Infective endocarditis is an infection of the inner surface of the heart, usually the valves. Signs and symptoms may include fever, small areas of bleeding into the skin, heart murmur, feeling tired, and low red blood cell count. Complications may include backward blood flow in the heart, heart failure – the heart struggling to pump a sufficient amount of blood to meet the body's needs, abnormal electrical conduction in the heart, stroke, and kidney failure.

The cause is typically a bacterial infection and less commonly a fungal infection. Risk factors include valvular heart disease, including rheumatic disease, congenital heart disease, artificial valves, hemodialysis, intravenous drug use, and electronic pacemakers. The bacteria most commonly involved are streptococci or staphylococci. Diagnosis is suspected based on symptoms and supported by blood cultures or ultrasound of the heart. There is also a noninfective form of endocarditis.

The usefulness of antibiotics following dental procedures for prevention is unclear. Some recommend them for people at high risk. Treatment is generally with intravenous antibiotics. The choice of antibiotics is based on the results of blood cultures. Occasionally heart surgery is required.

The number of people affected is about 5 per 100,000 per year. Rates, however, vary between regions of the world. Infective endocarditis occurs in males more often than in females. The risk of death among those infected is about 25%. Without treatment, it is almost universally fatal. Improved diagnosis and treatment options have significantly enhanced the life expectancy of patients with infective endocarditis, particularly with congenital heart disease.

Classification
Infective endocarditis is divided into the three categories of acute, subacute, and chronic based on the duration of symptoms. Acute infective endocarditis refers to the presence of signs and symptoms of infective endocarditis that are present for days up to six weeks. If these signs and symptoms persist for more than six weeks but less than three months, this is subacute infective endocarditis. Chronic infective endocarditis refers to the presence of such signs and symptoms when they persist for more than three months.
 Subacute bacterial endocarditis (SBE) is often due to streptococci of low virulence (mainly viridans streptococci) and mild to moderate illness which progresses slowly over weeks and months (>2 weeks) and has low propensity to hematogenously seed extracardiac sites.
 Acute bacterial endocarditis (ABE) is a fulminant illness over days to weeks (<2 weeks), and is more likely due to Staphylococcus aureus, which has much greater virulence or disease-producing capacity and frequently causes metastatic infection.

This classification is now discouraged, because the ascribed associations (in terms of organism and prognosis) were not strong enough to be relied upon clinically. The terms short incubation (meaning less than about six weeks) and long incubation (greater than about six weeks) are preferred.

Culture results
Infective endocarditis may also be classified as culture-positive or culture-negative. By far the most common cause of "culture-negative" endocarditis is prior administration of antibiotics and can occur in up to 31% of cases.

Sometimes microorganisms can take a longer period of time to grow in the culture media, for example Cutibacterium spp. and the HACEK bacteria group. Some organisms are said to be fastidious because they have demanding growth requirements. Some examples include pathogens like Aspergillus species, Brucella species, Coxiella burnetii, Chlamydia species. Due to delay in growth and identification in these cases, patients may be erroneously classified as "culture-negative" endocarditis.

Heart side
Endocarditis can also be classified by the side of the heart affected:
 People who intravenously inject opioids such as heroin or methamphetamine may introduce infection which can travel to the right side of the heart, classically affecting the tricuspid valve, and most often caused by S. aureus.
 Regardless of cause, left-sided endocarditis is the most common, while right-sided endocarditis accounts for 5-10% of cases and is more common in people who inject IV drugs and in patients with congenital heart disease.

Infection setting
Another form of endocarditis is healthcare-associated endocarditis when the infecting organism is believed to be transmitted in a health care setting like hospital, dialysis unit or a residential nursing home. Nosocomial endocarditis is a form of healthcare associated endocarditis in which the infective organism is acquired during a stay in a hospital and it is usually secondary to presence of intravenous catheters, total parenteral nutrition lines, pacemakers, etc.

Valve type
Finally, the distinction between native-valve endocarditis and prosthetic-valve endocarditis is clinically important. Prosthetic valve endocarditis can be early (within 1 year of surgery) or late (> 1 year following valvular surgery).
 Early prosthetic valve endocarditis is usually due to intraoperative contamination or postoperative bacterial contamination which is usually nosocomial in nature.
 Late prosthetic valve endocarditis is usually due to community-acquired microorganisms.

Prosthetic valve endocarditis is commonly caused by Staphylococcus epidermidis as it is capable of growing as a biofilm on plastic surfaces. Cutibacterium acnes  almost exclusively causes endocarditis on prosthetic heart valves.

Signs and symptoms
 Fever occurs in 97% of people; malaise and endurance fatigue in 90% of people.
 A new or changing heart murmur, weight loss, and coughing occurs in 35% of people.
 Vascular phenomena: septic embolism (a piece of infected debris or tissue breaking off and traveling through the bloodstream to a distant site) (causing thromboembolic problems such as a stroke or gangrene of the fingers), Janeway lesions (painless hemorrhagic cutaneous lesions on the palms and soles), bleeding in the brain, conjunctival hemorrhage, splinter hemorrhages, kidney infarcts, and splenic infarcts. Infective endocarditis can also lead to the formation of mycotic aneurysms.
 Immunologic phenomena: glomerulonephritis which allows for blood and albumin to enter the urine, Osler's nodes ("ephemeral spots of a painful nodular erythema, chiefly in the skin of the hands and feet"), Roth's spots on the retina, positive serum rheumatoid factor
 Other signs may include night sweats, rigors, anemia, spleen enlargement

Cause
Many microorganisms can cause infective endocarditis. These are generally isolated by blood culture, where the patient's blood is drawn and any growth is noted and identified. The term bacterial endocarditis (BE) commonly is used, reflecting the fact that most cases of IE are due to bacteria; however, infective endocarditis (IE) has become the preferred term.

Bacterial
Staphylococcus aureus is the leading cause of infective endocarditis in most parts of the world and is responsible for about 31% of cases. Staphylococcus aureus is the most common cause of endocarditis in people who use intravenous drugs. Viridans streptococci and Enterococci are the second and third most common organisms responsible for infective endocarditis. Viridans streptococci are a common cause of infective endocarditis in South America. Other Streptococci  are also a frequent cause. Infective endocarditis due to Streptococcus bovis occurs more commonly in Europe than in North America. HACEK group of bacteria are also rare causes of infective endocarditis in North America.

The viridans group includes S. oralis, S. mitis, S. sanguis, S. gordonii and S. parasanguis. The primary habitats for these organisms are the oral cavity and upper respiratory tract. These bacteria are present in the normal oral flora and enter the bloodstream due to disruption of tissues in the mouth when dental surgical procedures are performed (tooth extractions) or genitourinary manipulation. Similarly, HACEK organisms are a group of bacteria that live on the dental gums and can be seen with people who inject drugs who contaminate their needles with saliva. Patients may also have a history of poor dental hygiene or pre-existing valvular disease.

Viridans alpha-hemolytic streptococci, that are present in the mouth, are the most frequently isolated microorganisms when the infection is acquired in a community setting. In contrast, Staphylococcus bloodstream infections are frequently acquired in a health care setting where they can enter the bloodstream through procedures that cause breaks in the integrity of skin, such as surgery, catheterization, or during access of long term indwelling catheters or secondary to intravenous injection of recreational drugs.

Enterococcus can enter the bloodstream as a consequence of abnormalities in the gastrointestinal or genitourinary tracts.

Some organisms, when isolated, give valuable clues to the cause, as they tend to be specific.
 Pseudomonas species, which are very resilient organisms that thrive in water, may contaminate street drugs that have been contaminated with drinking water. P. aeruginosa can infect a child through foot punctures, and can cause both endocarditis and septic arthritis.
 S. bovis and Clostridium septicum, which are part of the natural flora of the bowel, are associated with colon cancers. When they present as the causative agent in endocarditis, it usually prompts a colonoscopy to be done immediately due to concerns regarding spread of bacteria from the colon through the bloodstream due to the cancer breaking down the barrier between the inside of the colon (lumen) and the blood vessels which drain the bowel.
 Less commonly reported bacteria responsible for so called "culture negative endocarditis" include Bartonella, Chlamydia psittaci, and Coxiella. Such bacteria can be identified by serology, culture of the excised valve tissue, sputum, pleural fluid, and emboli, and by polymerase chain reaction or sequencing of bacterial 16S ribosomal RNA.

Multiple case reports of infective endocarditis caused by unusual organisms have been published. Cutibacterium spp., which are normal skin flora, have been responsible for infective endocarditis, preferably in patients with prosthetic heart valves, in rare cases leading to death.Tropheryma whipplei has caused endocarditis without gastrointestinal involvement. Citrobacter koseri was found in an immunocompetent adult. Neisseria bacilliformis was found in a person with a bicuspid aortic valve.

Fungal
Fungal endocarditis (FE) is often fatal and one of the most serious forms of infective endocarditis. The types of fungi most seen associated with this disease are:

Candida albicans is found as a spherical or oval budding yeast. It is associated with endocarditis in people who inject drugs, patients with prosthetic valves, and immunocompromised patients. It forms biofilms around thick-walled resting structures like prosthetic heart valves and additionally colonizes and penetrates endothelial walls. C. albicans is responsible for 24-46% of all the cases of FE, and its mortality rate is 46.6–50%.

Other fungi demonstrated to cause endocarditis are Histoplasma capsulatum and Aspergillus. Aspergillus contributes to roughly 25% of FE cases. Endocarditis with Tricosporon asahii has also been reported in a case report.

Risk factors
Risk factors for infective endocarditis are based on the premise that in a healthy individual, bacteremia (bacteria entering the bloodstream) is cleared quickly with no adverse consequences. However, if a heart valve is damaged, the bacteria can attach themselves to the valve, resulting in infective endocarditis. Additionally, in individuals with weakened immune systems, the concentration of bacteria in the blood can reach levels high enough to increase the probability that some will attach to the valve. Some significant risk factors are listed here:
 Artificial heart valves
 Intracardiac devices, such as implantable cardioverter-defibrillators
 Unrepaired cyanotic congenital heart defects
 History of infective endocarditis
 Neoplastic disease
 Chronic rheumatic heart disease, which is an autoimmune response to repeated Streptococcus pyogenes infection (mostly in the developing world)
 Age-related degenerative valvular lesions
 Congenital heart valve abnormalities
 Hemodialysis, a medical procedure that filters the blood of individuals with kidney failure
 Poor oral hygiene
 Coexisting conditions, especially ones that suppress immunity. Diabetes mellitus, alcohol use disorder, chronic liver disease, HIV/AIDS, and intravenous drug use all fall in this category
More detailed descriptions of these and other risk factors are provided below.

Other conditions that result in large numbers of bacteria entering into the bloodstream include colorectal cancer (mostly Streptococcus bovis), serious urinary tract infections (mostly enterococci), and drug injection (Staphylococcus aureus). With a large number of bacteria, even a normal heart valve may become infected.

A more virulent organism (such as Staphylococcus aureus) can cause infective endocarditis by infecting even a normal heart valve.

People who inject drugs tend to get their right-sided heart valves infected because the veins that are injected drain into the right side of the heart. In rheumatic heart disease, infection occurs on the aortic and the mitral valves on the left side of the heart.

