text:
Meeting new clients for the first time can be nerve-wracking. You want everything to go smoothly, from the initial greeting all the way through the show-stopping presentation that convinces them they have to partner with you and your company.
There's a lot that goes into these types of meetings, whether you're meeting in-person or virtually. Regardless of how the first big meeting is conducted, here's how to project professionalism and make a great first impression with potential clients.
The first in-person meeting with a prospective client isn't the only event that matters. Prospects develop their opinions about you and your business from the very beginning. If those impressions aren't positive, there won't be a first meeting to worry about.
You can lay the groundwork for a positive client relationship by:
Some of these tips might sound like common sense, but it's all-too-easy to neglect smaller details while you're busy running a company. These small signs of respect can go a long way toward earning a new client's business.
You know that it's important to respond quickly to emails and calls from prospective clients, but sometimes it's just not possible to find time in an already busy day.
If it feels impossible to keep up with client communication, consider bringing in some outside help to keep everything on track. A virtual assistant is an affordable, flexible resource you can depend on to take calls, provide excellent customer service, schedule appointments and so much more.
Prospects will be impressed with your company's personalized service and quick communication, and they'll be far more likely to become loyal customers.
You should never meet clients at your home. Coffee shops and other public venues are slightly more professional options, but they're still far from ideal.
For starters, these gathering places can be noisy and crowded. You also have little control over vital things like the internet connection. If you have a presentation to deliver, things get even trickier without the right tools and equipment.
Renting a meeting or conference room by the hour (or longer, if needed) is one of the most cost-effective ways to showcase professionalism without breaking the bank. These rooms are helpful for entrepreneurs and small business owners without dedicated office spaces, but they're also ideal for traveling professionals or anyone who simply needs more space to meet.
Here's how meeting and conference room rentals work at Intelligent Office (IO) locations:
If you're convinced that a professional space can help you knock your next new client meeting out of the park, click here to find an IO location in your city.
In today's mobile economy, digital entrepreneurs often work from varying locations. While this can help save money and increase agility, it comes with one big drawback:Read More >
Countless small business owners rely on remote assistants or offsite receptionists to help with critical organizational duties. While some are content to offload simple tasks to self-employed, stay-at-home support people, others demand more comprehensive services...NULLRead More >
While the traditional virtual assistant is likely to work from home, an executive-level virtual assistant is part of a greater brick-and-mortar presence. This fundamental difference opens the door for extensive training opportunities that broaden the professional's support capabilities.Read More >
Work has changed. In an age of instant communication, cloud-based applications, and workplace versatility, the era of the traditional office culture has come to an end. Providers of virtual offices, executive suites and co-working spaces have effectively liberated the nation's work culture, adding dynamic and energizing new choices...Read More >
For entrepreneurs and small business owners, navigating the tricky terrain of creating a sound business plan, forecasting for growth and developing an operative growth strategy can be a major challenge. Fortunately, American entrepreneurs and operators have access to one of the most effective resources in the worldwide market...Read More >
Navigating the complex terrain of creating a sound business plan, forecasting for growth and developing an operative growth strategy can be a challenge for entrepreneurs and small business owners. Fortunately, American entrepreneurs have access to one of the most effective resources in the world via the Small Business Administration (SBA).
... Click to read more
Congratulations! You have gotten your small business up and running. Now what? This part of our four-part series on leveraging the Small Business Administration to help you launch and manage a small business will focus on the operational aspects of running a business. Whether you need leadership strategies, day-to-day decision making skills
... Click to read more
Understanding marketing and sales as well as the technical complexity of our Internet-driven society gives entrepreneurs a distinct advantage over the competition. This final segment of our four-part report will take a deeper dive into the logistics and philosophy of marketing and sales and their impact on your business success.
... Click to read more
If a business isn't marketing, its potential customers are not finding it. Small to medium size businesses often struggle with spending hundreds of thousands of dollars on marketing. New DIY marketing tools, however, have eliminated the need to spend astronomical amounts on online and traditional marketing. These tools
... Click to read more
Law firms (large and small) and solo legal practitioners alike can use virtual office services and spaces to run their entire legal operations or as a supplement to a home office or traditional brick-and-mortar offices. Virtual office services can be particularly useful during trial preparation
... Click to read more
Finance and tax professionals, whether they work solo or as part of a larger firm, can use virtual office spaces and services to stay on top of their workloads, especially during the busy tax season. Professional virtual office spaces can be particularly useful when back-to-back client meetings are necessary...Read More >
As business people and entrepreneurs continually strive to grow their business, doing so frequently involves traveling around the country to attend networking or tradeshow events, meeting clients and prospects on their own turf, and getting some face-time with colleagues, contractors or employees who may operate in a remote location. Preparation
... Click to read more
Have you ever wondered why some small businesses are successful and others are not and what do these successful companies do to gain an edge over their competition? Through our years of experience
... Click to read more


text:
Regular price
Beautiful hand stamped 1/2" 14k gold filled, 14k rose gold filled or sterling silver disc with a sunshine. Comes on a beautiful necklace card ready for gift giving- sunshine: fill the world with your sunshine.
Gold filled and rose gold filled are a high quality metal that won't flake or tarnish! Sterling silver comes with a polishing pad to shine your piece back up. Gold filled and rose gold filled will come with letters left natural and sterling silver will come with letters darkened in.

subset: commoncrawl


text: Get rested and ready for anything at the Comfort Inn in Ironwood, MI. Located within a mile of the Wisconsin state border, our hotel is situated on the western end the Upper Peninsula. Here, you can get work done in our business center, with access to copy and fax services, or hold a get-together in our meeting space. Additional amenities include free WiFi, free hot breakfast, outdoor parking, an indoor heated pool and valet cleaning services. All guestrooms feature coffee makers, hair dryers, TVs, irons and ironing boards. Some rooms include microwaves, refrigerators and a hot tubs. Also, earn rewards including free nights and gift cards with our Choice Privileges Rewards program.


text:
INTERNATIONAL SHIPPING / FREE US SHIPPING / EASY RETURNS / 3 FOR 30 is ON! BUY 3 OR MORE OF ANY REGULAR PRICED ITEM GET 30% OFF WITH CODE THREE30
Rip Stop Cargos Black/Lime
Our same best selling cargo fit with a lighter weight rip-stop fabric that feels softer without sacrificing durability. Embellished with a Grey woven Artform patch on the leg pocket
Signature colorway of Arform Team rider Jack Curtin
100% cotton rip-stop / See size chart for details


text:
Danielle Bregoli, known by her stage name Bhad Bhabie, is an American rapper and singer. She became famous after appearing on Dr. Phil, where her famous phrase "cash me outside, how 'bout dah?" came from. She is good friends with Billie Eilish.
Early Life
Danielle Bregoli was born March 26th, 2003. Her parents, Ira Peskowitz and Barbara Ann Bregoli, dated for a year before Danielle's mother became pregnant, later breaking up when she was an infant. Danielle was raised primarily by her mother, and is estranged from her father, a deputy who works for the Palm Beach Police Department.
On September 14th, 2016, Danielle and her mother, Barbara Ann, were interviewed on Dr. Phil for the segment "I Want To Give Up My Car-Stealing, Knife-Wielding, Twerking 13-Year-Old Daughter Who Tried To Frame Me For A Crime" to discuss Danielle's behavior, which included stealing a crew member's car while the episode was being filmed. When Danielle became irritated at the laughter that the audience exhibited at her expense, she responded to them by saying, "Cash me ousside how bout dat"; her pronunciation of the phrase became a meme "Cash Me Outside Howbow Dah", and Danielle became known as the "'Cash Me Outside' Girl". On February 10th, 2017, Danielle reappeared on the show, but without the studio audience, due to the response at her previous appearance. Her first appearance on the show, and the catchphrase it spawned, would inspire a single based on the clip, which was recorded by DJ Suede The Remix God, which entered the Billboard Hot 100, Streaming Songs, and Hot R&B/Hip-Hop Songs charts in its March 4th, 2017 issue. The song in turn led to a series of dance videos that were uploaded onto YouTube.
In early 2017, Danielle was signed by product placement manager Adam Kluger as a means to boost his reputation in the music industry.
Danielle released her first single These Heaux (pronounced "hoes") on August 26th, 2017. The recording reached number 77 on the Billboard Hot 100, making her the youngest female rap artist to debut on the music chart. The success of These Heaux prompted Atlantic Records to sign Danielle to a multi-album recording contract. In September 2017, she remixed the Kodak Black song Roll in Peace and Tee Grizzley and Lil Yachty song From the D to the A. On September 22nd, 2017, she released Hi Bich which reached number 68 on the Billboard Hot 100 and a day after, Whachu Know, as a single alongside the video, which received over 3 million views in 24 hours. After a shorter break, on November 30th, 2017 she released another single I Got It, followed by Mama Don't Worry (Still Ain't Dirty) in December. In the latter, she's rapping about her past, and that her appearance on Dr. Phil should be forgotten. This theme is echoed in the video for Both of Em, in which she buries her old self in a shallow grave. In Hi Bich (Remix) she collaborates for the first time with other artists, including YBN Nahmir, Rich the Kid and Asian Doll (in the video, for unknown reasons YBN Nahmir was replaced by MadeinTYO).
On March 26th, 2018, she celebrated her birthday with a new song release, Gucci Flip Flops featuring Lil Yachty. Two days later, she received a gold certification from the RIAA for her single Hi Bich. In mid-April, she released a freestyle called Who Run It.
Her first tour across North America and Europe with Asian Doll began on April 14th, 2018.
On May 2nd, 2018, the video for Gucci Flip Flops was released. Following the video's release, the song debuted on Billboard's Hot 100 Chart at No. 80, becoming her third charting single on the chart. She received a 2018 Billboard Music Award nomination in the category of Best Female Rap Artist, along with Cardi B and Nicki Minaj.
On June 14th, 2018, Danielle released another single Trust Me featuring Ty Dolla Sign.
Official Accounts
- There were rumors that Danielle and Billie were dating due to how close they are, plus several posts from Danielle. However, this was debunked by Billie.


