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What is DSC?
DSC or Digital Signature Certificate is used to establish one's identity while filing documents online through the internet.It is the digital equivalent to a normal hand written signature. A digital signature has extra data attached electronically to the document. A digital signature usually is valid for a year or two after which it has to be renewed again. It also acts as a method of confirming the authenticity of a document online. We are witnessing a gradual electronization of documents and digital signatures will play a very important role in this.
There are different types of Digital Signature Certificates. Listed below are the three different types of Digital Signature Certificates.
Class 2: This type of Digital Signature Certificate is usually used for filing Income Tax documents, Registrar of companies and Value Added Tax documents.
Class 3: The Class 3 type of Digital Signature Certificate is used in e-tendering which includes various areas such as supplier registration, downloading a contract form, submission of a bid document and also in evaluation of tenders.
DGFT DSC:DGFT Digital Certification Facility of Digital Signature Certificate is very useful for importers and exporters. It is operated under Director General of Foreign Trade, it enables importers and exporters in India to transact with DGFT online without having to worry about security.
What is DIN?
DIN or Director Identification Number is an identification number allotted to an individual who is already a director in their role or is expected to be a director soon. The DIN allotted usually contains personal information along with a unique code which also acts as an identifier. It came into existence when Section 266A and 266G was introduced in Companies Amendment act in 2006. It is mandatory for every director, current and prospective.
There are several reasons for the allotment of DIN.
Given below are some of the important reasons for the allotment of DIN.
- It is allotted to create a database of all directors which is also reliable
- To confirm the existence of the directors in the companies
- To avoid financial scams from fake companies wherein the director makes away with the money in most of the cases.
Major Difference between DSC and DIN:
Listed below are some of the major differences between DSC and DIN:
|DSC is a digital proof of authorisation for online transactions and filing certain documents.
|DIN is a unique identification number issued only to exisiting directors or soon to be directors.It contains all the personal information of the director
|DIN is not a prerequisite to avail DSC
|The individual should have DSC in order to avail DIN
|Directors, Auditors, Company secretaries, bank officials and other authorized organisations can apply for DSC
|Only existing directors and future directors can apply for DIN
- Special Allowance
- Medical Allowance
- Leave Travel Allowance
- Conveyance Allowance
- Dearness Allowance
- City Compensation Allowance
- Children Education Allowance
- Direct Tax Vs Indirect Tax
- DSC Vs DIN
- EPF Vs PPF
- Form 16 Vs Form 16A
- GPF Vs PPF
- Long Term Vs Short Term Capital Gains
- PF Vs PPF
- Section 80 Vs Section 80GGA
- TAN Vs TIN
- Vat Vs MODVAT
- Tax Credits Vs Tax Deductions
- Income Tax
- Sales Tax
- Service Tax
- Goods and Service Tax(GST)
- Income Tax Slab
- Income Tax Return
- Income Tax Refund
- Income Tax Refund Status
- Income Tax Calculator
- e-Filing ITR
- House Rent Allowance(HRA)
- HRA Calculation
- Income From House Property
- How To Calculate Income Tax
- e-Payment
- How To Pay Income Tax Online
- Which ITR To File
- ITR-V to Income Tax Department
- Challan 280
- TDS On Salary
- TDS Refund
- TDS Rates
- Capital Gains Tax
- Capital Gain Calculator
- Medical Reimbursement
- Tax Exemption
- Inflation Index
- Custom Duty
- Professional Tax
- Property Tax
- Union Budget
- Tax Calendar
- Tin Number
- Income Declaration Scheme
- Agriculture in Union Budget
- Union Budget for Rural Sector
- Budget for Youth Employment
- Budget for Health Care Sector
- Railway Budget
- Union Budget for Energy Sector
- Union Budget for Financial Sector
- Fiscal Situation
- Funding of Political Parties in Budget
- Union Budget for Defence Sector
- Union Budget Expenditure
- Union Budget Receipts
- Budget Appropriation Bill
- Finance Bill
- Union Budget Analysis
- Union Budget for Senior Citizen
- Union Budget for Logistics Sector
- Maternity Benefits from Union Budget


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Definition of an Apostolic Leader
An Apostolic Leader is gifted, taught and commissioned by God to function within an assigned sphere of ministry by hearing what the Spirit is saying to the Church, and is committed to establishing and extending the Kingdom of God in the earth. Such leaders reflect the character of Christ, spiritual maturity, and an ability to equip the saints for the work of ministry.
Apostolic leaders have a grace that has come to them in the form of a call to be one of five types of leader: apostle, prophet, evangelist, pastor and/or teacher. These leadership roles are not limited to functions within the church but can be validly exercised within all domains or spheres of influence in contemporary society e.g. Business, Government, Justice, Religion, Creative Arts, Education, Health, Media, Sport and Welfare, etc. Collectively the domains are known as the marketplace.
Christ's ministry fully demonstrates all of these five roles. We as members of His body, receive one of these five appointments, relying on one another for those areas we are not gifted in.
The New Testament clearly outlines the gift of the apostle in Ephesians 4:11-12: "And He Himself gave some to be apostles, some prophets, some evangelists, and some pastors and teachers, for the equipping of the saints for the work of ministry, for the edifying of the body of Christ." Also mentioned in Ephesians 2:20 and 1 Corinthians 12:28. The Apostle Paul and Christ's apostles spoke of the gift as essential for the healthy function of the Church and training of the Saints.
C. Peter Wagner briefly defines an 'Apostle' as a: "Christian leader who is gifted, taught, and commissioned by God with the authority to establish the foundational government of the Church within an assigned sphere of ministry by hearing what the Spirit is saying to the churches and by setting things in order accordingly for the advancement of the Kingdom of God." This is by no means a comprehensive definition.
A thorough study must be done to specifically understand what the term 'Apostle' means. ICAL Council Members, Drs. Ron Cottle and John P. Kelly have written a series entitled: APOSTLES: WHAT ARE THEY? Using the original Greek and Hebrew, they outline the term for more clarity.
By Dr. Ron Cottle and Dr. John P. Kelly
There is much discussion on what the word 'apostle' means and how to describe an apostle. Some of the confusion is because apostles don't all look or work alike. Some focus on world missions, some on the marketplace, and others on the local church or a network of churches. However, they all share at least three basic characteristics: Apostles are Ambassadors, Generals-Governors, and Patriarchs.
This series of teachings will begin with the Ambassador Apostle. The next two months will focus on Generals and Patriarchs. These teachings will become part of the ICA Prospectus.
One day Jesus called aside His twelve disciples and after He had given them authority, He commissioned them apostles: "When He had called unto Him his twelve disciples, He gave them authority…and the twelve apostles…." (Matthew 10:1-2).
A. Jesus Himself Chose the People and the Title
It was Jesus alone who chose the name "apostolos" for those whom He called, authorized, and sent out. Among the earliest uses of the term were the Greek historians who used it to describe an admiral over a fleet of ships sent out by his king to discover, explore, conquer, and establish his government in newterritories. Jesus' choice of the word reflects this meaning and stresses its emphasis on "one sent from
another" or a fully authorized representative, ambassador of the sender. (Lyssichus, Or., 19:21; Demosthenes, Or., 18:107) So, Apostles are fully authorized representatives or ambassadors of the one who sent them.
B. Apostles Were First Disciples
It is important to note that the people chosen and authorized to be apostles were already disciples—mathetes. That is, they were not just pupils learning facts from their teacher, or even students learning principles from a professor. They were disciples who were incarnating the character and essence (psuche) of their Master. Like Timothy with Paul, they took on the isopsuchos—same soul or DNA of their Lord (Philippians 2:20). Jesus led them to a mountain and there poured into them Himself. He did not release them until they were thoroughly filled with His vision and values. Only when they were ready did He release them for the task and turn His attention to "teach and preach in their cities."
C. The Difference between Disciples and Apostles is the Impartation of Exsousia
What is the difference between committed disciples and commissioned apostles? Exsousia! This is not power as the KJV translates it. Rather it is "the right to power" or authority (Matthew 10:1-2). When one is sent out as an apostolos, he is the full delegate and representative ambassador of his sender. He carries in his person the full authority of the one who sent him.
D. Apostle equals Sheliach
Jesus did not think or speak Greek, but Aramaic-Hebrew. He took the Greek word apostolos because Greek was the universal language of the Roman Empire. But He filled it with the content of the Hebrew Sheliach. What then is a Sheliach? He is one commissioned and authorized to fully represent his sender. He represents in his person the one who commissioned him.
Eliezer, the Syrian slave whom Abraham commissioned to bring a wife for Isaac, was the first Sheliach mentioned in scripture (Genesis 24:2ff and 15:2). He was already an elder and servant (zakenand ebed) in Abraham's house. As such, he was selected and appointed by Abraham himself to be his emissary. He placed his hand "beneath Abraham's thigh" to take an oath of loyalty and faithfulness. Only after this did Abraham send him out. While on his mission, he was as Abraham himself as he negotiated for Rebekah to be Isaac's wife.
So, while Greek apostolos gives us the form of the New Testament apostle, it is the Hebrew Sheliach that provides the content. A Sheliach-Apostolos is the full representative of his sender. As the Rabbis said: "The Sheliach of a man is as the man himself" (Beraita 5:5). Gerhard Kittel says: "The Sheliach (of Jesus) is as good as his Sender in all he says and does in the execution of his mission" (K., TDNT, 1:415).
The ancients called thisplenipotentiaryrepresentation—fully empowered. This is the true meaning of "representative government." Kittel adds "The emissary of the King is as the King Himself" (K., TDNT, 1:416).
An Apostle is an Ambassador of the One who sent him.
© Dr. Ron Cottle and Dr. John P. Kelly
Apostles are Generals and Governors
By Dr. Ron Cottle
Growing out of the basic identity presented in Section One, there are two important expressions. The first is the apostle as general or governor. In 2 Corinthians 10:4 Paul says:
"The weapons of our warfare are not carnal but mighty…."
Warfare in this verse is strateia and it is "military service." We are at war and God has provided equipment (hopla) that is powerful and fit for demolishing enemy fortifications erected against us. All this equipment is most effective under the command of a full representative of the King—an apostle-Sheliach on assignment and under orders. In the NT this person is a strategos, warrior-strategist, a general or governor in his assigned sphere.
As His representatives, God gives apostles commissions and goals; as apostles we devise the strategy to accomplish them. Some translations of strategos in the NT are: Praetor/Governor; chief magistrate or captain of the Temple—both are Caesar's representatives over either a territory or a temple. This person served as an officer of the government of Rome and was commissioned by Caesar to be "in charge" and responsible only to the government. If he served faithfully, he had the entire might of the Roman Empire behind him. If he served unfaithfully or abusively, he was subject to recall or banishment by Caesar but never by the subjects of his assignment. See Luke 22:4, 52; Acts 4:1; 5:24, 26; Acts 16:20, 22, 35, 36, 38.
A strategos was appointed by Imperial authority as its official, authorized representative. As such, he was "in charge and responsible" to the Emperor for the legal operation of the Provincial government or the Temple government, whichever was his sphere of assignment.
In Nehemiah 2:5, Nehemiah asked the king to send him (Shalach) as his authorized representative-ambassador and "man in charge" to rebuild Jerusalem. He was asking to be an apostle-Sheliach on mission. In 2:6 the Word says, "So it pleased the King and he sent (Shalach) me." Letters were given to others already in the field and on assignment by the King so that they might recognize and assist Nehemiah in his mission.
When he arrived, he took charge and became Governor (Pechad—overseer or Bishop) over Artaxerxes' work in all Jerusalem and Judea. The other rulers in the region dealt with him as with a head of state. Here we have a strong example of what an apostle really is. Nehemiah was a strategos, an apostle-Sheliach to Artaxerxes to establish and maintain governmental order. Apostles today are God's representatives commissioned to maintain His government in their assigned spheres. The apostle does not necessarily run a church or micromanage its departments and activities. But he exercises the authority necessary to keep the ministry of his assignment true to its Kingdom purposes.
I saw this work first-hand in China recently. We helped to start a university there. The communist government of China appointed one of their own leaders, a communist party member, to serve as president of the university. He has ultimate authority over the 20,000 students, the faculty, the Board of Directors, the 300 acres and 50 major buildings, the founder-chancellor, and his staff. He speaks for the government on all matters of policy and strategic planning. He does not interfere with the daily administration and instruction of the university except to keep them directed on a path approved by the government.
He is the strategos, an authorized representative of the government sent to maintain order. That is what an apostle of God is: God's appointed, anointed, authorized ambassador to maintain right government (shaphat) in his sphere of ministry.
© Dr. Ron Cottle
Some excellent resources on the topic include:
Apostles Today by C. Peter Wagner
Moving in the Apostolic by John Eckhardt
Apostles and the Emerging Apostolic Movement by David Cannistraci
Implementing the Apostolic by John P. Kelly, an 11 hour DVD course.

