text:
Hepatorenal syndrome is the development of renal failure in patients with acute or chronic liver disease.
There are no specific signs and symptoms of hepatorenal syndrome. Initially patients with liver dysfunction present with fatigue, general malaise, anorexia, abdominal distension.
- The onset of renal dysfunction is gradual but in some cases can be acute when precipitated by gastrointestinal bleeding or any type of bacterial infection.
- Spontaneous bacterial peritonitis is most likely to occur in individuals who already have some degree of renal impairment. Antibiotics alone do not help reverse the renal dysfunction.
- Even though some people do develop hepatorenal syndrome after taking diuretics, these agents alone are not the cause of the disorder. Diuretics cause azotemia, especially when fluids are rapidly removed. This disorder can be reversed with cessation of diuretics and fluid replenishing. On the other hand, hepatorenal syndrome usually worsens even after diuretics are discontinued.
Clinical features include the following:
- Oliguria –this may not be seen in all patients, especially during the early phase of the disease. In some patients urine volumes may be higher and then suddenly decrease a few days prior to death.
- Levels of BUN may vary depending on protein intake.
- Progressive increase of serum creatinine.
- Frequently normal urine sediment, but some cases may reveal hematuria due to bladder catheterization and underlying coagulopathy.
- Urine may reveal granular casts due to hyperbilirubinemia.
None or minimal proteinuria (less than 500 mg per day).
- Low rate of excretion of sodium (ie, urine sodium concentration less than 10 meq/L).
As the disorder progresses, patients will note that they do not make much urine. Clinical exam may reveal features of liver and renal disease which may include the following:
- Upper extremity may show palmar erythema, asterixis and clubbing.
- Eyes may reveal scleral icterus and xanthelasma.
- Oral cavity may have fetor hepaticus.
- Chest may show bilateral gynecomastia.
- Abdomen may be distended and have presence of Caput medusae, Paraumbilical hernia, spider veins and bruit.
- Genitals may lack secondary sexual characteristics with small testes.
- Extremities usually are atrophic with peripheral edema.
Entire Body System
- Anemia
Although anemia is a non-rare condition in advanced liver cirrhosis, there is no publication regarding the potential or additive effects of anemia on HRS and renal dysfunction in patients with cirrhosis. [ncbi.nlm.nih.gov]
Other presentations of bleeding included hematochezia, occult blood in stool, and anemia. [onlinejacc.org]
Case report A 72-year-old man presented with relapsing enterorrhagia and progressive anemia. [em-consulte.com]
Abstract Abstract 1403 In 1958, EC Heyde described a syndrome of iron deficiency anemia due to gastrointestinal bleeding (GI) in a patient with calcific aortic stenosis. [bloodjournal.org]
- Fatigue
Snapshot A 55-year-old man is admitted to the hospital due to fatigue, malaise, and weakness in the setting of poorly controlled cirrhosis. [step2.medbullets.com]
We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: May 29, 2019 [patientslikeme.com]
Initially patients with liver dysfunction present with fatigue, general malaise, anorexia, abdominal distension. [symptoma.com]
Signs & Symptoms Individuals with hepatorenal syndrome will have a variety of nonspecific symptoms including fatigue, abdominal pain, and a general feeling of ill health (malaise). [rarediseases.org]
- Weight Gain
On his 4th admission, there was lethargy, tense ascites, decreased urinary output, bilateral edema of the lower extremities and scrotum, serum creatinine of 6.2 mg/dl (reference range: 0.6 - 1.5 mg/dl), and weight gain of 16 kg during the prior 8 wk. [ncbi.nlm.nih.gov]
gain; and • Yellow skin (jaundice). [secure.ssa.gov]
Common symptoms of HRS include: confusion delirium nausea vomiting dementia weight gain jaundice (yellowing of your skin and eyes) decreased urine output dark-colored urine swollen abdomen HRS is always a complication of liver disease. [healthline.com]
gain Yellow skin (jaundice, a symptom of liver disease) Exams and Tests This condition is diagnosed after testing to rule out other causes of kidney failure. [mountsinai.org]
- Malaise
Snapshot A 55-year-old man is admitted to the hospital due to fatigue, malaise, and weakness in the setting of poorly controlled cirrhosis. [step2.medbullets.com]
Initially patients with liver dysfunction present with fatigue, general malaise, anorexia, abdominal distension. [symptoma.com]
Signs & Symptoms Individuals with hepatorenal syndrome will have a variety of nonspecific symptoms including fatigue, abdominal pain, and a general feeling of ill health (malaise). [rarediseases.org]
- Vomiting
In subsequent admissions, he had asterixis, nausea, vomiting, jaundice, and worsening pedal edema. [ncbi.nlm.nih.gov]
Other adverse effects include myocardial ischaemia, necrosis at the injection site, vomiting, diarrhoea and abdominal pain. The effectiveness of terlipressin is not completely clear. Many patients will not respond. [nps.org.au]
[…] may include: • Orthostatic hypotension (a fall in blood pressure occurring when a person sits up or stands up suddenly); • Edema; • Change in mental status; • Muscle spasms/jerks; • Dark-colored urine; • Decreased urine production (oliguria); • Nausea/vomiting [secure.ssa.gov]
Common symptoms of HRS include: confusion delirium nausea vomiting dementia weight gain jaundice (yellowing of your skin and eyes) decreased urine output dark-colored urine swollen abdomen HRS is always a complication of liver disease. [healthline.com]
- Nausea
In subsequent admissions, he had asterixis, nausea, vomiting, jaundice, and worsening pedal edema. [ncbi.nlm.nih.gov]
HRS may include: • Orthostatic hypotension (a fall in blood pressure occurring when a person sits up or stands up suddenly); • Edema; • Change in mental status; • Muscle spasms/jerks; • Dark-colored urine; • Decreased urine production (oliguria); • Nausea [secure.ssa.gov]
Common symptoms of HRS include: confusion delirium nausea vomiting dementia weight gain jaundice (yellowing of your skin and eyes) decreased urine output dark-colored urine swollen abdomen HRS is always a complication of liver disease. [healthline.com]
- Heart Disease
Monitor closely for: ischaemic heart disease, arrhythmias, fluid overload and digital ischaemia. [patient.info]
Valvular heart disease. In: Mann DL, Zipes DP, Libby P, Bonow RO, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 10th ed. Philadelphia, PA: Elsevier Science; 2014:1446-1514. 2. [jamanetwork.com]
Peripheral edema Bruits – A sound that is heard when one uses a stethoscope over the heart. Sometimes, the sound that it emits is confused with a heart murmur. [syndrome.org]
If systolic blood pressure is low and there is no response to volume expansion (less than 110 mmHg or MAP less than 65 mmHg): Consider vasopressor support (use caution if patient has a history of ischemic heart disease or cerebro or peripheral vascular [clinicaladvisor.com]
Liver, Gall & Pancreas
- Jaundice
In almost all cases of acute renal failure associated with cholestatic jaundice, the occurrence of renal failure is preceded by episodes of shock, hypotension, sepsis, or surgical intervention. [ncbi.nlm.nih.gov]
sepsis, infectious hepatitis Etiology Unclear Clinical ↓/absent urine, jaundice, bloating, delirium, confusion, N&V Prognosis Very poor; 1 ⁄ 3 relentlessly deteriorate. [medical-dictionary.thefreedictionary.com]
On physical exam, he is confused, has ascites, palmar erythema, jaundice, and gynecomastia. He is admitted into the intensive care unit to receive intravenous epinephrine and albumin. [step2.medbullets.com]
- Asterixis
In subsequent admissions, he had asterixis, nausea, vomiting, jaundice, and worsening pedal edema. [ncbi.nlm.nih.gov]
Asterixis or also known as liver flap, a tremor observed on the patient's wrist when it is dorsiflexed (extended). Muscle wasting and clubbing of hands Fetor hepaticus – This is known as severe bad breath among patients with hepatorenal syndrome. [syndrome.org]
Clinical exam may reveal features of liver and renal disease which may include the following: Upper extremity may show palmar erythema, asterixis and clubbing. Eyes may reveal scleral icterus and xanthelasma. Oral cavity may have fetor hepaticus. [symptoma.com]
- Ulcer
The patient unfortunately died 2 months later from adult respiratory distress syndrome post emergency surgery for a massive bleed related to a duodenal ulcer. Throughout this episode, the renal function remained stable. [ncbi.nlm.nih.gov]
Upper gastrointestinal endoscopic appearance of hemorrhagic ulcers on Vaters papilla (A), in the second (B), and first (C) partof the duodenum, and in the stomach (D).Figure 2. [docslide.com.br]
Pylori Infection Nausea-Vomiting NSAIDS GI toxicity GI Bleed-non variceal Obscure GI bleed Peptic ulcer Surgery for peptic ulcer Zollinger Ellison syndrome Gastroduodenal-Cancers GIST Gastric Cancer Gastric Polyps Gastric Subepithelial Masses MALToma [gastrotraining.com]
- Muscle Cramp
Patients with type-2 HRS and refractory ascites frequently present muscle cramps. [slideshare.net]
- Muscle Spasm
Muscle spasms can occur in the eyelid or the area around the eye when the eyelid or the surface of the eye is irritated. Adverse reactions to certain drugs, including corticosteroids and estrogen pills, can trigger muscle spasms. [healthline.com]
Physical findings: Symptoms of HRS may include: • Orthostatic hypotension (a fall in blood pressure occurring when a person sits up or stands up suddenly); • Edema; • Change in mental status; • Muscle spasms/jerks; • Dark-colored urine; • Decreased urine [secure.ssa.gov]
- Muscular Atrophy
Spinal muscular atrophy damages the motor nerve cells in the spinal cord, affecting the control of muscle movement. It can cause the tongue to twitch. [healthline.com]
- Kidney Failure
Hepatorenal syndrome (HRS) is a particular and common type of kidney failure that affects patients with liver cirrhosis or, less frequently, with fulminant hepatic failure. [ncbi.nlm.nih.gov]
[…] vasodilation is implicated in the kidney failure. [en.wikipedia.org]
[…] hepatorenal [ hep″ah-to-re´nal ] pertaining to the liver and kidneys. hepatorenal syndrome oliguria and renal failure in a patient with anatomically and morphologically normal kidneys in the presence of liver failure. [medical-dictionary.thefreedictionary.com]
A physical exam does not detect kidney failure directly. [medlineplus.gov]
- Altered Mental Status
Most people who develop HRS have cirrhosis, and may have signs and symptoms of the same, which can include jaundice, altered mental status, evidence of decreased nutrition, and the presence of ascites. [en.wikipedia.org]
- Lethargy
On his 4th admission, there was lethargy, tense ascites, decreased urinary output, bilateral edema of the lower extremities and scrotum, serum creatinine of 6.2 mg/dl (reference range: 0.6 - 1.5 mg/dl), and weight gain of 16 kg during the prior 8 wk. [ncbi.nlm.nih.gov]
The diagnosis of hepatorenal syndrome is made from the history and clinical presentation. There is no specific lab test that can help make the diagnosis but they can support the clinical diagnosis and exclude other disorders.
Diagnostic criteria
- Presence of acute or chronic liver disease with advanced liver failure and portal hypertension.
- Acute kidney injury (elevation in Creatinine of 0.3 mg/dl or more within 48 hours or an increase from baseline by 50% or more within 7 days.
- Absence of any other cause of acute renal dysfunction like shock or use of nephrotoxic drugs.
- Absence of ultrasound evidence of parenchymal kidney disease or obstruction of the urinary system.
- Presence of spontaneous bacterial peritonitis.
- No improvement in renal function after volume expansion with IV albumin for at least 48 hours and discontinuation of diuretics
Urine Analysis Criteria
- Urine sediment should not have more than 50 RBCs per high power field in patients with no foley catheter.
- Urine protein excretion should be less than 500 mg/day.
Other disorders that can present with similar features and need to be ruled out include vasculitic syndromes, glomerulonephritis, hepatitis C, obesity with fatty liver, and diabetic nephropathy.
Other Studies
- Follow BUN and creatinine and determine GFR.
- Complete blood count to assess for leukocytosis and anemia.
- Coagulation profile.
- Serum electrolytes.
- Liver function tests.
- Blood cultures.
- Hepatitis serology profile.
The urinary marker neutrophil gelatinase associated lipocalin is experimental and the levels overlap with other disorders like prerenal azotemia and acute tubular necrosis.
Ultrasound is performed to rule out kidney disease, and Echo to assess right heart filling pressures.
- Diagnostic paracentesis is done to obtain fluid for culture. Large volume paracentesis is not recommended as it may result in volume depletion and worsening of renal function. If large volume paracentesis is done to relieve abdominal discomfort, patients should be started on an IV albumin drip at the same time.
- Bladder catheterization should not be routinely performed as it predisposes patients to infection. One may use a condom catheter if urine output needs to be monitored.
- Central line and Swan-Ganz line insertion are required for hypotensive patients in the ICU. These lines provide information on fluid status. Unfortunately invasive monitoring lines are also prone to infection and there can be complications associated with insertion.
- Hyponatremia
Clinical Significance of Hyponatremia in Cirrhosis Hyponatremia is associated with a significantly higher risk of death with cirrhosis. [gastroenterologyandhepatology.net]
KEYWORDS: Acute kidney injury; Hyponatremia; Liver transplantation; Refractory ascites; Spontaneous bacterial peritonitis; Terlipressin [ncbi.nlm.nih.gov]
Abstract A kidney from each of five patients and both kidneys from a sixth patient dying with the hepatorenal syndrome (severe hepatic failure, oliguria, azotemia, hyponatremia and a urinary sodium of less than 5 mEq per day) were transplanted into seven [doi.org]
- Creatinine Increased
[…] t.i.d. with the goal of increasing the dose to 200 μg subcutaneously t.i.d. if a reduction of serum creatinine was not observed 27. [slideshare.net]
HRS should be diagnosed by demonstrating a significant increase in serum creatinine and excluding other known causes of renal failure. For therapeutic purposes, HRS is usually diagnosed only when serum creatinine increases to >133 μmol/L (1.5mg/dl). [easl.eu]
The prime finding consists of reduced glomerular filtration (creatinine clearance) < 40 mL/min or serum creatinine increase > 135 μmol/L under the exclusion of other causes of renal failure. [dx.doi.org]
- Creatinine Increased
[…] t.i.d. with the goal of increasing the dose to 200 μg subcutaneously t.i.d. if a reduction of serum creatinine was not observed 27. [slideshare.net]
HRS should be diagnosed by demonstrating a significant increase in serum creatinine and excluding other known causes of renal failure. For therapeutic purposes, HRS is usually diagnosed only when serum creatinine increases to >133 μmol/L (1.5mg/dl). [easl.eu]
