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Most Cited Resuscitation Articles
The most cited articles published since 2011, extracted from Scopus.
Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trialIan G. Jacobs | Judith C. Finn | George A. Jelinek | Harry F. Oxer | Peter L. Thompson
Volume 82, Issue 9, September 2011, Pages 1138-1143
Background: There is little evidence from clinical trials that the use of adrenaline (epinephrine) in treating cardiac arrest improves survival, despite adrenaline being considered standard of care for many decades. The aim of our study was to determine the effect of adrenaline on patient survival to hospital discharge in out of hospital cardiac arrest. Methods: We conducted a double blind randomised placebo-controlled trial of adrenaline in out-of-hospital cardiac arrest. Identical study vials containing either adrenaline 1:1000 or placebo (sodium chloride 0.9%) were prepared. Patients were randomly allocated to receive 1. ml aliquots of the trial drug according to current advanced life support guidelines. Outcomes assessed included survival to hospital discharge (primary outcome), pre-hospital return of spontaneous circulation (ROSC) and neurological outcome (Cerebral Performance Category Score - CPC). Results: A total of 4103 cardiac arrests were screened during the study period of which 601 underwent randomisation. Documentation was available for a total of 534 patients: 262 in the placebo group and 272 in the adrenaline group. Groups were well matched for baseline characteristics including age, gender and receiving bystander CPR. ROSC occurred in 22 (8.4%) of patients receiving placebo and 64 (23.5%) who received adrenaline (OR = 3.4; 95% CI 2.0-5.6). Survival to hospital discharge occurred in 5 (1.9%) and 11 (4.0%) patients receiving placebo or adrenaline respectively (OR = 2.2; 95% CI 0.7-6.3). All but two patients (both in the adrenaline group) had a CPC score of 1-2. Conclusion: Patients receiving adrenaline during cardiac arrest had no statistically significant improvement in the primary outcome of survival to hospital discharge although there was a significantly improved likelihood of achieving ROSC. © 2011 Elsevier Ireland Ltd.
The impact of increased chest compression fraction on return of spontaneous circulation for out-of-hospital cardiac arrest patients not in ventricular fibrillationChristian Vaillancourt | Siobhan Everson-Stewart | Jim Christenson | Douglas Andrusiek | Judy Powell | Graham Nichol | Sheldon Cheskes | Tom P. Aufderheide | Robert Berg | Ian G. Stiell
Volume 82, Issue 12, December 2011, Pages 1501-1507
Objective: Greater chest compression fraction (CCF, or proportion of CPR time spent providing compressions) is associated with better survival for out-of-hospital cardiac arrest (OOHCA) patients in ventricular fibrillation (VF). We evaluated the effect of CCF on return of spontaneous circulation (ROSC) in OOHCA patients with non-VF ECG rhythms in the Resuscitation Outcomes Consortium Epistry. Methods: This prospective cohort study included OOHCA patients if: not witnessed by EMS, no automated external defibrillator (AED) shock prior to EMS arrival, received >1. min of CPR with CPR process measures available, and initial non-VF rhythm. We reviewed the first 5. min of electronic CPR records following defibrillator application, measuring the proportion of compressions/min during the resuscitation. Results: Demographics of 2103 adult patients from 10 U.S. and Canadian centers were: mean age 67.8; male 61.2%; public location 10.6%; bystander witnessed 32.9%; bystander CPR 35.4%; median interval from 911 to defibrillator turned on 8. min:27. s; initial rhythm asystole 64.0%, PEA 28.0%, other non-shockable 8.0%; median compression rate 110/min; median CCF 71%; ROSC 24.2%; survival to hospital discharge 2.0%. The estimated linear effect on adjusted odds ratio with 95% confidence interval (OR; 95%CI) of ROSC for each 10% increase in CCF was (1.05; 0.99, 1.12). Adjusted (OR; 95%CI) of ROSC for each CCF category were: 0-40% (reference group); 41-60% (1.14; 0.72, 1.81); 61-80% (1.42; 0.92, 2.20); and 81-100% (1.48; 0.94, 2.32). Conclusions: This is the first study to demonstrate that increased CCF among non-VF OOHCA patients is associated with a trend toward increased likelihood of ROSC. © 2011 Elsevier Ireland Ltd.
Quality management in resuscitation - Towards a European Cardiac Arrest Registry (EuReCa)J. T. Gräsner | J. Herlitz | R. W. Koster | F. Rosell-Ortiz | L. Stamatakis | L. Bossaert
Volume 82, Issue 8, August 2011, Pages 989-994
Background: Knowledge about the epidemiology of cardiac arrest in Europe is inadequate. Aim: To describe the first attempt to build up a Common European Registry of out-of-hospital cardiac arrest, called EuReCa. Methods: After approaching key persons in participating countries of the European Resuscitation Council, five countries or areas within countries (Belgium, Germany, Andalusia, North Holland, Sweden) agreed to participate. A standardized questionnaire including 28 items, that identified various aspects of resuscitation, was developed to explore the nature of the regional/national registries. This comprises inclusion criteria, data sources, and core data, as well as technical details of the structure of the databases. Results: The participating registers represent a population of 35 million inhabitants in Europe. During 2008, 12,446 cardiac arrests were recorded. The structure as well as the level of complexity varied markedly between the 5 regional/national registries. The incidence of attempted resuscitation ranged between registers from 17 to 53 per 100,000 inhabitants each year whilst the number of patients admitted to hospital alive ranged from 5 to 18 per 100,000 inhabitants each year. Bystander CPR varied 3-fold from 20% to 60%. Conclusion: Five countries agreed to participate in an attempt to build up a common European Registry for out-of-hospital cardiac arrest. These regional/national registries show a marked difference in terms of structure and complexity. A marked variation was found between countries in the number of reported resuscitation attempts, the number of patients brought to hospital alive, and the proportion that received bystander CPR. At present, we are unable to explain the reason for the variability but our first findings could be a 'wake-up-call' for building up a high quality registry that could provide answers to this and other key questions in relation to the management of out-of-hospital cardiac arrest. © 2011 Elsevier Ireland Ltd.
Out-of-hospital airway management in the United StatesHenry E. Wang | N. Clay Mann | Gregory Mears | Karen Jacobson | Donald M. Yealy
Volume 82, Issue 4, April 2011, Pages 378-385
Objective: Prior studies describe airway management by single EMS agencies, regions or states. We sought to characterize out-of-hospital airway management interventions, outcomes and complications across the United States. Methods: Using the 2008 National Emergency Medical Services Information System (NEMSIS) Public-Release Data Set containing data from 16 states, we identified patients receiving advanced airway management, including endotracheal intubation (ETI), alternate airways (Combitube, Laryngeal Mask Airway (LMA), King LT, Esophageal-Obturator Airway (EOA)), and cricothyroidotomy (needle and open). We examined airway management success and complications in the full cohort and in key subsets (cardiac arrest, non-arrest medical, non-arrest injury, children <10 and 10-19 years, rapid-sequence intubation (RSI), population setting and US census region). We analyzed the data using descriptive statistics. Results: Among 4,383,768 EMS activations, there were 10,356 ETI, 2246 alternate airways, and 88 cricothyroidotomies. ETI success rates were: overall 6482/8418 (77.0%; 95% CI: 76.1-77.9%), cardiac arrest 3494/4482 (78.0%), non-arrest medical 616/846 (72.8%), non-arrest injury 417/505 (82.6%), children <10 years 295/397 (74.3%), children 10-19 years 228/289 (78.9%), adult 5829/7552 (77.2%), and rapid-sequence intubation 289/355 (81.4%). ETI success was success was lowest in the South US census region. Alternate airway success was 1564/1794 (87.2%). Major complications included: bleeding 84 (7.0 per 1000 interventions), vomiting 80 (6.7 per 1000) and esophageal intubation 12 (1.0 per 1000). Conclusions: In this study characterizing out-of-hospital airway management across the United States, we observed low out-of-hospital ETI success rates. These data may guide national efforts to improve the quality of out-of-hospital airway management. © 2011 Elsevier Ireland Ltd.
The influence of induced hypothermia and delayed prognostication on the mode of death after cardiac arrestIrina Dragancea | Malin Rundgren | Elisabet Englund | Hans Friberg | Tobias Cronberg
Volume 84, Issue 3, March 2013, Pages 337-342
Background: Brain injury is considered the main cause of death in patients who are hospitalized after cardiac arrest (CA). Induced hypothermia is recommended as neuroprotective treatment after (CA) but may affect prognostic parameters. We evaluated the effect of delayed neurological prognostication on the mode of death in hypothermia-treated CA-survivors. Study design: Retrospective study at a Swedish university hospital, analyzing all in-hospital and out-of-hospital CA-patients treated with hypothermia during a 5-year period. Cause of death was categorized as brain injury, cardiac disorder or other. Multimodal neurological prognostication and decision on level of care was performed in comatose patients 72. h after rewarming. Neurological function was evaluated by Cerebral Performance Categories scale (CPC). Results: Among 162 patients, 76 survived to hospital discharge, 65 of whom had a good neurological outcome (CPC 1-2), and 11 were severely disabled (CPC 3). No patient was in vegetative state. The cause of death was classified as brain injury in 61 patients, cardiac disorder in 14 and other in 11. Four patients were declared brain dead and became organ donors. They were significantly younger (median 40 years) and with long time to ROSC. Active intensive care was withdrawn in 50 patients based on a statement of poor neurological prognosis at least 72. h after rewarming. These patients died, mainly from respiratory complications, at a median 7. days after CA. Conclusion: Following induced hypothermia and delayed neurological prognostication, brain injury remains the main cause of death after CA. Most patients with a poor prognosis statement died within 2 weeks. © 2012 Elsevier Ireland Ltd.
