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GardenFurnitureWorld is the UK's leading garden furniture store with a huge range of garden furniture including garden furniture sets, garden tables, garden chairs, garden seats, teak garden furniture, wooden garden furniture, metal garden furniture and more.
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subset: commoncrawl


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Norman E. McSwain, MD
1938 - 2015
Dr. McSwain attended The University of The South in Sewanee, Tennessee and then returned to his birthplace of Alabama to learn medicine under Dr. Tinsley Harrison (of Harrison's Textbook of Medicine fame) and surgery from Dr. Champ Lyons at the University of Alabama School of Medicine. After completing two years of surgical training at Bowman-Gray School of Medicine in Winston-Salem, North Carolina, McSwain then joined the Air Force. There he performed more than a thousand surgical procedures. After his service he went to Grady Memorial Hospital in Atlanta to finish his initial education as a surgeon. Over the next three years, he learned more about true patient care as a partner in private practice with Dr. Harrison Rogers in Atlanta before he joined the clinical and academic faculty at the University of Kansas in Kansas City.
While there he was given the responsibility of EMS education and system development for the State of Kansas. When he was recruited four years later to Tulane University School of Medicine, Department of Surgery and Charity Hospital in New Orleans, he left behind 90 percent of the population of Kansas covered by paramedic quality care within ten minutes of home, and one out of every 500 Kansas (including the entire Kansas Highway Patrol) trained as an EMT-Basic.
Serving as academic and clinical faculty at Tulane, McSwain's main interest was in pre-hospital patient care through Charity Hospital, considered to be one of the three most important trauma centers in the United States at the time. Through his work there, he was recruited by the City of New Orleans to develop an EMS system for the city. He initiated both the EMT-Basic and EMT-Paramedic training within the New Orleans Police Department as well as a citywide EMS system.
McSwain also was recruited to the American College of Surgeons Committee on Trauma to assist in the development of the Advanced Trauma Life Support program. He worked with the ACS/COT and NAEMT to develop the PHTLS program. Today, PHTLS has trained over half a million people in 45 countries. It is considered to be the world standard for pre-hospital trauma care.
He has worked with the military and the Department of Defense to develop the Tactical Combat Casualty Care program for military medics. For the past 30 years, he has provided care to severely injured police officers at Charity Hospital and has written or revised more than 25 textbooks, published more than 360 articles and traveled throughout the world giving 800 presentations. McSwain has lectured in each of the U.S.'s 50 states and in all of Canada's provinces, most of the countries in Europe and Central America.


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6 reviews | 4.3 out of 5
We used to buy this juice at Sam's Club. For some reason they stopped carrying it. That was how I found myself on this site. We grew desperate and did a Google search to find out who sells it now.
At my home my family of 5 would go through almost 2 bottles every 3 days. To say that we enjoyed this juice is an understatement. The first few times I bought this product home my husband tried to hoard it all for himself. He even told the kids that they wouldn't like it and even started calling it yucky juice. Well after seeing him guzzle this stuff by the gallon they grew suspicious of just how yucky it really was. After taking a few sips while dad wasn't looking it was all over. They figured it out. Yucky juice is amazing!
Love this juice! Best juice out there, can't keep a gallon in the fridge longer than a day, two if I'm lucky
i have tried all flavors of minute maid but the fruit punch is just simply the best
My family loves this juice and I love the quality of it.
Love this juice. Not sweet
The product says its purely natural without preservatives and still its odour and taste is bad. It smells and taste like medicine and gives a feeling that you are having a tonic instead of a juice.


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Chinese brown sauce
Authentic Chinese Brown Sauce Recipe
Stir-Fry Sauce (Brown Garlic Sauce)
Easy Basic Chinese Brown Sauce (Vegan and GF) via lesleyeats.com
Chinese brown sauce just tried this! It's AMAZING
Chinese Brown Sauce http://doreenskitchen.com/ChineseBrownSauce.html While it's preferable to use pan drippings from beef, pork, chicken or seafood to make this sauce, sometimes that is not always possible.This is a way to make JUST the Chinese Brown Sauce, especially if you're putting it over steamed or sauteed veggies or rice, tofu, etc. If you make a larger batch, this sauce freezes well.
This was super easy and tastes awesome. I substituted mild sherry cooking wine and also only used 1/2 the soy( it was reduced sodium). It was still a little salty.---All-Purpose Stir-Fry Sauce Brown Garlic Sauce) Recipe - Food.com
Restaurant Secret: Real Chinese All Purpose Stir Fry Sauce you can make in 2 minutes and store in the fridge for when you need it. Incredibly versatile - recipe includes suggested flavour additions as well as directions for how to use.
Garlic Chinese Chicken. This really does taste just like our favorite chinese take out place. Add a bag of frozen broccoli!
Restaurant Secret: Real Chinese All Purpose Stir Fry Sauce you can make in 2 minutes and store in the fridge for when you need it.
One-pot meals are the best for a busy night... Try this One-Pot Chicken Breasts in Chinese Brown Sauce.


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Van 3 Auto Transport
Van 3 Auto Transport
Countryside, Illinois
This auto transport company shipped my vehicle from Naples to Milwaukee. I called around to get quotes from a lot of companies. They were not the cheapest, but they were also not the most expensive. T [More]
Shipping a car can be pretty stressful especially when you read horror stories from companies other than Van 3.
I shipped my BMW sedan from Denver to Fresno and could have not been happier. The dr [More]
Excellent Service and very professional. Price was very reasonable. Very responsive to any inquires or questions. The transporter was very courteous. Thank you for providing great service.
The whole experience was perfect. Easy to schedule, price below average, and super timing. Wish all companies work this way.
I worked with Bobby to get my car from Chicago to Nashville. Not only was he very professional and accommodating, but he kept me up to date every step of the way and I felt completely at ease knowing [More]


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WHEN TIGERS FIGHT Stream New Album Via MetalSucks
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Posted: 25 Apr 2012 at 10:32am
WHEN TIGERS FIGHT Stream New Album Via MetalSucks
Band To Play Two Shows This Week
With the release of their anthem-strewn sophomore LP Death Songs just one week from its official street date, today WHEN TIGERS FIGHT are streaming the entire album via MetalSucks. Get in the pit RIGHT HERE.
In celebration of the album's release, WHEN TIGERS FIGHT have booked two special performances, storming Chicago alongside The Killer and Dearborn with Ensign this week. Check out flyers for the shows and more AT THIS LOCATION.
WHEN TIGERS FIGHT Record Release Shows:
4/27/2012 Cobra Lounge - Chicago, IL w/ The Killer
4/28/2012 Refuge Skateboard Shop - Dearborn, MI w/ Ensign
Combining elements of melodic post-youth crew anthems with irate, metallic riffs, East Coast hardcore unit WHEN TIGERS FIGHT was founded by Mike McTernan of Damnation A.D. and Jonathan Dennison of Another Victim, Unholy, Santa Sangre, The Path Of Resistance and The Promise. Death Songs was recorded with Jocko at More Sound Studios in Syracuse, and bears cover art by Jon MacNair, known for his work on labelmates Harm's Way's last full length, Isolation.
Death Songs will see release on May 1st via Closed Casket Activities, the label responsible for previously co-released the vinyl version of the band's debut LP Ghost Story through Indecision Records. Preorders are available HERE.
Promos of Death Songs and interviews with WHEN TIGERS FIGHT are available worldwide via Earsplit right now. Stay tuned for more updates in the weeks ahead.
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The Federal Communications Commission is committed to producing public documents that are clear, concise, well-organized and follow other best practices in keeping with guidance from the Office of Management and Budget and the Plain Writing Act of 2010. This page outlines activities related to our commitment to plain language during the past year.
Using Plain Language
Specific FCC documents made available in formats consistent with Plain Writing guidelines include, but are not limited to:
- Consumer Publications Library: The Web and Print Publishing Division of the Consumer and Governmental Affairs Bureau conducted a thorough review and update of the Consumer Guides Library, consisting of approximately 180 consumer guides and factsheets. Documents were edited for plain language and updated with new information in consultation with subject-matter experts throughout the commission.
- Document Translations: All updated library documents online and in print continue to be translated into Spanish, and we also maintain a consumer-friendly directory of other translated pages. All Spanish translations are edited in accordance with Plain Writing principles.
- Consumer Call Center Resources: CGB also continued to regularly revise consumer call-center scripts in clear and conversational language. The scripts are used as resource documents for responding to consumer complaints and inquires.
- Reports, Proceedings and other Publications: Plain Writing principles continued to guide the development of web pages posted on FCC.gov as well as updates to existing online content. Examples include our new Consumer Outreach Hub, the Measuring Mobile Broadband Speed Test App, the Measuring Braodband America 2013 Report and our Distracted Driving Information Clearinghouse.
- Other Documents: In addition to the above, other documents covered by the Plain Writing Act include those that are necessary for obtaining a federal government benefit or service, that provide information about any federal government benefit or service, or that explain to the public how to comply with a requirement that the federal government administers or enforces were created in keeping with the federal guidelines.
Communication and Training Resources
We have communicated the requirements of the Plain Writing Act to document creators, editors and other staff members in a variety of ways, and we continue to provide our FCC University "Plain Language Workbook: Five Steps to Clear, Effective Communications for the Federal Communications Commission. The workbook is available for download as a PDF or via a Scrib'd reader on our main Plain Language page.
Available resources also include online training materials developed by other federal agencies. As with our Plain Language Workbook, these are freely available to other agencies and to the public. Examples include:
- Social Security Administration Videos On Demand: Windows Media and Flash zip files
- U.S. Patent and Trade Office: Plain Language: A Handbook for Writers in the U.S. Federal Government
- National Institutes of Health: Plain Language Training
- Plainlanguage.gov: More Training Resources
Ongoing Compliance
Approximately 880 staff members were briefed on requirements and expectations as part of our initial FCCU training program in the summer and fall of 2011. These include content creators, reviewers and publishers who continue to follow the guidelines and principles of Plain Writing and are responsible for ongoing compliance in performing their duties.


