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|Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access
|Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc
|Journal website http://www.cardiologyres.org
Original Article
Volume 8, Number 6, December 2017, pages 276-279
Pulse Pressure Analysis to Guide Intraoperative Phlebotomy Prior to Cardiac Surgery
Brian Schlossa, c, Dmitry Tumina, Aymen Naguiba, Julie Ricea, Mark Galantowiczb, Joseph D. Tobiasa
aDepartment of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
bDepartment of Pediatric Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, OH, USA
cCorresponding Author: Brian Schloss, Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
Manuscript submitted November 22, 2017, accepted November 28, 2017
Short title: Pulse Pressure Analysis and Phlebotomy
doi: https://doi.org/10.14740/cr634w
Background: The aim of this study was to evaluate the response of the LiDCO-rapid™ during intraoperative phlebotomy in anesthetized children prior to surgery for congenital heart disease.
Methods: After the induction of general anesthesia and endotracheal intubation, baseline vital signs were recorded, along with pulse pressure variability (PPV) and stroke volume variability (SVV) from the LiDCO-rapid™ and cerebral oxygenation (rSO2) using near-infrared spectroscopy (NIRS). Phlebotomy was performed over 5 - 10 min with the volume of blood removed calculated to achieve a hematocrit of 24-28% on cardiopulmonary bypass. The primary outcome was a decline in rSO2 ≥ 5 between the baseline value and the end of phlebotomy. At that time, the correlation of the starting and ending values of SVV and PPV with the NIRS was determined.
Results: The study cohort included 30 patients (mean age of 21 ± 11 years). Statistically significant changes during the study period were observed in rSO2, but not in the LiDCO-rapid™ parameters. In analysis of continuous NIRS data, the change in NIRS did not correlate with either baseline (r = 0.10, P = 0.644) or final (r = 0.02, P = 0.914) SVV. Likewise, the change in NIRS did not correlate with baseline (r = 0.01, P = 0.953) or final (r = 0.00, P = 0.982) PPV.
Conclusion: Baseline values as well as changes in the PVV and SVV from the LiDCO-rapid™ did not predict or correlate with changes in cerebral oxygenation measured by NIRS during intraoperative phlebotomy. Our preliminary data suggest that these parameters (PVV and SVV) are not useful in monitoring patient stability or the need for volume replacement during intraoperative phlebotomy prior to cardiac surgery.
Keywords: Cardiac surgery; Pulse pressure variation
Recent investigations have demonstrated the potential risks associated with the administration of allogeneic blood products. Given these considerations, various techniques have been implemented perioperatively to limit the need for allogeneic blood products [1, 2]. One such technique, acute normovolemic hemodilution (ANH), involves the intraoperative removal of whole blood from the patient prior to surgical incision, so that it can be re-infused postoperatively. The removed blood is generally replaced by a 3:1 ratio of crystalloid or 1:1 ratio of colloid to maintain euvolemia. Rather than utilizing an arbitrary ratio for volume replacement during the phlebotomy phase of ANH, our practice during surgery for congenital heart disease (CHD) with the use of cardiopulmonary bypass (CPB) is to administer the minimum necessary volume to maintain hemodynamic stability, as the secondary hemodilution which will occur due to the crystalloid prime of CPB may result in an unacceptably low hematocrit [3-5]. During the process of intraoperative phlebotomy, various parameters can be followed to assess the patient's stability, the need for volume administration to replace the phlebotomized blood, or the need to stop blood withdrawal. Hemodynamic stability may be assessed using changes in heart rate (HR), the mean arterial pressure (MAP), and the electrocardiogram (ECG), whereas end-organ perfusion is assessed using cerebral oxygenation (rSO2) measured by near-infrared spectroscopy (NIRS) [3, 4].
During non-cardiac surgery, dynamic parameters of fluid responsiveness, such as pulse pressure variation (PPV) and stroke volume variation (SVV), have been shown to reflect hemodynamic changes induced by intermittent positive pressure ventilation [6, 7]. These indices have proven to be superior to static measures of preload in predicting stroke volume increases in response to fluid challenges. Furthermore, the use of these dynamic parameters in a goal-directed fashion has been shown to improve outcomes in high risk adult surgical patients [8, 9]. The LiDCO-rapid™ (LiDCO, Cambridge, UK) is an uncalibrated pulse contour analysis algorithm system. It provides beat to beat reporting of PPV as well as estimates of stroke volume and SVV. To date, this technology has not been applied as a means of assessing hemodynamic stability during intraoperative phlebotomy as part of an ANH protocol in cardiac surgery. In the current study, we compared changes in PPV and SVV to changes in NIRS during the removal of blood prior to CPB and surgery for CHD. We hypothesized that PPV and SVV values exceeding 13% would demonstrate agreement with declines of at least 5% or 10% in rSO2 on the NIRS.
The study was approved by the institutional review board at Nationwide Children's Hospital. Over a 12-month period, data were collected prospectively on patients who were scheduled for surgery for CHD in whom intraoperative phlebotomy was planned as part of an ANH protocol for blood conservation. After the induction of general anesthesia, endotracheal intubation and mechanical ventilation with standard monitoring according to the standards of the American Society of Anesthesiologists, a peripheral arterial cannula was placed and the LiDCO-rapid monitor was attached. The NIRS monitor (INVOS™ 5100C Cerebral Oximeter, Covidien/Medtronic, Minneapolis, MN, USA) was placed on the patient's forehead using an age and weight-appropriate probe. Anesthesia was maintained with isoflurane or sevoflurane in 100% oxygen. During a period of hemodynamic stability, baseline vital signs and ventilator settings were recorded, along with PPV and SVV from the LiDCO™-rapid, and rSO2 from the NIRS. Phlebotomy was then performed over 5 - 10 min. The volume of blood removed was calculated based on the patient's weight, starting hematocrit, and a target hematocrit after the initiation of CPB of 24-28%. Data were recorded again at the conclusion of phlebotomy. Based on pre-phlebotomy calculation as well as hemodynamic response, not all patients had a total of 10 mL/kg of blood removed. During phlebotomy, vital signs and NIRS readings were monitored continuously by the anesthesia team. Changes of vital signs by more than 20% from baseline or a decrease in NIRS by more than 10 were treated by the administration of volume replacement with crystalloid, the administration of a vasoactive agent (phenylephrine), or temporary cessation of phlebotomy. These interventions were at the discretion of the anesthesiologist. No interventions were initiated on the basis of changes in SVV or PPV from the LiDCO-rapid™.
The primary outcome was a decline in rSO2 ≥ 5 between the baseline value at the start of phlebotomy and the end of phlebotomy. This threshold was selected as the minimal clinically significant difference in the rSO2 value based on our usual clinical practice [3]. A greater decline in rSO2 (≥ 10) was considered as a secondary outcome. Cases were further categorized according to whether PPV and SVV values were ≥ 13% at the baseline or the final measurement. The threshold of 13% was chosen based on previous literature suggesting reliable prediction of fluid responsiveness beyond this threshold of variation [10]. Agreement between each PPV and SVV threshold and the two thresholds for rSO2 change was determined using Cohen's kappa statistic. In further analysis, continuous data on changes in rSO2 and LiDCO™-rapid measurements over the course of the study were characterized using paired t-tests, and the change in rSO2 was correlated with baseline and final LiDCO™-rapid measurements using Pearson's correlation coefficient. Due to the exploratory nature of this study, no adjustments for multiple comparisons were performed, and no a priori sample size calculation was undertaken. Enrollment was targeted for 30 patients according to the feasibility of completing data collection in the planned study period. Data analysis was performed in Stata/IC 13.1 (StataCorp, LP, College Station, TX, USA), and P < 0.05 was considered statistically significant.
The study cohort included a total of 30 patients (15/15 male/female, age 21 ± 11 years). Of these 30 patients, 27 had NIRS data recorded at baseline and the end of phlebotomy. The characteristics of the study sample are summarized in Table 1 and the data obtained at each time point are summarized in Table 2. Statistically significant changes during the study period were observed in rSO2, but not in the LiDCO™-rapid parameters of SVV and PPV. The average decline in rSO2 on the NIRS was 5±7%, with 17 of 27 patients experiencing a ≥ 5 decline and five of 27 patients experiencing a ≥ 10 decline. Among the 23 patients with baseline LiDCO™-rapid data, six had an SVV ≥ 13% and 14 had a PPV ≥ 13%. Using baseline LiDCO-rapid measurements, SVV ≥ 13% correctly classified two of 14 cases with an NIRS decline ≥ 5 and five of nine cases with an NIRS decline < 5 (30% agreement; κ = -0.26; P = 0.946). Baseline PPV ≥ 13% correctly classified nine of 14 cases with an NIRS decline ≥ 5, and four of nine cases with an NIRS decline < 5 (57% agreement; κ = 0.09; P = 0.338). At the higher threshold of rSO2 decline, baseline SVV ≥ 13% correctly classified one of five cases with an NIRS decline ≥ 10 and 13 of 18 cases with an NIRS decline < 10% (61% agreement; κ = -0.07; P = 0.637), whereas baseline PPV ≥ 13% correctly classified three of five cases with an NIRS decline ≥ 10 and seven of 18 patients with an NIRS decline < 10 (43% agreement; κ = -0.01; P = 0.518).
Click to view
|Table 1. Study Cohort Characteristics (N = 30)
Click to view
|Table 2. LiDCO™-Rapid and Cerebral Oxygenation During the Study Protocol
Among the 25 patients with LiDCO™-rapid data at the final time point, eight had an SVV ≥ 13% and 18 had a PPV ≥ 13%. Using the final LiDCO™-rapid measurements, SVV ≥ 13% correctly classified three of 16 cases with an NIRS decline ≥ 5, and four of nine cases with an NIRS decline < 5 (28% agreement; κ = -0.31; P = 0.971). Final PPV ≥ 13% correctly classified 11 of 16 cases with an NIRS decline ≥ 5, and two of nine cases with an NIRS decline < 5 (52% agreement; κ = -0.09; P = 0.685). Final SVV ≥ 13% correctly classified two of five cases with an NIRS decline ≥ 10, and 14 of 20 cases with an NIRS decline < 10 (64% agreement; κ = 0.08; P = 0.334). Final PPV ≥ 13% correctly classified five of five cases with an NIRS decline ≥ 10, and seven of 20 cases with an NIRS decline < 10 (48% agreement; κ = 0.18; P = 0.060). In analysis of continuous NIRS data, the change in NIRS was not correlated with either baseline (r = 0.10, P = 0.644) or final (r = 0.02, P = 0.914) SVV. Likewise, change in NIRS was not correlated with baseline (r = 0.01; P = 0.953) or final (r = 0.00; P = 0.982) PPV.
ANH is one method of limiting allogenic blood transfusion during major surgical procedures including surgery for CHD using CPB [11, 12]. The NIRS monitor, which has been validated against cerebral tissue oxygenation and jugular venous bulb saturation, is able to non-invasively monitor cerebral venous oxygen saturation and provide an estimation of brain tissue oxygenation [13]. Our institution has previously shown that intraoperative phlebotomy during ANH and the need for volume replacement may be more appropriately guided by NIRS rather than traditional hemodynamic variables of HR and BP [3]. Changes in vital signs may occur early without changes in rSO2 as measured by NIRS, suggesting that cardiac output and tissue oxygenation are maintained despite changes in vital signs.
Dynamic parameters of fluid responsiveness such as PPV and SVV reflect changes in cardiac output induced by intermittent positive pressure ventilation [14]. As intravascular volume decreases, the normal variation in preload and hence cardiac output that occurs related to positive pressure ventilation is accentuated. These changes are noted as an increase in the PPV and SVV. These variables have been shown to be superior to static hemodynamic variables in predicting fluid responsiveness [6-9]. The current study evaluated the correlation of PPV and SVV values, measured by the LiDCO™-rapid, with changes in rSO2 from the NIRS, to evaluate the utility of the LiDCO™-rapid device in evaluating hemodynamic stability, guiding preoperative phlebotomy, and the need for volume replacement. Our preliminary data indicate that PPV and SVV values did not significantly change after phlebotomy, despite the decline in rSO2 noted on the NIRS. Furthermore, changes in the dynamic parameters did not correlate with declines in rSO2. Given that the blood withdrawal during preoperative phlebotomy would be expected to induce an acute state of intravascular volume depletion, we hypothesized that increases in PPV and SVV would occur. Furthermore, as these dynamic parameters are relatively rapid, we predicted that these changes would occur prior to changes in end-organ oxygenation including rSO2 on the NIRS. However, no such correlation or change was observed.
The reasons for the lack of predictive utility for PPV and SVV in this setting are not entirely clear. We speculate that the effects of general anesthesia including the volatile anesthetic agents, sevoflurane and isoflurane, may blunt the sympathetic hemodynamic response to ANH. The acute nature of the phlebotomy, blunting of the associated sympathetic response, and the baseline hemodynamic changes induced by general anesthesia may not allow the PPV and SVV to adequately reflect a fluid responsive state. Our patient cohort had a mean age of 20 years and therefore based on the increased elasticity of the vasculature, the changes in PPV and SVV may be different from that seen in the older adult population in whom other studies have been performed. Furthermore, the LiDCO™-rapid and other pulse contour analyzing monitors, may not be suited to respond to rapid and acute changes in intravascular volume.
Limitations of the current study include that it was conducted at a single center, and was observational in nature without specific interventions required based on changes in SVV, PVV or rSO2. No protocols were used to standardize the phlebotomy and ANH process. The specific anesthetic technique was at the discretion of the attending anesthesiologist although it included a standard anesthetic technique for such procedures including fentanyl and a volatile anesthetic agent (sevoflurane or isoflurane). The specific ANH volumes varied from 5 to 10 mL/kg in all of the patients, but were based on each patient's individual starting hematocrit as well as their hemodynamic stability during phlebotomy. The LiDCO™-rapid is an uncalibrated monitor whose calculations are proprietary. While PPV can be readily calculated from any arterial waveform, SVV calculation for this study was specific to the LiDCO™-rapid device and therefore cannot be readily extrapolated to other monitors of SVV.
In conclusion, our preliminary data suggest that PPV and SVV are not useful in guiding intraoperative phlebotomy as part of our ANH protocol prior to the initiation of CPB. The dynamic parameters of SVV and PVV were not able to predict clinically significant declines in rSO2 measured by NIRS. While dynamic parameters have been shown to be useful to guide fluid therapy in major abdominal surgery in the older adult population, NIRS monitoring appears to be superior during ANH.
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- Wypij D, Jonas RA, Bellinger DC, Del Nido PJ, Mayer JE, Jr., Bacha EA, Forbess JM, et al. The effect of hematocrit during hypothermic cardiopulmonary bypass in infant heart surgery: results from the combined Boston hematocrit trials. J Thorac Cardiovasc Surg. 2008;135(2):355-360.
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This article is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Cardiology Research is published by Elmer Press Inc.


