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Publications (147)1075.33 Total impact
Article: Standardizing Predicted Body Weight Equations for Mechanical Ventilation Tidal Volume Settings[Show abstract] [Hide abstract]
ABSTRACT: Abstract .Background: Recent recommendations for lung protective mechanical ventilation (MV) include a tidal volume (VT) target of 6 ml/kg predicted body weight (PBW). Different PBW equations might introduce important differences in tidal volumes delivered to research subjects and to patients. Methods: PBW equations use height, age, and gender as input variables. We compared NIH ARDS Network (ARDSNet), actuarial table (ACTUARIAL), and Stewart (STEWART) PBW equations used in clinical trials, across physiologic ranges for age and height. We used 3-D and 2-D surface analysis to compare these PBW equations. We then used age and height from actual clinical trial subjects to quantify PBW equation differences. Results: Significant potential differences exist between these PBW predictions. The ACTUARIAL and ARDSNet surfaces for women were the only surfaces that intersected and produced both positive and negative differences. Mathematical differences between PBW equations at limits of height and age exceeded 30% in women and 24% in men for ACTUARIAL versus ARDSNet, and about 25% for women and 15% for men for STEWART versus ARDSNet. The largest mathematical differences were present in older, shorter subjects, especially women. Actual differences for clinical trial subjects were as high as 15% for men and 24% for women. Conclusions: Significant differences between PBW equations for both men and women could be important sources of inter-study variation. Studies should adopt a standard PBW equation. We recommend using the NIH/NHLBI ARDS Network PBW equation because it is associated with the clinical trial that identified 6ml/kg PBW as an appropriate target. .
Article: Standardizing Predicted Body Weight Equations for Mechanical Ventilation Tidal Volume Settings[Show abstract] [Hide abstract]
ABSTRACT: Recent recommendations for lung protective mechanical ventilation (MV) include a tidal volume (VT) target of 6 ml/kg predicted body weight (PBW). Different PBW equations might introduce important differences in tidal volumes delivered to research subjects and to patients. PBW equations use height, age, and gender as input variables. We compared NIH ARDS Network (ARDSNet), actuarial table (ACTUARIAL), and Stewart (STEWART) PBW equations used in clinical trials, across physiologic ranges for age and height. We used 3-D and 2-D surface analysis to compare these PBW equations. We then used age and height from actual clinical trial subjects to quantify PBW equation differences. Significant potential differences exist between these PBW predictions. The ACTUARIAL and ARDSNet surfaces for women were the only surfaces that intersected and produced both positive and negative differences. Mathematical differences between PBW equations at limits of height and age exceeded 30% in women and 24% in men for ACTUARIAL versus ARDSNet, and about 25% for women and 15% for men for STEWART versus ARDSNet. The largest mathematical differences were present in older, shorter subjects, especially women. Actual differences for clinical trial subjects were as high as 15% for men and 24% for women. Significant differences between PBW equations for both men and women could be important sources of inter-study variation. Studies should adopt a standard PBW equation. We recommend using the NIH/NHLBI ARDS Network PBW equation because it is associated with the clinical trial that identified 6ml/kg PBW as an appropriate target.Chest 03/2015; 148(1). DOI:10.1378/chest.14-2843 · 7.48 Impact Factor
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ABSTRACT: Mechanical-ventilation strategies that use lower end-inspiratory (plateau) airway pressures, lower tidal volumes (VT), and higher positive end-expiratory pressures (PEEPs) can improve survival in patients with the acute respiratory distress syndrome (ARDS), but the relative importance of each of these components is uncertain. Because respiratory-system compliance (CRS) is strongly related to the volume of aerated remaining functional lung during disease (termed functional lung size), we hypothesized that driving pressure (ΔP=VT/CRS), in which VT is intrinsically normalized to functional lung size (instead of predicted lung size in healthy persons), would be an index more strongly associated with survival than VT or PEEP in patients who are not actively breathing. Using a statistical tool known as multilevel mediation analysis to analyze individual data from 3562 patients with ARDS enrolled in nine previously reported randomized trials, we examined ΔP as an independent variable associated with survival. In the mediation analysis, we estimated the isolated effects of changes in ΔP resulting from randomized ventilator settings while minimizing confounding due to the baseline severity of lung disease. Among ventilation variables, ΔP was most strongly associated with survival. A 1-SD increment in ΔP (approximately 7 cm of water) was associated with increased mortality (relative risk, 1.41; 95% confidence interval [CI], 1.31 to 1.51; P<0.001), even in patients receiving "protective" plateau pressures and VT (relative risk, 1.36; 95% CI, 1.17 to 1.58; P<0.001). Individual changes in VT or PEEP after randomization were not independently associated with survival; they were associated only if they were among the changes that led to reductions in ΔP (mediation effects of ΔP, P=0.004 and P=0.001, respectively). We found that ΔP was the ventilation variable that best stratified risk. Decreases in ΔP owing to changes in ventilator settings were strongly associated with increased survival. (Funded by Fundação de Amparo e Pesquisa do Estado de São Paulo and others.).New England Journal of Medicine 02/2015; 372(8):747-55. DOI:10.1056/NEJMsa1410639 · 55.87 Impact Factor
Article: Establishment of a prospective cohort of mechanically ventilated patients in five intensive care units in Lima, Peru: Protocol and organisational characteristics of participating centres[Show abstract] [Hide abstract]
ABSTRACT: Mechanical ventilation is a cornerstone in the management of critically ill patients worldwide; however, less is known about the clinical management of mechanically ventilated patients in low and middle income countries where limitation of resources including equipment, staff and access to medical information may play an important role in defining patient-centred outcomes. We present the design of a prospective, longitudinal study of mechanically ventilated patients in Peru that aims to describe a large cohort of mechanically ventilated patients and identify practices that, if modified, could result in improved patient-centred outcomes and lower costs. Five Peruvian intensive care units (ICUs) and the Medical ICU at the Johns Hopkins Hospital were selected for this study. Eligible patients were those who underwent at least 24 h of invasive mechanical ventilation within the first 48 h of admission into the ICU. Information on ventilator settings, clinical management and treatment were collected daily for up to 28 days or until the patient was discharged from the unit. Vital status was assessed at 90 days post enrolment. A subset of participants who survived until hospital discharge were asked to participate in an ancillary study to assess vital status, and physical and mental health at 6, 12, 24 and 60 months after hospitalisation, Primary outcomes include 90-day mortality, time on mechanical ventilation, hospital and ICU lengths of stay, and prevalence of acute respiratory distress syndrome. In subsequent analyses, we aim to identify interventions and standardised care strategies that can be tailored to resource-limited settings and that result in improved patient-centred outcomes and lower costs. We obtained ethics approval from each of the four participating hospitals in Lima, Peru, and at the Johns Hopkins School of Medicine, Baltimore, USA. Results will be disseminated as several separate publications in different international journals. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.BMJ Open 01/2015; 5(1):e005803. DOI:10.1136/bmjopen-2014-005803 · 2.27 Impact Factor
Article: The ten diseases that look like ARDSIntensive Care Medicine 12/2014; 41(6). DOI:10.1007/s00134-014-3608-x · 7.21 Impact Factor
Article: Timing of Low Tidal Volume Ventilation and ICU Mortality in ARDS: A Prospective Cohort Study.[Show abstract] [Hide abstract]
ABSTRACT: Rationale: Reducing tidal volume decreases mortality in ARDS. However, the effect of the timing of low tidal volume ventilation is not well understood. Objectives: To evaluate the association of ICU mortality with initial tidal volume and with tidal volume change over time. Methods: Multivariable, time-varying Cox regression analysis of a multi-site, prospective study of 482 ARDS patients with 11,558 twice-daily tidal volume assessments (evaluated in ml/kg of Predicted Body Weight [PBW]) and daily assessment of other mortality predictors. Measurements and Main Results: An increase of 1 ml/kg PBW in initial tidal volume was associated with a 23% increase in ICU mortality risk (adjusted hazard ratio 1.23, 95% confidence interval [CI] 1.06--1.44, p=0.008). Moreover, a 1 ml/kg PBW increase in subsequent tidal volumes compared to the initial tidal volume was associated with a 15% increase in mortality risk (adjusted hazard ratio 1.15, 95% CI 1.02--1. 29, p=0.019). Compared to a prototypical patient receiving 8 days with a tidal volume of 6 ml/kg PBW, the absolute increase in ICU mortality (95% CI) of receiving 10 and 8 ml/kg PBW, respectively, across all 8 days was 7.2% (3.0 - 13.0%) and 2.7% (1.2-4.6%). In scenarios with variation in tidal volume over the 8-day period, mortality was higher when a larger volume was used earlier. Conclusions: Higher tidal volumes shortly after ARDS onset were associated with a greater risk of ICU mortality compared to subsequent tidal volumes. Timely recognition of ARDS and adherence to low tidal volume ventilation is important for reducing mortality. Clinicaltrials.gov NCT00300248.American Journal of Respiratory and Critical Care Medicine 12/2014; DOI:10.1164/rccm.201409-1598OC · 13.00 Impact Factor
Article: Targeting Normoxemia in Acute Respiratory Distress Syndrome May Cause Worse Short-Term Outcomes because of Oxygen Toxicity[Show abstract] [Hide abstract]
ABSTRACT: It was recently suggested that targeting normoxemia (PaO2 85-110 mmHg) in ARDS patients might prevent neurocognitive dysfunction in survivors. However, targeting normoxemia may cause detrimental effects to the lungs from oxygen toxicity. Some have suggested that oxygen is not harmful to the lungs at FiO2s less than 0.6-0.7, but contrasting evidence in normal humans suggests that there can be untoward effects of moderate FiO2s. Furthermore, in experimental models of the acute respiratory distress syndrome, co-existing lung inflammation increases susceptibility to oxygen toxicity. Co-existing lung inflammation may lower the threshold for oxygen toxicity in patients with ARDS or in other acute illnesses in the lung. Moreover, physicians frequently prescribe higher FiO2s than are necessary to achieve their arterial oxygenation goal, further increasing the risk of oxygen toxicity. Targeting normoxemia in ARDS patients may prevent some long-term neurocognitive deficits in survivors, but it may increase lung inflammation and cause worse short-term clinical outcomes. We advocate for a clinical trial in ARDS patients to determine more appropriate goals for arterial oxygenation.10/2014; 11(9). DOI:10.1513/AnnalsATS.201407-297PS
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ABSTRACT: Background Donor to recipient lung size matching at lung transplantation (LTx) can be estimated by the predicted total lung capacity (pTLC)ratio (donor pTLC/recipient pTLC). We aimed to determine whether the pTLC-ratio is associated with the risk of primary graft dysfunction (PGD) after bilateral LTx (BLT). Methods We calculated the pTLC-ratio for 812 adult BLTs from the Lung Transplant Outcomes Group between 3/2002-12/2010. Patients were stratified by pTLC-ratio>1.0 ("oversized") and pTLC-ratio≤1.0 ("undersized"). PGD was defined as any ISHLT grade 3 PGD within 72 hours of reperfusion (PGD 3). We analyzed the association between risk factors and PGD using multivariable conditional logistic regression. As transplant diagnoses can influence the size matching decisions and also modulate the risk for PGD, we performed pre-specified analyses by assessing the impact of lung size mismatch within diagnostic categories. Results In univariate analyses oversizing was associated with a 39% lower odds of PGD3 (OR 0.61, 95% CI, p=0.003). In a multivariate model accounting for center effects and known PGD risks, oversizing remained independently associated with a decreased odds of PGD3 (OR 0.58, 95% CI 0.38-0.88, p=0.01). The risk adjusted point estimate was similar for the non-COPD diagnoses groups (OR 0.52, 95%CI 0.32-0.86, p=0.01); however there was no detected association within the COPD group (OR 0.72, 95% CI 0.29-1.78, p=0.5). Conclusion Oversized allografts are associated with a decreased risk of PGD3 after BLT; this effect appears most apparent in non-COPD patients.The Journal of Heart and Lung Transplantation 09/2014; 34(2). DOI:10.1016/j.healun.2014.09.030 · 6.65 Impact Factor
Article: Neuromuscular electrical stimulation in mechanically ventilated patients: A randomized, sham-controlled pilot trial with blinded outcome assessment[Show abstract] [Hide abstract]
ABSTRACT: Purpose: The purpose of the study is to compare neuromuscular electrical stimulation (NMES) vs sham on leg strength at hospital discharge in mechanically ventilated patients. Materials and methods: We conducted a randomized pilot study of NMES vs sham applied to 3 bilateral lower extremity muscle groups for 60 minutes daily in the intensive care unit (ICU). Between June 2008 and March 2013, we enrolled adults who were receiving mechanical ventilation within the first week of ICU stay and who could transfer independently from bed to chair before hospital admission. The primary outcome was lower extremity muscle strength at hospital discharge using Medical Research Council score (maximum, 30). Secondary outcomes at hospital discharge included walking distance and change in lower extremity strength from ICU awakening. Clinicaltrials.gov: NCT00709124. Results: We stopped enrollment early after 36 patients due to slow patient accrual and the end of research funding. For NMES vs sham, mean (SD) lower extremity strength was 28 (2) vs 27 (3), P = .072. Among secondary outcomes, NMES vs sham patients had a greater mean (SD) walking distance (514 [389] vs 251 [210] ft, P = .050) and increase in muscle strength (5.7 [5.1] vs 1.8 [2.7], P = .019). Conclusions: In this pilot randomized trial, NMES did not significantly improve leg strength at hospital discharge. Significant improvements in secondary outcomes require investigation in future research.Journal of Critical Care 09/2014; 30(1). DOI:10.1016/j.jcrc.2014.09.014 · 2.00 Impact Factor
Article: Chest Wall Strapping. An Old Physiology Experiment with New Relevance to Small Airways Diseases[Show abstract] [Hide abstract]
ABSTRACT: Chest wall strapping induces breathing at low lung volumes. Mild to moderate obesity can lead to similar changes in lung volumes, due to chest wall and abdominal restriction. Chest wall strapping is also conceptually similar to a mismatch between significantly oversized donor lungs transplanted into a recipient with a smaller chest cavity. Chest wall strapping increases lung elastic recoil, reduces pulmonary compliance, and substantially increases maximal expiratory flows. The interactions between elastic properties of the lung parenchyma and small airways are critical for pulmonary function. Chest wall strapping lowers residual volume and closing volume, likely from the interdependence between increased elastic recoil and airways leading to greater radial distending forces on small airways and small airway dilation. Chronic obstructive pulmonary disease (COPD) and chronic rejection of the transplanted lung, bronchiolitis obliterans syndrome (BOS), are primarily diseases of the small airways and are characterized by progressive obstruction and subsequent loss of small airways. In COPD, higher body mass index (BMI) (conceptually like being more tightly strapped) is associated with lower lung volumes, increased airway conductance, and with lower risk of progression to emphysema or death. Likewise, in lung transplantation, oversized donor lungs have been linked to higher expiratory airflows, lower risk of BOS, and improved survival. This paper reviews the physiology of chest wall strapping and explores how it could enhance the understanding or even the treatment of small airway diseases such as COPD and BOS.08/2014; 11(8). DOI:10.1513/AnnalsATS.201312-465OI
Article: Position Paper for the Organization of Extracorporeal Membrane Oxygenation Programs for Acute Respiratory Failure in Adult Patients[Show abstract] [Hide abstract]
ABSTRACT: The use of extracorporeal membrane oxygenation (ECMO) for severe acute respiratory failure (ARF) in adults is growing rapidly given recent advances in technology, even though there is controversy regarding the evidence justifying its use. Since ECMO is a complex, high risk, and costly modality, at present it should be conducted in centers with sufficient experience, volume and expertise to ensure it is used safely. This position paper represents the consensus opinion of an international group of physicians and associated healthcare workers, who have expertise in therapeutic modalities used in the treatment of patients with severe ARF, with a focus on ECMO. The aim of this paper is to provide physicians, ECMO center directors and coordinators, hospital directors, health care organizations, regional, national and international policy makers a description of the optimal approach to organizing ECMO programs for ARF in adult patients. Importantly, this will help ensure that ECMO is delivered safely and proficiently, such that future observational and randomized clinical trials assessing this technique may be performed by experienced centers under homogeneous and optimal conditions. Given the need for further evidence, we encourage restraint in the widespread use of ECMO until we have a better appreciation for both the potential clinical applications and the optimal techniques for performing ECMO.American Journal of Respiratory and Critical Care Medicine 07/2014; 190(5). DOI:10.1164/rccm.201404-0630CP · 13.00 Impact Factor
