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Merlin Copacabana Hotel Rio De Janeiro
Avenida Princesa Isabel, 392, Rio de Janeiro, Brazil
The excellent 4-star Merlin Copacabana Hotel is a great place to stay in Rio de Janeiro. Residing in a 12-story building, the hotel was opened in 1992 and renovated in 2007.
Thanks to its beautiful location, Merlin Copacabana Hotel provides direct access to Corcovado, Botafogo Beach and Copacabana Fort as well as museums and monuments. Nestled in the shopping district and 8 km from the city center.
Merlin Copacabana Hotel offers spacious rooms with standard décor featuring a laptop-size safe, cable TV, individual climate control, a mirror and a minibar. The property boasts views of Corcovado Mountain and Atlantic Forest from its rooms. They are fitted with coffee/tea makers and a fridge as well as en suite bathrooms with a hairdryer, a Jacuzzi and a shower.
Guests can have breakfast in the restaurant every morning. The restaurant menu features international dishes. At the comfortable poolside bar guests will enjoy a selection of coffee and tea.
This hotel is just 450 meters away from Avenida Lauro Sodre próximo ao número 3111 bus stop and within a 5-minute walk from Cardeal Arcoverde underground station. Santos Dumont airport lies within about 10 minutes' drive.
There are cars for rent on site.
On-site fitness facilities include a gym and fitness center.
Important information
- Children and extra beds
- All children under the age of 7 may stay free of charge when using existing bedding.
- There are no cribs provided in a room.
- Parking
- Wi-Fi in public areas
- 24-Hour Check-In
- 24-Hour Front Desk
- Non-Smoking Rooms
- Allergy-free rooms
- Soundproofed Rooms
- Connecting Rooms
- Non-smoking hotel
- Safety Deposit Box
- Business Center
- Projector
- Printers
- Lobby
- Rooftop terrace
- Garden
- Garden furniture
- Luggage Storage
- Elevator
- Multilingual Staff
- Credit Card Accepted
- No Pets Allowed
- Half board
- Buffet
- Coffee/tea in lobby
- A la carte restaurant
- Breakfast room
- Poolside Snackbar
- Lobby bar
- Cafe
- Children's buffet
Leisure & Sports
- Rooftop pool
- Private swimming pool
- Spa & Wellness Centre
- Fitness center
- Solarium
- Jacuzzi
- Sauna
- Beach umbrellas
- Towels
- Sun terrace
- Free shuttle
- 24-Hour Security
- 24-Hour Room Service
- Private dining services
- Tours/ticket assistance
- Meeting/Banquet Facilities
- Business services
- Computer Rental
- Fax/Photocopying
- Newspaper service
- Currency Exchange
- Medical Service
- Bellboy
- Car Rental
- Self-service laundry
- Dry Cleaning
- Ironing Service
- Baby-sitting/Child Services
Room Amenities
- In room air conditioning
- Outdoor dining area
- Living room
- In-room safe
- In-room desk
- Rollaway Beds
- Wardrobe
- Mini-Bar
- Direct dial telephone
- International calls
- Shared bathroom
- Bathtub
- Bathrobes
- Hair dryer
- Room toiletries
- Data Ports
- AM/FM Alarm Clock
Avenida Princesa Isabel, 392, Rio de Janeiro, Brazil
Merlin Copacabana Hotel offers spacious rooms with standard décor featuring a laptop-size safe, cable TV, individual climate control, a mirror and a minibar. The property boasts views of Corcovado Mountain and Atlantic Forest from its rooms. They are fitted with coffee/tea makers and a fridge as well as en suite bathrooms with a hairdryer, a Jacuzzi and a shower.
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If you have any questions regarding your reservation made through our website, please go to our Contact Us page.
Contact Us
Merlin Copacabana Hotel
Avenida Princesa Isabel, 392, Rio de Janeiro, Brazil
What's nearby
- Local attractions
- Leme Beach600 m
- Avenida Atlantica750 m
- Sala Baden Powell850 m
- Inside Rio Tours950 m
- Casa Daros950 m
- Morro da Urca1.2 km
- Claudio Coutinho Trail1.2 km
- Bondinho do Pão de Açúcar1.1 km
- Fundação Casa de Rui Barbosa1.7 km
- Pista Claudio Coutinho1.2 km
- Praia Vermelha - Rio1.2 km
- Urca Beach1.2 km
- Post 3 - Copacabana1.1 km
- Airports
- Santos Dumont5.8 km
- Train stations
- Estação D Pedro II Central Station6.7 km


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Prudential PLC held its position in Ecolab Inc. (NYSE:ECL) during the second quarter, according to its most recent filing with the Securities and Exchange Commission (SEC). The institutional investor owned 1,753 shares of the basic materials company's stock at the close of the second quarter. Prudential PLC's holdings in Ecolab were worth $233,000 at the end of the most recent reporting period.
Other institutional investors have also bought and sold shares of the company. Courier Capital LLC acquired a new position in shares of Ecolab during the 2nd quarter worth $282,000. Alps Advisors Inc. raised its holdings in shares of Ecolab by 21.3% during the 2nd quarter. Alps Advisors Inc. now owns 2,134 shares of the basic materials company's stock worth $283,000 after buying an additional 375 shares in the last quarter. Stephens Inc. AR raised its holdings in shares of Ecolab by 4.7% during the 2nd quarter. Stephens Inc. AR now owns 18,332 shares of the basic materials company's stock worth $2,434,000 after buying an additional 822 shares in the last quarter. State Street Corp raised its holdings in shares of Ecolab by 0.3% during the 1st quarter. State Street Corp now owns 11,935,943 shares of the basic materials company's stock worth $1,496,059,000 after buying an additional 31,277 shares in the last quarter. Finally, YHB Investment Advisors Inc. raised its holdings in shares of Ecolab by 0.6% during the 1st quarter. YHB Investment Advisors Inc. now owns 112,954 shares of the basic materials company's stock worth $14,581,000 after buying an additional 649 shares in the last quarter. 75.42% of the stock is owned by institutional investors.
Shares of Ecolab Inc. (NYSE:ECL) opened at 134.09 on Friday. Ecolab Inc. has a 12 month low of $110.65 and a 12 month high of $134.89. The company's 50-day moving average price is $131.21 and its 200-day moving average price is $130.32. The company has a market cap of $38.80 billion, a price-to-earnings ratio of 30.66 and a beta of 0.98.
Ecolab (NYSE:ECL) last announced its quarterly earnings data on Tuesday, August 1st. The basic materials company reported $1.13 earnings per share (EPS) for the quarter, beating the Zacks' consensus estimate of $1.12 by $0.01. Ecolab had a return on equity of 18.93% and a net margin of 9.66%. The firm had revenue of $3.46 billion for the quarter, compared to analysts' expectations of $3.40 billion. During the same period last year, the firm earned $1.08 earnings per share. The company's revenue for the quarter was up 4.4% compared to the same quarter last year. Analysts anticipate that Ecolab Inc. will post $4.73 EPS for the current year.
The business also recently disclosed a quarterly dividend, which will be paid on Monday, October 16th. Stockholders of record on Tuesday, September 19th will be paid a dividend of $0.37 per share. The ex-dividend date of this dividend is Monday, September 18th. This represents a $1.48 dividend on an annualized basis and a dividend yield of 1.10%. Ecolab's dividend payout ratio (DPR) is currently 33.79%.
A number of equities analysts have recently commented on the company. Zacks Investment Research cut Ecolab from a "hold" rating to a "sell" rating in a report on Tuesday, October 3rd. UBS AG reissued a "buy" rating and set a $147.00 price target (up previously from $144.00) on shares of Ecolab in a report on Tuesday, August 8th. BidaskClub cut Ecolab from a "sell" rating to a "strong sell" rating in a report on Monday, August 14th. Robert W. Baird reissued a "hold" rating and set a $140.00 price target on shares of Ecolab in a report on Thursday. Finally, Jefferies Group LLC reissued a "hold" rating and set a $130.00 price target on shares of Ecolab in a report on Wednesday, August 16th. Two research analysts have rated the stock with a sell rating, nine have issued a hold rating and seven have issued a buy rating to the company's stock. The stock currently has an average rating of "Hold" and an average price target of $134.21.
ILLEGAL ACTIVITY NOTICE: This news story was originally published by Daily Political and is the property of of Daily Political. If you are reading this news story on another site, it was illegally copied and republished in violation of United States and international copyright legislation. The correct version of this news story can be viewed at https://www.dailypolitical.com/2017/10/14/prudential-plc-has-233000-stake-in-ecolab-inc-ecl.html.
In related news, major shareholder William H. Gates III acquired 75,500 shares of Ecolab stock in a transaction dated Thursday, August 3rd. The shares were purchased at an average cost of $132.57 per share, with a total value of $10,009,035.00. The transaction was disclosed in a document filed with the Securities & Exchange Commission, which is available at this hyperlink. Also, insider Thomas W. Handley sold 7,397 shares of the firm's stock in a transaction dated Thursday, September 14th. The shares were sold at an average price of $130.63, for a total value of $966,270.11. The disclosure for this sale can be found here. 1.49% of the stock is currently owned by company insiders.
