This project was created on 03/23/2014 and last updated 5 years ago.
We attend to build a replica of the Jack dispenser of Futurama as seen on episode 109 "Hell is Other Robots". It will include an amplifier with 4 output channels (2 right, 2 left) and one input channel for audio auxiliary.
It will also include a Raspberry Pi as the main audio source. The Raspberry Pi will be used as a DLNA server and will act as a "media hotspot".
Most important, the Sci-fi style : the plasma ball !
THERE'S VIDEOS HERE! CHECK IT OUT! We think it's better to show details with videos so click on "Read more" to see videos of our project running fine.
You don't wanna get hooked on this stuff!
Hey we finally finished the Jack Dispenser!
We first had to finish the painting and add the final paint layer to give it the perfect touch. Next was to glue the plama ball circuit into the water sprayer, we wanted it to be the closer from the plasma ball to ensure the cable's contact in it. We then had to solder all of the speakers cables (4 one-end jack connector) the auxiliary input (one 3.5mm to 6.35mm jack). We used a jack to RCA adapter to plug the Raspberry Pi straight into the amplifier.
After assembling the 3-floor structure, well... We had to disassemble it because the leadscrews were too tall. So, after re-cutting the leadscrews and re-assembling the inner structure we were ready for the big final : put the plasma ball on the top the the Jack Dispenser and turn it on with some kickass guitar sounds. The results can be seen on the videos in the details of our project. Check it out!
...Not exactly. We still have to improve some of the features to enhance the user's experience a bit more as it is quite essential. So even if it is tagged complete as the Jack Dispenser is now fully funtionnal, things like the WebUI still need to be improved, for example we're actually thinking of a replacement for lighttpd in order not to go through the whole server configuration and its use with PHP. We'd like to find a server that could be directly implemented in the package, so if you think of one that could fit our need, tell us in the commentary section!
What about your amplifier ?
Nothing yet. The plane must have gone lost somewhere in the bermuda triangle as we still have no news or even the ability to track the package. We somehow hope to receive it in the week or even the next one but we can't know. We'll update the pictures and cabling of the amplifier as soon as we receive it so stay tuned for some more cool stuff! For the moment, all we have is an amplifier we borrowed to a friend.
What your project could be used for ?
We tried to make generic scripts that would be reusable in others projects. We already have some ideas on how to re-use our whc-switch in others projects like the "HackerBoy" which would basically be a Hacked GameBoy containing a rasberry Pi. It would of course be powered by a little battery. The HackerBoy would actually use the screen and buttons to control the Rasberry Pi and use command line softwares and utility. As it would be a connected GameBoy, it should be able to make a lots of cool things like our Jack Dispenser.
minidlna-autoconfig is now on the AUR and accessible by everyone. We think that some people are fighting to get a simple but working configuration for minidlna and we are distributing these scripts just for them. We will add an entry to the ArchLinux Wiki to make it more popular and see if it can help people.
We also created the "Share Your Profits License" you should take a look on, it is a just-borned license, but it'll be finalized soon and everything we coded for the Jack Dispenser is now distributed under it!
The Jack Dispenser, version 2 ?
After seeing the announcement of the new form-factor for the Raspberry Pi, we had some thoughts about making a new version of the Jack-dispenser, with custom PCB and fully integrated 4 channel audio amplifier (maybe a custom amplifier with some STA540 or alike amplifier). We will probably try to do a better structure, perhaps using fiberglass.
Briefly, we will try to keep this project alive ! Stay tuned for others updates and demonstrations !
Here we are for our third update since the begining of this project and we are actually about to tag it complete.
This week and the last one's work was a lot about coding and building the structure.
Like we planned, we bought some hinges at the local store and we used our Dremel to drill some place for one hinge that is discretly located on the upper outside border of the basins. One hinge seems enough for us but we had to find a way to keep it opened properly and so we chose the good old-fashion chains to keep it open at certain angle without falling.
Still with the Dremel, we drilled some holes in the water sprayer for the female jacks and cut the bottom of it so we could pass cables from the water sprayer to the basins. We also drilled a slot into the water sprayer in order to install the circuit from the plasma ball into it and have an access to the on/off switch. We will install it definitly when the Jack Dispenser will be painted.
As stated above, we also had to start painting the Jack Dispenser so it would be the same color as the device in the Futurama's episode, unfortunatly we weren't able to find the same colour and so went for the Bordeau painting spray. The entire painting spray was actually enough to correctly paint the entire structure (note that the basins received three successive layers of paint minimum as much as most of the other parts that needed to be painted).
We spent a lot of time on the software side, trying to figure out a simple way to enhance user experience without having to add a display and/or a keyboard. As described in our second Project Log, we made a script that reads the input from a physical switch and switches between hotspot and client mode depending on the switch state. The script, nammed whc-switch, is also able to start/stop/restart systemd services depending on the switch state. You are able to customize this by using the configuration file which is shipped with whc-switch. Actually, we needed it for gmrender-resurrect which doesn't react really well when changing network configuration.
More than that we have started working on a WebUI you can use to configure/add/remove netctl profiles as you wish and display the profiles specs. The WebUI is designed to receive only one connection at a time so you wouldn't actually be able to edit profiles from two computers causing troubles to happen when saving the files from two locations. It is more secure even if passwords from the netctl profiles are displayed in clear text (we will be working on encryption after the contest is finished).
We felt that we also needed a way to communicate the wifi state to the user. We chose the simplest way: leds. One blue for the wifi state and one red that will light up if a problem occurs. The blue led will blink when the wifi is in hotspot mode (host mode) and will stay on if the wifi is in client mode.
As we showed you on the last update, we thought of a little structure for the power supply, the Rasberry Pi and the motorcycle amplifier. We chose to use the rodolpheh's CNC to cut and drill the plates in MDF and now have our internal structure almost ready (we just need the amplifier to make the last floor).
We're still waiting for the motorcycle amplifier. We bought it one month ago from DealExtreme and have no news since the fourth of April. We don't think we will get it before the end of the contest but we still want to tag it as complete because nothing have to be made on the amplifier except plugging cables, which is not a hard task. We rely on the understanding of the Hackaday's team for accepting our project as complete.
"I'm gonna drink til I reboot!"
"We're back baby !" for our second update after two weeks since the last project log.
Things are real fine, we actually received most of the components we needed and were able to get to work on both hardware and software sides and so we were able to code the things we needed to configure minidlna quite easily and post a build instruction about it.
Last week, we took a day to go to the local store in order to prepare a good power cable for the power supply. We used a flat plug with a little hook to unplug it and a foot-triggered switch. This won't looks really futuristic but hey! if you have seen "THX1138", you know that white IS futuristic! Quickly, we got into testing and adjust the power supply.
The cables were tested with an adapter and plugged to a laptop. It worked perfectly as we planned.
The plasma ball has also been disassembled to see how it could fit in the whole structure. We also tried, with success, to add a longer wire to the plasma ball for when we will fit it in the Jack Dispenser. There is some kind of metal scrap inside the plasma ball and the wire should touch it in order to make a good electrode.
For the same concerns we made a 3D model of a tiny 3 floor wooden structure that will be placed in the lower part of the jack dispenser. The advantage of this little structure is that it will ballast the object so we can easily open it without worrying it would fall. Opening the jack dispenser will probably be done with hinges, by leaning the upper part like you would do with a treasure chest. The floors will be held with leadscrews and nuts. It is as simple as it could be and we should be able to get it in or out easily for maintenance.
Here is a quick model of our structure. We will probably update it as soon as it evolves.
Besides all the functions we can find in the amplifier (SD card, USB, aux input, FM/AM etc...), we felt like we needed a more modern way to play our music. We found a USB dongle that was lost on a previous project and decided to search a way to stream music from any devices without dragging kilometers of cables or having to install complex software.
We came up with minidlna which is a common software you can find in any good Operating System. Minidlna acts as a DLNA Server. With it, you should be able to read media contained in an external hard disk or in the SD card of the Raspberry Pi, on a DLNA Renderer such as your TV or your cellphone.
"If jacking on'll make strangers think I'm cool, I'll do it!"
Hello World, here's our first update, it's not a big and important one but it will allow us to present you the components we get and the thoughs we had on the design.
NOTE: all dimensions are in mm.
Buy online... And what ?
On a sunny sunday, between two naps, we bought the main components on Internet. We opted for a motorcycle amplifier with 4x20W output channels that will be the heart of our Jack Dispenser. We also bought two plasma balls (in case we would break one) that can be powered with USB. It's 80mm wide and won't be too power-hungry. After getting these components on the web, we have to wait for them to deliver so we will see how we will use them later. Stay tune !
The motorcycle amplifier. 80W under the (tiny) hood.
As we though of our project a little more, we encountered the first problem and one of the most important thing in our project : the design!
If it wasn't for the design the Jack Dispenser wouldn't look Sci-Fi enough to satisfy the Hack-A-Day team.
The first step for designing our project was to determine how it would be build. As seen later, our choice was to get common everyday-used objects that could be bought for a cheap price. But we had to choose what kind of objects could be used and their possible dimensions. At that point, it was obvious that we should get our hands on drawing it with the model we got on the Futurama's episode.
First, we used Inkscape to draw a half-cutted view of the object on a semi-transparent screenshot we placed on the background. The drawing was made roughly, to get a basic idea of the shape.
Next, using Qcad, we corrected the previous drawing and after struggling with Qcad, we finally were able to scale it using the only known dimension : the plasma ball which is 80mm wide. With some measures, we were able to make a list of everyday objects with a shape that would fit in our design with their dimensions.
Since it's an Hack-A-Day contest we thought common objects once assembled would perfectly do the trick with a bit of work and decided to go where some of these can be found a really resonable price as we intended it to be quite a low cost object to replicate. Fortunatly we were lucky and hit the strike as all of the objects for the design could be found at a crap-junk yard called Babou. For 12,90€ we had it all! 2 simple basins of 300mmØ, a water sprayer (or whatever you use that for), and plastic champagne flutes (pack of 8).
Back home we were able to assemble the very first crappy prototype in less than one minute.
The crappy design prototype. Really close, isn't it ?
Next ? We have to wait for the components to deliver and buy a few more components to build it perfectly. We will make updates as long as we build it, with pictures and details.
NOTE: We're aware that the device seen on Futurama does not fit the exact same dimensions. It's Matt Groening's fault, who's not aware of how a Jack Dispenser looks like in Y3K !
Power supply get quickly expensive when you want more than 100W output and you might want to buy a power supply that is a little bit more powerful than your amplifier.
The power supply should output enough power to power up the amplifier, the raspberry pi and some of the accessories you will add.
Having only one power supply is easier. Try to use converters if you need other voltages. Most of the amplifiers are 12V and the Raspberry Pi uses 5V, you don't need to be a genius to know that you will need a converter or another power supply, so you better make a choice. "This is your last chance. After this, there is no turning back."
This gave us 92W maximum so we took a 100W power supply.
The choice of the structure is up to you. Avoid metal as much as you can if you don't want to mess with electricity. Choose wood if you can. It's well insulated, is easy to use and it have some good looking.
When buying the cables, keep in mind how much you need and what kind of cables (for example, the outputs have two phases and the input have three phases). For outputs, you need as much cables as the number of outputs you got. For inputs: you probably need one cable for auxiliary input and one cable to connect the Raspberry Pi to the main input of the amplifier.
These are all the advices we could give you. In a more general way, you should refer to our component list to see what you need if you use the same amplifier. Audio connectors can be the size and the kind you want except for the auxiliary input on the amplifier and the main input on the Raspberry Pi. These should absolutely be 3.5mm stereo jack connectors.
Go to the Raspberry Download Page and download N.O.O.B.S. Follow the documentation to install N.O.O.B.S on your SD Card. When it's done plug it into your Raspberry Pi, power it up and choose your Operating System to install.
For the rest of the instructions, we will use Arch Linux as it's our favorite Linux distribution. If you are using Arch Linux, you will probably use yaourt in order to install packages from the AUR. If this is the case, you should fix your clock to the right date and time (the Raspberry doesn't have an RTC so it won't keep the right date and time) manually or using NTP. We advise you to install and start NTP right after having setup the network (see next step).
After installing Arch Linux using N.O.O.B.S, you can start and login with the account root and the password root.
The first thing you should do is set up the network and update your system. You could plug it on a wired connection or launch wifi-menu if you already want to use the wifi dongle.
WARNING: NetworkManager can conflict with netctl YOU WON'T BE ABLE TO SET UP CORRECTLY THE NETWORK IF YOU TRY TO USE BOTH OF THEM AT THE SAME TIME.
For your first wireless connection, we will use the command wifi-menu. Wifi-menu is part of the netctl package, so you can use it right after installation, this will be required for package installation and for connecting the device when not in access point mode. Using wifi-menu to connect to a wireless network will create a netctl profile into /etc/netctl. This profile will be named this way: <interface>-<SSID>. It will allow you to start/stop the connection using netctl start <profile> and netctl stop <profile>. You can get the list of saved profiles by doing netctl list.
Now it's up to you to configure the rest of your system (like adding NTP) before going to the next step. Remember that you can use netctl start <profile> in case you need to reconnect after rebooting.
We actually thought of a few ways to handle the lower chamber opening, but the problem was essentially to find one that would work fixed on a circular shape. We came up with the idea of the hinge as we knew we could find little ones that would allow us to open it easily, we actually had the same concerns about the hinge and thought of the chains to hold it opened not to make the hinge take all the weigh so guess it will take the use for quite a while!
I worry about the hinge on the lower chamber holding up. If it can take the use, this is a useful art-piece that deserves a place of honor!
The hinge is not the optimal solution but it works and we did took some time to test its strength by pushing it forward and back and on the sides. It doesn't seems to break easily nor the basins we used (cheap plastic is really deformable).
If we have one problem, it's for the paint that don't want to stick to the cheap plastic. We hope we will have some time between two projects to make a V2 that could be made of fiberglass. By making our own structure, we would be able to rethink the opening system and have a good paint.
For the moment, we have a lots of ideas for a better version with more features. This first jack dispenser was really a prototype but we're happy that we were able to comply with the first specifications that we have given ourselves.
An inexpensive audio player with a simplified interface to make driving safer.
Digital, portable, open source, and simple checklist for every day carry. Replace apps and paper for good.
[DISCONTINUED] An inexpensive bluetooth music system for cars with lacking stereos.
You are about to report the project "Futurama's Jack dispenser", please tell us the reason.


