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X-Factor: Staal rounding back into form on blue lineby Dave Lozo
For two seasons, Marc Staal was the Rangers' No. 1 defenseman, leading the team in minutes played while slowly improving the offensive side of his game.
However, concussion symptoms stemming from a hit during the previous season kept him out of the team's first 36 games of the 2011-12 campaign, and Staal has been playing catch-up ever since making his season debut in the Winter Classic on Jan. 2.
Coach John Tortorella says Staal will need an offseason and full training camp to return to his earlier form, but the 25-year-old has been improving throughout the second half of this season. Staal is showing more confidence in terms of joining the rush and has been playing more than 20 minutes per game since mid-February.
Staal's game hasn't progressed on the offensive side of things quite as much as it has defensively. Tortorella used him for a brief time on the power play, but it didn't work out well. The extended layoff has hurt Staal most in terms of his offensive confidence, but past performance illustrates that Staal has the ability to rediscover that facet of his game at any moment.
Still, the defensive zone remains the area in which Staal can give the Rangers the biggest lift.
Ryan McDonagh and Dan Girardi are the undisputed shut-down defensive pair for the Rangers and both players have done excellent jobs in that role all season. That won't change in the playoffs. When opponents throw their top scoring lines on the ice, Tortorella will counter with McDonagh and Girardi.
The difference in the postseason is the depth top teams possess. If the Rangers were to face the New Jersey Devils in the later rounds, no doubt McDonagh and Girardi would draw the assignment of stopping a line with Zach Parise and Ilya Kovalchuk. But the Devils' second line is no slouch and may feature the likes of Patrik Elias, Adam Henrique and/or David Clarkson, who scored 30 goals this season.
Should the Devils, or any team for that matter, take their top two scoring threats and place them on different lines, Tortorella's life is a little easier with the knowledge he can match up Staal against that secondary scoring line.
For that reason, having a No. 1 defenseman on the second pairing can be a difference maker.
Tortorella doesn't want to ride McDonagh/Girardi into the ground, and if he feels Staal is capable of handling a team's second line, it's a luxury that can help the Rangers make a deep run in the Stanley Cup Playoffs.


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subset: commoncrawl


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SAN FRANCISCO (CBS.MW) -- Waste Connections WCN, +0.33% said late Wednesday that third-quarter earnings were $22.5 million, or 46 cents a share, compared with $17 million, or 37 cents a share, a year ago. Analysts polled by Thomson First Call were expecting earnings of 45 cents a share. Revenue for the quarter was $165.4 million vs. $146.2 million a year earlier.
Waste Connections Q3 earns beats Wall Street by a penny
Quote References
+0.30 +0.33%


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How do scientists know that dark matter is not visible?
Astronomers keep discovering moons within our own solar system. Trying to spot a small moon, billions of light years away from us, would be much more difficult.
How do we know that the gravitational effects seen in distant galaxies are not due to planets and moons that our telescopes cannot detect?
Why do we attribute this mass and its gravitational affects to invisible dark matter and eliminate the possibility that it might come from visible matter that we just can't detect?
There has to be a reason, but I have no idea what it is. Thanks!


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If you're like a lot of people I know, every New Year's Eve, you pop the cork of a Champagne bottle, toast your friends, and take a sip of bubbly only to remember once again that you don't really like it all that much.
Part of this is due to the champagne itself. This year, a friend brought over a bottle of Veuve Clicquot (pictured above) and it was quite tasty, with enough depth and flavor to be extremely enjoyable. That said, most grocery-store type Champagne (such as Andre, Korbel, or Cook's) tends to be underwhelming to me. At its worst, the under-$10 sparkling wine often strikes me as a little pissy, a little skunky, and so carbonated as to make drinking a flute seem like a meal.
Most people also buy Brut or Extra Brut. Be warned: the term "Brut" doesn't mean, "This stuff is good Champagne." It's actually telling you it isn't sweet. Considering the tastes of most American wine drinkers for jammy, sugary red wine, Brut champagne has always seemed to me at odds with the local palate—my own included.
So here's the big question: what's a person to do with the post-celebration champagne that either gets left at the house by a relative or gifted by a well-meaning co-worker? I'll share with you three approaches I've used to "fix" a crappy bottle.
1. The Kir Royale
Thanks to my sister for sharing this with me. A Kir Royale is none other than champagne (or whatever variety of sparkling wine you have) topped with a splash of Creme de Cassis.
If you're out in the boonies, this stuff may be hard to source, but in most metro areas a larger liquor store should have it. It's really just a fancy name for black raspberry liqueur. Instantly, it makes the drink sweeter and fruitier without affecting the bubbles too drastically. Basically, it's a match made in heaven. On its own, the Creme de Cassis is extraordinarily viscous and sweet, whereas the sparkling wine is often too dry. Together, the two-ingredient cocktail becomes more than the sum of its parts. Also: I've heard you can also use Chambord in a pinch. Supposing that you're the type of person who stocks Chambord, let alone knows what it is.
2. The Elderflower Cocktail
While a bottle of St. Germain (an elderflower-based liqueur) tends to be a little pricey, I think it's worth it. I've tried a few of the budget-grade St. Germain alternatives, and they just don't stack up. I often refer to my bottle as a "champagne improvement serum."
The liqueur, like the Creme de Cassis, provides sweetness, but it's also wonderfully floral and aromatic. As an added plus, the bubbles in Champagne or Prosecco will whip up a frenzy of enticing smells from your champagne flute. Sacrifice your bottle of crappy Brut sparkling wine at the temple of St. Germain and never look back. Like the Creme de Cassis, about half an ounce of this stuff will do the trick.
3. The Champagne Cocktail
Technically, the above entries are champagne cocktails in the sense that you're adding ingredients to champagne, but this is THE champagne cocktail. The way you're supposed to make it is by putting one sugar cube at the bottom of a glass, soaking it in Angostura bitters, and then filling the glass with champagne. The less fussy can approximate the same results with simple syrup.
Admittedly, I include this here just for completion's sake and to say I tried it, since it's a classic recipe that shows up in 100% of every cocktail book I own. The Angostura does provide some earthier flavors and more aromatics to help a crappy bottle of sparkling wine limp towards competency, and again, the extra sweetness is usually appreciated (at least for my palate), but I prefer the other two. Still, it's much better than trash-grade champagne on its own.
Or, y'know, just buy better sparkling wine.
Easier said than done, though. As I said before, the Veuve Clicquot was an eye opener, and proof that even Brut Champagne can be wonderful. I'm normally a little suspicious of brands, but for about $40 for the regular-grade entry point, it's a very nice year-end treat.
I wish I could give you some good recommendations for other Champagnes, Proseccos, Cavas, or miscellaneous sparking wines, but I'm your liquor / cocktail guy, not your wine guy. Every year, the number of potential sparking wine options is dizzying, and I feel overwhelmed. For that reason, while I've not had a lot of luck in terms of blind purchases, I can tell you how much better life is when I can turn a mediocre bottle into a much better cocktail base.


