text:
Court Appointed Special Advocates
Franklin County CASA
Serving Franklin and Gasconade Counties of Missouri
Tax Breakdown
Franklin County CASA is a nonprofit, therefore, all contributions are tax deductible. Contributions over $100 may be eligible for the Champions for Children Tax Credit allowing up to a 50% credit for your generous donation. The benefits described below are based on a federal tax deduction assuming 28% tax bracket, Missouri income tax savings assuming 6% tax bracket, and Addiction Missouri Income savings from Champion for Children Tax Credit. Franklin County CASA advises you to consult your tax advisor to see how you can personally benefit from the tax credit.
Potential Tax Credit Benefits
Donor's tax savings $2,100
Donors out of pocket cost $400
Donor's tax savings $830Donor's out of pocket cost $166
Donor's tax savings $210
Donor's out of pocket cost $40
Donor's tax savings $84
Donor's out of pocket cost $16
Franklin County CASA
email@example.com | 636-583-4422
Follow us on Facebook | Instagram | Twitter
Copyright 2018 Franklin County Casa. All Rights Reserved.
Special thanks to:
- Email hosting and internet services provided by YHTI.
- Website design by Marcink Designs LLC.
- Hosting provided by StickyFolios.


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17 Apr CAMPAIGN BRIEF: Cook Islands programmatic campaign study
Cook Islands programmatic campaign study shows 20% online ad recall, 3% increase in Australians wanting to visit the Islands
Originally published: Campaign Brief, 17 August 2017
Sparcmedia ran a month long programmatic advertising campaign in April 2017 and included video, search and display ads across web and social targeting Australians and New Zealanders across all ages and regions. In addition, custom audience segments were built in a data management platform (DMP) to reach psychographic-based consumer segments interested in adventurous travel.
The campaign was backed by an online pre and post campaign survey conducted by parent company Pureprofile – an online profile marketing and insights technology business. The survey measured the key objectives of the campaign: the advertising impact on raising brand awareness; and whether the Cook Islands were now being recognised as an adventurous destination rather than a resort island. Read more >

subset: commoncrawl


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Material to be covered includes git version control and R programming. Short tutorials will alternate with hands-on practical exercises, and participants are encouraged to apply what they have learned to their own research problems. Participants should bring their own laptops and be sure to have admin privileges on them. Click the link below to register. Space is limited to 30 people.
Please direct questions to Sheena Murphy, Associate Vice President for Research Development.


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SmartInspect, our advanced logging tool for Java applications, helps you to identify and solve Java exceptions and Java errors and enables you to add sophisticated Java exception logging and Java exception handling to your desktop or JSP web application. SmartInspect assists you even where regular debuggers and other tools fail: It is possible to easily debug distributed systems, multi-threaded applications, software on production systems and inspect software that runs at customer sites.
SiAuto.Si.Connections = "file(filename=c:\\log.sil)";
SiAuto.Si.Enabled = true;
// Log simple messages, warnings and exceptions
SiAuto.Main.LogMessage("Processing Order 48843");
SiAuto.Main.LogWarning("Connection refused");
// Log variable values, datasets or any other object
SiAuto.Main.LogInt("index", index);
SiAuto.Main.LogObject("order", order);
SiAuto.Main.LogDataSet("dataSet", dataSet);
SiAuto.Si.Connections = "file(filename=c:\log.sil)"
SiAuto.Si.Enabled = True
' Log simple messages, warnings and exceptions
SiAuto.Main.LogMessage("Processing Order 48843")
SiAuto.Main.LogWarning("Connection refused")
' Log variable values, datasets or any other object
SiAuto.Main.LogInt("index", index)
SiAuto.Main.LogObject("order", order)
SiAuto.Main.LogDataSet("dataSet", dataSet)
// Log simple messages, warnings and exceptions
SiAuto.main.logMessage("Processing Order 48843");
SiAuto.main.logWarning("Connection refused");
// Log variable values, result sets or any other object
SiAuto.main.logInt("index", index);
SiAuto.main.logObject("order", order);
SiAuto.main.logResultSet("resultSet", resultSet);
Si.Connections := 'file(filename=c:\log.sil)';
Si.Enabled := True;
{ Log simple messages, warnings and exceptions }
SiMain.LogMessage('Processing Order 48843');
SiMain.LogWarning('Connection refused');
{ Log variables value, datasets or any other object }
SiMain.LogInteger('Index', Index);
SiMain.LogObject('Order', Order);
SiMain.LogDataSet('DataSet', DataSet);
Log and trace Java exceptions, errors, call stacks and more
By integrating the SmartInspect Java library into your desktop or JSP web application, you are able to log exceptions and errors to log files or to the SmartInspect Console. You will always know exactly where the exceptions occurred and what led to those exceptions – either during development or on your customer's production system.
Use SmartInspect to log and handle exceptions
Whether you use SmartInspect for your Java exception logging or JSP exception handling, you will be able to provide faster and better support to customers and users by analyzing their log files and errors. SmartInspect enables you to quickly find out what problems your users experience and which part of your code is responsible for the issues.
Monitor and analyze your applications in real-time
The SmartInspect Console is the powerful viewer application that helps you to analyze your logging information and enables you to monitor your applications in real-time. It lets you filter, search, navigate and edit your log data with ease and provides many different viewers for displaying your data.
Visitors use the following phrases to find this page: java exception, java exceptions, java exception handling, java exception logging, java errors, jsp exceptions, jsp exception
We have some exciting news to share today. When Tobias and I founded Gurock Software more than 10 years ago, and when we released our now fl..
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Almond Blossom Flowers Paintings Reproduction of Van Gogh - Print on Canvas
Returns - Returns are acceptable for defective or malfunctioning units, or if you are not satisfied with the quality of the item. Let us know within 60 days for a full refund on email@example.com.
Material: Canvas
Medium: Oil
Original: No
Type: Oil Paintings
Subjects: Abstract
Shape: Square
Frame mode: Unframed
Support Base: Canvas
Technics: Hand Painted
Style: Abstract
We accept payments via Credit Card and PayPal.


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You are here
How can we attract more men to be therapeutic radiographers?
A research project at Sheffield Hallam University (SHU) to understand the barriers to recruiting more males to train as therapeutic radiographers has come up with a range of innovative solutions.
Less than one in five radiographers involved in cancer treatment are men and the research project led by Jo McNamara, senior lecturer and admissions tutor, and Julie Nightingale, professor of diagnostic imaging education, sets out a recruitment strategy to target a male audience:
- School outreach to include physics and mathematics students, as well as traditional approaches where pupils are studying biology and health and social care courses.
- Recruitment language and terminology to include leadership attributes (decision-making, problem-solving, saving lives).
- Emphasise a sustainable career - working hours, pension, salary at entry, and career progression opportunities.
- Recruitment media needs to be suitable for different audiences and platforms, such as Prezi, wall and e-posters, videos, tablet and phone appropriate materials.
- Start awareness-raising of the profession much earlier and use age-appropriate language ('killing cancer with big laser guns!').
- More male role models at recruitment events.
"We have been able to produce all new marketing resources, a school and college engagement toolkit, and a recruitment strategy to target year 10s and 11s," Jo McNamara said.
"This strategy will be disseminated to our other professional courses where recruitment is an issue, and specifically the recruitment of male students, other higher education institutions, and the Society of Radiographers."
Jo continued, "Increasing male recruitment would impact positively on the workforce and represent the demographic of patients within the population. For example, a high proportion of the radiotherapy workload involves the management of prostate cancer patients, with 47,151 cases of prostate cancer being diagnosed each year, of which almost a third have radiotherapy as their primary treatment.
"Fingers crossed we shall see more male students starting on courses in the next couple of years!"
SHU have developed the following resources:
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In-Home Physical Therapy
Home PT Services in New York
The physical therapists at NY Physical Therapy & Wellness are so committed to your recovery that we will come to you if needed. If you're housebound due to pain, immobility, or travel difficulties, you'll want to find out more about NYPT Home PT, our in-home physical therapy services.
NYPT Home PT provides complete physical therapy treatment in the privacy and convenience of your home. We serve patients in Queens, Nassau, and Suffolk counties in New York. Most insurance plans are accepted.
Contact us for more information or to schedule an appointment:
Phone: (516) 520-7200
Fax: (516) 520-7625
Email: email@example.com
Benefits of In Home Physical Therapy
The friendly, professional, dedicated therapists at NYPT Home PT provide effective and personalized care in the comfort of your own home. You will receive an individualized plan of care suited to your specific condition and needs, from post-operative rehabilitation to ongoing care for an existing injury.
- Our treatment plans can help ease your pain while working on balance, strengthening, and walking.
- Your therapist will evaluate the safety of your home to help prevent falls.
- No equipment is necessary – we will bring everything you need!
Best of all, it is easy to get started. We're here to listen, and we're here to help you get back to your life.
"It was a pleasure to have high quality therapy performed in the comfort of my own home. I would often need to reschedule sessions if my ride fell through or if I was in too much pain to drive. The therapists NY Physical Therapy & Wellness sent over were excellent and solved the issue. I highly recommend NYPT Home PT." ~ Carol H.
Read more patient testimonials.
Contact Our New York Physical Therapists Today!
Call (516) 520-7200 or email us today to inquire about the in-home care provided by NYPT Home PT therapists. We look forward to hearing from you.


text: Introduction Shell Remote Access SSH is a method for secure communications without access to a local console. OpenSSH is feature rich supporting many different authentication mechanisms. It can also allow users to completely bypass firewall configurations via tunneling. Scale: Known configurations Scale Unknown Unknown Software Requirements Required packages Service Software package Installation command OpenSSH Server openssh-server OpenSSH Client openssh-clients denyhosts denyhosts Configuration Required Config Lines Requirement Action Config Comment Must Define Must Define Must Define Must Not Define Should Define Should Define Should Define Should Define Should Define If not using GSSAPI


