text:
Transient ischemic attack
I. What every physician needs to know.
The American Heart Association/American Stroke Association defines transient ischemic attack (TIA) as "a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction." In the past, TIA was defined simply as a focal ischemic neurologic event lasting less than 24 hours. However, it has become clear that an arbitrary, time-based definition of TIA is inadequate to differentiate TIA from stroke, as modern neuroimaging techniques have allowed detection of acute cerebral infarction even in patients whose symptoms completely resolve within hours of onset. This has led to a shift in emphasis from a time-based definition of TIA to a tissue-based definition that relies more heavily on neuroimaging as well as clinical data.
The major mechanisms of TIA are the same as stroke: large vessel atherosclerosis, cardioembolic, and small vessel occlusion/lacunar. In TIA, by definition, the obstruction to blood flow is temporary and resolves before tissue infarction occurs. It may be useful to think of TIA and stroke as conditions on the same clinical spectrum, similar to the relationship between unstable angina and acute myocardial infarction. Accurately diagnosing and risk stratifying patients who present with TIA is important since more than 10% of patients with TIA will go on to have an ischemic stroke in the next 3 months, and as many as half of these strokes occur within the first 48 hours following a TIA.
II. Diagnostic Confirmation: Are you sure your patient has Transient Ischemic Attack?
Clinical signs and symptoms of TIA can include any focal neurologic deficit (as opposed to global brain dysfunction as seen in delirium or encephalopathy). The specific symptoms depend on the vascular territory affected and the location of cerebral ischemia. TIA symptoms are transient by definition, and often (but not always) resolve within a matter of a few hours.
A. History Part I: Pattern Recognition:
The presenting symptoms of TIA can be any focal neurologic deficit with acute onset, such as unilateral weakness, numbness or paresthesia, drooping face, slurred speech, aphasia or dysarthria, dysphagia, double vision, monocular blindness, vertigo, or ataxia. Alterations of consciousness, tonic-clonic seizure, syncope, and/or generalized confusion are less common in TIA, and are more characteristic of other conditions in which brain dysfunction is global rather than focal.
B. History Part 2: Prevalence:
It is estimated that the incidence of TIA in the United States is between 200,000 and 500,000 per year, with a prevalence of 2.3%, or approximately 5 million people. The risk of TIA increases exponentially with age, regardless of gender or race. Other risk factors for TIA include diabetes, hypertension, smoking, hyperlipidemia, atrial fibrillation/flutter, alcohol or illicit drug use (e.g., cocaine), and hypercoagulable states.
C. History Part 3: Competing diagnoses that can mimic Transient Ischemic Attack.
The differential diagnosis for TIA includes seizure, migraine, hypoglycemia, and peripheral nerve conditions (e.g., Bell's palsy, nerve root compression, or vestibular neuritis). Other conditions such as multiple sclerosis, subdural hematoma, and CNS infection or malignancy can mimic TIA, as can psychiatric conditions such as conversion disorder. In elderly patients and in patients with existing cerebrovascular disease, systemic illness (e.g., pneumonia, UTI, C. diff) can worsen or unmask existing neurologic deficits that were previously mild or less apparent. A careful history and physical exam, including a complete neurologic exam, can often provide clues that help differentiate TIA from other conditions.
D. Physical Examination Findings.
The physical exam findings in TIA will depend on the vascular territory affected and the location of cerebral ischemia. Unilateral weakness, sensory deficits, or cranial nerve deficits are common exam findings in TIA. A patient with TIA will typically have a focal neurologic deficit rather than generalized confusion or alteration of consciousness.
E. What diagnostic tests should be performed?
Due to the high risk of stroke following TIA, all patients suspected of having TIA should be evaluated promptly, usually in an inpatient setting. Outpatient evaluation is reasonable in some instances if the appropriate tests can be obtained expeditiously (within 24-48 hours), but this is often not feasible.
1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?
Routine labs, such as a CBC, basic chemistries, INR, and PTT, should be ordered on all patients with suspected TIA, along with a fasting lipid panel and fasting blood glucose. A hemoglobin A1c may be useful in patients suspected of having undiagnosed diabetes mellitus. Other tests, such as urinalysis, blood/urine toxicology screens, ABG, BNP, or ammonia, may be useful depending on the clinical setting. While these tests do not help make the diagnosis of TIA they may identify coexisting conditions or TIA mimics that may help with diagnosis or management of the patient.
2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?
All patients suspected of having TIA should undergo neuroimaging as soon as possible. Magnetic resonance imaging (MRI) with diffusion weighted imaging is the preferred modality given its superior sensitivity in detecting cerebral ischemia or infarction, although in practice non-contrast head computed tomography (CT) is the most commonly ordered initial imaging study due to its lower cost and greater availability. Non-contrast CT has limited ability to detect cerebral ischemia or infarction, but it is useful to rule out hemorrhage or mass effect.
In patients with pacemakers or AICDs, or who have intolerance or other contraindications to MRI, a second non-contrast CT may be performed 24-48 hours after the initial study if symptoms are still present or if the diagnosis is unclear. Cerebral infarction not seen on the initial CT often shows up later as local tissue changes and edema develop at the site of the infarction. CT perfusion is another modality that can detect cerebral ischemia or infarction, but it has been better studied in stroke and is not often employed in TIA.
Other recommended imaging studies in patients with TIA include an evaluation of the extracranial vasculature with either Duplex ultrasound, CT angiography (CTA), or MR angiography (MRA). Detecting a lesion such as a high-grade carotid stenosis can alter management in patients with TIA and can help prevent subsequent stroke.
Evaluation of the intracranial vasculature by CTA, MRA, or trans-cranial Doppler is also recommended by the 2009 AHA/ASA guidelines, although its effect on patient management may be limited. There are no effective interventions for treating intracranial stenotic lesions other than standard medical therapy and risk factor reduction. The SAMMPRIS trial, the only published, randomized, controlled trial to address the efficacy of stenting intracranial stenotic lesions, suggested that intracranial stenting was inferior to medical therapy in preventing recurrent stroke.
An EKG should be obtained on all patients with suspected TIA to evaluate for arrhythmias, such as atrial fibrillation or atrial flutter, which can be associated with TIA. Continuous cardiac monitoring should be carried out for the duration of the hospitalization, and prolonged 30-day cardiac monitoring in the outpatient setting is recommended for patients in whom no clear etiology for their TIA was determined.
Up to 20% of patients with cryptogenic stroke or TIA will be found to have occult atrial fibrillation or atrial flutter on 30-day cardiac monitoring, and identifying these patients is important as they would be candidates for anticoagulation rather than antiplatelet therapy. There is growing recognition of the utility and cost-effectiveness of extended cardiac monitoring in stroke and TIA evaluation, and the practice has been more widely adopted in recent years.
Echocardiography is commonly performed in the evaluation of TIA under the rationale of looking for cardiac sources of embolism. The utility of echocardiography in the evaluation of TIA is discussed in greater detail below.
F. Over-utilized or "wasted" diagnostic tests associated with this diagnosis.
As many as 20% of TIA/stroke patients are cardioembolic, and consequently many experts recommend echocardiography as part of the initial evaluation of TIA. The AHA/ASA guidelines give echocardiography a class IIa recommendation (level of evidence B) and state that "echocardiography (at least TTE) is reasonable in patients with suspected TIAs, especially in patients in whom no cause has been identified by other elements of the work-up."
In practice, transthoracic echocardiography (TTE) is ordered routinely as part of the initial evaluation of TIA. However, multiple studies have demonstrated that the sensitivity of TTE in detecting cardiac sources of embolism is quite low, except for left ventricular thrombus, a rare cause of embolic TIA/stroke. Transesophageal echocardiography (TEE) has been shown to be significantly more sensitive than TTE in detecting most cardiac sources of embolism, especially left atrial appendage thrombus, the most common cause of embolic TIA/stroke. However, TEE is limited by cost, associated risks, and availability, and is not commonly ordered for TIA unless the patient has recurrent episodes of TIA and a negative TTE.
Multiple studies have demonstrated that both TTE and TEE findings rarely change the management of patients with stroke or TIA. Many sources of embolism detected by either TTE or TEE (e.g., PFO, atrial septal aneurysm, aortic atheromas, mitral annular calcifications) have no defined therapy, or therapy that does not differ from the standard medical therapy for TIA. Therefore, detecting these conditions does not typically alter management of the patient. In addition, given the increasing penetrance of EHR order sets and an increased emphasis on standardization of care, it is not uncommon for patients who have had a recent TTE, or who already have an indication for anticoagulation, or who are not candidates for anticoagulation, to have a TTE ordered and performed despite the fact that the test is unlikely to add anything to the work-up other than cost and increased length of stay. Hospitalists should recognize these instances of low/no-value care and strive to avoid them.