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Well it's day 1 of NaNoWriMo and I'm 1945 into my word count for the first day. And it's nowhere near midnight on the 1st so I have hours still to go before it's the second day if I feel the urge to write more. Errands to run, bills to pay. prescriptions to get, groceries to buy (namely coffee) and I'm feeling pretty good (so far).
Switching novels at the last minute, after having spent almost 2 months plotting a novel only to put it on the shelf in the closet for a different day, I'm excited about the new one that came to me in a dream. I've got a book about historic Charleston with lots of goodies 😀 to use if I get stuck or for more information that I already know about it having grown up there. And I'm also quite certain that although I haven't plotted this novel at all, and don't even have an actual synopsis yet I'm pretty sure that I know where I'm going with it. The idea is there. The main character is speaking to me. She's a lot like my grandmother was. Only she's a modern day version.
Here in the South there's a saying, "You can take the girl out of the country, but you can't take the country out of the girl." Well, I tried to make my home in Plotterville, but it just wasn't the right fit, so back to Plantser Land I went.
So here I go. Drinking my cup of afternoon coffee on a Friday afternoon, imagining how I'm going to get my MC to live in her grandparents townhouse. Do I kill off the grandparents? Have them hit the road in a camper? Put them in an old folk's home? I waiting for the MC to let me know as I research a few things necessary for her trip to visit her cousin after catching her b/f of 5 years in their bed in her house with her friend…Nasty bit of drama there. Gotta hate when that happens, but she really needed to kick his ass out a long time ago she was just set in her "comfort zone" with him taking the easy way out because she thought she could change him, instead she was the one making all the changes.
One bit of writing advice you always hear about is, "Write what you know." Well, I know bad relationships. I know heartbreak. I know what it's like to be cheated on. I also know what it's like when you finally find someone that calls out to your soul and accepts you, loves you, likes you, and makes you feel like a better person and strive to be better at the same time. I also know what it's like to lose a parent when you're young. What it's like to lose multiple family members in a short period of time. What it's like to have an uncle murdered. What it's like to have an aunt and then an uncle die of different kinds of cancer within a year of each other. So I'm going to write about what I know.
If I take any one of those real life experiences, like finding out that your significant other is sleeping with your friend, or losing a parent at a young age, or having your uncle murdered and the murder still isn't solved 4 years later, well there ya go… Add in the fact, that the MC undergoes emotional and mental changes because of those things, as well as a geographical change, and maybe the house she moves into is haunted, WELL…
And all of these are based on real life events (however, the names and events have been changed or altered to protect the innocent as well as the guilty).
By the way, I'm also participating in the National Blog Posting Month (NaBloPoMo) for November. So when I'm not posting about NaNoWriMo I'll be writing about something from one of the NaBloPoMo prompts. Hope you have a great November 😀


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Published at Wednesday, September 04th, 2019 - 03:58:16 AM. Sofas & Couches. By Mirka Pivonka.
Excerpt from Modern Sofas That Put Beauty At The Core Of Your Interior Decor :
If it's simplicity with formal elegance you′re looking for, check out the Montgomery sofa. Its design is a harmonious mix of good‐looks along with superior comfort. This isn′t the type of sofa that steals the‐notice from the living room's 'light −fixtures', coffee‐table or views. It's rather the type that stays in−the−background as well as offers unexpected benefits.
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Hearst Corp., press operators settling
SAN FRANCISCO — The Hearst Corp. and the union representing press operators at the San Francisco Examiner have agreed to settle their dispute through arbitration, the Hearst-owned San Francisco Chronicle reported Thursday.
The San Francisco Web Pressmen and Prepress Workers' Union Local 4 contends that Hearst should have required the new owners of the San Francisco Examiner to honor the union's contract when it transferred the paper to the Fang family in August.
The Fangs are scheduled to begin publishing the new Examiner Nov. 22. The family has said it will use its own nonunion presses or contract with other printers. The union tried to block the Examiner deal with a federal lawsuit filed in San Francisco. It soon dropped its request for an injunction, asking for arbitration instead.
The Examiner and the San Francisco Chronicle have also had difficulty lately getting their papers to customers.
About 40 of the papers' 2,000 carriers refused to deliver the San Francisco Sunday Examiner & Chronicle and Monday's papers in an effort to win higher pay. As a result of the walkout, on both days 13,000 subscribers received their papers late, said Stephen Johnson, vice president of circulation for both papers.
Throughout the week, the papers have hired about 23 replacement workers, Johnson said.
Even so, on Thursday about 4,000 subscribers were still receiving their papers late, he said.
The carriers are independent contractors and are not employees of either paper. Less than 10 have returned to their routes, Johnson said.
The Independent Delivery Carrier Association is asking for a 30 percent pay hike and a reduction in the weight of the newspapers, according to its picket-line literature.
The joint paper's Sunday circulation was 579,000, according to a September 1999 audit by the Audit Bureau of Circulation.


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Special Edition Green Amethyst and Diamond Necklace in Yellow Gold
In Stock
25.55cts of Green Amethyst, set within 18ct Yellow Gold, alternate with intricate Diamond (5.68ct) fan detailing in this Special Edition necklace. "Also known as Prasiolite (from the Greek for leek)," Kiki explains, "Green Amethyst is a very soft, pale shade of green and anyone can wear it. It's a beautiful, gentle colour that's just as great in summer – dressed up or dressed down – as in winter, worn with all black."
Each spectacular Special Edition piece is inspired by the gemstones sourced by Kiki. Each stone has been carefully chosen for its exceptional quality and striking colour, and the exquisite settings require intricate, expert craftsmanship.
|Gold Type
Diamond motif 11x11mm, Green Amethyst stones 9.5x7mm, Length 42cm
Delivery & Returns
We endeavour to dispatch all orders within 24 hours. Any order placed after 4pm is processed the following day. For our full shipping costs please visit our Delivery Page.
Items purchased on the KIKI website can be returned unworn and in the original packaging for a full refund within 14 days of receipt (does not apply to Kiki sale items). Please refer to our Terms and Conditions for further information.


