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Speaking of coptis root, which is also known as rhizoma coptidis and Huang Lian, bitterness may be the first thing that comes to mind for most people. Its bitterness is so strong and distinct that seemingly its bitterness could even sting your eyes when you lay your eyes on it. No wonder in China there is a widespread old saying, "The dumb man eating the coptis herb – he had to suffer the bitterness in silence." As you may know, this is one of commonly used Chinese herbs, which was initially recorded in the Shennong Bencao Jing (Shennong Emperor's Classic of Materia Medica) and listed as one of the best herbs. Today this herb becomes one of the 40 kinds of large bulk herbs and also one of the 30 kinds of most valuable Chinese herbal medicines. It is quite normal that you have an aversion to the bitter flavor as bitterness would stomp on the back of your tongue. However, you may not know the fact that the extensive coptis medicinal uses actually derive from this unsavory taste – bitter pills may have blessed effects. As it turns out, coptis is that type of blessed herb used for a variety of diseases, especially for gastrointestinal disorders.
What is coptis?
Medicinally it mainly means the dried root and rhizome of Coptis chinensis Franch. (Wei Lian), Coptis deltoidea C. Y. Cheng et Hsiao (Ya Lian), or Coptis teeta Wall. (Yun Lian), which are plants in the family Ranunculaceae. As you can see, these three species are different from coptis japonica that is native to Japan. Therefore, other common names of this herb are coptis rhizome, rhizoma coptidis, Chinese gold thread, Chuan lian, coptidis rhizoma, coptis chinensis root, coptis goldthread, etc. Commercially most of them are from cultivation and mainly produced in Sichuan, Yunnan, and Hubei. The one collected during autumn is usually considered superior medicinally. And after the harvest, it needs to remove its fibrous roots and dirt attached and dried. And it is used raw, fried alone, or processed with ginger juice, rice wine, or evodia decoction.
The plant of coptis chinensis is a perennial herb. Root & rhizome is yellow, branched often, and densely covered with many fibrils. All leaves are basal. Petiole is from 5 to 16cm. Blade is papery, ovate-triangular, 10cm wide, and 3-lobed. Flower stems are 1 to 2 in number, equal or longer to leaf in length. Dichotomous or pleiochasium cyme has 3 to 8 flowers. Bracts are lanceolate and 3 to 5 pinnatipartite. Seeds are 7 to 8 pieces, oblong, about 2mm, and brown. Its flowering period is from February to April and fruiting period from March to June.
Major chemical constituents of Coptis chinensis are 5.56% to 7.25% berberine, coptisine, epiberberine, berberrubine, palmatine, columbamine, jatrorrhizine, worenine, magnoflorine, ferulic acid, obakunone, and obakulactone.
Coptis root benefits
As one of articles of tribute in Ming and Qing Dynasties, this herb has a long history of treating illness. Actually coptis is a household name because there are tons of famous herbal formulas that contain this ingredient. As far as Shang Han Lun (On Cold Damage) is concerned, there are 12 prescriptions containing coptis, which accounts for about 10% of total number of this book. This book was introduced to Korea, Japan, and countries in Southeast Asia in Tang Dynasty and, more importantly, these formulas are still frequently put to use by the doctors of traditional Chinese medicine in these places. What's more, according to the statistics there are as many as more than 260 formulas included in Qian Jin Yao Fang (Thousand Golden Essential Prescriptions) and Wai Tai Mi Yao (The Secret Medical Essentials of a Provincial Governor). It is thus clear that how widely this herb is used medicinally. So far, there are various coptis preparations available on the market, such as coptis chinensis root extract, tea, oil, tablets, teapills, ointment, cream, supplement, tincture, capsules, etc. And these products are mainly used for lyme, diabetes, insomnia, endometriosis, acne, weight loss, and so on. And here is its pharmacology to justify its health benefits.
Modern pharmacological actions of rhizoma coptidis
1. It has a strong antibacterial effect on staphylococcus, streptococcus, pneumococcus, Vibrio cholerae, Bacillus anthracis, and dysentery bacterium except Shigella sonnei;
2. It also has an antibacterial effect on Klebsiella pneumoniae, Corynebacterium diphtheriae, Bacillus subtilis, Bordetella pertussis, yersinia pestis, brucellosis, and tuberculosis;
3. It has poor antibacterial effect on E. coli, Proteus, and Salmonella typhi;
4. The berberine can stimulate the heart, increase its contractility, and increase coronary blood flow when used in small dose and suppress the heart and weaken its contraction when used in large dose;
5. The berberine can reduce the heart rate of toad and stimulate the isolated atria of rabbit, guinea pig, and rat. It can also resist arrhythmia, have good cholagogic action, inhibit gastric secretion, arrest diarrhea, prevent acute inflammation, fight cancer, reduce tissue metabolism, and so on. And small dose of berberine can strengthen the excitability process in mouse's cerebral cortex while large dose instead can strengthen the inhibition process;
6. Berberine and tetrahydroberberine can reduce myocardial oxygen consumption;
7. Berberine and its extracts have anti-ulcer effect.
Popular herbal coptis formula
Chinese Materia Medica believes that it is bitter in flavor and cold in properties and covers four meridians, such as heart, liver, stomach, and large intestine. Essential coptis effects and functions are clearing heat-fire, eliminating dampness, and relieve internal heat. Fundamental coptis root uses and indications include high fever due to the attack of heart channel by heat pathogen, irritability, delirium or hematemesis and nosebleed caused by excess heat forcing blood's hyperactivity, feeling of stuffiness in chest due to damp heat, diarrhea, dysentery, annoyance and insomnia caused by heart-fire hyperactivity, vomiting swift digestion with rapid hungering caused by stomach heat, liver-fire induced swelling and pain of eye, heat-toxicity sore and ulcer, furunculosis, swelling and aching of gum, mouth sores, acute or chronic suppurative ear disease, swelling and pain in the pudenda, hemorrhoid bleeding, eczema, burns. Recommended coptis dosage is from 1.5 to 3 grams in decoction and 0.3 to 0.6 grams in powder or in pills.
1. San Huang Xie Xin Tang (coptis and rhubarb combination). From Jin Gui Yao Lue (Essential Prescriptions of the Golden Cabinet), this formula combines it with Da Huang (rhubarb) and Huang Qin (Scutellaria) for the treatment of spitting blood and bleeding from five sense organs or subcutaneous tissue because of blazing internal fire inducing blood's hyperactivity.
2. Huang Lian E Jiao Tang. From Shang Han Lun, this prescription is mainly formulated for the impairment of yin by excessive heat and vexation and sleeplessness. Other major herbal ingredients include Baical Skullcap, Bai Shao (White Peony), E Jiao (Donkey-Hide Gelatin), etc.
3. Huang Lian Shang Qing Wan. From 2002 Addendum to 2000 Pharmacopoeia, the recipe is primarily designed for wind heat in upper warmer induced head spinning, swollen gums, mouth sores, sore throat, earache, tinnitus, dry stools, and yellow urine. Other herbs include Zhi Zi (Cape Jasmine Fruit), Lian Qiao (Forsythia), Man Jing Zi (Vitex), Fang Feng (Saposhnikovia Divaricata), and so on.
4. Huang Lian Jie Du Tang (coptis decoction to relieve toxicity). From Wai Tai Mi Yao, the Coptis Detoxifying Formula uses it along with Scutellaria, Huang Bo (Amur Cork Tree Bark), and Gardenia to cure carbuncle and swollen boils.
5. Qing Wei San. From Lan Shi Mi Cang (Secrets from the Orchid Chamber), it is basically made for unbearable toothache because of stomach fire attack. The rest major herbs are Sheng Di Huang (Rehmannia), Sheng Ma (Black Cohosh Rhizome), Mu Dan Pi (Tree Peony Root Cortex), and more.
Coptis root side effects and contraindications
The most common adverse reactions about Chinese coptis root are vomiting and nausea in large dose taken in a long term. What's more, it should be avoided by patients who are using antihypertensive medications and infants with jaundice. TCM wise, it shouldn't be used in those who are suffering from deficiency-cold in spleen and stomach because overdose or long-term use of extremely cold-bitter natured herb may lead to the impairment of spleen and stomach. In addition, use with care in the case of deficiency of yin and body fluid impairment.


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I'm surrounded by change. Everywhere I go things are changing at a pace that's too fast for me.
Tonight my husband attended a marching band meeting for next year's incoming freshman. Next Tuesday, we'll be attending another meeting at the high school for incoming freshman. I can't ignore it. In three months, I'll have a freshman in my house.
I'm not ready for it.
My middle child will be starting his final year of elementary school. He's making plans to be a school crossing guard, learning the trumpet and oh yes, sex ed starts next year.
I'm not ready for it.
And my baby has one year left of preschool and then he starts kindergarten.
I'm not ready for it.
It doesn't matter. Change is coming and there's nothing I can do about it. Deep down, I don't want to stop my boys from growing up. (That's what I'm supposed to say, right?)
Those are changes I can't control. But the ones I can aren't any easier. Fear hangs over my head a lot lately. I'm terrified of changing things and making horrible mistakes.
Fear can't be in charge though. I've always been told that you can't stand still for very long before you start to die inside. You have to keep moving forward.
And no one said it was going to be easy.
Is change hard for you or do you embrace it?

subset: commoncrawl


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Trump and Clinton's gay rapport
With less than week until the US presidential election, candidates Hillary Clinton and Donald Trump tried to impress LGBT voters. Clinton answered a policy questionnaire from the Washington Blade and pledged to fight anti-gay religious freedom laws and conversion therapy. Trump meanwhile waved a rainbow flag on stage, but a BuzzFeed investigation into "LGBTs for Trump" found a tiny organization staffed by only gay white men.
Andrew Sullivan is anxious
Venerable gay conservative political blogger Andrew Sullivan once again emerged from quasi-retirement this week to talk about his political anxieties. In a continuation of a gloomy essay he published in May, Sullivan worries for the future of America in the face of Donald Trump.
The rise of "gender ideology"
In the face of a rising tide of LGBT acceptance, Conservatives worldwide have coined a new term to combat newly acceptable forms of family and sexuality. From the pope to activists in France and Mexico, conservatives have labeled "gender ideology", the idea that gender is not a fixed biological fact, as their philosophical enemy.
Gay testing persists in Uganda
Two men from Uganda reported to a Reuters journalist how they were beaten, arrested, and forced to undergo anal testing due to suspicions of homosexuality. Uganda is one of eight countries worldwide where anal testing, which credible scientists agree to be useless, is used by police.
Possible breakthrough in HIV treatment
Scientists in Jerusalem say they have discovered a compound that causes cells infected with HIV to self destruct. If effective, the drug would still be years away from human trials.


