text:
Clinical predictors of 30-day cardiac events in patients with acute coronary syndrome at a community hospital.
Methods: We prospectively collected data on 400 patients admitted through our emergency room for unstable angina and acute coronary syndromes. Patients with ST-segment elevation myocardial infarction and those who required thrombolysis were excluded.
Results: Of 383 patients who were eligible, 120 patients had coronary events within 30 days. Statistically significant variables associated with coronary events were advanced age, male sex, family history of premature coronary artery disease (CAD), diabetes mellitus, tobacco abuse, prior congestive heart failure, prior myocardial infarction, and history of CAD. Symptoms at presentation associated with cardiac events were typical angina and shortness of breath. Objective measures of ischemia associated with cardiac events were elevated troponin T, elevated creatine kinase MB, and ischemic electrocardiographic changes. Using forward stepwise regression analysis, we generated a model to predict 30-day major adverse cardiac events. The strongest predicting variable was serum troponin T (accounting for 33% of predicting [r.sup.2], P < 0.001) followed by typical angina ([r.sup.2] increasing to 37%), ischemic electrocardiographic changes (40%), prior CAD (42%), family history of premature CAD (44%), shortness of breath (46%), and positive creatine kinase MB (48%). The positive predictive power of the complete model was [r.sup.2] = 48%, P < 0.001.
Conclusion: Our model incorporating elements from the patient's demographic, medical history, presentation, and ischemic assessment identified 48% of patients presenting with unstable angina and acute coronary syndromes who will suffer a major adverse cardiac event within 30 days of admission. Although the strongest predictor was identified as serum troponin T, other clinical criteria offered improvement in our predictive abilities. Therefore, good initial clinical evaluation in addition to simple tests such as serum cardiac markers and electrocardiography are valuable in risk stratification of patients presenting with acute coronary syndromes and cardiac chest pain. Additional testing may be necessary to improve the positive predictive value of the model. Cardiac enzymes and electrocardiographic changes have the highest negative predictive value for occurrence of major adverse cardiac events. Identification of high-risk patients is essential to direct resources toward these patients and to avoid unnecessary costs and risk to the low-risk population.
Cardiovascular disease remains the leading cause of mortality in the United States. The increased prevalence of various risk factors and comorbid illnesses in the population has led to a marked increase in the incidence of atherosclerotic heart disease and ischemic complications. In spite of the marked improvement in therapeutic modalities of ischemic heart disease, it continues to be an enormous burden on the current health care system.
Before the advent of coronary angiography and noninvasive evaluation, clinicians relied on the severity of the patient's symptoms and abnormalities on the electrocardiogram (ECG) to predict the severity of coronary artery disease (CAD). (1) In an era when technological advances have changed the methods for diagnosing and managing multiple disease states, the art of good history taking and physical examination has lost its luster. Many studies have documented the use of several objective tests, including noninvasive and invasive techniques, to predict the extent and severity of outcomes from CAD. The results of these studies have led many clinicians to rely more on the findings at cardiac catheterization and echocardiograms to determine management strategies and ignore the patient's clinical presentation. Other investigators have incorporated various clinical characteristics into models, which included other objective findings for myocardial ischemia attempting to risk stratify patients and to predict outcomes after myocardial injury such as the Thrombolysis in Myocardial Infarction (TIMI) risk score and the Braunwald classification. (2), (3)
Few data are available from individual hospitals to reflect and validate the use of risk-assessment models in primary care settings. Also, there are scarce data on the outcome of acute coronary syndromes presenting to community hospitals. Therefore, the aim of our study was to focus on the patients admitted to a community hospital from the emergency department for acute coronary syndromes, unstable angina, and non-ST-segment elevation myocardial infarction. The main aim was to identify various clinical risk factors that can predict major adverse cardiac events (MACE) for patients while in the hospital and 30 days after discharge in this cohort. A risk-assessment model using the specified factors was formulated to assess the individual risk for each patient presenting with cardiac chest pain.
Patients and Methods
The study was conducted in a 250-bed community hospital with a slightly predominant white and elderly population. The cardiologist on call decided admissions to the cardiology team. A 24-hour cardiac catheterization facility was available in the hospital. All patients admitted through the emergency department for the clinical diagnosis, as determined by the cardiologist on-call, of unstable angina and acute coronary syndromes through the period from January to June 2000 were included in the study. An acute coronary syndrome was defined as a clinical presentation that included any of the following: cardiac chest pain, electrocardiographic changes, and elevation of serum cardiac markers. Four hundred consecutive patients were identified and their medical records were collected. The major exclusion criteria were patients with acute ST-segment elevation myocardial infarction and patients requiring thrombolysis. Analyzed records included the hospital admission data, clinic notes for the 30-day period after admission, and any subsequent readmission records within this 30-day period. Patients who did not have any available hospital data for follow-up were contacted through the telephone and were questioned about occurrence of any events in the 30-day period after admission using a standard telephone survey form. Approval from the hospital institutional review board was obtained.
Demographic data included age, sex, race, and family history of premature CAD. Medical history of CAD (defined as abnormal stress test, presence of ischemic heart disease on an ECG, or coronary angiography), prior acute myocardial infarction (>2 wk), hypertension, diabetes mellitus, hyperlipidemia, tobacco abuse, chronic renal insufficiency (chronic creatinine level, >2 mg/dl), end-stage renal disease on hemodialysis, and creatinine value were recorded. Presenting symptoms included type of chest pain, shortness of breath, palpitations, nausea, vomiting, and diaphoresis. Chest pain was further subdivided into typical angina, atypical angina, and nonanginal chest pain as previously stated. (2) Typical angina was defined as discomfort thought by the cardiologist to be characteristic of myocardial ischemia that would fulfill the classic triad of substernal chest pain induced by exertion or stressful emotions and relieved by rest or sublingual nitroglycerin. Atypical angina was defined as chest discomfort that included only two of the previous criteria, and nonanginal chest pain was defined as that which did not meet more than one of these criteria. (4)
All patients had an ECG at admission that was interpreted by two different cardiologists blinded to the study outcomes. Ischemic electrocardiographic changes were defined as one or more of the following in two or more adjacent leads; >1 mV ST-segment depression or transient ST-segment elevation, and new deep T-wave inversion of at least 1-mV depth. Persistent ST-segment elevation, new left bundle branch block, and new Q waves were considered as exclusion criteria from the study. The rest of the electrocardiographic changes were labeled nonspecific electrocardiographic changes. Also, all patients had three serial sets of serum cardiac markers: at admission and at 6 and 12 hours after admission. We used cardiac troponin T (CTnT) and isoenzyme of creatine kinase with muscle and brain subunits (CK-MB) as our serum cardiac markers. Cardiac troponin T was measured by the second-generation troponin T assay using the ES 300 automated analyzer (Boehringer Mannheim, Mannheim, Germany). The lower detection limit for this assay was 0.04 ng/ml. Patients were classified as CTnT-positive if the CTnT value was >0.1 ng/ml. CK-MB was measured by immunoassay with a Stratus II instrument (Baxter Diagnostics, Miami, FL), with a limit of detection of 0.4 ng/ml. Patients were classified as CK-MB positive if their levels were >7 ng/ml. Therapeutic interventions and medications given to the patients were left to the discretion of their primary physicians.
The primary endpoint for all patients was occurrence of a composite endpoint of MACE within 30 days of admission. These events included nonfatal acute myocardial infarction, need for urgent revascularization in the form of percutaneous coronary intervention or coronary artery bypass graft surgery, and cardiac death. A new acute myocardial infarction was defined on the basis of the combination of new ischemic electrocardiographic changes and elevation of cardiac enzymes. Cardiac death was defined by death attributed directly to cardiac disease according to autopsy or by assessment of the cardiologist. The need for urgent revascularization was defined as the need for coronary revascularization in the form of angioplasty, stent, or coronary artery bypass graft surgery in a case of failed medical therapy to control angina, prevent ongoing myocardial ischemia, and restore hemodynamic stability. Elective revascularization procedures were not included in this analysis.
Statistical Analysis
Patients were first classified as having experienced occurrence of any MACE or not. Univariate analysis was performed using the [chi square] test for the categorical variables and Student's t test for continuous variables. All the baseline demographic, medical history, presenting symptoms, and electrocardiographic and serum cardiac markers were analyzed. Each factor was tested independently in a univariate logistic regression model. The significant factors were included in a multiple logistic regression analysis to determine the independent predictors for occurrence of MACE. Odds ratios (ORs) were calculated from the coefficients and the 95% confidence intervals were calculated for the significant variables. Both forward and backward stepwise regression models were used to form the final risk model using the factors that were significantly independent in the multiple logistic regression analysis. To validate the OR 95% confidence intervals for the different variables with respect to sampling variation, we used the bootstrap technique. We also used the same technique to test the validity of [r.sup.2] in the final model and to estimate the upper and lower limits for [r.sup.2]. The results of the bootstrap's 95% confidence intervals were compared with the original model's estimates to test for agreement. All statistical procedures were performed using SAS statistical software, version 8.1 (SAS Institute, Inc., Cary, NC).
During a 6-month period, 400 patients were enrolled prospectively. Three hundred eighty-three patients were eligible according to the inclusion criteria and were admitted for cardiac chest pain. Seventeen patients were excluded for various reasons such as denial to consent, evolving into an ST-segment myocardial infarction in the emergency department, and lost to follow-up. In the 30-day postadmission period, 120 patients (34%) had an event and 263 patients (66%) did not have any events (Table 1). Univariate analyses of the demographic data, elements from the family, and medical and social histories are shown in Table 2. Elder, male, and white patients were more associated with worse cardiac outcomes at 30 days (P = 0.04, P = 0.09, and P = 0.006, respectively). Family history of premature CAD was a significant factor, with an OR of 3.4 (P = 0.001). From the medical history, patients who were diabetic; had history of tobacco abuse; and with prior history of congestive heart failure, hyperlipidemia, myocardial infarction, and CAD were more associated with occurrence of major cardiac events. We did not detect any differences between both groups regarding the incidence of hypertension or the mean creatinine levels. Patients with chronic renal insufficiency and those on hemodialysis did not have worse outcomes; however, they were more associated with elevated CTnT and CK-MB (r = 0.76, P < 0.001). Analysis of presenting symptoms revealed that typical angina and shortness of breath were associated with occurrence of MACE (P = 0.001). Although weaker than typical angina, atypical angina (P = 0.02) and diaphoresis (P = 0.002) were associated with major adverse cardiac events. Analysis of the objective evidence of myocardial ischemia revealed a significant difference between both groups in both serum cardiac markers and electrocardiographic changes. Patients with MACE had elevated CTnT, elevated CK-MB, and ischemic electrocardiographic changes (P = 0.001 for all variables). The sensitivity, specificity, and positive and negative predictive values of the significant univariate variables are shown in Tables 3 and 4.
Although several risk factors were significant in the univariate analysis, seven remained as significant independent predictors of major adverse cardiac events at the 30-day point (Table 2). The independent predictors of major adverse cardiac events were (in the order of significance) positive CTnT (OR, 12.3), typical angina (OR, 7.3), ischemic electrocardiographic changes (OR, 3.7), history of CAD (OR, 3.2), elevated CK-MB (OR, 2.8), family history of premature CAD (OR, 2.6), and shortness of breath (OR, 2.4). Using forward stepwise regression, we generated the model to predict 30-day major adverse cardiac events (Tables 3-5). The strongest predicting variable was serum CTnT (accounting for 33% of predicting value [r.sup.2], P < 0.001) followed by typical angina ([r.sup.2] increasing to 37%), ischemic electrocardiographic changes (40%), prior CAD (42%), family history of premature CAD (44%), shortness of breath (46%), and positive CK-MB (48%). The positive predictive power of the model was [r.sup.2] = 48%, P < 0.001.
Using the bootstrap technique, we found the OR for all the significant variables to be in agreement with the estimate from the original model (Fig. 1). The estimated [r.sup.2] from the bootstrap was 0.481, with upper and lower limits of 0.427 and 0.537, respectively. The C statistic was 0.933.
In our study, we generated a model that can assist primary care providers and emergency department physicians in assessing the in-hospital and short-term risk for patients presenting with cardiac chest pain and acute coronary syndromes. From the demographic characteristics, we found that advanced age, male sex, and white race were significant predictors of cardiac events only in the univariate analysis. Family history of premature CAD was significant as a univariate factor and an independent predictor in the multivariate model. In the univariate analysis of the medical history, history of prior myocardial infarction, CAD, congestive heart failure, diabetes, hyperlipidemia, and tobacco abuse was significant. In spite of the fact that patients with chronic renal failure and specifically those on hemodialysis were more associated with elevated CTnT and CK-MB, they were not significantly associated with worse short-term outcomes. We did not find any difference in the mean creatinine levels between both groups with and without MACE. Objective measures of ischemic injury were consistent with various studies in the past. Troponin T and CK-MB were significantly associated with MACE. Ischemic electrocardiographic changes, which were mostly ST-segment depression, were significantly associated with major adverse cardiac events. Cardiac troponin T was revealed to be the most significant in the univariate analysis with the highest [X.sup.2] and in the multivariate and forward stepwise regression models. Troponin T and CK-MB followed by ischemic electrocardiographic changes had the highest negative predictive values for occurrence of MACE.
The multiple logistic regression analysis identified seven independent predictors after adjusting for the other factors. Serum CTnT was the most significant, with the highest OR (12.3), followed by typical angina and ischemic electrocardiographic changes as the strongest predictors. Elevated CK-MB lost most of its power in the multivariate analysis and had a marginal addition to the predictive power after troponin T and ischemic electrocardiographic changes. All the demographic factors lost their significance except family history of premature CAD and history of CAD. Shortness of breath was the other significant independent factor besides typical angina from the presenting symptoms. The findings of the forward stepwise regression analysis confirmed the previous findings. The total predictive value of the whole model allowed us to predict nearly half of the patients that would suffer from adverse cardiac outcome either in their hospitalization or within the 30-day postdischarge period.
The attempt to validate the model was geared toward confirming the consistency of the presence of the previously mentioned risk factors as independent variables. The similarity of the resulting OR and 95% confidence intervals of these factors to those generated in the original model enforces the validity and reproducibility of this model. The total [r.sup.2] generated from the bootstrap with its upper and lower limits of prediction confirms the ability of the model to assess the individual risk score of each patient within reasonable limits. The high level of C statistic of 0.933 provides confidence in the clinical value of the model. Caution must be applied in this case, however, because the C-statistic value is usually higher when assessing the predictive accuracy in the same patient data set used to develop the model rather than independent sets of patients.
Incorporating clinical factors in models to predict outcome of CAD has been well established in the medical literature. Diamond and Forrester (4) emphasized the concept of pretest and posttest likelihood of significant CAD. Using elements from the patient's history such as age, sex, and characteristics of the presenting chest pain, they devised a model, using the Bayes theorem of probability, to estimate the likelihood of significant CAD. Sox et al (5) identified age older than 60 years, male sex, typical angina, history of myocardial infarction, and 20 pack-year smoking history as significant predictors of angiographic CAD. When compared with treadmill exercise testing, evaluation by elements from history, physical examination, and ECG had similar ability to identify patients with severe CAD and those with higher mortality. (6) In this study, the authors concluded that the emergence of strategies for cost-conscious quality care should start with history, physical examination, and simple laboratory tests.
