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Do I need to say more than that?
Here 'tis…
Oh how I miss this show. And I'm looking forward to the announced reunion show this November!
Oddities and profundities from Fitz!
Hi there!
The Mayan calendar poses an interesting challenge to thinkers in the modern age. On one hand, it is one of the most complex and accurate astronomically-based calendars that we have found in mankind's historical record. And on the other, it predicts, according to some anthropologists and archaeologists, the end of time on December 21, 2012.
As always, humankind has very different responses to this date. Some claim it signals an apocalypse or armageddon. Others say that it will bring a sea change to human consciousness. Still others say it will be just another day on Earth. I have to admit that I fall into the last category, though I'll be interested to see what happens in three years.
It was obvious that authors Chris Morton and Ceri Morton Thomas put a ton of hard work and research into their book 2012: The Secret of the Crystal Skull. And it provides yet another point of view on the subject. Their protagonist, Dr. Laura Shepherd, is an archaeologist with a specialty in Mayan hieroglyphics. When a colleague dies mysteriously in the possession of a strange crystal skull, Shepherd is put in charge of determining where it came from and what its significance may be.
Never has writing a report for a superior provided more of a winding path. Laura's path takes her to a hidden Mayan temple and into one of the most technologically advanced labs in the United States, not to mention her journey to what may be a parallel universe… But I won't spoil that spiritual quest for you.
Evidently this novel began as a screenplay that may have inspired Roland Emmerich to create his latest big budget disaster film – 2012. And the authors' previous best-seller (The Mystery of the Crystal Skulls) may have inspired the last Indiana Jones movie – Indiana Jones and the Kingdom of the Cystal Skull. So they seem to have a knack for getting Hollywood's attention.
It reads like a screenplay a good portion of the time with a ton of visual detail. And though I enjoyed the second half of the book and found the last 200 pages to go extremely quickly, the first half was tough sledding and took a long time to get rolling.
At one point, Dr. Shepherd spends a few chapters reading a journal written in the 1930s by the daughter of the archaeologist who actually discovered the crystal skull on an expedition. I felt that section could have been written to summarize the journal entries rather than including several long, detailed entries in the text of the book. I was reminded of Mary Shelley's classic Frankenstein, which is written as a series of journal entries that I have never finished after multiple attempts. So this may be more my failing than that of the authors.
In another part of the book, Dr. Shepherd remembers how her daughter died in a choking accident involving a piece of candy. As a parent, the scene was almost too detailed and graphic to read without thinking about how I would react if faced with the same situation. It was one of the stronger scenes, yet somehow fit awkwardly into the grander scheme of things. Again, I feel it might have been edited a bit to smooth out this rough patch.
However, from the point where Laura enters the jungle in search of the Mayan temple where the crystal skull had been found 80 years ago, I felt more connected to the story. It was at that point that the author's knowledge of Mayan history and architecture really shined through and the adventure kicked into high gear. From there to the end, it's a great thrill ride reminiscent of something you'd see in an Indiana Jones adventure.
Ultimately I enjoyed 2012: The Secret of the Crystal Skull by Morton and Thomas, but I wish it got going a bit faster than it did. If you're fascinated by the Mayan calendar, the impending date of December 21, 2012, and the mystery of the crystal skulls, be sure to check it out at your local bookstore.
p.s. Pick up this book and other 2012-themed media at Amazon!
Hey all…
On December 21, 2012, the Mayan calendar ends, according to anthropologists and archaeologists. A new cycle will begin at that point. And, whether you're a skeptic or believer, scientist or historian, there are some interesting facts in the new documentary – 2012: Science or Superstition.
Several authors and scientists discuss the many aspects of the end of the Mayan calendar. Astronomers discuss the rise in frequency of sunspot activity. Anthropologists discuss the techniques the ancients used to predict star patterns across lifetimes and how they traveled various planes of consciousness. And the viewer is exposed to multiple points of view, facts, and conjecture.
Ultimately it's up to the viewer to decide what they believe. I find myself squarely in the skeptics camp for this one.
It's interesting to go to the bookstore and see all the titles published around the topic of 2012. Doing a quick search of the term "2012" on Amazon brought up 50 different books and DVDs from a variety of authors and sources, including a Complete Idiot's Guide to 2012 published in October 2008.
Hollywood has jumped on the bandwagon as well. There's an upcoming movie based on Whitley Strieber's latest novel – 2012: The War for Souls is rumored to be in the works with Michael Bay involved as producer or director. And Roland Emmerich has a movie called 2012 slated to come out in November 2009 starring John Cusack as a researcher trying to counteract the events foretold by the end of the Mayan calendar.
Disinformation, the company producing the documentary, attempted to highlight multiple views of the subject matter and interview experts from a variety of disciplines – often conflicting ones – to provide as balanced a view as possible about what 2012 means. The documentary discusses a number of possibilities for what may occur, but doesn't come out and say that they will happen. The fact that the producers came at the topic from a multitude of viewpoints and scientific pursuits is very helpful to the viewer who becomes hooked by the idea. The documentary provides a jumping off place for viewers to do their own research and come up with their own conclusions.
Some of the people interviewed for the documentary have very interesting backgrounds as well.
Dr. Anthony F. Aveni is a professor of astronomy and anthropology at Colgate University. He helped create the field of archaeoastronomy, and is one of the founders of Mesoamerican Archaeoastronomy. In particular, his research focuses on the astronomical history of the Maya Indians.
Robert Bauval is the author of a number of books discussing the relationship of the stars and ancient cultures, especially in ancient Egypt. His first book, The Orion Mystery, proposed that the layout of the three Giza Pyramids was intended to mirror the layout of three stars in Orion's Belt. Other books by Bauval include The Message of the Sphinx, Secret Chamber, and The Egypt Code.
Walter Cruttenden is the Director of the Binary Research Institute and proposed an alternate view of history where the sun is one of two stars affecting the orbit of our solar system. This binary orbit theory may in fact be the reason for the repeating cycles of Golden and Dark Ages in mankind's long history.
Many others were interviewed, including:
p.s. Check out some of the books on 2012 at Amazon!


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Striped Dress (American Apparel from Myer city store) / Denim Shirt (Kmart) / Body Lotion (Burt's Bees) / Havaiana's (Paul's Warehouse) / Gingseng Bonsai Plant (Ikea) / Pot (Flower Power)
So happy Spring is finally here, the weather has been amazing and I can't wait to wear this American Apparel dress I picked up at Myer. The dress is quite form fitting so I think I'll be dressing it down with this bargain ($15) denim shirt and red-orange Havs. My Burt's Bees body lotion has become an essential again as the warm weather means I can't hide my legs in stockings.
Follow me on instagram and bloglovin x
filed under American Apparel, Bodylotion, Bonsai, Burt's Bees, Candle, Cosmetics, Denim, Denimshirt, Dress, Fashion, Havaianas, Ikea, Kmart, Myer, Plant, Stripes, Thongs
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MLSU Supplementary Result 2019
Mohanlal Sukhadia University recently conducted the UG and PG Examination for session year 2019-19 in the Month of September/October. Now the Udaipur University is preparing to announce the MLSU Supplementary Result 2019 for B.A, B.Sc, B.Com, BMS, BCA, BHM, B.Ed, LLB, M.A, M.Sc, M.Com and MCA courses on the official website of University. Students who have appeared in the BA, B.Sc, B.Com Part 1, Part 2 and Part 3 Compartment Examination 2019, will soon be able to check their MLSU B.A 1st, 2nd, 3rd Year Supply Result 2019 from below given link. The Udaipur University officials did not declared the MLSU Supplementary Result 2019 date yet. But it expected to announce in the Month of Nov/Dec. Students who want to know more details regarding to MLSU Supply Result 2019, may visit the official website of university.
Udaipur University B.A 1st, 2nd 3rd Year Supply Result 2019
Mohanlal Sukhadia University is also known as University of Udaipur. MLSU is situated in Udaipur city of Rajasthan. Later the agricultural University was turned into a multi courses university in 1964 and named as University of Udaipur. In the year 1984 it was renamed as Mohanlal Sukhadia University in memory of politician Mohanlal Sukhadia. Every year MLS university organizes the UG and PG Annual and Semester Examinations. Recently MLS University conducted the B.A, B.Sc, B.Com Ist Year, IInd Year and IIIrd/Final Year Main Annual Examination for session year 2019-19, in the Month of March/April. The Udaipur University will declare the B.A 1st, 2nd, 3rd, 4th, 5th, 6th Semester Exam Result after the one month of Examination.
MLSU B.A, B.Sc, B.Com Final Year Supplementary Result 2019
- Name of Univeristy:- Mohanlal Sukhadia University
- Name of Exam:- UG/PG Examination 2019-19
- Exam Date: March/April 2019
- Category:- MLSU Supplementary Result 2019
- Status:- Available Soon
- Official Website: www.mlsu.ac.in
Every year large number of candidates appeared in the B.A First, Second, Third/Last Year Compartmental Examination 2019. Like every year this year also several students participated in the university examinations. Now all these students are anxiously waiting for their MLSU M.A Previous and Final Year Supply Result 2019. Students are searching for MLSU Supplementary Result 2019 on internet regularly. We inform all those candidates that the MLSU B.Sc Part I, II, III Supplementary Result 2019 will be declared soon on the official website www.mlsu.ac.in. All the Private, Regular, Non College (NC) and Ex-Students can check and download their MLSU B.Com I, II, III, IV, V, VI Sem Reappear Result by Name Wise or Roll number Wise from the official website of university..
How to Check MLSU BA B.Com, B.Sc Supplementary Result 2019
- First visit the official website of university- www.mlsu.ac.in.
- Now click on the Results link.
- Now check for the link of Supplementary Result 2019 according to your course.
- Enter all mandatory details like as Name, Roll number.
- Now click on submit button and get your result.
- Take a print out of result for future uses.
These above given steps are very easy to get the results. Anybody can easily find his/her MLS University Supplementary Results 2019 by following these steps. University is planning to declare results very soon. Results will publish on the official website of University. Students will be able to check their MLS University B.Sc Results 2019 from the official website. Here on this page we will also provide link to check results. Students can also check it from the this page also. After the official declaration of result by the university, here on this page we will also update it. So it is suggested to all the students to visit this website regularly for latest updates of results.
All the Students are able to check MLSU Supplementary Result 2019 here on this page, after official announcement. We will update Result link on this page. Candidates can directly check their MLSU Supplementary Results 2019 from the link. You can check your MLSU UG/PG Exam Result Name Wise, Roll Number Wise etc.
नोट- MLS यूनिवर्सिटी ग्रेजुएशन रिजल्ट्स से समबन्धित सभी जानकारी हमने इस आर्टिकल के माध्यम से आप तक पहुचाने का प्रयास किया है. सभी अभ्यर्थी बहुत जल्दी ही यूनिवर्सिटी की ऑफिसियल वेबसाइट के माध्यम से अपने परिणाम चेक कर सकेंगे. सभी विद्यार्थियों को सूचित किया जाता है की यूनिवर्सिटी रिजल्ट्स हमारी वेबसाइट पर भी उपलब्ध रहेंगे . विद्यार्थी हमारी इस वेबसाइट के माध्यम से रिजल्ट्स चेक कर सकेंगे. हमारी सलाह है की आप लेटेस्ट updates के लिए हमारी वेबसाइट को नियमित रूप से विजिट करते रहे. अधिक जानकारी के लिए आप यूनिवर्सिटी की ऑफिसियल वेबसाइट भी विजिट कर सकते है.
Check Also:
MLSU Post Graduation Exam Form 2019


