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Claudia Eckley, MD
Gastroesophageal Reflux has been studied by the scientific community for over a century, and seemed to be a well known disease affecting individuals with anatomical or functional abnormalities of the lower digestive tract until otolaryngologists started reporting cases of atypical laryngitis and pharyngitis thought to be associated to the retrograde assent of gastroesophageal content into the upper respiratory tract, namely the pharynx and the larynx. The first known report of such an association in the English literature was that of Cherry and Margulies in 1968, who documented two patients with contact ulcers and granulomas and observed that the lesions could have been caused by reflux of the gastric contents into the hypopharynx 1. Interestingly, after this novel report, a few more decades elapsed until a consistent literature on the topic emerged. It was only in the 80`s that the medical community, namely otolaryngologists, thanks to the wider use of fibreoptic laryngoscopy in clinical practice, could document the chronic changes in the laryngopharyngeal tissue thought to be associated to direct or indirect injury caused by the gastroduodenal contents. As one may expect, the scientific community was very resistant to this change in paradigm regarding the well accepted knowledge of GERD, its diagnostic methods and treatment at the time.
Since a significant number of patients with extraesophageal manifestations of GERD do not present with the classical symptoms of the disease (epigastric pain, heartburn, digestive problems) 2,3, and the leading diagnostic tools at the time, namely esophagogastroduodenoscopy (EGD), barium swallows and single probe prolonged esophageal pH monitoring, presented a low sensitivity, the scientific community was clearly divided between believers and non-believers 2, 4-6.
The development of technology capable off establishing an objective association between the laryngopharyngeal symptoms, the mucosal abnormalities associated to LPR, and the presence of gastroesophageal contents in the upper airway has increased the number of believers, and has also changed the understanding of GERD and reflux-related diseases in the digestive tract, such as non-erosive reflux esophagitis and other respiratory disorders associated to reflux. However the sensitivity and specificity of the current existing diagnostic tools for LPR are still less than optimal, whereas the majority of the tests are invasive and costly, making the diagnosis of this highly prevalent disease still essentially clinical, especially in developing countries. One can imagine how questionable it may be, in the current age of high tech medicine, to establish the diagnosis of a disease that causes chronic pharyngitis and laryngitis based solely on suggestive symptoms and laryngoscopic signs of inflammation 3,7, since many of these signs have been reported in healthy individuals 8, 9. As much as the quality of laryngoscopes has evolved 10, inflammation and mucosal changes can be caused by an infinite number of intrinsic and extrinsic factors, many of them as prevalent as reflux. In fact, a number of studies on asthma and allergic laryngitis have shown that the laryngoscopic findings in such patients are quite similar to those of patients with LPR 3, 11,12. It is also expected that chronic alcohol and tobacco use will cause changes to the laryngopharyngeal mucosa, as well as vocal habits and even snoring 8,12-16. In an ideal world patients would present with only one of these risk factors. However, in the majority of patients an association of many of these causes of chronic laryngitis are found and it is the medical team`s task to diligently try to sort out base line structural or functional abnormalities, risk factors and habits to establish appropriate treatment strategies17,18. Medical treatment of LPR is also a challenge, since there is no available drug that effectively bars reflux of the gastric contents into the esophagus and the upper airway. Antiacids, H2 antagonists, proton pump inhibitors, alginates, and prokinectcs, most commonly used, may all provide temporary relief, but at best they only change the chemical properties of the refluxate or improve somewhat peristalsis and accelerate stomach transit 2,3 . Surgery can also be a strategy for treating refractory patients, those with complications, to avoid prolonged drug use, with drug resistance/intolerance, but short and especially long-term results of fundoplication in patients with LPR are not always optimal 3,19. The controversies on the diagnosis and treatment of this highly prevalent disease make GERD and LPR a continuous topic of medical and health related research.
The objective of the current review was to compile the significant literature published in the Journal of Voice on the topic of GERD-related head and neck disease, and specifically on Laryngopharyngeal Reflux (LPR) in the past 30 years.
The current review aimed to systematically study scientific articles on the topic of GERD and its extraesophageal manifestations published in the Journal of voice from March, 1987 to December, 2017. Initially a general search for articles that covered the topic was carried out using the specific terms GERD, laryngopharyngeal reflux, chronic reflux laryngitis, extraesophageal reflux, supraesophageal reflux and reflux. All the articles that contained any of these terms in the title or as key words were reviewed. Further, articles that contained reference to these terms were also reviewed. Because of the known association between certain laryngeal disease and LPR, additional search was carried out using the possible "reflux related" terms: muscle tension dysphonia, chronic cough, paroxysmal vocal fold movement, irritable larynx, contact ulcers and granulomas, laryngomalacia, laryngeal stenosis, leukoplakia, cancer.
A total of 615 articles were initially identified and after review 119 articles were selected, 8 reviews, 57 retrospective studies, 52 prospective studies and 02 case reports.
The chemical and enzymatic properties of the refluxate cause inflammation and mucosal abnormalities in the pharynx and larynx. The resulting symptoms and behavioral changes can have a significant impact on voice production 20.
Common symptoms related to LPR are throat pain or discomfort, foreign body sensation, globus, throat clearing, cough, dysphonia, layngospasm 2,7,21. These non-specific laryngopharyngeal symptoms were already associated to GERD in the first issues of J Voice. A Panel Discussion on medical management of voice disorders was published in the first issue of volume 1 of J Voice in 1987. Five clinical cases were presented, at least three of them with symptoms that today would likely be attributed to LPR, but only one case was suspected and worked up by a gastroenterolosist, who ordered a barium swallow (which was negative); the patient was treated with H2 antagonists and cimetidine nonetheless, and improved of the laryngeal irritation 13-15. However, the first article to specifically address GERD-related laryngitis was published in 1988 and reported on 32 patients with chronic laryngitis, investigated with manometry and prolonged double probe esophageal pH monitoring, finding that although 75% of patients had pathological reflux the majority (69%) referred no digestive complaints. The authors called attention to the importance of the silent character of atypical reflux 4. The first publication to use the term laryngopharyneal reflux reported on a multidisciplinary consensus about the topic in 1996 2.
Fibreoptic laryngoscopy, both flexible and rigid, reveals the suggestive inflammatory signs of posterior laryngitis, characteristically erythema and edema of the arytenoids, interarytenoid mucosa, and posterior pharyngitis 2. Although inflammation tends to be more severe in the posterior laryngopharynx and larynx, it may commonly be diffuse and described as varied degrees of edema, erythema and mucosal abnormalities, ranging from metaplasia of the interaritenoid mucosa (so called "coble-stoning"), to leukoplakia, displasia and rarely cancer 22-24. Posterior glottis lesions are believed to be a result of an association of intrinsic and/or extrinsic irritants (LPR, tobacco and alcohol use, trauma) associated with negative behavioral patterns, such as throat clearing and cough 23,25-27. Vocal process granulomas have also been associated to compensatory mechanisms due to glottic insufficiency 27-31. A retrospective cohort study conducted by Haggit et al in 2014 found that the majority of patients with spontaneous posterior glottic lesions were smokers and presented clinical signs of significant psychological stress; only 1.5% of the series had malignancy 23.
Dysphonia is a highly prevalent symptom in LPR, reported in 10 up to 91% of patients 18, 32-40, and especially in professional voice users 36, 41-47. Chronic laryngeal inflammation associated to abusive vocal habits and inadequate lifestyle frequently result in disturbed vocal production 44, 48. According to a systematic review conducted by Lechien at al on the etiology and pathophysiology of voice problems in patients with LPR, dysphonia can be caused by both microscopic and macroscopic histopathologic changes in the mucosa of the vibratory margin of the vocal folds, such as epithelial cell dehiscence, microtraumas, inflammatory infiltrates, Reinke space dryness, mucosal drying, and epithelial thickening 39. A number of epidemiological studies have reported a high incidence of LPR in dysphonic patients. Spantideas studied 340 randomly selected adults finding a positive answer to the question "hoarseness or a problem with your voice" in 38.5% in the general Greek population and in 90.6% of patients with LPR 18. Martins et al reviewed 2019 medical records of a voice clinic at a tertiary center and found LPR-related voice problems in 12.5% of children and 26.5% of adults 38. Myint et al in 2016 reviewed the charts and videolaryngoscopies of 51 opera student-singers comparing initial evaluation to follow-up after acute voice problems, finding a significant increase in LPR at follow-up visits suggesting that physical and behavioral aspects associated to singing predispose to the development or worsening of the disease 46.
A questionnaire that aimed to understand the opinion of three voice-related professional groups about factors influencing vocal fold nodules in singers reported that GERD was found to be very important or extremely important by all three professional groups and the treatment had a positive impact on voice49.
