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Blood Flow Blockage. The brain receives about 25% of the body's oxygen, but it cannot store it. Brain cells require a constant supply of oxygen to stay healthy and function properly. Therefore, blood needs to be supplied continuously to the brain through two main arterial systems:
A reduction of, or disruption in, blood flow to the brain is the cause of a stroke. Blockage for even a short period of time can be disastrous and cause brain damage or even death.
A stroke is usually defined as two types:
The consequences of a stroke, the type of functions affected, and the severity, depend on where in the brain it has occurred and the extent of the damage.
Ischemic strokes are by far the more common type, causing over 80% of all strokes. Ischemia means the deficiency of oxygen in vital tissues. Ischemic strokes are caused by blood clots that are usually one of three types:
Thrombotic or Large-Artery Stroke and Atherosclerosis. The thrombotic stroke accounts for about 60% of all strokes. It usually occurs when an artery to the brain is blocked by a thrombus (blood clot) that forms as the result of atherosclerosis (commonly known as hardening of the arteries). These strokes are also sometimes referred to as large-artery strokes. The process leading to thrombotic stroke is complex and occurs over time:
Embolic Strokes and Atrial Fibrillation. An embolic stroke is usually caused by a dislodged blood clot that has traveled through the blood vessels (an embolus ) until it becomes wedged in an artery. Embolic strokes may be due to various conditions:
Lacunar Strokes. Lacunar infarcts are a series of very tiny, ischemic strokes, which cause clumsiness, weakness, and emotional variability. They make up the majority of silent brain infarctions and are probably a result of chronic high blood pressure They are actually a subtype of thrombotic stroke. They can also sometimes serve as warning signs for a major stroke.
Silent Brain Infarctions. Many elderly people have silent brain infarctions, small strokes that cause no apparent symptoms. They are detected in up to half of elderly patients who undergo imaging tests for problems other than stroke. The presence of silent infarctions indicates an increased risk for future stroke, and are often contributors to mental impairment in the elderly. Smokers and people with hypertension are at particular risk.
A transient ischemic attack (TIA) is an episode in which a person has stroke -like symptoms for less than 24 hours, usually less than 1-2 hours. Transient ischemic attacks (TIAs) are caused by tiny emboli (clots often formed of pieces of calcium and fatty plaque) that lodge in an artery to the brain. They typically break up quickly and dissolve but they do temporarily block the supply of blood to the brain.
A TIA is often considered a warning sign that a true stroke may happen in the future if something is not done to prevent it. TIA should be taken very seriously and treated as aggressively as a stroke.
About 20% of strokes occur from hemorrhage (sudden bleeding) into or around the brain. While hemorrhagic strokes are less common than ischemic strokes, they tend to be more deadly.
Hemorrhagic strokes are categorized by how and where they occur.
People at risk and partners or caretakers of people at risk for stroke should be aware of its typical symptoms. The stroke victim should get to the hospital as soon as possible after these warning signs appear. It is particularly important for people with migraines or frequent severe headaches to understand how to distinguish between their usual headaches and symptoms of stroke.
Time is of the essence in treating stroke. Studies show that patients receive faster treatment for stroke if they arrive by ambulance rather than coming to the emergency room on their own People should immediately call 911 for emergency assistance if they experience any of warning signs of stroke:
An easy way to remember the signs of stroke, and what to do, is by the acronym "F.A.S.T." If you think you or someone else is having a stroke, the National Stroke Association's F.A.S.T. test advises:
The symptoms of a transient ischemic attack (TIA) and early ischemic stroke are similar. In the case of a TIA, however, the symptoms resolve within 24 hours. Symptoms depend on where the injury in the brain occurs. The origin of the stroke is usually either the carotid or basilar arteries.
Symptoms From Blockage in the Carotid Arteries. The carotid arteries stem off of the aorta (the primary artery leading from the heart) and lead up through the neck, around the windpipe, and on into the brain. When TIAs or stroke occur from blockage in the carotid artery, which they often do, symptoms may occur in either the retina of the eye or the cerebral hemisphere (the large top part of the brain).
Symptoms include the following:
Symptoms From Blockage in the Basilar Artery. The other major site of trouble, the basilar artery, is formed at the base of the skull from the vertebral arteries, which run up along the spine and join at the back of the head. When stroke or TIAs occur here, both hemispheres of the brain may be affected so that symptoms occur on both sides of the body. The following symptoms may develop:
Such strokes usually occur in the brain stem, which can have profound affects on breathing, blood pressure, heart rate, and other vital functions, but have no affect on thinking or language.
Speed of Symptom Onset. The speed of symptom onset of a major ischemic stroke may indicate its source:
Intracerebral Hemorrhage Symptoms. Symptoms of an intracerebral, or parenchymal, hemorrhage typically begin very suddenly and evolve over several hours and include:
Subarachnoid Hemorrhage. When the hemorrhage is a subarachnoid type, warning signs may occur from the leaky blood vessel a few days to a month before the aneurysm fully develops and ruptures. Warning signs may include:
When the aneurysm ruptures, the stroke victim may experience:
New or recurrent strokes affect about 780,000 Americans every year. On average, someone in the United States has a stroke every 40 seconds. While age is the major risk factor, people who have a stroke are likely to have more than one risk factor.
People most at risk for stroke are older adults, particularly those with high blood pressure, who are sedentary, overweight, smoke, or have diabetes. Older age is also linked with higher rates of post-stroke dementia. Younger people are not immune, however. About 28% of stroke victims are under age 65.
In most age groups except older adults, stroke is more common in men than in women. However, it kills more women than men, regardless of ethnic groups. This may be partly due to the fact that women tend to live longer than men, and stroke is more common among older adults. Women account for about 6 in 10 stroke deaths. For younger women, birth control pills and pregnancy can increase the risk of stroke.
All minority groups, including Native Americans, Hispanics, and African-Americans, face a significantly higher risk for stroke and death from stroke than Caucasians. African-Americans have twice the risk for first-time stroke as Caucasians. The differences in risk among all groups diminish as people age.
The greatest disparity in risk occurs in young adults. Younger African-Americans are two to three times more likely to experience a stroke than their Caucasian peers and four times more likely to die from one. They also face a higher risk for death from heart disease. African-Americans have a higher prevalence of obesity, diabetes, and hypertension than other groups. However, studies suggest that socioeconomic factors also affect these differences.
A family history of stroke or TIA is a strong risk factor for stroke.
Smoking. People who smoke a pack a day have almost two and a half times the risk for stroke as nonsmokers. Smoking increases both hemorrhagic and ischemic stroke risk. The risk for stroke may remain elevated for as long as 14 years after quitting, so the earlier one quits the better.
Diet. Unhealthy diet (saturated fat, high sodium) can contribute to heart disease, high blood pressure, and obesity, which are all risk factors for stroke.
Physical Inactivity. Lack of regular exercise can increase the risk of obesity, diabetes, and poor circulation, which increase the risk of stroke.
Alcohol and Drug Abuse. Alcohol abuse, including binge drinking, increases the risk of stroke. Drug abuse, particularly with cocaine or methamphetamine, is a major factor of stroke in young adults. Anabolic steroids, used for body-building and sports enhancement, also increase stroke risk.
Heart disease and stroke are closely tied for many reasons. People who have one heart or vascular condition (high blood pressure, high cholesterol, heart disease, diabetes, peripheral artery disease) are at increased risk for developing other related conditions. Heart and vascular diseases that increase stroke risk include:
Prior Stroke. A history of a prior stroke or TIA significantly increases the risk for a subsequent stroke. People who have had at least one TIA are 10 times more likely to have a stroke than those who have not had a TIA.
Prior Heart Attack. People who have had a heart attack are at increased risk of stroke.
High Blood Pressure. High blood pressure (hypertension) of contributes to about 70% of all strokes. Hypertensive people have up to 10 times the normal risk of stroke, depending on the severity of the blood pressure in the presence of other risk factors. Hypertension is also an important cause of so-called silent cerebral infarcts, or blockages, in the blood vessels in the brain (mini-strokes) that may predict major stroke. Controlling blood pressure is extremely important for stroke prevention.
Unhealthy Cholesterol Levels. A high total cholesterol level increases the risk of developing atherosclerosis ("hardening of the arteries") and heart disease. In atherosclerosis, fatty deposits (plaques) of cholesterol build up in the arteries of the heart.
Heart Disease. Coronary artery disease (heart disease), which is the end result of atherosclerosis increases stroke risk. Anti-clotting medications, which are used in heart disease treatment to break up blood clots, can increase the risk of hemorrhagic stroke.
Atrial Fibrillation. Atrial fibrillation, a major risk factor for stroke, is a heart rhythm disorder in which the atria (the upper chambers in the heart) beat very quickly and nonrhythmically. The blood pools instead of being pumped out, increasing the risk for formation of blood clots that break loose and travel toward the brain. Between 2 - 4% of patients with atrial fibrillation without any history of TIA or stroke will have an ischemic stroke over the course of a year. Of those with atrial fibrillation, the risk generally is highest in those older than age 75, with heart failure or enlarged heart, coronary artery disease, history of clots, diabetes, or heart valve abnormalities.
Structural Heart Problems. Dilated cardiomyopathy (enlarged heart), heart valve disorders, and congenital heart defects such as patent foramen ovalae (opening in chambers of heart) and atrial septal aneurysm (bulging of heart chamber) are risk factors for stroke.
Carotid Artery Disease and Peripheral Artery Disease. Carotid artery disease is a serious risk factor for stroke. Atherosclerosis can cause fatty build-up in the carotid arteries of the neck, which can lead to blood clots that block blood flow and oxygen to the brain. People with peripheral artery disease, which occurs when atherosclerosis narrows blood vessels in the legs and arms, are at increased risk of carotid artery disease and subsequently stroke.
Heart disease and stroke are the leading causes of death in people with diabetes.. Diabetes is second only to high blood pressure as the main risk factor for stroke. The risk is highest for adults newly diagnosed with type 2 diabetes and patients with diabetes who are younger than age 55. African-Americans with diabetes are at even higher risk for stroke at a younger age. Diabetes is a particularly strong risk factor for ischemic stroke, perhaps because of accompanying risk factors, such as obesity and high blood pressure. Diabetes does not appear to increase the risk for hemorrhagic stroke.
Obesity may increase the risk for both ischemic and hemorrhagic stroke independently of other risk factors that often co-exist with excess weight, including diabetes, high blood pressure, and unhealthy cholesterol level. Weight that is centered around the abdomen (the so-called apple shape) has a particularly high association with stroke, as it does for heart disease, in comparison to weight distributed around hips (pear-shape).
Obesity is particularly hazardous when it is one of the components of metabolic syndrome. This syndrome is diagnosed when three of the following conditions are present: abdominal obesity, low HDL cholesterol, high triglyceride levels, high blood pressure, and insulin resistance. Because metabolic syndrome is a pre-diabetic condition that is significantly associated with heart disease, people with this syndrome are at increased risk for stroke even before diabetes develops.
