text:
Management of post-acute covid-19 in primary care
BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3026 (Published 11 August 2020) Cite this as: BMJ 2020;370:m3026Read more on Long covid
Nisreen A Alwan: What exactly is mild covid-19?
Paul Garner: A roller coaster of ill health, extreme emotions, and utter exhaustion
Patients' experiences of "longcovid" are missing from the NHS narrative
Grant Stewart: My experience of covid-19—not just another experience
- Trisha Greenhalgh, professor of primary care health sciences1,
- Matthew Knight, consultant respiratory physician2,
- Christine A'Court, general practitioner1,
- Maria Buxton, consultant respiratory physiotherapist3,
- Laiba Husain, research assistant1
- 1Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- 2West Hertfordshire Hospitals NHS Trust, Watford, UK
- 3West Hertfordshire Respiratory Service – Central London Community Healthcare, London, UK
- Correspondence to: T Greenhalgh trish.greenhalgh{at}phc.ox.ac.uk
What you need to know
Management of covid-19 after the first three weeks is currently based on limited evidence
Approximately 10% of people experience prolonged illness after covid-19
Many such patients recover spontaneously (if slowly) with holistic support, rest, symptomatic treatment, and gradual increase in activity
Home pulse oximetry can be helpful in monitoring breathlessness
Indications for specialist assessment include clinical concern along with respiratory, cardiac, or neurological symptoms that are new, persistent, or progressive
Post-acute covid-19 ("long covid") seems to be a multisystem disease, sometimes occurring after a relatively mild acute illness.1 Clinical management requires a whole-patient perspective.2 This article, intended for primary care clinicians, relates to the patient who has a delayed recovery from an episode of covid-19 that was managed in the community or in a standard hospital ward. Broadly, such patients can be divided into those who may have serious sequelae (such as thromboembolic complications) and those with a non-specific clinical picture, often dominated by fatigue and breathlessness. The specialist rehabilitation needs of a third group, covid-19 patients whose acute illness required intensive care, have been covered elsewhere.3
Defining post-acute covid-19
In the absence of agreed definitions, for the purposes of this article we define post-acute covid-19 as extending beyond three weeks from the onset of first symptoms and chronic covid-19 as extending beyond 12 weeks. Since many people were not tested, and false negative tests are common,4 we suggest that a positive test for covid-19 is not a prerequisite for diagnosis.
How common is it?
Around 10% of patients who have tested positive for SARS-CoV-2 virus remain unwell beyond three weeks, and a smaller proportion for months (see box 1).7 This is based on the UK COVID Symptom Study, in which people enter their ongoing symptoms on a smartphone app. This percentage is lower than that cited in many published observational studies,89 whose denominator populations were those admitted to hospital or attending specialist clinics. A recent US study found that only 65% of people had returned to their previous level of health 14-21 days after a positive test.10
A patient's account
My wife, kids, and I all had symptoms of presumed covid-19 in early April 2020. They were soon fine, but I was more unwell and ended up in bed extremely fatigued, lethargic, and without appetite for four days.
The only person whose symptoms persisted was myself, and the fatigue which I had experienced was still lingering in the background. From this point onwards, it became difficult to engage fully in day to day activities with my normal energy levels. Exercise, of which I do a fair amount, was not at all possible.
I continued to feel like this for another three weeks, before finally feeling completely overwhelmed. This happened very quickly and without warning, resulting in me heading for bed immediately as I felt so bad. For the next 72 hours, I felt unwell in a way that was bordering on not coping. I was feverish, soaked with sweat to the point of having to regularly towel myself down, and with a persistent headache that had no relief in spite of increased doses of paracetamol or ibuprofen.
My chest was painfully tight, and my breathing was slightly erratic; I began to experience a shortness of breath in random waves that didn't leave me gasping for air but certainly made me uncomfortable and very worried. My glands were swollen to the point that it was physically challenging to swallow, and this was only possible with severe discomfort. I felt physically exhausted, mentally drained, and, for the first time in my life, began to consider asking for additional help.
It was at this point that I noticed I had also not had any sense of smell for the past week, and this has continued to be the case since.
Overall, I spent seven days feeling like I had been knocked sideways. I rarely get unwell, and if I do it's a fleeting fling with something that is usually seasonal and easily self medicated. This felt very different and was particularly challenging as there were points during my sickness that I was completely overwhelmed.
As far as recovery goes, it has now taken a full seven to eight weeks to start feeling close to my normal self again. In the aftermath of this, I have continued to experience the following: fatigued to the point of having to sleep in the day, inability to exercise, continued shortness of breath both motionless and when exerting, small waves of anxiety, considerable depression, continued loss of smell. These are all post-symptoms that I have had no experience or medical history with, and so it has been difficult to wrestle with the unexpectedness of them.
I'm back out doing moderate exercise now and glad to be through what has been a very difficult 12 week cycle from start to end.
40 year old man, who was previously fit
We also recommend recent articles by a social scientist5 and clinical academic6 with prolonged covid-19 symptoms.
Why are some people affected?
It is not known why some people's recovery is prolonged. Persistent viraemia due to weak or absent antibody response,11 relapse or reinfection,12 inflammatory and other immune reactions,1314 deconditioning,2 and mental factors such as post-traumatic stress1516 may all contribute. Long term respiratory, musculoskeletal, and neuropsychiatric sequelae have been described for other coronaviruses (SARS and MERS),171819202122 and these have pathophysiological parallels with post-acute covid-19.23
What are the symptoms?
Post-acute covid-19 symptoms vary widely. Even so-called mild covid-19 may be associated with long term symptoms, most commonly cough, low grade fever, and fatigue, all of which may relapse and remit.47 Other reported symptoms include shortness of breath, chest pain, headaches, neurocognitive difficulties, muscle pains and weakness, gastrointestinal upset, rashes, metabolic disruption (such as poor control of diabetes), thromboembolic conditions, and depression and other mental health conditions.424 Skin rashes can take many forms including vesicular, maculopapular, urticarial, or chilblain-like lesions on the extremities (so called covid toe).25 There seems to be no need to refer or investigate these if the patient is otherwise well.
What tests are required?
Blood tests should be ordered selectively and for specific clinical indications after a careful history and examination (see infographic); the patient may not need any. Anaemia should be excluded in the breathless patient. Lymphopenia is a feature of severe, acute covid-19. Elevated biomarkers may include C reactive protein (for example, acute infection), white cell count (infection or inflammatory response), natriuretic peptides (for example, heart failure), ferritin (inflammation and continuing prothrombotic state), troponin (acute coronary syndrome or myocarditis) and D-dimer (thromboembolic disease). Troponin and D-dimer tests may be falsely positive, but a negative result can reduce clinical uncertainty. Further research is likely to refine the indications for, and interpretation of, diagnostic and monitoring tests in follow-up of covid-19.
For patients who were not admitted to intensive care, British Thoracic Society guidance on follow-up of covid-19 patients who have had a significant respiratory illness proposes community follow-up with a chest x ray at 12 weeks and referral for new, persistent, or progressive symptoms.26 For those with evidence of lung damage (such as persistent abnormal chest x ray and oximeter readings), referral to a respiratory service is recommended; subsequent early referral to pulmonary rehabilitation probably aids recovery.