The concept of creating risk-stratifying models for ischemic heart disease has also been well documented. In many trials including patients with ST-segment elevation myocardial infarction and with the use of thrombolytics, the presence of multiple risk factors such as increased age, positive troponin T, and presence of electrocardiographic changes were associated with worse prognosis at 30-day and 1-year analysis. (7), (8) In contrast to the uniformity of the pathophysiology of ST-segment elevation myocardial infarction, acute coronary syndromes represent a gradation of severity of CAD from unstable angina through acute myocardial infarction. All share the same pathophysiology of acute plaque rupture, with various degrees of vessel occlusion and subsequent myocardial injury. Although they share this same pathophysiology on the continuum of severity, they have different outcomes and mandate different management strategies. Because of the heterogeneous nature of this disease, risk stratification has emerged as an essential tool for optimum management of the disease and better use of resources. (9) Moreover, devising a risk-stratification model for these patients was crucial to gauge the amount of benefit from specific treatment, knowing that patients with the highest risk get the utmost benefit from the treatment. The advent of improved therapies for unstable angina and non-ST-segment elevation myocardial infarction, such as platelet glycoprotein IIb/IIIa receptor inhibitors, has required the presence of risk stratification that can aid in optimum patient management and to avoid any unnecessary risks and costs. (10)
Results from recent studies that proved that the anatomic severity and extent of left ventricular function could predict outcomes better than just symptoms have dissuaded clinicians from optimal use of their clinical judgment. In spite of this, combining data from the clinical presentation with objective data may optimize our predicting capabilities. Califf et al (11) devised an angina score that included elements from the angina history such as acuteness, course, and daily frequency. In the presence of ST-segment abnormalities, these factors were significant predictors of mortality. In a model that included the ejection fraction, number of diseased vessels on cardiac catheterization, and presence of left main coronary artery stenosis, the angina score remained as a significant independent predictor of survival. The individual analysis of each factor of the score revealed that typical angina was a significant prognostic factor independent from the angina course and daily frequency. Also, the aforementioned study confirmed that the patient's symptoms could add to our ability to prognosticate even in the presence of coronary angiography findings.
More recently, Antman et [al.sup.2] defined the TIMI risk score that was very predictive of major adverse cardiac events and of benefit from therapy. Four of the seven identified risk factors were clinical factors: age >65, presence of at least three risk factors for CAD, severe angina, and use of aspirin in the last 7 days before presentation. In this study, the value of the risk score was apparent in the progressive increase in cardiac events with higher TIMI risk scores. Also, it was shown that the benefit from treatment was maximized in patients with the highest risk score. The only clinical limitation of the TIMI risk score is that one of the factors, significant prior coronary stenosis, required presence of coronary angiography data that may not be available to all primary care physicians at the time of the patient's presentation. Therefore, the authors concluded that similar studies should be conducted in cohorts of patients who present to emergency de partments or physicians' offices with chest pain to test for the generalizability of these risk-stratification models. Our findings are another example of the use of risk scores, but more specifically in primary care and community hospitals.
Similarly, major trials have studied adding simple objective criteria for risk stratification of CAD patients. In the multiple analyses generated from the GUSTO-IIB trial, (12) troponin T was found to be the strongest predictor of 30-day mortality, followed by electrocardiographic changes and CK-MB elevation. Other clinical factors such as hypertension, peripheral vascular disease, and smoking proved to be significant in this study. This was confirmed in the FRISC trial, (13) where CTnT was valuable in assessing risk of patients with unstable CAD followed by ischemic electrocardiographic changes. In the model generated from the PURSUIT trial, (14) the following factors were significant predictors: age, female sex, increased heart rate, lower systolic pressure, severity of prior angina, ST-segment depression, and signs of heart failure. In spite of the fact that these trials have placed the objective measures in the leading role for risk stratification, they have also incorporated strong clinical variables as independent risk factors. Our findings are in agreement with the data from those three major trials. Cardiac enzymes and ischemic electrocardiographic changes are the backbone of diagnosis and prognostication of patients with acute coronary syndromes, followed by clinical criteria.
The major limitations of our study are the number of patients in our study population and the lack of a separate validation group to test the risk-stratification model. Also, we did not include medications such as [beta]-blockers or intravenous nitrates, which were reported in a previous study as independent predictors of cardiac events in patients presenting with unstable angina. (2) Another limitation in our study was the absence of a separate analysis for the different kinds of ischemic electrocardiographic changes. The main reason was the small sample size. However, we have to take into consideration that ST-segment depression was the main ischemic electrocardiographic change in our patient population, which may have accounted for its significance. This confirms what other trials have demonstrated about the strength of ST-segment depression to predict both short-and long-term outcomes. (15), (16) Although we were not able to perform a comparative analysis between the different kinds of ischemic electrocardiographic changes, we demonstrated, with others, that the absence of ischemic electrocardiographic changes predicts a low incidence of short-term complications. (17) We excluded some objective hemodynamic measurements such as blood pressure and heart rate monitoring to maintain the simplicity of our risk model.
We excluded in the outcome analysis any elective revascularization procedure to avoid therapeutic bias. We only included emergent need for revascularization. We also did not include any data involving in-hospital therapies or interventions, as this was left to the discretion of the primary team on addition to our attempt to focus the risk-predicting model on admission data only. The fact that we did not detect the well-documented worse outcome for blacks could be because of the small sample size or because of referral bias and the skewed demographic distribution of our patient population, which included fewer blacks. Also, in spite of the higher correlation of elevated serum troponin T and CK-MB in patients with chronic renal failure, this was not translated into more MACE. This could be explained by either an increased incidence of false elevation of troponin T in patients on hemodialysis or that CTnT could be more specific to serve as a marker of chronic ischemic insult more than acute myocardial injury. We are more in favor of the latter explanation, which has been supported by various molecular studies and outcome studies that linked elevated CTnT with worse 1-year outcomes in this cohort. (18)
Our findings are important in various aspects. First, the importance of good history will allow identification of typical anginal patients. Clinical evaluation can add to the prognostic information obtained by costly tests. Using this simple riskstratification model will allow primary care providers and emergency department physicians to triage high-risk patients to either a cardiac intensive care unit or a specialized unit or referral to a tertiary care center where facilities for urgent revascularization are available. The use of all the factors in the risk model can allow prediction of MACE in approximately half of the patients presenting with acute coronary syndromes within a half hour of presentation. Additional testing may be necessary to improve the positive predictive value of the model. However, we still would like to stress the importance of starting with elements from the history and physical examination and simple laboratory studies. Objective data such as cardiac enzymes and electrocardiography remain the "gold standard" for ruling out acute coronary ischemia. Our study calls for more extensive validation of these risk factors in primary care settings of emergency departments or chest pain observation units to allow more generalizability of the results.
Table 1. Classification of major adverse cardiac events that occurred during the 30-day follow-up period Events No. % Cardiac death 14 4.9 Acute myocardial infarction 70 18.2 Urgent revascularization 36 9.3 Table 2. Univariate analysis of baseline characteristics regarding 30-day MACE (a) Positive Negative Factor MACE MACE(%) Demographic Male 52.5 43.4 Female 47.5 56.6 Mean age 76 [+ or -] 13.3 63 White race 75.8 61.6 Black race 24.2 38.4 Family history 39.1 15.9 Medical history Myocardial infarction 32.77 15.6 CAD 67.2 41.1 CHF 41.03 26.24 HTN 73.1 64.3 CRI 28.3 25.1 ESRD 11.1 8.75 CRF 38.33 34.6 Creatinine 2 1.92 Hyperlipidemia 25.4 16.8 DM 43.7 30.9 Tobacco abuse 66.1 48.9 Symptoms Typical angina 34.75 3.1 Atypical angina 29.66 19.5 Shortness of breath 77.3 50.76 Diaphoresis 22.1 15.3 Ischemic electrocardiographic changes 70 22.5 Serum cardiac markers TnT 92.5 28.9 CK-MB 73.3 15.97 Factor Wald [X.sup.2] OR (95% CI) Demographic Male 2.76 1.4 (0.9-2.2) Female Mean age 6.42 1.86 (1.3-3.1) White race 7.31 1.95 (1.2-3.2) Black race Family history 22.1 3.4 (2-5.7) Medical history Myocardial infarction 14.05 2.64 (1.6-4.4) CAD 21.64 2.94 (1.9-4.6) CHF 7.56 1.9 (1.2-3) HTN 2.9 1.5 (0.95-2.4) CRI 0.44 1.18 (0.72-1.91) ESRD 0.06 1.08 (0.57-2.04) CRF 0.49 1.17 (0.75-1.83) Creatinine 0.12 0.98 (0.89-1.08) Hyperlipidemia 4.07 1.7 (1.01-2.8) DM 5.8 1.7 (1.1-2.7) Tobacco abuse 9.2 2 (1.3-3.2) Symptoms Typical angina 48.07 16.9 (7.6-37.6) Atypical angina 4.76 1.74 (1.05-2.9) Shortness of breath 22.6 3.3 (2.01-5.4) Diaphoresis 11.9 2.1 (1.7-4.7) Ischemic electrocardiographic changes 70.48 8.02 (4.9-13.1) Serum cardiac markers TnT 84.01 30.3 (14.6-62.9) CK-MB 100.62 14.46 (8.6-24.4) Factor P value Demographic Male 0.09 Female Mean age 0.04 White race 0.006 Black race Family history 0.001 Medical history Myocardial infarction 0.002 CAD 0.001 CHF 0.006 HTN 0.08 CRI 0.5 ESRD 0.8 CRF 0.47 Creatinine 0.7 Hyperlipidemia 0.04 DM 0.01 Tobacco abuse 0.002 Symptoms Typical angina 0.001 Atypical angina 0.02 Shortness of breath 0.001 Diaphoresis 0.002 Ischemic electrocardiographic changes 0.001 Serum cardiac markers TnT 0.001 CK-MB 0.001 (a) OR, odds ratio; CI, confidence interval; MACE, major adverse cardiac events; CAD, coronary artery disease; CHF, congestive heart failure; CK-MB, creatine kinase MB fraction; CRI, chronic renal insufficiency; CRF, chronic renal failure; DM, diabetes mellitus; ESRD, end-stage renal disease; HTN, hypertension; TnT, troponin T. Table 3. Sensitivity, specificity, and positive and negative predictive values of the significant univariate variables (a) Sensitivity Specificity PPV NPV (%) (%) (%) (%) Troponin T 92 71 72 94 Typical angina 34 97 85 74 Ischemic 68 77 61 83 electrocardiographic changes History of CAD 67 59 45 78 Family history of 38 84 54 74 premature CAD Shortness of breath 35 85 54 72 CK-MB 72 84 70 85 White race 76 38 39 75 (a) CAD, coronary artery disease; CK-MB, creatine kinase MB fraction; PPV, positive predictive value; NPV, negative predictive value. Table 4. Multiple logistic regression model for predicting 30-day major adverse cardiac events (a) Factor Coefficient Standard error [X.sup.2] Constant -5.8 0.8 50 Positive CTnT 2.5 0.59 17.7 Typical angina 2.56 0.69 13.6 Electrocardiographic changes 1.23 0.36 11.2 History of CAD 1.16 0.44 6.98 Positive CK-MB 1.05 0.45 5.35 Family history 0.95 0.47 4.05 SOB 0.91 0.48 3.5 Race 0.66 0.4 2.68 Age 0.65 0.41 2.43 Atypical angina 0.64 0.42 2.3 History of MI 0.48 0.46 1.08 Diaphoresis 0.3 0.4 0.84 History of CHF -0.28 0.41 0.47 Hyperlipidemia -0.301 0.46 0.413 CRF 0.1 0.54 0.4 Tobacco abuse -0.235 0.408 0.33 Sex 0.22 0.39 0.3 Hypertension -0.1156 0.42 0.07 Diabetes 0.04 0.39 0.01 Factor OR (95% CI) P value Constant <0.001 Positive CTnT 12.3 (3.8-39.6) <0.001 Typical angina 7.3 (3.3-24.5) 0.001 Electrocardiographic changes 3.4 (1.6-7.02) 0.008 History of CAD 3.2 (1.35-7.5) 0.008 Positive CK-MB 2.8 (1.17-7.04) 0.02 Family history 2.6 (1.02-6.6) 0.04 SOB 2.4 (1.1-6.4) 0.05 Race 1.9 (0.8-4.3) 0.1 Age 1.9 (0.8-4.4) 0.1 Atypical angina 1.9 (0.83-4.3) 0.12 History of MI 1.62 (0.65-4.02) 0.29 Diaphoresis 1.4 (0.6-3.2) 0.35 History of CHF 0.75 (0.33-1.68) 0.489 Hyperlipidemia 0.74 (0.29-1.85) 0.52 CRF 1.2 (0.45-1.9) 0.7 Tobacco abuse 0.79 (0.35-1.75) 0.56 Sex 1.2 (0.57-2.67) 0.579 Hypertension 0.89 (0.38-2.04) 0.78 Diabetes 1.04 (0.47-2.28) 0.9 (a) OR, odds ratio; CI, confidence interval; CAD, coronary artery disease; CHF, congestive heart failure: CK-MB, creatine kinase MB fraction; CRF, chronic renal failure; SOB, shortness of breath; TnT, troponin T; MI, myocardial infarction. Table 5. Forward stepwise regression model for predicting 30-day major adverse cardiac events (a) Factor Coefficient Standard error Constant -5.66 0.67 Serum TnT 2.6566 0.5425 Typical angina 2.2571 0.6340 Ischemic electrocardiographic changes 1.3317 0.3513 History of CAD 1.27 0.3734 Family history 1.05 0.423 SOB 1.05 0.4645 CK-MB 0.89 0.4233 Factor [X.sup.2] OR (95% CI) Constant Serum TnT 23.98 14.24 (4.9-41.26) Typical angina 12.67 9.55 (2.75-33.1) Ischemic electrocardiographic changes 14.36 3.7 (1.9-7.5) History of CAD 11.59 3.56 (1.71-7.41) Family history 6.18 2.86 (1.25-6.57) SOB 5.13 2.86 (1.15-7.11) CK-MB 4.49 2.45 (1.07-5.62) Factor [R.sup.2] P value Constant Serum TnT 0.33 <0.001 Typical angina 0.37 <0.001 Ischemic electrocardiographic changes 0.40 <0.001 History of CAD 0.42 0.01 Family history 0.44 0.01 SOB 0.46 0.02 CK-MB 0.478 <0.001 (a) OR, odds ratio; CI, confidence interval; CAD, coronary artery disease; CK-MB, creatine kinase MB fraction; SOB, shortness of breath; TnT, troponin T.
From the Departments of Internal Medicine, Cardiology, and Clinical Research, Geisinger Medical Center, Danville, PA.
Reprint requests to George M. Tadros, MD, Geisinger Medical Center, 100 N. Academy Avenue, Danville, PA 17822-0139. Email: firstname.lastname@example.com
Accepted September 19, 2002.
Copyright [c] 2003 by The Southern Medical Association
1. White PD. Heart Disease. New York, Macmillan, 1944, ed 3, pp 828-832.
2. Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000;284:835-842.
3. Calvin JE, Klein LW, VandenBerg BJ, et al. Risk stratification in unstable angina: Prospective validation of the Braunwald classification. JAMA 1995;273:136-141.
4. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979;300:1350-1358.
5. Sox HC Jr, Hickam DH, Marton KI, et al. Using the patient's history to estimate the probability of coronary artery disease: A comparison of primary care and referral practices. Am J Med 1990;89:7-14.
6. Pryor DB, Shaw L, McCants CB, et al. Value of the history and physical in identifying patients at increased risk for coronary artery disease. Ann Intern Med 1993;118:81-90.
7. Lee KL, Woodlief LH, Topol EJ, et al. Predictors of 30-day mortality in the era of reperfusion for acute myocardial infarction: Results from an international trial of 41,021 patients--GUSTO-I Investigators. Circulation 1995;91:1659-1668.
8. Califf RM, Pieper KS, Lee KL, et al. Prediction of 1-year survival after thrombolysis for acute myocardial infarction in the global utilization of streptokinase and TPA for occluded coronary arteries trial. Circulation 2000;101:2231-2238.
9. Newby LK, Christenson RH, Ohman EM, et al. Value of serial troponin T measures for early and late risk stratification in patients with acute coronary syndromes: The GUSTO-IIa Investigators. Circulation 1998;98:1853-1859.
10. Roberts R, Fromm RE. Management of acute coronary syndromes based on risk stratification by biochemical markers: An idea whose time has come. Circulation 1998;98:1831-1833.
11. Califf RM, Mark DB, Harrell FE Jr, et al. Importance of clinical measures of ischemia in the prognosis of patients with documented coronary artery disease. J Am Coll Cardiol 1988;11:20-26.
12. Ohman EM, Armstrong PW, Christenson RH, et al. Cardiac troponin T levels for risk stratification in acute myocardial ischemia: GUSTO IIA Investigators. N Engl J Med 1996;335:1333-1341.
13. Lindahl B, Venge P, Wallentin L. Relation between troponin T and the risk of subsequent cardiac events in unstable coronary artery disease: The FRISC study group. Circulation 1996;93:1651-1657.
14. Boersma E, Pieper KS, Steyerberg EW, et al. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation: Results from an international trial of 9461 patients--The PURSUIT Investigators. Circulation 2000;101:2557-2567.
15. Savonitto S, Ardissino D, Granger CB, et al. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA 1999;281:707-713.
16. Hyde TA, French JK, Wong CK, et al. Four-year survival of patients with acute coronary syndromes without ST-segment elevation and prognostic significance of 0.5-mm ST-segment depression. Am J Cardiol 1999;84:379-385.
17. Stark ME, Vacek JL. The initial electrocardiogram during admission for myocardial infarction: Use as a predictor of clinical course and facility utilization. Arch Intern Med 1987;147:843-846.
18. Ishii J, Toriyama T, Nomura M, et al. Circulating concentration of cardiac troponin T is useful for risk stratification in patients with chronic hemodialysis: One-year outcome analysis in 394 hemodialyzed patients. J Am Coll Cardiol 2001;37(Suppl A):313A (Abstract 1050-76).
George M. Tadros, MD, Timothy R. McConnell, PHD, G. Craig Wood, MS, John M. Costello, MD, FACC, and Elias A. Iliadis, MD, FACC
Reader Opinion
|Printer friendly Cite/link Email Feedback
|Title Annotation:
|Original Article
|Iliadis, Elias A.
|Southern Medical Journal
|Nov 1, 2003
|Previous Article:
|Evaluation of lactate and C-reactive protein in the assessment of acute myocardial infarction.
|Next Article:
|Bioimpedance-derived differences in cardiac physiology during exercise stress testing in low-risk chest pain patients.