Houtte et al in 2011 published a review on muscle tension dysphonia (MTD) defining it as a clinical and diagnostic term which describes a spectrum of disturbed vocal fold behavior caused by increased tension of the (para)laryngeal musculature 50. Current knowledge seems to view MTD as a bridge between functional and organic disorders, caused by a possible combination between psychological and/or personality factors, vocal misuse and abuse, and compensation for underlying disease, such as LPR 50-52.
In fact, the phsychological distress caused by chronic disease, such as LPR and GERD, may significantly impact quality of life (QOL), especially in professional voice users 53,54. Connor et al surveyed 1845 adults in a community using VHI, SF-12, and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaires reporting significant reductions in perceived quality of general health, digestive health, and voice-related quality of life in subjects with both GERD and laryngeal symptoms, in comparison with subjects manifesting each symptom group alone, or in subjects with no symptoms 53. Lee et al used SF-36 to prospectively study 138 adults with LPR before and after treatment with lansoprazole for 12 weeks finding a significant improvement, not only in clinical symptoms and signs of the disease, but in overall quality of life 55. Moore et al, however, did not find a correlation between reflux related dysphonia and QOL in 15/80 patients studied with VHI and SF-12 short study after 6 months of follow-up 56.
Chronic cough has also been linked to LPR, whereas it is unknown if the cough mechanism is caused by chemical irritation of the upper respiratory tract of reflex vagal neuropathy, or most likely, a combination of both42. In patients with chronic cough there seems to be a two-way negative feedback, where cough causes reflux and the increased intraabdominal pressures during cough may also trigger reflux. Other neurological pathways will also be discussed further. Patients with chronic cough are frequently treated for reflux regardless of a positive objective diagnostic test establishing a direct correlation between the cough symptom and a reflux episode 57.
Patients with LPR may or may not have associated GERD. Rouev et al prospectively studied 46 adults with laryngopharyngeal symptoms suggestive of LPR with EGD and prolonged pH monitoring, finding that 72% had LPR and 51% had GERD as well. They concluded that GERD may cause laryngopharyngeal symptoms and that laryngopharyngeal symptoms can be predictors of GERD 58. A large community based survey found more than 66% of subjects reported either GERD or laryngeal symptoms, and 26% reported both GERD and laryngeal symptoms 53.
The diagnosis of LPR is controversial. Clinical symtoms and videolaryngoscopic signs may be non-specific and objective methods of assessing reflux are invasive, costly and not sufficiently sensitive to warrant their use in daily clinical practice, especially in developing countries 18,59.
In order to reduce subjectivity of diagnosis based on symptoms, a number of clinical scores has been proposed over the years. The most widely used score is the Reflux Symptom Index (RSI), a nine-domain questionnaire on laryngopharyngeal and digestive symptoms related to reflux, proposed by Belafsky et al in 2002 34. Several translations and adaptations of the RSI into other languages have been published in the journal, such as, Italian60, Arabic 61, Greek 18, Chinese59, French 62, and Pilipino 63 showing high psychometric properties and proving a reliable, reproducible clinical method of diagnosing and following clinical outcome in patients with LPR 18,34,59-63.
Videolaryngoscopic signs of inflammation, which depend on the subjective assessment of the naked human eye, seem to be less reliable for clinical diagnsosis. A cross section survey applied to one thousand general otolaryngologists found that half were concerned about overdiagnosing LPR based on laryngeal findings 64. Belasfsy et al also proposed The Reflux Finding Score (RFS), a 13-domain instrument that addresses endolaryngeal signs and severity of inflammation 65. However, this instrument seems to be less reliable than the RSI for diagnosis of LPR 66. A study conducted in a group of general otolaryngologists showed that these professionals did not show reliable, reproducible results on RFS scores, and that symptoms influenced the final scores66. Another study comparing RFS ratings between speech-language pathologists and otolaryngologists found significant discrepancies in the level of rater agreement regarding the presence and the severity of physical findings attributed to LPR 67.
However, when careful exclusion of other possible causes or even associated causes of chronic laryngitis are addressed, RSI and RFS combined have proven to be widely used in clinical practice for the diagnosis of LPR and seem to offer a more cost effective, less invasive means of diagnosis 18,60,62,63,68.
Other technologies have been proposed to assess laryngeal and pharyngeal signs of inflammation69-71. Improvements in the subjectivity of the analysis of endoscopic images have been suggested over the years, but none have been widely used in clinical practice. Jiang et al in 1998 used computer image analysis software to quantify the average color values, hue, saturation, and brightness from digitized color images obtained from videolaryngoscopies of patients with LPR and healthy controls finding significantly greater average color value ratings of redness of the vocal folds in patients with chronic laryngitis than normal subjects, and also a significant reduction in redness of the vocal folds after treatment of LPR72. Witt et al in 2014 used pattern recognition of a combination of hue and textural parameters to identify signs of chronic laryngitis comparing the laryngoscopic images of 20 patients with LPR diagnosed by a positive RFS to 42 controls, finding a high diagnostic accuracy when both parameters were combined 71. Based on the knowledge that colors in nature are produced by a combination of the three primary colors red, green, and blue (RGB) and that RGB measurements provide an objective numeric value, the degree of pathology of a tissue can be interpreted according to RGB values. This technology was used by Ozturan et al in 2017 in a case-control study comparing 72 patients with LPR and 35 healthy individuals73. The authors found significant RGB differences between the laryngoscopic images of patients and controls, as well as those of patients before and after treatment 73.
Narrow band imaging (NBI), an endoscopic technique using filtered wavelengths in order to enhance microvascular abnormalities offering optimal visualization of the subtle neoangiogenic changes associated with precancerous and neoplastic diseases, has not successfully aided in the diagnosis of LPR 69.
EGD and barium swallow with water siphonage have proven a very low sensitivity in the diagnosis of LPR, mostly because a great number of patients with this supraesophageal form of the disease do not have anatomical or functional abnormalities to the digestive tract 3,7,74,75. In 2002 Rubin et al tried to establish a correlation between the inflammatory signs found in patients with non-malignant laryngeal disorders associated to LPR and H. pylori 17.Although a trend toward greater infection in older patients when compared to healthy matched controls was found, no significant correlation between this pathologic agent, well known to contribute to erosive digestive tract disease and cancer, could be established 17.
Objective methods of monitoring reflux to the upper airway, such as wired or wire-less prolonged esophageal-pH monitoring, esophageal pH-impedance (MII-pH) and oropharyngeal pH monitoring (Restech DX), have greatly expanded our knowledge of the physiology of esophageal reflux 3,75,76. The challenge in these tests has been to establish normative data for the upper (pharyngeal or crycopharyngeal) sensor, as not only acid but also weakly acid reflux is known to cause damage to the laryngeal mucosa 4,75-78. Laryngopharyngeal reflux episodes are few in number and very brief in duration. For this reason, the parameters used to quantify lower esophageal reflux do not apply for the upper probe76. A great number of otolaryngologists seem to consider positivity for the upper sensor in double probe prolonged esophageal pH monitoring as any single drop below pH 4 regardless of its duration 4,77. However, studies showing that weakly acidic pH can also cause damage to the laryngeal tissue have taken a few authors to accept a pH cut-off at 5 for the proximal sensor 2,79. Vincent et al in 2000 used the Reflux Area Index (RAI), a ratio which incorporates not only the number and duration of episodes with pH < 4 but also the degree to which those events drop below pH 4, to try to establish normative data to the proximal probe during prolonged esophageal pH monitoring, observing that normal subjects display physiologic reflux above the upper esophageal sphincter mostly in the upright position, and that RAI appears to be a useful indicator of proximal reflux severity 76. Musser compared RAI scores to RSI and RFS finding a low intra and inter-rater agreement for all three scores, and especially for RFS79.
Vailati et al conducted a study using oropharyngeal pH monitoring for diagnosis and control of treatment outcome in patients with clinical and laryngoscopic sings of LPR finding a sensitivity of 69% and a specificity of 100%. All patients with a positive oralpharyngeal pH test and none of those with a negative test responded to clinical treatment with full dose PPI. Responsive patients showed both a higher oropharyngeal acid exposure in orthostatic position and a higher Ryan score, compared with nonresponders 80.
