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JOHNSON, Senior District Judge.
Plaintiffs Arthur DaPonte ("A. DaPonte") and Marcia DaPonte ("M. DaPonte") (collectively, "Plaintiffs") brought the current action against Defendants Manfredi Motors, Inc., Manfredi Management Corp., Staten Island Motors, Inc., Manfredi Auto Central, LLC, Nicholas "Nick" Manfredi, and Corrado "Joe" Manfredi (collectively, "Defendants"). Currently before this Court are Defendants' motion for summary judgment and Defendants' motion to strike portions of Dr. Mark Dennis DeLacure's affidavit. This Court listened to oral argument on October 17, 2003. For the reasons set forth herein, Defendants' motion for summary judgment is GRANTED IN PART and DENIED IN PART. Because this Court no longer has jurisdiction over the remaining state law claims, the motion to strike is moot.
On October 5, 2001, Plaintiffs brought this action against Defendants. Arthur DaPonte, a former employee of Defendants, alleged violations of the Americans with Disabilities Act ("ADA"), 42 U.S.C. § 12101 et seq.; New York State Human Rights Law ("NYSHRL"), N.Y. McKinney's Exec. Law § 296 et seq.; and New York City Human Rights Law ("NYCHRL"), New York City Admin. Code § 8-107 et seq., as well as common law claims for negligent and fraudulent misrepresentation. Marcia DaPonte, Arthur DaPonte's wife, brought a common law claim for loss of consortium. On December 2, 2002, Arthur DaPonte died of laryngeal cancer. Marcia DaPonte continues to litigate this action on behalf of herself and her deceased husband. For the sake of simplicity, the Court will refer to Arthur DaPonte and Marcia DaPonte individually as "A. DaPonte" and "M. DaPonte," and collectively as "Plaintiffs." The following is a brief history of the facts underlying this case.
A. DaPonte was hired as a car salesperson by Defendant Staten Island Motors on two separate occasions. He was initially hired in 1997, fired in 1998, and then re-hired in July 1999. Plaintiffs allege that before A. DaPonte was re-hired, Ira Romano, Staten Island Motors' Sales Manager, promised him health insurance within 90 days after commencing employment. (Compl. ¶¶ 53, 55-56; A. DaPonte Dep. at 94.) Plaintiffs claim that on the basis of that oral promise, A. DaPonte accepted the offer of employment. (Compl. ¶ 53.) Between November 1999 and April 2000, A. DaPonte repeatedly requested medical benefits, but was first issued medical coverage on April 1, 2000. (Compl. ¶¶ 57-58,
In December 1999, A. DaPonte began spitting up phlegm, his voice became raspy, and he frequently needed to clear his throat. (Id. at 120-21; Pls.' Mem. of Law in Opp'n to Summ. J. ("Pls.' Opp'n") at 3.) In early April 2000, shortly after he was issued medical coverage, A. DaPonte was diagnosed with throat cancer, for which he underwent surgery on April 28, 2000. Although Plaintiffs claim that A. DaPonte's employment was terminated in May or June 2000, the record clearly demonstrates that his job remained intact for more than one year after April 28, 2000, the date on which he went out on medical leave. (Ferrante Dep. at 48-49; Defs.' Ex. 11.)
A moving party is entitled to summary judgment if "the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law." Fed.R.Civ.P. 56(c); see also Celotex Corp. v. Catrett, 477 U.S. 317, 322-23, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). The burden is on the movant to establish the absence of any genuine issue of material fact. Celotex Corp., 477 U.S. at 323, 106 S.Ct. 2548; see also Goenaga v. March of Dimes Birth Defects Found., 51 F.3d 14, 18 (2d Cir.1995).
Once the movant has made a properly supported motion for summary judgment, the burden shifts to the nonmoving party to present "significantly probative" supporting evidence showing that there is a material factual issue for trial. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 249, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986). The Court must view the underlying facts in the light most favorable to the plaintiff, resolving all ambiguities and drawing all inferences in his favor. See Kerzer v. Kingly Mfg., 156 F.3d 396, 400 (2d Cir.1998). Summary judgment should be granted "against a party who fails to make a showing sufficient to establish the existence of an element essential to that party's case, and on which that party will bear the burden of proof at trial." Celotex Corp., 477 U.S. at 322, 106 S.Ct. 2548; see also Sim v. New York Mailers' Union No. 6, 166 F.3d 465, 469 (2d Cir.1999).
A. DaPonte alleges that: (1) at the time A. DaPonte was denied medical insurance by Defendants, he was suffering from symptoms of throat cancer, and that this constituted a disability under 42 U.S.C. § 12102(2)(A); (2) alternatively, A. DaPonte was disabled under 42 U.S.C. § 12102(2)(C) because Defendants perceived him as suffering from an impairment affecting his larynx; (3) Defendants' decision to withhold medical benefits was related to A. DaPonte's disability and/or perceived disability; and (4) in denying A. DaPonte medical benefits, Defendants denied A. DaPonte a reasonable accommodation for his disability. (Compl. ¶¶ 76-93.) Defendants counter that: (1) A. DaPonte was not disabled within the meaning of the
To make out a prima facie case of disability discrimination under the ADA, a plaintiff must establish that: "(1) his employer is subject to the ADA; (2) he was disabled within the meaning of the ADA; (3) he was otherwise qualified to perform the essential functions of his job, with or without reasonable accommodation; and (4) he suffered adverse employment action because of his disability." Giordano v. City of New York, 274 F.3d 740, 747 (2d Cir.2001). In the case at bar, Defendants do not dispute that they are subject to the ADA.
The ADA defines a disability as (A) a physical or mental impairment that substantially limits one or more of the major life activities of such individual; (B) a record of such an impairment; or (C) being regarded as having such an impairment. 42 U.S.C. § 12102(2). To prove that he is disabled under § 12102(2)(A), a plaintiff must prove that (1) he suffers from an impairment (2) which affects a major life activity, and (3) which "substantially limits" the major life activity. Bragdon v. Abbott, 524 U.S. 624, 631, 118 S.Ct. 2196, 141 L.Ed.2d 540 (1998).
Here, even if Plaintiffs could prove that A. DaPonte suffered from an impairment of his larynx which affected the major life activity of speaking, Plaintiffs could not prove that his ability to speak was "substantially limited." There is no dispute that, over the course of his employment, A. DaPonte experienced a change in the quality and tone of his voice, increased frequency in coughing, hoarseness, and throat clearing, and weight loss. However, the record is devoid of any evidence showing that prior to his operation on April 28, 2000, A. DaPonte's capacity to speak was substantially limited or that he could not communicate with others. As A. DaPonte testified in his deposition, he continued to work in his normal capacity as a car salesman until April 27, 2000 — the day before his operation. (A. DaPonte Dep. at 151.) He continued to smoke and even increased his smoking as his anxiety about his health increased. (Id.) In fact, as of April 3, 2000, he believed he was in good health. (Id. at 147.) Upon considering the evidence in the record, this Court finds that A. DaPonte's speech-related impairment did not substantially limit his major life activity of speaking. See Hooper v. St. Rose Parish, 205 F.Supp.2d 926, 929 (N.D.Ill.2002); Ross v. GTE Directories Corp., 73 F.Supp.2d 1342, 1346-47 (M.D.Fla.1999).
Alternatively, Plaintiffs argue that A. DaPonte was disabled under 42 U.S.C. § 12102(2)(C) because Defendants perceived him as suffering from an impairment affecting his larynx. A. DaPonte would fall within this subsection if Defendants made an employment decision based on a "physical or mental impairment, real or imagined, that is regarded as substantially limiting a major life activity." Sutton v. United Air Lines, 527 U.S. 471, 490, 119 S.Ct. 2139, 144 L.Ed.2d 450 (1999). Plaintiffs' arguments demonstrate, at best, that Defendants perceived a difference in A. DaPonte's voice as compared with that of the general population. See Hooper,
Because Plaintiffs have failed to show that A. DaPonte was disabled for ADA purposes, they have failed to make out a prima facie case of disability discrimination under the ADA. "The legal standards for discrimination claims under the ADA and under New York state and city law are essentially the same, except to the extent that the New York statutes support a broader definition of `disability,' a distinction not relevant here." Woolley v. Broadview Networks, Inc., No. 01 CV 2526, 2003 WL 554754, at
Defendants also move for summary judgment on the ground that Plaintiffs' state law claims are preempted by the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001 et seq. A claim styled as a state common law cause of action is preempted under ERISA "if it `relates to' an employee benefit plan within the meaning of section 514(a), 29 U.S.C. § 1144(a), and falls within the scope of the statute's civil enforcement provisions, found in section 502(a), 29 U.S.C. § 1132(a)." Smith v. Dunham-Bush, Inc., 959 F.2d 6, 8 (2d Cir.1992) (citation omitted). Defendants argue that "Plaintiff's fraudulent inducement misrepresentation and/or negligence claims, and any claim for emotional distress or for damages under state law, are preempted under ERISA § 514(a)." (Defs.' Mot. at 24.) Plaintiffs contend that because they do not seek benefits under any plan, but rather damages from A. DaPonte's employer for personal injuries sustained as a result of the absence of promised health coverage, their claims do not "relate to" Defendants' health benefits plan under § 514(a). (Pls.' Opp'n at 7-8.)
Before considering the question of whether Plaintiffs' state law claims are preempted by ERISA, this Court must first decide whether it has jurisdiction to consider these claims. "While the statute governing supplemental jurisdiction, 28 U.S.C. § 1367, does not require dismissal of pendent state-law claims where all of the federal claims have been dismissed, see id. § 1367(c)(3), `if it appears that the state law issues substantially predominate, whether in terms of proof, of the scope of the issues raised, or of the comprehensiveness of the remedy sought, the state law claims may be dismissed without prejudice and left for resolution to state tribunals.'" Giordano v. City of New York, 274 F.3d 740 (2d Cir.2001) (citing United Mine Workers v. Gibbs, 383 U.S. 715, 726-27, 86 S.Ct. 1130, 16 L.Ed.2d 218 (1966)). The Supreme Court has cautioned, however, that "[t]here may ... be situations in which the state claim is so closely tied to questions of federal policy that the argument for exercise of pendent jurisdiction is
For these reasons, this Court chooses to exercise limited supplemental jurisdiction over Plaintiffs' state law claims. The Court will decide whether these claims are preempted by ERISA. If the Court deems the state law claims to be preempted by ERISA, Plaintiffs will be given leave to amend their complaint to add ERISA claims. If the Court concludes that the state law claims are not preempted, it will dismiss them without prejudice and leave them for resolution in the state tribunal. See id. at 726-27, 86 S.Ct. 1130.
"The Supreme Court has consistently afforded a broad, though not absolute, reading" to ERISA's preemption provision, § 514(a). Smith, 959 F.2d at 9. Under this reading, a state law "relates to" a benefit plan if it "has a connection with or reference to such a plan," whatever the state law's underlying intent. Ingersoll-Rand Co. v. McClendon, 498 U.S. 133, 139, 111 S.Ct. 478, 112 L.Ed.2d 474 (1990) (citing Shaw v. Delta Air Lines, Inc., 463 U.S. 85, 96-97, 103 S.Ct. 2890, 77 L.Ed.2d 490 (1983)); see also Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 47, 107 S.Ct. 1549, 95 L.Ed.2d 39 (1987). However, "the word `related' must not be taken literally." Cerasoli v. Xomed, Inc., 952 F.Supp. 152, 156 (W.D.N.Y.1997) (citation omitted). "State law claims whose effect on employee benefit plans is merely tenuous, remote or peripheral are not preempted." Id. (citation omitted); Shaw, 463 U.S. at 100, 103 S.Ct. 2890.
The issue of whether a claim alleging benefit-related fraud or misrepresentations is preempted by ERISA is far from clear-cut. See Id. at 157. While most courts in the Second Circuit have held that such claims "relate to" a benefit plan and are therefore preempted, see, e.g., Smith, 959 F.2d at 10; De Pace v. Matsushita Elec. Corp. of America, 257 F.Supp.2d 543, 567-573 (E.D.N.Y.2003); Ullrich v. Linotype-Hell Co., 187 F.Supp.2d 68, 72-73 (E.D.N.Y.2002); Cerasoli, 952 F.Supp. at 157-161; Hamburger v. Southern New England Telephone Co., 97 CV 2392, 1998 WL 241214 at
The first question this Court must ask is whether the alleged misrepresentations relate directly to A. DaPonte's benefits under Defendants' medical benefits plan. Cerasoli, 952 F.Supp. at 157; Sandler, 721 F.Supp. at 514. Plaintiffs here do not claim that Defendants failed to pay benefits to which A. DaPonte was entitled pursuant to a plan. Rather, Plaintiffs have sued Defendants for personal injury damages alleged to have arisen from A. DaPonte's reliance on misrepresentations Defendants made concerning medical benefits before he commenced reemployment.
Plaintiffs' claims closely resemble those of the plaintiffs in McNamee v. Bethlehem Steel Corp., 692 F.Supp. 1477, and Sandler v. New York News Inc., 721 F.Supp. at 514-15. In McNamee, the plaintiff worked for Bethlehem Steel Corporation ("Bethlehem") from 1951 to 1965 (the defendant claimed 1963), when he was laid off. In 1978, he was offered reemployment with the defendant. McNamee claimed that as a condition of reemployment, Bethlehem agreed to "make such arrangements as were necessary to have his `break in service bridged' from 1965 to 1978 and to provide plaintiff with sufficient employment time in order to qualify for a fully vested pension."
In Sandler, the pension manager of the New York News ("the News") incorrectly advised the plaintiff, a News employee, that he would receive $1,049 per month in retirement benefits if he accepted early retirement in connection with an employment buyout offer. 721 F.Supp. at 509. In fact, under the terms of the plan, the monthly pension amount owed to him was $774.49. Id. Sandler accepted the buyout offer, resulting in his voluntary termination. Id. at 508-09. The pension manager's misrepresentation to Sandler, upon which Sandler relied in deciding to accept the buyout and to retire early, resulted in significant negative economic consequences for Sandler and his family. Id. at 509-10. Sandler sued the News for, inter alia, negligent misrepresentation, claiming he would not have relinquished his job and accepted the News' buyout offer had he been provided with accurate information about the financial consequences of accepting that offer. Id. at 513-14. The Court found that Sandler brought suit "not as a participant, seeking recovery of benefits from the [pension] Plan, but as an employee seeking economic damages from his employer
Plaintiffs' claims are distinguishable from the claims set forth in Smith, 959 F.2d 6, a case on which Defendants rely. In that case, the plaintiff, an employee of Dunham-Bush in the United Kingdom for 33 years, was asked to transfer to the company's Connecticut affiliate. When Smith expressed concerns about the inferiority of the Connecticut affiliate's pension plan, Dunham-Bush's president assured him that the company would provide him with a benefits package comparable to what he would have received upon retirement in the United Kingdom. Id. at 7. On the basis of that oral representation, Smith agreed to relocate to Connecticut. Id. When Dunham-Bush failed to follow through on its representation, Smith brought suit to enforce the promise. The Second Circuit found that Smith was seeking to supplement the pension plan's express provisions and secure an additional benefit, and that his cause of action therefore related "not merely to his benefits, but to the essence of the plan itself." Id. at 10. Accordingly, the court held that Smith's state law claims "related to" a plan within the meaning of § 514(a) and were preempted by ERISA. Id.; see also Diduck v. Kaszycki & Sons Contractors, Inc., 974 F.2d 270 (2d Cir.1992) (citations omitted) (finding that the plaintiffs' common law fraud claim was preempted on the ground that the claim had "as a critical factor in establishing liability the existence of a plan and duties similar to those imposed by ERISA.").
In the case at bar, the gravamen of Plaintiffs' claim is that A. DaPonte would not have agreed to reemployment with Defendants had they disclosed to him that he would not be eligible for health benefits within 90 days of commencing reemployment. This case resembles McNamee and Sandler, in that the plaintiffs in all three cases were receiving no plan benefits, and made major employment decisions — to commence or terminate employment — based on their employers' false promises of future benefits. In contrast, the plaintiff in Smith made a less monumental employment decision — to transfer to an affiliate office — and in so doing, attempted to supplement the benefits he already was receiving. Although this is a subtle distinction, the Court finds that Plaintiffs have claimed misrepresentations with respect to a collateral employment agreement, rather than with respect to Defendants' benefits plan. See McNamee, 692 F.Supp. at 1479.
A second and related question for this Court to consider is the nature of the harm flowing from A. DaPonte's reliance on
Finally, the Court must inquire as to whether allowing Plaintiffs to pursue their detrimental reliance claims "would pose some genuine threat of interference with the administration of primary plan functions." Sandler, 721 F.Supp. at 515. As in Sandler, the parties in this case have not identified such a threat, and any interference that might arise would be of "a procedural sort" — i.e. in the future, Defendants might represent more accurately the benefits options available to potential employees. Id. at n. 9. Allowing Plaintiffs to pursue their claims against Defendants would have "no substantive effect upon a plan participant's eligibility for a benefit and the amount of that benefit." Id. (citation omitted). Thus, "there is reason to believe that claims such as this one, which arise under hopefully unique circumstances only remotely related to central plan functions, will have no more than a minimal, indirect impact on the administration of benefit plans." Id. (citation omitted).
Although this is a close case, the Court finds that Plaintiffs' misrepresentation claims are not preempted by ERISA. The allegedly false representation was made to A. DaPonte in the context of an pre-employment interview and it concerned the terms of his employment rather than the administration of health benefits. Any relation between the state law claim and Defendants' health benefits plan is "too tenuous, remote, [and] peripheral" to warrant ERISA preemption. See Sandler, 721 F.Supp. at 511, 515 n. 9; Shaw, 463 U.S. at 100, 103 S.Ct. 2890; Geller, 86 F.3d at 23 ("[t]he plaintiffs' common law fraud claim, which seeks to advance the rights and expectations created by ERISA, is not preempted simply because it may have a tangential impact on employee benefit plans."). Moreover, Plaintiffs' state law claim does not arise out of any action taken in the execution, implementation, or administration of the plan, and resolution of the claim would not directly affect the primary administration of benefits function under the plan. See Cavico, Fraudulent, Negligent, and Innocent Misrepresentation in the Employment Context at 80-82; Geller, 86 F.3d at 23 ("the essence of the plaintiffs' fraud claim does not rely on the pension plan's operation or management"). Finally, allowing Plaintiffs to pursue their fraudulent and negligent misrepresentation claims would in no way compromise Congress' purpose in enacting ERISA, and would not impede federal control over the regulation of employee benefit plans. Geller, 86 F.3d at 23. Therefore, this Court finds that Plaintiffs' state law claims for fraudulent and negligent misrepresentation are not preempted by ERISA. The Court dismisses these claims without prejudice to them being brought in an appropriate state forum. Giordano, 274 F.3d at 755.
M. DaPonte also alleges that Defendants, in failing to provide plan benefits to A. DaPonte, have "deprived [her] of the society, services, affection, consortium and companionship services of her husband." (Compl. ¶ 120.) M. DaPonte is not a plan participant, and an ERISA plan is not implicated in her loss of consortium claim. As with the misrepresentation claims, M. DaPonte could recover for loss of consortium with only tangential reference to Defendants' health benefits plan or to any actions taken by Defendants pursuant to that plan. Thus, for the reasons stated above, the Court finds that M. DaPonte's loss of consortium claim is not preempted by ERISA. See Nealy v. U.S. Healthcare HMO, 844 F.Supp. 966, 974 (S.D.N.Y.1994); Blue Cross and Blue Shield of New Jersey, Inc. v. Philip Morris, Inc., 36 F.Supp.2d 560, 582 (E.D.N.Y.1999). This Court dismisses the loss of consortium claim without prejudice to that claim being brought in state court. Giordano, 274 F.3d at 755.
For the reasons described herein, Defendants' motion for summary judgment is GRANTED IN PART and DENIED IN PART. Plaintiffs' fraudulent misrepresentation, negligent misrepresentation, and loss of consortium claims are dismissed without prejudice to them being adjudicated in state court. Defendant's motion to strike portions of Dr. Mark Dennis DeLacure's affidavit is moot. The Clerk of the Court is directed to close this case.
Defendants also mistakenly contend that Geller is inapplicable to the case at bar because it is grounded upon 29 U.S.C. §§ 1132(a)(2), 1109. (Defs.' Reply at 6-7.) In fact, the Second Circuit's discussion in Geller about whether the plaintiffs' state common law claims of fraud were preempted under ERISA informs this Court's analysis in the present case. Geller, 86 F.3d at 22-23.
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Pittsburgh Pirates MLB Basic Gold 59FIFTY Cap
Made of 100% Wool, Woven
This Pittsburgh Pirates MLB Basic Gold 59FIFTY Cap features an embroidered Pittsburgh Pirates team logo on the front, stitched New Era® flag at wearer's left side and embroidered MLB® logo on the rear. Interior includes branded taping and a moisture absorbing sweatband.
- 20633613
- Color:
- Black/Metallic Gold
International shipping available to Canada - info
no sizes available

