text:
Research ArticleOriginal Research
Extracorporeal Life Support as a Bridge to Lung Transplantation: A Single-Center Experience With an Emphasis on Health-Related Quality of Life
Annemieke Oude Lansink-Hartgring, Wim van der Bij, Erik A Verschuuren, Michiel E Erasmus, Adrianus J de Vries, Karin M Vermeulen and Walter M van den Bergh
Respiratory Care May 2017, 62 (5) 588-594; DOI: https://doi.org/10.4187/respcare.05300
Annemieke Oude Lansink-Hartgring
Department of Critical Care
For correspondence: a.oudelansink@umcg.nl
Wim van der Bij
Department of Pulmonary Diseases and Lung Transplantation
Erik A Verschuuren
Michiel E Erasmus
Adrianus J de Vries
Karin M Vermeulen
Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.
Walter M van den Bergh
BACKGROUND: Extracorporeal life support (ECLS) as a bridge to lung transplantation is increasingly used, but information on long-term outcome is scarce. We aim to summarize our experience with an emphasis on health-related quality of life. Secondary outcomes include ICU and hospital stay and pre- and post-transplant mortality.
METHODS: A retrospective cohort study of all adult subjects receiving ECLS as a bridge to lung transplantation from 2010 to 2014 was reviewed and compared with all adult subjects who underwent bilateral lung transplantation in the same period. For the ECLS group, the general health status was assessed with the use of the EuroQol Group 5-Dimension Self-Report Questionnaire.
RESULTS: A total of 130 bilateral transplants were performed, 9 transplants were performed after ECLS therapy. Another 11 subjects died on the waiting list while receiving ECLS. Quality of life, at 12 months after surgery, from a subject's perspective was comparable in both groups with a median score of 80 on the visual analog scale. The median (interquartile range [IQR]) EuroQol Group 5-Dimension Self-Report Questionnaire 3L score from the societal perspective in the ECLS group was 0.73 (0.5–0.9). Median (IQR) ICU stay was 25 d (9–68 d) for the ECLS group versus 7 d (4–18 d) for the control group (P = .001), and in-hospital stay was 66 d (40–114 d) versus 42 d (29–62 d) (P = .004).
CONCLUSIONS: ECLS can be used as a bridge to lung transplantation. A significant number of subjects were not bridged successfully due to different reasons. Outcomes after successful transplantation after ECLS might be comparable with the general population undergoing lung transplantation in terms of quality of life, lung function, performance tests, and mortality, although ICU and hospital stay are longer.
health-related quality of life
The indication for extracorporeal life support (ECLS) by means of extracorporeal membrane oxygenation is acute, potentially reversible cardiac or respiratory failure, when conventional therapy has been insufficient.1 In addition, ECLS can also be used in patients with chronic respiratory or cardiac failure as a bridge to transplant or to support cardiopulmonary resuscitation.2 More than 3 decades ago, ECLS was introduced to manage patients on the waiting list for lung transplantation with a high risk of dying of acute respiratory failure refractory to mechanical ventilation.3 More recently, ECLS has become a treatment option for hemodynamic support of right-ventricular failure in patients with pulmonary hypertension awaiting lung transplantation as well.4 However, many centers had reservations to transplant patients from ECLS. This reluctance faded after it was shown that outcomes of patients receiving mechanical ventilation before transplantation were comparable with outcomes of patients without mechanical ventilation before transplantation, although postoperative mechanical ventilation duration and ICU stay were longer.5 A registry study from the United States demonstrated that the survival after lung transplantation was markedly reduced when preoperative mechanical support was used.6
With the introduction of the lung allocation score, organs are now allocated to patients who have the greatest need, such as those who are receiving ECLS but are also still likely to benefit from transplant.7 With this approach, the transplantation rates may increase for patients waiting for transplantation while receiving ECLS. A retrospective study of all lung transplantation recipients (N = 12,458) in the United Network for Organ Sharing database between 2000 and 2011 showed that 119 subjects were transplanted while receiving pre-transplant ECLS support. The 1-y survival for those subjects supported with ECLS was significantly lower than in subjects with lung transplantation without ECLS, but survival progressively increased over time, as did the number of subjects using ECLS as a bridge.8
In a systematic review with 14 retrospective studies, sample size ranged from 11 to 122, totaling 441 adult subjects who were supported with ECLS to lung transplantation in the period from 2000 to June 2014. This cohort had an acceptable 1-y survival, with a wide range of 50–90%.9 Information focusing on quality of life (QOL) after ECLS therapy as a bridge to lung transplantation is lacking in the literature. The aim of our study was therefore to summarize our institutional experience with ECLS as a bridge to lung transplantation with an emphasis on generic health-related QOL (HRQOL).
Current knowledge
Extracorporeal life support (ECLS) as a bridge to lung transplantation has been used more frequently in the last decade. The 1-y survival rates are acceptable. Health-related quality of life (HRQOL) is a very broad concept that refers to quality of life that is directly related to health or illness. To assess general health status, we used of the EuroQol Group 5-Dimension Self-Report Questionnaire. The impact of ECLS on HRQOL after lung transplantation is unclear, but it is important to focus on HRQOL as an outcome parameter after lung transplantation.
What this paper contributes to our knowledge
Nine of the 20 subjects were successfully transplanted after ECLS as a bridge, with 2 subjects dying within the first 40 d post-transplant. The 7 survivors all had a 1-y survival and a generic HRQOL and lung function comparable with other lung transplantation subjects, with a longer stay in the ICU and in the hospital.
Approval of the medical ethical committee of our institute was received before the study (METc 2014/011). We performed a retrospective cohort study in which the clinical course of all adult subjects who were receiving ECLS as a bridge to lung transplantation (ECLS group) was compared with that of all other adult subjects who underwent bilateral lung transplantation without ECLS (control group) between 2010 and 2014. All pre-transplant screenings, waiting list visits, preoperative hospital admissions, and postoperative follow-up visits took place in our hospital. Recipients were considered eligible for lung transplantation according to standard criteria. ECLS support, venovenous (VV) or venoarterial, was initiated in the presence of severe hypoxia or hypercapnia despite maximal ventilation support or, in subjects with pulmonary hypertension, in cases of hemodynamic deterioration despite maximal support at instructions of the team consisting of the intensivist, anesthesiologist, cardiothoracic surgeon, and transplantation physician. ECLS therapy was performed in all cases with the Cardiohelp HLS module 7.0 (Maquet, Wayne, New Jersey) with percutaneous inserted cannulas. Anticoagulation strategy while receiving ECLS consisted of unfractionated heparin targeted at a partial thromboplastin time between 60 and 80 s. Post-transplant immunosuppression consisted for all subjects of induction with basiliximab, 20 mg on the day of transplantation with a repeated dose on day 4 and additional triple therapy consisting of tacrolimus, mycophenolate mofetil, and prednisolone. Primary graft dysfunction was scored 0–3 according to International Society for Heart and Lung Transplantation guidelines at 0, 24, 48, and 72 h post-transplant. Severe primary graft dysfunction was defined as a score of 3 at 48 and/or 72 h.10
For patients in our lung transplantation program, it is standard follow-up to collect a visual analog scale score on HRQOL. For patients treated with ECLS in our hospital, it is standard to assess general health status once at 12 months after surgery with the use of the EuroQol Group 5-Dimension Self-Report Questionnaire 3L (EQ-5D) (see the supplementary materials at http://www.rcjournal.com). Subjects were interviewed by telephone. The EQ-5D measure of HRQOL consists of a descriptive system with 5 domains (mobility, self-care, usual activities, pain/discomfort, anxiety/depression), with 3 possible levels on each, which can be converted into a single summary index score ranging from −0.594 (Worst imaginable health state) to 1 (Best imaginable health state), which represents the societal perspective on QOL, and a score on a visual analog scale, ranging from 0 (worst possible health) to 100 (best possible health), which represents the patient's perspective on QOL.11 For both the index score of the EQ-5D and the visual analog scale, higher scores indicate a better quality of life. For comparison with the control group, only the subject's perspective on QOL (visual analog scale) was used because the full EQ-5D was not part of the standard follow-up in this group. Secondary outcomes were ICU and hospital stay (length of stay [LOS]), use of blood products, primary graft dysfunction, lung function and performance testing at 12 months after lung transplantation, and mortality.
For statistical analysis, continuous variables are shown as median (interquartile range). Outcomes between subjects with and without ECLS before lung transplantation were compared with the Mann-Whitney U test, chi-square test, or Fisher exact test where methodologically appropriate. A P value of <.05 was considered statistically significant.
During the study period, 20 subjects underwent ECLS as bridge to lung transplantation; of these, 9 subjects were transplanted, and 11 subjects died before lung transplantation was performed. This study population (ECLS group) was compared with 121 subjects who had lung transplantation without prior ECLS (control group). Baseline characteristics are shown in Table 1. ECLS subjects were younger, more likely to have lung fibrosis, and less likely to have COPD as an underlying diagnosis. Their time on the waiting list was shorter (P < .001); only 6 subjects received ECLS therapy due to clinical deterioration after a long time on the waiting list, and the other 14 subjects were urgently screened and put on the waiting list at Eurotransplant after the initiation of ECLS treatment. All subjects receiving ECLS therapy were listed as high urgency versus 51 subjects (42%) in the control group (P < .001). ECLS subjects depended more on mechanical ventilation (95%) than did controls (6%, P < .001). VV ECLS was used as the ECLS modality in 17 subjects: bi-caval dual lumen cannula in the jugular vein in 8 subjects, double lumen cannula in the femoral vein in 3 subjects, femoral-femoral vein in 3 subjects, and femoral-jugular vein in 3 subjects. Venoarterial ECLS, peripherally inserted in the groin, was used in 3 subjects with primary pulmonary hypertension. Reasons for death during ECLS support before lung transplantation were development of multi-organ failure (n = 5), bleeding complications (n = 3), and right-ventricular heart failure on VV ECLS (n = 3). Subjects who died while receiving ECLS were more likely to be female and had spent more time on the waiting list, although this was not statistically significant compared with subjects who survived to lung transplantation (see Table 2). The pre-transplant ECLS support had a median duration of 10 d in the 9 subjects who were transplanted. In 5 ECLS subjects (89%), transplantation was assisted with a cardiopulmonary bypass because of hemodynamic instability or inability to collapse the lungs. Cardiopulmonary bypass was used in 47 subjects (39%) from the control group. We chose to continue ECLS in all subjects for 1–2 d into the postoperative period to provide a smooth transition to the transplanted lung and remove the cannulas in the ICU. The subjects receiving ECLS had significantly more red blood cell, plasma, and platelet transfusions within the first 24 h after transplantation compared with standard bilateral lung transplants (see Table 3). The total ICU and hospital LOS was significantly longer in ECLS subjects (even when the pre-transplant ICU and hospital LOS is not included). In the ECLS group, 2 subjects (22%) died postoperatively; one subject died within 1 h upon arrival on the ICU of massive blood loss after retransplantation, and the other subject died after 40 d due to respiratory insufficiency, most likely due to nonadherence to immunosuppressive medication during her stay at home. Hospital mortality was one subject (11%) in the ECLS group and 10 (8%) in the control group, which is not significantly different. After hospital discharge, another 9 subjects died in the control group, resulting in a 1-y mortality for the control group of 15%. Severe primary graft dysfunction in the first 72 h was similar in both groups, as was lung function and performance tests after 12 months.
Recipient Characteristics Among Subjects With and Without Survival to Lung Transplantation
HRQOL at 12 months after lung transplantation was available for all 7 surviving subjects in the ECLS group. The 5 EQ-5D domains of these subjects are shown in Figure 1. The 2 deceased subjects were excluded from this analysis. One subject scored "worse than dead" from a societal perspective; he underwent urgent lung transplant after an exacerbation of his mild lung fibrosis after a diagnostic wedge resection with video-assisted thoracoscopy and remained dialysis-dependent. The median (IQR) summary index score of the ECLS group was 0.73 (0.5–0.9).
The EuroQol Group 5-Dimension Self-Report Questionnaire measure of health-related quality of life. n = 7.
The subject perspective on QOL assessed with the visual analog scale is shown in Figure 2. The visual analog scale was prospectively scored from 2012 onward and available from 77 subjects of the control group and all 7 survivors from the ECLS group. The median (IQR) visual analog scale was 80 (65–82) in the ECLS group, similar to the control group, 80 (72–95) (P = .33).
Subject perspective of quality of life (QOL) as assessed by the visual analog scale, where 100 represents perfect health. ECLS = extracorporeal life support. Error bars show 95% CI.
The main findings of our study are that only 9 of 20 of the subjects (45%) were successfully transplanted after ECLS as bridge, with 2 subjects dying within the first 40 d post-transplant. The 7 survivors all had a 1-y survival and a generic HRQOL and lung function comparable with other lung transplantation subjects.
The mortality rate of 55% of subjects receiving ECLS who did not make it to lung transplantation was relatively high compared with the 17–50% mortality rate reported in other studies.12–21 The most frequent causes of death in this group (multi-organ failure and bleeding complications) are the same as described in the literature.13,21 In the study with the highest reported mortality, liver failure was an important phenomenon.21 We did not see liver failure in our population. For the 3 subjects who died while receiving VV ECLS due to right-ventricular heart failure, the mode of support was ultimately insufficient. Compared with other studies that showed a mean waiting time of 6–7 d, our period receiving ECLS as a bridge was relatively long.12–15 A relationship between increasing mortality and an increasing number of days spent waiting for transplantation while on ECLS with a hazard ratio of 1.12/d has been reported.16 With the implementation of the lung allocation score, the waiting time while receiving ECLS might shorten, which could improve the waiting list outcome in the future.
When lung transplantation was performed, the ICU mortality in the ECLS group was comparable with lung transplants in the control group. The ICU and hospital LOS were significantly longer in the ECLS group than for the subjects in the control group. Although in some studies only LOS after lung transplantation is reported, our ICU and hospital LOS of our ECLS group were relatively long compared to other studies. This is partly explained by the longer time our subjects spent on the waiting list.12,13,17,19 Furthermore, we have a large catchment and most of our subjects are discharged directly to their home and are not transferred to their regional hospitals.
For lung transplantation in general, it is well known that it can improve generic HRQOL. In a Dutch cohort of 24 subjects, it was shown that as early as 4 months after transplantation, the domains of mobility, energy, sleep, activities of daily living dependence level, and shortness of breath are positively affected. These improvements were maintained in the follow-up.22 Also, in a 2001 study of generic HRQOL described with the EuroQol questionnaire in the United Kingdom, a mean utility value of 0.31 for subjects (n = 87) on the waiting list was assessed, which improved to 0.83 7–18 months after bilateral lung transplantation.23 Our ECLS group scored a median summary index score of 0.73, which seems comparable and acceptable.
Because of the retrospective nature of our study, the visual analog scale score was only available in two thirds of the control group, and the EQ-5D questions were not available at all. We therefore were only able to compare the subject's perspective on QOL with a score on the visual analog scale. However, the use of the visual analog scale score strongly agrees with the EQ-5D states.24
For intensive care patients in general, recovery after critical illness is achieved by measures applied during their stay in the ICU (eg, less sedation and awake ECLS). Specifically focusing on all of the 5 (mobility, self-care, usual activities, pain/discomfort, anxiety/depression) will enhance HRQOL after lung transplantation. We think that physical rehabilitation plays a great part in early recovery of HRQOL in patients after lung transplantation, and even more after bridge with ECLS because of their longer hospital stay and muscle weakness and wasting.
In subjects who underwent bilateral lung transplantation, the FEV1 6–9 months post-transplant is on average 78–85% of predicted, as it was in our control group.25,26 There are few available data on pulmonary function in subjects who have undergone lung transplantation after ECLS. In our cohort, the pulmonary function tests showed a FEV1 of 90% of predicted after 12 months. One study showed that 1 y after transplant, lung function did not differ between subjects requiring ECLS before lung transplant and those who did not.12 In a Scandinavian cohort of 10 subjects receiving ECLS as a bridge, the mean FEV1 was 2.0 ± 0.7 L (62% of predicted), and 6-min walk distance was 584 m; however, the timing of these pulmonary function tests was not clearly defined.18
Our study has several limitations. First, it is a single-center retrospective study of limited size. For this reason, we cannot exclude a possible confounding role of some relevant factors, such as diagnosis and comorbidity at the beginning of ECLS therapy, donor variables, or intra-operative findings (eg, bias by indication). Furthermore, when analyzing the overall population survival, the sample size did not allow meaningful use of statistics. This is also true for the QOL measure with incomplete data, and the EQ-5D questionnaire was not developed for specific ECLS-related issues. Finally, we started to use ECLS as a bridge to lung transplantation in 2010, so a learning curve bias effect cannot be excluded. Considering our results, we are convinced that ECLS support to lung transplantation is feasible and is a useful addition to our intensive care treatment; since the writing of this paper, we have already transplanted 3 patients who were receiving ECLS support.
ECLS can be used as a bridge to lung transplantation, but it remains a challenge. A significant number of subjects were not bridged successfully due to different reasons (multi-organ failure, bleeding complications, and right-ventricular heart failure on VV ECLS), for which a long period on the waiting list might be responsible. Outcomes after ECLS as a bridge to transplantation might be comparable with the general population undergoing lung transplantation in terms of primary graft dysfunction, lung function, performance tests, quality of life, and mortality. However, multi-center studies with larger subject cohorts are necessary to confirm our results.
Correspondence: University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, Netherlands. E-mail: a.oudelansink{at}umcg.nl.
Supplementary material related to this paper is available at http://www.rcjournal.com.
The authors have disclosed no conflicts of interest.
Copyright © 2017 by Daedalus Enterprises
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Annemieke Oude Lansink-Hartgring, Wim van der Bij, Erik A Verschuuren, Michiel E Erasmus, Adrianus J de Vries, Karin M Vermeulen, Walter M van den Bergh
Respiratory Care May 2017, 62 (5) 588-594; DOI: 10.4187/respcare.05300