Kavitt et al in 2017 reported on a novel esophageal impedance testing performed during EGD and that does not require prolonged use of catheters. They prospectively studied 41 patients with symptoms suggesting LPR through EGD (with esophageal surface impedance tested at 2, 5 and 10 cm above the sqamouscolumnar junction-SCJ) and 48-hour wireless pH monitoring comparing the presence or absence of erosive esophagitis to the presence of distal pathological reflux and finally to mucosal impedance (MI). They found that patients with LPR and evidence of acid reflux (with or without erosive esophagitis) had a lower MI than those without at 2 cm above the SCJ, with a trend at 5 cm and 10 cm as well. In those with nonerosive disease who had abnormal reflux by pH monitoring, MI values were similar to those with erosive esophagitis. The authors concluded that their findings pointing to the fact that MI can differentiate those with abnormal reflux pattern from those with normal reflux parameters in patients with normal EGD findings 75.
On the promising front of diagnostic tests for LPR is salivary pepsin dosage 81. Pepsinogen is a proenzyme secreted by gastric chief cells that is converted into pepsin in acidic conditions. Accordingly, several studies have suggested that pepsin is direct evidence of reflux, and can be considered a reliable diagnostic marker of LPR. Salivary pepsin detection is a convenient, non-invasive, and inexpensive way to diagnose LPR 81. Commercial ELISA kits using one or two recombinant pepsin 3b antibodies have shown moderate sensitivity and specificity for the diagnosis of LPR, comparable to those of more invasive methods, such as prolonged esophageal pH-metry and impedance-pH 81. Jung et al conducted a prospective study on 50 patients diagnosed with LPR by RSI, RFS and 24-hour multichannel intraluminal impedance pH monitoring. They reported that 41 of the 50 patients had positive saliva pepsin ELISA tests, but found no correlation between pepsin levels and RSI, RFS, MII-pH 82. Another recent study conducted by Gong et al used immunohistochemistry to detect pepsin in 26 biopsies from patients with vocal fold leukoplakia comparing them with 20 vocal fold biopsies from control subjects observing that 64.4% of the leukoplakia patients were pepsin positive compared to only 20% of the controls. The authors suggest that pepsin immunohistochemical staining could be a biomarker of LPR and that LPR may be a risk factor for the development of vocal fold leukoplakia83.
Studies comparing the sensitivity of clinical diagnostic methods, such as RSI and RFS, to objective methods have also been conducted 5. In 2014 Wan et al compared two groups of patients with LPR before and after treatment, one diagnosed clinically with RSI and RFS and the other with MII-pH, concluding that both methods were similar in diagnostic and prognostic capacity 5.
Acoustic Analysis has also been carried out trying to establish the vocal characteristics of patients with LPR 20,84-87. The pioneer study to use acoustic analysis as an outcome measure in 68 patients with reflux laryngitis found no significant difference in voice parameters after 12-week course of omeprazole 20 mg b.i.d. 88. A prospective study of 41 dysphonic patients with LPR designed to explore the impact of the selection of the analyzed time interval on the significance of acoustic measurements used to investigate laryngopharyngeal reflux (LPR) treatment efficacy observed that acoustic voice parameters, such as jitter, jitter percent, relative average perturbation, pitch perturbation quotient, shimmer, shimmer percent, amplitude perturbation quotient, and smoothed amplitude perturbation quotient were the indices most sensitive to medical treatment efficacy 20. Another study by Lopes et al observed that isolated acoustic measures were not able to discriminate patients with and without laryngeal alteration, but combined acoustic measures such as jitter, shimmer, fundamental frequency and glottal to noise excitation discriminated between the presence and the absence of laryngeal alteration and was able to differentiate laryngeal alterations like vocal fold nodules, paralysis and LPR 86.
GERD and LPR have been associated with a number of other diseases over the years and especially with those affecting the respiratory and digestive systems. Mechanical changes in the intraabdominal pressure and in the pressure of the upper (UES) and especially the lower esophageal sphincters (LES) during coughing, snoring or during laryngospasm have been associated to GERD and LPR 89.
LPR has also been shown to negatively influence the outcome of non-invasive and invasive procedures to the larynx 90-92. Wang et al observed that LPR was a significant negative prognostic factor on voice in patients with vocal fold polyps treated with intralesional steroid injection 91. In a retrospective study of the success rate of speech rehabilitation in patients undergoing laryngectomies and radiation therapy conducted by Cocuzza et al, a higher rate of failure of speech rehabilitation in laryngectomy patients with gastroesphageal reflux was observed 90.
Pregnancy is a physiological state that characterizes some of the above mechanical changes. Some of the voice changes reported in pregnant women may be associated to chronic reflux laryngitis, although this condition presents with a number of associated hormonal changes that notoriously influence fluid balance and edema. A study of 50 pregnant women in the first, second and third trimesters and 15 non-pregnant women using acoustic voice parameters, VHI-10 and RFS scores found that RFS was higher in the first and third trimesters than the second trimester and control groups. VHI-10 scores were significantly higher in the third trimester 93,94.
Changes in body weight and eating disorders may also predispose to LPR and voice problems 95,96. Rothstein in 1989 published a series of eight patients with bulimia and hoarseness. Reflux was diagnosed through esophagograms in four patients and double-probe 24-hour pH-metry (proximal positivity considered as any single drop in pH<4) in another four. Treatment with omeprazole improved symptoms in only half of the patients 97. Morrison et al in 1990 were the first to report on laryngoscopy findings associated with vomiting laryngeal injury in bulimic patients 95. They reported 13 females with eating disorders (3 bulemic with voice complaints) finding superficial telangiectasia of the glottic mucosa and subepithelial vocal fold hemorrhages with scaring even in those patients without voice complaints. Although forceful vomiting and passive reflux may cause very different strain to the larynx, many of the findings reported above can also be observed in patients with LPR and voice abuse 3.
On the other end of eating disorders is morbid obesity. Despite the known influence of increased intraabdominal pressure and decreased LES tone found in obese and morbidly obese patients on GERD/LPR, a study published by Hamden et al in 2014 failed to find and changes in laryngeal findings and voice quality in morbidly obese patients before and after significant weight loss following bariatric surgery 96.
A recent review of literature on episodic laryngeal breathing disorders (ELBD) defined it as a spectrum of respiratory disorders, with no known etiology 98. Included in this spectrum are the so-called paradoxical vocal fold motion/ movement disorder (PVFMD), vocal cord dysfunction (VCD), irritable larynx syndrome (ILS), exercise-induced laryngeal obstruction, laryngospasm, Munchausen stridor, and many additional terms implying functional laryngeal respiratory pathology 98. Based on their literature review, Shembel et al proposed a novel theoretical paradigm and algorithm for identifying trigger patterns and clinical presentation of distinct forms of ELBD and suggested that the diagnosis of any of these disorders should be made by systematic exclusion 98. Paradoxical vocal fold movement disorder (PVFMD) has thus been described as a laryngeal-based respiratory disorder characterized by the inappropriate, involuntary closure of the true vocal folds usually during inspiration 89,99-102. This may result in recurrent episodes of stridor, dyspnea, a choking sensation, and dysphonia has been associated with many triggers, including voice use, exercise, psychological conditions, environmental and occupational irritants, rhinosinusitis, gastroesophageal reflux disease, and neuroleptic drugs resulting in a poor quality of life 98,103-106. In children and adolescents it is most commonly seen in those who are high achievers academically and athletically 106. These symptoms frequently mimic those of asthma 11. The management of PVFMD and the other confounding Laryngeal Breathing Disorders involves treating underlying comorbid conditions, such as gastroesophageal or laryngopharyngeal reflux disease, in addition to behavioral breathing therapy 98,105,106.
Like ELBD neurogenic chronic cough is currently a diagnosis of exclusion. Vertigan examined cough triggers in individuals with chronic cough (CC) identifying sensory symptoms consistent with central reflex sensitization (paresthesia and allotussia), which in their opinion supports that chronic cough may be cough a sensory neuropathic disorder 107. A link between chronic cough and paradoxical vocal cord movement was also suggested 104. In a later study the authors treated cough-related voice problems with two specifically designed voice therapy programs finding improvement in subjective voice parameters and electroglottographic outcomes108. Bock et al compared the laryngeal electromyographic (LEMG) surface-evoked laryngeal sensory action potentials (SELSAP) from 30 patients with chronic cough to a control population without significant laryngeal symptoms, finding significantly lowered median SELSAP peak amplitude in patients also suggesting laryngeal sensory neuropathy 109.
Rheumatoid arthritis (RA) may cause dysphonia due to inflammatory crycoarytenoid anchyloses, central neuropathy and or GERD/ LPR secondary to chronic use of non-steroidal and steroidal inflammatory drugs, and immunosupressors 110. In 2016 Roy et al studied QOL and voice related complaints in 100 patients with RA to determine the frequency, severity, risks associated with, and quality of life burden of voice disorders. Although 35% of the patients interviewed reported chronic voice problems, only a small number had sought medical attention and the authors were unable to establish a correlation between vocal complaints and GERD-related symptoms or diagnosis 110.