subset: commoncrawl


text:
|All purpose flour
|3 Tablespoon
|Ground cumin
|1⁄2 Teaspoon
|Chili powder
|1⁄2 Teaspoon
|Garlic powder
|1⁄2 Teaspoon
|Ground cinnamon
|1⁄4 Teaspoon
|Beef chuck cubes
|1 1⁄2 Pound
|Vegetable oil
|2 Tablespoon
|Defatted beef broth
|1 Cup (16 tbs)
|Apple juice
|1⁄2 Cup (8 tbs)
|White potatoes
|6 Small, cubed (peeled)
|Green pepper
|1 Medium (cored, seeded, 2 " strip)
|Pepper red
|1 Medium (cored, seeded, 2 " strip)
|1 Medium, slivered (peeled)
|Tomatoes with green chilies
|10 Ounce
|Tomato sauce
|8 Ounce
|2 Tablespoon
|Granny smith apple
|2 (cored,1 " cubes)
|Red kidney beans
|15 1⁄4 Ounce (drained)
|Chopped parsley
|2 Tablespoon
|Shredded cheddar cheese
|1 Tablespoon (for garnish)
|Black olives
|1 Tablespoon, coarsely chopped
01. Combine the flour, cumin, chili powder, garlic powder and cinnamon in a large bowl.
02. Add the beef cubes and toss, with a fork to coat.
03. Heat the oil in a large, heavy pot over medium-high heat.
04. Brown the beef, in batches, on all sides.
05. Return the beef to pot.
06. Add the beef broth and apple juice.
07. Cover and simmer over medium heat until the meat is tender, about 1 hour.
08. Add the potatoes, bell peppers, onion, tomatoes with green chilies, tomato sauce and honey.
09. Cover and simmer until the potatoes are tender, about 30 to 35 minutes.
10. Add the apples and kidney beans.
11. Cover and simmer until the apples are tender, about 15 minutes.
12. Stir in the chopped parsley.
13. Serve in shallow bowls, garnished with the shredded cheese and chopped olives.