The prime finding consists of reduced glomerular filtration (creatinine clearance) < 40 mL/min or serum creatinine increase > 135 μmol/L under the exclusion of other causes of renal failure. [dx.doi.org]
The ultimate aim of treatment for hepatorenal syndrome is to improve liver function from whatever is causing the problem [5] [6] [7] [8]. The liver has remarkable ability to recovery from even severe injury if the individual abstains from alcohol or is started on antiviral therapy for hepatitis B. However, the liver improvement is not immediate and can take weeks or months. At the same time, while waiting for the liver to recover, steps should be taken to help reverse the acute kidney injury.
The type of therapy selected depends on the severity of the disorder, availability of certain medications and whether the patient is a candidate for a liver transplant. Many medications have been tried out for the treatment of HRS but most have shown no benefit. Today, drugs which vasoconstrict the splanchnic circulation are used to prevent the activation of endogenous vasoconstrictors like endothelin. Use of vasopressin agonists like terlipressin and ornipressin act predominantly on the splanchnic circulation. The limited studies so far indicate that medical therapy may help short term survival until a liver transplant is available.
Systemic vasoconstrictors
Agents that have shown some promise in the treatment of HRS include analogs of vasopressin like terlipressin ornipressin, alpha-adrenergic agonist like mododrine and somatostatin analog, and octreotide [9]. In most studies, these agents have been combined with albumin to expand the body volume and improve renal blood flow.
Today terlipressin is the most widely used vasopressin analog in combination with albumin. It is important to remember that these drugs do not cure HRS and only improve short term survival from few weeks to a few months. There are just many studies which have not shown any significant benefit from the use of these agents. The universal finding with all these agents is that if the precipitating cause is not reversed like spontaneous bacterial peritonitis, the disease progresses with eventual death.
Other drug therapies
Many other agents have been tried for treatment of hepatorenal syndrome such as N acetyl cysteine, misoprostol and angiotensin converting enzyme inhibitors. To date all these agents are considered experimental and no survival benefit has been shown in any study.
ICU management
Patients in the ICU with hepatorenal syndrome may benefit from norepinephrine and albumin to elevate the blood pressure. Another option is to use IV vasopressin and titrate the blood pressure so that organ perfusion can occur. In the ICU the goal is to raise blood pressure up by 10-15 mmHg.
For stable patients who are not hypotensive the following agents can be used:
- Terlipressin, which can be used in combination with albumin administered intravenously.
- If terlipressin is not available, other options include midodrine (orally), Octreotide (IV), and albumin (IV).
The duration of treatment with terlipressin, norepinephrine or octreotide may be 2 -4 weeks. In patients who respond, the treatment is continued to maintain an adequate blood pressure until the liver injury resolves or a liver transplant is performed. If the patient has no improvement after 2 weeks, further therapy is futile.
Spontaneous bacterial peritonitis (SBP)
These patients should be treated with intravenous albumin combined with IV antibiotics. The two classes of antibiotics widely used include the 3rd generation cephalosporins and fluoroquinolones. If the patients fail to respond to the above medical therapy, then the next step is transjugular intrahepatic portosystemic shunt (TIPS) or hemodialysis. Dialysis is sometimes used as a bridge to liver transplant or in patients whose liver function is reversible and expected to improve [10].
Transjugular intrahepatic portosystemic shunt (TIPS)
TIPS is performed in the radiology suite under local anesthesia. It was once widely used to treat variceal bleeding from portal hypertension. Unfortunately, most patients with hepatorenal syndrome are critically ill and unable to undergo TIPS. In addition, TIPS can also cause complications which include the following:
- Worsening of hepatic encephalopathy
- Deterioration of liver function.
- Bleeding from the puncture site.
- Risk of worsening renal injury due to use of contrast during the procedure.
- Failure to work.
The data on TIPs for hepatorenal syndrome are limited and anecdotal reports reveal mild benefit in some patients. In selected patients, TIPs may offer short term benefit but it is a treatment of last resort.
Patients with hepatorenal syndrome who develop renal failure can be managed with hemodialysis. Dialysis in selected patients can improve short term survival. However, hemodialysis is limited because of severity of liver disease, as well as concurrent respiratory failure. Further dialysis is often difficult to perform in patients who are hemodynamically unstable. Some success has been reported with continuous renal replacement modalities.
Peritoneovenous shunt
In selected patients a peritoneovenous shunt can be used to drain fluid from the abdomen and reinfused it into the jugular or femoral veins. This technique is sometimes used in patients with refractory ascites in patients with portal hypertension. The technique involves placing a shunt in the peritoneal cavity and inserting the other end in the femoral or jugular vein. The fluid return to the systemic circulation can lead to diminished activity of the sodium retaining and vasoconstrictive mechanisms, causes a rise in sodium excretion and also induces mild to moderate elevation in GFR.
However, the technique is fraught with complications and even short term patency of these shunts is difficult to maintain. There is lack of evidence that peritoneovenous shunting improves survival in hepatorenal syndrome.
Complications of the technique include:
- Infection of shunt
- Blockage of shunt
- Variceal bleeding from resulting volume expansion
- Rise in concurrent portal venous pressure
- Small bowel obstruction
- Heart failure
Liver transplant
The best treatment for patients with HRS is liver transplantation, but because of donor shortage this treatment is not available for all patients. The waiting list is very long and the majority of patients die before the surgery. Even after a liver transplant, a significant number of patients continue to require dialysis after the transplant. Once the early post-operative period has passed, long term survival rates are good and approach nearly 60% at 3 years [11].
Once a patient has been diagnosed with HRS, it is important to consult with the following specialists:
- Nephrologists to determine need for dialysis;
- Interventional radiologist to perform the TIPS procedure;
- Critical care physician for management;
- Hematologist to help manage the coagulopathy and DIC;
- Dietitian to assess calorie intake;
- General surgeon for performing a peritoneovenous shunt or insert a dialysis catheter.
A low salt diet is recommended but the protein should not be restricted unless the patient has evidence of severe encephalopathy. In general, there is no restriction in physical activity in these patients. All patients with hepatorenal syndrome must be fully analyzed to determine the precipitating cause. If the renal function does not improve after starting a 3rd generation cephalosporin for treatment of SBP, a diagnostic paracentesis should be performed 24-48 hours later to determine the cause. All patients with Type 2 HRS should be promptly referred to a transplant surgeon to determine their candidacy.
The prognosis of patients with HRS depends on the severity of the disorder. Without treatment, most patients die within a few weeks after the onset of renal failure. If the liver failure cannot be reversed or if the patient fails to respond to medications, then the mortality is high. For type 1 hepatorenal disease, most patients are dead within 2-10 weeks; for type 2 disease, patients may survive a little longer, on average after about 4-6 months.
Even the patients who survive have a poor quality of life as the disorder is progressive and lead to jaundice, severe encephalopathy and coagulopathy. Without a liver transplant, death is inevitable. The recovery of renal function following recovery of liver function is uncertain. Anecdotal reports indicate that some patients, who undergo liver transplant, do recover renal function gradually.
Affected individuals frequently have portal hypertension due to cirrhosis, metastatic cancer or alcoholic hepatitis, but the disorder can occur from any other condition that can cause fulminant liver failure.
The incidence of hepatorenal syndrome is not fully known because of different criteria used to make the diagnosis. Hepatorenal syndrome is a common disorder reported in at least 10% of patients admitted with cirrhosis. In patients with severe liver disease, the probability of developing hepatorenal syndrome is about 10% at 12 months and 40 % at 5 years. Those individuals with hyponatremia and elevated plasma renin activity appear to be at the highest risk.
Individuals of all races can develop ascites or chronic liver disease and are at risk for hepatorenal syndrome. The disorder is equally common in both genders and most often presents after the 4th decade of life.
Overall, hepatorenal syndrome is most likely to occur in individuals with acute or chronic liver dysfunction. It has been observed in severe forms of alcoholic hepatitis and primary biliary cirrhosis.
The pathophysiology of hepatorenal syndrome is based chiefly on the hemodynamic changes that occur in the portal circulation. The liver dysfunction results in portal hypertension which induces marked arterial vasodilatation in the splanchnic circulation. The vasodilatation is the result of increased production of vasodilators like nitric oxide and perhaps prostaglandins. As the liver function declines and becomes more severe, there is a gradual drop in ejection fraction and a severe fall in systemic vascular resistance. The reduced total vascular resistance also results from lowered vascular resistance in the splanchnic circulation, which is somewhat influenced by the levels of nitric oxide and antidiuretic hormone released from the endothelial cells. The renal vasculature develops increased vascular resistance. This may be due to release of endothelin and adenosine.
It is believed that translocation of microorganisms from the intestine into the mesenteric lymph nodes also plays a role in the process. The decline in cardiac output and renal perfusion is associated with progressive decrease in glomerular filtration rate and sodium excretion. The elevated portal pressure also results in production of ascites which can be significant and very resistant to treatment
Since spontaneous bacterial peritonitis can precipitate hepatorenal syndrome, the patient should seek medical help quickly. The infection can be treated with a variety of antibiotics including cephalosporins and fluoroquinolones. Some physicians routinely start patients with hepatorenal syndrome on prophylactic antibiotics irrespective of whether they have had SBP. In patients with early signs of HRS, albumin may be administered to increase systemic volume and improve blood pressure.
Patients who develop ascites after liver failure are at risk for developing HRS. One alternative is to refer these patients promptly for liver transplant. However, with the current shortage of donors, this may not be a practical approach for all patients. This is more applicable for type 2 HRS as they survive long. Patients with type 1 HRS may need dialysis or TIPS.
There are recent studies indicating that the use of pentoxifylline in patients with acute alcoholic hepatitis can reduce the risk of hepatorenal syndrome. However there are no randomized long term studies on this agent.
In patients with acute liver injury, it is vital to treat any bacterial infection promptly to prevent precipitation of HRS.
The hepatorenal syndrome (HRS) is one of the many potential causes of acute renal dysfunction in patients with chronic or acute liver disease.
The hepatorenal syndrome has a complex pathology that results in the synthesis of molecules that leads to a decrease in kidney perfusion which is primarily due to worsening liver injury. The diagnosis of HRS is not rare and often difficult to diagnose, mostly made by excluding other medical disorders. It has a poor prognosis even with treatment.
Type 1 hepatorenal syndrome is the most serious type and presents with at least a twofold increase in serum creatinine within 10-14 days. These patients also have oliguria and tend to have a poor prognosis, irrespective of treatment. Type 2 hepatorenal syndrome has less severe renal impairment but the resulting ascites is often resistant to diuretics. The patients do respond to therapy and may survive 4-6 months [1-4]
Patient Information
All patients who develop acute or chronic liver disease must know that they can develop hepatorenal syndrome. This syndrome usually progresses and leads to renal failure and without treatment it is fatal. The condition can present with low blood pressure and no urine output. Hence, most patients with HRS need hospital admission for treatment. The aim of treatment is to increase the blood pressure and offer the patient liver transplant. Unfortunately not all patients are candidates for liver transplant and medical therapy is not always beneficial. All patients should be very careful before taking any prescription or over the counter medications to avoid causing damage to the kidney. If there is any worsening of the condition like no urine output, extreme itching or distended abdomen, a visit to the healthcare provider is recommended.
- Prabhu MV, Sukanya B, Santosh Pai BH, Reddy S. The hepatorenal syndrome - a review. G Ital Nefrol. 2014 May-Jun;31(3).
- Low G, Alexander GJ, Lomas DJ. Hepatorenal syndrome: aetiology, diagnosis, and treatment. Gastroenterol Res Pract. 2015;2015:207012.
- Rognant N. Acute kidney injury in patients with chronic liver disease. World J Hepatol. 2015 May 8;7(7):993-1000.
- Pandey CK, Karna ST, Singh A, Pandey VK, Tandon M, Saluja V. Hepatorenal syndrome: a decade later. J Assoc Physicians India. 2014 Aug;62(8):696-702.
- Dundar HZ, Yılmazlar T. Management of hepatorenal syndrome. World J Nephrol. 2015 May 6;4(2):277-86.
- Pedersen JS, Bendtsen F, Møller S. Pedersen JS, Bendtsen F, Møller S. Ther Adv Chronic Dis. 2015 May;6(3):124-37.
- Lenz K, Buder R, Kapun L, Voglmayr M. Treatment and management of ascites and hepatorenal syndrome: an update. Therap Adv Gastroenterol. 2015 Mar;8(2):83-100.
- Achim C, Zgură A, Zgură D, Voiculescu M. Current therapies in hepatorenal syndrome. Rom J Intern Med. 2014 Oct-Dec;52(4):201-15.
- Nassar Junior AP, Farias AQ, D' Albuquerque LA, Carrilho FJ, Malbouisson LM. Terlipressin versus norepinephrine in the treatment of hepatorenal syndrome: a systematic review and meta-analysis. PLoS One. 2014 Sep 9;9(9):e107466.
- Siramolpiwat S. Transjugular intrahepatic portosystemic shunts and portal hypertension-related complications. World J Gastroenterol. 2014 Dec 7;20(45):16996-7010.
- Wong F, Leung W, Al Beshir M, Marquez M, Renner EL. Outcomes of patients with cirrhosis and hepatorenal syndrome type 1 treated with liver transplantation. Liver Transpl. 2015 Mar;21(3):300-7.