Matsumaki et al studied the prevalence of LPR in patients with lumbar kyphosis comparing the RSI scores of a group of 20 patients with this spinal deformity to 31 healthy controls. The authors found that patients with lumbar kyphosis scored higher on the RSI sub-domains heartburn, hoarseness, and problem with swallowing and concluded that the prevalence of laryngopharyngeal reflux disease and gastroesophageal reflux disease was significantly higher in patients with lumbar kyphosis than in controls 111.
A case-control study of 100 patients with type-II Diabettes Mellitus (DM) and 30 controls was carried out to establish the correlation between LPR and glycemic control, duration of the disease, and presence of neuropathy. The authors found a correlation between LPR and neuropathy, but could not establish a significant association between DM and LPR 112.
Lifestyle changes and Voice Therapy
The increasing incidence of GERD and LPR and the unsustainable results after discontinuing medical treatment point to the essential role of unhealthy, reflux promoting diet and lifestyle. Addressing these behavioral issues is key to treatment 7. Treatment compliance is poor, as many patients do not understand the correlation between their laryngopharyngeal symptoms and reflux, especially those that do not present significant digestive complaints. Pisegna et al studied patients` reflux-related symptoms and treatment compliance finding that PPI compliance was poor, and the reasons for poor compliance could have been prevented with patient education 113. Even when PPI compliance was adequate, symptoms like globus, mucous, voice dysfunction, and dysphagia persisted. They concluded that other interventions such as evidence-based diet and behavioral changes should be a part of voice/dysphagia/reflux therapy 113.
Selby et al in 2003 proposed that the hyperfunctional voice patterns observed in a group of patients with LPR was due to laryngeal inflammation and not vocal abuse 35. Patients underwent 8 weeks of speech therapy encouraging easy onset of phonation, decreasing muscular tension, decreasing vocal intensity, improving respiratory support, and improving coordination between respiration and articulation 35.
Clinical Treatment
Proton pump inhibitors (PPIs) are the mainstay of current medical management for LPR but may be insufficient in managing some patients' symptoms 3. The dose and duration of treatment varies widely amongst studies varying from a full therapeutic dosage twice daily 20,68,80 to a lower dose twice daily 5,20,55,59,63 for no less than 8 weeks duration. Despite their effectiveness, about 20-30% of patients report an inadequate response and alternative drugs are required. High dose PPI have been suggested for patients who have refractory disease or develop drug resistance 114. However, in a prospective study of the effect of super high dose of PPI (120 mg daily) on patients with refractory LPR conducted by Portnoy et al in 2014, no statistically significant decrease in acid reflux episodes was observed during 24-hour pH impedance monitoring 115.
Antireflux medications are also widely used before and after phonomicrosurgery based on the premise that reflux episodes occurring during the perioperative period could negatively impact healing. In 2014 Amin et al conducted a retrospective chart review to determine the influence of these medications on operative outcomes in 51 patients who underwent surgical treatment for benign vocal fold lesions finding no significant difference in Voice Handicap Index (VHI)-10 and RSI scores between those patients on antireflux therapy and those that did not receive this medication 116.
Caution must be exercised when prescribing these drugs for prolonged periods of time. The long-term adverse effects of PPI use have not been studied extensively, but several analyses have demonstrated epidemiological links between PPI use and adverse outcomes. These include altered mineral and vitamin absorption, orthopedic injury, acute coronary syndromes (ACS), and infectious risks, likely more prevalent in post-menopausal women, who are also frequently affected by GERD and LPR 117. Mc Kinnon, Hawkshaw and Sataloff made sensible considerations on the mortality associated to chronic PPI use in an editorial published in 2017 concluding that "medication prescribing should be based on an appropriate clinical indication, and the patient needs to be re-evaluated to ensure that the indications for medication use still exist, that the course of therapy is impacting the clinical condition positively, and that no significant complications have developed" 118.
Surgical Treatment
Laparoscopic Nissen fundoplication (LNF) is well established for treatment of gastroesophageal reflux disease with a high success rate, but its role in the treatment of LPR remains uncertain 19. In a pilot study conducted by Weber et al in 2014, 25 professional voice users refractory to standard or super-high-dose medical management were followed after Laparoscopic Nissen fundoplication (LNF). Despite no significant changes in laryngoscopic findings, 86% of patients referred improvement of LPR symptoms, 60% did not require any anti-reflux medication postoperatively and an additional 24% were on less medication 19.
An interesting article by Jiang et al noticed an improvement in the RSI scores and dysphagia when reviewing the outcome of 41 patients with dysphagia who underwent partial or complete crycopharyngeal myotomy. Contrary to the common concept that a lowered UES tone would facilitate reflux, the opposite was observed in their study 119.
GERD is currently considered the most prevalent disease of the digestive tract, affecting between 12-40% of the population. LPR is reported as a cause of 10 up to 60% of visits to the otolaryngologist 87. The incidence of this disease started to soar in the past 3 or 4 decades and is mostly associated to the drastic changes in behavioral and dietary habits. This must be considered with great caution by the health care professional seeking to treat patients with any form of the disease, and especially LPR, since patients many times do not have detectable anatomical or functional abnormalities in the digestive tract. Dispensing medication that interferes with the production of acid or the activation of gastric enzymes, or even with peristalsis, will not sustainably change the progress of the disease unless behavioral and eating habits are addressed. That remains our greatest challenge. In post-modern society of fast everything and overachieving goals, of processed foods and acidic tap water, it seems that such time-consuming conscious effort in controlling diet and habits, is a daunting task for the patients and even more daunting for the health professional trying to propose such. A multidisciplinary and knowledgeable approach is essential to achieve adequate diagnosis and treatment and to enable long lasting disease remission.
Our understanding of laryngopharyngeal reflux has significantly improved over the past 3 decades, but there still remain many challenges in its diagnosis and long-term treatment.
Please select at least one article in order to proceed.


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Kevin Hart's latest concert film, which didn't cost much of anything to make, has already picked up $4.7 million just from Wednesday. More Chevy Suburbans and leather shirts for Mr. "Let Me Explain."
"The Lone Ranger" did a middling $9.4 million Tuesday night and Wed.
But "Despicable Me 2" blew up — $35 million and counting. It's going to be an epic opening –$100 million? More. Box Office Mojo says it'll be at $130 by Sunday. Box Office Guru already seems like he lowballed it — $115 by Sunday.

subset: commoncrawl


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In 2015, when Bill Gates warned us about a possible global pandemic occurring in the future, which could kill above 10 million people, he predicted that it would not be because of a nuclear war but it would come in the form of a deadly virus. He warned us that we are not prepared enough to face the pandemic head-on and our unpreparedness will result into very adverse outcomes.
Looking back at it, he was right wasn't he. We remained unprepared ignoring the warnings and then coronavirus hit us, and it hit us so bad that even developed countries like China, Italy, USA and UK took a serious blow and the death toll is still increasing. Vaccines are being developed but we still have a long way to go.
And while we are still recovering, we are facing the danger of two more pandemics which are- Bio-terrorism and Climate change. In his recent interview, Bill Gates talked about these issues, he warned about increasing death toll in future due to changing climate and spread of biological weapons in form of infectious bacteria and viruses with the intention to cause damage globally. Many physical impacts of climate change are already visible, including extreme weather events, glacier retreat, increase in level of sea water, drought and wildfires etc. And he also suggested us the ways in which we could better prepare ourselves to fight effectively against these future pandemics, they are-
- Field based activity- Appointing a team of epidemiologists so that they could go to the affected locations and collect data about the problems and difficulties they are facing because vaccine research begins only after a careful assessment of public health priorities. Work conducted in the basic research laboratory forms the scientific foundation for all subsequent investigation.
- R&D activity- Investing more in the Research and development for the solutions to the pandemics, like in case of an infectious virus developing mRNA vaccines and developing warning systems using technology.
- Contact Tracing- Contact tracers use clear protocols to notify, interview, and advise close contacts to patients with confirmed or probable infections . Jurisdictions can use the following steps and considerations as a framework when developing a protocol for the tracing of close contacts.
To prevent climate change we have to take some important steps ourselves to save our environment and sustain our resources by-
- Planting more trees & Stop deforestation
- Using resources like water and fuels responsibly
- Using energy efficiently and minimizing wastage
- Using natural resources like solar power to generate electricity.
- Recycling and using renewable resources
- Informing and educating others of these dangers and ways to fight against it
Categories: Education, Educational News Channel, Environment, Health, News, Science


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Employers Liability Insurance Explained
There are some exceptions to this rule, however: In the event of demise, the family of the employee may demand compensation from the employer.