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Jonathan Frakes
Jesse Bradford
Paula Garc�s
French Stuart
Printer-Friendly version
I only wish they would have done more with this awesome concept, but then again, this is a "kid's movie" after all with a little bit of BACK TO THE FUTURE and SPY KIDS spread around for good luck. The pace of the film does help though, as well as its generally "upbeat" attitude, bright colors, palpable chemistry between the leads and fun freezing effect shots. But I can't complete this review without mentioning the lovely Paula Garc�s once again (check out her spread in Maxim magazine and thank me later). I guess I was somewhat smitten by the chickie-dee, and hope to see more of her around. Bradford also did well, and the film can certainly be enjoyed by adults as well, as long as you don't go in expecting to use your brain for more than three minutes. It's basically a high concept fluff piece that will likely not hurt anyone to pick on a lazy weekend evening, as a double-bill with something with a little more "oomph"!


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Hotel San Francisco Bogota has a strategic location at the International Center of the Capital. It is equidistant from the Cultural and Historical Center Bogota, close to major governmental and academic institutions in the city, 5 minutes from the Convention Center Gonzalo Jimenez de Quesada 10 min...
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|2 - 3 Nächte
Faun Lake ist eine Tat eingeschränkten Eigentums Vereinigung von 300 Campingplätzen in Adirondack-ähnliche Einstellung von über 238 bewaldeten Acres in up-Staat Wyoming County, New York gelegen.
Der Park umfasst 44 acre Faun See und den angrenzenden 27 acre Beaver Lake. Es ist ein Erholungs Gemeinschaft, die als Sommerresidenz für die einen, ein Wochenende zu Hause für andere und ein Freizeit-Treffpunkt für jedermann bietet.
Unsere Gemeinschaft ist eine Form von Camping mit all den Komfort von zu Hause verbessert.
Sie werden Ihre Zeit in diesem Park Modell mit einer vollen Sonne-Raum für zusätzlichen Raum zu genießen. Es hat Schlafgelegenheiten für bis zu 5 Personen. Es gibt einen Waschsalon und zusätzliche Toiletten zu Fuß zu erreichen, eine komplett eingerichtete Küche mit Koch- und Essgeschirr, Bettwäsche, Handtücher und einige andere Grundversorgung. Es ist ein Ersatz Kühlschrank im Schuppen für Getränke und zusätzliche Nahrungsmittelspeicher und einem Holzkohlegrill (eigene Holzkohle liefern müssen). Wir haben ein 4 Personen Paddelboot für Ihren Genuss auf dem See und der Park verfügt über einen Pool, See Strand, Volleyball, Hufeisenwerfen, Freitag Abend Bingo, einen kleinen Laden, Sonntag Kapelle im Wald und vieles mehr.
Sehen Sie unsere anderen Vermietungen .....
In Helen, GA
VRBO # 870081 (Stadthaus auf dem Fluss)
VRBO # 899348 (Kabine im Holz)
We had a wonderful time in bliss NY, despite the rainy weather. The accommodations were exactly what we needed for nice little retreat away from our busy lives. It was clean, tucked away, and in a nice little camping community on a beautiful lake. We were so grateful to be able to take a trip with our dogs too! We would love to return and would recommend Dave and Toni's vacation home to anyone.
My husband and I had a wonderful time staying here for our anniversary long weekend.Very close to Letchworth State Park which was our main destation.Letchworth is a beautiful park and and the weather cooperated so we were able to take our hot air balloon ride.The house was clean and well equipped with everything we needed to make this our home for the time we were there exploring upstate New York.The bed was super comfortable.We had a nice walk on the trail around the lake.The only disappointment was the pool,store and beach were all closed up tight.We were a little leary about taking the paddle boat out into the water since it was September and with the lack of rain not sure how safe the water quality was.
The Wolfe's vacation home at Faun Lake made an excellent "home away from home" for us. The cabin was comfortable and clean. We had everything we needed to make our three week stay a pleasant one. The Faun Lake property is in a beautiful wooded setting, with abundant winding roads and trails through the cool woods. The cabin itself, though not luxurious, is very comfortable. We were there for three weeks in August, and were cool the whole time even though there is no air conditioner. The A.C. was not needed. (this was the hottest August on record for the area) If you're looking for a rustic, cool home away from home , in a beautiful wooded setting, this is a good one. It is onlyn an hour from Niagara Falls. About 30 minutes from Letchworth State Park; an hour and a half from Watkins Glen State Park. Groceries and other shopping is available about 15 miles away the town of Warsaw. There is a beautiful wildlife preserve in nearby East Java, with many miles of hiking trails and lakes and ponds, sponsored and maintained by the Audubon Society. Short drives to Lake Ontario and to Lake Erie and a host of beaches and state parks on those lakes. There are many small towns all around, each with it's taverns and cafes. We found good food everywhere we went. The people in the park and in the surrounding towns were friendly and helpful
The place was lovely and clean and well supplied with all essentials -- even some plastic baggies! The paddle boat on the lake was an excellent added bonus! A bit heavy to drag to the water, but fun nonetheless. Even saw a bald eagle fly by low over the trees!! Firepit was well-designed so we enjoyed hot coals and hot dogs well after dark! Location was very quiet and restful, and near to some great farmer's markets and local produce stands for fresh corn! I have even recommended the place to some of my friends!
I wish we had been notified that the cleaning people were going to be late so we could have had a better first impression. Other than that, it was a very nice place.
We enjoyed our stay here very much. Our grandkids were able to ride their bikes around. The boys especially enjoyed using the paddle boat to go to the beach area and go to the store. Our granddaughter loved the pool and made some friends there. We all hiked around Faun Lake one day, and around Beaver Lake another day, and then spent a day at Niagara Falls. We would recommend this rental to others.
Letchworth State Park innerhalb von 15 Meilen.
|Minimum Preis
|Zusätzliche Nächte
|pro Nacht am Wochenende
|pro Woche
|pro Monat *
Memorial Day
26 Mai 2017 - 29 Mai 2017
3 Nächte Mindestaufenthalt
319 €
für 3 Nächte
ab91 €
Forth of July
30 Jun 2017 - 8 Jul 2017
3 Nächte Mindestaufenthalt
319 €
für 3 Nächte
ab91 €
Labor Day
1 Sep 2017 - 4 Sep 2017
3 Nächte Mindestaufenthalt
319 €
für 3 Nächte
ab91 €
2 Nächte Mindestaufenthalt
191 €
für 2 Nächte
ab73 €
ab82 €
550 €
1.836 €
|Cleaning Fee
|45,89 €
|Erstattbare Kaution
|183,57 €
|45,89 €
PETS: Are permitted (One, 40# or smaller) with a $50 fee paid at time of booking. If evidence of a Pet is found at the property during the allotted stay and the fee was not paid at booking you will forfeit your security deposit.
Check In Anytime after 3 PM - Check Out by 11 AM.
In the event of a same day check out and check in the cleaning may not be done until 5 PM.
* Ungefährer monatlicher Preis. Der tatsächliche Preis wird von den genauen Tagen Ihres Aufenthalts abhängen.


text: Divxturka.net is using Netload! Because Netload is better than Rapidshare,Hotfile and xxxxxxxx.to ! Click here and buy Netload premium account! Joffrey: Mavericks of American Dance (2012) DVDRip x264-Ganool Language: English 01:22:29 | 720x400 | x264 - 560Kbps | 23.976fps | AAC - 32Kbps | 349MB Genre: Documentary The Joffrey Ballet: Mavericks of American Dance, narrated by Mandy Patinkin, tells the full story of this groundbreaking company, from their founding in 1956 to the present. Screenshot: (Get an Premium Account Netload.in for Faster & Unlimited download, with NO waiting time !!) NETLOAD.in - FAST DOWNLOAD (Recommended) Code: http://netload.in/dateiTz1lXH0jVR/Joffrey.Mavericks.Of.American.Dance.2012.DVDRip.x264.Ganool.mkv.htm


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The Hollywood Reporter
Talk about jumping the proverbial gun! Although The Mortal Instruments: City of Bones doesn't open until August 23rd, Constantin Films is already working on a prequel, Infernal Devices. Read on for details.
According to THR the company has thrown into development an adaptation of the spin-off book series written by Mortal Instruments author Cassandra Clare and has hired Stephanie Sanditz to write the screenplay.
Mortal Instruments, a best-selling series of fantasy romance books, centers on a young girl who discovers she is part of a hidden race of angels known as Shadowhunters locked in a battle with warlocks and vampires called Downworlders.
Infernal Devices is set in Victorian England and sees a new teen girl plunged into a journey of adventure and self-discovery. The books feature the ancestors of many Mortal Instruments characters as well as some character overlap. Three books, titled Clockwork Angel, Clockwork Prince, and Clockwork Princess, have been published.
Constantin is currently seeking a director.
Got news? Click here to submit it!
Die by your own devices in the comments section below.


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Swing Faux Fur Collar Coat, Beige
Sign up now to get your own personal style guide to what to wear and to see clothes recommendations from over 500 retailers.
Out of Stock
from House of Fraser
What the retailer says
This coat will get you hot under the collar. The strokeable faux fur neck and a swishable swing silhouette will make the cold worthwhile., Winter Coat, Main, 32% polyester, 37% viscose, 31% wool, Dry clean only.


