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XIXA - New Single - 'The Code'
posted at 02/04/2019
Spotify: https://spoti.fi/2Rr2ypu
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For their new, four-track EP XIXA - Tucson's dark, dusty gothic overlords - reached further into the desert, into their instruments, and into their words to carve a more grandiose space for their cumbia-tinged psychedelic rock to swell. The guitar-slinging six-piece from the deep Southwest combine gritty guitars, the bumping grind of chicha, and windswept desert blues into a mesmerizing stew, The Code being the next step in their evolution. A swirling, raw collection of songs, intense and sun bleached yet shot through with an inky gothic horror, it's XIXA at their potent, eclectic best.
Pre-Order XIXA 'The Code' 10'' (ltd.): https://bit.ly/2D6sqBV
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Arquivos Brasileiros de Cardiologia
Print version ISSN 0066-782X
Arq. Bras. Cardiol. vol.100 no.4 São Paulo Apr. 2013 Epub Apr 02, 2013
Implementation of the myocardial infarction system of care in city of Belo Horizonte, Brazil
Milena Soriano MarcolinoI,II; Luisa Campos Caldeira BrantI,II; Janaina Guimarães de AraujoIII; Bruno Ramos NascimentoI,II; Luiz Ricardo de Ataide CastroI,II; Paula MartinsIII; Lucas Lodi-JunqueiraI,II; Antonio Luiz RibeiroI,II
IHospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, MG - Brasil
IIFaculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG - Brasil
IIISecretaria de Saúde da Prefeitura de Belo Horizonte, Belo Horizonte, MG - Brasil
BACKGROUND: The creation of an acute myocardial infarction (AMI) management systems is aimed at optimizing the management of patients from early diagnosis to proper and timely treatment.
OBJECTIVE: To assess the implantation of an AMI management system in the municipality of Belo Horizonte, state of Minas Gerais, and its impact on in-hospital mortality due to AMI.
METHODS: The AMI management system was implanted in the municipality of Belo Horizonte between 2010 and 2011, aiming at increasing the access of patients of the public health system to the treatment recommended by the existing guidelines. The teams at the prompt care units were trained, and the system of tele-electrocardiography was implanted in those units. The primary outcomes of this retrospective observational study were the number of admissions and in-hospital mortality due to AMI, from 2009 to 2011.
RESULTS: In the period studied, 294 professionals were trained and 563 electrocardiograms (ECGs) transmitted from prompt care units to coronary units. A significant reduction was observed in the in-hospital mortality rate (12.3% in 2009 versus 7.1% in 2011, p < 0.001), while the number of admissions due to AMI remained stable. The mean cost of admission increased (mean R$ 2,480.00 versus R$ 3,501.00; p < 0.001), the proportion of admissions including intensive care unit stay increased (32.4% in 2009 versus 66.1% in 2011; p < 0.001), and the number of patients admitted to tertiary hospitals increased (47.0% versus 69.6%; p < 0.001).
CONCLUSION: The AMI management system implantation increased the access of the population to proper treatment, thus reducing in-hospital mortality due to AMI.
Keywords: Myocardial infarction / mortality; Myocardial infarction / therapy; Emergency Medical Services; Intensive Care Units.
Over the past decades, an important reduction in the mortality rate of cardiovascular diseases has been observed, being related to advances in primary prevention and treatment of acute coronary syndrome (ACS)1-4. Although a world trend, that reduction has been more pronounced in developed countries, in which timely treatment is available, with reperfusion by use of primary angioplasty or fibrinolysis, dual antithrombotic therapy and critical care.
In Brazil, cardiovascular diseases remain the major cause of proportional mortality, and accounted for 29% of the deaths in 2010 (Department of Information Technology of the Brazilian Unified Health Care System [Datasus]). Acute myocardial infarction (AMI) is the second most frequent cause of death (7%, Datasus 2010). In the Brazilian public health system, the in-hospital mortality due to AMI remains persistently elevated: on average, 16.2% in 2000, 16.1% in 2005, and 15.3% in 2010 for all admissions in the entire country (Datasus). The elevated mortality in the Brazilian public health system has been attributed to difficulties experienced by patients with AMI to have access to intensive care, reperfusion methods and the therapeutic measures established for AMI5.
Recognizing that the proper treatment of AMI requires the interaction of several sectors [community, prompt care units (PCUs), emergency transportation service, and hospital with a catheterization laboratory and intensive care unit] has induced the creation of AMI management systems to optimize patient's care, from early diagnosis to timely treatment6-9. Most experiences reported have been developed in North-American and European countries, while descriptions of experiences in developing countries, such as Brazil, are rare.
This study aimed at implanting the AMI Management System in the municipality of Belo Horizonte, capital of the state of Minas Gerais, and at assessing its impact on in-hospital mortality due to AMI.
This is a retrospective observational study carried out in the municipality of Belo Horizonte, whose population in 2009 was 2,452,617 inhabitants10.
The municipality of Belo Horizonte is organized in regionals, as shown in Figure 1. The Mobile Emergency Care Service (Samu) provides pre-hospital care for urgency and emergency cases and operates with 18 Basic Support Units (BSU) and 6 Advanced Support Units (ASU). The Medical Regulatory Centre is the coordinating and instructing element of the system, which organizes the relationship between the various services and qualifies its flow.
Each regional has a referral center for pre-hospital care, the PCU. In addition, there are urgent entry points to the hospital and tertiary hospitals specialized in cardiology (THC) spread throughout the municipality.
Creation of the AMI management system in the municipality of Belo Horizonte
Aiming at increasing the access of patients of the Brazilian Unified Health Care System (SUS) to the treatment recommended in existing guidelines11-13, the Municipal Health Secretariat of Belo Horizonte (SMSA) established a flowchart for patients with ACS in need for emergency services in the municipality of Belo Horizonte, with the support of Samu and participation of the Hospital das Clínicas da UFMG (HC/UFMG), comprising the Telehealth Centre, the Cardiology and Cardiovascular Surgery Service, and the Hemodynamic Sector of that hospital. The HC/UFMG, a hospital with catheterization laboratory, opened a Coronary Unit (COU) in March 2010. In October 2011, the Hospital Santa Casa de Misericórdia began to integrate that flowchart, by making available its catheterization laboratory and COU beds. The objective of the COU is to ensure the timely acceptance, through transference, of patients with ACS admitted to emergency care units of the SUS-BH network and to provide, in addition to the treatment recommended by the guidelines for ACS and monitoring in an intensive care setting, access to primary and rescue percutaneous coronary intervention (PCI), when indicated. Patients with ACS can also be transferred to the THC of the SUS-BH network, which differs from the COU by not providing access to primary and rescue PCI (or urgency PCI).
Implantation of the tele-electrocardiology system
In the management of patients with ACS and ST-segment elevation, performing pre-hospital electrocardiography (ECG) in addition to the early activation of the catheterization laboratory represents an important strategy to reduce the door-to-balloon time, with a significant reduction in mortality14-19.
The implantation of the tele-electrocardiology system was an important component of the AMI management system. The tele-electrocardiology system was implanted by the Minas Gerais Telecare Service (Rede de Teleassistência de Minas Gerais - RTMG) with the support of the SMSA. The RTMG is a telecare service formed by a partnership between six universities of the state of Minas Gerais, and coordinated by the Telehealth Centre of the HC/UFMG20. That service began in 2005 and has performed more than 1,000,000 digital ECGs21.
Digital electrocardiographs were installed in seven PCUs, connected to computers. The analysis software was installed in the COUs. After performing the ECG, the exam can be transmitted to either COUs, if the case is an ACS with ST-segment elevation, or to the cardiology service of the RTMG, if an ECG report is required.
To ensure proper transmission, the quality of the signal emitted was tested in each PCU. The ECG transmission is immediate, via internet, and is identified at the COUs by the emission of a sound signal.
Training and motivating the teams
The following training and motivation strategies were developed for the PCU teams:
visits to the PCUs to provide information about the operational flow and potential benefits of the implantation of the AMI management system;
multidisciplinary training of the PCU teams regarding the approach of a patient with chest pain, ACS, and the use of the digital electrocardiograph (Figure 2);
disclosure of the Clinical Protocol on ACS of the State Health Secretariat of Minas Gerais22;
continued supervision by use of weekly telephone monitoring, in which the existence of problems in the digital ECG transmission or the need for new trainings are assessed. Technical problems are solved by the information technology team within 24 hours. Problems of infrastructure and internet are referred to the SMSA.
Operational flow
Considering the patient's clinical context and the health care system, an operational flow for the AMI management system implantation was created (Figure 3).
When ACS with ST-segment elevation is suspected, the physician of the PCU initiates the first measures for ACS treatment11,12 and performs digital ECG, which is sent to the COU. On the occasion, that PCU physician contacts the COU physician by use of a mobile phone. The latter assesses the ECG (Figure 4), and, if the diagnosis of ACS with ST-segment elevation is confirmed, the patient can follow either the rapid care path or the SMSA Admission Centre care path. At other emergency units with no digital ECG, the physician should call the COU to discuss the case.
When chest pain has initiated more than 3 hours and less than 12 hours before, or more than 12 hours before but is recurrent or refractory, or in the presence of cardiogenic shock, the patient should follow the rapid path, being referred by the Samu directly to the catheterization laboratory for primary angioplasty, reducing the delay for reperfusion. When chest pain has initiated less than 3 hours before, the PCU physician is instructed to administer the thrombolytic agent, except when contraindicated, and then to transfer the patient as soon as possible to the COU or THC. That transfer is regulated by the Admission Centre. However, when neither clinical (pain relief and hemodynamic stability) nor electrocardiographic (50% reduction in the ST-segment elevation in the lead with the greatest elevation, 90 minutes after initiating the thrombolytic agent)23 reperfusion criteria are met after the thrombolytic infusion, the COU should be contacted again and the patient transferred via the rapid path for rescue angioplasty.
In the presence of ACS without ST-segment elevation, the patient is registered at the Admission Centre, which refers the patient to the COU or THC. Transference to the COU is preferential for patients at high or intermediate risk of adverse cardiovascular events, identified by the presence of high levels of myocardial necrosis markers or depression of the ST segment compatible with myocardial ischemia, or by the TIMI or GRACE risk scores13.
Aiming at the continued care of patients with ACS, ward beds and outpatient clinics for post-AMI care are provided to those patients for six-month follow-up, during which cardiovascular risk stratification is continued and secondary prevention of new events is performed. In addition, there is the opportunity of follow-up at a cardiovascular rehabilitation center or a smoke cessation outpatient clinic in certain cases24. After six months, the patient is referred for primary care or to a cardiologist of the SUS-BH health care network.
The outcomes assessed were the number of admissions due to AMI and in-hospital mortality due to AMI assessed from 2009 (baseline) to 2011. Data from the Hospital Information System (HIS) on the procedure Treatment of AMI, code SIH/DATASUS 03.03.06.019-0, were used. That procedure was considered the one that best represented the cases related to coronary events and that encompassed the most severe cases. The percentage of hospitalizations due to AMI involving intensive care unit (ICU) stay and the percentage of authorizations of hospital admission (AHAs) to THC have also been obtained from the HIS. The populations of the regionals for the years studied have also been obtained from Datasus.
Statistical analysis
The epidemiological data generated by the HIS/Datasus were introduced in a data bank and analyzed by using the statistical package SPSS 20.0 (IBM Corporation, 2011). Qualitative variables were described by use of frequency distribution, and quantitative variables, by use of mean and standard deviation or median and interquartile range. The proportions, means and medians of independent and dependent variables in the period assessed (2009 to 2011) and between the groups (AHAs with and without ICU cost per day) were compared by use of appropriate statistical tests, including the chi-square, the Student t, and the Kruskal-Wallis tests. A p value < 0.05 was considered statistically significant.
The tele-electrocardiology system was implanted in the first PCU in January 2011. From January to December 2011, 294 professionals were trained and 1,496 ECGs were transmitted as follows: 563 (37.6%) to COUs and 933 (62.4%) for report. A great variation in the number of ECGs per PCU was observed, and the Centro-sul (66.0%), Leste (12.0%) and Venda Nova (9.8%) PCUs performed more exams.
Table 1 shows the indicators selected from 2009 to 2011. Analyzing the temporal trend, the demographic characteristics were similar, with mean age around 60 years, and male sex predominance. The number of hospital admissions remained relatively stable over the period analyzed, ranging from 1,113 to 1,358. The mean hospital length of stay did not differ statistically over the years. However, the number of in-hospital deaths decreased, resulting in a significant reduction in the in-hospital mortality rate: from 12.3% in 2009 to 7.1% in 2011, reaching statistical significance (p<0.001).
