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Volunteers counted 4,448 homeless people on Oahu's streets and in shelters during a survey earlier this year, a number that holds steady with the totals of the last two years.
Those counted include 3,716 adults and 732 children. Over half the population, or 2,346 individuals, were unsheltered, either on the street or somewhere else unfit for human habitation. Totals for veterans and families appeared to continue a downward trend, but the total number of homeless individuals on the island was slightly higher than last year.
However, the methodology for the count changed significantly this year, which makes it tough to draw conclusions when compared to previous years' data. This year, volunteers used a mobile app to input survey data and completed the count over a few hours instead of several days. They were also allowed to count people by observation, a practice that meant people who were sleeping in cars or were otherwise inaccessible were still counted. In previous years, they were not.
"The numbers haven't changed significantly, but we have sheltered more people," said Laura Thielen, executive director of Partners In Care, which organizes the PIT Count. "There were less unsheltered and more sheltered people. That is a step, somewhat, in the right direction."
The PIT Count is an annual effort to capture a rough snapshot in time of homelessness across the nation. While imprecise, the federal Housing and Urban Development office uses the data to allocate funding to cities and states. This year's count was conducted over several hours on the morning of Jan. 23 – weeks before the state shut down to prevent the spread of COVID-19.
Next year's count could be much higher.
"Researchers project significant financial challenges and increases in homelessness due to loss of jobs, wages, and stability and the inability to afford rent," the PIT report states.
Many Hawaii households were already in a precarious financial position before the coronavirus necessitated the shutdown of tourism, the lifeblood of the state's economy. Now, they're teetering on the brink.
The state's latest Housing Planning Study, released pre-COVID-19, estimated that a quarter of all Hawaii households were at risk of homelessness, meaning they would be forced out of their homes after two months or less of missed paychecks.
If only 10% of those households lost their primary source of income, the study said approximately 14,000 households would need assistance to keep them from becoming homeless.
About a third of Hawaii's regular labor force is out of work. Experts are bracing for a wave of additional homelessness, but they say it's too soon to tell what the full effect will be. Evictions are on pause until the end of this month pursuant to an order from Gov. David Ige.
If only 10% of Hawaii's at-risk households lost their primary source of income, an estimated 14,000 households would need assistance to keep them from becoming homeless, a 2019 state study found.
"You're going to see more people, definitely, in unstable housing situations," said Scott Morishige, Ige's coordinator on homelessness. "You're going to see more people finding themselves at imminent risk of eviction or foreclosure."
Even in the period of relative economic prosperity before COVID-19, new people were falling into homelessness all the time in Hawaii. Of the 6,610 households served in homeless programs between April 2018 to 2019, 33% of them, or 2,177, were new to the homeless service system, according to the study.
Pre-COVID, people of all income levels were in need of thousands of more housing units in the next five years – particularly rental units for people making $30,000 per year and below, the study said.
But from 2010 to 2018, on average, only 2,902 units were added statewide per year across income levels, according to the study.
The number of "hidden homeless" people – adults who have doubled up with friends or family for financial reasons – was rising before COVID-19 too. Across the state, the percentage of households that contained hidden homeless people increased from 17% in 2016 to 20% of households in 2019, according to the study.
"We are failing with affordable housing," Thielen said. "If we do not have housing, we will never solve homelessness."
The local and state government has struggled to manage the inflow of people becoming homeless but say they've made progress. In 2019, Hawaii homeless service providers prevented 1,198 households from becoming homeless, according to the housing planning study. And during 2019, 5,307 people were placed in permanent housing on Oahu, according to Honolulu's housing dashboard.
"That's a lot of people, and yet our count remains flat," said Marc Alexander, the director of Honolulu's housing office. "Obviously we have an inflow issue."
Oahu's homeless population skews male, making up 59% of the counted population, the report states.
Native Hawaiians, Pacific Islanders and multiracial people are disproportionately represented in the homeless population. According to the report, 51% of the survey respondents said they were at least partly Native Hawaiian or Pacific Islander. Black and Hispanic people are also slightly overrepresented, the report found. While African Americans are 2% of the island population, they make up 5% of the homeless population. Hispanics make up 10% of Oahu's population but 12% of the homeless count.
Among those counted, the report found:
The primary cause of homelessness cited by those surveyed was the inability to pay rent, job loss and alcohol/drug use. City officials have repeatedly pointed to the lack of mental health and addiction resources for homeless people who need them.
Just to address housing demand from the homeless population alone, the Housing Planning Study found that Hawaii needs:
The City and County of Honolulu does not have a health department and relies on the Hawaii Department of Health to provide services that address mental illness and addiction, Alexander said.
"The state legislature needs to fund those beds," he said. "We depend on the state to do this."
But there are steps the city can take to facilitate the development of affordable housing, Thielen said.
The city permitting process creates costly delays, she said.
A city audit this year found that low pay, insufficient training and high turnover contribute to a permitting department that can't keep up. An average of 2,513 outstanding permit applications roll over every year, the auditor found.
"If we can't get affordable housing through the permitting process in a reasonable amount of time, we're not going to have developers who can make a project pencil out," she said.
Island residents play a role too. Those who are protesting the development of an affordable housing complex in Kailua over concerns about traffic, parking and the character of the neighborhood need to think about the bigger picture, Thielen said.
"The crisis is going to be exponentially larger if we stop these projects from coming to fruition," she said. "That's not to say we shouldn't question the projects, but halting them is going to come back to haunt us in future years."
Morishige said he shares in the frustration of residents who want to see greater reductions in homelessness but noted the state made a significant improvement in 2016 by reversing an upward trajectory. This was done through expanding the Housing First and rapid rehousing programs and increasing accountability in homeless service contracts, he said.
The problem grew over many years, he said, and may take years to solve.
"Can we do more? Yes, we can do more," he said. "Is there a need for more housing resources? Yes. Is there a need for mental health and substance abuse resources? Yes."
However, he said it's only going to get harder to fund the state's homeless service needs. Lawmakers are facing a $2.3 billion budget shortfall.
"We're in very uncertain times," Morishige said. "With the impact to our economy and the impact on the state budget, we need to realize that the backbone of our homeless system is funded through the general fund of the state of Hawaii."
Federal funds will help to some extent, Alexander said. The city is offering assistance through a $25 million hardship relief fund through which families can be reimbursed up to $1,000 per month for housing and utility payments and up to $500 per month for child care. Assistance will last up to six months. And HUD just granted Honolulu $22.3 million to address housing and homelessness in response to the COVID-19 pandemic. The city hasn't yet announced how those funds will be spent.
"All of these things are designed to get real money into the hands of people that need it," Alexander said.
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text: The Guild Wars 2 functions also requirements the actual time occasion system. So this could aid the avid gamers to nicely realize the mode of GW2 Gold utilized to the game.This is fairly a ghost pulling system, saying it experienced been broke the traditional on-line outdated fixture regimen job occasion occurs, projects depending for the fixture edition within the incident is not rigid arrangement within the contents of 1 what happened at a particular time. Founded job occasion quest or perhaps an arbitrary occasion for players, can be a founded event, as lengthy since it is happening.It is inevitable, whether or not it experienced been accidental or was inevitable, emphasized the impact of vibrant gatherings on job is not the authentic Guild Wars 2, PVP in the exercise degree within the fixture obtained hostile camp kill or harassment can be a component within the vibrant occasion - nonsense! Obviously have an influence on founded events, ghosts know, harassed the mandate is obviously cannot operate correctly any lengthier hymns, the Guild Wars 2 Pediatrics all to produce this "system", and no fire weird. To the GW2 battle, far more avid gamers would like to learn the Guild Wars 2 gold purpose can carry them to possess the far better meanings with the game.Personal tales main: According for the standard Arena Net introduced, every player's account track record could be created by hundreds or a huge number of accounts content. Don't scare people, avid gamers produce a character is mentioned to get the initial, the participant will initial pick a race, occupation, gender, taken with a big quantity of character visual appeal choices to define character shapes? Right after the fundamental visual appeal of characters determines, the avid gamers you'll have to response the method randomly providing some within the tedious particulars of difficulties to define the character within the characters, history, origins and backgrounds. ill hasn't dried however roles have personality, history, history.Rebuttal write-up III: vibrant gatherings method refers for the monster in PVE mode dynamically refreshed, but will make some within the far more realistic action, which include an structured and premeditated assault by some avid gamers to get guarding villages Ah what, this does not refer to PVP, and far more importantly, is the reality that this really is not only a copy, and that's the wild. I think that no fixture is essentially like this.In addition, the standard Arena Net released when taken with a Word, for the impact that: some avid gamers may not like these tedious and thorough questions, certainly not mind, the participant can select to instantly response these questions, rather than these drama or something. Additionally to races and occupations, other difficulties have practically nothing to undertake with roles. Just for this, you can possess the far better amusing to buy GW2 Gold to the fixture playing. You will discover the method to perform the fixture could be far better and better.

