Australian spray tanners know their stuff; they lead the world in terms of professional tanning and with over 80 professional brands to choose from, they can afford to be discerning.
Since MoroccanTan launched there in 2011, it has captured the attention of tanning pros all over the country with salons loving the MoroccanBlend™ formula and DermalLock™ technology, both of which help to promote the perfect long lasting tan with luxurious results.
Enriched with nourishing vitamins and organic ingredients including organic argan oil, the luxurious tanning formulas of MoroccanTan absorb deep into the skin for a beautiful bronzed glow that leaves the skin soft and silky.
With 30 minutes to 2 hour formulas, it is easy to create the perfect, streak-free spray tan that is long lasting and provides a natural, gradual fade.
With its organic formula it uses deep absorbing Argan Oil, an antioxidant rich in Vitamin E sourced from Southwest Morocco, to nourish the skin.
MoroccanTan helps soften and moisturise the skin, producing a deep bronze tan that leaves the skin soft and silky. The flawless, streak-free tanning solution, helps hydrate the skin, making your spraytan last longer.
With wash off times from 30 mins to 2 hours, who says theres not enough time for a tan!
Gives the deepest, darkest olive colour, perfect for mediterranean skin.
Suitable for all skin types, MoroccanCoco is the darkest solution from the Original Collection and gives the deepest, darkest olive colour.
The MoroccanAccelerated 30 minute formula delivers a dark, natural and intense finish with the skin emerging supple, smooth and deeply bronzed. Containing new natural odour inhibitors, delivery systems ensuring faster absorption of DHA and Melanin Tanning technology, this newly formulated product works to hydrate and replenish the skin.


text:
These Women Who Don't "Fit the Mold" Will Take Your Breath Away
Fit the Mold Mannequin Photo Series
September 22, 2017 by Lauren Levy
After a friend gave Julia Busato a mannequin in 2015, she realized that she had the potential to create something incredible.
The bare mannequin inspired this talented photographer to create a body-positive photo shoot to promote self-love. "My friend said she would love to flip the bird at society's standards, so we grabbed the mannequin and started shooting," Julia told POPSUGAR. "From there it just evolved as more people came forward asking to be part of it."
Each person who volunteered to strip down and pose showed exactly what it looks like when women don't "fit the mold," and their diverse beauty is breathtaking. "Each person has their own personal story about how they don't fit the standards expected from society," Julia said. "It's not just about weight anymore; it's about being happy in your own skin."
Julia wants everyone to see the strength that people radiate when they completely embrace who they are. She also hopes that people realize that the women in her photos aren't models — they are everyday women who are using the mannequin in different ways to express their personal stories. "The stories of struggle, courage, and triumph that I hear while planning the shoots touches my soul and motivates me to keep going," Julia said. "Their stories are theirs to tell, but they range from body issues to mental issues and physical health. I'm giving them an outlet to share their stories and help them heal."
This powerful series is still in progress, as Julia plans to continue adding subjects until it feels complete. "It lets people know that they aren't alone and it's OK to be different than the norm," Julia said. "I feel that it is so important for us all to band together and realize that we are all human, need love and support now matter our statues or body size."
Check out the incredible photos ahead!
PhotographyWomenFeminismBody ImageFemale EmpowermentReal People Stories
When I Finally Have a Wedding After COVID-19, I'm Not Going to Care How Much I Weigh
by Dyana Goldman 4 days ago
Meena Harris's New Kids' Book Proves There's No Such Thing as Being "Too Assertive"
by Murphy Moroney 1 week ago
I'm Trying to Stop Taking "You've Lost Weight" as a Compliment, and It's Harder Than I Thought
by Shannon Vestal Robson 4 weeks ago
I'm Working Out Less Than I Have in Years, and I Feel Healthier
by Elizabeth Enochs 12/16/20
"I Have Never Been More Grateful For My Body," Allyson Felix Says After Overcoming Body Image Struggles
by Tamara Pridgett 12/15/20
Iskra Lawrence Stopped Working Out For Looks: "I Get Accomplishment, Fulfillment, and Energy"

redpajama_set_name: RedPajamaCommonCrawl


Then, within the body, you must include an event attribute to trigger a session start. In most cases, this will be an onclick event attribute on an anchor or button element. With this event, call the BG.start method, using the arguments to start the session with session key submission, representative selection, or issue submission.
Your HTML page must have a valid standards-compliant Doctype. View recommended Doctype declarations at http://www.w3.org/QA/2002/04/valid-dtd-list.html.
Below are several examples of the script.
Several common examples are listed below, though more are possible. Each of the sessions below can be called as any of the three session types by changing the start type to BG.START_TYPE.CHAT, BG.START_TYPE.BROWSER, or BG.START_TYPE.FULL.
Click-to-chat sessions may have an additional uiOptions object.
sessionKey String Exclusive - Start Method The numeric session key.
rep Object Exclusive - Start Method An object identifying the representative with whom to start the session. See the table below.
A DOM element specifying the support issue. The DOM element can be retrieved using document.getElementById('id'). See the table below.
An object specifying the support issue. See the table below.
skills Array No The skills to apply to this session for the purpose of routing. Can be combined with any start method.
customer Object No An object providing information about the customer. Can be combined with any start method. See the table below.
The locale code of the language to be used for this customer client. The language must be installed on your Secure Remote Access Appliance. To see which languages are installed, go to /login > Localization > Languages.
Available language packages may include English (en-us), German (de), Latin American Spanish (es), EU Spanish (es-sp), Finnish (fi), EU French (fr), Italian (it), Dutch (nl), Brazilian Portuguese (pt-br), EU Portuguese (pt-pt), Swedish (sv-se), Turkish (tr), Japanese (ja), Simplified Chinese (zh-hans), Traditional Chinese (zh), and Russian (ru).
attributes Object No Session attributes. Can be combined with any start method. See the table below.
uiOptions Object No User interface options. Available only for Click-to-Chat sessions. See the table below.
Only one of the properties marked as Exclusive - Start Method should be specified.
id Integer Required The representative's unique ID number. To get a representative's ID, see API Command: get_logged_in_reps.
name String Required The representative's public display name.
id Integer Exclusive - Issue Identifier The support issue's unique ID number. To get a list of issue IDs, see API Command: get_support_teams.
codeName String Exclusive - Issue Identifier The support issue's unique code name.
Only one of the properties marked as Exclusive - Issue Identifier should be specified.
name String No The customer's name.
company String No The customer's company name.
company_code String No The customer's company code.
details String No A description of the customer's problem.
The external key to associate with the session.
[custom field] String No The code name and value of any custom fields. These fields must first be configured in /login > Management > API Configuration.
fallbackToFullWindow Boolean No Only used with click-to-chat sessions. If true, then a full-screen browser window will be used to render the click-to-chat client if a pop-up window cannot be created.
ClickOnce - A session started in Internet Explorer uses the ClickOnce technology to attempt to download and run the BeyondTrust customer client.
Java applet download - A Java applet launches, which attempts to download and run the BeyondTrust customer client.
If the user has previously selected to remember the BeyondTrust customer client applet (even from another site), then the applet launches with no prompts.
Otherwise, the user is prompted to run the applet or to cancel.
If the user chooses to run the applet, then the applet proceeds to launch the customer client.
The Java applet requires Java 5+. Users who do not already have Java will not be prompted to download or install Java; the launch method will merely fall back to another download mechanism. If Java cannot be reliably detected, it will be assumed that Java is unavailable.
Manual launch - If the user cancels all dialogs, they can click a link to re-trigger the download.
Mobile display - Behavior varies on the type of session being requested.
For a full-client session, the device is searched for the BeyondTrust customer client app.
If the app is already installed, the app opens, and the session automatically begins.
If the app is not installed, a browser dialog provides a link to install the BeyondTrust customer client app from the device's app store. Once the app is installed, the second link in the browser dialog provides a method to start the session.
Because collaborative browser sharing is not currently supported on mobile devices, mobile users receive a message indicating that browser sharing is not available.
For the sake of appearance, opening click-to-chat in an appropriately sized window is the recommended method. A window that is not properly sized will function correctly but will result in disproportionate margins.


Pursuing an MBA is a significant investment of time, money and energy. Continuing education requires sacrifice, and the level of commitment required leaves many prospective students wondering: Should I get my MBA at all? You're the only one who can determine if an MBA is worth it for you. To help you sort it out, here are some more specific questions you can ask to help you determine why an MBA might be the right answer for you.
Am I Hungry for New Skills and Knowledge?
Fifty-seven percent of MBA students report the desire to learn more as their No. 1 reason why an MBA appeals to them.1 There is no doubt about it, business school can be challenging, but it's also an intellectually stimulating, dynamic way to grow your skill set and knowledge base. If you're motivated by a thirst for knowledge and if you respond well to an academic setting, you'll make an excellent candidate for an MBA program.
Do I Know the Next Step in My Career?
If the answer to this question is "I'm not sure" or "Yes, but I don't know how to get there," then you might consider heading back to school. The broader question of "Should I get my MBA?" isn't just about whether you could use new skills or knowledge; it's also about your specific direction and goals. Earning your MBA is a great investment for people who feel like they've hit the ceiling of their career development opportunities at their current job or have maxed out their earning power in their field.2 If you're feeling stuck, an MBA is an outstanding way to leverage your skills and experience to move into a leadership role.
Am I Ready for a Big Change?
Is My Network Cutting It?
Do I Want to Make More Money?
It's no secret: A higher salary is one of the key factors that can make an MBA worth it. In 2018, many MBA graduates fielded salary offers in the low six-figures.5 Even if you don't have a concentration in a high-paying field like finance, MBA graduates can still expect to earn starting salaries that are on average 47 percent higher than those for business bachelor's degree graduates.6 While increased earning power isn't the only reason to apply for business school, it helps to justify the sacrifices you'll have to make to earn that diploma.
One Last Question: Are You Ready?
There is actually one more important consideration that goes a long way to answering the question "Should I get my MBA?": timing. Is now the right time? Do you feel ready to dedicate yourself to a new chapter in your career? Can you afford it right now?
Though there's never a perfect time to go back to school, an affordable, flexible program like the online MBA from the KU School of Business can help make today the ideal time for you. KU offers you the freedom to choose when to complete your coursework, and you can be sure you'll have the support you need to follow through and succeed at every step along the way.


