Civilization VI Rise And Fall DLC Steam CD Key EU rolls up not only adds the new guides, units, maps, buildings and wonders that are needed, but also those who do things with only the basic concepts, greatly improving the original.
Most striking is the brave recognition that civilizations can thrive without aggressive military force or conquest, and are based on peaceful achievements to shape history.In Rise and Fall, the goal is to move the player away from the fight and create more creative ways to win.
Playing Rise and Fall feels less like a field and more like a sandbox. This change is achieved through the concept of citizen loyalty, which is closely linked to the power of a nation's culture and the distance of a city from its capital. A weak culture and a widely dispersed empire is a bad combination. It has been used in previous Civ games, but never with the clarity of purpose shown here. In essence, my people will be loyal to me only if they are part of the empire.
Unfortunately, the overall score still weighs heavily towards expansion and area, but this simple mechanics is a useful break to reduce the game to an endless cycle of conquest and expansion. The great empires that lack cohesion are weakened by their edges. This is an accurate reproduction of the history of the world.
Historical ups and downs, ebb and flow, civilization will reach the stage of history, into the dark ages or the golden age.Play Rise and Fall now,and build your own city and own your citizens.Collect the loyalty of your citizens in your city,but in Civilization VI Rise And Fall,the city can be mutinied.So,you must take care of your citizens to increase your loyalty,make the civilization into a golden age.


text:
William Potter
CNS Founding Director
Sam Nunn and Richard Lugar Professor
of Nonproliferation Studies
Founding Director of the James Martin Center for Nonproliferation Studies at the Monterey Institute of International Studies (MIIS)
Member of the Council on Foreign Relations
Nuclear terrorism
Forecasting proliferation developments
US-Russian relations
NPT review process
NAM nuclear politics
Dr. William Potter has served as a consultant to the Arms Control and Disarmament Agency, Lawrence Livermore National Laboratory, the RAND Corporation, and the Jet Propulsion Laboratory.
He has been a member of several committees of the National Academy of Sciences, including its Nonproliferation Panel.
He served for five years on the UN Secretary-General's Advisory Board on Disarmament Matters and the Board of Trustees of the UN Institute for Disarmament Research.
He has participated as a delegate at every NPT Review Conference and Preparatory Committee meeting since 1995.
CNS Work
Can Shared US–Russian Interests Lead to Joint Action?
William C. Potter and Anton Khlopkov in Kommersant.
CNS Director's Statement on January 6th Events
We must not be complacent in the face of existential threats of which, regrettably, the number is growing.
Happy Holidays and Happy New Year
My CNS colleagues and I wish you a peaceful and joyous New Year.
Death Dust
The little-known story of US and Soviet pursuit of radiological weapons.
Putin's Novel Delivery Systems
WEBINAR: Analyzing Russian military innovation.
The CTBT and the 10th NPT Review Conference
WEBINAR: Challenges facing the treaties and the potential to strengthen both at the 10th NPT Review Conference.
Nonproliferation Trends. What's News, What's True?
A nuclear war cannot be won and must never be fought. Can this basic principle find support?
It's Time to Rethink Our Russia Policy
America's mix of sanctions and diplomacy isn't working. An open letter reconsiders our approach to Putin—and whoever is next.
In Remembrance of Bruce Blair
The international peace and security field lost one of its most distinguished members this week.
From a Novel Idea to a World-Class Center
Dr. Bill Potter discusses the founding of CNS.
View list on separate page
Nuclear Politics and the Non-Aligned Movement (2012)
The Four Faces of Nuclear Terrorism (2005)
Tactical Nuclear Weapons: Options for Control (2000)
Nuclear Profiles of the Soviet Successor States (1993)
Soviet Decisionmaking for Chernobyl: An Analysis of System Performance and Policy Change (1990)
Nuclear Power and Nonproliferation: An Interdisciplinary Perspective (1982)
Verification and SALT: The Challenge of Strategic Deception (1980)
Verification and Arms Control (1985), and International Nuclear Trade and Nonproliferation (1990)
Once and Future Partners: The United States, Russia, and Nuclear Non-proliferation (2018)
Preventing Black-Market Trade in Nuclear Technology (2018)
Forecasting Nuclear Nonproliferation in the 21st Century (2 volumes, 2010)
Engaging China and Russia on Nuclear Disarmament (2009)
The Global Politics of Combating Nuclear Terrorism: A Supply Side Approach (2009)
Dangerous Weapons, Desperate States (1999)
Dismantling the Cold War: U.S. and NIS Perspectives on the Nunn-Lugar Cooperative Threat Reduction Program (1997)
Soviet Decisionmaking for National Security (1984)
The Nuclear Suppliers and Nonproliferation (1985
Continuity and Change in Soviet-East European Relations (1989)
International Missile Bazaar: The New Suppliers' Network (1994)
Dr. Potter has contributed chapters and articles to over 130 scholarly books and journals.
Articles by William Potter

redpajama_set_name: RedPajamaCommonCrawl


text:
Key West News
800-595-KEYS Get FREE travel plan
Beaches Water Activities Land Activities Top Attractions Restaurants
Our Story Testimonials
Where to Stay Upscale Hotels Boutique Inns Villas & Cottages Budget-Friendly
Experiences Beaches Water Activities Land Activities Top Attractions Restaurants About Us Our Story Testimonials Accommodations Where to Stay Upscale Hotels Boutique Inns Villas & Cottages Budget-Friendly Key West News Blog Calendar 800-595-KEYS
Key West Vacation Planning
Get FREE travel plan
Don't miss a thing. Sign up for our Key West newsletter!
Sign up with your email address to receive news, updates, & special insider-deals :)
The origin of Key West's official motto: One Human Family
Here in Key West, our motto is "One Human Family." The motto was created by local artist, J.T. Thompson in the early 2000's. It began as a grassroots effort, which eventually spread to be accepted by locals as the official motto. The idea is simple: "All people are equal members of One Human Family" –regardless of race, nationality, sexuality, and other differences, he believes that "differences are superficial distinctions and cannot be allowed to be twisted into cultural divisions."
Best times to visit Key West
Visiting Key West is all about timing & priorities. As natives, we know when the best times are to visit… not just the best weather, but also the best prices! Here's your guide to knowing what peak season is, when to visit if you're watching the wallet, and also when to expect rain. Along with each month, we've included a list of key events.
Is Key West it's own country? Yes, and no...
If you don't live in Key West, you may not be familiar with it's (humorous) history. Key West residents were frustrated with US Border Patrol for setting up a checkpoint upon entry to the rest of Florida. After failed attempts to get them to take it away, the Mayor of Key West took matters into his own hands… announcing that the Conch Republic was seceding from the US!
25 years of the same brand – why did we change it?
It's a big year for us here at Vacation Key West – not only are we celebrating 25 years in providing planning services for Key West visitors, but we are also excited to announce the launch of a new website, coupled with a refreshed logo.
About Key West
Key West, The Southernmost City in the USA! These are a few of our favorite Southernmost things.
Dolphin adventure
For children & adults, a dolphin encounter is unforgettable.
The official reservation service for The Key West Innkeepers Association • Copyright 2019 • Vacation Key West, Inc.
(800) 595-KEYS (5397)
Let's plan your dream vacay
Get the guide: best local hidden gems of the Key West
Get the authentic Key West experience. We've consolidated the best local tips and hidden gems, for your eyes only! Shhh! It's a secret. Sign up now to get the guide, as well as occasional updates.
Warning! You may fall in love with Key West and never want to leave. Also, we respect your privacy and won't share your email with anyone else.
Vacation Key West
100 Grinnell Street,
Key West, FL, 33040,
Contact UsPrivacy PolicyTerms & Conditions