subset: commoncrawl


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COVID-19: People: Webinar - Prioritising wellbeing
23 April 2020
People: prioritising wellbeing, will look at how we adapt to the impact of Coronavirus – longer periods of remote working, reduced physical and social contact with others and increasing uncertainty bring new opportunities, and unintended consequences for us as individuals and as teams in relation to culture, productivity and engagement.
We'll be joined by Petra Velzeboer, psychotherapist and leading mental health consultant. Proactively looking after our wellbeing, and that of those around us is increasingly important.
Among other things, we shall consider key questions, including in relation to:
- Leadership and management strategies in response to stress;
- The importance of developing a positive mindset;
- Recommendations for improving our wellbeing and those of our teams; and
- Sharing experiences and case examples of successful approaches.
This webinar will be chaired by Chris Parsons, partner and Chairman of the India practice, and a staunch advocate for mental health and wellbeing.
Webinar: Mind Your Head! What I Wish I'd Known about Anxiety, Depression and Wellbeing
04 June 2020
Andrew Wells is a Senior Associate specialising in Intellectual Property in our London Disputes team. During this session Andrew generously draws on his personal experience of anxiety and depression to offer his insights and thoughts on what we can do as individuals to combat mental ill health, break down the surrounding stigma and take practical steps to promote the well-being of ourselves and others, both at home and in the workplace.
Facilitated by Ian Cox, Executive Partner, Practices.
Parenting and Working from home webinar
13 August 2020
As many parts of the world work to keep new coronavirus outbreaks under control, many parents and carers are again facing the difficult juggle of work, parenting, and home-learning responsibilities.
We want to support working parents and carers through this stressful and often tiring period.
Dr Michael Carr-Gregg, renowned psychologist, author, broadcaster, and children and families specialist, will join Heidi Asten, Partner in our Melbourne Environment, Planning & Communities team, to explore parenting skills, knowledge and strategies from a psychological perspective; setting the emotional tone and talking about COVID-19 with your children; resilience and self-care for parents; and your questions about parenting in lockdown.
Legal Notice
The contents of this publication are for reference purposes only and may not be current as at the date of accessing this publication. They do not constitute legal advice and should not be relied upon as such. Specific legal advice about your specific circumstances should always be sought separately before taking any action based on this publication.
© Herbert Smith Freehills 2024


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Specialist Care or Medical specialists are specialists who have finished propelled instruction and preparing in a particular zone of medication.
You, as a rule, need a letter of referral from your general practitioner to arrange to see an authority.
In general, practice is viewed as a region of medical claim to fame. This article centres around different kinds of medical specialists, other than GPs.
Referrals for an authority
Your GP may send you to see an authority on the off chance that they think explicit expertise is essential to analyze or treat you. Your primary care physician can assist you with finding a pro.
Specialist Care will report back to your GP, who may remain as your principal contact and who arranges your healthcare with contribution from specialists and other healthcare experts varying.
When your primary care physician has given you a letter of referral, you can arrange to see a pro at an authority centre inside an open medical clinic or a private facility or emergency clinic.
How would I know whether I have to see an authority?
If you have another wellbeing concern, the best spot to begin is with your essential care specialist (additionally called your doctor).
Primary care specialists are prepared to care for a full scope of medical problems. They can assist you in deciding whether you should see a pro for assessment or treatment.
Do I need a referral to see a master?
At Care Connections Specialist Care, you can see numerous specialists without a referral from your essential care specialist.
Once in a while, you might be approached to check with primary care specialist first, regardless of whether wellbeing plan doesn't require referral.
That is because, in specific claims to fame and sub-fortes, arrangements openings are saved for patients with pressing needs. Your essential care specialist can assist you in deciding the best strides for your medicinal services.
To see specialists who contract with Care Connections, you will, for the most part, need a referral. Check your wellbeing plan or call Member Services if you have inquiries regarding whether you need a reference.
Getting to a Specialist Care
On the off chance that your specialist care physician figures you should see a master, they will keep in touch with you a referral letter, which should be introduced to the pro either previously or at your first arrangement.
Specialists are generally based at medical clinics or private centres. Every emergency clinic or authority facility has its procedure for surveying earnestness, tolerating referral letters and making arrangements.
Approach your centre for more data on how your referral will be taken care of.
Finding and picking the correct expert
Your primary care physician will have the option to assist you in finding an expert to address your medical problem.
You might be offered a decision of a few specialists you could see. You could likewise request a suggestion from confided in sources, for example, loved ones. To conclude who to pick, consider the specialists:
- capabilities and experience
- area
- accessibility
If you decide to consider a to be as a private patient, you may need to pay the authority's charges, and you won't generally have the option to guarantee repayment from Medicare.
If you have private wellbeing spread, it might repay you for a few or the entirety of the charges.
Ask your authority inquiries
Make a rundown of any inquiries you may have and put the most significant ones at the top.
A review will assist you with recalling the questions you need to pose, especially on the off chance that you are feeling worried about your finding. Instances of questions you might need to raise to your master:
- What is my analysis?
- What treatment do you suggest for me and why?
- What experience have you had with this treatment or methodology?
- How successful is this treatment?
- Are there any symptoms or risks for the treatment? Assuming this is the case, what right?
- How before long would I be able to have this treatment and will your office get in touch with me if another patient drops?
- What are the risks of not having the treatment and what other treatment alternatives do I have?
- What would it be advisable for me to do on the off chance that I have to postpone or drop the treatment?
- What kind of care will I need at home after the medical procedure?
- Is there anything I should stop or abstain from doing?
- Is there anything I can do to support and Specialist Care myself?
Also Read: Relationships Tips for Couples to Cope Up With the Lockdown Ordeal


text: Sterling is a senior in the College of Arts and Science, majoring in Chemistry and double-minoring in History and Political Science. A native of Alexandria, Virginia, Sterling developed a passion for studying, discussing, and engaging in American politics and government from a young age. Particular interests include the U.S. Senate, state judiciaries, constitutional law, and foreign policy. In the realm of global politics, he enjoys delving into the politics of Northern Ireland and the history of the Troubles. He hopes for the survival of print newspapers as well as to one day study public policy in graduate school.


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Win at Online Slots
Online slots can be a lot of fun, and can be quite profitable as well. Progressive jackpot slots can provide one of the best potential return on stakes of any casino game, and when you adhere to a simple method, you will increase your odds of winning.
First, it is essential to know what the pay tables are and the way in which the game operates. Progressive jackpot slots pay part of every stake that is played, sometimes just idn slot pulsa only a few cents, or just a fraction of a penny to be put into an eventual progressive jackpot. The progressive jackpot is usually only be paid out when the most coins have been played and it is essential to wager the maximum amount of money in any progressive jackpot slot. Many times have online players not followed this rule and missed the chance to win a huge jackpot. If your money isn't enough to allow you play with the maximum amount of money, pick a slot that has less stake – do not take the risk of losing the chance to win big.
It's not only with progressive slots that betting the maximum amount of coins is a great strategy. Even the most basic single payline slots typically come with pay tables that encourage the highest coin count. While it's not as vital to place bets at maximum coins on these slots given the sense that there isn't a progressive jackpot to gamble on, if you wish to increase your winnings, always place your bets at the highest level. In time it will provide you with the highest chance of earning.
One of the biggest errors that online slot players make is playing the "cold" machine in the false belief that a huge jackpot is due. While it's the case that all machines need to pay a certain percentage in the long-run but that doesn't mean you have to keep pumping the machine that isn't paying, believing that a huge winnings is due. The result of any slot machine's spin is contingent on the RNG (random number generator) which is a random number generator does not take into consideration the previous spins and the chances of winning a spin are the same whether you've experienced 10 winning spins in one go or 1000 losing ones.
This is an idea that which many gamblers aren't happy with. They often refer to"the law of averages which states that after 10 losing spins, then a winning spin should be expected. But, if you think of this to throwing coins, you'll realize that this logic is not true. If you throw five times and every time it land at the top of the head – after the sixth attempt, the majority of gamblers would wager that the coin will end up in the tails (apart from those who argue that the coin is weighed towards heads and thus will be landed on the heads!). Although, whatever may be happening, the chance that the coin will land either tails or heads remain at 50/50. This does not change. So, continuing to play an unpaying machine hoping that it will pay off is a guaranteed method of losing money!


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SIPRI's extended dataset of military expenditure of North Atlantic Treaty Organization (NATO) member states is now freely available online, alongside our main military expenditure dataset for all countries.
The data, which makes use of NATO data on members' military spending and other sources, extends back at least to each country's year of joining.
SIPRI military expenditure data is based on open sources only, including a SIPRI questionnaire which is sent out annually to all countries included in the database. For some NATO member states, and for most data on then-NATO members before 1988, NATO's annual press releases on Financial and Economic Data on NATO Defence is a key source.
The collected data is processed to achieve consistent time series which are, as far as possible, in accordance with the SIPRI definition of military expenditure, detailed in the sources and methods.
Enter the database or download the SIPRI Fact Sheet, 'Trends in world military expenditure, 2013'.