Other factors that increase the risk of developing infective endocarditis are low levels of white blood cells, immunodeficiency or immunosuppression, malignancy, diabetes mellitus, and excessive alcohol use.

Dental operations
In the past, one in eight cases of infective endocarditis was because of bacteremia caused by dental procedures (in most cases due to Streptococcus viridans, which reside in the oral cavity), such as cleaning or extraction of a tooth. This was thought to be more clinically significant than it actually was. However, it is important that a dentist or a dental hygienist be told of any heart problems before commencing treatment. Antibiotics are administered to patients with certain heart conditions as a precaution, although this practice has changed in the US, with new American Heart Association guidelines released in 2007, and in the UK as of March 2008 due to new NICE guidelines. Everyday tooth brushing and flossing will similarly cause bacteremia, so a high standard of oral health should be adhered to at all times.

Although there is little evidence to support antibiotic prophylaxis for dental treatment, the current American Heart Association guidelines are highly accepted by clinicians and patients.

Pathogenesis

Damaged valves and endocardium contribute to the development of infective endocarditis. Specifically, the damaged part of a heart valve forms a local blood clot, a condition known as non-bacterial thrombotic endocarditis (NBTE). The platelet and fibrin deposits that form as part of the blood clotting process allow bacteria to take hold and form vegetations. As previously mentioned, the body has no direct methods of combating valvular vegetations because the valves do not have a dedicated blood supply. This combination of damaged valves, bacterial growth, and lack of a strong immune response results in infective endocarditis.

Damage to the valves and endocardium can be caused by:
 Altered, turbulent blood flow. The areas that fibrose, clot, or roughen as a result of this altered flow are known as jet lesions. Altered blood flow is more likely in high pressure areas, so ventricular septal defects or patent ductus arteriosus can create more susceptibility than atrial septal defects.
 Catheters, electrodes, and other intracardiac prosthetic devices.
 Solid particles from repeated intravenous injections.
 Chronic inflammation. Examples include auto-immune mechanisms and degenerative valvular lesions.
The risk factors for infective endocarditis provide a more extensive list of conditions that can damage the heart.

Diagnosis

In general, the Duke criteria should be fulfilled in order to establish the diagnosis of endocarditis. Although the Duke criteria are widely used, they have significant limitations. For example, the sensitivity of the Duke criteria for detecting infective endocarditis decreases when prosthetic heart valves are present.

As the Duke criteria rely heavily on the results of echocardiography, research has addressed when to order an echocardiogram by using signs and symptoms to predict occult endocarditis among people who inject drugs and among non drug-abusing patients. However, this research is over twenty years old and it is possible that changes in the epidemiology of endocarditis and bacteria such as staphylococci make the following estimates incorrect.

The blood tests C reactive protein (CRP) and procalcitonin have not been found to be particularly useful in helping make or rule out the diagnosis.

Ultrasound
Echocardiography is the main type of diagnostic imaging used to establish the diagnosis of infective endocarditis. There are two main types of echocardiography used to assist with the diagnosis of IE: transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE).

The transthoracic echocardiogram has a sensitivity and specificity of approximately 65% and 95% if the echocardiographer believes there is 'probable' or 'almost certain' evidence of endocarditis. However, in endocarditis involving a prosthetic valve, TTE has a sensitivity of approximately 50%, whereas TEE has a sensitivity exceeding 90%. The TEE also has an important diagnostic role when the TTE does not reveal IE but diagnostic suspicion remains high,  since TEE is more sensitive for infective endocarditis and is better able to characterize infection-related damage to the heart valves and surrounding tissues.

Guidelines support the initial use of TTE over TEE in people with abnormal blood cultures, a new heart murmur, and suspected infective endocarditis. TEE is the preferred initial form of imaging in people with suspected infective endocarditis who have a moderate to high pretest probability of infective endocarditis, including people with prosthetic heart valves, blood cultures growing Staphylococcus,  or have an intracardiac device (such as a pacemaker).

Modified Duke criteria
Established in 1994 by the Duke Endocarditis Service and revised in 2000, the Duke criteria are a collection of major and minor criteria used to establish a diagnosis of infective endocarditis. According to the Duke criteria, diagnosis of infective endocarditis can be definite, possible, or rejected. A diagnosis of infective endocarditis is definite if either the following pathological or clinical criteria are met:

One of these pathological criteria:
 Histology or culture of cardiac vegetation, embolized vegetation, or intracardiac abscess from the heart finds microorganisms
 Active endocarditis
One of these combinations of clinical criteria
 Two major clinical criteria
 One major and three minor criteria
 Five minor criteria
Diagnosis of infective endocarditis is possible if one of the following combinations of clinical criteria is met:
 One major and one minor criteria
 Three minor criteria are fulfilled

Major criteria
Positive blood culture with typical IE microorganism, defined as one of the following:
 Typical microorganism consistent with IE from two separate blood cultures, as noted below:
 Viridans-group streptococci, or
 Streptococcus bovis including nutritional variant strains, or
 HACEK group, or
 Staphylococcus aureus, or
 Community-acquired enterococci, in the absence of a primary focus
 Microorganisms consistent with IE from persistently positive blood cultures defined as:
 Two positive cultures of blood samples drawn >12 hours apart, or
 Three or a majority of ≥four separate blood cultures (with first and last sample drawn at least one hour apart)
 Coxiella burnetii detected by at least one positive blood culture or IgG antibody titer for Q fever phase 1 antigen >1:800. This was previously a minor criterion
Evidence of endocardial involvement with positive echocardiogram is defined as
 Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation, or
 Abscess, or
 New partial dehiscence of prosthetic valve or new valvular regurgitation (worsening or changing of preexisting murmur not sufficient)

Minor criteria
 Predisposing factor: known cardiac lesion, recreational drug injection
 Fever >38 °C
 Vascular phenomena: arterial emboli, pulmonary infarcts, Janeway lesions, conjunctival hemorrhage
 Immunological phenomena: glomerulonephritis, Osler's nodes, Roth's spots, Rheumatoid factor
 Microbiologic evidence: Positive blood culture (that doesn't meet a major criterion) or serologic evidence of infection with organism consistent with IE but not satisfying major criterion

Risk
Among people who do not use intravenous drugs and have a fever in the emergency department, there is a less than 5% chance of occult endocarditis. Mellors in 1987 found no cases of endocarditis nor of staphylococcal bacteremia among 135 febrile patients in the emergency room. The upper confidence interval for 0% of 135 is 5%, so for statistical reasons alone, there is up to a 5% chance of endocarditis among these patients. In contrast, Leibovici found that among 113 non-selected adults admitted to the hospital because of fever there were two cases (1.8% with 95%CI: 0% to 7%) of endocarditis.

Among people who do use intravenous drugs and have a fever in the emergency department, there is about a 10% to 15% prevalence of endocarditis. This estimate is not substantially changed by whether the doctor believes the patient has a trivial explanation for their fever. Weisse found that 13% of 121 patients had endocarditis. Marantz also found a prevalence of endocarditis of 13% among such patients in the emergency department with fever. Samet found a 6% incidence among 283 such patients, but after excluding patients with initially apparent major illness to explain the fever (including 11 cases of manifest endocarditis), there was a 7% prevalence of endocarditis. During the Opioid epidemic in the United States, hospitals observed an increase in stroke associated with infective endocarditis.

Among people with staphylococcal bacteremia (SAB), one study found a 29% prevalence of endocarditis in community-acquired SAB versus 5% in nosocomial SAB. However, only 2% of strains were resistant to methicillin and so these numbers may be low in areas of higher resistance.

Prevention
Not all people with heart disease require antibiotics to prevent infective endocarditis. Heart diseases have been classified into high, medium and low risk of developing IE. Those falling into high risk category require IE prophylaxis before endoscopies and urinary tract procedures.
Diseases listed under high risk include:
 Prior endocarditis
 Unrepaired cyanotic congenital heart diseases
 Completely repaired congenital heart disease in their first 6 months
 Prosthetic heart valves or valves repaired with any prosthetic material
 Incompletely repaired congenital heart diseases
 Cardiac transplant valvulopathy

Following are the antibiotic regimens recommended by the American Heart Association for antibiotic prophylaxis:
 Oral amoxicillin one hour before the procedure
 Intravenous or intramuscular ampicillin one hour before the procedure
In patients allergic to penicillins
 Azithromycin or clarithromycin orally one hour before the procedure
 Cephalexin orally one hour before the procedure
 Clindamycin orally one hour before the procedure

In the UK, NICE clinical guidelines no longer advise prophylaxis because there is no clinical evidence that it reduces the incidence of IE and there are negative effects (e.g. allergy and increased bacterial resistance) of taking antibiotics that may outweigh the benefits.

Antibiotics were historically commonly recommended to prevent IE in those with heart problems undergoing dental procedures (known as dental antibiotic prophylaxis). There is, however, insufficient evidence to support whether antibiotics are effective or ineffective at preventing IE when given prior to a dental procedures in people at high risk. They are less commonly recommended for this procedure.

In some countries e.g. the US, high risk patients may be given prophylactic antibiotics such as penicillin or clindamycin for penicillin-allergic people prior to dental procedures. Prophylactics should be bactericidal rather than bacteriostatic. Such measures are not taken in certain countries e.g. Scotland due to the fear of antibiotic resistance. Because bacteria are the most common cause of infective endocarditis, antibiotics such as penicillin and amoxicillin (for beta lactamase-producing bacteria) are used in prophylaxis.

Treatment
High-dose antibiotics are the cornerstone of treatment for infective endocarditis. These antibiotics are administered by the intravenous (IV) route to maximize diffusion of antibiotic molecules into vegetation(s) from the blood filling the chambers of the heart. This is necessary because neither the heart valves nor the vegetations adhering to them are supplied by blood vessels. Antibiotics are typically continued for two to six weeks depending on the characteristics of the infection and the causative microorganisms. Antibiotic treatment lowers the risk of embolic complications in people with infective endocarditis.

In acute endocarditis, due to the fulminant inflammation, empirical antibiotic therapy is started immediately after the blood has been drawn for culture to clarify the bacterial organisms responsible for the infection. This usually includes vancomycin and ceftriaxone IV infusions until the infecting organism is identified and the susceptibility report with the minimum inhibitory concentration becomes available. Once this information is available, this allows the supervising healthcare professional to modify the antimicrobial therapy to target the specific infecting microorganism. The routine use of gentamicin to treat endocarditis has fallen out of favor due to the lack of evidence to support its use (except in infections caused by Enterococcus and nutritionally variant streptococci) and the high rate of complications. In cases of subacute endocarditis, where the person's hemodynamic status is usually stable, antibiotic treatment can be delayed until the causative microorganism can be identified.

Viridans group streptococci and Streptococcus bovis are usually highly susceptible to penicillin and can be treated with penicillin or ceftriaxone. Relatively resistant strains of viridans group streptococci and Streptococcus bovis are treated with penicillin or ceftriaxone along with a shorter two-week course of an aminoglycoside during the initial phase of treatment. Highly penicillin-resistant strains of viridans group streptococci, nutritionally variant streptococci like Granulicatella sp., Gemella sp., Abiotrophia defectiva, and Enterococci are usually treated with a combination therapy consisting of penicillin and an aminoglycoside for the entire duration of 4–6 weeks.

