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Pulmonary embolism
|Pulmonary embolism
|Classification and external resources
Chest spiral CT scan with radiocontrast agent showing multiple filling defects both at the bifurcation ("saddle" pulmonary embolism) and in the pulmonary arteries.
|med/1958 emerg/490 radio/582
Pulmonary embolism (PE) is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream (embolism). PE most commonly results from deep vein thrombosis (a blood clot in the deep veins of the legs or pelvis) that breaks off and migrates to the lung, a process termed venous thromboembolism (VTE). A small proportion of cases are caused by the embolization of air, fat, or talc in drugs of intravenous drug abusers or amniotic fluid. The obstruction of the blood flow through the lungs and the resultant pressure on the right ventricle of the heart lead to the symptoms and signs of PE. The risk of PE is increased in various situations, such as cancer or prolonged bed rest.[1]
Symptoms of pulmonary embolism include difficulty breathing, chest pain on inspiration, and palpitations. Clinical signs include low blood oxygen saturation and cyanosis, rapid breathing, and a rapid heart rate. Severe cases of PE can lead to collapse, abnormally low blood pressure, and sudden death.[1]
Diagnosis is based on these clinical findings in combination with laboratory tests (such as the D-dimer test) and imaging studies, usually CT pulmonary angiography. Treatment is typically with anticoagulant medication, including heparin and warfarin. Severe cases may require thrombolysis ("clot busting") with drugs such as tissue plasminogen activator (tPA) or may require surgical intervention via pulmonary thrombectomy.[1]
- 1 Signs and symptoms
- 2 Risk factors
- 3 Diagnosis
- 4 Treatment
- 5 Epidemiology
- 6 Prognosis
- 7 References
Signs and symptoms[edit]
Symptoms of PE are typically sudden in onset and include dyspnea (shortness of breath), tachypnea (rapid breathing), chest pain of a "pleuritic" nature (worsened by breathing), cough and hemoptysis (coughing up blood). More severe cases can include signs such as cyanosis (blue discoloration, usually of the lips and fingers), collapse, and circulatory instability because of decreased blood flow through the lungs and into the left side of the heart. About 15% of all cases of sudden death are attributable to PE.[1]
On physical examination, the lungs are usually normal. Occasionally, a pleural friction rub may be audible over the affected area of the lung (mostly in PE with infarct). A pleural effusion is sometimes present that is exudative, detectable by decreased percussion note, audible breath sounds and vocal resonance. Strain on the right ventricle may be detected as a left parasternal heave, a loud pulmonary component of the second heart sound, and raised jugular venous pressure.[1] A low-grade fever may be present, particularly if there is associated pulmonary hemorrhage or infarction.[2]
Risk factors[edit]
The most common sources of embolism are proximal leg deep venous thrombosis (DVTs) or pelvic vein thromboses. Any risk factor for DVT also increases the risk that the venous clot will dislodge and migrate to the lung circulation, which may happen in as many as 15% of all DVTs.[citation needed] The conditions are generally regarded as a continuum termed venous thromboembolism (VTE).
The development of thrombosis is classically due to a group of causes named Virchow's triad (alterations in blood flow, factors in the vessel wall and factors affecting the properties of the blood). Often, more than one risk factor is present.
- Alterations in blood flow: immobilization (after surgery, injury, pregnancy (also procoagulant), obesity (also procoagulant), cancer (also procoagulant)
- Factors in the vessel wall: surgery, catheterizations causing direct injury ("endothelial injury")
- Factors affecting the properties of the blood (procoagulant state):
- Estrogen-containing hormonal contraception
- Genetic thrombophilia (factor V Leiden, prothrombin mutation G20210A, protein C deficiency, protein S deficiency, antithrombin deficiency, hyperhomocysteinemia and plasminogen/fibrinolysis disorders)
- Acquired thrombophilia (antiphospholipid syndrome, nephrotic syndrome, paroxysmal nocturnal hemoglobinuria)
- Cancer (due to secretion of pro-coagulants)
To diagnose pulmonary embolism, medical societies recommend a review of clinical criteria to determine the need for testing, followed by testing to determine a likelihood of being able to confirm a diagnosis by imaging, followed by imaging if other tests have shown that there is a likelihood of a PE diagnosis.[3][4][5]
The diagnosis of PE is based primarily on validated clinical criteria combined with selective testing because the typical clinical presentation (shortness of breath, chest pain) cannot be definitively differentiated from other causes of chest pain and shortness of breath. The decision to do medical imaging is usually based on clinical grounds, i.e. the medical history, symptoms and findings on physical examination, followed by an assessment of clinical probability.[1]
The most commonly used method to predict clinical probability, the Wells score, is a clinical prediction rule, whose use is complicated by multiple versions being available. In 1995, Wells et al. initially developed a prediction rule (based on a literature search) to predict the likelihood of PE, based on clinical criteria.[6] The prediction rule was revised in 1998[7] This prediction rule was further revised when simplified during a validation by Wells et al. in 2000.[8] In the 2000 publication, Wells proposed two different scoring systems using cutoffs of 2 or 4 with the same prediction rule.[8] In 2001, Wells published results using the more conservative cutoff of 2 to create three categories.[9] An additional version, the "modified extended version", using the more recent cutoff of 2 but including findings from Wells's initial studies[6][7] were proposed.[10] Most recently, a further study reverted to Wells's earlier use of a cutoff of 4 points[8] to create only two categories.[11]
There are additional prediction rules for PE, such as the Geneva rule. More importantly, the use of any rule is associated with reduction in recurrent thromboembolism.[12]
The Wells score:[13]
- clinically suspected DVT — 3.0 points
- alternative diagnosis is less likely than PE — 3.0 points
- tachycardia (heart rate > 100) — 1.5 points
- immobilization (≥ 3d)/surgery in previous four weeks — 1.5 points
- history of DVT or PE — 1.5 points
- hemoptysis — 1.0 points
- malignancy (with treatment within 6 months) or palliative — 1.0 points
Traditional interpretation[8][9][14]
- Score >6.0 — High (probability 59% based on pooled data[15])
- Score 2.0 to 6.0 — Moderate (probability 29% based on pooled data[15])
- Score <2.0 — Low (probability 15% based on pooled data[15])
Alternative interpretation[8][11]
- Score > 4 — PE likely. Consider diagnostic imaging.
- Score 4 or less — PE unlikely. Consider D-dimer to rule out PE.
Blood tests[edit]
In low/moderate suspicion of PE, a normal D-dimer level (shown in a blood test) is enough to exclude the possibility of thrombotic PE, with a three month risk of thromboembolic events being 0.14%.[16] D-dimer is highly sensitive but not very specific (specificity around 50%). In other words, a positive D-dimer is not synonymous with PE, but a negative D-dimer is, with a good degree of certainty, an indication of absence of a PE.[17] The typical cut off is 500 ug/L.[18] In those over the age of 50 year changing the cut off value to age * 10 ug/L decreases the number of falsely positive tests without missing any additional cases of PE.[18]
When a PE is being suspected, a number of blood tests are done, in order to exclude important secondary causes of PE. This includes a full blood count, clotting status (PT, aPTT, TT), and some screening tests (erythrocyte sedimentation rate, renal function, liver enzymes, electrolytes). If one of these is abnormal, further investigations might be warranted.[citation needed]
In typical patients who are not known to be at high risk of PE, imaging is helpful to confirm or exclude a diagnosis of PE after simpler first-line tests are used.[3][4][5] Medical societies recommend tests such as the D-dimer to first provide supporting evidence for the need for imaging, and imaging would be done if other tests confirmed a moderate or high probability of finding evidence to support a diagnosis of PE.[4][5]
CT pulmonary angiography is the recommended first line diagnostic imaging test in most people.[19] Historically, the gold standard for diagnosis was pulmonary angiography, but this has fallen into disuse with the increased availability of non-invasive techniques.[citation needed]
- Non-invasive imaging
CT pulmonary angiography (CTPA) is a pulmonary angiogram obtained using computed tomography (CT) with radiocontrast rather than right heart catheterization. Its advantages are clinical equivalence, its non-invasive nature, its greater availability to people, and the possibility of identifying other lung disorders from the differential diagnosis in case there is no pulmonary embolism. Assessing the accuracy of CT pulmonary angiography is hindered by the rapid changes in the number of rows of detectors available in multidetector CT (MDCT) machines.[20] According to a cohort study, single-slice spiral CT may help diagnose detection among people with suspected pulmonary embolism.[21] In this study, the sensitivity was 69% and specificity was 84%. In this study which had a prevalence of detection was 32%, the positive predictive value of 67.0% and negative predictive value of 85.2% (click here to adjust these results for people at higher or lower risk of detection). However, this study's results may be biased due to possible incorporation bias, since the CT scan was the final diagnostic tool in people with pulmonary embolism. The authors noted that a negative single slice CT scan is insufficient to rule out pulmonary embolism on its own. A separate study with a mixture of 4 slice and 16 slice scanners reported a sensitivity of 83% and a specificity of 96%. This study noted that additional testing is necessary when the clinical probability is inconsistent with the imaging results.[22] CTPA is non-inferior to VQ scanning, and identifies more emboli (without necessarily improving the outcome) compared to VQ scanning.[23]