text:
Appointments & Offices
Check insurance plans, locations and make an appointment
Is Dr. Koka accepting new patients?
If you are a new patient, please check with Dr. Koka before scheduling an appointment.
What insurance does he accept?*
- Aetna
- Humana
- Medical Mutual of Ohio
- Medicare
- Meritain Health
- UnitedHealthCare


text:
Jacobs retained the top spot on this year's list of the area's largest engineering firms, according to Business Journal research.
Touchette Regional Hospital plans to double the size of its emergency room department through a sixth-month, $2.8 million construction project.
The top three companies on this year's list of the St. Louis area's largest engineering firms remained unchanged from last year. Jacobs again place No ...
Duane Siegfried has been named Horner & Shifrin's sixth president since its founding in 1933.


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A highly concentrated solution is provided which is both hyperosmotic and hyperoncotic with respect to blood plasma and has utility in treating patients experiencing or threatening to experience hypodynamic shock. The physiologically acceptable solution comprises a crystalloid to provide a osmolarity in excess of 5000 mOsms and a colloid to provide an oncocity in excess of 200 mm Hg. The solution is easily transported and administered by a single, rapid infusion of about less than about 1 ml/kg of body weight and results in a rapid and sustained normalization of circulatory function.
1. A physiologically acceptable solution for treating hypodynamic circulatory shock in a mammal, said solution containing a crystalloid having a molecular weight less than about 1,000 in a concentration of at least about 5,000 mOsms and a colloid having a molecular weight in excess of 30,000 in a concentration of at least about 200 mm Hg.
2. The physiologically acceptable solution of claim 1, wherein said crystalloid concentration is between about 8,000 to 15,000 mOsms.
3. The physiologically acceptable solution of claim 1, wherein the crystalloid is selected from the group consisting of sodium salts, sugar alcohols, and sugars.
4. The physiologically acceptable solution of claim 1, wherein said colloid concentration is between about 200 to about 600 mm Hg.
5. The physiologically acceptable solution of claim 1, wherein said colloid is selected from the group consisting of dextran, hydroxyethyl starch, gelatin and protein.
6. The physiologically acceptable solution of claim 1, wherein said crystalloid concentration is about 11,000 mOsms and said colloid concentration is about 300 mm Hg.
7. A method of preventing or treating hypodynamic circulatory shock in a mammal, comprising the step of administering to said mammal in a condition of existing or impending shock, a therapeutically effective dose of a physiologically acceptable solution containing a crystalloid in a concentration of at least about 5,000 mOsms and a colloid in a concentration of at least 200 mm Hg.
8. The method of claim 7, wherein said crystalloid concentration is between about 8,000 to 15,000 mOsms.
9. The method of claim 7, wherein said crystalloid is selected from the group consisting of physiologically acceptable sodium salts, sugar alcohols, and sugars.
10. The method of claim 7, wherein said colloid concentration is between about 300 to about 600 mm Hg.
11. The method of claim 7, wherein said crystalloid concentration is about 11,000 mOsms and said colloid concentration is about 300 mm Hg.
12. The method of claim 7, wherein said colloid is selected from the group consisting of a physiologically acceptable amount of any of dextran, hydroxyethyl starch, gelatin and protein.
13. The method of claim 7, wherein said physiologically acceptable solution is infused intravascularly.
14. The method of claim 7, wherein said physiologically acceptable solution is injected.
15. The method of claim 7, wherein said therapeutically effective dose is equal to or less than 1 ml/kg of body weight.
This invention was made with Government support under Grant No.: DAMD 17-86 C-6115 with the United States Department of Defense and the University of California. The Government has certain rights in this invention.
This invention relates generally to the area of treatments for circulatory shock and more specifically to a solution which is both hyperosmotic and hyperoncotic for use in preventing and treating hypodynamic shock.
Trauma is the major cause of death in persons under 38 years of age and accounts for over 150,000 deaths per year in this country. Among the most hazardous consequences of traumatic injury is bleeding. The loss of more than 50% of the starting blood volume is not unusual in such injuries and is fatal if not treated promptly.
While field therapy of many medical emergencies, such as cardiac arrest, asthmatic attacks and diabetic crisis has become increasingly successful due to the ever increasing armanentarium of effective drugs, considerably less success has been realized with field treatment of trauma and shock. No drugs have proven effective for the initial treatment of trauma victims. Initial therapy of trauma and hemorrhage currently centers on effecting the cessation of bleeding and on the infusion of large volumes of solutions to replace lost blood volume. Large volume infusion (2 to 8 liters) has generally been considered necessary to restore normal circulatory functions such as arterial blood pressure, cardiac output, oxygen consumption and renal function. Such treatment must be accomplished rapidly to be effective.
The infusion of large volumes of solution involves risks and complications, however. Fluid overload, or "overexpansion", and congestive pulmonary atelectasis may result after use of excessive amounts of fluid. Limited personnel and difficult conditions at the site of an accident make adequate field resuscitation difficult to impossible. In addition to the time necessary merely to infuse such volumes, critical minutes are lost due to difficulties in gaining access to the vascular system. Paramedical personnel must be highly trained to perform such operations. As a result, the average trauma patient has received only 700 ml of fluid prior to arrival in the emergency room, a volume which is normally insufficient to effectively treat hypodynamic shock.
Fluid replacement infusion normally utilizes solutions which have a similar osmolarity to blood plasma. Osmolarity refers to the total concentration of molecules or solutes in a solution. Water will tend to move across a semi-permeable membrane into a solution having a higher concentration of solutes. Thus, the introduction into, for example, the blood vessels, of a fluid having an osmolarity higher than that of normal body fluids will establish an osmotic gradient across the membranes, resulting in an initial change of fluid volume within the vascular system. Osmolarity is generally expresses as millimoles per liter of solution or mOsms.
Small molecules will themselves gradually leak out of the blood vessels, however, so that vascular volume will return eventually to preinfusion levels. Larger molecules, such as colloids, will not escape from the blood vessels as easily, and thus will maintain an osmotic gradient across the membranes. Because the osmotic pressure exerted by colloids in the blood, which is in the range of about 1 to 2 mOsms, is so much smaller than that of the total osmotic pressure generated by all solutes, colloidal osmotic pressure, or oncotic pressure, is expressed in terms of mm Hg. Blood plasma has an osmolarity of about 283 to 295 mOsms and an oncotic pressure of about 25 mm Hg. Solutions which exceed these levels are termed hyperosmotic or hyperoncotic, respectively.
Recently, attempts have been made to treat animals in hypodynamic shock with highly hyperosmotic saline solutions, having an osmolarity in the range of 2400 mOsms. Such treatment has the advantage of requiring smaller total fluid volume and results in brief initial promotion of circulatory function. Because this improvement is short-lived, however, with critical parameters deteriorating over time, hyperosmotic saline does not provide an effective, sustained treatment for shock.
There thus exists a longfelt need for an effective solution for treating shock victims, particularly those experiencing hypodynamic shock. Administration of a small volume of such a solution should result in the rapid and susstained normalization of circulatory function. Additionally, the solution should be inexpensive and have a long shelf life. The present invention satisfies these needs and provides related advantages as well.
The present invention provides physiologically acceptable solutions which are both hyperosmotic and hyperoncotic with respect to blood plasma and have utility in treating patients experiencing or threatening to experience hypodynamic shock. When given a small volume of the solution, on the order of 4 to 5 ml/kg of body weight, or even less if the solution is highly concentrated, patients who have lost a significant proportion of their blood volume exhibit immediate, unexpectedly improved and sustained circulatory functioning as indicated by increased arterial pressure, cardiac output, and oxygen consumption and lowered peripheral resistance. Moreover, cellular membrane potentials and intracellular electrolyte balances are thereby restored. In addition, blood flow to the kidneys and other vital organs may be augmented and urine output is unexpectedly and rapidly increased, thereby decreasing the possibility of acute renal failure, a major complication of shock. Because these solutions are effective in very small volumes, they are particularly convenient to both transport and administer.
In one embodiment, the physiologically acceptable solution comprises a hyperosmotic concentration of a crystalloid (in excess of about 1800 mOsms, preferably about 2000 to 2800 mOsms) and a hyperoncotic concentration of a colloid (in excess of about 30 mm Hg, preferably about 70 mm Hg). This solution has been found to be effective in treating victims experiencing shock when administered in a volume of 250 ml, or about 3 to 5 ml/kg. This physiologically acceptable solution is inexpensive to manufacture and is not adversely affected by temperature extremes, including freezing. As another aspect of the invention, the physiologically acceptable solution is easily administered by single, rapid infusion of approximately equal to or less than 4 to 5 ml/kg of body weight and results in a rapid and sustained normalization of circulatory function.
In another embodiment, the physiologically acceptable solution comprises a highly concentrated solution having an osmolality in excess of 5,000 mOsms, preferably about 8,000 to 15,000 mOsms, and an oncotic pressure or oncocity in excess of about 200 mm Hg, and preferably about 300 mm Hg. The maximum of concentration of the crystalloid is determined by the level at which the solution becomes fully saturated, about 29% sodium chloride in a Dextran 70 solution. The upper limit of the colloid concentration relates to the level above which the increasing viscosity of the solution makes it impractical to administer, about 30% Dextran 70.
Other features and advantages of the present invention will become apparent from the following, more detailed description which illustrates, by way of example, the principles of the invention.
FIG. 1 shows arterial pressure as a function of time in animals receiving a hyperosmotic sodium chloride/hyperoncotic dextran solution and those receiving control solutions.
FIG. 2 shows cardiac output as a function of time in animals receiving a hyperosmotic sodium chloride/hyperoncotic dextran solution and those receiving control solutions.
The present invention provides physiologically acceptable solutions which are hyperosmotic and hyperoncotic with respect to blood plasma. The term "physiologically acceptable" as used herein means that a small volume of the solution can be injected directly into a mammal without inducing pathological changes, such as an immune response or metabolic alterations due to toxicity. The physiologically acceptable solution has particular utility for use in preventing or treating hypodynamic shock, and results in an unexpected improvement in circulatory function which is sustained for at least several hours. The solution is effective when administered in small quantities, permitting relatively easy transport and rapid administration, thereby facilitating easy and effective treatment at or near the site of injury.
The solution comprises a crystalloid and a colloid, both of which are present in concentrations exceeding those of human blood plasma, thus establishing an osmotic gradient across the walls of the blood vessels. The crystalloid may be any small molecule which will exert osmotic pressure including, but not limited to, sugars, sugar alcohols, salts, and other ions having molecular weights less than about 1000. Preferably, the crystalloid is sodium chloride, which in water comprises a saline solution. The concentration of the crystalloid is selected to provide an osmolarity which is sufficiently high so as to be effective in restoring circulatory function, without exerting detrimental effect on the cells and tissues or causing adverse physiological effects such as convulsions. Preferably, the osmolarity is between about 1800 to about 3000 mOsms, e.g., 2000 to 2800 mOsms, and ideally about 2400 mOsms. Such a solution is effective in a dose of about 4 ml/kg. Alternatively, the solution may be considerably more concentrated, having an osmolality greater than about 5,000 mOsms, preferably in the range of about 8,000 to 15,000 mOsms and ideally about 11,000 mOsms.
A colloid is also provided in the solution, selected from physiologically acceptable colloids (i.e., so-called plasma volume expanders) having an average molecular weight higher than about 30,000 and usually lower than 400,000, preferably lower than 250,000, for example lower than 100,000. Such colloids include, but are not limited to, dextran, hydroxyethyl starches and gelatins of various average molecular weights and proteins, such as plasma proteins and hemoglobin. Preferably, the colloid is dextran 70 (molecular weight of about 70,000) or dextran 60 (molecular weight of about 60,000). The concentration is selected so as to provide maximum salutory effect without damage to cells or tissues, and the colloidal osmotic pressure is higher than 30 mm Hg, preferably about 70 mm Hg which is about 6% Dextran 70, or in excess thereof. Alternatively, the solution may be of much greater concentration, having an oncocity in excess of 200 mm Hg and preferably about 300 mm Hg. Because of the problems of maximum solubility and increasing viscosity which interferes with ease of administration by the means disclosed, the concentration is preferably below about 30% weight/volume. However, concentrations of as high as about 600 mm Hg and preferably about 300 mm Hg, or 24% Dextron 70, may be usefully employed.
A hyperosmotic/hyperoncotic solution is advantageously utilized to treat hypodynamic circulatory shock resulting from such cases as hemorrhage, trauma, burns, or shock. It is also useful to treat acute renal failure and cerebral edema. The solution is administered in the field or may be used as an initial treatment in an emergency room or critical care unit where a patient exhibits rapid blood loss or unresponsive hypodynamic circulation. The solution may be infused rapidly in a single bolus through a vascular catheter or may be injected directly into a peripheral vessel, with a concomitant saving of critical time. The solution is effective in unexpectedly low dosages, which, depending on the concentratin of the solution may be equal to or less than about 4 to 5 ml/kg of body weight, or less than 1 ml/kg with a highly concentrated solution, or with a highly concentrated solution less than about 1 ml/kg body weight, which amounts to only about 10% to 0.25% the volume presently used to treat victims exhibiting shock through conventional volume replacement therapy. Because only such small volumes are necessary, logistical problems of providing the solution at the site of injury are obviated. The same volume of fluid necessary to treat one patient through conventional therapy may be effectively used to treat many patients when a hyperosmotic/hyperoncotic solution is utilized.
After administration of a small volume of a hyperosmotic/hyperoncotic solution, various indicators of circulatory function are found to rapidly achieve normality, and to sustain such normality. Among these indicators are arterial pressure, cardiac output, oxygen consumption, peripheral resistance, urine output, cellular membrane potentials and intracellular electrolyte balance.
