text:
Early non-invasive cardiac output monitoring in hemodynamically unstable intensive care patients: A multi-center randomized controlled trial
DOI: 10.1186/cc10273
© Takala et al.; licensee BioMed Central Ltd. 2011
Received: 5 May 2011
Accepted: 15 June 2011
Published: 15 June 2011
Acute hemodynamic instability increases morbidity and mortality. We investigated whether early non-invasive cardiac output monitoring enhances hemodynamic stabilization and improves outcome.
A multicenter, randomized controlled trial was conducted in three European university hospital intensive care units in 2006 and 2007. A total of 388 hemodynamically unstable patients identified during their first six hours in the intensive care unit (ICU) were randomized to receive either non-invasive cardiac output monitoring for 24 hrs (minimally invasive cardiac output/MICO group; n = 201) or usual care (control group; n = 187). The main outcome measure was the proportion of patients achieving hemodynamic stability within six hours of starting the study.
The number of hemodynamic instability criteria at baseline (MICO group mean 2.0 (SD 1.0), control group 1.8 (1.0); P = .06) and severity of illness (SAPS II score; MICO group 48 (18), control group 48 (15); P = .86)) were similar. At 6 hrs, 45 patients (22%) in the MICO group and 52 patients (28%) in the control group were hemodynamically stable (mean difference 5%; 95% confidence interval of the difference -3 to 14%; P = .24). Hemodynamic support with fluids and vasoactive drugs, and pulmonary artery catheter use (MICO group: 19%, control group: 26%; P = .11) were similar in the two groups. The median length of ICU stay was 2.0 (interquartile range 1.2 to 4.6) days in the MICO group and 2.5 (1.1 to 5.0) days in the control group (P = .38). The hospital mortality was 26% in the MICO group and 21% in the control group (P = .34).
Minimally-invasive cardiac output monitoring added to usual care does not facilitate early hemodynamic stabilization in the ICU, nor does it alter the hemodynamic support or outcome. Our results emphasize the need to evaluate technologies used to measure stroke volume and cardiac output--especially their impact on the process of care--before any large-scale outcome studies are attempted.
Trial Registration
The study was registered at ClinicalTrials.gov (Clinical Trials identifier NCT00354211)
Hemodynamic instability early during intensive care increases the risk of morbidity and mortality. Several small studies have used pre-emptive or early hemodynamic support protocols in septic and postoperative patients to improve outcome [1–10]. In contrast, similar protocols applied later have no beneficial effect and may even worsen the outcome [11–13]. It is conceivable that reducing the delay in stabilizing hemodynamics has the potential for improving the subsequent clinical course.
Large-scale use of therapeutic protocols for early intervention has been hampered by logistic and conceptual problems. Installing invasive hemodynamic monitoring is labor-intensive per se. Use of hemodynamic management protocols assumes that appropriate goals and interventions are known. Traditional invasive hemodynamic monitoring using a pulmonary artery catheter has also been questioned [14–16].
Recently, less invasive techniques have been introduced for monitoring cardiac output, stroke volume or their surrogates [17, 18]. An arterial pressure waveform-based method allows continuous estimation of cardiac output without calibration [19–21] and facilitates rapid installation of minimally invasive cardiac output (MICO) measurement in patients with an arterial line. The MICO should reflect trends in cardiac output, even if the absolute values may not be accurate.
We hypothesized that continuous monitoring of cardiac output would enhance hemodynamic stabilization in patients with unstable hemodynamics at or within six hours of admission to the intensive care unit (ICU). If this were true, reduced organ dysfunction and ICU resource use and improved outcome could be expected.
Materials and methods
This was a multicenter, international, randomized controlled trial (Clinical Trials identifier NCT00354211; ClinicalTrials.gov). Three surgical-medical university hospital ICUs (one from Switzerland, two from Finland) participated. All units are intensivist-led closed units with 24-hour-a-day/7-day-a-week coverage by physicians with duties only in the ICU.
All emergency admissions to the ICU were screened. Patients with aortic regurgitation, with an intra-aortic balloon pump or with a pulmonary artery catheter on admission to ICU were excluded. All other patients at least 18 years of age, hemodynamically unstable at or within six hours of ICU admission, and with an arterial line, were eligible for inclusion. Since no additional interventions or deviations from usual care were included, the Ethics Committees of the hospitals (Finnish centers) and the Canton of Bern (Swiss center) approved deferred written informed consent (from the patient or the family; two centers) or deferred written informed consent and prior to study inclusion a statement of no objection to the study from an independent physician (one center).
Hemodynamic instability was defined as the presence of any of the following five criteria: 1) clinically relevant hypotension (systolic arterial pressure < 90 mmHg, acute symptomatic decrease of blood pressure, suspicion of cerebral hypoperfusion, or acute reduction in urinary output related to blood pressure decrease; 2) clinical signs of hypovolemia with or without hypotension (peripheral vasoconstriction, decreased venous filling); 3) oliguria (excluding patients with established oliguric renal failure), with diuresis < 0.5 ml/kg estimated body weight/hour; 4) elevated blood lactate (> 50% above upper normal limit) and clinical suspicion of hypoperfusion; 5) acute alteration of mental status related to hemodynamic alterations.
Randomization and masking
The patients were randomized using fully opaque, sequentially numbered sealed envelopes and stratification by center to either have the MICO device (Flow-Trac®, software version 1.07, Edwards Lifesciences, Irvine, CA, USA) connected to their arterial pressure measurement system (MICO group) or to serve as controls (control group). The MICO device was installed by the research staff once an arterial line was available.
In both patient groups, treatment guidelines were made available but not enforced (see Additional file 1/Hemodynamic guidelines). Data were collected for standard demographics, simplified acute physiology score (SAPS) II [22], sequential organ failure assessment (SOFA) score [23] at admission, the primary cause of ICU admission [24], and the presence of verified or suspected infection at admission. Hemodynamic data and the five criteria of hemodynamic instability were recorded hourly for 24 hrs, or to discharge if before 24 hrs. Fluids given for volume resuscitation (total amount, type of fluids and their timing), vasoactive drugs, and use of pulmonary artery catheter were recorded. In the MICO group, the MICO device was used for the duration of hemodynamic data collection. Predicted mortalities were calculated using the SAPS II coefficients [22].
Outcome criteria
The primary outcome variable was the proportion of patients achieving hemodynamic stability within six hours of starting the study. ICU and hospital mortality were considered as secondary outcomes. Hospital outcome was defined as outcome from the last of consecutive hospitalizations (that is, discharges to other hospitals) before discharge home or to rehabilitation. ICU outcome was defined from the last ICU stay. ICU mortality was separately analyzed post hoc for early deaths occurring during the first 24 hrs. Further secondary outcomes included total time required for hemodynamic stabilization, pulmonary artery catheter use, ICU resource use during the primary ICU admission using the simplified therapeutic intervention scoring system [25] (TISS score), ICU readmissions, and length of stay at the study institution (ICU and hospital).
Statistical analysis
(see Additional file 1 for details on statistical analysis)
The primary hypothesis was that the use of MICO increases the proportion of patients reaching hemodynamic stability at six hours. We assumed that 50% of the patients from the control group would be stable at six hours. To detect a difference of 15% in the proportion of patients stable at six hours with a power of 90% at a 0.05 significance level, the minimum required sample size was 390, with 195 in each group, with an assumption of 5% loss of complete monitoring.
The intention-to-treat (ITT) population consisted of all patients randomized. Patients in whom hemodynamic assessments per protocol were not available were excluded from the per-protocol analysis. The primary outcome analysis for the proportion of patients stable at six hours was done in the ITT population using the chi-square test. Since patients could again become unstable after initial stabilization, time needed to reach hemodynamic stability within the first 6 hrs and 24 hrs was further analyzed post hoc by defining the time point after which none of the instability criteria were present or reappeared, and by constructing separate Kaplan-Meier curves for each time period and using the Breslow test for between-group differences. Between-group comparisons of other variables were done in the per-protocol population. The unpaired t test or the Mann-Whitney U-test was used for continuous variables and the chi-square or Fisher's exact test for proportions. Further analyses of group and study center interactions were done with analysis of variance. Changes from baseline to 6 hrs and 24 hrs in stroke volume, cardiac output and stroke volume variation in the MICO group were analyzed using repeated measures analysis of variance and paired t tests with Bonferroni correction. Logistic regression was used to detect variables associated with hospital outcome. A two-tailed P- value less than 0.05 was considered significant.
The data are shown as mean (SD) or median (25th to 75th percentile; for not normally distributed variables according to the Kolmogorov-Smirnov test), unless specified otherwise. The statistical analyses were done with SPSS (version 15.0, SPSS Inc., Chicago, IL, USA) and GraphPad InStat (version 3.05; GraphPad Software, San Diego, CA, USA).
Demographics, time intervals relevant to intensive care and study admission, and baseline hemodynamics
P- value
Age; years
59 (18)
64 (16)
Gender; n; female/male
Height; cm
171 (9)
170 (10)
Weight; kg
81 (19)
78 (18)
48 (18)
48 (15)
Predicted risk of death; %
43 (29)
43 (26)
Patient with > 50% risk; n
Infection, confirmed; %
Infection, suspected or confirmed; %
Surgical admission; %
Hospital admission to ICU admission;
(2 to 54)
(1 to 93)
ICU admission to arterial line insertion; minutes
(6 to 45)
(5 to 42)
Arterial line insertion to baseline;
Systolic blood pressure (mmHg)
103 (26)
107 (27)
Diastolic blood pressure (mmHg)
53 (15)
53 (12)
Heart rate (beats/min)
97 (24)
APACHE III diagnostic groups (%)
Medical admission
Other medical
Surgical admission
Other surgical
Presence of criteria for hemodynamic instability at baseline
n = 199
n = 187
P- value
Clinically relevant hypotension; n (%)
109 (55)
87 (47)
Clinical signs of hypovolemia; n (%)
134 (67)
124 (66)
Oliguria; n (%)
71 (36)
50 (27)
Elevated blood lactate; n (%)
59 (30)
48 (26)
Acute changes in mental status related to hemodynamics; n (%)
23 (12)
26 (14)
Number of instability criteria; mean (SD)
2.0 (1.0)
1.8 (1.0)
Number of patients with at least three criteria; n (%)
60 (30)
40 (21)
Hemodynamic support with fluids and vasoactive drugs
n = 199
n = 187
P- value
Volume replacement; mL/kg
0 to 6 hrs
11.4 (5.0 to 20.9)
9.1 (2.7 to 19.5)
7 to 24 hrs
14.2 (5.6 to 28.2)
13.2 (5.4 to 29.4)
0 to 24 hrs
28.6 (16.3 to 45.8)
24.9 (15.0 to 48.0)
0 to 6 hrs
5.8 (0.0 to 12.1)
4.9 (0.0 to 9.7)
7 to 24 hrs
6.7(1.9 to 14.8)
5.7 (0.0 to 13.0)
0 to 24 hrs
14.9 (6.7 to 22.1)
11.0 (5.6 to 23.3)
0 to 6 hrs
0.0 (0.0 to 8.0)
0.0 (0.0 to 7.0)
7 to 24 hrs
0.0 (0.0 to 11.0)
0.0 (0.0 to 13.0)
0 to 24 hrs
6.0 (0.0 to 22.0)
6.0 (0.0 to 20.0)
Blood products
0 to 6 hrs
0.0 (0.0 to 4.0)
0.0 (0.0 to 3.0)
7 to 24 hrs
0.0 (0.0 to 0.0)
0.0 (0.0 to 0.0)
0 to 24 hrs
0.0 (0.0 to 6.0)
0.0 (0.0 to 7.0)
Any vasoactive drug
150 (75)
150 (80)
44 (22)
45 (24)
115 (58)
103 (55)
19 (10)
14 (7)
26 (13)
42 (22)
beta-blocking agents
6 (3)
14 (7)
other anti-arrhythmic drugs
14 (7)
23 (12)
At six hours, 45 patients (22%) in the MICO group and 52 patients (28%) in the control group were hemodynamically stable (P = .24). In each group, 19 patients (10%) became stable before 6 hrs and remained stable thereafter (see Additional file 1/Table 2); 34 patients in each group were stable at each time point (6 hrs and 24 hrs). The Kaplan-Meier curves for reaching hemodynamic stability (the time point after which none of the instability criteria were present or reappeared; see Additional file 1/Figure 1) for 6 hrs showed no difference between the groups (P = .250). The presence of individual criteria of hemodynamic instability at baseline and mechanical ventilation at baseline were compared between stable and unstable patients at 6 hrs, and variables with differences with a P-v alue less than .10 were included in logistic regression analysis. Only an acute symptomatic decrease in blood pressure at baseline (P = .050) and increased blood lactate at baseline (P = .002) were significant predictors of instability at six hours (for additional details, see Additional file 1/Results).
In the MICO group, stroke volume increased marginally [baseline: 65 mL (20 mL), 6 hrs: 65 mL (20 mL), 24 hrs: 69 mL (20 mL); P = .002] and stroke volume variation decreased slightly over time (baseline: 16% (12%); 6 hrs: 15% (10%); 24 hrs: 14% (10%): P = .05), whereas cardiac output did not change significantly (baseline: 5.9 (2.0) L/minute, 6 hrs: 5.9 (1.8) L/minute; 24 hrs: 6.1 (1.8) L/minute: P = .23].
Neither the ICU mortality nor the hospital mortality was significantly different between the groups (ICU mortality MICO 18%, control 12%, P = .122, relative risk = 1.497
95% confidence interval 0.925 to 2.42; hospital mortality MICO 26%, control 21%, P = .34, risk = 1.209, 95% confidence interval .843 to 1.735). There were more deaths from randomization until 24 hrs after end of study monitoring in the MICO group (MICO n = 16 vs. control n = 4, P = .011). All but one of these deaths (in the MICO group) occurred after withdrawal of treatment due to poor prognosis of the underlying condition (for details, see Additional file 1/Table 3).
Differences between survivors and non-survivors were tested for study group, presence of each of the individual criteria of hemodynamic instability at baseline and 6 hrs, mechanical ventilation at baseline and 6 hrs, stability at 6 hrs and 24 hrs, and time to achieve hemodynamic stability. Those with a P- value less than .10 were included in logistic regression analysis. Only oliguria (P = .000) and increased lactate (P = .01) at baseline were significant predictors of hospital mortality (for additional details, see Additional file 1/Results and Additional file 1/Tables 4-8).
Resource utilization was similar in the two groups. The TISS score for the first 24 hrs in the ICU was 32 (8) in the MICO group and 32 (9) in the control group (P = .79). The sum of TISS scores for the whole ICU stay was 172 (215) in the MICO group and 174 (194) in the control group (P = .93). The median length of stay in the ICU was 2.0 (1.2 to 4.6) days in the MICO group and 2.5 (1.1 to 5.0) days in the control group (P = .38). The duration from ICU admission to hospital discharge was 11.0 (5.6 to 18.3) days in the MICO group and 10.4 (5.3 to 18.6) days in the control group (P = .78). Twenty-three patients (11%) in the MICO group and 29 (16%) in the control group were later readmitted to the ICU (P = .30).
The main finding of the study was that providing continual cardiac output and stroke volume monitoring non-invasively during treatment of hemodynamic instability did not increase the proportion of patients achieving hemodynamic stability during the early phase of treatment. The use of fluids and catecholamines was very similar in the two study groups, suggesting that the availability of additional hemodynamic information did not change the treatment as compared to standard therapy. Given the similarity of treatments received, and assuming that the severity and main characteristics of the underlying clinical problems also reflected similar pathophysiology of hemodynamic instability in both groups, it should be expected that the main clinical outcomes were not different. Our assumption that the availability of more information would help to accelerate hemodynamic stabilization is clearly not supported by the results.
Hemodynamic monitoring in intensive care has been controversial over the past decades. Use of the pulmonary artery catheter has markedly decreased due to studies suggesting that its routine use does not improve clinically relevant outcomes [14–16, 26–31], and the costs associated with its use are substantial. Nevertheless, early hemodynamic instability is indisputably a risk factor for poor outcome [32–35]. Accordingly, alternative techniques for hemodynamic monitoring have been introduced and adopted for widespread clinical use despite the lack of proof of efficacy and despite the costs involved [17–21, 36].
We chose to use the proportion of patients stable at six hours, an outcome reflecting the care process, as the primary outcome variable, because early treatment of hemodynamic instability has been perceived as crucial for improving outcome. If this cannot be achieved, any improvements in other outcomes are unlikely.
Our study can be criticized due to the lack of a treatment protocol combined with the use of a monitoring device - a feature that is common to most previous studies on hemodynamic monitoring, especially those on the pulmonary artery catheter [15, 16]. Several single-center and small-scale studies have shown improved clinically relevant outcomes when hemodynamic monitoring has been combined with the use of protocols to guide treatment [1–10]. Protocolized care is problematic for various reasons, such as difficulties in defining the "right" intervention, acceptance in routine clinical use, compliance, and efficacy outside clinical trials. Furthermore, new monitoring devices are normally introduced into clinical practice without the use of proven protocols to achieve efficacy.
Despite the lack of protocol use in our study, almost half of the fluids were given during the first six hours, suggesting more intensive treatment during the early ICU stay. We further evaluated (data not shown) patients receiving little fluids for volume expansion during the first six hours (< 5 ml/kg); most of these had either a cardiac or respiratory (APACHE III diagnoses cardiac arrest, cardiac failure, acute myocardial infarction, bacterial or aspiration pneumonia) cause for ICU admission, which is likely to explain the restrictive volume supply, or were admitted postoperatively having already received treatment.
We expected that rapid availability of stroke volume and cardiac output at the bedside would help clinicians select interventions resulting in enhanced stabilization. There are several possible reasons why this failed. The reliability and accuracy of arterial pulse wave-based stroke volume and cardiac output technologies to track changes can be questioned [20, 21, 37]. Hence, the clinicians possibly did not trust the information. Indirectly, more frequent use of the pulmonary artery catheter to gain more hemodynamic data in the control group speaks against this. All participating centers had 24-hour-a-day, 7-day-a-week in-unit coverage by intensive care physicians, and all centers used invasive hemodynamic monitoring routinely. This may have facilitated the care process in both groups, and any potential improvements would be difficult to achieve. We consider this explanation unlikely, despite the substantially lower than expected hospital mortality (MICO 26% vs. 44%, control 21% vs. 43%). Despite the high physician coverage, the proportion of patients who became hemodynamically stable within 6 hrs and remained stable was low (only 10% in both groups), and less than half of the patients reached stability within 24 hrs. This was clearly less than expected in our power calculations, and would have reduced the chance of finding any difference. The lower than expected statistical power is probably not relevant, because not even a numeric trend in favor of MICO was seen for any relevant outcome. More importantly, the low rate of reaching stability suggests that the care process could have been improved. We consider that our results provide another example of the difficulties in changing clinical practice. In the future, combining such technologies with care protocols should be tested.
Patients in the control group were more likely to achieve hemodynamic stability at 24 hrs than patients in the MICO group. Despite lack of differences in achieving stability at six hours and in-hospital mortality, the possibility that stroke volume and cardiac output data delayed interventions should be considered. The similarity of the treatments, including the marginally higher use of colloids after six hours in the MICO group, speaks against this. The more frequent use of vasodilators in the control group is also unlikely to explain the difference at 24 hrs due to the small number of patients with vasodilators. Also, there were no differences between the groups in the frequency of each of the hemodynamic instability criteria in patients still in the ICU at 24 hrs (see Additional file 1/Tables 3-7). Subtle differences in the case mix are more likely to explain this result, especially the substantially higher number of patients in the MICO group who died early after discontinuation of treatment due to poor prognosis of the underlying disease. Most importantly, these early deaths in the MICO group markedly increased the proportion of patients unstable at 24 hrs. In addition, patients in the MICO group tended to have more instability criteria at baseline (P = .06), and more MICO patients had at least three instability criteria, suggesting more severe illness at baseline.
Our study has additional limitations. Results obtained with a specific device for stroke volume and cardiac output monitoring should not be generalized. The specific MICO technology used in the present study has been associated with problems of accuracy, especially in high cardiac output states [21, 37], and newer software versions have been developed to address this [37, 38]. Our results emphasize the need to evaluate these technologies - especially their impact on the process of care - before any large-scale outcome studies are attempted. The study centers had very high physician coverage, which may be rather exceptional. It is conceivable that the effect on process of care may be highly dependent on staff availability and presence.
In a heterogeneous population of hemodynamically unstable critically ill patients, early, non-invasive continuous cardiac output monitoring did not shorten the time to reach hemodynamic stability, produce any outcome benefit, or reduce the amount of resources used during the ICU stay as compared to standard treatment. The similarity of treatments received in both groups suggests that the availability of cardiac output data did not change the care process. Our results do not exclude the possibility that this device, when combined with a specific care protocol or used in other circumstances or with other non-invasive continuous cardiac output monitoring technologies, could have an impact on relevant outcomes. Future trials should test whether non-invasive cardiac output monitoring combined with a treatment protocol can shorten the time to reach hemodynamic stability.
Key messages
Only a minority of patients (22% in the MICO group and 28% in usual care) could be stabilized in the first six hours in the ICU.
MICO did not facilitate hemodynamic stabilization during the first 24 hrs of intensive care.
Additional monitoring with MICO per se had no effect on the care process (additional monitoring, fluid and vasoactive therapy).
MICO should be tested in combination with treatment protocols to enhance early hemodynamic stabilization in the intensive care environment.
Acute Physiology and Chronic Health Evaluation
minimally invasive cardiac output
simplified acute physiology score
sequential organ failure assessment
therapeutic intervention scoring system.
The study was sponsored by Edwards Lifesciences. Editing assistance was provided by Jeannie Wurz, BA, a medical editor employed by the Department of Intensive Care Medicine at the Bern University Hospital.
The protocol was finalized by the authors and the sponsor. The study was conducted by the authors. The data were collected by the authors, and the data collection and study conduct were monitored by the sponsor. The data were managed by the sponsor. The final database used for analysis was created by the authors (JT and SMJ) based on the full set of original data and copies of the original case report forms. The sponsor had no influence on data analysis, interpretation, or manuscript preparation. The authors provided a copy of the manuscript for comments to the sponsor before submission; the sponsor had no role in the approval of the final version of the manuscript.
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- Richard C, Warszawski J, Anguel N, Deye N, Combes A, Barnoud D, Boulain T, Lefort Y, Fartoukh M, Baud F, Boyer A, Brochard L, Teboul JL, French Pulmonary Artery Catheter Study Group: Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2003, 290: 2713-2720. 10.1001/jama.290.20.2713View ArticlePubMedGoogle Scholar
- Ivanov R, Allen J, Calvin JE: The incidence of major morbidity in critically ill patients managed with pulmonary artery catheters: a meta-analysis. Crit Care Med 2000, 28: 615-619. 10.1097/00003246-200003000-00002View ArticlePubMedGoogle Scholar
- Chittock DR, Dhingra VK, Ronco JJ, Russell JA, Forrest DM, Tweeddale M, Fenwick JC: Severity of illness and risk of death associated with pulmonary artery catheter use. Crit Care Med 2004, 32: 911-915. 10.1097/01.CCM.0000119423.38610.65View ArticlePubMedGoogle Scholar
- Afessa B, Spencer S, Khan W, LaGatta M, Bridges L, Freire AX: Association of pulmonary artery catheter use with in-hospital mortality. Crit Care Med 2001, 29: 1145-1148. 10.1097/00003246-200106000-00010View ArticlePubMedGoogle Scholar
- Dünser MW, Ruokonen E, Pettilä V, Ulmer H, Torgersen C, Schmittinger CA, Jakob S, Takala J: Association of arterial blood pressure and vasopressor load with septic shock mortality: a post hoc analysis of a multicenter trial. Crit Care 2009, 13: R181. 10.1186/cc8167PubMed CentralView ArticlePubMedGoogle Scholar
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- Mayr VD, Dünser MW, Greil V, Jochberger S, Luckner G, Ulmer H, Friesenecker BE, Takala J, Hasibeder WR: Causes of death and determinants of outcome in critically ill patients. Crit Care 2006, 10: R154. 10.1186/cc5086PubMed CentralView ArticlePubMedGoogle Scholar
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When Rally Monkeys fly: Angels are baseball's hottest team going into All-Star break
All-Star Break 2013
All-Star Break 2014
1 1/2
; W-L ; Pct. ; GB
All-Star break 2013; 44-49; .473; 11
All-Star break 2014; 57-37; .606 ; 1 1/2
Is it too soon to be hopeful, to wish – maybe even dream – about the Angels making it in the 2014 World Series?
"Anybody who's a true Angels fan is happy right now and not worried about jinxing anything," said an ebullient Corey Wylde, 57, of Fullerton, who has been true to the Halos since witnessing the club's home opener in 1961.
We're at the All-Star break for major league baseball, a gut-checkpoint for players and fans, and the Angels are expectedly (or surprisingly, depending on whom you ask) sitting pretty.
The high-payroll, high-profile squad that has broken hearts and the bank the past four seasons has morphed into baseball's hottest team. The hitting is strong, the pitching is strong. Manager Mike Scioscia even looks a little smarter this year than in the past couple.
At 57-37 – a whopping 20 games over .500 – they're within one solid tobacco spit of catching the stinking dog Oakland A's (59-36) in the AL West.
If the season ended today, the Angels would own the AL's top wildcard spot.
If it all sounds familiar, it should.
In 2002, a gritty, rag-tag collection of Angels reached the World Series as a Wild Card. And they too had to overcome a Bay Area opponent – the San Francisco Giants and their human pimple of a superstar, Barry Bonds. That Angels team got hot in June and stayed that way until they cooled off under some October champagne.
But today's Angels, on paper at least, are anti-rag tag; a glamour team with a payroll of $158 million, the sixth most bloated in baseball. And until about six weeks ago, that money seemed less-than-well spent.
Eye-rolling/head-scratching contracts of $246 million to three-time NL MVP slugger Albert Pujols in 2012, and $125 million to Josh Hamilton in 2013, did little more than whet fans' appetites.
The emergence of Mike Trout (2012 AL Rookie of the Year; hero to Internet statheads; probably the best player in baseball) took away some of the sting. But only some.
It was so bad that going into this season that Angels fans were already prepping for the worst.
"There weren't any expectations early this season after what happen the last three," said Donna Rodriguez, 36, of Huntington Beach.
Maybe playing without the pressure of a Steinway of expectations on their shoulders is what has allowed the Angels to just play baseball?
Scioscia frequently talks about playing loose and having fun, which is what Trout – the smiling, hand-slapping, Little Leaguer-in-The-Show – does.
It's spreading. These Angels are playing contract-free baseball; as if Pujols, Hamilton and even Trout trying aren't trying to live up to all the digits on their paychecks. The stars have become the Boys of Summer, hustling with the same hunger of the role players and clutch contributors, Kole Calhoun, Collin Cowgill and Grant Green.
The loose Angels are steamrolling opponents, going 26-9 since June 6, a major league best. They've won 19 of their past 23 games.
They're coming off their first-ever four-game sweep of Texas with Sunday's 10-7 victory on sauna-like 99-degree afternoon.
These Angels are looking as good on the field as they've looked General Manager Jerry Dipoto's blueprints.
That's after 94 games. The season is 162, plus some extras that are now expected. Now that they've found their mojo, can they keep it?
We can only dream.
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1217 Fawcett,White Oak PA, 15131
4 beds , 2 Full/1 Half baths
Status: Contingent
Berkshire Hathaway HomeServices The Preferred Realty
(800) 860-7653
Last Updated: 2/23/2017 1:50 AM
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Dishwasher, Gas Range/cooktop, Refrigerator, Washer/dryer, Window Treatments
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Exterior / Lot Features
1 Parking Spaces, Garage
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Current market conditions for 1217 Fawcett
Active Market Trends
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Median list price$109,900
Days on market125
Properties for sale39
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Median sold price$96,450
Sales to list price9,607.0%
Properties sold28
Median sq ft price$-1
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White Oak Real Estate
White Oak is located in Pennsylvania. White Oak, Pennsylvania 15131 has a population of 7,875.
The median household income in White Oak, Pennsylvania 15131 is $46,151. The median household income for the surrounding county is $50,664 compared to the national median of $53,046. The median age of people living in White Oak 15131 is 50.2 years.
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Lot 251: VINTAGE 22 PIECE SHELLEY BONE WHITE CHINA
Fall Seasonal Pre Halloween Antique Auction
by Auction Gallery of Boca Raton
October 23, 2016
Delray Beach, FL, USALive Auction
Past Lot
Looking for the realized and estimated price?
Description: Vintage SHELLEY Bone China England White 22 piece Cup Saucer Plate. Cup Measures approx 2 1/2 " tall saucer measures approx 4 1/2 " long. Will not ship can refer local shippers.
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Sourmilk - Mix
LA's DJ Sourmilk takes us on a tour of his city with a guest mix.
Y.G. - I'm Good
Priest "Soopafly" Brooks - Like It Or Not
Problem - Like What
Suga Free - Why U Bullshittin'
Nipsey Hussle - Hussle In The House
Tha Dogg Pound - New York, New York
Kendrick Lamar - Swimming Pools (Mano 93 Nostalgia Remix)
Daz Dillinger - Boyz In Tha Hood
Jay 305 - Youzza Flip
Featured in...
BBC Radio 1 Music Best Bits
Music highlights from the past week and beyond on BBC Radio 1.
Dance Music Highlights
Enjoy the latest mixes, DJ sets and interviews as broadcast on BBC Radio.