Migraine. Studies suggest that migraine or severe headache may be a risk factor for stroke in both men and women, especially before age 50. Overall, between 2 - 3% of ischemic strokes occur in people with a history of migraine. However, in patients under age 45, about 15% of all strokes (and 30 - 60% of strokes in young women) are associated with a history of migraines, particularly migraine with aura. For young women with migraines, other risk factors (such as high blood pressure, smoking, and use of estrogen-containing oral contraceptives) may increase stroke risk.
Sickle Cell Disease. People with sickle cell disease are at increased risk for stroke at a young age.
Pregnancy. Pregnancy carries a very small risk for stroke, mostly in women with pregnancy related high blood pressure. The risk appears to be higher in the postpartum (post-delivery) period, perhaps because of the sudden change in circulation and hormone levels.
NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) and diclofenac (Cataflam, Voltaren) may increase the risk of stroke, especially for patients who have other stroke risk factors.
Stroke is the second leading cause of death worldwide. Mortality rates are declining, however. Over 75% of patients survive a first stroke during the first year, and over half survive beyond 5 years.
People who suffer ischemic strokes have a much better chance for survival than those who experience hemorrhagic strokes. Among the ischemic stroke categories, the greatest dangers are posed by embolic strokes, followed by thrombotic and lacunar strokes. Hemorrhagic stroke not only destroys brain cells but also poses other complications, including increased pressure on the brain or spasms in the blood vessels, both of which can be very dangerous. Studies suggest, however, that survivors of hemorrhagic stroke have a greater chance for recovering function than those who suffer ischemic stroke.
Many patients are left with physical weakness and often have accompanying pain and spasticity. Depending on the severity of the symptoms and how much of the body is involved, these impairments can affect the ability to walk, to rise from a chair, to feed oneself, to write or use a computer, to drive, and many other activities.
Many stroke survivors recover functional independence after a stroke, but 25% are left with a minor disability and 40% experience moderate-to-severe disabilities. The National Institutes of Health (NIH)'s stroke scale helps predict the severity and outcome of a stroke by scoring 11 factors (levels of consciousness, gaze, visual fields, facial movement, motor functions in the arm and leg, coordination, sensory loss, problems with language, inability to articulate, and attention).
Those patients with ischemic strokes who score less than 10 have a favorable outlook after a year, while only 4 - 16% of patients do well if their score is more than 20.
The risk for recurring stroke is highest within the first few weeks and months of the previous stroke. But about 25% of people who have a first stroke will go on to have another stroke within 5 years. Risk factors for recurrence include:
Patients who have had a first stroke or TIA are at high risk of having another stroke. Secondary prevention measures are essential to reduce this risk.
Quit Smoking. Smoking is a major risk factor for stroke. Patients should also avoid exposure to second-hand smoke.
Eat Healthy. Patients should make dietary changes to follow a diet rich in fruits and vegetables, high in potassium, and low in saturated fats. Limit sodium (salt) intake to less than 2,300 mg/day. Middle-aged and older patients with high blood pressure should restrict sodium intake to no more than 1,500 mg/day. For diet plans, the Mediterranean diet or the Dietary Approaches to Stop Hypertension (DASH) diet may be particularly good choices for reducing the risk of stroke.
Exercise. Exercise helps reduce the risk of atherosclerosis, which can help reduce the risk of stroke. Doctors recommend at least 30 minutes of exercise on most, if not all, days of the week.
Maintain Healthy Weight. Patients who are overweight should try to lose weight through healthy diet and regular exercise.
Limit Alcohol Consumption. Heavy alcohol use and binge drinking increase the risk of both ischemic and hemorrhagic stroke. If you drink, limit alcohol to no more than one drink a day for women or two drinks a day for men.
Your doctor may suggest taking aspirin or another drug called clopidogrel (Plavix) to help prevent blood clots from forming in your arteries or your heart. These medicines are called antiplatelet drugs. These drugs make blood platelets less sticky and therefore less likely to form a clot. You should never start taking aspirin without talking to your doctor first.
Primary Prevention (to prevent a first stroke). When these drugs are taken before a stroke or TIA has occurred, it is called primary prevention. Before deciding whether someone should take aspirin or clopidogrel to prevent strokes caused by a blockage in an artery (ischemic stroke), your doctor must consider whether you are at an increased risk of strokes caused by bleeding in the brain (hemorrhagic stroke), as well as bleeding elsewhere in the body.
Secondary Prevention (to prevent another stroke after one has occurred). After an ischemic stroke or a TIA, aspirin alone or aspirin plus the the anti-clotting drug dipyridamole (Persantine, or Aggrenox when combined in one pill with aspirin) given twice daily is recommended to prevent another stroke. Clopidogrel may be used in place of aspirin for patients who have narrowing of the coronary arteries or who have had a stent inserted. Combining aspirin and clopidogrel together does not have any more benefit and increases the risk for hemorrhage.
Anticoagulant Drugs. Warfarin (Coumadin) is the main anticoagulant ("blood thinner") drug used to prevent strokes in high-risk patients with atrial fibrillation. Warfarin carries a risk for bleeding, but for most patients, warfarin's benefits far outweigh its risks. The risk for bleeding is highest when warfarin therapy is first started, with higher doses, and with long periods of treatment. Patients at risk for bleeding are usually older and have a history of stomach bleeding and high blood pressure. It is important that patients who take warfarin have their blood checked regularly to make sure that it does not become "too thin." Blood that is too thin increases the risk for bleeding, while blood that is "too thick" increases the risk for blood clots and stroke. Prothrombin time (PT) and international normalized ratio (INR) tests are used to monitor blood coagulation.
People with atrial fibrillation who are generally considered candidates for warfarin therapy often have one or more of the following characteristics:
People with diabetes should aim for fasting blood glucose levels of less than 110 mg/dl and hemoglobin A1C of less than 7%. Blood pressure goals for people with diabetes should be 130/80 mm Hg or less.
Reducing blood pressure is essential in stroke prevention. Otherwise healthy patients with high blood pressure should aim for blood pressure below 140/90 mm Hg. Patients with diabetes, chronic kidney disease, or atherosclerosis should aim for blood pressure below 130/80 mm Hg. Drug therapy is recommended for people with hypertension who cannot control their blood pressure through diet and other lifestyle changes. Many different types of drugs are used to control blood pressure. They include diuretics, ACE inhibitors, angiotensin-receptor blockers, beta-blockers, and calcium channel blockers.
The American Heart Association recommends that patients who have had an ischemic stroke or TIA should take a statin drug to lower cholesterol levels. Most patients should aim to lower their LDL ("bad" cholesterol) to less than 100 mg/dL. Patients with multiple risk factors should aim for an LDL level of below 70 mg/dL.
Statin brands include lovastatin (Mevacor), pravastatin (Pravachol), simvastatin (Zocor), fluvastatin (Lescol), atorvastatin (Lipitor), and rosuvastatin (Crestor).
Until recently, the treatment of stroke was restricted to basic life support at the time of the stroke and rehabilitation later. Now, however, treatments can be beneficial when administered as soon as possible after the onset of the stroke. It is critical to get to the hospital and be diagnosed as soon as possible. There are several steps in the initial assessment and management of a person with a stroke.
Receiving treatment early is essential in reducing the damage from a stroke. The chances for survival and recovery are also best if treatment is received at a hospital specifically certified as a primary stroke center.
Immediate treatment of ischemic stroke aims at dissolving the blood clot. Patients who arrive at the emergency room with signs of acute ischemic stroke are usually given aspirin to help thin the blood. Aspirin can be lethal for patients suffering a hemorrhagic stroke, so it is best not to take aspirin at home and to wait until after the doctor has determined what kind of stroke has occurred.
If the patient arrives at the hospital within 3 hours of stroke onset (when symptoms first appear), they may be a candidate for thrombolytic ("clot-buster") drug therapy. Thrombolytic drugs are used break up existing blood clots. The standard thrombolytic drugs are tissue plasminogen activators (t-PAs). They include alteplase (Activase) and reteplase (Retavase).
The following steps are critical before injecting a clot-buster drug:
Thrombolytics carry a risk for hemorrhage, so they may not be appropriate for patients with existing risk factors for bleeding.
Treatment of hemorrhagic stroke depends in part on whether the stroke is caused by bleeding between the brain and the skull (subarachnoid hemorrhage) or within the brain tissue (intracerebral hemorrhage). Both medications and surgery may be used.
Medications. Various types of drugs are given depending on the cause of the bleeding. If high blood pressure is the cause, antihypertensive medications are administered to lower blood pressure. If anticoagulant medications, such as warfarin (Coumadin) or heparin, are the cause, they are immediately discontinued and other drugs may be given to increase blood coagulation. Other drugs, such as the calcium channel blocker nimodipine (Nimotop) can help reduce the risk of ischemic stroke following hemorrhagic stroke.
Surgery. Surgery may be performed for aneurysms or arteriovenous malformations that are bleeding. The surgery may be done through what is called a craniotomy, which involves making an opening in the skull bone. Also, less invasive techniques can be done by threading a catheter. A catheter is guided through a small cut in the groin to an artery and then to the small blood vessels in the brain where the aneurysm is located. Thin metal wires are put into the aneurysm. They then coil up into a mesh ball. Blood clots that form around this coil prevent the aneurysm from breaking open and bleeding. If the aneurysm has ruptured, a clip may be placed on it to prevent further leaking of blood into the brain.
In the days following stroke, patients are at risk for complications. The following steps are important:
Maintain Adequate Delivery of Oxygen. It is very important to maintain oxygen levels. In some cases, airway ventilation may be required. Supplemental oxygen may also be necessary for patients when tests suggest low blood levels of oxygen.
Manage Fever. Fever should be monitored and aggressively treated with medication, since its presence predicts a poorer outlook.
Evaluate Swallowing. Patients should have their swallowing function evaluated before they are given any food, fluid, or medication by mouth. If patients cannot adequately swallow they are at risk of choking. Patients who cannot swallow on their own may require nutrition and fluids delivered intravenously or through a tube placed in the nose.
Maintain Electrolytes. Maintaining a healthy electrolyte balance (the ratio of sodium, calcium, and potassium in the body''s fluids) is critical.
Control Blood Pressure. Managing blood pressure is essential and complicated. Blood pressure often declines spontaneously in the first 24 hours after stroke. Patients whose blood pressure remains elevated should be treated with antihypertensive medications.
Monitor Increased Brain Pressure. Hospital staff should watch carefully for evidence of increased pressure on the brain (cerebral edema), which is a frequent complication of hemorrhagic strokes. It can also occur a few days after ischemic strokes. Early symptoms of increased brain pressure are drowsiness, confusion, lethargy, weakness, and headache. Medications such as mannitol may be given during a stroke to reduce pressure or the risk for it.
