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What the Anesthesiologist Should Know before the Operative Procedure?
Hemipelvectomy is a major surgical operation. When a tumor is not able to be resected with the use of a limb-sparing technique or via hip disarticulation, a hemipelvectomy may be required. In this procedure, the lower extremity and much of the bony pelvis are removed. This is also known as an external hemipelvectomy. Disarticulation frequently occurs at the level of the pubic symphysis and the sacroiliac joint. An internal hemipelvectomy may be performed in appropriate candidates. This is a limb-sparing or limb-salvage procedure that involves saving the patient's limb while resecting areas involved with the tumor. Given the importance of an adequate and tumor free surgical resection in the long-term outcome of patients, hemipelvectomy remains a potentially curative surgical method.
As a hemipelvectomy is a major surgical procedure, it is not surprising that initial surgical attempts resulted in patient death, and it was not until 1895 that Girard performed the first successful hemipelvectomy. Now with improved surgical technique, along with the advances in anesthesia, hemodynamic monitoring, fluid management, hemostasis, and the ability to provide packed red blood cells (PRBCs) and clotting factors as necessary, survival for patients undergoing this procedure has improved.
The incidence of hemipelvectomy has decreased as a result of more effective cancer therapy and use of limb salvage procedure. Furthermore, the development of non-orthopedic fields including management methods as early diagnosis and follow-ups by imaging, new chemotherapy and/or radiation therapies, and implants or bioengineering have led to improvement in the outcomes of hemipelvectomies. Reconstruction after hemipelvectomy has also led to better outcomes and quality of life for patients. Reconstructive plastic surgery techniques, such as free flaps, have improved reconstruction, in addition to helping reduce infection rates.
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Procedures for hemipelvectomy depend on tumor involvement and resectability. The hemipelvectomy that is limb-sparing is referred to as an internal hemipelvectomy.
1. What is the urgency of the surgery?
What is the risk of delay in order to obtain additional preoperative information?
The answer to this question depends on the indications for surgery. Procedures performed for tumor surgery are usually not urgent or emergent, but need to be performed to resect tumor. Trauma, vascular insufficiency, infection, or bleeding may result in the procedure becoming urgent or emergent.
Emergent indications for this major surgical procedure carry an associated high morbidity/mortality.
a. Trauma-bleeding: Life threatening blood loss with profound hemodynamic instability
b. Acute arterial insufficiency: Due to new-onset ischemia secondary to acute arterial occlusion
c. Severe infections: On patients showing signs of imminent septic shock (hypotension, tachycardia, decreased systemic vascular resistance [SVR])
a. Infections: Trying to address source of infection before the patient becomes hemodynamically unstable
b. Chronic vascular disease
a. Tumor resection.
2. Preoperative evaluation
The challenge of anesthetic management for a patient undergoing hemipelvectomy is the potential for massive blood loss, which at times may become difficult to control and may result in hypotension and coagulopathy. Extensive tissue trauma and fluid resuscitation can result in third spacing of fluids and edema. Postoperative pain management is also a challenge, as there is significant pain associated with the procedure, including the potential development of phantom limb pain.
As the patient may have received medical treatment including chemotherapy prior to the procedure, it is important that they are adequately evaluated for cardiac, respiratory, hematologic, and neurologic issues prior to their surgery. Routine laboratory results including complete blood count (CBC), liver function tests (LFTs), coagulation profile. Specific patient specific issues need to be addressed. Cardiac work-up may be required based on the chemotherapy given. Echocardiogram may be indicated.
The anesthesiologist must be prepared that he/she is undertaking a surgical procedure associated with significant blood loss, which can be rapid at times. Communication with the surgeon prior to the procedure can help the anesthesiologist in preparing for the amount of blood loss expected during surgery. The intra- and postoperative blood transfusion requirements appear to be related to the type and extent of the surgical reconstruction. For instance, in procedures where pelvic stability is the goal, blood loss will likely be less than those procedures in which pelvic stability is not the surgical goal. Blood loss can range from 400 to 12,000 ml or more. It is not uncommon as a result of rapid blood loss that hemodynamic instability occurs. The blood bank should be aware of the potential needs and have multiple units cross-matched.
Medically unstable conditions warranting further evaluation include:
Cardiac: Acute coronary syndrome, unstable angina, new-onset arrhythmia, congestive heart failure (CHF)
Pulmonary: Pneumonia, significant pleural effusions that compromise efficient oxygenation/ventilation of the patient, asthma, chronic obstructive pulmonary disease (COPD) exacerbation
Renal: Chronic renal failure, acute renal failure, hyperkalemia, hypokalemia, acidosis
Heme: Anemia, thrombocytopenia, coagulation disorders
Neurologic: Metastatic disease, recent transient ischemic attack (TIA) or cerebrovascular accident (CVA), new-onset paresthesia or motor deficit
Delaying surgery may be indicated if:
Any of the above conditions are not properly worked up or treatment needs to be optimized.
3. What are the implications of co-existing disease on perioperative care?
b. Cardiovascular system
Acute/unstable conditions: An effort must be made to make sure the patient is hemodynamically stable before going to the operating room (OR). A full cardiovascular evaluation is in order. Assessment of baseline functional status, electrocardiogram (EKG), echocardiogram as well as any further work-up (i.e., stress test, cardiac catheterization) and therapy (angioplasty, stent, coronary artery bypass surgery [CABG]) that may be indicated to medically optimize the patient prior to starting the procedure.
Baseline coronary artery disease or cardiac dysfunction – goals of management: The goal of management is to closely monitor hemodynamic status throughout the surgery and the perioperative period to minimize the risk of the patient developing an acute complication of baseline cardiovascular pathology, if there is any.
c. Pulmonary
Chronic obstructive pulmonary disease (COPD)
Assessment of preoperative respiratory status should be obtained, if indicated, by preoperative clinical evaluation, pulmonary function tests (PFT's) as well as compliance and effectiveness of recommended therapy. Bronchodilator therapy may be needed, and chronic use of steroids in severe cases, which would warrant administration of steroid stress doses perioperatively.
Obstructive sleep apnea (OSA)
Preoperatively it is important to know if the patient has been formally diagnosed with OSA, and if so, if he/she is compliant with any of the possible therapies and how much relief of some of the symptoms in response to the prescribed therapy. If no formal diagnosis has been made, clinical evaluation of the sleep pattern, snoring, and daytime somnolence are useful when evaluating the possibility of having difficulty ventilating the patient on induction of general anesthesia. Sleep apnea together with other predictors of difficult intubation are an indication for a possible awake fiberoptic intubation or use of other airway adjuvants. Echocardiographic evaluation for pulmonary hypertension is indicated in severe cases.
Reactive airway disease (asthma)
Medical optimization of any reactive airway must precede induction of general anesthesia. If steroids are part of this regimen, a stress dose must be administered in the perioperative period.
d. Renal-GI:
Evaluation of baseline renal function as well as any electrolyte or acid-base disturbance must be performed and corrected if possible.
If medical management is not effective or feasible, and the degree of such disturbances warrants it, hemodialysis must be considered.
e. Neurologic:
Perioperative concerns specific to this kind of procedure include maintenance of nerve function postoperatively (in the case of limb-salvage procedures) and the development of phantom limb pain (for hemipelvectomy). To help reduce either one from happening, proper surgical dissection is essential, but, for the latter even when this is provided, minimization of the length of preoperative limb pain and a multidisciplinary approach may improve outcomes. Development of phantom limb pain seems to be multifactorial. The use of epidural analgesia to prevent phantom limb pain is controversial.
Acute issues: Phantom limb pain (hemipelvectomy) and preservation of nerve function (limb-salvage procedures) are specific for this kind of surgery.
Chronic disease: Maintenance of therapy perioperatively on patients with Parkinson disease, as well as avoiding precipitating factors (i.e., dopamine antagonists) helps diminish exacerbations of symptoms during the perioperative period. In patients at risk for cerebrovascular events avoiding insults that may precipitate acute deterioration (such as hypotension, hypovolemia, and hypertension, to name a few) will hopefully minimize the incidence of complications.
f. Endocrine:
Diabetes: Optimal glycemic control in the perioperative period is known to decrease the incidence of diabetes complications (diabetic ketoacidosis, hyperosmolar coma), as well as complications of surgical relevance such as infections. In brittle diabetics, intraoperative blood glucose monitoring needs to be performed more frequently. In some instances, an insulin drip may be indicated.
Hypo/hyperthyroidism: Patients should be functionally euthyroid. Medical management of baseline pathology should be continued until the day of surgery. For acute exacerbations, an endocrinologist's input is important.
Hematologic: Baseline CBC, coagulation profile and type and screen are in order prior to surgery to optimize patients for what could be potentially massive blood loss. Understanding and correcting baseline derangements, whether by medical management or transfusion therapy, are important. Availability of blood products should be arranged ahead of time with the blood bank and continuous communication with that department is essential for a good outcome in the perioperative period.
4. What are the patient's medications and how should they be managed in the perioperative period?
Discontinue any over-the-counter drugs that may interfere with coagulation, normal platelet function, or cause any electrolyte disturbances, 1-2 weeks prior to surgery; this includes herbal medications.
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
Chemotherapeutic agents can have side effects influencing perioperative outcome. Specific to this patient population is a concern over Adriamycin cardiotoxicity and bleomycin pulmonary toxicity.
i. What should be recommended with regard to continuation of medications taken chronically?
Cardiac: Continue antihypertensive medications, with the exception of diuretics, which should not be taken on the morning of surgery. Antiarrhythmics should be continued up until the day of surgery.
Pulmonary: Continue COPD and asthma medications up until the morning of surgery. Interruption of optimal medical management in any of the two circumstances may increase the risk of the patient developing an acute exacerbation of the symptoms in the perioperative period. Patients with obstructive sleep apnea (OSA) are encouraged to bring their continuous positive airway pressure (CPAP) machine in to the hospital, to be used postoperatively.
Neurologic: Maintenance of therapy perioperatively on patients with Parkinson disease, as well as avoidance of precipitating factors (i.e., dopamine antagonists) aims to dodge exacerbations of the symptoms during that period. On patients at risk for cerebrovascular events, avoiding insults that may precipitate acute deterioration (such as hypotension, hypovolemia, and hypertension, to name a few) will minimize the incidence of this situation.
Antiplatelet: The surgeon should advise if antiplatelet therapy should be discontinued preoperatively. If so, medications need to be discontinued at an appropriate time to avoid antiplatelet activity, for example clopidogrel (5-7 days) and ticlodipine (14 days). If the indication for such therapy is the presence of cardiac stents, careful analysis of the risks/benefits must be evaluated if no alternative treatment is being administered (i.e., discontinuing clopidogrel without continuing aspirin). There is concern about acute thrombosis of stents if all antiplatelet medications are discontinued. Since this particular topic has been the subject of much controversy lately, the recommendation is to check on the most recent guidelines.
Psychiatric: Continue antipsychiatric regimen and restart as soon as possible in the perioperative period.
j. How to modify care for patients with known allergies?
It goes without saying to avoid any drug to which the patient has a known allergy, and any other drugs that belongs to the same family of drugs that may elicit an allergic reaction. In the specific case of antibiotic allergies, appropriate alternative medications must be chosen.
k. Latex allergy-
If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) one wants to avoid an anaphylactic reaction, so prepare the operating room with latex-free products.
Progressively, hospitals around the country are moving towards a latex free environment to avoid this kind of exposure in the perioperative period. If the facility you work in does not take this precaution, the availability of a latex-free cart is advised to have everything that may be needed to effectively avoid this allergen in this setting.
l. Does the patient have any antibiotic allergies?
If so, choose appropriate medications.
m. Does the patient have a history of allergy to anesthesia?
Malignant hyperthermia (MH)
Documented: Avoid all triggering agents such as succinylcholine and inhalational agents:
Proposed general anesthetic plan: total intravenous anesthesia (propofol, etomidate, ketamine, narcotics, nondepolarizing muscle relaxants, dexmedetomidine may all be used safely, as well as nitrous oxide.
Ensure MH cart available: fully stocked with dantrolene or other newer MH treatment medication. MH Hotline [MH protocol]
Family history or risk factors for MH: If any family history is present, take precautions as patient is at high risk. Previous uneventful exposure to anesthetics may be possible on patients who may later develop it. Always be vigilant.
Local anesthetics/muscle relaxants
Local anesthetics used in epidural solutions and nondepolarizing muscle relaxants are safe to use.
5. What laboratory tests should be obtained and has everything been reviewed?
CBC, basic metabolic profile (BMP), coagulation profile, LFTs, thyroid function tests (TFT)s, chest X-ray (CXR), EKG, echocardiogram if needed.
Hemoglobin levels: Hematocrit (hct) levels coming into the OR should be at a level that provides adequate oxygen delivery to end organ systems and should be maintained at those levels throughout the surgery and the perioperative period.
Electrolytes: Review to make sure there is no electrolyte disturbance or renal failure, whether acute or chronic. Correlate if necessary with previous exams done at an earlier date.
Coagulation panel: Check for appropriate coagulation profile.
Imaging: CXR, echocardiogram, stress test and cardiac catheterization results if indicated
Other tests: TFTs.
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
General anesthesia or combined general with the use of an epidural for neuraxial block may be used for this procedure. The use of a combined epidural and general anesthesia provides for pain relief but raises concern of an epidural in place in a patient undergoing a procedure potentially associated with significant blood loss and coagulopathy. The coagulation profile has to be monitored closely for proper management and timing of epidural catheter removal.
Since the patient is placed in the lateral decubitus position intraoperatively, it is preferable to employ a general anesthetic after implementation of the regional technique and avoid dealing with intubating a potentially hypotensive, bleeding patient in the lateral decubitus position who may also have a difficult airway. In limb-salvage procedures, regional techniques such as femoral and sciatic catheters may be used to supplement a general anesthetic. Coagulation issues still apply.
Standard ASA monitors, including temperature monitoring are to be followed.
Large-bore IV access with at least two IV catheters.
A central venous triple lumen catheter for fluid resuscitation and pressure monitoring may be inserted after induction of GA or with sedation if regional anesthesia will be used exclusively. In patients with known cardiac disease, a pulmonary artery catheter may prove helpful for intraoperative management.
An arterial line is placed to help maintain hemodynamic control as well as for ABGs, Hgb/Hct, coagulation profile, and platelet count.
Coordinate with the blood bank to ensure immediate availability of blood products and blood components (PRBCs, FFP, PLTs) as needed to correct anemia, thrombocytopenia, or any coagulopathy that may develop.
Cell Saver is not used if the procedure is performed for cancer or infection, while it may be used for chronic vascular or arterial occlusions.
Monitor blood loss carefully, initially utilizing crystalloids and colloids, until hemodynamics or lab values indicate that PRBCs should be administered. Monitor urine output, observe for lowered CVP, tachycardia, and/or hypotension as indicators that blood products are indicated. Administer blood products as needed (using PRBCs initially) and closely follow Hgb and Hct levels as well as CVP, so as to keep those values as reasonable as possible. After significant blood loss occurs, coagulopathy can become an issue so replace platelets and FFP in appropriate ratios (see below).
Damage control resuscitation (DCR) and the use of massive transfusion protocols are methods that can be used to approach and treat both massive hemorrhage and trauma situations. Massive transfusion protocols are used by many institutions and they involve blood banks preparing multiple units of red blood cells, plasma, and platelets in a 1:1:1 ratio. Damage control resuscitation involves control of surgical bleeding; early use of the massive transfusion protocol if needed; limiting the use of crystalloid intravenous fluids; preventing and treating hypothermia, hypocalcemia, and acidosis; and hypotensive resuscitation methods.
After conclusion of surgery, the decision to extubate the patient should be made carefully and should be based on factors such as the patient's comorbidities, degree of intraoperative fluid shifts, blood loss, urine output, hemodynamic stability, temperature, consideration as to whether significant postoperative bleeding is a concern, and the ability of the patient to meet basic extubation criteria.
Regional anesthesia
Epidural analgesia is very beneficial in treating acute perioperative pain. Lumbar plexus, femoral, sciatic blocks may be used, based on the extent of surgery. However, bleeding and coagulopathy are concerns when using any type of catheters in patients who are at risk for major blood loss. It is in limb-sparing procedures that peripheral catheters may be considered.
Benefits: Decreases the amount of systemic narcotics used.
Drawbacks: Coagulation profile abnormalities interfere with timing of the discontinuation of an epidural catheter.
Issues: Can worsen hypotension in a hypovolemic patient. If narcotics are used in the epidural infusion, respiratory depression may develop. Epidural hematomas, infections, nerve injury, and suboptimal spread of the local anesthetic solution in the epidural space are also risks.
Peripheral nerve block
Benefits: Decreases amount of systemic narcotics used. May be employed as a single injection or a catheter. Minimizes incidence of postoperative hypotension in comparison to that of local anesthetic epidural infusion.
Drawbacks: Potential for intravascular injection, direct nerve injury. In the presence of coagulopathy, a patient with an indwelling peripheral nerve catheter has a risk of developing a hematoma. It is advisable to make sure sciatic nerve function is present prior to using any local anesthetic in a sciatic nerve catheter.
Issues: Requires expertise in placement for optimal local anesthetic spread.
General anesthesia
Benefits: Airway is secured from the beginning of the procedure. Ability to provide profound analgesia, amnesia, anesthesia, and muscle relaxation during the operation.
Drawbacks: Depending on the length of the procedure and the degree of fluid shifts, it may be necessary to keep the patient intubated in the postoperative period.
Other issues: If the procedure is being performed for cancer, presence of metastatic disease as well as side effects from any chemo/radiotherapy must be considered.
Airway concerns: Airway is secured from the beginning of the procedure. The airway is always of concern when inducing a general anesthetic on a critically ill patient with potentially multiple organ system involvement. An effort must be made to induce anesthesia and secure the airway effectively in a timely fashion eliciting the least amount of hemodynamic instability.
Monitored anesthesia care
This is not an option.
6. What is the author's preferred method of anesthesia technique and why?
The preferred method of anesthesia would be a combination of general anesthesia together with a continuous epidural catheter.
What prophylactic antibiotics should be administered?
Utilize recommended hospital and national guidelines for determining perioperative antibiotic coverage.
What do I need to know about the surgical technique to optimize my anesthetic care?
Hemipelvectomy is a major surgical procedure. When the surgeon is unable to resect a tumor using a limb-sparing technique or a hip disarticulation, a hemipelvectomy may be required. In this procedure, the lower extremity and much of the bony pelvis are removed. An internal hemipelvectomy may be performed in appropriate candidates. This is a limb-sparing or limb-salvage procedure that involves saving the patient's limb, while resecting areas involved with the tumor. Hemipelvectomies are named based on the approach and structures involved. The procedures include disarticulating the lower extremity, except for the limb-sparing or internal resection procedure.
What can I do intraoperatively to assist the surgeon and optimize patient care?
Avoid hypertension and tachycardia, as it may result in increased bleeding. Maintaining hemodynamic stability while trying to avoid vasoconstrictors (which in turn would compromise adequate oxygen delivery to peripheral tissues) during the case and into the postoperative period will improve outcome by minimizing flap necrosis which is a known complication.
Prompt treatment of any coagulopathy that may ensue secondary to significant blood loss despite attempts to avoid it occurring.
Maintain normothermia.
What are the most common intraoperative complications and how can they be avoided/treated?
Hypovolemia/hypotension and blood loss: Avoided by treating with judicious fluid replacement and vigilance. Replace blood loss as necessary. Do not overcompensate for losses, which carries its own set of problems.
Coagulopathy: Amount of blood loss and subsequent transfusion therapy would make this entity likely to appear; in situations of massive blood loss start RBC, platelet, and factor administration as outlined above.
Hypothermia: Monitor temperature and institute both forced warm air devices and intravenous fluid warming devices from the beginning of the surgery.
Hypocalcemia: As a result of repeated PRC transfusion, replace depletion of calcium if needed.
Cardiac: Acute coronary syndrome, hypovolemic shock, new-onset arrhythmias, CHF.
Pulmonary: Fluid overload, pleural effusions, atelectasis, bronchospasm, aspiration, airway edema, inadvertent extubation, inability to reintubate.
Neurologic: Cerebrovascular insufficiency as a result of hypovolemia/hypotension, phantom limb pain, new-onset motor deficits.
a. Neurologic:
b. If the patient is intubated, are there any special criteria for extubation?
The patient must meet basic extubating criteria, namely, adequate tidal volumes and respiratory rate, sustained head lift, leak around endotracheal tube, adequate oxygenation/ventilation, and absence of wheezing. Review fluid status and physiologic parameters to make sure the patient is stable.
c. Postoperative management
Patients may exhibit significant postoperative bleeding into drains so serial Hct levels should be obtained.
Fluid status should be continually evaluated by observing CVP, urine output, and blood pressure. Third spacing or blood loss into the wound can result in significant intravascular hypovolemia, hypotension, and shock.
Pain control may be achieved with the use of epidural infusion with local anesthetics and narcotics after surgery with or without local anesthetics, depending on the current hemodynamic status. Lumbar plexus block or continuous catheter is another option in experienced hands. Catheters may be employed for patients with limb-salvage procedures.
In patients in whom regional techniques are not used, IV PCA is a very important consideration. Multimodal medication management is important as well. Overnight monitoring in the ICU of patient's hemodynamic status, urine output, and analgesia is strongly recommended.
What level bed acuity is appropriate?
Patient should be monitored in the ICU. Postoperative intubation may be warranted depending on several factors such as length of procedure, amount of blood loss, amount of fluid replacement, or any baseline cardiovascular or respiratory pathology which would warrant it. Extremely effective pain control may be achieved by the use of epidural narcotics after surgery with or without local anesthetics, depending on the current hemodynamic status. Lumbar plexus block/continuous catheter is another effective means of achieving significant pain control.
In patients in whom regional techniques are not employed, intravenous patient-controlled analgesia is an important modality.
Overnight monitoring in the ICU of patient's hemodynamic status, urine output, and analgesia level is strongly recommended. Keep in mind that postoperative bleeding may become an issue in the immediate postoperative period, that if it were to develop it must be addressed expeditiously. Low urine output may be an indicator of bleeding and hypovolemia.
What's the Evidence?
Asavamongkolkul, A, Pimolsanti, R, Waikakul, S, Kiatsevee, P. "Periacetabular limb salvage for malignant bone tumours". J Orthop Surg. vol. 13. 2005. pp. 2739
Bernstein, RL, Rosenberg, AD. "Manual of Orthopedic Anesthesia and Related Pain Syndromes". 1993. pp. 414-418.
"Canale and Beaty: Campbell's Operative Orthopaedics".
Carter, SR, Eastwood, DM, Grimer, RJ, Sneath, RS. "Hindquarter Amputation for Tumors of the Musculoskeletal System". J Bone Joint Surg. vol. 72. 1990. pp. 490-3.
Malawer, MM, Sugarbaker, PH. Musculoskeletal Cancer Surgery. 2004. pp. 305-313.
Miller, TE. "New evidence in trauma resuscitation – is 1:1:1 the answer". Perioperative Medicine. vol. 2. 2013. pp. 13
O'Connor, MI, Sim, FH. "Salvage of the limb in the treatment of malignant pelvic tumors". Journal of Bone and Joint Surgery. vol. 71.4. 1989. pp. 481-494.
Weinbroum, AA, Marouani, N, Lang, E, Niv, D, Rudick, V. Musculoskeletal Cancer Surgery. 2004. pp. 570
Yancey, AG, Johnston, GA, Green, JE. "Some surgical principles in hemipelvectomy". J Natl Med Assoc. vol. 42. 1950. pp. 210
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.
- What the Anesthesiologist Should Know before the Operative Procedure?
- 1. What is the urgency of the surgery?
- What is the risk of delay in order to obtain additional preoperative information?
- 2. Preoperative evaluation
- 3. What are the implications of co-existing disease on perioperative care?
- b. Cardiovascular system
- c. Pulmonary
- d. Renal-GI:
- e. Neurologic:
- f. Endocrine:
- 4. What are the patient's medications and how should they be managed in the perioperative period?
- h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
- i. What should be recommended with regard to continuation of medications taken chronically?
- j. How to modify care for patients with known allergies?
- k. Latex allergy-
- l. Does the patient have any antibiotic allergies?
- m. Does the patient have a history of allergy to anesthesia?
- 5. What laboratory tests should be obtained and has everything been reviewed?
- Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
- 6. What is the author's preferred method of anesthesia technique and why?
- What prophylactic antibiotics should be administered?
- What do I need to know about the surgical technique to optimize my anesthetic care?
- What can I do intraoperatively to assist the surgeon and optimize patient care?
- What are the most common intraoperative complications and how can they be avoided/treated?
- Complications
- a. Neurologic:
- b. If the patient is intubated, are there any special criteria for extubation?
- c. Postoperative management