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Loving & Caring Home
goodbye yellow brick road download DTTN free file
== Search results for goodbye yellow brick road ==
Searched file: goodbye yellow brick road
*Filename: goodbye yellow brick road.zip
*Year: 2015
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*Uploaded: 02/23/2015 00:11:27
*Type: WinZip
*Supported OS: All
== Searches related to goodbye yellow brick road: ==
02/23/2015 00:11:27
Goodbye Yellow Brick Road is the seventh studio album by the English singer-songwriter Elton John. Released in 1973, it has come to be regarded as one of his …"Goodbye Yellow Brick Road" is a ballad performed by musician Elton John. Lyrics for the song were written by Bernie Taupin and the music composed by John for his ...So goodbye yellow brick road Where the dogs of society howl You can't plant me in your penthouse I'm going back to my plough Back to the howling old owl in the woods ...Goodbye Yellow Brick Road es el séptimo álbum de estudio del cantautor británico Elton John , editado en 1973 por DJM. Se considera su mejor trabajo, siendo ...7/24/2011 LOVE this song! yaaaay! over 100,000 views :) At least one of my videos made it this far.Rarely mentioned as one of the great double albums, Goodbye Yellow Brick Road had to settle for ending up in a few million record collections. So sprawling that it ...11/30/2006 The first Leg of the 1976 "Louder Than Concorde(but not quite as pretty)" Tour took Elton and his band through the UK and this was the second night at Earl ...A comparison to the domestic release leaves no doubt in my mind this is the superior version. I can hear many more subtle sounds, the highs are not shrill, the bass ...Find album reviews, stream songs, credits and award information for Goodbye Yellow Brick Road - Elton John on AllMusic - 1973 - It was designed to be a blockbuster ...Amazon.com: Elton John: Goodbye Yellow Brick Road (40th Anniversary Super Deluxe Edition): Music
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This 2004 Dodge Ram 3500 is equipped with chrome wheels| DVD player| towing preparation package| and so much more. Dont look away! This won''t be here long! Did I mention it has a clean CARFAX?!!! What are you waiting for? Come enjoy the friendly atmosphere at Killeen Auto Broker today!
Call 254-526-4889 for more information.
Posted in truck on Friday, October 16, 2015 7:00 am.
Listing ID: caf98943-39db-5987-b215-7767b7955488


