text:
An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12-month follow-up study
DOI: 10.1186/cc12745
© Griffiths et al.; licensee BioMed Central Ltd. 2013
Received: 23 July 2012
Accepted: 24 May 2013
Published: 28 May 2013
The socio-economic impact of critical illnesses on patients and their families in Europe has yet to be determined. The aim of this exploratory study was to estimate changes in family circumstances, social and economic stability, care requirements and access to health services for patients during their first 12 months after ICU discharge.
Multi-center questionnaire-based study of survivors of critical illness at 6 and 12 months after ICU discharge.
Data for 293 consenting patients who spent greater than 48 hours in one of 22 UK ICUs were obtained at 6 and 12 months post-ICU discharge. There was little evidence of a change in accommodation or relationship status between pre-admission and 12 months following discharge from an ICU. A negative impact on family income was reported by 33% of all patients at 6 months and 28% at 12 months. There was nearly a 50% reduction in the number of patients who reported employment as their sole source of income at 12 months (19% to 11%) compared with pre-admission. One quarter of patients reported themselves in need of care assistance at 6 months and 22% at 12 months. The majority of care was provided by family members (80% and 78%, respectively), for half of whom there was a negative impact on employment. Amongst all patients receiving care, 26% reported requiring greater than 50 hours a week. Following discharge, 79% of patients reported attending their primary care physician and 44% had seen a community nurse. Mobility problems nearly doubled between pre-admission and 6 months (32% to 64%). Furthermore, 73% reported moderate or severe pain at 12 months and 44% remained significantly anxious or depressed.
Survivors of critical illness in the UK face a negative impact on employment and commonly have a care requirement after discharge from hospital. This has a corresponding negative impact on family income. The majority of the care required is provided by family members. This effect was apparent by 6 months and had not materially improved by 12 months. This exploratory study has identified the potential for a significant socio-economic burden following critical illness.
Over 100,000 patients are admitted to intensive care units (ICUs) in the United Kingdom (UK) per year. Over the 5 years following an ICU admission there is an excess mortality for these patients compared to an age and sex matched population [1, 2]. In addition to excess mortality, there is now a substantial body of evidence to show that significant numbers of survivors of critical illness experience reduced cognitive function and longer-term physical and psychological impairments [3–6].
Up to two thirds of ICU survivors may experience significant problems with physical and psychological health as well as social functioning [7–10]. However, there is limited rigorous research into the social and economic impact that a period of critical illness imposes on both the patient and their immediate family and to date there have been limited attempts to estimate the magnitude of this issue. In 1994, Covinsky et al. demonstrated that 34% of seriously ill hospitalized patients required considerable care-giving assistance from a family member in the 12 months following hospital discharge [11]. In 20% of cases, a family member had to leave work and overall a third of families reported a loss of the major source of income. In 2002, Swoboda and colleagues reported the long-term effects on patients' families after a prolonged stay in a surgical ICU [12]. Almost 60% of responding families provided a moderate or large amount of care-giving between 1 and 9 months after hospital discharge. Just under half had to leave work after 1 month, and more than a third of families had lost savings after 1 year; families moved to a less expensive home, delayed educational plans, or delayed medical care for another family member [12]. A Canadian study, which consisted predominantly of previously healthy and relatively young patients (median age of 43), reported that only 49% had returned to work 1 year after discharge from and ICU, increasing to 73% at 5 years. The reported return to work was mostly driven by economic necessity and difficulties in obtaining state financial support [13]. In the UK, extensive experience of talking with survivors of critical illness and their families [14], suggests that the socio-economic consequences of critical illness similarly extends beyond the individual to impact upon the health and social care systems. Potentially the incomplete physical and non-physical recovery from a period of critical illness experienced by some has an impact on the resumption of independent living and employment; this situation, plus any consequential requirement for care, may jeopardize their wider family social and economic stability.
Thus, the aims of this exploratory study of a representative sample of UK survivors of adult, general intensive care treatment were to: (1) explore the use of a novel questionnaire set; (2) estimate changes in family circumstances and social and economic stability; (3) assess what additional assistance (general care with living and specific health care) patients believed they required and whether these requirements had been delivered and (4) place the findings in the context of the health-related quality of life (HR-QoL) during the year of follow-up.
Materials and methods
This study was conducted by members of the Intensive Care After Care Network [15], a grouping of health-care professionals with an interest in understanding and improving the long-term outlook for survivors of critical illness, centered around hospitals that provide specific ICU follow-up clinics.
This prospective cohort study recruited patients admitted to the ICUs of 22 UK hospitals (11 teaching hospitals and 11 district general hospitals) from 31 August 2008 until 28 February 2010. This multi-center study was approved by an appropriate multi-center research ethics committee (Ref 08/H0502/90). All patients that had received at least 48 hours of level 3 dependency care (critical care for multi-system organ failure) were eligible for inclusion [16]. Patients less than 16 years old, prisoners, those whose primary abode was outside the UK or those who did not consent were excluded. Written informed consent was obtained from patients in the interval between ICU discharge and discharge from the hospital (a minority of patients were also recruited at a routine outpatient visit to a post-ICU follow-up clinic). If a patient lacked capacity then a personal legal representative gave assent for a future written approach from the study office once capacity had been regained. Written consent was sought at 6 months following discharge; patients not responding were excluded from the study.
Study design
This was a self-completed questionnaire-based study (the study questionnaire booklet forms are presented in Additional file 1). In outline, the booklet comprised the EQ-5D [17], EuroQol Visual Analogue Scale (EQ-VAS) [17], Short Form 36 Version 2 (SF-36v2; licensed pro bono from QualityMetric Inc, Lincoln, RI, USA) [18] and a novel question set designed to determine changes in family circumstances, socio-economic stability and care requirements. There was no prohibition on family members or carers helping with survey completion. The questionnaire booklet was mailed to consenting patients at 6 and 12 months after ICU admission together with an accompanying letter. In the case of a non-response, a second questionnaire booklet was mailed. In the event of non-return the protocol allowed the study team to make one telephone call. Patients who expressed a wish not to take part, or those not responding after a telephone call, were excluded from further contact.
For those patients who had initially returned the questionnaire booklet at 6 months, and remained alive, but had failed to respond at 12 months, a protocol amendment was sought and approved by the research ethics committee to allow the patient's primary care physician to be contacted. Death was determined using the NHS Strategic Tracing Service (NSTS). Primary care physicians were contacted after two failed mailing attempts and no response to a home phone call (14-15 months post-ICU discharge). Each primary care physician was asked to clarify whether the patient had died, changed address or had been admitted into a long-term care facility.
Study materials
Patients were first asked to complete the EQ-5D (minus the visual analogue scale) relating to their health state prior to ICU admission. The questionnaire booklet then included a further EQ-5D, EQ-VAS, SF-36v2 and our novel socio-economic question set to be completed with respect to status at the time of receipt [19–21]. The EQ-VAS is a self-rated health status using a visual analogue scale graduated from 0 (the worst imaginable health state) to 100 (the best imaginable state) [17].
The SF-36 is a comprehensive, generic 36-item questionnaire that is used extensively in clinical practice to describe HR-QoL [18]. It has been demonstrated to be an acceptable and reliable tool for use in the ICU population and its use for quality of life assessment following critical illness has been recommended [22, 23]. The Physical Component Score (PCS) and Mental Component Score (MCS) were then calculated in the documented manner and standardized against the UK population using a previously validated computerized macro [20, 24].