text:
Human rights defenders have addressed an appeal to Council of Europe Secretary General Thorbjorn Jagland, urging him to give a legal assessment of the proposed amendments to the Constitution of Azerbaijan.
"We are writing to urge your office to initiate the provision of the Venice Commission's opinion on the proposed changes to the Constitution of Azerbaijan as well as on the compatibility of the planned referendum with Council of Europe standards. We believe that some of the proposed amendments are contrary to the Council of Europe's statutory principles (democracy, human rights and the rule of law). Their adoption would further aggravate the democratic deficit in a country where the balance of powers between the organs of government is distorted, and where there is a dominance of power in the hands of the President. In other words, the proposed changes would only foster current undemocratic system in which the imbalance of powers is effectively institutionalised in the person of the present incumbent. The voters must be informed of the effects of the referendum. The present regime's intolerance of criticism, and the continuing restrictions on the media and on freedoms of expression, assembly and association, make it highly unlikely that a balanced assessment of the proposed amendments will be available to the electorate before the referendum. This attempt by Azerbaijani government to hastily ram through changes without consent from Parliament, combined with complete absence of public debate on the issue, suggest that the conduct of the current referendum is contrary to Council of Europe standards. In light of the above, we urge you to request the Venice Commission's opinion as a matter of urgency. We believe that the opinion would be pivotal in protecting the Constitution of Azerbaijan and more broadly human rights and the rule of law in Azerbaijan," the appeal reads.
The appeal has been signed by Head of Legal Education Society Intigam Aliyev, Head of Institute for Reporters' Freedom and Safety Emin Huseynov, Head of Human Rights Club Rasul Jafarov, Head of Election Monitoring Centre Anar Mammadli and Head of Institute for Peace and Democracy Leyla Yunus.
Background: The referendum on amendments to the Constitution in Azerbaijan will be held on September 26. The Draft Referendum Act stipulates establishment of the posts of first vice-president and vice-presidents of Azerbaijan. It also extends the term of office of the president from 5 years to 7 years. Minimum age requirements for the president and parliamentarians are removed. Besides, the president is granted the power to dissolve the parliament.