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|Home > Adriannah
♀ Adriannah
What does Adriannah mean?
Adriannah [adri-an-nah] as a girls' name has its root in Latin, and the meaning of the name Adriannah is "from Hadria". Adriannah is an alternate form of Adrienne (Latin): French feminine variant of Adrian.
Adriannah has 8 variants: Adreanna, Adriana, Adrianah, Adrianna, Adriena, Adrienah, Adrienna and Adrina.
4 more alternative forms via Adrienne: Adriah, Adrian▼, Adriane and Adrianne▼.Creative forms:
(male) Middle name pairings:
Adriannah Mercy (A.M.), ..
How popular is Adriannah?
Adriannah is an unusual first name for females. Adriannah is an equally unusual surname for both adults and children. (2000 U.S. Census)
Which version is better?with its source form and related girl names. Adriana (#186 last year), Adrianna (#292), Adrienne (#848), Adrianne, Adriane, Adrian and Adreanna are the prominent variation forms of Adriannah (outside Top 2000) ranked in the Top 2000. Usage of these relations of Adriannah was common among parents 9 years ago (average #1146) and is somewhat lower today (#1332, down 41%), with forms such as Adrienne becoming somewhat outmoded. (2015 Birth Statistics)
Similar Names
Adriannah is pronounced similarly to Audreanna, Audriana and Audrianna. Other suggested similar names are Abriana, Abrianna, Adanna, Adinah, Adrien, Adriene, Alannah▲, Alianna▲, Andreanna, Andriana, Andrianna, Andrianne, Ariadna, Ariana▲, Arianna▲, Arianne, Arionna, Arriana, Aryanna▲, Aubrianna▲, Audreana, Audrina, Auriana, Avianna▲, Aydrian, Aydrienne, Brianna▼, Briannah, Darianna, Diannah, Dorianna, Gerianna, Hadrianna, Karianna, Kerianna, Liannah, Marianna▲ and Orianna. These names tend to be more commonly used than Adriannah.See names in meaning and etymology.


