We compared the ability of inhaled nitric oxide (NO), oxygen (O2) and nitric oxide in oxygen (NO+O2) to identify reactive pulmonary vasculature in pulmonary hypertensive patients during acute vasodilator testing at cardiac catheterization.
In patients with pulmonary hypertension, decisions regarding suitability for corrective surgery, transplantation and assessment of long-term prognosis are based on results obtained during acute pulmonary vasodilator testing.
In group 1, 46 patients had hemodynamic measurements in room air (RA), 100% O2, return to RA and NO (80 parts per million [ppm] in RA). In group 2, 25 additional patients were studied in RA, 100% O2and 80 ppm NO in oxygen (NO+O2).
In group 1, O2decreased pulmonary vascular resistance (PVR) (mean ± SEM) from 17.2 ± 2.1 U·m2to 11.1 ± 1.5 U·m2(p < 0.05). Nitric oxide caused a comparable decrease from 17.8 ± 2.2 U·m2to 11.7 ± 1.7 U·m2(p < 0.05). In group 2, PVR decreased from 20.1 ± 2.6 U·m2to 14.3 ± 1.9 U·m2in O2(p < 0.05) and further to 10.5 ± 1.7 U·m2in NO+O2(p < 0.05). A response of 20% or more reduction in PVR was seen in 22/25 patients with NO+O2compared with 16/25 in O2alone (p = 0.01).
Inhaled NO and O2produced a similar degree of selective pulmonary vasodilation. Our data suggest that combination testing with NO+O2provides additional pulmonary vasodilation in patients with a reactive pulmonary vascular bed in a selective, safe and expeditious fashion during cardiac catheterization. The combination of NO+O2identifies patients with significant pulmonary vasoreactivity who might not be recognized if O2or NO were used separately.
Elevated pulmonary vascular resistance (PVR) complicates the evaluation, clinical course and outcome of patients with congenital heart disease or end-stage pulmonary disease. It is a crucial factor in determining the timing or type of intervention, and has been invoked as the primary determinant of mortality in many lesions (1,2). Opinion varies on what resistance must be achieved with vasodilator testing to insure safe operability for children with congenital heart disease. An increased or fixed elevation in PVR may deny patients the chance of corrective surgery, leaving them susceptible to the development of progressive obliterative pulmonary vascular disease and reduced life expectancy (3,4). Demonstration of pulmonary vasoreactivity in patients with end-stage pulmonary disease may differentiate patients who would benefit from long-term medical therapy (5,6)from those with high, fixed resistance who should be more urgently considered for lung transplantation (3). Safe and expeditious demonstration of maximal pulmonary vasodilation in patients with a reactive pulmonary bed is therefore an important objective.
Many vasodilators have been utilized for diagnostic testing during cardiac catheterization. Systemic vasodilators with their attendant risks of hypotension and increased intrapulmonary shunt may be hazardous (7), especially in patients with ventricular outflow tract obstruction. Breathing oxygen (O2) remains a standard means of pulmonary vasodilator testing in pediatric cardiac catheterization laboratories (8,9). However, failure to respond to acute treatment with O2has been reported in some patients who did indeed have reactive pulmonary vasculature (3,10).
Inhaled nitric oxide (NO) is a selective pulmonary vasodilator with minimal systemic effects and does not increase intrapulmonary shunting. It can be administered easily with O2or room air (RA) during cardiac catheterization by either ventilator or mask. The purpose of this study was to compare the ability of NO and O2to identify patients with a reactive pulmonary vascular bed during cardiac catheterization. We further compared the hemodynamic effects of breathing nitric oxide in oxygen (NO+O2) to breathing O2alone during acute vasodilator testing.
We enrolled patients between January 1992 and December 1996 who had mean pulmonary artery pressure ≥30 mm Hg, PVR >3 U·m2, and were determined during catheterization to require vasodilator testing. We included for analysis 71 patients who had complete hemodynamic measurements to allow calculation of vascular resistances.
The first 46 patients (group 1) were studied under the following four study conditions: A) in RA; B) after breathing 100% O2for 15 min; C) after another 15 min in RA, and D) after 15 min breathing NO at 80 parts per million (ppm) in 23% O2(NO+RA). As NO is titrated into a delivery circuit, the delivered fraction of inspired O2(FiO2) is decreased. Therefore a small amount of supplemental O2(23%) was added to NO to avoid administration of a hypoxic gas mixture. The patients in group 1 had a median age of 6.5 years, range 4 months to 59 years.
Twenty-five additional patients (group 2) were studied in the following three conditions: A) in RA; B) after breathing 100% O2for 15 min, and C) after 15 min of inhaling 80 ppm NO in 91% O2. This was the maximal FiO2attainable after dilution with 80 ppm of NO. Patients in group 2 had a median age of 3.5 years, range 5 months to 69 years.
The patients in each group represented a broad spectrum of diagnoses characteristic of a high volume pediatric cardiac catheterization laboratory. Most had unrepaired or previously palliated congenital heart disease, although some had end-stage pulmonary disease (Tables 1 and 2). ⇓Four of 46 patients in group 1 and three of 25 patients in group 2 were mechanically ventilated. The remainder in each group were breathing spontaneously. Sedation was given according to a routine, which included intravenous morphine and midazolam. Partial pressure of carbon dioxide (Pco2) was normal throughout the study in both groups.
Hemodynamic measurements included left atrial, right atrial, pulmonary and systemic arterial pressures during each of the conditions described above. Cardiac output was measured by thermodilution in patients without an intracardiac shunt. In those with shunts, O2consumption was measured (Waters Inc., model MM20, Rochester, Minnesota), and systemic and pulmonary blood flows were calculated using the Fick equation with inclusion of dissolved O2. Errors related to sampling site variances were minimized by ensuring that, for each patient, venous samples were collected at the same site during each of the study conditions.
Detailed descriptions of the technical aspects of our delivery of NO in both ventilated and spontaneously breathing patients have been published previously (11,12). We used NO gas (Scott Specialty Gases, Plumsteadville, Pennsylvania or BOC Gases, Murray Hill, New Jersey) of medical grade quality, which conformed to Food and Drug Administration standards. In the spontaneously breathing individuals NO was delivered using the titration technique from source tanks with an 800-ppm concentration. Flow rates greater than the patients' minute volumes were delivered through a one-way inspiratory valve to a face mask. The expired gases were scavenged using a reservoir bag and regulated wall suction. In the seven patients who were mechanically ventilated, ventilator settings were kept constant throughout the study. Nitric oxide, nitrogen dioxide (NO2) and FiO2were continuously monitored from a sampling port at the airway (Thermoenvironmental Instruments Chemiluminescence model 42H, Franklin, Massachusetts or NOxBOX Electrochemical Inhaled NO Therapy Monitor, Bedfont Scientific USA, Medford, New Jersey). Peak measured NO2concentrations were recorded in all patients during delivery of the drug. Because there were no reports of methemoglobinemia during 15-min diagnostic trials of NO at 80 ppm (11), we eventually ceased to routinely measure methemoglobin levels during brief inhalations. Therefore, methemoglobin levels were obtained by cooximetry (CIBA-Corning model 2500, Medfield, Massachusetts) after 15 min in the first 22 of 46 patients in group 1 and not thereafter. Written informed consent was obtained from the patients or their parents under a protocol approved by the Clinical Investigation Committee of Children's Hospital and submitted to the Food and Drug Administration.
Results are presented as mean values ± SEM. Vascular resistances were calculated using standard equations and were expressed in Wood units corrected for body surface area (U·m2). Groups 1 and 2 were analyzed separately with patients in each group acting as their own controls. Repeated measures analysis of variance was used to look for differences in the measurements over the four study conditions in group 1 and the three conditions in group 2. If differences were found, then the Bonferroni multiple comparisons procedure was used to determine where differences existed. A p value <0.05 was considered significant.
Pulmonary vascular resistance differed across the four conditions, (p < 0.0001) (Table 3). Oxygen decreased PVR from 17.2 ± 2.1 U·m2to 11.1 ± 1.5 U·m2(p < 0.05). Administration of inhaled NO at 80 ppm in RA caused a comparable decrease from 17.8 ± 2.2 U·m2to 11.7 ± 1.7 U·m2(p < 0.05) (Fig. 1). Comparison of the mean percentage decreases from RA to O2(36.9 ± 3.3%) and RA to NO+RA (35.1 ± 3.5%) revealed no difference by paired ttest. Changes in pulmonary artery pressures may not reflect pulmonary vasodilation, because there were patients with intracardiac shunts. Nevertheless, the mean pulmonary artery pressure was significantly lower in both O2and NO+RA compared with RA despite increases in pulmonary blood flow in 21 of 23 patients with intracardiac shunts during treatment.
Pulmonary vascular resistance (PVR) (mean ± SE) differed across the four study conditions in group 1 (p < 0.0001); PVR was lower in oxygen (O2) compared with room air (RA) (∗) and was lower in nitric oxide in RA (NO+RA) compared with RA (†) (p < 0.05 for both).
Mean systemic arterial pressure, systemic vascular resistance, right atrial pressure, left atrial pressure, heart rate, pH and Pco2did not change with administration of O2or NO. Arterial Pco2(Pao2) increased from 66 ± 3 mm Hg in RA to 278 ± 23 mm Hg with 100% O2; however, there was no significant difference in Pao2between RA and NO+RA (68 ± 4 vs. 73 ± 4 mm Hg).
Using a reduction in PVR of 20% or more as a marker for responsiveness, we compared individual patient results to O2and NO+RA (Fig. 2). Oxygen caused a positive response in 36/46 patients. Of the 10 nonresponders, four responded with a 20% or more decrease to NO. Nitric oxide in RA caused a positive response in 32/46. Of the 14 nonresponders to NO+RA, eight responded to O2. Six patients did not respond to either vasodilator (Table 1).
Individual patients' percentage change in PVR with O2is plotted against percentage change in PVR with NO+RA. Using a 20% decrease in PVR as a marker for responsiveness, some patients responded to one drug only. Neither O2nor NO+RA identified all patients with pulmonary vasoreactivity. Abbreviations as in Figure 1.
The peak NO2level was recorded in all 46 patients and was 1.3 ± 0.2 ppm. Methemoglobin measured at the conclusion of the 15-min period of NO inhalation in 22/46 patients was 0.8 ± 0.1%.
Pulmonary vascular resistance differed across the three conditions (p < 0.0001) (Table 4). Pulmonary vascular resistance decreased from 20.1 ± 2.6 U·m2in RA to 14.3 ± 1.9 U·m2in O2and further to 10.5 ± 1.7 U·m2in NO+O2(Fig. 3). Pulmonary vascular resistance was significantly lower in O2compared to RA (p < 0.05). The PVR with combination therapy was statistically lower than that measured in air or in O2(p < 0.05 for both). Oxygen caused a reduction in PVR from baseline of 20% or more in 16 of 25 patients. Of the remaining nine patients, six responded with a 20% or more decrease when inhaling NO+O2. Three patients did not have a positive response to either O2or the combination of O2and NO (see Table 2). Using the McNemar's test, if responsiveness differed between the two treatments, patients were more likely to respond to NO+O2than to O2alone (p = 0.01). Ten of the 25 patients underwent complete surgical repair of their cardiac defects within 1 month of their catheterization. Those 10 patients had a baseline PVR in RA of 12.9 ± 1.9 U·m2that decreased to 7.1 ± 1.9 U·m2in O2and to 4.1 ± 1.9 U·m2in NO+O2. Each patient undergoing surgical repair had a baseline PVR in RA >6 U·m2. Five of 10 had PVR >6 U·m2in O2, but only one had PVR >6 U·m2in NO+O2. All 10 patients survived and were discharged home on median postoperative day 5.5, range 4 to 29.
Pulmonary vascular resistance (mean ± SE) differed across the three study conditions in group 2 (p < 0.0001); PVR was lower in O2compared with RA (∗) and was lower in NO+O2compared with RA (∗) and O2(†) (p < 0.05 for all comparisons). Abbreviations as in Figure 1.
Mean pulmonary artery pressure decreased from 63.4 ± 3.7 mm Hg in RA to 57.7 ± 3.5 mm Hg in O2to 50.6 ± 3.5 mm Hg in NO+O2. This occurred despite an increase in pulmonary blood flow in 13 of 15 patients with shunts. The pulmonary artery pressure with NO+O2was significantly lower than that measured in air or in O2(p < 0.05 for both). There was no difference between left atrial pressure in RA and in O2. Left atrial pressure was significantly higher in NO+O2(15.5 ± 1.3 mm Hg) than in RA (13.1 ± 1.1 mm Hg) or O2(12.7 ± 1.0 mm Hg).
Mean systemic blood pressure increased over the three study conditions, from 76.8 ± 2.9 mm Hg in RA to 80.6 ± 2.5 mm Hg in O2to 83.4 ± 2.6 mm Hg in NO+O2. Blood pressure was significantly higher in NO+O2than in RA, but not statistically different from blood pressure in O2. Cardiac index, systemic vascular resistance, right atrial pressure, heart rate, pH and Pco2did not change. Arterial partial pressure of O2was significantly higher both in O2and in NO+O2as compared with RA. Arterial partial pressure of O2was not different in NO+O2compared with O2(302.8 ± 27.9 vs. 277.6 ± 30.4 mm Hg). The peak NO2level during NO delivery was 2.3 ± 0.3 ppm.
We compared the inhaled vasodilators O2and NO in 71 patients during acute vasodilator testing at cardiac catheterization. In 46 patients, 100% O2and inhaled NO at 80 ppm in air produced comparable and selective decreases in mean pulmonary artery pressure and PVR. However, O2or NO used separately failed to identify all patients with a significant capacity for pulmonary vasodilation. The combination of NO (80 ppm) with 91% O2in an additional group of 25 patients produced significantly more pulmonary vasorelaxation compared with O2used alone. In 22/25 patients there was a positive pulmonary vasodilator response during combination therapy compared to only 16/25 when breathing O2alone. None of the 71 patients studied showed any evidence of toxicity from either drug during the brief period of this diagnostic trial. Our data suggest that combination testing with NO in O2provides additional pulmonary vasodilation, can be safely and accurately delivered to patients during diagnostic cardiac catheterization and can rapidly identify patients with pulmonary vasoreactivity. The combination of agents appears to identify patients with significant pulmonary vasoreactivity who might not be recognized if O2or NO were used separately.