In addition, the mean admission cost almost doubled during a time in which no significant readjustment in the prices of the SUS procedures occurred, which is an indirect indicator of greater access to the THC. There was an increase in the percentage of admissions including ICU stay (from 32.4% in 2009 to 66.1% in 2011, p < 0.001) and in the proportion of patients admitted to the THC of Belo Horizonte (from 47.0% to 69.6%, p < 0.001).
Comparing the group of patients whose hospitalizations contemplated ICU stay with that whose hospitalizations did not contemplate ICU stay, higher mortality was observed in the former in 2009 (19.7% versus 8.8%, p < 0.001) and in 2010 (12.6% versus 7.6%, p < 0.001), but not in 2011 (7.8% versus 5.7%, p = 0.08). Analyzing separately those patients who stayed at the ICU, a statistically significant reduction in the mean hospital length of stay was observed, from 14.4±14.4 days in 2009 to 12.7±10.1 days in 2011 (p = 0.022), as well as an even more expressive reduction in mortality over the years than that of the entire sample, from 19.7% in 2009 to 12.6% in 2010 and 7.8% in 2011 (p < 0.001).
The creation of the AMI management system has led to the reorganization of the care provided to patients suspected of having ACS in the municipality of Belo Horizonte. That system included training and motivating the PCU teams, in addition to a higher integration between the services, enabling access to catheterization laboratories and beds in the ICU and THC. Data from the HIS showed a reduction in the in-hospital mortality rate due to AMI based on the implantation of that management system with rates lower than those observed in the major Brazilian capitals.
Previous studies have shown that the high in-hospital mortality due to AMI in the Brazilian public health care system is associated with difficulties to access and low use of the treatment recommended for AMI, such as reperfusion therapy, drugs and ICU facilities5. Thus, Evangelista et al25, studying SUS patients diagnosed with AMI in the municipality of Belo Horizonte in 2002 and 2003, have reported that only 33% of them had been admitted to the ICU during their hospitalization. In addition, having been admitted to a public hospital (as opposed to hospitals of the private health care system) was an independent factor of poor prognosis. A study carried out in Feira de Santana, state of Bahia, has reported a 19.5% mortality in patients with AMI admitted to a public hospital of that municipality, four times greater than that found in patients admitted to three private hospitals in that same municipality (4.8%, p = 0.001)26. Among the patients admitted to the public hospital, poor and illiterate ones predominated, took longer to arrive at the hospital and to be medicated, progressing to greater disease severity, manifested as the high frequency of patients with Killip class II or over. Only 8% of the patients of the public hospital were admitted to the ICU, and 21% underwent reperfusion therapy; 94% of the patients of the private health care system were admitted to the ICU, thrombolytic agents being used in 79% of them. Beta-blockers, independent predictors of prognosis in this sample, have also been more frequently used in private hospitals26.
Data regarding hospitalizations due to AMI in the municipality of Belo Horizonte in the period studied showed a tendency towards greater access of the population to high-complexity treatment after the implantation of the AMI management system. That tendency can be inferred based on indirect data, such as the increase in the mean cost of hospitalization, which is primarily due to the greater access to tertiary hospitals, and, thus, to ICU beds. The greater access to high-complexity treatment is demonstrated by direct data, with a statistically significant increase in the AHAs to that type of hospitals and in the percentage of ICU cost per day. By ensuring a greater access to those resources, the possibility of performing complementary tests of fundamental importance in the management of the acute phase of ACS, such as echocardiography, treadmill test and nuclear medicine tests, is increased. In addition, the access to cardiac catheterization and PCI, which have impact on in-hospital and late adverse events, is increased27-32.
Furthermore, the implantation of clinical protocols on the management of AMI, based on scientific evidence, is related to an improvement in the indicators of morbidity and mortality33,34. The Clinical Protocol on ACS of the State Health Secretariat of Minas Gerais22 was developed with the participation of professionals of the HC/UFMG, also involved with the implantation of the AMI management system in the municipality of Belo Horizonte and the training of the urgency and emergency teams. Knowing the local conditions for the application of the international guidelines is essential. Thus, when elaborating the flowchart, we chose to administer the thrombolytic agent at the PCU to patients with chest pain for less than 3 hours, because the shorter the ischemia duration, the more effective the thrombolytic therapy; primary PCI would benefit those patients only if their referral occurred within the first 60 minutes35,36, which cannot be accomplished within the transference system of the municipality of Belo Horizonte. The target delay time of that system is of up to 120 minutes, and the maximum target door-to-balloon time at the hospital with catheterization laboratory is 90 minutes11,35,36. It is worth emphasizing the option of direct case discussion, involving physicians at PCUs and general hospitals and specialists at COUs, providing greater safety to the assistant physician and improving referrals.
The implantation of the tele-electrocardiology system is an important component of the AMI management system in the municipality of Belo Horizonte, because it more quickly directs the transference of patients diagnosed with ACS with ST-segment elevation to the COU. A reduction in the door-to-balloon time and mortality has been evidenced with the use of pre-hospital ECG as a component of the AMI management system37.
The results of the present study suggest that the AMI management system implantation had a positive impact on the overall in-hospital mortality rates due to AMI after 2009. However, there are limitations regarding that analysis. This was an observational study, using secondary data derived from the AHAs issued in the period studied and dependent on data accuracy, from the primary care network to the in-hospital information flow. In addition, only one of the clinical SUS procedures was selected; there were at least two more clinical procedures, in addition to the codes related to the interventions (percutaneous and surgical), which were not selected because of the information bias that could be generated. For example, we can cite patients with ACS who ended up undergoing coronary angioplasty: in that case, with the change in the procedure, the patient passes to be in the system only among the cases of angioplasty and no longer among those with AMI. Angioplasty, however, could not be used in this analysis because it also encompasses outpatient elective procedures.
Another limitation is the fact that this study assessed only in-hospital mortality. Some patients with AMI die before hospital admission. Assessing out-of-hospital mortality is extremely important, because it also reflects access to treatment. Difficulties of access tend to increase the time to admission, decreasing the in-hospital lethality expected and increasing the out-of-hospital mortality.
However, despite those limitations, the missed data might relate to the subgroup of patients who benefited most from the network and access to high-complexity interventions, suggesting that the benefit might be even greater than that recorded. The mortality rates by the end of the AMI management system implantation are lower than the mean reported in a study on the Brazilian reality26 and those obtained directly from the HIS/Datasus.
Experiences on the organization of AMI care in other Brazilian cities have been reported38,39. All of them have been based, at least partially, on the observation that the organization of AMI management systems in other countries can significantly reduce mortality and morbidity due to AMI40. The importance of organizing the AMI care has been recognized by the Brazilian Ministry of Health, with the enactment, in December 2011, of an ordinance that regulates the implantation of AMI management systems in Brazil, aiming at reducing the mortality due to AMI in the entire country. Reporting the experience in the municipality of Belo Horizonte is important to support the debate on such actions that can effectively reduce the burden of AMI in Brazil.
Potential Conflict of Interest
No potential conflict of interest relevant to this article was reported.
Sources of Funding
There were no external funding sources for this study.
Study Association
This study is not associated with any post-graduation program.
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17. Diercks DB, Kontos MC, Chen AY, Pollack CV, Jr., Wiviott SD, Rumsfeld JS, et al. Utilization and impact of pre-hospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction: data from the NCDR (National Cardiovascular Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry. J Am Coll Cardiol. 2009;53(2):161-6. [ Links ]
18. Gross BW, Dauterman KW, Moran MG, Kotler TS, Schnugg SJ, Rostykus PS, et al. An approach to shorten time to infarct artery patency in patients with ST-segment elevation myocardial infarction. Am J Cardiol. 2007;99(10):1360-3. [ Links ]
19. Pedersen SH, Galatius S, Hansen PR, Mogelvang R, Abildstrom SZ, Sorensen R, et al. Field triage reduces treatment delay and improves long-term clinical outcome in patients with acute ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. J Am Coll Cardiol. 2009;54(24):2296-302. [ Links ]
20. Ribeiro AL, Alkmim MB, Cardoso CS, Carvalho GG, Caiaffa WT, Andrade MV, et al. Implementation of a telecardiology system in the state of Minas Gerais: the Minas Telecardio Project. Arq Bras Cardiol. 2010;95(1):70-8. [ Links ]
21. Alkmim MB, Figueira RM, Marcolino MS, Cardoso CS, Pena de Abreu M, Cunha LR, et al. Improving patient access to specialized health care: the Telehealth Network of Minas Gerais, Brazil. Bull World Health Organ. 2012;90(5):373-8. [ Links ]
22. Junqueira LL, Ribeiro AL, Mafra AA. Secretaria de Estado de Saúde de Minas Gerais. Síndrome coronariana aguda (protocolo clínico). [Acesso em 2012 dez 10]. Disponível em http://www.saude.mg.gov.br/protocolosclinicos. [ Links ]
23. Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation. 2008;117(2):296-329. [ Links ]
24. Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, et al. ACC/AHA 2008 performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures for ST-Elevation and Non-ST-Elevation Myocardial Infarction) Developed in Collaboration With the American Academy of Family Physicians and American College of Emergency Physicians Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, Society for Cardiovascular Angiography and Interventions, and Society of Hospital Medicine. J Am Coll Cardiol. 2008;52(24):2046-99. [ Links ]
25. Evangelista PA, Barreto SM, Guerra HL. Hospital admission and hospital death associated to ischemic heart diseases at the National Health System (SUS). Arq Bras Cardiol. 2008;90(2):119-26. [ Links ]
26. Ferreira GM, Correia LC, Reis H, Ferreira Filho CB, Freitas F, Junior I, et al. Increased mortality and morbidity due to acute myocardial infarction in a public hospital, in Feira de Santana, Bahia. Arq Bras Cardiol. 2009;93(2):97-104. [ Links ]
27. Hirsch A, Windhausen F, Tijssen JG, Verheugt FW, Cornel JH, de Winter RJ. Long-term outcome after an early invasive versus selective invasive treatment strategy in patients with non-ST-elevation acute coronary syndrome and elevated cardiac troponin T (the ICTUS trial): a follow-up study. Lancet. 2007;369(9564):827-35. [ Links ]
28. Lagerqvist B, Husted S, Kontny F, Stahle E, Swahn E, Wallentin L. 5-year outcomes in the FRISC-II randomised trial of an invasive versus a non-invasive strategy in non-ST-elevation acute coronary syndrome: a follow-up study. Lancet. 2006;368(9540):998-1004. [ Links ]
29. Fox KA, Poole-Wilson P, Clayton TC, Henderson RA, Shaw TR, Wheatley DJ, et al. 5-year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial. Lancet. 2005;366(9489):914-20. [ Links ]
30. Mehta SR, Cannon CP, Fox KA, Wallentin L, Boden WE, Spacek R, et al. Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials. JAMA. 2005;293(23):2908-17. [ Links ]
31. Di Mario C, Dudek D, Piscione F, Mielecki W, Savonitto S, Murena E, et al. Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial. Lancet. 2008;371(9612):559-68. [ Links ]
32. Cantor WJ, Fitchett D, Borgundvaag B, Ducas J, Heffernan M, Cohen EA, et al. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med. 2009;360(26):2705-18. [ Links ]
33. Peterson ED, Roe MT, Mulgund J, DeLong ER, Lytle BL, Brindis RG, et al. Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA. 2006;295(16):1912-20. [ Links ]
34. Polanczyk CA, Biolo A, Imhof BV, Furtado M, Alboim C, Santos C, et al. Improvement in clinical outcomes in acute coronary syndromes after the implementation of a critical pathway. Crit Pathw Cardiol. 2003;2(4):222-30. [ Links ]
35. Pinto DS, Frederick PD, Chakrabarti AK, Kirtane AJ, Ullman E, Dejam A, et al. Benefit of transferring ST-segment-elevation myocardial infarction patients for percutaneous coronary intervention compared with administration of onsite fibrinolytic declines as delays increase. Circulation. 2011;124(23):2512-21. [ Links ]
36. Ting HH, Yang EH, Rihal CS. Narrative review: reperfusion strategies for ST-segment elevation myocardial infarction. Ann Intern Med. 2006;145(8):610-7. [ Links ]
37. Ortolani P, Marzocchi A, Marrozzini C, Palmerini T, Saia F, Taglieri N, et al. Pre-hospital ECG in patients undergoing primary percutaneous interventions within an integrated system of care: reperfusion times and long-term survival benefits. EuroIntervention. 2011;7(4):449-57. [ Links ]
38. Gonçalvez-Junior I, Caluza AC, Barbosa AH, Oliveira CA, Amaral AZ, Zeefried CR, et al. Diminuição da mortalidade em infarto agudo do miocárdio com supra de ST na cidade de SP: efeitos da organização de uma rede de diagnóstico e terapêutica: análise de 171 casos. Arq Bras Cardiol. 2011;97(3 supl. 1):64. [ Links ]
39. Solla DJF, Carvalho ME, Martins MS, Neto OM, Filho PRF, Roriz PS, et al. Implantação de redes regionais integradas de atendimento ao Infarto Agudo do Miocárdio no Brasil: a experiência de Salvador, Bahia. 66o Congresso Brasileiro de Cardiologia; Porto Alegre: Arq Bras Cardiol. [ Links ] 2011;97(3 supl. 1):85.
40. Saia F, Marrozzini C, Guastaroba P, Ortolani P, Palmerini T, Pavesi PC, et al. Lower long-term mortality within a regional system of care for ST-elevation myocardial infarction. Acute Card Care. 2010;12(2):42-50. [ Links ]
Mailing Addres: Manuscript received September 20, 2012, revised manuscript November 19, 2012, accepted November 19, 2012.
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Manuscript received September 20, 2012, revised manuscript November 19, 2012, accepted November 19, 2012.