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At a time when travel is being actively discouraged, we will not be posting any sightings that may inspire individuals to do so. We will endeavour to continue to report routine sightings that may be of interest, but not of scarce or rare birds. We thank you for your understanding and of course visiting birders will be most welcome once this crisis is over. Please be safe and sensible and follow government advice and not put our community at risk.
All the latest Western Isles Bird / Outer Hebrides Bird sightings and information will be listed here - please log in or sign up if you would like to add your own. Alternatively you may email your sightings and photos to email@example.com or leave a voicemail at 01851 741250. All sightings will also be forward to the County Bird Recorder Thank you!
Western Isles Bird / Outer Hebrides Bird Sightings 2018
Sightings for previous years can be found in the archive
Reports by finders of some of the rare birds that have occurred on our islands
News and maps of colour ringed birds and ringing recoveries.
Need help finding the details of a colour ringed bird? Post here or send the details/photographs to firstname.lastname@example.com and we will endeavour to progress it on your behalf.
Alternatively post your own sightings
Outer Hebrides Bird sightings from previous years
Western Isles Bird / Outer Hebrides Bird Sightings 2018
Western Isles Bird / Outer Hebrides Bird Sightings 2017


text:
Rotary unions also known as rotary joints are used to provide hydraulic lines for the fixture. These Rotary Unions are mounted through the center bore of rotary table, the input lines are given to rotary union at rear of rotary table. the output lines are taken from the Rotary union front on the turn table top.
Whether you are a supplier, an engineer, or a sales spoc, we have you covered! Fill in the details and we will get in touch with you shortly. Step up to the cutting-edge machine tools manufacturers today!


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A fashion designer search competition dubbed Thread wars is in the making and today, model casting for the show is taking place at the industrial area based Club Play. The models to take part in the show are to be vetted and the best will be allowed to work alongside the competing fashion designers.
The height requirements for the models are as at least 5'8" for females and 5'11" for males. Each should come with a portfolio and several headshots. The dress code is casual smart The casting will start at 10:00am till 4pm.
The Thread Wars show is soon to air on Urban TV and will be like a reality Tv show having several fashion designers take part in the fashion designer search. The confirmed judges will be K Rafael, Martha Jabo and Kabs Haloha


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Search Directory
Directory Categories
Judith Richards
Creator of The Richards Trauma Process (TRTP)
Judith is the creator of The Richards Trauma Process (TRTP).
This process steps people through trauma-related issues, such as anxiety, depression and PTSD. It is safe, effective and fast, generally in just 3 sessions.
TRTP was created out of Judith's own need to resolve her own trauma. She found a way to resolve the extreme trauma which had resulted in a major PTSD breakdown. She teaches this process to health professionals across Australia.
Contact us to find out more about trauma therapy directly from Judith Richards.
'This process is Revolutionary' – according to academics and professionals in the trauma arena.
When choosing a TRTP practitioner:
- Click on the Practitioner's name to link to their information.
- 'Areas of Interest' will provide a strong indicator of issues in which a practitioner will be most knowledgeable and experienced. (See Practitioner more info)
- Distance is not a restriction. Practitioners use online video conferencing (skype, zoom etc), to connect with their clients anywhere in the world.
- The State Location buttons will filter the practitioners into groups by States of Australia.
These are TRTP Trainers and Senior Practitioners
Pam Damm
Biographical Info
Accredited Mental Health Social Worker, Clinical Family Therapist
I have many years experience in Private Practice, Child Protection and Community Health. I have been in my current Private Practice for over 8 years and have established a respectful reputation in the Macedon Ranges area.
Over the years working with clients suffering anxiety and/or depression, I identified a link between these symptoms and the client's experience of trauma or dreadful experiences. This led me to search for a methodology that successfully brought about change without the possibility of retraumatising my clients.
Following extensive research, I encountered The Richards Trauma Process (TRTP), a groundbreaking therapy that resolves extreme traumas and trauma related issues as mentioned above. Since using this process, I have had amazing results with my clients who are leading fulfilling lives.


text:
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Aloe Up White Collection Citrus Lip Ice contains a rich blend of natural moisturizers including Aloe Vera Oil, Avocado Oil, Sunflower Seed Oil & Beeswax to keep your lips feeling soft and smooth on your adventurous days in the sun.
White Collection Citrus Lip Ice is supplied here in a 4.25g stick.
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Active Ingredients
1.96% Octinozate, 4.41% Oxybenzone


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Whilst for years it has simply traded on its name, St Moritz is rightfully a world renown ski resort. Comprising 3 diverse ski areas, St Moritz, in the canton of Grisons (or Graubünden) Switzerland, has terrain and activities for all skier abilities and non-skier proclivities.
Feted as a playground for the wealthy, the St Moritz ski areas of Corviglia, Corvatsch & Diavolezza -Lagalb should instead be feted for the excellence of their lifts, pistes & freeride adventure possibilities.
St Moritz might be a little more expensive than some snow destinations in Switzerland & Europe, but it provides a superb ski experience for those with an open mind & a sense of adventure. The Powderhounds loved it.
St Moritz's three separate ski areas of Corviglia, Corvatsch and Diavolezza Lagalb offer completely different skiing experiences. All three are connected by bus and/or train and it is possible to ski back to St Moritz Bad from Corvatsch, but otherwise there are no lift or piste trail links between the three areas (although there are plans for one- read on).
Corviglia is a piste skiers paradise directly above St Moritz. Accessed by four different points in the valley, its 155km of sunny south facing slopes are wonderful for fast turns & long lunches. The off piste is vast as well & includes everything from expert only chutes to wide open alpine bowls. Strangely, the worst place to access the ski area is from the centre of St Moritz. The villages of Celerina and St Moritz Bad (as in 'spa') on the fringes are better. Start skiing early and the slopes will be deliciously perfect and deserted until after 1030ish when the glitterati finally get out. See the Corviglia ski trail map here.
Corvatsch is a north facing behemoth up to 3303m & includes 120km of piste and a glacier in its terrain. The polar opposite of Corviglia (literally - it is shaded & colder!), Corvatsch nonetheless has excellent snow quality & more terrain diversity than Corviglia. Superb mountain eateries & gob-smacking views add cream and a cherry on top! See the Corvatsch ski trail map here.
There are plans to replace the Corviglia's Signal cable car (St Moritz Bad) with a gondola & also to lift link Corviglia to Corvatsch via a gondola from the Signal car park to above Corvatsch's Hahnensee run. A tasty prospect indeed.
The freedom on St Moritz's third ski area, Diavolezza Lagalb, is absolutely pleasurable. Spending the night on top of Diavolezza in the Berghaus is fun. First tracks in the morning after a beautiful sunrise over the glaciers & peaks during breakfast were a bonus. Luggage was downloaded for you & picked up at the base station once finished skiing. The off-piste skiing and snow quality was excellent but we barely even scratched the surface. See the Diavolezza Lagalb ski trail map here.
Diavolezza's opposite number is Lagalb, which provides a similar ski experience to Diavolezza but with a different aspect. It is very quiet compared to other ski areas, but none of them is at all busy. Both Diavolezza & Lagalb have their own train station and are linked by connecting trails and surface conveyors. Snowboarders will need to push a bit - that'll teach you!
See our St Moritz Skiing & Snowboarding page for more information.
St Moritz is located deep in the Engadin valley of canton Grisons (Graubünden), splendidly surrounded by snow & glacier clad mountains.
The town of St Moritz is 86km south of Grisons capital Chur & 203km from Zurich by road. Milan Italy is 125km to the southwest of St Moritz as the crow flies.
Gateway international airports are Zurich & Milan Malpensa. Both are linked to St Moritz by train. The Powderhounds recommend taking the train to St Moritz, but for those that just cannot abide public transport or are travelling in larger groups, a private transfer from Zurich airport may be the most efficient mode of travel if one doesn't have a car.
Search & book all airport transfers to St Moritz here.
St Moritz has its own well-appointed train station with connections to Switzerland & Italy. Aside from landing your own private jet at the local airfield, the train provides the most scenic & comfortable mode of travel to the area.
Search & book train tickets to St Moritz here.
Driving to St Moritz is not the easiest thing to do in the world. Surrounded by high mountains on three sides, the easiest road access to St Moritz is via the Inn River valley from Landeck or Innsbruck in Austria (drive time <3hr). This route is not particularly useful for most travellers to St Moritz; hence three high mountain passes tend to provide the main driving routes, all of which are questionable in bad weather (take the train!).
See our Travel to St Moritz page for best options to get there.
Like Davos (but not nearly as bad!), St Moritz has lost much of its traditional architecture & succumbed to some fairly unsightly development. And just like Davos has lovely Klosters to offset it, so does St Moritz have Celerina and other villages to offset it.
Search & book all St Moritz ski accommodation here.
St Moritz has more enormous 5-star hotels than just about any ski resort in the world (Badrutt's Palace Hotel, Kulm Hotel & Carlton Hotel to name a few) and certainly caters to the high-end skier that demands fine dining, excellent service and exquisite comfort. But as with every other ski resort in the world, a full range of accommodation options are available to suit every budget. Case in point are the numerous apartments, hostels and 3-star hotels in & around St Moritz. Well located 3 star hotels include the Hauser Swiss Quality Hotel & the Soldanella Hotel.
Access to the Corviglia ski area from the actual town of St Moritz is via a 2-stage funicular. Better access to Corviglia is available from accommodation in St Moritz Bad via the Signal cable car. A full range of hotel budgets is catered for. from the 5 star Kempinski Grand Hotel to the budget pick - Hostel Pitsch (perfectly situated next to Signal cable car base & the funkiest restaurant in St Moritz, the La Baracca).
Celerina is the best place in St Moritz for a more traditional village experience and comes with the benefit of having the most efficient ski lift access to Corviglia, the best valley run and two train stations. The Cresta Palace Hotel is the pick the accommodation & the boutique Hotelino Petit Chalet as close second.
Above St Moritz, Salastrains is a short walk or horse drawn sleigh ride from the funicular mid station at Chanterella. The Hotel Salastrains at 2048m provides the best on mountain lodging at the ski resort. It is also close to the most comprehensive children's learn-to-ski area.
Suvretta has the classic Suvretta House an uber traditional 5 star at the western end of Corviglia, providing a sense of the old world in an otherwise thoroughly modern surround.
Other villages near St Moritz offer alternative (and sometimes cheaper) lodging options and are seamlessly connected to the ski areas by buses or trains. Near Corvatsch ski area there is Silvaplana, Surlej and Segl (Sils). Surlej is closest to the ski lifts, but Silvaplana gets the most winter sun. The Nira Alpina Hotel is the pick of the Corvatsch hotels.
Between St Moritz & Diavolezza is the surprisingly large village of Pontresina. Masses of cross-country ski enthusiasts stay there, but the bus & train transport links make it a viable option for alpine skiers as well. Further down the valley but also connected by ski trail s & the train line, Samedan offers great value accommodation, even in historic 4 star hotels like the Hotel Bernina 1865.
The small hamlet of Morteratsch at the base of the glacier and ski route of the same name has its own train station & some fabulously quiet accommodation convenient to Diavolezza like the Hotel Morteratsch. For something completely different, stay in the Berghaus on Diavolezza or the intriguing Berghotel Muottas Muragl, perched all by its lonesome above the valley.
A mind-boggling array of ski instructors ski schools & guides ply their trade in St Moritz & surrounding valleys. There is every kind of ski & snowboard lesson & duration all the way up to full day off-piste freeride guiding & heliskiing available. To narrow down the field, search & book private & group lessons or a mountain guide with the best providers via our St Moritz Ski Lessons & Guiding page.
St Moritz is not just a ski resort, it is far, far more. The Engadin valley fully embraces winter providing a variety of non-alpine ski activities that is boundless & far exceeds nearly all other ski resorts in the world.
See the St Moritz Activities page for more information.
As if skiing all the brilliant St Moritz ski areas wasn't enough, the Rhaetian train network puts the amazing Davos Klosters & a host of resorts from Chur in play. By car or bus, the secret stash at nearby Bivio & the larger Savognin provide a vastly different ski experience to St Moritz.
The ultimate Swiss ski holiday would involve taking the Glacier Express train from St Moritz all the way to Zermatt via wonderful Andermatt Sedrun and Brig for another week of skiing. Let's go!
The Powderhounds are constantly reviewing new ski resorts in Europe (& across the globe) or having a second or third look at old ones. Follow Powderhounds Europe on Facebook or Instagram to see where we are currently skiing.


