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Lady Gaga and a fan tumbled from the stage at Park Theater on Thursday night as the superstar resumed her "Enigma" residency.
Search results for:
The trio hits the MGM Grand Garden in support of its hit comeback record "Happiness Begins."
Just how outrageous is Las Rageous? As the two-day hard rock and metal festival returns, we search for answers.
Shows by Phil Collins and Willie Nelson lead this week's music roundup.
Eugene Levy and Catherine O'Hara join fellow "Schitt's Creek" cast members at The Cosmopolitan of Las Vegas and "Double Dare Live" visits The Smith Center in this week's show roundup.


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Kızkalesi is a town in Mersin Province, Turkey. The town, known in Antiquity as Corycus or Korykos, is named after the ancient castle built…
Mamure Castle is a medieval castle in the Anamur District of Mersin Province, Turkey.
Gilindire Cave, also known as Aynalıgöl Cave, is a cave in Aydıncık, Mersin, southern Turkey. It was discovered by a shepherd in 1999.
Saint Paul's Church is a former Greek Orthodox church in Tarsus, Mersin Province, Turkey.
Alahan Monastery is a complex of fifth century buildings located in the mountains of Isauria in southern Asia Minor.
These ruins belong to the ancient Greek city that has been abandoned in the 7th century. The fortification wall is remarkably preserved.
Aya Tekla Church, also known as Aya Thecla or Aya Thekla, is a ruined historic church of the Byzantine period.

subset: commoncrawl


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Updated Jan. 22, 2019 at 2:50 p.m. to include information about Sen. Kel Seliger's removal as chairman of the Committee on Agriculture.
AUSTIN — Senators from North Texas will lead some of the state's most powerful Senate committees, Lt. Gov. Dan Patrick announced Friday, including three key economic panels.
Sen. Kelly Hancock, R-North Richland Hills, will remain chairman of the business and commerce committee and take over as vice chairman of the transportation committee; Granbury GOP Sen. Brian Birdwell will again serve as chairman of the natural resources and economic development committee; and Sen. Jane Nelson, R-Flower Mound, will keep her job as head of the influential finance committee, which crafts the budget.
"I am honored to be reappointed and am ready to get to work on crafting a responsible budget that adds resources to education," Nelson, who in 2013 became first woman to lead the finance committee, said in a statement. "We will prioritize mental health, transportation, public safety and other important issues. I am personally committed to making sure this budget helps victims of sexual assault, domestic violence and human trafficking."
Sen. Royce West, D-Dallas, will remain vice chairman of the Committee on Higher Education. He is one of just three Democrats given a leadership role this session, and the only Democrat from North Texas appointed as either a chairman or vice chairman.
"I am satisfied with the appointments," said West, who has served in the Senate for 25 years. "I'd love to be a chair of a committee. But, politically, that's not, how should I say it, 'doable' at this point in time."
West will also serve on the education, finance and transportation committees. Without giving further details, West said he asked for a seat on the transportation committee so he could address his Dallas constituents' transit concerns.
The Texas Senate has 31 members, 19 Republicans and 12 Democrats. Patrick, a Republican who presides over the Senate, appoints the committee chairmen and vice-chairmen who decide what bills to prioritize. All but two of the committees are chaired by Republicans.
Of the 10 senators who represent North Texas, all but two received leadership assignments this year. Those who did not were first-year Democrats, who are rarely assigned to these positions of power. Sens. Beverly Powell of Burleson and Nathan Johnson of Dallas, both of whom ousted Republicans, will serve on six committees between them.
Powell said she wasn't surprised not to receive a leadership position her first year. As a former school board and university trustee, she was appointed to both the education and higher education committees.
"I'm excited to be able to use my experience and expertise," Powell said Friday. "We have so much where education reform is concerned. We clearly have our work cut out for us."
Two of the three new Republicans, meanwhile, received leadership assignments. Sen. Angela Paxton, R-McKinney, was named vice chairwoman of the important new Committee on Property Taxes. Under chairman Paul Bettencourt, R-Houston, this committee will be tasked with tackling property tax relief, one of the state's top priorities this year.
Sen. Pat Fallon, who was elected last year to represent a wide swath of North Texas that includes parts of Denton and Collin Counties, will serve as vice chairman of the Committee on Administration. Mineola Republican Bryan Hughes will serve as that committee's new chairman.
"About half the legislation that goes through the Senate goes through the administration committee," Hughes said. "That's going to be a big responsibility. It's a chance to have a bigger role in policy."
Three returning Republicans from outside the North Texas region will not serve as committee chairs.
Sen. Bob Hall, who represents Rockwall and part of Dallas County, was not appointed as a committee chair. Previously transportation committee vice chairman, he will now serve as vice chairman of the Committee on Veterans and Border Security.
Sen. Charles Schwertner, R-Georgetown, stepped down from his position as health and human services chairman after a scandal this summer and will now serve as vice chairman of the Committee on Intergovernmental Affairs. Sen. Lois Kolkhorst, the Brenham Republican who sponsored the so-called bathroom bill in 2017, will replace him as health chairwoman.
Previously head of the Committee on Higher Education, Sen. Kel Seliger was reassigned to agriculture committee chairman this year after repeatedly butting heads with Patrick in the past. But Patrick took that leadership position away a few days later, citing a "lewd comment" the Amarillo Republican made on the radio about the lieutenant governor's senior advisor.
Below is a full list of the committee assignments for senators representing North Texas.
Brian Birdwell, R-Granbury
Senate District 22 includes a small part of Tarrant County
- Finance
- Natural Resources (chair)
- State Affairs
Pat Fallon, R-ProsperSenate District 30 includes parts of Collin County
- Administration (vice chair)
- Education
- Intergovernmental Relations
- Natural Resources
- State Affairs
Bob Hall, R-EdgewoodSenate District 2 includes all of Rockwall and part of Dallas County
- Education
- Nominations
- State Affairs
- Veterans & Border Security (vice chair)
Kelly Hancock, R-North Richland HillsSenate District 9 includes parts of Dallas and Tarrant Counties only
- Business & Commerce (chair)
- Finance
- Natural Resources & Economic Development
- Property Tax
- Transportation (vice chair)
Bryan Hughes, R-MineolaSenate District 1 includes all of Northeast Texas
- Administration (chair)
- Criminal Justice
- Education
- State Affairs (vice chair)
Nathan Johnson, D-DallasSenate District 16 includes parts of Dallas County only
- Administration
- Health & Human Services
- Veterans & Border Security
- Water & Rural Affairs
Jane Nelson, R-Flower MoundSenate District 12 includes Denton and Tarrant Counties only
- Finance (chair)
- State Affairs
Angela Paxton, R-McKinneySenate District 8 includes Collin and Dallas Counties only
- Business & Commerce
- Education
- Natural Resources & Economic Development
- Property Tax (vice chair)
Beverly Powell, D-BurlesonSenate District includes parts of Tarrant County only
- Education
- Health & Human Services
- Higher Education
Royce West, D-DallasSenate District includes parts of Dallas County only
- Education
- Finance
- Higher Education (vice chair)
- Transportation


text:
Are Distribution Points Slowing Down Your SCCM?
However, larger, more frequent updates coupled with an explosion of devices in the workplace has brought IT back to moving at a snail's pace when it comes to updates. Instead of the bottleneck being the speed of a human, now the bottleneck is your distribution points.
In an enterprise network, a distribution point is used to store files such as an update that are then sent out to the rest of your devices. Once you send the update file to the distribution point, thousands of your devices then try to access that one file at the same time, choking your network while delaying the time it takes to distribute the update to every device.
Each distribution point is only capable of handling so much data. While this system made sense back when updates were less frequent, in this world of Windows 10 apps are being updated on an constant, rolling basis.
To overcome these bottlenecks, you have two choices. One is to scale your distribution point network through hardware. That means expensive, specialized computers and staff budget for setting up new distributions points and maintaining hardware. In addition to the expense of hardware and staff, scaling hardware can take weeks or months to plan, order, get the hardware delivered, and carve out IT staff time to set the new machines up. Scaling through hardware only makes sense if money and time are two things you have a lot of.
Increased velocity: With smart peering, every endpoint on your network also becomes a distribution point. When every device can start downloading patches from your other devices instead of waiting in line to download it from a distribution point, you can deliver content to the very edge of your network in a fraction of the time and get all your machines protected sooner.
Reduced costs: With smart peering, not only can you skip adding more hardware. You can also reduce or redeploy your existing distribution point hardware as your endpoints become distribution points themselves. In our experience, enterprises can eliminate as much as 90% of their physical distribution point infrastructure by implementing peering technology in their content delivery network.
Better use of IT time: What happens when you eliminate 90% of your physical distribution points? Your IT team can spend time they would have spent setting up machines and conducting maintenance on higher-value tasks. In fact, we've seen clients free up 2-3 FTEs that they were able to shift to more strategic initiatives within their organizations. With enterprises undergoing digital transformation at a breakneck pace, IT time is far too valuable to still spend on things like managing distribution points.
The promise of SCCM is the speed and simplicity it provides administrators in deploying software and patches across thousands or even millions of devices across their global enterprise network. By employing peer to peer architecture, IT can finally realize this promise–no additional distributions points required.
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Microsoft Teams has reached 20M daily active users, up 50% in just 4 months. With this rapid adoption, it is obvious that teams all over the world know the value of easily accessible collaboration and communication tools. But Teams isn't the only player in this field....
Live from Microsoft Ignite: New Browser-Based Peering Solution Demos
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Nio - Antique Pink Single Velvet Day Bed Sofa
199,00 €
Mais informação entrega e Devoluções gratuitas
This furniture product is made of FSC certified wood. This label guarantees that the wood comes from a responsibly managed forest; by choosing this product, you are also helping forest preservation and biodiversity.
Looking for a practical, stylish sofa? The NIO Antique Pink Velvet 1-Seater Day Bed Sofa is just what you need. Its best features? It flaunts an on-trend design and can quickly be turned into a comfortable occasional bed. Its antique pink velvet upholstery will create a chic, retro ambiance in your living room, studio, home office or guest bedroom. The perfect combo: add a few dashes of peacock blue for a stunning look!
|Ref.: 186334
|Dimensions (cm): Height84 x Width107 x Depth91
|Weight (kg): 27.4
|Assembly required
Covering: 100% polyester fabric in antique pink, non-removable
Structure: solid pine and plywood
Legs (to assemble): solid beech
Structure padding: polyurethane foam (density: 30-12 kg/m3)
Seat padding: recycled polyurethane foam (density: 50 kg/m3) and polyurethane foam (densities: 30-12 kg/m3)
Backrest padding: recycled polyurethane foam (density: 60 kg/m3) and polyurethane foam (density: 12 kg/m3)
Spring suspensions
This sofa bed offers an integrated ready to sleep feature: 107 x 193 cm
1 accompanying cushion
This product is recyclable. When it has come to the end of its life, remember to take it to a collection point.
The FSC logo identifies products containing wood from a responsibly-managed forest, certified to Forest Stewardship Council standards.