text:
Essay:Greatest Mysteries of American History
From Conservapedia
Here is a growing list of unsolved mysteries in American History:
- Where did the American Indians come from?
- Did the Vikings really settle in North American, at L'anse aux Meadows in Newfoundland? If so, then why would they abandon it?
- How was Christopher Columbus able to navigate himself across the Atlantic Ocean on his second voyage to find the precise same location that he colonized on his first voyage?
- What happened to the Lost Colony?
- Did the Puritans do better economically by abandoning socialism in the Mayflower Compact?
- Was the Mayflower trip motivated by profit, or by faith?
- Did Christopher Columbus bring back slaves to Europe?
- Did Puritans allow dancing?
- What was the cause of the possession-like symptoms of the young girls in Salem in 1692, which their doctor attributed to the devil?
- Did the U.S. Constitution incorporate Roman and other prior systems of government, or was the Constitution primarily an original work?
- Did Benedict Arnold lead the American Revolutionary army to triumph at Saratoga, or was his military leadership ineffective before be became a traitor?
- Did Alexander Hamilton cut a deal with Thomas Jefferson to make him president?
- Was Meriwether Lewis murdered?
- Was the so-called corrupt bargain real and, if so, was there anything wrong with it?
- Why did the Tariff of Abominations pass?
- What is the real source of the name "Whig" in the "Whig Party"?
- Did the bloodshed that started the Mexican War occur on American or Mexican soil, indicative of who was the aggressor?
- Why wasn't Congressman Preston Butler prosecuted for violently beating Senator Charles Sumner to near death?
- Did President James Buchanan arrange the Dred Scott decision?
- Did George McClellan scorn Abraham Lincoln because he was homeschooled?
- What caused the USS Maine to explode?
- What caused the Great Depression?
- What really caused the repeal of Prohibition?
- Who was the lone dissent on the jury in the court martial of Billy Mitchell?
- Did FDR have advance knowledge of the attack on Pearl Harbor?
- Why did FDR, who knew he was dying, replace his Vice President Henry Wallace with Harry S Truman to make Truman the next president?
- Why did the U-2 spy plane crash-land in the Soviet Union?
- Did a communist sympathizer in the U.S. government leak plans of the Bay of Pigs invasion to Castro?
- Why did the social movement of the 1960s end so abruptly?
- What happened to Jimmy Hoffa, Judge Crater and D. B. Cooper, who disappeared without a trace?
- What role did Justice William Brennan have in writing Roe v. Wade?
- Where did President Ronald Reagan get the idea and impetus for proposing the Strategic Defense Initiative?
(add to list)

