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Correspondence to: Brendan J. Canning, PhD, Johns Hopkins Asthma and Allergy Center, 5501 Hopkins Bayview Circle, Baltimore, MD 21224; e-mail: email@example.com
Objectives: To describe the anatomy and neurophysiology of the cough reflex.
Methods: A review of the literature was carried out using PubMed and the ISI Web of Knowledge from 1951 to 2004. Most of the referenced studies were carried out in animals
Conclusions: Studies carried out in animals provide suggestive but inconclusive evidence that C-fibers and rapidly adapting receptors (RARs) arising from the vagus nerves mediate coughing. Recent studies also have suggested that a vagal afferent nerve subtype that is not readily classified as a RAR or a C-fiber may play an important role in regulating cough. Afferent nerves innervating other viscera, as well as somatosensory nerves innervating the chest wall, diaphragm, and abdominal musculature also likely play a less essential but important accessory role in regulating cough. The responsiveness and morphology of the airway vagal afferent nerve subtypes and the extrapulmonary afferent nerves that regulate coughing are described.
Coughing occurs as a consequence of aspiration, the inhalation of particulate matter, pathogens, accumulated secretions, postnasal drip, inflammation, and mediators associated with inflammation. The elderly, newborns, lung transplant recipients, and patients with paralysis or neuromuscular disorders have a poorly developed and/or compromised cough reflex, and are rendered highly susceptible to lung infections and aspiration pneumonia.1–4 Under normal conditions, therefore, cough serves an important protective role in the airways and lungs. In diseases such as asthma, COPD, gastroesophageal reflux disease (GERD), and upper airway cough syndrome due to a variety of rhinosinus conditions (previously referred to as postnasal drip syndrome), however, cough may become excessive and nonproductive, and is potentially harmful to the airway mucosa.,4 These contrasting consequences of coughing can be attributed to the parallel afferent pathways regulating this important defensive reflex of the airways.
Our current understanding of the afferent neuronal pathways regulating the cough reflex is derived almost entirely from studies in animals. In these studies,5–10 conclusive evidence that vagal afferent nerves are responsible for initiating the cough reflex has been provided. The terminations of these vagal afferents are found in abundance in the airway mucosa and in the airway wall from the upper airways to the terminal bronchioles and lung parenchyma.
Afferent neuronal subtypes can be identified based on their physicochemical sensitivity, adaptation to sustained lung inflation, neurochemistry, origin, myelination, conduction velocity (A-fiber, > 3 m/s; C-fiber, < 2 m/s), and sites of termination in the airways (Fig 1
). The utility of each of these approaches for defining airway afferent nerve subtypes is limited in large part by the lack of specificity of the various characteristics studied.5–21 When evaluated in combination, however, these attributes can be used to identify at least three broad classes of airway afferent nerves (Fig 2
, Table 1
In this article, the classes of vagal afferent nerves innervating the airways and their role in regulating the cough reflex will be defined. The mechanisms by which extrapulmonary stimuli (eg, refluxate, upper airway irritation, or postnasal drip) initiate coughing will also be discussed. The information presented in this article was gathered by a literature search from 1951 to 2004 using both PubMed and the ISI Web of Knowledge.
The anatomy of rapidly adapting receptor (RAR) terminations in the airway wall is unknown. Functional studies11–17 of RARs suggest that they terminate within or beneath the epithelium of both intrapulmonary and extrapulmonary airways, but primarily the intrapulmonary airways. RARs are differentiated from other airway afferents by their rapid adaptation (ie, 1 to 2 s) to sustained lung inflations (Fig 2).,13–19 Other distinguishing properties of RARs include their sensitivity to lung collapse and/or lung deflation, their responsiveness to alterations in dynamic lung compliance (and thus their sensitivity to bronchospasm), and their conduction velocity (4 to 18 m/s), which is suggestive of myelinated axons.11–21 The sustained activation of RARs produced by dynamic lung inflation, bronchospasm, or lung collapse indicates that the adaptation of RARs is not attributable to an electrophysiologic adaptation.11,13,20–21 Perhaps RARs are thus better defined as dynamic receptors that respond to changes in airway mechanical properties (eg, diameter, length, and interstitial pressures).
RARs are sporadically active throughout the respiratory cycle (Fig 2), are activated by the dynamic mechanical forces accompanying lung inflation and deflation, and become more active as the rate and volume of lung inflation increase.13,20–21 It follows, therefore, that RAR activity during respiration correlates to respiratory rate, is higher in guinea pigs, rats, and newborns of all species (16 to 27 impulses per second), and is almost immeasurable in larger animals such as dogs (< 1 to 5 impulses per second). It also follows that, at least in smaller animals, RAR-dependent reflexes require a heightened activity in the already active RARs.
RARs are insensitive to many "direct" chemical stimuli (Fig 2). RARs are, however, activated by stimuli that evoke bronchospasm or obstruction resulting from mucus secretion or edema.11,14–15,19,22–28 Substances such as histamine, capsaicin, substance P, and bradykinin activate RARs in a way that can be markedly inhibited or abolished by preventing the local end-organ effects that these stimuli produce (eg, bronchospasm and mucus secretion). This sensitivity of RARs to bronchospasm becomes critical when interpreting the ability of stimuli such as capsaicin or bradykinin to evoke coughing in animals and in human subjects.
RAR activation initiates reflex bronchospasm and mucus secretion through parasympathetic pathways. RARs can also respond to stimuli that evoke cough and fulfill many criteria for mediating cough.5,8,14,17,29–31 Further evidence for their role in coughing comes from studies of vagal cooling, which blocks cough at temperatures that selectively abolish activity in myelinated fibers (including RARs) while preserving C-fiber activity.14,30–31 Surprisingly, however, many stimuli that are extremely effective at activating RARs (eg, thromboxane, leukotriene C4, histamine, tachykinins, methacholine, and inspiratory or expiratory efforts against a closed glottis) are ineffective or only modestly effective at evoking cough.,14,28,32–35 Moreover, it is difficult to reconcile the observation that RARs are spontaneously activate throughout the respiratory cycle in many species, and yet that cough is only induced under special circumstances and in response to very specific stimuli. This indicates that if RARs are indeed responsible for regulating cough, their pattern of activation must be changed or a specific subset of RARs must be recruited in response to a stimulus that results in coughing. Alternatively, RARs may act synergistically with other afferent nerve subtypes to induce coughing.
Slowly adapting stretch receptors (SARs) are highly sensitive to the mechanical forces that are put on the lung during breathing. SAR activity increases during inspiration and peaks just prior to the initiation of expiration (Fig 2).13,36 SARs are thus thought to be the afferent fibers involved in the Hering-Breuer reflex, which terminates inspiration and initiates expiration when the lungs are adequately inflated.36 SARs can be differentiated from RARs in some species based on action potential conduction velocity, and in most species by their lack of adaptation to sustained lung inflations. SARs may also be differentially distributed throughout the airways.36 In cats, guinea pigs, and rats, few if any SARs, but many RAR-like receptors and/or C-fibers, can be found in the extrapulmonary airways. Rather, SARs appear to terminate primarily in the intrapulmonary airways (in dogs, SARs may also be localized to the extrapulmonary airways). SARs also differ from RARs with respect to the reflexes they precipitate. SAR activation results in the central inhibition of respiration and the inhibition of the cholinergic drive to the airways, leading to decreased phrenic nerve activity and decreased airway smooth muscle tone (due to a withdrawal of cholinergic nerve activity).25,36–37
Yu and colleagues38have morphologically defined the structure of electrophysiologically identified SARs innervating rabbit intrapulmonary airways and lungs. The sensory terminals of SARs assume a complex and varying position within the airway wall. Most of these SARs were found in the peripheral airways (associated with alveoli or bronchioles). Occasionally, but not uniformly, SAR dendritic arbors were associated with the bronchiolar smooth muscle. This contrasts with the SARs innervating the dog trachea, which are intimately associated with the smooth muscle and are activated during bronchospasm.39 As mentioned above, however, cats, guinea pigs, rabbits, and rats appear to have few if any SARs in their extrapulmonary airways.36
Single-unit recordings from the vagus nerve in rabbits have suggested that SAR activity does not increase prior to or during ammonia-induced coughing.9 Although this suggests that SARs are unlikely to play a primary role in the cough reflex, their profound influence over the respiratory pattern makes it likely that they influence coughing and other airway defensive reflexes. It has been proposed, for example, that enhancing baseline SAR activity with the loop diuretic furosemide may account for the reported antitussive effects of this agent in animals and in human subjects.40In contrast, preloading, which would likely increase baseline SAR activity, has been reported to increase expiratory efforts during cough.41–42 Experiments performed on rabbits8,43in which inhaled SO2 has been used in an attempt to selectively block SAR activity show that the cough reflex is coincidentally attenuated. However, the selectivity of SO2 for airway SARs is questionable because several reports45 have indicated an excitatory action of SO2 on airway C-fibers. C-fiber activation may be inhibitory to cough.