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Monday, 5 July 2010
20 years....
10 comments:
Oh Anita this is such a beautiful layout, gorgeous colours too! I bet it looks stunning up on your wall and a constant remind of your 20 years together... congratulations on that!ReplyDelete
Sarah x
Truly gorgeous Anita, Congrats on the celebration :)ReplyDelete
Hello, gorgeous! My favourite colours too, it must be said. Fabulous layout and congrats to both of you for 20 years .... wonderful achievement these days! xReplyDelete
Absolutely beautiful - I love the colours and how you have cropped the photograph.ReplyDelete
Congratulations xx
Wow! Love the colours and the way you use b/w photos, very clever! Congratulations on yout anniversary, look forward to seeing the 21st :) xReplyDelete
Congratulations to You and Dale x. Love everything about this, another of your magic combos. Loved watching this come together on Saturday at the crop. xxReplyDelete
Forgot to sing... and it dont seem a day too long.....ReplyDelete
Just popped back for another look at this stunning layout, I do love your work, such an inspiration. I mst try those flowers, thanks for showing me how the other day. Wish I lived near enough to attend your classes.ReplyDelete
Wow, thank you all so much for your lovely, kind comments, you have made my day..xxxxxReplyDelete
Hi AnitaReplyDelete
I have got a little something on my blog for you ;-) here
You totaly deserve all the lovely comments, this layout it stunning, I keep coming back to look at it!
Sarah x


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Carefully Consider Webimax Reviews
Today, in this age of high speed Internet, it has become incredibly difficult to imagine the existence and survival of a business without a website.Globalization is something that is pretty famous and every individual is pretty acquainted with this term.If you intend to sell products or do any kind of business online, then it is important that you look for a reputed SEO company that provides good customer support, has efficient tracking and enabled client protection features.They have experts who are skilled people and are well trained in handling all types of online business works.It is considered to be a crucial venture for your online marketing strategy because seeking the services of an unethical company to handle the needs of your website can cause problems and waste your advertising budget, time and worst still can even ruin the image of your brand.
Today since there is a huge demand for these search engine optimization services the companies are increasing in number each day.People get sufficient information related to your business and its concerned services and this helps in magnetizing large number of individuals.Before seeking the services of a good company, it is always recommended to go through the Webimax reviews and these reviews help you in constructing a rough idea about how the company works.Being there on the first few pages of the search engines is challenging today.The web experts of a leading SEO agency employ a lot many innovative and relevant strategies to promote your brand image in the correct manner, as they have enough experience in winning the SERP race.You must read the Webimax reviews so that you will know the qualities of a good company.To bring web success to you, the SEO experts need to have a sharp mind, patience, smart thinking and in depth knowledge of whole process.These web specialists can either make your break the image of your brand online, therefore you must choose a reputable search engine optimization company that is known to deliver superior ethical SEO services to its clients.Just like any other field of business, in SEO industry in Webimax reviews also, experience and reputation play a vital role.
Before you finalize a deal, don't forget to confirm about the SEO services and its cost.A few basic SEO services include directory submission, article submission, press release, blog creation, ranking maintenance, link exchange, and forum posting, etc.Having ample knowledge about a company that you are planning to hire is essential these days and reading Webimax reviews would be very helpful.Make sure you are dealing with a genuine company through Webimax reviews.


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Whoop! It's a week later than I wanted, but I've reached 30,000 words.
My first week back to work was far more busy than I expected. I was bouncing from meeting to meeting, trying to prep for the first week of school and scrambling to finish up my summer classes. By the time I got home each night, I was beat. Writing just wasn't happening. Naturally, this has made me a little nervous about meeting my goal of 10,000 words per month while working. I'm not going to change anything yet though. As always, we'll see how it goes first and I'll rethink my goals only if necessary.
Now it's time to get ready for work. I've got a bunch of 14 year olds to meet in the morning.


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subbed in presents a writing workshop with Holly Isemonger: Writing Poems that aren't 'Poems'
There's an old saying that goes: you can lead a horse to poetry but you can't make it stanza. The aim of Holly Isemonger's workshop is to take poetry off its lyrical high-horse and make it funny, sad, banal, and playful.
This workshop will include learning how to use erasure, ekphrasis, constraints, google translate and other online text manipulators to create poems. Language is communication. How do we write what we want to say? How do these forms reflect the way we engage with language and media in our everyday life? In the workshop, Holly will guide you through creating poems using various experimental techniques. Furthermore, exploring how we can we use these methods to write poems that 'say something' in an original and meaningful way.
Using experimental techniques and exercises, we will craft poetry from surprising places: from a Simpsons script, an awful Miranda Devine article, a film, a constraint, an email, tweets, etc.
Let's ~ chill~ and write some poems 😎
Date: Saturday 20th May 2017, 1-3pm.
Location: Frontyard Projects, 228 Illawarra Rd, Marrickville, NSW 2204.
It is free to participate but numbers are limited (20 person capacity). Bookings essential.
Tickets available here: https://www.stickytickets.com.au/52187
Drinks and refreshments will be provided.
Please bring:
- A phone or a laptop (bringing solely a pen and paper is not advised).
- 2 chunks of text from any source: one that you love and one that you hate; e.g. an excerpt from the novel, 'Transit' by Rachel Cusk, an excerpt from Jack Kerouac, Henry Miller, E.L James, or Ted Hughes, or a poorly written review, or a particularly troll-esque comment from a message board. It can be anything.
- A poem you have written that you aren't happy with or too embarrassed to share.
- A poem you've read and feel you don't 'get', or are confused by, or a poem you like but don't know why.
Holly Isemonger lives in Sydney. She has been published in Shabby Doll House, Voiceworks, Clinic, and Seizure. Her writing has been featured in exhibitions for SPUR Publication at Embassy Gallery, Edinburgh and Tate Britain. She is assistant editor at The Bohemyth and studies at Western Sydney University. In 2017, she won the Overland Judith Wright Poetry Prize. Holly can be found on twitter @hisemonger
This project is supported by the Writing NSW Grants Program, a devolved funding program administered by the NSW Writers' Centre on behalf of the NSW Government and Arts NSW.