text:
Pulmonary vasculitis
Vasculitides are a heterogeneous group of diseases characterised by the inflammation and destruction of vessel walls, which reduces blood flow into tissues. These diseases are classified according to the affected organ and size of the vessels involved (1-4). Vasculitides can be primary or secondary to connective tissue disease, infection, neoplasm, or to a state of hypersensitivity (5). Primary vasculitides are rare diseases with an approximate incidence of 20–100 cases/million/year and a prevalence of 150–450 cases/million (5-7). Small-vessel vasculitides associated with antineutrophil cytoplasmic antibodies (ANCAs) generally affect the lungs.
Diagnosis is challenging and it is based on abnormal clinical, radiological, histopathological and analytical findings. More specifically, diagnosis is primarily based on ANCAs levels and other immunopathological markers (immunoglobulin A, cryoglobulin and anti-basement membrane antibodies). The primary objective of this article was to determine the features of primary systemic vasculitis with pulmonary involvement.
Normal pulmonary vessels
A pulmonary vessel is composed of three concentric layers called "tunics": the inner layer (tunica intima), which contains endothelial cells and loose subendothelial connective tissue; the medial layer (tunica media), which is formed by concentric smooth muscle cells and variable amounts of elastin, reticular fibers and proteoglycans. It is more developed in arteries than in veins and is virtually absent from capillaries. The outer layer (tunica adventitia) is made up of collagen and elastic fibers. Its thickness is variable, being relatively thin in arteries and thick in venules and veins. It is the outer covering of blood vessels (vasa vasorum).
More specifically, pulmonary vessels contain a lower number of smooth muscle cells. Pulmonary vessels have a thin wall (a third the thickness of the aorta), which confers them more elasticity and enables their functioning at low pressure with high blood flows. There are two types of pulmonary arteries: muscle arteries—with a 100–1,000-µm diameter and a significantly thicker layer, and elastic arteries, which do not contain muscle cells and have a diameter of >1,000 µm (8).
The clinical and radiological features of vasculitides depend on the organ affected and size of the blood vessels involved, i.e., large-calibre (aorta and its main branches); medium-calibre (primary visceral arteries); and small-caliber vessels (arterioles, capillaries and venules). Therefore, clinical and radiological findings are major criteria for the classification of vasculitides, which is based on the Revised International Chapel Hill Consensus Conference Nomenclatures of Vasculitides of 2012 (Table 1) (9-11).
Full table
Pulmonary vasculitis
Vessel size is a useful clinical descriptor. However, the reason why a particular disease affects vessels of a specific diameter is unknown. Vessels of the same size are not necessarily identical, as they are shaped by the needs of their anatomical location during embryonic development. Thus, same-calibre vessels of distinct organs have different characteristics, since each vessel is designed to satisfy the local needs of the tissue it perfuses (12).
The etiology of these vasculitides is unknown, although interaction between genetic and environmental factors might play a role in the etiology of these diseases (12) (Figure 1).
Large-vessel vasculitis
Takayasu's arteritis
Arteritis (which is often granulomatous) mainly affects the aorta and/or its branches of women <50 years old (9). Pulmonary arteritis is observed in 15–60% of patients (13). Initial symptoms usually are systemic and include malaise, low-grade fever and arthralgia (pre-ischemic phase). When the pulmonary artery is affected, it can cause dyspnea, coughing, chest pain, haemoptysis and, occasionally, pulmonary arterial hypertension. Late-term symptoms (ischemic phase) appear at an advanced stage and depend on the artery involved. These include variable pulse in the extremities and claudication of the vascular territory involved (10–25% of the cases). CT angiography and MRI scans can detect subtle changes in vessel walls, which helps differentiate current disease from stenosis caused by previously damaged vasculature. The use of positron emission tomography is, for the moment, the subject of intensive research (14). Diagnostic criteria are shown in Table 2 (15).
Full table
The treatment for pulmonary artery stenosis consists of high doses of corticosteroids occasionally combined with methotrexate and azathioprine. Cyclophosphamide has been traditionally used for refractory or severe disease, although it is being progressively replaced with new biological agents [tocilizumab (interleukin-6 receptor antagonist) and rituximab (monoclonal antibody anti-CD20, which reduces lymphocyte B count through various mechanisms)] (16). Therapeutical options for severe stenosis of the pulmonary artery include angioplasty, stent implantation, bypass and pulmonary artery (17,18).
Giant cell arteritis
Arteritis (which is often granulomatous) usually affects the aorta and/or its main arteries, with a predilection for the carotid branches, vertebral arteries and the temporal artery. It is observed in patients >50 years of age and is often associated with rheumatic polymyalgia (9). Histologically, it is indistinguishable from Takayasu's arteritis and is 2–6 times more frequent in women than in men. Pulmonary involvement is rare (non-productive cough in 10% of patients) but it should be considered in patients of advanced age with recent pharyngeal pain, aphonia or cough of unknown origin. Findings on CT and MRI scans are similar to those in Takayasu's arteritis. Diagnostic criteria are shown in Table 2 (19).
Treatment is based on corticosteroids (dose of 40–60 mg/day) (20) and results in rapid improvement. Methotrexate, cyclophosphamide and tocilizumab are therapeutic options in different settings (21). Like in Takayasu's arteritis, some patients can benefit from surgical interventions.
Medium-vessel vasculitis
Polyarteritis nodosa
Polyarteritis nodosa is a necrotizing arteritis with segment involvement of medium- and small-calibre muscular arteries without glomerulonephritis or vasculitis in arterioles, venules and capillaries not associated with ANCAs (9). Up to 30% of patients present antigens against hepatitis B virus. Pulmonary involvement is rare and its presence indicates a disease other than polyarteritis nodosa (22).
Kawasaki disease
Kawasaki disease is an arteritis associated with mucocutaneous lymph-node syndrome and it predominantly affects medium and small arteries (9). Its most relevant complication is coronary artery damage, which ranges from transitory dilatation to vessel wall destruction, with the development of aneurysms (23). It generally occurs in children younger than 5 years (24). Pulmonary arteritis is observed in 45–71% of autopsies (25). The prevalence of pulmonary involvement is associated with ethnicity. In a case series study performed in Japan, 14.7% presented pulmonary alterations on chest X-ray (26). In contrast, in an Italian study in 250 patients, no pulmonary involvement was documented in any subject (27). Respiratory symptoms are secondary to diffuse interstitial lung disease (which generally manifests with a reticular/micronodular echo pattern) or to the presence of pulmonary infiltrates and pleural effusion (26).
Small-vessel vasculitis
This type of vasculitis can be categorized into ANCA-associated vasculitis (AAV) and immunocomplex vasculitis (Table 1). The difference lies in the absence or small number of immunocomplex vessel wall deposits found in AAV, which contrasts with the moderate to marked deposits observed in immunocomplex vasculitis.
ANCA-associated vasculitis
ANCAs are IgG-type antibodies against cytoplasmic antigens in the cytoplasm of neutrophils and monocytes [proteinase 3 (PR3) and myeloperoxidase (MPO)]—essentially azurophilic granules of polymorphonuclear neutrophils. ANCAs promote neutrophil migration and vessel wall degranulation, thereby triggering the release of proteases and other toxic metabolites responsible for vascular damage. In the context of endothelial cells, this process leads to endothelial detachment and lysis (28). The presence of ANCAs in more than 90% of microscopic polyangiitis (MPA) and granulomatosis polyangiitis (GPA) suggests a relevant role in the etiology of the disease. This hypothesis is supported by the correlation between ANCAs titre and AAV (ANCAs decrease when a treatment is administered and increase in relapse); the effectiveness of plasmapheresis and B-cell targeted therapies (i.e., rituximab), and by a case of maternal MPO-ANCAs transfer to the neonate associated with the development of nephritis and pulmonary hemorrhage in the neonate. Yet, ANCAs must not be the only etiological factor for ANCA-induced vasculitis. Thus, some patients with ANCAs-induced vasculitis phenotype are ANCAs-negative, whereas some patients in remission are ANCAs-positive (29). The most relevant ANCAs staining patterns characterized by indirect immunofluorescence are cytoplasmic (c-ANCAs; specific antibodies against PR3 that can be observed in GPA) and perinuclear [p-ANCAs; antibodies against MPO and other antigens in eosinophilic granulomatosis with polyangiitis (EGP) and MPA].
Genetic factors
Different genetic factors could influence the etiopathogenesis of AAV. Mutations in the energy homeostasis associated gene (gene ENHO) reduce adropin production (a protein that protects the vascular endothelium), which is associated with endothelial damage. There is evidence demonstrating that ENHO mutations and adropin deficiency play a relevant role in the activation of endothelial cells during neutrophil recruitment. ENHO mutations and adropin deficiency have also been documented to be involved in neutrophil-endothelial interaction in vascular inflammation induced by interleukin-1 and tumor necrosis factor-α (TNF-α). This status increases susceptibility to ANCAs-associated lung injury (30). AAV raises the levels of soluble receptors of advanced glycated end products (RAGE), which promotes the production of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-ĸβ) and initiates the inflammatory cascade involved in vascular damage (31).
Granulomatosis with polyangiitis (Wegener's granulomatosis)
Granulomatous necrotizing inflammation affects the upper and lower airways, with necrotizing vasculitis mainly affecting medium and small vessels. It is common in pauci-immune necrotizing glomerulonephritis (9). The yearly incidence of this disease in Europe is 2.1–14.4 cases/million (32), and it occurs in all age groups.
Patients with GPA exhibit vascular cell adhesion molecule-1 (VCAM-1) overexpression in endothelial surface. VCAM-1 plays a crucial role in leukocyte recruitment and adhesion to the vascular endothelium, migration and extravasation. High levels of soluble VCAM-1 are a marker of endothelial cell activation in AAV (33). Soluble VCAM-1 levels are higher in GPA than in systemic sclerosis. High levels of soluble VCAM-1 are considered a marker of endothelial cell activation in AAV (33). Recent genetic studies have identified various loci strongly linked to predisposition to vasculitis, such as GPA and HLA-DP, PR3, SERPINA1 and semaphorin (SMA6A) (34).
Environmental factors—including exposure to toxic substances and infections—are known to be involved in the pathogenesis of vasculitis. Thus, two studies published in the 1990's revealed that chronic nasal infection by Staphylococcus aureus may trigger GPA activity (35,36). Some years later, several studies showed that chronic nasal infection by Staphylococcus aureus is an independent risk factor for GPA relapse, being patients previously treated with trimethoprim-sulfamethoxazole less likely to experience relapse (37-39). It has been demonstrated that fimbriated-pathogen infection frequently precedes pauci-immune focal necrotizing glomerulonephritis (acute inflammatory disease that results in rapid, irreversible kidney failure, typically in the context of systemic small vessel vasculitis such as GPA or MPA). Fimbriae of gram-negative bacilli present anti-FimH antibodies that have homologous sequences with epitopes on lysosomal-associated membrane protein-2 (LAMP-2), which promotes the activation of anti-LAMP-2. These antibodies cause neutrophil activation, and subsequent degranulation causes vascular cell apoptosis, which suggests that infection in a susceptible host could trigger the production of antibodies (40). Thus, FimH-triggered autoimmunity to LAMP-2 is a clinically relevant molecular mechanism that could induce the development of pauci-immune focal necrotizing glomerulonephritis (Figure 1).
Between 25% and 55% of patients with GPA show lung involvement, which occurs more frequently in c-ANCAs positive patients (41). The classical clinic triad includes upper airway (sinusitis, otitis, ulcerations, subglottic and bronchial stenosis) and lower airway involvement (haemoptysis, thoracic pain, dyspnea and cough) and glomerulonephritis (haematuria, azotemia), although not all occur at presentation (only 40% of patients have renal involvement at that moment) (42). Patients who do not show signs of systemic vasculitis and exhibit specific pathological and clinical changes in the respiratory tract should be considered GPA patients (especially if they are ANCA-positive). The most frequent radiological findings include pulmonary nodules and masses in any location (90% of cases) (43) that can join masses >10 cm, cavitate and get infected (hydro-aerial level in the interior of the mass). A perinodular ground glass halo may be observed. Other findings include thickening of the bronchial walls, atelectasis, bronchiectasis or pleural effusion (44). ANCAs test is positive in >90% of cases (mainly c-ANCAs/anti-PR3 positive). Diagnostic criteria are shown in Table 2. Differential diagnosis with MPA is complex as granulomas are not observed in all samples.
The management of GPA and all AAVs is based on a range of recently published recommendations (45,46). Treatment consists of an initial "Remission induction therapy", where a more intensive immunosuppressive therapy is administered to control the active illness, and a maintenance phase where the treatment is less intensive to minimize side effects while remission is maintained. When a new diagnosis of AAV—organ- or life-threatening—is confirmed, a combined treatment with glucocorticoids, cyclophosphamide or rituximab is recommended. If no organs are affected by AAV, management with a combination of methotrexate and mycophenolate is recommended. When AAV relapse occurs and compromises an organ or is life-threatening, the recommendation is the same as for newly diagnosed AAV (a combination of glucocorticoids and cyclophosphamide or rituximab). In patients with serum creatinine >5.7 mg/dL due to rapidly progressive glomerulonephritis—either de novo or recurrent—plasmapheresis should be considered. Plasmapheresis is also an option for the treatment of diffuse alveolar haemorrhage (DAH). In patients in remission, a combination of low doses of glucocorticoids and azathioprine, rituximab, methotrexate or mycophenolate for at least 24 months is recommended. For patients refractory to the treatment, it is recommended to replace cyclophosphamide with rituximab (or the other way round), refer the patient to an expert specialist, reconsider diagnosis, optimize the treatment, and arrange for inclusion in clinical trials. For decades, the standard treatment for patients with major organ involvement consisted of high doses of cyclophosphamide and glucocorticoids; consequently, approximately 75% of patients experienced remission within 3 months and 90% achieved it in 6 months. Yet, relapse and side effects were frequent (29). New recommendations are intended to limit exposure to cyclophosphamide and glucocorticoids during the induction and maintenance phase. Biological therapies (e.g., rituximab, among others) directed at cell and molecular components specific of autoimmune response and mediators of inflammatory damage could be more effective and less toxic (47). Patients treated with rituximab who exhibit a low proportion of B CD5+ cells relapse significantly earlier that the ones who have normal levels of B CD5+ cells. Thus, B CD5+ cells are considered an indicator of illness activity and guide remission maintenance therapy following treatment with rituximab (48).
MPA is a necrotizing vasculitis with little or no immune deposits (pauci-immune) that mainly affects small vessels. Recent genetic studies have identified various loci strongly associated with predisposition to vasculitis, most of which are important actors in immune and inflammatory response (49), as it occurs with MPA and HLA-DQ (50). Necrotizing glomerulonephritis is very common, pulmonary capillaritis is frequent and granulomatous inflammation is absent (9). Symptoms are discomfort, anorexia, fever, night sweats, arthromyalgia, weight loss and rapidly progressive glomerulonephritis (51). Pulmonary involvement is observed in 10–30% of cases usually in the form of DAH. Radiologically, a heterogeneous ground-glass pattern is observed accompanied by patchy and bilateral abnormalities suggesting DAH (52). ANCAs test is positive—mainly for p-ANCAs/anti-MPO—in 50–75% of patients. The treatment is the same as for AAV.
A granulomatous inflammation rich in eosinophils with necrotizing vasculitis mainly affecting medium and small vessels that is associated with asthma and eosinophilia. ANCAs test is positive in 45–70% of patients (mainly for p-ANCAs/anti-MPO). The presence of ANCAs is more frequent in the presence of glomerulonephritis (9). Moreover, genetic studies have identified a strong association between EGP and HLA-DRB4 that triggers an immune inflammatory response (53). Asthma and eosinophilia are relevant, and differential diagnosis should be done with allergic bronchopulmonary aspergillosis, cortico-dependent asthma and eosinophilic pneumonia, among others. There are two types of EGP: ANCAs-positive EGP—which affects the kidneys more frequently, and ANCAs-negative negative EGP—with more pronounced eosinophilia and severe pulmonary disease (54). Asthma is always present, is corticoid-dependent and, in the long term, usually precedes vasculitis. Rhinitis, nasal polyps or sinusitis are rarely ulcerating. Radiological images show ground-glass opacity; patchy, bilateral, homogeneous—occasionally migratory—infiltrates peripherally located; hyperinflation, bronchial wall thickening, and the characteristic mosaic pattern of severe asthma (55). A third of patients show pleural effusion, predominantly eosinophilic (56). Increased levels of eosinophils (>25%) in bronchoalveolar lavage contribute to the diagnosis. Transbronchial biopsy rarely provides a conclusive diagnosis. Diagnostic criteria are shown in Table 2. The treatment is the same as for AAV. Adding leukotrienes or omalizumab (monoclonal antibody anti-IgE) antagonists allows reducing the dose of corticosteroids in patients whose main limiting manifestation is asthma. This reduction of corticoids could help identify vasculitic manifestations of the illness (57,58).
Immune complex small vessel vasculitis
Anti-basement membrane antibodies disease
Anti-basement membrane antibodies disease is a type of vasculitis that affects glomerular/pulmonary capillaries—or both, and presents deposits of anti-glomerular basement antibodies. Pulmonary involvement causes pulmonary haemorrhage, renal glomerulonephritis and acute kidney failure (9). The term "Goodpasture disease" is used for patients who exhibit anti-glomerular basement antibodies, whereas Goodpasture syndrome is used to describe the coexistence of glomerulonephritis and DAH of any cause. The origin of this disease is unknown, although genetic and environmental factors seem to be involved (59). This disease is characterized by a bimodal presentation of age, its incidence peaking at thirty (prevalent in men with renal and pulmonary involvement) and at sixty/seventy (when isolated renal affectation is more frequent) (60). Pulmonary involvement (40–60% of patients, probably depending on the number of floating antibodies accessing the alveolar basement membrane) is less frequent than renal involvement, although the latter has also been documented (61). Radiological images are those characteristics of DAH. Lung biopsy shows alveolar haemorrhage with pulmonary capillaritis. Up to 20–30% of patients are also ANCAs-positive (generally against MPO) and usually show extra-renal involvement. Diagnosis is based on renal biopsy (lineal deposits of IgG in the glomerular membrane). The elective treatment is triple therapy [corticosteroids, immunosuppressors (generally cyclophosphamide) and plasmapheresis (to remove anti-glomerular basement antibodies)] (62). In dialysis patients, plasmapheresis is questionable since these patients do not recover renal function. Rituximab alone or associated with cyclophosphamide also provides good results (63).
Cryoglobulinemic vasculitis
Vasculitis with cryoglobulin immune deposits that affects the small vessels associated with seric cryoglobulins (9). Pulmonary involvement is rare (approximately 2% of patients). Radiological alterations are related to DAH (64), and prognosis is usually poor (65).
IgA vasculitis (Henoch-Schönlein purpura)
Small vessel vasculitis with IgA1-dominant immune deposits. This disease mainly affects children and usually involves the skin, peripheric nerves and glomeruli (glomerulonephritis indistinguishable from IgA nephropathy) (9). It is usually preceded by an upper airway infection, and infectious or chemical agents seem to be involved in its pathogenesis (66). Pulmonary involvement is rare in children and more frequent in adults. IgA deposits in the alveolar basement membrane lead to alveolitis. Radiological images show DAH (67) and pleural effusion (68).
Hypocomplementemic urticarial vasculitis
A type of vasculitis followed by urticaria and hypocomplementemia affecting the small vessels and associated with anti-C1q antibodies (69). It is often accompanied by glomerulonephritis, arthritis and ocular inflammation. Pulmonary affectation appears in 20% of patients, generally in the form of chronic obstructive pulmonary disease and bronchial asthma. Pulmonary vasculitis leads to the release of elastase by neutrophils and the development of panacinar pulmonary emphysema, mainly in basal zones (70). Pleural effusion has also been reported (71).