Some people may be treated with a relatively shorter course of treatment (two weeks) with benzyl penicillin IV if infection is caused by viridans group streptococci or Streptococcus bovis as long as the following conditions are met:
 Endocarditis of a native valve, not of a prosthetic valve
 A MIC ≤ 0.12 mg/l
 A complication such as heart failure, arrhythmia, or pulmonary embolism occurs
 No evidence of extracardiac complication like septic thromboembolism
 No vegetations > 5 mm in diameter conduction defects
 Rapid clinical response and clearance of bloodstream infection

Additionally, oxacillin-susceptible Staphylococcus aureus native valve endocarditis of the right side can also be treated with a short 2-week course of a beta-lactam antibiotic such as nafcillin with or without aminoglycosides.

The main indication for surgical treatment is regurgitation or stenosis. In active infective endocarditis, the surgery should remove enough leaflet tissue to ensure eradication of the infectious process. Subsequent valve repair can be performed in limited disease. Replacement of the valve with a mechanical or bioprosthetic artificial heart valve is necessary in certain situations:
 Patients with significant valve stenosis or regurgitation causing heart failure
 Evidence of hemodynamic compromise in the form of elevated end-diastolic left ventricular or left atrial pressure or moderate to severe pulmonary hypertension
 Presence of intracardiac complications like paravalvular abscess, conduction defects or destructive penetrating lesions
 Recurrent septic emboli despite appropriate antibiotic treatment
 Large vegetations (> 10 mm)
 Persistently positive blood cultures despite appropriate antibiotic treatment
 Prosthetic valve dehiscence
 Relapsing infection in the presence of a prosthetic valve
 Abscess formation
 Early closure of mitral valve
 Infection caused by fungi or resistant Gram-negative bacteria.

The guidelines were recently updated by both the American College of Cardiology and the European Society of Cardiology. There was a recent meta-analysis published that showed surgical intervention at seven days or less is associated with lower mortality.

Prognosis
Infective endocarditis is associated with 18% in-hospital mortality. However, adult patients with congenital heart disease can have relatively lower mortality down to 5% due to younger age, right-sided endocarditis and management by multidisciplinary teams. As many as 50% of people with infective endocarditis may experience embolic complications.

Epidemiology
In developed countries, the annual incidence of infective endocarditis is 3 to 9 cases per 100,000 persons. Infective endocarditis occurs more often in men than in women. There is an increased incidence of infective endocarditis in persons 65 years of age and older, which is probably because people in this age group have a larger number of risk factors for infective endocarditis. In recent years, over one-third of infective endocarditis cases in the United States was healthcare-associated. Another trend observed in developed countries is that chronic rheumatic heart disease accounts for less than 10% of cases. Although a history of valve disease has a significant association with infective endocarditis, 50% of all cases develop in people with no known history of valvular disease.

History

Lazare Riviére first described infective endocarditis affecting the aortic valve in 1616. In 1806, Jean-Nicolas Corvisart coined the term vegetation to describe collections of debris found on a mitral valve affected by infective endocarditis. The British physician Joseph Hodgson was the first to describe the embolic complications of infective endocarditis in 1815. It was not until 1878 that Theodor Klebs first suggested that infective endocarditis had a microbial infectious origin. In 1909, William Osler noted that heart valves that experienced degeneration and were sclerotic or poorly functioning had a higher risk of being affected. Later, in 1924, Emanuel Libman and Benjamin Sacks described cases of vegetative endocarditis that lacked a clear microbial origin and were often associated with the autoimmune condition systemic lupus erythematosus. In 1944, physicians reported on the first successful use of penicillin to treat a case of infective endocarditis.

References

External links

Valvular heart disease
Wikipedia medicine articles ready to translate

Infective endocarditis


Jurij Jakovenko ( ; født 3. september 1993 i Montbéliard, Doubs, Frankrig) er en ukrainsk professionel fodboldspiller, der spiller som angriber for Hamkam.

Personlige liv
Han er den yngste søn af den ukrainske tidligere fodboldspiller og nuværende træner Pavlo Jakovenko . Hans ældre bror Oleksandr Jakovenko er også fodboldspiller.

Referencer

Eksterne henvisninger

Fodboldspillere fra Esbjerg fB
Fodboldspillere fra Anorthosis Famagusta
Fodboldspillere fra AC Ajaccio
Angribere (fodbold)
Fodboldspillere fra Ukraine
Pages with unreviewed translations

Jurij Jakovenko


Lavaud ist der Familienname folgender Personen:

 Franck Lavaud (1903–1986), haitianischer General und Politiker
 Jean-Claude Lavaud (1938–2011), französischer Fußballspieler
 René Lavaud (1874–1955), französischer Romanist und Okzitanist
 Rose Lavaud (* 1992), französische Fußballspielerin
 Sophie Lavaud (* 1968), französisch-schweizerisch-kanadische Referentin und Alpinistin

Lavaud steht für:

 Lavaud (Fluss), ein Nebenfluss der Creuse

Lavaud


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Die Bahnstrecke Örebro–Pålsboda war eine schmalspurige Eisenbahnstrecke zwischen Pålsboda in Östergötland und Örebro in Närke in Schweden. Sie hatte eine Spurweite von 891 mm und wurde von der Norra Östergötlands järnvägsaktiebolag (NÖJ) errichtet.

Geschichte
Die Norra Östergötlands järnvägsaktiebolag wurde am 30. November 1895 gegründet. Zweck der Gesellschaft war der Erwerb der Pålsboda–Finspång järnvägsaktiebolag und der Finspång–Norsholms järnvägsaktiebolag, um deren Strecken zwischen Pålsboda und Finspång sowie Finspång und Norsholm gemeinsam zu betreiben.

Hinter dieser gesamten Entwicklung stand Patron Carl Edvard Ekman. Er war derjenige, der mit starker Unterstützung von Kommunen und Privatpersonen die Pålsboda–Finspångs järnväg erbaut hatte. Ebenso hatte er hauptsächlich mit eigenen Mitteln die Finspång–Norsholms järnväg errichtet. Es war sein Vorschlag, die beiden Bahnen zur Norra Östergötlands järnvägsaktiebolag (NÖJ) zu verschmelzen.

Bau der Strecke
Nach der Zusammenführung der beiden Strecken begann die Planung für eine Erweiterung. Örebro war in unmittelbarer Nähe. Deshalb wurde ein großes Frachtaufkommen erwartet. Der Vorstand genehmigte 1897 dem Bahningenieur J. Grönvall, eine Streckenführung von Pålsboda über den trockengelegten Kvismarssjö und weiter nach Örebro zu untersuchen. Die Konzession wurde von Bankier B. Söderbaum, Buchhalter N. H. Jochimsson, Oberstleutnant G. Falkengren und Hütteninhaber O. Lundqvist beantragt und am 13. August 1897 erteilt. Diese wurde am 12. April 1898 auf die NÖJ übertragen. Das notwendige Geld für den Streckenbau erhielt man durch den Verkauf von neuen Aktien und durch Hypotheken. Steigende Arbeitskosten forderten eine neue Kostenschätzung. Leutnant Blomberg vom Weg- und Wasserbaubüro berechnete die neuen Kosten auf 730.000 Kronen gegenüber dem alten Vorschlag von 650.000 Kronen. Die Kosten für den Bahnbau, aber ohne Rollmaterial, schätzten Leutnant K. A. Lagergren und Ingenieur A. Sjögren dagegen auf 415.000 Kronen. Die Gesellschaft ging aber nicht auf dieses Angebot ein.

Nun beschloss die Gesellschaft, die Strecke nach Örebro selbst zu bauen. Blomberg wurde als Vorarbeiter eingestellt. Vor dem Baubeginn legte man die jeweiligen Anschlüsse an das bestehende Netz in Örebro Södra und Pålsboda fest. Für den Anschluss in Örebro gab es keine Hindernisse, in Pålsboda war es komplizierter. NÖJ wollte die Västra stambanan niveaugleich überqueren, doch die Königlichen Eisenbahnverwaltung hatte eine andere Ansicht. Sie wollte kein Kreuzung mit der Schmalspurbahn. Nach Verhandlungen wurde vereinbart, dass die Strecke 850 m westlich des Bahnhofs die Staatsbahn unterqueren sollte. Die zusätzlichen Kosten wurden auf 35.000 Kronen berechnet. Dies bedeutete auch, dass die Strecke nach Finspång 4,6 Kilometer länger werden würde. Diese Veränderung erschwerte und verteuerte in den nächsten Jahren den Bau. Nachfolgende Untersuchungen zeigten, dass mit verschiedenen Änderungen die Verlängerung auf 2,9 Kilometer reduziert werden konnten.

Die Arbeiten an der Bahnstrecke Örebro–Pålsboda begannen am 1. April 1899 und mit der Fertigstellung wurde am 1. Oktober 1900 gerechnet. Die Kostenschätzung erwies sich als zu niedrig. Hinzu kam ein Streit mit der Stadt Örebro wegen einer Straßenkreuzung, der nur durch einen länger dauernden Prozess geklärt werden konnte. Daher musste für die Fertigstellung der Strecke ein Aufschub vom Königlichen Baubüro beantragt werden. Die Eisenbahn wurde am 5. Januar 1901 für die öffentliche Nutzung freigegeben. Die Streckenhöchstgeschwindigkeit wurde mit 40 km/h angegeben. Die Summe der Baukosten erreichte 1.026.000 Kronen. Nachträglich stellte sich heraus, dass mit dem Angebot von Lagergren die Strecke sehr wahrscheinlich viel billiger geworden wäre.

Die weitere Streckengeschichte ist unter Bahnstrecke Örebro–Norrköping zu finden.

Weblinks
 Geschichte der Norra Östergötlands Järnvägar bei historiskt.nu (schwedisch)

Einzelnachweise

Bahnstrecke in Örebro län
Bahnstrecke in Östergötlands län

Bahnstrecke Örebro–Pålsboda


Una erupción acneiforme se refiere a una erupción cutánea similar al acné. Se refiere a un grupo de dermatosis, incluyendo el acné vulgar, rosácea, foliculitis y dermatitis perioral.

La terminología utilizada en este campo puede ser compleja y a veces contradictoria. Algunas fuentes consideran al acné vulgar en el diagnóstico diferencial de una erupción acneiforme. Otras fuentes clasifican al acné vulgar como una erupción acneiforme. El término MeSH excluye explícitamente la dermatitis perioral de la categoría de "erupciones acneiformes", aunque agrupa a las erupciones acneiformes y la dermatitis perioral bajo "dermatosis faciales".

Véase también
Dermatitis

Referencias

Enlaces externos
 Imágenes de casos
 Erupción acneiforme en imagenmed.com
 mediagraphic

Enfermedades cutáneas

Erupción acneiforme


The Barnabas Fund is an international, interdenominational Christian aid agency based in Coventry, in the West Midlands of England that supports Christians who face discrimination or persecution as a consequence of their faith. It was established in 1993 and channels aid to projects run by national Christians in more than 50 countries.  It also campaigns in particular for the abolition of the Islamic apostasy law. The headquarters is based at The Rectory in Pewsey, Wiltshire.