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View parents Singles in Chevy Chase
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Active over 3 weeks ago
The best place on the web to find love in the Old Line State. Search Maryland for online singles today. Match.com has been the leading online dating site for over 10 years. This free Chevy Chase online dating site has millions of members and thousands of Chevy Chase singles. Flirting with the idea of dating again? View thousands of hot Chevy Chase single men and single women looking for dates on Match.com.
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Chapter three
Bay and I are really hitting it off. She still eats lunch in Mr. Luther's room, so Chucky and I talk in the cafeteria, until one day I just wanted to be around her and saw Chucky in science instead.
Her humor is sarcastic and witty, so whenever I tell her about my sister, she says one simple line that makes me wish I actually said that to Crystal. We talk about whatever's on our mind. She doesn't have any secrets and neither do I. Well, I leave Gabriella in the shadows. Other than that, Bay knows everything about me.
She rounds off another joke and that's when I ask her out. Forget Gabriella, she's a million miles away right now. And she has Carson. Bay stuns me by saying yes.
"So. I heard Abduction is coming out this week. Wanna see it?" Bay suggests it like the only reason she wants to see it is because of Taylor Lautner.
Friday is family night. Well, I don't want to watch a movie my father picks. It's always an old black-and-white picture that none of us likes. I'm sure the action flick Bay wants to see is much more interesting than To Kill a Mockingbird.
"I'll meet you there at six." Bay makes everything too easy.
During algebra I have no problem writing to Gabriella that I'll be going on my first date soon. Though I wish the first date was with her, I'm just happy to have someone new to hang out with after school. A few days ago she informed me that she and Carson were still strong and wishes me luck in finding someone. Looks like luck rubs off through paper.
I'm nervous for tonight. Gabriella and I went to movies all the time, but platonically and it was innocent Disney films. And our mothers went. I anxiously wait at the front and out comes Bay, wearing the simplest thing I've seen her in: regular gray t-shirt and boot-cut jeans. I can smell some kind of girly scent coming off her, like fresh flowers and pomegranate. It's odd, but I like it.
"Shall we?" She holds out her hand and I hesitantly take it. We find a spot in the middle of the theater and wait for people to come spilling in, but all I see are teenage girls squealing over Lautner's abs and willing him to be shirtless. Why did I agree to this movie?
Bay, too, is on the edge of her seat, staring at him. I sit back and don't mind. There's no pressure on me now to make a move. I try to catch up with the screen but I find it too complex. My mind takes turns wandering from Gabriella to Bay, investigating who I like more.
They're both girls.No, duh,I think. They look different but they're basically the same. Gabriella is smart and Bay is a bookworm. Gabriella is classic, orderly, and Bay is eccentric and unusual. The things she says makes me laugh while Gabriella makes me smile. But I've known Gabriella much longer, since we were born, actually. And it didn't take long to settle in, but then again, Bay lured me the day we met. Why is this so confusing?
Bay glances at me to see if I'm watching. Basically I'm just staring ahead.
"Having fun?" she whispers, her hand squeezing my knee.
"Uh…" I glance down. Why am I disgusted right now? I slightly push away from her. "Sure."Breathe, I tell myself. My throat closes up. Panic rises in my chest.
One thing I failed to mention. I get very uncomfortable when people get close to me. Like, throw me off a bridge into Antarctica water right now and let me freeze over uncomfortable. Bay must've realizes because her hand leaves my leg and asks, "What's wrong?"
"Too close," I murmur. She knows what I mean.
"Right. Sorry." Bay leans back into her chair.
"Look, I didn't mean to…"
"It's alright. I won't do it again." She doesn't look pissed, but she's not happy, either.
The night finally draws to a close and I'm anxious to disappear into bed. Bay lives six blocks over and she plans on walking home after we're at my house. I don't know what to say. The porch light glows on her pale face, bringing a warm and friendly expression.
"This was fun. You know, minus the last twenty minutes of it." Bay still smiles, letting me know that she's not too badly affected by what happened.
"Yeah!" I exclaim too brightly. "See you Monday."
Bay's blue eyes sparkles when she looks right at me. Oh no. She wants a kiss. What am I going to do?
Crystal opens the door. "Get inside, twerp. Gabriella called you."
Both excited but tense that Bay heard it, I see her face is crestfallen.
"Gabriella? Is she like, a cousin, I hope?" Bay is definitely disappointed and upset.
"She's my friend from Clovis. I didn't feel like I needed to bring her up," I trail, hoping Bay will get the message and leave me alone.
"Oh. Well, bye, Charlie." And Bay vanishes in the dark. Should I have walked her home? But then I wouldn't have had my escape.
Crystal pulls me in the door. I glare at her expectantly, and she realizes. "Right, here's the phone." Crystal prances up the stairs and shuts her door.
Instantly her voice breaks down. "Charlie, it's so awful!" Her sobs is the worst sound in the world. I can feel my eyes getting hot too. "Carson and I had a bad fight."
"What'd he do?" I say softly, knowing full well everything is always Carson's fault and never Gabriella's.
"Girls keep flirting with him, and so after school I confronted him, and he started talking about how close you and I were, so why can't he be close to the girls, and I shouldn't be jealous because the girls mean nothing to him, they're just his friends, and I'm the only one he cares about."
Carson mentioned me? I never thought he'd know my name.
Gabriella keeps rambling. Gabriella never rambles. "And all I wanted was one night where no one would go up to him and say a one-liner right when I'm standing there, clearly attached to Carson, and I had it. I pulled him away from our table and we fought next to the bathroom. And a boy came out of the door and whew, there was a smell coming from there. So we moved outside and that's when he called his mom and I was alone."
"Wow. I'm sorry, Gabriella." She's right, how Carson should stop these advancing girls, but she needs to let go a bit. To me.
"I would've written about this, but I thought it'd be easier to just say it."
Words are better spoken than written. So I don't have to repeat those gut-wrenching sobs again. "You'll be okay. Carson will be a good boy again on Monday, and you'll have forgotten it by then. You always do."
Gabriella sniffles. "Thanks, Charlie." She pauses. "I have to go. Goodnight."
How I hope to never hear her cry again.
My family wakes me in my room. "Happy birthday!" they all sing.
"Ugh," I grumble into my pillow. My hand is clutching something. The frame. Immediately I push it aside, hoping no one sees it.
"We have chocolate pancakes ready for you." Mom yanks my blanket away and cold air hits my body.
"Fine, I'll get up."
I stumble through the hall and pass by six family portraits, all of me smiling widely. But one. One was taken a month after we moved, and my expression's sad. Crystal, despite hating this place too, grins like a Teen Vogue model. I must've been thinking about Gabriella.
Blueberries and pancake batter floats around the kitchen. On the table is one medium sized box and I know exactly what it is.
"Open it," my father orders.
Of course, it's the wonderful Nikon. Sleek, black, and very expensive.
"You can try it at the park. They just opened up a new pathway." Mom plops three pancakes on my favorite orange striped plate and fills a cup with milk.
"I will. Thanks, guys."
"You're welcome, Charles." I don't even look at the man.
Once I've scarf down the breakfast, I turn the pedals on my bike to the park, the Nikon slung over my shoulder in a protective bag. I just drop the bike- there really isn't much crime rate here- and head for that new path. I'm frustrated that nothing is even worth a shot on the outside. I step onto the dirt and peer further in the unknown forest.
Green. Everywhere is green. Sparkling. Glittering. Lush. Fresh. Have I found a parallel world? Several large gray stones scatter through the place, and one big tree stands alone in the middle. Suddenly I'm glad the sidewalk didn't open to this. It's pure, not a trace of human, all untouched like the desert we passed through to get here.
I feel magic. I don't even think about Gabriella, or Bay, or Chucky for any matter. All I do is let the camera take over me, fill me with excitement on all these great pictures I'm taking. When I notice the battery is half run down, I rest on a rock and lay back.
The clouds are slowly chugging their way through the sky. Pipsqueaks emit from around me, chirps bounce off the trees and into my ears. I can't hear industrial life, and my breathing is barely there. Am I even alive now? I'm so calm.
I just lay there. Forget the world, forget girls, I'm alone. Maybe this is what I've been needing for a long time now. To clear my head. A bright ray shines down on me, and as I look beyond the canopy of this forest, I see it breaking through a heavy cloud. Heaven.
For several hours I ignore everything. This is a pit stop. Something will come up and I'll have to get moving again. But now I'm going to enjoy what I have and live it.
Dinner is raviolis, but Crystal doesn't complain this time. I'm about to scoop up a bite when my father drops another bomb, the exact same as four months ago.
Crystal just about jumps up. "Again? Seriously! I was just making new friends, and I got on varsity volleyball!"
"Honey, season's over." My father is so damn indifferent.
"Not playoffs. I can't believe you're doing this to me!" She doesn't get up. Not yet. "East or west?"
My parents look at each other. "East."
"God, why not just move to another continent altogether!" Now Crystal leaves to sprint up the stairs and slams her door very loudly.
East? That's even more miles away from Gabriella. When will I ever see her again? I pull together my best Crystal face by scrunching up my nose and making my eyes go furious, but it probably looks like a fail, and I run up to my room and repeat her.
Moving? Why would my father tell me this on my fourteenth birthday? Especially after I've found an amazing place to breathe. I trap myself under my blanket and wait for sleep to come. Right when I'm about to doze off, Mom appears. I can smell lemon soap seeping next to me.
"I'm sorry, Charlie. He shouldn't have said that tonight. I told him to wait for a few weeks."
"When are we going?"
"First semester ends. We decided to give you more time with your friends."
I flinch. I don't know about Bay, or Chucky, if they're considered friends to me anymore. Mrs. Juntz keeps separating Chucky and me during labs, and it's a bit more awkward with Bay now in Mr. Luther's class.
"Oh" is all I can say.
"Goodnight, Charlie." The light evaporates from the crack in the door and my eyes slides shut.
The only thing that reiterate in my head is, when will I ever see her again?