Some experts recommend an individualized, case-by-case approach to echocardiography in TIA/stroke, and this is probably the best and most cost-conscious strategy. Rather than ordering TTE routinely on all patients with TIA, it is reasonable to: assess the likelihood of an embolic event in each patient based on age, cardiac history, and other risk factors; consider whether the patient already has an indication for anticoagulation or whether they would be a candidate for anticoagulation should a source of embolism be found; determine if they have had a recent echocardiogram and if so whether it is necessary to repeat the study; and then order either a TTE, TEE, or no echocardiography accordingly.
Intracranial vascular imaging
Intracranial imaging (CTA or MRA) is commonly ordered as part of the initial work-up of patients with TIA. As compared to extracranial vascular imaging, which is an important component of the initial evaluation of TIA and can have a large impact on management of the patient, imaging of the intracranial vasculature is often a lower value test in many patients with TIA.
In certain populations with higher rates of intracranial large artery atherosclerosis (African-American, Hispanic, and Asian patients) the diagnostic yield of intracranial imaging may be higher, but the impact on patient management is less clear. This is in contrast to patients with acute ischemic stroke, in whom detection of an intracranial thrombus might be an indication for thrombolysis or mechanical thrombectomy.
For patients with TIA but not acute ischemic stroke, detecting an intracranial stenosis will likely not change management given the SAMMPRIS trial findings discussed above, which demonstrated that stenting intracranial lesions was inferior to medical therapy for secondary prevention of TIA and stroke.
There is weak evidence that short-term, dual antiplatelet therapy with aspirin and clopidogrel for 90 days can confer some benefit in certain populations with TIA due to high-grade intracranial lesions (70-99% stenosis), but this approach was given a Class IIb, level of evidence B recommendation by the most recent AHA/ASA guidelines, reflecting the weakness of the recommendation and the low quality of the data.
CTA and MRA, the most common modalities for evaluating intracranial vasculature, are relatively costly tests that are not without risk. Given the relatively low diagnostic yield, questionable impact on patient management, and relatively high cost of intracranial imaging, it may be a more cost-conscious strategy to defer intracranial imaging to later in the evaluation or even forgo it altogether in certain patients if it is clear that the results of the tests would not alter management of the patient.
Homocysteine and lipoprotein(a)
Elevated homocysteine and lipoprotein(a) levels are associated with an increased risk of cerebrovascular disease. However, there is no evidence that lowering either of these levels has any effect on either primary or secondary prevention of TIA or stroke, and therefore they should not be routinely ordered during the evaluation of TIA.
Autoimmune testing
In the absence of a history or clinical evidence of active lupus, tests such as ESR, ANA, and other auto-antibodies are unlikely to be useful in the initial evaluation of TIA.
Hypercoagulable testing
Antiphospholipid antibody testing or tests for other inherited thrombophilias may be indicated in specific patients (e.g., young patients with an otherwise negative evaluation, or patients with a personal or family history of thrombosis, lupus, or antiphospholipid syndrome) but should not be routinely ordered as part of the initial evaluation of TIA.
III. Default Management.
A. Immediate management.
Initial management in the emergency department should include basic labs, EKG, cardiac monitoring, and urgent neuroimaging (MRI or CT). A bedside swallow study should be performed, and once hemorrhagic stroke has been ruled out, aspirin (oral or rectal) should be given to all patients who do not have a contraindication. Admission to the hospital is usually advised to expedite the work-up. Permissive hypertension is generally recommended, although specific parameters for this are not well defined. The benefit of permissive hypertension is likely greater in patients with acute ischemic stroke as compared to patients with TIA. If a patient is taking a beta-blocker it may be reasonable to continue it even if other antihypertensives are held, in order to reduce the risk of myocardial infarction while in the hospital.
B. Physical Examination Tips to Guide Management.
Frequent neurologic checks by a physician or nurse are important to document the patient's clinical course during the hospitalization. TIA patients often have rapidly resolving deficits, but they are also at elevated risk of stroke in the time period immediately following the TIA. Progression or evolution of deficits in a patient after an initial negative neuroimaging study would be an indication for urgent reimaging to look for evolving stroke. Physical therapy, occupational therapy, and speech therapy services can be consulted as needed, although typically TIA symptoms will completely resolve prior to hospital discharge and rehab services will not be indicated.
C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.
Blood glucose should be monitored while the patient is hospitalized and, if elevated, insulin therapy should be instituted to maintain glycemic control. A fasting lipid panel should be drawn so that response to lipid-lowering therapy can be monitored in the outpatient setting. Changes in neurologic status should prompt urgent reimaging to look for evidence of evolving stroke.
D. Long-term management.
Long-term management of TIA focuses on secondary prevention of TIA or stroke with antiplatelet and statin therapy, and risk-factor reduction (blood pressure management, glycemic control, smoking cessation/substance abuse treatment, treatment of metabolic syndrome, etc.).
Antiplatelet therapy
Antiplatelet agents effective in secondary prevention of TIA include aspirin, clopidogrel (Plavix), and aspirin-dipyridamole (Aggrenox). Clopidogrel and aspirin-dipyridamole are each considered to be superior to aspirin alone, though the additional benefit of each agent is modest and is offset by significantly higher drug costs. Aspirin may actually be the best agent when efficacy, tolerance, and cost are taken into account.
The optimal dose of aspirin is not well-defined, but doses of 50-325 mg/day are recommended by the most recent AHA/ASA guidelines. Short-term combination therapy with aspirin and clopidogrel may be effective in certain populations (Asians, patients with high grade intracranial stenosis) but long-term dual antiplatelet therapy for TIA does not confer any additional benefit while significantly increasing the risk of bleeding complications.
Antihypertensive therapy
In general, the target for long-term blood pressure management in patients with TIA is <140/90. This may be accomplished with a single agent or some combination of a diuretic, ACE inhibitor, angiotensin receptor blocker, calcium channel blocker, or beta-blocker.
Lipid-lowering therapy
Statins are the only class of lipid-lowering agents shown to reduce the risk of TIA or stroke, even in patients with normal or average LDL. High dose atorvastatin (80 mg/day) has the best evidence from the SPARCL trial, and is therefore the agent of choice for secondary prevention of TIA.
Glycemic control
Strict glycemic control has not been shown to decrease macrovascular complications of diabetes, including TIA. However, it is reasonable to use existing guidelines for glycemic control in TIA patients with diabetes.
Smoking cessation
Smoking is associated with an increased risk of TIA and stroke, and all patients with TIA who are smokers should undergo smoking cessation counseling.
E. Common Pitfalls and Side-Effects of Management.
Adverse effects of medications started for secondary prevention of TIA are the most common side-effects of management. These can include bleeding complications from antiplatelet therapy, hypotension from antihypertensives, and LFT abnormalities or muscle pain or weakness from statins. Dose adjustment or changing or discontinuing medications may be required.
Antiplatelet therapy
Aspirin – start at 325 mg daily in the acute setting, then 50-325 mg daily thereafter (no clear evidence to recommend a specific dose)
Clopidogrel (Plavix) – 75 mg daily
Aspirin/ER dipyridamole (Aggrenox) – 25/200 mg twice a day
Antihypertensive therapy (commonly used generic agents)
Chlorthalidone (thiazide) – 12.5-25 mg daily (preferred over HCTZ due to longer duration of action and superior outcome data)
Lisinopril (ACE inhibitor) – 10-40 mg daily
Losartan (angiotensin receptor blocker) – 25-100 mg daily
Amlodipine (calcium channel blocker) – 5-10 mg daily
Metoprolol (beta-blocker) – 12.5-100 mg twice a day, or 25-200 mg daily ER
Carvedilol (alpha-1/beta-blocker) – 3.125-25 mg twice a day
Statins (commonly used agents)
Atorvastatin (Lipitor) – 10-80 mg daily (best evidence for secondary prevention from SPARCL trial, now available as generic)
Pravastatin (Pravachol) – 10-40 mg at bedtime (relatively less muscle toxicity)
Fluvastatin (Lescol) – 20-40 mg at bedtime (relatively less muscle toxicity)
Rosuvastatin (Crestor) – 5-40 mg daily (high potency, not generic)
IV. Management with Co-Morbidities.
A. Renal Insufficiency.
Choice of antihypertensive therapy could change in patients with CKD (e.g., furosemide instead of chlorthalidone, or forgoing an ACE inhibitor for another class of drug if the serum creatinine is markedly elevated). Some statins should be dose-adjusted for CKD.
B. Liver Insufficiency.
The FDA recommends that transaminases should be checked prior to initiation of statin therapy, and 12 weeks following initiation. Patients with chronic liver disease should be monitored closely for progressive LFT abnormalities while on statin therapy. Statins should not be used in patients with progressive or decompensated liver disease or hepatic failure.
Antiplatelet agents may increase the risk of bleeding in patients with impaired synthetic hepatic function and coagulopathy.
C. Systolic and Diastolic Heart Failure.