subset: commoncrawl


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Since moving back to the States, we use even more natural products at home, in the kitchen, for cleaning, and for beauty products. This project has been on-going for a while now, and it has been wonderful to take some bigger steps towards realizing the goal of more homemade and more self-sufficient. It has involved learning about a whole new range of ingredients and techniques. We now keep a lot of baking soda as well as borax, washing soda, vinegar, and liquid Dr. Bronner's to do most of our cleaning jobs.
My first ideas came from a couple of my favorite blogs. There, I found a recipe for homemade laundry detergent. We are now fullly converted to using homemade laundry detergent and it passes the Papa test. The Papa test means that Papa notices neither difference in quality nor extra hassle to use a greener product or method. It's a high standard. I made the first batches with Dr. Bronner's Peppermint and loved the fresh smell. Looking for a less expensive option, I tried Kirk's Castile for the last batch. It works just fine, but the scent is gone and it smells rather soapy. We're going back to Dr. Bronner's next time.
I've also found a useful scouring powder recipe and one for cleaning the toilet bowl, but forgotten to note where they come from. Here you go, though!
Scouring Powder
3 parts baking soda
1 part borax
I store this in a a recycled plastic hummus container with holes poked in half the lid. The other half makes a convenient shelf for my cleaning sponge.
Toilet Bowl Cleaner
You will mix this in the toilet bowl. Doing it on the counter results in a science experiment (trust me)!
1 cup vinegar
1/2 cup baking soda
They will fizzle like crazy for a minute and then settle down. Leave for a few minutes and then scrub for a clean bowl.
I'll follow up tomorrow with some homemade beauty products!


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Système de visualisation de la couleur
- GTI Lite - PVD
On est là pour vous aider!
PDV Professional Desktop Viewers are the industry's choice for D50 controlled viewing of small format color prints.
Utilizing GTI's Graphiclite 100 color viewing lamps and the latest electronic ballasts, the PDV e series guarantees tight compliance to the ISO-3664:2009 standard. All models feature a hinged design for easy set-up, storage, and transport. PDV viewers can also be configured with a single D65 light source, please specify when ordering.
Side Walls
Side walls will reduce the influence of ambient light and provide tighter control of the viewing environment.
Allows you to adjust the light intensity of the viewer to match the monitor. Ideal for soft proofing and color management applications.
Lower Luminaire
Add a lower luminaire for the most critical color appraisal applications. Includes side walls.
Transparency Viewer
Transparency viewing can be added to the PDV-2e (8″ x 12″ area) and PDV-3e (8″ x 16″ area) models.
Multi-Source Portable Desktop Viewer
The PDV-2e/M has the same viewing area and footprint as the PDV2-e; two models are available. The PDV-2e/M4 includes four light sources D50 or D65, CWF or TL84, Incandescent, and UV. While the PDV-2e/M3 has three light sources D50 or D65, CWF or TL84, and Incandescent. Each source is operated by a toggle switch.
|Viewing Area (H x W)
|Transparency (optional)
|11.7" x 16.3" (30 cm x 41 cm)
|13" x 19.3" (33 cm x 49 cm)
|8" x 10" (20 cm x 25 cm)
|16.5" x 25.3" (42 cm x 64 cm)
|8" x 12" (20 cm x 30 cm)
|23.5" x 25.3" (60 cm x 64 cm)


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The City of Rosenberg will hold the official opening ceremony for Fire Station No. 3, including a dedication and hose uncoupling, on Saturday, July 26, 2014, at 9 a.m. Fire Station No. 3 is located south of Reading Road, just off of FM 2977 on August Green Drive. Station tours and refreshments will be available following the ceremony, and members of the public are invited and encouraged to attend and help celebrate the opening of Rosenberg's newest station.
The City broke ground on the new station in December 2012, and the project reached substantial completion in April of this year. The project allows the City to better serve the by constructing a third station and locating the associated equipment and crews, in a rapidly developing area.
The total approximate cost for the station is $2.75 million. Construction project team members include project architect, BRW; and project contractor, LDF Construction. The site was constructed above building standards to withstand hurricane force winds and storms in order to help ensure operations during weather-related public safety emergencies. It includes an approximately 8,000 square-foot facility with dual apparatus bays, sleeping quarters and associated space for six, an exercise room and full kitchen for four shifts, as well as a rainwater harvesting system to handle site irrigation needs.
For more information on the dedication and hose uncoupling, please contact Fire Administration at (832) 595-3600, or email email@example.com


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I finally got hungry enough to get changed and leave my flat to buy groceries. I think my tolerance for hunger gets less as I get older. So now I have milk and eggs and sausages and bread and biscuits and crisps and frozen dumplings and ginger beer. I debated (with the self) about whether or not I should go… I think the deciding factor was that I probably won't go out tomorrow either, so I might as well.
Maybe tomorrow, somehow, I will find enough motivation to go to the gym. Or maybe not.


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Monday, January 22, 2007
Hesiod and the Myth of Origins
Jonathan Bate, The Song of the Earth (Cambridge: Harvard University Press, 2000), pp. 26-27:Newer› ‹Older
The earliest surviving version of this ancient Greek myth of origins is the Theogony of Hesiod. It tells of how the original Golden Age declined to Silver and thence to Bronze and finally to the Iron of the present.Bate is correct in naming Hesiod, but it is in the Works and Days (lines 106-201), not in the Theogony, that Hesiod relates the myth of origins and the ages of men. The Iron Age (Works and Days 182-201, tr. Hugh G. Evelyn-White) is no myth but reality:
The father will not agree with his children, nor the children with their father, nor guest with his host, nor comrade with comrade; nor will brother be dear to brother as aforetime. Men will dishonour their parents as they grow quickly old, and will carp at them, chiding them with bitter words, hard-hearted they, not knowing the fear of the gods. They will not repay their aged parents the cost their nurture, for might shall be their right: and one man will sack another's city. There will be no favour for the man who keeps his oath or for the just or for the good; but rather men will praise the evil-doer and his violent dealing. Strength will be right and reverence will cease to be; and the wicked will hurt the worthy man, speaking false words against him, and will swear an oath upon them. Envy, foul-mouthed, delighting in evil, with scowling face, will go along with wretched men one and all. And then Aidôs and Nemesis, with their sweet forms wrapped in white robes, will go from the wide-pathed earth and forsake mankind to join the company of the deathless gods: and bitter sorrows will be left for mortal men, and there will be no help against evil.