Jennifer Jones brings 20 years of title and settlement services industry experience to the position.
An attorney with 15 years' experience, Kelsea Laun will assist in providing legal and underwriting support to NATIC agents in Alabama, Georgia, North Carolina, South Carolina and Tennessee.
John Kotleba has wide experience in the title industry in operations, branch management and sales.
Ian Kyle has eight years' experience in real estate law, including experience in litigation and as an underwriting counsel at the commercial branch of a national title insurance company.
Heather Tally has 18 years' experience in title examination and production in Florida.
Kathy Hulbert is an attorney and was Indiana Land Title Association executive director for eight years.
Company to provide escrow and closing services in the active market.
Terri Poenitzsch has worked in the title industry for over 16 years.
Diane Davis has worked in the Dallas-Fort Worth real estate market for over 23 years.
Staff includes real estate closing professionals who are well known in the Lake Mille Lacs community.
An attorney for nearly 15 years and a title industry veteran of over 10 years, Sara Valenz will provide legal and underwriting support to NATIC agents in those two states.
David 'DJ' Downs has 10+ years of sales and marketing experience in title, fitness and medical industries.
Company responding to need for escrow services in the growing area.
New location on N. Loop 1604 W. offers better proximity to northwest San Antonio's robust real estate market.
New location is more centrally located and combines regional legal staff with residential closing team.
Jason McDonald has 20-plus years in the Bay Area title industry with significant sales and management experience.
Susie Sheffield is a 10-year title industry veteran, rejoins San Pedro branch.
Brynn Powers has 20-plus years' experience with area title and escrow companies.
Chad Barth, formerly the Northern California/Nevada area manager for North American Title, brings nearly 20 years of title insurance experience to this position.
Maria G. Alvarado has over 20 years' experience in title industry.
Bobbi Wright has 20 years' experience in the title industry.
Soviero to expand Florida footprint for North American Title Insurance Co.
Michael Soviero is the first to be hired as an agency relationship manager, a new position in NATIC's national sales division.
Stephanie Seabolt has over 28 years of diverse experience on both the agency and the underwriter side of the title industry.
Tony Chavez has been in the title industry for more than 35 years.
Michelle Witmer is a 19-year title industry veteran with deep ties to the Dallas-area real estate community.
Kim Correa has over 30 years' experience in the title industry.
Tom Harper has a distinguished career in title agency relations, public service, government relations and communications.
Jacqueline Clement has 14 years' experience and is a licensed Florida title agent.
Russell Hirayama has nearly 40 years' experience in the title industry.
Astrid Ashworth is a 28-year title industry veteran.
New office in iconic Wells Fargo Center will target transactions in the city's active commercial real estate market.
Lisa Marley has five years' experience as a local real estate and marketing professional.
Susie Nichols and Patty Zesch open new office in neighborhood, joined by Jeff Fielder.
Vince Foley has more than 21 years' experience in title and escrow.
Danielle L. Kaiser has more than eight years of title industry experience and has earned the ALTA National Title Professional designation.
Christina Isaac of North American Title Co. is honored for her business accomplishments, community service and for being an active ABoR affiliate volunteer.
Kevin Melberg has over 19 years' experience in the title industry throughout California.
G. Leigh Curry is a 20-year title industry veteran who will serve NATIC agents in six Midwest states.
Central Property Search provides Pennsylvania county searches, state-level corporate searches and more.
Casie Lowe has 14 years' experience in closing real estate transactions.
Angie Buford has over 17 years' experience in the real estate industry.
Mary Lucas has 37 years' experience in closing real estate transactions.
Kelli Nielsen has 25+ years of experience, managing operations and driving sales growth in the title insurance and lending industries.
Manoj Purohit has worked in sales and operations in the mortgage lending, title and title technology industries for 28 years.
Mark Hungate has nearly 25 years of sales, operations and management experience in the mortgage insurance, appraisal and title/settlement industries.
Jeff Pate has 20 years of sales experience, including new home sales and architectural sales, in addition to working as a residential loan officer.
Kimberly Martin has 20 years' real estate experience, with five years in title industry.
Crystal Widman has 15 years' experience as sales professional.
Anna O'Neil has experience in real estate sales, training and management.
Jennifer Gerlich has 13 years' experience in real estate industry.
NASSA, North American Title's short sale assistance division, helps real estate agents with short sale services to benefit homeowners who are delinquent with mortgage payments.
Attorney and escrow closer Ryan Carbery has 10 years' experience in closing and as real estate agent.
Columbia City office in Whitley County to be led by local expert, Operations Manager Laura Ormsby, joined by Escrow Manager Jessica Baker.
JoAnne M. Steiger has seven years' experience in title industry.
Business Consultant Maxwell Jackson accepts board of directors position and receives Ambassador of the Year award from Florida business association.
Business consultant Kimberly Reers has 18 years of closing experience and will work temporarily out of the Cape Coral branch.
Negron is a 21-year title industry veteran who serves as chairman of the association's education committee.
Former home of the San Francisco Giants and 49ers will be the site of a $1 billion development project, Candlestick Point, to include an urban mall, homes, parks, and office and retail space.
Individual home buyers, sellers and refinance customers who close with North American Title in Utah on or after Dec. 15, 2014, will receive access to 12 months of identity theft repair services at no cost.
Acosta and Lewis join the Arlington, Texas, branch of North American Title Co.
Claudia Acosta named managing escrow officer and Tiesha Lewis named escrow officer.
Company believes program is compliant and beneficial to consumers, but is seeking answers to regulatory compliance questions that have been raised.
Evan Koymarianos has more than 10 years' experience in title industry.
Vibrant Fort Bend County market southwest of Houston boasts excellent job market and intense competition for new and resale home listings.
Addition of veteran attorney Andres San Jorge strengthens North American Title Insurance Co.'s commitment to service the commercial sector.
Toni Carroll has worked in the title industry for 29 years and will be helping NATIC independent agents grow their business.
Annual conference and trade show presented by the National Association of Realtors will be Nov. 7-10 in New Orleans, featuring educational sessions and networking.
North American Title Company business consultant, Tara Corriveau Merritt, elected as 2015-2016 affiliate director for the Orlando-area real estate trade association.
Victor Aguilar joins office as business consultant; Karla Aguilar joins as escrow officer.
Kendall Halpern has 12 years' experience in commercial banking and legal fields.
Office expansion prompted by area's explosive growth in real estate development.
North American Title Insurance Company is adding vendors to its SearchLink Network to boost the network's effectiveness for its independent title agents.
Denise Harris brings over 13 years of experience and expertise in the title industry.
Richard Lundbeck has 15+ years of experience, managing and starting new lines of business in the title insurance and real estate industries.
Rashelle Gallegos has 16 years of experience in the title industry as escrow officer.
Tracie Byrd Norris has more than 20 years' experience in the title industry.
Addition of RedVision as a vendor to its SearchLink Network delivers fast service and cost savings to North American Title Insurance Company's independent title agents.
Renee Leniart and Miranda Verderame boast lengthy tenure in real estate and title industries.
Jeff Fielder has 17-year background in title and real estate industries and will be working in Park Cities, Uptown Dallas, East Dallas and Lake Highlands markets.
Company's growth and customers' need for quick quotes drives move to updated platform featuring robust content management system and high-visibility plug-in.
Michael L. Rubin is the state agency manager for North American Title Insurance Co. in Illinois, Minnesota and Wisconsin.
North American Title and its subsidiaries combined are one of the largest real estate settlement organizations in the United States. Handling both residential and commercial transactions, the company's extensive network provides or is able to coordinate settlement services spanning across all 50 states.
NAT's agency operation, North American Title Company (NATC), has provided real estate settlement services to homebuyers, sellers and borrowers since 1953 and is among the leading independent title agencies in the United States. Since NATC is not a direct operation of any one national title insurance underwriter, the company has the unique ability to be an agent for all major national title insurance underwriters, including its affiliate underwriter, North American Title Insurance Company (NATIC). This ensures that NATC customers receive the best title insurance products available throughout the entire industry at the best possible rates, granting NATC a truly competitive advantage.
With more than 100 offices across the country, NATC offers a depth and breadth of local expertise and knowledge in many of the premier real estate markets.
NAT's parent company is States Title Holding., Inc., headquartered in San Francisco, California. Founded by Max Simkoff and backed by leading venture capitalists in Silicon Valley, States Title uses predictive analytics and cutting-edge technology to deliver a modern title and escrow platform.


When they graduated in 1960, George and his friends traveled to Europe. They began work in Spain, sharing the Gospel and distributing literature. But the task of reaching the whole of Europe seemed overwhelming. George and his small team realised that God's plan was to mobilise His church to reach the nations. As they began to share their vision, hundreds of Christians responded. So Operation Mobilisation was born.
By 1963, 2,000 Christians had joined summer outreach teams in Europe. At the same time, the first year teams moved into the Indian sub-continent and the Muslim world. Their commitment was to reach those who had never heard the Gospel. Such simple beginnings have shaped OM ever since.
Today, more than 6100 OMers are working in over 110 countries bringing God's unchanging truth to literally millions every year.


An early painting by Jackson Pollock.
It's known as the "R" word.
Florida lawmakers are moving toward erasing the terms "mental retardation" and "mentally retarded" from myriad state laws, as the word "retarded" has become widely viewed as offensive to people with disabilities.
"Mental retardation" would be replaced by "intellectual disability," and "mentally retarded" would be replaced by "intellectually disabled." As an indication of how references to retardation thread through state laws, the House is considering a 71-page bill to replace the terms — which pop up in everything from criminal laws to health laws.
Deborah Linton, executive director of The Arc of Florida, said she has worked for three years to convince lawmakers to eliminate the "R" word and its variations. In the past, Linton's group was known as the Association for Retarded Citizens.
"It was a medical term, and it became an insult," Linton said Tuesday after the House Health and Human Services Committee voted unanimously to approve the bill (HB 1119). At the other end of the Capitol, the Senate Rules Committee also voted unanimously for the Senate version (SB 142).
House sponsor Janet Adkins, R-Fernandina Beach, said 39 states have made similar changes to their laws. A person with an intellectual disability typically has an IQ of 70 to 75 or below, has limits on the ability to carry on everyday life activities and had the disability before age 18, according to The Arc website.
But while advocacy groups have made a priority of changing the terms, two speakers with intellectual disabilities told the House committee Tuesday that they are still hurt by getting called retarded.
Members of the committee praised the measure.
"Sometimes the most simple of bills can be the most monumental," said Rep. Mark Pafford, D-West Palm Beach.
As the mother of a daughter with Rett Syndrome, the most severe form of Autism, I am very gratful to have the "R" word removed from the law, but it should also be removed from our vocabulary. It is hurtful to hear it. I realize that it is a medical term, but it has been widely misused and indicates something negative. My daughter is anything but negative. She holds the joy of a child, the smile worthy of a picture and the spirit of an Angel!
Standing "o" for the legislature from this mom of a special needs child! It's about time!
IQ lower then 75…..Well, I suppose we will have to call most of the progessive left politicians, " Mentally Disabled ". You know ole' VP Joe might not qualify at that high level. What's the word we use for someone with an IQ lower then -20 ? Oh yea….." The Un-Dead " !!!
This is long overdue. It is an insult using the "r" word referring to a human being. My son is a special needs child who is developmentally delayed. He is pretty bright, but not at his age level. Happy to see that word replaced.
As you know Jackson Pollock has has his dark years but as an artist he often brought the issue in his art to the forefront of public opinion.
Retarded is crude and rude as a term. Even Mentally disabled sounds wrong.
One can still use the term Retarded and not be mean while useing it. People need to be more tolorent of others and not be "OFENDED" at others for their words that where or are not meant to be crule.
I do agree with this one even though it reeks of political correctness. The fact is even I am guilty of saying by accident, using it as a pejorative. It also makes the deliverer of the word really seem intellectually weak. God Bless these sweet and innocent people with mental issues through no fault of their own. I would even hope that more special ed classes are funded to better help these children and their parents.
Wouldn't "intellectually disabled" also apply to the liberal goofballs who dream of a utopian society full of unicorns and rainbows? Does this mean we can't say "libtards" anymore as well?
Now if we could just get them excised from the state House and Senate.


Bed bath -- Care of the body after death.
A video from ECU's archive of documentaries and teaching films. Nasogastric tube insertion -- Nasogastric feeding -- Electrocardiogram. Produced by David Crewes.
A video from ECU's archive of documentaries and teaching films. Catheterisation - female -- Catheter specimen of urine -- Evacuant enema & rectal suppositories. Produced by David Crewes.
A video from ECU's archive of documentaries and teaching films. Injections -- Intramuscular injections. Produced by David Crewes.
A video from ECU's archive of documentaries and teaching films. Intravenous therapy - priming -- Removal of an IV cannula -- Central venous pressure monitoring. Produced by David Crewes.
A video from ECU's archive of documentaries and teaching films. Making an occupied bed -- Making an unoccupied bed -- Baby bathing and changing. Produced by David Crewes.
Training videos demonstrating critical skills for nurses.