Studies6 of CNS processing have suggested that SARs may facilitate coughing. A central cough network in which SARs facilitate cough via activation of brainstem second-order neurons (termed pump cells) of the SAR reflex pathway has been proposed. In this model, SARs, through the activation of pump cells, open an as-yet-unidentified "gate" in the brainstem that is thought to promote cough. But an excitatory role of pump cells in cough is difficult to reconcile with studies,25,46 showing that SARs (via pump cells) inhibit other RAR-mediated reflex pathways. Clearly, much about the role of SARs in coughing remains poorly defined.
The majority of afferent nerves innervating the airways and lungs are unmyelinated C-fibers.18,47They are similar in many ways to the unmyelinated somatic sensory nerves innervating the skin, skeletal muscle, joints, and bones that respond to noxious chemical and mechanical stimuli (called nociceptors).48 In addition to their conduction velocity (< 2 m/s), airway vagal afferent C-fibers are distinguished from RARs and SARs by their relative insensitivity to mechanical stimulation and lung inflation (Fig 2).,12–13,15–16,18,23,25,47 C-fibers are further distinguished from RARs by the observation that they are directly activated by bradykinin and capsaicin, not indirectly through effects on smooth muscle or the airway vasculature. Moreover, prostaglandin E2, adrenaline, and adenosine, which by bronchodilating the airways might inhibit RAR activation by bradykinin and capsaicin, actually sensitize C-fibers to capsaicin and bradykinin through direct effects on their peripheral nerve terminals.,47,49–50
Morphologic studies12,51–53 in rats (Fig 3
) and in guinea pigs have revealed that afferent C-fibers innervate the airway epithelium as well as other effector structures within the airway wall. C-fibers may synthesize neuropeptides that are subsequently transported to their central and peripheral nerve terminals.,12,51,53–54 This unique neurochemical property of bronchopulmonary C-fibers has been exploited to describe the distribution and peripheral nerve terminals of these unmyelinated airway afferent nerve endings. Although the expression of neuropeptides may be species dependent, C-fibers innervating the airways of other species are likely to be morphologically (if not neurochemically) similar to those that have been well characterized in guinea pigs and rats.52,55–56
In dogs, airway afferent C-fibers may be further subdivided into bronchial and pulmonary C-fibers, a distinction that is based both on sites of termination but also on responsiveness to chemical and mechanical stimuli.18 Notably, pulmonary C-fibers in dogs may be unresponsive to histamine, while bronchial C-fibers are activated by histamine. Whether similar physiologic distinctions between bronchial and pulmonary afferent C-fibers can be defined in other species, and what if any differences in reflexes are produced on their activation, is unknown. Kollarik et al57and Undem et al58 have described C-fiber subtypes innervating the intrapulmonary airways and lungs of mice and guinea pigs. In guinea pigs, C-fiber subtypes may be distinguished based on their ganglionic origin and on the sites of termination in the airways. C-fibers arising from the jugular (superior vagal) ganglia in guinea pigs innervate both intrapulmonary and extrapulmonary airways, and almost uniformly express the neuropeptides substance P and calcitonin gene-related peptide. These C-fibers are not activated by adenosine triphosphate (ATP), 5-hydroxytriptamine (5-HT), or adenosine, but are readily activated by capsaicin, bradykinin, and acid. By contrast, C-fibers with cell bodies in the nodose (inferior vagal) ganglia terminate almost exclusively in the intrapulmonary airways. These C-fibers rarely express substance P, and are activated by capsaicin, bradykinin, ATP, adenosine, and 5-HT. In mice, ATP activates all C-fibers, whereas capsaicin and bradykinin activated only a subset of the identified bronchopulmonary C-fibers. Unlike the situation reported in dogs, histamine appears to be without effect on bronchopulmonary C-fibers in other species.
C-fibers regulate airway defensive reflexes. Although C-fiber endings are polymodal, responding to both chemical and mechanical stimulation, their threshold for mechanical activation is much higher than that of RARs and SARs.12–13,18,28 Accordingly, C-fibers are generally quiescent throughout the respiratory cycle but are activated by chemical stimuli such as capsaicin, bradykinin, citric acid, hypertonic saline solution, and SO2.,12–13,16,18,23,45,47 Reflex responses evoked by C-fiber activation include increased airway parasympathetic nerve activity, and the chemoreflex, characterized by apnea (followed by rapid shallow breathing), bradycardia, and hypotension.18,25,47 In some species (particularly guinea pigs and rats) activated C-fibers release neuropeptides from their peripheral nerve terminals without involvement of the CNS. This process is called an axon reflex. The axon reflex in guinea pigs and rats results in bronchospasm, mucus secretion, and neurogenic inflammation.,47,59
Several lines of evidence support the hypothesis that the activation of airway C-fibers precipitates cough. Stimulants (including several putatively selective stimulants) of C-fibers such as capsaicin, bradykinin, SO2, and citric acid evoke cough in conscious animals and in humans.7,18,60–63 Capsaicin desensitization abolishes citric acid-induced coughing in guinea pigs, but has no effect on cough evoked by mechanical probing of the airway mucosa in these same animals.7,60 Finally, pharmacologic studies that take advantage of the unique expression of tachykinins by airway C-fibers have shown that cough induced by bradykinin, citric acid, and capsaicin in cats and guinea pigs is attenuated or abolished by neurokinin receptor antagonists.62–63
Although the evidence summarized above supports a role for C-fibers in the cough reflex, there is also considerable evidence to indicate that airway C-fibers do not evoke cough but may inhibit cough evoked by RAR stimulation. In anesthetized animals, for example, C-fiber stimulation has consistently failed to evoke coughing, even though cough can be induced in these animals by mechanically probing the airway mucosa.5,10,28–31,47 The systemic administration of C-fiber stimulants can even inhibit cough evoked by RAR stimulation in various species.5,28–31 The fact that vagal cooling to temperatures that can preserve C-fiber-dependent reflexes yet abolish cough is further evidence against a role for C-fibers in cough.5,30–31
It is unclear why so much conflicting evidence about C-fibers in cough has been reported. Perhaps general anesthesia selectively disrupts the ability of C-fibers to evoke cough in animals without adversely affecting cough that is induced by mechanoreceptor stimulation. General anesthesia has a profound influence over the cough reflex.64 Alternatively, because coughing in anesthetized animals is typically studied following tracheotomy with stimuli delivered to lower airways, larynx, and trachea, perhaps C-fiber-dependent coughing is evoked from or requires airflow through the bypassed airways (eg, the pharynx). It is unlikely, however, that anesthesia prevents C-fiber activation and C-fiber-mediated reflex effects entirely. C-fibers are readily activated in anesthetized animals and can precipitate profound cardiopulmonary reflexes.,18,23,25,28,65–68 Rather, anesthesia must selectively inhibit cough-related neural pathways or may act by accentuating the inhibitory effects of C-fiber activation on cough. Alternatively, general anesthesia may interfere with the conscious perception of airway irritation and the resulting urge to cough. In this context, it is interesting that capsaicin-evoked cough can be consciously suppressed in human subjects.69
The conflicting evidence that either C-fibers or RARs regulate coughing makes it reasonable to hypothesize that a previously unrecognized subtype of airway afferent nerve (ie, cough receptors) plays the primary role in regulating this defensive reflex. Subtypes of the recognized classes of airway vagal afferents have been described in several species,70–72 and recent studies in guinea pigs support the notion of a "cough receptor." Selective nerve cuts and a comprehensive analysis of the stimuli that evoke coughing and afferent nerve activation in guinea pigs reveal that the tracheal, laryngeal, and bronchial afferents that are primarily responsible for regulating cough arise from the nodose ganglia.28 These afferent nerves are polymodal, being activated by punctuated mechanical stimuli, acid, water, and the potassium channel blocker 4-aminopyridine.12,73–74 However, they are unresponsive to capsaicin, bradykinin, or hypertonic saline solution, and do not express transient receptor potential vanilloid (TRPV)-1, the capsaicin receptor.12,54,73–74 These putative cough receptors are myelinated and do not synthesize neuropeptides under normal conditions.12,54 Their myelination and insensitivity to capsaicin clearly differentiate the putative cough receptors from bronchopulmonary C-fibers.