text:
Advanced Search
Altius Education has launched a developer preview of Helix, an online learning environment designed to personalize higher education.
Blackboard has added both an open enrollment option and mobile support for its CourseSites cloud-based course option.
ShareStream has unveiled a streaming video extension for Blackboard Learn that integrates with the learning management system's (LMS) assignment tool, allowing for the creation and assessment of video assignments.
After an expansive "conversation" among faculty, students, and staff, the University of North Carolina Kenan-Flagler Business School has decided to adopt Instructure Canvas as its next learning management system (LMS).
Tufts University is taking its enterprise content, course, learning, knowledge, and curriculum management system for health sciences, known as Tufts University Sciences Knowledgebase (TUSK), open source.
Can the goals of 21st century learning be met by retooled legacy LMSs, or does the future belong to open learning platforms that utilize the latest technology?
Watchitoo and Pearson eCollege have teamed up to add an integrated collaboration solution, including real-time video chat, to the Pearson LearningStudio SaaS online education platform.
In this Q&A, Blackboard Learn President Ray Henderson and Moodlerooms Chairman and CEO Lou Pugliese explain why Blackboard is getting into the open source business, what's different about delivering services to those customers versus Blackboard's traditional customers, and what might be next on the open source agenda for the No. 1 learning management system company in the world.
Education customers that are still running the Angel learning management system and wondering what they should do when the product is officially retired have received a reprieve.
Blackboard is buying out two major players in the open source services space: Moodlerooms and NetSpot. With the purchases, the company is also launching its own open source division: Blackboard Education Open Source Services.
View More Webcasts
Campus Technology | CT Summer Educational Conference | CT Leadership Symposium | CT Forum ConferenceTHE Journal | FETC | FETC Virtual Event
[ + ] Feedback [ + ]
©2001-2015 1105 Media Inc, Ed-Tech Group. See our Privacy Policy and Terms of Use