The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and deathGary B. Smith | David R. Prytherch | Paul Meredith | Paul E. Schmidt | Peter I. Featherstone
Volume 84, Issue 4, April 2013, Pages 465-470
Introduction: Early warning scores (EWS) are recommended as part of the early recognition and response to patient deterioration. The Royal College of Physicians recommends the use of a National Early Warning Score (NEWS) for the routine clinical assessment of all adult patients. Methods: We tested the ability of NEWS to discriminate patients at risk of cardiac arrest, unanticipated intensive care unit (ICU) admission or death within 24. h of a NEWS value and compared its performance to that of 33 other EWSs currently in use, using the area under the receiver-operating characteristic (AUROC) curve and a large vital signs database (n= 198,755 observation sets) collected from 35,585 consecutive, completed acute medical admissions. Results: The AUROCs (95% CI) for NEWS for cardiac arrest, unanticipated ICU admission, death, and any of the outcomes, all within 24. h, were 0.722 (0.685-0.759), 0.857 (0.847-0.868), 0.894 (0.887-0.902), and 0.873 (0.866-0.879), respectively. Similarly, the ranges of AUROCs (95% CI) for the other 33 EWSs were 0.611 (0.568-0.654) to 0.710 (0.675-0.745) (cardiac arrest); 0.570 (0.553-0.568) to 0.827 (0.814-0.840) (unanticipated ICU admission); 0.813 (0.802-0.824) to 0.858 (0.849-0.867) (death); and 0.736 (0.727-0.745) to 0.834 (0.826-0.842) (any outcome). Conclusions: NEWS has a greater ability to discriminate patients at risk of the combined outcome of cardiac arrest, unanticipated ICU admission or death within 24. h of a NEWS value than 33 other EWSs. © 2013 Elsevier Ireland Ltd.
Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: A systematic review and meta-analysis. Part 2: Patients treated with therapeutic hypothermiaClaudio Sandroni | Fabio Cavallaro | Clifton W. Callaway | Sonia D'Arrigo | Tommaso Sanna | Michael A. Kuiper | Matteo Biancone | Giacomo Della Marca | Alessio Farcomeni | Jerry P. Nolan
Volume 84, Issue 10, October 2013, Pages 1324-1338
Aims and methods: To systematically review the accuracy of early (≤7 days) predictors of poor outcome, defined as death or vegetative state (Cerebral Performance Categories [CPC] 4-5) or death, vegetative state or severe disability (CPC 3-5), in comatose adult survivors from cardiac arrest (CA) treated using therapeutic hypothermia (TH). Electronic databases were searched for eligible studies. Sensitivity, specificity, and false positive rates (FPR) for each predictor were calculated. Quality of evidence (QOE) was evaluated according to the GRADE guidelines. Results: 37 studies (2403 patients) were included. A bilaterally absent N20 SSEP wave during TH (4 studies; QOE: Moderate) or after rewarming (5 studies; QOE: Low), a nonreactive EEG background (3 studies; QOE: Low) after rewarming, a combination of absent pupillary light and corneal reflexes plus a motor response no better than extension (M≤ 2) (1 study; QOE: Very low) after rewarming predicted CPC 3-5 with 0% FPR and narrow (<10%) 95% confidence intervals. No consistent threshold for 0% FPR could be identified for blood levels of biomarkers. In 6/8 studies on SSEP, in 1/3 studies on EEG reactivity and in the single study on clinical examination the investigated predictor was used for decisions to withdraw treatment, causing the risk of a self-fulfilling prophecy. Conclusions: in the first 7 days after CA, a bilaterally absent N20 SSEP wave anytime, a nonreactive EEG after rewarming or a combination of absent ocular reflexes and M≤. 2 after rewarming predicted CPC 3-5 with 0% FPR and narrow 95% CIs, but with a high risk of bias. © 2013 Elsevier Ireland Ltd.
Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trialLars Wik | Jan Aage Olsen | David Persse | Fritz Sterz | Michael Lozano | Marc A. Brouwer | Mark Westfall | Chris M. Souders | Reinhard Malzer | Pierre M. Van Grunsven | David T. Travis | Anne Whitehead | Ulrich R. Herken | E. Brooke Lerner
Volume 85, Issue 6, January 2014, Pages 741-748
Objective: To compare integrated automated load distributing band CPR (iA-CPR) with high-quality manual CPR (M-CPR) to determine equivalence, superiority, or inferiority in survival to hospital discharge. Methods: Between March 5, 2009 and January 11, 2011 a randomized, unblinded, controlled group sequential trial of adult out-of-hospital cardiac arrests of presumed cardiac origin was conducted at three US and two European sites. After EMS providers initiated manual compressions patients were randomized to receive either iA-CPR or M-CPR. Patient follow-up was until all patients were discharged alive or died. The primary outcome, survival to hospital discharge, was analyzed adjusting for covariates, (age, witnessed arrest, initial cardiac rhythm, enrollment site) and interim analyses. CPR quality and protocol adherence were monitored (CPR fraction) electronically throughout the trial. Results: Of 4753 randomized patients, 522 (11.0%) met post enrollment exclusion criteria. Therefore, 2099 (49.6%) received iA-CPR and 2132 (50.4%) M-CPR. Sustained ROSC (emergency department admittance), 24. h survival and hospital discharge (unknown for 12 cases) for iA-CPR compared to M-CPR were 600 (28.6%) vs. 689 (32.3%), 456 (21.8%) vs. 532 (25.0%), 196 (9.4%) vs. 233 (11.0%) patients, respectively. The adjusted odds ratio of survival to hospital discharge for iA-CPR compared to M-CPR, was 1.06 (95% CI 0.83-1.37), meeting the criteria for equivalence. The 20. min CPR fraction was 80.4% for iA-CPR and 80.2% for M-CPR. Conclusion: Compared to high-quality M-CPR, iA-CPR resulted in statistically equivalent survival to hospital discharge. © 2014 Elsevier Ireland Ltd.
Mild therapeutic hypothermia is associated with favourable outcome in patients after cardiac arrest with non-shockable rhythmsChristoph Testori | Fritz Sterz | Wilhelm Behringer | Moritz Haugk | Thomas Uray | Andrea Zeiner | Andreas Janata | Jasmin Arrich | Michael Holzer | Heidrun Losert
Volume 82, Issue 9, September 2011, Pages 1162-1167
Aim: Mild therapeutic hypothermia (32-34 °C) improves neurological recovery and reduces the risk of death in comatose survivors of cardiac arrest when the initial rhythm is ventricular fibrillation or pulseless ventricular tachycardia. The aim of the presented study was to investigate the effect of mild therapeutic hypothermia (32-34 °C for 24. h) on neurological outcome and mortality in patients who had been successfully resuscitated from non-ventricular fibrillation cardiac arrest. Methods: In this retrospective cohort study we included cardiac arrest survivors of 18 years of age or older suffering a witnessed out-of-hospital cardiac arrest with asystole or pulseless electric activity as the first documented rhythm. Data were collected from 1992 to 2009. Main outcome measures were neurological outcome within six month and mortality after six months. Results: Three hundred and seventy-four patients were analysed. Hypothermia was induced in 135 patients. Patients who were treated with mild therapeutic hypothermia were more likely to have good neurological outcomes in comparison to patients who were not treated with hypothermia with an odds ratio of 1.84 (95% confidence interval: 1.08-3.13). In addition, the rate of mortality was significantly lower in the hypothermia group (odds ratio: 0.56; 95% confidence interval: 0.34-0.93). Conclusion: Treatment with mild therapeutic hypothermia at a temperature of 32-34 °C for 24. h is associated with improved neurological outcome and a reduced risk of death following out-of-hospital cardiac arrest with non-shockable rhythms. © 2011 Elsevier Ireland Ltd.
European Resuscitation Council Guidelines for Resuscitation 2015. Section 3. Adult advanced life support.Jasmeet Soar | Jerry P. Nolan | Bernd W. Böttiger | Gavin D. Perkins | Carsten Lott | Pierre Carli | Tommaso Pellis | Claudio Sandroni | Markus B. Skrifvars | Gary B. Smith | Kjetil Sunde | Charles D. Deakin | Rudolph W. Koster | Koenraad G. Monsieurs | Nikolaos I. Nikolaou
Volume 95, Issue , January 2015, Pages 100-147
Strong and weak aspects of an established post-resuscitation treatment protocol-A five-year observational studyØystein Tømte | Geir Øystein Andersen | Dag Jacobsen | Tomas Drægni | Bjørn Auestad | Kjetil Sunde
Volume 82, Issue 9, September 2011, Pages 1186-1193
Aim of study: Favourable hospital survival increased from 26% to 56% in the implementation phase of a new standard operating procedure (SOP) for treatment after out-of hospital cardiac arrest (OHCA) in 2003. We now evaluate protocol adherence and survival rates after five years with this established SOP. Methods: This observational study is based on prospectively collected registry data from all OHCA patients with cardiac aetiology admitted with spontaneous circulation to Ulleval Hospital between September 2003 and January 2009. Three patient categories are described based on early assessment in the emergency department: conscious, comatose, and comatose patients receiving only palliative care, with main focus on comatose patients receiving active treatment. Results: Of 248 patients, 22% were consciousness on admission, 70% were comatose and received active treatment, while 8% received only palliative care. Favourable survival from admittance to discharge remained at 56% throughout the study period. Among actively treated patients 83% received emergency coronary angiography and 48% underwent subsequent percutaneous coronary intervention. In this cohort 63% had an acute myocardial infarction, ten of whom did not receive emergency coronary angiography. Among actively treated comatose patients, 6% survived with unfavourable neurology, while 51% of the deaths followed treatment withdrawal after prognostication of severe brain injury. Conclusion: The previously reported doubling in survival rate remained throughout a five-year study period. Establishing reliable indication for emergency coronary angiography and interventions and validating prognostication rules in the hypothermia era are important challenges for future studies. © 2011 Elsevier Ireland Ltd.
Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studiesYoung Min Kim | Hyeon Woo Yim | Seung Hee Jeong | Mary Lou Klem | Clifton W. Callaway
Volume 83, Issue 2, February 2012, Pages 188-196
Background: The benefit of therapeutic hypothermia (TH) for comatose adult patients with return of spontaneous circulation after cardiac arrest (CA) with non-shockable initial rhythms is uncertain. We evaluated whether TH reduces mortality and improves neurological outcome in comatose adults resuscitated from non-shockable CA. Methods: We searched PubMed, EMBASE, CENTRAL, and BIOSIS through March 2010, to identify studies using TH after non-shockable CA. Randomized and non-randomized studies (RS and NRS) comparing survival or neurological outcome in TH and standard care or normothermia were selected. We corresponded with authors to clarify data missing from published articles. Individual and pooled statistics were calculated as risk ratios (RRs) with 95% confidence interval (CI). Both fixed- and random-effects models were used for both meta-analyses. Findings: Two RS and twelve NRS were included in the meta-analysis and separately analyzed. The pooled RR for 6-month mortality of two RS was 0.85 (95% CI 0.65-1.11). The pooled RR for in-hospital mortality for 10 NRS was 0.84 (95% CI 0.78-0.92) and for poor neurological outcome on discharge was 0.95 (95% CI 0.90-1.01) in random-effects model. In subgroup analysis for the NRS with out-of-hospital CA, the pooled RR for in-hospital mortality was 0.86 (95% CI 0.76-0.99) and for the poor neurological outcome on discharge was 0.96 (95% CI 0.90-1.02). For the prospective NRS, the pooled RR for in-hospital mortality was 0.76 (95% CI 0.65-0.89) and for the poor neurological outcome on discharge was 0.96 (95% CI 0.90-1.02). Most of studies had substantial risks of bias and overall quality of evidence was very low. Interpretation: TH is associated with reduced in-hospital mortality for adults patients resuscitated from non-shockable CA. However, most of the studies had substantial risks of bias and quality of evidence was very low. Further high quality randomized clinical trials would confirm the actual benefit of TH in this population. © 2011 Elsevier Ireland Ltd.