The demographic, social and economic impact question set was developed in conjunction with the Department of Public Health, University of Oxford. The question set was specifically designed to determine changes in family circumstances, social and economic stability, and working lives and to assess what additional assistance (general care with living and specific health care) patients received or believed they required and whether this had in fact been delivered. The demographic questions were adapted from a draft of the Office of National Statistics' questionnaire intended for use during the 2011 national census [25]. A potential list of other questions was derived from previous question sets used in the study of chronic conditions that are associated with an established social, economic and caregiver burden [26, 27]. This potential list was reduced to a manageable question set in terms of time to complete, complexity and intrusiveness. The acceptability and face validity of this question set was subsequently assessed by a group of ICU survivors and relatives, who formed part of the UK Intensive Care Society Patient and Relatives Group, as well as a selection of experienced ICU clinical staff.
Information about the acute illness and ICU stay were derived from the Intensive Care National Audit and Research Centre's (ICNARC) Case Mix Programme data for those units contributing to the Case Mix Programme; a similar data set was retrieved manually from non-ICNARC-contributing ICUs.
Returned questionnaires were read using an electronic form reader (Teleform v10, Cardiff and Cambridge, UK) and the data uploaded into an SQL database (MySQL v5, Oracle Corporation, Redwood Shores, CA), which automated the follow-up process. Data was subsequently exported to Microsoft Excel and IBM SPSS v20 for analysis.
The data underwent a quality assurance process and outlying or inconsistent data points were verified with the contributing investigators. All data were assessed for normality, with subsequent analyses performed using t-tests, non-parametric equivalents or analysis of variance.
Demographics for patients responding at both 6 and 12 months (n = 293)
Median age (years)
18 ≤
> 18
Median dependency (days)
Level 3 care
Respiratory support
Median length of stay (days)
Surgical emergency
Surgical elective
ICNARC top 5 diagnoses [28]
Pneumonia, no organism isolated
Septic shock
Bacterial pneumonia
Aortic or iliac dissection or aneurysm
Large bowel tumor
Other white background
No answer
Any other
Family social and economic impact
Of the responders, 97% reported no change in their relationship status. There was little evidence of a change in accommodation status between ICU discharge and the 6-month and 12-month follow-up time points with the proportion of patients either owning their property outright or with a mortgage (71%) or living in rented accommodation (25%) remaining stable during this period.
Requirements for care
In 30 cases at 6 months (10% of the total cohort and 51% of those reporting themselves specifically as needing care), a family member had been given long-term leave, had to leave a job, reduce hours or stop work to provide care. By 12 months, 7 patients no longer declared a family care requirement and four of these family members had been able to return to work after a year. Thus in 8% of all cases, a family member had experienced a significant reduction in employment activity for at least a year.
Of the patients reporting a need for care, 23 patients (31%) at 6 months and 25 (38%) at 12 months had had to spend savings, borrow money, look to charity or remortage/sell their house (or a combination of these) to pay for care.
Clinical service utilization post-ICU discharge
Health-related quality of life data
EQ-5D results for patients responding at 6 and 12 months (n = 293)
Pre-admission %
6 months %
12 months %
N: I have no problems in walking about
M: I have some problems in walking about
E: I am confined to bed
N: I have no problems with self-care
M: I have some problems washing or dressing myself
E: I am unable to wash or dress myself
Usual activities
N: I have no problems
M: I have some problems
E: I am unable to perform my usual activities
N: I have no pain or discomfort
M: I have moderate pain or discomfort
E: I have extreme pain or discomfort
N: I am not anxious or depressed
M: I am moderately anxious or depressed
E: I am extremely anxious or depressed
EuroQol UK Tariff
25th percentile
75th percentile
25th percentile
75th percentile
SF-36v2 domain scores for patients responding at 6 and 12 monthsa
6 months
12 months
Jenkinson et al.[24]
Physical function
31.66 (15.89)
33.90 (16.66)
87.99 (19.65)
Role physical
31.74 (15.33)
35.23 (15.80)
87.17 (22.01)
Bodily pain
40.08 (12.65)
41.09 (13.11)
78.80 (23.01)
General health
39.76 (12.39)
40.30 (13.14)
71.06 (20.43)
43.55 (12.24)
45.33 (12.29)
58.04 (19.60)
Social functioning
40.92 (13.96)
42.95 (13.38)
82.77 (23.24)
Role emotional
42.29 (15.95)
43.10 (15.57)
85.75 (21.18)
Mental health
47.88 (12.48)
48.29 (12.80)
71.92 (18.15)
SF-36v2 component scores for patients responding at 6 and 12 months
Physical component score
6 months
12 months
≤ 64
> 64
≤ 18
> 18
Surgical emergency
Surgical elective
Mental component score
6 months
12 months
≤ 64
> 64
≤ 18
> 18
Surgical emergency
Surgical elective
Loss to follow-up
For the 74 patients who were lost to follow-up between the 6- and 12-month follow-up period, additional data was gathered from the respective general practitioners (GPs) for 65 (88%). For 46% of these patients their GP was unaware of any reason that would prevent them from responding to the study mailings. A further 23% were receiving home assistance, 15% had died without the knowledge of the investigators and 4% were in sheltered accommodation or homeless. These patients were not reported in the final cohort of 293 patients.
This is the first UK (or indeed European) study to estimate changes in family circumstance, describe social and economic stability, and quantify the care requirements amongst survivors of ICUs. From this exploratory study we report that approximately one quarter of patients who had received more than 48 hours of level 3 care report being in need of care assistance during the first 12 months after ICU discharge. Family members provide the majority of this care, and half of these family members have made a major adjustment to their own working lives. These ICU patients report reduced HR-QoL compared to population norms and three-quarters experience moderate or extreme pain. Following successful discharge to home, the former ICU patients have a high utilization of a variety of health services. The majority of these patients report attending either their primary care physician or their practice/district nurse.
Need for assistance with care
One quarter of patients followed up by this study reported themselves in need of assistance with care at 6 months, falling marginally at the 12-month follow-up period. For those patients receiving care at 12 months, a quarter needed greater than 50 hours. Family members provided the majority of this care. Other studies have shown a similar need for care assistance. In 1994, Covinsky et al. demonstrated that a third of seriously ill hospitalized patients required considerable care-giving assistance from a family member in the 12 months following hospital discharge [11]. Swoboda and colleagues [12] reported that almost 60% of responding families provided a moderate or large amount of care-giving. In a further study of informal caregiver burden, caregivers reported spending on average nearly 6 hours a day providing assistance [29]. The highest reported need for care comes from a short-term study by Im et al. of patients who had received at least 48 hours ventilation [30]; 74.8% needed support at 2 months after ICU discharge; the median time spent on providing care was 4 hours/day.
Family as caregivers
We found that of those families providing care at 6 months and 12 months, around half had to make a major adjustment to their working lives. Van Pelt et al. also showed that a reduction in employment and disruption in lifestyle were common [29]. At 26 months, only 30% of caregivers were employed and 10% indicated that they had stopped working.
It is only over the last few decades that an increased awareness of the potential distress experienced by families of ICU patients has kindled strong interest in family-centered care [31–33]. However, despite these additional stressors we failed to demonstrate either a breakdown of intimate relationships or change in accommodation status during the first 12 months of recovery. The exact reasons for this are unclear. With respect to a major change in accommodation status, one hypothesis would be that perhaps many patients hold a mortgage protection policy and these policies often protect against repossession for an initial 12-month period. Many home loan organizations allow repayment flexibility for a prolonged period after illness; the UK Building Society Association felt that a 1-year follow-up was too short a period to identify repossessions [34].