text:
DEPUTY PM Nick Clegg landed in hot water this week after branding gay
marriage opponents "bigots".
The comment was released to the press before he hosted an event to mark the
end of the Government's consultation on same-sex partnerships.
Here, a campaigner against plans to redefine marriage hits back at the Lib
Dem leader.
Nick Clegg's comments are not only offensive, but also demonstrate how out of
touch he actually is.
No one in this country had an opportunity to vote on the Government's plans to
tear up the centuries-old definition of marriage, as none of the political
parties put this in their manifestos.
And why didn't they?
Because 70 per cent of ordinary men and women oppose them.
Even within the gay community, fewer than 40 per cent consider the change a
There are many issues surrounding these proposals.
The word "marriage" appears more than 3,000 times across UK legislation of all
types. It is impossible to simply change all of this with the stroke of a
And words such as "mother" and "father" could also come under threat.
In Spain, where gay marriage has been introduced, the country's government
axed these words — replacing them with "Progenitor A" and "Progenitor B".
If such terms are adopted here, the forces of political correctness will then
turn their attention to others.
Then there are genuine concerns about how this will impact upon other aspects
of people's lives.
Legal experts have warned that public sector workers and education will be
affected — even whether parents can object to gay-themed books being used to
teach their children.
Opponents to the move are already being targeted.
A housing manager in Manchester had his pay docked by 40 per cent just for
asking if gay marriage was "an equality too far".
And Lillian Ladele, a registrar in London's Islington, lost her post after
refusing to perform any civil partnerships.
The Government has also been warned that, under human rights laws, members of
the clergy could be hauled into court if they refuse to wed a gay couple.
Hospital and Army chaplains could be sacked for delivering sermons backing
marriage's traditional meaning — even though they may be doing so on private
It is very easy for politicians such as Mr Clegg to try to shut down debate by
using terms like "bigot".
But this only shows why he is unfit for high office.
Instead of alienating decent people, he should answer the key questions raised
by this potentially huge and unwelcome change to marriage.


text:
Canada should declare overdose deaths a national health emergency, said British Columbia Health Minister Terry Lake.
Lake made the comment while reeling from the release of the province's year-end illicit drug overdose statistics by chief coroner Lisa Lapointe on Wednesday.
A record-high 142 people died of overdoses in December, bringing the province's 2016 total to a staggering and tragic 914 deaths.
Lake says the province has taken unprecedented measures to try to address the crisis, including the opening of 20 overdose prevention sites in December, but the prevalence of fentanyl and now the even more dangerous carfentanil in street drugs has continued to push the death rate up.
The crisis unfolding in B.C. and elsewhere in Canada should also spark debate about how drugs are regulated in the country, Kendall said.
In the meantime, Lapointe is urging people dependent on drugs to access supervised services and not use alone.
All recreational or experimental drugs users are being told avoid using drugs altogether.
Lake said almost 100 overdoses were reversed at provincially-sanctioned overdose prevention sites since they started opening last month.
Had it not been for those sites, and other initiatives in response to the crisis, "many, many more lives would have been lost," Lake said.


text:
Crest Premedia Solution Walkin For Non Technical Graduates Freshers
Company Name: Crest Premedia Solution (P) Ltd
Position: Non Technical Graduates Freshers
Education: Any Graduate
Experience: 0 to 3 yrs
Salary: Not specified
Location: Pune
Currently we are hiring Fresher's with excellent written and verbal communication skill, who are looking for a bright career and want to be a part of Crest Premedia Solutions..
Job Specification :
Education: Any Non technical Graduate with good communication skills.
Soft Skills:
*Good communication skill in English (Written and spoken)*
Technical Skill: Microsoft Word
Company Profile:
Crest Premedia Solutions, a part of Springer Science+ Business Media (www.springer.com), is a 100% EOU, ITES company providing Outsourcing services for typesetting (journals, books & magazines), Premedia & software. The company is located at Pune"s leading IT Park.
How to Apply:
Walkin Date : 3rd to 12th Sep 2014
Time : 10 am – 4 pm
Walkin Address : Crest Premedia Solutions Private Limited., Fifth Floor, Wing A , Tower 9, Magarpatta City SEZ, Hadapsar, Pune 411013, Maharashtra, India
Get Daily Job Updates through Email – Click here to Subscribe


text:
Learning to Teach in Higher Education
€ 43,49
Bisher € 43,99
Lieferbar innert 2 Wochen
Mai 2003
BeschreibungThe classic text has a simple message: to become a good teacher, first you must understand your students' experiences of learning. Out of this grow a set of principles for effective teaching in higher education. This fully revised and updated new edition reflects a changed higher education environment, addressing issues of quality, standards and professional development in today's universities. The book includes new research findings and suggestions for further reading, while case studies of exemplary teaching connect ideas to practice.
InhaltsverzeichnisPart 1. Learning and Teaching in Higher Education 1. Introduction 2. Ways of Understanding Teaching 3. What Students Learn 4. Approaches to Learning 5. Learning from the Student's Perspective 6. The Nature of Good Teaching in Higher Education 7. Theories of Teaching in Higher Education Part 2. Design for Learning 8. The Goals and the Structure of a Course 9. Teaching Strategies for Effective Learning 10 Assessing for Understanding Part 3. Evaluating and Improving Quality 11. Evaluating the Quality of Higher Education 12. What Does it Take to Improve University Teaching?
Untertitel: 2 Rev ed. Illustrations. Sprache: Englisch.
Verlag: Taylor & Francis Ltd
Erscheinungsdatum: Mai 2003
Seitenanzahl: 288 Seiten
Format: kartoniert


text:
× View Today's Deals
You missed it This great deal for The Lighthouse Salon is over. But don't despair, we've got more great deals every day.
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text:
Eliot Chair4.8182 22 Reviews
The ideal intersection of Mid-century sophistication and today's ultimate comfort in an armchair.
Save $150 now through May 30th
0% APR as low as $33/month
Product Description
Why Joybird?
- Free Returns
- 365-Day Home Trial
- Lifetime warranty
- Buy direct from manufacturer
- Get a free swatch kit to help you decide
Product Specifications
- Additional Dimensions
- Leg
- 7"h
- Construction Details
- Frame
- Kiln dried hardwood. Once assembled, frames are wrapped in 2lb foam exceeding industry standards. Made with responsibly-sourced wood.
- Cushions
- 2.0 high density polyurethane foam combined with layers of fiber for superior seating comfort. Contains no flame retardants or harmful chemicals.
- Legs
- Solid beech
- Suspension
- Seat-sinuous spring back with poly webbing. Back-sinuous spring back with poly webbing.
- Joints
- Glued, stapled and screwed to ensure frame stability and longevity.
- Assembly
- Screw on legs
- Style
- Loose back; loose seat
- Glue and Stains
- Water-based, low-VOC
- Weight Limit
- 500 lbs.
- Product Care
- Vacuum
- Vacuum regularly with a vacuum attachment.
- Cushions
- Flip & rotate removable cushions to ensure even wear and increase longevity of your cushions.
- Sunlight
- Do not expose upholstered pieces to direct sunlight.
- Spot Cleaning
- Use a cleaning product that corresponds with your fabric's cleaning code. Always blot stains; never rub. Use a clean, dry, white cloth.
- Cleaning Code W
- Water. Use only water based cleaning products.
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- Solvent. Use only water free cleaning solvents.
- Downloads
- Tearsheet
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How it's Made
Take a look behind the scenes to see how our products are handmade. Get an in-depth looks into our factory and see the talented craftsmen working on your piece.
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Starting with kiln-dried hardwood, Eliot's eco friendly as it is elegant. Constructed without harmful chemicals or flame retardants, every effort is made to recycle the materials we don't use. As if lounging on your new furniture couldn't get any better.Create Yours
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What is it that makes Eliot a superstar? Perhaps it's never-boring attitude, timeless and versatile style, and commitment to comfort. From its handmade, tapered wooden legs to its button tufting, every inch is simply the best and built to last.Create Yours
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Enjoy sitting upright comfortably against the nearly 90-degree angled frame.
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Our Eliot is a go-to for its sophisticated shape, sheltering arms and firm comfort that we consider unparalleled. Give your home the right amount of Mid-century modern cool in all the right spaces with this totally versatile design that's equally at home in the living room or bedroom.View Photo Gallery Create Yours
Handcrafted Just for You
We'll keep making furniture the old-fashioned way. Each piece is cut, glued, screwed, upholstered, and finished by our skilled craftsmen and women at our workshop.
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With over 100 colors of fabric and leather to choose from, go ahead and brag to your friends that you're the designer. We won't stop you.See It In Every ColorCreate Yours
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Request one of our free swatch kits and bring the showroom to you. See, touch and experience them for yourself.SEND A SWATCH KIT
Customer Reviews
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text:
Series: Cambridge Library Collection - Earth Science
856 pages, 25 b/w illustrations
A reprint of a classical work in the Cambridge Library Collection.
Adam Sedgwick (1785-1873), one of the founders of modern geology, was Woodwardian Professor of Geology at Cambridge from 1818 until his death. During his career, advances in stratigraphy and palaeontology revolutionised the subject, and Sedgwick participated in heated controversies about the classification of the oldest rocks. His fieldwork companions included John Stevens Henslow, Roderick Murchison and the young Charles Darwin, and the specimens he acquired propelled the Cambridge geological collection to international importance.
Sedgwick invited a young Irish palaeontologist, Frederick McCoy (1821-99), to catalogue the collection. In 1854 McCoy moved to Melbourne, Australia, where he spent the rest of his career energetically promoting scientific education and creating another impressive museum. Sedgwick oversaw the publication in 1855 of McCoy's catalogue of Palaeozoic fossils. His substantial introduction reveals Sedgwick's insistence on scientific precision and his growing impatience with rival proposals, which later culminated in his sceptical response to evolutionary theory.
- Introduction
- Description of the British Palaeozoic fossils in the Geological Museum of the University of Cambridge
- Plates
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View all titles in Britain & British Isles (GEN) combined with History of Science