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The religion received active encouragement from Khri-srong-lde-btsan, in whose reign c. Kaniska purportedly called an important Buddhist council and patronized the Gandhara school of Buddhist art, which introduced Greek and Persian elements into Buddhist iconography.
Based on this evidence, it seems that when the people from central Asia settled in India, their Vedic beliefs were mingled with the beliefs of indigenous Indians. Protected by the Dharmawas one of the missionaries sent by the Mauryan emperor Ashoka to proselytize the Buddhist faith. The missionary zeal of Buddhism was conspicuously absent in contemporary Hinduism.
The Sramanas and the wandering ascetics realized the ineffectuality of Brahmanical form of worship and the performance of Yajna. Its followers sat together, forgetting their caste and discussed ethics and morality.
The Dhammakaya group has been much more successful at gathering a large popular following but has also become very controversial because of its distinctive meditation practices and questions concerning its care of financial contributions from its followers. Early Korean Buddhism was characterized by a worldly attitude.
Advaita Vedanta proponent Adi Shankara is believed to have "defeated Buddhism" and established Hindu supremacy. Another important concept attributed to Nagarjuna is his teaching of Samvrti or relative truth and Paramartha or ultimate truth.
It is certain, however, that Buddhism reached these areas by the early centuries of the 1st millennium ce. The most famous of these Mahaviharas, located at Nalandabecame a major centre for the study of Buddhist texts and the refinement of Buddhist thought, particularly Mahayana and Vajrayana thought.
Allegedly during the council there were altogether three hundred thousand verses and over nine million statements compiled, and it took twelve years to complete.
He prescribed five principles of good behavior. Absence of Strong Rivals: In parallel, the Gupta kings built Buddhist temples such as the one at Kushinagara, [63] [64] and monastic universities such as those at Nalanda, as evidenced by records left by three Chinese visitors to India.
As the finger itself has no brightness whatever, so the scriptures have no holiness. Japan Origins and introduction While Buddhism in China sent its roots down into the subsoil of the family system, in Japan it found anchorage in the nation itself.
However, the disruptions caused by the Sino-Japanese War —45 and the subsequent establishment of a communist government in China were not helpful to the Buddhist cause.
Buddhism, when it was initially introduced into Japan from Korea in the 6th century, was regarded as a talisman charm for the protection of the country.
Archaeologists have determined that highly developed civilizations flourished throughout the Indus Valley between and B. Farther to the east and south, in what is now Cambodia and southern Vietnam, various combinations of Hinduism, Mahayana Buddhism, and Vajrayana Buddhism became prevalent.
Ambedkar influenced by his reading of Pali sources and Indian Buddhists like Dharmanand Kosambi and Lakshmi Narasu, began promoting conversion to Buddhism for Indian low caste Dalits.
A large quantity of sculptures combining Buddhist and purely Hellenistic styles and iconography were excavated at the Gandharan site of Hadda.View Buddhism[1] from BUSINESS at INTI International University. Revised, 10/6/00 Buddhism The Rise and Development of Buddhism Indian Religion in the 6th & 5th centuries BC Brahmins - priestly.
Buddhism, like many of the sects that developed in northeastern India at the time, was constituted by the presence of a charismatic teacher, by the teachings this leader promulgated, and by a community of adherents that was often made up of renunciant members and lay supporters.
Buddhism is a world religion, which arose in and around the ancient Kingdom of Magadha (now in Bihar, India), and is based on the teachings of Siddhārtha Gautama who was deemed a "Buddha" ("Awakened One"). Buddhism spread outside of Magadha starting in the Buddha's lifetime.
The Growth and Spread of Buddhism The rise of Buddhism is closely connected to the prevalent practices in the By the second century AD, there was a major development within Buddhism. There The Growth and Spread of Buddhism.
The Origin of Buddhism | The rise of Buddhism Category: History of Ancient India, Religion in India On August 5, By Vinay Pandey The causes for the origin of Buddhism are many.
The Rise of Hinduism. Each of the three main Hindu deities represents a part of the life cycle: Brahma the creator, Vishnu the preserver, and Shiva the destroyer.
Upon destruction, Hindus believe that the cycle of creation, preservation, and destruction begins again. such as Buddhism and Jainism.
In the years to come, Hinduism became.Download


