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What would happen if I changed my mind about surgery?
Doctor Answers 4
Nervous about surgery
Each practice has its own policies regarding refunds of this nature. I would stress to you though that it is very common to be anxious about surgery. You are not alone and your surgeon and his/her staff are there to answer your questions and help alleviate your concerns. A tummy tuck is a powerful surgery that can bring about very positive changes in how you feel about yourself. I definitely recommend that you contact your surgeon to discuss your feelings so that you can begin to feel more confident and look forward to your procedure. Good luck!
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What would happen if I changed my mind about surgery?
It is common to be nervous prior to any type of surgery. I highly recommend that you discuss this with your surgeon sooner rather than later.
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Robert Morris Inn - A Waterfront Country Inn
Top Romantic Hotel
Enough said My stay was to short!
View was wonderful. Parking too tight. Old room. Old bathroom. Second night, several fire alarms. Went out side with two other couples Others remained in the bar. Was not approached by any staff. was not told what the problem was. Was not told it was OK to go Bach to room called the desk when the alarms we t off again. Asked the front desk if we needed to evaluate again. Was told no and then hung up on. Very un professional. Not a well run ship at all. Sub part for 500 a day. Very sub par.
Reservation was for two double beds. (Couple plus adult daughter). Entered room and there was a queen. Ended up with a cot for daughter - not ideal, but were told no other rooms available. Parking lot had less than a dozen cars. Furniture was covered with grout dust from recent bathroom remodel. Attendant offered to clean it, but as it was very late, and we were tired, we opted to ignore it. Adequate for an overnight stay, - would not recommend for longer time.
Cute room decor. Clean, quiet and well managed. Bill included breakfast and it was hearty-included hot food. Just a 1.6 miles from downtown St. Michaels.Would go back.
Good room rate and close proximity to the main strip of St. Michael's shops and restaurants. The room didn't have great ventilation (the air felt damp) and the décor was dated.
Set back from the main highway, but right next to an excellent seafood resturant. Nothing, it was very nice - NOTE it is no longer a Best Western, but the standards are the same!
All the staff was incredibly friendly and helpful. It's a pet friendly hotel so we brought our dog, no issues. The hotel has a very nice atmosphere with multiple fireplaces and seating areas. Outdoor fireplace was nice to sit in the brisk December air and sip a cocktail. The restaurant was delicious.
Really liked this hotel, amd especially the location in the heart of downtown Easton. So convenient to walk to restaurants & shops! Staff was wonderful, sunday brunch was great. Clean rooms & comfy beds. Will definitely stay here again.
Location was center of historic district Bar was understaffed. The bathrooms were given a quick makeover and it showed. Tile work was bad.
In town quaint shops right out the door. Like having Georgetown on the Eastern Shore. Food is over the top. Oyster and crab cuisine. Entire staff are world class! NO COFFEE MAKER IN ROOM??!! Don't make me go to the restaurant and pay 3$ a cup when I'm in my pajamas! Bathroom is small one person at a time. No guide for tv and tv had volume problems which I reported but it wasn't fixed. Suspect it was the set itself.
The location of the resort is right on the water and beautiful. The staff were very friendly and accommodating. There was nothing that was too difficult or out of the ordinary. Clay, who runs the restaurant and bar, is wonderful. While the rooms are a bit dated, it is clear that improvements are being made. Regardless, it is a perfect place to stay if you are visiting St. Michaels and the Chesapeake Bay Maritime Museum.
It was clean. On the water. But if you don't golf, I wouldn't recommend it. The restaurant was completely reserved for a birthday party. The other option was the country club with medicre food. Over priced for one night stay. Terrible food in the country clubhouse: freezer style burgers and poor wine.
Location to St. Michaels, MD Front of vanity was leaning up against the wall. There was a strange odor in the room, like stale smoke. The bathroom needs to be caulked - where the tub met the wall was a huge crack all the wall around.
I came for Ironman MD and the location was very convenient. The woman at the front desk was very friendly and welcoming. We were overrun by fruit flies! Had to smash a roach crawling on the wall. The toilet had not been cleaned. We were right jext to the stairs and heard people going up and down all the time.
The blankets had holes and the breadspread had dirty stains. The room smelled horrible.
The motel was very, very clean and the staff was very helpful in solving any question or problem The motel is not new, but was very good value considering the price and how clean it was.
I was given a refund-staff was nice about my concernes tub was disgusting, faucet had a continuous stream of hot water coming out of it, mold on carpet by fridge which was also covered with some kind of sludge, sink with hair, flies in room, stank like smoke(non smoking room)/dog/mold combination
location and price ok Outside of building was filthy, flies in dumpster got into vehicle coming and going. Room was a little better, but not much. Evidence of previous guests, hair in shower, bobby pin on floor, some sort of construction material (spackle?) imbedded in rug. Complimentary "breakfast" was joke (thawed frozen waffles and cereal), coffee was terrible. On certain channels (ESPN & TWC notably) TV screen would malfunction.
Room was nice. Clean. Spacious. Comfortable. Standard continental breakfast. I was a wedding guest, and my car was at the reception. When the taxi cab I called failed, the manager literally got in his truck and took me to the reception, 15-20 min away. Stunning generosity, good people
Great customer service Low rate Kind and accommodating staff Clean comfortable room Free bottles of water No issues during my stay
Friendly and helpful staff Free and good breakfast Fruits, yogurt, juice, etc., available all day Well maintained
location cean Beds are terrible worst bed i have ever slept ( or not sleep is more like it ) in.