How designers and developers can actually work with their other halves to create great products (without the stress and frustration).
Every product team inevitably contains two roles core to the experience of the user and the success of the product: designer and developer. As central as this dynamic is, over our time working at multiple agencies and companies this is actually the single relationship that is most fractured in most teams.
This isn't surprising, really, since designers and developers have very different goals in mind, and often have very different personalities, preferences, and communication styles. Regardless of their differences, they're both of equal importance to the success of a product and learning to work together can not only lead to better results but can make your lives as equal parts of the same team fun.
Ryan Clark, Andy Rossi, and I have worked together in some capacity for almost 10 years. That's a whole decade (also it makes us feel old). Over that time, we've learned small things that have helped us stay sane and work well together despite our extreme differences in skill set and personality—and ultimately craft products and solutions that are better for it.
"This should be pretty easy," is a phrase you hear a lot around a product team, especially from the people not doing the work. Never assume anything is easy. Ever. This is applicable to anyone working on a team, but especially between designer and developer (middle-management can be given a pass, sometimes, maybe).
Over the years Ryan and I have established the habit of asking questions like, "When could we get this done?" or, "How can we do this?" instead of assuming a task is simple and should require minimal effort. Expectations exist whether we realize it or not, and can only be cleared up when the whole picture is in mind. Surprisingly, these discussions about complexity and scope can be some of the most fun parts of a project. Is it more complex than expected? Maybe it can be solved with a different design or different approach to the code, maybe it's not even necessary at all. Asking these questions and deferring to the other person allows us to craft the appropriate solution together.
Like most relationships, successful designer-developer relationships are very much a give and take. Most of the giving and taking in our relationship centers around our core goals. For Ryan, it's the narrative—what story are we telling? How can we say the right things in a captivating and clear way? For me, it's the functionality—how does that story work? How can we get it to the most people on the most devices?
The biggest hurdle to compromise is when we're more concerned about being right than doing it right. When you're focused on being right it's all about personal pride. When you're focused on doing it right it's about team pride.
Everyone's been in that meeting where you're discussing a feature or implementation and ideas are getting tossed around. The most interesting parts are people's reactions to their ideas being challenged. On teams that work well together challenges are accepted and worked through.
In the early days of working together there were lots of times that we wanted our own individual ideas to win out, but after years of working together we've learned (sometimes the hard way) that we're a team for a reason. By trusting each other we can be more than the sum of our parts. Challenges to an idea are challenges to make it better. Ideas aren't our own, they're the groups to mold and change and build on with each of our skill sets and perspectives. We quit caring if we were right. Instead we want the idea to be right.
The single greatest source of tension in a development team is usually the implementation of the work itself. Too often we hear stories about designers onion-skinning a staging server and adding GitHub issues for pixel edits. And too often we see developers who sloppily implement a design to the point it's not remotely representative of the initial design.
Pixel-perfection isn't a goal worth chasing. It's not that it isn't possible, it's that it doesn't matter. The differences between viewports and default browser settings make the idea of everything being perfect a fleeting reality. Most of Ryan's pixels become ems or percentages in my CSS, so I'm looking to him more for a basic style guide to how things should be implemented and interact with one another in any given layout. Instead, our goal is to craft something together that we are both proud of and that achieves the goals we set out to do in a beautiful and functional way. In the end, that has little to do with the original pixel counts.
Nit-picking is important. Let it happen. On the flip side, there is a time and place for specific revisions (and pixels, like icons for instance). As a developer, set aside time at the end of a project to sit down with your designer (in the same room on the same computer) and let them nit-pick all the little details. They'll love it. Just look at what you've created together in a real browser and make it look as good as it can possibly be. By allowing this process to take place and creating structure around it you can minimize the interruption while still allowing your designer to ensure the implementation is true to their original designs.
Communicate your expectations up front. It really is that simple. By establishing expectations up front you can avoid a lot of tension when it comes to the implementation of a design. Create a real plan for the design and code handoff. Talk about underlying frameworks being used on both sides. Don't waste time trying to bend a design or a browser to your will when it's a small detail. Don't be afraid to punt something to future-you. Embracing the messiness of our craft and the possibilities of iterative change can make this whole process much simpler and less stressful for everyone.
Give in to each other's workflows and feedback mechanisms. Developers: if your designer wants to use Sketch or Illustrator (or Powerpoint?!), let them. And learn how to take that and build from it. (Okay if they're using Powerpoint you have much bigger problems.) Designers, let your developers decide how they are going to build your design and learn their preferred method of code feedback (we <3 Github issues). This is a simple way to avoid unnecessary conflict.
Communicate your timelines. It's obvious that time is precious—your time, your client's time, your customer's time. Talk to each other about what you're working on and how long things will take. Designers, if there's a part of a design that needs more thought, tell your developer to avoid it until it's fully designed. Developers, if there's something that's a design blocker that can be easily addressed, ask if the designer can change focus to allow you to maximize your efficiency. Being courteous with each other's time will allow you to work at maximum efficiency and get your jobs done faster and with less stress. And that helps everyone.
Know the limitations. One of the things that makes our team work so well together is that we've taken the time to understand each other's complimentary roles and skills. Ryan knows how to wrangle CSS. Andy can design. We all overlap enough to make educated decisions about what's best for a project and help guide each other to appropriate solutions. That's not to say that we don't create fun challenges for one another, but we know how to be creative within the team's boundaries.
Most product teams exist in high stress environments already—the pressures of your business goals and project timelines are hard enough to achieve. Realize that your most trusted ally is your other half—both are equally valuable to your success. Stop trying to be right all the time, and defer to each other. Focus on making something that everyone can be incredibly proud of, as a team, because you might end up working with those same designers and developers a decade from now.


text:
The 59th Krakow Film Festival is open
Festivals 2019-05-27
The 59th Krakow Film Festival began on Sunday evening with a full room at the ceremonial gala at the Kijów.Centrum cinema and the screening of the documentary "Wind. A Documentary thriller " by Michał Bielawski. The official opening, headed by Krzysztof Gierat, director of the Festival, was attended by Robert Piaskowski, plenipotentiary of the Mayor of the City of Krakow for Culture, members of the jury and representatives of the film industry from around the world.
– Yesterday Cannes, today Krakow. Yesterday during the awards in Cannes the less known artists won with the masters of cinema. Will it also be the case at the Krakow Film Festival? – said Krzysztof Gierat, the festival director, inviting the audience to participate in the shows and events accompanying the festival.
Krzysztof Gierat, fot. Kamila Szatan
During the eight festival days, viewers will have the opportunity to see in almost nearly 250 films from all over the world showcased in the 4 competitions and 11 non-competition sections, most of which are shown in our country for the first time. The competition films will be judged by the international Jury, whose members were presented during the ceremony. Among them are Talal Derki, Brett Morgen, Jacek Petrycki, Marta Prus, Weronika Bilska, Tomasz Raczek and Xawery Żuławski.
Jury of 59. Krakow Film FGestival, fot. Kamila Szatan
A great celebratory welcome was given to Caroline Leaf room, winner of this year's Dragon of Dragon Award, who will receive her award for special contribution to the development of the world animated film which on May 27th.
– Krakow lives for the cinema and does not let you forget about it on the big screen. The capital of Małopolska is a place where not only the outstanding creators of cinema lived and created,but in which new films, documentaries and series are constantly being created. Film festivals, on the other hand, are a holiday for both the industry and the public – said Robert Piaskowski, plenipotentiary of the Mayor of Krakow for culture, opening the festival on behalf of President Jacek Majchrowski.
Michał Bielawski and Maciej Kubicki, fot. Kamila Szatan
The highly applauded screening of the "Wind. A Documentary Thriller ", which had its world premiere during the opening of the Festival, was preceded by the presentation of the film's creators and protagonists. Michał Bielawski, producer of the movie, producer Maciej Kubicki, production manager Anna Wereda, cinematographer Bartłomiej Solik, responsible for editing Hubert Pusek and heroine Ewa Kondera-Wołek appeared on the stage. The Krakow audience will have the opportunity to watch the film again on May 29th at 11:00 and on May 30th at 4:00 pm in the Pod Baranami Cinema, where a meeting with filmmakers and heroes will also take place.
We are in for a week filled with screenings of competition films and accompanying sections. The meetings with the creators and unique special events await for the spectators every day.
The 59th Krakow Film Festival takes place on May 26 – June 2, 2019
Follow our news on the website and in the social media: Facebook, Twitter i Instagram.
More in this category: « KFF Industry / Free events of the 59th Krakow Film Festival The 54th Karlovy Vary IFF announces line-up »


text:
FIND THE COOLEST GIFTS FOR KIDS ALWAYS.
Uber Menu
Ultimate Gift List for Teenage Girls
Gifts for 13 Year Old Girls
Ultimate Gift List for Teen Boys
Gifts for 13 Year Old Boys
Gifts for 1 Year Old Girls
Gifts for 1 Year Old Boys
Gag Gift Ideas
You are here: Home › 2016 Star Wars Merchandise Expected to Surpass $700M
2016 Star Wars Merchandise Expected to Surpass $700M
By Ralston Paes on September 5, 2016 in Toy News
ToyBuzz spends hours and hours finding the stuff that you will love. Just so you know, Toy Buzz may earn a small commission when purchasing through the many links on this page. As an Amazon Associate we earn from qualifying purchases.
Last Updated on May 10, 2021 by Danielle
Star Wars merchandise is expected to do well in 2017.
Last year, you may recall the enormous success Star Wars merchandise had after the big marketing push of 'Force Friday'. This year already approximately $233M has been generated and two-thirds of sales are yet to come. We expect that Star Wars merchandise will be among the hot toys for Christmas 2021. For 2016, Star Wars merchandise is expected to generate an estimated $700M. Because of this the U.S. toy industry is expected to have another strong year. In fact, it has been the single largest contributor to sales growth. Sales have tripled through June. With the upcoming release of the newest Star Wars blockbuster, "Rogue One: A Star Wars Story," Star Wars toy sales are expected to accelerate.
Sales of Star Wars related merchandise could potentially be bigger than 2015, given that two-thirds of toy sales have yet to come. Star Wars toys are the #1 and #6 best-selling items thus far.
A big sales drive is expected with the release of the newest Star Wars motion picture in December.
For the second quarter, Star Wars and Disney's Frozen were the fastest-growing businesses for Hasbro.
Movie tie-in toys continue to contribute to the success. More specifically, toys sales based on Teenage Mutant Ninja Turtles, The Secret Life of Pets, and Trolls movies are anticipated to boost toymakers' sales through the holiday season.
Other Related Ideas
Star Wars Toys Crowned Hottest Toys In America
Force Friday II Announced For Star Wars: The Last Jedi
Star Wars and Super Heroes To Drive 2016 Toy Sales
Argos Reveals Favorite Toy List For Christmas 2017
Most Awesome Star Wars Toys Of 2017
NPD: Toy Sales Grew Close To 7 Percent In 2015
Retro Gaming Expected To Heat Up For Holidays
Hasbro's Profits Buoyed by Disney Dolls & Star Wars
About Toy Buzz
Submit A Product For Review
Best Gifts By Age
Gifts For Teen Girls
Top Toys for Christmas
Toy Buzz is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to (amazon.com, amazonsupply.com, or myhabit.com)