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General Manager, Hotel Salary
The average salary for a General Manager, Hotel is $53,409 per year. A skill in Budget Management is associated with high pay for this job. Experience has a moderate effect on income for this job.
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Job Description for General Manager, Hotel
A hotel general manager usually has the responsibility of overseeing the entire workings of a given hotel. Keeping finances in order, planning for events within the hotel, and budgeting for new renovations to the building are all within the realm of a hotel general manager's duties. It is normally the hotel general manager's job to ensure that all employees at the hotel are performing their work in a satisfactory manner and are making the hotel guests feel welcome and pleased. If any hotel staff perform their work poorly, it is the hotel general manager's duty to terminate them.Read More...
Hiring new employees is also within the realm of a hotel general manager's duties as well. Ensuring that security measures are place to keep guests and employees safe at the hotel should be of utmost importance to a hotel general manager. According, budgeting for a security system and surveillance is normally on the to-do list of a hotel general manager. Maximizing profits is extremely important for the success of the hotel, and it is generally within the hotel general manager's list of duties to do so. Whether it be offering specials on rooms or discounts for certain times of the yea, it is the hotel general manager's duty to ensure the hotel stays afloat financially.
Hotel general managers normally do not need a specific degree, though having a degree in business management or hospitality is a huge plus. As a management position, years of experience is also usually required.
General Manager, Hotel Tasks
- Oversee all aspects of hotel operations.
- Resolve guest and employee concerns.
- Maintain accountability for each department.
- Develop an operational budget and monitor cost controls.
- Complete daily audits and monthly paperwork.
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Are you looking for Fish Farms? Hotfrog showcases more than 60 popular businesses related to Fish Farms! To find more business related to Fish Farms, use the left navigation menu.
Bobs Farm, NSW
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Revesby, NSW
S ince 1888, Haverford's have been supplying products for both commercial and recreational applications. The family owned and operated company now supply a large range of netting, rope, twine and tackle used for: Fishi…
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Pipers Creek Hatchery (also known as A & D Hambly Fish Hatchery) is located near Kundabung on the Pacific Hwy, 26 km North of Port Macquarie and 13 km South of Kempsey in NSW Our fish are bred and raised on our family ow…
Jamberoo, NSW
Jamberoo Aquaculture is a freshwater fish farm, located in Jamberoo, slightly west of Kiama, on the south coast of NSW, Australia.
We currently grow Silver Perch, Golden Perch and Blue Claw Yabbies that are for sale f…
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Dardanup, WA
Ferguson Springs produces quality Silver Perch and Trout fingerlings for aquaponics systems and farm dams. Ferguson Springs also offer a delivery service and will deliver fish to the Perth metro area and the South Wes…
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Marine and frehwater fish hatchery- Supplying high quality fingerlings for commercial farmers, farm dam owners and aquaponics enthusiasts- Silver Perch, Australian Bass, Estuary Perch, Golden Perch, Mulloway, Yellowfin B…
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Aquascene is owned and managed by local Darwin residents who have made several improvements to the facility, such as the expansion of the kiosk and viewing areas
Clifton Beach, TAS
We are the largest shellfish seed producing company in Australia, and Australia's preferred seed supplier. Producing Pacific Oyster seed since 1979, Shellfish Culture has always been a key supporter of the shellfish …
Aquaculture Equipment & Supplies
Geraldton, WA
We sell bulk Silver Perch from 800g - 1kg & fingerlings. Also you can go fishing, have a BBQ or picnic, catch yabbies or marron. Suitable for Birthday parties, Xmas Office parties or just a family outing
Heidelberg Heights, VIC
We specialise in marine fish, corals and invertebrates, including full tank kits. We also have a great supply of coldwater and tropical livestock. We stock a complete range of quality foods, additives and accessories. …
Wangaratta, VIC
Australian Aquaculture Products, based in Victoria, Australia, and specialising in farmed Murray Cod and cultured eels. Includes Chinese and Japanese language pages.
Aquaculture Products
Alexandria, NSW
Infinity Environmental provides innovative, environmentally friendly technology solutions for water purification, oxygenation and water treatment
Nelson Bay, NSW
Cookabarra Restaurant and Function Centre Bobs Farm Nelson Bay Port Stephens. Lots of fun and great food
Port Lincoln Holiday Apartment Accommodation
Aquaculture peek industry body representing land based aquaculture in Australia since 1994
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Devonport, TAS
Gold Rush Motor Inn - are situated in the heart of Queenstown, on the West Coast of Tasmania, Australia. With one and two bedroom second storey apartments with views over the riverside park and across the river to the ea…
Karuah, NSW
RBM Aquaculture has been leading the industry for over 20 years as aquaculture consultants and equipment suppliers. RBM Aquaculture offers a full farm design and licensing service, designing and developing aquaculture f…
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Port Lincoln, SA
Fully self contained luxury apartment located on the entrance to the Lincoln Cove Marina. Sleeps up to 9 persons. Spacious open plan living with spectacular views of Porter Bay and Boston Island. Luxurious spa bath, 3…
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Strahan Bungalows, quality self-contained two bedroom accommodation in Strahan, West Coast Tasmania
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Set on a One Acre Water Garden, with over 100 ponds displaying the best in Water Lilies, Koi and Goldfish . We stock everything you need to construct and filter a outdoor pond at this best prices in Perth. Water Li…
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Silverwater Native Fish has been producing Australian native fish species since 1995. We sell fish for farm dams. The species we sell are Silver Perch, Murray Cod and Golden Perch. We have freight arrangements in place t…
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Fish Farm
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This villa is well appointed in a beautiful tropical garden in a quiet and
From $350 / night
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Description from the manager
Description from the manager
Bedrooms: 4/
Bathrooms: 5/
Sleeps: 8/
Type: Villa
Book this 4 bedroom, 5 bathroom villa in Cabarete today! A total of 8 people can sleep here comfortably.
Guests can enjoy a pool, parking space, and internet access among other amenities offered by this rental.
Travelers are sharing their opinions on this property. It has an overall rating of 5/5 thanks to an average of 2 reviews.
The owner responds to 25% of inquiries, which is lower than average, and last updated the property's calendar today.
About the manager
About the manager
Residencial Casa Linda
Residencial Casa Linda
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Overall rating:
4.6 / 5.0
Proximity to TripAdvisor's Top Cabarete Attractions
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Definitions for calming
This page provides all possible meanings and translations of the word calming
Princeton's WordNet
appeasement, calming(noun)
the act of appeasing (as by acceding to the demands of)
Webster Dictionary
of Calm
Chaldean Numerology
The numerical value of calming in Chaldean Numerology is: 2
Pythagorean Numerology
The numerical value of calming in Pythagorean Numerology is: 5
Sample Sentences & Example Usage
It will have an immediate calming and cooling effect.
The markets were expecting calming words from the Fed.
The saliva you secrete when chewing gum really has a calming effect on acid reflux.
In the midst of the storm, your life boat appears. A psalm, a hymn, a word... calming the fiercest winds of the soul.
I've learned a lot from Amelie over the past two years, she's been a calming influence in the team and we'll miss having her around.
Images & Illustrations of calming
Translations for calming
From our Multilingual Translation Dictionary
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Ageing in Asia: Asia's Position in the New Global DemographyBy: Roger Goodman (editor), Sarah Harper (editor)Hardback
More than 4 weeks availability
DescriptionThe volume takes four key themes related to ageing - the experience of old age; intergenerational relations; economics of and social policy for ageing; longevity and the culture of ageing - and examines how these issues are emerging in different regions of Asia, specifically, the former Soviet Union, South Asia, China, Japan and South-East Asia. In placing these Asian cases studies in the broader context of debates about, and policies on, ageing more generally, it brings them into the mainstream of comparative research on ageing from which they have been too often excluded. As the studies show, the relationship between ageing and poverty is a complex one and often reflects policy towards the aged rather than that the aged themselves are unproductive and dependent. Ageing, moreover, can no longer be considered as simply a national question; we also need to consider the implications of its global dimension in terms of issues such as human rights and quality of life.
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About AuthorRoger Goodman is Nissan Professor of Modern Japanese Studies at the University of Oxford Sarah Harper is Director of the Oxford Institute of Ageing
Contents1. Asia's Position in the New Global Demography 2. Economic Reform and Intergenerational Relationships in China 3. 'No Wasting' and 'Empty Nesters': 'Old Age' in Beijing 4. Political and Economic Influences on the Health and Welfare of the Elderly in the USSR and Russia: 1955-2005 5. The Economic Marginalisation of Post-Soviet Russia's Elderly Population and the Failure of State Ageing Policy: A Case Study of Magadan City 6. Experiences in Old Age: A South Indian Example of How Functional Age is Socially Structured 7. The Inter-Generational Contract in the Changing Asian Family
Product Details
- publication date: 07/08/2007
- Format: Hardback
- Number Of Pages: 128
- weight: 385
Delivery Information
- Saver Delivery: Yes
- 1st Class Delivery: Yes
- Courier Delivery: Yes
- Store Delivery: Yes


