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It can be a long way to the top aboard a ski resort chairlift. As we climb out of the treeline, the surrounding peaks of the Italian Alps reveal themselves with all the drama of a theatrical performance. Pillows of perfect white snow lie beneath our dangling feet and, as the chill wind glides across our faces, Enrico begins talking.
"I am a man of the mountains," he says. "I have worked in the city but I do not like."
What he likes is skiing in Pragelato, where the name means frozen meadow and even the pronunciation has a chilly connotation. "Say it 'larto' like gelato," he instructs.
But there's more to the man born to live at high altitude. "My vices ..." he begins as we draw closer to the tip-off point of Anfiteatro chairlift, "they are cigarettes, wine and women ... in that order."
As we push off the seat and our skis glide across the hardened snow, you sense he's maybe rethinking. A (single) ski instructor. In Italy. And women come third in line.
But there's no time to rib him about that. With a shrug of the shoulders and a casual push of the stocks, we're off. Enrico leads our group of three across the mountain and then on a long descent of perfect powder.
We're on the Via Lattea, Europe's second-largest ski domain (Italy's biggest). It's renowned for powder snow, every skier's dream. There are 400 kilometres of runs across six resorts, much of it upgraded for the 2006 Turin Winter Olympics.
At one end of Via Lattea - or Milky Way - there's Sauze d'Oulx, where freestyle Olympians did their stuff and town planners created some rather ugly concrete housing blocks for them to live in.
The ski fields high above, on the other hand, are a joyful mix of wooded descents and open snow bowls. The region is paradise for intermediates and beginners, with some tricky blacks thrown in for experts' amusement.
Moving east across the mountain ranges, Pragelato sits at 1600 metres and includes a few tiny hamlets in the valley. It's just a blip on the map, but the opening of a new Club Med village, with 234 rooms and 684 beds, does its bit to boost the population.
If its neighbour is all concrete, this new village is all-timber chalets in classic European alpine style. My room, with a small lounge, large bathroom and decent coffee machine, is on the ground floor of a two-storey, snow-decked chalet. It's at the farthest reaches of the site and, during my holiday, it buckets with snow. But the three- to four-minute walk to the resort centre is a lovely stroll along cleared footpaths with expansive mountain views when the sun gets a look-in.
The spa is close by and that's a bonus. At the end of a long day on the slopes, the large indoor pool, heated to 30 degrees and with jets to ease aching limbs, is pure joy.
For the brave, or foolhardy, there's also a challenging combination of Finnish-style sauna, steam room and outdoor, frozen shower. Not for me, but a definite "yes" to a soothing massage. That's an extra charge, but one of the few.
The Club Med price includes all food, most drinks (champagne and XO cognac are extra), with some decent wines, ski pass, equipment, lessons and, if you have any energy left, entertainment in the evening. We found hanging out in the large bar with a glass of good red wine did the trick.
Food is good and plentiful. Breakfast can be a continental baker's basket in your room or buffet style at the resort. The main restaurant seats 550, in four dining rooms, and the choice of savoury dishes, desserts and gelato (we're in Italy, after all) is extensive.
There's a more formal restaurant included in the price, but my favourite is La Trattoria, a casual eatery in primary colours with big overhead lights. Here, you can choose parmigiano cut from a huge wheel, prosciutto sliced to order, olives, soft cheeses, salamis, breads and pickled vegetables. The pizzas are outstanding.
The main bar is large and, at night, full of skiers with tales about the size of the neighbouring mountains.
Next day, it's a short walk to the cable car in the Club Med village square. In four minutes, it takes you high on the mountain and from here, it's skiers' playtime from the Sauze d'Oulx in the west to Les Chalmettes in France to the east.
It's possible to ski the entire Via Lattea in a day, taking 21 lifts across six resorts. It takes an estimated six hours to complete, but that's one for next time.
The writer was a guest of Club Med Pragelato Vialattea.
Getting there
Emirates flies daily to Rome with onward connections to Turin. The drive from there to the resort is about 90 minutes. emirates.com.
Staying there
The cost of staying at Club Med Pragelato Vialattea includes accommodation, food, drinks (including wine, beer and most spirits), entertainment, ski hire, ski school and lift pass. The accommodation is in classic alpine chalets with various room configurations.
In Club Med rankings, it's a four-Trident resort and, if booked before July 1, costs $1803 an adult and $1394 a child (aged four to 11 years) for seven nights. After July 1 and before September 9, it's $1905 an adult and $1476 a child.
For children
There are children's club facilities for ages two to 17. Activities, including skiing for older youngsters, are organised throughout the day.
Eating there
You will never go hungry in a Club Med resort. The main restaurant, which features four dining rooms, is buffet style with a choice of interesting, well-prepared dishes at breakfast, lunch and dinner. La Taverna serves Savoyard cuisine, La Trattoria is all about pizza and pasta, and for those on the slopes, there are Club Med restaurants on the mountains.
More information clubmed.com.au.
- Sydney Morning Herald
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I don't mean to bash Chinese manufacturing, but come on guys, this is ridiculous. Pay a cheap price, get lousy quality. Upgrade and pay more and it shows up lousy, still made in China. Save your money, take a good stiff shoebox, make a hinge across the back from a piece of duct tape, and you will have a better box than this one.
Back she goes to the vendor...have to vote with my wallet and quit putting up with this junk!
The old originals had a follower made of steel and a stop to prevent over extension of the cover. Not anymore. The new improved import isn't worth its weight in scrap steel. Maybe a better name for it might be "ScrapMaster"
The sad part of it is that there are not any quality file boxes to be found anywhere,
It's sturdy enough and is working beautifully. Would it survive an elephant stepping on it? 'Course not.
Will it survive general office handling? Yes.!
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medium weight steel, not heavyweight, but ok for holding notecards. The hinge is good. However, the lid was tweaked out of alignment and no matter how we try, we cant get it to... Read morePublished 1 month ago by Scott
I bought this to use as a recipe file. It looks nice, and has a pretty matte finish, but the lid sticks a bit sometimes. Read morePublished 3 months ago by Patty Bol
Did not need one this big. Wish there was one maybe 6 inches longPublished 5 months ago by Rick Gillespie
I almost did not buy this card file because of complaints. This is exactly what I needed. I am so glad I took a chance and it is a great card file.Published 6 months ago by Nancy L. Carpenter
Box was not of the quality that I expected. The cover has a good deal of movement that suggests the hinge is of less than stellar quality. Read morePublished 8 months ago by Amazon Customer

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Baby's Box of Fun: A Karen Katz Lift-the-Flap Gift Set: Where Is Baby's Bellybutton?; Where Is Baby's Mommy?: Toes, Ears, & Nose! Board book – Box set, December 1, 2004
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Marion Dane Bauer is the author of many books for young readers, including the Newbery Honor book On My Honor and the New York Times bestseller My Mother Is Mine. Her other titles include A Mama for Owen, If You Were Born a Kitten, Grandmother's Song, and Thank You for Me! She has retired from the faculty of the Vermont College of Fine Arts MFA program in Writing for Children and Young Adults where she was the first Faculty Chair. She lives in Eden Prairie, Minnesota, and can be reached at MarionDaneBauer.com.
Karen Katz has written and illustrated more than fifty picture books and novelty books including the bestselling Where Is Baby's Belly Button? After graduating from the Tyler School of Art in Philadelphia, she attended the Yale Graduate School of Art and Architecture where she became interested in folk art, Indian miniatures, Shaker art, and Mexican art. Her book, Counting Kisses, was named one of the 100 Greatest Books for Kids by Scholastic Parent & Child and was a Children's Book-of-the-Month Club Main Selection. Karen, her husband Gary Richards, and their daughter Lena divide their time between New York City and Saugerties, New York. Learn more about Karen Katz at KarenKatz.com.
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This set includes 3 of her more popular titles. Belly Button and Toes both talk about different body parts, while the third book is a hide-and-seek game between Mommy and baby. The first 2 are useful in introducing children to names for their body parts, and all 3 will amuse even younger babies simply because of the drawings. Our 7-month-old is too young to grasp the concept of noses, tummies, etc., but she loves to pull the flaps and to make excited noises when she sees the illustrations of the babies.
You'd think that these might wear out their welcome quickly, but that hasn't been my personal experience. I've found that kids will continue going back to these ones over and over again. An inexpensive and worthwhile purchase.
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These books are super cute. My daughter (18months) loves them. The lift up flaps are thin and rip out easily though. Regardless I'd recommend these. Read morePublished 23 days ago by Lette.
Great lift the flap stories. My two year old niece loves them! My only complaint is not all of Karen Katz's best books were in this box. Read morePublished 1 month ago by Babs
Disappointed with this purchase. Very few pages and the quality is very low. The flaps are much to easy to tear. We have other flap books that are much better quality. Read morePublished 1 month ago by Courtney T.
My toddler loves these lift a flap books. My only complaint is some of the flaps come off pretty easy. I've had to tape/glue several back in.Published 1 month ago by Amazon Customer
These books are very nice, colorful, intercative and my daughter loves them. The only downside are the flaps. They are not made with a baby or toddler in mind. Read morePublished 1 month ago by Emely Valentin
Good books and engaging for little ones. I bought this for my 6-month-old nephew but my 2.5 year old now tears out the flaps so beware that the flaps are tempting for toddlers.Published 1 month ago by microtanya
My son got this as a first birthday gift and he loves all the books! He is 18 months now and they are still some of his favorites. Read morePublished 2 months ago by Amazon Customer
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How do you give your flesh and blood away? Turn your back and walk away from your child, your son? This is part of the quandary that is addressed in the latest offering from the incredible L. Wilder in Satan's Fury MC, Maverick. It is gut wrenching at times but is still a beautifully told story of forgiveness, love and redemption. Henley and Maverick's story is one that you will not want to put down until you've read the last page!
