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Lung transplantation has become an accepted treatment for many individuals with severe lung disease.1 It yields improvements in quality and/or quantity of life, depending on the underlying disease process leading to the transplant as well as many other pre- and posttransplant factors. Yet, transplant candidates and recipients experience a range of psychosocial issues that begin at the initiation of the transplant evaluation and continue throughout patients' wait for donor lungs, their perioperative recovery, and their long-term adjustment to posttransplant life. Psychosocial factors may comprise, be caused by, and result in changes to functional capacity, social roles and relationships, health maintenance behaviors, psychological status, perceptions of self, and life plans and goals. Quality of life has a strong association with these domains and their changes throughout the transplantation experience.
This article reviews the psychosocial factors implicated during the various phases of the lung transplantation experience. It will consider patients' perceptions of changes to quality of life and their reported well-being as they progress through each phase, with a focus on the following psychosocial domains: physical functioning, behavioral, psychological, and social. This article also highlights studies of interventions that aim to improve quality of care or reduce patient distress throughout the transplantation process. In addition, the authors address disease-specific differences in outcome, controversial issues in lung transplantation candidate selection, and palliative care for lung candidates and recipients. Lastly, they discuss some psychosocial effects of transplantation on patients' primary family caregivers, as caregivers play a major role in maintaining their loved ones' physical and mental health and also undergo significant exposure to the stressors of the transplantation experience.
Similar to other types of solid organ transplantation, the lung transplantation process begins in earnest as patients and their families begin to consider the idea of transplantation. Patients undergo a transplant evaluation that encompasses both medical and psychosocial realms. Fig. 1 depicts examples of events and stressors that contribute to different phases of the transplantation experience, as well as some of the interventions that have demonstrated efficacy in reducing the impact of these stressors. Specific stressors associated with the evaluation include uncertainty about whether or not a transplant program will judge the potential transplant candidate as suitable for listing, fear of surgery, worry about changes to future life plans, financial strain, and conflicting feelings about treatment options.2,3 Even participating in the transplant evaluation may cause distress and tension for some patients. Patients may be uncomfortable with the questions asked during the psychosocial portion of the evaluation because they are less familiar than those asked during the more routine medical portion of the evaluation. Patients may also be conflicted about whether revealing personal information that exposes their vulnerabilities may jeopardize their ability to present themselves favorably to maximize their chances of receiving a lung transplant.3 Moreover, consideration of mental health in the transplant evaluation may engender stress due not only to the nature of the questions but also because the mental health professionals conducting the evaluation are focused on judging suitability for transplant rather than providing treatment.4
Ultimately, transplant candidates are confronted with the reality, and underlying stressor, that they risk opening themselves to the possibility of an arduous treatment that may never finally materalize. For some patients who have already accepted their progressive disease state, the hope of transplant and subsequent letdown may cause more distress than the management of the physical and psychological aspects of the disease itself. Patients' stage of acceptance of their need for a transplant, which often depends on the acuity of their disease, affects the level of distress patients experience while considering whether or not to undergo transplantation.5 Patients with chronic, longstanding disease (eg, chronic obstructive pulmonary disease [COPD]) are more likely to have prepared themselves for the idea of a potentially long waiting period and the life changes that will ensue after the transplant than those patients with a more rapidly progressing illness and a shorter waiting time for transplant.
Patients with cystic fibrosis (CF)-associated lung disease are in a unique position with respect to accepting the idea of transplantation. Although disease counseling throughout their lifetime may have encouraged them to base life decisions on a projected rate of decline, transplantation represents a major change to their life timeline and simultaneously subjects them to stressors faced by all candidates about risks associated with the transplantation procedure.6 High levels of anxiety and decisional conflict about being listed for transplantation commonly affect patients with CF. A recent study demonstrated the potential value of a decision aid for these patients. The investigators found that a paper- and internet-based tool that directly addressed CF-specific issues, offered in addition to standard pretransplant educational sessions, made patients' expectations of potential surgical and posttransplant complications more realistic and reduced their feelings of decisional conflict about being listed for transplant.7 Similar decision aids might positively affect potential transplant candidates who may expect to experience quality but not quantity of life improvements from transplantation, including patients with COPD.
Once listed as a candidate, patients and their families enter what may be the most stressful period of the entire transplantation experience. Candidates and their families must balance the reality that they may not survive to the point of transplantation with the desire to make plans for life after transplantation. Lung candidates have described feeling that they have no choice but to accept that they and their family members must simply put their lives on hold until after the transplant surgery.8 Transplant candidates in general experience persistent anxiety about when, if ever, the call will come that a donor organ has become available. In addition, they typically experience monotony and frustration about the physical functional limitations associated with advanced disease, especially if they require oxygen support, as do many lung candidates. Patients who live in geographically remote areas may need to relocate to undergo transplantation, which further disrupts a candidate's family and adds to the sense of feeling hostage to the waiting list. Throughout the waiting period, some candidates feel supported by interacting with transplant recipients who can provide hope and fellow candidates who can identify with their current stressors5; however, jealousy may arise if one candidate receives a transplant before another.9
The stressors associated with waiting for transplant have a cumulative effect on patients' generally poor quality of life. Lung candidates appear to have a lower quality of life than candidates for other types of transplantation,10,11 likely because of their illness burden and physical impairments. They tend to have lower emotional well-being and higher risk for psychiatric disorders compared with the general population.12–14 Anxiety and panic disorders are common in patients with lung disease, perhaps because of the shared mechanisms underlying dyspnea, hyperventilation, and symptoms and triggers of anxiety.14 Prevalence rates of mood and anxiety disorders in lung candidates are high, reportedly ranging from 20% to 47%.3,15 Comorbidity is also common: one study showed that more than 25% of candidates who met criteria for any psychiatric disorder actually met criteria for 2 disorders.14 Lung candidates (as well as heart candidates) have also been found to report elevated depressive symptom levels compared with liver candidates.16 Moreover, psychological distress has been reported to increase the frequency of physical symptoms among lung transplant candidates,14 which may contribute to candidates' low overall quality of life.
Interventions aimed at improving psychosocial outcomes among lung transplant candidates have produced favorable results.17–19 Studies have generally structured their interventions as 8 to 12 weekly, telephone-based sessions that used cognitive behavioral strategies to improve coping skills, quality of life, mood symptoms, and relationships with caregivers. Compared to candidates who participated in control conditions, which varied between usual care and health education sessions depending on the study, candidates who received an intervention reported higher quality of life, fewer depressive and anxiety symptoms, lower perceived stress, and higher optimism and perceived social support.
Although receiving no empirical evaluation to date, interventions that address symptom management, end-of-life care, and palliative care also have potential importance in this population. Patients, families, and their physicians may face difficult and complex decisions regarding the implementation of such strategies while they focus on the hope of eventual transplantation. However, the pace with which some individuals decompensate may drive the need to address end-of-life considerations and palliative care as part of their medical treatment. Among candidates with CF, studies have demonstrated that palliative care takes a secondary role to aggressive medical management that aims to sustain patients until transplantation20,21; as a result, CF candidates are often likely to die in the intensive care unit without ever having discussed end-of-life wishes.20 A case report of a candidate with COPD depicted the patient's and family's difficult decision to forego the curative-restorative care necessary to keep the patient listed for transplantation in favor of palliative care that strived to optimize her quality of life while dying.22 Although, in her case (as well as in many other anecdotal reports from practice), the decision to switch from curative-restorative to palliative care prompted a distinct change in treatment regimen and medical team composition, these 2 types of care do not necessarily need to be implemented separately and sequentially. According to the Clinical Practice Guidelines for Palliative Care (which states the goal of palliative care as being "to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies"), palliative and restorative care are not at odds.23 By incorporating both types of care but changing the focus as patients move along their illness trajectory, clinicians may be able to address symptom management and palliative care while concurrently preparing lung candidates for transplantation.
Most patients undergoing lung transplantation experience a rapid change in health soon after transplant. Often, they transit quickly from life with minimal lung function and maximal anxiety before the transplant to a posttransplant honeymoon period characterized by feelings of high optimism and anticipation of steadily improving lung function.24 Many patients and their families face hospital discharge buoyed by the success of transplant surgery and encouraged by early postoperative improvement in lung function.2 In addition, many families may have welcomed the respite from caring for their lung recipient during the postoperative hospital stay and have thus begun to think about posttransplant life, sometimes prematurely, without the burdens of caregiving. Consequently, they may begin to set unrealistic expectations about the recovery process and long-term posttransplant life.
This posttransplant optimism may present a barrier to patients' and their families' participation in self-management after the transplant. Patient education efforts may stall, as patients may not see the need to carry out self-care activities important for preventing posttransplant complications.2 A qualitative study of lung recipients described this initial phase as "naiveté"; after experiencing a positive postoperative experience and then beginning to see the normalization of pulmonary function tests and oxygen levels, many recipients felt immune to transplant-related complications.24 Although health care providers instructed recipients about the high incidence of acute graft rejection during the early postoperative phase, these lung recipients tended to attribute symptoms to non-transplant-related causes and opted to call their primary care provider instead of their transplant team about emergent symptoms. Only after recipients had developed rejection did they and their families become more vigilant of symptoms of potential rejection. However, although this adjustment reduced patients' initial sense of denial about their posttransplant medical vulnerabilities, it also prompted feelings of guilt for thinking they were uniquely exempt from complications that affect nearly all lung recipients.