Employment and income
This UK study has demonstrated a negative impact on employment and on reported family earning sources and income; this resonates with the North American data in spite of the different social support and economic background. The study by Covinsky et al. reported that a family member had to leave work or make another major life change in 20% of cases [11], and many families reported the loss of the major source of their income and savings. Swoboda report that 44.9% of surviving patients had to quit work after 1 month, and more than 36.7% of families had lost savings after 1 year [12].
We demonstrated an increase in reported use of state financial support at 6 months (Figure 2) and a dominant reduction in reported income bands, for those returning to work. Of the patients reporting a need for care many had to spend savings, borrow money, look to charity or remortage/sell their house to pay for care. In the longer-term follow-up of survivors of Acute Respiratory Distress Syndrome (ARDS), only 49% had returned to work one year after discharge. This had increased to 73% at 5 years. Difficulties in obtaining social financial assistance were reported by many of the survivors [22]. In the study by Im et al., 28.7% of caregivers were working at 2 months but 30.3% had to reduce their working hours (median 16 hours/week) [30]. The economic impact of the critical illness on both patient and family can therefore be significant and long-lasting.
Health-related quality of life
The HR-QoL data were collected to provide a context for the social and economic data; the SF-36 data demonstrate a marked deficit in all domain scores at both 6 and 12 months and were consistent with previous reports [1, 20, 35, 36]. Conceptually, in this population HR-QoL scores may be related to social and economic burdens. However, evidence in the general literature demonstrates it is not always easy to relate somebody's HR-QoL from their general 'happiness,' financial well-being or social class [37, 38].
The EQ-5D data show many need assistance with everyday activities and medical care after they are discharged back to their homes. Family caregivers take on this new and unfamiliar role, and many will experience stress and negative health outcomes themselves. Caregiver distress scores are highest if the people that they are looking after are in obvious pain or discomfort [39]: significantly more of our patients reported themselves to be experiencing moderate or extreme pain than before their illness.
Access to care and services after ICU discharge
Patients who survive a prolonged stay in an ICU present many challenges to the health-care teams who assume responsibility for their subsequent care. We found that the majority of survivors in our study report visiting their primary care physicians and utilizing community nursing services. It is clear that the foundation of care following critical illness is provided in the community. Thus, primary care physicians are increasingly faced with assuming the responsibility for managing these complex patients.
A third of these patients are referred to specialist medical services and a further third to psychological services. Due to limitations in questionnaire design we cannot exclude a potentially unmet need for specialist care in this patient group. Of particular interest is the access to psychological services - this study demonstrated that 44% of patients report themselves to be moderately or extremely anxious or depressed at 12 months following discharge. However, the number of patients who were able to access psychological services was appreciably lower than the apparent demand. If psychological morbidity is not addressed then return to work may be delayed or prevented [40].
Strengths and limitations
This study was a comparatively large cohort study [12, 29, 30]. It is also a multi-center study, which increases its generalizability. We were able to compare services received with services that a patient felt were desirable. Further, we were able to present data on issues relating to patients, families and their caregivers.
The characteristics of the study group are similar to previously published longer-term outcome studies of ICU survivors in the UK and allow comparison with previously published work [1, 13, 20]. Losses to the study over the first year were due to deaths (10%), withdrawal, and loss to follow-up (36%) and are in keeping with previously published work. Such losses have often been related to the patient's or family member's reports of feeling 'overwhelmed' and reluctant to take on any additional burden of research [31].
This study has several limitations. All follow-up studies are vulnerable to enrolment bias. Patients were consented during the final days of their hospital admission or in an ICU follow-up clinic. This process has clear pragmatic advantages but also includes a potential bias towards those who are more physically or mentally able at this relatively early stage in their recovery.
Kruskal-Wallis one-way analysis of variance between responders and lost-to-follow-upa
Consented but no questionnaire returned (n= 300)
Six-month questionnaire only returned (n= 74)
Completed both questionnaires (n= 293)b
Median age
Median ICU stay (days)
Median APACHE II
Median level 3 (days)
Limited data were collected on the patients and their family status before ICU admission. As ICU admission is generally an unplanned event, it was necessary to rely on patients' recall of their prior functional status, which may have been subject to recall bias. However, others have used a similar approach to tackle this challenge [20]. The lack of a non-critical illness control or comparator population also represents a difficulty. A number of interventional studies have been able to randomize and thus have control data [41]. However, for observational studies, creating a retrospective control sample matched in terms of age, sex and acute and chronic disease is very challenging and has significant limitations.
This was a targeted exploratory study using a novel written question set. Although reviewed by patient and family groups, the question set had not been formally piloted. Following analysis we have excluded a variety of questions that were found to be inconsistent in terms of their response or application. Whilst we have succeeded in advancing our understanding of the socio-economic and family effects of surviving critical illness, we now recognize the limitations of some questions.
Such limitations include our definitions of care-giving and their relevance to the level of care being provided. A more specific assessment of activities of daily living (ADLs) using standardized instruments, such as the Caregiver Assistance Scale, Care-giving impact scale or Personal Gain Scale [29, 42], may be useful although they impose a significant question burden, which may have further negatively impacted response rates. Following analysis it became clear that phraseology was in places misleading. Reference to ICU-specific interventions often caused conflicting responses compared with using critical illness as a reference. Inconsistencies were also apparent with questions relating to marital status, household income and use of state financial support since many patients preferred to state their specific benefit or state relief by name and avoid general descriptors (see Additional files 1 and 2) [43].
As the study was conducted in the UK, data concerning access and provision of state financial/social support and health care may not be relevant elsewhere. Our findings concerning changes in employment status for this general ICU population do echo those of the Canadian ARDS cohort, although our population was around 10 years older and thus retirement was more common [13]. Importantly, outcome cohort studies such as this one cannot prove a causal relationship between critical illness or intensive care stay per se and the impact described; effects in individuals may be due to their acute illness or progression of pre-existing disease. Similar effects may possibly be observed in a population of survivors of serious illness who did not spend time in intensive care; future studies should perhaps enroll such populations as comparator groups.
The results of this exploratory study suggest that many patients surviving an intensive care admission have significant functional disabilities, may face a change in their employment and commonly have a care requirement after discharge from hospital. A significant proportion of those who do return to work do not return to their pre-existing level of income or workload commitment. The majority of the care required is provided by family members. In addition, the reduction in patients who return to employment at 6 months and the corresponding use of state financial support remains fairly static at 12 months. This suggests that those family members who become informal caregivers make adjustments to their working lives, resulting in a reduction in financial status. More positively, we did not observe patterns of intimate relationship breakdown or loss of original home, but we cannot exclude this being a major issue in other populations or occurring at a later date. We would cautiously conclude that in families who were experiencing the greatest disruption, this effect was apparent by 6 months and had not materially improved by 12 months. This exploratory study has demonstrated a significant socio-economic burden following critical illness. As important are the methodological lessons learnt, which will hopefully guide future research and ultimately intervention studies aimed at improving these important outcomes.
Acute Physiology and Chronic Health Evaluation II
EuroQol Visual Analogue Scale
general practitioner
- HR-QoL:
health-related quality of life
Intensive Care National Audit and Research Centre
interquartile range
- SF-36v2:
Short Form 36 Version 2
The research was supported by the National Institute for Health Research (NIHR) Biomedical Research Centres based at Imperial College Healthcare NHS Trust and Imperial College London and Oxford University Hospitals' NHS Trust and the University of Oxford. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
JG and SJB wish to acknowledge the support of the Department of Health and the Oxford Medical Research Charity.
