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San Cisco to perform at Etihad Stadium
Posted on 5 Jul 2012
This Saturday, San Cisco will perform at Etihad Stadium before and half-time of the St. Kilda vs Essendon Game as part of the AFL's 'Live At The Footy' program.
Jordi Davieson was interviewed by AFL.com.au and when asked "What are your thoughts playing at a footy stadium?" he replied, "We played to 4000 people at the Groovin' the Moo festival in Bendigo, so this will be a lot of people for us, provided they're not all queuing for a pie. It's a stadium show, I guess, so we've worked on our stadium moves." For his entire interview go to ALF.com.au
Prior to the game, be listening to Triple J on Saturday at 4.40pm for Jordi's "pre-match" interview. A highlights package of their performance will be available on Channel 7 and their partnering website.
San Cisco will be releasing their Awkward EP this Monday in the UK. It will be available on iTunes and at Rough Trade West.
For more live music check out their Triple J LIve At the Wireless here.


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On Sunday, The Residences at Kapalua Bay will launch as Montage Kapalua Bay, making it Maui's newest resort. Its doors will open for the first time to the public for dining and accommodations.
It's a soft opening, as the main restaurant, Cane & Canoe, is still under construction with a target date for late June.
The magnificent resort property that once was the site of Kapalua Bay Hotel will start its festivities by hosting the Grand Tasting on Friday, June 13, as the opener to the 33rd annual Kapalua Wine & Food Festival. It's coming full circle, as this was the original home of what was then called the "Kapalua Wine Symposium."
Article Photos
Executive Chef Riko Bartolome toasts to the Grand Tasting, which Montage Kapalua Bay will uncork under the stars on its oceanfront lawn.
The Maui News / CARLA TRACY photo
Some of us oldsters remember this place with fondness as the symposium presented wine legends, such as Robert Mondavi and Mike Grgich, and there were midnight swims in the bay.
"When I walk around here, I feel very privileged," says Richard Holtzman, vice president and managing director of Montage Kapalua Bay. "This place has such a rich heritage, and I have personal ties. My father was president of Rock Resorts that built the original hotel."
Holtzman, who previously ran hotels in Arizona and Colorado, and was president of the Kukui'ula luxury community of 1,000 acres on Kauai, says he abides by a cardinal rule of development.
Fact Box
The Grand Tasting: Montage will host the opening night event of Kapalua Wine & Food Festival from 6 to 9 Friday, June 13. Six Kapalua resort chefs will put their best food forward; hundreds of wines will flow; ukulele sensation Aidan James will play. Cost is $160 per adult and $150 for kamaaina. For tickets, visit www.kapaluawineandfoodfestival.com.
Stay awhile: lntroductory kamaaina rates start at $395 per residential style suite, per night, with a valid Hawaii I.D. Call 662-6600.
"If you want to find the best spot on the lake, you go to the oldest pier. Well, this is the oldest pier."
Besides being situated on one of the nicest sandy beaches and bays in the state, it's got commanding views of Molokai and Lanai and the ocean waters.
The 24-acre Montage Kapalua Bay will feature 50 intimate residential-style suites and 56 Montage branded residences, all with spacious living rooms, large private lanais, fully-equipped gourmet kitchens with sub- zero fridges, elegant master bedrooms and luxurious bathrooms that reflect the resort's Hawaiian heritage.
Overlooking picturesque Kapalua Bay, the resort has a multitiered lagoon pool, which cascades toward the sea. Kamaaina rates will be available from Sunday through Nov. 20.
As for dining, it's a new breed of Hawaii Regional Cuisine.
"Our dining outlets are the Sunset Patio for breakfast, lunch and dinner and the Hana Hou Bar," says Montage's Executive Chef Riko Bartolome. "We'll offer in-suite dining for our guests. As for the Cliff House, my plans are to do intimate sit-down dinners that are interactive where we cook and plate it in front of you."
As far as the signature Cane & Canoe that is targeted to open in late June, Bartolome will pay respect to local products by serving ulu, or breadfruit, hummus on Molokai sweet bread flat bread for a starter.
"We'll pay respect to the canoe crops. We want to be a little different than everybody else - give people a reason to get excited when they dine here."
As for the Grand Tasting, it will be on the oceanfront lawn right above the Cliff House, which was acquired by Montage for private parties.
Food and wine stations will be scattered about, and entertainment will be provided by ukulele sensation Aidan James.
"Each of the food booths will be paired with a beverage station," says Bartolome. "Maui Brewing Co. will also be there, taking over our Hana Hou bar by the pool, right in the main artery of the event."
Besides Montage's culinary team, other participating chefs will come from Kai Sushi Bar and The Terrace at The Ritz-Carlton, Kapalua; Plantation House; Pineapple Grill; and Merriman's Kapalua; along with a big representation from New Zealand (see Side Orders on Page 20).
"We'll be doing three items that will be featured at the hotel," says Bartolome. "One cold item: Keahole lobster panna cotta on panzanella or bread salad; one hot sea urchin and crab arancini (rice balls) with pickled pina and fennel salad with roasted Maui onion and olive oil.
"And for our dessert, we'll do chili-pepper chocolate mousse with hazelnut, streusel and clear chili sauce."
Merriman's will make Kauai prawns a la plancha on polenta; and Waialua chocolate pot de creme. Plantation House will make shrimp and Portuguese sausage etouffee and Kula strawberry and tomato gazpacho with feta and hazelnuts.
Pineapple Grill will braise Asian short ribs and serve ahi sashimi with lilikoi shave ice and kaffir lime pearls. The Ritz will be puttin' on seared sea scallops with candied bacon in brown butter; and curry-cumin lamb burger with local goat cheese. Its Kai Sushi will serve hamachi tartare in citrus ponzu and kalbi filet with Maui onion tempura and pickled vegetables.
Fine New Zealand wines will flow. Sip selections from Craggy Range, Babich, Matua, Mt. Beautiful, Villa Maria, Fromm, Omaka, Yealands, Pyramid Valley, Mishas Vineyard and others.
Brent Martin, Executive Chef of Andaz Maui at Wailea and a native of Wellington, will be on hand serving his gourmet take on his country's products.
Top American wines will be Justin, Peju, Scherrer and Pisoni, and you'll find gems like Lutum, Leonetti and Cirq, the new label from Kosta Browne - all at Maui's newest luxury resort property.

subset: commoncrawl


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Travel Chennai-Madurai non-stop on Duronto Express
By Express News Service - CHENNAI
Published: 23rd November 2012 08:21 AM
Last Updated: 23rd November 2012 08:21 AM
Commuting between Chennai and Madurai is all set to be a 'non-stop' experience with the Southern Railway gearing up to introduce a Duronto Express between the two cities by this month end.
The train, which would be the third direct service for Madurai from the Chennai, would depart from Chennai Central, and not Egmore railway station which is usually the boarding point for trains in this route.
Heavy rail traffic on the Tambaram-Villupuram-Madurai section is the prime reason behind operating the new service from Central, said sources.
"The point-to-point train would commence its journey from Chennai and go via Erode, Karur and Dindigul to reach Madurai. It would reach the temple city in eight hours and thirty minutes," an official said. The bi-weekly train would start from Chennai at 10. 30 pm on Mondays and Wednesdays and arrive in Madurai at 7 am on Tuesdays and Thursdays respectively, the official added.
Subsequently, another Duronto Express service from Chennai Central to Thiruvananthapuram, is also expected to be introduced around the same time. These trains were part of a list of new trains announced in the 2011-12 railway budget.
The travel time on the non-stop Duronto Express, is shorter than on the Rajdhani Express trains which are the fastest long-distance trains in India, as it has no intermediate halts. The trains, which have a unique yellow-green exterior in passenger coaches, make halts only for technical reasons.
When contacted, a Southern Railway spokesperson said a notification regarding the operation of the Duronto Express was received on Wednesday. Both the trains would be introduced by this month end, he added.
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Human beings vary in their internal anatomy in about the same degree that they vary in their external form and configuration. Were a man who was thin and 6 feet high to ask us to make him fat and 5 feet 6 inches high by operating on him, we would think him mentally deranged. Yet how frequently in the past have we attempted to correct surgically the internal anatomy because of variations from the average normal, especially the position of the abdominal viscera.
It is less than ten years since nephrorrhaphy, ventrofixation, gastrorrhaphy and kindred operations were resorted to on indications which would not be accepted to-day. We have come to appreciate the fact that comparatively few of the abdominal viscera have unchangeable anatomic characteristics and that variations within limits are not to be considered abnormal.
The large intestine, with its short heredity and changing function, has no such fixed
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Cannibal-plot case tossed; ex-cop gets out of jail
NEW YORK -- A former New York Police Department officer left jail Tuesday after a judge stunned prosecutors and overturned his conviction in a sensational case accusing him of plotting on the Internet to kidnap, kill and eat young women, including his wife.
Judge Paul Gardephe ruled late Monday that there was insufficient evidence to support a jury's guilty verdict in the kidnapping conspiracy conviction of Gilberto Valle. He agreed with defense arguments that the defendant's bizarre exchanges in fetish chat rooms about cannibalizing women never put anyone in danger.
Valle's "depraved, misogynistic sexual fantasies about his wife, former college classmates and acquaintances undoubtedly reflected a mind diseased," the judge wrote. But, he added, prosecutors failed to prove he had entered into genuine agreements to kidnap the women and taken concrete steps to carry them out.
After his release, Valle told reporters he was eager to go home after spending more than 20 months behind bars.
Prosecutors intend to appeal the ruling.