Patients with heart failure may be at higher risk of a cardiac source of embolism (CSE) or cardiac arrhythmia (such as atrial fibrillation) that can increase the risk of TIA. Management is not significantly changed by the presence of either systolic or diastolic heart failure. Antihypertensive therapy for heart failure (ACE inhibitors, beta-blockers, diuretics) aligns well with recommendations for treating hypertension in TIA.
D. Coronary Artery Disease or Peripheral Vascular Disease.
Long-term dual antiplatelet therapy is not recommended for secondary prevention of TIA given the lack of benefit and increased risk of bleeding, but patients with coronary artery stents or a recent myocardial infarction may have indications for dual antiplatelet therapy.
E. Diabetes or other Endocrine issues.
Monitoring of blood glucose or measurement of hemoglobin A1c during a hospitalization for TIA may lead to a new diagnosis of diabetes. Glycemic control according to established guidelines is recommended. Antihypertensive therapy for patients with TIA and diabetes should generally include an ACE inhibitor or angiotensin receptor blocker unless there is a contraindication to both of these agents.
F. Malignancy.
Malignancy is a hypercoagulable state and may increase the risk of TIA. CNS involvement of malignancy should be considered and ruled out in patients with TIA symptoms. Paradoxical embolism from DVT (e.g., via a PFO) should be considered in patients with malignancy who present with TIA.
G. Immunosuppression (HIV, chronic steroids, etc.).
CNS malignancy or infection should be considered and ruled out in immunosuppressed patients who present with TIA symptoms.
H. Primary Lung Disease (COPD, Asthma, ILD).
No change in standard management.
I. Gastrointestinal or Nutrition Issues.
No change in standard management.
J. Hematologic or Coagulation Issues.
Hypercoagulable states increase the risk of TIA, and paradoxical embolism should be considered in these patients. Caution should be exercised in patients with a bleeding diathesis when prescribing antiplatelet therapy.
K. Dementia or Psychiatric Illness/Treatment.
The extent of diagnostic testing may be changed by the presence of advanced dementia. For example, a patient with advanced dementia who is not a candidate for carotid endarterectomy or anticoagulation should probably not undergo evaluation of the extracranial vasculature or echocardiography during an evaluation for TIA. Patients with advanced dementia or active psychiatric conditions may not be able to tolerate MRI. Some psychiatric conditions, such as conversion disorder or tardive dyskinesia from neuroleptic therapy, can mimic TIA.
V. Transitions of Care.
A. Sign-out Considerations While Hospitalized.
An acute change in neurologic status in patients admitted with TIA should prompt urgent reimaging to look for stroke. Uncontrolled blood pressure, hyper/hypoglycemia, and cardiac arrhythmias such as atrial fibrillation are all issues that may come up during hospitalization.
B. Anticipated Length of Stay.
Most patients with TIA can undergo a complete evaluation within 24-48 hours and will not require an extended hospital stay. The availability of imaging modalities such as ultrasound and MRI, especially on nights, weekends, and holidays, can prolong the length of stay.
C. When is the Patient Ready for Discharge.
Patients with TIA are generally ready for discharge once their symptoms have resolved, when they have completed their diagnostic work-up, and when their relevant medical conditions and secondary prevention issues (blood pressure, glycemic control, smoking cessation, etc.,) have been addressed. Patient education regarding TIA/stroke symptoms should be completed prior to discharge. Rehabilitation services (physical/occupation/speech therapy) are generally not required since symptoms will generally have already resolved, but the lack of indication for rehab services should be documented in the medical record to satisfy Joint Commission Quality Measures.
D. Arranging for Clinic Follow-up.
Follow-up with a primary care provider after hospital discharge is important for long-term management of risk factors (blood pressure, lipids, diabetes, smoking cessation).
1. When should clinic follow-up be arranged and with whom.
When possible, a primary care clinic appointment within 7 days of discharge is recommended. For patients with recurrent TIA, or in whom the diagnosis is uncertain (e.g., TIA versus migraine versus seizure), follow-up with a neurologist is reasonable.
2. What tests should be conducted prior to discharge to enable best clinic first visit.
A baseline lipid panel is useful in patients who are starting statin therapy. Hemoglobin A1c should be ordered in patients in whom diabetes is diagnosed or suspected.
3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.
Creatinine and potassium should be ordered in patients started on diuretics or ACE inhibitors. It is reasonable to follow LFT's when starting statin therapy, especially in patients with liver disease or who are taking other medications with the potential for drug-drug interactions.
E. Placement Considerations.
Patients with TIA can generally return to their prior living situation, since their symptoms will have generally resolved by the time of discharge. Rehabilitation services (physical/occupational/speech therapy) are generally not required.
F. Prognosis and Patient Counseling.
Patients with TIA are at increased risk of stroke in the days and weeks following their initial event. All patients and their families should be counseled on signs and symptoms of stroke and should be urged to seek medical attention immediately if they develop these symptoms. Smoking cessation counseling should be performed in patients who have smoked in the past year. Patients should be advised to limit their dietary sodium intake in order to help with blood pressure control. Patients with diabetes should be instructed on glycemic control and a diabetic diet.
VI. Patient Safety and Quality Measures.
A. Core Indicator Standards and Documentation.
The Joint Commission requires facilities certified as Primary Stroke Centers to report on eight core quality measures each quarter. These measures generally apply to patients with TIA as well, and should be addressed in physician documentation, especially if a measure is not met. The eight quality measures are:
– Venous thromboembolism prophylaxis
– Discharged on antithrombotic therapy
– Anticoagulation for atrial fibrillation/flutter
– Thrombolytic therapy
– Antithrombotic therapy by the end of hospital day 2
– Discharged on a statin medication
– Stroke education
– Assessed for rehabilitation
B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.
In-hospital prophylactic measures for TIA include VTE prophylaxis, fall and aspiration precautions in patients whose deficits have not yet resolved, and frequent neurologic checks to detect progression of TIA to stroke. As with other non-ICU medical patients, GI prophylaxis is not indicated in most cases, and may even be harmful by increasing the risk of pneumonia and clostridium difficile infections.
Secondary prevention of TIA consists of prescribing an appropriate medical regimen and addressing modifiable risk factors in patients, as discussed above.
VII. What's the evidence?
Easton, J. "Definition and Evaluation of Transient Ischemic Attack". Stroke.. vol. 40. 2009. pp. 2276-2293.
Kernan, W. "Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack". Stroke.. vol. 45. 2014. pp. 2160-2236. (Updated 2014 AHA/ASA guidelines.)
Chimowitz, M. "Stenting Versus Aggressive Medical Therapy for Intracranial Arterial Stenosis". N Engl J Med. vol. 365. 2011. pp. 993-1003.
Amarenco, P. "High Dose Atorvastatin After Stroke or Transient Ischemic Attack". N Engl J Med. vol. 355. 2006. pp. 549-559. (SPARCL)
Wang, Y. "Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack". N Engl J Med. vol. 369. 2013. pp. 11-19. (First trial showing short-term benefit of dual antiplatelet therapy after TIA/stroke.)
McGrath, E. "Transesophageal echocardiography in patients with cryptogenic ischemic stroke: a systematic review". Am Heart J.. vol. 168. 2014. pp. 706-712. (Systematic review of TEE and its impact on management of TIA/stroke.)
Gladstone, D. "Atrial fibrillation in patients with cryptogenic stroke". N Engl J Med. vol. 370. 2014. pp. 2467-2477. (Trial showing significant prevalence of occult atrial fibrillation in stroke patients.)
Copyright © 2017, 2013 Decision Support in Medicine, LLC. All rights reserved.
No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. The Licensed Content is the property of and copyrighted by DSM.
- Transient ischemic attack
- I. What every physician needs to know.
- II. Diagnostic Confirmation: Are you sure your patient has Transient Ischemic Attack?
- A. History Part I: Pattern Recognition:
- B. History Part 2: Prevalence:
- C. History Part 3: Competing diagnoses that can mimic Transient Ischemic Attack.
- D. Physical Examination Findings.
- E. What diagnostic tests should be performed?
- 1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?
- 2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?
- F. Over-utilized or "wasted" diagnostic tests associated with this diagnosis.
- III. Default Management.
- A. Immediate management.
- B. Physical Examination Tips to Guide Management.
- C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.
- D. Long-term management.
- E. Common Pitfalls and Side-Effects of Management.
- IV. Management with Co-Morbidities.
- A. Renal Insufficiency.
- B. Liver Insufficiency.
- C. Systolic and Diastolic Heart Failure.
- D. Coronary Artery Disease or Peripheral Vascular Disease.
- E. Diabetes or other Endocrine issues.
- F. Malignancy.
- G. Immunosuppression (HIV, chronic steroids, etc.).
- H. Primary Lung Disease (COPD, Asthma, ILD).
- I. Gastrointestinal or Nutrition Issues.
- J. Hematologic or Coagulation Issues.
- K. Dementia or Psychiatric Illness/Treatment.
- V. Transitions of Care.
- A. Sign-out Considerations While Hospitalized.
- B. Anticipated Length of Stay.
- C. When is the Patient Ready for Discharge.
- D. Arranging for Clinic Follow-up.
- 1. When should clinic follow-up be arranged and with whom.
- 2. What tests should be conducted prior to discharge to enable best clinic first visit.
- 3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.
- E. Placement Considerations.
- F. Prognosis and Patient Counseling.
- VI. Patient Safety and Quality Measures.
- A. Core Indicator Standards and Documentation.
- B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.