Ecolab Company Profile
Ecolab Inc provides water, hygiene and energy technologies and services. The Company's cleaning and sanitizing programs and products, pest elimination services and equipment maintenance and repair services support customers in the foodservice, food and beverage processing, hospitality, healthcare, government and education, retail, textile care and commercial facilities management sectors in over 170 countries.
Want to see what other hedge funds are holding ECL? Visit HoldingsChannel.com to get the latest 13F filings and insider trades for Ecolab Inc. (NYSE:ECL).
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subset: commoncrawl


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Event Archive - Portal: remix wars: Arthur Kroker, Marylouise Kroker, Steve Gibson, Jackson 2 Bears, Tanya Doody, Tom Kuo
Sat. October 4th 2003 @ Open Space (All Ages)
8:00 pm
An evening of live electronic music, digital video, spoken word and turntable experimentations, 8pm at Open Space. With Arthur and Marylouise Kroker, Steve Gibson, Jackson 2 Bears & Tanya Doody, and Tom Kuo.
[Upload Show Photos] // [Add Video] // [Add Review] // [Upload Poster]


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Automatic Toilet Paper/Kitchen Towel Multi-Rolls Paper Packing Machine
|FOB Price:
|US $1-1,000 / sets
|Min. Order:
|1 sets
|Min. Order
|FOB Price
|1 sets
|US $1-1,000/ sets
|Production Capacity:
|Transport Package:
|in Standard Export Packing Wooden Case
|Payment Terms:
|L/C, T/T, Western Union, negotiation
Request a custom order and have something just for you!Send Customized Request
- Model NO.: CIL-SP-398
- Condition: New
- Production Speed: 60-100rolls/Min
- Plastic Film Size: 500*760mm
- Function 2: Easy Operation
- Function 3: Connect with Cutting Machine to Be Production Line
- Function 5: It Can 4 /6/8/10/12 Rolls One Bag
- Paper Thickness: Normal Specification Paper
- Customized: Non-Customized
- Sheet Former Type: Packing Machine
- Specification: 3*1.1*1.2
- Certification: CE
- Control: Automatic
- Control System: PLC
- Function 1: High Speed
- Use Range: Toilet Paper and Kitchen Towel
- Function 4: One Machine Can Be Have 3 Sizes
- Weight: 0.2t
- Automation: Automatic
- Type: Packaging Machine
- Trademark: Xinda Machinery
- Origin: Fujian, China
Video link:
This machine use plastic bag film to pack toilet paper rolls. It can 2 rolls in one bag, 4 rolls in one bag, 6 rolls in one bag, 8 rolls in one bag, 10 rolls in one bag and 12 rolls in one bag.
Function and characteristic:
1. This is special machine for packaging of toilet paper rolls and kitchen towel rolls. This equipment is easy to operate and fast speed.
2. Adopt PLC, return and push roll automatically, packing and sealing.
3. Equipped with touch screen man- computer conversation, display production parameter and producton malfunction on screen.
4. Photoelectric inspect, servo driving, pneumatic element and good quality bearing and knife tool.
Packing & shipping
in standard export packing wooden case(machine surface cover PE film, then pack by seaworthy wooden packing)
After-sale services
1. The machine will guaranteed for one year. We will replace the damaged spare parts (except easy damageable parts)within one year. After one year, we will trace the technology and quality for long time.
2. We will equipment the easy damageable parts with the machine.
Company information
Quanzhou Xinda Machinery Co. Ltd is located in the Quanzhou City, Fujian Province, China. Our company was founded in 1997. Beginning in the 1980s, we engaged in machinery manufacturing, main production toilet paper machine, napkin paper machine, facial tissue machine, and paper cup coaster machine manufacturing machinery. And we can also design and manufacture machine according to the customer's requirements. Including non-standard machine.


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Anyone else freaked out by the fact that our nightmare of a President is taunting North Korea's nuke-obsessed boy king? This is insanity we're dealing with here, and you don't poke it with a stick. When I am particularly stressed out, like I am after reading today's news, this image is where I go in my mind. We have such a spectacular world--why aren't we just happy, grateful, and deeply reverent of its beauty? Like, all the time? #oceanlove #voicesintheocean
I love my ocean tribe's photos of the universe below. This picture is from the sublimely talented @thomaspeschak. "There's another world and it's in this one." (Me, from #thedevilsteeth) #dolphins #ocean #voicesintheocean #magic 💙
Here we have--and I wish I were kidding-- *plastic utensils wrapped in plastic.* I saw this today in Manhattan and my knees buckled. Yesterday, a major science paper came out estimating that we have emitted *9 billion tons* of plastic since we invented the stuff around 1860, and here's the kicker: EVERY LAST MOLECULE OF IT IS STILL HERE. Plastic is far more tenacious than we knew. Single-use plastics are a scourge, a symptom of a major disease, a sign that we are not running this planet wisely (to say the least), a harbinger of doom. Based on what we know about plastic's longevity, its toxicity, and the harm it does to the natural world, we should be using it sparingly, and only for the most durable things--roofing tiles, heart stents, etc. Instead we use it as if it were ephemeral, like these plastic- wrapped polycarbonate forks and knives will simply vanish in a puff of smoke after we've used them. Instead, they will outlive our great-great-great grandchildren. Why can't we stop this? What the HELL is wrong with us? Oh, and by the way, for various reasons, only 10% of the plastic you dutifully toss in your recycling bin ever gets recycled. Most of it ends up in landfills or in the ocean. Calling anyone who gives a damn--we must stop it with this heedless, toxic habit. That is all single-use plastic is: a destructive habit. signsoftheapocalypse #sorryfortherant #fuckplastic #saynotoplastic
I wonder what it says about me that I see this image and think: *How incredibly beautiful.* And it reminds me of why I wrote the last line of The Devil's Teeth: "There's another world, and it's in this one." #sharks #thedevilsteeth #greatwhite #sublime


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If you use a wood or a plank for the decoration. Wood may be rotten you may use a mirror instead. Due to its durable and easy to clean. You may use a 4.5 inches to 5.0 inches mirror for a shelf and put bulbs or lights to make it look nice.
Light in the bathroom
A good bathroom should have enough light, especially if you don't want to pay a little more electronic bills. You should desire a bathroom to be more lighten it help reduce a moisture during daylight. In order to make you bathroom lighter you may use a window with a dense mirror or change bathroom wall with mirror. You may enjoy with surround nature.
Light from a lamp.
It is inevitable to have a lamp in your bathroom they are so many type of light bulbs its origin make a different color. Incandescent is an old bulb and common use nowadays. Halogen is newer and has many sizes and colors. They have Metal – Halide, Fluorescent or Fiber – Optics too.
Foyer decoration
Circle foyer decoration. Noting else could be better than decorate a floor with circle texture. If you put furniture in your little space room. You may find you room untidily. Incase you have as lager room you put your lovely sculpture or picture. Floor consist with granite and maple at the center of the floor its texture like Europe clock. By doing this it make circle texture delude your eyes and make it gibbously.


text: Mark, I gave you an IMF problem scenario a few weeks ago. Any progress in reproducing it and getting it on the way to a MSKB article? Thanks, Carl -----Original Message----- From: Mark Fugatt [mailto:markfu@xxxxxxxxxxxxx] Sent: Tuesday, December 27, 2005 7:20 PM To: [ExchangeList] Subject: [exchangelist] RE: IMF removal Andrew Please email me what the problem is with IMF. Mark Fugatt Dedicated Supportability Engineer (Exchange) Microsoft Limited Desk: +44 (0)118 909 5630 Mobile: +44 (0)7966 858108 MSN IM: markfu@xxxxxxxxxxxxxxxxx Blog: http://blogs.technet.com/mfugatt Dedicated to proactively supporting Microsoft's enterprise Customers


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The Hidden Benefits of Blogging
When I began to blog seriously a couple of months ago, my intention was to grow my audience, build a list, create joint venture relationships and, of course, to earn more money.
While some of those things have happened, it's not come as quickly as I'd hoped. At this moment, it's clear I'm not another John Chow and perhaps this is because I'm working in the travel niche, instead of Internet marketing.
Still, it's been an interesting journey so far. Part of my time has been spent creating relationships on the travel forums at LinkedIn and I've met some great people there. I've also been making use of social media with my posts.
For the most part I use facebook, LinkedIn, Twitter, Tumblr and Google+. So far so good, though I want to increase my reach.
Some of the hidden benefits of blogging are writing opportunities which have come up and having my blog read by people in other countries. I know the Internet is world-wide, but sometimes I forget and that can lead to pleasant surprises, like the link exchange with a blogger in Vietnam.
Then there's what happened with my living situation and so many people reaching back to me in ways I'd never expected. For a long time I've felt somewhat isolated (a downside of writing), but through blogging I'm making many friends and re-activating friendships which I'd thought were long gone.
I've really felt an enormous amount of love coming towards me from many places and this has spilled over into my offline life. I have no idea what's happening, only that my life is changing in many unexpected ways, and for the better.