subset: commoncrawl


text:
nederlands | english
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text:
The Social Fallout From Falling
An older adult falls every second of every day, according to the Centers for Disease Control. The likelihood of a fall increases with age, up to 37 percent in people 85 years or older. So, it's common to experience the fall of an elderly loved one. But what happensafter the fall can dramatically impact your loved one's recovery.
In the aftermath, the daily life of the senior involves new priorities: healing and recovering, occupational therapy, physical therapy and doctor's appointments. Meantime, the recovery process limits positive social interactions. Don't let loneliness and loss of confidence creep into your senior's life. These negative consequences are damaging to recovery.
Companionship is Critical
After the fall, your elderly loved one may be confined to the house for an extended period. When your senior feels lonely, companionship becomes critical. For example, Sheila had been walking her dog before slipping on snowy pavement. She underwent hip replacement surgery, a procedure that required extensive occupational and physical therapy afterward. Sheila had to give her dog away to a neighbor because she could no longer walk very well. The irony was that she had gotten the dog to keep her company.
Sheila said it felt like a "prison" to be confined first to the hospital bed and then to a wheelchair. When she finally returned home, she adjusted to walking with a cane. But her left leg muscles remained weak. So her daily activities were vastly diminished. When she first came home, she endured not being able to shower or bathe. Sheila felt uncomfortable and demoralized in her own skin. Even though she wanted to socialize, she didn't want people to see her without proper grooming. Discomfort and isolation left her feeling anxious and moody. The family finally decided to hire a professional caregiver for Shiela, who visits to help with bathing. It has made a world of a difference because this person is now a companion who she is eager to see.
Sheila misses other parts of her former routine. "I used to go the beauty parlor [every week]. I don't do those things anymore," she said about getting her hair and nails done regularly. Instead, she relies on the availability and kindness of her sister to drive her places. But she doesn't want to be a burden. So she compensates by rushing through errands. For instance, recently Sheila said she forgot to pick up coffee on a run to the grocery store with her sister. Now, she has to wait a few more days in hopes of catching another opportunity to go shopping again.
Under a different circumstance, Sheila would not have to feel rushed. A professional caregiver can restore a semblance of autonomy by serving as a regular driver and grocery companion. Meanwhile, Sheila would get the social interaction she craves while slowly recovering. "I didn't know the recovery was such a long process," said Sheila. "My left leg hurts me, and I really don't want to have a limp for the rest of my life."
Loneliness Can Be Dangerous
The social well-being of the elderly is critical to healthier outcomes, according to an NPR article: "Research shows older adults who feel lonely are at greater risk of memory loss, strokes, heart disease and high blood pressure."
While your senior is on the mend, it's important not to further put his or her health at risk. A professional caregiver can serve as the buffer against mental and emotional decline.
"There's a big difference when there's somebody in the house," said Sheila. "If you are watching the movie, you can say 'Oh, this is a good movie.'"
Kindness, patience and friendship. The bond between the elderly and the professional caregiver can be highly satisfying. Social feedback keeps the senior's brain stimulated and alert. And your elderly loved one is less prone to loneliness, anxiety and negative thoughts.
Reducing the Fear of Falling
After the traumatic experience of a fall, it's common for your senior to be fixated on the negative—fear of falling. The fear is so intense that it can leave them unwilling to venture beyond the home and even increase the likelihood of another fall. According to the medical article in Gait and Posture: "Many people who fall, even if they're not injured, become afraid of falling. This fear may cause a person to cut down on their everyday activities. When a person is less active, they become weaker, and this increases their chances of falling." The fear will induce stiffened body movements and hinder recovery to natural body movements.
Dick recalls the rapid decline of his father, who endured multiple falls. Claire was in his 80s when he first fell in his multi-storied house. The fall led to hip surgery. Claire tried to recover in the home, but it became clear, he needed to enter an assisted living center. Unfortunately, at the living center, Claire fell again while in a wheelchair. He fell one more time after his health rapidly declined and entered a nursing home. He remained confined to the wheelchair and bed at the end of his life.
But with a professional, Claire may have been able to age in place at home with the help of a professional caregiver. They are trained to prevent falls and motivate your elderly loved one to focus on recovery. By fall-proofing your loved ones home, which the right home care provider will help you accomplish, you can dramatically reduce your senior's chances of falling. In turn, they'll be mobile without risk of falling, and their confidence will hopefully increase alongside their mobility.
For more information on fall-proofing your loved one's home, click here.