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Suicides increased in Minnesota in 2017 with an alarming increase of men taking their own lives and a drop among women.
Those findings were released Monday by the Minnesota Department of Health, along with a plea from the state health commissioner to halt a decadeslong trend of rising suicide numbers by increasing public awareness, mental health treatment and prevention programs.
The 783 suicides in Minnesota last year represented a 5 percent increase since 2016 and a 79 percent increase since 1999. The state's suicide rate has historically been lower than the national rate, but that gap has been closing.
Suicide rates are growing nationally among white adults, American Indians and rural residents but the reasons are unclear. And Minnesota has ample populations of all three.
The increase in the state suicide rate was sharper last year for men in the metro area, but still higher among rural men.
Calls for mental health crisis response have increased over the past two years in Thief River Falls, where farmers and ranchers have struggled with everything from bad markets, to generational conflicts with children over staying on family farms, to Norwegian stoicism that makes it difficult to discuss their stresses.
"The crisis in the farming and ranching community is one of the contributing factors" to the rural suicide rate, said Sarah Lefebvre, who manages the crisis response program for the Sanford Medical Clinic in Thief River Falls, which also opened a stand-alone mental health hospital three years ago.
Increases in suicides in recent years have mostly been among older adults, while the rate among teens had been stable. But suicides among Minnesotans aged 15 to 18 increased from 32 in 2016 to 43 last year, according to updated mortality data from the U.S. Centers for Disease Control and Prevention.
Some public health officials feared such an increase was due in part to the 2017 debut of the "13 Reasons Why" series on Netflix that explored youth suicides in intense detail. Solutions can't focus too much on one media phenomenon or issue, though, said Dan Reidenberg of SAVE, a national suicide prevention program based in Minnesota.
More money is needed to fund public awareness, prevention and mental health care, he said.
Suicides declined 10 percent among women in Minnesota, whose means were more likely to involve poison or strangulation, according to a state data brief that was released Monday in conjunction with the commissioners' message. But suicides increased 9 percent among men, who were more likely to use firearms. Roughly 78 percent of firearms-related deaths in the state last year were suicides.
Several studies have shown that restrictions such as locking bullets and guns in separate locations, can be effective in preventing youth suicides and discouraging people until their transient urges to hurt themselves pass.
Reidenberg said they can work for adults as well, and that he recently talked with a man who was suffering depression and gave the keys to his gun cabinet to his wife.