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cool concept but the controls are confusing to me
The Legend Of Twins
Help the twins to make it through the levels.
Made for Mini Jam 30 Gameboy
Limitation: Multiple playable characters
Move: WASD
Interact: J
Didn't have much time to work on it this weekend so it is a bit short.
Ps.: Please play in fullscreen mode for crisp graphics
Log in with itch.io to leave a comment.
Great game! I really enjoyed the art style and the concept of having two characters working together to solve the puzzles :D
I don't know if you've heard of Game Development World Championship before (gdwc2019) but it's a competition for indie game developers where they can submit their games and it's free! It's great if you want some more visibility for the game and it only takes a couple of minutes to join :)


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Super Finds and Bargain Buys on Dundas West
Specializing in well-chosen vintage staples like dresses, shoes and boots, Penny Arcade also has a wealth of gems at bargain prices. And if you get tired of trying on its many treasures, there's a couch on which you can take a rest and chat up your fellow vintage-hounds.
Read my review of Penny Arcade Vintage in the fashion stores section.
Join the conversation Load comments


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Advances in heart failure medical therapy over the past few decades have improved the prognosis of patients with this condition. Despite this, heart failure remains a significant burden to the medical system as the incidence of heart failure hospitalisation continues to rise.1 Diuretics have been a mainstay of therapy in heart failure to relieve congestion and improve symptoms. Despite the widespread use of diuretics, there is a lack of guidance on how to best titrate these medications in chronic use. Guidelines support the use of diuretics at the lowest clinically effective dose, but do not specify a diuretic strategy beyond that.2 Here we review the diuretics available for use in heart failure, potential mechanisms of diuretic resistance and ways to address this in the ambulatory setting, and review tools that have been developed with the goal to help guide diuretic use to treat patients with chronic heart failure.
Loop Diuretics
Loop diuretics remain the diuretic of choice for treating patients with heart failure.3 Furosemide, torsemide and bumetanide are the agents widely available for clinical use, with furosemide the predominant agent of the three. All three loop diuretics are available in oral formulation and are first absorbed in the gastrointestinal track. Once absorbed, the majority of the diuretic becomes protein bound in the vascular space, which in turn requires the drug to be transported into the nephron by organic anion transporters.4 Loop diuretics then travel to the ascending loop of Henle and inhibit the Na+/2Cl/K+ cotransporter to block reabsorption of sodium and chloride, resulting in natriuresis. Loop diuretics also induce renal prostaglandin synthesis, which results in renal and peripheral vascular smooth muscle relaxation and venodilation.5 The dose–response curve is sigmoidal, demonstrating that the drug concentration must reach a diuretic threshold to have an effect, and further diuresis above this threshold is achieved by increased frequency of administration rather than increased drug concentration.5
There are key pharmacokinetic differences between the loop diuretics (Table 1). Torsemide and bumetanide have an oral bioavailability of 80–100 %, while furosemide has a wide variant bioavailability of 10–100 %.6 Ingestion of food also has an effect on pharmacokinetics as it can decrease the maximum concentration of loop diuretics by one-half and increase the time to peak serum concentration by 30–60 min.7–9 The effect of food intake on the impairment of diuretic absorption is greater with furosemide and bumetanide, whereas torsemide's bioavailability is relatively unchanged by food intake. The overall rate of absorption is also negatively affected when the patient is congested.10,11 In patients with chronic renal insufficiency, furosemide has been shown to have a variable dose response compared with a more consistent dose effect with bumetadine due to altered metabolism of furosemide in patients with kidney disease.12 With the oral formulations, furosemide has a half-life of 2 h, bumetanide has a half-life of 1 h, and torsemide has the longest half-life at 3.5 h.13 Furosemide is the most common loop diuretic prescribed but has a bioavailability that can be quite variable between similar patients as well as within the same patient during different disease states. This may be due to pharmacological factors inherent to furosemide and genetic differences between individuals as well.14,15
Despite the variable bioavailability, furosemide is commonly the first loop diuretic prescribed to patients with heart failure. However, there are few adequately powered or designed studies assessing the comparative effectiveness of these loop diuretics. The Torsemide in Chronic Heart Failure study is the largest study to date comparing furosemide to torsemide.16 The study found that after an average follow up period of 9 months in 1,377 patients, those in the torsemide group had a risk reduction in overall mortality, reduction in cardiac mortality and improvement in functional status. Unfortunately, the study was a non-randomised prospective cohort as it was a postmarket surveillance of safety, with surprisingly low use of beta-blockers and angiotensin converting enzyme inhibitors.16 Torsemide in Chronic Heart Failure was also an open label study, so the comparison between torsemide and furosemide was not without bias. Other smaller studies support the benefits of torsemide over furosemide, suggesting less heart failure-related hospital days but no differences in hospitalisations due to heart failure.17,18 Some of these plausible benefits might result from torsemide's aldosterone antagonistic properties.19,20 Practically speaking, the use of torsemide is reserved in patients that have demonstrated some degree of diuretic resistance to furosemide. However, doubts remain regarding its impact on clinical outcomes. Bumatenide, on the other hand, is even less well studied and its impact on clinical outcomes in comparison to furosemide is still unclear.21
Loop Diuretic Resistance
A diminished response to loop diuretics, or diuretic resistance, can lead to an adverse clinical course and prolong hospital stays. Diuretic resistance occurs frequently, with data from the Prospective Randomized Amlodipine Survival Evaluation study reporting that up to 25 % of participants displayed diuretic resistance, defined as absolute diuretic dose above the population median dose.3 This is a common clinical scenario that requires an increase in diuretic dose for decongestion. Another metric of diuretic resistance is diuretic efficiency, which is the net fluid loss per mg of diuretic. It may be a more precise measurement of diuretic resistance then absolute diuretic dose and low diuretic efficiency has a stronger association with mortality than does absolute diuretic dose.22
Although loop diuretics have not demonstrated a mortality benefit in heart failure, evidence of diuretic resistance carries a poor prognosis with a higher predicted mortality and increased risk of readmissions for heart failure.22–25 Mechanisms to explain diuretic resistance are multifactorial. In a congested state, aspects of gut wall oedema, decreased splanchnic blood flow and decreased intestinal motility due to an increased sympathetic state all lead to a delayed time to maximum peak and decreased peak concentration of the drug.10 In patients with renal insufficiency, other organic acids such as blood urea nitrogen can compete with loop diuretics for transport by the organic anion transporters, with less drug therefore reaching the site of action. This decrease in drug concentration results in a failure to reach the diuretic threshold concentration needed for the drug to be effective.
Further changes in sodium handling in response to loop diuretics also contribute to diuretic resistance. During periods of decreased drug levels between diuretic doses there is a rebound in sodium reabsorption that has been termed a 'post-diuretic effect'.26 A 'braking phenomenon' has also been described after chronic diuretic use due to renal adaptation. Hypertrophy of cells in the distal convoluted tubules, away from the site of action of loop diuretics, leads to increased efficiency of sodium reabsorption and decreases the effect of loop diuretics.25 And lastly, other drugs can contribute to diuretic resistance. Non-steroidal anti-inflammatory drugs are common over-the-counter medications that clinicians should ask their patients about as patients commonly view them as benign due to their availability but they can contribute to diuretic resistance as well as increased risk of hospitalisations.27
Diuretic resistance and decreased response to loop diuretics is, unfortunately, not uncommon in clinical practice. Guidelines do not dictate which loop diuretic to use, only to use the lowest dose possible to achieve the desired effect.2 As diuretic resistance becomes increasingly suspected due to a decreasing response to a stable dose of loop diuretic, the diuretic dose can be increased in an effort to achieve comparably efficacious natriuresis. Another option at this time can also be to change from one loop diuretic to another with the hope that better pharmacokinetics between the loop diuretics can achieve the desired effect. Changing from furosemide to torsemide is common due to more consistent bioavailability of torsemide and the longer half-life of torsemide can potentially counter the 'post-diuretic' effect seen with furosemide.
Ambulatory Intravenous Loop Diuretics
Another growing practice used to counter resistance to increasing oral doses of loop diuretic is to administer intravenous loop diuretics in the ambulatory setting. This strategy has been utilised by several centres to help reduce hospitalisations, specifically targeting those patients that would only require one or two doses of intravenous diuretic to achieve euvolemia. Preliminary reported experiences so far have demonstrated this as a safe and effective way to decongest hemodynamically stable patients and potentially reduce hospitalisations for heart failure and overall healthcare costs.28–30 These outpatient heart failure units may therefore be useful to address those stable patients who appear to have diuretic resistance not surmountable by oral doses and just need some decongestion in order to respond to oral doses again. Furthermore, these centers also present another opportunity to involve a multidisciplinary care team as these patients are being monitored for a few hours while being given intravenous diuretics.
Thiazide Diuretics