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At first i would like to apologize for my english.
I have put my applet outside wwwroot to a directory called APPLET to prevent hotlinking and now i'm having some accessing problems.
I have no idea how should i modify my codebase path. Could you please tell me what i am doing wrong? Everything was working perfectly fine when my applet was inside the wwwroot (my previusly code base was APPLET/classes).
This is how now i am building my applet object:
<object type="application/x-java-applet" name="program_name" width="995" height="588"> <param name="codebase" value="/users/user_name/APPLET/classes"/> <param name="code" value="program_dir/loading.class"/> <param name="archive" value="program_dir/program_jar.jar?x=<?php echo $rand ?>" /> <param name="cache_option" value="no"/> </object>


text:
Date Added: May 16, 2017
Lecture Description
If you'd like to help fund Wise Owl's conversion of tea and biscuits into quality training videos you can click this link www.wiseowl.co.uk/donate?t=1 to make a donation. Thanks for watching!
By Andrew Gould
Download example files here www.wiseowl.co.uk/videos/excelvba/scraping-multiple-web-pages.htm
www.wiseowl.co.uk - What's better than scraping one web page? Scraping lots of them with the same procedure, of couse! This video explains how to loop over multiple pages using Microsoft's HTML and XML object libraries. You'll learn about HTML tags and classes, the Document Object Model and how to loop over elements on a page.
Visit www.wiseowl.co.uk for more online training resources in Microsoft Excel, SQL Server, Reporting Services, Analysis Services, Integration Services, ASP.NET, C#, Visual Basic, Microsoft Access, Microsoft PowerPoint, Microsoft Word, Microsoft Project, Microsoft Publisher, Microsoft Visio and more
Course Index
- Getting Started in the VB Editor
- Writing Your First VBA Macro
- What to do When Things Go Wrong (Errors and Debugging)
- Buttons, Toolbars and Keyboard Shortcuts
- Selecting Cells (Range, Cells, Activecell, End, Offset)
- Worksheets, Charts and Sheets
- Workbooks
- Variables
- Object Variables
- Message Boxes
- Input Boxes
- Application.InputBox
- With Statements
- If Statements
- Select Case Statements
- Do Until and Do While Loops
- Find and FindNext
- For Next Loops
- For Each Loops
- Creating Functions
- Error Handling (On Error, Resume, GoTo)
- Event Procedures
- Application Events
- User Forms
- Files and Folders (FileSystemObjects)
- Text Files (FileSystemObjects)
- File Dialogs
- Arrays
- Constants and Enumerations (Const, Enum)
- Creating Word Documents
- Creating and Updating Linked Word Tables
- Creating PowerPoint Presentations
- Creating Outlook Emails
- ADO (ActiveX Data Objects) Querying a Database
- ADO (ActiveX Data Objects) Modifying Data with Recordsets
- ADO (ActiveX Data Objects) SQL Statements (INSERT, UPDATE, DELETE)
- Creating Add Ins
- Type Declarations (UserDefined Types)
- Class Modules
- Using Class Modules in Other Projects
- Custom Collections
- Typed Collections
- Dictionaries
- Disabling Screen Updates
- Saving as a PDF
- Data Labels in Scatter Charts
- ByRef and ByVal
- ByRef and ByVal (When to use Parentheses)
- Making Excel Talk
- Finding the Last Used Row, Column and Cell
- Querying Web Pages using Query Tables
- Browsing to Websites and Scraping a Web Page
- Web Scraping Across Multiple Pages
- Downloading Files from Websites
- Introduction to Charts in VBA
- Embedding Charts in Worksheets
- Introduction to Pivot Tables in VBA
- Pivot Tables using an Access Database
- Pivot Tables using a SQL Server Database
- Pivot Tables and Consolidation Ranges
- PowerPivot Data Models
- Pivot Charts
- Pivot Table Slicers
- Pivot Table Date Fields and Timelines
- Introduction to Shapes
- Formatting Shapes
- Adding Text to Shapes
- Working with Strings
- Splitting Strings
- The Join Function and Concatenating Strings
- Replacing Strings
- Converting the Case of Text
- The Asc and Chr Functions
- The IIf Function
- The Switch Function
- Working with Dates
Course Description
Excel VBA is a powerful (and fun!) tool which allows you to automate your Excel workbooks. These videos will help you through your first steps on the way to becoming a programmer in Excel. You don't need any prior programming knowledge as we'll take things from first principles and hopefully give you a flavour of the cool things you can do with a little bit of effort!


text: +3 Blue Q Women's Crew Socks JRI1BQwcfli $10.99 Out of stock Quantity: 1 Add to Bag Product Details Brand: Blue Q Show your sassy side on your socks! Women's shoe size 5-10. 52% combed cotton; 46% nylon; 2% spandex. PLEASE NOTE: This sock features panoramic art - awesome from every angle. There's no "right and left." The sassy phrase falls on the outside of your right leg, and the inside of your left. Save this product for later Favorite Search Products My Account Track Orders Favorites Shopping Bag Gift Cards Display prices in: USD Cool Stuff Scottsdale Location Events & Seminars Expert Advice About Us Blog Boring Stuff Price Match Return Policy Shipping Info Privacy Policy Terms & Conditions Where We Are 8658 E Shea Blvd., Ste 175 Scottsdale, AZ 85260 (480) 857-2477 email@example.com Contact Us Sign up for more emails! We know. You get a lot of emails already. But in the event you want more, or those of more intriguing content, you should probably sign up for ours! We do not sell lists and we don't bombard you will a lot of emails - that's a different list:) Success! First Name Email Subscribe


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November 25, 2017
8am - 5pm
Chris Ahrens
Anglican Church Hall
30 Ridley Rd
Bridgeman Downs, Queensland 4035
See Google map »
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The Queensland election is this Saturday and it's a big one for our reef, wildlife, climate and communities.
We need your help getting our independent scorecard in the hands of voters on election day. Will you volunteer a few hours to hand out our scorecard?
Our scorecard focuses on issues that Queenslanders care about – like protecting our beautiful reef and harvesting clean energy from the sun and wind.
RSVP to sign up for a three-hour shift starting at 8am, 11am, or 2pm. Once you've RSVP'd, we'll give you a call to discuss which shift you can make and answer any questions you might have.
Getting key information in the hands of voters at this critical time depends on passionate, engaged people like you dedicating a few hours on election day.
So join us to make a big impact for the issues you care about and be part of our democracy.
Check out our full scorecard here, and see how we came up with the scores here.


text:
- Get link
- Other Apps
Founded by Sofie Hellsing and Christian Duivenvoorden a few years ago, Artilleriet is country's most interesting design shop. The couple's latest innovation: A pop-up shoppable apartment featuring a mashup of some beautiful pieces from Scandinavian designers, artfully presented in a suite of well-proportioned rooms. It's a new way to visualize the possibilities and the potential of seemingly aesthetically unrelated pieces that, when combined, add up to character-filled, seemingly assembled-over-time spaces.