Outstanding Crochet: Worked on my Etsy shop. Some marketing to learn. A day spent well.
Worked on my Etsy shop. Some marketing to learn. A day spent well.
All I did yesterday was wiping out half of my posts here due to compliance with copyright law.
Today I decided it is time to open my Etsy shop! It it so much harder that opening Ravelry shop!
For every single field, like name of the listing, tags I did a search how to do that. It's an art of marketing itself!
Words in the beginning have to be the most likely searching words of a potential customer.
There are 140 characters are available for a name of the listing and you should use them all - it's the best way. All that for search engines to kick my listing hopefully on the first page!
Tags are a different story. There are 15 of them to include. I hope I did well. So as you see it is a lot of marketing involved.
I am happy I started though. The shop is not open yet and I am having red wine tonight and going to the beach tomorrow!!!!
Happy crocheting, my friends! Crochet rocks!


text:
Automating and estimating glomerular filtration ... - Semantic Scholar
Comparing Results of Five Glomerular Filtration Rate-Estimating
the Korean population depending on the equation used, especially in normal or ...... ic kidney disease. http://www.kdigo.org/clinical_practice_guidelines/pdf/.
Proteinuria, Estimated Glomerular Filtration Rate ... - Karger Publishers
How Measuring Glomerular Filtration Rate ... - InTechOpen
Automating and Validating Semantic Annotations - Semantic Scholar
Evolution of glomerular filtration rates and neutrophil ...
Glomerular filtration rate and albuminuria predict ... - Springer Link
Towards simplifying and automating business ... - Semantic Scholar
Iohexol Clearance for Determination of Glomerular Filtration Rate in ...
Measurement of Glomerular Filtration Rate - Journal of Nuclear Medicine
A New HPLC Method to Determine Glomerular Filtration ... - CiteSeerX
iohexol (IOX) and p-aminohippuric acid (PAH) in the plasma of dogs is evaluated according to ... Sorin (Milan, Italy). PAH and p-aminobenzoic acid (PABA) were.
Performance of glomerular filtration rate estimation equations ... - PLOS
Mar 2, 2018 - Justine B. Bukabau1*, Ernest K. Sumaili1, Etienne Cavalier2, Hans Pottel3,. Bejos Kifakiou1 ... Editor: Petter Bjornstad, University of Colorado.
Glomerular filtration rate measured by 99mTc ... - Wiley Online Library
Oct 30, 2015 - imaging is significantly lower than that estimated by the CKD-EPI equation in ... CKD-EPI equation, horseshoe kidney, glomerular .... 2012-001).
The impact of estimated glomerular filtration rate equations on chronic ...
Estimation of glomerular filtration rate by MDRD ... - Springer Link
Decreased Glomerular Filtration Rate is an ... - KoreaMed Synapse
Slower Decline of Glomerular Filtration Rate in the Japanese ... - Nature
ducted according to the Japanese law of privacy protection. Calibration of Serum Creatinine Values. Although the Jaffe method was generally used for creatinine.
Use of a serum-based glomerular filtration rate ...
Determination of Glomerular Filtration Rate by Gates' Method
Factors other than glomerular filtration rate affect serum cystatin ... - Core
Angiotensin II Modulates Glomerular Capillary ... - Semantic Scholar
JW: On the mechanism of angiotensin-induced proteinuria. I. Studies in aminonucleoside nephrotic rats and in saralasin blockade. Nephron. 1981 ;24:47-50.
Development and validation of equations estimating glomerular ... - Core
MEMBRANE FILTRATION OF BIOLOGICAL SOLIDS - Semantic Scholar
Pig manure treatment by filtration - Semantic Scholar
THE CORADICAL FILTRATION FOR QUANTIZED ... - Semantic Scholar
WILLIAM CHIN AND IAN M. MUSSON. ABSTRACT. We determine the ...... N. JACOBSON, Lie algebras (Dover, New York, 1979). 11. A. JOSEPH and G.
5 downloads 86118 Views 215KB Size Report
email [email protected] Objective: The ... disease (CKD) staging and to discuss how automated health information technologies (HIT) can enhance clinical ..... patients on long-term ramipril: REIN follow-up trial. Gruppo Italiano.
International Journal of General Medicine
Dovepress open access to scientific and medical research
Open Access Full Text Article
Automating and estimating glomerular filtration rate for dosing medications and staging chronic kidney disease This article was published in the following Dove Press journal: International Journal of General Medicine 2 May 2014 Number of times this article has been viewed
Katy E Trinkley 1 S Michelle Nikels 2 Robert L Page II 1 Melanie S Joy 1 Skaggs School of Pharmacy and Pharmaceutical Sciences, 2School of Medicine, University of Colorado, Aurora, CO, USA 1
Objective: The purpose of this paper is to serve as a review for primary care providers on the bedside methods for estimating glomerular filtration rate (GFR) for dosing and chronic kidney disease (CKD) staging and to discuss how automated health information technologies (HIT) can enhance clinical documentation of staging and reduce medication errors in patients with CKD. Methods: A nonsystematic search of PubMed (through March 2013) was conducted to determine the optimal approach to estimate GFR for dosing and CKD staging and to identify examples of how automated HITs can improve health outcomes in patients with CKD. Papers known to the authors were included, as were scientific statements. Articles were chosen based on the judgment of the authors. Results: Drug-dosing decisions should be based on the method used in the published studies and package labeling that have been determined to be safe, which is most often the Cockcroft– Gault formula unadjusted for body weight. Although Modification of Diet in Renal Disease is more commonly used in practice for staging, the CKD–Epidemiology Collaboration (CKD–EPI) equation is the most accurate formula for estimating the CKD staging, especially at higher GFR values. Automated HITs offer a solution to the complexity of determining which equation to use for a given clinical scenario. HITs can educate providers on which formula to use and how to apply the formula in a given clinical situation, ultimately improving appropriate medication and medical management in CKD patients. Conclusion: Appropriate estimation of GFR is key to optimal health outcomes. HITs assist clinicians in both choosing the most appropriate GFR estimation formula and in applying the results of the GFR estimation in practice. Key limitations of the recommendations in this paper are the available evidence. Further studies are needed to better understand the best method for estimating GFR. Keywords: laboratory automation, glomerular filtration rate, medications, dose adjustment
Correspondence: Katy E Trinkley Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA Tel +1 303 724 6563 Fax +1 303 724 0979 Email [email protected]
Accurate estimation of kidney function is essential for appropriate medical and medication management and to prevent medication errors. Common examples of medication errors in patients with kidney disease include: inappropriate drug dose adjustments for degree of kidney function; therapeutic omissions of renal protective agents; failure to monitor and adjust for chronic kidney disease (CKD) progression and subsequent changes to drug regimens; and avoidance of nephrotoxins. Approximately 23% of medications that need to be dose- or regimen-modified in CKD are not appropriately adjusted.1 Additionally, 13% of the medications given to persons with CKD are contraindicated.2 Failure to appropriately dose adjust medications for declines in kidney function significantly increases the risk of mortality by 40% and can significantly increase health 211
submit your manuscript | www.dovepress.com
International Journal of General Medicine 2014:7 211–218
Dovepress
© 2014 Trinkley et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php
http://dx.doi.org/10.2147/IJGM.S61795
Trinkley et al
care utilization costs.2 For example, inappropriate dose adjustment of antithrombotics can result in minor or major bleeding events, which cost more than US$600 and US$1,500, respectively.3 The progressive nature of kidney dysfunction warrants close vigilance to ensure that as the function declines, medications are appropriately managed. An estimated 59% of patients with CKD are prescribed drugs that are known to be cardioprotective and/ or renoprotective.4 As even mild CKD is an independent predictor of significant cardiovascular morbidity and allcause mortality, the timely addition of cardioprotective and renoprotective agents is imperative. There is extensive evidence that demonstrates slowing the decline of kidney function 5–10 and improvement in cardiovascular outcomes11–12 with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Preventable medication errors in patients with CKD are concerning because they not only contribute to the nearly $3 trillion spent annually on health care expenditures in the US, but they also lead to suboptimal health and quality-of-life outcomes. The reason for these medication errors is multifactorial and includes: inappropriate estimation of kidney function; the progressive nature of kidney function decline in CKD; lack of provider time to estimate kidney function; inadequate education on how to interpret and use the various measures for estimating kidney function; and confusion regarding the use of one equation for staging kidney disease and another equation for dosing drugs. Measuring kidney function requires measurement of inulin, iothalamate, or iohexol clearance by analytical techniques and equations not readily available to clinicians.13 Estimation of the glomerular filtration rate (GFR) is performed clinically through the use of an equation that can be performed at the bedside. As GFR declines, some medications require adjustments at specific GFR thresholds, and some medications do not require dose- or regimenadjustments at all. Examples of common drugs that primary care clinicians encounter that require dose- and regimenadjustments in CKD are presented in Table 1. Instead of using GFR, providers often inappropriately rely on serum creatinine (SCr) measurement alone to determine kidney function. SCr provides limited information, as there is significant variability between the measured SCr and GFR between patients. Furthermore, while declines in GFR and kidney function are in the same direction, SCr is reciprocal to kidney function with increasing SCr representing a decline in function. However, due to the busy practices of primary care clinicians, kidney function
Table 1 Commonly used drugs that require renal dose adjustments or are contraindicated at variable GFR thresholdsa Medications requiring dose adjustments Acyclovir Allopurinol Amoxicillin Amoxicillin/clavulanate Ciprofloxacin Dabigatran Enoxaparin Famotidine Fluconazole Gabapentin Gemifloxacin Glimepiride Levetiracetam Levofloxacin Memantine Metformin Metronidazole Penicillin g Phenazopyridine Piperacillin/tazobactam Pregabalin Ranitidine Rivaroxaban Sitagliptin Sulfamethoxazole/trimethoprim Tenofovir Tramadol Varenicline Zoledronic acid Contraindicated medications Eplerenone Exenatide Glyburide Liraglutide Nitrofurantoin Nonsteroidal anti-inflammatory drugs Probenecid Spironolactone Tramadol ER Notes: aThese medications do not require dose adjustments and are not contraindicated for all persons with CKD. Each medication requires either a dose adjustment or is contraindicated as a unique GFR value. Abbreviations: GFR, glomerular filtration rate; CKD, chronic kidney disease; ER, extended release.
is often mentally estimated via the SCr level versus the calculation of a GFR. A recent study of 19 clinicians found that 79% rely on both GFR and SCr measurements when the GFR estimation is automatically reported by the laboratory; however, 100% rely solely on SCr as an indicator of kidney function when GFR is not automatically reported by the laboratory.14 Some of the many factors that influence SCr include sex, age, racerelated differences in muscle mass, exercise, malnutrition, diurnal variation, cirrhosis, and drugs. Even when SCr is
International Journal of General Medicine 2014:7
Automating kidney function
within the normal range, a person can have CKD. Relying on SCr alone results in the underdiagnosis of CKD, given that 25% of SCr measurements within normal limits translates to a GFR that is diagnostic for CKD.15 For example, based on SCr alone, a patient with an SCr of 0.9 mg/dL would not be diagnosed with CKD; however, further assessment via GFR indicates stage 3 CKD. Table 2 summarizes the typical GFR values and measurement methods for CKD staging and drug dosing. Many formulas have been developed to estimate GFR, and most rely on SCr measurements. In general, the GFR e stimating equations have niches in clinical practice; however, the many formulas that can be used to estimate GFR make it challenging for providers to appropriately identify the ideal formula for a given situation. Further complicating the GFR estimation issue, laboratories, or health information technology (HIT) services may not automate GFR reporting, may use an incorrect formula, or may use a formula that has not been identified for the clinician. The purpose of this manuscript is to serve as a review for primary care providers on the bedside methods for estimating GFR for dosing and CKD staging and to discuss how HIT can be used to automate the reporting process to enhance clinical documentation of staging and to reduce medication errors in patients with kidney disease.
Methods A nonsystematic search of PubMed (through March 2013) was conducted to determine the optimal approach to estimate GFR for dosing and CKD staging and to identify examples of how automated HITs can improve health outcomes in patients with CKD. Papers known to the authors were included, as were scientific statements. Articles were chosen based on the judgment of the authors. Inherent in
the design of nonsystematic reviews is author bias in article selection.