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He was a product of eastern Arkansas:
Born in Kingsland in 1932, he and his family settled on the Arkansas side of the Mississippi Delta in 1935 when his dad, Ray Cash, received 20 acres of virgin land as part of a New Deal experiment to revive small farms, known as the Dyess Colony. The new farmers had to clear the land themselves, no easy task. Ray Cash farmed cotton. One of Cash's hit singles, "Five Feet High And Rising," was inspired by childhood memories of a major flood that inundated (but didn't destroy) the farm.
His early musical heroes:
Jimmie Rodgers, the Louvin Brothers, Ernest Tubb, Eddy Arnold and Hank Williams were among his country heroes, along with black gospel singer Sister Rosetta Tharpe and pop belter Frankie Laine. Cash's musical tastes were always broader than country music alone.
His real name:
"J.R. Cash." That's how family and close friends knew him. But initials didn't cut it when he enlisted in the Air Force in 1950, when he became "John R." Starting in 1955, Sun Records owner Sam Phillips billed him as "Johnny" on records to emphasize his youth. His original band was the "Tennessee Two," (guitarist Luther Perkins and bass player Marshall Grant), later the "Tennessee Three" with drummer Fluke Holland added.
The Older Brother:
Jack Cash (1929-1944) was John's best friend. A deeply religious youth, he worked at a primitive sawmill near the Cash farm. Horrifically injured when accidentally caught in the blades, he died soon after and never faded from his younger brother's memory.
What made him the "Man In Black?"
His 1971 Top Five single with that title claimed he wore black for the downtrodden. His empathy is accurate, but practicality drove his decision. In 1955, as his performing career began, he wore flashy stage outfits including white sport jackets, similar to the outfits Elvis Presley wore. Over time, black became a prudent choice as it hid the inevitable dirt picked up on tour.
The Man In White: Perkins, Cash and Grant, circa 1955
His first hits-country or pop?
Both. His first singles for Sun Records charted high in both fields. Not all his Columbia country hits succeeded on the pop charts except 1963's "Ring Of Fire." His surge in both fields came with his hit singles of "Folsom Prison Blues" (1968) and "A Boy Named Sue" (1969). recorded onstage at Folsom and San Quentin, respectively. Some early tunes like "Get Rhythm" (which inspired the name of this blog) qualify as rockabilly.
Who got him off drugs and when?
Robert Hilburn's definitive biography Johnny Cash: The Life, which I reviewed for the PG, reveals the truth about his 1967 detox. Cash was aided by then-girlfriend June Carter, her family and Nashville psychiatrist Nat Winston. He did not totally quit pill use (as the flawed biopic Walk The Line indicated) but could control his intake. He quit completely after son John Carter Cash was born in 1970, but relapsed several years later. His drug use didn't end until illness forced him to quit touring in 1997.
Was he part of the "Million Dollar Quartet?"
He popped in during the impromptu December 1956 jam session at Sun studios at Sam Phillips's behest to be photographed. Elvis, Jerry Lee Lewis and Carl Perkins had just started jamming out of nowhere when Elvis visited a Carl Perkins recording session. Cash had his photo taken with the group but on the tapes, he's inaudible. Only Elvis, Lewis and Perkins can be heard singing. He may have been absent or at least off mike.
Was he always somber and serious onstage?
Succinctly, hell no. Cash was funny and animated, and comedy was part of his stage show, not just in goofy songs like "Dirty Ol' Egg-Suckin' Dog," "The One On The Right Is On The Left" or "A Boy Named Sue." Check out this August 8, 1959 Elvis Presley impersonation from the Southern California Town Hall Party TV show
This skit came from a special comedy-themed episode of Cash's ABC TV show that aired February 10, 1971. He's introduced by master country comedienne Minnie Pearl. Other guests included June, who made her early name as a Grand Ole Opry comic along with Minnie, George Lindsey, Jim Nabors and country singer Ferlin Husky.
"Is he an "Americana" or "Roots" act?
He pretty much transcends category, and his country stardom has been a given as as his influence on rockabilly and rock. But Cash's fan base among folk artists and fans existed before the terms like "Roots" or "Americana" were used (or, in my opinion, overused) in a musical context. Bob Dylan, Joan Baez, Pete Seeger, Peter LaFarge (who wrote Cash's hit "The Ballad of Ira Hayes"), Ramblin' Jack Elliott and other Folk Revival artists considered Cash a peer. Besides, for over 30 years, his s stage show included the Carter Family, country and folk music fountainheads which included June and sisters Helen and Anita. Their mother, Maybelle Addington Carter, was one-third of the Oriignal Carter Family. Cash himself is justifiably in both the Country Music and Rock and Roll Halls of Fame.


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Common sense school rules
March 5, 2013
Several common-sense changes in state rules that often hobble rather than help public schools are being proposed by Ohio Gov. John Kasich....
Mr. Ed, could you give us some actual examples of what makes this a good idea, rather than just indorsing it. It seems to me that this paper among many other far right leaning publications already say that teachers don't work enough and that students are failing because they aren't getting enough classroom time. Under these provisions, high schools students would be loosing a little over a week of educational classroom time, while the elementary grades would be loosing 4.3 weeks of classroom time. So again I ask, what are the benefits of this provision you indorse? I see none, nor no valid facts that it would work. How about gooberment stop telling educators how to educate when they can't even run the gooberment. Every proposal they have forced into education has been a complete failure. Hire some old basstard/beauches that are retired educators to advise the gooberments stupid arzes as to what they believe teachers/schools should be doing to improve schools.
0 Agrees | 1 Disagrees | Report Abuse »
How many "study halls", are there in a typical school day?
How many "study halls", will there be under the new formula and "educationally speaking", . . . "what", is a study hall?
If study halls are basically "dead-time", having no educational value, then, under the new formula, could changing study halls to actual educational time, actually shorten a school-year?
1 Agrees | 2 Disagrees | Report Abuse »
I like the hours approach, but why aren't there more hours in the school schedule? Those two hour delay days would be a thing of the past which has been the school districts way around the day rule in bad weather without needing to make up the time. Of course the school unions object - they always do to progress.
2 Agrees | 2 Disagrees | Report Abuse »
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Police were called to the hospital around 10 p.m. Saturday. The woman had scratch marks on her neck, the report stated.
She said she was having pains in her stomach and wanted to go to the hospital to see if the child was OK. A domestic assault form was completed. There were no reports of any arrest.
The incident occurred in the Evergreen Regency apartment complex off Lippincott Boulevard.


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Latest Activity: Played Clout: The Game (Jul 26, 2014 11:26am)
Points needed for next level: 93 Level
I am almost always found chatting in the Hive, which is ran and moderated by an amazing angel (He's not human, even if he looks so) TWA. I spend a lot of my time playing League of Legends, (IGN: Nsqui), maining support and loving it, if you play, come send me a friend request. Just finished my thrid playthorough of Dishonored (Best Game Ever), recently completed Bioshock Infinite, and playing Skyrim anytime else. Currently enrolled in the University fo Southern California, studying Game Programming and Design.
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I had similar problems and asked a similar question a while ago and got
2 responses: (1) firewire works really well on freebsd; (2) usb
performance varies a lot by chipset. Both are true in my experience.
Unless you have the skills and knowledge to help the developers improve
performance for your chipset, I don't know of a more useful answer. If
you find one, please post!


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Bob's Upholstery Service - Council Bluffs, IA - Phone: (712) 328-6978
Our Own Furniture - Council Bluffs, IA - Phone: (712) 328-7206
Town & Country Upholstery - Council Bluffs, IA - Phone: (712) 325-1674
Zinger Upholstery - Council Bluffs, IA - Phone: (712) 322-5280
Furniture upholstery in Council Bluffs refers to the work of providing furniture, especially seats, with padding, springs, webbing, and fabric or leather covers. Furniture upholstery is applicable to domestic furniture and also to vehicles, like- automobiles, airplanes and boats.
Upholstery of domestic furniture, such as bed, sofa, chair or ottoman, may be grouped into four categories: the frame (usually wooden) on which the upholstery is to be constructed; the spring system; the cushioning or padding; and the final fabric or leather covering. While automobile upholstery involves production of soft furnishings, carpets, soft tops and roof linings often as per the customer's specifications.
Alliance for Green Heat and NYSERDA Announce Seven Finalists in International Pellet Stove Competition
Two New York teams are among the finalists (Long Island, NY) Alliance for Green Heat and the New York State Energy Research and Development Authority (NYSERDA) today announced that seven pellet stoves have been chosen as finalists in the Pellet Stove Design Challenge. This international competition, administered by the Alliance for Green Heat, identifies innovative low emissions and high efficiency..