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Following the Ancient Roads
I would walk between two civilizations. This ancient road would carry me through the heart of a young nation's gas fields.
I followed the red needle of my compass. For days I kept on it, never straying from the course it set across the badland desert of northwestern New Mexico. An ancient road ran beneath me, its perfect lines almost entirely obscured by blown sand and urchins of sage. The compass was the only thing that kept me on it.
I was here researching a network of thousand-year-old roads, meticulously engineered across the Four Corners region. Over a hundred miles of them have been documented so far; estimates go as high as a thousand. Their purpose is a mystery. Some archaeologists even hesitate to call them roads, since the people who constructed them had no mechanical transportation, no beasts of burden, no wheel. Yet they lie thirty feet wide, cut a foot deep into soil and bedrock, and run perfectly straight across complicated terrain. Rather than bending to go around cliffs or buttes, the roads resort to masonry steps, earthen ramps, or even stairways carved into the cliffs themselves.
For all that is not known about these ancient roads, it is clear that they were made by a highly organized society, one which demanded that its pathways be absolutely direct. Over the last few decades, archaeologists have come to believe that these roads connected an extensive desert community, and that goods were carried along them.
I took ten days to walk from the ruined metropolis of Chaco Canyon, north across the desert to the town of Aztec. I was documenting the remains of great masonry compounds that once stood like flagships along this particular road. I looked at the pottery, searching for signs of trade, for ceramics that had been brought from faraway places. These pots were not everyday possessions, but more likely, offerings brought to religious centers. It looks as if few people lived inside these masonry compounds. Very little sign of cooking fires or everyday trash shows up in the rooms. Perhaps the people came from great distances, only to leave behind their fine pottery, their ornate jewelry made of rare stones, their bundles of corn — pilgrims, maybe, walking the long, broad roads of ceremony, their offerings heavy on their backs.
I had left Chaco and its checkerboard ruins of standing walls, its deep round mouths of ceremonial rooms, and walked in the silent landscape beyond. Days of sage and saltbush. At dawn, I heard dogs barking, and a flustered rooster from a far-off, windswept ranch. Mid-day, a battered truck appeared and disappeared on the horizon. Otherwise, I saw no one. I heard only wind and the sky-rumble of jetliners passing over an inhospitable earth.
Walking through the lunar dust of badlands, I arrived at clusters of rubble marking buildings that had been in use around 1100 A.D. I could tell by the pieces of broken pottery, the thinness of black painted lines on white clay, to which era these buildings belonged. Some stood atop high, rock-headed buttes. Others left their marks in the desiccated soil below. At the top of one of the buttes, I found the remaining shoulders of two-story walls around the craters of collapsed rooms.
From this butte, I looked north and saw something I had not expected. The pump jacks of numerous natural gas wells swayed up and down like conductors' hands in the distance. I heard the puttering of motors. I was entering a new land. Different geology. Signs of modern humans. For the rest of my journey, I would walk between two civilizations. This ancient road would carry me through the heart of a young nation's gas fields.
The next morning, I came to the first well pad, walking up to it with my pack heavy on my back. It was driven by a single-spark-plug engine, spinning a few wheels, a couple of belts, huffing and kicking like a 1920s car engine. It raised and lowered the pump jack no faster than an old man bending for a penny on the ground. Oily water bubbled from old, sun-baked gaskets, darkening the hard earth.
I know a few petroleum geologists, and have walked with them on the land. I've seen in them less a love for industry than a fascination with the earth's labyrinthine interior. These are men who still enjoy maps made of paper, old-fashioned field geologists.
Thinking of them, I imagined this machine in front of me to be a Jules Verne vessel plunging into the invisible underworld, sending this finger of a steel rod into imagined salt domes and anticlines far below the surface. Maybe that's naive. These things were not built out of curiosity. Knowing the way we commonly use gas with such humdrum reliance, I imagined this machine, instead, as a metal slave, digging soullessly for money.
Looking out across these mumbling, tinkering machines, I decided to look at these modern landmarks the same way I studied the archaeological remains. Perhaps in this way I could see through veils of time and understand something about the drives of my own people. If these machines were dead and ancient, if I found them standing like skeletons in the deserts, what then would I believe?
Days and countless pumps passed as I walked north. The landscape was scored by curiously wide roads, broad enough for three flatbed trucks side-by-side. Yet I saw not one vehicle in days. These roads seemed abandoned, yet they were kept well graded. Sand dunes slowly crept across them. I climbed over their barbed wire fences and locked pipe rail gates, crossing one road after the next in a land consisting more of roads than not.
Of course, it made me think of the prehistoric road I was following, and its surrounding council of roads across the entire Four Corners. Archaeologists believe the ancient roads were primarily ceremonial. And if the buildings they led to were not houses, they must have been ceremonial, too.
These new roads and these wells were also the artifacts of ceremony. No people lived here; there were no schools, no markets, no homes. The roads lead only to these groaning, throbbing pumps. They proclaim industry and wealth, announcing the presence of civilization, yet not the presence of living people.
Commerce and engineering are hauled on sacred paths, assembled in the far lands. The lonely, sanctified prostrations of pump jacks go on day and night, a constant prayer to the black interior of the earth. For the civilization of America, this gas is more holy than any church.
Perhaps if I had not walked for days with the weight of water on my back, if I had not spent these nights alone under mobs of stars, I would have thought differently. I would have laughed at the notion that the ceremonies of the Chaco civilization were much like the rituals of the oil and gas industry. But now, moving to the ceaseless metronome of my footsteps, I felt as if my customary judgments had fallen away. What is the line that divides ceremony from religion, spirituality from money? Wars are waged over such things. Humans are always the same animal, pouring across the planet, scoring it with our desires.
There is something that happens when you are alone in the desert. You forget your name after a while. You forget even why you came. Your shadow and the tracks behind you become the only proof that you are truly here. Conventional ways of thinking suddenly seem awkward, alien. Perhaps that was why I came to walk this road. I wanted to see beyond the limits of my modern mind.
I kept walking north. From the slopes of distant mesas, I heard the hollow roars of the gas wells. They sounded like the long trumpets of Tibet bellowing from behind temple walls. Far ahead, I saw white banners of highway billboards. Their lettering was illegible in the mirage-waves of summer heat. I chose the middle one as my landmark, the place where my compass told me the ancient road passed. The billboard became a distant omen growing closer, its white-lettered message shimmering. Of what wonders would I be told? Finally, I could hear the racing of cars and trucks, the slick sound of tires on dry asphalt. I walked right up to the billboard, staring at it over my head.
What does that mean? I tentatively crossed the four-lane highway, its ground strangely textured, vehicles racing at me at unimaginable speeds. No wonder badgers and raccoons and deer so often meet their ends at the grillplates of cars. I scrambled away from the highway and dropped into a deep badlands canyon on the other side.
Here, I found only the inescapable rumble of wells pumping gas out of the canyon, the prized spice driven up through pipes, the force supplied by gasoline-powered engines. Gas feeding gas. I must have walked into an area of particular richness, because for the next three days I found not a moment of quiet. Choirs of capitalism sang day and night. The ship-engine roar of pumps and compressors registered in my ears as alarms constantly going off, ringing a warning across the canyon. I could not erase them from my every awareness as I walked, as I slept, as I ate.
At one point, I reached a butte-top rubble pile of 900-year-old buildings. Doorways still stood around me as I walked from room to room, studying the fine, tabular masonry. In the center of an exposed ceremonial kiva sat a mule deer antler, an offering that had been here for some few years, wearing into chalk, its tips melting into the ground. I touched the antler. Who placed this? A crystal-gazing white person? A Pueblo representative out maintaining claims to ancestral grounds? Perhaps this was an offering to human diligence, an acknowledgement of the fact that people once brought their lives to this dry and desolate region and invented a civilization here. Placed in the center of a round ceremonial room, this was a contribution to our survival, past and future.
Walls now standing only knee-high rose and fell around me as I toured the remains of this compound, thumbing up pieces of broken pottery. Building stones lay at the cliff edge, poised to fall into the canyon below. This would have once been an impressive two-story complex standing on this high neck of land. Now it was only a pile of rocks and broken pottery. From all around, I heard the voices of the oil and gas robots. Day-glo flagging fluttered from surrounding buttes, marking future endeavors. Were these also offerings? We had marked the buttes with our prayer flags, our wishes for prosperity, for survival. We fear vanishing, our civilization collapsing, so we plant ourselves everywhere we can. At any cost, we proclaim ownership over the nations and landscapes that fall beneath us.
Standing in the ruins of this building, I could have wept for all of us creatures who toil at the earth as if angry at it, but at the same time revere it, honor it — loving it so fiercely that it crumbles in our oil-stained hands. But I was still a scientist here; I did not weep. I thought: Both the ancient people and the people of today have built things of beauty and violence. We have done what we were told to do. We have multiplied. We have hardly paused to imagine where we might be going.
Back down in the canyon, I found myself in the thick of gas production. Instead of being deserted, the roads here were busy with motion, with the congested coughing of flat beds in low gear, with sun-glistening pickup trucks darting from site to site with the busy intensity of bees mobbing a bush of flowers. Each truck sported a high orange flag so that from a great distance it could be seen through the gauze of heat and windsand. I moved invisibly among these racing vehicles. No one glanced my way.
On my last night, I came to an overpass where the highway crossed over my head. The underside was lavished with surprisingly artful spray-painted graffiti. Yes, I thought, I have seen your rock art, too. I have walked your desert cliffs, passing your carefully carved images now a thousand years old.
The civilization that was once here is now gone, its memory lost to countless generations and discarded traditions. Its descendants have not lived in this region for hundreds of years. The old civilization did not fall easily. In certain ancient pueblos, the end was marked by incredible violence, as these beautiful, straight roads caved into disrepair. Many of the larger population centers bear records of conflict. Skulls are found in one room, and the rest of the bodies are scattered elsewhere. Within only a few miles of this overpass, an ancient tower was discovered, and in it were the remains of numerous children and infants who had been burned alive.
We did what we were told to do. We multiplied. We covered the land. And then we covered ourselves with time, blankets upon blankets of generations, one civilization after the next.
Into the evening, I listened to the most recent manifestation of this evolutionary dance. The highway ran like an urban freeway, tanker trucks hemming and hawing up the grade, street cars slick with speed. It sounded like rush hour. It was the end of the day in an oil and gas boomtown, Bloomfield, N.M. The hallowed gas wells had been serviced for the day and these supplicants returned home to spend whatever wages had come to them. The sound of civilization filled my night and I slept until I could hear it no longer.
Long after midnight, the driving ceased. I woke and for the first time in days, heard only silence.
Craig Childs is the author of The Secret Knowledge of Water and Soul of Nowhere. He writes from Crawford, Colorado.
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text:
Pittsburgh, PA (SportsNetwork.com) - The Pittsburgh Steelers signed safety Troy Polamalu and tight end Heath Miller to new three-year contracts that will keep them with the team through the 2016 season.
Polamalu, who turns 33 next month, had 69 tackles, two interceptions and five forced fumbles in 16 games last season.
Originally selected by the Steelers with the 16th overall pick in the 2003 draft, Polamalu has 709 tackles, 32 interceptions, 12 sacks and 13 forced fumbles in 146 career games. An eight-time Pro Bowl selection, Polamalu was the NFL Defensive Player of the Year in 2010.
Miller caught 58 passes for 593 yards and one touchdown in 14 games last season.
Originally taken by the Steelers in the first round of the 2005 draft, Miller has 466 receptions for 5,273 yards and 40 touchdowns in 137 career games.
Polamalu and Miller have each won two Super Bowls with Pittsburgh.