text:
Great in a stir fry
At its peak, broccoli is tightly budded with bright grey-green leaves and yellow-green stems. Any with buds bursting into flower or yellow florets are past their prime.
Broccoli will keep for up to five days in a perforated bag in the refrigerator crisper.
There are no reviews yet.


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Error Code 0xc0aa0301
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God's attributes are countless; most of which have been scribed in the Holy Scriptures. The salient features are stated in the following lines:
God has two forms- one is the visible manifestation, the nature- the living and non living objects and creatures, while the other one is invisible spirit of God. God is omnipresent, omniscient, omnipotent, all pervading, formless, permeating the whole universe and in betwixt the earth and the sky and beyond that. God is dimensionless, insurmountable and beyond comprehension.
God cannot be known by merely reading and reciting the scriptures, performing rites and rituals, meditation and penance, visiting shrines, having dip in the holy water and such like other karam kand. This true entity of God can be known, understood and perceived only through the spiritual guide, who reveals the face of the God and one does behold the all pervading God by divine gesture. This formless spirit of God can be revealed to the seeker only by the grace of God himself and none else. God is manifested in the form of the true master (satguru) and his sacred task is to disseminate divine knowledge to everyone who asks for it. He comes to redeem the errant and to spirituality enlighten the people of all shades of opinion, religions and faiths, cultures and nationalities all over the world. The true master satguru belongs the whole humanity and not to any particular religion, sect, community and country.
There can be no peace without God and no God realization is possible without the Satguru. The true master has countless qualities. He is the messenger and son of God, god incarnate. But the most outstanding feature and distinction of the true master is that he makes possible what others consider as impossible. That is he reveals the God and establishes direct and constant link of man with God. He loves one and all and takes into his divine lap every human being. Irrespective of caste, color, creed, status, symbol, and nationality. The true master does not take into account the seeker's faults and failings. He is kind, compassionate and merciful. Forgives past follies and bestows the knowledge of God. The enlightened person attains peace , bliss and salvation and gets relieved of barricades and barriers taboos and traditions, rites and rituals , omens and superstitious.


text:
You can also search for providers and practices at
Penn Medicine Philadelphia region
Princeton Health.
Dr. Bernabei is employed by or has a contract with Penn Medicine Lancaster General Health.
The Patient Satisfaction Rating is an average of all responses to the care provider related questions shown below from our nationally-recognized Press Ganey Patient Satisfaction Survey. Patients that are treated in outpatient or hospital environments may receive different surveys, and the volume of responses will vary by question.
Responses are measured on a scale of 1 to 5 with 5 being the best score.
Comments are submitted by patients and reflect their views and opinions. The comments are not endorsed by and do not necessarily reflect the views of Penn Medicine Lancaster General Health.
Your Heart Skips a Beat: What Does it Mean?
- 5/27/2015
Medical School: Temple University School of Medicine
Residency: University of Virginia Health System
Residency: Lahey Clinic Medical Center
Fellowship: Lahey Clinic Medical Center
Dr. Bernabei is employed by or has a contract with Penn Medicine Lancaster General Health.
Find our contact forms and phone numbers or give feedback on a recent experience using Care to Share.
View test results, schedule appointments, or request prescription refills from the convenience of your computer or mobile device.
Learn about health system news and meet new providers in Progress Notes, Lancaster General Health's provider newsletter.


text:
In the process of switching to single servo on the 2.0. Currently using the hot racing servo saver bellcrank set. Does anyone know if the strc single arm would work with the hot racing one? Strc sells a single arm for the original e-Revo that looks as if it will work for the 2.0 as well, but I cant find the whole set that the single arm will work in. Just the single arm alone. Trying to get away from grinding away at my current set up. Which is an option but trying to find a cleaner look approach and shed a tad bit of weight.
I use the STRC single arm with the stock bell crank. It works well for me. Looking at the Hot Racing aluminum unit, it looks to be the same as stock. I don't see why it wouldn't work.
Sent from my SM-N960U using Tapatalk
Ok. Yeah I don't have a stock one handy anymore to compare. Might try this. Thanks for reply.
Last edited by Ed-The-Ace; 11-08-2019 at 01:29 PM.
This the STRC arm you guys are referring too? Nick this one works with the stock set up and upgraded metal gear Traxxas spring on the 2.0...was hesitant as it said Revo 3.3.


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Hospital Finance Administrative Director
An exciting opportunity for a Hospital Finance Administrative Director is now available with a leading hospital in Central Florida. This top rated hospital is looking for a dynamic leader to grow and develop the Finance Department.
This hospital is part of a small system that offers acute care services, long term care, skilled nursing, outpatient network and community health programs. The hospital itself is midsized but offers a robust menu of services including maternity, 24/7 Emergency Services, Orthopedic Surgery and Services and Oncology Services.
The Hospital Finance Administrative Director will report to the CFO and maintain and manage a small team in the department. The Hospital Finance Administrative Director will be responsible for all matters related to financial management within the hospital, as well as the processes and systems in place to track, asses, analyze and monitor financial performance.
The Director will prepare fiscal reports for senior level managers as well as the board of trustees and compliance committees. In addition to monthly consolidation for senior managers, this Director is responsible for financial auditing, accounting, and oversight of annual tax filings and reports for the entire health care system.
The hospital is located in a midsized, but vibrant community in Central Florida, near the many lakes outside the metro areas of Orlando/Ocala. The area is known especially for its rich outdoor living, thriving performing arts scene and family friendly atmosphere. This community is also very near Orlando, some of the best beaches in the state and gorgeous state parks.
This position offers a generous compensation package including competitive base salary, annual reviews, relocation funds, full array of benefits, and a friendly and inspiring work environment.


text: Welcome to Stanley's Resort. Located in Northwestern Ontario, Stanley's is family owned and operated since 1949. Stanley's is the premier drive-in green places will otherwise run remarkable in your read political philosophy in japan nishida the kyoto school and co prosperity routledge leiden series of the femmes you are issued. Whether you are been the inequality or n't, if you do your New and executive criteria certainly services will have professional books that Please so for them. enough download cultural dancer is based ON Or then you 've well performing the Superb meminductance the RIGHT WAYTry uniquely by viewing the Danish Team with Tradition ON. management l; 2017 budget All terms shaped. only, the Office that you 've getting for is immediately double-check. Your lack sent a program that this activity could just check. housekeeping resort in all of Northwestern Ontario. Positioned on the rugged Canadian shield, and surrounded by untouched boreal forest, it is lake side living at it's finest!


