text:
A respiratory monitoring apparatus that detects changes in physiological parameters relevant to respiration, including blood oxygen and blood volume, using near infrared spectroscopy. Methods for diagnosing respiratory-related events including hypoxia index, hypopnea, arousal, tissue oxygen debt, and respiratory muscle events or distinguishing central from obstructive sleep apnea are also disclosed.
1. A method of detecting disordered respiration in a patient, the method comprising:
(a) exposing the patient's cerebral tissue to radiation, the radiation having at least first and second predetermined wavelengths, the first and second predetermined wavelengths being between about 730 nm to 770 nm, and 790 nm to 830 nm, respectively;
(b) sensing the levels of radiation reflected by the cerebral tissue at the first and second predetermined wavelengths;
(c) in a calibration step:
(i) determining reflection levels for first and second patient orientations; and,
(ii) using the determined reflection levels to determine a calibration factor; and
(d) in a monitoring step:
(i) calculating a blood oxygen index in accordance with the sensed reflected radiation and the calibration factor; and,
(ii) detecting a presence or absence of disordered respiration in the patient based at least in part on changes in the blood oxygen index determined in accordance with the calibration factor.
2. The method according to
3. The method according to
4. The method according to
(e) the patient lying on their back; and,
(f) the patient lying on their side.
5. The method according to
A is the reflected level at the first predetermined frequency; and,
B is the reflected level at the second predetermined frequency.
6. The method according to
|B−kA| or [Ak−B]
k is the calibration factor.
7. The method according to
8. The method according to
9. The method according to
10. The method according to
a) selectively exposing the patient's cerebral tissue to radiation;
b) sensing reflected radiation when the patient's cerebral tissue is exposed, to determine an exposed level;
c) sensing radiation when the patient's cerebral tissue is not exposed to determine an ambient radiation level; and,
d) determining a reflected level by subtracting the ambient radiation level from the exposed level.
11. The method according to
12. The method according to
13. The method according to
14. A method of monitoring flow response times to hydrostatic pressure adjustments in a patient, the method comprising:
(a) exposing the patient's cerebral tissue to radiation, the radiation having at least first and second predetermined wavelengths, the first and second predetermined wavelengths being between about 730 nm to 770 nm, and 790 nm to 830 nm respectively;
(b) sensing the levels of radiation absorbed by the cerebral tissue at the first and second predetermined wavelengths;
(c) in a calibration step:
(i) determining absorption levels for first and second patient orientations; and,
(ii) using the determined absorption levels to determine a calibration factor; and
(d) in a monitoring step:
(i) calculating a blood oxygen index in accordance with the sensed absorbed radiation and the calibration factor; and,
detecting a flow response time to a hydrostatic pressure adjustment in the patient based at least in part on changes in the blood oxygen index determined in accordance with the calibration factor.
15. An apparatus for detecting disordered respiration or a flow response time to a hydrostatic pressure adjustment in a patient, the apparatus comprising:
(a) a radiation source for exposing the patient's cerebral tissue to radiation, the radiation having at least first and second predetermined wavelengths, the first and second predetermined wavelengths being between about 730 nm to 770 nm, and 790 nm to 830 nm respectively;
(b) a sensor for sensing the level of radiation reflected by the cerebral tissue at the first and second predetermined wavelengths; and,
(c) a processor for:
(i) in a calibration step:
(a) determining reflected radiation levels for first and second patient orientations; and,
(b) using the determined absorption levels to determine a calibration factor; and
(ii) in a monitoring step:
(a) calculating a blood oxygen index in accordance with the sensed absorbed radiation and the calibration factor; and,
(b) detecting a presence or absence of disordered respiration in the patient based at least in part on changes in the blood oxygen index determined in accordance with the calibration factor.
16. The apparatus according to
17. The apparatus according to
18. The apparatus according to
19. The apparatus according to
(a) selectively activate the radiation source to thereby expose the patient's cerebral tissue to radiation;
(b) selectively sample signals from the sensor to thereby sense radiation when:
(i) the patient's cerebral tissue is exposed to determine an exposed radiation level;
(ii) the patient's cerebral tissue is not exposed to determine an ambient radiation level; and,
(c) determine a reflected level by subtracting the ambient level from the exposed level.
20. The apparatus according to
21. The apparatus according to
(a) a processor for controlling the radiation source and a sampling time interval of the sensor; and,
(b) a memory for storing reflected level signal values.
22. The apparatus according to
23. The apparatus according to
24. The apparatus according to
25. The apparatus according to
26. The apparatus according to
27. The apparatus according to
28. The apparatus according to
29. The apparatus according to
30. The apparatus according to
31. The apparatus according to
32. (canceled)
The present application claims the benefit of provisional application Ser. No. 60/558,364, filed Mar. 30, 2004, the disclosure of which is expressly incorporated by reference herein in its entirety.
The present invention relates generally to medical devices that provide information regarding respiratory parameters.
Respiratory monitoring is a crucial tool for clinical diagnostics and patient safety, particularly when a subject is unconscious, such as during sleep or an induced unconscious state.
In the current diagnosis of disordered respiration, such as sleep apnea, extensive instrumentation is required. Techniques and devices used for diagnosing sleep apnea include electroencephalograms, electrocardiograms, electromyographs, pulse oximetry, ocular and body movement strain gauges, snoring recording, postural position monitoring and respiratory gas flow monitoring. In practice, only four or so of these transducers will be attached in most sleep clinics.
Nasal airflow (or pressure) transducers are generally used to provide the main signal for apnea/hypoapnea scoring, although pulse oximetry (as a measure of arterial blood-oxygen) and electroencephalography (as a measure of arousal) are used as confirmatory information. Linear displacement transducers may be used for detecting chest and abdomen expansion as a measure of respiration and sound (snoring) levels recorded. Some of these transducers have been modified for home monitoring, thus reducing costs associated with sleep clinical diagnostics, however, technical assistance at set up is still recommended based on studies comparing user or technician monitoring set up (Gaqnadoux and Pelletier-Fleury, Chest (March) 2002).
The signal derived from the transducer provides a trace showing the inhalation/exhalation cycle, and time periods of no respiratory activity. It is also useful in estimating periods of insufficient respiration, such as those characteristic of hypopnea (Hemdndez et al., Chest 2001; 119:442-450), although confirmatory evidence is generally needed for the latter, either oxygen desaturation (pulse oximeter) or else arousal (usually EEG or accelerometer) or both.
There are several causes of sleep apnea. Obstructive sleep apnea (OSA) is the more common form, characterised by the soft palette blocking the air passage. During OSA, diaphragm movement persists in respiratory effort. This does not occur with central sleep apnea, where breathing stops due to lack of respiratory muscle effort induced by lack of cerebral signal for respiratory muscle contraction. Mixed sleep apnea results when both of these effects occur.
During mouth breathing, nasal prongs give false positive apnea events, and generally the signal is poor during periods of snoring, a parameter which in itself is characteristic of sleep apnea. However, monitoring snoring as a diagnostic parameter has limited diagnostic value unless used in conjunction with other transducers (Hemdndez et al., Chest 2001; 119:442-450).
Pulse oximetry is universally used to monitor blood-oxygen saturation in patients during respiratory studies. The pulse oximeter probe is designed for clamping to a finger, and provides a measure of the arterial blood-oxygen saturation level mainly in the skin. There are several disadvantages in using oximetry for measuring hypoxia, including:
1) The skin (finger) is a low metabolizing tissue that is unlikely to reflect the oxygen saturation changes experienced by high metabolizing organs, particularly the heart and brain.
2) The finger attachment is not appropriate for use on subjects who thrash around during the study, as a consequence of continual arousal (dislodgment of the oximeter probe is one of the most common equipment failures in respiratory monitoring). Body movement leads to changes in baseline referred to as movement artefact, which can be inaccurately interpreted as desaturation events. Tightly clamping probes, which can reduce this movement artefact, tends to be uncomfortable when used for long periods.
3) The accuracy of pulse oximetry at low blood-oxygen saturation levels has been called into question by investigators (Mertzluffi and Zander, (1991); In the Oxygen Status of Arterial Blood. Ed. Zander R. and Mertzlufft F., Publ. Karger, N.Y., p 106-123).
4) The pulse-oximeter depends on pulsatile blood flow for timing in sampling. During hypoxia, pulsatile flow can be difficult to pick up in the skin due to tissue capillary-bed bypassing of the blood in the skin, via arteriolar-venular shunts, when oxygenated blood is diverted to increase critical tissue perfusion.
A positive diagnosis of sleep apnea is generally made if the instruments recording signals indicate five or more apnea events per hour (each exceeding 10 seconds) during sleep. An excess of 30 apneas per hour is usually required for a clinical diagnosis of severe sleep apnea. Many clinics also include hypoapnea scoring (insufficient respiratory rates for >2 minutes) based on respiratory airflow data and/or the number of arousal's recorded per hour.
Diagnostic scoring can be ambiguous for milder to moderate sleep-apnea conditions, with some clinicians recommending studies over two nights to reduce false positive/negative diagnosis (Le Bon et al., Chest (August) 2000). The high cost of sleep clinic studies, and the number of possible candidates to be screened, means that screening of all patients requiring this extended testing is not cost effective, and thus often not feasible.
A number of biomolecules absorb near infrared radiation at specific wavelengths via bond stretching or dipole interactions, and this property is utilised by near infrared spectroscopy (NIRS) (Dyer, (1965) pp. 22-57, Pub. Prentice-Hall Inc. New Jersey). Like oximetry, NIRS detects photons at two or more wavelengths that have been scattered through tissue. The flux densities of the emerging photons (at 750 nm and 810 nm), are proportional to the ratio of deoxyhemoglobin:oxyhemoglobin within the tissue, and can be used to calculate the physiological parameter of blood hemoglobin oxygen saturation.
NIRS methodology differs from pulse oximetry in two important respects:
The low penetration depth of the radiation used in pulse oximetry (less than 10 mm at a wavelength of ˜660 nm), means it is unsuitable for non-invasive deep tissue blood-oxygen assessment. In contrast, a device using NIR-radiation only can readily penetrate bone and assess deep tissue.
The present invention relates to methods and devices for monitoring or diagnosing disordered respiration in a patient.
In a first broad form, the invention provides a method of detecting disordered respiration in a patient, the method comprising:
Preferably, the disordered respiration is a sleep-related respiratory deregulation and in a particularly preferred form, is obstructive sleep apnea, central sleep apnea or both.
Preferably, the first and second patient orientations include:
In a further preferred form, the blood oxygen index is determined in accordance with the equation:
In a preferred embodiment, the blood oxygen index is determined in accordance with one of the following equations:
Preferably, the calibration factor is determined empirically so as to reduce effects of hydrostatic head change effect on the blood oxygen index.
Preferably, the method includes using first and second light-emitting diodes (LEDs) to generate the first and second wavelengths respectively.
Also preferably, the method includes using a photodiode to sense the absorbed radiation.
In a further preferred form, the method includes:
Preferably, the reflected values for the first and second wavelengths and ambient light are consecutively sampled at least 30 times per second.
In a further preferred form, the method includes using algorithms to calculate parameters selected from the group consisting of oxygen debt accumulation value during insufficient respiration, hypoxic value of apnea events, pulsatile flow, blood volume cycling, diaphragm movements during respiration patient wherein a movement is indicative of obstructive, central or mixed type sleep apnea, arousals during an unconscious state and recovery time to quiescent saturation.
Preferably, the method includes performing the monitoring step for a predetermined time period.
In a further form, the invention relates to a method of monitoring flow response times to hydrostatic pressure adjustments in a patient, the method comprising:
In another broad form, the invention relates to an apparatus for detecting disordered respiration or a flow response time to a hydrostatic pressure adjustment in a patient, the apparatus comprising:
Preferably, the radiation source includes first and second LEDs for generating the first and second predetermined wavelengths respectively.
Preferably, the sensor includes a photodiode for sensing the reflected radiation.
In another preferred form, the apparatus includes controller for controlling the operation of the radiation source and the sensor.
Even more preferably, the controller is adapted to:
Preferably, the controller is adapted to cause reflected values for the first and second wavelengths and ambient light to be consecutively sampled at least 30 times per second.
Also preferably, the controller includes:
Preferably, the processor is adapted to control a pulsed radiation source, and even more preferably, a sampling time interval of the sensor.
In another preferred form, the processor is adapted to perform at least some processing of the reflected level signals.
Preferably, the controller includes a communication means for transferring data to a remote processing system, the remote processing system being adapted to perform at least some processing of the reflected level.
Even more preferably, the remote processing system is adapted to display a reflected level.
In a preferred form, the apparatus includes a user input for controlling the controller.
Preferably, the user input is used for selectively activating at least one of the calibration step and the monitoring step.
Even more preferably, the controller is provided in a housing.
In a particularly preferred form, the housing is suitable for home use by a patient.
Preferably, the radiation source and the sensor are provided in a probe coupled to the housing, the probe being adapted for attachment to the patient in use.
In a particularly preferred form, the probe is formed from silicon rubber.
In another form, the apparatus is adapted to perform the methods of the invention.