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Teatulia Earl of Bengal
Once again, I cannot say enough about Teatulia and their ethical growing practices. I love knowing that my tea is free of pesticides and helps the people who grew the tea. Their cooperative has established education, health and cattle-lending programs for the people working in the garden and surrounding areas. The dry leaves had a woodsy aroma, almost reminiscent of cedar. I steeped this tea in an infuser basket with 212 degree water for two minutes. This tea had a very thick mouth feel. So much so that I felt as though my throat was coated with oil. Bergamot can be tricky and I feel that a lot companies overdo it. There is a fine line between a yummy hint of citrus zing and drinking orange scented Lysol. That is the case with this blend as well. I'm a big fan of Teatulia's Black Tea but it was completely obscured by the flavoring. I would probably not recommend this tea unless you REALLY love bergamot.


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Our store is closed due to COVID-19 but we're still here for you.
We're shipping orders on a limited schedule.
Please allow for shipping delays. Read more...
Add instant swagger and style to your DJ, production, or laptop setup with the Xstatic LED Strip RGB KIT. 12 inches of SMD LEDs on a tough, durable 3M tape strip, is the new lighting solution from Xstatic and is a surefire way to illuminate everything from Flight Cases to kitchen counters. Did we mention the RGB color-changing capabilities of the LED strip, complete with strobe and color changing effects? This is a revolutionary new tool for venues, studios, retial stores and the home that is lightweight, flexible, and easy to install: just plug in the strip and watch Xstatic transform your lighting decor! This LED tape strip is a revolutionary lighting accent tool for anyone to use. Essential for any lighting needs in spaces with size limitations.