subset: commoncrawl


text:
If you are a Disney lover, you might have an urge to visit Disney Theme Park and Water Park located in different parts of the world. No matter how many times you visit these parks, you will always fall in love whenever you visit them.
There are a total of 14 Disney Parks out of which 12 are Theme Parks and 2 are Water Parks. It would take at least 13 days to visit all of them. When it comes to how much are Disney World tickets, it depends on what days you choose to visit, whether it is a weekday or weekend. It also depends on the seasons. You can either choose off-season or peak-season to visit these parks.
We are here to give you all the information you might need to know how much each one of the following parks can cost you:
Disneyland Park, Paris
A ticket to one of these parks can cost you more than $63 per person but you can also buy a Park Hopper which will allow you to hop over all of these parks, at $88 per person only.
Walt Disney Studios Park, Paris
If you buy a ticket to Park Hopper, it will cost you $108 per person. For visiting a single park you can buy a ticket for $82 per person.
Disneyland, Hong Kong
You can buy a ticket for $79 or more.
Tokyo Disney Resort
The cost of a one-day tour at this park can cost you from $65-95 per person.
Tokyo DisneySea
For this extremely wonderful place, you need to spend from $65-95 per person for a one-day trip.
Disneyland Resort: Disneyland Park
This is one of the very demanding parks. On a peak-season, it can cost you up to $149 per person.
Shanghai Disneyland Park
For weekdays, it costs $55-56 per person and if you choose to go on a weekend, you need to spend more.
Disney Resort's California Adventure
For a Park Hopper ticket, you would need to spend $199 but the cost can decrease to $149 in off-seasons.
Walt Disney World Resort's Magic Kingdom
One day ticket's price starts from $109 and can increase. For a Park Hopper add an amount of $60 to it.
Walt Disney World Resort's Hollywood Studios
It can cost you up to $109 and $169 for a Park Hopper Pass.
Walt Disney Blizzard Beach and Typhoon Lagoon
This is the favorite place for children. For both of the parks, you would need to spend $69 or $64 per person.
Walt Disney World Resort's Epcot
There is a different cost for 'Hollywood Studios' and 'Animal Kingdom'. On peak-seasons there may come a slight difference in the cost.
Walt Disney World Resort's Animal Kingdom
The cost of this visit is as that of 'Epcot' and 'Animal Kingdom'. Only a slight change can occur.


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There is nothing that rings in the holidays like a moist gingerbread cake. This layered gingerbread cake is heavily spiced and easy to make! It is filled with crumbled chocolate chip cookies with a drizzle of salted caramel. The cake is decorated with a cream cheese icing and gingerbread men. This is a serious cake guaranteed to impress your friends and family for the holidays.
How To Make Gingerbread Cake
Here are the steps to make this layered gingerbread cake.
- Step 1: Sift dry ingredients- First, all of the flour and the spices need to be sifted beforehand to make sure all flour lumps are gone. Use this sifter.
- Step 2: Beat the butter and sugar- To make sure the cake is aerated, the butter and brown sugar need to be beaten until light and fluffy.
- Step 3: Add in the rest of the wet ingredients- Next, add the molasses and the eggs to cake batter. Make sure to add the eggs one at a time, so they get mixed in properly. Then, scrape the bowl
- Step 4: Add in the dry ingredients- Next, add the buttermilk and dry ingredients in 3 intervals. This will help to make sure everything gets mixed in well.
Preventing The Cake Sticking To The Pan
First, start with three 8 inch cake pans. Make sure to spray the pans well with a baking non-stick spray. The kind with flour in it, it is the best! Then, place 8 inch parchment circle on the bottom of the pan. Spray the pans again.
Next, after the cake is done baking, let the cake sit in the pan for 10 minutes. This will allow it to shrink from the sides of the pan. Then, flip it on the cooling rack. It should come right out!
Chocolate Chip Cookie Filling
What makes this cake unique is the chocolate chip cookie crumbles as the filling! I thought, "what goes well with gingerbread?" Chocolate chip Cookies!
This is a regular chocolate chip cookie recipe. It is easy to make!
First, sift the dry ingredients together in a mixing bowl. Next, beat the butter and both sugars together. Then, add in the vanilla and the egg. It should be a wet batter at this point.
Next, add the dry ingredients to the dough. Once it is all combined add in the chocolate chips.
To prevent the cookies from spreading in the oven, chill the dough for 30 minutes.
Then, crumble the cookies with your hands or with a food processor into small crumbs.
Salted Caramel
This cake gets transformed when you drizzle salted caramel over the crumbled chocolate chip cookies. I have tried my homemade salted caramel and store bought salted caramel.
My homemade salted caramel is so much better! It has a ton more flavor and more salt. The store bought salted caramel is bland.
Look at this salted caramel mini cheesecake recipe for the salted caramel.
Gingerbread Men Cookies
These little gingerbread cookies are purely yummy decoration for this cake. They change the whole look of the cake.
The biggest key to making this dough is that it HAS to be chilled for 2 hours before rolling the dough.
When you make the dough, it creates a very wet dough. It is way too wet to roll out.
After you roll out the dough, use a cookie cutter and cut into the dough right away. The dough should still be cold before it goes in the oven. If it has warmed up slightly, place it back in the fridge for 30 minutes.
If it is warmed up slightly, it will spread too much in the oven.
Then, use the cream cheese frosting to decorate these gingerbread men.
Smaller Batch Cream Cheese Frosting
The main recipe for this cream cheese frosting will you give you extra frosting to decorate cookies and decorate extras on the cake.
If you are looking to have a simple frosting on the cake, then, use this recipe.
- 1 ½ cups butter
- 10 oz cream cheese
- 8 ½ cups powdered sugar
- pinch of salt
- 1 teaspoon vanilla
- ¼ cup heavy cream
Assembling The Cake
Here are all of the steps needs to decorate this cake like I did.
- For the 1st layer- Place it bottom side down. For easy transport, tape an 8 inch card board circle on top of a 10 inch card board circle. This will make it easier to transport to the freezer.
- Frost a very light layer over the cake. Then, pipe a double border around the edges of the cake. This will create a border, so the cookies won't escape.
- Then, crumble the cookies over the entire layer. It should be a thick layer and there should no holes.
- Next, drizzle salted caramel over the cookie crumbles
- For the second layer- Repeat the 1st step.
- For the last layer- Place the last layer bottom side up. This creates the flattest surface on top of the cake.
- Apply a crumb coat- This is a light layer of frosting. It is so light, you will be able to see parts of the cake. Then, freeze the cake for 15 minutes to set the frosting, so no crumbs will get in the final layer
- Apply last layer of frosting- Next, frost the cake and top with any frosting decoration. This rope border was made with a 1M Wilton tip.
- Place the cookies on the moist gingerbread cake- Pipe a small bit of frosting on the back of the cookie to get it to stay on the cake.
Storing The Cake
This moist gingerbread cake needs to be stored in the fridge, it will last up to 5 days in the fridge. Place whole cake in a cake carrier or sliced up in an air tight container.
Freezing The Cake
If you want to make the moist gingerbread cake ahead of time, wrap the cake in cling wrap and place it in the freezer. I will make the cake 1-3 days ahead of time before I decorate. It always turns out moist!
Before decorating the cake, pull the cake from the freezer for about 1 hour.
If you would like to freeze the decorated cake, wrap the slices individually with cling wrap and store them in an air tight container.
To thaw the cake, take it out 1 hour before eating.
Other Recipes To Try
Make sure to tag me on Instagram @stephaniesweettreats and leave me a review below if you made this cake. I hope you loved it! To get more ideas follow me on Pinterest.
📖 Recipe
Moist Gingerbread Cake
Gingerbread Cake
- 3 ¼ cup All-purpose flour
- 3 teaspoon Ground ginger
- 1 teaspoon Pumpkin pie spice
- 3 teaspoon Ground cinnamon
- 1 ½ teaspoon Salt
- 1 teaspoon Baking powder
- 1 teaspoon Baking soda
- 1 cup Unsalted butter room temperature
- 1 cup Brown sugar packed light or dark
- ½ cup Molasses unsulfured not blackstrap.
- 3 Large eggs room temperature
- 1 Egg yolk room temperature
- 1 ¼ cup Buttermilk room temperature
Chocolate Chip Cookies
- 1 ¼ cup All-purpose flour
- ½ teaspoon Baking soda
- ½ teaspoon Salt
- ½ cup Unsalted butter room temperature
- ¼ cup White granulated sugar
- ½ cup Brown sugar packed light or dark
- ½ teaspoon Pure vanilla extract
- 1 Large egg room temperature
- 1 cup Semi-sweet chocolate chips
- Salted Caramel see other recipe for instructions to make it
Gingerbread Cookies
- 2 ½ cups All-purpose flour
- ½ teaspoon Baking soda
- ¼ teaspoon Salt
- 3 teaspoon Ground ginger
- 3 teaspoon Ground cinnamon
- 1 teaspoon Pumpkin pie spice
- ⅛ teaspoon Ground nutmeg
- ½ cup Unsalted butter room temperature
- ¾ cup Brown sugar packed light or dark
- ¼ cup White granulated sugar
- ½ cup Molasses unsulfured not blackstrap.
- ½ tablespoon Milk
- 1 teaspoon Pure vanilla extract
- 1 Large egg room temperature
Cream Cheese Frosting
- 2 ¼ cup Unsalted butter slightly cold
- 15 oz Cream cheese room temperature
- 12 ½ cups Powdered sugar sifted
- Pinch of salt
- 2 teaspoon Pure vanilla extract
- 6 tablespoon Heavy cream *this amount of frosting is enough to frost cake, extra decoration, and decorate cookies. See notes for a smaller frosting recipe.
Gingerbread Cake
- Preheat oven to 350°F. Spray three 8 inch cake pans with baking non-stick spray. Line the bottoms with 8 inch parchment circles. Then, spray again. Set aside.
- In a mixing bowl, sift the flour, ginger, pumpkin pie spice, cinnamon, and salt. Set aside.
- Using a mixer, beat the butter and brown sugar. Mix for 1 minute until light and fluffy. Add in molasses. Scrape the bowl. Add in eggs and egg yolk one at a time. Mix on low until combined. Scrape the bowl and make sure it is all mixed together.
- Add in ⅓ of dry ingredients and half of the buttermilk. Mix until starting to combine. Add the next ⅓ of the dry ingredients and the rest of the buttermilk. Mix until just combined. Then, add in the rest of the dry ingredients and mix. Scrape the bowl and beat again on low for 30 seconds.
- Pour batter evenly throughout the three cake pans. Use a kitchen scale to make sure it is even. Bake for 18-22 minutes. The cake is done baking when a toothpick inserted comes out clean.
- Let the cakes sit in the pans for 10 minutes. Then, transfer to a cooling rack. Allow cakes to cool completely. At this point you can wrap and freeze the cakes if making ahead of time.
Chocolate Chip Cookies
- In a large mixing bowl, sift the flour, baking soda, and salt. Set aside.
- Using a mixer, beat the butter and both sugars on medium for 1 minute. The butter will be light and fluffy. Add in the vanilla and mix until combined. Add in egg. Scrape the bowl and mix until just combined.
- Add in the flour a little bit at time. Mix until fully combined. Add in chocolate chips. Chill for 30 minutes.
- Preheat oven to 350°F. Line 2 cookie sheets with baking silicone mats or parchment paper. Use a large ice cream scoop (to make large cookies) and scoop cookie dough. Place 6 cookie dough balls per cookie sheet.
- Bake for 11-14 minutes. The cookies are done baking when the edges are slightly golden brown. Let the cookies sit for 4 minutes before transferring to a cooling rack. Allow cookies cool completely. Store in an air tight container until using.
- Use the other recipe for salted caramel and store at room temperature.
Gingerbread Cookies
- In a large mixing bowl, sift together flour, baking soda, salt, ginger, cinnamon, pumpkin pie spice, and nutmeg. Set aside.
- Use a mixer and beat the butter and both sugars on medium for 1 minute. The butter should be light and fluffy. Add in vanilla, milk, and molasses. Mix until smooth. Scrape the bowl and the egg.
- Add in the dry ingredients a little bit at a time. Mix until fully combined. Cover and place in fridge for 2 hours.
- Preheat oven to 350°F. Line a cookie sheet with a silicone baking mat or parchment paper. Roll the dough on a floured surface. Roll until about ⅓ inch thick. Use cookie cutters to make the gingerbread men. The dough should still be cold. If too warm let it chill in the fridge for 30 minutes before baking.
- Bake for 8-12 minutes until slightly crispy. Cool the cookies on a cooling rack. Store in an air tight container.
Cream Cheese Frosting
- Let the butter sit on the counter for 30 minutes. The butter will be slightly cold. Sift the powdered sugar in a big bowl. Set aside.
- Using a mixer, beat the cream cheese on medium-high for 1 minute. Add in the butter and beat for 1-2 minutes until no butter chunks remain.
- Add in the powdered sugar very slowly. Once combined, add in salt, vanilla, and heavy cream. Mix on low until combined, then mix on high for 4 minutes.
- Chill the frosting for 15 minutes before using. Use a wooden spoon to beat the air bubbles out of the frosting.
- Place 1st layer bottom side down. Spread a small amount of frosting on the cake. Pipe 2 layers of frosting around the edges to create a border.
- Crumble chocolate chip cookies with your hands or in a blender into very small crumbles. Place the cookie crumbles over the frosting. It should a thick and even layer. You shouldn't see any of the frosting underneath. Drizzle salted caramel over the crumble cookies.
- Repeat step 1 and 2 for the second layer. Place last layer bottom side up. Frost the cake in a light layer for a crumb coat. Freeze the cake for 15 minutes.
- Frost the rest of the cake in an even layer. Then, pipe border on top of the cake and drizzle salted caramel on top of the cake.
- Decorate the cookies and freeze for 5 minutes to set the frosting. Dab a small amount of frosting on the back of the cookies and then place on the cake.