text:
package com.caricah.iotracah.server.httpserver.transform;

import com.caricah.iotracah.bootstrap.data.messages.*;
import com.caricah.iotracah.bootstrap.data.messages.base.IOTMessage;
import com.caricah.iotracah.server.transform.MqttIOTTransformer;
import io.netty.handler.codec.http.FullHttpMessage;
import io.netty.handler.codec.http.FullHttpRequest;
import io.netty.util.CharsetUtil;
import org.json.JSONArray;
import org.json.JSONObject;
import org.slf4j.Logger;
import org.slf4j.LoggerFactory;

import java.nio.ByteBuffer;
import java.util.AbstractMap;
import java.util.ArrayList;
import java.util.List;
import java.util.Map;

/**
 * @author <a href="mailto:bwire@caricah.com"> Peter Bwire </a>
 * @version 1.0 9/23/15
 */
public class HttpIOTTransformerImpl implements MqttIOTTransformer<FullHttpMessage> {

    private static final Logger log = LoggerFactory.getLogger(HttpIOTTransformerImpl.class);

    @Override
    public IOTMessage toIOTMessage(FullHttpMessage serverMessage) {

        if (serverMessage instanceof FullHttpRequest) {

            FullHttpRequest request = (FullHttpRequest) serverMessage;
            final String content = request.content().toString(CharsetUtil.UTF_8);
            final JSONObject json = new JSONObject(content);

            log.debug(" toIOTMessage : received content {} ", content);

            final String path = request.uri().toUpperCase();

            switch (path) {

                case "/CONNECT":

                    boolean isAnnonymousConnect = (!json.has("username") && !json.has("password"));

                    int keepAliveTime = json.has("keepAliveTime")? json.getInt("keepAliveTime"): 0;

                    return ConnectMessage.from(
                            false, 1, false,
                            "MQTT", 4, false, isAnnonymousConnect, json.getString("clientId"),
                            json.has("username") ? json.getString("username") : "",
                            json.has("password") ? json.getString("password") : "",
                            keepAliveTime, "");

                case "/PUBLISH":

                    ByteBuffer byteBuffer = ByteBuffer.wrap(json.getString("payload").getBytes());

                            PublishMessage publishMessage = PublishMessage.from(
                                    json.getInt("messageId"),
                                    json.has("dup") && json.getBoolean("dup"),
                                    1, json.has("retain") && json.getBoolean("retain"),
                                    json.getString("topic"), byteBuffer, true);

                    publishMessage.setSessionId(json.getString("sessionId"));
                    publishMessage.setAuthKey(json.getString("authKey"));
                    return publishMessage;

                case "/SUBSCRIBE":

                    SubscribeMessage subscribeMessage = SubscribeMessage.from(1, false, 1, false);

                    JSONArray jsonTopicQosList = json.getJSONArray("topicQosList");
                    for(int i=0; i< jsonTopicQosList.length(); i++) {
                        JSONObject topicQos = jsonTopicQosList.getJSONObject(i);

                        String topic = topicQos.getString("topic");
                        int qos = topicQos.getInt("qos");

                        Map.Entry<String, Integer> entry =
                                new AbstractMap.SimpleEntry<>(topic, qos);
                        subscribeMessage.getTopicFilterList().add(entry);
                    }
                    subscribeMessage.setReceptionUrl(json.getString("recipientUrl"));
                    subscribeMessage.setSessionId(json.getString("sessionId"));
                    subscribeMessage.setAuthKey(json.getString("authKey"));

                    return subscribeMessage;

                case "/UNSUBSCRIBE":

                    List<String> topicList = new ArrayList<>();
                    JSONArray jsonTopicList = json.getJSONArray("topicList");
                    for(int i=0; i< jsonTopicList.length(); i++) {
                        String topic = jsonTopicList.getString(i);
                        topicList.add(topic);
                    }

                    UnSubscribeMessage unSubscribeMessage = UnSubscribeMessage.from(1, false, 1, false, topicList);
                    unSubscribeMessage.setSessionId(json.getString("sessionId"));
                    unSubscribeMessage.setAuthKey(json.getString("authKey"));

                case "/DISCONNECT":

                    DisconnectMessage disconMessage = DisconnectMessage.from(false);
                    disconMessage.setSessionId(json.getString("sessionId"));
                    disconMessage.setAuthKey(json.getString("authKey"));

                    return disconMessage;

                default:
                    return null;
            }

        }

        return null;
    }

}

redpajama_set_name: RedPajamaGithub


Please note: You may choose to receive your unemployment benefits by direct deposit or on a debit card. Prior to choosing how you would like to receive your benefits, you must review the debit card disclosure information that explains all the fees relating to the benefits card program.
You must sign up for direct deposit online.
Sign up when you apply for unemployment benefits. You'll need your bank or credit union account and routing numbers. They are displayed on your check.
In the About me section, choose Update.
Under I want to, choose Update payment information and follow the instructions.
Q. Can I apply for direct deposit if my bank is not in the United States?
A. No. Direct deposit is available only with banks or credit unions within the U.S., including Alaska and Hawaii. We can't send direct deposit payments to banks or credit unions in other countries, Guam, Puerto Rico, the U.S. Virgin Islands or American Samoa.
Q. What if I didn't sign up for direct deposit when I first applied for unemployment benefits?
A. You must wait at least 24 hours from when you applied for benefits.
Q. What happens if I had direct deposit on an old claim and I file a new claim?
A. If you restart a claim, direct deposit stays active unless you change or cancel it.
If you open a new claim, the eServices website will give you the option to keep or change your payment method. If you don't choose direct deposit, it will be cancelled and any account information on record will be removed from your claim.
Q. How long does it take after I sign up?
A. Direct deposit takes effect immediately. One exception: If you sign up after 5 p.m. on a business day and we already have a payment ready to send to you, you'll get the payment via your previous method. Then, your next payment will be directly deposited into your account.
Q. When is money available in my account?
A. We transfer benefits to your bank or credit union within one business day after you submit your weekly claim. But your bank or credit union might take a few days to apply the funds to your account.
Q. I have been receiving my payment by direct deposit, but my weekly payment did not show up in my account. What do I do?
A. Contact your bank or credit union to see if a problem with your account prevented the deposit. We must wait at least seven calendar days from when we issued the payment before we can track it.
A. Yes. We use a secure website. If you remain on any page for 15 minutes, the application times out and your information is not saved. This prevents someone else from paging back to view your personal information. Employment Security Department staff do not have access to your bank or credit union information.
Q. What happens if I make an error when keying my bank account information and I don't know it?
A. If you enter incorrect account information, we can't deposit your payment to your account and we remove the incorrect information from our system. We can't correct the error, but we'll send you a letter to inform you. In the meantime, we'll send you a paper check for any benefits you're qualified to receive.
To correct your information on our eServices website, follow the steps in the How do I change, correct or cancel my direct deposit? question below.
Q What if I change my account?
A. If you change your account or routing information, you must update that information in your eServices account. Otherwise, you won't receive your payments. Update your information by following the steps in the question below.
How do I change, correct or cancel my direct deposit?
Q. How long will direct deposit last?
We remove it. We do this only if your bank or credit union rejects the payment.
If you restart a claim, direct deposit stays active unless you change or cancel it.
Q. Will I get direct deposit payment receipts in the mail?
A. No. Your bank or credit union statement will show the deposits.