Good outcome in every fourth resuscitation attempt is achievable-An Utstein template report from the Stavanger regionThomas Werner Lindner | Eldar Søreide | Odd Bjarte Nilsen | Mathiesen Wenche Torunn | Hans Morten Lossius
Volume 82, Issue 12, December 2011, Pages 1508-1513
Aim of the study: Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the western world. We wanted to study changes in survival over time and factors linked to this in a region which have already reported high survival rates. Methods: We used a prospectively collected Utstein template database to identify all resuscitation attempts in adult patients with OHCA of presumed cardiac origin. We included 846 resuscitation attempts and compared survival to discharge with good outcome in two time periods (2001-2005 vs. 2006-2008). Results: We found no significant differences between the two time periods for mean age (71 and 70 years (p= 0.309)), sex distribution (males 70% and 71% (p= 0.708)), location of the OHCA (home 64% and 63% (p= 0.732)), proportion of shockable rhythms (44% and 47% (p= 0.261)) and rate of return of spontaneous circulation (38% and 43% (p= 0.136)), respectively. Bystander cardiopulmonary resuscitation (CPR), however, increased significantly from 60% to 73% (p< 0.0001), as did the overall rate of survival to discharge from 18% to 25% (p= 0.018). In patients with a shockable first rhythm, rate of survival to discharge increased significantly from 37% to 48% (p= 0.036). In witnessed arrest with shockable rhythm survival to discharge increased from 37% to 52% (p= 0.0105). Conclusion: Overall, good outcome is now achievable in every fourth resuscitation attempt and in every second resuscitation attempt when patients have a shockable rhythm. The reason for the better outcomes is most likely multi-factorial and linked to improvements in the local chain of survival. © 2011 Elsevier Ireland Ltd.
Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: A prospective observational studyTetsuya Sakamoto | Naoto Morimura | Ken Nagao | Yasufumi Asai | Hiroyuki Yokota | Satoshi Nara | Mamoru Hase | Yoshio Tahara | Takahiro Atsumi | Nobuaki Kokubu | Ken Kozuma | Reo Fukuda | Takahiro Ueda | Tadayoshi Miyagi | Isao Takahashi | Mineji Hayakawa | Tomoyuki Endo | Ryouichi Tosa | Takashi Tagami | Taro Mizutani | Susumu Yasuda | Masaki Ano | Takashi Ogino | Kazuya Kiyota | Kazuyuki Ono | Migaku Kikuchi | Hisao Matsushima | Kitamura Shinya | Shunsuke Otani | Kazuhiro Watanabe | Harumi Hirose | Katsunori Sasaki | Yasuhiro Otomo | Yutaka Seki | Makiko Osawa | Munekazu Takeda | Arino Yaguchi | Kentarou Morikawa | Yasufumi Miyake | Masamune Kuno | Katsuhisa Tanjoh | Kosaku Kinoshita | Takao Arai | Kenichirou Kumasaka | Shingo Hori | Masaru Suzuki | Manabu Sugita | Hirokazu Okubo | Jun Sasaki | Yukihiro Watoh | Kiyoshi Matsuda | Tat Suho Kobayashi | Shinji Ogura | Hiroaki Ushikoshi | Shinsuke Ojio | Minoru Maeda | Masahiko Uzura | Hiroaki Higashioka | Terutake Yonemori | Tomonori Hattori | Yoshimi Kitagawa | Shigeki Tsuboi | Hirotaka Tatsukawa | Hirotaka Sawano | Hideki Arimoto | Yasunori Ueda | Kazunori Kashiwase | Minoru Ukikusa | Toshiaki Hamasaki | Shuichi Kozawa | Nobuaki Igarashi | Junya Sato | Noboru Ishii | Akira Takahashi | Kazunari Toyama | Joji Kotani | Masaharu Ishi-hara | Takayuki Otani | Shunji Kasaoka | Makoto Suzuki | Yusuke Yamamoto | Kumpei Osaka | Masaharu Yagi | Shuichi Kobashi | Naoki Momose | Hiroyuki Noguchi | Satoshi Tamashiro | Yoshinori Taka-hashi | Osamu Okawa | Toru Matayoshi | Takahiro Miki
Volume 85, Issue 6, January 2014, Pages 762-768
Background: A favorable neurological outcome is likely to be achieved in out-of-hospital cardiac arrest (OHCA) patients with ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) on the initial electrocardiogram (ECG). However, in patients without pre-hospital restoration of spontaneous circulation despite the initial VF/VT, the outcome is extremely low by conventional cardiopulmonary resuscitation (CPR).Extracorporeal CPR (ECPR) may enhance cerebral blood flow and recovery of neurological function. We prospectively examined how ECPR for OHCA with VF/VT would affect neurological outcomes. Methods and results: The design of this trial was a prospective, observational study. We compared differences of outcome at 1 and 6 months after OHCA between ECPR group (26 hospitals) and non-ECPR group (20 hospitals). Primary endpoints were the rate of favorable outcomes defined by the Glasgow-Pittsburgh Cerebral Performance and Overall Performance Categories (CPC) 1 or 2 at 1 and 6 months after OHCA. Based on intention-to-treat analysis, CPC 1 or 2 were 12.3% (32/260) in the ECPR group and 1.5% (3/194) in the non-ECPR group at 1 month (P< 0.0001), and 11.2% (29/260) and 2.6% (5/194) at 6 months (P= 0.001), respectively. By per protocol analysis, CPC 1 or 2 were 13.7% (32/234) in the ECPR group and 1.9% (3/159) in the non-ECPR group at 1 month (P< 0.0001), and 12.4% (29/234) and 3.1% (5/159) at 6 months (P= 0.002), respectively. Conclusions: In OHCA patients with VF/VT on the initial ECG, a treatment bundle including ECPR, therapeutic hypothermia and IABP was associated with improved neurological outcome at 1 and 6 months after OHCA. © 2014 Elsevier Ireland Ltd.
A 5-year experience with cardiopulmonary resuscitation using extracorporeal life support in non-postcardiotomy patients with cardiac arrestAssad Haneya | Alois Philipp | Claudius Diez | Simon Schopka | Thomas Bein | Markus Zimmermann | Matthias Lubnow | Andreas Luchner | Ayman Agha | Michael Hilker | Stephan Hirt | Christof Schmid | Thomas Müller
Volume 83, Issue 11, November 2012, Pages 1331-1337
Background: Cardiopulmonary resuscitation (CPR) using extracorporeal life support (ECLS) system has been successfully used to support patients with in- and out-of-hospital cardiac arrest (IHCA, OHCA) when conventional measures have failed. The purpose of the current study is to report on our experience with extracorporeal CPR in non-postcardiotomy patients. Methods: We retrospectively analysed a total of 85 consecutive adult patients, who have been treated with ECLS between January 2007 and January 2012. Results: The mean CPR duration was 40. min (20-70. min). The mean ECLS support duration was 49. h (12-92. h). Twenty-eight patients (33%) had ECLS related complications. Forty patients (47%) were successfully weaned and 29 patients (34%) survived to hospital discharge. Among survivors, 93% were without severe neurologic deficit. Duration of CPR was shorter for survivors than for non-survivors [(25: 20-50. min) vs. (50: 25-86. min); p=0.003]. Immediately after ECLS start, the mean blood lactate level was lower (p=0.003), and the mean pH value was higher in the survivors' group (p<0.0001) compared to the non-survivors' group. The CPR duration for the IHCA group (25: 20-50. min) was shorter compared to the OHCA group (70: 55-110. min; p<0.0001). The survival rate in this group was higher compared to the OHCA group (42% vs. 15%; p<0.02). Conclusions: CPR using modern miniaturized ECLS systems should be established in the treatment of prolonged cardiac arrest and unsuccessful conventional CPR in selected patients. CPR with ECLS for OHCA has worse outcomes compared to IHCA. Duration of CPR was independent risk factor for mortality after extracorporeal CPR. © 2012 Elsevier Ireland Ltd.
The role of hypothermia in post-cardiac arrest patients with return of spontaneous circulation: A systematic reviewJames H. Walters | Peter T. Morley | Jerry P. Nolan
Volume 82, Issue 5, May 2011, Pages 508-516
Objectives: To update a comprehensive systematic review of the use of therapeutic hypothermia after cardiac arrest that was undertaken initially as part of the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. The specific question addressed was: 'in post-cardiac arrest patients with a return of spontaneous circulation, does the induction of mild hypothermia improve morbidity or mortality when compared with usual care?'. Methods: Pubmed was searched using (" heart arrest" or " cardiopulmonary resuscitation" ) AND " hypothermia, induced" using 'Clinical Queries' search strategy; EmBASE was searched using (heart arrest) OR (cardiopulmonary resuscitation) AND hypothermia; The Cochrane database of systematic reviews; ECC EndNote Library for " hypothermia" in abstract OR title. Excluded were animal studies, reviews and editorials, surveys of implementation, analytical models, reports of single cases, pre-arrest or during arrest cooling and group where the intervention was not hypothermia alone. Results: 77 studies met the criteria for further review. Of these, four were meta-analyses (LOE 1); seven were randomised controlled trials (LOE 1), although six of these were from the same set of patients; nine were non-randomised, concurrent controls (LOE 2); 15 were trials with retrospective controls (LOE 3); 40 had no controls (LOE 4); and one was extrapolated from a non-cardiac arrest group (LOE 5). Conclusion: There is evidence supporting the use of mild therapeutic hypothermia to improve neurological outcome in patients who remain comatose following the return of spontaneous circulation after a cardiac arrest; however, much of the evidence is from low-level, observational studies. Of seven randomised controlled trials, six use data from the same patients. © 2011 Elsevier Ireland Ltd.