subset: commoncrawl


text:
Mountain Biking
German chocolate cake with coconut pecan filling. Chocolate butter cream and a layer of German's chocolate ganache. Finished in fondant with all fondant accents. Bike is fondant, tires have wire spokes.
Tags: mountain bike birthday green brown black cake german chocolate coconut pecan filling
Pamela's Creative Cakes ~ https://www.facebook.com/pages/Pamelas-Creative-Cakes/149142131854798


text:
Rains to continue in E. Visayas due to prevailing cold front
More News from Frances Mangosing
MANILA, Philippines — Eastern Visayas will continue to experience moderate to heavy rains and was alerted against flashfloods and landslides due to a diffused tail-end of a cold front, the state weather bureau said Friday.
"Eastern Visayas will experience cloudy skies with moderate to heavy rainshowers and thunderstorms which may trigger flashfloods and landslides," the Philippine Atmospheric Geophysical and Astronomical Services Administration said.
The rest of Visayas and Mindanao will be cloudy with light to moderate rainshowers and thunderstorms.
Meanwhile, Luzon will continue to experience cold weather with occasional rains due to a prevailing northeast monsoon.
Bicol Region, Cagayan Valley and the provinces of Aurora and Quezon will be cloudy with light rains. Metro Manila and the rest of Luzon will have partly cloudy skies with brief light rains.
Moderate to strong winds blowing from the northeast will prevail throughout the archipelago and the coastal waters will be moderate to rough, Pagasa said.
Get Inquirer updates while on the go, add us on these apps:
Disclaimer: The comments uploaded on this site do not necessarily represent or reflect the views of management and owner of INQUIRER.net. We reserve the right to exclude comments that we deem to be inconsistent with our editorial standards.
To subscribe to the Philippine Daily Inquirer newspaper in the Philippines, call +63 2 896-6000 for Metro Manila and Metro Cebu or email your subscription request here.
Factual errors? Contact the Philippine Daily Inquirer's day desk. Believe this article violates journalistic ethics? Contact the Inquirer's Reader's Advocate. Or write The Readers' Advocate:
c/o Philippine Daily Inquirer Chino Roces Avenue corner Yague and Mascardo Streets, Makati City,Metro Manila, Philippines Or fax nos. +63 2 8974793 to 94


text:
Men's Avenue of Americas Steel & Black Leather Watch
- Color:
- black
Please select an available size.
Please select a size.
Share This Item: Email
- Rectangular stainless steel case with black dia, date window at 3 o'clock, and subdial at 6 o'clock
- Black embossed leather strap with buckle closure
- Swiss automatic movement
- Water resistance tested at 165M
- Case measures 35mm (1.37 inches) wide
- Strap measures 24mm (0.94 inches) wide
- 2 year limited warranty
Material: Stainless steel and leather
Brand: Gevril
Origin: Switzerland


text:
Debra A. Kaelin, the assistant District Attorney who handled the case, spoke briefly at the sentencing, describing to the judge the effect the defendant's actions had on so many people, including Baker. "Officer Baker will remember that day each time he looks into the mirror and sees the 5 inch scar that remains. He, his family and his family of fellow officers are traumatized not only by what happened but by what could have happened," she said.
Murphy praised the witnesses at the scene, the Saratoga Springs Police Department and Four Winds Hospital for their good work and cooperation. ""
Prev Next
More like this story
Use the comment form below to begin a discussion about this content.


text:
Winter!: Prepare for holiday gaming!
Very fun action-rpg allowing you to upgrad and used up to 20 different Marvel Comics heroes and their powers. The plot isn't so great, but the gameplay and customization more than make up for it.
Game Traits applied to Marvel: Ultimate Alliance (PC) by PiccoloJr
Member actions:


text:
Mon-Fri: 7am-1am EST / Sat-Sun: 7am-11pm EST
ApplianceGeneral Electric Microwave
Level of DifficultyReally easy
Time to do repairLess than 15 mins
Age of ApplianceMore than 10 years
Screw drivers
Removed top phillips screw from inner side of door. Removed plastic inner door liner (seal???) which is around the glass by carefully inserting a flexible putty knife and teasing the seal outward. Only lifting the bottom of the seal outward is necessary to reveal the bottom screw which holds the bottom part of handle on the door. Removed bottom screw and removed old handle. Inserted new handle in place and using existing screws, tightened top screw firmly enough to hold in place. Inserted bottom screw and tightened until firmly attached to door. Then tightened top screw a little more until there was no space between handle and door. Be careful not to overtighten screws! Popped inner door liner seal back in place. To help preserve handle from prematurely breaking again, try opening door by grasping the top part of the handle each time you open the door.
Help other customers find the most helpful instructions.
Were these instructions helpful?
Part Number: PS232260
All brand logos are trademarks of their respective owners.
The PartSelect logo is a Registered Trademark of Atlantic Laundry Centres, Ltd.
Copyright © 1999-2015 , Eldis Group Partnership. All rights reserved.