As Sergeant of Arms for the Satan's Fury MC, Maverick is a man haunted by his past. A past that refuses to let him forgive himself for consequences of past decisions he made. His MC brothers have his back and support him as he tries to find his way out of his guilt ridden thoughts. It is hard letting go of his son even though he knows it is what is best for him, but letting go of the guilt and emotion is another thing. In walks a woman that lights up his world with laughter, joy and hope! Henley is like a ray of sunshine in the depths of hell. When he is assigned to protect her, Maverick is determined that he will not fail this time. He will keep her safe.
A good girl, a good student, conscientious and caring would describe Henley perfectly. However there is another side to her as well. Henley loves life and enjoys living! When she finds herself in the wrong place, at the wrong time there is nowhere to go, expect to Satan's Fury for protection. There is a certain, gruff biker that touches something inside her and causes emotions to flare to life that neither of them expected. Will Maverick be able to conquer his past and keep Henley safe? Can Henley's light lead him out of the darkness of his past? Read this remarkable book and find the answers, you will not be disappointed.
If you enjoy reading MC Romance then you will not one to miss out on this one. Ms. Wilder not only weaves a tale of life in an MC but also meshes it with true love and more!
This is the first book in the Satan's Fury MC series. I loved it and think it's a great start to the series. There were parts that had me cracking up and some that had me really worried.
Maverick goes through a lot at the beginning of the book. I think he made the right decision when it came to John Warren. It wasn't an easy decision, but it was the right one. I would love an update about his relationship with Gavin after everything that happened.
Henley witnessed a murder, the cops didn't believe her and now the killers are after her. She's a loose end that needs taken care of. Luckily for her, her sister Cassidy is a bartender for Satan's Fury. The murder victim was a member. She is now under their protection. More specifically, she's under Maverick's watch.
I loved the anonymous texts she was sending to Maverick and how they started the prank war.
I loved how things developed between them. It wasn't insta-love. Well, not an insta-love that they noticed right away.
"Henley…You're mine. I know I haven't been clear about that…I've been too bull headed to admit it out loud, but I've known it since the night you were trying to leave the club wearing nothing but that damn t-shirt. I couldn't stand the thought of you walking out that door. No one has been able to get to me the way you do… no one. I love you Henley."
I can't wait to read the next in the series.
Maverick has just returned from taking his son, John Warren, to the 2 people who he believes can give him a safer and more stable life. When he finds out a fellow member has been murdered and he is asked to help protect the only person who witnessed it, more than just his club is in danger, his heart could be too.
Together Maverick and Henley will discover that there is room for love also in this life.
This story is a mixture of toughness, compassion and strength. It not only deals with what MC's sometimes have to deal with, but ,it also throws in a great story about a child with Downs Syndrome and just how amazing they are.
Will Henley be safe or will when she decides to try and help the club find the killers by herself be the end of her?
And will Maverick ever find that silver lining his mother always talked about or will Henley be the end of him?
A must-read.
When he is charged with watching over the trusting but stubborn Henley after she sees one of his "brothers" murdered, it begins the end of his freeze out of life and love and he faces another huge challenge to maybe redeem himself.
As Henley and Maverick grow closer and life seems to be on the right track again, another huge betrayal comes to light and what might have been a case of "doing the right thing" becomes something else all together.
I really loved the start of this new biker series...Maverick intrigued me when I first met him in a previous book and was hoping we would get his story. This one is full of power packed exciting twists and turns and along with all the violent club business, there is plenty of sexy romance and emotional family drama. Great ending that made me happy as well.
***** 5 ***** "putting everyone before yourself takes a toll" stars
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The content was good, the writing was done well, but I wish it would of been a bit more detailed. I'm still interested in a few things so I think I'm going to start the second one... Read morePublished 2 days ago by Raylene Green
I really enjoyed reading Maverick. The characters just came to life and the story flowed well. I loved that the author showed a good side of motorcycle clubs instead of always just... Read morePublished 8 days ago by Amazon Customer
Sisters Henley and Cassidy Gray share an apartment. Henley is studying for college exams and decides to run out for a few snacks. Read morePublished 9 days ago by Kathy B
Really good starter to a great series of Bad Ass Bikers. Very hot as well.Published 9 days ago by tika88
This series is amazing. Once you start reading you cannot stop. I cannot wait to get started on the next book.Published 13 days ago by Marcy Rollins
Maverick has been through the ringer, and even though everyone has his back, no one has supported him and his decision until Henley. Read morePublished 16 days ago by Ruthless Bookfish
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Conflicts of Interest: None of the authors has a conflict of interest.
Acute-on-chronic liver failure in chronic hepatitis B
Version of Record online: 22 MAR 2012
DOI: 10.1111/j.1440-1746.2011.06971.x
© 2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
Journal of Gastroenterology and Hepatology
Volume 27, Issue 4, pages 662–669, April 2012
Additional Information
How to Cite
Seto, W.-K., Lai, C.-L. and Yuen, M.-F. (2012), Acute-on-chronic liver failure in chronic hepatitis B. Journal of Gastroenterology and Hepatology, 27: 662–669. doi: 10.1111/j.1440-1746.2011.06971.x
Role of the funding source: None of the authors has anything to disclose.
The authors declare they have participated in the preparation of the manuscript and have seen and approved the final version.
Publication History
- Issue online: 22 MAR 2012
- Version of Record online: 22 MAR 2012
- Accepted manuscript online: 18 NOV 2011 01:50PM EST
- Accepted for publication 29 September 2011.
- Abstract
- Article
- References
- Cited By
- acute-on-chronic liver failure;
- hepatitis B;
- hepatitis B virus DNA;
- liver failure;
- Model of End-stage Liver Disease;
- survival
- Top of page
- Abstract
- Introduction
- Acute severe exacerbation of CHB: natural history and predisposing factors
- Other causes of ACLF in CHB
- Pathogenesis of ACLF in CHB
- Prognostic indicators in ACLF in CHB
- Treatment of ACLF in CHB
- Conclusions
- References
Acute-on-chronic liver failure (ACLF) in chronic hepatitis B (CHB) is most commonly caused by acute severe exacerbation of CHB. The pathophysiology of ACLF in CHB is still poorly understood. Despite the identification of important predisposing factors and prognostic markers, ACLF in CHB remains a disease associated with high mortality. The majority of studies using nucleoside analog therapy did not show any significant improvement in survival, although larger prospective studies are needed. Liver transplantation is the definitive treatment for ACLF in CHB. The challenge ahead would be prognosticating cases with favorable or unfavorable outcomes in order to streamline patients for early transplantation or for medical therapy.
- Top of page
- Abstract
- Introduction
- Acute severe exacerbation of CHB: natural history and predisposing factors
- Other causes of ACLF in CHB
- Pathogenesis of ACLF in CHB
- Prognostic indicators in ACLF in CHB
- Treatment of ACLF in CHB
- Conclusions
- References
The introduction of nucleoside/nucleotide analog therapy in the last 15 years has dramatically transformed the treatment outcomes of chronic hepatitis B (CHB).1 Long-term nucleoside analog therapy, in maintaining a permanent state of virologic suppression,2 can result in reversal of fibrosis, histologic improvement,3 as well as reduce the incidence of cirrhotic complications and hepatocellular carcinoma (HCC).4,5 However, an estimated 600 000 patients are still dying annually from CHB.6 Liver-related mortality in CHB can be classified into three groups: (i) complications of chronic liver disease with the development of cirrhosis or HCC; (ii) gradual hepatic decompensation with liver failure; and (iii) acute decompensation, otherwise known as acute-on-chronic liver failure (ACLF).
The Asian Pacific Association for the Study of the Liver (APASL) was the first liver organization to publish a consensus recommendation on ACLF.7 ACLF is defined as an acute hepatic insult manifesting as jaundice and coagulopathy (international normalized ratio [INR] > 1.5), complicated within 4 weeks by ascites and/or encephalopathy in a patient with previously diagnosed or undiagnosed chronic liver disease. ACLF in CHB includes acute severe exacerbation of CHB, a disease presentation distinct from other types of chronic liver diseases by its sudden virologic surge followed by biochemical flares. Its pathophysiology and management are also very different from other causes of acute liver failure.8 ACLF in CHB should also be differentiated from acute hepatitis B, as nucleoside analog therapy for the latter is generally only reserved for fulminant cases. The different causes of ACLF in CHB, especially acute exacerbation of CHB, its prognostic indicators, and its management strategies will be discussed in this review.