Ventilation/perfusion scan (or V/Q scan or lung scintigraphy), which shows that some areas of the lung are being ventilated but not perfused with blood (due to obstruction by a clot). This type of examination is as accurate as multislice CT but is often used less because of the more widespread availability of CT technology. It is particularly useful in people who have an allergy to iodinated contrast, impaired renal function, or in pregnancy due to lower radiation exposure than CT.[24][25] The test can be performed with planar two-dimensional imaging, or single photon emission tomography (SPECT) which enables three-dimensional imaging.[19] Hybrid devices combining SPECT and CT (SPECT/CT) further enable anatomic characterization of any abnormality.
- Low probability diagnostic tests/non-diagnostic tests
Tests that are frequently done that are not sensitive for PE, but can be diagnostic.
- Chest X-rays are often done on patients with shortness of breath to help rule-out other causes, such as congestive heart failure and rib fracture. Chest X-rays in PE are rarely normal,[26] but usually lack signs that suggest the diagnosis of PE (e.g. Westermark sign, Hampton's hump).
- Ultrasonography of the legs, also known as leg doppler, in search of deep venous thrombosis (DVT). The presence of DVT, as shown on ultrasonography of the legs, is in itself enough to warrant anticoagulation, without requiring the V/Q or spiral CT scans (because of the strong association between DVT and PE). This may be valid approach in pregnancy, in which the other modalities would increase the risk of birth defects in the unborn child. However, a negative scan does not rule out PE, and low-radiation dose scanning may be required if the mother is deemed at high risk of having pulmonary embolism.[citation needed]
The primary use of the ECG is to rule out other causes of chest pain.[27] An electrocardiogram (ECG) is routinely done on patients with chest pain to quickly diagnose myocardial infarctions (heart attacks) an important differential diagnosis in an individual with chest pain. While certain ECG changes may occur with PE none are specific enough to confirm or sensitive enough to rule out the diagnosis.[27] An ECG may show signs of right heart strain or acute cor pulmonale in cases of large PEs — the classic signs are a large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III (S1Q3T3) which occurs in 12-50% of people with the diagnosis, yet also occurs in 12% without the diagnosis.[28][29] This is occasionally (up to 20%) present, but may also occur in other acute lung conditions and has therefore limited diagnostic value. The most commonly seen signs in the ECG is sinus tachycardia, right axis deviation and right bundle branch block.[30] Sinus tachycardia was however still only found in 8–69% of people with PE.[31]
In massive and submassive PE, dysfunction of the right side of the heart may be seen on echocardiography, an indication that the pulmonary artery is severely obstructed and the right ventricle, a low pressure pump, is unable to match the pressure. Some studies (see below) suggest that this finding may be an indication for thrombolysis. Not every person with a (suspected) pulmonary embolism requires an echocardiogram, but elevations in cardiac troponins or brain natriuretic peptide may indicate heart strain and warrant an echocardiogram,[32] and be important in prognosis.[33]
The specific appearance of the right ventricle on echocardiography is referred to as the McConnell's sign. This is the finding of akinesia of the mid-free wall but normal motion of the apex. This phenomenon has a 77% sensitivity and a 94% specificity for the diagnosis of acute pulmonary embolism in the setting of right ventricular dysfunction.[34]
Probability testing[edit]
Recent recommendations for a diagnostic algorithm have been published by the PIOPED investigators; however, these recommendations do not reflect research using 64 slice MDCT.[15] These investigators recommended:
- Low clinical probability. If negative D-dimer, PE is excluded. If positive D-dimer, obtain MDCT and based treatment on results.
- Moderate clinical probability. If negative D-dimer, PE is excluded. However, the authors were not concerned that a negative MDCT with negative D-dimer in this setting has an 5% probability of being false. Presumably, the 5% error rate will fall as 64 slice MDCT is more commonly used. If positive D-dimer, obtain MDCT and based treatment on results.
- High clinical probability. Proceed to MDCT. If positive, treat, if negative, additional tests are needed to exclude PE.
Pulmonary Embolism Rule-out Criteria[edit]
The Pulmonary Embolism Rule-out Criteria (PERC) help assess people in whom pulmonary embolism is suspected, but unlikely. Unlike the Wells Score and Geneva score, which are clinical prediction rules intended to risk stratify patients with suspected PE, the PERC rule is designed to rule out risk of PE in patients when the physician has already stratified them into a low-risk category.
Patients in this low risk category without any of these criteria may undergo no further diagnostic testing for PE: Hypoxia — SaO2 <95%, unilateral leg swelling, hemoptysis, prior DVT or PE, recent surgery or trauma, age >50, hormone use, tachycardia. The rationale behind this decision is that further testing (specifically CT angiogram of the chest) may cause more harm (from radiation exposure and contrast dye) than the risk of PE.[35] The PERC rule has a sensitivity of 97.4% and specificity of 21.9% with a false negative rate of 1.0% (16/1666).[36]
Anticoagulant therapy is typically the mainstay of treatment. Acutely, supportive treatments, such as oxygen or analgesia, may be required. People are often admitted to hospital in the early stages of treatment, and tend to remain under inpatient care until the INR has reached therapeutic levels. Increasingly, however low-risk cases are managed at home in a fashion already common in the treatment of DVT.[37]
In most cases, anticoagulant therapy is the mainstay of treatment. Unfractionated heparin, low molecular weight heparin (LMWH), or fondaparinux is administered initially, while warfarin, acenocoumarol, or phenprocoumon therapy is commenced (this may take several days, usually while the patient is in the hospital). LMWH may reduce bleeding among patients with pulmonary embolism as compared to heparin according to a systematic review of randomized controlled trials by the Cochrane Collaboration.[38] The relative risk reduction was 40%. For patients at similar risk to those in this study (2.0% had bleeding when not treated with low molecular weight heparin), this leads to an absolute risk reduction of 0.8%. 125 patients must be treated for one to benefit.
Warfarin therapy often requires frequent dose adjustment and monitoring of the international normalized ratio (INR). In PE, INRs between 2.0 and 3.0 are generally considered ideal. If another episode of PE occurs under warfarin treatment, the INR window may be increased to e.g. 2.5–3.5 (unless there are contraindications) or anticoagulation may be changed to a different anticoagulant e.g. LMWH. In patients with an underlying malignancy, therapy with a course of LMWH may be favored over warfarin based on the results of the CLOT trial.[39]
Similarly, pregnant women are often maintained on low molecular weight heparin until at least 6 weeks after delivery to avoid the known teratogenic effects of warfarin, especially in the early stages of pregnancy.[40]
Warfarin therapy is usually continued for 3–6 months, or "lifelong" if there have been previous DVTs or PEs, or none of the usual risk factors is present. An abnormal D-dimer level at the end of treatment might signal the need for continued treatment among patients with a first unprovoked pulmonary embolus.[41]
Massive PE causing hemodynamic instability (shock and/or hypotension, defined as a systolic blood pressure <90 mmHg or a pressure drop of 40 mmHg for >15 min if not caused by new-onset arrhythmia, hypovolemia or sepsis) is an indication for thrombolysis, the enzymatic destruction of the clot with medication. It is the best available medical treatment in this situation and is supported by clinical guidelines.[42][43][44]
The use of thrombolysis in non-massive PEs is still debated. The aim of the therapy is to dissolve the clot, but there is an attendant risk of bleeding or stroke.[45] The main indication for thrombolysis is in submassive PE where right ventricular dysfunction can be demonstrated on echocardiography, and the presence of visible thrombus in the atrium.[46]
Inferior vena cava filter[edit]
If anticoagulant therapy is contraindicated and/or ineffective, or to prevent new emboli from entering the pulmonary artery and combining with an existing blockage, an inferior vena cava filter may be implanted.[47]