text:
Our Members Say
- Luis_F
- Reviews: 2
Amazing: Sunbreeze Hotel San Pedro
I went to SunBreeze Hotel last year, and I can tell that the service is excellent, the rooms are big enough, the food is just delicious, and it was my first time on Belize and being on that hotel and the quick access to the beach made me want to go back, and I will, sometime this year.
- girdlebug
- Reviews: 9
Tara del Sol: Condo delight
Rented one of the three bedroom condos in Tara del Sol with the family. The location was perfect. It was about 2.5 miles south of town in a very private and quite area but yet close enough to grocery stores and restaurants. The condo was very clean and the managers quite helpful. Good size pool and beach area. Would highly recommend the condos in this complex.
Lovely beach with private pier. Can walk beach into town.
- Denissetag
- Reviews: 2
Corona del Mar: Nice, but needs new bed!
My husband and I just returned from a 7 nights stay at Corona del Mar, we stayed in room 307 (3rd floor). The room was a regular size hotel room, spacious enough to move around freely without bumping into the bed or your luggage, very clean, snow-white linens and towels, nice white rattan furniture, clean and brand new mini-fridge and an electronic safe, ceiling fan, dead quiet AC and cable TV. My only complaint is that the bed was incredibly uncomfortable, a very old mattress, we could feel the coil pushing through. If they get a new bed in there, this room would be perfect! The best thing about this room is the view! We had a big balcony with big French doors. Just open the doors to the balcony and the Caribbean Sea comes right to your bed! We could see the barrier reef lying on bed! Unfortunately, I don't have any photos to show you because I got mugged in Ambergris and the mugger took my brand new digital camera!
The view!
- kyoub
- Reviews: 2221
Coral Bay Villas: Sea view
I would recommend a stay at these lovely condos. They are nothing fancy but they are clean and well kept. You can look out from your patio or balcony and look at the sea. The pier is very nearby so you don't have to walk far to get on a boat to go snorkeling.
Nice size condo with full size appliances in kitchen. Bedrooms have ample closet and dresser space with queen size bed. Friendly and helpful service. The living room couch makes into an extra bed. They will do your laundry for you and do a good job.
- Gypsystravels
- Reviews: 3402
Las Terrazas: OMG - Condo living at its best
We didn't stay here but our new friend Ann Marie works here at this property and on our last day wanted to give us the grand tour. The property is amazingly beautiful and is located right next door to Journey's End Resort (same owners).
Las Terrazas is a luxury condo resort which also rents the apartments.
There are various kinds of apartments from studio to 3 bedrooms with full kitchens, living room, dining room, large bathroom with jacuzzi tubs, large balcony many with extras like hot tubs or large sunning areas.
Amazingly beautiful beachfront property with all the amenities you have back home and would want at a luxury apartment stay.
- Gypsystravels
- Reviews: 3402
Journey's End Resort: Good place to stay for our visit
Miriam and I choose Journey's End Resort for various reason, but mainly for the on-site spa. We were traveling to Belize for a short 5 days and we wanted to make the best of our time without having to leave the resort to enjoy the beach, restaurants or any of the amenities the resort had to offer.
Journey's End Resort is located on the northern end of Ambergris Caye. The distance from San Pedro Town is about 5-10 miles, which made the resort an ideal location for some much needed relaxation. Belize doesn't boast many luxury resorts, especially with beach front property but Journey's End Resort had just enough of what we wanted. The Resort is quite nice with an on site restaurant, bar, convenience store, tour desk, pool, beach and some complimentary water sports.
The Resort has a few types of rooms but we chose to stay at one of the cabanas. The cabana was quite nice with two double beds, ceiling fan, decent size bathroom (with shower that always had plenty of hot water, lol) and a nice front porch with a chair.
The room also had air conditioning which we did not use and a small fridge.
Although Miriam and I were a bit surprised at our Cabana (more further down), we enjoyed the atmosphere that Journey's End Resort afforded us. The staff from the concierge to the front desk, waiters, taxi drivers were all so amazingly kind and friendly and very accommodating.
Regarding the Cabana itself, when we walked in we were a bit surprised that the decor was uninspiring and lacking any type of style. The bathroom was the same and although served its purpose, it lacked anything that would make it stand out, there was a huge concrete wall and tub like area for the shower which made no actual sense.
One thing I must say is that I read that many people complain about the lack of clear/clean space near some of the cabanas. Unfortunately, many of the properties along side the resort are under construction and there can and was some unsightly trash in the area. It does not belong to the resort.
All in all I would say that we enjoyed our stay but it I return to Ambergris Caye again, I would probably stay in a small B&B in San Pedro Town.
- Paul2001
- Reviews: 1806
The Sunbreeze Hotel: Good Resort Hotel within San Pedro
The Sunbreeze Hotel was not my first choice as a place to stay while in San Pedro. The other two hotels I checked out were all booked up and the Sunbreeze was slightly above the rate that I wanted to pay. In hindsight I think that this was definitely the better choice as the other hotels really did not look all that good.
Pleasantly upon returning to Toronto, I received a letler thanking me for my stay at the Sunbreeze Hotel. That is a rare thing.
The Sunbreeze had everything that you would expect from a hotel at this standard. There was a very nice pool, a good bar and the restauant was probaby the best I ate in while in San Pedro. The room was clean but nothing special and the television did not work all that well.
- alanalew
- Reviews: 1
Costa Maya Reef Resort: Nice Timeshare, though a bit remote
We spent a week here in a two-bedroom, second floor bungalow. Very nice. Due to its remote location you will spend a fair amount of time, and extra cash, to take the boat to town and tour sites. Doing the time share talk (much lower pressure than other places I have been) will get you $200 off on a tour package and a free lunch. The sell themselves as a diver's paradise, though a storm canceled my scheduled dive day. Food in the restaurant is good, though a bit pricey. Their beach is very small.
Free: fishing equipment, kayaks, bikes
Mexico Rocks, one of the top snorkeling spots on the Caye, is directly in front of the resort (5 min kayak ride out).
- kennethmaage
- Reviews: 1
Changes in Latitude: Cozy B&B
Average room, private, cool enough with AC and a ceiling fan. Best part was the breakfasts. Nothing fancy, but the fruit was really fresh, and the breakfast was "traditional" made by the local girl who also cleaned the rooms. A very cozy start to the day.
The owner was helpful and very personable (in 2002, has new owners now, I've heard).
Stayed for 12 nights, and got a good discount, much lower than advertized on their website.
- CaptainDan
- Reviews: 24
Captain Morgan's Retreat: cool hotel but far
This is such a cool hotel on the island. We didn't stay here but went to visit during the day. It's a great quality place but the only bad thing is its so dam far from town. You can golf cart to town easily but the roads there are horrible. The other bad thing is go to town at night is a bad because there are no lights along the road. This is a good place if you're looking to get away from everything and just relax.
- CaptainDan
- Reviews: 24
Ramon's Village: good quality & location
Ramon's is a great place to stay. Its located right in the center of everything and is high quality all the way. It's a bit more expensive then most places on the island but well worth it. They have several huts for rent each with all the amenities you could think of. The pool was just remodeled not to long ago. The hotel is located right on the sand and the beach in front is great for relaxing and swiming.
I mainly stayed at Ramon's because they have one of the best dive operations on the island. If you're a scuba diver this is a great place. Though you don't need to stay here to enjoy the scuba shop it does make it very conveinent.
Also note that none of the rooms have TVs in them. At first I thought this would be bad but I rather enjoyed finding other things to do then watch tv. Just bring a little movie player if you want to watch something at night.
- Annie77
- Reviews: 4
Hotel del Rio: Budget friendly
We stayed at Hotel del Rio on all three trips to Belize. Rooms are basic- no TV, no phone but are very comfortable. We've stayed in the Casa Blanca rooms which are basic hotel rooms with bed, bath, small rack for hanging clothes, fridge and AC. We also stayed in the Double Guest House which was much larger with two beds, bathroom, fridge and very breezy balcony. There is a lovely sitting area under a palapa. La Popular Bakery and Dahlia's Market are right behind the hotel. I highly recommend Hotel del Rio!
- marc_berryman
- Reviews: 3
Royal Caribbean Resort: Royal Caribbean Resort treats you like Royality
Royal Caribbean Resort is new, but has worked through the start-up pains described in older reviews of this exceptional resort. Friendly, courteous, and helpful staff, along with individual cabanas, and probably the largest pool on Ambergris Caye, made this an enjoyable location. Every spot in the resort has a great ocean view.
The brightly colored individual cabañas, now with bone chilling air conditioning, were clean, well constructed, and all had a great views of the ocean, The cabanas are spacious, with separate bedroom, bathroom, cable TV, phones (upon request) and a large living area with one corner dedicated to the kitchen sink, microwave, small refrigerator, coffee maker, cooking and serving utensils. There are muli-speed ceiling fans in the living area and in the bedroom.
The staff goes out of the way to ensure you will have an enjoyable time. Bike and cart rentals, along with all other activity needs, are available through the attentive and detail minded staff. The golf carts were new and were loads of fun as we explored the island. We booked several SeaRious adventures through Yoram and his staff, and our expectations were always exceeded.
South of San Pedro, about a mile and a half from the center of San Pedro, the resort is very quite and peaceful. A 15 - 20 minute walk along the beach, or a fairly short bike or cart ride, will place you back in the center of San Pedro. Taxi ride from the airport or the water taxi site to the resort was $5.
Best Pool in Ambergris Caye
Every unit has an ocean view
Fantastic Staff
- Bwana_Brown
- Reviews: 3530
Hotel del Rio: A Simple Room
The room was very basic, with a double bed, one dresser, a ceiling fan and three louvered windows that did not have an air-tight closure. This, combined with a single thin blanket, led to a chilly first night's sleep as a cool and breezy spell of weather had swept in on the day we left Caye Caulker. We periodically awoke to the intermittant sound of distant dogs barking and the rattle of the nearby palm leaves in the wind. The shower was not too bad, but there seemed to be only one water temperature which was, fortunately, lukewarm!
To be fair, this was the low-end of the accommodations at the Hotel del Rio and we did have a chance to move into one of their more upscale Casa Blanca rooms for US$74, but we decided to 'rough it'! In addition, there are other individual nice-looking thatched roof casitas scattered here and there on the well landscaped grounds of the hotel (see second photo).
- Bwana_Brown
- Reviews: 3530
Hotel del Rio: On the Northern 'Outskirts'
Based on the summary in my 'Moons Handbook' on Belize, which said that the Hotel del Rio was "one of the best bargains on the island", I had booked one of their two economy guest-house rooms way back in December, for the second leg of our Belize trip following 'Caye Caulker'. You could tell that we were now on a higher real-estate valued island, because even this basic accommodations was US$51 per night. The photo shows our small second floor balcony with it's only 'window' toward the beach being a narrow gap past a building on the adjoining property, with the second photo showing our actual view from the balcony.
The Hotel del Rio is located almost at the very north end of San Pedro, only one block from the San Pedro River which actually cuts the town off from the remainder of Ambergris Cay. This is at the 'rougher' end of San Pedro, where most of the locals live, but we never had any problems coming or going on our 25-minute backpack walks from and to the Water Taxi terminal located in downtown. The hotel required a one-night nonrefundable credit card deposit when I booked it, and I paid the remainder of our planned 2-night stay on our second day there.
The hotel is very nicely landscaped with palm trees and it fronts onto a section of beach, with a private Hotel del Rio dock. A beach 'street' of sorts runs all along here (Boca del Rio), so the lounging area at the hotel is divided from the actual water's edge by this thoroughfare. We really enjoyed the Belizians who ran the place, and had a great afternoon chatting away one afternoon beneath the shade of their thatched roof common area (see 'Things to Do').
Sort by: Most recent | Most helpful
Sponsored Listings
Instant Answers: Ambergris Cay
Get an instant answer from local experts and frequent travelers