Acute severe exacerbation of CHB: natural history and predisposing factors
- Top of page
- Abstract
- Introduction
- Acute severe exacerbation of CHB: natural history and predisposing factors
- Other causes of ACLF in CHB
- Pathogenesis of ACLF in CHB
- Prognostic indicators in ACLF in CHB
- Treatment of ACLF in CHB
- Conclusions
- References
CHB is distinguished by its four disease phases: the immune tolerant phase, the immune clearance phase, the inactive carrier phase and HBeAg-negative hepatitis.9 The immune tolerant phase is characterized by its high HBV DNA levels but minimal damage in liver histology.10 Acute severe exacerbation of CHB can occur in the immune clearance phase affecting 40–50% of hepatitis B e antigen (HBeAg)-positive patients,11 and can be prolonged when there is repeated unsuccessful clearance of HBeAg. Reactivation of CHB at the HBeAg-negative phase, seen in 15–30% of HBeAg-negative patients, can also result in acute decompensation, and is occasionally associated with HBeAg seroreversion.12 There is no single cut-off HBV DNA level that can differentiate whether HBeAg-negative patients would remain inactive carriers or develop exacerbations.13
One of the first prospective studies investigating the natural history of acute exacerbations in CHB found that 15–47% of CHB patients developed exacerbations after 4 years of follow up. In patients with hepatitic flares, up to 8% of patients would develop decompensation.14 When comparing HBeAg-positive to -negative patients, the frequency of severe exacerbation was similar.15
Several predisposing factors of acute severe exacerbation had been identified, including elevated alanine aminotransferase (ALT) levels at presentation, male sex,14 and the presence of certain genotypes (Table 1). There are eight genotypes (A–H) in CHB. Asian CHB patients are predominantly infected with genotypes B and C. Although genotype C patients have an increased chance of cirrhosis and HCC,16 genotype B is associated with a higher mortality in acute severe exacerbation.17 The more aggressive nature of genotype B has also been reproduced in other studies.18 Since genotype B patients achieve HBeAg seroconversion at an earlier age,19 genotype B is likely to be more immunogenic and is associated with more immune-mediated damage.20 In the Caucasian population, genotype D was found to be more aggressive than genotype A.21
|Viral factors
|• Genotypes B and D
|• ? Precore and core promoter mutations
|Host factors
|• Elevated ALT at presentation
|• Male sex
|• ? Acute variceal bleeding
|• Superimposed acute hepatitis A and E
|• Systemic infections involving the liver
|External agents
|• Alcoholic hepatitis
|• Systemic corticosteroids and its withdrawal
|• Cytotoxic therapy (e.g. rituximab)
|• Hepatotoxic drugs
|• Herbal indigenous medicines
Mutations in the precore and core promoter region of the hepatitis B virus genome have been suggested to be associated with acute exacerbations. In a study in which the entire precore genome was sequenced, a point mutation at the A1896 loci was associated with the development of fulminant hepatitis.22 However, further clinical studies on precore mutations reveal conflicting results.23 Several mutation sites in the core promoter region have been described to be associated with fulminant disease.18 However a study in Asia found disease activity after HBeAg seroconversion to be unrelated to the presence or absence of both precore and core promoter mutations.24 It has been suggested that the presence of precore and core promoter mutations are more relevant in differentiating acute exacerbation of CHB from acute hepatitis B,25 although further validation of this proposal is needed.
Corticosteroid therapy and its withdrawal also predisposes to acute exacerbation of CHB.26 HBV replication is enhanced during steroid therapy, with exacerbations also possible during the immunologic rebound associated with steroid withdrawal. A study among 198 patients with either asthma or chronic obstructive pulmonary disease found the incidence of CHB reactivation to be significantly higher in patients receiving systemic steroids when compared to those receiving only inhalational steroids.27 A continuous period of systemic steroids for more than 3 months and a dose of prednisolone of more than 20 mg per day were associated with an increased chance of exacerbation.
A unique presentation of acute severe exacerbation is the reactivation of "occult" CHB after immunosuppressive or cytotoxic therapy,28 especially with therapy containing rituximab.29 Mortalities had been reported when pre-emptive antiviral or close monitoring were not enforced in hepatitis B surface antigen (HBsAg)-negative but antibody to the hepatitis B core antigen (anti-HBc)-positive patients in regions with a high prevalence of CHB.
Other causes of ACLF in CHB
- Top of page
- Abstract
- Introduction
- Acute severe exacerbation of CHB: natural history and predisposing factors
- Other causes of ACLF in CHB
- Pathogenesis of ACLF in CHB
- Prognostic indicators in ACLF in CHB
- Treatment of ACLF in CHB
- Conclusions
- References
Coexisting viral hepatitis is one important cause of ACLF in CHB. Superinfection by the hepatitis A virus (HAV) in CHB has been associated with a 5.6–29-fold increase in mortality.30 Similar findings had been observed in CHB patients infected with acute hepatitis E, contributing to 20% of acute exacerbations of CHB in regions endemic with the hepatitis E virus (HEV).31 HEV superinfection in CHB has been found to be associated with a higher mortality when compared to HAV.32 In addition, patients with compensated cirrhosis infected with HEV are at an increased risk of rapid decompensation.33
The inclusion of acute variceal bleeding as a cause of ACLF is controversial. A hemodynamic study in 144 ACLF patients found the mean hepatic venous pressure gradient (HVPG) in ACLF patients with large varices to be comparable to that of decompensated cirrhosis.34 It is possible that variceal bleeding is only an expression of elevated portal pressure due to decompensation, and not the actual event leading to ACLF.7
Other precipitants of ACLF in CHB include systemic infections involving the liver, coexisting alcoholic hepatitis, hepatotoxic drugs and herbal indigenous medicines7 (Table 1). Several herbs, including Ganoderma lucidum or lingzhi,35 have been identified as hepatotoxic. Studies in Asia found herbal indigenous medicines attributing 7.1–55% of cases diagnosed with drug-induced liver injury,36 of which patients with underlying CHB are prone to develop unfavorable outcomes.37
Pathogenesis of ACLF in CHB
- Top of page
- Abstract
- Introduction
- Acute severe exacerbation of CHB: natural history and predisposing factors
- Other causes of ACLF in CHB
- Pathogenesis of ACLF in CHB
- Prognostic indicators in ACLF in CHB
- Treatment of ACLF in CHB
- Conclusions
- References
HBV itself is non-cytopathic under the usual circumstances, with damage to the liver mainly caused by immune-mediated processes involving both CD4 + and CD8 + T cells.38 The inflammatory processes seen in ACLF are probably non-HBV-specific, since HBV-specific CD8 + T cells are found in liver tissues with minimal histologic changes, while non-antigen-specific T cells are found in CHB histologic specimens with massive liver necroinflammation.38
The immunologic changes seen in the inflammatory process of ACLF are very similar to that of severe sepsis.39 The host immune system is affected by a depression of different cellular immune parameters, especially monocytic HLA-DR. The reduced monocyte activation is associated with an exacerbated production of anti-inflammatory cytokines, including interleukin (IL)-6, IL-10, IL-12 and interferon-gamma.39 Cytokine production is associated with activation of toll-like receptors (TLR), an important component of the innate immune system in recognizing specific pathogen-associated molecular patterns (PAMP).40 TLR2 and TLR4,41 downregulated during chronic HBV infection, show an increased expression during ACLF. Other TLR (TLR3/5/7/9/10) are also upregulated in ACLF.42
A recent study found IL-17-producing CD4 + T (Th17) cells to be involved in liver injury, particularly in CHB patients with ACLF.43 The precise mechanisms remain to be determined, although a preliminary study found an increased frequency of CpG island methylation of IL-17 in CHB patients with ACLF.44 Th-17 also has a role in liver injury in alcoholic liver disease.45 It is therefore possible that TH-17 is not specifically involved in CHB but is also involved in ACLF of different etiologies. B cells may also be involved, as shown in a study demonstrating a massive accumulation of plasma cells secreting immunoglobulin (Ig)M and IgG targeting the hepatitis B core antigen in liver tissues of CHB patients who required liver transplantation because of ACLF.46
The I27V mutation in the HBV core gene is also found to be associated with severe liver inflammation in CHB, and has a high rate of occurrence in Chinese CHB patients.47 Peripheral glucocorticoid receptor expression is also increased in CHB patients with ACLF.48 These factors may contribute to the pathogenesis of ACLF in CHB, although their exact roles remain to be determined.
The clinical development of systemic inflammatory response syndrome (SIRS) is a poor prognostic factor, and is associated with progression of encephalopathy and reduced chances of transplantation.49 In its full-blown picture, the resulting inflammatory responses in the liver and its associated cellular immune dysfunction can result in renal, circulatory and cerebral dysfunction (Fig. 1). Kidney damage in ACLF is multi-factorial, including hepatorenal syndrome, hypovolemia, infective causes and drug-related causes.50 The increased secretion of nitric oxide and tumor necrosis factor results in exaggerated vasodilatation.51 This circulatory dysfunction, together with hyperammonemia, can be associated with the elevation of intracranial pressure and cerebral edema.52 Hence, ACLF if uncontrolled could result in multi-organ failure and hence mortality.
Prognostic indicators in ACLF in CHB
- Top of page
- Abstract
- Introduction
- Acute severe exacerbation of CHB: natural history and predisposing factors
- Other causes of ACLF in CHB
- Pathogenesis of ACLF in CHB
- Prognostic indicators in ACLF in CHB
- Treatment of ACLF in CHB
- Conclusions
- References
The prognosis of ACLF in CHB is extremely poor, with 3-month mortality rates without liver transplantation reported to be more than 50%.53,54 An Asian study of 47 patients with severe exacerbation of CHB identified several factors associated with adverse outcomes,15 including pre-existing cirrhosis, prolonged prothrombin time (PT), elevated bilirubin, low albumin level, low platelet count and the presence of encephalopathy/ascites. The presence of neither precore nor core promoter mutations was associated with a worse prognosis. Other studies from Asia also show similar findings.55,56 These studies conclude that ALT level is not a useful prognostic indicator of mortality.
Different scoring models had been established to stratify patients based on prognosis to facilitate organ allocation for liver transplantation. The Model of End-stage Liver Disease (MELD) score has been used extensively for the allocation of donor livers worldwide,57 and has been validated for the use in CHB.58 A study comparing the MELD score with the Child–Pugh score found the MELD score to be a more objective and efficient system in predictive survival in CHB patients with ACLF.59 A subsequent increase in MELD score after initial presentation of ACLF is also useful in stratifying patients for liver transplantation.60 Serum sodium levels have been previously found to be associated with increased mortality in patients awaiting liver transplantation,61 and incorporating serum sodium into the MELD score is shown to improve the mortality prediction.62 The modified MELD-sodium score has been validated as a predictor of mortality in CHB.63 Further studies are needed to determine the MELD-sodium score in the setting of ACLF in CHB.