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ABSTRACT: Background: In the acute respiratory distress syndrome (ARDS), inflammation in the lungs and other organs can cause life-threatening organ failure. Inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A reductase (statins) can modulate inflammatory responses. Previous observational studies suggested that statins improved clinical outcomes in patients with sepsis. We hypothesized that rosuvastatin therapy would improve clinical outcomes in critically ill patients with sepsis-associated ARDS. Methods: We conducted a multicenter trial in which patients with sepsis-associated ARDS were randomly assigned to receive either enteral rosuvastatin or placebo in a double-blind manner. The primary outcome was mortality before hospital discharge home or until study day 60 if the patient was still in a health care facility. Secondary outcomes included the number of ventilator-free days (days that patients were alive and breathing spontaneously) to day 28 and organ-failure-free days to day 14. Results: The study was stopped because of futility after 745 of an estimated 1000 patients had been enrolled. There was no significant difference between study groups in 60-day in-hospital mortality (28.5% with rosuvastatin and 24.9% with placebo, P=0.21) or in mean (±SD) ventilator-free days (15.1±10.8 with rosuvastatin and 15.1±11.0 with placebo, P=0.96). The groups were well matched with respect to demographic and key physiological variables. Rosuvastatin therapy, as compared with placebo, was associated with fewer days free of renal failure to day 14 (10.1±5.3 vs. 11.0±4.7, P=0.01) and fewer days free of hepatic failure to day 14 (10.8±5.0 vs. 11.8±4.3, P=0.003). Rosuvastatin was not associated with an increased incidence of serum creatine kinase levels that were more than 10 times the upper limit of the normal range. Conclusions: Rosuvastatin therapy did not improve clinical outcomes in patients with sepsis-associated ARDS and may have contributed to hepatic and renal organ dysfunction. (Funded by the National Heart, Lung, and Blood Institute and the Investigator-Sponsored Study Program of AstraZeneca; ClinicalTrials.gov number, NCT00979121.).New England Journal of Medicine 06/2014; 370(23):2191-2200. DOI:10.1056/NEJMoa1401520 · 55.87 Impact Factor
Article: Mechanical Ventilation after Lung Transplantation. An International Survey of Practices and Preferences[Show abstract] [Hide abstract]
ABSTRACT: Between 10-57% of lung transplant (LTx) recipients develop primary graft dysfunction (PGD) within 72 hours of LTx. PGD is clinically and histologically analogous to the acute respiratory distress syndrome (ARDS). In patients at risk for, or with ARDS, lung protective ventilation strategies (low tidal volumes and positive end expiratory pressure) improve outcomes. There is, however, little information on mechanical ventilation strategies after LTx. The aim of this international survey was to describe the current practices of mechanical ventilation immediately after LTx. An electronic survey was sent to the medical and surgical directors of U.S. LTx programs (n=111) and to members of the Pulmonary Council of the International Society for Heart and Lung Transplantation (n=470). One hundred and forty-nine individuals from 18 countries responded to the questionnaire. The most common modes of ventilation were Pressure Assist/Control (37%) and Volume Assist/Control (35%). Tidal volumes were most often determined by recipient characteristics; donor characteristics were rarely considered (35%) and infrequently known by the team managing the ventilator (42%). When presented with a choice of ideal tidal volumes, a majority of respondents selected 6 ml/kg recipient predicted body weight (58%), fewer selected 10 ml/kg (21%), and none selected 15 ml/kg. A majority preferred limiting the fraction of inspired oxygen rather than positive end expiratory pressure (PEEP) (69% versus 31%, p = 0.006). The median minimum PEEP was 5 cm H2O and the median maximum PEEP was 11.5 cm H2O. The presence of PGD increased the perceived importance of monitoring plateau pressure to adjust tidal volumes. The median plateau pressure limit perceived as a threshold triggering reduction in tidal volumes was 30 cm H2O. Most respondents reported using lung-protective approaches to mechanical ventilation after lung transplantation. Low tidal volumes based on recipient characteristics were frequently chosen. Donor characteristics were often not considered and were frequently not known by the team managing mechanical ventilation after LTx.Annals of the American Thoracic Society 03/2014; 11(4). DOI:10.1513/AnnalsATS.201312-419OC
Article: Developing, Implementing, and Evaluating a Multifaceted Quality Improvement Intervention to Promote Sleep in an ICU[Show abstract] [Hide abstract]
ABSTRACT: Critically ill patients commonly experience poor sleep quality in the intensive care unit (ICU) because of various modifiable factors. To address this issue, an ICU-wide, multifaceted quality improvement (QI) project was undertaken to promote sleep in the Johns Hopkins Hospital Medical ICU (MICU). To supplement previously published results of this QI intervention, the present article describes the specific QI framework used to develop and implement this intervention, which consists of 4 steps: (a) summarizing the evidence to create a list of sleep-promoting interventions, (b) identifying and addressing local barriers to implementation, (c) selecting performance measures to assess intervention adherence and patient outcomes, and (d) ensuring that all patients receive the interventions through staff engagement and education and regular project evaluation. Measures of performance included daily completion rates of daytime and nighttime sleep improvement checklists and completion rates of individual interventions. Although long-term adherence and sustainability pose ongoing challenges, this model provides a foundation for future ICU sleep promotion initiatives.American Journal of Medical Quality 11/2013; 29(6). DOI:10.1177/1062860613509684 · 1.25 Impact Factor
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ABSTRACT: Rationale: The association between a high predicted total lung capacity (pTLC)-ratio (=pTLCdonor / pTLCrecipient), suggestive of an oversized allograft, with improved survival after lung transplantation (LTx) remains controversial. Objective: To characterize the donor-recipient lung size matching based on the pTLC-ratio and to investigate the relationship of the pTLC-ratio with post-LTx survival. Methods: All subjects in the SRTR transplant registry, who underwent first-time LTx in the lung allocation score based system between May 4th 2005 and March 31st 2012 were studied, and the pTLC-ratio was calculated based on gender, height and age. Risk of death after LTx was analyzed using Cox proportional hazards models. Measurements and Main Results: The pTLC-ratio was available for 10,289 of the 10,318 study subjects (99.7%). The mean pTLC-ratio was 1.015 ± 0.175 (interquartile range [IQR] 0.918-1.119). Univariate analysis showed that the pTLC-ratio was strongly associated with death in the first LTx year (p < 0.0001). With the pTLC-ratio entered as a spline there was a non-linear association with declining risk of death with higher pTLC-ratio from 0.5 to about 1.3, where an inflection occurred with rising risk at higher values. Accounting for the pTLC-ratio, recipient and donor gender were not independently associated with death after LTx. The comparison of pTLC-ratio from 1.119 to 0.918 (the IQR) was associated with similar point estimates of reduced risk of death at one year across univariate (HR 0.78) and comprehensive risk adjusted multivariate models (HR 0.86). Conclusion: The pTLC-ratio is an independent predictor of death in the first year after LTx and explains the association of gender with survival after LTx. Incorporating the pTLC-ratio in the lung allocation mechanism could improve outcomes after LTx.Annals of the American Thoracic Society 08/2013; 10(5). DOI:10.1513/AnnalsATS.201301-008OC
Article: Editorial: Time to reach a new equilibrium after changes in PEEP in acute respiratory distress syndrome patientsIntensive Care Medicine 08/2013; 39(11). DOI:10.1007/s00134-013-3064-z · 7.21 Impact Factor
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ABSTRACT: A higher predicted total lung capacity (pTLC)-ratio (=pTLC donor/pTLC recipient), suggestive of oversized allografts, is associated with improved survival after lung transplantation. It is unknown whether the pTLC-ratio has a different association with survival in bilateral (BLT) versus single lung transplantation (SLT). The pTLC-ratio was calculated for all adult patients in the United Network of Organ Sharing lung transplant (LTx) registry who underwent first-time LTx in the post lung allocation score era, between May 2005 and April 2010. The LTx recipients were stratified according to procedure (BLT vs SLT). Risk of death at 1 year after LTx was analyzed using Kaplan-Meier survival and Cox proportional hazards models. In the 4,520 BLT patients, each 0.1 increase in pTLC-ratio conferred a 7% decrease in the hazard for death at 1 year (p < 0.001) in univariate analysis. This association remained significant after controlling for diagnosis, comorbidities, acuity, donor, and transplant factors (hazard ratio [HR] 0.93, 95% confidence interval [CI] 0.88 to 0.98, p = 0.01). Additional adjustment by a propensity score to account for biases to oversizing showed similar results (HR 0.94, 95% CI 0.90 to 0.99, p = 0.018). In the 2,477 SLT patients, each 0.1 increase in pTLC-ratio conveyed a 6% decrease in the hazard for death at 1 year (p = 0.002) in univariate analysis, which did not persist in the multivariate model (HR 1.00, p = 0.8). A higher pTLC-ratio, suggestive of an oversized allograft, is associated with improved survival after lung transplantation. This association is primarily evident in BLT patients.The Annals of thoracic surgery 06/2013; 96(2). DOI:10.1016/j.athoracsur.2013.04.064 · 3.85 Impact Factor
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ABSTRACT: Purpose Donor to recipient lung size mismatch at lung transplantation (LTx) can be estimated by the predicted total lung capacity (pTLC) ratio (=donor pTLC/recipient pTLC). We aimed to determine if the pTLCratio is associated with the risk of primary graft dysfunction (PGD) after bilateral LTx (BLT). Methods and Materials The LTx Outcomes Group is a prospective cohort study of patients undergoing first LTx at 10 centers. The pTLCratio was calculated for all adult BLTs between 3/2002-2/2010. Patients were stratified by pTLCratio>1.0(oversized) and pTLCratio≤1.0(undersized). PGD was defined by any ISHLT grade 3 PGD within 72 hours of allograft reperfusion. Logistic regression (LR) was used to estimate odds ratios (OR) for the association of the pTLCratio and PGD. Potential confounders were selected into multivariable models based on plausible association with pTLCratio or PGD. LTx center effects were accounted for by conditional LR. Results PGD developed in 37.6% of the 311 undersized and in 27.1% of the 501 oversized patients (p=0.001), table. In a multivariate model accounting for diagnosis, center volume, LTx era, ischemic time, bypass, transfusions, pulmonary artery systolic pressure, BMI, age, donor smoking and tidal volume at reperfusion oversizing was associated with a decreased probability of PGD (HR0.60, 95%CI0.42-0.88, p=0.009). This association was somewhat attenuated after additional accounting for clustering within centers (OR 0.69, 95%CI 0.46-1.01, p=0.06). [figure 1] Conclusions A pTLCratio >1.0 appears to be associated with a decreased risk of PGD after BLT. An oversized allograft may operate at relatively smaller tidal volumes and lower pulmonary vascular resistance, which could be a mechanistic link to PGD.The Journal of Heart and Lung Transplantation 04/2013; 32(4):S41. DOI:10.1016/j.healun.2013.01.906 · 6.65 Impact Factor
Article: Reducing Deep Sedation and Delirium in Acute Lung Injury Patients: A Quality Improvement Project[Show abstract] [Hide abstract]
ABSTRACT: OBJECTIVE:: Deep sedation and delirium are common in the ICU. Mechanically ventilated patients with acute lung injury are at especially high risk for deep sedation, delirium, and associated long-term physical and neuropsychiatric impairments. We undertook an ICU-wide structured quality improvement project to decrease sedation and delirium. DESIGN:: Prospective quality improvement project in comparison with a retrospective acute lung injury control group. SETTING:: Sixteen-bed medical ICU in an academic teaching hospital with pre-existing use of goal-directed sedation with daily interruption of sedative infusions. PATIENTS:: Consecutive acute lung injury patients. INTERVENTION:: A "4Es" framework (engage, educate, execute, evaluate) was used as part of the quality improvement process. A new sedation protocol was created and implemented, which recommends a target Richmond Agitation Sedation Scale score of 0 (alert and calm) and requires failure of intermittent sedative dosing prior to starting continuous infusions. In addition, twice-daily delirium screening using the Confusion Assessment Method for the ICU was introduced into routine practice. MEASUREMENTS AND MAIN RESULTS:: Sedative use and delirium status in acute lung injury patients after implementation of the quality improvement project (n = 82) were compared with a historical control group (n = 120). During the quality improvement vs. control periods, use of narcotic and benzodiazepine infusions were substantially lower (median proportion of medical ICU days per patient: 33% vs. 74%, and 22% vs. 70%, respectively, both p < 0.001). Further, wakefulness increased (median Richmond Agitation Sedation Scale score per patient: -1.5 vs. -4.0, p < 0.001), and days awake and not delirious increased (median proportion of medical ICU days per patient: 19% vs. 0%, p < 0.001). CONCLUSION:: Through a structured quality improvement process, use of sedative infusions can be substantially decreased and days awake without delirium significantly increased, even in severely ill, mechanically ventilated patients with acute lung injury.Critical care medicine 03/2013; 41(6). DOI:10.1097/CCM.0b013e31827ca949 · 6.31 Impact Factor
Article: Factors Associated With Elevated Plateau Pressure in Patients With Acute Lung Injury Receiving Lower Tidal Volume Ventilation.[Show abstract] [Hide abstract]
ABSTRACT: OBJECTIVES:: Lung-protective ventilation with lower tidal volume and lower plateau pressure improves mortality in patients with acute lung injury and acute respiratory distress syndrome. We sought to determine the incidence of elevated plateau pressure in acute lung injury /acute respiratory distress syndrome patients receiving lower tidal volume ventilation and to determine the factors that predict elevated plateau pressure in these patients. PATIENTS:: We used data from 1398 participants in Acute Respiratory Distress Syndrome Network trials, who received lower tidal volume ventilation (≤ 6.5 mL/kg predicted body weight). DESIGN:: We considered patients with a plateau pressure greater than 30 cm H2O and/or a tidal volume less than 5.5 mL/kg predicted body weight on study day 1 to have "elevated plateau pressure." We used logistic regression to identify baseline clinical variables associated with elevated plateau pressure and to develop a model to predict elevated plateau pressure using a subset of 1,188 patients. We validated the model in the 210 patients not used for model development. SETTING:: Medical centers participating in Acute Respiratory Distress Syndrome Network clinical trials. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Of the 1,398 patients in our study, 288 (20.6%) had elevated plateau pressure on day 1. Severity of illness indices and demographic factors (younger age, greater body mass index, and non-white race) were independently associated with elevated plateau pressure. The multivariable logistic regression model for predicting elevated plateau pressure had an area under the receiving operator characteristic curve of 0.71 for both the developmental and the validation subsets. CONCLUSIONS:: acute lung injury patients receiving lower tidal volume ventilation often have a plateau pressure that exceeds Acute Respiratory Distress Syndrome Network goals. Race, body mass index, and severity of lung injury are each independently associated with elevated plateau pressure. Selecting a smaller initial tidal volume for non-white patients and patients with higher severity of illness may decrease the incidence of elevated plateau pressure. Prospective studies are needed to evaluate this approach.Critical care medicine 01/2013; 41(3). DOI:10.1097/CCM.0b013e3182741790 · 6.31 Impact Factor
Top Journals
Johns Hopkins University
Baltimore, Maryland, United States
- • Department of Medicine
- • Department of Physical Medicine and Rehabilitation
- • Division of Pulmonary and Critical Care Medicine
University of California, San FranciscoSan Francisco, California, United States
Johns Hopkins Medicine
Baltimore, Maryland, United States
- • Department of Medicine
- • Division of Pulmonary and Critical Care Medicine
University of TorontoToronto, Ontario, Canada
University of PennsylvaniaPhiladelphia, Pennsylvania, United States
Duke UniversityDurham, North Carolina, United States