The precise stage when pulmonary vascular disease has progressed to a point where surgical repair of congenital heart lesions cannot be safely performed is unknown. Morphologic criteria (2)and pulmonary hemodynamics (13)are useful, but imprecise. Pulmonary vascular resistance calculated to be more than 6 to 8 U·m2has been shown to be associated with poor operative outcome regardless of lung histology (1,4,14). In contrast, patients who respond to vasodilators with a PVR less than 6 to 8 U·m2do well postoperatively (13). Demonstration of a reactive pulmonary bed in patients being evaluated for transplantation has enabled patients to be offered a single organ heart instead of heart–lung block with successful results (15). Patients with elevated resistance but reactive pulmonary vasculature may need more intensive postoperative care and presumably would be excellent candidates for NO therapy in the postoperative period should pulmonary hypertension emerge. Response to acute vasodilator testing in patients with primary pulmonary hypertension is an important marker for survival (3)and may identify patients who would benefit from chronic medical therapy (5,6).
Prior research in children with pulmonary hypertension has shown that O2failed to unmask all reversible pulmonary vasoconstriction (3,10). Prostacyclin administration in patients with pulmonary hypertension breathing O2caused further pulmonary vasodilation. However, prostacyclin can cause systemic side effects including tachycardia and hypotension (16). Previous studies of vasoreactivity in children during cardiac catheterization found variable responsiveness to NO that seemed to parallel the progression of established vascular disease (17). Studies examining the efficacy of NO in O2, including recent work by Allman and colleagues, have suggested differences between the responses to NO, O2and/or the combination of agents (18–20). Each prior study, however, has had insufficient power to establish a significant difference in PVR.
Nitric oxide causes vasorelaxation through a cyclic guanosine monophosphate–mediated pathway. The mechanism of vasorelaxation caused by O2is not clearly known (21). The fact that some patients responded to one agent with significant vasodilation but not the other, and that the majority of patients experienced increased vasodilation with combination therapy compared with O2alone, suggests that the mechanisms may not be identical.
The major recognized toxicities associated with inhaling NO are cytotoxic effects in the lung due to exposure to excess NO2and methemoglobinemia due to the intravascular binding to hemoglobin. Nitrogen dioxide will develop in delivery systems at a rate that is proportional to NO and O2concentrations and contact times between the two gases. When NO was delivered with maximal amounts of O2in this study, NO2levels averaged 2.3 ± 0.3 ppm, below the accepted environmental exposure level of 5 ppm (22). Nitrogen dioxide should be continuously monitored, especially in patients mechanically ventilated with circuits that do not use continuous gas flows. If patients receive prolonged treatment with NO in high concentrations of O2, we recommend reduction in the NO dose to diminish potential dose-related toxicity. There have been no reports of clinically significant methemoglobinemia during brief exposure to NO at doses as high as 80 ppm. Methemoglobin measured at the conclusion of the 15-min period of NO inhalation in 22/46 patients was 0.8 ± 0.1%. This along with previously published results (11)supports the contention that routine measurement of methemoglobin may be unnecessary during brief diagnostic trials of NO.
It is notable that the combination of NO in O2resulted in an increase in left atrial pressure compared with RA or O2alone. Reports have suggested that O2(23)or NO (24)may have deleterious effects to patients with heart failure. In this study no patient demonstrated clinically important pulmonary edema, hemodynamically significant systemic vasoconstriction or decreased cardiac index during the brief administration of O2or NO in O2. Nevertheless, we believe that NO, especially when used with O2, should be carefully monitored in patients with elevated left atrial pressures due to the potential induction of pulmonary edema.
The patient population studied was quite heterogeneous. However, this accurately reflects the typical spectrum of patients presenting for vasodilator testing during cardiac catheterization. Subgroup analysis of patients with congenital heart disease showed no differences in response compared to the group as a whole. Patients with lung pathology analyzed separately showed similar results, but numbers were too small to form conclusions. Subgroup analysis of patients with left to right shunts did not reveal any difference in response compared to those without shunts. The definition of responder and nonresponder is arbitrary, but a 20% change is often used in drug testing as a marker of responsiveness. There was no apparent predictive marker in patients who responded to one agent but not the other. It may be that repeated exposure to O2or NO would minimize differences between responders and nonresponders. Nonetheless, a single exposure to a drug is the common catheterization protocol. Limited information exists concerning optimal dosing of NO, with some investigators showing maximal vasodilation at doses as low as 2 ppm (19), and others demonstrating a dose–response relationship up to 80 ppm in a similar population (18). This study was designed as a brief diagnostic trial in a catheterization laboratory to determine the most effective and inclusive method of identifying patients with pulmonary vasoreactivity. Accordingly, 80 ppm was used during this brief testing with the appreciation that, if delivered for prolonged periods, it may be associated with dose-related increased toxicity. This study was not designed to demonstrate differences in long-term patient outcomes or clinical value of vasodilator testing. Maximal vasodilatory capacity may be of limited clinical value in some patients. Nevertheless, as a result of information acquired during combination therapy, some patients were offered surgery who did not respond to NO or O2alone; all patients survived.
Individually, NO and O2produced significant and comparable selective pulmonary vasodilation in a heterogeneous group of patients presenting to cardiac catheterization for pulmonary vasodilator testing. However, neither agent used separately identified all patients with the capacity to relax their pulmonary vascular bed. The combination of NO+O2caused significantly greater pulmonary vasodilation compared to O2and identified patients who had pulmonary vasoreactivity that was not appreciated during O2breathing alone. This study suggests that combination testing with NO+O2provides additional pulmonary vasodilation in patients with a reactive pulmonary vascular bed in a specific, safe and expeditious fashion during cardiac catheterization. Nitric oxide in O2distinguishes patients with significant pulmonary vasoreactivity who might not be identified using either agent separately.
We are grateful to John F. Keane, MD for his critical review of the manuscript and to Kimberlee Gauvreau, ScD for her expert assistance with statistical analysis.
☆ Dr. Atz is supported by an award from the National Institutes of Child Health and Human Development and a grant from the United States Food and Drug Administration. Dr. Wessel is supported by grants from the United States Food and Drug Administration and the Research Endowment of Children's Hospital.
Presented in part at the 45th Annual Scientific Sessions of the American College of Cardiology, Orlando, Florida, March 1996.
Revision received September 18, 1998.
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From Ibex wool to Princeton Tec headlamps, outdoor gear is increasingly being manufactured in American factories. Tom Vanderbilt explores the amazing new economics of insourcing.
LIKE ITS HOME state of Vermont, with its woodstoves and Subarus, the apparel maker Ibex has always had a pragmatic contrarianism about it. The company, which makes wool-based outdoor clothing, launched in the late 1990s—right when advanced synthetics were taking off. "People thought we were nuts," says CEO John Fernsell, who sits across from me at Ibex's headquarters in White River Junction, his bare feet poking out from under his desk.
On paper, there's no reason why Ibex shouldn't make all of its products in China. New Zealand wool is an expensive raw material with a complex supply chain. Saving on labor would be a boon, and big Chinese producers can finance production. Then there are the duties: when Ibex sells its U.S.–made products in Canada, for example, it gets hit with a 37 percent tax. It would pay less if it sent goods to Canada directly from China.
AS MUCH AS Ibex's move runs counter to the dominant narrative in manufacturing, the company is not alone. Whether referred to as reshoring or insourcing, the return of U.S. manufacturing is emerging as a serious topic in the national conversation. Earlier this year, the White House sponsored a well-publicized forum called Insourcing American Jobs. A recent report by the Boston Group, a consulting firm, notes that more than a third of large U.S. companies plan to return some production to the United States, or are at least considering it. Meanwhile, U.S. manufacturing jobs, long in decline, have actually rebounded since 2010.
Whether it's because of rising Chinese labor costs, the increasing value of China's fiercely protected yuan, the desire for nimbler supply chains, or simply a need to guard against patent theft, some companies are finding U.S. manufacturing to be not only possible but profitable. That seems especially true in the outdoor industry. In 2009, footwear giant Keen, which still does the bulk of its manufacturing overseas, began taking another look at the numbers. "Seventy percent of Keen's sales are in the U.S.," says James Curleigh, until recently the company's CEO. (He was hired away by Levi Strauss.) Among other things, Curleigh realized he could avoid transportation costs and the 37.5 percent duty for imported leather. Pair those advantages with new, highly automated direct-injection machines from Germany—which do away with stitching and toxic adhesives—and insourcing made sense. Keen opened a factory in Portland, Oregon, in 2010.
Part of the reason we often think nothing gets made here anymore is that clothing, a giant category, is the sector where foreign production looms largest. "It's hard to automate," says Sirkin. "There's a high labor content, and companies are very sensitive to labor costs." So, over the past few decades, the U.S. apparel industry migrated toward the 72 cents an hour that was the average wage paid in Yangtze River Delta factories in 2000, versus $15.81 an hour in the American South. At the peak of outsourcing, in 2010, Chinese workers were making 40 percent of the clothes Americans bought.
IN A CORNER of the factory floor at Princeton Tec, maker of headlamps and bike and dive lights, marketing coordinator George Chevalier, 28, points to a neatly arrayed grouping of bins, each piled high with brightly colored plastic parts.
So-called mass customization is one of the value-added things you can offer by having production close at hand. Giving the customer the power to control the creation of his product is a kind of parable for the company's relationship with its suppliers. As we sit in a conference room in Princeton Tec's low-slung headquarters in suburban New Jersey, global marketing director Gerard Armendinger tells me that, a few years ago, the company, which had been manufacturing in the Garden State since the 1970s, shifted some production to China. "It was the right moment," he says. "We were hitting critical mass, our capacity was maxed out, and LED costs were coming down." The move worked well—until it didn't.
There was just one problem. The light didn't sell, which Emerson blames on his own company's poor design. But Light and Motion had committed to the factory for a 10,000-lamp order. If he'd produced it in the U.S., he says, Light and Motion could have done a midstream redesign.
IBEX, AS IT happens, is bringing more than just production back to the U.S. It's bringing sheep. While most of its wool is sourced from New Zealand and some from Uruguay, about eight percent now comes from the Lehfeldt family ranch in Lavina, Montana. A short film on Ibex's website shows Bob Lehfeldt, the creased and tan patriarch of the ranching family, presiding over a pastoral landscape upon which Rambouillet sheep, bearing ultra-fine 21-micron wool, languorously graze.
While it might seem like an image campaign, studies have shown that American consumers aren't willing to pay more for a product just because it's made in the USA. No, the move to bring raw materials closer to factories has to do with an industrial process called superwashing—preshrinking yarn to make it laundry safe. Superwashing wasn't available in the U.S. until the late 2000s, when French textile processor Chargeurs opened a facility in South Carolina at the behest of the U.S. military.
Why the Pentagon's sudden interest in wool? The answer is surprising—and grisly. "The military is changing its stance on synthetics," says Keith Anderson, Ibex's VP of marketing. "So many guys were coming back with synthetics literally welded to their skin," he says, due to the intense heat of IEDs and other explosives. Wool, says Anderson, offers a superior melt point. This accidental fact, as well as the 2009 Kissell Amendment—which requires that all military apparel be made in America—is why, for the first time ever, wool can be superwashed domestically.
The superwashing story underscores a larger issue: industries are like ecosystems, comprising many symbiotic parts. Just as the U.S. military's shift in materials can help kick-start a domestic supply chain, when you take one key piece away, like highly educated workers, you can begin to lose entire networks that are hard to rebuild when companies want to bring production home.
Certain fields have already seen this type of outsourcing drain the talent pool. Emerson despairs of being able to find qualified toolmakers. "My lead toolmaker is probably going to retire in 10 years, and it scares the hell out of me. I advertised for toolmakers for six months, and most people don't even know what one is." In the end, he decided it was easier to have his toolmaker train someone in-house.
It hardly helps domestic manufacturing that the IRS allows companies offshoring to treat their moving expenses as a tax deduction—a practice that politicians refer to as paying American businesses to move away. And negotiators working on the Trans-Pacific Partnership, a landmark trade agreement, are currently working to eliminate the 20 percent tariff on shoes made in Vietnam, a move opposed by companies like New Balance, which makes a quarter of its shoes in New England. Although Congress hasn't passed a budget in three years, President Obama's 2013 budget proposal replaces that loophole with a 20 percent tax credit for companies returning production to the U.S.
But just as much as financial incentive, American production requires a leap of imagination, as Keen veteran Curleigh describes it. "I think people get locked into a supply-chain loop that's hard to get out of," he says. "You're fighting for capacity, fighting for materials—most companies don't have the wherewithal to step off that train.