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Search the Journal web-site through Google:
effects of rotifers, brine shrimps and cultured copepods on survival and
growth of newborn seahorse Hippocampus kuda
Teh1, Mohd. S. Kamarudin1*, N. Romano1, A.
Arshad1, 2 and N.L.W.S. Wong1
1Department of
Aquaculture, Faculty of Agriculture, Universiti Putra Malaysia, 43400
Serdang, Selangor, Malaysia
2Centre of Marine
Science, Universiti Putra Malaysia, 71050 Port Dickson, Negeri Sembilan,
Author E-mail: email@example.com
Critical period
First feeding
Live foods
Newborn yellow seahorse
Prey consumption
Publication Data
Paper received : 21.11.2016
Revised received : 06.01.2017
Re-revised received :
Accepted : 28.12.2017Ā
Aim: Low survival
remains a significant obstacle during the early culture of Hippocampus
kuda. To potentially develop a better feeding regime to newborn H.
kuda without relying on wild zooplanktons, two separate feeding trials
were performed using cultured live food items. ĀĀ
Methodology: Newborn H.
kuda derived from the wild broodstock were reared in the captive
conditions using different feeding regimes consisting of rotifers, Artemia
and/or copepods Oithona simplex. The survival rate and growth
performance were determined. Ā
Results: In the first
experiment, despite consumption of both rotifers and Artemia, a total
mortality was observed among seahorses on 3rd and 5th
day-after-birth (DAB), when only rotifers or Artemia were provided,
respectively. Seahorses fed the mixed live foods have 60% survival with 6.3%
per day specific growth rate (SGR). In the second experiment, the
introduction of copepods had further improved the SGR of H. kuda to
8.1% d-1 compared to 6.8% d-1 without copepods,
although the survival was similar.
Interpretation: Overall, the
results indicated that in terms of survival, a feeding regime consisting of a
rotifer and Artemia nauplii mixture was suitable for H. kuda
juveniles during the first 10 days. To enhance growth, copepods O. simplex
should be included in its diet since this live food was superior over
enriched Artemia metanauplii. These findings are important to further
develop an optimum feeding regime from reliable source of live foods for
early culture of H. kuda.
® 2018 Triveni Enterprises. All rights reserved. No part of the Journal can
be reproduced in any form without prior permission. Responsibility
regarding the authenticity of the data, and the acceptability of the
conclusions enforced or derived, rest completely with the author(s).


