text: For an immersive gaming experience, the OPTIX MAG241C 23.6" 16:9 Curved Gaming Monitor from MSI features a 1500R curved Full HD panel with a 144 Hz refresh rate and FreeSync technology. A virtually frameless bezel surrounds this 1920 x 1080 resolution display that features a 3000:1 contrast ratio, a 300 cd/m² brightness rating, a 1 ms response time, and support for up to 16.7 million colors. Setup is simple thanks to HDMI and DisplayPort inputs, while the USB hub lets you connect USB compatible peripherals directly to the display. Once configured, gamers can take advantage of the Gaming OSD App, and an included headset hanger keeps your headset close by in between gaming sessions. Furthermore, this monitor has a 5-way OSD navigation joystick and can be tilted from -5 to 20° for maximum viewing comfort.


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8:00am-5:00pm EDT
Monday - Friday
8:00am-5:00pm EDT
Monday - Friday
$15 million over three to four years, from a company valued at $100 billion.
Shein, the fast fashion behemoth, is killing it. Look at this headline! And this one! Look at all these kids wearing its stuff! This company was only founded in 2008, is now valued at over $100 billion, and frankly it doesn't seem to matter that the cotton in its garments has been found to have been sourced from Xinjiang, or that reports are piling up of labor violations at the Chinese factories with which it contracts.
Well, maybe it matters to the company a little, insofar as it hurts its image. And so this week Shein announced – after a recent report of labor abuses brought some unwelcome attention and PR fallout, like the Rolling Stones canceling a clothing line through the brand – that it will spend $15 million "over the next three to four years to help upgrade hundreds of factories in its supply chain."
$15 million, over three to four years, from the company valued at $100 billion? Slow down! Don't break the bank, guys!
But will that sum of money, drop in a bucket as it may be, be enough to improve the working conditions for those who churn out Shein's garments? Experts told Vogue Business no, not on its own:
"Fast fashion brands compete in a race to the bottom, where they are always looking for the cheapest labour and they shirk responsibility onto suppliers to make changes and meet deadlines," says (fair fashion campaigner Venetia La Manna). "This system is not 'flawed'; it was created to do that," adds Swatee Deepak, environmental activist, practitioner-in-residence at London School of Economics's Marshall Institute, and co-founder of Remember Who Made Them (alongside La Manna).
Shein sells its products in 150 countries and makes a lot of money doing it. However, it would be making a lot less if it weren't able to exploit a U.S. trade rule that allows it to import duty free its piles of questionably sourced and made garments. Congress should close the de minimis loophole.

subset: commoncrawl


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Pottery, a conventional art form of India, as a profession faces multiple challenges in terms of productivity, income and inefficient technology. Traditionally, pottery involves a lot of manual labour. Due to low production, many potters have switched to alternate professions for better and secure income sources. In order to preserve an ancient profession, SELCO Foundation identified and designed mechanized interventions to scale. The interventions in the past case studies have successfully accelerated production, reduced input costs (electricity cost), increased power reliability, enabled long-run work hours, and have significantly reduced manual drudgery. The approach to scaling a program intervention is to first test an innovation at a smaller scale, rigorously evaluate it, and scale the pilot up in the same context if it is shown to be successful, as is in this case and other pottery value chain interventions. In particular, this method is now applied by government cooperative societies (Khadi and Village Industries Commission), NGOs with deep local context ( Akshara, Terracota and Max Potteries societies, and REACH) that have created space for piloting and evaluation as a means to test promising solar innovations or tweaks to existing programs. However, there can be important differences in context even within the same state, so it is important to factor in administrative capacity to implement the intervention on a broader scale and to consider potential general equilibrium effects, a model adopted by SELCO Foundation. For example, in Andhra Pradesh, the micro businesses team found that providing solar power as an alternative to grid connection doubled potter's per day production in the area. The team found that most of the potters already owned the machinery but the efficiency was massively cut short due to lack of reliable power supply and poor load shedding in this context. The team demonstrated the use of solar powered interventions to mobilize and spread awareness in partnership with KVIC and Terracota and Max potter Societies. It increased end user's participation and confidence in the intervention. This successful demonstration helped scale the program in Andhra Pradesh in partnership with KVIC and Terracota Max Societies. To scale appropriately and effectively, SELCO Foundation and all the implementing partners account for local conditions and implementation capacity, and then adapt programs to that new context accordingly. The Pottery program intervention provides participants with a combination of productive use assets (such as solar powered pottery wheel, blunger, pugmill, efficient kiln), training, access to microfinance institutions/bank loans, and usage/service support. Key questions include how the training component can be made relevant for local markets, whether local financial infrastructure is sufficiently widespread and accessible to facilitate bank loans or end users paying capacity, and what intervention asset would make sense for local conditions. By partnering with organizations that have deep local knowledge, SELCO Foundation team and staff have helped to identify ways in which this program can be adapted to new contexts.
SELCO Foundation (SF) in collaboration with KVIC to spread awareness regarding solar compatible pottery machinery. Accordingly , SF installed demo units at the Common Facility Centre to increase acquaintance. Thereafter, the Foundation solar powered existing pottery wheels for 40 end users. The intervention includes establishing panels and light systems at each users' workstation to power their pottery wheels. According to personal testimonials by end users, it has significantly increased their confidence in taking bulk orders. Earlier they weren't able to deliver big orders due to power unreliability during work hours and suffered losses on bulk orders. Other than reliable power supply, end user electricity bills have reduced from Rs. 400 - 500 per month to Rs. 250 - 350. There is a significant growth in production as there is a 20-30% rise in daily productions in the AP cluster. According to SELCO Foundation and its partner organization's reports, the program intervention has directly impacted 40 end user's livelihood and positively affected 150 families in this cluster.
Individual model: Individual Solar operated pottery wheel- 40 systems. Demo systems at Two Common Facility Centres: Pottery wheel- 2 systems Blunger- 2 systems Pug Mill- 2 systems Kiln- 2 units.
Impact: Reduced electricity cost per end user per month - (from INR 400-500) to (INR 250 -350) Increased confidence in taking bulk orders which was not possible earlier due to poor load sharing and unreliable electricity Per day production increased by 20-30% Increased work hours not limited by power cuts as the intervention enabled 24/7 accessibility to lighting and energy
SELCO Foundation's focus on solar technology efficiency, increase in productivity and use of on ground case studies has inspired commitments from potter's societies ( Terracotta and Max Pottery Societies), government entities (KVIC) and partner organizations helping us expand our reach and scale up successfully piloted program implementations. In Andhra Pradesh's case as a new geography since implementation, SELCO Foundation has enrolled over 40 households in program intervention and reached 150 families indirectly. On a larger scale, the organization has also influenced a state level conversation about how to best improve livelihoods driven by solar power. Many facets of its standard operations are part of the successful case studies to further inform the organization's programming and expansion.


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Mutti Polpa tomatoes are exclusive to Coles, but they are a well known Italian brand and top of their game; they have been awarded Italy's best medium-sized family business by the Harvard School of Business.
To help entice you to try the flavourful Mutti Polpa tomatoes we thought we'd bring you some delicious recipes using the product, continuing with Moroccan Lamb Shanks.
Serves 4
1 tablespoon olive oil
4 frenched lamb shanks
1 large brown onion, chopped
1 red capsicum, seeded and diced
1 medium carrot, diced
1½ tablespoons Middle Eastern spice mix
3 cloves garlic, crushed
1 tablespoon finely grated ginger
½ cup dried pitted dates
1 tablespoon honey
4 long strips lemon peel
400g can Mutti 'Polpa' Chopped Tomatoes
2 tablespoons Mutti Tomato Paste Double Concentrated
1 cup beef stock
To serve:
pearl couscous
steamed beans
1. Preheat oven to 160ºC.
2. Heat oil in a large flameproof casserole dish over a high heat. Cook lamb shanks, turning frequently until browned. Remove lamb and pour off excess oil.
3. Reduce heat to medium. Add onion, capsicum and carrot and cook for 5 minutes, stirring occasionally. Add spice mix, garlic and ginger and cook stirring for 1 minute longer. Add dates, honey, lemon peel, polpa, tomato paste and stock and stir to combine. Return lamb shanks to dish. Cover and place in oven. Cook for 2 hours.
4. Serve with Pearl couscous and beans.
Tip: Moroccan lamb shanks can also be served with rice or mashed potato or mashed sweet potato if preferred.
Beauty and Lace is an online magazine for women. We hope you enjoyed this article!