Various-calibre vessel diseases
Behçet disease
Vasculitis in patients with Behçet disease is characterised by recurring oral and/or genital aphthous ulcers and inflammatory lesions in the skin, eyes, joints, and in gastrointestinal and/or central nervous system. This type of vasculitis affects vessels of any size (20% arteries, 80% veins). Thromboangeitis, thrombosis, arteritis and arterial anaeurysm may also exist (9). It is generally observed in young men, with more cases in silk route countries, especially in Turkey (72). Thoracic involvement may be observed in less than 10% of cases (73), mainly in men. Clinical manifestations include haemoptysis, thoracic pain, cough and dyspnea (74). The most frequent findings are main and lobar pulmonary artery aneurysm—usually multiple and bilateral (75,76), superior caval vein obstruction, thromboembolism and pulmonary infarction (77). CT angiography may show affectation of the pulmonary artery (78-80). Peripheral vascular damage may also be present (superficial or deep vein thrombosis). The management of vein thrombosis is controversial. While some experts recommend immunosuppressive treatment, others support the combination of immunosuppressants with blood thinners (81). The treatment is a combination of high doses of corticosteroids with cyclophosphamide, azathioprine or infliximab (82-84). Anticoagulation is also used in patients with stenotic or occlusive disease. For refractory haemoptysis, surgical interventions such as endovascular embolization or lobectomy can be performed (85,86). Hughes-Stovin syndrome is a limited form of Behçet disease without oral or genital ulceration (87) with similar image findings (88).
Medical records and physical examination
Vasculitides are difficult to diagnose, even for a well-trained specialist, as the symptoms of this rare group of diseases are similar to those of more common conditions (i.e., infection, neoplasm). However, there are particular signs that should raise suspicions, namely: (I) DAH [triad of diffuse alveolar infiltrates, hemoptysis (not always present) and dropped hematocrit followed by increased diffusion capacity by 30%]; (II) rapidly progressive glomerulonephritis [active urinary sediment (erythrocyte cylinders, haematuria with dysmorphic erythrocytes and proteinuria >500 mg/dL), elevated urea and creatinine serum levels, arterial hypertension and edema]; (III) lung-kidney syndrome (patients with DAH and glomerulonephritis); (IV) ulceration or deformity of upper airway lesions (for example, refractory chronic sinusitis with ulcers or soft tissue destruction); (V) cavitating lesions or pulmonary nodules on imaging; (VI) tangible purpura (suggests skin vasculitis); (VII) peripheral nervous system manifestations like mononeuritis; (VIII) Systemic disease (simultaneous presence of symptoms and signs that suggest simultaneous or sequential affectation of various organs). Cough, fever or dyspnea are frequent manifestations; yet, the most characteristic sign is the presence of DAH as a result of capillaritis and the subsequent destruction of the alveolar-capillary membrane. At the onset of DAH, patients may be asymptomatic (symptoms will appear over days) or show acute respiratory failure. The majority of patients experience haemoptysis, although approximately a third of patients won't (89). Physical examination could reveal crepitant breathing.
Laboratory findings
The most frequent finding in DAH is anaemia, although leucocytosis may also appear. Lactate dehydrogenase values double the normal upper limit and are a risk factor for intrahospital mortality (90). Creatinine values may be elevated if DAH is a manifestation of a lung-kidney syndrome with concurrent glomerular disease. Elevated levels of eosinophils in peripheral blood and tissues in patients with EGP suggest that these cells play a role in the pathogenesis of the disease. CD95-induced inhibition of apoptosis prolongs the half-life of eosinophils, which decisively contributes to the development of chronic eosinophilia. Although the mechanism by which the activation of eosinophils causes endothelial damage is not completely understood, recent data suggest a potential role of T lymphocytes secreting eosinophil-activating cytokines (91).
In DAH, high resolution thoracic computerised tomography (CT) may show bilateral consolidations, although diffuse bilateral ground glass areas can also be observed, sometimes restricted to the lower lobes (64). When clinical symptoms resolve, radiological images improve, although symptoms may persist some weeks after bleeding have been stopped. After DAH, a septal thickening called "beaded pattern" may be observed (92). Recurrent DAH can lead to pulmonary fibrosis. Thoracic CT scan will help discard other potential causes of pulmonary haemorrhage in patients with haemoptysis.
In DAH, sequential aliquots of bronchoalveolar lavage look increasingly bloodier. Diagnosis of DAH is confirmed when at least 20% of the alveolar macrophages collected demonstrate hemosiderin deposits on iron staining. Yet, haemorrhage may not be detected if bronchoalveolar lavage is performed incorrectly.
The diagnostic profitability of the transbronchial biopsy is usually <10% (93). For small vessel diagnosis, a biopsy of the radiologically anomalous pulmonary parenchyma by videothoracoscopy is highly effective (94,95). Histopathological findings should be interpreted in conjunction with clinical and serological data, and final diagnosis should be confirmed by immunofluorescence. Comparative histopathological analysis of another tissue should also be performed, if available.
Figure 2 shows the algorithm with recommendations for the management of AAV.
Figure 3 displays the diagnostic algorithm of pulmonary vasculitis that correlates radiological findings with clinical and laboratory findings (44).
To summarise, many systemic vasculitides may affect the pulmonary vasculature. Their signs and symptoms may be non-specific, and diagnosis becomes a real challenge. Laboratory findings contribute to reduce differential diagnosis, although overlapping with other vasculitides and pathological processes may occur. Imaging tests can reveal specific alterations that guide the clinician to the right diagnosis. Vascular pulmonary involvement is a severe manifestation of severe systemic vasculitis and generally requires immediate treatment with corticosteroids and immunosuppressants.
The authors would like to thank Fernando Vázquez-Vázquez for his help with the figures.
Conflicts of Interest: The authors have no conflicts of interest to declare.
- Frankel SK, Schawarz MI. The pulmonary Vasculitides. Concise clinical review. Am J Respir Crit Care Med 2012;186:216-24. [Crossref] [PubMed]
- Fauci AS, Haynes B, Katz P. The spectrum of vasculitis: clinical, pathologic, immunologic and therapeutic considerations. Ann Intern Med 1978;89:660-76. [Crossref] [PubMed]
- Elefante E, Tripoli A, Ferro F, et al. One year in review: systemic vasculitis. Clin Exp Rheumatol 2016;34:S1-6. [PubMed]
- Kallenberg CG. Pathogenesis and treatment of ANCA-associated vasculitides. Clin Exp Rheumatol 2015;33:S11-4. [PubMed]
- Brown KK. Pulmonary vasculitis. Proc Am Thorac Soc 2006;3:48-57. [Crossref] [PubMed]
- González-Gay MA, Garcia-Porrua C. Systemic vasculitis in adults in northwestern Spain, 1988-1997. Clinical and epidemiologic aspects. Medicine (Baltimore) 1999;78:292-308. [Crossref] [PubMed]
- Watts RA, Lane SE, Bentham G, et al. Epidemiology of systemic vasculitis: a ten-year study in the United Kingdom. Arthritis Rheum 2000;43:414-9. [Crossref] [PubMed]
- Peinado-Cabré VI, Pizarro-Serra S, Barberà-Mir JA. Circulación pulmonar. In: Casan-Clarà P, García-Río F, Gea-Guiral J. editors. Fisiología y biología respiratorias. Ergon edition. Majadahonda, Madrid, 2007;173-94.
- Jennette JC, Falk RJ, Bacon PA, et al. 2012 Revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum 2013;65:1-11. [Crossref] [PubMed]
- Gómez-Román JJ. Diffuse alveolar hemorrhage. Arch Bronconeumol 2008;44:428-36. [Crossref] [PubMed]
- Jennette JC, Falk RJ. Small-vessel vasculitis. N Engl J Med 1997;337:1512-23. [Crossref] [PubMed]
- Hoffman GS, Calabrese LH. Vasculitis: determinants of disease patterns. Nat Rev Rheumatol 2014;10:454-62. [Crossref] [PubMed]
- Manganelli P, Fietta P, Carotti M, et al. Respiratory system involvement in systemic vasculitides. Clin Exp Rheumatol 2006;24:S48-59. [PubMed]
- Arnaud L, Haroche J, Malek Z, et al. Is (18)F-fluorodeoxyglucose positron emission tomography scanning a reliable way to assess disease activity in Takayasu arteritis? Arthritis Rheum 2009;60:1193-200. [Crossref] [PubMed]
- Arend WP, Michel BA, Bloch DA, et al. The American College of Rheumatology 1990 criteria for the classification of Takayasu arteritis. Arthritis Rheum 1990;33:1129-34. [Crossref] [PubMed]
- Clifford A, Hoffman GS. Recent advances in the medical management of Takayasu arteritis: an update on use of biologic therapies. Curr Opin Rheumatol 2014;26:7-15. [Crossref] [PubMed]
- Qin L, Hong-Liang Z, Zhi-Hong L, et al. Percutaneous transluminal angioplasty and stenting for pulmonary stenosis due to Takayasu's arteritis: clinical outcome and four-year follow-up. Clin Cardiol 2009;32:639-43. [Crossref] [PubMed]
- Hamamoto M, Futagami D. Pulmonary artery replacement for pulmonary Takayasu's arteritis. Gen Thorac Cardiovasc Surg 2012;60:435-9. [Crossref] [PubMed]
- Hunder GG, Bloch DA, Michel BA, et al. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum 1990;33:1122-8. [Crossref] [PubMed]
- Dasgupta B, Borg FA, Hassan N, et al. BSR and BHPR guidelines for the management of giant cell arteritis. Rheumatology (Oxford) 2010;49:1594-7. [Crossref] [PubMed]
- Villiger PM, Adler S, Kuchen S, et al. Tocilizumab for induction and maintenance of remission in giant cell arteritis: a phase 2, randomized, double-blind, placebo-controlled trial. Lancet 2016;387:1921-7. [Crossref] [PubMed]
- Frankel SK, Sullivan EJ, Brown KK. Vasculitis: Wegener granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, polyarteritis nodosa, and Takayasu arteritis. Crit Care Clin 2002;18:855-79. [Crossref] [PubMed]
- Burns JC. The riddle of Kawasaki disease. N Engl J Med 2007;356:659-61. [Crossref] [PubMed]
- Jennette JC, Falk RJ. Nosology of primary vasculitis. Curr Opin Rheumatol 2007;19:10-6. [Crossref] [PubMed]
- Amano S, Hazama F, Kubagawa H, et al. General pathology of Kawasaki disease on the morphological alterations corresponding to the clinical manifestation. Acta Pathol Jpn 1980;30:681-94. [PubMed]
- Umezawa T, Saji T, Matsuo N, et al. Chest x-ray findings in the acute phase of Kawasaki disease. Pediatr Radiol 1989;20:48-51. [Crossref] [PubMed]
- Falcini F, Cimaz R, Calabri GB, et al. Kawasaki's disease in northern Italy: a multicenter retrospective study of 250 patients. Clin Exp Rheumatol 2002;20:421-6. [PubMed]
- Kallenberg CG. Pathogenesis of ANCA-associated vasculitides. Ann Rheum Dis 2011;70:i59-63. [Crossref] [PubMed]
- Jennette JC, Nachman PH. ANCA Glomerulonephritis and Vasculitis. Clin J Am Soc Nephrol 2017;12:1680-91. [Crossref] [PubMed]
- Gao F, Fang J, Chen F, et al. Enho mutations causing low adropin: a possible pathomechanism of MPO-ANCA associated lung injury. EbioMedicine 2016;9:324-35. [Crossref] [PubMed]
- Kamo T, Tasaka S, Tokuda Y, et al. Levels of soluble receptor for advanced glycation end products in bronchoalveolar lavage fluid in patients with various inflammatory lung diseases. Clin Med Insights Circ Respir Pulm Med 2016;9:147-54. [PubMed]
- Gibelin A, Maldini C, Mahr A. Epidemiology and etiology of Wegener granulomatosis, microscopic polyangiitis, Churg-Strauss syndrome and Goodpasture syndrome: vasculitides with frequent lung involvement. Semin Respir Crit Care Med 2011;32:264-73. [Crossref] [PubMed]
- Kawano-Dourado L, Ab'Saber AM, Capelozzi VL, et al. In situ evidence of pulmonary endothelial activation in patients with granulomatosis with polyangiitis and systemic sclerosis. Lung 2015;193:355-9. [Crossref] [PubMed]
- Xie G, Roshandel D, Sherva R, et al. Association of granulomatosis with polyangiitis (Wegener's) with HLA-DPB1*04 and SEMA6A gene variants: evidence from genome-wide analysis. Arthritis Rheum 2013;65:2457-68. [Crossref] [PubMed]
- Stegeman CA, Tervaert JW, Sluiter WJ, et al. Association of chronic nasal carriage of Staphyloccocus aureus and higher relapse rates in Wegener granulomatosis. Ann Intern Med 1994;120:12-7. [Crossref] [PubMed]
- Stegeman CA, Tervaert JW, de Jong PE, et al. Trimethoprim-sulfamethoxazole (co-trimoxazole) for the prevention of relapses of Wegener's granulomatosis. Dutch Co-Trimoxazole Wegener Study Group. N Engl J Med 1996;335:16-20. [Crossref] [PubMed]
- Zycinska K, Wardyn KA, Zielonka TM, et al. Chronic crusting, nasal carriage of Staphylococcus aureus and relapse rate in pulmonary Wegener's granulomatosis. J Physiol Pharmacol 2008;59:825-31. [PubMed]
- Laudien M, Gadola SD, Podschun R, et al. Nasal carriage of Staphylococcus aureus and endonasal activity in Wegener's granulomatosis as compared to rheumatoid arthritis and chronic Rhinosinusitis with nasal polyps. Clin Exp Rheumatol 2010;28:51-5. [PubMed]
- Bonaci-Nikolic B, Andrejevic S, Pavlovic M, et al. Prolonged infections associated with antineutrophil cytoplasmic antibodies specific to proteinase 3 and myeloperoxidase: diagnostic and therapeutic challenge. Clin Rheumatol 2010;29:893-904. [Crossref] [PubMed]
- Kain R, Exner M, Brandes R, et al. Molecular mimicry in pauci-immune focal necrotizing glomerulonephritis. Nat Med 2008;14:1088-96. [Crossref] [PubMed]
- Hirayama K, Kobayashi M, Usui J, et al. Pulmonary involvements of antineutrophil cytoplasmic autoantibody-associated renal vasculitis in Japan. Nephrol Dial Transplant 2015;30:i83-93. [Crossref] [PubMed]
- Hoffman GS, Kerr GS, Leavitt RY, et al. Wegener granulomatosis: an analysis of 158 patients. Ann Intern Med 1992;116:488-98. [Crossref] [PubMed]
- Lee KS, Kim TS, Fujimoto K, et al. Thoracic manifestation of Wegener's granulomatosis: CT findings in 30 patients. Eur Radiol 2003;13:43-51. [PubMed]
- Mahmoud S, Ghosh S, Farver C, et al. Pulmonary vasculitis: Spectrum of imaging appearances. Radiol Clin N Am 2016;54:1097-118. [Crossref] [PubMed]
- Frankel SK, Jayne D. The pulmonary vasculitides. Clin Chest Med 2010;31:519-36. [Crossref] [PubMed]
- Yates M, Watts RA, Bajema IM, et al. EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis. Ann Rheum Dis 2016;75:1583-94. [Crossref] [PubMed]
- Specks U, Merkel PA, Seo P, et al. Efficay of remission-induction regimens for ANCA-associated vasculitis. N Engl J Med 2013;369:417-27. [Crossref] [PubMed]
- Bunch DO, McGregor JG, Khandoobhai NB, et al. Decreased CD51 B cells in active ANCA vasculitis and relapse after rituximab. Clin J Am Soc Nephrol 2013;8:382-91. [Crossref] [PubMed]
- Carmona FD, Martín J, González-Gay MA. Genetics vasculitis. Curr Opin Rheumatol 2015;27:10-7. [Crossref] [PubMed]
- Lyons PA, Rayner TF, Trivedi S, et al. Genetically distinct subsets whitin ANCA-associated vasculitis. N Engl J Med 2012;367:214-23. [Crossref] [PubMed]
- Gayraud M, Guillevin L, le Toumelin P, et al. Longterm followup of polyarteritis nodosa, microscopic polyangiitis, and Churg-Strauss syndrome: analysis of four prospective trials including 278 patients. Arthritis Rheum 2001;44:666. [Crossref] [PubMed]
- Primack SL, Miller RR, Müller NL. Diffuse pulmonary hemorrhage: clinical, pathologic, and imaging features. AJR Am J Roentgenol 1995;164:295-300. [Crossref] [PubMed]
- Vaglio A, Martorana D, Maggiore U, et al. Secondary and primary vasculitis study group. HLA-DRB4 as a genetic risk factor for Churg-Strauss syndrome. Arthritis Rheum 2007;56:3159-66. [Crossref] [PubMed]
- Sinico RA, Di Toma L, Maggiore U, et al. Prevalence and clinical significance of antineutrophil cytoplasmic antibodies in Churg-Strauss syndrome. Arthritis Rheum 2005;52:2926. [Crossref] [PubMed]
- Buschman DL, Waldron JA Jr, King TE Jr. Churg-Strauss pulmonary vasculitis. High-resolution computed tomography scanning and pathologic findings. Am Rev Respir Dis 1990;142:458-61. [Crossref] [PubMed]
- Lanham JG, Elkon KB, Pusey CD, et al. Systemic vasculitis with asthma and eosinophilia: a clinical approach to the Churg-Strauss syndrome. Medicine (Baltimore) 1984;63:65-81. [Crossref] [PubMed]
- Keogh KA, Specks U. Churg-Strauss syndrome: clinical presentation, antineutrophil cytoplasmic antibodies, and leukotriene receptor antagonists. Am J Med 2003;115:284-90. [Crossref] [PubMed]
- Wechsler ME, Wong DA, Miller MK, et al. Churg-Strauss syndrome in patients treated with omalizumab. Chest 2009;136:507. [Crossref] [PubMed]
- Hellmark T, Segelmark M. Diagnosis and classification of Goodpasture's disease (anti-GBM). J Autoimmun 2014;48-49:108-12. [Crossref] [PubMed]
- McAdoo SP, Pusey CD. Anti-glomerular basement membrane disease. Clin J Am Soc Nephrol 2017;12:1162-72. [Crossref] [PubMed]
- Lombard CM, Colby TV, Elliott CG. Surgical pathology of the lung in anti-basement membrane antibody-associated Goodpasture's syndrome. Hum Pathol 1989;20:445-51. [Crossref] [PubMed]
- Dammacco F, Battaglia S, Gesualdo L, et al. Goodpasture's disease: a report of ten cases and a review of the literature. Autoimmun Rev 2013;12:1101-8. [Crossref] [PubMed]
- Syeda UA, Singer NG, Magrey M. Anti-glomerular basement membrane antibody disease treated with rituximab: a case-based review. Semin Arthritis Rheum 2013;42:567-72. [Crossref] [PubMed]
- Chung MP, Yi CA, Lee HY, et al. Imaging of pulmonary vasculitis. Radiology 2010;255:322-41. [Crossref] [PubMed]
- Ramos-Casals M, Robles A, Brito-Zerón P, et al. Life-threatening cryoglobulinemia: clinical and immunological characterization of 29 cases. Semin Arthritis Rheum 2006;36:189-96. [Crossref] [PubMed]
- Rigante D, Castellazzi L, Bosco A, et al. Is there a crossroad between infections, genetics, and Henoch-Schönlein purpura? Autoimmun Rev 2013;12:1016-21. [Crossref] [PubMed]
- Nadrous HF, Yu AC, Specks U, et al. Pulmonary involvement in Henoch-Schönlein purpura. Mayo Clin Proc 2004;79:1151-7. [PubMed]
- Cream JJ, Gumpel JM, Peachey RD. Schönlein-Henoch purpura in the adult. A study of 77 adults with anaphylactoid or Schönlein-Henoch purpura. Q J Med 1970;39:461-84. [PubMed]
- Wisnieski JJ, Baer AN, Christensen J, et al. Hypocomplementemic urticarial vasculitis syndrome. Clinical and serologic findings in 18 patients. Medicine (Baltimore) 1995;74:24-41. [Crossref] [PubMed]
- Schwartz HR, McDuffie FC, Black LF, et al. Hypocomplementemic urticarial vasculitis: association with chronic obstructive pulmonary disease. Mayo Clin Proc 1982;57:231-8. [PubMed]
- Paira SO. Bilateral pleural effusion in a patient with urticarial vasculitis. Clin Rheumatol 1994;13:504-6. [Crossref] [PubMed]
- Sakane T, Takeno M, Suzuki N, et al. Behcet's disease. N Engl J Med 1999;341:1284-91. [Crossref] [PubMed]
- Erkan F, Gül A, Tasali E. Pulmonary manifestations of Behcet's disease. Thorax 2001;56:572-8. [Crossref] [PubMed]
- Erkan F, Cavdar T. Pulmonary vasculitis in Behcet's disease. Am Rev Respir Dis 1992;146:232-9. [Crossref] [PubMed]
- Castañer E, Alguersuari A, Gallardo X, et al. When to suspect pulmonary vasculitis: radiologic and clinical clues. Radiographics 2010;30:33-53. [Crossref] [PubMed]
- Chae EJ, Do KH, Seo JB, et al. Radiologic and clinical findings of Behcet disease: comprehensive review of multisystemic involvement. Radiographics 2008;28. [Crossref] [PubMed]
- Efthimiou J, Johnston C, Spiro SG, et al. Pulmonary disease in Behcet's syndrome. Q J Med 1986;58:259-80. [PubMed]
- Hassine E, Bousnina S, Marniche K, et al. Pulmonary artery aneurysms in Behcet's disease: contribution of imaging in 5 cases. Ann Med Interne (Paris) 2002;153:147-52. [PubMed]
- Emad Y, Abdel-Razek N, Gheita T, et al. Multislice CT pulmonary findings in Behcet's disease (report of 16 cases). Clin Rheumatol 2007;26:879-84. [Crossref] [PubMed]
- Trad S, Bensimhon L, El Hajjam M, et al. 18F-fluorodeoxyglucose-positron emission tomography scanning is a useful tool for therapy evaluation of arterial aneurysm in Behcet's disease. Joint Bone Spine 2013;80:420-3. [Crossref] [PubMed]
- Hatemi G, Yazici Y, Yazici H. Behcet's syndrome. Rheum Dis Clin North Am 2013;39:245-61. [Crossref] [PubMed]
- Hamuryudan V, Er T, Seyahi E, et al. Pulmonary artery aneurysms in Behet syndrome. Am J Med 2004;117:867-70. [Crossref] [PubMed]
- Saadoun D, Asli B, Wechsler B, et al. Long-term outcome of arterial lesions in Behçet disease: a series of 101 patients. Medicine (Baltimore) 2012;91:18-24. [Crossref] [PubMed]
- Schreiber BE, Noor N, Juli CF, et al. Resolution of Behcet's syndrome associated pulmonary arterial aneurysms with infliximab. Semin Arthritis Rheum 2011;41:482-7. [Crossref] [PubMed]
- Ceyran H, Akçali Y, Kahraman C. Surgical treatment of vasculo-Behcet's disease. A review of patients with concomitant multiple aneurysms and venous lesions. Vasa 2003;32:149-53. [Crossref] [PubMed]
- Kalko Y, Basaran M, Aydin U, et al. The surgical treatment of arterial aneurysms in Behet disease: a report of 16 patients. J Vasc Surg 2005;42:673-7. [Crossref] [PubMed]
- Durieux P, Bletry O, Huchon G, et al. Multiple pulmonary arterial aneurysms in Behcet's disease and Hughes-Stovin syndrome. Am J Med 1981;71:736-41. [Crossref] [PubMed]
- Rockall AG, Rickards D, Shaw PJ. Imaging of the pulmonary manifestations of systemic disease. Postgrad Med J 2001;77:621-38. [Crossref] [PubMed]
- Collard HR, Schwarz MI. Diffuse alveolar hemorrhage. Clin Chest Med 2004;25:583-92. [Crossref] [PubMed]
- de Prost N, Parrot A, Picard C, et al. Diffuse alveolar haemorrhage: factors associated with in-hospital and long-term mortality. Eur Respir J 2010;35:1303-11. [Crossref] [PubMed]
- Hellmich B, Ehlers S, Csernok E, et al. Update on the pathogenesis of Churg-Strauss syndrome. Clin Exp Rheumatol 2003;21:S69-77. [PubMed]
- Spira D, Wirths S, Skowronski F, et al. Diffuse alveolar hemorrhage in patients with hematological malignancies: HRCT patterns of pulmonary involvement and disease course. Clin Imaging 2013;37:680-6. [Crossref] [PubMed]
- Schnabel A, Holl-Ulrich K, Dalhoff K, et al. Efficacy of transbronchial biopsy in pulmonary vasculitides. Eur Respir J 1997;10:2738-43. [Crossref] [PubMed]
- Mukhtyar C, Guillevin L, Cid MC, et al. European Vasculitis Study Group. EULAR recommendations for management of primary small and medium vessel vasculitis. Ann Rheum Dis 2009;68:310-7. [Crossref] [PubMed]
- Travis WD, Colby TV, Lombard C, et al. A clinicopathologic study of 34 cases of diffuse pulmonary hemorrhage with lung biopsy confirmation. Am J Surg Pathol 1990;14:1112-25. [Crossref] [PubMed]