Other models used for predicting prognosis of ACLF in CHB have been reported (Table 2). One regression model, using the presence of hepatorenal syndrome, liver cirrhosis, positive HBeAg, low albumin and prolonged PT, was found to be superior to the MELD score in predicting 3-month mortality.53 Another model based on the presence of hepatic encephalopathy, hepatorenal syndrome, positive HBeAg, liver cirrhosis and prolonged PT was also found to be superior to both the MELD and Child–Pugh score.64 Further studies to externally validate these models would be needed before widespread use could be recommended. The King's College Criteria have been used extensively for prognostic purposes in acute liver failure,8 but have never been validated for the use of ACLF in CHB.
|Predictive model
|MELD score57–60
|Prothrombin time
|More objective score when compared to Child–Pugh score
|MELD-sodium score63
|Prothrombin time
|Predictor of mortality in chronic hepatitis B
|Needs further studies in the setting of ACLF
|Sun et al. 200953
|Presence of cirrhosis
|Found superior to MELD when predicting 3-month mortality
|Presence of hepatorenal syndrome
|HBeAg status
|Needs external validation
|Prothrombin time
|Zheng et al. 201164
|Presence of cirrhosis
|Found superior to MELD score and Sun et al. 2009 in predicting 3-month mortality
|Presence of encephalopathy
|Presence of hepatorenal syndrome
|Needs external validation
|HBeAg status
|Prothrombin time
Treatment of ACLF in CHB
- Top of page
- Abstract
- Introduction
- Acute severe exacerbation of CHB: natural history and predisposing factors
- Other causes of ACLF in CHB
- Pathogenesis of ACLF in CHB
- Prognostic indicators in ACLF in CHB
- Treatment of ACLF in CHB
- Conclusions
- References
All supportive measures recommended for other causes of acute liver failure hold true for CHB with ACLF,8 including antibiotics for superimposed infection, treatment for hepatic encephalopathy,52 and terlipressin and albumin for hepatorenal syndrome.65 The preliminary results of a randomized placebo-controlled trial found the administration of granulocyte-colony stimulating factor improved survival after 2 months,66 although this cannot be recommended for routine clinical practice at this juncture. Series with a small number of patients have found the use of bioartificial liver support systems to be safe and well tolerated in ACLF, and are able to bridge patients while waiting for liver transplantation or till recovery.67 However the preliminary results of a randomized controlled multicenter study in ACLF patients failed to identify any survival benefit.68
Interferon therapy is contraindicated in CHB with ACLF as it will exacerbate hepatic decompensation. Corticosteroids, based on their anti-inflammatory activity, have been used in CHB with ACLF.69 In a recent study, intravenous dexamethasone 10 mg daily was given for 5 days together with continuous lamivudine to 56 patients. When compared with controls, dexamethasone treatment was an independent factor influencing survival, with a rapid decline in serum bilirubin in the first 5 days predictive of survival.70 More studies would be needed to validate this result, especially since steroid withdrawal is an important predisposing factor of ACLF in CHB.
Medical literature on the efficacy of nucleoside analogs, while scarce, has been emerging in recent years (Table 3). Long-term lamivudine treatment in CHB is associated with improved biochemical and virologic outcomes.4,5 This also holds true for patients with severe acute exacerbation.74 However, the use of lamivudine in CHB with ACLF has been disappointing. A Japanese study compared lamivudine-treated patients with acute severe exacerbation with historical controls. Among those developing liver failure, although there was a reduction in viral load in lamivudine-treated patients, there was no difference in the incidence of 3-month mortality.56 Although a more recent study found a survival benefit in lamivudine-treated patients when compared to controls in patients with a MELD score of 30 or less,71 those treated with lamivudine still had a 3-month mortality of 50.7%. This study also identified a low pretreatment HBV DNA and a rapid decline in viral load as predictors of good outcome.
|Tsubota et al. 2005†56
|Sun et al. 201071
|Cui et al. 201054
|Wong et al. 201172
|Garg et al. 201173
|Hong Kong
|Patient cohort
|LAM (n = 6)
|LAM (n = 130)
|LAM (n = 34)
|LAM (n = 117)
|TDF (n = 14)
|Controls (n = 7)
|Controls (n = 130)
|ETV (n = 33)
|ETV (n = 36)
|Placebo (n = 13)
|Controls (n = 37)
|Compensated Cirrhosis
|38.5% (5/13)
|10% (26/260)
|Median: 4.42–4.92
|Mean: 2.1–3.6
|Mean: 2.27–2.61
|Mean: 1.58–1.59
|Median: 1.85–1.93
|HBV DNA (IU/mL)
|Median: 8 × 107 (range: 4 × 106–7.6 × 108)
|56 patients < 20 000
|Mean: 1.1–1.7 × 105
|Mean: 3.9–7.3 × 106
|Median: 7.5 × 105–1.7 × 106 (range: 1.7 × 104–1.7 × 109)
|204 patients ≥ 20 000
|Controls: 71.4%
|Placebo: 85%
|Controls: 75.7%
|Controls: 59.5%
|Controls: 100%
|No benefit with LAM
|LAM improves survival for MELD 20–30. No survival benefit for MELD > 30
|No benefit with LAM or ETV
|ETV treatment associated with increased short-term mortality
|TDF improves survival
|Low pretreatment HBV DNA and rapid decline in HBV DNA predictors of favorable outcome
|Survivors had favorable long-term outcomes
|Small patient number in ETV group
|Week 2 HBV DNA > 2-log reduction predictive of survival
The survival rates from the above two studies are much lower than that of lamivudine in decompensated acute hepatitis B.75 A possible explanation is the presence of substantial hepatic necrosis by the time lamivudine is started in ACLF, with synthetic function not correctable by a reduction in viral load. This hypothesis is consistent with a study showing that commencement of lamivudine before serum bilirubin reached 20 mg/dL was able to improve survival in cases of severe acute exacerbation.55
More recent studies have been performed with more potent nucleoside analogs. A study from China compared patients receiving entecavir (n = 33), lamivudine (n = 34), or no nucleoside analogs (n = 37).54 As with previous studies, both nucleoside analogs achieved significant viral suppression after 3 months, but there were no improvements in survival, with 3-month survival rates being 48.5%, 50.0% and 40.5%, respectively. A recent study from Hong Kong found entecavir (n = 36) to be associated with increased short-term mortality when compared to lamivudine (n = 117),72 of which lactic acidosis has been hypothesized as a possible cause.76 This finding needs further confirmation from other centers, especially since another study found the usage of entecavir and tenofovir (another potent nucleoside analog) in decompensated CHB to have similar outcomes.77
A prospective study from India found tenofovir to be associated with improved survival in ACLF. This study randomized patients into taking either tenofovir (n = 14) or placebo (n = 13).73 After 3 months, the tenofovir group had a survival rate of 57%, compared to 15% for placebo (P = 0.03). Another significant finding was a 2-log reduction in HBV DNA levels in 2 weeks indicating better survival. However, this study is limited by its small sample size and the unavailability of liver transplantation. Despite having a lower median INR of 1.85 at treatment commencement, the survival rate of the tenofovir-treated group was not better than that of the studies quoted above54,56,71 (Table 3).
There are two limiting factors for all nucleoside analog studies. First, the number of patients in these studies was very small. Second, there were no head-to-head comparisons between patients receiving different nucleoside analogs. The vast difference in 3-month survival rates (ranging between zero and 40.5%) found in controls suggested that different studies recruited patients with different severity of ACLF. A meta-analysis of existing studies would be useful. In addition, larger prospective studies are needed to validate the clinical efficacy of tenofovir, to clarify the survival.
The definitive treatment for ACLF in CHB is liver transplantation. A study from Hong Kong retrospectively analyzed 149 patients presenting as ACLF who received liver transplantation, of which 50 had severe exacerbation of CHB.78 The 5-year survival rates exceeded 90%. The application of different predictive models mentioned above should help in the selection of patients for liver transplantation, although further studies in this area are required. Nucleoside analog therapy after liver transplantation had been shown to be effective in achieving good long-term outcomes.79 Randomized trials comparing nucleoside analog therapy with hepatitis B immunoglobulin found the former to be convenient and cost-effective for long-term HBV prophylaxis.80–82
- Top of page
- Abstract
- Introduction
- Acute severe exacerbation of CHB: natural history and predisposing factors
- Other causes of ACLF in CHB
- Pathogenesis of ACLF in CHB
- Prognostic indicators in ACLF in CHB
- Treatment of ACLF in CHB
- Conclusions
- References
The clinical and immunological features of ACLF in CHB are distinctive from other causes of ACLF. Unlike the majority of the CHB population, patients with ACLF belong to a subgroup that does not usually respond satisfactorily to nucleoside analogs. Determining the efficacy of nucleoside analog therapy would need larger prospective studies, and this would probably require multicenter collaborative efforts to ensure patient recruitment. Liver transplantation is still considered a luxury in many developing countries, and hence it is essential to develop prognostic indicators to identify patients with poor outcomes. The clinical challenge in the future is how to incorporate different predictive models into daily clinical practice and streamline patients for either liver transplantation or medical management.
- Top of page
- Abstract
- Introduction
- Acute severe exacerbation of CHB: natural history and predisposing factors
- Other causes of ACLF in CHB
- Pathogenesis of ACLF in CHB
- Prognostic indicators in ACLF in CHB
- Treatment of ACLF in CHB
- Conclusions
- References
- 1Treatment of chronic hepatitis B: evolution over two decades. J. Gastroenterol. Hepatol. 2011; 26 (Suppl. 1): 138–43., .
- 2Chronic hepatitis B—new goals, new treatment. N. Engl. J. Med. 2008; 359: 2488–91., .
- 3Long-term entecavir therapy results in the reversal of fibrosis/cirrhosis and continued histological improvement in patients with chronic hepatitis B. Hepatology 2010; 52: 886–93., , et al.
- 4Lamivudine for patients with chronic hepatitis B and advanced liver disease. N. Engl. J. Med. 2004; 351: 1521–31., , et al.