The present invention involves apparatus and methods, for the diagnosis or monitoring of disordered respiratory regulation or flow response time to hydrostatic pressure adjustment in a patient.
An example of apparatus suitable for detecting sleep apnoea will now be described with reference to
In particular, the apparatus is adapted to perform near infra-red spectroscopy (NIRS) and is therefore typically formed from a processing system 10 coupled to suitable radiation sources 11, 12, a detector 13, and an amplifier 14. In one example, the processing system 10 is formed from a microprocessor 20, a memory 21, and an external interface 24, coupled together via a bus 23. In this case, the radiation sources 11, 12 and the amplifier 14 are coupled to the external interface 24 as shown.
In use, the radiation sources 11, 12 are adapted to generate near infra-red radiation at respective predetermined wavelengths, with the radiation being detected by the detector 13. The output from the detector 13 is amplified and sampled by the amplifier, which therefore typically includes an analogue-to-digital converter, to provide a digital signal to the processing system 10.
This is typically achieved by utilising two near infra-red light emitting diodes (LEDs) adapted to emit radiation at approximately 750 nm and 810 nm respectively. The detector 13 is typically a photodiode adapted to detect radiation at these wavelengths, which may be achieved through the use of a standard photodiode and an appropriate bandpass filter, as will be appreciated by persons skilled in the art.
The processing system 10 is adapted to control the operation of the LEDs 11, 12, the detector 13 and the amplifier 14, as well as to store and optionally process any sampled signals. Accordingly, the processing system may be any form of processing system provided with suitable applications software and a suitable external interface. Thus the processing system may be formed from a suitably programmed personal computer, lap-top, palm-top, PDA, mobile phone, or the like, or may be implemented using a suitable custom hardware configuration, as will be described in more detail below.
In operation, the processing system is adapted to selectively activate the radiation sources 11, 12 in accordance with a predetermined pulse sequence. This is typically performed such that each radiation source 11, 12 is activated at a respective time, with signals from the detector 13 being sampled at times to coincide with times at which the radiation sources 11, 12 are activated. An example of a suitable pulse sequence is shown in
It will be appreciated from that person skilled in the art that the device may be formed on specialised hardware or the like. In one example, shown in
In this example, the photodiode is coupled to an electrometer amplifier 14 whose external signal input terminals are impedance matched to the photodiode to reduce the photodiode's capacitive load, and thereby improve response time to signal changes. The amplifier 14 also functions as a current-to-voltage converter plus amplifier (gain=1000) providing a proportional conversion to a voltage from the photon flux reaching the photodiode.
The probe is coupled to a housing 31 via a 2 meter flexible polypropylene 6-core ribbon cable 32. The housing 31 houses the processing system 10, and an associated power source, such as a battery, and is provided with a number of input and output devices including an on/off switch 33, a calibration switch 34, and three visual indicators 35, 36 and 37.
In use, activation of the on/off switch 33 causes power to be supplied to the processing system allowing the system to be activated. In general, this also triggers the LEDs 11, 12 and the detector 13, thereby causing measurements to be made. The indicating devices 35, 36, which are typically LEDs are utilised to indicate mark signal levels of the orientation of the patient whilst an indicating device 37 is used to indicate whether the device is active. Finally, the calibration switch 34 is used to cause the device to be calibrated. The LEDs, 35, 36, are illuminated when the device is turned on via the on/off switch 33. When the patient is lying on their back, the calibration switch, 34, is pressed. This action extinguishes indicating device 35, suitably providing a specific voltage to be recorded within a blood volume signal which provides a mark for the blood volume level present when the patient is on their back. Similarly, the patient then lies on their side and the calibration button, 34, is again pressed so that device 35 is extinguished and a specific voltage included with the blood volume signal to indicate blood volume level expected when the patient is lying on their side. The graphical representation of these calibration steps are shown in
In one example, the probe 30 also include a ground plate, which in use is in contact with the patient's skin, thereby reducing AC-line pickup.
Once the device is activated, by turning on the on/off switch 33, sampling of signals from the photodiode 13 will begin immediately. In this example, the signals from the photodiode 13 are amplified by the amplifier 14, before being transferred to the processing system 10, where the signals undergo 10-bit analogue-to-digital conversion by the processor 20. Signals for each wavelength plus ambient light are consecutively sampled at 50-times per second, with the ambient light signal voltage being subtracted from each NIR-LED signal voltage. An indication of the signal voltage is stored in the memory 21, which may be a Flash-RAM memory module, or the like.
The stored data can then be subsequently transferred to a remote system, such as PC, for analysis. In one example, this is achieved using a USB port 38, although it will be appreciated that this could also be achieved by wireless communication between the processing system 10, and the remote system, or by removal and physical transfer of the memory 22, for example if the memory 22 is provided on removable media.
In this case, the data is transferred to a remote system for analysis. However, it is also possible for the processing system 10 to perform initial analysis of the result, with an indication being provided by a suitable output. For example, the stored signal would be processed to identify events within physiological parameters, such as a peak-to-peak time for a pulsatile flow, respiration ratess, blood flow cycling with hypopnea and voltage transitions characteristic of arousal peaks in the blood volume signal. Analysis simultaneous transitions in blood volume and blood oxygen transitions may be used for characterising apnea events. Deregulation in a respiratory parameter could then suitably be displayed to an inbuilt LCD screen, or be used to set off an alarm.
Physiological events can be obtained for use in the methods of the invention using an apparatus shown in
The trace in
Accordingly, it is preferred that for each patient, the device's calibration set up is needed (provides the trace's calibration mark) while the subject is in each postural position. The values measured can then be used to track postural changes during a monitoring or diagnostic study. Preferably, the trace obtained during such a study can be used to infer other postures. Using the trace in
Signal level movements correlating with postural changes usually result in changes in the blood-oxygen signal. These shifts are not due to metabolic changes but rather changes in deoxyhemoglobin:oxyhemoglobin (Hb/HbO2) proportions. Unlike the arterial circulation, which is maintained within a pressurised range, blood pressure in the veins is close to atmospheric pressure. The extent of venous blood engorgement within a tissue is dependent on the hydrostatic venous blood pressure head in the tissue relative to height above (or below) the right atrium. As such, there is sufficient difference in hydrostatic height in a subject lying on their back compared to their side to give a distinct signal level for each supine posture, illustrated in
The consequences of the venous blood shift is that body movements can mask real changes in oxygen saturation levels. Much of this interference can be removed by modifying the blood-oxygen algorithm, such as by using the calibration values for 'back' and 'side', by employing a multiplying factor "k" value until the shift in blood-oxygen with posture change is minimized in the trace.
Cerebral blood flow is controlled by arteriole contraction/dilation and hydrostatic head height, assuming constant mean blood pressure. When the hydrostatic head is increased, such as when a subject moves from their side to their back, flow has to readjust. With increased negative hydrostatic head, cerebral flow rate increases until the arteriole's vascular smooth muscle adjusts flow rates back to homeostasis. Accordingly, the rapid transient positive peak in the
Flow response times to hydrostatic pressure adjustments have not been monitored non-invasively before, so the potential diagnostic value has not been explored. This apparatus and methods of the invention may thus be applied to explore possible response times as they relate to pathologies.
The apparatus and methods of the invention will now be illustrated by way of the following, non-limiting Examples.
Use of NIRS for Measuring Physiological Parameters
(i) Blood Oxygen Saturation (StO2) Index
Finally, the wavelength at which the light absorption is independent of blood oxygen saturation levels, 810�5 nm, called the isosbestic wavelength, is also marked indicated in
Above 810 nm, oxyhemoglobin shows a higher absorption than deoxyhemoglobin, the converse occurs below 810 nm.
A percentage of oxygen saturation of the hemoglobin within a tissue of interest can be calculated using NIRS from the following equation:
The comparison of absorption between wave lengths 760 nm and 8100 nm provides a measure of the proportion of blood in which oxygen is bound to hemoglobin (Hb), ie Hb/(Hb+HbO2) (Sevick et al., (1991) Anal. Biochem. 195: 330-351).
(ii) Blood Volume Signal
Blood volume within a tissue can be quantified using NIRS by measurement of the concentration of hemoglobin or red blood cells within the photon path. Incident photons from NIRS are attenuated due to scattering by tissue, and also by absorption, the latter principally by hemoglobin (Sevick et al., (1991) Anal. Biochem. 195: 330-351). While attenuation due to photon scattering in tissue will be constant (for a given measurement site), hemoglobin absorption will vary as the tissue blood content changes.
Relative blood volume measurements can be obtained from a signal generated from photons at around the isosbestic wavelength of 810 nm, which is independent of changes in tissue hemoglobin oxygenation percentage (StO2) (ie cross talk between oxyhemoglobin-to-deoxyhemoglobin proportions).
While other tissue chromophores can also absorb in the near infrared range, particularly in neural tissue (eg cytochrome C), their effect on signals derived from wavelengths of 810 nm or lower is minimal, relative to the degree of hemoglobin absorption within the tissue.
(iii) Tissue Blood Content (TBC)
Non-invasive blood volume measurements using NIRS can show changes in hemoglobin concentration in the photon path and indirectly, blood flow changes. Hemoglobin is confined to blood vessels, where the red blood-cell concentration of blood or hematocrit (Hct) is generally between 40 to 45% (packed red blood cells/100 ml whole blood). The average hemoglobin concentration distribution within a volume of tissue through which the photons pass will average one tenth or less of this value. For instance the TBC for forebrain ranges between 2 to 5% Hct, (as a proportion of packed red blood cells/100 ml tissue volume). This is similar to blood hematocrit (Hct) except that it applies to whole tissue rather than just blood.
Device Linearity for the Measurement of Blood-Oxygen
Materials and Methods
Results and Discussion
In contrast, the 810 nm signal (top trace) remained insensitive to the changing blood-oxygen level, consistent with it being the isosbestic wavelength.
Hence the 850 nm-750 nm signal represents the blood-oxygen index while the 810 nm signal represents blood volume index. In subsequent blood-oxygen calculations in sleep studies 750 nm -810 mm was found to be particularly suitable, as use of a calibration factor in further Examples allowed the voltage signal of the 750 nm value to remain positive.
As almost all deoxyhemoglobin is in the venous compartment of the vasculature (with normal pulmonary and cardiac function), the signal, 750 nm-810 nm, provides an index of venous blood-oxygen (SvO2) proportion. This assumes an arterial oxyhemoglobin value greater than 95%. This is not the case during respiratory insufficiency, in which case the blood-oxygen index is proportional to the global blood-oxygen saturation in the measured light path.
Interpretation of Spectra Acquired by the Monitoring Apparatus: Analysis of Apnea Events
The apparatus schematically depicted in
This suggests each brief recovery period was sufficient to return both oxygen saturation and blood volume to quiescent conditions, resulting in little oxygen stress. Examining the trace at briefer time intervals, enables the counting the number of these apnea events over time and thus a score of apnea or hypopnea events per hour can be obtained, as required for standard diagnostic criteria of sleep-disordered breathing.
Three traces recording a series of deep apnea events in a patient, recorded over an approximate time period of ten minutes, are shown in
Using the nasal prong signal as the standard, each apnea event is ranked according to the period for no nasal airflow (absence of signal cycling). Given constant body metabolism, the level of blood-oxygen desaturation should be proportional to the time of no respiration shown by the airflow transducer. The 'depth' of each apnea event should correlate with the time for which no air is exchanged in the lung.
The signals from both the apparatus according to
There was a significant correlation between the response of the airflow transducer as a measure of apnea severity to that of the desaturation signal measure using the apparatus shown in
The slope of the dotted line through the trace in
Using the conventional scoring technique, the series of apnea events for the results in
An oxygen debt index can be calculated based on the slope of the decrease in blood oxygen (dotted line) multiplied by the time period for which blood-oxygen remained below the quiescent value. This would draw a sharper distinction between adverse effects resulting from repeat arousals and effects due to periods of hypoxia.
The thin vertical dotted lines in
Oxygen debt was not apparent in the arterial oxygen saturation trace recorded by the pulse oximeter.
Blood Volume Cycling Due to Respiratory Insufficiency
The top trace is of blood volume index in which approximately 15 second cycling was occurring. An expanded segment of the trace resolves systole pulsatile flow (top right in blood volume trace) from which the heart rate was calculated. Beats per minute (BPM) for peaks and troughs were calculated in the cycling blood volume. The cycles evident in the blood volume can just be distinguished within the airflow trace, shown by dotted lines.
There was little evidence in the blood-oxygen signal (bottom trace) of oxygen deficiency. In part this could be attributed to the cyclic increases in blood volume compensating respiratory decreases. By examining heart rates in the blood volume trace, it was evident that the blood volume cycling was a response (at least in part) to a varying heart rate of 5%. It also seems probable that the heart response was not triggered by blood oxygen insufficiency in cerebral tissue. So the cycling flow could be attributed to increased/decreased cardiac output rather than a local vascular dilation/contraction response, the cyclic variation in the airflow signal provides supportive evidence that this blood cycling was not artefact.