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On the Scene with Sandy Lavigne
Welcome to the incredible investment opportunity at 17 Brians Rd! This versatile income property boasts a strategically designed layout featuring a 3-unit apartment building and a charming detached house, all currently occupied and generating rental income. But that's not all envision the additional potential with five mini homes on the property that, with some TLC, could possibly be revitalized and turned into profitable rentals. Conveniently situated just off Highway 1, the property offers easy access, making it only a short 25-minute drive to the US Border and a mere 50 minutes to the vibrant city of Saint John. The location is not just a geographical advantage; it's a strategic positioning for both local and cross-border accessibility. What sets this property apart is its boundless potential for growth and income generation. With a motivated price to sell quickly, now is the perfect time to seize this golden opportunity. Whether you're an experienced investor or a first-time buyer, this property is primed for success. Don't miss out on the chance to transform this real estate gem into a lucrative venture! (id:42007)
MLS® Number | NB095322 |
Property Type | Multi-family |
Equipment Type | Water Heater |
Rental Equipment Type | Water Heater |
Exterior Finish | Vinyl |
Fireplace Present | No |
Heating Fuel | Electric |
Total Finished Area | 3464 Sqft |
Type | Fourplex |
Utility Water | Well |
Access Type | Year-round Access |
Acreage | Yes |
Sewer | Septic System |
Size Irregular | 2.74 |
Size Total | 2.74 Ac |
Size Total Text | 2.74 Ac |
Contact us for more information


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When Skyrim came out in 2011, everyone knew it was going to be big — but even within the already massive Elder Scrolls fandom, few had any idea of just how it would blow up into a long-running mainstream gaming phenomenon that spawned memes, various platform editions (including Alexa), and something like 30 million-plus copies sold worldwide.
But with fame comes fatigue and backlash, which Skyrim has also experienced in the years since. Some fans were more than done with this setting, while others were so fond of it that another chance to explore these snowy crags was a welcome invitation indeed. So when Elder Scrolls Online: Greymoor came out in 2020 — right at the start of the pandemic, even so — it was hard to tell whether there was an audience or not for Skyrim II: The Prequelling.
Nearly two years later, and I still can't answer this from where I'm sitting. At the time, Greymoor felt like it arrived without much of the splash we expected — but then again, it was a weird year all around. Since then, however, this expansion has quietly cultivated a reputation as a solid piece of entertainment with one of the absolute best systems that the game's added since launch.
Since I'm quite behind the curve, I've only recently completed my very first run through the base chapter (no Markarth — not yet). And I have thoughts to share, even if they are a couple of years late!
So as I indicated in my opening, there are many preconceptions a player can have going into this expansion. The combination of Vikings and gothic horror might be music to your ears. The Skyrim connection could be a plus or a minus. Or maybe you're like me, more of a neutral party that doesn't really have much of a connection to the single-player RPG at all and is willing to judge the expansion on its own merits.
I will admit that during the first third or so of my questing through Western Skyrim, I felt like it was all adequate if underwhelming. I'm almost always on board more for the side stories than the main questline in ESO because they tend to tell better tales, but aside from one kind of funny chain that had me bending over backwards to convince two stubborn Nords to meet for a conference, nothing really popped out at me. And when the vampire and werewolf elements started to pop up, I gave a world-weary sigh of one fantasy fan who is sick to death of these tropes.
Yet Greymoor gradually won me over. While the up-above world of Western Skyrim is fine — adequate — it was the caverns of Blackreach that made my jaws drop. I itched to explore this colorful realm that had just the right amount of tunnels and cliffs without being truly annoying to navigate. There's a whole lot to see down below, and every time that the main questline sent me there, I felt my excitement rise.
And weirdly enough, it was the main story that started to grab me (well, that and a mystery involving missing miners that you encounter early on in Blackreach). I really adore how Elder Scrolls Online latches on to a few recurring characters to help tell the story of a chapter, and here it was a threesome of the vampire Fennorian, the capable Lyris Titanborn, and the reluctant princess Svana.
It's not the most astounding story I've ever experienced, but it was sufficiently interesting enough through its twists and turns to keep me hooked. There are genuine character arcs — especially for Svana — and I think Fennorian may be one of the first vampires I've actually liked in this game. By the end, where we were literally racing ahead of an apocalyptic storm to save a city, I genuinely felt like I was reading a novel where I was also fighting to be the hero. Good stuff.
I will say that even if the story and zone aren't enough to nudge you into a purchase, the Antiquities system definitely should be. It is simply fantastic and has quickly become a favorite past time for me.
Antiquities repurposes every single zone in the game for a secondary activity, which is the discovery and unearthing of special artifacts. This is accomplished via a three-step process. The first is to "scry" for dig sites using a hexagon minigame that will narrow down potential sites to just one if you're very good. Then you have to travel to the general area and use a little doohickey to point you in the direction of a dig mound.
Finally, there's a second minigame that challenges you to find and unearth the antiquity — and some extra goodies — before your time/moves runs out. Like the first minigame, this second one can be very simplistic or fiendishly hard depending on the rarity of the item you're trying to acquire.
This is just a simplistic overview, as the system involves a lot of strategy, skill lines, and difficulty levels. But it's quite accessible and is always there as a way to take a 10-minute break from questing to get some free gold, mounts, or housing decor. Now, I always get excited when I see purple leads drop while I'm in dungeons, because I know that I'm bound to get something good in the near future.
In any case, it's such a good system in its design and execution that I have to heap on some praise here. It adds a side progression that doesn't have anything to do with combat, it's engaging in its own right, and it offers up fun rewards that make the effort feel worthwhile. It's easily the single best reason to buy Greymoor if you haven't yet.
All in all, Greymoor was a great romp, even if it didn't get the giant crowds that ZeniMax probably hoped.


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31 January 2020
The United Kingdom is leaving the European Union today
It has been 1,317 days since Britain voted for the unknown and the future is still uncertain
3 April 2018
Let's Stay Together rally dispatch
Reading about an march after the fact is never as engaging. The placards, the chanting, the keynote speakers - attending a rally is a multi-sensory experience, and we have tried to capture the best bits of it for you in audio format!
3 April 2018
BREXIT: We all need to do better
Below is a more thought through version of a speech I had intended to make at the Let's Stay Together rally held in Ipswich two weeks ago.
1 February 2018
Brexiters furious as inevitable Brexit outcomes become reality
What do you mean we can't have our cake and eat it?
5 December 2017
The road to Brexit: A dead end?
The wheels are falling off and the sat nav has packed in
1 June 2016
Staying in the EU: Better together?
The official campaign team for remain is called 'Britain Stronger in Europe', but what are they basing that on?
1 June 2016
Leaving the EU: Is it time to go?
The Brexit campaign feel Britain would be better out of the European Union. But what are the arguments for leaving?
1 June 2016
How the European Union works
It's not always clear how exactly the European Union works. This article will hopefully help to clear a lot up for you!
1 June 2016
EU Referendum
What is the EU, who is Brexit, what do Remain really want? We have articles answering all of those questions!
1 June 2016
The European Union
There is often a lot of confusion over how the European Union came into existence. Got questions? You're in the right place.


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Tepetzingo, Magdalena, Veracruz, Mexico is located close to Magdalena. The costume here is a black wrap skirt, solid colored sash of commercial material, lace trimmed blouse and a black ikat reboso. Main roads are paved Robert Freund 10/31/2007 Return to Magdalena Veracruz, Mexico Home Page firstname.lastname@example.com |
Home - The Collection - Indigenous women- Bob's Top 10 - Textile Patterns - Documented Villages - Participate The Store Other traditions Video Page Email me at: firstname.lastname@example.com
© 2006 Bob Freund All Rights Reserved |


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The food industry is constantly changing, so it is not surprising that the robotic process gained popularity in it. Modern industrial robots are used for secondary food processing steps such as control of the quality, putting labels, packaging, etc. They are easy to introduce and have lots of other benefits.
How to introduce robots as a service?
The first step towards the introduction of robots is the identification of monotonous routine operations in production. Performing repetitive tasks such as loading and unloading products, and working on a conveyor, quickly causes fatigue and stress for employees. Therefore, in these areas of production, there are problems with the quality of operations and a high turnover of personnel. It is routine tasks that a robot can perform with greater productivity than a person.
In addition, automation services provide additional benefits:
- clarity of work and the ability to control it;
- the robot can simultaneously perform operations that a person did not or could not do.
The second step is the calculation of the economic efficiency of the usage of robotics as a service companies. The cost of introducing a robot is calculated along with the payback.
The third step is a meeting with a robot developer or integrator, for example, on https://www.rios.ai/
How long will the implementation take?
The timing depends on the features of the robotic solution. If the typical option is applicable, then the robot will arrive at the factory within 1-2 months, but usually tuning is still necessary. On average, the delivery of the robot to the factory takes 2-3 months, and installation and testing take another 2-4 weeks.
By implementing robotic technologies, the food industry is getting significant benefits. Robots increase the quality of products and productivity of enterprises, reduce overhead costs, and free staff from monotonous work. Robots give a clear competitive advantage, and technology development is worth taking advantage of.