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Samuel Marateck, a senior lecturer at NYU's Courant Institute of Mathematical Science, unpacks scholarship dating back to the era following World War II that provided the scientific foundation for the search.
Lost in the exhilaration surrounding this summer's presumed discovery of the Higgs boson, the sub-atomic particle that is a building block of the universe, were the theoretical clues that led to the breakthrough.
In an article that appeared this summer in the Notices of the American Mathematical Society, Samuel Marateck, a senior lecturer at NYU's Courant Institute of Mathematical Sciences, unpacks scholarship dating back to the era following World War I that provided the scientific foundation for the search.
For some time, physicists have been searching for the Higgs boson, the only particle of the Standard Model of Particle Physics that scientists had yet to detect. The Standard Model of Particle Physics describes the universe in terms of its fundamental particles and the forces between them.
The hunt was primarily conducted in the Large Hadron Collider (LHC), located at the CERN laboratory near Geneva. But mathematical physicists had, more than a half century ago, laid a theoretical groundwork that ultimately gave physicists clues of where and how to look.
The initial underpinning, Marateck writes, was the Yang-Mills theory, formulated in 1954. Yang and Mills invented what was then a new type of particle field strength based on the electro-magnetic one—a contribution that would allow physicists to obtain a calculable result in future analyses.
However, the Yang-Mills theory had a significant shortcoming. The particles it hypothesized had to have zero mass —that is, they must be weightless. These hypothesized particles belong to the particle family called bosons—and the only zero-mass bosons are photons.
Given the theory's limitations, it lay dormant for a decade, Marateck explains, until others found a way to give these bosons mass.
Three different research teams—working independently in the 1960s—updated Yang-Mills by devising a theory that not only imparted mass to bosons, but also hypothesized a new particle. This particle became known as the Higgs boson, named after Peter Higgs, one of these researchers. The addition by Higgs and others offered a way to explain why atoms have weight.
The apparent discovery of the Higgs boson should now provide fundamental insights into why particles have mass. It has been dubbed the "God Particle" because it is associated with an energy field that gives other particles their mass, or resistance. Its discovery was fictionalized in Dan Brown's Angels & Demons and in the 2009 film of the same name.


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Duca - 1950Nicola Gallizia, 2015
DUCA is the project specifically designed by Nicola Gallizia for the new ME Milan Il Duca, a prestigious address in terms of luxury hotels in Milan.
A lamp created for the contract sector that now holds its rightful place in the company catalogue, DUCA was produced thanks to the Bespoke tailoring service from Oluce, offering tailor-made solutions to large and small supplies: lamps designed especially for specific projects or in modular variants on existing designs, as well as the production of products from the catalogue.
Initially envisaged by Gallizia in the table version for decorating the sleeping area in the suites, a wall-mounted adaptation was then also developed to light up the corridors on the floors.
The initial idea for DUCA was a light source able to take up where the concept of the classical bedside lamp had left off, reinventing its shape, combining it with a very soft, indirect light, of which it is almost impossible to perceive the source but which lights up the table and beside table area accurately and efficiently. Fascinated by theatrical lighting, which takes the origin of the source away from the eye and only allows itself to be detected in the beam on the front of stage, Nicola Gallizia works on structural subtraction to focus on the lighting effect, entrusting the light with task of revealing itself.
A relativism that becomes a connotative trait in the wall-mounted DUCA version: the perception of the wall lamp changes radically within the space in relation to where the observer is located. Like during a lunar eclipse, the light source appears, disappears and then reappears: involving the eye in an unexpected and dynamic game.
Technical data
Wall lamp in metal painted in warm grey.
Source bulbs
1 x max 14 W (LED) - 220V - 3000°K - 1350 lm - CRI >85
Warm grey


text: SignWriting List September 2, 2010 Hello Fernando - Thank you for your messages and this message below is very interesting regarding your research... To answer your question below about line drawings or illustrations... Since this is the SignWriting List, I can answer it from the SignWriting perspective... Yes, of course your line drawings as illustrations of signs are very useful and easy to understand.....and you have developed an excellent way to produce the illustrations to illustrate the signs, and that has been proven by your research below, that Deaf students are understanding them well - that is a terrific accomplishment, Fernando. Congrats on this important work. And thank you for including SignWriting in your dictionary entries too. But to change the subject slightly related to SignWriting and literacy...SignWriting has a different purpose than line drawings. Most signers are not professional artists who can draw their own line drawings when writing their own sign poetry or stories, so the purpose of SignWriting is to provide the world with a real writing system for daily use, for writing sign poetry and literature directly without translation from any other language. Signers can express themselves directly on a daily basis in their daily language, writing in the handshapes, facial expressions and movements of their language, in full sign sentences. And I understand this is happening more and more in Brazil...so it is another avenue of communication that perhaps can be researched more later...really two different subjects...dictionaries and literature are different topics. But when it comes to Deaf Literacy, SignWriting seems to help some Deaf people improve their literacy skills in both spoken and signed languages...there is some research, but not enough yet to prove this, but in Saudi Arabia, Germany, Quebec and New Mexico, some research has taken place and seems to be positive. I understand that SignWriting is taught in some schools and classrooms in Brazil ...are you testing your work in classrooms that are specfically using SignWriting? That would be interesting research for us to know about. And by the way, have you considered joining the Sign Language Linguists List and share your work with them? The SLLING List is related to Sign Language Linguistics in general. To join the SLLING, go to: http://listserv.valenciacc.edu/cgi-bin/wa?HOME They have over 600 subscribers and perhaps someone might want to write a review of your beautiful dictionary! Congrats once again - Val ;-) --------- On Sep 2, 2010, at 9:17 AM, fernando capovilla wrote: > Dear friends, > > > It is great to know SW renditions, sign illustrations, and English glosses help make Libras signs clear. I wonder what you think about meaning illustrations (the line drawings that specify what signs mean). Do you think they may help as well, specially deaf kids who are still acquiring literacy skills? We hopoe so, and want to discover if that is really the case. We have just conducted a comprehensive and systematic study on that. This curious study on meaning illustrations goes like this: > > We took all the Libras dictionary illustrations and showed to 2,000 college students who named them by writing, one by one. (Nice people!). > Then we separated the subset of pictures that have achieved at least 70% of univocity (the same name attibuted to them). We called them good, univocal pics to college students. > > Then we presented this subset to 2,000 high school students. (We thanked them a lot!). Again, we separated the pictures that achieved at least 70% of univocity. We called them good, univocal pics to high school students. > > After that we presented this subset to 2,000 primary school students. (We gave them goodies in return. Nothing edible. Just stationary paper, special pens, etc.). Always using written naming. Once more, we separated the pictures that achieved at least 70% of univocity. We called them good, univocal pics to primary school students. > > Then we presented this subset to 2,000 5 year old kindergarten students for oral naming this time. That took a lot of time and effort. One by one, kids had to be heard patiently and in good spirit. (They received goodies ad libitum). Once more, we separated the pictures that achieved at least 70% of univocity. We called them good, univocal pics to 5 year old kids. > > Since we had nothing else to do, we presented this subset to 1,000 4 year old kids for oral naming. That took us even more time and effort. But it was fun. Kids that age are lovely. Once more, we separated the pictures that achieved at least 70% of univocity. We called them good, univocal pics to 5 year old kids. > > Again, we separated the pictures that achieved at least 70% of univocity and presented them to 1,000 3 year old kids. Again, because we thought it was fun, we separated the pictures that achieved at least 70% of univocity and presented them to 1,000 2 year old kids. > > In the end, we ended up with 240 perfectly transparent pictures (in addition to some periorbital dark circles...). > > This 240 picture set is to be used in literacy acquisition assessment and intervention tools, as well as for naming assessment tools for anomic patients (anomia characterizes all types of aphasias, as you know). Nice stuff. > > In the beginning of 2011 we'll publish all these picture naiming data banks along with statistical criteria of iconicity, univocity, written word orthographic familiarity, written decodificability and codificability, etc. Now we are using them to assess receptive & expressive signing standardized parameters in deaf kids. Science is fun. > > > Again, thank you for your kind words, Valerie, Charles and Maureen! We are deeply satisfied that you have enjoyed it, and that the signs are easy to understand. That is precisely what we intended. Thank you so much for telling us. That kind of feedback is what we need to create courage to keep on moving ahead and swimming up the mountain river. Each sign is a salmon egg than matures and hatches when one lays one's warm eyes upon it, giving birth to knowledge that is to multiply and expand the domain of that deep and vast ocean we call deaf cognition. Thank you. > > Fernando > > -- > Fernando C. Capovilla, PhD > Professor Associado > Instituto de Psicologia, USP > Coord Lab Neuropsicolinguística Cognitiva Experimental, IP-Usp > Av. Prof. Mello de Morais 1721 > São Paulo, SP, 05508-900 > fcapovilla3 at gmail.com > visite-nos: http://lanceusp.hdfree.com.br/ > veja nossos novos livros em: http://lanceusp.hdfree.com.br/livros.html > > Timor Domini initium sapientiae est. Vincit qui se vincit. > Ora et labora. Usus optimus rerum magister. > Veritas Liberate Vos. Ergo, aude sapere. > > > >


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French Twinks Bang Themselves With Dildos And Fuck, Cum & Piss In The Shower
We know you guys are going to like this new video featuring two big uncut cock French Twinks. Paul Delay and Gabriel Lambert have been fooling around together for the last few years and they always like to push their limits during their sexual encounters. Paul starks sucking on Gabriel's big uncut cock and the two twinks exchange head. They decide that they are tired of sucking each other off. Paul pulls out two big dilods and suggest that they bang each other in the ass with them. Gabriel thinks this is a great idea and the two shove the dildos up their asses and begin jacking off together. Their two tight holes swallow every inch of the big fake cocks. After fucking each other with the dildos, Paul leads Gabriel to the bathroom. Gabriel's big uncut cock starts fucking Paul in the shower who screams with pleasure. After some intense shower fucking, Gabriel pulls out and shoots a huge load cum all over Paul's face. Paul, who is on his knees, starts sucking on Gabriel's spent cock and shoots his load all over Gabriel's hot twink feet. Paul eats his cum off Gabriel's feet while Gabriel starts to piss all over his twink buddy. Fuck yeah! Twinks cumming and pissing all over each other. Hot!