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SCRIPT USAGE AND DIFFERENCES FROM OTHER APT TOOLS
apt - command-line interface
apt [-h] [-o=config_string] [-c=config_file] [-t=target_release] [-a=architecture] {list | search | show | update | install pkg [{=pkg_version_number | /target_release}]... | remove pkg... | upgrade | full-upgrade | edit-sources | {-v | --version} | {-h | --help}}
apt provides a high-level commandline interface for the package management system. It is intended as an end user interface and enables some options better suited for interactive usage by default compared to more specialized APT tools like apt-get(8) and apt-cache(8).
Much like apt itself, its manpage is intended as an end user interface and as such only mentions the most used commands and options partly to not duplicate information in multiple places and partly to avoid overwhelming readers with a cornucopia of options and details.
update (apt-get(8))
update is used to download package information from all configured sources. Other commands operate on this data to e.g. perform package upgrades or search in and display details about all packages available for installation.
upgrade (apt-get(8))
upgrade is used to install available upgrades of all packages currently installed on the system from the sources configured via sources.list(5). New packages will be installed if required to satisfy dependencies, but existing packages will never be removed. If an upgrade for a package requires the remove of an installed package the upgrade for this package isn't performed.
full-upgrade (apt-get(8))
full-upgrade performs the function of upgrade but will remove currently installed packages if this is needed to upgrade the system as a whole.
install, remove, purge (apt-get(8))
Performs the requested action on one or more packages specified via regex(7), glob(7) or exact match. The requested action can be overridden for specific packages by append a plus (+) to the package name to install this package or a minus (-) to remove it.
A specific version of a package can be selected for installation by following the package name with an equals (=) and the version of the package to select. Alternatively the version from a specific release can be selected by following the package name with a forward slash (/) and codename (stretch, buster, sid ...) or suite name (stable, testing, unstable). This will also select versions from this release for dependencies of this package if needed to satisfy the request.
Removing a package removes all packaged data, but leaves usually small (modified) user configuration files behind, in case the remove was an accident. Just issuing an installation request for the accidentally removed package will restore its function as before in that case. On the other hand you can get rid of these leftovers by calling purge even on already removed packages. Note that this does not affect any data or configuration stored in your home directory.
autoremove (apt-get(8))
autoremove is used to remove packages that were automatically installed to satisfy dependencies for other packages and are now no longer needed as dependencies changed or the package(s) needing them were removed in the meantime.
You should check that the list does not include applications you have grown to like even though they were once installed just as a dependency of another package. You can mark such a package as manually installed by using apt-mark(8). Packages which you have installed explicitly via install are also never proposed for automatic removal.
search (apt-cache(8))
search can be used to search for the given regex(7) term(s) in the list of available packages and display matches. This can e.g. be useful if you are looking for packages having a specific feature. If you are looking for a package including a specific file try apt-file(1).
show (apt-cache(8))
Show information about the given package(s) including its dependencies, installation and download size, sources the package is available from, the description of the packages content and much more. It can e.g. be helpful to look at this information before allowing apt(8) to remove a package or while searching for new packages to install.
list (work-in-progress)
list is somewhat similar to dpkg-query --list in that it can display a list of packages satisfying certain criteria. It supports glob(7) patterns for matching package names as well as options to list installed (--installed), upgradeable (--upgradeable) or all available (--all-versions) versions.
edit-sources (work-in-progress)
edit-sources lets you edit your sources.list(5) files in your preferred texteditor while also providing basic sanity checks.
The apt(8) commandline is designed as an end-user tool and it may change behavior between versions. While it tries not to break backward compatibility this is not guaranteed either if a change seems beneficial for interactive use.
All features of apt(8) are available in dedicated APT tools like apt-get(8) and apt-cache(8) as well. apt(8) just changes the default value of some options (see apt.conf(5) and specifically the Binary scope). So you should prefer using these commands (potentially with some additional options enabled) in your scripts as they keep backward compatibility as much as possible.
apt-get(8), apt-cache(8), sources.list(5), apt.conf(5), apt-config(8), The APT User's guide in /usr/share/doc/apt-doc/, apt_preferences(5), the APT Howto.
apt returns zero on normal operation, decimal 100 on error.
APT bug page [1] . If you wish to report a bug in APT, please see /usr/share/doc/debian/bug-reporting.txt or the reportbug(1) command.