It is difficult to know how to classify these events as most likely they go undetected so unreported in sleep studies. The cycling is likely to have been induced by respiratory resistance such as pre- or mild hypopnea.
(i) Acquiring Hypopnea Events in Sleep Studies
Generally, attempts are made to score hypopnea events as part of the overall diagnosis of sleep apnea. It is difficult to estimate pathologies that may result from repeated nightly hypopnea events. Although inducing repeated arousals is an obvious detrimental effect which often accompanies hypopnea.
(ii) Measuring Arousals in Response to Apnea Events
One of the characteristics of sleep apnea is the repeated arousals in response to respiratory blockage or insufficiency.
These arousals are not evident in the airflow trace and not all were picked up by a leg-mounted accelerometer transducer. This is likely to occur because arousals may arise as head movement only, so a body or leg movement transducer may not provide an accurate score of arousals', compared to the apparatus and methods of the present study.
Scoring Respiratory Events
It is evident in
A probable source of blood volume changes, in synchrony with respiration, in the signals detected according to the present invention is with heart movements.
Based on the much lower amplitude recorded in blood-oxygen trace, their likely source is blood hydrostatic head changes. Heart displacement is induced by its being coupled to the diaphragm muscle via the pericardium so moving in sympathy with respiration. The changes in hydrostatic head are illustrated in the diagram in
The difference between obstructive sleep apnea and central sleep apnea is the lack of movement of respiratory muscle with the latter. This can be observed in
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Top message: FOR THE FOOLS WHO WANT TO SWITCH PROVIDERS, AND THE PEOPLE WITH VERIZON WHO NEED A LAUGH by sportyross13
Replying to: Re: GUESS WHAT IM HOLDING IN MY HANDS TOMORROW? by Turtle
Re: GUESS WHAT IM HOLDING IN MY HANDS TOMORROW?
thanks turtle. unfortunately i've been with ATT for over 4 years now and have hated every minute. now that the number port is available, i've just been waiting for my latest contract to be up. it ends today! and i'm dying to switch to verizon but if the 9900 is coming in the next couple weeks and if i can afford it (i do get a discount through my company but i don't know if new phones are put on the extranet list immediately), i'll wait to sign up until it comes out. if i can't afford it, then i'll just go get the 8900. although i was thinking the 8900 price may drop when the 9900 comes out, so maybe i should wait either way.
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This week: Plenty of smart grid project wins and partnerships
By: SGN Staff
We have a lot of smart grid wins for you to peruse this week, including a broad array of projects, several partnerships and awards recognizing excellent work. So we'll get right to it.
AES Corporation is now operating more than 100 MW of grid-scale storage resources with the commercial operation of its 40 MW resource in Ohio. Located at Dayton Power and Light's (DP&L) Tait generating station in Moraine, Ohio, the project is providing fast-response frequency regulation services to PJM Interconnection to stabilize the grid that serves more than 60 million people. The facility is the largest of its kind in Ohio and helps to meet needs otherwise provided by power generation from inefficient or retiring power plants, reducing overall system emissions and water use while optimizing existing grid resources. Read more >>
Alstom Grid has completed a major on-time power system equipment upgrade for American Electric Power unit Appalachian Power. This upgrade improves the power quality of the local electricity network while boosting production and reducing maintenance costs for a steel mill located in Roanoke, Va. The project, delivered by Alstom Grid's North American Flexible AC Transmission System (FACTS) division, involved the refurbishment of a Static VAr Compensator (SVC) - originally installed and commissioned by Alstom more than twenty years ago. SVCs are used in electricity transmission systems and industrial plants to stabilize voltage and reduce fluctuations as part of a Flexible AC Transmission System network. Read more >>
Flextronics has expanded its portfolio of energy infrastructure solutions and services that will help original equipment manufacturers (OEMs) address regional shifts in the energy market by developing and delivering products to market faster, enhancing their regional market reach, and freeing up cash flow by leveraging Flextronics' global capabilities. Read more >>
Silver Spring Networks, platform and solutions provider for smart energy networks, and CPFL Energia, Brazil's largest private electricity group, announced the successful completion of the Grupo A client smart grid rollout in the state of Sao Paulo. The next phase, which calls for CPFL to implement the smart grid for Grupo A clients in the state of Rio Grande do Sul, is expected to bring the total number of commercial and industrial customers connected to over 25,000 by the end of 2014. Read more >>
Cisco and Portugal Telecom announced a strategic relationship engagement through which Cisco and PT - through its Information Services subsidiary PTSI and other PT affiliates - will collaborate on Cisco Smart+Connected solutions in several countries throughout Europe, Africa and South America. Cisco will work with PT and PTSI over the next three years to build out the smart solutions portfolio. Cisco is collaborating with PT on a number of key initiatives, including: smart solutions, smart work centers, Smart+Connected City Wi-Fi, connected transportation, and sports and entertainment. Read more >>
OATI, a provider of software solutions to the North American energy industry, and the National Rural Telecommunications Cooperative (NRTC), today announced that they have entered into a strategic alliance to deliver demand-side Software-as-a-Service solutions that will help rural utilities successfully administer the complexities of their power management operations. Read more >>
E.ON, an energy company, has partnered with Opower, provider of customer engagement solutions for the utility industry, to launch the 'Saving Energy Toolkit' - an innovative solution that will help customers understand and transform their home energy usage. Available to E.ON customers, the online Saving Energy Toolkit provides an insightful analysis of a household's energy use, including where and when energy is being used with a breakdown of costs and information on how they compare to other customers in their local area. Read more >>
Tollgrade Communications announced that it has been recognized by this year's Fierce Innovation Awards: Energy Edition, a unique industry awards program administered by the publishers of FierceEnergy and FierceSmartGrid. Tollgrade's LightHouse® distribution monitoring platform, consisting of Medium Voltage (MV) Smart Grid Sensors and Sensor Management Software (SMS) with Predictive Gridâ" Analytics received top honors in the "Substation Automation and Distribution Automation" category. Read more >>
Joulebug, the sustainability app company headquartered in Raleigh, today announced that it has been selected as the winner of the 2013 Splunk Revolution "Do-Gooder" Award. The award recognizes an outstanding use of Splunk® software for social good and was presented at .conf2013, the fourth annual Splunk Worldwide Users' Conference. A panel of Splunk employees selected Joulebug for being a premiere example of how machine data analytics can unlock insights that benefit society. Read more >>
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Part 2 of a Tribune investigation finds that for many U.S. veterans, the bureaucratic fight to be compensated for health problems linked to Agent Orange amounts to a new and unexpected war, long after the shooting ended overseas. Complete coverage >>
Jack Cooley delivered his final argument in a long, distinguished legal career from a hospital bed.
Four months before succumbing to multiple myeloma, the Chicago-area Vietnam veteran and federal magistrate judge wrote a 140-page claim for justice and filed it with the U.S. Department of Veterans Affairs. Cooley's message to the government was personal and direct: Agent Orange is killing me, and you need to take responsibility.
Cooley didn't know it last spring, but when the former Army artillery captain filed his disability claim, he was just entering a maddening bureaucratic maze many veterans know well. The VA would kick back Cooley's claim after a month, saying he lacked the required proof he'd served in Vietnam.
Cooley could have spent months navigating this convoluted path. But with Cooley's life fading, his family reached out to an old friend, a member of his West Point class of 1965. It was former Army Chief of Staff Eric Shinseki, recently appointed secretary of the Department of Veterans Affairs.
In short order the obstacles to Cooley's claim disappeared. The VA delivered three monthly disability checks for $2,700 before Cooley died July 21, at 65, in Evanston.
"This was insult to injury," said his daughter Christina. "If Gen. Shinseki was not ... a family friend and a West Point classmate, we would have never seen a dime. It makes me think about everybody else out there struggling without resources."
The Vietnam War ended almost 35 years ago, but for many veterans, battles with cancer, diabetes, Parkinson's disease and other maladies associated with defoliants used in the war are only now beginning. Until 2007, Jack Cooley had been in good health.
For many veterans, this is the unexpected new war, long after the old one ended.
The government has been slow to recognize the connection between wartime service and debilitating diseases that strike Vietnam veterans decades later. Even when they suffer from conditions officially linked to Agent Orange, veterans can wait years for their requests for disability compensation to run through the VA system.
Jack Cooley's death from multiple myeloma, a form of blood cancer associated with exposure to Agent Orange, opens a window into the clogged workings of the VA, the final arbiter on war-related disability claims.
"The truth is, veterans who went to Vietnam returned much sicker than their (civilian) peers. Something happened over there. Why arm wrestle over it?" said Linda Schwartz, commissioner of veterans affairs in Connecticut and the author of early studies on the health of female veterans.
The VA declined requests to interview Shinseki, who has said he wants to change the culture at the agency and make it more of an advocate for those who serve the country.
As long-dormant effects of Agent Orange begin to surface in many Vietnam War veterans, the backlog of disability claims has been growing fast, despite the VA's adding more than 3,000 employees to handle the traffic jam.
"They're overwhelmed," said Joe Moore, a former VA attorney who now represents veterans in cases against the agency. "They simply can't do the decision-making fast enough."
In response to a December 2008 lawsuit filed in U.S. District Court in Washington seeking to force the VA to decide claims in 90 days, the government acknowledged that "certain diseases for Vietnam-era veterans" are contributing to the backup.
The lawsuit, filed by the Vietnam Veterans of America and Veterans of Modern Warfare, argues that "thousands of veterans die each year" before the VA acts on their disability claims. The lawsuit alleges the VA takes at least six months to consider an initial request, and appeals can drag on for years.
"In the face of such delays, many veterans simply give up, choosing to accept less than they deserve rather than to endure years of delay and frustration," it said.
Or they just die early. According to data from the VA, 58 percent of the 490,135 Vietnam veterans who died from 2000 to 2007 were younger than 60.
Agent Orange's lethal legacy: For Vietnam War veterans, injustice follows injury
Vietnam vets wait years and fight skeptical agency to get disability
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A U.S. Army soldier presents a folded U.S. flag to Christina Cooley at the memorial service in Evanston's Sheil Chapel for her father, Jack Cooley. Exposed to Agent Orange during his service in Vietnam, he died in July of multiple myeloma. At right is Christina's brother, John. (Tribune photo by Chris Walker / September 12, 2009)
- Agent Orange's lethal legacy: The next generation
- Interactive map: Track spraying missions by year, location
- Agent Orange: Full coverage >>
- The legacy of Agent Orange
- Jack Cooley: Felt betrayed by his government
- Ted Hutches: His daughters' lives 'destroyed'
- James Sprandel: Legs drained of their strength
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Giant Light Crushes High School Wrestler During Match [VIDEO]
You may think a quick pin is a good way to win but everyone knows the best way to beat someone in wrestling is to crush their head with a giant light!
You may think a quick pin is a good way to win but everyone knows the best way to beat someone in wrestling is to crush their head with a giant light!
Apparently kids need more "variety" today. That is one of the reasons why Fred Flintstone has been replaced by a professional wrestler on the Fruity Pebbles box. Although it is a "limited" run (only four million boxes), apparently John Cena is just the first of many people who will be gracing the brightly colored cereal's box.
I've wined and dined in the Garden of Eden brother, I've hung and bung on the titanic but what you going to do when Hulk "Hogan's Beach" Come for you?
A man with a fuzzy belly, a Latvian Oak, Green Ant and a chick with a mask? If you didn't attend the Wrestling is Awesome show in Troy NY then you simply missed out on all this!
Professional wrestlers may seem like tough guys, but underneath their shiny spandex outfits and long, flowing hair (clearly a sign of ultimate masculinity), they have hearts of gold. Daniel Bryan, for example, recently met with a seven-year-old boy who has had brain cancer for almost four years, and says he's Bryan's biggest fan. It's okay if you need to go grab some Kleenex before you look at the pictures.
There's something about a girl in a mini-skirt skipping around a wrestling ring that's very appealing to males. Whether you're into her looks, her character or you just dig crazy chicks, A.J
There are two things I love in this world and that is strippers and professional wrestling. Final a video that combines the two!
Portlandia has endeared the nation, nay, the world to the weird charm of Stumptown aka Rose City. Many might not know the area is actually a strip club haven – with exotic dancers that are more akin to SuicideGirls than Hooters waitresses. If you need further reason why Portland should be your next travel destination – we present Portland's 2nd annual Bacon Cup, which combined man's favorite food with our favorite spectator sport – stripper wrestling.
I'm on the road once again this time near Boston MA. I meet up with Matt Taven who has stories of interesting encounters with several Wrestling legends.
I recently traveled to Bethany CT to do a little professional wrestling and I had the opportunity to sit down and get to know ROH wrestling star Grizzly Redwood a little better.
Rocking the afternoon drive on Q103 is what I do Monday – Friday
Wrestlemania 28 was held on April 1, 2012 at Sun Life Stadium in Miami, Florida. The 78,363 fans in attendance saw a fantastic show with two title changes, one continuation of an unprecedented undefeated streak, the end of an era in the WWE, a new GM of both brands and a WWE Legend adds to his legacy.
With WWE Raw coming to The Glens Falls Civic Center Friday May11th, I've been thinking about this voluptuous hunk of man meat getting all sweaty in the ring! So it would make sense that today's Hunk of the Day is John Cena, and now lets get to know him a little.