Because they are myelinated and adapt rapidly to punctuate mechanical stimulation, it is tempting to conclude that the cough receptors are merely the RARs of the extrapulmonary airways. However, there are a number of attributes that differentiate the cough receptors from the classically defined RARs. Unlike RARs, which primarily innervate the intrapulmonary airways, the putative cough receptors are found primarily in the extrapulmonary airways (ie, larynx, trachea, and mainstem bronchi) where cough is most readily initiated. Also unlike RARs, the cough receptors are utterly unresponsive to a wide variety of spasmogens and autacoids that induce airway smooth muscle contraction, including methacholine, histamine, leukotriene C4, substance P, neurokinin A, 5-HT, ATP, and adenosine.12,28,54 All of these stimuli have been shown11,14,32–35 to activate RARs, and yet none of them are effective, or are only modestly effective, at inducing cough. Maximal inspiratory or expiratory efforts against a closed glottis, like bronchospasm, are also very effective stimulants of RARs but are very ineffective at evoking cough in healthy individuals.13–14 Cough receptors are unresponsive to changes in luminal pressure, even pressures changes exceeding –100 to + 100 cm H2O.,28 Finally, the cough receptors may also be distinguished from RARs based on conduction velocity. Laryngeal, tracheal, and bronchial cough receptors in guinea pigs conduct action potentials at approximately 5 m/s, whereas intrapulmonary RARs in guinea pigs conduct action potentials at a much faster rate (upward of 15 m/s).11–12,28
Using the styryl dye FM2–10,75the receptive fields of putative cough receptors innervating the guinea pig tracheal and bronchial mucosa have been identified (Fig 4
). Their terminals are found in abundance and in a stereotypical position of the airway mucosa, with complex dendritic arbors that are invariably arranged along the circumferential axis of the airways. Terminations are confined to the space between the smooth muscle and the epithelial cell layers. As might be expected, then, neither smooth muscle contraction nor epithelial removal activates or alters the excitability of these receptors and does not inhibit cough that is evoked electrically or by citric acid. The left and right vagus nerves contribute approximately equal numbers of these receptors, with terminals located primarily ipsilateral to their vagal origin. Comparable structures have been identified in the airways of fixed tissue using the osmium tetroxide-staining method.76 The terminal adhesions of the cough receptors and their orientation within the tissue indicate that they have attached to components in the extracellular matrix comprising the basement membrane, which undergoes extensive remodeling in disease conditions.77
FM2–10 labeling of the putative cough receptors has facilitated the identification of a key regulatory mechanism for the excitability of these afferent nerves. Labeling with FM2–10 is absolutely dependent on Na+-K+-ATPase activity. Subsequent immunohistochemical analyses revealed that the putative cough receptors, but not C-fibers, express an isozyme of the sodium pump containing the α3 subunit. The unique expression of this isozyme is of interest, given its association with mechanoreceptors and not with the C-fibers in the somatic nervous system.78The intense and brilliant labeling of the cough receptors with FM2–10 suggests that sodium pump activity is particularly high in the putative cough receptor endings, which may play an essential role in regulating their excitability. Indeed, ouabain potently and selectively inhibited coughing evoked by citric acid, mechanical stimulation, or electrical stimulation of the tracheal and laryngeal mucosa in anesthetized guinea pigs while having no effect on C-fiber-dependent reflexes evoked from the trachea. In vitro electrophysiologic recordings confirm the potent and selective inhibitory effects of ouabain on the putative cough receptor. This inhibitory effect of ouabain on the cough receptors contrasts with the ability of this compound to greatly enhance the excitability of SARs in the lung, aortic baroreceptors, and renal arterial mechanoreceptors.81
Activated C-fibers can release the neuropeptides substance P, neurokinin A, and calcitonin gene-related peptide from their peripheral nerve terminals without involvement of the CNS, and even without action potential formation.59 This process is called the axon reflex, and has been well-described in human skin and in the viscera of many species. Axon reflexes in the airways and lungs of guinea pigs result in bronchospasm, mucus secretion, vasodilatation, edema, leukocyte recruitment, altered parasympathetic nerve activity, and the stimulation of endothelial and epithelial cells,82–88 (Fig 5
). Peripheral neuropeptide release in the airways or exogenously administered substance P has also been shown to activate RARs.,26–27,89 The neuropeptide-evoked RAR activation occurs indirectly, secondary to actions on structural cells in the airway wall that in turn activate RARs.17,23,29 As might be predicted, then, preventing the consequences of the axon reflex with β-agonists, inhaled neurokinin receptor antagonists, or inhaled neutral endopeptidase (which enzymatically inactivates tachykinins and bradykinin) is effective at preventing RAR activation and cough evoked by capsaicin, cigarette smoke, bronchospasm, or the neutral endopeptidase inhibitor phosphoramidon.90–94
It is unclear whether axon reflexes or any peripheral interactions between C-fibers and RARs play a role in defensive reflex responses in the airways of humans or in any species other than guinea pigs. In cats and dogs, bradykinin and capsaicin evoke bronchospasm, bronchial vasodilatation, and mucus secretion, but these responses can be prevented with the administration of atropine or with vagotomy, indicating a CNS-dependent parasympathetic reflex, not an axon reflex.18,95–96 Similar findings have been reported in humans.97 Morphologic and functional studies52,56,98–100 also have indicated that a neuropeptide-dependent axon reflex is unlikely to play a major role in humans (young or adult), as few substance P-containing nerve fibers are found in human airways, and electrically or capsaicin-induced responses of human airway preparations in vitro are not dependent on tachykinins. C-fibers may, however, release other transmitters such as purines (eg, adenosine or ATP) during an axon reflex, and these transmitters may initiate responses in human airways that are similar to the effects of neuropeptides that have been reported in guinea pig and rat airways.101
The lack of an axon reflex in the airways of humans (and other species) not withstanding, there is good evidence that C-fiber activation is extremely effective at evoking cough. This indicates that other mechanisms may underlie C-fiber-dependent coughing. Thus, peripheral interactions between C-fibers and RARs may proceed independently of axon reflexes (Fig 5). C-fiber activation evokes CNS-dependent parasympathetic reflex-induced bronchospasm, vasodilatation, and mucus secretion.18,25,47,65–67,95–97 These end-organ effects are mediated in large part by acetylcholine released from airway parasympathetic nerves and may be sufficient to activate RARs in the airway wall. That inhaled anticholinergic agents have some antitussive properties in animals and in human subjects is consistent with this notion.102–103
The central integration of airway afferent nerve input is poorly understood. Insights into how C-fibers and RARs might interact in the brainstem may be gained from studies in other systems, particularly the nervous pathways regulating somatic tissues such as the skin, skeletal muscles, joints, and bones. C-fibers and mechanoreceptors arising from somatic tissues interact in the spinal cord in a process known as central sensitization.48,104 The consequence of this central interaction manifests as a heightened reflex responsiveness and exaggerated sensations of pain following cutaneous stimulation. Studies of central sensitization in the spinal cord have revealed two features of the somatosensory system that facilitate this hyperreflexia. First, C-fiber and mechanoreceptor reflex pathways appear to converge through common integrative circuits in the spinal cord. Second, this convergent input can amplify afferent signaling following the coincident activation of both afferent nerve subtypes. The synergy and resulting hyperreflexia is often dependent on tachykinins released from the central terminals of somatosensory C-fibers, producing a long-lasting hyperexcitability of spinal integrative neurons.48,104
Several lines of evidence have suggested that a process similar to central sensitization regulates airway defensive reflexes. The morphologic, electrophysiologic, and pharmacologic properties of airway C-fibers and mechanoreceptors are similar to those of the somatic nervous system.12–13,18,47–48,104Anatomic and functional studies105–107 have also demonstrated the convergence of vagal afferents at sites of brainstem integration, particularly in the nucleus of the solitary tract (nTS). As mentioned above, lung mechanoreceptors are sporadically active throughout the respiratory cycle, whereas C-fibers are typically quiescent, even during large lung inflations.13–18 The central processing of C-fiber activity must therefore be integrated into a reflex pathway that is continually receiving input from airway mechanoreceptors. C-fiber activation, via central interactions with RARs, may promote coughing by facilitating synaptic transmission at RAR relay neurons in the brainstem (Fig 5). Indeed, substance P can facilitate synaptic transmission between lung afferents and nTS neurons in guinea pigs.,108–109
Direct evidence for central interactions between C-fibers and RARs in the regulation of airway parasympathetic tone has been documented.107 Airway C-fiber activation evokes profound increases in cholinergic tone in the airways by facilitating airway mechanoreceptor actions in the brainstem. Without airway mechanoreceptor activity, C-fibers are ineffective at evoking reflex responses. The facilitating effects of C-fibers on the brainstem RAR reflex pathways appear to be mediated by tachykinins, as the central synergistic interactions are prevented entirely by neurokinin receptor antagonists administered intracerebroventricularly. The sensitizing effect of nociceptor stimulation can also be mimicked, in the absence of C-fiber stimulation, by administering substance P to the brainstem.107 Importantly, a comparable interaction between cough receptors and C-fibers has been documented in studies of cough. Thus, in anesthetized guinea pigs, C-fiber activation does not evoke cough but greatly sensitizes the cough reflex evoked by activating the cough receptors. Neurokinin receptor antagonists prevent this sensitizing effect of nociceptor stimulation.110Similar sensitizing effects of nociceptor stimulation on cough may be evoked from the esophagus, and observation that may explain how GERD initiates and/or exacerbates coughing.111–113
Afferent nerves carried by the auricular branch of the vagus nerve (ie, the Arnold nerve) innervate the external auditory meatus.114In a small subset of patients (< 5%), several visceral reflexes, including cough, may be evoked by the mechanical stimulation of the ear. Tracing studies115 in cats have shown that afferent neurons carried by the Arnold nerve have their cell bodies in the superior vagal (jugular) ganglia, and terminate in several areas throughout the brainstem, including the commissural sub-nTS. It is interesting that in guinea pigs the nociceptors that can modulate cough also have their cell bodies in the jugular ganglia and terminate centrally in the commissural subnucleus of the nTS.107,110 It seems likely that the cough initiated by the stimulation of the ear involves the integration of both ongoing airway vagal afferent nerve input with the additional afferent input arising from the ear.