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Echocardiographic Correlates of Acute Heart Failure, Cardiogenic Shock, and In-Hospital Mortality in Tako-Tsubo Cardiomyopathy
Author + information
- Received July 6, 2013
- Revision received August 27, 2013
- Accepted September 5, 2013
- Published online February 1, 2014.
Author Information
- Rodolfo Citro, MD∗,†∗ (rodolfocitro{at}gmail.com),
- Fausto Rigo, MD‡,
- Antonello D'Andrea, MD§,
- Quirino Ciampi, MD‖,
- Guido Parodi, MD¶,
- Gennaro Provenza, MD#,
- Raffaele Piccolo, MD∗∗,
- Marco Mirra, MD††,
- Concetta Zito, MD‡‡,
- Roberta Giudice, MD††,
- Marco Mariano Patella, MD§§,
- Francesco Antonini-Canterin, MD‖‖,
- Eduardo Bossone, MD†,
- Federico Piscione, MD††,
- Jorge Salerno-Uriarte, MD∗,
- Tako-Tsubo Italian Network Investigators
- ∗Department of Heart Sciences, Circolo Hospital and Macchi Foundation, University of Insubria, Varese, Italy
- †Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
- ‡Department of Cardiology, Dell'Angelo Hospital, Mestre, Italy
- §Department of Cardiology, Second University of Naples, Naples, Italy
- ‖Department of Cardiology, Fatebenefratelli Hospital, Benevento, Italy
- ¶Division of Cardiology, Careggi Hospital, Florence, Italy
- #Division of Cardiology, Civic Hospital, Villa d'Agri, Potenza, Italy
- ∗∗Department of Clinical Medicine, Cardiovascular Sciences and Immunology, Federico II, University of Naples, Naples, Italy
- ††Department of Medicine and Surgery, University of Salerno, Salerno, Italy
- ‡‡Division of Cardiology, University of Messina, Messina, Italy
- §§Division of Cardiology, S. Maria Hospital, Terni, Italy
- ‖‖Division of Cardiology, S. Maria degli Angeli Hospital, Pordenone, Italy
- ↵∗Reprint requests and correspondence:
Dr. Rodolfo Citro, Department of Heart Sciences, Experimental and Clinical Physiology Institute, University of Insubria, Varese, Italy, and University Hospital San Giovanni di Dio e Ruggi d'Aragona, Heart Tower Room 810, Largo Città di Ippocrate, 84131 Salerno, Italy.
Objectives The purpose of this study was to determine clinical and echocardiographic correlates of acute heart failure, cardiogenic shock and in-hospital mortality in a large cohort of tako-tsubo cardiomyopathy (TTC) patients.
Background Despite good long-term prognosis, life-threatening complications due to hemodynamic instability can occur early in TTC patients.
Methods The study population consisted of 227 patients (66.2 ± 12.2 years of age; females, 90.3%) enrolled in the Tako-tsubo Italian Network, undergoing transthoracic two-dimensional echocardiography on admission and at short-term follow-up (4.3 [4 to 6] weeks). Patients were divided into two groups according to the presence or absence of major adverse events, a composite of acute heart failure, cardiogenic shock, and in-hospital mortality.
Results Major adverse events occurred in 59 patients (25.9%). The variables for elderly patients ≥75 years of age (42.4% vs. 23.8%; p = 0.011): left ventricular (LV) ejection fraction (35.1 ± 5.9% vs. 38.4 ± 4.6%, p < 0.001), wall motion score index (1.9 ± 0.2 vs. 1.7 ± 0.2, p < 0.001), E/e′ ratio (13.5 ± 4.3 vs. 9.9 ± 3.3 [where E/e′ is ratio of mitral E peak velocity and averaged e′ velocity], p < 0.001), LV outflow tract obstruction (23.7 vs. 8.9%, p = 0.006), pulmonary artery systolic pressure (47.4 ± 12.3 mm Hg vs. 38.0 ± 9.2 mm Hg; p < 0.001), right ventricular involvement (28.8 vs. 9.5%; p < 0.001), and reversible moderate-to-severe mitral regurgitation (49.1 vs. 11.9%; p < 0.001), were significantly different between groups and were associated with adverse events. At multivariate analysis, LV ejection fraction (HR: 0.92; 95% CI: 0.89 to 0.95; p < 0.001), E/e′ ratio (HR: 1.13; 95% CI: 1.02 to 1.24; p = 0.011), reversible moderate to severe mitral regurgitation (HR: 3.25; 95% CI: 1.16 to 9.10; p = 0.025), and age ≥75 years (HR: 2.81; 95% CI: 1.05 to 7.52; p = 0.039) were independent correlates of major adverse events.
Conclusions Echocardiographic parameters provide additional information compared to other variables routinely used in clinical practice to identify patients at higher risk of hemodynamic deterioration and poor in-hospital outcome, allowing prompt institution of appropriate pharmacological treatment and adequate mechanical support.
Tako-tsubo cardiomyopathy (TTC) is typically characterized by transient left ventricular (LV) systolic dysfunction with morphological features of apical ballooning, although other variant forms (e.g., midventricular ballooning) have also been described (1–3). It occurs most often in post-menopausal women and is usually triggered by emotional or physical stress, with complete recovery of LV systolic function within a few days or weeks (4,5). Despite its favorable long-term prognosis and very low mortality, TTC is not considered a benign condition, because of the occurrence of life-threatening complications during the acute phase, related to hemodynamic instability (e.g., acute heart failure, cardiogenic shock) in a substantial proportion of patients (6–8). Owing to its widespread use in critical care settings, echocardiography has become the noninvasive imaging modality of choice for assessing TTC (2,9). However, the combination of clinical, electrocardiographic (ECG), laboratory, and echocardiographic measures routinely used in clinical practice for TTC patients experiencing major adverse events due to hemodynamic instability have not yet been well described. The aim of this study was to identify the clinical and echocardiographic determinants of major adverse events, a composite of acute heart failure, cardiogenic shock, and in-hospital mortality, in a large cohort of TTC patients.
Study population
The study population consisted of 227 patients enrolled in the Tako-Tsubo Italian Network, undergoing comprehensive transthoracic 2-dimensional echocardiography on admission and at short-term follow-up (4.3 [4 to 6] weeks) (8,10). The diagnosis of TTC was based on the following Mayo Clinic criteria (5):
• Transient akinesia or dyskinesia of LV apical and/or midventricular segments;
• No angiographic evidence of ≥50% coronary artery stenosis, or plaque rupture, or intracoronary thrombus formation;
• New ECG abnormalities (dynamic ST-T changes or T-wave inversion);
• Absence of intracranial bleeding, pheochromocytoma, and myocarditis.
Patients with a poor acoustic window (suboptimal visualization of endocardial borders) were excluded. All participants provided informed written consent, and the study was approved by the local ethics committee.
Data collection
Clinical variables were recorded on a standardized form that included information on patient demographics (sex, age, heart rate, systolic and diastolic blood pressure), signs and symptoms at presentation, medical history, trigger events, ECG ST-segment changes and presence of prolonged QTc interval on admission, and clinical observations during hospitalization (including major cardiac events). Emotional or physical triggers were identified as previously described (8). Venous blood was collected every 3 hours to measure troponin I concentration in the acute phase, and collection continued until a peak value was observed. All patients underwent coronary angiography and left ventriculography within 24 hours of symptom onset.
Definition of major adverse events due to hemodynamic instability
Major adverse events were defined as a composite of acute heart failure, cardiogenic shock, and in-hospital mortality. In particular:
• Acute heart failure was defined as the presence of pulmonary edema, dyspnea, and/or oxygen desaturation requiring drug therapy and/or mechanical support;
• Cardiogenic shock was defined as systolic blood pressure <90 mm Hg with signs of tissue hypoperfusion requiring inotropic agents and/or fluid therapy;
• In-hospital mortality was defined as cardiac death or death from any cause.
All echocardiographic examinations were performed within 6 hours of hospital admission, before coronary angiography, and were repeated at 5 ± 1.6 (range 4 to 6) weeks after symptom onset. A commercially available cardiac ultrasonography system with a 2.5 to 4.5-MHz phased-array transducer with second harmonic capability was used for complete 2-dimensional Doppler echocardiography. All examinations were performed by observers blinded to clinical data. LV regional wall motion abnormalities and presence of typical circular systolic dysfunction with involvement of ≥4 coronary territories were evaluated by visual assessment of multiple apical and short-axis views, as previously described (9). All echocardiographic images were digitally recorded and reviewed by 2 expert readers (R.C. and F.R.). Three cardiac cycles from the apical 4- and 2-chamber views and the parasternal short-axis view at the level of the mitral valve and papillary muscles were stored in cine-loop format for off-line analysis. LV ejection fraction (EF) was calculated using biplane Simpson's rule from the apical 4- and 2-chamber views (11). Left atrial (LA) volume was assessed by the biplane area-length method and indexed to body surface area (11). Right ventricular (RV) wall motion was evaluated by visual assessment for the detection of RV involvement (12). The echo transducer was adjusted to the level of the RV chamber to achieve optimal visualization of RV size and RV endocardial borders. Tricuspid annular plane systolic excursion (TAPSE) was calculated as previously described (13). LV diastolic function was evaluated according to American Society of Echocardiography recommendations (14). Early (e′) diastolic tissue Doppler velocities were measured at the septal and lateral corners of the mitral annulus, and the mean between the two values was calculated. The ratio of mitral E peak velocity and averaged e′ velocity (E/e′) was calculated. Mitral regurgitation (MR) was quantified from color Doppler imaging and semiquantitatively graded as absent, minimal (within normal limits), mild, moderate, or severe, using standardized criteria (15). Moderate MR was confirmed by vena contracta measurement (3 to 7 mm) (16). Reversible significant MR was defined as reversible moderate to severe MR detected during the first echocardiographic evaluation that disappeared at follow-up examination. LV outflow tract obstruction (LVOTO) was detected by continuous wave Doppler. Using the modified Bernoulli equation, a cut-off value of 25 mm Hg for dynamic intraventricular pressure gradient was considered significant LVOTO (17). With continuous wave Doppler echocardiography, peak tricuspid regurgitant velocity recorded from any view was used to determine pulmonary artery systolic pressure (sPAP) with the simplified Bernoulli equation [sPAP = 4 (peak velocity)2 + mean right atrial pressure]; mean right atrial pressure was estimated as previously described (18).
Statistical analysis
Statistical analyses included descriptive statistics (frequency and percentage of categorical variables, mean ± SD of continuous normally distributed variables, and median values and an interquartile range of continuous non-normally distributed variables). The normal distribution of continuous variables was verified with the Kolmogorov-Smirnov goodness-of-fit test. Continuous variables were then compared by using an independent sample Student t test or Mann-Whitney U test, and categorical variables were compared with chi-square statistics or a Fisher exact test, when appropriate. The associations of selected variables with major adverse events were assessed with Cox proportional hazard models using univariate and stepwise multivariate procedures. A significance of 0.05 was required for a variable to be included in the multivariate model, whereas 0.1 was the cut-off value for exclusion. Hazard ratios (HR) with 95% confidence intervals (CIs) were estimated. The following covariates were analyzed: age ≥75 years, heart rate, chest pain with dyspnea, brain natriuretic peptide (BNP), LVEF, E/e′ ratio, sPAP, moderate to severe MR, RV involvement, and LVOTO. The Hosmer-Lemeshow statistic was used to assess the goodness-of-fit of the logistic regression model. A p value <0.05 was considered statistically significant. In addition, to investigate the incremental prognostic value of echocardiographic correlates of major adverse events compared with clinical, we conducted interactive stepwise procedures with ECG and laboratory findings. Therefore, clinical data (including age, sex, presenting symptoms, blood pressure, heart rate) were first analyzed and the global chi-square value was calculated. Subsequent steps were created after adding ECG changes at admission, laboratory findings (troponin I, CK-MB, and BNP peak) and independent echocardiographic correlates of major adverse events (moderate to severe MR, E/e′ ratio, and EF). The incremental prognostic value of the added variables was determined by comparison of the global chi-square value calculated at each step. The chi-square of the model was calculated from the log likelihood ratio. A statistically significant increase in global chi-square after the addition of further variables was considered the incremental prognostic value. Statistical analysis was performed using SPSS version 20.0 statistical software (SPSS Inc., Chicago, Illinois).
Demographic and clinical characteristics
The study population included 227 patients (66.2 ± 12.2 years of age; females, 90.3%). Demographic, clinical, and ECG characteristics of the overall population are shown in Table 1.
Patients with and without major adverse events were compared. There was a striking prevalence of females (91.5% vs. 89.9%, respectively; p = 0.80) in menopause (85.1% vs. 88.7%, respectively; p = 0.47) in both groups. A significantly higher proportion of elderly patients ≥75 years of age (42.4% vs. 23.8%, respectively; p = 0.011) was observed between those with major adverse events. Chest pain with dyspnea (25.4% vs. 8.9%, respectively; p = 0.003) and increased heart rate (88.8 ± 20.5 beats/min vs. 83.4 ± 14.1 beats/min, respectively; p = 0.031) were significantly more frequent among patients with major adverse events. No significant differences were found between groups in ECG presentation, LV morphology, prevalence of triggers, and common cardiovascular risk factors. Conversely, the involvement of ≥4 coronary territories was more frequent (89%) and prevalent in patients with hemodynamic instability (57 [96.6%] vs. 147 [87.5%] patients, respectively; p = 0.047). Length of hospital stay was significantly longer in patients with major adverse events (9 [5.0 to 12.2] vs. 6 [5 to 9] days, respectively; p = 0.002].
Major adverse events: acute heart failure, cardiogenic shock, and in-hospital mortality
Overall complications are listed in Table 2. Acute heart failure was the most common major complication (n = 45; 19.6%). Among the patients with acute heart failure, 5 patients had cardiogenic shock, 1 patient had cardiogenic shock and stroke, 3 patients had ventricular tachycardia/fibrillation, 1 patient had ventricular tachycardia/fibrillation and atrial fibrillation, 2 patients had atrial fibrillation alone, and 1 patient had apical thrombosis. Among patients with cardiogenic shock (n = 18; 7.8%), 3 had active cancer, 1 had stroke and preexisting atrial fibrillation, and another one had new-onset atrial fibrillation. Thirteen patients with cardiogenic shock (5.7%) were treated with positive inotropic drugs or vasopressors or both (dobutamine at an infusion rate of 2 to 20 μg/kg/min; norepinephrine at an infusion rate of 0.2 to 1.0 μg/kg/min; or levosimendan at an infusion rate of 0.1 μg/kg/min). Despite treatment, 3 patients died during intensive care unit stay. Intra-aortic balloon pumping was used in 6 of 18 patients with cardiogenic shock admitted to facilities where implantation of the device could be performed. Of note, 10 patients with cardiogenic shock had reversible moderate to severe MR. Death occurred in 6 patients (2.6%). Cardiac death was related to cardiogenic shock in 3 patients and to acute heart failure in 1 patient. Noncardiac death was associated with malignancy in the remaining 2 patients. Among 11 patients with ventricular tachycardia/fibrillation, only 1 had torsade de pointes, and 9 had prolonged QTc intervals (p = 0.012).
Echocardiographic findings on admission
Patients with major adverse events had significantly higher indexed LV end-diastolic volume (p = 0.002) and LV end-systolic volume (p < 0.001), lower EF (p < 0.001), higher wall motion score index (WMSI) (p < 0.001) and larger LA volumes (p < 0.001) than patients without major adverse events (Table 3). Regarding diastolic function, all mitral inflow-derived parameters were significantly different between groups, as follows: E peak velocity (p < 0.001), E/A ratio (p < 0.001), E-wave deceleration time (p = 0.011), and e′ peak velocity (p = 0.007). In the overall population, LVOTO was detected in 29 patients (only 2 received inotropic agents) and was more common in patients with major adverse events (p = 0.006). Reversible moderate to severe MR was detected in 49 patients and was prevalent in patients with major adverse events (49.1% vs. 11.9%, respectively, p < 0.001). Acute heart failure and cardiogenic shock occurred in 28 of 49 patients (57%). Patients with moderate to severe MR had lower EF (median [IQR] = 38% [31 to 40] vs. 40% [36 to 42], respectively) than patients without significant MR. Apical ballooning (40 of 49 patients; 81%) was prevalent in this subgroup. Seventeen patients had concomitant LVOTO and systolic anterior motion (34.6%). RV involvement (28.8% vs. 9.5%, respectively; p = 0.001) was more frequent among patients with major adverse events. Indexes of LV filling pressure, such as E/e′ ratio (p < 0.001) and sPAP (p < 0.001), were significantly higher, suggesting a more compromised hemodynamic status in the group with major adverse events.