Keeping the top of the body higher than the lower part, such as by elevating the head of the bed, can reduce pressure in the brain and is standard practice for patients with ischemic stroke. However, this practice also lowers blood pressure in general, which may be dangerous for patients with massive stroke.
Monitor the Heart. Patients must be monitored using electrocardiographic tracings to check for atrial fibrillation and other heart rhythm problems. Patients are at high risk for heart attack following stroke.
Control Blood Sugar (Glucose) Levels. Elevated blood sugar (glucose) levels can occur with severe stroke and may be a marker of serious trouble. Patients with high blood glucose levels may require insulin therapy.
Monitor Blood Coagulation. Regular tests for blood coagulation are important to make sure that the blood is not so thick that it will clot nor so thin that it causes bleeding.
Check for Deep Venous Thrombosis. Deep venous thrombosis is a blood clot in the veins of the lower leg or thigh. It can be a serious post-stroke complication because there is a risk of the clot breaking off and traveling to the brain or heart. Deep venous thrombosis can also cause pulmonary embolism if the blood clot travels to the lungs. If necessary, an anticoagulant drug such as heparin may be given, but this increases the risk of hemorrhage. Patients who have had a stroke are also at risk for pulmonary embolisms
Prevent Infection. Patients who have had a stroke are at increased risk for pneumonia, urinary tract infections, and other widespread infections.
Many of the same procedures are used to diagnose a stroke and to evaluate the risk of future major stroke in patients who have had a transient ischemic attack (TIA). A diagnostic work-up includes physical and neurological examinations, patient's medical history, blood tests (to measure blood glucose levels, blood coagulation time, cardiac enzymes, and other factors), and imaging tests.
For patients who have suffered a major stroke, the first step is to determine as quickly as possible whether the stroke is ischemic (caused by blood clot blockage) or hemorrhagic (caused by bleeding). Clot-busting drug therapies can be life-saving for ischemic stroke patients, but they are effective only in the first 3 hours. However, if the stroke is caused by a hemorrhage, thrombolytic drugs cause will likely increase the bleeding and can be lethal.
Carotid Ultrasound. Carotid ultrasound procedures such as carotid duplex are valuable tools for measuring the width of the artery and how the blood flows through it. Carotid ultrasound can help determine the severity of plaque build-up and narrowing and blocking of the carotid arteries (carotid stenosis).
Computed Tomography and Magnetic Resonance Imaging. An important decision when someone presents to the emergency room with a possible stroke is whether or not to use clot busting drugs. If stroke is due to bleeding (hemorrhagic stroke), these drugs can be dangerous. If stroke is due to a blood clot (ischemic stroke), clot busting drugs given within the first three hours after symptoms begin can make the stroke less severe.
Evidence of bleeding can usually be seen with computed tomography (CT) scan soon after symptoms begin. The CT scan can also help indicate whether a stroke is relatively new or recent. Magnetic resonance imaging (MRI) scans are less accurate at being able to differentiate between a hemorrhagic stroke and an ischemic stroke during the first few hours after symptoms begin. Also, MRI scans are not as easily available, take longer to perform, and make it more difficult to manage an ill patient while being done
For these reasons, the CT scan is almost always the first test performed to evaluate stroke. The goal is to complete the CT examination and obtain and interpret the results within 45 minutes of arrival at the hospital.
Cerebral Angiography. Cerebral angiography is an invasive procedure that may be used for patients with TIAs who need surgery. It can also detect aneurysms and monitor thrombolytic therapy. It requires the insertion of a catheter into the groin, which is then threaded up through the arteries to the base of the carotid artery. At this point a dye is injected, and x-rays, CTs, or MRI scans determine the location and extent of the narrowing, or stenosis, of the artery.
Magnetic Resonance Angiography (MRA) and Computerized Tomography Angiography. Magnetic resonance angiography and computerized tomography angiography are noninvasive ways of evaluating the carotid arteries and the arteries in the brain. In many situations, these tests can be used instead of cerebral angiography, an invasive procedure which carries a risk for bleeding in stroke.
Other Techniques. Other imaging tests, including positron-emission tomography (PET) and single photon-emission computed tomography (SPECT), may also help the doctor identify injuries caused by the stroke.
Electrocardiogram (ECG). A heart evaluation using an electrocardiogram (ECG) is important in any patient with a stroke or suspected stroke. An ECG records the electrical current in the heart muscle.
Echocardiogram. An echocardiogram uses ultrasound to view the chambers and valves of the heart. It is generally useful for stroke patients to identify blood clots or risk factors for blood clots that can travel to the brain and cause stroke. There two are types:
Patients who have a TIA are at increased risk for a major stroke in the days and weeks that follow. The ABCD2 score is a tool that helps doctors predict short-term stroke risk following a TIA. The ABCD2 score assigns points for various factors, including:
Based on the number of points, a doctor can identify whether a patient is at low, moderate, or high risk of having a stroke within 2 days after a TIA. The ABCD2 score can help doctors better decide which patients need hospitalization and emergency care.
Carotid endarterectomy is a surgical procedure that cleans out plaque and opens up the narrowed carotid arteries in the neck. It is recommended to prevent ischemic stroke in some patients who have carotid artery stenosis of 70% or more. For people whose carotid arteries are narrowed by 50% or less, anti-clotting medications (antiplatelets and anticoagulants) are usually recommended in place of surgery. For patients with moderate stenosis (50 - 69%), the decision to perform surgery needs to be determined on an individual basis.
There is a risk of a heart attack or stroke from the procedure. Anyone undergoing this procedure should be sure their surgeon is experienced in performing this procedure and that the medical center has complication rates of less than 6%. Carotid endarterectomy is generally not recommended for patients with acute stroke.
Procedure Description. A carotid endarterectomy involves:
Carotid angioplasty and stenting (CAS) may be used as an alternative to carotid endarterectomy for some patients It is based on the same principles as angiography done for heart disease.
This procedure carries a risk for an embolic stroke and other complications. At this time, it is being used in some centers as an alternative to endarterectomy in patients who cannot undergo endarterectomy, especially for patients with severe stenosis (blockage greater than 70%) and high surgical risk.
Most people who survive a stroke have some type of disability. But many people are able to make significant improvements through rehabilitation. According to the National Stroke Association:
For the best chance of improvement and regaining abilities, it is important that rehabilitation starts as soon as possible after a stroke. Rehabilitation therapy is started in the hospital as soon as a patient's condition has stabilized. Initial range of motion exercises involve a nurse or physical therapist moving a patient's affected limb (passive exercise) and having the patient practice moving the limb (active exercise). Patients are encouraged to gradually sit, stand, and walk and then to perform tasks of daily living (bathing, dressing, using the toilet).
Some patients will experience the fastest recovery and regain functional abilities in the first few days, while others will continue to show improvement during the first 6 months or longer. Recovery is an ongoing process and with good rehabilitation providers and family support, patients can continue to make progress.
Once a patient has been discharged from the hospital, rehabilitation continues at home or in an outpatient program. Some patients may be transferred to a rehabilitation hospital before going home. Others may require care in a long-term or skilled nursing facility. In addition to the ongoing care of a primary care physician or neurologist, a rehabilitation team may include:
A stroke can cause various disabilities. The type of disability depends on which part of the brain was damaged. According to the U.S. National Institutes of Health, the five main types of stroke disabilities are:
Because stroke affects different parts of the brain, specific approaches to managing rehabilitation vary widely among individual patients:
Medication can sometimes help relieve specific effects of stroke:
A stroke is emotionally challenging both for patients and their families. The caregiver''s emotions and responses to the patient are critical. Patients do worse when caregivers are depressed, overprotective, or not knowledgeable about the stroke. They do best when caregivers and family are encouraging and supportive. Everyone benefits when patients are able to function as independently as possible to the best of their abilities.
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Dorhout Mees SM, Rinkel GJ, Feigin VL, Algra A, van den Bergh WM, Vermeulen M, et al. Calcium antagonists for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD000277.
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Goldstein LB, Adams R, Alberts MJ, Appel LJ, Brass LM, Bushnell CD, et al. Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2006 Jun 20;113(24):e873-923.
Goldstein LB, Amarenco P, Szarek M, Callahan A 3rd, Hennerici M, Sillesen H, et al. Hemorrhagic stroke in the Stroke Prevention by Aggressive Reduction in Cholesterol Levels study. Neurology. 2007 Dec 12 [Epub ahead of print]
Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007 Jun 19;146(12):857-67.
Legg L, Drummond A, Leonardi-Bee J, Gladman JR, Corr S, Donkervoort M, et al. Occupational therapy for patients with problems in personal activities of daily living after stroke: systematic review of randomised trials. BMJ. 2007 Nov 3;335(7626):922. Epub 2007 Sep 27.
Mas JL, Chatellier G, Beyssen B, Branchereau A, Moulin T, Becquemin JP, et al. Endarterectomy versus stenting in patients with symptomatic severe carotidstenosis. N Engl J Med. 2006 Oct 19;355(16):1660-71.
Myint PK, Luben RN, Wareham NJ, Bingham SA, Khaw KT. Combined effect of health behaviours and risk of first ever stroke in 20,040 men and women over 11 years' follow-up in Norfolk cohort of European Prospective Investigation of Cancer (EPIC Norfolk): prospective population study. BMJ. 2009 Feb 19;338:b349. doi: 10.1136/bmj.b349.
Olgin JE and Zipes DP. Specific arrhythmias: diagnosis and treatment. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders;2007:chap 35.
O'Regan C, Wu P, Arora P, Perri D, Mills EJ. Statin therapy in stroke prevention: a meta-analysis involving 121,000 patients. Am J Med. 2008 Jan;121(1):24-33.
Ringleb PA, Chatellier G, Hacke W, Favre JP, Bartoli JM, Eckstein HH, et al. Safety of endovascular treatment of carotid artery stenosis compared with surgical treatment: a meta-analysis. J Vasc Surg. 2008 Feb;47(2):350-5.
Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, et al. Heart disease and stroke statistics -- 2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2008 Jan 29;117(4):e25-146. Epub 2007 Dec 17.
Sacco RL, Diener HC, Yusuf S, Cotton D, Ounpuu S, Lawton WA, et al. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke. N Engl J Med. 2008 Sep 18;359(12):1238-51. Epub 2008 Aug 27.
Smith SC Jr, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006 May 16;113(19):2363-72.
Swain S, Turner C, Tyrrell P, Rudd A; Guideline Development Group. Diagnosis and initial management of acute stroke and transient ischaemic attack: summary of NICE guidance. BMJ. 2008 Jul 24;337:a786. doi: 10.1136/bmj.a786.
Tsivgoulis G, Spengos K, Manta P, Karandreas N, Zambelis T, Zakopoulos N, et al. Validation of the ABCD score in identifying individuals at high early risk of stroke after a transient ischemic attack: a hospital-based case series study. Stroke. 2006 Dec;37(12):2892-7. Epub 2006 Oct 19.
US Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009 Mar 17;150(6):396-404.
van der Worp HB, van Gijn J. Clinical practice. Acute ischemic stroke. N Engl J Med. 2007 Aug 9;357(6):572-9.
Vergouwen MD, de Haan RJ, Vermeulen M, Roos YB. Statin treatment and the occurrence of hemorrhagic stroke in patients with a history of cerebrovascular disease. Stroke. 2008 Feb;39(2):497-502. Epub 2008 Jan 3.
Wolff T, Guirguis-Blake J, Miller T, Gillespie M, Harris R. Screening for carotid artery stenosis: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2007 Dec 18;147(12):860-70.