Pharyngeal stimulation initiates coughing in human subjects.116It is possible but unproven that the pharyngeal afferent nerves regulating cough are vagal in origin, but pharyngeal afferents may also arise from the glossopharyngeal nerves or from nerve branches emanating from the trigeminal ganglion.117–118 The physiologic properties of the pharyngeal afferent nerves regulating cough are poorly defined, but they may be similar to the cough receptors innervating the larynx, trachea, and bronchi. Thus, mechanical stimulation, postnasal drip, and a water bolus placed into the pharynx evoke vigorous coughing in human subjects and in animals, while capsaicin may be unable to initiate coughing when applied selectively to the pharynx.117,119–120
There have been conflicting reports111–112 regarding the ability of esophageal afferent nerve activation to initiate coughing. In animals, neither distension nor luminal challenge of the esophagus with acid or capsaicin evokes coughing.121 Comparably negative studies have been reported in human subjects.111 Nevertheless, the association between chronic cough and GERD is quite clear, and the ability to markedly reduce coughing in subjects with GERD with effective treatment of the reflux disease argues strongly for the hypothesis that reflux initiates coughing in susceptible patients.4,113 A simple explanation for these results is that refluxate is aspirated into the airways and directly activates the airway vagal afferent nerves regulating cough. However, pH monitoring in GERD patients has provided little evidence122that refluxate can or needs to reach the proximal esophagus, much less the airways, to initiate pulmonary symptoms or coughing. Rather, it is well-established that airway reflexes (ie, mucus secretion, bronchospasm, and cough) can be initiated from the stomach or the esophagus.124 These reflexes are effectively reduced or abolished by vagotomy. Although untested directly and thus unproven, these results may indicate that esophageal and airway afferent nerves converge centrally to regulate and initiate parallel and overlapping reflex effects in the airways and GI tract.
Studies in GERD patients have provided evidence that refluxate may also sensitize the cough reflex. Acid challenges of the esophagus111–112 markedly reduced the concentration of capsaicin required to evoke cough or resulted directly in coughing. Ing et al112reported that this sensitizing effect of the esophageal challenge was prevented by the administration of inhaled atropine, suggesting that a CNS-dependent reflex initiated from the esophagus resulted in bronchospasm and/or mucus secretion in the airways that initiated coughing. Medical treatment of GERD has also been reported113 to greatly reduce the sensitivity to tussive stimuli. This sensitizing effect of refluxate or experimental acid challenges likely depends on CNS integration and amplification of the parallel vagal sensory inputs controlling cough.123
Coughing, like swallowing, belching, urinating, and defecating, is unique in that there is higher cortical control of this visceral reflex.125 The cortical control of coughing can manifest both as inhibition (eg, coughing that is suppressed until a break in a live performance or activity) but also as voluntary cough.,125–126 The implications of this conscious control of cough are severalfold. It is clear, for example, that placebos can have a profound effect on coughing that has been studied experimentally.126As such, any study of a novel or existing cough treatment should include a blinded (preferably double-blinded) placebo arm. It is also clear, however, that cough may be an affective behavior, perhaps indicating that an underlying physiologic disease (eg, GERD or asthma) is poorly controlled or that a psychological issue, which is more difficult to detect, needs to be considered (called psychogenic cough).127 The motor pathways controlling voluntary and induced cough are identical, so it is not possible to distinguish physiologically a cough that is voluntary from a cough that is a consequence of some visceral disease. The cortical pathways controlling cough are also not well-understood. Addressing the psychological impact of coughing on a patient's sense of well-being should therefore be a component of any treatment regimen for chronic cough, whether or not an underlying cause has been identified.128
Studies carried out in animals have provided clear evidence that vagal afferent nerves regulate coughing. It remains unclear, however, what relative role the identified afferent nerve subtypes play in mediating cough. Evidence both for and against the role of C-fibers and RARs has been reported. These conflicting data suggest that the activation of both afferent nerve subtypes may be required to induce coughing, or that a previously unrecognized airway afferent nerve subtype subserves a primary role in cough. Recent studies in guinea pigs and circumstantial evidence gathered from the existing literature suggest that a cough receptor quite distinct from either C-fibers or RARs may exist. Moreover, these afferent nerve subtypes may interact to produce cough and heightened sensitivity to tussive stimuli. It seems imperative that future studies should identify the mechanisms of integration of afferent nerve input in the CNS, the role of consciousness and perception in coughing, and the mechanisms by which afferent nerves are activated.
Evidence for the extensive remodeling of airway afferent innervation in diseases associated with cough has been conflicting.129–134 Perhaps chronic coughing occurs not because of a hyperinnervation of the airways but because there are more triggers for coughing in the airways or in other organs associated with coughing. Consistent with this notion, the levels of inflammatory mediators are elevated in the lavage fluid of asthmatic and nonasthmatic chronic coughers, and therapeutic agents that target the identified triggers of coughing or inflammation have proven to be effective in treating cough in several patient populations.135–139 Future therapies may also target the mechanisms by which afferent nerve excitability is regulated, perhaps by blocking the ion channels associated with nerve activation (eg, TRPV1) or perhaps other enzymes, ion channels, or ion pumps that regulate the repetitive, high-frequency action potential formation that is required to initiate coughing. But it is unknown whether any meaningful changes in afferent nerve excitability or ion channel expression occur in patients with chronic cough. Other rational therapeutic strategies may target the interactions between the afferent nerves regulating cough at the level of the CNS (Fig 5). These central synapses may change with inflammation, with new transmitters being selectively expressed in and released from the afferent nerve terminals regulating cough.,129,133,140 This selective expression in disease and in subsets of afferent nerves may limit the unwanted side effects associated with CNS-penetrant therapeutic agents.
Abbreviations: 5-HT = 5-hydroxytriptamine; ATP = adenosine triphosphate; GERD = gastroesophageal reflux disease; nTS = nucleus of the solitary tract; RAR = rapidly adapting receptor; SAR = slowly adapting stretch receptor; TRPV = transient receptor potential vanilloid
Typical attributes of the afferent nerve subtypes are listed. Species differences and subtypes of each class with distinct physiologic properties and responsiveness have been reported.
The activation of RARs by capsaicin and bradykinin is prevented by bronchodilator pretreatment, suggesting that activation occurs secondary to obstruction in the lung.
C-fiber activation by bradykinin and capsaicin is enhanced by bronchodilators such as adrenaline, adenosine, and prostaglandin E, suggesting that agents directly stimulate C-fibers in the airways. See text for further details and references.
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Group training is generally perceived as the only form of training, because of our early classroom experiences. Group training has a lot in common with presentation. If you marry the principles of employee learning to the skills of presentation, you will need to take control of the session through effective planning and to encourage activity, challenge and participation in the group that you are training.