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Since 2012, China has been trying to get the European Union to agree to initiate bilateral free trade agreement talks. China is absent from both the transpacific (TPP) and the transatlantic (TTIP) trade deals and wants "in" on a similarly large pact itself in order to avoid losing out on trade flows or to have to follow new "global" standards set by others. European firms, for their part, want greater openings into China and a more even playing field with domestic companies, especially State-owned enterprises.
In March 2014, Brussels agreed that once an EU-China investment treaty is concluded it will consider broader trade talks with Beijing. The investment treaty negotiations began just a few months prior, in November 2013. Once finalised, this BIT willl replace the 26 existing BITs that China has signed over the years with individual EU member states.
The EU is China's largest trading partner, while China is the EU's second export market.
July 2014
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12-May-2019 Global Times EU needs unified stand to conclude BIT with ChinaChina - EU were committed to achieving "decisive progress" for the conclusion of a China-EU Comprehensive Investment Agreement in 2020 - the bilateral investment treaty (BIT) between China and the EU.
11-Apr-2019 Xinhua Net China, EU aim to conclude comprehensive investment agreement in 2020China and the European Union (EU) aim to conclude a comprehensive bilateral investment agreement in 2020.
22-Mar-2019 Euractiv L'UE resserre les rangs face à la ChineLes négociateurs européens ont inclus dans leur proposition envoyée à leurs homologues chinois la volonté de conclure d'ici à 2020 un accord d'investissement « ambitieux » entre la Chine et l'UE.
21-Mar-2019 Euractiv EU urges China to progress on demands to dispel 'frustration'In order to address some of the main outstanding issues at the EU-China summit, the EU negotiators included in their proposal sent to their Chinese counterparts to conclude by 2020 an "ambitious" EU-China investment agreement.
30-Jan-2019 Xinhua Chinese envoy calls for more flexible approach in investment treaty talks with EUChina and the European Union could take a more flexible approach by setting phase-based targets in bilateral investment treaty negotiations.
2-Jan-2019 MENAFN EU's investment court may be bump in China's Belt and Road planThe EU has proposed to reform the investor-state-dispute-settlement system, a move that could further complicate negotiations with China over a bilateral investment agreement, as well as their dialogue on the Belt and Road Initiative's implementation in Europe.
6-Dec-2018 Global Times China to release new negative list for investment: sourcesThe new list will lay down foundations that will be conducive for further negotiations on the bilateral investment treaty (BIT) between China and the EU.
20-Jul-2018 Global Times China-EU investment, trade cooperation can provide new paradigm for worldChina and the EU are moving fast toward completing a bilateral investment treaty (BIT), given the two sides' desire to increase their investment in each other's markets.
29-Jun-2018 ICTSD EU, China officials prepare to ramp up investment treaty talksOfficials promised to hit a key milestone in their negotiations for an investment treaty, saying that they would exchange market access offers at next month's leaders' summit.
1-Jun-2018 Asia Times China's Belt and Road a dilemma for GermanyChinese Foreign Minister Wang Yi tried to ease Germany's concerns over Beijing's cooperation with 16 countries in Central and Eastern Europe, which many European Union leaders consider a threat to the bloc's integration, during his visit to Berlin on Thursday.
9-May-2018 Latin America Herald Tribune European Parliament delegation in China to discuss tradeThe European lawmakers will discuss the recently-imposed US tariffs on steel and aluminum, the question of overcapacity, a bilateral investment agreement, market access and intellectual property rights among other topics.
15-Mar-2018 Global Times China, EU close to BIT: reportsDespite rising concerns about Chinese investment among some European officials, China and the EU are moving fast toward completing a bilateral investment treaty (BIT) and a free trade agreement (FTA), according to media reports.
2-Jun-2017 China.org.cn Talks on China-EU investment agreement to speed upChina and Germany have agreed to speed up negotiations on a China-EU investment agreement so as to further enrich the two countries' cooperation and ties.
1-Jun-2017 China Daily European firms bet on BIT prospectsEuropean companies are hoping that a bilateral investment treaty between China and European Union can be concluded within 12 months.
28-Jan-2017 Latin America Herald Tribune Merkel wants to finalize bilateral investment agreement between EU, ChinaThe German Chancellor wants to push forward negotiations to conclusively finalize a bilateral investment agreement between the European Union and China
11-Apr-2016 Ecns Beijing seeks free trade agreement talks with European UnionBeijing wants Brussels to set the ambitious goal of launching free trade agreement talks in a bid to maximize the potential benefits for both sides while China implements its new five-year (2016-20) social and economic program.
7-May-2015 China Daily China 'willing' to seek EU investment treaty"China is willing to push forward talks for a bilateral investment treaty" with the EU, Premier Li Keqiang said, adding that it would include a "negative list" of areas off-limits to European investors.
2-Mar-2015 Xinhua Service trade with China set to be new impetus for EU recovery: expertBrussels and Beijing should speed up negotiation of a Sino-EU Bilateral Investment Treaty and strive to sign it within this year, a Chinese think-tank argues
23-Jan-2015 Xinhua Le Premier ministre finlandais appelle pour un ALE entre l'UE et la Chine"Nous travaillons actuellement pour essayer d'arriver à un accord sur un traité d'investissement bilatéral entre l'UE et la Chine, pour ensuite espérer (...) aussi obtenir un accord de libre-échange (ALE)," a déclaré le Premier ministre finlandais Alexander Stubb.
23-Jan-2015 Xinhua Interview: Finnish PM calls for EU-China FTA"Now we are working very much on trying to agree on a bilateral investment treaty between the EU and China, then hopefully ... get a free trade agreement (FTA) as well," Finnish Prime Minister Alexander Stubb told Xinhua in an interview.