Echocardiographic findings at short-term follow-up
At short-term follow-up, all echocardiographic measures examined were not significantly different between groups, except for LA volume (p < 0.001), E peak velocity (p = 0.002), E/A ratio (p = 0.001), e′ peak velocity (p < 0.001), E/e′ ratio (p < 0.001), and sPAP (p = 0.027), which remained higher in patients who experienced major adverse events (Table 4).
Independent clinical and echocardiographic correlates of major adverse events
At univariate analysis, age ≥75 years, heart rate, LVOTO, RV involvement, chest pain with dyspnea, LVEF, E/e′ ratio, sPAP, and presence of moderate to severe MR at admission were significantly associated with the occurrence of major adverse events (Table 5). At multivariate analysis, LVEF, E/e′ ratio, reversible moderate to severe MR and age ≥75 years were independent correlates of the composite outcome (Table 5). When considering only 2 of 3 components of the composite outcome, that is, cardiogenic shock and death, heart rate (HR: 1.028, 95% CI: 1.004 to 1.052, p = 0.022), LVEF (HR: 0.872, 95% CI: 0.819 to 0.928, p < 0.001), and reversible moderate to severe MR (HR: 4.498, 95% CI: 1.366 to 14.811, p = 0.013) were identified as independent predictors. The Hosmer-Lemeshow statistic was not significant (p = 0.45), indicating a good model fit.
Incremental prognostic value of independent echocardiographic correlates of major adverse events
Sequential models for the prediction of major adverse events were used to assess the incremental contribution of echocardiographic correlates of major adverse events compared with clinical, ECG, and laboratory findings. For major adverse events, the clinical model (chi-square: 40.7, p < 0.001) was slightly but not significantly improved by the addition of ECG (chi-square: 46.2, p = 0.24) and laboratory data (chi-square: 50.9, p = 0.19), respectively. A major and significant improvement was obtained only by the addition of echocardiographic findings (chi-square: 88.7, p < 0.001) (Fig. 1).
This study addressed the role of echocardiography compared with those of other clinical, ECG, and laboratory measures routinely used in daily practice in the early evaluation of patients with TTC. The main findings can be summarized as follows: 1) in a large series of TTC patients, approximately 25% developed pulmonary edema or cardiogenic shock during the acute phase; 2) several echocardiographic findings, such as LVEF, WMSI, E/e′ ratio, LVOTO, sPAP, and RV involvement and reversible moderate to severe MR, were associated with such adverse events; and 3) LVEF, reversible moderate to severe MR, E/e′ ratio, and age ≥75 years were independent correlates of acute heart failure, cardiogenic shock, and in-hospital mortality. In addition, the prevalence of some peculiar echocardiographic findings previously reported in small cohorts of TTC patients have been documented in larger series.
Clinical relevance of systolic and diastolic echocardiographic parameters
Most patients with TTC are usually paucisymptomatic and have a favorable in-hospital course. However, adverse events due to hemodynamic instability (e.g., acute heart failure or cardiogenic shock) may occur in up to one-fourth of patients, even during the first hours after clinical onset.
In our study, higher WMSI and lower LVEF were associated with pulmonary edema and cardiogenic shock, confirming the fact that marked LV systolic dysfunction contributes to the development of hemodynamic instability (7). Increased sympathetic stimulation seems to play a central role in the occurrence of systolic impairment related to myocardial stunning in TTC patients, through a variety of pathophysiological mechanisms, including myocyte calcium overload, oxidative stress, and microvascular dysfunction (4,19,20). Lower peak levels of cardiac enzymes are observed in TTC than in acute coronary syndrome, despite more pronounced myocardial dysfunction. The slight elevation of troponin and CK-MB levels seems to be associated with myocardial stunning rather than necrosis, as abnormal troponin levels do not necessarily indicate true myocardial damage. The potential role of ECG abnormalities in predicting adverse events in TTC has been previously investigated (21). In the study by Takashio et al. (21), the magnitude and extent of ST-segment elevation with ECG were found to be independent predictors of in-hospital adverse events. However, those findings were not confirmed by other authors (22). Although ST-segment elevation is the most common ECG presentation, it is detected in roughly 50% of patients, especially in Western countries (23). In clinical practice, a marked disproportion between troponin peak levels and the magnitude of ECG changes compared with the extent of regional myocardial dysfunction is frequently observed. Our results demonstrate that LVEF is an independent correlate of acute heart failure and is superior to troponin and ECG in identifying patients at risk of hemodynamic instability. Echocardiography seems to better mirror the amount of dysfunctioning myocardium than ECG alterations and serum parameters, confirming the importance of multiparametric LV assessment in TTC patients.
TTC patients may show volume and pressure overload secondary not only to acute systolic but also to diastolic dysfunction. Interestingly, advanced age and female sex that typically prevail in TTC were found to be associated with LV diastolic stiffening coupled with a stiff vascular system and endothelial dysfunction (24). Basal hyperkinesis and apical LV wall stress induce intraventricular diastolic and systolic pressure gradients and are believed to be the primary mechanisms responsible for increased LV filling pressure in this peculiar cardiomyopathy. In TTC patients, elevated BNP levels were shown to correlate with the severity of LV diastolic dysfunction independent of troponin peak levels (25). In our study as well as in other series, E/e′ ratio was elevated (26).
A relationship between decreased LV untwisting (a regional diastolic index) and increased E/e′ ratio (a global diastolic index) has been reported, demonstrating that diastolic function is impaired even in the early phase of TTC (27). E/e′ ratio is considered a good predictor of LV filling pressure, and it has already been proven useful in predicting outcome in different cardiovascular diseases, also showing an incremental prognostic value compared to BNP (28). Our study demonstrates for the first time that E/e′ ratio is a strong determinant of acute heart failure and in-hospital mortality in patients with TTC. This parameter should therefore be assessed early and systematically in order to identify patients at higher risk of hemodynamic instability and to guide appropriate management. In addition, the improvement in E/e′ ratio and LV systolic function at follow-up may be considered a useful indicator of LV function recovery. Heart failure can also be precipitated by elevated pulmonary artery pressure, usually related to reduced LA compliance (advanced LV diastolic dysfunction in elderly patients) or LA volume overload (significant MR) (28). Of note, in our study, the echocardiographic parameters of both systolic and diastolic function, including E/e′ ratio, were significantly more compromised in patients with adverse events than in those without. At short-term assessment, despite comparable recovery of systolic function, some parameters of diastolic function (namely, E/A ratio, E/e′ ratio, and LA volume) remained significantly outside of the normal range in patients who experienced adverse events. As a possible explanation for this finding, it may be hypothesized that pre-existing diastolic dysfunction may have been unmasked following the resolution of the acute phase, suggesting that TTC patients with impaired diastolic function are more prone to develop acute heart failure.
Reversible mitral regurgitation, acute heart failure, and cardiogenic shock
Several aspects regarding the impact of reversible significant MR on the clinical picture of TTC patients are still debated. First, the true incidence remains to be clearly defined. In our study population, reversible significant (moderate to severe) MR during the acute phase was observed in 21% of TTC patients. This finding is consistent with the prevalence (range 19% to 25%) reported in the literature (29–31). Second, the cause of acute MR remains to be fully elucidated. Two distinct underlying mechanisms seem to be associated with the development of MR in TTC: 1) the coexistence of systolic anterior motion and LVOTO; and 2) tethering of the mitral valve leaflets (31). In our study, only a minority of patients with significant MR showed concomitant LVOTO and systolic anterior motion (7%), confirming the hypothesis that different underlying mechanisms may induce dynamic functional MR. Finally, equivocal data for the association of MR with ballooning pattern, systolic function, and prognosis have been reported so far. In our study, patients with significant MR had a striking prevalence of apical ballooning pattern and, if compared with patients without MR, had a lower EF. These findings lead us to hypothesize that significant MR may be associated with more extensive myocardial dysfunction. It is unquestionable that in a context of stunning myocardium typical of TTC, the left ventricle can compensate for the development of an acute MR by increasing preload and emptying, as expected in a normal ventricle (32). LV volume overload results in increased myocardial tension that, in a vicious circle, leads to systolic dysfunction and reduced stroke volume (33). Ejection of the regurgitant volume into the left atrium before aortic valve opening further reduces forward effective cardiac output, predisposing to cardiogenic shock. In addition, LA pressure rises abruptly, especially in the presence of normal or reduced LA compliance, often leading to pulmonary congestion and acute heart failure. In our study, 18 patients developed cardiogenic shock and among these 10 (55%) had moderate to severe MR. The prevalence of cardiogenic shock in TTC was 15% in the study by Tsuchuhashi et al. (1), but even rarer in other series (34). Song et al. (35) reported the occurrence of cardiogenic shock in 16 of 50 (32%) TTC patients. Patients with cardiogenic shock had a significantly higher prevalence of reversible MR and apical ballooning pattern than patients without cardiogenic shock. Our data are consistent with those of Song et al. (35), demonstrating that reversible moderate to severe MR is an independent determinant of major adverse events. In addition, reversible MR remained a significant independent correlate even after considering cardiogenic shock and death as the only components of the composite outcome. Owing to its potential negative impact on in-hospital course, early echocardiographic assessment of the mitral valve should be performed, with special attention to hemodynamics in moderate to severe MR, in particular in patients with advanced systolic dysfunction and LVOTO.
LVOTO has been reported in 25% of patients in a small series of 32 TTC patients (17). In our larger population, the prevalence of LVOTO was 12.8%. LVOTO should be systematically ruled out by echocardiography in order to implement an appropriate therapeutic strategy. In patients with LVOTO and markedly impaired LV systolic function, ß-blockade and intra-aortic balloon counterpulsation should be the preferred treatment options compared to inotropic agents to prevent the development of significant intraventricular gradients and subsequent hemodynamic deterioration (36).
Study limitations
Several issues should be considered when interpreting these data. First, only patients with good acoustic windows were evaluated. Although our intraobserver and interobserver variability in evaluating LV wall motion contraction were good (9), visual assessment of wall motion may have been affected by the tethering phenomenon. Second, catecholamine levels were not reported. However, our observation reflects clinical practice in a real-world setting, where measurement of catecholamine levels is not systematically performed in the acute phase of TTC. In addition, to date, the link among sympathetic activation, elevated circulating catecholamines, and the occurrence of stunned myocardium in TTC remains hypothetical (37). It would have been of interest to compare the association of echocardiographic and cardiac magnetic resonance (CMR) parameters in TTC patients with and without complications. In a prospective study, Eitel et al. (38) reported robust data for CMR in a large cohort of TTC patients enrolled from 7 tertiary care centers in Europe and North America. However, their series included only 1 patient with cardiogenic shock, probably because CMR is difficult to perform in patients with hemodynamic instability. Finally, CMR is not largely available and not systematically used, especially in the early evaluation of patients with acute coronary syndrome or similar conditions.
Echocardiographic parameters provide additional information compared to other variables routinely used in clinical practice in identifying patients at higher risk of hemodynamic deterioration and poor in-hospital outcome. Our study demonstrates for the first time that LVEF, reversible moderate to severe MR, E/e′ ratio, and age ≥75 years are independent correlates of major adverse events (i.e., acute heart failure, cardiogenic shock, and in-hospital mortality) in a large cohort of TTC patients. Comprehensive seriated echocardiographic examinations should be systematically performed in patients with TTC to monitor systolic and diastolic LV function recovery. Special attention should be paid to patients with significant MR and intraventricular obstruction to promptly institute appropriate pharmacological treatment and adequate mechanical support.
For a complete list of Tako-Tsubo Italian Network participants, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- brain natriuretic peptide
- cardiac magnetic resonance
- ejection fraction
- left atrial
- left ventricular
- left ventricular outflow tract obstruction
- mitral regurgitation
- sPAP
- pulmonary artery systolic pressure
- right ventricular
- tricuspid annular plane systolic excursion
- tako-tsubo cardiomyopathy
- wall motion score index
- Received July 6, 2013.
- Revision received August 27, 2013.
- Accepted September 5, 2013.
- American College of Cardiology Foundation
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- Tsuchuhashi K.,
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- Chamber Quantification Writing Group; American Society of Echocardiography's Guidelines and Standards Committee; European Association of Echocardiography
- ↵
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- et al.
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text:
Algemene informatie
Over the last 30 years Robert Walters has grown into a world leading recruitment consultancy, employing over 2,900 talented professionals across 24 countries. In response to our rapidly growing business, we are currently looking for a Researcher to join our successful team in the Antwerp office. As an integral part of our organisation, you will be working directly with our hiring managers to assist all recruitment efforts for our businesses in the Antwerp region.
Uitgebreide informatie
Responsibilities of the Researcher:
Candidate Management
• Screening CVs.
• Sourcing new candidates for the business using a variety of methods, including headhunting, referrals and job boards
• Managing a portfolio of candidates by remaining in close contact with individuals actively seeking a new position and those who may be considering new roles in future
• Creating company maps/profiles for headhunting purposes
• Conducting telephone based and face-to-face interviews with candidates to complete the first phase of registration.
Business Development
• Researching news and developments affecting relevant industry sectors in order to build knowledge and credibility within the market place
• Proactively acting upon information gathered from candidates and research
• Actively promoting and continuing to build the reputation of the Robert Walters brand in the recruitment market place
Ideal Profile of the Researcher:
• University degree, a first experience is not a must but a plus
• Fluency in English, Dutch and/or French is necessary
• Strong team working mentality, commercial awareness and understanding
• Able to utilise effective interviewing techniques in order to analyse applicant's qualifications in relation to job requirements and to determine a quality match
• Results driven, people focused and the ability to come up with creative problem solving
Are you looking to develop a career in corporate recruitment? This an excellent opportunity to develop your skills within a fast-paced and challenging environment. You will employ your strong investigative skills to source, develop, screen and present top talents. Don't hesitate to apply now!
Send your CV to email@example.com or apply directly through the website.