text:
Fluids and Barriers of the CNS
Opposing CSF hydrodynamic trends found in the cerebral aqueduct and prepontine cistern following shunt treatment in patients with normal pressure hydrocephalus
Robert B. Hamilton1,2,4,
Fabien Scalzo1,4,
Kevin Baldwin1,
Amber Dorn4,
Paul Vespa3,
Xiao Hu1,2 &
Marvin Bergsneider1,2
Fluids and Barriers of the CNS volume 16, Article number: 2 (2019) Cite this article
This study investigated cerebrospinal fluid (CSF) hydrodynamics using cine phase-contrast MRI in the cerebral aqueduct and the prepontine cistern between three distinct groups: pre-shunt normal pressure hydrocephalus (NPH) patients, post-shunt NPH patients, and controls. We hypothesized that the hyperdynamic flow of CSF through the cerebral aqueduct seen in NPH patients was due to a reduction in cisternal CSF volume buffering. Both hydrodynamic (velocity, flow, stroke volume) and peak flow latency (PFL) parameters were investigated.
Scans were conducted on 30 pre-treatment patients ranging in age from 58 to 88 years along with an additional 12 controls. Twelve patients also received scans following either ventriculoatrial (VA) or ventriculoperitoneal (VP) shunt treatment (9 VP, 3 VA), ranging in age from 74 to 89 years with a mean follow up time of 6 months.
Significant differences in area, velocity, flow, and stroke volume for the cerebral aqueduct were found between the pre-treatment NPH group and the healthy controls. Shunting caused a significant decrease in both caudal and cranial mean flow and stroke volume in the cerebral aqueduct. No significant changes were found in the prepontine cistern between the pre-treatment group and healthy controls. For the PFL, no significant differences were seen in the cerebral aqueduct between any of the three groups; however, the prepontine cistern PFL was significantly decreased in the pre-treatment NPH group when compared to the control group.
Although several studies have quantified the changes in aqueductal flow between hydrocephalic groups and controls, few studies have investigated prepontine cistern flow. Our study was the first to investigate both regions in the same patients for NPH pre- and post- treatment. Following shunt treatment, the aqueductal CSF metrics decreased toward control values, while the prepontine cistern metrics trended up (not significantly) from the normal values established in this study. The opposing trend of the two locations suggests a redistribution of CSF pulsatility in NPH patients. Furthermore, the significantly decreased latency of the prepontine cisternal CSF flow suggests additional evidence for CSF pulsatility dysfunction.
The pathophysiology of normal pressure hydrocephalus (NPH) and that of communicating hydrocephalus in general, remains an enigma. The traditional tenet, dating back more than 70 years to the work of Walter Dandy [1], posited that cerebrospinal fluid (CSF) malabsorption or obstruction at the level of the arachnoid granulations was responsible for the accumulation of CSF within the ventricles. Several lines of evidence suggest that alternative mechanisms may be at play [2,3,4,5], including the hypothesis that interference in pulsatile CSF dynamics plays an important role [6, 7], and that absorption may take place into the parenchymal capillaries [8]. Williams proposed that venous dysfunction is an important initiating factor in the etiology of NPH [9]. We previously proposed [6] that a possible underlying mechanism relates to the role of pulsatile CSF inflow and outflow across the foramen magnum in relation to changes in cerebral blood volume with every heartbeat. Rather than relegating the rapid caudal flow of CSF seen on cine MRI flow studies to a response to the net increase in arterial cerebral blood volume during systole, we proposed that cranial-spinal CSF volume buffering is intimately related to cerebral blood flow reactivity (the response of cerebral blood flow to changes in vasculature analogous to an increase in induction). The term buffering refers to the ability of the CSF to dampen the arterial input into the cranial vault (the amplitude of the arterial pulse). Arterial resistance is the amount of wall resistance that the blood must overcome in order to flow through that particular vessel. A reduction in CSF volume buffering would increase CBF reactivity leading to a compensatory reduction in arterial resistance to maintain a constant CSF pressure.
Greitz et al. [10] elegantly demonstrated that pulsatile CSF movement occurs via two basic routes: the cisterns and ventricles. The larger cisternal movement occurs in response to an up-and-down piston-like motion of the brain with every heartbeat driven in relation to changes in blood volume in the subarachnoid spaces. The smaller CSF movement out and back into the ventricles, on the other hand, resulted from a medial (normal to the surface of the brain) movement of the cerebral hemispheres, primarily as a result of an increase in brain volume due to the increase in blood volume. Both cisternal and ventricular CSF volume buffering are important for normal cerebral hemodynamics.
Here, we hypothesized that communicating hydrocephalus (CH) arises primarily from a disturbance of either cisternal or other subarachnoid CSF pulsatile movement. In some respects, this concept is not too different from the Dandy traditional theory except that the putative point of "obstruction" to CSF flow is "upstream" from the arachnoid granulations and related primarily to pulsatile movement rather than solely on bulk CSF flow. Egnor et al. published a model on CH that suggested the increase in ventricular pulsatility (causing ventriculomegaly) was a result of increased impedance in the subarachnoid space (SAS) [11]. This idea did not develop exclusively based on theoretical machinations, but rather as a result of trying to explain a well-established observation in NPH: that the CSF stroke volume (SV) through the cerebral aqueduct of Sylvius is markedly elevated in NPH [12,13,14]. We reasoned that a reduction in cisternal and/or subarachnoid CSF volume buffering would have to be compensated by an increase in ventricular buffering—thereby producing aberration in pulsatile CSF dynamics described by Bradley [15] and others [16,17,18].
CSF pressure and flow oscillations within the cranium originate from the arterial pulsations, causing changes in cerebral blood volume entering the cranial vault through the internal carotid and vertebral arteries [10]. CSF flow from ventricle and intracranial subarachnoid spaces into the spinal compartments comprise the majority of the bulk flow [19]. Phase contrast (PC)-MRI has measured increased amplitudes of fluid flow through the aqueduct during the cardiac cycle [7]. It has been shown by Wagshul et al. [20] and others [10, 17, 19, 21] that the CSF latency (temporal difference in peak flow in relation to the cardiac cycle) varies throughout the cranial vault. Additionally, it has recently been established that some attributes of net CSF flow even vary with different phases of the respiratory cycle [22]. Ventricular CSF flow represents a very small but important part of the system; it is where the spinal CSF flow originates [19]. Using PC-MRI and the carotid arteries as a reference, Wagshul et al. showed a shorter latency in the prepontine cistern pulse compared with the cerebral aqueduct pulse [20]. Combining this information with aspects of Egnor's model of CH [11] we could also reasonably expect alterations in CSF flow latency between the cerebral aqueduct and the prepontine cistern. In fact, it has been well-established that hyperdynamic aqueductal CSF oscillations are found in NPH patients [23]. Specifically, we hypothesized that pre-treatment NPH patients should have shorter latency in both the cerebral aqueduct and prepontine cistern.
The treatment of CH typically entails the implantation of a CSF "shunt," a diversionary system that allows CSF flow through a catheter from the ventricle to either the peritoneum or atrium of the heart. The success of these shunting procedures can be variable and is dependent on patient selection and timing of procedure [24]. In terms of CSF pulsatile dynamics, a CSF shunt offers an alternative pathway for CSF volume buffering. We therefore further hypothesized that successful implantation of a CSF shunt in a hydrocephalic patient would result in normalization of both the aqueductal and cisternal SVs towards control values.
Study cohort and image acquisition
This study measured CSF flow in the cerebral aqueduct and the prepontine cistern using PC-MRI in three distinct groups: pre-shunt NPH patients, post-shunt NPH patients, and controls. All imaging and procedures were approved by the IRB committee and patients and normal controls provided written consent prior to the imaging (10-001128, 06-11-013, and 07-08-038). Scans were conducted on 30 pre-treatment patients (77.8 ± 7.1 year, 19 males and 11 females) ranging in age from 58 to 88 year and 12 controls (66.3 ± 9.2 year, seven males and five females). Additionally, 12 patients received scans following either ventriculoatrial (VA) or ventriculoperitoneal (VP) shunt treatment (nine VP, three VA), ranging in age from 74 to 89 year (81.7 ± 4.6 year) with a mean follow up time of 6 months, the remaining patients either received an endoscopic third ventriculostomy (ETV) or were not recommended for treatment. Of the 12 follow up scans, there were nine matched pre-post aqueduct scans and six matched cisternal scans.
All MRI scans were performed using a 3T Siemens Trio T-class MRI (Siemens Medical Systems, Erlanger, Germany). The participants were placed in the supine position with neck and head in the neutral position using a Siemens Head Matrix coil. All participants received the same imaging protocol, starting with anatomical sequences: a 3D axial T1-weighted MPRage gradient-echo sequence (1900 ms/3.44 ms/0.84375 mm/0.899 mm/320 mm × 320 mm/268.8 mm × 268.8 mm/9°, TR/TE/real acquired spatial resolution/slice thickness/matrix/FOV./flip angle), axial T2-weighted BLADE (7110 ms/107 ms/0.5729 mm/3 mm/384 mm × 384 mm/268.8 mm × 268.8 mm/120°), and a sagittal T2-weighted Turbo spin echo sequence (750 ms/100 ms/0.34375 mm/8 mm/616 mm × 640 mm/209.44 mm × 217.6 mm/170°).
Flow quantification was achieved using a series of imaging sequences including localization, anatomical, velocity estimation, and phase contrast (PC). Using a midsagittal slice, an oblique plane was defined perpendicular to the presumed direction of CSF flow for both the aqueduct and prepontine cistern (Fig. 1). A true FISP (5.36 ms/2.36 ms/0.625 mm/3 mm/256 mm × 256 mm in aqueduct, 320 mm × 320 mm in cistern/299.68 mm × 199.68 mm in aqueduct, 200 mm × 200 mm in cistern/60°) steady-state coherent sequence was used to visualize the local anatomy of the oblique slice; CSF appears as hyperintense as contrast is determined by T2*. The velocity encoding parameter (Venc) is a variable set by the MRI technician and defines the range of the measured velocities in the phase contrast sequence. A flow scout sequence was used initially to estimate the range of Venc values prior to setting the final Venc for the phase contrast sequence which varied based on the peak flow velocity of each patient. Following the definition of the Venc, the phase contrast sequence (39.1 ms/6.01 ms/0.625 mm/3 mm/240 mm × 320 mm in aqueduct, 192 mm × 256 mm in cistern/150 mm × 200 mm in aqueduct, 149.7 mm × 199.68 mm in cistern/15°) was applied; to ensure its accuracy, the results were checked for aliasing and further adjustments to the Venc were made, if necessary. For the aqueduct, the mean and standard deviation for the Venc used was 17.8 ± 4.5 in the pre-shunt group, and 13.1 ± 4.9 for the post-shunt group. For the prepontine cistern pre-shunt group, the Venc was 9.7 ± 5.39, and 7.6 ± 4.0 for the post-shunt group. The duration time of one PC-MRI acquisition was between 1.5 and 3 min for a single acquisition based on the period of the cardiac cycle. The cistern pre- and post- groups average beats per minute (BPM) were 66.9 ± 8.83 and 65.23 ± 11.59, respectively. The aqueductal pre-shunt and control groups had BPM 69.2 ± 8.3 and 66.6 ± 9.3, respectively. Finally for the PC-MRI sequence, there was retrospective gating with either ECG or pulse oximetry with a temporal resolution of 30 frames. Due to additional noise from arterial blood flow (basilar artery) in the phase contrast images of the prepontine cistern, a Time-of-Flight sequence (24 ms/3.69 ms/0.78 mm/0.8 mm/216 mm × 320 mm/168.4 mm × 249.6 mm/18°) aided the segmentation from the phase contrast sequence.
Left) Midsagittal T2-weighted image, flow acquisition planes for (1) cerebral aqueduct and (2) prepontine cistern. Planes were defined perpendicular to CSF flow. Center top) Example of cerebral aqueduct (T2 TruFisp) with the region of interest for the flow quantification outlined in red. Center Bottom) Example of the phase contrast sequence for the cerebral aqueduct during peak caudal CSF flow. Right top) Example of prepontine cistern (T2 TruFisp) with the region of interest for the flow quantification outlined in red and the basilar artery highlighted in yellow. Right bottom) Example of the phase contrast sequence for the prepontine cistern during peak caudal CSF flow
A semi-automated segmentation algorithm was implemented for the designation of the region of interest (ROI) for the cerebral aqueduct and the prepontine cistern. The algorithm utilized dynamic time series information coupled with spatial information [25] for segmentation of the individual voxels used in the analysis. The segmentation algorithm was developed using MATLAB 7.5 R2007b (The MathWorks, Inc., Natick, MA, USA) with a general description below [26].
The algorithm used a three-step process: (i) reference waveform generation, (ii) correlation map construction, and (iii) threshold determination. First, an edge detection algorithm segments the CSF from the magnitude image provided by the phase contrast sequence. The selected voxels from the binary mask are used to create the reference waveform by aggregating time-series information from the 30 frames of the PC-MRI sequence. Next, dynamic (temporal) information is included into the segmentation algorithm by comparing the reference waveform to each voxel's time-series information and builds a correlation map. The dynamic information improves in the segmentation of regions impacted by flow voids. Finally, a threshold value is used to segment the final region [26].
CSF dynamics quantification