Supporting recovery from covid-19
After excluding serious ongoing complications or comorbidities, and until the results of long term follow-up studies are available, patients should be managed pragmatically and symptomatically with an emphasis on holistic support while avoiding over-investigation.2 Fever, for example, may be treated symptomatically with paracetamol or non-steroidal anti-inflammatory drugs. Monitoring functional status in post-acute coivd-19 patients is not yet an exact science. A post-covid-19 functional status scale has been developed pragmatically but not formally validated27—a simplified version of this is reproduced in the supplementary material.
Referral to a specialist rehabilitation service does not seem to be needed for most patients, who can expect a gradual, if sometimes protracted, improvement in energy levels and breathlessness, aided by careful pacing, prioritisation, and modest goal setting. In our experience, most but not all patients who were not admitted to hospital recover well with four to six weeks of light aerobic exercise (such as walking or Pilates), gradually increasing in intensity as tolerated. Those returning to employment may need support to negotiate a phased return. Box 5 links to patient resources, including a comprehensive patient guide from Homerton University Hospital.28
Respiratory symptoms and support
The British Thoracic Society defines chronic cough as one that persists beyond eight weeks.26 Up to that time, and unless there are signs of super-infection or other complications such as painful pleural inflammation, cough seems to be best managed with simple breathing control exercises28 (see box 2) and medication where indicated (such as proton pump inhibitors if reflux is suspected).
Breathing techniques
About 80% of the work of breathing is done by the diaphragm. After illness or general deconditioning, the breathing pattern may be altered, with reduced diaphragmatic movement and greater use of neck and shoulder accessory muscles. This results in shallow breathing, increasing fatigue and breathlessness, and higher energy expenditure. The "breathing control" technique is aimed at normalising breathing patterns and increasing the efficiency of the respiratory muscles (including the diaphragm) resulting in less energy expenditure, less airway irritation, reduced fatigue, and improvement in breathlessness.
The patient should sit in a supported position and breathe in and out slowly, preferably in through the nose and out through the mouth, while relaxing the chest and shoulders and allowing the tummy to rise. They should aim for an inspiration to expiration ratio of 1:2. This technique can be used frequently throughout the day, in 5-10 minute bursts (or longer if helpful).
Other breathing techniques—such as diaphragmatic breathing, slow deep breathing, pursed lip breathing, yoga techniques, Buteyko—are used in strategies to manage patients' breathing patterns and breathlessness but require specialist advice to identify which technique best suits each patient.
RETURN TO TEXTBreathlessness
A degree of breathlessness is common after acute covid-19. Severe breathlessness, which is rare in patients who were not hospitalised, may require urgent referral. Breathlessness tends to improve with breathing exercises (box 2). Pulse oximeters may be extremely useful for assessing and monitoring respiratory symptoms after covid-19, and we could find no evidence that their use in the home leads to increased anxiety (box 3).
Use of pulse oximetry in post-acute covid-19
Hypoxia may reflect impaired oxygen diffusion and is a recognised feature of covid-19. It may be asymptomatic (so called silent hypoxia29) or symptomatic (reflecting increased work of breathing, or secondary pathology such as a bacterial pneumonia or thromboembolism). Oxygen saturation probes (pulse oximeters) have been used as part of a package of care for patients with covid-19 and are recommended as part of the assessment of acute covid-19 in national and local guidelines.303132
Self monitoring of oxygen saturations over three to five days may be useful in the assessment and reassurance of patients with persistent dyspnoea in the post-acute phase, especially those in whom baseline saturations are normal and no other cause for dyspnoea is found on thorough evaluation. An exertional desaturation test should be performed as part of baseline assessment for patients whose resting pulse oximeter reading is 96% or above but whose symptoms suggest exertional desaturation (such as light-headedness or severe breathlessness on exercise). In the absence of contraindications, such patients should be invited to repeat the oximeter reading after 40 steps on a flat surface (if self testing remotely) and then after spending one minute doing sit-to-stand as fast as they can (if supervised on site).33 A fall of 3% in the saturation reading on mild exertion is abnormal and requires investigation.33
Patients should be provided with a pulse oximeter and an observations diary and given instructions for how to self monitor.34 Typically, this would be a daily reading taken on a clean, warm finger without nail polish, after resting for 20 minutes; the device should be left to stabilise and the highest reading obtained should be recorded. While the range of commercially available oxygen saturation probes from healthcare suppliers and pharmacies seem to work within normal ranges (92% and above), smartphone apps that purport to measure oxygen saturations using the phone camera and torch should not be used.35
British Thoracic Society guidelines define the target range for oxygen saturation as 94-98% and a level of 92% or below as requiring supplementary oxygen (unless the patient is in chronic respiratory failure).36 In the context of a normal assessment (history, examination, and appropriate investigations) without red flags, an oxygen saturation of 96% or above and the absence of desaturation on exertional tests is very reassuring. Further investigation or referral in the first six weeks after covid-19 in such patients is rarely indicated, though regular support by telephone or video is likely to be appreciated. Oximeter readings persistently in the 94-95% range or below (indicating substantially farther down the oxygen-haemoglobin desaturation curve37) require assessment and investigation. The patient should be provided with safety-netting advice (such as contacting their general practice or NHS111) in the event of recurrent low saturation readings. Appropriate adjustments should be made for patients with lung disease and known hypoxia—in whom the range of 88-92% is considered acceptable.
RETURN TO TEXTRecovery after any severe debilitating illness may be prolonged.38 Survivors of covid-19 acute respiratory distress syndrome are at risk of long term impairment of lung function.394041 Serious interstitial lung disease seems to be rare in patients who are not hypoxic, though data on long term outcomes are not yet available.42
Pulmonary rehabilitation
Many patients are still recovering spontaneously in the first six weeks after acute covid-19 and do not generally require fast-track entry into a pulmonary rehabilitation programme. Those who have had significant respiratory illness may benefit from pulmonary rehabilitation, defined as "a multidisciplinary intervention based on personalised evaluation and treatment which includes, but is not limited to, exercise training, education, and behavioural modification designed to improve the physical and psychological condition of people with respiratory disease."43 In the context of covid-19, rehabilitation is being delivered by various virtual models, including video linked classes and home education booklets with additional telephone support. We describe one such programme in the supplementary material on bmj.com.
The profound and prolonged nature of fatigue in some post-acute covid-19 patients shares features with chronic fatigue syndrome described after other serious infections including SARS, MERS, and community acquired pneumonia.19202244 We found no published research evidence on the efficacy of either pharmacological or non-pharmacological interventions on fatigue after covid-19. Patient resources on fatigue management45 and guidance for clinicians on return to exercise43 and graded return to performance for athletes (box 4) 46 in covid-19 are currently all based on indirect evidence.