European Resuscitation Council Guidelines for Resuscitation 2015. Section 2. Adult basic life support and automated external defibrillation.Gavin D. Perkins | Anthony J. Handley | Rudolph W. Koster | Maaret Castrén | Michael A. Smyth | Theresa Olasveengen | Koenraad G. Monsieurs | Violetta Raffay | Jan Thorsten Gräsner | Volker Wenzel | Giuseppe Ristagno | Jasmeet Soar | Leo L. Bossaert | Antonio Caballero | Pascal Cassan | Cristina Granja | Claudio Sandroni | David A. Zideman | Jerry P. Nolan | Ian Maconochie | Robert Greif
Volume 95, Issue , January 2015, Pages 81-99
Endotracheal intubation versus supraglottic airway insertion in out-of-hospital cardiac arrestHenry E. Wang | Daniel Szydlo | John A. Stouffer | Steve Lin | Jestin N. Carlson | Christian Vaillancourt | Gena Sears | Richard P. Verbeek | Raymond Fowler | Ahamed H. Idris | Karl Koenig | James Christenson | Anushirvan Minokadeh | Joseph Brandt | Thomas Rea
Volume 83, Issue 9, September 2012, Pages 1061-1066
Objective: To simplify airway management and minimize cardiopulmonary resuscitation (CPR) chest compression interruptions, some emergency medical services (EMS) practitioners utilize supraglottic airway (SGA) devices instead of endotracheal intubation (ETI) as the primary airway adjunct in out-of-hospital cardiac arrest (OHCA). We compared the outcomes of patients receiving ETI with those receiving SGA following OHCA. Methods: We performed a secondary analysis of data from the multicenter Resuscitation Outcomes Consortium (ROC) PRIMED trial. We studied adult non-traumatic OHCA receiving successful SGA insertion (King Laryngeal Tube, Combitube, and Laryngeal Mask Airway) or successful ETI. The primary outcome was survival to hospital discharge with satisfactory functional status (Modified Rankin Scale ≤3). Secondary outcomes included return of spontaneous circulation (ROSC), 24-h survival, major airway or pulmonary complications (pulmonary edema, internal thoracic or abdominal injuries, acute lung injury, sepsis, and pneumonia). Using multivariable logistic regression, we studied the association between out-of-hospital airway management method (ETI vs. SGA) and OHCA outcomes, adjusting for confounders. Results: Of 10,455 adult OHCA, 8487 (81.2%) received ETI and 1968 (18.8%) received SGA. Survival to hospital discharge with satisfactory functional status was: ETI 4.7%, SGA 3.9%. Compared with successful SGA, successful ETI was associated with increased survival to hospital discharge (adjusted OR 1.40; 95% CI: 1.04, 1.89), ROSC (adjusted OR 1.78; 95% CI: 1.54, 2.04) and 24-h survival (adjusted OR 1.74; 95% CI: 1.49, 2.04). ETI was not associated with secondary airway or pulmonary complications (adjusted OR 0.84; 95% CI: 0.61, 1.16). Conclusions: In this secondary analysis of data from the multicenter ROC PRIMED trial, ETI was associated with improved outcomes over SGA insertion after OHCA. © 2012 Elsevier Ireland Ltd.
Therapeutic hypothermia is associated with improved neurologic outcome and survival in cardiac arrest survivors of non-shockable rhythmsJustin B. Lundbye | Mridula Rai | Bhavadharini Ramu | Alireza Hosseini-Khalili | Dadong Li | Hanna B. Slim | Sanjeev P. Bhavnani | Sanjeev U. Nair | Jeffrey Kluger
Volume 83, Issue 2, February 2012, Pages 202-207
Background: Therapeutic hypothermia improves neurologic outcomes in patients resuscitated from cardiac arrest due to ventricular fibrillation. However, its role in patients with cardiac arrest due to non-shockable rhythms (pulseless electrical activity (PEA) and asystole) is unclear. We hypothesized that therapeutic hypothermia favorably impacts neurologic outcome and survival in patients resuscitated from cardiac arrest due to non-shockable rhythms. Methods: Retrospectively collected data on consecutive adult patients admitted to Hartford Hospital from 1/1/2004 to 11/1/2010 who survived a cardiac arrest due to PEA or asystole were analyzed. Patients who underwent therapeutic hypothermia (1/1/2007-11/1/2010) formed the hypothermia group while patients admitted prior to the institution of therapeutic hypothermia (1/1/2004-1/1/2007) at Hartford Hospital formed the control group. The primary end-point was measured using the Pittsburgh cerebral performance category (CPC) scale and patients were assessed for a good (CPC 1 and 2) or poor (CPC 3-5) neurological outcome prior to discharge from hospital. A secondary end-point was measured as survival at discharge from hospital. Results: Of 100 post-cardiac arrest patients included in the study, 15/52 (29%) patients in the hypothermia group had a good neurologic outcome as compared to 5/43 (10%) patients in the control group (P=0.021). On multivariate analysis, the odds ratio for good neurologic outcome and survival at discharge from the hospital with therapeutic hypothermia as compared to control were 4.35 (95% CI 1.10-17.24, P=0.04) and 5.65 (CI 1.66-19.23, P=0.006) respectively. Conclusion: Therapeutic hypothermia is associated with favorable neurologic outcome and survival in patients resuscitated after cardiac arrest due to non-shockable rhythms. © 2011 Elsevier Ireland Ltd.
Documenting Rapid Response System afferent limb failure and associated patient outcomesRebecca M. Trinkle | Arthas Flabouris
Volume 82, Issue 7, July 2011, Pages 810-814
Objective: Describe afferent limb failure (ALF), defined as documented Rapid Response System (RRS) calling criteria, but no associated call, in the 24. h prior to an event. Methods: Retrospective medical record and database review. Adult in-patients whose hospital length of stay (LOS) was greater than 24. h, an event being a cardiac arrest, Medical Emergency Team (MET) call or unanticipated Intensive Care Unit (ICU) admission. Results: Over 6 months, there were 443 patients with 575 events, of which 35 (6.1%) were cardiac arrests, 395 (68.7%) MET calls, and 145 (25.2%) ICU admissions. 131 (22.8%) events had documented ALF, of which 47/131 (35.9%) had documented criteria across more than one time period. Patients with ALF, compared to those without ALF, were significantly more likely to have an unanticipated ICU admission (45/131 (34.4%) vs 100/443 (22.5%), p= 0.01), but be of similar age (71 years vs 72 years, p= 0.44), male gender (51.1% vs 53.2%, p= 0.38), APACHE 2 score (22.8 vs 21.4, p= 0.67), predicted risk of death (0.394 vs 0.367, p= 0.55), ICU LOS (2 days vs 2 days, p= 0.56), likelihood of not-for-resuscitation order during an event (4/131 (3.4%) vs 22/444 (5.0%), p= 0.34), and hospital mortality (42/107 (39.3%) vs 125/236 (37.2%), p= 0.70). Hospital mortality for patients with ALF across multiple, compared to single time periods was higher, 21/40 (52.5%) vs 22/69 (31.9%), p= 0.03. Conclusions: RRS ALF is a useful performance measure for a mature RRS, and is associated with unanticipated ICU admissions. The duration of, and not timing of, ALF criterion occurrence may affect hospital mortality. © 2011 Elsevier Ireland Ltd.
Neurological prognostication after cardiac arrest-Recommendations from the Swedish Resuscitation CouncilTobias Cronberg | Marco Brizzi | Lars Johan Liedholm | Ingmar Rosén | Sten Rubertsson | Christian Rylander | Hans Friberg
Volume 84, Issue 7, July 2013, Pages 867-872
Cardiopulmonary resuscitation is started in 5000 victims of out-of-hospital cardiac arrest in Sweden each year and the survival rate is approximately 10%. The subsequent development of a global ischaemic brain injury is the major determinant of the neurological prognosis for those patients who reach the hospital alive. Induced hypothermia is a recommended treatment after cardiac arrest and has been implemented in most Swedish hospitals.Recent studies indicate that induced hypothermia may affect neurological prognostication and previous international recommendations are therefore no longer valid when hypothermia is applied. An expert group from the Swedish Resuscitation Council has reviewed the literature and made recommendations taking into account the effects of induced hypothermia and concomitant sedation.A delayed neurological evaluation at 72. h after rewarming is recommended for hypothermia treated patients. This evaluation should be based on several independent methods and the possibility of lingering pharmacological effects should be considered. © 2013 Elsevier Ireland Ltd.
Chest compression depth and survival in out-of-hospital cardiac arrestTyler Vadeboncoeur | Uwe Stolz | Ashish Panchal | Annemarie Silver | Mark Venuti | John Tobin | Gary Smith | Martha Nunez | Madalyn Karamooz | Daniel Spaite | Bentley Bobrow
Volume 85, Issue 2, February 2014, Pages 182-188
Aim: Outcomes from out-of-hospital cardiac arrest (OHCA) may improve if rescuers perform chest compressions (CCs) deeper than the previous recommendation of 38-51. mm and consistent with the 2010 AHA Guideline recommendation of at least 51. mm. The aim of this study was to assess the relationship between CC depth and OHCA survival. Methods: Prospective analysis of CC depth and outcomes in consecutive adult OHCA of presumed cardiac etiology from two EMS agencies participating in comprehensive CPR quality improvement initiatives. Analysis: Multivariable logistic regression to calculate adjusted odds ratios (aORs) for survival to hospital discharge and favorable functional outcome. Results: Among 593 OHCAs, 136 patients (22.9%) achieved return of spontaneous circulation, 63 patients (10.6%) survived and 50 had favorable functional outcome (8.4%). Mean CC depth was 49.8±11.0mm and mean CC rate was 113.9±18.1CCmin-1. Mean depth was significantly deeper in survivors (53.6mm, 95% CI: 50.5-56.7) than non-survivors (48.8mm, 95% CI: 47.6-50.0). Each 5mm increase in mean CC depth significantly increased the odds of survival and survival with favorable functional outcome: aORs were 1.29 (95% CI 1.00-1.65) and 1.30 (95% CI 1.00-1.70) respectively. Conclusion: Deeper chest compressions were associated with improved survival and functional outcome following OHCA. Our results suggest that adhering to the 2010 AHA Guideline-recommended depth of at least 51. mm could improve outcomes for victims of OHCA. © 2013 Elsevier Ireland Ltd.