Consider the following steps when preparing to train a group:
Ask yourself the following questions:
This stage involves you taking action that will prepare your audience. You may wish to negotiate or set the goals for the session and establish your own responsibilities as a leader or trainer. Above all, be explicit about the values of the session, the methods to be used and the ground rules.
This third stage involves deciding the tools that you will use. Above all, you should be comfortable with the methods that you choose. Consider your own special interests and skills, as your enthusiasm will help get the message across. Make a list of the resources you need and the resources available to see if there are any gaps.
Ideally, the objectives should be specific and measurable: 'by the end of this workshop you should be able to...'. Objectives should be set through discussion and negotiation with the staff. Remember that you should present the objectives to the participants at the start of each session. If participants have clear goals, this will help them to learn more readily.
This should be specific: introduction, 10 minutes; forming groups and giving instructions, five minutes; working on the task, 40 minutes; etc. On a larger scale, review the schedule to see if sufficient time is available for what is planned for each element. Try to remember to provide 'fillers'. Is more time available than the work will consume? Avoid planning so much that the participants feel hurried.
If you decide to use other tutors, remember to make sure that the responsibilities are clearly defined and that everyone knows what they are supposed to deliver. No matter how good a trainer is, they cannot read minds. If you don't specify what you want, you won't get what you want and will have nobody to blame but yourself.
Make sure that your location is suitable and that you have everything you need for the training session, eg handouts, pencils, flip-chart paper, name tags, workbooks, masking tape, blu-tac, markers, reference materials, tape recorder and tapes, video recorder and tapes, etc. Remember housekeeping details: breaks, meals, special needs, and socialisation. The socialising effect of training can be very useful - don't discount it.
Consider how you will integrate the evaluation process into the programme and into your overall development strategy.
After designing the session and preparing the group and the material, the final issue is actually to deliver the training. This checklist is designed to offer you some ways that may help you keep the attention of a group in a 'pure' training situation:

subset: commoncrawl


text:
Nursing Scholarship Sources
These mammals likewise get caught in water-control systems or in internet and lines planned to capture fish and crabs. Their most major danger comes from a loss of their habitat.
A ninth way of dressing for pregnancy functions may consist of choosing clothes that moms feel comfy putting on after pregnancy too. When a child is very first born, the mom typically has a lot of physical discomfort that can recently or perhaps months. Nursing bras will fit during pregnancy too, and maternity wear after pregnancy can reduce mothers into their new function with greater convenience.
I was born and bred in Baltimore and went to the Baltimore School for the Arts and Morgan State University under the late Dr. Nathan Carter. My heritage is discovered in Baltimore. I served as the Assistant Pastor under my father, Bishop James D. Nelson, Sr., who was Pastor of the Greater Bethlehem Temple for over 30 years. So, my roots run deep in Baltimore.
If you truly want to protect your marriage and ensure that your husband does not look in other places, except in such cases where a man is so randy that no matter how attractive the better half is or no matter what she does he would still not be satisfied, you must constantly care for your physical look. Don't provide up on what you have been doing that got him attracted to you in the very first place and you should be in tune with time and changes in fashion and design. He is your hubby which implies there is no limitation to the extent in which you can go to seduce him. Offer him a reason to constantly desire you and you will certainly do well in keep other ladies outside at bay.
The mood of the film resembles a gothic pulp novel that you discover in a made use of book shop. I'm unsure the number of audiences can connect to residing in a lovely waterside home with their Papa as a reasonably successful author, but then that's a fantasy. I stay in a city and I'm constantly wishing to get away from it.
Mind you, this is a rough guide and is not completion all be all the grieving process. This is simply implied to be an overview of assit you through an attempting time. Always inspect with a member of the healthcare system if you have concerns or questions.
Don't measure yourself in numbers-- measure instead in content. You are paying doctors good money for them to stress over your age and numerous other things. If you think about your age or other numbers you will avoid the pleasure of life.
Because of that, it was clear to me that I desired to be much more clear and open about how I express my sensations to other individuals. I have learned through this health problem the best ways to be more congruent with how I feel and how I act, although it's not always simple.
I can still see her glazed eyes, the method they looked passed me and my partner. Mommy was looking at something. She had a celestial aura about her that night in the hospital. To this day, I think that she was taking a look at Jesus Christ. Her behavior was serene and peaceful. My only regret was that Mike and I went house after the Nurse informed us that mommy would be fine. The Nurse urged us to come back after they finished doing some tests on her. Mommy died alone. I had not been there with her. I still feel guilty about that, but my good friends keep informing me that I shouldn't. She wouldn't have known that I was there anyhow, if I was. Mother was not alone, she was with our Lord. That gives me some convenience.
I strolled and left the restroom around bench a bit trying to find my pal. He was no place to be found. I couldn't believe he would simply ditch me and I chose to leave too. I strolled outdoors and a few blocks towards my automobile and discovered him resting on the walkway. He looked like he was in a daze. I asked him what occurred and he said he was abducted by two space aliens with ray guns. They took him to their ship and did experiments on him. I chuckled and informed him to get in the automobile.
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SLIDESHOW: West Seattle Wildcat girls punish the Pirates 38-12
The lady Wildcats traveled to Burien Tuesday night and soundly defeated Highline High School 38-12.
As the teams took the court and readied for the tipoff one could sense the outcome. West Seattle fielded a much larger team and the Wildcats size could not be ignored.
From the beginning West Seattle controlled the game. The Pirates played hard but were simply outmatched by the bigger, faster, stronger Wildcats.
Highlines fast break attempts were constantly thwarted by a wall of blue forcing the Pirates to shoot from the outside and they seemed uncomfortable doing so.
Led by #24 Lydia Giomi at the post the Wildcats took away every missed shot by Highline and quickly pushed the ball up court. The Pirates were speedy and got back in coverage to thwart West Seattles fast break forcing the Wildcats to shoot from the outside but this is where size comes into play. West Seattle's offensive rebounding gave them the edge and second chance shooting under the hoop was the difference and at the end of the first period the Wildcats were up 11-2.
This trend continued throughout the game and in the end the Wildcats headed back to the west side with a 38-12 victory.
Coach Elliott had this to say after the game, " We have talented group of kids with great attitudes".
West Seattle faces a team that may give them more of a challenge on Monday when Garfield comes to the west side.
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Glitter on Ceilings
I want to use glitter on my daughters ceiling. However, the color of glitter I want to use is just a craft glitter. Does anyone know if that is o.k. to use? Or do I have to use a ceiling glitter. Thanks:)
Hi and welcome to the forum.
I used multi-colored glitter mixed into my paint for a textured wall and it went well. Very subtle little sparkles.
However, I used the same paint on a ceiling and cannot see one sparkle. I imagine I'd be able to see little sparkles a bit better if I had a lamp there.... hmmmm..... My advice to you would be roll the paint on thick, and use LARGE glitter flakes "tossed" or blown up onto the paint to be able to see them. Perhaps others here will have better ideas?
If you're going to paint the ceiling during this process, paint it first and let it dry. I'd apply the glitter to a clear poly. Mix the glitter in with the clear poly and just roll it on the ceiling. You can use a water based poly since it dries quickly and has a milder odor. Add coats as you need to get the coverage you want.
Good idea!
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Cambridge Service Alliance
developing new understanding and approaches to complex service systems
Welcome to the Cambridge Service Alliance…
Members of the Cambridge Service Alliance include BAE Systems, Caterpillar, IBM and the University of Cambridge.
A Systems Perspective on Business Model EvolutionJun 15, 2017
June Paper Release on 'A Systems Perspective on Business Model Evolution: The Case of an Agricultural Information Service Provider in India' by Chander Velu
Customer Satisfaction Scores Hide ProblemsJun 12, 2017
Marketing Week Article by Mohamed Zaki, 12 June 2017, on Customer Satisfaction Scores.
Webinar - Exploring the Journey to Services - Veronica MartinezJun 12, 2017
12 June 2017 - Exploring the Journey to Services - Veronica Martinez
Latest Alliance Newsletter - June 2017Jun 01, 2017
June 2017 Cambridge Service Alliance Newsletter
Seminar on Co-Creation in Living Labs - ItalyMay 18, 2017
Seminar on 'Co-creation in Living Labs: An Interorganisational Perspective' at Carlo Cattaneo University in Castellanza, Italy.