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Famous French Fries | Mc Donald and OPTP Style Chips | Aloo Ships at Street Food of Karachi Pakistan
Top reviews top searched nyc events, christmas in new york, raw food healing, holidays in china, and New York Street Food Potato, Famous French Fries | Mc Donald and OPTP Style Chips | Aloo Ships at Street Food of Karachi Pakistan.
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Cruise Food – Will I Gain Lots On Our Very First Cruise?
In fact, a mix of surf and turf dish would make your dinning experience much more cherishable.
Burgers are served at the counter and in the lounge area, in addition to a full dinner menu.
14 reasons why VIETNAM is the MEXICO of Southeast Asia
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NYC GUIDE | MIDTOWN, MANHATTAN: Your PERFECT One-Day Itinerary
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SPICY MEAT MOUNTAIN, Legendary Noodles & Thai Street Food in Bangkok Thailand Train Market
Puerto Rico Street Food Face Off | Game Changers
Famous French Fries | Mc Donald and OPTP Style Chips | Aloo Ships at Street Food of Karachi Pakistan, Play trending explained videos relevant with New York Street Food Potato.
Hosting Your Wedding In Nyc
Sick of the old Empire State Building tour and spin around Times Square? Delta Airlines, Kuwait Airways and KLM are amongst the other inexpensive flights to New York City. The diverse culture is actually assisting the nation now.
Reconstructing of the West Market of Xian has just been completed. This ancient market is located in Xian, the capital city of China's Northwest Shaanxi Province. It was established 1300 years back on a massive piece of land that stretches throughout 2 city wards. It was divided into 9 areas, all of which offered buyers with a host of items.
Another city that does not get much shut-eye is Los Angeles. This city of 3.8 million has numerous mouths to feed that it is guaranteed to have a range of 24 hour dining establishments, right? Yes, this city has plenty of them. One excellent example is Fred 62. This restaurant is known for its high quality food, enormous menu, and decent rates. Here you can get eggs with toast and hash browns for as little as $6. Being among the most varied cities on the planet, it is not a surprise that LA is likewise house to Canters: a Jewish-style deli including whatever from corned beef to matzo ball soup. East Coasters love going to Canters to get some grub that advises them of house, LA locals go there since they like excellent New York street food blog at reasonable prices.
The final stage is now total. Residential houses and workplaceshave likewise been built on part of this location which covers a total of 629,000 square meters. This area UK street foods delhi is more focused on the heritage, culture and traditions of the old Silk Roadway. Visitors are offered the possibility to peek into this duration of Chinese history that includes major developments in science, medicine and astronomy.
I've seen a squirrel sitting on a bench sharing food with 3 people. In another park a squirrel munched a walnut while presenting for an artist. The artist had a tray of walnuts; the squirrel would take one, hop 10 feet away and literally resume its position, spinning the walnut and munching the meat. In a lot of other locations the squirrels escape as soon as they have actually gotten their treasure. Robins, finches and sparrows rave their daily lives with no worry of joggers, canine walkers, toddlers, strollers, or traffic. There's an unexpected poetry to this habitat.
Nevertheless, if you are one of the tens of thousands of average consumers who are actually feeling the crunch, then you require a list of suggestions for enjoyable, low-cost travel destinations – after all, everybody deserves eggs street food Portland Oregon a holiday! This list will reveal the leading ten must-see travel locations all throughout the United States for summertime 2009. These trips will not spend a lot, yet they have a great deal of excitement to use. Who understands, you might not require to look any even more than your own proverbial garden to have a good adventure!
Green tea is a terrific drink choice for any celebration, and particularly if you are trying to pack up on anti-oxidants. Green tea has plenty of them – just one cup of green tea has 8 to 10 times the amount of anti-oxidants as one serving of veggies! If you are a coffee drinker, you may consider replacing some of your joe for this green tea – you'll still get a caffeine repair, but you'll be adding a lots of advantageous anti-oxidants to your early morning routine too.
Thus concludes my list of the top 10 must-see travel destinations for summer season 2009. Not just are they heaps of fun to visit, however these destinations are perfect for individuals who have to take a trip on a spending plan. Make sure to book all your reservations ahead of time and search for special deals and vouchers online. Likewise search around for any complimentary trips or discount rates to special events at the location of your choice. And do not stress – even in an economic crisis, you can budget plan for travel to terrific locations, and have yourself an adventure.
However it isn't so simple when you boil down to it. Make sure to book all your reservations ahead of time and search for unique deals and vouchers online. Patrick's Cathedral, and the Museum of Modern Art.
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Mar 30, 2017 AM EDT Tsinghua University revives swimming requirement for students.
Feb 06, 2017 AM EST Students and staff were evacuated after an explosive substance was accidentally created in the chemistry lab.
Feb 03, 2017 AM EST A fourth Bristol University student has committed suicide.
Feb 01, 2017 AM EST Pyongyang University of Science and Technology has asked for help from Texas A&M University regarding food security.
Jan 31, 2017 AM EST Oxford University to have its own diabetes research center.
Jan 24, 2017 AM EST Oxford University is being sued by a former student because he failed to have a first-class degree.
Jan 24, 2017 AM EST A new Lego professor of play will soon be teaching at Cambridge University.
Jan 18, 2017 AM EST The university has apologized for its failings.
Jan 17, 2017 AM EST More and more students are turning to matchmaking websites to fund their higher education.
Jan 17, 2017 AM EST The University of Maiduguri was attacked by suicide bombers.
Jan 16, 2017 AM EST Oxford University unintentionally reveals list of rejected applicants.
Jan 16, 2017 AM EST Iraqi forces have taken over Mosul University and another area near the Tigris river.
Jan 14, 2017 AM EST Unknown chemical substances killed a Bournemouth University student.
Jan 12, 2017 PM EST Brexit is expected to have a negative impact on the higher education sector.
Jan 09, 2017 AM EST Students at the University of London's School of Oriental and African Studies (SOAS) want white philosophers to be removed from curriculum for diversity purposes.