As recipients progress farther from their transplant surgery, they become increasingly reliant on themselves and their families to manage day-to-day posttransplant care, mainly because of longer periods between follow-up clinic appointments. Despite this positive achievement, recipients may feel anxious on realizing that their contact with the transplant team is diminishing. Family dynamics often remain in flux during the early months after transplant. As patients' steep rate of recovery during the early postoperative period begins to plateau, the slower pace of functional improvement may be disheartening even though patients generally have higher levels of posttransplant functional ability and quality of life compared to their pretransplant levels. It often takes several years after transplant for patients and their families to fully adjust to the new range of stressors associated with life posttransplant and to accept that, with the transplant, they have traded one chronic disease for another. Studies have observed posttransplant adjustment in multiple areas of psychosocial outcomes, which are discussed in the following sections.
The most significant improvements in quality of life from pre- to posttransplant tend to occur during the early posttransplant phase and remain stable for several years thereafter.25–27 Although lung recipients' quality-of-life levels are typically lower than the general (nondiseased) population,25,28 they show dramatic improvements in health-related quality of life1,26,29,30 and feelings of well-being and life satisfaction28,31 when compared with their pretransplant ratings of these outcomes. Nevertheless, their rate of improvement in quality of life tends to be slower than that of heart recipients, for example, most likely because their physical recovery from surgery is more prolonged.31 In addition, improvements in quality of life tend to plateau between 6 and 7 months after transplant,27,31 with smaller gains observed thereafter.
Improvements in physical functioning show a slower trajectory of change than do recipients' perceptions of improvements in global quality of life. Whereas global quality of life has been shown to reach its plateau around 6 months posttransplant, physical functioning has been shown to improve throughout the first 2 years after transplant before leveling off.32 Similar to global quality-of-life ratings, physical functional status posttransplant does not reach that of the general population.33
Interventions that aim to improve physical functioning represent an important part of comprehensive posttransplant rehabilitation, particularly because transplantation has not been shown to bring about the same gains in exercise capacity that it does in lung function.34 Many transplant centers thus enroll or refer lung recipients to some form of exercise or pulmonary rehabilitation program. A review of 7 studies of aerobic and resistance exercise training programs for lung recipients showed that exercise training brought about improvements in maximal and functional exercise capacity, skeletal muscle function, and bone mineral density, all of which are impaired in lung recipients.35 Moreover, exercise training improved health-related quality of life over the course of each program. Studies published since the aforementioned review demonstrated improvements in lung function, functional exercise capacity,36 physical fitness indicators, blood pressure,33 and exercise tolerance37 among recipients who participated in exercise training. In studies that included a comparison group, greater improvements were seen in the intervention group relative to controls. Given the overall positive outcomes of empirically tested exercise training programs with varied structures, transplant centers have some flexibility around program location (eg, inpatient vs home-based) and program structure (eg, frequency, duration, and content of sessions).
Another important element of physical functional status, chronic postoperative pain, affects 18% to 49% of lung recipients during the first several years posttransplant.38,39 One study identified the pre-transplant diagnosis of emphysema as the strongest correlate of pain in lung recipients at least 3 months after transplant. Correlates of pain at this time point included older age, having had a single lung transplant, higher levels of depression symptoms, and lower health-related quality of life in areas other than pain.38 Another study of lung recipients who had survived, on average, 3.5 years posttransplant showed that more than half of patients with chronic pain believed that it had a major impact on their quality of life and, depending on the intensity of the activity, reported pain to be a limiting factor in their daily social activities.39
Side effects of maintenance immunosuppression also factor into patients' overall physical functional status. These side effects range from transient to permanent, and they vary with respect to the distress they produce. Because lung recipients receive higher doses of immunosuppression medications than any other solid organ recipients, they tend to experience the most side effects.40 A study of 287 lung recipients showed that the most common side effects were tremor, hirsutism, changed appearance, gastrointestinal complaints, and fragile skin, whereas the most common moderately-to-severely distressing side effects were gastrointestinal complaints, changed appearance, moon face, fragile skin, and muscle weakness (Fig. 2). A review of psychiatric considerations when treating transplant recipients in a critical care context noted that the most common neurotoxic side effects of immunosuppressants include tremors, headache, restlessness, insomnia, vivid dreams, photophobia, hyperesthesia, anxiety, and agitation, all of which affected 40%to 60% of those on immunosuppressive medication.9 In addition to causing discomfort and pain, studies have demonstrated that these symptoms affect patients' adherence to their medication regimen.41,42
Lung recipients must follow a complex self-management regimen as part of their posttransplant care. Adherence to this regimen is particularly important for lung recipients because, relative to recipients of other solid organs, lung recipients have higher rates of infection and acute and chronic rejection.43,44 The regimen includes taking immunosuppressants; monitoring spirometry, vital signs, weight, and symptoms; communicating effectively with the transplant care team; attending clinic appointments; getting regular blood work, pulmonary function testing, chest X-rays, and bronchoscopies; and following diet and exercise guidelines. One study found wide variability in lung recipients' adherence across these components of their regimen. Out of 178 recipients observed for the first 2 years after transplant, only 13% of recipients were nonadherent to immunosuppressants (based on a combination of self- and family caregiver-report).43 In contrast, 26% were nonadherent to clinical appointments, 62% were nonadherent to required spirometry, and 70% failed to monitor their blood pressure as required. In general, adherence declined over time.
University of Pittsburgh investigators recently developed an intervention that uses a handheld device called Pocket Personal Assistant for Tracking Health (Pocket PATH) to assist lung recipients with monitoring data related to their self-care behaviors and reporting potentially concerning values to the transplant team.45 After 2 months of participation in a randomized controlled trial of Pocket PATH versus standard paper-and-pencil monitoring methods, recipients in the Pocket PATH group reported higher self-care agency, adherence to self-care behaviors, and quality of life than the other group. These findings support the need for further study of interventions to improve adherence to self-care behaviors, especially as recipients progress farther beyond the point of transplant. The University of Pittsburgh group is currently conducting a randomized trial to evaluate these long-term issues.
Aside from interventions that focus directly on adherence-related behaviors themselves, identification of risk factors for nonadherence after lung transplantation may allow for more targeted education of patients and their families. Risk factors identified to date include pretransplant nonadherence to medications, less social support, and lower conscientiousness46; more side effects from immunosuppressants41; and younger age.47 Patients who considered themselves to have little influence over their health reported a higher rate of nonadherence to self-monitoring activities.43 Similarly, patients with weaker beliefs in medications' ability to prevent rejection and stronger concerns about adverse effects of medication reported a higher rate of non-adherence to medication taking.48 Although not yet used in lung transplant recipients, interventions that address patient knowledge about the role of self-management have improved adherence in non-transplant chronic disease populations.49,50
Lung transplant recipients have reported prevalence rates of up to 30% for depression or anxiety disorders during the first year posttransplant, and these disorders are highly comorbid.13,51 One study showed that despite similar rates of depression, posttraumatic stress disorder related to the transplant, and generalized anxiety disorder in lung and heart recipients, lung recipients had a significantly higher rate of panic disorder than heart recipients, with prevalence reaching 18% for lung recipients (relative to 8% in heart recipients).13 Major risk factors for depression and/or anxiety included having a history of these disorders, female gender, spending a longer time on the waiting list, having early posttransplant complications, and having poor caregiver support. Awareness of these predictors may allow clinicians to recognize patients at high risk for posttransplant psychiatric distress.
Despite the high rates of diagnosable psychiatric disorders, it is noteworthy that most patients do not experience such disorders.12,13,25,28,51–53 Moreover, subclinical depression and anxiety symptoms tend to decline from pre- to posttransplant,52 as recipients experience dramatic improvements in physical functioning and optimism about their recovery. Nevertheless, a significant minority may not show this improving pattern. In a study of lung, heart, liver, and kidney recipients, 40% showed declining levels of emotional well-being from pretransplant across the first 2 years posttransplant.25 These individuals reported poorer pretransplant emotional well-being and a higher burden adhering to the posttransplant immunosuppressant regimen when compared with patients who had a more favorable pre- to posttransplant mental health profile. They may thus warrant additional support from the transplant team to avert a continued pattern of decline posttransplant.
The lung transplant literature lacks data regarding the impact of posttransplant psychiatric status on medical outcomes. A prospective study of 177 lung recipients found that depression and anxiety disorders did not predict mortality at up to 10 years posttransplant.53 However, these disorders were associated with posttransplant morbidities, although in diverging directions. The study found that depression was associated with increased risk for bronchiolitis obliterans syndrome (BOS; the clinical correlate of chronic rejection), and lymphocytic bronchiolitis (the small airway disease that often precedes acute rejection), whereas anxiety was associated with decreased risk for graft loss and BOS. Adherence and frequency of screening (eg, pulmonary function tests and biopsies) did not mediate the relationship for either depression or anxiety.
After reaching plateaus in physical functioning and psychological adjustment to the transplant around the end of the first year posttransplant, lung transplant recipients tend to have more stability in medical and psychosocial outcomes during the subsequent years.2,27 Recipients and their families shift their focus from preventing and caring for acute transplant-related complications to reestablishing normalcy in everyday life. Yet, the risk of medical complications does not disappear. Long-term survivors of lung transplantation develop chronic rejection and sequelae of prolonged immunosuppression (eg, diabetes,2 renal failure,54 osteoporosis,55 malignancy,56,57 neurologic complications, and opportunistic infections58). Some of these post-transplant complications, specifically, infections, rejections, and BOS, have been associated with reduced health-related quality of life59 and an increased risk for anxiety and negative emotional well-being during the later posttransplant years.60
