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Gary Leon Ridgway (born February 18, 1949), also known as the Green River Killer, is an American serial killer. He was initially convicted of 48 separate murders. As part of his plea bargain, another conviction was added, bringing the total number of convictions to 49, making him the second most prolific serial killer in United States history according to confirmed murders.[n 1] He killed many teenage girls and women in the state of Washington during the 1980s and 1990s.[2]
Most of Ridgway's victims were alleged to be sex workers and other women in vulnerable circumstances, including underage runaways. The press gave him his nickname after the first five victims were found in the Green River before his identity was known.[3] He strangled his victims, usually by hand but sometimes using ligatures. After strangling them, he would dump their bodies in forested and overgrown areas in King County, often returning to the bodies to have sexual intercourse with them.[4]
On November 30, 2001, as Ridgway was leaving the Kenworth truck factory where he worked in Renton, Washington, he was arrested for the murders of four women whose cases were linked to him through DNA evidence.[4] As part of a plea bargain wherein he agreed to disclose the locations of still-missing women, he was spared the death penalty and received a sentence of life imprisonment without parole
Early life
Gary Leon Ridgway was born on February 18, 1949, in Salt Lake City, Utah, the second of Mary and Thomas Ridgway's three sons. His home life was somewhat troubled; relatives have described his mother as domineering and have said that, while young, he witnessed more than one violent argument between his parents. His father was a bus driver who would often complain about the presence of sex workers.[5]
Ridgway had a bed-wetting problem until he was 13,[6] and his mother would wash his genitals after every episode.[7] He would later tell defense psychologists that, as an adolescent, he had conflicting feelings of anger and sexual attraction toward his mother, and fantasized about killing her.[6][7]
Ridgway is dyslexic, and was held back a year in high school.[5] When he was 16, he stabbed a six-year-old boy who survived the attack. Ridgway had led the boy into the woods and then stabbed him through the ribs into his liver.[8]
Ridgway's IQ was recorded as being in the "low eighties".[9]
Adult life
Ridgway graduated from Tyee High School in 1969 and married his 19-year-old high school girlfriend, Claudia Kraig. He joined the U.S. Navy[8] and was sent to Vietnam, where he served on board a supply ship[10] and saw combat.[5] During his time in the military, Ridgway had frequent sexual intercourse with sex workers and contracted gonorrhea; although angered by this, he continued this activity without protection. While Ridgway was abroad, Kraig had an extramarital affair. Their marriage ended within a year.[8]
When questioned about Ridgway after his arrest, friends and family described him as friendly but strange. His first two marriages resulted in divorce because of infidelities by both partners. His second wife, Marcia Winslow, claimed that he had placed her in a chokehold.[5] He had become religious during his second marriage, proselytizing door-to-door, reading the Bible aloud at work and at home, and insisting that his wife follow the strict teachings of their pastor.[8] Ridgway would also frequently cry after sermons or reading the Bible.[5] Despite his beliefs, Ridgway continued to solicit the services of sex workers and wanted his wife to participate in sex in public and inappropriate places, sometimes even in areas where his victims' bodies were later discovered.[8]
According to women in his life, Ridgway had an insatiable sexual appetite. His three ex-wives and several ex-girlfriends reported that he demanded sex from them several times a day.[11] Often, he would want to have sex in a public area or in the woods.[8] Ridgway himself admitted to having a fixation with sex workers,[12] with whom he had a love/hate relationship. He frequently complained about their presence in his neighborhood, but he also took advantage of their services regularly. Some have speculated that Ridgway was torn between his lusts and his staunch religious beliefs.[5]
With his second wife Marcia, Ridgway had a son, Matthew (b. 1975).[1]
Throughout the 1980s and 1990s, Ridgway is believed to have murdered at least 71 teenage girls and women near Seattle and Tacoma, Washington. In court statements, he later reported that he had killed so many that he lost count. A majority of the murders occurred between 1982 and 1984. The victims were believed to be either sex workers or runaways picked up along Pacific Highway South, whom he strangled. Most of their bodies were dumped in wooded areas around the Green River, Seattle–Tacoma International Airport, and other "dump sites" within South King County.[13]
There were also two confirmed and another two suspected victims found in the Portland, Oregon area. The bodies were often left in clusters, sometimes posed, usually nude. He would sometimes return to the victims' bodies and have sexual intercourse with them. Ridgway later explained that he did not find necrophilia more sexually satisfying, but having sex with the deceased reduced his need to obtain a living victim and thus limited his exposure to being caught.[7] Because most of the bodies were not discovered until only the skeletons remained, three victims are still unidentified. Ridgway occasionally contaminated the dump sites with gum, cigarettes, and written materials belonging to others, and he even transported a few victims' remains across state lines into Oregon to confuse the police.[13]
Ridgway began each murder by picking up a woman, usually a sex worker. He sometimes showed the woman a picture of his son, to trick her into trusting him. After raping her, Ridgway strangled her from behind. He initially strangled them manually. After many victims inflicted wounds and bruises on his arm while trying to defend themselves, Ridgway began using ligatures. He killed most victims in his home, his truck, or a secluded area.[4]
In the early 1980s, the King County Sheriff's Office formed the Green River Task Force to investigate the murders. Task force members included Robert Keppel and Dave Reichert, who periodically interviewed incarcerated serial killer Ted Bundy in 1984. Bundy offered his opinions on the psychology, motivations, and behavior of the killer. He suggested that the killer was revisiting the dump sites to have sex with his victims, which turned out to be true, and if police found a fresh grave, they should stake it out and wait for him to come back.[14] Also contributing to the investigation was John E. Douglas, who developed a profile of the suspect.[15]
Ridgway was arrested in 1982 and 2001 on charges related to prostitution.[16] He became a suspect in the Green River killings in 1983.[17] In 1984, Ridgway passed a polygraph test.[7] On April 7, 1987, police took hair and saliva samples from Ridgway.[18]
Around 1985, Ridgway began dating Judith Mawson, who became his third wife in 1988. Mawson claimed in a 2010 television interview that when she moved into his house while they were dating, there was no carpet. Detectives later told her he had probably wrapped a body in the carpet.[19] In the same interview, she described how he would leave for work early in the morning some days, ostensibly for the overtime pay. Mawson speculated that he must have committed some of the murders while supposedly working these early morning shifts. She claimed that she had not suspected Ridgway's crimes before she was contacted by authorities in 1987, and had not even heard of the Green River Killer before that time because she did not watch the news.[19]
Author Pennie Morehead interviewed Ridgway in prison, and he said while he was in the relationship with Mawson, his kill rate went down, and he truly loved her.[19] Of his 49 known victims, only three were killed after he married Mawson. Mawson told a local television reporter, "I feel I have saved lives…by being his wife and making him happy."[20]
The samples collected in 1987 were later subjected to a DNA analysis, providing the evidence for his arrest warrant.[21] On November 30, 2001, Ridgway was at the Kenworth Truck factory, where he worked as a spray painter, when police arrived to arrest him. Ridgway was arrested on suspicion of murdering four women nearly 20 years earlier after first being identified as a potential suspect, when DNA evidence conclusively linked semen left in the victims to the saliva swab taken by the police. The four victims named in the original indictment were Marcia Chapman, Opal Mills, Cynthia Hinds, and Carol Ann Christensen. Three more victims—Wendy Coffield, Debra Bonner, and Debra Estes—were added to the indictment after a forensic scientist identified microscopic spray paint spheres as a specific brand and composition of paint used at the Kenworth factory during the specific time frame when these victims were killed.[19]
Plea bargain, confessions, sentencing
Early in August 2003, Seattle television news reported that Ridgway had been moved from a maximum security cell at King County Jail to an Airway Heights Minimum-Medium Security Level Tank. Other news reports stated that his lawyers, led by Anthony Savage, were closing a plea bargain that would spare him the death penalty in return for his confession to a number of the Green River murders.[22]
On November 5, 2003, Ridgway entered a guilty plea to 48 charges of aggravated first degree murder as part of a plea bargain, agreed to in June, that would spare him execution in exchange for his cooperation in locating the remains of his victims and providing other details. In his statement accompanying his guilty plea, Ridgway explained that he had killed all of his victims inside King County, Washington, and that he had transported and dumped the remains of the two women near Portland to confuse the police.[13]
Deputy prosecutor Jeffrey Baird noted in court that the deal contained "the names of 41 victims who would not be the subject of State v. Ridgway if it were not for the plea agreement." King County Prosecuting Attorney Norm Maleng explained his decision to make the deal:
We could have gone forward with seven counts, but that is all we could have ever hoped to solve. At the end of that trial, whatever the outcome, there would have been lingering doubts about the rest of these crimes. This agreement was the avenue to the truth. And in the end, the search for the truth is still why we have a criminal justice system … Gary Ridgway does not deserve our mercy. He does not deserve to live. The mercy provided by today's resolution is directed not at Ridgway, but toward the families who have suffered so much …[23]
On December 18, 2003, King County Superior Court Judge Richard Jones sentenced Ridgway to 48 life sentences with no possibility of parole and one life sentence, to be served consecutively. He was also sentenced to an additional 10 years for tampering with evidence for each of the 48 victims, adding 480 years to his 48 life sentences.[24]
Ridgway led prosecutors to three bodies in 2003. On August 16 of that year, the remains of a 16-year-old girl found near Enumclaw, Washington, 40 feet from State Route 410, were pronounced as belonging to Pammy Annette Avent, who had been believed to be a victim of the Green River Killer. The remains of Marie Malvar and April Buttram were found in September 2003.
