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Pain Management in Knee Arthroplasty: An Overview
Curr Orthop Pract. 2016;27(4):360-370.
Perioperative pain management after knee arthroplasty has undergone a conceptual revolution in the last decade. Along with other exciting innovations, including minimally invasive techniques, computer-assisted procedures and a significant stride in tribology, understanding pain modulation and drug action at a molecular level is recognized as the game changer in arthroplasty surgeries. While most patients usually recover and experience pain relief within 3 mo after TKA, about 20% (10–34%) of the patients are left with an unfavorable long-term pain outcome. Fifty-two percent of patients report moderate pain and 16% report severe pain at rest 30 days after TKA, while pain at movement affects as much as 78% of the patients. Inability to adequately control postoperative pain causes undue suffering, inability to participate in fast-track rehabilitation programs, sleep disturbance (44% patients first 3 nights), delayed discharge, and the development of persistent postsurgical pain. The goal of this review article is to give an overview of the fundamental concept of surgical pain, the molecular mechanism of action of different drugs, evolution of the concept of preventive analgesia, and state of the art for current pain management. When combined and standardized, these factors allow arthroplasty surgeons to offer outpatient arthroplasty procedures.
By relieving pain and improving mobility, hip and knee replacement surgeries have successfully alleviated suffering of debilitating conditions such as osteoarthritis, inflammatory arthritis, and avascular necrosis of the femoral head. Improvement in perioperative pain management along with innovations in minimally invasive techniques, computer-assisted procedures, and tribology have improved longevity of the implant and quality of life in patients the world over. Understanding pain modulation and drug action at a molecular level revolutionized postoperative pain management and rehabilitation protocol. Today, most surgeons[1,2] recognize this cultural shift as the game changer in arthroplasty.
While most patients usually recover and experience pain relief within 3 mo after TKA,[3] about 20% (10–34%) of the patients are left with an unfavorable long-term pain outcome. According to Grosu et al.[4]52% of patients report moderate pain and 16% report severe pain at rest 30 days after TKA, while pain on movement occurs in as many as 78% of patients. Inability to adequately control postoperative pain causes undue suffering, inability to participate in fast-track rehabilitation programs, sleep disturbance (44% patients first 3 nights), delayed discharge, and the development of persistent postoperative pain.[5–7] The unexplained painful TKA without problems related to implants continue to be a challenge for the surgeon[5] (55 of 10) and remain a cause of revision surgery.[8]
The goal of this article is to provide an overview of the fundamental concept of surgical pain, the molecular mechanism of action of different drugs, risk factors for acute and chronic pain, evolution of the concept of preventive analgesia, and finally state of the art current pain management. When combined and standardized, these factors allow arthroplasty surgeons to offer outpatient arthroplasty procedures.[9,10]
Pathophysiology of Pain Pathway
The complex pain pathway can be briefly summarized as transduction, transmission, modulation and perception .
Transduction (Noxious Stimuli Translated Into Electrical Activities at the Sensory Nerve Endings)
The surgical incision is the starting point that effects potassium, serotonin, and histamine release from damaged cells, bradykinin (BK) from injured vessels and prostaglandin (PG) from nerve endings (nociceptors). These mediators induce further recruitment of other inflammatory agents like interleukin (IL)-1, IL-6, tumor necrosis factor (TNF)-alpha, Substance-P, Acetylcholine (Ach) among others. Substance-P, a vasoactive neuropeptide is responsible for further release of BK. Histamine from mast cells and serotonin from platelets together then stimulate additional nociceptors. Stimulation of nociceptors results in depolarization of nerve endings, which is carried to the spinal cord via A-delta and C fibers. Neural depolarization reduces excitatory threshold of nociceptors of both the injured area (primary hyperalgesia) and that of noninjured areas (secondary hyperalgesia), and this phenomenon is known as peripheral sensitization.[11–13]
A-delta fibers are myelinated fibers responsible for quickly conducting pain perception and accurately localizing the pain producing area. C-fibers are unmyelinated and slower in conducting pain information from a diffuse area.[14] These fibers mainly terminate at secondary afferent neurons of Rexed laminae 1 and 2 in the dorsal horn of spinal cord. Adjacent interneuron circuits, descending inputs from higher spinal cord, midbrain areas (periaqueductal areas, raphe nucleus, locus coeruleus, reticulo-spinal) and cerebral centers significantly modulate information carried by afferent fibers.
Transmission (Synaptic Transfer of Generated Electrical Activities From One Neuron to Another From Periphery to Higher Centers Through Spinal Tracts)
Neurotransmitters of the majority of interneurons are gama-aminobutyric acid (GABA) and glycine both of which are inhibitory in action. The main excitatory amino acid is alpha amino-3-hydroxy-5-methyl-4-isozole propionic acid (AMPA/kinate receptor) located at the post-synaptic to primary afferent fibers. It is important to note that N-methyl-D-aspartate (NMDA) receptors are postsynaptic to interneurons and the AMPA/kinate and substance-P must be activated prior to NMDA receptor activation.[11,15] The first event at a molecular level in the dorsal horn is release of excitatory amino acids like glutamate and aspartate from primary afferent fiber nerve endings (Figure 2). They bind to AMP/kinate receptors leading to the opening of ion channels and depolarization of second order neurons. These voltage sensitive events remove a magnesium plug responsible for keeping NMDA receptors in an inactive state. Glycine binding also takes place to finally activate NMDA receptors.
Now a complex cascade of events occurs, which includes marked release of intracellular calcium, which then activates phospholipase-A2, enhances PG production and increases production of substance-P. NMDA activation also causes release of nitric oxide (NO). Both PG and NO diffuse extracellularly to induce primary afferent neurons and release excitatory neurotransmitters. It is believed that once the cascade of events is initiated, the blockade of peripheral nociceptor input fails to completely stop dorsal horn neurons from firing. This wind-up phenomenon leads to clinical sequelae of hyperalgesia, muscle spasm, allodynia, increased sympathetic tone, and subsequent decrease in blood flow.[16–18] Higher doses of analgesics such as opiates are required to suppress the pain, and hence NMDA receptors are implicated in the development of opiate tolerance. This also explains why long standing pain syndrome fails to improve even after surgical intervention and correction of primary anatomic abnormality. This is responsible for chronic pain and pain syndrome even after successful TKR in some patients who have had severe long-term osteoarthritis pain. NMDA receptors also are held responsible for the complex phenomenon of central sensitization (ability of benign and low-threshold stimuli to activate second order neurons) if afferent nerve stimulation is intense and of sufficient duration.[4,11–13,15]
Modulation (Release of Chemical Messengers From Higher Center and Brain Stem That Modulates the Painful Stimuli)
After extensive modulation at the dorsal horn, the second-degree afferent from the dorsal spinal cord ascends one to two levels before crossing to other side, ascending as a crossed spinothalamic tract. These tracts end in the thalamus, and third order neurons start from here to end in the cerebral cortex. It is where that second degree of modulation takes place, also known as central nociceptive processing.[6,11,15,16] On the way there are projections to periaqueductal gray matter (PAG), which is specialized for pain localization. The spinoreticular tract is another ascending tract that has a synapse at the brainstem reticular formation, before terminating in the thalamus and hypothalamus. This tract is particularly responsible for the emotional aspect of pain. Descending tracts through PAG and rostral ventromedial medulla inhibit pain transmission due to presence of high concentrations of opioid receptors and endogenous opioids.
Perception (Complex Interaction in Thalamus, Cortex, Limbic System and Reticular System Leading to Recognition and Reaction to Primary Stimuli)
A large area of cerebral cortex known as the «pain matrix» is activated during acute pain activation, which includes the somatosensory area (S1 and S2), insular, anterior cingulate cortex as well as thalamus. Thalamus modulation is responsible for sensory discriminative processing, whereas the cerebral cortex produces emotional and affective responses. This explains why pain perception is affected by factors such as cognition (e.g. distraction or catastrophizing), mood, beliefs, and genetics.
Traditional Pain Management
Conventional pain management is unimodal and additive in nature. In other words, it usually involves administration of opioids (injectable) with or without nonsteroidal antiinflammatories as required. This often requires higher doses of opioids, with its potential side effects and the administration of drugs being dependent on nursing staff usually gets delayed. To overcome this, patient-controlled analgesia (PCA) gained worldwide acceptance by both patients and surgeons.
Patient Controlled Analgesia (PCA)
PCA is an interesting, attractive, appealing, and effective concept that involves patients in pain control management. The PCA uses a microprocessor controlled infusion device that can deliver a continuous baseline dose. It is programmed for additional, small, and repetitive doses with a lock-out period (5–10 min) after each demand dose. The program also decides maximal total dose to be delivered per hour. Lock-out time needs calibration in the beginning. Setting the lock-out time too short allows the patient to self-administer additional medication (overdose) whereas a prolonged lock-out interval fails to give adequate analgesia.[4,19,20]
PCA remains a popular and reasonably[21] viable option; however, it has certain flaws. (1) The chances of overmedication with potential adverse effects such as nausea, vomiting, respiratory depression, ileus, urinary retention, pruritus, hypotension, bradycardia, hyperalgesia and cognitive changes can occur. (2) Despite the ease of administration and titratability, parenteral opioids typically do not provide adequate analgesia for total joint replacement patients, particularly during movement with ambulation. Movement evoked pain (MEP) is 95% to 226% more intense than pain at rest (PAR), awakens the patients from sleep, is not reduced by opiates, and is a potential risk of persistent postsurgical pain syndrome (PPSP).[4,22] (3) By activation of NMDA receptors in the central nervous system, opioids induce a complex phenomenon of hyperalgesia by paradoxically lowering the pain threshold. This, in turn, rapidly escalates greater opioid requirements (overdose) in an attempt to reduce pain after surgical procedures with unacceptable side effects. This phenomenon may be minimized by limiting opioids and maximizing nonopioid drugs.[23]
Transdermal PCA utilizes ionotophoresis technology to deliver drug (fentanyl) through the skin by use of an external electrical field.[24–26] This includes a needle-free credit-card-size system that is applied to the patient's upper arm or chest for 24 hr. The system utilizes on demand delivery dose of 40 microgram of fentanyl for 10 min up to six doses an hour with a maximum dose of 80.
Definition and Constitution of Multimodal Pain (MMP) Control
Multimodal analgesia is a multidisciplinary approach to pain management that takes advantage of synergistic effects of various analgesics with different mechanisms of action (Figure 1) to achieve maximal control of pain with minimal side effects.[27] A multimodal pain protocol consists of patient education, pre-emptive oral pain medications preoperatively, preference to regional anesthesia, peripheral nerve block, and intraoperative modalities like periarticular infiltration of a cocktail of drugs and finally a standardized postoperative rehabilitation program. Because many of the negative effects of analgesic therapy are related to parenteral opioids, limiting their use is a major principle of multimodal analgesia.[2,19,28]
Pain perception has two major components: the sensory discriminating component and affective-motivational component, which underlies the emotional effects of the pain and is responsible for learned avoidance and other behavioral responses. MMP control begins with patient education in the form of preoperative interactions with patients and relatives to draw a realistic goal, to explain various steps the patient would undergo, the likely things to happen, and the supportive care available. This decreases anxiety and the «fear of the unknown» and hence improve cooperation and decrease in pain score and overall better patient satisfaction.[29,30]
Preemptive Analgesia
This involves the administration of analgesics before painful stimuli to prevent peripheral and central sensitization. This starts before surgery, during surgery, and the initial period after surgery. Preemptive analgesia[1] is more effective only when the treatment used is adequate to break the vicious cycle of noxious stimuli recruiting more and more neural pathways. The interventions, therefore, must produce a dense blockade of appropriate duration to block the transmission of noxious afferent information from the peripheral nervous system to the spinal cord and the brain.[31] Scientific communities have attempted multiple modifications in the pursuit of uniformly acceptable multimodal pain control regimens in the last few years. This includes fixed-dose versus titrated-dose of opioids in PCA, single-dose versus continuous-epidural analgesia, single-shot versus continuous peripheral nerve blocks (femoral, sciatic, or adductor nerve block), and periarticular soft-tissue infiltration of drugs.