text:
|Norelli, John (jay) - Jay
|Bassett, Carole
|Farrell, Jr., Robert
|Baldo, Angela
|Malnoy, Mickael
|Borejsza-wysocka, Ewa
|Lalli, Donna
|Korban, Schuyler
|Gardiner, Susan
|Wisniewski, Michael
|Celton, Jean-marc
|Aldwinckle, Herb
Submitted to: Plant and Animal Genome Conference
Publication Type: Abstract Only
Publication Acceptance Date: 11/1/2007
Publication Date: 1/12/2008
Publication URL: http://intl-pag.org/16/abstracts/pag16_P05h_455.html
Citation: Norelli, J.L., Bassett, C.L., Farrell, Jr., R.E., Baldo, A.M., Malnoy, M., Borejsza-Wysocka, E., Lalli, D., Korban, S.S., Gardiner, S.E., Wisniewski, M.E., Celton, J., Aldwinckle, H.S. 2008. Using functional genomics to develop tools to breed fire blight resistant apples. Plant and Animal Genome Conference. P. 455. Interpretive Summary:
Technical Abstract: Fire blight, caused by the bacterium Erwinia amylovora, is a destructive disease of apple (Malus), pear (Pyrus) and other plants in the rose family (Rosaceae). Suppression subtractive hybridization (SSH) using cDNA from pathogen and mock-inoculated samples, and cDNA-AFLP analysis were used to identify over 650 ESTs associated with the response of apple to fire blight challenge. ESTs were ranked for their potential impact on resistance based on bioinformatic analysis and inferences drawn from model systems and the scientific literature. Simple sequence repeat (SSR) and single nucleotide polymorphism (SNP) markers derived from highly ranked fire blight EST candidate genes were mapped in a M.9 X Robusta 5 population in which a major QTL for fire blight resistance has been located on Linkage Group 03. Candidate genes were mapped to this QTL, as well as, to the positions corresponding to the location of at least two QTLs reported in other populations (Calenge et al. 2005, Khan et al. 2006). These markers are being evaluated for their potential application in marker assisted selection. The expression of highly ranked ESTs is being determined in resistant (G.41) and susceptible (M.26) apple rootstocks. RNAi mutants of highly ranked ESTs are being selected using a high-efficiency transformation and selection system developed for Malus. This project is supported by a National Research Initiative Competitive Grant 2005-35300-15462 from the USDA Cooperative State Research, Education, and Extension Service, and by the New Zealand Foundation for Research, Science and Technology, contract no. C02X0406.


text:
DLA Piper joint chief executive Nigel Knowles looks set to stand unopposed for reelection.
According to a spokesperson at the firm the period for partners to put themselves forward as candidates for the joint chief executive role lapses at the end of this month. At present, Knowles is the only candidate.
Knowles' three-year term as joint chief executive comes to an end next month. If successful, he will begin his new term in January 2012.
Knowles shares the chief executive role with Lee Miller, who is based in Chicago.
Earlier this month DLA Piper hired former Linklaters chief Tony Angel as senior partner of the firm's international LLP, the non-US side of its business (8 November 2011).


text:
Long Island: People and Places, Past and Present
A 2nd Edition of the history of Long Island, New York, it begins with the geological formation and updates to the present day. Illustrated with photographs, paintings, drawings, documents and maps.
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text:
J&K Java Kitchen Cabinet Dealer Showroom Sale in Casa Grande AZ
Casa Grande J&K Cabinet Dealer Showroom Special Sale
$5795 – $6195 10′ X 10″ Java Kitchen Remodel with All the Cabinets, Trim, Toe Kicks, Custom Granite Countertops and Frigidaire Stainless Steel Appliances Delivered & Installed in 3 Weeks
Stop in our showroom today! 1147 E Florence Blvd. Casa Grande, AZ 85122 or call us at 520-705-9354. You can visit our website at http://pinalkitchencabinets.com/
Spread the love


text:
Tony Addison
Executive Director
Brooks World Poverty Institute
University of Manchester
Manchester, M13 9PL England
He was previously deputy director of the United Nations University's World Institute for Development Economics Research (UNU-WIDER) in Helsinki. He has also held positions at the University of Warwick, the School of Oriental and African Studies (London University), and the Overseas Development Institute (London). He began his career as an ODI fellow in Tanzania, and is a graduate of the University of East Anglia and Birkbeck College, London University.
His publications include From Conflict to Recovery in Africa (Oxford University Press), Debt Relief for Poor Countries (Palgrave Macmillan), and Fiscal Policy for Development (Palgrave Macmillan), as well as papers in the Journal of African Economies, the Journal of Development Economics, Journal of International Development, Journal of Peace Research, World Development, and World Economy. He is currently working on chronic poverty, post-conflict reconstruction, and development finance.
Focus: Development, Finance, Poverty, Security, Tax, Finland, Tanzania, United Kingdom, Africa, Asia, Europe
Link: http://www.sed.manchester.ac.uk/idpm/
Related Resources:
- Income Distribution Policies for Faster Poverty Reduction (Policy Library)
Selected Publications:Tony Addison's papers at UNU-WIDER
Language Fluency:English
Last Updated: Apr 27, 2009


text: Cnc Machined Milled Hydraulic Parts - Jingjiang Jinlun Machince Manufacturing Co.,ltd. Toggle navigation TRADE DEALS Products Companies Product Company Search LOGIN E-mail Password Remember me Join Free JOIN FREE HomeTextiles & Fabrics Textile Related Services Cnc Machined Milled Hydraulic Parts PRICE: contract price Product Description Machining competences: CNC cutting, turning, milling, drilling, threading, grinding, hobbing, etc.Advanced CNC equipments ensure the precision accurate. Skilled workers had long experiences of CNC machining. We are skilled to machine many kinds of metals and non ferrous metals, like the stainless steels, alloy steels, carbon steels, tool steels, coppers, bronzes, aluminums, etc. Machining ranges: Diameter up to 1800mm, length up to 5000mm. Other products Gear square splined drive shafts Price: contract price Stainless steel valve shafts handles Price: contract price Gear tooth ring gear Price: contract price Solid ball tractor pins Price: contract price Company Info Jingjiang Jinlun Machince Manufacturing Co.,ltd. Contact Person: Li Xia Phone: 86-523-84208366 Contact now × Contact form Your name: Your E-mail: Your Phone: Subject: Enter a message: Close


text:
I participated in a campaign on behalf of Mom Central Consulting for Cascade. I received a product sample to facilitate my review and a promotional item as a thank you for participating.
It's week 4 of the Cascade Platinum Ambassadorship and I have to say that I am loving the sparkle that the Platinum puts on my dishes. The glasses look so bright and shiny that it almost makes it appear as if my fruit juice actually sparkles!
If you stare at the glass hard enough, you can see a bit of my reflection and my gray cardigan I was wearing in the glass. That is how sparkly the dishes are, they reflect well!
Since we've been using the Platinum pacs in our home, we have noticed that our dishes, silverware, and glasses are all sparkling shiny. Also, as I mentioned in my last post, we've seen an improvement with the inside of the dishwasher. We have really hard water here and I've noticed that the inside of our dishwasher is much cleaner than it used to be. The Platinum pacs cut down on hard water so that the inside of your dishwasher is left sparkling also!
Don't forget that the Cascade Platinum Instagram contest is now in it's 4th week. This week the focus is My Platinum Table. To enter, visit the website and register and be sure to tag your photos on Instagram with #MyPlatinum and @MyCascade in order to correctly be counted for an entry.
My family will definitely continue to use and purchase the Cascade Platinum pacs for the dishwasher. We have faithfully used Cascade products and have had a strong brand loyalty to them for years. Simply put, I believe they are the best. The new platinum pacs come in fresh and lemon burst scents and you can visit their website to find a retail store near you that sells the pacs.
Just say no to water spots, and yes to the cleaning power of Cascade Platinum.


text:
It only takes a minute to get started. Fill out our simple sign up form and login to the site.
This step is up to you but will seriously boost your chances of getting interest from other over 50s members on the site. Write a few sentences about yourself, your interests and upload some good photographs of yourself.
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Identified someone who could be a good match? Send them a message or just a wink and take it from there. With a little luck you'll be on your way to an amazing adventure.
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text:
The Aparthotel Green Garden Cala Ratjada is a beautiful establishment in a natural setting that has won the property the international EMAS environmental protection recognition. Its manmade facilities and buildings are so subtle that they fuse imperceptibly with the diaphanous world of Nature.
Rooms Description:
All guest rooms are equipped with: private bathroom terrace or balcony with view of garden or pool music satellite TV airconditioning safe refrigerator kitchen. Apartments feature an extra lounge with two sofabeds.
Facilities and Services:
24hour front desk Air conditioning ATMCash machine Bilingual staff Brailed elevators Car rental desk Check cashing policy Currency exchange Doctor on call Elevators Exercise gym Florist Accessible facilities Heated pool Housekeeping daily Indoor pool Jacuzzi Live entertainment Massage services Outdoor pool Playground Pool Poolside snack bar Ramp access Restaurant Safe deposit box Sauna Wakeup service Wheel chair access Whirlpool Multilingual staff Video games Public area air conditioned Buffet breakfast Communal bar area Continental breakfast Loungesbars Limited service housekeeping High speed internet access for laptop in public areas Phone services Children play area Early checkin Nonsmoking rooms generic Bicycle rentals Late checkout available Children welcome Hotspots Internet services Child programs Hair dryer Heated guest rooms Toilet Video game player Handicap rooms Kitchenette Private bath or shower Fire safety compliant


text:
Shakespeares has launched a fresh redundancy round with 19 secretarial roles put at risk of being cut across its seven offices at the end of the month.
The firm launched the consultation with 19 of its 100 secretaries, with five positions expected to go from its insurance team in Birmingham and 13 across the firm's other offices, a source close to the firm confirmed today.
Shakespeares will also create 18 new administrative roles, nine of which will be "comparable" to the secretarial positions according to the source, while nine will be back office positions based in cash office and document management.
Some of the departing secretaries may be hired as adminstrators, performing paralegal as well as secretarial work.
Shakespeares has been expanding rapidly for the past six years, with two bolt-on acquisitions announced earlier this week, adding 97 new members of staff (5 September 2013). The firm has confirmed the addition of Leicester-based Marrons, first mooted in May (31 May 2013) while also tying up with Coventry-based Newsome Vaughan.
Shakespeares first launched a redundancy consultation in September last year (5 September 2012) cutting 54 roles following its largest merger to date with Harvey Ingram in July (16 July 2012), which made it the second largest in the Midlands behind Wragge & Co.
At that point staff numbers had doubled – shooting from 398 to 680 by April 2012. This year the firm's revenue increased by 34 per cent, going from £29.6m in 2011/12 to £39.6m in 2012/13 (1 July 2013).