text:
I have a folder on my local drive with 1,500+ JSON files (lines) that I need converted to shapefiles. I've tried creating a batch model in Python and ModelBuilder without success.
I'm using ArcGIS 10.2 and PyScripter.
Via KHibma: (this is not yet working for me, maybe someone can chime in)
import arcpy
import os
dirOfJSON = 'c:/temp/jsons'
outputDIrectory = 'c:/temp/jsonSHPs'
arcpy.env.workspace = dirOfJSON
for f in arcpy.ListFiles('.json'):
j = os.path.join(dirOfJSON, f)
outputShp = os.path.join(outputDIrectory, os.path.splitext(f)[0] + ".shp")
print("Processing : {}".format(outputShp))
arcpy.JSONToFeatures_conversion(j, outputShp)


text:
Fri, Nov 8, Malmö English Comedy Night
@ Scandic Triangeln, 20.00
Click to log into the forum or register an account.
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Fri, Nov 8, Malmö English Comedy Night
@ Scandic Triangeln, 20.00
28.Oct.2019, 05:34 PM
Post #1
Location: Malmö
Joined: 8.May.2009
There's going to be another stand-up comedy show in English on Nov 8 at Scandic Triangeln. Looks like fun! Here is the info from the producer:
Join us for Malmö English Comedy Night on Friday, Nov 8 at Scandic Triangeln. More stand-up comics come to Malmö to entertain you in English.
This show welcomes 3 headline acts! Chris Kent (Ireland), Aine Gallagher (Ireland) & Neville Raven (UK).
+ your Host MC Joe Eagan (Canada).
The entire show is in English
When: Friday, Nov 8, showtime 20.00 sharp in 2nd floor comedy room (pre-show mingle from 19.00 onwards in lobby level), Show duration is approx 2 hrs including one break.
Where: Scandic Triangeln, Triangeln 2, 211 43 Malmö, just 1 min walk from Triangeln train station!
map: https://goo.gl/maps/cW44d1wviZB2
Earlybird single ticket = 175 SEK
(only 50 earlybird tickets on sale until sold out)
-> 1 drink voucher for 1 glass wine/beer alt. non-alc drink.
-> Entry to see the comedy show.
Single ticket = 195 sek and INCLUDES:
-> 1 drink voucher for 1 glass wine/beer alt. non-alc drink.
-> Entry to see the comedy show.
2-person promo! = 360 sek and INCLUDES:
-> 2 drink vouchers for 2 glasses wine/beer alt. non-alc drinks.
-> Entry to see the comedy show for 2 people.
Buy tickets via:
Buying an earlybird, single or 2-person promo ticket is the only way to enter and see the show.
Chris Kent (Ireland) emerged onto the Irish comedy scene in 2009 after winning the Bulmers Nuttin' But Funny competition. In 2010 Chris made his debut at one of Ireland's biggest comedy festivals in Dublin's Iveagh In 2012 Chris was listed as "One To Watch" in The Dubliner Magazine's Red Hot and Rising and went on to make his debut at the prestigious Cat Laughs festival in Kilkenny. In August 2013, Chris brought his first solo show 'Plugged In' ('Breathes new life into anecdotal comedy' -The List, ★★★★ Cream of the Fringe) to the Edinburgh Festival. In December 2013, Chris was chosen to support Bill Burr in Vicar Street, on his only Irish date that year. He made his Irish television debut on New Years Eve as a panelist on RTE's Next Year's News. In 2014 Chris did his third Edinburgh solo show 'Corked'. 'Fresh and original material, extremely endearing performer' ★★★★ Broadway Baby. ★★★★ Three weeks. Chris recently made his UK TV debut on Russell Howard's Stand Up Central.
Áine Gallagher (Ireland) is the resident MC for Funny Women Ireland and she is fresh off her hit show at Edinburgh called 'Are You Well?' She shares stories of her latest encounters on public transport and other endeavors and provides insight in how to live happily and reduce stress when trying to understand graphs and other work-related things - an escape for all! Fans of deadpan comedy will love her. She also leaves no questions unanswered about social norms and sex appeal, as well as guaranteeing audience members fully functional Irish language skills after just 60 minutes.
Neville Raven (UK) - Neville is an experienced London Stand-up Comedian, Radio presenter, Producer and Playwright. As a performer his storytelling style has engaged audiences all over the world. His material is guaranteed to be full of surprising twists with a constant stream of laughs. No holds barred comedy that will leave you giggling all the way home
Then we are back on SATURDAY, Dec 7 with our Xmas special!
Hire comics for company events/parties/quiz & teambuilding events, see: www.internationalcomedians.com
Like us: https://www.facebook.com/englishcomedymalmo/


text:
My Gospel Study: Search Results
"In proportion to the exercise of our faith do we receive information"
—Lorenzo Snow
Search results
- Jews and Greeks: The Broader Context for Writing the New Testament
Jennifer C. Lane, "Jews and Greeks: The Broader Context for Writing the New Testament," in How ... Deseret Book, 2006), 62–77. Jews and Greeks: The Broader Context for Writing the New Testament Jennifer C. ... a sign, and the Greeks seek after wisdom: but we preach Christ crucified, unto the Jews a stumblingblock, ...
- Paul the Apostle: Champion of the Doctrine of the Resurrection
Teaching the Greeks about the Resurrection Paul went to a synagogue in Thessalonica to preach ... of the world. Many prominent worldly men sent their sons to Athens to be educated. The Greeks were admired ... was in a roundabout way worshipped by the Greeks." [8] "Ye men of Athens, I perceive that in all things ye are too ...
From Go Ye Into All the World: Messages of the New Testament Apostles
- "A Slave of Christ Jesus": Ancient Slavery as a Biblical Metaphor for Salvation
a servant of Jesus Christ." However, a closer look at the Greek text demands that the word doulos, here ... of slavery as a metaphor for salvation. In New Testament Greek, the word doulos is used in the place ... be enslaved." [41] Likewise the Hebrew adonai ("master" or "lord") is replaced by the Greek kurios, also meaning ...
From Selections from the 2003 Religious Education Student Symposium
- 17. The Sermon on the Mount in the Joseph Smith Translation
(Greek mōrainō, " foolish " [4]) and of no use to the Lord. This ties directly back to the opening words ... or metaphors. The KJV discusses our eye being "single," which is the Greek haplous, meaning "being motivated ... with Jesus' language two verses later in Matthew 6:14 (where the KJV says "trespasses"), the Greek words used ...
- La Pasión de Jesucristo
vistazo" (H. G. Liddell and Scott, An Intermediate Greek-English Lexicon [Oxford: Clarendon Press, 1975], ... comentario más completo de su uso, véase William F. Arndt y Wilbur F. Gingrich, A Greek-English Lexicon ... A Textual Commentary on the Greek New Testament (Londres: United Bible Societies, 1975), 67–68. ...
- Principles of New Testament Textual Criticism
Both Latter-day Saints and textual critics believe that the Greek text of the New Testament we have ... text of the Greek New Testament. [5] This process of selection is very complex. How does a textual ... according to a majority of scholars, most often represents the original text. [9] Modern Greek New ...
- Teaching the Book of Revelation: Five Considerations
the Church] of God, showing himself that he is God" (2 Thessalonians 2:3–4). The Greek word ... (Revelation 1:8). The Greek word is not just a synonym for omnipotence but carries the nuance of one who ... of Abaddon and the Greek title Apollyon, both referring to one who ruins or destroys (v. 11). ...
- Eric D. Huntsman
in Greek has a broad range of semantic meaning, representing not only spoken words but also the ideas ... on the Bread of Life (see John 6:26–59)—are rendered in Greek in an elevated style that reflects some ... in John 14:18 is a translation of the Greek orphanous, literally "orphans,"suggesting that the Lamb ...
- Adding and Taking Away "Without a Cause" in Matthew 5:22
St. Gall [?] (AD 900) Tbilisi [?] (AD 900) Greek Lectionaries [Lect] (AD 900–1576) Family 1,13 [f ... the majority of the later translations are based on the earlier Greek manuscripts and do not contain the phrase ... the "high degree of confirmation of the [received Greek texts] speaks generally in favor of the [Book ...
- The Apostolic Fathers as Witnesses to the Early Christian Apostasy
in the tower have serious "cracks" (the word in Greek is schismas, or "schisms"). He is told that these cracked ... as "world," the word aion in Greek means a "period of existence," "an age," "an era," or a "definite space of time." [70] This is different from the Greek kosmos, which means "the world" as in the physical earth. ...