Image result for CLP Labelling for candles Health and
It ensures that a legal minimum of money is available to pay employees compensation for any illness or injury arising out employer negligence.
Employers liability insurance explained. It's a key type of insurance, because if one of your employees falls ill or sustains an injury in the context of the work they do for you, you could be held liable. Not covered by the accident compensation corporation (acc). Employers liability limits can often be increases to a maximum of $5 million for each part of coverage.
An employers liability claim can occur in a number of different ways. In such cases, the employer is liable, as both an employer and a manufacturer. Having employers' liability insurance in place means you're covered if anyone makes a claim against you.
Employers' liability insurance (el) will help you to pay compensation to employees who get injured or fall sick as a result of your business activity. This provides coverage to employers if their employees sustain injuries during the course of their employment. A quick look on employers liability insurance in nigeria as earlier said, this law applies to employees in the public and private sector and provides financial compensation for their families.
While employers may try to enforce safety regulations wherever possible, they will still need the protection of employers liability insurance from the potential risk of an accident. Employers' liability (compulsary insurance) act 1969 page 2 of 6 which insurance companies can sell me employers' liability insurance? Workers compensation and employers liability insurance coverage for an insured's employees traveling through or temporarily working in states other than the insured's home state, as specifically listed in item 3.c of the information page of the policy.
An insurance policy that provides coverage for an employer's two key exposures arising out of injuries sustained by employees. For example if an employee has an accident and suffers an injury through the negligence of. Employers liability insurance provides covers for:
All employers must get employers' liability insurance as soon as they become an employer.the policy must cover them for at least £5 million and come from an authorised insurer. Employers' liability insurance is one of the main types of business insurance, and most employers are legally obliged to take out a policy. A typical claim could involve an employee sustaining a back injury from lifting something heavy because they hadn't had proper training.
This provides protection from the actions of a third party. It is an insurance policy which will meet the costs of damages and any legal fees should an employee be injured or become ill at work through the fault of the employer. Employers' liability insurance safeguards businesses against legal and compensation expenses from employee claims.
There are only a few rare cases where employer liability insurance coverage might be used by a policyholder. You must use an authorised insurer. What is an example of an employers liability claim?
Most public organisations and businesses that only employ close family members (as long as they're not incorporated as limited companies) don't necessarily need to have employers' liability insurance. The endorsement expands the policy so that an injured employee can receive compensation. The costs of settlement or damages in respect of claims for personal injury to employees;
This guide explains employers liability insurance and how it fits with workers' comp. You should check that your insurer is authorised before you take out employers' liability insurance. And employment practices liability insurance (epli) covers lawsuits related to employment practices.
6 things you must know about employers liability. If you do not, you may be breaking the law. Employers' liability (el) insurance is compulsory for all employers under the employers' liability (compulsory insurance) act.all firms who employ staff are legally required to hold employers liability insurance.
An umbrella policy may also provide additional coverage over employers liability insurance. Workers' compensation can't handle such. Employers' liability insurance covers your business if an employee is injured or becomes ill at work, says it's your business' fault and claims against it for compensation.
These are lawsuits brought by an employee against the employer when the injury stems from a product manufactured by the employer. Employer's liability coverage helps pay for lawsuits over employee injuries. Most employers are required to have at least £5 million of employers' liability cover, or face a fine of up to £2,500 per day.
Since an employer liability claim is unlikely, other considerations usually factor into decisions to increase the limits above the basic $100,000/$500,000/$100,000 level. It may be the case that employees get hurt by accident or as a result of their work being rather mentally or physically demanding. Employers' liability insurance offers far more protection to employees than it does to employers.
What employer liability insurance covers. Which occurred in the course of their employment; Employers liability insurance can pick up the tab for these types of claims.
Both lawsuits protect business owners from employee lawsuits, which can cost your business more than $125,000.however, epli is a separate insurance policy that protects your business from allegations of employment.
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Why Some Nodes Have Buttons
In this quick tutorial, we will cover Why Some Nodes Have Buttons. These buttons allow manual interaction with the node from within the editor.
In this video, we will cover:
- Launching Node-RED in your terminal
- What these node buttons allow
- What isn't required
- A Catenis Development or Production account
- Node-RED installed on either a local or cloud environment
- Catenis Flow Pallet installed on Node-RED
- Basic understanding of how to use Node-RED
You are all set to move on to the other videos in this tutorial series.
After watching Why Some Nodes Have Buttons, watch the next video, Understanding the Debug Sidebar, to further expand your knowledge.
Subscribe to our channel for more Bitcoin Blockchain-building videos! https://www.youtube.com/c/BlockchainofThings
Links from this video for easy access:
- Getting Help for Catenis Flow Nodes: https://blockchainofthings.com/tutorials/get-help-for-catenis-flow-nodes
- Understanding the Debug Sidebar: https://blockchainofthings.com/tutorials/understand-debug-sidebar
To sign up for your free account, head to our website www.blockchainofthings.com.
Join our community forum for the quickest response time to all your questions and concerns. This forum is our customer support. https://forum.blockchainofthings.com/
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Dixie State-Utah Tech name change a 'litmus test' for some Washington County Republicans
This past November, a majority of Utah lawmakers voted to change the name of Dixie State University to Utah Tech University, to the displeasure of some Washington County residents.
The name won't officially change until July 1, but the new name and the overall idea of "preserving Dixie" has become a key political issue for the upcoming Republican Party convention and primary.
Starting with the local Washington County convention, which takes place on Saturday, the debate over "Dixie" could play an outsized role in which politicians get picked to become policymakers in local government. Because the GOP dominates local politics — currently every partisan elected official is a Republican — many local positions could essentially be decided this weekend, rather than in November.
At the Republican Caucus meetings in March, where the party chose its delegates for the upcoming convention, one attendee told The Spectrum she had attended specifically because the Defending Southwest Utah Heritage Coalition (DSUHC) —a nonprofit group that's maintained a fierce stance of keeping the name Dixie State — told residents to vote for delegates that support the Dixie State name.
Rep. Walt Brooks (R-St. George), an incumbent who is the only local legislator currently running unopposed, was a staunch defender of keeping the Dixie State name, and he said the issue has been a point of discussion in multiple precincts.
"It seems to be a point of interest for those that are electing delegates," he said.
Brooks, who voted against the name change in November, said that the public's position on the name of the university hasn't changed and that he thinks the majority of Washington Count residents prefer Dixie State over Utah Tech. He said he doesn't think a reversal of the name change is likely, but that the issue could influence some votes.
"In order for that to change back to Dixie from Utah Tech, it would have to have the board of trustees' support and I don't see that changing," Brooks said. "Without the support of a name change back to Dixie from the board of trustees, the other legislators are not going to change."
No more "Poly": Utah Tech University to be recommended as the new name for DSU
The name was changed to Utah Tech after both the university's board of trustees and the Utah Board of Higher Education voted unanimously in favor of the change.
The decision then moved to the Utah Legislature, where the vote for the name change was successful but not unanimous — 73 lawmakers voted for it, 26 against. Among Southwest Utah's seven-member delegation, only Rep. Lowry Snow (R-Santa Clara) and Rep. Brad Last (R-Hurricane) voted in favor.
Since their vote for Utah Tech, both Snow and Last have been criticized by the DSUHC group and others. Both also announced they won't be seeking re-election.
Last said this criticism didn't play into his decision to not seek another term. Snow said his decision was made for health reasons and because he thinks others should have the chance to be elected representatives for the area.
Snow said he doesn't have any regrets over the decisions he's made as a lawmaker when it came to Dixie State, including getting funding for several new buildings on the campus. He admits voting for Utah Tech was a "hard" decision but one that he wouldn't change.
"I've tried to take the long view," Snow said. "What is in the best interest for our area in the long run and, in the case of Dixie State University, what is in the best interest of it, for the students, the students who attend, the faculty we recruit, and providing the very best place possible for the students."
Nina Barnes, who this year is running as a candidate in the GOP race for Utah House District 73, was a member of the state board of higher education when it voted to recommend the change, but she said in a recent interview that the body could only decide on whether or not to advance the name to the Legislature, not pick a different name or choose to keep the Dixie State name.
"I think it's really important for people to understand that the local control of that campus belongs with those board of trustees," Barnes said.
Response since the special session
Not everyone in Washington County is pleased with taking the long view approach to the university's name.
The DSUHC both before and after the November special session has been loudly criticizing anyone who helped move along the Dixie State name change. Tim Anderson, an area attorney affiliated with DSUHC and its operations, said the group is so focused on the name change because it wasn't a change pursued by the locals who have long supported the university.