On November 23, 2005, the Associated Press reported that a weekend hiker found the skull of one of the 48 women Ridgway admitted murdering in his 2003 plea bargain with King County prosecutors. The skull of another victim, that of Tracy Winston, who was 19 when she disappeared from Northgate Mall on September 12, 1983, was found on November 20, 2005 by a man hiking in a wooded area near Highway 18 near Issaquah, southeast of Seattle.[25]
Ridgway confessed to more confirmed murders than any other American serial killer. Over a period of five months of police and prosecutor interviews, he confessed to 48 murders—42 of which were on the police's list of probable Green River Killer victims.[26][27] On February 9, 2004, county prosecutors began to release the videotape records of Ridgway's confessions. In one taped interview, he initially told investigators that he was responsible for the deaths of 65 women.[28] In another taped interview with Reichert on December 31, 2003, Ridgway claimed to have murdered 71 victims and confessed to having had sex with them before killing them, a detail which he did not reveal until after his sentencing.[28]
In his confession, he acknowledged that he targeted prostitutes because they were "easy to pick up" and that he "hated most of them."[29] He confessed that he had sex with his victims' bodies after he murdered them, but claimed he began burying the later victims so that he could resist the urge to commit necrophilia.[30]
Ridgway later said that murdering young women was his "career."[7]
Life imprisonment
Ridgway was placed in solitary confinement at Washington State Penitentiary in Walla Walla in January 2004.[31] On May 14, 2015, he was transferred to the USP Florence, a high-security federal prison east of Cañon City, Colorado. In September 2015, after a public outcry and discussions with Governor Jay Inslee, Corrections Secretary Bernie Warner announced that Ridgway would be transferred back to Washington to be "easily accessible" for open murder investigations.[32] Ridgway was returned by chartered plane to Washington State Penitentiary in Walla Walla from the High Security Federal Prison in Florence, Colorado, on October 24, 2015.[33]
Before Ridgway's confession, authorities had attributed 49 murders to the Green River Killer.[34] Ridgway confessed to murdering at least 71 victims.[28]
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At the time of Ridgway's December 18, 2003 sentencing, authorities had been able to find at least 48 sets of remains, including victims not originally attributed to the Green River Killer. Ridgway was sentenced for the deaths of each of these 48 victims,[35] with a plea agreement that he would "plead guilty to any and all future cases (in King County) where his confession could be corroborated by reliable evidence."[36]
|Wendy Lee Coffield
|July 8, 1982
|July 15, 1982
|Gisele Ann Lovvorn
|July 17, 1982
|September 25, 1982
|Debra Lynn Bonner
|July 25, 1982
|August 12, 1982
|Marcia Fay Chapman
|August 1, 1982
|August 15, 1982
|Cynthia Jean Hinds
|August 11, 1982
|August 15, 1982
|Opal Charmaine Mills
|August 12, 1982
|August 15, 1982
|Terry Rene Milligan
|August 29, 1982
|April 1, 1984
|Mary Bridget Meehan
|September 15, 1982
|November 13, 1983
|Debra Lorraine Estes
|September 20, 1982
|May 30, 1988
|Linda Jane Rule
|September 26, 1982
|January 31, 1983
|Denise Darcel Bush
|October 8, 1982
|June 12, 1985
|Shawnda Leea Summers
|October 9, 1982
|August 11, 1983
|Shirley Marie Sherrill
|October 20–22, 1982
|June 14, 1985
|Rebecca "Becky" Marrero
|December 3, 1982
|December 21, 2010
|Colleen Renee Brockman
|December 24, 1982
|May 26, 1984
|Sandra Denise Major
|December 24, 1982
|December 30, 1985
|Alma Ann Smith
|March 3, 1983
|April 2, 1984
|Delores LaVerne Williams
|March 8–14, 1983
|March 31, 1984
|Gail Lynn Mathews
|April 10, 1983
|September 18, 1983
|Andrea Marion Childers
|April 14, 1983
|October 11, 1989
|Sandra Kay Gabbert
|April 17, 1983
|April 1, 1984
|Kimi-Kai Pitsor
|April 17, 1983
|December 15, 1983
|Marie M. Malvar
|April 30, 1983
|September 26, 2003
|Carol Ann Christensen
|May 3, 1983
|May 8, 1983
|Martina Theresa Authorlee
|May 22, 1983
|November 14, 1984
|Cheryl Lee Wims
|May 23, 1983
|March 22, 1984
|Yvonne "Shelly" Antosh
|May 31, 1983
|October 15, 1983
|Carrie Ann Rois
|May 31 – June 13, 1983
|March 10, 1985
|Constance Elizabeth Naon
|June 8, 1983
|October 27, 1983
|Kelly Marie Ware
|July 18, 1983
|October 29, 1983
|Tina Marie Thompson
|July 25, 1983
|April 20, 1984
|April Dawn Buttram
|August 18, 1983
|August 30, 2003
|Debbie May Abernathy
|September 5, 1983
|March 31, 1984
|Tracy Ann Winston
|September 12, 1983
|March 27, 1986
|Maureen Sue Feeney
|September 28, 1983
|May 2, 1986
|Mary Sue Bello
|October 11, 1983
|October 12, 1984
|Pammy Annette Avent
|October 26, 1983
|August 16, 2003
|Delise Louise Plager
|October 30, 1983
|February 14, 1984
|Kimberly L. Nelson
|November 1, 1983
|June 14, 1986
|Lisa Yates
|December 23, 1983
|March 13, 1984
|Mary Exzetta West
|February 6, 1984
|September 8, 1985
|Cindy Anne Smith
|March 21, 1984
|June 27, 1987
|Patricia Michelle Barczak
|October 17, 1986
|February 3, 1993
|Roberta Joseph Hayes
|February 7, 1987
|September 11, 1991
|Marta Reeves
|March 5, 1990
|September 20, 1990
|Patricia Yellowrobe
|January 1998
|August 6, 1998
|Unidentified White Female (Jane Doe B-10)
|Died prior to May 1983
|March 21, 1984
|Unidentified White Female (Jane Doe B-17)
|December 1980 – January 1984
|January 2, 1986
|Unidentified Female (Jane Doe B-20)
|August 21, 2003
- Before Ridgway's confession, authorities had not attributed to the Green River Killer the deaths of victims Rule, Barczak, Hayes, Reeves, Yellowrobe, and "victim 49."[34]
- Ridgway's confession and directions led police search crews to find the bodies of Avent, Buttram, and Malvar in August and September 2003.
- On Tuesday, December 21, 2010, hikers near the West Valley Highway in Auburn, WA found a skull in the vicinity of where Marie Malvar's remains had been found in 2003. The skull was identified as belonging to Rebecca "Becky" Marrero, who was last seen leaving the Western Six Motel at South 168th Street and Pacific Highway South on December 3, 1982. The King County Prosecutor confirmed that Ridgway would be formally charged with her murder on February 11, 2011.[36] On February 18, 2011, he entered a guilty plea in the murder of Rebecca Marrero, adding a 49th life sentence to his existing 48. Ridgway confessed to murdering Marrero in his original plea bargain, but due to insufficient evidence, the charges could not be filed. Therefore, there is no change in his current incarceration status.[37]
- The remains of Tracy Winston were found, without a skull, in Kent's Cottonwood Grove Park in March 1986. Winston's skull was found in November 2005 near Tiger Mountain, miles away from the discovery site of the rest of her body. Police assume someone carried it to the location.[38]
- Sandra Denise Major was not identified until June 2012. A family member asked the King County Sheriff to investigate after seeing a TV movie about Ridgway. DNA confirmed Major's identity.[39][40]
- Jane Doe B-10, discovered on March 21, 1984, is currently unidentified. Ridgway claimed that she was a white female in her early 20s and possibly had brown hair. Examination of the remains suggested that she was actually between 12 and 18, most likely around 15.[41] Analysis of the victim's skeleton indicated she was probably left-handed, and had at one point in her life suffered a healed skull fracture to the left temple.
- Jane Doe B-17, also unidentified, was discovered on January 2, 1986; remains that had been found in another area February 18, 1984 were later matched to this victim. In 2003, Ridgway claimed responsibility for her death.[42]
- Jane Doe B-20, a female between 13 and 24, was discovered in August 2003. Because the remains were partial, her face could not be reconstructed and her race could not be determined. She was murdered between the 20-year span of 1973 to 1993, but is believed to have been murdered during the first decade of Ridgway's murder spree.[43]
Task force victims list
Ridgway is suspected of—but not charged with—murdering the remaining six victims of the original list attributed to the Green River Killer.[34] In each case, either Ridgway did not confess to the victim's death, or authorities have not been able to corroborate their suspicion with reliable evidence.
|Amina Agisheff
|July 7, 1982
|April 18, 1984
|Kasee[n 2] Ann Lee (née Woods)
|August 28, 1982
|Tammie Liles
|June 9, 1983
|April 1985
|Kelly Kay McGinniss[n 3]
|June 28, 1983
|Angela Marie Girdner
|July 1983
|April 22, 1985
|Patricia Osborn
|October 20, 1983[49][50]
- Ridgway denied killing Amina Agisheff. Agisheff does not fit the profile of any of the victims of the Green River Killer considering her age, and she was not a sex worker or a teenage runaway.[51]
- Although he has never been charged with her murder, during police interrogations in 2003, Ridgway did confess to killing Kasee Ann Lee (née: Woods). He stated that he strangled Lee in 1982 and left her body near a drive-in theatre off of the Sea-Tac Strip.[52] Law enforcement officials have been unable to locate Lee's remains at the dumpsite that Ridgway indicated.[53]
- Evidence exists to suggest that Ridgway murdered Kelly Kay McGinniss. Shortly before her disappearance, McGinniss was questioned by a Port of Seattle police officer while "dating" Ridgway near the SeaTac Strip. Furthermore, during the summer of 2003, Ridgway led authorities to the bodies of several of his victims. One of those bodies, later identified as that of April Buttram, was initially identified by Ridgway as being that of McGinniss. According to Ridgway, he often confused McGinniss with Buttram because of their similar physiques.[54]
- Ridgway is a suspect in the deaths of Angela Marie Girdner and Tammie Liles. Their bodies were discovered within a mile of the bodies of known victims Shirley Shirell and Denise Bush. Liles remained unidentified until 1998 and Girdner until October 2009.[55]
Ridgway has been considered a suspect in the disappearances/murders of five other women not attributed at the time to the Green River Killer. No charges have been filed.
|Unidentified Black Female
|December 1980
|Kristi Lynn Vorak
|October 31, 1982
|Patricia Ann Leblanc
|August 12, 1983
|Rose Marie Kurran[n 4]
|August 26, 1987
|August 31, 1987
|Darci Warde
|April 24, 1990
|Cora McGuirk
|July 12, 1991
- An unidentified black female, possibly bearing the first name Michelle, was a possible victim of Ridgway. She has never been located or identified.[57]
- Cora McGuirk was the mother of NBA player Martell Webster. McGuirk disappeared when her son was four years old.[58]
- Ridgway was long suspected for the 1987 murder of Rose Marie Kurran, a 16-year-old addict and prostitute,[59] but was recently ruled out as a suspect.[60]
Popular culture
In artwork
- In 2004, Phil Hansen created and displayed artwork depicting Gary Ridgway's face, composed of 11,792 portraits of the 48 victims.[61]
In documentaries and films (fiction and non-fiction)
- The 1984 documentary Murder, No Apparent Motive, about serial killers and FBI Profilers, mentioned that the (then-ongoing) Green River Killer's murders were one of the latest examples of serial murders that go on in America without any apparent motives.[62]
- Unsolved Mysteries Season 8, episode 11, Green River Killer segment.