text:
Although "The Fresh Prince of Bel Air" has been gone from the television airwaves for at least a decade, the theme song continues to be one of the most popular pieces of music ever. Two musicians decided to have a bit of fun recently and posted a uniquely country version of "The Fresh Prince of Bel Air" theme song, positioning themselves for their performance outdoors right next to a rolling river.
One of the musicians, who calls himself Samurai Guitarist, is accompanied by his electric guitar and a harmonica. His fellow musician, identified as Jeff Gagne, sings the now very familiar lyrics in a slow and haunting fashion, starting with "Now this is a story about how my life got flipped, turned upside down".
He accompanies himself with some mean action from a tambourine near the end of the duo's musical set. Reaction to this video blues version of "The Fresh Prince of Bel Air" theme song has been incredible, with many fans of the popular television comedy show starring Will Smith asking if this song might soon become available on CD.
This blues rendition of "The Fresh Prince of Bel Air" theme song also has many individuals feeling nostalgic for what was unquestionably one of the best comedy series to hit the airwaves during the 1990s.


text:
Aris, Noor Aiysah (2014) Extraction of Phoenix Dactilyfera seeds oil using supercritical carbon dioxide / Noor Aiysah Aris. Masters thesis, Universiti Teknologi MARA.
Date fruits {Phoenix Dactylifera L.) contain high nutrients such as carbohydrate, fat, protein, dietary fibre, vitamins, minerals and antioxidant. However, the waste (seeds) from date fruit was always neglected since it cannot be consumed as it is, although it contains lots of nutrient same as the fruit. Most of the previous researcher extracted date seeds oil using conventional method. However, the conventional method for extraction of date seeds oil by using organic solvent is toxic and harmful towards human and environment. Thus, supercritical carbon dioxide (SC-CO₂) extraction method is introduced as a clean technology to extract oil from date seed. It can also be an alternative method to replace the current conventional method which utilized organic solvent. The objectives of this study are to extract oil from date seed type Mariami from Middle East, within a range of temperature (40, 50, 60, 70 and 80˚C) and pressure (27.6, 34.5, 41.4, 48.3 and 55.2MPa). In addition, to determine the best condition for highest oil yield, to identify the valuable components in the oil using gas chromatography equipped with mass spectrometry (GC-MS) and also to model the solubility data of date seed oil in SC-CO₂. The highest oil yield achieved was 3.3% with the solubility of 0.174 g oil/kg CO₂ achieved at pressure 55.2MPa and temperature of 50 ˚C. Analysis of component in the oil using GC-MS showed that the components detected were lauric acid, myristic acid, palmitic acid, linolelaidic acid, laurostearic acid, oleic acid, stearic acid and ascorbyl palmitate. Solubility data from experiment fitted well with the correlation model. Based on Paired T-test analysis, Chrastil model, Del Valle-Aguilera model and Adachi-Lu were found to correlate well with the experimental data with coefficient correlation (R²) of 0.941, 0.940 and 0.917 respectively. Therefore, Chrastil model, Del Valle-Aguilera model and Adachi-Lu model are suitable to represent the thermodynamic modeling of solubility date seed oil in SC-CO₂ at temperature range 40-80°C and pressure range 27.6-55.2MPa.
|Item Type:
|Thesis (Masters)
|Universiti Teknologi MARA, Shah Alam > Faculty of Chemical Engineering
|Item ID:
|Uncontrolled Keywords:
|Date fruits; Phoenix Dactilyfera seeds oil; supercritical carbon dioxide
TM_NOOR AISYAH ARIS EC 14_5.pdf
Download (6MB) | Preview
ID Number
Actions (login required)
|View Item