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LCVs
Turning diesel vehicles into electric! This company led by a former Elon Musk aide wants to do it
Why buy an EV if you can convert your existing vehicle into one? That is what Power Global wants to do with around 9 lakh three wheelers that run on diesel or CNG over the next 6-7 years. In the next phase it plans to do the same with petrol two wheelers too.
Sumant Banerji
Updated: October 14, 2021, 09:28 IST
There are around 2.5 million three wheelers on the road in India. It is also a segment where the acceptance of EVs is already high.
One of them is a bonafide expert in battery technology and was an energy storage engineer at Elon Musk's SpaceX. Porter Harris spent nearly five years working on the batteries that propel the F9 Rocket and Cargo Dragon Spacecraft of SpaceX. Later he was also the chief battery engineer at EV startup Faraday Future. The other is an Indian automotive industry veteran with a nearly three decade long career. Pankaj Dubey has built his expertise with stints at Hero Motors, LML, Yamaha and Polaris.
In the middle of the pandemic last year, LinkedIn brought Harris and Dubey together and a few messages and many hours of facetime led to the birth of a company--Power Global. Curiously, Dubey and Harris have not even met each other personally.
"It is actually funny. We have not even met once yet," Porter says. "When we started interacting we weren't even talking about business to start off with. That came much later. At a certain point you just see the people for who they are even if it's over a screen and that was pretty obvious to me."
The aim of the firm is to expedite India's electric mobility story in the two and three wheeler segments by covering not just vehicles rolling off the assembly lines or those that will hit the roads in future but also the millions that are already on the road ~
The aim of the firm is to expedite India's electric mobility story in the two and three wheeler segments by covering not just vehicles rolling off the assembly lines or those that will hit the roads in future but also the millions that are already on the road. It wants to retrofit existing vehicles--replacing the engine and exhaust system with an electric motor and battery, which makes Power Global different from the dozens of startups that have come up in the last couple of years.
"The concern for the environment is very high everywhere and especially in India which has 14 of the top 20 most polluted cities in the world. With new technologies coming especially in electric vehicles, it makes a lot of sense for good high quality products to be manufactured in India," Dubey says. "But the number of EVs that are going on the road are very few so I happened to get in touch with Porter and came up with a strategy of manufacturing high quality, efficient and safe lithium ion battery in a retrofit kit to convert existing vehicles."
Though it may sound like one, the idea of a retrofit kit to convert existing vehicles into zero emission products isnt that unique. In India too, a number of unorganised players are doing it under the radar in the nooks and corners of the country. What is revolutionary here is the scale that Dubey and Harris want to bring to the table with the assurance that the vehicles would be legal, safe and duly ratified by testing agencies like ARAI.
"Based on our experience the conversion can be done in just a few hours. People have tried it in regional centres but retrofit is not something that can be done in a small area. There is a requirement of getting them approved by organisations like ARAI if you really want to do it on a scale nationally and to do that you have to behave like an OEM," Dubey adds. "We are the first company to try it at this scale. Because no organized player has tried it yet, there are a lot of opportunities here for us."
Power Global eZee Battery Module
The company recently launched its first swappable lithium ion eZee battery aimed at the e-rickshaw market and is setting up a battery manufacturing factory at a former Honda Logistics site in Greater Noida. It will have a capacity of 1 Gigawatt hour that roughly translates into 400,000 batteries every year. Power Global will be investing Rs 200 crore over the next 2-3 years.
As the largest three wheeler market in the world, the choice for the firm to start its journey in India is an obvious one. There are around 2.5 million three wheelers on the road in India. All of them are potential customers. It is also a segment where the acceptance of EVs is already high--around 40 percent of current new three wheeler sales in the country is electric. So when Dubey says he is looking at converting 9 lakh three wheelers over the next 6-7 years, it does not sound very outlandish.
"My expertise is in gaining scale and that is what I have learnt while working with so many global OEMs," he says. "The three wheelers are already on the road so our customers are out there. We are talking about tapping into 400-500 cities in the country. Then you also have OEMs who would buy our kits so that is another revenue stream."
By being able to take the initial cost of the battery out of the equation and extrapolate that over time, we're able to give the benefit to the driver. Our EV kit is somewhere around a third of the cost (of a new EV) Porter Harris, Founder, Power Global
Further, the company also wants to offer battery swapping through the subscription model which brings down the acquisition cost of the vehicle while solving the problem of range anxiety. It is also something that a number of other companies like Chetan Maini's Sun Mobility are also trying. Yet, there are some who believe a fixed battery offers the highest efficiency--one of the reasons why most smartphones dont have removable batteries anymore, and a swappable battery is relatively inefficient.
"Fixed batteries are more efficient but in the case of swappable batteries the loss of efficiency is very minor as compared to the benefits. Our battery is already extremely efficient and very capable of handling high shock and vibration loads, dust etc," says Porter. "By being able to take the initial cost of the battery out of the equation and extrapolate that over time, we're able to give the benefit to the driver. Our EV kit is somewhere around a third of the cost (of a new EV). Further, we can bring down operational costs by having a swappable battery, saving the driver somewhere between 25 and 35 percent in operating costs per day. Both combined that is a lot of savings."
EV Day Special: EV sales set to grow fast, can charging network keep pace?
The inflection point for electric two and three wheelers is now visible but investment in charging infrastructure in the country is lagging behind. It can pose a big hurdle and even potentially hurt growth in future.
Blow to Mahindra, Bajaj : Govt not in favour of extending FAME subsidy for electric quadricycles
In the absence of FAME 2 subsidy, electric quadricycles would be uncompetitive against electric three wheelers. It could spell doom for the segment still in its infancy.
Power global
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Pankaj Dubey
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redpajama_set_name: RedPajamaCommonCrawl