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On October 30th, Whitechapel will unleash their new feature length video release, 'The Brotherhood of the Blade', which follows the sextet on tour and at home, and dives deep into the hearts and minds of one of metal's brightest acts.Read More
Twitching Tongues
Southern California's rising underground metal/hardcore band Twitching Tongues has unveiled a new song called 'Sacrifice Me' today at NPR.org.Read More
New Releases
Upcoming Releases
Latest News
DICTATED guitarists Sonja and Jessica release "The Basher" guitar play through video!
- 15/12/14 – Dutch death metal newcomers, DICTATED, released their...Read More
VISIGOTH to release debut album "The Revenant King" January 23rd on Metal Blade Records!
- 15/12/14 – Artwork and track listing revealed; first song...Read More
BELOW to head out for European tour in February of 2015!
- 25/11/14 – Swedish Doomster BELOW are heading out for the...Read More
SIX FEET UNDER confirmed as headliners for HATEFEST tour 2015 featuring Marduk and Vader among others!
- 25/11/14 – April 2015 will see the return of the HATEFEST Tour. The...Read More
PRIMORDIAL release official videoclip for 'Babel's Tower'!
- 24/11/14 – New album "Where Greater Men Have Fallen" out...Read More
ENSIFERUM announce special guests for 'One Man Army' European Tour!
- 20/11/14 – ENSIFERUM has completed work on their upcoming new album,...Read More
CRIPPER launches third single for new album 'Hyena'!
- 19/11/14 – "Hyëna" to be released this week...Read More
PORTRAIT release RAM cover 'Blessed To Be Cursed'!
- 17/11/14 – "Under Command" split album out in two...Read More