The sportsperson returning to exercise (summarised from Stanford-Hall statement43)
After recovery from mild illness: 1 week of low level stretching and strengthening before targeted cardiovascular sessions
Very mild symptoms: limit activity to slow walking or equivalent. Increase rest periods if symptoms worsen. Avoid high-intensity training
Persistent symptoms (such as fatigue, cough, breathlessness, fever): limit activity to 60% maximum heart rate until 2-3 weeks after symptoms resolve
Patients who had lymphopenia or required oxygen need respiratory assessment before resuming exercise
Patients who had cardiac involvement need cardiac assessment before resuming
There is much debate and controversy about the role of graded exercise in chronic fatigue generally (see patient responses to a recent Cochrane review47) and in covid-19 in particular (see a recent statement from the National Institute for Health and Care Excellence (NICE)48). Pending direct evidence from research studies, we suggest that exercise in such patients should be undertaken cautiously and cut back if the patient develops fever, breathlessness, severe fatigue, or muscle aches. Understanding, support, and reassurance from the primary care clinician are a crucial component of management.
Cardiopulmonary complications, assessment and management
Perhaps 20% of patients admitted with covid-19 have clinically significant cardiac involvement4950; occult involvement may be even commoner.5152 Cardiopulmonary complications include myocarditis, pericarditis, myocardial infarction, dysrhythmias, and pulmonary embolus; they may present several weeks after acute covid-19. They are commoner in patients with pre-existing cardiovascular disease,49 but they have also been described in young, previously active patients.435354 Various pathophysiological mechanisms have been proposed, including viral infiltration, inflammation and microthrombi, and down-regulation of ACE-2 receptors.515354
Chest pain
Chest pain is common in post-acute covid-19. The clinical priority is to separate musculoskeletal and other non-specific chest pain (for example, the symptom described by a large patient-led survey as "lung burn"4) from serious cardiovascular conditions. Clinical assessment of the post-acute covid-19 patient with chest pain should follow similar principles to that for any chest pain: a careful history, taking account of past medical history and risk factors, a physical examination, backed up as indicated by investigations (infographic).43 Where the diagnosis is uncertain, or the patient is acutely unwell, urgent cardiology referral may be needed for specialist assessment and investigations (including echocardiography, computed tomography of the chest, or cardiac magnetic resonance imaging).
Covid-19 is an inflammatory and hypercoagulable state,50 with an increased risk of thromboembolic events.5556 Many hospitalised patients receive prophylactic anticoagulation. Recommendations for anticoagulation after discharge vary, but higher risk patients are typically discharged from hospital with 10 days of extended thromboprophylaxis.57 If the patient has been diagnosed with a thrombotic episode, anticoagulation and further investigation and monitoring should follow standard guidelines.58 It is not known how long patients remain hypercoagulable following acute covid-19.
Ventricular dysfunction
Left ventricular systolic dysfunction and heart failure after covid-19 can be managed according to standard guidelines.59 Intense cardiovascular exercise must be avoided for three months in all patients after myocarditis or pericarditis; athletes are advised to take three to six months of complete rest from cardiovascular training followed by specialist follow-up, with return to sport guided by functional status, biomarkers, absence of dysrhythmias, and evidence of normal left ventricular systolic function.60
Neurological sequelae
Ischaemic stroke, seizures, encephalitis, and cranial neuropathies have been described after covid-19, but these all seem to be rare.61 A patient suspected of these serious complications should be referred to a neurologist. Common non-specific neurological symptoms, which seem to co-occur with fatigue and breathlessness, include headaches, dizziness, and cognitive blunting ("brain fog").4 Until evidence based guidance appears on how to manage or when to refer such symptoms, we recommend supportive management and symptom monitoring in primary care.
The older patient
Covid-19 tends to affect older patients more severely.62 Those who survive are at high risk of sarcopenia, malnutrition, depression, and delirium.2 Post-covid-19 chronic pain may affect patients of any age but seems to be commoner in elderly patients.63 Physical symptoms add to the psychosocial impact of disrupted access to health care (such as arrangements for obtaining regular medication), core personal routines (such as walking to local shops), social interactions (such as meeting friends), and lay and professional support networks.64 Support should be personalised with input from the multi-professional team (for example, general practitioner, district nurse, social worker, rehabilitation teams, and occupational therapist as needed).
Mental health and wellbeing
Most publications on covid-19 and mental health have emphasised individual reactions to the pandemic such as anxiety, stress, and conditions related to broken routines, loneliness, and social isolation in uninfected individuals6566; the World Health Organisation has issued guidance on these.67 Lay accounts suggest that post-acute covid-19 is often associated with low mood, hopelessness, heightened anxiety, and difficulty sleeping.6 Post-traumatic stress disorder may occur, especially in healthcare workers and others with caring responsibilities.151643
While a minority of patients may benefit from referral to mental health services, it is important not to pathologise the majority. Physical manifestations of covid-19 may distort responses to assessment tools (such as the PHQ9) designed to measure anxiety and depression in a physically healthy population, though these complications may occur. Patient organisations emphasise wellbeing, mindfulness, social connection, self care (including diet and hydration), peer support, and symptom control. Mental illness is strongly associated with social determinants such as poverty, discrimination, and social exclusion; mental health and wellbeing are enhanced by increased social solidarity, informal social support, mutual aid, and other community based and collective measures.6869 Given how pervasive and unequal the impact of covid-19 has been,7071 community level, cross-sector collaborations may be needed to develop locally relevant solutions. A recent report from general practice in a deprived area of Glasgow describes the importance of accessible, relationship-based care for patients with complex needs, and of system-level interventions such as attached financial advisers and outreach mental health services.69
Social and cultural considerations
Covid-19 is more common and has a worse prognosis in the acute phase in people who are poor, elderly, and from certain minority ethnic groups (notably black, south Asian, and Jewish70). It is too early to say whether these sociodemographic patterns persist in post-acute covid-19. Our own experience suggests that patients with post-acute covid-19 are from diverse social and cultural backgrounds. Many have comorbidities including diabetes, hypertension, kidney disease, or ischaemic heart disease. Some have experienced family bereavements as well as job losses and consequent financial stress and food poverty. Strain on many carers has been high. For an important few, lockdown has worsened safeguarding concerns such as the risk of child or intimate partner abuse. A detailed discussion of all these issues is beyond the scope of this article, but there are strong arguments for working with other agencies to develop local, system-level solutions. Box 5 provides some links to covid-19 advice from specialist social care, lay care, and faith organisations.