Indeed, the threat of BOS remains a predominant concern for recipients and their families, with impacts on many psychosocial domains. International transplant registry data suggest that BOS occurs in 49% of recipients by 5 years posttransplant and in 75% by 10 years.61 Because BOS is largely unresponsive to treatment, mortality from BOS remains high among recipients who survive at least one year. One study reported frequent hospitalizations, emergency department visits, and intensive care unit admissions following the onset of chronic rejection.62 The intense medical treatment required to manage BOS may explain the negative impact BOS has on multiple domains of psychosocial outcomes, including physical functional and emotional well-being.27,63,64 Further, a qualitative study of family caregivers of lung recipients with chronic rejection showed that caregivers considered the incidence of BOS "inevitable" and were distraught by what they perceived as recipients' regression to their pretransplant state.65
Additional correlates of quality-of-life outcomes among long-term lung transplant survivors sometimes differ per outcome domain and time since transplant. Some studies showed a negative association between length of time since transplant and low quality of life in physical functioning domains in cohorts assessed at both 3 and 10 years posttransplant.66,67 These recipients had lower quality-of-life scores than those of population norms and nontransplant chronic disease patients at 10 years. Conversely, another study found a positive association between length of time since transplant and mental health domains of quality of life, with quality-of-life scores equivalent to those of nontransplant populations at 10 years posttransplant.67
Predictors of low physical quality of life appear to differ according to time since transplant. In one study of recipients at 3 years posttransplant, some clinical events such as hospitalization predicted low physical quality of life.66 Another study of recipients at 5 years posttransplant identified marital status and return to work as the strongest predictors.27 At 10 years posttransplant, the strongest predictors of low physical quality of life were BOS, pretransplant physical quality of life, age, and gender.63
Predictors of psychosocial domains of quality of life differ from predictors of physical quality of life. Regarding psychological quality of life, BOS and pretransplant depression predicted posttransplant depression, whereas BOS and age predicted post-transplant anxiety, in a cohort of recipients at 10 years posttransplant.63 In the social domain of quality of life, return to work has been considered one of the main indicators of success of transplantation, although only 28% to 39% of recipients have been found to be employed posttransplant.27 Studies have shown that predictors of posttransplant employment include younger age, greater mobility, having had a previous occupation, having been off work for less than 2 years pretransplant, and having identified return to work as a main motivator for transplant.68–70
These findings underscore the need for psychosocial interventions that support recipients throughout the later-term posttransplant years. The only intervention study to date randomized solid organ recipients (including lung) to an 8-week long, weekly mindfulness-based stress reduction program, a peer-led health education program, or a standard care control.71 One year after the end of the intervention, recipients who had received the intervention reported less anxiety and better sleep quality than recipients who had received the health education control and less depression and better sleep quality than recipients who had received the standard care control. Moreover, those who had received the intervention also reported increasing quality of life over the 8 weeks of the intervention. The study did not show differential effects of the intervention based on time since transplant.
Transplant programs strive to carefully select transplant candidates to optimize outcomes for patients and for the program. Such selectivity often leads to the exclusion of controversial patient populations. In many of these populations, psychosocial issues and outcomes may factor largely into the benefit they receive from transplantation, as is the case with older adults, or may complicate the decision to transplant them, as is the case with psychotic patients.
Older adults have demonstrated positive psychosocial outcomes after transplantation. A review of solid organ transplantation in older adults reported that older recipients have equivalent, and sometimes better, adherence, mental health outcomes, and quality of life relative to younger recipients.72 Similarly, a study that compared lung recipients of various age groups showed that older recipients did not experience more posttransplant complications or worse hospital-related outcomes than younger recipients.73 Moreover, the few studies that have considered the impact of age on posttransplant psychosocial outcomes have not found any predictive relationship.72 Relative to the general population, however, older recipients reported higher rates of psychiatric disorders and lower rates of employment. Despite these favorable data regarding lung transplant outcomes in older adults, studies cannot fully adjust for the other factors that may lead transplant programs to screen out older candidates.
Transplant programs have traditionally considered patients with psychotic disorders to be questionable candidates for transplantation because of fears that the stress of transplantation or side effects from steroids will destabilize their psychotic disorder and subsequently cause nonadherence to the posttransplant regimen.60 Across all organs, a survey of transplant programs' experiences with patients with psychotic disorders reported incidence rates of rejection and nonadherence to immunosuppressants that were consistent with rates seen in nonpsychotic organ recipients.74 Specific to lung transplantation, one case report of a lung recipient with schizophrenia described favorable respiratory and psychiatric outcomes after lung transplantation, as well as consistent attendance at monthly visits to the psychiatric clinic.75
The decision to initiate palliative care after transplant is complex because patients, families, and their clinicians may consider palliative care to conflict with the life-sustaining goals of transplantation. However, palliative care is not, by definition, end-of-life care; rather, it aims to optimize quality of life throughout patients' illness trajectory. In a study of palliative care referrals after lung transplantation, the misconception that palliative care is end-of-life care was endorsed by most transplant and palliative care clinicians as a barrier to initiating palliative care.76 An additional barrier noted by transplant clinicians was uncertainty about patients' prognosis, which often prevented the initiation of palliative care until patients were ill enough to require stopping life-sustaining treatment. Moreover, the prospect of retransplantation makes the decision to stop aggressive treatment measures even more difficult for many patients and their families.65 It may be ideal for palliative care and restorative care to proceed in parallel, with the focus of care shifting as patients' illness trajectory and treatment options change over time.
Family caregivers provide crucial supports for maintaining patients' physical and mental health throughout the transplantation process. During phases of the process in which patients may experience severe illness and disability, caregivers carry out practical activities that patients often take for granted in daily life. Exposure to the chronic stresses of transplantation may cause caregivers of both lung candidates and recipients to experience a lower quality of life than noncaregiving adults.77 Moreover, up to 30% of caregivers for lung candidates reported clinically significant levels of depression and anxiety, both of which were associated with a higher perceived burden of caregiving.78,79 Caregivers may feel confined and inconvenienced by having to be available to help their loved one at any time, and they may also feel disappointment that the illness has substantially changed their loved one.77 One qualitative study determined that 30% of caregivers' daily activities during the first 6 months after transplant were related to supporting their loved one's health.80 Although performing these activities can often be gratifying, adjusting to the changing family dynamics, household responsibilities, and job-related capacities associated with transplant may compound the discrete burdens of caregiving, as evidenced by caregivers reportedly spending less of their day in a positive mood than did the lung recipients for which they care.80 At the same time, however, caregivers also reported positive outcomes of caregiving, such as discovering inner strength and support from others and realizing the important things in life.77
Interventions to improve caregivers' quality of life may have benefits for both patients' and caregivers' health. Evidence from nontransplant populations show that psychological interventions for caregivers of patients with a chronic illness may improve caregivers' mental health and coping skills.81 The only such study in lung transplantation that evaluated the effect of a psychological intervention on caregivers' quality of life showed that caregivers of lung candidates who received the psychological therapy reported better quality of life, fewer mood disturbances, and higher social intimacy than caregivers of patients who did not receive the therapy.82
The process of lung transplantation brings with it a range of successes and stressors from the time a patient contemplates undergoing evaluation to the years beyond the transplant. Although transplantation may improve quality of life, physical functioning, and psychiatric status, not all patients experience the same degree of improvements; moreover, benefits do not always occur as quickly as many patients anticipate. Patients often expect that the transplant will restore their health and quality of life to a level comparable to levels before they ever became ill. Instead, adjustment to life after transplant often requires coming to terms with ongoing medical illness burden and continued reliance on caregivers. After experiencing improvements in pre- to posttransplant psychosocial status (eg, global quality of life, physical functioning, and mental health), patients' levels of psychosocial outcomes typically plateau and do not return to levels equivalent to the general population. Nevertheless, because patients may still experience dramatic pre- to posttransplant improvements in psychosocial status, clinicians should work with lung recipients and their families, particularly their caregivers, to find ways to sustainor increase those gains, such as by optimizing adherence, symptom management, and complication prevention.
Transplant programs could consider incorporating elements from the evidence-based interventions reviewed here into care of both candidates and recipients. Because most recipients and their families cite the waiting period as the most distressing part of the transplantation experience, pretransplant psychosocial interventions could include those that aim to ease the stresses related to the uncertainty of being on the waiting list while simultaneously managing a deteriorating condition. Immediately after transplant, although recipients and their families optimistically enjoy the successes of the surgery and patients' marked gains in physical functioning, interventions could focus on education about the risks of posttransplant complications and the importance of self-monitoring in order to involve patients in the prevention of infections and complications. During the years beyond the transplant, interventions could aim to improve quality of life (in both recipients and their caregivers), physical functioning, and adherence to the medical regimen. Although it is sometimes challenging to reconcile the treatment goals of patients, families, and the transplant team, evidence suggest that deliberate and preemptive integration of palliative care and restorative care maximizes quality of life over the course of the pre- to posttransplant illness trajectory; transplant programs could thus strive to offer palliative and restorative care in parallel.
To meet the broad needs of lung recipients and their families, clinicians must remain aware of the many psychosocial issues lung recipients face throughout the transplantation process. At the same time, clinicians should address the many psychosocial benefits recipients may experience, as a means of acknowledging progress and facilitating greater grains. An understanding of these psychosocial issues over the course of the transplantation timeline and an inclusion of approaches to improve various posttransplant issues based on evidence-based interventions may aid transplant programs in improving the care of their lung recipients.
Funding support: Funded, in part, through the following grants from the National Institutes of Health: TL1 TR000145, R01 NR010711 and R01 HL083067.
Financial disclosures and/or conflicts of interest: The authors have nothing to disclose.
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.