Surgical management of acute pulmonary embolism (pulmonary thrombectomy) is uncommon and has largely been abandoned because of poor long-term outcomes. However, recently, it has gone through a resurgence with the revision of the surgical technique and is thought to benefit certain people.[48] Chronic pulmonary embolism leading to pulmonary hypertension (known as chronic thromboembolic hypertension) is treated with a surgical procedure known as a pulmonary thromboendarterectomy.
Pulmonary embolism occur in more than 0.6 million people in the United States each year.[49] It results in between 50,000[49] and 200,000 deaths per year in the United States.[50] The risk in those who are hospitalized is around 1%.[51] The rate of fatal pulmonary emboli has declined from 6% to 2% over the last 25 years in the United States.[50]
Mortality from untreated PE is said to be 26%. This figure comes from a trial published in 1960 by Barrit and Jordan,[52] which compared anticoagulation against placebo for the management of PE. Barritt and Jordan performed their study in the Bristol Royal Infirmary in 1957. This study is the only placebo controlled trial ever to examine the place of anticoagulants in the treatment of PE, the results of which were so convincing that the trial has never been repeated as to do so would be considered unethical. That said, the reported mortality rate of 26% in the placebo group is probably an overstatement, given that the technology of the day may have detected only severe PEs.
Prognosis depends on the amount of lung that is affected and on the co-existence of other medical conditions; chronic embolisation to the lung can lead to pulmonary hypertension. After a massive PE, the embolus must be resolved somehow if the patient is to survive. In thrombotic PE, the blood clot may be broken down by fibrinolysis, or it may be organized and recanalized so that a new channel forms through the clot. Blood flow is restored most rapidly in the first day or two after a PE.[53] Improvement slows thereafter and some deficits may be permanent. There is controversy over whether or not small subsegmental PEs need to be treated at all[54] and some evidence exists that patients with subsegmental PEs may do well without treatment.[22][55]
Once anticoagulation is stopped, the risk of a fatal pulmonary embolism is 0.5% per year.[56]
Predicting mortality[edit]
The PESI can estimate mortality of patients. The Geneva prediction rules and Wells criteria are used to calculate a pre-test probability of patients to predict who has a pulmonary embolism. These scores are tools to be used in conjunction with clinical judgement in deciding diagnostic testing and types of therapy.[57]
Underlying causes[edit]
After a first PE, the search for secondary causes is usually brief. Only when a second PE occurs, and especially when this happens while still under anticoagulant therapy, a further search for underlying conditions is undertaken. This will include testing ("thrombophilia screen") for Factor V Leiden mutation, antiphospholipid antibodies, protein C and S and antithrombin levels, and later prothrombin mutation, MTHFR mutation, Factor VIII concentration and rarer inherited coagulation abnormalities.[citation needed]
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- ^ Rodger M, Makropoulos D, Turek M, et al. (October 2000). "Diagnostic value of the electrocardiogram in suspected pulmonary embolism". Am. J. Cardiol. 86 (7): 807–9, A10. doi:10.1016/S0002-9149(00)01090-0. PMID 11018210.
- ^ Amal Mattu; Deepi Goyal; Barrett, Jeffrey W.; Joshua Broder; DeAngelis, Michael; Peter Deblieux; Gus M. Garmel; Richard Harrigan; David Karras; Anita L'Italien; David Manthey (2007). Emergency medicine: avoiding the pitfalls and improving the outcomes. Malden, Mass: Blackwell Pub./BMJ Books. p. 10. ISBN 1-4051-4166-2.
- ^ Kucher N, Goldhaber SZ (2003). "Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism". Circulation 108 (18): 2191–4. doi:10.1161/01.CIR.0000100687.99687.CE. PMID 14597581.
- ^ Lankeit M, Jiménez D, Kostrubiec M, Dellas C, Hasenfuss G, Pruszczyk P, Konstantinides S (December 2011). "Predictive value of the high-sensitivity troponin T assay and the simplified Pulmonary Embolism Severity Index in hemodynamically stable patients with acute pulmonary embolism: a prospective validation study". Circulation. 124(24) (24): 2716–24. doi:10.1161/CIRCULATIONAHA.111.051177. PMID 22082681.
- ^ McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT (1996). "Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism". Am. J. Cardiol. 78 (4): 469–73. doi:10.1016/S0002-9149(96)00339-6. PMID 8752195.
- ^ Kline, Jeffrey A; Mitchell, AM; Kabrhel, C; Richman, PB; Courtney, DM (2004). "Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism". Journal of Thrombosis and Haemostasis 2 (8): 1247–55. doi:10.1111/j.1538-7836.2004.00790.x. PMID 15304025.
- ^ Kline, Jeffrey A; Courtney, DM; Kabrhel, C; Moore, CL; Smithline, HA; Plewa, MC; Richman, PB; O'Neil, BJ; Nordenholz, K (2008). "Prospective multicenter evaluation of the pulmonary embolism rule-out criteria". Journal of Thrombosis and Haemostasis 6 (5): 772–780. doi:10.1111/j.1538-7836.2008.02944.x. PMID 18318689.
- ^ Vinson, DR; Zehtabchi, S; Yealy, DM (November 2012). "Can selected patients with newly diagnosed pulmonary embolism be safely treated without hospitalization? A systematic review.". Annals of emergency medicine 60 (5): 651–662.e4. doi:10.1016/j.annemergmed.2012.05.041. PMID 22944455.
- ^ Erkens PM, Prins MH (2010). "Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism". In Prins, Martin H. Cochrane Database Syst Rev (9): CD001100. doi:10.1002/14651858.CD001100.pub3. PMID 20824828. ACPJC Review
- ^ Lee AY, Levine MN, Baker RI, Bowden C, Ajay Kakkar, Ajay Kakkar, Baron Kakkar, Prins M, Rickles FR, Julian JA, Haley S, Kovacs MJ, Randomized Comparison Of Low-Molecular-Weight Heparin Versus Oral Anticoagulant Therapy For The Prevention Of Recurrent Venous Thromboembolism In Patients With Cancer (Clot), Investigators (2003). "Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer". N Engl J Med 349 (2): 146–53. doi:10.1056/NEJMoa025313. PMID 12853587.
- ^ Benson, MD (October 2012). "Pulmonary embolism in pregnancy. Consensus and controversies.". Minerva ginecologica 64 (5): 387–98. PMID 23018478.
- ^ Palareti G, Cosmi B, Legnani C, et al. (2006). "D-dimer testing to determine the duration of anticoagulation therapy". N. Engl. J. Med. 355 (17): 1780–9. doi:10.1056/NEJMoa054444. PMID 17065639.
- ^ British Thoracic Society Standards Of Care Committee Pulmonary Embolism Guideline Development, Group (June 2003). "British Thoracic Society guidelines for the management of suspected acute pulmonary embolism". Thorax 58 (6): 470–83. doi:10.1136/thorax.58.6.470. PMC 1746692. PMID 12775856.
- ^ Torbicki A, Perrier A, Konstantinides S, et al. (September 2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur. Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.
- ^ Hirsh J, Guyatt G, Albers GW, Harrington R, Schünemann HJ (June 2008). "Executive summary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)". Chest 133 (6 Suppl): 71S–109S. doi:10.1378/chest.08-0693. PMID 18574259.
- ^ Dong B, Jirong Y, Liu G, Wang Q, Wu T (2006). "Thrombolytic therapy for pulmonary embolism". In Dong, Bi Rong. Cochrane Database Syst Rev (2): CD004437. doi:10.1002/14651858.CD004437.pub2. PMID 16625603.
- ^ Goldhaber SZ (2004). "Pulmonary embolism". Lancet 363 (9417): 1295–305. doi:10.1016/S0140-6736(04)16004-2. PMID 15094276.
- ^ Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, Laporte S, Faivre R, Charbonnier B, Barral F, Huet Y, Simonneau G (1998). "A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group". N Engl J Med 338 (7): 409–15. doi:10.1056/NEJM199802123380701. PMID 9459643.
- ^ Augustinos P, Ouriel K (2004). "Invasive approaches to treatment of venous thromboembolism". Circulation 110 (9 Suppl 1): I27–34. doi:10.1161/01.CIR.0000140900.64198.f4. PMID 15339878.
- ^ a b Rahimtoola, A; Bergin, JD (February 2005). "Acute pulmonary embolism: an update on diagnosis and management". Current problems in cardiology 30 (2): 61–114. doi:10.1016/j.cpcardiol.2004.06.001. PMID 15650680.
- ^ a b Kumar,Abbas,Fausto, Mitchell (2010). Basic Pathology. New Delhi: Elsevier. p. 98. ISBN 978-81-312-1036-9.
- ^ Wood, Kenneth E. (2002). "An approach to Venous Thomboembolism/Pulmonay Embolism in the Critically Ill". In Murray, Michael J.; Coursin, Douglas B.; Pearl, Ronald G. et al. Critical Care Medicine: Perioperative Management: Published Under the Auspices of the American Society of Critical Care Anesthesiologists (ASCCA). Lippincott Williams & Wilkins. p. 536. ISBN 978-0-7817-2968-0.
- ^ Barritt DW, Jordan SC (1960). "Anticoagulant drugs in the treatment of pulmonary embolism: a controlled trial". Lancet 1 (7138): 1309–12. doi:10.1016/S0140-6736(60)92299-6. PMID 13797091.
- ^ Walker, R. H. Secker; Jackson, Judy A.; Goodwin, Jan (17 October 1970). "Resolution of Pulmonary Embolism". British Medical Journal 4 (5728): 135–9. doi:10.1136/bmj.4.5728.135. PMC 1819885. PMID 5475816.
- ^ Le Gal G, Righini M, Parent F, van Strijen M, Couturaud F (2006). "Diagnosis and management of subsegmental pulmonary embolism". J Thromb Haemost 4 (4): 724–31. doi:10.1111/j.1538-7836.2006.01819.x. PMID 16634736.
- ^ Perrier A, Bounameaux H (2006). "Accuracy or outcome in suspected pulmonary embolism". N Engl J Med 354 (22): 2383–5. doi:10.1056/NEJMe068076. PMID 16738276.
- ^ White RH (October 2008). "Risk of fatal pulmonary embolism was 0.49 per 100 person-years after discontinuing anticoagulant therapy for venous thromboembolism". Evid Based Med 13 (5): 154. doi:10.1136/ebm.13.5.154. PMID 18836122.
- ^ Jiménez D, Yusen RD, Otero R, et al. (2007). "Prognostic models for selecting patients with acute pulmonary embolism for initial outpatient therapy". Chest 132 (1): 24–30. doi:10.1378/chest.06-2921. PMID 17625081.
|Wikimedia Commons has media related to Pulmonary embolism.