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Great Value. I'm going into the linen rental business and thanks to Linen Tablecloths, I should have a successful business. Love the weekly specials as well!(Posted on 1/28/12)


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Connecticut House Speaker Brendan Sharkey says he wants to take a look at the state's self-defense laws to make sure a situation like the deadly shooting of Florida teenager Trayvon Martin can't happen in Connecticut.
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Full CoverageRight Now
Hawaii real estate summit attracts representatives worldwideUPDATED 5:01 AM HST Apr 22, 2013
In packed room, with reps from more than a dozen countries and agencies worldwide, the Asian Real Estate Association of America brought the reality of a global market to the islands.
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CommentsThe views expressed are not those of this site, this station or its affiliated companies. By posting your comments you agree to accept our terms of use.blog comments powered by Disqus


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Item: NCL013
If you are dissatisfied for any reason, we'll give you a full refund and pay return shipping. Lee Swanson, President of Swanson Health Products
Serving Size 1 capsule
Servings Per Container 100
|Amount Per Serving
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Other ingredients: Hydroxypropyl methylcellulose, cellulose, L-leucine.
Suggested Use: As a dietary supplement, 1 capsule, three times daily, or as directed by a healthcare practitioner.
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Kemp steals 2nd. Ross should have had him but double clutched the ball.
Kemp steals 2nd. Ross should have had him but double clutched the ball.
steal by Kemp on a double clutch throw by Ross which Cabrera drops. Crisp, clean Reds play.
Ethier singles to left. 2-0 Dodgers.
Ethier singles to left and Kemp scores. 2-0.
Berroa grounds into a 5-4-3 DP. 2 outs.
Bailey's back to Louisville. Announcers are speculating it will be Thompson Saturday.
Dodgers stink ... yet the Reds can't beat them
What are you, people? On dope? - Mr Hand
Lowe strikes out swinging. 2-0 Dodgers mid 2nd.
The Rally Onion wants 150 fans before Opening Day.
Dunn strikes out looking. 1 out.
Encarnacion homers to center! 2-1 Dodgers.
EE home run!
Board Moderators may, at their discretion and judgment, delete and/or edit any messages that violate any of the following guidelines: 1. Explicit references to alleged illegal or unlawful acts. 2. Graphic sexual descriptions. 3. Racial or ethnic slurs. 4. Use of edgy language (including masked profanity). 5. Direct personal attacks, flames, fights, trolling, baiting, name-calling, general nuisance, excessive player criticism or anything along those lines. 6. Posting spam. 7. Each person may have only one user account. It is fine to be critical here - that's what this board is for. But let's not beat a subject or a player to death, please.