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If life were a fairy tale, Oribella Bettencourt would have a "happily ever after" kind of future ahead of her. A Hollywood producer has come to Des Moines in search of a perfectly modern Princess Rapunzel, and Ori -- a model, dancer, and star of the beauty pageant circuit -- lands the part. And why shouldn't she? With her hardworking, self-sacrifi cing mother guiding her career, Ori is stunning, dedicated, poised...and then there's her hair. Breathtakingly lustrous blond hair that sets her apart from all the other girls at school. So what if she doesn't have any friends her age, or anyone to talk to other than her mother? She's on the verge of having everything she's ever dreamed of. But in this fairy tale, the beautiful princess wakes up to her worst nightmare -- when almost overnight, Ori begins to lose her hair....
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did you know that pre-mixed, refrigerated formula is good for 24 hours? save yourself the hassle and mix it all at once in this pitcher! then just pour and warm! travel with your powder formula is this cute carrying case.
Baby's Only formula is labeled for "toddlers" because they want to promote breastfeeding for the first year of life, BUT it is SAFE for infants too. Always talk to your doctor before starting a new formula. This formula is one that is closest to breastmilk and made in the US. I supplemented with this with my son, he loved it!


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These flatirons are a great investment. I loved the results. For styling black hair. I would advise to curl you hair first and then apply oil. The irons gives a better curl on less greasy hair. It made my hair silky.
Ghd styler is the best. Had it for years
Easy to use styler no waiting for long periods of time for it to heat. It heats within seconds.
Work great
bought these after hearing so much about ghd and I am glad I did best straighteners I have ever used I bought them of amazon as I was unsure from reading other reviews that they couldn't register there product I had no problem registering with ghd.
When using a brush straightener, you should keep several things in mind. First, always apply some kind of a thermal protectant. Comb your locks properly. Second, be aware of the hot bristles – you don't want them to touch your scalp. Third, don't hold a brush straightener as a regular brush however tempting and easy this seems. You should hold it kind of upside down so that bristles won't touch your skin. To straighten a strand in one pass, hold the brush tight to the surface of the hair. More detailed guide on how to use a hair straightening brush you can find in this article.
I am absolutely in love with this ghd styler I had tried the chi first and returned it right away... This one does what I expected and more it straightens my hair curls it and keeps it healthy it is worth every penny I paid ....
after reading review with titles like fake I was a bit nervous but took a gamble anyway. Its authentic. I also found out that ghd has outsourced the production of some of there irons to china. In fact when I went to register my iron I clicked the help link for the date code and the example label had made in china clear as day on it.on the iron amazing night and day with the old one my favorite feature is the no tangle swivel cord
"I debated whether to buy this product or the more expensive titanium flat irons and decided to give these a try. I have been natural for about two years … But could never find flat irons that would tame my hair. GIRL, I am telling you these flat irons are like that. One pass through over freshly washed and blow-dried hair and I was in awe. Why go to a salon? I did my own silk press and a week later, I still got shine and body. Best iron I've had in years, and I love the color."
Product just as described
Great product
Great purchase
Celebrity hair stylist Priscilla Valles's go-to straightner is the classic GHD 1-inch straightener. "I start in the nape and bring down small sections, one row at a time and I use a GHD flat Iron with a comb in the other hand," says Valles. "I place the comb in front of the iron while ironing at the same time in a slow motion all the way down. Never stopping cause that will cause dents in the hair. At the end a dime size of ouai rose from top to bottom just to add some shine and control any fly aways!"
It is one of the best straighteners I've ever used. Its lightweight and takes literally 15 seconds to heat up. Works perfectly and would not trade it for any other straightener.
Great product and fastest shipment ever
Great straighteners. I only use ghds
I bought a ghd in london while traveling. I couldn't love a hair straightener more. It heats up so quickly and is universal voltage so you can use it anywhere in the world. I've had mine for over a year and use it almost every day. Don't mind the price it is worth it
I love this straightener I have super long thick hair...naturally wavy frizzy. This straightens my hair easily. I used to have a chi but it eventually broke short in the wire...apparently this happens to all chis so I had to buy a new one. I think the ghd works better than the chi
ghd is the best hair styler I've ever got it's very fast in heating up .. And you'll be ready in no timeit would be great if it included a glove though
I had a set of ghd straighteners a few years back and my daughter always said they were the best she used.this new set is of apparent equal standard containing the straighteners and a heat resistant mat. The real bonus with these is the heat limiting built in setting of 185 degrees which ensures no hair burn. The second bonus is the hot plates being both above and below the hair.great and highly recommended
This is a really lovely gift set the packaging is so nice and the presentation makes it feel really special. The brush and hair clips are both very nicely made I don't really understand the design of the clips exactly as they are very flexible but they certainly hold my hair well during styling the brush is as a brush is... Brushy I have very fine hair and it tends towards the static this made the issue slightly worse. I plan on sticking with my regular wooden brush. The carrying bag and heat proof mat are both well made not quite my style as the quilted look isn't my favourite but both are quite posh and it's just really handy to have somewhere to always put the straighteners wherever I am. I particularly like the silicon cap to put over the end of the straighteners though it's very minimalistic and I think I'll use this item the most.as for the straighteners they are just as good as ghd are renowned for. They heat up really quickly and they beep to let you know when you switch on the power and when they are ready. I appreciate the auto off feature too that switches off after 30 minutes just in case. The plates are smooth and don't catch my hair too much there is a slight issue with that and one of the seams it doesn't always happen but sometimes I do catch a hair. Overall I'm really pleased and looking forward to lots more good hair days.
Hair care can be hard to shop for. You want to be picking products that are effective enough to achieve your desired results, without having to pay an exorbitant amount to get the job done. When it comes to hot tools, you also want to make sure you'll be using a product that won't cause undue damage to your hair — totally fried tresses are the opposite of chic. And while there's a whole world out there of pricey pro-level straighteners from high-end hair brands, it turns out it's actually possible to score a satisfactory straightening tool for much less.
The current temperature is shown on the LCD screen, and the screen changes the color depending on how high the temperature is. According to the instructions, the blue one is for fine or fragile hair (0-370°F), the green one is for medium or wavy hair (375-395°F), and the red one is for coarse, resistant hair (400-425°F). The mode button also helps you to choose the right heat level for your hair type.
This one's the LBD of all hair straighteners. With 100 percent pure tourmaline ceramic plates, the classic tool will never lose its luster (and neither will your hair). No need to tug or pull, as this tool is made with a small suspension system — the floating plates adjust to compress your hair while styling. And with a fully-rotating swivel power cord, you'll have all the styling control in your hands.
Like everyone else I was really afraid of getting a fake ghd product from here. In the past I have been ripped off before when trying to buy this straightener but I took a chance anyway and its real I verified it on the website and I got an email back saying its authentic. I am really pleased I got this straightener for 90 dollars
We've all heard the saying that the grass is always greener on the other side, and our hair types tend to follow the same old adage. If you were born with a head full of beautiful curls, you probably spent your childhood longing for straight hair; if you were born with bone straight hair, then you've probably spent more hours than you'd care to admit with a throbbing curler-induced headache. No matter how hard we may try to love the hair we're born with; the truth is that most of us wish there were something else perched on top of our heads from time to time.
Another excellent budget hot air styler is the Remington Style and Curl Air Styler and with 9 customer reviews giving 4.7 out of 5 stars I would recommend this product. This is a great on the go styler because it is lightweight so easy to pack away. It has two attachments so is suitable for medium length and shorter hair (25mm brush and 19mm brush) and has two heat and speed settings so you can set your curls and fast dry hair prior to styling. The Remington Style and Curl is good for flicks, curls and adding volume, giving a glossy, lustrous finish. Reviewers like the fact that it can be used on damp as well as dry hair and all say that it works a dream.
GHD went and nabbed itself a 2018 Best of Beauty award with this miracle of a flatiron. The tool maintains a constant temperature of 365 degrees Fahrenheit, but get this: It reads the thickness or thinness of the sections you use so it can adjust the amount of power it exerts. That way, it keeps the same temperature while straightening your hair and gets all the sections evenly straight without you having to worry too much about heat damage. "My hair felt relatively healthy after ironing which I am not used to," says Tracey Zane, director of content development for Allure. "The tool moves much effortlessly across my hair, and actually makes it feel silky smooth once ironing."
In March 2013, ghd launched the "Eclipse" hair straightener, which uses six sensors in the plates to maintain a constant heat of 185 degrees celsius, a temperature ghd claims is the optimum temperature for styling results.[17] The consistent temperature reduces the time to style hair, particularly coarse hair that may previously taken multiple run throughs.[18] The Daily Mail called the Eclipse "The Rolls-Royce of irons".[19]
Product just as described
So, which ones are worth their weight? HSI Professional's flat iron hair straightener, $39.36, has more than earned a mention, with over 21,000 five-star reviews on Amazon. The ceramic-plate iron has won over its fans because of how quickly it heats up, how smoothly it straightens hair (no painful snags!), and how long the results last. One reviewer says it works well enough to keep hair smooth for up to four days, while another claims it's more effective than a much more expensive alternative. The kit sold on Amazon also comes with a travel pouch, hot tool glove, and a sample argan oil hair treatment, so you'd be getting more than your money's worth with this cheap pick.
pricey yes but what can I say daughter swears by ghd's no substitute no point buying cheaper brands. If she's happy then so am i. Her second paid of ghd's in 10 years so good value.