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That I give and bequeath to my dear wife Fanny Mason all my property whatever I am possessed of at my Decease or otherwise entitled to either in Goods, Chattels, Money., Estates, Vessel and Furniture and every other property whatever or wherever.
That I do constitute make and ordain my dear wife Fanny Mason my sole executrix of this my last will and testament, recommending her to dispose of and sell for the greatest sum that can be obtained for the vessel called the Trusty Friend together with all her furniture. In order to enable her my dearest wife together with my dear child Susannah to return again to their friends at New York from whence they came (the said vessels conveyance papers and Register being at this time deposited) for the care thereof in the hands of my good friend Mr. John Plaw of Charlotte Town aforesaid Gentleman.
And lastly I do hereby utterly disallow Revoke and Disannul all former testaments wills, legacies, bequests and Executors, by me in any way before named willed or bequeathed; And I do hereby request that my Executrix do pay all my just and lawful debts and demands together with my Funeral expences soon as convenient after my decease Ratifying and confirming this, and no other to be my last Will and testament.


Companies who invest in complaints handling systems and software have an opportunity to learn from their mistakes, reduce risk and improve customer satisfaction.
No one likes making mistakes and in our experience, many businesses are not sufficiently prepared to manage complaints from their customers. We believe that effective complaint management needs to be correctly established and properly resourced - as ad hoc methods will sooner or later cause problems.
Workpro's Ken Naismith explained the importance of having a dedicated system that allows you to identify any problem cases, so that you can act quickly and 'nip complaints in the bud'.
Ken said: "Our software gives you oversight so that you can readily identify the cases and complaints that need to be escalated so you can prevent a complaint from going toxic.
Ken said that Workpro ensures that organisations follow the correct procedure when handling complaints and that this can protect them from regulatory fines and customer backlash.
He said: "Workpro is a specialist complaint handling system that gives you a process that works, and that is transparent and fair."
He added: "A further benefit of using a dedicated complaint handling system, is that it provides opportunities for the organisation to learn from mistakes.
"Workpro has tools that can help identify trends and root cause, so that you have an opportunity to improve your systems and processes.
Find out more about how Workpro can help you to achieve more with less, click here to get your demo.