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Changes to the legislation regarding special hardship orders (SHO) means that a suspended driver can now apply at any point during their suspension for a SHO. A second and more recent change also sees a strict approach taken to the number of demerit points that a person can accrue while subject to a SHO.
Application period
Prior to 1 April 2019 a person was allowed a maximum of 21 days after their licence was suspended to apply for a SHO. From 1 April 2019, the application period for suspended drivers seeking a SHO was removed. This means that a suspended driver can apply for a SHO at any point during their suspension. The strict eligibility requirements still apply and a suspended driver must show that they, or their family, would suffer extreme financial hardship if they were unable to drive during the suspension period. This amendment allows a driver who experiences a change in circumstances during their suspension the flexibility to apply for a SHO.
It must be noted that any time that a driver has already been suspended for does not affect the length of the SHO. Irrespective of how many days the driver's licence has been suspended before they are granted a SHO, the duration of the SHO must be equivalent to the initial suspension period.
Accumulation of demerit points
Effective from 1 July 2019, a driver is unable to accumulate any demerit points while driving pursuant to a SHO. Previously, a driver who was subject to a SHO was able to accrue three demerit points during the period of the order. This amendment seeks to establish that a SHO is usually a driver's 'third chance' to continue to drive having previously been issued with a one-year good driving behaviour period (and allocated one demerit point). If a driver incurs any demerit points under a SHO their licence will be immediately suspended for double the initial suspension period.
It is anticipated that the removal of the demerit point limit will cause strain on driver's subject to the order. Prior to applying for a SHO you should consider all of your options. As the process is quite involved it is highly recommended that you seek legal advice before applying for an order.
Should you wish to discuss this further or make an enquiry regarding a SHO, please contact Alysha Jacobsen of our office on 07 4617 8100.


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To find out more information on each of our treatments, please view our explanation of treatments.
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Carine Yachts lists Cerri FlyingSport superyacht for sale
by Malcolm MacLean
Andrew Noble at Carine Yachts reports that he has listed for sale a 31.1 metre Cerri 102 FlyingSport motor yacht.
Built by the Italian yard Cerri Yachts, she was delivered in 2013 as the third in the FlyingSport line, a concept introduced as far back as 2004 and now reaching its ultimate evolution.
The yacht features a roomy saloon including a conversation area with sofas, a large pop-up television set and a central dining area seating 10 guests. Outside, the 28 square metre flybridge hosts a second pilot station, an extendable dining table to stern, a barbecue and a large sunbathing area.
The owner's suite is on the main deck and the below deck area has been rearranged following the wishes of the owner: it now features two VIP staterooms with double beds and full en suite facilities, and both staterooms can be accessed via the staircase from the main deck saloon.
Twin MTU 2600hp engines and ZF Searex surface drives power the yacht to a cruising speed of approximately 30 knots with a top speed of 40 knots.
Lying in San Remo, Italy, the Cerri 102 FlyingSport yacht is asking €6.2 million.