When higher doses of a loop diuretic or changing loop diuretics are not achieving adequate decongestion, adding non-loop diuretics is an additional strategy – commonly referred to as 'sequential nephron blockade'. Thiazide diuretics and metolazone are frequently utilised with loop diuretics to achieve this sequential blockage as thiazide diuretics inhibit the Na+Cl– cotransporter in the distal convoluted tubule. This can counter sodium reabsorption that occurs with the increased sodium load being delivered to the distal convoluted tubule after loop diuretic administration, as well as counter the increased sodium transport capacity or 'braking phenomenon' that occurs with chronic loop diuretic use. Although the use of loop and thiazide diuretics is common clinical practice, the majority of the data on this combination diuretic use is limited to small observational trials or case studies.31 Despite this, the evidence in these studies supports the use of combination diuretic therapy in those on high dose loop diuretics demonstrating diuretic resistance.31 Common diuretics used to augment loop diuretics are metolazone, hydrochlorothiazide, chlorothiazide and bendroflumethiazide. Metolazone is commonly used for combination therapy, but no study thus far has demonstrated one thiazide-type drug as being superior to another in augmenting diuresis and this appears to be a class effect.31,32 This strategy does have risks, as a more robust diuresis with combination diuretic therapy can lead to electrolyte abnormalities including hypokalemia and, less commonly, hyponatremia and hypochloremia. The increase in decongestion can also worsen renal function if hypovolemia develops. Due to this, frequent monitoring of electrolytes and renal function is paramount when this strategy is used. When starting combination therapy in the outpatient setting, starting with a low dose of metolazone such as 2.5 mg (or equivalent dosing of another thiazide-type diuretic) two to three times a week and close monitoring to assess response and monitor for adverse events is warranted.31 Similar to loop diuretics, the concentration of thiazide diuretics must be adequate enough to cross a threshold for effectiveness. After the initial dose of thiazide diuretic, if there is not an augmentation in diuretic response, a higher dose of thiazide diuretic is then warranted. Although it is common clinical practice to administer the thiazide-type diuretic at least 30 min prior to the loop diuretic, evidence is lacking with regard to this practice as most studies administered the diuretics simultaneously.31
Mineralocorticoid Receptor Antagonists
Mineralocorticoid receptor antagonists (MRA), such as spironolactone and eplerenone, are common medications used in chronic heart failure to reduce adverse clinical outcomes.33–35 However, the doses commonly used and studied in these landmark trials have minimal diuretic effect, with their prognostic benefits likely resulting from their neurohormonal antagonism. In contrast, small studies have suggested that using doses in the range of 100–200 mg spironolactone daily may increase diuretic efficacy in those thought to have diuretic resistance and improve symptoms of congestion.36–38 The Aldosterone Targeted NeuroHormonal Combined with Natriuresis Therapy – Heart Failure study evaluated spironolactone 100 mg versus placebo in hospitalised patients with acute decompensated heart failure and did not find differences in their primary end point between NT pro B-type natriuretic peptide levels or their secondary outcome of dyspnea relief, clinical congestion, net urine output or weight loss between standard of care and high-dose spironolactone.39 Of note, there was no difference in the safety outcomes of incidence of hyperkalemia or change from baseline estimated glomerular filtration rates between the placebo and high-dose spironolactone groups at 96 h. Although this study demonstrated that high doses of spironolactone were reasonably well tolerated, the use of high-dose MRAs for treating diuretic resistance remains unclear. Although uncommon, the evolution of hyperkalemia remains a strong consideration with MRA use. Estimations suggest that the incidence rates in heart failure patients using MRAs range from 5 to 15 %.40–42
Vasopressin Antagonists
Vasopressin antagonists have also been considered for use in those with diuretic resistance. This class of drug blocks the effects of vasopressin on the aquaporin V2 receptor at the cortical collecting duct, leading to an increase in free water excretion or 'aquaresis'. In the Efficacy of Vasopressin Antagonism Heart Failure: Outcome Study with Tolvaptan, the investigators evaluated the addition of tolvaptan 30 mg daily to intravenous loop diuretics in hospitalised patients for heart failure. There was an increase in weight reduction and lower discharge weight in the tolvaptan group, but no evidence of long-term benefit in morbidity or mortality.43 When tolvaptan was started in addition to chronic loop diuretic therapy in ambulatory patients with heart failure, a dose-dependent weight loss was observed early on, but this failed to translate into any long-term improvement in congestion with continued therapy.44,45 As a result of these disappointing findings in combination with two recent null clinical trials attempting to elucidate the use of tolvaptan as part of an additional strategy for the management of acute decompensated heart failure, the role of tolvaptan for the routine management of congestion remains in question.46,47
Strategies to Guide Diuretic Titration
Heart failure is the leading cause of hospitalisation in the US and Europe; from 2001 to 2009, more than 1 million patients were hospitalised with heart failure as the primary diagnosis, comprising 1–2 % of all hospitalisations.48 This, in addition to the high rate of readmission after heart failure hospitalisation, presents a significant burden to the healthcare system. Optimising diuretic therapy in heart failure patients is a challenging task. Not surprisingly, there has been an increase in research to investigate complementary tools to help clinicians monitor and adjust diuretics, as well as other therapies to avoid congestion and prevent subsequent hospitalisations. Here we review several recent advances, such as ambulatory hemodynamic monitoring both invasive and non-invasive, and the emergence of subcutaneous furosemide as a potential option for patients in the future.
Many patients with heart failure have implantable cardioverter devices in place, and these devices allow for the collection of additional clinical data such as heart rate variability, patient activity and arrhythmias. These devices are also capable of calculating intrathoracic impedance, which is a characteristic of the electrical current that can pass from the device case to the right ventricular electrode.49 As pulmonary congestion increases, the device senses a drop in electrical impedance. Not surprisingly, there is an inverse correlation between the intrathoracic impedance with both pulmonary capillary wedge pressure and net fluid loss during an acute hospitalisation.49 This information, in addition to other parameters measured from the device, may identify patients at risk for heart failure events, heart failure hospitalisations or 30-day rehospitalisations after discharge. However, whether thoracic impedance might guide diuretic titration and or impact doses in other heart failure therapies still has no clear impact on rehospitalisations or clinical outcomes.50–53
Direct pulmonary artery pressure device monitors have had promising results in the management of heart failure. The CardioMEMSTM device by St Jude Medical (Atlanta, GA, USA) is placed in the pulmonary artery during a right heart catheterisation and allows for measurement of pulmonary artery pressures. The CardioMEMSTM Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA class III Heart Failure Patients (CHAMPION) study evaluated this device. In that study, clinicians had access to the treatment group's pulmonary artery pressure results but not the pressure results of the control group.54 Patients in the treatment group had a 28 % relative risk reduction in the primary end point of heart failure hospitalisations at 6 months, and over the entire study period of 15 months there was a 37 % relative risk reduction in heart failure hospitalisation in the treatment group.54 One caveat when interpreting these results is that the treatment group had additional clinical contact and support due to having a device implanted, which may have a had a confounding effect on clinical outcome.55 Post-marketing efficacy studies are ongoing, testing whether the benefits in the CardioMEMSTM device translate into improvement in real-world patient care.56 For example, a recent retrospective cohort study observed a reduction in heart failure hospitalisations in the 6 months after CardioMEMS implantation compared with the 6 months prior to implantation, supporting the results of the CHAMPION trial on the use of the device in addition to standard of care.57 At this point, however, the therapeutic role of the CardioMEMS device continues to evolve.
In contrast to invasive implantable monitors, non-invasive systems have been developed to assess pulmonary congestion and avoid acute decompensations. An electromagnetic energy-based technology (Remote Dielectric Sensing, ReDSTM) non-invasively measures the dielectric properties of tissues using low-power electromagnetic signals. This is performed non-invasively as patients wear a vest for a few minutes in which this measurement is recorded to give an indication of the fluid content in the lungs, a method that has been validated in prior studies using chest computed tomography as a comparator.58 A recent small study using 50 patients shows that in patients recently discharged for decompensated heart failure, outpatient therapy guided by the ReDSTM device results appears to decrease the rate of heart failure rehospitalisation.59 A larger multicentre trial is ongoing to further confirm these preliminary findings.60 Non-invasive lung impedance monitoring is also being investigated as a surrogate to monitor for pulmonary edema. A recent moderate-sized randomised control trial performed at two centres demonstrated that patients who had their heart failure therapies guided by lung impedance measurements at outpatient visits over 1 year had a reduction in hospitalisations for heart failure.61 If proven effective in improving clinical outcomes, these devices can potentially serve as another tool available for clinicians to monitor patients in the ambulatory setting and provide additional objective data to assist in titrating diuretics. However, non-invasive assessments, whether through measurement of electrical impedance, lung impedance or dielectric properties, with routine care have yet been shown to improve hard clinical outcomes in patients with heart failure. Nevertheless, these methods do provide additional insight that may guide chronic decongestion strategies.
Although furosemide has been used for decades, utilisation of a novel administration route by subcutaneous injection may be a viable alternative for patients with congestive heart failure. One early case series evaluated subcutaneous furosemide to a placebo injection of normal saline, with the group receiving subcutaneous furosemide demonstrating a higher amount of urine voided and higher urine sodium concentration.62 The subcutaneous furosemide group demonstrated a 30-min onset of diuresis and a duration of increased diuresis of be 3–4 h. Currently, this is an off-label use, with the limited published data available being from small case studies and uses in palliative care.63–65 The sc2WearTM Infusor, developed by scParmaceuticalsTM (Burlington, MA, USA), is a small pump that attaches to the body via an adhesive and delivers subcutaneous injections of medications. It is currently being investigated for the administration of subcutaneous furosemide in patients admitted for acute decompensated heart failure.66 The study will compare the strategy of early discharge with subcutaneous furosemide compared with usual care in a group of patients that have been stabilised but need further decongestion with intravenous diuretics. As a result, subcutaneous furosemide may be another option in the ambulatory setting for patients that become less responsive to escalating oral diuretic doses.
Diuretics play a pivotal role in the management of heart failure to decrease congestion and symptoms. This is made difficult by the development of diuretic resistance, which is sometimes insurmountable with the common practices of increased doses of diuretics or a change in the loop diuretic. Combination therapy is frequently employed, with thiazide-type diuretics being the most commonly used. Despite diuretics being used for decades in the treatment of heart failure, guidance on the best management strategy of heart failure is still lacking. Continued investigations into diuretics and fluid-management strategies will benefit our knowledge base on the use of these medications and hopefully improve clinical outcomes for our patients with heart failure.