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Live in Miami on www.raymondwojcik.com Welcome to our Website with Me Auberta, and i'm reviewers for this film, now i am going to talk about Live in Miami Produced by in the with the duration
Watch & Download Live in Miami (2009) : full movie online free DIRECT hd NO LIMIT Roberto Carlos, considered the king of romantic music in Brazil, launched the DVD recorded in Spanish in May 2007 in a presentation at the Ziff Opera House, the home of shows Carnival Center for the Performing Arts of Miami. It is "Roberto Carlos live", which includes several of the biggest hits of his career in the Spanish market and its versions of "The Cat in the dark" (the Italian Toto Savio) and "The Day You Love Me" (Carlos Gardel and Alfredo Le Pera).
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Oakland Raiders
Redskins get QB, draft Ohio State's Haskins with 15th pick
By Stephen Whyno 31 minutes ago
Steelers trade up in first round to draft linebacker Bush
By Dan Scifo 40 minutes ago
Jets draft Alabama DT Quinnen Williams with No. 3 pick
By Dennis Waszak Jr. an hour ago
AP NewsAlert
2 hrs ago
NASHVILLE, Tenn. (AP) — Arizona Cardinals select Oklahoma QB Kyler Murray with the No. 1 draft pick. ...
Abc FC RN vs America FC RN 4/24/2019
Apr. 24, 2019 12:35 PM EDT
Roethlisberger, 37, to remain with Steelers through 2021
By Will Graves Apr. 24, 2019 12:32 PM EDT
Falcons sign 6-year veteran safety J.J. Wilcox
Apr. 22, 2019 05:48 PM EDT
FLOWERY BRANCH, Ga. (AP) — Safety J.J. Wilcox, who started 35 games in four seasons with the Dallas Cowboys, has signed a one-year deal with the Atlanta Falcons. ...
Jaguars' Marrone, Ramsey finally talk, share 'little laugh'
By Mark Long Apr. 22, 2019 03:56 PM EDT
Bears have a different view of the draft this year
By Andrew Seligman Apr. 18, 2019 05:37 PM EDT
Clemson at Georgia Tech 9/22/2018
Apr. 18, 2019 03:10 PM EDT
Drafting a quarterback in play for Redskins in early rounds
By Stephen Whyno Apr. 18, 2019 02:16 PM EDT
Titans have flexibility to add help at No. 19 in NFL draft
By Teresa M. Walker Apr. 18, 2019 01:55 PM EDT
Saints Draft Preview Capsule
By The Associated Press Apr. 18, 2019 11:39 AM EDT
62. NEW ORLEANS (14-4) LAST SEASON: Saints tied best regular-season mark in franchise history, and came agonizingly close to their second Super Bowl...
Cowboys Draft Preview Capsule
By The Associated Press Apr. 18, 2019 11:35 AM EDT
DALLAS (11-7) LAST SEASON: Cowboys beat Seattle for just third playoff win since last Super Bowl title (1995 season) after second NFC East crown in...
Vikings Draft Preview Capsule
By The Associated Press Apr. 18, 2019 11:41 AM EDT
18. MINNESOTA (8-7-1) LAST SEASON: Crumbled underneath weight of Super Bowl goal they carried into 2018 with new QB Kirk Cousins following trip to NFC...
Garoppolo recovering well from major left knee injury
By Josh Dubow Apr. 18, 2019 03:04 AM EDT
Jones, Jarrett absent as Falcons launch offseason program
By Charles Odum Apr. 17, 2019 01:01 PM EDT
Tennessee Titans at Los Angeles Chargers 10/21/2018
Apr. 16, 2019 06:37 PM EDT
Raiders re-sign RB Jalen Richard
Apr. 10, 2019 09:35 PM EDT
ALAMEDA, Calif. (AP) — The Oakland Raiders have re-signed restricted free agent running back Jalen Richard. Richard originally joined Oakland as an...
Burfict gone, rest of Bengals intact in Taylor's 1st day
By Joe Kay Apr. 09, 2019 04:49 PM EDT
CINCINNATI (AP) — Zac Taylor got up early Tuesday and headed to Paul Brown Stadium for his first meeting with his new team, one that was watching closely to see how...