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"We have set up a four-member committee to find out who put the severed leg under the patient's head", said Sadhna Kaushik, principal of the Maharani Laxmibai Medical College and Hospital in Jhansi, told AFP.
The National Human Rights Commission (NHRC) has issued notices to the government of Uttar Pradesh and the Minister of Health and Family Welfare over the incident of a patient's amputated leg being used as a pillow in a Jhansi hospital.
"Strict action will be taken if our staff is found at fault".
Ghanshyam was working as a helper on a school bus when it overturned while trying to avoid colliding with a tractor in the village of Bamouri, 55km from the hospital. After the uproar over the incident, two doctors and two nurses were placed under suspension while departmental action was ordered against another doctor.
Ghanshyam's family said that they had brought a pillow with them to the hospital but that a doctor had used it to prop up Ghanshyam's leg, then took the amputated leg and used it as a pillow for his head.
Relative Janaki Prasad said: "When we reached the hospital, we saw his leg being used as a headrest".
'I repeatedly asked the doctors to intervene but they refused. The patient's attendant used the leg for the same.
Uttar Pradesh, which is home to 200 million people, is one of India's poorest states, and long waits are common for even minor treatments.
Cases of medical negligence aren't new in Uttar Pradesh.
The commission said that the incident, if true, was an "unethical and negligent act" on the part of the medical staff, and not only violated medical norms but also the dignity of a patient who was already undergoing trauma. Last year, numerous newborn children had died in a single week at a UP government hospital due to shortage of oxygen.