text:
A Ruby library for accessing the Amazon Web Services EC2, ELB, RDS, Cloudwatch,
and Autoscaling APIs.
WWW: https://github.com/grempe/amazon-ec2
make generate-plist
To install the port: cd /usr/ports/net/rubygem-amazon-ec2/ && make install cleanTo add the package: pkg install rubygem-amazon-ec2
cd /usr/ports/net/rubygem-amazon-ec2/ && make install clean
pkg install rubygem-amazon-ec2
PKGNAME: rubygem-amazon-ec2
SHA256 (rubygem/amazon-ec2-0.9.17.gem) = 4cbbd8cada5534cc6d081281b26bbb777c53410ea571829d0b7d0826b7d1e971
SIZE (rubygem/amazon-ec2-0.9.17.gem) = 124416
NOTE: FreshPorts displays only information on required and default dependencies. Optional dependencies are not covered.
This port is required by:
No options to configure
Number of commits found: 8
http://github.com redirects to https://github.com, spare everyone a redirect.
Sponsored by: Absolight
Convert USES=gem:autoplist to USES=gem since autoplist is default
create USES=gem and update rubygem- ports to use it
Note that for now ports still have to have USE_RUBY=yes to use USES=gem
Differential Revision: https://reviews.freebsd.org/D6070
Remove ${PORTSDIR}/ from dependencies, categories m, n, o, and p.
With hat: portmgr
Sponsored by: Absolight
Set NO_ARCH for remaining rubygem-* ports with no arch dependent files
Obtained from: DEVELOPER_MODE
With Hat: ruby@
Sponsored by: RideCharge Inc / Curb
- Stage Safe
Add NO_STAGE all over the place in preparation for the staging support (cat:
A Ruby library for accessing the Amazon Web Services EC2, ELB, RDS, Cloudwatch,
and Autoscaling APIs.
WWW: http://github.com/grempe/amazon-ec2
Feature safe: yes
Servers and bandwidth provided byNew York Internet, SuperNews, and RootBSD
No vulnerabilities have been reported in the past 14 days
* - modified, not new
All vulnerabilities