Met all my expectations!
Staff was incredibly nice and helpful. Great value, clean room, comfy bed. WiFi was easy to access, had a strong signal, and very fast. Facility is clean but getting older and worn. Some items need updating or replacement. Directly under the flight-line of a small plane airport.


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|Bill Davidson <bill...@gmail.com>
|Re: Fun with the JVM crashing.
|Fri, 06 Feb 2009 20:01:58 GMT
Caldarale, Charles R wrote: > Only if that shows up repeatedly. It does. >> I'm thinking that the JVM shouldn't be getting SIGSEGV's. > > You're right about that. However, it could also be an OS or > hardware problem. You might want to run some serious memory > tests on the box, just to eliminate the latter. Does this > particular system use ECC memory, or just plain old > parity-checking DIMMs? Not sure. However, it has happened on three different boxes, always with the same CompileTask mentioned. > You can also try either moving up to the recently released > JDK 6u12, or dropping back to 6u7. Lots of changes went in > at 6u10, and something might still be broken in there. The > C2 compiler is an extremely complex beast. I'll try that. BTW, it also happened with 6u10. I'm wondering if -Xint might help. --------------------------------------------------------------------- To unsubscribe, e-mail: firstname.lastname@example.com For additional commands, e-mail: firstname.lastname@example.com
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By Michael Hiestand, USA TODAY
Editor's note: The following story appears in its original form with two clarifications that are noted in italics below.
Technology can seem cumbersome.
Consider the NBC Beijing Olympics onscreen graphic saying action is "live." That's accurate for programming — including prime-time swimming, gymnastics and beach volleyball — airing in Eastern and Central time zones. But it's inaccurate when "live" remains onscreen as that same prime-time footage airs tape-delayed in Pacific and Mountain time zones.
During the Games, NBC has said repeatedly the "live" designation can't be dropped from tape-delayed coverage for technical and financial reasons.
But the technical side, says Ken Fitzpatrick, a vice president at Chyron, which supplies NBC's graphics, is no big deal. That "live" graphic, he says, could be erased "almost in real-time — in seconds!"
But wouldn't it be complicated? "Not at all," he says. "That's the beauty of the automation we've done. Anyone with the proper NBC authorization — even local stations or station groups — can make changes on the fly. They have the discretion and it can be done simply. They can dynamically move them off anytime."
(Clarification: According to Kevin Prince, chief operating officer of Chyron, the "live" label can only be removed from the screen image "at the source and during the event" and cannot be removed by local stations.)
Sounds darn easy. Melville, N.Y.-based Chyron, says Fitzpatrick, has created TV sports graphics for decades but is working on NBC Olympic graphics for the first time. Chyron's innovations, he says, include making the NBC Olympic logo revolve on a pedestal and allowing on-site producers to instantly call up graphic packages on individual athletes.
(Clarification: Prince said Chyron has worked with NBC on at least four Olympic Games. This is Fitzpatrick's first.)
For NBC, this seems like a matter of wanting to use everything in the tool box.
Holding for prime time:
NBC has done a terrific job in changing what annoyed viewers about Olympic TV — long maudlin features, not giving viewers clues about what was coming up in prime time — but the biggest dinosaur remains: Prime time, above all else, must be served.
The choicest TV cuts of Olympic action continue to be saved for prime time no matter when they happened.
But here's a hunch: This will be the last Summer Olympics when U.S. viewers will have to put up with that.
Consider Usain Bolt's dominant wins in the 100 meters Saturday and Wednesday's 200 meters — both glamour events that occurred during NBC's daytime coverage hours but were held for prime time anyway. The reason is supposed to be obvious: Despite the round-the-clock coverage on NBC and its cable TV channels, more than 90% of total Olympic TV viewing comes from NBC's prime time.
But consider that any other TV outlet — other broadcast or cable networks, local stations that aren't NBC affiliates — have to wait to show any Olympic highlights each day until NBC's coverage has ended, well after midnight. (And then, highlights have to be on regularly-scheduled news shows.) NBC could do what Olympic TV networks do around the globe: Show top events live — no matter the time — then again in prime time. Given the rules, non-NBC outlets still wouldn't get to air events as highlights before NBC's prime time.
This might necessitate new policing, such as MLB chasing local TV stations airing unauthorized highlights of games in progress. Another reason for a change: The Internet is out of control. I watched Bolt shortly after he ran Wednesday via a Belgium TV video on YouTube.
Spice rack:
Fox Sports Net will today announce that its Pro Football Preview, taped Thursday nights and aired Friday nights, will have what's billed as the first active athlete — the San Diego Chargers' Shawne Merriman — to be a regular analyst on a preview show. He'll fly to the show's Los Angeles set each week. Says producer Rick Jaffe: "I was excited to hear how excited he was." … In its debut of live SportsCenter shows from 9 a.m. ET to 3 p.m. ET, ESPN drew 0.3% of U.S. cable TV households — down 27% from taped shows in the previous week.
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text: Our marvelously merry Red Flannel Readers express a festive sense of style. We think these readers are fashionable year-round - but are particularly well-suited for reading tiny gift tags, notes to Santa, and Christmas-themed novels. Comes with matching poly case. Please specify lens magnification: 1.0, 1.5, 2.0, 2.5, 3.0, 3.5, or 4.0.


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On the Estate. Memoirs of a Russian Lady Before the Revolution
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Mariamna Davydoff, the Russian lady who wrote and illustrated this memoir, was born in 1871. It was after she fled Russia for France in 1919 that she set down her detailed recollections and painted the accompanying watercolours. She did this mainly to enlighten one of her granddaughters about the familys life in the last decades of Tsarist Russia. The result is a first-hand account of a way of life that weve known mainly through the writings of Chekhov and Turgenev. Here are the country estates, the large families indulging in sports and pastimes, the Easter and Christmas holidays, the heat of summer and the frost of winter. Mariamna Davydoff had studied painting and made something of a reputation as a caricaturist, but when she fled from Russia she had to leave behind all her watercolours and drawings. These were destroyed by the Bolsheviks, but the portfolios she created in France are fortunately intact. This book will appeal to anyone with an interest in 19th-century Russian history, art or literature, or simply in the deeply human story of our recent but irretrievable past.


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How has the weather affected your center? i.e. hard for staff to get in, increased calls, service requests etc?
During the 2011 Floods, our CBD office was closed down along with the rest of the CBD and we were able to move to the other sites. In the 2013 floods, we needed to get 220 temps in a very short peoriod of time, we have 4 recruitment agencies on standby and ensured that they had staff available once we knew that the severe weather events were coming out way
What plans do you have in place to cope with weather related incidents?
Our centre is responsible for disaster recovery and State Emergency Service calls, so we are impacted every time there is a severe weather event. We have a mixed strategy, with three different sites that staff can attend when weather events occur. We also have a Work From Anywhere rapid response team that use laptops and mobile phones to be able to work from anywhere.
What advice would you share with other centers who may face weather related challenges or natural disaters and how to prepare for these?
The best way is to have mulitple plans, as you can never know what exactly is going to be impacted. A diverse and distributed workforce helps as does having a work from anywhere capability (essentially a mobile and roving contact centre)
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Published: Tuesday, January 7, 2014


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The development team has always been a strong believer in pushing people together in a friendly way, in the online game. There will be team match making, guild match making, PvP match making, formation gameplay for teams, PvP mini-games, social building of villages, massive RTS-like guild encounters and so forth. There will be substantial experience point bonuses for teaming, though it is not the only option. You can solo all the way, if you want.
IGN, 11th May 2005 (Gaute Godager)


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Print advertisment created by Y&R, Panama for Sony, within the category: Electronics, Technology.
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Bassist Nick Allbrook leaves Tame Impala, Replaced By Cam Avery
After difficulties with time management between Tame Impala and side project Pond, bassist Nick Allbrook split from Tame Impala last Saturday, May 18th. His last show with the band was at the Belvoir Amphitheatre where Allbrook played his first show with the band years prior.
The band posted a statement about the departure on their website saying, "he needed to try and screw his head back on, and make an attempt to assimilate back into society."
As a replacement they've brought on Cam Avery of Pond and The Growl. They added, "Heir to the throne is our long time super best musical blood brother Cam Avery, ape/womaniser/former pro golfer…cam has big shoes to fill, which is fortunate because Cam has big feet. big stinky feet that leave sock footprints in your house when he comes in and he's like, hey man can I sleep on youz guysez' couch?"
Tame Impala's last album Lonerism was well received last year and was on the best album lists of 2012 for NME, Rolling Stone, Triple J, Filter Magazine and Urban Outfitters.


text: Updated December 26, 2014: Hope y'all had a very nice Christmas this year! Now that it's behind us and we are all beginning to recover from all the food, it's time to see what's on sale this year from Costco. The've just released their mailer with coupons good from December 30, 2014 through January 24, 2015. Besides the usual coupons, you'll also save $70.00 on a new set of Michelin tires so it's a great time to consider replacing any old and worn out tires you may have. Of course certain offers may vary from state to state and often these sale items will have limits on how may you can purchase at the discounted price. We've included the full ad mailer below. Most items are available both in-store and online (often with free shipping) but you will need to be a current club member to be able to shop at Costco.


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"I don't like spiders and snakes," say the words of an old country music song, but they might as well say, "I don't like spiders and snakes and math." Researchers at Stanford University in California have determined that youngsters with math anxiety show the same neurological reactions to math as people with phobias about spiders and snakes exhibit when they come into contact with these creepy crawlers.
Luckily, these same researchers have determined that, like these phobias, math anxiety can be successfully treated with a therapy called exposure therapy. It exposes the sufferers repeatedly to the thing they fear in a safe environment. In the case of students with math anxiety, the therapy takes the form of one-on-one tutoring that employs a positive approach.
Exploring the Brain
The research team, led by Vinod Menon, a professor of psychiatry and behavioural sciences, sought to identify a biological basis for math anxiety. Using magnetic resonance imaging, they determined that when children were asked to perform basic calculations, the brain showed increased activity in the amygdala, its major fear centre, and the hippocampus, the structure that aids in the formation of new memories. The heightened activity in the amygdala interfered with the function of the brain regions involved in numerical processing.
"It's remarkable that, although the phenomena was first identified over 50 years back, nobody had bothered to ask how math anxiety manifests itself in terms of neural activity," Menon told the Stanford University news service. "Our findings validate math anxiety as a genuine type of stimulus- and situation-specific anxiety."
It is possible to be good at math and still have math anxiety, but over time, those who are anxious shy away from pursuing advanced mathematics, thus limiting career options. Until recently, little effort had been placed on addressing this problem.
"Math anxiety has been under the radar," said Kaustubh Supekar, PhD, the lead author of the study, told Science Daily. "People think it will just go away, but for many children and adults, it doesn't."
Tutoring to the Rescue
Lessening math anxiety is possible, however, with the help of one-on-one cognitive tutoring, the research indicated.
In their 2015 study, the Stanford team looked at 46 Grade 3 students, a critical age for acquiring basic mathematics skills. They gave each child a test to determine his/her level of math anxiety and separated them into two groups: high anxiety and lower anxiety. They also gave them neuropsychological assessments and required them to complete addition or subtraction problems while undergoing a magnetic resonance imaging (MRI) scan.
Next, the children were provided with 22 sessions of one-to-one tutoring that focused on addition and subtraction. All of them showed improvement in addition and subtraction at the end of the tutoring program. The youngsters with high math anxiety had reduced anxiety afterward, while the others didn't show any difference. A follow-up MRI scan while adding or subtracting indicated that the high-anxiety students no longer displayed activity in their amygdalas, meaning that the tutoring had relieved their anxiety, rather than finding a workaround.
"It's reassuring that we could help these children reduce anxiety by mere exposure to [math] problems," Supekar told the Stanford news service.
The tutoring was highly personalized, Menon told National Public Radio. If a child got stuck on a particular concept, the tutor would work with the student to "get beyond the bottleneck in a non-negative, encouraging way."
The scientists believe that more research is required to determine whether the one-on-one sessions were effective in reducing the typical anxiety partly because the students had no fear of having to perform in front of classmates or others.
Tips for Tutors, Students
Boise State University in Idaho offers a number of useful suggestions for both math tutors and students with math anxiety.
1. Guide the student through the process of doing a math problem by asking leading questions. Avoid doing the problem for the student.
2. Teach concepts, rather than just process to help the student become an independent learner. Students need to understand why something is important, rather than just following steps.
3. Encourage class attendance. Tutoring is a wonderful aid, but it is not a substitute for teaching.
4. Work in conjunction with the teacher. Don't confuse the student by using different methods for solving problems than the teacher uses in class. Make sure you are on the "same page."
1. Don't use self-defeating talk. Give yourself a break! Use positive self-talk when reviewing your math abilities.
2. Don't consider your questions dumb. There is no shame in not understanding something and there is no such thing as a bad question.
3. Don't run away from your frustrations. Keep a journal of your math successes, your strengths, your frustrations and areas for further study.


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INTRODUCTION — A distinct type of hypoxemic respiratory failure characterized by acute abnormality of both lungs was first recognized during the 1960s. Military clinicians working in surgical hospitals in Vietnam called it shock lung, while civilian clinicians referred to it as adult respiratory distress syndrome [1]. Subsequent recognition that individuals of any age could be afflicted led to the current term, acute respiratory distress syndrome (ARDS).
The Berlin Definition of ARDS (published in 2012) has replaced the American-European Consensus Conference's definition of ARDS (published in 1994) [2,3]. However, it should be recognized that most evidence is based upon prior definitions. The current diagnostic criteria for ARDS are provided separately. (See "Acute respiratory distress syndrome: Clinical features and diagnosis in adults", section on 'Diagnostic criteria'.)
The prognosis of ARDS is reviewed here. Other issues related to ARDS are discussed separately. (See "Acute respiratory distress syndrome: Clinical features and diagnosis in adults" and "Acute respiratory distress syndrome: Epidemiology, pathophysiology, pathology, and etiology in adults" and "Mechanical ventilation of adults in acute respiratory distress syndrome" and "Acute respiratory distress syndrome: Supportive care and oxygenation in adults" and "Acute respiratory distress syndrome: Investigational or ineffective pharmacotherapy in adults".)
MORTALITY — ARDS is associated with appreciable mortality, with estimates ranging from 26 to 58 percent [4-12]. Mortality increases with disease severity. As an example, in a multicenter, international, prospective cohort study of 3022 patients with ARDS, unadjusted hospital mortality was reported to be 35 percent among those with mild ARDS, 40 percent for those with moderate disease and 46 percent for patients with severe ARDS [12]. Similar to other studies, mortality directly correlated with driving pressure (ie, the difference between plateau and positive end expiratory pressures) [13]. (See "Mechanical ventilation of adults in acute respiratory distress syndrome", section on 'Driving pressure'.)
The underlying cause of the ARDS is the most common cause of death among patients who die early [7,8,14,15]. In contrast, nosocomial pneumonia and sepsis are the most common causes of death among patients who die later in their clinical course [14]. Patients uncommonly die from respiratory failure [8].
Numerous studies suggest that survival has improved over time [10,15-17]. As an example, an observational study of 2451 patients who had enrolled in ARDSNet randomized trials found a fall in mortality from 35 to 26 percent between 1996 and 2005 [16]. Although encouraging, a 2016 observational study of ARDS patients demonstrated that global mortality remains high with 40 percent dying in the hospital. To the extent that mortality may be decreasing with time, several issues should be considered:
●It is not known if mortality has decreased among patients who received their care outside of a specialized center or a clinical trial.
●The improved mortality may be attributable to patients who have ARDS related to risk factors other than sepsis, such as trauma [15].
●To the extent that mortality has decreased, the reasons are uncertain. Likely causes include better supportive care and improved ventilatory strategies, such as low tidal volume ventilation [3,16,18]. (See "Mechanical ventilation of adults in acute respiratory distress syndrome", section on 'Low tidal volume ventilation'.)
Predictors — Many studies have sought to identify factors during the acute illness that predict mortality. Such factors can be categorized as patient-, disease-, or treatment-related. No single factor has proven to be superior to the others.
Patient-related — Older patients appear to be at an increased risk for death [5,19]. This was illustrated by a multicenter cohort study that followed 1113 patients with ARDS for 15 months [5]. The mortality rate increased progressively with age, ranging from 24 percent among patients 15 to 19 years of age to 60 percent among patients 85 years of age or older. The overall mortality rate was 41 percent. Although it has been suggested that obesity may impact the mortality of critically ill patients with or without ARDS, evidence is conflicting [20-26].
Disease-related — Disease-related predictors of mortality include severe hypoxemia, failure of oxygenation to improve, pulmonary vascular dysfunction, increased dead space, infection, a high severity of illness score, a non-traumatic cause of the ARDS, and certain biomarkers and gene polymorphisms.
●Gas exchange – The severity of hypoxemia determines whether the patient has mild ARDS (arterial oxygen tension/fraction of inspired oxygen [PaO2/FiO2] >200 but ≤300 mmHg), moderate ARDS (PaO2/FiO2 >100 but ≤200 mmHg), or severe ARDS (PaO2/FiO2 ≤100 mmHg). Mortality appears to increase as ARDS becomes more severe, according to an observational study of 3670 patients with ARDS that found that patients with mild, moderate, and severe ARDS had mortality rates of 27, 32, and 45 percent, respectively [27]. Similarly, there is general agreement that improvement of oxygenation during the early intensive care unit (ICU) course correlates with survival [28]. Severe hypercapnia (partial arterial pressure of carbon dioxide [PaCO2 ] ≥50 mmHg) may also indicate increased mortality, higher complication rates, and more organ failures [29].
●Pulmonary vascular dysfunction – Pulmonary vascular dysfunction is indicated by an elevated transpulmonary gradient (ie, ≥12 mmHg) or pulmonary vascular resistance index (ie, >285 dyne s/cm). The transpulmonary gradient is the difference between the mean pulmonary artery pressure and the pulmonary artery occlusion pressure, while the pulmonary vascular resistance index is the transpulmonary gradient divided by the cardiac index. Pulmonary vascular dysfunction appears to be an independent risk factor for 60-day mortality and fewer ventilator-free, ICU-free, and hypotension- or vasopressor-free days [30].
●Higher extravascular lung water and pulmonary vascular permeability indices correlate independently with 28 day mortality [31].
●Dead space – Dead space ventilation early in the course of ARDS appears to correlate with mortality. This was illustrated by a series of 179 patients with early ARDS who had their ratio of dead space to tidal volume (ie, the dead space fraction or Vd/Vt) determined by measuring exhaled carbon dioxide (CO2) levels [32]. The dead space fraction was markedly elevated (mean 0.58, normal <0.30) and there was a linear correlation between the degree of dead space ventilation and mortality. For every 0.05 increase in dead space fraction, the odds of death increased by 45 percent.
●Infection – Infection and/or multiorgan dysfunction are better predictors of mortality than respiratory parameters [15,33-38]. This is probably because they predict death from a nonrespiratory cause, which is more common than death due to respiratory failure.
●Severity of illness score – Severity of illness scores appear to correlate with mortality. As an example, patients with a higher APACHE III score have an increased likelihood of death (odds ratio 1.78 per 25-point increase, 95% CI 1.16-2.73) [19]. (See "Predictive scoring systems in the intensive care unit", section on 'Acute Physiologic and Chronic Health Evaluation (APACHE)'.)
●Underlying cause of the ARDS – Patients with trauma-related ARDS appear to have a lower likelihood of death at 90 days than patients with ARDS that is unrelated to trauma [39]. Severe but not mild or moderate alcohol misuse, in patients with acute lung injury, is associated with an increased risk of death or persistent hospitalization at 90 days (adjusted odds ratio, 1.7; 95% CI 1.00 to 1.87) [40]. The presence of diffuse alveolar damage (DAD) on lung biopsy is also associated with a worse prognosis compared with those who had non DAD-associated ARDS [41]
●Laboratory – Routine laboratory parameters are not helpful for predicting the outcome of ARDS. However, a large body of emerging evidence suggests that many biomarkers and gene polymorphisms are associated with both susceptibility to ARDS and outcome from ARDS [42]. The practical utility of these observations is uncertain, but the research may lead to new preventative and therapeutic strategies in the future.
Treatment-related — Treatment-related predictors of mortality include a positive fluid balance, glucocorticoid therapy prior to the onset of ARDS, packed red blood cell transfusions, and being in an ICU that does not mandate care by an intensivist.
●Fluid balance – A positive fluid balance may be associated with higher mortality [43,44]. This was demonstrated by the ARDSNet low tidal volume trial, which found that a negative fluid balance at day 4 was associated with decreased mortality compared to a positive fluid balance, after adjustment for factors such as age, severity of illness, and ventilator strategy (adjusted odds ratio 0.50, 95% CI 0.28-0.89) [44]. (See "Acute respiratory distress syndrome: Supportive care and oxygenation in adults", section on 'Fluid management'.)
●Treatment with glucocorticoids – Patients who received glucocorticoids prior to the onset of ARDS may have an increased likelihood of death (odds ratio 4.65, 95% CI 1.47-14.7) [19]. (See "Acute respiratory distress syndrome: Investigational or ineffective pharmacotherapy in adults", section on 'Glucocorticoids'.)
●Packed red blood cell transfusion – Patients who receive packed red blood cell transfusions may have an increased likelihood of death (odds ratio 1.10 per unit transfused, 95% CI 1.04-1.17) [19,45].
●Organization of the ICU – Patients cared for in an ICU that mandates transfer to an intensivist or co-management by an intensivist may have a decreased likelihood of death (odds ratio 0.68, 95% CI 0.53-0.89) [46].
●Late intubation – Patients who are intubated late in the course of the disease may have a higher risk of death from ARDS when compared with patients who are intubated early and those who are never intubated (56 verus 26 versus 26 percent) [47]. Although unproven, it suggests that initial strategies (eg, noninvasive ventilation and high flow oxygen) may impact the timing of intubation, to ultimately affect mortality.
Predictors of improved survival include lung protective ventilation strategies, which are discussed separately. (See "Mechanical ventilation of adults in acute respiratory distress syndrome".)
MORBIDITY AMONG SURVIVORS — Cognitive, psychologic, and physical morbidity is common among survivors of ARDS. Similar to that observed in survivors of any critical illness, morbidities are usually evident upon discharge from the intensive care unit (ICU). Many of the cognitive, psychiatric, and physical manifestations are present for at least five years and they tend to resolve slowly. The occurrence and resolution of symptoms are frequently co-dependent. Neuropsychologic and physical impairments after ARDS are discussed in this section. The epidemiology, diagnosis, clinical manifestations, outcome, and treatment of post-intensive care syndrome are discussed separately. (See "Post-intensive care syndrome (PICS)".)
After ARDS, the following impairments have been reported [48-57]:
●Cognitive – Rates of cognitive dysfunction following ARDS varies among studies, ranging from 30 to 55 percent [54,58,59]. In two observational studies of a total of 310 ARDS survivors, impaired neurocognitive function was reported in 30 percent and 49 percent of patients at 12 months following the acute illness [54,58]. These rates are similar to that reported in the largest study of survivors of critical illness where 40 percent had neurocognitive deficits at three months; these persisted at 12 months in the vast majority [59]. (See "Evaluation of cognitive impairment and dementia".)
●Psychiatric – Psychiatric illnesses also appear to be common among survivors of ARDS, with depression, anxiety, and post-traumatic stress disorder as the most common disorders reported [58,60,61]. The absolute risk varies between studies. One prospective cohort study of ARDS survivors estimated that the incidence of depressive symptoms was 40 percent during the two years following the acute illness [60]. In another observational cohort, depression, post-traumatic stress disorder, and anxiety were present in 36, 39, and 62 percent of survivors at one year [58]. These rates are higher than those reported from a national data base study that reported 1 percent of survivors had a newly diagnosed psychologic disorder (mostly anxiety and depression) and 19 percent received one or more prescriptions for psychoactive medications [56]. The difference may be due to differences in the study population (all comers as opposed to ARDS), location (Denmark as opposed to North America), technique to acquire data (database as opposed to following a cohort), and diagnostic criteria (medication, referral to a psychiatrist as opposed to self-reporting). In a study reporting psychiatric symptoms, 66 percent of ARDS survivors had substantial symptoms of depression, anxiety, or posttraumatic stress disorder (PTSD) during one year follow up [61]. The majority of symptomatic patients experienced morbidity in two or more domains. Risk factors for symptoms included younger age, female sex, unemployment, alcohol misuse, and greater opioid use in the ICU, whereas there was no association between symptoms and severity of illness or ICU length of stay. (See "Comorbid anxiety and depression in adults: Epidemiology, clinical manifestations, and diagnosis" and "Co-occurring substance use disorder and anxiety-related disorders in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".)
●Physical – Survivors of ARDS frequently have persistent, abnormal exercise endurance and physical disabilities [48-50,60,62-66]. The persistent nature of this abnormality was demonstrated by a prospective cohort study that followed 109 survivors of ARDS for five years [50]. The six minute walking distance at one, three, and five years was 66, 67, and 76 percent of predicted, respectively. During a two-year follow-up study of 186 ARDS survivors, the cumulative incidence of impaired physical function was as high as 66 percent [60]. Another prospective cohort study reported that 38 percent of patients with ARDS had muscle weakness at discharge, which was associated with worse five-year survival [66]. Risk factors for physical dysfunction were longer ICU stay and prior depressive symptoms. (See "Cardiac rehabilitation programs".)
Data suggest that many ARDS survivors experience additional physical decline after their critical illness. For example, in one prospective cohort study, 69 percent of 193 ARDS survivors experienced decline in >1 physical measure such as muscle strength, exercise capacity, and physical functioning [67]. Significant risk factors for subsequent physical decline included increased age and pre-ARDS comorbidity.
A longitudinal prospective cohort study of 156 ARDS survivors showed an association between muscle weakness at hospital discharge and increased five-year mortality [66]. Thirty-eight percent of patients had demonstrable muscle weakness at discharge, and this was associated with worse five-year survival. Fifty percent experienced either persistent or resolving weakness trajectories during the follow up period, and these were associated with more than a threefold greater hazard of death compared to patients without weakness.
●Lung function – Lung function following ARDS is commonly compromised for as long as five years [48,50,51]. However, it is uncertain whether decreased lung function results in physical impairment. The degree of compromise depends on which parameter of lung function is measured (spirometry, lung volumes, diffusing capacity). For example, upon discharge, approximately 80 percent of patients will have a reduction in diffusing capacity and a smaller percentage will have airflow obstruction (20 percent) or restriction (20 percent) on spirometry and lung volumes [48]. In most patients, lung volumes and spirometry will normalize (ie, measure within 80 percent of predicted values) by six months, and diffusion capacity should normalize by five years [48,50,51]. A small percentage of patients are left with residual deficits and supplemental oxygen is rarely required [48,49,62-65]. (See "Overview of pulmonary function testing in adults".)
●Other – Additional sequelae of ARDS include complications of endotracheal intubation, minor imaging abnormalities, increased risk of death, poor quality of life, and family stress (also known as post-intensive care syndrome-family [PICS-family]]) [11,55,68,69].
•Complications of intubation – Patients with ARDS may experience complications associated with prolonged intubation including laryngotracheal stenosis, tracheomalacia, and speech or swallowing impairment, the details of which are discussed separately. (See "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients".)
•Imaging abnormalities – Although most patients experience excellent radiologic recovery, at 180 days post diagnosis, abnormalities persist in a significant minority and correlate with worse pulmonary function and quality of life [55,69].
•Increased mortality – One multicenter prospective cohort of 646 ARDS survivors reported mortality at one year that was substantially higher than in-hospital mortality (41 versus 24 percent) [11]. Important predictors of death were the presence of comorbidities and discharge to another facility (eg, hospital, long term acute care facility, nursing home, hospice).
•PICS-family – All of these morbidities place substantial stress on family members many of whom are in decision-making and caregiving roles for their loved ones [68]. (See "Management and prognosis of patients requiring prolonged mechanical ventilation" and "Post-intensive care syndrome (PICS)", section on 'Post-intensive care syndrome-family'.)
Despite these abnormalities, some survivors are able to return to work. In a prospective five-year follow-up cohort study, 77 percent of those who were working at the time of their acute illness returned to work, while 17 percent did unpaid work within the home, and six percent became full-time students [50]. Most of those who returned to work did so within two years after ICU discharge, although many required a gradual transition back to work.
Several studies have sought factors during the acute illness that predict long-term sequelae [51,64,70,71]:
●Persistent symptoms one year after recovery correlate with the duration of mechanical ventilation and the lowest static thoracic compliance during the acute illness [64].
●Abnormal lung function one year after recovery correlates with the following factors measured during the acute illness: lowest static thoracic compliance, mean pulmonary artery pressure, positive end-expiratory pressure (PEEP), initial intrapulmonary shunt fraction, and requirement of a fraction of inspired oxygen (FiO2) >0.6 for more than 24 hours [70,71].
●A better functional outcome at one year correlates with the absence of steroid treatment, absence of illness acquired during the ICU stay, and rapid resolution of multiple organ failure and lung injury [51].
●There is no known correlation between ventilatory strategies and either long-term pulmonary function or health-related quality of life [48,72].
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Adult respiratory distress syndrome (The Basics)")
●Acute respiratory distress syndrome (ARDS) is a type of respiratory failure characterized by the acute onset of bilateral alveolar infiltrates and hypoxemia. Diagnostic criteria for ARDS are provided separately. (See "Acute respiratory distress syndrome: Clinical features and diagnosis in adults", section on 'Diagnostic criteria'.)
●ARDS is associated with appreciable mortality, with estimates ranging from 26 to 58 percent. In-hospital survival appears to have improved over time. (See 'Mortality' above.)
●The underlying cause of the ARDS is the usual cause of death among patients who die early. In contrast, sepsis due to nosocomial pulmonary infection is the most common cause of death among patients who die later in their clinical course. Patients seldom die from respiratory failure. (See 'Mortality' above.)
●There are numerous factors that can be assessed during the acute illness that may predict mortality. However, no single factor appears to be superior to the others. (See 'Predictors' above.)
●Survivors of ARDS can develop cognitive, psychological, and physical impairments that may last for months to years following their acute illness. In addition many have abnormalities in pulmonary function that are generally mild, as well as reduced quality of life for at least two to five years following the acute illness. (See 'Morbidity among survivors' above.)
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- Bone RC, Balk R, Slotman G, et al. Adult respiratory distress syndrome. Sequence and importance of development of multiple organ failure. The Prostaglandin E1 Study Group. Chest 1992; 101:320.
- Suchyta MR, Clemmer TP, Elliott CG, et al. The adult respiratory distress syndrome. A report of survival and modifying factors. Chest 1992; 101:1074.
- Sloane PJ, Gee MH, Gottlieb JE, et al. A multicenter registry of patients with acute respiratory distress syndrome. Physiology and outcome. Am Rev Respir Dis 1992; 146:419.
- Headley AS, Tolley E, Meduri GU. Infections and the inflammatory response in acute respiratory distress syndrome. Chest 1997; 111:1306.
- Ely EW, Wheeler AP, Thompson BT, et al. Recovery rate and prognosis in older persons who develop acute lung injury and the acute respiratory distress syndrome. Ann Intern Med 2002; 136:25.
- Calfee CS, Eisner MD, Ware LB, et al. Trauma-associated lung injury differs clinically and biologically from acute lung injury due to other clinical disorders. Crit Care Med 2007; 35:2243.
- Clark BJ, Williams A, Feemster LM, et al. Alcohol screening scores and 90-day outcomes in patients with acute lung injury. Crit Care Med 2013; 41:1518.
- Cardinal-Fernández P, Bajwa EK, Dominguez-Calvo A, et al. The Presence of Diffuse Alveolar Damage on Open Lung Biopsy Is Associated With Mortality in Patients With Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis. Chest 2016; 149:1155.
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- Treggiari MM, Martin DP, Yanez ND, et al. Effect of intensive care unit organizational model and structure on outcomes in patients with acute lung injury. Am J Respir Crit Care Med 2007; 176:685.
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Hirdesh Singh better known by his stage name Yo Yo Honey Singh or Honey Singh is an Indian rapper, music producer, singer and film actor. Yo Yo Honey Singh is one of the highest paid music producers in the Bollywoord of Hindi film industry. The tracklist for Honey Singh Album is Blue Eyes Hypnotize Teri Kardi Ai Mennu by Honey Singh. Bebo Diya Gallan Pink Pink Hai by Alfaaz and Honey Singh. London by Money Aujla Feat., Nesdi Jones, Honey Singh. Mast Kalander by Mika Singh, Honey Singh. Bakwaaspan - 9XM by Honey Singh and Bade-Chote. Mere Mehboob Qayamat Hogi by Yo Yo Honey Singh. Issey Kehte Hain Hip Hop by Honey Singh featuring Lil Golu. Meherama by Sam Sandhu and Honey Singh. Tere Ishq Mein Main Tha Jiya by Honey Singh. One Bottle Down by Yo Yo Honey Singh. Dheere Dheere Se by Honey Singh.
I hope you will have fun and learn all the Hindi Lyrics of Yo Yo Honey Singh Album songs using this app.
It doen t work


text:
Fangirling too hard by LittleFlower23Watch
©2013-2017 LittleFlower23
true story
Sometimes, me fangirling is the equivalent to me throwing a tantrum
UM ya that happens to me!
pfft ourmergurd this is so me all the time
omg so true!!!
oh yes
Very true
Story of my life, man. XDDD
Shouldnt this be on the "retarded 12 year old fat twilight fan wannabe girl" cathegory? Instead of the F***ing first page
and you say you are a helper of god, but you try to bring chaos with your words, and bring weak people to their knees, instead of giving them strengh
But look you are right. Maybe Im sometimes not as gentle as God would like me to be, Im sorry. Look one day I was a teen like you, I was an anime fan, I think you will keep improving your talents and become a brilliant person, at least you have good taste. Ive seen many teenagers like you grow up to become professional artists. I wish you all good luck in the world, and God bless you.
Ok, sorry it was not nice of me for commenting like that... I liked the avengers movie too, although I would find unpleasant to watch it in the same movie hall that you were in, screaming in a, let's say, non-civilized way. And I'm sure a lot of people felt like that because of some behaviour you may think is "cute"? well its not, for most people who paid for the ticket.
i fucking hate twilight.... im talking about th avengers and im 15... and im not fat....
Umm, I was going to gently point something out to you...
'Breathe' has an e on the end...
I'm sorry...
But yeah, true story XD
'Breathe' has an e on the end...
I'm sorry...
But yeah, true story XD
oxygen? screw that , hiddleston ftw
Hiddles FTW!
fangirl powers unite!!
Oh please ; Who needs respiration when you've got Jack Frost
roflmao same here.
well its more like "legitamitaly" but i got my own sytle so
That's not "your own style", it's incorrect grammar XD
that is how i roll, sometimes i'll try on a dress, i'll look short fat, and flat, and i say i look frumpy, if someone is tall and skinney i say theyre lanky, instead of confused i say confuzzeled, and instead of dizzy i say jujily
A cow is still a cow, even when you call it a bovine.
yea... and legitly is still legitamitly... but...well....I DO WHAT I WANT THOR!!!!
No, "legitly" is still the incorrect version of "legitimately".
oh no! the dumb little fangirl, megafan23, isnt as stupid as i thought!! maybe i should just bite my tounge...
do remind me, are you a perfect human?
yes, because i am an incorrect human, more meaning, imperfect human, no ones perfect
Happens to me all the time <3 ! My face gets purple and I squeel, I also can't breathe <3
Me during all The Avengers movie (especially those parts with Loki)
some one's got a crush on a baaad boy, dont feel ashamed., I secretly like purple guy!
the avengers wuz wut i wuz thinking lol but dude uploaded this, this morning drowning in comments and faves
Hasn't happened to me yet. Kinda looking forward to it now, though.
looking forward to it?? watch every single avenger movie, become a TOTAL fangirl like i am, search all over deviantart for gifs of ur fav avenger... that should help


text:
Namal College Mianwali Admission Fall 2017 Form, Apply Online has been all opened up now! You can also visit the site: www.namal.edu.pk to get in hand further updates about this Namal College Mianwali Admission Fall 2017. As we all know that all the students who are a part of Namal College, their degrees have been awarded by the University of Bradford. All the 2nd year students who have been still waiting for their results, they can also apply in these Namal College admissions 2017. If you want to get more details and information about this Admission Fall 2017 then you get in hand all the updates and information right from this webpage. We will also be posting the result list of this Namal College Admission Fall 2017.
Namal College Mianwali Admission Fall 2017
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You can make a contact on this email address: email@example.com. You can also visit the admission centre: Namal College, 30 km, Talagang road, Mianwali, 42250 Pakistan. As we all know that Namal College is the associate college of the University of Bradford. It was inaugurated by Syed Yousaf Raza Gillani on April 27, 2008. It is seen that University of Bradford has worked closely with Namal College while designing the courses and also curriculum. So, this was all about the Namal College Mianwali Admission Fall 2017 Form, Apply Online, if you have any question in your mind then do ask from us. It is high time to start filling out and submitting the application forms and make yourselves prepared well for this test 2017. Know all about the entrance test and their details and also their deadlines right from this webpage.