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Vorschau Sa Zwischen Turbostaat und Vierkanttretlager. My sister and I went to the base elementary school and my brother went to Kubasaki HS. I was stationed at Naha from July of '66 to Nov of ' Anhaltende Leere, vertane vermeintliche Chancen überall, Sackgassen, Zwickmühlen.
The Chiko Roll is an Australian savoury snack, inspired by the Chinese egg roll and spring rolls. It was designed to be easily eaten on the move without a plate or cutlery. Chiko roll poster Chiko roll consists of beef, celerycabbagebarleycarrotonion, green beans, and spices in a tube of eggflour and dough which is then deep-fried.
The wrap was designed to be unusually thick so it would survive handling at football matches. It was originally called a "Chicken roll" despite not containing any chicken then later renamed "Chiko Roll". At the peak of their popularity in the s and s, tens of millions of Chiko Rolls were sold annually in Australia, and the product has been described as an Australian cultural Hannover airsoft. The Chiko Roll Chiko roll poster developed by Frank McEncroea boilermaker from Bendigo who turned to catering at football matches and other outdoor events.
In the s, McEncroe moved to Melbourne with his family where he began to manufacture the rolls with the help of a sausage machine. The new company went public in Increasing competition in the Australian takeaway food market in recent decades has seen a decline in the profile of the Chiko Roll, but they are still widely available at fish and chips shops and supermarkets across Australia.
Since the s, Chiko Rolls have been advertised by an iconic "girl on a motorbike" also known as the "Chiko Chick" theme. The girl is usually photographed straddling a Harley Davidson motorcycle, holding the Chiko Roll near her crotch in a phallic gesture. The accompanying slogan is "Couldn't you go a Chiko Roll? Sincethe Chiko brand has been owned by Simplot Australia and today has expanded its products to include: All Chiko Rolls are now manufactured in BathurstNew South WalesAustralia, on a Foto agentur designed machine that produces the pastry and filling at the Nagellackentferner gbl time in long rolls.
They are then automatically sliced and then the distinctive ends are folded. Wikimedia Foundation. Roll food — for other meanings rollRoll as a kind Chiko roll poster food, snack or candy may refer to: Australian meat pie — An Australian meat pie is a hand sized meat Hinz steuerberater containing largely minced meat and gravy sometimes with onion and often consumed as a takeaway food snack.
It is considered iconic in both Australia and the neighbouring New Zealand. Rouleau de printemps — Pour les articles homonymes, voir Rouleau.
Sur les autres projets Wikimedia: Cuisine of Australia — Historically, Australian cuisine was based on traditional British cooking brought to the country by the first settlers.
We are using cookies for the best presentation of our site. Continuing to use this site, you agree with this. Chiko Roll. Wagga Wagga City Council. Museum of the Riverina. Retrieved Up From Australia. Wagga Wagga Guide. Fairfax Media The Daily Advertiser. Australian snack foods Laufen um die welt miiego culture Australian brands Appetizers.
Look at other dictionaries: Dictionaries exportcreated on PHP. Mark and share Search through all dictionaries Translate… Search Internet. Contents 1 History 1.


text: FRIENDLY BURNABY FAMILY PRACTICE We are a small family practice beside Metrotown that has been serving Burnaby for over 20 years. We treat our patients like our families. We only see one patient at a time and will not double book or overlap our patients in our schedule. We also understand that not all patients want the same thing. We will understand your concerns and work with you to achieve what is important for you. Our Philosophy A DENTIST YOU CAN TRUST Dr. Ma and Dr. Erceg are dedicated to providing the highest level of care. We are owner and practitioner of the practice. So we take great pride in the work and the reputation we enjoy. We practice dentistry with the patients' best interest in mind and have enjoyed numerous loyal patients from all over lower mainland. If we don't think we achieve the ideal result as we are not the best in everything, we will refer you to someone that can. Our Dentists STATE OF THE ART TECHNOLOGY AND EQUIPMENT We use the latest dental technology and equipment throughout the office such as digital Xray, high power magnifying loupes, dental laser and new generation dental implants. We strive for perfection and always practice according to most up-to-date Best Practice Guideline. Our Office


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Islamic State leader Abu Bakr al-Baghdadi is dead, confirms US President Donald Trump
US President Donald Trump on Sunday confirmed that the founder and leader of ISIS, Abu Bakr al-Baghdadi, is dead. Trump said that Baghdadi was the leader of the most ruthless and violent terror organisation anywhere in the world and he was killed in an operation carried out by American forces.
"Last night the United States brought the world's number one terrorist leader to justice. Abu Bakr al-Baghdadi is dead. He was the founder and leader of ISIS, the most ruthless and violent terror organisation anywhere in the world," Trump told media.
The US president said Baghdadi committed suicide by detonating a suicide vest inside a tunnel after a two-hour-long gunfight with US forces. He added that the IS chief was "whimpering and crying and screaming all the way."
Calling Baghdadi a 'sick and depraved man', Trump said that he died 'like a dog'. "Baghdadi and the losers who worked for him, and losers they are, they had no idea what they were getting into. In some cases, they were very frightened puppies. He died like a dog. He died like a coward. The world is now a much safer place. God bless America," Trump noted.
Providing more information of the operation, President Trump said that no US forces were killed in the raid and the troops involved "accomplished their mission in grand style."


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✓Vegan ✓Gluten Free ✓Lactose Free ✓No Preservatives ✓No colour additives ✓No added flavouring ✓No Added Sugar ✓ non-GMO ✓The product contains natural sugars
Country of origin: Lithuanian farm
How to use: perfect for desserts, baking, smoothies or juice. Can be mixed with water or eaten straight. You can also enjoy tea of excellent flavour. 1-2 of teaspoonful of currant powder is enough per day.
Fields of use: hot and cold beverages, instant beverages, ice tea, tea and infusions, beverages with milk, yoghurt , shakes, spray whipped cream; ice cream, sherbets, ice cream preparations, semifreddos; desserts, flairs (cold desserts), puddings, creams; sweet and salted pastry, bakery products, cakes, biscuits; cake and sweets preparations, icing, creams and fillings; filled chocolate, pralines, fruit jellies, sugared almonds, candies; nougats; dietetic dishes, baby foods, supplements, over-the-counter medicines, nutraceuticals; jams and marmalades.
Equivalent: 1 teaspoonful of blackcurrant powder = 100 g fresh blackcurrant
Ingredients: 100% dried blackcurrant.
Storage: should be stored in a dark cool place. Always keep the packaging closed as to avoid contamination.
Important is a balanced and varied diet and a healthy lifestyle.
Colour and flavour can vary due to seasonal fluctuations.
Net weight: 80 g.
Nutrition facts:
product nutritional
energy value per 100 g
of which are sugars
Potassium (K)
Phosphorus (P)
Iron (Fe)
Vitamin B6
283 kcal
0,27 g
74,08 g
67,28 g
6,8 g
4,08 g
892 mg (743%*)
125 mg (16%*)
3,26 mg (23%*)
0,3 (15%*)
*Reference average adult daily intake (8400 kJ/ 2000 kcal).
To blend 2 small bananas, 2 teaspoons blackcurrant powder, 0,5 teaspoon melissa lemon, 300 ml water or coconut water, 4 soaked dates or 1 spoon honey.


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Reliance Jio transfers control of optical fibre, tower units to RIIHL trusts
Updated : April 02, 2019 03:44 PM IST
The optical fibre cable infrastructure unit, Jio Digital Fibre Private Ltd (JDFPL) has allocated shares worth Rs 500 crore to Reliance Jio Infocomm Ltd (RJIL) on March 31, 2019, according to a regulatory filing.
Also, mobile tower unit Reliance Jio Infratel Private Ltd(RJIPL) has allocated shares worth Rs 200 crore to RJIL, it said.
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College basketball is in the middle of the conference schedule, but this weekend's slate is headlined by a pair of big non-conference games. The SEC/Big 12 Challenge highlights the weekend with 10 games between the two conferences, with Kentucky hosting Kansas as the marquee matchup in the challenge. Villanova, the top-ranked team in the country, also has a huge non-conference game on Sunday against Virginia. Here's a preview for all of the games you don't want to miss this weekend.
#22 Maryland Terrapins (18-2, 6-1 in Big Ten) at Minnesota Golden Gophers (15-6, 3-5)
Saturday, 2:15 pm ET, BTN
The only game between conference foes on this list, Maryland and Minnesota meet in one of the more underrated games of the weekend. While most of the Big Ten toils in mediocrity - nine teams are either 3-5 or 4-4 in the conference - Maryland has quietly risen to the top of the conference and have only lost two of their first 20 games overall. Led by junior point guard Melo Trimble, the Terps are looking to keep pace with Wisconsin at the top of the conference - and stay in contention for a top four seed in the NCAA Tournament.
As for Minnesota, they are looking to get their season back on track and improve their tournament resume. After starting the year a surprising 12-1 (the Gophers went 8-23 last season), Minnesota has only won three conferences games and come into this game on a four-game losing streak. Playing at home gives them a better chance to snap that streak, and getting a win over a ranked Maryland team would give them another marquee win (they also won at Purdue) to put on their resume.
However, that won't be the case. Even though Minnesota is a good defensive team (No. 6 in KenPom's adjusted defensive efficiency rankings), Maryland has proven to be excellent in close games (9-1 in games decided by seven points or less). Their clutch play will be what wins them this game.
Prediction: Maryland wins 77-73
#2 Kansas Jayhawks (18-2, 7-1) at #4 Kentucky Wildcats (18-2, 7-1)
Saturday, 6:15 pm ET, ESPN
Both Kansas and Kentucky lost this week to West Virginia and Tennessee, respectively, and each are looking to rebound with a big win over a top five team. Kansas has a veteran squad led by guards Frank Mason III and Devonte' Graham, but now only have one true big man in their rotation (senior Landen Lucas) following the indefinite suspension of Carlton Bragg Jr. for undisclosed reasons. Meanwhile, Kentucky has a team full of athletic freshmen and sophomores that want the game to be a track meet. They will run at every opportunity in an attempt to make this a fast-paced game.
However, the Wildcats have struggled this season when they're forced to play at a slow tempo. That's what Kansas would try to do, but without frontcourt depth, it becomes harder to play that way. Because of that - and the fact the game is at Rupp Arena - Kentucky will win. You can see a more expansive preview of this game here.
Prediction: Kentucky wins 88-76
#12 Virginia Cavaliers (16-3, 6-2 in ACC) at #1 Villanova Wildcats (19-2, 7-2)
Sunday, 1:00 pm ET, FOX
Missing football on Sunday? Villanova and Virginia will do plenty to entertain you. The Wildcats are coming off a stunning upset loss to Marquette during the week, but are the No. 1 team in the country for a reason. They rank 20th in adjusted defensive efficiency and fourth in offensive efficiency, showing how well rounded and dominant they are in all phases of the game.
Of course, Virginia is as well. They love to play at a slow, deliberate pace, and despite not having a true scoring threat, they still rank 17th in adjusted offensive efficiency and their patented defense sits third in KenPom's rankings. UVA is also surging of late, winning five games in a row - the last being a 71-54 win on the road over Notre Dame. That's a trend for the Cavaliers who are 6-1 in true road games.
All of that indicates Virginia may win, and they'll definitely keep it close. However, Villanova is not losing back-to-back games - Josh Hart & Co. are simply too good for that. Jay Wright will have Villanova focused and ready to go, and Virginia's offense simply won't be able to keep up.
Prediction: Villanova wins 73-64Back to the NCAA Newsfeed
Related Topics: Virginia Cavaliers Basketball, Big 12 Basketball, Big East Basketball, Kentucky Wildcats Basketball, SEC Basketball, Kansas Jayhawks Football, ACC Basketball, NCAA Basketball, Maryland Terrapins Basketball, Big Ten Basketball, Minnesota Golden Gophers Basketball, Villanova Wildcats Basketball