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East Bay Express: Climate Change Will Unleash Buried Toxics, July 12, 2012
Toxic sites ringing the San Francisco Bay tell the story of its recent past. Smelting plants, hazardous waste dumps, landfills, shipyards, fuel depots, and military bases recall an era when the bay was prized more for its tactical and commercial values than for its ecology. Most have been closed or removed, but their toxic legacy often remains intact, hidden just beneath the surface; long-buried chemicals, heavy metals, and hazardous waste still seep into the bay on a daily basis.
Among the most contaminated locations are Alameda's Naval Air Station, Richmond's United Heckathorn site (a former shipyard and agricultural chemical warehouse), and San Francisco's Hunters Point Naval Shipyard. Other cities containing waterfront toxic sites include Oakland, Hayward, Newark, Hercules, Rodeo, Antioch, Novato, Tiburon, Sausalito, South San Francisco, Redwood City, San Mateo, and East Palo Alto; Richmond has more waterfront toxic sites than any other city, with a total of nine. Contaminants at the various sites include heavy metals, petroleum products, asbestos, and chemicals like banned DDT, all of which currently leak or could eventually leak into groundwater or the bay itself. Cleanup or containment is in progress at some sites, while others still need to be evaluated.


text: EL SEGUNDO, CALIF. - It was a moment that had Los Angeles Kings fans holding their collective breath. Drew Doughty yelped in pain after taking a slash from Ducks defenceman Francois Beauchemin to the back of the knee Monday night. He slowly skated off the ice struggling to put weight on the injured leg. "It was just a numb feeling," said Doughty, who has logged a team-high 27:14 of ice time per game in the playoffs. "It hits a little nerve and just goes numb for three minutes, four minutes and then its fine. Ive had it happen before so I wasnt scared, but its numb so its awkward to skate on." Doughty, who returned to the ice a few shifts after the slash, doesnt believe Beauchemin hit him in the sensitive spot on purpose. But that doesnt mean hell forget what happened. "Well, I always keep it in the back of my mind," Doughty said. "I know exactly who it was. Im not going to take any runs at him, but if hes coming down [the ice] Im not going to shy up on a hit." The Ducks are eager to make Doughty pay a physical price in this series, because his presence on the blue line is absolutely crucial to the Kings success, especially considering they are down two regulars (Willie Mitchell and Robyn Regehr) due to injury. "I know teams are going to target me," said Doughty. "Theyre going to target other guys on the team too. Its just part of the game. If anything, that makes you hungrier. It makes you want to work harder to avoid those hits and make a difference. When theyre targeting you and youre still being successful, thats the most frustrating thing for them." Anaheim is also doing its best to get Jonathan Quick off his game. Corey Perry crashed into the Los Angeles crease during the second period of Game 2, which led the soft-spoken Kings keeper to give him a shot and take a roughing penalty. "Some people think you get him off his game by doing those types of things, but you dont," said Kings forward Jarret Stoll. "If anybody knows Quickie, hes a very, very competitive, determined guy in the net and hell do anything to win and hell back up his teammates even when we dont want him to sometimes. We dont want him in the scrums, but sometimes hes in there like he was in round one [when he went after big San Jose Sharks centre Joe Thornton]. "Its no secret: we want to target their best players too. If their best players are the best players in the series then theyre going to win the series and were going to lose. If Drew Doughty and Anze Kopitar and Jeff Carter and Marian Gaborik are the best players in the series, were probably going to win." For his part, Darryl Sutter thinks all the targeting talk is a bit much. "Every game he plays he gets extra attention, but I dont think anyone is going out of their way to hit Drew Doughty," the Kings head coach said. "Theyre a big, physical team. The reason Drew may get touched more than other guys is he plays half the game. Quite honest, we need some of our other defencemen to get touched that much." Thats just one adjustment the Kings can make. There will be others. Despite stealing the first two games of the series in Anaheim, Sutter and his players are far from content. There are certainly ways they can improve. "Hopefully lots of ways," Sutter said, "but Im not going to give you that little secret." The tight-lipped coach did admit he felt the Kings were lucky to be in such a commanding position in the series. "We had to use a short bench [in Game 1] because some guys werent up to standards. We were fortunate to win that game." One area where the Kings can be better is in dealing with the Anaheim forecheck. "Theyre quick. They read off each other really well," Stoll explained. "Theyre very aggressive. They get two guys down to the goal line very quickly on our defencemen. If were not going to support our defencemen like we should, were going to get outmanned and out-supported. The key is to out-support their forecheck in those situations. Come up with the pucks, and get it going the other way. Everybody wants to play in the offensive zone. Thats the whole battle. Thats the whole series right there." So there are issues to be addressed, but at the same time there are reasons to believe coming back on the Kings will be a very, very difficult task. The Kings were outshot by the Ducks 37-17 in Game 2, but they have done well to prevent second-chance opportunities. "Our D have done a really good job of defending," said Doughty. "We maybe havent been the best at moving the puck or as good as we usually are, but our defending has been really, really good. Were playing physical. Were boxing guys out, getting under sticks, clearing pucks and thats our job in the D zone. When were doing that, when were clearing the bodies, Quickies going to make the first save." Doughty had a four game point streak snapped on Monday and he has the same number of penalty minutes (two) as shots on net in the series so far. And yet he remains a key reason why the Kings are in such a good spot. "I thought we controlled him pretty good," said Ducks head coach Bruce Boudreau. "I dont think he made many rushes [Monday], but hes a smart player and hes very good defensively when he has to be. Thats based on the individual. Theres not much we can do about the fact were playing against a good player. I mean, hes good and hes going to make good plays. We try and disrupt him as much as we can, but youre not going to do it all the time." Doughty believes he is "10 times the player" he was during the 2009-10 season when he racked up a career-high 59 points en route to a Norris Trophy nomination. He says he is much better in his own zone now and all-around more mature. "I feel Ive improved as a player and been a better leader for this team and Ive played a lot better. I make a difference in every game." The other major thorn in Anaheims side, other than Doughty and Quick, is Anze Kopitar. The Selke Trophy nominee is the leading scorer in the playoffs with 14 points despite being matched up consistently against other teams top players. Kopitar has registered at least one point in all nine of the Kings playoff games this spring. "When Im on the ice with Kopi Im playing completely different," said Doughty. "When I get the puck rather than maybe trying to rush it or something like that, if Kopis open Im just giving it to him no matter what and Im joining the rush. "When Kopis there you have full trust in him. He just makes things happen when he has the puck so I figure why not give it to the guy that makes things happen and try and get open for him." Despite their success, the core players on the Kings arent about to start feeling too good about themselves despite the current six game win streak. This is a veteran team just two years removed from a championship. And theyre way too smart to feel satisfied. "We know how quickly a series can change," said Doughty. "It just takes one moment sometimes. It can be a fight, just a big goal or anything like that. A series can change so quickly so you got to keep that foot on the gas pedal. We cant let them back in the series. "We have that killer instinct and we have to show that in the next game. If we let up for any second that [can be] the difference in the game, the difference between winning and losing." Only a couple weeks ago, the Kings appeared dead in the water after dropping the first three games against the Sharks. They dont want to give the Ducks a chance to author their own comeback story. "A 2-0 lead is great, but its not four," Stoll said. "Its not four wins and we know that better than anybody and we also know we havent played our best hockey to date." Jae Crowder Jersey .com) - James Harden had 32 points, including a tying layup late in regulation, and the Houston Rockets scored eight of their 13 points in overtime at the foul line to beat the Memphis Grizzlies 117-111 on Friday night. Jonas Jerebko Jersey . "I dont know where we would be without him," McClendon said. "Hes done a tremendous job for us and (Wednesday) was no different." Logan Morrison drove in two runs in Seattles big sixth inning, Young pitched seven strong innings and the Mariners beat the Houston Astros 5-2 to complete a three-game sweep. http://www.cheapjazzjerseys.info/Authent...azz-Jersey/.com) - A pair of Eastern Conference rivals will meet on Saturday as D. Grayson Allen Jersey . In the days leading up to the draft, TSN.ca and TSN Radio basketball analyst Duane Watson looks at some of the names that will be headlining the event. Watch the 2014 NBA Draft on TSN, Thursday at 7pm et/4pm pt. 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Announced for PS1 in 1998, the game was released exactly 23 years later
The Japanese game Magic Castle, which was sent to publishing companies in 1998 and thus announced, made its debut exactly 23 years later.
- 06-01-2021 12:25
We have seen many games since the game world started to emerge. Of course, not only the games we see, but many games have either been canceled or shelved without our knowledge. A game of this kind has surfaced recently.
In 1998, a small Japanese developer team sent Magic Castle, the game it had been working on for about 8 months, to several publishing companies, including Sony. Unfortunately, the game's development process did not continue and the game remained with its announcement in 1998.
About 20 years after the game was announced and shelved, PIROWO, one of the former team members, found the source code of the game and completed the game. In short, Magic Castle made its debut approximately 23 years after its announcement. You can find the gameplay video for the game released in 1998 below. You can also download the game free of charge from here.