Solutions of varying composition were used to treat hypodynamic circulatory shock in adult sheep weighing 40 to 50 kg. Chronic cannultion of the thoracic aorta, superior vena cava and pulmonary artery were performed on sheep anesthetized with halothane/nitrous oxide, and silastic and Swan-Ganz thermodilution catheters (Edwards Laboratories, Santa Ana, CA) inserted. A Foley catheter was emplaced to monitor urine output. Food and water were withheld for 24 to 36 hours before the beginning of the experimental protocol. Experiments were performed at least 72 hours after surgery.
All experiments were conducted on unanesthetized animals kept unrestrained in cages. Physiological parameters measured and recorded during experiments includded vascular pressures (arterial, central venous, pulmonary artery and pulmonary wedge), cardiac output, urine flow rate, heart rate and respiratory rate. Blood samples were taken for subsequent analysis of hematocrit, serum osmolarity and serum Na+, K+ and Cl-. After an initial one hour period of baseline data collecting, the sheep were bled to a mean arterial pressure of 50 mm Hg, and maintained at 40 to 55 mm Hg by continued bleeding for the next two hours. Measurement protocols followed those detailed in Example II.
Each experimental sheep received a bolus infusion of about 4 ml/kg of hyperosmotic/hyperoncotic solution (1.2M sodium chloride, 6% weight/volume dextran 70 (Macrodex�, Pharmacia Fine Chemicals, Piscataway, NJ) in deionized, sterile water; osmolarity 2400 mOsms, oncotic pressure 70 mm Hg) and was monitored for three hours. Control sheep were given either no resuscitation, a hyperosmotic sodium chloride solution (1.2M, 2400 mOsms), or a hyperoncotic dextran solution (6% weight/volume, 70 mm Hg). As indicated in FIGS. 1 and 2, administration of all solutions resulted in an enhancement of cardiac output and arterial pressure. However, only the hyperosmotic/hyperoncotic solution effected a full restoration of baseline levels and resulted in sustained, near normal functioning. No other solution produced so full or sustained a response. The animals exhibited no apparent ill effect from the experimental protocol.
Vascular pressures were measured with a Gould P23 pressure transducer (Gould, Inc., Oxnard, CA) connected to a multichannel strip chart recorder for continuous monitoring. Transducers were leveled to the point of the shoulder. Cardiac output was measured by thermodilution, using a Model 9520A Cardiac Output Computer (Edwards Laboratories, Santa Ana, CA). Urine was collected in a closed drainage system equipped with a graduated cylinder. Hematocrits were determined with an IEC Microhematocrit Centrifuge (Damon Instruments, Needham Heights, MA). Sodium and potassium were measured by a Model 143 Flame Photometer (Instrumentation Laboratories, Lexington, MA). Blood urea nitrogen and creatinine were measured on a Clinical Chemical Analyzer System 103 (Gilford Instruments, Oberlin, OH). Osmolarity was determined on an Osmette A Freeze Point Osmometer (Precision Instruments, Sudbury, MA). Plasma volume was measured by the Evans Blue dye dilution technique (Gibson et al., J. Clin. Invest., 16:301 (1937) which is incorporated by reference).
Studies were performed to compare the efficacy of a hyperosmotic/hyperoncotic solution (1.2M NaCl, 6% dextran 70), with a hyperosmotic sodium chloride solution (1.2M), a hyperoncotic dextran solution (6%) and with no resuscitative measures.
FIGS. 1 and 2 depict the effect which these solutions have on arterial pressure and cardiac output, respectively. Baseline arterial pressure ranged from about 86 to 101 mm Hg. In order to induce hypodynamic circulatory shock, the pressure was reduced to about 50 mm Hg. When no resuscitative measures were undertaken, this level rose spontaneously to about 65 mm Hg. An infusion of a small volume of dextran solution resulted in elevation of arterial pressure to about 70 mm Hg, but this level deteriorated over the course of the following three hours. An infusion of either the hyperosmotic sodium chloride solution or the hyperosmotic sodium chloride/hyperoncotic dextran solution resulted in an immediate return to baseline levels. With the hyperosmotic sodium chloride solution, however, the arterial pressure declined some 20% below baseline. The hyperosmotic sodium chloride/hyperoncotic dextran solution effects a rapid, immediate, sustained return of arterial pressure to baseline levels.
Cardiac output decreased from about 5 1/min to about 2.25 1/min upon bleeding. An infusion of a small amount of hyperoncotic dextran solution resulted in a small improvement in cardiac output while an infusion of hyperosmotic sodium chloride solution resulted in a transient return to baseline, followed by rapid deterioration. Infusion of the hyperosmotic sodium chloride/hyperoncotic dextran solution, however, not only immediately resulted in cardiac output even somewhat above baseline but a sustained level at or near baseline as well. Thus, the hyperosmotic/hyperoncotic solution results in a rapid and sustained normalization of cardiac output.
Different hyperoncotic colloid solutions were also compared. In addition to the studies referred to above utilizing hyperoncotic dextran 70, experiments were performed utilizing 1.2M sodium chloride solutions to which different colloids were added in hyperoncotic concentrations. These included hyperoncotic human albumin (25% weight/volume), hyperoncotic dextran 40 (15% weight/volume) and hyperoncotic hydroxyethyl starch (6% weight/volume). The oncotic pressure of these solutions is not known precisely, but such is well above 70 mm Hg and presumably above 150 mm Hg. Two hundred milliliters of each solution were used in an experimental protocol as in Example I. Results of the cardiac output responses are shown in Table I.
TABLE I______________________________________DIFFERENT HYPERONCOTIC SOLUTIONSEACH MIXED WITH 1.2 M SODIUM CHLORIDE INDEIONIZED STERILE WATERCardiac Outout (liters/minute) 15% 25% Albumin Dextran 40 6% Starch______________________________________Baseline 4.3 5.2 5.6Hemorrhage 1.75 2.3 2.910 min. post 8.5 5.3 5.6resuscitation60 min. post 6.9 5.6 6.5resuscitation120 min. post 6.9 5.0 6.4resuscitation______________________________________
All hyperosmotic/hyperoncotic solutions resulted in an immediate and sustained improvement in cardiovascular function.
Different hyperosmotic sodium chloride solutions (1200, 1800, 2400 and 3600 mOsms) and an isoosmotic sodium chloride solution (about 285 mOsms), each mixed with 6% dextran 70 (70 mm Hg) were also compared. Results of these studies are shown in Table II. All hyperosmotic solutions were more effective than the isoosmotic solution. Cardiovascular response generally improved as osmolarity increased to 2400 mOsms. Concentrations equivalent to 3600 mOsms and higher caused convulsions. Data suggests 2400 mOsms sodium chloride/70 mm Hg dextran solution is near optimal, when given in volumes of 3-5 ml/kg.
TABLE II______________________________________SODIUM CHLORIDE SOLUTIONS OFDIFFERENT OSMOLARITIES,EACH MIXED WITH 6% DEXTRAN 70Cardiac Outout (liters/minute) Osmolarity 300 1200 1800 2400 3600______________________________________Baseline 5.1 5.9 4.9 5.3 4.3Hemorrhage 2.2 2.3 2.1 2.2 1.810 min. post 3.2 4.6 5.0 6.2 7.0*resuscitation60 min. post 3.1 4.3 4.8 4.9 4.8resuscitation120 min. post 3.2 4.4 4.3 4.7 4.3resuscitation______________________________________ *Convulsion occurred after infusion with 3600 mOsm solution.
The efficacy of a total of 6 solutions having osmolarities of about 2400 mOsms, but varying in ionic compositions and concentrations were compared using the experimental protocol in Example I. All solutions were made up in sterilized deionized water and included aqueous solutions of sodium chloride, sodium chloride/sodium acetate, sodium chloride/mannitol, sodium chloride/dextran, qlucose and sodium bicarbonate. The solutions tested are listed in Table III.
TABLE III______________________________________ SIX 2400 mOsms SOLUTIONS______________________________________NaCl 1.2 M NaClNaHCO3 1.2 M NaHCO3NaAc 0.6 M NaCl and 0.6 M NaAcetateMan 0.7 M NaCl and 1.0 M MannitolDex 1.2 M NaCl and 6% Dextran 70Glu 2.4 M Glucose______________________________________
The results of the tests with these various solutions are presented in Table IV. All hyperosmotic crystalloid soltions caused a rapid improvement in cardiac output. However, the response was only sustained with the addition of a hyperoncotic colloid. With a hyperosmotic/hyperoncotic solution, such as sodium chloride (2400 mOsms)/dextran 70 (70 mm Hg), the sheep exhibited a sustained normalization of cardiac output, oxygen consumption, vascular pressures, urine output and total peripheral resistance.
TABLE IV______________________________________SIX 2400 mOsms SOLUTIONSEFFECTS ON CARDIAC OUTPUT (liters/minute) NaCl NaHCO3 NaAc Man Dex Glu______________________________________Baseline 5.1 5.3 5.5 5.0 5.3 5.3Hemorrhage 2.3 2.0 2.3 2.1 2.2 2.110 min. post 5.3 4.0 6.3 5.0 6.2 5.3resuscitation60 min. post 3.9 3.5 3.9 3.4 4.9 3.3resuscitation120 min. post 3.6 3.0 3.5 3.2 4.7 3.2resuscitation180 min. post 3.8 -- 3.9 -- 5.0 --resuscitation______________________________________
Experimental tests performed by Dr. Peter Maningas at the U.S. Army's Letterman Institute of Research have confirmed the efficacy of hyperosmotic/hyperoncotic solutions for treating hypodynamic shock. Experiments compared the effects of hyperosmotic and hyperoncotic solutions on survival in a severe hemorrhage rapid exsanquination model in swine (Traverso, Circulatory Shock, 12:1, (1984) which is incorporated by reference). Adult swine which were bled to 50% of estimated blood volume in 15 minutes, were treated with small resuscitation volumes of the following aqueous solutions: isoosmotic sodium chloride solution; hyperosmotic sodium chloride solution (2400 mOsms); hyperoncotic dextran solution (70 mm Hg); and hyperosmotic sodium chloride (2400 mOsms)/ hyper oncotic dextran (70 mm Hg) solution. Survival rates are shown in Table V. There was 100% survival with a solution of hyperosmotic/hyperoncotic solution while only limited success was achieved with solutions of either solute alone. No animals survived with isotonic saline or with no treatment.
TABLE V______________________________________SWINE SURVIVAL AFTER RAPID 50% BLOOD LOSSResuscitation Fluid Survival______________________________________Isoosmotic Sodium Chloride 0Hyperosmotic Sodium Chloride 50%Hyperoncotic Dextran 66%Hyperosmotic Sodium Chloride/ 100%Hyperoncotic DextranSolution______________________________________
A paramedic gives about 200-300 ml of a hyperosmotic/hyperoncotic solution by bolus injection into the peripheral vein of a trauma victim experiencing shock or threatening to experience shock at the scene of an accident. This small volume rapidly stabilize the patient's circulatory function until arrival at an emergency room or trauma center. This rapid restoration of cardiac output, blood pressure, renal function and oxygen consumption lowers the morbidity and mortality of trauma and hemorrhage.
Small volume resuscitation is also effective in several other hypodynamic circulatory states, such as during and after extensive surgical procedures, for burn injury and after organ transplantation, where hypodynamic shock is threatened or experienced.
Adult sheep in which hypodynamic shock was induced were treated with a small volume with a highly concentrated hyperosmotic/hyperoncotic solution. Six unanesthetized sheep weighing 36 to 43 kg were bled of more than half of their estimated blood volume (about 1500 ml) so as to maintain an arterial pressure of 50 mm Hg for 2 hours.
A solution was prepared containing 28.2% sodium chloride and 24% Dextran 70 (Macrodex, Pharmacia Fine Chemicals, Piscataway, N.J.) in deionized sterile water. The solution was calculated to have an osmolarity of about 12,000 mOsms, and an oncotic pressure (oncocity) of 24 mm Hg. The solution was almost fully saturated and had the viscosity of maple syrup. Attempts to make a more concentrated solution were abandoned because over a concentration of about 30% Dextran 70 the viscosity became too high to be acceptable for injection and was therefore unacceptable for therapeutic use.
Each experimental sheep received a bolus infusion of about 1 ml/kg body weight of this hyperosmotic/hyperoncotic solution. Physiological parameters were monitored as in Examples I and II for 3 hours post-infusion.
As indicated in Table VI, cardiac output and mean arterial pressure returned to or exceeded baseline levels shortly after administration.
TABLE VI______________________________________Resuscitation of hemorrhagewith 40 ml of 28%NaCl/24% Dextran 70 Mean Arterial Cardiac Pressure Output______________________________________Baseline 90 � 6 4.8 � 0.3Hemorrhage 48 � 4 2.3 � 0.83 min. post 98 � 8 6.4 � 1.6resuscitation15 min. post 98 � 8 5.5 � 1.3resuscitation30 min. post 91 � 6 5.4 � 1.4resuscitation60 min. post 83 � 9 4.8 � 1.3resuscitation120 min. post 80 � 6 4.8 � 1.4resuscitation180 min. post 79 � 4 4.6 � 1.2resuscitation______________________________________ Mean Arterial Pressure in mm Hg Cardiac Output in 1/minute
A trauma victim experiencing shock, or having been injured so to be as expected to experience shock imminently, is given a bolus injection of the highly concentrated hyperoncotic/hyperosmotic solution of Example VI. The volume of solution given is sufficiently small such that it can be administered through a single syringe. The solution is preferably administered by injection into a peripheral vessel, although alternative modes of injection are possible. The amount given is about 50 ml, which is equal to about 0.7 ml/kg for a 150 pound victim. This small volume rapidly restores the cardiac output, blood pressure, renal function and oxygen consumption to near normal conditions.
Alternatively, the victim may be given multiple small doses of the solution, either by injection of about 25 ml at the time of injury followed by injection of 25 ml approximately 5 minutes later if blood pressure response to the first injection is inadequate.
Although the invention has been described with reference to the presently-preferred embodiment, it should be understood that various modifications can be made by those skilled in the art without departing from the invention. Accordingly, the invention is limited only by the following claims.
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text: Products Assurant Offers Healthcare Discount Card for Employees By Rebecca Moore email@example.com | August 15, 2012 August 15, 2012 (PLANSPONSOR.com) – Assurant Employee Benefits has introduced its WellCard Savings Program. The WellCard Savings Program provides an average savings of up to 30% on medical visits, up to 65% on brand name and generic prescriptions, and discounts on hearing and diabetes care, diagnostic and lab tests, daily living products and more. Additionally, those carrying a WellCard Savings Card automatically join a nationwide network of more than 59,000 pharmacies and more than 350,000 physicians, and can receive rewards for everyday purchases made through a network of merchants. "In everyday life, and especially when they have an illness or accident, employees incur unplanned expenses that are not covered by their traditional health insurance," said Mark Sylvester, vice president of sales at Assurant Employee Benefits. "The WellCard Savings Card can provide savings and options to help them control these costs as much as possible. Also, through the WellCard program, employers can provide an additional benefit to their employees while reinforcing the value of one-on-one enrollment meetings in educating employees about their benefits packages and how various insurance coverages can help protect from unforeseen financial risks." The WellCard Savings Program will be offered at no charge to employees whose employers offer Assurant Employee Benefits' voluntary or employee-paid insurance products. Employees will receive a card after attending a one-on-one enrollment meeting. For more information, visit www.assurantemployeebenefits.com. Tagged: Healthcare, more from plansponsor related articles related research most e-mailed More in news topic from the magazine UpFrontACA Transforming Benefits From plansponsor.com Employers Relieved as Obamacare StandsHealth Plan Sponsors Must Exercise PrudenceHSAs a Growing Retirement Savings OpportunityDOL Announces Health Benefits Law SeminarsHigh Court Marriage Decision Will Affect Health BenefitsCatastrophic Claims Warrant Use of Stop-Loss Insurance More in news topic from the magazine UpFrontACA Transforming Benefits From plansponsor.com 2015 Recordkeeping SurveyDefined Benefit Administration Survey2015 Participant Survey2014 DC Survey: Plan Benchmarking2014 Defined Contribution Survey2014 Consultant Buyer's Guide More in news topic from the magazine UpFrontACA Transforming Benefits From plansponsor.com Fidelity Offers Fiduciary ServicesIntroducing Automatic Enrollment to K12 403bsOneAmerica to Acquire BMOs US Retirement BusinessBest Practices for Reducing Fiduciary Liability RiskNon-ERISA 403bs Off the RadarBuilding Up go to news topic