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Writer David Templeton takes interesting people to interesting movies in his ongoing quest for the ultimate post-film conversation. This is not a review; rather, it's a freewheeling, tangential discussion of art, alternative ideas, and popular culture.
It's lunch-time in Washington D.C. Tom Rosenstiel--director of the Project for Excellence in Journalism, an influential Washington think tank--is taking a break from his directorial duties, munching on what sounds like a celery stick as he takes my call to discuss the semi-satirical thriller 15 Minutes.
"I saw the movie. Yesterday," Rosenstiel affirms, with a sigh and a crunch, uttering these words with the same level of enthusiasm one might use in saying, "I've just had my spleen removed."
15 minutes stars Robert De Niro, Edward Burns and Kelsey Grammer. De Niro is a media-savvy cop. Burns is a shy arson investigator. Kelsey Grammer runs a sensational TV news show that strongly resembles Hard Copy.
In the course of the film, these characters each encounter a pair of psychotic Russians out on a murderous Big Apple crime spree, video camera in hand. On a quest for fame and fortune, American style, the bad guys--with the cop and the fireman hot on their trail--film their nasty little crimes, then attempt to sell the tapes to Grammer, who huffs about spouting stuff like, "Image is everything!" and "If it bleeds, it leads!" When he's offered graphic footage of a beloved celebrity being beaten to death, Grammer forks over a million George Washingtons and runs the murder smack in the middle of dinner hour.
The message of 15 Minutes is obvious: we are a violent society and the news only feeds our appetite for blood. Ouch. Take that, Tom Brokaw. Or maybe it's saying that being famous will get you killed.
Or, actually, I don't know what the point was, other than to lure innocent people to the theater to pay good money to sit in the dark watching mindless violence--and maybe that is the point.
To help out, I've asked Rosenstiel to provide a little context.
Rosenstiel knows the treacherous terrain through which 15 Minutes crawls. A journalist since the late '70s, he's served as media critic for the Los Angeles Times and MSNBC, and 1996 founded the aforementioned Project for Excellence in Journalism. WIth Bill Kovach--himself an award-winning journalist and editor--Rosenstiel is the author of the much-anticipated new book Elements of Journalism: What Newspeople Should Know and the Public Should Expect (Crown; $20.00), a sharp, entertaining romp through the ethical crises inherent in the today's deeply-conflicted News Biz. Or is that the Advertising-and-Entertainment Biz? It's hard to tell the difference sometimes--but maybe that's also the point.
First things first.
"So. If you were the news guy in the movie," I ask, "would you have made the call to run the murder on TV?"
I am answered with a few seconds of thoughtful munching before Rosenstiel responds that he might show some of the killing--but not all of it.
"We've defined 'sensationalism' as the moment that you are no longer imparting any information," he explains. "So I think that at a certain point, once you've communicated that [the victim in question] is being killed, you don't have to actually show the murder itself. You do have a responsibility to kids who might be watching."
As if kids actually watch the news. But more on that later.
Next question.
"Does anybody in the journalism ever really say, 'If it bleeds, it leads?'"
"They may think it, but they never say it," Rosenstiel tells me. "And nobody also says, 'Image is everything,' or 'Perception is reality.' Those clichés undermine the reality of the film, which could have been good. It has pretensions of being a movie with a serious message, but it's basically just a big, violent, cop thriller."
He munches thoughtfully for a few seconds. "But does what bleeds truly lead in a lot of cities, on a lot of newscasts? Yes. Is that because people think murder and gore are good for ratings? It's not that simple."
Crime and slime have, at various times, been very good for ratings. But it's not a foolproof formula, as evidenced by the fact that 15 Minutes itself dropped out of the top ten faster than the two psycho Russians start killing people. Sometimes, indulging in such voyeurism does make us feel dirty--and a bit guilty.
"As evidenced in the movie by the scene where Edward Burns punched Kelsey Grammer, and all the cops cheer," Rosentiel says. He goes on to point out that many newscasts are getting the picture, realizing that a strategy of "all crime all the time" is not the solidly dependable cash cow it once was. Or at least not as effective among the increasingly attractive advertising demographic of women.
Still, the news we watch, when we do watch--and our level of news consumption is definitely down--is decidedly more harrowing than it once was.
"When I was little, my parents used to insist that I watch the news with them," recalls Rosenstiel. 'They'd tell me, 'This is important. You need to see this.' Today though, because of the character of local television, the news is something I feel I need to shield my kids from."
Isn't that ironic? Because of the desire of some broadcasters to treat the news so sensationally in order to drive up viewership, the next generation of potential news-watchers are not being allowed to acquire an appreciation for watching or reading the news.
"We've effectively destroyed the news habit in this country," says Rosenstiel. "We've broken the cycle. By becoming too graphic and crime-addicted in our coverage of the news, we've all but killed the Golden Goose."
There is hope, however, he says, and it comes in taking a careful look at the history of journalism. When we trace today's news programs all the way back to the first journalists--brave lads with strong legs who could run over the hill and back, then relate what was going on over there in a succinct, accurate, and entertaining fashion--we see that cycles of journalistic sensationalism always tend to burn themselves out. Sometimes at the stake.
"Styles go in and out and up and down and change all around," Rosenstiel reports. "But the thing that makes journalism exist is the human need for information. 'Is it going to snow? Will the roads be closed?' That's what people want from journalism. The business end of news flows out of that, and if you get too far away from serving that need . . . you go out of business. Those who continue to pander to the lowest common denominator will one day end up the way Kelsey Grammer does--flat on their backs."
From the March 29-April 4, 2001 issue of the Northern California Bohemian.


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How to prepare for severe winter weather
Keep your family safe through blizzards, storms and extreme cold
Every year, exposure to cold kills hundreds of Americans, according to the U.S. Centers for Disease Control (CDC). Cold also can exacerbate other health conditions and cause hypothermia and frostbite, which can lead to loss of fingers and toes or cause permanent kidney, pancreas and liver injury - even death, according to the National Weather Service (NWS).
addition, severe winter weather causes numerous vehicle accidents and
fatalities, and more than 52,000 house fires due to dangerous use of heating
equipment, according to the National
Fire Protection Association.
keys to surviving severe winter weather are to prepare now, keep informed and stay
off roads and inside a warm shelter during winter storms.
are preparation steps to take today, according to the Federal
Emergency Management Agency (FEMA) and the NWS.
- Build a winter readiness kit for your vehicles and store the kit where you can reach it from inside the vehicle (i.e. not in a separate trunk).
- Meet with your family to create an emergency plan. Pick two places to meet: a spot outside your home for an emergency and a place away from your neighborhood in case you can't return home. Choose an out-of-state friend as your "family check-in contact" for everyone to call if the family gets separated. Discuss what you would do if advised to evacuate.
- Keep up to date on weather. Sign up for local text/phone alerts and warnings with your local authorities. Consider purchasing a NOAA (National Oceanic and Atmospheric Administration) Weather Radio with a battery backup, which receives warnings from the NWS.
- Stock emergency supplies, including food, water and prescription medicine for the entire family (including animals) for at least three days.
- Winterize and prepare your home ahead of winter weather.
- Review your property insurance, and secure critical documents.
- Be equipped to tend to any current or unexpected medical conditions your family members may have.
- Identify a place nearby, like a local emergency shelter, where you can safely warm up should you lose heat in your home because of a utility outage.
During a storm
Once a storm hits, the Department of Homeland Security (DHS) and the American Red Cross advise:
- Find shelter right away, ideally by staying home and staying off the roads.
- If trapped in your car, then stay inside. Never walk for help during a storm, as you can become quickly disoriented in wind-driven snow and cold. Get more tips if trapped in a vehicle during a winter storm.
- Limit your time outside. If you need to go outside, then wear layers of warm clothing.
- Watch for signs of frostbite and hypothermia. Frostbite causes loss of feeling and color around the face and extremities, numbness and waxy skin. Treatment is to go to a warm room and soak the frostbite area in warm (not hot) water. Do not massage or use a heating pad. Hypothermia is a dangerously low body temperature; below 95 degrees is an emergency and should be treated in the emergency department. Signs include: shivering, exhaustion, confusion, fumbling hands, memory loss, slurred speech and/or drowsiness. Treatment is to go to a warm room and warm the chest, neck, head and groin first. Keep the person dry and wrapped up in warm blankets, including the head and neck.
- Avoid carbon monoxide poisoning. Only use generators and grills outdoors and at least 20 feet from windows. Get more generator tips here. Never heat your home with a gas stovetop or oven. Get more safe heating tips here.
- Avoid overexertion, such as shoveling heavy snow, pushing a car or walking in deep snow. The strain from the cold and the hard labor may cause a heart attack, and sweating could lead to a chill and hypothermia.
- Check on neighbors. Older adults and young children are more at risk in extreme cold.
- Bring your companion animals indoors. Stock up on supplies to clean up after them (large plastic bags, paper towels and extra cat litter), particularly if they are used to eliminating outdoors.
preparing ahead of time, and then staying off the road during severe winter
weather, you can keep your family safe through the worst storms of the winter.