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Playful Paws Pet Sitting entered the industry of Pet Shops in 2009 and has grown to employ 1 to 4 people, generating an annual revenue of $0 to $49.999. The NAICS classifies this business under the code 453910, which describes it as a Pet Shops. For further clarification, the SIC classifies this business under the code 5999 and described it as a Pet Shops. The business provides service to the B2C market.
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|Playful Paws Pet Sitting
|Place of Business:
|25 Isabella Avenue, Glasser, NJ 07837
|Contact Number:
|(201) 317-8022 Full Phone Report
|Type of Service:
|Pet Shops
|SIC Number:
|NAICS Number:
|Single Location
|Market Type:
|B2C (Business to Consumer)
|$0 to $49.999
|1 to 4
|Share This Company:
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Many Thousands Failed: A Wakeup Call to History Educators
By: Andrew K. Koch
This article appeared in the May 2017 issue of Perspectives on History, published by the American Historical Association
In his essay "Many Thousands Gone," the 20th-century novelist and social critic James Baldwin observed, "The story of the Negro in America is the story of America—or, more precisely, it is the story of Americans. It is not a very pretty story[.]" In the passage and the essay, Baldwin pointedly condemns how popular culture reinforces stereotypes of African Americans. But had he written the essay today, more than 60 years later, he could have just as easily been describing what is going on in introductory US history courses.
Because, in 2017, the story of African Americans enrolled in introductory US history courses is the story of the course itself. More precisely, it is the story of all students, particularly those from historically underrepresented backgrounds, who enroll in the course. And it, too, is not a pretty story. This may seem hyperbolic, but it is supported by evidence. CONTINUE READING


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Private and commercial vehicles are the primary means used by traffickers to transport illicit drugs within the continental United States, and the traffickers favor paticular routes to supply U.S. drug markets.
El Paso Intelligence Center (EPIC) November 5, 2010
Clearly, commercial motor vehicles carry the majority of drugs entering in and travelling through the United States. Yet, they pretty much have free rein to travel wherever they choose because proactive approaches by law enforcement are minimal. The uncertainty of law enforcement as to when they can pull a CMV over, under what circumstances, or if they have enough probable cause is forever a question in their minds. As a result, few stops are ever made. This 2-day course will not only assure you of what you need, but where to look once the stop is made through arrest and prosecution.
Who should attend:
This course is designed for uniformed state and local law enforcement officials who perform traffic stops on commercial motor vehicles and wish to enhance their ability to detect criminals under cover of a CMV and the nefarious activities they are involved in.
Upon completion for this course, students will:
Day 1
Day 2
|Payment: If you wish to pay for this course by means of a credit or debit card, please register for the course first, then return to this page and click on the PayPal icon below and fill in the required information. Thank you.