text:
About Adventures with M
There's nothing glamorous about bushwalking, caving or canyoning, but it sure is fun! If you're an armchair bushwalker, someone looking for new adventures, or one of my friends who just wants to see what I've been up to, this site is for you, sign up to get email alerts now!
Instagram SnapshotsInstagram has returned invalid data.
Monthly Archives: January 2018
My Northern Lights Adventure
NORWAY – FINLAND – THAILAND – 11 – 29 January 2018 This trip was conceived in a casual conversation with Christine. Me: "I wouldn't mind seeing the Northern Lights". Christine: "ok, let's do it", and next thing we knew we … Continue reading
Posted in Road Trips 10 Comments
Are the canyon gods trying to tell me something?
SOUTH BOWENS CREEK AREA – January 6, 2018 The day started out perfectly, everyone arrived on time, we nailed the route we wanted to take and explored the creek we wanted to explore, but by the end of the day, … Continue reading
Posted in BWOC, Canyoning, MSS 16 Comments
ALCATRAZ CANYON – January 5, 2018 A repeat of Alcatraz Canyon ordinarily wouldn't be blog worthy. However, based on the next day's adventure, I thought Alcatraz was worth a mention as it shows that not all of my trips are … Continue reading
Posted in BWOC, Canyoning, MSS 4 Comments