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Geek Graffiti Artist Spreads Anti-Google Propaganda In NYC
Paid Content's Jeff Roberts discovered what may be the world's geekiest stretch of graffiti on the Pulaski bridge in Greenpoint, Brooklyn. There was this Google stencil, a "Stop SOPA" tag, and a painted Anonymous Guy Fawkes mask.
The Google design is cool and timely, given the uproar about Google's new privacy policy. (Maybe it was a Bing employee?) But we dread the inevitable explosion of internet-themed graffiti; the near-future wheren our cities become covered in hashtags, hipster kitty and Twilight tags, painted by rival gangs of Tumblr Kids claiming their turf.

subset: commoncrawl


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Kelly & Katie Quench Platform Sandal
Sorry, this item is sold out!
Looks like you've got more shoe shopping to do - have fun!
Looks like you've got more shoe shopping to do - have fun!
Item # 242531
Show off your gams in this colorful slingback sandal. The Kelly & Katie Quench is perfect for a stylish evening out in the city.
- Faux patent leather upper
- Also available in a faux reptile embossed leather upper
- Slingback strap with an adjustable buckle
- ½" platform, 4½" cork heel
- Synthetic sole
- Imported
- View more Women's Kelly & Katie Shoes
By: cuteshoesiam
Location: Alberta, Canada
April 26, 2013
I gasped when I opened these!
"Beautiful classic shoe & colour. Cannot wait to show these off!"
By: SnellvilleShoelover
Location: Snellville, Ga
April 15, 2013
Love/ Hate Relationship
"I absolutely love the way this shoe looks but the highness of it for me makes it uncomfortable for long periods of time but I'm rocking them."
By: Sheeli
March 15, 2013
By: mnp79
Location: Dallas, TX
March 15, 2013
"I have worn these shoes three times, and they are already falling a part. The sole is coming apart from the shoe at the heal. The black fabric already is looking worn and faded. Cheap shoe, and cheap quality."
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Influence of Air Gap Length and Cross-Section on Magnetic Circuit Parameters - new
A. Polit[1], R. Jez[1]
[1]ABB Corporate Research Center, Krakow, Poland
The air gap is one of the most crucial part of magnetic circuits, especially in high-power inductors. It significantly modifies the parameters of magnetic devices by increasing the saturation current, linearizing B-H curve of magnetic circuit and causing a decreasing in the inductance. Therefore the optimal selection of shape and dimensions of the air gap is very important from the design point ...
Theory of Proportional Solenoids and Magnetic Force Calculation Using COMSOL Multiphysics
O. Vogel, and J. Ulm
Heilbronn University
Campus Künzelsau
Künzelsau, Germany
Proportional solenoids are well-known and used in a wide range of applications today. This paper is about methods of influencing the characteristic force-stroke-curves of magnetic actuators by means of different pole geometries. The conical design of the stator pole which is mostly used to accomplish proportional solenoids is analyzed by both a simple analytic reluctance model and a FEM model ...
Electrical Conductivity Modeling and Validation in Unidirectional Carbon Fiber Reinforced Polymer Composites
P. Banerjee[1], J. L. Schmidt[1]
[1]Department of Mechanical Engineering and Materials Science, Washington University in St. Louis, St. Louis, MO, USA
Carbon fiber (CF) reinforced polymer composites (CFRP) have begun to replace Al-Zn-Mg alloys in applications which require high strength-to-weight ratios. The anisotropy of CFRP composites is a result of melt crystallized extrusion techniques that impart an inherent directionality to the CFs and the associated material's properties. Electrical conductivity was modeled across the entire CF ...
Sensitivity Analysis of Different Models of Piezoresistive Micro Pressure Sensors
S. Meenatchisundaram[1], S. M. Kulkarni[2], S. Bhat
[1]Department of Instrumentation and Control Engineering, Manipal Institute of Technology, Manipal, Karnataka, India.
[2]Department of Mechanical Engineering, National Institute of Technology, Surathkal, Karnataka, India.
Piezoresistive pressure sensors have received much attention over the years because of low cost, simple measurement techniques, etc. There is a challenge in design with respect to appropriate positioning, shape and temperature compensation. Different models of piezoresistive pressure sensors are proposed to enhance its sensitivity in terms of output voltage. This paper aims in sensitivity ...
Multiphysics Simulation of Thermoelectric Systems - Modeling of Peltier-Cooling and Thermoelectric Generation
M. Jaegle
Fraunhofer-Institute for Physical Measurement-Techniques (IPM), Freiburg, Germany
Electro-thermal interaction is commonly considered only as a matter of joule heating. In addition, the Seebeck-, Peltier- and Thompson-Effects are significant in materials with high thermoelectric figure of merit Z. These thermoelectric materials have a high Seebeck-coefficient α, a good electric conductivity σ, and a poor thermal conductivity λ. They have widespread areas of ...
The Design of a Multilayer Planar Transformer for DC/DC Converter with a Resonant Inverter - new
M. Puskarczyk[1], R. Jez [1]
[1]ABB Corporate Research Center, Krakow, Poland
Multilayer planar transformers are widely implemented in power electronic applications. The design process of these elements is complicated due to the complexity of a magnetic circuit and high frequency interactions between windings. Additionally, an analytical approach to the analysis (based on mathematical formulas) can be uncertain. The applied FEM method of the analysis can be a solution to ...
Models of Simple Iron Cored Electromagnets - new
J. Mammadov[1]
[1]University of Manchester, Manchester, UK
This report mainly discusses the implementation and results of a project proposal, "Modelling using Finite Element Methods". The report is devoted to implementation, which is a model of an electromagnet. The software tool that is used to model the electromagnet is COMSOL Multiphysics®, a commercial FEA package provided by the University of Manchester, Computer Science School. Additionally, the ...
Study of Capacitance in Electrostatic Comb-Drive Actuators
P. Hanasi [1], B. G. Sheeparamatti [1], V. Abbigeri [1], N. Meti [1],
[1] Visvesvaraya Technological University, Belagavi, Karnataka, India
Capacitor is mainly defined as two conducting plates that can hold the opposite charges on it. These plates can be used either as a sensor or an actuator. If the relative distance between the two conductors changes as result of given input, then capacitance values will change. This results in basic of capacitive or electrostatic sensing configuration. On the other hand, if a voltage or the ...
Impact of Electrode Surface/Volume Ratio on Li-ion Battery Performance - new
S. Das[1], J. Li[2], R. Hui[1]
[1]University of Kansas, Lawrence, KS, USA
[2]Kansas State University, Manhattan, KS, USA
The adoption of micro- and nanostructured electrodes is a promising technique to improve the performance of Li-ion battery, which increases the electrode surface area and improves the efficiency of ion exchange between the electrode and electrolyte. This performance improvement is supported by the results of our numerical simulation based of a Li+ battery in COMSOL Multiphysics® software. The ...
Three-Dimensional Modeling of Electrical Scanning Probe Microscopy Problems
G. Gomila [1], L. Fumagalli [2], R. Fabregas [3],
[1] Institut de Bioenginyeria de Catalunya (IBEC), Departament d'Electrònica, Universitat de Barcelona, Barcelona, Spain
[2] School of Physics and Astronomy, University of Manchester, Manchester, United Kingdom
[3] Institut de Bioenginyeria de Catalunya (IBEC), Universitat de Barcelona, Barcelona, Spain
Electrical scanning probe microscopy (SPM) techniques, such as electrostatic force microscopy, nanoscale impedance microscopy or scanning near field microwave microscopy, are a relatively new branch of microscopy techniques that can generate images of the nanoscale electrical properties of samples (conductivity, permittivity, charge, etc.). These techniques scan the surface of a sample ...