text:
Why Breast Implant Prices Vary by Type and Size
posted on
What is My Breast Implant Type and Size?
When comparing breast implant prices from different surgeons, you'll notice a significant difference in costs for different types of implants and procedures. Most breast implant surgeons don't set flat-fee breast implant prices and instead work by extending a quote based on several factors related to your particular surgery. Contact a cosmetic surgeon or board-certified plastic surgeon in your area to discuss the different sizes and types of implants available and their respective costs.
When you go in for a breast augmentation consultation, your breast implant doctor will take the time to learn about your goals and determine whether you'd be a good candidate for silicone implants or saline implants. Some surgeons prefer one breast implant type over another and will explain why during your visit. Click here to see some of our breast implant before and after pictures to see cases similar to yours. Before you meet with your surgeon, read more about the difference between silicone and saline implants, and check out our breakdown of breast augmentation costs.
What Are Some Factors Related to Breast Implant Prices?
- Size of your implants
- Type of surgery: breast augmentation, breast lift or breast reduction (combination)
- Silicone implants or saline implants
- Brand of implants (Mentor® or NATRELLE®)
- Shape of implant (round or teardrop)
- Incision location (armpit, belly button, etc.)
Why Are Breast Implant Prices Different?
Since breast implant cost vary significantly from surgeon to surgeon, it's in your best interest to compare fees from at least three or four breast implant surgeons or board-certified plastic surgeons in your area. Set up a consultation with each surgeon and request a customized quote from each. Most breast implant surgeons offer free consultations and are willing to extend a quote or special offer immediately after your visit.
Keep in mind that going with a surgeon who offers the lowest breast implant prices may mean you're compromising on the quality of your surgery or working with a surgeon who doesn't have as much experience or as many skills as other more qualified surgeons.


text:
A van driver targeted families in a hit-and-run "journey of mayhem", killing one mother and leaving another 17 people injured, a court has heard.
Matthew Tvrdon, 32, is believed to have set out to kill parents with children after splitting up with his girlfriend.
Over 30 minutes, Tvrdon, who has paranoid schizophrenia, drove eight miles around Cardiff aiming for young mothers walking children home from school. Tvrdon ploughed into a mother of three, Karina Menzies, 31, hitting her three times, reversing to drive over her again and leaving her with fatal injuries.
Ian Murphy QC said: "Tvrdon deliberately targeted five family groups and in each incident intended to kill at least one member of that family.
"It was a journey of mayhem, it covered a distance of eight miles and a duration of 30 minutes. It was a series of deliberate and horrific incidents.
The court was told that in interviews with psychiatrists, Tvrdon claimed he had targeted people who had been "gas-lighting" him – trying to make him think he was insane.
"I do admit I wanted to kill those people, just recognising the faces of the people who had been involved in the gas-lighting. I just wanted revenge on them," he said.
Cardiff crown court was told the victims were all strangers to Tvrdon, who had an office job but had been sleeping rough after falling out with his girlfriend. He had no criminal record and no previous driving offences.
The court heard on Wednesdaythat Tvrdon aimed his three-tonne van at Menzies as she walked her two children – Ellie, eight, and Tiana, four – home from school.
Murphy said: "The van veered across the carriageway and drove directly at Karina Menzies and her two young children on the forecourt of a fire station, striking all three.Witness Kevin O'Callaghan, who saw what happened, told police: "This van suddenly veered off and drove to the other side of the road straight at a woman and two young children. All I remember is bodies flying through the air. The only way I can describe it is that it was like skittles. He then swung the van around in the forecourt and I could hear the engine revved up high.
"He then drove straight back at the female. I saw her moving slightly – he drove back over her and she got stuck under the vehicle and was dragged for 10 to 20 feet.
"He was running out of room so he hit the brakes. The van came to a stop just before a brick wall so he reversed it, which meant running over the body again with one of his wheels."
Another witness, Samuel Fowler, saw Menzies desperately throw her children out of the way of the van as he turned to hit them.
Fowler told police: "She raised herself up and had hold of a child. She was trying to push her daughter out of the way – the van just drove straight at them. She had her free hand up to gesture to stop and was screaming." Both her daughters were hurt, but have made full recoveries from their physical injuries.
The court heard that Tvrdon's drive started on a Friday afternoon in Ely, Cardiff, just as children were pouring out of school.
Murphy said: "Karina Menzies and all the others attacked by Tvrdon were strangers. They were in places where they should have been safe. None of them had done or said anything to Tvrdon to attract his attention, let alone this violence. "
The court heard how Tvrdon had driven erratically and dangerously earlier in the day in his black Renault Clio. CCTV footage captured him parking the Clio close to the home of his girlfriend, Lisa Davis, and getting into his white Iveco van.
Davis approached him and tried to stop him leaving, but he ignored her and drove off.
His first victim was Mandy Morgan, 30, who was walking with her children Kieanoh, eight and Deeroy, nine. His next targets were Adam Lewis, 25, and his partner Anastasia Jones, 22, who were pushing their baby daughter, Amelia May, in her pushchair. Amelia May, two, was catapulted through the air in a terrifying attack caught on shocking CCTV footage.Tvrdon then aimed the van at Menzies. A few minutes later, Tvrdon ran over Aalyiah Selio, 31, and her daughters Jadah, 10 and Shaielle, 12, outside shops. They had been browsing for birthday cards.
Finally he ploughed into Rebecca White, 27 and her mother Gill, 49, as they left Asda with their shopping.
Murphy said: "Tvrdon then attempted to escape from the police who were pursuing him."
Tvrdon, of Cardiff, admitted manslaughter on the grounds of diminished responsibility. He pleaded guilty to seven counts of attempted murder and other offences.
Murphy said Tvrdon's condition "affected his ability to recognise what was going on around him and to exercise self-control".
The court was told Tvrdon believed people were "gas-lighting" him, a term that comes from the 1944 Ingrid Bergman film Gaslight, in which a husband tries to convince his wife and other people that she is insane.
In interviews with psychiatrists, Tvrdon claimed Menzies and her children had been gas-lighting him in a supermarket.
He told psychiatrists that when he saw them in the street, he deliberately sped across at them. "It all happened in a blur – it was a fast and furious thing that happened," he said. "I just ploughed straight into them. I guess I wanted to kill her and her children. I had become really revengeful at that point. I knew I was doing wrong."
Tvrdon worked at tax offices in Cardiff, where colleagues had described him as acting bizarrely in the days before the incident. He told police he was stressed from breaking up with his girlfriend and had been sleeping rough in his van.
The court heard there is a history of mental illness on both sides of his family.
Murphy said: "His mental health issues started in his late teenage years, manifesting themselves as mild hypochondria. By 2003 he had a severe psychotic illness and was out of touch with reality.
"At this point he was involuntarily admitted to a mental health hospital after jumping out of a window."
The court heard that in 2007 Tvrdon was apprehended carrying an airgun and was sectioned under the mental health act.
It was found he was suffering from auditory hallucinations and believed people were conspiring against him. Murphy said: "However, he is able to mask the symptoms and convinced a tribunal to release him."
"He was last seen in 2011 when he was considered to be mentally well. After this he decided to stop taking his anti-psychotic medicine."
Paul Keleher QC, defending, argued Tvrdon should be sent to a mental hospital and not prison. He said: "If he hadn't been ill, this would never have happened."
The court heard Tvrdon had spent time in a psychiatric hospital, but was not considered a danger to society.
Keleher said: "Because Tvrdon had never displayed any signs of being a danger to himself or anyone else by 2011, he was effectively signed off.
"He was advised to continue his medication, but to cut it down every two months until stopping completely.
Tvrdon will be sentenced onThursday.