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We're going to need a bigger shed! Another arts venue to expand
Created in 1982 as Britain's first media centre, over the past 20 years Watershed has continually grown, building a reputation for inclusive talent development, diverse cultural cinema, and innovation.
In that time, cinema audience has grown from 85,000 to 170,000, the range of films shown has diversified from 33 producing countries to 52, and the number of artists worked with each year has expanded from 50 to over 150. This growth has been enabled by embracing digital technologies, the building of Cinema Three, and the opening of the Pervasive Media Studio.
Watershed has now submitted a Pre App to Bristol City Council – which is a way to ask the Council for formal advice before a a full planning application is made. Continuing Watershed's journey of leadership and stewardship and to meet increasing demand, they have shared an ambitious vision for physical expansion that will deliver improved environmental sustainability and financial security for years to come.
"Watershed's expansion is a project driven by the why rather than what we will do," says Clare Reddington, creative director and CEO. "It is about fulfilling increasing demand from people who want to visit, work and co-locate with us. It is about celebrating the new ideas that are developed under our roof and giving them increased visibility in the heart of the city. It is about ensuring our building is the most welcoming and inclusive space it can be. A bigger shed is a bigger home for creativity and will be a powerful celebration of Bristol's flourishing cluster."
With the submission of the Pre App, Watershed is entering into a period of discussion and exploration with stakeholders, public, artists, industry, neighbours and partners. This will test thinking and help further develop plans. This period is expected to run until March 2019 and following a period of evaluation, the team will publish findings from these discussions and formulate a timetable for the progression of their ambitions.
The building will increase from 4,400sqm to 6,360sqm with new work space for over 100 creatives in the four floors above the rear of the existing building. The planned re-development will house the Pervasive Media Studio, new incubation and grow-on studios, an additional cinema screen (taking the total to four), additional flexible event spaces (taking the total to five), and the café and bar – to help to sustain the growth of new talent and ideas.
Ambitious aims, ensuring the environmental sustainability of the whole venue is improved, are at the heart of plans, and new spaces will see improved access and accessibility through an extended ground-floor street-front presence and improved physical access to the upper floors of the building. They also plan to improve the toilets and facilities for people who are disabled and young children; gender neutral facilities will also be introduced.
"As well as increasing our capacity for creativity and inclusive innovation, our new expanded building will radically improve our sustainability, securing a bright future for our historic building and boosting the resilience of our economic model," says Miriam Randall, executive director. "Sustainable design and energy efficient facilities and materials across our workspaces, studios, cinemas and event spaces will transform our environmental impact and significantly improve the visitor experience."
There will be a number of open forums which will be advertised as part of the public programme and the team will be meeting with interested groups and stakeholders. The first open forum will be on 10 January 2019 at 6pm in Pervasive Media Studio and is open to all who have booked a free ticket.
"Watershed is a space where I am accepted for just being me," says Pervasive Media Studio resident Lawrence Hoo. "Expansion means they will be able to spread their all-inclusive ethos to a greater number of people whilst also enabling more engagement with diverse and marginalised communities."
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Mar 1, 2010 Issue
Management of COPD Exacerbations
This is a corrected version of the article that appeared in print.
ANN E. EVENSEN, MD, University of Wisconsin School of Medicine and Public Health, Verona, Wisconsin
Am Fam Physician. 2010 Mar 1;81(5):607-613.
Patient information: See related handout on COPD exacerbations, written by the author of this article.
Definition and Classification
Initial Evaluation
Indications for Hospitalization
Oxygenation and Ventilation
Preparation for Hospital Discharge
Preventing Future Exacerbations
Exacerbations of chronic obstructive pulmonary disease contribute to the high mortality rate associated with the disease. Randomized controlled trials have demonstrated the effectiveness of multiple interventions. The first step in outpatient management should be to increase the dosage of inhaled short-acting bronchodilators. Combining ipratropium and albuterol is beneficial in relieving dyspnea. Oral corticosteroids are likely beneficial, especially for patients with purulent sputum. The use of antibiotics reduces the risk of treatment failure and mortality in moderately or severely ill patients. Physicians should consider antibiotics for patients with purulent sputum and for patients who have inadequate symptom relief with bronchodilators and corticosteroids. The choice of antibiotic should be guided by local resistance patterns and the patient's recent history of antibiotic use. Hospitalized patients with exacerbations should receive regular doses of short-acting bronchodilators, continuous supplemental oxygen, antibiotics, and systemic corticosteroids. Noninvasive positive pressure ventilation or invasive mechanical ventilation is indicated in patients with worsening acidosis or hypoxemia.
In patients with known chronic obstructive pulmonary disease (COPD), exacerbations occur an average of 1.3 times per year.1 Exacerbations range in severity from transient declines in functional status to fatal events. In the United States, exacerbations have contributed to a 102 percent increase in COPD-related mortality from 1970 to 2002 (21.4 to 43.3 deaths per 100,000 persons).2 Effective management of a COPD exacerbation combines relieving acute symptoms and lowering the risk of subsequent exacerbations.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendation
Noninvasive positive pressure ventilation improves respiratory acidosis and decreases respiratory rate, breathlessness, need for intubation, mortality, and length of hospital stay.
Inhaled bronchodilators (beta agonists, with or without anticholinergics) relieve dyspnea and improve exercise tolerance in patients with COPD.
Short courses of systemic corticosteroids in patients with COPD increase the time to subsequent exacerbation, decrease the rate of treatment failure, shorten hospital stays, and improve FEV1 and hypoxemia.
1, 6, 7, 9, 17–20
Low-dosage corticosteroid regimens are not inferior to high-dosage regimens in decreasing the risk of treatment failure in patients with COPD.
Oral prednisolone is equivalent to intravenous prednisolone in decreasing the risk of treatment failure in patients with COPD.
Because they are bioavailable, inexpensive, and convenient, oral corticosteroids are recommended in patients who can safely swallow and absorb them.
Antibiotics should be used in patients with moderate or severe COPD exacerbations, especially if there is increased sputum purulence or the need for hospitalization.
The choice of antibiotic in patients with COPD should be guided by symptoms (e.g., presence of purulent sputum), recent antibiotic use, and local microbial resistance patterns.
There is limited evidence that broad-spectrum antibiotics are more effective than narrow-spectrum antibiotics.
Smoking cessation reduces mortality and future exacerbations in patients with COPD.
Long-term oxygen therapy decreases the risk of hospitalization and shortens hospital stays in severely ill patients with COPD.
COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in one second.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.xml.
Jump to section +
Criteria for the diagnosis of COPD have been established.3 However, there is no validated diagnostic test or biomarker of COPD exacerbations.4 The American Thoracic Society (ATS) and European Respiratory Society (ERS) define an exacerbation as an acute change in a patient's baseline dyspnea, cough, or sputum that is beyond normal variability, and that is sufficient to warrant a change in therapy.5 The ATS and ERS classify COPD exacerbations as mild, moderate, or severe, based on the intensity of the medical intervention required to control the patient's symptoms (Table 1).4,5 In addition to the hallmark symptoms of a COPD exacerbation (cough, dyspnea, and increased sputum), systemic inflammation also causes extrapulmonary symptoms (Table 2).6–8 Factors that increase the risk of a severe exacerbation are listed in Table 3.5–7,9–11
Classification of COPD Exacerbations by Severity
Severity of exacerbation
Can be controlled with an increase in dosage of regular medications
Requires treatment with systemic corticosteroids or antibiotics
Requires hospitalization or evaluation in the emergency department
COPD = chronic obstructive pulmonary disease.
Information from references 4 and 5.
Symptoms of COPD Exacerbation
Body system
Decreased exercise tolerance
Change in volume, color, or tenacity of sputum
Tachypnea
Systemic
Information from references 6 through 8.
Factors that Increase Risk of Severe COPD Exacerbations
Altered mental status
At least three exacerbations in the previous 12 months
Body mass index of 20 kg per m2 or less
Marked increase in symptoms or change in vital signs
Medical comorbidities (especially cardiac ischemia, congestive heart failure, pneumonia, diabetes mellitus, or renal or hepatic failure)
Poor physical activity levels
Poor social support
Severe baseline COPD (FEV1/FVC ratio less than 0.70 and FEV1 less than 50 percent of predicted)
Underutilization of home oxygen therapy
COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in one second; FVC = forced vital capacity.
Information from references 5 through 7, and 9 through 11.
Infection of the tracheobronchial tree and air pollution (e.g., tobacco smoke, occupational exposures, ozone) are the most common identifiable causes of COPD exacerbations. One third of exacerbations have no identifiable cause.6 Other medical problems, such as congestive heart failure, nonpulmonary infections, pulmonary embolism, and pneumothorax, can also prompt a COPD exacerbation.9