redpajama_set_name: RedPajamaCommonCrawl


text:
Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: mmwrq@cdc.gov. Type 508 Accommodation and the title of the report in the subject line of e-mail.
Primary Amebic Meningoencephalitis --- Georgia, 2002
In early September 2002, the Georgia Division of Public Health and CDC were notified about a fatal case of primary amebic meningoencephalitis (PAM) caused by Naegleria fowleri in a boy aged 11 years who had recently swum in a local river. This report summarizes the case investigation. In response to this case, the district health department recommended that local community authorities advise persons to avoid swimming in this river during periods of high temperature and low water depth.
In late August, the previously healthy boy was evaluated in a local emergency department for a 2-day history of headache and emesis; he was febrile and lethargic without focal neurologic or meningeal signs. A computerized tomography (CT) scan of the head without contrast was normal. Lumbar puncture was unsuccessful, and the patient was started on intravenous antibiotics for suspected bacterial meningitis. Within several hours of admission, he had spontaneous nonpurposeful movements, was unable to follow verbal commands, and was transferred to a children's hospital intensive care unit (ICU). En route to the ICU, he had a 30-minute right-sided seizure. A CT scan of the head on admission to the ICU showed edema of the midbrain, and cranial magnetic resonance imaging (MRI) demonstrated areas of meningeal enhancement in the brainstem suggestive of meningitis. No organisms were observed on a Gram-stained smear of cerebrospinal fluid (CSF); CSF antigen-detection tests were negative for bacterial pathogens. Fresh preparation of CSF revealed no amebae. CSF red blood cell count was 1,550/mm3 (normal: 0/mm3), white blood cell count was 13,650/mm3 (normal: 0--5/mm3), glucose was <5 mg/dL (normal: 40--70 mg/dL), and protein was 679 mg/dL (normal: 12--60 mg/dL). Follow-up lumbar puncture later the same day revealed motile amebae in a centrifuged CSF specimen. The patient was started on intravenous amphotericin and oral rifampin and ketoconazole.
Approximately 12 hours after admission to the ICU, the patient had apneic episodes and anisocoria and was tracheally intubated. Treatment included hyperventilation, hypertonic sodium chloride infusion, mannitol infusion, and the placement of a ventriculostomy. Despite these efforts, the patient's condition worsened, with progressive neurologic deterioration. On the fourth hospital day, the patient died. A postmortem lumbar puncture demonstrated a few motile amebae.
Autopsy findings revealed acute PAM caused by N. fowleri identified by immunofluorescence testing with an N. fowleri-specific antibody (Figure). The patient's CSF, which was innoculated on non-nutrient agar plates streaked with Escherichia coli (1), yielded amebae identified by immunofluorescence as N. fowleri.
Four days before onset of illness, the patient had attended a social event and had swum in a freshwater river with a group of friends in southern Georgia. An epidemiologic investigation was initiated to evaluate risk factors associated with N. fowleri infection. Interviews were conducted with 13 of 15 children aged 6--12 years who attended the event and their parents. In addition, an extensive environmental investigation of the site was conducted in conjunction with state and district health departments. Laboratory analysis of river water samples was performed at state public health laboratories and at CDC.
Of the 15 children who attended the event, 10 had water exposure in the river despite a sign prohibiting swimming, a posting that was not connected to concern for N. fowleri. The maximum exposure time in the water was 2.5 hours (range: 30 minutes--2.5 hours). Water activities included swimming, swimming under water, wrestling in the water, and diving into the water. The patient was one of five children who spent the most time in the water (>2 hours) and engaged in underwater swimming, water wrestling, and diving. He also might have incurred trauma to the face or nose earlier that day during rough play.
The environmental investigation revealed a high ambient temperature (>90º F [>32º C]) and water temperature (91º F [33º C]) in the river at the time of the exposure. In addition, because no recent rainfall had occurred in the region, the river level was low, and the river was flowing slowly. Bacteriologic testing of the river water demonstrated that fecal coliform levels were within acceptable limits. N. fowleri was isolated from two of three river water samples tested and from a control sample taken from a local lake.
Reported by: T McKee, MD, Memorial Health Univ Medical Center, Savannah; L Davis, MD, South Central Health District, Dublin; P Blake, MD, L Kreckman, S Bialek, MD, Georgia Div of Public Health. MJ Beach, PhD, G Visvesvara, PhD, JH Maguire, MD, Div of Parasitic Diseases, National Center for Infectious Diseases; L Fox, MD, J Amann, MD, EIS officers, CDC.
Editorial Note: PAM is a rare but nearly always fatal infection caused by N. fowleri, a thermophilic, free-living ameba that inhabits freshwater ponds, lakes, and rivers, minimally chlorinated pools, and hot springs throughout the world (2). PAM results when amebae-contaminated water incidentally enters the nose during swimming or other aquatic activity, followed by migration of amebae to the brain through the olfactory nerve. Symptoms occur 1 day--2 weeks after exposure, are indistinguishable from fulminant bacterial meningitis and can include headache, fever, stiff neck, anorexia, vomiting, altered mental status, seizures, and coma. Death typically occurs 3--7 days after the onset of symptoms (3). Autopsy findings usually show acute hemorrhagic necrosis of the olfactory bulbs and cerebral cortex (4). The disease is extremely rare despite the millions of persons with exposure to recreational water. During 1989--2000, CDC's waterborne disease outbreak surveillance system documented 24 fatal cases of PAM in the United States (5). The majority of these cases occurred during the summer months and among children. Because of the thermophilic nature of N. fowleri, an increased incidence occurs in areas where temperatures are high (6). The case described in this report is the first case of PAM in Georgia since 1987. In 2002, two cases were reported in Texas, two in Arizona, and two in Florida.
Recognition of PAM depends on clinical suspicion based on patient history (Box). CSF findings mimic those of bacterial meningitis, with a predominantly polymorphonuclear leukocytosis and increased protein and decreased glucose concentration. Occasionally, amebae can be observed on Gram-stained smears. If PAM is suspected, a fresh-centrifuged specimen of CSF should be inspected by wet-mount preparation and with fixation and staining (7). Confirmation of N. fowleri infection requires a culture or an indirect fluorescent antibody test, which is performed at a reference laboratory (8).
Only three survivors of PAM have been documented (9,10). Successful therapy appeared to be related to early diagnosis and administration of intravenous and intrathecal amphotericin B with intensive supportive care. One surviving patient received intravenous and intrathecal miconazole and oral amphotericin B and rifampin (10).
Little is known about the risk factors for infection with PAM. Although these amebae are ubiquitous in freshwater bodies, high water temperatures and decreased precipitation leading to a low river depth might have contributed to proliferation of amebae in this river, subsequently increasing the risk for infection. In response to this case, the district health department recommended that local community authorities advise persons to avoid swimming in this river during periods of high temperature and low water depth.
This report is based on contributions by M Harden, MPA, South Central Health District, Dublin; EA Franko, DrPH, C Daniell, Georgia Div of Public Health. R Sriram, Div of Parasitic Diseases, National Center for Infectious Diseases, CDC.
Visvesvara GS. Pathogenic and opportunistic free-living amebae. In: Murray PR, Baron EJ, Pfaller MA, Tenover FC, Yolken RH, eds. Manual of clinical microbiology, 7th ed. Washington, DC: American Society for Microbiology, 1999.
Martinez AJ, Visvesvara GS. Free-living, amphizoic and opportunistic amebas. Brain Path 1997;7:583--98.
Barnett ND, Kaplan AM, Hopkin RJ, Saubolle MA, Rudinsky MF. Primary amoebic meningoencephalitis with Naegleria fowleri: clinical review. Ped Neuro 1996;15:230--4.
Krogstad DJ, Visvesvara GS, Walls KW, Smith JW. Blood and tissue protozoa. In: Lennette EH, Balowes A, Hausler WJ Jr, Shadomy HJ, eds. Manual of clinical microbiology, 4th ed. Washington, DC: American Society for Microbiology, 1985.
Lee SH, Levy DA, Craun GF, Beach MJ, Calderon RL. Surveillance of water-borne disease outbreaks---United States, 1999--2000. In: CDC Surveillance Summaries (November 22). MMWR 2002;51(No. SS-8).
Wellings FM, Amuso PT, Chang SL, Lewis AL. Isolation and identification of pathogenic Naegleria from Florida lakes. Appl Environ Microbiol 1977;34:661--7.
Ma P, Visvesvara GS, Martinez AJ, Theodore FH, Daggett PM, Sawyer TK. Naegleria and acanthamoeba infections: review. Rev Inf Dis 1990;12:490--513.
Schuster FL. Cultivation of pathogenic and opportunistic free-living amebas. Clin Micro Rev 2002;15:342--54.
Apley J, Clarke SK, Roome AP, et al. Primary amoebic meningoencephalitis in Britain. BMJ 1970;1:596--9.
Seidel JS, Harmatz P, Visvesvara GS, et al. Successful treatment of primary amebic meningoencephalitis. N Engl J Med 1982;306:346.
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redpajama_set_name: RedPajamaGithub


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Peregrine Falcon Chicks at Buck Park
This year, four wild peregrine chicks have hatched at our Buck Park site in Denholme, West Yorkshire.
A scheme was set up in 1997 to collect DNA from wild peregrines and, more recently, a tagging scheme has been introduced. Last week, Steve Downing with the Wildlife Crime Unit visited the site to tag the new chicks - three female and one male.
A colour coded ring is fitted to indicate which geographic region the birds are from. A second special ring, called a PIT tag, is also fitted and this contains a microchip. When these young birds take up their own territories and start to breed, the microchip will feed information to special readers set up on the nest ledge. Each movement on and off the ledge is recorded and this information helps determine which specific birds are nesting where, and the amount and timing of food being brought into the nest.
Until this tagging programme was introduced, it was thought that pairs of birds returned to the same nest site each year. The programme has shown, though, that this is not always the case.
For more information about peregrines, you can check out the National Geographic website - http://animals.nationalgeographic.com/animals/birds/peregrine-falcon/


Just because America's birthday is on a Wednesday doesn't mean we're not going to party! This is your complete guide to the Fourth in the Forest City.
Get your red, white and blue on and get ready for a full day of fun in Rockford this Wednesday, July 4.
The Fourth of July parade and fireworks of course!
According to the City of Rockford Government on Facebook, the parade will begin downtown at 7 p.m.
The Facebook posts also includes the following information about the event.
Avenue with the traditional "Motorcycle Parade" at 6:50 p.m. Please note, this year the parade route will end at Chestnut and Church Streets.
Because of the parade, there will of course be street closings and things to watch out for and you can get all of that info here.
If you're looking for fireworks around the Rockford area, we have those for you here as well.