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The occurrence of a pilonidal sinus extending to and communicating with the arachnoid space seems to be of sufficiently rare occurrence to justify a report of such a case.
History.—DeWitt de'L., aged 3½ months, was referred to the Mountainside Hospital on June 7, 1927, by his private physician, with a diagnosis of pneumonia.The patient was born at term in normal delivery. Constipation had been present in a varying degree since birth, but otherwise he apparently was normal up to two weeks previous to admission to the hospital. At that time, he became fretful. The fretfulness became more pronounced and one week before admission was associated with vomiting and loss of appetite. Two days before admission it was noticed that any attempt to lift the child caused it to scream, in apparent pain, throw its head back and become somewhat rigid. The temperature was said to
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"I Am Smarter Than You Think, Mom and Dad!": How to Raise Responsible Kidsby Mridula Agarwal
Ever wondered how to keep your little angel from the negative influences of the world in this challenging time? How to help her grow into a responsible, successful and happy adult you can be proud of? Does it feel that divine intervention is needed?
Inner Line: The Zubaan Book of Stories by Indian Womenby Urvashi Butalia
In one way or another the woman's body becomes a site upon which many battles take place: for control, for power, for progeny, but there is seldom a resolution in which the women remain a mere victim, or more acted upon the acting.
Lunatic in My Headby Anjum Hasan
The 1990s. It's raining in Shillong. Eight-year-old Sophie Das has just realised she is adopted, but there is also the baby kicking inside her mother's stomach whom she's dying to meet.
Shadow Lives: Writings on Widowhoodby Uma Chakravarti Preeti Gill
This volume documents the focus on the widow, regarded as the dark half of womankind in tradition, the structural counterpart of the sumangali or the auspicious married woman, and to provide an archive on widowhood.
Song Sung True: A Memoirby Malka Pukhraj Saleem Kidwai
Music and dance became Malka's life as she began her career as a court singer in the erstwhile princely state of Jammu and Kashmir, going on to become an independent performer, whose voice and words are now familiar to millions in the Indian subcontinent.
Speaking Peace: Women's Voices from Kashmirby Urvashi Butalia
This book reflects the range of women's experiences in the Kashmir conflict, which, for some years, has been a key issue on the Indian political map.
We Also Made History: Women in the Ambedkarite Movementby Urmila Pavara Minakshi Moon
The book explores the history of women's role, contribution and shaping of the Ambedkarite movement in Maharashtra taking its cue from We Were Also Making History edited by Lalitha and Susie Tharu.
Younguncle Comes to Townby Vandana Singh
In a small, sleepy town in northern India, three children gaze out onto a rain-drenched street, waiting for a most unusual guest. Their father's younger brother is coming to stay. Who is Younguncle? What's his real name?
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Michigan and Trumbull is missing an old friend as crews raised most of the remaining Tiger Stadium on Monday.
The stadium's upper deck, which had remained mostly in tact, collapsed around 2:30 p.m.
Freep.com, June 22: Witnesses said the first base portion of the structure began peeling away, and then the rest of the upper deck quickly collapsed upon itself.
The result is a massive pile of rubble, including the roof, twisted steel and concrete chunks.
A preservation group earlier this month attempted to postpone the final demolition, but a judge ruled against the delay and the razing resumed.