The initial evaluation of patients with a suspected COPD exacerbation should include a history of baseline and current symptoms, such as limitations in activities of daily living. If available, previous chest radiographs, arterial blood gas measurements, and spirometry results can help establish the baseline lung function and illustrate a typical exacerbation. Because increasing confusion is a hallmark of respiratory compromise, the physical examination should include a mental status evaluation, as well as heart and lung examinations.
Recommended diagnostic evaluation of an exacerbation depends on its severity (Table 4).5,8,9,12,13 Pulse oximetry should be performed in all patients. Chest radiography is appropriate in hospitalized patients and can guide treatment by revealing comorbid conditions such as congestive heart failure, pneumonia, and pleural effusion. A room air arterial blood gas (ABG) measurement should be obtained at the time of hospital admission to quantify hypercarbia and hypoxemia. Measurement of brain natriuretic peptide and serial cardiac enzyme levels should be considered in hospitalized patients, because cardiac ischemia and congestive heart failure are common comorbidities in patients with COPD.5,12,13
Diagnostic Evaluation of Patients with Suspected COPD Exacerbation
Potential diagnosis
Perform routinely
Hypoxemia
Perform if hospitalized
Arterial blood gas measurement
Hypercarbia
Respiratory acidosis
Chest radiography
Alternate sources of dyspnea
Complete blood count
Polycythemia
Cardiac arrhythmias
Cardiac ischemia
Metabolic panel
Electrolyte disturbances
Hypo- or hyperglycemia
Metabolic acid-base changes
Consider performing, especially if patient is not responding to conventional exacerbation treatment
Brain natriuretic peptide measurement
CHF (one third of dyspnea in chronic lung disease may be attributable to CHF)
Cardiac enzyme measurement
Cardiac ischemia (myocardial infarction is underdiagnosed in patients with COPD)
CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease.
Information from references 5, 8, 9, 12, and 13.
Other physical examination maneuvers, laboratory tests, and assessments of cardiac function have not been proven beneficial in the treatment of COPD exacerbations.9
About 50 percent of COPD exacerbations are not reported to physicians, suggesting that many exacerbations are mild.14 The risk of death from an exacerbation increases with the development of respiratory acidosis, the presence of significant comorbidities, and the need for ventilatory support.5 Patients with symptoms of respiratory distress and those at risk of distress should be admitted to the hospital to provide access to critical care personnel and mechanical ventilation. Inpatient mortality for COPD exacerbations is 3 to 4 percent.9 Patients admitted to the intensive care unit have a 43 to 46 percent risk of death within one year after hospitalization.9
Nonambulatory patients should receive routine pro-phylaxis for deep venous thrombosis. Because COPD is a progressive and often fatal illness, physicians should consider discussing and documenting the patient's wishes concerning end-of-life care.
Oxygen supplementation should be titrated to an oxygen saturation level of at least 90 percent. High-flow oxygen devices deliver oxygen more reliably than nasal prongs, but nasal prongs may be better tolerated. Noninvasive positive pressure ventilation (NIPPV) is indicated if adequate oxygenation or ventilation cannot be achieved using a high-flow mask.15 Patients requiring NIPPV should be monitored continuously for decompensation.
If the patient cannot be adequately oxygenated, complications, such as pulmonary embolism or edema, should be considered.6 Carbon dioxide retention is possible in moderately and severely ill patients; therefore, ABG should be measured 30 to 60 minutes after initiating oxygen supplementation.
Invasive mechanical ventilation is needed if the patient cannot tolerate NIPPV; has worsening hypoxemia, acidosis, confusion, or hypercapnia despite NIPPV; or has severe comorbid conditions, such as myocardial infarction or sepsis.6 Worsening hypercarbia and acidosis herald respiratory failure. A pH of less than 7.36 and an arterial partial pressure of carbon dioxide of more than 45 mm Hg indicate the need for mechanical ventilation.
SHORT-ACTING BRONCHODILATORS
Inhaled short-acting bronchodilators include beta agonists (e.g., albuterol, levalbuterol [Xopenex]) and anti-cholinergics (e.g., ipratropium [Atrovent]). These agents improve dyspnea and exercise tolerance.6,9 The first step in treating a COPD exacerbation is increasing the dosage of albuterol delivered via metered dose inhaler or nebulizer.9 Levalbuterol is more expensive than albuterol but has similar benefits and adverse effects.16 If the patient is not already taking ipratropium, it can be added to the treatment regimen.5 Fixed-dose albuterol/ipratropium (Combivent) is available.
Short courses of systemic corticosteroids increase the time to subsequent exacerbation, decrease the rate of treatment failure, shorten hospital stays, and improve hypoxemia and forced expiratory volume in one second (FEV1).1,6,7,9,17–20 Administration of oral corticosteroids early in an exacerbation decreases the need for hospitalization.21 A randomized controlled trial (RCT) of patients with COPD compared eight weeks of corticosteroids, two weeks of corticosteroids, and placebo; participants in the treatment groups had fewer treatment failures than those in the control group.17 Treatment failure rates were the same for long and short courses of corticosteroids.
High-dosage corticosteroid regimens (methylprednisolone [Solu-Medrol], 125 mg intravenously every six hours) and low-dosage regimens (prednisolone, 30 mg orally daily) decrease the length of hospitalization and improve FEV1 compared with placebo.17,19 [ corrected] An RCT comparing oral and intravenous prednisolone in equivalent dosages (60 mg daily) showed no difference in lengths of hospitalization and rates of early treatment failure.22
Because oral corticosteroids are bioavailable, inexpensive, and convenient, parenteral corticosteroids should be reserved for patients with poor intestinal absorption or comorbid conditions that prevent safe oral intake (e.g., decreased mental status, vomiting).5,6 Inhaled corticosteroids have no role in the management of an acute exacerbation.8
One half of patients with COPD exacerbations have high concentrations of bacteria in their lower airways.6,23 Cultures often show multiple infectious agents, including Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Mycoplasma pneumoniae, and viruses.6,23
The use of antibiotics in moderately or severely ill patients with COPD exacerbations reduces the risk of treatment failure and death.24 Antibiotics may also benefit patients with mild exacerbations and purulent sputum.5 The optimal choice of antibiotic and length of use are unclear. Increasing microbial resistance has prompted some physicians to treat exacerbations with broad-spectrum agents, such as second- or third-generation cephalosporins, macrolides, or quinolones. One meta-analysis showed a lower risk of treatment failure with broad-spectrum antibiotics compared with narrow-spectrum antibiotics (odds ratio = 0.51; 95% confidence interval, 0.34 to 0.75), but no change in mortality rates.25 Another meta-analysis showed no difference in clinical cure rates when broad-spectrum antibiotics were administered for at least five days versus less than five days.26 There is no comparable study of narrow-spectrum antibiotics. The decision to use antibiotics and the choice of antibiotic should be guided by the patient's symptoms (e.g., presence of purulent sputum), recent antibiotic use, and local microbial resistance patterns.18,23,25 Prophylactic, continuous use of antibiotics does not improve outcomes in patients with COPD.6
Parenteral methylxanthines, such as theophylline, are not routinely recommended for the treatment of COPD exacerbations.27 These agents are less effective and have more potentially adverse effects than inhaled bronchodilators.
Several therapies lack adequate evidence for routine use in the treatment of COPD exacerbations, including mucolytics (e.g., acetylcysteine [formerly Mucomyst]), nitric oxide, chest physiotherapy, antitussives, morphine, nedocromil, leukotriene modifiers, phosphodiesterase IV inhibitors (drug class not available in the United States), and immunomodulators (e.g., OM-85 BV, AM3 [neither drug available in the United States]).6,7 Table 5 summarizes the treatment options for acute COPD exacerbations.5,6,8,9,18,25
Treatment Options for Acute COPD Exacerbations
Outpatient management
Inpatient management
Disadvantages/common adverse effects
Typical dosage
Antibiotic, broad spectrum (e.g., amoxicillin/clavulanate [Augmentin], macrolides, second- or third-generation cephalosporins, quinolones)
Consider if sputum is purulent or after treatment failure
Use if local microbial patterns show resistance to narrow-spectrum agents
Decreases risk of treatment failure and mortality compared with narrow-spectrum agents
Antibiotic resistance, diarrhea, yeast vaginitis; side effects specific to the antibiotic prescribed
Amoxicillin/clavulanate: 875 mg orally twice daily or 500 mg orally three times daily for 5 days
Levofloxacin (Levaquin): 500 mg daily for 5 days
Antibiotic, narrow spectrum (e.g., amoxicillin, ampicillin, trimethoprim/sulfamethoxazole [Bactrim, Septra], doxycycline, tetracycline)
Use if local microbial patterns show minimal resistance to these agents and if patient has not taken antibiotics recently
Believed to decrease mortality risk, but has not been tested in placebo-controlled trials
Amoxicillin: 500 mg orally three times daily for 3 to 14 days Doxycycline: 100 mg orally twice daily for 3 to 14 days
Anticholinergic, short acting (e.g., ipratropium [Atrovent])
May add to beta agonist; if patient is already taking an anticholinergic, increase dosage
Improves dyspnea and exercise tolerance
Dry mouth, tremor, urinary retention
Ipratropium: 500 mcg by nebulizer every 4 hours as needed; alternatively, 2 puffs (18 mcg per puff) by MDI every 4 hours as needed*
Beta agonist, short acting (e.g., albuterol, levalbuterol [Xopenex])
Increase dosage
Headache, nausea, palpitations, tremor, vomiting
Albuterol: 2.5 mg by nebulizer every 1 to 4 hours as needed, or 4 to 8 puffs (90 mcg per puff) by MDI every 1 to 4 hours as needed*
Consider using oral corticosteroids in moderately ill patients, especially those with purulent sputum
Use oral corticosteroids if patient can tolerate; if not suitable for oral therapy, administer intravenously
Decreases risk of subsequent exacerbation, rate of treatment failures, and length of hospital stay Improves FEV1 and hypoxemia
Gastrointestinal bleeding, heartburn, hyperglycemia, infection, psychomotor disturbance, steroid myopathy