"There's a lot of concern, a lot of rage and anger in this community," he said, arguing that the decision to get rid of "Dixie", wasn't made by the local community but by "those sort of visitors that run the university."
The DSUHC is a "loosely knit" group that's made up of people committed to preserving the heritage, culture and tradition of Southwest Utah, according to Anderson.
The group's website says it was founded in July of 2020 to stand against the "most extreme and egregious assaults on our nation and our communities that we have seen in our lifetimes."
When DSUHC was first formed, advocating for the Dixie State name was just a small aspect of the group's origin but has taken on a much bigger focus, with a majority of press releases and social media posts made by the group focusing on the name change.
After Snow and Last announced they wouldn't seek reelection, the DSUHC directed its focus to grading the candidates who are seeking office in 2022, publishing a voter guide online describing whether or not each candidate is a "Dixie Supporter."
Of all the candidates running for the various elected positions that represent Washington County, the group has only listed two candidates opposed to supporting Dixie — Barnes and Kristy Pike, who both are seeking a term in the Utah House of Representatives, Pike for District 74, covering the western part of Washing County, and Barnes for District 73, which covers parts of St. George, Washington City and Leeds.
Both Pike and Barnes say they do support the Dixie name, but also want to be supportive of the Utah Tech name.
"I love Dixie heritage, I love what it means," Barnes said. "The best way we can honor our heritage and the pioneer ancestors is to ensure that our community is a place where our children can afford to live, and to work and to stay."
"I support our university," said Pike. "I supported our university when it was a college, when it was Dixie State College. I supported it as Dixie State University and I support it as Utah Tech."
That may not be enough for some area voters, though.
George Floyd protests: Crowd of 800-plus joins protest in St. George over death of George Floyd
Anderson said he thought the name change was enabled by the political momentum created in the summer of 2020 by the death of George Floyd and the ensuing protests held nationwide, including in St. George. He argued it was a "season of wokeness" and that the university used the emotions of the time to push the name change.
"By the time they changed it, it was no longer as big an issue nationally as it was back in early 2020," said Anderson.
Confederate flags, mock slave auctions, minstrel shows: Can Utah's 'Dixie' be separated from past associations?
The changes to the university's brand and identity have been going on for a long time: in 1993, the university stopped using the Confederate flag as a school symbol; in 2007, the school stopped calling its mascot the Rebels and made unsuccessful plans to be called University of Utah-St. George; in 2016, the university picked a bison as its mascot and embraced the "Trailblazer" identity for its athletics.
But the biggest change to Utah Tech has come with accusations of "wokeness" and cancel culture.
Vince Brown, the director of Dixie State's Institute of Politics, said he thinks tying the name change to these issues is about specific ideologies coming to southern Utah.
"Part of it was this idea that this is political correctness, this is wokeness, coming into our community," Brown said.
Brooks said he agrees with that assessment, saying that for some voters, how a candidate feels about the Dixie State name change could be a determining factor.
"For them, it seems to be a litmus test on the woke culture," he said.
Snow, who is staying neutral in the election to pick his successor, said he thinks the issue will be an issue for some voters but is unsure about whether they represent a majority.
"Dixie has its place and among the voters and they're making it an issue, so I'm not going to say it shouldn't be," he said. "For a state lawmaker, there are lots of issues that should not be overlooked."
In fast-growing southwestern Utah, where the St. George area was just named the fastest-growing metro area in the U.S., another key topic could be how candidates say they plan to deal with the burgeoning population and fast-paced development.
Things like how to keep up with infrastructure and how to manage finances are the types of issues Snow, Barnes and Pike said they would like to see take center stage in the 2022 election. Both Barnes and Pike said they think the best thing a candidate can do to preserve the heritage of the area is to make sure it grows in a smart way for future generations.
"Let's look forward. Let's take care of the next generation," Pike said. "Part of that is allowing our university to be successful."
Dixie State has been making progress in several key areas in recent years, according to the university, boasting a 95% rate of graduates either getting jobs or continuing their education. The institution's projected budget for 2021-22 is just over $169 million, and its student population grew by 44.25% from 2015 to 2021.
For some, those signal reasons to change the name to look more attractive to people from outside the area. For others, like Brooks and Anderson, those improvements suggest that the school should've maintained the Dixie State name.
Brown said both students and professors have struggled somewhat with the Dixie State name. He pointed to one study that found 22% of students reported that they experienced challenges in the professional world with the school having the word "Dixie" in its name. He also pointed to experiences with faculty at the university that say the Dixie State name causes confusion for those unfamiliar with Utah and forces those affiliated with the university to answer questions about whether the school has some connection to Confederacy.
"The number one state that I heard from the faculty over and over is that everyone thought that we were a university in Alabama," Brown said.
The university says its main purpose is to educate and prepare students for their careers and pointed to that 22% figure as a reason to change the name. The university also mentioned how the Dixie name was good for its earlier stages but now that it's a polytechnic university with a national recruitment strategy, instead of a regional one, it's more important to have a name that is more easily understood by a national audience.
Those explanations for the name change still don't satisfy DSUHC or Anderson, since they feel like Dixie State is still a community school and pointed to multiple occasions in the university's history how the community rallied to save the school. He specifically pointed to a period in the 1930s when The Church of Jesus Christ of Latter-day Saints decided to stop funding the school and community members had to fund the school's operations for two years until the state government could finance the school.
Snow said the university is a huge part of the community but that as the university has undergone changes so has its operations. As the school has progressed from a junior college to a national university, its focus can't remain to only reflect the needs of the community.
"I think the objectives of the university are now much more far-flung and far-reaching," Snow said.
Anderson thinks the university can reach its wider objectives with the Dixie State name and worries removing the Dixie name from the university could impact other areas of Washington County.
"It starts the ball rolling, to try to take out the heritage and tradition of this very important name," he said.
That worry isn't shared by Snow, Brooks, Barnes, Pike or Brown. They all said they see strong support for the Dixie name in the community when it comes to local institutions and landmarks: including any business with Dixie in its name; the D on the hill; the Dixie name on the Sugarloaf overlooking St. George and Dixie High School.
Time will tell whether ire of the DSUHC will impact Barnes' and Pike's races. Both are in crowded Republican primaries but both choose to gather signatures to ensure they wouldn't be knocked out of the race before this Saturday's Republican county convention.
Both have already gathered more than the 1,000 required signatures required to appear on the June primary ballot and said they gathered signatures to pursue all paths to securing a spot in the primary and to get a better understanding of what voters are concerned about.
As Washington County continues into the future as one of the fastest-growing areas in the nation, the Dixie name will still be a relevant issue. Anderson says the DSUHC has no plans to slow down after the 2022 elections in maintaining the local heritage.
Snow said he thinks that in to do this, the area needs to focus on telling its history.
"I think we could do a better job in Washington County of telling the story," he said. "The Dixie story, the founding of the area, too. To all of the citizens, including those who have moved in here."
Sean Hemmersmeier covers local government, growth and development in Southwestern Utah. Follow on Twitter @seanhemmers34. Our work depends on subscribers so if you want more coverage on these issues you can subscribe here: http://www.thespectrum.com/subscribe.


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Punjab lifts all COVID-19 restrictions day ahead of swearing-in ceremony of new Chief Minister
Though government claimed that decision was taken as number of COVID cases have dropped, it has evidently been taken in view of swearing-in ceremony of new Punjab CM which is expected to draw a crowd
A day ahead of the swearing-in ceremony of the new chief minister, the Punjab government on Tuesday lifted all COVID-19 restrictions in the state with immediate effect.
CM designate Bhagwant Mann will take oath as the 17th CM of Punjab at Khatkar Kalan, the birthplace of legendary Bhagat Singh in Nawanshahr district. It is learnt that Mann will have 17 ministers in his cabinet and the MLAs will be administered oath later.
Though the government claimed that the restrictions were lifted as the number of COVID cases have dropped drastically across the state, the decision has evidently been taken in view of the swearing-in ceremony of new Punjab CM which is expected to be attended by thousands of people.
Anurag Verma, Principal Secretary of Home Affairs and Justice Department, Punjab, issued an order in this context on Tuesday morning.
"In exercise of the powers conferred under section 2 of the Epidemic Disease Act, 1897, read with all other enabling provisions of Disaster Management Act, 2005, in supersession of all previous instructions on the subject all COVID-19 related restrictions are removed with immediate effect," the order read.
"However, the residents of the state are advised to follow COVID appropriate behavioural norms," it added.
The AAP is likely to appoint a woman MLA as the Speaker of Vidhan Sabha. The names of Saravjit Kaur Manuke and Baljinder Kaur are doing the rounds in this context.