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='''WormBase Gene Ontology Progress Report, December 2010'''=
='''WormBase Gene Ontology Progress Report, December 2010'''=
Revision as of 18:27, 16 July 2014
WormBase Gene Ontology Progress Report, December 2010
Juancarlos Chan
Developer, WormBase, Caltech, Pasadena, CA.
Ranjana Kishore
Curator, WormBase, Caltech, Pasadena, CA.
Paul Sternberg
PI, WormBase, Caltech, Pasadena, CA.
Kimberly Van Auken
Curator, WormBase, Caltech, Pasadena, CA.
Jolene Fernandes
Phenotype Curation, WormBase, Caltech, Pasadena, CA.
Gary Schindelman
Phenotype Curation, WormBase, Caltech, Pasadena, CA.
Ruihua Fang
Bioinformatician, Developer, WormBase, Caltech, Pasadena, CA
Additional technical support:
Anthony Rogers
WormBase, Sanger Center, Hinxton, UK
Gary Williams
WormBase, Sanger Center, Hinxton, UK
Hans Michael Muller
Project Leader, Textpresso, Caltech, Pasadena, CA
Arun Rangarajan
Developer, Textpresso, Caltech, Pasadena, CA
Annotation Progress
Table 1: Number of Genes Annotated
|Type of Annotation
|Number of Genes Annotated, Dec 2010
|% Change from Dec 2009
|Number of Unique GO Terms
|Total Number of GO Terms
|Manual Annotation
|Phenotype2GO Mappings
Methods and Strategies for Annotation
Literature Curation
Manual curation of the C. elegans literature remains our highest curation priority, contributing to ~90% of our total curation efforts. Curators use a GO curation check-out form that affords curators easy visual access to the curation status of all named C. elegans gene, e.g. vha-6 or egl-9. Genes are displayed in a list that includes the current number of published papers (references) indexed to that gene and the last date for which annotations to any of the three ontologies were made. Curators can query and sort the list according to reference count, gene name, and curation status.
Computational Methods
InterPro2GO mappings for IEA annotations: These annotations are annotations of C. elegans proteins to GO terms based on electronic matching of protein motifs/domains to those documented in the InterPro database (http://www.ebi.ac.uk/interpro/), and their mapping to GO terms provided by the InterPro2GO file generated by the EBI (PMID:12654719, PMID:12520011). Note that the 'IEA' annotations are not reviewed for accuracy by human curators. As such, all of these annotations use the evidence code 'IEA'.
TMHMM2GO mapping for IEA annotations: We also include the results of an internal pipeline that maps proteins containing a transmembrane domain, as predicted by the TMHMM algorithm, to the GO Cellular Component term, integral to membrane. About 6,710 gene products are annotated to the term 'integral to membrane' via this pipeline.
InterPro2GO and TMHMM2GO annotations are updated at every database release.
Semi-automated Methods
Review and improvement of the Phenotype2GO data pipeline
WormBase uses a well defined phenotype ontology to annotate gene-allele and RNAi-based phenotypes. A total of 201 phenotype terms used in annotation have been mapped to a GO term. These mappings are used to automatically generate Biological Process annotations to genes using the IMP evidence code, at every WormBase database build . The complete list of WormBase phenotype to GO term mappings can be found here: http://www.wormbase.org/wiki/index.php/Gene_Ontology. We have begun a detailed review of our phenotype to GO term mappings. We are in the process of making changes to this pipeline so that annotations are made with a stricter use of the IMP evidence code, as recently described in GO consortium annotation policies. This process will involve removing some high-level phenotype term to GO term mappings and/or removal of certain RNAi experiments/papers from being included in this pipeline and the review and changing of scripts.
Textpresso-Based Cellular Component Curation
As a complimentary approach to our manual curation pipeline, we continue to employ the Textpresso information retrieval system to annotate C. elegans gene products to the Cellular Component ontology. Textpresso searches for component annotations use three different categories (Assay Terms, Component Terms, and Verbs) plus a category of C. elegans protein names. Searches using these categories return sentences that contain a match to at least one term in each category. We use this approach to annotate newly published papers as well as papers published prior to 2010. For newly published papers, we prioritize our searches by first searching through papers that, as determined by a Support Vector Machine document classifier, have a relatively high probability of containing expression data.
Over the past year, through our manual and Textpresso-based pipelines, we added new cellular component annotations to 292 genes. Of these, 113 genes were annotated from papers published in 2010, with the remainder of the annotations coming from previously published papers. For the 2010 papers, Textpresso's annotation recall was 91.3%. We have not yet measured the recall on papers annotated this year but published prior to 2010.
Priorities for Annotation
Our annotation priorities are as follows:
1) Reference Genome genes
2) Genes presented for annotation via our Textpresso-based semi-automated Cellular Component curation pipeline
3) Genes from training set papers used for piloting semi-automated Textpresso-based Molecular Function curation
4) Newly described genes for which previous annotation was not available
5) C. elegans orthologs of human disease genes
Presentations and Publications
Publications, Talks, Posters 2010-
Ontology Development Contributions
WormBase curators have contributed to ontology discussion and development in the areas of:
Biology of the cilium:
- updates/revisions to terms added in 2005
Biology of the phagosome-lysosome during apoptotic cell clearance, terms added:
- phagosome maturation involved in apoptotic cell clearance
- phagosome acidification involved in apoptotic cell clearance
- phagolysosome assembly involved in apoptotic cell clearance
- phagosome-lysosome docking involved in apoptotic cell clearance
- phagosome-lysosome fusion involved in apoptotic cell clearance
Biology of muscle, terms added:
- striated muscle contraction involved in embryonic body morphogenesis
- striated muscle myosin thick filament assembly
- striated muscle paramyosin thick filament assembly (2010)
- alpha-tubulin acetylation
Biology of nematode larval development, terms added:
- regulation (includes positive and negative regulation child terms) of nematode larval development
- regulation of (includes positive and negative regulation terms) dauer larval development
Other terms added were:
- neuropeptide receptor binding
- determination of left/right asymmetry in the nervous system
- regulation of locomotion (including positive and negative regulation child terms) involved in locomotory behavior
- detoxification of arsenic
- chondroitin sulfate proteoglycan binding
- chondroitin sulfate binding
- octapamine/tyramine signaling involved in the response to food (and the regulation terms)
Annotation Outreach and User Advocacy Efforts
Kimberly Van Auken continues to participate in the go-help rotation. Ranjana Kishore continues to participate in the efforts of the GO News group.
Other Highlights
Curation Tools: Ontology Annotator
We have continued development on our web-based curation tool, the Ontology Annotator, that can be used to annotate genes to any ontology, including the Gene Ontology and the WormBase Phenotype Ontology. The Ontology Annotator incorporates and expands upon much of the functionality of the Phenote curation tool. Some of the more useful features of the tool include bulk annotation capabilities, autocomplete functions, retrieving data and filtering of the retrieved data for editing purposes. We have improved functionalities for existing annotation interfaces and have added the following curation interfaces that are fully functional: antibody, small molecule and gene regulation. We are currently working on 2 new curation interfaces: gene regulation and expression pattern related pictures.
Textpresso- and HMM-Based Molecular Function Curation
In addition to using Textpresso for Cellular Component Curation, we have developed pipelines for semi-automated Molecular Function (MF) curation. Given that Molecular Function annotations can be made based upon evidence from a wide variety of experiments, our approach has been to divide molecular function curation into two broad categories: 1) macromolecular interactions and 2) enzymatic and transporter activities.
Macromolecular Interactions
For the former, we employ a two-step curation pipeline. First, we use an SVM-based document classification algorithm to identify new papers likely to contain reports of macromolecular interactions. These papers are then searched for matching sentences using Textpresso categories developed specifically for identifying sentences describing macromolecular interactions. Our initial results indicate that the SVM performs very well on predicting high confidence true positive papers (precision=86.4%) as well as true negative papers (precision=88.9%). The Textpresso categories also have a high recall (89.7%), but have a relatively low precision (precision=47.3%). In practice, this means that while curators are able to retrieve and curate nearly all macromolecular interactions, they still must examine a number of false positive sentences, so the curation efficiency needs to be improved. We are in the process of fine tuning the Textpresso categories for macromolecular interactions in hopes of addressing this issue and improving curation efficiency. The new Textpresso categories for this data are scheduled to be in place at the end of December 2010.
Enzymatic and Transporter Activities In parallel to these efforts, we are also investigating semi-automated curation methods for annotating enzymatic and transporter activities. For this data type, we are developing Textpresso categories as well as training a Hidden Markov Model (HMM) to identify curatable sentences. For the former, we have collected 419 sentences from 64 papers. Using these sentences, we have developed two new Textpresso categories for enzymatic and transporter activities. As for the new macromolecular interaction categories, we plan to implement these categories on Textpresso by the end of December 2010.
In collaboration with Hans-Michael Mueller, we are also training a Hidden Markov Model to identify sentences describing enzymatic and transporter activities. At present, we are in the third round of training and evaluation for the model. We hope to complete an initial evaluation of the model by early next year and will report on its performance.
Textpresso-Based identification of literature for human disease gene orthologs
Human disease gene orthologs are a high priority annotation list for WormBase and other model organism databases. Sequence-based or similarity searches for human disease gene orthologs provide useful candidates but the biological information needs to be extracted manually from the literature. We are working on a project that combines the use of Textpresso-based categories and key word searches to identify elegans papers which describe the study of a human disease gene ortholog. Sentences in which a C. elegans gene co-occurs with a human disease term were deemed important for this process. A new 'human disease' Textpresso category was formed using the human disease ontology in the OBO foundry, the Neuroscience Information Framework Standardized (NIFSTD) ontology and the existing Textpresso human disease category. Several disease terms that would increase the number of false positives were removed iteratively by a manual process. As performing an 'AND' query on just two categories--human disease and C. elegans gene, returned too many false positives, a third category was formed with the words 'ortholog', `homolog', `similar', `relate' and `model', and added to the 'AND' query. The query is being fine-tuned for increasing precision and recall. Once established, it will automate the flagging of new articles that have disease gene ortholog data. Subsequently this method can be used for the extraction of relevant information.
Textpresso-Based Curation Pipelines for Other MODs
We have been collaborating with The Arabidopsis Information Resource (TAIR) and dictyBase to develop and implement Textpresso-based curation pipelines for Cellular Component annotation. At present, we have been working with TAIR to develop a pipeline by which they can perform Textpresso searches on the Arabidopsis corpus from 2008 to identify potentially new annotations that were not previously captured in their existing GO curation pipeline. The results of these searches are being presented in a curation form that will allow TAIR curators to make new annotations and retrieve the annotations in both a gene_association file format and a more basic, three-column format that is similar to their user submission format. We hope to generalize this pipeline so that other groups, including dictyBase, will be able to perform Textpresso queries, send the results to a curation form, and retrieve the output of the curation as a gene_association file.
Collaboration with BioGRID
In late summer, we begin a collaboration with the BioGRID (Biological General Repository for Interaction Datasets) to add protein binding annotations (IPI evidence code) curated for GO into BioGRID. In addition, we also plan to add curated genetic interactions (IGI evidence code) to BioGRID. Our initial work will focus on adding interactions curated as part of the Reference Genome's Wnt signaling pathway annotation project. Concurrently, we will also add any newly curated protein binding annotations (Wnt pathway or otherwise) to BioGRID.