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The Indian Army and the Royal Thai Army today completed a two-week-long platoon level annual joint military exercise aimed at strengthening partnership and cooperation between them, the Army said in New Delhi.
'Exercise Maitree' commenced on August 6 in Thailand.
The exercise last year was conducted in Himachal Pradesh.
This year, the exercise began with a cross-training period involving familiarisation training between the two armies to evolve drills and procedures involved in counter-insurgency and counter-terrorist operations in urban, rural and jungle terrain under the United Nations mandate.
The initial days of field training focused on familiarising with each other's modus operandi, basic maneuvers and evolving joint drills.
The second phase included practising various drills and tactical scenarios in counter-insurgency environment, execution of tactical and search and destroy operations, house intervention and survival techniques.
The exercise culminated with a 72-hour joint exercise on planning and execution of a series of tactical operations such as raid, pursuit, establishing military check-post and cordon and search operations.
"Both the armies immensely benefitted from each other's expertise and experience in conduct of tactical level counter terrorist operations. The exercise helped in enhancing the cooperation between two armies and bonhomie between troops," the Army said in a statement.
Get the latest election news, live updates and election schedule for Lok Sabha Elections 2019 on ndtv.com/elections. Like us on Facebook or follow us on Twitter and Instagram for updates from each of the 543 parliamentary seats for the 2019 Indian general elections.