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Revelation Introduction and Outline
Why Read Revelation?
"Why read this strange book? John gives a good clue in the first phrase, which introduces this book as "the revelation of Jesus Christ." Revelation gives a unique picture of Jesus Christ, and the New Testament would be incomplete without it. The Gospels describe Jesus' life on Earth from four different viewpoints. The letters discuss the deep significance of the resurrected Christ and what he accomplished. But Revelation shows Jesus Christ from a new perspective: as the mighty ruler of the cosmic forces of good. When John saw him in this exalted state, he fell at Jesus' feet as though dead (1:17).
Although Revelation does not remove the mystery surrounding Jesus' return and the end of the world, it does throw light on those events. It cannot be reduced to a mere timetable of events; it speaks lasting truths to every generation of readers. Revelation tells of Christ's future triumph over all the evil in the universe. This crucial message of final hope was needed by its original readers in the first century and is still needed by us today." —NIV Student Bible
Who wrote Revelation? John the Beloved Apostle (see Rev 1:1)
DATE: A.D. 96? There is some dispute about this though. From the Harper Collins Study Bible's notes we learn "Many early Christian writers thought that Revelation had been written toward the end of Domitian's reign (81–96 ce), but a few later writers thought that John had written a generation earlier, during the persecution that occurred in 64 under Nero (54–68 ce). Evidence supporting both dates can be found in the book. In favor of the earlier date, 11.1–3 suggests that the Jewish temple in Jerusalem (destroyed by the Romans in 70) was still standing when the book was written. Further, the code name of the beast in 13.18 is 666, widely thought to symbolize the name Nero Caesar. Other data, however, suggest a date late in the first century. For example, there are several allusions (13.3; 17.9–11) to the legend of Nero's return, which circulated throughout the eastern Mediterranean during the two decades following his suicide in 68. Further, Revelation frequently uses "Babylon" as a code name for Rome (14.8; 16.19; 17.5, 18; 18.2, 10, 21), but the evidence suggests that Jews used this code name only after the Romans destroyed Jerusalem in 70."
As a general rule, I favor the dating of approximately 96 A.D. We need to remember that there is, oftentimes, an already but not yet in prophecy. John certainly wrote to comfort Christians who were already under persecution but he also wrote to comfort those under persecutions yet to come.
The spiritual decline of the 7 churches (chaps. 2, 3) also argues for the later date. Those churches were strong and spiritually healthy in the mid-60s, when Paul last ministered in Asia Minor. The brief time between Paul's ministry there and the end of Nero's reign was too short for such a decline to have occurred. The longer time gap also explains the rise of the heretical sect known as the Nicolaitans (2:6, 15), who are not mentioned in Paul's letters, not even to one or more of these same churches (Ephesians). Finally, dating Revelation during Nero's reign does not allow time for John's ministry in Asia Minor to reach the point at which the authorities would have felt the need to exile him.
THEME: The theme of the Revelation is Jesus Christ (Rev 1:1) in all His post-resurrection glory and majesty. He is presented in a threefold way: (1) As to time: "which is, and which was, and which is to come" Rev 1:4); (2) as to relationships–the churches Rev 1:9 through Rev 3:22), to the tribulation Rev 4:1 through Rev 19:21), to the kingdom Rev 20:1 through Rev 22:21); (3) in His offices–High Priest Rev 8:3-6), Bridegroom Rev 19:7-9), King-Judge Rev 20:1-15).
Christ is the central theme of the book, but all of the events move toward one consummation, the bringing in of the covenanted kingdom. The key-phrase is the prophetic declaration of the "great voices in heaven" Rev 11:15), lit, "The world kingdom of our Lord and of his Christ has come."
Introductory Remark
The three major divisions of Revelation must be clearly held if the interpretation is to be sane and coherent. John was commanded to "write" concerning three classes of "things" Rev 1:19):
I. Things past, "the things thou hast seen," i.e. the Patmos vision, Rev 1.1-20.
II. Things present, "the things which are," i.e. things then existing–obviously the churches. The temple had been destroyed, the Jews dispersed: the testimony of God had been committed to the Churches (1Ti 3.15). Accordingly we have seven messages to seven representative churches, Rev 2.1 through Rev 3.22. It is noteworthy that the church is not mentioned in chapters 5 through 18.
III. Things future, "things which shall be hereafter," lit. "after these," i.e. after the church period ends, Rev 4.1 through Rev 22.21. The third major division, falls into a series of six sevens, with parenthetical passages, making, with the church division, seven sevens. The six sevens are:
(1) The seals, Rev 4.1 through Rev 8.1.
(2) The seven trumpets, Rev 8.2 through Rev 11.19.
(3). The seven personages, Rev 12:1-14:20.
(4). The seven vials (bowls), Rev 15.1 through Rev 16.21.
(5). The seven dooms, Rev 17.1 through Rev 20.15.
(6). The seven new things, Rev 21.1 through Rev 22.21.
The parenthetical passages are:
- The Jewish remnant and the tribulation saints, Rev 7:1-17.
- The angel, the little book, the two witnesses, Rev 10:1 through Rev 11:14.
- The Lamb, the Remnant, and the everlasting Gospel, Rev 14:1-13.
- The gathering of the kings at Armageddon, Rev 16:13-16.
- The four alleluias in heaven, Rev 19:1-6. These passages do not advance the prophetic narrative. Looking backward and forward they sum up results accomplished, and speak of results yet to come as if they had already come. In Rev 14:1, for example, the Lamb and Remnant are seen prophetically on Mount Zion, though they are not actually there till Rev 20:4-6.The end of the church period Rev 2 through Rev 3.) is left as indeterminate. It will end by the fulfillment of 1Th 4:14-17. Revelation 4 through Rev 19 are believed to synchronize with Daniel's Seventieth Week (Dan 9:24). The great tribulation begins at the middle of the "week," and continues three and a half years Rev 11:3 through Rev 19:21). The tribulation is brought to an end by the appearing of the Lord and the battle of Armageddon Mat 24:29, 30; Re 19:11-21). The kingdom follows Re 20:4, 5); after this the "little season" Re 20:7-15), and then eternity.
As we study Revelation we should bear in mind two important passages: 1Pe 1:12; 2Pe 1:20, 21. Doubtless much which is designedly obscure to us will be clear to those for whom it was written as the time approaches.
THEORIES OF INTERPRETATION: There have been many approaches to this book, but these can be divided into four major theories:
- Preterist theory: All of Revelation has been fulfilled in the past. It had to do with local references in John's day. It had to do with the days of either Nero or Domitian.
- Historical theory: Fulfillment of Revelation is going on in history, and Revelation is the prophetic history of the church, according to this theory.
- Historical-spiritual (Symbolic) theory: This theory is a refinement of the historical theory and was advanced by Sir William Ramsay. It states that the two beasts are Imperial and Provincial Rome. The point of the book is to encourage Christians. According to this theory, Revelation has been largely fulfilled and there are spiritual lessons for the church today. Amillennialism, for the most part, has adopted this view. It dissipates and defeats the purpose of the book.
- Futurist theory: This theory holds that the Book of Revelation is primarily prophetic and yet future, especially from Revelation 4 on to the end of the book. This is the view of all premillennialists and is the view which we accept and present.
We should note that at least 10 Themes in Scripture find their consummation in Revelation
- The Lord Jesus Christ (Genesis 3:15)
- The church (Matthew 16:18)
- The resurrection and translation of saints (1 Thessalonians 4:13- 18; 1 Corinthians 15:51, 52)
- The Great Tribulation (Deuteronomy 4:30, 31)
- Satan and evil (Ezekiel 28:11-18)
- The "man of sin" (Ezekiel 28:1-10)
- The course and end of apostate Christendom (Daniel 2:31-45; Matthew 13)
- The beginning, course, and end of the "times of the Gentiles" (Daniel 2:37; Luke 21:24)
- The second coming of Christ (Jude 14, 15)
- Israel's covenants (Genesis 12:1-3), five things promised Israel
Christ in Revelation
Revelation has much to say about all three Persons of the Godhead, but it is especially clear in its presentation of the awesome resurrected Christ who has received all authority to judge the earth. He is called Jesus Christ (1:1), the faithful witness, the firstborn from the dead, the ruler over the kings of the earth (1:5), the First and the Last (1:17), He who lives (1:18), the Son of God (2:18), holy and true (3:7), the Amen, the Faithful and True Witness, the Beginning of the creation of God (3:14), the Lion of the tribe of Judah, the Root of David (5:5), a Lamb (5:6), Faithful and True (19:11), The Word of God (19:13), KING OF KINGS, AND LORD OF LORDS (19:16), Alpha and Omega (22:13), the Bright and Morning Star (22:16), and the Lord Jesus Christ (22:21).
This book is indeed "The Revelation of Jesus Christ" (1:1) since it comes from Him and centers on Him. It begins with a vision of His glory, wisdom, and power (1) and portrays His authority over the entire church (2; 3). He is the Lamb who was slain and declared worthy to open the book of judgment (5). His righteous wrath is poured out upon the whole earth (6–18), and He returns in power to judge His enemies and to reign as the Lord over all (19; 20). He will rule forever over the heavenly city in the presence of all who know Him (21; 22).
The Scriptures close with His great promise: "'Behold, I am coming quickly!'" (22:7, 12). "'Surely I am coming quickly.' Amen. Even so, come, Lord Jesus!" (22:20).
Keys to Understanding Revelation
Key Word:
The Revelation of the Coming of Christ
The purposes for which Revelation was written depend to some extent on how the book as a whole is interpreted. Because of its complex imagery and symbolism, Revelation is the most difficult biblical book to interpret, and there are four major alternatives: (1) The symbolic or idealist view maintains that Revelation is not a predictive prophecy, but a symbolic portrait of the cosmic conflict of spiritual principles. (2) The preterist view (the Latin word praeter means "past") maintains that it is a symbolic description of the Roman persecution of the church, emperor worship, and the divine judgment of Rome. (3) The historicist view approaches Revelation as an allegorical panorama of the history of the (Western) church from the first century to the Second Advent. (4) The futurist view acknowledges the obvious influence that the first-century conflict between Roman power and the church had upon the themes of this book. It also accepts the bulk of Revelation (4–22) as an inspired look into the time immediately preceding the Second Advent (the "Tribulation," usually seen as seven years; 6–18), and extending from the return of Christ to the creation of the new cosmos (19–22).
Advocates of all four interpretive approaches to Revelation agree that it was written to assure the recipients of the ultimate triumph of Christ over all who rise up against Him and His saints. The readers were facing dark times of persecution, and even worse times would follow. Therefore, they needed to be encouraged to persevere by standing firm in Christ in view of God's plan for the righteous and the wicked. This plan is especially clear in the stirring words of the epilogue (22:6–21). The book was also written to challenge complacent Christians to stop compromising with the world. According to futurists, Revelation serves the additional purpose of providing a perspective on end-time events that would have meaning and relevance to the spiritual lives of all succeeding generations of Christians.
Key Verses:
Revelation 1:19 and 19:11–15
"'Write the things which you have seen, and the things which are, and the things which will take place after this'" (1:19).
"Now I saw heaven opened, and behold, a white horse. And He who sat on him was called Faithful and True, and in righteousness He judges and makes war. His eyes were like a flame of fire, and on His head were many crowns. He had a name written that no one knew except Himself. He was clothed with a robe dipped in blood, and His name is called The Word of God. And the armies in heaven, clothed in fine linen, white and clean, followed Him on white horses. Now out of His mouth goes a sharp sword, that with it He should strike the nations. And He Himself will rule them with a rod of iron. He Himself treads the winepress of the fierceness and wrath of Almighty God" (19:11–15).
Key Chapters:
Revelation 19–22
When the end of history is fully understood, its impact radically affects the present. In Revelation 19–22 the plans of God for the last days and for all of eternity are recorded in explicit terms. Careful study of and obedience to them will bring the blessings that are promised (1:3). Uppermost in the mind and deep in the heart should be guarded the words of Jesus, "Behold, I am coming quickly."