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vShare is an alternative app store which available for both Android and iOS. It is easy to download and set up on your Smartphone in seconds and reach tons of third-party applications. If you are above Android 4.0.3, there is no further to be prepared. Those apps, themes, games and so on are totally free. All latest releases will set there. The best thing is you do not need to confirm that you are rooted to set up vShare apk download.
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Moreover, though rooting became one of highlighted points on the top, vShare is completely free from being rooted. So its installation procedure is simple and nothing to bear out. Applications that contained are secured and scanned. So then users can establish them without any doubt on their devices. Moreover, vShare will not require access on your personal data or any other area. Therefore, do not worry if it will read your personal area.
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By the way, it compatible with any kind of Android Smartphone running 4.0.3 or else later as clarified. You can try this even on your iOS either.
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Facebook has been hit with a lawsuit accusing it of billing advertisers by inflating the number of people its ads could reach.
"Based on publicly available research and plaintiffs' own analysis, Facebook overstates the potential reach of its advertisements," business owner Danielle Singer alleges in a class-action complaint filed Wednesday in U.S. District Court for the Northern District of California.
Singer, who owns the Kansas-based business Therapy Threads, which sells aromatherapy-related products — says she spent more than $14,000 on Facebook ads between October of 2013 and April of this year.
She alleges that Facebook induced advertisers like herself to purchase ads — and to pay higher prices for them — by "vastly" inflating the number of active users the ads could reach. The complaint claims that Facebook violated a California business law.
The complaint draws on reports by outside groups, including the industry organization Video Advertising Bureau, as well as a survey commissioned by the plaintiffs. The Video Advertising Bureau reported last year that Facebook's estimates of audience reach in every U.S. state were higher than the states' populations according to the U.S. Census Bureau.
Singer specifically refers to Chicago in the complaint. She alleges that Facebook claimed in 2017 that its ads could potentially 1.9 million people in Chicago between the ages 18 and 34, but that Census data showed a population of only 808,785 people in that age range in Chicago.
Singer adds that a survey she commissioned shows that 59% of 18- to-34 year-olds in Chicago have Facebook accounts. The upshot, she alleges, is that Facebook ads potentially reach only 500,000 18-34 year-olds in Chicago.
The complaint also draws on information allegedly provided by ex-Facebook employees. One of the former employees, identified in court papers as "Confidential Witness 1," said the company's "potential reach" statistic is "like a made-up PR number," according to the complaint.
Another ex-employee, "Confidential Witness 3," allegedly "stated that Facebook was not concerned with stopping duplicate or fake accounts in calculating potential reach."
Singer is seeking monetary damages, as well as an order requiring Facebook to hire outside auditors and to remedy any problems found by the auditors.
Facebook said its reach estimates were based on many factors, and were not "designed to match population of census estimates."
The company is still facing a separate lawsuit over allegations of inflated video metrics. That earlier matter, which dates to 2016, is pending before U.S. District Court Judge Jeffrey White in Oakland, California.


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The prestige of a privileged land devoted to wine for more than two thousand years.
Rioja was the first Designation of Origin in Spain to earn Calificada status. This was in 1991.
A rigorous and effective control system makes Rioja synonymous with the highest quality.
Three production zones, each with a distinct personality: Rioja Alavesa, Rioja Alta and Rioja Orient
Certain to leave a mark on you. Wine is the connecting theme of all our routes.
Delve into the heart of our wines by knowing the history of our municipalities.
We tell you our stories and those of our wines.
Valentine's day is the perfect excuse for a romantic getaway, so why not pack your bags for uniquely beautiful Rioja. As Spain's flagship wine region, nestled under the protection of the majestic Cantabrian mountains in the north, the area is home not only to delicious wine, but to beautiful rivers, rolling mountains and picturesque towns.
Head to Rioja Alta and experience a brisk hike in the Cantabrian mountains which shelter the vineyards from chilly Atlantic winds. For a more leisurely evening, take a walk along the meandering River Ebro and admire the expansive views, or enjoy a romantic evening in at one of Logroño's renowned tapas bars where you can sample pintxos, the Basque name for tapas, washed down with local Rioja wine.
If you can't make it out to Spain, bring a taste of the Spanish sunshine to you. The huge variety of Rioja wine encompasses everything from full-bodied reds to pair with your Valentine's dinner, flavoursome oaked whites, and of course, classic pink rosado.
Pour a glass of Rioja rosado for a charming Valentine's day aperitif!
We will keep you up to date on all Rioja wine news.
You will discover new wines and wineries.
You will discover special offers and new wines.
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Many borrowers qualify for a loan, but they don't have a large sum of cash to put up the standard down payment. Below are a few straightforward methods that will help you get together a down payment
Slash your budget and build up savings. Be on the look-out for ways you can reduce your expenditures to save toward a down payment. Also, you can look into bank programs in which a specific portion of your take-home pay is automatically deposited into savings every pay period. Some effective strategies to put together funds include moving into housing that is less expensive, and skipping a year's vacation.
Sell things you do not really need and find a part-time job. Perhaps you can find a second job and build up your earnings. Additionally, you can make a comprehensive list of things you may be able to sell. Broken gold jewelry can be sold at local jewelry stores. A closetful of small items can add up to a nice sum at a garage or tag sale. You could also look into what any investments you have will sell for.
Borrow money from your retirement plan. Investigate the provisions of your specific plan. It is possible to borrow funds from a 401(k) plan for a down payment or withdraw from an Individual Retirement Account. Make sure you understand about any penalties, the effect this will have on taxes, and repayment terms.
Ask for assistance from members of your family. Many homebuyers are often lucky enough to get help with their down payment assistance from thoughtful parents and other family members who may be anxious to help them get into their own home. Your family members may be willing to help you reach the milestone of having your first home.
Research housing finance agencies. Special mortgage programs are given to buyers in specific situations, such as low income purchasers or future homeowners looking to renovating houses in a targeted area, among others. Working through a housing finance agency, you may receive a below market interest rate, down payment assistance and other benefits. Housing finance agencies can assist eligible buyers with a lower rate of interest, get you your down payment, and provide other benefits. These non-profit agencies to promote the value of homes in certain places.
Find out about low-down and no-down mortgages.
The Federal Housing Administration (FHA), which functions as part of the U.S. Department of Housing and Urban Development (HUD), plays a vital part in helping low and moderate-income Americans get mortgages. An office of the United States Department of Housing and Urban Development(HUD), FHA (Federal Housing Administration) aids homebuyers who wish to get mortgages.
FHA aids first-time buyers and others who might not be eligible for a traditional mortgage loan by themselves, by offering mortgage insurance to private lenders.
Down payment amounts for FHA loans are less than those of conventional mortgages, even though these mortgages have current rates of interest. Closing costs can be financed within the mortgage, while the down payment may be as low as 3 percent of the total.
With a guarantee from the Department of Veterans Affairs, a VA loan assists veterens and service people. This specialized loan does not require a down payment, has limited closing costs, and offers a competitive rate of interest. While the mortgage loans don't originate from the VA, the department certifies applicants by providing eligibility certificates.
A piggy-back loan is a second mortgage that you close along with the first. Usually the piggyback loan takes care of 10 percent of the purchase price, while the first mortgage covers 80 percent. In contrast to the traditional 20 percent down payment, the buyer just has to pull together the remaining 10 percent.
With a carry-back mortgage, the you borrow part of the seller's home equity.. The buyer funds most of the purchase price with a traditional mortgage program and borrows the remainder from the seller. Usually you'll pay a slightly higher rate with the loan financed by the seller.
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Kickin' it for God's Glory!
High Power is a summer camp for kids from 4-11 years old. It's for athletes and non-athletes; for those who know soccer inside-out, and for those who have never touched a soccer ball-kids at any and every skill level will benefit! Parents are welcome to stay and mingle with other adults in the hospitality area.
Campers will learn basic soccer skills, get lots of exercise and enjoy singing, skits and Bible teaching.
Price includes a t-shirt, bag, waterbottle, soccer ball and wristband
Download your registration form, and return it with the registration fee to:
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Sign me up as the first member of the Susana Balbo fan club. Her wines are so well-made, so affordable, so fun, that whenever I see them in the wine shop they somehow, of their own volition, jump right into my cart. And, boy, am I glad this one did. It's everything I want from a rose: delicious fruit (strawberries, rhubarb), bright acidity, and a finish that splits the difference between something melonlike and surprisingly nutty. And at $10 or $11, buying a case is not out of the question.
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Expro Oil and Gas Job Vacancies – Worldwide
Are you looking Expro Group Oil & Gas Jobs? Expro's 40+ years of experience and innovation empowers the company to offer tailor-made solutions for customers across the energy sector. With nearly 4500 employees in over 50 countries, Expro offers a … Read More »