subset: commoncrawl


text:
14 Stories You Need To Know Today
First Bitcoin ATM, 'Ungoogleable' scrapped at Google's request and T-Mobile reveals details of no contract plans...links to start your day with.
First Bitcoin ATM. Mashable.
Your Google+ pic can now be an animated GIF. Engadget.
Google has selected its 'glass explorers.' Engadget.
Sweden can't use 'Ungoogleable' as a word after protest from Google. Engadget.
Woolworths to create own milk brand. Business Spectator.
Study entrepreneurship without doing it. Seth Godin Blog.
Move over dollars; this guy wants Bitcoins for his home. Mashable.
Looking will cost you – $5 – at this Australian store. Business Insider.
Google releases a new opt-out tool. Google blog.
Nike Draws Criticism for Tiger Woods tribute. Mashable.
In 10 day Venezuelan election, candidates can only buy 5 minutes of TV ads per day. AdAge.
Unfortunately, bizarre, brilliantly, unintentionally hilarious ads. Lost At E Minor.
British director says what everone else is thinking. Guardian.
T-Mobile Fills readers in on its no contract plans. Engadget.
- Share
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PSFK Labs Presents
The Future of Connected Life
The New Consumer and Their Journey to Effectiveness, Balance & Personal Growth


text:
edison international (EIX:New York)
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Category Navigation:
- Shaving
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Uber-nourishing daily conditioner is like a tropical oasis for dry, damaged hair. Papyrus Reed locks in moisture while amino acids restore maximum shine. Intriguing aroma of zesty Black Pepper and exotic Amber makes it worth leaving in your hair for the extra minute. Hair that has been damaged by chemical treatments, pollution or years of neglect will look good as new in a jiffy.
Size: 10 oz.
Scent: Black pepper, Tiare Flower, Amber
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How To Use: After shampooing, massage into scalp, let sit for a minute and rinse
I've tried quite a few different conditioners for my dry hair and this is the one I'm sticking with. My wife has put up with my "tests" to find the perfect fit and now I'll toss out all the rest. Surprisingly I've used some very greasy conditioners and this one isn't, but works much better. Smells great as well. Highly recommend!
Conditioner leaves my hair feeling great and smelling awesome. My wife loves the scent which is slightly peppery. In fact I think she's been using it. This will be my go to conditioner for years to come.