See also
Persecution of Christians

References

External links
Barnabas Fund Official site
Bi-monthly magazine

Evangelical parachurch organizations
Organisations based in Coventry
1993 establishments in England
Religion in Warwickshire

Barnabas Aid


La harmina es un alcaloide fluorescente perteneciente a la familia de las beta-carbolinas. Se encuentra en varias plantas, notablemente en la planta de harmal del Medio Oriente (Peganum harmala) también conocida como ruda siria, en la liana sudamericana Banisteriopsis caapi y en Zygophyllum fabago. Se ha encontrado también en las exudaciones de las raíces de la oca (Oxalis tuberosa) transformadas por Agrobacterium rhizogenes.

La harmina es un inhibidor reversible de la monoamina oxidasa A (MAO-A), una enzima que degrada las monoaminas. La harmina se une selectivamente a la MAO-A pero no inhibe la variante MAO-B.

Usos

Entre las monoaminas se incluyen neurotransmisores (serotonina, dopamina), hormonas (melatonina) y drogas, así como muchos alucinógenos (psilocybina, dimetiltriptamina (DMT), mescalina). Al retardar la degradación de los neurotrasmisores, los inhibidores de la monoamina oxidasa (IMAO) pueden ayudar a incrementar las reservas de estos productos, y muchos IMAO se usan como  antidepresivos. La harmina no ha sido objeto de muchas investigaciones clínicas en el tratamiento de la depresión, lo que puede en parte ser debido a su restricción legal en muchos países, así como a la existencia de IMAO sintéticos con menos efectos colaterales.

P. harmala y B. caapi se han usado por sus efectos psicoactivos. B. caapi tiene tradición de uso combinado con plantas que contienen la droga  DMT. Tradicionalmente B. caapi se consume en forma de bebida, con la planta que contiene DMT o sin ella (véase ayahuasca). Ordinariamente, la DMT no es activa cuando se toma oralmente, pero los usuarios reportan efectos muy diferentes cuando la DMT está presente en tales brebajes. La harmina y sustancias que la contienen se han usado junto con otras drogas por los experimentadores modernos. Muchos alucinógenos parecen aumentar su potencial  cuando se usan en esta forma.
La harmina también se usa como un indicador fluorescente de pH.  Cuando aumenta el pH del medio, la emisión de fluorescencia de la harmina decrece.

Con el radioisótopo carbono 11 la harmina se usa en neuroimágenes por tomografía de emisión de positrones para examinar su unión a MAO-A.

Se ha encontrado harmina en las exudaciones de las raíces de la oca (Oxalis tuberosa) transformadas por Agrobacterium rhizogenes. La harmina y harmalina exududadas tienen propiedades antimicrobianas.

También se ha descubierto que la harmina incrementa la expresión de la bomba de glutamato EAAT2 en sistema nervioso central reduciendo, por lo tanto, la toxicidad del glutamato.

Referencias

Alcaloides
Alucinógenos

Harmina


Kaiser Permanente (; KP) is an American integrated managed care consortium, based in Oakland, California, United States, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney Garfield. Kaiser Permanente is made up of three distinct but interdependent groups of entities: the Kaiser Foundation Health Plan, Inc. (KFHP) and its regional operating subsidiaries; Kaiser Foundation Hospitals; and the regional Permanente Medical Groups. As of 2023, Kaiser Permanente operates in eight states (Hawaii, Washington, Oregon, California, Colorado, Maryland, Virginia, Georgia) and the District of Columbia, and is the largest managed care organization in the United States.

Kaiser Permanente operates 39 hospitals and more than 700 medical offices, with over 300,000 personnel, including more than 87,000 physicians and nurses.

Each Permanente Medical Group operates as a separate for-profit partnership or professional corporation in its individual territory, and while none publicly reports its financial results, each is primarily funded by reimbursements from its respective regional Kaiser Foundation Health Plan entity. KFHP is one of the largest not-for-profit organizations in the United States.

KP's quality of care has been highly rated and attributed to an emphasis on preventive care, its doctors being salaried rather than paid on a fee-for-service basis, and an attempt to minimize the time patients spend in high-cost hospitals by carefully planning their stay. However, Kaiser has had disputes with its employees' unions; repeatedly faced civil and criminal charges for falsification of records and patient dumping; faced action by regulators over the quality of care it provided, especially to patients with mental health issues; and faced criticism from activists and action from regulators over the size of its cash reserves.

Structure and governance

Kaiser Permanente provides care throughout eight regions in the United States. Two or three (four, in the case of California) distinct but interdependent legal entities form the Kaiser system within each region. This structure was adopted by Kaiser Permanente physicians and leaders in 1955.

Governance
Each entity of Kaiser Permanente has its own management and governance structure, although all of the structures are interdependent and cooperative to a great extent. There are multiple affiliated nonprofits registered with the U.S. Internal Revenue Service. According to Form 990 governance questions, Kaiser Foundation Hospitals and Kaiser Foundation Health Plan do not have members with the power to appoint or elect board members, meaning that the board itself nominates and appoints new members.

James A. Vohs was appointed CEO in 1978 and chairman in 1980, and he would serve until his retirement in 1992.  He was the first chairman to not be a member of the Kaiser family.

David M. Lawrence served as chairman and CEO until his retirement in 2002.

George Halvorson became the chairman and CEO until his retirement in December 2013.

On November 5, 2012, the board of directors announced that Bernard J. Tyson, Kaiser's president and chief operating officer for the last two years, would replace Halvorson, marking the first time an African American was appointed as chairman. Tyson died in November 2019.
Greg A. Adams assumed the role of chairman and CEO in December 2019.

Operations
As of 2022, Kaiser Permanente had 12.6 million health plan members, 216,776 employees, 23,597 physicians, 63,847 nurses, 39 medical centers, and 724 medical facilities. As of December 31, 2022, the nonprofit Kaiser Foundation Health Plan and Kaiser Foundation Hospitals entities reported an operating loss of $1.3 billion in net income on $95.4 billion in operating revenues.

The two types of organizations which make up each regional entity are:
 Kaiser Foundation Health Plans (KFHP) work with employers, employees, and individual members to offer prepaid health plans and insurance. The health plans are not-for-profit and provide infrastructure for and invest in Kaiser Foundation Hospitals and provide a tax-exempt shelter for the for-profit medical groups.
 Permanente Medical Groups are physician-owned organizations, which provide and arrange for medical care for Kaiser Foundation Health Plan members in each respective region. The medical groups are for-profit partnerships or professional corporations and receive nearly all of their funding from Kaiser Foundation Health Plans. The first medical group, The Permanente Medical Group (TPMG), formed in 1948 in Northern California, is one of the largest doctors groups in the United States with 11,225 medical professionals and 186 locations at the beginning of 2023. Permanente physicians become stockholders in TPMG after three years at the company.

In addition, Kaiser Foundation Hospitals (despite the plural name, a single legal entity) operates medical centers in California, Oregon, and Hawaii, and outpatient facilities in the remaining Kaiser Permanente regions. The hospital foundation entity is not-for-profit and relies on the Kaiser Foundation Health Plans for funding. It also provides infrastructure and facilities that benefit the for-profit medical groups.

Regional entities
Kaiser Permanente is administered through eight regions, including one parent and six subordinate health plan entities, one hospital entity, and nine separate, affiliated medical groups:

 Northern California, 3,351,449 members
 Kaiser Foundation Health Plan, Inc. (KFHP)
 Kaiser Foundation Hospitals (KFH)
 The Permanente Medical Group, Inc. (TPMG)
 Southern California, 3,499,035 members
 Kaiser Foundation Health Plan, Inc. (KFHP)
 Kaiser Foundation Hospitals (KFH)
 Southern California Permanente Medical Group (SCPMG)
 Colorado, 531,908 members
 Kaiser Foundation Health Plan of Colorado (KFHPCO)
 Colorado Permanente Medical Group, P.C. (CPMG)
 Georgia, 222,074 members
 Kaiser Foundation Health Plan of Georgia, Inc. (KFHPGA)
 The Southeast Permanente Medical Group, Inc. (TSPMG)
 Hawaii, 226,900 members
 Kaiser Foundation Health Plan, Inc. (KFHP)
 Kaiser Foundation Hospitals (KFH)
 Hawaii Permanente Medical Group, Inc. (HPMG)
 Mid-Atlantic (vicinity of Washington, D.C., including Maryland and Virginia), 581,000 members
 Kaiser Foundation Health Plan of the Mid-Atlantic States Inc. (KFHPMA)
 Mid-Atlantic Permanente Medical Group, P.C. (MAPMG)
 Northwest (Northwest Oregon and Southwest Washington), 480,386 members
 Kaiser Foundation Health Plan of the Northwest (KFHPNW)
 Kaiser Foundation Hospitals (KFH)
 Northwest Permanente, P.C. Physicians and Surgeons (NWP)
 Washington (except Southwest Washington), 681,386 members
Kaiser Foundation Health Plan of Washington
Washington Permanente Medical Group (Group Health Cooperative before 2017)

In addition to the regional entities, in 1997, the then-twelve Permanente Medical Groups created The Permanente Federation LLC, a separate entity, which focuses on standardizing patient care and performance under one name and system of policies. Around the same time, The Permanente Company was also chartered as a vehicle to provide investment opportunities for the for-profit Permanente Medical Groups. One of the ventures of the Permanente Company is Kaiser Permanente Ventures, a venture capital firm that invests in emerging medical technologies.

Lobbying entity

A mutual benefit corporation named "Kaiser Foundation for the Advancement of Integrated Health Care" was established on December 27, 2017. The specific purpose of the corporation is "to advocate for and promote the integrated models of health care". The corporation's founder, Maryann Bodayle, has served as the "Governance Administrator" of Kaiser Foundation Health Plan, Inc. since 2013.

History

Early years
The history of Kaiser Permanente dates to 1933 and a tiny hospital in the town of Desert Center, California. At that time, Henry J. Kaiser and several other large construction contractors had formed an insurance consortium called Industrial Indemnity to meet their workers' compensation obligations. Sidney Garfield had just finished his residency at Los Angeles County-USC Medical Center at a time when jobs were scarce; he was able to secure a contract with Industrial Indemnity to care for 5,000 construction workers building the Colorado River Aqueduct in the Mojave Desert. Soon enough, Garfield's new hospital was in a precarious financial state (with mounting debt and the staff of three going unpaid), due in part to Garfield's desire to treat all patients regardless of ability to pay, as well as his insistence on equipping the hospital adequately so that critically injured patients could be stabilized for the long journey to full-service hospitals in Los Angeles.

However, Garfield won over two Industrial Indemnity executives, Harold Hatch and Alonzo B. Ordway. It was Hatch who proposed to Garfield the specific solution that would lead to the creation of Kaiser Permanente: Industrial Indemnity would prepay 17.5% of premiums, or $1.50 per worker per month, to cover work-related injuries, while the workers would each contribute five cents per day to cover non-work-related injuries. Later, Garfield also credited Ordway with coming up with the general idea of prepayment for industrial health care and explained that he did not know much at the time about other similar health plans except for the Ross-Loos Medical Group.