We wish to acknowledge the assistance of the Intensive Care National Audit and Research Centre's Case Mix Programme for the provision of acute illness diagnostic and severity data.
We wish to also to thank the principal investigators and hospitals: Dr Carl Waldmann, Royal Berkshire Hospital; Dr Jonathan Thompson, Leicester Royal Infirmary; Dr Mike Vangikar, Southport Hospital; Ms May Nel, St Mary's Hospital; Dr Alasdair Short, Broomfield Hospital; Dr Jonathan Walker, Royal Liverpool University Hospital; Dr Daniel Conway, Manchester Royal Infirmary; Dr Huw Twamley, Royal Preston Hospital; Dr Stephen Drage, Royal Sussex County Hospital; Prof Richard Griffiths, Whiston Hospital; Ms Michele Platt, Kings Mill Hospital; Dr Jason Cupitt, Blackpool Victoria Hospital; Dr Ian Nesbitt, Freeman Hospital; Dr Gerlinde Mandersloot, The Royal London Hospital; Dr Philip Young, Queen Alexandra Hospital; Dr Jon Cardy, West Suffolk Hospital; Dr Dolores Mateo, Newham General Hospital; Dr Mark Blunt, Queen Elizabeth Kings Lynn; Dr Gillian Saville, Royal Cornwall Hospital; Dr Marius Terblanche, St Thomas' and Ms Katie Scales, Hammersmith Hospital and Charing Cross Hospital.
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- Van Pelt DC, Milbrandt EB, Qin L, Weissfeld LA, Rotondi AJ, Schulz R, Chelluri L, Angus DC, Pinsky MR: Informal caregiver burden among survivors of prolonged mechanical ventilation. Am J Respir Crit Care Med 2007,175(2):167-173. 10.1164/rccm.200604-493OCPubMed CentralView ArticlePubMedGoogle Scholar
- Im K, Belle SH, Schulz R, Mendelsohn AB, Chelluri L: Prevalence and outcomes of caregiving after prolonged (≥48 hours) mechanical ventilation in the ICU. Chest 2004,125(2):597-606. 10.1378/chest.125.2.597View ArticlePubMedGoogle Scholar
- Daly BJ, Douglas SL, Kelley CG, O'Toole E, Montenegro H: Trial of a disease management program to reduce hospital readmissions of the chronically critically ill. Chest 2005,128(2):507-517. 10.1378/chest.128.2.507View ArticlePubMedGoogle Scholar
- Douglas SL, Daly BJ: Caregivers of long-term ventilator patients: physical and psychological outcomes. Chest 2003,123(4):1073-1081. 10.1378/chest.123.4.1073View ArticlePubMedGoogle Scholar
- Rossi Ferrario S, Zotti AM, Zaccaria S, Donner CF: Caregiver strain associated with tracheostomy in chronic respiratory failure. Chest 2001,119(5):1498-1502. 10.1378/chest.119.5.1498View ArticlePubMedGoogle Scholar
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- Dowdy DW, Eid MP, Sedrakyan A, Mendez-Tellez PA, Pronovost PJ, Herridge MS, Needham DM: Quality of life in adult survivors of critical illness: a systematic review of the literature. Intensive Care Med 2005,31(5):611-620. 10.1007/s00134-005-2592-6View ArticlePubMedGoogle Scholar
- Ridley SA, Chrispin PS, Scotton H, Rogers J, Lloyd D: Changes in quality of life after intensive care: comparison with normal data. Anaesthesia 1997,52(3):195-202. 10.1111/j.1365-2044.1997.073-az0068.xView ArticlePubMedGoogle Scholar
- Chandola T, Jenkinson C: Social class differences in morbidity using the new UK National Statistics Socio-Economic Classification. Do class differences in employment relations explain class differences in health? Ann NY Acad Sci 1999, 896: 313-315. 10.1111/j.1749-6632.1999.tb08126.xView ArticlePubMedGoogle Scholar
- Chandola T, Jenkinson C: The new UK National Statistics Socio-Economic Classification (NS-SEC); investigating social class differences in self-reported health status. J Public Health Med 2000,22(2):182-190. 10.1093/pubmed/22.2.182View ArticlePubMedGoogle Scholar
- Choi J, Donahoe MP, Zullo TG, Hoffman LA: Caregivers of the chronically critically ill after discharge from the intensive care unit: six months' experience. Am J Crit Care 2011, 20: 12-22. 10.4037/ajcc2011243PubMed CentralView ArticlePubMedGoogle Scholar
- Adhikari NK, McAndrews MP, Tansey CM, Matte A, Pinto R, Cheung AM, Diaz-Granados N, Barr A, Herridge MS: Self-reported symptoms of depression and memory dysfunction in survivors of ARDS. Chest 2009,135(3):678-687. 10.1378/chest.08-0974View ArticlePubMedGoogle Scholar
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This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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We did have such a good time! It seems that as long as we are gardeners all
our differences disappear. I agree with Jesse that one more day is absolutely
necessary to see everything. The three of us are definitely going to Hot
Springs again next year. We're up for any number joining us.
zone 7
West TN
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please check my sentence.
The next morning when I went to university, I asked my friends about the test.
Is it correct or should I put the before university?
asked Jan 24 '13 at 22:21 user22 Contributor
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Depends what you want out of your game. If you want a pure sandbox full of whatever you want to do ever. Then I suggest finding a nice group of friends on a MineCraft server and building stuff up.
If you're looking for something more structured, I would suggest EVE and get into one of the training or PVP corps to get you into the game, then from there you can figure out what you want to do.
There really isn't much else out there.
this is like asking who the best player on the Heat was Tuesday
LFD tools are great for cramming people into content, but quality > quantity.
I am, usually on the sandbox .. more "hardcore" side of things, but I also do just want to have fun. So lighten up already
Gaming since 1985; Online gaming since 1995; No End in Sight! My YouTube Channel: https://www.youtube.com/channel/UC8POVoJ8fdOseuJ4U1ZX-oA
UO,Shadowbane,SWG,Darkfall,MO,Wurm Online,Secretworld,GW,GW2,PotBS,LotR,Atlantica Online,WWII Online,WoT,Battlestar Galactica,Planetside2,Perpetuum,Fallen Earth,Runescape,WoW,Eve,Xsylon,Dragon Prophet, Salem
Ok, best is just a viewpoint.
Now there is plenty out there. The ones id recommend are Darkfall, Wurm and Salem.
each are extremely diffrent from the other
Let's play Fallen Earth (blind, 300 episodes)
Let's play Guild Wars 2 (blind, 45 episodes)
Fallen Earth is a get better gear to get another level, to get better gear to get another level, treadmill.
Xsyon is a sandbox game where you can terraform the land, build with parts such as roofs , walls, floors etc. Animals give stuff like guts, bones and skin. There are scrap piles you get resources such as metal from. It is open world pvp except on your home spot or tribe land. Animals can mutate into stronger deadlier animals, and there are revenants , or zombie like things from abandoned areas. The revenants can kill and loot you as well. They will take your weapon and use it, as well as wear the armor they just took from you.
You can check it out for free, but restricts skills to level 30. To open up skill level, you have to purchase it, and then after first free month from purchase, you sub for 9.99 a month.