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This 2.5 day course will give you the real world tools, techniques and tactics you need to excel as an F&I Manager.
A variety of topics are included in this class including but not limited to:
Some of what you'll learn:
Effective Sales Skills for F&I Managers Investment
Standard Investment: $995.00
Preferred client: $695.00
View Course Calendar
Taught by Protective's team trainers this course is designed for individuals with experience in the F&I office.
This one and half day class will help you eliminate most objections BEFORE they even become objections.
Class concepts and activities include:
Specialty Products F&I Sales Master Class
Taught by battle tested veterans of the F&I world, this course is designed specifically to improve your PVR, sharpen your skills and make you more money. There's not an ounce of fluff anywhere in this course.
We took the most important parts of being a deal closing F&I manager and built this course around four things:
You'll spend 2.5 days working with Protective's team trainers learning what works. And more importantly, you'll know how to use it when you get back to your dealership.
You will learn an effective Interview and Menu presentation that features the products your dealership is currently selling, not some tired old word track that has been around forever. It will be your presentation and no one else's.
So if your PVR isn't where you'd like it or you need to get back the tools that made you successful in the first place this is your course.
Specialty Products F&I Sales Master Class Investment
Protective clients: $495.00
Making certain all employees are performing at peak levels is an important feature of all successful dealerships. There are two levels of customized performance training to help ensure maximum sales penetration and efficiency: Dealer Development and the Finance & Lease Professionals Training Course.
Training specialists hold regionally focused classes–in or out of the dealership–covering successful F&I sales strategies, CSI and compliance. Classes of 1 to 5 days can be customized to meet the exact needs of each dealership.
For your convenience Protective offers customized on-site training programs held at your dealership or at an offsite facility, tailored directly to the areas in which you wish to improve. Popular topics include:
Request a Custom F&I Road Training Course by filling out this form.
Protective offers customized RV training programs held at various points throughout the year. For more information regarding RV training, consult the training calendar and contact Bill Koster


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Shell Stops Arctic Drilling for 2012 - Greenpeace Declares Victory for People Power
Shell's much-protested plans for Arctic oil exploration off Alaska have already come to a halt for the year. After initial technical mishaps, including a ship breaking free of its mooring and potentially running aground, apparently a dome designed to help clean up any potential oil spills was damaged.
The time required to repair the dome, along with steps we have taken to protect local whaling operations and to ensure the safety of operations from ice floe movement, have led us to revise our plans for the 2012-2013 exploration program. In order to lay a strong foundation for operations in 2013, we will forgo drilling into hydrocarbon zones this year.Greenpeace, which has been leading the charge to protest and hopefully prevent Shell's Arctic drilling operations, is claiming the halt as a victory.
"You did it," Greenpeace's statement to supporters begins. "For over six months, huge numbers of us have been pressuring Shell to stay out of the Arctic...This morning company bosses announced they were scrapping their oil drilling program for this year. It's a huge victory for people power."
Indirectly, of course—Greenpeace actions have certainly brought attention on Shell that otherwise might not be there. But in any direct way it's very difficult to say that "people power" really stopped Shell.
Drilling offshore in Arctic waters off Alaska is technically challenging, to say the least. Conditions are so difficult in fact that the head of the US Coast Guard testified before Congress, prior to Shell being given the go ahead by the Obama administration, saying that should an oil spill occur in icy waters we have no way of cleaning it up. Let that sink in, should an oil spill occur (really, when an oil spill happens...) in icy waters of the Arctic, we really can't clean it up at all.


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About Our Emerald Isle Restaurant: Dishing Up Flavorful Cuisine in the Crystal Coast
Established by owner Kris Shoffner in 2001, Flipperz Family Bar & Grill has been an Emerald Isle, NC institution for over a decade. Appealing to the holiday crowd and visitors of Bogue Banks, our restaurant brings the ultimate island experience to Emerald Isle guests and residents with its fun, distinctive island motif.
Not only do we provide savory dishes that use bold, zesty ingredients in our foods, we offer our patrons a casual, yet classy dining experience, delectable homemade fudge, and unique memorabilia. And don't forget — we're one of Emerald Isle's favorite live music and entertainment venues!
Constructed by hand, Flipperz Family Bar & Grill is housed in an establishment with uncommon characteristics like our "penny bar," which is topped with 4,000 shiny, new uncirculated pennies that were carefully placed with gloved hands in exactly the "heads up" position, except for one lone penny that was placed in the "heads down" position. What fun it is to search for the "heads down" penny!
Enjoy Homemade Marinades & Our Signature "George's Mix"
At Flipperz Family Bar & Grill, we proudly create all our fresh marinades, which add a special touch of flavor to each entrée. One of our signature secrets is George's Mix, a dry blend of seasonings that wakes up anything from salads to steak, to fish to soup. Concocted by Knoxville, TN native and close friend of Shoffner's, George Sterchi, George's Mix has become an integral part of the food we produce at Flipperz.
In fact, George's Mix is such an essential component of our dishes we couldn't keep it to ourselves. Now, you too can enjoy the seasonings we use when you purchase George's mix from our Flipperz Retail store or through our online shop.
Flipperz Family Bar & Grill is conveniently located in Emerald Isle along North Carolina's Crystal Coast. We are proud to serve both residents and visitors of the Bogue Banks.


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(Photo Credit: KDKA)
PITTSBURGH (NewsRadio 1020 KDKA) — Did you know that the USX Tower roof is the largest, highest flat space on top of any building on earth, the highest "artificial acre" in the world?
Now, imagine riding to the top of the Steel Building and looking out from a special three-story observation deck that is accessible all year long and showcases our city in a whole new way.
It could happen if David Bear at the STUDIO for Creative Inquiry at Carnegie Mellon University has his way.
He tells KDKA AM's Larry Richert and John Shumway about his idea for a special public area and if it is possible.
Click the link below to listen to the full interview:
For more, visit his website at http://highpointpark.org.