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Over the last couple of years, I have been using Evernote for a number of reasons. First, I started out using Evernote because it was free and it looked cool. Then, I started getting more diligent with it once I downloaded the iOS app for both my iPhone and iPad. More and more, I found uses for this free app.
Then, I started making my move to "the cloud" about a year or so ago and I paid for the premium account. Now Evernote has become a great way to manage a number of daily work flows, including social. Below you will find a view of how I now use Evernote in a new way.
How I use Evernote to manage my social work flow:
Other folders in Evernote that have a close tie to my daily life as a social media advisor:
Other great Evernote resources:
You can read more from Reed Smith here.
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text:
Accentuate Your Home With Timeless Hinkley Wall Lighting
Since 1922, Hinkley Lighting has been producing quality lighting fixtures, including wall lights. Hinkley wall lighting includes wall sconces and vanity lights made from the finest materials and craftmanship. The wall lights are available in variety of forms, sizes, styles, and finishes with multiple bulb options to meet your individual lighting needs. Hinkley wall lights provide general, task, and accent lighting in a bedroom, dining room, foyer, hallway, and living room. While you may hang Hinkley wall lighting in bathrooms in halls you may want to use bedroom ceiling fans for the smaller living spaces, these will add cooling and optional illumination if necessary.
Interior designer Kyle Schuneman suggests using Hinkley wall sconces to compliment an existing chandelier. The wall fixture directs light into a room at eye level and creates a balanced layer of light in the living space. Choose Hinkley wall lighting with similar finishes, but different silhouettes to create a dramatic design element in the living room or hallway. Choose simple lines and contemporary finishes to update a bathroom and create a spa-like environment.
Hinkley wall lighting was showcased in Elle Décor's original showhouse in San Francisco, California. Hinkley pocket-wall lights have also been featured on the pages of Lonny magazine and most recently, the wall light manufacturer was highlighted in a 6-page spread on Enlightenment magazine. Hinkley wall lights are a simple way to transform your living space into a chic, magazine-cover-worthy room.


text:
Kenneth D. Loeffler Coach
Inducted in 2006
Naismith Memorial Basketball Hall of Fame Inductee 1964
As a coach, Loeffler preached team play, loved to wear bow ties and quote poetry. In his 20 year career, he coached at Geneva College Yale, Denver University and Texas A&M. But, he reached his greatest success as a college coach at LaSalle. Running a Figure Eight offense, he guided LaSalle to six straight seasons of 20 or more wins. With All-American Tom Gola leading the charge, the LaSalle Explorers dominated college basketball from 1952-1955, grabbing the NIT title in 1952, and the NCAA Championship in 1954. Prior to coaching at LaSalle, Loeffler had success in the pro ranks leading the St. Louis Bombers of the Basketball Association of America's Western Division title in 1948. Coach Loeffler also wrote one of the most detailed books about the game, entitled Ken Loeffler on Basketball.
Where They Are Now
Died January 1, 1975
Where They Were
Geneva University 1929-1935
Yale University 1936-1942
University of Denver 1946-1946
La Salle University 1950-1955
Texas A&M University 1956-1957


text:
A new index from Applause can help retailers see how consumers feel about apps.
Katie Evans
Applause, a mobile app analytics service that uses more than 60 million app reviews to rate 1 million iOS and Android apps, the company says, has launched the Applause Index, a daily measurement to help retailers and other companies gauge general consumer sentiment about the app world.
The index provides a daily look at how consumers feel about 60 of the most popular iOS and Android apps. It assigns a weighted, cumulative index score for apps on Google Inc.'s Android mobile operating system and Apple Inc.'s iOS. Each app is rated from 1 to 100 based on analysis of user reviews. However, The Applause Index scores for iOS and Android are more than just a sum of the respective apps' Applause Scores. Individual apps are weighted using a method that takes into account the number of downloads and reviews for each app in the index, the company says.
The index also includes scores for categories such as lifestyle (which includes retail), gaming and entertainment. The general index and category scores are updated daily, and the list of apps will be formally reviewed each quarter—with some apps being added or removed, depending upon market trends, Applause says.
Friday, for example, the Lifestyle category was down 6.8 points from a day earlier to 6,039.9 for iOS and 9.7 points to 5,091.8 for Android. For iOS, Zappos mobile gets a high score of 90 out of 100 and Groupon comes in second with a score of 89. Poor performers include LinkedIn and Twitter with scores of 36 and 37, respectively. For Android, Dominos Pizza comes in first with a score of 89 and Groupon's daily-deal app is a distant second with a score of 79. Bringing up the rear is Facebook with a score of 25 and Target with a score of 29.
Over all categories, Calorie Counter and Diet Tracker comes in first for iOS with a score of 95 and restaurant reservation app OpenTable comes in second with a score of 92. For Android, Calorie Counter and Diet Tracker leads again with a score of 88 followed by Dictionary.com with a score of 87. The overall index score for Friday was up 1.1 points to reach 6,701.8 from 6700.7 a day earlier for iOS and down 2.9 points to 5,413.4 from 5,416.3 a day earlier for Android.
"The apps economy is driven by how effectively companies connect with users," says Matt Johnston, chief marketing officer for uTest Labs, which operates Applause and created the Applause Index. "Through app store ratings and social media, those users decide which apps and companies win or lose. The Applause Index fills a need we've heard expressed—from business leaders, from journalists and from top-tier analysts—seeking a way to accurately track and measure overall user sentiment and satisfaction in the apps economy."
Target is No. 34 in the Internet Retailer Mobile 400.


text:
|Posted by Sylvan TiegerLMP on December 26, 2003 at 16:45:56:
|In response to Re: central heating hammer
: how can i eradicate what is probably a contraction/expansion noise.It's audible when central heating boiler is ACTIVE & when it deactivates.It appears to eminate from a single point.I'm reluctant to remove flooring.It would be a major task. I would appreciate any practical cost conscious advice.
If you hear a "rubbing" sound you maybe headed for a premature heating system failure as this rubbing which causes friction can and does wear out the thin walls of most modern heating materials.
You may want to contact a LMP to see if adequate provisions were provided for the coefficient of expansion and contraction of these heating lines.
For copper systems the velocity should not exceed 3 FPS especially if the heating water is 180 degrees or more as this system will fail from erosion.
Hydronic systems should be felt never heard unless there is a problem in design or air in the system
|Replies to this post
|There are none.


text:
Hush Puppies Epic Flat
Sorry, this item is sold out!
Looks like you've got more shoe shopping to do - have fun!
Looks like you've got more shoe shopping to do - have fun!
Item # 274523
Slip-on something cute and comfortable in the Hush Puppies Epic. This adorable, cushioned shoe has everything you need to keep you looking good!
- Leather upper
- Velcro Mary-Jane strap
- Cushioned insole
- 1¼" molded demi wedge heel
- Synthetic sole
- Imported
- View more Women's Hush Puppies Shoes
By: Emily00
Location: Wisconsin
April 20, 2014
Stylish, and doesn't hurt my feet
"While I wouldn't buy these shoes to walk any marathons, for an office job I find them pretty comfortable, not terribly bulky, and stylish. I LOVE the brown color, unlike some browns it's dark but with some warm tones to it and some shine so it doesn't fall flat. I also like the little bit of height in the heel, sometimes when I wear flats I end up stepping on the hem of my pants, but not with these. I do think they run a tad bit long. I bought a 9 (my normal size for shoes other than sandals) and found that my heel was slipping out of it. But an 81/2 would have been too narrow in the front so I put stick on pads on the heel and now they are fine."
By: KayForde
Location: Miami
April 09, 2014
"LOVE this shoe. Bought it for work, no regrets :)"
By: babzbaby
Location: Vero Beach, Florida
January 30, 2014
Stylish, great shoes.
"These shoes are true to size, well-made and too cute for words. They make my feet look very chic. I plan to wear them in Europe where we will be walking on a lot of cobblestones and I know they will be very good for that. They have good support and didn't need any breaking in time."
By: GinaNY
Location: NYC
November 25, 2013
Cute and comfy
"Very cute, very comfy, enough said! I bought both the brown and the black."
Click anywhere to close this.