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Christopher Lee Parker
Position: RB
Height: 5-11 Weight: 213 lbs.
Born: December 31, 1972 in Lynchburg, VA
High School: Lynchburg
College: Marshall (school history)
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Aug 6
BEATS & BARS Streatham Thursday 6th August 2015 : 7PM - 12PM The White Lion, 234 Streatham High Road, London SW16 1BB International Hip-Hop Showcase USA Acts: RICH QUICK (New Jersey) REDICULUS (Chicago) FDOT1 (New York) UK Acts: TRADEMARK BLUD | FILFY BIG RIBZY | OLIVER SUDDEN DJs: TRICKSTA | J HART DJ TMB | DJ SKAMROKTickets Save
Aug 15
Label: Ben Frank Recordings
Manager: Alberto Riccelli, Exponent Entertainment
Bio: In April 2012 Rich Quick released "I'm With The DJ" Hosted by DJ NoPhrillz and Benja Styles. The first 500 physical copies of the mixtape included 1 of 5 limited edition hand drawn Hip Hop themed Art Cards. Rich included the Art Cards as a testament to Hip Hop's influence on art and pop culture. ...See Full Bio
: RT @BizZarRadio_: Now Playing @RichMFNQuick - On My Shoulderz - Want in Rotation? Goto http://t.co/weY2teRbQi TuneIn Player @ http://t.co/