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Introduction to the Matter
Australia is considered one of only some nations with the capabilities to design automobiles from scratch and manufacture in vital volumes. Automobile gross sales in Australia are additionally an vital issue of the Australian Automotive Business and the Australian Financial system in complete.
The Australian Auto Business (A.A.I. in brief) may be divided into two interrelated sectors, the Manufacturing ( Manufacturing) sector and the Automobile Gross sales (or Import-Gross sales) sector, each equally vital for the full efficiency of the A.A.I. On one hand, the Manufacturing sector refers back to the market circumstances underneath which Australian Manufacturing companies compete, by producing automobiles and associated merchandise, with the primary intention of maximizing income. However, the Gross sales sector refers back to the market circumstances underneath which automobile consultant sale companies compete, by the sale of automobiles and associated merchandise, having the identical intention with companies inside sector one.
It is extremely vital to state the excellence between these two sectors throughout the A.A.I., as we will probably be speaking about two totally different market buildings, enterprise methods, competitors circumstances, e.t.c. So as to analyse these market buildings it will be applicable to develop two financial fashions, one for every A.A.I. sector.
1.1-Analyzing the Manufacturing Sector
There is just one market construction that may greatest describe the market circumstances within the Manufacturing sector if A.A.I., that is Oligopoly. As there are solely two organizations that produce automobiles in Australia, and these are Ford and Holden, the competitors strategies and pricing methods are based mostly between these two organizations. The next financial mannequin shall assist outline the competitors and financial circumstances for the Australian Automotive Manufacturing market.
The primary vital attribute of Oligopoly that must be acknowledged is that costs between rivals are typically "sticky", which implies that they alter much less steadily than another market construction. This assertion will probably be defined in additional element afterward, once we will probably be growing the Recreation-Idea mannequin, as it's a crucial idea of competitors. The second most vital attribute is that when costs do change, corporations are prone to change their pricing insurance policies collectively. These two traits can increase up competitors throughout the market. Corporations will both attempt to match rivals' value modifications or ignore them. That is relied on the Recreation-Idea that's defined bellow.
Nonetheless, the latest market circumstances for the Australian Automotive Business and the actions of the Australian Authorities have worsen the competitors circumstances and doable pricing choices out there for corporations out there. The manufacturing and upkeep prices for a producing enterprise in Australia are already excessive and rising, principally attributable to lack of financial sources and advance of expertise. That's, as Holden and Ford attempt to compete one another, provided that costs are typically "sticky", they're pressured to give attention to technological benefit and advertising. Each of those enterprise sectors produce excessive prices. Moreover, the Australian authorities has made it clear that's unwilling to additional subsidize automotive organizations out there. All these components acknowledged above produce a detrimental impact on the competitiveness of each corporations. In different phrases, rising prices alongside with decreased income push corporations in experiencing decrease and lowering ranges of profitability.
Profitability and the extent of competitiveness are extremely interrelated in an oligopolistic market construction, being the 2 most vital components, alongside with product differentiation, within the competitors insurance policies that the corporations observe. After we say that the extent of competitiveness of a agency may be very low, we imply that the agency can not react successfully to any value modifications or competitors modifications and even modifications in manufacturing prices. This will likely go away the agency relied on its' competitor's pricing and competitors actions, not having the ability to have an effect on the market competitiveness in any respect. The agency is then uncovered to exterior hazard and may be pushed out of the market, and even worse to close manufacturing and declare bankrupt.
1.2- The Recreation-Idea Mannequin for Oligopoly
The Recreation Idea mannequin is used to clarify the pricing and competitors insurance policies of corporations in an oligopolistic market construction. Moreover, it might present the few totally different competitors insurance policies based mostly on pricing that the 2 corporations can observe, that's Excessive and Low as acknowledged above. All corporations on this market construction observe a Recreation-Idea mannequin, though it's absolutely extra detailed than our instance, within the strategy of attempting to forecast rivals' pricing and competitors actions and in addition hold monitor of the competitors ranges out there and market share. However how does this occur?
For instance, as an example that there are 4 totally different fields, every divided in half. These fields characterize the pricing methods that Holden and Ford could use within the strategy of competing one another. Subject A and C characterize a Excessive-Pricing coverage for Holden, whereas fields A and B characterize a Excessive-Pricing coverage for Ford. Lastly, fields B and D characterize a Low-Pricing coverage for Holden, whereas fields C and D characterize a Low-Pricing coverage for Ford. When each corporations resolve to observe a Excessive-Pricing coverage they share a revenue of, as an example, $12 million. If Holden determined to maneuver to a Low-Pricing coverage it should expertise a most of $15 million revenue, whereas Ford's profitability will fall to $6 million. The precise reverse might also happen, whereas if each corporations determined to observe a Low-Pricing coverage they'd understand a most of $eight million of revenue.
What we will determine from the above instance is that corporations in an oligopolistic aggressive market not often change their pricing insurance policies as a result of this may increasingly produce a detrimental impact on their profitability ranges. Nonetheless, Holden and Ford, being the one two corporations within the Australian Automotive Business, they'll give attention to competing by way of product differentiation and advertising. That's, they'll attempt to compete by differentiating their merchandise, for instance by producing automobiles with totally different options, and even base their manufacturing on technological benefit. Advertising performs an vital function right here, as it's the fundamental device that delivers and connects the client with product. For instance, if Holden introduces a brand new driving expertise that improves driving expertise and security and produces this expertise alongside with a newly designed car, it's fairly doubtless that Holden will successfully differentiate its newly designed car from a relative car of Ford and lure extra prospects within the retailer. Holden might also use advertising methods to ship this expertise to the general public, within the type of data; therefore attempt to increase gross sales with out altering its pricing coverage. Nonetheless, you will need to state that this new expertise could produce larger manufacturing prices, if not evaluated correctly; therefore Holden can solely rely in rising its market share to realize better profitability. The gross sales half, nonetheless, will probably be analyzed in additional prolong throughout the subsequent chapter of this report.
The Recreation-Idea is not only a principle for the Automotive Business in Australia, it is a reality. It exhibits us that auto producers in Australia have based mostly their competitors methods on all of the components acknowledged above and as a lot as they probably can on pricing methods. They might promote that they've low costs, however in truth their costs are very steady. If now we have an in depth have a look at Holden's or Ford's web sites, we are going to determine that there's a enormous number of merchandise and every agency competes in that. Nonetheless, the brand new market circumstances acknowledged earlier than have enormously modified the way in which auto producers consider the long run and this in flip could change their pricing and competitors insurance policies, and even decide their existence out there.
2.1- Analyzing the Import/Gross sales Sector
Whereas the auto producers are thought-about to be working in an oligopolistic market construction, importing and promoting automobiles or relative merchandise is a unique story. The import and sale of automobiles is the second and equally vital enterprise sector of the Australian Automotive Business. There are numerous totally different automobile promoting companies and we will solely contemplate first-hand gross sales, as second-hand gross sales on the whole should not included in economics and extra particularly in GDP measurements. To enter the trade onerous in any respect as there should not many limitations to entry, nonetheless somebody who's wants to contemplate of the excessive prices in organising an automotive dealership. All companies on this market are principally based mostly on product differentiation to compete and whereas costs should not "sticky", pricing competitors is about up by the market mechanism and tends to not be thought-about an everyday phenomenon. Lastly, value evaluation and value administration play an important function. All the above traits check with the Monopolistic Competitors Market Construction. On this market construction we are going to give attention to two phases, the short-run part and the long-run part, every with totally different competitors traits and outcomes.
An vital issue that we have to state right here is that when the prices of growing a car within the manufacturing sector rise, then the associated fee for promoting the car for a dealership could rise as properly. That is at all times depended after all on if the car was produced in Australia and if it was produced abroad, underneath what financial circumstances was it produced. Worth could be "sticky" for producers, nonetheless costs will change a lot simpler on this sector if wants be. Right here corporations will change their pricing insurance policies if prices both rise or fall and that is at all times depended available on the market mechanism. The quantity of competitiveness together with the quantity of value elasticity of demand will rely upon what number of rivals the monopolistic aggressive agency must face.
In such market the next state of affairs is quite common, a state of affairs that helps us distinct between short-run and long-run:
Stage One
On this stage the agency experiences financial income. Nonetheless, this reality will draw new corporations out there inflicting the income to be competed away.
Stage Two
The financial losses indicated on this stage will trigger many corporations to exit the market, as they can not hold promoting underneath these market circumstances.
Stage Three
Within the closing stage, the market clears-up, or reaches equilibrium level. As all corporations that wanted to exit the market have executed so, the market mechanism involves the purpose the place no financial income/losses are realized by the corporations. That is the purpose the place the market is most steady.
Finding out the state of affairs above we will determine one crucial reality for any monopolistic aggressive agency within the Australian Automotive Business/ Gross sales sector. That's that on this market construction, in the long term, corporations will understand solely regular income and the market mechanism will finally attain an equilibrium level. Therefore, within the long-run corporations will compete principally by way of product differentiation. Nonetheless, within the brief run corporations could expertise financial income or losses and that is what causes corporations to enter or exit the market and "exhibits" corporations the way to compete and when to use pricing competitors insurance policies.
The Australian Automotive Business could also be experiencing tough market circumstances, principally as a result of there is no such thing as a extra authorities assist; nonetheless competitors and revenue maximization remains to be doable. Pondering of shifting abroad isn't at all times a superb possibility for the manufacturing companies, because the Australian Financial system wants the manufacturing sector, because it represents a fairly large a part of GDP.
Market competitors circumstances are properly outlined for each producer or automobile dealership, therefore any enterprise out there ought to make use of the out there to them competitors methods and obtain larger market share and profitability stage or stabilize its profitability ranges. Both manner, these are the primary targets for nearly each profit-motivated enterprise in any market kind underneath any market construction. Nonetheless, each enterprise must outline the market construction that's working in, in order that it might then clearly outline its targets, methods and insurance policies. The market mechanism is in all circumstances accountable for all of the above methods and a lot of the circumstances accountable for organising pricing insurance policies or indicating pricing and advertising methods.


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1 استاد دانشگاه تهران
2 دانشجوی دکترای دانشگاه اصفهان
عنوان مقاله [English]
There are quite number of researches in the area of convergence either at countries level or at the regions. Among them there has been limited number of researches for the MENA region. In this paper we are using the Nahar and Inder's (2002) technique in order to test the convergence of the nonstationary process for the MENA countries for the 1975-2002 periods.
This has been done to investigate the possibility of convergence of these countries to the leader country -Japan – and the reduction of the income gap between these countries and Japan.
In our analysis there has been special attention to Iran and the path taken so far.
کلیدواژهها [English]


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Regional Consultant
Albuquerque, NM
Thomas Pennington joined YOUNG & Associates in 2021. Thomas has worked in retail residential and commercial roofing as a project manager, job estimator, sales, and commercial division vice president. Thomas holds a HAAG certification for commercial roofing, International Institute of Building Enclosure Consultants member, NRCA Member as well as OSHA 10 certification. Thomas has, also, completed manufacture training programs in low slope and steep slope from Carlisle, Owens Corning, GAF, Ludowici, and Sika Sarnafil.