- 5Long-term lamivudine therapy reduces the risk of long-term complications of chronic hepatitis B infection even in patients without advanced disease. Antivir. Ther. 2007; 12: 1295–303., , et al.
- 6World Health Organization. WHO Fact Sheet N*204. Published August 2008. Cited 16 April 2011. Available from URL: http://www.who.int/mediacenter/factsheets/fs204/en/
- 7Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the Study of the Liver (APASL). Hepatol. Int. 2009; 3: 269–82., , et al.
- 8AASLD position paper: the management of acute liver failure. Hepatology 2005; 41: 1179–97., .
- 9The natural history and treatment of chronic hepatitis B: a critical evaluation of standard treatment criteria and end points. Ann. Intern. Med. 2007; 147: 58–61., .
- 10Chronic hepatitis B virus carriers in the immunotolerant phase of infection: histologic findings and outcome. Clin. Gastroenterol. Hepatol. 2007; 5: 636–41., , et al.
- 11Hepatic decompensation associated with hepatitis B e antigen clearance in chronic type B hepatitis. Gastroenterology 1985; 89: 732–5., , , .
- 12Spontaneous hepatitis B e antigen to antibody seroconversion and reversion in Chinese patients with chronic hepatitis B virus infection. Gastroenterology 1987; 92: 1839–43., , , , .
- 13Quantitative serum HBV DNA levels during different stages of chronic hepatitis B infection. Hepatology 2002; 36: 1408–15., , .
- 14Acute exacerbations in Chinese patients with chronic hepatitis B virus (HBV) infection. Incidence, predisposing factors and etiology. J. Hepatol. 1990; 10: 29–34., .
- 15Prognostic factors in severe exacerbation of chronic hepatitis B. Clin. Infect. Dis. 2003; 36: 979–84., , et al.
- 16Risk for hepatocellular carcinoma with respect to hepatitis B virus genotypes B/C, specific mutations of enhancer II/core promoter/precore regions and HBV DNA levels. Gut 2008; 57: 98–102., , et al.
- 17Role of hepatitis B virus genotypes in chronic hepatitis B exacerbation. Clin. Infect. Dis. 2003; 37: 593–7., , et al.
- 18Distribution of hepatitis B viral genotypes and mutations in the core promoter and precore regions in acute forms of liver disease in patients from Chiba, Japan. Gut 2003; 52: 1630–7., , et al.
- 19Significance of hepatitis B genotype in acute exacerbation, HBeAg seroconversion, cirrhosis-related complications, and hepatocellular carcinoma. Hepatology 2003; 37: 562–7., , et al.
- 20Difference in T helper responses during hepatitis flares in hepatitis B e antigen (HBeAg)-positive patients with genotypes B and C: implication for early HBeAg seroconversion. J. Viral Hepat. 2007; 14: 269–75., , et al.
- 21Influence of hepatitis B virus genotype on the long-term outcome of chronic hepatitis B in western patients. Gastroenterology 2002; 123: 1848–56., , , , .
- 22Mutations in the precore region of hepatitis B virus DNA in patients with fulminant and severe hepatitis. N. Engl. J. Med. 1991; 324: 1699–704., , , , .
- 23Relationship between the development of precore and core promoter mutations and hepatitis B e antigen seroconversion in patients with chronic hepatitis B virus. J. Infect. Dis. 2002; 186: 1335–8., , et al.
- 24Hepatitis B e antigen–negative chronic hepatitis B in Hong Kong. Hepatology 2000; 31: 763–8., , , , .
- 25Detection of HBV core promoter and precore mutations helps distinguish flares of chronic hepatitis from acute hepatitis B. J. Gastroenterol. Hepatol. 2008; 23: 790–3., , et al.
- 26Systemic corticosteroid and reactivation of chronic hepatitis B. Respirology 2010; 15: 1017–18., .
- 27Risk of hepatitis B virus reactivation in patients with asthma or chronic obstructive pulmonary disease treated with corticosteroids. Respirology 2010; 15: 1092–7., , et al.
- 28Diagnosis, prevention and management of hepatitis B virus reactivation during anticancer therapy. Hepatology 2006; 43: 209–20., .
- 29Hepatitis B virus reactivation in lymphoma patients with prior resolved hepatitis B undergoing anticancer therapy with or without rituximab. J. Clin. Oncol. 2009; 27: 605–11., , et al.
- 30Acute hepatitis A and B in patients with chronic liver disease: prevention through vaccination. Am. J. Med. 2005; 118: 21–7..
- 31Hepatitis E virus as an etiology of acute exacerbation of previously unrecognized asymptomatic patients with hepatitis B virus-related chronic liver disease. J. Gastroenterol. Hepatol. 2008; 23: 883–7., , .
- 32Comparison of effects of hepatitis E or A viral superinfection in patients with chronic hepatitis B. Hepatol. Int. 2010; 4: 615–20., , , , , .
- 33Hepatitis E virus (HEV) infection in patients with cirrhosis is associated with rapid decompensation and death. J. Hepatol. 2007; 46: 387–94., , et al.
- 34Hemodynamic studies in acute-on-chronic liver failure. Dig. Dis. Sci. 2009; 54: 869–78., , , , , .
- 35Hepatotoxicity due to a formulation of Ganoderma lucidum (lingzhi). J. Hepatol. 2004; 41: 686–7., , , .
- 36Drug-induced liver injury in Japan: an analysis of 1676 cases between 1997 and 2006. Hepatol. Res. 2009; 39: 427–31., , , , .
- 37Epidemiology of idiosyncratic drug-induced liver injury. Semin. Liver Dis. 2009; 29: 337–47., .
- 38The role of virus-specific CD8(+) cells in liver damage and viral control during persistent hepatitis B virus infection. J. Exp. Med. 2000; 191: 1269–80., , et al.
- 39Patients with acute on chronic liver failure display "sepsis-like" immune paralysis. J. Hepatol. 2005; 42: 195–201., , et al.
- 40The role of pattern-recognition receptors in innate immunity: update on Toll-like receptors. Nat. Immunol. 2010; 11: 373–84., .
- 41Expression profiles and function of Toll-like receptors 2 and 4 in peripheral blood mononuclear cells of chronic hepatitis B patients. Clin. Immunol. 2008; 128: 400–8., , et al.
- 42Correlation of TLR1-10 expression in peripheral blood mononuclear cells with chronic hepatitis B and chronic hepatitis B-related liver failure. Hum. Immunol. 2010; 71: 950–6., , et al.
- 43Interleukin-17–producing CD4+ T cells increase with severity of liver damage in patients with chronic hepatitis B. Hepatology 2010; 51: 81–91., , et al.
- 44Elevated CPG island methylation of IL-17 promoter in acute-on-chronic hepatitis B liver failure [abstract]. J. Hepatol. 2011; 54 (Suppl.): S158., , et al.
- 45The interleukin-17 pathway is involved in human alcoholic liver disease. Hepatology 2009; 49: 646–57., , et al.
- 46B cell gene signature with massive intrahepatic production of antibodies to hepatitis B core antigen in hepatitis B virus-associated acute liver failure. Proc. Natl. Acad. Sci. U.S.A. 2010; 107: 8766–71., , et al.
- 47The high prevalence of the I27 mutant HBcAg18-27 epitope in Chinese HBV-infected patients and its cross-reactivity with the V27 prototype epitope. Clin. Immunol. 2007; 125: 337–45., , et al.
- 48Expression of human glucocorticoid receptor in T lymphocytes in acute-on-chronic hepatitis B liver failure. Dig. Dis. Sci. 2011; 56: 2605–12., , , , , .
- 49The systemic inflammatory response syndrome in acute liver failure. Hepatology 2000; 32: 734–9., , , , , .
- 50Acute-on-chronic liver failure: the kidneys. Curr. Opin. Crit. Care 2011; 17: 184–9., .
- 51Acute-on-chronic liver failure: the heart and systemic hemodynamics. Curr. Opin. Crit. Care 2011; 17: 190–4., .
- 52Acute-on-chronic liver failure: the brain. Curr. Opin. Crit. Care 2011; 17: 177–83., .
- 53Prediction of the prognosis of patients with acute-on-chronic hepatitis B liver failure using the model for end-stage liver disease scoring system and a novel logistic regression model. J. Viral Hepat. 2009; 16: 464–70., , et al.
- 54Nucleoside analogue can improve the long-term prognosis of patients with hepatitis B virus infection-associated acute on chronic liver failure. Dig. Dis. Sci. 2010; 55: 2373–80., , et al.
- 55The effect of lamivudine therapy in hepatic decompensation during acute exacerbation of chronic hepatitis B. J. Hepatol. 2003; 38: 322–7., , .
- 56Lamivudine monotherapy for spontaneous severe acute exacerbation of chronic hepatitis B. J. Gastroenterol. Hepatol. 2005; 20: 426–32., , et al.
- 57Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology 2003; 124: 91–6., , et al.
- 58Evaluation of model for end-stage liver disease for prediction of mortality in decompensated chronic hepatitis B. Am. J. Gastroenterol. 2006; 101: 1516–23., , , , , .Direct Link:
- 59Prediction value of model for end-stage liver disease scoring system on prognosis in patients with acute-on-chronic hepatitis B liver failure after plasma exchange and lamivudine treatment. J. Gastroenterol. Hepatol. 2008; 23: 1242–9., , , .
- 60Indicators and outcome of liver transplantation in acute liver decompensation after flares of hepatitis B. J. Viral Hepat. 2011; 18: 193–9., , , , , .
- 61Hyponatremia and mortality among patients on the liver-transplant waiting list. N. Engl. J. Med. 2008; 359: 1018–26., , et al.
- 62A revised model for end-stage liver disease optimizes prediction of mortality among patients awaiting liver transplantation. Gastroenterology 2011; 140: 1952–60., , , , , .