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Re-exploration for bleeding after cardiac surgery is an indicator of substantial haemorrhage and is associated with increased hospital resource utilization. This study aimed to analyse the costs of re-exploration and estimate the costs of haemostatic prophylaxis.
A total of 4232 patients underwent isolated, first-time, coronary artery bypass graft (CABG) surgery during 2005-8. Each patient re-explored for bleeding (n=127) was matched with two controls not requiring re-exploration (n=254). Cost analysis was based on resource utilization from completion of CABG until discharge. A mean cost per patient for re-exploration was calculated. Based on this, the net cost of prophylactic treatment with haemostatic drugs for preventing re-exploration was calculated.
Patients undergoing re-exploration had higher exposure to clopidogrel before operation, prolonged stays in the intensive care unit, and more blood transfusions than controls. The mean incremental cost for re-exploration was (sic)6290 [95% confidence interval (CI) (sic)3408-(sic)9173] per patient, of which 48% [(sic)3001 (95% CI (sic)249-(sic)2147)] was due to prolonged stay, 31% [(sic)1928 (95% CI (sic)1710-(sic)2147)] to the cost of surgery/anaesthesia, 20% [(sic)1261 (95% CI (sic)1145-(sic)1378)] to the increased number of blood transfusions, and <2% [(sic)100 (95% CI (sic)39-(sic)161)] to the cost of haemostatic drugs. A cost model, at an estimated 50% efficacy for recombinant activated clotting factor VIIa and a 50% expected risk for re-exploration without prophylaxis, demonstrated that to be cost neutral, prophylaxis of four patients needed to result in one avoided re-exploration.
The resource utilization costs were substantially higher in patients requiring re-exploration for bleeding. From a strict cost-effectiveness perspective, clinical interventions to prevent haemorrhage might be underutilized.
Background: Radiological methods for screening, diagnostics and therapy are frequently used in healthcare. In infants and children, anaesthesia/sedation is often used in these situations to relieve the patients' perception of stress or pain. Both ionising radiation (IR) and ketamine have been shown to induce developmental neurotoxic effects and this study aimed to identify the combined effects of these in a murine model. Methods: Male mice were exposed to a single dose of ketamine (7.5 mg kg(-1) body weight) s.c. on postnatal day 10. One hour after ketamine exposure, mice were whole body irradiated with 50-200 mGy gamma radiation (Cs-137). Behavioural observations were performed at 2, 4 and 5 months of age. At 6 months of age, cerebral cortex and hippocampus tissue were analysed for neuroprotein levels. Results: Animals co-exposed to IR and ketamine displayed significant (P <= 0.01) lack of habituation in the spontaneous behaviour test, when compared with controls and single agent exposed mice. In the Morris Water Maze test, co-exposed animals showed significant (P <= 0.05) impaired learning and memory capacity in both the spatial acquisition task and the relearning test compared with controls and single agent exposed mice. Furthermore, in co-exposed mice a significantly (P <= 0.05) elevated level of tau protein in cerebral cortex was observed. Single agent exposure did not cause any significant effects on the investigated endpoints. Conclusion: Co-exposure to IR and ketamine can aggravate developmental neurotoxic effects at doses where the single agent exposure does not impact on the measured variables. These findings show that estimation of risk after paediatric low-dose IR exposure, based upon radiation dose alone, may underestimate the consequences for this vulnerable population.
Background: Tidal recruitment/derecruitment (R/D) of collapsed regions in lung injury has been presumed to cause respiratory oscillations in the partial pressure of arterial oxygen (PaO2). These phenomena have not yet been studied simultaneously. We examined the relationship between R/D and PaO2 oscillations by contemporaneous measurement of lung-density changes and PaO2. Methods: Five anaesthetised pigs were studied after surfactant depletion via a saline-lavage model of R/D. The animals were ventilated with a mean fraction of inspired O-2 (FiO(2)) of 0.7 and a tidal volume of 10 ml kg(-1) Protocolised changes in pressure-and volume-controlled modes, inspiratory: expiratory ratio (I:E), and three types of breath-hold manoeuvres were undertaken. Lung collapse and PaO2 were recorded using dynamic computed tomography (dCT) and a rapid PaO2 sensor. Results: During tidal ventilation, the expiratory lung collapse increased when I: E <1 [mean (standard deviation) lung collapse = .7 (8.7)%; P<0.05], but the amplitude of respiratory PaO2 oscillations [ 2.2 (0.8) kPa] did not change during the respiratory cycle. The expected relationship between respiratory PaO2 oscillation amplitude and R/D was therefore not clear. Lung collapse increased during breath-hold manoeuvres at end-expiration and end-inspiration (14% vs 0.9-2.1%; P<0.0001). The mean change in PaO2 from beginning to end of breath-hold manoeuvres was significantly different with each type of breath-hold manoeuvre (P<0.0001). Conclusions: This study in a porcine model of collapse-prone lungs did not demonstrate the expected association between PaO2 oscillation amplitude and the degree of recruitment/derecruitment. The results suggest that changes in pulmonary ventilation are not the sole determinant of changes in PaO2 during mechanical ventilation in lung injury.
Background: We aimed to examine whether using a high fraction of inspired oxygen (FIO2) in the context of an individualised intra- and postoperative open-lung ventilation approach could decrease surgical site infection (SSI) in patients scheduled for abdominal surgery. Methods: We performed a multicentre, randomised controlled clinical trial in a network of 21 university hospitals from June 6, 2017 to July 19, 2018. Patients undergoing abdominal surgery were randomly assigned to receive a high (0.80) or conventional (0.3) FIO2 during the intraoperative period and during the first 3 postoperative hours. All patients were mechanically ventilated with an open-lung strategy, which included recruitment manoeuvres and individualised positive end-expiratory pressure for the best respiratory-system compliance, and individualised continuous postoperative airway pressure for adequate peripheral oxyhaemoglobin saturation. The primary outcome was the prevalence of SSI within the first 7 postoperative days. The secondary outcomes were composites of systemic complications, length of intensive care and hospital stay, and 6-month mortality. Results: We enrolled 740 subjects: 371 in the high FIO2 group and 369 in the low FIO2 group. Data from 717 subjects were available for final analysis. The rate of SSI during the first postoperative week did not differ between high (8.9%) and low (9.4%) FIO2 groups (relative risk [RR]: 0.94; 95% confidence interval [CI]: 0.59-1.50; P=0.90]). Secondary outcomes, such as atelectasis (7.7% vs 9.8%; RR: 0.77; 95% CI: 0.48-1.25; P=0.38) and myocardial ischaemia (0.6% [n=2] vs 0% [n=0]; P=0.47) did not differ between groups. Conclusions: An oxygenation strategy using high FIO2 compared with conventional FIO2 did not reduce postoperative SSIs in abdominal surgery. No differences in secondary outcomes or adverse events were found.
Background. Laparoscopic liver surgery is evolving rapidly. Carbon dioxide embolism is a potential complication. The aim of this work was to study the frequency and severity of gas embolism (GE) during laparoscopic liver lobe resection in a pig model and the resulting cardiovascular and respiratory changes. Methods. Fifteen anaesthetized piglets underwent laparoscopic left liver lobe resection. Haemodynamic and respiratory variables were monitored, including systemic and pulmonary arterial pressures, end-tidal CO2, and pulmonary dead space. Online blood gas monitoring and a transoesophageal echocardiography (TOE) were used. GE was graded semi-quantitatively as grade 0 (none), grade 1 (minor), or grade 2 (major), depending on the TOE results. Results. In 10 of 15 piglets, GE occurred. In total, 33 separate episodes of GE were recorded. All 13 episodes of grade 2 and three of grade 1 were serious enough to cause mainly respiratory, but also haemodynamic effects. Mostly, grade 1 GE caused only minor respiratory or haemodynamic changes. Most variables were affected during grade 2 GE; the most important were Pa-O2, Pa-CO2, end-tidal CO2, Vd/Vt, and mean pulmonary arterial pressure. Conclusions. GE occurred frequently during laparoscopic liver resection in this experimental study. Approximately half of the embolisms were serious enough to cause respiratory or haemodynamic disturbances or both. Pending further human studies, a combination of several monitoring techniques, with narrow limits for the alarm settings, will ensure correct interpretation of the complex physiological response to GE and reveal it early enough to alert the anaesthetist and the surgeon to the ongoing problem.
Background. Positive pressure mechanical ventilation causes rhythmic changes in thoracic pressure and central blood flow. If entrainment occurs, it could be easier for carbon dioxide to enter through a wounded vein during laparoscopic liver lobe resection (LLR). High-frequency jet ventilation (HFJV) is a ventilating method that does not cause pronounced pressure or blood flow changes. This study aimed to investigate whether HFJV could influence the frequency, severity, or duration of gas embolism (GE) during LLR. Methods. Twenty-four anaesthetized piglets underwent lobe resection and were randomly assigned to either normal frequency ventilation (NFV) or HFJV (n=12 per group). During resection, a standardized injury to the left hepatic vein was created to increase the risk of GE. Haemodynamic and respiratory variables were monitored. Online blood gas monitoring and transoesophageal echocardiography were used. GE occurrence and severity were graded as 0 (none), 1 (minor), or 2 (major), depending on the echocardiography results. Results. GE duration was shorter in the HFJV group (P=0.008). However, no differences were found between the two groups in the frequency or severity of embolism. Incidence of Grade 2 embolism was less than that found in previous studies and physiological responses to embolism were variable. Conclusion. HFJV shortened the mean duration of GE during LLR and was a feasible ventilation method during the procedure. Individual physiological responses to GE were unpredictable.
Carbon dioxide (CO2) embolism is a potential complication in laparoscopic liver surgery. Gas embolism (GE) is thought to occur when central venous pressure (CVP) is lower than the intra-abdominal pressure (IAP). This study aimed to investigate whether an increased CVP due to induction of PEEP could influence the frequency and severity of GE during laparoscopic liver resection. Twenty anaesthetized piglets underwent laparoscopic left liver lobe resection and were randomly assigned to either 5 or 15 cm H2O PEEP (n10 per group). During resection, a standardized injury to the left hepatic vein [venous cut (VC)] was created to increase the risk of GE. Haemodynamic and respiratory variables were monitored, and online arterial blood gas monitoring and transoesophageal echocardiography (TOE) were used. The occurrence and severity of embolism was graded as 0 (none), 1 (minor), or 2 (major), depending on the TOE results. No differences were found between the two groups regarding the frequency or severity of GE, during either the VC (P0.65) or the rest of the surgery (P0.24). GE occurred irrespective of the CVPIAP gradient. Mechanisms other than the CVPIAP gradient seemed during laparoscopic liver surgery to contribute to the formation of CO2 embolism. This is of clinical importance to the anaesthetists.
I.v. administration of the nitric oxide synthase inhibitor, nitro-L-arginine methyl ester (L-NAME), not only reduces blood flow in a hypoxic lung region but also causes systemic vasoconstriction and a decrease in cardiac output. In this study, we delivered nebulized L-NAME 0.2-1 mg kg-1 to the left lower lobe of 10 anaesthetized pigs. The left lower lobe was made hypoxic by selective inhalation of 5% oxygen or collapsed by interrupted ventilation, or both. Inhalation of L-NAME reduced fractional blood flow to the left lower lobe from 5.3 (SD 3.1)% to 1.7 (1.4)% (P < 0.05) in lobar hypoxia and from 6.0 (3.3) to 2.7 (2.7)% (P < 0.05) in lobar collapse. These reductions were accompanied by a significant increase in PaO2. There were no significant changes in arterial pressure, cardiac output or heart rate. We have shown that selective inhalation of L-NAME reduced blood flow to a hypoxic or collapsed lung region without systemic effects. The possible role for nitric oxide synthase inhibition in reducing shunt during one-lung ventilation, however, requires further study.
The current guidelines for preoperative fasting recommend intervals of 6, 4, and 2 h (6-4-2) of fasting for solids, breast milk, and clear fluids, respectively. The objective is to minimize the risk of pulmonary aspiration of gastric contents, but also to prevent unnecessarily long fasting intervals. Pulmonary aspiration is rare and associated with nearly no mortality in paediatric anaesthesia. The incidence may have decreased during the last decades, judging from several audits published recently. However, several reports of very long fasting intervals have also been published, in spite of the implementation of the 6-4-2 fasting regimens. In this review, we examine the physiological basis for various fasting recommendations, the temporal relationship between fluid intake and residual gastric content, and the pathophysiological effects of preoperative fasting, and review recent publications of various attempts to reduce the incidence of prolonged fasting in children. The pros and cons of the current guidelines will be addressed, and possible strategies for a future revision will be suggested.
Background: General anaesthesia is increasingly common in elderly and obese patients. Greater age and body mass index (BMI) worsen gas exchange. We assessed whether this is related to increasing atelectasis during general anaesthesia.
Methods: This primary analysis included pooled data from previously published studies of 243 subjects aged 18-78 yr, with BMI of 18-52 kg m(-2). The subjects had no clinical signs of cardiopulmonary disease, and they underwent computed tomography (CT) awake and during anaesthesia before surgery after preoxygenation with an inspired oxygen fraction (FIO2) of >0.8, followed by mechanical ventilation with FIO2 of 0.3 or higher with no PEEP. Atelectasis was assessed by CT.
Results: Atelectasis area of up to 39 cm(2) in a transverse scan near the diaphragm was seen in 90% of the subjects during anaesthesia. The log of atelectasis area was related to a quadratic function of (age+age(2)) with the most atelectasis at similar to 50 yr (r(2)=0.08; P<0.001). Log atelectasis area was also related to a broken-line function of the BMI with the knee at 30 kg m(-2) (r(2)=0.06; P<0.001). Greater atelectasis was seen in the subjects receiving FIO2 of 1.0 than FIO2 of 0.3-0.5 (12.8 vs 8.1 cm(2); P<0.001). A multiple regression analysis, including a quadratic function of age, a broken-line function of the BMI, and dichotomised FIO2 (0.3-0.5/1.0) adjusting for ventilatory frequency, strengthened the association (r(2)= 0.23; P<0.001). PaO2 decreased with both age and BMI.
Conclusions: Atelectasis during general anaesthesia increased with age up to 50 yr and decreased beyond that. Atelectasis increased with BMI in normal and overweight patients, but showed no further increase in obese subjects (BMI >= 30 kg m(-2)). Therefore, greater age and obesity appear to limit atelectasis formation during general anaesthesia.
BACKGROUND: One-lung ventilation (OLV) increases mechanical stress in the lung and affects ventilation and perfusion (V, Q). There are no data on the effects of OLV on postoperative V/Q matching. Thus, this controlled study evaluates the influence of OLV on V/Q distribution in a pig model using a gamma camera technique [single-photon emission computed tomography (SPECT)] and relates these findings to lung histopathology after OLV. METHODS: Eleven anaesthetized and ventilated pigs (V(T)=10 ml kg(-1), Fio2=0.40, PEEP=5 cm H2O) were studied. After lung separation, OLV and thoracotomy were performed in seven pigs (OLV group). During OLV and in a two-lung ventilation (TLV), control group (n=4) ventilation settings remained unchanged. SPECT with (81m)Kr (ventilation) and (99m)Tc-labelled macro-aggregated albumin (perfusion) was performed before, during, and 90 min after OLV/TLV. Finally, lung tissue samples were harvested and examined for alveolar damage. RESULTS: OLV affected ventilation and haemodynamic variables, but there were no differences between the OLV group and the control group before and after OLV/TLV. SPECT revealed an increase of perfusion in the dependent lung compared with baseline (49-56%), and a corresponding reduction of perfusion (51-44%) in non-dependent lungs after OLV. No perfusion changes were observed in the control group. This resulted in increased low V/Q regions and a shift of V/Q areas to 0.3-0.5 (10(-0.5)-10(-0.3)) in dependent lungs of OLV pigs and was associated with an increased diffuse alveolar damage score. CONCLUSIONS: OLV in pigs results in a substantial V/Q mismatch, hyperperfusion, and alveolar damage in the dependent lung and may thus contribute to gas exchange impairment after thoracic surgery.
BACKGROUND: One-lung ventilation (OLV) exposes the dependent lung to increased mechanical stress which may affect the postoperative course. This study evaluates regional pulmonary gas/tissue distribution in a porcine model of OLV. METHODS: Nine anaesthetized and mechanically ventilated (V(T)=10 ml kg(-1), FI(O(2))=0.40, PEEP=5 cm H(2)O) pigs were studied. After lung separation by an endobronchial blocker, lateral thoracotomy and OLV were performed in six pigs. Three animals served as controls. Static end-expiratory and end-inspiratory spiral computed tomography (CT) scans were done before, during, and after OLV and at corresponding times in controls. CT images were analysed by defined regions of interest and summarized voxels were classified by defined lung X-ray density intervals (atelectasis, poorly aerated, normally aerated, and overaerated). RESULTS: Dependent lungs contained poorly aerated regions and atelectasis with a significant tidal recruitment during conventional two-lung ventilation (TLV) before OLV (expiration vs inspiration: atelectasis 29% vs 14%; poorly aerated 66% vs 44%; normally aerated 4% vs 41% of the dependent lung volume, P<0.05). During OLV (V(T)=10 ml kg(-1)), cyclic recruitment was increased. The density spectrum of the ventilated lung changed from consolidation to aeration (expiration vs inspiration: atelectasis 10% vs 2%; poorly aerated 71% vs 18%; normally aerated 19% vs 79%, P<0.05). After OLV, increased aeration remained with less atelectasis and poorly aerated regions. Lung density distribution in the non-dependent lung of OLV pigs was unaltered after the period of complete lung collapse. CONCLUSIONS: Cyclic tidal recruitment during OLV in pigs was associated with a persistent increase of aeration in the dependent lung.
Background Teaching trainees to become competent professionals who can keep the complex system of anaesthesia safe is important. From a safety point of view, non-technical skills such as smooth cooperation and good communication deserve as much attention as theoretical knowledge and practical skills, which by tradition have dominated training programmes in anaesthesiology. This study aimed to describe the way excellent anaesthetists act in the operating theatre, as seen by experienced anaesthesia nurses.
Methods The study had a descriptive and qualitative design. Five focus group interviews with three or four experienced Swedish anaesthesia nurses in each group were conducted. Interviews were analysed by using a qualitative method, looking for common themes.
Results Six themes were found: (A) structured, responsible, and focused way of approaching work tasks; (B) clear and informative, briefing the team about the action plan before induction; (C) humble to the complexity of anaesthesia, admitting own fallibility; (D) patient-centred, having a personal contact with the patient before induction; (D) fluent in practical work without losing overview; and (F) calm and clear in critical situations, being able to change to a strong leading style.
Conclusions Experienced anaesthesia nurses gave nuanced descriptions of how excellent anaesthetists behave and perform. These aspects of the anaesthetist's work often attract too little attention in specialist training, notwithstanding their importance for safety and fluency at work. Creating role models based on studies like the present one could be one way of increasing safety in anaesthesia.
Background. Traditionally, programmes for specialist education in anaesthesia and intensive care have been based on lists of attributes such as skills and knowledge. However, modern research in the science of teaching has shown that competence development is linked to changes in the way professionals understand their work. The aim of this study was to define the different ways in which trainee anaesthetists understand their work.
Methods. Nineteen Swedish trainee anaesthetists were interviewed. The interviews sought the answers to three open-ended questions. (i) When do you feel you have been successful in your work? (ii) What is difficult or what hinders you in your work? (iii) What is the core of your anaesthesia work? Transcripts of the interviews were analysed by a phenomenographic approach, a research method aiming to determine the various ways a group of people understand a phenomenon.
Results. Six ways of understanding their work were defined: giving anaesthesia according to a standard plan; taking responsibility for the patient's vital functions; minimizing the patient's suffering and making them feel safe; giving service to specialist doctors to facilitate their care of patients; organizing and leading the operating theatre and team; and developing one's own competence, using the experience gained from every new patient for learning.