Current games playing: MechWarrior Online
Games being watched: Project Genom
Favorite played games: SWG, RomaVictor, and Xsyon
Originally posted by benseine
Short list atm: Darkfall: Unholy Wars, Salem, Worms Online, Mortal Online, EVE. If we are lucky we can play The Repopulation within a year. In a few years you have Gloria Victis, World of Darkness, Pathfinder Online, Embers of Caerus and probably some others.
There is not much sand in the box over at Darkfall anymore. More of a safe zone gathering, then go out into a pvp arena.
"EVE is likely the best MMORPG that you've never really understood or played" - Kyleran


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Does this activity require advanced planning, ticketing or reservations?
Is this activity accessible without advanced planning or reservations?
Is this attraction popular with tourists?
Is this attraction a "must-see" location?
Is this attraction a good picnic spot?
Does this attraction provide visitors with a taste of the local culture?
Does this attraction require above average amounts of physical activity (long walks, climbs, stairs or hikes)?
Does this attraction have good scenic or skyline views?
Is this location a solemn or serious place like a memorial, cemetary, etc.?
Is this attraction good for couples?
Thanks for helping!
Underground cave. Many tours throughout the day. Tour is about 1 hour long. There is charge to tour the Cave and temperature is about 48 degree's . Tour guide explains history and...
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Underground cave. Many tours throughout the day. Tour is about 1 hour long. There is charge to tour the Cave and temperature is about 48 degree's . Tour guide explains history and about artifacts . Does have a small underground water fall and a chapel where many people have gotten married in the cave. Great attraction to see when in...
The caves are very cool! Our tour guide was younger but spoke clearly and effectively to the group. It was really neat to see all the stuff they showed us. The gift shop was also great and affordable. & the mini golf course was not notch and beautiful with fall colors as a back drop. There is also a nice...
Toured both Niagara and Mystery caves in one day. Only about 30 minutes apart. Very busy on Saturday of Labor Day weekend. We bought our tickets and had a 40 minute wait. Allowed enough time to browse the gift shop and make a pressed penny souvenir for 51 cents! There are many stairs, not handicap accessible. Cave is quite cool...
I went to Niagara Cave and was glad that I did. The tour lasts about an hour, the guides are informative, and the overall experience is positive. As there is only one way in and out of the cave, there are no bats, bugs, or insects in the cave. In fact, outside of humans on the tour, there are no...
The tour of Niagara Cave was very interesting and educational. The tour guide did a good job. The Niagara Cave site also allows for picnics and pan-mining. Be prepared to get wet from water dripping off the top of the cave! Unlike the Mystery Cave tour, it is not handicap-accessible.
Enjoyed this cave tour! Great guide who was very knowledgable. Lots of stairs with handrails. We had one person with us who has mild knee issues and she did just fine.
Not far from Decorah, Iowa, this cave is an off-the-beaten path gem. The story behind its discovery was interesting and the spelunkers who developed it had a great idea. Love that the stairs are spread throughout the cave.The temperature was perfect after having been in some hot temps for days before.I loved the waterfalls. Guide was very knowledgeable,
Earlier I was reluctant to go there but I was wrong. This place is super awesome. Tour cost is $18 per person and children under 3 are allowed free of cost. I went there with my 2-year toddler and he also enjoyed it. There is a picnic spot out there to have lunch and a mini golf for kids. The...
We visited Niagara Cave a few weeks ago. It had been raining a lot, and we were lucky enough to view the cave when the water was really flowing. Even our tour guide was surprised by the strong flow!
The tour lasts about an hour; is guided, and for the most part is non-strenuous. I will admit going back up...
Would highly recommend this to anyone! It was a great tour for sure. Was definitely worth driving out of our way for it. We couldn't stop talking about it.
Is it poosible to go there with 2 year kid?
About how long was the tour, start to finish?
which cave tour was better? Niagra or Mystery
Do u just go down the stairz or do u have to climb them too
See all questions


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We had a joke all lined up. With Big Baby rumbling to 23 points and 12 rebounds, and with Dwight Howard in an injury/depressed/look at me funk, Orlando was setting themselves up. In his last three games before last night, Davis was averaging 21.3 points, 11 rebounds and 50 percent from the floor. For once, he WAS more useful than Howard. But somehow after hurting his lower back enough to be stretched out by the team's physical therapist at midcourt before the third quarter, and with his shot not falling, Dwight didn't give up. He did work. The Magic came from behind to beat Philly, 88-82, and Howard had 20 points and 22 rebounds. He claimed afterward that he will never give up on his team, and this one was a perfect example. The Sixers hit them with a huge first half run, and were up eight at the half as Howard had tweaked his back and made just two shots. For the Magic to come back and win, even with everything going on around that team, that says a lot … Paul Pierce and the Celtics answered the bell in Indiana. Pierce's 24 pushed Boston to a 86-72 win against the Pacers just one game after Doc Rivers called them out for playing their worst 48 minutes of the year. They reached out and snatched the victory during the second quarter. They held the hosts without a bucket for basically seven minutes with the Pacers missing 11 straight shots. How did they do it? We actually don't know. Their lineup was Sasha Pavlovic, Greg Stiemsma, Ray Allen and then Kevin Garnett (who had 10 fourth quarter points) and Avery Bradley. The Pacers went about as meekly as possible against the Celtics, one night after crowning OKC and looking like a legit contender. We've given up trying to figure out the East after the obvious top two. The Pacers had won four straight, and now have given the C's life as far as catching them for playoff seedings. Maybe if Darren Collison would do something, the Pacers might be able to make some moves. Remember when people were actually calling for New Orleans to trade Chris Paul JUST because they had DC? Where are all of them now? … Rajon Rondo has recorded 10-plus assists in the last 16 games, which passes John Stockton (15 straight in 1995) for the longest streak in the last 20 years … We miss the days when Paul Pierce used to go against Indiana and show up to the postgame pressers with head bandages … Kobe didn't start up the #KobeSystem last night, sitting it out with tenosynovitis of the left shin. So as the Lakers were busy getting throttled by Phoenix, 125-105, Bryant spent the spent joking around and making the #KobeSystem hand signal to fans behind the bench. Shannon Brown had 24 against his old team … Behind 27 and 14 from Blake Griffin, the Clippers won again, 109-94 over Sacramento … In this year's Nike Hoop Summit, despite 35 from Shabazz Muhammad, the World beat Team USA by nine behind Canada's Andrew Wiggins (20 points), the youngest player there … And Antoine Walker announced his retirement to his Idaho Stampede teammates last night after their D-League game. We know most of y'all think he retired years ago, but we figured you should know … Keep reading to hear about O.J. Mayo's JaVale McGee impersonation …
Rudy Gay put one on Dallas last night. Just a few nights after the Mavs took out Memphis, the Grizz came back and returned the favor, winning 94-89 behind Gay's 25 points. Dallas just didn't have it from the start, shooting 1-for-12 to start the game. After a Gay LeBron-lite on the break, it was 26-6 Memphis, and they controlled it the rest of the way. Gilbert Arenas had 11 more points in the second half before hurting his ankle. His mojo was back too; one corner three came after he motioned for the team to settle down. Then he immediately fired it. Arenas now has probably made more shots in his last two games than he did in the previous two years (It almost feels that way doesn't it?) … But the real fun happened with O.J. Mayo. During a jump ball in the second half, Zach Randolph (15 points, 11 rebounds) recovered it on the Mavs' side of the court. Mayo sprinted back to the opposite end like JaVale McGee. He was calling for the pass from Z-Bo, which would've been an obvious backcourt violation. Randolph almost passed it to him too before regaining his senses … We like how Brandon Jennings says the Bucks struggle with plus-.500 teams. Um, that means you're not very good. Milwaukee still blew out Portland by 22. Somehow, some way, Jennings and Monta Ellis are making it work, and are doing it under Scott Skiles' watch. They had a combined 38 against Portland. But maybe we shouldn't be all that surprised. Skiles made beautiful music with Ben Gordon in Chicago. Now that they've broken up, no one's heard from BG ever since Detroit stole his game and hid it in a garage somewhere … Jason Smith built a grave and buried the T'Wolves' season last night, going wild with 26 points and 10 rebounds. New Orleans won 99-90 as Minnesota seems content to let Kevin Love get his numbers (29 and 12) and play out the string now that their season is over … How do you know the Hawks destroyed Charlotte? Ivan Johnson, Jannero Pargo, Marvin Williams and Willie Green all scored in double digits. Since it's quite obvious Charlotte is tanking, who should they go after in the draft? Outside of Anthony Davis, it gets murky. Do you want a swingman (Harrison Barnes)? A project (Andre Drummond)? Or a solid big man (Thomas Robinson)? … Cory Higgins, you know, the guy who's only on the team because his dad is in management, somehow scored 22 points in 24 minutes. He'll be recalling this night to his grandkids someday … And Golden State smashed Denver by 15 as they put seven players in double figures … We're out like 'Toine's shimmy.