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Alibaba Group's CEO Speaks At 2009 APEC SME Summit; Watch The Video
Posted: September 14th,2009 | By: doug.herman
The Asia-Pacific Economic Cooperation's Small and Medium Enterprises summit (APEC SME Summit) was held in Hangzhou, ChinaExpo this past weekend. The organization is the premier forum for facilitating economic growth, cooperation, trade and investment in the Asia-Pacific region and included speakers this year such as: President Bill Clinton, Starbucks CEO Howard Schultz, Lenovo Chairman Liu Chuanzhi, and Alibaba Founder and CEO Jack Ma.
According to a press release, e-business visionary Jack Ma, who 10 years ago founded Alibaba Group in his Hangzhou apartment along with 17 associates, will reveal a vision of the coming virtual world of e-commerce where both buyers and sellers benefit from lower prices, higher profit margins and infinite tailor-made choices thanks to mass customization.
Check out some video highlights of Jack Ma from APEC SME 2009:
"Internet-based technologies are going to revolutionize the way business is done and shift forever the power dynamics between customers and businesses, and entrepreneurial small and medium companies around the world who take advantage of these new developments and emerging trends will be the ones who come out ahead.
Over the next decade, technology will permit the creation of a virtual business world populated by real entrepreneurs who choose to operate under principles of simplicity, fairness, transparency and affordability, and who will offer tailor-made products and the same superior level of service to all customers, regardless of their size or status.
A significant portion of the world`s consumers will rely on these small Internet entrepreneurs selling goods made only for online stores for their everyday goods and services. As a result, these `Netrepreneurs,` as we call them, will play a central role in global manufacturing, job creation and social responsibility, and will also be able to better compete effectively with major corporations in terms of satisfying customers` needs better and making superior returns as a result."
– Jack Ma, Founder & CEO, Alibaba Group.