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Indo - Swedish Conference And Workshop - 6th to 10th January 2020.
3 Days Workshop on BORDERLESS BIOLOGY FROM BASICS TO BUSINESS on 18th to 20th Dec 2019.
Three Days Workshop on the theme BORDERLESS BIOLOGY FROM BASICS TO BUSINESS at JSS AHER, Mysuru-15.
Kind Attention M.Phil Clinical Psychology 2019-20 Admissions Interview Preponed to 17th December 2019 at 2.30PM at JSS Medical College, Mysuru..
Public Viva-Voce Examination - Ms. M Renukadevi.
58th National Pharmacy Week Celebrations @ JSSCP, Ooty.
Joint Ph.D Program between JSS AHER - LaTrobe Univ. Australia - Physiotherapy & Oral Health.
MBBS Phase-Il, Phase-Ill-Part-I & Phase-III-Part-ll examinations - January 2020 - Notification and Time Table.
Master of Public Health (MPH) examinations - January 2020 - Notification and Time Table.
2nd State level Emergency Medicine Conference in Karnataka from the 15th to 18th of January, 2020..
Danta Manthana on AIR MYSURU 100.6 FM - Akakshavani Radio Talk will be broadcasted from 10th Nov 2019 to 2nd Feb 2020, on every Sunday`s between 09.05am to 09.20am.
Royal College of Physicians of Edinburg online Courses.
Medical Counselling Committee Public Notice.
Activities & Events
Site Map
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( Formerly Known as Jagadguru Sri Shivarathreeshwara University )
Student/Parent/Staff Portal
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Parivarthan School, Srirangapatna
Dr Bhagyalakshmi invited for Radio interview
La Trobe University, Australia Students visit
NSS Day Celebrations
White Coat Ceremony
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Guest Lecture By Dr Avinash B S
Miss Nurdalila Binti Ahamad
Graduates Reception 2019
Indo-UK Workshop held at DW&H
Independence Day Program 2019
Student Dental Conference 2019
Sammilana 2019
Dr Tanaka Eiji
Workshop on Anti Ragging
Oral Hygiene Day 2019
Intl Guest lecture By Dr Ashwini Kanade USA
Intl Guest lecture By Dr Ashwini Kanade USA.
Workshop - Beyond The Syllabus
12th ISPRP National Conference
I BDS Students - Orientation Program 2019 - 2020
New Batch of House Surgeons
Dr S Meenakshi
Dr. Elbert de Josselin de Jong
Certificate Program in Aesthetic Dentistry
Guest Lecture By Dr Jitendra Ariga
Guest Lecture By Dr Mohit Kothari,
Dr Meera Gopalakrishnan
Innovation and Patents in Dentistry
Fundamentals of Research Methodology
International Yoga Day 2019
Orientation Program - By Dr Nandini C P
Hands on Demonstration
Faculty & Student visit to University of Malaysia
SIG - Dental Cariolgy
FAIMER Fellowship Award to Dr. Chandrashekhar B R
Dental Photography & Documentation
World Tobacco Day - 2019
Dr Kavitha Dodmanne Patil, DMD, MS
World Environment Day 2019
Workshop on Outcome Based Curriculum Framework
Dr Manu Bhaskaran Nair
CDE- Oral Cancer Update Programme
Road Safety Awareness Programme
World Health Day Celebration 2019
Training Programme - Oral Prophylaxis course
International Collaboration
Sten Olsson - President ISOP Europe
Workshop on Endodontic Retreatment
Intan Masyitah Binti Mohd Murad - Malaysia
Dr.Bhagyalaxmi - will be Live on AIR on 24-03-19
Workshop on Basics of Good Clinical Practice
Prof Ragunath.P Director ICD USA
Inaugaration of Oral Health Exhibition at Suttur
NSS Camp at B R Hills on 2019
Pariksha Pe Charcha 2.0 Programme
Breath Healthy - Special Clinic at JSSH
Guest Lecture By Dr. Darshan Devang Divakar
Guest Lecture, By Dr. Lakshman R Prasad
Vist of International Dentist Dr. Murtaza Ansari
ISDR-IADR International Conference
Best paper and Poster award - Dept of Paedodontics
Best Scientific Paper Award
World Diabetic Day, Dept of Periodontology
Starting of value added course on endodontics
International Conference of (AAPD)
Nasal Obstruction E-poster Award
Laurels Award at ISPPD National Conference
JSS receives top QS rating in Karnataka
Go Green - Go Clean


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Some days, it seems the only thing teenagers love more than their cell phones is staying in bed. But are they a "lazy, unaware and apathetic" Generation Z, as The Huffington Post put it in 2013? If it's tough getting your teen to take an interest in schoolwork, community life or the chores, take heart. Your teen's behavior is a natural part of growing up. Understand the causes and you'll maybe even forgive those lost hours under the duvet.
Squeezed Schedules
You know all about juggling work and home pressures, but teens are still learning how to manage their time and their demanding high-school schedules. Parents have plenty of real-life experience of getting organized. It's hardly surprising teenagers find it hard to keep up. According to "Psychology Today" teen guru Dr. Carl Pickhardt, "If parents had as much to do and think about as their teenager, sometimes they might feel like acting 'lazy' too."
Poor Prioritizing
If you've been nagging your teen to tidy his room, only to find he's spent the afternoon online, messaging friends and tinkering with a school assignment, it's easy to call this laziness. He might call it multi-tasking. At least he shows no lack of energy in following his own interests. Maybe the problem is his priorities just don't fit with yours. Try to take a relaxed view. Multi-tasking is a valuable skill and, in time with the proper guidance, he'll learn to prioritize, too.
Brain Changes
A 2003 study by neuroscientist James Bjork suggests teenage brains are still to develop the key structures that deal with motivation. Bjork compared MRI scans of teenage and young adult brains and says his discoveries explain why teens find it hard to stick to routine tasks but are ready to take big risks for what look like easy rewards. His theory does have its critics. Harvard-educated psychologist Dr. Robert Epstein dismisses the "teen brain" as "a myth."
Body Clock
The surging hormones of puberty affect teenage sleeping patterns, typically prompting adolescents to stay up late and sleep longer in the morning. Teens can then end up sleep-deprived, cranky and unmotivated. A 2005 study by Northwestern University Illinois argues there is an "epidemic" of teenage sleep deprivation. It suggests we take account of the natural, "in-born" adolescent sleep cycle by scheduling tasks for teenagers in the afternoons, when they work best.
Screen Time
Teens spend a lot of time with electronic media. They can end up glued to the couch by a non-stop diet of TV, text messaging and the Internet. Previous generations tended to have more active and outdoor lifestyles. A 2011 report from the American Association of Pediatrics even suggests "Facebook Depression" can result from so much screen time, interfering with "homework, sleep and physical activity." Encourage teens to take regular screen breaks and do something active.
Growth Spurts
One moment you're taller than your child, then seemingly all at once, your child is towering over you. Teenagers often experience very swift "growth spurts" during adolescence. The body chemicals that promote this swift growth are secreted during sleep and this helps to explain why teenagers need more sleep than either children or adults.


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I've pretty much made my mind up on a camera (600D) but not on lenses yet... Expert Infotech has the 600D plus 18-55/3.5-5.6 IS and 55-250/4.0-5.6 IS kit lenses for $1129 and the body for $819 which seem to be the best deals in NZ right now. So the difference is $500 which is exactly what you'd pay for those 2 lenses separately anyway so no real saving. Wondering what else you might recommend as a good lens for travelling, getting a good variety of shots including some pretty grand landscape but also some close up work too and something which won't break the bank.
Loads of people seem to recommend something like the Canon EF-S 18-135/3.5-5.6 IS might fit the bill? perhaps the Canon EF 28-135/3.5-5.6 IS USM? Or should I just get those 2 lenses and swap em when I need to?
Will also get a good bag that fits at least 2 lenses plus body and gear, some spare generic batteries, a few 32GB SDHC cards and a cleaning kit. Still deciding on whether to take a tripod...
Would like to get the opinions of some geekzoners!


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ASK SAL has now completed it's third year as a 'sole trader'....!
Jane is still travelling all over the country attending events in her faithfull van Vera...!
2009 was a difficult year in retail, and I would like to take this opportunity to thank all my customers, especially my returning customers, for all your support. I don't know what I would have done without you. It is such a pleasure to meet you in different parts of the country, and be made to feel so welcome.
I still have the help of my mother, Joan, who is as youthful as ever..! And also my friend and 'super salesperson' Victoria Feilden. The Events I exhibited at during 2009 include:- The British Showjumping Championships, Badminton, Burghley and Blenhim Horse Trials, The CLA Gamefair, and Hunstanton Tennis Tournament, The Horse Of The Year Show, The Living North Christmas Fair and The Country Living Christmas Fair in Glasgow.
I hope to exhibit at all those events during 2010, and many more, so visit my events page soon to find an update, and hopefully I'll see you at one or more of them.
If you would like ASK SAL to exhibit at an event, please contact me.
If you are holding a charity Tennis Event, please contact me because I can bring a great selection of Tennis clothing and shoes for ladies and men...Set up my stand.....Sell lots....Hopefully...! Then donate 10% of my takings to the charity concerned. Nowhere is too far to travel..... My van...Vera is a very well travelled van...!!!
To my customers, I really enjoy meeting you at various events, and if you miss seeing me so much - or more importantly, if you want to place an order! - you can now visit my shop all year round at www.asksal.co.uk
Thank You
Jane x
These are the events we will be attending in 2012
Ask Sal
Tudor Lodge, The Lanes, Tetney, Nr. Grimsby, N.E.Lincolnshire, DN36 5LX, UK
Mobile: +44 (0)7768 660515
E: firstname.lastname@example.com - W: www.asksal.co.uk
This site is produced, hosted and managed by Independent Web Marketing