Following the determination of the ROI, several CSF hydrodynamic metrics are derived from the PC-MRI sequence: velocity, flow, and stroke volume. Prior to calculating these metrics, a phase correction was made to offset accumulated phase or eddy currents due in part to the position of the patient in the scanner and the intrinsic properties of the magnet by selecting a region within the midbrain, and subtracting the average velocity over the 30 timepoints from the ROIs in the cerebral aqueduct and pre-pontine cistern, this methods has previously been described [19]. The velocity (cm/s) is derived from the intensity waveforms obtained from the PC-MRI sequence after correction of the Venc. The metrics included both maximum (peak) and mean velocity for both the caudal and cranial directions. Flow (mL/min) was computed on a voxel-by-voxel basis, by incorporating the pixel area and integrating over the ROI. Bradley et al. defined aqueductal stroke volume (SV) as the average of the volume of CSF moving in the cranio-caudal direction and the volume moving in the caudo-cranial direction [8]; this is in comparison to Bateman et al., which defined the SV as the area between the baseline (zero flow) and the peak portion of the flow curve [27]. In practice, these values should be approximately equal due to the near-zero bulk flow throughout the cardiac cycle; however, only values based on Bradley's definition will be reported in this study. Finally, the ROI area was compared among the three groups for both the aqueduct and prepontine cistern.
Peak flow latency calculation
Peak Flow Latency (PFL) is defined as the percent cardiac cycle at peak caudal CSF flow in the cerebral aqueduct and prepontine cistern. Following the calculation of the ROI, several additional steps were needed to reliably calculate the PFL. First, due to influence of partial volume, the ROI boundary voxels were removed to increase flow signal. Second, the remaining voxel's temporal waveforms were averaged to produce an intermediate reference waveform (this is the "characteristic flow" within the reduced ROI). The third step correlated the reference waveform to each with each voxel in the reduced ROI to rank representative flow velocity waveforms. Based on this value, the top 25% of highly correlated voxels were averaged to represent the final reference waveform (75% of the voxels were removed). The new reference waveform's temporal resolution was limited to the PC-MRI imaging parameters which is 30 samples. Therefore, the final step in the calculation of the PFL was the fitting of a six degree polynomial to the final reference waveform which increased the temporal resolution from 30 to 1000 samples per cardiac cycle (selection of the six degree polynomial as well as the percentage of voxels used in the determination of the waveform are discussed later in the manuscript). The PFL latency was defined as the percent cardiac cycle at peak caudal CSF flow which is the minimum of this waveform. For the PFL to be comparable, only patients whose MRI was gated with ECG were used in this analysis.
Ventricle segmentation
For the nine patients that had pre- and post- treatment scans, the total lateral and third ventricle volumes were calculated (3DSlicer, http://www.slicer.org). The segmentation was performed semi-automatically, following the placement of a seed point in the lateral ventricles and then edited manually by an expert.
Patient outcome
Patient outcome was assessed at the time of the post-treatment scan, approximately 6 months following surgery. The outcome was based on clinical notes at the time of the clinic visit, with an emphasis on the improvement in gait based on the suggestion by Edwards et al. [28]. Although further valve adjustments were made for majority of patients, the outcome was assessed at the time of the post-treatment scan prior to any valve adjustment. All clinical evaluations were blinded to the results of the flow analysis presented in this work.
All statistical analysis was performed using MATLAB 7.5 R2007b functions. For the comparison of the pre-treatment NPH and healthy control groups, the Mann–Whitney Rank sum test with a significant level of 0.05 was used. When comparing paired pre- and post-treatment NPH results the Wilcoxon signed rank test was used.
Hydrodynamic results pre-shunt NPH and control group
Significant differences in area, velocity, flow, and aqueductal stroke volume (ASV) metrics for the cerebral aqueduct were found between the pre-treatment NPH group and the healthy controls. Mean flow and max velocity in both the caudal and cranial direction as well as ASV and ROI area were significantly higher in the pre-treatment group. Selected median and interquartile ranges are shown in Table 1.
Table 1 The quantitative results from the pre-shunt NPH and healthy control groups for both the aqueduct and prepontine cistern
In the prepontine cistern, no hydrodynamic metrics were found to be significantly different between the pre-treatment group and the healthy controls (Table 1); however, the range of values was wider in the NPH group. Violin plots for the caudal mean flow and stroke volume for both the aqueduct and cistern are shown in Fig. 2 (cranial mean flow results are given in Table 1 but not plotted).
Violin plots for the comparison between the pre-treatment NPH group and controls: a Aqueductal caudal mean flow. b Aqueduct stroke volume. c Cisternal caudal mean flow. d Cisternal stroke volume. **p < 0.001
Impact of shunt treatment on hydrodynamic metrics
Of the 12 post-treatment patients, three underwent VA shunt placement and nine were treated with VP shunt. In the cerebral aqueduct (nine matched pre-post pairs) ROI, caudal and cranial mean flow, and SV (Fig. 3a) were significantly reduced after shunt placement (Table 2). In the prepontine cistern (six matched pre-post pairs), there were no significant changes in velocity, flow rates, or SV (Fig. 3b). Complete results for both the aqueduct and cistern are shown in Table 2.
Comparison of pre-treatment and post-treatment stroke volume in a aqueduct and b prepontine cistern. The decrease in aqueduct stroke volume was significant *p < 0.05
Table 2 The quantitative results from the pre- and post-shunt NPH groups for both the aqueduct and cistern
Peak flow latency
The PFL required ECG gating of the PC-MRI data and therefore a subset of the overall data was analyzed with the initial time point equal to the ECG signal performed in the MRI. For the cerebral aqueduct, 16 pre-treatment NPH patients and seven control patients were analyzed. The pre-treatment group showed a latency of 32.7% ± 8.16% compared to the control group latency of 34.4% ± 13.0% but the difference was not significant. In the prepontine cistern there was a significantly shorter PFL (p < 0.01) in the 15 pre-treatment patients (24.5% ± 6.3%) verse the five control subjects (29.6% ± 13.2%).
Following the shunt treatment, there were trends in both the cerebral aqueduct and prepontine cistern PFL toward control values; however, they failed to reach significance. In the cerebral aqueduct seven post treatment NPH patients had a mean ± SEM of 33.2 ± 12.5%. The post-treatment NPH patients had a slightly longer PFL of 27.9 ± 9.3% in nine patients, which again was not significantly longer than the pre-treatment group but trended toward the control group.
Ventricle volume
The ventricle volume reported is the superposition of the lateral and third ventricles of the nine patients with pre- and post- treatment scans. The pre-shunt ventricular volumes ranged from 63.8 to 147.4 mL, mean and SEM 109.8 ± 8.2 mL. Following shunting, ventricular volumes were significantly reduced (p < 0.001), mean and SEM 91.51 ± 9.8 mL. Ventricle volumes were not compared for the control group.
Stroke volume ratio
The stroke volume ratio was derived from the ratio of the ASV and the prepontine cistern SV for the pre-shunt, post-shunt, and control cohorts (Tables 1 and 2). For the pre-shunt group, there were 17 patients with technically adequate aqueduct and cisternal values resulting in a stroke volume ratio of 50.0 ± 7.3% mean and SEM, respectively. For the post-shunt patients, the stroke volume ratio was reduced but not significantly to 29.5 ± 7.2% (n = 7). The control group had a stroke volume ratio that was significantly lower (p = 0.0086) than the pre-shunt group, 17.7 ± 2.5%. The post-shunt and control groups did not differ significantly. In addition to the stroke volume ratio calculations for the entire pre- and post-shunt groups, the ratios for the six matched pre-post patients were also calculated. For the six matched patients, there was a significant reduction (p = 0.0321) from 50.2 ± 13.3% to 31.5 ± 8.3%.
Of the nine patients receiving pre- and post- treatment scans, eight received a VP shunt and one received a VA shunt. Of these nine patients, only one (a VP shunt) failed to clinically improve at the 6-month follow-up period.
In our study we investigated both cerebral hydrodynamic and peak flow latency (PFL) parameters in three groups, pre-treatment NPH patients, post-shunt NPH shunts, and controls within the cerebral aqueduct and the prepontine cistern. No significant differences were found in the mean CSF volumetric data for the prepontine cistern between the pre-treatment NPH group and the control group, although the range of values was higher in the pre-shunt NPH group. We documented prepontine SV values in NPH patients nearly twofold lower than the smallest value obtained in the control group. Balédent et al. reported that the prepontine cisternal CSF flow in patients with CH was smaller than healthy controls, but no quantities were given [17]. In a study published by Greitz, they reported SVs for the prepontine cistern in two healthy controls (SV = 0.33 ± 0.08 mL) and one CH patient (SV = 0.14 mL) [29]. It is difficult to make the comparisons between these results and those of other studies due to differences in ROI segmentation and imaging metrics.
Our study, like several others, demonstrated a significant difference in ASV and other hydrodynamic metrics between hydrocephalic patients and healthy controls [12,13,14, 23]. Balédent et al. implemented an automated method for segmentation of CSF and blood flow and found significant differences between area and SV within the aqueduct between healthy controls and patients with CH. Their results, based on 16 phase segments showed an increased area (17.0 mm2 vs. 8.0 mm2) and increased ASV (196.0 μL/mL vs. 51.0 μL/mL) for hydrocephalic patients versus healthy controls, respectively [17]. Furthermore, significant differences between CH (various etiologies) and healthy controls were also found by Abbey et al. within the aqueduct for area (10.0 ± 8.9 mm2, 2.0–27.0 mm2 and 2.0 ± 1.0 mm2, 1.0–4.0 mm2) and ASV (5.6–256.4 μL, 87.20 ± 79.04 μL and 1.9–33.2 μL, 17.4 ± 10.1 μL). However, differences in peak systolic and diastolic velocities were not found to be significant between the two groups [16], as we also found in our study. Ringstad et al. assessed net ASV and CSF aqueductal flow rate derived from PC MRI in patients with idiopathic NPH before and after ventriculoperitoneal shunt surgery. Net ASV was negative in 16 (76%) of 21 patients before shunt placement and in 5 (42%) of 12 patients after shunt placement, and increased from a median of − 5 μL (range − 175 to 27 μL) to a median of 1 μL (range − 61 to 30 μL; p = 0.04) [30].
Not unexpectedly, an increase in the mean ASV combined with no difference in the prepontine SV value resulted in an increase in the stroke volume ratio. Wagshul et al. investigated the CSF stroke volume ratio between the aqueduct and foramen magnum in 15 healthy adults [20]; although the study did not include CH patients they were able to define values for the stroke volume ratio in controls. In a related study by Balédent et al., the CH patients showed a significantly increased stroke volume ratio as compared to healthy controls, 42% and 11% respectively [17].
Impact of shunting
Shunting remains the primary treatment of NPH; however, there remains controversy over the selection of those patients who are likely to respond to shunt. Although not investigated in this work, CSF flow quantification with MRI [12, 14, 31, 32] has been used along with other methods such as radionuclide cisternography [33], overnight ICP monitoring [34,35,36,37,38,39,40,41], CSF tap test [42,43,44], extended lumbar drainage (ELD) [40, 45, 46], and CSF infusion (outflow resistance [42, 47,48,49,50,51,52,53,54]) to aid in the diagnostic/prognostic assessment of these patients. Following shunt surgery, cisternal CSF flow and SV were slightly increased but did not reach significance. Similar results have been published supporting that CSF pulsatility and stroke volume through the aqueduct is correlated with a positive response to shunting in patients with NPH [55].
The diversion of CSF resulted in a significant decrease in both the caudal and cranial mean flow (p < 0.05) and ASV (p < 0.05) in the aqueduct, which is consistent with one similar study [16]; however, in that study, peak velocities (caudal and cranial) and area were not found to be significantly reduced [16]. Again, there have been several studies that show a decrease in the ASV, flow, and velocity following a shunt procedure [13, 16, 17, 32]; although the mechanisms underlying this decrease in hydrodynamics have been relatively unexplored.
The CSF shunts used in our study include a valve mechanism that is a one-way check valve that has a pre-set opening pressure. For the post-shunt studies, we assume that the system is in steady-state, and therefore CSF flow down the shunt would occur when the peak CSF pulsatile pressure exceeds the threshold value, resulting in microbolus flow. In a study by Miyaje et al., the CSF flow through the shunt was measured using a microflowmeter in seven NPH patients; which included changes in valve opening pressure and changes in posture (sitting and standing) [56]. For patients in the recumbent position (same as the MRI), the study reported that, at low valve opening pressures, flow within the shunt varied between 100 and 200 μL/min. In our study, there was an average decrease in the caudal and cranial mean flow of 147.2 ± 105.9 and 93.0 ± 33.3 μL/min, respectively (median data reported in Table 2). The magnitude decrease in mean flow volume through the aqueduct is approximately equal to the data reported by Miyaje et al. for the flow through a shunt while in the supine position.
The stroke volume ratio following shunt surgery showed a decrease in the larger (unmatched) cohort but was not significant; however, in the six matched patients with pre and post scans, there was a significant reduction in stroke volume ratio following the surgery (p = 0.0321). Furthermore, the pre-shunt group had a significantly higher stroke volume ratio than the control group (p = 0.0086) which correlated well with Balédent's work described above. The absolute value of the ratios cannot be directly compared to work by Balédent et al. or Wagshul et al. because of the difference in location for the SAS stroke volume measurement. When investigating the contributions of the aqueduct and the cistern, the significant differences shown would be expected. Although the significant decrease in stroke volume ratio seems to be driven by the significant decrease in ASV shown in Table 1 and Table 2, the upward trend of cisternal SV following surgery could support the hypothesis of redistribution of intracranial CSF pulsations; however, additional work is needed to confirm or reject the stated hypothesis.