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Dental Implant is Too Deep, Tooth Looks Long
This is especially true on a patient who has what we call a "high smile line". This is when you smile and you show more of your gums than average. If she had a low smile line, then it wouldn't be noticeable when she smiles.
Here is an example of a patient that had an implant placed in about the year 2004. The dental implant was placed as an immediate tooth replacement which is a great option most of the time. Unfortunately the dental implant was placed too deeply into the bone. She hated this tooth.
When this happens you end up with a very long tooth. And worse yet, there is not a lot of good options that can be done to correct it once it is in this position. So in her case, I had to actually extract the implant and rebuild her jaw bone with 2 to 3 bone grafting and gum grafting procedures in order to put a new implant in a more shallow position. A block bone graft was needed also.
This is about as difficult as it gets. This case is difficult because I had to regrow bone vertically, closer to the edge of the natural teeth. Building bone vertically rather than horizontally is always more tricky and requires several very advanced techniques.
You can see in the picture with the white dental implant custom abutment, that the new implant is at a better level because the gumline is more even with the tooth next to it.
Compare the levels of the two implants on the x-rays. One is much more shallow than the other. The shallow one was placed by myself and the deeper one was placed back in 2004 by another dentist.
Occasionally you can recover a deep, long tooth implant with a new custom abutment and gum graft. But I caution you that this is truly a very difficult procedure and should be completed by an expert in implant dentistry so that you can anticipate a result before you ever even get started.
Please feel free to ask questions or leave comments below.
Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry


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Since Personal Learning Plans was part 3 of the three part blog series, we decided to focus our #plearnchat on this topic. When learners turn challenges they have into strengths, then they can enhance their strengths so they are self-confident in what and how they learn.
To do this, learners learn how to set their own goals to explore careers and determine what experiences they need to be college and career ready. Learners first need to understand how they learn best and realize the skills they need to become future ready. The conversations in #plearnchat were around our big question:
How can we support all learners to become future ready?
We use the Q1, A1 format and asked the following questions:
In our discussion of Personal Learning Plans, here is what future ready means to our PLN.
Carol Frey Reinagel @MrsReinagelKnow how to learn, your strengths, be an advocate. Be kind, Care.
Lisa Murray @LMurray_Future ready is providing students skills to open doors and make options limitless.
Bonnie Schuh @teacherSchuhIt means you have to take risks and accept mistakes as learning.
Prepared to meet the challenges and opportunities for a time yet to come.
Todd Russo @MrRussoRH
Lisa Westman @lisa_westmanFuture-ready schools stop using the term "future-ready". Actions speak louder than words.
Sean Russell @seanrussell311Presently, future ready translates to supreme flexibility.
Congratulations to Dr. Michael Vose, Ed.D who won our book, Make Learning Personal.
Dr. Vose has presented across New England on topics such as technology integration, intervention programs, enhancing 21st Century learning, and teacher evaluation in competency based schools.
[Information via the Bethel Public Schools website: http://www.bethel.k12.ct.us/]
[Information via the Bethel Public Schools website: http://www.bethel.k12.ct.us/]
How to Personalize Learning is now available for pre-order at a discount.
Save the Date: Monday, October 10th
Our next #plearnchat Topic: Curriculum of PurposeBig Question:
How can we foster purpose with our learners?


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Brown steps in to reduce state gas prices
Best gas prices?
Search map or by city or zip code for the lowest gas prices in your area.
Gov. Jerry Brown took emergency action Sunday hoping to quickly drive down gas prices, which skyrocketed almost 50 cents across California in a week.
Brown directed the California Air Resources Board to increase the fuel supply by allowing the immediate production of the more abundant winter blend of gasoline used in California.
The state doesn't typically switch to its winter blend, which contains butane, until Nov. 1. Moving up the date will release any stockpiled winter-blend gas, and allow refiners to make between 5 percent to 10 percent more gas per unit of oil.
"It's like adding a refinery overnight, and (prices) should start coming down by Tuesday," said Dave Hackett, an industry analyst with Stillwater Associates in Irvine.
Approval by the Air Resources Board marks the first time in California history that the state has granted a waiver to switch to winter blend fuel earlier than usual because of a spike in prices, Hackett said. He expects that refiners were working on the blends Sunday night and that the new fuel could be at stations on Monday.
In Mission Valley, Justin Kang of El Cajon pulled into gas station Sunday night where regular gasoline was selling for $4.97 a gallon. "We were just talking about how expensive it is," he said. "Is there somewhere else that's cheaper?"
He said the price has pinched his driving habits and forced him to avoid filling his tank all the way. Kang was said everyone hopes Brown's move works.
"If it went down like $1, that would be great," he said.
Summer blends resist evaporation during warm weather to reduce smog. Charles Langley, a public advocate with the San Diego based Utility Consumers' Action Network, said environmental concerns are falling by the wayside because record gas prices can quickly have a ripple effect on the economy, consumer confidence and even political sentiments.
"The governor is calling the oil industry's bluff," Langley said. "He's saying, 'OK you got what you wanted ... now lower the fuel prices.'"
The historic jump in fuel prices was spurred by an outage Monday at Exxon Mobil's Torrance refinery, which produces 8 percent of the state's fuel supply.
Also on Monday, a Chevron pipeline that carries crude from Kern County to Northern California refineries was shut down after elevated levels of organic chloride were detected in the oil. Chevron's Richmond plant, the largest refiner in Northern California, has also been running at reduced capacity since a fire Aug. 6.
Even though the Torrance refinery was starting to come back online, Brown didn't want to wait for any more price increases or supply issues, saying it could cause "unacceptable price impacts for consumers and small businesses, significant economic disruption, and serious harm to public safety and welfare."
"Allowing refiners to make an early transition to winter-blend gasoline could quickly increase fuel supply and provide a much needed safety valve with negligible air quality impacts," Brown said in a statement.
San Diego gasoline prices jumped 19 cents Thursday into Friday, and records were set this weekend. AAA reported Sunday that the county average for a gallon of regular was $4.71, breaking Saturday's high of $4.674. The weekend prices are the highest since June, 19, 2008, when the record was $4.63. A year ago, consumers paid $3.799 at the pump.
The state's average jumped to a record of $4.655 this weekend, up almost 50 cents from the previous week, AAA figures show. A year ago, the state average for regular was $3.803.
The sudden spike, while prices fell in other regions of the country, underscored vulnerabilities in California's fuel supply.
Sen. Dianne Feinstein, D-Calif., on Sunday asked the Federal Trade Commission to investigate whether gas prices in the state were being illegally manipulated.
"Something is wrong with the market," said UCAN's Langley. "The market isn't functioning properly."
"This is an extreme event," Hackett said. "There is a lot of head scratching over this because of the extreme volatility that occurred in the market. People will be going over the data in the next few weeks to see if maybe it was more than just (refinery problems)."
Some gasoline station owners in Southern California ran out of fuel or closed temporarily because of the super tight gasoline supplies.
Just how fast will prices come down?
Hackett thinks they could drop as fast as they went up. On Friday, prices on the spot market had already dropped 46 cents, he said. Consumers should start to see that decline at the pump in the next few days. In previous price spikes, consumers have said prices rise quickly but drop back slowly.
In some locations, fuming motorists paid $5 or more per gallon. Sunday Gasbuddy.com showed the highest price in the county at $5.79 for a gallon of regular at a station in Escondido. The lowest price? A station in south San Diego showed $3.99 but most of the updated prices were in the $4.40 range.
Anthony Biondo, who commutes about 85 miles a day between Fallbrook and La Jolla, was buoyed by the governor's announcement — even though he doesn't figure it will influence the price of his next gas purchase on the way to work Monday morning.
"My hope is it would come down and it would be effective immediately — not only for consumers, but to save jobs" at gas stations, he said. "By next week if there was a reduction of 15 to 20 cents, that would be a sign that it was … going in the right direction."
AAA's Daily Fuel Gauge report said the national average both Saturday and Sunday was about $3.81 a gallon, the highest ever for this time of year. However, gas prices in many other states have started decreasing, which is typical for October.


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Last year, A-Leg-Up was approached by a local TV Director/ Producer, named Ken Gora. His company, Branded Entertainment had seen that we were looking for someone to help us get the message out about A-Leg-Up. I'll have to admit, when I received the following note, it was a pleasant surprise.
I noticed you are scaling up your business A-Leg-Up. I looked at the website and read your need for increasing your media/internet footprint. One of the things that I can offer is to get your product shown in an episode of our TV series or a series of TV commercials to 1.2 million San Diego households. Open to discussions, thanks for connecting…Ken
Ken understood the concept behind our product with it helping individuals get their feet up off the floor. He went on to tell me about a TV show he had filmed that was going to aired locally called The Romance. He explained that the show could provide us product placement in the show and that we could film a television commercial that would follow the spot.
I explained to Ken that as much as I wanted to take him up on the opportunity, the timing didn't feel right. I knew that I really wanted to spend quality time with my family and that trying to get something like this done during the holidays was not in the cards. I politely told him, "Maybe next year". The New Year began and once again I was contacted by Ken asking if A-Leg-Up wanted to do a commercial for its product. Once more, I informed him that the timing wasn't right and we politely declined.
Some call it serendipity, others call it fate, but I'll call persistence on Ken's part because he wrote us again on March 6th, 2016 and asked if we wanted to do a commercial and or a product placement for the A-Leg-Up. Our response this time?, "I'll have to get back to you on that". I called my brother telling him the discussions of the past few months and I asked him what he thought we should do. He said let's do it! I wrote back to Ken to schedule the meeting. We agreed to meet on March 25th and the wheel of motions began to what I am going to describe as destiny.
You see, neither Ken and nor I knew that on March 25th, there was going to be a meeting that neither of us had planned for. We had no idea there would be another character added to the script. The character that I am referring to is a gentleman by the name of Brian Smith… for those that know him, know that he is synonyms with one of the largest brand names there is, Ugg Boots. Brian or Mr. Ugg, didn't know he would be at this meeting either, but that Friday morning driving to Encinitas, all I knew was that I was playing golf with Brian and I had this meeting in the afternoon with Ken.
For those that have made it this far, I should tell you that going back a few years, I was looking for a mentor to help me with A-Leg-Up. I had never started a business before and was reaching out to the universe for a mentor. You know, someone to ask, "Am I doing this right?" Well, that person was Brian and I couldn't have asked to meet a better person to come into my life. We met in beach town here in San Diego at a coffee shop and talked for about an hour and a half. He was able to answer so many of my insecure questions and when I left him, I left knowing I was on the right path and that we would become friends.
Fast forwarding back to March 25th 2016, I am driving to meet Brian for golf when this idea pops into my head. Would Brian be interested in being in our commercial?
They say pictures are worth a thousand words…


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Friday of the Twenty-third Week in Ordinary Time
(I Timothy 1:1-2.12-14; Luke 6:39-42)
The words attributed to St. Paul in today's first reading describe what many westerners think of the Muslim jihadists. "…a blasphemer and a persecutor and an arrogant man" seem to fit perfectly Mohamed Atta, the leader of the September 11, 2001 massacres, and the Islamic State warrior today. These men and women do not seem to care that they violate all decency by taking the lives of innocent people.
The letter to Timothy also bestows a blessing on its recipient of "grace, mercy, and peace." Should such a display of goodness be extended to the barbarians today? Some may think it necessary, but it seems fitting to wait for a sign of repentance from the perpetrators of violence. Prayers are to be offered so that true reconciliation comes about. Certainly, no leader of state can suffer the delusion that these violent people are ready to change their thinking.
Westerners might also examine their consciences. The hedonism that passes for sophistication in many circles is corrupting our sensitivities. The individualism that is touted as the expression of freedom is depleting common resources. The 9-11 attacks and the persecution of Christians in Syria and Iraq are proof that world civilization has not advanced as much as some think. Contemporary sophistry in Western culture indicates that it contributes to the disintegration of the general welfare.