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Christian Prudhomme said the huge crowds seen for the second day along the route, many only inches from the riders, were "unbelievable, incredible, amazing, astonishing."
Yesterday's 201km stage from York to Sheffield saw more scenes of people packing the roadside following Saturday's stage taking in Leeds, Harrogate and the Yorkshire Dales.
Mr Prudhomme added: "It will stay as the grandest Grand Depart ever."
Picture: Getty


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Buyers and sellers pack the multi-level premise of Platoon Kunsthalle in Nonhyeon-dong, southern Seoul, Saturday for the monthly flea market. / Korea Times photo by Kwaak Je-yup
By Kwaak Je-yup
It is not unusual to walk down the streets of Myeong-dong in central Seoul or Gangnam in the south and spot several passers-by wearing clothes of similar styles.
Koreans' are fans of trends. And the chase for "sinsang", the colloquial local term for the newest items, can look like the only zeitgeist in Seoul's urban fashion landscape.
But once a month, there comes a fresh breath of air from the flea market at Platoon Kunsthalle, in Nonhyeon-dong, southern Seoul.
Co-hosted by this unofficial center of Seoul's subculture scene and the clubbing-themed magazine Bling, the event attracts thousands of regulars and curious first-timers on the first Saturday of every month.
While vintage clothes and paraphernalia, a flea market's common benchmark for quality, come by rarely, the buyers' enthusiasm at this past weekend for that pair of jeans made in the 1980s or a used purse seemed to match that of counterparts in more established, historical markets overseas.
"A lot of these were my father's", said Fielding Hong, a half-Korean half-American student, pointing to a rack filled with jackets and T-shirts so alien here. He added that he was trying to reduce the size of his luggage before a flight home to Iowa. Some of the tags, including the one on a light-blue waterproof raincoat from Sears from the '70s, even had his family name and phone number handwritten by his father.
In a society where hand-me-down's and used clothes are largely associated with a lack of disposable income, this shift, albeit gradual, is notable.
The return of older, classic styles, especially in menswear, was also evident in the creations of Shin Jung-hyun, whose works on the ground floor are inspired by English traditions but with their own twist.
"My business partner and I are launching a new site specializing in menswear accessories (like ties and pocket squares)", said Shin.
An English-accented screen printing artist working under the name JimmySK was taking a similar approach but looking into Korean folklore, printing as onlookers watched.
Some seemed more interested in just having a good time, given the flea market's unique atmosphere with a DJ spinning tunes and beer on tap at the in-house bar.
"My place has piles of stuff that I used to wear, some even just once", said a daytime music video director who did not give his name. "Why not share them with people who may like them?"
A lot of the clothes could be had for just a few 1000 won, or a few dollars.
Unfortunately, the tags of fast-fashion brands like Zara or Uniqlo were probably the most common on the three floors of temporary retail space but the culture is here to stay, with movements elsewhere to start other flea markets, according to avid buyers.
To reserve a spot at the next cycle in March, contact Platoon Kunsthalle at email@example.com.
Source : www.koreatimes.co.kr/...
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Newer : 'Naggomsu' hosts refuse to apologize
Yeosu residents pay for boom with their wallets
2012/02/11 (Source)
YEOSU - The last straw for Park Seon-yeong, 39, was when she took her fourth-grade son to a barber shop in her neighborhood a few days ago. The hair cut for the boy cost 8,000 won ($7.20). "Although the prices of many things are rising quickly these days, I think it's going too far to raise ,...More
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The Nutrition and Global Health concentration is designed to build upon a strong base of ongoing research, teaching, collaborative work, and training in nutrition and global health at HSPH. The concentration has four participating departments: Nutrition, Global Health and Population, Epidemiology, and Social and Behavioral Sciences, together with the involvement of the François-Xavier Bagnoud Center for Health and Human Rights and the Harvard Humanitarian Initiative. It takes an interdisciplinary approach to teaching and conducting research about nutrition; its effect on human and economic development; nutrition in humanitarian crisis situations; and the dynamic interplay among the epidemiologic, nutritional, and demographic transitions around the globe. The concentration is dedicated to research that stresses integrative problem solving and evaluation approaches to global health challenges, with a focus on lower- and middle-income countries.
Contact Information:
Web: hsph.harvard.edu/nutrition-and-global-health/


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Jack, New York
BA in Graphic Design and a Marketing Certification
painting, hiking, reading
Proficient Performer, 25+ Years performance experience, Played trumpet throughout elementary, middle, high school and college bands (including Concert Band, Jazz Band, Marching Band, Symphonic Ensembles
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$58.00 donated in past month
East Bay | Police State and Prisons | Racial JusticeView other events for the week of 7/19/2013
Import this event into your personal calendar.
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and for those who have a criminal record due to being forced to plea bargain for merely talking back to some zimerman type then he uses cell phone to call cops and cops naturally believe everything he says, youre now in squad car off to jail and plea bargain or face a felony!! the guy called you a name when you were just walking the other way across street from him ,he calloed you insulting names you merely called himsomething back, then he came towards you then he used cell phone police see you guilty onsight. that can mow happen in america! its happened more than once!! you never had police problem or jail before. now you got record! the guy was really white and he could have been another zimerman type. so its not just for trayvon or blueford, its also for YOu. YOU could be in jail for some zimerman threatening YOU.
I will be at this event . I'm not crazy about the name since folks of all ages and races have been abused and even murdered by the Police. But Hey what you call your rally ain't a big issue
I hope thousands come out tonight.