Drugs Commonly Used in MMP Control
The various drugs employed are acetaminophen, cyclooxygenase (COX) inhibitors, opioids (and their derivatives), gabapentinoids, dexamethasone, and others.
Acetaminophen. Acetaminophen is a nonopioid, non-NSAID analgesic. Its action is predominantly by inhibiting prostaglandin synthesis in the central nervous system, which possibly plays a role in preventing central sensitization syndrome. These attributes make it an integral part of most multimodal postoperative pain regimens. Oral acetaminophen continues to be most commonly prescribed route; however, its intravenous administration is very effective and reduces postoperative opioid consumption.[32] In an adult weighing more than 50 kg the 1 g of intravenous paracetamol can be administered four times a day. However, in those weighing over 50 kg, the safe dose is 15 mg/kg with a maximal dose of 60 mg/kg a day.
NSAIDS and COX-2 Inhibitors. NSAIDs operate by binding and inhibiting COX 1 and 2 involved in the conversion of arachidonic acid to prostaglandins, which truncates the inflammatory mediator cascade. By inhibiting reduction of PG synthesis both peripherally and centrally, NSAIDS not only prevent peripheral tissue sensitization and secondary hyperalgesia effect on the uninjured tissues but also minimizes central sensitization.
The COX-1 isoenzyme, ubiquitous in gastric mucosa, platelets, kidneys, and liver, is involved in maintaining normal organ function, such as mucosal blood flow and barrier function in the stomach, and in mediating platelet aggregation. Hence, use of nonselective NSAIDS before surgery potentially increases bleeding (by decreasing platelet aggregation), gastritis, and peptic ulcer disease, renal impairment, and poor wound healing. NSAIDs are, therefore, relatively contraindicated in patients who are anticoagulated with warfarin, unfractionated and low molecular weight heparin (LMWH), Factor Xa inhibitor (rivaroxaban), direct thrombin inhibitors (dabigatran and fondaparinaux).
COX-2 isoenzyme, typically present at a lower level in these organs, is produced primarily in inflamed tissues. COX-2 selective inhibitors lack platelet inhibition and adverse gastrointestinal effects; however, its long-term use has fallen out of favor due to its unfavorable risk of cardiovascular side effects. Published literature demonstrated that use of COX-2 inhibitors (celecoxib and rofecoxib) as preemptive analgesia significantly reduces pain scores as compared to placebo at 1, 2, and 24 hr after surgery.[33]It is further established that use of COX-2 significantly reduces consumption of opioids (referred as opioid sparing), produces faster time to physical rehabilitation, reduces nausea and vomiting, provides better sleep patterns, and has greater patient satisfaction after surgery.[34,35] Alexander et al.[36]showed that a single dose of preoperative diclofenac or ketorolac reduced morphine consumption by 29% compared to placebo with an additional decrease in postoperative nausea, vomiting, and pruritus in patients undergoing joint arthroplasty. Ketorolac and diclofenac are nonselective NSAIDs with potent analgesic effects that can be given intravenously, intramuscularly, orally and topically without respiratory or central nervous system depression effects. It is shown that a single dose of preoperative diclofenac or ketorolac reduced morphine consumption by 29% compared to placebo with an additional decrease in postoperative nausea, vomiting, and pruritus in patients undergoing joint arthroplasty.[36,37]
Glucocorticoids. Glucocorticoids are known for their potent antiinflammatory properties. It is established that a single preoperative dose of long-acting glucocorticoids like dexamethasone and methylprednisolone are effective in preventing postoperative nausea and vomiting.[38–40] Additionally, dexamethasone has been shown to reduce postoperative dynamic pain.[41,42] Koh et al.[43] concluded that dexamethasone as part of a multimodal regimen reduced postoperative emesis and pain without an increased risk of wound complications.
Opioids. Opioid analgesics have long been, and continue to be, part of the surgeon's armamentarium for the treatment of postoperative pain. Opiates exert their effect by binding to three principal opioid receptors viz. mu, kappa and delta.[13] Opiates or their synthetic derivatives (meperidine or fentanyl) are metabolized in the liver and their onset of action largely depends on lipid solubility. Lipid soluble agents such as meperidine and fentanyl have rapid action but are of short duration because they cross the blood brain barrier easily. In presence of renal impairment, morphine and meperidine are avoided while fentanyl, hydromorphone, and oxycodone (which have minimal renal excretion) are preferred.
Oral opioids are available in immediate-release and controlled-release formulations. The former are effective in relieving moderate to severe pain, but require administration every 4 hr. Interruption in timely administration offers suboptimal pain control particularly in the night. The Acute Pain Management Guidelines developed by the Agency for Healthcare Policy and Research[40] recommend a fixed dosing schedule for all patients requiring opioid medications for more than 48 hr postoperatively. The adverse effects of oral opioid administration are considerably less than those of intravenous administration and are mainly gastrointestinal in nature.
Morphine is metabolized to its active metabolite morphine-6-glucuronide (M6G) in the liver and has a half-life of between 2 and 5 hr, and is excreted in the urine. In patients with renal impairment (estimate glomerular filtration rate <60 mL/min/1.73 m2) there is a risk of respiratory depression because of accumulation of M6G. Morphine may cause significant biliary and urinary tract spasm with few cardiovascular effects.
Fentanyl is a synthetic opiates with a half-life of 2 to 3 hr which demonstrates rapid onset of action due to lipid solubility but for shorter duration because of redistribution. It has excellent cardiovascular safety profile. It is available as transdermal patches (25, 50, 75 or 100 μg/h), which last for 72 hr, transoral formulations, intrathecal and epidural. It is useful for PCA analgesia, with typical 4-hour doses of 200 to 400 μg depending on weight of patient and tolerance.
Oxycodone: Controlled-release formulation of oxycodone demonstrates excellent and sustained pain relief over an extended period of up to 72 hr and is associated with less sedation, vomiting, or sleep disturbances.
Codeine is probably the most widely prescribed oral opiate that differs from other opiates in having a ceiling effect at 60 mg. It has a relatively low incidence of euphoria and thus perhaps a lower abuse potential; however, nausea and vomiting are common side effects. Its semisynthetic derivative hydrocodone is more potent with lesser side effects and is commonly prepared in combination with ibuprofen.
Tramadol is another synthetic analog of codeine. Besides being a weak μ-receptor agonist, it blocks serotonin and norepinephrine reuptake similar to tricyclic antidepressants. It has excellent oral bioavailability with a half-life of 4 to 6 hr. Tramadol has gained popularity because of the low incidence of adverse effects, specifically respiratory depression, constipation, and potential for abuse.
Gabapentinoids (Pregabalin and Gabapentin). Pregabalin and its predecessor gabapentin were first developed as anticonvulsant medications. They have shown promising results in neuropathic pain by acting on the voltage gated calcium channels in the central nervous system through alpha 2-delta ([alpha]2-[delta]) subunit thereby decreasing neurotransmitter release. Neuropathic pain is a complex phenomenon recognized in as high as 12.7% of patients after TKA. Use of pregabalin in the perioperative period reduces neuropathic pain, minimizes opioid consumption, and lessens sleep disturbance.[44,45] They also demonstrate synergistic effects with COX-2 inhibitors in clinical studies. The adverse side effects of gabapentinoids include dizziness and somnolence with long-term use.
Ketamine. Ketamine is a noncompetitive N-methyl-d-aspartate (NMDA) receptor antagonist that may play a critical role in the intensity of perceived postoperative pain and preventing central sensitization. Ketamine has opioid-sparing effects but no reduction in opioid-related adverse effects. In patients undergoing knee arthroplasty, a low-dose infusion of ketamine (3 μg/kg per minute intraoperatively and 1.5 μg/kg per minute for 48 hr postoperatively) reduced morphine requirements and decreased the time to achieve 90 degrees of active flexion.[29] Intravenous ketamine can be used in conjunction with femoral nerve blocks or epidural analgesia after total knee arthroplasty. It can also be infiltrated into the wound.
Anesthesia Option
Hypotensive regional anesthesia (spinal, epidural, or combined) gained rapid popularity over general anesthesia because it avoids central nervous system depression and by modest reduction in arterial blood pressure it also contributes to reduced surgical blood loss and decreases risk of deep venous thrombosis (DVT) and thromboembolism. Furthermore, it has less cardiac and respiratory depression. Besides neuraxial anesthesia allows postoperative pain management by appropriately titrating the dose of opioids with local anesthetics.
Neuraxial and Regional Anesthesia. Spinal and epidural opioids provide superior analgesia compared with systemic opioids. The onset and duration of neuraxial opioids are determined by the lipophilicity of the drug. For example, lipophilic opioids, such as fentanyl, provides a rapid onset of analgesia (10–15 min), is effective for shorter duration (2–4 hr), has limited spread within the cerebrospinal fluid (and hence less respiratory depression), and gas rapid clearance and resolution. Conversely, hydrophilic opioids, including morphine and hydromorphone, have a longer duration of action (18–24 hr) but are associated with a greater frequency of side effects, such as pruritus, nausea, and vomiting, as well as delayed respiratory depression.[46] Patients given a single dose of extended release epidural morphine[47] have demonstrated 48-hour period of analgesia.
Though epidural anesthesia (EA) is preferred by some clinicians, the limitations are failed or dislodged catheters. Epidural catheters used for analgesia also lead to motor blockade (quadriceps weakness necessitating use of knee immobilizer), numbness in contralateral limb, urinary retention, and chances of epidural hematoma if clexane or fondaparinaux is concomitantly used for DVT prophylaxis. It is important to note that the typical side effects of opioids are much more common (and more prolonged) after neuraxial administration compared with all other routes. For example, in a large series, the frequency of pruritus, nausea and vomiting, and respiratory depression was 37%, 25%, and 3%, respectively, with an intrathecal morphine injection.[48] Therefore, patients who exhibit sensitivity to an opioid when administered systemically should not receive that agent neuraxially.
Peripheral Nerve Block (PNB). Use of nerve stimulator and ultrasound have facilitated accurate localization of the neural structure and thereby significantly improved their safety and success rate. Recently, single-dose and continuous peripheral nerve block techniques (femoral, sciatic, and adductor canal block) have drawn attention in joint replacement surgery because of its ability to provide quality of analgesia similar to those of continuous epidural analgesia but with fewer side effects (reduced incidence of arterial hypotension or urinary retention) besides being compatible with anticoagulants.[49–52]
After total knee arthroplasty, patients receiving epidural analgesia or continuous femoral block reported lower pain scores, better knee flexion, faster ambulation, and shorter hospital stays than did patients who received intravenous PCA morphine. However, continuous femoral block was the preferred analgesic technique in each study because fewer technical problems and fewer side effects were noted compared with the epidural and PCA approaches. Recent literature notes that 90% of patients undergoing minimally invasive primary hip or knee replacement were ready for discharge from the hospital within 48 hr if continuous peripheral nerve block is combined with multiple scheduled analgesics.[2,53]
Neurologic dysfunction and intravascular injection are the primary concerns associated with peripheral blockade. However, in a large series involving more than 50,000 peripheral blocks, there were six seizures, and 12 patients (0.02%) reported postoperative nerve injury. Most neurologic complications were transient.[54]
Block Techniques
Femoral Block
Lumbar plexus block can be achieved by psoas approach, femoral approach, or fascia iliaca approach. Psoas approach blocks the femoral nerve along with lateral femoral cutaneous nerve and obturator nerve rendering it preferable in hip replacement surgeries. For knee replacement, femoral approach and fascia iliaca approaches are sufficient. The patient is positioned supine and a linear transducer (8–14 MHz) is placed just below inguinal ligament and moved slightly medial or lateral to identify the femoral artery (Figure 3). If it cannot be seen, tilting the transducer craniocaudal helps artery visualization or a color Doppler can be used. Then the femoral nerve is located lateral to the artery as hyperechoic triangular or oval shape on the iliopsoas muscle under fascia lata. The needle is placed 1 cm lateral to the nerve, and after negative aspiration 15–25 mL of a local anesthetic drug is injected. If a nerve stimulator is used, the presence of patellar or quadriceps twitch between 0.3–0.5 mA confirms appropriate positioning of the needle.
Figure 3.