subset: commoncrawl


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Slips To Avoid When Buying Hamsters
How often have you created incorrect choices by doing unnecessary purchases? If you buy something you aren't aware about, you get distressed. Pet retailers normally promote several types of hamsters. If you're planning to get a hamster as a family pet, there are particular faults that you need to stay away from so that you can have a pet which will satisfy your desires and requirements. For first-time hamster masters, you have to avoid these typical slips.
Getting a hamster without to begin with understanding about its character and well being needs. It truly is rather critical that you just order the hamsters from the trustworthy pet shop or breeder within your location. This is due to the fact that the personality in the hamsters depends on exactly how these were inseminated. In terms of wellness needs, it is possible to ask the pet shop operator or the breeder for advice. It might also assistance when you conduct some type of research on the net to have valuable details.
Do not be pleased by merely gazing at the hamster from your windows or cage. It might support if you ever hold the hamster with your hands. By performing so, you might know when the creature has personality issues. When the hamster bites you, this signifies that the breeder will not be that excellent. At these times, it is considerably far better to appear for one more hamster. Also, by touching the hamster, you might be capable to tell if it is healthy! Verify the ears principal to see if it is upright. When the ears are flat, it indicates that the creature is just not properly. You possibly can also examine the coat by holding the hamster with your hands. The coat ought to be properly groomed, thick, and thoroughly clean. Check out the eyes for any discharge. If you can actually locate eye waste, appear for an additional hamster.
Do not be extremely troubled at the looks on the hamster. You also have to verify the cages and also the surroundings. An location that is certainly not that clean should certainly serve like a danger sign. Wellness situations aren't often visible and may surface down the road. When the surroundings usually are not clean, your hamster may suffer from well being issues inside the future.
Whenever you invest in a hamster, you need to make sure the hamster has already been four to 5 several weeks old. Any hamster that's sold young than that might not be an ideal pet as they may well die later on for the reason that it will not be ready to become separated from its mother. Also, examine the cage where the infants are put. At this time, the hamsters must now be separated by sex. Only a dependable breeder or vendor can supply you with the ideal and healthiest domestic pets.
All hamsters need a hamster cage to have a place to stay. Make sure it is large enough and it is complete with all hamster supplies and other needs of the hamster.
categories: hamster cage,hamster care,hamster supplies,pet care,pets


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Distressed Ombre Denim Pencil Skirt
Please select a size.
Add to bag
Item #80468
Keep up on the denim trend, with this denim, ombre pencil skirt! This ombre denim skirt also features distressing, along with 5-pocket construction and belt loops and a slit on the back .Style with a graphic tee and sneakers for a trendy look.
- 73% Cotton, 24% Terylene, 3% Spandex
- Machine Wash Cold
- Imported


text:
GraphicRiver Map of United Kingdom 6601208
Stock Vector \ Conceptual \ Travel
Regions \ United \ Kingdom \ Location \ VectorVector \ Package \ Pixels \ Version
Stock Vector - Map of United Kingdom 6601208 by sateda2012 @ GraphicRiver
Stock Vector \ Conceptual \ Travel
Vector map of United Kingdom with regions, coat of arms and location on world map. Package contains: EPS (10 version), JPG (5000×5000 pixels, RGB).
Last Update: ; Layered: No; Graphics Files Included: Vector EPS; Minimum Adobe CS Version: CS.
Map of Northern Ireland with Subdivisions; Great Lakes Region of United States; Map of Saskatchewan, Canada; Map of Scotland with Subdivisions; Map of Wales with Principal Areas; East Coast of the United States; Actec Calendar.
Keywords: administrative, areas, atlas, borders, boundary, button, country, divisions, england, europe, flag, geography, great britan, icon, land, map, national, official, regions, republic, shape, sign, silhouette, symbol, template, travel, uk, united kingdom, vector.


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"Impressive services from paramedics"
About: Scottish Ambulance Service Scottish Ambulance Service EH12 9EB
Posted by Gideon (as ),
In Debenhams restaurant on Princes St. Edinburgh recently I felt unwell and the staff there called for your assistance.
A young man on a motor cycle was immediately there, took control and started checking me out. Two young ladies then appeared with an ambulance outside and got to work as well.
To close off they took me down to the ambulance and checked out my heart ect.
they were all very professional, re-assuring, attentive, caring, pleasant and thorough.
I would like them to know how impressed I was and grateful I am.
Response from Sharon Hammell, Head of Corporate Affairs and Engagement, Scottish Ambulance Service 5 years ago
Thank you for your feedback about your positive experience of the Scottish Ambulance Service. I hope you are feeling much better.
I will pass your comments on to the staff concerned, who will appreciate that you took the time to share your experience.
- {{helpful}} {{helpful == 1 ? "person thinks" : "people think"}} this response is helpful
- Was this response helpful? Yes
Thank you for your feedback.
See more responses from Sharon Hammell


text: Autokiller is a must have app for any android phone especially if you have your phone rooted and overclocked! A feature that I love most about this app compared to any other task killer is the feature to set your phone to moderate, optimum, strict, aggressive, extreme, or a custom value. These options help your phone tell what things to autokill and when to do it to keep it running how you want it to run. This is the preset screen for setting your values. (extreme, aggressive etc.) This screen shows what apps you have running and all you have to do is click the app name and it will kill it for you. This is your settings screen for autokiller! After this review I want you guys to take away that autokiller is a must have app on your android phone and is one of the best if not the best task killer out there!


text:
GraphicRiver Hand-drawn Number Characters 3600437
Photoshop \ Stock Graphic \ Illustrations \ Characters
Counting \ Monsters \ Numbers \ Learning \ Dragon \ Squirrel \ Modeled \ Related
Stock Graphic - Hand-drawn Number Characters 3600437 by dxc @ GraphicRiver
Photoshop \ Stock Graphic \ Illustrations \ Characters
These fun little number monsters would be perfect for the classroom, a game, a birthday party decoration or anywhere else where you want to make counting, numbers, math, and learning fun!
Each critter is hand drawn to resemble some sort of animal (mythical or real). For example, the one is a fish. Two in a squirrel. Three was modeled after a saber-tooth tiger. Four is a dog. Five is a dragon. Six is a hippo. Seven is a bird. Eight is a hairless rodent. Nine is a cuttlefish. Zero is a… well, to be honest we have no idea what that one is.
Related Items
High Resolution: No; Layered: Yes; Graphics Files Included: Photoshop PSD, Transparent PNG; Minimum Adobe CS Version: CS4; Pixel Dimensions: 2544x2599.
Jackhammer - Under Construction Page; Geometric Political Elephant and Donkey; 182 Waving Country Flags; Robots vs. Aliens Pinball Game Asset Pack; Stone iOS Icon Maker; Werewolf Cub Illustration; Isometric Cube Map Builder Kit + USA Map.
Keywords: cartoon, counting, creatures, critters, eight, five, four, hand drawn, learning, math, monsters, nine, numbers, one, seven, six, three, two, zero.


text:
Locate towns and parishes within a County in England
From FamilySearch Wiki
The Old-Maps website allows you to locate where your ancestor lived from the address/information obtained from 1841-1901 British Census.
- Town/Parish name
- County
Zoom in to locate street and major buildings in the town
Internet Address
Using the site
1. Type in town/parish in place name block – click search
2. At top of the map it lists county and time period of map
3. Allows you to zoom in on any area of the map
4. Able to print
5. View aerial map
6. View modern map
Maps are helpful in determining distances between parishes where families lived and where different children in the same family were christened.
I felt closer to my Grandparents (who died when my Father was 14-16 years old) knowing they walked down those streets/roads that I was able to pinpoint on the map.