I want to thank all of you who have read my blog and for your comments on the blog itself and to me, directly.
See you soon.
© Nathan Segal
1 responses to "The Hidden Benefits of Blogging"
Yes Nathan, my intention was the same to travel and make few money from blogging. But it has been a tough journey so far. But all the experiences you gain while traveling and the relationships you build with other travel bloggers, photographers, both online and offline and the things you learn from them is is so amazing.Good luck in you future endeavors.
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text:
FC Barca Zapped Psg (See Match details)
Football is magical, the sublime, the ridiculous and the historic.
There is no other way to describe the match, that may well be seen as one of the greatest match in the CHAMPIONS LEAGUE and certainly saw the greatest comeback as Barcelonia recover from the 4-0 first leg deficit to pull off a divine 6-1 victory over Paris Sain-German to go through quarter-finals
No side had ever come doown from 4 down in the first leg before, no can ever. Barcelonia did the unbelievable now through the next round
FT: Barcelona 6-1 PSG
Suarez (3'),
Kurzawa own goal (40'),
Messi (50'—pen),
Cavani (62'),
Neymar (88', 90'—pen),
Sergi Roberto (90+4')
Barcelona win 6-5 on aggregate
Barcelona: PSG:
Barcelona win 6-5 on aggregate
Barcelona: PSG:
Ter Stegen Trapp
Pique, Meunier (Krychowiak)
Mascherano, Marquinhos
Umtiti Silva
Rakitic, Kurzawa
Busquets, Rabiot
Iniesta (Arda), Verratti
(Sergi Roberto) Matuidi
(Sergi Roberto) Matuidi
Messi, Lucas (Di Maria)
Suarez, Cavani
Neymar. Draxler (Aurier).
WATCH Highlights
WATCH Highlights


text:
Previously: Aashima Enjoying Sex With Horny Sanju Mama - I
Once again I puffed in unjustified sensation but ultimately pushed him and came out of his grip. "Aashima…please Maan ja…I am requesting you…" Mama somewhat pleaded me to agree but in impolite tone and with that revealed the fact of his married life that and since Richa Mami has gone through her uterus removal
she has lost interest in sex and further told me that he has not done sex with her from last two years. Standing 3-4 feet away, no words and for few seconds I continued looking into Mama's eyes and he once again came close to me and embracing my waist pulled me closer. I tried pushing him but not very hard and this time Sanju Mama tried kissing my lips.
He was stinking because of alcohol and this time I pushed him hard. "Mama this is wrong….please ye sab matt karo" I spoke out in loud voice and Mama requested again "Aashima… please help me….mere bare mein bhi soch… Richa bilkul kuch nahin karti…what should I do….?" and I didn't have anything to say in reply.
I was silent and he continued telling his mental state and told me that he hates drinking and he wants to leave it forever but Alcohol is the only way he could see to tranquilize his mind. That was true, everyone among close family was worried about Mama's drinking habit and truly speaking what I could recall that since beginning he was a non drinker but from last 2 or two and half years
he was drinking consistently and according to Richa Mami slowly he was turning into a short tempered beast; that's what she told my mom without revealing the other side of the coin, that he has started drinking because she has stopped having sex with him. I stayed silent and remained lost in what he was saying and Mama once again came close to me and also grabbed me again.
I was unwilling but I don't know why I was losing strength to oppose him, I could shout, I could hit him and running away from him I could easily call my mother, but consciously or unconsciously I did not thought about doing anything like that, but why? For me it is an unanswered question even today.
Can't say this was the only reason why I surrendered myself to him but certainly it was one of the reasons. Since my childhood I have always liked Sanju Mama as a person, he is a tough man who has rose up in life just with his hard work, moreover he was special for me because my father was absolutely against my post graduation and wanted to marry me right after my graduation
but Mama has always inspired me to make my separate identity before getting into any such knot. Not only that, Mama was the one who was alone standing beside me when my father was saying no to me for independent job. Readers might find my thinking of that moment as an excuse of my lust, if not they might consider me foolish, I won't say they are wrong,
virtually I was behaving foolish because I was not trying to run or save myself. One arm around my waist and other hand over my shoulder, our face were closed and unconsciously I was in big shuffle within myself and Mama once again tried kissing me and his mouth fragrance staggered me once more and I pushed him another time.
Once again no words for few seconds, we just looked at each other's face, apparently his expressions were firm but I could read core of his heart, I wanted to help him but how can I do sex with him, after all he was real brother of my mom and I came out another hide out that if somebody will come to know about this it will be a big trouble
"Mama ye sab kisi ko patta chal gaya to problem ho jaayegi…" and Mama saw sign of hope in my words "I promise it will be always our secret…" he assured me with a tiny smile and I once again denied "Nahi nahi…mujhe nahin karna" "kyun nahin karna…you have do to…tujhe karna padega…" he tried dominating me in little rough and loud voice and my heart started pounding.
I was standing barely few inches away from him and momentary thought of me getting fucked by somebody close like Mama staggered me and I started sweating. Madly scared just in few seconds my fever was evident over my expressions and next instant Mama changed his temperament, moving ahead he once again took me in his arms and caressed my cheek tenderly,
I was nervous, worried and frightened still I felt bit of blissful sensation passing through my spine and next before I would have tried setting myself free Mama started kissing me all around my neck and ears and I once again puffed in undesired pleasure.
I tried pushing him but not with much strength and holding me hard he continued rubbing his lips over my soft skin and soon after neck he started kissing me all over my face and I cried in irritation of his stinking mouth "Mama aapke muhn se bahut gandi smell aa rahi hai…".
He stopped for a fraction, looked into my eyes closely and suddenly planted his lips over mine and started sucking them with all his passion and affection. I was lip locked and at my end I did my best preventing Mama from kissing me but holding my waist and clenching me hard against his chest Mama did not stopped sucking my lips.
He was gone crazy in lust and somewhere deep I was also feeling myself getting weaker, my breasts were getting crushed against his hard chest and along with feeling my melons getting heavier in excitement I could feel evident stiffness in my nipples. I was getting aroused, still I was not willing and keeping my lips closed I did not reacted to Mama's kiss at all.
After a minute of sucking my lips eventually he broke the kiss, I was thinking that he might scream over me for not responding to his kiss but he stayed calm, caressed my face softly and in the end came out with a promise that he will stop drinking if I will start fucking with him in really very weird words "Tu mujhse Chudwana suru kar de…I promise main Daaru peena chhod dunga".
Words he spoke were dirty but what he said was a big thing to take place, everybody in the family wanted that to happen but for that I could not justify myself being in sexual relation with him. "No…I can't do that…" I spoke that but in low voice, "You have to help me…tujhe karna padega…"
Holding my waist with both the hands Sanju Mama stayed firm over his demand and next instant I felt his hands moving down to my ass. I was already feeling aroused and his hands over my ass; over thin cloth of my capri shivered me intensely and with evident sweat over my face and neck I puffed while looking into his eyes.
"Dekh kisi ko kuch bhi patta nahin chalega….bus sirf ek baar mujhse achhe se Chudwa lay" "I promise main aaram aaram se karunga aur tujhe bahut mazza aayega" and after hearing all that I got further breathless. Weird and extremely shameless Mama was gone crazy in lust and I wanted to hit him for what he just said but I stayed jammed, possibly because his prior statement;
that he will stop drinking against having sex affair with me was also alive in my mind, I wanted to help him from coming out of his drinking habit but at any rate I was not ready give him consent of fucking me for that. Anyhow that instant it was not about what I wanted, it was about what he wanted and he wanted to fuck me somehow, he could sense that I am not revolting much,
moreover he could also feel that I am little aroused too and caressing my cheek tenderly Mama spoke that if I would have been virgin then he would have done nothing with me "agar tu Virgin hoti to main tere saath kuch nahin karta…but you have already done all this…" and in continuation he asked me to let him fuck once "ek baar mere saath bhi kar lay"
and hearing that unconsciously I did big mistake by asking him just once "Ek bar…?" and Mama considered my unnecessary question my acceptance and saying "Haan…bus ek baar" he instantly started kissing me again. Once again I was lip locked and this time I could feel that physically I am not protesting much,
certainly this fact that Mama will stop drinking if I will fuck with him was driving me into this, still I would say I was melting more because of my lust. As such I don't have any genuine reason for that desire still I would say biologically the time span I was going through was high as far as my sex hormones were concerned.
My periods were recently ended and I have noticed my sexual urge use to rise high at this time, moreover I use to confront with my seiner; my boy friend every month exactly in this span to nullify threat of pregnancy but this time my boy friend didn't got keys of his friend's flat to tranquilize mine and his own yearn and unluckily with that I was stuck in the situation
where I was literary failing to hold my undue sexual desire poking my brain. Don't know exactly from how long, but I was realizing that I am wet and while getting sucked over my lips slowly I was feeling releasing myself and in that hobble I don't when I opened my lips and Mama's tongue wiggled all around my mouth.