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|Noam Postavsky
|Re: Speeding up Flymake in emacs-lisp-mode
|Fri, 2 Nov 2018 10:07:19 -0400
On Fri, 2 Nov 2018 at 10:01, João Távora <address@hidden> wrote: > But now I see what you mean, I think! You mean just put another > long-running emacs, reading sexps from stdin, but shielding the main > emacs from doing the slow process creation? I had actually meant something more like what Stefan suggested, but your idea to add another layer of indirection sounds good. :)
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Lyrics Depot is your source of lyrics to MTC by Hüsker Dü. Please check back for more Hüsker Dü lyrics.
MTC Lyrics
Artist: Hüsker Dü
Album: Land Speed Record
Gotta gotta go now
Gotta keep a date
Be at the corner
Mistake to be late
Half block away now
Bus is at the light
Driver's grinning madly
It's a run for your life
You did it again, you did it to me
Getting on the bus now
Throw away your change
Don't forget your transfer
Driver's acting strange
Bus is really crowded
Can't find a seat
Going real fast
Gonna crash in the street
Picking up the pieces
In a fight that never ends
Getting away this time
I know we'll meet again
Hüsker Dü Lyrics
Hüsker Dü Land Speed Record Lyrics
More Hüsker Dü Music Lyrics:
Hüsker Dü - Back From Somewhere Lyrics
Hüsker Dü - Bed Of Nails Lyrics
Hüsker Dü - Beyond The Threshold Lyrics
Hüsker Dü - Chartered Trips Lyrics
Hüsker Dü - Diane Lyrics
Hüsker Dü - Eight Miles High Lyrics
Hüsker Dü - Perfect Example Lyrics
Hüsker Dü - Standing By The Sea Lyrics


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Adorable blue checkered dress with high neckline, ruffle trim details, and adjustable tie-waist detail. Keyhole back detail with top button closure. Fully lined. Fits true to size, Hunter (5'9") is shown wearing a small. Made of cotton/poly fabric. Hand wash cold- hang dry.
Length Measurements:
Small: 32"
Medium: 32.5"
Large: 33"


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Speaking about her role Indumati Tomar, Bhumi said, "I cut off from the world to understand the psyche and behaviour of the person I was becoming."
Sharing the screen space with Priyanka Chopra Jonas was definitely a fan moment for Prachi Kundra of Siddhivinayak.
"Ranveer Shrivastav is a man with a plan and he is out there to right whatever wrongs were done to him and his family," Tanuj speaks about Poison.
Just when you thought that everything was going smooth, Ira and Mishri meet an accident and an unimaginable thing happened to them.
Interact With And TV


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C.S. Lewis, one of the most beloved authors of the 20th century, created a magical, fictional world called Narnia. The primary villain of the first book of this series, The Lion, the Witch, and the Wardrobe , is Jadis, the White Witch. Below is the character Edmund's description of the White Witch when he first meets her:
Related pins: · Kids Room Wallpaper Borders · Mitochondria In Plant Cell ·


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- About
FY2016 Graduation Ceremony (24 March 2017)
The FY2016 Graduation Ceremony was held 24 March at Miyako Messe (Kyoto International Exhibition Hall) with executive vice-presidents, deans, and other faculty and staff, as well as former President Hiroo Imura, in attendance.
This year's graduates numbered 2,888.
- Statistical summary of Kyoto University graduates (in Japanese)