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Return to Main Index
Heritage of the Desert by Zane Grey in mp3 audio format.
|Popular author Zane Grey's first western novel , Heritage of the Desert, was published in 1910. It became a bestseller and launched his successful career. The novel tells the story of a young desert rancher's battles with claim jumpers. Download the e-text version here.
Heritage_of _the_Desert_01.mp3 4.9M
Heritage_of _the_Desert_02.mp3 6.4M
Heritage_of _the_Desert_03.mp3 7.3M
Heritage_of _the_Desert_04.mp3 5.2M
Heritage_of _the_Desert_05.mp3 7.4M
Heritage_of _the_Desert_06.mp3 3.3M
Heritage_of _the_Desert_07.mp3 5.8M
Heritage_of _the_Desert_08.mp3 4.8M
Heritage_of _the_Desert_09.mp3 5.2M
Heritage_of _the_Desert_10.mp3 8.8M
Heritage_of _the_Desert_11.mp3 5.0M
Heritage_of _the_Desert_12.mp3 5.3M
Heritage_of _the_Desert_13.mp3 4.2M
Heritage_of _the_Desert_14.mp3 4.7M
Heritage_of _the_Desert_15.mp3 3.1M
Heritage_of _the_Desert_16.mp3 7.6M
Heritage_of _the_Desert_17.mp3 5.9M
Heritage_of _the_Desert_18.mp3 3.7M
Heritage_of _the_Desert_19.mp3 8.4M
Heritage_of _the_Desert_20.mp3 4.0M
Heritage_of _the_Desert_21.mp3 2.1M
Download links for our recommended mp3 and m4b audio player software. iTunes Player Software (m4b and mp3)


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Basics Of 2D Game Development
Designing Online game involves a collection of development steps. The programmers can additional use Java runtime surroundings and libraries to make the sport run seamlessly on numerous mobile devices. There may be an abundance of internet sites that are into video games improvement. It is preferable to go with a sport app which may be in-built much less time and low budget along with the usage of excessive-degree know-how to stay synced with modern avid gamers.
Google additional recommends developers to write new Android purposes and video games in Java. Games improvement is completed on a story board, which is step one of a games creation. Revenue technology in Android apps is principally as a result of in app purchases, cost per set up, ads, and by providing a paid model of the apps with more features.
CocosSD is great for creating your first iPhone games. The developers can additional avail numerous instruments to build SECOND and 3D cell games in Java rapidly. This platform is known for generating awesome 3D assets for games. Engine improvement: Building the core Engine.
Many sport manufacturing firms are embracing this gaming pattern to make new on-line games for the avid customers. Has developed …Continue Reading


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With the TOPCAJ2WN, instead of simultaneously offering a seat and a playing surface, the Turbo Slap-Top Cajon is placed onto your lap. This has a number if advantages:
You sit more comfortably, which is particularly advantageous for long playing sessions while the sound projection can be targeted with more accuracy for audiences i.e. forward. Plus the vertical orientation ensures the play feeling is improved due to the fact that the playing surface is easier to reach.
The playing surface of the Turbo Slap-Top Cajon consist of Walnut wood while the body is made from environmentally friendly fibreboard. A combination, that promises beautiful highs and warm, deep tones.
The typical snare effect of the Turbo Slap-Top Cajon is delivered by the snares attached to both sides of the T-piece. Two holes at the same height ensure for perfect sound development.
The main features of the TOPCAJ2WN include:
Needed an instrument for acoustic blues n folk gigs but not a fan of sit-on cajons.
This item is perfect and goes great with the Meinl Bassbox that I have.
Fantastic price and service from DV247


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In this tutorial by Wpalgoridm from Design School show how to apply page scroll effects and animations using Dynamic Content for Elementor
Made with in Venice – Italy
Copyright © 2023 Ovation S.r.l.Registered Office: Via Bernardo Quaranta 45 – 20139 Milan – ItalyOperating Office: Via Don Tosatto 127 – 30174 Venice – ItalyVAT ID IT04331280273 – R.E.A. MI 2661115Share capital euro 10.000 full paid
DYNAMIC·OOO is a registered trademark of Ovation S.r.l.Usage without permission is prohibited.
Dynamic.ooo is an independent product.It does not represent Elementor.com


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Jaypro Sports Bleacher - 27' (5 Row - Single Foot Plank with Guard Rail) - Enclosed - Powder Coated |n BLCH-527GRPC
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Original price $0.00 - Original price $0.00
Original price $0.00
$13,044.00 - $13,044.00
Current price $13,044.00
No Additional Fee's Added At Checkout and NO SALES TAX. The price you see is the price you pay. We have private relationships with all of our manufacturers which allows us bottom line pricing backed by our 100% Best Price Guarantee. If you find it somewhere else for cheaper. We will match the price. No Questions Asked.
Heavy-duty enclosed bleacher. Vertical guard rail on side and back encloses the bleachers for safety. Dual braces and rear stabilizing bar added for increased strength.
- 5 row configuration
- 27' long benches
- 80 seat capacity
- 10" wide aluminum non-skid seat planks
- Galvanized steel under structure
Sold as 1 Each
- Risers and double foot planks added to bleachers over 30" high for code and safety regulations.
Specify plank color when ordering:
Available in: Red, Navy Blue, Yellow, Gold, Gray, Black, Maroon, Dark Green, Kelly Green, Royal Blue, White, Orange, Purple
3 – Year Limited Warranty


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Huawei Silkroad Electronic Technology Co., Ltd.
- Sales manager:Mr. Liu
- Mobile/WhatsApp:+86 15931673319
- Address: Building 21, Junding Science Park, Shanyin Village, Luquan District, Shijiazhuang City, Hebei Province
author: click::419 Publication time:2022-08-08
Integrated Product Development (IPD) is a set of models, concepts and methods of product development. IPD product development process is clearly divided into six stages: concept, planning, development, verification, release and life cycle, and there are clearly defined decision review points in the process. The reviews at these review points are no longer technical reviews, but business reviews, paying more attention to the market positioning and profitability of products. The evaluation points have consistent measurement standards, and only after the specified work has been completed can one decision point enter the next decision point. The following is a typical product development process: IPD Core Project Management System Framework A) At the beginning of the conceptual stage, once IPMT thinks the ideas of new products, new services and new markets are valuable, they will form and appoint PDT members. IPD conceptual stage flow chart
b) PDT understands the future market, collects information and makes business plans. The business plan mainly includes market analysis, product overview, competitive analysis, production and supply plan, market plan, customer service support plan, project schedule and resource plan, risk assessment and risk management, financial overview and other information, all of which should be considered and determined from the perspective of business to ensure that the enterprise can finally make a profit.