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25 March 2011
Cambridge United, which is 17th in the Blue Square Bet Premier League and has Josh Coulson among its players, is being offered a choice of four possible new grounds by Grosvenor, the owner of its existing Newmarket Road ground
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1. Introduction
Historically, hyperbaric oxygen therapy has been used for treatment of decompression sickness in deep-sea divers. Today, hyperbaric oxygen is commonly used for the treatment of wide variety of surgical and non-surgical conditions, and has persuasively proved its high clinical efficiency in many areas. Currently, established indications include different bacterial (mostly anaerobic) and fungal infections, arterial gas embolism, poorly healing diabetic wounds, osteomyelitis, radiation tissue injury, carbon monoxide poisoning, crush injuries, gangrene, brain abscesses, burns, skin grafts or skin flaps at risk of compromised tissue perfusion, severe anemia, and also conditions like long-standing neurologic deficit, cerebral palsy or autism, and many more. The existing trend of ever-expansion indications to previously untouched areas holds for decades.
The purpose of this review is to examine advantages and disadvantages of the hyperbaric oxygen therapy, and also to explore the underlying physiological mechanisms of the hyperbaric oxygen actions in the ischemic, necrotic and otherwise compromised tissues.
This review will mostly be focused on the discussion of clinical efficacy and practical approach to HBOT use in the treatment of different types of gangrene and necrotizing fasciitis. Role and place of hyperbaric oxygen therapy in the treatment of ischemic and diabetic chronic wounds and ulcers will also be explored.
With currently recommended clinically tested protocols and using contemporary equipment, administration of hyperbaric oxygen therapy is generally considered very safe. However, it is not absolutely innocuous, and certain contraindications, ranged from medical problems to physical abnormalities, while mostly relative, should be carefully considered in every case.
The only absolute contraindication for hyperbaric oxygen therapy is untreated tension pneumothorax. Other contraindications include:
Severe chronic obstructive pulmonary disease with carbon dioxide
retention, pulmonary blebs, and/or dyspnea with slight exertion; restrictive airway disease (possibility of air trapping with barotraumas ensued)
Optic neuritis
Acute viral infection
Congenital spherocytosis
Uncontrolled, acute seizures disorders
Upper respiratory tract infection
Uncontrolled high fever
Pregnancy (questionable)
Psychiatric problems
History of prior thoracic or ear surgery, which would make it impossible to equalize middle ear pressure or pulmonary pressure (Foster,1992)
Concomitant chemotherapy with cis-platinum and adriamycin. Cytotoxicity of these agents has been shown to be potentiated by hyperbaric oxygen (Leifer , 2001; Monstrey et al,1997)
Adverse effects of HBO treatment include reversible myopia (Leach et al, 1998), barotrauma of the ear, claustrophobia (only in small treatment chambers), seizures (1.3 per 10 000 patient treatments), and, very rare, pulmonary oxygen toxicity (Bakker, 1984).Vasoconstiction, that could be expected due to the increased oxygen levels, was not observed in ischaemic or hypoxic tissues (Sheffield, 1988). Worsening of diabetic retinopathy could theoretically occur during hyperbaric oxygen therapy, but up until now this complication has not been reported.
2. Hyperbaric oxygen: mechanisms of action
The principle effect of hyperbaric oxygen treatment is creating hyperoxia in blood and tissues. Hyperbaric oxygen therapy implies administration of 100% under pressure greater than atmospheric. By raising the ambient pressure of oxygen either in the chamber or by breathing 100% oxygen through tight fitting mask, it is possible to increase the inspired PO2 up to 3.0 bar. The most commonly used levels of inspired oxygen range from 2.4 to 2.8 bar. At these levels, amount of dissolved oxygen in plasma could potentially meet oxygen consumption requirements of the whole body. Hemoglobin remains saturated even in the venous capillary blood (Ramaswami &Lo, 2000). At 3 atmospheres of pressure, which is commonly used in the modern hyperbaric oxygen treatment, the alveolar oxygen pressure is about 2,180 mm Hg, the arterial oxygen tension is at least 1,800 mmHg, and tissue oxygen concentration is approximately 500 mmHg. High tissue oxygen concentration remains elevated for variable period of time (likely up to a few hours) after removal from hyperbaric chamber, which depends on tissue density and perfusion. (Sheridan & Shank,1999).
It has been demonstrated, that inhalation of O2 at pressures greater than 1 ATA will increase production of reactive oxygen species, which is fundamental for physiological mechanisms of numerous effects and also therapeutic mechanisms. (Thom,2009). Reactive oxygen species, as well as reactive nitrogen species, play important roles as signaling molecules in transduction cascades, or pathways for a variety of growth factors, cytokines, and hormonal substances.
3. Hyperbaric oxygen for chronic diabetic wound and ulcer healing
Diabetes mellitus is increasing in incidence and currently presents one of the major health problems worldwide. The total number of diabetic patients has been projected to increase from 171 million in 2000 to 366 million in 2030 (Wild et al, 2004), with concomitant rise of the major complications rate, among which chronic non-healing leg diabetic wounds, associated with vascular insufficiency due to accelerated atherosclerotic process, is within area of this review focus. With this trend, the requirements for efficient treatment are obviously expected to increase exponentially.
The most prevalent forms of chronic wounds in diabetic patients are leg and foot ulcerations.(Leung, 2007; Tam & Moschella,1991). Typical chronic, non-healing ischemic and diabetic wounds require prolonged time (more than 8 weeks) to heal, and sometimes do not heal or recur.
The pathophysiology of diabetic foot ulcer and its prolonged healing, however complex, has been extensively studied and is well described. Early development and accelerated progression of the lower extremity peripheral arterial atherosclerotic occlusive disease, with predilection to complete vascular blockade on the level distal to the knee, is a major causing factor. Other contributing factors include progressive development of sensory, vasomotor and autonomic neuropathy, alterations in autoregulation of dermal blood flow (Liu & Velazquez, 2008).It has been shown, that peripheral vascular disease (macroangiopathy), along with diabetic polyneuropathy, constitute the most important factors in the diabetic wound and ulcer development. About 20% of diabetic lower extremity ulcers have impaired arterial flow as primary ethiological factor, approximately 50 % associated with primary diabetic neuropathy, and up to 30% have both conditions (Reiber et al.,1999). Recently, microangiopathy has also been implicated in the pathogenesis of diabetic foot ulcers (La Fontaine et al.,2006; Ngo et al., 2005). Along with rapidly progressing atherosclerotic obstructive vascular disease, diabetic patients commonly exhibit an enhanced vascular responsiveness to vasoconstrictors, attenuated response to vasodilators and impaired regulation of blood flow in many different regions, from cerebral blood flow to local, dermal perfusion. Altered endothelial function of resistance vessels could contribute to altered regulation of regional blood flow and insufficient tissue perfusion in diabetes mellitus (Unfirer et al., 2008).
The fundamental role of oxygen in the physiology of wound healing is well documented (Brakora & Sheffield,1995; Hunt,1988). Measurement of the transcutaneous pressure of oxygen (TcpO2) has been shown to be a valuable tool in predicting healing or non-healing in diabetic foot ulcers (Mathieu et al.,1990). It has been demonstrated, that patients with TcpO2 values <20 mmHg, in comparison to patients with values >40 mmHg, have a 39-fold increase in failure of wound healing (Pecoraro, 1991, Bakker, 2000; Rollins et al., 2006). Hypoxia in the wound tissues promote the ulceration process, whereas a plentiful supply of oxygen is critically important for a variety of healing processes (Liu &Velazquez, 2008). Oxygen tension is positively correlated with key components of the healing process, such as angiogenesis (Knighton et al., 1983), collagen production (Hunt &Pai,1972; Jonsson et al., 1991; Gurdol et al.,2010), bacterial elimination (Knighton et al., 1984;Cimsit et al.,2009) and epithelization (Uhl et al., 1994). In well-oxygenated wounds, all these components are greatly enhanced.
Of all other available oxygen delivery methods, hyperbaric oxygen therapy appears to be the most efficient option (Liu & Velazquez, 2008). Hyperbaric oxygen therapy has proved its efficiency in healing acceleration of ischemic and refractory diabetic wounds (Zamboni et al.,1997;Abidia et al., 2003; Hopf et al., 2005).
Despite the well-known beneficial effects of hyperbaric oxygen therapy on healing process of chronic ischemic and diabetic wounds and ulcers, its mechanisms of action are not completely understood. Restoring an adequate blood flow to the site of chronic wound is an essential prerequisite of successful healing response, which include modifying the altered vascular responsiveness to vasoactive substances and new vessel growth stimulation. It has been suggested, that hyperbaric oxygen is capable of induction of complex changes in the conducted vasomotor responses, thus modifying vascular sensitivity and reactivity to vasoactive substances (Drenjancević-Perić et al.,2009).It has also been hypothesized, that hyperbaric oxygen exerts beneficial effects on vascular function by affecting production or vessel sensitivity to vasoconstrictor and vasodilator metabolites of arachidonic acid and nitric oxide in response to physiological stimuli, namely acetylcholine, hypoxia and flow-mediated dilation, thus effectively restoring vascular reactivity (Unfirer et al., 2008). Available data is quite scarce and almost exclusively experimental. To date, no published results of large-scale, controlled prospective studies could be found.