text:
The Princeton Review And USA TODAY Present The Princeton Review's List: "Best Value Colleges For 2014″
– #1 "Best Value Public College" University of North Carolina at Chapel Hill / #1 "Best Value Private College" Williams College
NEW YORK, Jan. 28, 2014 /PRNewswire/ — The Princeton Review today released its annual list of the nation's "Best Value Colleges" and its companion book, The Best Value Colleges: The 150 Best-Buy Schools and What It Takes to Get In (Random House / Princeton Review, 2014 Edition, January 28, $21.99).
The 2014 list names 150 colleges – 75 public and 75 private – the education services company identifies as "Best Values" based on its surveys of 2,000 undergraduate institutions in 2012-13 concerning their academics, cost and financial aid awards.
The company reports the top 10 schools in each group – public and private – in ranked order. The University of North Carolina at Chapel Hill is the #1 "Best Value Public College" for 2014 while Williams College is the #1 "Best Value Private College." (Top 10 lists follow.) The Princeton Review lists the remaining 65 colleges in each group in alphabetical order.
For this project, which The Princeton Review originated in 2004 and has reported in cooperation with USA TODAY since 2009, the company selects schools based on its analysis of more than 30 data points with cost data reflecting school-reported figures for 2013-14. The company also factors in data it collected over the past three academic years from its surveys of students about their satisfaction with their financial aid awards and academic experiences at their schools.
The Princeton Review's "Best Value Colleges" list appears in two free online resources as well as its companion book released today. The company posted its list with profiles of the schools at http://www.princetonreview.com/best-value-colleges.
USA TODAY posted the list in an exclusive interactive database at a dedicated area on its site at http://bestvaluecolleges.usatoday.com. There, users can access information about each college and sort the list in useful ways including by state, tuition, enrollment, and average freshman grant.
The Princeton Review's book – The Best Value Colleges: The 150 Best-Buy Schools and What It Takes to Get In - has detailed profiles of the colleges with advice for gaining admission and financial aid from the schools. The book also includes profiles of nine tuition-free colleges.
The Princeton Review's Top 10 Best Value Public Colleges for 2014 are:
1. The University of North Carolina at Chapel Hill 2. New College of Florida (Sarasota) 3. University of Virginia (Charlottesville) 4. North Carolina State University (Raleigh) 5. University of Michigan - Ann Arbor 6. University of California - Los Angeles 7. University of Florida (Gainesville) 8. The College of William & Mary (Williamsburg, VA) 9. Truman State University (Kirksville, MO) 10. State University of New York at Binghamton
The Princeton Review's Top 10 Best Value Private Colleges for 2014 are:
1. Williams College (Williamstown, MA) 2. Harvard College (Cambridge, MA) 3. Swarthmore College (Swarthmore, PA) 4. Yale University (New Haven, CT) 5. Princeton University (Princeton, NJ) 6. The Cooper Union for the Advancement of Science and Art (New York, NY) 7. Vassar College (Poughkeepsie, NY) 8. Massachusetts Institute of Technology (Cambridge, MA) 9. Amherst College (Amherst, MA) 10. Pomona College (Claremont, CA)
Robert Franek, The Princeton Review's Senior VP/Publisher and lead author, The Best Value Colleges, commented: "We salute these colleges for their outstanding academics and affordability either via comparatively low sticker prices or generous financial aid awards to students with need–or both."
At 65% (97) of the 150 "Best Value" colleges, the average grant to freshmen with need is more than $10,000. Among the top 10 private "Best Value" colleges, the average cost of attendance is about $17,000 after deducting the average grant to students with need. Among the top 10 public "Best Value" colleges, the average cost for in-state students is about $8,400 after deducting the average grant awarded to students with need.
The Best Value Colleges book profiles have information on each school's financial aid offerings, cost, application requirements, average SAT/ACT scores of enrolled freshmen, acceptance rate, graduation rate, and graduates' loan debt. The book is one of 150 Princeton Review titles published by Random House. Others include The Best 378 Colleges, known for its college rankings in 62 categories (http://www.princetonreview.com/college-rankings), and Paying For College Without Going Broke.
The Princeton Review is not affiliated with Princeton University.
About The Princeton Review
Founded in 1981, The Princeton Review (http://www.princetonreview.com) is a privately held education services company headquartered in Framingham, MA. The Company has long been a leader in helping students achieve their education and career goals through its test preparation services, tutoring and admissions resources, online courses, and more than 150 print and digital books published by Random House LLC. The Princeton Review delivers its programs via a network of more than 5,000 teachers and tutors in the U.S.A., Canada, and international franchises. The Company also partners with schools and guidance counselors worldwide to provide students with college readiness, test preparation and career planning services.
About USA TODAY
USA TODAY is a multi-platform news and information media company. Founded in 1982, USA TODAY's mission is to serve as a forum for better understanding and unity to help make the USA truly one nation. Through its unique visual storytelling, USA TODAY delivers high-quality and engaging content across print, digital, social and video platforms. An innovator of news and information, USA TODAY reflects the pulse of the nation and serves as the host of the American conversation — today, tomorrow and for decades to follow. USA TODAY reaches a monthly audience of more than 44 million. USA TODAY is owned by Gannett Co., Inc. (NYSE: GCI).
SOURCE The Princeton Review


text:
One of the healing measures suggested when Ireland's Catholic clerical sex scandals shocked the country last year was a proposal to erect a monument in Dublin to all the youths abused for decades at schools and orphanages run by religious orders that looked the other way. The idea, proposed by the government's Ryan report last May, won so much support that half a million euros were earmarked for the project. The government appointed a group to consider what the Irish Times called "the most difficult public art commission in the history of the state."
Child abuse crisis to spark Irish Catholic Church shake-up
Could Irish abortion case lead to a "European Roe v. Wade"?
Ireland has defended its strict law against abortion at the European Court of Human Rights (ECHR) in Strasbourg in a case that could overturn that ban if the judges agree with three women who said it endangered their health and violated their rights. The women, two Irish and one Lithuanian living in Ireland, had travelled to Britain to have abortions because traditionally Catholic Ireland allows the procedure only when the mother's life is in danger. Read our full story on Wednesday's hearing here.
Pope and Irish Catholic Church to hold summit on child abuse by clergy
(Photo: Irish Justice Minister Dermot Ahern while discussing abuse report with journalists, 26 Nov 2009/Cathal McNaughton)
Ireland's top Roman Catholic leaders will hold talks with Pope Benedict this week to formulate the Vatican's response to an Irish government report on a 30-year cover-up of sexual abuse of children by priests.
A small book on a huge topic — about responding to suicide
There's a knock on the door and it's your ashen-faced neighbour come to tell you her son has just been found hanging in his bedroom. Your brother calls to inform you that his daughter has taken her life. You are shocked and speechless. And then what do you do?
Irish Catholics damage eyes staring at sun for Virgin Mary
Irish Catholic pilgrims have suffered eye damage after staring at the sun in the hope of witnessing an apparition of the Virgin Mary, a doctor said on Wednesday. On one occasion in October, some 10,000 people gathered at the Knock shrine in northwestern Ireland hoping to see Mary, despite pleas from an archbishop to ignore invitations to the event by a self-proclaimed spiritual healer.
In abuse by Irish priests, a little "mental reservation"
It was a ride and I was hitchhiking around Ireland and the driver of a tiny Morris Minor who'd stopped was a priest, so what could be wrong?
Ireland braces for another Catholic clergy sex abuse report
A damning report on sexual abuse of children by Catholic priests in Dublin is due out later this week, only six months after another report on abuse in industrial and reformatory schools across the country accused priests and nuns of flogging, starving and, in some cases, raping children in their care.
Bishops see more selfish Europe 20 years after Berlin Wall fell
Photo; Irish "Yes" campaigners celebrate in Dublin, 3 Oct 2009/Cathal McNaughton)
Europe has become increasingly selfish and materialistic in the 20 years since the fall of the Berlin Wall, the heads of the Roman Catholic bishops' conferences across Europe said at the end of their three-day annual meeting at the weekend. "The crisis sweeping Europe today is serious," they said in a statement after the session in Paris. They cited materialism, individualism and relativism as major challenges facing European society.
Trees, worshippers and Ireland's new blasphemy law
What do Monty Python, the Virgin Mary and environmentalists have in common? They have all been at the centre of a debate in Ireland's parliament this week before the upper house passed a bill imposing a fine of up to 25,000 euros for the crime of blasphemy. For days, Irish media has been excited about a tree stump in the western county of Limerick which has attracted a flow of pilgrims who believe it is an image of the Virgin Mary. As one senator recalled in the debate however, a local Catholic priest has warned his flock not to worship what he said is, after all, "just a tree."
(Photo: Crucifixes with Irish flags in a shop in the pilgrimage town of Knock, 10 June 2009/Cathal McNaughton)
"Fr. Russell might be at risk of being found guilty of blasphemy since he is being critical, grossly abusive or insulting to people of a religion who seem to want to worship a tree," Senator Ivana Bacik said. "We should be mindful of the danger of introducing an offence like blasphemy in light of the sort of events that we are seeing in Rathkeale in Limerick."Senator Dan Boyle, the chairman of the Green Party, the junior member in Ireland's governing coalition, quipped that he apparently led a party of "tree worshippers" and argued that the offence of blasphemy was archaic and should be made obsolete. "The concept of blasphemy was brilliantly satirised by Monty Python in the film 'Life of Brian' where a Pharisee was unintentionally stoned to death for repeatedly, although unwittingly, saying the word 'Jehovah'," Boyle said. "Much of the debate on this issue is a political equivalent of repeatedly saying the word 'Jehovah'. It is something we need to get out of our political system as soon possible."The house passed the bill, but only after an initial hiccup when two senators' absence — one reportedly away at the dentist — all but caused the bill to be defeated by a small margin or at least its main provisions weakened to meaninglessness by an opposition amendment. The government of the traditionally Catholic country has defended the law by pointing out that there was already an existing piece of legislation dating back to 1961 that called for much stricter punishments. Ireland's constitution requires some form of punishment of blasphemy and the new law would decrease the penalty involved.Abolishing the crime of blasphemy altogether would require a constitutional amendment and a referendum. A referendum would not be impossible to organise — for example, Oct. 2 will see the second vote in less than two years on just one issue, the European Union's Lisbon reform treaty, which was rejected by the Irish electorate last year. Some have suggested a referendum on defamation could be held on the same day. But the government has argued a referendum on blasphemy would be too costly and "distracting" for a country busy fixing one of Europe's worst public finances and the worst recession in the industrialised world.
(Photo: Dermot Ahern, 9 March 2007/Thierry Roge)
Justice Minister Dermot Ahern also defends his bill by pointing to clauses which stipulate that blasphemous matter will only be prosecutable if it causes actual outrage among a substantial number of adherents of a religion. It also exempts works in which a "reasonable person" would find genuine literary, artistic, political, scientific, or academic value.Which works qualify for that seems to open up a whole new debate. Atheists, who have separate campaigns running against the requirement for religious oaths before taking the office of judge or president of Ireland, say they will test the new law by quickly publishing a deliberately blasphemous statement. "The law also discriminates against atheist citizens by protecting the fundamental beliefs of religious people only," said Michael Nugent, one of the founders of Atheist Ireland. "Why should religious beliefs be protected by law in ways that scientific or political or other secular beliefs are not?," Nugent asked in an op-ed piece in Friday's Irish Times.(Additional reporting by Ashley Beston)