Oral prednisone: 30 to 60 mg once daily Intravenous methylprednisolone (Solu-Medrol): 60 to 125 mg 2 to 4 times daily
Use if patient cannot tolerate NIPPV; has worsening hypoxemia, acidosis, confusion, or hypercapnia despite NIPPV; or has comorbid conditions such as myocardial infarction or sepsis
Decreases short-term mortality risk in severely ill patients
Aspiration, cardiovascular complications, need for sedation, pneumonia
Titrate to correct hypercarbia and hypoxemia
NIPPV
Use in patients with worsening respiratory acidosis and hypoxemia when oxygenation via high-flow mask is inadequate
Improves respiratory acidosis and decreases respiratory rate, breathlessness, need for intubation, mortality, and length of hospital stay
Expensive, poorly tolerated by some patients
Oxygen supplementation
Use in patients with hypoxemia (PaO2 less than 60 mm Hg)
Decreases mortality risk
Titrate to PaO2 > 60 mm Hg or oxygen saturation ≥ 90 percent
COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in one second; MDI = metered dose inhaler; NA = not applicable; NIPPV = noninvasive positive pressure ventilation; PaO2 = arterial partial pressure of oxygen.
*— Spacer can be used with MDI to improve delivery.
Information from references 5, 6, 8, 9, 18, and 25.
To qualify for discharge, a patient should have stable clinical symptoms and a stable or improving arterial partial pressure of oxygen of more than 60 mm Hg for at least 12 hours. The patient should not require albuterol more often than every four hours. If the patient is stable and can use a metered dose inhaler, there is no benefit to using nebulized bronchodilators.28 Patient education may improve the response to future exacerbations29; suggested topics include a general overview of COPD, available medical treatments, nutrition, advance directives, and advice about when to seek medical help. In-home support, such as an oxygen concentrator, nebulizer, and home health nurse services, should be arranged before discharge.
Smoking cessation, immunization against influenza and pneumonia, and pulmonary rehabilitation have been shown to improve function and reduce subsequent COPD exacerbations.6,7,30 Long-term oxygen therapy decreases the risk of hospitalization and shortens hospital stays in severely ill patients with COPD.7,31,32 The indications for long-acting inhaled bronchodilators and inhaled corticosteroids to improve symptoms and reduce the risk of exacerbations in patients with stable COPD are reviewed elsewhere.5,7,33–38
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ANN E. EVENSEN, MD, FAAFP, is an assistant professor in the Department of Family Medicine at the University of Wisconsin School of Medicine and Public Health, Verona....
Address correspondence to Ann E. Evensen, MD, FAAFP, University of Wisconsin School of Medicine and Public Health, 100 N. Nine Mound Rd., Verona, WI 53593 (e-mail: ann.evensen@uwmf.wisc.edu). Reprints are not available from the author.
Author disclosure: Nothing to disclose.
The author thanks Brian Earley, DO, for assistance in the preparation of the manuscript.
1. Singh JM, Palda VA, Stanbrook MB, Chapman KR. Corticosteroid therapy for patients with acute exacerbations of chronic obstructive pulmonary disease: a systematic review. Arch Intern Med. 2002;162(22):2527–2536....
2. Jemal A, Ward E, Hao Y, Thun M. Trends in the leading causes of death in the United States, 1970–2002. JAMA. 2005;294(10):1255–1259.
3. Stephens MB, Yew KS. Diagnosis of chronic obstructive pulmonary disease. Am Fam Physician. 2008;78(1):87–92.
4. Cazzola M, MacNee W, Martinez FJ, et al., for the American Thoracic Society, European Respiratory Society Task Force on Outcomes of COPD. Outcomes for COPD pharmacological trials: from lung function to bio-markers. Eur Respir J. 2008;31(2):416–469.
5. American Thoracic Society, European Respiratory Society Task Force. Standards for the Diagnosis and Management of Patients with COPD. Version 1.2. New York, NY: American Thoracic Society; 2004. http://www.thoracic.org/go/copd. Accessed January 11, 2010.
6. Rabe KF, Hurd S, Anzueto A, et al., for the Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;176(6):532–555.
7. Decramer M, Nici L, Nardini S, et al. Targeting the COPD exacerbation. Respir Med. 2008;102(suppl 1):S3–S15.
8. Snow V, Lascher S, Mottur-Pilson C, for the Joint Expert Panel on COPD of the American College of Chest Physicians and the American College of Physicians/American Society of Internal Medicine. The evidence base for management of acute exacerbations of COPD: clinical practice guideline, part 1. Chest. 2001;119(4):1185–1189.
9. McCrory DC, Brown C, Gelfand SE, Bach PB. Management of acute exacerbations of COPD: a summary and appraisal of published evidence. Chest. 2001;119(4):1190–1209.
10. Kessler R, Faller M, Fourgaut G, Mennecier B, Weitzenblum E. Predictive factors of hospitalization for acute exacerbation in a series of 64 patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1999;159(1):158–164.
11. Garcia-Aymerich J, Monsó E, Marrades RM, et al., for the EFRAM Investigators. Risk factors for hospitalization for a chronic obstructive pulmonary disease exacerbation. Am J Respir Crit Care Med. 2001;164(6):1002–1007.
12. Mueller C, Laule-Kilian K, Frana B, et al. Use of B-type natriuretic peptide in the management of acute dyspnea in patients with pulmonary disease. Am Heart J. 2006;151(2):471–477.
13. Brekke PH, Omland T, Smith P, Søyseth V. Underdiagnosis of myocardial infarction in COPD—Cardiac Infarction Injury Score (CIIS) in patients hospitalised for COPD exacerbation. Respir Med. 2008;102(9):1243–1247.
14. Seemungal TA, Donaldson GC, Bhowmik A, Jeffries DJ, Wedzi-cha JA. Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2000;161(5):1608–1613.
15. Ram FS, Picot J, Lightowler J, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2004;(3):CD004104.
16. Donohue JF, Hanania NA, Ciubotaru RL, et al. Comparison of levalbuterol and racemic albuterol in hospitalized patients with acute asthma or COPD: a 2-week, multicenter, randomized, open-label study. Clin Ther. 2008;30(spec no):989–1002.
17. Niewoehner DE, Erbland ML, Deupree RH, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group. N Engl J Med. 1999;340(25):1941–1947.
18. Quon BS, Gan WQ, Sin DD. Contemporary management of acute exacerbations of COPD: a systematic review and metaanalysis. Chest. 2008;133(3):756–766.
19. Davies L, Angus RM, Calverley PM. Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Lancet. 1999;354(9177):456–460.
20. Walters JA, Gibson PG, Wood-Baker R, Hannay M, Walters EH. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2009;(1):CD001288.
21. Wilkinson TM, Donaldson GC, Hurst JR, Seemungal TA, Wedzicha JA. Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2004;169(12):1298–1303.
22. de Jong YP, Uil SM, Grotjohan HP, Postma DS, Kerstjens HA, van den Berg JW. Oral or IV prednisolone in the treatment of COPD exacerbations: a randomized, controlled, double-blind study. Chest. 2007;132(6):1741–1747.
23. Sethi S, Evans N, Grant BJ, Murphy TF. New strains of bacteria and exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 2002;347(7):465–471.
24. Ram FS, Rodriguez-Roisin R, Granados-Navarrete A, Garcia-Aymerich J, Barnes NC. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;(2):CD004403.
25. Dimopoulos G, Siempos II, Korbila IP, Manta KG, Falagas ME. Comparison of first-line with second-line antibiotics for acute exacerbations of chronic bronchitis: a metaanalysis of randomized controlled trials. Chest. 2007;132(2):447–455.
26. El Moussaoui R, Roede BM, Speelman P, Bresser P, Prins JM, Bossuyt PM. Short-course antibiotic treatment in acute exacerbations of chronic bronchitis and COPD: a meta-analysis of double-blind studies. Thorax. 2008;63(5):415–422.
27. Barr RG, Rowe BH, Camargo CA. Methylxanthines for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. . 2003;(2):CD002168.
28. Jenkins SC, Heaton RW, Fulton TJ, Moxham J. Comparison of domiciliary nebulized salbutamol and salbutamol from a metered-dose inhaler in stable chronic airflow limitation. Chest. 1987;91(6):804–807.
29. Turnock AC, Walters EH, Walters JA, Wood-Baker R. Action plans for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005;(4):CD005074.
30. Au DH, Bryson CL, Chien JW, et al. The effects of smoking cessation on the risk of chronic obstructive pulmonary disease exacerbations. J Gen Intern Med. 2009;24(4):457–463.
31. Poole PJ, Chacko E, Wood-Baker RW, Cates CJ. Influenza vaccine for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;(1):CD002733.
32. Drummond MB, Dasenbrook EC, Pitz MW, Murphy DJ, Fan E. Inhaled corticosteroids in patients with stable chronic obstructive pulmonary disease: a systematic review and meta-analysis [published correction appears in JAMA. 2009;301(10):1024]. JAMA. 2008;300(20):2407–2416.
33. Singh S, Amin AV, Loke YK. Long-term use of inhaled corticosteroids and the risk of pneumonia in chronic obstructive pulmonary disease: a meta-analysis. Arch Intern Med. 2009;169(3):219–229.
34. Ernst P, Gonzalez AV, Brassard P, Suissa S. Inhaled corticosteroid use in chronic obstructive pulmonary disease and the risk of hospitalization for pneumonia. Am J Respir Crit Care Med. 2007;176(2):162–166.
35. Tashkin DP, Celli B, Senn S, et al., for the UPLIFT Study Investigators. A 4-year trial of tiotropium in chronic obstructive pulmonary disease. N Engl J Med. 2008;359(15):1543–1554.
36. Singh S, Loke YK, Furberg CD. Inhaled anticholinergics and risk of major adverse cardiovascular events in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. JAMA. 2008;300(12):1439–1450.
37. Rabe KF, Timmer W, Sagkriotis A, Viel K. Comparison of a combination of tiotropium plus formoterol to salmeterol plus fluticasone in moderate COPD. Chest. 2008;134(2):255–262.
38. Aaron SD, Vandemheen KL, Fergusson D, et al., for the Canadian Thoracic Society/Canadian Respiratory Clinical Research Consortium. Tiotropium in combination with placebo, salmeterol, or fluticasonesalmeterol for treatment of chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2007;146(8):545–555.
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Dodávaná položka () je hmotné či nehmotné zboží nebo služba vyprodukovaná jako výsledek projektu, který má být dodán zákazníkovi (internímu nebo externímu). Dodávanou položkou může být zpráva, dokument, softwarový produkt, upgrade serveru nebo jakýkoli jiný stavební blok celkového projektu. Dodávaná položka se může skládat z několika menších částí. Může to být buď výsledek, kterého mělo být dosaženo (např. podle formulace "Dodávkou je dosažení ziskovosti v tomto roce"), nebo výstup, který má být poskytnut (např. "Dodávaná položka dokončeného projektu sestává ze speciálního elektronického zařízení a jeho řídícího softwaru").