Hatch's solution enabled Garfield to bring his budget back into the positive, and to experiment with providing a broader range of services to the workers besides pure emergency care. By the time work on the aqueduct concluded and the project was wrapped up, Garfield had paid off all of his debts, was supervising ten physicians at three hospitals, and controlled a financial reserve of $150,000.

Garfield returned to Los Angeles for further study at County-USC with the intent of entering private practice. However, in March 1938, Consolidated Industries (a consortium led by the Kaiser Company) initiated work on a contract for the upper half of the Grand Coulee Dam in Washington state, and took over responsibility for the thousands of workers who had worked for a different construction consortium on the first half of the dam. Edgar Kaiser, Henry's son, was in charge of the project. To smooth over relations with the workers (who had been treated poorly by their earlier employer), Hatch and Ordway persuaded Edgar to meet with Garfield, and in turn Edgar persuaded Garfield to tour the Grand Coulee site. Garfield subsequently agreed to reproduce at Grand Coulee Dam what he had done on the Colorado River Aqueduct project. He immediately spent $100,000 on renovating the decrepit Mason City Hospital and hired seven physicians.

Unlike the workers on Garfield's first project, many workers at Grand Coulee Dam had brought dependents with them. The unions soon forced the Kaiser Company to expand its plan to cover dependents, which resulted in a dramatic shift from industrial medicine into family practice and enabled Garfield to formulate some of the basic principles of Kaiser Permanente. It was also during this time that Henry Kaiser personally became acquainted with Garfield and forged a friendship which lasted until Kaiser's death.

World War II

In 1939, the Kaiser Company began work on several huge shipbuilding contracts in Oakland, and by the end of 1941 would control four major shipyards on the West Coast. During 1940, the expansion of the American defense-industrial complex in preparation for entrance into World War II resulted in a massive increase in the number of employees at the Richmond shipyard. In January 1941, Henry Kaiser asked Garfield to set up an insurance plan for the Richmond workers (this was merely contract negotiation with insurance companies), and a year later Kaiser asked Garfield to duplicate at Richmond what he had done at Desert Center and Mason City. Unlike the two other projects, the resulting entity lived on after the construction project that gave birth to it, and it is the direct ancestor of today's Kaiser Permanente.

On March 1, 1942, Sidney R. Garfield & Associates opened its offices in Oakland to provide care to 20,000 workers, followed by the opening of the Permanente Health Plan on June 1. From the beginning, Kaiser Permanente strongly supported preventive medicine and attempted to educate its members about maintaining their own health.

In July, the Permanente Foundation formed to operate Northern California hospitals that would be linked to the outpatient health plans, followed shortly thereafter by the creation of Northern Permanente Foundation for Oregon and Washington and Southern Permanente Foundation for California. The name Permanente came from Permanente Creek, which flowed past Henry Kaiser's Kaiser Permanente Cement Plant on Black Mountain in Cupertino, California. Kaiser's first wife, Bess Fosburgh, liked the name. An abandoned Oakland facility was modernized as the 170-bed Permanente Hospital opened on August 1, 1942 (this facility evolved over the decades into today's flagship Kaiser Oakland Medical Center). Three weeks later, the 71-bed Richmond Field Hospital opened. Six first aid stations were set up in the shipyards to treat industrial accidents and minor illness. Each first aid station had an ambulance ready to rush patients to the surgical field hospital if required. Stabilized patients could be moved to the larger hospital for recuperative care. The Northern Permanente Hospital opened two weeks later to serve workers at the Kaiser shipyard in Vancouver, Washington. Shipyard workers paid seven cents per day for comprehensive health care coverage, and within a year, the shipyard health plan employed sixty physicians with salaries between $450 and $1,000 per month. These physicians established California Physicians Service to offer similar health coverage to the families of shipyard workers. In 1944, Kaiser decided to continue the program after the war and to open it up to the general public.

Meanwhile, during the war years, the American Medical Association (AMA) (which opposed managed care organizations from their very beginning) tried to defuse demand for managed care by promoting the rapid expansion of the Blue Cross and Blue Shield preferred provider organization networks.

Courage to Heal, a novel by KP Historical Society President Paul Bernstein, MD, is based on the story of Garfield's life, his struggles with the AMA, and the origins of Kaiser Permanente.

Postwar growth
In 1943, Henry J. Kaiser and Dr. Sidney R. Garfield opened a 50-bed hospital, housing six physicians for the 3000 employees and their families at the new Kaiser Steel Mill in Fontana, California, offering a pre-paid health care plan for $0.60/week for adults, and $0.30/week for children. In 1945, the Kaiser Permanente health plan was opened to the public.

In 1948, Kaiser established the Henry J. Kaiser Family Foundation (also known as Kaiser Family Foundation), a U.S.-based nonprofit, private operating foundation focusing on the major health care issues facing the nation. The Foundation, not associated with Kaiser Permanente or Kaiser Industries, is an independent voice and source of facts and analysis for policymakers, the media, the health care community, and the general public.

The end of World War II brought about a huge plunge in Kaiser Permanente membership; for example, 50,000 workers had left the Northern California yards by July 1945. Membership bottomed out at 17,000 for the entire system but then surged back to 26,000 within six months as Garfield aggressively marketed his plan to the public. Sidney Garfield & Associates had been a sole proprietorship, but in 1948, it was reorganized into a partnership, Permanente Medical Group.

During this period, a substantial amount of growth came from union members; the unions saw Kaiser Permanente care as more affordable and comprehensive than what was available at the time from private physicians under the fee-for-service system. For example, Fortune magazine had reported in 1944 that 90% of the U.S. population could not afford fee-for-service health care. Kaiser Permanente membership soared to 154,000 in 1950, 283,000 in 1952, 470,000 in 1954, 556,000 in 1956, and 618,000 in 1958.

From 1944 onward, both Kaiser Permanente and Garfield fought numerous attacks from the AMA and various state and local medical societies. Henry Kaiser came to the defense of both Garfield and the health plans he had created.

In 1951, the organization acquired its current name when Henry Kaiser unilaterally directed the trustees of the health plans, hospital foundations, and medical groups to add his name before Permanente. However, the physicians in the Permanente Medical Group deeply resented the implication that they were directly controlled by Kaiser, and successfully forced him to back off with respect to their part of the organization. That same year, Kaiser Permanente also began experiments with large-scale multiphasic screening to identify unknown conditions and to facilitate treatment of known ones. Simultaneously, although no one questioned his medical competence, Garfield's deficiencies as an executive were becoming apparent as the organization expanded far beyond his ability to manage it properly.

Henry Kaiser became fascinated with the health care system created for him by Garfield and began to directly manage Kaiser Permanente and Garfield. This resulted in a financial disaster when Kaiser splurged on the new Walnut Creek hospital; his constant intermeddling led to significant friction at every level of the organization. The situation was not helped by Kaiser's marriage to Garfield's head administrative nurse (who had helped care for Kaiser's first wife on her deathbed), convincing Garfield to marry the sister of that nurse, and then having Garfield move in next door to him. Clifford Keene (who would eventually serve as president of Kaiser Permanente) later recalled that this arrangement resulted in a rather dysfunctional and combative family in charge of Kaiser Permanente.

Keene was an experienced Permanente physician whom Garfield had personally hired in 1946. During 1953 he had been trying to get a job at U.S. Steel, but on the morning of December 5, 1953, with internal tensions worsening day by day, Garfield met with Keene at the Mark Hopkins Hotel in San Francisco and asked him to turn around the organization. It took Keene 15 years to realize that Kaiser had forced Garfield to ask Keene to become his replacement. Due to the chaos on the board, Keene at first took control with the vague title of Executive Associate, but it soon became clear to everyone that he was actually in charge and Garfield was to become a lobbyist and "ambassador" for the HMO concept.

However, even with Garfield relieved of day-to-day management duties, the underlying problem of Henry Kaiser's authoritarian management style continued to persist. After several tense confrontations between Kaiser and Permanente Medical Group physicians, the doctors met with Kaiser's top adviser, Eugene Trefethen, at Kaiser's personal estate near Lake Tahoe on July 12, 1955. Trefethen came up with the idea of a contract between the medical groups and the health plans and hospital foundations that would set out roles, responsibilities, and financial distribution. Trefethen, already a successful attorney, went on to a successful career with Kaiser Permanente and in retirement became a famous vintner.

While Keene and Trefethen struggled to fix the damage from Kaiser's micromanagement and Garfield's ineffectual management, Henry Kaiser moved to Oahu in 1956 and insisted on expanding Kaiser Permanente into Hawaii in 1958. He quickly ruined what should have been a simple project, and only a last-minute intervention by Keene and Trefethen in August 1960 prevented the total disintegration of the Hawaii organization. By that year, Kaiser membership had grown to 808,000.

Managed care era

Having overseen Kaiser Permanente's successful transformation from Henry Kaiser's health care experiment into a large-scale self-sustaining enterprise, Keene retired in 1975. By 1976, membership reached three million. In 1977, all six of Kaiser Permanente's regions had become federally qualified health maintenance organizations.

In 1980, Kaiser acquired a nonprofit group practice to create its Mid-Atlantic region, encompassing the District of Columbia, Maryland, and Virginia. In 1985, Kaiser Permanente expanded to Georgia.

Regional evolution

By 1990, Kaiser Permanente provided coverage for about a third of the population of the cities of San Francisco and Oakland; total Northern California membership was over 2.4 million.

Elsewhere, Kaiser Permanente did not do as well, and its geographic footprint changed significantly in the 1990s. The organization spun off or closed outposts in Texas, North Carolina, and the Northeast. In 1998, Kaiser Permanente sold its Texas operations, where reported problems had become so severe that the organization directed its lawyers to attempt to block the release of a Texas Department of Insurance report. This prompted the state attorney general to threaten to revoke the organization's license. Kaiser Permanente closed health plans in Charlotte and Raleigh-Durham in North Carolina four years later. The organization also sold its unprofitable Northeast division in 2000. The Ohio division was sold to Catholic Health Partners in 2013.

In 1995, Kaiser Permanente celebrated its fiftieth anniversary as a public health plan. Two years later, national membership reached nine million. In 1997, the organization established an agreement with the AFL-CIO to explore a new approach to the relationship between management and labor, known as the Labor Management Partnership. Going into the new millennium, competition in the managed care market increased dramatically, raising new concerns. The Southern California Permanente Medical Group saw declining rates of new members as other managed care groups flourished.

In 2017, Kaiser acquired Group Health Cooperative, which serves clients in the state of Washington outside of Southwest Washington. Group Health was started in part from funds from longshoremen in Washington state, who were left out when Kaiser chose not to expand north of the Portland area.

On April 26, 2023, Kaiser announced it would acquire Geisinger Health System. As part of the deal, Geisinger would operate as an independent subsidiary, folded into a new non-profit group called Risant Health.