Oprah Winfrey's 'The Next Chapter' preview: Steven Tyler talks monogamy and more. Oprah Winfrey is debuting today with a new show on her OWN channel. "Oprah's Next Chapter" is a show in which Oprah steps outside the studio for in-depth interviews with newsmakers, celebrities, leaders and real-life families.
"American Idol" judge and rocker Steven Tyler is the first interview of the series. His rumored fiance Erin Brady also joins them, where they speak very honestly about how hard it is to be monogamous in Tyler's kind of lifestyle.
After today's debut, the series continues in its regular time slot starting Sunday, Jan. 8 (9 p.m. to 10 p.m. ET/PT) on OWN.


I'm Nicole, a filmmaker based in Boulder looking to collaborate with a local actress on a film project. The role is for a female voice-over recording to be used with a variety of imagery (S-VHS footage, paintings, still images, etc). The concept is to present a woman's reactions and musings (like a journal/confessional) to a series of dreams she's recently experienced and the subsequent shift of thought she is going through. I'm looking for a woman with an older vocal range — so, the ability to sound about age 45-75.
I'd love to find someone interested in a form of collaboration. Much of the script is written, but I would very much prefer to incorporate natural shifts/improvisations throughout the recording process.
If you're interested in being a part of the project or learning more, send me an email. Feel free to send along examples of your previous work (if you have any — none required!) and any thoughts you have. As this is a self-funded film, I can't afford to pay much, but I'd be more than happy to do a barter/skills trade for graphic design or website creation.
Let's make some thought-provoking cinema together!
Nicole is an audio/video artist and filmmaker currently based out of Boulder, CO. Nicole received her BFA in Film & Television from New York University in 2013, during which time she received the Tony Hawkins Award for Audio Art and the Sony Award for Digital Art. In 2015, her short film Athanasia's Waltz was selected as a part of the New Filmmakers Festival and screened at Anthology Film Archives in New York, NY. Her most recent projects are an exploration of memory, specifically landscape memory and how a physical place can be viewed as a dynamic embodiment of time.


Welcome to my website! I'm Gemma and I'm a family and child photographer based in the Vale of Glamorgan. I'm Mum to two (not so little anymore) children and married to Hywel and we live in a little village called Colwinston.
I started my photography business in 2005 after the birth of my daughter. I'd always loved taking pictures but after having my daughter the true value of photography really struck me. To have beautiful images of my children as they have grown up and have them dotted around my house to see each day is just wonderful. I love capturing family love – sibling hugs, Daddy's girls, Mummy's boys, big squeezy hugs, snuggles and private family jokes. There's something so wonderful about the family dynamic, I thoroughly enjoy hanging out with each family and getting to know them as we tramp through the woods or meander through a meadow together.
If you'd like me to join you on a family adventure, get in touch.
My aim from each family photoshoot is to capture some of your family magic. I want you to feel it, when you look at images every day and for them to fill you with joy.
If you'd like to book a family photo session then please get in touch. I'm happy to give you a ring for a chat and answer any questions that you might have.
Any Questions? They might be answered in my F.A.Q.
Although I'm mostly behind the camera, I did venture over to the other side to have a family photo session myself! Here are just a few photos from our shoot at the beach. I'm so happy with them, the beach is my happy place and I just love looking at these images every day. They are taken by the wonderful and super talented photographer Aga Tomaszek.
Get in touch to book now!


Peace Patch Embroidered Iron On Patches - ON SALE NOW!
Wear this peach patch with pride on your sleeve... or on your hat, backpack, or anywhere else you want to express yourself! The colorful and cool design makes this embroidered iron-on peach patch bright, bold, and beautiful.


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Teaching Resources > Quantitative Writing > How to Use Quantitative Writing > Decide on Scaffolding
Decide How Much Scaffolding You Will Supply
Scaffolding is the frame or structure you provide for an assignment. Scaffolding is important for several reasons. An unstructured assignment is more difficult to complete since students may not be clear on what you want them to do. Even if they do understand the goal, they may not think to include all the steps you wish to see. Thus, the simplest form of scaffolding is to explicitly identify everything students should do to complete the assignment. An unstructured assignment also is more difficult to grade since different students may take the assignment in different directions.
The earlier the assignment is in the curriculum (introductory vs. senior capstone), and the earlier it is in a course, the more structure you should give students. In a more advanced assignment, it's appropriate to expect students to infer the appropriate steps, but in a more basic assignment, if you don't tell them what you want, you are unlikely to get it.
Another form of scaffolding is to create assignments which build on one another. Early assignments can be used to help students develop skills for subsequent, more complex assignments. Earlier assignments don't have to be formal papers; some could be given as exploratory tasks or as problems for small group discussion and oral arguments. If one assignment requires students to produce a table or a graph, a simple earlier assignment could be designed to teach this skill (e.g., an assignment asking students to design a graph; to write the title, legends, and labels; and to reference the graph in a short piece of text). Examples of "built-on" assignments might include:
In an economics course, one short paper might have students explain how the model of supply and demand can be applied to immigration reform. The next paper might incorporate a supply and demand analysis into a policy brief that includes data on the number of immigrants and their average skill level.
A research paper could be divided into multiple parts (e.g a proposal, a literature survey, a theoretical analysis, an empirical analysis, etc.) each with a separate deadline.
The last assignment for a course often brings together a number of learning outcomes connected both to subject matter and to methods of inquiry, analysis, and argument. By imagining the project you want students to complete at the end of the course, you can assess the project's difficulty level, analyze its component parts, and identify the "moves" students will need to make to complete it successfully. Such scaffolding is particularly helpful when you have students in your class with a range of backgrounds and levels of familiarity with quantitative reasoning.
Another aspect of scaffolding QW assignments involves the data. Will you provide the data, ask students to collect the data from a source you specify, ask students to find data to meet your parameters, or ask students to construct the data (e.g. survey)?
Carleton on Camera
Coached Problem Solving
Quantitative Writing
What is Quantitative Writing?
Why use Quantitative Writing
How to Use Quantitative Writing
Decide on Scaffolding
Rubrics for QW Assignments
Elements of Good Writing
Managing the Paper Load
Quantitative Writing in Economics
Teaching with Visualizations
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Last Modified: May 07, 2018
Short URL: https://serc.carleton.edu/46783

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I spent half of this past year living at the Regenerative Design Institute at Commonweal Garden, outside of Bolinas, California, between the vast Pacific Ocean and the wilderness. I want to share some photos I took during my time there — though of course there are too many for one post!
Coming up in part 2: beekeeping, flower crowns, the fruits of our labor, and lots of community feeling.
When the ceremony was over, the party began! Ben and Elana's reception included games, music, dancing, several theatrical performances written and acted by guests (including Elana's youngest relatives), contra dancing, delicious food, a fun photobooth, and plenty of laughter and mingling. In addition to signing the guestbook, guests could contribute to a quilt or type away at a typewriter. When the sun began to set, everyone chipped in to help clean up the site before heading home.
My sweet and fabulous friends Ben and Elana were married on August 27th at Newt Hollow in Briones Regional Park in the East Bay hills. I was honored to photograph their wedding, and I hope I've done justice to their thoughtful, personal, and totally rockin' party. I took so many great pictures (hard not to with such great subject matter!) that in this entry I'm just posting photos from before and during their ceremony.
Ben and Elana began their ceremony with a human-powered Rube Goldberg machine, and then walked through a labyrinth lined with all the friends and family who have helped them become the people they are today. They entered separately, met in the middle, and walked together, past friends who have known and supported them as a couple, to meet their pastor. They called first upon their parents, then upon their family, and finally upon their friends to surround them and to support them and their marriage by symbolically placing a hand upon their shoulders. I learned that I can in fact take photos with an enormous zoom lens one-handed!
After reading their vows to one another and exchanging rings, they stood together as spouses and invited us to the party! More soon!