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Christmas is right around the corner and starting tonight, we are offering FREE 2nd Day Air Shipping for orders over $75!!! This offer is only valid for online orders and we cannot reimburse or refund any shipping charges prior to this promotion. Personalized golf balls as well as custom and special orders will not be able to be shipped 2nd day but rather UPS Ground. In the event that we cannot fulfill order because the item is out of stock or is backordered, we will notify you within 24 hours via phone and email to let you know your order status and will ship those items via UPS Ground when they become available. If you have waited until the last minute to shop for that special someone, take advantage of our FREE 2nd Day Air promotion today! This promotion will expire on December 20th, no exceptions. Happy Holidays!
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Posts Tagged 'golf clubs'
FREE UPS 2nd Day Air Shipping Holiday Promotion!!!Thursday, December 16th, 2010
What are the aspects to consider when buying a golf travel bag?Monday, March 8th, 2010
A wide variety of golf travel bags is now available with several value-adds and stunning styles. They come with several interesting, user-friendly features to meet your needs. Following are the important things to keep in mind while selecting a golf travel bag: (more…)
What are the attributes of user-friendly golf equipment resource?Tuesday, February 16th, 2010
There is a section of golf professionals and coaches who believe that your game can significantly improve if you make use of the golf clubs and other golf equipment well suited to your style and level of play. (more…)
What are the new rules that have confused tour professionals?Thursday, February 4th, 2010
The USGA and The Royal & Ancient (R & A) introduced rules this January aiming to stop tour professionals from imparting excessive spin on balls while playing out of rough, long grass. (more…)
Why is it a wise idea to go for used clubs?Wednesday, December 30th, 2009
It is advisable for a non-proficient golfer or new learner to not to rush through the decision.
Beginners on the course, just learning the tricks of the game, should be no hurry to purchase used clubs. They should take a decision with care after taking a good look at the piece you are buying and ideally, by seeking expert advice. Most golfers have a tendency to throw away their old clubs to purchase a better or superior golf game. (more…)
Adams RPM Iron Set ReviewThursday, June 4th, 2009
Rev up the car and prepare it for some new toys! The Adams RPM Iron set is a solid set at a solid price point that not a lot of people know about. The irons are oversized heads with a cavity back design. (more…)
Tour Edge Bazooka QLS Iron Set ReviewMonday, April 6th, 2009
Tour Edge Golf has become famous for bringing high quality golf products at affordable prices. The New Tour Edge Bazooka QLS Iron set is no exception. The All Stainless Steel Iron head has all the features that the average golfer is looking for, and is willing to pay. (more…)
Cleveland CG7 Iron ReviewWednesday, January 21st, 2009
The New Cleveland CG7 Irons are coming out and I had a chance to hit them on our launch monitor. At first glance it is very eye appealing with its classic look with a little tech behind it. (more…)
Points To Consider Before Buying Golf ClubsThursday, July 3rd, 2008
The golf clubs are the most important accessories for your game. So before you buy them, it is important for you to consider the following points (more…)
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Chapter Four
Jen met me at Riverside cafe just as we had arranged.
"So, how was your first day?"I asked after we had ordered drinks and food.
"It wasn't that bad to be honest. Paul Tyner was a bit of a nuisance but then we can't hope for miracles there can we?"
"I suppose not." I looked over the river and sighed.
"Alright, what's up?"
"Nothing." I saw the look on her face and laughed in an attempt to convince her. "Seriously, nothing is wrong. I'm just a little zoned after the first day back. On the plus side, it looks like our Romeo and Juliet trip is quite popular, at least in my class."
"That's good. If only my class would be so enthusiastic."
"Just give them time and mention the shopping trip. That's what spun it for my group. Well for most of them."
"Kieran was happy to go as soon as I said that I was going."
"Ah Kieran. He does cheer me up with all his flirting. Although I must admit he does seem to like you more than the rest of us. You might have to watch yourself there. You know what young boys with hormones are like."
"He's only a joker. He doesn't mean it."
"I hope for your sake that's true." I thought of Charlie and how she looked at me. Maybe I was in danger from another student. "Summer? Summer, you've gone again."
"Sorry. I told you, I'm zoning." Luckily our food came and we spent the next few minutes tucking in to the best tuna pasta bakes I've ever had. After our meal we parted, and I returned home to attempt some more of my book.
Two hours later I gave up, turning off my laptop and throwing down my notes. Carrie and David weren't meant to be, I was sure of that now, but I didn't know who else to bring in. I rubbed my eyes in an attempt to shove away the tiredness, and decided that enough was enough. It was time for bed.
My last thought before I dozed off was about who Carrie could love. There were only three more main characters; her best friend Sally with whom she shared a flat, George who worked for David as his personal assistant, and her aging father in a nursing home. Somehow I couldn't see Carrie with George, who was too uptight for her fun loving ways, but Sally...


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We are pleased to offer the following equipment that may benefit those who have had a stroke, traumatic brain injury, spinal cord injury and other neurological diseases, like multiple sclerosis and cerebral palsy.
Lite Gait (Pediatric and Adult)
The Lite Gait is a lift and harness system that supports a patient over a treadmill while they practice walking with a therapist's assistance. The technique is called "body-weight-supported treadmill training" (BWSTT) or "partial-weight-bearing treadmill." BWSTT has undergone extensive research in the last two decades and is shown to enhance walking ability for adults and children who suffered specific types of stroke, amputation, spinal cord injury, or bran injury, or who have conditions such as Parkinson's disease, multiple sclerosis, cerebral palsy, or Down syndrome, and many other mobility impairing diseases. BWSTT can benefit individuals whose walking is severely impaired even years after the disease onset or injury date.
The NeuroMoverTM
The NeuroMoverTM utilizes both electrical stimulation and biofeedback to improve muscle movement of the arm or leg by providing both visual and sensory feedback. As the individual uses the NeuroMoverTM it monitors their attempt at muscle movement. The individual watches a screen and is provided with visual feedback when muscle movement is achieved. Then, the NeuroMoverTM provides electrical stimulation to facilitate muscle contraction. Through this system the individual learns to control their muscle movement. The sensitivity of the NeuroMoverTM can be adjusted as the ability to control the muscle movement improves.
The SaeboFlex and SaeboReach
The SaeboFlex is a custom-fabricated orthotic used to improve grasp and release. The SaeboFlex places the wrist and fingers in extension. Then due to the support provided by the SaeboFlex, the individual is able to grasp an object by voluntarily flexing his or her fingers. An extension spring system assists in re-opening the hand to release the object. People, up to 20 years after a neurological injury, have been found to benefit from treatment using the SaeboFlex.
Upper extremity function does not stop at the wrist and hand. For many with a hemiparetic arm where the elbow cannot flex and extend, the SaeboReach may be appropriate. The SaeboReach is similar to the SaeboFlex, with a custom-fabricated above the elbow attachment that facilitates use of the elbow during grasping and releasing.
The assessment and fitting of the SaeboFlex or SaeboReach is completed by a Saebo certified therapist.
The Hand MentorTM
The Hand MentorTM is used to help restore range of motion and strengthen muscles of the wrist and hand by facilitating active movement of the wrist and fingers using biofeedback and pneumatic active assistance. The Hand MentorTM has three programs to reduce spasticity, improve motor control and recruit specific muscle groups.
Pressure Mapping
Pressure Mapping is used to determine what type of wheelchair cushion is needed. When skin is pressed between a bony area of the body and a firm surface such as a bed or wheelchair, the pressure can cut off blood circulation to the tissues resulting in a pressure ulcer. Pressure Mapping is a computerized system that uses a sensor pad placed between the body and another surface to produce a color-coded picture showing exactly how much pressure is exerted and where. Different wheelchair cushions then can be tried to determine the best one. Pressure mapping can also be used to determine the best positioning in a wheelchair such as leg rest height, slant of the seating surface, armrest height and special positioning aids.
VitalStim Therapy
VitalStim Therapy is the only FDA cleared therapy treatment approach that successfully combines electrical stimulation and traditional swallowing therapy. Electrodes are placed on the muscles of the throat that are involved with swallowing. The electrical stimulation combined with swallowing therapy improves the quality of muscle contraction. This therapy is provided by a VitalStim certified speech language pathologist.
Wii, WiiFit and EyeToy
These three devices provide an interactive therapy experience to address strength, coordination, postural control, balance, weight shift and range of motion through games. Research has shown that multiple repetitions for physical movements are needed to stimulate recovery or the neurological systems. These devices, by virtue of being games, provide much needed motivation and fun to therapy.
Interactive Metronome
Interactive Metronome (IM) allows patients to attempt to match rhythmic beats heard through headphones with repetitive hand and foot movements; it supports the retraining of the brain by helping patients stay focused longer on the actions they are doing and provides auditory and visual feedback in the process. This therapy program can be helpful for individuals who have experienced a range of illnesses or injuries, such as traumatic brain injury or stroke.
The Rehabilitation Institute of Kansas City (RIKC) exists to help those we serve achieve greater independence at home, school or work, and in the community
Events like: A Day at the Lake and Baconfest give RIKC a chance to show the community what we're all about.
RIKC Exists because of generous individuals just like you, help us continue the tradition of helping others.


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www.rodsreelsbaits.com The website specializes in fishing products which includes various types of rods, reels and numerous type of different baits. We offer baits that are hot on the market for differnt types of fish, baits that are used by professional angles in competions in USA and Canada. Also we provide other fishing accesorites like fishing lines, hooks sunglasses.
Fishing products and accesories 4
by seovideo0710


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Popular Now
Popular Now
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01803 865913
+44 1803 865913
By: Chen Wen-Pin (Author)
519 pages, colour photos
Huayu Nature Book Trade Co.Ltd
Language: Chinese with scientific nomenclature and English summary
As the first illustrated handbook comprehensively introducing the native plants of Northern Taiwan in recent years, Native Plants of Northern Taiwan has been compiled using the most recent botanical research findings, and serves as a detailed guide to more than four hundred native plants of Northern Taiwan with rich and original information and high-quality pictures.
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ED Magedson – Founder
Ripoff Report
Timeshare InvestorsHoustib, Texas United States of America
Does your business have a bad reputation?
Fix it the right way.
Corporate Advocacy Program™
This report was posted on Ripoff Report on 06/16/2012 01:28 PM and is a permanent record located here: http://www.ripoffreport.com/reports/timeshare-investors/houstib-texas-/timeshare-investors-nick-charles-and-laure-promised-that-there-was-a-buyer-from-a-company-898454. The posting time indicated is Arizona local time. Arizona does not observe daylight savings so the post time may be Mountain or Pacific depending on the time of year.
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Plants → Magnoliophyta → Magnoliopsida → Fabales → Fabaceae Lindl. → Vigna Savi → Vigna radiata (L.) Wilczek
Perennial or annual, herb or climber, to 3 m high. Fl. white-cream-yellow-purple, Feb to May. Clay, sandstone, basalt. Floodplains, grasslands, drainage depressions, tidal flats.
Beard's Provinces: Northern Province.
IBRA Regions: Central Kimberley, Dampierland, Northern Kimberley, Victoria Bonaparte.
IBRA Subregions: Fitzroy Trough, Mitchell, Mount Eliza, Pindanland, Victoria Bonaparte P1.
IMCRA Regions: Kimberley.
Local Government Areas (LGAs): Broome, Derby-West Kimberley, Wyndham-East Kimberley.
Publication or other use of content on this site is unauthorised unless that use conforms with the copyright statement.