Using appropriate GFR estimation formula Common equations for estimating GFR include: the Modification of Diet in Renal Disease (MDRD);16 the Cockcroft–Gault (CG);17 and the Chronic Kidney Disease Epidemiology Collaboration (CKD–EPI).18 Although each equation has its unique niche in practice and its own set of limitations, central to all of these equations are the incorporation of corrections for age, race, weight, sex, and other factors in addition to SCr. Body surface area (BSA) is incorporated into some equations with the thought that GFR is proportional to kidney size, which is proportional to BSA. The CG or estimated creatinine clearance equation was the first of these three equations developed; it was determined by studying predominately hospitalized adult male patients.16 The CG equation attempts to control for age, sex, and weight; it is reported as mL/min.16 The CG equation is often the standard equation used for calculating drug doses, since historical drug labeling contains dosing information in reference to CG. However, the CG equation underestimates GFR in the elderly and is less accurate in patients with normal kidney function. The MDRD equation (abbreviated as "eGFR") was the second equation developed. It was developed by studying nonhospitalized persons with CKD.17 MDRD normalizes for race, BSA, age, and sex; it is reported as mL/minute/1.73 m2. MDRD is predominantly used for CKD staging in clinical practice. Several limitations of the MDRD equation have been documented. Since the MDRD equation was derived from persons with CKD, it is imprecise and underestimates GFR at higher values, yielding false positives for CKD. Furthermore,
Table 2 Methods for assessing kidney function by GFR and staging CKD Formula for assessing GFR
Interpretation by GFRa
MDRD16 CKD-EPI17
Staging CKD Staging CKD
Cockcroft–Gault (CG)18
Dose adjustment
CKD stage 1: GFR .90 mL/minute/1.73 m2 CKD stage 2: GFR 60–89 mL/minute/1.73 m2 CKD stage 3: GFR 30–59 mL/minute/1.73 m2 CKD stage 4: GFR 15–29 mL/minute/1.73 m2 CKD stage 5: GFR ,15 mL/minute/1.73 m2 Degree of dose adjustment varies by drug and CG-estimated GFR Normal renal function: .80 mL/minute Mild impairment: 50–80 mL/minute Moderate impairment: 30–50 mL/minute Severe impairment: ,30 mL/minute End stage renal disease: dialysis required5
Note: aCKD staging also includes evidence of kidney damage, which is not included in this table. Abbreviations: GFR, glomerular filtration rate; CKD, chronic kidney disease; MDRD, Modification of Diet in Renal Disease.
the MDRD equation has not been evaluated in: persons ,18 years of age; persons .75 years of age; pregnant women; extremes in body size; or in races other than Caucasian and African American.17 CKD–EPI, the newest equation, was determined with a cross-sectional analysis of a sample of persons who were representative of the US population.18 The CKD–EPI normalizes for race, BSA, age, and sex and is reported as mL/min/1.73 m2. In clinical practice, CKD–EPI is most commonly used for CKD staging. Although the CKD–EPI is a more accurate estimation of GFR than MDRD at all values and more representative of the US population, the CKD–EPI sample population included limited elderly and minority populations.18 To compare the MDRD or CKD–EPI values with CG, it is customary to multiply or to adjust the MDRD and CKD–EPI values (mL/minute/1.73 m2) by the patient's BSA to have all equation results in the same units of measurement (mL/minute). Table 3 describes the MDRD, CG, and CKD–EPI formulas and the applicable factors in each equation. Each equation incorporates SCr. However, in recent years, all SCr measurements in the US became standardized to prevent variations due to the assay or instrument used, which can impact the accuracy of the equations if not taken into account. Of the commonly used GFR estimation formulas, the CKD–EPI was actually developed using the standardized SCr measurements, while the MDRD equation was reexpressed for use with the standardized SCr measurements. Unfortunately, CG cannot be re-expressed, because the original blood samples used to develop the CG equation are no longer available. As a result of not being able to re-express the CG equation for standardized SCr, CG-estimated GFR results are 5%–10% higher using the standardized SCr measurements when compared to nonstandardized SCr.19 Relying on CG-estimated GFR based on standardized SCr measurements decreases the accuracy of this GFR estimation and could lead to unintended consequences, including insufficient
dose adjustments for kidney function. However, the clinical significance of this theoretical issue requires study.
Estimating GFR for medication adjustment Appropriately adjusting a medication dose or regimen for kidney function ensures the medication reaches safe and effective drug concentrations for the targeted indication and ultimately achieves optimal clinical outcomes. Therefore, appropriate drug dose- and regimen-adjustments are imperative to the provision of quality health care. However, the use of several estimating equations for kidney function assessment can be confusing for clinicians who need to discern which equation should be used for dosing medications. The CG equation is the most often used formula for doseadjusting medications based on kidney function and is endorsed by the National Kidney Foundation (NKF)20 and the American College of Cardiology (ACC)/American Heart Association (AHA).21 However, the NKF also recommends that – in addition to CG – the MDRD unadjusted for BSA (not multiplying MDRD by the patient's BSA) is a reasonable method for adjusting medication doses based on kidney function.20 It is important to discriminate that while the NKF and the ACC/AHA have more leverage regarding clinical practice issues, the US Food and Drug Administration (FDA) has less impact on clinical practice but extensive oversight on the pharmaceutical industry and drug development process. Despite some inconsistency in the national recommendations as to which formula to use for drug dose and regimen adjustments in CKD, the 1998 FDA Guidance for Industry document recommends using CG for drug l abeling recommendations.22 However, a 2010 updated draft of the 1998 FDA document incorporates reporting both CG and MDRD GFR estimates in the literature of new products,23 but the draft has not yet been finalized. It is important to understand that most recommendations in the drug product
Table 3 Common GFR estimation formulas Cockcroft–Gault (eCrCl)16 MDRD (eGFR)17 CKD–EPI18
([140 - age in years] × ideal body weight in kg)(× 0.85 if female) ([SCr in mg/dL] × 72) 170 × (SCr in mg/day)-0.999 × (age in years)0.318 × (0.762 if female) × (1.18 if African American) 166 × ([SCr in mg/dL]/0.7)-0.329 × (0.993)(age in years) African American, female, SCr #0.7 166 × ([SCr in mg/dL]/0.7)-1.209 × (0.993)(age in years) African American, female, SCr .0.7 163 × ([SCr in mg/dL]/0.9)-0.411 × (0.993)(age in years) African American, male, SCr #0.9 163 × ([SCr in mg/dL]/0.9)-1.209 × (0.993)(age in years) African American, male, SCr .0.9 144 × ([SCr in mg/dL]/0.7)-0.329 × (0.993)(age in years) White or other, female, SCr #0.7 144 × ([SCr in mg/dL]/0.7)-01.209 × (0.993)(age in years) White or other, female, SCr .0.7 141 × ([SCr in mg/dL]/0.7)-0.411 × (0.993)(age in years) White or other, female, SCr #0.9 141 × ([SCr in mg/dL]/0.7)-1.209 × (0.993)(age in years) White or other, female, SCr .0.9
Abbreviations: eCrCl, Cockcroft–Gault equation; GFR, glomerular filtration rate; eGFR, glomerular filtration rate; CKD–EPI, CKD–Epidemiology Collaboration equation; SCr, serum creatinine; CKD, chronic kidney disease; MDRD, Modification of Diet in Renal Disease.
literature are based on studies using the CG equation,22 and many of these recommendations are based on CG before the implementation of standardized SCr. Because drug labeling recommendations for safe and effective dose and regimen adjustments are based on the CG equation, it is customary to use CG for drug-dosing decisions. Although the current FDA Guidance for Industry recommends the use of CG when designing studies, it does not provide guidance on whether CG should be adjusted for body weight. As a consequence, drug labels usually do not indicate information about whether GFR was adjusted for weight. A systematic review of drug labels approved from 1998–2007 identified 44 labels that recommended dose adjustments based on kidney function; however, only eleven specified that CG should be used and adjusting for body weight was not specified in six of the eleven labels.24 The original CG formula, published in 1976, used the patient's actual versus adjusted or ideal body weight. Later applications of CG most often adjust for ideal body weight, given the higher body weights of today versus those in 1976. Interestingly, CG adjusted for ideal body weight is less accurate at estimating GFR than unadjusted weight.5,25–28 CG accurately estimates GFR 66% of the time when adjusted for ideal body weight, compared to 73% of the time when using actual body weight.37 When using CG for dosing decisions, the decision to adjust for body weight should be based on the method used in the studies that determined the dose adjustment recommendations. Several studies have compared MDRD with CG for dosing medications. One study evaluated 15 FDA-approved drugs and determined the actual GFR for 5,000 subjects. The study found that MDRD adjusted for BSA (reported as mL/minute) correctly identified dose reductions 88% of the time, while the CG equation accurately calculated the renal dose adjustments 85% and 82% of the time, using actual and ideal body weights, respectively.27 In contrast, data from the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) compared CG using ideal body weight with MDRD adjusted for BSA for dosing dose-adjusting antithrombotics for kidney function.29 This study found that CG led to 43% more cases of antithrombotic dose adjustments than MDRD (30,386 versus 17,329 dose adjustments with CG and MDRD, respectively). Major bleeding occurred in 17.8% and 21.8% of patients who received excessive antithrombotic doses as determined by the CG and MDRD formula, respectively. Minor bleeding events were not reported. Given the narrow
therapeutic index of the antithrombotics, the risks of bleeding and increased hospital stays are elevated if the dose is not appropriately adjusted for kidney function. Despite these risks, as well as drug-product labeling and national recommendations to dose adjust antithrombotics based on CG,21 87% of hospitals do not follow the drug-labeling recommendations for renal dose adjustments.30 Another study evaluated dose adjustments in kidney dysfunction for digoxin, another narrow therapeutic index drug. Similar to the results of CRUSADE, this study found that the CG unadjusted for body weight led to 32% more dose reductions of digoxin than MDRD unadjusted for BSA.31 Although there are several studies comparing MDRD to CG for drug doses and adverse events, no clinical trials have compared the clinical outcomes of dose and regimen adjustments for patients with CKD on the basis of CG adjusted for ideal body weight compared to unadjusted MDRD. Until more information is available from GFR calculating methods on a comprehensive list of drugs and/or information is available that demonstrates the clinical outcomes associated with these dosing methods, clinicians should dose adjust medications for kidney function based on the methods used in the published studies and package labeling that have been determined to be safe.
Estimating GFR for staging CKD Correctly diagnosing and staging CKD is imperative to add appropriate nephroprotective agents and nondrug management to the regimen, to improve vigilance in avoiding nephrotoxic agents, and to screen for and initiate therapies for the common complications of CKD, such as anemia, derangements in electrolytes, and mineral metabolism disorders. The two most common equations for staging CKD are the MDRD and the CKD–EPI. There is controversy over whether the MDRD or the CKD–EPI is the most appropriate method for estimating GFR for CKD diagnosis, which may stem from a limited knowledge of the new CKD–EPI formula and of the evidence supporting its superiority to MDRD. While MDRD is commonly used for estimating GFR, CKD–EPI is gaining momentum as the optimal GFR estimating equation. In fact, the NKF now recognizes the CKD–EPI formula as more accurate than the MDRD equation, based on head-to-head comparisons of the two formulas.20 The CKD–EPI equation was specifically developed to overcome the limitations of the MDRD equation. As a result of differences in study populations used to define the GFR estimating equations, the CKD–EPI equation is as accurate as the MDRD at GFR ,60 mL/minute and more
accurate than MDRD at GFR .60 mL/minute. The superior accuracy of CKD–EPI across the ranges of GFR has led to a lower estimated prevalence of CKD than that reported with the MDRD (11.5% versus 13.1%). Additionally, more reclassifications of CKD staging to less-severe CKD stages have been reported for patients in the 30–59 mL/minute/1.73 m2 range of GFR (stage 3 CKD). For example, patients who were originally classified as stage 3 CKD with MDRD may be reclassified as stage 2 by the CKD–EPI equation. When comparing the discordance of CKD staging between MDRD and CKD–EPI, classification by CKD–EPI was correct 65% of the time, compared to MDRD, which was correct only 34% of the time (P,0.001).18 Relying on the MDRD to screen for CKD decreases the sensitivity and specificity of identifying persons who are near the GFR threshold of 60 mL/minute/1.73 m2 (stage 3 CKD) and decreases the likelihood that CKD staging is accurate. Hence, CKD–EPI is preferred for identifying patients with CKD and for staging the disease. The risk of underestimation of kidney function with MDRD is highest when the GFR is .30 mL/minute/1.73 m2. Therefore, it is especially important to calculate the CKD–EPI for these persons. Using CKD–EPI for diagnosis and staging may more accurately be recommended when the addition of appropriate prophylactic drugs or avoidance of certain nephrotoxic drugs should occur.