Conclusions. Trainee anaesthetists understand their work in different ways. The trainee's understanding affects both his/her way of performing work tasks and how he/she develops new competences. A major task for teachers of anaesthesia is to create learning situations whereby trainees can focus on new aspects of their professional work and thus develop new ways of understanding it.
Background: The aim of this study was to explore difficulties at work from anaesthetists' own perspective and to examine how anaesthetists handle and cope with situations that are perceived as difficult and potentially stressful.
Methods: Two sets of interviews were conducted with 19 specialist anaesthetists in Sweden. The first set of interviews aimed at finding how the anaesthetists experienced difficulties at work. It consisted of in-depth interviews based on one open-ended question. We analysed the interviews with a phenomenological method, looking for themes in anaesthetists' descriptions of difficulties at work. In the second set, the interviews were semi-structured with open-ended questions, based on themes found in the first interview set. These interviews aimed at exploring how the interviewees described their ways of handling difficulties and how they coped with potentially stressful situations.
Results: Analysis of the first set of interviews resulted in five themes, describing how the anaesthetists experienced difficulties at work. All interviewees talked about difficulties related to more than one of the themes. The second set of interviews revealed two main categories of ways of handling difficulties. First, problem solving consisted of descriptions of methods for handling difficult situations which aimed at solving problems, and second, coping strategies described ways of appraising potentially stressful situations that minimized stress, despite the problem not being solved.
Conclusions: The anaesthetists interviewed in this study maintained that they enjoyed work and could see no external obstacles to doing a good job. They had arrived at a reconciliation of their work with its inherent difficulties and problems. Getting access to their coping strategies might help young anaesthetists to come to terms with their work.
Abstract: The anaesthetist's work, aimed at giving safe anaesthesia to patients, can do both harm and good to the anaesthetist. Research on stress in anaesthesia has traditionally focused on how the negative effects of stress can be avoided and much effort has been put into improving anaesthetists' work environment to reduce the level of stress. In this review, however, we give attention instead to what the individual anaesthetist can do to improve his or her well-being at work. Stress is, and will remain, an inevitable aspect of the anaesthetist's occupation but, as for any professional working in a stressful environment, adaptive coping can make a big difference in outcome. The choice between construing a difficult clinical situation as threat or challenge is important here because of the difference in the resulting stress response. The anaesthetist can reduce the stress effect of a potentially stressful situation by thinking of it in a new way, by redefining it through reappraisal. We describe here some lines of thought that experienced anaesthetists use to buffer the effects of work stress on physical health and mental well-being. By reframing a situation, they can reduce its stress content even if the problem at hand cannot be successfully solved. Trainee anaesthetists, who experience much stress at work and are at risk of burnout, would benefit from learning about these coping strategies.
New ventilators have simplified the use of supraglottic superimposed high-frequency jet ventilation (SHFJVSG), but it has not been systematically compared with other modes of jet ventilation (JV) in humans. We sought to investigate whether SHFJVSG would provide more effective ventilation compared with single-frequency JV techniques.
A total of 16 patients undergoing minor laryngeal surgery under general anaesthesia were included. In each patient, four different JV techniques were applied in random order for 10-min periods: SHFJVSG, supraglottic normal frequency (NFJVSG), supraglottic high frequency (HFJVSG), and infraglottic high-frequency jet ventilation (HFJVIG).
Chest wall volume variations were continuously measured with opto-electronic plethysmography (OEP), intratracheal pressure was recorded and blood gases were measured.
Chest wall volumes were normalized to NFJVSG end-expiratory level. The increase in end-expiratory chest wall volume (EEVCW) was 239 (196) ml during SHFJVSG (P<0.05 compared with NFJVSG). EEVCW was 148 (145) and 44 (106) ml during HFJVSG and HFJVIG, respectively (P<0.05 compared with SHFJVSG). Tidal volume (VT) during SHFJVSG was 269 (149) ml. VT was 229 (169) ml (P=1.00 compared with SHFJVSG), 145 (50) ml (P<0.05), and 110 (33) ml (P<0.01) during NFJVSG, HFJVSG, and HFJVIG, respectively.
Intratracheal pressures corresponded well to changes in both EEVCW and VT. All JV modes resulted in adequate oxygenation. However, PACO2was lowest during HFJVSG [4.3 (1.3) kPa; P<0.01 compared with SHFJVSG].
SHFJVSG was associated with increased EEVCW and VT compared with the three other investigated JV modes. All four modes provided adequate ventilation and oxygenation, and thus can be used for uncomplicated laryngeal surgery in healthy patients with limited airway obstruction.
The lower inflection point (LIP) of the inspiratory limb of a static pressure-volume (PV) loop is assumed to indicate the pressure at which most lung units are recruited. The LIP is determined by a static manoeuvre with a PV-history that is different from the PV-history of the actual ventilation. In nine surfactant-deficient piglets, information to allow setting PEEP and VT was obtained, both from the PV-curve and also during ongoing ventilation from the dynamic compliance relationship. According to LIP, PEEP was set at 20 (95% confidence interval 17-22) cm H2O. Volume-dependent dynamic compliance suggested a PEEP reduction (to 15 (13-18) cm H2O). Pulmonary gas exchange remained satisfactory and this change resulted in reduced mechanical stress on the respiratory system, indirectly indicated by volume-dependent compliance being consistently great during the entire inspiration.
The arterial pressure target for optimal splanchnic function during cardiopulmonary bypass (CPB) is uncertain. Thus, we aimed to compare the effects of two different arterial pressure targets during CPB on trans-splanchnic oxygenation, acid-base regulation, and splanchnic interleukin-6 (IL-6) and interleukin-10 (IL-10) flux.
Sixteen patients undergoing cardiac surgery with CPB in a university affiliated hospital were subjected to a prospective alternating treatment design interventional study. We measured arterial and hepatic vein blood gases, electrolytes, IL-6, and IL-10 while targeting a mean arterial pressure (MAP) of between 60 and 65 mm Hg for 30 min, a MAP of between 80 and 85 mm Hg for 30 min (using norepinephrine infusion), and finally 60-65 mm Hg MAP target for 30 min.
The MAP targets were achieved in all patients [65 (4), 84 (4), and 64 (3) mm Hg, respectively; P<0.001] with a greater dose of norepinephrine infusion during the higher MAP target (P<0.001). With longer time on CPB, hepatic vein O2 saturation decreased, while magnesium, lactate, glucose, IL-6, and IL-10 increased independent of MAP target. The decrease in hepatic vein saturation was greater as the temperature increased (re-warming). Overall, there was trans-splanchnic oxygen, chloride, lactate, and IL-6 removal during CPB (P<0.001) and carbon dioxide, bicarbonate, glucose, and IL-10 release (P<0.001). Such removal or release was not affected by the MAP target.
Targeting of a higher MAP during CPB by means of norepinephrine infusion did not affect splanchnic oxygenation, splanchnic acid-base regulation, or splanchnic IL-6 or IL-10 fluxes.
Australian and New Zealand Clinical Trial Registry: ACTRN 12611001107910.
Atelectasis after either vaginal or Caesarean delivery has not been adequately quantified. This study addresses the hypothesis that atelectasis may be worse in women who undergo Caesarean section when compared with vaginal delivery under regional anaesthesia.
Twenty healthy non-smoking women submitted to a chest computed tomography (CT) 2 h after delivery in a University Hospital, who had experienced vaginal delivery (n=10) under combined spinal-epidural analgesia or a Caesarean section (n=10) under spinal anaesthesia, were evaluated. The percentage cross-sectional area of atelectasis in dependent lung regions were measured from the CT images obtained at cross-section of the xiphoid process and the top of the diaphragm.
The percentage cross-sectional area of atelectasis was 3.95% in the vaginal delivery group and 14.1% in the Caesarean group (P<0.001, Mann-Whitney rank sum test).
These results suggested that pulmonary atelectasis is greater after Caesarean section delivery under spinal anaesthesia than after vaginal delivery with combined spinal-epidural analgesia.
Background. Interleukin-18 (IL-18) is a pro-inflammatory protein, which mediates ischaemic tubular injury, and has been suggested to be a sensitive and specific biomarker for acute kidney injury (AKI). The predictive value of IL-18 in the diagnosis, evolution, and outcome of AKI in critically ill patients is still unclear. Methods. We measured urine IL-18 from critically ill patients at intensive care unit (ICU) admission and 24 h. We evaluated the association of IL-18 with developing new AKI, renal replacement therapy (RRT), and 90-day mortality. We calculated areas under receiver operating characteristics curves (AUCs), best cut-off values, and positive likelihood ratios (LR+) for IL-18 concerning these endpoints. Additionally, we compared the predictive value of IL-18 at ICU admission to that of urine neutrophil gelatinase-associated lipocalin (NGAL). Results. In this study population of 1439 patients the highest urine IL-18 during the first 24 h in the ICU associated with the development of AKI with an AUC [95% confidence interval (CI)] of 0.586 (0.546-0.627) and with the development of Stage 3 AKI with an AUC (95% CI) of 0.667 (0.591-0.774). IL-18 predicted the initiation of RRT with an AUC (95% CI) of 0.655 (0.572-0.739), and 90-day mortality with an AUC (95% CI) of 0.536 (0.497-0.574). Conclusions. IL-18 had poor-to-moderate ability to predict AKI, RRT, or 90-day mortality in this large cohort of critically ill patients. Thus, it should be used with caution for diagnostic or predictive purposes in the critically ill.
BACKGROUND: The influence of hydroxyethyl starch (HES) solutions on renal function is controversial. We investigated the effect of HES administration on renal function in critically ill patients enrolled in a large multicentre observational European study. METHODS: All adult patients admitted to the 198 participating intensive care units (ICUs) during a 15-day period were enrolled. Prospectively collected data included daily fluid administration, urine output, sequential organ failure assessment (SOFA) score, serum creatinine levels, and the need for renal replacement therapy (RRT) during the ICU stay. RESULTS: Of 3147 patients, 1075 (34%) received HES. Patients who received HES were older [mean (SD): 62 (SD 17) vs 60 (18) years, P = 0.022], more likely to be surgical admissions, had a higher incidence of haematological malignancy and heart failure, higher SAPS II [40.0 (17.0) vs 34.7 (16.9), P < 0.001] and SOFA [6.2 (3.7) vs 5.0 (3.9), P < 0.001] scores, and less likely to be receiving RRT (2 vs 4%, P < 0.001) than those who did not receive HES. The renal SOFA score increased significantly over the ICU stay independent of the type of fluid administered. Although more patients who received HES needed RRT than non-HES patients (11 vs 9%, P = 0.006), HES administration was not associated with an increased risk for subsequent RRT in a multivariable analysis [odds ratio (OR): 0.417, 95% confidence interval (CI): 0.05-3.27, P = 0.406]. Sepsis (OR: 2.03, 95% CI: 1.37-3.02, P < 0.001), cardiovascular failure (OR: 6.88, 95% CI: 4.49-10.56, P < 0.001), haematological cancer (OR: 2.83, 95% CI: 1.28-6.25, P = 0.01), and baseline renal SOFA scores > 1 (P < 0.01 for renal SOFA 2, 3, and 4 with renal SOFA = 0 as a reference) were all associated with a higher need for RRT. CONCLUSIONS: In this observational study, haematological cancer, the presence of sepsis, cardiovascular failure, and baseline renal function as assessed by the SOFA score were independent risk factors for the subsequent need for RRT in the ICU. The administration of HES had no influence on renal function or the need for RRT in the ICU.
BACKGROUND: One-lung ventilation (OLV) induces a pro-inflammatory response including cytokine release and leucocyte recruitment in the ventilated lung. Whether volatile or i.v. anaesthetics differentially modulate the alveolar inflammatory response to OLV is unclear. METHODS: Thirty patients, ASA II or III, undergoing open thoracic surgery were randomized to receive either propofol 4 mg kg(-1) h(-1) (n = 15) or 1 MAC desflurane in air (n = 15) during thoracic surgery. Analgesia was provided by i.v. infusion of remifentanil (0.25 microg kg(-1) min(-1)) in both groups. The patients were mechanically ventilated according to a standard protocol during two-lung ventilation and OLV. Fibre optic bronchoalveolar lavage (BAL) of the ventilated lung was performed before and after OLV and 2 h postoperatively. Alveolar cells, protein, tumour necrosis factor alpha (TNFalpha), interleukin (IL)-8, soluble intercellular adhesion molecule-1 (sICAM), IL10, and polymorphonuclear (PMN) elastase were determined in the BAL fluid. Data were analysed by parametric or non-parametric tests, as indicated. RESULTS: In both groups, an increase in pro-inflammatory markers was found after OLV and 2 h postoperatively; however, the fraction of alveolar granulocytes (median 63.7 vs 31.1%, P < 0.05) was significantly higher in the propofol group compared with the desflurane group. The time courses of alveolar elastase, IL-8, and IL-10 differed between groups, and alveolar TNFalpha (7.4 vs 3.1 pg ml(-1), P < 0.05) and sICAM-1 (52.3 vs 26.3 ng ml(-1), P < 0.05) were significantly higher in the propofol group. CONCLUSIONS: These data indicate that pro-inflammatory reactions during OLV were influenced by the type of general anaesthesia. Different patterns of alveolar cytokines may be a result of increased granulocyte recruitment during propofol anaesthesia.
Background: Low positive end-expiratory pressure (PEEP) can result in alveolar derecruitment, and high PEEP or high tidal volume (V-T) in lung overdistension. We investigated cardiogenic oscillations (COS) in the airway pressure signal to investigate whether these oscillations can assess unfavourable intratidal events. COS induce short instantaneous compliance increases within the pressure-volume curve, and consequently in the compliance-volume curve. We hypothesised that increases in COS-induced compliance reflect non-linear intratidal respiratory system mechanics. Methods: In mechanically ventilated anaesthetised pigs with healthy (n = 13) or atelectatic (n = 12) lungs, pressure-volume relationships and the ECG were acquired at a PEEP of 0, 5, 10, and 15 cm H2O. During inspiration, the peak compliance of successive COS (C-COS) was compared with intratidal respiratory system compliance (C-RS) within incremental volume steps up to the full V-T of 12 ml kg(-1). We analysed whether C-COS variation corresponded with systolic arterial pressure variation. Results: C-COS-volume curves showed characteristic intratidal patterns depending on the PEEP level and on atelectasis. Increasing C-RS- or C-COS-volume patterns were associated with intratidal derecruitment with low PEEP, and decreasing patterns above 6 ml kg(-1) and high PEEP showed overdistension. C-COS was not associated with systolic arterial pressure variations. Conclusions: Heartbeat-induced oscillations within the course of the inspiratory pressure-volume curve reflect nonlinear intratidal respiratory system mechanics. The analysis of these cardiogenic oscillations can be used to detect intratidal derecruitment and overdistension and, hence, to guide PEEP and V-T settings that are optimal for respiratory system mechanics.
BACKGROUND: /st> Carbon dioxide (CO(2))-pneumoperitoneum (PP) of 12 mm Hg increases arterial oxygenation, but it also promotes collapse of dependent lung regions. This seeming paradox prompted the present animal study on the effects of PP on ventilation-perfusion distribution (V/Q) and gas exchange. METHODS: /st> Fourteen anaesthetized pigs were studied. In seven pigs, single photon emission computed tomography (SPECT) was used for spatial analysis of ventilation and perfusion distributions, and in another seven pigs, multiple inert gas elimination technique (MIGET) was used for detailed analysis of V/Q matching. SPECT/MIGET and central haemodynamics and pulmonary gas exchange were recorded during anaesthesia before and 60 min after induction of PP. RESULTS: /st> SPECT during PP showed no or only poorly ventilated regions in the dependent lung compared with the ventilation distribution during anaesthesia before PP. PP was accompanied by redistribution of blood flow away from the non- or poorly ventilated regions. V/Q analysis by MIGET showed decreased shunt from 9 (sd 2) to 7 (2)% after induction of PP (P<0.05). No regions of low V/Q were seen either before or during PP. Almost no regions of high V/Q developed during PP (1% of total ventilation). Pa(o(2)) increased from 33 (1.2) to 35.7 (3.2) kPa (P<0.01) and arterial to end-tidal Pco(2) gradient (Pae'(co(2))) increased from 0.3 (0.1) to 0.6 (0.2) kPa (P<0.05). CONCLUSIONS: /st> Perfusion was redistributed away from dorsal, collapsed lung regions when PP was established. This resulted in a better V/Q match. A possible mechanism is enhanced hypoxic pulmonary vasoconstriction.
BACKGROUND: Intraperitoneal insufflation of carbon dioxide (CO2) may promote collapse of dependent lung regions. The present study was undertaken to study the effects of CO2-pneumoperitoneum (CO2-PP) on atelectasis formation, arterial oxygenation, and arterial to end-tidal PCO2-gradient (Pa-E'(CO2)). METHODS: Fifteen anaesthetized pigs [mean body weight 28 (SD 2) kg] were studied. Spiral computed tomography (CT) scans were obtained for analysis of lung tissue density. In Group 1 (n=5) mechanical ventilation (V(T)=10 ml kg (-1), FI(O2)=0.5) was applied, in Group 2 (n=5) FI(O2) was increased for 30 min to 1.0 and in Group 3 (n=5) negative airway pressure was applied for 20 s in order to enhance development of atelectasis. Cardiopulmonary and CT data were obtained before, 10, and 90 min after induction of CO2-PP at an abdominal pressure of 12 mmHg. RESULTS: Before CO2-PP, in Group 1 non-aerated tissue on CT scans was 1 (1)%, in Group 2 3 (2)% (P<0.05, compared with Group 1), and in Group 3 7 (3)% (P<0.05, compared with Group 1 and Group 2). CO2-PP significantly increased atelectasis in all groups. PaO2/FI(O2) fell and venous admixture ('shunt') increased in proportion to atelectasis during anaesthesia but CO2-PP had a varying effect on PaO2/FI(O2) and shunt. Thus, no correlation was seen between atelectasis and PaO2/FI(O2) or shunt when all data before and during CO2-PP were pooled. Pa-E'(CO2), on the other hand correlated strongly with the amount of atelectasis (r2=0.92). CONCLUSIONS: Development of atelectasis during anaesthesia and PP may be estimated by an increased Pa-E'(CO2).
Background. Superimposed high-frequency jet ventilation (SHFJV) has proved to be safe and effective in clinical practice. However, it is unclear which frequency range optimizes ventilation and gas exchange. The aim of this study was to systematically compare high-frequency jet ventilation (HFJV) with HFJV by assessing chest wall volume variations (Delta EEVCW) and gas exchange in relation to variable high frequency.
Methods. SHFJV or HFJV were used alternatively to ventilate the lungs of 10 anaesthetized pigs (21-25 kg). The low-frequency component was kept at 16 min(-1) in SHFJV. In both modes, high frequencies ranging from 100 to 1000 min(-1) were applied in random order and ventilation was maintained for 5 min in all modalities. Chest wall volume variations were obtained using opto-electronic plethysmography. Airway pressures and arterial blood gases were measured repeatedly.
Results. SHFJV increased Delta EEVCW compared with HFJV; the difference ranged from 43 to 68 ml. Tidal volume (V-T) was always >240 ml during SHFJV whereas during HFJV ranged from 92 ml at theventilation frequency of 100 min(-1) to negligible values at frequencies >300 min(-1). We observed similar patterns for Pa-O2 and Pa-CO2. SHFJV provided generally higher, frequency-independent oxygenation (Pa-O2 at least 32.0 kPa) and CO2 removal (Pa-CO2 similar to 5.5 kPa), whereas HFJV led to hypoxia and hypercarbia at higher rates (Pa-O2 < 10 kPa and Pa-CO2 > 10 kPa at f(HF) > 300 min(-1)).
Conclusions. In a porcine model, SHFJV was more effective in increasing end-expiratory volume than single-frequency HFJV, but both modes may provide adequate ventilation in the absence of airway obstruction and respiratory disease, except for HFJV at frequencies >= 300 min(-1).
This study was conducted to determine whether an alveolar recruitment strategy (ARS) applied during two-lung ventilation (TLV) just before starting one-lung ventilation (OLV) improves ventilatory efficiency.
Subjects were randomly allocated to two groups: (i) control group: ventilation with tidal volume (VT) of 8 or 6 ml kg−1 for TLV and OLV, respectively, and (ii) ARS group: same ventilatory pattern with ARS consisting of 10 consecutive breaths at a plateau pressure of 40 and 20 cm H2O PEEP applied immediately before and after OLV. Volumetric capnography and arterial blood samples were recorded 5 min (baseline) and 20 min into TLV, at 20 and 40 min during OLV, and finally 10 min after re-establishing TLV.
Twenty subjects were included in each group. In all subjects, the airway component of dead space remained constant during the study. Compared with baseline, the alveolar dead space ratio (VDalv/VTalv) increased throughout the protocol in the control but decreased in the ARS group. Differences in VDalv/VTalv between groups were significant (P<0.001). Except for baseline, all PaO2 values in kPa (sd) were higher in the ARS than in the control group (P<0.001), respectively [70 (7) and 55 (9); 33 (9) and 24 (10); 33 (8) and 22 (10); 70 (7) and 55 (10)].
Recruitment of both lungs before instituting OLV not only decreased alveolar dead space but also improved arterial oxygenation and the efficiency of ventilation.