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While You're sharing our blog on 20 international trips costing less than an iPhone, here are 10 Beach resorts in India which are even more Kickass! Beaches, sand, sun, and exotic resorts make for a wonderful way to spend a romantic getaway with your loved one. India has some of the most beautiful beaches in the world spread across its vast coastlines majorly the Bay of Bengal and the Arabian Sea. Located on these beautiful beaches are some private beach resorts in India.
Here are top 10 beach resorts in India which won't disappoint you on a romantic getaway.
1. Taj Exotica, Goa: For a Romance Tucked Away from Crowd!
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Located on the Southwest Coast of Goa, overlooking the Arabian Sea, the Taj Exotica is a Mediterranean style luxury beach resort property. Spread along 56 acres along Benaulim Beach with the tranquil water of the private beach, you and your partner can unwind in the plush romantic setting. Beautiful landscaping, excellent room service and delicious food, Taj Exotica is easily one of the most romantic and sought after beach destinations for a vacation the both of you will never forget!
- Popular sightseeing places close to the hotel are Varca beach(6 km), Madgaon City (7.5 miles) and Colva beach(5 km)
- Tariff: Room with ocean view starting from INR 11,900/-
- Website
Looking To Book Your Honeymoon Package?
Book memorable honeymoon on TravelTriangle with 650+ verified travel agents for 65+ domestic and international destinations.
2. The Ramada Caravela Beach Resort, Goa
Romance has all new definition when you book a trip to the Ramada Caravela Beach Resort which will give you an unforgettable experience of the sun, sand and beach. Sunset point in the hotel is the highlight adding charm to the whole sight with your loved one by your side. Perfect plan to relax is sinking into a chair, sipping on a cocktail and watching the beautiful sunset painting the landscape!
- Some famous places that are situated in close vicinity to the hotel are Varca Beach (2km approx.), Cavelossim Beach (5km), Sernabatim Beach (7km), Fatorda Stadium (9km), Pandit Jawaharlal Nehru Stadium (9km), Sunset Beach (11km), Bogmallo Beach (21km) and Shri Naguesh Temple (22km).
- Tariff: Ocean Front View Room starting from INR 11,000/-
- Website
3. The Leela Kempinski, Kovalam: Indulge into Panoramic Romance!
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Situated on a cliff, The Leela offers panoramic views of the Kovalam shoreline and the Arabian Sea. The beauty of the resort lies in its private beach and spa. Imagine a vacation staring over the pristine beaches to the far horizon with your loved one: having goose bumps already? Well the Leela Kovalam is Kerala's largest beachside resort and of course understands opulence and unstinting luxury like nobody. Don't forget to try cocktails at their Sky Bar while watching the sunset with arms wrapped around your partner.
- The resort is approximately 9 miles from Trivandrum City and the famous Padmanabhaswamy Temple
- Tariff: Room with beach view starting from INR 14,500/-
- Website
Suggested Read: 16 resorts in Kerala you will yearn to be with your sweetheart
4. Vivanta by Taj Fisherman's Cove, Chennai : Soak in the spirits of Sea & Love
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Built on the ramparts of an Old Dutch Fort, the charming luxury resort comes across as almost one with the Bay of Bengal. From location to service, everything about this place is sure to make the two of you fall in love again! Be prepared to get thoroughly pampered with its renewed cottages & villas, semi-private beach, over the top spa experience and mouth watering cuisines. The resort is located on Covelong Beach in Kancheepuram district.
- The heritage village of Dakshina Chitra (Approx. 3 km), MGM Dizzee World, Mayajaal Sports Complex and Tiger Cave, a rock-cut Hindu temple complex, The Madras Crocodile Bank Trust are some of the attractions located nearby.
- Tariff: Room with Sea View starting from INR 9,900/-
- Website
5. Best Western-Blue Ocean Resort & Spa, Ratnagiri, Maharashtra: Captivating Romance Assured!
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Quietly located at Malgund, near Ganpatipule in Ratnagiri district of Maharashtra, the property will greet you with a sense of openness and romance. The shimmering blue coastline, tropically dense premises is inspired from Thai culture. Set in 75 acres, the Best Western Blue Ocean Research & Spa is an abode of peace and luxury. Treat your romance with a sensual experience.
- Travelers must visit: Ganapatipule Beach (Approx. 5km) and Malgund Beach (Approx. 0.1km). Ganapatipule Virgin Beach for several water sports like motor boats, rowboats, water scooters etc, Ganpatipule Temple, Jaigad Fort and Jaigad Lighthouse.
- Beach front villa starting from INR 15,730/-
- Website
Planning your honeymoon but confused about where to go? These honeymoon stories help you find your best honeymoon trip ever!
Real honeymooners. Real stays. Real opinions to help you make the right choice.
6. Mayfair Palm Beach Resort, Ganjam, Orissa
Opt for the rooms with sea facing balconies and you going to experience paradise at the Mayfair Palm Beach Resorts. Located on the Bay of Bengal, enjoy the splendor of the Gopalpur Sea while you take a romantic walk in their beautiful stretches of landscaped gardens. Cherry on the cake is their sunrise and sunset points: take her for a surprise and watch the sun appear or disappear together!
- The resort is about about a 2-hour drive from Bhubaneswar and approximately 16 km from Berhampore, the commercial hub of Southern Orissa (head out for shopping here)
- Rooms starting from INR 10,000/-
- Website
7. Hotel Sea Face, Kovalam, Kerala
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Have you ever dreamt of an intimidating vacation while you witness various hues of nature? Well, if no then Hotel Sea Face, Kovalam is an idea beach retreat. Located on the Hava Beach of Kovalam known for its breezy character, the private sit out area facing the Arabian sea is assured to give you a sense of oneness with the waters.
- Go for activities like catamaran rides, ayurveda massages, lagoon cruises etc.
- Rooms starting from INR 2400/- during off seasons and INR 4800/- during peak seasons
- Website
8. Paradise Isle Beach Resort, Udupi, Karnataka
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Situated on the Maple Beach, Paradise Isle Beach Resort is one of the best beach resorts in Karnataka. It offers best of the views of the sun, sand and the sea. Indulge in the magic as the sun makes the off-white sands and silver waters sparkle and allow your love strings to attach anew. The night view when the whole landscape of the sky and water gets painted blue is also a sight you would not want to miss!
- Prominent tourist attractions like Kaup Beach, Shree Krishna Temple and St. Mary's Islands are situated few kilometers away from the resort.
- Sea view rooms starting from INR 5500/-
- Website
9. The Radisson Blu Temple Bay Beach Resort, Mahabalipuram
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The aesthetic landscape of palm trees rising from blue lagoons is a sight that will make your romantic trip here completely worthwhile. The spectacular vision of the inviting beach and the 44 acres of tropical land set against the Bay of Bengal, is going to keep you hooked to your loved one in the lap of tropical nature.
- Places that can be explored during the stay : Shore Temple (700 m approx.), Arjuna's Penance (750 m approx.), Krishna Mandapam (800 m approx.)
- Rooms starting from INR 9500/-
- Website
10. Cherai Beach Resorts, Cochin, Kerala : Oasis of Beauty
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The resort offers the best of both worlds with a beach in the front and the backwaters behind. If you are planning a date trip to Kerala, this is one place which will help satisfy all your Kerala lust. Sit and laze about enjoying the fascinating greenery all around.
- Hot spots in the city : Gowreeswara Temple (Approx. 2km), St. Mary's Orthodox Syrian Church (Approx. 3km), Santhanagopala – Krishnaswamy Temple, Vamanamoorthy temple, Bolghatty Palace and Hill Palace Museum.
- Villas starting from INR 9000/- onwards
- Website
11. The Barefoot at Havelock Resort, Andaman and Nicobar Islands
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Set amidst dense tropical forests on the infamous beach No. 7, the Barefoot at Havelock Resort will charm you forever. Staying in one of the 25 lavishly designed and decorated tents, cottages and villas, this resort overlooks green foliage which lets you unearth the treasures of nature with your partner. You may also want to explore the enchanting views hidden underwater, as you go for scuba dive at Barefoot, the first and only PADI 5 Star Instructor Development Resort in the Andaman Islands.
- Places to Explore in the Vicinity: The Cellular Jail National Memorial, famous for its sound & light show; Mahatma Gandhi Marine National Park; Chidiya Tapu; Viper Island
- Rooms starting from Rs. 6500 onwards
- Website
Suggested Read: Top 12 Places To Visit In Andaman
These natural wonders are equally modish and can make anyone go weak in the knees. And if you are with your partner, the stay at these resorts becomes even more exotic. So pack your bags and surprise your better half with this once in a lifetime vacation experience.
Further Read: 10 Romantic Resorts In India That Assure Gorgeous Settings, Utmost Privacy, & Unmatched Comfort
Looking To Book An International Honeymoon?
Book memorable honeymoon on TravelTriangle with 650+ verified travel agents for 65+ domestic and international destinations.


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I love my trusty granola recipe and have made it countless times. This is the simplified and stripped-down version which also lends itself to endless varieties. The star of the show are the pumpkin seeds, but there are also flax seeds in there and feel free to add/substitute for sesame and sunflower seeds as well.
To serve as a great, filling, and healthy breakfast, add the granola over some natural yogurt and top with fresh fruits of choice and maybe even a drizzle of honey for added sweetness.
3 cups oats
1/2 cup unsweetened coconut flakes
1 cup pumpkin seeds, shelled
1/4 cup flax seeds
1/2 cup honey
1/4 cup olive oil
1/2 tsp salt
In a large mixing bowl, combine the oats, coconut flakes, pumpkin seeds and flax seeds.
In a second bowl, whisk together honey, olive oil and salt. They will combine easier if you heat them in the microwave 15-30 seconds.
Drizzle the liquid mixture over the dry ingredients and gently toss/stir until evenly coated.
Spread out onto a large baking sheet and bake at 325F for 18-20 minutes, stirring once halfway through baking for even toasting.
Remove from the oven and let cool completely and store in an airtight container at room temperature.
Serve over natural yogurt topped with fresh fruits of choice and a drizzle of runny honey.
صحة و عافية


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Earplug fit testing
November 1, 2008
Howard Leight's VeriPRO earplug fit testing system consists of software and an optimized headset; it utilizes a 3-part process to determine the effectiveness of employees' earplugs fit over a range of frequencies. The result identifies the actual protection received from each earplug to determine if employees are receiving optimal protection.
Sperian Hearing Protection, LLC; 800-430-5490; www.haynesmfg.com


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Check it out. Twttr is just out from the guys who brought you Blogger and this is similarly about self-expression. This time it's about short, frequent updates from your mobile via SMS and they have, perhaps fortuitously, stripped out some vowels.
It's a killer idea but I think I've seen it done better 😉


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Copywrite 2014Priax Corporation
Priax Corporation's GSA Contract No. GS-07F-0314T, effective 4-15-2007 through 4-14-2017, allows Federal purchasers to buy our products at a discount using the GSA Advantage! system. Free training on the GSA Schedules Program is available at fsstraining.gsa.gov. State and local purchasers should refer to the 1122 Program page on this site.
Products available through the GSA Advantage! system include:
[Hand-Held Devices][Accessories][Filling Station]
Although your can view these products here on this site as well as in our catalog on the GSA Advantage! site, you may also request a printed copy of our GSA Price List by calling (619) 478-2600 Ext. 10. We accept Visa and Mastercard payments for purchases.