To supplement the volumetric analysis, latency metrics were also investigated in this study. Unlike the volumetric results, the aqueduct showed no significant differences in PFL between the groups; however, there was a trend showing a shortened latency in the pre-treatment group compared with the healthy controls. In the prepontine cistern the pre-treatment group showed a significantly shorter PFL compared with the healthy controls (Fig. 4). This change in CSF latency partially supports our hypothesis that pre-treatment NPH patients should have reduced latency in both the cerebral aqueduct and prepontine cistern. Although we were not able to show a difference in aqueductal latency between the two groups, the change in cisternal latency is an interesting finding as it supports the work from Egnor's model of CH of redistribution of CSF pulsations in the cranial vault.
Mean uncalibrated flow curves (voxel intensity) over the cardiac cycle. Top) aqueduct and bottom) prepontine cistern for the pre-treatment and control groups. The curves are the average of the polynomial fit (6th degree) of the entire group (SD also shown as shaded region). The difference seen between the peak latency (defined as the minimum point of the curve) is significantly shorter (p < 0.01) in the pre-treatment group than in the control group for the prepontine cistern. The objective of this figure is to show the phase change during the cardiac cycle
The PFL calculations were dependent on two variables: the degree of the polynomial used to increase the temporal resolution and the percentage of voxels removed from the original ROI. Table 3 shows the corresponding p-values for the prepontine cistern for a number of different combinations of degree of polynomial (4–10) and percentage of voxels removed. The analysis reported is for a six-degree polynomial and 75% voxel removal (marked with an asterisk in Table 3). There is minimal impact on the overall significance of the PFL by altering these two variables between the pre-treatment NPH group and healthy controls. However, when 95% of the data is removed (thus a majority of the voxels) and the degree of the polynomial fit is relatively high (8–10) the results are no longer significant. This trend is expected; as voxels are removed there is more influence from individual voxels, increasing the noise in the results along with "over-fitting" from the high degree polynomial fit. Taken at both extremes, a poor-fitting or over-fitting polynomial will confound the final results. Finally, when no polynomial fit is performed the results become very irregular and significance is rarely reached (Table 3).
Table 3 p-value from the Mann–Whitney Rank sum comparing pre-treatment NPH and control patients for prepontine cistern peak flow latency
As established earlier, the pathophysiology of NPH has been discussed to great extent in the literature and one can find a wide variety of possible root causes. One topic that has been relatively unexplored is the role of parenchymal changes leading to pathogenesis and symptoms in NPH. The variability in shunting success and neurodegenerative pathology in some patients may indicate that NPH is not quite as simple as misguided CSF, and that the pathology may lie in parenchymal abnormalities [57]. A new technology known as magnetic resonance elastography (MRE) [58], has the ability to quantify the mechanical properties of the microstructure of the parenchyma. Using this technology, a study by Freimann et al. investigated the changes in mechanical properties of the pre- and post- shunt brain of NPH patients and compared those changes to healthy controls [59]. Two significant findings were reported: first, there was a significant difference in shear elasticity (μ) between the control group and the pre-shunt NPH group that did not correct following shunting. Shear elasticity is a measure of global brain stiffness; therefore, the significant decrease in μ represents a decrease in brain stiffness of the NPH patients. The other finding showed a significant decrease in a parameter known as the connectivity parameter (α) between the healthy control group and the pre-treatment NPH group. Following surgery, the connectivity parameter returned to normal ranges. Unlike the brain stiffness the connectivity parameters is slightly more abstract, being described by the authors as being "sensitive to the geometry of the mechanical network" [59]. Succinctly, there is a reorganization of the parenchymal microstructure toward healthy values (more organized). We hypothesize that this reorganization following shunting could contribute to the reversal in both the volumetric and latency trends in the prepontine cistern. As previously discussed, the aqueductal change is also influenced by the removal of the CSF via shunting.
Potential study pitfalls
Our study was limited by the number of subjects, particularly patients who were studied both pre- and post-shunt, as well as the control group. Furthermore, the lack of specific age and ventricular volume matching also was also a limitation. There were also significant technical challenges. The prepontine cistern is a complex anatomical structure that includes the basilar artery as well as small veins. Arachnoidal septations within the cistern, if present, could possibly direct pulsatile CSF in directions not aligned with the axis of the brainstem (Fig. 1). Each or both of these could have contributed to errors in the automated segmentation algorithm, resulting in both inaccurate ROI areas and flow values. Ultra-high resolution imaging with stronger Tesla MRIs and multiplane imaging interpreted with mathematical modeling could address these gaps in information regarding CSF dynamics as a discovery and exploratory tool [60], but were not possible here. Additionally, technical challenges in latency calculations using the percentage of cardiac cycle could also introduce some level of variability. Future studies should investigate absolute time to peak-systolic flow.
For our purposes, PC-MRI provided a method to quantify the hydrodynamic changes that occur following a CSF diversion. Furthermore, we were able to compare those hydrodynamic changes with previously reported values for CSF flow within a shunt. Although several studies have quantified the changes in aqueduct flow between groups and a few studies have investigated prepontine cistern flow, our study is the first to investigate both regions for NPH pre- and post- treatment. Following shunt treatment, the aqueductal CSF metrics decreased toward control values. This is contrary to the prepontine cistern metrics that trended upwards (although not significantly) away from the normal values established in this study. Additionally, our study is the first to report latency differences within the prepontine cistern CSF flow between healthy controls and pre-treatment NPH patients.
PC-MRI:
phase-contrast MRI
NPH:
normal pressure hydrocephalus
PFL:
ASV:
aqueductal stroke volume
SV:
stroke volume
ventriculoperitoneal
VA:
ventriculoatrial
ETV:
endoscopic third ventriculostomy
CBF:
cerebral blood flow
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Scollato A, Gallina P, Gautam B, Pellicano G, Cavallini C, Tenenbaum R, et al. Changes in aqueductal CSF stroke volume in shunted patients with idiopathic normal pressure hydrocephalus. Am J Neuroradiol. 2009;30:1580–6.
Vanneste J, Augustijn P, Davies G, Dirven C, Tan W. Normal-pressure hydrocephalus Is cisternography still useful in selecting patients for a shunt? Arch Neurol. 1992;49:366–70.
Raftopoulos C, Chaskis C, Delecluse F, Cantraine F, Bidaut L, Brotchi J. Morphological quantitative analysis of intracranial pressure waves in normal pressure hydrocephalus. Neuro Res. 1992;14:389–96.
Stephensen H, Andersson N, Eklund A, Malm J, Tisell M, Wikkelso C. Objective B wave analysis in 55 patients with non-communicating and communicating hydrocephalus. J Neurol Neurosurg Psychiatry. 2009;76:965–70.
Kasprowicz M, Asgari S, Bergsneider M, Czonskya M, Hamilton R, Hu X. Pattern recognition of overnight intracranial pressure slow waves using morphological features of intracranial pressure pulse. J Neurosci Methods. 2010;190:310–8.
Eide PK. Intracranial pressure parameters in idiopathic normal pressure hydrocephalus patients treated with ventriculo-peritoneal shunts. Acta Neurochir. 2006;148:21–9.
Eide P, Brean A. Intracranial pulse pressure amplitude levels determined during preoperative assessment of subjects with possible idiopathic normal pressure hydrocephalus. Acta Neurochir. 2006;148:1151–6.
Eide P, Sorteberg W. Diagnostic intracranial pressure monitoring and surgical management in idiopathic normal pressure hydrocephalus: a 6-year review of 214 patients. Neurosurgery. 2010;66:80–91.
Hu X, Hamilton R, Baldwin K, Vespa P, Bergsneider M. Automated extraction of decision rules for predicting lumbar drain outcome by analyzing overnight intracranial pressure. Acta Neurochir Suppl. 2012;114:207–12.
Williams M, Razumovsky A, Hanley D. Comparison of Pcsf monitoring ad controlled CSF drainage diagnose normal pressure hydrocephalus. Acta Neurochir Suppl. 1998;71:328–30.
Malm M, Kristensen B, Karlsson T, Fagerlund M, Elfverson J, Ekstedt J. The predictive value of cerebrospinal fluid dynamic tests in patients with the idiopathic adult hydrocephalus syndrome. Arch Neurol. 1995;52:783–9.
B. Kahlon. Comparison between the lumbar infusion and CSF tap tests to predict outcome after shunt surgery in suspected normal pressure hydrocephalus. J Neurol. Neurosurg, Psychiatry. 2002. vol. 73, pp. 721–726.
Walchenbach R, Geiger E, Thomeer R. The value of temporary external lumbar drainage in normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry. 2002;72:503–6.
Marmarou A, Young H, Aygok G, Sauwachi S, Tsuji O, Yamamoto T, et al. Diagnosis and management of idiopathic normal-pressure hydrocephalus: a prospective study in 151 patients. J Neurosurg. 2005;102:977–87.
Petersen R, Mokri B, Laws E. Surgical treatment of idiopathic hydrocephalus in elderly patients. Neurology. 1985;35:307–11.
Boon AJ, Tans JT, Delwel EJ, Egeler-Peerdeman SM, Hanlo PW, Wurzer HA. Dutch normal-pressure hydrocephalus study: prediction of outcome after shunting by resistance to outflow of cerebrospinal fluid. J Neurosurg. 1997;87:687–93.
Andersson K, Sundström N, Malm J, Eklund A. Effect of resting pressure on the estimate of cerebrospinal fluid outflow conductance. Fluids Barriers CNS. 2011;8:15.
Kim D, Czosnkya Z, Keong N, Radolovitch D, Smielewski P, Sutcliffe M, et al. Index of cerebrospinal compensatory reserve in hydrocephalus. Neurosurgery. 2009;64:494–501.
Eklund A, Smieleski P, Chambers I, Alperin N, Malm J, Czosnkya M, et al. Assessment of cerebrospinal fluid outflow resistance. Med Biol Eng Comput. 2007;45:719–35.
Kahlon B, Sundbarg G, Rehncrona S. Lumbar infusion test in the diagnosis of normal pressure hydrocephalus. Acta Neurol Scand. 2005;111:379–84.
Meier U, Bartels P. The importance of the intracathecal infusion test in the diagnostic of normal-pressure hydrocephalus. Eur Neurol. 2001;46:178–86.
Boon AJ, Tans JT, Delwel EJ, Egeler-Peerdeman SM, Hanlo PW, Wurzer JA, et al. Does CSF outflow resistance predict the response to shunting in patients with normal pressure hydrocephalus? Acta Neurochir Suppl. 1998;71:331–3.
Czosnyka M, Whitehouse H, Smilewski P, Simac S, Pickard J. Testing of cerebrospinal compensatory reserve in shunted and non-shunted patients: a guide to interpretation based on an observational study. J Neurol Neurosurg Psychiatry. 1996;60:549–58.
Battal B, Kocaoglu M, Bulakbasi N, Husmen G, Tuba Sanal H, Tayfun C. Cerebrospinal fluid flow imaging by using phase-contrast MR technique. J Radiol. 2011;84:258–765.
Miyake H, Ohta T, Kajimoto Y, Nagao K. New concept for the pressure setting of a programmable pressure valve and measurement of in vivo shunt flow performed using a microflowmeter. Technical Note. J Neurosurg. 2000;92:181–7.
Espay AJ, Da Prat G, Dwivedi A, Rodriguez-Porcel F, Vaughan J, Rosso M. Deconstructing normal pressure hydrocephalus: ventriculomegaly as early sign of neurodegeneration. Ann Neurol. 2017;82(4):503–13.
Muthupillai R, Lomas D, Rossman P, Greenleaf J, Manduca A, Ehman R. Magnetic resonance elastography by direct visualization of propagating acoustic strain waves. Science. 1995;269:1854–7.
Freimann F, Streitberger K, Klatt D, Lin K, McGlaughlin J, Braun J, et al. Alteration of brain viscoelasticity after shunt treatment in normal pressure hydrocephalus. Neuroradiology. 2012;54:189–96.
Linninger A, Tangen K, Hsu C, Frim D. Cerebrospinal fluid dynamics and its coupling to cerebrovascular dynamics. Annu Rev Fluid Mech. 2016;48:219–57.
RBH, PV, XH, and MB conception of design and research; RBH, KB, and FS analyzed data; RBH, XH, and MB interpreted results of experiments; RBH prepared figures; RBH and AYD drafted manuscript; RBH, XH, and AYD edited and revised manuscript; RBH, and XH approved final version of manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests. Neural Analytics has no technology in the area of MR Imaging or any interests related to the subject of this paper.
This work was partially supported by National Institute of Neurological Disorders and Stroke Grants NS-059797, NS-054881, and NS-066008.
The authors are no longer members of the institution to which this data belongs and are thus unable to provide it upon request. The raw data is held by the University of California Los Angeles Ronald Reagan Medical Center, Department of Neurosurgery (300 Stein Plaza Driveway #420, Los Angeles, CA 90095.
Consent for publication was also included in the forms described above.
All imaging and procedures were approved by the IRB committee and patients and normal controls provided written consent prior to the imaging (10-001128, 06-11-013, and 07-08-038).
Neural Systems and Dynamics Laboratory, Department of Neurosurgery, The David Geffen School of Medicine, University of California-Los Angeles, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
Robert B. Hamilton, Fabien Scalzo, Kevin Baldwin, Xiao Hu & Marvin Bergsneider
Biomedical Engineering Graduate Program, Henry Samueli School of Engineering and Applied Science, University of California-Los Angeles, 7400 Boelter Hall, Los Angeles, CA, 90095, USA
Robert B. Hamilton, Xiao Hu & Marvin Bergsneider
The David Geffen School of Medicine, University of California-Los Angeles, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
Paul Vespa
Neural Analytics, Inc., 2440 S Sepulveda Blvd, Suite 115, Los Angeles, CA, 90064, USA
Robert B. Hamilton, Fabien Scalzo & Amber Dorn
Robert B. Hamilton
Fabien Scalzo
Kevin Baldwin
Amber Dorn
Xiao Hu
Marvin Bergsneider
Correspondence to Amber Dorn.
Hamilton, R.B., Scalzo, F., Baldwin, K. et al. Opposing CSF hydrodynamic trends found in the cerebral aqueduct and prepontine cistern following shunt treatment in patients with normal pressure hydrocephalus. Fluids Barriers CNS 16, 2 (2019). https://doi.org/10.1186/s12987-019-0122-0
Phase contrast MRI (PC-MRI)
Aqueduct of Sylvius
Cerebrospinal fluid (CSF)
Prepontine CISTERN
Cerebral compliance
CNS Fluid and Solute Movement: Physiology, Modelling and Imaging
Submission enquiries: nagapriya.nagarajan@springernature.com