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Link to get lucky lottery: https://goo.gl/WWxA24


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Pricing, Passes & Policies
New to Radiance Yoga?
Take unlimited yoga classes in your first month for a $1 a day! We realize that beginning yoga or visiting a new place can be intimidating and overwhelming. This unlimited class pass, for students new to Radiance Yoga, lets you try as many classes as you want over a 30-day period, to kick-start your yoga practice and find out what Radiance Yoga is about.
Yoga is better when practiced on a regular basis. Take advantage of this great opportunity to sample all of the classes on our schedule and enjoy all of the the benefits of a consistent yoga practice!
New Student Pass begins on the date of first class and expires 30 days after first class.
Membership Passes
Enjoy unlimited yoga and automatically renew your basic monthly membership with a credit card. Three month participation required. Email us 14-days before your next billing cycle to cancel membership. Any changes to the monthly membership need to take place on the billing cycle date. Members are limited to one suspension, a minimum length of 30 days, to their membership per 12 month period.
Monthly basic membership
- Unlimited yoga classes
- 10% off workshops
- 10% off boutique items (some exclusions apply)
Monthly Premium Membership
- Unlimited yoga classes
- 15% off workshops
- 15% off boutique items (some exclusions apply)
- 13th month free
- Free mat storage (space permitting)
Yearly Membership
- Unlimited yoga classes
- 15% off workshops
- 15% off boutique items (some exclusions apply)
- 13th month free
- Free mat storage (space permitting)
Studio Policies
- All class passes and unlimited passes are non-refundable, non-transferable and cannot be shared with another student.
- 10 class passes never expire.
- If cancellation is received more than 24 hours prior to a workshop or private lesson, a full refund is given. If cancellation is submitted between 24-4 hours, the registration payment will be put on the Radiance account for future use. If cancellation is 4 hours or less or the student is a no-show, no refund will be offered. Cancellations must be submitted by email to email@example.com
- All boutique sales are final.
- Drop-ins are welcome to any class, with the exception of classes offered as Series.
- Online registration is encouraged. To ensure your space, you must arrive 10 minutes before class starts. (First-time students, without a Radiance Yoga account, should arrive 20 minutes early to register.)
- We only hold online reservations up to 5 minutes before the start of class.
- We cannot always accept late arrivals and we do not allow entry 10 minutes after a class begins. If you do arrive late, please enter the studio quietly once the front desk has given you permission to do so.
- We accept cash, checks and Visa, MasterCard, American Express or Discover.
- 10% discount for seniors (60 years and older), military and full-time students with proper ID can be applied to most purchases. To receive the discount, purchases must be made at the studio. These discounts cannot be combined with other offers and cannot be used with the New Student Pass.