text:
Level II
Sat. March 28
Facilitated by GinaGenest
Fee $35
Compassionate Communication Level I is required for this course.
*This class meets requirements for Board of Trustee Application.
Class must have 6a minimum of 6 participants.
This workshop will provide learning opportunities so that you will be able to:
- Share the joys and challenges of applying Compassionate Communication in everyday life
- Discover the healing power of Empathy and Presence
- Learn how to connect empathically with yourself and others
- Participate at your level of comfort in a safe, accepting environment.
About Gina:
Gina is at the forefront of providing individuals the opportunity to create lives of unlimited possibilities! Grounded through her training in non-violence, psychology, counseling, education, coach training, and holistic health, Gina easily connects with those she works with. A former school counselor of twenty-one years and a three time start up program designer, Gina established her company, The Mindful Zone, in 2011 offering two paths focused on conscious living.
Through mindful and compassionate communication, Gina provides organizations and individuals the opportunity to learn effective communication strategies to use when faced with conflict and life's challenging moments. Participants learn new ways to maintain connection when confronted with disagreement using a conscious approach resulting in greater confidence and increased ease when strong emotions show up in life.
A Certified Life Design Coach through the cutting edge Life Design Program developed by Jackie Woodside, Gina supports others in stepping out of their comfort zones to live an empowered and conscious life with meaning and purpose. A committed advocate for those she works with, Gina supports her clients as a strategic partner helping them achieve dynamic life changes in a short amount of time as they create a life of clarity, focus and joy! To learn more about Gina and The Mindful Zone go to: www.themindful-zone.com.
|Class Fee
|$ 35.00


text:
It is amazing what a difference a few minutes makes
This morning I woke up before my alarm. I then made the fatal mistake at looking at the time – 3:58 am. Somehow that just seemed too early to be awake. There was a 3 at the front of the time. Oh my word. 3 am! Who in their right minds gets up at 3 am to train – 4 am just seems so much more respectable….
Talking about training… Ironman South Africa 70.3 or more commonly known around these parts as "The Half" is in less than 2 weeks. I have been so worried about the cycle that I kind of just forgot about the other two disciplines… I have not done much swimming or running and am now beginning to stress a little bit about it. Especially the swim – there could be a possibility that I don't even make the swim cut off and am not allowed to continue on the bike. Then all my cycle training would have been for nothing!!!
Well, not exactly for nothing. I have loved it, I am so happy to be back out on the road, getting fit again. I feel good about myself and have been spending a lot of time with my sister. But still – I would like to finish this race!


text:
Just like in their previous works, both vocalists have been in charge of the lyrics while Soan has produced and composed all the music. Other participant musicians on the first mini-album are DuelJewel's Shun and ex-BORN's K on guitars, and Ivy from Lack-co on bass. Listen to the audio previews below:
As for the second mini-album, Soan recurred to Kra's Taizo on guitar, DuelJewel's Yuuya on the kokyuu, and Kokusyoku Sumire's Sachi on violin. Listen to the audio previews below:
Doumou naru Kyousou, Doumyaku ni Utsu
Edition B
Seiren naru Kyousou, Joumyaku ni Ategau
More info:
Blog (Soan)
Blog (Temari)
Twitter (Soan)
Twitter (Akuta)
Share your opinion!


text:
Try our innovative BODYCYCLE Class
Whether you're looking to lose weight, build muscle or endurance, combining both strength training and cardio into your workout regimen is key. Cardio and weight training are the two best methods for altering your body composition.
Our BODYCYCLE classes uniquely integrate cardio and strength training by combining cycling (spinning) with free weight routines - all while on your bike. BODYCYCLE will help you maximize workout efficiency and calorie expenditure while you improve muscular strength and endurance.
Try a free class today !
Our fitness trainers are highly qualified and experienced athletes in their own right. They're passionate, experienced and committed to ensuring you meet your fitness goals faster and more effectively. They will ensure that all of our training is delivered to a consistently high standard as well as in a fun and engaging manner, so you'll enjoy working out even more!
Spinning® Instructor/CrossFit® Instructor/Owner-Manager
- Nicos is a former boxer and highly qualified health and physical education professional that employs multi-disciplinary sports science to create workout programs that pack a powerful punch that will leave you totally wanting more!
Functional and Cross Train Coach
- Efi is an experienced fitness and functional training coach that delivers highly motivational, intense and diverse workouts using a mix of TRX, floor exercises and weights to deliver a whole body muscle workout
Booking Administrator
- Theoni is our super friendly and efficient booking administrator that is available to take your bookings or answer any questions you may have...always with a smile :)
Spinning® Instructor
- Sotiris is a world class track cyclist and competes in sprint, team sprint and scratch events. His spin class workouts are precise and effective, providing speed and resistance variations designed to enhance your cardiovascular and muscular endurance
Spinning® Instructor
- Varvara is road and mountain bike Greek national women's champion. She uniquely combines rhythm and resistance, striving to inspire riders to challenge themselves by delivering a high-energy class that leaves you feeling positive, invigorated and powerful
Spinning® Instructor
Nasos is an experienced spin instructor that delivers high energy, intense and motivating brand of cycling routines that will get you sweating and screaming for more!
Spinning® And Functional Training Instructor
- Konstantinos is an experienced fitness coach and competes in triathlons, Iron man and duathlon events. He brings enthusiasm, positivity and huge amounts of energy to his on and off the bike workout sessions.
Row Coach & YOGA Instructor
- Antonis, a former Hellenic rowing national athlete, is our dedicated row coach that will ensure you learn the correct rowing technique. He will guide you through alternate training intervals on and off of the row machine delivering a high intensity, low impact, cardio and strength training workout.
Class Policies
Corporate Fitness Programs
Corporate Fitness or Wellness is among the most important investments that your company can make. In fact, research shows that businesses that start Corporate Fitness Programs are able to improve the overall employee morale and productivity, reduce health care costs and helps employees discover the value that health can bring to their lives. Healthier employees are more likely to work more diligently, better manage stress and miss fewer days of work due to illness.
At TrainSmart, we believe Corporate Fitness shouldn't be boring. We create personalised, dynamic and fun programs that consistently evolve over time, ensuring the best possibility of long term success for your employees. We challenge and stimulate your staff using the latest and proven training methods to deliver positive health change.
A successful corporate wellness program is embedded into the culture of the company and combines physical exercise, education, communication, incentives, and long term commitment. Our programs are modular and can be tailored to your company's needs and culture.
Contact us to today for a free consultation
Join our champion rowing coach Antonis for this intense workout experience !
Feel free to contact us with any questions or to book your free trial class
Leoforos Olimpionikou Spirou Loui, Marousi, 151 23, Greece
(C)Copyright OAKA37. All rights reserved.Privacy Policy