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Free shipping on all orders over $75.00!
Welcome to Pink Coconut Boutique. If you have an existing account please enter your email address and password below to sign-in. If you do not have an existing account please click the "Create an Account" button to register. If you have forgotten your password please enter your email in the "Reset Password" text box and click "Reset Password"
Password format should be Max 20 characters and Min 6 Characters with Alpha Numeric Characters(atleast 1 number and 1 uppercase)


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Regional Europe United Kingdom England West Sussex Chichester Health
Related categories 1
Sites 12
Chichester Anaesthetic Group
Providers of full anaesthetic services in West Sussex, based at St Richard's Hospital. Includes profile, member list, details of services and payment, and contact form.
Chichester Orthodontic Clinic
Private dental treatment for adults and children. Includes profile, FAQs, information on braces, treatments, emergencies and costs, and contact details.
City Denture Clinic
Profile, services and product range.
Gillie Horne
This counsellor describes her services and includes prices.
Healthwise Chiropractic
Offers chiropractic consultation and treatment, as well as chiropody and alternative therapies. Includes profile, information on treatments and conditions treated, team profiles, opening times and contact details.
Life Centre
Provides counselling and supports for survivors of rape and sexual abuse; information about their services, resources, and contact details.
The Parklands Surgery
Six partner training practice on the west side of Chichester offering general practice health care and clinics. Includes profile, news, patient information, details of clinics, services, staff, and training, and health advice.
The Sanctum
Day spa offering a range of beauty treatments and complementary therapies. Profile, available treatments and news with beauty tips and special offers.
The South Downs School of Homoeopathy
Offers practitioner training. Includes profile, prospectus, and course information.
St Wilfrid's Hospice
Offers specialist palliative care to patients at home, in hospital and in the Hospice. Information about services, the hospice movement, recruitment and fundraising.
Veronica Pettifer
Offers mobile reflexology and champissage. Profile, services and area covered.
West Sussex Fire Brigade
Functions are to save life and property, to provide safety and prevention advice and to provide an emergency rescue service. Provides details of staffing and appliances, brigade area map, photo galleries, and news.
Last update:March 10, 2016 at 6:05:06 UTC
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At any time, hundreds of species of bacteria — both potentially harmful and potentially helpful — inhabit the human digestive tract.
Babka is a Polish Easter bread, slightly sweet, and made with yeast and raisins. It may have sweet cheese incorporated into the dough. This is a special Easter bread, not to be confused with the word Babcia, (pronounced bop-cha), which is the Polish word for grandmother.
"I had my first kiss on your street," said the salesman who just sold my younger son, Ted, his first new car. "We were under a big, old tree, and I can't even remember the girl's name." Turns out that our salesman grew up in our neighborhood and had gone to the same grade school as my sons. Our sales guy chuckled as he punched the calculator to give us the drive-out price. I chuckled as I wondered whether it was that kiss or the commission that was bringing this man such obvious joy.
This week, in Think Beer, Drink Beer, columnist Tim Patton looks at some of the harder to find - but surprisingly worth the effort - sour and wild beers
This week's Think Beer…Drink Beer looks at using beers as an ingredient in baking.


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Tracking ad industry awards through 2012, the Gunn Report singles out Omnicom's OMD Worldwide as the top creative agency for the year. By Gunn's measure, WPP's Mindshare was second most creative, and Publicis Groupe's Starcom was third. The Holding Company of the Year honor went to WPP's GroupM, and Coca-Cola was selected as Advertiser of the Year.
Full Story:MediaPost Communications


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Eva Wedding Guide
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With Instructables you can share what you make with the world, and tap into an ever-growing community of creative experts.
A simple pencil bow that has the following supplies *two pencils *1 rubberband
You will need to get these suppliesa rubberbandTwo pencilsYou will need to take the metal and eraser part off of one of the pencils and put a notch ...
Next you need to put the rubber band on anyway but it has to work like a bow. It is all about using your head.
It should be something like this.
Please look at Naruto 777's throwing star it works great. His username should have a picture like this.
I have got comments and I forgot to add how to make the notch. You simply take off the metal part near the eraser and get scissors and ...
pen crossbowby bobtet
Easy to make "Bic" pen bow and arrowby construct5
Bic Crossbowby jaknife1102
Join 2 million + to receive instant DIY inspiration in your inbox.
© 2016 Autodesk, Inc.


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Semi Sweet Orange Bars
|All purpose flour
|1 1⁄2 Cup (24 tbs)
|Baking powder
|1 1⁄2 Teaspoon
|1⁄2 Teaspoon
|Vegetable shortening
|1⁄2 Cup (8 tbs)
|Firmly packed brown sugar
|2⁄3 Cup (10.67 tbs)
|Grated orange rind
|2 Tablespoon
|Orange juice
|3⁄4 Cup (12 tbs)
|2 Teaspoon
|Semi-sweet chocolate pieces
|6 Ounce (1 Package)
|10x confectioners' powdered sugar
|1 Cup (16 tbs)
|Orange juice
|2 Tablespoon
1. Sift flour, baking powder and salt onto wax paper.
2. Beat Shortening and brown sugar until fluffy in a large bowl with electric mixer at medium speed; beat in egg, 1 tablespoon of the orange rind, 3/4 cup orange juice and vanilla until creamy and smooth.
3. Stir in flour mixture with a wooden spoon until smooth; stir in chocolate pieces until well blended. Spread into a greased and floured 13x9x2-inch baking pan.
4. Bake in moderate oven (375°) 30 minutes, or until golden brown. Cool in pan on wire rack for 10 minutes.
5. While cake cools, combine 10X sugar, remaining 1 tablespoon orange rind and 2 tablespoons orange juice in a small bowl until well blended. Drizzle over cake. Cool completely in pan. Cut into 48 bars.
Rate It
Nutrition Rank
Nutrition Facts
Serving size: Complete recipe
Calories 4137 Calories from Fat 1390
% Daily Value*
Total Fat 158 g242.7%
Saturated Fat 57.5 g287.5%
Trans Fat 13.5 g
Cholesterol 211.5 mg70.5%
Sodium 1684.9 mg70.2%
Total Carbohydrates 659 g219.6%
Dietary Fiber 8.7 g34.8%
Sugars 481.3 g
Protein 28 g55.6%
Vitamin A 16% Vitamin C 248%
Calcium 80.7% Iron 68.3%
*Based on a 2000 Calorie diet


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A warm up to the main Slopestyle competition, Teva Best Trick was an entertaining affair with riders free from the normal pressures of competition.
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Rock Shox Pump Track Challenge, FRI 12 July, 20:45 PM CET
Slopestyle presented by IXS, SAT 13 July, 16:30 PM CET