Once started Mama did not stopped for next 4-5 minutes, moving all around while releasing his tart saliva into me he pulled out my tongue into his mouth and sucked it. He was drunk and because of his deep and long kiss soon I also started feeling intoxicated, it could be physiological but it was significant and I don't know while kissing when Mama started squeezing my breasts.
As I realized his hands over my melons I tried pushing him and he broke the kiss, "Mama please leave me….!" I requested while swallowing his sour dribble into my mouth and knobbing his head Mama came out that now he will not leave me "NO! You have responded to my kiss….Ab main tujhe nahin chhodunga…"
and with that holding my ass with both the hands he tried lifting me abruptly and with a loud shocking hiss in fear of falling down I unconsciously wrapped my arms around his neck. Next Mama rapidly folded my legs around his waist and smiled while gripping me harder over my ass and I went through strange shivering till my soul.
"You know… jab tu chhoti thi aur jab bhi main tujhe godi mein leta tha…tu mere oopar susu kar deti thi…" Saying that when I was small and he use to uphold me I use pee over him every time; for an instant he spoke funny but I got nervous with his words but before I would have tried pushing him and jumping out of his arms to set myself free he stared to walk towards h is bedroom.
"Mama please leave m e…" I fluttered a bit on the way to his bedroom and finally throwing me on his soft spongy bed he once again tried coming out with humor; that he wants to see the place from where I use to pee over him "Mujhe teri wo jagah dekhni hai jahan se tu mere oopar Susu karti thi…." and soon after saying that Mama started taking off his clothes.
Being a sexually experienced girl I would say Mama has an amazing body. Standing almost six, with bit of belly, his arms and forearms are thick, shoulders wide and strong; his chest is hairy, broad and deeply cleaved. Thick dark hairs along with dark mustache but cheeks and chin clean-shaven,
altogether Sanju Mama is a very good looking male with very caring nature and it will not be exaggeration at my end that if he wouldn't be my Mama then possibly I would have fucked with him with complete consent. Anyway that particular instant I was not at all looking at his gorgeous body, I was nervous and madly confused,
I could feel evident heaviness and wetness over my breasts and cunt, which meant that I am aroused but I was yet not ready surrender and as Mama took off his t-shirt I tried to drift back. "Kahan Jaa rahi hai meri Jaan…" Saying that Mama moved forward swiftly and holding my both the ankles pulled me hard and I was flat on his bed over my back.
After that he took off his lower and before I would have thought about running again he climbed on the bed with just jockey over his body.
To Be Continued...
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Supplier Homepage Product List Drawer lock (Hl508P) Furniture Office Desk Drawer Lock Cabinet Lock
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Omnicare Won't Accept "No."
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Packed Red Blood Cell (PRBC) transfusion is associated with Acute Lung Injury (ALI) development after trauma, but this risk may not be constant through time after trauma. We hypothesized the relationship between PRBC delivery and ALI risk varies through time after injury.
Data were collected prospectively from 1999–2006. Inclusion criteria: age > 13 years, SICU admission, and injury severity score (ISS) ≥ 16. Exclusion criteria included discharge/death within 24 hours of admission. Patients were followed prospectively for ALI development for 5 days after trauma. Discrete time models were fit to test the association of timing of PRBC delivery with development of ALI while controlling for patient demographics, resuscitation variables, ISS, and APACHE III scores.
At total of 602 patients were included. Median age was 33 years, 77% were male, and 50% were African American. Using a discrete time-survival model, the relation between transfusion and ALI development was found to vary by transfusion time-window (p<0.0001). The major effect of PRBC delivery on ALI risk occurred in the first 24 hours after trauma; this finding persisted in multivariable modeling (adjusted OR = 1.07 per unit; 95%CI 1.02–1.11, p<0.001). Cumulative incidence of ALI approached 50% in patients receiving ≥ 6u PRBC in the first 24 hours.
The association between PRBC transfusion and ALI development in trauma patients is time-dependent, with PRBC delivery in the first 24 hours after injury driving the overall relation. Each PRBC unit during this time period increases odds of subsequent ALI development by 7%.
Injury remains one of the ten most common causes of death worldwide1, with exanguination being responsible for over 50% of all deaths after trauma. Advances in transfusion medicine over the past century have lead to the survival of patients who would have otherwise died, but at the cost of morbidities related to transfusion therapy. Risks of transfusion include hemolytic reactions, transmission of blood-borne diseases, hypothermia, and immunosupression2. In trauma patients, transfusion is associated with increased rates of infection3, organ failure4, and mortality.5
Blood transfusion is recognized as an important risk factor for the development of acute lung injury (ALI) after trauma5–7. The impact of packed red blood cell (PRBC) delivery on ALI risk after a trauma may vary through time; prior studies demonstrating an association between packed red blood cell transfusion and the development of ALI focused on transfusion in the first 24 or 48 hours of hospitalization and were unable to assess whether the association varied during the days following traumatic injury.
We sought to better understand the relationship between the timing of PRBC administration and ALI development. We hypothesized that the relationship between PRBC delivery and risk of ALI after trauma varies by time after traumatic injury and that the majority of the risk of transfusion is incurred early after traumatic injury.
A prospective cohort study was conducted at the Hospital of the University of Pennsylvania (a state-designated level I trauma center) from June 28, 1999 to November 20, 2002 (ARDS I study) and again from October 1, 2005 to April 30, 2010 (ARDS II study). All critically ill trauma patients presenting to the hospital's emergency department (ED) and admitted to a surgical intensive care unit (SICU) were studied to determine clinical and molecular factors associated with the development of ALI 8. The two year hiatus was due to a funding gap. All subjects over the age of 13 admitted to the SICU from the ED with severe trauma as defined by an injury severity score (ISS) ≥ 16 were eligible. Major exclusion criteria included discharge or death within 24 hours of admission, or the presence of an isolated head injury (defined as an Abbreviated Injury Score ≥ 3 for head/neck but ≤ 1 for all other body regions). Patients were also excluded if they had current or prior congestive heart failure, respiratory disease, morbid obesity, were burned over >30% of total body area, or were lung or bone marrow transplant recipients. Funding for this effort was provided a prior National Institutes of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI) Specialized Center of Research (SCOR) in ALI/ARDS (grant number P50 HL60290) and continued with funding by NIH NHLBI P01-HL79063.
The institutional review board for the University of Pennsylvania reviewed and approved this study with waiver of informed consent. All patients were followed prospectively for the first 5 days following ICU admission after acute trauma for the development of ALI. All blood gas, clinical laboratory, and ventilator data from admission through day 5 in the SICU were recorded using specific case report forms designed for the trauma population. To be designated as having ALI, subjects had to meet all American-European Consensus Conference (AECC) definition criteria within a 24-hour period while endotracheally intubated and receiving mechanical ventilation. Determination of ALI was made by two physician investigators who underwent training to standardize chest radiograph interpretation and independently reviewed all arterial blood gas and ventilator data without knowledge of transfusion or other clinical variables9. Time was windowed into 24 hour periods after admission with day '0' being defined as the first 24 hours after ED admission; day of onset of ALI was defined as the 24 hour time period after admission in which criteria for ALI were first met.
Logistic regression models were fit to test the association of recent PRBC delivery with development of ALI while adjusting for potential baseline confounding factors. Potential confounders considered included age, ISS, mechanism of trauma (blunt vs. penetrating), sex, ICU admission APACHE III scores, and amount of crystalloid fluids delivered. The exposure of interest was the transfusion of PRBC coded as a dichotomous factor of any transfusion received. To achieve a parsimonious model, we excluded variables that did not affect the association of PRBC and ALI, as indicated by a change in odds ratio of greater than 15% on adjustment10.
Subjects who were diagnosed with ALI within 6 hours of PRBC delivery could theoretically have been considered to have transfusion related lung injury (TRALI). To assess the possible contribution of TRALI to the overall incidence of ALI in this cohort, any patient who received PRBC in the 6 hours immediately prior to meeting the criteria for diagnosis of ALI was labeled as possible TRALI (P-TRALI) as per 2004 consensus criteria11. In a sensitivity analysis to assess for the potential impact of these cases, we repeated our analyses after removing these patients.
The development of "damage control resuscitation" paradigms in which PRBC, fresh frozen plasma (FFP), and platelets are transfused in predefined ratios occurred prior to this study. Our own institutional massive transfusion protocol (MTP) was initiated in 1999 and called for PRBC, FFP, and platelets to be delivered in a 10:6:1 ratio in the first cycle of delivery; subsequent cycles of delivery call for units in a 6:4:1 ratio. These cycles of delivery occurred until discontinuation was requested by the attending trauma surgeon. To further assess the impact of the ratio of blood product delivery on ALI, the ratio of FFP to PRBC was calculated and binned into a categorical variable. Logistic regression analysis was used to examine the relationship between product ratio and the development of ALI using patients who received no products as the referent category.