- 63Performance of the new MELD-Na score in predicting 3-month and 1-year mortality in Chinese patients with chronic hepatitis B. Liver Transpl. 2007; 13: 1228–35., , , , .
- 64A model to determine 3-month mortality risk in patients with acute-on-chronic hepatitis B liver failure. Clin. Gastroenterol. Hepatol. 2011; 9: 351–6., , et al.
- 65A randomized, prospective, double-blind, placebo-controlled trial of terlipressin for type 1 hepatorenal syndrome. Gastroenterology 2008; 134: 1360–8., , et al.
- 66Granulocyte-colony stimulating factor (G-CSF) therapy improves survival in patients with acute-on-chronic liver failure (ACLF)—a randomized placebo controlled trial [abstract]. Hepatology 2010; 52: 333A., , , , , .
- 67Acute-on-chronic liver failure: extracorporeal liver assist devices. Curr. Opin. Crit. Care 2011; 17: 195–203., , .
- 68A prospective randomized controlled multicenter study of extracorporeal liver support by fractionated plasma separation and adsorption (Prometheus) in patients with acute-on-chronic liver failure (HELIOS study) [abstract]. Hepatology 2010; 52: 333A., , et al.
- 69A combination treatment of entecavir and early-phase corticosteroid in severe exacerbation of chronic hepatitis B. World J. Gastroenterol. 2009; 15: 1650–2., , et al.
- 70Efficacy of short-term dexamethasone therapy in acute-on-chronic pre-liver failure. Hepatol. Res. 2011; 41: 46–53., , et al.
- 71Influential factors of prognosis in lamivudine treatment for patients with acute-on-chronic hepatitis B liver failure. J. Gastroenterol. Hepatol. 2010; 25: 583–90., , , , .
- 72Entecavir treatment in patients with severe acute exacerbation of chronic hepatitis B. J. Hepatol. 2011; 54: 236–42., , et al.
- 73Tenofovir improves the outcome in patients with spontaneous reactivation of hepatitis B presenting as acute-on-chronic liver failure. Hepatology 2011; 53: 774–80., , , , , .
- 74Long-term follow-up of lamivudine treatment in patients with severe acute exacerbation of hepatitis B e antigen (HBeAg)-positive chronic hepatitis B. Antivir. Ther. 2008; 13: 571–9., , et al.
- 75Safety and efficacy of lamivudine in patients with severe acute or fulminant hepatitis B, a multicenter experience. J. Viral Hepat. 2006; 13: 256–63., , et al.
- 76Severe lactic acidosis during treatment of chronic hepatitis B with entecavir in patients with impaired liver function. Hepatology 2009; 50: 2001–6., , et al.
- 77Tenofovir disoproxil fumarate (TDF), emtricitabine/TDF, and entecavir in patients with decompensated chronic hepatitis B liver disease. Hepatology 2011; 53: 62–72., , et al.
- 78Liver transplantation for acute-on-chronic liver failure. Hepatol. Int. 2009; 3: 571–81., , et al.
- 79Liver transplantation in Asian patients with chronic hepatitis B using lamivudine prophylaxis. Ann. Surg. 2001; 233: 276–81., , et al.
- 80Randomized trial of lamivudine versus hepatitis B immunoglobulin for long-term prophylaxis of hepatitis B recurrence after liver transplantation. J. Hepatol. 2001; 34: 888–94., , et al.
- 81A randomized study comparing lamivudine monotherapy after a short course of hepatitis B immune globulin (HBIg) and lamivudine with long-term lamivudine plus HBIg in the prevention of hepatitis B virus recurrence after liver transplantation. J. Hepatol. 2003; 38: 811–17., , et al.
- 82A randomized study of adefovir dipivoxil in place of HBIG in combination with lamivudine as post-liver transplantation hepatitis B prophylaxis. Hepatology 2008; 48: 1460–6., , , , .


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Donald Trump's campaign is a grand gamble that he can turn enough angry white men, who have not voted in a while, into voters in 2016. He is ignoring the rules of the game and trying to find new supporters just like the ones he already has.
Sanders has started a social welfare advocacy organization to support progressive groups seeking to coach and vet those who want to run for office.
Lauren Elliott is program associate at Other Worlds, a women-driven, multimedia education and movement-building collaborative.


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Staybridge Suites Longview, Longview
- Free buffet breakfast and free parking
Main amenities
- 82 guestrooms
- Multilingual staff
- Tour/ticket assistance
What's around
- Heart of Longview
- Longview University Center (1.1 mi / 1.8 km)
- Longview Mall (1.5 mi / 2.4 km)
- Paul Boorman Trail Park (2.2 mi / 3.6 km)
- Alpine Golf Course (2.4 mi / 3.9 km)
- Gregg County Historical Museum (3.9 mi / 6.3 km)
For families
- Cribs/infant beds available
- Sofa bed
- Kitchen
- Cookware, dishware, and utensils
- Microwave
- Full-sized refrigerator/freezer
Staybridge Suites Longview, Longview
Hotel Info: 866-539-8117from $127
- Room, 1 Queen Bed, Non Smoking
- Room, Accessible, Non Smoking
- Room, 1 King Bed, Non Smoking
- Room, Non Smoking
- Room, Multiple Beds
- Room, Accessible, Non Smoking
- Standard Room
- Room
- Room, Non Smoking
- Room, Accessible
Also popular with travelers from the USA
At a glance
Key facts
Hotel size
- This hotel has 82 rooms
- This hotel is arranged over 4 floors
- Check-in time starts at 3 PM
- Check-out time is 10 AM
Required at check in
- Credit card or cash deposit required
- Government-issued photo ID required
Travelling with others
- Pets allowed *
- Free self parking
Nearby Three Star Longview hotels
In the hotel
- Free buffet breakfast daily
- Tours/ticket assistance
- Multilingual staff
In the room
- Coffee/tea maker
- Iron/ironing board
- Sofa bed
- Separate living room
- Private bathroom
- Hair dryer
- Desk
- Free newspaper
- Phone
- Full-sized refrigerator/freezer
- Microwave
- Kitchen
- Cookware, dishware, and utensils
- Dishwasher
Top Longview hotels
Recently reviewed hotels in Longview
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"Overall best, nicest and most comfortable hotel ever stated in!!!! Add the price it deserves a 5+ rating. I have stayed in hotels double the price and not nearly as nice as this…"Jul 20, 2016
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"This was a conveniently located,roomy motel with helpful staff."Jul 18, 2016
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"Nice Room. Good breakfast. Friendly staff, especially the guy working the front desk. He made a great restaurant recommendation. Sorry I can't remember his name. We had a good…"Jun 6, 2016
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"Awesome"Jun 5, 2016
Nearby hotels
Staybridge Suites Longview, Longview's small print
Also known as
- Staybridge Suites Hotel Longview
- Staybridge Suites Longview
Optional extras
Pets are allowed for an extra charge of USD 75 per week
We have included all charges provided to us by this hotel. However, charges can vary, for example, based on length of stay or the room you book.
Recent reviews
Outstanding 4.9 /5 from 23 reviews
Only downside is the poor wifi. Very slow.
Wonderful hotel but they accidentally charged me again after the room was paid. Was not happy with this but the hotel is wonderful.
This is a great hotel for a weekend getaway or a long term stay. It is more like a small apartment than a hotel with a full upscale kitchen, living room and separate bedroom suite. Everything is brand new and extremely clean. It is located in a quite area with many restaurants to choose from and shopping close by. We will definitely stay here again.
The hotel staff was friendly and personable. We were very impressed.
The room was great, and they even bumped us up to a bigger room. I would definitely stay here again.
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Crazy Substitute Teachers
Enjoy, NG4.02 / 5.00 2,174 Views
Vacuum Salesman
This dude and his Megazord vacuum cleaner4.00 / 5.00 2,628 Views
Markiplier Animated | Mark Of The Survey Corps
This took far too long to make...3.97 / 5.00 5,623 Views
Words cannot not describe what i just saw other than....wow....just wow.
Just three words... Laughing Out Loud ^^ Sorry for the low score, I'm just picky. Really, i is great.
"Gross" isn't what I'm thinking
I can't tell what I like more--the fact that you had the balls to make something like this, or the fact that almost every guy reviewing it thinks it's gross. The animation was great, the voice acting wasn't bad, and the concept was hysterical. Loved it.
At least know I know that I have super power ! Watch out for the league of the menstrual avengers !
thats all i can saw....wow


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Comments about 'Officer who killed man with explosive device was justified, D.A. says'
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Salt Lake City, UT
I was not aware that a TRAX station existed near 300 West and Main Street. Since Main Street and 300 West run parallel to each other,they never intersect. Could this possibly be another example of The Deseret News getting the SLC addresses mixed up again?? Perhaps the intent was to refer to the TRAX station located near 300 South and Main Street!!
- 6:55 p.m. Oct. 25, 2012
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Clearfield, UT
Left unexplained is why the original negotiating officer really left the scene and if this was an action that was really in the best interest of all concerned.
- 2:53 p.m. Oct. 26, 2012
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There are much verse lessons to be had than those enjoyed at Riddlesdown Collegiate on Friday, when acclaimed poet Luke Wright dropped by to talk to teens.
The wordsmith brought English classes to life in a poetry workshop with the Purley secondary school's Year 10 pupils, who he helped to create their own characters then pen a poem on them.
Wright, who has published four books and whose poems include Fat Dandy and Have a Gong!, encouraged youngsters to look at metre, rhyme, form, story-telling techniques, imagery and metaphor through exciting and unusual examples.
Philippa Bigden, the school's assistant director of learning, said: "Luke Wright offers a fantastic opportunity for students to understand and engage with poetry in a completely different and contemporary way.
"He provides a forum for young people to begin to understand that poetry isn't just something they study in an anthology, but actually something they can identify with, be entertained by and ultimately enjoy and learn from".