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The Benefits of Charter Jet Travel to Christ Church
Emergency flights offered by air ambulance are very important services that can be the lifeline of a patient. Aircraft used for air medical aid have appropriate interiors and equipment that have advanced and vital life support aids. This is with exceptions of some military and charter aircraft. Though not much can be done about the levels of noise and in some aircraft, limited working space, efforts are usually made to have advanced equipment which is space-saving and conveniently placed. Pressures in the aircraft cabins are standardized and expert aviation medics have the advanced knowledge to deal with expected or unexpected changes in pressure. The equipment and interiors of these emergency flights make patients who are sometimes tourists or travelers, feel safe to be evacuated to their preferred or authorized medical assistance providers. Reliable air ambulance services Bridgetown, medevac are available and can mean the difference between life and death.
When you are hunting for a way to have medical help, it can be difficult to find the proper assistance. That is when you should know the medical air transport Bridgetown, air ambulances can easily be the best choice for you for major medical problems. By using these services, you will have the best chance of survival from any of the complications that you have. Without having the services help, though, you may not be able to survive some of the traumatic accidents that you have had. However, if you have an option, you may need to find out if your medical insurance that you have will cover for this service or not, but even if this is not covered, you should still use the service to ensure you get the proper level of care.
It is important that every council member step forward to endorse the approval of medical air transport Bridgetown. Air ambulances can routinely be the reason someone survives an incident, or not. Because of their small sizes, these flying saviors will work well in both our commercial and more rural areas. Having the abilities to bypass traffic and to travel great distances at fast speeds, ensure quick transport to local or larger regional hospitals for accident victims. These services do not replace standard ambulances, rather they work in tandem to ensure the best and most efficient service possible. For example, in a large multi-vehicle accident, both van and air ambulance will head for the scene. Highly critical patients will be taken via air, while those more stable will go by land. It is a win-win situation for everyone.
Often a serious accident victim arrives at a local trama center with severe head and organ injuries that are beyond the medical skills of the local doctors on staff. At that point, a call is routinely made to an air medical Bridgetown service requesting an emergency flight to a different city that has the medical skills and the equipment to treat the critically injured patient. Within minutes a crew from Medevac, an air ambulance service, arrives on the scene and prepares the patient for a quick flight to the new destination. This air ambulance service not only provides emergency medical flight service for land-based emergencies but is often called for medical emergencies on river and ocean accidents. Often this life flight is the difference between life and death.
There are many ways to travel big distances these days. You could go by train, car, ship or commercial airline depending on where you are going. If you can afford it, however, private jet charters are the best way to go. Private jet charters are more available than you think. There is a plane for every occasion; the size and type will vary depending on how far you are traveling. If you are traveling to Christ Church, for example, you'll want to tailor your jet choice to the best for that distance. Renting a private jet charter opens up many doors to a person, when you have to ability to choose your destination it can lead to very fun and exciting adventures to exciting new places.


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Introduction: How to Make a Mini Mickey Mouse Sugar Cookie (clay)
Hello everyone! Today I will be showing you how to make this clay Disney sugar cookie. I hope you enjoy!
Step 1: Materials
Sand clay
White clay
Orange clay
Pink clay
Red clay
Yellow clay
Step 2: Step 1
Separate your sand clay into three pieces, two small, and one large.
Step 3: Step 2
Flatten the pieces.
Then, Take your two small pieces, and flatten the bottom with a ruler.
Step 4: Step 3
Take your white clay and flatten it, cut it into the shape of icing, and press it down on the large piece of sand clay. You can use any rounded tool to press it down
Step 5: Step 4
Make tiny balls of orange, pink, red, etc clay, and press them on the icing. Bake/dry, and glaze
And you are done!
Participated in the
Big or Small Challenge


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The phrase appears to have originated among conservative writers, but has been adopted by those liberals critiquing the concept as something to be forgotten rather than striven for. The phrase stretches over a number of areas of contention between the two camps. Some of these issues are environmental law, reproductive rights, gun control, campaign finance reform, and the signifigance of the Commerce Clause. Liberals fear the return of the Constitution in Exile will mean the rolling back of environmental protections, the repealing of Roe v. Wade, and the removal of worker protections such as those instituted by the Occupational Safety and Health Act. Conservatives trumpet an era of limited government and the return of states' rights.
Whether the transition will be good or bad, it does appear that the Supreme Court is moving toward a stricter interpretation of the Constitution. One of the most telling signs of this was the recent decision limiting Congress' use of the Commerce Clause to make law on essentially any matter. In the case of United States v. Lopez, the Supreme Court ruled, in a 5-4 decision, that Congress could not pass a law making it illegal to posses a gun in a school zone. They held that because the action did not involve commerce in any way, despite its possible indirect effect on commerce, it was not under Congress' jurisdiction. Furthermore, it appears that decisions such as these will only be increased under a Supreme Court that will be gaining a number of new justices during the Bush Administration.
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Maxi dress
The dress can be worn with or without sleeves, thanks to bra-like straps so as to be adjustable that you can keep or take off as you like.
When worn in a tank top, the long sleeves can be knotted in front or behind to shape the dress.
Similarly it can be worn as a high-waisted maxi skirt using the sleeves as a belt.


text: This hands-on, interdisciplinary course is modelled on the pioneering Biodesign training concept of Stanford University, that has been adopted by leading universities around the world. Participants will benefit from lectures and intensive project coaching by Stanford and ZHAW faculty, top tier health innovation and medical experts, clinical immersion and an exclusive international network. The CAS aims at aspiring corporate intrapreneurs and start-up entrepeneurs passionate about developing breakthrough medtech products. Candidates must possess at least three years of professional healthcare experience in e.g. medicine, clinical research, product management, sales, business development, R&D, or software development. A fee reduction of CHF 1500,- is applicable for applications received by May 15th, and 1'000,- for applications by Sep 1, 2020 Please email your complete application to firstname.lastname@example.com Swiss Healthcare Startups sponsors a 'SHS Swiss Biodesign Fellowship' for a young, high potential innovator. In order to benefit from the 'SHS Swiss Biodesign fellowship' worth CHF 7'800 (to participate at CHF 4'000 vs. the standard rate of CHF 11'800), applicants must meet the following requirements: Be an SHS member Early career-stage with max. 5 years of work experience in startups, research, clinics, medtech, pharma, IT or consulting companies Successfully completed Bachelor, Master or MD degree and first international experience Demonstrated academic, intra- or entrepreneurial excellence Strong interest in radically innovating medical devices or digital health The deadline for sending the fellowship application (motivation letter, CV, two reference letters) to email@example.com is Oct 1, 2020.