subset: commoncrawl


text:
Help the National Space Society achieve its vision for a vigorous future of exploration and settlement of outer space by becoming a recruiter for new members to the Society. NSS needs your help in finding other people who share our vision to become a part of a dynamic community of space enthusiasts. Help us grow our ranks and at the same time earn rewards for your NSS Chapter.
The Campaign for the Future will be an ongoing (multiyear) membership recruitment campaign, and participants can accumulate reward points over multiple years if desired to earn higher reward levels.
Learn more about Campaign for the Future for NSS Chapters
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Brookhaven Lab Scientist David Diamond Receives American Nuclear Society's Tommy Thompson Award
May 26, 2010
David Diamond Receives ANS Award
UPTON, NY — David Diamond, a senior scientist at the U.S. Department of Energy's Brookhaven National Laboratory, has been chosen to receive the 2010 Tommy Thompson Award from the American Nuclear Society (ANS). Named in honor of Theos J. Thompson (1918 – 1970), a Massachusetts Institute of Technology professor and a member of the Atomic Energy Commission who made important contributions to nuclear reactor safety, the award recognizes individuals who have "provided outstanding wisdom and direction to key elements of world nuclear safety activities." Diamond will receive the award, which consists of a plaque and $1,000, at an ANS meeting in San Diego on June 15.
"I am honored to receive this award," Diamond said. "Also, I honor the contributions and dedication of colleagues throughout my long and rewarding career at Brookhaven Lab. Their dedication and camaraderie provide the motivation for me to come to work every day."
Diamond is a consultant on safety, design and related technical aspects of nuclear reactors, primarily for the U.S. Nuclear Regulatory Commission, but he has also been a consultant for other nuclear regulatory agencies around the world, with a particularly long relationship with the Canadian Nuclear Safety Commission. He does computer simulations to show how nuclear power reactors function under various transient and hypothetical accident conditions — crucial information to assure the safety of these power plants. Currently, there are 104 power reactors in operation in the U.S. and 22 in Canada. Diamond also has provided technical support for the National Institute of Standards and Technology's research reactor in Gaithersburg, Maryland, one of about 40 research reactors in the U.S.
As head of Brookhaven Lab's Nuclear Energy and Infrastructure Systems Division (NEISD), Diamond oversees 25 employees who analyze factors in nuclear energy systems that affect their safety. His staff includes civil, nuclear, mechanical, electrical, and human performance engineers. Recently, his division has taken on research in a new area: small reactors with about one-tenth of the power of currently operating power reactors. These proposed reactors of the future are designed to be more economical than the current generation of larger ones.
"There has been a renaissance in nuclear energy in the last few years," Diamond said. "We hope Brookhaven Lab will be actively involved in the design and safety issues in this frontier area."
After earning a Ph.D. in nuclear engineering from the Massachusetts Institute of Technology, Diamond joined Brookhaven Lab as an assistant nuclear engineer in 1968. He rose through the ranks to become division head of NEISD in 2001. Diamond is a Fellow of the ANS.
2010-11142 | INT/EXT | Newsroom


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Doug Gross, the 2002 Iowa GOP nominee for governor, and Steve Scheffler, president of the Iowa Faith and Freedom Coalition, are the guests on this weekend's Iowa Press, which airs on IPTV @ 7:30 this evening. Gross was first to address the controversy:
"I don't personally have the information…I've read the news reports associated with it and it looks troubling and troubling in the sense that Rick Santorum said that they talked about money and he raises the issue of money in return for an endorsement. Now, he said it wasn't specifically said that way, but instead what they talked about was the need for money in order to help promote the endorsement. Whatever, it looks troubling.
"…What I think we've got going is Bob is very much interested in his own future candidacy, at least for some particular higher office. He's run three times, so I think there's a pattern here that's developing and it appears that he wants to run again, I suspect, and anytime Bob can try to help promote himself he attempts to do that and I think what he was trying to do is get himself in a position where he could play a prominent role to help promote himself for a future candidacy."
Scheffler was asked, by AP's Mike Glover: "Do you find that whole episode troubling, assuming that the reports we've seen about it are accurate?" Scheffler's answer:
"Well, naturally I'm concerned about what the reports might contain or not contain. Certainly Bob is free to do what he wants to do. As far as I'm concerned, on my part, I and the organization I work for decided not to endorse anybody…And of course it also is a little bit troubling the reports that some campaigns, like Michele Bachmann's campaign, was asked to basically kind of fold in or whatever the terminology was used and quite frankly I think in a process where these candidates have spent a lot of time and a lot of money and a lot of energy, to ask a candidate to fold their efforts into another campaign is just not the way we do things here in Iowa."
Here's The Family Leader's statement on this, issued yesterday, and more background. Gross was chief of staff to Terry E. Branstad a couple of decades ago and you may recall that BVP ran against TEB in a GOP primary in 2010.


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What's the worst wine in the world? Not the worst type of wine, varietal or style (these are matters of taste and degustibus non est disputandum here at The Wine Economist). And let's rule out the worst idea for a wine, too, because Miles's dump bucket cuvée from the film Sideways (shown above) is the clear winner.
No, I'm talking about the worst professionally made (amateur efforts are another category), commercially sold wine — the wine with the most serious objective flaws that was released to the market despite its potentially reputation-ruining qualities?
Corked and Screwed
In terms of a single vintner economic impact, it was probably the 1985 David Bruce Chardonnay that George Taber talks about in his excellent book To Cork or Not to Cork? David Bruce is known today as a maker of fine Pinot Noir but back in the 1980s their Chardonnay was a big hit. A hit, that is, until the 1985 vintage was plagued by massive incidence of cork taint that almost destroyed the winery by ruining the reputation of its most important wine and effectively drove it out of the Chardonnay business.
Turns out the faulty corks had been rejected as tainted by Robert Mondavi and the cork importer sold them off to David Bruce rather than having them destroyed or sent back to Portugal. A big economic hit indeed. But I need to rule out cork taint for this extreme wine competition because it is so utterly unexceptional. Virtually everyone who bottles wine with cork will experience cork taint — 3-5 percent loss is the figure usually cited.
Bad Wine Uncorked
I had the opportunity to understand what really bad wine is like last week when I attended a professional wine faults workshop organized and taught by Amy Mumma, director of the innovative World Wine Program at Central Washington University (profiled in this recent Yakima Herald-Republic article) .
Amy's background is in biochemistry and wine business and this gives her an unusual ability to detect and analyze wine flaws and advise wineries (something that the legendary Emile Peynaud was famous for). To steal a line from Ghostbusters, Amy is the answer to the question "who ya gonna call?" when something goes wrong with your wine.
Amy led my group of about 50 wine professionals through a tasting of twelve wines that illustrated different fundamental flaws ranging from what was probably a simple shipping problem ("cooked" when its shipping container got too hot) to a palate-destroying example of a badly corked wine. When retailers are suspicious that a wine on their shelves may be faulty, they call Amy and, if the problem is bad enough, she buys the bottles for use in her classes. All of the flawed wines we sampled were purchased through normal retail channels.
Worst of the Worst
The worst wine we sampled was a real dog (no offense to canines intended). It was a Columbia Valley Merlot plagued by the thankfully rare combination of reduction, oxidation and Brettanomyces. It looked bad, smelled bad and tasted (gasp!) horrible. Certainly one of the worst wines I've ever tried. Why in the world would anyone put their label on this wine and send it into the marketplace to represent them?
Drawing upon her science background, Amy was able to explain to us how this awful combination of defects occurred, but the question of why anyone would try to sell it remains. Ignorance? Incompetence? Arrogance? Cash flow demands? Hard to say. Some wine flaws (like the "cooked" wine) can happen after wine leaves the maker's control, but many of the flawed wines on retail shelves were already in bad shape when they left the warehouse. No excuse for this. Reputation is critically important in the wine business and it is established (or destroyed) one bottle at a time.
You May Not Want to Know the Answer
Amy's class was great — she's a wonderful teacher — and gave us a lot of useful tools for detected and understanding wine flaws and for dealing with related trade and consumer issues. Amy answered all our questions but one: who made these awful wines? She kept the makers secret, so I can't report them here (although I have a guess concerned one particularly nasty white wine that was clouded with silky black strands of dangerous bacteria).
What's the worst wine you've ever tasted, I asked Amy. You may not want to know her answer.
The worst wine ever sampled smelled and tasted like somebody urinated in a tin can of clams. Seriously. Absolutely disgusting. It was a process of putrification caused by high levels of bacteria and was a Washington State Cab Sauv. And it was at retail price in wine shops. I think some of the worst have been high levels of mercaptans or those with excessive ethyl acetate that you can't even get near your face without your eyes watering.
I'm trying to imagine who would sell a wine like that! I wonder what consumers thought when they brought home the bottle and pulled the cork? I imagine that some of them probably thought the wine was supposed to taste like that. You can scratch that customer off your mailing list!
Watch for a future post on the World Wine Program at CWU, a unique approach to educating wine business professionals.
[Note: This post is part of an occasional feature on extreme wines. Extreme wines? You know, the cheapest, the most expensive; the biggest producers, the smallest; the oldest, the newest and so forth.]