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Wrestling Forum : WWE, TNA, Indy Wrestling, Lucha Underground, Women of Wrestling Forums (http://www.wrestlingforum.com/forumindex.php)
- General WWE (http://www.wrestlingforum.com/general-wwe/)
- - Has Vince Lost It? (http://www.wrestlingforum.com/general-wwe/668161-has-vince-lost.html)
Has Vince Lost It?
wow i dont even know where to begin
that ending was overbooked like the end days of wcw, its not just that rock won, but how he won
punk not only lost, but lost even with the sheilds help, and losing to a weak elblow drop and not the rock bottom made him look so weak
its lame and predictable, and very anti-climatic, and craps over the last 400 days, vince allows a part timer who barely appears come in and win the title in his second match in 10 years
it also disvalues once in a lifetime, last year fans will feel ripped off knowing this match will take place AGAIN
lesnar could of returned and took out the rock, punk wins
setting up brock/rock at rumble
cena vs undertaker
punk vs rumble winner ziggler unify match
how can anybody be interested in cena/rock, there match last year wasn't that good and what more could they possibly do
rock was gassed again, only this time it happened in less than 10 min
Re: Vince Disvalues His Company Bigtime.....
I actually thought Lesnar would come in and cost The Rock. But oh well.
And in 10 years, this is his 4th win. There was Hogan and Austin in 03.
Re: Vince Disvalues His Company Bigtime.....
Rock has beaten plenty of people with the People's Elbow. Not sure why you would complain about that. And the Shield actually put Rock down for the 3 count. It's not like he kicked out of that. Rock got his second wind after the restart. Not sure why you complain about that.
Re: Vince Disvalues His Company Bigtime.....
whatever anything besides cena/rock
the only thing that would save this for me is if cena comes out tomorrow and says he wants takers streak instead of title, but its not happening
how anyone can defend that ending is beyond me
overbooked, made punk look extremely weak, even if i wanted rock to win make it look pure, and without any clustermess
Re: Vince Disvalues His Company Bigtime.....
Vince has no proof the Shield did anything
I got a feeling the decision will be overturned on Monday
Re: Vince Disvalues His Company Bigtime.....
I agree about the predictability, everyone knew it was going to be Cena vs Rock 2 considering how well it sold last time. So by knowing that you can come to the conclusion that Rock was going to beat Punk and Cena was going to win the Rumble. And can we really blame WWE? They only promote what brings in the real money, why would they change that?
Re: Vince Disvalues His Company Bigtime.....
i saw a screenshot that clearly showed it was the shield, plus punk looked weak either way, all i know is that before the rumble i was excited about RTWM
now im starting to care alot less, rock/cena lesnar/hhh does nothing for me, predictable and we seen it before
rock looked bad tonight also, guy gasses out in less than 10 min, he barely did any of his moves, i more one thinks about this match the worst it gets
Re: Vince Disvalues His Company Bigtime.....
Re: Vince Disvalues His Company Bigtime.....
ROck vs Punk could have been classic match but why the fuck they have Shield interfere? Punk=transition champions
Sheamus on final 3? what the fuck? this guy can't and never able to carried smackdown then how the fuck he's in final 3?
Bryan and Kane? this 2 guy should break up already and have unused guys estblished them as tag team like Alex Riley /Swagger and Zack Ryder/Curt Hawkings ...so many unused talented wrestler,
Re: Vince Disvalues His Company Bigtime.....
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*From the Center for Emerging Infectious Diseases (Drs. Hui and Sung), Departments of Medicine and Therapeutics (Drs. Ko, Woo, and Tam), and Diagnostic Radiology and Organ Imaging (Ms. Chan and Dr. Wong), Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong.
Correspondence to: David S. Hui, MD, FCCP, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing St, Shatin, N.T., Hong Kong; e-mail: email@example.com
Objective: To examine pulmonary function, exercise capacity, and health-related quality of life (HRQoL) among severe acute respiratory syndrome (SARS) survivors.
Methods: We evaluated survivors with confirmed SARS at the Prince of Wales Hospital, Hong Kong, at 3, 6, and 12 months after symptom onset. Our assessment included: lung volume (total lung capacity [TLC], vital capacity, residual volume, functional residual capacity), spirometry (FVC, FEV1), diffusing capacity of the lung for carbon monoxide (Dlco), inspiratory and expiratory respiratory muscle strength, 6-min walk distance (6MWD), chest radiographs (CXRs), and HRQoL by Medical Outcomes Study 36-Item Short-Form General Health Survey questionnaire.
Results: Ninety-seven patients completed the serial assessments. There were 39 male and 58 female patients, and 63 patients (70%) were health-care workers (mean age, 36.9 years [SD, 9.5 years]; body mass index, 23.7 kg/m2 [SD, 4.0 kg/m2]). At 1 year, 27 patients (27.8%) had abnormal CXR findings. Four patients (4.1%), 5 patients (5.2%), and 23 patients (23.7%) had FVC, TLC, and Dlco values < 80% of predicted values, respectively. The 6MWD at 12 months was 511.0 m (SD, 89.8 m), which was higher than at 3 months (mean difference, 47.0 m; 95% confidence interval [CI], 31.8 to 62.1 m; p < 0.01) but not different from 6 months (mean difference, 9.7 m; 95% CI, − 4.4 to 23.8 m; p = 0.18). The 6MWD was lower than that for normal control subjects of the same age groups, and there was impairment of HRQoL at 12 months. Patients who required ICU admission (n = 31) showed higher CXR scores (1.6 [SD, 3.1]; vs 0.4 [SD, 1.1]; p = 0.04) and lower percentage of predicted FVC, TLC, and Dlco than those who did not, but there were no differences in 6MWD and health status.
Conclusion: Significant impairment in Dlco was noted in 23.7% of survivors 1 year after illness onset. Exercise capacity and health status of SARS survivors were remarkably lower than those of a normal population.
The emergence of severe acute respiratory syndrome (SARS) in Southern China in November 2002, followed by the global outbreak in 2003, caught the medical profession by surprise.1–3 Studies on SARS-coronavirus viral loads have shown that peak viral levels were reached at the second week of illness when patients were receiving hospital care, and thus health-care workers (HCWs) were particularly prone to infection while caring for their patients.4–5
The morbidity of SARS is highlighted by the observation that even when there was only 10% of total lung field involved by consolidation, 50% of patients would require supplemental oxygen in order to maintain oxygen saturation > 90%.6Several studies7–9 have shown that 20 to 36% of patients required ICU admission, whereas 13 to 26% progressed into ARDS, necessitating invasive ventilatory support.
In a major outbreak of SARS at our hospital in 2003, over half of those with SARS infection were previously healthy HCWs.7 High-resolution CT (HRCT) performed at 5 weeks after hospital discharge selectively on 24 outpatients with residual opacities revealed multiple patchy ground-glass appearance and interstitial thickening in 9 patients (38%) and CT evidence of fibrotic changes in 15 patients (62%).10It is likely that ongoing active alveolitis, probably as a result of an uncontrolled host immune response triggered by the viral antigen, may lead to pulmonary fibrosis in some patients. Previous studies on survivors of acute lung injury11and ARDS12–15 unrelated to SARS have shown variable degrees of residual abnormalities in pulmonary function, exercise capacity, and impairment in health-related quality of life (HRQoL).
We have recently reported that 15.5% of our SARS survivors (n = 110) had abnormal diffusing capacity of the lung for carbon monoxide (Dlco) at 6 months, whereas overall their exercise capacity and health status were lower than normal populations of the same age groups.16 We report herein the 1-year outcome of a prospective follow-up study of the same SARS patient cohort, which was epidemiologically linked to a single index case during a major hospital outbreak in 2003.7,17 We examined serial lung function, exercise capacity, chest radiographs (CXRs), and HRQoL at 3, 6, and 12 months after the onset of illness. In addition, we compared SARS survivors who required ICU admissions to those who were treated on the medical wards with reference to the same outcome parameters.
This is a prospective, longitudinal, follow-up study of patients with SARS discharged from our hospital after surviving the major outbreak in 2003. The patients came from our previously reported cohort7 recruited over a period of 2 weeks from March 11 to March 25, 2003. The diagnosis of SARS was based on the Centers for Disease Control and Prevention criteria at the time.18All patients in this study had subsequent laboratory confirmation of SARS.19 Treatment and outcome of these patients during hospitalization have been reported in detail elsewhere.19 This prospective outcome study of SARS survivors was approved by the Ethics Committee of the Chinese University of Hong Kong.
Following discharge from the hospital, patients were evaluated in the lung function laboratory at the end of 3, 6, and 12 months after disease onset. During the visit, subjects were interviewed and underwent a physical examination, pulmonary function testing, respiratory muscle strength measurement, posteroanterior CXR, resting oximetry, and a standardized 6-min walk test (6MWT).20–21 In addition, they completed the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36) to measure HRQoL.22
The 6MWT provides a standardized, objective, integrated assessment of cardiopulmonary and musculoskeletal function that is relevant to daily activities.20–21 The self-paced 6MWT assesses the submaximal level of functional capacity21 and has been applied in a long-term follow-up study12 of survivors of ARDS. The 6-min walk distances (6MWDs) were compared to normative reference data collected from a population survey of 538 normal healthy subjects in 2004 by the Coordinating Committee in Physiotherapy, Hong Kong Hospital Authority, on 2 separate days. The 6MWDs of the control subjects (n = 538) on day 1 and day 2 of assessment were 598.4 m (SD, 98.7 m) and 609.2 m (SD, 100.4 m), respectively, with an intraclass correlation coefficient of 0.87 (95% confidence interval [CI], 0.84 to 0.89); SE of measurement, 35.3; minimum detectable change, 97.8 m; and limit of agreement, 10.8 (95% CI, − 87.1 to 108.6). The 6MWD data stratified into different age groups are available for comparison with the SARS patients, although we have no access to individual data of this population survey.
The SF-36 includes eight multiple-item domains that assess physical functioning (PF), social functioning (SF), role limitation due to physical problems (RP), role limitation due to emotional problem (RE), mental health (MH), bodily pain (BP), vitality (VT), and general health (GH).22Scores for each aspect can range from 0 (worst) to 100 (best) with higher scores indicating better HRQoL. The validated Chinese (Hong Kong [HK]) version of the SF-3623was applied for this study, and the results were compared to the HK normative data collected from a random telephone survey24 of 2,410 Chinese adults ≥ 18 years old. Based on this survey,24 SF-36 domain scores stratified into two age groups (18 to 40 years and 41 to 64 years) are available for comparison with those of our SARS survivors.
Lung volumes (total lung capacity [TLC], vital capacity [VC], residual volume [RV], functional residual capacity [FRC] using the nitrogen washout method), spirometry (FVC, FEV1), FEV1/FVC ratio, forced expiratory flow rate, midexpiratory phase (FEF25–75), and surface area for gas exchange (Dlco adjusted for hemoglobin, and Dlco adjusted for alveolar volume [Kco]) were performed (Vmax System; SensorMedics; Yorba Linda, CA). Dlco was determined by the single-breath technique using an infrared analyzer. We performed spirometry (FEV1 and FVC) according to the standards of the American Thoracic Society.25–26 The results were compared to the normative data,27 which have been widely adopted as the reference data in HK.
Measurement of the maximum static inspiratory pressure (Pimax) that a subject can generate at the mouth or the maximum static expiratory pressure (Pemax) is a simple way to gauge inspiratory and expiratory muscle strength.28–29 Since respiratory muscle weakness may lead to a restrictive pattern on lung function testing, Pimax and Pemax were assessed with a mouth pressure meter via a flanged mouthpiece30 after full lung function testing. In a study of 24 normal subjects (23 Chinese and 1 Indian; mean age, 29.2 years) in Singapore, the maximal static inspiratory effort from RV for the group was 83.5 cm H2O (SD, 35.5 cm H2O).31 A Pimax of − 80 cm H2O and a Pemax of + 80 cm H2O generally exclude clinically significant weakness of the inspiratory and expiratory muscles, respectively.32