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Have you been to Stonehenge? Perhaps on one of the many tours offered to this magnificent English prehistoric monument in Wiltshire? I have managed to visit twice, and within a couple of months of each other. Believe me that walking inside the circle is an almost spiritual experience.
First Visit
I first went in July of 2007. We were visiting a customer in Andover, which is a nice little train ride from Waterloo Station on the South Bank of the Thames. Very pleasant going back and forth. We taxied to the customer site and back to the station, and when we arrived at the station we realized that we had several hours before the last train and we asked a local taxi driver what it would take to get to Stonehenge? He said something like 20 minutes and he would take us and wait for about 50 quid I think it was.
Well ... we weren't about to pass that offer up. So Rick, Nick and I hopped in and off we went. It was a grey day, so we didn't know what to expect, but it was still plenty stunning when it came into view. From a ways off, it's pretty tiny looking, and the circle itself is really not very large in diameter at all.
Since this was midday, the usual rules were in effect in that you pay your 15 pounds (approximately) and then go for a long walk around the pathway, which varies from about 20 feet to 50 feet from the stones. Not bad, and with my telephoto I was able to get some nice shots.
An interesting view of the stones from a long way off ...
A couple of shots that were processed for drama, since the cloudy skies suck all the life from almost any an image. Stonehenge is a beautiful structure and screams for a beautiful sky ...
And of course my friends, Nick and Rick, in that order.
Once we were done, we walked back to the parking lot, got into our taxi and off we went to catch the train. That was at the end of a long trip, as we had already spent 2 days at the Dublin lab speaking with colleagues in two days of intensive meetings.
Second Visit
I went back to Stonehenge in September of that same year. I was invited to speak at the Rational Software Developer Conference UK Edition, and since I never pass up a few days in London, off I went.
But I knew I would have a day off in the middle of the week with a customer meeting at the end of the week, so I booked a premium tour of Stonehenge, Lacock and Bath. This is a small group tour that is carried in a coach (think Greyhound Highway Bus) with a tour guide and a driver and is granted access to the stone circle itself for almost an hour.
I was staying at the airport this time (the only time in 5 trips where I have not stayed on the South Bank for some of all of the trip) and had to catch a taxi in the middle of the night to Victoria Station to catch the bus. It arrived more or less on time and we set off in the dark. It was light by the time we passed Windsor Palace on the way out of town and was approaching 9am as we arrived at Stonehenge.
The day was really foggy, but it seemed to miraculously lift as we approached. And wow! I was just as blown away as the first time. But this time we were led together by security directly into the middle of the circle and cast loose to do as we please. The first thing I went for was the classic sunrise shot, as the sun was just peeking over the stones and looked pretty amazing. I have printed and processed many versions of that shot over the last few years, but one of the nicer renderings I have is this one, with huge color shift to the yellow.
Forgive the pride, but I *really* like this shot.
Meanwhile, I was carrying the D70s with ultra-wide angle lense (Sigma 10-20) on it and thew D2Hs with the 18-200VR on it. Both performed well enough but my back really paid the price. This was a lot of equipment slung about my neck *all* day ...
I shot most images at wide and ultra-wide, trying to capture the vastness of these stones. They are as huge as you might imagine.
And with the D70s, I got the ultra-wide shots ...
The next stop on the tour was Lacock Village, where the first two and the most recent Harry Potter movies were shot. The Lacock Abbey contains the original black cauldron I believe. This was less intense than the stop at Stonehenge, but certainly no less interesting.
A very simple building, and sadly we were to early for it to be open. But all was not lost, for this village also contains the George Inn, the pub with the longest continuous liquor license in all of England. Since about 1200 I believe. We went there for an incredible English breakfast where they simply brought you food until you could eat no more. I found this the most relaxing part of the tour, as we had nothing to do here but rest and enjoy the fabulous food.
It's a pretty little village and well worth seeing.
Finally, on to Bath. A fairly long ride ... luckily, the premium tour buses are very comfortable ... we approached the west end of the country here, indeed we saw Bristol on the coast as we left for London later on.
This city is, of course, the famous site of the Roman Baths where you can walk on thousand year old Roman pavement, but the city became a World Heritage Site in 1987 and contains a lot of other interesting architecture as well as a couple of Universities and so on.
We were dropped at the front of the Roman baths, which happens to share a site with Bath Abbey, another wonderful sight. I chose to tour the baths first, and they were impressive to say the least. I would have loved to be there in the evening to catch that moment when the water and sky are in balance and the reflections simply glow. Another time perhaps ...
The Roman pavement showed some very interesting architecture down below. For example, they used stones to suspend floors and allow cool air to flow underneath, thus keeping the room above comfortable. Here are the stones without the suspended floor in one such spot.
Of course, I am a sucker for churches and it wasn't long before Bath Abbey grabbed hold of me. The Abbey shows up here just beyond the baths. This put a perfect cap on the tour, as I had already shot many images in Southwark Cathedral on the south bank of the Thames.
What can I say? Beautiful, like all English churches from what I have seen.
The trip back home was almost 3 hours, grueling actually after such a long day. One young girl cried all the way back because she had left her camera in a shop and someone had nicked it. This camera contained most of the images she had shot on her tour of Europe over the summer and this was the *last day* of her entire trip. I sh*t you not. It remains one of the saddest moments I have ever witnessed in my entire life.
I suggest that you consider one of the premium tours the next time you are in London. And please note that they do not run all the time. I was incredibly lucky that one of the tour dates coincided with my off day, else I would have missed the Stonehenge sunrise.
And finally, when in England, please remember to mind the gap. You will be forgiven for jeering at that one ...
This blog is my personal space. Do not confuse this with statements or opinions on behalf of any employer I have ever had, have now, or will ever have in the future.
Thursday, June 11, 2009
Posted by Unknown at 10:56 PM
4 comments:
- sarsen56 said...
Great Images, especially the Stonehenge sunlit close-up shots which are superb. People may think it's easy to photograph the stones, but I'm sure you will agree that to do credit to their size is not an easy task - well done!
- June 12, 2009 at 6:23 AM
- Kim Letkeman said...
Thank you very much. I agree that the stones are enormous and once inside the circle, rather in your face. I am very pleased to have had time to work out a few angles that caught some of their majesty.
- June 12, 2009 at 8:24 AM
- Denise Todd said...
Amazing and wonderful photos you got here! I really like your eye for detail. :)
- June 23, 2009 at 5:28 AM
- Kim Letkeman said...
Thanks so much Denise.
- June 23, 2009 at 7:56 AM
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Talking With Children About Death
By Jenise Harmon, MSW, LISW A close friend of your child dies unexpectedly in a horrific car crash. An aunt loses her battle with cancer. The beloved cat has to be put to sleep. A parent is diagnosed with a terminal disease. All these are examples of ways children can encounter death for the first time. A child's first …Read More →


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Metal Gear Solid returns with a highly anticipated release. Ever since the E3 demo people have been asking, is the Phantom Pain the new Metal Gear Solid title. Well the answer is yes and it is out November 15th.
The espionage action behind Ground Zeroes promises to deliver dynamic and more complicated play techniques that will allow gamers to silently overcome their enemies without raising an alert. The first game on the FOX Engine Metal Gear Solid Ground Zeroes is currently slated for released on current generation consoles but next gen consoles haven t been taken completely off the table either.
The ever popular Metal Gear franchise returns on the Xbox 360. With an array of new features your ability to sneak past enemy lines will be tested more than ever before.
In addition to the franchises returning characters, such as Snake, Kazuhira Miller, Ocelot, and Emmerich, Metal Gear Solid V: The Phantom Pain will introduce all new characters to the Metal Gear universe. The storyline will focus on dark themes that portray the ugliness and tragedy of war, as a legendary hero falls from grace.
Day One Edition Includes:
metal gear solid 5 is the best metal gear solid game that has ever been released with amazing graphics use a dog to scout ya enimees use a chick called quiet to silently remove enimees use air strikes use ya helecopter for back up game is 5 out of game is the best metal gear game
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Chris Harrell
Service Manager
Chris Harrell has 13 years of experience in the refrigeration and cold storage industry. For the past four years, he has served as the service manager. His experience includes the installation and repair of industrial and commercial refrigeration and HVAC equipment which includes walk-in coolers and freezers, reach-in coolers and freezers, milk boxes, ice machines, refrigerated trucks, ammonia central plant maintenance applications, insulated cooler doors, door gaskets and door heaters.


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Sunday, July 27, 2014
August 2014 LET Results K - Secondary
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August 2014 Licensure Exam Results for Teachers
Secondary Level
Surname starts with letter K
Daily Bread
Therefore, since we are surrounded by such a great cloud of witnesses, let us throw off everything that hinders and the sin that so easily entangles. And let us run with perseverance the race marked out for us,
Hebrews 12:1
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Click on the video above to see how our worms are doing!
The worms seem very happy, especially that the cooler weather is gone for good. Summer has arrived, and with it, a few new challenges. Our worm bin was in a shady spot during the spring, but now the sun is starting to hit it during the late morning hours.
I noticed the materials inside were starting to dry out pretty quickly, especially around the edges. At first I just sprayed the compost material with a spray bottle every couple days. Now that our daily temperatures are averaging around 90 degrees, I went ahead and moved the bin to a spot that stays shady almost all day long. This helps, but I still have to use a spray bottle at least once a week to keep the material moist.
Another thing that's happening is because of the low humidity, we're not collecting much liquid from the bin. I think that's also related to the fact that we're probably around 20-30% capacity for our worms. I'm guessing we have around 400 worms in there, instead of the 2000 we started with.
Things we're adding to the bin these days:
Old lettuce, corn cobs, corn husks, washed egg shells, moistened paper egg cartons, and coffee filters with coffee grounds.
I'm the only person who drinks coffee at home, so it's a filter (unbleached) for a one-cup coffee maker.