Additional resources for patients and professionals
Advice for patients
Homerton University Hospital. ACERS: Post COVID-19 patient information pack. https://www.hackneycitizen.co.uk/wp-content/uploads/Post-COVID-19-information-pack-5.pdf
Royal College of Occupational Therapists. How to conserve your energy: Practical advice for people during and after having COVID-19. https://www.rcot.co.uk/conserving-energy
Chartered Society of Physiotherapy. Covid-19: The road to recovery activity planner. https://www.csp.org.uk/system/files/documents/2020-06/001751_covid19-the_road_to_recovery_activity_planner_v3.pdf
Mental Health Foundation. How to look after your mental health during the coronavirus outbreak. https://www.mentalhealth.org.uk/coronavirus
Mind. Coronavirus and your mental health. https://www.mind.org.uk/information-support/coronavirus/
Asthma UK and British Lung Foundation. Post-COVID HUB. https://www.post-covid.org.uk/
Facebook. Long Covid Support Group. https://www.facebook.com/groups/longcovid
Social, financial, and cultural support
Citizens Advice Bureau. Helping people through the COVID-19 pandemic. https://www.citizensadvice.org.uk/cymraeg/about-us/policy/policy-research-topics/welfare-policy-research-surveys-and-consultation-responses/welfare-policy-research/helping-people-through-the-covid-19-pandemic/
Advisory Conciliation and Arbitration Service (ACAS). Coronavirus (COVID-19): advice for employers and employees. https://www.acas.org.uk/coronavirus
Social Care Institute for Excellence. Supporting people who are isolated or at risk during the COVID-19 crisis. https://www.scie.org.uk/care-providers/coronavirus-covid-19/support-for-isolated
Carers UK. Coronavirus guidance. https://www.carersuk.org/help-and-advice/coronavirus-covid-19/coronavirus-covid-19
Faith organisations:
Sikh Helpline. Coronavirus update. https://www.sikhhelpline.com/coronavirus/
Jewish Care. Online and local resource library. https://www.jewishcare.org/informationduringcovid
Muslim Council of Britain. COVID-19 guidance for Muslim communities. https://mcb.org.uk/resources/coronavirus/
Ethnic organisations:
Ubele. COVID-19 resource page for African diaspora communities. https://www.ubele.org/
Greater Manchester Centre for Voluntary Organisation. Support and resources for BAME Communities. https://www.gmcvo.org.uk/Coronavirus/BAMESupport
Professional guidelines and resources
European Respiratory Society. ERS COVID-19 resource centre. https://www.ersnet.org/the-society/news/novel-coronavirus-outbreak--update-and-information-for-healthcare-professionals
European Cardiology Society. COVID-19 and cardiology. https://www.escardio.org/Education/COVID-19-and-CardiologyEuropean Cardiology Society
Diabetes UK. Advice for healthcare professionals on coronavirus (Covid-19) and diabetes. https://www.diabetes.org.uk/professionals/resources/coronavirus-clinical-guidance
Renal Association. COVID-19: Information and guidance for renal professionals. https://renal.org/covid-19/
Royal College of Psychiatrists. COVID-19: Guidance for clinicians. https://www.rcpsych.ac.uk/about-us/responding-to-covid-19/responding-to-covid-19-guidance-for-clinicians
British Geriatric Association:
Coronavirus and older people. https://www.bgs.org.uk/resources/resource-series/coronavirus-and-older-people 2020
COVID-19: Managing the COVID-19 pandemic in care homes for older people. https://www.bgs.org.uk/resources/covid-19-managing-the-covid-19-pandemic-in-care-homes
Implications for the primary care team
From the limited current evidence, we anticipate that many patients whose covid-19 illness is prolonged will recover without specialist input through a holistic and paced approach. Much can be achieved through interprofessional, community-facing rehabilitation services which embrace patient self management and peer support and harness the potential of video and other remote technologies. An information platform for the public has recently been launched, and a virtual rehabilitation platform is planned for later in 2020.72 Management of post-acute covid-19 must occur in conjunction with management of pre-existing or new comorbidities (see professional resources in box 5).
The natural history of post-acute and chronic covid-19 in a community population is unknown at the time of writing. The results of ongoing research studies7374 are eagerly awaited. If 10% of covid-19 survivors experience post-acute disease, and we assume (conservatively) that half of all cases were not formally diagnosed, this translates to around 60 000 people in UK with post-acute covid-19 (around six per general practice). Patients, many of whom were young and fit before their illness, have described being dismissed or treated as hypochondriacs by health professionals.4 They have rightly contested the classification of non-hospitalised covid-19 as "mild."5 In these uncertain times, one key role that the primary care practitioner can play is that of witness, "honouring the story" of the patient whose protracted recovery was unexpected, alarming, and does not make sense.75
How this article was created
There are not yet definitive, evidence based recommendations for the management of post-acute covid-19. We therefore used a pragmatic approach based on published studies on SARS and MERS,171819202122 early editorials and consensus based guidance on covid-19,226437677787980 a living systematic review,81 early reports of telerehabilitation (support and exercise via video link8182), and our own clinical experience. Academic sources were identified using a systematic search of PubMed database up to 10 July 2020 with the following terms: management of chronic covid-19, long-term sequelae, rehabilitation, mental health, chronic and post-acute care; we supplemented this by citation chaining key papers in Google Scholar.
How patients were involved in the creation of this article
A patient contributed to the description in box 1. The paper was read by four additional lay people with experience of covid-19 in themselves or their friends or relatives, and extensively modified in response to their feedback before submission. Peer reviewers included people with post-acute covid-19. The main changes in response to patient feedback were in relation to management of fatigue.
We thank Nia Roberts for specialist help with database searches and the patient (who wished to remain anonymous) for the descriptions in box 1. We thank Anica Alvarez Nishio, Jake Suett, Paul Garner and another anonymous patient reviewer who commented on earlier drafts. We also thank two editors and four reviewers, one with lived experience of post-acute covid-19, for extremely helpful feedback on a previous draft.
Contributors: MK and TG jointly conceived the article and are guarantors. MK and MB provided a detailed service model and primary data on 1500 patients followed up in the Watford Virtual Ward service. Literature review was undertaken by TG and LH, supported by professional librarian Nia Roberts. TG wrote an initial draft of the paper and infographic, drawing on detail on rehabilitation provided by MB and cardiac complications by CA'C. All authors provided additional information and references and contributed to several iterations of the paper and infographic.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare
Patient consent: Patient consent obtained.
This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.


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subset: commoncrawl


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so for our second day at disneyland we hauled out the nerd and all wore matching t-shirts
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Direct-Hire Staffing
Finding talented, well-qualified employees who are the best long-term fit for your company requires considerable time and financial investment. Free up your internal resources and leave the search to us. Snelling has the knowledge, resources and expertise to quickly identify the best-fit candidates for your company. By engaging us, you and your colleagues can focus on other aspects of your business. Want to know more? Read: Meeting Direct Hiring Needs with a Staffing Firm.
Contract-to-Hire Staffing
Snelling actively recruits candidates who are seeking direct hire positions with our clients. When it's time to expand your workforce, Snelling makes it easy to evaluate promising candidates in a temporary capacity before making a final hiring decision. To learn more about the benefits of this approach, read Why You Should Follow a Temp-to-Hire Model.
Contingent (Temporary) Staffing
Today, there can be many strategic benefits to leveraging temporary rather than full-time employees—most notably, significant cost savings. To learn more about flexible staffing, read The Cost of Temporary Staffing vs. The Cost of Full-Time Employees.
Whether you need one person or an entire team of star performers, additional manpower at one location or multiple locations in several states, Snelling is your trusted resource for candidates who can hit the ground running. We can even manage your flexible staffing plan to save you time and money.