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Microsoft Brings SQL Server to Linux
[March 15, 2016] Microsoft announced that it will bring SQL Server to Linux, enabling a consistent data platform across Windows Server and Linux. For now, the core relational database capabilities are in preview (starting immediately) with availability coming mid-2017. "SQL Server on Linux will provide customers with even more flexibility in their data solution," said Scott Guthrie, Executive […]
The Linux Foundation Announces Partnership with Linux Academy on Training
[February 2, 2016] The Linux Foundation recently announced a new partnership with Linux Academy on discounted Linux training for SysAdmins. The Foundation says it negotiated a special rate for Sysadmins around the world ($75 for 3 months). "Subscription-based training opportunities offer SysAdmins another way to access Linux and open source training materials," the Foundation said. "A quarterly subscription […]
Update Apps and Programs on Ubuntu Linux
[December 11, 2015] I'm running Ubuntu 15.0 Linux on my home file server and so far it's going great, but I can't figure out how to force an app update. What's the easiest way to update the programs on my Ubuntu box? I love that I'm getting Linux questions, as I'm a lifelong fan of Linux and Unix, […]
Microsoft Partners with Red Hat
[November 11, 2015] Microsoft announced on Wednesday that it has entered a partnership with Red Hat to include Red Hat solutions on Microsoft Azure. Red Hat Enterprise Linux is to be offered as the preferred choice for enterprise Linux workloads. The two companies are also working together to address enterprise, ISV and developer needs for building, deploying, and […]
The Linux Foundation Has Declared There Will Be A New Real-Time Linux Collaborative Project
[October 7, 2015] The Linux Foundation announced the new Real-Time Linux (RTL) Collaborative Project, which sees Altera, ARM, Google, Intel, IBM, National Instruments, OSADL, Texas Instruments, and others working together to work on technologies for industries including robotics, telecom, manufacturing, aviation, and medical, among others.
Microsoft's Developer Announcements From The Build Conference
[May 8, 2015] It was a big day in Microsoftland, where the company announced new Windows 10 features and unveiled a set of SDKs to help developers bring their code for the web, .NET, Win32, Android and iOS to Windows 10. Additionally, the company announced new Microsoft Azure data services for intelligent apps, Visual Studio and .NET tools […]
Getting Started with JARVYS Backups
[March 4, 2015] I previously interviewed the creators of JARVYS, a Linux backup solution that makes backups and restores as easy as a single command. I wanted to post a follow-up to show just how easy it is to setup and use on a Linux system. I'll be using a virtual server running Debian 7 as my test […]
JARVYS, Set It and Forget It Linux Backups
[February 4, 2015] Wouldn't it be great if there was a cloud based file backup system that put Linux FIRST? One that made it so we didn't have to use FUSE? One that didn't put out a Windows client first and the Linux client was an afterthought? One that you could get installed and configured quickly and easily […]
Red Hat Announces Enterprise Linux for SAP HANA Platform is Now Available
[December 17, 2014] Red Hat announced that Red Hat Enterprise Linux for the SAP HANA platform is now available to be deployed across the open hybrid cloud. This of course includes via those public cloud providers certified by Red Hat.
Netrunner – The Best Distro You've Barely Heard Of
[September 10, 2014] In my quest to find a professional and polished distribution of Linux that used KDE as the default desktop…I tried out quite a few flavors: Kubuntu, Salix, Manjaro, PCLinuxOS and evenOpenSuse. All done in the past few weeks.
Manjaro KDE Notes
[July 30, 2014] This week I decided to step up from Window Manager Manjaro Openbox and give the latest version of the Desktop Environment in KDE try. I'm one of those odd people who love minimalist desktops like openbox, xmonad, and i3 but still have a soft spot in their hearts for KDE.
OpenStack Support Coming To Oracle Linux and VM
[May 28, 2014] Oracle announced OpenStack support for Oracle Linux and Oracle VM. The company introduced a preview of an OpenStack distribution that allows users of either to work with the open source cloud software. Oracle says it provides customers with more choices and interoperability while taking advantage of "efficiency, performance, scalability, and security" of its offerings. At […]
Canonical Finally Has Hardware Partners For Ubuntu Touch
[March 5, 2014] Last year, Canonical unveiled its plan to upend the mobile industry with Ubuntu Touch. The mobile friendly version of Linux already runs on a wide variety of Android devices, but the company wants to start producing Ubuntu Touch hardware as well. It tried its hand at crowdfunding one such device last year that ended in […]
New Linux 3.13 Kernel Released
[January 22, 2014] The latest Linux kernel was officially released this week, bringing several new features with the start of the new year. Linux 3.13 can now be compiled and installed freely.
Google Compute Engine Now Available To All
[December 3, 2013] Last year, Google unveiled Compute Engine at Google I/O, apparently seeking to compete with Amazon Web Services and Microsoft Azure for the cloud computing needs of businesses.
Steam Dev Days Coming In January
[October 25, 2013] There's no denying that Valve is a major force in PC gaming. After all, the company singlehandedly revived the PC gaming market with Steam. Now it's entering the gaming hardware and operating system markets, and it wants developers along for the ride.
HostGator, Linux and The Dukes of Hazzard
[August 28, 2013] If you're old, like me…let's say, over 30 years old…you might remember the television show "The Dukes of Hazzard". Waylon Jennings, a popular country music singer during the late 70′s and early 80′s sang the theme song. The lyrics are:
Ubuntu Smartphone Needs $32 Million In Funding
[July 23, 2013] Ubuntu announced earlier this year that it was bringing its unique flavor of Linux to smartphones and tablets. At the time, it said that it was working with carriers to bring hardware to the market. Now it's taking its plea directly to its users with what may be the largest crowdfunding campaign ever.
Cumulus Linux Emerges After Three Years Of Development
[June 25, 2013] Cumulus Networks has now launched after operating in stealth mode for about three years, and revealed Cumulus Linux for datacenter networking. In fact, the company calls it "the first true, full-featured Linux operating system for datacenter networking".
Windows Replaced By Linux In The International Space Station
[May 10, 2013] Linux has become the operating system of choice for NASA's laptops when it comes to the International Space Station. The ISS has been using Windows XP, though the majority of its ground-based support systems on Earth are reportedly Linux-based.
Lightweight Command Line Downloading with Aria2
[March 13, 2013] Sometimes you just want a quick and easy way of downloading large files. If you're like me, you want this with as little of a memory footprint as possible. Aria2 gives me this ability. When downloading a torrent for a recent Linux release, I was able to do this with only 5MB of memory being […]
Could Linux Get Microsoft Office In 2014?
[February 18, 2013] After years of being ignored by major software vendors, Linux is starting to get the attention and respect it deserves. The open source OS has already nabbed a major partner in Valve as the company is working on bringing Steam over. Now Microsoft may be jumping on board by bringing its flagship productivity suite to […]
Comic Books, Linux and KDE 4
[February 6, 2013] Sometimes I read comic books. I would hope that some of you do as well. I collected the paper version of comic books when I was a kid (Mostly Superman and Spiderman) and I've graduated up to the digital version now. Comic books in digital format usually use the .cbz or .cbr file extension. To […]
Valve's Steam Box Has More Details Revealed
[January 18, 2013] Last week, CES 2013 opened with the news that the oft-rumored Steam box was real. The hardware is a mini-PC that will bring PC gaming to the living room. It's Valve's attempt at taking on the console market, and it just might work. Of course, we won't know for sure until we get more details […]
Valve To Enter Hardware Development Next Year
[December 12, 2012] There were a few rumors from earlier this year that Valve was building its own game console. It would be a big step for the company that made its fortune on its Steam digital distribution service. It was also exciting since nothing has really shaken up the console market since Microsoft entered into the equation in 2001 with the Xbox. At the time, however, Valve said its game console was just a rumor, but it appears that the rumor is finally graduating into a truth.