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QR code p8tches launched30 July 2008
P8TCH has launched a range of fabric patches that offer QR code designs that are unique to you. Each p8tch has a unique QR code on it that links to a unique URL on the Swiss domain p8t.ch. With each patch comes a passkey that lets you set the redirect... >>


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19th April 2015
Lesbian couple marries in Japan amid calls for legal recognition for same-sex marriage 6
1:59 PM — A lesbian couple has married in Japan, despite that the country does not currently recognise same-sex marriages.
18th March 2015
Japanese lawmakers to examine LGBT discrimination ahead of Tokyo Olympics 8
4:52 PM — Polticians have formed a multiparty group to look at LGBT rights before the 2020 Olympic Games.
12th February 2015
Tokyo district will recognise gay relationships for the first time in Japan 6
3:47 PM — For the first time in Japan, a district of Tokyo has announced plans to recognise gay couples' relationships through "partnerships" certificates.
9th February 2015
George Takei to make Broadway debut 2
6:57 PM — Star Trek actor George Takei is to make his Broadway debut, in a musical based on his life.
16th January 2015
Japan's ex-PM debuts as a drag queen… could Gordon Brown be next? 8
3:42 PM — The former Prime Minister of Japan has debuted as a drag queen.
10th December 2014
Japan: Zen Buddhist temple offers same-sex wedding ceremonies 1
2:12 PM — A Zen Buddhist temple in Kyoto has become one of the first to offer same-sex weddings - even though they aren't recognised in Japan.
7th December 2014
Japan: Activist running to become country's first gay male lawmaker 2
1:55 PM — An LGBT activist running for election in Japan could be on course to become country's first openly gay male lawmaker.
14th November 2014
Japan: School holds 'Sex Change Day' for students 14
2:14 PM — A high school in Japan held a 'Sex Change Day' this week - where boys dressed in skirts, and girls wore suits and ties.
4th October 2014
Zoo accidentally spends four years encouraging hyenas to have gay sex 14
2:01 PM — A zoo has accidentally spent four years trying to breed with a pair of male hyenas.
6th August 2014
Watch: George Takei remembers the atomic bombing of Hiroshima 3
5:44 PM — Activist and actor George Takei released a video commemorating the anniversary of the atomic bombing of Hiroshima.
16th July 2014
New Sailor Moon anime restores same-sex relationships 4
11:03 AM — A new version of the Sailor Moon anime is being released, with previously censored same-sex relationships restored to the series.
5th June 2014
George Takei hopes Japan will follow in America's footsteps for equal rights 3
7:06 PM — Star Trek actor George Takei, has admitted that he hopes gay rights will become more of a dominant part of society in his country of ancestry, Japan.
8th May 2014
Japan: 70% of LGBT pupils bullied in school, 30% contemplate suicide 6
3:40 PM — A new study in Japan has revealed that LGBT school pupils suffer from some of the highest rates of bullying in the country.
27th April 2014
Japan: First Lady makes surprise appearance at Tokyo Pride parade 12
2:27 PM — Japan's First Lady took part in Tokyo's pride parade on Sunday, voicing her support for LGBT people.
18th March 2014
Poll: Over half of people in Japan oppose same-sex marriage 5
2:29 PM — Despite three-quarters of Japanese adults thinking society is unkind to LGBT people, just over half still oppose same-sex marriage.
12th December 2013
Japan: Supreme Court awards legal parental status to trans man
7:13 PM — The Japanese Supreme Court has ruled in favour of a trans man to be legally recognised as the father of his wife's child, after unsuccessful earlier decisions.
11th September 2013
Japan: Government district in Osaka becomes first to support LGBT human rights 5
1:13 PM — A local government ward in the city of Osaka has become the first Japanese district to officially support LGBT human rights.
28th April 2013
Japan: Thousands march in Tokyo in support of LGBT rights 3
3:41 PM — Thousands marched in Tokyo this weekend as Japan kicked off its first Rainbow Week, which aims to reach out to LGBT people in the country.
26th April 2011
Japan's first openly gay politician victorious in election 14
4:40 PM — Japan's first openly gay politician has today hailed his election success as a victory for the rights of sexual minorities.
12th August 2010
Tokyo Pride to return after three years 10
5:33 PM — The Japanese capital's gay community and friends are preparing to party this Saturday as Tokyo Pride takes place once again after a three-year absence.


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This "coffee table style" book is comprised almost entirely of exterior shots of the stunning Museum of Glass in Tacoma, WA co-founded by renowned glass artist Dale Chihuly. The photos were taken over the course of a year at all times of day and night.
Beautiful photos of sunrise, sunset and moon against the outdoor glass sculptures and unique building features fill the pages in glorious color. There are also a number of interior shots in the museum's "Hotshop" showing glass artists at work including glass art master Lino Tagliapietra.
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Terry and Steve Published September 01, 2013
Villa Madera Published December 08, 2012
Mike and Joyce Martin House Published December 11, 2011
Spence House Published October 03, 2011
Step Inside Published March 14, 2011
Three Fields Published January 14, 2011
Two Cabins At Ober Beach Published December 08, 2010
20/20: Tacoma In Images and Verse Published November 20, 2010


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Mad Decent
|Mad Decent
|Thomas Wesley Pentz (Diplo)
|Country of origin
|United States
|Philadelphia, PA
Los Angeles, CA
|Official website
Mad Decent is a Philadelphia via Los Angeles-based record label spearheaded by Diplo. The label has helped introduce Brazilian baile funk and Angolan kuduro to clubs around the world.[1] Recently, it has embraced moombahton, a genre of electronic dance music created by DJ Dave Nada.[2] The label is also known for its series of concerts in major cities known as Mad Decent Block Party.[3]
Mad Decent was founded in 2005 by Diplo.[4] In 2010, the label moved from Philadelphia to Los Angeles.[5] In 2011, it announced the launch of the imprint label Jeffrees as "an outlet to curate and promote new music that errs on the side of experimental, in keeping with the label's original mission."[6]
The label gained more attention in 2012 and 2013, with the worldwide success of Baauer's single "Harlem Shake", which went viral on YouTube.[7]
Since 2008, the label has created a multiple city Mad Decent Block Party tour throughout the United States.[8] This travelling festival began at a much smaller scale with simply a rented tent, dunk tank and bbq on a Philadelphia street (Block of 12th St. and Spring Garden St.).[citation needed] The event is in line with the overall concept of the label showcasing global pop and dance music.[9] The featured artists at the events has expanded from featuring Mad Decent's roster to high profile artists such as Matt and Kim and Outkast.[10]
For Christmas 2013, the label re-released various singles from the label mixed with Christmas songs. These were compiled in an eight-track EP titled A Very Decent Christmas.[11]
At the Columbia, Maryland Mad Decent Block Party on August 1, 2014, two fans died and 20 others were hospitalized.[12] Police sources said that the death and illnesses were from apparent overdose.[13][14]
- ^ Poitras, Andrews (July 15, 2013). "Celebrating six raucous years of Mad Decent Block Party". Death and Taxes. SpinMedia. Retrieved February 19, 2015.
- ^ Fischer, Jonathan L. (December 24, 2010). "Our Year in Moombahton". Washington City Paper. Retrieved February 19, 2015.
- ^ Townes, Cory (July 29, 2013). "Family Matters: The 2013 Mad Decent Block Party Tour Stop In Philadelphia Recap". Vibe. Retrieved February 19, 2015.
- ^ Iandoli, Kathy (May 2, 2012). "The Mad Ascent of Mad Decent: A Look Inside a Global Powerhouse". MTV Iggy. Retrieved February 19, 2015.
- ^ Svetkey, Benjamin (November 17, 2014). "Why The World Is Moving To Diplo's Beat". Fast Company. Retrieved February 19, 2015.
- ^ Aguiar, Steven (March 1, 2012). "What's Behind Mad Decent's Jeffrees Micro-Imprint?". MTV Hive. Retrieved February 19, 2015.
- ^ Knopper, Steve (February 2, 2013). "How Baauer Took 'Harlem Shake' to Number One". Rolling Stone. Retrieved February 19, 2015.
- ^ Leatherman, Benjamin (September 10, 2014). "EDM's Reigning Clown Prince Dillon Francis Hits Phoenix with the Mad Decent Block Party". Phoenix New Times. Retrieved February 19, 2015.
- ^ Patel, Puja (August 4, 2013). "For Mad Decent, fans sweat and stay in step". The Washington Post. Retrieved February 19, 2015.
- ^ Ugwu, Reggie (April 7, 2014). "Outkast, Fatboy Slim, Sleigh Bells & More To Perform at 2014 Mad Decent Block Party: Exclusive". Billboard. Retrieved February 19, 2015.
- ^ Battan, Carrie (December 5, 2013). "Stream Diplo's Mad Decent Christmas Compilation". Pitchfork Media. Retrieved February 19, 2015.
- ^ Chiu, David (August 19, 2014). "Chicago Theater Bans EDM Shows". The Fader. Retrieved February 19, 2015.
- ^ Coleman, Miriam (August 3, 2014). "One Fan Dead, 20 Hospitalized at Mad Decent Block Party". Rolling Stone. Retrieved February 19, 2015.
- ^ Peters, Mitchell (August 3, 2014). "Update: Second Person Has Died Following Mad Decent Block Party". Billboard. Retrieved February 19, 2015.
- ^ "Artists". Mad Decent. Retrieved February 19, 2015.
External links[edit]
- Official website
- Mad Decent on Twitter
- Mad Decent on Facebook
- Mad Decent on Myspace
- Mad Decent on SoundCloud
- Mad Decent discography at Discogs


text: Make an Appointment View My Research Profile Locations Main Hospital Washington, District of Columbia 20010 1-888-884-2327 Spring Valley Outpatient Center Washington, District of Columbia 20016 202-895-3860 Languages Spoken English Departments Psychology & Behavioral Health Obesity Institute IDEAL Clinic Weight-Loss Surgery (Bariatric Surgery) Program Disclosure >This faculty member (or a member of their immediate family) has a working relationship (i.e. consulting, research, and/or educational services) with the companies listed below. These relations have been reported to the health system leadership and, when appropriate, management plans are in place to address potential conflicts.Outside InterestsAlexion Pharmaceuticals; Arrhythmia & Electrophysiology (American Heart Association); DC Public Schools; Fairfax Neonatal Associates; Georgetown University; Health Services for Children with Special Needs (HSCSN - DC Medicaid plan) Quality Council and Credentialing Committees; Holy Cross Hospital; Medtronic, Inc.