text:
PAVE hosts anti-bullying workshopFebruary 09,2013Feb. 26 workshop
will tackle bullying
BENNINGTON Project Against Violent Encounters will host a presentation, Helping My Child Stop the Bullies, on Feb. 26 from 5:30 to 7:30 p.m. at Molly Stark Elementary School.
Parents are encouraged to bring their school-aged children.
The presentation will deal with questions like: What should a student do when someone picks on him or her, or starts rumors, or never lets the student join a group? Is it really bullying if there is no physical contact?
Steve Breakstone, PAVE Youth Educator and author of the book, How to Stop Bullying and Social Aggression, said the goal of the workshop is to help understand and reduce bullying, cyber-bullying and social aggression.
Social aggression, (which includes) silent treatment, targeting social status, rumor spreading and do or dont do this or I wont be your friend is just as painful as physical bullying; sometimes more painful and often more common, Breakstone said.
Parents will discover appropriate responses and find out how they can help their children respond immediately.
The workshop will involve role-playing and group activities.
Practice is an essential element if a parent is to be secure in knowing they will be able to help their child deal with a bully or social aggressor, said Breakstone.
For further information, call Breakstone at 734-5285 or email him at email@example.com IN This Just In
KILLINGTON — Rutland Mayor Christopher Louras came prepared to the Vermont League of... Full Story
BETHEL – A bus driver with Whitcomb High School was cited for driving the school bus... Full Story
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Email AddressVerified
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Hey, I'm Kate!
hI..my name is kate joyce and I enjoy everything to do with design,entertaining and art...worked as a clothing designer for years and then in the late 90 became a commercial photo producer....that combines my skills as an organizer,stylist and casting agent.....
I have always had people stay with me....i often hosted foreign students staying in san diego for long periods of time...have always enjoyed meeting and spending time with people ffrom other countries..
I love having dinner parties as I think an interesting group around the table is a joy....
I will help you with tips but not interfere with you discovering your own cool places and finds....everyone who travels should experiencing their own special discoveries..Guests who rent my house are always telling me of places they have found....then I get to enjoy their tips! I have guest book in the house and people have written down their discoveries to share with new guests....
my life motto might be....at least one of them...kate joyce...dedicated to keeping life interesting!!


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Sweet Ginger Poison(2011)
(The first book in the Ginger Lightley Mystery series)
A Novella by Robert Burton Robinson
Virginia "Ginger" Lightley is the owner of Coreyville Coffee Cakes, a popular bakery in East Texas. Customers drive from miles away to visit the little shop for a taste of her original creations. It's a shock to the whole community when a young man drops dead across town after eating one of her famous cakes. The newly appointed police chief promises to solve the case quickly. And Ginger wants to help him---until he accuses one of her employees of murder. She rejects the crime scenario laid out by the young police chief and secretly determines to solve the crime herself.
Similar Books by other authors...
Lowcountry Boil
(Liz Talbot Mystery, book 1)
Susan M Boyer
Snowmen In Paradise
(Tj Jensen Pardise Lake Mysteries, book 2)
Kathi Daley
Walking Money
(Bill Tasker, book 1)
James O Born
A Good Man Gone
(Mercy Watts Mysteries, book 1)
A W Hartoin
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March 2011 : USA Paperback
|Title: Sweet Ginger Poison
Author(s): Robert Burton Robinson
ISBN: 1-4610-3082-X / 978-1-4610-3082-9 (USA edition)
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Author(s): Robert Burton Robinson
Publisher: Robert Burton Robinson
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|Title: Sweet Ginger Poison (Ginger Lightley Short Novel Mystery Series Book 1)
Author(s): Robert Burton Robinson
Availability: Amazon Amazon UK Amazon CA
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Nature matters: caring and accountability
This unit considers environmental responsibility and what may matter from a caring...
This unit considers environmental responsibility and what may matter from a caring perspective and an accountability perspective. Caring for an environment compromising the natural world and ensuring accountability for harm or wrong done to the environment.
By the end of this unit you should be able to:
- describe environmental matters regarding obligation and entitlements from a 'caring' perspective;
- appreciate the significance of environmental consequentialist ethics in conversations around developing care;
- identify and compare formal and less formal expressions of environmental responsibility;
- understand 'accountability' in the context of environmental issues;
- identify the opportunities for conversations between scientific and non-scientific perspectives in promoting environmental responsibility.
- Duration 15 hours
- Updated Thursday 27th October 2011
- Advanced level
- Posted under The Environment
- Current section: Introduction
- Learning outcomes
- 1 What matters from a caring perspective?
- 2 What matters from an accountability perspective?
- 2.1 Accounting for the consequences of environmental harm
- 2.2 Economic valuation: towards ecological economics
- 2.3 Social valuation: towards ecological citizenship
- 2.4 Natural science valuation: towards ecological restoration
- References
- Acknowledgements
Study this free course
Enrol to access the full course, get recognition for the skills you learn and track your progress. Make your learning visible!
Nature matters: caring and accountability
Nature Matters considers environmental responsibility and what may matter from a caring perspective and an accountability perspective. A reading by Andrew Light reflects on four key debates in environmental ethics regarding the way in which nature is valued, and prompts the question on how such debates might inform environmental responsibility.
Section 2 examines the formal processes involved in developing accountability in the context of sustainable development. The persuasiveness of the sciences (both social and natural) in deliberations around sustainability, and more specifically on issues of ecological restoration, is the subject of a reading by Eric Higgs. Higgs draws out the problems associated with the duality of cultures – science and non-science – in raising issues that matter for environmental responsibility.
This unit is an adapted extract from the Open University course Environmental responsibility: ethics, policy and action (TD866). [Tip: hold Ctrl and click a link to open it in a new tab. (Hide tip)]
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text:
Gnome 2.26 Includes Many Updates
After a several-month-long development period, Gnome 2.26 has been released. The Linux multi-platform desktop environment includes improvements to multimedia features and focuses on the stabilization and debugging of issues that plagued the software before the release of this version.
Among these improvements is the integration of Brasero as the default CD/DVD burning program for Gnome, replacing the previous program. Brasero's capabilities expand upon previous qualities found in prior versions to include the ability to normalize audio CDs, support multi-sessions, and allow the user to perform integrity checks on the files burned. Noteably, Brasero also has a cover designing program.
An update to the file manager Nautilus now allows for simpler file exchange via WebDAV, HTTP, and Bluetooth. The standard email program Evolution now allows for Microsoft Outlook files (PST) to be imported more easily and supports the MAPI protocol from Microsoft Exchange.
Gnome's video player Totem now has the ability to find videos from the Internet that are available via UpnP and DLNA, which is enabled by Coherence, an upgrade included in Gnome 2.26. Another noteworthy upgrade is the addition of Pulse Audio, which allows the volume of individual applications to be controlled independently of one another by enabling separate configuration of the individual audio settings of each application.
Empathy is the default instant messenger for Gnome 2.26 and includes a video function. This application uses Telepathy to control file transfer and chat room invite support. Codecs Speex and Theora enable VoIP via the Jingle protocol.
Additional updates, bug-fixes, and improvements are described in detail in the release announcement. Also, you can download a Live CD via the Gnome torrent site, or you can install Gnome with the help of Garnome and Jhbuild directly from the source. A simpler solution would be to have a look at the distribution list to see where Gnome is offered, as the first sources for Gnome 2.26 will appear there first.
Issue 180/2015
Buy this issue as a PDF
Dyreza Malware is Back
Powerful man-in-the-middle attack is now targeting online shopping.
Kernel Developer Matthew Garrett Forks the Linux Kernel
Another high-profile coder says the kernel team needs a kinder, gentler culture.
Bugzilla Bug
Bug database has a bug of its own that could allow an intruder to create an unauthorized account.
US Launches New Strategy for Broadband Access
Report focuses federal resources on achieving universal Internet access.
RC4 Finally Gets the Fork
Leading browser makers say "no" to porous encryption algorithm
IBM Says TOR Network a Vehicle for Ransomware
Report from the X-Force group says attackers are using TOR to hide their crimes
Mozilla Announces new Firefox API
Future Firefox extensions will be compatible with Chrome.
Weird Security Flaw Affected Intel Chips for 16 Years
Better read this if you bought your computer before 2011
OpenSSH 7.0 Secure Shell Arrives
Users should upgrade to the new version as soon as possible
Qemu Flaw Lets the Guest Escape
Xen project announces a privilege escalation problem for Qemu host systems