text:
Free download - Education Animated SVG Icon Set - Nulled version
Free download !
Education Animated SVG Icon Set is a pack of 16 different types of education related svg animated icons which you can easily integrate to any project to make it feel more lively.
All the svg are distributed as separate files so that you can easily distinguish one from another and use it on your next awesome project.


text:
The Servant Trailer (1979)
19 July 1979
Two cops are on the trail of gang that are planning a jewel robbery. Inspector Chow lives at home with his mother, while Inspector Pang has gambling problems that the gang exploits. Soon, innocent victims will pay with their lives.
Watch the official The Servant 1979 trailer in HD below or find more The Servant videos on Vidimovie.


text:
In 1482, Catharina Arndes lifted up her skirts in front of the archbishop's chaplain. She was a respectable townswoman from Hamburg, and her action was carried out in defense of the Cistercian monastery of Harvestehude which was close to the city and where several of Catharina's nieces lived as nuns.
Skirts and Politics: The Cistercian Monastery of Harvestehude and the Hamburg City Council
Transvestites in the Middle Ages
An examination of the lives of the transvestite saints whose legends and myths help set Western attitudes toward transvestism.
Crafting the witch: Gendering magic in medieval and early modern England
This project documents and analyzes the gendered transformation of magical figures occurring in Arthurian romance in England from the twelfth to the sixteenth centuries.
Late Medieval Knight Reflecting on his Public Life: Hugo de Urriés (c. 1405-c. 1493), Diplomacy and Translating the Classics
This article focuses on Aragonese courtier Hugo de Urriés's public profile by means of analyzing the critical points derived from examining his personal, political, cultural and historical stands making use of an invaluable primary source, his letter to Fernando the Catholic in the early 1490s.
The Gendered Nose and its Lack: 'Medieval' Nose-Cutting and its Modern Manifestations
Rather clearer is its connection with patriarchal values of authority and honor: the victims of such punishment have not always been women, but this is nevertheless a gendered punishment of the powerless by the powerful.
'There is more to the story than this, of course': Character and Affect in Philippa Gregory's The White Queen
Philippa Gregory has critiqued gendered representations of Elizabeth Woodville and has stated that her 2009 novel The White Queen fictionalises Woodville's history with the aim of challenging such depictions.
Grainne Uaile: The Movie
An up and coming movie about Grace O' Malley (Grainne Uaile), Ireland's famous female pirate!
Nicolette : action transvestite, or, who and what is the heroine of Aucassin et Nicolette?
In this paper, I will show how Nicolette is constantly, deliberately, changing, in appearance and identity, from the beginning of the story, and how she is thus Izzard's action transvestite.
Pope Joan and the Black Swan: Medieval Christianity as a Resource for Gender Justice in the Church
This essay offers resources from within medieval European Christianity in a feminist reading of the Christian dogma of hypostatic union, medieval political theory on royal twinning, and two medieval legends on the numinous double.
Medieval Misogyny and Gawain's Outburst against Women in "'Sir Gawain and the Green Knight'
The view has been gaining ground of late that the Gawain of Sir Gawain and the Green Knight, a knight renowned as 'Pat fyne fader of nurture' (1. 919) and as 'so cortays and coynt' of his 'hetes' (1. I525), degenerates at the moment of leave-taking from the Green Knight, his erstwhile host, to the level of a churl capable of abusing the ladies of that knight's household (11.2411 -28).
Caught in Love's Grip: Passion and Moral Agency in French Courtly Romance
French royal courts in the late twelfth century were absolutely smitten with love. Troubadaours traveled from place to place reciting stories of knights and the ladies they wooed.
Kissing Cousins: Incest and Sex Change in Tristan de Nanteuil
In this paper I re-examine Blanchandine's sex change in light of its relation to the issue of incest; as I will show, incest is directly related to the sex change and also punctuates the narrative at other points. Tristan de Nanteuil depicts two sexual and/or romantic relationships between cousins…
A Kiss Is Just a Kiss: Heterosexuality and Its Consolations in Sir Gawain and the Green Knight
The famous line from that modern romance- "A kiss is just a kiss"- is the message the Gawain-poet gave his listeners six centuries ago.
Man, woman or monster : some themes of female masculinity and transvestism in the Middle Ages and Renaissance
This dissertation discusses medieval and Renaissance clerical and cultural constructions of femininity and female masculinity, and it analyses the complex relationship between such conceptions and the literary representation of the transvestite woman.
Royal and Magnate Bastards in the Later Middle Ages: The View from Scotland
Theory and Practice in Scotland and Elsewhere Medieval Scotland's law on bastardy is set out in the lawbook Regiam Majestatem (c.1320)…In England things were different, as Michael Hicks has demonstrated. Admittedly, English heraldic practice eventually followed the French, and the formula 'X bastard of Y' is occasionally found for magnates' bastards.
Making a difference in tenth-century politics: King Athelstan's sisters and Frankish queenship
In the early years of the tenth century several Anglo-Saxon royal women, all daughters of King Edward the Elder of Wessex (899-924) and sisters (or half-sisters) of his son King Athelstan (924-39), were despatched across the Channel as brides for Frankish and Saxon rulers and aristocrats. This article addresses the fate of some of these women through an analysis of their political identities.


text:
Asked by:
Can not use calculated measure in DAX query
I have a tabular model which has one table which contains one calculated column. I am writing DAX query in SSMS to get that column value. I am getting the error below, but when I use non calculated measure I can see the values.
Can we use calculated measure from Tabular\BISM model to write DAX query?
"Column 'CalculateColumn' in table 'TabularTable' cannot be found . "
- Edited by Arun..Singh Friday, May 10, 2013 8:58 PM updated
- Changed type Ed Price - MSFTMicrosoft employee, Owner Friday, September 13, 2013 7:00 PM We need the OP to answer questions in order to give an answer
General discussion
All replies
Yes you can. Did you spell your column name correctly? And use the "TableName[ColumnName]" syntax?
You can also post the exact DAX you're using, as well as a screenshot of your model's table with column names. That will help with context for the issue.
Brent Greenwood, MS, MCITP, CBIP // Please mark correct answers and helpful posts // http://brentgreenwood.blogspot.com
Thanks Brent for your reply. I am using correct syntax, Below is my DAX query
'Baseline Version Fact'
, "Sales Amount"
, SUM('Baseline Version Fact'[Baseline Benefilt Amount]))
"Baseline Benefilt Amount" column is calculated measure.
Could you also post the screenshot Brent asked for?
Ed Price, SQL Server Customer Program Manager (Blog, Small Basic, Wiki Ninjas, Wiki)
Answer an interesting question? Create a wiki article about it!
- Edited by Ed Price - MSFTMicrosoft employee, Owner Thursday, August 22, 2013 7:07 PM