Automation of GFR and HIT When GFR estimation is automated, the GFR is reported any time that SCr is ordered by clinicians. Although not all laboratories or HIT services automate GFR estimation, there are many benefits to automating GFR estimation. Automation of GFR estimation improves: detection of CKD; appropriate referral to nephrology services; provider reliance on GFR versus SCr alone; and, ultimately, clinical outcomes. Implementation of automated GFR estimation significantly improves identification of CKD by nearly 50%. It also can result in blood pressure goal attainment and the addition of nephroprotective angiotensin-converting enzyme inhibitors or angiotensin receptor blockers to therapy. While the improvements in blood pressure and the addition of nephroprotective agents were statistically significant, the relative percent improvements in achieving these endpoints were found to be modest at 3% and 4.6%, respectively. This may suggest that despite incorporation of HIT services, widespread outcome improvements are not automatic due to patient-related factors, including compliance. Automation can also improve referrals to nephrology by 40%.32,33 Most importantly, it has been reported
that automation of GFR estimation assists in decreasing the decline in GFR from 3.69 mL/minute/1.73 m2 during the 9 months prior to automation to 0.32 mL/minute/1.73 m2 during the 12 months postimplementation (P,0.001).34 The reduction in kidney function decline could have huge benefits for health care costs. Because of the many benefits of automated GFR estimation, automation is becoming standard of practice. Currently, most laboratories and HIT services that report automated GFR use the MDRD equation. It is important to realize that MDRD reporting may be underestimating the actual GFR. There are many GFR estimating equations and as automation becomes the standard, the automation process needs to clearly identify which GFR formula was coded and reported. Additionally, the variables used in the formula (ideal body weight versus actual body weight) and units of the GFR result (mL/minute versus mL/minute/1.73 m2) need to be clearly identified. Furthermore, it may be useful for automation to include reporting more than one GFR estimation formula, given no one formula is appropriate for all clinical situations. Reporting both CG and either MDRD or CKD–EPI would enhance drugdosing adjustments as well as enable CKD staging. Choosing the appropriate method for determining GFR is challenging, given the multiple formulas, varying patient care situations in which GFR is used and the complexity of determining the method of kidney function estimation used in the original drug studies or recommended by drug labels. Using clinical decision-support tools within an HIT service that automates GFR estimation could serve a dual purpose to educate providers of which formula is most appropriate to use and how to apply the formula in a given clinical situation. Within HIT services, it is possible to automatically report estimated GFR using several equations and highlight when each should be used based on the clinical situation. For example, while ordering or refilling dabigatran for a patient with an estimated GFR of 29 mL/minute, the HIT would be programmed with decision support that would pop-up and educate the provider that the dose of dabigatran needs to be reduced or an alternate anticoagulant initiated, because of the patient's estimated GFR. Such decision-support tools are especially helpful for drugs with narrow therapeutic indexes, such as the new oral anticoagulants (dabigatran, enoxaparin, apixaban) and older injectable antithrombotics (enoxaparin) that require renal dose adjustments to prevent bleeding events. Appropriate dose adjustments for the new oral anticoagulants are especially imperative, because there is currently no reversal agent in the event of excess dose or bleeding. Another such decision-support tool may be a best practice alert that
pops up during an outpatient encounter with a patient who has a CKD–EPI estimated GFR of 58 mL/minute/1.73 m2, and who is not on appropriate renoprotective and cardioprotective agents, such as an angiotensin-converting enzyme inhibitor. This decision-support tool educates the provider at the point of care that the patient should be on certain prophylactic medications, unless there are contraindications. HIT is increasingly being used for automated GFR estimation reporting. However, there are limitations to the automation of GFR reporting, including inaccurate coding of the equations in the HIT, lack of reference to the equation(s) being used, lack of understanding of the reference equation's clinical limitations, and incorrect interpretation and application of the result. Currently, automation of GFR estimation is typically only reported as MDRD adjusted for BSA, despite the feasibility of incorporating automated reporting of CKD–EPI at most institutions. Automated reporting of MDRD instead of CKD–EPI could contribute to an overdiagnosis of CKD.
Conclusion Although there are divergent opinions regarding the best GFR estimation equation to use for the staging of CKD and the dosing of medications, most current data support CKD–EPI as the most accurate method for diagnosis and staging of CKD and CG for drug-dosing decisions. Historically, drug labeling recommendations are based on the CG equation. However, the FDA is considering recommending that both CG and MDRD be incorporated into the drug label.23 Despite some current confusion regarding GFR estimating equations for CKD staging as opposed to drug dosing, one central element that clinicians should take from this review is that SCr measurements alone should never be used for estimating kidney function. Clinicians need to ensure that HIT services at their institutions convey the necessary level of detail regarding the equation used to report estimated GFR (MDRD versus CKD–EPI versus CG) and the education surrounding the limitations of the estimating equation used. Appropriate estimation of GFR through HIT can improve health outcomes, improve patient safety, and decrease unnecessary health care expenditures.
Disclosure The authors report no conflicts of interest in this work.
1. Frölich T, Zorina O, Fontana AO, Kullak-Ublick GA, Vollenweider A, Russmann S. Evaluation of medication safety in the discharge medication of 509 surgical inpatients using electronic prescription support software and an extended operational interaction classification. Eur J Clin Pharmacol. 2011;67(12):1273–1282.
Automating kidney function 2. Breton G, Froissart M, Janus N, et al. Inappropriate drug use and m ortality in community-dwelling elderly with impaired kidney function – the Three-City population-based study. Nephrol Dial Transplant. 2011;26(9):2852–2859. 3. Gould MK, Dembitzer AD, Sanders GD, Garber AM. Low-molecularweight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis: A cost-effectiveness analysis. Ann Int Med. 1999;130(10):789–799. 4. Wyatt C, Konduri V, Eng J, Rohatgi R. Reporting of estimated GFR in the primary care clinic. Am J Kidney Dis. 2007;49(5):634–641. 5. Kshirsagar AV, Joy MS, Hogan SL, Falk RJ, Colindres RE. Effect of ACE inhibitors in diabetic and nondiabetic chronic renal disease: a systematic overview of randomized placebo-controlled trials. Am J Kidney Dis. 2000;35(4):695–707. 6. Brenner BM, Cooper ME, de Zeeuw D, et al; RENAAL Study Investigators. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001;345(12):861–869. 7. Hou FF, Zhang X, Zhang GH, et al. Efficacy and safety of benazepril for advanced chronic renal insufficiency. N Engl J Med. 2006;354(2): 131–140. 8. Ruggenenti P, Perna A, Gherardi G, Gaspari F, Benini R, Remuzzi G. Renal function and requirement for dialysis in chronic nephropathy patients on long-term ramipril: REIN follow-up trial. Gruppo Italiano di Studi Epidemiologici in Nefrologia (GISEN). Ramipril Efficacy in Nephropathy. Lancet. 1998;352(9136):1252–1256. 9. Maschio G, Alberti D, Janin G, et al; The Angiotensin-ConvertingEnzyme Inhibition in Progressive Renal Insufficiency Study Group. Effect of the angiotensin-converting-enzyme inhibitor benazepril on progression of chronic renal insuff iciency. N Engl J Med. 1996;334(15):939–945. 10. Ruggenenti P, Perna A, Gherardi G, et al. Renoprotective properties of ACE-inhibitors in non-diabetic nephropathies with non-nephrotic proteinuria. Lancet. 1999;345(9176):359–364. 11. de Zeeuw D, Remuzzi G, Parving HH, et al. Albuminuria, a therapeutic target for cardiovascular protection in type 2 diabetic patients with nephropathy. Circulation. 2004;110(8):921–927. 12. Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G; The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med. 2000;342(3):145–153. 13. Stevens LA, Levey AS. Measured GFR as a confirmatory test for estimated GFR. J Am Soc Nephrol. 2009;20(11):2305–2313. 14. Smith DH, Schneider J, Thorp ML, et al. Clinician's use of automated reports of estimated glomerular filtration rate: a qualitative study. BMC Nephrol. 2012;13:154. 15. Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. Am J Kidney Dis. 2003;41(1):1–12. 16. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16(1):31–41. 17. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D, et al; Modification of Diet in Renal Disease Study Group. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Ann Intern Med. 1999;130(6): 461–470. 18. Levey AS, Stevens LA, Schmid CH, et al; CKD–PI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to estimate glomerular filtration rate. Ann of Intern Med. 2009;150(9):604–612. 19. Miller WG, Myers GL, Ashwood ER, et al. Creatinine measurement: state of the art in accuracy and interlaboratory harmonization. Arch Pathol Lab Med. 2005;129(3):297–304. 20. National Kidney Foundation. Frequently Asked Questions About GFR Estimates. New York: National Kidney Foundation; 2011. Available from: http://www.kidney.org/professionals/kls/pdf/12-10-4004_KBB_ FAQs_AboutGFR-1.pdf. Accessed April 12, 2013.
Trinkley et al 21. Braunwald E, Antman EM, Beasley JW, et al; American College of Cardiology; American Heart Association. Committee on the Management of Patients With Unstable Angina. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction – summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol. 2002;40(7):1366–1374. 22. US Department of Health and Human Services. Guidance for Industry: Pharmacokinetics in Patients with Impaired Renal Function – Study Design, Data Analysis, and Impact on Dosing and Labeling. Silver Spring, MD: US Food and Drug Administration; 1998. Available from: http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatory Information/Guidances/ucm072127.pdf. Accessed February 2, 2013. 23. US Department of Health and Human Services. Guidance for Industry: Pharmacokinetics in Patients with Impaired Renal Function – Study Design, Data Analysis, and Impact on Dosing and Labeling. Silver Spring, MD: US Food and Drug Administration; 2010. Available from: http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulat oryInformation/Guidances/UCM204959.pdf. Accessed February 24, 2013. 24. Dowling TC, Matzke GR, Murphy JE, Burckart GJ. Evaluation of renal drug dosing: prescribing information and clinical pharmacist approaches. Pharmacotherapy. 2010;30(8):776–786. 25. Gonwa TA, Jennings L, Mai ML, Stark PC, Levey AS, Klintmalm GB. Estimation of glomerular filtration rates before and after orthotopic liver transplantation: evaluation of current equations. Liver Transpl. 2004;10(2):301–309. 26. O'Meara E, Chong KS, Gardner RS, Jardine AG, Neilly JB, McDonagh TA. The Modification of Diet in Renal Disease (MDRD) equations provide valid estimations of glomerular filtration rates in patients with advanced heart failure. Eur J Heart Fail. 2006;8(1):63–67.
27. Stevens LA, Nolin TD, Richardson MM, et al; Chronic Kidney Disease Epidemiology Collaboration. Comparison of drug dosing recommendations based on measured GFR and kidney function estimating equations. Am J Kidney Dis. 2009;54(1):33–42. 28. Park EJ, Pai MP, Dong T, et al. The influence of body size descriptors on the estimation of kidney function in normal weight, overweight, obese, and morbidly obese adults. Ann Pharmacother. 2012;46(3): 317–328. 29. Melloni C, Peterson ED, Chen AY, et al. Cockcroft–Gault versus modification of diet in renal disease: importance of glomerular filtration rate formula for classification of chronic kidney disease in patients with non-ST-segment elevation acute coronary syndromes. J Am Coll Cardiol. 2008;51(10):991–996. 30. Barras MA, Kirkpatrick CM, Green B. Current dosing of low-molecularweight heparins does not reflect licensed product labels: an international survey. Br J Clin Pharmacol. 2010;69(5):520–528. 31. Gill J, Malyuk R, Djurdjev O, Levin A. Use of GFR equations to adjust drug doses in an elderly multi-ethnic group – a cautionary tale. Nephrol Dial Transplant. 2007;22(10):2894–2899. 32. Noble E, Johnson DW, Gray N, et al. The impact of automated eGFR reporting and education on nephrology service referrals. Nephrol Dial Transplant. 2008;23(12):3845–3850. 33. Richards N, Harris K, Whitfield M, et al. The impact of population-based identification of chronic kidney disease using estimated glomerular filtration rate (eGFR) reporting. Nephrol Dial Transplant. 2008;23(2): 556–561. 34. Richards N, Harris K, Whitfield M, et al. Primary care-based disease management of chronic kidney disease (CKD), based on estimated glomerular filtration rate (eGFR) reporting, improves patient outcomes. Nephrol Dial Transplant. 2008;23(2):549–555.
Publish your work in this journal The International Journal of General Medicine is an international, peer-reviewed open-access journal that focuses on general and internal medicine, pathogenesis, epidemiology, diagnosis, monitoring and treatment protocols. The journal is characterized by the rapid reporting of reviews, original research and clinical studies across all disease areas.
A key focus is the elucidation of disease processes and management protocols resulting in improved outcomes for the patient.The manuscript management system is completely online and includes a very quick and fair peer-review system. Visit http://www.dovepress.com/ testimonials.php to read real quotes from published authors.
Submit your manuscript here: http://www.dovepress.com/international-journal-of-general-medicine-journal
Report "Automating and estimating glomerular filtration ... - Semantic Scholar"