To address the timing (day) of ALI onset and the observed follow-up time (six days total), we implemented a discrete time failure model of the probability that on any day a patient developed ALI, given that the patient was ALI-free on all prior days. This model allowed us to derive an odds ratio assessing the odds of developing ALI on each day, given being "ALI-free" the previous day (it is conceptually similar to Cox's proportional hazard model12). We implemented this model using the GENMOD procedure in SAS by entering daily PRBC separately in the model. Heterogeneity of PRBC over study days was assessed. To address the potential bias attributable to patients receiving PRBC as a function of other baseline factors that might also be related to ALI in the above modeling framework, we also implemented marginal structural models13. This method estimated inverse probability weights (IPW) with respect to the probability of receipt of PRBC for each patient. These weights were then used in the response model of the association of PRBC (and other factors) and the development of ALI. This method of weighted regression was used to control for the potential confounding among the baseline factors and the receipt of PRBC on estimates of factors leading to the subsequent development of ALI. Parameter estimates for the marginal model were empirical estimates from the generalized estimating equations (GEE) model implemented using data as appropriate from the discrete time failure model.
Due to a funding gap, patients in this study were enrolled from two different time periods (June 28, 1999 to November 20, 2002 and from October 1, 2005 to April 30, 2010). To ensure that changes in clinical care through time did not have an impact on our findings, we repeated the analyses for the overall cohort to patients from each time period and found no significant changes in our point estimates or confidence intervals.
A total of 609 patients met eligibility criteria and were enrolled in the study. Transfusion data were unavailable on 7 patients, leaving 602 patients for analysis. Patients in the cohort tended to be young (median age 33 years), male (77%), and were equally split between African American and Caucasian (Table 1). Compared to patients who did not develop ALI, patients in the ALI group were more likely to be older (median age 38 (IQR 23–50) vs. 33 (IQR 23–47) years), have a blunt mechanism of injury (73% vs. 66%), to be more severely injured (median ISS 25 (IQR 20–29) vs. 22 (IQR 18–27)), and to have a greater degree of physiologic derangement as measured APACHE III scores (median score 65 (IQR 52–77) vs. 58 (IQR 48–71)). When the contribution of the arterial blood gas was removed, APACHE III scores were similar between the two groups (58 (IQR 49–72) in ALI group vs. 56 (IQR 46–67) in non-ALI group)).
In univariate analysis, APACHE III score, ISS, pulmonary contusion, and blood products delivered at resuscitation were associated with the development of ALI (Table 1). Using logistic regression, we examined the risk of ALI across the range of ISS seen in our subjects and found that there was an inflection point in ALI risk corresponding to an ISS of 28, above and below which ISS scores were linear in the logit for ALI risk. Injury severity scores below 28 were not found to be significantly associated with the development of ALI, whereas an ISS ≥ 28 was found to contribute significantly to the development of ALI (OR 1.2 per 5 ISS points, 95% CI 1.01–1.60).
Age, sex, race, mechanism of injury were not found to be associated with the development of ALI. Patient comorbidities of alcohol use, diabetes, hypertension, respiratory disease, and smoking status were also not found to be associated with ALI development, likely due to small numbers of subjects with these exposures.
Nearly 20% of patients who developed ALI received greater than 6 units of PRBC, compared to 7% of patients who did not develop ALI. Similarly, the number of fresh frozen plasma (FFP) transfusion units were greater than in those who developed ALI than those who did not (50% vs. 33%), while platelet transfusion volume was similar between the two groups. Ratios of FFP:PRBC in patients who developed ALI and those who did not were not significantly different and were not associated with the development of ALI (Table 2). Patients who developed ALI tended to receive greater volume of crystalloid and blood products than those who did not. Median crystalloid volume infused was 2.3L (IQR 0.7–5.0L) in the ALI group vs. 2.7L (IQR 0.4–5.1L) in the non-ALI group, but this was not significantly associated with the development of ALI.
Possible TRALI was identified in 7 out of 184 patients who developed ALI after receiving PRBC within 6 hours prior to diagnosis of ALI. Repeating our analyses with these cases censored did not demonstrate significant changes in univariate analyses.
During the course of the study, individuals who died, were transferred out of the ICU, or developed ALI were censored from the next study day's analysis. The number of patients at risk per day of the study is shown in Table 3. Focusing on repeated delivery of PRBC over the ICU period using the discrete time failure model, we found that PRBC transfusion beyond the first 24 hours after ED admission was not consistently associated with subsequent development of ALI. Assessment the risk of delivery of FFP on ALI risk was confounded by collinearity with PRBC delivery and therefore could not be included simultaneously in the multivariable model as PRBC delivery. The strength of the association between ALI and transfusion was dependent on the time-window for the transfusion of PRBC.
The overall number of PRBC transfusion per day was not found to have a significant effect on subsequent development of ALI (Chi (1) =0.06, p=0.80). However, including the interaction of the effect of interest (PRBC) and time yielded a significant interaction (Chi (4) =819.70, p<0.0001), indicating that the effect of PRBC on ALI risk was modified by day of transfusion. The degree to which amount of daily PRBC delivery impacted on of subsequent development of ALI was therefore dependent on the study day in the ICU; the effect of PRBC delivery in this model was driven by the amount of PRBC delivered during the first 24 hours. We therefore included the number of units of PRBC transfused during the first 24 hours as a risk factor variable in our discrete time survival model and found a significant effect (Chi (1) =13.37, p=0.0003) and OR=1.07 (95% CI: 1.03 – 1.11). Therefore, with each additional unit of PRBC at resuscitation during the initial 24 hours the odds of subsequent ALI development increased by 7%. Because some patients received uncrossmatched PRBC the first 24 hours, we assessed the relationship between uncrossmatched PRBC delivery and ALI risk. In our final model, uncrossmatched PRBC delivery was not found to be associated with risk of ALI in (Chi (1) =2.81, p=0.094). Adjusting for age, ISS, sex, mechanism of trauma (blunt vs. penetrating), APACHE III score, and total fluids delivered during the resuscitation period, yielded a similar effect (Chi(1)=10.52, p=0.0012, OR = 1.07(95%CI: 1.02–1.11). Similarly, implementing the marginal mode to control for the potential confounding of the delivery of any blood product yielded a similar effect (Z=3.68, p=0.0002, OR=1.08 (95%CI: 1.04–1.13).
In univariate analysis, pulmonary contusion was found to be significantly associated with the development of ALI. To examine the effect of pulmonary contusion on the PRBC-ALI relationship of our above results, we examined the consistency of the relationship for both groups and found consistency of the effect of PBRC in the Pulmonary Contusion group (OR=1.07 (95% CI: 1.01–1.14) and the No Pulmonary Contusion group (OR=1.07 (95%CI: 1.02–1.12).
To examine the effect of the dose of PRBC transfused in the first 24 hours on the subsequent cumulative incidence of ALI, PRBC transfusion was binned in to 0, 1–3, 4–5, and >6 units of PRBC in the first 24 hours. The distribution of transfusion of PRBC showed a heavy positive skew, with more than 60% of patients receiving no transfusion in the first 24 hours. Overall, 17% of patients received 1–3 units of PRBC, 8% of patients received 4–5 units of PRBC, and 11% of patients received ≥ 6 units of PRBC in the first 24 hours after presenting to the ED (Table 1). Cumulative incidence rates of ALI during the ICU study period varied as a function of the amount of PRBC delivered within the first 24 hours (Figure 1). Transfusion of any amount of PRBC in the first 24 hour time period was associated with an increased risk of ALI at 24 hours. By 48 hours, the cumulative incidence of ALI was no longer statistically different between patients receiving no PRBC transfusion and those receiving 1–3 units. At 72 hours, the cumulative incidence of ALI was no longer statistically different between patients receiving no units of PRBC and 4–5 units of PRBC. Patients who were transfused >6 units of PRBC in the first 24 hours exhibited a steep rise in the cumulative incidence of ALI between 24–72 hour time period and had a significantly greater cumulative incidence of ALI than all other transfusion groups throughout all days of the study. At day 5, the cumulative incidence of ALI in the > 6 PRBC transfusion group was 53% and was found to be significantly higher than in the 4–5 unit PRBC transfusion group (30%), the 1–3 unit PRBC transfusion group (29%), or the no PRBC transfusion group (27%), (p < 0.001 for each group).
In this prospective cohort study of patients who sustained severe trauma, transfusion of PRBC was associated with an increase in subsequent risk of development of ALI when transfusion occurred within the first 24 hours after ED presentation but not during other time periods. Furthermore, patients who received any PRBC transfusion during the first 24 hours were nearly twice as likely to develop ALI compared to those who received no PRBC transfusion at all during the first 24 hours after ED admission. While there are other studies that demonstrate an adverse impact of transfusion after trauma, ours is distinguished by a rigorous definition of ALI (prospective collection of data, dual independent physician review of radiographs, blood gasses, and ventilator data). In addition, our study is the first study to use a discreet time failure model methodology to prospectively examine the time-dependent relationship between transfusion and risk of ALI. Therefore, we can more confidently state that the risk of ALI conferred by transfusion occurs most strongly due to transfusion within the first 24 hours after admission and not in the following days.