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A court in Russia has sentenced three women to up to 15 days imprisonment on charges of dancing with "twerk" moves in front of a World War II monument. The girls posted the dance video online.
Three women in Russia's southern city Novorossiysk were sent to jail for dancing with "twerk" moves in front of a war memorial.
The city's lawyers ran a check after one of the dancers posted a video on Youtube which showed six girls dancing in front of a World War II monument. The women made "twerking" moves, a dance made popular by pop artists like Beyonce and Miley Cyrus, which includes provocative hip-thrusting movements.
All six were found guilty of hooliganism, but two were spared jail terms because of bad health. The district court in southern Russian city Novorossiysk sentenced one dancer to 15 days and the other two women to 10 days in jail.
Prosecutors said the women were performing "an erotic and sexual dance" and that the incident "of disrespect for the memory of war history" was unacceptable. "Any attempts to desecrate sites of military glory will be stopped immediately," the state representatives said.
Russia is soon celebrating the 70th anniversary of the World War II victory of the Allied powers, an emotionally charged holiday for the Kremlin.
The latest incident of "twerking" dances comes after a video of Russian school students performing a similar dance angered many people, prompting Russian authorities to launch a probe into indecency.
mg/rc (AFP, AP)
This year's Hannah Arendt Prize for political thinking goes to Nadezhda Tolokonnikova and Maria Alyokhina. The two Russians are recognized for their political action through performance art. (05.12.2014)