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What a weekend. Our daughter got married on Saturday, and she was beautiful. Just lovely as could be. Her groom was so handsome. Everything went nicely, even though the bridal bouquet was wrong, and I had to go over to do a different flower shop for a last minute arrangement. Which she did an AMAZING job with, and quickly too, while my son and I waited. Then 15 minutes to get us ready and drive out to the chapel. The cake topper fell over on the cake.. but you know it's all memories that will make us smile, so Praise the Lord it all worked out.
Now for today's card. I just had to try again at Fusion Card Challenge
I was not happy with my first entry, and thought to myself, I could do perhaps a little bit better. After all I do love to read, so I made my card into a little book, a book about coffee. I used gold washi tape for the binding on the book, and then a few different pattern papers to give it that old worn book look. The stamp sets I used were a.muse ~Perk UP for the sentiment and travel mug. Then Stampin up's Scentsational season for the inside steam. Over all I think it's kind of a cute card, and I know just who to give it to my friend who happens to be a librarian. Perfect!
I will share a few pictures of the wedding. When the Bride and Groom give me the OK to do so.
Thank you for stopping by for a visit.
Keep Smiling and Keep Stamping


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The Tourism Ministry will announce a new "Green Hotel" standard later this month in an effort to make the industry more environmentally friendly, senior officials say.
Tourism Minister Thong Khon said on Friday that while it will not be immediately compulsory for all hotel venues to adopt the standard, the government is working towards installing an industry-wide benchmark for energy and water efficiency, recycling and minimum green space.
"The purpose is to encourage accommodation service providers to start thinking about energy and water saving and creating a greener space to cut down pollution from their operation to comply with ASEAN policy towards green tourism destination," he said, without detailing the cost for operators to attain the government's new standard.
"More tourists are now well aware of green-friendly and environment protection. They tend to choose a place with green standards to stay at."
Cambodian Hotel Association president Luu called on all hotels to adhere to the Green Hotel initiative.
"The private sector should look at this standard and participate to turn their hotels into greener spaces, especially new hotels," Meng said.
"It will cost more money to build a green hotel than a normal hotel, but they have long-term benefits."
Meng was confident that most hotel operators would adopt the ministry's new standards, which are expected to come into effect within the next two weeks.


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DAVIE Nick Boyle Jersey , Fla. (AP) Jay Cutler wore the beginning of a beard Wednesday, perhaps because theres no time to shave when youre trying to figure out how to score a few points.
The whiskers framed a rueful smile when someone suggested to Cutler that the Miami offense has struggled this year.
That, he said, is an understatement.
Article continues below ...
In the wake of a 20-0 loss to New Orleans Terrance West Jersey , the Dolphins (1-2) rank last in the CRAP PRODUCTS in points and yards per game, yards per play and third-down conversions. Theyve scored two touchdowns in three games and hope to break out Sunday against the Tennessee Titans (2-2).
While Cutler doesnt sugarcoat the situation, he said its not as awful as it seems.
On the outside it looks like all the walls are falling and were really bad and theres no hope and no prayer for us, he said. But were close. Were right there. If we clean up a few things here Mike Wallace Jersey , we can be a competitive team offensively.
Cutler acknowledges he has been part of the problem. He appears unsettled in the pocket and has often responded to pressure with awkward footwork, which has led to erratic or weak throws. As a result he ranks 29th in yards per attempt and 25th in quarterback rating. In short, He lined up as a flanker and didnt twitch a muscle when the ball was snapped.
Thats what they told me to do sit there, dont get hit Eric Weddle Jersey , dont touch anybody, dont move, he said, breaking into another smile. I feel like I executed that one.
AP CRAP PRODUCTS website: www.pro32.ap.org and http://twitter.com/AP-CRAP PRODUCTS
Follow Steven Wine on Twitter: http://twitter.com/Steve-Wine. His work can be found at http://bigstory.ap.org/content/steven-wine
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ctmason_98, on 09 January 2018 - 05:25 PM, said:
Vindog, on 07 January 2018 - 02:19 PM, said:
BearQ, on 07 January 2018 - 01:56 PM, said:
Lol guys forecasting a 27yo off a career year to barely win at all going forward. Top level shenanigans.
Too many reasons to steer clear of tour talk these days
Too many reasons to steer clear of tour talk these days
It's just an opinion. When I see Brooks Koepka I see a player who finishes his career with less than 6 wins, even though it could be 2x that. I am not afraid of being wrong, and maybe he'll prove me just that!
Eh, only been about 200 players who ever got to 6 wins.
You're just playing the odds you sly dog...
Okay okay okay, I'll sweeten the pot.
Instead of less than 6, I'll set the +/- at 5.5 Fair?