Frontal CXRs were performed at 3, 6, and 12 months using standardized techniques with computed radiography equipment as we have reported during the major hospital outbreak.7 The images were assessed using a picture archive communications system (MagicView VA22E; Siemens; Erlangen, Germany) and viewer (model 2K; Siemens). Each lung was divided into three zones (upper, middle, and lower) on frontal radiography. The observers assessed the presence, appearances (airspace opacities or reticular opacities), distribution, and size of lung parenchymal abnormalities on each CXR of all patients. The size of the lesion was assessed by visually estimating the percentage of area occupied in each zone on each side. The overall percentage of involvement was obtained by averaging the percentage of involvement of the six lung zones. The frontal CXR closest to the date of the lung function test was assessed by two radiologists, both of whom were blinded to the clinical information. The findings were reached by consensus. The assessment method was described in our previous study.33
Statistical analysis was performed using statistical software (Statistical Package for Social Science, version 11.0; SPSS; Chicago, IL). Cumulative steroid dosage during inpatient treatment and outpatient follow-up was converted into hydrocortisone in milligrams to facilitate analysis of this study. Continuous variables were compared using independent-sample t test, whereas the Mann-Whitney U test was used for nonparametric data. Categorical variables were compared using the χ2 test. All statistical tests were two tailed. Statistical significance was taken as p < 0.05. Univariate analyses were performed to evaluate the potential determinants of exercise capacity expressed as the 6MWD. Variables significant in univariate analysis (p < 0.1) were included in the multivariate analysis. Age and sex were controlled in the analysis of the final multivariable models because they are independent determinants of the 6MWD.16,34 Repeated-measures analysis of variance (ANOVA) was used to assess serial changes in 6MWT distance and CXR scores.
Of the first 138 patients with SARS infection in March 2003, 15 patients (10.9%) died.19 Among the 123 survivors, 13 patients (10.6%) did not attend follow-up at 3 months and 6 months,16 whereas another 13 patients (10.6%) defaulted the 12-month assessment. Of the 13 defaulters at 12 months, 11 patients had normal lung function indexes, whereas the other 2 patients had Dlco of 68% and 78% of predicted normal values, respectively, at 6 months. Thus, there were only 97 patients (78.9%) who had completed the three assessments; among these, 63 patients (65%) were HCWs (doctors, nurses, ward assistants, and medical students) and 58 patients (66%) were women. The mean age was 36.9 years (SD, 9.5 years) and body mass index (BMI) was 23.7 kg/m2 (SD, 4.0 kg/m2) during the visit at 12 months from illness onset. The hospital length of stay (LOS) for the group was 22.7 days (SD, 14.6 days). There were only three smokers (3.3%) among the whole group. There were 15 patients with medical comorbidities, which included COPD (n = 1; 1.1%); ischemic heart disease (n = 1; 1.1%); ischemic stroke (n = 1; 1.1%); breast cancer (patient in stable clinical condition receiving tamoxifen) [n = 1; 1.1%]; diabetes mellitus (n = 3; 3.3%); cirrhosis (n = 1; 1.1%), hypertension (n = 4; 4.1%); and asymptomatic hepatitis B carrier (n = 3; 3.3%).
Among the 97 patients, 31 patients (32%; 17 men and 14 women) required ICU admission, with an ICU LOS of 13.5 days (SD, 15.6 days; median, 7 days; range, 2 to 64 days), whereas 6 patients (5.5%) required invasive mechanical ventilation. Based on our ICU admission criteria,19 all 31 patients would have a Pao2/fraction of inspired oxygen ratio < 300 mm Hg, whereas the 6 patients who were intubated had a Pao2/fraction of inspired oxygen ratio < 200 mm Hg. Among these 31 patients, 6 patients had medical comorbidities, including ischemic heart disease (n = 1; 0.9%), diabetes mellitus (n = 1; 0.9%), hypertension (n = 2; 1.8%), and asymptomatic hepatitis B carrier (n = 2; 1.8%), but none had any history of smoking or pulmonary disease.
An overview of the serial lung function tests and respiratory muscle strength results for the group are shown in Table 1
. Overall, lung volume parameters and surface area for exchange were well preserved at 3, 6, and 12 months. There was significant reduction in Dlco, FEF25–75, and alveolar volume (Va), whereas there was an increase in Kco over the study period of 12 months. Pimax and Pemax values < 80 cm H2O were noted in 16 patients (14.5%) and 8 patients (7.3%), respectively, at 12 months.
The frequency of SARS survivors with lung function parameters < 80% of predicted values is as follows: 3 months, FEV1 (n = 3; 3.1%), FVC (n = 6; 6.2%), VC (n = 6; 6.2%), TLC (n = 7; 7.3%), Dlco (n = 13; 13.5%), and Kco (n = 2; 2.1%); 6 months, FEV1 (n = 4; 4.1%), FVC (n = 4; 4.1%), VC (n = 5; 5.2%), TLC (n = 8; 8.2%), Dlco (n = 15; 15.5%), and Kco (n = 1; 1.0%); and 12 months, FEV1 (n = 5; 5.2%), FVC (n = 4; 4.1%), VC (n = 5; 5.2%), TLC (n = 5; 5.2%), Dlco (n = 23; 23.7%), and Kco (n = 0; 0%). Thus, there were 23 patients (23.7%) with impaired Dlco, whereas up to 5.2% of patients had reduction in parameters of lung volume at 12 months.
The mean 6MWD increased significantly, from 464 m (SD, 87 m) at 3 months to 502 m (SD, 97 m) and 511 m (SD, 90 m) at 6 months and 12 months, respectively (p value for trend < 0.01). When the subjects were stratified into different age groups and compared to the corresponding normative values, their exercise capacity was generally significantly lower than the normal subjects (Table 2
). The 6MWDs of the SARS survivors at 3, 6 and 12 months, in comparison with normative data, are shown in Table 3
Univariate followed by multivariate analyses, controlled for age and gender, were performed to look for factors associated with 6MWD (Table 3). At 3 months, there was no independent predictor identified, whereas percentage of predicted FVC was the only positive independent predictor for 6MWD at 6 months. At 12 months, the independent positive predictors for 6MWD were percentage of predicted FVC and percentage of predicted Dlco.
Thirty-seven patients (38.1%) were noted to have abnormal total CXR scores at 3 months involving 3.9% (SD, 3.5%; range, 0.5 to 15%) of the total lung fields, whereas 32 patients (33%) had abnormal CXR scores involving 3.1% (SD, 3.4%; range, 0.8 to 15%) of the lung fields at 6 months. At 1 year, 27 patients (27.8%) had abnormal CXR findings involving 2.9% (SD, 3.1%; range, 0.8 to 15%) of lung fields. By repeated-measures ANOVA analysis of patients with abnormal CXR scores (n = 37), there was a significant trend for improvement from 3 to 12 months (p = 0.001).
Correlations between the extent of CXR abnormality vs cumulative steroid dosage, lung function parameters, and 6MWD at 12 months were examined. There was a significant positive correlation between the extent of radiographic abnormalities (percentage of lung fields) and the cumulative hydrocortisone dosage (r = 0.43, p < 0.01). There were significant negative correlations between the extent (percentage) of radiographic abnormalities and TLC (r = − 0.25, p = 0.01) and Dlco (r = − 0.37, p < 0.01). However, no significant correlations were noted between the extent of radiographic abnormalities vs 6MWD (r = − 0.14, p = 0.17), FEV1 (r = − 0.08, p = 0.42), RV (r = − 0.21, p = 0.05), FVC (r = − 0.19, p = 0.06), Kco (r = − 0.16, p = 0.11), Pimax (r = − 0.02, p = 0.88), and Pemax (r = 0.09, p = 0.41).
Patients who had required ICU admission (n = 31; 17 men and 14 women) had a higher peak lactate dehydrogenase (LDH) level, a higher peak C-reactive protein (CRP) level, a longer hospital LOS, and received a significantly higher total steroid dose than those who did not require ICU care (Table 4
). The lung function tests at 12 months showed significantly lower percentage of predicted FVC, VC, TLC, RV, and Dlco in survivors who required ICU support than those who were treated on medical wards, although no significant difference was noted for 6MWD and respiratory muscle strength between the two groups (Table 5
By repeated-measures ANOVA of the serial scores of the eight SF-36 domains for the entire cohort over 12 months, there were significant trends for mean improvement in RP of 37.6 (SD, 39.7), 61.1 (SD, 43.8), and 58.5 (SD, 43.0) at 3, 6, and 12 months, respectively [p for trend < 0.001]; SF of 63.4 (SD, 25.0), 72.4 (SD, 22.5), and 68.9 (SD, 25.1) at 3, 6, and 12 months, respectively [p for trend 0.001]; and RE of 51.6 (SD, 43.8), 68.4 (SD, 39.5), and 63.6 (SD, 42.8) at 3, 6, and 12 months, respectively [p for trend < 0.001], whereas there was worsening of GH: 53.4 (SD, 19.7), 51.5 (SD, 19.2), and 49.1 (SD, 19.1) at 3, 6, and 12 months, respectively (p for trend 0.023). There were no significant serial changes in PF, BP, VT, and MH (data not shown).
Correlations between lung function parameters, 6MWD, and SF-36 domains at 12 months are shown in Table 6
. In general, there were significant positive correlations between lung function parameters (FVC, VC, FEV1, and Dlco) with several SF-36 domains (PF, RP, GH, SF, and RE). 6MWD had significant positive correlations with all SF-36 domains except MH.
SF-36 domain scores at 3, 6, and 12 months after illness onset in patients who did and did not require ICU support during the acute illness in comparison to normative data are shown in Figure 1
(more data are available only in on-line supplemental Tables 789
). There was significant impairment of health status among our SARS survivors at 12 months compared to control subjects of the same age groups.
When directly comparing those who had required ICU admission against those treated on the medical wards, there was no significant difference in all SF-36 domains between the two groups at 12 months. When comparing the 25 patients who did not require intubation in ICU against those who had required intubation (n = 6), the latter had more severe lung injury, as reflected by a higher peak LDH level: median, 466.0 U/L (interquartile range [IQR, 259.0 U/L]) vs 652.0 U/L (IQR, 124.5 U/L) [p = 0.02]. There was, however, no statistically significant difference with regard to age (36.0 years [IQR, 15.5 years] vs 36.5 years [IQR, 17.5 years], p = 0.87) and 6MWD (538.5.7 m [IQR, 170.2 m] vs 548.3 m [IQR, 118.1 m]; p = 0.71) at 12 months. In addition, there were no significant differences between the two groups with regard to lung function indexes and SF-36 domain scores at 12 months (data available only in on-line supplemental Table 10).
This prospective cohort study has shown that 23.7% and 27.8% of SARS survivors had impairment of Dlco and abnormal CXR findings, respectively, at 1 year after illness onset. Overall, the serial assessments of 6MWD showed a significant improvement over 12 months, but exercise capacity and health status were still significantly lower than those of normal control subjects of the same age groups. The 1-year lung function indexes (percentage of predicted FVC, VC, TLC, RV, and Dlco) in survivors who required ICU support were remarkably lower than those of patients who were treated on medical wards, although no significant differences were noted for 6MWD, respiratory muscle strength, and health status between the two groups. Interestingly, there was no difference in lung function indexes, exercise capacity, and health status at 1 year between the ICU-intubated and the ICU-nonintubated SARS patients, although the former had more severe lung injury.
Based on the HRCT appearance of bronchiolitis obliterans organizing pneumonia (BOOP) and the clinical suspicion that progression of the pulmonary disease might be mediated by the host inflammatory response,4 pulse methylprednisolone was administered during clinical progression of SARS with a favorable response.7,19,35–37 Lung histopathologic condition of fatal SARS cases was dominated by diffuse alveolar damage and extensive consolidation,38–40 but features of BOOP were indeed noted.41
At 6 months after admission to hospital, residual abnormalities of pulmonary function were observed in three fourths of the Queen Elizabeth Hospital cohort in HK (n = 57), mostly consisting of isolated reductions in Dlco, whereas an abnormal HRCT score was detected in 75.4% of patients.42 In contrast, 15.5% of our SARS survivors had impaired Dlco at 6 months,,16 whereas HRCT performed on 44 patients revealed ground-glass opacification and reticulation in 38 patients (86.4%) and 35 patients (92.1%), respectively.43 At 1 year, 23.7% of our patients had significant impairment of Dlco with well-preserved Kco. The serial results suggest an increase of the intra-alveolar diffusion pathway, which might be the result of diffuse alveolar damage and/or BOOP initially,,38–41 followed by postinflammatory changes such as atelectasis, ongoing alveolitis, and parenchymal fibrosis later in the course of the disease. Our results are similar to a long-term follow-up study44in Beijing that reported that 27.3% of their SARS survivors (85 of 311 patients) had impaired Dlco, whereas 21.5% exhibited radiographic evidence of lung fibrotic changes at 1 year. Several studies47 on ARDS survivors have shown that their pulmonary function generally returns to normal or near normal by 6 to 12 months, but Dlco may remain abnormal in up to 80% of patients at 1 year after recovery.,14 The decreasing trend for Va, discordant with TLC, observed in our study suggests there might be maldistribution of the inert gas during the single-breath Dlco maneuver, such as in the setting of occult small airway obstruction in some patients. Although expiratory HRCT was not performed in adult patients,,42–43 a pediatric study48 of 47 asymptomatic children at 6 months from diagnosis of SARS showed that 16 patients (34%) had pulmonary abnormalities, whereas 8 patients (17%) had evidence of air trapping on expiratory HRCT.