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Syndicate 5678 offers products in a number of insurance classes, including Professional Indemnity and Financial Institutions.
Click the links below to find out more about the products offered by our innovative, highly experienced team or click on a name in the team area to the right to learn more about each Underwriter.
North American Specialty Programs


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By On Aug 13, 2019 Free Templates
Typically each kind of invoice follows a similar format. Your business may call for unique specifics like clauses, return policies, or disclaimers. Make sure to adapt the invoices you create to fit your distinct business needs. Because every business is different, you will likely need to customize your invoices. One of the most important modifications you can make is adding an electronic payment method. Luckily, there are many tools out there that make this super easy. The most common example is PayPal, but we'll talk a little about this later. Unfortunately, simply administering an invoice is not a guarantee that you will get paid. To ensure payment, you need to be aware of some invoicing best practices.
Lets face it, the digital space has made invoicing a lot easier than it used to be. Currently, to create an invoice, all you need to do is follow a template. Rest assured, we have you covered there. But, because there are so many different businesses that you might work with, it's worthwhile to consider exactly how an invoice works. An invoice is a commercial instrument, a document or put simply, a written verification issued by a seller to a buyer. It includes the list of services or products with their cost. The invoice is given to a buyer or client. An invoice shows that there is an obligation from the customer's end to pay for products or provided services.
The simple truth of the matter is that your customer may just forget to pay your invoice. To plan ahead, we suggest developing a tactful follow-up plan to get paid before things go awry. Some businesses offer a discount to customers who pay early or on time to help steer them towards payment. Others set up an automated email response to let their customers know as the due date for an invoice approaches or reminds them to pay when the outstanding balance becomes past due. You have to put some thought into your invoicing routine. Simple cobbling together a bill of sale is not the best idea – sure it's easy enough considering everyone has a word processor on their computer. But making smart use of invoicing practices and implementing a few of the latest cloud-based tools will help you get paid on-time, every time.
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This site needs a new editor. It could be you! Please read more about Joining the BellaOnline Editor Community
Home Improvement Forum - Stop by to share your creative ideas, get advice and input on home improvement projects, participate in forum games and show off your own DIY accomplishments. All are welcome!
Home Improvement Forum
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Floormec scrubber dryers are designed and built in the United Kingdom, by engineers who have worked within the cleaning industry for twenty five years. All Floormec machines utilise stainless steel body and tanks, and food-grade rubber is used on components to help keep the machines bacteria free.
- New product designed and built in the U.K.
- Stainless steel body and tanks
- Powerful 36 volt battery driven
- Solid state electronics – easy maintenance
We are seeking to establish a national network of distributors who can partner with us in our planned growth of a new emerging market.
Please contact us for more details.


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When you use your pupil credit card, you must ensure that you adequate funds to cover balance of your statement. This article will give you an indication why you must only spend with your credit card what you have available.
To start this away from, think about your life being a high school student and also what has happened so far. For the majority of high school graduates that have lived with their mother and father through their teenage formative years, they have not were required to worry about finances. Coming onto campus together with little knowledge of funds can be a tough combination with the rewards in which credit card companies are willing to provide if you open up a credit card. The first key any time thinking about budgeting for the student credit card is to study what you are signing up for. The particular rewards you will receive for signing up for a new credit card pale in comparison to the particular finance charges if you run up a balance on your credit card.
Get this fact into account when you are filling out any credit card application. The average graduate from college owes approximately twenty-two hundred dollars on credit credit cards, according to Nellie Mae who qualified prospects the nation in student loans. If you think about this truth and how long it will take to pay back this money whenever including interest, you would probably not take out which credit card.
If you have $2200 in credit card financial debt and your interest rate on the card was twenty percent, choosing paying over $ 400 in interest. Most students feel that they'll pay this when they graduate and make money in the real world. What is not often considered is how lengthy this can take to pay back and it can be difficult to cover this back with living expenses such as lease, car payments, insurance, and also the list goes on. Appears like a big check usually is much less once you have taken into consideration the costs of living everyday activity.
To make sure you are appropriately budgeting for your student credit card, you should only devote what you can pay for. This ought to be included in a monthly price range if you need to. Some pupils will only put fuel on a credit card or groceries and have that money sitting in their checking account at the end of the month. Making the effort to understand when you should spend money and not spend money is really a key to making sure that an individual properly maintain a disciplined budget with your credit card. Budgeting and not spending beyond what you can pay for is a skill which must be learned at a young age. If you do not develop this kind of habit at a early age, you could find yourself continuing with the same habits as you get older. This can partially explain why the common American household owes approximately nine thousand money in credit card debt.
Ideally this article on the significance about budgeting for your college student credit card has explained exactly why it is so imperative. Experiencing the type of credit card debt the average student finds him or her or herself within should explain completely why you want to plan for your student credit card.


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G-Q. Zhong and F. Ayrom
EECS Department
University of California, Berkeley
Technical Report No. UCB/ERL M84/81
BibTeX citation:
@techreport{Zhong:M84/81, Author = {Zhong, G-Q. and Ayrom, F.}, Title = {Periodicity and Chaos in Chua's Circuit}, Institution = {EECS Department, University of California, Berkeley}, Year = {1984}, URL = {http://www2.eecs.berkeley.edu/Pubs/TechRpts/1984/385.html}, Number = {UCB/ERL M84/81} }
EndNote citation:
%0 Report %A Zhong, G-Q. %A Ayrom, F. %T Periodicity and Chaos in Chua's Circuit %I EECS Department, University of California, Berkeley %D 1984 %@ UCB/ERL M84/81 %U http://www2.eecs.berkeley.edu/Pubs/TechRpts/1984/385.html %F Zhong:M84/81


text: Cape Town - The Springbok Sevens squad assembled in Mossel Bay on Sunday for a final training camp before departure to San Francisco, where the Rugby World Cup Sevens tournament will be played at AT&T Park from July 20-22. Springbok Sevens coach Neil Powell will name his final 12-man squad on Wednesday and will use the next four days in the Southern Cape to fine-tune preparations for their final event of the 2017/18 season. The Blitzboks last month won the World Rugby Sevens Series crown for a second consecutive season and also placed fourth at the Commonwealth Games in Australia in April, with the Melrose Cup - the only major silverware yet to be owned by South Africa - the final hurdle in a bumper season. "We are now fully focussed on what we want to achieve in San Francisco and all our planning is geared towards being ready to that first match," said Powell. "The format of the Rugby World Cup Sevens is such that no team can afford even the slightest slip up, and we need to ensure our timing is right." South Africa will face the winner of Ireland and Chile in their first match of the event, on Saturday, July 21 (06:15). "We will be fine-tuning all aspects of our play this week," said Powell. "The game plan is well drilled in as we have just played finished the World Series, but the application and commitment comes with every match we play. " The Blitzboks played a warm-up match against the Golden Lions in Johannesburg last week and Powell was pleased with the outcome: "The first highlight was that all players came through that without any new injury concerns, while guys such as Rosko Specman and Selvyn Davids showed good progress in their return to play phase of recovery." Powell confirmed that Chris Dry and Stedman Gans will not form part of the final week as they will not be fit to play next weekend. The team will train at Van Riebeeck Sports Stadium in Mossel Bay on Monday and Tuesday.


text:
- 4 Beds
- 4 Full
- 3,894 +/- Sqft
Property TypeResidential – Single Family
SubdivisionGOLD KING PLACER UNSUB
Listing Date09/01/19
Year Built1998
Lot Size10.46 Acres
Parking2 Car Garage, See Remarks
Property Description
One-of-a-Kind setting on over 10 Acres just a few miles from Main Street Breckenridge! Gorgeous 4 bedroom 4 bath home has a bonus bunkroom, hot tub, massive fire pit, oversized 2 car garage, small barn and shed. Beautifully treed and ready for you and your horses to move in and enjoy some elbow room! The lot offers space to store all your toys plus you can buy the adjacent 10 acre lot and own over 20 acres just minutes from Breckenridge. Just a few miles from ski and bus access!
Presented By
- Adjacent to Natl Forest
- Nordic Ski In/Out
- Mountains
- See Remarks
- Zoned for Horses
- Deck
- Fireplace - Gas
- Fireplace - Wood
- Hot Tub - Private
- Vaulted Ceilings
- Cross Country Trails
- Hiking / Pedestrian Trails
- Cable Tv
- Electricity
- Gas
- Phone
- Snow Removal
- Trash Pickup
- Natural Gas
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Financial Information
About Breckenridge
Victorian, family-oriented, and breathtaking natural beauty describe the classic Colorado ski town of Breckenridge. Enjoy countless outdoor activities, in both winter and summer, because Breckenridge averages over 300 days of sun each year and over 300 inches of snow each winter! With over one-million skier visits last year, Breckenridge is one of the most popular winter resorts in the country. Highlights include Breckenridge's historic main street, thrilling terrain parks, boutique restaurants and shops, and the Riverwalk Center. Throughout the year, cultural events like the Breckenridge Film Festival, the Backstage Theatre, weekend farmers markets and art festivals will entertain you. Quaint streets feature fine dining and endless shopping opportunities. With an array of ski-in/ski-out housing opportunities, you can throw open your front door and go. The resort ski runs come right down into town, so you can even ski home for lunch! A perfect mountain town!
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3 Beds 2.5 Baths
5 Beds 4.5 Baths
4 Beds 4.5 Baths
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text: EMS recently launches "Powering Mobility" as its new tagline for its corporate brand. EMS has always been at par with the latest innovative technology products and solutions. Offering its customers the best tailored solutions to date. EMS is now powering mobility through offering a range of new mobility solutions in the region. A new range of products have been launched including: EMS Mobility, EMS Monifi, EMS Link and many other products to follow.