An early, novel illness severity score to predict outcome after cardiac arrestJon C. Rittenberger | Samuel A. Tisherman | Margo B. Holm | Francis X. Guyette | Clifton W. Callaway
Volume 82, Issue 11, November 2011, Pages 1399-1404
Background: Illness severity scores are commonly employed in critically ill patients to predict outcome. To date, prior scores for post-cardiac arrest patients rely on some event-related data. We developed an early, novel post-arrest illness severity score to predict survival, good outcome and development of multiple organ failure (MOF) after cardiac arrest. Methods: Retrospective review of data from adults treated after in-hospital or out-of-hospital cardiac arrest in a single tertiary care facility between 1/1/2005 and 12/31/2009. In addition to clinical data, initial illness severity was measured using serial organ function assessment (SOFA) scores and full outline of unresponsiveness (FOUR) scores at hospital or intensive care unit arrival. Outcomes were hospital mortality, good outcome (discharge to home or rehabilitation) and development of multiple organ failure (MOF). Single-variable logistic regression followed by Chi-squared automatic interaction detector (CHAID) was used to determine predictors of outcome. Stepwise multivariate logistic regression was used to determine the independent association between predictors and each outcome. The Hosmer-Lemeshow test was used to evaluate goodness of fit. The n-fold method was used to cross-validate each CHAID analysis and the difference between the misclassification risk estimates was used to determine model fit. Results: Complete data from 457/495 (92%) subjects identified distinct categories of illness severity using combined FOUR motor and brainstem subscales, and combined SOFA cardiovascular and respiratory subscales: I. Awake; II. Moderate coma without cardiorespiratory failure; III. Moderate coma with cardiorespiratory failure; and IV. Severe coma. Survival was independently associated with category (I: OR 58.65; 95% CI 27.78, 123.82; II: OR 14.60; 95% CI 7.34, 29.02; III: OR 10.58; 95% CI 4.86, 23.00). Category was also similarly associated with good outcome and development of MOF. The proportion of subjects in each category changed over time. Conclusions: Initial illness severity explains much of the variation in cardiac arrest outcome. This model provides prognostic information at hospital arrival and may be used to stratify patients in future studies. © 2011 Elsevier Ireland Ltd.
The frequency and timing of epileptiform activity on continuous electroencephalogram in comatose post-cardiac arrest syndrome patients treated with therapeutic hypothermiaRam Mani | Sarah E. Schmitt | Maryann Mazer | Mary E. Putt | David F. Gaieski
Volume 83, Issue 7, July 2012, Pages 840-847
Aim: The incidence and timing of electrographic seizures and epileptiform activity in comatose, adult, post-cardiac arrest syndrome (PCAS) patients treated with therapeutic hypothermia (TH) have not been extensively investigated. We hypothesized that onset most frequently occurs within the first 24. h post-arrest and is associated with poor neurologic outcome. Methods: Single-center, retrospective analysis of a cohort of 38 comatose PCAS patients treated with TH and continuous-EEG-monitoring (cEEG), initiated as soon as possible after ICU admission. All raw cEEG waveform records were cleared of annotations and clinical information and classified by two fellowship-trained electroencephalographers. Results: Twenty-three percent (9/38) of patients had electrographic seizures (median onset 19. h post-arrest); 5/9 (56%) had seizure-onset prior to rewarming; 7/9 (78%) had status epilepticus. Forty-five percent (17/38) had evidence of epileptiform activity (electrographic seizures or interictal epileptiform discharges), typically occurring during first 24. h post-arrest. Interictal epileptiform activity was highly associated with later detection of electrographic seizures (6/14, 43%, . p=. 0.001). Ninety-four percent (16/17) of patients with epileptiform activity had poor neurologic outcome or death at discharge (Cerebral Performance Category scale 3-5; . p=. 0.002) as did all (9/9) patients with electrographic seizures (. p=. 0.034). Conclusions: Electrographic seizures and epileptiform activity are common cEEG findings in comatose, PCAS patients treated with TH. In this preliminary study, most seizures were status epilepticus, had onset prior to rewarming, evolved from prior interictal epileptiform activity, and were associated with short-term mortality and poor neurologic outcome. Larger, prospective studies are needed to further characterize seizure activity in comatose post-arrest patients. © 2012 Elsevier Ireland Ltd.
Prognostication in comatose survivors of cardiac arrest: An advisory statement from the european resuscitation council and the european society of intensive care medicineClaudio Sandroni | Alain Cariou | Fabio Cavallaro | Tobias Cronberg | Hans Friberg | Cornelia Hoedemaekers | Janneke Horn | Jerry P. Nolan | Andrea O. Rossetti | Jasmeet Soar
Volume 85, Issue 12, January 2014, Pages 1779-1789
© 2014 The Authors.Objectives: To review and update the evidence on predictors of poor outcome (death, persistent vegetative state or severe neurological disability) in adult comatose survivors of cardiac arrest, either treated or not treated with controlled temperature, to identify knowledge gaps and to suggest a reliable prognostication strategy. Methods: GRADE-based systematic review followed by expert consensus achieved using Web-based Delphi methodology, conference calls and face-to-face meetings. Predictors based on clinical examination, electrophysiology, biomarkers and imaging were included. Results and conclusions: Evidence from a total of 73 studies was reviewed. The quality of evidence was low or very low for almost all studies. In patients who are comatose with absent or extensor motor response at ≥72. h from arrest, either treated or not treated with controlled temperature, bilateral absence of either pupillary and corneal reflexes or N20 wave of short-latency somatosensory evoked potentials were identified as the most robust predictors. Early status myoclonus, elevated values of neuron specific enolase at 48-72. h from arrest, unreactive malignant EEG patterns after rewarming, and presence of diffuse signs of postanoxic injury on either computed tomography or magnetic resonance imaging were identified as useful but less robust predictors. Prolonged observation and repeated assessments should be considered when results of initial assessment are inconclusive. Although no specific combination of predictors is sufficiently supported by available evidence, a multimodal prognostication approach is recommended in all patients.


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zie.nl: England: US should not act as Air Force for S...
General David Petraeus said that the U.S should be careful not to act as the Air Force for Shia grou
zie.nl: Ex-chef CIA schikt met aanklagers
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De Amerikaanse generaal David Petraeus is de nieuwe directeur van de CIA. Petraeus voerde eerder het
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Former four-star US General David Petraeus said that the rise of ISIL in Iraq was forseen by people
blinkx video: One on one with General David Petraeus
Oct. 1: In an extended interview with NBC's Brian Williams as part of the Atlantic magazine's "First Draft of History" conference, U.S. Commander Gen. David Petraeus, discussed... - 10.01.2009, MSNBC
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NBC's David Gregory has the first interview with Gen. David Petraeus since he took command of the war in Afghanistan. He joins Hardball live from Kabul, Afghanistan, with a... - 08.12.2010, MSNBC
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Scion tC Repair and Maintenance
A guide to problems, costs, maintenance and repair for your Scion tC
Verified by mechanics, reported by drivers like you
Ask a mechanic in our community
Never overpay. Check prices with our estimator
Our experts translate recalls into plain English
Scion tC ProblemsCheck Engine Light Due to Defective VVT-i Controller
An illuminated Check Engine Light could be caused by a defective VVT-i controller, which changes cam timing for optimal power. Updated parts are available and the repair may be covered under the powertrain warranty.
Check Engine Light Illuminated
Problem: Diagnostic Showed Error Code 420: "Catalytic Converter Efficiency Below Threshold (Bank 1)
Solution: Free Replacement by Dealer Under California 7yr/70k or Federal 8yr/80k Warranty Covering Emissions Parts
Some vehicles may develop a condition where they cannot be shifted from "Park" to "Drive" and/or multiple warning lights illuminate when exposed to extreme cold conditions (-14 degrees F) or lower. Our technicians tell us the ignition (IG) relay should be replaced with an updated part to correct this concern.
Scion tC QuestionsWill adding a cold air intake affect my warrenty? (1 answer)
I want to enhance the performance of my vehicle. I am currently under a 3 yr warranty. Would swapping my stock intake with a after market intake void my warranty?
Scion has been discontinued now. Does this mean they wont be supporting the car anymore? What happens once my warrenty runs out?
My car rollsback a lot worse than any other automatic car i've seen. It's like it's a manual. How do I help prevent this?
Scion tC RecallsLoad Rating Label Inaccurate After Accessory Installation
The vehicle certification label may have the incorrect load carrying capacity listed on it. Toyota will provide owners with a corrected label, and dealers will aid in installation if necessary free of charge to resolve the concern.
The vehicle certification label may indicate the improper load carrying capacity rating for the vehicle. This is because accessories were added to them after the vehicle was built, changing the available load that the vehicle can handle carrying. Vehicle owners will be provided a corrected label and dealers will aid in installing them free of charge to resolve the concern.
Specific parts of the rear suspension may not have been torqued properly when installing the rear coil springs. As a result, the rear suspension arms may detach, increasing risk of a crash. The dealership will replace the bolts, nuts, rear suspension arms and rear suspension member sub-assembly free of charge to resolve the concern.


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Shangri La Hotel At The Shard London - London
You will be spoilt for choice in terms of dining at this hotel as there are 2 restaurants serving breakfast, lunch and dinner where you will find great menu choices and a nice spot to eat during the day. If you want low-key dining options, you will be pleased to find a snack bar/deli and 24-hour room service. Relax in the indoor pool during your stay. The bar/lounge is a perfect place to have a drink.
Leisure facilities on offer include the 24-hour fitness and spa services. Free WiFi is provided.