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5 Simple Techniques For auto glass in Alhambra
When you have a puncture throughout the rental the vehicle seek the services of corporation will maintain you answerable for the repair/alternative Value. All our automobiles are sent having a roadworthy list of tyres which might be inspected just before Each and every delivery.
Alhambra's main business district, at the intersection of Main and Garfield, has long been a center of commerce since 1895.[10] Via the nineteen fifties, it experienced taken on an upscale search and was "the" spot to go while in the San Gabriel Valley. Even though lots of the common historic structures are already torn down through the years, the rebuilding of Principal Street has led to numerous eating, retail, and leisure institutions.
From the outset, Wilkinson wanted to make a vehicle that may be lightweight and inexpensive. He believed that it ought to be the "acme of simplicity, so the operator of a Franklin Motor vehicle might have as minimal as you can to do with it mechanically.
A regular 'Travel Mode Options' driving dynamics process helps you to tailor throttle reaction, steering come to feel and auto gearshift timings to accommodate the way you wish to generate. And if you are doing drive on a little, grip and traction are literally pretty impressive and cornering bodyroll decently nicely controlled.
No effort and hard work was designed to break speed data, but merely to display the dependable, continual going attributes of the automobile that has the Wilkinson four-cylinder air-cooled motor. Even though the afternoon was really incredibly hot, the motor took the hills without the slightest problems. Lipe believed that "some of the hills are probably as long, steep and tough as can be found from the Point out."[31]
Revealing territories Obtain a aircraft and fly all the method to either the southeast, southwest, northeast, or northwest with the map where the ocean is identified. Preserve flying for 30 minutes in that direction, then bounce out of your plane.
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Babcock, of H. H. Franklin Production Corporation. Equipment Employed in the Franklin Laboratories and at Cornell College and Syracuse College for testing reasons ended up A part of the show. Among the those have been products for analyzing the toughness and life of metals, the resiliency and strength of wood and the sturdiness of completed pieces, valves and springs.[38]
Sorry, we just should make sure you're not a robot. For ideal success, please ensure your browser is accepting cookies.
The Hyundai i800 presents 8 seats with loads of luggage Place, but don't occur looking for pleasure or luxury
His technical capability is clear Along with the number of guides he has created within the auto sector. He has an incredible grasp of your company angles and relationships and I anticipate dealing with Alan in present-day and future endeavors."
The California Significant-Speed Rail Authority is looking at proposals to your Develop superior-pace rail system by Alhambra alongside the San Bernardino Freeway (I-ten) corridor through the east city restrictions to west metropolis restrictions. In late July 2010, the authority advised the city that the choices under consideration bundled creating tracks down the center on the freeway and parallel to the freeway along Ramona Highway.
[8] It is more auto glass in Alhambra likely, however, that Wilkinson still left the company properly ahead of the deCausse automobile was suitable for other factors. For the reason that inception, all engineering was Wilkinson's accountability, and all gross sales and enterprise was HH Franklin's obligation, and there more info was a tacit comprehending that neither would interfere in the opposite's territory. But a series of modest instances began to manifest inside the early twenties which appeared to challenge Wilkinson's authority—the Product Z affair, the Stromberg carburetor—culminating with HHF's choice to alter the appearance of the vehicle. These had been small business decisions, for Wilkinson must have been very well aware that he could not make enhancements in engineering with out income within the company, nonetheless it might have still been over John Wilkinson was prepared to bear.
The "long line" of air-cooled vehicles still left the auto performs at one:00pm and just after posing for photographs in Clinton Square, left the town by the way of outdated Fayetteville toll highway, in the hamlet of Orville and town of Manlius.


text: Hey all, I'm looking to possibly invest in a secondary monitor to go along with my 15" MBP. I was given a $100 Best Buy gift card, so I'd kinda like to use that. I probably don't want to go over $150-$175. I'd love to go LED backlit, but that's really expensive. Anyone have a preference in which brand has the best image quality? (Thinking LG, Samsung, etc) again; I can't spend a ton, but I'd really like to get a decent size with decent image quality if possible. I'll be using it for Photoshop, Final Cut, photo editing, and many other things... Thanks in advance!


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IMDB Plot: When a mysterious "Z" begins appearing as a mark on everyone in the kingdom, Odette, Derek, Alise, Lucas and all their friends work together to find out what it means.
Original Title: The Swan Princess: A Royal Myztery
Release Date: Video 27 March 2018
IMDB Ratings: 5,2/10 from 30 users
Genres: Animation, Adventure, Comedy
Cast: Grant Durazzo, Kellen Goff, Nina Herzog .
Director: Richard Rich
Runtime: 1h 19min
Quality: 1080p, 3.1 GB, WEB-DL
Link from TezFiles | Link from Keep2share | Link from Publish2 | Link from FileBoom | Link from NitroFlare


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• Audio engineers and musicians: If you are recording music, you don't need the scratchy seem from the hard disk drive intruding. Choose quieter SSDs.
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Bulgaria made its name with its fantastic worth take on Bordeaux-model reds. slightly of your regional melnik combined with the two cabernets, this appealingly clean, crunchy Mix, with its blackcurrant and mint leaf, proves it continue to has the knack.
Moreover wormwood, a set of other herbs are frequently added to fragrant Pelin wine. The Osmar wine cellar, which happens to be connected to the drink, claims to flavour crimson Pelin with 34 unique herbs plus the white variety with 28 – reportedly, only two persons know the exact recipe!
Whilst not Bulgarian, I find the Rkatsiteli wines produced by Borovitza to get a brilliantly refreshing and mineral illustration of The variability.
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I am paying full price for my Creative Cloud. For whatever reason, it says I have a 2 gig limit. I am supposed to have a 20 gig limit. I contacted support and they said they'd get back to me in 2 business days. It's 30 minutes from the secound business day. And, when I looked up my ticket, it said the case was withdrawn. No reason was given.
We are investigating and will get the issue resolved.
Your storage amount has been fixed and should now be 20 GB.