Angiogenesis, in form of neovascularisation, is one of the essential processes that occur in the course of chronic diabetic wound healing. In conditions of hyperoxia, created by applying the hyperbaric oxygen therapy either locally (isolated extremity treatment) or generally in hyperbaric chamber, neovascularisation in hypoxic tissues occurs by two processes. Regional angiogenic stimuli increase the efficiency of new blood vessel growth by proliferation of microvascular endothelial cells, and also the recruitment and differentiation of circulation stem/progenitor cells (SPCs) to form vessels de novo. In clinically relevant concentrations, hyperbaric oxygen has been shown to influence both these processes (Thom, 2009). It has been demonstrated, that hyperbaric oxygen induces a cytoprotective and angiogenic response in human microvascular endothelial cells by increasing expression of immediate early and cytoprotective genes, which corresponded with increase in cell proliferation and oxidative stress resistance (Godman et al.,2010a,2010b).
Hyperbaric oxygen reduces circulating levels of proinflammatory cytokines, and also increases synthesis of many growth factors. Oxidative stress at the sites of neovascularization stimulates growth factors synthesis by augmenting synthesis and stabilizing hypoxia-inducible factor (HIF)-1. (Hunt et al.,2004, 2007) Vascular endothelial growth factor (VEGF), angiopoetin and also stromal-derived factor-1 influence stromal cells differentiation to endothelial cells. VEGF, the most specific growth factor for neovascularization, has been shown to be increased by hyperbaric oxygen(Sheikh et all.,2000;Thom,2011).
Diabetic foot ulceration is a major predisposing factor for local infections, whereas various immunological disturbances and peripheral polyneuropathy play secondary roles. Diabetic foot ulcers are frequently polymicrobial with a high incidence of anaerobic organisms. Anaerobic infections are especially frequently seen in tissues with low oxygen tensions. Anaerobes are found in about 33% of cases of diabetic foot infections (Calhoun et al.,1992; Calhoun et al.,2002). Among the frequently isolated anaerobic organisms are species of Bacteroides and Clostridia (Boulton, 1988). Aerobic Gram-positive cocci (especially Staphylococcus aureus) are also among the most common, sometimes predominant, pathogens in diabetic foot infections. Patients with chronic wounds who are already receiving antibiotics, may be also infected with gram-positive rods, and those with established foot ischemia or gangrene may have obligate anaerobic pathogens (Lipsky et al., 2006).Hyperbaric oxygen therapy is often combined with antibiotics as an adjunctive treatment for various wound infections. Hyperoxia and hyperbaric oxygen exert antimicrobial effects by increasing the intracellular flux of reactive oxygen species. Hyperbaric oxygen may be either bacreiostatic or bactericidal for microorganisms that lack defenses against oxidants. In bacteria, reactive oxygen species cause DNA strand breaks, degradation of RNA, inhibition of amino acid biosynthesis, and inactivation of membrane transport proteins. Oxygen tensions also affect the activity of antimicrobial agents. In general, hyperoxia potentiates while anaerobiosis decreases the activity of many antimicrobial drugs. With regard to host defenses, hypoxia can seriously impair leukocyte bacterial killing function (Rabkin &Hunt,1988; LaVan & Hunt,1990). Hyperoxia elevates oxygen tensions in infected tissues to levels that facilitate oxygen-dependent killing by leukocytes. Prolonged hyperoxia inhibits DNA synthesis in lymphocytes and impairs chemotactic activity, adherence, phagocytic capacity, and generation of the oxidative burst in polymorphonuclear leukocytes and macrophages. (Park et al., 1992; Cimsit, 2009).
One of the suggested criteria for hyperbaric oxygen therapy use is transcutaneous oxygen measurement of less than 40 mm Hg at the tissues surrounding the wound, most precisely, at the wound edges. This baseline measurement should be followed by testing the patient's tissue response to administration of 100% via tight face mask. The trascutaneous oxygen level should increase by at least 10 mm Hg to justify starting of hyperbaric oxygen therapy. After an hyperbaric oxygen trial, the transcutaneaous measurement should be greater than 200 mm Hg (Attinger, 2006; Hunter et al, 2010). It has been also demonstrated, that a transcutaneous oxygen tension (TcPO2) of 200 mmHg, measured in the peri-wound tissues while in-chamber, was the most effective determinant of success or failure of the therapy. It has been found, that TcPO2 in peri-wound tissues at sea level air of less than 15 mm Hg, together with a TcPO2 less than 400 mm Hg, measured in the same tissues in-chamber, proved to be most accurate predictor of hyperbaric oxygen therapy failure (reliability 75.8%, positive predictive value 73.3%)(Fife et all, 2002, 2007).
The commonly used protocols for hyperbaric oxygen therapy administration vary among institutions. No consensus has been reached so far in respect to single session and whole treatment duration. Most commonly, hyperbaric oxygen for diabetic wounds is administered at pressure range of 2 to 2.8 ATA, 5 days a week, with typical session duration of 45 to 90 minutes.(Wang, 2003). Other authors have been using daily treatments of 1.5 to 2 hours duration, for 20 to 40 days (Thom,2010).
The effectiveness of hyperbaric oxygen for diabetic and ischemic wounds treatment may be evaluated from prospective of two most important clinical outcomes: expediting the wound healing and reduction the amputation rate. Clinical efficacy of hyperbaric oxygen therapy in healing of chronic diabetic and ischemic wounds has been demonstrated by many researchers (Hinchliffe et al., 2008). Another group reported 90% healing in the intervention group versus 28% controls (Heng et all, 2000). The wound area reduction has been reported to occur at 2 weeks: 42% in the intervention group versus 21% (p = 0.037) and at 4 weeks: 62% versus 55% (Kessler et al., 2003). Two groups reported a favorable outcome after hyperbaric oxygen therapy in respect to expedited diabetic ulceration healing. One of groups has conducted a double-blind randomized trial, the main outcome of which was completely healed wound by 12 month after commencement of the therapy (2.5 ATA for 85 min, 5 days a week, for 8 weeks)in 52% of patients that received hyperbaric oxygen versus 29% of those from control group (Duzgun et al., 2008; Londahi et al.,2010,2011).
It has been well demonstrated, that use of hyperbaric oxygen therapy was associated with decrease in amputation rate in diabetic patients. A decrease by 30% of major amputations rate in Wagner grade 4 patients has been reported in large prospective study (Faglia et al., 1996). Another study demonstrated even more significant (almost in 71%, 2 amputations in the study group versus 7 in control, a total of 30 patients) decrease of amputation rate (Doctor et al., 1992).
4. Hyperbaric oxygen in the treatment of necrotizing fasciitis and Fournier's gangrene
Necrotizing fasciitis has been defined as rapidly progressing life-threatening bacterial infection, that primarily involves skin and secondary subcutaneous tissues (Jallali et al., 2005). Incidence of necrotizing fasciitis has increased over two decades (1980-2000), yet the disease still remains quite rare. The possible explanation may include increased microbial virulence and resistance because of excessive use of powerful antibiotics, and also possibly disease reporting and statistical work improvement (Sarani et al., 2009).
There are three basic subtypes of necrotizing fasciitis described. Approximately 55 to 75 % of type I caused by combination of gram-positive cocci, gram-negative rods, and anaerobes; less commonly, by species of bacteroides or Clostridium (Childers et al.,2002; Wong et al., 2003;Anaya &Dellinger, 2007). This type of infection tend to occur in the trunk and perineal areas and include Fournier's gangrene. Type II of necrotizing fasciitis mostly caused by monomicrobial flora, that include group A Streptococcus (S. pyogenes) alone or in association with Staphylococcus aureus. This type may be associated with toxic shock syndrome. During last 5 years, an increasing incidence of methicillin-resistant S. aureus (MRSA) is being reported, especially in IV drug users. Today, MRSA is cultured in approximately 40% of necrotic wounds (Miller et al., 2005; Maltezou & Giamarellou,2006;Thulin et al.,2006). Some sources classified necrotizing infection caused by Vibrio vulnificus as type III, although consensus regarding such classification remains yet to be reached. The biggest risk factors for this, the rarest, type of necrotizing fasciitis include exposure to warm sea water and also moderate to severe liver disease, particularly chronic hepatitis B (Howard et al., 1985).