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COMMENTARY: Minnesota Vikings are exactly who we thought they were
November 28, 2016
I'm very sad.
Back on Sept. 29, I published this article on why I believed the Minnesota Vikings, my favorite National Football League (NFL) team, were truly back.
Now that they've lost five of the past six games, I'm really starting to doubt myself.
It all began after a convincing 31-13 victory over the Houston Texans in Minnesota on Oct. 9, 2016. The victory moved the Vikings to 5-0, filling fans with a huge sense of hope and giving me that "I told you so" feeling.
The Vikings defense hadn't allowed an opponent to score over 20 points since Week 14 of the 2015 season, until they lost their first game this season 21-10 to the Eagles the week after the Texans game.
Since the Eagles game, the Vikings have allowed at least 20 points every single week. They followed the Philadelphia loss with an embarrassing Monday Night Football loss to the Chicago Bears 20-10, after which came 22-16 and 26-20 losses to the Detroit Lions and Washington Redskins, respectively.
That's four losses in a row. I only cried a little.
An enormous factor in those games was the play of the offensive line. Quarterback Sam Bradford was sacked 16 times in the four-game stretch, per ESPN Stats.
It also didn't help that the team's starting right and left tackle wound up on injured reserve and the starting right guard was out for three of the four games.
In Week 11, the Vikings got back in the win column with a nail-biting 30-24 victory over the disappointingly average Arizona Cardinals.
In the victory, the offense looked average at best. It was the defense that won the game.
Cornerback Xavier Rhodes intercepted a pass, one of two picks for him in the game, and returned it 100 yards for a touchdown and Cordarrelle Patterson returned a Cardinals kickoff 104 yards for a score.
The Vikings defense racked up four sacks as well.
Then, on Thanksgiving, the Vikings faced off against the Lions in Detroit and fell 16-13.
The defense again played well, but the offense killed any chance of winning as Sam Bradford threw a late interception to set up the Lions' game-winning field goal.
After winning their first five games, the Vikings have now lost five of the past six. Injuries to the offensive line, including the loss of their starting center on Thursday, and the injuries at quarterback and running back finally caught up to them. They're back to where everyone expected them to be: mediocrity.
I'm not mad. I'm just disappointed.
Contact the writer: [email protected]


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CoastLine: Chef Dean Neff On Seafood In The Cape Fear Region
Halibut and yellowtail flounder fish populations are at all-time lows in the Atlantic. That's according to Seafood Watch of the Monterey Bay Aquarium. Cod, once prolific in the North Atlantic, is struggling. Closer to home, catfish from the Cape Fear River and blue crab and mullet from the Brunswick River have high enough levels of mercury that officials recommend avoiding them.
Some guides point consumers to wild-caught fish – with advisories about the cleanliness of farmed seafood. But some species of wild-caught fish are so over-fished, that it can be hard to know how to do the right thing – for your body and the planet.
On this edition, we explore how to find good-quality, lower-mercury fish, easy ways to cook it in a healthier way, and how some of the changes to aquaculture are affecting the fish market – and why farmed seafood could actually be healthier.
Dean Neffis here with A Place At The Table to help us sort this out today. He's former Chef and Co-owner of PinPoint Restaurant in Wilmington. He was also a James Beard Semifinalist for Best Chef in the Southeast in 2019. And he teaches cooking at The Seasoned Gourmetwhile planning some pop-up meals at Love, Lydia – his partner's bakery – also in Wilmington.
Fish Smart Celebration: Sunday, May 26, 2019, 1-5 PM, Northern Regional Park, Castle Hayne
Free, fresh fish meals offered by Chef Keith Rhodes and the Catch Restaurant food truck ~ Cooking demonstration by Chef Dean Neff of Pinpoint Restaurant using healthier, sustainable fish ~ Vendors ~ Music ~ Health information and giveaways ~ Reporting back the results of the study and education campaign….
This event is sponsored by a collaboration between New Hanover County NAACP, Cape Fear River Watch, New Hanover County Health Department, Duke University Environmental Law and Policy Clinic, Wake Forest School of Medicine, Duke University Superfund Research Center, and local organizations.


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#VegRunChat Founder Brandon Frye
Written by Matt Frazier
One of the best things to come from Twitter is Twitter chats, and if you're a plant-based runner and Twitter user, #vegrunchat is probably one of your favorites.
In this episode we welcome #vegrunchat founder Brandon Frye to get to know the man behind the popular chat (Sunday nights at 9pm ET), as well as talk about the factors we believe have made our projects in the plant-based running niche successful.
Here's what we talk about in this episode:
- Brandon's journey from overweight to a plant-based runner
- How #VegRunChat got started
- The mission behind the chats
- Building a successful online project
Click the button below to listen now:
- Click here to download the MP3 file (you may need to right-click and "save link as")
- Subscribe to the show on iTunes
If you're a fan of NMA Radio (and like all these new episodes we're making!), we'd greatly appreciate it if you'd leave us a rating and review on iTunes. Thank you!
Links from the show:
- #VegRunChat (website)
- Forks to Feet (Brandon's Website)


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Thu, Feb. 3rd, 20224:00 ~ 5:00 PM PST Winter Quarter, 2022
Click below button to join the Microsoft Teams for Community Building Event Day. The meeting will be in the main channel.
All prospective, current, and future students who takes MSCS courses are welcomed to join!
After the main event, everyone is welcomed to stay for the Happy Hour/Networking Breakout Session.
The Team


text: I have to be truthful -- I'm not always super-precise as a crafter. I don't typically find that spending an extra 30 minutes to affect a change of .001% is worth it. If I'm moving my images around on the Design area in the Silhouette Studio software, … [Read more...]


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No 47
Lukoil And Statoil Sign MOU On Caspian Cooperation
Russias Lukoil and Norways Statoil signed a memorandum of understanding (MOU) on future cooperation in the Russian section of the Caspian Sea during a visit to Oslo on 12 November by Russian President Vladimir Putin. The MOU mentions in particular the Yalama-Samur structure, which is thought to be an extension into the Russian sector of Azerbaijans offshore Yalama (D-222) oilfield, where Lukoil is operator...
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You may purchase access to entire MEES digital archives by subscribing. This subscription gives you access to all the content of MEES digital archives up to 1978!


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DC Comics Presents #26 Bronze Age DC Comic Book
Not a professional grader, see photos and notes below for condition. Book is complete and unrestored. All books mailed securely in comic book mailer. Individual comic issues all bagged and boarded.The item "DC Comics Presents #26 Bronze Age DC Comic Book" is in sale since Sunday, August 8, 2021. This item is in the category "Collectibles\Comic Books & Memorabilia\Comics\Comics & Graphic Novels". The seller is "monstercomicshop" and is located in Columbia, Maryland. This item can be shipped to United States, Canada, United Kingdom, Denmark, Romania, Slovakia, Bulgaria, Czech republic, Finland, Hungary, Latvia, Lithuania, Malta, Estonia, Greece, Portugal, Cyprus, Slovenia, Sweden, Belgium, France, Ireland, Netherlands, Poland, Spain, Italy, Germany, Austria, Mexico, Switzerland, Norway, Ukraine, Croatia, Bermuda, Guernsey, Gibraltar, Iceland, Jersey, Liechtenstein, Luxembourg, Monaco.
- Superhero Team: Avengers
- Character: Batman
- Issue Number: 26
- Series: DC Comics Presents
- Type: Comic Book
- Artist/Writer: Louise Simonson
- Universe: Conan The Barbarian
- Publication Year: 1963
- Publisher: Marvel Comics
- Tradition: US Comics
- Genre: Action
- Cover Artist: J.


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Accepting credit cards, warehouses, and shipping and fulfilling orders
Driving me crazy! Shopify say that my store is set up correctly and Paypal say that I've set up correctly on their side. I had my first sale last week Wednesday that just wont go through and no one can tell me why. I'm convinced that there's a set up somewhere that's not complete. The transaction amount is there, pending, but nothing on the paypal side - almost as if the two arent talking to one another. Any help?
Hi there
No error showing. Just that it shows as pending on shopify and when I log in to Paypal there's no activity on the account
ok I got it.
Contact to Shopify Support System.
Believe it or not, I got hold of the Shopify "experts" and they told me to contact my developer and lodge a query. I dont have a developer for my site and no one comes back to me. I think I'll look for a telephone number to call again...
Hi, @Mandy000!
Sorry to hear you've been having some troubles receiving your first PayPal payment. Happy to help troubleshoot this with you.
From your Shopify admin, Under Settings > Payments, what do you see in the PayPal Express Checkout section? Is there a button asking you to complete your setup?
If everything appears setup, please confirm that the email address that is listed for PayPal Express Checkout is the correct email address.
If this is the correct email address, is this the same email address you used to sign up for Shopify? If you have changed the address, the payment will likely have been sent to the original address.
Next, please confirm the PayPal is a business account. This is a common issue. Once that is confirmed, please check the email inbox associated with this email address and see if you have a confirmation email waiting from PayPal. This may be required to finalize the setup and start accepting payments.
Lastly, did you receive the order before or after completing the account setup? If you received it before completing the setup, it can take another order using PayPal to come through to trigger that the setup has been complete. I'll also share our FAQ page on common issues with setting up PayPal.
As you mentioned looking for a phone number, here is the link to contact our Support team directly for live assistance via chat or callback request. Please log in to your account to create a support request if you prefer this option.
Otherwise, I look forward to hearing back from you on this so we can continue to troubleshoot together here.
To learn more visit the Shopify Help Center or the Community Blog.
I'm having the exact same issue. I went to test the PayPal button and it just keeps trying to load the pop up page. Then when I instead used the CHECKOUT button, the payment went through, but no orders were logged at all. There's a disconnect between Shopify and PayPal even though everything is set up right.
What settings in PayPal's WEBSITE PREFERENCES do we have to set up? Do we have to set up the "Auto return for website payments" and "Payment data transfer" and "Encrypted website payments" options in PayPal?
Explore the 30-30-30 rule, a dynamic social media strategy for new businesses. Learn how t...By Trevor Sep 20, 2023
Discover how to leverage the often overlooked footer of your ecommerce site to gain custom...By Skye Sep 15, 2023
In this blog, we'll be shining a light on Shopify Partners, Experts, and Affiliates. Who a...By Imogen Sep 13, 2023


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Ski Doo XP/XM/XS Rear Chromalloy Aluminum Bumpers available from short tracks up to the 174" Summits.
- Lightweight Aluminum- Black Powder Coated
- Super Strong
- Baja Styling
- Easy Installation
- 1"x1" Square Tube
- Stronger than OEM
- Protects your Machine
Made in the U.S.A.
Payment & Security
Your payment information is processed securely. We do not store credit card details nor have access to your credit card information.