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Home > News > Data & Research > Gen Y Looks to Personal Network for Advice
Data & Research September 30, 2014
Gen Y Looks to Personal Network for Advice
Workers in Generation Y want advice on budgeting, saving and how to manage student loan debt, says TIAA-CREF, but they aren't necessarily eager for professional advice.
By John Manganaro
A new TIAA-CREF survey finds Gen Y relies predominately on personal networks for financial advice, with adults ages 18 to 34 being more likely than the general population to involve their parents (47% vs. 19%), extended family (22% vs. 14%) and other trusted adults (31% vs. 21%) in their search for advice. Thirty-seven percent also involve a spouse or partner to help with their finances.
TIAA-CREF's annual Gen Y Advice Matters Survey shows Gen Yers are actively planning for their financial future. Of those who sought out advice, many expressed an interest in creating and managing a formal budget (72%), saving for education (65%), or managing their outstanding student loans (53%).
When it comes to financial advice, TIAA-CREF says it's not just the topics but also the delivery method that matters to Gen Y. The majority (55%) of Gen Y said their first choice for receiving financial advice is face-to-face, though that number dropped from 65% in 2012 as more Gen Yers selected online advice as their first choice. Seventy-nine percent of those surveyed say it would be helpful to have advice that's customized for their age group, and they are more likely to say they value online tools and calculators than the general population (74% vs. 57%). Gen Yers are also more likely to value seminars (68% vs. 53%) and webinars (67% vs. 54%) as channels for professional financial advice.
"Gen Y gives new meaning to the term connected," explains Kathie Andrade, executive vice president and head of individual advisory services at TIAA-CREF. "It's important for them to access financial advice via multiple platforms. While this may present a challenge for financial advisers, plan sponsors and employers, it also offers multiple opportunities for them to engage with Gen Y and speak their language when it comes to financial topics."
According to Andrade, the survey also found individuals who seek advice are invested in their financial well-being and tend to make positive changes after getting professional guidance. Gen Yers, for example, are 12 percentage points more likely to monitor their spending frequently compared to the general population (75% vs. 63%). They are also 14 percentage points more likely to change their spending habits (76% vs. 62%) and increase their monthly savings (70% vs. 56%) after getting professional advice.
As Gen Yers look to their parents for help, they may be learning from their parents' experiences and trying to find financial stability earlier in life. Only 57% of those ages 55 to 64 said they feel optimistic about their finances, and many said they are encouraging their children to take more aggressive action on saving and investing than they did.
"Gen Yers understand how to leverage financial advice to their advantage," Andrade adds. "They make concrete changes to their financial well-being early on that can help them prepare for the future and think ahead to retirement."
TIAA-CREF says Gen Yers who have received professional financial advice continue to rely on their personal network on an ongoing basis, which demonstrates that they value personal relationships in dealing with financial issues. The findings revealed that 70% consistently turn to their family and friends, 45% look to their employer, and 17% turn to social media on a regular basis. More than half (51%) of the survey respondents also take advantage of financial service provider websites or other online tools.
TIAA-CREF has developed a website geared toward the needs of young professionals, called Starting Your Financial Life. The Advice Matter survey was conducted by an independent research firm and polled a random sample of 1,000 adults nationwide to assess their attitudes, preferences and behaviors about receiving financial advice. An executive summary of the survey is available here.
Tagged: Education, Participants
« Employers Look to Enhance 401(k) Investments