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I think to some degree the show has always been about Kiera's personal journey. She started the show thinking that Liber8 was comprised only of terrorists and that she was protecting a righteous government, but now seeing how things used to be before the Corporate Congress took over, hearing the message Liber8 spreads, and talking with Alec, she's been forced to re-evaluate her beliefs ever since the pilot.
Well, outside the Alec's meeting each other, the fact that Kira corpse is hidden still and Emily is still hiding her secret from the other timeline alec, what was there to talk about?
2077 is Hitler, Stalin and any other dictator's wet dream. The guy got pissed because she saved a child rather than a guy who was a board member making tons of money. Oh and did you notice the comment, "These things aren't supposed to happen anymore?"
I am happy Escher is dead. I am hoping for a Liber8 confrontation where current timeline Alec gets killed.
Something to chew on. The time police are there to maintain their timeline. What if in this timeline The congress fails? The time police assume Kira is from their future so maybe it is a good future not the evil one we saw and she remembers.
The SyFy channel had a snafu which affected the DVRs of U.S. viewers and we missed these them.
the only legal way is via VPN. if you are looking for the episodes there are many ways. However, the only way that doesn't involve you in the copyright infringment trade war is vpn. Shaw is canadian and won't show content unless it thinks the end point is canadian as well.
the only legal way is via VPN. if you are looking for the episodes there are many ways. However, the only way that doesn't involve you in the copyright infringment trade war is vpn. Shaw is canadian and won't show content unless it thinks the end point is canadian as well.
VPN = virtual private network
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TiVo Bolt, Roamio Pro, Premiere XL4, Premiere 2TB-WD20EURS, TiVo Mini
Cisco Tuning Adapter Status Troubleshooting
Carlos is constantly pissed/depressed and openly criticizes and questions orders, Capt. Dillon has a permanent stick up his butt, Kira hasn't smiled this season, and the two Alex's almost had a throw-down.
The good guys make Liber8 look like a bunch of happy-go-lucky school kids lately. Even The Walking Dead has more joy than Continuum at this point.
"You cannot play God and then wash your hands of the things you created."
– Commander Bill Adama
I was going to post about that too. Not very comprehensible that suit-Alec made a 180° turn in just one episode (or even a few minutes).
But who can ask for reason in a time travel show anyway...
Am I the only one who has a hard time following all the different angles?
- Old Alec / evil time
- Suit Alec
- Nice Alec
- Alec's dad
- Alec's son
- Alec's step-brother
- Liber8
- Keira's story
- Weird Carlos
- Protectors for every timeline
- Different parallel timelines
- The freelancers
- Kellog
I don't think it was a good idea to open a new (parallel?) timeline. Did the new timeline extended from the old one as a branch or was it always there parralel?
The thing with parallel timelines / multiverse is, it renders pretty much everything irrelevant. Don't like what happened in this timeline? Well, let's just open or jump to another one. You end up with endless characters in endless timelines. It would have been hard enough to make somewhat plausible sense of the puzzle if they kept it to a single timeline where some characters were able to jump back and forth.
Using time travel only opened the can of worms. But adding different timelines poured it all over the table.
Everything that happened up until the point where old Alec arrived in the new timeline was the same between the old timeline and the new one, as far as we know. Things are only different now because of old Alec's (and old Kiera's) arrival.
That only becomes a problem if the writers choose to use it, and thus far they've indicated that they won't. Alec blew up the power source when he jumped back, so there's no way for anyone to engage in more time travel at this point, except maybe Kiera, since she has access to the Freelancers' base.
Sturgeons Revelation: "Ninety percent of everything is crud."
My Thoughts: "A reasoned argument must share some basic common points."
'Continuum' doesn't have that pedigree of course, but the ending is likely going to be rushed and similarly unsatisfying.
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Doojoon revealed why he was against making any potential relationship public.
On the December 13th episode of 'Happy Together', he confessed, "I don't know any female idols." When asked if he wanted to date when he sees Junhyung and Hara, he answered, "Well, I'm at the age where I want to date", but when asked if he would make his relationship public, he said he wouldn't.
He reasoned, "It's extra work and worry when everything is revealed. There is also an effect from Junhyung and Hara. Our fans are still young, and a lot of them left the fanbase and cried after learning about the relationship."
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Milwaukee Minnesota tells the story of Albert Burroughs, who has won hundreds of thousands of dollars as a champion ice fisherman. His secret; listening to the fish talking under the ice.
When street smart Tuey and her hypochondriac teenaged brother Stan drift into Albert's quaint Milwaukee suburbs, they stumble on an opportunity to fill their empty pockets. Smooth-talking travelling salesman Jerry James has also just sleazed into town and is always on the lookout for a quick buck.
Before long, trusting Albert falls for Tuey's sexy outfits and Jerry's claim of being his real father. But everyone has underestimated Albert. He's a lot smarter than everyone thinks. At least he knows that Milwaukee isn't in Minnesota...
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Your Dog, Your Life
The Scoop
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Wildebeest creates the perfect present for new dog parents.
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My mommie has been planning on starting a diary fur all ob us here on Dogster, but she says dat dese days just seem to fwy by and she neber seems to get all da fings done dat she wants too. Me and my sissies always follow Mommie awound to gif her all da support we can. I guess we're all going to be goin to a new doggie club cause dat plwace dat Bella is going to Obedience twainin isn't "Twippin" Mommie's twigger. Da facility is horrible and to make matters worse, dey start new doggies in obedience wif dem aweful prong collars. Mommie finks dat is cwuel and senseless to do dat to a doggie who has neber had any twainin before. Dis new club is bery big and dey do most anyfing a doggie wants to do. Part of a new membership is to volunteer for 15 hours....Mommie's gonna be weal busy but she says we are all gonna haf wots of fun at da new club. Dat being said, Mommie read dis beautiful wetter from a sweet doggie in da club's newswetter and we wanted to share it all wif you. We fought it was a bery nice way to start one ob our diaries!!
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need instantly and knew I had to help her.
I wagged my tail, not too exuberantly, so she wouldn't be afraid. As she stopped at my kennel I blocked
her view from a little accident I had in the back of my cage. I didn't want her to know that I hadn't been
walked today. Sometimes the shelter keepers get too busy and I didn't want her to think poorly of them.
As she read my kennel card I hoped that she wouldn't feel sad about my past. I only have the future to
look forward to and want to make a difference in someone's life.
She got down on her knees and made little kissy sounds at me. I shoved my shoulder and side of my
head up against the bars to comfort her.
Gentle fingertips caressed my neck; she was desperate for companionship. A tear fell down her cheek
and I raised my paw to assure her that all would be well.
Soon my kennel door opened and her smile was so bright that I instantly jumped into her arms. I would
promise to keep her safe. I would promise to always be by her side. I would promise to do everything I
could to see that radiant smile and sparkle in her eyes.
I was so fortunate that she came down my corridor. So many more are out there who haven't walked the
corridors. So many more to be saved. At least I could save one.
I rescued a human today.
Author unknown!
I forgots to tell you guys dat you too haf to list 5 funny fings about you on your Dogster page and DEN go and tag 5 of your buddies (or more if ya wants to! Da more da merrier!!) Told ya I'd scwew up!! heheheehe
Dats all fur now, I finks I got it wight dis time, but be sure to wead the most important part ob da instructions bewoe!!!
Otay, otay.....
My buddy Harwey (too wike me!) tagged me to pway football and make a touchdown so here I go! I'b neber pwayed a game on Dogster before so I hopes I don't scwew it up! Now if I remember wight I haf to tell Five (5) funny fings about me....and if I do and you are now readin my new diary den you got's my pawmail to come and pway wif me!.....Abter you wead my 5 funny fings, you need to go to your diary (if ya's doesn't hab one, den ya need to start one wike I did! hehehehe) and den go back to your furpals and tag 5 ob dem to help us finish da game!! otay????good, good....den I wikes da idea dat my pal Harwey had and dat was leave me a couple bones so I know ya stopped by!! Hab fun guys!!
1. I hab all sortsa woud squeals when my Mommie comes home! Mommie says I could wake da dead! But my bwudder Adam tells Mommie dat dose are my "Happy Sounds".
2. I can swim in da Chesapeake Bay fur hours and hours! and I doesn't sink eiber!! hehehe
3. I wuf ice cream and give anybody a wun fur der money on the last in da container!
4. I'm a smart guy! Wiving wif 3 fur sissies, I just stay outa da way! hhrruuuuumph!
5. I can roll ober and pway dead when my weal Bwudder pretends to shoot me! My wegs stick up in da air and eberyfing! I'm good at pwaying dead!!
Tail Wags and spins!