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How to Meet and Date Rich Men in Ukraine
Formerly part of the Soviet Union, Ukraine threw off the shackles of a closed economy and embraced market economy after 1991. However it has not been a smooth ride for the country, first struggling with recession and then buffeted by the effects of 2008 global slump. Even then many entrepreneurs from Ukraine have made it good and eight of them even figure on Forbes 2012 World Billionaire List1 . Thus Ukraine may be a good place to visit if you are looking to be dated by successful and single men.
Meet the Mining Majors
How to Meet and Date Rich Men in Newcastle Upon Tyne, UK
Newcastle is the commercial and financial hub of North East England. The saying 'Carrying coal to Newcastle' is an indicator of the importance the city held during the heavy mining and manufacturing sectors during the Industrial Revolution. And even though much of that is now history, Newcastle still maintains a significance in the regional economy. So if you find yourself in this part of the country and are looking for eligible dates, the singles of Newcastle could offer a sporting chance.
Meet the Knowledge Professionals
How to Meet and Date Rich Men in Montreal, Canada
Montreal is the largest city in the Canadian province of Quebec as well as the second-largest in the country. Despite being surpassed in population and economic strength by Toronto in the 1970s, Montreal remains an important centre of commerce, finance, technology, culture, tourism and world affairs. So if you are looking to meet the wealthiest of Canadian singles, the Ville de Montreal should be the ideal place to start.
Meet the high-flying singles
How to Meet and Date Rich Men in Edinburgh, UK
As the capital city of Scotland, Edinburgh is an important hub of the economic, recreational and educational activities. So if you are looking for wealthy singles to wine and dine you in style in this part of UK, here are a few ways you can meet and date rich men in Edinburgh.
Get to know the finance fat cats
How to Meet and Date Rich Men in Quebec, Canada
Quebec is Canada's largest province by area and its second-largest administrative division. With a proud heritage of French culture and language, blessed with varied natural resources and a burgeoning economy Quebec offers a high quality of life to its residents. Hence if you are looking to jazz up your social life, the rich singles of Quebec could prove to be generous dates.
Meet the guys of the Knowledge sector
How to Meet and Date Rich Men in Bradford, UK
Bradford lies at the heart of West Yorkshire region in the UK and forms part of the West Yorkshire Urban Area conurbation which is the fourth largest urban area in the United Kingdom. Though the city gained economic significance as one of the earliest drivers of the Industrial Revolution in UK, now its economy is diversified. So if you find yourself in this part of the country, Bradford can be a good place to get to know rich single men.
Connect with the textile barons
How to Meet and Date Rich Men in Liverpool, UK
Liverpool is the fourth most populous British city and is the largest in Northern England. In eighteenth century, the city was a major hub of the Industrial Revolution, particularly because of its location as a major port. Though Liverpool enjoys a more diverse economy now, it is still one of the most economically vibrant cities of UK and thus a great place to enjoy a luxurious dating life.
Drop anchor with Shipping Honchos
How to Meet and Date Rich Men in Nova Scotia, Canada
Nova Scotia is the second-smallest province in Canada but the beauty and diversity of its maritime culture makes this one of the best places to live in the country. if you are based in this part of Canada and eager to date the well-off singles, here are a few tips on how to go about it.
Wealth of the Sea
How to Meet and Date Rich Men in Bristol, UK
Bristol is the largest centre of economy, culture and education in the South-Western region of England. Until the rapid rise of Liverpool, Birmingham and Manchester in the latter part of the 18th century, Bristol was one of the top three biggest cities of England together with London and Norwich. So if you are find yourself in this part of UK and are keen to meet eligible singles, Bristol may just offer you the best socializing opportunities.
Look for the shipping barons
How to Meet and Date Rich Arab Men
The image of wealthy Arabs has become a byword in popular culture for generous spending and lavish lifestyle. Add to this the exotic appeal of their culture and a rich Arab may be just the kind of partner you have been looking for. Here are then a few pointers on how to meet and date wealthy Arab men who can help you live the good life.
Be seen at the right places


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Piscine was a multidependent exhibition phenomenon that handled solo, group and collaborative situations: a hybrid apparatus that simultaneously worked as an exhibition space and as an artist group.
The phenomenon operated between 2015 and 2020.
Michael Roloff (2015 – 2016)
Mikkeline Daa Natorp (2015 – 2016)
Mark Tholander (2015 – 2020)
Jens Settergren (2016 – 2020)
Ida Sønder Thorhauge (2016 – 2018)
Anna Ørberg (2019 – 2020)
bonjour@piscine.dk
(2018) Be a Pattern for the World: a conversation between Piscine and Bergman & Salinas
(2016) Piscine: Fra Passé til Parasit
(2016) Piscine som flagskib for et nyt kunstmiljø i Aarhus?
(2016) Udstillingsplatformen Piscine indgår nyt samarbejde med Kunsthal Aarhus
(2016) Hjemløse kunstnere får tag over hovedet
(2015) Piscine – et friskt pust til den aarhusianske kunstscene
Newsletter from Piscine
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Piscine (Jens Settergren, Mark Tholander & Ida Thorhauge) (DK)
13. oktober – 30. december 2017
"The field of imaginary sciences has grown remarkably in recent years. New subfields are constantly emerging within the interstices of social production which Piscine Think Tank term The Terrain. We wish to recognise the need for the development of products oriented towards the subject of The Terrain, whom Piscine Think Tank addresses as The User. Piscine Think Tank strives towards the goal of solving problems between The User and The Terrain through the application of new technological developments. It is required that The User imagines the machines as body schema utilizing their mechanics to redefine body schema. If applied correctly, the machines enable The User to transform spatialities, and thus correct spatial discrepancies between The Terrain and The User itself. "
Imagineering was a collaborative project presented by Piscine at Adult exhibition space in Copenhagen. The Piscine group presented itself as a think tank which developed imaginary machines aimed towards the contemporary user. The exhibition itself presented 5 machine concepts, which were described through 8 light boxes on the walls, as well as in an accompanying publication containing text. Each machine corresponds to a body part, making the conceptual machinery represent both the actual and the abstract body.
Art Viewer: http://artviewer.org/piscine-think-tank-at-adult/
Kopenhagen: http://kopenhagen.dk/artguide/single/article/imagineering/
IDoArt: https://www.idoart.dk/kalender/piscine-imagineering
A. T-REACTOR, or Stomach
The T-REACTOR, or Stomach, is an imaging machine capable of transforming the cultural icon of the T-Rex dinosaur into virtually any type of image or consumer product. The T-REACTOR, or Stomach, uses the T-Rex as an energy source to initiate its operation. Thus, the T-REACTOR, or Stomach, produces products that are morphological variants derivative to the T-Rex.
The T-REACTOR, or Stomach, needs the T-Rex as its source of energy in order to initiate its operation. When The User inserts the T-Rex energy source, and activates the machine, it establishes a transfer function between the object sectors of The Terrain. The Terrain can be seen as a mass divided into different rings, just as in a tree trunk. These different rings are called modules, or landscapes. The rings are all subdivided into smaller pieces, like a pie chart, and these pieces are called sectors. Incorporated in this area, both horizontally and vertically, are the object sectors. These sectors imply that all objects belong to their class of objects, for example, that the T-Rex belongs to the class of dinosaurs. As soon as the T-Rex is inserted as an energy source in the T-REACTOR, or Stomach, the movement between the object sectors will transform so that the objects can change class. As a result of this, the leg, for example, may differ from the class of legs and now belong to the class of sofas, and the table can leave the class of tables and now belong to the class of weather conditions. Of itself, this process will allow the T-Rex module to spin between any type of dinosaur, which, in essence, means that the energy source gains free movement between any object sector. The transformation of the T-Rex into any dinosaur whatsoever, will furthermore accelerate to such a level that the T-Rex is transformed into any dinosaur simultaneously, and can no longer be measured. Because of this, the T-Rex can also be termed as Any-Dinosaur. As the products produced by the machine are morphologically identical to the T-Rex, these products can also be denoted as Any-Dinosaur, or Any-Product.
The T-REACTOR, or Stomach, is composed of an opaque black box system, where only the input (T-Rex, or Any-Dinosaur, energy source) and output (Any-Dinosaur, or Any-Product) can be determined. This is because the internal structure is working at such an accelerated speed, that it cannot be measured by any device available today. Unlike other black box systems, the input and output of the T-Reactor, or Stomach, cannot be thought of as unidentical, but rather as morphological variants which are derivative to the energy source (T-Rex, or Any-Dinosaur).
B. PLEASURE MACHINE, or Nose
The PLEASURE MACHINE, or Nose, is a machinery capable of extracting currents from the Zeitgeist, and cross-pollinating these ideas with the purpose of generating new unique variants. Through this mechanism, the machine is always at the forefront of development, and invents products yet unknown to The User.
Combining big data statistics and in-depth psycho-geographic reviews, the PLEASURE MACHINE, or Nose, can foretell specific movements in historical timeliness. In this way, it is possible to invent new concepts for user-stimulation by offering solutions to problems yet unknown to the contemporary consumer. The machine is operated from a control house beneath the nose, from where the tentacles submit to the Easy-Touch Interface.
When switched on, the PLEASURE MACHINE, or Nose, immediately shoots out two tentacles through the nostrils. The external nostril-openings function as a gateway to the turbinates, in which two separate shafts connect to the machine-core. The tentacles are rooted at the machine-core, and instead of an additional cooling system, the exhalation of the tentacles is used as a means to maintain a constant 32°C core-temperature. By maintaining this temperature, hypertrophy is avoided, and a comfortable working environment is ensured. Utilizing ultrasensitive cilia located at the outermost edges of the tentacle-apertures, the nose can sniff new currents in the Zeitgeist and incorporate them into the machine itself. The tentacles draw on the latest ventilation technology, specifically, the newly invented ventron, which extracts the particulate materiality of the air in relation to current flows, primarily through sweat. The ventron collects sweat fumes, and is capable of distinguishing between a large number of bodies, and further subdividing the biological composition of each separate body. The fume-input of the PLEASURE MACHINE, or Nose, is the substance that historical timeliness allocates. The machine will convert this historical substance into an ahistorical use-mass by processing it in its ventilation shaft, and converting it into product concepts. It is then up to The User to employ the use-mass in an appropriate manner.
C. CAROUSEL, or Pelvis
The CAROUSEL, or Pelvis, is a merry-go-round whose axis is centered around several points at the same time. It produces vanishing points which will be usable to add more perspectives to the domestic space.
To activate the machine, The User must provide an energy source, which initiates the rotation of the centrifuge. Only the rotation makes the carousel a spatial principle, which means that the carousel gains a surface upon activation. This surface is determined by the axis of rotation. As any surface can be considered a collection of points, or coordinates, these will be determined by the several points on which the rotation is centered. This makes the rotation extremely unstable, as the de-centralised center makes the coordinates, or points, constantly appear and reappear, resulting in an overall movement which filters out these coordinates as vanishing points. When the vanishing points becomes disposed of by the mechanism, they can be collected by The User. As the surface of the CAROUSEL, or Pelvis, is not subject to a reduction of coordinates, the mechanism is not transforming points into vanishing points, but rather actively producing vanishing points. Thus, the CAROUSEL, or Pelvis, adds distortion to the worldspace.
Upon rotation, the CAROUSEL, or Pelvis, will produce a number of vanishing points which are to the disposition of The User. If The User places them in a given room, for example in the living room or in the kitchen, the vanishing points will bend the room according to the point of view. The User will thus be able to add more perspectives to the home environment by constantly adding new vanishing points. If The User is tired of the perspective of the furniture, for example, then The User will be able to add a number of vanishing points, which will make the furniture converge according to these points in a multi-perspective. Using the CAROUSEL, or Pelvis, The User is not limited to the 6-point perspective, but can also converge the surrounding objects in, for example, 10-point, 20-point or 47-point perspectives. The User can thus relax in an 18-point perspective armchair or drive to work in a 78-point perspective car.
If the vanishing points are applied to consumer products such as the gender, it will bend the dimensions, as each line of the gender object will have several directional vectors simultaneously.
The CAROUSEL, or Pelvis, is constructed as a multifaceted floor property, built up as a truss structure of arbitrary triangles. Each triangle is composed of impossible measures, making the architecture highly unstable.
D. VAMPIRE, or Spleen
The VAMPIRE, or Spleen, is a machine that filters and recharges particles. It sucks up energy from the outside, and by internalising it, regenerates itself. It has an unlimited ability to circulate matter. By eternally circulating matter in a vacuum, it can create immortality through vampiric reassemblage of particles.
The VAMPIRE, or Spleen, consists of a steel-reinforced coffin mounted with a conical section. An airflow is established inside the VAMPIRE, or Spleen, by use of cyclonic separation, as in a vacuum cleaner, separating heavier fractions such as particles, or finite events, from lighter fractions such as gases, or infinite time. Datacom cables connect the coffin to the external folklore motor, allowing folkloric energy to charge the machine before use.
The collected particles, or finite events, are filtered through the mortician-unit and end up in the cyclone, or veins, of the VAMPIRE, or Spleen, where a spinner and an inserted airflow creates an inner vortex of the particles, or finite events. The curved veins of the cyclone spins the inlet stream, which makes the finite number of events, or particles, stream in an infinite time. As this cyclonic action is indefinite, due to the added forces of the external folklore motor, each finite particle, or event, will end up in the same position at an infinite number of times in the infinite time stream. This mechanism, known as the Eternal Return Cyclone, allows the inserted events, or particles, to constantly re-enter through the different circumferential gaps, and in this vortex they metabolize and merge once again with the main stream of infinite time. During metabolization the vacuumised particles rotate in the Eternal Return Cyclone until complete assimilation.
The VAMPIRE, or Spleen has the potential for providing immortality for body shells or eternity for events, so long as its external energy source, the folklore motor, keeps running. The User must ensure that the motor is fueled before taking the VAMPIRE, or Spleen, into use.
E. CHASSIS, or Thorax
The CHASSIS, or Thorax is a device for the synchronisation between user and object. The machine is constructed as an inhalation-architecture utilising friction energy to stretch and manipulate objects.
The CHASSIS, or Thorax is a containing principle in a multi-plan formation that can restructure the sculptural conceptions of objects in relation to The User. The User can insert objects, such as furniture or body parts, into the mechanism. The CHASSIS, or Thorax, will then stretch the sides of the inserted object until all sides are on the same plane. In solid geometry, the sides of an object are also called faces: in this way, the CHASSIS, or Thorax, can be said to transform the multiple faces of an object into a singular face.
If multiple objects are inserted simultaneously into the mechanism, they will be stretched indefinitely so that the numerous sides, or faces, of both inserted objects will be on the same plane. This procedure will align the outer boundaries of any inserted solid object. The CHASSIS, or Thorax, can be used in any home to transform the body parts of The User to form the same spatial principle as, for example, household items and furniture. In this way, the CHASSIS, or Thorax, can be used to synchronise user and home. If The User chooses to insert an arm while inserting a toothbrush in the operation room of the CHASSIS, or Thorax, the mechanism will stretch them into a singular spatiality.
The internal vehicle frame is tightened as symphonic fractals in spinal chords. The containing principle is constructed as an inhalation-architecture that exhumes rotoric coughs through an aspiration-motor. The inhalation-architecture can be imagined as rotating discs, and it is these rotating discs, which, in cough, stretches the inserted objects by mutual friction.
When using the CHASSIS, or Thorax, The User must be aware of following the correct loading order, as any haphazard application may cause the different faces to conflict.
Photo: David Stjernholm. Copyright and courtesy of Piscine.