KP HealthConnect
In 2002, Kaiser Permanente abandoned its attempt to build its own clinical information system with IBM, writing off some $452 million in software assets. This information technology failure led to major changes in the organization's approach to digital records. Under George Halvorson's direction, Kaiser looked closely at two medical software vendors, Cerner and Epic Systems, ultimately selecting Epic as the primary vendor for a new system, branded KP HealthConnect. Although Kaiser's approach shifted to "buy, not build," the project was unprecedented for a civilian system in size and scope. Deployed across all eight regions over six years and at a cost of more than $6 billion, by 2010, it was the largest civilian electronic medical record system, serving more than 8.6 million Kaiser Permanente members, implemented at a cost exceeding a half million dollars per physician. As of 2020 KP HealthConnect supports 12.2 million members.

International reputation

Early in the 21st century, the NHS and UK Department of Health became impressed with some aspects of the Kaiser operation and initiated a series of studies involving several health care organizations in England. Visits occurred and suggestions of adopting some KP policies are currently active. The management of hospital bed-occupancy by KP, by means of integrated management in and out of hospital and monitoring progress against care pathways has given rise to trials of similar techniques in eight areas of the UK.

In 2002, a controversial study by California-based academics published in the British Medical Journal compared Kaiser to the British National Health Service, finding Kaiser to be superior in several respects. Subsequently, a group of health policy academics who were experts on the NHS published a competing analysis claiming that Kaiser's costs were actually substantially higher than the NHS and for a younger and healthier population.

2023 strike
From October 4 to 7, 2023, more than 75,000 Kaiser Permanente workers went on strike. This has been regarded as the largest health care worker strike in U.S. history.

Quality of care

In the California Healthcare Quality Report Card 2013 Edition, Kaiser Permanente's Northern California and Southern California regions, KP received four out of four possible stars in Meeting National Standards of Care. KP North and South also received three out of four stars in Members Rate Their HMO. KP's performance has been attributed to three practices: First, KP places a strong emphasis on preventive care, reducing costs later on. Second, its doctors are salaried rather than paid per service, which removes the main incentive for doctors to perform unnecessary procedures. Thirdly, KP attempts to minimize the time patients spend in high-cost hospitals by carefully planning their stay and by shifting care to outpatient clinics. This practice results in lower costs per member, cost savings for KP and greater doctor attention to patients. A comparison to the UK's National Health Service found that patients spend 2–5 times as much time in NHS hospitals as compared to KP hospitals.

In June 2013, the California Department of Managed Health Care (DMHC) levied a $4 million fine, the second largest in the agency's history, against Kaiser for not providing adequate mental health care to its patients. Alleged violations of California's timely access laws included failures to accurately track wait times and track doctor availability amid evidence of inconsistent electronic and paper records. It was also found by the DMHC that patients received written materials circulated by Kaiser dissuading them from seeking care, a violation of state and federal laws.  DMHC also issued a cease and desist order for Kaiser to end the practices. DMHC conducted a follow-up investigation which published in April 2015. The report found Kaiser had put systems in place to better track how patients were being cared for but still had not addressed problems with actually providing mental health care that complied with state and federal laws.  Kaiser's challenges on this front were exacerbated by a long, unresolved labor dispute with the union representing therapists.

Kaiser appealed the findings, the order, and the fine, and sought to keep the proceedings closed, but in September 2014, in the face of the administrative judge's order to keep the proceedings open, and facing the beginning of public testimony,  Kaiser withdrew the appeal and paid the $4 million. It also issued a statement which denied much of the wrongdoing.  Kaiser faces ongoing inspections by DMHC and three class-action lawsuits related to the issues identified by the DMHC.

Research and publishing
Kaiser operates a Division of Research, which annually conducts between 200 and 300 studies, and the Center for Health Research, which in 2009 had more than 300 active studies. Kaiser's bias toward prevention is reflected in the areas of interest—vaccine and genetic studies are prominent.  The work is funded primarily by federal, state, and other outside (non-Kaiser) institutions.

Kaiser has created and operates a voluntary biobank of donated blood samples from members along with their medical record and the responses to a lifestyle and health survey. As of November 2018, the Kaiser Permanente Research Bank had over 300,000 samples, with a goal of 500,000. De-identified data is shared with both Kaiser researchers and researchers from other institutions.

Kaiser Permanente Bernard J. Tyson School of Medicine

Kaiser Permanente announced its plan to start a medical school in December, 2015, and the school welcomed its inaugural class in June, 2020. The vision for the school is to redesign physician education around the pillars of patient-centered care, population health, quality improvement, team-based care, and health equity.

Mark Schuster was named the medical school's Founding Dean and CEO in 2017. The Kaiser Permanente Bernard J. Tyson School of Medicine was renamed from the Kaiser Permanente School of Medicine in November 2019 in honor of late Kaiser Permanente Chairman and CEO Bernard J. Tyson. The medical school received preliminary LCME accreditation in February 2019 and is expected to receive full LCME accreditation by 2023. The school will waive all tuition for the full four years of medical school for its first five classes.

Controversies

Patient dumping

In 2006 Kaiser settled five cases for alleged patient dumping—the delivery of homeless hospitalized patients to other agencies or organizations in order to avoid expensive medical care—between 2002 and 2005.  Los Angeles city officials had filed civil and criminal legal action against Kaiser Permanente for patient dumping, which was the first action of its kind that the city had taken. The city's decision to charge Kaiser Permanente reportedly was influenced by security camera footage, allegedly showing a 63-year-old patient, dressed in hospital gown and slippers, wandering toward a mission on Skid Row (this footage was prominently featured in the Michael Moore 2007 documentary Sicko). At the time that the complaint was filed, city officials said that 10 other hospitals were under investigation for similar issues. Kaiser settled the case, paying $5,000 in civil penalties and agreeing to spend $500,000 on services for the homeless. During that same period, the Department of Health and Human Services' Office of the Inspector General settled 102 cases against U.S. hospitals that resulted in a monetary payment to the agency.

Organ transplant program

In 2004, Northern California Kaiser Permanente initiated an in-house program for kidney transplantation. Prior to opening the transplant center, Northern California Kaiser patients would generally receive transplants at medical centers associated with the University of California (UC San Francisco and UC Davis). Upon opening the transplant center, Kaiser required that members who are transplant candidates in Northern California obtain services exclusively through its internal KP-owned transplant center.

While it was in operation, the Kaiser program had a 100% survival rate, which is better than other transplant centers.  However, patients who needed a kidney were less likely to be offered one. Northern California Kaiser performed 56 transplants in 2005, and twice that many patients died while waiting for a kidney. At other California transplant centers, more than twice as many people received kidneys than died during the same period. Unlike other centers, the Kaiser program did not perform riskier transplants or use donated organs from elderly or other higher-risk people, which have worse outcomes. Northern California Kaiser closed the kidney transplant program in May 2006. As before, Northern California Kaiser now pays for pre-transplant care and transplants at other hospitals. This change affected approximately 2,000 patients.

Mandatory arbitration
In order to contain costs, Kaiser requires an agreement by planholders to submit patient malpractice claims to arbitration rather than litigating through the court system. This has triggered some opposition.

Wilfredo Engalla is a notable case. In 1991, Engalla died of lung cancer nearly five months after submitting a written demand for arbitration. The California Supreme Court found that Kaiser had a financial incentive to wait until after Engalla died; his spouse could recover $500,000 from Kaiser if the case was arbitrated while he was alive, but only $250,000 after he died. The Foundation for Taxpayer and Consumer Rights contends that Kaiser continues to oppose HMO arbitration reform.

Watchdogs have accused Kaiser of abusing the power imbalance inherent in the arbitration system. Kaiser engages in many cases whereas a customer will usually engage in just one and Kaiser can reject any arbitrator unilaterally, thus they can select company-friendly arbitrators over those that rule in favor of customers. As a large organization, Kaiser can also afford to spend much more on lawyers and orators than the customer, giving them more advantages. In response to criticisms, Kaiser established an Office of Independent Administrators (OIA) in 1999 to oversee the arbitration process. The degree to which this office is actually independent has been questioned.

Patients and consumer interest groups sporadically attempt to bring lawsuits against Kaiser Permanente. Recent lawsuits include Gary Rushford's 1999 attempt to use proof of a physician lie to overturn an arbitration decision.

In one case, Kaiser attempted to significantly expand the scope of its arbitration agreements by arguing it should be able to force nonsignatories to its member contracts into arbitration, merely because those third parties had allegedly caused an injury to a Kaiser member which Kaiser had then allegedly exacerbated through its medical malpractice.  The California Court of Appeal for the First District did not accept that argument: "Absent a written agreement—or a preexisting relationship or authority to contract for another that might substitute for an arbitration agreement—courts sitting in equity may not compel third party nonsignatories to arbitrate their disputes."

Labor unions
While Doctors of Medicine (M.D.) and Doctors of Osteopathic Medicine (D.O.) are partners within the for-profit physician groups, many employees are members of various unions and guilds, depending on their role and service area.

KP's California operations were the target of four labor strikes in 2011 and 2012 — two (September 2011, January 2012) involved more than 20,000 nurses, mental health providers, and other professionals. The National Union of Healthcare Workers (NUHW) has accused Kaiser of deliberately stalling negotiations while profiting $2.1 billion in 2011 and paying its CEO George Halvorson $9 million annually. The workers were dissatisfied with proposed changes to pensions and other benefits.

On November 11, 2014, up to 18,000 nurses went on strike at KP hospitals in Northern California over Ebola safeguards and patient-care standards during union contract talks. 21 hospitals and 35 clinics in the San Francisco Bay Area were affected.

On October 4, 2023, up-to 75,000 health workers went on a 3-day strike at KP hospitals predominately in California over higher pay demands and considerations over amount of patients the workers are expected to care for at any one-time.

Cash reserves
Jamie Court, president of the Foundation for Taxpayer and Consumer Rights has said that Kaiser's retained profits are evidence that Kaiser policies are overpriced and that health insurance regulation is needed.

State insurance regulations require that insurers maintain certain minimum amounts of cash reserves to ensure that they are able to meet their obligations; the amount varies by insurer, based on its risk factors, such as its investments, how many people it insures, and other factors; a few states also have caps on how large the reserves can be.

Kaiser has been criticized by activists and state regulators for the size of its cash reserves.  As of 2015, it had $21.7 billion in cash reserves, which was about 1,600% the amount required by California state regulations.  Its reserves had been a target of advertising by Consumer Watchdog supporting Proposition 45 in California's 2014 elections.  At the end of 2010 Kaiser held $666 million in reserves, which was about 1,300% of the minimum required under Colorado state law.  Those funds were in Kaiser's risk-based capital account, held to pay for disasters or major projects.  In 2008, the Colorado regulator required Kaiser to spend down its reserves; after negotiations Kaiser agreed to spend $155 million of its reserves giving credits to its clients and building clinics in underserved parts of the state.

COVID-19
Kaiser has been fined nearly $500,000, more than any other health care employer in California, by the California Division of Occupational Safety and Health for its violations regarding patient and staff safety following outbreaks of COVID-19 in its hospitals across the state, particularly in the Bay Area. Kaiser is responsible for more than 10% of all COVID violations in California. A COVID-19 outbreak sickened 92 people at Kaiser San Jose Medical Center on Christmas Day 2020. Kaiser San Leandro received the largest portion of fines, nearly $90k, for delays in reporting COVID infections and for failure to ration medical equipment according to pandemic regulations.