subset: commoncrawl


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Phone: 1-800-935-0045, 1-479-738-2348
Ozark Mountain Publishing publishes only non-fiction metaphysical and spiritual material. Our purpose is to provide readers with accurate, interesting and educational information that opens the mind to fascinating possibilities. We hope that you will take the journey with us and explore the possibilities of the Universe and Beyond.


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It has been sooo hot! I guess that we are paying for the mild winter that we had. I know I felt that heat here in Charleston, where I'm working right now. So, when it feels like 110 in the shade, it's a great time to cool down with icy cold and delicious summer drinks. Especially since you can find fresh fruit to go in them right now!
The recipes for this week will make you feel cooler even just reading them. But, I hope that you will give them a try! Let me know how you like them.
The first is one I've used before but I love it so much that I couldn't leave it out. It's orange juice, banana and pineapple. That is a great combination and you can't go wrong with this one. This also has no added sugar, so it's great and great for you.
The second is banana, strawberry and apple juice. However, you can substitute blackberries, blueberries, etc. for the strawberries. Again, no added sugar to this one either. It won't need any extra sweetness.
The third recipe has a strange name. It's called June Bug. That is just to be cute, it has nothing to do with the ingredients, so relax! This one uses OJ, ginger ale, grenadine and sherbet. You could also sub lime juice and lime sherbet for the orange flavor. I love lime, so that's my preference.
The last recipe uses melon. Any time you can make a smoothie type drink with melon, it's going to be a winner. This will be one of your favorites!
Remember that you can make a smoothie out of almost anything or a cool summer drink out of almost anything. If you have an interesting drink recipe, let me know.Orange & Pineapple Smoothie
Cool Summer Drinks
It has been sooo hot! I guess that we are paying for the mild winter that we had. I know I felt that heat here in Charleston, where I'm working right now. So, when it feels like 110 in the shade, it's a great time to cool down with icy cold and delicious summer drinks. Especially since you can find fresh fruit to go in them right now!
- Food
Culinary Creations by (and for) Families
Encouraging kids to get creative in the kitchen is a fun way to make great memories, meals and moments together. And for more than 10 years, Jif(r) has inspired parents to creatively collaborate with their kids in the Jif Most Creative Sandwich Contest(tm) for the chance to win a $25,000 college fund. Last year's top entries ranged from a sweet and spicy sandwich to satisfying snacks and dreamy desserts. Inspire your family with these delicious recipes or check out www.jif.com for even more creative options.
Snappy Beans
Green beans are no longer a plain side dish for dinner. Here are some fun, kid-friendly recipes to try at home to help encourage your kids to eat a healthy serving of green beans.
"Florida green beans are great with a dip. Try them with hummus, ranch or any of your favorite dressings," suggested Justin Timineri, Executive Chef and Culinary Ambassador, Florida Department of Agriculture and Consumer Services.
- Cooking with leftovers a challenge
Fresh Tips for Game Day Dips
When family and friends gather together to watch the game, loading up the table with a variety of easy-to-grab, flavorful appetizers is a winning plan. After all, casual food and good times are what game day is all about.
In the world of appetizers, dip is king. From savory to sweet, this simple tailgating party addition can take on flavors that span the globe, or that are as American and as beloved as the gridiron game itself.
Raising the Bar on Healthy Smiles
Sports drinks, energy drinks and those must-have morning coffees all have one thing in common - they typically contain an abundance of sugar or sugar-alternatives that are harmful to the health of those pearly whites. Another beverage, whose ingredients can also wreak havoc on your smile, is always the life of the party - the cocktail.
"Selecting healthy, natural superfoods with specific functions improves the ability of our body to create that beautiful smile we all desire," said Dr. Ken Banks, AACD cosmetic dentist and contributor to the recipe collection.
According to recent studies, cocktails infused with wholesome ingredients can improve immunity and offer a tasty tonic for teeth. The next time you are looking for refreshment, seek beverages that use fruits, vegetables, grains, and other superfood ingredients.
Kitchen Confections
There are few things more enjoyable than biting into a rich and delicious chocolate dessert. By using a more robust flavor like that of dark chocolate, show-stopping desserts can be crafted right from your own kitchen - and it is easier than you think.
Breakfast Bounty
Getting kids back to school each morning can be exhausting and feeding them a good, hot breakfast often gets put on the back burner. Start them out right with easy, wholesome meals full of the protein necessary to fuel their day.
A protein-rich breakfast - one that includes lean ham or pork sausage - reduces daily hunger, increases daily fullness, improves morning blood sugar control and leads to less latter-day snacking, according to a recent study by the University of Missouri. That means teenage boys and girls who chronically skip breakfast have a new, tasty weapon in the fight against obesity. Studies show as many as 20 to 30 percent of adolescents in the United States skip breakfast, which is a habit associated with excess body weight.
Spicy, Sweet or Zesty
Spicy, sweet or zesty, it's never been easier to enjoy the crisp, tangy taste of homemade pickles. And with recipes like these you can preserve perfect pickles for any palate.
Here are a few tips from the pickling pros at Mrs. Wages to help you give your cukes a kick of great homemade flavor:
Master Mediterranean Grilling
Abundant plates of fresh vegetables, delicate fish from the nearby sea and splashes of olive oil are all hallmarks of traditional meals found in the Mediterranean.
The Mediterranean diet has been embraced for thousands of years by those living along the Mediterranean Sea, and is now followed around the world as consumers discover its delicious flavor components and researchers uncover its countless health benefits, including helping to prevent heart attacks and strokes according to a study conducted by The New England Journal of Medicine.
Grill Up Flavor
Every big, juicy steak deserves to be seasoned with an equally big, bold flavor. Next time you fire up the grill, layer on savory goodness with spices and marinades. They bring out the natural flavor of steaks, ribs, roasts, burgers, chicken and fajitas.
- More Food Headlines
- Culinary Creations by (and for) Families


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This May 16, 2012, photo shows dairy cows on the Meyer farm in Chilton, Wis. The owners have hired a chiropractor to look at a couple of their cows experiencing physical issues in the hopes it will help them feel better. It's all part of the effort to ensure maximum milk output. There's no sound scientific data to back up the claims, but dairy farmers say they believe they're seeing improved productivity. (AP Photo/Carrie Antlfinger)
Read the article: Dairies Pamper Cows With Chiropractors, Waterbeds


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Tributes to ex Workington miner who emigrated to Australia
Last updated at 23:43, Saturday, 19 May 2012
A former Seaton man has died in Australia after a battle with pancreatic cancer.
Roger Bancroft, formerly of Kennedy Road, was 72.
Mr Bancroft attended Seaton infant and junior schools, then Guard Street School, going on to Workington Technical School.
He started work at 16 at St Helen's Colliery, known as Siddick Pit, and continued attending the college for his mining certificates.
He married Pat Broderick, of High Harrington, in 1963 and shortly afterwards went to work in Derbyshire at Cresswell Colliery.
While there, he continued to study and got his under manager's certificate.
In 1968 the couple and their sons Mark and Neil emigrated to Australia and Roger worked at South Bulli Mines as a deputy.
He later became the manager of Avon Colliery and Yallah Rock in New South Wales and worked as manager of Middlemount Colliery in Queensland.
His last position before retiring was as inspector of mines for Queensland.
Mrs Bancroft died in 2004 but her husband found love again and had been happily married to Jill in recent years.
He leaves behind his wife, sons Mark and Neil, daughter Claire, daughters-in-law Michelle and Bev and six grandchildren who all live in Australia.
His sister Judy, brother-in-law Joe and their family live near Sydney.
His brother John Stuart, sister-in-law Rose and family live in Manchester and his younger sister Diana, brother-in-law Joe and their family live in Kendal.
Mr Bancroft's parents Clara and Bernard retired to Australia from Seaton in 1981 but died in 2010 and 2011.
First published at 19:20, Thursday, 17 May 2012
Published by http://www.timesandstar.co.uk
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Light and economical. Ideal for beginners. Double spring wire barbs and point unscrew for removal from a fish. 135 grains.
Order ONLINE Today!
Cajun® Wee Stinger Bowfishing Point
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Darren Heath is very pleased to offer the chance for you to own a fantastic exhibition quality print of any photograph on the site. Particularly F1 prints or Formula 1 photographs re-printed.
Prepared for printing by a top photo-technician to ensure that all possible sharpness, colour and clarity is evident in the final artwork the prints are produced on the very latest machine using only the finest quality paper and once finished, are carefully packaged and delivered in a cardboard tube.
To inquire about prints sizes, prices and specific images please click here.
© Copyright Darren Heath 2011. All images on this site are protected under international copyright laws. Images may not be used without the written consent of Darren Heath. All rights reserved.