text:
Clinical Value of Acute Rest Technetium-99m Tetrofosmin Tomographic Myocardial Perfusion Imaging in Patients With Acute Chest Pain and Nondiagnostic Electrocardiograms
Author + information
- Received August 25, 1997
- Revision received December 30, 1997
- Accepted January 13, 1998
- Published online April 1, 1998.
Author Information
- Gary V Heller, MD, PhD, FACCA,* (gheller{at}harthosp.org),
- Stephen A Stowers, MD, FACCB,
- Robert C Hendel, MD, FACCC,
- Steven D Herman, MD, FACCD,
- Edouard Daher, MD, FACCA,
- Alan W Ahlberg, MAA,
- Jack M Baron, MSE,
- Carlos F Mendes de Leon, PhD, MPHC,
- John A Rizzo, PhDF and
- Frans J.Th Wackers, MD, PhD, FACCF
- ↵*Dr. Gary V. Heller, Director, Nuclear Cardiology, Division of Cardiology, Hartford Hospital, 80 Seymour Street, P.O. Box 5037, Hartford, Connecticut 06102-5037.
Objectives. We sought to evaluate the clinical use and cost-analysis of acute rest technetium-99m (Tc-99m) tetrofosmin single-photon emission computed tomographic (SPECT) myocardial perfusion imaging in patients with chest pain and a normal electrocardiogram (ECG).
Background. Current approaches used in emergency departments (EDs) for treating patients presenting with chest pain and a nondiagnostic ECG result in poor resource utilization.
Methods. Three hundred fifty-seven patients presenting to six centers with symptoms suggestive of myocardial ischemia and a nondiagnostic ECG underwent Tc-99m tetrofosmin SPECT during or within 6 h of symptoms. Follow-up evaluation was performed during the hospital period and 30 days after discharge. All entry ECGs, SPECT images and cardiac events were reviewed in blinded manner and were not available to the admitting physicians.
Results. By consensus interpretation, 204 images (57%) were normal, and 153 were abnormal (43%). Of 20 patients (6%) with an acute myocardial infarction (MI) during the hospital period, 18 had abnormal images (sensitivity 90%), whereas only 2 had normal images (negative predictive value 99%). Multiple logistic regression analysis demonstrated abnormal SPECT imaging to be the best predictor of MI and significantly better than clinical data. Using a normal SPECT image as a criterion not to admit patients would result in a 57% reduction in hospital admissions, with a mean cost savings per patient of $4,258.
Conclusions. Abnormal rest Tc-99m tetrofosmin SPECT imaging accurately predicts acute MI in patients with symptoms and a nondiagnostic ECG, whereas a normal study is associated with a very low cardiac event rate. The use of acute rest SPECT imaging in the ED can substantially and safely reduce the number of unnecessary hospital admissions.
Over 5 million U.S. patients annually present to the emergency department (ED) with complaints of chest pain, possibly of cardiac origin [1–4]. Although ∼50% of these patients are admitted to the hospital at an annual cost of $10 to $12 billion [4, 5], acute myocardial infarction (MI) or unstable angina is confirmed in only a small proportion (10% to 15%), and many do not have coronary artery disease [3, 4, 6, 7]. Conversely, of patients not admitted to the hospital, 5% to 10% have unrecognized MI, with an annual mortality rate of 6% to 8%, and others have unstable coronary artery disease, resulting in a subsequent hospital admission, representing a group with high litigation risk [2, 6–10].
To improve the efficacy and efficiency of treating patients in the ED, specialized chest pain centers, computerized algorithms, new cardiac enzyme markers and noninvasive diagnostic approaches have been introduced [11–27]. Recent studies demonstrating the use of radionuclide myocardial perfusion imaging have been encouraging but are limited by the small number of patients involved and the lack of blinded imaging results [23–27]. Technetium-based imaging agents, including technetium-99m (Tc-99m) sestamibi and tetrofosmin (recently approved by the Food and Drug Administration) may have advantages over thallium-201 in emergency situations because of better image quality and nonredistribution [28–30].
The present multicenter study sought to evaluate the use of Tc-99m tetrofosmin single-photon emission computed tomographic (SPECT) myocardial perfusion imaging in patients with acute chest pain and a nondiagnostic electrocardiogram (ECG) to confirm the presence of acute cardiac ischemia and to develop a net cost analysis of this approach.
1 Methods
1.1 Study Design
The study was performed at six medical centers: Hartford Hospital, Hartford, Connecticut; Yale–New Haven Medical Center, New Haven, Connecticut; St. Luke's Medical Center, Jacksonville, Florida; Northwestern University Medical Center, Chicago, Illinois; Memorial Hospital, Pawtucket, Rhode Island; and Tel Aviv Medical Center, Tel Aviv, Israel. Patients presenting with symptoms suggestive of myocardial ischemia but with a normal or nondiagnostic ECG underwent Tc-99m tetrofosmin SPECT during or within 6 h of symptoms. Follow-up evaluation was performed during the hospital period and 30 days after discharge.
1.2 Patient Selection
Entry criteria included 1) acute chest pain suggestive of myocardial ischemia, either ongoing or within 6 h before radiopharmaceutical injection; chest pain symptoms were scored on the basis of a previously published scale of 1 to 29 [31]; 2) a normal or nondiagnostic ECG; 3) hospital admission (without imaging information); and 4) written, informed consent. Appropriateness of the patient for study inclusion was determined by the study site investigator. The decision for hospital admission was made by the attending physician. Exclusion criteria were acute MI at the time of evaluation, a history of previous MI or diagnostic Q waves, ECG changes (T wave inversions ≥0.2 mV) in two or more leads or ST segment depression ≥0.1 mV, a history consistent with unstable angina [32]or pregnancy.
1.3 Radionuclide Imaging
Patients received an injection of 20 to 30 mCi of Tc-99m tetrofosmin at rest, and SPECT imaging data were acquired 15 min to 3 h after injection. SPECT imaging studies were performed according to standardized protocols, and the results were submitted to the Radionuclide Core Laboratory at Yale University for uniform processing [33].
1.4 Image and ECG Interpretation
Interpretation of SPECT images was performed by consensus of four investigators (F.W., R.H., S.H., G.H.) who had no knowledge of patient identity or clinical information. The images were interpreted according to a five-point scoring system: 1 = definitely normal; 2 = probably normal; 3 = equivocal; 4 = probably abnormal; and 5 = definitely abnormal. The presence of a suspected artifact was also recorded. All entry ECGs were reinterpreted by the consensus of three investigators who had no knowledge of patient identification or imaging results. Patients whose ECGs did not meet the study criteria were retrospectively excluded.
1.5 Follow-Up Evaluation
All patients were monitored for the occurrence of cardiac events during the hospital period and 30 days after discharge by means of telephone contact with the patient or the patient's family or attending physician. Primary cardiac eventsincluded ischemic cardiac death (immediate consequence of ischemia) and nonfatal MI (rise in creatine kinase [CK] and its MB fraction [CK-MB] levels above the normal range in participating laboratories). Secondary cardiac end pointsincluded cardiac catheterization, coronary revascularization and readmission for unstable angina.
1.6 Concurrent ED Registry
To evaluate whether the patients enrolled in the study were representative of eligible patients seen in the EDs, a registry of all patients presenting with chest pain was collected during a 5- to 6-month period in four of the participating U.S. centers. The same study criteria were applied, and in-hospital cardiac events were tabulated. Of 4,704 consecutive patients, 615 met the entry criteria. Of the eligible patients not enrolled, 35 (6.2%) had an acute MI.
1.7 Receiver Operating Curve Analysis
To evaluate potential differences in the diagnostic approach to acute images, the interpretation of SPECT images was submitted to receiver operating curve (ROC) analysis [34–36]using the scoring system described. Eight interpretative scenarios were considered for classifying readings as abnormal, ranging from placing the cutoff between a score of 1 (definitely normal) and 2 (probably normal), to between 4 (probably abnormal) and 5 (definitely abnormal), with or without the presence of artifact (see Appendix A).
1.8 Statistical Analysis
Continuous variables are presented as the mean value ± SD. Significant differences were predetermined at p ≤ 0.05. Univariate analysis of the relation between selected clinical variables, SPECT images and outcomes during the hospital period was performed using the chi-square test. To test the association between SPECT images and outcomes during the hospital period, independent of the other clinical variables, a multivariable logistic regression model was computed, retaining those clinical variables that showed significant associations (p < 0.05) on univariate analysis. Logistic regression coefficients (and their standard errors) were converted into odds ratios (ORs) and 95% confidence intervals (CIs). A hierarchic series of logistic regression models was computed to test the incremental predictive contribution of several sets of variables. A base model was computed using age and gender as predictor variables, followed by the number of risk factors and then ECG changes and chest pain score. In the final model, abnormal SPECT image data were entered.
1.9 Economic Evaluation of Acute Myocardial Perfusion Imaging
To consider the economic impact of an additional test in the triage process of patients with chest pain, net cost analysis was performed. Net cost analysis compared the potential cost savings from reduced hospital admissions with the increased diagnostic cost of SPECT imaging. Actual hospital charges for all patients and the charge of performing SPECT imaging (mean $487, including technical and professional charges) were obtained from the five U.S. medical centers participating in the study. To estimate the extent to which tetrofosmin SPECT imaging would reduce hospital admissions, two admission strategies were considered. Strategy 1assumed that all patients with abnormal SPECT images would be admitted to the hospital and that no patient with normal images would be admitted. Strategy 2arbitrarily assumed that, in addition to admitting all patients with abnormal images, 20% of patients with normal images would be admitted on the basis of clinical information. The net cost savings per patient for each strategy was estimated. As part of the analysis, two cost scenarios were considered: 1) mean cost for hospital stay and mean cost for SPECT imaging; and 2) mean lower 10th percentile hospital costs and mean cost for SPECT imaging. The second scenario assumed that the costs of SPECT imaging were relatively high, whereas the cost savings from reduced hospital admissions were relatively low, thus providing a conservative estimate of any net cost saving that may accrue from the use of SPECT imaging.
2 Results
2.1 Study Patients