text:
This week we will continue to look at how curb appeal affects how buyers see your home. There is a whole range of ideas that can be tailored to fit just about any budget. Getting a head start on spring lawn care can make a drastic difference, for example. The home improvement stores are beginning to set out flowers and soon the outdoor sections of the local nursery will be overflowing with color. Apply some of that color in some freshly-mulched beds in your yard, roll up your DIY sleeves and watch how these changes can impact the feedback on your home, and bring in an offer!
For free, you can:
• Clean up overgrown flower beds, remove weeds
• Rake leaves and remove overgrown brush
• Wash windows and glass doors
• Properly store outdoor garbage & recycling cans
• Clean up toys, store bicycles, put away hoses
• Clean up any outdoor grill areas
For $100 you can:
• Invest in pots / planters on front porch with seasonal plants for a welcoming entrance
• Upgrade door hardware to a current finish
• Power wash siding, and wood surfaces to remove dirt and mold
• Repair or replace loose shutters
For $500 you can:
• Proper landscaping can provide a huge wow factor, add in size-appropriate trees
• Hire tree trimmers to correctly trim back overgrown bushes, & trees that block your home from street view
• Install fencing for privacy and block unsightly views of neighbor's property
• Have a brick mailbox built
• Invest in having an old cracked walkway repaved with stone or pavers


text:
Aoi Tsubaki (津場木 葵, Tsubaki Aoi) is the main character of Kakuriyo no Yadomeshi. She is the granddaughter of Shirō Tsubaki who has the ability to see ayakashi when she was very young.
Aoi is a beautiful young woman with shoulder-length brown hair that has bangs hanging over her forehead, but it mostly swept to the right and purple eyes.
She usually wears a light blue colored dress with a bluish gray jacket or wears a green or blue kimono. She usually wears her hair down or in a ponytail when wearing a kimono.
Aoi is a very kind, caring and friendly young woman, although that is not to say she can not be stubborn when she feels the need. This is best exemplified by her refusing to become the ogre's bride and rather paying off her debt on her own. She also tends to help those around her, and will take support if it supports her goals.
As a child, Aoi was able to see ayakashi, an ability inherited from Shirō Tsubaki and her mother was unable to put up with her ability that she abandoned her, which forced Aoi to reside in an orphanage. All alone and close to starving, she meets a kind ayakashi who gave her food where Shiro soon found her and adopted her. Prior to his death, Shirō taught Aoi how to cook in a manor that would be enjoyed by ayakashi. After his death, Aoi lived on her own, only then to be taken by the ogre and start her new life in the hidden realm.
One day, shortly after the death of Shirō Tsubaki, Aoi gives a boxed lunch to a hungry oni (ogre/demon). To her surprise, he responds by whisking her away to the Hidden Realm where ayakashi live and declaring that she will become his bride. The oni explains that he is the master of an inn for ayakashi known as "Tenjin-ya". Her grandfather, the only known human able to cross freely into the ayakashi world, had during his lifetime racked up a debt of 100 million yen at the inn. Lacking the money to repay the inn owner, he instead offered the hand of his granddaughter in marriage.
Furious, Aoi refuses to marry the oni and declares that she will instead work off her debt by finding a job at Tenjin-ya. However, the various ayakashi employees treat her coldly and refuse to work with her. The sole exceptions are Kasuga and Ginji, a shapeshifting nine-tailed fox. Ginji used to own a restaurant on the inn's grounds, but it failed due to a lack of customers. After the two bond over cooking for one another, Ginji suggests that Aoi reopen the restaurant and cook food from the human world, which ayakashi find extremely delicious.[1]
Powers & Abilities
Aoi has the ability to see ayakashi which is not visible to the normal human eye. She is also an excellent cook with an ability to make food that ayakashi find delicious.
Shirō Tsubaki
When sent to the adoption center, Shirō gladly takes Aoi in and raises her. He teaches her how to cook food delighting the ayakashi palate. She attended his funeral when he fell down the stairs and hit his head, having him sent to the hospital. She wanted to cook for him before he died, but his last meal was hospital food. It was Shirō's fault that Aoi has to live at Tenjin-ya in order to pay off the debt he left before he died. Aoi continues to learn move about her grandfather from the ayakashi she encounters in Tenjin-ya.
While passing by, Aoi meets a masked man and gives him food. She then meets him again and is left a wrapped box as well as a hairpin resembling a flower. She proceeds to open this and is sent to the hidden realm to be Ōdanna's bride. As collateral for Shiro's debt of 100 million yen, Aoi is forced to marry him. She immediately declines and decides to work to pay off her grandfather's debt.
Since arriving in Tenjin-ya, she has grown comfortable with Ōdanna and enjoys learning more about him as they spend more time together. At first, she feared him because he enjoys eating human girls, but soon she came to respect him. Aoi does develop feelings for the ogre that she struggles to admit to and she eventually stops correcting Ōdanna when he calls her his bride to others, proving how she's grown comfortable with the idea of marrying him. The two almost kissed in their mission to obtain a mermaid scale, which Aoi would have let happen, had Ōdanna not pulled away first.
Aoi meets Ginji on her first night at Tenjin-ya. He gives her food and shows her his shapeshifting abilities. Ginji is the one who urges Aoi to open her own restaurant so that she can earn the money needed to pay back her grandfather's debt. Ginji has proven to be a loyal friend and is always willing to help Aoi. Although many at Tenjin-ya are suspicious of Ginji, since he was originally from Orio-ya (a rival inn), Aoi is one of the only ones to fully trust Ginji.
At first Oryō does not like Aoi. Oryō also liked the master and didn't think Aoi was good enough to marry him. She also didn't think a human should be working at Tenjin-ya, as Oryō worked hard to get where she is at the inn. However, after Aoi cares for Oryō when she falls ill, the two become closer and Oryō comes to respect Aoi as a chef and a good person.
Like most of the other staff at Tenjin-ya, Akatsuki doesn't think Aoi belongs at the inn. However, after Aoi nurses Akatsuki back to health, he comes to like her. He enjoys her cooking and even helped hang the new sign in Aoi's restaurant.
As chief of the accounting office of Tenjin-ya, Byakuya thinks Aoi is destined to fail in her attempts of opening up her eatery. However, after Aoi receives a successful review in a newspaper, the restaurant becomes prosperous, thus leading to Byakuya's respect. Aoi also caught Byakuya playing with the tube kittens in the forest, which he found embarrassing.
Chibi is a Kappa Aoi is fond of. He later joins her in the hidden realm claiming to be her sidekick. He is devoted to Aoi and doesn't hesitate to join her on any of her adventures that she sets out on even if he is scared. He is always happy to eat cucumbers (and other foods) from Aoi.
When Aoi calls for Chibi to come back, thinking he will disturb the umi-bouzu, the latter suddenly becomes sad and scared. Aoi further lifts the blinds to discover the small child with Chibi clinging to the umi-bouzu. Aoi touches the scared ayakashi and is given a vision of how lonely and hungry he always feels - a feeling that Aoi is empathetic to due to her own loneliness when she was a child. She then decides to gather everyone on the island to eat and share company with the umi-bouzu. Everyone has a good time until it is time for the umi-bouzu to return to the sea. Before he leaves, Aoi asks him if he wanted to stay with her but he cannot due to his job of protecting the Southern Land. He leaves, saying he will see them in 100 years - although Aoi notes she may not be around by then.
- The name Aoi means "hollyhock, althea" (葵) (aoi).
- Aoi's surname Tsubaki means "haven, port, harbor, ferry" (津) (tsu), "place" (場) (ba) and "tree, wood" (木) (ki).
- Aoi is afraid of thunder and lightning, due to the fact that she was abandoned by her mother at a young age.


text:
However, a home business need not be a far-off dream. You can start your own business with some knowledge and research. This article describes many tips about developing your home business.
You need a backup plan just in case your home business doesn't go well. Disaster can strike at anytime, such as not receiving a shipment in time for a project deadline, and it is important to have a backup plan for such emergencies. Planning for such events will ensure that your needs can still be met.
It can be both fun and challenging to begin a home business. You should start by finding your own niche. It can be quite helpful if you pick an area that showcases your expertise. Do a lot of research before deciding what kind of business you want to launch. Be certain to network whenever possible with other home business entrepreneurs.
Breaks are necessary, but be disciplined about how long they are so that you do not get distracted and your work suffers. Don't start painting a bathroom or playing a video game. Take some time to recharge your batteries by taking a walk or sipping on a cup of tea.
Prior to starting your home business, you need to be sure your office is supplied with the right equipment and is comfortable. It may seem silly, but if you are not comfortable and have all you need, you may not be very productive.
You should make it a priority to obtain a post office box for routing your business mail to, as opposed to your current address. You don't want to be posting your physical home address on the Internet. This ensures your identity is protected and your family is also.
A helpful peer group can support you in your home business endeavors. You can find others to enlarge your own network. Even though these people might not be in your niche, you all are alike in your motivations to succeed.
Create a small office at home. It can be small, but it has to be organized. Make your working area inviting so that you can feel inspired, productive, efficient and calm there. Don't be concerned about size as you can do well with whatever sized space you have.
Make sure you develop a game plan when you are running a home business. No matter the size of your business, make sure you plan out your goals and how you will get there. As your business expands, the business plan you write will help keep things growing in the right direction.
Whenever your business makes a profit, set some of it aside so you are able to pay taxes at year-end. Your taxes are going to be roughly 20 percent of profits, and if you set aside when it is earned, you will not have problems when it comes time to pay.
As was stated at the beginning of this article, many people dream about starting their own home business. However, this could be hard if you don't have the proper education about it.


text: This summer the University of Wisconsin-Whitewater will continue the tradition of providing outstanding basketball camp instruction in a fun and competitive atmosphere. It is our goal to teach the fundamental building blocks that make up a great player while creating a fun and exciting learning environment! We offer a low camper to coach ratio which allows campers to learn more effectively while enjoying their experience.