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Currently sitting in an internet cafe in Logroño, the capital of Rioja. I am here for a friend´s wedding tomorrow night which inconveniently sits on the same day as my Aunt´s celebration in Edinburgh and 2 days before my next wine test.
It is rather frustrating to be in this beautiful part of the world but have nothing but fortified wines on my mind so I can´t even properly enjoy the Rioja. My current worry is that I really ought to be trying to taste some Vin Doux Naturel, particularly a red like Banyuls, in case it comes up in the exam on Monday. Unfortunately I am not even likely to find any Sherry here, never mind Banyuls, so I think I will have to simply drink through the guilt barrier.
… oh, and before you ask, no I will not be seeking out any Moscatel de Valencia! I don´t care if it is on the syllabus.


text: \u00a0\u00a0\u00a0\u00a0Photo: Table Mesa by Dragan Maksimovic (Creative Commons)Before Jonathan Trull took over as Chief Information Security Office for the state of Colorado in 2012, he had already been working in the Colorado Office of the State Auditor for a decade. As the Deputy State Auditor, he was responsible for overseeing annual audits of the state's systems.It was during that time that Trull said he became concerned with what he observed as repeated mistakes and violations that were not addressed, and even took part in a penetration test on state systems with results he says were "horrifying."Trull recently spoke with CSO about his new role, and how he hopes to create effective change in Colorado's security infrastructure\u2014even on a miniscule budget.CSO: You have an interesting story about how you came to the position of CISO of the state of Colorado. Tell us about it.Jonathan Trull, State of Colorado: One of the catalysts was that I was doing the audit work in my previous position, and I came to a point where I was concerned about the seriousness with which people took the audit findings. A typical audit finding might be "your password complexity is not sufficient." It's pretty boring actually. But, after a while, you see enough of those and there didn't seem to be a lot of progress in areas that I thought were critical\u2014significant to the prevention breaches. We seemed to do well on compliance issues: check-box sort of stuff like "I've got this policy or procedure in place." But the question was: Has it been operationalized? Is it actually working? [Also read Case study: Security on a shoestring budget]To test that in 2010, my team and I did a covert penetration test against the state systems. The only person that knew was one person in the governor's office. We also wanted to test our security staff's ability to detect and respond to attacks. The results were fairly horrifying. Really pretty bad. Significant breaches were accomplished by our team. We were able to steal thousands of confidential records of taxpayers, citizens. Shortly after that, the CISO in place left for another job and they asked me to come in and fix what I found.Where did you start?The SANS 20 critical security control seemed, to me, from my experience with doing pen tests myself, to be the best place to start. When I starting going through the list I thought "These will prevent the majority of how we got into our systems." Then it became a matter of prioritization.It felt like a no brainer for me to focus on those areas first.But I've got a very limited budget. I've got about ten staff across 17 departments, executive branch agencies and our operational budget for this year was $6,000. In the state we divide our dollars between personnel (salaries) and operating (software, tools, professional services, et cetera).Our fiscal year runs July 1 to June 30. The total operating budget available for the year was probably around $35K. Our fiscal year runs July 1 through June 30, and $6,000 was what we had left for the year when I started in September. The question became: how can I make the most impact quickly?I'm shocked at your budget figures. Are you anticipating more in the future?We are in the middle of fighting for a budget of between $1.1 and $1.7 million a year. We feel strongly that with that we will be able to implement the first five critical controls. The majority of the other 20 we plan to then implement within a three-year period of time, but we definitely want to keep our operational budget below $2 million a year.How are you working with such a meager budget now?For now, our strategy is to do the best with what we've got.We are using existing technologies. For example, application whitelisting. We have Microsoft products in place. It's not a perfect scenario, but there are some other representatives in the NSA (National Security Agency) doing it and we are trying to put it in place with the tools we have.We are doing a lot with open source and other tools, and features that are already built into our existing software. A lot of this stuff isn't perfect and not as robust as some of the tools that are available, but, for example, Active Directory should keep a good list of the systems that are in your environment. There are other free tools like Nmap that allow you to do fairly robust scans to detect new and rogue systems on your network.Even in the face of budget restrictions, have you made any significant changes yet worth highlighting? I'm really pushing my staff to use a risk-based approach even in this deployment. Not all of our agencies are created equally. Some have much more sensitive data than others and we would be silly not to focus on those. It's the same as a persistent attacker who is going to do their homework and know what they are going after. We need to have the same mindset.One thing that I did when I took over was put a stop on all security products. We were getting different requests for things like Splunk and ArcSight - requests all over the map. I didn't even know what I had yet. So I put a stop on all buying.Once I did an inventory of all of the security products we owned, and all of the licensing and contract terms, I found we had a lot of shelf ware; things purchased years before that were now not being utilized. Excess licenses were everywhere. Honestly, part of this is going to be a return on investment for eliminating products no longer being used or focusing on new ones we are going to actually put to use.What specific goals are you bringing before lawmakers to make the case for getting that budget figure you mentioned earlier?We're tying all of this to a three-year initiative that I am calling "Secure Colorado." The focus is on the SANS critical security controls in terms of our operational security posture. As I said before, we're focusing on the first five within 12 months, and, over the next three years, we will deploy the rest of the 20.Other goals include using our existing vendors as partners to help us get this done. One of the things we saw in the past is a lot of activity during the time of renewal\u2014and then everyone disappears until it's time for renewal again. We just can't tolerate that anymore. We are really trying to build in to our contracts that you are partnering in our success and we are going to make it contingent on that. In other words, you only get a portion of this and the rest is hinging on successful deployment of this product.We are also working on building the next generation of security workforce. We just started a cybersecurity internship program. Our first two cybersecurity interns started in January. College students. We are working with the different universities on that.Those are the big areas. The successful implementation of the controls, the public and private relationships and building the workforce.The data itself is proving quite useful in making our case, too. The number we get, in terms of our network, is it's getting hit 600,00 times per day by some kind malicious event. Whether its scanning viruses or malware, we can show the escalation in that as well. When you couple that with the stagnation of the funding and resources to the security program, I'm hoping funding will prove to be a no-brainer.If so, what will be solid progress in a year? What will be some of the benchmarks you point to as proof of success when you need to go back and make the case for funding again?We have a few benchmarks we set up that we will track closely. I wanted to put those in place before we even started because I knew we would be accountable.We put together a scorecard, a security-metrics scorecard. It includes tracking the percentage of our systems that are under management. The way we define that is basically from a central location, the number of systems that I can view and observe their current risk and security status within a 48-hour period. [Also read Information security, value creation and the balanced scorecard]Other metrics include the percentage of critical or high vulnerabilities per every host. We are also looking at the number of successful malware infections and the number of computers that we have to reimage because of that. That number should really go down.Those are our outcomes-based measures. We have other input-based measure we are looking at, too. They include number of hours per staff activity. The idea is the more we get things under control, the less time our staff should be spending on reactive-type issues. We should have a much less running around, putting out fires in the day.The other thing is mean time to resolve an incident. We are looking for that to go down significantly as well.


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Necrotic NYDM band Thevetat will enter the studio on February 19, 2014 to record three songs for an upcoming EP on Dark Descent Records.
"While the style is akin to the early material, a progression can be heard," said main composer and band anchor Thomas Pioli. The lineup is Thomas Pioli (vocals, guitars, bass), and John Mischling (drums).
Thevetat rocked the underground and old school metal world with Disease to Divide, a short but potent EP of raging fermentive occult death metal with doom undertones.
Tags: ceremonium, dark descent, john mischling, thevetat, thomas pioli