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We are proud to be partnered with a company focused on transparency and honesty in the VPN industry. Last week Golden Frog debunked 7 myths about online anonymity and VPN logging in their article, I am Anonymous When I Use a VPN – 7 Myths Debunked.
The "7 Myths" article addresses a disturbing trend in the VPN industry over the past year. More and more VPN providers are perpetuating the myth of an "anonymous" or "no logging" VPN service while providing minimal or zero transparency about how they actually handle users' data. This has diverted privacy conscious VPN users to focus on the false promise of anonymity instead of focusing on what really matters when choosing a VPN provider: transparency, trust, ease of use, performance and reliability.
Learn the truth about each of these myths:
- Myth #1: I can be anonymous on the Internet.
- Myth #2: Anonymity and Privacy are the same.
- Myth #3: When my VPN Provider advertises an "anonymous" service, that means they don't log any identifying information about me.
- Myth #4: When my VPN Provider's privacy policy says they "don't log", that means I am anonymous.
- Myth #5: Even if my VPN Provider uses Hosted or Cloud based VPN servers I can still be anonymous.
- Myth #6: Even if my VPN Provider doesn't own and operate the network I can still be anonymous.
- Myth #7: Any VPN Logging is Bad.
For other insightful discussions on online privacy and security check out Golden Frog's "Take Back Your Internet" policy microsite.


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11.00 "You Can't Move History: You Can Secure the Future": Young People, Activism and the Indivisible Nature of Intangible and Tangible Heritage
My Session Status
Debates spanning the value of urban heritage have recently intensified with the increasing belief that tangible and intangible heritage are "indivisible." Conflicts over this position reach their clearest expression within the city as the everyday practices carried out by a range of different urban actors are increasingly threatened by the desire, especially in a UK context, to privatize and commercialize the public space. This paper is located at the heart of this conflict as it will seek to examine the ways in the everyday practice of skateboarding on London's south bank motivated the campaign, primarily led by young skaters, to retain the physical fabric of the "world's oldest surviving skatespot." In doing so the paper will engage with questions surrounding the role of space and place in heritage activism as well as a greater understanding of how young people engaged with urban decision-makers, primarily through the use of social media and film.
The tag line: "You Can't Move History. You Can Secure the Future" speaks to the ways in which this campaign group, Long Live Southbank (LLSB), articulated their desire to preserve the cultural practice of skateboarding within the physical space of the Southbank Undercroft. This campaign, while ultimately successful in its goal to prevent the loss, forced existing organizations to re-consider the relationship between intangible and tangible heritage in ways that reverberate across planning, urban design, and architecture. Drawing on a body of existing archival material and new material created through walking interviews, films, and oral histories, this paper will develop an understanding of the micro-politics of heritage campaigns. Specifically, the paper will firstly ask how successive generations of young people developed embodied attachments to the skatespot, and secondly consider the ways in which the campaign narrative was constantly negotiated by the individuals behind the campaigns to secure the future of the Southbank Undercroft.


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November 20, 2012
Agencies announce increases in dollar thresholds in regulations Z and M for exempt consumer credit and lease transactions
Board of Governors of the Federal Reserve System
Consumer Financial Protection Bureau
For immediate release
The Federal Reserve Board (Board) and the Consumer Financial Protection Bureau (CFPB) today announced increases in the dollar thresholds in Regulation Z (Truth in Lending) and Regulation M (Consumer Leasing) for exempt consumer credit and lease transactions. These increases are consistent with the Dodd-Frank Wall Street Reform and Consumer Protection Act (Dodd-Frank Act) amendments to the Truth in Lending Act and the Consumer Leasing Act to adjust these thresholds annually by the annual percentage increase in the Consumer Price Index for Urban Wage Earners and Clerical Workers. Transactions at or below the thresholds are subject to the protections of the regulations.
The adjustments to the thresholds reflect the annual percentage increase in the consumer price index as of June 1, 2012 and will take effect on January 1, 2013.
Based on the adjustments announced today, the protections of the Truth in Lending Act and the Consumer Leasing Act generally will apply to consumer credit transactions and consumer leases of $53,000 or less in 2013. However, private education loans and loans secured by real property (such as mortgages) are subject to the Truth in Lending Act regardless of the amount of the loan.
Although the Dodd-Frank Act generally transferred rulemaking authority under the Truth in Lending Act and the Consumer Leasing Act to the CFPB, the Board retains authority to issue rules for certain motor vehicle dealers. Therefore, the agencies are issuing these adjustments jointly.
In addition, the CFPB is separately adjusting the dollar amount that triggers additional protections for certain home mortgages under the Home Ownership and Equity Protection Act of 1994 (HOEPA), as required by statute. Consistent with the increase in the consumer price index, the dollar amount of the HOEPA fee trigger will increase to $625 for 2013.
The notices that will be published in the Federal Register are attached.
Federal Register Notices
Media Contacts:
Media Contacts: | ||
CFPB | Moira Vahey | 202-435-7170 |
Federal Reserve Board | Susan Stawick | 202-452-2955 |


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European Investment Bank Funding for SME Loans
Through an agreement with the European Investment Bank (EIB; www.eib.org) we are supporting small and medium sized businesses (SMEs) [and small projects carried out by enterprises having less than 3,000 employees (MidCaps)] by providing access to an invaluable source of lower cost finance and flexible repayment schedules.
A European Cooperation with Sustainable Finance for the benefit of SMEs
The EIB is the long-term lending bank of the European Union; its task is to contribute towards the integration, balanced development and economic and social cohesion of the EU Member States. Thanks to its best possible rating on the capital markets (AAA), the EIB can borrow funds on favourable terms, which it passes on to SMEs and MidCaps through us. The SMEs and MidCaps are specifically and individually informed by us of the EIB's involvement and its impact on the financial terms of the loan received. Extensive information related to the EIB Group support to SMEs and MidCaps can be found in the EIB website (www.eib.org).
In view of the climate commitment of both entities, the loan is earmarked to support investments benefitting the transition to a low-carbon economy.
What is EIB funding?
The EIB is strengthening its support for Europe's SMEs and MidCaps by helping this important sector to access vital new lines of credit. The loan term is a minimum of 2 years (the actual length of the loan will depend on the economic and technical life of the project financed) and it can be used to finance from very small projects to investments with a maximum cost of EUR 25 million. The EIB's contribution, however, cannot exceed EUR 12.5 million.
Who can apply for an EIB loan?
- SMEs with less than 250 employees on a consolidated basis prior to investment based in one of the 27 EU Member States;
- MidCaps with less than 3,000 employees on a consolidated basis prior to investment based in one of the 27 EU Member States;
- all economic sectors and activities are eligible with few exceptions, amongst which pure property speculations, production of weapons and ammunition, arms, military or police equipment or infrastructures, and equipment or infrastructure limiting people's individual rights and freedom, gambling, tobacco related industries, activities considered ethically or morally controversial such as human cloning and animal testing insofar as not in compliance with the "Council of Europe's Convention for the Protection of Vertebrate Animals used for Experimental and other Scientific Purposes", activities prohibited by national legislation or whose environmental impact cannot be mitigated or offset.