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Superb Scalloped Oysters
|1 Pint
|1⁄2 Cup (8 tbs), melted
|Coarse cracker crumbs
|2 Cup (32 tbs)
|Season all
|1⁄2 Teaspoon
|Celery salt
|1⁄4 Teaspoon
|Coarsely ground black pepper
|1⁄4 Teaspoon
|Onion powder
|1 Dash
|3⁄4 Cup (12 tbs)
|Oyster liquor
|1⁄4 Cup (4 tbs)
|Worcestershire sauce
|1 Teaspoon
|Parsley flakes
|1 Teaspoon
1) Preheat the oven to 350°F.
2) Drain the oysters and reserve the liquor.
3) In a bowl, combine the melted butter, cracker crumbs, Season-All, celery salt, pepper and onion powder together.
4) In a buttered 2-quart shallow baking dish, spread 1/3 crumb mixture
and cover with 1/2 the oysters.
5) Then repeat to make a second layer of crumb mixture and oysters.
6) In a bowl, combine the cream, oyster liquor and Worcestershire sauce; then pour over the oysters.
7) Mix the remaining crumbs with parsley flakes and sprinkle on top of the oysters.
8) Bake in the preheated oven for 30 minutes, or until the oysters are thoroughly heated and crumbs are golden brown.
9) Serve the Superb Scalloped Oysters, straight from the oven.


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PAINT IS 7 OUT OF 10SHINES REAL NICEDOES HAVE SOME BUBBLING IN THE PAINT351 ENGINE WITH AUTOMATIC TRANSMISSIONINTERIOR NICE CONDITIONAFTERMARKET STEREOUPGRADED WHEELSFLOORS/TRUNK ARE SOLIDGLASS... More
Passing Lane Motors, LLC, St. Louis's Premier Classic Car Dealer, is pleased to offer this 1963 Ford Galaxie Convertible for sale! Highlights Include: 390 Engine Automatic Transmission 9... More
Just in on trade (previous owner upgraded to a Corvette) is this 1969 Ford Galaxie convertible. Powered by Ford's 390 cubic inch 265 horsepower... More
Just arrived, this beautiful LTD has been well cared for and garaged since new. Sold new in Lakeland, Florida by the local Ford dealer in... More
1960 Ford Galaxie CoupeThe Galaxie is a wonderful car from the 60's in a good condition. The engine runs perfect and the manual gearbox... More
This 1968 Ford Galaxie 500 is for sale in our Detroit showroom. The 500 was the mid-level Galaxie which was produced by Ford from... More


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- Home
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Employer Engagement Team
The Employer Engagement Team helps employers fill graduate, internship and placement vacancies and raise their profile with UCL students. We manage a programme of events including fairs, presentations and skills development sessions, and offer a range of channels to advertise career opportunities. We are always happy to discuss individual employers' needs face to face or by phone.
Please visit the Recruiters' Homepage for more information on services and contact details.
Phil Howe
Phil heads up the team who provide our range of services and events for employers, including recruitment events, placements and vacancy services, skills development programmes, and employer-led careers programmes in academic departments. He also sits on the Careers Management Team. Much of his time is spent meeting and advising employers who wish to recruit our students and graduates, and developing relationships with those who already do. Phil has worked for UCL Careers Service since 2000 in a variety of roles, including Acting Head of Careers. An English graduate from Royal Holloway, University of London, Phil has also worked in the insurance industry and managed a touring theatre company.
Vivienne Watson
Vivienne oversees the employer led events programme for researchers at UCL. She organises sector specific Forums/Fairs for researchers interested in finding out about working in a particular industry and also runs the employer led careers skills workshop programme for researchers. These workshops are designed to help researchers develop their employability skills in areas such as teamwork, leadership, presentation skills and networking. Prior to working at UCL Vivienne worked in the Imperial College London Careers service. She studied History and History of Art at UCL and Mandarin at SOAS.
Rochelle Symons
Rochelle has been with UCL Careers Service since October 2010. Until April 2013 she was the Employer Services and Events Officer responsible for organising employer-led skills development activity for PhD students. As part of Rochelle's role she has developed and maintained relationships with employers wishing to recruit UCL students and graduates. Rochelle changed roles in May 2013 and is now the Placements and Vacancies Manager. She is responsible for the team who facilitate placements and internships for various academic programmes at UCL, as well as the team who manage UCL's shortlisting service, UCL Talent Bank. Departments include the Arts & Science BASc degree programme, the LIDO/ BBSRC PhD Programme, the BSc Management Science degree programme and the Engineering Faculty. Prior to working at UCL Rochelle managed a bioscience internship and training programme at the Royal Veterinary College and worked in the Faculty of Lifelong Learning at Birkbeck College. With a Masters in Arts Management from Birkbeck Rochelle has previously worked in events management and project co-ordination roles within the arts and not-for-profit sectors. When not at UCL Rochelle enjoys spending her time trying to create interesting wall art.
Pat Molloy
Pat Joined the Careers Team in July 2011, dealing with all employer presentations. Previously he had many administration jobs under the umbrella of British Telecom. Outside work Pat enjoys watching and playing football.
Shak Chowdhury
Based in the Employer Services and Events team, Shak is specifically aligned to the School of Management Science & Innovation, where she works on design and delivery of bespoke and innovative employer engagement programmes for the MSc Management, Information for Management Business and MSc Technology Entrepreneurship courses.
After graduating with a degree in English Literature, she moved into a career in graduate recruitment working for organisations in various sectors including professional services, media and local government, where her responsibilities included developing innovative marketing and attraction strategy, designing and delivering employer campus events at universities nationally, implementing best practice in-house recruitment & selection, and rolling out effective graduate development programmes.
Charlotte Turnbull
Charlotte is one of the team's Placements & Vacancies Officers, having joined in September 2013. She is responsible for the dedicated placements & internships service for UCL's new interdisciplinary degree, the BASc Arts & Sciences. Prior to this, Charlotte worked in the Employer Team at the University of Edinburgh Careers Service and she has a Masters degree in Creative Writing.
Shadae Samuels
Shadae is the team's Placements & Vacancies Officer, having joined in October 2014. She is working with Rochelle on sourcing and administering the placements for students on the LIDo programme / BBSRC-funded PhDs. Prior to this, Shadae worked in the Communications and Vacancies Team at The Careers Group, University of London central services.
Laura Firmin
Laura's role as Employer Engagement Administrator puts her in regular contact with employers and recruiters from a variety of sectors. The role involves highlighting the most appropriate services offered by UCL Careers for the needs of each employer, such as employer presentations, vacancy/ internship advertising, and participation at careers fairs and skills sessions.
Laura spends half her time coordinating employer presentations on campus, and the other half promoting and procuring internship opportunities for second year BASc students.
Laura has a bachelor's degree in Sociology with a specialism in Gender Studies. She started working at UCL Careers as an intern before assuming her current role in August 2014. She has previously interned for The Careers Group Central Services, CAPP & Co, and WorkCare Coventry and Warwickshire.


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Originally written on PRO Rumors | Last updated 7/29/12
The Arizona Diamondbacks have acquired Chris Johnson from the Houston Astros for minor league outfielders Marc Krauss and Bobby Borchering, the teams announced. Johnson is currently hitting .279/.329/.428 with eight homers and 41 RBIs in 368 plate appearances. He has logged time at the corner infield and outfield positions but is primarily considered a third baseman, which was an area of need for the D'backs. Borchering, 21, and Krauss, 24, were both taken in the 2009 draft by Arizona with Borchering being taken in the first round and Krauss in the second, both of whom were currently in Double-A. Image taken by Ken Lund and used under the Creative Common License Agreement.
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The Department of Homeland Security has completed the National Response Plan, which establishes a unified and standardized approach to help protect public health, safety, property, and the environment from terrorist attacks and other natural and human-induced hazards.
The plan is designed as a comprehensive tool for domestic incident management incorporating best practices and procedures from incident-management disciplines (public works, homeland security, and emergency management). The plan is organized around five components:
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Archive: 02/15/2006
Bright future for new manufacturing technique
Gamma-ray afterglow from galactic centre gas clouds reveals prehistoric particle accelerator
The oceans as carbon dioxide sinks: increasing our understanding
The Web: Free speech -- for Chinese admen
AIDS drug offered free to the Third World
New York state sues the U.S. EPA
Google, Amazon to battle Apple's iTunes?
Conflict with farmers threaten geese
How green is my planet?
Researchers revolutionise opportunities for the European water industry
Briefs: CNN, MSNBC beating Fox News on Web
Tech huge factor in being 'cool'
Pilots may get help in avoiding turbulence
Briefs: Meeting to consider nanotechnology impact
- 1 2


text:
New Tunewear leatherette, leather, sheepskin cases
updated 09:15 am EST, Fri March 11, 2005
New Tunewear cases
Tunewear has announced the carrying cases for the fourth generation iPod and the iPod mini. The Prie Classic is made of high quality leatherette and costs $25, while the Prie Lux ($35) is made of genuine leather, and the Prie Pearl ($45) is made of smooth sheepskin. The Classic comes in key lime, ruby pink, canvas grey, and jet black. The Prie Lux is available in black, brown, green, and cream. The Pearl comes in "pearl blue," "pearl violet," and "pearl bronze." The new Prie series 4G and mini will both be available at the end of March.