text:
Show your love for your pet and bring them home with a Heart Large Engravable Pet I.D. Tag in Pink!
Why We Love It:
The Heart Large Engravable Pet I.D. Tag in pink will ship to your door, ready to use. Don't let your pet leave your house without I.D. so they know how to get back. Made of Anodized Aluminum. Look for other charms to enhance your tag bling. Made in the U.S.A.
* After adding to cart, you will add your pet's information.
Important Sizing Note: The following measurements are the dimensions of the actual product, not of the pet they fit. After measuring your pet, make sure all measurements fit within the following dimensions (with a little room to spare in the chest and neck).Large Pink
Popeye is a exceptionally handsome 11 year old boy of mine. He was rescued from a Los Angeles City Shelter in 2012 and immigrated to BC, Canada. He's a blessing to have aling with his two sisters that are rescues too.By Treasure on Aug 5, 2017
Princess is a very good dog. She is also treated like a little Princess. She is very loved!!By Lucy on Nov 8, 2013
Great AdditionPosted On 07/11/18 by Korena S from King City, OR Yes, Korena S recommends this product!
Love this. Basic large heart but goes with so many of her things and easy to read from a distance!
Pet I'd heartPosted On 06/02/17 by Rebecca C from Cameron, IL Yes, Rebecca C recommends this product!
Hi! I had been wanting to get a pink heart pet ID tag. I was buying a new collar which it matched. The inscription was great. It was easy to attach to the collar.
Loved my little Maggie's pink heartPosted On 05/18/16 by Amber H from Nashville, TN Yes, Amber H recommends this product!
The pink heart was too cute. I didn't know they were going to put her name on the front. I just wrote hey I am Maggie on the backside... whoops. It looks great I would say to definitely buy a tag silencer with it. I am purchasing one now. Great product.
Heart tagPosted On 02/07/15 by michelle h from Sacramento, NM Yes, michelle h recommends this product!
This is a nice light weight tag. I had so much to put on it I had to get the bigger one. Looks really nice and the lettering is very legible. She lost her last collar so hope she doesn't lose this one.
Summer loves it!Posted On 11/07/13 by Amanda W from Stratford, CT Yes, Amanda W recommends this product!
I love that this tag is big enough for my boxer, it fits her collar and is in proportion to her, which is hard to find at your normal even day pet store. It custom tag was great with no mistakes as well.


text:
In the grown up world, two people may have an altercation. There will be harsh words exchanged. Later, when cooler heads prevail, one or both may well apologise for their intemperate behaviour and that is the end of it.
The Police Federation and Labour both want an inquiry, while some Lib Dems were unimpressed by the statement.
Okay, so anyone who has read my witterings here and at my own place will be aware that I hold no torch for politicians – hang the lot and I won't shed a tear – but for fucking fuckitty fuck's sake already; Andrew Mitchell may be an arrogant arsehole, but he has apologised. Any grown adult would accept that as this was no more than a minor altercation, that should have been the end of it days ago. But here we are still going on, and on, and on about it. And some lackwits want a fucking inquiry? As if we have the money to waste – oh, yeah as it's our money they are perfectly happy to waste it as there's always more where that came from. Silly me.
Jeebus! Look, two people had an argument. Who gives a flying fig who was right and who was wrong? It was a non–incident. There are important things going on in the world. This isn't one of them, yet the media is making a meal of it, political parties are trying to make capital out of it yet at the bottom of it all, someone called someone else a silly name and may or may not have used naughty cuss words.
FFS, grow up, people.


text:
Schleswig-Holstein has over 120 varieties of cheese made from cow's, sheep's and goat's milk. Produced to new as well as traditional recipes, most of them are made by hand in artisan dairies. The Schleswig-Holstein Cheese Route runs right through the region for more than 500 kilometres, linking all the producers and events involved with this gourmet dairy produce. It also takes in several places of interest and of course the wonderful Schleswig-Holstein scenery.
Dvije korisne kombinacije tipki za zumiranje u pregledniku:
Povećavanje: +
Smanjivanje: +
Dodatnu pomoć dobit ćete od proizvođača preglednika klikom na ikonu:


text:
The Great Wide Sea (Paperback)
Usually Arrives to Store in 1-5 Days
Ben, Dylan, and Gerry are still mourning their mother's death when their dad decides to buy a boat and take them on a year-long sailing trip. Tensions flare between Ben and his father, but they gradually learn to live together in close quarters. Then one morning the boys wake up to discover their father has disappeared—and they are lost. What happened to him? Where are they? And what will they do when a terrible storm looms on the horizon?
About the Author
M. H. Herlong lives in New Orleans, Louisiana. The author's four sons inspired this debut novel.


text:
The purpose of providing schooling is to make sure that a major a part of the inhabitants is literate and for many who obtain training, the aim is to ensure a wholesome development of the thoughts, having a positive impression in the progress of the character. A Preschool Trainer, (however not Particular Education) with mid-profession expertise which includes employees with 5 to 10 years of experience can anticipate to earn a median total compensation of $27,000 based on 1,406 salaries. For common wage info for preschool teachers (and several other other early childhood training-associated positions), go to our Jobs web page and select a state.
If I'm having an off-day, I can always ask a type of individuals to take cost of circle time while I do one thing extra mundane, like washing tables, or to observe my classroom whereas I take a 5-minute break. Preschool teachers assist their college students be taught mainly by way of play and interactive actions, capitalizing on youngsters's play to additional language and vocabulary development.
Some preschool lecturers pursue the Youngster Care Professional (CCP) credential, especially these and not using a school degree (or who possess a degree in one other field). In fact, this interprets into more jobs for preschool lecturers. Academics may obtain help from a teacher assistant to manage classroom behavior.
According to the printed BLS data from 2016, the national average wage for Preschool Teachers is $33,300, with an estimated 385,550 being employed nationwide. Employment of preschool lecturers is projected to develop 7 p.c over the subsequent ten years, about as fast as the typical for all occupations.
Many lecturers enter the career with starting skills and work to earn extra training whereas gaining experience in the discipline of major training, thus incomes more cash. Head Start programs must have 50{04635035f75bca215772cb4fee7893c5deac51ef8b75b635034078069d90796a} of their academics maintain at minimum a Bachelor's Diploma.


text:
00:00 - 00:00
Shuttle bus transfer between Ivalo airport and Inari village. Pre-booking needed.Upon booking please inform your flight details, pick up and drop off place, and phone number. We will get back to you with the pick up time through email.Please note the shuttle bus service is not available 1.5.-30.6.2021.


text:
When the year has just started, we wrote a few articles about web development trends of 2018. The truth is, when you think about what is supposed to happen in the future (even just within the year), it's always interesting to see how things shape up. Furthermore, as someone who works in a software development company, it's my job to be aware of all these trends.
So I thought it would be fun to make a list of 2018 web programming trends that actually became the tendency and proved themselves to be worth all the lists and ratings.
These are 5 trends of web development that not only took shape but actually have grown tremendously during this half of a year.
Trend #1 – Accelerated Mobile Pages
As was shown by multiple reports, user attention span becomes shorter and shorter every year. A few years ago it was ten seconds, now it's seven, who knows what's going to be the next year? The one thing is clear though – waiting until the web page loads is not an option anymore.
Nevermind that waiting is annoying people but search engine algorithms don't like it as well. Now that page loading speed is one of the main SEO ranking criteria, it's evident that the fastest kill the slow.
Of course, with increased user demands for high speeds, developers figured out the latest web development technologies that helped face the challenge. Accelerated Mobile Pages load 3-4 times faster than the regular ones.
You have definitely seen such pages yourself. At the beginning of 2017, Adobe reported that AMP pages acquired 7 percent of all web traffic for top publishers in the United States. Such websites as HuffPost, BuzzFeed, TechCrunch use Accelerated Pages all the time – and they work.
Why are they faster than the regular pages?
Because the page is not refreshing right away which means, it takes way less time for the content to load. Considering user demands and SEO ranking requirements, it's safe to say that the technology will definitely be a future of web development 2019.
Trend #2 – Chatbots
You've heard a lot about them to the point when it became annoying I get it. Chatbots suck so far and the fact that each web development technologies list features them sucks even more. However, there is one thing to be true: chatbots are not going anywhere, no matter whether we like them or not.
Why are we so sure of this?
First of all, with the development of AI technology, it's evident that there is much more to chatbots than we currently see. As researchers predict, we will be able to talk with chatbots about our hobbies and lifestyles, and not just in a written form. Chatbots will become a great part of our lives.
Have you seen the Oscar-winning movie 'Her', about Samantha, a smart operating system? That's just about how smart chatbots can become, not in 2019, that's for sure, but sooner than we think. Just imagine what a value it could bring businesses in terms of understanding their customers.
Trend #3 – More push notifications
Push-notifications have already proven themselves to be useful. According to Localytics Data Team, 50% of users opt to push and find push messages useful. That means users voluntarily opt to receive information from a web app or a page. At our age of ad blockers, this seems beyond realistic – yet it is.
The best part about this trend is that it's relatively easy to implement. An experienced web development team will make a solid push-notification system in a week (maybe even less). That's a small time investment – and the results are definitely rewarding.
Just imagine what wonders could perform a push-notification powered by Artificial Intelligence. Mind-blowing.
Of course, if history is any indication, this trend will not last for long. It might be sad but it's a truth. As any advertising innovation appears, we tend to overuse it, rubbing it in customers' faces. However, for 2019 the trend still stands strong – and it might last for a long time if we use it with consideration.
Trend #4 – Browser Extensions
Yes, trends in web development are not just limited to IoT or AI. Extensions is a good way to solve customer's need with software technologies while bringing profits to the company. Do you want an example? Grammarly, FireShot, Google Analytics URL Builder – you name it. These are all cases of successful extensions that solve a real challenge and bring a lot of profit to their creators.
The possibilities of extensions are endless. You can develop it as a separate product (that's what already mentioned Grammarly did) or use it to improve user experience on your website. Google is a smart example of such approach. Basically, it's not the main company's product, just an add-on to what Google already has to offer.
No matter what is the purpose of your product, consider security. Most browsers, especially the most used ones – Chrome and Firefox, precisely check whether the extension is not malicious. Internet Explorer has limited support for add-ons – consider that while doing cross-browser testing.
Trend #5 – Virtual Reality
Same as AI or IOT, VR is really a buzzword. It has gotten so popular that it's difficult for company owners to perceive it seriously – as one of the most popular web development technologies that can be applied to their website. VR seems an unrealistic concept, something that undoubtedly exists but it's very far away.
That's, however, not what numbers show. Venture Capital Alliance announced a $10 billion-worth Virtual and Augmented Reality projects. VR companies raise huge funds and receive unbelievable brand support, along with extensive media coverage.
Looks super-real. Just have to warn you: with no German knowledge the voice can seem creepy (or so it was for me since I could not grasp what the voice was telling). Yet the experience overall is definitely unforgettable.
We've come a long way from HTML 1.0 to virtual reality, and it's great to see that as user demands grow—technologies that help businesses meet them are developed. From UX improvements that double as SEO boosters to chatbots and browser extensions that completely change the way users interact with the web—it's clear that conventional web pages are not always the best option.
The innovation is here, why not bring it to the market? Surprise your customers – and the results will surprise you.


text:
Six Things Patients Want from Social Media
| June 27, 2012
A few weeks ago, I spoke at the Connecting Healthcare + Social Media conference in New York about what we patients want from health social media. Michelle McNickle, New Media Producer for Healthcare IT News wrote the following piece summarizing my talk and the '6 things patients want from social media.
On the second and last day of the Connecting Healthcare + Social Media Conference, produced by NYC Health Business Leaders, in New York this past week, Jessie Gruman, president of the Center of Advancing Health, took the stage to present an honest and point-blank keynote on what she, and a majority of patients, ultimately want to see from an organization's social media efforts.
"I speak as someone who's been diagnosed four times with cancer," she said. "I'm a frequent user of healthcare, and I draw on my experiences to inform my own work ' many of us personally know healthcare is a delicate balance between the cognitive and emotional, the subjective with objective and individuals with populations. Websites are an ever-changing puzzle, and as we become more familiar with looking for health things online ' social media makes this puzzle less puzzling for us."
Gruman outlines six things patients want from social media.
Read the rest of this piece on the Healthcare IT News website.