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Masterchef Recap: Doughnuts, or an Emergency Medical Procedure?
Hi Trashies!
Has it been a month already? Ep 4 is on us and it's time to consider what's happened so far. Apart from the fact haven't I lost a single damned pound in weight, we've seen a few of the mini's culled, favorites are being called (not literally I don't know her number) and there's a few wounded gazelles that are being are being outpaced by the herd. I'm looking at you Elise.
Courtney is showing a real all-around skill level that has so far been unstoppable – unlike her skills at being evil which are mediocre at best. Its the thought that counts Courtney, I'm sure you'll be a hated pariah that everyone calls 'bitch' soon if you keep up the practice.
We start up with the typical overly dramatic voice-over declaring that last week was 'all out culinary war'. I'm sorry I missed that episode and recapped the one where they made food for the soldiers instead. No one really argued with anyone. Malibu didn't really push his point about making beef, and I'm fairly certain he'dve been ignored anyway. Maybe there would have been more fuss on the other team about the woeful 'mac and what-the-hell-is-that?' but they won, so that tends to defuse the tension.
This episode we're promised a front runner failing (Courtney by the editing) and Ahran speaks!
I just wandered in last week to be honest. No one's said anything so far.
Get used to this, she speaks a lot this week.
Its a mystery box! Courtney mouths off, in secret this time so at least she's learning, and then a real surprise. The first appearance of the sinister blood-red 'memory' framing, of a picture of Little Gordy. Is he dead?
Little Gordon has fallen!
Fallen sick that is. He's fine, but he's out. That has to be a crappy way to get eliminated from anything, let alone a competition for $250000. Poor sod.
So its 18 cooks now, and that likely means they'll lose 2 before the next team challenge. Why they worry about having perfectly even teams is beyond me but they do. Perhaps Gordy is a little OCD.
There's something alive in the mystery box, and it's a net of live sea food, slowly dying on the bench. Its an unwelcome discovery for Elizabeth.
I can't believe my box has crabs.
Cheap shot. I'm not proud.
The more excitable mini's start squealing so it seems some of them haven't cooked with live seafood before. On the other hand, we see various shots of shrimps and crabs being dismembered so they have probably been taught how do this in one of the practice lessons they get in between episodes. I really can't believe they'd risk a disaster like happened once before, when someone just pulled the seafood apart and lobbed it in a pot without killing it first.
Tell little Jimmy I won't be coming home tonight …glurk
There's no 'remember to kill your food in a nice way' today though.
Is it just me or is Bastich phoning it in this week? He seems off his game somehow.
Francis B apparently works in a restaurant that is Southern, Low-country style with European influences. That's just word-soup to me, I'll be honest. He seems to know what he's going to do though.
Christian comes from Nawlin's and is going shrimp and grits. Could be anything from bland mush to most awesome thing ever, but he says the sauce is the main lynchpin of the dish. The grits hes putting cheddar in, with bell pepper and cream. Again it sounds like it could be great, depends how he does it.
Christian, either awesome or really bland. Or sort of ok.
Ahran gets some air time! Shes making a spicy asian seafood stew. Unfortunately she puts her foot firmly in her mouth within two seconds. Bastich asks her who the best cook is, she says Willie, and not Courtney as 'she gets favoritism'. She has it pointed out to her that this means she thinks the judges are playing favorites. It might be what a lot of the cooks are saying back in the dorms, as people often find it hard to admit someone they aren't fond of is better than someone they like, but it goes over like a lead balloon with Bastich.
You think those nude aerial dances have influenced my Judgement? How dare you!
I like her for walking into that and trying to wiggle out by saying she doesn't know why Courtney would get favoritism. Self-preservation kicking in, better late than never.
Courtney, Francis B, Ahran and Christian are flagged as doing well. Elise is shown making what look like giant fries – what the Brits call chips, which for seafood is more pubfood than restaurant so she needs to be doing them really well. Which on past experience I don't think is likely.


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The Gallery
The Gallery is the venue of choice for an exciting racing experience. The venue has plenty to offer – a spectacular view of the finishing line, a stylish horse racing-themed decor and an immersive digital experience.
Along with complimentary iPad rental service, customers can participate in Racing 101 hosted at the Racing Touch Zone, with Racing Specialist sharing racing knowledge and betting strategies. Serving bistro-style Mediterranean semi-buffet, there is a bar offering tempting cocktails and a selection of fine wine. Private rooms (for up to 16 people) are available for an exclusive venue to entertain guests.
For more details about happy wednesday events, please click here
- Location
- 3/F Grandstand, Happy Valley Racecourse
- Nearest Access
- Entrance G (through Lift 1)
- Opening Hours
- Happy Valley Night Race: 18:15–23:00
Happy Valley Day Race: 12:00–18:00
(1 hour prior to the first race until the end of the last race)
- Reservation Hotline
- 1817(24-hour booking service)
- Buffet Serving Time
- Happy Valley Night Race: 18:45 - 22:15 (last order for main course: 21:15)
Happy Valley Day Race: 12:00 - 16:00 (last order for main course: 14:45)
- Price
- Dress Code
- Causal, e.g. pants, jeans1, T-shirts, tracksuits, overalls and shoes for sports activities
- Unacceptable Attire2:
Shorts, tattered clothing, singlets, sandals, flip-flops and plastic footwear
1. Ankle-length pants and jeans are required
2. The Club reserves the right to refuse entry of those Members
and guests who do not meet the dress requirement
- Facilities
- Free iPad rental service is available at The Gallery. Limited stock and first-come first-served
- Remarks
- Broadcast commentary of the venue will be in Cantonese. Alternative languages are available for all private TVs
- SMS notification will be sent once the seat is confirmed
- Table selected at booking is tentative as the Club reserves the right of final decision to make table allocation based on the size of the groups
- For further enquiries of reservation or table arrangement, please call our hotline at 1817
- Should there be any disputes, the Club reserves the right of final decision
|Normal Race
|HK$410 up / per head
Private room for 8 pax HK$7,500 up
Private room for 16 pax HK$13,000 up
|* Major Race:
|HK$510 up / per head
Private room for 8 pax HK$8,300 up
Private room for 16 pax HK$14,600 up
Minimum charge applies to each dining table and private room.
* Major Race: LONGINES Hong Kong International Jockeys' Championship(7/12/2016)


text:
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text: The WoodTones DesktopThe How-To Geek7/03/09 9:00amFiled to: Featured DesktopDesktopsWindowsRainmeterCustomizationWallpaperSkinsThemesSystem Monitoring23EditPromoteShare to KinjaToggle Conversation toolsGo to permalink Reader karmat's desktop adds wood paneling to almost everything on the desktop, including a very nice Firefox configuration that combines a slick, dark skin with a wood panel persona. Advertisement The desktop is a combination of:Wallpaper - Abandon Otis by OtisBeeWindowBlind - GarageBanded by ^mrrsteObjectDock Icons - Parquet Iconset by speg84Cursor - Stargate SG1 by ArocheYahoo Widget - widescapeWeather by Robert WunschFirefox 3.5 Skin - Ruler DarkFirefox Persona - MWoods by roloz78Personas Extension for FirefoxSJOGRO Rocks Rainmeter skin by sjogroNoxxNotes Rainmeter skin by ~albinozzGreat job, karmat!This desktop not your style? Why waste time complaining? Instead, get started creating your own killer desktop with the easy-install Enigma 2.0 package and show the world what you can do. If you get stuck and need some help, join up with the Lifehacker Desktop Customization Google Group to collaborate on new ideas for desktop configurations. Once you've created your own beautifully tweaked (and hopefully productive) desktop, post it over in the Lifehacker Desktop Show and Tell Flickr Group complete with a description of the programs and tweaks you used (and preferably links as well!), and we just might feature it here. Advertisement WoodTones Desktop [Flickr]Reply23 repliesLeave a reply


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While Geffen Records assiduously over-milked their old album for new singles, Nirvana never managed the swift follow-up they had hoped for, but they did keep their mystique, and their balance, on a dizzying rumour-go-round. In December they released Incesticide, a motley retrospective selection - half brilliance, half formative raggedness - which offered fascinating hints as to where they might go next. All year, major record companies paid absurd amounts to anyone with long hair, cranked-up guitars and hesitant speech patterns, unaware that all the best 'Nirvana-style' bands had either, like old-stagers Sonic Youth, already been signed up, or, like newcomers Pavement, decided small was beautiful.
Old arguments about corporate buy-outs of rock 'n' roll rebellion were given a new perspective in the United States where the Time/Warner conglomerate publicly backed two of its artists - Ice-T, with his police-baiting thrash-metal anthem 'Cop Killer', and Madonna, with her picture book. This was also the year in which the Eighties became history at last, when nostalgia for Husker Du and The Human League raged as warmly as that for Abba and the Sex Pistols. And a couple of living rock legends made surprisingly interesting contributions: U2's determination to prove they had a sense of humour spurred them to scale spectacular new heights of self-importance, and REM pulled back from self-parody to make probably their finest album.
While America ruled the rock roost, and cornered the market in sassy eloquence via politicised rappers Arrested Development and Disposable Heroes of Hiphoprisy, Britain triumphed in bedroom dancefloor experimentation. The Orb took ambient house to number one in the album charts, but more interesting noises were made just outside the mainstream. Baby Ford, Ultramarine and The Future Sound of London all made richly compelling records. And, in a better year for rock than for pop, there were a couple of notable exceptions. Right Said Fred refused to be one-hit wonders, and The Shamen's ability to be both humourless and hilarious was little short of inspirational.
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