Sequential steps of peripheral nerve block.
Sciatic Nerve Block
A sciatic nerve block results in anesthesia of the skin of the posterior aspect of the thigh, hamstring, and biceps femoris muscles, part of the hip and knee joint, and the entire leg below the knee with the exception of the skin of the medial aspect of the lower leg. A sciatic nerve block can be given by posterior or anterior approach. In the classic posterior approach, the patient is placed in a lateral decubitus position with slight forward tilt. Needle insertion is 4–5 cm caudal and perpendicular to the midpoint of the line connecting the greater trochanter and posterior superior iliac spine (Figure 3). A 10-cm (4-in) stimulating needle is advanced until either a tibial or peroneal motor response is elicited, then 20–30 mL of a local anesthetic is incrementally injected. The nerve stimulator may be used to deliver an initial current intensity of 1.5 mA to visualize twitches of either tibial or peroneal motor response (hamstring, calf, foot, or toe twitches). The stimulating current is gradually decreased until twitches are still seen or felt at 0.2 to 0.5 mA, which typically occurs at a depth of 5 to 8 cm. At this low current intensity, any observed motor response is from the stimulation of the sciatic nerve rather than direct muscle stimulation (false twitch). After negative aspiration for blood, 15 to 20 mL of local anesthetic is injected slowly.
Adductor Canal Block (Hunter's Block)
An adductor canal block targets the saphenous nerve (sensory only branch of the femoral nerve) in adductor canal. The saphenous nerve travels between the medial border of the vastus medialis muscle and the medial border of the adductor muscles, along the femoral artery and courses from lateral to medial beneath the sartorius muscle. Being a purely sensory block, it relieves pain and also spares the quadriceps muscle thereby facilitating physiotherapy, rehabilitation, and early independent ambulation.
The patient lies supine with the knee slightly flexed and leg externally rotated. A high-frequency, linear array ultrasound probe is placed in the anteromedial thigh to first localize the femoral artery and trace it distally where it gives off genicular artery (Figure 3). Doppler scanning may be used in difficult situations to trace the femoral artery caudally from the inguinal crease. Once the femoral artery is identified, the needle is inserted in-plane in a lateral-to-medial orientation, and advanced toward the femoral artery. The needle tip is placed just medial to the artery in the adductor canal, underneath the sartorius muscle. The saphenous nerve is identified along the genicular artery. If nerve stimulation (0.5 mA) is used, the passage of the needle through the sartorius or adductor muscles and into the adductor canal usually is associated with the patient reporting a paresthesia in the saphenous nerve distribution. After confirming needle placement and negative aspiration, 15 mL of local anesthetic drug is injected.
Periarticular Soft-tissue Infiltration
Periarticular infiltration in TKA is a technique in which a cocktail of drug combination is injected into the periarticular soft tissues such as posterior capsule, medial and lateral collateral ligaments, quadriceps mechanism, and peripatellar tissue at the end of the surgery (Figure 4). Though there is no standardized protocol, it usually is a combination of long-acting local anesthetic drug along (bupivacaine, ropivacaine) with steroids, morphine, and epinephrine. Steroids prevent local inflammation. Morphine blocks the three opiate receptors and epinephrine prolongs the action of local anesthesia by decreasing its absorption via its alpha-2 adrenergic effect. Injection of the mixture is avoided in the posterolateral corner to prevent inadvertent injury to the peroneal nerve (Figure 4).
Figure 4.
Infiltration of cocktail of drugs in periarticular soft tissues.
Recent studies[55–62] found that periarticular injection significantly improved pain relief from 24 hr to 1 wk and straight leg raise in the early postoperative period. In addition, the meta-analysis of opioid consumption through PCA also corresponded well with the outcome of pain score, which showed that periarticular injection consumed significantly less PCA during the first 24 hr postoperatively. The meta-analysis showed that more patients could do active straight leg raise in the injection group than that in noinjection group from postoperative 1 day to discharge day. Ropivacaine has the similar efficiency to bupivacaine but is longer acting and has fewer complications in the nervous and cardiovascular systems.[52] Some prefer leaving an indwelling catheter tube before joint closure for postoperative analgesia.
Authors Preferred Method
All patients received Pregabalin 150 mg the night before and celecoxib 400 mg orally 2 hr before surgery with a sip of water. Intravenous dexamethasone (8 mg) is given for antiinflammatory effects and to minimize nausea and vomiting. A cocktail of drug mixture (Figure 5) is injected after component implantation into the posterior aspect of the joint capsule, medial and lateral collateral ligaments, soft tissue around the quadriceps tendon, and patellar tendon, fat pad, and synovium. Rationale of ropivacaine is its longer action and superior cardiovascular and neurotoxic profile. Morphine relieves pain by acting on morphine receptors present in the articular activity and addition of adrenaline slows release of ropivacaine into the vascular system.
A standard postoperative regimen included acetaminophen, celecoxib, and pregabalin along with morphine/fentanyl or tramadol as rescue drugs (Figure 5). Onandesterone 4 mg is used to control vomiting in the postoperative period and pantoprazole 40 mg daily is given for gastrointestinal prophylaxis until discharge. Liberal ice-pack application, limb elevation, and pneumatic compression device of both legs are other measures to reduce swelling. Standard DVT prophylaxis is followed, active straight-leg raising and range of motion is encouraged from the same day. The patient is discharged usually on the third postoperative day after gaining 80 to 90 degrees of flexion and can walk independently with support for at least 50 feet.
A fundamental understanding of different modes of pain control techniques along with limitation of each technique is the first vital step towards effective control of postoperative pain. Close observation for potential side effects of any drug is the next most important thing. We must move forward toward a more holistic, interdisciplinary, multimodal approach to pain medicine. Educating patients about a realistic goal is the cornerstone of pain management.
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- Srikandarajah S, Gilron I. Systematic review of movement-evoked pain versus pain at rest in postsurgical clinical trials and meta-analyses: a fundamental distinction requiring standardized measurement. Pain. 2011; 152:1734–173.
- Gandhi K, Viscusi E. Multimodal pain management techniques in hip and knee arthroplasty. J NYSORA. 2009; 13:1–8.
- Ashburn MA, Strisand J, Zhang J, et al. The iontophoresis of fentanyl citrate in humans. Anesthesiology. 1995; 82:1146–1153.
- Viscusi ER, Reynolds L, Taint S, et al. An iontophoretic fentanyl patient-activated analgesic delivery system for postoperative pain: A double-blind, placebo-controlled trial. Anesth Analg. 2006; 102:188–194.
- Viscusi ER, Reynolds L, Chung F, et al. Patient-controlled transdermal fentanyl hydrochloride vs intravenous morphine pump for postoperative pain: a randomized controlled trial. JAMA. 2004; 291:1333–1341.
- Kehlet H, Dahl JB. The value of »multimodal» or »balanced analgesia» in postoperative pain treatment. Anesth Analg. 1993; 77:1048–1056.
- Maheshwari AV, Boutary M, Yun AG, et al. Multimodal analgesia without routine parenteral narcotics for total hip arthroplasty. Clin Orthop Relat Res. 2006; 453:231–238.
- Dorr LD, Long WT, Inaba Y, et al. MIS total hip replacement with a single posterior approach. In: Manoj MK, ed. Seminars in Arthroplasty. 2005; 16:179–185.
- Giraudet-Le Quintrec JS, Coste J, Vastel L, et al. Positive effect of patient education for hip surgery: a randomized trial. Clin Orthop Relat Res. 2003; 414:112–120.
- Kissin I. Preemptive analgesia. Anesthesiology. 2000; 93:1138–1143.
- Sinatra RS, Jahr JS, Reynolds LW, et al. Efficacy and safety of single and repeated administration of 1 gram intravenous acetaminophen injection (paracetamol) for pain management after major orthopedic surgery. Anesthesiology. 2005; 102:822–831.
- Reuben SS, Bhopatkar S, Maciolek H, et al. The preemptive analgesic effect of Rofecoxib after ambulatory arthroscopic knee surgery. Ambulatory Anesthesia. 2002; 94:55–59.
- Buvanendran A, Kroin JS, Tuman KJ, et al. Effects of perioperative administration of a selective cyclooxygenase 2 inhibitor on pain management and recovery of function after knee replacement: a randomized controlled trial. JAMA. 2003; 290:2411–2418.
- Reuben SS, Connelly NR. Postoperative analgesic effects of celecoxib or rofecoxib after spinal fusion surgery. Anesth Analg. 2000; 91:1221–1225.
- Alexander R, El-Moalem HE, Gan TJ. Comparison of the morphine sparing effects of diclofenac sodium and ketorolac tromethamine after major orthopedic surgery. J Clin Anesth. 2002; 14:187–192.
- De Oliveira GSJr, Agarwal D, Benzon HT. Perioperative single dose ketorolac to prevent postoperative pain: a meta-analysis of randomized trials. Anesth Analg. 2012; 114:424–433.
- Pulos N, Sheth N. Perioperative pain management following total joint arthroplasty. Ann Orthop Rheumatol. 2014; 2:1029.
- Miyagawa Y, Eijiri M. Methylprednisone reduces postoperative nausea in total knee and hip arthroplasty. J Clin Pharm Ther. 2010; 35:679.
- Backes JR, Bentley JC, Politi JR, et al. Dexamethasone reduces length of hospitalization and improves postoperative pain and nausea after total joint arthroplasty: a prospective, randomized controlled trial. J Arthroplasty. 2013; 28(8 Suppl):11–17.
- Kardash KJ, Sarrazin F, Tessler MJ, et al. Single-dose dexamethasone reduces dynamic pain after total hip arthroplasty. Anesth Analg. 2008; 106:1253–1257.
- Rockville, MD. Acute pain management guideline panel: acute painmanagement: Operative or medical procedures and traumaclinical practice guideline. AHCPR Pub No 92–0032. Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, 1992:15–26.
- Koh IJ, Chang CB, Lee JH, et al. Preemptive low-dose dexamethasone reduces postoperative emesis and pain after TKA: a randomized controlled study. Clin Orthop Relat Res. 2013; 471:3010–3020.
- Mathiesen O, Jacobsen LS, Holm HE, et al. Pregabalin and dexamethasone for postoperative pain control: a randomized controlled study in hip arthroplasty. Br J Anaesth. 2008; 101:535–341.
- Lee JK, Chung KS, Choi CH. The effect of a single dose of preemptive pregabalin administered with COX-2 inhibitor: a trial in total knee arthroplasty. J Arthroplasty. 2015; 30:38–42.
- Rathmell JP, Lair TR, Nauman B. The role of intrathecal drugs in the treatment of acute pain. Anesth Analg. 2005; 101:S30–S43.
- Viscusi ER, Martine G, Hartrick CT, et al. Forty-eight hours of postoperative pain relief following total hip arthroplasty with a novel, extended-release epidural morphine formulation. Anesthesiology. 2005; 102:937–947.
- Fu PL, Xiao J, Zhu YL, et al. Efficacy of a multimodal analgesia protocol in total knee arthroplasty: a randomized, controlled trial. J Int Med Res. 2010; 38:1404 –1412.
- Chelly JE, Greger J, Gebhard R, et al. Continuous femoral blocks improve recovery and outcome of patients undergoing total knee arthroplasty. J Arthroplasty. 2001; 16:436–445.
- Kaloul I, Guay J, Cote C, et al. The posterior lumbar plexus block and the 3-in-1 femoral nerve block provide similar postoperative analgesia after TKR. Can J Anesth. 2004; 51:45–51.
- Ben-David B, Schmalenberger K, Chelly JE. Analgesia after total knee arthroplasty: Is continuous sciatic blockade needed in addition to continuous femoral blockade? Anesth Analg. 2004; 98:747–749.
- PhamDang C, Gautheron E, Guilley J, et al. The value of adding sciatic block to continuous femoral block for analgesia after total knee replacement. Reg Anesth Pain Med. 2005; 30:128–137.
- Hebl JR, Kopp SL, Ali MH, et al. A comprehensive anesthesia protocol that emphasizes peripheral nerve block markedly improves patient care and facilitates early discharge after total hip and knee arthroplasty. J Bone Joint Surg Am. 2005; 87:63–70.
- Auroy Y, Benhamou D, Bargues L, et al. Major complications of regional anesthesia in France: The SOS regional anesthesia hotline service. Anesthesiology. 2002; 97:1274–1280.
- Teng Y, Jiang J, Chen S, et al. Periarticular multimodal drug injection in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2014; 22:1949–1957.
- Essving P, Axelsson K, Kjellberg J, et al. Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty a randomized doubleblind study involving 48 patients. Acta Orthop. 2010; 81:354–360.
- Fu P, Wu Y, Wu H, et al. Efficacy of intraarticular cocktail analgesic injection in total knee arthroplasty–-a randomized controlled trial. Knee. 2009; 16:280–284.
- Joo JH, Park JW, Kim JS, et al. Is intra-articular multimodal drug injection effective in pain management after total knee arthroplasty? A randomized, double-blinded prospective study. J Arthroplasty. 2011; 26:1095–1099.
- Koh IJ, Kang YG, Chang CB, et al. Does periarticular injection have additional pain relieving effects during contemporary multimodal pain control protocols for TKA? A randomised, controlled study. Knee. 2012; 19:253–259.
- Koh IJ, Kang YG, Chang CB, et al. Additional pain relieving effect of intraoperative periarticular injections after simultaneous bilateral TKA: a randomized, controlled study. Knee Surg Sports Traumatol Arthrosc. 2010; 18:916–922.
- Mullaji A, Kanna R, Shetty GM, et al. Efficacy of periarticular injection of bupivacaine, fentanyl, and methylprednisolone in total knee arthroplasty: a prospective, randomized trial. J Arthroplast. 2010; 25:851–857.
- Qian WW, Weng XS, Fei Q, et al. Application study of periarticular multimodal drug injection in total knee arthroplasty. Zhonghua Yi Xue Za Zhi. 2010; 90:2593–2596.