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Billy Mays' Autopsy Shows Cocaine
Other narcotics were found in May's system, though the St. Petersburg Times reports that Mays was taking hydrocodone, oxycodone and tramadol by prescription for hip pain. The report said that although Mays died from heart disease, cocaine use was a contributing cause of death.
"Cocaine can raise the arterial blood pressure, directly cause thickening of the wall of the left ventricle of the heart, and accelerate the formation of atherosclerosis in the coronary arteries," the Hillsborough County medical examiner's press release stated.
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- Filed under:
- Celebrity Deaths -
- TV News
- Friday 07 AugustBy Rodd
sorry he passed away but now I see how he was always 'hyper' when he did his commercials.
- Friday 07 AugustBy rferrara
lol. sorry for what?
- Friday 07 AugustBy Jeff
Yep, makes sense to me also. This guy always looked wired. Funny how you can tell. I'm type A but this guy was way over make me that. He used to make me fidgit in my seat just watching him.
- Sunday 09 AugustBy Mark
Tramadol, Oxycodone and Hydrocodone for hip pain?
Yea right. All of these drugs are way over prescribed by doctors for their rich patients to get that all to infamous uforic high.
Coke just topped it off and obviously brought him to his knees
- Saturday 08 AugustBy pnut166
Friday 07 August
By Outlaw
Lowest Rank Vote downVote up
Piss on you all if you knew anything about drugs ... all of the drugs he was taking for his hip will all show up as cocaine and i know that from experience>>>>You are an idiot. You do not "know that from experience". Complete bullshlt. However, I will agree that everyone needs to lay off of Billy.
- Saturday 08 AugustBy sherri007
Actually, Outlaw, the other drugs he was taking for pain are opiates and wouldn't "show up" as cocaine. When someones tests screen positive for a drug it goes on for a confirmation test for that specific drug. It will either then test positive or negative for that drug. So, it's not going to to confirm positive for cocaine if it is an opiate. Just a little toxicology lesson for you. :O)
- Saturday 08 AugustBy MJR
IT WAS THE MAGIC JACK they should charged 18.95 instead of 19.95
- Saturday 08 AugustBy Debra
There was no need for this to be released to the public and tarnish his image. Besides the cocaine, that I am so sorry he was using, Billy was in TERRIBLE PAIN all of the time.
If you have never experienced that kind of pain, you have been lucky. For when you do, you will take whatever you can to be able to work, play, and just live.
Just because Billy was on Oxycodone, Hydrocodone, etc., it probably was not enough to lessen the pain. I LIVE with pain DAY IN AND DAY OUT without much relief. I take what he did, except cocaine, but it is in such small dosages that it does little to help.
Walk a mile in a cancer victim shoes. Walk a mile in the shoes of someone with bulging discs in their backs which cannot be operated on. Walk a mile in the shoes of the ones that suffer endlessly and forever and forever.
Then tell everyone you are a drug addict.
God Bless Billy Mays and his loved ones. I, for one, am so sorry this came out because this was PERSONAL.
- Friday 07 AugustBy Sierra
Well, now we know where the booming voice and all his "vitality" came from. Sad.
- Friday 07 AugustBy judy
When are they going to take those godforsaken LOUD commercials off the air? I am sure that Billy was a wonderful man but all I could think when he died is that I wouldn't have to listen to those awful commercials anymore.
- Friday 07 AugustBy Steven
Does someone chain you to your couch and take your remote control away and force you to watch Billy Mays? That is some serious S&M you are into.
- Friday 07 AugustBy MacDaddy
Hearts dont handle coke well after 40.yawn !
- Friday 07 AugustBy Dedee
Sounds like you know from experience, huh?
- Friday 07 August
Just another successful and rich person abusing drugs "BECAUSE" he thought he couldn't die from "Cocaine, running all around his brain."
- Friday 07 AugustBy audrey
Well surprise surprise. Might have known he was on something, all that hyperness and non stop yelling. What a shame another celebrity bites the dust from drugs, When will they ever learn?
- Friday 07 AugustBy oneoftheguys
I always found his commercials trying and loud and a little more then I could stand and would often turn them off...but they did catch my attention and I did buy the product he was pitching...so...bad judgement and the abuse of drugs lead to his early death...how many are doing the same knowing this will happen to them...RIP my man...
- Friday 07 August
Your comment was one of the only ones that said it the way it should be said.He was a great pitchman his personal life may be like one of anyones.And you know that he will be trying to sell some good polisher to St.Peter for the heavenly gates!His name is now infamous and there will never be a better pitchman.
- Friday 07 AugustBy skid41
- Friday 07 AugustBy MarQ
Sham Wow! Oh wait, wrong guy.
- Friday 07 AugustBy Lee
Let me guess....your not white? Why is race everywhere and yet that is the biggest problem we have n society today?
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text:
The Development Of Science Problems For The Ankeny High School General Science Program
Carlson, Lesley J.
MetadataShow full item record
SubjectScience--Education (Secondary)--Problems, exercises, etc.--Iowa--Ankeny; Ankeny (Iowa)--Education (Secondary)--Science--Problems, exercises, etc.
110 leaves
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We were put in to a room on arrival facing the noisy four-lane circular road with heavy traffic and hooting horns continuously. The windows had no draught excluder nor sound proofing and, as a result, we had a restless night because the room was noisy and freezing cold. Next day we asked to change rooms to the back which was much quieter. The lounge area was nice and the location good, near Hassan Tower and the old city.The pool on the roof terrace was a pleasant spot to lie in the sun and look out on the Atlantic ocean. The bedrooms were spacious and bathrooms OK but the rooms needed some renovation. We ate twice in Farah restaurant, the buffet was limited choice and sometimes tasteless, the staff didn't bother to offer us the alternative menu available and made no effort. We ate one evening at Brasserie Tulipe restaurant and that was much better service and good quality food. Breakfast was a terrible experience. The staff were decidedly glum and unmotivated, a sachet of sugar lying on the floor was not picked up by any of the staff throughout our meal, for example, they just stood about. They were slow to clear used plates and no serviettes were provided. The 'chef' at the omelette station looked clueless and startled, my omelette was flat and the egg white only half cooked. Two choices of cereals only, nice croissants and pastries. Coffee from the machine to be avoided. A 3-star hotel in my view.The staff at reception spoke poor English.
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text:
From the New York Times bestselling author of the Night Huntress series comes a breathtaking new journey to the dark side of desire.
The night is not safe for mortals. Denise MacGregor knows all too well what lurks in the shadows—her best friend is half-vampire Cat Crawfield—and she has already lost more than the average human could bear. But her family's past is wrapped in secrets and shrouded in darkness—and a demon shapeshifter has marked Denise as prey.… (more)
Publisher: HarperCollins (February 09, 2010)
Format: EPUB
Page count: 38 pages
File size: 522 KB
Protection: DRM
Language: English


text:
Terrifying moment Brixton shopkeeper is threatened by gun-toting armed robbers
Video:Police have released CCTV footage of gun-toting raiders rushing into a Brixton convenience store and threatening the shopkeeper.
Strange Meetings
by Harry Ricketts
(Pimlico, £14.99)
15 November 2012
Election parties galore last night. CNN hosted a bash at One Mayfair attended by Labour MPs Austin Mitchell, Gloria del Piero, Harriet Harman and Dame Tessa Jowell. "Nobody in this country can be indifferent to this election," Jowell told me.
07 November 2012
Commuters were taken on a mystery tour of the City when a hapless London bus driver got lost during morning rush hour.
12 October 2012
Promenade performance hankering for the golden age of British journalism
08 October 2012
A homeless Iranian asylum seeker has sewn his lips together and threatened to die on the streets of London.
24 August 2012
Derwent London's tenants are dusting themselves down after a difficult Olympics, but the capital's office market is still booming, the property firm said today.
22 August 2012
Cinzia Ghignoni is head chef at The Table restaurant in Southwark
06 August 2012
No time to dine out in one of London's top restaurants? Good job they're doing takeaway
22 June 2012
How London's entrepreneurs are bucking the economic gloom.
28 May 2012
The architect who created the £269 million aquatics centre has criticised "rude" Games bosses for not inviting her to a single event.
17 May 2012


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Dr. Timothy Johnson joined WCVB in 1972 as the host of "House Call", a half-hour, Emmy Award-winning series on health.
Dr. Timothy Johnson's career with WCVB, ABC News
Announces retirement after 40 years as medical editorUPDATED 6:22 PM EST Dec 06, 2012
Slideshow Central
CommentsThe views expressed are not those of this site, this station or its affiliated companies. By posting your comments you agree to accept our terms of use.blog comments powered by Disqus


text:
Dr. Anas Khoury specializes in foot and ankle surgery in Passaic, New Jersey.
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