Our findings regarding the relationship between RBC transfusion and the development of ALI after trauma are consistent with previous studies that did not use time dependent models. Silverboard et al. found that the number of units of PRBC transfused in the first 24 hours was an independent predictor of ALI in severely injured trauma patients (ISS>16). They found that 21% of patients who received 0–5 units, 31% of patients receiving 6–10 units, and 57% of patients receiving >10 units developed ALI. This effect was differential by mechanism of injury, with blunt trauma patients having a lower transfusion threshold to develop ALI5. This study found no association between markers of concomitant shock (as measured by APACHE III scores, base deficit, and use of vasopressor in the first 24 hours) or thoracic trauma and the development of ALI, but the sample size was relatively small (n=102). Chaiwat et al. found that with respect to patients receiving no blood products, patients receiving 1–5, 6–10, or >10 units of PRBC had an OR of 1.88, 2.48, and 2.62 of developing ALI, respectively14.
In our cohort ISS was not found to be consistently associated with ALI development across the entire range of values; for ISS from 16–27, ISS was not significantly associated with the development of ALI. Because the physiology associated with severe injury may be more directly associated with the development of ALI than the injury per se, we also attempted to control for deranged physiology using APACHE using APACHE III scores. Even after controlling for ISS and APACHE III scores, transfusion of PRBC in the first 24 hours was found to be significantly associated with ALI development. Because the abnormal results of arterial blood gas (ABG) measurements contribute to both ALI and APACHE III this analysis was then repeated with using the APACHE III score without ABG with similar findings. These results were similar to those observed by other authors15.
To assess the association between PRBC delivery and ALI risk in a timeframe more remote from acute hemorrhage and injury, Croce et al. found that delayed transfusion was still associated with an increased risk of ALI in a cohort of blunt trauma patients with an ISS of less than 25. In this study, patients who received transfusion within 48 hours of admission were excluded, those patients with delayed transfusion were still found to have increased risk of developing ALI compared to those who did not (OR 3.42; 95% CI 4.02–34.12, p<0.0001).16 A large sample size (n=1040) allowed for ample statistical power to detect small differences; the overall incidence of ARDS in this delayed transfusion cohort was 1%, with an incidence of 0.2% in the non-transfused vs. 2.8% in the transfused group. Our study failed to confirm the effect of transfusion outside of the first 24 hours on subsequent development of ALI, possibly due to our smaller sample size or shorter duration of follow-up. While the short length of follow up may have limited our ability to study longer-term associations between transfusion and ALI, it did allow us to assume that the ALI cases we studied were temporally related to traumatic injury.
There are several putative mechanics through which transfusion may contribute to the subsequent development of ALI. With storage, the plasma membrane of PRBC become less deformable and may "sludge" or lodge in tissue capillary beds after transfusion, directly contributing to local tissue hypoperfusion17. In addition, lipids that accumulate during storage of PRBC may directly activate neutrophils that may become sequestered in the lungs early after trauma leading to neutrophil mediated injury to pulmonary parenchyma18. When ALI occurs within 6 hours of transfusion in the absence of other identified risk factors for ALI, the diagnostic criteria for TRALI have been met11. If other putative risk factors are present such that the development of ALI cannot be definitively ascribed to transfusion, P-TRALI is said to occur. TRALI may result from neutrophil-mediated damage to the pulmonary vascular endothelium. The 'two-hit hypothesis' holds that a primary stimulus (such as trauma or surgery) causes pulmonary sequestration of neutrophils followed by a pro-inflammatory stimulus as a result of blood transfusion; this in turn leads to neutrophil activation and local tissue damage, causing fluid and protein to leak into the alveolar space19. There are inherent difficulties with the diagnosis of TRALI and P-TRALI secondary to timing of the diagnosis of ALI. Timing of transfusion was relatively straightforward to capture, but the time at which a patient met criteria for ALI was in part determined by the timing of laboratory values and available chest radiographs. Within these constraints, to the best of our estimation P-TRALI consisted of only 3.8% of cases of ALI after transfusion and repetition of our analysis with these removed did not significantly affect the association between PRBC delivery and ALI.
Evidence of a dose effect for PRBC transfusion on subsequent development of ALI has been suggested by previous studies5,14. Using our continuous risk model we were able to examine the cumulative risk of ALI through the first 5 days of admission by number of units of PRBC transfused. In all categories of PRBC transfusion, the majority of patients who will develop ALI have done so at the end of the first 24 hours, with cumulative incidence rising and additional by 3–5% per day thereafter. In contradistinction, patients who were never transfused exhibit a more linear rise in ALI incidence across the study period. This suggests a synergistic effect between risk of transfusion and other risk factors at play in the first 24 hours. An obvious approach to mitigate ALI risk in this patient population would be to minimize PRBC delivery in the early ICU course. Previous studies of attempts to restrict transfusion in critically ill patients have shown benefit. In 1999, Hebert et al reported the results of a randomized controlled trial which demonstrated a reduction in in-hospital mortality for ICU patients receiving a restrictive (target hemoglobin 7.0 to 9.0 g per deciliter) vs. liberal (target hemoglobin 10.0 to 12.0 g per deciliter) transfusion policy. Although there were decreased ARDS rates in the restrictive vs. liberal transfusion group, this did not reach statistical significance (7.7 vs. 11.4%, p=0.06)20. A post-hoc analysis of trauma patients in Hebert's original trial demonstrated no difference in mortality or organ dysfunction scores between the two transfusion groups, but ALI rates were not specifically examined in this study21. No studies exist in on restrictive transfusion policies early after trauma; it is obvious that this approach must viewed with extreme caution secondary to risk of ongoing bleeding early after injury.
While in univariate analysis both PRBC and FFP delivery within the 24 hours of injury were both associated with the development of ALI, we did not find any significant association between in ALI risk and ratios of FFP to PRBC; that is, 'damage control resuscitation' did not appear to change the risk of ALI. The current literature examining the role of blood product ratios in trauma patients does not specifically address how transfusion ratios are associated with ALI risk, but our finding of that high FFP:PRBC ratios is not associated with subsequent development of ALI must be interpreted with caution. Use of blood product ratios as a predictor of ALI risk is limited as the ratio itself does not account for the overall volume of blood products delivered, which is a known predictor of ALI. Due to significant collinearity between PRBC and FFP delivery during the study period, only one variable could be included in the construction of a parsimonious multivariable model. Because PRBC delivery was found to be a more strongly associated with ALI development than FFP delivery, only PRBC delivery was included in the final multivariable model.
This study has several limitations. While other authors have reported FFP delivery may contribute to the development of ALI22, we cannot specifically comment on this relationship because of collinearity between PRBC and FFP delivery. For the same reason, the ratio of FFP:PRBC did not influence the development of ALI. As this study is observational in nature, we cannot report a causal relationship between PRBC transfusion and ALI. It is possible that the association we describe is related to predictor variables not captured by our study. Transfusion is intertwined with patient physiology, and it is possible that hemorrhagic shock and not the blood transfused in response contributes to the development of ALI (confounding by indication). We have attempted to control for this by using the ISS and APACHE III scores, but ultimately these may not adequately risk-adjust this cohort of patients.
The way in which blood is processed and stored may have implications for the development of transfusion related complications. Specifically, older blood products and non-leukoreduced blood products have in some series been shown to be associated with the development of ALI. While we do not have data on the average age of blood products, there were no systemic changes in the collection or storage of blood that would predispose to changes in the average age of PRBC units across the study period. The use of leukoreduction has gradually increased over the past 10 years and now approaches 90% at our institution, but we do not have specific data on whether or not individual units of PRBCs were leukoreduced. However, since the literature on the impact of leukoreduction on outcomes after transfusion is mixed 23–25 and no study has specifically focused on the impact of leukoreduction on ALI after transfusion in trauma patients, there is no overwhelming argument that the amount of leukoreduced blood a subject received must be controlled for when examining ALI as an outcome. Finally, because this is a single-center study, our findings may not be generalizable to other institutions.
Risk of transfusion of PRBC on the subsequent development of ALI varied within the period after injury. PRBC transfusion in the first 24 hours after injury but not thereafter independently predicted subsequent risk of development of ALI in a dose-dependent fashion. Transfusion of >6 units of blood in the first 24 hours after injury was associated with a cumulative incidence of ALI of >40% after 24 hours; this rate increased to >50% by post-injury day 5.
This research was supported in part by National Institutes of Health National Heart, Lung, and Blood Institute grants P50- 60290 and P01-HL79063.
This work was presented as a poster presentation at the 2011 Society for Critical Care Medicine meeting in San Diego, CA.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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Shoes For Crews Mens Cabbie Canvas Lace Up Boot
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High grade aisi 304 stainless steel exterior & interior With glass structure Wet well accepts gn1/1 upto 150mm depth (not supplied) Wet well bain marie with easy access drain tap Fan assisted 130w halogen lamps Digital controller with temperature display Supplied with perspex sliding doors to rear of display area
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Dualit's 11 Litre Hotpot soup kettle can be used with either wet or dry heat and incorporates a double pole variable simmerstat. Like the 10 litre...
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Iconic Kiwi company, Christchurch-based Cookie Time Limited, has launched a limited edition version of its original Chocolate Chunk cookie as it throws its weight behind the Love Christchurch Made campaign.