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Rumble in the Jungle
Can anyone unseat Hun Sen's dictatorship by democracy in Cambodia?
PHNOM PENH — Armed with a surprise royal pardon, Cambodia's veteran opposition leader Sam Rainsy stepped into the steamy Phnom Penh air on July 19 to a delirious welcome from an estimated 100,000 people.
PHNOM PENH — Armed with a surprise royal pardon, Cambodia's veteran opposition leader Sam Rainsy stepped into the steamy Phnom Penh air on July 19 to a delirious welcome from an estimated 100,000 people.
After four years of exile in France, to escape from what most regard as trumped-up charges of falsifying documents and disinformation that saw him sentenced in absentia to 11 years in prison in 2010, Rainsy returned a hero — but with just nine days of campaigning left before his party faced the polls.
Hope was in the air for the infectiously excitable young crowd — about two-thirds of Cambodia's population is under 30. They chanted the question in unison: "Change? No change?" and answered with the resounding: "Change, change, change!" The country's urban youth was, for the first time, making a very public statement of its preferences.
Rainsy harks from a distinguished but controversial Cambodian political dynasty. He fled the country for the first time in 1965, after his politician father disappeared in suspicious circumstances. He settled in France, where he still holds a passport, and worked as a banker and accountant before returning, rising to become finance minister in 1993 for the Royalist Funcinpec Party. That year, the party's leader, Prince Norodom Ranariddh, was forced into an uneasy coalition with current Prime Minister-cum-dictator Hun Sen. The next year, Rainsy was expelled; in a 1997 coup Hun removed Ranariddh and has been ruling ever since. But Rainsy remained active in political life. He set up his own party, which won 18 percent of seats in the 2003 election, and boosted its representation in the last poll in 2008.
But Hun reigns supreme. The 60-year-old former Khmer Rouge guerrilla with no formal education has consolidated power for his Cambodian People's Party (CPP) over the last 28 years, under the fig leaf of the constitutional monarchy — by using the apparatus of the state to dispatch his competition. He says he wants at least another decade at the top and is busy creating a dynasty by installing at least a dozen family members — including his three sons — in key military and political positions.
Last year, Rainsy and Kem Sokha, a leading human rights campaigner since the 1990s and another opposition stalwart, united to form the Cambodian National Rescue Party (CNRP) in what may be their last chance to upset the political balance, before it's too late. Though they can't reasonably hope to unseat Hun, they could possibly force him to form a coalition — if they can garner enough seats in the July 28 election being contested by eight parties.
On Wednesday, Rainsy and Sokha were on the campaign trail in Siem Reap, a shabby provincial center notable only as the jumping-off point for Angkor Wat. There is nowhere more symbolic for the nation's struggling 15 million people than the awe-inspiring ancient temple complex. It is at once both a symbol for the country's Khmer people of the mighty empire they once ruled and, in its semi-ruin, of the country's decline.
The opposition veterans ended their four-hour parade through the pot-holed streets of the town at the verge of the wide stone causeway to Angkor Wat's entrance. Rainsy and Sokha stood on crates atop a truck, addressing tens of thousands of people who had followed them in a convoy the eight miles from town.
Rainsy railed at the corrupt government and its relationship with Vietnam. The long, bloody history between the two nations is the source of much of Rainsy's rhetoric, and it's a potent political message in this country. For centuries, the Khmer ruled over a kingdom stretching from Thailand in the west to Vietnam in the east to Malaysia in the south. In the early 1400s, the roles were reversed with Cambodia becoming a vassal state to Vietnam and Thailand, only to come under French rule in 1863. Vietnam invaded the country in 1979 to overthrow the brutal genocidal regime of Pol Pot, assisted by a Khmer Rouge splinter group led by Hun. Links between Hun and Hanoi have remained strong ever since.
"We need to promote and protect the symbol of our nation — Angkor Wat temple," Rainsy said to cheers from the crowd. "We need to take Angkor Wat back from the Vietnamese." His message referred to Solimex, the company that runs the complex and which is owned by Oknha Sok Kong, an ethnic Vietnamese Cambodian businessman. The claim is unabashedly nationalistic, though Rainsy and Sokha have a broader platform: a better social safety net, a crackdown on corruption, and more jobs for the nation's frustrated youth.
"I have seen that the economy of Mr. Hun Sen is headed the wrong way. Cambodians have no jobs to do and migrate oversees to Thailand," Rainsy said to the assembled crowd.
But his stirring words could be for naught. On Thursday, Rainsy was refused a place on the ballot for the second time in a week — and there's no time left to register before the National Electoral Commission's deadline. Rainsy argues his pardons should have automatically reinstalled his right to contest the race. But, for the time being, it appears that the CNRP and other smaller opposition parties are simply left to field local candidates across the country.
The Committee for Free and Fair Elections in Cambodia, the main non-partisan election monitoring organization has noted serious irregularities already, including voter registrations at over 100 percent in some areas, security forces openly participating in pro-government campaigning, and voter intimidation at opposition rallies.
It would certainly be tough for Hun's Cambodian People's Party to run on its record alone. With a gross national income of $880 per capita each year, Cambodia's people are the poorest in Southeast Asia, after Myanmar. About half the government's budget is provided by foreign aid. Roughly 80 percent of Cambodian workers are subsistence farmers, with about 35 percent eking out a living on just $0.60 per day, well below the international poverty line. And state-sanctioned land theft is rampant. Perhaps worst of all, Cambodia's children are getting smaller with each generation for lack of nutrition — and if they go to school at all, it's minimal: primary schoolers in state curricula get just four hours a day.
In addition to impoverishing its own people, Cambodia is now emerging as a regional wild card that could prove the thorn in the side of the 10-member Association of South East Asian Nations (ASEAN), which will in 2015 create its own trade bloc. As Myanmar wriggles out of Beijing's suffocating embrace, Cambodia is now China's main regional friend. And as the United States steps up engagement with Asia, Cambodia is emerging as a player in all the wrong ways.
Last June, when Cambodia chaired ASEAN's annual meeting, it refused to sign a communiqué that would have expressed a unified stance on China's jaw-dropping claim to the entire South China Sea — where it is in dispute with seven of its neighbors but refuses to engage in multilateral negotiations.
Cambodia is not a party to the disputes itself, but its rulers are increasingly reliant on China's largesse. By kyboshing the communiqué, it has put itself squarely in China's corner against its neighbors and the United States, ratcheting up security concerns and adding fuel to the region's already alarming arms race. In December, Cambodia joined that race in its own small way: taking delivery of 100 tanks and 40 armed personnel carriers.
Last November, Barack Obama made the first-ever trip by a U.S. president to Cambodia — a visit made through gritted teeth and only in order to attend the East Asia Summit. In a private meeting pointedly described later by U.S. Deputy National Security Advisor Ben Rhodes as "tense," Obama admonished Hun, urging him to end human rights abuses, halt land theft, and to hold free and fair elections.
Hun's pardon of Rainsy and his token nod to a fair election (the king is effectively his rubber stamp, so complete is Hun's control of the country) appears to be his only concession to Washington's concerns.
And yet Rainsy's support appears widespread — there were factory managers, hospitality workers, students, tuk-tuk drivers, even police, among his supporters at the extremely well-attended rallies I attended over the past week, although reports from smaller towns said crowds were thinner.
"The government does nothing with my taxes, they don't help old people, when I am old they will give me nothing," said Sopha, a manager of a motorbike factory waiting to catch a glimpse of Rainsy on the road into Phnom Penh. "There are no jobs for young people. We need to see if someone else can do a better job."
Foreign diplomats who spoke on the condition of anonymity said the public display of support for the opposition is unprecedented in a country where the censors allow no mention of other parties on television or in Khmer-language newspapers, and where the government's security apparatus has eyes and ears everywhere. Hun likely holds an advantage in the countryside thanks to his peasant background and links to the Khmer Rouge. People there also have little access to non-state run media sources. Plus, the country's gerrymandered election gives far more weight to votes from rural areas.
If Hun wins comfortably, Cambodia's latest tragedy is likely to continue. Hun and his CPP elite will continue to get richer, while the country risks sliding backward into something resembling junta-era Myanmar. If somehow, implausibly, the opposition were to win, Hun has already issued dark warnings of "civil war." In a country where there are no reliable polls, it's almost impossible to tell what will happen on Sunday, although few beyond the opposition faithful believe there is much chance of change.
Still, the flurry of excitement over the election can be seen as a promising development: the return of Rainsy, the increasing numbers of young voters, and the improved flow of information thanks to social media, has given the country its first taste, in a long time, of what real electoral politics feels like.
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text: Glen Ellis Falls is a jewel in Pinkham Notch. The parking area is a 9 miles drive north from the inn on Route 16 along the Ellis River. Take the well-marked .2 mile trail under the highway and climb down the series of stone steps to reach the vantage point at the base of the 65 foot high falls.


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I have a fresh install of Debian 6.0.5 (i386) on VMware Player. I was trying to install libglib2.0-0 using this command:
sudo aptitude install libglib2.0-0
Unfortunately, I don't remember the exact output from the terminal but I remember there were 0 bytes installed or something. I'm guessing it didn't install correctly, so I want to remove it and try installing from the Software Center instead. However, when I click on remove, it just "greys out" and nothing happens. How do I uninstall it? Is there a command that could remove it from the terminal?
EDIT: The output of:
dpkg -l 'libglib2.0-0'
root@vmware:/home/mohamed# dpkg -l 'libglib2.0-0'
| Status=Not/Inst/Conf-files/Unpacked/halF-conf/Half-inst/trig-aWait/Trig-pend
|/ Err?=(none)/Reinst-required (Status,Err: uppercase=bad)
||/ Name Version Description
ii libglib2.0-0 2.24.2-1 The GLib library of C routines


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New to meditation? Here are 4 tips to get you started:
- You can go it alone. You don't need an organized group or meditation center to get started. If you want to start a meditation practice on your own, it's easy to find meditation apps, meditation music apps, CDs and online videos to guide you through the process.
- Set the stage. There is no one right way to meditate. But it helps to do it in an environment with minimal distractions, in a comfortable, seated position.
- Focus on your breathing. Try focusing on measured breathing (breathe in for a count of two; breathe out for a count of two) while trying to quiet the thoughts that race through your mind. If you get distracted, quickly acknowledge the distraction and bring your focus back to your breathing.
- Consistency is key. A meditation practice of just 10 minutes per day can make a big difference in your long‐term physical and emotional health.


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Get The Bamboo Forest print for a great cause!
A special print offering
100% of the money is going to a special charity set up for Eliza O'Neill. If you're not familiar with the story about her, check out this link. It's a great effort by the wonderful photographer Benjamin Von Wong.
Daily Photo – The Bamboo Forest
This is one my favorite photos, still, after all these years. I'm happy to offer this special print for the cause above! If you don't know the story of it, here it is. 🙂
While exploring Kyoto, I eventually found my way to this fanciful bamboo forest. There had been a light rain most of the morning and everything was quite lovely. The rain does strange things as it moves its way through these sorts of trees. I waited and waited, and that was nice too. In the early afternoon, the rain stopped while the sun peeked through the top. It shone down while the earlier rain misted down from the tops of the trees.


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By: Charlie Nadler
20 Signs You Should Stop Going To Your Office Happy Hour
1. Your office happy hour is at a rave.
2. Your day-drinking tends to lead to night-weeping.
3. After your second drink, you're an "I need to show the bartender where my neighbor's Doberman bit off part of my penis when I was in fourth grade" kinda guy.
4. You'll do literally anything to be accepted by Kevin the intern 'especially now that he has the really good bath salts hookup.
5. In your experience, your office "happy hour" could more accurately be described as your "uncontrollable-meat-sweats-in-the-ladies-room hour." And yet, you continue to order the BBQ pork shoulder plate.
6. Your desire to climb up the corporate ladder invariably leads to you resting your head on your boss's lap and singing the entirety of "Closer" by Nine Inch Nails.
7. You work in a toll booth.
8. Your office happy hour is every morning at 9:30 am, under your desk; you provide the booze, and your Soviet-era nesting dolls Yuliya and Lenochka provide the eye candy.
9. At the last three happy hours, your boss has described a "really vivid dream" he keeps having about you wearing a "super hot Catholic school girl's uniform."
10. At the last four happy hours, you've worn your super hot Catholic school girl's uniform.
11. As you've aged, you've come to see your office happy hour for what it really is: a frivolous gathering of vacant corporate drones, everyone listless and blathering, like so many dying fish at the bottom of the fisherman's barrel, each offering one last futile twitch before the knife comes down '
12. The time conflict with Two and a Half Men reruns has become a problem.
13. You're tired of being the only one at the table who doesn't have any new jokes about "Orientals."
14. Your office happy hour is in the supply closet, and instead of having drinks and appetizers, you quietly read through old archives of client billing statements.
15. The marketing department doesn't seem to appreciate your Jim Carrey The Mask routine like they used to.
16. You've started referring to your office happy hour as "therapy."
17. You live in Kuwait, where the consumption of one glass of alcohol is punishable by 80 lashes, in case you needed reminding.
18. Your coworkers make you pick up the tab every time you forget to come to happy hour dressed as your favorite "Pretty Little Liars" character.
19. You've already had sex with everyone you work with, so like, what's the point?
20. You were laid off six months ago.