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Go to site - Liberty Union High School District http://libertyunion.schoolwires.net/site/default.aspx?PageID=1'
School review and Information: Brentwood schools' administration news, support contact information, and school directory.
|Previous 10 school
|Beverly Hills Unified School District
|http://www.bhusd.org/ Beverly Hills Unified School District
|Directory guide to schools, district office, school board and academic programs. Personnel and employment information.
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|Brentwood Union School District
|http://www.brentwood.k12.ca.us/ Brentwood Union School District
|District news and information on programs and curriculum studies for students and faculty.
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|Minnesota Association of School Business Officials
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|http://www.cesd.k12.ca.us/ Centralia School District
|Established in 1875 and was the first school district in California to provide free textbooks to students. Today, the district's nine elementary schools are in the neighboring cities of Buena Park, Anaheim, and La Palma. Centralia School District is located in beautiful Southern California in the north part of Orange County. Orange County is located between Los Angeles and San Diego counties.
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VIDEO: LeriQ ft. Wizkid – Say You Love Me
Aristokrat Records hit-maker, LeriQ, releases the visuals to his smash hit single "Say You Love Me" featuring Star Boy, Wizkid. It is the third single off of his highly anticipated debut album, TLS (The Lost Sound) set for release in the coming weeks. The video, directed by Mex, and Aristokrat Visions, is a light blue-themed, slow, and colorful pictorial which shows both artistes frolicking and grinding with a couple of pretty chics.
NOTE:- "Android Users Should Hold on the download Link & Choose 'Save Link' Option to start Downloading"
DOWNLOAD: VIDEO: LeriQ ft. Wizkid – Say You Love Me


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Founded by art collector and fashion designer Larry Aldrich in 1964, The Aldrich Contemporary Art Museum is one of the oldest contemporary art museums in the United States. The Museum is one of the few independent, non-collecting institutions in the country and the only museum in Connecticut solely dedicated to the presentation of contemporary art.
The New York Times writes that our exhibitions are the kind you expect at a "big-guns urban institution, but [find] at The Aldrich Contemporary Art Museum in leafy suburban Connecticut." – September 2019


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Chapter Five, Page Fifteen
on August 15, 2014 at 12:01 am
Posted In: Chapter 5
Finally, proof of Seamus' claims of lycanthropy.
Quick update for all readers: I have recently accepted a new position and am going through a transition and training period. As a result, my time is much more limited and I will need to rethink my update schedule. I hope to continue updating on the current Friday and every-other-Tuesday schedule, but I may need to cut back to the once a week updates on Fridays. I will keep you informed in this little chatbox.
As always, thank you so much for reading – and for your patience as I continue to juggle work and art.


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With Covid-19 putting paid to any travel plans in the near future, Mr David Yong plans to sample the resort life at Sentosa Cove instead.
The 33-year-old bachelor has been shopping for his next home at the upscale residential enclave on Sentosa island since the beginning of the year. His budget: $10 million to $15 million.


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Coach Joe Amplo does not need to do much to motivate the Navy men's lacrosse team ahead of Saturday's showdown with archrival Army.
It's a clear case of David versus Goliath.
Army (10-2, 5-1 Patriot League) moved up to fifth in the latest Inside Lacrosse media poll after knocking off previously No. 4 Cornell, 17-10, last Saturday. Earlier this season, the Black Knights went into the Carrier Dome and beat Syracuse when it was ranked 14th.
All-American attackman Brendan Nichtern is the quarterback of a potent offense that is averaging just shy of 15 goals per game. Army's lone losses were 13-10 to No. 4 Rutgers and 11-10 to Lehigh.
Meanwhile, Navy (7-5, 3-3) has endured an up-and-down season, mixing impressive performances with some real clunkers. The Midshipmen were no-shows in two of three games against top tier Patriot League programs, getting blown out by first place Boston University (17-9) and third place Loyola Maryland (18-7).
Navy sits in fifth place in the Patriot League standings and a victory would clinch one of six spots in the postseason tournament.
Scoring has been an issue at times for Navy, which has been held to single digits in five of six conference contests.
Army is a very veteran team with 19 seniors, while Navy is relatively inexperienced with a large contingent of sophomores and freshmen getting playing time, while only a handful of seniors are key contributors.
"On paper, Army is more talented and more experienced. So far this season, they've performed on the field and won some big games," Amplo said. "I definitely think there is more pressure on them than us. We're the clear underdog and nobody thinks we're going to win."
Amplo hopes his troops go into Michie Stadium with a chip on their shoulder and feeling like the Black Knights don't respect them. At the same time, the third-year coach thinks the Mids are capable of pulling the upset provided they finally put a complete game together
"We've been frustrated because we have yet to put together a consistent performance for 60 minutes," he said. "I do believe that if we play up to our potential, we're going to have a chance against these guys."
Army is extremely talented on the offensive end with Nichtern the straw that stirs the drink. The reigning Patriot League Offensive Player of the Year leads the Black Knights in scoring with 70 points on 30 goals and 42 assists.
"Brendan is as valuable a player to our team as any player in the country, and it's not necessarily just his point production," Army coach Joe Alberici said. "It's also his leadership the direction he provides the offense."
However, Nichtern is far from a one-man show as Army has four other players that have scored 19 goals or more. Junior left-handed attackman Reese Burek has displayed superb balance with 19 goals and 14 assists, while junior running mate Paul Johnson is a former midfielder who can also run by a long pole.
"Army's starting attack is as talented and potent as any we've seen all season," Amplo said.
Midfielders Bobby Abshire (21 goals) and Jacob Morin (20) are outstanding shooters with range. The Black Knights had 10 different goal-scorers in the victory over Cornell.
"To contain Nichtern, you have to limit the other people. It's more about what you do defensively off the ball whenever he has it in his stick," Amplo said.
Army's defense has proven susceptible at times this season with five different opponents scoring 12 goals or more. Starters Jack Weigand, A.J. Pilate and Deacon Donaldson have all missed multiple games with injuries for the Black Knights, who are giving up more than 10 goals per game.
"It's been a bit of revolving door on close defense, which impacts the chemistry and trust you need down there," admitted Alberici, who was encouraged Army only allowed five goals through three quarters versus Cornell.
Army is blessed with a veteran goaltender in Wyatt Schupler, a three-year starter who is stopping almost 60% of shots. Schupler recorded 10 saves in last season's 9-4 loss to Navy on the way to being named second team All-Patriot League.
Navy has been led offensively all season by the high-scoring first midfield featuring junior Patrick Skalniak along with sophomores Dane Swanson and Max Hewitt. That trio has accounted for 91 points with Skalniak leading the way with 22 goals and 17 assists.
Swanson has used his wicked crank shot to score 17 goals and has also dished off 17 assists, while Hewitt has been very effective when dodging against short stick defenders in totaling 16 goals and seven assists.
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"Skalniak is one of the nation's elite midfielders. He's got outstanding speed, superb skills, a tremendous shot and great vision," Alberici said. "Swanson and Hewitt are both terrific players as well. That is an outstanding midfield line that Navy relies on a lot. That's going to be a challenge for our defense."
Attackman Nick Cole has enjoyed a strong senior season with 13 goals and a team-leading 18 assists, while plebe Henry Tolker has proven an accurate lefty sniper scoring 17 goals. Sophomore attackman Jon Jarosz (Severn School) is a load at 6-foot-5, 230 pounds and has bull dodged his way to 12 goals.
Sophomore attackman Xavier Arline, who has played in just three games due to multiple injuries, resumed full-contact practice this week and could possibly see some action.
"We can't let the moment become too much and we need to play our very best. We can't shoot ourselves in the foot, which we've had a tendency to do this season," Amplo said. "We need to play a clean game. We can't turn the ball over; we need to clear effectively and offensively we need to win matchups and draw slides."