Některé dodávané položky závisí na jiných, které byly dodány dříve; je to běžné u projektů s více po sobě jdoucími milníky. Tímto způsobem je možné dosáhnout mnoha časových úspor, což může výrazně zkrátit konečnou dodací lhůtu projektu. Tato projekční činnost může být na výkresech znázorněna "oblakem" kolem dosud nenavržené součásti, což znamená: "tato část (popis velikosti nebo jiné vlastnosti) bude studována později". Dokončená část může být "doručena" zúčastněným stranám.

Dodávaná položka se liší od milníku projektu tím, že milník je vyjádření postupu směrem k výstupu, zatímco dodávaná položka je výstup dodaný zákazníkovi nebo sponzorovi. Pro typický projekt může být milníkem dokončení návrhu výrobku, zatímco dodávanou položkou může být technický diagram nebo podrobná zpráva o návrhu produktu.

V technických projektech lze dodávané položky dále klasifikovat jako hardware, software nebo návrhové dokumenty. V rámci smluvního úsilí se může předmět dodávky vztahovat na položku konkrétně vyžadovanou ve smluvních dokumentech, jako je například položka na seznamu požadavků na údaje o smlouvě nebo uvedená v prohlášení o díle.

Odkazy

Reference

Řízení projektů

redpajama_set_name: RedPajamaWikipedia


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Posted by Cango on Fri April 5, 2019 in Cango Wildlife Ranch - Out & About.
Four of the worlds' most beautiful and endangered Tortoises born, just in time to celebrate Easter!
There are few moments as memorable as bearing witness to four critically endangered Radiated Tortoise hatchlings embracing their first day in the world. On 10th of March, a glorious autumn morning, our animal care team experienced exactly such a moment when the hatchlings took their first breath of fresh air. We celebrated their birth for two full weeks, when with pure delight, on the 24th of March another hatchling made his surprise appearance!
A determined mom, who celebrates her 78th birthday this year, had dug two specially excavated holes (15cm – 20cm deep), which incubated four conservation heroes. In both holes/burrows, she laid two clutches consisting of 6 eggs in total, and a magical four survived their life's first great challenge. The incubation period for this species is quite long and could take up to 9 months – but is more than worth the wait!
A very excited Neal Martin (Reptile Curator), has been nurturing them in our Animal Care Centre, to ensure the highest possible survival rate. Their living quarters are kept at a toasty 25 -28 °C, and just to be sure, also includes a cozy 40 °C heat-pad for 'cuddle time'. Their teeny-tiny meals include fresh and juicy foods like baby marrows, green beans, rocket, hibiscus flowers, cucumber & spekboom leaves.
Radiated Tortoise hatchling, slightly longer than a strand of grass
Narinda Beukes, Zoological Director, is the PAAZA (Pan African Association of Zoos and Aquaria) studbook holder for the Radiated Tortoise. A studbook in animal husbandry is an official list of animals within a specific breed whose parents are known. All ethically operating and responsible facilities should be contributing to each species local studbook, to ensure efficient records of the species in a captive environment. We are passionate about keeping appropriate records, as it coincides with their efforts in creating a genetically viable and sustainable group to contribute to the international populace.
The species' name Radiated Tortoise comes from their carapace which is dazzlingly marked with yellow lines radiating from the center of each dark plate of the shell. Although few things surpass a hatchlings' cuteness, good genes surely make good babies and credit must be given to their 78-year-old mom and beautifully marked 33-year-old dad.
Known as the world's most beautiful tortoise, these four siblings are invaluable for a species truly facing extinction. Sadly, beauty has also made them one of the most sought-after tortoises in the world - and history has proved many times over, that humans are capable of awful things. Human consumption and the illegal pet trade have removed many radiated tortoises from the wild, and within their native range, Madagascar, they are now only found seldom and sporadically.
The Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES) has classified the radiated tortoise as an Appendix I species for which there is no legal export or import, yet they often appear in the black-market pet trade in Southeast Asia. Human consumption also remains a major concern in Madagascar, where eerie and emptied shells can be found on the sides of roads – especially over Easter & Christmas.
Thankfully, this will never be the fate for our new residents. Their birth is a milestone for conservation and has brought with it, new hope for the entire species' survival. Though still young, these 6cm hard-shelled gems have a massive role to play in the awareness, education, and preservation of a species, who should we lose them, would leave a very dull and unadorned hole in Mother Natures crown.


Collecting antique clothing can be lots of fun and rewarding. To avoid costly mistakes here are some guides to use.
Condition: Inspect the fabric carefully, a small tear could mean something larger later. Look for repairs, as sometimes these are not done in the best interest of the fabric. A garment in mint condition could fetch a higher price, but might be a better investment in the long run.
Style: Does the garment have beautiful lines and is it well made?
Design: Vintage clothing should have clear lines, quality of structure, color and texture.
Structure: How a garment, or fabric is made is crucial to determining the age and price.
Material: What is it made of, or from? Is there more than one type of workmanship involved, and is the material and workmanship still used today?
Quality: Thought in designing or the care given in workmanship can never be underestimated.
When shopping for vintage clothing have a tape measure handy to measure clothing size and fabric length. Standardized sizing started in the forties as a result of fabric rationing during the war. Taking measurements is the best way to size a garment. Look carefully for rust stains on whites and perspiration stains on all clothing before you purchase, because they are not easy to remove.
But, most of all have fun looking for that great vintage outfit!
I was very excited to find out I had won 3rd place with my 1988 Buick Reatta having entered it in class 21 for non-Ford, Non-Chevy, all, for 1966-1990 model years. I had my car entered for judging last year, but was not available during the judging process and I think this may have hurt my chances. This year I made sure to be with my car because the judges had a lot of questions.
I bought my Reatta in 2014 with money I had earned from a part time job I've had since I was 11 (I'm 14 now). I found the car in Fairfax, VT and paid $640.00 for it. The body of the car was and is in very good condition mainly because the front fenders are made from a plastic polymer and the remaining body panels are double sided galvanized steel. With over 185,000 miles on the car, the complete suspension, braking, and exhaust systems needed to be replaced. As my dad completed repairs on one side of the car, I would try to repeat the process on the other side. Sometimes things worked out, sometimes not so much.
I think I chose to buy a Reatta because our family already had two 1991's and I thought it would be neat to have my own. I like the styling and all the digital instrumentation including a fully functional CRT touch screen that controls the radio, climate control, gauges, trip computer, and full onboard engine diagnostics.
1988 was the first year of production for the Buick Reatta and 4708 were hand built that year at the Craft Center in Lancing, Michigan. All Reattas' are front wheel drive and used GM's popular and "bullet proof" 3.8L V6 engine with a 4spd automatic transmission. The engine produces 165HP but the car weighs 3400 lbs so with these specs, it's performance although acceptable, is lack luster compared to its sporty appearance. I am real happy with my Reatta, but if I could choose any vehicle to own, it would be a Mercedes Benz Unimog.
I will be a Freshman at Lamoille Union High School this fall and have plans to enter into the Auto Tech Center for my Junior and Senior year. My favorite subject in school is science and I think I would like to have a future in either automotive or motor sport repair. I like all things with engines especially if they are vintage. I'm already looking forward to working at and bringing my car back to the Antique & Classic Car Meet next year.


Welcome to the webpage of the Embassy of the Republic of Djibouti in Japan.
Our website also links with other websites of the government ministries, news agencies and organizations to enable the readers to get more information and to gain a broad spectrum of knowledge about Djibouti.
On this site you can learn about our development cooperation with Japan. You can also read about the Djibouti Business Partnership and about business opportunities in Djibouti.
Djibouti and Japan enjoy strong relations, and in the field of development cooperation Japan is one of our most important partners.
High potential for rapid growth and development along with its natural resources, abundant labour force and strategic locations and gradually embracing wide-raging reforms in Djibouti brought tremendous amount of foreign investments into Djibouti recently.
Thanks to harbor, made of modern installations, the railway and the international airport, and the performing telecommunication, there is a great development of Banks, commerce and insurances, depending on the transport. In addition, the country possesses a liberal commercial and financial regime which helps the exchanges with foreign country and insure a stability for its money.
I can assure you that Djibouti is a promising land where one can see the wonderful natural beauties and feel the generosity and hospitality of our people and has various opportunities for the investment.
Djibouti possesses a rich and vibrant cultural tradition. Although Djibouti tourism is traditionally based on cultural, blessed by nature with natural attractions such as cool and scenic places, long rivers, beautiful lakes and many unspoiled beaches and archipelagos, now the eco-tourism and sky diving and sand-yachting in the desert and kite-surfing on the sea are becoming popular for foreign visitors. Scuba diving and fishing are one of the main resources of the country, because the abundance of fauna and flora in the Gulf of Tadjourah makes it a paradise for photographers.
They can dive among beautiful, delicate and colored tree-like coral reefs, specific and privileged shelters for shells of more than twenty species of magnificent fish. The reefs of the Republic of Djibouti are classified among the most beautiful jewels of the tropical underwater world. Underwater hunting is prohibited.
Geological discovery, ornithological observation and archaeological tours represent privileged focus for passionate tourists who want to mix business with pleasure.
I thank you for visiting our website and also for your interest in Djibouti.
GDP per capita: 1423 USD.
Djibouti has also opened its doors to international financial markets and the geographic position, the political and economic stability hearten the development of banking sector.
The country has one of the most liberal economic regimes in Africa banking and commercial sectors are almost unrestricted.
Currently nine international new banks has set up a branch in Djibouti.
In Djibouti any international investor resident or non resident in the country can without any period of time open an account and can also transfer his or her money all over the world tanks to appropriate regulations.
Business and investment projects set upped on the Republic of Djibouti territory are eligible to the preferential rate insurance prime of the Multilateral Investment Guarantee Agency (MIGA) of the World Bank.
Protection of intellectual and industrial properties accordingly to relevant international agreements.
Funding opportunities of Foreign Direct Investments by specialized regional and international financial institutions like International Financial Corporation (IFC) of the World Bank and private sector financing branches of both African Development Bank and Islamic Development Bank.
Dedicated and personalized assistance at the National Investment Promotion Agency's One Stop Shop.


At the intersection of two steep valleys is the site of a castle which shows, by the earthworks which remain, that it once had an inner ward and a large outer enclosure, a formation perhaps developed from a very early motte and bailey castle. Its history is unknown, but in 1244 a wooden castle was documented as being "at Coleshill" which is less than half a mile away. There are also traces of a stone structure from the 13th or 14th century, but it has been established that these had no military purpose.


The day all PSP-owning dungeon-crawler fans have been waiting for since early February finally has arrived: boxed copies of the English version of Class of Heroes 2 are now available for purchase at gaijinworks.com.
Initially, I wasn't too pleased with the $36.99 price tag that's been attached to this release, but I've since softened a bit because it includes shipping as well as a physical copy of Class of Heroes 2 and a download code for the digital iteration of this portable RPG.
Anyway, I just handed over my hard-earned cash for a copy. Are any of you planning to do the same before this pre-sale drive ends on May 8?
Saw the email when I got home today and went straight out to put money on my credit card to but it. Have it booked now. Even though I'm paying extra from international shipping it's still a good bit less than a physical release here.
Still can't bring myself to buy it, Bryan! :P Glad to see it's finally out, though. Unfortunately it looks like they had to take the opening animation due to some legal issues?
Don't feel bad, Anne. It really doesn't sound like your kind of thing, and in such cases why buy a game you aren't really interested in?
As for the opening animation being cut: yep, that's the case, as far as I'm aware. I don't much care, though, as it sounds like the opening wasn't all that amazing to begin with.
Isn't the opening animation in the digital version? I'm not sure and could be wrong but heard something a little to that effect.
Oh, sure, Ziggy, stomp on my hopes and dreams! Just kidding :) Honestly, I don't much care if it's good or bad at the moment--I just want a copy of it and a chance to experience it in English. I'll let you know what I think of it regardless, though!


