdl.handle.net/1805/17291
Xiande Zhao, Baofeng Huo, Barbara B. Flynn, and Jeff Hoi Yan Yeung. The impact of power and relationship commitment on the integration between manufacturers and customers in a supply chain. Journal of Operations Management. (2008). http://hdl.handle.net/1805/17299
Marjorie A. Lyles, Barbara B. Flynn, and Mark T. Frohlich. All Supply Chains Don't Flow Through: Understanding Supply Chain Issues in Product Recalls. Management and Organization Review. (2008). http://hdl.handle.net/1805/17297
Barbara B. Flynn, Xiande Zhao, Baofeng Huo, and Jeff Hoi Yan Yeung. We've got the power! How customer power affects supply chain relationships. Business Horizons. (2008). http://hdl.handle.net/1805/17298
Vinod Singhal, Barbara B. Flynn, Peter T. Ward, Aleda V. Roth, and Vishal Gaur. Editorial: Empirical elephants—Why multiple methods are essential to quality research in operations and supply chain management. Journal of Operations Management. (2008). http://hdl.handle.net/1805/17300


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