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A new leaf: the latest plant-based products for foodservice
After years of settling for a garden salad and a side of chips, vegans and vegetarians across the UK are enjoying a surge in plant-inspired innovation across the restaurant industry. Angela Frewin reports
A revolution in plant-based eating is well under way. "While vegetarians once had trouble ordering when dining out, choices these days extend much further than a simple salad or pasta," says David Partridge, head of food development at Fresh Direct. "Now, the spotlight is being shone on the once unassuming vegetable and it is taking centre stage in such an irresistible way that even meat-lovers are wanting a taste. Veggie-centric dishes are part of a major movement in the culinary world, with an increasing number of chefs delivering bold flavours to ingredients that were once solely considered for side dishes."
It's not just the burgeoning ranks of flesh-rejecting vegetarians and ovo-lacto-averse vegans powering this plant revolution. The biggest boost is coming from meat-reducing flexitarians with similar health, animal cruelty and environmental motivations.
A new way of thinking
"To avoid menu proliferation, one of the key pieces of advice is to offer plant-based dishes that will appeal to all diners, not just those who are vegetarian or vegan," suggests Gordon Lauder, managing director of Central Foods. That's the idea behind its new vegan (and gluten-free) frozen Menuserve meals of cauliflower and lentil dhal bundt with spiced mango, or Cajun-spiced sweet potato roulade with vegan cream cheese, red pepper and black bean salsa, plus two baked cheesecakes.
"Many international cuisines have a far stronger vegetarian or vegan heritage, in comparison to the UK's traditional offering of meat and two veg. This means that there's often a long history of developing truly sensational plant-based recipes," says James Robinson, product trainer at Spanish operator and supplier Brindisa, whose new Navarrico chickpeas aren't just for hummus and salads - they make hearty meat replacements in casseroles.
Popular and versatile curry and rice dishes are adjustable for both carnivores and meat-avoiders, says Tripp at Bidfood, which offers vegan versions of jambalaya and Keralan curry.
Meat your match
Tofu and Quorn are facing new challengers with direct meat replacements. Jodie White, marketing manager at Bunzl, describes Beyond Meat's pea and beetroot juice-based Beyond Burger as "the world's first plant-based burger that looks, cooks and tastes like a fresh beefburger - it even bleeds!"
Bland but flavour-absorbing jackfruit is in vogue, adds Bidfood's Tripp: "It can be shredded, giving it a very similar texture to pulled pork, which can be used in tacos and burritos and as part of the popular Tex-Mex trend." Similarly chewy seitan - made from wheat gluten - has the appearance and texture of shredded duck, making it ideal, she says, for vegan Asian dishes, such as mock duck pancakes, noodles, rice and broths.
French chef Alexis Gauthier - a high-profile vegan convert - convinced many with his 'faux gras' (a blend of lentils, mushrooms, beetroots, walnuts and shallots) launched recently at his Gauthier Soho restaurant. And similar vegan substitutes include the much lauded aquafaba (chickpea water), and frozen avocado flesh, which can be a great replacement for eggs in desserts, such as in dark chocolate mousse, says Brakes food marketing manager Becky Hover. White suggests substituting sugar and milk in brownies with sweet potato, and flour and milk in pizza with cauliflower and almonds.
Cheesed off
Protein-rich cheese adds not just flavour but essential nutrients that are sparse in vegetarian fare, such as iodine and vitamins B12 and D. James Millward, managing director at Eurilait, suggests making cheese the star of a dish, such as halloumi burgers, baked Camembert and deep-fried Brie wedges. Ribble Farm sees rennet-free quark as a low-fat, low-calorie alternative to cream and béchamel sauce.
The vegan cheese market is predicted to approach £3b by 2024, while the number of new vegan ice-creams has more than doubled since 2014 globally. Veganarella, Dairy Partner's first vegan offering, provides coconut oil-based mozzarella and Cheddar alternatives, designed to mimic the structure, texture and melting properties of dairy. Bidfood offers coconut- and rice-based vegan cheeses, including Parmesan and mozzarella replacements, along with a soya bean-based ice-cream range.
For home-made, dairy-free gelato, Michele Stanco, training and development chef at ice-cream equipment specialist Carpigiani UK, suggests combining nuts with soya, coconut, rice or almond milk for a smooth consistency.
Make your mark
Clear labelling is essential for on-the-go meals, where the Vegan Society found 91% of vegans struggled to find suitable options. Mr Lee's Pure Foods Co plumped for the internationally recognised Vegan Society logo on its newest gluten-free noodle pots, while Planglow's vegetarian and vegan stickers and Bunzl's vegetarian and dairy-free Label 2 Go stickers help operators highlight meat-free takeaways.
Menu design plays a critical role in take-up - research by a London School of Economics graduate found frequent vegetarians were 56% less likely to order a plant-based meal if it was listed in a separate vegetarian section rather than being incorporated in the main menu. Conversely, highlighting plant-based dishes as chef's specials increased take-up among infrequent vegetarians. "Foodservice outlets will need to try different possibilities for menu design to find out which works best for them," concludes Lauder.
Nevertheless, Jo Robinson at We Create Clarity suggests trialling some in prime positions: "Providing the food sounds delicious, it seems that many meat eaters will choose a vegetarian or vegan option when eating out, so you may find that they are as popular as the best-selling meat options - but with a higher margin."
Vital statistics
•There are 1.2 million vegetarians (NDNS/NHS 2017) and 16.5 million flexitarians (Mintel 2017) in the UK
•UK vegan numbers soared by 360% between 2006 and 2016, from 150,000 to at least 542,000 (Vegan Society/Ipsos Mori)
•3.5 million people in Britain now identify as vegan (Comparethemarket.com, April 2018)
•Half of UK vegans are aged 15-34 (Vegan Society 2017) and 10% of 16- to 24-year-olds are vegan (Mintel/TUCO 2017)
•Menu mentions of vegan dishes rose by 72.3% year-on-year in 2017 (Technomic)
•Demand for vegetarian options grew by 987% in 2017, and 11% of UK adults tried to follow a vegan diet (Just Eat)
•28% of people are meat reducers (Mintel 2017) and 44% are reducing their intake of red meat (Mintel 2018)
•200 million additional meat-free evening meals (+7%) were consumed in 2017 than 2016 (Kantar WorldPanel)
•The meat-free market will be worth £658m by 2021 (Mintel)
Back to school
The Vegetarian Society Cookery School, based in Manchester, has refreshed its professional chefs' diploma course to include a full day on vegan pÁ¢tisserie and desserts.
The five-day intensive course includes workshops, information about nutrition, discovering new flavours, menu planning, practical cooking sessions and an introduction to vegetarian and vegan ingredients. Chefs will learn how to maximise flavours and adapt menus to keep them on-trend.
The next course runs from 8 to 12 October. Find out more at www.vegsoccookeryschool.org
Café accommodations
n "explosion of interest" in vegetarian and vegan options over the past year means that Scandi-style café Baltzersens now offers Oatly's Barista Edition oatmilk (the café's favourite) along with Alpro soya, coconut and almond milk. It's also trialling Artemis nitro cold brew as a vegan iced latte - served on draught, its velvety head gives a thicker, creamier mouthfeel, says owner Paul Rawlinson.
"We have limited space in our kitchen, so our menu needs to remain fairly tight," Rawlinson explains. "Offering more variety has been about altering methods and finding ways to offer vegan versions of our existing dishes." He substitutes egg yolk with potato and tapioca-based Orgran egg replacer in cakes, and with aquafaba in the garlic aÁ¯oli that accompanies Baltzersens' avocado on toast.
"The holy grail is to find a recipe with universal appeal as this reduces waste," he adds. He pairs the Baltz Bowl (pictured above) of cooked rye, nuts, seeds, pickles, beans and salad with chicken, salmon or halloumi; similarly, he replaces butter with rapeseed oil in Baltzersens' vegan pyttipanne, a type of potato hash, which comes with spinach and mushroom in place of halloumi or smoked sausage.
Seeds of inspiration
e web is awash with plant-based recipe inspiration, but Seedbank (www.seed-bank.co.uk) targets foodservice operators. Vegetarian Express, the UK's only dedicated plant-based foodservice business, designed the interactive recipe service to provide operators with vegetarian and vegan meals to tempt meat and non-meat eaters alike.
Recipes can be filtered by occasion, world flavour inspiration or main ingredient, and come with nutrient analyses, allergen and sensitivity lists, and environmental benefits.
Increased demand - particularly from B&I, foodservice, schools and universities - prompted Vegetarian Express to launch 10% more products in the past year, including bigger packs of jackfruit and tempeh (a fermented soy-based meat alternative), Khorasan grain, and Korean gochujang chilli paste. Pipeline products include a plant-based frankfurter and seitan with Italian, smokey and Cajun flavourings.
Bunzl Catering Supplieswww.bunzlcatering.co.uk
Carpigiani UKwww.carpigiani.co.uk
Central Foodswww.centralfoods.co.uk
We Create Clarityuk.wecreateclarity.com
Dairy Partnerswww.dairypartners.co.uk
Fresh Directwww.freshdirect.co.uk
Mr Lee's Pure Foods Cowww.mrleesnoodles.com
Ribble Farmwww.ribblefarmfare.co.uk
Thomas Ridley Foodservicewww.thomasridley.co.uk
Vegetarian Expresswww.vegetarianexpress.co.uk
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text:
In case you're from some other planet, this is Peppa Pig.
Peppa's a hit and her features seem to be easy to reproduce. And therein lies the problem, because...
1. Everybody now thinks they can make a Peppa cake.
2. And that's just not true, as you can see:
3. This nose is an abomination.
4. But making a Peppa cake without the nose doesn't quite work either...
5. You're always left feeling that you ALMOST had the proportions right.
6. And that you put the eyes in ALMOST the right place.
7. Sometimes, you get the impression that nothing is actually where it's supposed to be.
9. This is Peppa after eating a few too many of these botched cakes.
10. And here she looks like she forgot to wax her upper lip.
11. Something's missing...
12. Hmmm, that's not quite it, is it?
13. I think Peppa stepped somewhere she shouldn't have.
14. And, of course, sometimes Peppa turns out like something just downright obscene.
This post was translated from Portuguese.


text:
Men of Style: Abhishek Bachchan
Tall, dark and not really a conventional good looker, is Abhishek Bachchan.
AB's baby seems to be quite aware of what's going on in the fashion scene. He plays it safe when it comes to style and is only rarely caught in red-handed by the fashion police. Even when he is not the best dressed, his outstanding and naturally stylish personality makes it up for him.
Here is our man of style, Abhishek Bachchan.
Style Evolution
Abhishek Bachchan has always been an extremely shy guy since childhood. Fashion or no fashion, Abhishek has never really been one to go flaunting his cool outfits like many of his contemporaries. However, today, he appears much more comfortable and relaxed in what he wears which makes him look all the more endearing.
Wardrobe Basics
Though Abhishek also mentions the clichéd 'white shirt and blue denims' as the basics in his wardrobe, he is often seen in macho suits which he carries so well. He also plays a lot with stud-sy jackets adding a whole new dimension to his otherwise mundane and regular outfits.
Top Fashion Moment
With the release of 'Dostana', Abhishek was suddenly catapulted to an all new high in terms of fashion. Though co-actor, John Abraham stole the show with his tiny yellow briefs, AB held his own with his floral shirts and colorful stoles. In fact, he made floral shirts a trend amongst men by sporting them with such panache and exuding masculinity in spite of the feminine patterns.
Trademark Style
Abhishek's style is cool and composed. Though his style statement is very easy and laidback, he always appears very suave and debonair, nonetheless. It is this effortless sense of style that cuts him apart from the other stylish men in Bollywood.
Best Feature
Above all the features that Abhishek boasts of, it is his magnetic personality that scores the maximum points. His intelligence as well as his amazing sense of humor make him all the more likeable. He is an inherent charmer and, keeping aside wifey Aishwarya Rai, still manages to sweep women off their feet most of the time.
Hair Story
Abishek has always been game at experimenting with his looks, especially his hair. Therefore, while he sported long hair for 'Drona' he went for a total buzz-cut for his film 'Raavan', with many hairstyle changes for other films in between.
Style Mentor
AB isn't dependent on a mentor in order to look stylish. Style, being a personal factor for him, remains a 'family business' to a large extent. As he himself states, "My mother and sister are the only women who've complimented me". Of course now that he's married, we're sure that his fashion-conscious wife plays a major role in helping him decide what to wear. (Fashion, MensXP.com)
Also read: Men of Style: John Abraham