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Watches of Switzerland debuts at...
Watches of Switzerland debuts at the new Encore Boston Harbor
US expansion continues for the luxury timepiece retailer as it opens its fourth store in less than a year
Watches of Switzerland has debuted a new boutique at the just opened Encore Boston Harbor. Designed by New York-based architecture firm MNA, the aesthetic of the boutique follows the Watches of Switzerland global retail concept - minimalist, yet luxuriously appointed. The storefront is clad in Spanish marble and the interior is lined in a zebra grass wall covering with white oak trim and wall board. The space features dedicated areas for Hublot and Panerai, as well as a private consultation room for VIP clients. Standalone boutiques for Omega and IWC, that Watches of Switzerland will operate, are located just next- door and accessed through an entry vestibule that will highlight emerging and artisanal watch brands. For the opening, these include offerings from Franck Muller, Ressence, Bovet, and Jacob & Co. that range in price from $2,500 to $340,000. Jacob & Co. will also showcase a small selection of exceptional jewelry.
Encore Boston Harbor is the second Wynn Resorts collaboration for Watches of Switzerland. It opened a boutique in the Esplanade at Wynn Las Vegas in December 2018. This new 3 million- square-foot Encore casino-resort is located just across the Mystic River from the city of Boston and is in close proximity to Logan International Airport. It is expected to attract national and international guests, as well as a local Boston clientele. The expansive property is opulently appointed with, red venetian glass chandeliers, an iconic floral carousel and a curated selection of world-class art throughout, including Popeye, by Jeff Koons and Jaume Pensa's 10-foot stainless steel sculpture portraits along the Harborwalk. The Watches of Switzerland boutique occupies a premium position aside the casino entrance and is expected to be a major shopping destination for guests.
"We are thrilled to now have a presence in Boston and continue our partnership with Wynn Resorts. Their best-in-class approach echoes our own, and we look forward to offering the finest Swiss timepieces along with an unparalleled customer experience to their discerning guests."
Brian Duffy CEO the Watches of Switzerland Group
Opening at Encore Boston Harbor is a key component of Watches of Switzerland's strategic US expansion plan that in addition to Las Vegas includes two flagship Manhattan boutiques, one in SoHo and the other at Hudson Yards. Watches of Switzerland plans to open in the new American Dream shopping complex in the New Jersey, Meadowlands later this year.


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Earth, Wind & Fire That's The Way Of The World Numbered Limited Edition 180g LP
Label: Impex
IMXLP6015
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Limited To 2500 Numbered Copies!
180 Gram Vinyl! Cut from the Original Analog Master Tapes by Kevin Gray and Robert Pincus! Pressed at RTI!
Rolling Stone 500 Greatest Albums of All Time - Rated 420/500!
This item not eligible for any further discount offers!
The 1975 album "That's The Way Of the World" was also the soundtrack for a 1975 motion picture of the same name which featured some of the band members of Earth, Wind, & Fire in cameo roles. The album includes the ballad "Reasons" alongside the #1 US pop and R&B hit single "Shining Star" as well as the title track which reached #12 on the pop chart.
"Before he got into African thumb pianos and otherworldly philosophizing, EWF founder Maurice White was a session drummer at Chess Studios. EWF's sixth album is make-out music of the gods." - rollingstone.com
"Earth, Wind & Fire has delivered more than its share of excellent albums, but if a person could own only one EWF release, the logical choice would be That's the Way of the World, which was the band's best album as well as its best-selling. Open Our Eyes had been a major hit and sold over half a million units, but it was World that established EWF as major-league, multi-platinum superstars. Fueled by gems ranging from the sweaty funk of "Shining Star" and "Yearnin' Learnin'" to the gorgeous ballad "Reasons" and the unforgettable title song, EWF's sixth album sold at least five million units. And some of the tracks that weren't major hits, such as the exuberant "Happy Feelin'" and the gospel-influenced "See the Light," are equally powerful. There are no dull moments on World, one of the strongest albums of the 1970s and EWF's crowning achievement." - allmusic.com
• 180 Gram Vinyl
• Limited To 2500 Numbered Copies!
• Cut from the Original Analog Master Tapes by Kevin "Dr. Groove" Gray and Robert "Mr. Record" Pincus
• Pressed at RTI
• Gatefold Jacket
1. Shining Star
2. That's the Way Of the World
3. Happy Feelin'
4. All About Love
1. Yearnin' Learnin'
2. Reasons
3. Africano
4. See the Light
Earth, Wind & Fire That's The Way Of The World 180g LP
Earth, Wind & Fire Earth, Wind & Fire LP
Earth, Wind & Fire That's The Way of the World LP
Earth, Wind & Fire That's The Way Of The World Numbered Limited Edition 180g LP Scratch & Dent
Earth, Wind & Fire That's The Way Of The World Limited Edition 180g LP
Availability: Awaiting Repress
The Eagles One of These Nights Numbered Limited Edition 180g 45rpm SuperVinyl 2LP Box Set
The Dave Brubeck Quartet Time Further Out: Miro Reflections 180g LP
Elliott Smith Alternate Versions from Either/Or 33rpm 7" Vinyl (White Vinyl)
Nick Harley Easy Moon LP
Carmell Jones The Remarkable Carmell Jones (Blue Note Tone Poet Series) 180g LP
Andrew Hill Dance with Death (Blue Note Tone Poet Series) 180g LP
Phish LP on LP 04 (Ghost 5/22/00) LP (Color Vinyl)
Anne Bisson Be My Lover Hand-Numbered Limited Edition 180g 45rpm 2LP (Autographed)


We need a dynamic Masters student to help us tackle a major challenge... have you got what it takes?
A student in engineering, logistics, industrial finance, or an equivalent subject?
Able to speak English and Swedish?
Sika doesn't just sell products - we offer our customers technical and customer service that is unrivalled in our industry. Without our chemists, technical product experts, and everyone in the local Sika team we would not be who we are today. But how can we make sure everyone is connected to sales and understands the customer journey?
sim-ple way to help us make sure that it's working for our company.
deliveries of these products to our customers.
Sweden's teams. Is anyone dropping the ball? And if so where and how?


We will eventually add our 2 year old to this room once she is out of her crib. I wanted to make a room with decor that could grow with them versus being so baby like.
The room had this beautiful crystal chandelier that inspired all the sparkle in this room.
Serena and Lily for bedding. Home Goods for rug, art and crystal items in bathroom. ETSY for Hermes Paper Baby Carriage. ETSY for hanging crystals. Luna Bazaar for paper lanterns and poms for hanging paper grouping.
Hang the lanterns and poms up one at a time on a screw in loop. Arrange after you get the heights that you like. Combine new and old like new bedding and vintage furniture and save money by using stores like Home Goods for accessories.
This is such a pretty girly room. Love the colors and all the feminine elements. It's really perfect for sisters!


These crazy Brits are messing with the abscess caused by getting a really hideous tattoo. At least they claim to have sterilized the tweezers first! The running commentary is priceless, as are the girl's fingernails. This is a good reminder that if you are going to get a tattoo, you need to keep it clean to prevent infection.