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During New Mexico's 2011 legislative session, a tiny controversy erupted in the two press galleries overlooking the House and Senate chambers.
"The Governor's videographer in the pressroom. Paid for by your tax dollars," Albuquerque political strategist Keegan King tweeted on March 3.
In, fact, there were two—both employees from the Governor's Office, both taking footage that often highlighted partisan differences and was later posted on the governor's website.
"We've never had a governor do that," House Speaker Ben Luján says. "The best way to try to accomplish things and govern is to reach out and try to have compromises, not to put in wedge issues or…try to use scare tactics."
The state's Sunshine Portal, which is required to regularly update salary information for all state employees by this July (and will add public school district budget data by July 2012) hasn't been updated since Gov. Susana Martinez first took office in January. SFR requested a list of Martinez' employees under the state's Inspection of Public Records Act.
Of the 24 employees hired by or transferred into the governor's office this January, only four make less than $50,000 per year, including the two videographers, Morgan Nelson and Maralyn Beck, paid $42,000 and $43,000, respectively.
The average annual salary for an employee hired for the Governor's Office this January is $70,916.67. Click here for the full breakdown.
Santa Fe Reporter


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Wedding Folder Sample
Client: Citywest Hotel, Dublin, Ireland.
Project: Wedding Brochure, Design and Print.
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Concept, design and finished artwork for a promotional wedding folder. The folder had generic wedding offerings but the detailed information comes on preprinted backing A4 paper that fits in with the over all branding of the wedding offering.
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For more information on how we can help your company create great brochures and other marketing tools to help you sell your product, service or message call us on 01 4508057 or email firstname.lastname@example.com.
» Back to the Brochure Portfolio


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12 Month Loans Guide
There was a sign in the pub window which said: 'Free pint of beer tomorrow'. Sounds too good to be true, doesn't it?
And so it is. Because, as the old saying has it, tomorrow never comes.
It's the same when a cash-flow problem causes you to put off buying something that you've had your eye on. You keep putting it off until another day – when you can afford it.
But why wait? Ever thought about taking out a 12-month loan? Never heard of it?
Then it looks as though you will soon be in the minority, because 12 month pay-day loans are becoming more and more popular with the general public. It's a great way to get your hands on some instant cash, which has to be paid back, as the loan title suggests, within a 12-month period.
So, that little something that you think you can't afford just at the minute, is now wonderfully affordable.
12 month pay-day loans are the ideal loan option for you as a salaried person requiring some quickly available cash, usually for up to $3,000, with a relatively longer paying back period of up to one year. What a tonic! Just what the doctor ordered!
On the other hand, it may be that you have a poor credit rating and are desperately searching to secure a loan because you have been turned down by the high street banks and building societies. Then look no further. A 12-month loan could be a lifesaver for you. It will be offered to you without the need for a credit check. Your history is not taken into account. The slate is wiped clean. As far as most 12-month loan providers are concerned it matters not one jot whether or not your credit history involved IVAs, CCJs, defaults or bankruptcy.
So, if you are faced with a sticky situation, here is the answer. Twelve month pay-day loans are tailor-made for you, with their generous payback period of twelve months making them a particularly popular option. A loan like this could see you apply for the required amount of money and be accepted within a matter of minutes, with no questions asked.
12-month loans have the additional advantage of being available in small amounts. Your need is for just a bit of cash to help with an unexpected situation - and that is exactly what you will receive.
It may be that your car has broken down and you don't have the ready cash to pay for it being repaired. Yet you need your car to get around. You simply could not cope without your personal mode of transport. Just getting to work would be a huge problem.
But don't panic. Simply take out a 12-month loan. How?
Go on-line and you will find plenty of companies willing to help. Check them out. The process to apply is free from any kind of paperwork, as all you are required to do is fill in and submit an on-line form with your personal details. The funds are made available to you in the least possible time, either straight into your account or in the form of a cheque. No fuss. No hassle.
It has never been so easy to get the cash you need for today quickly and conveniently from the comfort and convenience of your own home. No need to travel or take time off from work. Just think, a five-minute application and your immediate troubles are over. Now you have 12 months –- to repay at your own agreed pace.
Just compare the sites for the best deal that suits your needs and budget without having to go through any of those tiresome credit check formalities. You will find that by applying for a 12-month loan no hard credit check you will be able to obtain between $100 and possibly $3,000 over that 12-month period according to your needs and pay-back ability. And remember, you can use the money to meet any short-term need. No restrictions.
It may be, as in your case, to pay a car repair bill, but the money can also be used to pay off other overdue debts, pay household and utility bills, pay to repair the washing machine – whatever you need at the time. So what are you waiting for?


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New show: OH NO I'M A VENDING MACHINE in another world – ep 01
OOPS last week on ep number
Nier Automata: readding show, as final eps were released. ep 09
Oshi no Ko – ep 09
Golden Kamuy S4 – ep 48
Heavenly Delusion – ep 13 S1 Finale
Jojo's Part6 – Star Ocean – ep 35
EVAC and AJAS have moved to the Hartley (Music) Building due to the renovations at the Union building.
MAP here https://www.adelaide.edu.au/campuses/north-terrace


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Use the best cheats site for One Clue Crossword. Our guide includes word solutions, and a screenshot of the final puzzle grid with all the answers and solutions. Last Updated on September 13 with 46 Chapters.
Feb 28, 2020 · Interests: Cowboy Action Shooting, Old West History, Crossword Puzzles, Music, Butterfly Garden. Mostly spending time with my lovely bride and our two (2) Cocker Spaniels. SASS# 103314; Lake County Pistoleros
Jun 25, 2017· This time we are looking on the crossword puzzle clue for: Granite excavation site. it's A 23 letters crossword definition. Next time when searching the web for a clue, try using the search term "Granite excavation site crossword" or "Granite excavation site crossword clue" when searching for help with your puzzles.
Some crossword puzzles I've filled out recently refers to this as a one and I thought that's what I've heard it called too. When people say you got any ones these days, they're less popular because it takes too many of them. to do just about anything.
The Crossword Solver found 20 answers to the granite source crossword clue. The Crossword Solver finds answers to Americanstyle crosswords, Britishstyle crosswords, general knowledge crosswords and cryptic crossword puzzles. Enter the answer length or the answer pattern to get better results. Click the answer to find similar crossword clues.
Jul 10, 2020 · Base camp: We made our base camp at Granite Meadow for the next 3 nights. The campsite includes a primitive outhouse (useable) and a simple table (no benches). Day 4: Day hike up the Granite Creek Trail. Hiked about 4 miles (one way) to an area with unimproved roads and mine tailings from 1890's gold mining in the area.
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Danger in a uranium mine crossword clue? Find the answer to the crossword clue Danger in a uranium mine. 1 answer to this clue. ... (especially in areas over granite) and is considered a hazard to health ; Other crossword clues with similar answers to 'Danger in a uranium mine' Artist and lecturer are a gas ... » Crossword Puzzles » Contact ...
May 28, 2019 · The RuralUrban Divide Is More Complied Than You Think. Bob Strong / Reuters. Here are a few stories I found intriguing from the past week's .
The Crossword Solver found 20 answers to the Granite mine crossword clue. The Crossword Solver finds answers to Americanstyle crosswords, Britishstyle crosswords, general knowledge crosswords and cryptic crossword puzzles. Enter the answer length or the answer pattern to get better results. Click the answer to find similar crossword clues.
Sep 25, 2016 · It happens without any aid of mine, pretty often.' John Baptist having smoked his cigarette down to his fingers' ends, Monsieur Rigaud had the magnanimity to throw him another. He lighted the second at the ashes of the first, and smoked on, looking sideways at his companion, who, preoccupied with his own case, hardly looked at him.
Jan 13, 2021 · 4. Mask wearing and practicing social distancing are the lowest cost options for preventing COVID. iStock. Researchers found that the combination of mandatory mask use and social distancing could be done at a moderate cost. According to the study's model, the two measures would result in an associated cost of 170 per averted infection.
Utah is home to 5 National Parks Arches, Canyonlands, Capitol Reef, Bryce Canyon and Zion. Get information you need to plan your trip including information about hotels (including deals and packages), restaurants and things to do. Millions come each year to admire the sensational scenery.
All Geodes Are Not Created Equal The first one is quite hollow but for a nice layer of mediumsized blue crystals. These dugway geodes have bands of blue and pink. The geode at the left and the one at the top of the page are both dugways from Utah. The colors come from the different minerals that flowed through the bubble so many millions of years ago.
Jul 28, 2021 · There are two main strategies for getting crossword puzzle help: enter in the clue and have our crosswordtracker grab answers, or try out our wordsolver to find the specific word by the letters you have and size of the space you need to fill in. Search Crossword Clues and Find Answers.
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Get a Clue! Welcome to OneAcross! According to Will Shortz, editor of the New York Times crossword puzzle, perhaps as many as 50 million people do crosswords just in this is your first puzzle ever or your fourth today, if you get stuck, OneAcross can help. Enjoy and good luck!