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Take control of your PhD journey: EndNote advanced
How to use EndNote to optimise your workflow
Present-day academics spend much of their time writing articles for journals, often in collaboration with fellow researchers. Preparing a manuscript requires expert navigation through the research literature. Both aspects of the writing process involve challenges relating to the handling of references: how to share them with your co-author(s), and how to organise them in order to most efficiently extract what is relevant for your manuscript.
In this seminar, we will focus on more advanced functions in EndNote (http://endnote.com), in particular:
- How to (not) save, sync and share EndNote libraries and folders
- How to efficiently manage PDF attachments
- How to find and edit reference styles
- How to use EndNote during systematic literature reviews
The last subject (systematic literature reviews) is not necessarily relevant for all participants, and we therefore place this in the end of the course. Further, we will try to adjust the course content to the needs of the participants. If there are any subjects you wish to learn more about, not listed here, please fill out a short questionnaire.
Note that we expect all participants to have a basic knowledge of EndNote, including:
- Setting up an EndNote library and collecting references
- Importing references from external databases (e.g. Oria)
- Searching for and organising references in an EndNote library
- Inserting references into a Word document using references from an EndNote library
- Editing citations and reference lists in Word
- Basic syncing and backing up an EndNote library
If you need a refresher prior to the seminar, please consult the course material available from this page. If you have not set up your library to sync, please consult this video for step-by-step instructions. If you need help sorting out any EndNote troubles, hiccups or messes, please get in touch with our EndNote support well before the seminar. We will not be able to provide one-on-one EndNote support during the seminar itself, but will be happy to assist you in preparation for it.
The seminar is organised by Helene N. Andreassen and Grete Overvåg.
Light refreshments will be served during the break.
This seminar is a freestanding part of the seminar series Take control of your PhD Journey: From (p)reflection to publishing.


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Quick Questions
Where do you live?
ln Sydney, Australia. I love living in a beautiful, laid back city by the ocean with wonderful weather.
Describe your photographic style in one word.
Describe your design process?
I'm mainly a lifestyle/documentary photographer so I usually have a pre-conceived idea in my head, but then only truly know what I'm up against when I arrive at the scene. After that I'm on auto. I look at the light, the angles, the subject and quickly work out the best way to shoot what's in front of me. Or I redesign the scene to get the best shot in a limited amount of time.
Who are your artistic heroes?
I studied Fine Art at uni, so I admire a great many artists. But I was really inspired by Peter Beard - I grew up in Kenya and so was surrounded by his work. I also love the work of Steve McCurry.
What is in your dream fine art photographic collection?
I love so many images so this is a very hard question. Who wouldn't want to own a Helmut Newton?
What is your favourite part of what you do?
Delving into different cultures, and seeing beauty in the ordinary.
What do you want to accomplish that you haven't already?
I want to publish a coffee table book of my African series. And I want to see even more of the world. On a more serious note, next year I begin working on an ongoing project in Africa to aid women who suffer from Obstetric Fistula; I'd like to see this grow into something that can make a real difference.
Describe the best party you have ever been to.
Definitely Burning Man in the Nevada desert. It's the most incredible festival/ party I have ever experienced. Words can't describe how amazing it is!
What are your favourite things to do on a Sunday?
Have breakfast with my favourite people in a café at Bondi Beach watching the ocean. And then spend the rest of the day reading a good book.


text: One Ring Zero is a modern music group led by Joshua Camp and Michael Hearst that melds many genres and sounds to create a unique type of music. Michael plays the theremin and Joshua plays the accordion. They both play the claviola and prove to be extremely versatile musicians, often switching instruments for each song. Other instruments inclu… Read More


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Go to the product you want to buy and click "Add to Cart". The product will then be placed in your shopping cart, which is shown in the top right corner of www.gymplay.eu. To pay, tap the shopping cart and select "Checkout" and enter your billing address. If you want the product delivered to a different address than your billing address, place a check mark in the box that says "Send to other than the billing address," and fill in the delivery address.
No. At www.gymplay.eu you do not need to register as a user/customer. Simply submit your information details in connection with the purchase. We do recommend that you subscribe to our newsletter for information about new products, new training videos, exciting competitions and other relevant news.
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YES. You can bring your Gymplay Airtrack outside. Just place the Airtrack Trainer on the grass, but make sure the area on which you place the Airtrack is clean, flat, dry and free of obstacles. We recommend that you use a groundsheet or a pvc-mat under your Gymplay Airtrack. We also recommend that you avoid putting your Airtrack Trainer in direct sunlight over a longer period, partly because you run the risk of the colors fading, and partly because the adhesive glue is temperature resistant up to 80 degrees Celsius, after which there is a risk of leaks.
We recommend an Airtrack Trainer(10 cm) for children aged 5-13 years. Younger children can easily use it, but an Airtrack Trainer is designed to provide the ideal bounce for children weighing between 20-60 kilos. For adult or highly skilled gymnasts, we recommend our pro models such as the Airtrack Talent Trainer Series(15 cm).
The Gymplay Airtracks come with a two-year warranty against damage not attributable to normal wear and tear (See our terms and conditions). Remember to check the product for any defects when it is delivered and if its broken. If you notice any flaws in the product please call tel. +45 71 99 96 95 or email us at firstname.lastname@example.com
It is easy to inflate your Airtrack Trainer. With the manual pump, it can be done in 2-3 minutes, whereas, the electric pump only takes 20 seconds. Your pump can also be used to deflate the Airtrack, follow the instructions in the enclosed manual. Your Airtrack Trainer is also easy to store away and does not take up more space than a sleeping bag!
Your Gymplay Airtrack is not easy to puncture because it is made of very durable materials. If you are so unfortunate that the Gymplay Airtrack gets flat, you can easily patch it. We have included a repair kit with glue and PVC with all our Gymplay Airtrack, so you can be up and jumping again in no time.


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Buy designer dog collar today for a reasonable price! Do not miss the opportunity to make your dog the most handsome and respectable. This dog collar is an ideal choice for daily dog walking in style. You will not find better quality dog accessory anywhere! Each piece of the collar is hand crafted making this powerful tool as unique as the one who wears it.
Check how this FDT Artisan collar looks on Luke / Pictures Provided by @v "@luke_thegsd "
Click on the pictures to see bigger image
Luke's New Collar is the Best- Stylish FDT Artisan Leather German Shepherd Collar
Luke's new Artisan collar from @fordogtrainers_fdt looks so good on him. 😍 New collars are the best!
Finally, you can spoil your dog with best ever collars on the market from FDT Artisan! Find your favorite design and make your dog unique with extraordinary sets of decorations!
Strong Leather German Shepherd Collar for Luke's Daily Activity
Key features of this Dog Collar:
Intended use of this Canine Collar:
Sizes available:
Available colors:
Please be advised that:
Designer Leather German Shepherd Collar for Luke's Perfect Style
The hardware is heavy duty as it is made of brass plated steel. Decorations are long-lasting as well. Old bronze look plates are securely riveted by hands. Brass-plated small circles are installed in columns - 2 circles between plates. It is hardly possible to find the same attractive and durable product for your beloved dog. The collar will look fashionable on the dog every season.
German Shepherd Luke During Joyful Walk in FDT Artisan Collar
Custom design is the specialty of the store's craftsmen. The collar is made of pure softest full grain leather - precious natural material which has a plenty of advantages. Attractive handset decoration are properly secured in leather. The collar is quite wide - 1 1/2 inch (40 mm), which is also very convenient. Make life of your dog more interesting - walk him in this collar!
Black Leather FDT Artisan German Shepherd Collar Handcrafted for Luke


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MSNBC can't even keep liberal politics out of sports. Nation sports editor Dave Zirin appeared on the cable network, Wednesday, to hyperventilate over the announcement that Tim Tebow has been traded to the New York Jets.
Zirin berated, "...There are a lot of LGBT people that live in New York City who are also football fans and they might want to know why the new, possibly, starting quarterback for the New York Jets wants them to move backwards 30 or 40 years."
Why does Tebow want to set gays back 40 years? Because he once did a very mild pro-life commercial for Focus on the Family?
Completely going off on a tangent, Zirin whined, "Now, I don't want to shock you, Tamron, but there are a lot of women in New York who use birth control." [MP3 audio here.]