The specially packaged cookie, featuring the red and black Love Christchurch Made tag, will be available at more than 6000 retail outlets throughout New Zealand for the next six months.
The aim is to encourage people to buy Christchurch-made products, and help get the city back on its feet as it continues to deal with the impacts of two major earthquakes and ongoing aftershocks.
Cookie Time general manager Lincoln Booth said local businesses needed support now as much as ever.
"Nearly 12 months down the track from the first major earthquake, many companies are back on their feet but still need ongoing support."
While the company was back to full production two weeks after the devastating February earthquake, many staff had their homes damaged and its franchised distributors with Christchurch runs remain affected by lower demand as people move out of the area.
"Since February, we have donated more than 25,000 cookies and bars to the relief effort. Now we want to look at ongoing ways to help our city and rebuild our local economy," Booth said.
"As a proud family-owned, Christchurch-based business, we want to see our city once more become a vibrant centre."
He said using the strength of the Cookie Time brand to promote the cause made sense and would have flow-on benefits for its Christchurch suppliers as well.
The Love Christchurch Made campaign is a BusinessNZ initiative designed so that consumers can be sure they are buying from Canterbury companies.


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February 2013
Changes Coming to Personal Data Protection Institutions
On 12 February 2013 a draft law "On Amendments to the Laws on Improvement of the Institutional System for Personal Data Protection" (the "Draft") was submitted to the Ukrainian Parliament by the Cabinet of Ministers.
The Draft provides for the liquidation of the State Service on Personal Data Protection and transfer of all of its key functions to the Ukrainian Parliament's Human Rights Commissioner (the "Ombudsman"). Registration of the personal databases will be performed by the State Registration Service and supervised by the Ministry of Justice of Ukraine.
Currently, the Ombudsman already has the power to exercises parliamentary control over the observance of human rights to personal data protection, however, if adopted, the Draft will extend the Ombudsman's powers, including those related to inspections, settlement of the relevant claims, etc.
The Draft also extends the list of administrative offences in this field and increases the penalties.
Since the Draft was put forward by the Cabinet of Ministers the chances are rather good that it will be adopted by the Parliament.
For further information please contact partner Oleksandr Padalka
© Asters 2013


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Beautiful plots in Hassan Perwana colony.Near Khabren News+Honda Atlas Front 40 feet for 10 merla and Front 80 feet for 20 Marla Near Khbren Akhbar office and Honda Atlas Office Near to Cant Nice area for residence. Near Cant Railway Station. Cantt Bazaar.Dera Adda Chow
Mubashar Ali
Business Name:
Hassan Parwana Colony, Multan, Punjab
|Property ID: 38197
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Based on the acclaimed book "History on Trial: My Day in Court with a Holocaust Denier," DENIAL recounts Deborah E. Lipstadt's (Academy Award winner Rachel Weisz) legal battle for historical truth against David Irving (Cannes Award winner Timothy Spall), who accused her of libel when she declared him a Holocaust denier. In the English legal system in Defamation, the burden of proof is on the accused, therefore it was up to Lipstadt and her legal team to prove the essential truth that the Holocaust occurred. Also starring two-time Academy Award nominee Tom Wilkinson, the film is directed by Emmy Award winner Mick Jackson ("Temple Grandin") and adapted for the screen by BAFTA and Academy Award nominated writer David Hare (THE READER). Producers are Gary Foster and Russ Krasnoff.
Trailer: here
More info: here
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Answering Your Non-Qualified Questions
Are you looking for a simple way to explain how Liberty Life's non-qualified assignment program works? This video explains how the non-qualified assignment process works, the tax advantages, and the relationship between BARCO Assignments Ltd. and Liberty Life.
Structuring LTD Claims
Our Structured Settlement program offers an innovative way for disability carriers and claimants to settle long-term disability claims with a periodic payment option. This video will explain the benefits of settling with period payments and how the process works.


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Contact Info / Websites
- Skype
- zombielsayer102
All 134 game Reviews
EmMaze! The Grow Game Parody!
Rated 5 / 5 stars
<3 your work emma :)
Haha thank you very much!
Rated 5 / 5 stars
its simple its fun and its got the most insane replay value you can imagine. i love this game.
Rated 4 / 5 stars
just a heads up the characters name is Bloo not blue.
Haha, I made this on purpose so that people comment on my game... I win.
Even though you're the only one that spotted it.
Lognes Island
Rated 3 / 5 stars
the concept is good. but it is really unpolished and difficult to play the movement is a bit fast you glitch on ladders and the hitboxes for the coins might be too big as i got coins out of destructible boxes without breaking them. like i said its good its just not there yet.
yea I agree. thanks for the feedback!
Rated 2 / 5 stars
I have To agree with Vayday here. you have basically told a run of the mill story that the player has zero affect upon... its touching like most games of its kind and it is cool for being 4bit with 16 bit sound but as a game it has absolutely no substance.
its like needing a balanced diet and eating nothing but grains and vegetables with a huge serving of desert (being the games completion) but you wanted that main dish you wanted the meat and that's what is missing here. if the process of collecting things had effected the story in some way it would have made the experience much more meaningful. you have accomplished something really cool but it is only your accomplishment you've given the player no reward for actually playing this should have been submitted as an interactive movie if there is such a thing.
it was good but take these comments as a lesson and learn from them strive to make something people can genuinely enjoy and have and actual experience with. you have here a delicious cake that only you can eat we can only watch you eat it we want a slice too. :)
I'm got the point, thx~
Rated 5 / 5 stars
please help the world newgrounds by telling the guy below me to stop being a grammar nazi douchebag...
ANYWAY. i think you kinda over stated your point you should have made the game draw out a bit more than what turned out to be a half a level.
Going Blind
Rated 5 / 5 stars
a wonderful tribute to mans best friend who gives us the greatest gift they can and thats there love and loyalty which they give without being asked. you notice how it becomes more difficult as he goes more and more blind. its touching... a dog doesn't complain when he hurts or cannot see. he just continues on. even when hes blind he knows its your hand on his head he knows its your scent in his nose... he loves you because you love him. thanks for this.
A Dance of Fire and Ice
Rated 5 / 5 stars
this game is fantastic its simple but challenging clean simple images its a truly awesome bit of work you have here the level im on is hard as shit though.
The Deepest Sleep
Rated 5 / 5 stars
here goes.
Ive been voracious for this one i loved the first two it tells a creepy story but i have to admit this one was the easiest and frankly the shortest in the series. i'm sad to see it end. but you did end it well i just wish for all the time i can only assume you spent on this it would have been harder. the hardest part was the stone puzzle. this series after playing all three decidedly hit its stride in the second game.
Its one of the better play along games like this ive played the only one coming close is the first two exmortis games the third was a sell out for money and added things like combat to the game and ruined it. so kudos on a strong story finish if not a seemingly half hearted game finish. i gotta give you 5's because all in all you told an amazing story. consider doing more like this please.
You Are Disabled
Rated 5 / 5 stars
Fuck you for making me remember all those years of throwing down my controller in anger whilst playing mega man. this was a great little game diffrent disabilities and walking though the maze was something unique it give you some small appreciation for those who are disabled. good stuff.


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On your bike
The real villains of London's streets are the "professional" cyclists, who treat it as an extreme sport
Sir, Sure, Boris's blue bikes are a bit clunky and safe cycling in London probably demands more of the rider than in, say, Paris, with its wide boulevards ("My message to the novice cyclists: get off your bike", Joanna Sugden, Thunderer, Aug 11). But, having subscribed to the scheme from the start, my wife and I, and thousands like us, find these bikes a liberating experience, filling a niche between the cab and the bus. It may be the best thing Boris has done. We are reasonably wobble-free, our hair is quite short, we don't wear flip-flops and we have never been to Center Parcs. My wife prefers trousers to the maxi-dress, as do I.
But you don't have to ride a bike to know…


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Store's Best Items
|farmasi parkcity@medicalsupply
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11street receives report on products to protect buyers' right. For further information on safe trade, please contact us.Reportgo
For order related and other issues, kindly click on E-mail Enquiry here.E-mail Enquiry
Cerumol Ear Drops is for the loosening and removal of ear wax.
5 drops to be instilled with the head inclined, preferably when lying down. Repeat twice a day for up to three days. Unless the ear wax is unusually hard, it should run out of its own accord. If not, consult your doctor for possible syringing.
Arachis Oil 57%, Chlorobutanol 5% Contra
Not Available
For external use only. Store below 30 degree Celcius. Cerumol contains Arachis oil (peanut oil). If you are allergic to peanut oil or soya, do not use Cerumol. The ear is a delicate organ. You are advised to consult your doctor in all cases of ear disorder before using any ear drops. Use within six months of opening. Not to be used when there is inflammation of the ear or if the eardrum is perforated.
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|farmasi parkcity@medicalsupply
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Delivery :
• Delivery will take place 2 to 7 working days after Order date. Any changes to the shipping and/or billing address is not possible once the order has been received.