Outstanding commercial opportunity in a thriving corridor. Zoned CS-MU-NP. Endless use possibilities. FAR is 2:1, 95% impervious cover with parking, sidewalks, etc. Existing residential home currently on property. Only two blocks from Ben White Blvd. and directly across from LCRA. Prime south Austin location.


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Poetry Reading: Marin Poetry Center, California.
Marin Poetry reading @ Mill Valley Library Mill Valley Library, 375 Throckmorton Ave., Mill Valley, California California, 94941 United States (map)
I'm delighted to be part of the Fall 2019 reading series run by the Marin Poetry Center. On Thursday Sept 19th, I'll be reading, alongside the wonderful Matthew Siegel. This event is free and open to the public. You can get more details here.
The Marin Poetry Center was founded in 1981 by a dedicated group of Northern California poets as a non-profit organization whose mission is to nurture the enjoyment of poetry and the craft of writing throughout the Bay Area.
Matthew Siegel is the author of Blood Work, winner of the Felix Pollak Prize in Poetry from University of Wisconsin-Madison. Blood Work was also released on CB Editions in the U.K. where it was shortlisted for The Felix Dennis Prize for Best First Collection by the Forward Foundation. Siegel's poems and essays have appeared in The Guardian, Indiana Review, Mid-American Review, Ninth Letter, The Rumpus, Salt Hill, Southern Humanities Review, Tusculum Review, Washington Square, and elsewhere. A former Wallace Stegner Fellow at Stanford, he holds a B.A. from Binghamton University and an M.F.A. from University of Houston. Siegel is a member of the general education faculty at San Francisco Conservatory of Music. Born in New York City and raised in nearby Rockland County, NY, he currently lives in San Francisco.
Posted in USA
Festival of Preaching
Anglican Clergy Diocesan Retreat in British Columbia