Next up
Saturday, noon
TV: CBS Sports Network


text: On Mon, Feb 08, 2021 at 05:02:59PM -0500, Peter Xu wrote:> On Mon, Feb 08, 2021 at 02:51:33PM -0400, Jason Gunthorpe wrote:> > On Fri, Feb 05, 2021 at 01:14:11PM -0500, Peter Xu wrote:> > > > > But I do have a question on why dax as the only user needs to pass in the> > > notifier to follow_pte() for initialization.> > > > Not sure either, why does DAX opencode something very much like> > page_mkclean() with dax_entry_mkclean()?> > > > Also it looks like DAX uses the wrong notifier, it calls> > MMU_NOTIFY_CLEAR but page_mkclean_one() uses> > MMU_NOTIFY_PROTECTION_PAGE for the same PTE modification sequence??> > > > page_mkclean() has some technique to make the notifier have the right> > size without becoming entangled in the PTL locks..> > Right. I guess it's because dax doesn't have "struct page*" on the> back, so itIt doesn't? I thought DAX cases did?Jason


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Perfume: The Story of a Murderer (German: Das Parfum: Die Geschichte eines Mörders ) is a 1985 literary historical fantasy novel by German writer Patrick Süskind. The novel explores the sense of smell and its relationship with the emotional meanings that scents may have. An acclaimed bestseller and international sensation, Patrick Suskind's classic novel provokes a terrifying examination of what happens when one man's indulgence in his greatest passion – his sense of smell – leads to murder. This novel was later adapted into a famous movie in 2006 with the same name, starring Ben Whishaw, Alan Rickman, Karolina Herfurth and others.
About The Author
Patrick Süskind ( born 26 March 1949) is a German writer and screenwriter, known best for his novel Perfume: The Story of a Murderer, first published in 1985. Süskind lives as a recluse in Munich, in Seeheim , and in France at Montolieu. After spending the 1970s writing what he has characterized as "short unpublished prose pieces and longer un-produced screenplays", Patrick Süskind was catapulted to fame in the 1980s by the monodrama Der Kontrabass [The Double Bass, 1981:], which became an instant success and a favourite of the German stage. In 1985 his status as literary wunderkind was confirmed with the publication of the novel Das Parfüm. Die Geschichte eines Mörders [Perfume. The Story of a Murderer], which quickly topped the European best-seller list and eventually sold millions of copies worldwide.The public knows little about him; he has withdrawn from literary society and does not grant interviews or allow himself to be photographed.
Storyline of The Novel
The novel is set in Paris in the 1700's and follows the life of a man named Jean-Baptiste Grenouille who is born with an incredibly strong sense of smell. His nose is so keen that he is able to smell people coming, can locate lost items simply by their scent, and can catalogue smells in his mind. Whilst his sense of smell may be keen, his heart is empty and he seems to be completely unrestrained by everyday emotions. As a young lad, Grenouille encounters the irresistible smell of a young girl entering puberty. He promptly murders her and sniffs every inch of her body to catalogue the unique scent. Believing it is his destiny to bottle such a scent, Grenouille decides to pursue a career as a master perfumer, he works as an apprentice where his unique skills quickly make him the best perfumers in France. The story then follows Grenouille as he becomes a famed perfumer and experiments in scents that allow him to either go unnoticed or incite various emotions among those who smell it. His obsession with scents goes on to reaches a head with extreme consequences for all.
Analysis of The Storyline
A book about the sense of smell could have been a dull affair, were it not for the excellent way it is written by Suskind. His use of language is beautiful and his descriptions make even some with a dull nose like mine feel like they can smell the essences on the page. It's not hard to see why this book has become such a modern classic given how excellent Suskind's prose is. I challenge anyone not to read this and not then start using their nose a little more.
The character of Grenouille is both fascinating, sympathetic, and yet also repulsive. In early life he is beat down at every corner and one can't help but root for the character as he tries to rise above his terrible beginnings. As he becomes more in control of his life, Grenouille quickly becomes insidious and deceptive and there's something very creepy in the way he is described as living like a tick. Grenouille does indeed live like a parasite, taking whatever he needs from people. As he becomes more unstable, eventually resorting to killing a young virgin, Grenouille turns into a monster, but a compelling one nonetheless. Like Humbert Humbert from Lolita, he's a character you feel bad for sympathising with, though Grenouille may be a little more redeemable.
Criticism of The Storyline
this is in every sense an olfactory novel gives a striking sensory immediacy to the fiction itself. "Perfume" is a historical novel but one in which the sheer physicality of its theme lends it an honorary present tense. And if Grenouille is the hero of the novel, his obsessions are also its informing presence. Just as he has difficulty with words "designating non-smelling objects, with abstract ideas and the like," so the novel itself creates an elemental world in which such abstract matters are only of token significance. The nose is defined here by a priest as "the primitive organ of smell, the basest of the senses," with its powers springing from "the darkest days of paganism"; but it flourishes in Grenouille, even in an age of "enlightenment," and the unspoken message of "Perfume" is that it flourishes still. The point about genuine historical fiction is that it is primarily concerned with the contemporary world. This is not a historical romance, full of "Prithees!" and strange objects known as poniards, but a meditation on the nature of death, desire and decay.
The story of perfume made us really re-evaluate the importance of scents and how certain smells can influence us on a subconscious level. It makes one wonder how much of our everyday lives are dictated by scents without us even realising it. Throughout the book, you get the feeling pressure is mounting and it ends in a finale that sees an orgy of scents come together in one hell of an ending that isn't likely to leave you any time soon.
Categories: Book Review, book reviews, Western, World


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The new episode of The Agency Podcast is up. Listen here, or find it at all the good places.
Much movie talk this week! Stillwater and it's similarities, or not, to The Amanda Knox story. The delicious VAL documentary: the original "selfie artist" Val Kilmer. And we have a contest to win a cd!
Please email us about anything. Thanks for listening.


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Photos via @tezza
Nothing gets us more excited than a new styling trick to add the arsenal, and NYFW is showing us how all the cool fashion girls are wearing their strappy heels this fall. As seen on fashion influencer Tezza, tie your lace-up sandals over relaxed denim or long trousers. This is no doubt the styling trick to try this fall if you're looking to elevate your basic pants to another level of cool.
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infra-Legalities team participate in 2021 4S conference
The infra-Legalities research team recently presented early research at the 2021 Meeting of the Society for the Social Studies of Science (4S conference) organised from the University of Toronto. The paper, entitled 'Transparency Multiple: Algorithmic Regulation and the Governance of Terrorist and Extremist Content (TVEC) Online', critically engaged with the politics of transparency in online CT space. We hope it provides the foundation for future project research and publications in this area.


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Late last year I began planning for a major update of two websites, but I was really hungry for some metrics about A/E/C websites. Metrics that I couldn't find anywhere! So I polled several dozen colleagues from the Society for Marketing Professional Services, and received some useful insight. A comprehensive survey about the current state of industry websites it was not, but yet it provided some interesting opportunities to benchmark my company's sites with others.
Roughly half of the participants were from engineering firms, with the balance representing architects, A/E firms, and general contractors/construction managers. Firm size ranged from less than ten to as many as 2500 employees. Slightly fewer than 50% of firms represented employed 10-49 people, with about a third of participants representing firms with 50-250 employees – meaning that the data shared was mostly from small and midsize firms, with no mega-firms represented.
I was curious how "current" the websites were, and found that only 15% of firms had updated their website in the past two years; however, almost a third of firms underwent a redesign in 2012. A quarter of firms had not redesigned their website within the past five years.
When I asked about the size of the websites, the answers were all over the board. However, almost 40% of firms fell into the 25-49 page range, with another 15% in the 50-99 page range.
Surprisingly, half of firms participating do not have an active blog on their website! Of course, if I'd asked this question a few years ago, I'm sure that the vast majority of firms would not have had an active blog. For those firms that have a blog, almost 60% update it twice per month, or less. However, 18% reported that they post new blogs more than once per week. When it comes to bloggers, slightly more than 40% of firms reported that they only have one company blogger, while 30% have 2-4 bloggers and another 30% have 5-9 bloggers.
I queried about how firms are driving traffic to their websites, and the top two responses were LinkedIn and e-mail marketing. Facebook, Twitter, Search Engine Optimization, and Blogging followed in that order.
When it came to analytics, the responses were varied, as you'd expect with a smaller sample size; however, I made some general observations. When it came to website sessions, 250-499 and 1000-1499 sessions per month were the most common. But ten percent of firms saw less than 99 sessions per month while six percent of firms experienced more than 5000 sessions per month.
One of the areas in which I was particularly interested was whether or not firms were getting leads from their websites. Approximately 40% of participants noted that their website has never generated leads. Among firms reporting leads, one-third receive one or two leads annually, while 13% each reported 3-4, 5-6, and 7-10 leads per year. The outlier was one firm that reported more than 25 leads annually! The value the leads ranged from $5,000 to $1,000,000, but it doesn't seem like this metric is accurately tracked by most A/E/C firms.
This mini-survey was a great start, but it left me longing for more! Fortunately, the SMPS Foundation has launched research about what makes A/E/C websites tick! Foundation researchers are diligently working on A/E/C Firms and the Web: The Seller's Perspective as the inaugural report in their new Quarterly Reports: The Informed Strategies Series.Watch for the report later this year at www.smpsfoundation.org.