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As my buddy Sam said, it is always interesting to see what Rich finds interesting and watch him burrow down…well, continuing that tradition, we were in "Back to School" mode and someone asked, what's the best pen? Can't help but use Google to answer and found some wonderful sites like Penaddict to help. We were in Office Max, but still found one to try, but can't help but see what (mainly) the Japanese have been up to. here are some notes:
Top 5 Pens – Overall
- Pilot Vanishing Point – Fountain pen goodness in a sleek, portable package. [This has amazing reviews on Amazon too as a vanishing point nib with these amazing refills. He likes the black matte with a fine nib for $140 at Amazon and these use the Pilot Namiki Ink Refill cartridges which are $8 from Amazon]
- Pilot Hi-Tec-C – My go-to micro tip gel ink pen. [He likes the 0.3 Grip Black. Jetpens seems to be the site to get Japanese imports and Amazon has a 10 pen gift set for $30)
- Sakura Pigma Micron – My favorite drawing-type pen. Archival ink is a huge plus. [Just $1.50 each as a t-pack from Amazon]
- Ohto Graphic Liner – A very pleasant surprise.
- Uni-Ball Jetstream – One of the best ever still in heavy use.
Top 5 Pens In The Store
- Uni-ball Signo 207 – "But what can I buy at Staples that is good?" This. [This is the one we got, can't wait to try it!]
- Uni-ball Jetstream – Stay away from the 1.0 mm.
- Sharpie Pen – Would be #1 if it was more durable.
- Pentel EnerGel – People swear by their EnerGels.
- Pilot Precise – The only liquid ink pen to consider.
Top 5 Paper Products
- Doane Paper Idea Journal – Beautiful, durable, and portable. [These look so amazing direct from Doane, $50 gives you free shipping]
- Rhodia Dot Pad – My favorite fountain pen paper. [ $5.50 from Amazon]
- Maruman Mnemosyne Inspiration – As good as Rhodia and more portable, but costs more.
- Field Notes Memo Books – Love the seasonal releases.
- Doane Paper Utility Notebook – More fountain pen friendly than Field Notes.
Top 5 Pen & Pencil Cases
- Nomadic PD-04 Roller – My all day, every day pen case. [Not available anymore which is too bad]
- Doane Paper Leather 4 Barrel Holster – If it's not in the PD-04 it's in here.
- Alter Manufacturing Mod.02 – Durability at its finest.
- Nomadic PE-10 Tri-Fold – Love this case for extra storage.
- Kokuyo NeoCritz Transformer – Perfect for students or cube jockeys.
Top 5 Extreme Weather Pens
- Tombow Airpress – My pressurized refill pen of choice. [Pretty amazingly cool for $10 from Amazon]
- Uni-ball Power Tank – Writes great, could use a more durable barrel.
- Fisher Space Pen – The classic, but not the best writer.
- Tombow Airpress Apro – Smaller, slimmer sibling of the Airpress.
- Pilot Down Force – Solid clip and barrel, average writer.


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Product Details
Sometimes recovering from a hand or wrist surgery may entail some added assistance, depending on the procedure. InstantRecoveryMD had created a new compression short wrist guard for men and women who need some extra pressure around their wrist area. Simply slip these partial gloves on and instantly feel the extra reinforcement you need. These single layer compression wrist guards will provide comfort and support during all your daily activities while your body is still recovering from whatever type of hand/arm surgery.
These doctor recommended pieces may also help prevent discomfort due to repetitive motion or over exertion even if a surgical procedure never occurred. Sometimes you just need some extra support around your wrists for whatever extracurricular activities you might be a part of during the week.
This fabulous item is invisible under even your tightest of long sleeve fashions, so you can hide them if need be. Post-surgery or not, these wrist bands are an essential wardrobe must have for the men and women who are always active or are needing that extra compression stability assistance. Comfortable enough to wear during work or play, night, or day, from the office to the gym to a night out on the town.
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Size Chart
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InstantFigure and InstantFigure sister brands (IFPRO USA, LaMonir, InstantRecoveryMD, Insta Slim, ISPRO USA, ISPRO Tactical & InstantBeauty) are committed to bringing you the most value for your money. If for any reason you need to return or exchange your purchase please fill out and return your packing slip to the address listed below. We can exchange or refund your purchase as long as it is returned within 30 days of receipt in new/unused condition (shipping/handling non-refundable). Please allow 1-2 weeks for processing.
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Eater LA has learned that chefs Jon Shook and Vinny Dotolo will close their seminal restaurant Animal on Saturday, June 17 after 15 years of operation. The Fairfax Avenue stalwart debuted in June 2008 and soon received local and national attention for its bold cooking and even bolder chef personalities. Known as the Two Dudes, Shook and Dotolo grew Animal's following with a menu chock-full of rich cuts of pork belly, under-appreciated offals, and plenty of then-legal foie gras.
"After 15 years we have decided to close Animal. Our last day of service will be the 17th of June. A huge heartfelt thank you to all of the farmers, artisans, purveyors, team members past and present, guest chefs, the diners who came to support us and to all of our friends and families. We had fun, made great memories and will cherish it forever," said Shook and Dotolo in a joint statement sent to Eater.
Animal took the city by storm with its no-holds-barred approach to food, and demand quickly ballooned for dishes like foie gras loco moco, crispy pigs ears, and a bacon chocolate crunch bar. This style of cooking grew to prominence in places like Montreal at Au Pied de Cochon and Joe Beef, and in London at Fergus Hendersons's iconic St. John, but was a novelty at the time on this particular stretch in the Fairfax District.
While then-LA Weekly restaurant critic Jonathan Gold mostly embraced Shook and Dotolo's drippy, over-the-top "Boy Food," former Los Angeles Times restaurant critic S. Irene Virbila sniffed at its approach ("Hide the salt and the sugar … and maybe — just a thought — cut back on the bacon") and former New York Times restaurant critic Frank Bruni wasn't completely sold ("Animal isn't a great restaurant, or at least it wasn't when I tried it"). Shook and Dotolo received best new chef honors from Food & Wine magazine in 2009. Despite the mixed critical reception, Animal came to define an important moment in the late aughts LA dining scene.
Shook and Dotolo, who met at culinary school in Fort Lauderdale in the late '90s, initially rose to fame with a Food Network show called "Two Dudes Catering" and the cookbook Two Dudes, One Pan. In 2004, the two chefs launched a successful local catering company called Carmelized Productions. The chefs continue to operate Son of a Gun on West 3rd Street, Jon & Vinny's (multiple locations), Helen's Wines (multiple locations), and Cookbook Market in Echo Park and Highland Park.