What can an EIB loan be used for?
The EIB loan can be used to finance all investments and expenditures that are incurred in the development of an SME or a MidCap i.e.:
- Tangible investments: purchases of plant and equipment, with some exceptions concerning land purchases.
- Intangible investments: particularly the expenditure involved in R&D, building up distribution networks in domestic or other markets within the EU.
- Medium and long-term working capital requirements to re-establish businesses' general liquidity ratio.
What are the benefits for your Business?
- You can receive beneficial interest rates compared to standard business lending rates.
- You can negotiate the term or repayment frequency of the loan to suit the circumstances and cash-flow requirements of your business.
- It allows you to invest significantly in your business without adversely affecting your cash-flow or liquidity.
You shall agree that (a) upon reasonable notice you will permit representatives of the EIB to inspect all sites, installations and works that comprise the project which is the subject of the loan; and (b) following a request by the EIB, we may provide any information about you to the EIB.
EIB loans for SMEs are channelled through us, therefore it is entirely up to us to examine the application and to decide whether or not to grant the loan.
Please contact Bartosz Tomaszewski to discuss if your business qualifies for funding supported by the EIB "Loans for SMEs" or EIB "Loan for MidCaps" scheme.
About EIB
The European Investment Bank (EIB) is the long-term lending institution of the European Union owned by its Member States. It makes long-term finance available for sound investment in order to contribute towards EU policy objectives.
The EIB is active in around 160 countries and is the world's largest multilateral lender for climate action projects. The EIB Group recently adopted its Climate Bank Roadmap to deliver on its ambitious agenda to support EUR 1 trillion of climate action and environmental sustainability investments in the decade to 2030 and to deliver more than 50% of EIB finance for climate action and environmental sustainability by 2025. Also, as part of the Roadmap, from the start of 2021, all new EIB Group operations will be aligned with the goals and principles of the Paris Agreement.


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Service is the opening gun of tennis. It is putting the ball in play. The old idea was that service should never be more than merely the beginning of a rally. With the rise of American tennis and the advent of Dwight Davis and Holcombe Ward, service took on a new significance. These two men originated what is now known as the American Twist delivery.
From a mere formality, service became a point winner. Slowly it gained in importance, until Maurice E. M'Loughlin, the wonderful « California Comet, » burst across the tennis sky with the first of those terrific cannon-ball deliveries that revolutionized the game, and caused the old-school players to send out hurry calls for a severe footfault rule or some way of stopping the threatened destruction of all ground strokes. M'Loughlin made service a great factor in the game. It remained for R. N. Williams to supply the antidote that has again put service in the normal position of mere importance, not omnipotence. Williams stood in on the delivery and took it on the rising bound.
Service must be speedy. Yet speed is not the be-all and end-all. Service must be accurate, reliable, and varied. It must be used with discretion and served with brains.
Any tall player has an advantage over a short one, in service. Given a man about 6 feet and allow him the 3 feet added by his reach, it has been proved by tests that should he deliver a service, perfectly flat, with no variation caused by twist or wind, that just cleared the net at its lowest point (3 feet in the centre), there is only a margin of 8 inches of the service court in which the ball can possibly fall; the remainder is below the net angle. Thus it is easy to see how important it is to use some form of twist to bring the ball into court. Not only must it go into court, but it must be sufficiently speedy that the receiver does not have an opportunity of an easy kill. It must also be placed so as to allow the server an advantage for his next return, admitting the receiver puts the ball in play.
Just as the first law of receiving is to, put the ball in play, so of service it is to cause the receiver to fall into error. Do not strive unduly for clean aces, but use your service to upset the ground strokes of your opponent.
Service should be hit from as high a point as the server can COMFORTABLY reach. To stretch unnecessarily is both wearing on the server and unproductive of results. Varied pace and varied speed is the keynote to a good service.
The slice service should be hit from a point above the right shoulder and as high as possible. The server should stand at about a forty-five degree angle to the baseline, with both feet firmly planted on the ground. Drop the weight back on the right foot and swing the racquet freely and easily behind the back. Toss the ball high enough into the air to ensure it passing through the desired hitting plane, and then start a slow shift of the weight forward, at the same time increasing the power of the swing forward as the racquet commences its upward flight to the ball. Just as the ball meets the racquet face the weight should be thrown forward and the full power of the swing smashed into the service. Let the ball strike the racquet INSIDE the face of the strings, with the racquet travelling directly towards the court. The angle of the racquet face will impart the twist necessary to bring the ball in court. The wrist should be somewhat flexible in service. If necessary lift the right foot and swing the whole body forward with the arm. Twist slightly to the right, using the left foot as a pivot. The general line of the racquet swing is from RIGHT to LEFT and always forward.
At this point and before I take up the other branches of serving, let me put in a warning against footfaulting. I can only say that a footfault is crossing or touching the line with either foot before the ball is delivered, or it is a jump or step. I am not going into a technical discussion of footfaults. It is unnecessary, and by placing your feet firmly before the service there is no need to footfault.
It is just as unfair to deliberately footfault as to miscall a ball, and it is wholly unnecessary. The average footfault is due to carelessness, over-anxiety, or ignorance of the rule. All players are offenders at times, but it can quickly be broken up.


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Integrate Events Manager with Zoom and start creating webinars and meetings directly from your WordPress dashboard, as well as displaying these in calendars and handling bookings (including payments).
Seamless integration with both Events Manager and Zoom. Install and set up, create an event, choose a Zoom Meeting/Webinar as your location type, enable bookings, and you're good to go!
- Create Webinars and Meetings while creating an event.
- Support for recurring events, each event has its own webinar/meeting.
- Adjust all your webinar/meeting settings directly from your event editor.
- Enabling bookings on your events will automatically register users to that webinar/meeting.
- Send users unique URLs
- Integrated placeholders and search attributes for Events Manager, including:
- Filter event types by Webinar, Meeting or Rooms
- Conditional placeholders to display specific content for meetings/webinars/rooms.
- Display meeting information via Placeholders
- Provide unique Join URLs to users who've booked in custom email templates.
- Select a Zoom Room for an event (scheduling features not available in Zoom API).
Additionally, this plugin integrates automatically, at no extra cost, with Events Manager Pro including:
- Accept online and offline payments for webinars/meetings!
- Allow one person to book multiple individual attendees using our custom attendee booking forms, each with unique Join URLs!
- Custom booking forms integrate with Zoom fields and custom questions.
- Checkout-flow using our Multiple Bookings Mode
How it works
This integration creates a connection between Events Manager and your Zoom account. When creating events and you select a Zoom Webinar or Meeting as your location type, a new meeting/webinar will be created with the same name/time as your event.
Bookings are handled by Events Manager when a booking is made and approved (either automatically or manually), a registration will be made to the related meeting/webinar. Since bookings are handled by Events Manager, you can also make use of all the Pro features such as accepting payments for your event and asking custom questions.
You can alternatively link directly to your meetings and disable bookings via Events Manager entirely.
Visit our documentation pages for more information on setup.