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Refugee Food Festival: an Ansamble restaurant promotes Syrian cuisine
This year, nearly 50 French caterers opened their kitchens all over France to around fifty refugee chefs. Ansamble took part in the Refugee Food Festival event on October 22 in Rennes, offering participants the opportunity to come together around a common passion, cooking, and to discover new savors from elsewhere. Chef Arnaud Besnier and Syrian refugee Chef Hadil Jlilati look back on their shared experience in the kitchen.
What was your collaboration at the Refugee Food Festival like and what did you learn from it?
Arnaud Besnier For me, it was a first! I had never heard of this festival before. I thought it was great. It promotes refugee chefs, and provides an opportunity to discuss other recipes and ways of cooking. During this collaboration, it was mainly the kitchen team who worked with Hadil on the menu starters and desserts. She played chef for a day to lead the team and it went very well, there was a lot of exchange between them. As for me, I mainly worked upstream to prepare the event (editor's note: general organization, taking orders for the desired ingredients, etc.).
Hadil Jlilati I learnt a lot about French cuisine, about starters and desserts, alike. It wasn't easy for me at the beginning as it was my first time cooking for contract catering. I am used to working in modest-sized kitchens and particularly preparing smaller quantities. But in the end, it went well. The teams helped and supported me a lot, it was a great experience.
What did you learn and take away from this day of exchange?
AB The thing that particularly struck me is how open cuisine still is, be it French or Syrian. It's a world where there's always something to learn and where everything can eventually be combined.
HJ I am very pleased to have worked with such a large team. All of this was new to me.
The thing that particularly struck me is how open cuisine still is, be it French or Syrian.
Chef Arnaud Besnier
Arnaud, how would you qualify French cuisine? And you Hadil, Syrian cuisine?
AB French cuisine is world famous! What I particularly like about this cuisine is how open-ended it is. Once the culinary basics have been established, they can be adapted to other styles of cuisine from around the world (Syrian, Italian, etc.). French cuisine is also synonymous with sharing. But above all it is a passion for me!
HJ I agree with Arnaud. For me, Syrian cuisine is rich in all respects and I was particularly happy to be able to present it to a large number of people today.
What do you like cooking the most and why?
AB Without hesitation, pastries; my péché mignon! I have a sweet tooth. I trained as a Pastry Chef before joining Ansamble. This is a very rigorous job; you need to be meticulous and stick to the recipe.
HJ I also prefer desserts, in general. I often use rose water and orange blossom in my recipes. The smell is sweet and pleasant and adds that extra finishing touch to desserts.
To sum up, Arnaud do you have a message for Hadil? And reciprocally?
AB We integrated Hadil without knowing neither her level nor skills, and she did very well! Although communicating wasn't always that easy because of the language barrier we must continue to share this passion! Everyone loves cooking. I would like to thank you Hadil for participating in the festival, and wish you all the best for the future!
HJ Thank you very much Arnaud for your confidence in me and the responsibilities you gave me. For me, it was a great and totally new experience!