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Making Miracles at Cottage Children's Hospital
Cottage Children's Hospital relies on your support to provide the absolute best in care for children throughout Santa Barbara County and surrounding areas; kids like Dominic, Bradley, Ava, and many more.
Your support goes to research and training, purchasing equipment, and paying for uncompensated care, all in support of our mission to save and improve the lives of as many kids as possible.
Support Cottage Children's Hospital when you visit these local businesses
Buy a Miracle Balloon at
• Rite Aid: April 6 - May 24
• Costco: May 1 – May 31
• Walmart: May 1 – June 11
• Chico's, White House Black Market and Soma Intimates: May 1 – June 30
Buy a Care for Kids Cup at
• Blenders in the Grass:
May 1 – May 31
We are grateful for the sponsorship support of the many individuals and local businesses as well as for the donations received from hundreds of individuals who made pledges, responded to our spring appeal, made a gift online, or donated at participating retail businesses. 100% of these gifts will remain in Santa Barbara to help Cottage Children's Hospital provide care to local children.
Children's Miracle Network Hospitals raises funds for 170 premier children's hospitals across North America. Donations stay in the community, ensuring that every dollar is helping local kids. Since 1983 Children's Miracle Network Hospitals have raised more than $4 billion, much of it $1 at a time.
Cottage Children's Hospital is a regional referral center for the medical needs of infants, toddlers, children and teens in the tri-county area (Santa Barbara, San Luis Obispo and Ventura counties), the greater Los Angeles area, and the inland region of California, and has earned a reputation for excellence by drawing some of the nation's top pediatric specialists to our community.
We offer comprehensive pediatric services, including the only
pediatric intensive care unit Santa Barbara County, the only Level III neonatal intensive care unit, the only comprehensive pediatric hematology/oncology, gastroenterology, and endocrinology services for the Central Coast, and a specially designed ambulance to meet the needs of our young patients. In 2009, more than 1,300 children were cared for in the pediatrics unit; 334 infants were treated in the NICU; more than 360 children were admitted to the PICU; more than 400 children with cancer are receiving ongoing treatment through the pediatric hematology-oncology program.
For more information on how to make a contribution to Cottage Children's Hospital, call (805) 879-8980. You may also use the online donation page and note that you would like your gift directed to children's services at Santa Barbara Cottage Hospital. Donate $100 or more and receive a Cottage Children's Hospital tote bag as our gift to you.
Local businesses: partner with Cottage Children's Hospital and Children's Miracle Network Hospitals (CMN Hospitals) to help us reach out to the community to garner financial support and raise awareness about the critical services provided to thousands of children each year. Contact Audrie Krause at firstname.lastname@example.com or at 879-8985 for information about Miracle Balloon Campaigns, Miracle Kids Day, and other fundraising programs.
Find us on Facebook!


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Narrow your search
Jaguar did more than merely put a hard top on its Jaguar F-type, it created a thing of real beauty, with performance that should outstrip all other Jaguar models.
Pricing not available
We fell in love with the gorgeous curves and excellent performance of the 2014 Jaguar F-Type, but middling tech and a very big price tag have us looking twice at its German competitors.
Running Android 4.1.2 with 4G LTE, the prepaid LG Optimus F3Q is aimed for QWERTY fans on T-Mobile.
The Xpression has a slider design in red, a full keyboard, a touch screen, and basic features for $49 with service.
Jaguar unveils its F-Type Coupe at the LA Auto Show. The all-new Coupe comes with three engine choices: two supercharged 3-liter V-6 engines, and a supercharged 5-liter V-8 -- with horsepower ranging from 340 all the way up to 550.
It's got the look, the power and the noise. The new Jaguar F-Type R Coupe is the Jag we've all been waiting for.
When the F-Type was launched last year we were only given the convertible, now the coupe truly gives us a successor to the E-type.
The SanDisk Connect Wireless Media Drive makes up for its slow USB speed by offering an excellent feature set and an SD card slot that will make most casual mobile users happy, especially photographers.
The Pegasus J4 is currently the only good choice on the market if you're looking for a compact four-bay Thunderbolt storage device.
Jaguar follows up the F-type convertible, released earlier this year, with a hardtop version featuring a very svelte appearance.


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You must earn 10,000 points to post other members' whiteboard
WE spent our honeymoon there and 4 other vacations, coming back this year.. Congratulations on 500 consecutive days posting, that's commitment. Happy New Year to you and yours. Lets be cross country buddies. Thanks. Shep
Congratulations on having the dedication to post for 500 consecutive days. Have a Wonderful 2014! Warren :)
A BIG CONGRATS on reaching that 1M mark and your first new red car! Awesome, most new GBs will never make it to 1M, but you did! : ) You're one of only 7,675 GBs of more than 8,000,000 that signed up to be GasBuddies to have accumulated at least 1,000,000 points! Keep going another 2 or 3 million! Another 2M and you'll be into that nice big limo! : ) Only 2,852 GBs have made it to 2M, so there is room for you there also! Many GBs ahead of you have already retired! DON'T give up now like so many of those that retired once they got to 1M and those that got to 2M! You're doing great, it takes persistence and dedication to keep climbing that GasBuddy ladder, but you can do it, so keep going! Keep going like a PRO Honolulu GasBuddy, leading the way here in GasBuddyland for others to follow! You've been a great GasBuddy! Have a nice weekend! Thanks! Ron
Congratulations on posting for400 consecutive days, that's dedication, . Lets be buddies. Thanks. Shep
The crooks, I mean companies are making lots of money both here and overseas. By exporting, the companies can keep prices high here while also exporting highly profitable refined products.
Welcome to Honolulu! I just had to say that since I say Welcome to Fresno to all the people there.
"human made items will naturally have human made mistakes" === Interesting comment!
Congratulations on having the dedication to post for 200 consecutive days. Keep up the Great Work and Good Luck in the future! Want to become buddies??? Warren :-)
How is the weather there, it has been 5 or 6 years since I was there. Lets be buddies
Thanks for the supportive comment in the "EPA Heightens Scrutiny Over Pa. Gas Drilling" article. If you support further discussion of this article, you may choose to "Pump it UP" by voting for it on the recent news page.


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Request for Qualifications - Construction Manager at Risk
New Production Well - Tempe Well # 16
Project No. 3206121
RFQ Due Date: December 4, 2013, 4:30 p.m. (Arizona time)
Project Documents:
Request for Qualifications
Click here to register as a Plan Holder. You MUST register as a Plan Holder to be notified of project addenda. If addenda are released for this project we will attempt to notify all Plan Holders at the email address provided. It is the Plan Holder's responsibility to confirm that they have received all addenda prior to submitting a bid/RFQ.
Home | Tempe Forum | Residents | Visitors | Businesses | City Hall | Tempe 311 | My Tempe | Get Involved | Site Map
©2014 City of Tempe, AZ. All Rights Reserved. Website Design & Developed by Vision Internet


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Narrow your search
Home users, especially Apple fans who own 802.11ac-enabled devices, will love the new AirPort Extreme for its all-new elegant design, ease of use, and great performance; advanced users should look elsewhere for more features and customization.
Fresh salads may soon be on the menu for astronauts aboard the International Space Station as they try out a new zero-gravity greenhouse.
A traveling group of artists stops over in Santa Fe, N.M., for a festival blending art, yurts, music, and technology.
The Internet's top radio service adds station recommendations to its app for iOS and Android smartphones and tablets, aiming to stretch listening longer.
The new Apple AirPort Express Base Station is a decent upgrade to the previous generation, but it doesn't have much beyond its supersleek looks to impress us when compared with its peers.
A train full of artists crossing the nation stops in Santa Fe, N.M., to unleash a yurt installation and an experimental art festival.
A single high-speed Thunderbolt port can link to a lot of devices. CalDigit's docking station is designed to ease the cable hassles of taking your laptop with you.
Get alerts anytime the International Space Station flies over your location, so you can wave, send a tweet, or run outside to see it at night.
During a robbery in Winter Garden, Fla., a gunman fires at a gas station clerk, and the Sprint HTC in the clerk's shirt pocket takes the blow.


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Ever since I was presented with skittles vodka last weekend, my mind has been racing with thoughts of different kinds of candy flavored vodka. How did I spent 4 years of college without knowing this genius combination? The two were major staples in my diet– why did I never think of combining them? It all seems so obvious! And so easy…
Take a cup of sugar candy.
Soak for two days in a Mason Jar filled with vodka.
And, behold: Candy flavored vodka.
It dresses up so pretty.
I'm thinking teacher's holiday gifts right here.
The only problem is that I like making pretty things more than I like doing shots.
So… Who's coming over for cocktails?


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No Really, We're Sheep
Welcome to "No Really, We're Sheep"
This is a chronicle that will start with a new pack's Rite of Passage and take them through some trials and tribulations on their way to becoming full fledged Garou.
Go check out the wiki.
Or jump straight to our Characters. Some of our characters have begun keeping Character Journals, to lend you additional insight into their adventures.
Or maybe you want to just dive into the Story So Far.
Here's the landing page for the Sept of the Second City and its Caern.