- The ninth episode of the 2010 American documentary show Who the (Bleep) Did I Marry? features his story and his third wife's side of it.
- The Riverman is based on the true story of Ted Bundy assisting investigators trying to identify and catch the Green River Killer.[63] It is based on the book of the same name by Robert D. Keppel.
- The direct-to-DVD movie Green River Killer was released in 2005.
- A 2006 episode of the TV series Crimes That Shook the World focuses on Gary Ridgway (played by Frank Violi).
- In 2008, the Lifetime Movie Network aired The Capture of the Green River Killer, a TV movie loosely based on his crimes. John Pielmeier portrays Ridgway. In 2014, they aired a documentary called My Uncle is the Green River Killer which featured Ridgway family members.
- The Court TV (now TruTV) television series Mugshots released an episode on Ridgway titled Gary Ridgway The Green River Killer, aired in 2013.[64][65]
- In 2005, A&E series Cold Case Files aired an episode called obsession: Dave Reichert and the Green River Killer. (Season 5, Episode 1)
- On June 2, 2017, HLN (Headline News) premiered the true crime series Beyond Reasonable Doubt with the episode The Green River Killer. The one-hour episode reports on the advanced trace evidence that directly link tiny paint particles from the victims' clothing to Ridgway, lay summary – CNN.[66][67]
- Bundy and The Green River Killer a 2019 Horror film by Andrew Jones (filmmaker) in which Jared Nelson stars as Gary Ridgway [68]
In print (non-fiction)
- Search for the Green River Killer by Carlton Smith with help from Tom Guillen (March 5, 1991)
- The Riverman: Ted Bundy and I Hunt for the Green River Killer by Robert D. Keppel (November 27, 1995)
- The Green River Killer by the King County Journal Staff (November 23, 2003)
- Chasing the Devil by Sheriff David Reichert (July 28, 2004)
- Green River, Running Red by true-crime author and former police officer Ann Rule (September 27, 2005)
- Serial Killers: Issues Explored Through Green River Murders by Tomas Guillen (January 14, 2006)
- Green River Serial Killer: Biography of an Unsuspecting Wife by Pennie Morehead, telling the story of his third wife and her struggles with the truth (April 1, 2007)
- Case of the Green River Killer by Diane Yancey (April 27, 2007)
- Defending Gary: Unraveling the Mind of the Green River Killer by Mark Prothero with help from Carlton Smith (May 25, 2007)
- Green River Killer: A True Detective Story, a 2011 graphic novel by Jeff Jensen and Jonathan Case. Jensen's father was Tom Jensen, one of the detectives who worked on the case for 20 years.
- The Thirty-Ninth Victim by Arleen Williams, sister of Maureen Sue Feeney (April 6, 2008)
In print (fiction)
- The Green River murders are discussed in the Jodi Picoult novel House Rules.
- The novel River by Roderick Thorp is subtitled "A Novel of the Green River Killings" (ISBN 044990704X).
- Discussed in Stephenie Meyer's third Twilight book, Eclipse, when there are murders in Seattle
In music
- The seminal grunge band Green River was named in reference to the murders. As well, the title track of their 1985 debut EP Come On Down discusses the murders from Ridgway's point of view.[69]
- In 1989, the UK EBM band M.D.M.A (featuring two future members of Utah Saints) released the single "Green River Waves." The lyrics directly reference the murders.[70]
- The 2002 song "Deep Red Bells" by Neko Case was inspired by her own life growing up as a teenager near the metropolis during the time of the murders.[71]
- In 2003, Philadelphia power electronics duo Deathpile released G.R., a concept album about Ridgway and his murders.[72]
In television (fiction)
- In a May 2013 interview,[73] Veena Sud stated her inspiration for The Killing season 3 (2013) came from Streetwise, Mary Ellen Mark's book of photographs about teenaged runaways in Seattle[74] that was made into an eponymous 1984 documentary.[74] One of the street kids Mark documented in that and later books, 21-year-old Roberta Joseph Hayes, fell victim to The Green River Killer (Gary Ridgway). Sud said she was "very fascinated" with Ridgway, the serial killer of numerous women and girls near Seattle and Tacoma, Washington in the 1980s and 1990s.[36]
- Ridgway is mentioned by his nickname, "the Green River Killer", in the fourth episode of the first season of the American comedy show The Last Man on Earth, when Kristen Schaal's character mentions having attended a class from the police sketch artist whose "drawings led to the capture of the Green River Killer."
- Ridgway is repeatedly mentioned in episodes of the American crime drama show Criminal Minds
« CrimeCrowd: Seattle Oct 17-20, 2019 Book Signing CrimeCon


text:
While some economists foresee a slowdown in the overall economy and a flat construction industry in 2019, the precast concrete sector could fare slightly better. There is no single factor that points to a solid year ahead for precasters, but many variables should fall in line to keep the slow-but-steady growth pattern in place for at least one more year. Our annual Precast Forecast predicts a 3% increase in total sales next year, raising the industry's bottom line to $21.2 billion in annual sales of precast concrete, prestressed concrete and reinforced concrete pipe products in North America.
If that forecast holds true, the precast sector should fare slightly better than the overall construction industry, which appears headed for flat or low single-digit growth in 2019, according to several of the leading construction economists, who see a period of slow growth ahead.
"The fundamentals continue to be sound," according to Robert A. Murray, chief economist for Dodge Data and Analytics. Speaking at the 2019 Dodge Construction Outlook Conference last fall, Murray said his data points to a deceleration of the double-digit growth experienced the last several years as the current cycle winds down.
That doesn't mean the construction industry will necessarily be declining in the coming years, Murray noted. "It's a deceleration – a slower rate of growth, but not a decline."
Murray's forecast actually shows a 0% rate of growth for 2019, but that is not a pessimistic outlook, he stressed. After a 10-year period of orderly growth, we are "maintaining the enhanced level that we achieved in 2018," he said.
Ken Simonson, chief economist for Associated General Contractors of America, said contractors are bullish on 2019, based on a recent survey completed by more than 1,300 AGC members. The survey asks contractors to forecast whether they believe the dollar volume of available projects in the coming year will be higher, lower or about the same. When more contractors respond higher than lower, the net is positive. Simonson noted that all of the construction categories in the survey came out as a net positive. More specific to the precast sector, one of the highest levels of confidence came in the water and sewer category, where positive responses outpointed negatives by 14 points.
The outlook appears positive in those sectors that would be of interest to most precasters. Categorized as nonbuilding construction, this sector would include highways and bridges, sewer systems, stormwater conveyance and storage, utilities and other environmental and public works. The Dodge outlook predicts growth in this sector, with total public works rising 4% in 2019.
Ty Gable, NPCA president, agrees that the 10-year run of growth is probably not sustainable, given the normal construction cycle. "We've recovered most of that 40% crash in business felt by most precasters during the Great Recession, but a day of reckoning is coming. Probably not in 2019, but more likely in the last half of 2020 or in 2021. It's just part of the normal cycle," he said. "It doesn't appear to be anything drastic, but more of a decline in the high single digits over a couple years, followed by a return to orderly growth." That could all change, Gable added, but for now, most precasters should be confident that there will be plenty of opportunities ahead.

subset: commoncrawl


text: Saint Paul Convent was built in 1919 for the religious order, the Sisters of the Holy Family. The historic significance of this building includes contributions made by Marie Henriette DeLille (1813-1862), a fourthgeneration free woman of color in New Orleans. Around 1829, inspired by French Sister St. Marthe Fontier of the Dames Hospitalières, Henriette DeLille joined her best friend, Josephine Charles, and Haitian-born Juliette Gaudin, in efforts to evangelize slaves and free people of color in New Orleans. In 1836, before it was legal for a non-white religious order to exist, Henriette and her friends joined the Congregation of the Sisters of the Presentation of the Blessed Virgin Mary, opening the first convent for non-white women in New Orleans. In 1855, they formed the Sisters of the Holy Family. The sisters expanded to Lafayette in 1903, and began teaching classical Catholic education to African-American and Creole children. Classical academic subjects included college preparatory education and music. Before the sisters' intervention, schools for African-American students taught only basic domestic and manual labor education. The religious order also bravely spoke out against the then popular system of plaçage, a contractual extra-marital arrangement between young women of color and wealthy, married, white men. Plaçage was a violation of the women's Catholic faith and the Holy Sacrament of Matrimony.


text:
Audio House 2019 Models Clearance 2 – 7 April 2020
Home owners in Singapore alert, there is the Audio House 2019 Models Clearance sale taking place from 2 – 7 April 2020. Audio House is looking to clear all their 2019 electronic stocks at up to 80% OFF! Electronic items, especially the 2019 models such as TVs, Fridges, washer dryers, sound system, fan, small appliances like blender, robotic vacuum, rice cooker etc are to be cleared at extremely low prices at the sale.
Among the participating brands, there will be Ariston, Daikin, Dyson, Electrolux, Samsung, LG, Sharp, Mitsubishi, Panasonic, Philips, Tecno, Toshiba and more. Expect to find some of the exclusive deals below:
- 50? TV from $580 with additional $100 cashback
- 55? TV from $888 with additional $160 cashback
- Front Load Washer from $780 with additional $140 cashback
- Air Cons from $1390 with additional $260 cashback
All stocks are being sold on first-come-first-served basis.
Audio House 2019 Models Clearance Sale
Date: 2 – 7 April 2020
Time: 1230pm to 9pm
Venue: Audio House Showroom
Address: 72 Bendemeer Rd, Luzerne building Level 1, Singapore 339941


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Las Las Vegas 2020 But just as much as payday advances are appropriate
If you should be a permanent resident of Las vegas, nevada, Nevada, need urgent cash, yet can't delay until the next payday, then an online payday loan is your quickest option. Nevada is one of the liberal states in just about any aspect, and therefore, permits payday and look cashing services. What's more, qualifying for a financial loan let me reveal as simple as ABC, and you will find lots of options.