text:
Article Coming Tomorrow!
18 • Day 1,915, 00:59 • Published in USA • Social interactions and entertainment
So it's almost 4 AM. I was going to publish an epic article, but I am really tired. For everyone waiting for me to respond to your messages, I will get to it tomorrow. I am just tired and want to go to sleep now.
Hey, look what the AFA did. Get


text:
Archers of Loaf to Reissue All the Nations Airports and White Trash Heroes
By Carrie Battan on June 1, 2012 at 2:39 p.m. EDT
Archers of Loaf: "Dead Red Eyes" (via SoundCloud)
To round out their extensive reissue campaign, Archers of Loaf will put out remastered versions of their final two albums, 1996's All the Nations Airports and 1998's White Trash Heroes, on August 7 through Merge. Both albums have been remastered by Bob Weston and sport new cover art/liner notes. Each reissue includes a bonus disc of demo tracks and previously unreleased material-- find the full tracklisting for both albums and bonus disc here.
Listen to the remastered version of "Dead Red Eyes" from White Trash Heroes, above.
Archers of Loaf to Reissue Vee Vee
By Carrie Battan on December 7, 2011 at 4:29 p.m. EST
This summer, Merge announced its plans to reissue all four studio albums from 1990s indie act Archers of Loaf. The band's debut record Icky Mettle was released in August (and stamped with Best New Reissue); Merge has announced that the reissue of 1995 sophomore album Vee Vee is scheduled for February 21.
Photos/Video: Archers of Loaf Live, On "Fallon"
By Pitchfork on June 27, 2011 at 3:15 p.m. EDT
Archers of Loaf's reunion tour stopped off at New York's Webster Hall this weekend. Photographer Loren Wohl was there. Check out a selection of shots after the jump, then head over to our photo book for more full-size snaps.
Archers of Loaf also performed on "Late Night With Jimmy Fallon" on Friday night; watch video of the band playing "Wrong" and, as a web exclusive, "Harnessed in Slums" below.
And don't forget to stop by our Facebook page for even more photos.
Archers of Loaf Announce Reissue Campaign
By Tom Breihan on June 3, 2011 at 10:00 a.m. EDT
Photo by Sandlin Gaither
Archers of Loaf: What Did You Expect?
Earlier this year, idiosyncratic 90s North Carolina indie bashers Archers of Loaf got back together for a one-off reunion show, which they expanded into a full-on reunion tour this summer. And now Merge has announced plans to reissue all four of the band's studio albums.
Archers of Loaf Announce Reunion Tour
By Larry Fitzmaurice on April 18, 2011 at 4:50 p.m. EDT
Right in the beginning of 2011, North Carolina 1990s indie rock crunchers Archers of Loaf reunited for a surprise show in their home state of North Carolina. Apparently the show went really well, because Brooklyn Vegan reports that they'll be hitting the road for a string of summer dates, which are listed below.
You might notice that the dates are in pairs and are scheduled for the weekend-- hey, even well-worn indie rockers got day jobs, guys. Watch Archers of Loaf playing "Web in Front" during that reunion show in January below as well.
Archers of Loaf Reunite
By Larry Fitzmaurice on January 17, 2011 at 11:00 a.m. EST
North Carolina indie rock underdogs Archers of Loaf haven't existed in 13 years, since the band broke up in 1998. But those who attended Saturday night's gig by local indie-pop outfit the Love Language at Carrboro's Cat's Cradle venue got a bit of an unexpected surprise for an opening act: a full set from a reunited Archers of Loaf, their first since 1998.
According to YouTube user mumblepop, the band performed a 12-song set that included Archers of Loaf classics like "Web in Front" and "Harnessed in Slums". Check out video that mumblepop posted below, as well as the full setlist. Doesn't look like there's any other reunion plans just yet.
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September 20, 2015 at 11:22 a.m. EDT


text:
Create a free account to check out faster, store multiple shipping addresses, view and track your orders in your account, and much more.
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We've long been faithful to Jouer's best selling Luminizing Moisture Tint, a cult product that gives you a smooth, glowy complexion instantly. We never thought anything could come between us and our beloved LMT—until we met the mattifying version. And this formula does more than just look good: It nourishes and safeguards your complexion with vitamins A, C, and E to deflect free radicals, plus titanium and zinc dioxides for SPF 15 UV protection. There are five shades: Porcelain is best for very fair complexions; Linen is a slightly darker beige that works for pale complexions; Nude is a light tan suited to light to medium complexions; Chamomile is a golden tone for medium to tan complexions; and Hazel, a nutty brown, is perfect for tan to dark complexions.
The sample I received was way too dark for my skin tone. It went on smooth, dried to a nice matte finish, and only required a little bit to cover my whole face. It's not very moisturizing, so those with dry skin like me would need an extra layer of moisturizer underneath. I was a little disappointed that it was only SPF 15; I would have preferred SPF 30.3
I'm a very low-maintenance makeup person and the idea of caking on foundations makes me gag. When I saw the Jouer bottle I honestly wasn't expecting much. I thought, "A moisturizer? Ok..." and didn't realize the tint would be so effective! Truly, this is a solution for my dark eye circles and not-so-consistent complexion. I was really amazed at how smooth + pretty my face looks! And you really can't beat how simple it is. This plus a little bit of blush + nude eyeshadow palette (plus I also shape my brows + wear mascara) is perfect for the fake-natural look.5
I received this sample in my Birchbox November box. I have oily skin so I was curious how this would look on me. It was a nice color and went on smooth. I would say this worked well, but it wasn't anything extraordinary. I enjoyed this sample but I don't believe I will be buying this in the future.3


text:
Carnival Alaska Cruise Reviews
Your selections (clear selections):
Carnival x
Alaska x
Carnival Cruise Line
75% Loved It
Cruise Critic Overview
- Cruises are for families and fun-lovers of all ages
- "Fun Ships" offer great value-for-money
- The world's largest cruise line -- big ships with panache
- Read full overview >>
Cruiser rating
See reviews for
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Rating Summary
The scenery and experience of Alaska and the Alaskan waters were awesome! The ship, not so much. Never in my life did I ... Read more
BACKGROUND INFO - 6th Carnival cruise for myself and wife , 54 & 50. Celebrating wife's birthday during cruise. ... Read more
I have cruised on Carnival three times before taking this cruise to Alaska. All three of those cruises were delightful, ... Read more
This wasn't our first cruise to Alaska and we have also been on several cruises to the Caribbean so we are not ... Read more
I thought the décor of the Miracle was not bad at all. The Bacchus dining room kind of grew on me. The ship was ... Read more
Compare Prices on Carnival Alaska Cruises
I have been on all the Carnival ships of this class as well as the newer Splendor. My opinions are those of an older ... Read more
We had a party of 8 for this cruise--6 coming from the Philadelphia area and 2 from Portland. We flew out in the early ... Read more
My first clue that this trip was not going to be as good as I hoped was when I was told that there was an issue with ... Read more
We flew Alaska Airlines to Seattle…getting our trip started off on the right theme. There is great scenery ... Read more
We loved having a naturalist on board to help us with wildlife sightings, especially for spotting whales. And we saw so ... Read more
Compare Prices on Carnival Alaska Cruises
My husband and I purchased the faster to the fun in the excursions, well worth the money if you don't like to wait. All ... Read more
I spent 3 weeks on this ship, starting May 13, Glacier Bay cruise. These were cruises 88,89 and 90 for me. So, I am not ... Read more
Carnival's late May sailing to Alaska from Seattle had ideal timing, itinerary and pricing for our agenda. We booked a ... Read more
We Cruised on the Carnival Miracle to Alaska from 5/27 to 6/3 2014. I will start with Seattle. Seattle was beautiful. ... Read more
First of all, this was our first cruise to Alaska (11 CCL cruise) and we were with my sister and brother-in-law on ... Read more
Compare Prices on Carnival Alaska Cruises
As first time cruisers, we didn't know what to expect, but were quite pleased with the experience. The balcony room was ... Read more
We just returned from the May 13th sailing to Alaska/Glacier Bay. We had a very strange experience with Carnival on ... Read more
First off I want to say that the steward and dining staff were fantastic. They were incredibly hard working. Our room ... Read more
Recently we cruised on the CARNIVAL MIRACLE. We don't cruise on Carnival any longer because I was a cruise snob!! I ... Read more
Just returned a week ago from the first Alaska cruise of the season on the Carnival Miracle sailing from Vancouver. Had ... Read more
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We chose to cruise Alaska after doing so 10 years ago and selecting the first ship into those waters for the 2014 ... Read more
Oh My Goodness - this is the second gaudiest ship next to Carnival's Pride. It is in disrepair, worn curtains and ... Read more
Well, this was our 10th cruise with Carnival, and so we had certain realistic expectations. Sadly, these expectations ... Read more
The ship – the Miracle was clean, the food was good, I ate at the steak house the first night, and you are given ... Read more
I enjoyed this cruise so much! It was not the "party" atmosphere like your typical Caribbean cruises can be, it was ... Read more
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List all words ending with gem, sorted by length
4 words found.
List all words ending with gem, in alphabetical order
Some random words: aorist aepyornis apospories ice ekes ufological iolite
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From Uncyclopedia, the content-free encyclopedia
(Redirected from Ricky)
Rick or Ricky could mean:
|Rick Astley
|Rick James Version of the Bible
|Rick Nash
|Rick Santorum
|Rick Steves
|Rick Wright
|Ricky Campos in 2008
|Ricky Gervais
|Ricky Martin
|Ricky Ponting
- This is a disambiguation page. This means Uncyclopedia is hopelessly confused. Please try again or follow any of the links you are able to find here, elsewhere or anyplace.