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Model Mayhem #:
Last Activity:
Apr 13, 2019
Very Experienced
Depends on Assignment
Feb 12, 2009
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Friends (83)
About Me
I was born in Buenos Aires, in February of 1970, but I live in Miami since 2001.
I experienced the allure of photography because of my father who first taught me about it when I was a teenager. Together we took some basic classes at a local photography club in Buenos Aires. At that time digital photography did not exist, so we not only learned the basics of composition and exposure, but also the techniques for developing our own rolls. It was a lot of fun and we really enjoyed doing it.
After years of serious amateurism, I started to do it professionally, being the main core of my work Commercial Stock Photography, Glamour and Portraits.
I love to help models develop portfolios, but I don't offer TF* at this time. However there are exceptions and occasionally I offer very limited TF*. So if you think you have exceptional ideas and you're a very special model, send me an email with your details and I'll consider it. But bear in mind that any TF* session will require a full commercial model release.
Rates and Services:
Model Portfolios – All portfolio session pricing assumes that you will sign a model release allowing the images to be included in my Stock Photo portfolio. A differential price will be charged if you prefer to maintain the full rights.
Standard Package: $350.00 - $575.00 without release
3 hours in studio or on location 3 different looks or outfits 4 retouched images per look. Hair and makeup included. Access to web gallery with the images of the session. Order Prints form the web gallery at discounted prices.
Advanced Package: $580 - $780.00 without release
5 hours in studio or on location 4 or 5 different looks / outfits 4 retouched images per look. Hair and makeup included in first 2 looks. Access to web gallery with the images of the session. Order Prints form the web gallery at discounted prices.
Extended Portfolio Package: $950.00 - $1,350.00 without release
Full 8 hour day in the studio or on location Unlimited looks / outfits, the 20 best images of your shoot Hair and makeup included in first 2 looks. Access to web gallery with the images of the session. Order Prints form the web gallery at discounted prices. 100 5.5 x 8.5 Composite Cards Included with your pictures and Bio and 50 8 x 10 Headshots.
Additional Services:
All your high res images in a CD: $ 90.-
Additional Looks: $ 60 p/look.
Additional Retouched Image: $ 25 p/Image
100 8x10 Headshots with Free Design: $ 150.-
100 8.5x5.5 Compcards with Free Design: $ 109.-
8 x 10 Prints: $ 8.- Each.
Like Us on Facebook http://www.facebook.com/ModelMixStudios
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See our blog http://blog.modelmixstudios.com/
Verified Credits (0)Worked with DK Photo? Share your experience and become verified! Add Credits
Credit Notes
Some of the MM models I have worked with or took photos of
PrettyGoris #1421688
Val Dvore #770275
Klubnichka #833256
Miss Whitney Morgan #904207


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Infosys among world's 100 fastest growing cos: FortuneTuesday, August 18, 2009
IT bellwether Infosys Technologies, along with Internet major Google and software giant Apple, has been named among the world's 100 fastest growing companies by American publication Fortune.
The league of 100 is topped by Canada-based Research In Motion, the maker of Blackberry phones.
The list also features Cognizant Technology Solutions, headed by India-origin Chief Executive Francisco D'Souza. Infosys is placed at the 100th place while Cognizant is ranked 90.
Apple and Google are at 39th and 68th spots, respectively.
Writing about Infosys, the magazine said, "India's No 2 IT firm counts Goldman Sachs and UBS among its 570 clients".
Fortune noted that Cognizant attributes a part of its growth to expansion in India and China. Other companies in the list include Nasdaq OMX Group (42), Amazon.Com (52) and Dreamworks Animation SKG (63).
Source: Hindustan Times


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Irish design makes you happy.
Dublin.ie talks to Mark Haybyrne of Jam Art Factory about his family business and the future of Irish art and design.
Since 2011 brothers Mark and John Haybyrne have been showcasing the best of contemporary Irish art and design in their store, Jam Art Factory. Stocking a range of Irish art and design they give independent artists – such as illustrator Claudine O'Sullivan, Arty Smarty Jewellery and KaroArt Ceramics – a platform to exhibit and sell their work. Having started in the Liberties, they now have another thriving store in Temple Bar and ship internationally from jamartfactory.com.
It started as an art gallery, displaying people's work but then we saw a trend and it's evolved naturally from there
Dublin.ie met Mark to find out what motivated the brothers to start the business and to discuss what's next for Jam Art Factory and the Dublin art and design scene.
"My brother and I set up Jam Art Factory five years ago. I was working in a retail job that I wasn't mad about and John was looking for something to do as well, so somehow, we decided to do this.
It started as an art gallery, displaying people's work but then we saw a trend and it's evolved naturally from there. Design was growing in Dublin. It's a bit of design and art together. Rather than just being a gallery, we started to sell things that are pleasing to the eye that you can bring home and hang on your wall. We now sell jewellery, ceramics, gifts and prints, which are our main product.
There is a demand for handmade products; people have gotten sick of mass-produced products
In 2011 we opened the Patrick Street store. Then, three and a half years ago we opened the second shop to bring the business to a different audience. This (Patrick Street) is a touristy area. Dublin people might not come up here too often, so we decided to open in Temple Bar.
We also have a website. We get a lot of orders not just from Ireland but from overseas; America, the UK, France, Italy, Germany, Spain, Australia and even Hong Kong. I don't know how they found out about us, they must have come into the shop when they visited Dublin.
Since the recession people want to shop local a lot more rather than buying from chain stores. There is a demand for handmade products; people have gotten sick of mass-produced products.
There are so many people out there with talent and now I think there is a desire to help people out who might be struggling, especially artists and designers whose funding was cut during the recession.
We aim to support artists and designers that are trying to start out and don't know how to go about it. They need experience to get a job but how can you get experience without having a job? A lot of people have started selling their work with us here and gone on to getting jobs in their fields or gone on to sell their work full time.
I think Irish design is just going to grow bigger and bigger as people see how many talented people there are here. I think you'll see more independent craft fairs and initiatives, all supporting local artists. We're happy to do our bit to help artists and designers to make a living out of what they love doing."
So, next time you're buying a gift for someone, Dublin.ie says consider giving Mark and John a hand with their mission to support Irish artists. Instead of a voucher or novelty socks, give someone the gift of craft from Jam Art Factory.


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However, the home side then dominated for the first 20 minutes of the second half to take an 18-10 lead.
When Lydney fly-half Neil Merrett kicked a 75th minute penalty to stretch the lead to 21-10, the game was all but over.
In truth, there will not be too many tears shed in Reading at the result. A home match against Worcester in the next round may have been something of a money-spinner but Reading's target is to win the league and injuries in cup games will not help that cause.
As it was on Saturday two Reading players, one playing for the 1st XV and another playing for the Wanderers, also at Lydney, received serious injuries.
In the senior game, winger Anthony Morrison suffered a dislocated shoulder, while promising Chris dislocated his knee in the Wanderers' game. For both players, it is not the first time this injury has happened to them.
Reading caught Lydney cold as in the second minute a home scrum wheeled round. Reading scrum half Simon Dyson snatched their ball and fly half Mike Crisp kicked to the corner.
At the subsequent lineout, lock Mark Skrypec took possession and Reading drove for Dyson to squeeze over. Crisp's conversion made it 7-0.
With Jon Summers having a great game in the second row, Reading continued to compete well, only to see Lydney score in the 12th minute through left winger Charlie Vine. Neil Merrett hit the post with the conversion.
Reading came back and, with the forwards driving well from lineouts and with Crisp kicking well from fly half, they set up a penalty chance for the fly half which he kicked from 40 metres.
At 10-5 up Reading were very much in the game but, with loose head prop Hein Spies being injured, they came under increasing pressure up front.
Nevertheless, Reading had two golden opportunities to seal the game before half time.
First, Simon Dyson stole away down the blind side of a ruck, drew the last man and passed inside.
Unfortunately for Reading, the pass was dropped. On another occasion flanker Chad Steetskamp made a great break but failed to spot the support on his left and threw the ball right for the home side to scramble the ball away.
For the first 20 minutes of the second half Reading were forced to defend as the home forwards got on top. Merrett kicked a penalty, left wing Vine was pulled down just short, and Reading had to defend several five metre scrum and lineouts. But eventually the pressure told.
Dyson was penalised for killing the ball in front of the posts and Merrett kicked the points to edge his side in front for the first time.
Four minutes later Vine scored his second try after a fine run, Merrett converting and then, finally, Merrett's late penalty finished the scoring.
READING: McEwan; Morrison (Patterson 45 mins), Burd, Sly, Brooks; Crisp, Dyson (Jenn 72 mins): Spies (Michael 30 mins), Pemble, Grierson (Bramhall 40 mins), Summers, Skrypec, Stewart (Southern, 70 mins), Steetskamp, Le Roux.
How the scoring went: 3 mins Dyson try, Crisp con (0-7), 12 mins Vine try (5-7), 19 mins Crisp pen (5-10), 46 mins Merrett pen (8-10), 58 mins Merrett pen (11-10), 62 mins Vine try, Merrett con (18-10); 75 mins Merrett pen (21-10).


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Amaretto Praline Pecan
The ultimate old-world indulgence as San Bernardo® combines the distinctively sweet flavor of Amaretto with the delicious, sugary crunch of praline pecans to bring you our Amaretto Praline Pecan ice cream. Effortlessly transport yourself to another time and place and escape with us. Let it melt on your tongue and savor the moment. If it tasted any more like Amaretto we would have to ask for ID.
16 oz. Pint


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Janelle and Samuel live in Ottawa, Canada's capital, but Samuel grew up in Montreal an hour away. Many of their guests would be traveling from Montreal or be visiting from China and Japan, so they decided to host their beautiful wedding in the beautiful Quebec city.
A unique industrial art gallery was the perfect backdrop for Janelle & Samuel's organic, romantic wedding. They are inherently contemporary by nature and wanted to find a space that they could make their own without changing the room too much. They love organic textures and mixed mediums and wanted to balance masculine and feminine, raw and refined - so we needed a space that could be flexible, multi-functional and original. When we found Parisian Laundry, a contemporary art gallery with concrete floors, 360 degrees of windows and a wood ceiling, they fell in love and booked it just based on pictures we found online!
This wedding flourished in its personal details, like traditional fans custom made by a family member in Japan to include persimmon trees (Samuel proposed to Janelle under a persimmon tree), a globe for guests to sign as their guest book since most guests were coming from all over the world, and even the emoji photo booth props made with their favourite emojis. The day was a beautiful, warm vision of organic floral arrangements, warm blush and marsala tones, and candlelight. The seating arrangement was even unique and encouraged intimate and warm conversations with everyone around. And if the seating plan didn't encourage conversation, our very strong signature cocktails - Janelle's bourbon cayenne lemonade and Samuel's Sake Lychee Martini - certainly did the trick!
The groom has many talents: he is a former break dancer, a concert-level pianist now in a jazz band, a mathematician and a skilled software designer. We brought a jazz trio to perform during cocktails, the guests were seated to the Harry Potter theme song (another mutual love), dinner was a traditional duck course, their late night was a famous Shwartz Montreal Smoked Meat station, and we even surprised the guests with a performance by Janelle and Samuel singing together (followed by a surprise professional breakdance performance to kick off the dance party!). It was quite the wonderful night filled with love and quirky details and beautiful moments. One for the records!