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Brusa Bezistan
Brusa Bezistan is surely one of the prettiest buildings from the Ottoman period in Sarajevo. Built in the heart of Baščaršija in 1551 by Rustem Pasha Opuković, Grand Vizier and son-in-law to Suleiman the Magnificent, it served as a place to sell silk produced in Bursa, the Turkish city that this bazaar is named after.
This monumental stone structure has six cupolas, and there were entrances and spaces for shops facing all four cardinal points: Ćurčiluk Veliki St. (north), Bazardžani St. (west), Kundurdžiluk St. (south) and Abadžiluk St. (east).
The bazaar didn't just sell textiles, but also household items and smaller pieces of furniture. During his stay in Sarajevo in the 17th century, travel writer Evlija Čelebi described the building with these words:
"…The main streets are clean and cobbled, and there is a covered bazaar with cupolas that has been built from sturdy material. It contains all manner of Indian, Sindhi, Arabic, Persian, Polish and Czech goods. A countless variety of valuable items to be sold are brought on horseback by merchants from Dubrovnik and the great Venice…".
Given that there were frequent fires in Sarajevo, the most important city documents of that period were deposited inside two of the bazaar's special stone niches.
The Museum of Sarajevo
The Museum of the City of Sarajevo was founded in 1949 with the goal of preserving the city's historical and cultural heritage. It comprises a central building, depots and five annexes: the Museum of Sarajevo 1878-1918 (founded in 1953 as the Mlada Bosna Museum), the Jewish Museum (1966), Svrzo's House (1960), the Despić House (1960) Brusa Bezistan (2004).
While it was damaged during the Siege in the 1990s, it was later renovated and made an annex of the Museum of Sarajevo in 2004. with an entrance off Abadžiluk St.
Bezistan's permanent exhibit comprises a chronological display of archeological pieces from pre-history, antiquity and the Middle Ages, and the upstairs exhibit shows items from the Ottoman and Austro-Hungarian periods.
Besides items from Butmir (a Neolithic settlement), and Mycenaen pottery dating from the iron age (from Debelo Brdo), the museum also houses the Ilidža patera (200 BCE), fragments of a clay bowl showing the oldest depiction of a lily found in BiH, as well as valuable examples of equipment used by Ottoman soldiers….
The most popular item is a model of Baščaršija between the Ottoman and Austro-Hungarian periods, which was done by modeler Husein Karišik in 1953 under the guidance of historian Hamdija Kreševljaković. Many of the objects depicted were destroyed after WWII, and many more changed their original purpose.
Other models on display include one of Gazi Husrev Bey's Mosque (1932), and another of Vratnik's Miščina Mahala, made under the supervision of Juraj Neidhardt, an architect who pushed for the preservation of Baščaršija's authentic look.
The entire Brusa Bezistan complex (also known as Rustem Pasha's Bezistan or Little Bezistan) became a National Monument of BiH in 2016.
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Nestled between Liverpool Street and Aldgate, Studio Figura is slimming and weight loss clinic located in Spitalfields offering services for ladies only. The classically styled decor combines with rich cream and purple tones, producing a lush and indulgent ambience in which to spoil yourself.
The Ashanti Treatment Room is a carefully considered spa experience offering Medi Spa & Beauty Treatments within close proximity of both Liverpool Street Station and Aldgate. This centre takes you on a journey of relaxation and rejuvenation. It provides the perfect respite from London's hustle and bustle. Offering an upscale treatment environment with affordable treatment prices.
Most of the products used on the treatments are natural and free from unnecessary, artificial chemicals and additives, also they offer a wide range of treatments that are especially suitable pre and postnatal. The Ashanti Treatment Room's treatments are the perfect way to combine a relaxing pampering experience, with a healthy treat.
They are known for delivering an affordable wellness and spa experience which doesn't compromise on luxury, with a core, measurable health benefits. All the treatments offered are prescriptive meaning or focus is only ever on you.
Ashanti Treatment Room welcomes men, women and children when accompanied by a consenting adult.
KIWe1 Beauty is a boutique beauty salon located on Middlesex Street in Liverpool Street, conveniently located in the heart of London. This glamorous, vibrantly decorated salon offers a wide range of beauty treatments, including manicures, facials and eyebrow tinting, all of which are carefully carried out by the expert therapist.
The staff here also provide several male grooming options, meaning there is something for everyone in this welcoming, accommodating venue.
Improve your physical and mental well-being 7 days a week at Afya Sports & Massage Clinic.
Being partnered with STA ( Sports Therapy Association) we offer a range of sports, deep tissue and injury treatments available at this professional London Bridge site.
Following a string of successful periods of practising diagnostic and rehabilitation work, this distinctive duo founded Afya Sports & Massage Clinic earlier in 2018.
Both talented therapists have gained university degrees specialising in injury treatments using manual therapy, acupuncture, electrotherapy and exercises designed for each clients needs.
Throughout their experiences they have demonstrated an outstanding ability to work with runners, in need of recovery particularly at the London Marathon. As well as providing rehabilitation programs and strength and conditioning protocols for members of the London Blitz American Football club.
Centrally located and only within a 10-minute walk from London Bridge station, you can seek out personal treatment and alleviate any injuries and stress.
TruthPie is a wellbeing and massage therapy centre specialising in bespoke treatments. Based in Tanner Place, a converted workshop close to Tower Bridge, they offer a variety of health and wellness treatments including deep tissue, relaxing and aromatherapy massage, facials and reflexology.
Therapist Scott specialises in deep tissue treatments on the back, shoulders and neck. Using a combination of deep and more relaxing strokes, he aims to not only help with any aches and pains but also make you feel incredibly relaxed. His sessions are suitable for stay at home mums, office workers and athletes alike. A treatment with Scott will undoubtedly help you relax, recover and rejuvenate.
Joanna is a trained clinical aromatherapist, an expert in bespoke aromatherapy massages who uses 100% cruelty-free and organic ingredient products wherever possible. All aromatherapy sessions begin with a personal consultation and treatments with Joanna can help with relief from not only muscular aches and pains but also to balance feelings of anxiety, depression, and stress. Her personally designed skincare products are extremely popular with her clients, and can often be prepared on the day upon request.
Bespoke wellness like no other, this clinic offers a free 15 minute consultation to help you get started. Benefit from single or regular sessions to enhance your overall wellbeing. Wellness with TruthPie, take a slice!
Based near Liverpool Street Station, BodyCure is an exclusive therapy centre specialising in sports and remedial massage treatments. Located inside 1 Broadgate Circle, they consider every client's individual needs, helping to achieve a higher state of wellness and vitality.
Elevated above the noise of the city, you are treated to a private and calming space. Their treatment rooms are simply decorated, creating a tranquil environment for you to unwind and relax in. Their menu includes therapeutic, Swedish and deep tissue massages, provided by a highly trained team with a focus on delivering an effective treatment and a rejuvenating experience each and every time.
The Beauty Box - Liverpool Street is a salon in the Arcade near Liverpool Street station offering a full range of beauty services for women and men. Many of their flexible treatments conveniently fit into your lunch break.
It's a small, clean and tidy venue that's well stocked with great products and sleekly presented. You've a particularly wide choice of nail polishes here, from CND Shellac and OPI. Expect lots of care and attention from friendly, efficient staff. They take the time to listen to you and are able to achieve great results quickly.
Kat Maconie is a boutique designer shoe store in Southwark offering designer beauty treatments to match.
Shoes and beauty treatments, need we say more? At Kat Maconie's you can browse the bold and vibrant footwear designs whilst you treat yourself to a quick manicure or luxury facial.
If you're looking for beauty that can keep pace with your London lifestyle, we've found just the trick.
Opt for an 'On The Run' manicure for a quick buff and polish in your lunch hour, take your face on a 'City Break' with the unique pollution fighting facial or prep your pins with a speedy, hot wax.
Just a 5-minute walk from London Bridge station, pop in for beauty with a designer touch - just don't blame us if you leave with a pair of to-die-for heels to flaunt your new pedi.
A centre for classic and therapeutic massages in the heart of London, Body Perfected is the place to go to ease any knots and tensions.
Found within the boutique offices at 46 New Broad Street, just moments from Liverpool Street and Moorgate Stations, this tranquil treatment room provides the perfect backdrop for your treatments by renowned therapist Claudia.
With a background in international competitive swimming and in contemporary dance, as well as a diploma in Sports Therapy and bachelor's in Traditional Chinese Medicine, she has a strong knowledge of sports-related injuries and Eastern and Western medical traditions.
She uses her own methodology linking these all to tailor each treatment to you, whether it be a Swedish or deep tissue massage, lymphatic drainage or acupuncture.
Book in today and take a moment to experience the benefits of her years of expertise.
Sergii Mazunin is registered remedial massage therapist with over 13 years of experience, situated in the City of London, offering a range of services for all your needs.
Sergii specializes in remedial massage therapies. He has a high level of understanding of human anatomy and specific knowledge of problem areas of muscular-skeletal system. He has been working with many patients with different spine issues, such as osteochondrosis, acute and dull pain, localized numbness, sciatica, frozen shoulders, dizziness, chronic tiredness, etc. In addition, he is qualified and experienced in ayurvedic massage techniques.
This education combined with his experience in massage therapy enables him to select the most efficient techniques to achieve the results and help people with any spine or muscles issues and make all the stress, tiredness and tension go away. Sergii is most passionate about helping people being happier through keeping their body healthy and relaxed.
Conveniently located in the London Wall Buildings, Facial Gym is a wellness centre which is completely unique, offering facial massages which are specifically designed to treat wrinkles, puffiness, tension and jaw pain without the use of creams or masks.
Face massages relax facial muscles that cause wrinkles and also drain lymph which lifts and slims the face. This highly experienced and knowledgeable team of specialists first analyse every centimetre of your face and then tailor the most effective treatment to stop any signs of ageing.
Located near Finsbury Circus Garden between Moorgate and Liverpool Street Stations and with a number of bus stops nearby, Facial Gym couldn't be more convenient. Whether you're looking for a routine face massage therapist or want to try a treatment for the first time, Facial Gym is an ideal place to treat any and all facial ailments.
Along Royal Mint Road, a few minutes away from Tower Gateway DLR station, is ER Beauty Salon. Offering an array of services for weight loss, skin care and massage, the salon is your next stop for pampering perfection.
Brazilian owned, the salon brings a unique angle to classic, efficient and professional services. You can be sure that your treatment will be done with care and precision, with your needs at the core of each visit.
Please note that payments made at the salon are only cash.
Shen-Yi Rejuvenation & Acupuncture at Light Centre Monument is located on St Mary at Hill Road, a few minutes away from Monument train station, in London.
They offer acupuncture and weight loss treatments which are guaranteed to help you restore that feeling of well-being. Their professional therapists are experts in Chinese medicine and will cater to your every need to deliver instant relief on the painful area. Relax in a stress-free environment and walk out feeling like yourself again.
Shen-Yi Rejuvenation & Acupuncture Space is located at Light Centre Moorgate, London. Committed, compassionate, and highly skilled in multiple disciplines, therapist Giedre seeks to empower both women and men to achieve their optimal life and health goals through natural medicine practices, informed integrative nutrition and lifestyle management.
Giedre's approach is to treat the individual as a whole, by working with the body and mind in tandem to bring the person back to a state of homeostasis. From there true health and a real sense of well-being emerge. Being as an adult nurse, Giedre, had always strived to bridge the gap between Eastern and Western medicine. She became interested in Chinese medicine through a practice of yoga and meditation, what led her on a wonderful journey to the practitioner she is today.
Giedre graduated from Middlesex University, London with First Class degree in Traditional Chinese Acupuncture.
In 2012, during her clinical practice at Liaoning hospital of Chinese Medicine in Shenyang, China, Giedre had deepened her knowledge and practical skills with top Chinese doctors and professors. She specialized in treating neurological, muscular –skeletal and gynaecological diseases, and had clinical practice in anti-aging & cosmetology department.
With years of extensive study and learning different techniques, Giedre is able to provide a bespoke, holistic service incorporating current research and findings. In addition, Giedre completed Manual Lymphatic drainage course and was awarded with Diploma in Manual Lymphatic Drainage & Combined Decongestive Therapy from Original Dr. Vodder School in Walchsee/Austria.
Giedre is covered by professional indemnity insurance and bound by a strict code of professional conduct, ethics and safe practice.
London Bridge Massage is a mobile massage therapist covering the South East & South West regions of London.
A team of professional therapists, with over 30 years of experience combined between them, cater to your needs with a range of relaxing massage treatments.
Trained in luxury Spas around the UK and Thailand, the team provides a five-star service for each and every one of their clients.
So whether you need to sort out a nagging pain, or simply just need to de-stress, the friendly team of therapists will be happy to help you feel better in the comfort of your own home.


For a contractor, Eurosense performed a lidar survey over the Houtribdijk (NL). This dam (although called a dike) was constructed between 1963 and 1975 and splits the lake into two parts: On the west side the Markermeer and on the east the IJsselmeer. It will be renovated in the coming years to be ready for future storms. In the picture below a half meter DSM of the naviduct (an aqueduct which includes a lock) on the Houtribdijk in Enkhuizen (NL) is shown.
For more news concerning Eurosense in The Netherlands, click here.