text:
LV Police Use Technology To Fight Crime
(Las Vegas)–Las Vegas police have a new way to fight crime with the touch of a finger. The Las Vegas Metropolitan Police Department launched a new texting feature on Thursday so people can report suspicious […]
Ridesharing Company Uber Launching In Nevada
Uber is making good on the rumors.
Ford Launches New 2015 Mustang
Ceremonial first 2015 Mustang rolls off the assembly line at Ford.
REWIND: Blake Shelton And Thompson Square Talk New Albums
Blake Shelton is in the news a lot these days, and for good reason. The ACM Entertainer of the Year nominee is back on TV's The Voice for a fourth season, and today he just released his brand-new album, Based On […]


text:
Since 2009, Pocketthermometers.net has been taking the temperature of America one order at a time! Quality products and customer service is our #1 priority. Here are some of the different products you will find here at Pocketthermometers.net. We have digital thermometers and traditional thermometers and a very nice selection of cooking thermometers. If outdoor thermometers are what you're looking for, we have plenty to choose from. Please do not forget the most overlooked thermometer of them all - the medical thermometer. This is a thermometer that you will not use every day but when you need it, you surely will be glad you have it. Also, you will find miscellaneous items such as video borescopes for the building contractor or clocks and timers for home or commercial use. Our mission is to make sure that each and every sale is a pleasant transaction for you, the customer.
Pocket Thermometers - A rapid template development framework


text:
Sterling Publishing Selects Magnify.net to Power Video on New Pixiq.com Photography Site
NEW YORK, Sept. 22 /PRNewswire/ — Magnify.net today announced that is has been chosen to power video publishing for the newly launched digital photography site Pixiq.com. Pixiq is poised to be the "go to" site for DSLR enthusiasts and professionals. Whether it is the long-awaited announcement of a hot new camera, the sale of a major photographic company, coverage from the floor of the industry's biggest trade show, or tips and techniques for getting the most from your equipment, Pixiq will cover the news. Contributors will include respected authorities such as Bob Krist, Jack Reznicki, Steve Sin and Peter Burian, among others, and will be the biggest destination for photography professionals and amateurs alike.
Said Magnify.net CEO Steven Rosenbaum: "We see book publishing being in a time of momentous change. For publishers like Sterling, with a long-standing tradition of high-quality printed books, to extend its brands by building best-of-breed digital offerings is very exciting. We're proud to have been chosen to power video publishing, aggregation, and curation for Pixiq – and see it as a sign of great things to come."
According to Joseph Craven, Sterling's Director of Corporate Development overseeing the Pixiq launch, "Whether or not you're a photo 'gearhead,' there is no doubt that being fluent in the technology underlying digital photography is a huge benefit to your shooting. Here you can see the latest gear reviewed by trusted authorities, search for essential accessories to augment your shooting style, and learn what exactly happens when you press that shutter button. Pixiq experts are some of the most highly respected and technically astute professional digital photographers shooting today."
Pixiq is a product of Sterling Publishing Co. Inc., whose mission is to publish high-quality non-fiction books that educate, entertain, and enrich the lives of their readers.
Said Sterling's Craven of the choice of Magnify.net to power Pixiq's video: "We were looking for a partner who could provide a solid infrastructure for video hosting, storage, delivery, and mobile – and Magnify.net fit the bill. But then, as we knew we wanted pixel perfect pages, and the ability to mix Created, Curated, and Contributed content from multiple sources, Magnify.net stood head and shoulders above the rest. We are excited to be working with the Magnify.net team – and look forward to being able to share video with our visitors in an organic and immersive way."
About Sterling:
For 60 years, Sterling has been one of the world's leading publishers of non-fiction books. We strive to publish high-quality books that educate, entertain, and enrich the lives of our readers. We have the reach of a major publisher with the passion and creativity of an independent press. Sterling Publishing Co. Inc. is a wholly owned subsidiary of Barnes & Noble, Inc.
About Magnify:
Magnify.net platform currently provides video discovery, upload, and encoding to more than 80,000 publishers, ecommerce sites, and communities.
For more information, contact: Filip Szymanski email@example.com 212-787-5273 x 110
This press release was issued through eReleases(R). For more information, visit eReleases Press Release Distribution at http://www.ereleases.com.
SOURCE Magnify.net


text:
Resolution: standard / high
Figure 3.
Construction of confusion matrices for the semi-automated abstract screening strategy. The leftmost matrix represents citations that are labeled by the reviewer while training the classification model. The middle matrix displays the predictions of the trained model over the remaining unlabeled set of citations U. The rightmost matrix shows the corresponding crosstabulation at the end of "Level 1a" (see Figure 1). The quantities mentioned in this figure are used in the definition of Yield and Burden, the chosen evaluation metrics (see Equations 1 and 2). Superscripts T and U refer to model training and applying the model to yet unlabeled citations, respectively. tp[T|U]: "true positives", tn[T|U]: "true negatives", fp[T|U]: "false positives", fn [T|U]: "false negatives". We assume that reviewers will never erroneously exclude a citation that is eligible for systematic review, i.e. fnT = 0.
Wallace et al. BMC Bioinformatics 2010 11:55 doi:10.1186/1471-2105-11-55


text:
Posts: 2892
Registered: 10-06
Posts: 3318
Registered: 10-12
Name at Zandoronum:jo3-ilya . name at Zdaemon:ilya_the_joe_12
YouTube channel My DSDA
Posts: 710
Registered: 09-06
Posts: 1785
Registered: 12-12
mrthejoshmon said:
When the part of the thread I was reading vanishes right before my eyes...
joe-ilya said:
No wonder, you're using firefox. IE... heh I mean GC is better.
Posts: 2011
Registered: 08-13
Posts: 2476
Registered: 07-11
plums said:
So I was playing theJF's E4 maps today and almost killed myself by shooting a rocket point-blank into a spectre. Not a death but close enough, still felt pretty shameful.
Posts: 2810
Registered: 07-03
Posts: 1755
Registered: 11-09
Posts: 1590
Registered: 06-08
Da Werecat said:
Well, at least you picked up an armor bonus!
Posts: 4332
Registered: 03-10
Posts: 898
Registered: 07-13
Last edited by Piper Maru on 03-13-14 at 21:06
Posts: 870
Registered: 11-04
C30N9 said:
Punching a barrel with a berserk.
Posts: 560
Registered: 12-13
Posts: 657
Registered: 02-10
Posts: 1255
Registered: 03-14
Posts: 312
Registered: 12-08
Professor Sir said:
As mentioned above, what is your darkest moment of Doom? It doesn't necessarily have to be a death, but it could be.
Probably my most shameful moment is when I was playing multi-player on Dues Vult II. We were blazing through Crow's Nest, when I got side-tracked by something non-computerific. I had survived all those projectiles, only to be killed by ONE FRICKIN IMP. It still haunts me to this day.
Posts: 61
Registered: 12-04
Posts: 1555
Registered: 09-07
Posts: 74
Registered: 08-13
Posts: 5
Registered: 04-14
Posts: 1096
Registered: 10-13
< Contact Us - Doomworld
Powered by: vBulletin Version 2.2.5
Copyright ©2000, 2001, Jelsoft Enterprises Limited.


text:
Call Us: Mon-Fri 8.30-5pm
01284 765522
Not in stockThis product may be on order and is subject to possible delivery delays.
Price incls.VAT & Free delivery
Approx. dimensions: H:12" x W:12" (31cm x 30cm)
Cold cast bronze dog sculpture.
Made in the UK
Candle and Blue Blog Google+ Natalie Rice on Google+
T: 01284 765522 | E: email@example.com | Mon-Fri 8.30 - 5.00pm ©2014 Candle and Blue.All rights reserved.VAT No: GB 868 5858 49


text:
IPVideo Corporation Sentry VMS Now Integrates with Access Control and C3 Fusion PSIM
BAY SHORE, N.Y., June 16, 2011 /PRNewswire-USNewswire/ – IPVideo Corporation, a leading provider of video management and physical security information management (PSIM) solutions, today announced that its Sentry VMS now offers integration with access control systems and its physical security management solution C3 Fusion PSIM for organizations who want to integrate with additional sensor subsystems.
The new access control integration improves response times and efficiency by allowing security administrators to seamlessly retrieve access control data along with video – eliminating the need to toggle from system to systems when alarms are signaled.
"As a long-term user of IPVideo's Sentry VMS we are pleased to learn of the new integration capabilities. We can see the value they can provide in enhancing security operations," said Seve Padilla, Director of Facility and Security Services, Falls Church City Public Schools in Virginia. "Access control is a key component of an organization's safety procedures."
Sentry VMS integrates with access control systems from leading vendors including ISONAS Security Systems Inc., S2 Security, Lenel, RS2 Technologies, DSX Access Systems Inc. and Imron Corporation.
The Sentry VMS video management solution provides organizations with a complete solution including software, hardware and storage. Its purpose-built hardware platform is custom designed to withstand with rigors of 24/7 IP security applications. Increased redundancy, performance and simplicity are provided by RAID 1 storage. Sentry VMS supports all megapixel and HTDV video resolutions. The solution offers system health monitors that send alerts if a system is disturbed by power outages, cameras offline, temperatures out of range, etc.
"Our VMS systems have been deployed in over 1,000 installations," said Steve Sleicher, COO of IPVideo Corp. "Our new integration capabilities with access control systems and our C3 Fusion PSIM solution demonstrate how we continue to enhance our solutions to meet customers evolving needs."
Sentry VMS Solution Suite
The Sentry VMS solution has three variations depending on installation configuration:
- Sentry PRO is designed for SMB installations and supports up to 32 cameras and up to 3TB of storage.
- Sentry EDGE is for installation with up to 64 cameras and 6TB of storage.
- Sentry Enterprise is a fully scalable system designed to manage an unlimited number of cameras.
About IPVideo Corporation
IPVideo Corporation provides Physical Security Information Management (PSIM) solutions and Video Management Systems (VMS) that empower organizations to proactively mitigate security risks while maximizing return on investment. A pioneer in network physical security technology, the company has been deploying proven IP-based security solutions for over fifteen years. The company's latest C3 Fusion PSIM product suite enables clients to identify, prioritize and resolve security events, thereby improving safety, increasing security and managing compliance with internal and external regulations. IPVideo Corporation's worldwide client base represents a diverse cross-section of Fortune 500 companies and other market leaders including Con Edison, Fordham University, Georgia Ports Authority, Georgia-Pacific, George Washington University, Gold Medal Bakery, Lockheed Martin, Nestle, Panama Ports Company, Poland Spring and the U.S. Embassy in Honduras. The company is headquartered in Bay Shore, NY with research and development offices in Punta Gorda, FL. For more information visit http://www.ipvideocorp.com.
C3 Fusion and USCP are trademarks of IPVideo Corporation. All other company names and products are trademarks or registered trademarks of their respective companies. The company reserves the right to introduce modifications without notice.
SOURCE IPVideo Corporation