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Rolly Tasker Inshore Sails are suitable for small boats up to 28ft. These are at least factory equivalent replacement sails which originally come with most production boats. They are perfect for cruising and light racing. These sails are manufactured with quality cruising dacron weaves that last for many years. They have been extremely popular for the Hunter, Catalina, MacGregor, Precision and similar yacht ranges.
Rolly Tasker Coastal Sails are designed for recreational cruisers and club racers who look for a combination of durability and performance for boats up to 36ft. The sails are built in crosscut design in a strong construction finish with use of High Modulus dacron fabrics to ensure durability and shape holding.
The sails are manufactured to our highest construction and finish specification to guarantee trouble free long life use and performance. They are extremely strong and low in stretch due to choosing the highest quality dacron available from the world's leading cloth manufacturers. We recommend this range for boats above 37ft, sailing both coastal, blue water and ocean passage making.
The Rolly Tasker Performance line is designed for performance orientated sailors who want to participate in racing as well as cruising.
Rolly Tasker Sails offer four types of down wind sails to cater for all applications.
Explore your options here.
Rolly Tasker makes storm sails to standard sizes. They are rugged and strongly finished to ensure they are capable of handling storm conditions reliably. The sailcloth used is heavy duty dacron constructed with over sized and heavy corner patches with webbing and hand sewn leather re-inforcement: the seams are triple stitched and leech lines are installed. They are made in plain white with highly visible orange balls both sides of the sail, or all orange. Many race organizations insist on all orange storm sails now.
Storm jibs have the option of brass hanks on the luff, or a luff tape if feeding into a furling unit. Trysails can be equipped with luff slides, or left with eyelets for parrel beads to be installed.
Submit your details below and a dealer will be in touch...


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Here we have the lunch menu while playing PSO.
Sqwirl5252's PSO Lunch Menu: Drinks: Iced Tea, Vanilla Coke, or Cream Soda. Foods: Slim Jims, Cereal(any kind), Cheez-its, and Ramon Noodles.
Soundtracks are always good to listen to when you are playing.
There we have it folks, the classical good ol' PSO tradition.


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Interested in learning more about Vedic Meditation? The Introduction is a free one hour lecture and question/answer session designed for anyone interested in learning more about Vedic Meditation - a simple, effortless and highly beneficial practice that absolutely anyone can learn.
Attendance at an Introduction to Vedic Meditation class is a prerequisite for enrollment in the 4-day Course in Vedic Meditation. Click here for more details about the Introduction to Vedic Meditation class.
Note: the Chicago 4-day Course in Vedic Meditation begins December 17 and runs through December 20. Space is limited, please RSVP. There will also be a Free Info Session in Chicago on Thursday, December 15.


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Please remember to bring your insurance identification card and driver's license to your appointment.
Vermont Open MRI participates in most local and national insurance networks. Every insurance plan is different and each patient will have a different out-of-pocket responsibility based on both insurance coverage and your benefit plan (deductibles, co-insurance). We would be happy to give you an estimate of what your out-of-pocket expenses will be. Please call us prior to your appointment at 866-452-4999 or request a price quote. We realize that navigating the financial aspects of healthcare can sometimes be challenging and confusing, so please contact us with any of your questions or concerns. We will be happy to assist you.


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Data and roaming
Within the EU and EEA - no extra cost for roaming and data
You can stop worrying about high costs when your use your mobile in other EU and EEA countries, including Norway and Iceland. All of our subscriptions, both those newly taken out and previous ones, allow you to telephone and send SMS and MMS with the same conditions as in Sweden.
It's also to use up to 10 GB of data traffic on a standard subscription, when travelling in another EU/EEA country, without extra cost. The Max subscriptions give up to 20 GB data traffic.
Outside the EU and EEA
All LiU telephones can be used to make calls when abroad.
Data traffic, however, is very expensive abroad. This is why LiU has set a barrier at a cost of SEK 100 for data traffic. If you exceed SEK 100, you will no longer be able to send and receive data. It's possible to lift this block, or order a data traffic package designed use abroad. Information about this should be automatically sent by SMS to a LiU telephone when it's used abroad.
The link below has a price list for making calls and using data traffic abroad: Prices when travelling.
Remember that all use that may incur costs for LiU must be approved by your manager.
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Last updated: 2018-11-12


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Z Sold Clit Clip Emerald Teardrop Simplicity Under The Hoode Stud Button Hugger
Silvertone base clip features beautiful sparkling emerald green crystal teardrop in simple goldtone four point setting; stud clip design for fake pierced look; measures 3/8 inch across (approx. 10mm) and approx. 1/2 inch long (12mm). Illustrated instructions included with purchase. Stays on. Contains mixed metals and small rubber insert on the base clip.
COPYRIGHTS: Under The Hoode and clip design are exclusive copyrights of Under The Hoode, LLC Feb. 2006 (c)