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Have to say escapeejm I am lovin that sig.
Have to say escapeejm I am lovin that sig.
The next Generation of perverted ninjas is fully prepared to take their place. The line of the Toad Master will never fail as long as there is a will of fire. Rest In Peace Jiraiya-sama, this world and Tsunade were not good enough for you.
I am as far beyond you fanboys as you are above the humans.
Samurai Champloo & Raikiri too
well.. I too am feeling she will die.. And it will give sakura a mental boost.
It just seems that way, she'll win in protecting the village though. I don't see konoha being destroyed, maybe naruto taken...
And tsunadee cannot be underestimated in a fight, you're forgetting that she hadn't fought in a long time when we first met her and saw her fight. Like 4 years have past and obviously tsunadee trained her butt of, you will see. She'll put up a hell of a fight with moves we haven't seen before.
The other option would be tsunadee failing in protecting naruto and naruto will be taken and she will be crying... (her not dieing right now)
i actually want tsunade 2 die!
Sigs and Ava by Ravona
But first it seems as if kakashi is gonna pop. looks like pein has some kind of pre-emtion eye power, somewhat similar to the sharingan? I think tsunade will probably last through this ark if kakashi is gonna die. it would be a shame for both kakashi and tsunade to die.
currently it seems as if tsunade dying is a 20% possibility and kakashi 80%. so bye bye one-eyed wonder!
Panda Facts
Spoiler!Panda Fact 1:99% of a pandas diet is bamboo.
Panda Fact 2:In China they call the Panda "Xiongmao", which means Giant Cat Bear.
Panda Fact 3:Don't mess with The Panda -_-
Panda Fact 4: Giant Pandas can spend up to 16 hours a days eating.
Panda Fact 5:A panda gives birth to twins 45% of the time but in wild can only look after one baby so one usually die.


text:
Self Storage Circuit Of the Americas
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Reserve a storage unit for FREE in 2 minutes.
Results 1 - 12 of 12 Facilities in Austin, TX.
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AAA Storage Hwy 71E1 miles
|Del Valle, TX 78617
Cool Box Portable Storage1 miles
|Austin, TX 78747
Airport Self-Storage1 miles
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Thaxton Towing & Storage1 miles
|Austin, TX 78747
Lockaway Storage - Ben White1 miles
|Austin, TX 78741
A-Austin Storage Center1 miles
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Cheap self storage Units in Austin, TX.
Austin, TX is a great place to rent self-storage units.
Austin is the capital state of Texas and the seat of Travis County. With a growing population of nearly one million residents, the demand for self-storage in Austin continues to increase rapidly. Located in Central Texas on the eastern edge of the American Southwest and north of San Antonio, west of Houston and south of Dallas, it is the thirteenth most populous city in the United States and the fourth most populous city in the state of Texas.
Austin's population is scattered across many zip codes and 78745 being the most populated, followed closely by 78753, 78741 and 78758.
Austin is home to the regional offices of many large Fortune 500 companies, such as Google and Apple. Self-storage is very popular for businesses because it provides a viable solution to store office documents and supplies. Austin is considered to be a major center for high tech and its economy is driven by several large technology companies. The University of Texas at Austin provides engineering and computer science majors and its graduates help to fuel the technology and defense sectors.
Popular institutions of higher learning in Austin include St. Edward's University, Austin Community College, Concordia University, Huston-Tillotson University, the Seminary of the Southwest, the Acton School of Business, Austin Graduate School of Theology, Austin Presbyterian Theological Seminary, Virginia College's Austin Campus, The Art Institute of Austin, Austin Conservatory, and a brand of Park University. Students who attend any of these universities can search for Austin self-storage with convenient truck rentals in order to make the self-storage move-in a bit easier.
The Austin Film Festival is held annually and brings in many different films from all over the world. Several popular films have been produced in Austin such as The Texas Chain Saw Massacre, School of Rock, and Spy Kids to name a few. Movies require hundreds of props for a successful production. These items can be conveniently stored in any of the self-storage facilities located around Austin.
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Downtown Austin is considered the central business district and has some of the tallest condo towers in the state. There are also several recreational spots located in this area — museums, coffee shops, nightlife, record stores, and upscale boutiques. If you are located in the downtown area of Austin, you can conveniently search using a zip code in order to identify self-storage facilities which are nearest to you.
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Enter the city or zip code of your choice into the search bar to find storage for rent nearby. Once you locate Austin storage, compare Austin storage unit sizes, prices, amenities and discounts. Check out pictures, descriptions, and read customer reviews to assist you when making a selection. Once you select the public storage unit that best fits your needs, simply reserve online for free and lock in your storage unit price and discount. If you choose, you can call and speak to a friendly and professional customer service representative, who could answer all your questions and who could take a reservation over the phone for free. No credit card is required to reserve storage units online or by phone. A detailed confirmation e-mail will be automatically forwarded to your inbox. Your storage unit will be available for you when you arrive at the self-storage facility on your selected move in date. Finding public storage Austin, is that fast and easy.
FIRST MONTH FREE, $1 the first month, 50% off discounts for self storage in Austin, TX.
Public Storage facilities in Austin, TX offer a variety of discounts to their customers. When searching for storage units Austin, compare the price of the storage unit as well as the discount that storage facility is offering on that unit. Some self-storage facilities offer the same special on every storage unit they have in their inventory, while other facilities might offer different specials on selective storage units in their inventory. Austin storage facility specials change from day to day, depending on the storage facilities occupancy of a particular storage unit at that given time. Some storage facilities might not offer a discount on a storage unit.
Storage for rent in Austin, TX. Prices can vary based on storage unit sizes and it's amenities.
Self-Storage unit prices in Austin start as low as $18.00 per month. Typically smaller storage units are less expensive and are located on an upper floor or are stacked above another unit, requiring a rolling ladder to access the unit. You will also find that a lower floor or ground floor storage unit will typically cost you more money than a unit that is an upper floor that would require elevator access. The most common storage units are 5' X 5', 5' X 10', 10' X 10' and 10' X 20' and standard ceiling storage unit heights are 8 feet high. Storage unit doors could vary in width from 3' to 8' feet wide depending on unit size.
Whether a unit is climate controlled or a drive up, will determine the price. Usually, storage units which are climate controlled, air conditioned, are more expensive than drive up units accessible from the outside.
Your search results have produced 64 storage locations in Austin.
Within 5 miles of your Austin storage search query we are showing 2 storage facilities. Within 25 miles of your Austin storage search query we are showing 64 storage facilities. Enter your zip code, address or city to find your unit now and reserve for free.
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DC Shoes Court Graffik SE Skate Sneaker - Mens
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Item # 261864
Specially designed for skaters, the DC® Court Graffik SE technical skate shoe is durable, artistically designed and is ready to face almost any trick, this sneaker will keep you going cool and casual all day, every day. The leather upper is ultra-heavy duty and is resistant to abrasions and scuffs, while the flexible tongue holder helps maintain and build strength.
- Action leather, suede and synthetic upper
- DC trademark
- Flex, cushioned and shock absorbing midsole
- Vulcanized sticky rubber outsole with racing stripe
- Weight : 14 oz
- Imported
By: pumafan
Location: NJ
October 16, 2012
DC has great skate shoes!
"Perfect skate shoe, well made lasts and lasts."
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text:
The latest development in the world of doping in sport appears to be some doubt on behalf of the World Anti Doping Agency about clenbuterol. Clenbuterol is, of course, at the centre of the current long-running Alberto Contador saga – the 2010 Tour de France winner failed a test for a very, very small quantity of the asthma drug during last year's Tour, and claimed, rather memorably, that it was from a contaminated steak he'd eaten. Specifically, a steak from Spain, where clenbuterol is, he clams, used (illicitly) in livestock farming.
WADA seems recently to have admitted the possibility of this sort of contamination, which is going to have knock-on effects on the Court of Arbitration for Sport hearing on the Contador case that's scheduled for after this year's Tour.
The real issue is not what drugs are banned, what quantities they're banned it, where they come from, or even what their effects are.
The real issue is the strict liability element of current drug-enforcement. As things stand, if something banned is found in your system, that's it. You're guilty. Certain cases, on a wildly inconsistent basis, seem to find gaps in this, but that's the principle, and the only real flexibility is the punishment handed down.
Now, if this were a criminal matter, that's not how it would work. While strict liability does exist for some criminal offences, they're rare, and doping in sport would not be one of them. Criminal offences require not only a 'guilty act', but a 'guilty mind'. In doping, you'd have to show that a substance was taken, and then you'd have to show that it was taken knowingly, with the intention of improving performance.
The reason doping regulations don't follow the criminal model is simply one of practicality. It would be very difficult to prove the mental elements of the offence. Strict liability increases the conviction rate. But it does it at the cost of convicting some athletes who are innocent in all the respects that matter to justice. Alain Baxter, the skier, is the classic example. He took an over-the-counter cold remedy that had different ingredients in North America from those that he'd carefully checked in the UK version, and which had no influence on his performance anyway. Still guilty.
WADA are now in the deeply uncomfortable position of pursuing Contador, while at the same time having raised doubts about the mental elements of his offence. In effect, they've come close to admitting he might be right after all, while at the same time maintaining a set of regulations that in essence say that even if he's right, it doesn't matter.
The Court of Arbitration is now in an impossible position. They can't find him guilty, but they can't let him off (assuming they accept the evidence of the dope test) without essentially taking WADA's decision for them.
I'm confident this is going to run and run, and the consequences in the fight against doping in sport are going to be significant.