See also

Kaiser Family Foundation
Kaiser Permanente Arena

References

External links

 The Permanente Federation, which represents the Permanente Medical Groups
 Search all Kaiser hospitals in the CA Healthcare Atlas A project by OSHPD
 Nightly News with Brian Williams Report on successful Kaiser Permanente initiatives including declaration by Louise Liang falsely attributing Vioxx discovery to KP HealthConnect even though it was not yet in production use in Northern California
 Health Administration Responsibility Project Home page of a group scrutinizing managed care and its failures, contains links to several pages about issues involving Kaiser Permanente
 Kaiser Permanente Oral Histories  Transcripts of oral history interviews conducted by UC Berkeley's Regional Oral History Office with KP executives, attorneys, and clinicians, including Keene and Trefethen.

Health care companies based in California

Health insurance in the United States
Health maintenance organizations
Hospital networks in the United States
Healthcare in California
Healthcare in Colorado
Healthcare in Georgia (U.S. state)
Healthcare in Hawaii
Healthcare in Oregon
Healthcare in Washington (state)
Healthcare in Los Angeles
Healthcare in the San Francisco Bay Area
Companies based in Oakland, California
Non-profit organizations based in California
Privately held companies of the United States
American companies established in 1945
1945 establishments in California
Henry J. Kaiser

Kaiser Permanente


An Guzmania osyana in uska species han Liliopsida nga syahan ginhulagway ni Charles Jacques Édouard Morren, ngan ginhatag han pagkayana nga asya nga ngaran ni Carl Christian Mez. An Guzmania osyana in nahilalakip ha genus nga Guzmania, ngan familia nga Bromeliaceae. Ginklasipika han IUCN an species komo nangangarat-an. Waray hini subspecies nga nakalista.

Mga kasarigan

Mga sumpay ha gawas

Guzmania

Guzmania osyana


Glückstadt, Almanya'nın kuzeyinde Schleswig-Holstein eyaletinde, Steinburg iline bağlı kent. 22,76 km² yüzölçümüne sahiptir. Nüfusu, 30 Eylül 2006 itibarıyla yaklaşık 11792 olarak tespit edilmiştir. Belediye Başkanlığı Gerhard Blasberg tarafından yürütülmektedir.

Dış bağlantılar
 www.glueckstadt.de

Steinburg iline bağlı yerleşim birimleri

Glückstadt


قائمة حاملات الطائرات لكل دولة هي قائمة تشمل كل حاملات الطائرات مرتبة وفقا لدول المنشأ ودول الخدمة. مع ملاحظة أن هناك حاملات طائرات محصاة لعدة دول.

قائمة بحاملات الطائرات العاملة

انظر أيضًا
 حاملة طائرات
 حاملة مروحيات

مراجع

حاملات طائرات
حاملات طائرات حسب البلد
قوائم حاملات طائرات
قوائم عسكرية حسب البلد

قائمة حاملات الطائرات لكل دولة


Hermann Peters (* 12. November 1873 in Stralsund; † 17. Juni 1951 in Parchim) war ein deutscher Politiker (SPD).

Leben
Nach dem Besuch der Volksschule absolvierte Peters eine Tischlerlehre, die er mit der Gesellenprüfung abschloss. Er arbeitete bis 1907 als Tischlergeselle, bestand die Meisterprüfung und war danach bis 1920 als selbständiger Tischlermeister in Parchim tätig. Nach dem Eintritt in die SPD wirkte er als Partei- und Gewerkschaftsfunktionär, zunächst in Rostock und dann in Parchim, wo er 1919 Mitglied der Bürgervertretung wurde. Von 1919 bis 1920 war er Mitglied der Verfassunggebenden Versammlung des Freistaates Mecklenburg-Schwerin.

Literatur

 Andreas Frost: Aufbruch in die Demokratie. Landtage und Abgeordnete in Mecklenburg-Strelitz und Mecklenburg-Schwerin zwischen 1918 und 1920. Landeszentrale für politische Bildung Mecklenburg-Vorpommern, Schwerin 2019, ISBN 9783981643978, S. 99.

Weblinks

Landtagsabgeordneter (Mecklenburg-Schwerin)
SPD-Mitglied
Deutscher
Geboren 1873
Gestorben 1951
Mann
Person (Parchim)
Mitglied einer Verfassunggebenden Versammlung

Hermann Peters (Politiker, 1873)


Synarthrophyton nom. rejic.,  rod crvenih algi iz porodice Hapalidiaceae. Taksonomski se vodi kao sinonim za Phymatolithon, ali još postoji 11 priznatih vrsta od kojih su sve osim jedne, fosilne.

Vrste
 †Nullipora annulata Schafhäutl
 Nullipora floreabrassica Millet
 †Nullipora glomerata d'Orbigny
 †Nullipora granulosa Michelin
 †Nullipora lycoperdioides Michelin
 †Nullipora polyphyllamea D.S.Jordan
 †Nullipora provencialis d'Orbigny
 †Nullipora ramosissima d'Orbigny
 †Nullipora ramosissima Reuss
 †Nullipora rhodica Unger
 †Nullipora tuberosa Michelin

Izvori

Hapalidiaceae

Nullipora


Pollard's rho algorithm is an algorithm for integer factorization. It was invented by John Pollard in 1975. It uses only a small amount of space, and its expected running time is proportional to the square root of the smallest prime factor of the composite number being factorized.

Core ideas
The algorithm is used to factorize a number , where  is a non-trivial factor. A polynomial modulo , called  (e.g., ), is used to generate a pseudorandom sequence. It is important to note that  must be a polynomial. A starting value, say 2, is chosen, and the sequence continues as , , , etc. The sequence is related to another sequence . Since  is not known beforehand, this sequence cannot be explicitly computed in the algorithm. Yet, in it lies the core idea of the algorithm.

Because the number of possible values for these sequences is finite, both the  sequence, which is mod , and  sequence will eventually repeat, even though these values are unknown. If the sequences were to behave like random numbers, the birthday paradox implies that the number of  before a repetition occurs would be expected to be , where  is the number of possible values. So the sequence  will likely repeat much earlier than the sequence . When one has found a  such that  but , the number  is a multiple of , so  has been found.

Once a sequence has a repeated value, the sequence will cycle, because each value depends only on the one before it. This structure of eventual cycling gives rise to the name "rho algorithm", owing to similarity to the shape of the Greek letter ρ when the values , , etc. are represented as nodes in a directed graph.

This is detected by Floyd's cycle-finding algorithm: two nodes  and  (i.e.,  and ) are kept. In each step, one moves to the next node in the sequence and the other moves forward by two nodes. After that, it is checked whether . If it is not 1, then this implies that there is a repetition in the  sequence (i.e. . This works because if the  is the same as , the difference between  and  is necessarily a multiple of . Although this always happens eventually, the resulting greatest common divisor (GCD) is a divisor of  other than 1. This may be  itself, since the two sequences might repeat at the same time. In this (uncommon) case the algorithm fails, and can be repeated with a different parameter.

Algorithm
The algorithm takes as its inputs , the integer to be factored; and , a polynomial in  computed modulo . In the original algorithm, , but nowadays it is more common to use . The output is either a non-trivial factor of , or failure. It performs the following steps:

Pseudocode for Pollard's rho algorithm
     x ← 2 // starting value
     y ← x
     d ← 1

     while d = 1:
         x ← g(x)
         y ← g(g(y))
         d ← gcd(|x - y|, n)

     if d = n:
         return failure
     else:
         return d

Here  and  corresponds to  and  in the previous section. Note that this algorithm may fail to find a nontrivial factor even when  is composite. In that case, the method can be tried again, using a starting value other than 2 or a different .

Example factorization
Let  and .

Now 97 is a non-trivial factor of 8051. Starting values other than  may give the cofactor (83) instead of 97. One extra iteration is shown above to make it clear that  moves twice as fast as . Note that even after a repetition, the GCD can return to 1.

Variants
In 1980, Richard Brent published a faster variant of the rho algorithm. He used the same core ideas as Pollard but a different method of cycle detection, replacing Floyd's cycle-finding algorithm with the related Brent's cycle finding method.

A further improvement was made by Pollard and Brent. They observed that if , then also  for any positive integer . In particular, instead of computing  at every step, it suffices to define  as the product of 100 consecutive  terms modulo , and then compute a single . A major speed up results as 100  steps are replaced with 99 multiplications modulo  and a single . Occasionally it may cause the algorithm to fail by introducing a repeated factor, for instance when  is a square. But it then suffices to go back to the previous  term, where , and use the regular ρ algorithm from there.

Application
The algorithm is very fast for numbers with small factors, but slower in cases where all factors are large. The ρ algorithm's most remarkable success was the 1980 factorization of the Fermat number  = 1238926361552897 × 93461639715357977769163558199606896584051237541638188580280321. The ρ algorithm was a good choice for  because the prime factor  = 1238926361552897 is much smaller than the other factor. The factorization took 2 hours on a UNIVAC 1100/42.

Example: factoring  = 10403 = 101 · 103

The following table shows numbers produced by the algorithm, starting with  and using the polynomial .
The third and fourth columns of the table contain additional information not known by the algorithm.
They are included to show how the algorithm works.

The first repetition modulo 101 is 97 which occurs in step 17. The repetition is not detected until step 23, when . This causes  to be , and a factor is found.

Complexity
If the pseudorandom number  occurring in the Pollard ρ algorithm were an actual random number, it would follow that success would be achieved half the time, by the birthday paradox in  iterations. It is believed that the same analysis applies as well to the actual rho algorithm, but this is a heuristic claim, and rigorous analysis of the algorithm remains open.

See also
 Pollard's rho algorithm for logarithms
 Pollard's kangaroo algorithm

References

Further reading

External links
 Comprehensive article on Pollard's Rho algorithm aimed at an introductory-level audience

 Java Implementation
 About Pollard rho

Integer factorization algorithms

Pollard's rho algorithm


Fortul 8 este un fort situat în districtul Hoboken al orașului Antwerpen din Belgia și o parte a centurii de forturi Brialmont. Fortul ocupă aproape întreaga parte de sud a districtului și este unul dintre cele mai autentice și mai bine păstrate forturi Brialmont, deoarece nu a fost niciodată armat, întărit cu beton sau modernizat.

Istoric
Fortul 8, a cărui construcție s-a desfășurat între 1860 și 1864, este unul din cele opt forturi destinate apărării orașului Antwerpen împotriva unor eventuale invazii și care constituiau așa-numita centură Brialmont. Lucrările s-au desfășurat sub supravegherea căpitanului și arhitectului de forturi Henri Alexis Brialmont, pe terenuri aparținând anterior unor domenii nobiliare, inclusiv Scaldisburg al contelui Moretus. Zidurile fortului au o înălțime remarcabilă, precum cele ale Fortului 7, iar construcția găzduia o baterie de artilerie, la fel ca Fortul 5 din Edegem.