But just as much as payday advances are appropriate, you can't get picking in any pay day loan as Nevada does not have any limitations as to just how much a lender may charge. That's just why there are a couple of facets we must start thinking about before selecting a short-term loan to sort your cash-flow issue. In this piece, we review all of the features of these kinds of loans Sin City and place together a summary of the most useful cash advance providers. Keep reading.
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Nevada calls for loan that is payday to get legitimate permit, if they run a storefront or online financing solution, depending on chapter 675 of NRS.
Loan providers should never additionally lend you significantly more than 25% of the anticipated gross income that is monthly additionally the term for the loan should never meet or exceed 35 times. Besides, that state additionally forbids expanding your debt for a duration more than 60 days.
The silver state protects borrowers from harassment or any threat of legal action with sky-high interests. You've got the right to negotiate a repayment plan that actually works for your needs in any case you standard from the loan.
But with the laxity of the continuing state laws and regulations, loan providers have actually plenty of freedom. Nevada doesn't have limitations as to just how numerous outstanding loans you can take, and also the loan providers have the freedom to charge the maximum amount of interest while they want. In line with the stats from the Centre for Responsible Lending, cash advance providers charge on average 682% in APR, making the area being among the most costly places to look for same-day credit in the US. In brief, Las vegas, nevada can be a exceptional destination to be described as a lender, but a tremendously tricky anyone to be described as a debtor.
Exactly How Cash Advance Work in Las Vegas, NV
You can find pay day loan stores across Sin City and many online vendors. You are able to elect to walk to a storefront or complete the online business through the application process that is online. Additionally, some enable you to finish every thing throughout the phone, while other people provide most of the three options, and you're able to choose what type most useful suits you.
Just before also want to make an application for an online payday loan, make sure you meet with the after eligibility needs:
You may be 18 years or older. You have to offer your Social Security or Taxpayer Identification quantity Proof of income. Have valid bank account with a debit card that is active. Offer a phone that is active and a message target
Once you fill the form out and submit, the financial institution offers you an agreement form declaring the total amount of the loan, the APR, and outlining most of the relevant costs and re re payment schedules. Your loan demand is born for approval the moment you signal the contract. Nevertheless, the loan can be cancelled by you within a day of application without being accountable for any penalty. But this will take place by the close associated with the next working day.


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By Paula Redmond
Many of the Irish who fled the potato Famine of the 1800s settled along the waterfront in Brooklyn, New York. They chose this area as the many piers and docks offered employment. Many found work in the ship building yards of the local Brooklyn Navy Yard and gas work companies. The area became known as Irishtown.
In the late eighteenth century businessmen and developers Joshua Sands and John Jackson bought lands in the area. Sands manufactured ropes for merchant rigging and Jackson opened a shipbuilding company. In the hope of attracting Irish immigrants to the district, Jackson named his area after the site of the famous 1798 battle at Vinegar Hill in Enniscorthy, Co. Wexford.
Irishtown resembled a commune and it was policed by the various gangs that existed within it. Although similar to the other notorious Irish district in New York, the Five Points, Irishtown was known for having a code of secrecy like no other. It was infamous for its illegal whiskey distilleries and the many wars that were waged to defend them.


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Light brings form and function to everything. Without light, human life would be very different to how it is today.
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5 - 6
FATMAP difficulty grade
Mount St.
Helens is famous as one of the most active volcanoes in the Lower 48, with its 1980 eruption cementing it in the collective national memory.
While this volcano is still very much alive and active, it is actually the only one of the five volcanoes in Washington that doesn't require any technical mountaineering skills to climb it. A hike to the summit of this active volcano is unlike any other peak hike that you're ever likely to undertake! On the flanks of Mount St.
Helens, "you get the opportunity to see recent geologic history firsthand," according to Hannah Singleton on [WildlandTrekking.com](https://www.wildlandtrekking.com/blog/top-five-summit-hikes-in-washington/).
"This dynamic landscape is in flux: the lava dome atop Mount St.
Helens has grown as the years pass" and "a new glacier has since wrapped around the rocky crater rim and continues to advance," she continues.
Since this landscape is ever-changing, it's not a bad idea to plan your hike sooner rather than later! Even though the climb to the rim of the volcanic crater is non-technical, that doesn't make it easy! This hike is steep and arduous, gaining over 4,800 vertical feet in a short 4-mile climb to the rim.
The first two miles wind through the forest on a well-graded trail, but once you break out of the trees, the climb gets much more difficult. "The next 2500 vertical feet is through boulder fields – and not any ordinary boulder fields," according to [WTA.org](https://www.wta.org/go-hiking/hikes/mount-st-helens-monitor-ridge).
"These rocks are dusted with an ash pumice that can shred the skin in a fall," they warn.
"You'd be wise to bring garden gloves for this section!" The final thousand-foot climb to the rim slowly ascends a field of loose, sliding ash and small rocks.
With the soil sliding backward with every step, each foot of upward progress is hard-won! Most sources recommend gaiters to keep dirt out of your boots, and trekking poles for stability and to aid with your upward power. Once on the rim of the crater, soak in the stupendous views as you observe volcanic history in the making.
Steam rises from vents, lava flows nearby, and lava domes expand slowly.
And around it all, you can see the incredible destruction from the infamous 1980 eruption. Remain cautious of snow cornices along the rim, which can crumble without warning.
Once you've had your fill of the views of the cauldron, turn around and return the way you came. Sources: https://www.wildlandtrekking.com/blog/top-five-summit-hikes-in-washington/ https://www.wta.org/go-hiking/hikes/mount-st-helens-monitor-ridge https://www.summitpost.org/monitor-ridge/155892 https://volcanoes.usgs.gov/volcanoes/st_helens/st_helens_hazard_74.html


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Increasingly complex machines, worldwide locations, costs and competitive pressure – these are just a few of the challenges machine builders / operators face. Customer requirements have to be met as quickly as possible, but there is often a lack of time and (qualified) personnel for 24-hour support. The solution: digitalization and remote maintenance. The collaboration between INSYS icom and Bitnamic offers both.
INSYS icom provides the hardware, Bitnamic the software
The company INSYS icom from Regensburg, Bavaria is a digitization expert for industrial data communication. With the help of specially developed hardware, especially industrial routers and gateways, production plants and machines can be easily linked. In this way, systems or other devices can be reached remotely and operating data can be transmitted. Remote maintenance, remote control, status monitoring and networking of data form the cornerstones of INSYS icom and thus connect OT with IT.
As soon as a system has been equipped with a router from INSYS icom and connectivity has been established, Bitnamic comes into play: Our Remote Maintenance software solution – the main component of the bitnamic CONNECT smart service app – allows the service technician on site and an external expert to be connected in the form of a live video transmission, for example, in the event of a problem. The WLAN connection for smartphones, data glasses or other end devices that are compatible with bitnamic CONNECT is enabled by the INSYS icom router.
Advantages of complementary technologies
The combination of the now networked system and remote maintenance access via bitnamic CONNECT offers a multitude of opportunities for machine builders / operators:
- Fast response times and optimization of service calls.
- Real-time data from the machine are made accessible to the user of bitnamic CONNECT via the INSYS icom gateway and thus provide an additional picture of the overall situation.
- The external expert has direct access to the data of the defective system on site.
- Predictive maintenance: When does the machine need service, when does a wear part break? Thanks to predictive remote maintenance, potential incidents can be avoided in advance.
INSYS icom and Bitnamic enable secure, immediate worldwide access to machines, which makes long journeys by experts – and the associated time and high travel costs – obsolete.
The cooperation between INSYS icom and Bitnamic does not only offer the opportunity to save money. To increase efficiency and thus increase sales, it is advisable to integrate remote systems into an (industrial) Internet of Things (IoT / IIot). This allows additional value, for example through data-based process optimization.
Test bitnamic CONNECT without obligation
Digitalization has become indispensable in the mechanical engineering sector; those who want to remain competitive cannot avoid jumping on the Industry 4.0 bandwagon. Bitnamic would be happy to assist you: Experience live the possibilities and additional value for your service, free of charge and without obligation. Simply request your preferred demo appointment.
You can find more information about the INSYS icom solutions on the website: www.insys-icom.com.
If you have any further questions about the topic of system networking and connectivity, as well as operating data acquisition, INSYS icom is at your disposal:
Kristian Haizmann
Business Development Manager


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"Fox & Friends" co-host Brian Kilmeade said Monday he believes that Dr. Anthony Fauci has known from the outset of the COVID-19 pandemic that it was created in a lab in Wuhan, China after the nation's lead immunologist refused to dismiss the possibility over the weekend.
Earlier this month during an event sponsored by the Poynter Institute, Fauci, who is also the Biden administration's chief coronavirus medical adviser, was asked about whether he was confident COVID-19 developed naturally.
"No actually. I am not convinced about that. I think we should continue to investigate what went on in China until we continue to find out to the best of our ability what happened," he said.
Fauci's comments were followed by a Wall Street Journal report on Sunday revealing that the first COVID-19 "cluster" likely occurred months before the virus spread throughout the world.
(Video: Fox News)
The paper reported that "three Wuhan Institute of Virology researchers became sick enough in November 2019 that they sought hospital care," according to a U.S. intelligence report, a finding that "could add to calls for a fuller probe of whether the Covid-19 virus may have escaped from the lab."
To begin the segment, Kilmeade noted that before the pandemic reached U.S. shores, Sen. Tom Cotton (R-Ark.) noted that he was tracking events in Wuhan city, China, where authorities were taking people off the streets and sealing them off in hospitals and their homes in the vicinity of the country's only top-level bio-research laboratory.
Now, hundreds of thousands of deaths later (in the U.S.) and tens of millions of illnesses later, Kilmeade said there were still too few people asking hard questions about the virus' origin, adding that those who did were denigrated and labeled "xenophobic," and dismissed outright.
"No, we're trying to find out why a Communist country poisoned the world, and they won't tell us how it started, and scientists say we can't stop it unless we find out how it started," he noted further.
"So, when you bring up things, up until recently, about the origin of the virus, people said that's conspiracy theories," Kilmeade said, adding that big tech sites including Twitter and Facebook censored and banned anyone who suggested the virus may have come from the Wuhan Institute of Virology.
That, suddenly, is changing, however, as noted by Fauci and as reported by the WSJ, Kilmeade said.