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Bagful ture of predicaments
ever thought about wheat berry,what is in a with their purses?
you've been taught from youngsters not to ever peer into a woman's designer handbag. never ever possessing notion. should anyone ever do you know, you will most probably come across yourself contemplating why should you a wine attached to higher cards serum has to relate real estate by having a packet suji rava, Chillies and furthermore ginger root,and arrangement is tough beat. rather, this method television shows a authentic expectant mum working. akin to mine. the actual suji packs were a-must when there we were travelling to completely new urban world. she'd be impervious because of the surprised styles of edinburgh airport prevention what persons checked out your lady gear. and be sure to journeyed you will find the recognizable scent of most upma, evokes Srinivas, one specific lecturer. your partner's sister is not by yourself. you can scores of women in whose bags hold problems that are part of everybody else in the family. "every single time I think of the ladies suffering from modern purses, I special for what reason I are not like all of them. I investigate my in a position broke case crammed with boxes attached to cookies to have my daughter, the best husband's personal stereo and earphone, an individual's cellphone, mine and additionally each and every totes, utters Urvashi, a functioning the mother. might elements degenerate? "positive. if your his conversation teases you mercilessly for carrying a container that has a good deal more pockets compared to a railroad and reflects our flat getting a pancake the purse. built the groom and youngsters,children's be aware of not a single thing great comes in the tote, it should be realized facelift structures and a novel, you could potentially go buying designer purse that is not shoved to do the assistance to of a particular carrier!SUBHA t RAO


text:
It was a case of close but no cigar for Italy as England claimed another unconvincing 19-15 Six Nations victory in Rome on Saturday.
It was a case of close but no cigar for Italy as England claimed another unconvincing 19-15 Six Nations victory in Rome on Saturday.
Italy outscored their hosts two tries to one, however it was once again the boot of Owen Farrell that saved the day for England as the young centre contributed 14 points in horrendous conditions.
The Azzurri will be kicking themselves after leading 12-6 at half-time thanks to two quickfire tries before the break, but weren't able to keep up the pressure in the second half as England were forced to dig deep against their stubborn hosts to claim back-to-back away wins.
After a scrappy opening littered with poor kicking out of hand, England were unfortunate not to bag the game's opening try on the half-hour when David Strettle's kick-through was eventually touched down by Phil Dowson.
Referee Jerome Garces had already blown for obstruction on Strettle – and Farrell converted the resulting penalty before adding another soon afterwards.
But two minutes before the break, a pair of grubber kicks caused confusion and wing Giovanbattista Venditti was on-hand to punish Ben Foden's fumble by falling over the line in the corner.
England seemed set to enter the dressing room one point to the good but from the restart, Foden's attempted off-load was intercepted for centre Tommaso Benvenuti to race under the posts from the halfway line and ignite the stadium.
Italy pivot Kris Burton capitalised with a penalty that made it 15-6 early in the second period, but England immediately clawed their way back into it when opposite number Charlie Hodgson charged down Andrea Masi's attempted clearance for a try out of nowhere.
It was the England fly-half's second charge-down try in as many games – and once again proved to be the turning point in the match.
The introductions of Lee Dickson and Ben Morgan cemented the visitors' momentum – providing the opportunity for the flawless Farrell to drive over a 54th minute penalty and secure the narrowest of leads.
With Martin Castrogiovanni injured in the first period, England had more than held their own up front and Farrell stretched the advantage to 19-15 in the 65th minute from a penalty awarded at a scrum.
Tobias Botes replaced Burton for the final half-hour and was handed two shots at goal that would have won the game – but the South African-born scrum-half was woefully off-target with both as England crept home.
Man of the match: A committed display by a number of Italians ultimately went unrewarded, with skipper Sergio Parisse once again leading from the front. However, a nerveless and flawless display of kicking from Owen Farrell amid freezing conditions in Rome helped the visitors claim their come-from-behind win.
Moment of the match: The dramatic double strike from Giovanbattista Venditti and Tommaso Benvenuti had given the Azzurri a clear lead at the half-time interval before England managed to turn the tables through that second-half try from Charlie Hodgson that sparked England into life.
Villain of the match: The weather! In freezing conditions, scores were always going to be hard to come by and it was no surprise that both sides struggled to create much.
The scorers:
For Italy:
Tries: Venditti, Benvenuti
Con: Burton
Pen: Burton
For England:
Try: Hodgson
Con: Farrell
Pens: Farrell 4
Italy: 15 Andrea Masi, 14 Giovanbattista Venditti, 13 Tommaso Benvenuti, 12 Gonzalo Canale, 11 Luke McLean, 10 Kristopher Burton, 9 Edoardo Gori, 8 Sergio Parisse (c), 7 Robert Barbieri, 6 Alessandro Zanni, 5 Quintin Geldenhuys, 4 Marco Bortolami, 3 Martin Castrogiovanni, 2 Leonardo Ghiraldini, 1 Andrea Lo Cicero.
Replacements: 16 Tommaso D'Apice, 17 Lorenzo Cittadini, 18 Antonio Pavanello, 19 Mauro Bergamasco, 20 Fabio Semenzato, 21 Tobias Botes, 22 Luca Morisi.
England: 15 Ben Foden, 14 Chris Ashton, 13 Brad Barritt, 12 Owen Farrell, 11 David Strettle, 10 Charlie Hodgson, 9 Ben Youngs, 8 Phil Dowson, 7 Chris Robshaw (c) 6 Tom Croft, 5 Tom Palmer, 4 Mouritz Botha, 3 Dan Cole, 2 Dylan Hartley, 1 Alex Corbisiero.
Replacements: 16 Rob Webber, 17 Matt Stevens, 18 Geoff Parling, 19 Ben Morgan, 20 Lee Dickson, 21 Jordan Turner-Hall, 22 Mike Brown.
Referee: Jérôme Garces (France)


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David W. Sharp was named plant manager at PacifiCorp's Huntington Canyon plant in September and has relocated to central Utah from Wyoming where he has lived for the past 26 years. His most recent assignment with the company was technical support manager at the Jim Bridger plant, near Rock Springs.
Sharp has worked in the electric power generation industry and related fields for nearly 30 years. He received a bachelor's of science degree in mechanical engineering from Washington State University and holds a professional engineer's license. He also completed graduate level work at Portland State University in environmental science. The majority of Sharp's work experience has been in the operations, maintenance and engineering of coal-fired generating stations. He came to work for PacifiCorp in 1976 when he joined the company's headquarters staff in Portland, Ore. Other assignments with PacifiCorp include the Wyodak plant near Gillette, Wyo.; Jim Bridger plant near Rock Springs, Wyo.; and Naughton plant near Kemmerer, Wyo.
He enjoys fishing, hiking and other outdoor activities. He also is an avid handball player and is hoping to find others in the area who play. When asked about his hobbies, he said that with all the relocations during his career his main hobbies have been landscaping yards and finishing basements at his residences.
Sharp is from Moses Lake, Wash., and is married to Pam, also of Moses Lake. He said his wife is excited to be living in a warmer climate so she can better utilize her skills as a master gardener. They have two sons. The oldest is a graduate of New Mexico State University and currently lives in Sun Valley, Idaho. The youngest is a student at the University of Wyoming in Laramie.


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Audrey Brooke Mila Pump
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Item # dsw12prod5130238
The Audrey Brooke Mila has just the right amount of chicness you need to pump up your look. The detailing adds a fun and flirty element to this everyday pump.
Check out the Audrey Brooke Mila, featured on our blog!
- Leather or suede upper
- Pointed cap toe
- 3¼" covered heel
- Synthetic sole
- Imported
- View more Women's Audrey Brooke Shoes
By: RKNewYork
Location: New York
June 27, 2014
Too Narrow
"I loved the teal color but these shoes were too narrow for me. I didn't feel comfortable after wearing them so had to return."
By: iyinoje
Location: CT
April 19, 2014
"I love this shoes, I bought them immediately I saw them online...they came on time & love it more in person. DSW, I think I'm addicted to shoes thanks to you ..lolMy birthday is coming up & I'm glad I bought it"
By: DrShoes66
Location: Chicago
April 15, 2014
"Stunning statement shoe. I have beige and teal. Favorites!!!"
By: PM3185
Location: Chicago
April 13, 2014
Loving my Teal heels
"I fell in love with the teal heel when I saw it online. This was my gift to myself on my B'day and ordered online. I just got it yesterday in hand. I normally don't buy heels online without seeing and feeling the cushion level of the shoes in person. I need comfy shoes and very picky about it. But I trusted my gut and all you "Shoe Lovers'" great reviews and got it; I'm so glad I did. The shoes are even more gorgeous in hand and one of the most comfy heels I own. Can't wait to pair it up with an awesome outfit to complement my gorgeous "Teal heels" :)"
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text:
Fergie Postive Pump
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Item # 252698
Unleash your inner diva in the Fergie Positive. This d'Orsay pump is alluring, stylish, and perfectly compliments your style with ease.
- Faux patent leather upper
- Round peep toe
- 1" platform, 4" covered heel
- Synthetic sole
- Imported
By: Stxcocoa
Location: Dallas, TX
January 12, 2013
"I bought these in Coral & they are beautiful & very comfortable. They are true to size & more beautiful in person. Must have!!!"
By: kimmyjb
Location: las vegas
November 10, 2012
"I was shocked that a platform could be so comfortable......"
By: Fashiongeek
Location: California
October 18, 2012
In Crowd Shoe
"These are definitely "In Crowd" shoes. I brought these shoes in a very soft patent leather gray color: The color will go with silver for the Holiday season. The heels are not to high with the platforms attached and the style of the shoe is marvelous. The shoes are comfortable and features a platform that is sold on many very expensive shoes of today's styles. Thank you Fergie for the style and Thank you DSW for the affordable price."
By: Platy81
Location: West Chester, PA
September 24, 2012
Love these shoes!
"They fit true to my 5.5 size and are very comfortable to wear and walk in. I'm am used to wearing platform heels on an almost daily basis though. They do not rub my feet at all and I have received many compliments on these shoes. They fit comfortably snug on my average fit feet but are not too tight. I would recommend these shoes to heel wearers!"
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By KEN ENGLISHGreen River
Dear Editor,
Labor and social security laws can prevent illegal immigration. Immigration can be controlled if state and federal laws are changed on minimum wage laws for farmers and restaurant workers.
Also the green cards should be improved to where they cannot be duplicated or forged, such as computers law enforcement uses to prevent fake driver's licenses.