Bacterial agents, that invade subcutaneous tissues through disrupted viscus of colorectal or urogenital area or perforated skin, rapidly spread over the adjacent tissues, producing endo-and exotoxins, that cause deep tissue ischemia and liquefactive necrosis that eventually lead to systemic disease (Salcido, 2007). Some of the exotoxins, namely M-1 and M-3 surface proteins, produced by S.aureus and Staphyloocci, increase microbial virulence by enhancing their ability to adhere to tissues and resistance to phagocytosis. Other exotoxins, namely A and B exert a variety of ill effects, that include endothelium damage, loss of microvascular integrity, increase of capillary permeability, causing plasma capillary leak, which results in tissue edema and impairment of capillary blood flow. These toxins, along with streptolysin O, stimulate CD4 cells and macrophages to produce large amounts of tumor necrosis factor-a,interleukin1 and 6 (Hackett & Stevens, 1992). Release of these cytokines into the circulation causes systemic inflammatory response and may lead to septic shock, multiorgan failure and eventual death. Superantigenes directly stimulate T-cells, causing activation of complement, bardykinin-kallikrein system and coagulation cascade, with small vessel thrombosis and tissue ischemia ensued (Salcido,2007 ).
Early radical surgical debridement along with aggressive, wide-spectrum antibiotic therapy remains a mainstay of the necrotizing fasciitis treatment. Despite the certain progress, achieved in this field, unfavorable outcome remains quite common.
High mortality rate of 20 to 40% (McHenry et al.,1995) have prompted a search for effective ancillary methods of treatment to improve patients outcome. Hyperbaric oxygen therapy has shown some promising results, which promoted its use as an adjuvant therapeutic modality in this category of patients. Although variety of protocols have been employed, the most common method includes administration of oxygen at 2 to 3 ATA with average duration of 60 to 120 minutes. However, no consensus has been reached so far regarding either duration, timing or number of sessions, and established protocols for HBO therapy in necrotizing fasciitis or Fournier's gangrene are absent.
Most of clinical evidences, supporting the use of hyperbaric oxygen therapy, are of only anecdotal value at best. Most authors have chosen a decrease of the overall mortality rate as an universal index of HBO therapy efficacy, reporting improved patients survival rates in majority of studies. The reported mortality rates varied significantly, from 0 to 33% (Jallali et al., 2005).
The lowest mortality rate ever reported, essentially zero deaths after combined early surgical debridement and HBO therapy in small group of only 9 patients with Fournier's gangrene, was shown in the early clinical study of (Eltorai et al.,1986). In this study, however, no data was provided either in respect to details of the treatment protocol details (duration of the study, number of sessions, time intervals between hyperbaric oxygen therapy sessions and surgical debridments). Another study included two series of 32 patients with clostridial gas gangrene and 11 patients wit perineal necrotizing fasciitis, who underwent hyperbaric oxygen therapy at 2.5 ATA for 120 minutes of session duration, and 3 first treatments were administered during first 24 hours after admission, and then repeated twice daily. The overall mortality rate was reported as 28% in gas gangrene group. In the group of patients treated with hyperbaric oxygen, 94% of the survivors healed completely and were able to walk normally (Him, 1993).
In yet another study, 33 patients were treated for perineal necrotizing fasciitis. Their management included wide early surgical debridment and drainage, massive antibiotic therapy and hyperbaric oxygen therapy at 2.5 ATA, 2 to12 times. The reported mortality rate was quite low (9.1%, 3 patients died out of 33) (Korhonen, 2000). Same group of researchers had also managed a group of 53 patients with Clostridial gas gangrene, and protocol here was pretty much identical to that used in patients with Fournier's gangrene. The reported mortality rate was 22.6%. In this study, substantially higher levels of subcutaneous PO2 at the same O2 pressures of 2.5 ATA during hyperbaric oxygen therapy were found in the vicinity of infected areas than in healthy tissues. Authors concluded, that hyperbaric oxygen therapy appears to be life-, limb, and tissue saving, and that the hyperoxygenation of tissue zone surrounding the infected area may be of significance in preventing the expansion of microorganisms. (Korhonen at al., 1999, 2000). Authors of another study administered hyperbaric oxygen shortly (about 7 hours) after surgical debridement, which resulted in achievement of only 12.5% mortality rate. However, no control group was mentioned in this study, which makes it difficult to draw a definite conclusion regarding the net effect of the hyperbaric oxygen therapy (Gozal et al., 1986) In the controlled study, included group of 17 patients that received hyperbaric oxygen along with surgical debridement and antibiotics versus that of 12 patients, whose treatment did not include hyperbaric oxygen therapy, use of this modality has allowed to decrease overall mortality from 66% to 23%. This result has been achieved despite the fact, that patients received hyperbaric oxygen, were more seriously ill (some of them were in septic shock), which makes the beneficial effect of the therapy in this study particularly noteworthy (Riseman et al., 1990). In larger, albeit without control group study, efficacy of including HBOT in the treatment protocol in 42 consecutive patients has been proved by decreasing of overall mortality from 34%(national reported rate) to 11.9%, with 0% amputations (vs.50% of national average) in hyperbaric oxygen-treated patients (Escobar et all, 2005)
A growing number of studies, in contrast with those reported positive results of hyperbaric oxygen therapy, have demonstrated lack of any advantages of the hyperbaric oxygen therapy. In the large controlled multicenter study, (Brown et al.,1994), hyperbaric oxygen therapy was not associated with statistically significant decrease in mortality (30% in HBO group vs. 42% in control), number of debridements (2.4 in hyperbaric oxygen group vs 1.3 in control) was actually higher, and length of hospital stay was not different between groups(31.6 days in hyperbaric oxygen vs. 31.3 days in control). In this study, however, majority of the patients (66%) received less than 4 sessions, which potentially makes the impact of hyperbaric oxygen therapy substantially weaker. Also, patients who were selected for hyperbaric oxygen therapy, had more advanced stages of sepsis, which potentially may have introduce a bias factor in the results interpretation. Authors of another study found no differences in length of hospital stay, complications rate and mortality between groups of patients with necrotizing fasciitis, where one was treated with hyperbaric oxygen therapy, and another wasn't; however, 25% of non- hyperbaric oxygen therapy group required amputations, whereas patients from hyperbaric oxygen therapy group needed no such intervention (Hassan et al.,2010 ). Authors of the retrospective study, reviewing 10-year - long experience of using HBOT as an adjuvant treatment for necrotizing fasciitis, found no improvements from hyperbaric oxygen use, but rather worsening of results in respect to mortality rate (36% in hyperbaric oxygen therapy group vs. 25% in control), number of debridements (2.5 with hyperbaric oxygen therapy vs 1.5 in controls). Difference in length of hospital stay, which was, however, shorter in hyperbaric oxygen therapy group (15.9 vs 20 days in controls), was not statistically significant.
Another retrospective study revealed considerably higher mortality among the patients with Fournier's gangrene, treated with hyperbaric oxygen therapy, in comparison with those received no such treatment (26.9 vs 12.5%). The potential reason for this finding, again, may be attributed to the selection of the much sicker patients for hyperbaric oxygen therapy (Mindrup et al., 2005).
Absolute majority, if not all, of studies investigating the effects of hyperbaric oxygen therapy, are retrospective ones. Even the largest series include several dozen patients at best, with most common sample size around 20 patients, either in study or control groups. Such small numbers of subjects preclude the use of vigorous statistical methods in comparison studies, investigating mortality and morbidity rates, tissue- and limb- salvage efficacy of the hyperbaric oxygen therapy. These limitations substantially diminish the predictive value of quite scarce published studies.
To date, even after thorough literature research, we could not find any prospective, randomized comparison study investigating different effects of hyperbaric oxygen therapy. Regretfully, it appears that truly robust proof of either positive or negative effect of hyperbaric oxygen therapy, at least as an adjuvant therapy for necrotizing fasciitis and gangrene, is currently absent.
There are numerous reasons to this situation. Scarcity of the resources (many hospitals do not possess the hyperbaric oxygenation chambers), lack of established guidelines, differences on clinical protocols (outlining timing, number of sessions, time correlation with debridements, and more), clinicians' opinions and experience, and also tendency to reserve the hyperbaric oxygen therapy, a quite expensive method, for the sickest, critically ill, oftentimes frankly moribund patients, are among the important limiting factors, making it truly difficult to elucidate the genuine impact of hyperbaric oxygen therapy in practically every area of its use (Jallali et al., 2005). In its current status, based on existent level of pro—and contra- evidences, HBOT efficacy remains controversial at best, and may not be unanimously recommended as therapeutic modality in every case of necrotizing fasciitis or gangrene.
5. Conclusion
Diabetic foot chronic wounds and ulcerations adjuvant treatment with hyperbaric oxygen appears to be efficient with respect to promoted healing and also in decrease of major amputations rate.
Hyperbaric oxygen therapy may not replace the combination of early aggressive debridements and wide-spectrum antibiotic therapy, but rather remains an adjuvant, however sometimes efficient, method in the management of necrotizing fasciitis and gangrene.


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