text:
... only to see the last parking space get taken.
Aw crap.
We'd driven an hour and a half to this place and there was literally NO other place to park anywhere CLOSE to this place. I saw Zack's worried face in the rear view mirror and I told him that I believed when things like this happened, there was a very good reason. For instance, maybe we didn't have all the right equipment. We forgot a bucket, and a sieve, so would he be ok if we turned around and checked out the nearby town of Chesapeake Beach?
Fortunately, the word "beach" was the operative word, and we drove a few miles to the quaint town.


text:
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text:
|We've learned caution from the ducks, so Ambrose's first picture was through the blinds.
|But the geese have always been a bit bolder, less inclined to run from scary things happening inside the apartment.
|For once, I'm glad the geese were not easy to scare away, because I wasn't here to witness the cuteness.
|If I had been home, I would have tried to get some up close zoom pictures of the adorable little goslings.
|Alright, I suppose Ambrose did a pretty good job getting those lings. So cute!


text:
Oak Cliff Cultural Center Night Of Spoken Word
An evening of talented spoken word performers and singers – Produced by Priscilla Rice, Hosted by B Randall, Introduced by Tisha Crear, Cultural Program Coordinator Gerardo M. Robles.
The Full Program (Live) on The Journey – Your Radio Show is Also available for free download on iTunes and free sharing in all formats.
Audio and video versions of performances are being rolled out here on The Journey's Life Blog. Uploads are continuing through October. Performers appearing at Verse & Rhyme (See also Live Broadcast) are as follows:
Priscilla Rice – A Plea To Oscar
Ricardo Garza
JuNene K
Spankey D
Reign Bad Guy
desertedpoetic – BiLingual Poetry
Additional selected videos and audio of broadcasted Verse & Rhythm performances are on the following pages. Enjoy. Share. (Podcast of The Journey's Broadcast of Verse & Rhythm).


text:
EC Book Study - Sun Prairie Series
The maximum of 44 registrations has been reached.
Registration Closed.
Presenters: Nicole Aldworth, Karen Russell & Mary Jo Ziegler
Description: The focus of this book study is supporting high quality inclusionary opportunities for all students. Play will be used as an intentional, research based strategy as well as embedding supports from the Preschool Inclusion Toolbox. Teams of regular and special education staff are encouraged to attend together focusing on preschool through 1st grades. Site visits to support implementation may be included. Google folders and resources will be used to organize and share resources and graduate credit/continuing education hours are available upon request. Depending on the number of participants there may be a slight fee to cover the cost of books.
About the Presenters:
Nicole Aldworth is an Early Childhood Program Support Teacher at CESA 2. She joins CESA 2 with almost 20 years of experience working with young children and their families. Nicole spent most of her career working in the Sun Prairie Area School District and Marshall Public Schools teaching Early Childhood Special Education, 4K, and 5K. She holds undergraduate and graduate degrees in the field of early childhood education, special education. Providing rich and engaging early literacy opportunities for all children is a passion of hers, along with coaching and support of those working with young children.
Karen Russell is the Early Childhood Program Support Teacher at CESA 2. She comes to this position with over 20 years of experience as a teacher working with children and families in a variety of settings as an ECSE teacher within school district programming, an Early Interventionist with Birth to Three Programming, and as a 4K and 5K teacher. Karen holds undergraduate and graduate degrees in the field of early childhood education and special education.
Mary Jo Ziegler has worked in diverse educational settings for over 30 years. The first 15 years of her career were spent in classrooms teaching grades 2-8. After earning an M.S. in Reading, she moved into an instructional coaching and intervention role at Sherman Middle School in Madison, Wisconsin. A second Master's Degree in Educational Leadership led to roles as district instructional resource teacher, a literacy coordinator, PK-12 director of instruction, and DPI consultant. Across the years, MJ has worked to support educators as they design engaging and effective learning opportunities that motivate achievement by building routines and scaffolds to guide students through successful learning experiences.
Note: If you are a nursing mother, please be sure to include that in the notes of your registration. We have a private room available for nursing mothers, which must be reserved. The key can be obtained from Emily at the front desk when you arrive.
It's that time of the year where the unpredictable weather outdoors makes our training rooms either too cold or too warm. Training room temperatures are controlled offsite and often take time before the adjustment is noticed. We suggest bringing a sweater, wearing close-toed shoes and/or dressing in layers to assure you are as comfortable as possible while at our facility.
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Sugi® Rhino absorbent swabs remove blood and secretion from wounds very fast. Thanks to their extreme tear resistance and retrieval cords, these swabs, which have been developed specifically for nasal surgical applications, are an ideal aid for pre-surgical, intra-surgical and post-surgical lnasal endoscopic procedures.. They can also be used as drug administering media for vasoconstricting solutions and as a post-operative tamponade..
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Julius Baer Defends Wikileaks Shut Down; Digs A Deeper Hole
from the backed-into-a-corner... deptThe "Wikileaks" shutdown situation continues. The Associated Press covered the story late yesterday, noting how Julius Baer's lawyers were apparently unfamiliar with the concept of the Streisand Effect, and how the attempt to get Wikileaks taken offline would only get it -- and the content the company was trying to hide -- a lot more attention. Today, Julius Baer has finally made a statement on the matter, claiming a variety of contradictory things. It says that it didn't want the entire site taken offline, but hasn't asked the court to reverse its order shutting down the site. As Slashdot points out, the bank also seems to be claiming that the controversial documents in question need to be taken offline both because they're forged and also because they reveal confidential info. While it is possible that a forged document would also have some legitimate confidential info, it does seem like a strange defense to bring up both of these things. At the very least, it certainly seems like the bank keeps digging itself a deeper and deeper hole. If it really was afraid that having this content out there would make things worse in its ongoing legal battles, things seem a lot worse now as many more people are aware of the documents.
Filed Under: streisand effect, wikileaks
Companies: julius baer