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AI and the future of work
AI isn't just the future – it's the present. And now the Metaverse has arrived, the AI revolution is gathering even more pace, opening up a new world of opportunities. How can organisations make the most of them?
What is artificial intelligence?
In a nutshell, AI is the science of creating machines with human-type capabilities. It's a huge leap forward: Machines that can plan, reason, communicate and learn are enhancing our lives, as well as lowering costs and boosting efficiency and profitability. But fears are also frequently voiced about AI's potential for negative disruption, especially in the labour market, as they take over routine, low-level tasks.
There are several different fields of AI, all of which have a profound influence on the way we work now and how we'll work in the future:
Machine learning: This type of AI can "learn" based on recognising patterns in data. It's revolutionary because, rather than being programmed, the software can analyse the data it's given to make predictions, create rules, or make recommendations for action. Deep learning takes this process a step further, reducing human input even more and allowing the use of larger data sets. It's responsible for some of the recent progress in speech and image recognition and natural language processing. But machine learning is only as good as the data fed into it. For example, if that data is biased, the AI output will also be biased.
Robotics: Organisations are using robots to automate physical tasks remotely or by algorithms or sensors. As well as the now-familiar sight of robotic "arms" on production lines, robots have numerous uses today – anything from assisting with surgery to inspecting sewers.
Natural language processing: Although computers are very smart, they have found it surprisingly difficult to understand, generate and respond to human language. Natural language processing (NLP) is redressing this using machine learning. NLP has various applications, from translation, voice recognition and transcription to extracting information from reports.
Let's talk about the future of work
We're working on providing answers to some of the most crucial questions about working in the Metaverse. Take a look.
What's the difference between AI and automation?
AI and automation are terms often used interchangeably. They're not quite the same thing, although they have the same purpose of helping humans by taking over routine, repetitive tasks. But while automation involves programming machines to carry out tasks, AI is all about machines learning automatically by recognising patterns in data.
How will AI affect the future of work?
AI is already deeply embedded into everyday life and work. Everything from digital personal assistants to smart appliances, online shopping to factory robots are made possible by AI. According to McKinsey's State of AI report, 56% of respondents use AI in at least one function. This rises to 57% in emerging economies, including China, the Middle East and North Africa. And this growth is set to continue, with automation and digitisation goals featuring in 54% of companies' long-term corporate strategies, according to PwC's Global CEO Survey.
AI is poised to make more advances in several areas.
The Metaverse
Virtual reality and augmented reality technologies are enabling an internet you can step inside – for games, entertainment and work. Shared virtual spaces will blend with the physical world, transforming collaboration, communication and training.
Fraud prevention
By analysing large numbers of transactions, AI can uncover fraud trends. It can then automatically block suspect transactions or flag them up for further investigation. People can also use AI in cyber security to recognise and block threats.
Chatbots and digital assistants
As NLP is developing, so too are the capabilities of chatbots, allowing them to communicate more naturally with users rather than simply responding to "yes" or "no" questions. This is making significant customer service improvements and is freeing employees to manage the most complex customer queries.
AI in healthcare
The World Health Organisation estimates that by 2030, there will be a global shortfall of 18 million health workers. AI may be able to provide part of the solution to this by automating routine tasks, improving productivity and, most importantly, giving staff more time to spend with patients. Practitioners are already using AI in numerous healthcare applications, including hospital management, medical diagnosis and patient-focused apps.
Explainable AI
AI doesn't operate in a vacuum. The fact that organisations are using it to reach decisions raises transparency, privacy, fairness and responsibility issues. This is where explainable AI (XAI) comes in. It aims to make sure that algorithms' rationales are understandable by humans. XAI is also vital in helping with the detection of artificial intelligence errors.
AI in HR
As well as automating routine tasks, like payroll, AI is transforming recruitment. It can take over the lengthy process of filtering profiles. It can screen resumes, shortlist candidates and schedule interviews. This makes for a far more efficient process, especially at the beginning of the recruitment journey, saving an enormous amount of time and reducing costs. AI also has the potential to enhance training –39% of leaders plan to use AI simulations to hire and train employees, according to one survey. And for job candidates, AI can avoid time-wasting by connecting them with roles most suitable for them.
What jobs will be automated in the future?
Perhaps the biggest concern about AI is that it will lead to loss of jobs and therefore, unemployment. But in fact, it's estimated that automation will lead to far more jobs being created than lost – up to 890 million by 2030.
Plus, in the case of many jobs, AI isn't automating all functions – just the more routine tasks, like payroll for example, or extracting information from documents. And humans are still needed to oversee the process and step in if things go wrong. So rather than replacing humans, AI will work alongside humans, helping us work better and focus on the more creative and satisfying elements of our work. For example, while AI might be used to help make medical diagnosis, it will still be down to doctors and nurses to treat patients.
What AI is bringing with it is a growing demand for people with tech skills, like programmers, statisticians, data scientists and analysts, as well as those with skills involving creative and emotional intelligence – the things AI can't provide.
Benefits of AI at work
AI has the potential to produce enormous economic gains. As well as greater productivity, it's predicted that these gains will come from consumer demand as AI makes a larger variety of products more possible and more affordable. In fact, PwC estimates that AI could contribute USD 15.7 trillion to the global economy by 2030. Artificial intelligence benefits include:
Productivity – productivity can soar without people and resources bogged down in routine tasks: 44% of business leaders are looking to increase productivity through automation, according to PwC
Efficiency – AI can carry out some routine tasks faster and more efficiently than humans. And of course, unlike human employees, AI-driven services are available 24/7 to monitor for fraud, answer customer queries and scan job applications, saving time and resources
Solving complex problems – advances in machine learning mean AI can now be put to work on more complex tasks – medical diagnosis, for example, again freeing up resources and increasing productivity
Innovation – AI-generated ideas in brainstorming sessions, interaction in virtual spaces in the Metaverse, and using AI in the supply chain to understand what consumers want (and then make relevant product decisions). AI is helping organisations innovate to succeed
Making AI work for your organisation
Being wholehearted about adopting AI is paying off for organisations. According to PwC's AI Business Survey, companies seeing significant ROI from AI are using it in three areas at the same time: business transformation, decision making and modernising processes.
But widespread adoption of AI in a company means big changes for the way people do their jobs. So how do organisations show employees that AI is a force for positive change? That it can help people do their work better, taking over dull tasks and giving them the chance to concentrate on more creative work that uses their skills more effectively?
One way is to stress that AI is designed to complement, not replace, human workers. Even more importantly, as people will be working alongside AI, it's vital to make sure they have the tech skills they need to do so. This will involve upskilling and reskilling the workforce if necessary, so that they're able to take advantage of all the opportunities AI has to offer.
Step inside the future of work
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Coagulation: In medicine, the clotting of blood. The process by which the blood clots to form solid masses, or clots.
More than 30 types of cells and substances in blood affect clotting. The process is initiated by blood platelets. Platelets produce a substance that combines with calcium ions in the blood to form thromboplastin, which in turn converts the protein prothrombin into thrombin in a complex series of reactions. Thrombin, a proteolytic enzyme, converts fibrinogen, a protein substance, into fibrin, an insoluble protein that forms an intricate network of minute threadlike structures called fibrils and causes the blood plasma to gel. The blood cells and plasma are enmeshed in the network of fibrils to form the clot.
Tissue can also be subjected to coagulation by various means, as by electrocoagulation, laser coagulation, or photocoagulation.


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PORTLAND, Maine — A new boatyard and marine repair facility may soon buoy a blighted area of Portland's waterfront and expand the city's vessel services.
Portland Yacht Services is seeking approval to expand from its 10-acre location at 58 Fore St. to a 16-acre site at 40 West Commercial St., just west of the Casco Bay Bridge.
Phineas Sprague Jr., the company's president, recently met with city planners to discuss plans for the new site, which would be dubbed Canal Landing. The site is currently home to overgrown brush, idle train tracks and a fenced-in storage area for propane tanks.
Portland Yacht Services has an agreement to purchase 14 acres from Pan Am Railways, and plans to lease another two acres from the natural gas company Unitil, according to Sprague.
Canal Landing would include two boat ramps, a dry dock, a heavy-duty hydraulic boat hoist, storage areas and shops for painting and repairs.
Besides rejuvenating the area, the proposed expansion would allow Portland Yacht Services to haul vessels weighing up to 1,500 tons — compared with its present capacity of about 40 tons, Sprague said Monday.
With the additional capacity, he said he hopes to service large yachts and commercial craft, including barges and tugboats. For vessels like these, he said, Portland has offered few options.
"Portland hasn't been on the shortlist for [large boats] because there just aren't the facilities," Sprague said. "There is work to be done. But Portland needs a new boatyard to attract that kind of business."
Sprague said he's confident such new clientele will benefit Portland's entire marine community.
"The expansion is just going to make things better for everyone on the waterfront," he said. "It's an extremely good thing for the harbor and for Portland."
As part of the expansion, he said the company probably will add to its staff. Portland Yacht Services has 34 employees at its Fore Street space.
"The yard has been growing over the years, and so today we're bumping into each other," Sprague said.
The Fore Street property also is the home of the Maine Narrow Gauge Railroad and Museum, and frequently hosts public events such as the Maine Boatbuilders Show and the Portland Flower Show.
When the expansion is complete, Portland Yacht Services would do much of its boat work at Canal Landing. The company's marina and event space would continue to operate at Fore Street.
The expansion would be completed in phases over the next three or four years, Sprague said. But first, his plans must get approvals from the city's Planning Board, the Board of Harbor Commissioners and the U.S. Army Corps of Engineers.
Still, Sprague said he's optimistic about the prospects for Canal Landing. Since he began Portland Yacht Services in 1981, repairing a 13-foot Boston Whaler, the business has grown "steadily and slowly," he said.
"This expansion is just the next logical step," Sprague said.