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This competition is now closed.
This summer, Tate Britain presents a major exhibition of landscapes by the much-loved British painter LS Lowry (1887-1976). This is the first show held by a public institution in London since the artist's death. Bringing together around eighty works, the show aims to re-assess Lowry's contribution as part of a wider art history and to argue for his achievement as Britain's pre-eminent painter of the industrial city.
Our exclusive readers evening on Monday 15 July offers you a chance to see the exhibition away from the crowds, with drinks and nibbles, as well as art guides within the exhibition to answer any questions you may have. Taking place at Tate Britain (entering via the Manton entrance), the event begins at 19.00 and runs until 22.30.
To be in with a chance of winning one of 100 pairs of tickets to this exclusive event, enter your details below.
Terms and conditions
Promotion closes at 23.59 Sunday 23 June 2013. There are 100 prizes of a pair of tickets to the Lowry and the Painting of Modern Life exhibition Independent reader evening on Monday 15 July 2013 at Tate Britain. The winners will be the first 100 entries selected at random after the closing date and will be contacted by email by Friday 28 June 2013. The prizes are non-transferable and there is no cash alternative. When you respond, Independent Print Ltd may use your information to contact you with offers/services of interest by SMS or email. Only one online entry per person. Promoter: Tate Britain. Usual promotion rules apply. For further information, please write to Customer Care, Room 203b, Independent Print Ltd, Northcliffe House, 2 Derry Street, London, W8 5TT.
To find out more about the exhibition click here
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text:
Order a Big Mac from a mobile app
You can soon order your favorite McFoods on your smartphone.
McDonald's is testing a new mobile app that lets customers order food online, and then drive to curbside check-in spots outside the store.
Customers register with an email, password and credit or debit card number.
The online order is still in the testing phase and is only available at a handful of McDonald's in Georgia and Alabama.


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ED Magedson – Founder
Ripoff Report
Jereonisha Nelson, blue hippoHouma, Louisiana U.S.A.
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This report was posted on Ripoff Report on 01/12/2009 03:17 PM and is a permanent record located here: http://www.ripoffreport.com/reports/jereonisha-nelson-blue-hippo/houma-louisiana-70364/jereonisha-nelson-blue-hippo-computer-houma-louisiana-411203. The posting time indicated is Arizona local time. Arizona does not observe daylight savings so the post time may be Mountain or Pacific depending on the time of year.
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SailNet Community (http://www.sailnet.com/forums/)
- Gear & Maintenance (http://www.sailnet.com/forums/gear-maintenance/)
- - Toe Rail Replacement (http://www.sailnet.com/forums/gear-maintenance/53698-toe-rail-replacement.html)
Toe Rail Replacement
Has anyone replaced the toe rail on thier boat? I am considering this for the fall but trying to get some background before investing money and time. The boat is a 1979 Sabre MKI 34. It is a teak toe rail. I have the spec from sabre and can have a local shop mill the rail and generate the plugs. The other option would be to replace with an aluminum rail.
The difficult part is getting to some of the existing bolts. The concern is with the seam where the deck and hull join it appears to be glassed/epoxied but not certain. Any thoughts from those who have taken on a similar project would be appreciated.
I have seen it done on a J24 and bending the toe rail while lining up the screw holes and getting sealent under it seems to be the BIG issue :)
Re: Toe Rail Replacement
Hi, did you ever undertake this repair? I am considering a used Sabre 34 mark ii and the toe rails clearly will need to be replaced, wondering how large an issue it may be. Thanks and hope it went well.
Re: Toe Rail Replacement
Wondering the same thing. Did you ever go through with this project?
Re: Toe Rail Replacement
I've added a teak toe rail to a modern 33 ft yacht.
The toerail was done in pieces to fit between the stanchions, holes for screwes were pre-drilled and sunk in the toe rail as well as the deck. Goop was added under the rail which was then placed onto the first screw hole.
One person screwed it in place while the other bent it upwards. As the rest of the screws were put in place the person holding the toe rail bent it to match the screw holes in the deck.
Some goop got where it shouldn't have gone, but a bit of sanding the teak deck got rid of it.
Re: Toe Rail Replacement
Make sure to avoid using full scarf joints. A stopped joint will last a lot longer. Pointy top ends don't last long.
Re: Toe Rail Replacement
We took our toe rail off (with all the other deck hardware) to paint the deck. We had a very difficult time getting the thing back on. Didn't help that we were a month late for launch, and it was 100 degrees out. At the time, I thought the original installation was easier because they would have just drilled the holes through the wood and deck and dropped a bolt in rather than try to line up existing holes.
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FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.
Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa, Iowa City, IA
∗CORRESPONDENCE TO: Gregory A. Schmidt, MD, FCCP, Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, Department of Internal Medicine, 200 Hawkins Dr, C33-GH, University of Iowa, Iowa City, IA 52246
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
The inferior vena cava (IVC), a capacitance reservoir leading directly to the heart, encodes valuable hemodynamic information. When examined throughout the respiratory cycle, dynamic changes in the IVC diameter (ΔIVC) can guide fluid resuscitation,, akin to other dynamic predictors such as pulse pressure variation and respiration-related changes in stroke volume, arterial flow velocity, and ventricular outflow tract velocity time integrals. During positive pressure ventilation of the passive patient, inspiration raises the pleural, juxtacardiac, and right atrial pressures much more than abdominal pressure, transiently depressing venous return to the heart and tending to distend the IVC. The magnitude of this cardiopulmonary interaction depends on IVC compliance, the rise in pleural pressure, and whether the heart is on the steep portion of the cardiac function curve.
For passively ventilated patients, four studies have shown a strong correlation between ΔIVC and the change in cardiac output following a fluid bolus, with typical area under the receiver operating characteristic curve of nearly 90%.,,, When combined in a meta-analysis, the diagnostic OR was 30.8, illustrating excellent test performance. Thus, significant dilation of the IVC during tidal ventilation accurately predicts fluid responsiveness (FR) as long as the following conditions hold: (1) the patient is receiving passive ventilation; (2) tidal volume is 8 to 12 mL/kg; and (3) there is an absence of acute cor pulmonale.
For spontaneously breathing patients (including those triggering the ventilator), inspiration tends to collapse the IVC, and the physiology explaining ΔIVC is rather different. Inspiration lowers the pleural pressure (the degree depending on effort, lung compliance, and airways resistance), which lowers the right atrial and ventricular pressures (depending on the compliance of those chambers). At the same time, inspiration raises abdominal pressure. This scenario produces a gradient tending to shift blood from the abdominal IVC to the thorax, but the magnitude of this effect is conditioned by the absolute level of right atrial pressure and IVC compliance. IVC collapse can be seen whenever inspiratory effort is large (eg, with acute asthma or other forms of respiratory failure), not only when the circulation is fluid responsive. For this reason, ΔIVC during spontaneous breathing still predicts FR (diagnostic OR, 13.2) but with less confidence than in passively ventilated patients.,,
In light of the complex underlying physiology, it should be self-evident that IVC diameter and its respiratory variation will never serve as a one-size-fits-all test to guide fluid resuscitation; that would be asking too much. Instead, we should judge its usefulness the way we do other diagnostic tests: when pretest probability and clinical context are integrated, does IVC ultrasound significantly alter the posttest probability of fluid response? Considered this way, the answer is a resounding "yes."
Alternative approaches to fluid resuscitation are seriously flawed. Static predictors such as central venous and wedge pressures are little better than a coin toss.,, Dynamic predictors such as pulse pressure variation and passive leg raising (PLR) are accurate (assuming all of the conditions for validity are met) but require an arterial catheter (pulse pressure variation, stroke volume variation) or significant echocardiographic expertise (velocity time integrals of the left or right ventricular outflow tracts). PLR has the advantage of being accurate even during spontaneous breathing, which is ΔIVC's weakest link. Nevertheless, it is cumbersome to perform (often using a specialized bed) and requires some measure of effect, such as obtaining an apical five-chamber view to estimate the velocity time integral. In carefully conducted clinical trials, investigators can obtain adequate five-chamber views in both the semi-upright and PLR positions without introducing large measurement errors, but I doubt this approach can be utilized as part of usual care.
In practice, using IVC ultrasound to guide fluid resuscitation has significant advantages. The subcostal longitudinal view is readily obtainable in > 90% of patients; it is one of the easiest point-of-care ultrasound techniques to master (Table 1); and the entire examination takes < 3 min. It can be repeated at will (eg, after each fluid bolus or clinical change), is noninvasive, and can be integrated into a more comprehensive ultrasound examination that includes goal-directed echocardiography to exclude tamponade, cardiogenic shock, cor pulmonale, or major valvular lesion; lung ultrasound to rule out tension pneumothorax or diffuse anterior B lines; and (when appropriate) abdominal imaging. Applied this way, point-of-care ultrasound has tremendous value for many patients diagnosed with shock.
ΔIVC = dynamic changes in the inferior vena cava (IVC) diameter.
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You cannot skip the lively capital of Spain! Sightseeing with our warm (and hot) LC people during an awesome city rally, eating typical "calamares" at "KM 0" and partying like animals! You will regret not coming!
The event of the summer!!
Date: 5th-7th August 2016
See more details here! And follow our Facebook event!
Registration Form
Deadline for registration: 1st August 2016
The number of spots is limited! So make sure to register soon if you don't want to miss it!!
Any questions? Just Ask us!
Like our Page on Facebook!
Looking forward to seeing you in Madrid!!
IAESTE Spain Events Department & IAESTE Madrid LC