Shangri La Hotel At The Shard London - London
Hotel Info: 1-877-214-4288from $410
- Premier Room, 2 Single Beds, City View
- Premier Shard Suite
- Room, City View (Iconic)
- Deluxe Room, City View
- Premier Shard, King room
- Premier Room, 1 King Bed, City View
- Iconic Shard Suite
- Superior Room (Shard)
- Virtual Signature Suite (London or Westminster Suite)
Also popular with travelers from the USA
At a glance
Key facts
Hotel size
- This hotel has 202 rooms
- This hotel is arranged over 19 floors
- Check-in time starts at 3 PM
- Check-out time is noon
- Express check-in/out
Required at check in
- Credit card or cash deposit required
- Government-issued photo ID required
Travelling with others
- No cribs (infant beds)
- Babysitting/childcare *
- Pets not allowed (service dogs only)
- Free WiFi in public areas
- Free WiFi and wired Internet access in rooms
- Airport shuttle (available on request) *
- Valet parking *
Other information
- Smoke-free property
In the hotel
- Buffet breakfast daily (surcharge)
- 2 restaurants
- Bar/lounge
- Coffee shop/café
- Snack bar/deli
- 24-hour room service
- Coffee/tea in a common area
- Indoor pool
- 24-hour fitness facilities
- Spa services on site
- Number of meeting rooms - 3
- Conference space
- Meeting rooms 3
- Conference space size (feet) - 2335
- Conference space size (meters) - 217
- 24-hour front desk
- Concierge services
- Tours/ticket assistance
- Dry cleaning/laundry service
- Laundry facilities
- Free newspapers in lobby
- Wedding services
- Multilingual staff
- Porter/bellhop
- Elevator/lift
- Safe-deposit box at front desk
- Terrace
- Accessible bathroom
- In-room accessibility
- Roll-in shower
In the room
- In-room climate control (air conditioning)
- Air conditioning
- Minibar
- Coffee/tea maker
- Bathrobes
- Slippers
- Iron/ironing board
- Pillow menu
- Blackout drapes/curtains
- Turndown service
- Frette Italian sheets
- In-room massage available
- Private bathroom
- Separate bathtub and shower
- Bidet
- Designer toiletries
- Hair dryer
- 40-inch LED TV
- Pay movies
- Digital TV channels
- IPod docking station
- Desk
- Free newspaper
- Free WiFi
- Phone
- Daily housekeeping
- In-room safe
Special features
DiningLang - This coffee shop specializes in British cuisine and serves breakfast, lunch, dinner, and light fare.
Gong - Overlooking the pool, this cocktail bar serves light fare only.
Ting Lounge - This restaurant specializes in Asian cuisine and serves breakfast, lunch, dinner, and light fare. A children's menu is available.
Ting Restaurant - This restaurant specializes in British cuisine and serves breakfast, lunch, and dinner. A children's menu is available.
Awards and affiliations
- Shangri La Hotel At The Shard London is listed in the 2015 Condé Nast Traveler Hot List.
Shangri La Hotel At The Shard London - London's small print
Also known as
- Hotel London Shard
- Shard London Shangri Hotel
- Shangri-La Hotel, At The Shard, London England
- Shangri Hotel Shard London
- Shangri Hotel Shard
- Hotel Shard
- London Hotel Shard
- Shangri Hotel London
- Shangri London
- Shard Hotel London
- Shard Hotel Shangri
- Shard London Hotel
For transfers, guests must contact the property before arrival at the number on the booking confirmation.
Reservations are required for massage services and spa treatments and can be made by contacting the property before arrival at the number on the booking confirmation.
Optional extras
Self parking costs GBP 50.00 per night
Valet parking costs GBP 50.00 per night
Buffet breakfast is offered for an extra charge of GBP 36 for adults and GBP 18 for children (approximately)
Babysitting/childcare is available for an extra charge
Airport shuttle service is offered for an extra charge of GBP 155.00 per vehicle (one way)
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.


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Flights to Oulu from Prague
Flights to Oulu from Prague
Flights Prague - Oulu fly from Prague to Oulu at the best prices in the market. Flights from Prague (Prague-Václav Havel) to Oulu (Oulu) with Destinia. To search for availability and reserve your flight Prague - Oulu look at the box above and select the departure and return date as desired. You can also buy several airplane tickets Prague (Prague-Václav Havel airport) - Oulu (Oulu airport) at the same time, by selecting the adults, children and babies travelling. You can filter the type of flight if you only want direct flights to Prague - Oulu, multiple destinations or flight stopovers.
Prague and Oulu are 1779 kilometres away from each other, with an estimated flight time of 02:32 h (this may vary depending on the weather or air routes)
Airports near Oulu
Oulu has one airport: Oulu (OUL), located 11 km away from the city centre. The hotels in Oulu closest to its airport are:
- Airport Oulu (OUL) from €45€
All Oulu airports
Top destinations in Finland
Book your flights now from Oulu (Finland) to the most important cities in the world. The box below contains flights from Oulu (Finland) to the most important cities.
- Flights to Kittila
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- Flights to Kuusamo


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Like the intricate cosmological model that lends its name, Orrery is redolent with attention to detail and elegance. Head Chef Igor Tymchyshyn, previously of Michelin-starred Mirabelle, has created seasonally changing menus of exceptional quality and full of the tastes of France. Signature dishes include: Escalope of red wine poached duck foie gras, pear riesling jelly; Pied de cochon farci, pommes mousseline Madeira and truffle; Kentish fillet of lamb, beetroot puree, gratin dauphinois, olive lamb jus; Pannacotta, orange and Champagne terrine, fennel essence.
This content has been supplied by Orrery
Venue Details & Map
- Address
55 Marylebone High StreetLondonW1U 5RB
- Public transport:
- Tube: Baker Street
- Accessible Bathroom Facilities
- Designated wheelchair accessible public toilet
- Access into the Building
- Flat routes from parking area to entrance
- Booking Facilities
- Group bookings accepted
- Catering Facilities
- Set price menu
- Event Facilities
- Available for wedding receptions
- Event facilities
- Licenced for civil marriages
- General Facilities
- Good views
- Payment Facilities
- Credit cards accepted
- Debit cards accepted
Really miss this place being on our corner. They do a great set menu - delicious food (and cheese plate at the end!) for great value. They also have an excellent wine list. Good service, fun location above the Conran, intimate bar for a drink before or after your meal. We were so disappointed to not have the chance to go back here before moving out of London.more
This might just become our birthday ritual after Hugo's in Portland, ME, which seemed unbeatable.
Simple french cuisine done amazingly. The three course Menu Du Jour seemed never ending with additional little treats; amuse bouche, bread, and chocolate! Highlight of the dinner were confit of chicken and duck terrine, poussin, and passion fruit tart!more
What is whong with the Michelin inspectors ?
This place is worth easilly a two star, from the amuse-bouche to the deserts, the menu was truely excellent.
Beautiful tables, crockery and cutlery set well chosen, all pleaseing to the eye.
Now if you want to be accurate, the service, although very efficient and well orchastrated, was cold and impersonal. This was a clear let down where the...more
I came here on a lunch date dining on the Evening Standard. From when we entered the restaurant to when we left the service was spectacular. There were so many different types of servers I can't even tell the difference in their roles - there were almost more servers to diners in the restaurant on this Thursday afternoon!
We had the 3 courses for £30. You'd think Orrery would 'downgrade'...more
A group of us enjoyed a spot of french cuisine here as part of the London Restaurant Festival. Some dishes were excellent, delicious and delicate the roasted cod and caramelized onion and goat's cheese tart were especially well received. Other plates were a little more mystifying, like the oddly presented and very mild salmon mousse.
However, the final course was a triumph. We agreed the...more


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Hannah Kopydlowski
GW Women's Swimming & Diving Downs Rider on Saturday
Colonials Dominate in Home Opener
GW Swim & Dive Lands Three on A-10 All-Academic Team
Fitch, Kopydlowski and Steagall Earn Postseason Academic Award
GW Athletics Honors Exemplary Commitment to Academics in Dean's List Ceremony
Professor Richard Zamoff of the Sociology Department is Student-Athletes' Choice for Professor of the Year
GW Women's Swim & Dive Sets Two More Records
Colonials Continue Strong Start to A-10 Championships
GW Swimming and Diving Holds Team Awards Banquet
Alumni Join in Celebrating 2014-15 Achievements
2015-16: 2016 Atlantic 10 Academic All-Conference Team member... Finished fifth as the third leg in the 200-yard freestyle relay with a school-recording breaking time of 1:33.82 at the A-10 Championships...Swam season-best times in the 50-yard freestyle (23.90) and the 100-yard backstroke (58.08) at the 2016 Atlantic 10 Championships (Feb. 20)... Posted three season-fastest times at the Magnus Cup Invitational (Nov. 20) in the 200-yard freestyle (1:55.95), the 50-yard backstroke (27.43) and the 50-yard breaststroke (30.63)...Touched the wall in a career-best time of 2:16.06 in the 200-yard individual medley at Howard (Oct. 17)... Member of Fall 2015 Atlantic 10 Commissioner's Honor Roll... Named to the GW Athletics Academic Dean's List.
2014-15: Swam season-best time of 23.90 in the 50-yd freestyle at the 2015 Atlantic 10 Championships (Feb. 19), good for third on GW's all-time list...Posted season-fastest times in the 100-yd free (52.30) and 100-yd backstroke (58.66) at the A-10 Championships (Feb. 20-21)...Touched the wall in a career-best time of 1:58.58 in the 200-yd free at the American-Catholic-Loyola Quad meet (Oct. 11)...Finished the 100-yd breast in a season-best 1:11.16 against Howard (Jan. 23)...Named to GW Athletics Department Academic Dean's List...Member of Fall 2014 Atlantic 10 Commissioner's Honor Roll.
High School: Ten-time Michigan All-State selection from Powers Catholic...Won 2012 Michigan State Championship in 50 free and took home 2013 state title in 100 back...Named 2013 Michigan High School Athletic Association Division 3 Swimmer of the Year...Two-time Flint Journal Swimmer of the Year (2012-13)...Owns seven Powers Catholic school records...Tabbed 2013 Academic All-State and NISCA Academic All-American...Also swam for Liquid Lightning and Aqua Club...Member of National Honors Society and Rotary Interact Club.
Personal: Born Hannah Kopydlowski on July 3, 1995 in Flint, MI...Daughter of Lydia and Jim Kopydlowski...Has two older brothers, Nate, who played football for Kalamazoo College, and Tyler, who played football for Trine University...Intends to major in biology at GW.


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Mercure Royal Fontainebleau - Fontainebleau
Free self parking, dry cleaning/laundry and an elevator (lift) are offered at this hotel. The bar/lounge is a perfect place to have a drink. Make the most of your trip, whether for business or pleasure, by taking some time to relax as you will find an outdoor tennis court on offer.
Multilingual staff at the 24-hour front desk can provide express check-in and express check-out. Free WiFi is provided.