Cooks Creek Apartments The Joys of Cooking With an Infrared Oven, Cooking games are popular games online; in reality population of girls showing interest in playing online games has significantly increased by almost 100%. A quick turn around for such market if this has been barely a couple of years old. Online games are usually centered on boy games although there are a couple of girls that enjoy playing boy's game; the speed is extremely minimal particularly when compared to the speed of boys playing online.
First, it will likely be better for you to stay in your home when you are cooking something on your own stove. Many people leaving their cooking for the stoves since they watch TV or get a trip. In this certain condition, the potential risk of fire within your kitchen is highest level. Do not ever cooking something on the stove leave them for an additional activity that might take long time.
Of all the research while keeping focused groups, one of the most poignant continues to be discovering what teens think parents should do whenever they desire them to understand in order to cook. We identified eight tips. I still struggle to keep a straight face when I recall how deadly serious these folks were. So but they might be laced with humor – make no mistake, your children meant them.
It is a common misconception that people who're not doing anything invest their time and energy in cooking. This is an utter baseless assumption. As discussed earlier, cooking good food is difficult rather than everybody's job. You have to master it with sheer hard work and dedication. If you are good cook that will not mean about to catch efficient at other activities. Shun these baseless values and prepare to rein your home.


text:
Steven Lohrenz
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SMAST / Estuarine & Ocean Sciences
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School for Marine Science & Technology West, New Bedford 104
1978 University of Oregon B.A.
1985 Massachusetts Institute of Technology/Woods Hole Oceanographic Institution Ph.D
Satellite Oceanography
Phytoplankton Ecology
Aquatic Optics
Intercampus Marine Science Programs MS, PhD
Marine Science and Technology MS
Marine Science and Technology PhD
University of São Paulo Dual PhD PhD
ECE 653: Satellite Oceanography
Provides an overview of the use of satellite-based remote sensing for making measurements within the marine environment. Each of the primary satellite sensors used by oceanographers is introduced along with the principles behind their operation, measurement retrieval, data handling, and data interpretation/usage. Emphasis is placed on physical and biogeochemical applications of satellite-based data, along with their analysis and advantages, rather than engineering and physical/optical theory of measurement. This course relies heavily on outside readings from the primary oceanographic literature to showcase satellite data analysis and specific applications of these data types. Included in the course are a series of student-led presentations and discussions of assigned class readings and a possible class project utilizing a satellite-derived data set and data processing techniques.
MAR 462: Satellite Oceanography
Overview of the fundamental concepts of remote sensing and applications within marine environments. Course examines various satellite sensors used by oceanographers along with the principles behind their operation, measurement retrieval, data handling, and data interpretation/usage. Physical and biogeochemical applications of satellite-based data are explored as well as the underlying engineering principles and physical/optical theory of the measurements .
MAR 600: Masters Thesis Research
Thesis research on an experimental or theoretical project in Marine Science or Technology under a faculty advisor.
PI, "An Integrated Terrestrial-Coastal Ocean Observation and Modeling Framework for Carbon Management Decision Support" (collaborative project with Auburn University, University of Delaware, and North Carolina State University) NASA, $1.2M over three years ($228K to UMass Dartmouth)
PI, "Research and Education in Quantitative Fisheries and Ecosystem Science," NOAA (subaward through the Woods Hole Oceanographic Institution), $360K over three years
PI, " Collaborative Research: A RAPID response to Hurricane Harvey's impacts on coastal carbon cycle, metabolic balance and ocean acidification", (collaborative project with Univ. Delaware, Louisiana Universities Marine Consortium, and Dauphin Island Sea Lab), NSF, $34,232 over one year
Biological distributions and productivity
Cycling of carbon and nutrients in coastal and ocean waters using ship-based measurements and optical and remotely sensed observations
Characterization of land-ocean interactions using coupled ecosystem models to assess impacts of climate and land use change
Optical assessment of air-sea carbon fluxes in river-dominated margins
Optical detection and assessment of harmful algal blooms
Tian, H., R. Xu, S. Pan, Y. Yao, Z. Bian, W.-J. Cai, C. S. Hopkinson, D. Justic, S. Lohrenz, C. Lu, W. Ren, and J. Yang (2020).
Long-Term Trajectory of Nitrogen Loading and Delivery From Mississippi River Basin to the Gulf of Mexico
Global Biogeochemical Cycles, 34(5), abstract.
Fennel, K., S. Alin, L. Barbero, W. Evans, T. Bourgeois, S. Cooley, J. Dunne, R. A. Feely, J. M. Hernandez-Ayon, X. Hu, S. Lohrenz, F. Muller-Karger, R. Najjar, L. Robbins, E. Shadwick, S. Siedlecki, N. Steiner, A. Sutton, D. Turk, P. Vlahos, and Z. A. Wang (2019).
Carbon cycling in the North American coastal ocean: a synthesis
Biogeosciences, 16(6), abstract.
Lohrenz, S. E., W. J. Cai, S. Chakraborty, W. J. Huang, X. Guo, R. He, Z. Xue, K. Fennel, S. Howden, and H. Tia (2018).
Satellite estimation of coastal pCO2 and air-sea flux of carbon dioxide in the northern Gulf of Mexico
Remote Sensing of Environment, 207, 71-83.
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A bottle of Black 3.0. Image courtesy of Stuart Semple.
As its name suggests, this is Semple's third effort to create an ultra-black black. After soliciting input from the artistic community, he introduced the cherry-scented Black 2.0 in March 2017. He's spent the past two years working to improve on that effort. Now, after a successful round of beta testing, which saw samples sent to 1,000 artists, Semple is ready to share his latest creation with the world—except Kapoor, of course.
A graphic about Black 3.0. Image courtesy of Stuart Semple.
Semple has been making his own pigments for personal use for the past 20 years. When he found out about Kapoor's exclusive deal with Vantablack producers Surrey NanoSystems, Semple was outraged. It also occurred to him that he hadn't been offering others the chance to experiment with his custom-made art supplies.
A chart comparing Black 3.0 to other black paints. Image courtesy of Stuart Semple.
But even after the success of Black 2.0—more than 3,500 people have posted about it on Instagram under the hashtag #sharetheblack—Semple knew he could do more to eliminate the reflective quality that plagues traditional black pigments (think of how coal and charcoal are both slightly shiny, for instance).
Stuart Semple breaks down the genesis of his Vantablack-fueled feud with Anish Kapoor. Image courtesy of Stuart Semple.
Black 3.0 applied to a sculpture. Image courtesy of Stuart Semple.
Scientists have also taken steps to thwart Kapoor's Vantablack monopoly. NanoLab, Inc., in Waltham, Massachusetts, unveiled a carbon nanotube black paint of its own, called Singularity Black, in August 2017.
As of press time, Semple had already raised $55,430, or an impressive 169 percent of his original $32,720 goal, which he hit after just 38 hours.


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Submission on the Retirement Villages Amendment (Standard Contract)
Publication published 25 January 2013
CPSA Planning for Later Life webinar series
Social Security (Administration) Amendment (Continuation of Cashless Welfare) Bill 2020 – Submission to the Senate Community Affairs Legislation Committee
Submission to the Royal Commission into Aged Care Quality and Safety – System Governance
Comments on the NSW Federal Financial Relations Review
A Housing Strategy for NSW – submission to NSW Department of Planning, Industry and Environment
CPSA's Submission
CPSA welcomes the opportunity to make comment on the draft Retirement Villages Amendment (Standard Contract) Regulation 2013.
CPSA welcomes the introduction of standard contracts for retirement villages as well as standardised general enquiry and product disclosure documents. Confusion surrounding retirement village contracts has been an area of great concern to retirement village residents, who often find out too late that the contract they signed was not what it seemed. Current contracts are unnecessarily complex for consumers and this leads to problems for residents who have not understood the terms and conditions of the contract, even after seeking legal advice before moving in.
Retirement villages are often a housing option examined by retirees looking to downsize or looking to move into more appropriate housing. However, these advantages are currently overshadowed by complex contracts, unfair fees and capital gains arrangements that favour operators. Standardised and more transparent disclosure statements and contracts will hopefully remove some of the complexity and the tendency for retirement village residents to feel tricked by contracts that don't spell out the financial arrangements.
CPSA hopes that the retirement village standard contract will result in greater transparency for residents and prospective retirement village residents. In particular the breakdown of financial matters including departure fees, how the sale of units takes place and the capital gain or loss structure of the village as well as a breakdown of the services included in regular fees are welcome additions to the Retirement Villages Act.
CPSA is, however, concerned that the standard form of retirement village contracts will not apply to residence contracts that are part of a community land scheme, company title scheme or strata scheme. CPSA has contacted the Department and a number of industry groups to ascertain how many retirement village places will be excluded from the benefits of a standard contract but has been told that there is no way to determine how many retirement village places will be affected by this exclusion. CPSA is also concerned that this could result in a move by operators to these forms of village structures for new retirement villages in order to evade adhering to providing new residents with all the information that must be provided in a standard disclosure statement and contract.
The NSW Consumer, Trader and Tenancy Tribunal (CTTT) received 86 applications about matters and disputes relating to retirement villages in 2011/12. This is almost double the 45 applications that were made in 2007/08. Matters dealt with included disputes about the terms of the retirement village contract, the legality of a village rule, recurrent charges, annual budgets and accounts, payment of money and compensation, termination and vacant possession, security and safety, and disputes about the sale or lease of a premises within the village.[1] Hopefully the new contract will alleviate some of these issues but it is of real concern that certain residents will be excluded.
CPSA understands that both the Retirement Villages Act 1999 and the Strata Schemes Management Act 1996 apply to strata retirement villages and that the Acts operate side by side with the owners corporation being responsible for the maintenance of the common property and residents being responsible for the capital items in their unit. As such this may influence certain aspects of a draft contract but as much as possible, potential residents of such villages should be able to reap the benefits of greater transparency and the ability to compare options.
CPSA notes that strata title regulation is currently under review. One proposed reform is to change the way strata schemes are terminated, which currently requires a unanimous decision by the owners of a strata scheme, but which is proposed to be changed to termination by a majority decision. CPSA strongly opposes any move to changes in strata law which removes the autonomy of individuals living in strata. CPSA suggests that should changes be made to strata title regulation, that these need to accommodate the radically different purpose of strata titled retirement villages.
[1] Consumer, Trader and Tenancy Tribunal Annual Report 2011 – 2012, available at: http://www.cttt.nsw.gov.au/pdfs/About_us/Corporate_publications/Annual_reports/Annual_report_1112.pdf, p. 42.
For more information please call our media contact on 0410 612 182 or contact us