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References on Complex Systems in the Geosciences
If you have a suggestion to add to this collection, please contribute a reference on complex systems.
Results 21 - 30 of 46 matches
Students' Understanding of Complex Dynamic Systems part of SERC Print Resource Collection
Federica Raia
This study from the Journal of Geoscience Education looks at students' approach to complex dynamic systems and the mental models they use to construct knowledge. Results show that students tend to ...
Why Some Students Have Trouble with Maps and Other Spatial Representations part of SERC Print Resource Collection
Toru Ishikawa, Kim A. Kastens
This survey published by the Journal of Geoscience Education has discovered several insights that cognitive and learning sciences can use in geoscience education. First, different students respond to ...
Journal of Geoscience Education special issue on Student Thinking about the Earth part of SERC Print Resource Collection
National Association of Geoscience Teachers
The papers included in this volume represent a significant contribution to the literature on student conceptions, cognition, and conceptual change specifically related to the geosciences. A wide ...
Earth and Mind: How Geologists Think and Learn about the Earth part of SERC Print Resource Collection
C.A. Manduca, D.W. Mogk
What does it mean to be a geoscientist? What characterizes the expertise that geoscientists bring to understanding the Earth? How do students develop this expertise? This volume brings together ...
An Investigation of Student Engagement in a Global Warming Debate part of SERC Print Resource Collection
Diane M. Schweizer, Gregory J. Kelly
This study investigates how using debate as a pedagogical tool for addressing earth system science concepts can promote active student learning, present a realistic and dynamic view of science, and ...
Exploring the Social, Moral, and Temporal Qualities of Pre-Service Teachers' Narratives of Evolution part of SERC Print Resource Collection
Deirdre Hahn, Sarah K Brem, Steven Semken
This study, published in the Journal of Geoscience Education, presents the idea that addressing personal barriers and misunderstandings that might impede geoscience education may become an effective ...
Outside the Lines: Issues in Interdisciplinary Research part of SERC Print Resource Collection
Liora Salter, Alison Hearn (eds.)
This book explores the nature and practice of interdisciplinary research in Canada. Contributors address the ways in which interdisciplinary research is defined, positioned, and handled by ...
Inquiry learning through students' East-West Coast online collaboration about plate tectonics part of SERC Print Resource Collection
J. Gobert
This paper describes a collaborative online project about plate tectonic activity involving middle and high school students in California and Massachusetts. The students collaborated online using ...
The Learning Sciences and Geoscience part of SERC Print Resource Collection
M.C. Linn
The author asserts that too often, science instruction in the United States results in memorized details rather than linked or connected ideas. High stakes assessments can inadvertently reinforce ...


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Google details its ambitious Project Ara modular smartphone
For a potentially revolutionary smartphone, it wasn't the best start.
Philips smart TVs open to remote attacks via default wireless connection, researchers say
The latest firmware in some Philips smart TV models opens an insecure Miracast wireless network, allowing potential attackers located in the signal range to control the TV remotely and perform unauthorized actions.
Google tightens HTTPS protections in Gmail in light of government snooping
Citing the need to protect users from government cyber-spying, Google has tightened Gmail's encryption screws by removing the option to turn off HTTPS.
Security firm discloses Apple iOS 'malicious profile'
At the RSA Conference yesterday, security start-up Skycure plans to disclose a vulnerability in Apple iOS devices that can impact mobile-device management (MDM) systems running on them.
Wi-Fi 'virus' could be used to attack wireless access points, researchers discover
Dense concentrations of Wi-Fi access points and routers in large cities could be attacked by malware able to spread silently from node to node, researchers at the University of Liverpool have shown for the first time.
Cyberespionage operation 'The Mask' compromised organizations in 30-plus countries
A cyberespionage operation that used highly sophisticated multi-platform malware went undetected for more than five years and compromised computers belonging to hundreds of government and private organizations in more than 30 countries.
Extreme marries network, application and cloud data to up user performance
Extreme Networks has unveiled an ASIC-based big data analytics system that marries network data with application data to make it easier to manage large networks and cloud deployments.
Connected clothing can tell how soundly your baby is sleeping
Singing along to the Disney movie playing in the background, Dulcie Madden helped hand-package thousands of high-tech baby clothes from her start up in Boston's Leather District. Madden is the CEO and co-founder of Rest Devices, which just last weekend started shipping its Mimo connected "onesie" to stores across the US. The $200 system aims to help anxious parents by monitoring a baby's movement, respiration, position and skin temperature and delivering the information with audio to smartphones.
Argos hiring developers to support digital growth
Argos has launched a ?digital hub' in London in a bid to attract more developers to its business.
Ofcom approves satellite broadband for trains and boats and planes
Passengers on trains, boats, planes, and coaches could see a ten-fold increase in broadband speeds after Ofcom authorised the use of satellite broadband receivers.
Topic Zone
Latest News
Latest Features
Why software-defined security is essential in a virtualised environment
Virtualisation is widely accepted to be the most effective way to improve efficiency and reduce running costs in the data centre. But the issues of security and compliance within a virtualised environment continue to make many enterprise IT managers nervous about the technology.
Indoor positioning market heats up with Apple acquisition of WifiSLAM
The news this week that Apple has acquired indoor positioning company WifiSLAM is a sign that the war over indoor mobile location services is hotting up.
Microsoft Surface RT vs Apple iPad - Tablet showdown
Microsoft Tuesday announced that it is accepting online orders for its ARM-based "Surface with Windows RT" touch tablet. This is the first Microsoft-designed and -sold mobile device, due to ship Oct. 26 with the formal launch of Windows 8.
10 ways to get the most from your Wi-Fi-only tablet
Much to the chagrin (and much against the ill wishes) of wireless carriers such as AT&T, Verizon, Sprint, and T-Mobile, people are buying Wi-Fi-only tablets. In fact, some studies have shown that in 2011 up to 90 percent of all tablets sold in the United States relied on Wi-Fi, rather than on 3G or 4G LTE.
BT: delivering the most connected Olympic Games ever
London 2012 will be the first ever Olympic Games to offer public WiFi access inside the competition venues, thanks to a new high-density network from BT.
Are small cells ready for the 4G data deluge?
As data usage on mobile networks continues to grow, small cells will have an increasingly important role to play in supporting mainstream network providers, and boosting signal in areas where coverage is weak.
Wi-Fi-Blocking wallpaper keeps your signal in and intruders out
French scientists have created a type of wallpaper that can block Wi-Fi signal, meaning you can boost your network security and redecorate all in one go.
Is end point security a waste of time?
The first board member at your organisation to walk through the door with an iPad did the IT team a massive favour. Put bluntly, there was no longer an argument. They had to ease the purse strings on your requests to fund management and security systems to go with your enterprise mobility projects.
What's next for the Digital Economy Act?
Last week, British internet service providers BT and TalkTalk lost their court appeal against the Digital Economy Act, meaning that they will have to send warning letters to customers suspected of illegal file-sharing.
Is end point security a waste of time?
The first board member at your organisation to walk through the door with an iPad did the IT team a massive favour. Put bluntly, there was no longer an argument. They had to ease the purse strings on your requests to fund management and security systems to go with your enterprise mobility projects.
Featured White Papers
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Two major issues to consider when planning for 802.11n are power consumption and WLAN architecture. It is important to select an 802.11n solution that operates at full dual-concurrent 3x3 MIMO when using 12.95 Watts. Siemens is the only vendor supporting fully functional 802.11n within the 802af PoE standard.
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There is a lot of confusion surrounding the capabilities and status of the new 802.11n WiFi standard. The confusion is understandable since the standard is very broad and has been slow to develop, and even slower to finalize. (Full ratification is not expected until mid 2009).
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In a global economy driven by speed and agility, competitive edge is intrinsically tied to the enterprise?s ability to get information quickly and efficiently to workers, partners and customers, regardless of location.
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Some low-down, dirty, rat**** mother****er stole my iPod out of my truck last night, along with the Belkin car-charger I had.
Apple knows the serial number of every iPod sold. They also know serial number of each iPod that has been connected to iTunes (along with the IP address from which the connection to the internet is made). In addition, they have the name, address, and telephone number of everyone who purchases music through iTunes.
So why the **** doesn't Apple have the ability to do anything when someone reports their iPod stolen? They should easily be able to maintain a list of serial numbers from stolen iPods and ensure that, at the very least, anyone in possession of that iPod is able to obtain music or other services from iTunes. At the very most, they should be reporting users who attempt to attach stolen iPods to their computers and iTunes to the police.
I know, I know. There are so many of these things that it'd be a major hassle for any law-enforcement office to do anything about it. That's not the point. The point would be that maybe these things wouldn't be such hot commodities if they were trackable in a way similar to cell-phones.
I am so ****ing pissed I could ****.


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The 3'x5' Protective Entry Mat with Tufted Decalon Yarn Top is perfect for the entryway or mudroom of your home, protecting all interior flooring types! The rubber back is a non-slip wonder!
This rubberbacked floor mat features a raised waffle pattern made with tufted Decalon yarn that facilitates the scraping and drying of shoes, while a channel design traps moisture and debris. The raised rubber border on all four sides of the doormat acts as a containment barrier ensuring that moisture and dirt is not carried further in to the home. Molded gripper treads on the back of the carpet entry mat help reduce movement on hard surfaces. The low profile of this door mat works well with low clearance doorways. Crisp pattern, contemporary design and updated color choices complement any decor! All mats measure 0.25" thick.