text:
Foundry and Fleet Marks - 2 simple questions for a DEV
So when will the Foundry be online again?
How are we supposed to keep out fleets running (the small ones) without fleet marks?
(there is a nice proposal to give the Officer on the Watch a little sense - let the reward be 50 Fleet Marks)
Defera invasion gives fleet marks, Nukara invasion gives fleet marks, the new save the ship STF gives fleet marks, all of those a 5 mans. Defera and Nukara, take about 15 to do the whole set if you just do just the hards and are worth 20 per quest, Defera has 4 quests and Nukara has 2 thats 120 fleet marks or 240 during the fleet mark hour, you could round out the hour with a saving ships and no win senario they both give fleet marks, or team up with another guild(s) and do one of the 15s. I'm active in two good sized guilds and we almost always fill out 20 mans with a couple folks from another fleet. Take a look around there are plenty of Fleet Marks available.
I think the point the OP is trying to make is that the rewards given aren't enough for small fleets to grow. With the Daily clickie you get 60 per day per toon which was enough to grow your fleet at a slow but steady pace. With those fleet marks gone, fleet and embassies for small fleets will grind to a halt.
we are a 2 man fleet. before i could do my clickie daily on 6 toons, fill the fleet marks, and PLAY. now i am supposed to grind fleet marks for how long? i tried nukara and defera, alone, and got o 28 fleetmarks in 40 minutes..
The queues for fleet actions which reward fleet marks are RARE and have no other rewards.
So now i am in the position where i either
1 - grind fleet marks and buy dillithium (NO)
2 - grind dillithium and EC's and abandon my fleet ( i am good at this, almost everything now did sink in the starbase)
i would not mind the changes if i knew that in the moment i started to work on the fleet starbase, but now, things have changed BIG TIME and without announcement.
Considering they are "glad to have small fleets ingame"..
prior to these changes almost everything of my grinded Dill went to the starbase. Now? I do not have a slot to fill, cause of the fleet marks.
They should be thankful for small fleets, cause it means only more Dill sink in the playerbase.
|All times are GMT -7. The time now is 07:56 AM.


text:
Loading stream...
Now Playing
Podcasts & RSS Feeds
|All Content
|View all podcasts & RSS feeds
Connect with Us
Behind the Mics
Host of Wind & Rhythm
Public Radio 89.5-1 Reporter & All Things Considered anchor
Classical 88.7-1 host
Host of Swing on This
Classical 88.7-1 host
Local & Regional
6:45 am
Thu June 21, 2012
Thursday's First News from KWGS!
By John Durkee
Topping Our Local News:
· A huge grant will be officially announced later this morning for the Tulsa School of Community Medicine. It is a joint venture of TU and OU.
· City leaders vote tonight on Tulsa's new 700-million dollar-plus budget.
· Renovation work is ahead for Tulsa's Port of Catoosa.


text:
In Jan of this year we came out with tools to help migration IMAP mail to Exchange 2007. The tool can be found here: http://www.microsoft.com/downloads/details.aspx?FamilyId=35FC4205-792B-4306-8E4B-0DE9CCE72172&displaylang=en
Some tips for the tool. The first thing is to ensure you have permission for the mailboxes on the IMAP side. The Active Directory user used to perform the migration must have permission to impersonate the users to inject mail into their mailboxes. This permission can be set using an Exchange Management Shell command of the form:
Add-ADPermission –Identity 'DN_of_ClientAccessServer' ‑User 'domain\username' ‑ExtendedRights ms‑Exch‑EPI‑Impersonation
What the different parameters in the tool mean:
SourceIdentity: <This is the SMTP address of the person that is moving, and is used by the GUI to identify the row that is being processed and to find the target mailbox if you have not indicated another one in the CSV. >
SourceLoginID: < This is the login ID that is used to access the mailbox on the source system. >
SourcePassword: < This is used if a unique password is needed for each SourceLoginID >
SourceAdminCredential: <Note this cannot be passed through the CSV: This is used to open a mailbox based on the option 1 below >
How the different parameters are used for Admin Logins to an IMAP Server through the transporter:
Since different IMAP servers support administrative access to a user's mailbox in different ways, it is important to understand how you support admin access to the user's mailbox on the IMAP side. Here are the different options that we have found supported that work through the transporter.
1. Combined Admin/UserID Login Option
This is the default option in the tool and is based on how Exchange 2003 initially supported Admin login. Transporter will construct the login name for the source server based on SourceLoginId and the SourceAdminCredential as 'AdminUsername/SourceLoginID'
For servers that support this login name format the user mailbox will be opened and can be migrated.
To configure this, the transporter needs just the following minimal set of data in the CSV
Your CSV will then be
And in the migration wizard, you can specify the Admin credentials.
2. Manually Combined Admin+UserID Login Option
We have found that other servers support a similar login with both the UserID+AdminName, however using a different format. In a IMAP sever, this login name combination worked 'SourceUser*AdminUsername'. Since this is different the default way that the transporter combines the login IDs, this whole format needed to be included in the CSV for the source LoginID. In addition the admin password then had to also be provided in the CSV.
For servers where a combined Admin+UserID login was needed that was different than Exchange 2003 format the following worked.
Minimal CSV parameters
SourceIdentity,SourceServer,SourceLoginID, SourcePassword
firstname.lastname@example.com,CS050,SourceUser01*AdminuserName, AdminPassword
firstname.lastname@example.com,CS050,SourceUser02*AdminuserName, AdminPassword
>> Note again that the SourceLoginID that the userID and AdminID was combined based on how the source IMAP server supports admin login.
When you run the migration wizard select "Use individual account credentials" since the admin ID/Password is already in the CSV
3. SourceRootFolder Option
Finally some IMAP systems allow administrative access by logging in as administrator and accessing mailboxes using the mailbox relative to the root folder.
To use this feature of transporter you can specify in your csv the AdminUserID in the SourceLoginId plus you then need to indicate what the SourceRootFolder is that you need to migrate. Note that NO passoword is required in this, since you can enter the password during the wizard. The SourceRootFolder should be the path to the mailbox you need to access and will be unique based on your server.
For servers using the SourceRootFolder Option
For ex
firstname.lastname@example.com,CS050,AdminUserName, ~/mail/SourceUser01
firstname.lastname@example.com,CS050, AdminUserName , ~/mail/SourceUser02
And in the migration wizard, you can specify the Admin credentials. Again, please do ensure your administrator has proper access rights to the other user's mailbox.
How can I determine the root folder path of my IMAP server? Thanks.
Any ideas on if this will work with Exchange 2003?
just wanted to shout out some thanks, I may be blind but your blog had the only reference I could find anywhere to the 3 different authentication types
big thanks!
If you want to avoid all these complex configurations, you should try: http://bit.ly/eskrY5
It solved my Exchange migration in a matter of minutes!


text:
This is one of the best courses you can take if you want to learn to play piano by ear step by step. The creator of the course is Jermaine Griggs who teaches you how to play chords and understand how they work together. The course is easy to understand for beginners, well organized, you can easily recall the new information, and most of all it is really a joy to learn.
Hear and Play has a new audio series that you can listen to while you are in your car, with your ipod, or in your stereo by your piano. There are no books, sheet music--- you learn how to play by ear and understand what you are playing. He covers intervals, chord inversions, how to sound good with the chords you use and how to put them together, and much more in Hear and Play 101 and 102. You are taught what chords pull strongly to other chords, which is the secret to successfully learning pieces by ear rapidly.
We recommend this course for adults and older adults who have always dreamed of playing piano by ear. You can learn at your own pace, and upgrade to a more advanced course if you want. Remember the course is on audio where you can listen and learn to play.
We were also impressed by the 90 day guarantee for this course, which gives you plenty of time to explore the course. The other thing is you get the course in physical form, in the form of audio CDs, and right now there is a special on two courses. The 90 day guarantee is the longest guarantee we have seen so far. Highly recommended for people who want to learn to play piano by ear.
No payment or discount were promised, offered, or made to reviewer(s) or website writer(s) from the product owners of products reviewed or mentioned on this website. Also, no free gift, monies, or trips were made or promised to reviewer(s) or website writer for each product reviewed or mentioned. As a result, no money, free gifts or trips were received or exchanged by reviewer(s) or website writer(s). No discounts, free gifts or free trips were accepted or exchanged by this website owner regarding products mentioned in this website. Website owner receives a commission for each product sold to each visitor.


text:
Search the collections
Where is it from?
- A Place & Date Depicted Port Melbourne, Australia
Similar items over time
Negative - Port Melbourne, Victoria, circa 1920 Reg. No: MM 001880
- Description Of Content:
- Four men outside the shop of V. Clifford, hairdresser and tobacconist. A sign advertises 'Happy Thoughts Tobacco'. There is wrought iron lacework above the verandah of the shop.
- Acquisition Information:
- Copied from J Sherritt, 1985
- Acknowledgement:
- The Biggest Family Album of Australia, Museum Victoria
More information
|Tagged with:
|advertising, barbers, shops, signage, tobacco, verandahs, workers
|Themes this item is part of:
|Images & Image Making Collection, Sustainable Futures Collection, The Biggest Family Album in Australia Collection
|Primary Classification:
|Secondary Classification:
|Tertiary Classification:
|shop fronts
|People Depicted:
|Field, Thomas
|Organisations Depicted:
|Clifford, Hairdresser & Tobacconist
|Negative: Black & White; 35 mm
|Place & Date Depicted:
|Port Melbourne, Victoria, Australia, circa 1920
This item is part of the following themes:
Similar items
Previous Page
| More