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Only show results in Virginia? Ok
Related terms for "mining waste ":
mining waste disposal companies
, gold mining waste companies
, mining waste assessment companies
D`Appolonia is a client-focused provider of consulting engineering services. Since the founding of the firm in 1956, we have provided engineering, scientific and construction-related services to industrial and governmental clients in the U.S. and in many foreign countries. Our core capabilities include civil, geotechnical, and environmental engineering; geology and ...
based in Monroeville, PENNSYLVANIA (USA).
Virotec Global Solutions Pty Ltd. is a world leader in meeting the demand for effective, sustainable solutions to deal with serious environmental and waste problems. The proven, patented, state-of-the-art technologies developed by Virotec enable companies and public utilities to meet government regulatory waste treatment standards, reduce future liabilities, and help ...
based in Coomera Waters, AUSTRALIA.
Lorax Environmental Services Ltd. is a privately-owned, environmental consulting company that provides leading-edge environmental, geochemical and project management services to our clients. Our corporate goal is to provide the highest quality services in the most cost-effective and timely manner and, where appropriate, implement innovative techniques and approaches to ...
based in Vancouver, BRITISH COLUMBIA (CANADA).
The environment is the world in which we live and play. It requires care and consideration through the application of knowledge and experience. EcoMetrix is a team of experienced environmental professionals applying leading edge science and knowledge of regulatory requirements to measure, assess and quantify the potential effects of human activities on the environment. ...
based in Mississauga, ONTARIO (CANADA).
Tetronics International is an environmental company with 50 years' global experience delivering clean plasma technology for maximum resource recoveryand the highest levels of hazardous material destruction. This brochure focuses on Tetronics' solutions for managing Air Pollution Control residue (APCr)/Incinerator Fly Ash. Tetronics has a proven, turnkey capability, from ...
based in Swindon, UNITED KINGDOM.
Urban Mines is a team of environmental specialists committed to finding practical and innovative solutions for resource management. It provides consultancy support to public and private sector clients, to develop and support its own schemes, including recycling focused business parks, working with partners and networks to influence policy and develop good practice.
based in Norwood Green, UNITED KINGDOM.
UMS' origins date back to the very beginning of ore mining and dressing. In the mid-19th century. Since any recycling technology is essentially derived from mining, it was only natural that UMS, a successor to Germany's renowned Preussag AG, began to focus on secondary raw materials recovery in 1991. Enhancing existing technology for urban mining applications, UMS has ...
based in Remscheid, GERMANY.
The Central Mining Institute is a scientific and development organization, subordinated to the Minister of Economy, working not only for the benefit of the mining industry, but also for enterprises representing different branches - including small and medium enterprises, state and local administration institutions and offices, and foreign partners. Currently the four ...
based in Katowice, POLAND.
Ida-Ore Mining LLC is a Zeolite mining and Product Development Company, dedicated to exploring ways Zeolite can benefit industries and the environment. IDA-ORE Zeolite has been supplying Zeolite since 2005. We have worked tirelessly to advance theBigmax Screener for Zeolite Remediation and supply application and research of Zeolite for industrial use, and have come to ...
based in Nampa, IDAHO (USA).
Central Mine Equipment Company was founded in St Louis, Missouri in 1928. Our initial product line included augers, cutters and related accessories for the coal mining industry. In 1962, we introduced our first drill rig, the CME-55.Today, we design and manufacture a complete line of drilling equipment for the geotechnical, environmental, mineral exploration, and ...
based in St. Louis, MISSOURI (USA).
As the mining industry demands better productivity to ensure profitability, we're providing the cutting-edge solutions needed to succeed. Our equipment and services help our customers in every corner of the world ...
based in Amsterdam, NETHERLANDS.
Power and Mine Supply Co. Ltd. is a Winnipeg based distributor and system fabricator specializing in serving the needs of those involved in pulp & paper, mining, chemical processing, power generation, water distribution, wastewater treatment, oil and gas production, irrigation, pipeline, pharmaceutical, aerospace, general industry and agriculture. We are specialists for ...
based in Winnipeg, MANITOBA (CANADA).
We offer solutions for your NORM Waste from petroleum, mining and metalurgical industries. We decontaminate NORM from soil, water and equipments. Our company is able to handle, decontaminante and disposal NORM wastes from petroleum exploration like oil sludges, pipe scales and equipments. NORM disposal solutions for Brazil and South America.
based in Niteroi, BRAZIL.
OBE Waste & Agri Engineering manufactures a complete range of Masterburn animal, medical and waste incinerators, OBE Agri trailers, and Slurry-TEK vacuum tankers and slurry handling equipment. OBE's varied client base includes farmers, veterinary practices, meat processors, medical facilities, aquaculture sites, oil exploration and mining camps, government organisations ...
based in Donaclone, UNITED KINGDOM.
World Waste Systems designs, builds and manages municipal solid waste management recycling and composting waste systems (recycling facilities) that range in size from 50 tons per day to 2,000 tons per day and operate at a fraction of the cost of our competitors. We specialize in recycling municipal solid waste, residential and commercial waste, industrial waste and ...
based in Ocala, FLORIDA (USA).
New Waste Concepts, Inc. was founded in 1987 in Toledo, Ohio as Newastecon Inc. It is the mission of New Waste Concepts to work closely with our clients to develop products, equipment and operational services that solve the unique problems they face on a daily basis in a simple, reliable and cost effective manner. We develop and supply diversified remedial systems for ...
based in Perrysburg, OHIO (USA).
Casella Waste Systems provides integrated waste management solutions crucial to public health in a unique collection of communities throughout Vermont, New Hampshire, Maine, upstate New York and northern Pennsylvania. Founded in Rutland, Vermont in 1975 with a single truck, Casella has grown by anticipating and meeting changing cultural and public policy expectations ...
based in Rutland, VERMONT (USA).
Training courses for transportation and shipping, safety, mining, hazardous waste, environmental & more.
based in Chapel Hill, NORTH CAROLINA (USA).
Innovative Waste Consulting Services (IWCS) provides consulting services for private and public sector clients on challenging solid waste issues. Developed from a university research environment, IWCS has state-of-the-art expertise in areas including landfills, waste treatment and recycling, and characterization of environmental risk from waste operations. IWCS has ...
based in Gainesville, FLORIDA (USA).
Liquid Waste Technology (LWT) specializes in the design and manufacture of custom dredging system solutions for the dredging industry. LWT builds high quality computer and remote controlled portable dredges uniquely equipped for a variety of applications including: Dewatering Projects, Wastewater Lagoon Dredging, Water Treatment Plant Maintenance, Mine Tailings, Canal ...
based in New Richmond, WISCONSIN (USA).
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text:
in the correct palce please?
p: 0425218181
e: email@example.com
Specialising in Pinup, Vintage, Boudoir, Glamour and Old Hollywood style portrait photography, your Celebrity Obsession Experience will be unforgettable!
Individually crafted Celebrity Obsession Portrait Experiences are your ultimate celebration!
With a little help from our friends we can deliver 'The Look' just for you, with professional makeup and hair styling in a party atmosphere in studio, at exclusive locations and with prop options including, but not limited to Classic Cars, Hot Rods, Classic & Custom Bikes and even Vintage & War Planes...with more to come!
Your Celebrity Obsession Experience is much more than a photo shoot, it is a fun and uplifting experience to remember.
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See examples of our work in the portfolio
Or contact us to discuss your requirements and let us give YOU the Celebrity Obsession treatment!
Warm regards,
John Turton
Celebrity Obsession
*conditions apply