Wright began writing and performing poetry in his teens, regularly appears on BBC radio and has written two verse documentaries for Channel 4. He began leading poetry workshops in schools in 2004.
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Mountains of data are collected during our annual salary survey, but not all of it makes it into the IT Skills and Salary Report we release each spring.
For the first time, Global Knowledge Sr. Market Research Manager Greg Timpany is giving us a peek behind the data curtain and revealing his insights. Timpany has been collecting and analyzing IT salary information and trends for Global Knowledge since 2009.
As part of our annual report we always release the top-paying certifications and highest salaries by industry, region and area of expertise, including non-IT professionals. But, Timpany says there are a lot of other useful statistics he's been able to uncover through the survey. Here are some of his top picks for things you should know that didn't make it into the report.
IT Pros Control Their Own Economic Destiny
"People in the IT industry have the ability to positively impact their economic potential. We don't have to sit around and wait for companies to give us a two percent and three percent raise," Timpany said.
IT professionals can control their own destiny even at a time when most companies are putting their profits in reserve or in capital expenses instead of increasing compensation of expanding hiring plans, Timpany said.
"Employees can adapt to this trend by increasing their value through tactics such as developing additional skills and a willingness to take on new tasks, as well as getting into the job market," he said. "The largest salary gains seen in the current study came from respondents who had changed companies and negotiated a higher salary for themselves."
Forty-six percent of respondents who took a promotion to another company saw a raise of 11 percent or greater. This is 2.5 times greater than would be otherwise expected, Timpany said.
Branching Out Can Lead to Better Pay
Most companies understand that if you don't have the right people in-house, other people in the marketplace will beat you to the punch. So, having a versatile IT department is key in order to support go-to-market strategies.
The key skill that IT professionals need to gain is communication. And over half of non-IT professionals reported that communication within their organization is a top workplace challenge. Other in-demand skills for IT decision makers and non-IT professionals are leadership and project management.
"If you are willing to step out of working strictly in the technology vertical, you can see some substantial gains in economic compensation," Timpany said. "What we've seen is if they are willing to accept management roles their salaries will go up. A technologist willing to step outside the traditional job role can do extremely well."
An employee who combines an IT certification with a project management or ITIL® certification can gain about $10,000 to $35,000 more a year, according to data collected as part of the salary survey.
|IT Certs
Avg. Salary by Adding ITIL v3 Foundation Cert
Avg. Salary Without
Avg. Salary by Adding PMP Cert
Avg. Salary Without
|Red Hat / Linux
Certified Pros Continue to Out Earn Their Peers
"The technical space, IT in particular, is faring well overall. With the number of respondents we have each year, you can get a glimpse into the full spectrum of salaries—from entry-level help desk to senior-level enterprise architects," Timpany said. "A consistent factor that I have seen for several years now is the salary advantage held by certified practitioners compared to their non-certified peers. Overall, there is a 20 percent gap in favor of the certified IT professional ($88,447 vs. $74,003)."
A Salary Increase Isn't the Top Reason for Training
While training or earning a certification can lead to higher pay, it's not what is driving people to seek out professional development.
"What's of primary importance is the development of new skills. This supersedes the drive for increased salary by providing a more immediate gain: enhanced skills that can impact the job performance now versus salary gains that tend to be longer term," Timpany said.
For the second year in the survey, Global Knowledge asked respondents from all backgrounds to state the perceived benefits they receive from professional development, which is available as part of the survey report. But, Timpany thought it was important to highlight the No.1 reason for training within this blog.
"Topping the list is the ability to stay current on technological changes," Timpany said. "This is followed by the ability to gain insight that enables the respondent to be more effective in his or her current position. Expanding earning potential is number eight on the list."
That is similar to the results he saw last year. Timpany can relate to the reasons why. "People who put salary (as their top reasons for training) are few and far between," he said. "For most, it's 'We are going to find a solution to an immediate problem. I may get my CCNA today and over the course of the next year I may see an increase in salary next year. But, I may be on top of my game and see benefits in my job right here, right now.'"
Data Can Be Empowering
Timpany believes the salary survey and report can help to empower professionals through data. "They can make decisions on their career path—not on gut instinct but on real market data—and create a career path that's best for them," he said.
Throughout the year we will be releasing several blog posts to provide further insight and highlight interesting statistics included in the salary report, so make sure to stay tuned.
In the meantime, be sure to download the Global Knowledge IT Skills and Salary Survey Report. Questions or comments? Add yours to the comment section.
With the release of Cognos Analytics (v11), we all have to learn a new product. Cognos Connection is gone. Report Studio is gone. Workspace Advanced (or Business Insight Advanced, if you're using v10.1) is gone. The new UI makes Cognos new again. All the functionality that we know is there, it's just somewhere else, or accessed in a different way. From a training standpoint, it's a whole new world.
In a number of Cognos 10 classes in the last year, students commented regularly about the proliferation of tools in Cognos for reporting and that making it hard to know which one to use. With Cognos 8 and the introduction of an integrated web environment under Cognos Connection, the reporting tools were clearly defined. Query Studio for ad-hoc reporting for the infrequent Cognos user or if you just wanted to create a quick report. Report Studio was positioned for the power user or professional author to create highly formatted and complex reports, and Analysis Studio was designed for real-time data analysis of multidimensional data by business analysts. With a half-step towards expanding the reporting capabilities for business users, Express Authoring mode was introduced to Report Studio.
With Cognos 10.1, two new tools were added, Business Insight and Business Insight Advanced, the first to allow user creation of dashboards and the latter for report creation targeted to business authors, and though a stand-alone reporting environment (kind of Report Studio light), its name implied it being an "advanced" version of the former, mainly because it was positioned as the tool to create and edit components for the Business Insight dashboard. With Cognos 10.2, both components were renamed to Cognos Workspace and Cognos Workspace Advanced (to avoid naming confusion with the desktop Cognos Insight) and still maintain the concept of the advanced tool for dashboard content maintenance.
With Workspace Advanced sharing much of the interface and functionality of Report Studio, it might have been unclear which to use, and requests for training asked us to teach both to the same audience. Since there was so much overlap in functionality, training was somewhat redundant, and there seemed to be confusion about the product in the user community.
IBM seemed to have realized and responded to this product confusion and overlap of functionality by creating Cognos Analytics Reporting, a unified single environment for reporting using Cognos, along with an updated Cognos portal. Right out of the box, the new Analytics UI looks like a new app, with a very modern interface that works on all platforms. Very similar to modern app interfaces that you'd find on mobile devices that is very icon driven, very sparse and simplified, and very activity centric. Instead of a toolbar of buttons to click or studio icons, you can concentrate on what you want to do. To create something new, you click the New icon, and you're presented with a choice of things you can create, a report, a dashboard, etc.
At the top of the Analytics portal, there is a very simple toolbar, the Application Bar, which has a Save, Edit, Undo, Redo, Run and Refresh. Along the side is the Side Panel, which provides Search, My Content (My Folder), Team Content (Public Folder) and Recent. With Recent you can easily recall what you've been working on. Both toolbars do change with context, and will include more options based on context. You also, have the options to create new content, upload user files, and access common admin tasks, as well as access the legacy Admin Console and other components, if enabled.
You can access content using the My Content or Team Content, using fly-out menus to navigate the path within Cognos, and then from those menus perform an action by either clicking the item or the "more", which is the familiar app icon of the ellipsis. Most of the same options are available there that are in Cognos 10, so we just need to get used to a new interface. Though when you run a report, there's no Cognos Viewer. The report opens in the report area, with various options to manipulate the output, and the report name is added to a dropdown in the Application Bar that gives access to all open content in the Work Area. From that drop down you can switch to that content or remove it from the work area.
To create a report, select Report from the fly-out menu of the New icon, and the Work Area changes to Analytics Reporting, The Side panel changes to give access to the main functionality of the reporting environment. You'll be presented with the familiar New dialog to select the starting report template, but one big difference is that picking a package is not required here. You can select it after you've entered Reporting. From the Side Panel you can click the Data icon to select the data source and access data items to add to the report (like the Source and Data Items tabs in Report Studio). You can access the Toolbox, which is now a hammer icon, and which changes based on context, as it did earlier. A third icon in the Side Panel lets you navigate to the different "explorers", Page, Query and Condition. Added to the Application Bar is the Page Views icon (an eye) that lets you changes your views in Reporting as the default Report Studio design mode, or to see the Page Structure, or the Business Insight/Workspace Advanced defaults of Page Preview, so that you can see the report with data. You can edit in Page Preview mode, as well. Next to Page Views is the Properties icon (slider switches) that lets you toggle the visibility of the Properties pane. Also, there are no reporting toolbars. Instead, Analytics Reporting uses on-demand toolbars that popup above the object in the report that you click on. These toolbars are context sensitive, and include a More icon to access the full set of options for that object.
I won't go into more detail of the differences in the product. There are more, but as I said, pretty much everything that was there before in Cognos Connection, Report Studio and Workspace Advanced is there. They are just accessed in a different way or from a different location. That's where Cognos training comes in. Since Cognos is very much a new product with this new version, it's very worthwhile to take some time to learn how to navigate the environment. Though you could learn as you go on the job, I think you'll be much more productive, much more quickly, if you take time to learn.
One of the valuable offers from Cognos training is the one day Overview of IBM Cognos Analytics (v11.0) which gives a great start to working with the new Cognos. It covers the reasons behind Analytics and introduces the new interface and capabilities, like the new Dashboard environment (different than Business Insight/Cognos Workspace), the capability to upload and easily report with personal data, and to integrate and report on different data sources (including personal data) by creating Data Modules, eliminating the need to wait for modelers to create or modify, and publish a package to create a report. The course gives you a chance to become familiar with the ways to consume and manipulate content using the new Analytics portal, as well as using Analytics Reporting. The course also teaches the basics of Cognos Active Reports (which has changed a little in v11), a bit about Cognos data source options available through metadata modeling with Framework Manager and multidimensional data with Cube Designer to create Dynamic Cubes under Dynamic Query Mode. There's a bit about extending Cognos with Cognos Mobile and Cognos for Microsoft Office, and finally a quick look at some of the legacy tools like Event Studio and Metric Studio.