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Getting around San Francisco is relatively easy regardless of whether residents choose to drive themselves or take advantage of the city's public transportation.
The city is small in size, so many of the places that people want to visit are within walking distance. It's best to keep in mind, though, that San Francisco is a city of hills, some of which are steep. This is worth paying attention to as new arrivals begin to orientate themselves.
People who enjoy walking are likely to find it easy to walk through most areas of the city but may opt to take public transportation in the areas where the hills are at their steepest.
Many expats living in San Francisco do own cars, but it's possible to get by without one.
Public transport in San Francisco
There are many public transport options in the city. Most residents use buses and trains for getting around San Francisco on a day-to-day basis, but making use of the city's famous cable cars and ferrying across the Bay make for a nice change when enjoying a leisurely day out in the city.
The Bay Area Rapid Transit, or the BART, is the rail system that moves through the city. With six lines and nearly 50 stations, it's a quick and easy way to travel.
The BART trains arrive every 15 minutes on weekdays and every 20 minutes at night and on weekends. Service begins at around 5am on weekdays, while service starts slightly later on weekends. Train service ends at around midnight every day.
Bus services are run by Muni. Services are fairly frequent during the day when buses stop at six- to 20-minute intervals, depending on the particular route and time of day. Owl services run from 1am to 5am and arrive every half hour. It generally only takes one or two buses (with minimal walking) to reach most destinations from anywhere in the city.
Taxis in San Francisco
Taxis in San Francisco are reasonably priced, especially since travel distances around the city tend to be short. Frequent use of taxis does add up in cost but they are a great way to get around quickly and efficiently.
It is safe and easy to wave a cab down on the street, or they can be called in advance. Taxis are available at all hours of the day and night.
Ride-hailing services such as Uber and Lyft are also available in San Francisco.
Driving in San Francisco
Getting around San Francisco in a car is fairly simple, although expats living in the urban city centre will certainly encounter some traffic problems.
One of the things to get used to when driving around San Francisco is the many one-way streets in the city. There are many areas of the city where drivers cannot make left turns off of major streets so they have to make a series of right turns instead. This can be frustrating.
The major problem for most people who own cars in San Francisco isn't driving but rather parking. Parking lots in the city are expensive. Most areas allow street parking for free but only for two hours at a time. Expats will find that their best bet may be to purchase a parking permit for the area in which they live.


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Environment Agency: Reducing Flood Risk in Abingdon
The Environment Agency is working with the Vale of White Horse District Council to develop potential schemes to reduce flood risk in Abingdon.
There are 2 schemes currently being considered: a small flood defense wall at St Helen's Mill and a larger scheme on the River Ock, EA said.
The project team have completed surveys of areas immediately adjacent to the works at St Helen's Mill to better understand the condition of existing foundations. The contractor, AMCO, started construction of the flood wall in May 2017, which will take up to 6 weeks to build.
"During construction vehicle access will be restricted and the car park will be shut, however, pedestrian access to footpaths will be maintained. The scheme will reduce risk to 5 ground floor properties that frequently flood and will not increase flood risk to any properties on the opposite bank," EA said in its release.
The Environment Agency is investigating several options for the River Ock flood scheme and has completed baseline modelling of the River Thames and the River Ock.
The team is using this model to assess all the possible options for reducing flood risk in Abingdon, including flood storage, modification of structures, temporary or permanent defenses and natural flood management.
[mappress mapid="24209″]


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Read the CESBC AGM 2020 (2020 Council) - President's Report
2020 CESBC AGM Election News
Our Chapter AGM was held on November 20, 2020 using Zoom Platform. Only the position of Secretary was up for re-election. In accordance with the structure and procedures laid out in our Chapter Bylaws, Michelle Naimi chaired our AGM election which produced the following results:
Appointed positions:


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Our Christmas cushion covers have arrived! Decorate your bedroom, apartment, or any room with our Christmas cushion covers! This cushion cover has arrived to boost your Christmas spirit!
- 45 x 45 cm (18 x 18 inches)
- Square
- Santa and Christmas tree on green background
- Tapestry style embroidery (Gobelin)
- Plain burgandy backing
- Cover only, filler not included
- 65% Polyester, 35% Cotton
- Made in China


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learn to connect
get up to date on the latest articles, videos, and more
Learn More About Connect St. Helens
Connect SH is a coalition of people and organizations who believe and act together as if when we all belong, our citizens and our community will thrive. This means we strive to connect relationally and care for each other purposefully. Find out how you can share the time, energy, and resources you have in a way that increases well-being for you and your community.
dedicated to making a difference in every community
the future of connectsh
and our mission
As we move into 2021, we understand there is a bigger need than ever for connection, inter-personal relationships, and support systems for those in our society who need it most.
Our mission moving forward is to honor our initial promise of creating a connection coalition in St. Helens, while also focusing on the following:
photo credit to heidi timmons photography
get involved, make intentional relationships, discover new connections
what's happening in st. helens now?
Interested in being a part of our mission? We have something for everyone to enjoy as we all give back to the community we love. Here are just a few of our initiatives you can join – just give us a call or send us a message!
photo credit to heidi timmons photography
everyone has a superpower that's unique to them
where do you fit?
Fitting in isn't just a middle school problem, fitting in is an essential to life. If you are here, if you are breathing, You fit in because you are you, and the world needs you!
ConnectSH helps you take the next step by helping you identify your own superpower and how to share your glory with the community. We're also working on the ConnectSH app, which will offer online questionnaires, event listings, directories, resources, & much more.


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A black and white world doesn't exist. If I were to tell you, "There's absolutely no downside to starting your own business", I would be be wrong. Rather, starting your own enterprise involves entering a world of complexity you've only glimpsed from the outskirts.
The good news: about one-third of new businesses survive 10 years or longer, while about half survive five years or longer. If you're really in this for the long-term and are ready to go all out, you stand a good chance of sticking around. If you're not, you stand a good chance of being among the two-thirds who fail.
- There's a lot of assistance available: Simply Google "How to start a business" and there's a wealth of information. The Small Business Association offers a ton of resources, and you can attend conferences, or other meetups; for an example of the type of info available, check out my article about saving money on internet marketing.
- There are a ton of options: For one, the possibility of e-commerce opens up a world in which all you need is a product and a website. If you don't have your own product, there are organizations like Amway that supply products for you to sell. The Amway model is called "Direct Selling", it typically provides a supplemental option for aspiring entrepreneurs. Three million people worldwide are Amway "Independent Business Owners", and the direct selling model—in general, not just Amway's—brought in $36.12 billion in 2015.
- You can do what you want: What you do with your business is only limited by your own ambition. If you want to keep it small, keep it small. If you want to go big, do your best to appeal to a wider and wider audience.
- You can offer true personalization: You are the shop-next-door, the equivalent of today's mom-and-pop operation, the underdog, the face of what has made America great from the get-go. You can get to know your customers face-to-face, learn their names, what they like, what their friends like, and, ultimately, what your target audience wants and needs.
- You can end your job search: Young adults ages 20-28 change careers an average of seven times before arriving where they want to be; start a business doing something you really want to do, and stop the vicious cycle of looking for a new job and being dissatisfied with what you find.
- There's a lot of responsibility: Some people thrive on responsibility and love it, while for others the level of responsibility involved in starting a business is just too much. Before starting a business, evaluate what type of person you are and ask yourself if you're willing to invest your entire life in it.
- There's a ton of competition: On one hand, the many advanced, ravenous competitors make it tough to gain an advantage; on the other, competition is good for business because your competitors will push you to be better.
- You can't just sit there and focus on product: If your offering is all you're passionate about, this can be a difficult truth to recognize: a great deal of your success will depend on marketing and branding, networking with other business owners, maintaining inventory and keeping air-tight books. This is why it's important to raise funds for hiring consultants and specialists, but nothing beats learning how to do everything yourself.
- People try to take advantage of you: The more your business grows, the more you'll be on the radar of other businesses and individuals who will try to take advantage of you in one way or another—and there's simply no escaping the fact that there are bad actors in the world. Beware, do your homework, and don't go into business with anyone unless they're squeaky clean. Make sure their proposition is legitimate in terms of how you'll come out on the other end.
- You can end up being out-of-touch, overconfident, or overly-stressed: Of course, this won't necessarily happen, but single-mindedness can be the result of overzealous pursuit. Out of Forbes' reasons why businesses fail, a big one is leadership failure. The other reasons, such as failure to properly communicate a value proposition, stem from the owner being disconnected from the people upon which the business depends.
- It's about nothing but money: In the beginning, making good money was going to be a byproduct, not the end-all-be-all, because you were passionate about people and ideas, not just money; don't let dollar signs become your only reason for doing business. Those bad actors I talked about earlier? They're motivated by moolah.
- It becomes ho-hum: You're not doing anything different, you're set in your ways, and so are the people who keep you afloat; continue on this way, and you'll soon find yourself gasping for air.
The great thing about starting a business is the cons depend on you. Decide to steer clear of the bad actors, not to be one yourself, and to stay attuned to the evolving business world. Evolve with it, even ahead of it, and you'll see more pros than cons.


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Denver can have some unpredictable weather that might prohibit you from getting a round of golf in. Luckily there are numerous options around the city that offer everything from double sided grass tees to a water driving range to keep your game in shape. We have listed some of the best driving ranges where you can hit balls and even get out on their par 3 or executive courses.
1) Aqua Golf
201 W. Colfax Ave. Denver, CO 80202 - $6-$15 per bucket
If you are looking for anything golf related all in one place, Aqua Golf is your one stop shop. With a 36 hole mini golf course, water driving range and a clubhouse for events it has an option for the whole family. You can also choose to hit balls after dark as their range is fully lighted. This is a mats only facility that offers 25 hitting stations year round (weather depending).
2) Foothills Golf Course
6612 S. Ward St. Littleton, CO 80127 - $2-$9 per bucket & range passes available
Located just south of Denver, Foothills Golf Course has a state of the art driving range to go along with a par 3 and executive course. It has expansive grass tees and automated ball dispensers as well as short game practice areas and putting greens. Very reasonably priced, you can choose from a $2 warm up bucket or if you are really looking to work on some things a large bucket for $9. There are also range passes available for the frequent visitor.
3) CommonGround Golf Course
10300 E. Golfers Way, Aurora, CO 80010 - $6-$12 per bucket or $30 daily unlimited
This range is located east of the City of Denver and is one of the top golf courses in the area. On top of that, they offer a par 3 course and top of the line practice facility. The 9 hole par 3 course ranges in distances from 72 to 142 yards is fun for the hole family similarly to the large putting green/short game area. The massive double ended range is 400 yards long and allows for 50 players to practice at a time. This all grass facility gives you the best conditions for you practice daily!
4) Family Sports Golf Course
6901 S Peoria St, Centennial, CO 80112 - $5-$15 per bucket & range card programs available
Located southeast of the city, Family Sports Golf Course truly fits its name with practice options for everyone! This is only facility in the metro area to feature a double deck, heated driving range making it one of the best driving ranges in Denver. They are open year round and at night with their lighted decks. They also have a short game area and two large putting greens to go along with a 9 hole executive course. They have PGA Professionals on staff for any lesson inquiries and also works with GOLFTEC to provide lessons for every level.
If you're interested in playing golf indoors during poor weather, check out our article on the best places to play indoor golf in Denver.