Later in the segment, the co-host was adamant that he believes Fauci has long known, perhaps from the outset of the pandemic, that COVID-19 did not naturally occur and that it was lab-produced.
"If it came from a bat who bit another crazy animal and someone ate it, why is the Wuhan lab — who is doing some very risky research — why are three workers coming down with this virus and why do we have to beg China to tell us the truth?" he asked rhetorically.
Co-host Steve Doocy noted that throughout the pandemic, Fauci has frequently dismissed any notion that the virus escaped from the lab, up until his recent statements.
"Now he's curious," Kilmeade said derisively. "Couldn't he have backed up [former President] Donald Trump when he said that from the podium?"
Co-host Ainsley Earhardt then remarked that Fauci "keeps flip-flopping" regarding the virus, adding: "I don't understand why he is the leading expert on this because everything he says, he changes."
"I think Dr. Fauci knows the whole time there was an excellent chance there was a lab leak," Kilmeade offered. "He just is now realizing 'I can't duck this anymore.'"
"Why would he lie about it then?" Earhardt queried.
"Because he thought it would never come down to it," he said, implying that perhaps Fauci believed the lab leak, if indeed that is what happened, would never be made public.
Please help us! If you are fed up with letting radical big tech execs, phony fact-checkers, tyrannical liberals and a lying mainstream media have unprecedented power over your news please consider making a donation to BPR to help us fight them. Now is the time. Truth has never been more critical!
- Jan. 6 committee chair Benny Thompson offers a stunning take on potential Trump criminal actions - January 2, 2022
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Wings 2(2021)
Modern electric trains replaced the old diesel equipment, and Vityaz was sent to the reserve. But when the city is attacked by aliens who are hunting for energy, the Knight again soars into the sky to save the earth. On new bends he is helped by good old friends and the liner Lightning, with which he again falls in love as a boy.


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It is hard to remember a life before Instagram, but there was one. It
didn't even exist until 2010, but now, eight years and 500 million worldwide
users later, it has become the most popular social media channel, opening
up possibilities and opportunities for people in all walks of life.
Whether you primarily use it as an outlet for personal photos on a social level, for following your favourite celebrities, sports stars or bands, or whether your business uses it as a marketing tool, Instagram has overtaken all the other social media platforms as the most fashionable around. So why is that?
Instagram is perfect for artists, businesses and for brands, because they can connect to their audience and show a human side to themselves. And it is great for regular users because they can connect with friends, they can seek out influencers and take some tips off them and they can maybe use it to start their own business.
Undoubtedly, Instagram is fashionable because it is 'living in the moment', it is live, it is on the go. Wherever you are and whatever you are doing, you can share it worldwide within seconds and people are attracted to that. It is also a pretty simple app with a robust structure, and not too many options to make it confusing and complex when you are just trying to capture the moment.
Of course the major attraction of Instagram is that it is visual and exciting. Scrolling through your timeline is a constant feed of something new and often unexpected. If you mix your timeline with friends and celebrities your feed will be both funny and inspirational and even aspirational. Where else can you scroll from an image of your best friend to Kylie's latest post and check out how they both look? Your feed is a cosy little hub that is unique and only you control.
Young and fresh
Instagram has a younger average demographic compared to Twitter, Facebook and LinkedIn, for example. It is of course more image-led, and has more energy and vivacity than other platforms, which can be more of an outlet for personal thoughts or political messages.
Maximum exposure
Of course you can play around with your security settings, but Instagram offers you maximum public exposure in an instant, which can be a great outlet for your message or images. Other social media platforms have limits and are more text-based, but hashtag well on Instagram and the world's your oyster.
Instagram is not a place for heavy or extended engagement, it is a platform for fun, colour, ideas and inspiration. Brevity is the order of the day and in today's fast-paced, on-the-move environment a short, sharp, strong message is what creates attention, and Instagram is perfect for that.
Check out what's happening
Finally, it is so easy to track trends on Instagram and appreciate what is happening, whether you are looking for fashion, music, dining out, art, culture or interior design. A quick search will open up everything you need as a reflection of what is happening now. This is great for brands or start-up businesses as it acts effectively as cheap market research and gives you instant access to what people in your target market are doing.
How Instagram Became The Fashionable Social Media Channel
It is hard to remember a life before Instagram, but there was one. It
didn't even exist until 2010, but now, eight years and 500 million worldwide
users later, it has become the most popular social media channel, opening
up possibilities and opportunities for people in all walks of life.


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Vol 93, No 4 (2021)
- Year: 2021
- Articles: 27
- URL: https://ter-arkhiv.ru/0040-3660/issue/view/3854
Full Issue
Nuclear medicine and molecular imaging in clinical practice: yesterday, today and tomorrow
Over the past 40 years, nuclear medicine has grown to be the largest non-invasive diagnostic and therapeutic industry in the world, playing a pivotal role in various fields and disciplines of clinical practice and contributing to improved quality of life and patient prognosis. Over the first 20 years of the XXI century, the number of radionuclide procedures in the world has increased significantly, primarily due to innovations in radiopharmaceuticals, continuous improvement of the technical properties of equipment and the expansion of the boundaries of multimodal imaging. The review examines the historical and current trends in the development of nuclear medicine in the world and in Russia, including those related to radionuclide diagnostics, therapy and theranostics.
Original articles
Clinical and angiopulmonographic association in pulmonary embolism
Aim. To detect the effect of the feature of the pulmonary vascular obstruction on the clinical manifestations of pulmonary embolism (PE).
Materials and methods. The 127 patients with PE were included in this study. PE verified with multidetector computed tomography with pulmonary angiography. Among them were 57 patients with high-risk PE, and 39 patients with intermediate-risk PE and 31 patients with low-risk PE. The pulmonary artery obstruction index and the obstruction level were determined.
Results. The mean values of the pulmonary artery obstruction index in high and intermediate risk patients were 42.5%, and in low risk patients – 12.5% (p<0.001). The trunk or main branches obstruction was in 80.7% of high-risk PE patients, the main or lobar branches obstruction – in 92.3% of intermediate-risk patients and lobar or segmental branches obstruction – in 93.5% of low-risk patients. Pulmonary infarction was detected in 89.2% of patients with the segmental branches obstruction and with another level of obstruction – in 28.0% of patients only (p<0.001).
Conclusion. The hemodynamic disorder in pulmonary embolism associate with the pulmonary artery obstruction index of more than 30%. The development of obstructive shock is associated with the pulmonary artery trunk obstruction, and the development of pulmonary infarction associated with the segmental branches obstruction.
Peculiarities of sonoelastographic imaging of thyroid papillary cancer in presence of autoimmune thyroiditis
Aim. To determine the features of visualization of papillar thyroid cancer (PTC) in presence of autoimmune thyroiditis (AIT) according to sonoelastography data.
Materials and methods. 155 patients were examined (75 – PTC, 30 – AIT, 20 – PTC in presence of AIT and 30 – with diffuse parenchymal changes) and 30 patients of the control group. Among patients with PTC 68 (90.7%) were represented by female (mean age 46.7±13.12 years) and 7 (9.3%) – by male (average age – 48.1±4.05 years) patients, PTC in presence of AIT – by 19 female (average age 46.9±16.98 years) and 1 male (22 years) patients. Ultrasound investigation was performed with devices Toshiba Aplio-400 and Toshiba Aplio-500 (Japan) by the standard method and using elastography. A surface transducer with a frequency of 10–14 MHz was used. An analysis of the thyroid ultrasound image was performed in correspondence with TI-RADS. For a qualitative assessment of the elastographic picture of thyroid foci, the Tsukuba–Ueno assessment visual standardized system was implemented.
Results. According to the TI-RADS scale, most nodular formations are assigned to category 4. With TPC with an unchanged thyroid gland, category 4 was determined in 52 patients (69.3%), and with PR in presence of AIT – 15 patients (75%). When determining the qualitative criteria for Tsukuba – Ueno, the majority of tumors were assigned to types 3b and 4: cancers in presence of AIT – 95% and cancers with no changes to thyroid gland – 81.3%. Sonoelastographic criteria for thyroid parenchyma with AIT with a high degree of confidence are significantly higher than in the control group (p<0.000). In a comparative analysis of thyroid sonoelastography in PTC with unchanged parenchyma and AIT, changes according to compression elastography are statistically unreliable. In shear wave elastography, sonoelastographic criteria for PTC are significantly higher in patients with AIT (p<0.02 when measured in kPa, p<0.01 when measured in m/s).
Conclusion. Sonoelastography data can be used as additional criteria in the differential diagnosis of focal thyroid formations.
Cardiovascular magnetic resonance in myocardial infarction with non-obstructive coronary arteries
Aim. To analyze diagnostic performance of cardiovascular magnetic resonance (CMR) in patients, presented with myocardial infarction with nonobstructed coronary arteries (MINOCA).
Materials ant methods. 46 consecutives patients presented with myocardial infarction without evidence of obstructive coronary disease on angiography between January, 1 2018 and October 1, 2019 were included in the study. All patients underwent CMR within 10 days after admission. MRI was performed on 1.5 T Magnetic Resonance Imaging (MRI) using comprehensive protocol (T2-images, Cine-CMR, late gadolinium enhancement (LGE)).
Results. CMR revealed myocardial infarction (MI) pattern in 14 patients (30.4%), myocarditis in 12 (26.1%), hypertrophic cardiomyopathy in 6 (13.1%). In 14 patients (30.4%) no LGE was observed. Notably in 2 patients without LGE features of takotsubo syndrome were noted. Mean age was significantly lower in patients with MI versus patient with non-ischemic causes of MINOCA (56.1±12.3 vs 64.6±12.8; p=0.04). ST elevation at admission frequency didn't differ between MI and non-ischemic patients (35.7% vs 25.0%; p=0.76). However MI patients had significantly increased troponin level, 0.87 [0.22; 1.85] vs 0.22 [0.07; 0.38]; p=0.008. CMR allowed to establish the précised clinical diagnosis in 73.9% of the cases.
Conclusion. Clinical data doesn't allow to differentiate ischemic or non-ischemic causes of MINOCA. However, CMR establish the correct diagnosis in most cases.
Familial left ventricular noncompaction: phenotypes and clinical course. Results of the multicenter registry
Aim. To analyze and demonstrate various phenotypes in patients with familial left ventricular noncompaction (LVNC).
Materials and methods. In 2013 was created a multicenter registry of LVNC patients. On its basis 30 families with a familial LVNC were selected.