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Title: Affliction Z: Patient Zero
Author: L.T. Ryan
Genre: Horror, Gritty Realism, Zombies, Apocalyptic
Publisher: Self-Published
Published: March 11, 2013
Page Amount: 167 pages
Blurb From Goodreads:Something dark lurks in the wilds of Southern Nigeria. An experiment has gone horribly wrong and threatens to wipe all traces of humanity from Earth. 3rd Ranger Battalion, Bravo Company is sent in to assist, clean up the mess before it gets out of control.
They've vanished.
Sean Ryder is an Air Force Pararescueman. Attached to SEAL Team 8, he believes he is on a routine rescue and recovery mission. Less than half an hour after landing in Nigeria, he knows that is not the case. And the further his mission leads him, the harder it becomes to get out alive.
Patient Zero is the first book in the zombie apocalypse / post-apocalyptic series Affliction Z.
Why Read: This strange read is not courtesy of NetGalley or an author coming straight to me – no, it was because of BookBub (which indirectly was a result of Book Riot… as are most things). Although not my usual pick up, I can't deny that I enjoy a good gritty thriller when I find one – and if there are zombies involved… I mean, I won't say no.
Review: Violence, whether it be in video games, movies or books, has always been something of an interesting subject for me – and this book is no exception. Violence combined with a pandemic, zombies and empathetic characters is a dangerous concoction for addiction.
Patient Zero felt like one of those cheap and quick horror movies that you watch at the theaters and rave about to your friends – but at the end, you know it's not anything special. But thankfully it read nothing like that and it certainly had an ending that I appreciated more than I can put into words. There was something that seemed realistic about the whole situation… which is concerning, but not in the worse case scenario sense.
The main character, Sean Ryder, was one I felt I could agree and disagree with. He wasn't the most level headed, but neither was his companion, Turk. Their actions weren't the smartest, and they weren't the ones you'd want the people in the field to be taking necessarily. But damn, they are actions you want the characters to take if you're the one doing the reading.
Plot-holes there were. But at the same times, you're so caught up in the action; it's difficult to focus on those holes while a zombie is begging Sean to end its life. I won't deny I did believe a different end would come, but the ending that ultimately I read was perfectly situated for a sequel: one I will happily read.
Rating: 3.7/5 Stars
Review Coming Soon: From Souk to Souk: Travels through the Middle East


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|INQU 5036: Particulate Systems
|Creation, characterization, separation and agglomeration of particles. Sizing fractionation of powders, surface area and pore size determinations. Pulverization, crystallization, agglomeration, tableting and granulation.
|INQU 6009: Colloids and Interfaces
|Study of the principles of colloid science and interphases and their applications. Development of the fundamental understanding of how various properties of colloids and their interactions at a microstructural level lead to the observed bulk behavior of the material under study.
|INQU 6016: Advanced Transport Phenomena (II)
|Advanced analysis of momentum, energy and mass transport of continuous media. Analytical and numerical solutions to the equations of change, transport coefficients, boundary layer theory, relationship between microscopic and macroscopic balances, and dimensional analysis.
|INQU 6020: Structure and Rheology of Complex Fluids
|Study of the mechanical and flow properties of complex fluids, and the relationship with their microstructure. Discussion of fundamentals of rheological measurements, including flow kinematics, material functions, rheometry, and structural probes. Overview of rheological properties of colloids, liquid crystals, and polymer solutions and melts, amongst others.
|INQU 8010: Special Topics in Transport Phenomena
|Special topics in transport phenomena and related areas.
|INQU 8025: Food Fermentation and Biotechnology
|A study of the chemistry, microbiology and technology in fermentation processes in the food industry. Includes topics such as: kinetics of biological processes, optimal conditions for the design of fermentors, thermodynamic and stoichiometric limitations, and production of industrial microorganisms by genetic engineering processes.
|INQU8103: Fundamentals, Fabrication, and Applications of Metallic and Magnetic Nanoparticles
|Study of the theory, fabrication techniques, and applications of metallic and magnetic nanoparticles. Topics include: synthesis and derivatization methods, physical and chemical properties, and particle-particle and particle surface interactions.
|INQU8997: Special Topics in Complex Fluids
|Special topics in rheology, structure, characterization, modeling, and processing of complex fluids. Application of engineering concepts to novel and classical research areas of complex fluids.
|INQU 4006: Transport Processes
|Introduction to mass transport and energy, and analogies with momentum transfer.
|INQU 4075: Food Technology
|Commercial food processing, preservation and packaging, with emphasis on Puerto Rico's food industry.
|INQU 5075: Polymer Engineering
|Application of the principles of fluid mechanics, and heat and mass transfer describe the production and processing of polymeric materials. Application of engineering principles to the analysis of polymer processes such as extrusion, molding and other industrial relevant unit operations. Emphasis on the effects of processing on structure and physical properties of polymers, and vice versa.
|INQU 5076: Polymer Science
|Introduction to the fundamental physical and chemical properties of polymers and their relevance in the synthesis, production, and characterization of polymer-based materials, Discussion of polymerization and reaction kinetics of polymers and copolymers, structure and morphology in solution, melt, and solid phases, thermodynamics of solutions and blends, molecular weight characterization, and mechanical and rheological properties.
|INQU 5085: Soft Materials
|Introduction to the fundamental physical and chemical properties of soft condensed matter and how they are used to engineer technologically relevant materials. Relevant systems include colloids, emulsion, lipids, polymers, hydrogels, foams, liquid crystal, and granular materials, amongst others.
|INQU 6607: Polymer Physics
|This graduate-level course introduces the fundamental topics in physics and chemical physics of macromolecules. The course covers the static and dynamic properties of polymers in solution, melt, and solid states, and their relevance in industrial polymer processing, nanotechnology, and materials science. Discussion of chain conformations and dimension, structure, morphology and thermodynamics of polymers in solutions, melts, blends, block copolymers and nanocomposites, optical and transport properties.
|INQU 8103: Nanoparticle Science and Engineering
|Study of the theory, fabrication techniques, and applications of metallic and magnetic nanoparticles. Topics include: synthesis and derivatization methods, physical and chemical properties, and particle-particle and particle surface interactions.
|INQU 8104: Introduction to Nanomedicine Science and Technology
|This course provides an overview of the distinctive feature of nanotechnology and their application to biomedical problems. The course contrasts macro/micro/nano technologies to bring out the unique properties of nanotechnology in nanomedicine. Cutting-edge nanomedical technologies for sensing and imaging, drug delivery, and therapeutic applications will be addressed.
|CIIM 6020: Diffusion Phenomena in Materials
|Study of the bases of atomic transport phenomena and diffusion mechanisms in solids, Fick's laws and the Kirkendall effect. Discussion of the characteristics of diffusion in ionic solids. Mathematical analysis of diffusion phenomena and the application of Green's function. The students will be able to analyze multi-component diffusion processes as well as other forms of diffusion in materials processing.
|CIIM 6016: Polymer Science & Engineering
|Discussion of the concepts related to the structure, properties, synthesis, and selection of polymeric materials, which will permit the explanation and prediction of the behavior of such materials. Application of these concepts to the study of the mechanical behavior of polymers, viscosity, and creep, as well as to processing issues, including copolymerization in blends and alloys.
|CIIM 6015: Computational Material Science
|Study of the concepts of computer-assisted modeling and their applications to atomistic processes, which will permit the development of skills necessary for the computational analysis of processes such as kinetics and diffusion phenomena. The behaviors governed by isotropic or anisotropic properties (e.g., texture development) and phase transformation processes (e.g., segregation, precipitation, quenching), are also covered.
|INME 6115: Biomaterials
|Study of advanced materials as applied to biomedical systems. Integration of materials science and engineering concepts with biology for the design of successful interfaces between living cells and organic and inorganic materials as well as medical devices.
|INME 6135: Tissue Engineering
|Study of tissue engineering applied to biomedical systems. Review of quantitative cell and tissue biology, cell and tissue characterization, engineering methods and design, and clinical implementation. Discussion of cells and their behavior, followed by the effect of external stimuli on cells. The properties of the extracellular matrix will be studied. Specific cases of vascular tissue engineering, cartilage tissue engineering and bone engineering will be studied. The implications of using stem cells for tissue engineering will be discussed.
|INME 6165: Design of Microfludic Systems
|Discussion of advanced concepts and technologies of micro-scale flows. Study of microfabrication techniques, special cases of the Navier-Stokes equations, inertial microfluidics, capillary effects, droplet microfluidics, electrokinetics, acoustofluidics, optofluidics, nanofluidics, and transport phenomena in micro-scale flows. Determination of design parameters and optimization of micro-scale fluidic structures based on analytical and computational solutions of the Navier-Stokes and energy.
|QUIM 5165: Polymer Chemistry
|Structure, properties, synthesis, reactions, and physical behavior of polymers. Experimental methods used in their analysis.
|INME 6030: Mechanics of Composite Materials
|The course covers the description and properties of fiber and matrix materials in composite materials, the micromechanics and macromechanics governing composite materials, laminated composites and their behavior under loads, and the strength and fracture of composites.
|INME 5066: Recycling of Materials
|Analysis of the recycling situation in the global context and its laws and regulations. Design of separation and collection centers for recyclable waste materials including electronic devices, aluminum cans, bottles, plastics, steel, tires, construction debris, and hazardous wastes. Planning of processing facilities.