Events Manager for Zoom works like any standard WordPress plugin, and requires little configuration to connect with Zoom. If you get stuck, visit our documentation and support forums.
Whenever installing or upgrading any plugin, or even WordPress itself, we always recommended you back up your database first!
- Please ensure you've installed Events Manager beforehand.
- If installing, go to Plugins > Add New in the admin area, and search for "Events Manager for Zoom".
- Click install, once installed, activate and you're done!
Once installed, you will need to create an OAuth app on Zoom.us, add this information to your settings page, and connect your WordPress site with Zoom. For more information on this, please see our Zoom Documentation
Contributors & Developers
"Events Manager – Zoom Integration" is open source software. The following people have contributed to this plugin.
Contributors"Events Manager – Zoom Integration" has been translated into 1 locale. Thank you to the translators for their contributions.
Translate "Events Manager – Zoom Integration" into your language.
Interested in development?
Browse the code, check out the SVN repository, or subscribe to the development log by RSS.
1.6.1 (dev)
- added fix for showing ical location in confirmation emails to zoom meeting/webinar including actual private Join URL instead of public reg form (unavaialble for multi-attendee urls, requires Pro 3.1.5)
- fixed booking deletion not cancelling a booking on Zoom itself
- fixed connection issues due to API changes to the Zoom OAuth process
- added default webinar and meeting location types activation if not already enabled
- added notification email for EM 6.4 when registrations don't work as expected
- fixed compatibility issues with EM 6.2 booking meta (atomic tickets) update
- fixed zoom registration issues when no first or last name supplied
- added support for downloading dev versions via EM
- added support for ical LOCATION property (requires EM 5.12.1)
- fixed #_BOOKINGZOOMJOINLINK not showing a join URL if approval type is set to 'no registration required' on Zoom
- fixed booking approval issues in MB mode and "no registration required" for Zoom meeting/webinar
- fixed duplicate zoom.com confirmation emails getting sent,
- added extra explanations to email and registration settings
- added meta box for zoom join link info and synchornizer in case of error on booking edit/view page
- fixed some PHP warnings
- fixed start_url placeholder not working in email templates (requires EM 5.9.11)
- fixed changing webinars to "no registration" causing save errors if bookings enabled with a custom booking form
- fixed errors when publishing zoom meetings/webinars with a global dial-in country selected
- fixed booking approval errors with custom Pro forms containing country field
- changed start url placeholder for meetings/webinars to display only to users with event edit rights
- added deletion of linked Zoom Meeting/Webinar when switching to another event location type,
- changed admin text to specifically name webinar or meeting in context,
- added detection of deleted Zoom Meeting/Webinar
- added deletion support for linked Zoom Meeting/Webinar when switching to another event location type (requires Events Manager 184.108.40.206 or higher)
- changed admin text to specifically name webinar or meeting in context
- added detection of deleted Zoom Meeting/Webinar
- added importing of bookings to meeting/webinar if event already has bookings
- created rate limit error messages and contingencies
- added recurring event support so that individual recurrences will have their own meeting/webinar
- changed data storage location to $data property in Event_Location object rather than directly in the EM_Event
- moved meeting/webinar passcode storage out of settings array into its own meta field to allow recurring event support
- added deletion of meeting/webinar when event is deleted, event location is changed or if recurring events recreate/reschedule events
- added export of bookings to meeting/webinar for events already containing bookings being changed into a zoom event location
- added placeholder docs for the help page
- Deprecated use of $post in get_post() functions
- Added sanitization for incoming post variable in zoom rooms
- First Release


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Linium Expands Financial Services Expertise with Onboarding of Crossbridge
Summary:The Linium Blues line of elite services and solutions is enhanced by the addition
of Crossbridge's financial services expertise, which provides new capabilities to help
clients address challenges, innovate and modernize operations.
Linium, a world-class provider of business services that empower the entire enterprise, today announced it will onboardCrossbridge, a top-tier financial services consulting firm, to further expand its Linium Blues line of elite services and solutions that launch clients on the path to enterprise modernization.
The addition of Crossbridge provides Linium with enhanced consulting expertise in the capital markets and investment banking industries. Fortified by a broadened platform of state-of-the-art services and solutions, Linium has expanded its expertise to address all aspects of operational challenges faced by financial services institutions and free them up to focus on innovation and improve the bottom line.
Expanding Financial Services Expertise
"We are delighted to expand the services and solutions offered through our elite Linium Blues line with the addition of Crossbridge's leading-edge financial services," said Linium CEO Joe Burke. "This onboarding will accelerate our ability to help businesses modernize operations by building the innovative platforms and systems that are critical to their success. It's a particular pleasure to welcome our new colleagues from Crossbridge, with whom we share a commitment to engaging outstanding professionals and teams, providing proactive vision and next generation solutions, and adhering to the highest levels of integrity and ethics."
"We are excited for the opportunity to combine our deep expertise in financial services with Linium's exceptional ability to deliver groundbreaking enterprise platform solutions," said Crossbridge Partner Steve Shyn, who will become Chief Strategy Officer. "We join forces at a time when the financial markets face critical challenges, driven by a myriad of new and complex rules and regulations, and the growing pressures of global terrorism and cybercrime. Together, we will provide fresh approaches and new solutions to keep our clients safe, effective and profitable."
Linium is particularly strengthened by Crossbridge's Regulatory Change and Risk Management services, which assist best-in-class companies in navigating a myriad of evolving rules and regulations and mitigating compliance risks, and Crossbridge's top-ranked Commercial Lending (Loan IQ) services, which improve performance and maximize operational effectiveness.
The onboarding builds on a longstanding and trusted relationship between Linium and Crossbridge, including collaboration with multiple clients on a host of projects. Each of the more than 50 Crossbridge consultants will be retained and continue to work from their offices in New York City, where Linium also maintains offices, with the expectation of further growth in the future.
About Linium
Linium is a nationally recognized firm with over 16 years of experience specializing in consulting, recruiting and managed services that position companies to achieve modernization and change the way people work anytime, anywhere. We partner with our clients to solve today's most pressing operational challenges by leveraging people, process, and platforms; whether it's streamlining how business services are delivered across the enterprise, acquiring top talent, or enabling financial transparency with accurate plans and forecasts. The bottom line – we help you achieve operational efficiencies so you can grow confidently and focus on innovation. For more information, visit www.linium.com and www.linium.com/financialservices.
Contact Detail:
Company Name: Linium
Contact Person: Sarah Noonan
Address: 187 Wolf Road
City: New York
State: New York
Phone No: 5186893198
Email: email@example.com
Country: United States
Website: http://www.linium.com
Source: www.PRExhibition.com


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Home Brewing Beer With CO2 Can Go With A Pop
Beer has been brewed at home, more or less for the past several thousand years. There is not much said about the practice before the nineteenth century. At some point though, men figured out that CO2 (carbon dioxide) was needed for brewing beer at home. This most likely strengthened the fascination with home brewing. Larger breweries were not quite so thrilled with the home-based competition.