The self-paced 6MWT was performed to evaluate the global and integrated responses to exercise, although it did not provide specific information on the function of individual organs and systems.21 Although showing considerable improvement over 12 months, the 6MWD was markedly reduced for most age groups compared to normal control subjects. Previous studies12,49 have shown that 6MWD was substantially lower among ARDS survivors than control subjects 1 to 2 years after mechanical ventilation, whereas the absence of systemic steroid treatment, absence of illness acquired during ICU stay, and rapid resolution of lung injury were important factors associated with a longer 6MWD at 3, 6, and 12 months, respectively.12 After controlling for the known effects of age and gender, our analysis has shown that percentage of predicted FVC was the positive independent factor associated with higher 6MWD at 6 months, whereas percentage of predicted FVC and percentage of predicted Dlco were the positive independent predictors at 12 months.
Given the relatively well-preserved lung function in the majority of our SARS survivors, the poor performance in the 6MWT in most age groups could be due to additional factors such as muscle wasting, myopathy, and possibly cardiac diastolic dysfunction.50Lau et al51noted that muscle strength and endurance were more impaired in proximal than in distal muscles among survivors in our SARS cohort at 3 months after illness onset. Eighteen of 44 SARS survivors in Singapore had reduced exercise capacity at 3 months after hospital discharge that could not be accounted for by impairment of pulmonary function.52 These results suggest that the inability to exercise in recovered SARS patients is primarily due to extrapulmonary causes such as physical deconditioning and possibly steroid myopathy.51–52 In addition, 53% of SARS survivors complained of some degree of large-joint pain, although only 12 patients (4.7%, including 7 patients in the current study) of 254 SARS survivors in our cluster of hospitals had evidence of osteonecrosis of the long bones on MRI conducted at a median of 6.7 months from hospital admission.53
There are several possible causes for muscle weakness among SARS survivors. More than 60% of our patients complained of myalgia with elevation of creatinine kinase in 32.1% suggestive of viral-induced myositis at initial presentation.7 Most of our patients required bed rest during hospitalization for an average of 3 weeks. The long period of bed rest could lead to muscle wasting and deconditioning, whereas the use of systemic corticosteroid therapy to suppress immune-mediated lung injury4,7–9,19 could contribute to myopathy. Steroid myopathy has been reported in patients administered high-dose steroid for acute lung transplant rejection54and status asthmaticus.55Critical illness-associated polyneuropathy/myopathy has also been observed in SARS survivors.56 A small proportion of our SARS patients had evidence of respiratory muscle weakness. Inspiratory muscle weakness may cause atelectasis, whereas expiratory muscle (abdominal and intercostal muscles) weakness may lead to air trapping.
In addition, there was significant impairment of health status in most SF-36 domains among our patients at 12 months. There were significant and positive correlations between lung function parameters (VC, FVC, FEV1, and Dlco) and SF-36 domains such as PF, RP, GH, SF, and RE. There were also significant positive correlations between 6MWD and all SF-36 domains except for MH. The results are not surprising as, in addition to the physical impairment, the long period of isolation and extreme uncertainty during the SARS illness had created enormous psychological stress57and mood disturbances.58In addition, steroid toxicity, personal vulnerability, and psychosocial stressors might have jointly contributed to the development of psychosis in some patients.59 Other studies11–14 on acute lung injury or ARDS survivors unrelated to SARS have reported impaired health status at 1 to 5 years after recovery, whereas pulmonary function abnormalities, especially Dlco, correlated with SF-36 domains.,13–14
Twenty-seven patients (27.8%) in this study still had abnormal radiographic scores at 12 months, although their serial CXRs showed significant improvement. The positive correlation between the extent of residual radiographic abnormalities and the cumulative steroid dosage used for SARS was expected, as the former was an indication on the treatment protocol for more systemic steroid during the outbreak.4,7,19 The negative correlation between residual radiographic abnormality and lung volume parameter (TLC) and parameter of surface area for gas exchange (Dlco) reflected the physiologic effects of parenchymal inflammation and fibrosis. Patients with more severe disease (as reflected by higher peak LDH level),7,19,35 who had required ICU support during the acute illness had more residual opacities on CXRs at 12 months. In addition, they had more extensive pulmonary injury and fibrosis, as reflected by a significantly lower lung volume parameter (TLC) and Dlco at 12 months than those treated on the general wards. There were, however, no significant differences in 6MWD and HRQoL between the two groups at 12 months. In addition, there were no differences in any functional parameters between ICU patients receiving and not receiving mechanical ventilation. Herridge et al,12 reported that 20% of their ARDS survivors had minor abnormalities on CXRs at 1 year.
There are several limitations to this study. Firstly, we did not perform cardiopulmonary exercise testing (CPET), as many patients complained of generalized muscle weakness on initial follow-up. CPET would also be too labor-intensive for a large cohort of SARS survivors. Nevertheless, reduced pulmonary gas exchange has been detected with CPET in some survivors of SARS at 3 months with normal Dlco.52 Secondly, only 97 of 123 survivors (79%) in the cohort had completed the serial assessments over 12 months, and the results might not be representative of the entire cohort. Thirdly, we assessed respiratory muscle strength with mouth pressure, but low Pemax values do not always indicate expiratory muscle weakness and might result from technical difficulties such as mouth leakage. Lastly, we could not measure the effects of extrapulmonary factors (such as muscle deconditioning, steroid or viral-induced myopathy, cardiac diastolic dysfunction, critical illness polyneuropathy and/or myopathy) in the poor performance of the 6MWT. It is difficult to determine the contribution by psychological and motivational factors, as many patients are seeking compensation for occupation-related SARS.
In summary, this study has shown significant impairment of Dlco in 23.7% of SARS survivors, whereas their exercise capacity and health status were remarkably lower than the general population at 12 months after illness onset. The functional disability appears to be out of proportion to the degree of lung function impairment and may be due to additional factors such as muscle deconditioning, steroid-related musculoskeletal complications, critical illness-related neuropathy/myopathy, and other psychological factors. Further follow-up is needed to assess if these deficits are persistent.
Abbreviations: ANOVA = analysis of variance; BMI = body mass index; BOOP = bronchiolitis obliterans organizing pneumonia; BP = bodily pain; CI = confidence interval; CPET = cardiopulmonary exercise testing; CRP = C-reactive protein; CXR = chest radiograph; Dlco = diffusing capacity of the lung for carbon dioxide; FEF25–75 = forced expiratory flow, midexpiratory phase; FRC = functional residual capacity; GH = general health; HCW = health-care worker; HK = Hong Kong; HRCT = high-resolution CT; HRQoL = health-related quality of life; IQR = interquartile range; Kco = diffusing capacity of the lung for carbon dioxide adjusted for alveolar volume; LDH = lactate dehydrogenase; LOS = length of stay; MH = mental health; Pemax = maximum static expiratory pressure; Pimax = maximum static inspiratory pressure; PF = physical functioning; RE = role limitation due to emotional problems; RP = role limitation due to physical problems; RV = residual volume; SARS = severe acute respiratory syndrome; SF = social functioning; SF-36 = Medical Outcomes Study 36-Item Short-Form General Health Survey; TLC = total lung capacity; Va = alveolar volume; VC = vital capacity; VT = vitality; 6MWD = 6-min walk distance; 6MWT = 6-min walk test
Funding was provided by the Research Fund for the Control of Infectious Diseases (Health, Welfare and Food Bureau, Hong Kong Special Administrative Region).
Data are presented as mean (SD).
In comparison between 12 months and 3 months, the mean difference for FEF25–75 was − 8.2% (95% CI, − 11.2 to − 5.2; p < 0.001), whereas the mean difference was − 2.2% (95% CI, − 5.1 to 0.7; p = 133) in comparison between 12 months and 6 months (p value for linear trend < 0.001).
In comparison between 12 months and 3 months, the mean difference for Dlco was − 3.8% (95% CI, − 6.6 to − 1.0; p = 0.008), whereas the mean difference was − 3.7% (95% CI, − 6.0 to − 1.4; p = 0.002) in comparison between 12 months and 6 months (p value for linear trend 0.008).
In comparison between 12 months and 3 months, the mean difference for Kco was 7.0% (95% CI, 4.5 to 9.5; p < 0.01), whereas the mean difference was 3.2% (95% CI, 1.1 to 5.2%; p = 0.004) in comparison between 12 months and 6 months (p value for linear trend < 0.001).
There was a significant decrease in Va from 3 to 12 months (mean difference, 0.32; 95% CI, 0.23 to 0.40; p < 0.01), and from 6 to 12 months (mean difference, 0.19; 95% CI, 0.11 to 0.28; p < 0.01) [p value for linear trend < 0.001].
NA = not applicable; NS = not significant. Δ = mean difference compared to normal.
Including one female patient aged 61 years with 6MWDs of 492 m, 465 m, and 419 m at 3, 6, and 12 months, respectively. Data are presented as mean (SD).
Significant at p < 0.01.
Significant at p < 0.03.
Significant at p < 0.05.
Data are presented as mean (SD) unless otherwise indicated.
Statistically significant.
Data are presented as mean (SD); 95% CI; p value.
Reported values are Pearson correlation coefficients (r).
From Lam et al.24 Among the normal control subjects, 1,244 subjects and 695 subjects were in the age groups 18 to 40 years and 41 to 64 years, whereas there were 19 subjects and 12 subjects who were SARS survivors in the same age categories, respectively. NS = not significant.
From Lam et al.24 Among the normal control subjects, 1,244 subjects and 695 subjects were in the age groups 18 to 40 years and 41 to 64 years, whereas there were 50 subjects and 16 subjects who were SARS survivors in the same age categories, respectively. See Table 9 for expansion of abbreviation.
Data are presented as median (IQR).
We thank the following colleagues who have provided help in this ongoing study: M. Tong, RN; P.Y. Chan, RN; M.S. Cheng, RN; T.Y. Cheong, RN; M.Y. Leung; EN; E Lee (clerk); and C Ho (research assistant). We also acknowledge the Coordinating Committee in Physiotherapy, Hong Kong Hospital Authority, for collecting the updated normative data on 6MWDs.
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Coast shul wants sea change
Bournemouth Hebrew Congregation could be on the move after receiving an offer for its Wootton Gardens premises in the town centre.
After the Shabbat service, relocation committee chair Geoffrey Feld told members that "a substantial offer had been received which we are looking upon most favourably".
He could not reveal the prospective buyer, or the price being offered. However, if the sale went ahead, a clause allowing two or three years for the shul to find a replacement site would be included in the contract.
Mr Feld added that the trustees would have to obtain Charity Commission approval for the sale. And as agreed at a special general meeting two years ago, members will be asked to authorise the sale. Should matters proceed as hoped, a meeting will be called after the High Holy-Days.
As for a replacement site, "the search is continuing and if a suitable location is identified we will bring it to your attention".
In April, synagogue leaders welcomed a decision by then Culture Secretary Ben Bradshaw to reject a request by English Heritage to list the Edwardian shul building. Listed status would have made the sale more difficult.
Consecrated in 1911, the synagogue has been expanded down the years to accommodate 800 people. It has a small social hall, a mikveh and a multi-storey extension featuring a banqueting hall, kitchen, six classrooms and two flats.
Many of the 720 members feel the complex is now too big for their needs and expensive to maintain. They also consider its location in the heart of Bournemouth's nightlife area as undesirable.
Synagogue president Brian Bradley said: "We are all sorry to leave our beautiful shul but it makes practical sense for the future of our community to relocate to Bournemouth's East Cliff."