text:
BRAINERD, Minn. (Aug. 15, 2012) - NTB/Service Central Racing Funny Car pilot Johnny Gray is still a thrill-seeker. His eyes are still wide with anticipation, his veins still crave the rush of natural adrenaline, and he still walks along the road of life kicking over rocks in search of fun.
None of that has changed in the past year since the Artesia, New Mexico-based driver won his first nitro Funny Car national event title at the Lucas Oil NHRA Nationals in Brainerd, but boy, has Gray's program picked up, and that should be bad news for his fellow Funny Car competitors at this season's rendition of the annual event held at Brainerd Int'l Raceway.
In 2011, Gray qualified his Service Central-backed Dodge Charger in the No. 7 position and eliminated Jeff Arend, Cruz Pedregon and Bob Tasca III before squaring off with Don Schumacher Racing teammate Ron Capps in the raceday final. Their match was truly something to see as neither driver was willing to give an inch, and Gray scored a narrow 4.11 to 4.13 victory to take home the first NHRA trophy as a professional fuel Funny Car racer.
"It would be real nice to go up there and repeat, and we've got a hot rod that could do it," said Gray. "Last year was sure special - it would have been a lot more special if my wife, Terry, had been there to share it with me. But we went up there with a pretty good racecar thinking we maybe could have a chance.
"This year we have a totally different mentality; there is just no comparison whatsoever from last year to this year in terms of our program. This is a whole new deal, and we have shown ourselves and everyone else that we absolutely have the capability to put together four good runs and get that win. There's no maybe about it."
Since claiming that first national event title last year, Gray has returned to the final round a remarkable six times, and he has twice more brought home the win with victories earned this season at the SuperNationals in Englishtown and the NHRA Sonoma Nationals. Gray, currently fourth in the Full Throttle Series Funny Car points, only needs to make a qualifying pass in Brainerd to secure a position in the Countdown to the Championship playoffs.
"I don't think anybody was really that afraid to be in the other lane at this time last year, but now they have a different attitude when they see the NTB/Service Central car," said Gray. "They know they better put their best foot forward."
With temperatures throughout the weekend expected to be in the low 70s - the coolest block of days that the Full Throttle Series tour has experienced in some time - Brainerd will provide drivers and crews with a much-needed respite from the blazing heat and should allow them the opportunity to return to the go-fast conditions they so crave.
For Gray, the scenery is ideal to underscore what he and the NTB/Service Central crew have already established: they cannot be taken lightly.
"Oh, we're excited to get there," said Gray. "This should be real interesting."
Source: Don Schumacher Racing


text:
FARR can't find items in when it is in a folder that contain a folder of the same name. If I am in c:\devel and there is a c:\devel\devel\, I won't be able to see and select anything.Manu
still one step to go to be as user friendly as Launchy (but much more powerfull )the ability to search without the consecutive letterswhen i want to launch, say the power calculator (microsoft powertoys)with launchy i can type : pwor to launch my favorite game, warcraft 3 Frozen Throne, i just type : fzand believe me it makes a huge differenceI have no idea if this is possible, easy/hard, ... i would just love it ! (of course i guess you would make it an option !)
good release, mouser.. anyway, i have another suggestion. how about incorporating an internal command or alias to quit Farr by typing something like this: @quit? this is because WinXP always hides the systray icon and i'm less inclined to use the mouse.
Page created in 0.128 seconds with 71 queries.


text:
Rookie Wade Graham could hold the key to unlocking NSW's attacking potential in next week's must-win State of Origin game, according to star Michael Jennings.
Whether or not he'll get to play is the million dollar question.
The Cronulla backrower was to leave Blues camp in Coffs Harbour for Sydney on Wednesday to fight a grade-one careless high tackle charge at an NRL judiciary hearing in Sydney in a bid to keep his Origin debut alive.
If he succeeds, strike weapon Jennings believes Graham will not only deliver him more quality ball on the Blues' left edge but help keep the series alive too.
"With Wado coming in, that adds more to my game," Jennings said on Wednesday.
"He's played five-eighth, and having a backrower like that can put you through holes, and ask questions of the other defenders, that's always a plus."
The Parramatta centre believes Graham's Cronulla club combination with pivot James Maloney is another bonus.
"At club level they have that combination so having them two is always a plus," he said.
The Blues are banking on Graham, as well as development from another nine-day preparation for new "spine" Matt Moylan, Maloney, Adam Reynolds and Robbie Farah, to spark their stuttering attack.
Blues greats Andrew Johns and Phil Gould led a barrage of criticism of the Blues' game plan in game one, which conjured just one try in a 6-4 defeat at ANZ Stadium and left them on the cusp of series defeat.
Tellingly, NSW have averaged just 10 points and have topped 14 points just once under coach Laurie Daley's 10-game tenure.
"I don't think it's the preparation. I think Loz (Daley) and the staff here have done an awesome job in getting everyone ready for game one," Jennings said.
"Our kicking game was good, (Adam Reynolds has) got a good kicking game.
"But we do need to score some more tries. It was just one of those games in game one, it's more executing and making sure that we do the right job."
The Blues have their first training session on Wednesday.


text:
100% Cotton Jersey, very soft knit tubular circle scarf printed with images of Lutetia, a large main-belt asteroid. Image courtesy of ESA 2010 MPS for OSIRIS Team MPS/UPD/LAM/IAA/RSSD/INTA/UPM/DAS/IDA
Width of tube: 16"/40cm Circumference of circle: 58"/147cm Machine wash cold, air dry.
AHAlife is committed to help you live a conscious and inspired life.
Many of the items you discover here are exclusive to AHAlife, which is what makes our community of designers and artisans so special.
If you find one of our products anywhere else for less than it's being sold on our site, we will match it. No questions asked.
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text:
Mallery Neff, M.D.
Mallery Neff, M.D., MPH
|Personal Statement
|I have always had interest in disruptive behavior disorders and how that impacts a youth's ability to function at home. Utilizing a team approach that solves multifaceted problems is essential for maintaining children in their homes, and I look forward to clinically encouraging these processes within our state.
Undergraduate: BA in Biology, Minor Chemistry/East. European Studies, Indiana University
Residency: Triple Board, Indiana University School of Medicine
Board Certificatoins/Certifications: Pediatrics
|Current Academic Interests
Teaching: Involved in teaching medical students, residents, and child fellows at LaRue Carter hospital as well as Riley Outpatient Center. Currently a preceptor for ICM-I for MS1 students and provide MS3 students with lectures on depression during their Pediatric Clerkship.
Clinical: Provides psychiatric care for the Adolescent Boys unit at LaRue Carter State Hospital, as well as pediatric care to the Youth Services division. Sees pediatric primary care patients in the Riley MSA1 clinic as well.
Research: No current research.
|Recent Publications


text: 3 Dan's Twitter Funny Pic. May 5, 2011 by Sybuu http://twitpic.com/4tf3f2 Thoughts on what this could be for or how this happened? Read more > Retrieved from "http://icarly.wikia.com/wiki/User_blog:Sybuu" Ad blocker interference detected! Wikia is a free-to-use site that makes money from advertising. We have a modified experience for viewers using ad blockers Wikia is not accessible if you've made further modifications. Remove the custom ad blocker rule(s) and the page will load as expected.


text:
MacCarthy, Fiona
From Library of Congress Name Authority File
MacCarthy, Fiona
Instance Of
Scheme Membership(s)
Collection Membership(s)
- Mellor, Fiona MacCarthy
Additional Information
Birth Date
- (edtf) 1940-01-23
- female
Associated Language
Exact Matching Concepts from Other Schemes
- found: Author's All things bright and beautiful design in Britain ... 1972.
- found: William Morris, 1994: t.p. (Fiona MacCarthy) jkt. (authority on British 20th cent. visual arts; biographer)
- found: Anarchy & beauty, 2014: page 165 (Fiona MacCarthy, curator)
- found: Wikipedia, June 27, 2016 (Fiona MacCarthy; Fiona MacCarthy, OBE (born 23 January 1940) is a British biographer and cultural historian best known for her studies of 19th and 20th century art and design; in 1966 she married the Sheffield-based silversmith and cutlery designer David Mellor; se began her career on The Guardian in the 1960s as a features writer and columnist before becoming a biographer and critic; she came to wider attention as a biographer with a once controversial study of the Roman Catholic craftsman and sculptor Eric Gill first published in 1989; MacCarthy is known for her arts essays and reviews, appearing regularly in The Guardian, the Times Literary Supplement and The New York Review of Books; she has contributed to TV and radio arts programmes)
Change Notes
- 1981-02-18: new
- 2016-06-29: revised
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