text: Technology, Computing, and Simulation: Research ReportAn Assessment of Global End-Diastolic Volume and Extravascular Lung Water Index During One-Lung Ventilation Is Transpulmonary Thermodilution Usable?Haas, Sebastian A., MD*; Trepte, Constantin J. C., MD*; Nitzschke, Rainer, MD*; Jürgens, Tim P., MD†; Goepfert, Matthias S., MD*; Goetz, Alwin E., MD, PhD*; Reuter, Daniel A., MD, PhD*Author Information From the Departments of *Anesthesiology, Center of Anesthesiology and Intensive Care Medicine and †Systems Neuroscience, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. Accepted for publication February 4, 2013 Published ahead of print April 16, 2013 Funding: This study was funded solely from departmental sources. Conflict of Interest: See Disclosures at the end of the article. Sebastian A. Haas, MD and Constantin J. C. Trepte, MD contributed equally to the manuscript. Reprints will not be available from the authors. Address correspondence to Sebastian Haas, MD, Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany. Address e-mail to [email protected]. Anesthesia & Analgesia: July 2013 - Volume 117 - Issue 1 - p 83-90 doi: 10.1213/ANE.0b013e31828f2c39 Free SDC Metrics AbstractIn Brief BACKGROUND: The thermodilution curve assessed by transpulmonary thermodilution is the basis for calculation of global end-diastolic volume index (GEDI) and extravascular lung water index (EVLWI). Until now, it was unclear whether the method is affected by 1-lung ventilation. Therefore, aim of our study was to evaluate the impact of 1-lung ventilation on the thermodilution curve and assessment of GEDI and EVLWI. METHODS: In 23 pigs, mean transit time, down slope time, and difference in blood temperature (ΔTb) were assessed by transpulmonary thermodilution. "Gold standard" cardiac output was measured by pulmonary artery flowprobe (PAFP) and used for GEDIPAFP and EVLWIPAFP calculations. Measurements were performed during normovolemia during double-lung ventilation (M1), 15 minutes after 1-lung ventilation (M2) and during hypovolemia (blood withdrawal 20 mL/kg) during double-lung ventilation (M3) and again 15 minutes after 1-lung ventilation (M4). RESULTS: Configuration of the thermodilution curve was significantly affected by 1-lung ventilation demonstrated by an increase in ΔTb and a decrease in mean transit time and down slope time (all P < 0.04) during normovolemia and hypovolemia. GEDIPAFP was lower after 1-lung ventilation during normovolemia (M1: 459.9 ± 67.5 mL/m2; M2: 397.0 ± 54.8 mL/m2; P = 0.001) and hypovolemia (M3: 300.6 ± 40.9 mL/m2; M4: 275.2 ± 37.6 mL/m2; P = 0.03). EVLWIPAFP also decreased after 1-lung ventilation in normovolemia (M1: 9.0 [7.3, 10.1] mL/kg; M2: 7.4 [5.8, 8.3] mL/kg; P = 0.01) and hypovolemia (M3: 7.4 [6.3, 9.7] mL/kg; M4: 5.8 [5.2, 7.4]) mL/kg; P = 0.0009). CONCLUSION: Configuration of the thermodilution curve and therefore assessment of GEDI and EVLWI are significantly affected by 1-lung ventilation. Published ahead of print April 16, 2013 Advanced hemodynamic monitoring has become increasingly important as surgical procedures and patients, suffering from various comorbidities, increase the complexity of the perioperative and intensive care setting.1,2 In this context, optimization of cardiac preload guided by global end-diastolic volume index (GEDI) and extravascular lung water index (EVLWI) both derived from transpulmonary thermodilution (TPTD) has been shown to result in improved clinical outcome.3 Methodologically, a central venous bolus injection of an indicator, i.e., cold saline is required. This bolus dilutes within the blood on its passage through the right heart, pulmonary circulation, left heart, and aorta. The change in blood temperature then is detected by a thermosensor located at the tip of an arterial catheter. The resulting thermodilution curve is determined by the difference of blood temperature (ΔTb) and its chronological sequence. Cardiac output (CO) can be assessed based on the modified Stewart-Hamilton equation. Calculation of various volumetric variables derived from the thermodilution curve is also possible. For this purpose, 2 variables are needed: mean transit time (MTT) and down slope time (DST). The MTT is the time required for half of the indicator to pass the thermistor in the femoral artery. MTT divides the area under the thermodilution curve into 2 areas of the same size.2 DST is defined as the exponential elution time. In detail, the time between 85% and 45% of the maximum temperature response is measured.4 This method of thermodilution curve assessment is illustrated in Figure 1. On the basis of CO, MTT, and DST, it is now possible to calculate the intrathoracic thermo volume (ITTV = CO·MTT) and pulmonary thermovolume (PTV = CO·DST). The difference between ITTV and PTV is the global end-diastolic volume (GEDV). Intrathoracic blood volume (ITBV) is calculated by ITBV = 1.25·GEDV.5 The difference in ITTV and ITBV equals the EVLW (Fig. 2).Figure 1: Method of transpulmonary thermodilution. Tb = blood temperature; Ti = temperature of injection bolus; Vi = volume of injection bolus; C = a constant proportional to the specific weights and specific heat of blood and injectate; ΔTb = delta of maximum and minimum of blood temperature; dt = duration of thermodilution; CO = cardiac output; black line = down slope time (DST); dashed line = mean transit time (MTT).Figure 2: Principles of global end-diastolic volume (GEDV) and extravascular lung water (EVLW) estimation by transpulmonary thermodilution. The GEDV is derived from the difference of the intrathoracic thermo volume (ITTV) and the pulmonary thermovolume (PTV). The difference between ITTV and intrathoracic blood volume (ITBV) yields EVLW. CO = cardiac output; MTT = mean transit time; DST = down slope time; RAEDV = right atrium end-diastolic volume; RVEDV = right ventricular end-diastolic volume; LAEDV = left atrium end-diastolic volume; LVEDV = left ventricular end-diastolic volume; PBV = pulmonary blood volume.One-lung ventilation is a routine anesthesia procedure.6 Due to progress in surgical techniques, there is increasing necessity for prolonged intraoperative 1-lung ventilation (lung transplantation, esophagectomy, spinal surgery, minimally invasive cardiac surgery). One-lung ventilation results in the total atelectasis of 1 lung and an increase in the pulmonary vascular resistance provoked by hypoxic pulmonary vasoconstriction. This may influence transit time and contact time of the indicator with the extravascular space resulting in altered indicator loss in the surrounding tissue, especially in the deflated lung.7 Consequently, configuration of the thermodilution curve and thereby all derived volumetric variables for monitoring and guidance of therapy would be questionable if these effects have a significant impact on the accuracy of measurement. As part of this experimental study, we have already reported that the assessment of CO by TPTD is clinically useful during 1-lung ventilation even if accuracy is reduced.8 Even more clinically important, the validity of GEDI and EVLWI during 1-lung ventilation remains unclear. Therefore, we evaluated the influence of 1-lung ventilation on the configuration of the thermodilution curve and consequently the calculation of GEDI and EVLWI. Measurements were conducted in normovolemic and hypovolemic conditions representing a wide range of preload and CO. METHODS The study was approved by the local governmental commission for the care and use of animals. The animals received care in compliance with the "Guide for the Care and Use of Laboratory Animals" (National Institutes of Health publication No. 86-23, revised 1996). Anesthesia and Instrumentation Animals were fasted overnight. Premedication was conducted by IM injection of ketamine (10 mg/kg), azaperone (4 mg/kg), midazolam (0.5 mg/kg), and atropine sulfate (1 mg). Thereafter, tracheotomy and placement of an endotracheal tube (8.5 Ch) were performed. Anesthesia was maintained by continuous infusion of fentanyl (0.05 mg·kg−1·h−1) and propofol (10 mg·kg−1·h−1). After securing the airway, a single dose of pancuronium (0.1 mg/kg) was administered to facilitate surgical preparation. Animals were monitored with a 5-lead electrocardiograph and pulse oximetry. Controlled mechanical ventilation was performed using a volume-controlled mode. Tidal volumes were set at 10 mL/kg, inspiration to expiration ratio at 1:1.6, and positive end-expiratory pressure at 5 cm H2O. (Zeus, Drägermedical®, Lübeck, Germany). End-expiratory pCO2 was continuously controlled and maintained at 5.3 to 6.0 kPa by adjusting respiration rate. A saline infusion was given at a rate of 13 mL·kg−1·h−1 to maintain hydration. Body temperature was measured by the arterial catheter and kept constant by using warming blankets and prewarmed infusions. For catheter placement and surgical preparation, animals were placed in the supine position. An 8.5 French central venous catheter was introduced into the right internal jugular vein for drug and fluid administration as well as for central venous pressure measurement, for injection of the cold indicator for thermodilution and detection of injection temperature (Ti) via a thermistor (Pulsion®, Munich, Germany). A 5 French thermistor tipped catheter (PiCCO Catheter, PV 2015L20N, Pulsion) was placed into the femoral artery for estimation of blood temperature (Tb) and ΔTb as well as the thermodilution curve. TPTD was also used for assessment of MTT, DST, ITTVTPTD, GEDITPTD, intrathoracic blood volume index (ITBI)TPTD, and EVLWITPTD for which the DuBois formula was used for indexing variables to body surface area ([m2] = 0.20247·Height [m]0.725·Weight [kg]0.425). Based on the results of CO, Ti, Tb, ΔTb, MTT, and DST, averaged thermodilution curves for double-lung ventilation and 1-lung ventilation in normo- and hypovolemia were reconstructed using MATLAB software (MathWorks® Inc., Natick, MA). To eliminate any potential falsification of GEDITPTD and EVLWITPTD by less precise measurement of cardiac index (CI) based on TPTD during 1-lung ventilation, an ultrasonic pulmonary artery flowprobe (PAFP) was positioned for "gold standard" CI measurement (CIPAFP).8 For positioning of the PAFP, a median sternotomy was performed. The pericardium was longitudinally incised at midline, the pulmonary artery and ascending aorta were exposed, and the perivascular ultrasonic flowprobe (18 mm, Medistim®, Oslo, Norway) was fit around the pulmonary artery. Acoustic gel was placed between the pulmonary artery and flowprobe to avoid any air