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My name is Richard. So what else do you need to know? Stuff about my family, or where I'm from? None of that matters. Not once you cross the ocean and cut yourself loose, looking for something more beautiful, something more exciting, and yes, I admit, something more dangerous. So after 18 hours in the back of an airplane, three dumb movies, two plastic meals, six beers and absolutely no sleep, I finally touch down... in Bangkok.
-Richard, The Beach (2000)
Anyone my age surely remembers Danny Boyle's movie The Beach, a sun-drenched tale of a secret paradise discovered by beautiful people lusting after each other, rounded out with a killer soundtrack and a young, shirtless Leonardo DiCaprio. The Thailand-based movie opened the millenium to a lukewarm reception, probably because it didn't translate well from book form, but the movie strangely has a special place in my heart. Maybe it's the breathtaking tropical scenes and promise of new adventures. Maybe it's because I agree with DiCaprio's character Richard when he says we're all looking for that "wow" experience that sets us apart from everyone else, be it discovering an untouched island in Southeast Asia or tasting the best unheard-of rum in the world or even finding an amazing restaurant before the critics get to it. But I probably like The Beach because it's a complicated story of a man seeking paradise only find that the promised land is a farce. And that's exactly how I felt about traveling in Southeast Asia: its alluring, exotic façade was exactly that, a façade covering the grinding reality of life in Southeast Asia.
There was a lot about Bangkok and Thailand that I didn't like, and little that I actually did. What did I not like? The long and expensive flight to the country. The pervasive monoculture of dirty, ugly concrete buildings. The oppressive heat and humidity. In-your-face poverty and ostensible wealth. The omnipresent smell of raw sewage and incense. Electrical wires, cars, motorbikes, trash, and malnourished street dogs everywhere. But what did I like? Inexpensive massages (less than $10 for an hour!), surprisingly affordable top-notch medical facilities (a thorough teeth cleaning for $35!), and a kitschiness unique to Southeast Asia (hot pink taxis! gold Buddhas! neon lights in temples!). And while people rave about Bangkok's vibrant street food scene, they can have it; I strive to eat a clean vegan diet, so carts offering a bounty of meats and unknown fried things didn't appeal to me (BUT I did love the carts selling fresh pineapple and mango).
There are many travelers that thrive in "adventurous" environments like this, and it turns out I'm not one of them. People in this category especially enjoy the rock bottom prices of Southeast Asia, and I equate low prices with low wages and standards of living; someone's gain is another's loss, in other words. I don't regret my first trip to Asia and I think experiencing this part of the world was (mostly) worth the hassle. Japan is still on the top of my travel bucket list and I'd be open to visiting Indonesia and Vietnam, but for now I'm back in Europe enjoying potable water and septic systems that can handle toilet paper. After this experience, I learned two important things: one has to be in a certain mindset to visit countries like this, and traveling with a dog is not feasible unless you are willing to put up with significantly more effort and expense. As much as I tried during my month in Southeast Asia I never arrived at the point where I could relax and 100% enjoy the experience and I ended up cutting my trip short to book a long and expensive flight to Bosnia. Not only was I scared that I'd be stuck in Thailand for four months because Mango didn't have a titer test to fly out (more on the nightmare of traveling with a dog in a future post) but I was also dealing with a complicated, stressful medical situation, two things that consumed my time, triggered a major bout of depression, and left me feeling completely helpless to the unknown.
But negativity aside, I did manage to visit some interesting sights in Bangkok that were truly a feast for the eyes. Enjoy my photos of Bangkok!
Around Bangkok
Apart from visiting the United Kingdom ages ago, I don't believe I've ever traveled to a purely-kingdom kingdom country like Thailand. The country's king for the past 60+ years, King Bhumibol Adulyadej, passed away last fall and the country is now in mourning for a one-year period. Thais are literally in love with this guy, worshiping the ground he walks on, which surprises me because not only was he born and raised in the US but he was purportedly worth $30 billion. That being said, black ribbons, large images of the king, billboard advertisements, even an announcement after the Air Asia safety check are opportunities for mourners to express their grief, and Bangkok is especially full of mourners. Hundreds of thousands of Thais are visiting the Grand Palace to pay their respects, and the green park nearby is being turned into an elaborate site where his funeral will soon be held. As for urban Bangkok, that's another post in itself.
Grand Palace
Since 1782, the Grand Palace has served as the official residence of the King of Siam. For a whopping $15, visitors are invited to cram their hot, sweaty bodies inside the palace gates to walk around the well-manicured grounds. Admiring the bright, whimsical buildings and temples was a delightful experience and it was fun to drink in all the architectural details (mirrors! mosaics! shells! lacquer!). Unlike the palaces of Vienna, Thailand's Grand Palace is instead an organic complex of buildings, courtyards, gardens and pavilions. There were so many people at the temple that I couldn't figure out if visitors could actually go inside the palace building, but I'm guessing the cursory cordoned-off glance was the closest I'd get.
Wat Mahathat Yuwaratrangsarit
A bit north of the Grand Palace is Wat Pho, or the Temple of the Reclining Buddha. Bangkok is speckled with colorful, borderline garish, temple complexes welcoming visitors and Buddhists alike, and this one is unique in that it's one of Thailand's "highest grade of first-class royal temples." Information on its history is scant, but the temple was built before the 1800s. What original buildings remain at Wat Pho is unknown; I had a hard time distinguishing the age of these glossy temples, because they are so meticulously kept. Wat Mahathat is home to 28 Buddha statues, 108 holy monks, and 5 Buddha thrones. Instead of paintings, the temple has wood carvings that depict Buddhist history and art as decoration. Call me culturally ignorant, I never completely grasped the concept of what to do as a visitor to Buddhist temples: who are all the locals standing around? are vendors selling things to visitors... or Buddha? is it okay to freely walk the grounds and take photos in a sleeveless shirt?? Seeing one temple was fun, but after a while they start to run together. I didn't make an effort to visit other temples in Bangkok (the city is so spread out) and that was fine with me, but it was still nice to pass one and admire the occasional amusement-park-with-no-amusements complex known as a Buddhist temple. The entrance fee to the temple for foreigners is about $6 (200 baht) plus 20 baht to rent a shawl if your shoulders are uncovered; paying to visit a religious site was something new and surprising to me.


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Cohabitation And Spousal Support: Do They Mix?
For those previously married, getting hitched again is probably not the first thing on their minds. Nowadays, it's not uncommon for people to just "live together" without the benefit of any legal agreement whatsoever, and this can be especially true for those who have left a bad marriage. Since two really can often live cheaper than one when it comes to rent and housing expenses, cohabitation has become extremely popular. One frequently problematic issue is the financial arrangements of that cohabitation in relation to spousal support. Read on to learn more.
Why is spousal support still ordered? Some may be surprised to find that alimony, now usually referred to as spousal support, is still being ordered through separation and divorce. While women now make up a large portion of the workforce, not all choose to go that route. Many couples decide that it makes more sense for one of them to be full-time parents and for one of them to be full-time wage earners. This can be the man as often as it can be the woman. When a divorce occurs, it can send the stay-at-home spouse into a financial head-spin. Often, this spouse has given up both career and education opportunities to be a caregiver, and now must deal the the bleak financial reality of that decision. Spousal support can help even the playing field until that spouse can get on their feet, financially speaking.
What is your current financial situation? If you are now cohabiting and are facing some flack from your ex about the spousal support, a close look at your finances may be in order. Just because you are living with someone does not automatically mean that your financial situation has been changed for the better; it really depends on how you and your partner have set up the division of bills. While it may be only natural for your former spouse to object to the continued need to pay spousal support, your cohabitation arrangement may have no bearing on that arrangement. If your ex takes you back to court to have the spousal support reduced or eliminated, you may need to show your math, so be prepared.
What the judge may consider: The judge will be questioning how much support you were awarded and the reason for that support. For example, if you were meant to return to school using rehabilitative spousal support, you should be prepared to show that you are complying with that order. Other issues likely to be brought forth are:
How much income are the two of you making?
Are you sharing bank accounts?
What does your current budget look like, and who is paying what expenses?
Do you and your partner have any joint debts, like a car? Are you both on the rental lease?
One of the best moves you can make is to speak to your divorce attorney, like Marlene Dancer Adams, before you change your living arrangements so that you can move on with your life without it affecting your financial status.