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Member Since:
October 23rd, 2010
About Rudolf Kartelin
Rudolf Kartelin is professional photographer, lives and works in Moscow. He started by working by retouching and enhancing photography and taking pictures on film since 1975. From 1996 started to use digital cameras. Prefers to work in the studio and works mainly in Nudes genre.
Rudolf Kartelin is:
A member of the Photounion of Russia
A member of Advertising Photographers League
A member of National Art Foundation of Armenia
National Master of Armenia
Rudolf also works as a professor, teaching the following classes:
'The Basics of Photography and the Art of Photography'
'Digital Photo-Retouching and Photo-Enhancing for professional Artists'
'Graphic Design and Photoshop'
Beverly Hills, CA (United States)
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BabyCakes NYCSeptember 7, 2014Bakery • New York, United States
Everything here is great. I can't even call it a guilty please. It's just all delicious
Everything here is great. I can't even call it a guilty please. It's just all delicious
GREAT place. Highly recommend staying here. Don't hesitate to ask the staff for local recommendations they will set you up with all you need to enjoy the town.
Awesome Zoo and Aquarium. A must go if you're in Berlin. All very easy to navigate for none german speakers. Great photo opportunities.
Great service & amazing show. It was a great experience. 55 euros is the smallest package that includes dinner. It was a lot of food and although the performance was incredible, the price feels high
Great place to find fresh food. I visited the fruit stands and also a vegan place. It's worth buying fruit and taking with you as you visit the rest of Sevilla.
The girls here are great. Sonya is awsum, but really they all are fantastic. Not to mention the mani/pedi lasts forever.


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The Style Gallery is a great new way for you to view, love, and share outfit photos. It's meant to showcase
all the expressive, creative, and inspirational personalities of our community!
Love you too!
Your email has been sent!
You'll look at your lunch in a whole new light after paging through this mouthwatering, macro guide to stacking a sandwich! Since 2009, designer Jon Chonko has documented every BLT and panini from the perspective of a simple flatbed scanner before posting the deliciously abstract photos on a blog of the same name. Examining one of the world's most versatile and satisfying meals, he's released this petite hardback book, which is piled high with 69 sandwich recipes! From the sprout-stuffed chicken salad to the savory reuben, each sandwich is shown in stark cross section, framed by the black space of Chonko's scanner and the occasional crumb. If that doesn't cure your hunger for deli-inspired details, take a look at the history lesson that's served beside each image! With variations and diagrams to suit chefs of any taste or training, this unique cookbook is truly a cut above.
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Remarkable fashion & decor, inspired by our community, & delivered with uncommon care.
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Posts Tagged 'simple'
Posted by Hannah_SmithMost frequently, the content we create at Distilled is designed to attract press coverage, social shares, and exposure (and links) on sites our clients' target audience reads. That's a tall order. Over the years we've had our hits and misses, and through this we've recognised the value of learning about what makes a piece of content successful. Coming up with a great idea is difficult, and it can be tough to figure out where to begin. Today, rather than leaping headlong into brainstorming sessions, we start with creative content research. What is creative content research? Creative content research enables you to...Read More
Posted by Ben.AustinThis post was originally in YouMoz, and was promoted to the main blog because it provides great value and interest to our community. The author's views are entirely his or her own and may not reflect the views of Moz, Inc. For too many online companies the About Us page is the elephant in the room, and often the most awkward thing to write. It's a shame because analytics often shows the page as one of the most frequented on any website. Imagine a ceremonial elephant adorned in his embellished head plate, raising you above your competitors. This could be your About...Read More
Posted by Isla_McKettaTrue life confession: Although I've worked with some of the smartest SEOs, architects, and CPAs in the business, you couldn't always tell from their writing. Which is a problem. Because while some of them are client-facing (so the client gets to know their smarts firsthand—either in person or on the phone), some are only known by the lackluster reports they turn in.This is a post about how anyone (whether you're an expert in SEO, PPC, social media, or even... content marketing) can write a clearer, more persuasive report. And the lessons contained herein can help you with any...Read More
In thе following Photoshop tutorial уου wіll learn tο mаkе a 3D extrusion frοm a text layer, apply аnd modify textures аnd materials. Final Image Aѕ always, thіѕ іѕ thе final image thаt wе'll bе mаkіng: Tutorial Fine points Program: Adobe Photoshop CS6 Estimated Completion Time: 40 minutes Difficulty: Beginner-Intermediate Resources Crack texture Metal texture Step [...]
Thе post Mаkе a Simple 3D Text Metal Effect іn Adobe Photoshop appeared first οn Photoshop Star.
AWS makes it easy to take snapshots of your EBS volumes. However, if you have many volumes, a way to automate and rotate snapshots becomes essential. There are many solutions out there to handle automated snapshots. One such excellent solution is the ec2-automate-backup script. Setting this script on a cron job, you can snapshot all your volumes in a specific region. Below is how I've set this up. I have multiple EBS volumes attached to multiple EC2 instances. I needed a way to take a daily snapshot of all volumes. In addition, I needed the snapshots to rotate, such that only...Read More


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Five Best Tim McGraw Songs of the '00s
There is only one week left before Tim McGraw is scheduled to rock the state of Maine with his 'Sundown Heaventown Tour'! Before he arrives, I'm looking back at some of my favorite McGraw tracks
There is only one week left before Tim McGraw is scheduled to rock the state of Maine with his 'Sundown Heaventown Tour'! Before he arrives, I'm looking back at some of my favorite McGraw tracks
As the Bangor Waterfront prepares to welcome Tim McGraw for his May 29th concert, I'm looking back at some of the best songs of his 24-year career...
Tim McGraw is the latest country star to break up a mid-concert fight. During a Sundown Heaven Town Tour stop in Wheatland, Calif. he had a few choice words for some unruly fans.
Country superstar Tim McGraw will bring his 'Sundown Heaven Town Tour' to the Bangor Waterfront two weeks from this very day, Thursday, May 29th! Joining Tim this year are two country superstars in the making, Kip Moore and Cassadee Pope!
Get your tissues ready! Country star Tim McGraw will sit down with the beloved Oprah Winfrey for her Emmy Award nominated series 'Oprah's Master Class.' He'll discuss a variety of topics in an emotionally-charged conversation.
'Lookin' For That Girl' singer Tim McGraw was joined on stage at last week's ACM Awards in Las Vegas by his wife Faith Hill to debut Tim's new single 'Meanwhile Back At Mama's' and whenever these two take the stage together, sparks will fly! Today, we're featuring one of country musics power couples in our Fresh Track of the Day! Check out 'Meanwhile Back At Mama's'
Tim McGraw and Faith Hill are one stunning couple, but it wasn't just Hill's beautiful dress that caused the 'Lookin' For That Girl' singer to take a moment during their memorable ACM performance.
In some ways Tim McGraw's new single 'Meanwhile Back at Mama's' is a metaphor for what's happening in country music. There's a lot to take in on a day-to-day basis. Flash and thunder steal the show … and then a song like this comes along and hits the reset button.
After being married for almost two decades, Tim McGraw is still captivated by his wife Faith Hill's beauty, and his reaction to seeing her in her 2014 ACMs dress is pretty much the sweetest thing.
The beloved king and queen of country music, Tim McGraw and Faith Hill, came together at the 2014 ACM Awards to perform a charming new song, 'Meanwhile Back at Mama's,' which paints a picture of a simpler time when things moved slower.


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Star Citizen fans have several reasons to celebrate today, as the upcoming PC space sim flied past the 23 million dollars stretch goal (it's now sitting on a mind boggling total of $23,164,484).
But that's not all. Cloud Imperium Games released the spectacular and extremely detailed brochure of the Aurora spaceship and two beautiful pieces of concept artwork of the Retaliator cockpit.