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Marine Park Man Confesses To Sexual Abuse Of Two Kids, Sentenced To 20 Years
Marine Park resident Michael Sabo, 38, was sentenced to 20 years-to-life, after admitting to sexually abusing two children over the course of several years.
The plea deal came just as Sabo was to go to trial, and it spared the two kids the painful ordeal of having to relive the experience through testimony on the stand.
Here's the Daily News' take:
He could have faced an "almost incalculable" sentence of up to hundreds of years if convicted by a jury for nine sex abuse and 120 child pornography charges, Justice Vincent Del Giudice told him.
The father of four, who used to work as a registered nurse, then finally copped.
He pleaded guilty to molesting a 5-year-old boy for five years starting in 2001 and to repeatedly forcing a little girl to engage in sex acts when she was between the ages 6 and 9.
"I had her perform oral sex on me," Sabo, speaking almost inaudibly and leaning on the defense table, told the judge.
"One can argue that he is a victim himself," said defense lawyer Jeffrey Schwartz, arguing that Sabo was likely a victim of sex abuse as a child.
The sordid case came to light a number of years ago, when someone saw a picture of the boy victim – clothed but tied up – on a Russian porn site and shared it with a rabbi. It took the rabbi two years to locate the child's family and they eventually identified the second victim, a source said.
In the photo, Sabo's hand is visible as well as the background of his Marine Park home. A search warrant unearthed some 120 child pornography images, about half of them videos.
Sabo lived on Burnett Street, one block from two different yeshivas. When the story first broke and Sabo was released on bail, local Jewish publications expressed the community's outrage. They also noted that Sabo had attended a Jewish school made infamous by the deeds of a pedophile teacher. They wrote:
Sabo attended Yeshiva Torah Temimah in Brooklyn. The school was made infamous when its owner, Lipa Margulies, deflected investigations of a longtime teacher, Yehuda Kolko, who last yearpleaded guilty to multiple counts of child endangerment and who is suspected of widespread sexual abuse. Sabo said he could not recall if he had been a victim of sexual abuse by Kolko.
"My therapist says it's repressed, right now, but I don't remember," said Sabo.


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- Science
- Not Exactly Rocket Science
MRSA in pigs and pig farmers
Methicillin-resistant Staphylococcus aureus (MRSA) is very difficult to kill. This notorious "superbug" can withstand a broad and growing range of antibiotics, and is the leading cause of hospital infections in many countries. But it's not restricted to hospitals. According to studies coming in from all over the world, MRSA has found a new route into our bodies -piggyback.
Pig farms throughout the world have become breeding grounds for strains of MRSA that can jump from swine to humans. These strains have already been isolated in the Netherlands, Denmark and Canada, and now, the latest study adds the USA to that list. The research was led by Tara Smith from the University of Iowa, who I know as a Scibling and who many of you will recognize as the author of the excellent Aetiology blog.
Smith found widespread traces of MRSA in two different production systems in the states of Iowa and Illinois. Within the nostrils of 49% of pigs and 45% of pig farmers, her team detected traces of the "superbug" (although it's worth noting that none of the farmers had experienced any actual infections). Piglets had the highest rates of infection and in fact, every single pig under the age of 12 weeks harboured MRSA colonies.
The high levels of the bacterium in both man and pig suggest that it can spread readily between the two species. To MRSA, both four leg and two legs are good…
The link between MRSA and pigs was first discovered a few years ago in the Netherlands. Dutch hospitals have little to fear from MRSA – aggressive "search-and-destroy" policies and restricted antibiotic use have controlled the bug to such an extent that hospitals list "treatment in foreign hospitals" as a risk factor for infection!
But in 2003, Dutch researchers started to find unexpected cases of MRSA in pig farmers and eventually identified the culprit as a new strain that became known as ST398, or non-typeable MRSA (NT-MRSA). It's this same strain that Smith found in the Iowan pigs.
In 2007, Albert de Neeling and Xander Huijsdens found ST398 in 39% of pigs and 81% of local pig farms, suggesting again that the bacteria was jumping from pigs to humans. In the same year, Huijsdens, together with Inge van Loo, found further proof for this theory. By comparing 35 people with ST398 to 76 people carrying other strains, they found that the ST398 carriers were 12 times more likely to have come into close contact with pigs and 20 times more likely to have come into contact with cattle. On a map, they saw that the distribution of ST398 uncannily matched the spread of pig and cattle farms.
ST398 is a newcomer. By reviewing a national MRSA database, Dr Huijsdens and Dr van Loo found that the strain was non-existent in 2002 but now accounts for over one in five human infections. Its origin is unclear. It almost certainly jumped from pigs to humans, but the researchers think that this was just the return part of a round-trip. They think the bacteria may have originally jumped from humans to pigs.
In their new porky hosts, the bacteria developed new antibiotic resistances and returned, stronger than ever. Unlike other strains, ST398 strongly withstands tetracyclines, a group of antibiotics that is heavily used to medicate livestock. Unnecessary antibiotic use has been blamed for the evolution of MRSA strains in humans and the same could apply to pigs, especially since the farming industry uses more antibiotics than hospitals. Under such heavy assault, it is almost inevitable that bacteria, which reproduce quickly and swap beneficial mutations, will develop resistance.
So far, it is not clear if ST398 is spreading beyond pig farms or if it causes so-called community-associated MRSA, which occurs outside the hospital setting. For the moment, people who frequently come into contact with pigs or cattle, including vets, have the highest risk of infection. The bacteria could also spread to their friends and family by hitching a ride on clothes or skin.
Even the food chain is not entirely safe. Van Loo detected ST398 in 2 out of 79 meat samples from Dutch supermarkets and butchers, but only at low levels that are unlikely to cause disease if food is properly prepared. For the general population, there's no need to panic over ham and bacon but the risks could be higher for people who handle meat directly, or those with weakened immune systems. At least one hospital outbreak began when an immunocompromised patient ate contaminated meat. Even though this was a different MRSA strain, it set a dangerous precedent.
The problem is not confined to the Netherlands either. Pigs are heavily exported around the world and ST398 may have stowed away inside them. It has already been detected in France, Singapore and Denmark. Scott Weese from the University of Guelph in Ontario found the Dutch strain in a quarter of local pigs and more worryingly, in a fifth of pig farmers. Human cases of ST398 are extremely rare in Canada but that could change as it spreads among the pig population.
And as we've seen, the US is affected too. As the largest importer of Canadian pork, their farms could have become contaminated by swine brought in from their northern neighbour, but only further studies can confirm that. It's also unclear how widespread ST398 is in the US, but Iowa alone accounts for a quarter of all the swine raised within its borders.
It is clear that we need more research and better monitoring to fully understand the scale of the MRSA epidemic in pigs and the role that agricultural antibiotics have played in it. Only then we recommend the right control measures to protect farmers and the wider population.
Reference: Tara C. Smith, Michael J. Male, Abby L. Harper, Jennifer S. Kroeger, Gregory P. Tinkler, Erin D. Moritz, Ana W. Capuano, Loreen A. Herwaldt, Daniel J. Diekema (2008). Methicillin-Resistant Staphylococcus aureus (MRSA) Strain ST398 Is Present in Midwestern U.S. Swine and Swine Workers PLoS ONE, 4 (1) DOI: 10.1371/journal.pone.0004258
More on drug resistance:
- Drugs that work against each other could fight resistant bacteria
- The secret of drug-resistant bubonic plague
- Super-bacteria eat antibiotics for breakfast
Image: My MRSA GiantMicrobe, with enormous thanks to Rebecca Skloot


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PARKING DECALS – OUTSIDE WINDOW – Use a permanent adhesive and attach to outside of vehicle window. These decals are made of all-weather vinyl.
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Yes, that's right. Musiville, the second book in the award-winning Niditales series, has now officially been released into the wild. Cue glorious music, angels singing, trumpets blaring, and all the other trappings of a book launch.
And, of course, gifts.
You have given me your thoughts on the cover. You have voted for me and my books. You have shared and commented. You have offered me your friendship and support. So, it's only fair that, until the year's end, I will post here the entire book for you to read and enjoy, as my small thank-you for your sheer awesomeness.
Please keep in mind that, come next year, only a limited part will be available. So, if anyone wishes to read it then, just let me know through the contact form or in the comments.
Let's Face the Music and… Conduct!
A group of animals has evolved into musical instruments. Or is it the other way around? Whichever the case, they have now formed their own little village: Musiville. And bands. Lots and lots of bands. When everyone starts playing their own tune, buildings get torn down by an invader. Can Musiville be saved from this unexpected threat?
The book
Here is Musiville, in all its glory. I think you'll agree that Dimitris Fousekis did a amazing job with the illustrations, and Alexios Saskalidis a great job with DTP. I hope you enjoy it!
Musiville is available on Amazon and CreateSpace. As always, if you've enjoyed my work, I'd be grateful if you could leave a review 🙂