subset: commoncrawl


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Shutting Down Energy to Brain CancerMRI image of a glioblastoma multiforme. (Source: Wikimedia/The Armed Forces Institute of Pathology)
A multicenter team of researchers has identified an enzyme key to the survival and spread of glioblastoma cancer cells that is not present in healthy brain cells, making the enzyme a promising therapeutic target.
"With this enzyme, we may have found a way to make sure that these cancer cells that are very invasive do not become as aggressive," said Alfredo Quinones-Hinojosa, professor of neurological surgery and oncology at the Johns Hopkins University School of Medicine. Glioblastoma is considered the most devastating human cancer, with median survival at only 14 months after diagnosis. "Our latest findings provide an inroad to possibly stopping cancer cells from having enough energy to grow."
These findings are described in Molecular Cancer Research.
Previous research had shown that the enzyme, glucose-6-phosphatase (G6PC), is present in cells from other cancers, enabling them to use glucose at a rate up to 200 times higher than normal, healthy cells. In searching the literature, however, the team found nothing to suggest that G6PC was present in glioblastoma. Quinones-Hinojosa was certain it was in his patients' tumors, however, so the team set out to study glioblastoma cells from patients.
"Essentially all cells, including cancer cells, need energy to grow and spread," said Sara Abbadi, a research fellow on the team. And cancer cells have the ability to survive in situations where normal, healthy cells cannot, which has been an important factor for why glioblastoma is so difficult to treat, said Abbadi.
By inhibiting G6PC production, the team found that the cancer was less viable, including less able to move. The team also challenged glioblastoma cells— some with G6PC production inhibited, some not— with the glucose analog 2-deoxy-D-glucose (2DG), which previously had been shown to transform glioblastoma cells into a less malignant form, making them sensitive to other treatments. With G6PC expression unchecked, some of the glioblastoma cells could recover their malignancy after being challenged with 2DG and, in the lab, could move even faster than they had before. Dual treatment with 2DG and blocking G6PC expression, however, not only prevented those cells from recovering their malignancy but also killed them.
"Part of the problem in treating cancer is that it's going to be virtually impossible to find one magic bullet," said Quinones-Hinojosa, "but at least we're beginning to dismantle the different mechanisms that these cells use."
The next step in turning this discovery into a treatment is to find a pharmaceutical method to inhibit G6PC expression in the brain. G6PC is naturally produced elsewhere in the body— including in the liver, kidney and pancreas— so while further studies are underway, any human trials are still years away. Because G6PC expression is shared by many cancers, however, the team's discovery "is worth exploring in other cancers," the authors write in their paper.


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SPEC Kit 315: Leave and Professional Development Benefits · 19
Survey Questions and Responses
The SPEC survey on Leave and Professional Development Benefits was designed by Cathleen Martyniak,
Chair, Preservation Department, and Brian Keith, Assistant Dean, Human and Financial Resources,
University of Florida. These results are based on data submitted by 73 of the 123 ARL member libraries
(59%) by the deadline of August 4, 2009. The survey's introductory text and questions are reproduced below,
followed by the response data and selected comments from the respondents.
This survey is for the human resource officer or other senior administrator responsible for policy decisions about the various leave
and professional development benefits available to librarians. The benefits covered in this survey include sick, vacation, and holiday
leave, and leave and financial support for professional development, employee education and training, and internships. The benefits
not considered in this survey, but well represented in other surveys, include retirement and insurance plans. In determining the
scope of this survey, the authors wanted to develop an understanding of the less researched and more varied plans currently offered
to professional library staff and benefits over which library administrators would typically have some plan design authority. These
benefits represent an area ripe for exploration.
While it is likely that the benefits within the scope of this survey are offered to librarians and other library employees, they will
be most commonly afforded to librarians. Since the variance in the extent to which the benefits are offered to other categories of
employees might make the responses to the survey more difficult to interpret, the survey authors have opted to narrow the focus of
the survey to librarians (though respondents may include other staff who are eligible for the same benefits).
Results of this survey should help provide a better understanding of the prevalence of these leave benefits and identify typical plan
components and design.


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Sat, 01 Feb|
Wild Learning
Fun with lino
A short workshop where you will create your own lino prints. Cut your lino block and then print ready for framing. Beginners welcome. All materials provided including morning tea.
Time & Location
01 Feb 2020, 10:00 am – 1:00 pm
Wild Learning, 111 Wollombi Rd, Cessnock NSW 2325, Australia
About the Event
A morning workshop in which you will create your own lino prints for the wall, to create greetings cards or give as gifts.
You will cut your own lino learning about about reversing of images and positive/negative space, cutting techniques, and how to ink up your block. We will print images using a barren and the press, on a variety of papers to create a print that is absolutely yours ready to frame and gift or hang at home.
A great workshop for beginners to get a taste for printmaking - see here what previous participants have created.
All materials and tools are provided including inks, quality printmaking paper a lino block.
What to bring: Ideas for a 10 x 10 cm square image, for example a simple black and white drawing.
It'll be great fun and at the end you'll have a unique print to keep or give away. You'll also have your own unique lino block that you can re-use to print your own cards or other items.
Price includes:
All inks and tools
Quality printmaking paper
Lino square
About your tutor:
Amanda Donohue studied printmaking at Sydney College of the Arts graduating with a Bachelor of Visual Arts (Honours). She has been a printmaker for over twenty years and a member of the Newcastle Printmakers Workshop for seven years. See more about Amanda at www.amandadonohue.org.


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Allergen friendly Chocolate Snowman Lollipop. Perfect for anyone with a nut allergy or dairy allergy! Made in a dedicated nut free facility and dairy free facility.
Get in the holiday spirit with our adorable Chocolate Snowman Lollipop! Each lollipop is wrapped in plastic and tied with a beautiful ribbon bow.
A great holiday gift for someone you know who suffers from food allergies! But you certainly don't need to have a food allergy to enjoy it! Our semi-sweet chocolate is so good that many of our customers choose it simply because it's vegan and it tastes great!
Certified Kosher Pareve. Please contact us directly with any questions about our Kosher certification or inspections.
Net weight 0.6 oz.
Allergy Free Info: No Peanuts, No Tree Nuts, No Dairy, No Eggs, No Soy, No Gluten, No Sesame, No Mustard, and No Corn Syrup! Non-GMO and Vegan!
INGREDIENTS : Organic Cane Sugar, Unsweetened Chocolate, Cocoa Butter [non dairy]


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This website contains information about some of the road races in the counties of Kerry, Limerick, Clare, Tipperary and Waterford in Munster, Ireland. For races in Cork, see the Running in Cork website which is the largest athletics website in Munster. That site also contains plenty of national and international news items as well.
Friday, December 14, 2012
Nominations for best Half-Marathon in Munster in 2012
So it's your choice! What Half-Marathon races in Munster should be nominated for the vote? Forget about the bad ones or those you didn't like. Just leave a comment below and tell us what ones you did like and why? I'll put up a poll on the Running in Cork site in about a week and we'll see who wins.
If you want to send me an e-mail with your nomination then that's fine as well.
Posted by John Desmond at Friday, December 14, 2012
2 comments:
think you got the year wrong there in the title..:)
- December 14, 2012 at 11:15 AM
- John Desmond said...
Now corrected! Always thinking too far ahead ;o)
- December 14, 2012 at 11:21 AM
Subscribe to: Post Comments (Atom)


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Knitted Hat with Faux Fur Pompom in Black
is backordered and will ship as soon as it is back in stock.
Women's knitted hat for cold winter days made of particularly soft yarnbeautiful cable patternCuddly soft liningEnvelope and faux fur pompomOne size
Shell 50% viscose; 29% polyester; 21% polyamide100% polyester lining
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First time customers get 10% off by using the code:


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Goodbye, Miiverse, you beautiful, mutant thing.
If you're a Nintendo fan, it's hard not to get a little emotional about it. The Miiverse was a great expanse for small, lonely shouts into the abyss that is Nintendo's communication infrastructure. Sometimes, we saw great, well-rendered gestures of love for dear Nintendo characters like Splatoon's Callie. Other times, posts were very dark and full of upsetting innuendo.
Today, Nintendo launched a final community for fans to mourn the going-away of the Miiverse. On the Miiverse home page, it's listed as a "special community" for players to share their memories and thoughts about the Miiverse. Right now, it's full of tears and pleads stick around. Take a look and post your own Miiverse goodbyes the comments:


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IllinoisRock Island County Contractor Bond
Cost: $100
Contractors who wish to work in the county of Rock Island must provide the Zoning & Building Safety Department with a $10,000 surety bond prior to receiving a license or permit.
Secure Checkout
Backed by SSL, our online bonding process is secure. We are committed to your privacy.
Purchase your bond today and we'll email your bond directly to you. No shipping required.
Best Prices
We shop the top surety markets to find you the best rate.
- State:
- Illinois
- Amount:
- $10,000
- Term:
- 1 year
- Licensing Agent:
- Brooklyn Ventures, LLC
- License Number:
- 100288586


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IDFC Mutual Funds has launched its latest pan-India investor awareness campaign titled #PaisonKoRokoMat. With this new campaign, IDFC Mutual Fund aims to shift the conversation regarding wealth creation from the traditional to the contemporary.
Boost your Banking Awareness Knowledge with Adda247 Live Batch: TARGET GA BATCH | Banking Awareness Batch for SBI, RRB, RBI and IBPS Exams
About the campaign:
- This new campaign of IDFC Mutual Fund urges savers to become investors and explore the smart and modern mutual fund vehicle for their investments.
- The 360-degree campaign focuses on looking beyond the traditional ways of growing your money and using your goals to allocate your money across asset classes and investment solutions.
- The campaign has been conceptualised and created by TBWAIndia.
Important takeaways for all competitive exams:
- IDFC First Bank CEO: V. Vaidyanathan.
- IDFC First Bank Headquarters: Mumbai.
- IDFC First Bank Founded: October 2015.