See ya guys later!!!
Copyright © I-5 Publishing, LLC. All rights reserved.
Visit Catster


text:
Delete a Places To Swim Listing
Current Entry:
- Katy - LTHO Life Time Swim Houston - CIRL Life Time Swim Cinco Rancho
- Gulf LMSC
- Lifetime Fitness - Cinco Ranch
- 23211 Cinco Ranch Blvd Katy, TX 77494
- Lap Swim / Workout Times: Tuesdays & Thursdays, 6:30-7:30PM
- Contacts: Jeff Rocheleau - email@example.com
- Web Site: http://www.lifetimefitness.com/clubs/index.cfm?strWebAction=club_details&intClubId=158
- Miscellaneous Info: Indoor pool. Cost is $34/month for Lifetime members, $43/month for non members.
- Record Last Updated: 10/3/09
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Please provide your name and E-Mail address so that we know who to contact if there are any questions. Note that the your database deletion request will be reviewed by the database administrator for verification and future update - the listing will not be immediately deleted.


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Essays about School: What Themes Are Possible to Develop
Posted On October 19th, 2011 | Essay Writing
Essays about school may touch upon different issues from your personal attitude to the school you have to attend to an idea of how your perfect school should look like. The point is that such type of assignments like writing essays about school are considered to be rather helpful for both students and tutors.
On the one hand, students develop their writing skills and share their ideas about the process of education; on the other hand, tutors get a good opportunity to define strong and weak sides of education and to comprehend how to attract students' attention.
Writing essays about school may become one of the most captivating tasks for you. Everything you should do is to choose an appropriate topic and be involved into discussions. Maybe, the following ideas for essays about school will attract your attention:
- Write essays about school about the positive aspects of education which make you believe that this process has an important effect on your life;
- Create essays about school which you find the most appropriate for your future children (such type of work will also make you think about human needs and purposes);
- Develop essays about school where you would like to study and think about the reasons of your choice (such essays about school may be contrast or analytical);
- Introduce essays about school where you focus on building itself and develop interesting ideas of how classes have to be located.
You are welcome to choose any topic you like for essays about school in case your tutor does not give you one particular aspect to develop. Mind that your topic choice should be specific and properly grounded, this is why you should not hurry up but weigh all pros and cons.


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Aerial View
Project Visualization
(No Audio)
Run Time: 1:20
Bridge Design
Attempts to Minimize Environmental Impact
Run Time: 5:46
The St. Croix Crossing (project offices)
1862 Greeley Street South
Stillwater, MN 55082
Office hours are 8 a.m. - 4:30 p.m.
Monday - Friday.
The red dotted line marks the location of the new bridge and highway. Purple marks the existing Stillwater Lift Bridge.
The existing Stillwater Lift Bridge
This major project will divert traffic from the 80-year-old Stillwater Lift Bridge to a four-lane bridge that will connect expressways on both sides of the St. Croix River. Currently, severe traffic congestion in downtown Stillwater causes pedestrian and traffic safety problems, which are amplified by Lift Bridge operations.
The St. Croix Crossing project will provide a safer, more reliable river crossing. The project includes a four-lane river bridge, new roadway approaches on both sides of the river, historic and environmental mitigation, and extensive trail facilities that will include converting the Lift Bridge to a bike and pedestrian facility. The project will provide jobs for suppliers, subcontractors, disadvantaged business enterprises as well as general contractors.
The existing St. Croix River crossing at Stillwater, Minnesota, is a highway bridge connecting downtown Stillwater to the Town of St. Joseph in St. Croix County, Wisconsin. The crossing consists of a 1,050‑foot-long, 10-span, 2-lane bridge and a 750-foot earthen causeway extending from the Wisconsin shoreline. It is known as "the Lift Bridge," because one of the spans is a distinctive vertical lift span.


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Business Intelligence in Microsoft Office and SharePoint 2010
What separates the Microsoft Business Intelligence platform from the competition? Be armed with the Microsoft SharePoint Server 2010 integrated analytics platform that allows your customers to discover and share business insights in dynamic business environments. Come see demos of the integrated platform across Microsoft SQL Server, SharePoint and Office as well as global case studies from the field. We show the solution roadmap with the key features SharePoint provides for Business Intelligence applications through collaboration dashboards, multidimensional reports and self-service analytics.
For more information, check out these courses on Microsoft Virtual Academy:
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Dozens of San Franciscans fearful of being uprooted from their homes, and some who have already been displaced, lined up at City Hall Thursday to tell their stories during a hearing on Ellis Act evictions sweeping the city.
The sometimes emotional testimony included a man living with AIDS in the Castro, a mom who has been homeless for three months and a senior who has lived in the Mission for more than three decades.
"We are fighting, I think, for the soul of San Francisco," said Supervisor David Campos, who called the hearing before the Neighborhood Services and Safety Committee "to put a human face to what's happening."
"We have a tale of two cities," he said. "We have a small segment of the population that is doing extremely well, and the economy certainly is booming for many people, but the vast majority of individuals are, in fact, struggling to stay in San Francisco."
Budget and legislative analyst Fred Brousseau presented a just-completed study that found 162 Ellis Act evictions in the 12 months ending last Sept. 30. The act allows landlords to evict tenants in order to get out of the rental business.
Brousseau noted the evictions through September amount to a 145 percent increase compared to the previous 12 months. The figure is likely much higher, he said, because it doesn't account for tenants who accepted buyouts. The neighborhood with the highest number of Ellis Act evictions was the Mission, followed by the Castro.
The increased number of evictions is hitting a city where more and more residents are struggling to keep up with higher rents. Brousseau's report says 42 percent of San Francisco households are "rent burdened," meaning they spend more than 30 percent of their household income on rent. The number was highest in the Bayview, Excelsior and Visitacion Valley neighborhoods, where 57 percent of households are considered rent burdened.
"The fear is real and it's based on facts that we now have," said Supervisor Eric Mar.
Through a translator, Anna Gutierrez with the housing justice and immigrant rights nonprofit Just Cause, described in Spanish how she is facing an imminent eviction from her Mission home, where she has lived for 35 years.
"This injustice has to end now," she said. "I have seen too many of my neighbors evicted and it doesn't seem to stop."
Beverly Upton, who has helped women find shelter and housing in her role as director of the San Francisco Domestic Violence Consortium, said she and her neighbor are facing Ellis Act evictions from her building on Gough Street, where she has lived for 25 years.
"We've never been late on our rent. We've never asked for any big improvements," she said. "Once the advocates and the organizers and the artists are gone, who will be left to care about our city?"
The testimony included a lone landlord, Andrew Long, who argued that small property owners are also hurting.
"Your rent laws need to be more even-handed for landlords," he said. "You're driving landlords, especially small landlords, out of business."
Exploring ways to curb evictions
Campos said it's important for the city "to have a united front to tackle this crisis." He's exploring a number of measures to curb evictions, including a moratorium on all Ellis Act evictions. That would require state legislation, which Campos said he is working on with Assemblymember Tom Ammiano.
Campos has also introduced legislation to create a mechanism for tenants to file complaints when they are harassed by landlords. He's also asked the city attorney to draft a bill that would double the amount of relocation assistance landlords must provide to tenants under the Ellis Act, and is exploring a measure that would require landlords to report buyouts to the Rent Board.
Meantime, Mayor Ed Lee announced Thursday that he's formed a "broad coalition" of elected officials, tenants groups and other organizations "to help address the issue of affordability for working-class families in California's major metropolitan areas."
"We have to protect our valuable housing stock and prevent Ellis Act evictions that displace longtime tenants and do nothing to add needed housing in our City," Lee said in a statement.
Below: Report on evictions in San Francisco by budget and legislative analyst Fred Brousseau:


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Katy Perry has been on her worldwide Prismatic Tour for a little more than three months, and she's not stopping anytime soon. Her opening acts have changed as she's traveled, and recently, when I had the pleasure of seeing Katy in Columbus, Ohio, she was with country star Kacey Musgraves and singer/songwriter Ferras.
Ferras was truly a treasure. His style is really unique and fun, and he seemed at ease on stage. This says a lot since he's an up-and-comer opening for names like Kacey and Katy. His EP was handed out free with any purchase at the merchandise table, and I have since listened through it a few times. He's a talent that I hope will become an award-winning performer.
Kacey Musgraves is famous for her open and honest style of music. Mixed in with her own songs, she did a few covers and didn't disappoint in any way.