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Sclafani Bagni Hotels
The Best Hotels in Sclafani Bagni
Search our Top Sclafani Bagni Hotels
See a map of Sclafani Bagni Hotels
Best Hotels in Sclafani Bagni
What's Sclafani Bagni like?
If you're looking for a place to get away, look no further than Sclafani Bagni. Whether you're planning to stay for a night or for the week, the area around Sclafani Bagni has accommodation options to fit every need. Search for hotels in Sclafani Bagni with Hotels.com by checking our online map. Our map displays the areas and neighbourhoods around all Sclafani Bagni hotels so you can see how close you are from landmarks and attractions, and then refine your search within the larger area. The best Sclafani Bagni hotel deals are here with our lowest price guarantee.
Where are the best places to stay in Sclafani Bagni?
The top hotel in Sclafani Bagni:
Le Case di Cardellino
4-star farm stay with bar, conference centre
• Free parking • Free WiFi • Restaurant • Outdoor pool • Health club
What types of hotels are available in Sclafani Bagni?
We have Sclafani Bagni accommodation options with prices starting at GBP 23. Choose one of our 889 deals and get discounts of up to 30%.
Below are the number of accommodation options by star rating in Sclafani Bagni and the surrounding area:
Things to see and do in Sclafani Bagni
What is there to see near Sclafani Bagni?:
• Vivaio Piano Noce (8 mi/12.8 km from the city centre)
• Gurfa Cave (7.5 mi/12 km from the city centre)
• Church of Santa Maria della Grazie (8.3 mi/13.3 km from the city centre)
• Vallone Madonna degli Angeli (8.7 mi/14 km from the city centre)
What is there to do near Sclafani Bagni?:
• Civic Archaeological Museum (7.9 mi/12.7 km from the city centre)
• The Madonita Ambientalistic Museum of Polizzi Generosa (8.1 mi/13 km from the city centre)
• Targa Florio Museum (8.2 mi/13.2 km from the city centre)
When is the best time to visit Sclafani Bagni?
• Coldest months: January, February, March, December (average 10°C)
• Rainiest months: December, November, January and October (average 85.60 inches of rainfall)


I've seen less than half of those, but I'm still going to be offended that they misspelt Rashomon.
Well, technically speaking, they misromanjied it.
They're talking about The Professional, here. I know you've seen The Professional.


When the colder month come around, you need a warm and comfortable beanie to help tackle the elements, and there is no better hat than the Carhartt Watch beanie! With so many years keeping workers warm whilst out chopping wood and tarmacking, Carhartt really know what they are doing. The Watch beanie is a standard cuff beanie with a small woven logo on the front. No frills, just great quality and a classic style.


What time KCG RAL FASTPASS depart from KACHEGUDA Railway Station?
KCG RAL FASTPASS (57620) departs from KACHEGUDA Railway Station at 21:00.
How much time KCG RAL FASTPASS take to reach REPALLE Railway Station?
KCG RAL FASTPASS reach on day 2 to REPALLE Railway Station. The arrival time of KCG RAL FASTPASS at REPALLE Railway Station is 06:20.
Distance covered by KCG RAL FASTPASS?
KCG RAL FASTPASS covers 347 km to reach REPALLE Railway Station at average speed of 38 km/hr. KCG RAL FASTPASS passes through 24 stations.


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Сушица () — село в Болгарии. Находится в Великотырновской области, входит в общину Стражица. Население составляет 593 человека (2022).

Политическая ситуация
В местном кметстве Сушица, в состав которого входит Сушица, должность кмета (старосты) исполняет Димитранка Стоянова Калева (Болгарская социалистическая партия (БСП)) по результатам выборов правления кметства.

Кмет (мэр) общины Стражица — Стефан Рачков Стефанов (Национальное движение «Симеон Второй» (НДСВ)) по результатам выборов в правление общины.

Примечания

Ссылки
 Статистика населения

Сёла Великотырновской области

redpajama_set_name: RedPajamaWikipedia


The federal government is perhaps hoping for a pre-election boost from its latest regional telecommunications policy, which includes $160 million continuation of funding for the Mobile Black Spot Program, and $60m for a new Regional Connectivity Program.
Described as a response to the recent Regional Telecommunications Independent Review, the Government said it will establish a $220 million Stronger Regional Digital Connectivity Package.
Deputy Nationals Leader and Regional Services Minister Bridget McKenzie said technological change is relentless and regional areas must keep pace.
"If we get this right, the potential of the regions, and therefore our nation, is immense," Senator McKenzie said.
Labor's regional development spokesman Stephen Jones said the Coalition's policy wouldn't fix significant connectivity problems in the bush.
"This announcement won't touch the sides. It's a plan to get them (the government) to the next election, not deal with the real problems," Mr Jones said.
Senator McKenzie said in this round the Mobile Black Spot Program would focus on mobile coverage for regional community facilities such as hospitals, schools as well as business hubs.
"With the growth in demand for data and the movement of essential government and industry services online, the timing for this new investment is now," Senator McKenzie said.
Announcing the policy, Senator McKenzie said the pre-budget commitment totalled $220m, a figure in-line with the previous program, however unlike the previous fund, only $160m would be directed to fund rounds five and six of the Mobile Black Spot Program, while the remaining $60m will be committed to a new Regional Connectivity Program.
While the Regional Connectivity Program was formed in response to last year's Regional Telecommunications Independent Review, the government has not yet provided a strategic plan behind the spend, except to say it would be targeted at areas predominately serviced by the nbn SkyMuster satellite service and locations would be selected by the government through a competitive tender process, targeting areas of economic, social and public safety need.
Bush advocacy group, Better Internet for Rural, Regional and Remove Australia (BIRRR), co-founder, Kristy Sparrow said she believed the Regional Connectivity Program would be developed through a consultation process.
"It think it is going to be place specific, not a one size fits all approach," she said.
"There will be be infrastructure upgrades, but what that looks like will be up to consultation and it may be different in Alpha compared to Albury, or somewhere else faced with unique challenges around their telecommunications, some areas have unique terrain, other areas have backhaul constraints."
Projects funded by the program could include business grade broadband networks, network transmission upgrades, fixed and mobile wireless projects, or upgrades to National Broadband Network access technologies.
Ms Sparrow said she commended both the Minister for Regional Services, Bridget McKenzie, and the Federal Government for listening to regional advocates.
"Improvements in connectivity and digital literacy will result, not just in improvements in agriculture, exports, economy, health and education, but also help create social change and equitable services for people living in rural and remote areas," she said.
"We appreciate being offered a seat at the table and are happy that the current Government and communications stakeholders are listening, and responding, to our concerns.
Ms Sparrow said she particularly appreciated Senator McKenzie visiting remote areas to speak one-on-one with those affected.
"Its important to experience the issues on the ground and to listen to our concerns."
Along with infrastructure programs, the $60m commitment includes provision for a "Digital Tech Hub" aimed at increasing digital literacy in rural areas.
Regional Telecommunications Independent Review Committee (RTIRC) member and BIRRR co-founder, Kylie Stretton said the hub would address some of the significant concerns raised by the review.
"It was very clear during the RTIRC consultations that telecommunications were difficult to navigate for rural, regional and remote communities, and that the 'tech hub' has the potential to achieve such positive outcomes for these communities," Mrs Stretton said.
While industry advocacy groups have welcomed the announcement, Labour spokesperson, Mr Jones said the Regional Connectivity Program was an inadequate government response to ailing services.
"Wireless NBN towers are increasingly congested and the satellite system is underperforming, so on the eve of the election they're throwing money at problems of their own making," Mr Jones said.
"It's an acknowledgement they've stuffed up the rollout of the NBN and also the 5G spectrum auction, which are causing a data drought in the regions without fixed-line connections."
Mr Jones conceded Labor had not yet released its regional telecommunications policy, and praised the findings of the Regional Telecommunications Independent Review.
The story Bush connectivity pitch first appeared on Farm Online.


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Dropbox becomes the latest company to embrace AMD EPYC and see a benefit to single-socket platform adoption.
Dropbox, with its 500 million users and 300,000 business customers, becomes the latest in a long list of companies to see a future in embracing AMD's one-socket EPYC platform to support future growth and refresh its infrastructure to meet the compute workloads that the company faces.
According to a blog post by Scott Aylor, AMD's CVP and GM of datacentre and embedded solutions, Dropbox will utilize AMD EPYC 7351P one-socket processor servers to "support future growth beyond its current capabilities and refresh its existing infrastructure for its most demanding compute workloads."
The EPYC 7351P is a 16-core/32-thread processor with a base speed of 2.5GHz and a boost frequency of 2.9GHz, and a TDP range of 155 to 170W.
Each EPYC processor package can support up to 2TB of DDR4 RAM over eight channels, and has 128 PCIe lanes means that the platform has more than two-and-a-half times the I/O density of a processor such as Intel's Xeon SP Series.
"AMD EPYC is a compelling processor option for our compute technology, providing Dropbox with the technical specifications required to support the workloads that matter to teams and our individual users," said Rami Aljamal, Head of Hardware Engineering and Supply Chain at Dropbox. "We are excited to deploy EPYC processors and look forward to working closely with AMD in the future."
Processor pricing ranges from $400 to over $2,000 per chip.
One of the truly revolutionary things about EPYC was its single-socket capability. And not just single-socket, but what AMD called "the industry's first no-compromise one-socket solutions."
Over the past twelve months EPYC has seen a huge number of wins across the server industry, both among server partners such as Dell and HPE, and from companies looking to benefit from the new silicon, companies such as Microsoft, Yahoo Japan, Packet, Baidu, Cisco, and Cray.


text:
Harry-Carl Voigt (ur. 15 czerwca 1913 w Barver w powiecie Diepholz, zm. 29 października 1986 tamże) – niemiecki lekkoatleta sprinter, medalista olimpijski i mistrz mistrzostw Europy.