The Inland Revenue Act of 1880 in the United Kingdom demanded private citizens to pay for a license in order to pursue their pastime. The same types of hardships were felt by home brewers in the United States. A law passed in 1920 banned anyone, private of company to produce alcohol. Organized crime saw a boost in activity during the famous "Prohibition" period.
Times have changed now and home brewing is enjoyed by many, with interest in the process growing as more time passes. It can be a very relaxing and enjoyable hobby. There is some work that goes into making beer at home, but it is minimal and the result is something really great that you can share with friends and family.
What CO2 Is To Brewing Beer At Home
Brewing beer at home is not at all difficult as long as you can and will follow directions. There are four basic ingredients necessary for every batch you make:
Malted Grain
There is a fifth ingredient, but it arrives a little late to the party: carbon dioxide, or CO2. You cannot brew beer at home without it. Actually no one can brew beer anywhere without carbon dioxide. How do you get it? It is produced by the yeast and hops in the beer. There is an important process of aging that is necessary if you want really good beer.
Once bottled, leave it be for no less than two weeks. It is during this time that the carbon dioxide is produced and your beer is carbonated. There are a few other ways to add CO2 to your home brewed beer, but the aging is still something to allow.
The quick way to possibly add CO2 to beer brewed at home is to pump it into your keg or container directly. This speeds up the aging process and gets you to your brew a lot faster.
The more traditional way for home brewing beer with CO2 is by adding wort to the finished product before sealing it. Wort is simply unfermented beer; adding that for the yeast produces carbon dioxide.


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Slavic Ash Blonde #18C (SAB) / Nano Secret / Tape In
Buy now, pay later with
Slavic Ash Blonde: Very light brown with blonde and pink undertones.
Total Weight: 50 gr / 1.76 Oz
Total Pieces: 60 per pack
Length: 18" - 40"
Hair type: Virgin Hair
Product Info
Nano Tape Extensions are a permanent hair solution that creates length, thickness, style and color. The nano technology is made out of 1 cm x 0.5 cm strands specifically designed to be added to the edges of the head or to a very fine hair. It can be combined with a Secret Tape hair application to give the most undiscovered natural look. Generally, one pack of Nano Tape is combined with 3 Pack of Secret Tape. Nano Strands are also perfect for creating instant color effects such as highlights, lowlights and any added shades that blends with your original shade. The Nano Tape In extensions are available in 60 strand packs.
Application Method
Application Type: Professional Use
Application Time: 0.5 - 1.5 hours (7 min per pack)
Reapplication: 6-9 weeks
Life span: 2–3 years


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Cognitive Bias Codex print
Sale price
Regular price
188 different cognitive biases, unified into one conceptual model and condensed into a single piece of educational art. This infographic print is a powerful reference, reminder, and conversation-starter.
Deluxe, museum-quality print on heavyweight, matte paper for highest possible readability. Designed and printed in California. Available with simple, minimal frame in charcoal black, assembled and ready to hang. Perfect complement to any office, classroom, or lab. Note that unframed prints are shipped rolled in a protective tube, while framed prints are shipped in a large, padded box.
Choice of two easily readable sizes:
- Medium: 18x24" (458 x 610 mm) - for cubicles & small spaces
- Large: 24x36" (610 x 915 mm) - for classrooms, home, or office
As seen in HuffPo: Science, Quartz, and Wikipedia.
"We see the world not as it is, but as we are." Remember that with an amazing diagram of 188 cognitive biases, designed by John Manoogian III (jm3) and organized by Buster Benson in the Cognitive Bias Cheat Sheet.
View an unboxing video:


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When the Bible refers to a worldwide Flood in Genesis 7–8, that's exactly what it means. Not local, not metaphorical, not some crazy dream—the waters covered the whole earth. Don't just take our word for it, though. Take a look at the evidence right beneath your feet.
We find fossils of sea creatures in rock layers that cover all the continents. For example, most of the rock layers in the walls of Grand Canyon (more than a mile above sea level) contain marine fossils. Fossilized shellfish are even found in the Himalayas.
Focus in: High & Dry Sea Creatures
We find extensive fossil "graveyards" and exquisitely preserved fossils. For example, billions of nautiloid fossils are found in a layer within the Redwall Limestone of Grand Canyon. This layer was deposited catastrophically by a massive flow of sediment (mostly lime sand). The chalk and coal beds of Europe and the United States, and the fish, ichthyosaurs, insects, and other fossils all around the world, testify of catastrophic destruction and burial.
Focus in: The World's a Graveyard
We find rock layers that can be traced all the way across continents—even between continents—and physical features in those strata indicate they were deposited rapidly. For example, the Tapeats Sandstone and Redwall Limestone of Grand Canyon can be traced across the entire United States, up into Canada, and even across the Atlantic Ocean to England. The chalk beds of England (the white cliffs of Dover) can be traced across Europe into the Middle East and are also found in the Midwest of the United States and in Western Australia. Inclined (sloping) layers within the Coconino Sandstone of Grand Canyon are testimony to 10,000 cubic miles of sand being deposited by huge water currents within days.
Focus in: Transcontinental Rock Layers
We find that the sediments in those widespread, rapidly deposited rock layers had to be eroded from distant sources and carried long distances by fast-moving water. For example, the sand for the Coconino Sandstone of Grand Canyon (Arizona) had to be eroded and transported from the northern portion of what is now the United States and Canada. Furthermore, water current indicators (such as ripple marks) preserved in rock layers show that for "300 million years" water currents were consistently flowing from northeast to southwest across all of North and South America, which, of course, is only possible over weeks during a global Flood.
Focus in: Sand Transported Cross Country
We find evidence of rapid erosion, or even of no erosion, between rock layers. Flat, knife-edge boundaries between rock layers indicate continuous deposition of one layer after another, with no time for erosion. For example, there is no evidence of any "missing" millions of years (of erosion) in the flat boundary between two well-known layers of Grand Canyon—the Coconino Sandstone and the Hermit Formation. Another impressive example of flat boundaries at Grand Canyon is the Redwall Limestone and the strata beneath it.
Focus in: No Slow and Gradual Erosion
Rocks do not normally bend; they break because they are hard and brittle. But in many places we find whole sequences of strata that were bent without fracturing, indicating that all the rock layers were rapidly deposited and folded while still wet and pliable before final hardening. For example, the Tapeats Sandstone in Grand Canyon is folded at a right angle (90°) without evidence of breaking. Yet this folding could only have occurred after the rest of the layers had been deposited, supposedly over "480 million years," while the Tapeats Sandstone remained wet and pliable.
Focus in: Folded Rock Layers
The Bible's history is reliable throughout—from the creation of man from the dust of the ground to the worldwide Flood to the coming of Jesus Christ. But just reading the evidence isn't enough. The message of salvation founded in the Bible's history is also true, and, God wants us to accept the gift of salvation He freely offers us.
The evidence is real. God has revealed Himself to us in His Word and in His creation (Romans 1:20).
How will you respond?
Answers in Genesis is an apologetics ministry, dedicated to helping Christians defend their faith and proclaim the good news of Jesus Christ.