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15 Apr Senate Ave Smoke Show Jalapeño Blonde
Senate Ave Smoke Show Jalapeño Blonde
Senate Avenue Brewing Company
Jersey Village
Blonde with Jalapeños
IBUs: ?
Packaging: Draft, 32-ounce Crowlers
I heard Senate Ave had a pepper beer, and my ears perked up. I love spicy food, spicy drinks, hot sauce, and my love for craft beer actually started with Don Jalapeño from No Label. I'm always glad to try a new pepper beer, so I had to grab a crowler from Senate Ave.
When I stopped in, I was lucky that there was no line. A few folks were enjoying beers with friends, but I was able to belly up and order my crowler in 30 seconds flat! The guy that was filling it was either verrrry careful, or he needed a little more training. 13 minutes later, I headed home, ready to try some Senate Ave Smoke Show Jalapeño Blonde alongside my chicken enchiladas verdes.
Fire up the grill, pour up a glass, and start cleaning the tomatillos.
Senate Ave Smoke Show Jalapeño Blonde crowler is black, white, and silver with the twistee top. I haven't seen any of their Taphandles out and about yet, but I haven't really been out and about much either!
I poured it as I was grilling, and the color was a copperish-gold with a slight haze, but it was just a step away from clear. The tiny ghost-white head disappeared quickly, and the lacing was delicate and spotty.
The smell of Senate Ave Smoke Show Jalapeño Blonde was rich and toasty with savory pepper notes.
The first sip of Senate Ave Smoke Show Jalapeño Blonde was nuanced and inviting. The smokiness of the peppers was so airy, and there was nearly no burn on the finish like some others. The light, clean blonde base beer shone through well without being dominated by the peppers. It fell pretty flat carbonation wise, but I think that may be due to a 3/4 filled crowler. I can't wait to give it another shot on draft.
The only thing I can think to compare it to is No Label Don Jalapeño. It's a lot more tame and approachable, though. That may be a good thing or a bad thing depending on who you ask. Senate Ave Smoke Show Jalapeño Blonde is certainly sweeter as well. I'd love to get another crowler of this and make some micheladas with it.
As far as I know, this Jalapeño Blonde is on draft at the Senate Ave taproom, and only at the Senate Ave taproom. Bummer for those of you on the other side of town!
Senate Ave Smoke Show Jalapeño Blonde
Overall, it was pretty dang good. I think the crowler experience set my expectations pretty low, but despite the lack of carbonation, I could taste all the goodness that was hidden within. This is a good beer, and I expect to see good stuff from the team in Jersey Village thanks to this one!
User Review( vote)
Beers to you, Houston! 🍻


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In the past several years, the aboriginal knowledge organization structure has received a respectable amount of attention. However, aboriginal knowledge is commonly spread by oral tradition and rarely through writing. With regards to such behavior, it is understandable that the aboriginal knowledge organization structure is incomplete. Currently, the classification of Taiwan's aboriginal knowledge in the New Classification Scheme for Chinese Libraries is still roughly sorted with descriptions of aborigines classified simply by tribe while other subject matters and aspects relating to the indigenous people are scattered under the classification number of relevant subjects. It is clear that applying this type of classification on aboriginal documents and records has quite a number of inadequacies.
Responding to contemporary trends in information management and to the needs of Taiwan's Indigenous Peoples Resource Center, this research aims to detail Taiwan's aboriginal knowledge organization structure starting with the upper-level structure, and through the integrated and interactive participation of aboriginal scholars, anthropologists, and professionals in library and information sciences., the core of the upper-level structure is established and confirmed. In this way, further work division and collaboration is possible, and aboriginal knowledge with different themes and facets can be classified by experts of different fields. This research hopes to provide Taiwan's Indigenous Peoples Resource Center with a classification system that can correspond more to the indigenous people's point of view and also serve as future reference for the Center.
This paper explores the rational, issues and instructional strategies for developing and implementing an Information Literacy and Ethics curriculum for Taiwan college students. The paper first questions why it is infact this curriculum is needed and identifies the lack of an effective learning domain in the existing computer/network curricula. Secondly, important topics for the curriculum content are outlined which include information literacy, information use and verification, information society, information ethics, and Internet safety and behaviors. Thirdly, possible instructional design strategies for the curriculum are discussed, including problem-based learning, case-based instruction, media design principles, course activities design, and evaluation approaches.Finally, the effectiveness of fully online and face-to-face courses is examined.
構成唐宋詞的形式元素是文字及音樂,詞人們以情境相通,物我交融的寫作技巧,將深刻細膩的情感內涵以文字及音樂傳遞到閱聽者心中。唐宋詞多媒體網站的設計,便是以能夠引發情境感知(Context - Awareness)的文字、影音、圖像、動畫等多媒體,作為引導閱聽者欣賞唐宋詞文本內涵的媒介為主要的設計方向,著重在表現唐宋詞文體特色,讓使用者登入網站,即可感受到唐宋詞文字、音樂、心境、情境、意境之美。
The Tang and Song Dynasties witnessed the greatest literary achievements in Chinese history. In addition to the traditional genres of poems, ci (or lyrical poetry), articles, and legendary novels, the fine arts including music, painting, and calligraphy also reached their creative heights. These periods were characterized by mutual interchange of materials and their blending. Many men of letters boasted talents in the various arts. Men of letters such as Su Shi were skilled at producing articles and paintings; Emperor Huizong was both a calligrapher and painter.
The elements of ci (or lyrical poetry) in Tang and Song Dynasties are words and music. Composers of lyrical poetry conveyed profound and delicate sensitivities to their audiences through words and music. The design goal of this multimedia website is to focus on words, videos, pictures and animations that stimulate Context-Awareness cognition to guide readers and listeners in appreciating lyrical poetry of the Tang and Song dynasties. The emphasis is on presenting characteristic writing styles so that once logged onto the site, users can discover the beauty of words, music, psyche, context and prospects.
Therefore, the focus of this paper aims at exploring the establishment of a website that stimulates users to understand lyrical poetry in the Tang and Song Dynasties through multimedia and by means of Context-Awareness cognition, to aid browsers, and to promote literature in a brand-new form and medium.
This paper reviews the significance and recent development of web archiving projects and includes a summary of the current state of web archiving in many countries. This paper focuses on NTUWAS as an example of an archive which combines approaches for acquiring information collections, and establishs institutional repository and eventsoriented web sites for future studies.
在知識經濟的時代裡,世界各國不斷地持續推動圖書館資源共享,而且績效卓越,文獻傳遞服務已成為圖書館服務項目裡的重要一環,而臺灣大學圖書館乃依據其近年來使用國內館際合作NDDS服務系統及國際文獻傳遞服務RapidILL系統的實務經驗與數據進行整體分析,而研究方法主要是採用著名的科技接受模式(TAM Model)來進行調查使用者對NDDS及JADE的使用情形(JADE為RapidILL的申請介面系統),其結果發現JADE在系統有用性、容易使用度及系統效益三個構面的表現均比NDDS來得佳;最後,希望藉由本研究報告的各種分析調查結果,能更進一步了解讀者的內隱與外顯之資訊需求,以提昇文獻傳遞服務的效率及效能,並期望能藉由臺灣大學圖書館案例的分享,來提供國內其它圖書館進行文獻傳遞服務時的參考資訊。
Purpose - This paper aims to identify the information needs of users of the National Taiwan University Library and to formulate improvements to the interlibrary loan service by examining the usage statistics of the document delivery systems NDDS and RapidILL. These results may serve as future reference materials for other libraries operating document delivery services.
Design/methodology/approach - The study used the technology acceptance model (TAM) to analyze user behaviors and system acceptance levels in the NDDS and JADE document delivery service systems (JADE is the application interface of the RapidILL in National Taiwan University library).
Findings – 1.RapidILL performs better than NDDS in the following areas: usefulness, ease of use and system satisfaction. 2.Yields a clearer understanding of users' needs from statistical analysis
In order to understand users' opinions regarding the quality of service at the National Taiwan University Library, a survey was conducted through questionnaires distributed from May 25th to June 8th in 2009. Using the survey tool, LibQUAL+, respondents were asked 22 questions about their needs, expectations and actual experiences relating to the library's collections and resources, the physical environment and library facilities, and the quality of services. Furthermore, another four questions that focused on the satisfaction level of the overall quality were also asked. The evaluations were rated on a scale of 1 to 9. There were 5,948 valid questionnaires in total. In addition to analyses on basic information, the responses to all 22 questions were analyzed. The results were presented in tables and graphs to show scores for minimum expectation, satisfaction, maximum expectation, acceptability, and flawlessness. The conclusion and suggestions made based on the survey will serve as guidelines for future management and development of the NTU library.