text:
Q: Modifyng a for loop While the code below works great to iterate over an array using a for loop and then printing out column names based on the array values onto an excel sheet, I wanted to know if it was possible to have the code amended such that it would combine and group the array values that have the word "apples" somewhere in the array and just make one excel column name "apples" like the example provided below.
I am unsure as to how to modify the for loop to accomplish this.

The desired result is:

function search_array(arr, str){
  var searchExp = new RegExp(str,"gi");
  return (searchExp.test(arr))?true:false;
}

var temp = ["red apples", "fuji apples", "grannysmith apples", "mcintosh apples", "honeycrisp apples", "gala apples", "oranges", "pears", "bananas"]

var col = 2
for(var i = 0; i < temp.length; i++){

    if (search_array(temp[i], "apples") == true) {

        Sheet.Cells(2,col).Value = "apples"

    }
    else {
        Sheet.Cells(2,col).Value = temp[i]
    }

++col
}

A: You could just filter the array first, add the word you're looking for, and then iterate
var temp = ["red apples", "fuji apples", "grannysmith apples", "mcintosh apples", "honeycrisp apples", "gala apples", "oranges", "pears", "bananas"]
var col  = 2;
var word = 'apples';
var has  = false;

temp = temp.filter(function(item) {
    var i = item.indexOf(word) === -1;
    if (i) has = true;
    return i;
});

if (has) temp.unshift(word);

for(var i = 0; i < temp.length; i++){
    Sheet.Cells(2,col).Value = temp[i]
}

FIDDLE

A: Add a flag to your code inside the loop:
var col = 2,
    foundApples = false,
    hasApplesInString;

for(var i = 0; i < temp.length; i++){
    hasApplesInString = search_array(temp[i], "apples");

    if ( !hasApplesInString || !foundApples ) {
        Sheet.Cells(2,col).Value = temp[i];
        if (hasApplesInString) { foundApples = true };
        col++;
    }
}

A: You can create a new array for the filtered values and push these new values into the cols:
var temp = ["red apples", "fuji apples", "grannysmith apples", "mcintosh apples", "honeycrisp apples", "gala apples", "oranges", "pears", "bananas"]

var temp_filtered = [];

for (var i = 0; i < temp.length; i++) {

    var value = temp[i]

    if (search_array(temp[i], "apples") == true) {

        value = "apples"

    }

    if (temp_filtered.indexOf(value) === -1) {
        temp_filtered.push(value);
    }

}

var col = 2;

for (var j = 0; j < temp_filtered.lenth; j++) {
    Sheet.Cells(2, col).Value = temp_filtered[j];
    ++col;
}

A: if the fruit are always going to be "name space fruit" (fuji apples).
This is how I would do it.
var fruitList = ["red apples", "fuji apples", "grannysmith apples", "mcintosh apples", "honeycrisp apples", "gala apples", "oranges", "pears", "bananas"]

console.log(uniqueFruit(fruitList));

function uniqueFruit(arr) {
  var returnarray = [];
  for (var i = 0; i < arr.length - 1; i++) {//iterate through the fruitList
    var fruit = arr[i].split(' ').reverse();//split each into an array of two words
                                           // ["red","apples"]
                                           // Reverse the order
                                           // ["apples","red"]
    fruit = fruit[0];                      // fruit = "apples"
    if (returnarray.indexOf(fruit) < 0) {  // find apples in returnarray
      returnarray.push(fruit);             // if not there push it into it
    }
  }
  return returnarray;
}