Listening to her sing brought a whole new vibe and made me want to dance in cowboy boots and play the washboard. She's a joy to watch, and her stage setup made you feel like you were at a neon barbecue in Arizona. (That's surprisingly not a bad thing.)
Finally, Katy took her triangular stage in a silver-and-neon outfit singing her hit song, "Roar." Her energy was lively, and the whole set was like a party.
All of her outfits and set changes brought to life new characters and events. She went from being an Egyptian queen to a killer cat and finished the night off as a walking firework.
My personal favorite section was the acoustic session. Katy, with her rainbow hair and beautiful flowing dress, preformed a few of her slower songs with nothing but a guitar. It was raw and moving.
Her talent is so underestimated by those who don't see this side of her. She gives her all in her performances and really connects to the audience.
She truly connected with the audience when she shared a pizza with a fan and when she sang "Birthday" to another. Also during "Birthday," she flew into the sky on a balloon seat and floated around the stadium so that everyone could experience her close up.
She loves her fans so much, and it shows during her concerts. It was a complete honor and a privilege to witness this.
Katy Perry is a wonderful artist, and I hope to see her again. It was completely worth the travel and the money to see her.
She'll be on this tour until sometime in 2015, staying in the U.S until February and then heading to Europe. The concert is a visual treat, a musical delight and a bangarang of a blowout. Any KatyCat or plain old Perry fan is sure to be impressed.


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Please sign our new Personhood Petition - our legislators need to hear from you! Follow us on Facebook & Twitter
Don't forget to subscribe to our E-Newsletter and Alerts!
Greater Augusta Chapter LIFE Happenings
Primary tabs
General contact information:
Gene Binet: 706-855-0906
George Vozniak: 706-726-1269
Events Coming Soon
To see events coming soon, please either refer to our website
Or our facebook page
Thank you!
Past Events
Pro-Life Summer Banquet 2013
"A Southern Evening for Life"
|Saturday August 17th, 2013 at 6:00 PM
|St Mary on the Hill School Dining Hall
1220 Monte Sano Avenue
|Individual tickets are $50.00 each
Table reservations for groups of eight are available for $400
A limited number of Sponsorship Tables are available for $500
- Sponsored by the Greater Augusta Chapter of Georgia Right to Life
- Down Home Southern Cooking by Events and More
- Authentic Southern Music by Erin Eubanks and the Family Fold
- Mike Griffin, the Vice President of Georgia Right to Life, will provide a Pro-Life update
- MC - Stan Byrde
All proceeds will be used to support Pro-life activities in the CSRA.
Please contact Dr. Gene Binet at 706-855-0906 ( email@example.com ),
George Vozniak at 706-726-1269 ( firstname.lastname@example.com ),
Vern Simon at 706-860-1119 ( email@example.com )
Faith and Public Policy Workshop
|Sunday, Sept 23, 2012, 2- 4:30pm
|St. Teresa of Avila
|This Faith and Public Policy Workshop includes presentations for Catholics on forming consciences for faithful citizenship and responding to our choices in the current political landscape.
There will be time for small group discussions as well as questions and answers.
Hosted by the Georgia Catholic Conference and the Diocese of Savannah.
For more information and for a list of speakers, click here.
Augusta Life-Chain 2012
|Sunday, Oct. 7, 2012, starting @ 2pm till 3:30pm
|Intersection at 2819 Peach Orchard Rd. and Lumpkin Rd., Augusta, GA.
The main speaker will be Bishop Hartmayer, Savannah Diocese.
For more information: Gary or Nancy Garner, 706-793-8090
Sponsored by the Alleluia Christian Community
Youth Bus Trip to March for Life 2012
|Thursday morning Jan 24 - Sunday morning Jan 27
|Washington D.C.
More information coming soon! (As date approaches.)
Youth Bus Trip to National March for Life
For more information: Michael Lammers, 706-736-5516 ext 19
Pro-Life Summer Banquet 2012
"A Southern Evening for Life"
|Friday August 17th, 2012 at 7:00 PM
|St Mary on the Hill School-Gym
1220 Monte Sano Avenue
|Individual tickets are $50.00 each.
Table sponsorships are $500 each (8 tickets) to include:
Table reservations are $400 each (8 tickets), name on table
- Sponsored by the Greater Augusta Chapter of Georgia Right to Life
- Catered by Terry Wick
- Cash bar
- Music by Erin Eubanks and the Family Fold
Proceeds benefited Augusta Covanent Care Adoption Agency, January Pro-Life Youth Bus Trip, Augusta Area Rachael's Vineyard Post Abortion Counseling, Augusta Care Pregnancy, Georgia Right to Life Chris Pregnancy Hot Line, and Augusta Youth Pro-Life Oratory and Essay Contests.


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Hey guys, I've had my subaru since 2003 and she's got 80k miles with NO ISSUES EVER except this one! It's been a great car!
I'm in Miami and just DYING without A/C
When I turn the car on and hit the A/C button, the system blows cold air for a few minutes then starts to turn hot.
I checked the freon pressure, and added 16 oz to get 25 PSI (top part in the green of this gauge).
The system is still having the same issue. I spent some time watching the compressor kick on when the A/C button is pressed while the car is running...The compressor kicks on for a couple revolutions and then stops.
Is it an issue with the clutch? Maybe the high pressure side is too low pressure still? I've heard there's a solenoid that engages the clutch, maybe that's bad? What should I check?


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Fashion is an everlasting topic since the day we began to pay attention to how we dressed. If you are looking for fashion, this is the right place to come. You can find the right skater midi skirt here from Fashionmia's latest and hottest collection of skater midi skirt. We provide customers fashion items like skater midi skirt with totally affordable price and high quality. Come discover the skater midi skirt you need from our suggestion and guide to save time in choosing the most suitable skater midi skirt. Have fun shopping online at Fashionmia.
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© 2017 FashionMia, Inc.


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Browsing by Subject "Watershed restoration--Monitoring--New Mexico--Santa Fe Region--Citizen participation."
Now showing items 1-1 of 1
[2010-09-17] Volunteer river monitoring plan for the urban reach of the Santa Fe River Watershed In designing a monitoring plan, it is important to first look at the overview of the watershed, issues and uses. In our case, we are looking at the Santa Fe River Watershed. It is 241 square miles and approximately 37 ...


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No one wants to spend prime beach time on mundane house repairs. Get your coastal home ready this spring so you can spend the coming months strolling the sand.
Check heat and AC systems. Your home's hardest-working heating and cooling components are in out-of-sight, out-of-mind locations such as basements and backyards. Avoid costly problems by asking your dealer or service person to monitor and maintain compressors, furnaces, ducts, and other components of your climate-control system. If you're interested in a DIY project, try one of these:
• Put a coat of car wax on the exposed metal housing around your outside central-air unit; wax helps protect metal in corrosive coastal environments.
• Replace the filters in your furnace/AC unit at least as often as the manufacturer recommends.
• Vacuum air vents to remove dust.
• Repair tears in insulation around ductwork with duct tape.
• Clean AC vents with a household cleanser to remove mold.
Remember the refrigerator. Clean your fridge's condensing coils now to make sure you don't run out of cold drinks later. Turn off the refrigerator by pulling the plug or throwing the appropriate circuit breaker. Remove the base plate or top grate (check your owner's manual to locate coils), then use a vacuum cleaner with nozzle attachment to remove any dirt and lint. For more suggestions, see hometips.com (click on "Kitchen Appliances & Fixtures," then "Refrigerator Maintenance").
Prepare for spring showers. Gutters and downspouts can cause expensive problems when they're clogged. Clean them yourself, or pay a pro to do the job. Installing gutter screens or shields to keep debris out and water flowing can prevent blockages. For more information, visit gutterjacket.com, guttertopper.com, or thegutterbrush.com.
Inspect the irrigation. Now's the time to check out all components of your in-ground irrigation system. Look for leaks, and adjust sprinklers so you're watering the ground beneath plants instead of the shingles on the side of your house. If this puts you in the mood for gardening prep, see this valuable site: landscaping.about.com (click on "Yard Maintenance").
Listen up! A good way to check for leaks or faulty spigots is to head for the basement (or wherever the water main enters your home). Switch off machinery such as sump pumps or furnaces, and just listen. If you hear water running, it's time to investigate. You might have a running toilet or a punctured hose line.
Head upstairs. Planning to clean, insulate, or make repairs in your attic space? This is the ideal time. Attics can be prohibitively warm during the summer months. If you live in a warm climate, consider installing thermostatically controlled attic fans. For homes with no electricity upstairs, solar-powered fans are now widely available. Visit solaratticfan.com.