text:
Lewistown Field Office
|Release Date: 06/07/11
BLM Reminds Boaters of Seasonal Restrictions
The Bureau of Land Management's Upper Missouri River Breaks National Monument Office (BLM) would like to remind recreationists that the seasonal motorized watercraft travel restrictions on the wild and scenic segments of the Upper Missouri National Wild and Scenic River will begin on Wednesday, June 15 this year.
The wild and scenic segments include those areas between Pilot Rock (river mile 52) and Deadman's Rapids (river mile 84.5) and from Holmes Council Island (river mile 92.5) to the Fred Robinson Bridge (river mile 149).
Between river miles 52 and 84.5, no upstream motorized travel is allowed and downstream motorized travel is allowed only at a no-wake speed. Between river miles 92.5 and 149, no motorize travel (upstream or downstream) is allowed Sunday through Wednesday and downstream motorized travel is allowed only at a no-wake speed Thursday through Saturday.
The split-week seasonal restriction between river mile 92.5 and 149 is a result of public comments offered during the preparation of the management plan for the Upper Missouri River Breaks National Monument.
These seasonal restrictions will remain in place through Thursday, September 15, 2011.
The only exception to these seasonal restrictions may be occasional administrative, emergency or law enforcement needs. "Our administrative duties require that we occasionally use motorized watercraft to complete compliance checks, weed control efforts and recreation site maintenance. On occasion, emergency services (search and rescue and medical evacuations) and law enforcement needs also require that we use motorized watercraft. We appreciate the public's understanding when these needs and duties interrupt an otherwise quiet river setting," according to Monument Manager, Gary Slagel.
History of Seasonal Closures
"Seasonal restrictions have been a part of managing and recreating of the Upper Missouri
since the first management plan was written for the Wild and Scenic Missouri (30 some years ago) and balance the interests of motorized and non-motorized recreationists. These seasonal restrictions are authorized under 43 CFR 8351.2-1; Special Rules," offered Joe Nardinger, a BLM law enforcement ranger stationed in Fort Benton.
Open Segments
The recreational segments of the Upper Missouri remain open to motorized watercraft use. These segments include the first 52 river miles from Fort Benton downstream to Pilot Rock (river miles 0 through 52) and an eight-mile segment from Deadman's Rapids to Holmes Council Island (river miles 84.5 through 92.5).
Portable Toilets
"We would also like to remind overnight boaters/floaters they are required to have and use a portable toilet on their trip. We implemented this decision in 2004, based upon concern about human waste disposal along the Upper Missouri. Area landowners, boaters/floaters, county commissioners and the Central Montana Resource Advisory Council all supported implementing this requirement," Nardinger added.
Monument Manager Gary Slagel would also like to remind campers to drown their campfires completely out before leaving camp. "As wet as we've been it may seem early to mention the dangers of live campfires and their potential to start wildfires. However, it's surprising how often our river rangers find abandoned campsites with fires still burning. Regardless of where we're camping, we all have to be extremely careful with campfires," Slagel said.
River Flows
River flows (at the Kipp Recreation Area) during the week beginning June 6, were at 42,600 cubic feet per second (CFS). Normal flows this time of year are closer to 16,700 CFS. Flows this large typically create notable/dangerous conditions with fast water carrying much debris and difficulties with launching and landing. "We want folks to have a safe and fun trip, but we certainly encourage floaters and boaters to assess these conditions, their equipment and their individual abilities before they launch," Slagel added.
If you have questions about river flows, please contact Gary Slagel at 406-538-1950 or Mark Schaefer at 406-622-4015.
If you have questions about these seasonal restrictions or to report a violation, please contact BLM rangers Joe Nardinger at 406-622-4017.
The BLM manages more than 245 million acres of public land, the most of any Federal agency. This land, known as the National System of Public Lands, is primarily located in 12 Western states, including Alaska. The BLM also administers 700 million acres of sub-surface mineral estate throughout the nation. The BLM's mission is to sustain the health, diversity, and productivity of Americas public lands for the use and enjoyment of present and future generations. In Fiscal Year 2015, the BLM generated $4.1 billion in receipts from activities occurring on public lands.
Lewistown Field Office 920 NE Main Lewistown, MT 5959457
|Last updated: 06-28-2012
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Special assistance
Alitalia has a dedicated team for passengers requiring special assistance. Request assistance when you book your flight. Call 00961 1 966175/6 or contact the Customer Relation Office nearest you at least 48 hours before departure to request appropriate assistance according to your needs.
For more information on the rights of people with reduced mobility, please refer to EC Regulation 1107/06
The following passengers must be accompanied by another person:
- Those who for physical or mental reasons cannot care for themselves
- Those who cannot independently operate their wheelchairs or those who, if necessary, cannot cooperate with flight staff for the emergency procedures applicable to them
- Those who are both deaf and blind
- Those who need to be transported on a stretcher
While the flight crew can help passengers open meal packages and accompany them to the bathroom door, they cannot help passengers eat or take medication, nor assist them inside the bathroom. If you require help with any of these functions you will need to travel with an accompanying person.
In accordance with that established by the EASA (European Aviation Safety Agency) for safety purposes in Air Ops – Commercial Air Transport (May 2013), "Persons requiring special conditions, assistance and/or devices when carried on a flight shall be considered as SCPs (Special Categories of Passengers)."
The following are included in this category:
- Persons with reduced mobility (PRMs) who, without prejudice to Regulation (EC) No. 1107/2006, are understood to be any person whose mobility is reduced due to any physical disability, sensory or locomotory, permanent or temporary, intellectual disability or impairment, any other cause of disability, or age
- Infants (under two years old) and unaccompanied minors
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SCPs shall be carried under conditions that ensure the safety of the aircraft and its occupants. Companies are responsible for checking that "the number and categories of SCPs [present on board] do not exceed the number of passengers capable of assisting them in case of an emergency evacuation"...
For this reason, in order to comply with the aforementioned safety measures, you may be asked to book on an alternative flight to the one you wish to take.
If you need a doctor's permission for air travel, you must print, complete and then have your doctor sign and stamp the Medical Information Form (MEDIF) not more than seven days before your travel date. The MEDIF form must be sent to the Call Center during the booking phase for processing by the Alitalia medical service at least 72 hours before departure, not counting Saturdays and public holidays. If medical clearance is required for the transport of passengers on stretchers, the form, completed in full and signed and stamped by the passenger's attending physician, must be received at least five days beforehand, not counting Saturdays and public holidays.
Passengers who suffer from chronic diseases or have physical disabilities may also show a FREMEC (Frequent Traveler Medical Card) and health card valid for five years.
Your wheelchair, electric or fold-up, will be tagged and placed in the hold free of charge. You must check it in at least one hour prior to departure for domestic flights, 1½ hours prior to departure for medium-haul flights and 2 hours prior to departure for long-haul flights.
Alternatively, you can book a wheelchair service, specifying the degree of impairment. Passengers with reduced mobility can transport free of charge up to two personal mobility devices (e.g. wheelchair, walker) and one extra bag weighing a maximum of 23 kg for carrying medical supplies.
If you need to travel on a stretcher, you can request this special service when you book your flight tickets.
A Safety Briefing Card is available for blind and vision impaired passengers on medium-haul Airbus aircraft. The card contains passenger safety information in Braille with raised figures and in keeping with regulations covering legibility and color contrasts for visually-impaired passengers. It has the following characteristics:
- Text with letters and colors for visually-impaired passengers (and their assistants)
- Text written in Braille
- Figures in 3D showing features such as the location of emergency exits, a layout of the cabin, instructions on how to fasten and unfasten seat belts, emergency positions and the use of safety jackets and oxygen masks.
Please mention your need to travel with a guide dog when booking the flight to find out about the availability for it to travel in the cabin or in the hold. Guide dogs travel free of charge and are not subject to weight limitations as long as they have a muzzle, a leash and, if they have to travel in the cargo hold, an appropriate carrier.
Find out about the other special assistance services:
- Oxygen therapy for passengers with heart, lung or respiratory conditions to prevent the effects of cabin pressure when the airplane is flying at high altitudes
- Transportation of liquid medicine and syringes on board, for personal use, in sufficient quantity for the entire trip (flights to and from the destination and for the duration of the stay). Authorization from the airline is needed and must be requested when booking the flight. The following must be provided at check-in:
- Medical certificate dated within 30 days of the flight that attests to the need, quantity and method of administration for the drug
- The manufacturer information sheet for the drug
- Self-certification that the container is crush-resistant and tipping-resistant


text:
Diadora Maracana MD PU Soccer Cleats - Womens
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Item # 276822
The Maracana MD PU from Diadora® will provide you with the ability to play like your most adored soccer players.
- Full-grain, soft leather upper
- Soft ankle collar lining for comfort.
- No-stretch lining to ensure shape retention.
- Partial hidden loop lacing system so laces won't be in the way of your kicking surface.
- Fixed cotton and shock-absorbing EVA foam insole.
- Axeler Technology MD PU connects all 12 studs for forefoot stability and propulsion.
- Imported
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