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SCETV Passport
This video is only available in SCETV Passport, a member benefit that provides on-demand access to a rich library of PBS programs.Log in to Watch Online
SurvivorsS1 Ep3 |As cities grow, animals are displaced. Witness their stories of conflict and resolution.
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CommutersS1 Ep2 |Follow animals as they travel in and out of cities for food, shelter and to start family.
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ResidentsS1 Ep1 |Discover the extraordinary ways wildlife is making itself at home in the world's cities.
About Wild Metropolis
Discover the extraordinary animals adapting to life in the world's most loved cities, and witness the remarkable ways they meet the challenges of surviving in the newest habitat on the planet.


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Contact Us
Are you a customer who needs help?
If you have questions about your order, our products or anything else, please use the form below or contact us by email email@example.com , call us on 01294 508184, or you can find us on Facebook, Instagram and Twitter @mecocoUK
If you are visiting our workshop our address is below. If possible use Google Maps and search for Mecoco as this will bring you to our door. The postcode can drop you at a garage which is a few hundred yards too close to the town of Dalry. (Capital Business Park is directly next to the DSM factory.)
Unit 32, Capital Business Park, 11A Drakemyre, Dalry, KA24 5JD
Opening hours:
Tuesday 9:30am - 4pm
Thursday 9:30am - 4pm
Friday 9:30am - 1pm


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The Gallatin Lions Club Horse Show was held Saturday May 9, 2009. Representing SHOW as Designated Qualified Persons (DQP) were Andy Messick, DQP Coordinator, Lonnie Messick and Charles Thomas. There were six representatives from the USDA present including Veterinarian Medical Officers (VMO) Dr. Hamel, Dr. Kirsten and Dr. Binkley. Two videographers and one security representative rounded out the delegates from the USDA.There were 15 horses presented for inspection with two horses ticketed for unilateral sore and one for a scar rule violation.
Many opinions have been expressed over the inspection of Silver Design. Silver Design had a "not normal" reading on his left foot on the thermography aspect of the USDA inspection. The horse was inspected by the DQP and then by USDA which included the horse being hoof-tested.
Silver Design did react to the hoof testers on the right foot and was referred back to the DQP for further examination. The DQP hoof-tested Silver Design and got the same reaction to the hoof-testers on the right foot as the USDA inspector.
The custodian of Silver Design, Jack Way, asked the DQP to allow him to take the hoof testers with him to his trailer. At the completion of the show, Way returned the hoof testers and advised that the horse had a cracked bar on the right foot (it was later determined to be a bruised bar).
Way further advised the DQPs that he was not complaining about the fact that the horse did not get to show and admitted that the horse did have a condition that should have precluded him from showing. His complaint, however related to the 30-day suspension for unilateral sore violation.
Way felt this was a condition he could not have been aware of and the horse was kept out of the ring. Pursuant to protocol, the trainer was given the opportunity to take the horse back to the trailer upon being advised that he had a "not normal" reading from thermography.
The following was read at the Cascade High School Homecoming Game on Friday, September 15, 2023:
Our flag horse tonight is My Diamonds and Pearls. She is presented by Madison Wilson. Owned by Christie Scrivner, My Diamonds and Pearls is a four-time Reserve World Champion Tennessee Walking Horse.
If you are not already registered for the Walking Horse Report, you can register here.


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The Eclectic Peach LLC.
Love Yourself Dress
Regular price $ 34.99 Sale price
$ 44.00
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Beautiful fully lined, red mini-dress with crochet knit waist. A low back and v-neck. The perfect dress to stun your Valentine's day date or Christmas Party! Model is wearing size small.
Small: 2-4
Medium: 4-6
Measures 36 inches.


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Health & Fitness:Mental Health
Be Victorious: Intuitive Eating with Victoria Dorsano
Victoria Helle (before she was married this summer ) and I sat down and talked about Intuitive Eating . I have seen the Intuitive Eating book in our home and always wondered what it was all about. Many eating disorder programs follow the intuitive eating model. And yet you don't have to have an eating disorder to get value out of this episode. If you are a chronic dieter, Intuitive eating will help you come to peace with your food.
Victoria is the founder of Be Victorious Coaching.
Be Victorious offers health, lifestyle and performance coaching to help you work towards your personal, lifestyle and nutrition goals. Services include health coaching, weight loss coaching, performance coaching, customized meal planning, and workshops.
Like this podcast ? Give it a 5 start review, subscribe and share . Thank you !
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Click through this link and find the application and schedule
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An urgent call for ecosystem restoration action
In response to the ongoing drought, fires and catchment water quality issues, we call for national leadership to support large-scale ecosystem restoration across Australia.
Ecosystem restoration and creation, when applied throughout the entire catchment (from the coastline to the top of the catchment), can repair damaged landscapes, mitigate carbon and climate change impacts, reduce fire risk, stabilise shorelines and improve water quality. There is currently a significant opportunity to apply ecosystem restoration techniques across Australia from the fire-impacted coastal communities of Victoria, throughout drought-stricken NSW, and across QLD's threatened Great Barrier Reef catchments subject to extreme hazards. In response to the existing and pending environmental crisis, national leadership and action is urgently needed to scale-up planning, strategy and on-ground actions.
A range of recommendations are provided to foster immediate and long-term solutions. These include:
- Priority Mapping: The development of a country wide restoration map to prioritise action sites and significantly upscale efforts.
- On-ground Actions: Implementation of large scale on-ground restoration actions to repair damaged ecosystems across the entire catchment, including estuaries.
- Blue Carbon Corridor: Creation of a blue carbon corridor across coastal catchments of Victoria, New South Wales and Queensland to mitigate climate impacts and reduce storm surge risks facing coastal urban and agricultural areas.
- Monitoring: Deployment of water quality hazard reduction monitoring for impacted river communities based on downstream risks to waterways.
- Natural Infrastructure Taskforce: Establishment of an independent Natural Infrastructure Taskforce, similar to Infrastructure Australia, that links with state based groups, to deliver large-scale restoration projects and improve coastal ecosystems for future Australians.
Australian researchers and professionals are internationally recognised as leaders in ecosystem restoration. This strategy, once implemented, can be applied across coastal Australia to ensure a long lasting, catchment solution that improves the environment, mitigates carbon and reduces ongoing risks. We are calling on the Government and Industry to rise to this opportunity and become world leaders in coastal ecosystem restoration action and knowledge.
The co-signed authors of this letter represent an experienced collective of ecosystem restoration experts across the eastern seaboard of Australia including Victoria, New South Wales and Queensland.
|Dr William Glamore
Associate Professor
Principal Research Engineer
Water Research Laboratory
School of Civil and Environmental Engineering
UNSW Sydney, NSW
Dr Nathan Waltham
|Dr Peter Macreadie
Associate Professor
Head - Blue Carbon Lab
Centre for Integrative Ecology
School of Life and Environmental Sciences
Faculty of Science Engineering & Built Environment,
Deakin University, VIC


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We're Moving!
This product is either very difficult to find or no longer available through DRE, please see the list of related items to the right or ask your equipment expert for advice on a similar available product.
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The medical products division of Hewlitt Packard was purchased by Philips. For this reason, some of these monitors may carry the Philips logo instead of the HP logo (as shown), but the monitors are identical.
Available professionally refurbished from DRE, the Hewlett Packard Merlin (HP Merlin, also known as the Philips Merlin) is a modular patient monitor with networking and data management capabilities. The H.P. Merlin can be configured to measure ECG, Respiration, NIBP, Invasive Blood Pressure, SpO2, Cardiac Output, Temperature, End Tidal CO2, or recorder (printer).
The 14-inch display screens can be either monochrome or color and can show up to 8 waveforms simultaneously. "Merlin" refers to both models 1175A and 1176A. These monitors are available refurbished from DRE.
The system can be physically disassembled to leave various major components. The major components are:
|Web ID
|Compatible ECG Cables, Leads, & Electrodes
|Part #
|3-Lead ECG Trunk Cable


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Sunday, 27 October 2019
Blood Angels Terminator - 1989 Space Hulk Test Model
14 comments:
Looks amazing, like it just stepped out of the pages of a 1990 WD!ReplyDelete
I still have that transfer set too, I think that was one of the first blisters I ever bought cause I knew I couldn't freehand insignia at age 12 ;-)Replies
Cheers Mate! I'm really pleased I managed to capture that old school feel! God I miss those good old days of the hobby!!Delete
I was chuffed the decals still worked even after 30 years!! Amazing qualify and longevity!
You really channeled the vibe from the old days with this one, those old termies still have it and I had tremendous fun (after a painful start) getting them done for SH last year !ReplyDeleteReplies
Thanks JB! These old Terminators definitely still have loads of charm and character even if the new models are technically superior!Delete
I can't wait to get him aboard that Space Hulk!!
Classic stuff! Great work.ReplyDeleteReplies
Cheers Greg! Definitely gonna do some mates to accompany him!Delete
Fantastic. This is time travel!ReplyDeleteReplies
Cheers Skull... time travel to a much more fun period of the hobby I think!! When it was just a game... not an arms race!!Delete
Simply wonderful. I love the design of the Terminators of old, and I think you made a terrific paintjob here. So great!ReplyDeleteReplies
Cheers Mate! There is definitely something special about these old school Terminators. Every time I see them I'm transported back to 1990 and fall in love with the hobby all over again!Delete
Perfect! Great work :)ReplyDeleteReplies
Thanks Dude.... I'm just working on some friends for him!!Delete