Specjalizował się w biegu na 400 metrów. Na mistrzostwach Europy w 1934 w Turynie zdobył złoty medal w sztafecie 4 × 400 metrów (biegli w niej:Helmut Hamann, Hans Scheele, Voigt i Adolf Metzner). Na igrzyskach olimpijskich w 1936 w Berlinie zdobył brązowy medal w sztafecie 4 × 400 metrów (w składzie: Hamann, Friedrich von Stülpnagel, Voigt i Rudolf Harbig). W obu tych startach niemiecka sztafeta poprawiała rekord kraju.

Voigt był mistrzem Niemiec na 400 metrów w 1933 i wicemistrzem na tym dystansie w 1936.

Przypisy

Niemieccy sprinterzy
Medaliści Letnich Igrzysk Olimpijskich 1936
Urodzeni w 1913
Zmarli w 1986
Niemieccy medaliści olimpijscy


text:
Skier dies at Vail on opening day
Vail Daily Staff Report
VAIL, Colo. – The Eagle County Sheriff's Office has confirmed that a man died while skiing at Vail Mountain Friday, the resort's opening day.
A statement issued by Vail Mountain Friday afternoon says the skier was a 62-year-old Colorado man.
The man "was transported to the Vail Valley Medical Center after a ski incident on the Gitalong Road, a beginner trail between the Columbine and Bear Tree trails on Vail Mountain. A call came into Vail Ski Patrol at approximately 10:17 a.m. and ski patrol responded immediately," the statement says.
"Ski patrol provided basic life support and transported the patient to an awaiting ambulance. He was then transported to the Vail Valley Medical Center. The skier was wearing a helmet at the time of the incident, which is under investigation," the statement said. "Vail Mountain, the Vail Ski Patrol and the Vail Resorts family extend their deepest sympathy and support to the family and friends of the skier."
Vail Valley Medical Center spokeswoman Lindsay Warner said the man was transported to the hospital at 11 a.m. and was pronounced dead at 1:06 p.m.
In Breckenridge, a 19-year-old man died after a snowboard incident on Northstar, an intermediate run.
The man has not yet been identified. He was put on advanced life support and taken to the Breckenridge Medical Center by ambulance after the incident, according to a statement from the resort. Summit County Coroner Joanne Richardson confirmed that he later died. The man was reportedly wearing a helmet.
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Hi guys, this blog post is about Allbits Eden White Gloss Combination 650 Vanity Unit & 4 Drawer . ( 650 Vanity Unit Amazing Ideas #1). It is a image/jpeg and the resolution of this attachment is 1312 x 1312. This image's file size is just 81 KB. Wether You ought to download It to Your computer, you have to Click here. You also also download more images by clicking the following photo or see more at here: 650 Vanity Unit.
You're among those who tend to be hectic and rarely spend some time at home? Do not ensure it is as being an obstacle to own flowers athome. But, ofcourse, you've to get the best vegetable since it is powerful with regards to choosing a 650 Vanity Unit. Greater use of exotic plants for maintenance is relatively easy, in case you are among those who rather busy.
Cactus, like, only needs a small water inside their care and that means you do not need a lot of awareness of it. So you can select a little box anyway typically, cacti are sold in tiny styles. Choose a shade pan that matches one's home's entire layout theme.
Other crops that you can choose are Sansevieria. Remedy is similar to a cactus, however, you must pick a unique pan because of the dimension that's Sansevieria that is bigger. Whichever container you select, attempt to make sure that it's a discharge hole at the end. Box putting locations become rainy and muddy, initiating the beginning of root decay can be led by stagnant water in a box. If at all possible, please also select Allbits Eden White Gloss Combination 650 Vanity Unit & 4 Drawer . ( 650 Vanity Unit Amazing Ideas #1) that have thighs for easy drainage.
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Sheridan Whiteside (Parker Ostrander) spends his days in Mesalia inside of the house of Mr. and Mrs. Ernest Stanley. "I've been playing with my penguins," Whiteside said, "and working on my broadcasts."
The Inklings staff wants to introduce readers to this year's spring play, "The Man Who Came to Dinner." Following is a report with actors speaking on behalf of their characters.
While traveling the world on his lecture tour, radio personality Sheridan Whiteside (Parker Ostrander) slips and falls on the ice outside of the Stanley residence in Mesalia, Ohio.
Local practitioner Dr. Bradley (Laiken Blommers) immediately tells Whiteside he needs complete rest for one month.
For the man who never seems to slow down, being told to stop is unexpected.
The Stanley household is forever changed as the hustle and bustle of New York life invades the Mesalia household.
A little bit of spice does not even begin to cover the guests that rush in and out of the Stanley abode: musical genius Beverly Carlton (Olivia Neuzil), insect enthusiast Professor Adolph Metz (Casey Weber), and even international theater royalty Lorraine Sheldon (Grace Reiss).
Neighbors report also seeing convicts, penguins, sarcophaguses, and even octopuses entering the home.
Performances of West Delaware's "The Man Who Came to Dinner" will take place on Friday, April 12 at 7:30 p.m., and Saturday, April 13, at 6 p.m. in Hanson Auditorium.
Tickets cost $10 for adults and $5 for students and are available at the door or through the high school office (in person).


They are also something that will get used as long as the man is into wet shaving of any kind. So if that is something that interests you, then you should enjoy this article. Here at the Shaving Emporium we guys have received quite a few of these, so we are well placed to offer you decent reviews on these shaving products.
These sets typically come with a combination of products which is usually a choice of a mug, a brush, a razor and either a soap or a cream. Some other men prefer just to get the items separate, but these sets make a nice starter kit as well.
If you just fancy buying a good quality brush, then you can click on this link if you prefer which will take you to what we believe are the best shaving brushes.
Likewise if you like the more traditional shaving mug scuttle, then please click here.
Why Buy a Shaving Brush & Mug Set?
A shaving brush and a shaving mug really go together like ham and eggs, bread and butter and ice-cream and jelly. A shaving mug is the perfect item to create a nice creamy lather when used with a good quality shaving brush.
Most of these shaving sets also come with a shaving soap, so as you have the complete kit to get started. I can tell you from a male point of view, that receiving one of these gifts, is something that we really enjoy.
There are many of these available, and I know a few guys who actually collect these. I am not one of those but I do understand how easily this could happen.
They look great and can actually add a bit of character to a bathroom. Like many shaving products on the market, there are a lot to pick from, so we have put together a short list of the ones we liked the best.
We have picked out our favourites based on customer feedback. We have then put these in order of preference of the ones we thought we liked the best and were also the best value for money.
The company offers a 100% money back guarantee if you are not completely satisfied with the product.
This one is about twice the price of the one above. So what you are getting with this shaving set is it is a much better quality of product.
I can tell you that any man who takes his wet shaving seriously will want to have this in their collection. This one is rated at 88% buyer satisfaction by online buyers, and that in itself is a strong indication of its quality.
This one is a high quality set and that is of course reflected in the ratings it receives.
It is a compact size so also ideal for travelling.
This is a well finished product.
So hopefully you can now get an idea of what is available on the UK market when it comes to this type of shaving mug and brush set. There are other choices of course so always worth having a good look around.
Why Pick a Badger Hair Shaving Brush?


Every few weeks, we ask women we love — be it our talented knitters or our muses — a set of 15 random questions, giving you an opportunity to know them a little better. We kick this week off with Sandra, one of our co-founders.
1. Sandra, what's your happy place?
This week, it's Marina's turn — which is very special to us. She was the very first knitter we ever hired and has been with us from day one. Today no knit goes out through the door before being checked and approved by this lady first.
You might recognize her from our photoshoots. A model who's also a clinical psychologist?! Say no more. We are obsessed with this girl.
Every few weeks, we ask women we love — be it our talented knitters or our muses — a set of 15 random questions, giving you an opportunity to know them a little better. We kick this week off with Danute, one of our co-founders.