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All quotes tagged Institution
(459 quotes found)
"The only justifiable purpose of political institutions is to ensure the unhindered development of the individual."
"Between the black box proprietary code, barebones computers we call voting machines and a mass of completely unqualified election officials, our election system is up for grabs to anybody with even a modest interest and some script kiddie capability. The cyber-kinetic attack surface here is wide open."
"Look at the stealth and sophistication of foreign nation state APTs who break through even the most sophisticated layers of security daily and tell me why they would just give our completely unprotected election systems a pass"
"I am ashamed to think how easily we capitulate to badges and names, to large societies and dead institutions"
"The press is no substitute for institutions. It is like the beam of a searchlight that moves restlessly about, bringing one episode and then another out of darkness into vision. Men cannot do the work of the world by this light alone."
"Institutions -- government, churches, industries, and the like -- have properly no other function than to contribute to human freedom; and in so far as they fail, on the whole, to perform this function, they are wrong and need reconstruction."
"Chinese hackers are unsophisticated and little more than glorified script kiddies. They succeed in their attacks due to an unlimited State budget, the desperation of their 12th Five Year Plan, sheer volume of attacks and the fact that American and European companies possess virtually zero cyber hygiene or layered defenses"


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Marquette v Louisville
LOUISVILLE, KY - FEBRUARY 03: Gorgui Dieng #10 of the Louisville Cardinals shoots the ball during the game against the Marquette Golden Eagles at KFC YUM! Center on February 3, 2013 in Louisville, Kentucky. (Photo by Andy Lyons/Getty Images)
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/ multi pitch sport routes???
What do you look for in a winter baselayer? The fabric should be medium-to-heavy weight, to offer a good amount of insulation for... Read more
Mick Ward reminisces about the British magazines that transformed climbing media as we venture ever further into the digital age,... Read more
13 year-old Leo Skinner from South Wales has ticked 8A at , the day after his 13th birthday. Leo has been working his way up... Read more
We know that our forums have played Cupid over the years: furtive glances in the form of winky faces and flirty replies to the... Read more
The UKC team recently returned from the annual gear-fest in Munich that is ISPO. Here are some video interviews with brand... Read more


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Arts , Government reform , Volunteering , Family , Health and medicine , Poverty and hunger , Youth , Community development , Human services , Education , , , , , , , , , More
Haiti:Circle of Friends
About us
Haiti Circle of Friends is an alternative, sustainable, and community based model for improved care of neglected orphans in Haiti. We create small family home environments, train Haitian staff in child care and development, and we are a volunteer based organization that brings hope, love, respect and dignity into the lives of young children while empowering the people who take care of them. Our social mission, "One Child, One Community, One Family," is to sustain this successful model of improved child care and development by providing housing, medical, educational, nutritional, and emotional support through our cadre of generous volunteers. We have private and clean housing for our volunteers and welcome all people who can share their skills to help improve our homes, spend quality time with children, as well as train, guide and empower the staff to provide appropriate care.
Contact information
Date Founded: August 1,2010
Government ID number: 45-2875651
Email: Log in to view email addresses.
Phone: 509-3-995-0358
Route DuPlan, Fermathe #55, Centre, Haiti


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Integrated Micro and Nano Electro Mechanical Systems (MEMS and NEMS)
Development of thermo electric generators and polymer-based micro sensors
15.04.2016 13:15, room CLA G2
Presentation by Verena Maiwald (ETHZ, MNS), titled "A micro-mechanical frequency selective motion trigger for Acoustic Emission detection"
Find more MNS Events here
18.09.2016 "The microdoctors in our bodies" is featured in the ETH Globe magazine! Check it out here!
02.05.2016 Ian Mihailovic will start a new PhD thesis towards nanostructured materials for TEGs and fabrication technology. Please join in welcoming Ian!
01.04.2016 We welcome Ms. Manuela Kägi as a Team Assistant and thank her in advance for future support!
28.01.2016 Prof. Henry Baltes receives the 2016 IEEE Robert Bosch Micro and Nano Electro Mechanical Systems Award "for contributions to the exploration and development of CMOS-MEMS, to production using IC foundries and MEMS post-processing, and for inspirational leadership in the worldwide MEMS community" !
28.01.2016 The paper "Degradable Magnetic Composites for Minimally Invasive Interventions: Device Fabrication, Targeted Drug Delivery, and Cytotoxicity Tests" by Christian Peters, Salvador Pané et al. is featured on NanoScribe's application notes!
Read more MNS News here


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For the second time in four games, Mitchell was stellar on the mound and this time it led to Clemson getting the 11-3 victory over High Point on a wild-weather Wednesday at Doug Kingsmore Stadium. The game was called in the bottom of the sixth due to fog.
Mitchell was forced into the game in an emergency situation in the top of the third when starter Josh Thrailkill was forced to the bench following a line drive off his left shin. All Mitchell did was toss four innings of three-hit ball and allowed only one run to get his first-career win.
"It's been a long process," Mitchell said of his convergence from an everyday outfielder to that as a part-time pitcher, as well. "I just tried to come in and throw strikes and things happened. I just tried to let them hit the ball to my fielders."
With the entire pitching situation still in doubt, Tigers head coach Jack Leggett said Mitchell is becoming more and more valuable.
In six innings of work this year, Mitchell has allowed just four hits and one run, while striking out seven.
There's a real chance Mitchell will become a midweek starter.
"There's a chance of everything," Leggett said. "He's probably going to help the team as a pitcher more than anything."
Because of the ankle injury to starting pitcher David Kopp, Leggett said Mitchell could get the start Sunday against Pacific. P.J. Zocchi will get the start Friday and Ryan Hinson will go on Saturday.
Wednesday's game was also a breakout game for the Clemson offense, which struggled Saturday and Sunday against George Mason.
Against the Panthers (2-5), Clemson pounded out 12 hits, two of which were home runs. Catcher Doug Hogan hit his third homer of the season with a two-run shot in the fifth and freshman designated hitter Ben Paulsen his a two-run blast in the third. It was the first dinger of his career.