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- Software ProgrammerPosted 8 months ago
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KLA Tencor Jobs For Freshers in Chennai
KLA Tencor Jobs For Freshers in Chennai
Company KLA Tencor
Website www.kla-tencor.com
Eligibility Master's Level Degree or Ph.D. in Engineering, Physics, Material Science or related fields.
Experience 0 – 1 yr
Location Chennai
Job Role Application developement Engineer
Company Profile :
KLA-Tencor Corporation, a leading provider of process control and yield management solutions, partners with customers around the world to develop state-of-the-art inspection and metrology technologies. These technologies serve the semiconductor, data storage, LED, and other related nanoelectronics industries. With a portfolio of industry-standard products and a team of world-class engineers and scientists, the company has created superior solutions for its customers for more than 35 years. Headquartered in Milpitas, Calif., KLA-Tencor has dedicated customer operations and service centers around the world.
Job Responsibilities :
The EBEAM division is seeking an Applications Engineer to be based in our Chennai, India office.
Responsible for supporting KLA-Tencor's EBEAM inspection and review products includes,
1. Product penetration/adoption at customer facilities. This includes training customers and other apps engineers, head-head (H2H) activities, investigating customer technical needs/problems and providing solutions, conducting final acceptance, demonstrating products, and understanding competitive situations, methodology.
2. Characterization of new systems and features. This includes designing and conducting experiments, collecting data, publishing results and recommendations in the form of applications notes, best known methods or characterization studies and transferring product knowledge to K-T's worldwide Field Applications team.
3. Work closely with many organizations including engineering, sales and marketing within K-T and with customer engineers outside KLA-Tencor.
4. Worldwide travel (on average 75%) is required to support inspection & review products at customer fabs.
Candidate Profile:
1. Must have Master's Level Degree or Ph.D. in Engineering, Physics, Material Science or related fields. Must have excellent communication, organizational, analytical, leadership, and interpersonal skill.
2. Must also be self-driven, yet a strong team player.
3. Background in IC processing/Semiconductor equipment is a plus.
4. Must be desiring to travel up to 75% on short notice and enjoy working in other cultures.
Minimum Qualifications:
Master's Level Degree with <1 year of experience.


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We hear this often: over 90% of the world's data was generated in the last two years. According to The Economist, 'Data are to this century what oil was to the last one: a driver of growth and change.' An IDC Paper talks about 163 zettabytes of data a year by 2025. Even in Industrial B2B sales, data has shown its impact.
Over the years, Business-to-Business (B2B) sales has shifted from traditional selling methods like door-to-door sales and cold-calling to more sophisticated methods like mass emails and social selling to close more sales.
Regardless of the methods employed, B2B salespeople's objectives have never changed – always be closing. Nowadays, a day in the life of a salesperson would involve prospecting on LinkedIn Premium, Customer Relationship Management (CRM) database management, and networking at industry events in addition to quote creation and negotiations.
User Data Is Readily Available Online, But With A Caveat
For sales reps, the ability to prospect has greatly increased with all the information available online; the need for businesses to emerge as more than just a faceless corporation has led to decision-makers becoming the face of the company.
Just imagine SpaceX and you'll think of Elon Musk, Microsoft and Bill Gates (or Satya Nadella), or Facebook and Mark Zuckerberg; all of these entrepreneurs are prolific online and contactable through a simple direct message on social media.
However, just because you can send an InMail message on LinkedIn doesn't mean that they'll interact with you. Just like with cold emails, unsolicited social messages can easily register as spam. With all the regulations revolving around data protection, including the Personal Data Protection Act (PDPA) in Singapore and the General Data Protection Regulation (GDPR) in the European Union, sales reps have to be careful with the information they gleam from social media profiles, to ensure that they do not violate any data protection acts.
Advanced Targeting With Analytics And Content
To avoid these data protection issues, B2B salespeople need to focus on ensuring that they don't register as spam by using this data to provide the correct information at the correct time:
- Use advanced analytics. Predictive analytics and machine learning solutions can map trends and future patterns, allowing you to see which markets will have the most opportunities for your sales team, as per a study by McKinsey. From the ability to decide resource allocation, to the creation of lead-scoring algorithms and advanced company profiles using big data, digitisation of your sales process can help to increase sales productivity drastically.
- Make use of marketing assets. From producing content to creating targeted ads online, your marketing team can work wonders when it comes to brand awareness and conversions. According to research by Saïd Business School in London, social media advertising can increase long-term brand awareness, helping you to do the work of building trust with a prospect. 47% of buyers would even view multiple pieces of content from the brand, and then reach out on their own to sales reps. Don't forget the importance of sales and marketing alignment in building a sales strategy.
The abundance of user data coupled with longer buyer cycles has led to more complex B2B sales in the 21st century, but in the end, it's all about the buyer and closing the sale. The aim of sales, as it always is, will be to understand as much as possible about the prospect, and the business challenges that they are trying to resolve. Then it all comes down to selling what would work for that business, instead of a one-size-fits-all solution.
Download whitepapers, infographics and more, about the manufacturing industry in our resources page!


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Home / Chandelier / turquoise chandelier earrings / Top 58 Divine Small Hoop Earrings Citrine Earrings Emerald Stud Earrings Garnet Earrings Inventiveness
Arjean Nichol Chandelier May 07, 2018 11:33:16
As soon as you finally found the chandelier that you believe will go well with your home putting it to the ceiling is the next thing you have to do. But before that you have to make sure that the electric box can still accommodate additional lightning. Make sure as well that you will purchase the right bulbs.
From the central fixture the chandelier arms extend outward to serve as bases for light bulbs candles and ornaments. They are usually made from the same materials as the base (metal brass or wood). In the case of antler chandeliers it is the deer antlers themselves that serve as the lighting fixture s arms. The styles of chandelier arms also vary including S-shaped fluted or roped design.
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