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Media about S&P Agency
TAX ISSUES / DISPUTES PROTECTION
COMPREHENSIVE SUPPORT FOR INVESTMENT PROJECTS
PROTECTION IN CRIMINAL PROCESSES
CRISES / BUSINESS CONFLICTS SOLVING
REPUTATION PROTECTION
CRISIS COMMUNICATIONS, REPUTATION PROTECTION
COMPREHENSIVE BUSINESS PROTECTION
CORPORATE STAFF TRAINING
LEGAL DISPUTES/PROTECTION IN THE COURT
SERVICES IN THE FIELD OF TAXATION
Assistance in the development of an investment project
ROUND TABLE ON THE THEME: "NEW SANCTIONS WITH REGARD TO THE COUNTRY-AGGRESSOR: BLOCK or ALLOW".
/Insurance
ROUND TABLE ON THE THEME: "NEW SANCTIONS WITH REGARD TO THE COUNTRY-AGGRESSOR: BLOCK or ALLOW".
In Ukraine, a wave of lawsuits is expected to be submitted to the Supreme Administrative Court, as well as to the European Court of Human Rights, demanding the repeal of the Presidential Decree on new sanctions against a number of Russian companies. This was stated by Nataliia Osadcha, a partner of Siutkin&Partners (S&P Agency) company, during the round table on the topic "New sanctions against the aggressor country: block or allow".
The event was held by the company LIGA Zakon on May 23rd. Representatives of the government, business, political scientists, lawyers, public figures and participants of the telecommunication market took part in it. Experts discussed the mechanism for implementing the presidential decree on new sanctions against Russian companies, blocking social networks, as well as improving legislation in this area.
According to partner of Siutkin&Partners (S&P Agency) Nataliia Osadcha, at the moment in Ukraine there is no legal mechanism for implementing the decree. Those. for state bodies, there is no procedure for blocking the assets of enterprises that fall under sanctions. "If there is no procedure, then any company can apply to the court and cancel all measures taken on the block.
a specialist!
For example, the National Bank can not, without having a clear procedure and deadlines, and is guiding only by decree to commit an act that later will violate someone's rights", Nataliia notes.
According to Nataliia Osadcha, if in the near future for government agencies and businesses the procedure for implementing the decree and the responsibility for failure to implement sanctions measures will not be fully documented, then a mass appeal to the courts will be expected from the business side in order to protect their rights and assets.
She also noted that lawyers have already developed two types of lawsuits. The first concerns the violation of the rights of individuals and legal entities to use the acquired property, the second concerns the blocking of access to social networks. In this case, the lawsuit provides for the recovery of losses from the state in favor of companies that have paid for the right to use the software.
According to Nataliia Osadcha: "If a natural or legal person wants to return money or hold the state accountable for violation of his rights, that is, a very clear practice of the European court that will give them such an opportunity."
Author: Mykola Siutkin
Name: Mykola
Surname: Siutkin
Email: siutkin@sp.agency
Company address: 10 Redutnaya Street, Kyiv, Ukraine
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Patrick Shanahan, acting defense secretary, arrived in Afghanistan on an unnamed visit amid a United States push to negotiate peace with the Taliban.
Shanahan will join Afghanistan's President Ashraf Ghani, whose government is not part of major talks between US and Taliban officials last month that officials hope to make a breakthrough in the 17-year conflict. The Afghan government is involved in discussions about Afghanistan, "Shanahan told a small group of reporters who traveled with him on a surprise trip on Monday.
The Pentagon chief actor said Washington had important interest in regional security and want to hear from land commanders.
Shanahan replaced Jim Mattis, who left December on US policy differences Donald Trump.
Taliban refused to speak Directly in Ghani's government, it is called the "puppet" of the West. But Ghani's allies in Washington say that the Afghans must lead to the peace process.
4,000 US troops in Afghanistan could lead to regional riot.
Taliban wanted all American troops to leaving, and officials saying at the top of the list of armed group demands in conversation discussions.
Shanahan, who also meets US commanders, told reporters that he did not receive directions to reduce troops in Afghanistan.
Kabul's report from Al Jazeera that Tony Birtley says that Shanahan's journey was "a mission to search the truth."
"His views on Afghanistan are not well known, and are expected to be introduced to them after this visit," Birtley added. "His comments about the Afghan government's involvement in peace talks are important for the government because they feel the statements of US-led talks."
Zalmay Khalilzad, a special envoy of the Trump administration for Afghan peace talks, said on Friday that although the Taliban peace talks were in its early stages, he hoped that a deal could be done by July.
Since the end of September as a special US representative for the reconciliation of Afghanistan, Khalilzad launched a multitude of talks with Taliban and other regional representatives in Afghanistan, Pakistan, United Arab Emirates, India, Russia, Uzbekistan, Turkmenistan, Saudi Arabia, and Qatar.
The latest US envoy's talk was in Doha late last month where two sides met in six days.
Washington wants to ensure that Afghanistan will not have teams that will use the country as a base to launch US attacks.
The next conversation was due in Qatar on February 25.
In December, many reports that Trump had planned to divide the number of US forces in Afghanistan. At his State of the Union address last week, the US president said that any elimination group would be linked to progress in peace talks.
General Joseph Votel, the commander of the US Central Command, which appeared before Congress last week, offers more reliable view of Afghanistan, stating that the current maneuvering between US negotiators and the Taliban are "our first true opportunity for peace and reconciliation since the beginning of the war."
Votel said the Taliban were still capable of making a huge casualty in the Afghan government's forces.
Just last week, Taliban fighters killed several dozen Afghan troops in an attack on an army base in the northern province of Kunduz.
In addition to fighting the Taliban, the US and the coalition forces in Afghanistan are focused on a member of Islamic State of Iraq and the Levant (ISIL, or ISIS), known as ISIS-Khorasan, made up of foreign warriors from Pakistan.