Here is a fiddle https://jsfiddle.net/alex_at_pew/7o7tfrq8/

redpajama_set_name: RedPajamaStackExchange


The United States Academic Decathlon (USAD) is a program that provides high school students an opportunity to experience the challenges of rigorous academic competition through participation in team activities. In addition, the Academic Decathlon involves members of the business/industry as active supporters of a program promoting academic excellence. Long term relationships, developed through joint participation, benefit the students and the community.
The Academic Decathlon program was initiated in California in 1968 by Orange County Academic Decathlon in cooperation with the Orange County Superintendent of Schools. Region contests were held until 1979 when California held the first statewide competition. In 1982, the competition became a national event and the USAD was formed. Texas became a USAD member in 1984 and won the national championship in Los Angeles with a team from J.J.Pearce High School, Richardson Independent School District. Pearce repeated as champions for the next two years. Texas claims 11 national championships.
Region and state contests are held for schools categorized as large, medium and small. Based on a point system, the highest scoring team represents Texas at the national USAD competition. All members of the winning team receive scholarships. Texas provides $150,000 in scholarship money each year. Registration fees and the Texas Education Agency contribute to this scholarship fund.
The Academic Decathlon is designed to include students of three academic levels. Each nine-member team consists of three "A" students, three "B" students, and three "C" students. The Academic Decathlon is the only competition to award "C" student's scholarships!


text:
North SeaTac Park
North SeaTac Park is a 205-acre piece of land located between S. 128th Street on the north, S. 144th Street on the south, Des Moines Memorial Drive S. on the west, and approximately 24th Avenue S on the east. As part of a larger area of nearly 220 acres, the park is located within the City of SeaTac, on land owned by the Port of Seattle and leased to the City of SeaTac as a buffer for airport operations, including park uses. The City is responsible for managing the full property, including the Highline Botanical Garden, SeaTac Community Center, the acreage referred to as North SeaTac Park, and other sites. Much of the property is currently used for recreation activities including walking, biking, and picnicking. City-licensed activities on the property also feature sports fields, a BMX track, mountain biking, disc golf course, bicycle pump track, and a radio control race car track.
The land was formerly a neighborhood north of the airport and developed prior to the opening of Seattle-Tacoma International Airport (SEA) in 1947. In 1974, the Port, with grant funding from the Federal Aviation Administration (FAA), began purchasing the land for noise mitigation purposes. In 1994, the City of SeaTac entered into a lease agreement with Port to manage the open space and developed much the area into a park and recreational facilities. As part of a later amendment, 55 acres of the 205-acre parcel was set aside for future development to meet airport needs.
Future of the park
The City's lease with the Port ends in 2070. There are no current proposals by the Port to develop property in North SeaTac Park.
The Port and City of SeaTac are conducting discussions regarding the future of the park property. The City of SeaTac and Port of Seattle are committed to finding solutions together to address the long-term health and wellness of the park. In August 2022, Port of Seattle Commission President Ryan Calkins and City of SeaTac Mayor Jake Simpson issued this joint statement:
"For the past several weeks, representatives from the Port of Seattle Commission and the City of SeaTac have met to discuss our shared vision for the future of North SeaTac Park. As leaders of the Joint Advisory Committee, a partnership between the Port of Seattle and the City of SeaTac, we are in complete agreement that we need to work together to figure out a plan for the long-term health and wellness of the park that the Port of Seattle leases to the City of SeaTac. Parks and green spaces matter to our community's quality of life. We share each other's commitment to protecting parks and green spaces and echo each other's commitment to finding solutions together."
Removal from SAMP review
In 2021, Port staff submitted the draft federal environmental assessment (EA) for the Sustainable Airport Master Plan (SAMP) to the FAA for its review. The EA's screening of alternatives included the proposed surface parking lot in North SeaTac Park (project name: L06) and considered alternate ways to meet future employee parking needs.  In that draft document set, Port environmental staff made the recommendation that the L06 project be removed from further consideration and that different alternatives be explored.
The FAA concurred with our analysis and issued a notification that L06 is removed from further consideration.
Port staff made this recommendation based on:
environmental concerns identified in public comments submitted during the scoping process in 2018-2019;
staff's determination that L06 was not the best path forward from an environmental perspective; and
the availability of an environmentally preferable alternative identified when preparing the draft federal EA
L06 was one of more than 30 projects being studied during the environmental review for the SAMP. The remainder of the draft EA is still subject to FAA review and public comment
Please read this statement for further details.
Port of Seattle Plans to Study North SeaTac Park
North SeaTac Park 55-Acre Parcel Inventory
Joint statement on the future of North SeaTac Park
Related to North SeaTac Park
Joint Statement on North SeaTac Park
The following statement is attributed to Port of Seattle Commission President Ryan Calkins and City of SeaTac Mayor Jake Simpson. "For the past several weeks, representatives from the P...
Editor's Note: The Port completed and published the Inventory of North SeaTac Park on June 17, 2022. The Port of Seattle will conduct an inventory of the environmental, community, and recreational ...
Project in North SeaTac Park Removed from SAMP
Early this year, Port staff submitted the draft federal environmental assessment (EA) for the Sustainable Airport Master Plan (SAMP) to the FAA for its review. The EA's screening of alternatives i...
Duwamish Valley Port Community Action Team (PCAT)
StART 2021 Meeting Materials
Highline Forum Meeting Materials Archive
Port Public-Facing Biometrics Policies
Terminal 91 Neighbors Advisory Committee
Highline Forum
Duwamish Valley Community Equity Program


text:
Bobby Feaster Joins TPH-St. Louis Team
May 28, 2020/TPH/Comments Off on Bobby Feaster Joins TPH-St. Louis Team
TPH is pleased to announce that Bobby Feaster has joined the TPH-St. Louis team as a Player Development Coach / Mentor. Feaster brings a dynamic of hockey administrative, instruction and operations-related experience to the position.
"I am extremely excited to add Bobby Feaster to the TPH-St. Louis staff." said Philip McRae, TPH-St.Louis Director of Hockey-Operations. "Bobby has experience on the operations and analytical side of the game at every high level, from Division 1 college hockey, to the American Hockey league, as well as the National Hockey League. Bobby has a wealth of experience where I do not. I believe our combined knowledge on all sides of the game gives us the ability to not only run the program to its full potential, but more importantly, allow us to make the greatest positive impact on each student-hockey player that comes through the CoE. I am excited to get Bobby to St. Louis, up to speed, and get to work with him."
A native of Hershey, PA, Feaster spent the 2019-2020 season as the Team Services Coordinator for the Manitoba Moose of the AHL. In his role with the Moose, who are the AHL affiliate of the Winnipeg Jets, Feaster was responsible for many critical behind the scenes functions for the Moose, who many in hockey regard as one of the American Hockey League's model franchises.
Prior to his arrival in Manitoba, Bobby served on the hockey coaching staff at the University of North Dakota in a variety of roles under the direction of Brad Berry as a student manager . While at UND, the 25-year-old graduated, cum laude with a Bachelor's Degree in Business Administration and made the Dean's list three years in a row.
In addition, Feaster has served as an intern for the Columbus Blue Jackets , has won a championship as a youth hockey player in Calgary, Alberta and has grown up around the game his entire life. Bobby's father Jay is a former National Hockey League General Manager, having guided the Tampa Bay Lightning to the Stanley Cup in 2004.
Everyone within the TPH family joins Philip McRae in welcoming Bobby to the team.
← Goal Achieved.
Jenkins Signs with New York →


Ferrochel® Iron Chelate - 120 Vegetarian Capsules - is currently on backorder. You may still purchase now though and we'll ship as soon as more become available.
This amino acid chelated iron has a very high absorption rate.


Of all the embarrassing fiascoes to have taken place on c2c, last Wednesday's Ouija Board Special takes the grand prize. After months of hype that resulted in at least one death (according to Noory), nothing happened. When I say nothing happened I don't mean they got out the Ouija Board and got no result, I mean they didn't even try the Ouija Board. It was obvious to me that Jordan Maxwell was invited on the show to talk Noory out of it, even though I don't believe Noory ever planned to do it. More about that in Grey Matters on Tuesday.
Ian had a smorgasbord of guests last night. After he finished being outraged over Pat Tillman, his first guest was Dennis Cole with a pretty interesting Illinois ghost story. Next was c2c favorite R. Gary Patterson who talked about a new book on the death of Jim Morrison. After that, Todd Standing returned to discuss his efforts to make Bigfoot a protected species. The show finished up with Bigfoot researcher, Autumn Williams. I enjoyed hearing from Williams. Although, I know who she is and have heard her interviewed before it has been a long while.
The week ahead looks quite a bit better than last, at least on paper. John Lear will return to the show on Monday. Tuesday will be a discussion of Hallucinogenic Substances with Dr. Charles Grob and Dr. Marilyn Schiltz. Wednesday Stanton Friedman will debate Michael Shermer. Who knows what surprises may be in store for the weekend? I will make a prediction that at least part of Punnett's show will be a guest discussing the Pat Tillman murder.
Ian Punnet remains the best on C2C and last night proved it. I appreciated his outrage about Tillman and I hope he follows up on it.
With a program like C2C devoted to arcane subjects, it's impossible to shy away from conspiracies, yet Art Bell turned his back on them and Noory fails miserably to explore them.
Looking forward to John Lear again, he's always good.


What are the consequences of incorrectly assessing risk? What does it cost you in lost opportunities and lost business when risk is not well managed? Do you want to be able to understand the general concepts of risks? Do you want to be able to identify a potential future threat to your company? Do you want to have the appropriate skills to manage that risk? How can you reduce surprises while gaining productivity?
This workshop will allow the participants to formulate, analyze, develop and implement strategies for effective risk management. Delegates will gain a detailed understanding of risk management's crucial aspects and how to apply the most up-to-date modeling, forecasting and credit risk management applications.
Senior managers, directors, treasurers, general managers, managing directors, risk managers, auditors, regulators, credit risk analysts, loan portfolio managers, traders & marketers, finance directors, quantitative analysts & financial engineers, management consultants, asset managers and everyone that would like to learn about how risk management fits into the bigger corporate picture.
Be knowledgeable of available approaches and techniques used.
Develop critical thinking with regards to data analysis.
Develop risk management practices in their businesses.
Have all the tools necessary to analyze and control the risk.