• FREE DELIVERY is ONLY applicable within Peninsular Malaysia.
• Additional Surcharge for shipment to East Malaysia RM15.00 is applicable .
• Free delivery is only for the first initial shipment. Customer will need to bear the Re-delivery of returned parcel.
• Customer must inspect product immediately upon arrival to ensure that the product is in good condition. DO NOT accept if packaging is severely damaged or tampered with.
• Warranty is within 1 week from date received.
Return Policy: 7 days return or exchange policy
• If you are NOT 100% satisfied with your purchase for any reason, we will gladly accept returns of packages within 7 days of the order date and issue a full refund.
• All we ask is that the product is...
o not used
o in the same cond
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- Check seller's approval on buyer's request.
- Buyer sends product in question to seller.
- Seller receives and checks returned product
- Seller approves return and return is completed.
- Request for exchange within 7 calendar days following receipt of delivery.
- Check seller's approval on buyer's request.
- Buyer sends product in question to seller.
- Seller receives and checks returned product
- Seller send new product to buyer, and buyer receives it, and exchange is completed.
How to Request for Cancellation/Return/Exchange
You can request for cancellation after completing payment and if product has not been dispatched by then, cancellation request is approved and you can receive refund.
But, in case seller has already dispatched product, cancellation request can be rejected.
You can request for return after obtaining product, you should send the product in question to seller.
After seller checks if returned product is flawed, and approves your request, return is completed and payment is refunded.
You can request for exchange if wrong product is shipped, you should send the product in question to seller.
After seller checks if returned product is flawed, seller approves your request, and re-sends new product.
- You can request for cancellation after completing payment and if product has not been dispatched by then, cancellation request is approved and you can receive refund.
Criteria for Return/Exchange
You can request for return/exchange within 7 calendar days following delivery date. But return/exchange request cannot be made in following cases:
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- When product is used, destroyed or damaged
- When tag attached to product is removed or package of product is opened and product value is damaged
- When sealed package is opened or packaging materials are lost
- When too much time has passed and product value has so decreased that its re-sale is not possible
- When return/exchange request is made for customized product such as hand-made shoes or accessories
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- As e-voucher products are immediately sent to your e-mail, returns/exchanges are not available. Please take note of this before purchase, and input your e-mail address correctly.
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For any inconvenience regarding Cancellation/Return/Exchange, please contact Customer Service at 03-2720 0000 and we will do our best to help you.
- Please note that, direct transaction with the seller without using 11street payment service can cause problems such as; not receiving the product, receiving different product etc.
- For sales products and contents registered by the seller, 11street run by Celcom Planet has no responsibility on any of the registered contents.


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U.S. Fiat dealers eager for more products to fill their showrooms are to get some relief soon. On Wednesday, Fiat revealed a concept version of a Fiat 500X crossover in Italy. Fiat plans to begin production of the 500X in December 2013 as part of an expansion of its Mirafiori plant in Turin to build 280,000 small crossovers a year, according to Automotive News.
Source: Detroit Free Press
[back to top]
Some dealers take on aftermarket rivals while others stay on the sidelines
Manufacturers from Audi to Subaru want to capture the consumer spirit for personalization. The aftermarket is booming with business for custom wheels, tinted windows, electronics, lighting and interiors. But the natural link between the two -- the new-vehicle dealer -- isn't quite so zealous about it.
Source: Automotive News
Americans are buying slightly less fuel-efficient vehicles as gas prices fall and demand for SUVs and pickups climbs. The University of Michigan Transportation Research Institute said average fuel economy of new vehicles sold in the U.S. in June was 23.6 mpg, down 0.1 mpg from May and down 0.5 mpg from the peak in March, "likely reflecting the continuing reduction in the price of gasoline."
Source: The Detroit News
Those who thought sport utility vehicles were going the way of the dodo were wrong. SUVs haven't died off amid higher gasoline prices. To the contrary, Jeep's flagship SUV, the Grand Cherokee, just posted its best June sales in the United States since 2005 and is up 38 percent so far this year from the year-ago period, when sales already rose impressively from 2010.
Source: The Associated Press
Ford Motor Co. and its new C-MAX Hybrid are looking to go head-to-head with Toyota's Prius, and the Dearborn automaker says it will soon one-up Toyota's Prius v. Ford said Thursday its C-MAX Hybrid is projected to achieve a fuel-efficiency of 47 city miles per gallon, three miles per gallon better than the Prius v. And Ford said the car will debut at a $1,300 discount compared to the Japanese automaker's hybrid.
Source: The Detroit News
With brand's demise, Boston retailer hopes to tap orphaned owners
Dealer Ray Ciccolo, owner of the oldest Saab store in the country, is not giving up on the defunct brand just yet. Ciccolo is expanding his Saab service and parts operations at a time when most Saab dealers are winding down theirs. "If a customer trades in a Saab, someone else is going to buy it and they'll need service," says Ciccolo, president of Village Automotive Group in Boston. "So that's our goal: We're going to be the go-to Saab dealership for the Northeast."
Source: Automotive News
Jerry Seinfeld is a Porsche guy in the purest sense of the word. The New York-based comedian owns such rarities as a 1973 Porsche 911 RSR and a 1949 Gmuend Porsche.... [Seinfeld] has created an Internet show ... called Comedians in Cars Getting Coffee, [which] launches July 19 at 9 p.m. EDT. According to Richard Greenfield, an analyst for BTIG Research, distribution will be solely via Seinfeld's new website, the Crackle channel via YouTube and Crackle.com.
Source: Forbes
-- Peter MacGillivray, SEMA vice president, referring to the business of customizing or personalizing vehicles estimated at $30 billion a year in the U.S., Automotive News, July 2
NADA Data 2012
Audi Partners with NADA University to Train Dealership and Company Staff
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Sarah Teasing On The White Sofa
Beautiful and fresh pics of Sarah Teasing On The White Sofa. More than 16 fresh pictures from thisisglamour! We update galleries daily!!!
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We have some fantastic options for cruise & stay deals 2017, with something for everyone. Whether the ship, itinerary or destination ashore is the most important part, there will be a great holiday out there for you.
Our most popular cruise and stay deals include Med cruises, followed by a stay in charming cities like Barcelona, Rome and Venice, or a beach-filled holiday in the Balaeric Islands. Caribbean cruise and stay deals offer some wonderful combinations including indulging in a week of sandy white beaches and Caribbean sunshine, or a trip to a world renowned resort such a Disney World or Universal Orlando Resort.
At Iglu Cruise we offer cruise and stay deals 2017 holidays for every budget, from 3* family-friendly holidays, to the ultimate in luxury with some fabulous 6* cruise lines. The hardest part of a cruise and stay holiday is picking your choice from the incredible selection on offer.
(Inside cabin)
Costa Diadema
Line: Costa Cruises
Ship Rating:
Cruise and Stay
Ports of Call: Fly from the UK, Barcelona Hotel Stay - 2 Nights, Barcelona, Spain, Palermo, Italy, Civitavecchia (Rome)...
Costa Diadema
Costa Cruises
Ports of Call: Fly from the UK, Barcelona Hotel Stay - 2 Nights, Barcelona, Spain, Palma, Majorca, Palermo, Italy, Rome (Civitavecchia)...
Ports of Call: Fly from the UK, Rome Hotel Stay - 2 Nights, Rome (Civitavecchia), La Spezia, Italy, Savona, Marseille (Provence)...
Costa Luminosa
Ports of Call: Fly UK/Venice, Venice, Brindisi, Italy, Athens (Piraeus), Katakolon (Olympia), Greece, Kotor, Montenegro...
Costa Luminosa
Costa Cruises
(Outside cabin)
Thomson Majesty
Line: Thomson Cruises
Ports of Call: Fly from the UK, Malaga, Spain, Mahon, Balearics, Marseille (Provence), Barcelona, Spain, Valencia, Spain...
Thomson Majesty
Thomson Cruises
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The UCLA Bruins are off to the road to face the Stanford Cardinal in an NCAA college football game set for Thursday October 15th.
CALL 888-711-4311–Tonys Courtesy Line
Start Time: 10:30PM ET
Location: Stanford
Point Spread Odds: Stanford -5 ½ points
Notes: In their 2014 meeting is was Stanford with the 31-10 road win at UCLA as a +6 point underdog which cost the Bruins a PAC 12 South title. The game went under 48 ½ points. UCLA fell to 4-1 following the 38-23 home defeat in week five to the Arizona St Sun Devils as a -12 ½ point wagering favorite. The total went under 61 ½ points. The Bruins struggled on offense with 62 rushing yards on 28 carries and 3 of 14 conversions on third down. UCLA is 100th in all of college football in defending the run by allowing 197 yards on the ground per game.
Stanford improved to 4-1 following the 55-17 home victory in week five to the Arizona Wildcats as a -12 ½ point wagering favorite. The total went over 59 points. The Cardinal offense ran all over the Wildcats defense for 314 yards on 46 carries for nearly seven yards per carry. Their defense limited the Wildcats to 314 yards. Stanford is 29th in all of college football in scoring defense by allowing just 19 points per game.
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