I think students have found formal training with Cognos, especially now with a dramatic change in the product, is extremely valuable. These days it might seem like a luxury, but there are a few options that can be taken advantage of. Not only are the courses available as live or virtual instructor-led (ILT or VILT), but can also be taken as a Self-Paced Virtual Class (SPVC) which lets you set the time and pace of your education.
Feel free to email your questions to firstname.lastname@example.com or visit www.ingrammicrotraining.com
Click here to continue reading the article]]>
The IBM Certifications team is indebted to all of the IBM, Partner, and Customer SMEs around the globe who make it possible to build these exams and raise the bar for the product expertise found in our IBM, Partner, and Customer communities! To all of our SMEs we say, Thank You!
For more information about any of these exams:
Information Governance exam – http://www-03.ibm.com/certify/tests/ovrC2090-650.shtml
Information Governance certification – (http://www-03.ibm.com/certify/certs/28000801.shtml
DataStage exam – http://www-03.ibm.com/certify/tests/ovrC2090-424.shtml
DataStage certification – http://www-03.ibm.com/certify/certs/28000404.shtml
QualityStage exam – http://www-03.ibm.com/certify/tests/ovrC2090-304.shtml
QualityStage certification – http://www-03.ibm.com/certify/certs/28000503.shtml
Information Analyzer exam – http://www-03.ibm.com/certify/tests/ovrC2090-305.shtml
Information Analyzer certification – http://www-03.ibm.com/certify/certs/28000303.shtml
The offer details are as follows:
*IBM recommends taking the most current version of the certification test
To secure the 50% discount, a test candidate is required to register for and take one or more IBM Security test from July 1, 2016 to September 30, 2016. The candidate will register through the Pearson VUE Test Center web site.
Please note: The same test may be taken twice within a 30 day period. After that, a 30 day waiting time is required for additional test preparation before attempting the same test a third time.
It is strongly recommended that a test candidate adequate prepares for a certification test by selecting the applicable certification role name beside the desired test listed on the IBM Security certification tests page, and referring to the
For any inquiries regarding this announcement, please contact firstname.lastname@example.com
Arrow Education now provides you an effective and proven online learning option with an extensive catalog on IBM mainframe solutions, and the freedom to increase your skills from virtually anywhere, anytime!
Based on the recently launched cooperation with Interskill Learning, the largest creator of mainframe online training, we have added over 25 years of expertise to the Arrow training portfolio for System z. This comprehensive, interactive online library includes more than 200 courses on IBM's solutions, including quizzes, testing and mentoring – a curriculum of unmatched depth, breadth & currency, and supported by a team of experts that has been working with the world's premier mainframe computing organizations and trained over one million personnel – a highly successful, proven and cost-effective experience.
Take a look at the Arrow Mainframe Online Library and start to increase your System z skills with Arrow now anytime, anywhere: enroll today!
The ITCC is a resource for employers, government officials, academia, and individuals seeking information about the many benefits of IT certification. The council establishes industry best practices, markets the value of certification, enhances exam security and works on other certification issues the council identifies.
Learn more about each member of the ITCC Board of Directors]]>
With a massive arsenal of programs which includes a magazine, annual conference and awards programs, Training Industry, Inc. has become an essential go-to partner for training professionals to understand the latest news, articles, case studies and best practices within the training industry.
At the recent Training Industry Conference and Expo (TICE) in Raleigh, IBM was recognized as a leader in the industry in content development, outsourcing and skills recognition.
IBM awarded 2016 Top 20 Content Development Award
For the fifth consecutive year, IBM won Training Industry's Content Development Award. The award recognizes the 2016 Top 20 Content Development companies in the training industry and is designed to help buy-side organizations in their search for the right training partner. IBM was recognized for its leadership based on the following criteria:
According to Ken Taylor, president, Training Industry, Inc, IBM, as an award winner, is "able to bring together innovative technologies and best-in-class instructional design to generate some of the most exciting examples of corporate learning in the marketplace."
Want to see more? Go to the IBM Training website to see how IBM is leading in the development and delivery of IT training.
IBM awarded 2016 Top 20 Outsourcing Award
IBM was also recognized for its leadership in outsourcing for the ninth consecutive year. The award was given to IBM based on the following criteria:
Want to see more? Go to the IBM Training website to see how IBM is leading in the development and delivery of IT training.
Global Knowledge, IBM's Global Training Provider, wins a Leadership Award
Rounding out the award winners at this year's event, Global Knowledge was recognized for its leadership in training, repeating its 2015 success in this category. Global Knowledge achieved the award for its excellent performance in the following categories:
IBM presents its Open Badge Program story at TICE 2016
Open Badges are quickly emerging as an important component of a holistic accreditation program, providing a nano-credential to show that a person's skills are up to date. At TICE, IBM presented its success with Open Badges, showing a case study which brings to life what happens when you merge credentials and recognition with social media, like LinkedIn, Facebook and Twitter. The session used real data to show the audience how to design, manage and measure the success of an Open Badge program.
Want to see how Open Badges work? You can earn an IBM badge by completing a selected activity, like a free online course in BigDataUniversity.com, participating in a Bluemix function, completing select IBM certifications, contributing todeveloperWorks or passing a course at one of IBM's Global Training Providers, including Arrow, Avnet and LearnQuest.
David Leaser is the senior manager, innovation and growth initiatives, for IBM's Training & Skills organization. Leaser developed IBM's first cloud-based learning solution and is the author of a number of thought leadership white papers on talent development, including "Migrating Minds" and "The Social Imperative in Workforce Development." Leaser has trained more than 4,000 clients and developed more than 30 technology training manuals and video tutorials. You can reach David on LinkedIn or Twitter @david_leaser.
IBM is actively helping the world solve the talent gap, and our content development, outsourcing and the IBM Open Badge Programs are examples.
To find out more, please join the conversation on our websites and social networks:
WW IBM Training Home Page
Training Search
Contact IBM Global Training Provider
IBM Training on LinkedIn
IBM Training on Twitter
IBM Training on Facebook
To contact one of IBM's authorized IBM Global Training Providers or to search for IBM courses that use official IBM created content, please visit ibm.com/training]]>
Given the fast pace of change and the heavy workload of today's technology professionals, it is clear that the traditional approach to updating skills is no longer the best approach. IT professionals and their employers can no longer afford multi-days or weeks of training that require off-site travel. IT professionals need a way to update skills that takes into account how each person learns in a different way and has reference and starting points that vary for the knowledge they need.
Enter Arrow365
To address these concerns Arrow Education has developed a unique and streamlined approach to learning: Arrow365. Arrow365 is a cloud-based, just-in-time learning platform that saves employers and trainees time and money while delivering exceptional results. As a distributor for multiple vendors, Arrow is in a unique position to effectively aggregate content and simplify the delivery of programs that allows students to quickly absorb material on their own schedules from anywhere, on any device including laptops, tablets and smartphones.
Learning For Your Own Needs
Arrow 365 came about as our classroom instructors were concerned about students who missed critical content when they stepped out to tend to production issues and answer staff questions. They also noticed that students were impatient to dig right in and find the specific content that was most relevant to them at the time. In a given class, everyone was at a different starting point and absorbed information at a different pace.
Originally, our platform was developed to distil, consolidate and deliver vendor technology information in a way that worked efficiently for our partner community. What started with certification test objectives and synthesized vendor source documentation turned into a curriculum that enables students to efficiently self-study over two weeks of lecture materials on their own schedule, whenever and wherever they can squeeze study time into their day.Our unique approach turns the traditional training model completely on its head: the student controls what they see and when they see it, instead of passively consuming a curriculum designed and paced by an instructor in an in-person or virtual training class.
Assess Your Skills to Determine Knowledge Gaps
IT technologists need to analyze their current skills to understand where their knowledge gaps exist. Arrow 365 understands this need and puts the student in control of what they want to learn as opposed to what the vendor or instructor has told them they need to learn.The Spartan platform design ensures that students have ease-of-access and retrieval of materials in real-time and for crucial activities such as preparation for vendor certification.
A minimalist, intuitive interface makes it easy to access and retrieve information quickly. Most importantly, as the technology changes, Arrow Education delivers fresh content to update training materials almost immediately, a feature that is crucial in today's world of rapid change. After registering, students receive a custom key that is distributed to the partners. With this key, they will always be able to log back in and see the latest updates.
Training Programs To Meet Your Needs
Arrow leverages an extensive network of vendor subject matter expertise and in-house talent to create leading-edge programs that are nimble and cost-effective for multi-vendor environments. Arrow Education courses meet the needs of today's busy workforce whether it's online, self-paced or micro-learning sessions.
Training is essential to all organizations and when you partner with Arrow Education Services, you will have access to our highly experienced technology consultants who provide specialized services and expertise across the entire product lifecycle. Maximizing your technology investment is crucial to impact business and Arrow Education Services prides itself on delivering exactly the courses you need, in the locations you want, and with the quality of instruction that you deserve.]]>


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mds nurse rn jobs near Miami, FL
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MDS Coordinator – Registered Nurse RN – Healthcare Info Manager. Experience as a MDS Coordinator preferred. Additional responsibilities for the MDS Coordinator...
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Working knowledge of MDS, care plan development and chart auditing of the nursing process. Currently licensed in the State as a Registered Nurse plus a minimum...
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Staff Development Nurse - RN. We are searching for a hardworking, compassionate, and enthusiastic Staff Development Nurse - RN for one of our client locations....