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Medica Kosova non-governmental organization (NGO) English Shqip
+381 390 321139 st. Luigj Gurakuqi, no. 39 Gjakova, The Republic of Kosova
-Members
-Board
-Financing
-Our vision and Mission
-Facts and figures
-Working strategies and principles
-Projects
-Implemented Projects
-Ongoing projects
-Donors
-Trainings
-Project's evaluation
-Interviews and articles
-Presentations
-Awards and appreciations
-Images
Home/ Members
Medica Kosova is founded and registered based on Law on Freedom of Association according to which Assembly of Members is the highest decision making body and the Advisory Board proposes solutions and strategies to be approved by the Assembly.
At least 2/3 of Assembly Members must be present in the Annual Assembly meetings for adopting narrative and financial reports issued by Management and strategies designed for implementation of organisational objectives and goals.
"Medica Kosova" is established in Aug 1999 and registered as a local NGO since Oct 2003 for improving mental and physical situation of women affected by war and post-war violence. The support consists of psychosocial counseling, legal assistance, provision of agricultural and bee-keeping activities for increasing family incomes, medical care in the center ambulance and the mobile unit traveling to the villages of Dukagjini Region. To this end, the organization implemented over 30 projects providing social and rehabilitation services, reproductive health care, women's access to properties and other legal rights, and since 2011 access to justice and documentation of war rape.
Medica Kosova addresses implementation of National Strategy against Domestic Violence in line with Istanbul Convention
After two decades, the hidden victims of the Kosovo war are finally recognised
IMPLEMENTING NORMS, CHANGING MINDS: EWL MEETS WITH WOMEN'S ORGANIZATIONS FROM THE WESTERN BALKANS AND TURKEY
WOMEN'S RIGHTS ACTIVISTS FROM WESTERN BALKANS DEVELOP A STUDY VISIT TO VILNIUS IN LITHUANIA
Medica Kosova non-governmental organization (NGO)
st. Luigj Gurakuqi no. 39,
Gjakova,
The Republic of Kosova
Web: http://www.medicakosova.org
Facebook: Follow us on Facebook
Medica Kosova © 2019 | Privacy Policy


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Q: asp.net mvc3 redirect user after cookie expired I have this problem. When user log in, I create cookie with formsauthanticationticket:
var formAuthTicket = new FormsAuthenticationTicket(1, model.UserName, DateTime.Now, DateTime.Now.AddMinutes(1), false, "");
                    var encryptedFormAuthTicket = FormsAuthentication.Encrypt(formAuthTicket);
                    var cookie = new HttpCookie(FormsAuthentication.FormsCookieName, encryptedFormAuthTicket);
                    Response.Cookies.Add(cookie);
                    return RedirectToAction("Index", "Home");

Now. In PreRequestHandlerExecute event i check, if user is authenticated/cookie exists.
var cookie = context.Request.Cookies[FormsAuthentication.FormsCookieName];
        if (cookie != null)
        {

            var formAuthTicket = FormsAuthentication.Decrypt(cookie.Value);
            var newFormAuthTicket = new FormsAuthenticationTicket(formAuthTicket.Version, formAuthTicket.Name,
                                                                    formAuthTicket.IssueDate,
                                                                    DateTime.Now.AddMinutes(1),
                                                                    formAuthTicket.IsPersistent,
                                                                    formAuthTicket.UserData,
                                                                    FormsAuthentication.FormsCookiePath);
            cookie.Value = FormsAuthentication.Encrypt(newFormAuthTicket);
            context.Response.Cookies.Set(cookie);
        }

But when cookie not exists/expired I want to redirect the user to login page, when he clicks on some link. Any idea?
Thanks
EDIT
Because I can't use Authorize attribute. I know about it. I have httpmodule, in assembly, which is referenced in web project. In httpmodule I have Init method, where I initialize PreRequestHandlerExecute() event. In the event I check authentication of user. If I use in "else" something like this -> Response.Redirect(url), occurs cycle redirection, that's wrong. After 10minutes without any request, user clicks some link, he will be redirected to login page -> that's my problem, I can't solve.

A: Why you just don't use the [Authorize] attribute? Added in the sign of your action and if the cookie related with authentication expired will be automatically redirected to the login Page
For example
[Authorize]
public ActionResult Profile()
{
}

And if you need a custom implementation created your custom attribute implement the interface for example
public class FooAuthorizeAttribute : AuthorizeAttribute
{
     public string fooField{ get; set; }

public override void OnAuthorization(AuthorizationContext filterContext)
{
    //Do my stuff
}

Then called in your action
[FooAuthorizeAttribute]
public ActionResult Profile()
{
}

redpajama_set_name: RedPajamaStackExchange


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SPH full-year net profit falls 17.5% to $265.3 million
Singapore Press Holdings said its net profit for the full year ended Aug 31 fell 17.5 per cent to $265.3 million. PHOTO: ST FILE
Yasmine Yahya
Senior Political Correspondent
Oct 14, 2016, 6:22 pm SGT
http://str.sg/4fkV
SINGAPORE - Singapore Press Holdings said its net profit for the full year ended Aug 31 fell 17.5 per cent to $265.3 million.
This included impairment charges of $28.4 million, which primarily related to the magazine business, whose performance was affected by unfavourable market conditions.
Excluding the impairment charges, net profit would have fallen by 11.2 per cent.
At the operating level, recurring earnings declined 13.7 per cent to $305.2 million, while revenue dipped 4.5 per cent to $1.12 billion, as the economic slowdown and structural challenges continued to hurt the company's core media business.
The media business saw revenue slide by 7.6 per cent from a year ago as advertising revenue fell 9.2 per cent and circulation revenue dipped 3 per cent.
The decline in the media business was cushioned by contribution from the property segment, which put in a resilient performance despite a sluggish retail environment.
Property revenue rose 4.6 per cent from a year ago, bolstered by higher rental and services income from the company's retail assets, including The Seletar Mall, which started business in November 2014.
Revenue from SPH's other businesses grew 11.4 per cent, lifted by higher income from the exhibitions and online classifieds businesses.
SPH chief executive Alan Chan said it has been a challenging year, marked by a "very tough" operating environment.
"Looking ahead, market conditions are expected to remain difficult in view of the uncertain economic outlook and the continuing disruption of the media industry," he added.
"We reported in the last quarter that the group has embarked on a comprehensive review of its core media business. This exercise is ongoing."
SPH will continue to focus on its drive to transform and sustain the media business, whilst pursuing growth opportunities, he said.
SPH directors have proposed a final dividend of 11 cents a share. Together with the interim dividend of 7 cents, the total dividend payout for the full year will be 18 cents a share.
SINGAPORE PRESS HOLDINGS