Results. 30 LVNC families were selected from the register. From a total of 115 people (probands and relatives) in 71 (61.7%) LVNC was diagnosed (30 probands and 41 relatives with non-compact myocardial criteria). The most common type of remodeling in patients was the dilated type (DT) (n=30), the isolated LVNC with preserved ejection fraction (EF) was slightly less common (n=23), and the hypertrophic type (GT) was detected in 8 patients. 4 patients were diagnosed with the isolated LVNC with a reduced EF. 3 patients were with a combination of non-compact myocardium with congenital heart disease and with a combination of DT and GT (DT+GT). During the analysis of cases a combination of different phenotypes in the same family was observed. The largest number of families was diagnosed with a combination of DT and the isolated LVNC with preserved EF. The development of cardiovascular complications was associated with DT.
Conclusion. Family cases of LVNC had different types of myocardial remodeling and variants of clinical course. In one family a combination of different types of left ventricular remodeling is possible. DT is associated with the most severe clinical manifestations. The clinical picture of the isolated LVNC with preserved EF, is the most favorable, but in rare cases, serious clinical manifestations were observed.
Chromogranin A in diagnosis of pheochromocytoma (comparative analysis)
Aim. To study the prognostic value of determining Chromogranin A blood level in the diagnosis of PHEO.
Materials and methods. We conducted a comparative analytical study of 157 patients with suspected PHEO, statistical analysis of 24-hour urinary metanephrine and normetanephrine excretion test was performed, as well as a blood test for CrA, in groups that included patients without PHEO, with primary tumor or its recurrence, confirmed according to MSCT and/or scintigraphy with MIBG and/or the clonidine suppression test.
Results. The parameters of efficiency of these methods were calculated by groups and it was noted that the lowest sensitivity of the CrA determination method was observed in the group with recurrence of PHEO (43.8%), their exclusion from the entire sample didn't change specificity of the method and it remained at a high level (85.45%), though sensitivity significantly increased up to 87.1%. Sensitivity of determining 24-hour urinary metanephrine excretion also increased significantly up to 96.8%, with 98.2% of specificity. The correlation between diameter of the tumor and its secretory activity was identified: small – with CrA level (rho 0.491) and strong – with total level of methylated catecholamines (rho 0.765). False positive results were more often observed in patients present with other neuroendocrine tumors (37.5%), as well as those taking proton-pump inhibitors (43.75%). The sensitivity and specificity of CrA determining method in the group of patients with methanephrins elevated within "gray zone" appeared to be 50 and 86.1%, respectively.
Conclusion. A blood test for CrA can be recommended as a confirmatory test for diagnosing PHEO in cases of questionable methylated catecholamines indicators or in cases of suspected relapse of PHEO. The use of the test as a first-line method is only possible if there is no possibility to study methylated catecholamines. When interpreting CrA level, it is necessary to take into account the conditions that may cause false-positive results.
Aortic stiffness and content of adipokines in the serum in persons of European and South Asian ethnic
Aim. To evaluate the cardiovascular risk (CVR) based on arterial stiffness and content of adipokines in young-aged persons of different ethnicity (European and South Asian).
Materials and methods. 290 persons of European (Slavic) and South Asian (Korean) ethnicity aged from 19 to 49 years with and without arterial hypertension (AH) were examined. Clinical, anthropometric, laboratory examinations were performed, levels of resistin and adiponectin of blood were assessed. Total CVR was assessed by SCORE scale, patients under the age of 40 years were assessed by relative risk scale. Aortic stiffness was examined by non-invasive arteriography.
Results. Patients of European ethnicity had higher blood pressure (BP), body mass index (BMI), waist circumference (WC), levels of resistin and adiponectin. Pulse wave velocity in the aorta (PWVA) did not differ significantly in ethnic groups. According to the SCORE scale in individuals of the European and South Asian races in general groups and groups with arterial hypertension a moderate absolute risk was determined, in individuals under 40 years of age a moderate relative risk was determined without a significant difference between the groups. However increased levels of PWVA (more than 10 m/s) were registered more often in Korean ethnicity (46.9% compared to Slavic ethnicity, 22.2%). Closer reliable correlations between the level of BP and BMI, WC, PWVA were revealed in Korean ethnicity. Ethnic differences in correlation of adipokines in blood and their dependence on anthropometric and hemodynamic characteristics were described.
Conclusion. The assessment of CVR according to traditional scales does not always accurately represent its real level. New information was obtained on the features of adipokine metabolism and its connections with early manifestations of vascular remodeling in young-aged depending on the race. Taking into account ethnic differences, we recommend in-depth diagnostics of CVR in South Asians. The data can be useful for the design of personalized programs for the diagnostics and assessment of CVR.
Analysis of the effectiveness of multiple myeloma treatment based on the clinical experience of European countries
Aim. The main aim of this study was to model the effectiveness of multiple myeloma (MM) therapy using machine learning, which was based on the analysis of various methods of MM treatment, a number of prognostic factors and their results in the daily routine clinical practice of medical centers in European countries.
Materials and methods. The present study was retrospective, non-interventional, multicenter. A structured database of MM patients provided by the Oncology Information service (O.I.s.) was used for the study. Registration took place in medical institutions in eight countries: Austria, Belgium, Switzerland, Germany, Spain, France, Greece and Great Britain.
Results. In total, 57% of men and 43% of women were analyzed in the base of 6074 patients with MM. The median age was 71 years. The median follow-up time along the lines was 387 days. High-risk cytogenetics are represented in 15% of cases. The efficacy endpoint was the best response to each line of therapy, as measured by time to death (TTD) as an indirect indicator of overall survival and time to next treatment (TTNT) as an indirect indicator of progression-free survival. The median TTD and TTNT were 730 and 399 days respectively. After a multi-step selection process, characteristics with the greatest importance for the therapy prognosis were selected: age at the beginning of therapy, line of therapy, time after MM verification, ECOG (Eastern Cooperative Oncology Group), cytogenetic risk, transplant eligibible or not, TTNT after the previous line of therapy, therapy regimen.
Discussion. To continue the study it is necessary to analyze literature data and compare with real practice. Also analysis and comparison with Russian data on the treatment of patients with MM is required.
Conclusion. The analysis of the presented data provides a basis for modeling a tool for assessing the effectiveness of MM therapy (prognosis of TTD and TTNT) for each patient, based on a number of prognostic factors and the results of routine clinical practice in various medical centers in European countries.
Mobile application "Aterostop" for a comprehensive assessment of cardiovascular risk in patients in the Russian population
The article provides an overview of an innovative software product for a comprehensive assessment of cardiovascular risk in cardiac patients in the Russian Federation. Based on the new recommendations of the Russian National Atherosclerosis Society (2020), the Aterostop application allows to assess cardiovascular risk, determine the patient's achievement of target levels of low-density lipoprotein cholesterol, and also provides recommendations for correcting lipid-lowering therapy. The calculator is implemented as a web browser version, as well as a mobile application for Android and iOS platforms.
Impact of summer heat waves on key parameters of oxidative stress in patients with coronary artery disease
Aim. To assess the impact of summer heat waves on key parameters of oxidative stress in patients with coronary heart disease.
Materials and methods. We included 30 male patients aged 52±13 years with stable angina pectoris of II–III functional class with at least one coronary artery stenosis proved by angiography (ischemic group) in comparison with 10 male patients aged 48±7 years with no angiographic sings of significant coronary stenosis and without angina manifestation (non-ischemic group). The following parameters were studied: activity of superoxide dismutase (Cu,Zn-SOD), catalase (CAT), glutathione peroxidase (GSH-Px), the level of malondialdehyde (MDA) and MDA-modified low-density lipoproteins (MDA-LDL). The analysis of indicators was performed at normal average daily temperature (daytime temperature not higher than 20°С) and after a heat wave (daytime temperature above 27°C for more than 2 consecutive days).
Results. Our study revealed the decrease of CAT and GSH-Px activities with increased activity of Cu,Zn-SOD in both groups after the heat wave. At the same time we observed accumulation of MDA and increased MDA-LDL level in both groups. Initially ischemic patients showed significantly increased level of CAT and GSH-Px activity compared to the non-ischemic group, while it was no difference in activity of Cu,Zn-SOD and MDA and MDA-LDL level. We observed significant reduce of Cu,Zn-SOD activity in ischemic patients compared to non-ischemic group with no significant differences in all other studied parameters of oxidative stress after heat wave.
Conclusion. Changes in the key parameters of oxidative stress in patients with ischemic heart disease during summer heat waves are comparable to those in patients without ischemia, however significantly greater inhibition of GSH-Px activity and significantly lower increase in Cu,Zn-SOD activity was noted. These results may indicate misregulation of free radical processes in patients with ischemic heart decease
Liver and COVID-19: possible mechanisms of damage
The global epidemic of a new coronavirus infection caused by SARS-CoV-2 is a major threat to human health. In the clinical picture, along with acute respiratory distress syndrome, liver lesions are also noted. The following mechanisms are currently being considered: direct damaging effects of SARS-CoV-2, immuno-mediated inflammation, hypoxia, drug exposure, and reactivation of pre-existing liver disease. We studied 150 patients with COVID-pneumonia who are under inpatient treatment at the University Clinical Hospital No. 1 of Sechenov First Moscow State Medical University. Of these, the presence of SARS-CoV-2 RNA was confirmed by polymerase chain reaction in 84 (56.0%) patients. In 55 (36.7%) patients, an increase in serum aminotransferases was registered, mainly alanine aminotransferase max. up to 572 U/L and aspartate aminotransferase up to a max. of 232 U/L. The long-term consequences are unknown and require monitoring of these patients.
The role of a combined probiotic in the treatment of lactase deficiency
Aim. To study the effectiveness of the combined probiotic Bifiform and the enzyme lactase in the treatment of secondary lactase deficiency (SLD).
Materials and methods. We examined 79 patients with SLD, isolated from the group of patients with post-infectious irritable bowel syndrome (IBS) with a predominance of diarrhea. The age of patients reached 27±3.5 years, women predominated by gender – 62%. Diagnosis of SLD was carried out in biopsies of the small intestine mucosa using a color rapid test. To diagnose small intestinal bacterial overgrowth (SIBO) all patients underwent lactulose breath test (LBT) during 2 hours by gas analyzer. All patients with lactase deficiency (LD) were divided into 2 groups: group 1 included 54/79 patients who received the combined probiotic Bifiform (1 capsule per day), group 2 was treated with the enzyme lactase [1 capsule (3450 ME) 3 times a day]. The effectiveness of therapy was evaluated by the dynamics of clinical symptoms, indicators of LBT and the detection of hypolactasia in biopsies of the small intestine mucosa twice, before and 2 weeks after treatment.