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Ratings based on 251 Verified Reviews
They paid and stayed. We double-checked.
4.1 Room cleanliness
4.1 Service & staff
4.1 Room comfort
3.8 Hotel condition
They paid and stayed.
We double-checked.
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for Familiesby april from Bath NY
Ok stay....Posted Feb 17, 2015 on Hotels
There was no hot water the first morning we were there. There was a loud party in the conference room that Saturday night which ended at 10, the walls were thumping with the music, hard to get a little one to go to sleep. It looks like they tried to take care of a mold problem in the bathroom unsuccessfully! Breakfast on Sunday was lacking not enough of anything to eat, empty dishes, no variety of breads, cereal or pastries. The staff was friendly but there was no one at the desk when we went to check out.
for Personal Eventby A verified traveler
B.Y.O.L.- Bring your own LysolPosted Feb 15, 2015 on Hotels
Overall the staff were very nice but the hotel needs to be updated and I noticed a few stains in the carpet and the entertainment stand in the room felt very greasy for some reason. And the shower curtain was stained. I never complained because I was only there for the night and just dealt with it. I would rate the cleanliness of the hotel 7/10.
by A verified traveler from Pittsburgh pa
FilthyPosted Jan 29, 2015
Pool closed, room filthy, rude staff sand management.
for Everyoneby A verified traveler
OkayPosted Jan 28, 2015
Staff was friendly, breakfast was good, pool was not working because the ceiling collapsed 2 days before
for Familiesby Olayinka from Seattle
Not too good stayPosted Jan 10, 2015 on Hotels
The TV in the room was messed up and they could do nothing about it.
for Familiesby Dan from PA
A good value for the moneyPosted Dec 30, 2014 on Hotels
Just one night here passing through. A good value for the money and a better than expected breakfast selection.
for Everyoneby A verified traveler
Posted Dec 29, 2014
Two night stay. Very quiet. Fridge and microwave didn't work but it was an issue they didn't know about and has since been resolved. Staff was great. New cable setup with DVR and free On Demand was installed when I arrived. I'd would definitely stay again.
for Business Travelersby david from They can do better
Not PleasedPosted Dec 12, 2014 on Hotels
room service was sloppy. Dirty towels left in room and room appliances did not work. Quality was not up to standards for this hotel chain.
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Posted Dec 4, 2014 on Hotels
for Familiesby John from OSU fan
Cool spot for an overnightPosted Dec 4, 2014 on Hotels
In the middle of renovations. Some of the rooms are undergoing painting, new carpets, etc. Our room has patching holes filled in but due for a paint. No wonder why they put us with a dog in this room. It will be renovated soon. But overall its a pretty decent hotel.


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By Gabby Landsverk, Staff Writer More than 1,700 miles away from Cape Canaveral, students in Swanville had their own version of a space launch Friday morning as a team of Central Lakes College students and teachers picked the school as the perfect site to send a high-altitude weather balloon into t...Read More
Seven people stranded in a resort by a blizzard. Cut off from the outside world — then murder. It could be a February day in Minnesota. Instead, it's the Agatha Christie murder mystery "The Mousetrap," presented by Central Lakes College (CLC) Theatre. The play opens Friday, Feb. 13, with a m...Read More
Minneapolis' Mixed Blood Theatre's production of The Deaf Duckling will be performed at Central Lakes College (CLC) in Brainerd, in the Chalberg Theatre Thursday, April 10, at 10 a.m. Playwright Aditi Kapil weaves together the classic "Ugly Duckling" fairy tale with the story of a deaf chi...Read More
"To Kill a Mockingbird," an adaptation of Harper Lee's Pulitzer Prize-winning novel of violent racial events in a small town, will be staged at Central Lakes College (CLC) in Brainerd, Feb. 11-19. Set in 1935 Alabama, this popular, oft-performed play is scheduled for the 100-seat Dryden Theatr...Read More
Following a month-long residency at the Guthrie Theater in Minneapolis, the Acting Company will make Central Lakes College the first stop of its 2012 tour to perform Shakespeare's "Julius Caesar" at 7:30 p.m. Wednesday, Feb. 8 in Chalberg Theatre on the Brainerd campus. "Julius Caesar" is ...Read More


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Broadway Shows: 2014 / 2015 Season
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Your independent guide to the best shows in Buffalo
Sheas Performing Arts Center, 646 Main Street, Buffalo, NY 14202
Shea's Buffalo Theatre is part of the Shea's Performing Arts Center complex.
Sheas Performing Arts Center, 646 Main Street, Buffalo, NY 14202
Opens Sep 29
Opens Dec 08
Opens Jan 26, 2016
The Wizard Of Oz
Opens Apr 05, 2016
Dirty Dancing
Opens May 03, 2016
September 29-October 4, 2015
The record-breaking, Tony Award-winning Broadway phenomenon that tells the story of an unlikely band of underdogs who take on the biggest names in publishing in an "inspirational" (The Hollywood Reporter) fight for justice, is touring the country!
December 8-13, 2015
Leapin' lizards... Annie is coming to town! Annie is a delightful theatrical experience for the entire family. Don't miss this Tony-winning Broadway production of the timeless family tale of Little Orphan Annie. This season's tour stars talented nine-year old actress Issie Swickle in the lead role performing classics like 'Tomorrow' and 'Hard Knock Life'!
January 26-31, 2016
A young prince sets out on a journey to find the ultimate meaning of life in the vaudevillian spectacular of Pippin, from Godspell creator Stephen Schwartz. Told by a roving cast of an anachronistic acting troupe, the musical first wowed audiences in 1972, seducing them with the astonishing musical fable, set to a rousing 1970's rock score, including the hits 'Magic to Do' and 'I Guess I'll Miss the Man.'
April 5-10, 2016
Andrew Lloyd Webber's lauded production of The Wizard Of Oz is an enchanting adaptation of the perennial MGM movie classic starring Judy Garland, totally re-imagined for the stage. Following highly successful productions in London and Toronto, the show has embarked on the ever-winding Yellow Brick Road that is North America. Join Dorothy and Toto as they meet a motley crew of lost characters, all with one thing in mind; to gain their hearts' desire from the great Oz.
May 3-8, 2016
Dirty Dancing treats you to an unprecedented live experience, exploding with achingly cool music, romance, and above all, sensational dancing. This touring production hews closely to the movie, packing in all its anthemic songs and cheesy one-liners with aplomb. It delivers everything the audiences can hope for - lots of sexy dancing and plenty of rock 'n' roll!
Jul 23, 2015
Aug 23, 2015
Sep 26, 2015
Sep 29-Oct 4, 2015
Sep 29-Oct 4, 2015
Oct 7, 2015
Oct 10, 2015
Nov 3-8, 2015
Dec 5, 2015
Dec 8-13, 2015
Dec 15, 2015
Dec 19, 2015
Jan 26-31, 2016
Feb 12-14, 2016
Mar 15-20, 2016
Apr 5-10, 2016
May 3-8, 2016
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New Orleans Saints WR Lance Moore Moves 'Like Bernie' [VIDEO]
If you got the moves go for it right? Well looks like the New Orleans Saints Wide Receiver Lance Moore is not just talented in football, but also has some killer dance moves.
If you got the moves go for it right? Well looks like the New Orleans Saints Wide Receiver Lance Moore is not just talented in football, but also has some killer dance moves.
What a great season for the Ragin Cajun football team, we're undefeated at home this year and headed into the final game against Arizona at 8 and 3! Along with the Cajuns success in 2011, the season will not not be over after Saturday's game against Arizona.....It's time to go BOWLING!! The Big Announcement will come Monday November 21st at 5:30pm!
Former Penn State Assistant Coach, Jerry Sandusky, who is accused of abusing several children while working under ousted coach/legend, Joe Paterno, has finally broken his silence. The former coach was on MSNBC and spoke directly to Bob Costas. In the interview he says that while he have may acted inappropriately with children, he claims to NOT be a pedophile.
Just after the big victory Saturday night at Cajun Field aganist in-state rival ULM, UL-Lafayette Head Coach Mark Hudspeth got a little emotional in the post-game interview. It is quiet obvious that UL, Louisiana, and the fans of UL have a special place in the heart of the first year head coach.
KATC-TV recently went behind the scenes with first year head coach of the UL Ragin Cajuns, Mark Hudspeth, to document a day in his life. From early morning meetings, to press conferences, and even a quick workout before practice, all are part of a very busy day for the first year head coach. Still, coach finds it in him to be the best he can be, and bring out the best in many of his young athletes.
The University & UL Football has requested that for their final home game of the year, Saturday Nov. 5th at 2:30pm, against UL-Monroe that fans "whiteout" the stadium. The team and university have requested that all UL fans and students wear white shirts to the game. We have seen many stadiums pull this off before, but this may be a first for Cajun Field.
When Patrick Myshrall scored a touchdown during a Massachusetts high school football game, a win for his team was already impossible. But the touchdown signaled a different sort of victory for Myshrall since he has Down Syndrome.
See what happens when a high school football player goes across the field and attempts to catch a pass in the middle of the field during a game. Analyst say that they most dangerous place to catch a pass on the field is always across the middle. Well, let's just say that this video only supports the claim. Buckle-up and brace yourself for this one.
Reggie Bush is quickly realizing that Miami is definitely not New Orleans. Bush is under fire with fans yet again, and just like his previous fiascos, Twitter is at the center of it all. Last night Reggie hit the clubs drinking, as TMZ described it, "like he just won the Super Bowl" -- but the problem is
It was a record-setting week for several players, and the Green Bay Packers and Detroit Lions are the only remaining unbeaten teams after week four of the NFL's 2011 season. Here's a recap of all the action:
Green Bay 49 – Denver 23
Aaron Rodgers threw for a career-high 408 yards, four touchdown passes and added two rushing scores, as the Green Bay Packers trounced the Denver Broncos 49-23. The Packers led 21-3