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How An Obscure Government Code — 834 — Became Big In 2013
Monday is the last day Americans in most states will be able to enroll in Affordable Care Act health exchanges if they want coverage to start in January. But technical problems have foiled sign-ups from the start, which led an otherwise obscure number to become a big deal in 2013.
The government code for electronic files — 834 — came up a lot in the news this fall. What is it? The 834 forms are read by computers, not humans. They give insurance companies basic information about customers — name, contact information, social security number — so the health plans can enroll consumers. It's critical they get to insurers accurately so insurance plans can bill for premium payments and start coverage.
"It's remarkable that this obscure decades-old data file format has actually been so much in the news this fall," says Larry Levitt, a health industry watcher with Kaiser Family Foundation. He says 834's would never have gotten this kind of attention had HealthCare.gov actually worked smoothly at launch.
"There was a bit of [a] hidden problem with these 834 files [in October and November], so even when people could get through the system and actually apply for coverage and pick a plan, it turns out that much of the information was never making it to the insurance company," Levitt says. "In the first couple of months as many as 15,000 people simply didn't even exist in the 834 files. That problem seems to have gone away."
The 834 files may be sending clean information now, but for the previously missing or inaccurate files, reconciling the data entered into HealthCare.gov with information insurance plans received started early this month.
"We are in the process of actually hand-matching individuals with insurance companies," Health and Human Services Secretary Kathleen Sebelius said on Capitol Hill in early December.
The rush to finish matching files and process the enrollments still coming in had some people panicked about gaps in coverage. That's because an administration rule said consumers were required to send in their first month's premium payment by the end of December for coverage to start in January. But given the thorny back-end problems with the 834's, health insurance plans have extended the payment window to Jan. 10.
"They wanted to make sure consumers could have peace of mind, that they could enjoy their holiday break with their families and not worry that their payment did not make it there by Dec. 31," says Robert Zirkelbach, who represents the insurance industry group America's Health Insurance Plans.
President Obama says he expects the mismatched files and missing information will be fixed in time for people to get their coverage in January.
"Then I think all eyes will turn to January," says Levitt. "To make sure people who think they have coverage actually are insured and can go to the doctor, go to the pharmacy, and get services."
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Huawei Y6s features a Dual Sim, 64GB of internal storage, 3GB of RAM, 6.09 "screen, 13 MP camera, Android 9.0 system and a 3020mAh Battery. Order for this Huawei Y6s online from Jumia Kenya and have it delivered to you.
6.09″ Dewdrop Display
An impressive 6.09" Dewdrop display with 87% screen-to-body ratio2 provides an ultra-broad view for gaming, browsing and reading. The HUAWEI Y6s also blocks out harmful blue light with a TÜV Rheinland certified screen, protecting your eyes from all-around.
3GB + 64GB Large Storage
Keep your favorite movies, photos and apps as you want with the 64 GB ROM memory and 512 GB4 expandable storage. Further more, the EROFS technology can automatically compress the pre-installed files into a smaller size for up to 2 GB5 more storage saved in the other apps.
Octa-Core Processor. Enhanced Performance
The built-in 12nm Octa-core chipset includes four 2.3 GHz big cores and four 1.8 GHz tiny cores, effectively enhancing the running performance to full-speed and efficiently lowering the power consumption.huawei y6s octa-core processor phoneEnhanced PerformanceThe built-in 12nm Octa-core chipset includes four 2.3 GHz big cores and four 1.8 GHz tiny cores, effectively enhancing the running performance to full-speed and efficiently lowering the power consumption.
Unlock in A Flash
The HUAWEI Y6s provides a rear fingerprint sensor and face un-lock. This phone can be un-locked in a flash and protects your personal information perfectly.
Huawei SuperSound
Equipped with the Super Linear Speaker and powerful smart PA, HUAWEI Y6s can intelligently deliver deeper bass and brighter treble even in loud music. This phone is your personal portable speaker while listening to music at home, partying with friends or hanging out at the beach.
Amazing 13MP and 8MP Cameras
Capture every fantastic moment with the stunning 13 MP rear camera and 8 MP front beauty camera. Featuring a wide f/1.8 aperture lens, with up to 50% more light,6 the quality and clarity in your brilliant shots will be enhanced no matter during the day or night.
Intelligent Battery Life
The HUAWEI Y6s leverages a 3020 mAh battery with intelligent battery optimization. The software with hardware synergy works together to keep your phone going all day long.
EMUI 9.1 Smart Life
Supported by EMUI 9.1, the simple and intuitive interface on this phone allows it to be stress-free and easy to use. The Easy Mode, Phone Clone and full screen gesture navigation provide more possibilities for a convenient and smart life.
Technical Specifications
- Dimensions: 156.3 x 73.5 x 8 mm (6.15 x 2.89 x 0.31 in)
- Weight: 150 g (5.29 oz)
- Build: Glass front, plastic back, plastic frame
- SIM: Dual SIM (Nano-SIM, dual stand-by)
- Type: IPS LCD capacitive touchscreen, 16M colors
- Size: 6.09 inches, 91.0 cm2 (~79.2% screen-to-body ratio)
- Resolution: 720 x 1560 pixels, 19.5:9 ratio (~282 ppi density)
- OS: Android 9.0 (Pie); EMUI 9.1
- Chipset: Mediatek MT6765 Helio P35 (12nm)
- CPU: Octa-core (4×2.3 GHz Cortex-A53 & 4×1.8 GHz Cortex-A53)
- GPU: PowerVR GE8320
- Card slot: microSDXC (dedicated slot)
- Internal: 64GB, 3GB RAM
- eMMC 5.1
- Single: 13 MP, f/1.8, PDAF
- Features: LED flash, HDR, panorama
- Video: 1080p@30fps
- Single: 8 MP, f/2.0
- Video: 1080p@30fps
- Loudspeaker
- 3.5mm jack
- WLAN: Wi-Fi 802.11 b/g/n, Wi-Fi Direct, hotspot
- Bluetooth: 4.2, A2DP, LE
- GPS: Yes, with A-GPS, GLONASS, BDS
- NFC: Yes (JAT-LX1 NFC only)
- Radio: FM Radio, built-in antenna
- USB: microUSB 2.0
- Sensors: Fingerprint (rear-mounted), accelerometer, proximity
- Non-removable Li-Po 3020 mAh battery
- Handset x 1
- Charger x 1
- USB Cable x 1
- Quick Start Guide x 1
- Eject tool x 1
- TP protective x 1


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Charisma Carpenter, known for playing Cordelia Chase on Buffy the Vampire Slayer and its Angel spinoff, has accused director Joss Whedon of abusive on-set misconduct.
Carpenter revealed her experiences with Whedon in an Instagram post, which she preceded with a series of quotes about speaking up. Preempting any criticisms about waiting over two decades to raise her allegations, one of the quotes read, "Don't ask why victims wait so long to speak up. Ask what systems were in place to keep them quiet."
Stating that she feels traumatized by Whedon's behavior to this day, Carpenter said "Whedon abused his power on numerous occasions" during both Buffy and Angel. "While he found his misconduct amusing, it only served to intensify my performance anxiety, disempower me, and alienate me from my peers," she wrote. "The disturbing incidents triggered a chronic physical condition from which I still suffer. It is with a beating, heavy heart that I say I coped in isolation and, at times, destructively."
In particular, Carpenter claimed Whedon would frequently and passive-aggressively threaten to fire her, especially while she was pregnant during shooting of Angel. "Unfortunately, all this was happening during one of the most wonderful time in new motherhood," she wrote. "All that promise and joy sucked right out. And Joss was the vampire." She added he would "callously [call] me 'fat' to colleagues when I was 4 months pregnant, weighing 126 lbs. He was mean and biting, disparaging about others openly, and often played favorites, pitting people against one another to compete and vie for his attention and approval."
She said it took "multiple calls from my agents" to connect with Whedon and inform him of Carpenter's pregnancy. Once he found out, he brought her in for a closed-door meeting where "he asked me if I was 'going to keep it' and manipulatively weaponized my womanhood and faith against me. He proceeded to attack my character, mock my religious beliefs, accuse me of sabotaging the show, and then unceremoniously fired me the following season once I gave birth."
Carpenter said she was once called to set at 1:00 a.m. while pregnant, despite a doctor's recommendation to shorten her work hours. "Due to long and physically demanding days and the emotional stress of having to defend my needs as a working pregnant woman, I began to experience Brazton Hicks contractions," she wrote. "It was clear to me the 1:00 a.m. call was retaliatory."
Carpenter also recalled getting a rosary tattoo during her time on the shows "to help me feel more spiritually grounded in an increasingly volatile work climate that affected me physically." This, too, became a point of contention with Whedon, who called her in "for a sit-down meeting to interrogate and berate" her.
As for why Carpenter is coming forward with these accusations now, she wrote,
"Despite the harassment, a part of me still sought his validation. I made excuses for his behavior and repressed my own pain. I have even stated publicly at conventions that I'd work with hima gain. Only recently, after years of therapy and a wake up call from the Time's Up movement, do I understand the complexities of this demoralized thinking. It is impossible to understand the psyche without enduring the abuse. Our society and industry vilify the victims and glorify the abusers for their accomplishments. The onus is on the abused with an expectation to accept and adapt to be employable. No accountability on the transgressor who sails on unscathed. Unrepentant. Remorseless."
Carpenter explicitly cited Ray Fisher's treatment by Warner Bros. after he raised his own accusations of Whedon's behavior on the set of Justice League. The actor, who played Cyborg in the DC superhero film, has long been vocal about Whedon's alleged racist and abusive actions while working on Justice League. The allegations led to an investigation by WarnerMedia, but Fisher argued DC Films President Walter Hamada conducted it improperly, choosing to protect Whedon and executives Jon Berg and Geoff Johns rather than actually addressing the core issues.
In the end, "remedial action" was taken against Whedon. Whedon departed the upcoming HBO series he created, The Nevers, though the public story was that it was due to emotional strain caused by the pandemic. However, Fisher implied his departure was part of the disciplinary actions resulting from the investigation. Unfortunately, it appears the ongoing battle also cost Fisher his role as Cybrog in the upcoming Flash movie.
In her statement, Carpenter stood in solidarity with Fisher. She revealed she had participated in WarnerMedia's Justice League investigation "because I believe Ray to be a person of integrity who is telling the truth." She added that it was his apparent firing as Cybrog that proved to be "the last straw." "Although I am not shocked, I am deeply pained by it," she wrote. "It troubles and saddens me that in 2021 professionals STILL have to choose between whistleblowing in the workplace and job security."
Carpenter also added,
"With tears welling, I feel an overwhelming sense of responsibility to Ray and others for remaining private about my experience with Joss and the suffering it has caused me. It is abundantly evident that Joss has persisted in his harmful actions, continuing to create wreckage in his wake. My hope now, by finally coming forward about these experiences, is to create space for the healing of others who I know have experienced similar serialized abuses of power."
Fisher has since responded in his own tweet. "Charisma Carpenter is one of the bravest people I know," he wrote. "I am forever grateful for her courage and for her lending her voice to the Justice League investigation. Read her truth. Share her truth. Protect her at all costs. 'It is time.'"
Update 3:00 p.m. ET: Buffy stars Sarah Michelle Gellar, Michelle Trachtenberg, and Amber Benson have each commented on the new accusations. Gellar, who played the title heroine on the long-running series, wrote on Instagram,
"While I am proud to have my name associated with Buffy Summers, I don't want to be forever associated with the name Joss Whedon. I am more focused on raising my family and surviving a pandemic currently, so I will not be making any further statements at this time. But I stand with all survivors of abuse and am proud of them for speaking out."
Reposting Gellar's statement, Trachtenberg said she was only "brave enough now as a 35 year old woman… to repost this." "As a teenager. With his not appropriate behavior….very. Not. Appropriate […] There was a rule. Saying. He's not allowed in a room alone with Michelle again."
Meanwhile, Benson never appeared on Buffy at the same time as Carpenter, but they've become close over years on the convention circuit. Benson tweeted, "Buffy was a toxic environment and it starts at the top. @AllCharisma is speaking truth and I support her 100%. There was a lot of damage done during that time and many of us are still processing it twenty plus years later."
Read Carpenter's full statement and her fellow actors' responses below.
Charisma Carpenter is one of the bravest people I know.
I am forever grateful for her courage and for her lending her voice to the Justice League investigation.
Read her truth.
Share her truth.
Protect her at all costs.
"It is time."
A>E#IStandWithCharisma https://t.co/XcT8OnAfbV
— Ray Fisher (@ray8fisher) February 10, 2021
Buffy was a toxic environment and it starts at the top. @AllCharisma is speaking truth and I support her 100%. There was a lot of damage done during that time and many of us are still processing it twenty plus years later. #IStandWithRayFisher #IStandWithCharismaCarpenter https://t.co/WJAmDGm76C
— Amber Benson (@amber_benson) February 10, 2021