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Monday, May 7, 2018
Cathedral City CA Home For Sale
By: PShouseblog On: May 07, 2018 In: #3 Bed, 3.5 bath, cathedral city CA, fireplace, Gated community, Golf Cart Garage, HOA, home for sale, newer construction, views, You Own The Land No comments
One Year old home, Stunning views to the South and the West. Unique home in the development due to open space on the West side. Premium lot, nothing like it available or coming available. You will not want to miss this one!
Michael Layton
Written by PShouseblog
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If properly maintained, fine rugs like woven wool, oriental, and Persian can last a lifetime. However, correctly caring for these rugs is harder than it looks.
Because of their construction combined with the ability of wool to hold and hide soil, these rugs can retain a large amount of soil without looking dirty. The reason for this is the soil is caught in the bottom of the rug, out of sight. Even normal vacuuming isn't effective in removing it, and over time, the soil will build up and start to damage the wool.
This is why washing your fine rugs is so important to their health and longevity.
To help keep your precious woven wool rugs healthy and looking their best, Precise Carpet Cleaning offers oriental rug washing and area rug cleaning at our facility in St. Charles, MO.


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Grand Rounds Recap - 10/22/14/
M&M Learning Points with Dr. Mike Bohanske
Acetaminophen can be one of the most dangerous drugs in overdose, as the toxic dose of acetaminophen is 250 mg/kg
There are 4 stages of acetaminophen overdose:
- Stage 1 from 0-24 hours when labs may be normal but the patient has nonspecific symptoms such as nausea, vomiting, and fatigue
- Stage 2 from 24-72 hours when labs may be normal or be trending upward but the patient is asymptomatic
- Stage 3 from 72-96 hours when significant metabolic derangement can occur such as profound metabolic acidosis, florid liver failure, and AKI.
- Stage 4 takes place only if you are able to get them through the acute illness precipitated in Stage 3 when hopefully recovery takes place, though there is no guarantee of liver recovery
- Use the Rumack-Matthew nomogram to determine the need to treat, the downside is you need to know the time of ingestion and this needs to be a single acute ingestion to apply it
- Treatment is with N-acetylcysteine (NAC) based on a 4-hour APAP level and should be initiated as soon as the 4-hour level returns
- If the time of ingestion is unknown and any signs of liver injury it is still work starting NAC
- NAC has a high co-incidence of anaphylactic-like reaction (10-20%) and there is correlation with how quickly it is given
Not all urine that fluoresces is ethylene glycol, in fact urine high in bilirubin can even cause it to fluoresce
Sepsis is a dynamic illness that requires vigilance to both identify and treat effectively
- Source control and time to antibiotics is essential, mortality has been demonstrated to be directly correlated to time to antibiotics
- Ertapenem is a carbapenem which can be useful for some intra-abominal infections but does NOT cover MRSA, Pseudomonas, or Enterococcus, thus limiting its use as a broad spectrum antibiotic
- While new studies such as ProCESS and ARISE continue to shine light on the way we resuscitate septic shock, neither proved that EGDT is unnecessary. Instead, they likely both highlighted just how far "usual care" has come in terms of aggressively identifying and treating septic shock.
- ARISE and ProCESS have shown that all aspects of the intensive "Rivers Protocol" approach to sepsis may not be necessary (i.e. invasive access and ScVO2 monitoring), but we should still aim for an early goal directed therapy of septic shock.
Spinal epidural abscess (SEA) may be increasing in incidence with increasing heroin use
- Remember that IVDU is by no means the only risk factor, recent instrumentation, DM, and ESRD all increase your risk significant for spinal epidural abscess
- The classic triad of back pain, fever, and neurological deficits do not all have to be present, have a high suspicion in anyone with the right constellation of risk factors with back pain
- SEA are notorious hard to diagnosis and on average patients required at least 2 ED visits before diagnosis, but sometimes as many as 8 visits!
- On average a SEA spans ~4 spinal levels but can be occult and so be sure to expand the search to include all appropriate spinal levels with imaging
- Thoracic spinal cord disease can be notoriously hard to localize so be sure to do an appropriate neurological exam if ordering imaging
Other Learning Points
- Do not forget about the importance of informing patients of incidental findings during their ED work-up verbally and in writing
- Trauma usually has a cause - if someone does not know why they were in a single-vehicle car accident, start searching for something more insidious than just traumatic injuries, cardiac incidents often precipitate trauma
Update on Therapeutic Hypothermia with Dr. Bill Knight
Until recently the classic teaching was that the Number Needed to Treat for Therapeutic Hypothermia (TH) in post-cardiac arrest patients was 6. However, the Targeted Temperature Management (TTM) study has raised some questions on the utility of 33C TH vs. maintaining euthermia at 36C post-arrest, but certainly this highlighted that 36C seems non-inferior to 33C. It can be difficulty to compare studies in a field as dynamic as cardiac arrest research as resuscitation science has come a very long way quickly.
We still have no way of prognosticating who will do well after cardiac arrest and who will not. Typically this determination cannot be made until 72+ hours without any extenuating circumstances (i.e. early signs of anoxic injury on CT)
Consider discussing early cardiac catheterization for post-arrest patients as there is data to indicate this may have mortality benefit, but this should not delay cooling
Adrenal Disease with Dr. Ludmer
Adrenal Insufficiency (AI) is difficult to diagnose due to the nonspecific symptoms and often can take years to diagnose with multiple incorrect diagnoses initially
- Symptoms can range dramatically but almost always include anorexia and generalized weakness/fatigue. You should consider it as one of the "next great imitators" (along with Lupus, HIV, and Syphilis)
- The metabolic panel can be very telling and AI should be seriously considered in anyone with hyponatremia, hyperkalemia, and hypoglycemia
- Hyperpigmentation is the classic physical exam finding in primary adrenal insufficiency
- AI can be worked-up in the outpatient setting and does not necessarily need admission unless the patient has hypotension, significant electrolyte abnormalities, or has no access to follow-up
Adrenal crisis occurs when the symptoms of AI progress to cause refractory shock state
- If you're considering adrenal crisis a random cortisol of <15 mcg/dL significantly increases your post-test probability of disease, while a random level of >34 mcg/dL makes it fairly unlikely. Consider a cosyntropin stim test if the patient has a level between 15 and 34.
- There is conflicting data on the utility of corticosteroids in septic shock based on results from the Annane and CORTICUS trials.
- Annane was based in a much more acute phase of septic shock and seems to have some more applicability to the ED population and thus its results, which do show a mortality benefit for steroid use might be more appropriate to generalize to ED patients
Case Follow-Up with Dr. Denney
27yoM w/stable wide complex tachycardia requiring multiple anti-arrhythmics and cardioversions
The differential diagnosis for wide complex tachycardia in the ED is either ventricular tachycardia versus SVT with aberrancy. Unless you are sure that a wide complex tachycardia is sinus tach with aberrancy than assume that it is ventricular tachycardia
- Stable ventricular tachycardia can be treated with procainamide, amiodarone, or synchronized cardioversion (both procainamide and amio can precipitate hypotension forcing a cardioversion)
- Patients with episodes of stable VT require admission to determine a cause and for assessment of implanted automatic cardioverter-defibrillator