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British Airways launching legal action against Unite for strike threats
Shares in British Airways, hurt by the threat of cabin crew strikes and legal proceedings, lost 2.2% yesterday, as rival carriers report rising booking levels.
On Monday, BA cabin crew, represented by the Unite union, voted overwhelmingly in favour of strike action between 22-Dec-2009 and 02-Jan-2010, which would cause massive disruption over the peak Christmas/new Year period.
In response, the carrier announced plans yesterday to commence legal action in an attempt to "protect customers from the massive stress and disruption threatened by Unite's decision to call a 12-day strike". The carrier has written to Unite, highlighting "irregularities in the union's strike ballot, which the airline believes renders the ballot invalid". As a back-up to the legal action, BA managers have been establishing which cabin crew might wish to work normally during the strike period.
BA employs 13,500 cabin crew, of whom 11,500 work at Heathrow.
Iberia RPKs down, but sees load factor stabilisation
Shares in Iberia dipped 1.6% upon the release of the Spanish carrier's traffic report for Nov-2009. Passenger traffic (RPKs) declined 5.9% year-on-year for the month, while the carrier stabilised capacity, as load factor rose 0.7 ppts year-on-year to 77.8% in Nov-2009.
Elsewhere, rivals Lufthansa and Air France-KLM declined 0.2% and 0.8%, respectively. An Air France A380 aircraft with 511 passengers operating to Paris failed to depart from New York yesterday, due to technical issues with its fuel tank.
Europe selected airlines daily share price movements (% change): 15-Dec-09


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Located 15 minutes from Hervey Bay on Queensland's Fraser Coast region, River Heads is a major departure point for vehicles and walk on passengers to World Heritage-listed Fraser Island and has magnificent views of Fraser Island, the Great Sandy Strait and the Mary River estuary. The boat ramp is suitable for launching a large range of craft and there is ample car and trailer parking available. Rock fishing at the point will give you a good opportunity to land yourself an impressive catch as well as giving you the chance to admire the dolphins, turtles and dugongs which frequently pass by.
Barges to the world's largest sand island (Fraser Island) depart daily from River Heads to both Kingfisher Bay Resort and Wanggoolba Creek.
Note: Information on listed products and services are provided by the operator and were correct at the time of publishing. Rates are indicative based on the minimum and maximum available prices of products and services. Please visit the operator's website for further information. All prices quoted are in Australian dollars (AUD).


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Ocean Carrier Alliances: What You Need to Know
While the changing atmosphere of ocean carrier alliances for containerized cargo isn't something new, it's certainly top of mind for many shippers and carriers alike thanks to a tumultuous last few years. This is especially true today, as what used to be four primary ocean carrier alliances transformed into three different ocean carrier alliances – taking effect on April 1, 2017. But what does this realignment mean for the industry?
Read more here.


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I wanted to make a larger piece to enter in a couple competitions. This "Surf Sifter" is 24"H x 18"W showing a great blue heron in the surf. I made the collage of the bird using 3 filtered photos cut into quarter inch strips. Then I added irregularly cut shapes of green handmade papers along the edge to give the feel of seaweed in the surf.
Wednesday, April 25, 2018
Big Bird
Posted by Lori Reed at 10:53 AM No comments:
"Media Mix" show
For many years, I've "workshopped" my art with several other women. The current group of four women was offered a show at the Buchanan Center for the Arts in Monmouth, Illinois. The show runs April 17 - May 25, 2018.
Posted by Lori Reed at 10:51 AM 1 comment:
Labels: mixed media collage
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I just received and listened to the new Michael Dees CD, "The Dream I Dreamed". I don't think I can express in words how musically great this CD is, but I am going to try. Michael Dees has been writing and performing music on the West Coast for many years but mostly behind the scenes. His many musical accomplishments date back to the 60's when he was featured several times on "The Steve Allen Show". As most Jazz lovers know, Steve Allen was a big-time lover and performer of Jazz and once he heard Michael sing, he instantly recognized Michael's musical talents. In 1968 Michael was voted the "Best New Male Singer" at the International Popular Song Festival in Rio de Janeiro. It was in Rio that he met Elmer Bernstein who asked Michael to record the song "A Walk In the Spring Rain" for the soundtrack of the movie of the same name. Michael next recorded two albums for Capital Records including "Talk To Me Baby' that featured several Alan and Marilyn Bergman songs. The Bergmans liked his work so much, they asked him to sing their block-buster song, "What Are You Doing the Rest of Your Life" for the soundtrack of the movie "Happy Ending".
In the 70's Michael began a long career as a studio singer, performing in over 100 television and movie tracks. In 1995 he recorded songs on the soundtrack for Harrison Ford's remake of the movie "Sabrina". More recently Michael was asked by HBO to be the singing voice of Frank Sinatra in HBO's "The Rat Pack". Over the past 30 years, Michael has sung, written and produced hundreds of commercial "jingles" for radio and television.
Two years ago, Michael moved from the LA area to Palm Springs and a few lucky music lovers have been fortunate to hear Michael sing in a couple local Jazz clubs. I first heard about Michael when my friend and fabulous Bass player, Larry Holloway told me he was playing for a great new singer who I had to hear. I did go to hear Michael, and I became a fan after the first song he sang.
And that brings us to his new CD, "The Dream I Dreamed" due to be released on May 12th, 2015. Multi-talented Michael Dees wrote all 14 songs on the CD, and his compositions are nothing short of brilliant. Michael writes in the finest tradition of the "Great American Songbook". His melodies are powerful and his lyrics are alive and full of passion. If Sinatra were alive today, I am positive he would have wanted to record several of the songs on this CD. Michael Dees' compositions are alive and current and tell believable stories that instantly relate to the listener. Young singers today would do well to record some of Michael's tunes; songwriting doesn't get any better than this!
Michael's voice's has deep velvet tones, and, yet, great force when the music calls for it. I believe his best vocal talents are his wonderful phrasing, very much Sinatra-like, and his skill in vocally telling a story with the lyrics that instantly connects with the listener. These qualities have been captured by very few singers. Michael Dees is one of these singers!
The last part of this wonderful CD belongs to the marvelous supporting musicians Michael has captured for this CD. They all fit Michael's voice and style and melt seamlessly together. They make the final product just about as good as it can get.
This Cd deserves consideration for a "Grammy" in several categories; Best Jazz Vocal CD, Best Popular Songwriting and Best Male Vocal of the Year.
Michael Dees: Vocals, Compositions, and Arrangements
Terry Trotter: Piano
Chuck Berghofer: Bass
Steve Schaeffer:Drums
Steve Huffsteter: Trumpet, Flugelhorn
Chuck Manning: Tenor Sax
Sal Marquez: Trumpet
Bob Sheppard: Tenor Sax, Clarinet
Doug Webb: Tenor Sax
Don Williams: Percussion
1. "In A Moment" 2. "Look At Me"
3. "A Kiss" 4. "I Miss You"
5. "So Crazy For You" 6. "I'm Home"
7. "Back In New Orleans" 8. "I Stay"
9. "A Long Time Comin" 10. "Every Time You Touch Me"
11. "Am I Supposed To Care" 12. "Where Love Goes"
13. "Truly Love" 14. "The Dream I Dreamed"
For you're listening enjoyment, I have attached a "YouTube" of Michael Dees singing "What Are You Doing For The Rest Of Your Life" from the 1969 soundtrack of the movie "Happy Ending".


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Type: Offering Category: Office Space For: Sale
Price: 3,200,000
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Advertiser: Kapil Kumar | City: Noida | Posted: Feb 21, 2017 4:20 AM | Hits: 317
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Loving Pets Stainless Steel and Coastal Blue Bella Bowl features veterinarian recommended stainless steel interior that resists bacteria. A removable rubber base prevents spills, eliminates noise, and makes Bella Bowls fully dishwasher safe. Medium - 2.5 Cups (7" D x 2" H)
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To create your booking, we ask you to create a customer account, where you can record your information and keep track of your order securely.
We ask that you pay a 30% deposit when you place your order, with the balance to be paid at least two months before your departure date. You will receive a reminder email before this date to allow you to make payment. If your departure date is less than two months away, payment cannot be made on-line.