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The Obergefell decision has been understandably generating tremendous media coverage and analysis. Most of the commentary has discussed either the speed at which society has given approval to same-sex marriages or the potentially dramatic "legal overreach" by the judiciary. One very foundational point,...Read more →
The terrorist attack on the offices of Charlie Hebdo bring into sharp relief a major contradiction in the intellectual framework of modern democracy. In fact, it highlights a fault line. Freedom of speech is one of the supposedly unshakeable pillars of liberal social order. But the way liberals have...Read more →
From TS Eliot's Idea of a Christian Society: That liberalism may be a tendency towards something very different from itself, is a possibility in its nature. For it is something which tends to release energy rather than accumulate it, to relax, rather than to fortify. It is a movement not so much defined...Read more →
Assuming the rightness of the critique provided by anti-revolutionary thinkers such as Groen van Prinsterer, what then should be the result? Obviously, by the nature of the case, Christians, being anti-revolutionaries (whether Rousseauian or Jeffersonian: the difference is not as great as one might...Read more →
Having given his name to an international theological and political movement, indeed an ism, it is perhaps surprising to learn that Abraham Kuyper is not more widely read outside of Dutch-speaking audiences. Of the North American followers claiming his name, relatively few have read any of Kuyper's...Read more →
Mr. J. L. Leidl has written a worthy salvo at Ethika Politika in the ongoing debate about American liberalism and the politics of virtue. Near the end of his piece he addresses the question of what a eudaimonist can do in a pervasively liberal society. He rightly dismisses three options: MacIntyrean...Read more →
There is often heated debate, in the realms of politics and church history, over the religious (or antireligious) nature of the Enlightenment and of early modern political thought, especially the school of Liberalism. The loudest is the debate about the question of whether or not the United States'...Read more →
Dr. Paul Helm has written some quite useful things on John Calvin and philosophical theology, but he also has his contrarian side, which yields some very unfortunate results. This latest post is a case in point, wherein Dr. Helm offers up a confused yet troubling articulation and application of the doctrine...Read more →
At last Darryl Hart admits that we're the consistent Protestants, but with the proviso that in this case consistency is not a virtue. It is nevertheless quite a concession from the redoubtable Dr Hart, first, because it is an admission regarding our position which he's never before granted, and second,...Read more →
Peter Leithart here draws attention to libertarian guru Ludwig von Mises' animosity toward Christianity. Mises' charges are old ones, whose most recent variants include Nietzsche's critique of Christianity as resentment-driven Sklavenmoral. This is not to say that there's nothing at all to the thesis...Read more →


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basket full of fresh colorful vegetables isolated on white background. (A shopping)
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USC Pacific Asia Museum
Established in 1971, the museum is one of few U.S. institutions dedicated to the arts and culture of Asia and the Pacific Islands. Its collection continues to grow and now numbers more than 15,000 objects, plus a variety of exhibitions throughout the year.
Classical KUSC
91.5 KUSC broadcasts handpicked commercial-free classical performances, expert music commentary and coverage of the arts in Southern California. Classical KUSC can also be heard online via web stream.
USC Thornton Opera Presents Il viaggio a Reims
April 25, 2014
8:00 pm
University Park Campus
Bing Theatre (BIT) (Map)
Bing Theatre (BIT) (Map)
Free for USC students, staff, and faculty with valid ID. $12 seniors, alumni and non-USC students. $18 general admission. For general ticket information, call (213) 740-4672 or visit www.usc.edu/tickets.
Pop the champagne corks, sit back, and relax with Gioachino Rossini's silly, fun comedy Il viaggio a Reims.
A diverse group of upper class internationals find themselves stranded at a French spa on their way to the coronation of the new king of France. What else is there to do but celebrate life with Rossini's bubbly score and the talented young artists from the USC Thornton School of Music's Opera Program and Orchestras. Don't miss this chance to see a rarely performed opera by one of the great masters of the 19th century!
Performance schedule
Wednesday, April 23, 8:00 p.m.
Friday, April 25, 8:00 p.m.
Sunday, April 27, 2:00 p.m.
For tickets, click here.


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Beaten to a bloody pulp by Chun Jae Man's minions, Young Joo dies. In the meantime, Kim Jong Shik wakes up in his hospital bed. Yoon Sung takes Young Joo's phone, and sees the text message supposedly sent from the City Hunter that directed him to the junkyard. He asks Jin Pyo why he did it, and Jin Pyo replies that all he was doing was sending the prosecutor to find the truth...
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Rapper + Actor
Born Nov 2, 1974 Age 40
Hometown Austin, Texas Net Worth $55 Million
Genres Contemporary R&B ... Performed With T.I. + St. Lunati...
Record Label Republic Records Height 6' " (185 cm)
Cornell Iral Haynes, Jr., better known by his stage name Nelly, is an American Grammy Award-winning hip hop recording artist, entrepreneur and occasional actor from St. Louis, Missouri. He has performed with Southern hip hop group St. Lunatics since 1993… Read More
View newly released photos of Nelly.
Check out the latest love interests for Nelly.
Shantel JacksonDated 2014
Lashontae HeckardDated 2012 - 2014
Kat StacksFling 2010
Nicole NarainDated 2004
AshantiDated 2004 - 2009
Claudia JordanFling 2003
Kelly RowlandDated 2002
Joss StoneDated
News + Updates
Browse recent news and stories about Nelly.
Missouri State Cancels Nelly Concert After Drug ArrestUSA Today - Apr 14, 2015
Nelly's Lawyer 'Extremely Confident' Drug Charges Will Be ClearedLATimes - Apr 13, 2015
Rapper And Reality Tv Star Nelly Arrested On Drug ChargesYahoo News - Apr 12, 2015
Rapper Nelly ArrestedReuters.com - Apr 12, 2015
Learn about the memorable moments in the evolution of Nelly.
1974 Birth Born on November 2, 1974.
2000 25 Years Old 1 More Event
Under Universal, Nelly began his solo career in 2000 with his debut album Country Grammar, the title track of which was a top ten hit. … Read More
2003 28 Years Old 1 More Event
He won Grammy Awards in 2003 and 2004 and had a supporting role in the 2005 remake film The Longest Yard with Adam Sandler and Chris Rock. … Read More
2004 29 Years Old 3 More Events
Another number-one hit, "Shake Ya Tailfeather" won the 2004 Grammy Award for Best Rap Performance by a Duo or Group.
2009 34 Years Old 1 More Event
In the summer of 2009, Nelly made a public announcement in Las Vegas about the yet-to-be-titled album.
2010 35 Years Old 7 More Events
… He was one of the owners of the Charlotte Bobcats, along with Robert L. Johnson and Michael Jordan until Jordan became the new owner in March 2010. … Read More
2011 36 Years Old 1 More Event
On December 24, 2011, Nelly released a mixtape titled O.E.M.O. (which stands for On Everything MO), which features guest performances from T.I., 2 Chainz, Bei Maejor, St. Lunatics and more.
2012 37 Years Old On July 4, 2012, via his Twitter, Nelly announced the title for his seventh studio album and revealed that Chris Brown is featured on "Marry Go Round", the first single from M.O.. … Read More
Original Authors of this text are noted on http://en.wikipedia.org/wiki/Nelly.
Text is made available under the Creative Commons Attribution-ShareAlike License.
Text is made available under the Creative Commons Attribution-ShareAlike License.


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There have been warnings that abrupt withdrawal of propranolol hydrochloride therapy in patients with or without coronary heart disease may be hazardous. This happens more often in patients treated for severe angina, especially those with unstable disease. Slome1 reported that sudden withdrawal of propranolol therapy was often followed by myocardial infarction, and Olson et al2 described acute and catastrophic exacerbation of symptoms following the abrupt cessation of treatment with large doses of propranolol in patients with coronary artery disease.
The latest warning comes from Mizgala and Counsell,3 who observed 15 acute coronary episodes in 14 patients with severe angina who had been receiving propranolol hydrochloride in daily doses of 80 to 400 mg for periods of seven days to six years. Abrupt cessation of propranolol therapy in these patients produced severe, sudden, acute coronary syndromes. Cessation was followed by rapid worsening of symptoms in 11 of 15
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Snow cute…Credit: Bob Dreeszen
The 36 Hottest Bikinis Ever Worn on Survivor
Snow cute…Credit: Bob Dreeszen
Un ptit gif que j'avais fait pour mon autre tumblr
Utile dans beaucoup de situations :)
Plans have been released by London's Mayor to create elevated cycle lanes designed by Exterior Architecture. 1 UKP allows you to bicycle without buses, trucks or other hazardous elements.
Dubbed 'SkyCycle' - check out a video here.
Is this the future for bicycle commuting in major cities?
Eu falei coração, eu avisei. Mandei você se afastar e parar de bater tão forte quando ele chega perto de ti. Eu falei para as pernas e as mãos pararem de tremer, eu avisei. Agora ta ai, deu nisso. Todo mundo foi pro buraco, todo mundo doido e apaixonado, eu avisei. Eu falei coração, para ir maia devagar e ter certeza de que era certo. Mas não me escuta né? Gosta de se machucar, coleciona cicatrizes. Só desejo que essa não seja tão profunda e cure mais rápido.
This photo is AMAZING!!!
did yall see that commercial about diapers where sisa is looking for absorbent non-plastic ones for crispin n basilio and was asking ibarra and maria for help or was it just me
Comme promis, des gifs pour Frandredi! (et puisque j'ai eu une demande pour des gifs venant de NMT… j'en ai une bonne trentaine à proposer :) )
Quel est votre professeur préférer ? :D
Silver/Silver Chloride cell. Who says chem lab isn't fun? Sometimes you get to play with Hg!
Fresh tunes from Neon Trees, Taking Back Sunday, Lee Bannon and more — it must be New Music Tuesday.
Get it all right here!
what i was expecting:
what i got:
Elibarra Modern/University AU can I get a yes? owo
It's an over-used AU trope but I can't help it. I had to haha XD.
Anyways, I imagine Elias being a senior to Crisostomo, but since he's practically involved in a lot of (varsitarian, academic, social justice, theatre arts, etc.) stuff, he got held back by a few semesters (therefore, delayed na siya huhu).
Crisostomo, on the other hand, can manage being the editor of the campus newspaper and being a councilor for the university's student council, all the while running for summa cum laude and preparing for med school. (E di wow.)
These two are polar opposites IS2G (evident in their clothing styles that blatantly express their social class), but they both agree that the current system sucks thus they seek reformation.
Cris's shirt in the second pic is actually a reference to an Eraserheads' song "Ligaya" (Tatlong oras na akong nagpapa-cute sa 'yo/ 'Di mo man lang napapansin ang bagong T-shirt ko). Wala lang, shameless flirting lang hahaha XD
Das it. Maybe next time I'll draw something agsty for these two. owo/


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"The print and card quality surpassed that of similar companies, but the real standout was the individual customer service given. An adviser called me to discuss my question and when asked to leave a message, they left an actual phone number so that I could call them back! So nice to hear from a person that the design works or that something needs to change instead of trusting the coloring on the computer screen."
"I ordered the light grey and was a little concerned the pattern on the card would be too light. I was pleasantly surprised when I got the cards - they turned out to be absolutely beautiful and look just like the picture. Subtle and classy, I would definitely recommend it!"
"I got this for Thank You cards after my daughters 2nd birthday party. They're pretty adorable. The paper is nice and thick but I was just ever so slightly disappointed with the photo quality. It's probably just the photo I chose or the fact that it's on this thick paper (it just wasn't as clear and smooth as I thought it might be). Overall, I thought it was a great card and would recommend."
"The quality of these cards is very good, very nice cardstock and easy to write on with, I assume, any kind of pen (and I am a picky pen / paper person). They are perfect for our wedding thank you notes. It would be nice if the envelopes had been available in a bigger array of colors, but the card itself is wonderful. Shipped on-time and no issues with delivery or product. Thanks, tinyprints!"
"This Thank You card cover turned out so beautiful! I love the paper it is printed on. I wish I would have paid closer attention to the measurements because I would have ordered a larger size but they turned out so good! Thank you!"