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PRICE is approximate and may vary if additional coupons or discounts are applied to the purchase transaction. You can use coupons on Kohl's only brands and other great brands such as Apt. 9, Croft & Barrow, FLX, Jumping Beans, SO, Sonoma Goods For Life, Tek Gear, The Big One, LC Lauren Conrad, Nine West, Simply Vera Vera Wang, and more. See Kohls.com/details for a full list of included brands.
Pricing, promotions and merchandise availability may vary by location and at Kohls.com. "Sale" prices and percentage savings offered are discounts from Kohl's Regular (Reg.) or Original (Orig.) prices, and are valid on selected styles of merchandise unless otherwise indicated. The Reg. or Orig. price of an item is the former or future offered price for the item or a comparable item by Kohl's or another retailer. Actual sales may not have been made at the Reg. or Orig. prices, and intermediate markdowns may have been taken. Orig. prices may not have been in effect during the past 90 days or in all trade areas. Merchandise could be offered at the same or lower "Sale" prices during future promotional events beginning on or after the last day of this advertised event. The following merchandise are excluded from "Entire Stock" promotions in this advertisement: Clearance, Kohl's Cares® cause or other charitable items, Licensed Team, Sephora at Kohl's, emerging brands and Kohl's Online-Exclusive items. In some events, actual savings may exceed the percent savings shown. Kohl's® and Kohl's brand names are trademarks of KIN, Inc. ©2024 Kohl's, Inc. With respect to certain Price Break merchandise featured in this advertisement, the "previous sale" price represents sale prices recently advertised in Kohl's print advertising.


text:
The First National Bank of Arenzville has announced the winner of this years Blue Diamond Community Service Award. This years winner is Kevin Eckhoff of Jacksonville. Eckhoff is an active volunteer with Salem Lutheran Church and is a member of several local boards, including the Jacksonville Public Library, Pathway Services Unlimited and Presbyterian Daycare.
Eckhoff says he is excited to be chosen for the award.
"I am very honored to receive the award from the bank. I feel honored they selected me out of a large list of very well deserving volunteers."
Eckhoff says he is happy to volunteer in Jacksonville.
"Jacksonville is a great community with a lot of organizations that do a lot of good and it is a pleasure to be a part of a couple of those organizations."
Eckhoff has been donating his time for a number of organizations for close to 30 years and says he hopes to set a good example to others.
"I would encourage other folks in the community that if they have the time and the energy to devote to a civic organization or a not-for-profit, to jump in and do it. It is very rewarding, you meet lots of great people and it gives you a sense of being involved and being a part of the community."
The Blue Diamond Community Service Award was created to recognize outstanding volunteers in the First National Bank service area. 2016 was the third year of the award.


text: We have enjoyed quite an Indian Summer in west central Missouri, but it appears to have ended now. Temperatures are dropping into the 30's at night and the leaves are changing and falling. Funny how things are still the same inside of Bast Storage's facilities: clean, pest-free, well-lit, and steady temperature. Come be a part of our great little community.


text:
Kdvs Fm
Kdvs Fm
Kdvs Fm based on USA is one of the popular music station. Kdvs Fm station streaming music and programs both in air and online. Originally it is a community radio channel plays around the clock 24 hours live online. Kdvs Fm also operate various musical programs consistently for the people of all ages. Besides all of these programs its strength is the listeners participation and feedback through online.
Pop music is a genre of popular music that originated in its modern form in the Western world during the 1950s and 1960s, deriving from rock and roll. The terms "popular music" and "pop music" are often used interchangeably, although the former describes all music that is popular.
Pop music is eclectic, and often borrows elements from other styles such as urban, dance, rock, Latin, and country; nonetheless, there are core elements that define pop music. Identifying factors include generally short to medium-length songs written in a basic format as well as the common employment of repeated choruses, melodic tunes, and hooks. Throughout its development, pop music has absorbed influences from most other genres of popular music. Early pop music drew on the sentimental ballad for its form, gained its use of vocal harmonies from gospel and soul music.
Radio Information: |
Location: USA |
Language: English |
Genres: Pop |
WebSite: www.kcsufm.com |


text:
Tesla paid $10,000 a researcher that found a stored cross-site scripting (XSS) vulnerability that could have been exploited to change vehicle information.
The security researcher Sam Curry has earned $10,000 from Tesla after reporting a stored cross-site scripting (XSS) flaw that could have been exploited to obtain vehicle information and potentially modify it.
Curry discovered the issue in the software on his Tesla Model 3. He used the XSS Hunter tool to insert a payload in the "Name Your Vehicle" field in the infotainment system.
The XSS Hunter works by hosting specialized XSS probes which, upon firing, scan the page and send information about the vulnerable page to the XSS Hunter service.
Curiously Carry discovered the XSS issue months later when he used the mobile app to contact Tesla support after his windshield was cracked by a rock.
He was setting up an appointment when he noticed from the XSS Hunter panel that the flaw was triggered. He discovered that some information about the vehicle was collected from a page of Tesla application that was used to see the vital statistics of the car.
The exposed information included the vehicle's VIN, speed, temperature, version number, whether it was locked or not, tire pressure, and alerts. The data also included other firmware info such as geofense locations, CAN viewers, and configurations.
"The thing that was very interesting was that live support agents have the capability to send updates out to cars and, most likely, modify configurations of vehicles. My guess was that this application had that functionality based off the different hyperlinks within the DOM," Curry wrote."I didn't attempt this, but it is likely that by incrementing the ID sent to the vitals endpoint, an attacker could pull and modify information about other cars."
"If I were an attacker attempting to compromise this I'd probably have to submit a few support requests but I'd eventually be able to learn enough about their environment via viewing the DOM and JavaScript to forge a request to do exactly what I'd want to do."he added.
The researcher reported the flaw to Tesla that acknowledged it and addressed it is only 12 hours. Below the timeline of the flaw:
- 20 Jun 2019 06:27:30 UTC – Reported
- 20 Jun 2019 20:35:35 UTC – Triaged, hot fix
- 11 Jul 2019 16:07:59 UTC – Bounty and resolution
Curry was awarded $10,000 for reporting the flaw to Tesla.
"Looking back, this was a very simple issue but understandably something that could've been overlooked or regressed somehow. Although I'm unsure of the exact impact of the vulnerability, it seems to have been substantial and at the very least would've allowed an attacker to view live information about vehicles and likely customer information," Curry concludes.


text:
Our hazel wood: the heart of "Cuor di Nocciola"
We have been cultivating hazelnuts for generations.
We have been cultivating hazelnuts for generations. In the Twenties, Grandpa Giovanni decided to cultivate the hazelnut trees in flat fields normally used for other crops. At the beginning everyone in the village thought he had gone nuts. Until then the hazelnut had been cultivated only in places where other crops were impossible, such as banks, steep slopes and small fields in unfavorable positions. He had a really good intuition!
The harvest takes place in summer, generally August. The hazelnuts that drop from the trees are blown away from the bushes with special shoulder-carried blowers and pushed toward the center of the paths between the trees. We collect them from there with machines that suck them from the ground.
Each tree produces around 10kgs of hazelnuts. A tree needs up to 8 years to achieve full production.
The harvested hazelnuts are placed in the farmyard and in the dryer, where they complete the natural drying process for a couple of days.
How do we know when the hazelnuts are ready?
By ear! According to how much they dried, the hazelnuts will produce different sounds. Just put a hand in the pile and listen to the melody of the shells, if they are dry they will "sing" clearly and sharply.
The yield is determined and certified, according to the PGI trademark. We select 1kg of product from each load of hazelnuts. The hazelnuts are then shelled by hand. Among the shelled fruits, the rotten, bug, imperfect or shriveled ones are eliminated.
The percentage ratio between the gross weight of the shelled hazelnuts and the net weight of those of good quality represents the yield. A ratio of 44% or superior is considered a good one.
"Cuor di Nocciola" is a big family. During the harvest family friends come to help us out. For 25 years X has been coming to help us out. He was only 15 years old the first time he joined us. It's nice to get together every year to share such a special moment for us!