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Governor Wolf Announces Naloxone Standing Order to Combat Heroin Epidemic (+ FAQs)
Government That Works, Press Release, Results, Substance Use Disorder
On January 10, 2018, Governor Tom Wolf declared the opioid epidemic a statewide disaster. Under this declaration, emergency service providers are now able to leave naloxone behind after a 911 visit. Centralized Coordinating Entities (CCE) can contact the Pennsylvania Commission on Crime and Delinquency (PCCD) to obtain naloxone for first responders under their jurisdiction. For more information, visit PCCD's website.
Updated with the paragraph above: February 15, 2018, 12:00 PM
Updated with FAQs: October 29, 2015, 3:59 PM
Posted: October 28, 2015, 1:20 PM
Harrisburg, PA – Governor Tom Wolf today continued his "Government That Works" Tour and announced a significant step forward in his administration's fight against the heroin epidemic in Pennsylvania. Governor Wolf stood with Physician General Dr. Rachel Levine at the Pennsylvania Medical Society as Dr. Levine signed a statewide standing order for naloxone*, a medication that can reverse an overdose that is caused by an opioid drug. The governor was also joined by Secretary Ted Dallas, Secretary Gary Tennis, Secretary Karen Murphy, and Chairman Josh Shapiro.
"This standing order is the next step in my administration's fight against the addiction and overdose epidemic in our state," said Governor Wolf. "We must do all that we can to support those Pennsylvania families suffering from the effects of addiction. I am proud to take this action with my cabinet members today."
Through the signing of this standing order, Dr. Levine has signed a prescription for naloxone to all Pennsylvanians. For more information about naloxone and how to administer it, please visit the Department of Drug and Alcohol Program's page on overdose reversal.
"Making it possible for all Pennsylvania residents to access the life-saving drug naloxone is a huge victory in our battle against drug overdose deaths in the commonwealth," said Physician General Dr. Rachel Levine. "I am proud to sign this standing order and continue the efforts of the Wolf Administration to protect the most vulnerable Pennsylvanians. This forward-thinking initiative gives people the tools they need to keep their communities and families intact."
The rise in heroin addiction and prescription drug abuse has quickly led to a public health crisis in Pennsylvania, where 1 in 4 families suffer from the effects of substance abuse addiction. Heroin and opioid overdose are now the leading cause of accidental death in Pennsylvania, killing more individuals than those involved in fatal motor vehicle accidents. In 2014, 2,400 Pennsylvanians died from drug overdoses.
"Addiction can happen to anyone from any walk of life, and heroin is now the second leading cause of years of life lost," said Department of Human Services Secretary Ted Dallas. "I am not going to accept that. We must fight to ensure our children, our loved ones, and our neighbors have access to these critical life-saving programs."
"Too many Pennsylvania families are being affected by this crisis," said Department of Drug and Alcohol Programs Secretary Gary Tennis. "In addition to finding solutions like these to save lives, we are also working hard to raise awareness and break down stigmas about substance abuse disorders. My department will continue to work tirelessly to provide the best possible recovery and treatment options, to ensure that we do not see high rates of overdose recurrences."
"It is our goal at the Department of Health is to ensure that life-saving resources such as naloxone are available to every Pennsylvanian," said Department of Health Secretary Dr. Karen Murphy. "Educating Pennsylvanians on how to use naloxone in case of an emergency is essential to curbing the devastating number of opioid-related overdose deaths that we have seen in the commonwealth over the past several years."
"The opioid epidemic is a serious public health issue and is it also an issue of public safety," said Pennsylvania Commission on Crime and Delinquency Chairman Josh Shapiro. "PCCD is working to ensure that the healthcare and law enforcement communities are working collaboratively to bring all our resources to this fight."
Since his inauguration, Governor Wolf has worked with his administration to provide real solutions not only to save lives but also to help addicted individuals and their families get the treatment they need to live long, productive lives. Such actions taken by the Wolf Administration include the development of the ABC-MAP prescription drug monitoring program, the creation of the interagency Heroin Task Force, the support for the use of naloxone at schools across the Commonwealth, and stocking all Pennsylvania State Police cars with the naloxone drug. Since equipping State Police cars with naloxone, over 300 lives have been saved with this drug.
Governor Wolf's 2015-16 budget proposes $7.5 million in funds to provide more naloxone to police and to provide more and better treatment options for Pennsylvanians.
"My administration, law enforcement agencies, those in the health care field, those in county services offices, and many others work hard every day to fight back against heroin epidemic," concluded Governor Wolf. "My greatest hope is that today's action will continue to aid these statewide efforts to overcome the addiction and overdose crisis in Pennsylvania."
Naloxone FAQs:
What is naloxone?
Naloxone is a medication that can temporarily reverse an overdose that is caused by an opioid drug (prescription pain medication or heroin). When given during an overdose, naloxone blocks the effects of opioids on the brain and restores breathing within two to eight minutes. Naloxone has been used safely by medical professionals for more than 40 years and has only one function: to reverse the effects of opioids on the brain and respiratory system in order to prevent death. Naloxone has no potential for abuse- a person can't get high or become addicted to it – and it is safe to use. (Naloxone does not work to reverse overdose from other types of substances).
How do I get naloxone?
Family members and friends can access this medication by obtaining a prescription from their family doctor or by using the standing order (a prescription written for the general public, rather than specifically for an individual) issued by Rachel Levine, M.D., PA Physician General. The standing order is kept on file at many pharmacies, or may be downloaded here.
If you cannot access Scribd, you can also download the standing order here from the Department of Health's website.
Naloxone prescriptions can be filled at most pharmacies. Although the medication may not be available for same day pick up, it can often be ordered and available within a day or two.
What types of naloxone are available?
Two of the most common ways that naloxone is administered are intranasal (nasal spray) and the auto-injector. Please note, not all pharmacies stock both forms and insurance coverage may vary depending on the type of medication being purchased and each individual insurance plan. Check your insurance prescription formulary or call your benefits manager to determine if the medication is covered by your particular plan or if your purchase of the medication will be an out-of-pocket cost.
Intranasal currently has two pieces that are easily assembled: a prefilled medication tube and an atomization device which is sold separately. The nasal piece may not be stocked at your local pharmacy; however, they may assist in ordering it. Additionally, the nasal atomization device can be ordered from a number of medical supply companies without a prescription.
The Auto-injector comes in a manufactured dosage form (similar to an epi-pen) and has a recorded message to talk you through giving the medication.
How do I administer naloxone?
In addition to talking to your healthcare provider or the pharmacist about how to use naloxone, individuals giving this medication to someone should take the online training ahead of time. Training is available at one of the Department of Health approved training sites: Get Naloxone Now or PA Virtual Training Network. These easy to understand, brief trainings explain how to recognize the signs and symptoms of an opioid overdose, what to do in the event of an overdose, and instruct on how to give naloxone. While it is not necessary to obtain a training certificate in order to purchase naloxone, learning these important details will help you respond properly in the event of an overdose and also meet the immunity requirements of PA Act 139.
Could I get in trouble for giving someone naloxone (statutory immunity)?
Good Samaritan: Through the 'Good Samaritan' provision of Act 139, friends, loved ones and bystanders are encouraged to call 911 for emergency medical services in the event an overdose is witnessed and to stay with the individual until help arrives. The provision offers certain criminal and civil protections to the caller so that they cannot get in trouble for being present, witnessing and reporting an overdose.
Administering Naloxone: Physicians are permitted to write third party prescriptions for naloxone and you are immune from liability for giving naloxone if you believed the person was suffering from an opioid overdose (heroin or prescription pain medication) and you called for medical help/911 after giving the medication.
Does insurance cover naloxone?
Insurance companies vary in how they cover naloxone and other drugs used to treat an opioid overdose. Prior to having a naloxone prescription filled with a pharmacy, consumers are encouraged to check with their insurance carriers to find out whether naloxone is a covered benefit under their policy, and, if so, what form of naloxone is covered, and any cost-sharing amounts that may apply under their policy.
Will Fee-for-Service and the managed care organizations (MCOs) pay for naloxone dispensed under the standing order for Medical Assistance recipients?
Will Medical Assistance require a prescription in order for the pharmacist to fill the naloxone for a Medical Assistance recipient?
Yes, per 55 Pa Code, Chapter 1121 – Pharmaceutical Services – §1121.52, pharmacists can treat the standing order as a verbal order for Medical Assistance recipients.
Can a person other than the eligible Medical Assistance recipient (friend or family member) obtain the naloxone at the pharmacy on the recipient's behalf? Will the Medical Assistance Program make payment?
PA Medical Assistance will make payment for naloxone for the eligible Medical Assistance recipient.
Is prior authorization required by Medical Assistance for any of the naloxone products or supplies?
The Evzio Auto-Injector is covered by Medical Assistance, but requires prior authorization. Generic naloxone is covered without the need for prior authorization.
Where can a pharmacy access Medical Assistance billing procedures for naloxone and the nasal actuator?
The Fee-for-Service Program will post information related to billing for naloxone on the DHS Pharmacy Services website. Pharmacies will need to contact each MCO individually to obtain information about their billing procedures.
Will copays apply for the naloxone products and nasal actuator?
No, the Medical Assistance copay will not apply.
Is there a limit to the number of times that a Medical Assistance recipient can get naloxone?
No, there is no limit to the number of fills that can be obtained.
How can someone with an addiction to prescription pain medicines, heroin or other drugs get help?
Treatment for drug abuse and addiction is available! You can find out more by calling the County Drug and Alcohol Office where you live. For more information or to get the contact information for your local office visit the Department of Drug and Alcohol Programs website or call 717-783-8200.
While it may be uncomfortable to talk to someone about their substance abuse problem, research shows that it is more likely for an individual to seek help for their problem within 30 days following an overdose if someone talks to them right after the overdose event about going to treatment.
Are there any other standing orders in Pennsylvania?
Yes. There have been three well publicized standing orders that we are aware of to date that impact Pennsylvania which include: 1) CVS who has developed one for their pharmacies nationwide; 2) Montgomery County; and 3) Allegheny County.
The standing order being signed today does not affect these standing orders. Instead the Physician General's standing order expands upon them to ensure statewide access.
Naloxone Standing Order by Governor Tom Wolf
*If you cannot access Scribd, you can also download the standing order here from the Department of Health's website.