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content violation
You can write your comment.
Your thoughts in regard to the site
logammulia.com are very important to us. Please share your thoughts about
the site with us.
Title Caracter Number :
Meta Description :
Meta Keywords :
0 ()
Code Type :
Site Country :
Ip Address :22.214.171.124
Country Code :ID
Country :Indonesia
Google Pagerank : 3
Google Backlink :
7 Link
Google Indexed :
149 Link
Yahoo Indexed :
0 Link
Yahoo Backlink :
0 Link
Rank :
User Time On Site
- Speed : 1.13 - Comments : Fast - Rate : 64%
High Search Queries :
We are looking for the exper friends about online sale. If there is someone, They can contact with us.
I'm gonna make the holiday site but I did not find a good script. Is there any web site which I can find annexs for Joomla.?
I wanna set up a forum on my ownself. I searched internet There are too many free software. Please send me your comments if you use the free software.
You can direct the your domains If you buy empty domains from following domain versions.
As such, the man who write your web site wrong or who remember your web site wrong,
can contact with you. You might decrease the possibilty of imitation of your domain.
By clicking the collected buton, determine the domains who are suitable for sale
and buy with a click.
It is given the extensions of the other countries belonging to your domain following.
You can purchase these domains to improve your brand and your known. By clicking
the register link next to the domains, you can check that domain name is the extension
of this country, is empty or full, If it is empty, you can buy.
It is given on the following that the wrong searchings about your domain. You can
check them and If you think you lose too many visitors, by creating subdomains about
wrong searchings, you can direct the visitors to your main site and you don't lose


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Golf Genius Novelty Golf Balls
Product Details
Cool and quirky, the Golf Genius Novelty Golf Balls are the perfect gift for any golfing fanatic. The set contains six sports themed golf balls that are fully functional as well as being a novelty item.
- 6 sports themed golf balls
- One of each in the style of football, tennis, basketball, baseball, american football and pool ball
- Fully functional
Delivery & Returns
How long will it take to arrive?
Please check the stock availability notice on your item when placing your order. This item is: Sold out
Please remember to add postal time (2-3 working days) to obtain a complete estimate of delivery to your door.
How will I know it has been sent?
You will receive an email to confirm when your item has been sent.
You can also check the status of your order and individual items by accessing My Account details and following the prompts.
Please allow 10 working days from dispatch of your order before notifying us of any late deliveries.
It may be advisable to check with your neighbours to see if a parcel has been left with them, check any outhouses you might have where it may be left if it cannot fit through your letterbox and contact your local sorting office to see if the item has been returned to the depot as undelivered and awaiting collection.
If I'm not completely happy with my item?
Please see our returns policy.
There are currently no reviews.


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I have accidentally upgraded to 3.1.3 and since then I am no longer able to unlock my iPhone. I was in a unlocked version (via Pwnage) of 3.1 before.
Unfortunately I have not found a way to restore to this unlocked version as I do not have an AT&T SIM card (the phone was bougth second hand) and of course iTunes wants me to unlock the SIM 1st, which I cannot do.
I have followed the procedure from the site iClarified but the process fails for me at the Step eleven as my Iphone does not reboot at all after entering the DFU mode.
Any chance to obtain the help of someone ? Or a way to restore without iTunes ?
Thks in advance.


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UPDATE: SPI Group swaps Barry & Fitzwilliam for Findlater in Ireland
By Olly Wehring | 3 January 2012
SPI Group has switched distributors for its Stolichnaya vodka portfolio in Ireland.
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SPI Group has switched distributors for its Stolichnaya vodka portfolio in Ireland.
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GLOBAL: SPI Group launches Stolichnaya campaign
Stolichnaya owners SPI Group has overhauled its global advertising campaign for the flagship vodka brand.
Comment - Belvedere Group: The Storm is Coming
Belvedere's sales are rising, but only the sale of a core asset looks likely to placate the French drinks firm's creditors.


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Time for some reality show math. "American Idol" has four finalists left and four weeks of competition before a winner is named May 16.
The Fox singing contest will need two contestants that last week. But how do we get there? The judges didn't use a save this season, and that one-time twist supposedly ended last week.
Perhaps Ryan Seacrest will explain a contingency plan that keeps one of the four women another week. I'm sure fans would like to know as soon as possible, because another twist might infuriate the dwindling audience this season. The two-hour competition starts at 8.
Candice Glover is the favorite in a field with Kree Harrison, Angie Miller and Amber Holcomb. Of course, Fox would never end the show a week early and proclaim Candice the winner. The network needs the ratings in the May sweeps, which start Thursday.
Elsewhere Wednesday:
"Duck Dynasty" heads to Hawaii for its third-season finale at 10 on A&E. How will the Robertsons fare in a tropical paradise? It's not going to be pretty, and A&E is serving one hour of vacation highlights.
CBS delivered a rousing tribal council on the last "Survivor." It's highly unlikely that the episode at 8 will be as memorable. But the Three Amigos -- Malcolm, Reynold and Eddie -- will continue to try to outwit and outplay the alliance of six. Reality show math is not in the Three Amigos' favor. "Survivor" names its winner May 12.
Most scripted series are in reruns, because the networks are saving fresh episodes for sweeps. But "Law & Order: Special Victims Unit," at 9 on NBC, has a new installment about a frat-party crime that reveals a history of sexual assault at a college. "Arrow," the best thing to happen to The CW this season, is new at 8.
The broadcast dramas at 10 are all repeats, but "The Americans" is new at 10 on FX. The show, Keri Russell and Matthew Rhys all deserve Emmy consideration for outstanding work. The disguises have been nifty, too, in this spy thriller. The freshman drama delivers its season finale next week.


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County Home » Departments »
Sheriff's Office » Press Releases
Location: McKinleyville
On Friday, December 11, 2009, from 10:00 a.m. to 4:00 p.m. the Humboldt County Sheriff's Animal Shelter will be hosting our annual Holiday Open House. The public is invited to come to the shelter to celebrate the fifth anniversary of the Humboldt County Sheriff's Animal Shelter, which has housed over 12,000 animals during the five years it has been open. The shelter officially opened December 22, 2004.There will be cake, cookies and punch, and staff will provide tours of the shelter. The shelter will again have Memorial Star Christmas Tree Ornaments available for purchase. The Memorial Stars can be purchased and hung on the Animal Shelter Christmas trees in memory of a pet - past or present. The proceeds from the stars are applied to the shelter's emergency medical fund. This fund is used for the medical treatment of shelter animals with serious medical conditions that otherwise prevent them from being adopted. Several sick and injured dogs and cats have been saved and adopted to great homes thanks to this fund. Donations for the shelter animals are gladly accepted. Animals will, of course, be available for viewing and adoption.The Humboldt County Sheriff's Animal Shelter is located at 980 Lycoming Avenue, McKinleyville, CA, 95519.
:: Operations
Corrections ::
:: Stations ::
Press Releases


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How about higher taxes for everybody?
Tim Boyle/Getty Images
The top of a form 1040 individual income tax return.
I'm generally a fan of NPR's Planet Money, but I'm a little perplexed by what one of its founders, Adam Davidson, has been writing since he took up residence at the New York Times Magazine.
This weekend, for example, he argued that the middle class needs to get over the idea that rich people and corporations should pay higher taxes. And while he runs the numbers quite well, the conclusion are, to say the least, troubling:
It serves the interest of both parties to argue about taxes on corporations and the wealthy because neither wants to discuss the alternative, which is where things get touchy. To solve our debt problems, we have to go to where the money is — the middle class. People who earn between $30,000 and $200,000 a year make a total of around $5 trillion and pay less than 10 percent of that in taxes (owing mostly to tax incentives and the fact that most families make less than $68,000, where larger tax rates begin). Increasing the middle-class tax burden an additional 8 percent, however, would actually have a bigger impact than taxing millionaires at 100 percent.
It's a tough but manageable financial math problem. And America's middle class is actually a lot luckier than its counterparts in Greece, Spain or Ireland, who will be paying higher taxes while their countries' economies shrink, or stagnate. Even the Fed's dark forecasts anticipate that the U.S. economy will return to healthy growth (about 3 percent annually) within a couple of years. Unless we hold on to the fantasy that the solutions to our problems lie in the bank accounts of rich people and corporations.