Three hundred eight-five nonconsecutive patients were enrolled in the study. Twenty-eight patients (7%) were retrospectively excluded from the analysis: 8 whose entry ECG did not meet predefined criteria, 15 with injection of a radiopharmaceutical but who did not undergo imaging for clinical reasons and 5 whose SPECT images were considered uninterpretable. Thus, 357 patients constituted the study cohort (Table 1). There were slightly more men (57%) than women (43%). One-third of the patients (n = 120) underwent injection of a radiopharmaceutical during chest pain, whereas two-thirds (n = 237) underwent injection after resolution of symptoms (median interval 170 min, range 5 to 360). The distribution of patients undergoing injection after resolution of pain was 0 to 2 h in 87 patients, 2 to 4 h in 86 patients and 4 to 6 h in 55 patients. In 11 patients, the interval between chest pain and imaging was not documented.
2.2 Cardiac Events during the Hospital Period
The median length of hospital stay was 2 days (range 0.5 to 24). No patient died of ischemic cardiac-related causes. Twenty patients (5.6%) had an acute MI (Table 2), with a mean peak CK of 565 ± 385 U/liter. This MI rate was not significantly different from that of the eligible but nonenrolled patients identified in the registry (see Methods). A total of 88 patients (25%) underwent cardiac catheterization, and 34 (10%) underwent coronary revascularization.
2.3 SPECT Imaging and In-Hospital Cardiac Events
A normal reading constituted those images interpreted as "definitely normal" in the presence or absence of a recognized artifact (scenario 7 in Appendix). All other interpretations were considered abnormal. SPECT images were normal in 204 patients (57%) and abnormal in 153 patients (43%). The distribution of abnormal images was not significantly different in patients with an injection during symptoms (39%) or any time after resolution of symptoms (hourly range 32% to 40% abnormal). Of 20 patients with an acute MI, images were abnormal in 18 (sensitivity 90%, 95% CI 87% to 93%) (Fig. 1). Of 337 patients without infarction, images were abnormal in 135 (specificity 59.5%, 95% CI 55% to 65%). The positive predictive value was 12%, and the negative predictive value was 99%.
Patients with abnormal images and an acute MI included all those with an anterior or Q wave MI, 13 of whom underwent cardiac catheterization, with seven requiring revascularization. Two patients with normal images had a non–Q wave MI (mean CK 310 U/liter), and one underwent catheterization but did not require revascularization.
Overall, cardiac catheterization was performed significantly less frequently in patients with normal images than in those with abnormal images (Fig. 2). Similarly, patients with normal images who underwent cardiac catheterization had significantly less coronary artery disease and required less revascularization than those with abnormal SPECT images.
2.4 Relation between Clinical Variables, SPECT Imaging and Acute MI
On univariate analysis, abnormal SPECT images were highly predictive of acute MI during the hospital period, even after controlling for male gender, diabetes and nondiagnostic ECG (Table 1). Multiple logistic regression analysis was performed on the positive univariate predictors described (Table 3). Male gender, diabetes and an abnormal SPECT image remained predictors of acute MI, although abnormal SPECT imaging had the highest odds ratio. The incremental chi-square results demonstrate that the addition of abnormal SPECT imaging added significantly to the prediction of acute MI compared with clinical data and ECG results (Fig. 3).
2.5 SPECT Imaging and 30-day Follow-Up
Follow-up after hospital discharge was complete in 329 patients (91%). The 31 patients (9%) lost to follow-up were not statistically different from the follow-up group in terms of admission demographic data. No patient with follow-up died of ischemic cardiac-related causes or had an MI. Nine patients (2.3%) were readmitted with chest pain symptoms (study SPECT images were normal in four and abnormal in five). Six patients underwent subsequent cardiac catheterization, and four patients had coronary revascularization (SPECT images normal in two and abnormal in two).
2.6 ROC Analysis and Economic Impact of SPECT Image Interpretation
The diagnostic impact of identifying acute MI using varying interpretive cutoff values is demonstrated in Fig. 4. Sensitivity ranged from 90% to 50%, depending on the strictness of criteria for consideration of a normal image (Appendix A). The interpretive scenarios 5, 6 and 7 (present data) were almost equidistant from the point of optimal performance (upper left corner) and represent reasonable alternative image interpretations. Using scenario 5, seven small, uncomplicated acute MIs would go undetected.
The economic impact of SPECT imaging by net cost analysis is shown in Table 4demonstrating the mean cost savings resulting from the use of SPECT imaging. By applying either of the considered strategies, SPECT imaging would reduce costs. The largest cost savings is achieved when only patients with abnormal SPECT images are admitted to the hospital and mean costs are considered. However, even the least favorable scenario (admission of all patients with abnormal images and 20% of those with normal images while considering the lowest 10th percentile of hospital costs) resulted in a cost savings of $543 per patient.
3 Discussion
This multicenter trial of patients with chest pain and nondiagnostic ECGs demonstrated that abnormal rest Tc-99m tetrofosmin myocardial perfusion imaging in the ED was strongly associated with acute MI and revascularization. Moreover, a normal rest SPECT image was associated with a very low likelihood of cardiac events. Using a triage strategy of admitting only patients with abnormal images would result in a >50% reduction in hospital admissions at a substantial cost savings, with a significantly lower risk of MI (1%) for discharged patients, compared with reports of conventional strategies (5% to 10%) [7–10].
3.1 Comparison with Previous Acute Rest Imaging Studies
Several previous studies have suggested a role for acute rest myocardial perfusion imaging in patients presenting to the ED with chest pain [22–27]. The results of our study are similar to those of previous studies for the detection of MI and the very high negative predictive value of normal images (Table 5) [22, 24–27]. In contrast to previous studies, the current trial included institutions of varying size and geographic location. Image interpretation was performed in blinded manner, and attending physicians did not use imaging results for clinical decisions. As a result, the potential value of SPECT imaging in our patients was evaluated in an unbiased and more generalizable manner than in previous studies.
3.2 Importance of a Normal Image
Patients with definitely normal SPECT images had a very low cardiac event rate both during the hospital period and the short-term follow-up period, with a high negative predictive value (99%). Thus, under most circumstances, patients with normal SPECT images may not warrant hospital admission. This approach is corroborated by a recent observational study demonstrating a low cardiac event rate (0% for MI, 2% for revascularization) in nonhospitalized patients with normal Tc-99m sestamibi SPECT images [27, 37]. However, physicians may choose to admit patients with a high likelihood of coronary artery disease and MI on the basis of clinical features such as male gender, diabetes and characterization of symptoms. Cost data for strategy 2 (Table 4) was developed to reflect such decisions.
It should be emphasized that although cardiac event rates were low in patients with normal rest SPECT images, coronary artery disease may be stable. In our study, and that of Tatum et al. [27], 2% to 5% of patients with normal rest SPECT images underwent subsequent revascularization. This indicates that selected patients with normal SPECT images warrant further (outpatient) evaluation.
3.3 ROC Analysis of Image Interpretation
Our study suggests that in patients with acute chest pain imaging, it may be prudent to use more strict interpretative criteria for rest myocardial perfusion images than the criteria usually employed for standard stress imaging. In rest SPECT imaging studies, only one image set and no stress data are available to the interpreting physician, making the distinction between artifact and a true positive finding more difficult. In contrast, for patients undergoing elective stress evaluation, imaging studies are part of a more extensive data set that assist in determining management decisions.
3.4 Study Limitations
A limitation of this study is the lack of an objective standard for acute myocardial ischemia. Only acute MI was well defined by a serial rise and fall in cardiac enzymes. We hypothesized that patients with abnormal myocardial perfusion images but no acute MI may have myocardial ischemia. The significant association between abnormal SPECT images and the clinical need for cardiac catheterization and revascularization corroborates this notion but does not provide objective proof in all patients, as not all patients underwent catheterization. In contrast, some patients with normal images who were injected after resolution of symptoms may have had ischemia that was resolved at the time of injection.
3.5 Conclusions
Abnormal rest Tc-99m tetrofosmin SPECT myocardial perfusion imaging in patients with acute chest pain and nondiagnostic ECGs is highly associated with acute MI or the need for subsequent coronary revascularization. Patients with chest pain and definitely normal rest SPECT images are unlikely to have acute MI and may have an uncomplicated subsequent course and may not need to be hospitalized. Acute rest SPECT imaging can be safely used to achieve efficient treatment of patients with chest pain in the ED at substantial cost savings.
We gratefully acknowledge the technical assistance of Donna Natale, CNMT, and Laurie Finta, RN, in the processing of images and data, and Elizabeth Doucette for manuscript preparation, as well as cardiology fellows Michael Shen, MD, and Scott Morris, MD, for participation in this study.
Appendix 1
Tabulation of Shifts of Interpretative Scores in Various Interpretative Scenarios for Receiver Operating Curve Analysis
|Normal Interpretative Scores
|Abnormal Interpretative Scores
|1, 2, 3, 4, 6-1, 6-2, 6-3, 6-4
|5, 6-5
|1, 2, 3, 4
|5, 6
|1, 2, 3, 6-1, 6-2, 6-3
|4, 5, 6-4, 6-5
|1, 2, 3
|4, 5, 6
|1, 2, 6-1, 6-2
|3, 4, 5, 6, 6-3, 6-4, 6-5
|1, 2
|3, 4, 5, 6
|1, 6-1
|2, 3, 4, 5, 6-2, 6-3, 6-4, 6-5
|2, 3, 4, 5, 6
Scores: 1 = definitely normal; 2 = probably normal; 3 = equivocal; 4 = probably abnormal; 5 = definitely abnormal; 6-1 = artifact but definitely normal; 6-2 = artifact but probably normal; 6-3 = artifact but equivocal; 6-4 = artifact, probably abnormal; 6-5 = artifact, definitely abnormal.
This study was presented in part at the 69th Annual Scientific Sessions of the American Heart Association, New Orleans, Louisiana, November 1996 and was supported in part by a grant from Amersham Medi-physics, Arlington Heights, Illinois.
- Abbreviations
- confidence interval
- creatine kinase
- electrocardiogram, electrocardiographic
- emergency department
- myocardial infarction
- receiver operating curve
- single-photon emission computed tomography (tomographic)
- Tc-99m
- technetium-99m
- Received August 25, 1997.
- Revision received December 30, 1997.
- Accepted January 13, 1998.
- The American College of Cardiology
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