Results. In the group of patients with LD, as a result of 14-day therapy with the combined probiotic Bifiform, 85.2% showed positive clinical dynamics, the values of SIBO in the small intestine decreased from 58±14 to 21±9 ppm, p≤0.05, and the activity of the lactase enzyme was completely restored. In 14.8% of patients, LD was preserved against the background of persistent SIBO. In the second group of 25 patients, 84% of patients did not achieve a positive dynamics of the disease as a result of taking the lactase enzyme, and hypolactasia and changes in the lumen microflora of the small intestine were preserved after repeated examination of small intestine biopsies. Recovery of the activity of the lactase enzyme was observed in a small percentage of patients, which was 16%.
Conclusion. In 85.2% of patients, as a result of therapy with the combined probiotic Bifiform, the activity of the lactase enzyme was restored, due to the suppression of bacterial contamination in the lumen of the small intestine. Replacement therapy with the enzyme lactase only led to remission of LN in 14.2%, while in the majority – 85.8% – hypolactasia and SIBO remained. Pathogenetic therapy of LN in the adult population includes the appointment of a combined probiotic Bifiform 1 capsule 3 times a day, a course of at least 14 days. As a symptomatic therapy for LN, replacement therapy with the enzyme lactase can be prescribed.
Experience of the preventive use of the drug Riamilovir in the foci of coronavirus infection (COVID-19)
Aim. The assessment of the effectiveness, safety and tolerance of the drug Riamilovir for emergency drug prevention in the foci of a new coronavirus infection (COVID-19).
Materials and methods. The trial included 113 persons aged 18 years and older who had level 1 contacts with patients with a new coronavirus infection (COVID-19), who had not previously been ill, with negative PCR results for COVID-19.
Results. The high effectiveness, safety and good tolerance of the preventive use of the drug Riamilovir for the period of 20 days of taking a prophylactic dose of 1 capsule (250 mg) per day in the foci of COVID-19 has been established.
Conclusion. The effectiveness and safety of the preventive use of the drug Riamilovir allow to recommend it for emergency drug prophylaxis in contact persons in the foci of a new coronavirus infection (COVID-19).
Features of antihypertensive therapy and real-world prescription of selective imidazoline receptor agonists in Russia vs other countries: STRAIGHT study data analysis
Analysis of routine clinical practice of hypertensive patient management represents one of the important tools in the search for further ways to minimize hypertension-associated cardiovascular and renal adverse outcomes.
Aim. To compare the strategies for hypertension management and features of clinical use of I1-imidazoline receptor (I1-IR) agonists in the Russian Federation and other countries where the STRAIGHT (Selective imidazoline receptor agonists Treatment Recommendation and Action In Global management of HyperTension) study was conducted.
Materials and methods. It was a cross-sectional online study involving physicians of various specializations. The study was conducted from January 18 to July 1, 2019, in seven countries with a high rate of I1-IR agonist prescription, including Russia.
Results. A total of 125 (4.5%) responders filled out the survey in the Russian Federation, which was somewhat lower than in other countries (6.8%). The participants were mostly general practitioners (54.0%) and cardiologists (42.0%), while in other countries greater diversity was seen. Most Russian physicians (83.0%) seemed to rely on national clinical guidelines in their routine practice, while in other countries the US guidelines were more popular (66.0%). The majority of responders stated that they took into account the traditional risk factors of hypertension when initiating the therapy; every second responder noted if sleep apnea was present. Awareness of I1-IR agonists, their prescription rate and their preference were higher in Russia. The main reported benefits of I1-IR agonists were their efficacy, including in resistant hypertension, and their metabolic effects (in Russia). Most participants preferred I1-IR agonists as third-line therapy (65.0% in Russia vs 60.0% in other countries) and in combination with an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blockers (ARB) (55.0% in Russia vs 54.0% in other countries). Compared to responders from other countries, Russian physicians prescribe I1-IR agonists as first-line (15.0% vs 5.0%) and second-line (48.0% vs 21.0%) therapy more often.
Conclusion. Russian physicians were the most aware of I1-IR agonists and tended to prescribe drugs of this class for hypertension management more often, and I1-IR agonist combination with ACEi was preferable compared to physician responders from other countries. Antihypertensive efficacy and metabolic effects were reported as the major benefits of I1-IR agonist therapy.
Peculiarities of Mild Asthma in Russia: the Results of SYGMA2 Study
Aim. Patients with mild asthma may experience severe exacerbations. This analysis was conducted to investigate regional peculiarities of mild asthma population in Russia.
Materials and methods. The SYGMA2 is a double-blind multinational study involving adult patients with mild asthma (n=4176). We conducted an open-label descriptive analysis of the baseline characteristics of the Russian group (n=579) of SYGMA2 trial comparing to SYGMA2 population from other countries. The subanalysis was descriptive only, and no hypothesis were tested.
Results. The Russian population of patients with mild asthma was comparable to the rest of countries in terms of demographic characteristics, smoking status and duration of asthma. The spirometric parameters in the Russian group was slightly worse than in the other population. At the study entry 48% of Russian patients had symptom control on maintenance therapy, but 52% were uncontrolled on short-acting bronchodilators. While in other countries this ratio was inverse (55/45%). More patients with mild asthma in the Russian group had at least one severe exacerbation in the previous year (30.1% vs 20.7% in other countries).
Conclusion. We revealed a delayed prescription of controller therapy and overuse of short-acting bronchodilators in the Russian group of mild asthma patients, that may increase risk of asthma non-control and severe exacerbation.
Efficiency of application of sorbed probiotics in complex therapy of pneumonia caused by SARS-CoV-2. Part 1. Heating clinical displays period
Aim. To determine the clinical efficacy and safety of the sorbed probiotics Bifidobacterium bifidum 1 (5×108 KОЕ) and B. bifidum 1 (5×107 KОЕ) in combination with Lactobacillus plantarum 8P-А3 in the complex therapy of pneumonia caused by SARS-CoV-2 in adult patients without severe risk factors.
Materials and methods. An open, randomized prospective study included 100 patients (45 men, 55 women), aged 18 to 60 years without risk factors for severe COVID-19 with pneumonia confirmed by computed tomography, and an area of lung lesion no more than 75% (moderate forms). SARS-CoV-2 RNA in nasal and oropharyngeal swabs (RT-PCR) was detected in 72% of the participants, in the rest it was highly probable in terms of the aggregate parameters. Diagnostics of COVID-19 and its severity, the appointment of a standard examination and treatment were carried out in accordance with the Temporary Methodological Recommendations of the Ministry of Health of Russia, version 8 of 09.03.2020. This publication presents the results of using B. bifidum 1 (3 capsules twice a day for 10 days) during the peak of clinical manifestations (in a hospital).
Results. In those who received sorbed B. bifidum 1, by the 10th day of treatment, the frequency of weakness was 32% lower (RR 0.55 [95% CI 0.24–0.73], OR 0.25 [0.11–0.59]); hypoosmia/dysgeusia – by 22% (RR 0.42 [0.05–0.65], OR 0.40 [0.17–0.90]) and cough – by 24% (RR 0.39 [0.07–0.60], OR 0.38 [0.17–0.84]). B. bifidum 1 reduced the average duration of weakness by 3 days [1.1–4.9], hypoosmia/dysgeusia by 3.2 days [1.3–5.1], cough by 1.9 days [0.4–3,4], dyspnea – by 1.8 days [0.7–2.7], diarrhea – by 1.7 days [0.1–3.5]; reduced the risk of antibiotic-associated diarrhea by 20% (RR 0.77 [0.24–0.93], OR 0.18 [0.05–0.68]). Due to the deterioration of the condition and the increase in the symptoms of respiratory failure, additional treatment was required less often by 24% (p=0.005). After the end of the intervention, the frequency of virologic debridement, levels of CRP, leukocytes, lymphocytes, platelets and the degree of lung damage on computed tomography did not statistically differ in the compared groups. No side effects of B. bifidum 1 (5×108 KОЕ) have been identified.
Conclusion. The use of sorbed B. bifidum 1 (5×108 KОЕ) improved the well-being of patients without risk factors with moderate viral (SARS-CoV-2) pneumonia and reduced the duration of diarrheal syndrome in a short time. The safety profile of their use was high. More research is needed to clarify the anti-inflammatory effects of the sorbed probiotic.
Clinical notes
Tachicardia-induced cardiomyopathy. Case report
The tachycardia-induced cardiomyopathy is a rare case of reversible heart failure and left ventricle disfunction. The diagnostic approach and treatment strategy are described in this article. Also the clinical case of heart failure compensation in the patient with left ventricle dilatation and atrial flutter after the reverse to sinus rhythm is after catheter ablation presented.
Сardiac myxoma: challenge in diagnostics. Case report
Cardiac myxoma is the most common primary benign cardiac tumor (up to 50% of all primary cardiac neoplasms). The implementation of the modern imaging techniques into the clinical practice, particularly, 2D e–chocardiography, computed tomography and magnetic resonance tomography (MRI) results to the prompt diagnosis of the myxoma. However, the absence of specific clinical features, insufficient awareness of this condition among the physicians along with a rare prevalence, may lead to a misdiagnosis. This case report is notable for the relatively late diagnosis of a giant left atrial myxoma due to a number of circumstances but with successful surgical treatment.
Some features of the diagnostics of thrombophilia. Case report
Differential diagnosis of causes of the pulmonary embolism in patients can be associated with certain difficulties and requires the exclusion of a wide range of diseases. There is a description of a clinical case of pulmonary embolism caused by verified thrombophilia. Features of tactics of management and treatment of the patient according to modern views are given.
The periprocedural myocardial infarction and probability of the developing of the contrast-induced acute kidneys injury in clinical practice. Case report
Nowadays, taking into account the number of elderly patients with sеveral associated diseases requiring percutaneous transluminal balloon coronary angioplasty (PTCA), the risk of the development of unwanted complications is also growing. In this article we present the clinical case, where the PTCA had complications with myocardial infarction of the 4a type without contrast-induced acute kidney injury (contrast-induced nephropathy).