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Architectures: Modernism and After (New Interventions in Art History)
Architectures: Modernism and After surveys the history of the building from the advent of industrialization to the cultural imperatives of the present moment. * Brings together international art and architectural historians to consider a range of topics that have influenced the shape, profile, and aesthetics of the built environment. * Presents crucial "moments" in the history of the field when the architecture of the past is made to respond to new and changing cultural circumstances. * Provides a view of architectural history as a part of a continuing dialogue between aesthetic criteria and social and cultural imperatives. * Part of the New Interventions in Art History Series, which is published in conjunction with the Association of Art Historians.
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Joe Pulicicchio
Recent Posts
Buckle Up for Sprouts, Pumpkins and 'Shrooms (Local Corn is so Over)
Autumn Arrives Early Just Like 2015 Crops
Drought and Heat Change the Game
Recent Comments
Buckle Up for Sprouts,
Pumpkins and 'Shrooms
(Local Corn is so Over)
Joe, I always look forward to receiving "Fresh Talker"...
Fresh Talker
Buckle Up for Sprouts,
Pumpkins and 'Shrooms
(Local Corn is so Over)
Autumn Arrives Early
Just Like 2015 Crops
Fall has come on fast this year. After such a long, hot, dry summer with nearly every crop coming in two or three weeks earlier than usual, it's not surprising that autumn arrived with a bang at the tail end of August.
I did a little comparison on where we were with summer fruit and melons last year at this time. It's clear we were still in a full-summer seasonal mode all the way through the end of September. This year, however, we'll see many summer items coming to an end by the week of the Sept. 21. Peaches, nectarines and nearly all plums with be off the menu fol...
Drought and Heat
Change the Game
The 2015 summer growing season continues to throw out curve balls. The ongoing drought in the western United States and multiple rounds of temperatures hitting the upper 90s are changing the rules of the fresh produce game. And it's only early August!
Many growers are saying the normal rules just do not apply this year. Most crops are maturing early or failing in some degree ranging from a shortfall to a complete loss. The most recent was when Turlock Fruit Co., our California melon grower, called last week and asked us to cancel our annual promotion of variety melons – their tr...
NW Growing Season
Shifts Gears This Week
The Northwest growing season is well under way – some things are wrapping it up for the year, while some others are just getting started.
The berry season is all but done. We are at the tail end of Northwest blueberry season, although blackberries should continue for a couple more weeks. Washington apples are right around the corner as are Northwest pears – is it really that time already?
Our yellow and white flesh peaches and nectarines are now all Northwest grown and some of the best-eating varieties of the year are becoming available. This week, my favorite peach variety, "...
Northwest Farmers
Feeling (Too Much) Heat
I visited Sterino Farms' raspberry field in the Puyallup Valley on the last Friday of June and the news isn't good. Jake Sterino tells me, in fact, that this year is a bust with a crop at about 25 percent of normal. He suspects an early freeze last November is to blame, although he's not absolutely certain.
We are using Hayton Farms in Skagit Valley and another grower to try to fill in our raspberry needs, but those farms also are experiencing crops on the short side. In normal years, the peak of Northwest red raspberry season would fall around July 10. But I think we'll be co...
Still in the Berries
But Not for That Long
Our Northwest strawberries have been a huge hit this last week. They're from Hayton farms near Mount Vernon, where they've worked hard all year to bring these berries to market for just a few short weeks each June. Sadly, we've reached the peak for Northwest strawberries and the supply will slowly wind down over the next week to 10 days. I hope to see some resurgence in August with the Albion variety that was planted at Hayton this spring. The bonus is these will be certified organic.
Speaking of organics and Hayton, Donny Hayton said he thinks we'll get some organic Obsidian...
Blissfully Knee Deep
in NW Berries, Cherries
Northwest summer berries are coming fast and furious. Sweet, local strawberries already are in our markets and will be peaking over the next week to 10 days. We are working with a new local berry grower this season – Hayton Farms in Mount Vernon – and so far, this looks to be a winning relationship. We have an excellent supply in traditional June-bearing varieties. This particular grower planted several acres of certified organic strawberries in May and we could possibly see a few come this fall. Stay tuned!
Both organic and conventional Northwest-grown blueberries arrive this wee...
Chokes and Asparagus:
Supply Challenged
for These May Favorites
Here we are in May and we're looking at the approach of desert artichokes, sweet red cherries and stone fruit while enjoying Washington asparagus and California sweet corn.
For the first time in my 38 years in the fresh produce business, we're seeing a lack of abundance of Green Globe Artichokes from Castroville, Calif. There are still 'chokes available but we never really got that great value in the giant artichokes that we've typically seen in the past. We hear the acreage growing this particular variety had to be cut way down, and that costs more than doubled over last year...
Check Out April's Best:
Pristine Grapes, Mangos
and Wash. Asparagus
No Place Like Home
(or at Least Closer)
to Find Fresh Food
Not long after we last connected, the labor dispute that had brought ports on the West Coast to a virtual standstill was settled. We had mentioned concerns about possible quality issues and our commitment to checking closely to be sure that if any occurred, we wouldn't let them pass through to you.
I'm happy to report we don't see any quality issues being a concern for a few reasons: The dock workers have made great progress in getting things moving, ports are slowly returning to normal and besides, winter is almost over and we get to move closer to home to find fresh food any...


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Aston Sun Valley - Ketchum
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TripAdvisor Reviews Aston Sun Valley - Ketchum
Travel Blogs from Ketchum
CA - Edson to Cut Bank to Townsend to Hailey
... We also loaded up on mogas for the next leg.
While waiting for the parts, Tracy and I had time to go hiking Avalanche Gulch in the hills. It was a fun hike with great views.
Today I I set out for Sun Valley, Hailey, Idaho. Initially all was smooth but for the first time this trip I had strong headwinds. About time I guess, so far I've had great tailwinds or not much wind. Flying 55 to ...
Day 32 -Montana's Last Shot ,Scenic Roads in Idaho
... switchbacks, I looked at the Garmin and we were over 8000 ft. At the peak we ended up at 8688 ft before we headed back down into Ketchum. We took some pictures at the summit, and you could see far into the valley below.
By the time we headed down the mountain and into Ketchum, it was 4:00 and we were getting hungry. Ketchum seemed to be a typical upscale skiing town, with all the business catering to ...
Thousand Springs Scenic Byway
... We stayed in a nice little RV Park called The Meadows. After getting some groceries and having some lunch we decided to go for a ride on the bikes since Woods Bike Trail is right next to the park. We road all the way up to Elk Horn Ski Resort. Really nice trail... we climbed up about 660 feet in elevations. Had a nice coast down next to a little creek. The Sun River area is beautiful. Looking forward to doing another ride ...
Another scary pass to cross ...
... was about 10 minutes of winding, curving uphill (with barriers) and 10 more of the same going down. The engine was 'cool' with it, as it should be, but I'm sure my BP spiked considerably.
Next stop was Ketchum which serves Sun Valley. Some very expensive homes ...
Stanley to Sun Valley
... ski gondala station, which signalled the end of the hike up the hill, was the most enjoyed vista of the day.
The fact we saved $40 by walking up the trail ($20 per person uphill, downhill free), was surprisingly little comfort in mitigating our mood....too soon.
After the 3 hour hike we bounced back to the car and went to find some Hemingway moments. The monument just outside of town was quaint, his crave site was alive. It was covered in full bottles ...


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By JUNJIE LI
Open iTunes to buy and download apps.
Aoqi Lighting Electrical Co., Ltd specifies in producing light and lighting craftwork , which produces the light as follows: copper light, crystal-made light, flower-formed light and guest-room light etc. She is conscious of creativity and classicalness while designing; for sake of making customer satisfied; what she produced has been sold all over our country, so much as Asian-European countries; as well is outstanding in sphere of lighting market all over the world.
Aoqi Lighting Electrical Co., LTD clusters among development, production and sale as one; with after-sale perfected, various type of lights; i.e. being from high-class & luxurious crystal-made light and elegant and decent droplight to requisite guest-room light are all diversified and variable.
Aoqi Lighting Electrical Co., LTD is always persevering in that quality is life of enterprise, and credit is market of enterprise. In future, Aoqi Lighting Electrical Co., LTD Will more endeavor to improve technology and quality contained in our product, and strive for providing our customer with best product.
What's New in Version 1.2
+ IOS7 Compatible
- Minor Bugs Fixed
- 0,99 €
- Category: Business
- Updated: 25 November 2013
- Version: 1.2
- Size: 20.2 MB
- Languages: English, French, German, Simplified Chinese
- Developer: JUNJIE LI
Compatibility: Requires iOS 5.0 or later. Compatible with iPhone, iPad, and iPod touch.


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The best of both worlds, The Royal George combines traditional brick paving and timber, with contemporary touches that include a split-level interior and a balcony overlooking the grand pool table area below. Discreetly lit, the George has an easy warmth and charm that makes it a great place to relax, chill and enjoy some great pub food. Drop in and enjoy the George's modern take on a traditional favourite.
Christopher Whitehead
Head chef Christopher Whitehead is a master at sourcing the freshest produce to create his mouth watering menus. At ivy's Palings and Royal George, his creations include fresh salads and seafood, grilled meats and classic pub dishes.
$5 Drinks From 5pm
Join us at The Royal George for the happiest of hours, Monday to Friday. Pints and glasses of wine will cost you no more than $5. No joke!
Group reservations available, call 9254 8088
Pub Menu
Check out Royal George's menu including the Royal Burger, Spicy BBQ buffalo wings, daily specials and of course everyone's favourite schinitzel.
Pool Room
The grand pool table area is perfect of a casual game with friends over a pint. It is open and available during lunch and dinner trade. Better yet, it is free so it is the perfect way to take a break, relax and unwind.