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Winter 2010
Conducted from January 11 through January 22, the Winter 2010 survey was taken by 360 ARM professionals. The survey was separated into three parts: one for ARM companies, one for creditors, and one for vendors that serve the industry.
Please click the menu options below to see the raw results for each group, with ARM company responses further broken down into Collection Agencies, Debt Buyers, and Collection Law Firms.


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Conference on Food Security and Climate Change Releases Declaration Calling for Urgent Action on Dryland Agriculture
4 February 2010: The International Conference on Food Security and Climate Change in Dry Areas, organized by the International Center for Agricultural Research in the Dry Areas (ICARDA), a member of the Consultative Group on International Agricultural Research (CGIAR), the Ministry of Agriculture of Jordan and others, met from 1-4 February 2010, in Amman, Jordan.
Over 200 scientists from 29 countries attended the meeting and produced the Amman Declaration, which calls for urgent action to buffer dryland agriculture. The Declaration seeks to spur international partnerships that will identify solutions to the impacts of climate change on food security. Participants highlighted the challenges facing dryland agriculture, including high temperatures, frequent droughts and land degradation. They also presented technical and policy solutions that will facilitate the development of tolerant crops, improved irrigation techniques and the implementation of diversified farming systems. [Conference Website] [Press Release]


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Attendees will receive $600 in tax-free gifts
Presents for presenters are a thing of the past at the Golden Globe Awards.
Presenters at the 64th annual awards Monday night will go home without the usual multithousand-dollar swag bags. However, the 1,200 attendees (including those presenting awards) will still receive goodie bags containing about $600 in tax-free gifts.
The Hollywood Foreign Press Assn. and the Internal Revenue Service have agreed that the HFPA will pay income tax for the presenter boxes for 2004 and 2005 and will assist the '06 crowd in filing tax forms.
While the actual dollar amount the HFPA paid in back taxes was undisclosed, org prexy Philip Berk called the figure "substantial."
"We are pleased to have reached an agreement with the IRS," Berk told Daily Variety on Wednesday. "We thought it only proper that we assume the tax burden for 2004 and 2005; we felt it didn't seem fair to ask those who had donated their services to pay additional tax after they had already filed tax returns for those years."
Although presenters from those years are in the clear, the HFPA will issue informational 1099 tax forms to recipients of 2006 boxes, who will be responsible for satisfying their income tax obligations.
Last summer, Daily Variety broke the story that the Academy of Motion Picture Arts & Sciences had reached an agreement with the IRS over their awards show gifts to presenters and performers (Daily Variety, Aug. 17).
In September, the HFPA voted to discontinue the presenters' gift boxes.
The HFPA approached the IRS seeking to clarify the tax issues surrounding the presenter boxes, as well as to ensure that any obligations for the prior years were met.
Following the Oscar shakeup, the IRS started an outreach campaign aimed at the entertainment industry. This effort focused on distribution of celebrity gift bags and presenter boxes in conjunction with appearances by the stars at award shows and other gatherings.
Last summer, the IRS reps said they were targeting swag that could be considered income for work — i.e., when celebs are given freebies after performing or making an appearance. Generally, swag given to guests would not fit this definition.
"We appreciate the Hollywood Foreign Press Assn. coming forward to resolve this issue," IRS commissioner Mark W. Everson said. "We're pleased that the groups holding award ceremonies are keeping in mind the tax consequences of gift bags and other promotional items."


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About Neale
Adventurer. Humanitarian. Motorcyclist. Road Warrior. Writer. Photographer. Tennis Player. Father. Storyteller.
Neale Bayly, renowned motorcycle journalist and philanthropic adventure rider, has explored much of the world on two wheels, riding across 45 countries in 35 years, many of them at the helm of adventure-seeking expeditions.
Nearly 30 years ago, the unshaven, mop-haired Brit arrived in the US on a one-way ticket and $200 in his pocket. Neale worked odd jobs, bought a $400 bike, and rode from Florida to Alaska. Declaring America a "big freak show" that he couldn't possibly leave, Neale, father of Patrick (12) and Luke (17), now calls Charlotte, NC home.
During an adventure motorcycle ride to Peru years ago, Neale was transformed by the abandoned children he met at the Hogar Belen orphanage. He formed Wellspring International Outreach, a nonprofit dedicated to helping orphans around the world.


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Greta Gerwig
March 25, 2014
Meet CBS' new sitcom star! Greta Gerwig, known for her roles in Noah Baumbach's films Greenberg and Frances Ha, will star in the How I Met Your Mother spinoff show How I Met Your Dad, according to The Hollywood Reporter. The comedy will be a whole new story line, but like HIMYM, there will be a voice at its center, only this time that person will be a female named Sally.
THR describes Gerwig's character as "a female Peter Pan who never has grown up and has no idea where she's going in life. She just has figured out that she has nothing in common with her husband of less than a year. A breakup is inevitable, but Sally will find a solid circle of support in her friends and family."
In addition to starring in the sitcom, Gerwig is expected to write on the show and will also be credited as a producer.
' More Sad Details Revealed About Robin Williams' Final Resting Place'(Fox News)
' WOW: 'Dating Naked' Is In Big Trouble'(Fox News)
' Katie Holmes Talks More About Tom Cruise'(Celeb Dirty Laundry)
' Are Taylor Swift and John Mayer Back Together?'(Celeb Dirty Laundry)
' What Is Really Going On With Nick Cannon and Mariah Carey?'(Hollywood Hiccups)


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California Restaurant...
9/25/16 - 10/2/16
"Crazed clown murders wife in front of live audience" is what the headlines would have screamed after the jealous Canio stabs his wife Nedda and her lover to death in a jealousy-driven rage while performing a comedy before an audience of shocked Italian villagers.
One of the most powerful operas in the repertoire, Pagliacci is gut-wrenching as Tonio, a member of the traveling troupe of players rejected by Nedda, sees her with another man and tells Canio how to get vengeance. In the famous aria "Vesti la giubba," Canio applies his clown make-up saying that the show must go on, but creates his own tragic ending.
Debuting artists Romanian soprano Adina Nitescu, a consummate actress at the Paris Opera, Metropolitan Opera and Florence, and powerful Brazilian baritone Rodolfo Giugliani, join Uruguayan tenor Carlo Ventre, fresh from successes at Covent Garden, Hamburg and the Verona Arena. Yves Abel, following his great success leading The Daughter of the Regiment last season, returns to conduct with Andrew Sinclair directing this extraordinary production.
Pagliacci by Ruggero Leoncavallo
California Restaurant...
9/25/16 - 10/2/16
9/28/16 - 10/2/16
Fashion Week San Diego
9/29/16 - 10/2/16
San Diego Brewers Guild
11/5/16 - 11/5/16