With an announcement coming straight out of left field, Ken Levine, Creative Director and Co-Founder of Irrational Games took the stage at Sony's E3 2011 Press Event and announced that their upcoming title, Bioshock Infinite will have Move support. There was no demonstration or mention as to how Move will be used during gameplay. In addition to Move support, the PS3 version of Bioshock Infinite will come exclusively bundled with the original Bioshock on the same Blu-Ray.
And what can either be construed as pure evil or generous tipster on his part, Levine also teased some sort of PlayStation Vita integration/new game at the end of his discussion by pulling a PSV out of his pocket. What this means, only time will tell.
Bioshock Infinite is scheduled for release on PlayStation 3, Xbox 360 and PC in 2012.


text:
from tempfile import NamedTemporaryFile
import zipfile
import requests

__author__ = 'selimnairb@gmail.com'
"""
Tastypie REST API tests for resources modeled after: http://django-tastypie.readthedocs.org/en/latest/testing.html

"""
from tastypie.test import ResourceTestCase
from tastypie.test import TestApiClient

from django.contrib.auth.models import User
from hs_core import hydroshare
from hs_core.models import GenericResource

import logging

class ResourceTest(ResourceTestCase):

    def setUp(self):
        self.logger = logging.getLogger(__name__)

        self.api_client = TestApiClient()

        self.username = 'creator'
        self.password = 'mybadpassword'

        # create a user to be used for creating the resource
        self.user_creator = hydroshare.create_account(
            'creator@hydroshare.org',
            username=self.username,
            first_name='Creator_FirstName',
            last_name='Creator_LastName',
            superuser=False,
            password=self.password,
            groups=[]
        )
        self.user_url = '/hsapi/accounts/{0}/'.format(self.user_creator.username)

        self.api_client.client.login(username=self.username, password=self.password)

        # create a resource
        self.resource = hydroshare.create_resource(
            resource_type='GenericResource',
            title='My resource',
            owner=self.user_creator,
            last_changed_by=self.user_creator
        )
        self.resource_url_base = '/hsapi/resource/'
        self.resource_url = '{0}{1}/'.format(self.resource_url_base, self.resource.short_id)

        self.post_data = {
            'title': 'My REST API-created resource',
            'resource_type' : 'GenericResource'
        }

    def tearDown(self):
        User.objects.all().delete()
        GenericResource.objects.all().delete()

    def get_credentials(self):
        k = self.create_basic(username=self.username, password=self.password)
        print k
        return k

    def test_resource_get(self):

        resp = self.api_client.get(self.resource_url)
        self.assertTrue(resp['Location'].endswith('.zip'))

    def test_resource_post(self):
        resp = self.api_client.post(self.resource_url_base, data=self.post_data )
        self.assertIn(resp.status_code, [201, 200])

        # PID comes back as body of response, but API client doesn't seem to be
        # parsing the response for us
        pid = str(resp).split('\n')[-1]
        new_resource_url = '{0}{1}/'.format(self.resource_url_base, pid)

        # Fetch the newly created resource
        resp = self.api_client.get(new_resource_url)
        self.assertTrue(resp['Location'].endswith('.zip'))

    def test_resource_put(self):
        new_data = {}
        new_data['title'] = 'My UPDATED REST API-created resource'

        resp = self.api_client.put(self.resource_url, data=new_data)
        self.assertIn(resp.status_code, ['202','204'])

    def test_resource_delete(self):
        x = self.api_client.delete(self.resource_url, format='json')
        self.assertIn(x.status_code, [202, 204, 301])
        self.assertHttpNotFound( self.api_client.get(self.resource_url, format='json'))


text:
TINY FISH FUEL CORAL REEFS STUDY SHOWS
Tiny fish fuel coral reefs. Scientists have long sought to understand how coral reefs support such an abundance of fish life despite their location in nutrient-poor waters. According to a new study published May 23 in the journal Science, an unlikely group fuels these communities: tiny, mostly bottom-dwelling creatures called "cryptobenthic" reef fish.
The study shows that these fish perform a critical role on coral reefs, supplying almost 60% of consumed fish food by constantly replenishing their populations in a rapid cycle of life and death.
"Scientists have puzzled over coral reefs for centuries, wondering how such productive, diverse ecosystems survive in what is essentially a marine desert," said lead author Simon Brandl, formerly with the Smithsonian's Tennenbaum Marine Observatories Network and currently a postdoctoral research fellow with Simon Fraser University. "It's remarkable to find that these tiny, almost universally overlooked fish actually serve as the cornerstone of coral-reef fish communities."
Cryptobenthic reef fish, such as gobies, blennies or cardinalfish, are the smallest of all marine vertebrates. Although they vary in size, the tiniest cryptobenthics will never reach 1 inch and weigh almost nothing. Other coral-reef dwellers eat these fish in large quantities, most within the first few weeks of their existence.
Instead of disappearing, however, cryptobenthic fish populations somehow flourish in the face of constant predation. The researchers solved this paradox by studying the larvae of reef fish. While the larvae of most fish species disperse into the open ocean, where only a few survive, cryptobenthics behave differently. Brandl and his team found that most cryptobenthic larvae appear to remain close to their parents' reefs, yielding many more survivors among their babies. These larvae then rapidly replace cryptobenthic adults eaten on the reef, sustaining the growth of larger reef fish.
"We found that cryptobenthic fish larvae absolutely dominate the larval-fish communities near reefs, which provides a continuous stream of new generations of tiny fish as a food source for other reef creatures," said Carole Baldwin, co-author on the study and curator of fish at the Smithsonian's National Museum of Natural History. "It's incredible that these fish contribute so much to coral reefs. They're so small that historically we haven't recognized their enormous significance."
Scientists from Australia, Canada, France and the United States contributed to this research. The team studied cryptobenthics in Belize, French Polynesia and Australia, combed decades of data on coral-reef fish larvae and developed a population model to better understand how cryptobenthics contribute to the diet of coral-reef dwellers.
The study began in 2015, when Brandl was a postdoctoral fellow at the Smithsonian's Marine Global Earth Observatory (MarineGEO), but these tiny fish are more relevant today than ever. As coral reefs undergo dramatic declines, their fish communities—and the people who depend on them—may be in jeopardy. The researchers hope that the vast diversity of cryptobenthics and their unique way of life can make them a resilient foundation for coral reefs.
After publication, the paper will be available at https://science.sciencemag.org/cgi/doi/10.1126/science.aav3384.
Cryptobenthic reef fish.
LANDING OBLIGATION SIX MONTHS IN
MARKET POTENTIAL FOR MATURE STOCKFISH


It's a simple routine using 4 best-selling products that share advanced anti-aging ingredients. Hyaluronic acid (hydrates & plumps). Amino-peptides (boosts collagen production). A variety of botanical extracts (like green tea leaf). Vitamin B3 (smooths out wrinkles, improving elasticity, reducing circles and redness). Carob fruit extract (antioxidant & skin brightener). All tried and true.


We are looking to hire a Qualified Technician to work in our busy Service Department on the North Road, Drogheda.
Ford qualification an advantage but not compulsory.
Diagnose, repair and service vehicles as required.
Maintain a clean, orderly workplace, adhering to all company policies, procedures and safety standards.
A Minimum of two years post apprenticeship experience working in a Main Dealership.
Experience in all aspects of vehicle servicing, engine overhaul, diagnostics and electronics.
Be highly motivated and able to work on their own initiative.
Ability to clearly communicate, to ensure the smooth and efficient flow of work.
Be efficient and be capable of producing high quality work consistently.
Be in possession of a Full, Clean Driving Licence.
This is a Full time position with our Company who are committed to growth and continuous development.
The successful candidate will be offered an attractive package and terms of employment.
If you are interested in this position and believe you could make a significant contribution to our business please apply by forwarding your C.V. to kevin@smithsofdrogheda.com.


A Fresh Start; Welcome to our New Brand!
You are here: Home / Company updates / A Fresh Start; Welcome to our New Brand!
You may have noticed a few changes to our Facebook and Instagram pages overnight!
You told us, we listened.
The main reason people have given for not getting their 'financial stuff' sorted is being too busy with life, work and family. In the past few years, we've lost count of the number of times we hear that it just takes too much time and energy to get a 'Plan B' sorted.
So, we decided to do things differently and found ways to make using our services faster and easier for our clients. We began to offer KiwiSaver and Insurance reviews over the phone and online, and we started to streamline our processes, cutting out paperwork and saving trees and time!
Eventually, we found that we'd moved so far away from the traditional image of financial advisers that we needed a brand to represent our new look.
We wanted our brand to represent the way we help our customers, by making 'financial stuff' easy, and to represent our love for New Zealand's beauty.
We help busy families and business owners to go from fearing life's 'what-ifs', to feel confident about their financial futures, by giving straightforward advice, professional support and custom solutions to make future-proofing easy!
As we move to more sustainable business practices and reducing the environmental impact of what we do, Coast Advisers is a great brand to represent our love of the beautiful country we live and serve our customers in.
It reflects our independence, integrity and unwavering focus on putting our customers first in all that we say and do.
Whether you're an existing customer, or only just discovering what we can offer, we'd love to hear from you and find out what you think of our rebrand.
Registered Financial Adviser, often found hanging at the beach with his two boys and rescue dogs.


If you've engaged a midwife for your primary care, she will most likely be present at your cesarean birth. She can be on both sides of the curtain, meaning she can easily relay your requests to doctors, give you status updates, and offer emotional support throughout. If you have a doula, ask if she can join you in the operating room. She can help you and your partner find calm and focus. If your partner needs to follow the baby to the warmer or NICU, your doula can stay at your side. Both your midwife and doula can be resources throughout your recovery and can help support breastfeeding.


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