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More Information
Submitted: December 05, 2022 | Approved: December 22, 2022 | Published: December 23, 2022
How to cite this article: Cheikhrouhou T, Dhaou MB, Elleuch A, Hbaieb M, Zouari M, et al. The thoracoscopic approach in the management of parapneumonic pleural effusion in children. J Pulmonol Respir Res. 2022; 6: 025-029.
DOI: 10.29328/journal.jprr.1001041
Copyright License: © 2022 Cheikhrouhou T, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Keywords: Parapneumonic pleural effusion; Empyema; Thoracoscopy; Children
Abbreviations: VATS: Video-Assisted Thoracoscopic Surgery; US: Ultrasound; CT: Computed Tomography
The thoracoscopic approach in the management of parapneumonic pleural effusion in children
Taycir Cheikhrouhou1,3*, Mahdi Ben Dhaou1,3, Amal Elleuch2,3, Manar Hbaieb1,3, Mohamed Zouari1,3, Mahfoudh Abdelmajid2,3 and Riadh Mhiri1,3
1Department of Pediatric Surgery, Hedi Chaker Hospital, University of Sfax, Sfax, Tunisia
2Department of Pediatrics, Habib Bourguiba Hospital, University of Sfax, Sfax, Tunisia
3University of Medicine of Sfax, University of Sfax, Sfax, Tunisia
*Address for Correspondence: Taycir Cheikhrouhou, Department of Pediatric Surgery, Hedi Chaker Hospital, University of Sfax, Sfax, Tunisia, Email: email@example.com
Background: Parapneumonic pleural effusion is a relatively common entity and continues to be a major cause of morbidity in children. However, managing this disease is still a matter of controversy between surgical and non-surgical options. With the advancement of mini-invasive surgery, video-assisted thoracoscopic surgery (VATS) has become a mainstay in the treatment of parapneumonic effusion in children. This study aimed to evaluate the clinical characteristics and pathological features of parapneumonic pleural effusion in children and to explore the feasibility and safety of the thoracoscopic approach in the pediatric population.
Methods: The clinical data of all patients who underwent VATS for parapneumonic effusion between 2007 and 2021 were analyzed retrospectively. Factors that were documented included demographic criteria, clinical manifestations, preoperative examinations, therapeutic procedures, intraoperative findings, postoperative complications, and outcomes.
Results: Totally, 35 patients with a mean age of 5.14 ± 3.9 years were operated on thoracoscopically. The mean duration of evolution before VATS was 9 days ± 4. All children were hospitalized in a Pediatric Continuing Care Unit. Antibiotic therapy was administrated in combination in all cases. Corticosteroid therapy was used in 2 patients. Thoracentesis was performed in 6 patients. Thoracostomy tube drainage was placed before surgery in 11 patients. The average duration of drainage before VATS was 6 days ± 4. VATS decortication and/or debridement was indicated as second-line in 23 patients. The average duration of the surgery was 51 minutes (20 min - 115 min). There is no conversion to open surgery and no intraoperative procedure-dependent complication. 4 children have early complications after the VATS and one patient had a late postoperative complication. There were no deaths during the hospital stay or follow-up.
Conclusion: In skilled hands, VATS is safe, feasible, and effective in the management of parapneumonic pleural effusion in children with excellent outcomes.
Parapneumonic effusion is defined as pleural effusion associated with lung infection [1-4]. These effusions result from the spread of inflammation and infection to the pleura. The pleura becomes inflamed early in the course of parapneumonic effusion, and subsequent leakage of proteins, fluid, and leukocytes into the pleural space forms the effusion. The pleural effusion is usually sterile and has a low leukocyte count when it forms. Bacteria infiltrate the fluid over time, resulting in empyema, which is defined as the presence of grossly purulent fluid in the pleural cavity [5]. It is associated with significant morbidity, including prolonged hospitalization and frequent, and sometimes repeated, invasive acts [5-7]. Treatment is still a matter of controversy between surgical and non-surgical options [2,3,6,8]. Therapeutic options include antibiotics, thoracentesis, thoracostomy tube drainage, fibrinolysis, video-assisted thoracoscopic surgery (VATS), and thoracotomy [2].
With the advancement of mini-invasive surgery, VATS has become a mainstay in the treatment of parapneumonic effusion in children, shortening hospitalization and decreasing the need for more invasive surgery. The timing of the thoracoscopy is critical [9]. However, few studies have evaluated the safety and feasibility of the thoracoscopic approach in the management of parapneumonic pleural effusion in children [2].
We aimed to present our experiences with parapneumonic effusion management in children and to evaluate the feasibility, safety and radicality of the thoracoscopic approach.
We conducted a retrospective study of the charts of all patients who underwent VATS for parapneumonic effusion between 2007 and 2021. Patients with the obvious non-infectious cause or insufficient data in the hospital chart or lost during follow-up were excluded from the analysis. Ethical consent was obtained from the local board.
Any patient between the ages of 0 and 15 with evidence of community-acquired bacterial pneumonia and an associated parapneumonic effusion was eligible to enroll in the study.
Qualification for thoracoscopic intervention was performed in the pediatric-surgical team based on the history, clinical symptoms, and imaging tests according to the established pattern.
The technique of the procedure: The thoracoscopy procedure was performed under general anesthesia with endotracheal intubation with a single lumen endotracheal tube. The patient was placed in a lateral decubitus position with pronounced intercostal space (Figure 1).
Figure 1: Patient position, crew and equipment.
The place of insertion of the first 5 mm or 10 mm optical trocar was at the point of intersection of the middle axillary line and the fifth or sixth intercostal space. The 5 mm working trocars (one or two) were located under visual control and depending on the anatomical conditions prevailing in the inflamed pleural cavity.
In all patients, the bacteriological examination was collected, pleural biopsies were performed and then we performed pneumolysis or pleurolysis, a toilet of the pleural cavity with physiological serum, and finally double drainage of the pleural cavity (the first drain in the posterior and upper direction and the second drain in the basal direction).
We recorded the data of demographic characteristics, clinical manifestations, details of preoperative examination, the therapeutic procedure performed, intraoperative findings, short-term and midterm complications, and outcomes. The follow-up period ranged from 6 months to 9 years.
All data were processed using descriptive statistical procedures for calculating means, frequencies, and percentages.
General clinical data
A total of 35 patients (15 boys and 20 girls, sex-ratio = 0.75) were identified with parapneumonic effusions and treated by VATS, between 2007 and 2021 at the department of pediatric surgery at Hedi Chaker Hospital. The patient's age ranged from 6 months to 14 years (mean 5.14 ± 3.9 years). Among them, 54.3% of VATSs were made in winter (28.6% in February). A history of infectious pneumonitis was found in 40% of cases. The mean duration of evolution before VATS was 9 days ± 4 (4 to 21 days). All children had a fever, and 14 of them (40% of the cases) persisted for more than a week. Respiratory signs were found in 40% of the cases. At physical examination, all children exhibited abolition of vesicular murmuring on the effusion side and alteration of the general condition in 71.5% of the cases.
Preoperative complementary investigation
The results of blood investigations showed a persistent inflammatory biological syndrome in all patients. All children had chest radiographs performed and all were abnormal: 22 children (62.9%) had right-sided involvement (Figure 2).
Figure 2: Chest X-ray showing right pleural effusion.
Chest ultrasound (US) was performed in all children and showed a hemi-circumferential effusion in 3 cases (8.7%), thickness between 2 cm and 5 cm in 17 cases (48.6%), and signs of gravity: pneumothorax in 5 cases (14.3%), mediastinal deviation in 6 cases (17.1%), pleural partitioning in 30 cases (85.7%) and pleural abscesses in 2 cases (5.8%). (Figure 3).
Figure 3: Chest ultrasound showing the volume of effusion.
Computed tomography (CT) was performed in 22 patients (62.9%). The results of CT exploration are summarized in Table 1.
Initial therapeutic treatment before VATS
All children were hospitalized in a Pediatric Continuing Care Unit, Oxygen therapy was performed in 30 cases (85.7%) and only 2 patients (5.8%) had respiratory assistance. Antibiotic therapy was administrated in combination (mean duration = 6 days ± 3.4) in all patients. Corticosteroid therapy was used in 2 patients (5.8%). Thoracentesis was performed in 6 patients (17.1%). Thoracostomy tube drainage was placed before surgery in 11 patients (31.4%) with six positive cultures (4 streptococcus Pneumoniae, 1 staphylococcus aureus, and 1 streptococcus constellatus). The average duration of drainage before VATS was 6 days ± 4. All the children had respiratory physiotherapy but no children received intrapleural fibrinolysis before VATS.
Of the 35 patients, VATS decortication and/or debridement was indicated as second-line in 23 patients (65.7%). Indications were summarized in Table 2.
Intraoperative findings
Intraoperatively, the severity of the empyema, the accumulation of fibrinous aggregates forming the pleural empyema, and the coexistence of pulmonary abscesses, parenchymal necrosis, or pyothorax, were assessed (Table 3).
The average duration of the surgery was 51 minutes (20 min - 115 min). There is no conversion to open surgery and no intraoperative procedure-dependent complication. Extubation was performed immediately after surgery for 24 patients (68.6%) with an average duration of intubation of one day ± 2.5. Respiratory improvement was in less than two days in 25 patients (71.4%) with an average duration of 2.4 days ± 2.4. The mean duration of the febrile state was 1.8 days ± 1.2. A biological improvement was at least on the third day after thoracoscopy in 27 patients (77.1%). Radiological improvement was observed in 24 cases (68.6%) with an average duration of 3.6 ± 4.3 days.