AL-amyloidosis with cardiac involvement. Diagnostic capabilities of non-invasive methods
There are presented the literature data and a description of the clinical course of the disease in isolated/predominant cardiac amyloidosis. Amyloid cardiomyopathy is the most common phenocopy of hypertrophic cardiomyopathy. The modern possibilities of non-invasive diagnostics using osteoscintigraphy for the differential diagnosis between amyloid cardiomyopathy caused by AL- and transthyretin amyloidosis are described in detail.
The role of cardiac magnetic resonance imaging (cardiovascular magnetic resonance) in defining the prognosis of patients with acute ST-segment elevation myocardial infarction. Part 1. Indications and contraindications to cardiovascular magnetic resonance
Recently, the role of cardiac magnetic resonance imaging (cardiovascular magnetic resonance) in the diagnosis of coronary artery disease and acute myocardial infarction has increased significantly. This method is defined as the "gold standard" for differentiation between ischemic vs non-ischemic and acute vs chronic myocardial injury. This part of the review summarizes the main methods of cardiovascular magnetic resonance, its safety, indications and contraindications.
Central hemodynamic monitoring in patients with cardiogenic shock
Cardiogenic shock is the pathology most commonly encountered by intensive care physicians. Its frequency averages 4–10% in STEMI (ST-elevation myocardial infarction) patients and 2–4% in NONSTEMI (non-ST-elevation myocardial infarction) patients. Effective shock therapy is impossible without understanding the hemodynamic mechanisms of its occurrence. Many authors emphasize that cardiac output is the most important indicator of cardiac function, which necessitates its monitoring. Meanwhile, the cardiac output monitoring is associated with a number of difficulties, including those related to the technology of recording this function. In this article, the authors emphasize the importance of measuring central hemodynamic parameters in patients with predominantly cardiogenic shock. We have tried to structure the knowledge about different techniques of central hemodynamics monitoring, considered advantages and disadvantages of each of them. We believe that the data obtained by hemodynamic monitoring should be closely studied and used, because sometimes multidirectional mechanisms may be involved in the genesis of shock; therefore, therapy should be based on the data obtained in a particular patient.
Exocrine pancreas insufficiency: clinical significance and approaches to correction from evidence medicine
Exocrine pancreatic insufficiency (EPI) is a common complication of both benign and malignant diseases of the pancreas, as well as a consequence of radical surgical operations on the pancreas and a whole range of other variable extra-pancreatic causes. In clinical practice in the adult population, most cases of EPI are associated with chronic pancreatitis, while in the pediatric population – with cystic fibrosis. The regression of the production of digestive enzymes in EPI mediates the development of the syndrome of maldigestion and malabsorption, leading to the progressive development of malnutrition, the importance of which is often underestimated by practitioners. At the same time, the development of nutritional deficiency is not just a complication of EPI, but also has an important effect on the course of the underlying causative disease, worsening the prognosis and quality of life of the patient, and is also a proven risk factor for osteoporosis and sarcopenia. To date, compensation for the absolute deficiency of pancreatic enzymes using enzyme replacement therapy is the only possible way to correct the EPI and prevent nutritional deficiency.
Mixed steatohepatitis: more questions than answers (part 2)
In this review, we discussed the epidemiological and pathogenetic aspects of mixed steatohepatitis (SH), developed due to non-alcoholic fatty liver disease, metabolic associated fatty liver disease, drug-induced liver injury. We discussed the mechanisms of the mutually aggravating influence of etiological factors. Drugs can cause steatosis and SH, as well as contribute to the progressive course of existing SH, primarily of metabolic origin. The issues of interaction of pathogenetic factors, peculiarities of diagnostics and perspectives of pathogenetic and symptomatic treatment are considered. Therapy of mixed SH is based on avoidance of hepatotoxic drugs and lifestyle modification, medications with demonstrated efficacy (such as ademetionine) in certain SH might be used.
Extraesophageal signs of gastroesophageal reflux disease: otorhinolaryngologist's view
The data on association between various pathologies of the ENT organs and gastroesophageal reflux disease (GERD) is analysed in the article. The variety of extraesophageal signs of GERD in children and adults is given, what is advisable to inform physicians of different specialties about the possibilities of antireflux therapy. These options are expanded with the emergence of a unique new drug, Alfasoxx. Its bioadhesive formula is based on hyaluronic acid and chondroitin sulphate thereby protecting the esophageal mucosa. Alfasoxx acts on the surface of the esophageal mucosa without penetrating into the systemic bloodstream and it also has a low allergenic potential, which has been confirmed by numerous studies. With its healing and repairing effect on erosive lesions of the esophageal epithelium, Alfasoxx in combination with proton pump inhibitors is more effective in achieving regression of clinical manifestations of the disease and improving patients' quality of life (according to SF-36 questionnaire) compared to proton pump inhibitors monotherapy.
History of medicine
From palpation of the pulse to cuff-free methods: evolution of arterial pressure measurement methods
The arterial pressure is an important physiological indicator. The review describes the different techniques of measurement of arterial pressure, their advantages and limitations. Moreover, it also represents a historical reference about the main stage of the development of clinical sphygmomanometrya that nowadays is a relevant method for measuring arterial pressure. The emergence and the development of devices for daily monitoring of arterial pressure and modern techniques for non-invasive arterial pressure measurement are described too.


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Process of Selecting a Colour Theme For an Effective Graphic Designby Ravi Bhadauria ADMEC Multimedia Institute An effective graphic design does not only consist of the shapes. It is also about selecting the correct colour theme. Diverse colours convey different moods and emotions. So how do you select a colour theme that best suits your graphic design?
Following are some of the few tips which should be keep in mind: -
1. Psychology and representation
There are several colours and each of them symbolise different emotions. But there are some commonly accepted colour association like red colour is used to show danger while green is used to display safety. This is main reason why green is preferred to display nature, youth & money related designs, whereas on the other hand red is used to highlight caution or things that need attention. Dark blue is usually used to signify trustworthiness & safety, while pink & light purple stand for femininity. But dark purple is used to represent luxury. Nevertheless, it will be your creativity and experience which will guide you to choose a colour theme.
2. Know your target audience
Who is going to see your ad will also help you in selection of colour theme. The best thing is you can create two versions of the same design with different colour themes so that you can attract people across geographies & cultures. For example, in the Western countries red symbolizes passion, danger or risk. So, you can to use it for social awareness or love stories related designs. Whereas, in South Asian countries red represents wealth. So, you can use red in your festivities & prosperity designs. Always ask some important questions before starting your designing work like about the demographics (age, gender, cultures, etc.). Subsequently, you don't want to choose a colour theme that can be misinterpreted for some reason.
3. Take help from the given source
At the time of complete loss, take help from the already existing source material. This will consist of a company logo or some other branding material. It will also support you choose a colour theme. For example, in the case of McDonald's, it is always recognised by the big yellow M against the red background. And it is best to follow these colour variations for better brand recall & impact. But that does not mean that everything related to them should be made in red & yellow. Use these colours as the starting point, and explore various options till you find the right colour combination.
4. Stick to three primary colors
At times you may be tempted to use a lot of colours, but it is advisable that colours should be used in moderation. Always try to choose a colour theme that make best impact. The best solution is to have one dominating colour, with one or two other colours to complement it. In case you feel that there is a need of using more colours, make sure that they are used only when required & do not outshine everything else.
5. Use of shades and tints
Apart from choosing the primary colours, if you require any additional colours, then make use of shades and tints. It can be easily attained by adding black (for a shade) or white (for a tint) to the main colour. Using them will make the whole design look as one without making it look boring.
6. Experiment to create unique designs
In many instances, it may be best not to stick to the rules and try something different. Once you have understood the basics, there is no harm in experimenting to create something striking designs. It will lead to invention of new designs. Use those colour combinations that would usually not be used together.
Best Color Scheme Tools
Below are some of the renowned and best software that can be used to experiment & find the best colours schemes.
1. Adobe Kuler
It is one of the best-known colour theme tool available on the internet. Adobe Kuler can generate an entire colour theme from a single base colour. You just have to upload a photo to extract colours from it. It also gives the provision to store or share your colour themes for later use. It comes with a feature of direct integration with the Creative Suite apps and downloadable colour palettes.
2. Colors on the Web
Whether you work for web design (RGB) or for print (CMYK), this tool will fulfil your purpose. The tool provides colour theme outputs based on different mathematical equations, similar to Kuler.
3. ColoRotate
This tool is similar to Kuler in numerous ways, it also provides a 3D visualisation of the colour wheels. It can also generate more than five colours in a single theme. ColoRotate can also be integrated into Creative Suite apps.
4. Toucan
This is one of the most popular online colour theme generators. This tool can create palettes with up to 20 different colours. So, if you often work with multiple colours then this is the tool for you.
While there are many tools available for creating compelling visuals, some parts of graphic design take a little more background knowledge. For instance, picking the right colours, seem easy at first, but when you're staring down a colour wheel, you're going to wish you had some information on what you're looking at.
Whether you are a Graphic designer or a professional photographer, all will be required to understand visual arts which needs an accurate understanding of colour theory. GDI is one of top graphic design institutes in Delhi offers professional courses like Visualization Master, Advertising Design, Graphic Master Plus, Graphic Premium, Graphic Standard etc. which will not make you master some of the best graphic design tools but also help you comprehend the colour dimensions by observing colour relations, and picking and mixing colour. You will learn the meaning of chroma, saturation, hue, lightness, colourfulness and brightness. For a free career counselling session, get in touch with us at 9911-782-350.
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Ceylon Cold Stores, trading as Elephant House, is a Sri Lankan company which produces carbonated drinks, ice cream and processed meat products. Despite competition from global competitors such as Coca-Cola and Pepsi, Elephant Soft Drinks remains the market leader in Sri Lanka.
Elephant House - Ceylon Cold Stores PLC
- Elephant House - Ceylon Cold Stores PLC 148 Vauxhall St, Colombo 2
- 011 231 8798
- www.elephanthouse.lk


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"Angst", 1993, Gouache, Conté & Nupastels on raw canvas, 62" x 31", ©Julie Castillo 2023.
Always inspired by the human figure. This is about the sensual desires we all feel. Touch. It can mean many things to different people. This depiction is meant to be shameless. You will see what you want to see.
Materials used are Nupastels, Gouache and Conté on Raw Canvas. Thank you in advance for viewing.
SKU: Angst/Painting
Archival framiing advised.