Mercure Royal Fontainebleau - Fontainebleau
Hotel Info: 1-877-214-4288from $104
- Standard Room, 1 Double Bed
- Standard Twin Room, 2 Single Beds
Also popular with travelers from the USA
At a glance
Key facts
Hotel size
- This hotel has 97 rooms
- This hotel is arranged over 4 floors
- 24-hour check-in
- Check-out time is noon
- Express check-in/out
Required at check in
- Credit card or cash deposit required
- Government-issued photo ID required
- Minimum check-in age is 18
Travelling with others
- No cribs (infant beds)
- Pets allowed *
- Free WiFi in public areas
- Free WiFi in rooms
- Free self parking
Other information
- Smoke-free property
In the hotel
- Buffet breakfast daily (surcharge)
- Bar/lounge
- Snack bar/deli
- Room service (during limited hours)
- Outdoor tennis court
- Bicycle rentals nearby
- Golfing nearby
- Hiking/biking trails nearby
- Business center
- Number of meeting rooms - 2
- Meeting rooms 2
- Conference space size (feet) - 829
- Conference space size (meters) - 77
- Computer station
- 24-hour front desk
- Dry cleaning/laundry service
- Laundry facilities
- Free newspapers in lobby
- Luggage storage
- Multilingual staff
- Number of buildings/towers - 1
- Elevator/lift
- Garden
- Terrace
- Fireplace in lobby
- Accessible bathroom
- In-room accessibility
In the room
- Air conditioning
- Coffee/tea maker
- Iron/ironing board (on request)
- Blackout drapes/curtains
- Private bathroom
- Bathtub only
- Hair dryer
- 42-inch flat-screen TV
- Satellite TV channels
- Desk
- Free weekday newspaper
- Free WiFi
- Phone
- Free bottled water
- In-room safe
- Connecting/adjoining rooms available
Special features
DiningBar Lounge Le 41 - This lobby lounge specializes in French cuisine and serves breakfast, lunch, and dinner. Open daily.
Mercure Royal Fontainebleau - Fontainebleau's small print
Also known as
- Fontainebleau Mercure
- Mercure Royal Fontainebleau Hotel
- Mercure Fontainebleau
- Mercure Fontainebleau Royal
- Mercure Royal
- Mercure Royal Fontainebleau
- Mercure Royal Hotel
- Mercure Royal Hotel Fontainebleau
- Royal Mercure
- Royal Mercure Fontainebleau
The property has connecting/adjoining rooms, which are subject to availability and can be requested by contacting the property using the number on the booking confirmation.
The name on the credit card used at check-in to pay for incidentals must be the primary name on the guestroom reservation.
Mandatory fees
You'll be asked to pay the following charges at check in or check out:
- A tax is imposed by the city: EUR 2.48 per person, per night
Optional extras
Early check-in can be arranged for an extra charge of EUR 70
Late check-out can be arranged for an extra charge of EUR 70
Buffet breakfast is offered for an extra charge of EUR 19 per person (approximately)
Pets are allowed for an extra charge of EUR 10.00 per pet, per day
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.


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Ask The Mayor
Q: Can you direct me to the right person/office to answer this question: Are any of the county pools in Wailuku and Kahului heated, and, if so, which ones? I swim laps three days a week, and I'm looking to make a change. I am 58 years old and am partially disabled with leg and shoulder injuries resulting from an accident as a pedestrian when I was hit by a vehicle many years ago. Swimming laps is my main exercise, but it is difficult to share lap lanes. My right leg is very fragile, and it seems whenever I share a lap lane with someone my leg gets accidentally kicked, which is particularly painful.
A: The New Wailuku, Sakamoto, Kokua and Kahului pools are all heated. I would recommend Kokua Pool, which is located at 275 Uhu St. in Kahului. It is a heated, 25-yard pool with six lap lanes available to the public all day. Pool hours are 9 a.m. to 4:30 p.m. Mondays, Tuesdays, Thursdays, Fridays and Saturdays, and 10 a.m. to 4:30 p.m. Wednesdays and Sundays. Entry stairs are approximately 5 feet wide with a handrail down the middle; another option for pool entry there is the chairlift. Our pool staff informed me that the best days and times that might meet your needs are Tuesdays and Thursdays from 10:30 to 11:45 a.m. However, there are times when we permit large groups to use the pool throughout the year so it is not possible to guarantee availability. Please feel free to inquire with our staff at any time so they may be of assistance to you.
Q: I was at Wailea Beach a few weeks ago early in the morning and I noticed employees from the condos and nearby resorts putting out chairs and umbrellas in front of their hotels. Is this legal? Can I put my own chair and umbrella in their area and not get kicked out? Aren't beaches in Hawaii open to all? Please advise, as it was very upsetting to see this happening. I am a concerned taxpaying Maui resident. Mahalo.
A: Our beaches and coastlines below the upper reaches of the wash of the waves are public lands, under the jurisdiction of the state Department of Land and Natural Resources. The land mauka or above this point can be public or private. In many areas, the county or state control beach reserve parcels that border the high wash of the waves, used for beach parks, public access, or to provide a greater buffer between the coastline and private uses. In other areas, though, the land abutting the high wash of the waves is privately owned, including hotels, apartments, homes and businesses. To check on landownership by address, owner name, parcel number or map, you can access the county property tax website at www.mauipropertytax.com.
Q: What is the name of a feral chicken deterrent and where can you purchase it? I checked at a local hardware store, and they had no clue.
A: Unfortunately, to my knowledge there is no commercial deterrent product on the market. We held a community meeting earlier this year on the topic of feral animals, and the meeting was attended by more than 100 members of the public with a forum presented by several local and national experts. As one of the results of that meeting, I am allocating funding in my fiscal year 2015 budget proposal to the Maui Humane Society so that it can develop and implement a plan to reduce the number of feral chickens in our community; it will be up to the County Council to decide whether to allot the funds. For now, you can contact the Maui Humane Society to borrow chicken traps or to request information on additional methods of removing feral animals.
Ask The Mayor
Q: I am a Lahaina business owner and also work for one of the global hospitality leaders. A few months ago, I took a trip to the Mainland. My travels included stops at the St. Louis, Denver, Eugene, Ore., and San Francisco airports. I try to stay hydrated and usually purchase several bottles of water at the airports. In every airport I visited there were a number of accessible containers for recycling bottles and newspapers. To my dismay, when I returned home to Maui I couldn't find one receptacle to recycle my plastic bottles. I found this nearly impossible to believe since we are such a global destination and wanting to become more "green." Is there anything you can do to provide this important feature in our airport?
A: Thank you for the feedback. All Hawaii airports are under the jurisdiction of the state Department of Transportation Airports Division. At Kahului Airport, HI-5 beverage bottle recycling bins are available at the Transportation Safety Administration checkpoint, and recycling bins for cardboard and other materials are located in the back of house. DOT airports maintenance staff separate out cans, bottles and other things that can be recycled from rubbish bins in the secure areas as well as from the recycle containers near the TSA checkpoints. In the future, the DOT plans to have more specific recycle bins throughout its airport system.
Q: What happened to the ambulance that was stationed in Lahaina at the Lahaina Comprehensive Health Center area? For the past month, the ambulance has no longer been there. There seems to be an exercise machine parked in its place?
A: The ambulance is operated under a state contract with American Medical Response, and Lahaina Comprehensive Health Center is a state-owned building operated by the state Department of Health. According to AMR Maui Operations Manager Curt Morimoto, the ambulance had to be moved about a month ago due to a sewage leak at the building. State District Health Officer Dr. Lorrin Pang said that the building is being assessed and that any needed repairs will be made to allow AMR staff to reoccupy the building in the future. Until then, the ambulance and its paramedic crews will continue to serve the west side from its temporary Lahaina location.
Q: I live on Akala Drive in Maui Meadows, which borders Piilani Highway. There are a lot of large trucks that drive up and down the highway all day long, and they use their "Jake brakes" to slow down when they see the light at the corner of Mapu and Piilani turn red. During times of construction in Wailea or Makena this happens every couple of minutes, which makes it impossible to enjoy our yard or take a nap during the day because the noise is very loud. Is there some way we can get a "No Engine Braking" sign posted along the highway? Is there some sort of ordinance regarding engine braking near a residential neighborhood? I know when I drive on the Mainland I see these signs all over the place. Thank you for your help.
A: Piilani Highway is a state highway, and according to the state Highways Division Motor Vehicle Safety Office, there currently are no restrictions on the use of compression release engine brakes, or "Jake brakes." The Transportation Department also says that there are no state laws in the Hawaii Revised Statutes prohibiting the use of Jake brakes.
Ask The Mayor
Q: I've received some unusual calls regarding a grayish white box on the telephone poles in South Kihei, from Azeka Shopping Center to Kamaole Beach Park III. The boxes have red and blue lights and are very visible at night; the lights change color from blue to red. The boxes don't appear to belong to the county, telephone company or Maui Electric. Would you happen to know what the boxes are? Are they cameras, Wi-Fi or aliens?
A: The colored lights are power indicator lights on boxes that are part of Oceanic Time Warner Cable's Wi-Fi system that was recently installed in South Maui. There are currently 17 devices installed in South Maui, and Wailuku town is being eyed as the next possible area for up to 125 installations over the next year. There are approximately 600 similar Wi-Fi devices installed on Oahu, including several large public facilities such as shopping malls and athletic complexes. The Maui devices installed on poles are part of a "joint pole agreement" with the corresponding utilities. Cable Wi-Fi is a wireless network name created through a collaboration of U.S. Internet service providers, including Time Warner Cable, Bright House Networks, Cablevision, Comcast and Cox Communications. It allows each other's high-speed Internet customers free access to a collective network of over 200,000 Wi-Fi hotspots nationwide.
Q: Why are there two refuse pickups instead of once a week like in other counties? Switching to once a week pickups could reduce costs in staff, trucks, gas, etc. Residents could also benefit with a reduction of the $18-per-month fee, or this fee could be used to expand the 3-Can-Plan, other recycling programs or expand the hours at the landfill. Most residents can manage with once-weekly collections, and residents with more trash could use and pay for two bins.
A: We can all benefit from producing less waste and recycling more, and reducing residential refuse pickups to once weekly with the option of purchasing an additional bin could be considered. However, from an operations perspective, there are a number of considerations that must be taken into account. First, the current refuse collection fee of $18 per month would still barely cover the total cost of residential refuse collection even if pickups were reduced to once a week. The heavily subsidized $18 fee does not begin to cover the cost of landfilling the trash once it's been collected, even with once-weekly pickups. Second, employee union contracts set restrictions on the number of refuse bins that may be picked up in one day, which could be an issue if many homes on one route all opted to pay for second bins. Lastly, residential refuse customers may not be eager to have their service cut by 50 percent, or paying 200 percent more to receive the same level of service they receive now. I would be interested in hearing from residents on automated routes on whether they would prefer once-weekly pickups at a reduced cost, and if they are willing to pay for a second bin. Any changes to the fee structure or number of pickups would need to be approved by the County Council during the budget process next year.
Q: Our county is lacking an annual, biannual or quarterly published parks and recreation resource guide. Without such a guide it is easy to miss sign-ups and community activities for our residents and keiki. What will it take to create such a guide and to provide this to our community members?