Otherwise, antibiotic therapy was given with an average duration of 10 days ± 4.2 (4-21 days). Corticosteroid therapy was administrated to 14 patients (40%) with an average duration of 24.5 days ± 18.8. Fibrinolysis was used in 8.6% of cases. The mean time of drainage of the pleural cavity after the procedure was 4.2 days ± 4.6 for the first drain and 5.6 days ± 4.4 for the second one. The mean length of hospital stay after the thoracoscopic procedure was 12 days ± 7.8 and there is no recurrence.
4 children have early complications after the VATS, namely, laryngotracheal injury (N = 1), pneumothorax (N = 1), pneumomediastinum associated with pneumothorax (N = 1), and hemothorax (N = 1). One patient had a late postoperative complication: he presented a pneumothorax two weeks after the removal of the two chest drains. There were no deaths during the hospital stay or follow-up.
Parapneumonic pleural effusion is the most frequent complication of bacterial pneumonia in childhood. In some series, up to 30% – 40% of pneumonia requiring hospitalization are complicated by pleural effusion, and 0.6% – 2% progress to empyema [10]. Empyema evolves in three stages: stage 1 is the "exudative" phase with thin and free-flowing, purulent fluid; stage 2 is the "fibrinopurulent" stage with a thickening of the pleural exudate and formation of loculations; stage 3 is the "organized " stage with fibrosis and scar formation. The incidence of parapneumonic effusion in the pediatric population is increasing worldwide [11]. The reasons for this significant increase are unknown, but possibilities include the increase in bacterial resistance, climatic changes, the introduction of the pneumococcal vaccine, and the prescription of antibiotics from primary care [12].
In our series, we observed a median age of 5.14 years and a slightly higher incidence in females, results similar to those described in the literature [2,13]. This study found that 54.3% of cases were admitted during the winter. This result was consistent with previous reports [14].
As in our series, physical examination, radiography, and thoracic ultrasound were used to establish the diagnosis in other studies. Imaging is crucial in pleural space disease diagnosis and treatment. Chest x-rays, US, and CT scans are the most commonly used methods of exploration. Conventional radiography has a place in diagnostic time and disease monitoring, but its impact on severity assessment is declining [14]. The pulmonary US allows for the emergent diagnosis of pneumothorax (without waiting for a chest x-ray) with a sensitivity greater than 95% versus less than 60% for a chest x-ray and a negative predictive value of 100% [15]. Because of its lower cost, greater availability, portability, discretionary use of sedation, and lack of ionizing radiation, the US has advocated for confirming the presence of an effusion. Some studies have based the treatment of parapneumonic effusions on whether or not adhesions were detected using the US [16]. In our study, pleuro-pulmonary ultrasound was used to look for signs of the severity of pleuro-pneumonitis. According to Berlioz M and al [17], a CT scan is only used to confirm a surgical indication and to assess the condition of the underlying pulmonary parenchyma before surgery. Some authors recommend it away from pleurisy to assess the parenchymal and pleural sequelae [18,19]. In our series, a CT scan was used in 62.9% of the cases; it has been recommended in cases of slow evolution, puncture, drainage failure, or before surgical indication.
Historically, the treatment of parapneumonic effusions was primarily nonoperative (antibiotics and thoracentesis or chest tube drainage). Although antibiotics and thoracostomy tube drainage may be adequate therapy for early (stage 1) parapneumonic effusions, the presence of loculations and fibrinous adhesions frequently limits this therapy's success [3]. It is frequently difficult to distinguish between stage 1 and stage 2 disease clinically and radiographically. As a result, this primary nonoperative approach frequently leads to extended hospitalizations [2]. Many retrospective case series have suggested that children who fail conventional chest tube therapy improve after thoracotomy or VATS, especially if the procedure is performed early [9]. Based on these reports, many pediatric surgeons believe that primary VATS is a better approach for children with parapneumonic processes [6,9,13]. When compared to a conventional thoracotomy, VATS has the potential for better lung expansion after the removal of pleural debris and exudate, an excellent enlarged view of the pleural space, optimization of chest tube location, and reduction of chest wall trauma [13].
However, the main prognostic factor for the treatment of pleural empyema by thoracoscopy is the interval between diagnosis and surgery. A delay of more than 4 days between diagnosis and surgery was associated with more frequent surgical difficulties, a longer duration of intervention, longer post-operative apyrexia, longer drainage time, longer hospitalization, and more postoperative complications [20]. A retrospective study of children with documented empyema found that VATS performed within 48 hours of diagnosis reduced hospitalization time by an average of four days [21]. In our series, the mean duration of evolution before VATS was 9 days ± 4 (4 to 21 days) and we opted for the VATS as the second treatment in 65.7% of cases.
Because of current delays in the management of purulent pleurisy , most children are seen in the fibro-purulent stage, with a significant risk of conservative treatment failure. As a result, it is critical that we evaluate these children to the best of our ability to optimize the therapeutic option.
The VATS allows for precise positioning of the chest tube, as well as complete pleural fluid discharge and pneumolysis or extreme pulmonary «decortication.» Most importantly, it hastens complete lung expansion, which reduces hospitalization [2,3,6,7,9,13,20]. In our series, the mean persistence duration of the biological inflammatory syndrome was 3 days ± 1.4 with extremes ranging from 2 days to 9 days and this was comparable with the results of other studies. The mean duration of the radiological improvement was 3.6 days ± 4.3 with extremes ranging from 1 day to 7 days and this was comparable with the literature [2].
For long-term results, aesthetic results are satisfactory and complications are rare. The majority of children with parapneumonic effusions often have favorable long-term outcomes. This is especially true with adults, as they generally do not have chronic underlying lung disease [3].
We are aware of the limitations of the study. They are small groups, which undermines the statistical results; the long period of collecting the data could bias the results due to changes in the disease itself and clinical management (antibiotics, increased recognition of the need for surgical management). The study relies on retrospective data and its focus is objective outcomes; thus, the patient perspective is not known.
The current treatment times for purulent parapneumonic pleural effusion are such that the majority of children are seen in the fibro-purulent stage, with a high risk of treatment failure. It appears to be critical, then, to evaluate these children as thoroughly as possible to optimize therapeutic choices. In skilled hands, VATS is safe, feasible, and effective in the management of parapneumonic pleural effusion in children with excellent outcomes in terms of decreased hospitalization time, decreased chest drainage time, rapid recovery, and reduced duration of parenteral antibiotic therapy. Further large studies are required to confirm these findings. Furthermore, the issue of the indication and location of a prospective VATS during the progression of a medically managed parapneumonic pleural effusion persists.
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SUMMERVILLE, S.C., Sept. 2, 2022 /PRNewswire/ — The Maritime Sustainment Know-how and Innovation Consortium (MSTIC), established by The Naval Floor Warfare Heart, Philadelphia Division (NSWCPD), is happy to announce the achievement of its milestone 300th member. That member is Systel, Inc. positioned out of Sugar Land, Texas. Systel designs and manufactures rugged computing options purpose-built for mission-critical functions in austere environments.
Established in June 2021, MSTIC focuses on revolutionary sustainment options to successfully handle present and future safety threats in maritime environments. The consortium brings collectively conventional and non-traditional authorities contractors, small and huge companies, for-profit and not-for-profit entities, and educational organizations collaborating to carry out analysis and improvement and prototyping efforts. Their aim is to develop and mature applied sciences within the subject of Maritime Sustainment that improve the Navy's mission effectiveness.
"MSTIC is delighted to welcome our 300th member to the consortium. Our members' capabilities align with options for which the Authorities is trying and the collaboration amongst them yields the relationships, teaming, and revolutionary concepts that ship these options at mission pace," acknowledged Program Supervisor, Tim Macon with Superior Know-how Worldwide (ATI).
"Systel is proud to be part of this collaborative effort to ship the options that our Authorities must help maritime sustainment and ship benefit for any mission," stated Systel CEO, Vimal Kothari. "We have now delivered 1000's of techniques for maritime functions over the previous 30 years with a relentless dedication to enabling mission success; MSTIC is exactly aligned with that dedication and supplies a good way to attach with different like-minded main innovators."
MSTIC is managed by ATI.
ATI, a public-service nonprofit primarily based in Summerville, South Carolina, builds and manages collaborations that conduct analysis and improvement of latest applied sciences to resolve our nation's nationwide safety challenges. Fueled by a neighborhood of specialists from trade, academia, and authorities, ATI accelerates affect through the use of the ability of collaboration to assist the federal authorities shortly purchase novel applied sciences. ATI is a subsidiary of Analytic Providers, Inc. (ANSER), a public-service analysis institute organized as a nonprofit company, which is devoted to informing choices that form the nation's future.
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