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Sorry, my loyal readers, for missing a post yesterday! I've been feeling all "third-trimester" and going to bed at 9:30 the last couple of nights.
For those of you in the Ottawa area, Blog Out Loud is happening tonight at Raw Sugar from 7 to 10 pm. I'll be showing up with my little girl to listen to my friend Capital Mom read from her blog.
Raw Sugar is on Somerset, in the block just West of Bronson, and it's just about the cutest café I've ever been to. Check it out for the cuteness alone.
See you there!


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Wandlebury Country Park is a great place to take the dog and the children to get them out of the house. I am sure that it is as lovely in the summer as it is in the fall. It only cost me £2 for the parking. There are over 8 miles of trails and is a perfect place for the children to run a muck and have a picnic. The dogs must stay on the lead due to the wildlife but find it is good for socialization for Dusty and he loved the smells along the way.
The country park is on the grounds of the remains of a 5th Century BC Iron Age Hill Fort.
Anyways, this is another inexpensive day out!
All the Best!
American to Britain


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Building the Right Environment to Support AI, Machine Learning and Deep Learning
At the end of its second fiscal quarter 2011, Red Hat provided revenue guidance of between $226 million to $228 million. In a research note, analyst Trip Chowdhry of Global Equities research, noted that he expects that Red Hat will beat their forecast revenue numbers with revenues of $228.6 million.
Part of Chowdhry's optimism comes from growth in new Red Hat Enterprise Linux installations against those from rival Microsoft.
"For every 8 new project starts, 5 are occurring on Red Hat Linux Platform and 3 are occurring on Microsoft Platform," the Global Equities Research note states.
A key part of Red Hat's continuing growth during the quarter comes from the launch of the Red Hat Enterprise Linux 6 (RHEL 6) platform. RHEL is Red Hat's flagship Linux platform and the RHEL 6 release marked the first major release upgrade since RHEL 5 debuted in 2007.
According to Chowdhry, RHEL 6 is already off to a solid start and benefits from hardware partnerships from multiple vendors including HP, IBM and Fujitsu.
Another important trend that is helping to fuel Red Hat's growth is the movement from free users of Linux to paid users of RHEL. Red Hat has been focusing on converting free users to paid users and it's an effort that is paying off. Chowdhry noted that as enterprise projects get funded, enterprise customers are switching from free Linux to paid Linux.
The movement to the cloud is seen as a driver for the movement from free to paid version of Linux. Red Hat has multiple efforts currently underway as part of its Cloud Foundations initiative. Red Hat is positioning Linux and its integrated KVM virtualization technology as the core infrastructure for enabling multi-tenant cloud services.
From a competitive perspective, Novell, Red Hat's primary Linux rival in the enterprise space has been undergoing a period of transition which may also benefit Red Hat. Novell is now set to be acquired by privately held Attachmate in a deal valued at $2.2 billion.
"Our research indicates that Red Hat's business is showing improving secular growth trends, including accelerated new project starts on Red Hat Linux, launch of new RHEL 6.0, and acceleration in market share wins against SUSE Linux, and continued acceleration in shift from Free to Paid Linux," Chowdhry wrote. "These data points give us confidence that Red Hat's business will continue to show incremental growth in revenues and earnings."
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City of Costa MesaHome Menu
Director's Decisions
The Costa Mesa Zoning Code authorizes the Director of Economic and Development Services to make certain decisions about zoning and land use issues affecting specific properties. These written decisions are published here. For more information, please contact the Planning Division at (714) 754-5245.
| Decisions Listed by Address
|September 7, 2016
| 1180 Augusta House
|582 Pierpont Drive
|1055 Cheyenne Street
|653 Joann Street
|2152 Raleigh Ave.
|3044 Grant Ave.
|631 Victoria Ave.
|Decision Letter for Time Extension (PA-17-32 & TTM 18127)


text: n0b0 0 · ID: 1 Posted April 23, 2017 Hello Guys, I'm trying to figure out if I can add additional USB to RJ45 network card to my Synology DS212+. I know that it most probably require driver but still, I was thinking if adapter has same or similar chip as Syno box it might be able to recognise it So, does anyone know what is network card/ chip on Synology DS212+ ? Quote Share this post Link to post Share on other sites


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10 Ninja Tips for Getting Motivated When Your Just Can't Even
As entrepreneurs, it's inevitable that you're going to have days where you have no motivation to do anything. When you work from home or work for yourself, there really is no one holding you accountable to do your job except for yourself and sometimes this can be a big downfall. Pushing yourself to show up as the best version of yourself every day can be tricky!
I share my 10 ninja tips about how I'm able to stay motivated each and every day, how I get my mind back on track when it wonders, and how I'm able to set the best example for my team that I can. From writing down targets for the day, to reaching out for support, all the way to taking a break from work I am giving you my best tricks about how to continue to stay motivated day in and day out.


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Contact Details
Yanqing Lai is a Research Assistant in Leadership/HRM in Edinburgh Napier Business School. She received her PhD in Business Management from Kingston University London in 2016, MSc in Accounting and Finance from University of Manchester (2009-2010), and BA (Hons) in International Business Management from University of Nottingham (2005-2009). Her primary research interests include strategic human resource management, subjective employee well-beings, and strategy and growth in entrepreneurial SMEs. Her work has been published in in top-tier business and management journals, including Journal of Business Venturing, International Small Business Management, and Human Resource Management Review.
Actual and intended growth in family firms and non-family owned firms: Are they different? Research Paper No 60
Published: 13 July 2017
This article uses the first wave of Longitudinal Small Business Survey (SBS, 2015), and investigates the role of owner-management structure in affecting the growth behaviours of small- and medium-sized enterprises (SMEs) in the UK. Specifically, the study compares the growth propensities among family firms managed by the family member(s) only, family firms managed by externally sourced manager(s), and non-family-owned small firms. Based on the change-in-amount perspective (Penrose, 1951), growth is measured using three different indicators, including growth in employment size, growth in turnover, and growth in sales.


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4 to 5 years
We use the Florida VPK standards that are mandated by the state. Our curriculum is designed to prepare the students for early literacy, and pre-math success. It enhances the age-appropriate progress of students in attaining the state-adopted performance standards and prepares students to be ready for kindergarten based on the statewide kindergarten screening.
If you live in Florida and have a child who turns 4 years of age by September 1st, your child is eligible for Florida's FREE VPK program. The school-year program includes 540 hours of instructional time and begins in August. For more information visit the Florida VPK website.
We have implemented technology in this class, computer knowledge is vital in our society and we believe that the earlier children begin to use the computer, the better. Some experts suggest that allowing preschoolers to have computer time can be beneficial because computer use: introduces educational skills, teaches spatial and logical skills, prepares children for future computer use, increases self-esteem and self-confidence, boosts problem-solving skills, stimulates language comprehension, improves long-term memory and manual dexterity.
The assessment addresses these critical areas of development for school readiness:
- Gross motor development
- Fine motor skills development – pre-scissor and cutting development, marker/crayon and easel painting
- Sensor motor and dramatic play
- Structured construction play
- Patterning development (critical thinking)
- Writing development
Ratio: Approximately 1:12.
There will be a graduation ceremony at the end of the school year. We will send more detailed information two weeks prior.
Talk to one of our enrollment specialists
Champs Brickell 1050 Brickell Ave Suite 110 Miami, FL 33131


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Meet Your Brewers
Matt Gundrum
Sr. Head Brewer
Matt started his Iron Hill career in 2006 as a bartender. His love for craft beer, though, took from behind the bar and into the brewery, taking a position as an Assistant Brewer. He started by cleaning kegs and cleaning up one day per week. Over time, however, Matt took on more and more responsibilities. He is now full-time brewer and hasn't looked back since.
Marc Campolongo
Head Brewer
Marc started working at our Lancaster location in 2008 as a server, went on to become a bartender at our North Wales location and was on the opening team when Chestnut Hill opened in 2011. Home brewing for about a year prior, he joined the brewery department at Iron Hill in 2017 as an assistant brewer. He moved throughout breweries at Iron Hill before finding his way back to Chestnut Hill as the Head Brewer! A music enthusiast, Marc is the Assistant Director of the Central Bucks West High School Marching Band, as well as an Eagle Scout Instructor who has been involved with scouting since the first grade.


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3 Steps To Make Reading Stick
What's the point of reading if we don't remember what we've read? What's the point of reading without understanding?
It's time to shift our way of reading. Try this. Every book you read from now on, apply these 3 steps to make it stick.