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human rights
HEALhuman rights 2y ago
Lauren Southern: Safe spaces, white tears and getting banned from yet another grouphuman rights 4m ago
The Bobs Award Ceremony 2015 | Documentaries and Reportshuman rights 2h ago
Business & human rights: Next 5 years Part 08human rights 2h ago
Mental capacity and detention - a review of the lawhuman rights 3h ago
Newsroom Swazi Justice Campaignhuman rights 4h ago
شب شعر و داستانخوانی زمانه: مرسده هاشمیhuman rights 5h ago
Denied: Human Rights in Jammu and Kashmirhuman rights 5h ago
African Migration and Human Rightshuman rights 5h ago
Pyongyang Reports on Reddit's Loss of Victoriahuman rights 15h ago
GICJ Interview with RThuman rights 15h ago
Liberation Day celebrations: Kagame asks some Western nations to keep off Rwandahuman rights 20h ago
"Nie Ma Zgody Dla Tej Mowy:" Interviewshuman rights 21h ago
ما بعد الإلحاد؟ وماذا يريد الملحدون؟ رباعية الديمقراطية مع حسن كمال من مصر - برنامج البط الأسود 167human rights 22h ago
US airstrikes claimed at least 6 lives including a child, in Syriahuman rights 22h ago
Head to Head - Israeli settlers: Patriots or invaders?human rights 1d ago
The Fifth Estate: Human Rights Watchhuman rights 1d ago
I DIRITTI UMANI #2human rights 1d ago
ISIS Attacks Heseke Cityhuman rights 1d ago
Mexico Report Says Top Military Officials Ordered Tlatlaya Massacrehuman rights 1d ago
Joel Anico on Instagram: "Un mensaje breve para Human Rights Watch desde NYC"human rights 2d ago
UN Human Rights Council condemn Israel for 2014 war on Gazahuman rights 2d ago
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Gaza One Year Onhuman rights 2d ago
Life in the Canadian Armyhuman rights 2d ago
- afghanistan
- april 7th
- audience award
- beijing
- beijing film academy
- best picture
- big bear
- canada
- chapman university
- child actor
- comic-con
- comic-con international
- feature films
- festivals
- film festivals
- frank capra
- gifted child
- human rights
- imdb
- independent film
- india
- international film festival
- japan
- jury prize
- lake arrowhead
- list of awards
- march 30th
- music
- music festivals
- northern ireland
- oscars
- pakistan
- people
- production design
- rhode island
- sacramento
- san diego
- sci-fi
- science
- short films
- short shorts
- the academy
- the leo
- third eye
- united states
- universities
This film is specially being made available directly to the 'People.' Please SHARE it with EVERYONE, EVERYWHERE. This film may not be copied to any other source or reproduced in any form. THANK YOU :) JOIN HEAL on Facebook: www.facebook.com/heal.film VOTE for HEAL on IMDb: www.imdb.com/title/tt1523296/ CONTACT: firstname.lastname@example.com "Amidst the conflict in Afghanistan and Pakistan, a gifted child makes an extraordinary effort for his people." WINNER, Best Science Fiction / Fantasy Film, Comic-Con International Independent Film Festival 2011 WINNER, Frank Capra Award, Fallbrook Film Festival 2011 HEAL won in 3 categories at the 2011 Silent River Film Festival. Awards received include: - River Rock Award for "Best Child Actor" (Ameer Zhowandai) - River Pearl Award for "Best Child Actress" (Hannah Sher) - River Admiration Award for "Outstanding Short Film" WINNER, Best Student Film, Victoria Film Festival 2011 WINNER, Audience Award (Student Film), Sacramento Film & Music Festival 2011 WINNER, Jesse Epstein Humanitarian Award, Cleveland International Film Festival 2010 WINNER, Audience Award, The 9th International Film & Video Festival of Beijing Film Academy 2010 WINNER, Best Subject, International Festival of Cameramen "Golden Eye" 2010 WINNER, Outstanding Filmmaker (Overall Directing), HATCHfest 2010 WINNER, Best Cinematography, HATCHfest 2010 WINNER, Jury Prize for Best International Shorts (Special Mention), Fantasia International Film Festival 2010 WINNER, Best of Festival, Lake Arrowhead Film Festival 2010 (while in competition against short films, feature films and documentaries. HEAL is the first short film to have ever received this award) WINNER, Best Student Film, Lake Arrowhead Film Festival 2010 HEAL was nominated in five categories at Chapman University's annual CECIL Awards ceremony, winning in four, including BEST PICTURE. List of awards won include: - Best Picture - Excellence in Producing - Best Cinematography - Best Production Design Leo Freedman Award, presented by the Leo Freedman Foundation Award from The Caucus Foundation for Producers, Writers & Directors FILM FESTIVALS Comic-Con International Independent Film Festival 2011, USA (July) Tiburon International Film Festival 2011, USA (April 7th - 15th) Fallbrook Film Festival 2011, USA (April 8th - 10th) Reynolda Film Festival 2011, USA (March 30th - April 2nd) Victoria Film Festival 2011, Canada (February 14th - 13th) Sacramento Film & Music Festival WinterFEST 2011, USA (January 15th - 17th) Foyle Film Festival 2010, Northern Ireland, U.K (November 19th – November 27th). Qualifying film festival for the Academy Awards 9th International Film & Video Festival of Beijing Film Academy 2010, China (November 9th – 11th) Third Eye Asian Film Festival 2010, India (October 28th – November 4th) San Diego Asian Film Festival 2010, USA (October 21st – October 28th) UN Association (O.C) Human Rights Film Festival 2010, USA (October 24th) BendFilm Festival 2010, USA (October 7th – October 10th) HATCHfest 2010, USA (September 22nd – September 26th) Big Bear Film Festival 2010, USA (September 17th – 19th) Rhode Island International Film Festival 2010, USA (August 10th – 15th). Qualifying film festival for the Academy Awards Fantasia International Film Festival 2010, Canada (July 8th – 28th) Short Shorts Film Festival & Asia 2010, Japan (June ...


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Written on: 03/03/2013 by Craig444 (1 review written)
Appalling service.
I booked 3 rooms at the George Inn at Wadworth some 5 days previous, which were all confirmed by email.
I then received a further email 1 day before I started my journey direct from the George Inn only to be told there are no rooms available.
A very poor service and one I will not be experiencing again.
I am still unclear if this is the fault of late rooms or the hotel itself, but all I'd like to say is very poor service indeed.
Written on: 04/03/2013
Hey Craig,
I'm really sorry to hear of the issues you experienced with your booking. I can only imagine how frustrating this must have been.
Please can you email us your details and your booking reference number to email@example.com so that we can investigate what happened?
Kind regards,
As rated by our community of reviewers
" Wonderful trip,super site " Read More
Written by lejik7
" Choose the right time of the year " Read More
" Bookit Misrepresented the Hotel I Booked " Read More
" A dream family holiday in Mexico " Read More
" Quick and easy booking " Read More


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Thank you to all our sponsors, musicians and attendees for making Music Break 2014 a huge success!
More than 200 music and business professionals joined us for an evening of local entertainment and networking.
Looking to experience Music Break all over again or maybe you didn't get the chance to attend this years rocking event, watch it all over again with this feature video by RJ Foley at Light Road Media.
Don't forget to check out the star-studded pictures from Music Break 2014.
We look forward to doing business like rock stars again next year, August 2015!
Thanks to our 2014 Sponsors!


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- 74 1974 Plymouth PB200 Van Fuel Filter 3.7L 6 Cyl VIN: B CARB AC Delco
- 74 1974 Plymouth PB200 Van Fuel Tank Cap 3.7L 6 Cyl GAS Gates
It was pretty clear to navigate to the part I wanted using the web site's built in drop down menus. The checkout was simple (I can't comment if my credit card info will be secure). My order arriv...
Happy customer. Everything went smoothly and I received the part I ordered several days ahead of schedule. The e-mail updates (order confirmation, payment approval, shipper tracking) were great. ...


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Privacy and Cookies
has described the current phase of its ramp-up in A380 production as entering a
critical stage after writing to customers to clarify its current review of the
spokesman for the manufacturer says the review is standard practice for this
stage of a programme ramp-up and stresses that the letter makes no mention of
any changes to the delivery schedule.
has written to the airlines to update the situation after Airbus CEO Tom
Enders' recent disclosure that a major review was currently taking place.
spokesman says the letter reiterates that the production schedule for the A380
"has been challenging and continues to be challenging", noting it is entering a
critical phase.
refers to moving from 'wave one' aircraft to 'wave two' aircraft, which
involves transitioning to an industrial manufacturing process and installing redesigned
electrical harnesses in the jets.
any programme transitioning it is standard practice to have the review," says
the spokesman. Airbus last month passed the power-on milestone for the first of
its 'wave two' aircraft, serial number MSN026.
sources expect the review to take around two weeks. The manufacturer's A380
production plan calls for 13 deliveries this year and 25 in 2009, with output
then stabilising from 2010 at the maximum planned rate of 45 a year.


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The Latest On: Fish and Wildlife Service
Why I Fight For Our Forests: Earthjustice's Kristen Boyles
Monday Reads: The Midway Atoll Tsunami Edition
Several hours after the devastating March 11 earthquake and tsunami struck northern Japan, towering waves raced west across the Pacific, engulfing the three tiny islands of Midway Atoll National Wildlife Refuge.
Congress v. The Environment: The House Is On Fire
As I write this, members of the House of Representatives continue to debate and move their way through votes on hundreds of amendments to the chamber's government spending bill. The voting and debate has been a marathon process, stretching from morning through late at night for the last three days, and looks to carry on until late tonight or tomorrow.
Massive Attacks on Environment Launched in Congress
Teabag by teabag, the anti-environment faction in the House of Representatives has filled its federal government spending bill with amendments that will cripple protections for our water, air, natural resources, wildlife and public health.