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You eat a big heaping bowl of comfort food...at least that's what I do. That food for me is usually a warm bowl of chocolate cake with ice cream on top, but we all know that's not a meal. As much as I wished cake and ice cream were their own food groups, I've been told they're not.
And that's where my girl Karly comes in...She'll be joining my team in the upcoming months as my Recipes contributor. Today she's sharing one of her favorite comfort foods, lasagna soup. If you have any leftovers, which I doubt you will, maybe send some my way?
I am weird about soups. Very picky. It has to have the perfect taste and texture to win my vote, so when you see a soup recipe from me, you can trust that it's tried and true and absolutely delish!
What I love about this soup is how versatile it is. It's easy to substitute italian sausage for the ground beef, or change out the diced tomatoes for something a little more..."kid friendly" such as petite diced or crushed tomatoes. My eldest hates tomatoes, so the smaller I can make the pieces, the more she'll likely miss seeing them and eat without complaint. Bah ha ha.
Now, this recipe may look a little demanding when you see the ingredient list, but trust me, it comes together very quickly and easily. No need to be a pro chef to master this bowl of awesome!
Lasagna Soup
Printable Recipe
chopped fresh basil leaves
Heat the olive oil in a large pot over medium heat, then add the ground beef and brown until cooked. Add the onions and cook until softened and translucent, about 6 minutes.
Next, add the garlic, oregano and red pepper flakes and stir, cooking for about 1 minute. Then add the tomato paste and cook until it turns a rusty brown color.
Once the tomato paste is fully incorporated, add the diced tomatoes, chicken stock and bay leaves, stirring gently. Turn up the heat and bring the whole pot to a rolling boil for a good minute, then reduce the heat to low and let it simmer, uncovered, for at least 30 minutes.
Now, when it comes to the chicken stock, you can feel free to use bouillon cubes if that's what you have on hand. I personally use Better Than Bouillon, the refrigerated stuff. I love the taste and it doesn't seem watered down or chalky like some other brands, which is always a plus. If you plan on leaving the soup to simmer for longer than 30 minutes, add more stock to the pot, because it will slowly evaporate, and you need the extra liquid for the noodles. I tend to leave mine on the stove for a good few hours, so I generally add an extra 3 or so cups of stock. You can always just watch the liquid level and add more stock as needed.
After 30 minutes, or whenever you are ready, toss in the pasta and let it cook until al dente. You don't want to bring the pot back up to boiling, just stir in the noodles and let it sit. It'll take probably double the cook time on the box, so check on it now and again.
For a helpful tip, this is a fairly large batch of soup, so if you think you may have leftovers, I suggest cooking the pasta in a separate pot, that way you can just add the pasta to the bowls and ladle the soup on top of it. No mushy pasta leftovers!
During the downtime as the soup simmers, you can very quickly whip up the cheese mixture. Seriously, you don't want to miss out on the cheese. Toss the ricotta and parmesan together and sprinkle it with some salt and pepper and mix well. Just toss a heaping dollop in the bottom of each bowl before serving the soup, that way the noodles and soup will melt it to the most perfect gooey-ness.
Yes, that's right, I just said gooey-ness.
Once you've served up the soup, garnish with some freshly chopped basil and shredded mozzarella and you are ready to enjoy a soup you won't soon forget!
I hope you all enjoy this soup as much as I do. Just typing all this makes me want to whip up a new batch, especially since it will be cool and rainy here in Phoenix this weekend. Let me know what you think if you try it! {For the simple, printable recipe, click HERE!}


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Saints Row IV - Inauguration Station Trailer
07 Aug 13: The game is a direct sequel to Saints Row: The Third. It is set in a fictional Washington, D.C. and futuristic Steelport, and the Saints leader has been elected president. As the leader was elected, an alien invasion occurs and the eart...
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ph: 845.463.3011 / 800.468.3011
Access your accounts from any page of our website with this secure Internet Banking sign on.
Contact Info |
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What to Expect
© 2011 Hudson Valley Federal Credit Union
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ph: 845.463.3011 / 800.468.3011
Routing Number : 221979363
You are now leaving Hudson Valley Federal Credit Union's web site. Hudson Valley Federal Credit Union does not control external links and cannot guarantee the relevance, timeliness or accuracy of the materials provided by other agencies or organizations.


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Project learning can inspire the best of high-performance teamwork, or it can be devolve into unfocused chaos. How can we support each other to keep our eye on the prize? Share your project ideas, questions, and implementation experiences.
3-minute Video of my Projects & Activities 2012
I created a short video of pictures from projects I created and workshops I taught or attended in 2012.
Happy New Year,
Bill Kuhl
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Frequently Asked Questions
Hey all! I thought this might help everyone get nice and cozy in their new home here! Please let me know if I've missed anything.
Q: How can I add my Avatar?
A: Go to http://thinkcommon.com/account/avatar and click the "browse" button. This will allow you to search a photo on your computer that you wish to upload as your avatar.
Q: How do I change my username?
A: Go to http://thinkcommon.com/account/avatar and in the box next to "Display Name" type in a name you'd like to have!
Q: How can I get notifications sent to my email?
A: Go to http://thinkcommon.com/account/notifications/ and click on the appropriate boxes in which you'd like to have notifications sent directly to your email!
Q: How do I post a blog?
A: Go to http://thinkcommon.com/account/blogs/ and click on "Post New Blog" located on the upper right hand of the page.
Q: Can I block other users?
A: Not at this time.
Q: How can I contact ground(ctrl)?
A: You can either call us at 877-GND-CTRL (M-F 7am-6pm PST) or visit http://support.groundctrl.com
Q: I have an iPhone, is there an app I can download to send and receive messages, approve friends and see the latest on thinkcommon.com?
A: You can download our ground(ctrl) app at the app store! It's free and keeps you updated when you are on the go! (just search ground ctrl).
Q: How can I check the status of my order?
A: Go to http://thinkcommon.com/account/orders/
Q: What are points used for?
A: Points are for special items (physical and/or digital) that will be available in the future!
Q: How do I get points?
Sign up: 1 pts
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Have 5 friends: 50 pts
Have 15 friends: 100 pts
Have 50 friends: 500 pts
Creating a blog: 10 pts
Comment on a blog: 1 pts
Comment on a profile: 1 pts
There are communities where members sometimes like to simply collect points, well just to collect points. Below is a general outline.
The "RIGHT WAY" to get points (AKA not considered spam)
Create a meaningful blog (something that tells us how you're feeling, one that puts forth effort to create, one that may provoke discussion)
Comment on a blog (respond to a blog already created that answers a question asked, provides further discussion, etc)
Comment on another members profile (example: Hi! Thanks for the friend request!" or "I like Common too!")
The "WRONG WAY" to get points (AKA SPAM)
Creating a meaningless blog (example, subject: "HI" body: "I'm bored.")
Creating a blog every minute, 5 minutes, 10 minutes, every hour..You get the idea.
Creating a blog contains only a picture.
Commenting on a blog with " :) " or a one word answer that doesn't enhance or further discussion, or a comment that has nothing to do with the blog in the first place.
Commenting on another members profile by using numbers, letters, emoticons or anything else that wouldn't be considered part of a discussion, or a true "comment".
Commenting on either a blog or profile multiple times with the same comment.


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Accepted Offer
Neutral Experience
Easy Interview
I applied online and the process took 2 weeks - interviewed at Citizens Financial Group in January 2010.
Interview Details The recruiter I worked with was horrible. She was never in the office and took days to return my phone calls. I have worked with other Citizens recruiters however who were far better at their jobs. I interviewed with the manager of my division and went through the standard interview process. It was clear that she wasn't well trained in interview skills as she asked very few questions and spent most of the conversation going off on tangents. I've interviewed for a lot of positions with Citizens and you definitely need to keep the interviewer on target as most do not interview frequently. Be prepared with specific examples of your experience. Can you describe a time you had to deal with an uncooperative coworker? How would you handle a disagreement with your manager? Also be prepared for the very open, "tell me about yourself" as most fall back on that at some point. Come in with a lot of questions. How long do most people stay in this job? How much opportunity for growth is there? What's the best thing about working here? etc.
Interview Question – Give an example of how you have dealt with a difficult manager or coworker Answer Question
Negotiation Details – Negotiate. Negotiate. Negotiate. This is the last time you will ever speak directly with the person who has the decision power about your salary. If you don't get a decent salary at this point YOU WILL NEVER BE PAID FAIRLY for the rest of your career. Everything is based on percentages and most jobs max out at 6%. Which means that if you're lucky enough to be promoted, your raise will likely be 6% of your current salary regardless of what your new colleagues are making. So if you're not comfortable negotiating, get ready to do the same job as people making thousands more than you with no hope of ever catching up.
About Citizens Bank Citizens Bank is a division of RBS Citizens, N.A., operating its seven-state branch network in Connecticut, Delaware, Massachusetts, New Hampshire, New York, Rhode Island and Vermont. It has… — Full Overview
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Smith's® Adjustable-Angle Pull-Thru Knife Sharpener$29.99A great value on an innovative design offering new features never before offered on a manual knife sharpener. And so much easier and faster to use than standard edge-maintenance kits. Learn More
The Art of Stand Up Paddling: A Complete Guide to SUP on Lakes, Rivers, and Oceans$21.95From the popular "How To Paddle" series by Falcon Guide®, this large, full-color book covers all aspects of stand up paddling, from buying a board and getting started on your local lake to surfing waves in Hawaii! Learn More
Victorinox® Swiss Army® Classic Knife with Cub Scouts® Logo$24.99Complete with seven functions, this knife keeps Cub Scouts prepared for any number of tasks. Knife includes blade, nail file with screwdriver, scissors, key ring, tweezers, and toothpick. Includes Cub Scout insignia on handle. Learn More
Victorinox® Swiss Army® Classic SD Knife with Eagle Scout® Logo$24.99Licensed by the Boy Scouts of America, the Classic featuring the Eagle Scout logo will keep you prepared for any number of tasks. Compact enough to fit in your pocket, and with its seven popular implements, it's functional enough to save the day! Includes 2¼" blade, nail file with screwdriver, scissors, key ring, tweezers, and toothpick. Learn More


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Williams: Health care, meth key issues
By Ashley Rader
State Rep. Kent Williams updated Carter County commissioners on upcoming state legislation and issues Monday, focusing on health care changes and the state's drug problems.
Williams said state leaders must decide whether to oversee the Affordable Health Care Act on the state level or let the federal government have control of the program for Tennesseans.
"My personal feeling is that the state can do a much better job than the federal government, but whatever the governor decides to do, I will support him," Williams said.
"He has the staff and the knowledge to determine the issues, and whatever they decide is what I am going to go along with.
"They know a lot more about the health care program than I do. In the past, I have seen that the state does a much better job. There is a misconception that if we don't do anything it will go away, and that is just not true. The health care program is here to stay, and we need to make the best of it. We have to roll up our sleeves and do what is best for the citizens of the community."