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|Up a level
Arbia, Giuseppe and Bee, Marco and Espa, Giuseppe (2007) Aggregation of regional economic time series with different spatial correlation structures. UNSPECIFIED.
Azaro, Renzo and Debiasi, Luca and Zeni, Edoardo and Benedetti, Manuel and Rocca, Paolo and Massa, Andrea (2008) A hybrid prefractal three-band antenna for multistandard mobile wireless applications. UNSPECIFIED. (Submitted)
Azaro, Renzo and Zeni, Edoardo and Gazzini, Tommaso and Dallapiccola, Ramona and Massa, Andrea (2006) Synthesis of a Three-Dimensional Triband (L1-L2 GPS and Wi-Fi) Prefractal Tree Antenna. UNSPECIFIED. (In Press)
Brunetti, Romeo and Franceschini, Lorenzo and Moretti, Valter (2008) Topological features of massive bosons on two dimensional Einstein space-time. I: Spatial approach. UNSPECIFIED. (Unpublished)
Brunetti, Romeo and Moretti, Valter (2007) Quantum Field Theories in Curved Spacetime. UNSPECIFIED. (Unpublished)
Fernandes, Paolo and Valli, Alberto (2006) Lorenz gauged vector potential formulations for the time-harmonic eddy-current problem with L∞-regularity of material properties. UNSPECIFIED. (Unpublished)
Moretti, Valter (2010) Local z-functions, stress-energy tensor, field fluctuations, and all that, in curved static spacetime. UNSPECIFIED. (Unpublished)
Moretti, Valter (2006) Quantum ground states holographically induced by asymptotic flatness: Invariance under spacetime symmetries, energy positivity and Hadamard property. UNSPECIFIED. (Unpublished)
Moretti, Valter and Pinamonti, Nicola (2003) Holography, SL(2,R) symmetry, Virasoro algebra and all that in Rindler spacetime. UNSPECIFIED. (Unpublished)
Moretti, Valter and Pinamonti, Nicola (2003) QFT holography near the horizon of Schwarzschild-like spacetimes. UNSPECIFIED. (Unpublished)
Pinamonti, Nicola (2005) De Sitter quantum scalar field and horizon holography. UNSPECIFIED. (Unpublished)
Pinamonti, Nicola (2006) On time observables in thermal theories. UNSPECIFIED. (Unpublished)
Pinamonti, Nicola and Vanzo, Luciano (2003) Central Charges and Boundary Fields for two Dimensional Dilatonic Black Holes. UNSPECIFIED. (Unpublished)
Viani, Federico and Benedetti, Manuel and Donelli, Massimo and Lizzi, Leonardo and Cresp, A. and Aliferis, L. and Pichot, Christian and Massa, Andrea (2008) SVM-based Classification Approach for Synthetic-Impulse Microwave Imaging. UNSPECIFIED. (Unpublished)


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VATICAN CITY (RNS) Pope Francis will travel to the heartland of the Italian mafia for the first time Saturday (June 21), visiting the southern town where a 3-year-old was murdered in a local drug war earlier this year.
Security will be extremely tight when the pope makes his one-day visit to Cassano allo Ionio in Calabria, one of Italy's poorest regions, in what is certain to be his most powerful political statement against organized crime.
The trip has renewed questions about Francis' health; on Thursday, Vatican officials said he would not lead a religious procession on the streets of Rome late Thursday so that he could save his energy for his trip to Calabria.
Francis, who had already put his weekly audiences and daily Mass on hold for much of the summer, opted to travel by car less than a mile between the St. John Lateran and St. Mary Major basilicas instead of leading a candle-lit procession for the Feast of Corpus Christi.
In Calabria, the 77-year-old pontiff will go to a prison and a hospital and have lunch with the poor in the area before celebrating Mass with as many as 100,000 pilgrims.
On his visit to Castrovillari Prison, Francis is not expected to meet inmate Nicola Campolongo, father of the slain toddler Nicola, or "Coco," whose charred remains were found in a burned-out car with the bodies of his grandfather and his grandfather's companion in January.
Church officials also said there were no plans for the pope to meet the child's mother, Antonia Iannicelli, who is living under house arrest and made a personal plea to meet the pontiff.
The brutal killing shocked Italians accustomed to reports of mafia violence and prompted a heartfelt response from Francis, who urged the killers to "repent."
Referring to the "globalization of evil," the secretary-general of the Italian Bishops' Conference, Bishop Nunzio Galantino, said Francis offered hope with his "simplicity and determination."
"We are losing hope, we don't know who to turn to, we have no credible political leaders," said Galantino, who is also the bishop of Cassano. "Even in the church we are no longer enthusiastic."
Francis' frank determination to challenge organized crime groups has sparked warnings that he could become a mafia target. The pope met the families of mafia victims in May and warned mobsters that they would "go to hell" if they did not repent.
Last November, respected anti-mafia prosecutor Nicola Gratteri, who investigates the Calabrian mafia or 'Ndrangheta, said: "If the mafia bosses can trip him up, they won't hesitate."
In a recent interview with the Spanish daily La Vanguardia, the pope shrugged off concerns about his own security, saying he did not want to travel in a protective bulletproof vehicle that was like a "sardine can."
"It's true that anything could happen," he said, "but let's face it, at my age I don't have much to lose."
KRE/MG END McKENNA


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Should You Buy SABMiller Today?
LONDON -- Although cross-market risk aversion has dented investor thirst for SABMiller in recent days, the beverage giant has still clocked up a 22% gain in the year to date and hit record highs above 3,500 pence in the process. And just today, Credit Suisse plonked a 4,000 pence price target on the company's stock, providing plenty of upside from current levels.
I am convinced that SABMiller -- whose stable of more than 200 beer brands include Peroni, Grolsch, and Pilsner Urquell -- should continue to drive revenues skyward as it ramps up activity in emerging markets around the globe.
Latin America in the crosshairs
The company announced in January's interims that group turnover leapt 17% in the third quarter, or 8% on an organic basis, with total volumes rising 6% on-year. Global lager sales rose 2%, pushed by Latin American growth of 6% and consumption in Africa jumping 4%, even though European demand rose just 1% and Chinese drinking fell 3% because of poor weather.
SABMiller continues to target developing geographies to bolster sales in coming years, and yesterday it announced plans to significantly improve its footprint in Latin America by targeting the region's black market. Around 80% of consumers here are considered "low income," and the company intends to attract these customers away from illegal alcohol by introducing larger, more cost-effective bottles, providing excellent growth opportunities.
Elsewhere, the lager maker announced last month that its China Resources Snow Breweries joint-venture intends to acquire the brewery business of Kingway Brewery Holdings for $864 million, boosting its presence in some of China's richest and fastest-growing regions.
Go with the earnings flow
Earnings-per-share are expected to rise 4% to 147 pence in the year ended March 2013, according to broker estimates, before taking off thereafter -- growth of 18% and 12% are penciled in for 2014 and 2015 correspondingly, to 173 pence and 194 pence.
The drinks manufacturer currently changes hands on a P/E ratio of 23.4 for the current year, trading at a premium to a forward earnings multiple of 20.1 for the wider beverages sector. However, this is set to dip considerably as earnings ramp up, with readings of 19.8 and 17.7 expected this year and next.
Tap in to SABMiller's dynamic dividend policy
On top of SABMiller's exciting earnings acceleration story, the firm's extremely progressive dividend policy sweetens the investment case in my opinion. Although yields are expected to remain below the 3.5% average for the U.K.'s 100 largest listed firms -- readings of 1.8%, 2.2% and 2.4% are expected in each of the next three years -- investors can be confident of readings heading much higher further out.
Analysts predict a dividend of 62.8 pence this year, before rising to 73.6 pence in 2014 and 82.7 pence in 2015. And these are extremely well protected, with coverage of between 2.3 and 2.4 times expected through to 2015.
The expert view to growth elsewhere
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Our "10 Steps to Making a Million in the Market" report highlights how fast-growth small-caps and beaten-down bargains are all fertile candidates to produce 10-fold returns. Click here NOW to enjoy this exclusive "wealth report" -- it's 100% free and comes with no obligation.
The article Should You Buy SABMiller Today? originally appeared on Fool.com.
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Sojourners Magazine: January-February 2000
Subscribe to Sojourners for as little as $3.95!
Cover Story
Judy Wicks sees her restaurant, the White Dog Cafe in Philadelphia, as an experiment in bringing business and social responsibility together.
Founded by a handful of Oklahoma farmers in 1903, family-owned First Bethany Bank & Trust recalls some of the finest traditions of small-town business.
Ten principles for saving a corporate soul---and (who knows?) maybe your own.
The body of literature on business ethics is growing rapidly. Here are some resources that treat the subject soundly without making it seem that ethical decision-making is simple.
Participants in conversations about corporate responsibility and wages often use the same words to mean entirely different things.
As the old moral infrastructure crumbles, will faith take its place?
Jack Feldbaile, CEO of a large firm, describes a business decision that he feels highlights the tensions he faced as a Christian in business.
Many corporations in the global marketplace have severed their social contract with workers and local communities.
(And Why Being Good is Good for Business).
A growing number of Web sites focus on business ethics. Inc. Online's Ethics Corner features links to articles on business ethics for Inc. magazine www.inc.com/extra/columns/ethics.
To be a woman of faith in the midst of the city, I was forced to develop a contemplative stance. I am naturally pulled toward God in the midst of nature.
I do not view myself as a contemplative. I'd say that I am a "seeker" of God. This seeking has been a lifelong process.
Mark's gospel offers an antidote to domesticated, superficial Christianity.
To be a contemplative has traditionally meant leaving the city for a quiet life of prayer.
Labor activists and people of faith rally around 'core values.'
Why the living wage campaign is working.
Who would you choose as Person of the Millennium?
Artists and believers have something to talk about.
Putting a price on pollution.
Nyerere, Africa's father of independence.
After the test ban vote, what next for the peace movement?
Are we only liberated from something or are we also liberated into something?
The breakfast table was covered with birthday cards decoratively labeled "50," which meant somebody in our home had crossed the half-century mark. But who?
A school system cannot hope to solve school violence simply by increasing security.
The Spice Girls won't be remembered. Martin Luther King will.
Culture Watch
The harsh glare of life on the streets.
Capturing sorrow with hope.
Get out the garlic! Hef is back. That was the gist of a series of articles last summer and fall chronicling the return to the limelight of Playboy magazine founder Hugh Hefner.
A movement for a fair economy.
Listening for God's voice.
A modern pilgrim walks an ancient path.
Bishop Belo's struggle for freedom in East Timor.
Will Campbell's 'scandalizing' faith.
The U.S. State Department this fall cited Sudan as potentially subject to economic sanctions under the International Religious Freedom Act for its persecution of Christians and other religious groups.
What's good for General Motors---and other megacorporations---isn't necessarily good for the rest of us.
CTR readies for approaching Summit.
Food---and much more---for the poor.
Celvin Galindo, the prosecutor investigating the murder of Guatemalan Bishop Juan Jose Gerardi, has fled to the United States for fear of his life.
50 Years of Good News (on the Radio)
Bringing people together.
An estimated 10 million Colombians—a quarter of the country's population—took to the streets this fall in protests demanding an end to 40 years of armed conflict t
While the U.S. military has spent more than $30 million on its fortress-like base in Kosovo—complete with a Burger King—Kosovars themselves are left with a war-ravaged homeland...
On September 29 President Clinton announced that the administration would erase 100 percent of the debt owed to the United States by 30 heavily indebted poor countries.
Dear Gail: