text:
Strength by FIT is a comprehensive Strength program combining Olympic Lifting, Power Lifting, and general strength training so that you can increase strength and proficiency in all your lifts. The program is flexible to individual athlete's needs. Improving technique and strength is one of the best ways to increase your performance in all areas of the gym. We will work on a wide range of lifts, including but not limited to:
We will work on the following lifts:
- Snatch
- Clean and Jerk
- Power, split, squat jerks
- Snatch and clean and jerk accessory movements
- Back squat
- Front squat
- Deadlifts and pulls
- Press
- Push Press
- Bench Press
- Pull ups
- Rows
- Strongman type movements
Come today to increase your strength, improve technique, and improve power output today!


text:
We are looking forward getting in contact with you.
Newsletter registration.
We will provide you with news about Surface Air and Missile Defence topics usually about once a month or if there is any special occasion.
I hereby confirm that I did read and understand the Data Protection statement!
Newsletter Archive:
The following Newsletters were already published and can be downloaded as PDF files here:

subset: commoncrawl


text:
The Rock Theme Songs 1996-2011 MP3
All theme songs from The Rock is uploaded here. Also check out the HD version! 1080p HD Version Link - https://www.youtube.com/watch?v=tcdj-l5I39M.
Electrifying The Rock's entrance music: WWE Behind the Theme MP3
Go behind The Rock's theme and see how WWE composer Jim Johnston came up with the entrance music for The Most Electrifying Man in All of Entertainment.
The Rock's 2003 Heel Theme MP3
This is the full version of the rock's 2003 theme.
WWE: "Electrifying" ► The Rock 24th Theme Song MP3
"Electrifying" by Jim Johnston Album: WWE: "Electrifying" (feat. The Rock) - Single Genres: Rock, Music, Soundtrack Released: Mar 24, 2011 ℗ 2011 WWE, Inc.
WWE Mashup - Know Your BOSS - (CantBreakSteelMashes) MP3
Check out this unique mashup of Sasha Banks and The Rock's entrance videos. Presented by WWE Universe member, CantBreakSteelMashes.
WWE The Rock Titatron with 2000 Theme MP3
All WWE programming, talent names, images, likenesses, slogans, wrestling moves, trademarks, logos and copyrights are the exclusive property of WWE, Inc.
The Rock 4th Theme (Nation) MP3
This is the 4th WWE themesong for "The Rock" Rocky Maivia. Debuted in early May of 1998 on an episode of Raw Is War. This theme started off The Rock's ...
The Rock theme 1998 - 1999 MP3
"Do You Smell It" [V2] by Jim Johnston (1998--1999)
The Rock Theme 2000 2001 MP3
one of his best themes.
The Rock (2003) - It's Conquered V2 MP3
DOWNLOAD LINK (MP3): https://mega.co.nz/#!DF50VDaQ!KYvj65N4BIz5C4bRnTehjfrLJByH1LceR3l7ydSGW6I The Rock's (2003-2004) "HOLLYWOOD" ...
The Rock Returns 2011 With His 1998 Theme (Nation Theme) MP3
FINALLY, The Rock has come back...with his BEST theme, The Nation Theme! :D PERSONAL: http://www.facebook.com/profile.php?id=100002610433927 FAN ...
The Rock's Original Theme song 1997 (HD BEST VERSION) MP3
My personal favorite theme of The Rock's many different versions throughout the years. This original one just captures the essence of the 90's and the Rock a ...
The Rock 2003 Hollywood Theme (HQ) MP3
All Rights go to WWE No Copyright Intended This is the full version of The Rock's 2003 theme. Make sure you subscribe to stay up to date with my current ...
2001-2003: The Rock 14th WWE Theme Song - If You Smell... [ᵀᴱᴼ + ᴴᴰ] MP3
The Rock 14th WWE Theme Song - If You Smell... Artist : Jim Johnston Copyright : WWE, All Rights Reserved.
The Rock 24th Theme Song for 30 mins: Electrifying MP3
The LONG Awaited 10000 View Special! Thank you so much! (Thanks for 60 subscribers as well!) Theme Count: 1st: "Destiny (I)" (as Rocky Maivia) 2nd: ...
The Rock - Current Theme - Electrifying (Extended Version) + Download Link MP3
Studied videos online on how his theme repeats.... SO I've decided to extend his theme. I simply love his new theme to where I looped it twice to where it ends ...
wwe the rock says theme song MP3


text:
Product Description
The David Clark DC 6230-M Modular Two-Way Communication Headset is designed to provide crisp, clear communications and superior comfort, ideal for UAV shelters, data vans, Command and Control vehicles and other low-noise applications.
Please Note: These are not for typical Aircraft Use. They are specialized Headsets for the uses indicated above.
The Model DC 6230-M is a dual-ear, over-the-head style headset with a supra-aural design (rest-on-ear, as opposed to circumaural), capable of affording comfort and communication clarity. It features the new M-55 electret noise-cancelling microphone, delivering superlative speech intelligibility.
Metal alloy hardware is used for a rugged, yet lightweight headset platform. Comfort features such as leatherette head- pad and ear seals with slow-recovery 'memory' foam are specifically chosen for exceptional comfort over long periods of time. With it's full feature engineering and ultra-lightweight design (8.4 oz/238g), the DC 6230-M provides the ultimate in performance, comfort and communication clarity for a wide variety of applications.
Modular Configurations provide even greater flexibility with headsets utilizing interchangeable communication cords for connection to a wide variety of radios.
- Dual ear compatible with all C6200 radio cords including C62-USB
- Passive electronic design for low-noise environments
- Requires U6210 inline PTT body switch in order to have PTT functionality.
- M-55 noise-canceling microphone ensures superior transmit clarity
- Dynamic earphones provide excellent reception quality
- Leatherette head-pad and ear seals with slow-recovery 'memory' foam, coupled with an extremely lightweight and rest-on-ear headset design, affords countless hours of superior comfort
- Magnesuim Alloy headband/suspension system and swivel hinge stirrups integrate a rugged, durable design with fully adjustable platform for personalized fit and comfort
- Provides superior comfort and performance over long work hours
- Full flex mic boom, 280° rotating for perfect mic placement on left or right side
- Adjustable headband/suspension assembly and swivel hinge stirrups ensure a perfect, personalized fit
- Compatible with all C6200 cords including C62-USB
- Requires U6210 in-line PTT body switch in order to have PTT functionality.
- Cable Length ~9" straight cord
- Made in the USA
Other Information
|Part #
|Model #
|David Clark
|1 Year
Customer Reviews
Write Your Own Review
Summary of Customer Ratings & ReviewsThis item has not been reviewed. Be the first to write a review.
Our Guarantee
100% Satisfaction
Marv has had a 30-Day Return Policy for over 30 years!
If you're not satisfied, we'll refund your money!
Our Customers Say it Best
"This was my first purchase from Marv Golden, but it certainly won't be my last! With their great selection, exceptional customer service, and superb pricing, you really can't go wrong. - Charlie (Cessna 172)"
"Rick spent more time with me than I expected in order to help me select the correct iPad yoke mount for my Aerostar. He even stayed on the phone while I took some measurements in my plane! Above and beyond – will call again in a heartbeat. - Jack (Piper Aerostar, Instrument Pilot)"
"As always, the quality is outstanding, and it was delivered promptly. These are great people and they're always there to help! - JR (Private Pilot)"
"My order shipped very quickly. I highly recommend buying any product from this website. - Dave (CFII)"
"Great prices and great Customer Service at Marv Golden.com! - DJ (Hawker 800)"
"Marv has the best prices and service! - John K (Piper Arrow)"
"Marv Golden Pilot Supplies go above and beyond. I received a brand new release watch at a great price and it was safely delivered half way around the world to country NSW. My first international transaction over the net and was a wee bit anxious but fully satisfied with these guys. 10 stars! - Wiggy (Paramedic Flight Crew)"
"Service, Selection, and Prices were were excellent! Marv's is my new Aviation Store! - Susie (A320)"


text:
- In-house ASIC Registered Liquidators, Administrators and Receivers
- CPA and CA Qualified Accountants
- ARITA (Restructuring & Turnaround Association) memberships in-house
- Over 40 staff
- Offices in Sydney, Melbourne, Perth, Brisbane and Gold Coast
- One of Australia's fastest growing insolvency firms
- Dedicated enquiry team with 24/7 service
- National legal network and expertise
- Diverse funding and finance options if required
- Rated 4.9 out of 5 on service review site Trust Pilot
Our Business Services
Exploring the idea of liquidation? Unsure about the best financial course of action to take for your business?
Regardless of what financial guidance your business requires, Australia Debt Solvers is on hand to ensure the tough answers are easy to find.
Our dedicated team of experts take a case-by-case approach to even the most complex of financial issues, meaning we will take the most appropriate course of action for you in the shortest possible time.Find Out More
Our passion is to help people that face financial challenges.
David Hill Founder, Australian Debt Solvers
Learn more about the peace of mind we've achieved for our clients by reading our case studies
Australian Debt Solvers has helped countless Australians relieve themselves of debt stress
- Case Study RESTRUCTURING Read More
- Case Study Debt Recovery Read More
- Case Study Liquidation Read More
- Case Study Legal Support Read More
Our Services For Individuals
Navigating the complex world of personal bankruptcy and insolvency can be an incredibly tough challenge for even the most confident of individuals. At Australian Debt Solvers, we pride ourselves on being able to make the difficult times as easy as possible.
Our team of experienced experts will be on hand to ensure your case is dealt with efficiently and with the best possible outcome.
Our Business Assistance
Are you an Accountant, Book Keeper or Advisor looking for advice? Perhaps your client has a query that falls a little outside your area of expertise? Our team have been providing advice to other industry professionals for years.
We appreciate how specialised our services are and we're more than happy to provide professional advice to those who advise themselves.


text:
Functional fitness builds strength you can use every day, whether wrestling your competitive brother or holding back tears with your powerful face muscles. Gain practical strength with this Groupon.
The Deal
- C$39 for a four-week CrossFit Foundations program or a two-week CrossFit Foundations and boot-camp program (C$197 value)
Students must complete at least six CrossFit foundations classes before they can proceed to boot-camp classes. The four-week CrossFit Foundations program is valid for both CrossFit and boot-camp classes. See the schedule.
The Maker's Body CrossFit
As a kinesiologist and CrossFit Level 1-certified coach, Tyron Piteau knows how the body should move normally and when it's being pushed to the limit. The latter is a regular occurrence at The Maker's Body CrossFit, where Piteau and his team of coaches lead groups through CrossFit workout of the day. Built around functional exercises such as pull-ups, dead lifts, and jumping onto things to get away from a mouse, the fitness discipline can be scaled for newcomers and regulars alike. Other classes at the facility have a similarly functional nature, including the olympic lifting class and Throwdown class, which is a free-range version of the daily CrossFit workout.


text:
Bahamas Magic: Bahamas Celebration Cruise Review by Kiwipairz
Overall Member Rating
Bahamas Magic
Destination: Bahamas
Embarkation: Freeport
Would recommend an outside cabin, it was roomy, the ensuite a good size and very clean - in fact we were impressed with the overall decor and cleanliness of the whole ship, and people we met at dinner who had cruised on several cruise lines commented positively about this also.
The restaurants and food were great, the evening meal in Rio restaurant was far better than the usual buffet, with a great selection and quality food. The wine list was extensive, even great NZ wines at reasonable More prices.
The ship is lively from the time you step on board. Staff are friendly, attentive but not in your face. The entertainment in all the various bars and decks was outstanding, something for everyone and we enjoyed wandering from deck to deck. The spa was also great - massage and hair conditioning fab.
This was a fantastic first experience, the Bahamas is beautiful & we enjoyed our couple of days there before cruising back. Totally recommend Celebration Bahamas. Less
Published 06/05/13
Cabin review: 6
6th deck - outside cabin with windows, roomy good sized bathroom, bed a little hard. Quiet, had no problems sleeping, very clean.
Read Cruise Critic's Bahamas Celebration Review >>
Oldie But A Goodie!
Family Cruise
First time cruisers
Caribbean Cruise
Te most horrible experience in...
Incredible Experience!
Sponsored Links


text:
Through that same society, I recently got into designing and building props and sets. I'm doing most of my work pro bono right now, but I'd like to eventually set up a page online with my portfolio and start accepting contracts.
I'm also a GM at a pizza place. I run a staff of ~50 people. The lack of unstructured time is why I maintain this profile, and I get 2 nights off which is really great for what I'm responsible for at work.
I recently bought a bottle of Duke bourbon, which was made to replicate John Wayne's personal bourbon. I got this tip from a cowboy who tended bar at a saloon in the desert.
I can be noticed if I want to be, but sometimes I just like to blend in.
*Surprisingly I liked the new movie Spy, and LOVED Kingsman, if that helps keep this up to date.
Game of Thrones is my masochistic choice of TV show. My favorite things ever on TV were Breaking Bad, Lost, Twin Peaks, The Sopranos, and The X-Files. I'm currently watching Rick and Morty, Ray Donovan, and An Idiot Abroad.
I like a lot of music, depends on what I'm in the mood for. I'm on an MSI inspired, punk/hardcore/industrial bender. I like System of a Down, Tool, Nirvana, Mr. Bungle, The Black Keys, Reel Big Fish, Ke$ha, Deadmau5, Skrillex, Infected Mushroom, even Ravi Shankar. My most frequented radio preset is 107.1, and I'm thinking about the fall already, help me narrow down a new playlist.
My favorite author is Kurt Vonnegut. I also like Joseph Heller's Catch-22. I like reading Tang dynasty poetry from China and Heian Japanese literature. A Song of Ice and Fire series also was fun to read. I also have a Pottermore account because growing up is hard.
I eat a lot of different cuisines, and can cook almost anything I eat. I watch some shows like Bizarre Foods because I like to push my boundaries on strange and wonderful food. I love Vietnamese, Korean, and Indian food when I eat out because I'm still bad at cooking those styles. My strong suits are Italian, Chinese, and French styles, as well as traditional American comfort food.
Hockey (playing more than watching).
My ability to travel.
Ironic humor.
I want a tattoo but can't physically handle getting one, so I have to live without.
-You like taking off for a day to a place you've never been.
-You like guys who cook.
-You have ever gotten the urge to golf and acted on it.
-You hate golf.
-If your idea of adventure involves a dark room and an indie band.


text:
|Message view
|« Date » · « Thread »
|« Date » · « Thread »
|"Craig R. McClanahan" <craig...@apache.org>
|Re: Where does manager put webapp deployment information?
|Fri, 10 May 2002 23:41:33 GMT
On Fri, 10 May 2002, Xinji Gu wrote: > Date: Fri, 10 May 2002 14:11:04 -0400 > From: Xinji Gu <firstname.lastname@example.com> > Reply-To: Tomcat Users List <email@example.com> > To: firstname.lastname@example.com > Subject: Where does manager put webapp deployment information? > > hi, I am using Tomcat4.1 integrated in SUN's JWSDP. I used Tomcat > manager to deploy my application (a simple jsp war file), and it ran > very well. What confused me is I could not find where did Tomcat manager > put the deploy information. > If you use Manager's "/install" command, the webapp is not copied -- it is run directly from the WAR file or directory that you specified as the "war" parameter value. (This works because the "docBase" property can contain an absolute pathname, not just a relative one.) If you use Manager's "/deploy" command (added more recently), the WAR is uploaded into the Manager webapp's temporary working directory (somewhere under $CATALINA_HOME/temp). > The war file is not under \webapps, and I didn't find any .xml file > contain my app information. How does Tomcat know where to find my app > when request comes? > > I don't know if I expressed myself clearly ... I just want to know where > does Tomcat store information about all the deployed applications. > > Thanks a lot > > Jim Gu > > Craig -- To unsubscribe, e-mail: <mailto:email@example.com> For additional commands, e-mail: <mailto:email@example.com>
|View raw message


text:
In the last 10-15 years the study of plant sciences has been revolutionised by the development of new tools and technologies which have allowed unprecedented progress in the study of plant biology - knowledge which is being applied to develop sustainable solutions to some of the major challenges of the 21st century.
This programme provides training in modern molecular aspects of plant science. Teaching is delivered by academics from the University's Centre for Plant Sciences (CPS) and is often related to their areas of expertise and current research projects.
You'll benefit from the research of international experts in DNA recombination and repair mechanisms and explore the wide range of approaches used in bio-imaging alongside the range of modern techniques and methodologies that underpin contemporary biomolecular sciences. You'll explore the key topic areas of molecular biology; structural biology; cell imaging and flow cytometry; high throughput techniques; and transgenic organisms.
Our Facilities
You'll study in a stimulating environment which houses cutting-edge facilities. The CPS laboratories feature a state-of-the-art plant growth unit, including tissue culture suites with culture rooms, growth rooms and cabinets alongside glass-houses to meet a range of growth requirements.
You'll gain an overview of a range of modern techniques and methodologies that underpin contemporary biomolecular sciences through the investigation of five topic areas: molecular biology; structural biology; cell imaging and flow cytometry; high throughput techniques; and transgenic organisms. You'll also conduct an extended practical investigation in the form of a laboratory-based project, involving practical training in a range of modern molecular biology and protein engineering techniques such as gene cloning, PCR, mutagenesis, protein expression, protein purification and analysis.
A module on plant biotechnology will address topics such as the engineering of plants, development of stress-tolerant crop varieties and techniques for gene expression and gene silencing. You'll have the opportunity to benefit from the research of international experts in DNA recombination and repair mechanisms and their importance for transgene integration and biotechnological applications; biogenesis of mitochondria, chloroplast and peroxisomes; and the biosynthesis, structure and function of plant cell walls. You'll also explore the wide range of approaches used in bio-imaging and their relative advantages and disadvantages for analysing protein and cellular function.
In the final part of the course you'll work on an independent laboratory-based research project related to your course options. You'll receive extensive training in experimental design, the practical use of advanced techniques and technologies, data analysis and interpretation, and will be assigned a research project supervisor who will support and guide you through your project.
Compulsory modules
For more information on typical modules, read Plant Science and Biotechnology MSc in the course catalogue
We provide the very best learning resources and academic support and our teaching draws on the University's world-class research base and highly-qualified professionals from industry, non-governmental organisations and charities.
You'll experience wide range of teaching methods including formal lectures, interactive workshops, problem-solving, practical classes and demonstrations.
Through your research project and specialist plant science and biotechnology modules, you'll receive substantial subject-specific training. Our teaching and assessment methods are designed to develop you into a scientist who is able to think independently, solve problems, communicate effectively and demonstrate a high level of practical ability.
We use a variety of assessment methods: multiple-choice testing, practical work, data handling and problem solving exercises, group work, discussion groups (face-to-face and online), computer-based simulation, essays, posters and oral presentations.
The strong research element of the Plant Science and Biotechnology MSc, along with the specialist and generic skills you develop, mean you're equipped for a wide range of careers.
Our graduates work in diverse posts, ranging from bioscience-related research through to scientific publication, teacher training, health and safety and pharmaceutical market research.
Links with industry
We have a proactive Industrial Advisory Board who advise us on what they look for in graduates and on employability-related skills within our programmes.
We collaborate with a wide range of organisations in the public and commercial sectors. Many of these are represented on our Industrial Advisory Board. They include:
Industrial research placements
Some of our partners offer MSc research projects in their organisations, allowing students to develop their commercial awareness and build their network of contacts.
Further study
A substantial proportion of our graduates undertake further study at Leeds or elsewhere. Recent graduates have gone on to:
We encourage you to prepare for your career from day one. That's one of the reasons Leeds graduates are so sought after by employers.
The Careers Centre and staff in your faculty provide a range of help and advice to help you plan your career and make well-informed decisions along the way, even after you graduate. Find out more at the Careers website.


text:
Walter Pyramid
- DJeremih, Juicy J and Ella Mai come to CSULBdaily49er.com
- DLong Beach State introduces Jeff Cammon as new women's basketball coachdaily49er.com
- DLong Beach State's Anna Kim hope to cap career with Big West titledaily49er.com
- DLong Beach State men's basketball team holds off Hawai'idaily49er.com
- NMen's Basketball Drops Second Consecutive Game at Davisnewuniversity.org
- DLong Beach State women's basketball team dominates Biola; wins fourth straight gamedaily49er.com
- DLong Beach State snaps 9-game losing streak with win against Pepperdinedaily49er.com
- DLong Beach State's Walter Pyramid will be full house with doubleheaderdaily49er.com
- DBusiness student, dancer remembereddaily49er.com
- DLong Beach State introduces bag checksdaily49er.com
- DLong Beach State women's volleyball team looks to remain at the top of the Big Westdaily49er.com
- DSeason-ticket holders get first peek at Long Beach State men's basketball teamdaily49er.com
- DLong Beach State women's volleyball team look to remain unbeaten in Big Westdaily49er.com
- DLong Beach State upsets Hawai'i; take over first place in Big Westdaily49er.com
- DWalter Pyramid hosted the USA women's national volleyball team for FIVB world tournamentdaily49er.comBangkok , Hong Kong , Rio de Janeiro , China , Germany
- DCongressman condemns deportationdaily49er.com
- DWhat you missed at LBSUdaily49er.com
- DWeekend previewdaily49er.comItaly , Imperia , Berkeley , California , Pacific Ocean
- DLBSU splits weekend matches against CSUNdaily49er.com
- DLBSU suffers second half collapse against UC Irvinedaily49er.com
Frequent names
Newstral's extraction of names of people and organisations from the world's news is completely automated. If you do not want your name to appear here, please contact us. We will be happy to look at your request.


text:
"Life is what you make it, but Greyston helps you achieve what you want in life." Dion Drew – Bakery Trainer
Our incredible team of bakers crafts 35,000 lbs of decadent brownies a day.
The cornerstone of Greyston's success if our team of bakers making brownies everyday in our world-class facility. Through Open Hiring™, we fill jobs without asking any questions. A collaborative approach, the Open Hiring™ Model demonstrates how businesses, communities and local governments can work together to everyone's benefit. Generations of poverty and unemployment can be reversed. A single individual's ability to find and keep a job can have a profound repercussions throughout a community: inspiring hope in families, neighborhoods and among local businesses.
Here's how it works:
Anyone that comes to the front door of our bakery is given the chance to work, no questions asked. When a job becomes available we hire the next person on our waiting list. During the apprenticeship period, our employees learn baking and employment readiness skills. And, we offer Community Gardens, Workforce Development, Environmental and Cultural Education and an Early Learning Center to create a truly thriving community. To learn more about Open Hiring™, contact Karen Tumelty.
Eat Brownies. Change Lives.
Enjoy Greyston Brownies at your next event!


text: Shout out to Proctor & Gamble for an empowering ad that says what I've been trying to say my entire life! The #LikeAGirl campaign is designed to flip the switch on what it means to run like a girl or throw like a girl. No longer should "girl" be associated with something weak, flippant and just a hot mess. Hopefully this can help girls see themselves for the strong, beautiful beings they are.


text: Just curious what others experience has been ordeing directly form the DJI store. I placed an order several weeks ago for some supplies and never have received 1 of the items. Tracking says it was shipped out and few days later it was shipped back to China so the tracking say delivered but no to my USA address. Have made numerous attempts to contact DJI but with no positive results.


text:
Current Diagnosis & Treatment of Pain, 1st Edition
4. Interventional Procedures for Pain Control
Samuel Samuel MD
Salim Hayek MD, PhD
Michael Stanton-Hicks MB, BS
Interventional nerve blocks remain the mainstay treatment of chronic pain despite advances in pharmacologic and nonpharmacologic modalities. However, multiple factors (including social, emotional, financial, and legal issues) further compound the complexityofchronic pain, necessitating a multidisciplinary approach to its management. Such a discussion is beyond the scope of this chapter, which will primarily focus on interventional nerve blocks for chronic pain conditions and when the primary care physician should refer patients for these procedures. Some aspects of the techniques are described to assist the internist in determining whether a patient might tolerate the procedure. Although the internist is unlikely to be performing these techniques, it is important to understand the goals of the procedures, the potential benefits, and the possible complications.
While diagnostic regional anesthetic procedures have been applied to practically every peripheral and cranial nerve, in the interest of demonstrating that by its interruption either somatosensory, visceromotor, or sudomotor efferents abolish or change the described pain, it is probably the systematic blocking of the axial spine and sympathetic blocks that have the greatest usefulness in clinical diagnosis of chronic pain conditions.
Interventional nerve blocks can be broadly classified into three types: diagnostic blocks, prognostic blocks, and therapeutic blocks. Prognostic blocks are conducted to predict the efficacy of a neurodestructive procedure (to prevent a potentially unnecessary operation). Prognostic blocks also temporarily provide patients the sensations of a more definitive procedure, thereby allowing them to determine whether the resulting numbness might be tolerable to them.
The use of blocks for diagnosis and prognosis depends on an assumption of anatomic consistency. Nerve structures are expected to be found in predictable places and to have predictable connections, but there are important limitations to these assumptions, with most anatomic parameters showing normal variance. There is 50% accuracy in guessing vertebral level for needle placement without fluoroscopy and for this reason most nerve block techniques have no validity unless conducted under fluoroscopic guidance. The use of a high-resolution C-arm image intensifier with associated computerized image generation is considered to be essential if the results are to contribute to both diagnosis and definitive therapeutic maneuvers.
Nerve blocks are used for diagnosis and treatment of multiple pain syndromes, including low back pain, headache, abdominal pain, failed backsurgery syndrome, post-thoracotomy pain syndrome, postherpetic neuralgia, myofascial pain syndrome, pain secondary to malignancy, compression fractures, complex regional pain syndrome (CRPS) type I and type II, whiplash injuries, pain originating from vascular insufficiency, diabetic neuropathy, and the diagnosis of central pain syndrome.
Diagnostic Blocks
Selective Nerve Root Sheath Injection
Essential Criteria
- Useful diagnostically and therapeutically.
- Diagnostically, symptomatic nerve roots causing radiculopathic symptoms can be identified and the source of pain for subsequent surgical interventions can be pinpointed.
- Therapeutically, nerve root irritation resulting from lateral recess spinal stenosis, disk herniations, or dynamic nerve root irritation from instability or spondylolysis can be treated.
General Considerations
Chronic back pain, radiculopathies, and their associated disabilities represent a significant health problem. At some time in life, 70 to 85% of all people have back
pain, with an annual prevalence ranging from 15 to 45%. Symptoms are most common in middle-aged adults, with back pain equally common in men and women. Back pain is the most frequent reason for activity limitation in persons younger than 45 years of age, the second leading reason for doctor visits and absenteeism from work, and the third common cause for surgical interventions.
The primary site of back pain is the lower back in 85% of back pain sufferers. Annually, about 2% of the work force has back injuries covered by the Bureau of Workers Compensation. The total annual direct cost of treating this subgroup of patients rose from $4.6 billion in 1977 to $11.4 billion in 1994. From 1979 to 1990, rates of back surgery in the United States increased dramatically; the increase in surgical rates was especially marked for spinal fusions.
Patient Selection
Back pain associated with radiculopathy is the main indication for selective nerve sheath injection, since the contribution of root inflammation to pain may not be certain or the level of the lesion may be unclear.
Computed tomography (CT) or magnetic resonance imaging (MRI) and electrophysiologic evaluation by electromyography may be inconsistent or may be inconclusive. Abnormal imaging findings in asymptomatic persons (prevalence as high as 40%) demonstrates the inability of abnormal anatomy to indicate a pain source. A further cause of confusion is the presence of disease at multiple levels, because the origin of pain may be any one site or a combination of sites. Finally, evaluation is especially difficult after laminectomy because imaging is impeded by the presence of hardware or the presence of scar tissue in the epidural space.
Duration of Benefit
In diagnostic blocks, the duration of the block essentially reflects the duration of action of the local anesthetic used (short, intermediate, or long-acting). Therapeutic benefit from the block is variable, with multiple confounding variables involved; however, the average success rate after 12 months of follow-up is approximately 75-80% in patients with disk abnormality.
When used therapeutically, a mixture of local anesthetic and corticosteroid is used. Corticosteroids decrease pain due to inflammation and sensitization of nerve fibers through their anti-inflammatory action and the release of phospholipase A2 inhibitor. Corticosteroids also block nociceptive input, block the transmission in C fibers but not in A β fibers and inhibit the formation of adhesion and fibrosis.
The following are possible complications due to selective nerve root sheath injection:
- Damage to the nerve root.
- Intrathecal injection.
- Intravascular injection (in case of corticosteroid injection, anterior spinal artery syndrome may result from intravascular injection and embolization of the artery of Adamkiewicz).
- Bleeding.
- Pneumothorax.
Stanton-Hicks M. Nerve blocks in chronic pain therapy-are there any indications left? Acta Anaesthesiol Scand. 2001;45:1100.
Differential Epidural Block
Essential Criteria
- Valuable in diagnosing chronic abdominal pain, chronic pelvic pain, and thoracic pain of unknown origin.
General Considerations
When the location of pain makes diagnosis difficult (as in abdominal pain), differential nerve blocks can be valuable in providing the information necessary to verify a certain diagnosis and delineate a treatment plan. The test relies on the selective differential blockade of one structure, without blocking others, using specific concentration of local anesthetic and saline. The three classes of nerve fibers are as follows:
- A fibers (which are further subdivided into Aa [motor function and proprioception], Ab [touch and pressure], Ag [muscle spindle tone], and Ad [pain and temperature sensation]).
- B fibers (thin myelinated preganglionic autonomic nerves).
- C fibers (unmyelinated fibers mediating pain and temperature impulses).
The test can be carried out using epidural, spinal anesthesia, or peripheral nerve plexus blocks and interpreted in an antegrade or retrograde fashion. In the antegrade approach, the clinician observes the gradual onset of analgesia with increasing doses of local anesthetics injected, whereas in the retrograde approach, after analgesia is achieved with a large bolus, the clinician observes the relationship between the block wearing off and the gradual return of pain. For instance, in cases of visceral abdominal pain, pain is abolished first in the antegrade approach and its relief outlasts the duration of local anesthesia in the retrograde approach. Musculoskeletal pain, on the other hand, returns as soon as dermatomal anesthesia is resolved.
Two shortcomings of this technique are that (1) the differential nerve blocks can be very time consuming and (2) occasionally, no clear-cut end points are obtained, with overlap of results making interpretation of the test difficult.
The following are possible complications of a differential epidural block:
- Postdural puncture headache with an incidence ranging from 1 to 7% after neuraxial blocks.
- Bleeding (including epidural hematoma).
- Infection (abscess formation, meningitis).
- Inadvertent intrathecal injection with resultant spinal anesthesia.
- Local anesthetic toxicity.
Zygapophyseal Joint Injection (Facet Joint Injection)
- Lumbar Facet Syndrome
Essential Criteria
- Low back pain with radiation to the hip and buttock.
- Cramping lower extremity pain (usually not lower than the knee).
- Low back stiffness (especially in the morning) and pain that is commonly aggravated by prolonged sitting or standing.
- Patients with axial low back pain who have not responded to conservative therapy (nonsteroidal antiinflammatory drugs, rest, and physical therapy).
- Absence of radiologic evidence of disk herniation, lumbar stenosis, orforaminal stenosis with resultant nerve root impingement.
- Paraspinal tenderness, worse over the affected joint.
- Positive facet loading (hyperextension, rotation, and side bending).
- Absence of signs of nerve root irritation as well as hip, buttock, and back pain on straight leg rising.
General Considerations
The zygapophyseal (facet) joints are paired diarthrodial joints between the posterior elements of the adjacent vertebrae that can contribute drastically to the problem of low back pain. The percentage of all patients with low backpain who have a significant proportion of their pain attributable to the facet joint varies from 15 to 50% in published series.
Injection of a small amount of local anesthetic into the facet joint (0.5 mL, 0.75% bupivacaine) or interruption of the median branch nerves to the facet joints are standardized techniques for the diagnosis of zygapophyseal joint-symptoms. Because each joint is innervated by at least two medial branches, two adjacent levels should always be blocked.
Patient Selection
Table 4-1 shows a scoring system that was developed to determine which patients will benefit from facet joint injection. Patients with a score of 60 points or higher had 100% prolonged response from a facet joint injection. A score of 40 points or higher predicted 78% prolonged response.
Table 4-1. Scorecard for Probability of Pain Relief with Facet Joint Injection.
Duration of Benefit
The duration of pain relief in diagnostic blocks probably reflects the duration of the local anesthetic used. Patients with consistent pain relief with such a block but of short duration may benefit from radiofrequency ablation of the median branch block with reported duration of up to 1 year. Another alternative to radiofrequency lesioning is pulsed radiofrequency, with reported duration of 4 months and decreased incidence of complications compared with radiofrequency ablation.
Unless there are localizing signs, the L4-5, L5-S1 are the most affected joints. The block is performed under fluoroscopy with the patient in the prone position and a pillow placed under the lower abdomen. After the back is prepared and draped, the facet joint or the junction of the transverse process with the facet joint (in case of median branch block) is identified. Using a 22-gauge spinal needle, the needle is introduced and a mixture of 0.5 mL of 0.75% bupivacaine and 20 mg of triamcinolone is injected into each of the designated joint or median branch.
Although rare, complications may include infection, transient radicular pain, subarachnoid injection, backache, muscle spasm, allergic reaction, joint rupture and necrosis in case of intra-articular injection, and neuritis in the case of radiofrequency ablation.
Dreyfuss PH et al. Lumbar zygapophysial (facet) joint injections. Spine J. 2003;3:50S.
Saal JS. General principles of diagnostic testing as related to painful lumbar spine disorders: a critical appraisal of current diagnostic techniques. Spine.2002;27:2538.
- Cervical Facet Syndrome
Essential Criteria
- Neck pain and stiffness.
- Shoulder, suprascapular, scapular, and upper arm pain.
- Headaches, mostly occipital.
- Decreased range of motion of the neck.
- Pain on lateral flexion on the affected side.
- Decreased discomfort with forward flexion.
- Tenderness over the affected joints.
General Considerations
Cervical facet joint has been shown to be the most commonly involved structure following neck injury, especially in whiplash injury. This injury represents 1 of the major causes of neck pain with an estimated incidence of 4 per 1000 population. An estimated 42% of whiplash injuries become chronic, with pain persisting in about 10% of the cases; it may also result from twisted neck and poor sleep postures.
Chronic neck pain represents about 30% of the chronic pain conditions, with a staggering impact on US society; an estimated annual cost of about $90 billion is split between treatment and work losses. This economic impact reflects the importance of recognizing and promptly treating conditions that lead to chronic neck pain.
Cervical facet joints and its innervations are slightly different than the lumbar facet joints. The atlanto-occipital (C0-1) and the atlantoaxial (C1-2) are innervated by C1 and C2 ventral rami and not the dorsal primary ramus; hence, the intra-articular injection is the only way to block these joints. Cervical facet joints from C3-T1 are supplied by medial branches of the dorsal rami above and at the same level as the joint, so either intra-articular or median branch block could be used for diagnostic or therapeutic purposes. Table 4-2 describes the distribution of pain of cervical facet joint origin.
Patient Selection
Patients with cervicogenic headaches may benefit from facet joint medial branch block since the third occipital nerve (dorsal ramus C3) has a close anatomic proximity to and innervates the C2-3 zygapophyseal joint. This joint and the third occipital nerve appear most vulnerable to trauma from acceleration-deceleration ("whiplash")
injuries of the neck. Pain from the C2-C3 zygapophyseal joint is referred to the occipital region but is also referred to the frontotemporal and periorbital regions.
Table 4-2. Distribution of Pain of Cervical Facet Joint Origin.
Duration of Benefit
Despite the wide variability in the duration of pain relief with cervical facet injection, some reports cite pain relief and improved range of motion for up to 12 months. In conjunction with the facet injection, other adjuvant treatment includes traction, local heat, manipulation with correction of facet subluxation, and medical treatment with nonsteroidal anti-inflammatory drugs (NSAIDs).
With the patient lying prone (some clinicians advocate a lateral or even a supine position with easier accessibility to the airway), the posterior neck is prepared and draped. Under fluoroscopic guidance, a 22-gauge spinal needle is inserted at the desired levels to be blocked; the importance of slow advancement of the needle with serial anteroposterior and lateral fluoroscopic imaging for correct needle placement and direction must be emphasized. After negative aspiration (close proximity of the vertebral artery), 0.5 mL of 0.75% bupivacaine and 20 mg of tri-amcinolone is injected.
In addition to the complications of the lumbar facet blocks, complications related to the cervical facet injection include epidural and intrathecal injection progressing to total spinal anesthesia, intravascular injection, and seizures.
Bogduk N et al. Biomechanics of the cervical spine Part 3: minor injuries. Clin Biomech (Bristol, Avon). 2001;16:267.
Freeman MD et al. A review and methodologic critique of the literature refuting whiplash syndrome. Spine. 1999;24:86.
Kwan O et al. A review and methodologic critique of the literature supporting 'chronic whiplash injury': part I-research articles. Med Sci Monit. 2003;9:RA203.
Peloso P et al; Cervical Overview Group. Medicinal and injection therapies for mechanical neck disorders. Cochrane Database System Rev. 2005;(2):CD000319.
Siegmund GP et al. Mechanical evidence of cervical facet capsule injury during whiplash: a cadaveric study using combined shear, compression, and extension loading. Spine. 2001;26:2095.
Essential Criteria
- Axial back pain that is the predominant feature of discogenic pain in the lower back.
- Gluteal extension is not uncommon; however, there is an absence of radicular symptoms, with no weakness affectingthe lower extremity and the pain rarely follows dermatomal or myotomal patterns.
- The pain is worse with positions that increase the in-tradiscal pressure, including standing for a long time, prolonged sitting due to back flexion, and intolerance to cumulative axial loading.
General Considerations
Discography can be considered as a purely diagnostic modality for the diagnosis of back pain. Discography is only indicated to rule out or to rule in discogenic pain with concordant or nonconcordant pain in the suspected degenerated disk.
For diagnostic purposes, MRI is sensitive in detecting disk abnormalities, yet MRI is capable of detecting degenerated, desiccated disks. Therefore, discography is considered the gold standard and an invaluable adjunct for the diagnosis of discogenic pain.
Patient Selection
Indications for discography include, but are not limited to, the following:
- Further evaluation of demonstrably abnormal disks to help assess the extent of the abnormality or correlation of the abnormality with the clinical symptoms. Such symptoms may include recurrent pain from a previously operated disk and lateral disk herniation.
- Patients with persistent, severe symptoms in whom other diagnostic tests have failed to reveal clear confirmation of a suspected disk as the source of pain.
- Assessment of patients who have not responded to surgical intervention to determine whether there is painful pseudoarthrosis or a symptomatic disk in a posteriorly fused segment and to help evaluate possible recurrent disk herniation.
- Assessment of disks before fusion to determine whether the disks within the proposed fusion segment are symptomatic and to determine whether disks adjacent to this segment are normal.
While the specificity may range from 20 to 90% depending on patient selection, discography results should be carefully validated and the procedure should be performed by an experienced clinician. Most clinicians will perform discography on two consecutive disks.
After placing the patient in a prone position, a postero-lateral extraspinal approach with fluoroscopic guidance to the desired disks is used. The skin is prepared and draped. The C-arm is then obliquely rotated until the facet joint "shadow" projects to about the middle of the vertebral body. A 22- or 25-gauge 6-inch needle with introducer is inserted, until it reaches the inner third of the disk. Upon confirmation of needle position using a true anteroposterior and lateral pictures, 0.5-1.5 mL of water-soluble radio-opaque contrast material is injected. The patient's response, the distribution of the dye, resistance, and volume injected are all noted and recorded.
A normal disk accommodates between 0.5 mL and 1.5 mL of contrast material; in the case of a fissured disk, there will be a path of least resistance with an increase in the capacitance of the disk and apparent abnormal spread of the contrast. However, these findings should be accompanied by concordant pain to label this study as a positive provocative discography.
Discitis represents one of the most devastating complications of discography. Thus, discography requires a surgically sterile environment with extreme caution when entering the disk, and despite lack of data to support the use of prophylactic antibiotics, most clinicians do provide a dose of antibiotics prior to the procedure.
Nausea, convulsions, and severe back pain during the procedure may occur. Meningitis, spinal headache, sub-dural or epidural abscess, intrathecal hemorrhage, arachnoiditis, nerve root injury, paravertebral muscle pain and contusions, postprocedural pain exacerbation, vasovagal reactions, allergic reactions, and damage to the disk including but not limited to herniation are other possible complications.
Anderson MW. Lumbar discography: an update. Semin Roentgenol. 2004;39:52.
Olmarker K et al. Selective inhibition of tumor necrosis factor-alpha prevents nucleus pulposus-induced thrombus formation, intra-neural edema, and reduction of nerve conduction velocity: possible implications for future pharmacologic treatment strategies of sciatica. Spine. 2001;26:863.
Willems PC et al. Lumbar discography: should we use prophylactic antibiotics? A study of 435 consecutive discograms and a systematic review of the literature. J Spinal Disord Tech. 2004;17:243.
Selective Sympathetic Blocks
Selective sympathetic blockade interrupts the efferent sympathetic fibers that are sometimes pathologically involved in a number of medical conditions, including CRPS, neuropathic pain (mononeuropathy, plexopathy), cranial neuralgia, hyperhidrosis, and many other conditions. Surgical or chemical sympathectomy is used to manage a variety of syndromes, yet relief following sympathetic blockade is not consistent, and relapses are common.
- Cervicothoracic Ganglion Blockade (Stellate Ganglion Block)
Essential Criteria
- CRPS or vascular insufficiency of the upper extremity.
- Pain of herpes zoster.
- Postherpetic neuralgia.
- Congenital prolonged QT syndrome (left cervicothoracic ganglion blockade).
- Migraines, tension, and cluster headaches.
- Cerebral angiospasm and cerebral thrombosis.
General Considerations
The cervical sympathetic trunk contains three ganglia: the superior, middle, and inferior cervical ganglia. In 80% of the population, the lowest cervical ganglia is fused with the upper thoracic ganglion to form the cervicothoracic ganglion. The cervicothoracic ganglion lies on or just lateral to the longus colli muscle between the base of the seventh cervical transverse process and the neck of the first rib. The cervicothoracic ganglion receives preganglionic fibers from the lateral gray column of the spinal cord. The preganglionic fibers for the head and neck emerge from the upper five thoracic spinal nerves, ascending in the sympathetic trunk to synapse in the cervical ganglion. The preganglionic fibers supplying the upper extremity originate from the upper thoracic segment between T2-T6, which in turn synapses in the cervicothoracic ganglion. The paradox of accepting Horner syndrome as a gold standard for sympatholysis of the upper extremity is still widely accepted; yet, the presence of Horner syndrome does not indicate complete sympatholysis of the upper extremity. Of the postganglionic sympathetic
supply to the upper extremity, 30% passes directly out of the thoracic outlet from the T2-T8 fibers to the brachial plexus and thus escapes the stellate ganglion (fused C7-T1 ganglia).
Patient Selection
The efficacy of stellate ganglion block in conditions such as phantom limb pain, postherpetic neuralgia, and Me-niere disease have yielded questionable results.
Duration of Benefit
The duration of relief with diagnostic blocks is variable; however, there is evidence that repeated blocks may overall decrease the level of sympathetically mediated pain. Radiofrequency ablation of the stellate ganglion is generally avoided to prevent a permanent Horner syndrome.
This block can be performed either blind or by using fluo-roscopy. The advantages of fluoroscopy include visualization of the C7 transverse process (which if targeted carries a higher incidence of pneumothorax and intra-arterial injection) and visualization of the local anesthetic spread. Intravenous access is mandatory in this procedure, which may be associated with rare but potentially critical, emergent complications. The patient is placed supine with a small roll or pillow between the shoulder blades to improve extension of the neck. The patient is asked to open his or her mouth in order to relax the neck muscles. After palpation of the cricoid cartilage to determine the level of the C6 transverse process, the carotid pulse is felt and the sheath is then displaced laterally. A 22-gauge, short beveled 5-cm needle is then advanced between the ster-nocleidomastoid muscle and the trachea until bone is encountered (C6 tubercle); the needle is withdrawn 3 to 5 mm to avoid injecting the substance into the longus coli muscle. A test dose of 0.5 to 1.0 mL is injected to exclude intravascular injection, since as little as 0.5 mL of local anesthetic could result in seizure and loss of consciousness. This is followed by injection of 8 to 12 mL of local anesthetic (local anesthetic concentration can be reduced because autonomic C-fibers are small with no myelin).
Potential complications include the following:
- Horner syndrome, which includes ptosis, myosis, and enophthalmos as well as nasal congestion.
- Seizures and loss of consciousness.
- Hoarseness, foreign body sensation in the throat resulting from recurrent laryngeal nerve block.
- Difficulty breathing secondary to phrenic nerve block.
- Air embolism.
- Pneumothorax.
- Epidural, subarachnoid injection.
- Infection and hematoma formation.
Birklein F. Complex regional pain syndrome. J Neurol. 2005;252:131.
Marples IL, Atkin RE. Stellate ganglion block. Pain Rev. 2001;8:3-11.
Pather N et al. The anatomical rationale for an upper limb sympathetic blockade: preliminary report. Surg Radiol Anat. 2004;26:178.
Schurmann M et al. Assessment of peripheral sympathetic nervous system function for diagnosing early post-traumatic complex regional pain syndrome type 1. Pain. 1999;80:149.
- Lumbar Sympathetic Block
Essential Criteria
- Sympathetically mediated pain of the lower extremity; this type of block could serve as a diagnostic, prognostic as well as therapeutic intervention in such a condition.
- Improvement of peripheral circulation in patients with peripheral vascular diseases.
- Postherpetic neuralgia, phantom limb pain, and intractable back pain.
General Considerations
The psoas major muscle and fascia separate the sympathetic chain and ganglia from the somatic nerves at the L2 to the L5 levels; the lumbar sympathetic chain contain both preganglionic and postganglionic fibers to the pelvis and the lower extremities. The sympathetic chain and ganglia are situated close to the anterolateral side of the vertebral bodies at the lumbar level; the best site for the needle tip placement would be the lower one-third of the L2 or the upper third of the L3 body. The rami communicantes course in a fibrous tunnel around the vertebral body; thus, caution is necessary when using a paramedian approach for neurolytic sympathectomy because the neurolytic agent could backtrack and cause ipsisegmental somatic painful neuritis.
Fluoroscopy is used for optimum needle placement. Accurate diffusion of the local anesthetic is based on the
optimal spread of the contrast material. After temperature probes are attached to the feet of the patient to monitor skin temperature, the skin on the patient's back is prepared and draped. The skin is then infiltrated with local anesthetic 7 to 10 cm lateral to the spinous process of L3. A22-gauge, 6- to 8-inch needle is directed toward the upper or middle third of the L3; the correct positioning of the needle anterior to the psoas fascia is verified using a loss-of-resistance technique. Correct placement of the needle is identified by injecting nonionic contrast showing a linear spread along the anterolateral aspect of the vertebral body. The contrast material is followed by injecting 15 to 20 mL of local anesthetic (may use bupi-vacaine 0.375%) while monitoring the increase in the lower extremity temperature.
When performing a neurolytic block, a solution of phenol 6% in Conray-420 dye (to add visibility while injecting the neurolytic agent) is used. The injection is performed while the C-arm is in the lateral position to detect any retrograde spread of the dye with resultant somatic neuritis.
Possible complications associated with lumbar sympathetic block include the following:
- Bleeding secondary to perforation of the lumbar vessels or the aorta.
- Orthostatic hypotension.
- Perforation of abdominal viscera.
- Subarachnoid or epidural injection.
- Backache and muscle spasm.
- Nerve root injury.
- Hematuria.
- Celiac Plexus Block
Essential Criteria
- Malignant and nonmalignant pain originating from abdominal organs supplied by the celiac plexus. Although celiacplexus block for nonmalignant abdominal pain has been described, its role as a proven therapy for benign abdominal pain has never been established and may notrepresent the most effective modality for the treatment of such conditions.
- Chronic pancreatitis.
General Considerations
The celiac plexus is located retroperitoneally in the upper abdomen at the level of T12-L1 vertebrae. This plexus innervates most of the abdominal viscera, including the stomach, liver, biliary system, pancreas, spleen, kidneys, adrenals, and small and large bowel through the splenic flexure. The celiac plexus receives pregan-glionic sympathetic contribution from the greater (T5-T10 spinal roots), lesser (T10-T11), and least splanchnic (T11-T12) nerves, which relay in the celiac ganglia after running in the posterior mediastinum and traversing the crura of the diaphragm; postganglionic fibers run along the course of blood vessels to innervate the abdominal viscera. The ganglia receive parasympathetic contribution from the vagus nerve. The celiac ganglia are formed by the right and left splanchnic nerves with a network of interconnecting fibers and a great anatomic variability.
Patient Selection
Celiac plexus block has proved both efficient and safe for the treatment of inoperable pancreatic cancer, with patients experiencing sustained pain relief for up to 24 weeks following neurolytic blocks; patients also required fewer medications with resultant decreased side effects related to the medications. This effect extended to other intra-abdominal malignancies of the upper abdomen. Some of the factors that may affect the efficacy of the block include the anatomic site of the tumor, with cancer head of pancreas showing more favorable responses compared with cancer body or tail. As a rule of thumb, celiac plexus block should be implemented early to maximize the benefits to the patient and to avoid technical difficulties related to the late spread of the tumor. The efficacy of celiac plexus block for chronic pancreatitis pain has been less established with studies yielding different results. Patients over 45 years of age and those who had never undergone pancreatic surgery were more likely to experience pain relief.
Multiple techniques have been described for the celiac plexus block, including the classic retrocrural approach, the transaortic approach, and the anterior approach.
Following are potential complications of celiac plexus block injections:
- Orthostatic hypotension.
- Backache.
- Diarrhea.
- Bleeding, aortic dissection, and rupture.
- Infection.
- Paraplegia (spasm of the segmental arteries).
- See Neurolytic nerve blocks later in chapter.
Cunha JE et al. Surgical and interventional treatment of chronic pancreatitis. Pancreatology. 2004;4:540.
Gress F et al. Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience. Am J Gastroenterol. 2001;96:409.
- Superior Hypogastric Plexus Block
Essential Criteria
- Malignantand nonmalignant pelvic pain.
- Cancer pain syndromes that could be amenable to superior hypogastric block include cervical, proximal vaginal, uterine, ovarian, testicular, prostatic, and rectal cancers.
General Considerations
The superior hypogastric plexus mediates most of the nociceptive afferents from the pelvic organs. It receives preganglionic sympathetic fibers from the aortic plexus and the L2, L3 sympathetic nerves; it also receives preganglionic parasympathetic fibers from S2 and S3. The superior hypogastric plexus is continuous with the in-termesenteric plexus and is located retroperitoneally, inferior to the origin of the inferior mesenteric artery. It lies anterior to the lower part of the abdominal aorta, its bifurcation, and the middle sacral vessels; it is located anterior to the L5-S1 vertebrae.
Despite the paucity of data on the long-term efficacy of the superior hypogastric block, its use as a diagnostic block for chronic nonmalignant pelvic pain syndrome is well established. Conceptually patterned after celiac plexus block, hypogastric plexus block can be used to delineate the source of pain in such conditions as endometriosis, adhesions, interstitial cystitis, and irritable bowel disease. In malignant pelvic pain, sympathetic blocks should be intended as adjuvant techniques to reduce analgesic consumption and not as a panacea, given that multiple pain mechanisms are often involved because progression of disease is able to change the underlying pain mechanisms. Patients who respond favorably to diagnostic blocks have a higher success rate with neurolytic blocks.
Due to the proximity of the iliac vessels, intravascular injection and vascular injury are possible complications. Other potential complications include epidural, subarachnoid, and intraperitoneal injection as well as discitis with the transdiscal approach.
de Oliveira R et al. The effects of early or late neurolytic sympathetic plexus block on the management of abdominal or pelvic cancer pain. Pain.2004;110:400.
Erdine S et al. Transdiscal approach for hypogastric plexus block. Reg Anesth Pain Med. 2003;28:304.
Mercadante S et al. Pain mechanisms involved and outcome in advanced cancer patients with possible indications for celiac plexus block and superior hypogastric plexus block. Tumori. 2002;88:243.
- Ganglion Impar Block
Essential Criteria
- Sympathetically mediated pain as well as visceral pain in the perineum resulting from pelvic malignancy.
- Perineal hyperhidrosis.
General Considerations
Ganglion impar is a single retroperitoneal structure that represents the most caudad ganglia of the sympathetic chain. It is also known as the ganglion of Walther. The location of the ganglion is typically midline, anterior to the sacrococcygeal junction, where it represents the confluence of the two sympathetic chains on each side to form a single structure in the midline. However, the exact location of the ganglion is variable.
Patient Selection
Most of the long-term efficacy data are reported with malignant perineal pain, with reported efficacy of complete relief in 50% of the patients and 60 to 90% pain relief in the remaining 50% of patients in one series. Cryoablation and neurolysis as a means for long-term relief of cancer-related pain should be considered in the armamentarium of pain procedures as a useful adjunct to oral pharmacologic therapy.
With the patient in a prone position, the area is prepared and draped. After making a skin weal, a 20-gauge 1.5-inch needle is inserted through the sacrococcygeal ligament and advanced until the tip is just posterior to the rectum. For diagnostic purposes, 5 to 8 mL of local anesthetic (1% lidocaine or 0.375% bupivacaine) is injected. For neurolysis, 4 to 8 mL of 10% phenol is used.
This is a relatively safe block; however, potential complications include rectal perforation, infection, and bleeding.
Han KR et al. Effects of neurolysis of the ganglion impar on the hyperhidrosis in the buttock and perineum. J Korean Pain Res Soc. 2001;11:114.
Oh CS et al. Clinical implications of topographic anatomy on the ganglion impar. Anesthesiology. 2004;101:249.
Therapeutic Blocks
Epidural Corticosteroid Injection
Essential Criteria
- Symptoms of nerve root irritation, including sciatica.
- Patients with herniated disks causing clinically significant nerve root compression or irritation.
- Degenerative spinal stenosis.
- Tumors infiltrating nerve roots causing radiculopathic pain.
- Postural back pain with radiculopathy.
- Postherpetic neuralgia.
- Discogenic back pain as a temporizing measure until definitive treatment is undertaken.
- Acute vertebral compression fractures.
General Considerations
Epidural corticosteroid injection is intended to deliver the medications in the vicinity of the inflamed nerve root; the therapeutic effects of epidural corticosteroids are attributed to an inhibition of synthesis or release of proinflammatory substances. Corticosteroids block phospholipase A2, which inhibits the conversion of phos-pholipids to arachidonic acid. NSAIDs work by a different mechanism, inhibiting the cyclooxygenase pathway. Failure of NSAIDs to produce pain relief, therefore, does not preclude the use of corticosteroids. Local infiltration of betamethasone at a nerve root compression model showed significant decrease in the expression of substance P, which proposes a possible direct effect of corticosteroids on pain mediators as well. Epidural installation of corticosteroids is not hampered by the decrease in local blood flow, which is frequently seen with com-pressive lesions. This can explain the decreased efficacy of orally administered corticosteroids, since the effectiveness is presumed proportional to the local concentration of the corticosteroids.
Despite the widespread use and acceptance of epidu-ral corticosteroid injection, it remains controversial, especially outside the United States. The question about whether there are long-term benefits for patients remains unanswered.
When epidural corticosteroid injections were given on an outpatient basis to persons with low back pain and sciatica, repeated injections improved the success rate and provided a safe, cost-effective means of treatment without the necessity of hospital admission. Most patients received a series of three epidural corticosteroid injections with progressive improvement after the second and third injection, which is a common pattern of practice in many pain management centers. The reported success rates varied greatly ranging anywhere from 18 to 90%. Selective nerve root injections of corticosteroids were significantly more effective than those of bupivacaine alone. Caudal epidural corticosteroid injections using triamci-nolone was superior to placebo, with reported better pain control and mobility at 4 weeks.
Patient Selection
The choice of the patient and the technique used is pivotal when epidural corticosteroid injection is considered. Patients who report superior pain relief include those with a higher educational background, a primary diagnosis of radiculopathy, and pain duration of less than 6 months. Those patients involved in litigations, who were unemployed, had constant back pain, and were symptomatic for 6 to 24 months historically had higher failure rates.
The choice of the technique should be symptom oriented. Patients with unilateral radicular symptoms are
good candidates for transforaminal epidural cortico-steroid injections, whereas the interlaminar or caudal approach is more appropriate for patients with axial back pain resulting from degenerative spinal stenosis or for patients with bilateral radicular symptoms.
The transforaminal approach is showing very encouraging results, with long-term success rates of 71 to 84%. The advantages of this approach include decreased risk of dural puncture and delivery of the medications in the anterior epidural space very close to the irritated nerve root. Transforaminal approach is particularly beneficial in large disk herniation, foraminal stenosis, and lateral disk herniations.
Different approaches to the epidural space have been described. Traditionally, two techniques have been used: the interlaminar and the caudal approaches. The trans-foraminal approach as mentioned above is a novel approach that has proved effective in the hands of experienced clinicians.
Regardless of the technique used, the use of fluoroscopy seems to play a crucial role as far as corticosteroid delivery and minimizing risks. Epidural corticosteroid injections have been demonstrated to be very safe, although inhibition of the hypothalamic-pituitary axis is possible. It is generally considered safe to repeat the injections. In a national survey, the average number of epidural cor-ticosteroid injections a single patient received was 5 to 7 per year; this survey included both academic as well as private practice pain centers.
Central neuraxial injections generally can result in the following:
- Infection and abscess formation.
- Bleeding, including epidural hematoma.
- Backache, lightheadedness, diaphoresis, and vasovagal reaction.
- Cardiovascular collapse.
- Neurologic complications include aseptic meningitis, paraplegia, quadriplegia, and arachnoiditis.
- Postdural puncture headache can result from dural encroachment; this particular complication is more common with interlaminar approach and less likely with caudal and transforaminal approaches. The incidence of postdural puncture headache <1%.
- Transforaminal epidural corticosteroid injection may result in intravascular injection into the artery of Adamkiewicz with subsequent anterior spinal artery syndrome and paraplegia.
- Systemic complications related to corticosteroid and local anesthetic injection, which is mentioned later in this chapter.
Neurolytic Nerve Blocks
Essential Criteria
- Best method for treating pain that is localized and of somatic or visceral origin.
- Candidates should have limited life expectancy.
General Considerations
Visceral cancer pain can be very difficult to treat; neurolytic sympathetic blocks can be effective. In one study despite optimized systemic analgesic therapy (SAT), patients with unresectable pancreatic cancer treated with SAT only did not have as effective pain control as a comparable group that received neurolytic celiac plexus block.
Patient Selection
Because of possible side effects that can adversely alter the quality of life, candidates for neurolysis should have limited life expectancy.
Solutions used for neurolytic block include phenol or ethyl alcohol. Phenol, in a concentration of 5 to 6%, has the advantage of being painless on injection, as well as the fact that it can be mixed with contrast material.
Ethyl alcohol is usually used in an undiluted form (95% and above). Alcohol injection may be painful secondary to irritation of the perineurium; therefore, some clinicians inject local anesthetic prior to the neurolytic block.
The most ominous complication related to alcohol neurolytic blocks includes alcohol-induced neuritis, which can occur during sympathetic blocks secondary to retrograde spread of the neurolytic agent injuring the somatic nerves. Therefore, neurolytic blocks should only be performed by an experienced interventional pain specialist. Pain related to alcoholic neuritis subsides within weeks to months in most cases.
Local Anesthetic Toxicity
Since local anesthetic is used in all the above-mentioned blocks, it is important to be aware of the possible complications related to local anesthetic overdose and toxicity, including neurotoxicity, cardiac toxicity, allergies, and methemoglobinemia.
Neurotoxicity can range from mild toxicity (including ringing in the ears, circumoral numbness, metallic taste, lightheadedness, and confusion) to severe toxicity (progressing from grand-mal seizures to coma and death).
Local anesthetics cause a dose-dependent inhibition of cardiac contractility and conduction, which may result in cardiovascular collapse and cardiac arrest. Guidelines of maximum dosage should be strictly followed, and in-travascular injection should be avoided.
Allergy to local anesthetics is very rare; however, allergy to aminoester local anesthetics has been reported. These drugs are derivatives of p-aminobenzoic acid, which is known to be allergenic.
A unique systemic side effect associated with a specific local anesthetic is the development of methemoglobine-mia after the administration of large doses of prilocaine. In most cases, this condition does not necessitate treatment and usually resolves spontaneously; however, intravenous administration of methylene blue can be used.
Botwin KP et al. Complications of fluoroscopically guided trans-foraminal lumbar epidural injections. Arch Phys Med Rehabil. 2000;81:1045.
Botwin KP et al. Fluoroscopically guided lumbar transforaminal epidural steroid injections in degenerative lumbar stenosis: an outcome study. Am J Phys Med Rehabil. 2002;81:898.
Cluff R et al. The technical aspects of epidural steroid injections: a national survey. Anesth Analg. 2002;95:403.
Furman MB et al. Is it really possible to do a selective nerve root block? Pain. 2000;85:526.
Mulligan KA et al. Epidural steroids. Curr Pain Headache Rep. 2001;5:495.
Riew KD et al. The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled, double-blind study. J Bone Joint Surg Am. 2000;82-A:1589.
Stojanovic MP et al. The role of fluoroscopy in cervical epidural steroid injections: an analysis of contrast dispersal patterns. Spine. 2002;27:509.
Vad VB et al. Transforaminal epidural steroid injections in lum-bosacral radiculopathy: a prospective randomized study. Spine. 2002;27:11.
Wong GY et al. Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial. JAMA. 2004;291:1092.
Wong HK et al. Effects of corticosteroids on nerve root recovery after spinal nerve root compression. Clin Orthop Relat Res. 2002;(403):248.


text: How do I gain points? ← Scattergories The object of the game is to come up with unique answers for each category presented. You don't get any points if you give the same answer as your opponents. Score even more points if your answers are alliterations or are rare. The more unique your answer, the more points you score!


text: World 14 April 2010 TV debates: what Sarah Palin knew Lessons for Brown, Cameron and Clegg? You betcha. Sign up for our weekly email * Print HTML In the next issue of the New Statesman, Dominic Sandbrook has a terrific essay on the televised leaders' debates, What Ronald Reagan knew. His hook is Reagan's folksy, charm-laden, policy-lite performance against President Jimmy Carter in 1980 -- "There you go again" and all that. If the actor-turned-president Reagan is a role model, what (if anything) can Gordon Brown, David Cameron and Nick Clegg hope to learn from John McCain's one-time running mate, Sarah Palin? Well, two things. First, lower expectations to such an extent that anything other than a complete meltdown will be seen as a triumph. According to John Heilemann and Mark Halperin's account of the 2008 presidential race, Game Change (aka Race of a Lifetime), "McCainworld was ecstatic" after the 2 October debate. "Palin had not only survived, but fought Biden to something like a draw," they wrote, though not everyone saw it that way. Second, avoid tricky words. Again, we're grateful to Heilemann and Halperin for this account of the Republican's debate prep: Over and over, Palin referred to Obama's running mate as "Senator Obiden" -- or was it "O'Biden"? -- and the corrections from her team weren't sticking. Finally, three staffers, practically in unison, suggested, Why don't you just call him Joe? And that's exactly what she did. As the two would-be VPs greet each other, you can just hear above the applause Palin eagerly asking Biden: "Hey, can I call you Joe?" By the way, you can join the New Statesman team for some live blogging on Thursday night's debate. › Web Only: the best of the blogs Jon Bernstein, former deputy editor of New Statesman, is a digital strategist and editor. He tweets @Jon_Bernstein. Subscribe from just £1 per issue More Related articles Donald Trump was Steve Bannon's creation. What happens now he's gone? "We are not going to change": Barcelona defies terror with a return to normality The wildfire victims of forestry neglect - and the trees that saved them Subscription offer 12 issues for £12 + FREE book LEARN MORE Close This week's magazine


text:
As if we needed a new singing competition, Rising Star debuts 9pm EDT Sunday on ABC. What makes this show different than American Idol, X-Factor or The Voice, is that you can be a judge. In fact, all you need to do to become a judge, is to download the Rising Star app, and use it to vote for your favorite contestants.
The app is available from the Apple App Store, Google Play Store, and the Windows Phone Store, and allows you to vote in real-time. Before each contestant performs, you check in via the app. When it is time to vote, you swipe to the right to vote YES, or swipe to the left to vote NO. Your vote is counted immediately. If enough voters swipe to the right, the three-story wall that the contestant is standing behind starts to rise, exposing him or her to the live audience.
You must be 13 or older to use the app, and 18 or older if you want to see your profile picture appear on national television. If you're the shy sort, you can opt-out of sharing your picture with the rest of the world. Unlike the other singing competitions, which allow you to vote multiple times, you are allowed just one vote per act.
If you've always wanted to be the one to determine if an act moves on or goes home, this is your chance. Click on the video below, and if you're still interested, download the Rising Star app from the appropriate app store.
source: RisingStar (iOS|Android|Windows)
Rising Star debuts on ABC Sunday; download the app and become a judge
2 Comments
posted on 20 Jun 2014, 22:36 0
1. KingKurogiii (Posts: 5713; Member since: 23 Oct 2011)
i think this is great. thing is by the time i get time to watch TV i'm watching recordings so i won't be able to take part in this too often.
Rising Star debuts on ABC Sunday; download the app and become a judge


text:
Even if we are not actively hiring, we are always interested in meeting new people! If you are interested in pursuing a career with Blue Laser Design, here are some of the opportunities.
What Are You Interested In?
Get In Touch
Also, if you are a current or former web development business owner call us today to discuss some special opportunities.
No Openings Currently, But Say Hello!
For outgoing and friendly people who enjoy working both in and out of the office, and are ultimately able to ask for – and get – the sale. Sell yourself to us!
WordPress / Web Development
3-5 Years Exp Required. If you speak different languages like PHP, ASP, HTML5, dream about DIVs, WordPress, responsive frameworks and databases, we have a desk for you!
Search Engine Optimization (SEO)
If analyzing stats is in your wheelhouse, and you worship the almighty Google, search no more, you may have found the right place to work.
No Openings Currently, But Say Hello!
Are you creative, always coming up with new ideas, and love to write and tell stories? Then tell us your story (it might have a happy ending of working with us!)
Social Media
No Openings Currently, But Say Hello!
If you post, tweet, pin, link in, photograph and video tons of stuff in your daily life, why not get paid to do it? We think you'll "like" us!
Project Management
Exploring new candidates for 2018, submit your resume!
If you enjoy organization, meeting deadlines, managing schedules and working with people, then pencil in a meeting with us.
Graphic Design
No Openings Currently, But Say Hello!
Whether you are a recent graduate from school or a seasoned professional, we are open to different levels of experience—as long as you have mad skills! MAKE sure you have an online portfolio to send us.
No Openings Currently, But Say Hello!
If you love numbers, balancing accounts, checking things off your list, using the phrase "in the black," and having a place for everything and everything in its place, then BLD could be the place for you!
Office Management
No Openings Currently, But Say Hello!
No need for a psychology degree here. You just need to love organization, working with people, problem solving, adapting to change, and time management, and in the words of the Richmeister, "Makin' copies."


text:
Google (NASDAQ:GOOG) provides a wide, interlinked array of utilities such as Calendar, Maps, and Docs. This overlap in functionalities streamlines efficiency for users, which in turn helps the company attract more users and make more money from ads. A recent improvement offers insight into Google's approach to future interlinked functionalities: smartphone users can now review recent searches from a dedicated tab. This new tab, while fairly simple, and previously available through web history functions, shows where Google is trying to go in terms of ubiquity.
Google would like to become an extension of your brain. If you want to know something, you ask Google -- this is a sensory function. If you want to email someone, you use Gmail -- this is an expressive function. If you want to remember something, you might email it to yourself. Extending this memory service with the new "recent searches" tab, Google moves a step closer to becoming an implant in your head.
It does so not by burdening you with organizing the information in your phone. Rather, Google makes it effortless, by default storing your information through "the cloud", and acting as your secretary, ready with any note you've recently made in case you need to recall it. Also, not only does Google benefit from enticing you to use its services more and become a target of its advertising sponsors, Google also gains a new metric. Your habitual remembrance of some notes rather than others could help Google fine tune its algorithms -- big data sees no metric as "too small to crunch".
With many traditional professions being replaced by technology, there has yet to be a broad displacement of human capital. Our smarts are still resources, largely irreplaceable by artificial intelligence. However, there are some low-level tasks that can be outsourced to computers that we still do ourselves out of habit. The more we eventually outsource low-level, rote, quantitative tasks to computer brains, the more we can use our high-level abilities and exploit a comparative advantage.
Another feature in the works for Google is a voice recognition feature like those of Apple (NASDAQ:AAPL) and Nuance (NASDAQ:NUAN). However, Apple's and Google's voice recognition implementations will not be copies of each other. As I have argued previously, Google is better at productivity, and Apple is better at entertainment. Google helps you solve life problems; Apple makes your problematic life more enjoyable. If you want your phone to refer to you as a rock god, you have Siri for that. If you want to remember what you were supposed to be doing after you picked up the dry cleaning, then your recent search on Google Maps might tell the story. The theme with all of these services is a convergence of mediums. Written, spoken, or recalled via recent searches tab, it doesn't matter--you can access information via the most convenient medium. This convergence allows a more economic allocation of your attention span.
Google's new tab is a quiet improvement which fits with the trend of Google assisting in the background while you focus on your work. The only time you notice how valuable Google is, is when it is no longer available. Try a day without Google and see what I mean. This new mobile recent search tab might not be news to you. It might not be as exciting as smart glasses, Skynet, and robots. But it's news to me. Not just because I personally feel Google is a natural extension of human computing. But also, and less controversially, because Google's recent search tab allows us to be more human -- it allows us to not have to worry so much about remembering things. In an age of technology, what greater gift could we ask for than to be allowed to be more human? Certainly a P/E of 20 is not too much to ask for such a gift.
Disclosure: I have no positions in any stocks mentioned, and no plans to initiate any positions within the next 72 hours.


text:
Sunshine Motel, motels in Tacoma, WA, Conveniently located 5 minutes from Tacoma, is your gateway to famous attractions such as Tacoma Dome, Mount Rainier National Park, Emerald Queen Casino, Six Flags Enchanted Parks, Emerald Downs, Tacoma Art Museum, SeaTac Airport and much more. If you need to be at the center of the action, downtown Seattle is a short 30-minutes drive.
We are the best choice for reasonably priced, comfortable and affordable accommodations in Pacific Highway East of Fife, WA.
Hotel Features
- FREE Wireless Internet
- Close To Shopping
- Easy Access to Area Attractions
- 24 Hour Security Surveillance
- FREE Local Calls
- Kitchen Units Available


text:
The Buyel'Ekhaya Music Festival has released a public statement defending itself after controversy surrounding a 'lifeless' performance by Babes Wodumo.
The drama between festival organisers and the singer became public after the singer addressed criticism aimed at her performance on 19 December in East London.
In a video posted to Instagram, Babes accused event founder Nomahlubi Mazwai of verbally abusing her. Babes also said Mazwai threatened to kill her moments before forcing her on stage with the help of security guards
In a statement posted to the event's official Facebook page, Buyel'Ekhaya took shots at Babes, giving a 17 point response to the allegations made.
Among the claims, organisers say Babes missed her call time, insisted on a bath even though she was late and then refused to perform when she arrived at the venue.
"10. On route to the stadium Babes Wodumo made a demand, to our artist manager Sharif Baker, to go to her hotel to take a bath. This was rejected as she had to get on stage immediately as the Venue Operations Committee had resolved to switch the music off at the venue by 04:30am. 11. On arrival at the venue at 03:00am, Babes Wodumo refused to perform," reads part of the statement.
Babes was the closing act for the 24-hour music show and created a stir when she walked onto stage and just stood there, not showing off her usual signature dance moves.
The singer has been unavailable for comment.


text:
Macon Community News was founded in July of 2013 as a free monthly print newspaper with a mailed circulation of approximately 12,000 households by Doug Deal and his wife Lauren Deal. The print run was 6 months and ended December of 2013.
The mission was to focus on the positive aspects of Macon and the surrounding area by running stories solely about local people, businesses and events, basically to focus on what isn't printed in any newspaper that simply reruns the same wire stories one can find in any paper. Our goals was to create a venue where people of Macon and Middle Georgia could write about their neighbors, their neighborhoods and their interests and then share it with others, without the gloom and cynical pessimism of the paper of record.
Three years later, this online edition is the rebirth of that mission. We will start slowly and tentatively, as we rebuild our relationships with the talented writers, artisans, business people and volunteers that make Macon a better place. But also, we will add commentary and news about how we can do better as a community, but instead of using it as a hammer to knock things down, hopefully we can help move things forward.
Everyone has a story, what's yours? If you would like to contribute, please click the link in the menu and fill out our contact form or submit a story idea.
Macon Community News:
Doug Deal – Publisher / Editor-in-Chief
Lauren Deal – Assistant Editor / Contributor
Jason M. Harper – Contributor


text:
Question: Refer to the balance sheet of Arctic Cat in Appendix
Refer to the balance sheet of Arctic Cat in Appendix A. Does it use the direct write- off method or allowance method in accounting for its accounts receivable? What is the realizable value of its receivable's balance as of March 31, 2011?
View Solution:
View Solution:
Answer to relevant QuestionsRefer to the financial statements of KTM in Appendix A. What does KTM title its accounts receivable on its consolidated balance sheet? What are KTM's accounts receivable at December 31, 2011?Dominika Company's December 31 year- end unadjusted trial balance shows a $ 10,000 balance in Notes Receivable. This balance is from one 6% note dated December 1, with a period of 45 days. Prepare any necessary journal ...Dexter Company applies the direct write- off method in accounting for uncollectible accounts. Prepare journal entries to record the following selected transactions of Dexter. March 11 Dexter determines that it cannot collect ...Prepare journal entries to record the following selected transactions of Ridge Company. Mar. 21 Accepted a $ 9,500, 180- day, 8% note dated March 21 from Tamara Jackson in granting a time extension on her past-due account ...Archer Co. allows select customers to make purchases on credit. Its other customers can use either of two credit cards: Commerce Bank or Aztec. Commerce Bank deducts a 3% service charge for sales on its credit card and ...
Post your question


text:
Report summaryAs India's economy embarks on the industrialisation phase, we estimate power demand to grow at an average 6.8% per annum through 2025. Distribution sector and tariff reforms will however be needed to support this growth. Coal will remain the dominant fuel source in the power sector, but in the longer term, India will require greater contribution from nuclear and renewables to support its demand growth.
What's included?
This report includes 2 file(s)
- India energy markets outlook 2014 - power PDF - 621.53 KB 16 Pages, 7 Tables, 9 Figures
- India.xls XLS - 783.09 KB


text:
Question: A restaurant bakes its own bread for 152 per
A restaurant bakes its own bread for $ 152 per unit (100 loaves), including fixed costs of $ 39 per unit. A proposal is offered to purchase bread from an outside source for $ 105 per unit, plus $ 12 per unit for delivery. Prepare a differential analysis dated August 16, 2014, to determine whether the company should make (Alternative 1) or buy (Alternative 2) the bread, assuming fixed costs are unaffected by the decision.
View Solution:
View Solution:
Answer to relevant QuestionsA company manufactures various sized plastic bottles for its medicinal product. The manufacturing cost for small bottles is $ 67 per unit (100 bottles), including fixed costs of $ 22 per unit. A proposal is offered to ...Product R is normally sold for $ 52 per unit. A special price of $ 39 is offered for the export market. The variable production cost is $ 31 per unit. An additional export tariff of 25% of revenue must be paid for all export ...A condensed income statement by product line for Celestial Beverage Inc. indicated the following for Star Cola for the past year: Sales .............. $ 290,000 Cost of goods sold ......... 155,000 Gross profit ...Rise N' Shine Coffee Company produces Columbian coffee in batches of 6,000 pounds. The standard quantity of materials required in the process is 6,000 pounds, which cost $ 5.50 per pound. Columbian coffee can be sold ...Based on the data presented in Exercise assume that Smart Stream Inc. uses the total cost concept of applying the cost-plus approach to product pricing. In Exercise, Smart Stream Inc. uses the product cost concept of ...
Post your question


text:
Добавлено (28.04.2014, 13:08)---------------------------------------------http://sharkeysbarandgrill.com/wp-content/plugins/jordanconcordsforsale.php - low concord 11s Now it's everywhere. But Valentina Lupan, one of 2,000 architects who worked on the project, says Ceausescu demented. All of the raises were explained as compensation for "extra duties" incurred as the state's former education system merged into the new Board of Regents, regents officials said.. http://tacstrat.com/images/jordan11concord.html - low concord 11s Julien Lorcy : Les gens du voyage et les autres Fran ont peur les uns des autres. We brainstormed some of the possibilities that may exist. Director Alfred Hitchcock was denied permission to shoot at the South Dakota attraction officials balked at the idea of an attempted murder being filmed at a national monument. I was born in Michigan and grew up in Oklahoma. A third of those National Institutes of Health dollars supports clinical research (3). Games and movies are art much likeIf America wants to reduce the incidences of violence in America it should lead by example.Operates through a nationwide network of more than 200 franchisees. When there are a few drops of rain or in the Lakers' case few losses, the sky is falling. Check back later for more!. In 2004, Lewis moved to global revenue management in Peoria, Ill., before moving to Nashville, Tenn., as district manager in what is now the Caterpillar Americas Distribution Division. http://www.swiss-corner.com/images/concordsforsale.html http://www.swiss-corner.com/images/concordsforsale.html - concords 11s Sales came to $236,000 in 1986, and rose to $980,000 for the first seven months of 1987, McKay said.. Not only are some 70,000 dead and perhaps two million people dislocated, but the ultimate fall of the Assad regime raises the specter of further slaughter and, worse in a geopolitical sense, the spreading of unrest, armed factions, and destabilizing trends to Lebanon, Jordan, and perhaps Iraq as well. http://www.swiss-corner.com/images/concordsforsale.html - jordan 11 concord 2014 Security Council measures aimed at ending the bloodshed in Syria. "I went all the way home to North Carolina to vote. Clair, Mo., Mixon will relocate with his wife and daughter from Andover, Maine, to Minnesota.. Instead, she delivered a speech in which she demanded that the warlords should be put on trial for their numerous crimes, not sitting on constitutional committees and holding government posts. http://sharkeysbarandgrill.com/wp-content/plugins/jordanconcordsforsale.php - buy jordan 11 concord Nobody paid much attention when Sejdic and Finci won their case back in 2009. Many officials believe the assistance is unlikely to bolster the rebellion enough to push President Bashar al Assad of Syria to the negotiating table. 11, and Feb. One of the things that's so wonderful about working on Brahms' Requiem (if you've read the blogs below you know Pro Musica is performing it on April 5 at the Troy Music Hall) is that every day it gets more and more clear how this piece synthesizes Bach and Beethoven.
Добавлено (28.04.2014, 14:09)---------------------------------------------concord lows for sale 68 67?135 Steve Elkington. On every page there are sentences to ignite your mind and sentences to scoff at, dismiss, curse. It is the job of the Senior Military Leader(s) to provide a rallying point/purpose, a Mission Statement, clearly stating what the Purpose of the War is. cheap jordan concord lows C'est un cureuil avec ces paroles Qua non ascendam O ne monterai je point Le roi se les fit expliquer. Supreme Court.. Will it all end tonight? Either the most exciting season in the Nationals' young history comes to a disappointing finish this evening, or it advances to an all or nothing fifth game against the St. We also reached out on Facebook to find out what concerns or questions you might have. Several Presidents attended college but dropped out, among them William McKinley who dropped out of both college and law school.. He had no apparent political or religious agenda for the government of Kim Jong Un. http://www.hogardelnorte.com/wp-content/concordlows.html jordan 11 low concord for sale Governor, if you have an account with a prostitution service, you've lost your credibility, and the privilege to lead this state. Improving science education, Kalman says, is the only way for nations to remain at the forefront of the knowledge based economy.. low concord 11s Last September, Bloomberg News tested Obama's pledge by filing FOIA requests for the 2011 travel records of top officials at 57 agencies. They did not make any public remarks, but then spoke to survivors and relatives of those who died.. Xx xx about the incident when Ofcr. jordan 11 concord low No one wants to be number two. A law in North Carolina imposes a special voter ID requirement while invalidating several forms of government or public employee ID, including student IDs and those issued by public assistance agencies. Republican Conference chairman Jeb Hensarling, who was the Republican co chair of the supercommittee on deficit reduction, pointed to consistently high unemployment during the Obama administration as justification to try the GOP plan rather that veto it out right..
Добавлено (28.04.2014, 14:59)---------------------------------------------http://www.tys568.com/ http://www.magionenews.it/ http://www.amalgamated-services.co.uk/ http://www.szwedshop.com/ http://www.mediationthatworks.co.uk/ Those are strong words. http://www.transport-jouve.fr/ - sac a main lancel http://www.muellerleile-online-dienst.de/ - montblanc classique kugelschreiber http://www.fiafant.it/ - tods outlet http://www.seriesmusic.it/ - outlet bottega veneta vicenza http://www.monsoonpress.co.uk/ - cheap fred perry to produce a show-quality level of detail. when people talked about fascism in the 1920s and 1930s. mbt boots cheap red wing boots lancel french flair miu miu borse cheap fred perry Although these may seem expensive they do offer the best protection to your coin collection.


text:
Free Preview of Initiation Of Anissa Kate, The
Customers Who Bought This Product Also Bought
Initiation Of Anissa Kate, The
Watch and enjoy the ride as Gazzman takes you on a journey around Los Angeles, where dreams can come true for the beautiful and talented. Anissa Kate, the newest slut on the block; seeks out her destiny by learning how to fuck her way to the top. Enrolling in LA's biggest porn factory, this determined, gorgeous French whore is taught all the tricks of the trade. Her tight ass is stretched, her pink pussy is fucked raw.
This is the making of a true porn star!
Watch and be in awe of The Initiation Of Anissa Kate.
Product Information
- Length: 3 hrs. 4 mins.
- Rating: XXX
- Released: Apr 25 2012
- Production Year: 2012
- Empire SKU: 1611293
- Studio: Harmony
- Number of Discs: 1
- UPC Code: 5060089422068
Interactive Menus
Chapter Selection
Website Information
Slide Show
Cumshot Recap
Chapter Selection
Website Information
Slide Show


text:
After much anticipation, Patch 1.13c was released for Diablo II on March 23, 2010, along with a reset of the ladder. Among the most noticeable changes are a new way to respec skills and stats.
Arreat Summit: The 1.13 patch for Diablo II is now live! With this patch we have included a number of changes including a new respec system, allowing you to reset your character's stats and skills. With the release of 1.13 the Diablo II ladder has been reset and all previous ladder characters are now normal non-ladder characters. To participate in the new ladder you'll need to create a new character and ensure the "Ladder Character" option is checked.
The changes in the new patch can be read here.
The patch can be downloaded here: [1]