Fortul 8 se întinde pe o suprafață de 36 de hectare. La izbucnirea Primului Război Mondial el s-a dovedit însă inutil; tehnologia sa era deja depășită.

Situația actuală
În 1977, fortul a fost cumpărat de fosta comună Hoboken. În acest moment, domeniul face parte din vasta zonă verde a districtului Hoboken și este, cu excepția fortului interior, accesibil fără restricții publicului. Fortul interior poate și el fi vizitat de turiști, însă doar însoțiți de ghizii de specialitate ai instituției. În fort se află o sală de sport și terenuri unde se pot practica atletism, badminton, baschet, handbal, korfball, volei și futsal. Fortul 8 este sediul mai multor organizații sportive (cea mai notabilă fiind Sportschuur), precum și de tineret.

Note

Galerie de imagini

Forturi din Belgia
Clădiri și structuri din Antwerpen
Hoboken

Fortul 8 (Antwerpen)


Guitare populaire du Chili o Guitarra popular chilena es el décimo séptimo álbum de estudio del cantautor chileno Ángel Parra como solista, lanzado originalmente en Francia en 1978, bajo la licencia de DICAP, país donde vivió luego de haber sido exiliado de Chile producto de la dictadura militar, y posteriormente relanzado en Chile el año 1996 en formato de casete y disco compacto, con algunos pequeños cambios en la carátula y las canciones.

En la carátula original del disco, escrita en francés, Ángel explica la procedencia de cada una de las canciones que conforman el disco.

Lista de canciones

Créditos
 Studio Résonnance: registro
 Joseph Prudon: ingeniero de sonido
 Marie-Josée Vilar: traducción al francés
 Roland/Michel: grabación
 Éric Madelaine: fotografía
 Gilbert Absil: maqueta

Referencias

Enlaces externos
 Sitio web oficial

Álbumes de Chile de 1978
Álbumes de Ángel Parra
Álbumes de Alerce

Guitare populaire du Chili


Besuch aus heiterem Himmel ist eine deutsche Verwechslungskomödie von Ferdinand Dörfler aus dem Jahr 1959.

Handlung
John Underhower, Präsident einer US-amerikanischen Firma, wettet mit seinen Kollegen um 20.000 Dollar, dass es Gespenster gibt. Zum Beweis soll er ein echtes Gespenst mit nach Amerika bringen. Einst verbrachte er seine Kindheit in der Nähe der Burg Waldenfels, die er nun in der Hoffnung auf ein Schlossgespenst kauft. Sein Cousin Hans Unterhuber, der ihm von Reichtum und Burgbesitz vorgeschwindelt hat, arbeitet unterdessen auf der Burg als Museumsführer. Seine einzigen Mitstreiter sind die junge Monika und sein Neffe Beppi. Als sich John per Karte zum Besuch auf der Burg ankündigt, beschließen die drei, John reiche Verhältnisse vorzugaukeln.

John will seinen Cousin ebenfalls hereinlegen und tut sich mit einem Zirkus zusammen, der unweit der Burg Halt gemacht hat. Er gibt sich als Artist aus und zieht mit dem Zirkus in der Burg ein. Hier ist unterdessen auch Johns Tochter Eve angekommen, die in München Malerei studiert und vor Ort einige Zeichnungen anfertigen wollte. Ihr folgt so hartnäckig wie verliebt der Spielzeugmacher Peter, den Eve jedoch regelmäßig abblitzen lässt. Erst als beide während einer Burgführung in der Speisekammer der Burg eingeschlossen werden, versöhnen sie sich. In der Kammer findet sie auch Hans, der sie eigentlich rauswerfen will, jedoch vor John das Gesicht wahren muss. Er gibt Eve und Peter als Herzogspaar aus und beide dürfen auf der Burg bleiben. Monika spielt unterdessen eine ungarische Gräfin, während Hans vor John den Burgbesitzer mimt.

Es kommt zu einer feuchtfröhlichen Nacht, die am nächsten Tag zum Eintreffen des zuständigen Domänenverwalters von Säuerlich führt. Der will sich davon überzeugen, dass vor Ort alles mit rechten Dingen zugeht. Hans hat vor John behauptet, eine weiße Frau, die Ausländern gegenüber sehr garstig reagieren kann, spuke nachts in der Burg. John wiederum hofft, ein echtes Gespenst fangen zu können, ahnt jedoch, dass jemand des Burgpersonals einfach ein Gespenst spielt. Auch vor Säuerlich muss Hans an seiner Gespensttheorie festhalten, und so gehen Hans, Beppi und Säuerlich die nächste Nacht auf Gespensterjagd. John hat unterdessen das Zirkuspersonal in gruselige Kleider gesteckt, und so spukt es in der Nacht an jeder Ecke, während John der weißen Frau folgt und sie schließlich mit einem Lasso einfangen kann – es ist Monika, in die sich John längst verliebt hat. Auch Eve und Peter finden zusammen, nachdem sie sich wegen Monikas engem Kontakt zu John, ihrem Vater, eifersüchtig zerstritten hatten. Säuerlich wiederum kann in der Nacht durch striktes Befolgen jeglicher Überwachungsregeln keinerlei Unregelmäßigkeiten erkennen, während Hans und Beppi von den zahlreichen "Gespenstern" in Angst und Schrecken versetzt werden. Als Säuerlich beide maßregeln will, erscheint John und löst auf, dass er als neuer Besitzer längst das Sagen über die Burg hat. Er ernennt den dankbaren Hans zum neuen Domänenverwalter und Beppi wird der neue Kastellan. Mit Monika im vorbereiteten Gespensterkäfig zieht John schließlich davon.

Produktion
Besuch aus heiterem Himmel war der letzte Film des Produzenten und Regisseurs Ferdinand Dörfler. Seine Tochter Johanna, bekannt als Schauspielerin Hanna Hutten, übernahm unter ihrem bürgerlichen Namen die Produktionsleitung.

Der Film wurde 1958 auf der Burg zu Burghausen an der Salzach gedreht. Die Innenaufnahmen entstanden in den Bavaria Filmstudios.

Besuch aus heiterem Himmel erlebte am 5. Februar 1959 im Kölner Rex seine Premiere.

Ein Alternativtitel des Films lautet nach einem im Film gesungenen Lied Jetzt ist er da aus USA.

Kritik
Der film-dienst kritisierte 1959, dass, "weil nichts Rechtes geschieht, … das Ganze nur als ein mühsam lustiger Klamaukscherz dahin[plätschert]. Schön und von jedem Blickwinkel gleich reizvoll-romantisch zeigt sich dabei Deutschlands größte Burg, Burghausen an der Salzach. Man bedauert, kein hübscheres Spiel vor diesem Hintergrund abrollen zu sehen."

Das 1990 vom film-dienst herausgegebene Lexikon des Internationalen Films nannte den Film ein "inhaltsarmes Verwechslungsspiel zwischen armen und reichen Vettern". Besuch aus heiterem Himmel sei "ein mühsam lustiger Klamaukfilm".

Cinema befand, dass die "fröhlichen Verwechslungsspielchen" "heute eher langweilen. Fazit: Der Spukschlossposse fehlt Geist."

Weblinks

Einzelnachweise

Filmtitel 1959
Deutscher Film
Filmkomödie

Besuch aus heiterem Himmel


El LXVII Campeonato Mundial de Halterofilia se celebró en Cantón (China) entre el 16 y el 26 de noviembre de 1995 bajo la organización de la Federación Internacional de Halterofilia (IWF) y la Asociación China de Halterofilia.

En el evento participaron 438 halterófilos (345 hombres y 93 mujeres) de 63 federaciones nacionales afiliadas a la IWF.

Medallistas

Masculino

Femenino

Medallero

Enlaces externos
Base de datos iat.uni-leipzig.de .

1995
Halterofilia en 1995
Deporte en la ciudad de Cantón
Deporte en China en 1995

Campeonato Mundial de Halterofilia de 1995


est une comédie fantastique italienne réalisée par Bruno Bozzetto et sortie en 1987.

C'est le seul film en prise de vues réelles de son réalisateur, plus connu pour ses films d'animations et ses bandes dessinées.

Synopsis
Ivan est un étudiant universitaire qui vit avec sa mère. Il est sur le point d'épouser Ursula, sa fiancée, qui est aussi sa patronne. Un jour, alors qu'il quitte son domicile pour faire une course, il rencontre un vieil ami, diplômé de l'université mais exerçant un modeste emploi de déchargeur de marchandises. Pendant leur conversation, trois voleurs étrangers attaquent une banque et Ivan se retrouve impliqué dans le casse. Il parvient à s'échapper, mais les malfaiteurs, bien décidés à l'écarter parce qu'il a vu leurs visages, le traquent, le poursuivant jusqu'à une impasse où se trouve un restaurant chinois.

Ivan se réfugie dans la cave du restaurant et, en tentant de se cacher dans un débarras, ouvre une porte qui, à son immense étonnement, mène à une plage tropicale. N'ayant pas d'autre choix, le garçon décide de franchir le seuil et se retrouve catapulté dans un monde parallèle, peuplé d'étranges créatures. Il y fait la connaissance d'Eva, une jeune fille qui vit dans ce monde depuis son enfance en compagnie de son père. Ce dernier est un professeur qui a réussi grâce à une télécommande de science-fiction à ouvrir une passerelle dimensionnelle : avec cet appareil, il est en effet possible de pénétrer dans d'autres mondes.

La jeune fille, qui a vécu pratiquement toute sa vie avec son père sans pouvoir rencontrer personne, est fascinée par Ivan et décide de le suivre dans le monde dans lequel il vit, l'entraînant dans une série de malentendus et de petites mésaventures. Le garçon découvre peu à peu qu'il est tombé amoureux d'elle, mais Ursula et surtout la bande de malfrats sont toujours à sa recherche, pour deux raisons différentes, ce qui va amener Ivan à prendre une décision qui va changer sa vie.

Fiche technique
 Titre original italien :
 Réalisateur : Bruno Bozzetto
 Scénario : Bruno Bozzetto, Fabio Comana
 Photographie : Agostino Castiglioni
 Montage : Ugo De Rossi
 Musique : Roberto Frattini
 Décors : Carmelo Patrono
 Costumes : Lia Francesca Morandini
 Production : Bruno Bozzetto, Alessandro Calosci, Antonio D'Urso
 Sociétés de production : Bozzetto International S.r.l., Reteitalia
 Pays de production :
 Langue originale : italien
 Format : Couleur - Son mono - 35 mm
 Durée : 94 minutes
 Genre : Comédie fantastique
 Dates de sortie :
 Italie :

Distribution
 : Ivan
Amanda Sandrelli : Eva
 : Bibi, la mère d'Ivan
Bernard Blier : le professeur, le père d'Eva
Nancy Brilli : Ursula
Giuseppe Cederna : Giovanni, le chauffeur d'Ursula
Cinzia Monreale : le voleur
Haruhiko Yamanouchi : le cuisinier chinois
 : le type louche au bar

Notes et références

Liens externes

Film italien sorti en 1987
Film réalisé par Bruno Bozzetto
Comédie fantastique italienne
Film en italien

Sotto il ristorante cinese