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- 21156 Miles
- Petrol
- Automatic
- 104 CO² (g/km)
- £20.00 12m Tax
- £0.00 6m Tax
- 65.7 Avg. MPG
- Group 4 Ins.
- 21156 Miles
- Petrol
- Automatic
- 104 CO² (g/km)
- £20.00 12m Tax
- £0.00 6m Tax
- 65.7 Avg. MPG
- Group 4 Ins.
Vehicle Information
- Features
- Description
- Finance
- Gallery
Vehicle Summary
- Body styleCoupe
- Engine size999cc
- Engine capacity1.0 L
- Fuel typePetrol
- Number of doors2
- Number of seats2
- TransmissionAutomatic
- CO2 emissions104 g/km
- Insurance group4
Performance & Economy
- Fuel consumption (urban)57.6 mpg
- Fuel consumption (extra urban)72.4 mpg
- Fuel consumption (combined)65.7 mpg
- 0 - 60 mph13.3 seconds
- Top speed90.0 mph
- Cylinders3
- Engine power71 bhp
- Engine torque68 lbs/ft
- Height1542mm
- Length2695mm
- Wheelbase1867mm
- Width1559mm
Interior / Exterior
- 12V Accessory socket
- Auto air conditioning with pollen filter
- Coin holder
- Design cloth upholstery
- Door net pockets
- Door trim, knee pad and instrument panel to match upholstery
- Front head restraints
- Interior light
- Leather gear knob
- Passenger seat fold down backrest
- Passenger vanity mirror
- Retractable luggage compartment cover and net bag
- Storage compartment in tailgate
- Storage compartment on passenger side
- Storage compartments in doors
- Body coloured bumpers
- Comfort windscreen wipers
- Electric front windows
- Headlight range control
- Heated rear window
- Lanechanger indicator lights
- Projector headlamps
- Rear wash/wipe with intermittent wipe setting
- Rear window release
- Speed sensitive front wipers + wash/wipe
- White side indicators
ComfortNo features available.
Safety / Other
- Digital gear display with gear recommendation
- Electric tailgate release
- Exterior temperature gauge with frost alarm
- Service interval indicator
- Trip computer
- ABS+Electronic Brake force Distribution
- Crash sensor (auto switch - on of hazard warning lights/interior lighting)
- ESP + Hill Start Assist
- Full size driver and passenger airbags
- HBA (Hydraulic Brake Assist)
- Seat belt force limiter
- Seat belt tensioners
- Traction control
- Auto door lock when driving
- Radio remote control central locking with immobiliser
- Remote locking fuel filler flap
- SOFTOUCH automatic gear programme
Factory Fitted Extras
For more info on this vehicle call our showroom on 0114 285 2577
Every effort has been made to ensure the accuracy of the above information but errors may occur. Please check with a salesperson.
- Registered: 2010
- Mileage: 21156 miles
- Engine Size: 1.0 L
- Fuel Type: PetrolGearbox: AutomaticBody Style: CoupeColour: RedOwners: 3
For more info on this vehicle call our showroom on 0114 285 2577
We take in any part exchange (car, bike, try us!!)
Finance available 3.9% APR
Existing finance settled
Whats included on all of our vehicles?
Free MOT for life
12 Months AA warranty
Full service on sale of the vehicle
HPI clear report
182 point inspection
Fully valeted and detailed
12 months warranty subject to a £199 fee or standard warranty with no fee, please feel free to give us a call anytime for further information
Every effort has been made to ensure the accuracy of the above information but errors may occur. Please check with a salesperson.
Representative APR shown in example above.
Fees are already accounted for within the payments displayed and are also included within the total amount payable.
Finance available subject to status. Indemnities may be required. Other finance offers may be available but cannot be used in conjunction with this offer. We work with a number of carefully selected credit providers who may be able to offer you finance for your purchase. We are only able to offer finance products from these providers. Postal Address: , , Sheffield, , S62FU
The following documents are available for this vehicle:


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Search Word Here
Advisory service
|مشاورتی خدمت ۔
|Words Matching "Advisory service"
English Urdu Dictionary English to urdu dictionary and english to urdu translation on internet is really a gift for all those people who want to learn English language in Urdu. Now a days electornic devices has taken charge of every other thing. Computer and internet has changed the whole life of human beings and a desktop computer is not only for fun now a days but it is for studying online and getting knowlege for every part of the world using internet connection. English is the language of globe and if you are lucky to know how to speak English then every part of the world is your home as you can find people speaking English wehrever you go from Pakistan to last corner of this world.Words Being Searched Now at English Urdu Dictionary
Advisory service Meaning, Chak Meaning, Souvenir Meaning, Abash Meaning, Swing Meaning, Remissness Meaning, Airmanship Meaning, Partake Meaning, Unaccomplished Meaning, Tiring Meaning,


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Casino Mel – Trap Ni**a (Feat. Gucci Mane) (Official Music Video)
June 6, 2017 | Music Videos, Videos | No Comments|
Casino Mel dropped his ChopHouze-produced track "Trap Ni**a" featuring Gucci Mane earlier this year, and now decides to follow up by releasing an official music video.
Watch the Glassed By Chop-directed footage below and purchase a copy of the song on iTunes now.


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We want the reasearch project proposal of my reasearch methodology.my topic is design and optimisation of electric regenerative braking system.Im attaching my literature review of my assignment.The assignement should be of 4000words.You need to make 2000 words new and you need to copy the remaining 2000 words of literature review.
Great work,good reference with APA format.Thank you very much for such a good job.I will recommend you to my friends and i will definitely use it again.
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Tips to Promote Your Travel Agency
The travel industry has gone through some huge changes in recent years. As so much research and booking are done online, travel agencies must engage customers with their website content and on social media, as well as in more traditional ways. The industry is also extremely competitive. If you want to be noticed and reach your target audience you need a strategy. Here are some of the most effective ways to promote your travel agency:
Find or Refine Your Niche
Before the internet, travel agencies were usually fairly broad in scope. Someone would call or walk into the business and book any type of trip or vacation. In the digital age, however, travel has become far more specialized and segmented.
If you want to reach the right audience, you have to identify your niche. If you're having trouble attracting business, one reason might be that you're not sufficiently specialized. You might, of course, have multiple audiences but you should appeal to them separately by criteria such as:
If you don't currently have a specialization you should consider finding one (or more than one) so you can create a more segmented marketing plan.
Make the Most of Social Media
Social media is crucial to promote any business nowadays. However, it's especially advantageous to connect with people on social media sites when you run a travel business. This is true for a number of reasons.
Be sure to focus on the social media platforms that your target audience uses most.
Reap the Benefits of a Host Agency
There are several advantages to working with a host agency.
A host agency can save you time and simplify many areas of your business.
Offer Add-on Services and Packages
Everyone likes to save money when they travel. People also appreciate learning about events and services that they might not be familiar with. As a travel agent, you can offer more value by connecting your customers with local tours, city passes, favorable rates on car rentals, transfer services, and other benefits.
The more you can customize offers to the needs of your customers and seek unique services offered in different areas, the better. For example, in large cities with metro systems, travelers often like to get day or week public transportation passes. If there are popular museums, amusement parks, or other attractions see if you can arrange for discounted tickets.
Integrating with GDS systems makes it easy to locate such deals for your customers. You can also connect with local tour groups and business owners to provide your customers with deals and discounts.
Optimize Your Website
Even in the social media age, your website is still your digital storefront. This will often be the first impression potential customers get of your business. It's therefore essential to make sure it's engaging, informative, and user-friendly.
Build an Email List
An email list lets you stay in touch with your customers and inform them about your latest offers. People who travel tend to do it regularly so it's important to do everything you can to attract repeat business.
These are some proven strategies to help you promote your travel agency. To reach today's travelers, you need to be in tune with their needs. This includes reaching them on social media and on their mobile devices. You also need to provide them with information that helps them find good value as well as find the travel experiences that keep them coming back to you again and again.
Written by Angie Habiger
So, you're thinking of joining Travel Quest? That's great to hear! My name is Angie and I'm typically the main point of contact at Travel Quest for agents new to TQ. I thought it would be helpful to do a little write up on the typical process of signing up with TQ.
Researching and Interviews
Starting way at the beginning, the best piece of advice I can give you is to research and compare host agencies. That way when you make your decision, you know it is the right one for you! If you haven't already, I'd highly recommend reading the Tips on How to Find the Best Host Agency post from HostAgencyReviews.com. It is full of really great advice and even has a nice Excel spreadsheet of questions to ask a host agency.
We think interviewing host agencies is so important that we actually have an 'interview' stage with agents looking to join TQ. It isn't nearly as daunting as it sounds - we just want to make sure that all of your questions are answered on us and, if you're a newbie, the travel industry in general!
Registering Your Business & Getting an EIN #
Registering a business name in the state you reside in is a good place to start setting everything up for your business. It is also something Travel Quest requires in order to sign up with us! We often get asked is it best to register as a Sole Proprietorship, DBA, or LLC. Any one of them works for us. To make sure you are doing what's best for your business, we suggest consulting with a tax professional or accountant. Each state has different costs and processes set in place so be sure to check with your State Agencies for what you need to do! The Small Business Administration has a great list of filing requirements for each state.
After you register your business, you'll also need to get an EIN (Employee Identification Number) through the IRS. This is super easy to do online at IRS.gov.
Travel Quest's Sign Up Process
Alright, you've been researching and interviewing host agencies and have made your final decision. I know that once you make that decision you want to get started right away so our sign up process is streamlined to get you set up in a jiffy.
We send all of our documents via an online signature program to make things super-fast and easy to track. Once you let us know you want to sign up there are just 3 stages:
The length of time it takes from start to finish depends mostly on how fast we get the documents back. Typically you receive your log in sheet 3-5 business days after you fill out the TQ Sign Up form! If you have any questions along the way, everyone at Travel Quest is there to help! Now that you know the sign up process, I hope we get to chat soon!
Written by Nicole Marson
Networking is a crucial element in the world of small business owners. That's why I wanted to go over the importance and benefits of networking.Then I'll go over some networking opportunities, essentials and best practices to get you going!
Benefits of Networking
Networking with fellow agents, vendors and other business owners can really help you grow your business and expand your reach. Whether it's client referrals, partnerships, speaking or writing opportunities; networking can help connect you with people who can help you grow your business. Looking for more specifics on how networking can benefit you? Here you go!
Attending networking events on a regular basis is important. Not sure where to look for local networking events? Here are a few ideas to get you started!
The thought of attending your first few networking events may seem daunting but don't worry - you're not alone! Many people struggle the first few times out of the gate when walking into a room full of strangers and having to introduce yourself. We've put together a list of best practices to help you out!
Making conversation and knowing what to ask people can be just as terrifying as walking through that door. I've found that having a few questions prepared eases my anxiety and makes my interactions a lot more engaging and meaningful. The people you chat with will appreciate you taking the time to ask quality questions instead of the usual "Where are you from? What do you do?". Here are some example questions to help you get started!
Happy networking!