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Beach & Gulf View Retreat
Perfect location on beach w/ BeachHouse Restaurant / Bridge Street /Trolley/Wifi!
Perfect location!! Relax, relax, relax. Five-star rated vacation property says it all! The options are many once you enter the Beach View Retreat. Wake up to the sunrise across the Inter-coastal bay on the east side of the complex. Check out the beach, dolphins and fish/tarpon jumping, and diving birds in the Gulf of Mexico through the high-powered binoculars. Head out to the white powder sand of the beach. Return to enjoy a dip or more horizontal time at our condo swimming pool. Watch the sunset into the Gulf of Mexico from the beach, from the home's living room, from the home's master bedroom, or from the home's lanai open-air patio. End the perfect day with a walk across the street to the BeachHouse Waterfront Restaurant or a couple blocks south to the Bridge Street restaurants for dinner.
Florida's best kept secret, Anna Maria Island, features beautiful white sugar sand beaches, older Florida charm, award-winning restaurants, year-round golf courses, and pristine shopping all within easy walking and driving distance, or a ride aboard the free 'Anna Maria Island Trolley', which stops near your next vacation destination, the Beach View Retreat. One of the few places in the world where the sunset is regularly applauded, this tiny slice of paradise stretches for 7 miles into the Gulf.
The Beach View Retreat is located in the highly valued Bridgeport Condos. Sightings along the Gulf of Mexico beach and inter-coastal waterway include Manatees, Rays, Dolphins, many kinds of fish, huge Pelicans, Blue Herons, Egrets, Osprey, Terns, Gulls, and other amazing creatures. Some people even get married at the beach area and stay in the home with family! Common sites along the beach areas include Sea Turtle nests and bird nesting sanctuaries during special times of the year.
"Anna Maria Island's Hot Spot" is now Historic Bridge Street on Bradenton Beach, the southernmost city of Anna Maria Island. Bridge Street, where the original wooden bridge was the only means of access to the island, where a beautiful fishing pier is in its place today, leading to an active street where you can Shop~Dine~Play from beach to bay. Bridge Street offers a walkable community with spectacular water views from the both the pier and the gulf beach and only a couple blocks from Beach View Retreat.
The Beach View Retreat offers everything you need for your beach stay! Just bring your food, clothing and toiletries. Beach chairs, beach umbrella, and beach toys for the kids are available in our garage level storage room including beach chairs and toys. Dishes, pots, pans, linens and towels are all provided – just bring your swimsuit and enjoy! The Beach View Retreat features a master bedroom having an en-suite bathroom with large closet and a guest bedroom with its own bathroom. Additionally, there is a LazyBoy sleeper sofa in the family room. Other amenities to perfect your stay include:
• Covered Lanai/Patio with nearly 180-degree direct beach views
• Living Room picture window with nearly 180-degree Gulf of Mexico views
• Elevator access or stairwell access for handicap access at your convenience
• Grocery cart for easy carrying from car to elevator and up to home
• Garbage bag drop right around corner from home
• High-Speed Wireless Internet service with 120 MB+ per second download speeds + 12 MB per second upload speeds
• Cable on the high definition LED flat-screen TV
• New Trane air conditioning unit
• Keurig K55 Programmable Coffee Cup Maker
• 1,060 square feet living space
• 2 Car Parking Spaces
• 2 Televisions
• 2 Bathrooms
• Washer & Dryer
• Grill on lanai/patio
In less than 2 minutes, you will be spending your day on the beach, or venture out a bit further and hang out fishing in one of the many great spots nearby. Sightings along the Gulf of Mexico beach and inter-coastal waterway include Manatees, Rays, Dolphins, many kinds of fish, a wide variety of birds, and other amazing creatures. Common sights along the beach areas include Sea Turtle nests and bird nesting sanctuaries during special times of the year. Once in a while, you'll come across a Gulf-side wedding!
While some prefer the isolation of the nearby beaches, others opt toward more people at the public beaches. If that is your desire, venture to Coquina Beach at the south end of Bradenton Beach and Anna Maria Island, or Manatee County Beach at the west end of Manatee Avenue in Holmes Beach, or Anna Maria Pier at the east end of Pine Avenue for the intercoastal/Tampa Bay access. Anna Maria Pier is a special place where many times you can see fish, rays, dolphins, and manatees swimming underneath you as well as fish from the dock and have a nice meal or an ice cream cone at Two Scoops Ice Cream Shop. (The Pier is currently under repair, Winter 2017.)
If you're in the mood to tour around the rest of the island, catch the free trolley around the corner and it will take you to any of the beaches, restaurants, shops or grocery stores along Gulf Drive anywhere on Anna Maria Island. Take the trolley to the old historic Bridge Street area of Bradenton Beach to enjoy the Key West style restaurants and shops. If you enjoy painting or photography, the sunsets are among the best in the world.
Enjoy live music nightly and dinner at Manatee Public. By timing it right (usually 7 pm), you can enjoy sea creature (fish, eel, and shark) feeding by the owner while enjoying Ice Cream at Holy Cow Ice Cream.
A lovely sunrise can be enjoyed along the Coquina Baywalk. Bean Point and Coquina Beach are great beaches to visit along with Sunset Park next to our home.
Just across the Cortez bridge on the south side of the island, is the old school Florida fishing village of Cortez, where restaurants have excellent seafood and some have live music. Swordfish Grill is our favorite on the dock.
We have 3 favorites for breakfasts: 1) Rod & Reel Pier, 2) Ginny's & Jane E's, and 3) The Donut Experiment (fun for the kids but not completely filling).
Eco tours and on the Gulf and Intercoastal via boats, kayaks and jet skis are always nice. The Ringling Museum in Sarasota is great.
The Regina is a sugar barge that sunk just off our beach during a storm in 1940. It is in about 20 feet of water just 150 feet or so off the beach. It is marked with a buoy. The Regina is 10th Florida Shipwreck Underwater Archaeological Preserve.
There is a small reef of rocks about 150 feet northwest from the Sunset Park Beach directly west of our home. I like to swim out to it and then dive down 8-10 feet to see colorful fish like the striped Sheepshead, etc.
Our kids love going to the Bridge Street Pier or taking the free trolley just outside the door up to Anna Maria Pier and looking for fish in the water (especially in the morning to early afternoon when you can see well through the clear water), talking to the fisherman, and eating at the restaurant or getting ice cream at Two Scoops. The Blueberry Pie ice cream is my favorite… The Trolley stops every 20 minutes from about 6 am to 10 pm.
Come enjoy the unbelievable location of the Beach View Retreat near corner of Gulf & Cortez!
Check out this beautiful location in 360º VR!
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The graphics & signage industry is built on innovation. Finding new and more creative ways to express a client's vision is our bread and butter. This begs the question: why aren't more of us taking advantage of R&D tax credits when almost everyone qualifies for them?
Vism sat down with Dan Handforth from R&D tax incentive advisors & print and signage industry specialists, Kene Partners, to take a closer look at the scheme and how unbelievably easy it is to take advantage before the year ends.
R&D tax credits explained
Research and development (R&D) tax credits aren't a new thing—they've been around for 17 years and exist with the sole purpose of rewarding UK businesses for their innovation initiatives.
"Through considerable research we've discovered that the most overlooked aspect of tax relief is in the area of R&D", Adam Kene, (MD of Kene Partners) told Image Reports magazine. "Of all the creative enterprises it is, in particular, signage and large-format digital print companies that are the ones most engaged in R&D and which can therefore most benefit from these tax breaks."
So why aren't they? The simple fact is that many companies don't believe they qualify and those who do feel as though the claim process is too complex to deal with. Dan Handforth encourages print & signage companies to reconsider, and here's why…
Which activities qualify for R&D tax credits?
Technology in the graphics & signage industries has progressed at an alarming rate in recent years, partly in response to customer demand and partly due to innovation in the wider technology field.
Innovative finishing options, high definition presses, automated processes and more sustainable/environmentally-friendly changes are all initiatives that hold the potential for HMRC tax relief, says Dan. And Kene Partners MD, Adam, agrees:
"If you, as a director of a digital print or signage company, want to be able to meet the demands of any customer, whether they're asking for apparently straightforward results or far more complex work that requires any change or alteration in the equipment you're using to produce the best work you can, the R&D tax relief scheme is almost certainly for you."
According to Dan, if you can prove a project or initiative meets any of the following criteria, you have a solid R&D tax credit claim:
- An attempt to make advancement in science or technology
- The project was designed to overcome an element of industry uncertainty
- The project could not have been carried out readily by competent professionals/industry experts
Much of this should sound familiar and, if it does, you could have a solid tax relief claim on your hands!
How much can I get back with R&D tax credits?
The size of your company determines how much tax relief you can get. Dan gave the following estimations as a guide:
SMEs: Signage & print businesses with less than 500 employees or a turnover of less than €86m can claim up to £33,350 for every £100,000 spent on eligible R&D activities.
Large companies: Larger businesses that have over 500 employees or turnover more than €100m can claim something known as 'research and development expenditure credits', which are valued at 11% of the cost of eligible activities.
Claiming R&D tax credits
Although you can submit a claim through the HMRC website, Dan advises working with an R&D professional so you can get the maximum amount of relief available to you.
Large format printing specialists RMC Digital revealed that they were able to submit a more substantial claim to HMRC in less time by working with Kene Partners. It took a single half-day workshop to collate details from relevant stakeholders, after which time, Kene Partners wrote a detailed report which could be submitted to HMRC:
"It was clear to us from the initial presentation that if we attempted to process the claim ourselves we would not have been able to get the full value of the claim," RMC said in a recent interview.
The same was true of Signbox, who successfully claimed £125,000 by working with Kene Partners, showing the value of working with a team who really understand the print & signage industries. They recorded a great 2 minute video explaining how.
"We previously made an R&D tax claim in-house. It was significantly less than the £125,000 that Kene Partners secured for us" Watch how Industry leaders, Signbox secured £125,000 in R&D Tax Credits to invest in the launch of a new e-Store and precision cutter #innovation
R&D tax advisors like Kene Partners work on a success-fee basis, so you won't be charged anything unless your claim is successful. Dan also advises that you can backdate your claim for the previous two years to maximise your payout. Better yet, initial consultations are free!
So why not give it a try? R&D tax credits are an excellent way to fund even more innovation and to be rewarded for something you do already.