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DALLAS - Trainer Toni Beck's students are giving the workout all they've got. Grunting, sweating and panting, they stretch and flex until they reach the day's goal - getting up off the floor. "You all have the muscles - you're just afraid," Beck coaxes them.
The weekly workouts are small miracles for the participants, who are in their 60s, 70s and 80s. Many use canes, walkers or portable oxygen tanks and have physical problems such as osteoporosis or artificial hips and knees.
There's no "going for the burn" or thumping club music here. Instead, there's soft music, folding chairs and gentle stretches.
"I want you to grow 2 inches taller for me," Beck said, as she led the 11 participants through a stretch at the Baylor-Tom Landry Fitness Center. "This is going to keep us mobile." Beck, 76, calls the class "functional training."
A former chairwoman of the Southern Methodist University Dance Department, she blends yoga, Pilates and physical therapy into a workout that focuses on everyday tasks, such as balancing, getting out of a chair and picking up a dropped object.
The class members use oversized rubber bands and springy metal rings to exercise their legs, particularly the thighs. Strong thighs are the key, she said. If a person can use the thighs rather than the back or knees, there's less risk of injury. "If you keep that strong, you can function."
"I haven't conquered getting up and down off the chair yet, but I'm getting there," said Dorothy Reed, 84. Reed, who uses a walker, has been able to balance better and walk short distances on her own since starting the class, Beck said.
Many of the participants were active when they were younger but were sidelined by injury or illness.
Colburn Aubrey, a retired grocer, said he used to lift weights, and he was so flexible that he could lie on his back and put his feet by his ears.
These days, his back is literally bent - he broke it last year in a shower-stall fall - and he must work hard just to flex his shoulders, but he soldiers on.
"I believe in exercise," he said. "I've done it for years."
Rachelle Young, coordinator of the center's 50-Plus programs, believes this sort of fitness program will become popular as the baby boomers age.
"These moves are a lot harder than they look," she said. "Fitness centers are going to have to get on board. It's not as much fun as watching a young, go-go class, but it has to be done," said Beck.
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QUINCY, Mass. — John Fegan, the well-known senior vice president of pharmacy at Ahold USA here, will leave the company next week to become vice president of pharmacy at Winn-Dixie Stores, Jacksonville, Fla. The Winn-Dixie position is open at this time. A pharmacist, Fegan has been with Ahold for 12 years. Jim Wonderly, currently vice president of general merchandise and health and beauty care at Stop & Shop Supermarket Co., also here, and head of Ahold's American Sales Co., Lancaster, ...
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Written by So Lost in Wisconsin
Inspired by the latest Kaybot's letter to Tracy , I felt compelled to write a Pink version of twelve steps. I guess what it boils down to is this- — challenge accepted.
Here are twelve important steps toward Mary Kay recovery. I hope you all have taken each and every one of them towards your recovery. If you haven't . . . don't worry. There's still hope for you on your path towards lifting the pink fog. Continue reading "A 12-Step Recovery Program For Mary Kay"


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on August 22, 2013 - 11:40 AM
, updated August 23, 2013 at 6:22 PM
Before he was found guilty of a May 2011 shooting death in Cheektowaga Town Park, Dontre Jones was calling three teachers at Cheektowaga Central High School from jail, during school hours.
Those phone conversations outraged police, who have embarked on a campaign to make their content public and to hold the teachers, now on paid administrative leave, accountable. The anger was palpable at a news conference Thursday afternoon, when Cheektowaga Police Chief David Zack said he wasn't able to release details of those conversations because of the threat of legal action.
"I can assure the public that we are not intimidated," Zack said. "We are now more resolved than ever to make sure the public learns of what went on at Cheektowaga Central."
"I wanted to play audio and I wanted to give you the transcript of what came out of this investigation," the police chief said. "It's very limited what I can speak on at this point."
That's because attorneys representing two teachers sent "cease and desist" letters to town officials.
Carl Morgan and John Gilmour are representing a male teacher they declined to identify.
"My opinion, this is the most appalling abuse of power by a police chief or anyone in a position of authority that I ever witnessed," said Morgan, a retired police office. "It's a vendetta on his part."
According to police, Jones had attended classes at Cheektowaga Central until shortly before the May 31, 2011, shooting that killed Ira Watkins Jr., 19, of Buffalo. Though the shooting was related to an earlier argument between rival gangs from Buffalo, police said, neither Jones nor Watkins was involved in it.
Jones telephoned the teachers from behind bars between February 2012, when he was charged with second-degree murder, and this past June, when he was found guilty of first-degree manslaughter in a non-jury trial. Sentencing is scheduled for Monday.
"The conduct in question does not rise to a criminal offense under the laws of the State of New York," District Attorney Frank A. Sedita III said Friday morning, declining to comment on the content or nature of the conversations.
Should the tapes be made public?
"I don't have a problem with them being made public. It's not part of the criminal investigation or anything," Sedita said. "It's not mine to release or not to release."
Zack said that the decision by police to go public wasn't made in haste.
"We are not just police officers, we are parents," he said. And, as parents, they agreed that all parents should know.
"When parents send their children to school, they must have faith and trust in the institution," he said. "We felt strongly that parents would question that faith and trust, if they heard the communications we heard. Parents have a right to know what is taking place in the school, and in the classroom."
In listening to the phone calls, which are routinely monitored in jails, police came to a point when they felt the conversations were negatively impacting their ability to investigate the homicide, Zack said.
"An investigation's never over," Zack later explained, in response to a reporter's question. "The investigation doesn't end until the trial is over."
Police went to the Erie County District Attorney's Office with their concerns.
"When we played the tapes to prosecutors, they were outraged," Zack said. "It was their feeling that some of those communications would negatively impact their ability to successfully prosecute the case."
Zack said the DA's office contacted school district officials with those concerns before Jones went on trial. Then police met with the School Board earlier this month.
Two police officers are members of the School Board; Lt. Brian Gould is the board president and Officer Paul A. Nazzarett Jr. is a trustee. They are among those who voted unanimously to place the three teachers on leave while the district investigates their conduct.
There's been no contact with the board since, Zack said. "My officers on the School Board, we don't talk about it," Zack said. "It's a little bit awkward. I think it's awkward for them."
District officials haven't commented on the situation. "We are investigating," School Superintendent Dennis Kane said Thursday.
Blocked from talking about the phone conversations Thursday afternoon, police subsequently released links to Jones' Facebook page, with photos and a video open to the public, as well as a Photobucket page with photographs of him and his friends.
Another attorney representing a teacher spoke out Thursday on the police dogged pursuit.
"I don't get it," said Kevin P. Shelby. "It seems to be a witch hunt."
Shelby had sent a "cease and desist" letter to Zack, in which his client was identified as Sharon Campbell, a math and computer science teacher at the school. Shelby's letter directed copies to local media outlets as well as the school superintendent.
Contacted Thursday morning by The Buffalo News, Shelby described his client's relationship with Jones as "purely teacher-student, together with role model, parent figure. It's all appropriate," he said. Their conversations, he said, were "small talk."
If there's any action to be taken involving his client, Shelby said, "The way it should be handled is administratively."
Gilmour and Morgan said they haven't heard the taped conversations involving their client. "He's denied any wrongdoing," said Gilmour.
"The chief couldn't charge these people criminally, so he's trying these people in the public," Gilmour said. "He decided he was going to go after their jobs."
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The rising cost of an aging prison population has Kentucky looking for alternatives for sick inmates.
The state Legislature approved a pilot program that requires the state to parole some eligible inmates to private nursing homes.
House Speaker Greg Stumbo said he would like to see a facility similar to the one being opened in Georgia at the former Otter Creek Correctional Facility in Wheelright.


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|Warrior Transition Battalion
371 Brannon Road, Bldg 663
Schofield Barracks, HI 96857
Command Sergeant Major Robert A. Balatico, Warrior Transition Battalion
Command Sergeant Major Robert A. Balatico enlisted in the United States Hawaii Army National Guard in April of 1980, in Hawaii. He received his Basic Individual Training at Fort Dix, New Jersey and his Advanced Individual Training at Aberdeen Proving Grounds in Maryland as a Track and Wheeled Vehicle Repairman.
During his 33 years of service, he has held numerous leadership positions to include: Section Leader, Squad Leader, Section Chief, Platoon Sergeant, BDE S2 NCOIC, BDE S3 Operations NCOIC, First Sergeant, and Command Sergeant Major. His previous assignments include: 291st Maintenance Company (Heavy); 29th IBCT; 229th Military Intelligence Company; and 29th Brigade Special Troops Battalion.
From January 2005 until January 2006, Command Sgt. Maj. Balatico served in Iraq as the Joint Defense Operation's Sergeant Major. Upon his return to Hawaii, Command Sgt. Maj. Balatico was attached to the 196th Infantry Brigade. During his four years there, he served as the Brigade S2, Individual Replacement Training NCOIC, and the Operations Sergeant Major.
Throughout his career, Command Sgt. Maj. Balatico has continued to further his military education and training. He has completed Senior NCO Safety Orientation, Maintenance Management Leadership Course, BNCOC Track Vehicle Repairer Phase II, ANCOC Track Vehicle Repairer Phase I, ANCOC Track Vehicle Repairer Phase II, ANCOC Intelligence Analyst Course Phase II, ANCOC Intelligence Analyst Course Phase I, and First Sergeant Course. In June 2011, Command Sgt. Maj. Balatico graduated from the United States Army Sergeants Major Academy Resident Course (Class-61) at Fort Bliss, Texas and in April 2012, he completed the PRE Command Course at Fort Leavenworth, Kansas. In 2011, he received his Bachelor of Science Degree in General Studies from Excelsior College.
Command Sgt. Maj. Balatico's awards and decorations include: Bronze Star Metal, Meritorious Service Metal, Army Good Conduct Medal, Army Achievement Medal, Army Reserve Components Achievement Medal (6th award), National Defense Service Medal (2nd award), Global War on Terrorism Expeditionary Medal, Global War on Terrorism Service E Medal, Humanitarian Service Medal, Armed Forces Reserve Medal, Overseas Service Bar (2nd award), NCO Professional Development Ribbon (with numeral 4), Army Service Ribbon, Overseas Service Ribbon, Army Reserve Component Overseas Training Ribbon (4th award), and Armed Forces Reserve Medal (with M Device).
Command Sgt. Maj. Balatico has been concurrently employed with the Department of Defense at Kaneohe Marine Corps Base Hawaii since September 16, 1991.