hindering for accurate flowprobe measurement. Measurements and Experimental Protocol Normovolemia was established with hydroxyethylstarch (Voluven 130/0.46%, Fresenius Kabi®, Bad Homburg, Germany) until the stroke volume variation was below 10%, and then baseline measurement was performed (M1). All TPTD measurements were assessed by 3 sequential central venous injections of 10 mL (Vi = 10 mL) cold saline solution (<8°C), randomly administered throughout the respiratory cycle. All thermodilution curves were examined, and measurements were accepted if none of the 3 consecutive values differed by >10% from the mean. Coefficient of variation of the 3 measurements was calculated. One-lung ventilation was initiated by deflating the left lung. An endobronchial blocker (5 French G44109, CookMedical®, Bloomington, IN) was placed into the left main bronchus using a fiberbronchoscope (BF-P60, Olympus®, Hamburg, Germany). During 1-lung ventilation, tidal volumes were reduced to 6 mL/kg. After an equilibration period of 15 minutes, measurements were repeated (M2), and thereafter, 1-lung ventilation was ceased. The period of 15 minutes was chosen because hypoxic pulmonary vasoconstriction reaches maximum within this period of time.9,10 Hypovolemia was induced by the withdrawal of blood (20 mL/kg) over a period of 30 minutes. After the third set of measurements (M3), 1-lung ventilation was implemented as described before (M4). Simultaneously with every thermodilution measurement, CO from the flowprobe was recorded using EMKA software (EMKA Technologies®, Paris, France) and the mean and coefficient of variation was calculated. After completion of the experimental protocol, the animals were euthanized by rapid injection of 50 mmol potassium chloride during deep anesthesia. Later offline analysis was performed to calculate ITTVPAFP, GEDIPAFP, ITBIPAFP, and EVLWIPAFP based on the PAFPs measurement of CI. Statistical Analysis Descriptive statistical analysis was performed using SigmaStat™ (Version 3.5) and SigmaPlot™ (Version 10.0; Systat Software®, Chicago, IL). Because there are insufficient data on the effects of 1-lung ventilation on thermodilution-derived variables GEDI and EVLWI, 15% was defined as the minimal detectable difference for these variables corresponding to a clinically relevant change. The calculated minimally required group size was n = 21 (SD: 17%, α error: 0.05, and power: 0.8). Normal distribution of all absolute data was tested using Kolmogorov-Smirnov test with Lilliefors correction. Normal distribution was assumed if P > 0.2. Results are given as mean ± SD for normally distributed variables and as median (25% percentile, 75% percentile) for non-normally distributed data. Furthermore, absolute and percentaged difference of the mean as well as for estimation of clinical relevance 95% confidence interval of the absolute and percentaged difference of the mean was given.11 The coefficient of variation was calculated for averaged CO measurements as SD divided by the mean.12 Paired Student t test was used for comparison between measurements during double-lung ventilation and 1-lung ventilation for normally distributed data and equal variances. Mann-Whitney-Wilcoxon test was used for non-normally distributed data. Beforehand, testing for normal distribution was performed using Kolmogorov-Smirnov test with Lilliefors correction, and homoscedasticity was ascertained by means of Levene test. Results were regarded statistically significant with P < 0.05 and clinically relevant with a difference of >15%. RESULTS Hemodynamics Twenty-three female German domestic pigs (Landrace) in overt good health were studied. The mean size of the animals was 109.2 ± 6.3 cm, and mean body weight was 36.0 ± 5.6 kg. Hemodynamic variables such as heart rate (/minutes), mean arterial blood pressure (mm Hg), central venous pressure (mm Hg), CI (L·min−1·m−2) measured by TPTD (CITPTD), and CI measured by PAFP (CIPAFP) are given in Table 1. None of the variables was significantly affected by the onset of 1-lung ventilation, in normovolemia or in hypovolemia (P > 0.05).Table 1: Hemodynamic Findings During Double-Lung Ventilation and 1-Lung Ventilation in Normovolemia and HypovolemiaAnalysis of Transpulmonary Thermodilution Blood temperature (Tb), injection temperature (Ti), and the difference of both (Tb−Ti) did not change significantly after 1-lung ventilation in normovolemia or in hypovolemia. The delta between maximum and minimum blood temperatures (ΔTb) changed significantly after 1-lung ventilation in normovolemia as well as in hypovolemia. MTT was significantly reduced by 1-lung ventilation by approximately 12% in normovolemia (M1: 189.5 ± 34.4 seconds; M2: 166.9 ± 26.3 seconds; P = 0.02) (difference: −22.6 seconds = −11.9%; 95% confidence interval, −4.4 to −40.8 seconds = −2.3% to −21.5%) and hypovolemia (M3: 229.7 [201.1, 274.6] seconds; M4: 202.0 [168.4, 244.8] seconds; P = 0.04) (difference: −27.7 seconds = −12%; 95% confidence interval, 3.8 to −63.9 seconds = −1.6% to 27.8%). DST decreased significantly after onset of 1-lung ventilation by approximately 15% in normovolemia (M1: 93.8 ± 21.8 seconds; M2: 80.0 ± 16.9 seconds; P = 0.02) (difference: −13.8 seconds = −14.7%; 95% confidence interval, −2.2 to −25.4 seconds = −2.3% to −27.1%) and by approximately 18% in hypovolemia (M3: 123.6 [105.5, 146.3]; M4: 101.0 [87.0, 131.9]; P = 0.02) (difference: −22.6 seconds = −18.3%; 95% confidence interval, 1.1 to −44.2 seconds = 0.9% to −35.8%). Results are presented in Table 2. Reconstructed thermodilution curves based on these results illustrate the alteration of curve configuration after 1-lung ventilation as shown in Figure 3 for normovolemia and in Figure 4 in hypovolemia. One-lung ventilation induced a faster start to the curve, a higher peak, and a faster decline both in normo- and in hypovolemia.Table 2: Results Derived from Analysis of ThermodilutionFigure 3: Reconstructed averaged thermodilution curves based on overall results of cardiac output, temperature of injection bolus (Ti), blood temperature (Tb), delta of maximum and minimum of blood temperature (ΔTb), mean transit time, and down slope time during double-lung ventilation (black curve) and 1-lung ventilation (dashed curve) in normovolemia.Figure 4: Reconstructed averaged thermodilution curves based on overall results of cardiac output, temperature of injection bolus (Ti), blood temperature (Tb), delta of maximum and minimum of blood temperature (ΔTb), mean transit time, and down slope time during double-lung ventilation (black curve) and 1-lung ventilation (dashed curve) in hypovolemia.Volumetric Variables Derived from Transpulmonary Thermodilution In Table 3, the results of volumetric variables calculated from the CO estimated by TPTD are shown. GEDITPTD remained statistically unchanged in both normovolemia (M1: 554 ± 94.2 mL/m2; M2: 521.8 ± 83 mL/m2; P = 0.23) (difference: −32.2 mL/m2 = −5.8%; 95% confidence interval, 19.9 to −85.5 mL/m2 = 3.6% to −17.9%) and in hypovolemia (M3: 413.5 ± 59.9 mL/m2; M4: 394.8 ± 65.0 mL/m2; P = 0.32) (difference: −18.7 mL/m2 = −4.5%; 95% confidence interval, 18.5 to −55.8 mL/m2 = 4.5% to −13.5%). EVLWITPTD in normovolemia decreased significantly after implementation of 1-lung ventilation (M1: 10.7 [9.5, 12.2] mL/kg; M2: 9.1 [7.5, 11.6] mL/kg; P = 0.035) (difference: −1.6 mL/kg = −15.0%; 95% confidence interval, 0.2 to −2.9 mL/kg = 1.9% to −27.1%). Also, in hypovolemia EVLWITPTD showed a statistically significant reduction (M3: 10.1 [8.6, 13.9] mL/kg; M4: 8.6 [7.4, 10.7] mL/kg; P = 0.037) (difference: −1.5 mL/kg = −14.9%; 95% confidence interval, −0.1 to −3.5 mL/kg = −1% to −34.7%).Table 3: Volumetric Variables Assessed by Transpulmonary Thermodilution (TPTD) Based on cardiac Output Measurement by Transpulmonary Thermodilution During 1-Lung Ventilation and Double-Lung Ventilation in Normovolemia and HypovolemiaResults of volumetric variables calculated from the CO measured by PAFP are given in Table 4. In normovolemia, GEDIPAFP was M1: 459.9 ± 67.5 mL/m2 and decreased significantly to M2: 397.0 ± 54.8 mL/m2 (P = 0.001) (difference: −62.9 mL/m2 = −13.7%; 95% confidence interval, −26.4 to −99.4 mL/m2 = −5.7% to −21.6%). In hypovolemia, GEDIPAFP also decreased significantly (M3: 300.6 ± 40.9 mL/m2; M4: 275.2 ± 37.6 mL/m2; P = 0.03) (difference: −25.4 mL/m2 = −8.5%; 95% confidence interval, −2.0 to −48.8 mL/m2 = −0.6% to −16.2%). EVLWIPAFP also showed a significant change in normovolemia after 1-lung ventilation (M1: 9.0 [7.3, 10.1] mL/kg; M2: 7.4 [5.8, 8.3] mL/kg; P = 0.01) (difference: −1.6 mL/kg = −17.8%; 95% confidence interval, −0.3 to −3.6 mL/kg = −3.3% to −40%). EVLWIPAFP in hypovolemia was also significantly changed after 1-lung ventilation (M3: 7.4 [6.3, 9.7] mL/kg; M4: 5.8 [5.2, 7.4] mL/kg; P = 0.0009) (difference: −1.6 mL/kg = −21.6%; 95% confidence interval, −0.4 to −2.8 mL/kg = −5.4% to −37.8%).Table 4: Volumetric Variables Assessed by Transpulmonary Thermodilution (TPTD) Based on Cardiac Output Measurement by Pulmonary Artery Flowprobe During One-Lung Ventilation and Double-Lung Ventilation in Normovolemia and HypovolemiaDISCUSSION In this experimental animal study, our data demonstrate that configuration of the thermodilution curve is significantly influenced by 1-lung ventilation consequently introducing errors in the measurement of GEDI and EVLWI calculations especially when the gold standard CO is used. Therefore, in clinical use, GEDI and EVLWI measured by TPTD have to be interpreted with caution when assessed during 1-lung ventilation. The thermodilution curve is the basis for calculation of all variables that can be derived from TPTD. The 3 variables directly assessed from the thermodilution curve are the area under the thermodilution curve, and thereby CO, as well as MTT and DST. However, various factors affect the validity of the method. These factors include structural malfunction of heart valves such as aortic valve defect, mitral, and tricuspid valve insufficiencies.1,13,14 Intracardiac shunts can also increase the recirculation phenomenon of the thermoindicator falsifying the contour of the thermodilution curve.12 CO is calculated by the modified Stewart-Hamilton method focusing on the area under the thermodilution curve. As we recently published as an independent part of this experimental trial, the CO itself is not significantly changed by 1-lung ventilation. However, we also showed that the methodology of CO assessment by TPTD is influenced by 1-lung ventilation with a significant increase in bias of CITPTD compared with CIPAFP.8 