A: The Department of Parks and Recreation is currently in the process of upgrading its website to house all of this information to include the organization's contact information and time frames for registration and sign-up for these valuable recreational programs. Parks anticipates this project will be finished with updated information on the website around August; we will issue an announcement when this new feature is ready for use. In the meantime, the department provides class and program listings in various local media to reach families with children and teens.
Ask The Mayor
Q: I heard the county has an Immigrant Services Office. Is that the same thing as the U.S. Citizenship and Immigration Services? Where are they located?
A: No, the county office provides distinctly separate functions from the federal program. There are four locations of the county's Immigrant Services Division: One Main Plaza, Suite 547 (2200 Main St., Wailuku); Moore Center on Molokai (2 Kamoi St., Kaunakakai); Lanai Community Center (Eighth Street, Lanai City) and a satellite office that opens every Thursday in Lahaina (West Maui Senior Center, 788 Pauoa St.). While the county's Immigrant Services Division does not provide legal representation or adjudicate citizenship cases, staff members provide free assistance to immigrants, nonimmigrants, migrants and citizens in three main areas: citizenship, employment eligibility and family-based petitions. Referrals to translators and interpreters may be provided, and if an immigrant is a victim of domestic violence or other crimes, he or she may be able to receive help. Staff also can assist with Deferred Action for Childhood Arrivals, which is a program started by President Barack Obama to assist undocumented young people who arrived in the United States as children. To see a full listing of office days/hours and services, visit "http://www.mauicounty.gov/immigrantservices">www.mauicounty.gov/immigrantservices and click on "Summary of Services." The Wailuku office can be reached at 270-7791.
Q: I took my mother, who is in her 80s, to the Senior Fair this year at War Memorial Gym. We both enjoyed the event, but noticed that it was sweltering inside the gym. Are there any plans to install air conditioning in the gym?
A: Depending on the time of year, it can get rather steamy in the gym when it is crowded during a special event such as the Senior Fair. However, on most days when it is being used for basketball and other gymnasium activities, the louvers' natural ventilation does the trick. Those louvers, which are old and do not close tightly, also make it costly to adequately seal the windows for air conditioning. However, we have just begun to discuss master planning for a new sports and/or aquatics civic center for Central Maui, and air conditioning the new gym will definitely be considered.
Q: My aunty works for the county, and she told me about the newsletter that is published for county employees. Is there a way that the public can read the newsletter too? My niece was featured in one of the articles, and I'd like to get a copy.
A: Yes, the newsletter, called the "High Street Journal," is available for digital reading online at www.mauicounty.gov/newsletter. To access a printable version, click on the link on the Web page to the pdf. The December issue will be coming out soon.
Ask The Mayor
Mayor Alan Arakawa answers some of the most-asked questions submitted to his office staff.
Q: I'm considering buying a home that I'd like to turn into a bed-and-breakfast. Which county office can I contact to get information on the process to apply for a B&B permit?
A: Anyone with questions about permits for short-term rental homes or bed-and-breakfasts can call the Maui County Planning Department's Current Planning Division at 270-8205 or visit the county website at www.mauicounty.gov/Planning and select a link under the "Hot Topics" header. There you will find links to information about both types of permits.
Q: This is something I've always wondered about: Do planning commission members get paid?
A: No. Members of county boards, councils, commissions and committees provide volunteer service. Members serve terms of two to five years, and help county government function more efficiently by reviewing policies, listening to public testimony and making recommendations. A few other examples of county boards and commissions include the Animal Control Board, the Board of Water Supply, the Cost of Government Commission, the Fire and Public Safety Commission, the Liquor Control Commission, the Police Commission, the newly formed Public Works Commission and the Real Property Tax Review Board. Applications are being taken now for open seats, and are available online at www.mauicounty.gov/Boards or from my office on the ninth floor of the County Building. Deadline to apply is Dec. 31. Questions may be directed to my office at 270-7855.
Q: Is it required for trucks carrying loose items to be covered? Much of roadside rubbish seems to be blown off of trucks carrying uncovered items or loads.
A: According to both the Maui County Code and the Hawaii Revised Statutes, drivers are responsible for ensuring that their load is tied down or covered properly, and that loose material from the load cannot escape into the air or onto the road. Police cite violators under state law, specifically HRS 291C-131. To read the details on requirements and penalties, read the posting on my blog at www.mauicounty.gov/Mayor and click on "Mayor's Update" on the left. Keeping loads covered not only helps reduce the amount of debris and litter on the road, it also helps keep other drivers safe from flying objects, sand, dirt and other projectiles that could potentially cause an accident.
* Want to Ask the Mayor? Submit your questions about County of Maui programs, services, operations or policies to Mayor Alan Arakawa via email: firstname.lastname@example.com, phone: 270-7855 or mail: 200 S. High Street, ninth floor, Wailuku 96793. Questions submitted will be considered for inclusion in the "Ask the Mayor" column.


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realmagick.com The shrine of knowledge.
Townsville Queensland History
A selection of articles related to townsville queensland history.
Original articles from our library related to the Townsville Queensland History. See Table of Contents for further available material (downloadable resources) on Townsville Queensland History.
- Indian History Rewritten
- The Indian civilisation, considered to be the product of clash and subsequent inter mixture of the white-skinned civilised invaders and the dark savages native to India, has been rightly questioned in recent years, and the mischievously fabricated history of...
History & Anthropology >> Indic / Vedic
- The Truth Behind the History of the Necronomicon
- I don't think there are many people out there who haven't heard of the Necronomicon and the dreadful things connected with it. We've all heard the theories about how it is a Satanist tool; actual copies of the book are bound in human skin and how you risk...
Deities & Heros >> Chthulu
- History of the Egyptian Religion, part I: Early Dynastic Period
- I - Predynastic - Early Dynastic Period. The temples were in essence the *Home of the God* and thus a place where only Pharaoh as the Son of God and those he appointed as his deputies, could meet with the god. This goes all the way back to Archaic and...
Religions >> Egyptian
- History of the Egyptian Religion, part II: The Old Kingdom
- II - The Old Kingdom ca 2686-2181 BC During the Old Kingdom the Egyptian society moved from tribal communities to a fully developed theocratic system, where the power of the king was absolute. The great pyramids of Dynasty 4 was made possible by technological...
Religions >> Egyptian
- History of the Egyptian Religion, part IV: Middle Kingdom
- First Intermediate - Middle Kingdom (ca 2181 -1786 bc.) The powers that built the solar temples of the 5th dynasty and the pyramids of the 6th dynasty weakened towards the end of the Old Kingdom, perhaps as a result of eroding economics, leaving the King less...
Religions >> Egyptian
Townsville Queensland History is described in multiple online sources, as addition to our editors' articles, see section below for printable documents, Townsville Queensland History books and related discussion.
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This luscious dessert sundae is a perfect ending to any meal!Watch Video
Here is a quick, no-fuss dessert using a vanilla cake mix.Watch Video
Nadia G makes fancy Raspberry Champagne Truffles for a bridal shower.Watch Video
Crumbles get Asian flair in Ching's Apple Lychee Raspberry Crumble recipe.Watch Video
This dessert is a shortbread base topped with raspberry jam and almonds.
Dave Lieberman makes the perfect raspberry parfait in minutes.
Take our word for it: on a hot summer day, this mojito is the (ras)berries!
In one minute, learn how to make a raspberry vanilla smoothie.
These teeny lemon-raspberry dessert shots pack huge, unforgettable flavor.
Ginger beer tops off Ching's refreshing raspberry-citrus cocktail.
How to make a refreshing low-calorie cocktail.
G. discovers the amazing ice cream from Bennett's in Los Angeles.
Low-cal chocolate truffles and raspberries jam in a fudgy, fruity treat.
Try this raspberry dessert, topped with mascarpone cheese and walnuts.
Get Cooking Channel on your TV.


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D. R. Evans
D. R. Evans is the author of the Three Lands fantasy trilogy, as well two popular thrillers and the children's story "The Boy With Green Hair." Visit his web site.
D. R. Evans is the author of the Three Lands fantasy trilogy, as well two popular thrillers and the children's story "The Boy With Green Hair." Visit his web site.
1. In the left menu, click "Manage Profile" 2. It will ask you for your email. Use the one SFWA has on file for you. Send an email to email@example.com to get your temporary password or use the "Forgot my password" option. (The first time you log in the website will ask you to accept […]
If you're having trouble logging into the discussion forums there are a couple of possible answers.
For the best experience with the SFWA website, your browser must allow the use of cookies. (What's a cookie?) To set your browser to allow cookies from SFWA but not from other sites, follow these instructions:
Joan Marie Verba has a physics degree, wrote novels Action Alert and Countdown to Action, nonfiction books Boldly Writing and Voyager: Exploring the Outer Planets.
Eileen Gunn is a Nebula-award-winning writer and the editor/publisher of the Infinite Matrix website. She serves on the board of Clarion West.
Mike Allen edits the anthology series Clockwork Phoenix and the poetry journal Mythic Delirium. His story "The Button Bin" is a 2008 Nebula Award nominee.
Alma Alexander is a Pacific Northwest fantasy author who writes for both adult and YA audiences. Her work has appeared in 13 languages worldwide to date.
Bud Sparhawk has sold about seventy science fiction stories and recently published one novel – VIXEN. He has been a three-time Nebula finalist for his novellas.
James David Audlin, author of The Circle of Life; novelist, poet, playwright; most fiction based on dreams. Ordained in several religions; multilingual; instrumentalist-composer; jamesdavidaudlin.com under construction.


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JWoww Bikini Pictures
I've always liked JWoww, so I want to congratulate her for moving on from The Jersey Shore to the second phase of her career: looking hot in a bikini, and hosting no-name events and promotions. And unlike those Victoria's Secret models, JWoww actually seems to understand the importance of combining those two skills. Because when you're hired to host the second round of something called the Rehab Bikini Invitational, you'd better show up in a bikini. Anyway, if JWoww's looking for another gig after this, I'd love to hire her to host my next pool party. It's going to be a nice intimate gathering in the kiddie pool on my front lawn, and I think she'd make a great guest of honor.
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Connecting the Dots
A Quora blog post must have a question, right?
Ray N. Kuili
If there's one thing that has been making Quora experience stand out from dozens of social platforms for me it's the spirit of
. More than any other platform, Quora has been successful not just in connecting me with people who share my interests, but also in creating the right envir...