The other hitting star for the No. 2 Tigers (3-1) was senior third baseman Marquez Smith, who went 3-for-4 with two runs and an RBI.
"We just tried to flush the whole weekend," Smith said. "It felt good. Everything played out pretty well tonight."
Thrailkill, a freshman making his first-career start, had to wait more than three hours to throw that first pitch. The game was originally slated to start at 4 p.m., but lightning and then rain delayed the start to 7:36 p.m.
Then in the top of the third, Robby Kuzdale started the inning off with a shot right up the middle that caught the left shin square on Thrailkill, who still tried to make the play at first, but threw the ball down the right field line and Kuzdale ended up at third.
"He'll remember this day for a long time," Leggett said of Thrailkill.
Thrailkill was helped off the field and Mitchell came in with no outs and a runner on third. Considering Clemson was already trailing 2-0, the situation was not looking good.
But Hogan was able to pickoff Kuzdale at third and High Point failed to score. The spirit of the Tigers was lifted as they scored six runs in the bottom of the inning to grab the lead for good.
"We've just got to get ourselves in a rhythm and figure out our pitching," Leggett said.
Mitchell Mows Down Panthers
CUTigers.com Top Stories
RECRUITING RADARIn our weekly Recruiting Radar, CUTigers Recruiting Analyst Gary McDaniel updates you on the latest news and intel on the Clemson recruiting front!
CUTigers.comThursday at 2:18 AM
Pagano to TransferAfter helping Clemson win a National Championship and earning his degree, Scott Pagano has decided it is time for him to move on.
TIGERS TAKE A W FROM WAKEAfter back-to-back heartbreaking losses to Syracuse and Duke, the Tigers built a 21-point lead on Wake Forest and won by 12 to complete the season sweep of the Deacs and keep their…
DEJA BLUEFor the second straight game, Clemson had the lead or a chance to win on the final possession of the game and came up just short. This time, it was against #18 Duke in the most…


text: in san luis o, last minute sushi decisions can be crazy. you can wait forever at goshi, so yanagi is a good bet if you wish to stay in the old town area. every place has a slightly different spin on sushi etc. (yanagi was hoppin' too though the other night.) while this is generally not my 1st pick place,... More


text: Nissan GT-R Fire-Fighting Safety Car Now Patrols The RingMatt Hardigree8/04/09 11:00amFiled to: Safety CarsNissan GT-Rnissan gt-r safety carNissan GT-R Rapid Response VehicleNurburgringNordschlefeNissanGt-rThe RingTop511EditPromoteShare to KinjaToggle Conversation toolsGo to permalinkThe 2010 Nissan GT-R is one of the quickest cars around the 'Ring, which explains why the Nubrugring selected it as a fire-fighting, life-saving rapid response vehicle. When it comes to Nurburgring's Nordschliefe, seconds count for both automakers and injured drivers. This is why the GT-R is an ideal way to get safety crews out to any tourists wiping out on the ring. In addition to the special graphics and lightbar, the GT-R features a full roll cage, racing seats, emergency equipment and a large tank of fire retardant hooked up to a quick-release hose. Advertisement Advertisement We actually want this one more than a stock GT-R.[Nissansportz.com via gtrblog.com, World Car Fans] Reply51 repliesLeave a reply


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Gift Premium Subscription To WortMonger
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I like to brew and make things. I am of Scottish and German descent and love wearing my kilt, eating sauerkraut, and drinking my beer. The best thing about wearing a kilt whilst drinking should be obvious, lol.
Anyone else kiltie?
- Metal casting,machining,anything fun and crafty.
- I'z a Maintenance Technician now!
- Now, that's just Recockulous!!
- Led Zeppelin and Pink Floyd definitely, Audioslave, Rage against machine, Alice in Chains, Metallica
- Caddyshack, Vacation, Beerfest, Tin Cup, Grandma's Boy..................
- CSI, Dexter, Weeds, Californication
- Designing Great Beers, Homebrewer's Bible, How to Win Friends and Influence People (ok kidding there
- Pi Kappa Alpha, BSA Eagle Scout, thats about it right now.
- As for a little bit about me, I've been brewing since I was 14 (20+ years now) and still keep adding to my arsenal of ideas and techniques thanks to this forum. I may do things a little different, but I always love a good experiment. Here as of late, I have been experimenting with higher pressure fermentation and have adapted a system I really enjoy working with fermenting in big Sanke kegs. You can check that out by copying this link here> http://www.homebrewtalk.com/f13/closed-system-pressurized-fermentation-technique-44344/
- Everything is "on the list!"
- Nada, my cupboards are bare and can't even reach my equipment after the move :(
- Your Mom uses a secondary, lol.
- Pffft, bottle, right... I'm too lazy to bottle.
- Sanitizer and some are just full of CO2 right now :(
- Male
- Married
- Edmond, OK
- Oklahoma
Posted in thread: Closed-system pressurized fermentation technique! on 10-08-2015 at 11:31 PM
I took a lot of time making that wiki article, wish they would get it working. I have tried
numerous times and it's been down for years now.
Posted in thread: HomeBrewSupply Amcyl Brew Kettle w/ 3-Piece Ball Valve Giveaway! on 08-15-2015 at 04:42 PM
I'm in. Just remember that wortmonger = John Lowry, and John Lowry lika-da-winning.
Posted in thread: Cold Break Brewing Microbrew Series Giveaway - Open to All! on 07-01-2015 at 01:11 PM
Awww yeah! I'm in.
Posted in thread: Closed-system pressurized fermentation technique! on 05-31-2015 at 02:36 PM
I'll keep saying it with the same little cracked smile, "I told ya so." Lol, glad you guys are
still posting with your results. Spread the word, and remember it doesn't brew better beer...
it makes br...
Posted in thread: Closed-system pressurized fermentation technique! on 05-18-2015 at 11:40 PM
You need to check it, kinda like a smoker. If it goes over, it's harder, or more difficult, to
go down than to go up. Also, it allows the beer to not be saturated with CO2 until later in the
process t...
Posted in thread: The HomeBrewTalk 2015 Big Giveaway! on 04-11-2015 at 12:31 PM
Oh, I'm in this one for sure! Awesome vendors in HBT.
Posted in thread: Closed-system pressurized fermentation technique! on 03-18-2015 at 02:23 PM
I told ya so, ;) lol. It doesn't make better beer, it just makes making beer better... to me
that is! I hope more continue to try this method and continue to improve upon it. Thank you all
for contrib...
Posted in thread: Closed-system pressurized fermentation technique! on 03-07-2015 at 05:32 PM
They are good for estimating finishing fermentation, but you need to get a hydro sample to get
good numbers. They work great before fermentation starts though.
Posted in thread: BrewHardware.com RIMS hardware Kit and more Giveaway! on 01-07-2015 at 05:21 PM
Oh, I'm definitely in!
Posted in thread: Growing and Taking Care of Fruit Trees For Beverages on 01-03-2015 at 07:46 PM
I'm so happy this thread is moving now. I get excited every time I see new posts. I can't wait
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Antique Gift Shop (GN 10)
Title: Antique Gift Shop
Volume: GN 10
Pages: 176
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Release date: 2010-03-31
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Having decided to return to the Antique Gift Shop, Bun-Nyuh discovers that one of her most precious antiques is missing and leaves the store in search of it. Little does she know her quest will follow a path laid out by fate, setting the present onto a collision course with the past - one that will reveal the truth behind the bond shared by Bun-Nyuh's grandmother and her friend, as well as Mr. Yang's true identity. Will Bun-Nyuh be able to fulfill her destiny as a shaman? Or will she deny the essence of her being until the very end?! Find out in the conclusion to The Antique Gift Shop!