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Borden is a fan of all types of glute bridges for activating your glutes, especially when you're on the road. "Traveling means sitting a lot," she says. "When we sit a lot, our hamstrings [and] hip flexors all shorten and tighten up." Over time, this can make it challenging for your glutes to engage the way they're supposed to, in the gym and in day-to-day life (this is also known as dead butt syndrome). Incorporating glute bridges in your routine can help combat this.
Lifestyle factors have a huge impact on certain conditions – and diabetes is one of them. Exercise can help to reduce your insulin requirements, lower your cholesterol levels and high blood pressure, and in the long term can reduce the development of heart disease and stroke. This is important because diabetics have a higher risk of developing heart and circulatory problems. Exercise can also promote weight loss, improve circulation and reduce stress levels (raising your glucose level).
Stubborn arm fat can make it difficult to wear short-sleeved tops comfortably due to poor fit or poor self-image. Although you cannot spot-reduce fat from the body, you can lose arm fat by adopting a healthy lifestyle, committing to an exercise routine and eating a nutritious diet. Schedule cardio five times per week, and strength-training three times per week, to slim down your arms.
Use of and/or registration on any portion of this site constitutes acceptance of our User Agreement (updated 5/25/18) and Privacy Policy and Cookie Statement (updated 5/25/18). Your California Privacy Rights. The material on this site may not be reproduced, distributed, transmitted, cached or otherwise used, except with the prior written permission of Condé Nast.
Exercise can have a number of emotional benefits. Stress can be caused by elevated levels of the hormones cortisol, adrenaline, and norepinephrine. Exercise lowers these hormones, and increases serotonin, otherwise known as the happy hormone, which helps reduce stress. Working out can help keep depression and anxiety at bay. Plus, coping with mood disorders that are often associated with stress can be a little bit easier when you are in good physical shape.
Some call it "flab", others call it "sag", or even "jiggle." Whatever it is that you call the excess fat on your arms, know that you're not alone. A lot of us have found ourselves in the dilemma, wondering how to lose arm fat and why it's even there in the first place. Is it something I ate? Is it something I did or didn't do? What shirt can I wear to hide to cover those parts?
Getting rid of arm fat quickly may seem daunting, but it is doable! While you can't get rid of just arm fat, you can eliminate fat overall which will make your arms smaller. Aim to do muscle-building exercises 3 times a week for a total of 90 minutes to tone your arms. Burn fat by adding at least 75-150 minutes of moderate to strenuous aerobic exercise to your week as well. Address any health problems that might be contributing to the buildup of arm fat, and make an effort to sleep more and eat a healthy diet.
First things first. You cannot—I repeat you CANNOT—lose body fat without eating a good, clean, nutritious diet. This might be the hardest part for most people to hear, but you'll never succeed unless you change what goes into your mouth. And while it may seem like a daunting task, it is probably much more simple than you think. The key is to eat real food! Put simply:
Exercise has long been correlated with a longer life, but it's only recently started to become clear why this might be. Studies, like a new one in the journal Preventive Medicine which found that exercise is linked to longer caps at the ends of chromosomes, have helped flesh this out a bit more. These caps, called telomeres, naturally shorten as we age, with each cell division. People who live a long time have telomeres that are in better shape than those who don't—but there's a lot we can do to affect the rate at which they shorten over the years. The team behind the new study looked at data from CDC's National Health and Nutrition Examination Survey, and found that for people who exercised regularly, their telomeres were 140 base pairs longer on average than sedentary people's. Which correlates to being years "younger" than their sedentary peers.


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Listing courtesy of Realty One Group Preview.
Paradise found in this 7+ acre parcel! Beautiful level property with Legal Lot Status, perfect to build your dream home! This parcel includes 500 feet of Deer Creek frontage, just minutes from Hwy 530 where the Historic Deer Creek meets the North Fork of the Stillaguamish River. Property also includes a 12x12 cabin.
The database information herein is provided from and copyrighted by the Northwest Multiple Listing Service (NWMLS). NWMLS data may not be reproduced or redistributed and is only for people viewing this site. All information provided is deemed reliable but is not guaranteed and should be independently verified. All properties are subject to prior sale or withdrawal. All rights are reserved by copyright.


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The Relationship Between the Declaration of Independence and the Constitution
- March 21, 2017
"THE POWERS OF THE SWORD ARE IN THE HANDS OF THE YEOMANRY OF AMERICA FROM SIXTEEN TO SIXTY … Who are the militia? are they not ourselves[?]."READ MORE
This is the second article examining contributions to our understanding of the Constitution from the three brand new volumes of the Documentary History of the Ratification of the Constitution of the United States. My first article observed that probably the greatest contribution of these three new volumes is reproduction, in indexed and easy-to-use hard copyREAD MORE
The Constitution created a strictly limited central government, which . . . would have no authority over religion, most criminal offenses, civil justice, social services, education, or most aspects of transportation or the economy.READ MORE


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Shared Workspace (BSCW)
BSCW can be used for document management and for administering and coordinating your projects.
The BSCW Shared Workspace System is an efficient tool for collaboration. You can easily coordinate cooperative efforts in BSCW and share documents, calendar events, contacts, tasks and notes.
All students, staff and teachers at Reutlingen University have access to BSCW.
Take a look at this BSCW Guided Tour or at this list of features.
In order to use BSCW you need a university account and a web browser (Firefox, Chrome) with Internet access. Follow this link to log in to BSCW. You can log in with your university user name and password.
First Steps
To edit your personal profile, choose "Options > Profile > Change" from the top menu bar.
In order to upload documents and begin sharing material continue as follows:
- Choose "File > New > Folder" in order to create a new folder.
- Choose "File > New > Document" to upload a file.
- To give others access to a folder simply click the triangular button on the right in the row where the folder appears and choose "Access > Invite Member".
- Enter the person's email address in the field on the left, click the +-Symbol and then click OK.
Logging in to BSCW
Open your Web browser and enter the address: https://bscwserv.reutlingen-university.de/bscw/bscw.cgi/
Log in with your university username and password.
Here are a few examples of what you can do on BSCW:
- Add folders and documents to share with a group of people
- Set up a calendar
- directly open and edit office documents
You will find more example here.