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Hump Day Report It's America…We Can Get Over The Hump!
Hump Day Report: Who's A Wimp?
ALOHA, ALL!! You've no doubt heard about or seen the Newsweek cover claiming Romney has a "wimp factor" problem. Well, I think it's fair to call someone a wimp on the cover of a national rag OOPS! publication. In fact, here are some future covers that Newsweek may want to consider
I like the more appropriate spelling of the publication on this one:
So what gives Newsweek the basis for calling Romney a wimp? I guess just…well…because. But if you want to see a champion, gold-medal-worthy wimp, look no further than Dirty Harry Reid. This guy is in a different league! He now claims to have an anonymous source telling him that Mitt Romney hasn't paid taxes for 10 years: Romney Is Guilty Of My Evidence-Free Accusations Until He Proves Himself Innocent Bravo, wimp extraordinaire!!!!! What's next, calling Romney a felon? Oh yeah, that already happened. Anyhow, Harry, we'll always remember this classic speech from you:
Gee – I wonder what Harry Reid's Senate will do? House Extends All Bush-Era Tax Rates "With lawmakers about to leave Washington for a five-week recess, the House action amounts to little more than a campaign message. Both parties have jumped headfirst into the tax debate, a confidence reflected in the political votes the Democratic-controlled Senate and GOP-led House have taken in consecutive weeks."
Meanwhile: Has Any Administration Policy NOT Killed Jobs Lately? "Reid is a major driver of these tax increases and job-killing policies. He has abused his authority as majority leader to block the minority party from the opportunity to offer amendments more than 60 times, more than all of his predecessors combined." TODAY'S JOBS REPORT: The unemployment rate ticked up to 8.3 percent, 12.8 million Americans are out of work, and 5.2 million have been out of work for at least a half a year. NOTE: the real unemployment rate – including unemployed and underemployed – is now 15%.
Definitely not a wimp! America's Jewish Gymnastics Star Clinches Gold To The Tune Of 'Hava Nagila' "Watching a strong, beautiful Jewish woman finish her last tumbling pass, triumphant, as the whole stadium clapped along to a Hebrew folk song of celebration was a great moment— a moving, joyous contrast to Munich and an example of the kind of cultural tribute that's unstoppable in free people, no matter what the IOC says." Take that, IOC! BTW…Aly was the one who was actually singing the National Anthem as the Stars and Stripes were raised! And how about that Gabby Douglas???? USA! USA!
Of course, the IRS will get its share of those Olympic medals (Shaka to George for the link). Win A Medal, Pay The Price "That prize money is taxed at a rate of as much as 35 percent, Americans for Tax Reform calculated. On top of that, the medals themselves are taxed: You only have to fork over $2 to the IRS for the privilege of keeping your bronze medal, but carve off $236 worth from that gold medal." Marco Rubio thinks this is wrong: Rubio Introduces Bill To Eliminate Olympic Medal Tax "Rubio's Olympic Tax Elimination Act would amend the Internal Revenue Code of 1986 to strike taxes on American athletes' Olympic medals and prize money. The law would retroactively apply to Olympic winnings after December 31, 2011."
We Ate Mor Chikin!! Chick-fil-A Americans Give Big Government The Bird "Millions of Americans across the country lined up for hours to buy chicken sandwiches — and take a stand for free speech. That's a de facto demonstration, from a public fed up with overweening big government." I got emails from many of you across the country about how the crowds were phenomenal! I especially like this story from HDR reader Steve: Ted Cruz Serves Chick-fil-A At Victory party Read more about Ted Cruz here: Tea Party Staying Power – The Ted Cruz Victory He's a rising star! I saw him speak in Hawaii once – great guy!
Want to make a tangible difference in the November election? Especially the swing states of Virginia, Ohio and North Carolina? Go to the Smart Girls Politics 'Heels on the Ground' campaign! They need volunteers in these key states…and we know face-to-face interaction is very effective in persuading swing voters. Can't be in Virginia, Ohio or North Carolina? Donate! Go HERE to help support this effort. Each $25 donation helps Smart Girls knock on 50 doors!!!! On a personal note: I belong to this organization and can vouch for their authenticity – Smart Girls Mean Business!!!
It's Friday – time for NewsBusted!!
Final Thought: "Freedom isn't for wimps." Neal Boortz
GOD BLESS AMERICA – PASS THIS ON – REMEMBER IN NOVEMBER – 94 DAYS AND COUNTING!!
Newsweek: That heartless vampire capitalist is kind of a … wimp? (hotair.com)
Tags: Aly Raisman, Chick-fil-A, Harry Reid, Marco Rubio, Mitt Romney, NewsBusted, Newsweek, Olympics, Smart Girl Politics, Ted Cruz, Unemployment
About giliar
An American patriot who has gone rogue - I will remember in November!
View all posts by giliar »
5 responses to "Hump Day Report: Who's A Wimp?"
Carl says : August 3, 2012 at 5:06 pm
EXCLUSIVE—MUST CREDIT ACE OF SPADES HQ: Harry Reid's Office Responds To Rumors That He's A Pederast
As you know by now, when baseless but serious charges are laid against a powerful political figure, it is the responsibility of the maligned individual to prove their innocence.
With that understanding, I requested comment from Harry Reid's office on the swirling charges that someone said they heard from someone that Harry Reid is pederast.
The email response from Reid Spokesman Adam Jentleson can only be characterized as chilling:
First, note the non-denial. Based on the rumors we've all heard, we can only conclude that at best questions of Reid's abuse remains an open question.
Second, "Cute" is not how I would describe this situation. Senator Reid has been accused by multiple unnamed figures as a serial abuser. The fact that Reid's spokesman thinks anything about this situation is "cute" is disturbing and only leads to more questions about the unreleased records that might (or might not) clear Senator Reid's name.
We will of course be following up on this explosive and developing story….for the children.
In fairness to Harry Reid, does he look like the kind of creepy old man who sees a young boy and thinks, "tasty"?
Hmmm, forget I asked.
giliar says : August 3, 2012 at 6:43 pm
Wow! Will keep updated on this. Thanks, Carl.
neenergyobserver says : August 3, 2012 at 5:14 am
"Watching a strong, beautiful Jewish woman finish her last tumbling pass, triumphant,…"
Very close to the quote of the year, top 5 certainly!!!
The teens are turning into the decade of the conservative woman, and the "Smart Girls" lead. I'm very proud to have a couple of you as friends. You girls are the absolute best!! 🙂
Love those covers, too.
giliar says : August 3, 2012 at 5:19 am
Mahalo, NEO!! I can honestly say that Smart Girl Politics is one of the best groups out there for conservative women activists! I'm privileged to be a part of the group and editor of the Smart Girl Nation magazine. Teri Cristoph and Stacy Mott, founders of SGP, are tireless, dedicated workers. There are some smart guys involved, too 😉
I know Giliar, it absolutely is, I'm one of the organization's fans, although I didn't know you had any guys involved. Love the magazine too! 🙂


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Obsessive-Compulsive Personality Disorder |
Obsessive-Compulsive Personality Disorder Treatment
Apr 11, 2006 Viewed: 843
The literature describing the treatment of OCPD is somewhat confusing because of a lack of clear distinction between OCPD and OCD. This is especially true of the older literature and the earlier pharmacological studies reporting efficacy in obsessional syndromes. Generally, symptoms of OCPD have not been regarded as responsive to biological interventions. Favorable treatment responses to a variety of psychotherapies are consistently described. Intensive dynamic therapies, including psychoanalysis, continue to be recommended as the treatment of choice for OCPD.
No medications specific for the treatment of OCPD are currently available. The serotonin reuptake inhibitors used in the treatment of OCD have not been carefully studied in the OCPD population. There are a few anecdotal reports of the efficacy of these medications in patients with OCPD, but controlled studies are lacking. Nonspecific anxiolytic agents may be used, but the chronic nature of OCPD presents the potential problem of medication dependency. Swartz (1998) reported that betaxolol, a long-acting ÞÂ-adrenergic blocker, was useful in anxious patients with OCPD. Antidepressants may be useful in OCPD patients with significant depressive symptoms. One study reported that the presence of compulsive personality disorder was a positive predictor of response to serotonergic antidepressants. Ekselius and von Knorring reported that patients with comorbid major depression and OCPD responded to sertraline or citalopram with a reduction in OCPD symptoms.
History and Theoretical Perspective
Brief Psychotherapy
Short-term individual therapy may be useful for patients with OCPD, especially those in crisis. Specific, focused goals in helping the individual accommodate to change can be accomplished in a limited number of sessions, generally 10-20. Suess suggested that focusing on validation of the patient's current feelings will help to relieve guilt, self-doubt, and fear and that growth and change are possible within the limits of short-term therapy.
In one study of a 16-session brief therapy, moderate changes in personality, a decrease in negative and ambivalent self-references, and an increase in positive self-references were reported. Procrastination and narcissism also decreased. Because long-term psychotherapy is becoming less available for many patients, further study of the efficacy of brief therapy for OCPD is indicated.
Some authors report a favorable response in OCPD patients treated in the group setting. Confrontation of the patient's defenses may be more effective in group therapy settings than in individual treatment. Issues that can be confronted in the group setting include modification of cognitive style, assistance with decision making, modification of harsh superego, increased comfort with emotional needs, increasing comfort with affective experience, resolution of control issues, and modification of interpersonal style. Advantages of group therapy include a diffusion of power among group members, which lessens the potential for the "tug-of-war" that is common in individual treatment, as well as an opportunity to develop trust in a number of group members.
Group consensus and peer pressure may lessen resistance. The emphasis on here-and-now interaction among the group members brings conflicts to life. The therapeutic process within the group, with its potential for alternating roles, helps to increase patient flexibility.
Cognitive and Behavioral Therapy
Although much of the data on cognitive treatment have focused on affective illness, exploring the exaggerated perception of risk in obsessional patients may be helpful in diminishing their anxiety (Hamilton and Alagna 1984). Various behavioral treatments, especially exposure with response prevention, have been very efficacious in the treatment of rituals in OCD patients. In patients with obsessional thinking without compulsive behaviors, this treatment is much less useful. Because the thinking of patients with OCPD tends to be ego-syntonic and not intrusive, behavioral approaches do not appear to be helpful.
Dynamic Psychotherapy and Psychoanalysis
Individual psychodynamic psychotherapy or psychoanalysis continues to be the treatment of choice for patients with OCPD. Although formal outcome studies evaluating the efficacy of these treatments have not been carried out, decades of good experience with these admittedly time-consuming approaches have persuaded most clinicians of their value.
Indirect and uncompelling empirical support for this treatment derives from Winston et al., who described 25 patients with Cluster C disorders who were treated with dynamic therapy for a mean length of 40.3 sessions. Although many patients will require longer treatment, those in this sample improved significantly by all measures compared with others on a waiting list. Follow-up at an average of 1.5 years showed continued benefit. In an uncontrolled study, Barber et al. reported on 14 patients with OCPD treated with 52 sessions of time-limited supportive-expressive dynamic psychotherapy. By the end of treatment, only 15% of the patients retained their diagnosis.
Next article Clinical Challenges in Dynamic Psychotherapy of Obsessive-Compulsive Personality Disorder » »
Revision date: June 18, 2011
Last revised: by David A. Scott, M.D.
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STRAC designed, developed, and deployed a data collection system for the region, EMS Patient Care Records (ePCR), which is used by over 60 agencies and contains over 2.5 million records. In tandem, STRAC developed a regional Trauma Registry with an outside vendor, which has been implemented at 25 of the 31 designated trauma facilities in TSA-P and holds over 175,000 records in the trauma registry.
STRAC operates MEDCOM, a regional coordination center which facilitates trauma transfers to the appropriate level of care in the TSA-P area and adjacent Trauma Service Areas. Given the plethora of data elements and the strategic partnerships harnessed through stakeholder engagement, STRAC has conducted research in the areas of Trauma, Stroke, and Cardiac care.


We've seen a lot of artists and producers turn their hand at classical music by having their original music reworked by a full orchestra. From Armand van Helden to Pete Tong, Eskimo Joe to Pink Floyd, the genres of rock, pop and dance never had it so large.
Now it's Basement Jaxx's turn. The esteemed electronic duo are bringing their orchestral live show to Australia this month, featuring The Metropolitan Orchestra.
The tour opens up in Melbourne on Saturday 13 April and moves on to Sydney on Sunday 14 April before winding up in Brisbane on Thursday 18 April.
Cream has two double passes to each of the shows to give away. Simply email your name, address and Subject heading 'Basement Jaxx' (along with the city you'd like to see the concert in) to cream@pobox.com no later than 5pm AEST, Friday 5th April, 2019.