For this reason, we also calculated the volumetric variables based on the CO measured by the PAFP to eliminate any influence from imprecise values. When considering some aspects of the thermodilution curve, the following holds true. We know that the area under the thermodilution curve, necessary for CI assessment, is not altered by 1-lung ventilation. MTT and DST are derived from the contour of the thermodilution curve. Until now, there was no evidence in the literature as to whether or not physiological changes induced by 1-lung ventilation affected the shape of the thermodilution curve and thereby MTT and DST estimation. In prior studies, microembolization of pulmonary vessels was shown to lead to underestimation of extravascular lung water.15–17 It has to be assumed that hypoxic pulmonary vasoconstriction in the deflated lung, as with embolization, affects the contour of the thermodilution curve, because the thermal indicator cannot pass through and cannot equilibrate within the extravascular water space in the same manner.7,18,19 This probably delays arrival at the detection site to such an extent that a certain portion of the indicator passing through the deflated lung disappears as recirculation phenomena. Due to hypoxic pulmonary vasoconstriction, the passage of the cold indicator shifts from the deflated lung to the ventilated lung and more cold indicator passes through the ventilated lung where this bolus passes more en bloc, resulting in a faster start to the curve, increased peak, and an accelerated decline of the thermodilution curve. This hypothesis is confirmed by our results where the ΔTb was increased, and MTT and DST were both significantly decreased after 1-lung ventilation, as illustrated in Figures 3 and 4. With this in mind, it may initially be surprising that GEDI was not significantly affected, if based on measurements of CO by TPTD (GEDV = CO·[MTT − DST]). The reason for this is that both MTT and DST decreased, and therefore, the difference between both, paired with a more imprecise CO measurement, resulted in a nonstatistically significant change in GEDI. However, when eliminating the falsification factor of a less accurate CO measurement by TPTD during 1-lung ventilation and calculating GEDI based on the gold standard CO measurement by PAFP, GEDI showed a significant change after onset of 1-lung ventilation. Indeed, the same applied to ITBI, which is also used as a volumetric variable of cardiac preload, because the calculation of ITBV is solely based on multiplying GEDV by 1.25.5 Regarding EVLWI, the other clinically important variable derived from thermodilution, the following applies. EVLWI requires ITTV and ITBV for its calculation (EVLW = ITTV − ITBV). When calculating ITTV, the same phenomenon applies as for the estimation of GEDI and ITBI. ITTV showed a tendency to decrease when calculated with less precise assessment of CO by TPTD; however, a level of statistical significance was not reached. When the calculation was based on CO measured by PAFP, ITTV showed significant changes. When put in the equation to calculate EVLWI, the tendencies to decrease for ITTV in absolute values are much larger than for ITBV adding up to a statistically significant change in EVLWI even if calculation was based on measurement of CO by TPTD. Some limitations of this study should be considered. The main limitation of our study is that gold standard evaluation for comparison of GEDI and EVLWI was not possible during the special situation of 1-lung ventilation because the experimental reference technique was not available. Other aspects include statistical considerations. In our study after onset of 1-lung ventilation, a statistically significant change was demonstrated for GEDI and EVLWI when calculated on the basis of CO assessed by PAFP. However, one has to differentiate between a statistically significant and a clinically relevant change.11 For the design of our study, we had arbitrarily defined a difference of >15% to be of clinical relevance. However, our results only allow the conclusion that thermodilution-derived variables during 1-lung ventilation do present a statistically significant change and therefore have to be interpreted with caution for clinical use. No final conclusion regarding the magnitude and the clinical relevance of change of thermodilution-derived variables can be drawn from the results, and therefore, our study needs to be considered a pilot study. For an exact determination of the magnitude of change, our study does not provide adequate power to reliably define the magnitude of this change. The question to which extent our findings are clinically relevant lack a definite answer making further studies, probably with a larger sample size and maybe another, possibly lower definition of clinical relevance, necessary to finally conclude this issue. Another aspect is that factors for the calculation of intrathoracic compartments differ from pigs to humans.20–22 Therefore, calculation of absolute values is not correct in our study and is biased by a systematic error. Nonetheless, alterations due to interventions within the same subject, such as 1-lung ventilation in our study, still are reliably detected. Also, midline thoracotomy was performed in our study. In most surgeries requiring 1-lung ventilation, excluding lung transplantation, lateral thoracotomy is usually performed. These different thoracic approaches might have different impacts on TPTD. For practical reasons, we performed 1-lung ventilation of the right lung, excluding the smaller left lung from ventilation as pigs do have an accessory upper lobe branch for the right upper lobe complicating 1-lung ventilation and making it less reliable for experimental purposes. Proportions of left to right lung are 3 to 4. Effects of 1-lung ventilation could therefore have been even more distinct if the right lung was excluded. Nonetheless, we consider the effects achieved by exclusion of the left lung adequate. In conclusion, during 1-lung ventilation, the thermodilution curve is significantly changed, and consequently, an underestimation of GEDI and EVLWI has to be assumed. As a consequence, both variables have to be evaluated and interpreted with caution for guidance of therapy in this special situation. DISCLOSURES Name: Sebastian A. Haas, MD. Contribution: This author helped design and conduct the study, collect the data, analyze the data, and prepare the manuscript. Attestation: Sebastian Haas approved the final manuscript. Sebastian Haas attests to the integrity of the original data and the analysis reported in this manuscript. Sebastian Haas is the archival author. Conflicts of Interest: The author has no conflicts of interest to declare. Name: Constantin J. C. Trepte, MD. Contribution: This author helped design and conduct the study, collect the data, analyze the data, and prepare the manuscript. Attestation: Constantin Trepte approved the final manuscript. Constantin Trepte attests to the integrity of the original data and the analysis reported in this manuscript. Conflicts of Interest: The author has no conflicts of interest to declare. Name: Rainer Nitzschke, MD. Contribution: This author helped design the study, analyze the data, and prepare the manuscript. Attestation: Rainer Nitzschke approved the final manuscript. Rainer Nitzschke attests to the integrity of the original data and the analysis reported in this manuscript. Conflicts of Interest: The author has no conflicts of interest to declare. Name: Tim P. Jürgens, MD. Contribution: This author helped analyze the data and prepare the manuscript. Attestation: Tim P. Jürgens approved the final manuscript. Tim P. Jürgens attests to the integrity of the original data and the analysis reported in this manuscript. Conflicts of Interest: The author has no conflicts of interest to declare. Name: Matthias S. Goepfert, MD. Contribution: This author helped design the study, analyze the data, and prepare the manuscript. Attestation: Matthias Goepfert approved the final manuscript. Matthias Goepfert attests to the integrity of the original data and the analysis reported in this manuscript. Conflicts of Interest: The author has no conflicts of interest to declare. Name: Alwin E. Goetz, MD, PhD. Contribution: This author helped design the study, analyze the data, and prepare the manuscript. Attestation: Alwin Goetz approved the final manuscript. Alwin Goetz attests to the integrity of the original data and the analysis reported in this manuscript. Conflicts of Interest: Alwin Goetz is member of the editorial board of pulsion medical system. Name: Daniel A. Reuter, MD, PhD. Contribution: This author helped design the study, analyze the data, and prepare the manuscript. Attestation: Daniel Reuter approved the final manuscript. Daniel Reuter attests to the integrity of the original data and the analysis reported in this manuscript. Conflicts of Interest: Daniel Reuter is member of the editorial board of pulsion medical system. 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Overview of the Government
The constitution of the Empire of Brazil stated that "The representatives of the Brazilian Nation are the Emperor, and the General Assembly." [Art. 11. Os Representantes da Nação Brazileira são o Imperador, e a Assembléa Geral.] In this way, the Empire of Brazil was a constitutional monarchy, wherein the Emperor and the Parliament were servants of the people of the empire. The idea was that the emperor was the enduring, big-picture ruler (the "permanent will" as Nabuco says in Um Estadista [vontade permanente]), while the General Assembly attended more to the day to day concerns of the state.
The Emperor appointed judges, magistrates, senators, provincial presidents, ministers of state, and eventually the President of the Council of Ministers—a position similar to Prime Minister. The Emperor was responsible for sanctioning laws in order for them to go into effect, though parliament could force a bill into law if it was voted through by two consecutive legislatures. The Emperor could also commute sentences and grant amnesty.
While it's wrong to say that the emperor was just a figurehead, certainly the General Assembly was the main governing body of the Empire. It consisted of the Chamber of Deputies (the lower house) and the Senate (upper house.) The General Assembly (which is alternately referred to as "parliament" and "the legislature") held the power of the purse, power to modify, suspend, and enact laws, control of the military, and power to create government offices.Read More »