(added on 2009-09-07, modified on 2009-09-07)
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The long-term objective of this Academic Leadership Award is to build a world-class research program in disability and disabling disorders at the Yale School of Medicine. The immediate objective is to elevate the visibility and stature of the candidate's newly established Center on Disability and Disabling Disorders, both locally and nationally. The Disability Center strives to address fundamental questions related to the epidemiology and prevention of disability, a problem of immense importance to older persons, their families and society. Under the direction of the candidate, the Center conducts epidemiologic studies and clinical trials to enhance the scientific knowledge base of the disablement process and to rigorously evaluate promising intervention strategies. The Center includes an expanding number of clinical investigators and trainees, across disciplines, who are pursuing aging research related to disability and disabling disorders. This includes functional assessment in general as well as the functional consequences of highly prevalent disease-specific conditions such as arthritis, heart failure, chronic obstructive pulmonary disease, influenza, diabetes, stroke, depression, and dementia. To accomplish its long-term objective, this Academic Leadership Award will carry out four specific aims: (1) to strengthen the infrastructure of the Disability Center by: (a) establishing and maintaining an operational registr of potential participants for pilot and other field studies;and (b) creating a repository of longitudinal studies and clinical trials focused on disability and disabling disorders;(2) to recrit and train outstanding fellows and junior faculty from multiple disciplines in the science of patien-oriented, aging research, with a primary focus on functional assessment, disability and disabling disorders;(3) to establish a pilot grant program to support the most promising epidemiologic and intervention studies focused on disability and disabling disorders;and (4) to expand the scope of research at Yale related to disability and disabling disorders. The candidate is an internationally recognized geriatrician and epidemiologist and a leading authority on the epidemiology and prevention of disability among older persons. By leveraging start-up funds from the Yale School of Medicine and an impressive array of outstanding institutional resources in aging research, training, and career development, this Academic Leadership Award will position the candidate to make the Disability Center self-sustaining through the subsequent receipt of a Program Project (P01) award and/or support from private philanthropy and other federal and non-federal sources.
This proposal seeks support for a newly established Center on Disability and Disabling Disorders. The Disability Center strives to address fundamental questions related to the epidemiology and prevention of disability and functional decline, a problem of immense importance to older persons, their families and society. The Center conducts epidemiologic studies and clinical trials to enhance the scientific knowledge base of the disablement process and to rigorously evaluate promising intervention strategies.
|Hartaigh, Bríain ó; Allore, Heather G; Trentalange, Mark et al. (2015) Elevations in time-varying resting heart rate predict subsequent all-cause mortality in older adults. Eur J Prev Cardiol 22:527-34
|Brummel, N E; Girard, T D; Ely, E W et al. (2014) Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial. Intensive Care Med 40:370-9
|de Rekeneire, Nathalie; Leo-Summers, Linda; Han, Ling et al. (2014) Epidemiology of restricting fatigue in older adults: the precipitating events project. J Am Geriatr Soc 62:476-81
|Lipska, Kasia J; Ross, Joseph S; Wang, Yun et al. (2014) National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011. JAMA Intern Med 174:1116-24
|Makris, Una E; Melhado, Trisha; Lee, Simon C et al. (2014) Illness representations of restricting back pain: the older Person's perspective. Pain Med 15:938-46
|O Hartaigh, Bríain; Gaksch, Martin; Kienreich, Katharina et al. (2014) Associations of daytime, nighttime, and 24-hour heart rate with four distinct markers of inflammation in hypertensive patients: the Styrian Hypertension Study. J Clin Hypertens (Greenwich) 16:856-61
|Makris, Una E; Fraenkel, Liana; Han, Ling et al. (2014) Risk factors for restricting back pain in older persons. J Am Med Dir Assoc 15:62-7
|Vaz Fragoso, Carlos A; Hsu, Fang-Chi; Brinkley, Tina et al. (2014) Combined reduced forced expiratory volume in 1 second (FEV1) and peripheral artery disease in sedentary elders with functional limitations. J Am Med Dir Assoc 15:665-70
|Vaz Fragoso, Carlos A; Beavers, Daniel P; Hankinson, John L et al. (2014) Respiratory impairment and dyspnea and their associations with physical inactivity and mobility in sedentary community-dwelling older persons. J Am Geriatr Soc 62:622-8
|Gill, Thomas M (2014) Disentangling the disabling process: insights from the precipitating events project. Gerontologist 54:533-49
Showing the most recent 10 out of 19 publications


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Historical & Historical Fiction
The Journals of Lewis and Clark, 1804-1806 by Meriwether Lewis and William Clark
Living in Portland, you can't turn a city corner without being reminded of Lewis and Clark's fabled journey across the Northwest. They traversed a nation with the aid of Shoshone guide Sacajawea in the early 1800s, chronicling all the flora, fauna, tribal encounters, and vast landscapes they encountered along their journey. The language can be difficult to decipher at times, but it's a richly detailed account of our nation's early natural history, and exploration.
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Autobiography of Benjamin Franklin by Benjamin Franklin
Benjamin Franklin was always renowned for his eccentric and intriguing personality, whether he was dabbling in electricity, drinking beer, or serving as Postmaster General of the United States. Needless to say, he remains a hallmark of American history more than 200 years after his death. His autobiography offers personal stories, exploits, and general insights to his life in the days before the American Revolution.
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The Life of Buffalo Bill: An Autobiography by William Frederick Cody
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Two Years Before the Mast by Richard Henry Dana
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Les Misérables by Victor Hugo
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Life on the Mississippi by Mark Twain
The Mississippi River had a profound and pivotal on Twain from the time he was a little boy until his death in 1910. Mississippi is a memoir, a steamboat-era novel that summarizes the river's discovery by Hernando de Soto in 1541, Twain's time as a steamboat pilot, and his eye-opening return to the river many years after industry and greed had befallen upon the surrounding banks. It revels in Twain's knack for observation, while providing backdrop for the author's classic tales.
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South: The Story of Shackleton's Expedition by Sir Ernest Henry Shackleton
It seems like almost all stories coming out of Antarctica either deal with penguins, polar bears, or survival. Being a first-hand account of 28 men marooned on polar ice a nearly fatal shipwreck in unforgiving waters, Shackleton's tale represents the third option. It recaps the journey, from Shackleton's burning desires to traverse Antarctica to the subsequent catastrophe and ensuing struggle to survive, albeit with descriptive prowess and sea-log flare.
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|Chris Hostetter <hossman_luc...@fucit.org>
|Re: Does LUCENE-831) "Complete overhaul of FieldCache API" provide fieldcache offloading to disk?
|Fri, 18 Apr 2008 02:13:33 GMT
: But then the FieldCache is just starting to feel alot like column-stride : fields : (LUCENE-1231). that's what i've been thinking ... my goal with LUCENE-831 was to make it easier to manage FieldCache and hopefully the norms[] as well particularly in the case of reopen ... but with column-stride fields the need for both of those might go away completely) that doesn't mean LUCENE-1231 won't still be usefull .. it could probably still be leveraged by things like CachingWrapperFilter, and some of the Solr caches to reduce the amount of work on reload -- i just don't know that FieldCache will really need to exist in the future. -Hoss --------------------------------------------------------------------- To unsubscribe, e-mail: email@example.com For additional commands, e-mail: email@example.com
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