text:
Jay's Movie Blog
I see a lot of movies, and have an opinion on most of 'em.
Boston Sci-Fi Film Festival 2020.02: The Dustwalker, Synchronic, Sea Fever
I'm not going to lie - with a marquee that wide, I'm mildly disappointed that someone didn't go for the entire (original) title of Birds of Prey, but as you can see, there's just too much else going on at the Somerville to put all that up.
Like I said when writing up the first day of the fest, the opening weekend in particular was a pretty impressive schedule. When announcements started, my jaw kind of hit the floor when I saw Synchronic on the list. Dig back through my stuff, and you'll see that Moorhead & Benson are favorites, and this festival landing their newest is, let us say, a bit more than I have sometimes expected. I'll happily hit it again if it plays Fantasia in July, especially if the directors do a Q&A, because theirs are generally great. I'm a fan, and when I heard the folks behind me saying it was "pretty good for an indie film", my initial instinct was to ask them to show more respect.
Which is fun; there aren't a lot of movie-related things that get me feeling that sort of passionate fan energy these days.
I did errands between the first movie of the day and Synchronic and had been back and forth on seeing the last one, with both winding up a little closer to the DTV/VOD/streaming fare that the festival has generally featured. They're an interesting contrast, though - The Dustwalker feels like something that aimed higher than its level of resources and wound up a mess, while Sea Fever worked to its budget and more or less worked, even if it maybe doesn't have as many big swings. I'm not sure which approach is better, in general, although it's long been what we as science fiction/fantasy enthusiasts have had to choose from at the movies.
* ¾ (out of four)
Seen 7 February 2020 in Somerville Theatre #3 (Boston Sci-Fi Film Festival, DCP)
The distributors that pick this Australian horror movie up will likely be able to cut a good enough trailer that the people who stream it wonder why it just doesn't click afterwards, even discounting the visual effects that look a few years out of date. Watching it, I noted that it's been a while since I've seen a film struggle so much to string scenes together, leaving one always a bit out of sync. It feels a bit like someone took a prefabricated monsters-from-space movie kit and didn't read the instructions, just tossing the "extra" bits away after gluing the obvious ones together.
It starts with something crashing outside a small town in Western Australia, taking out communications with the outside world and hitting the man who comes to investigate with some sort of red dust. Everyone naturally leans on Joanne Sharp (Jolene Anderson), one of the town's two police officers, to figure out what's going on, even as she and sister Samantha (Stef Dawson), plan to pack up and move to the city. A lot of people have started acting very strange, though, and geologist Angela (Cassandra Magrath) has found some unusual material in a brand new crater.
The audience never gets a look inside that crater (or it was too quick to register with this viewer) which makes one wonder if the production budget was sometimes tighter than anticipated, like there was no money to either render something that could be the melted remains of a spaceship or even commission one from a local sculptor, at least once the visual effects budget was spent on a dust storm and some under-skin motion on the faces of the infected. It doesn't necessarily feel like something director Sandra Sciberras is shooting around, and there are no scenes later where Joanne and Angela refer to anything particularly specific about what they saw, but it's an odd thing to be missing. Add some rough CGI creature effects, and a picture quickly emerges of a movie whose budget was no match for its ambition.
Full review on EFilmCritic
Synchronic
* * * (out of four)
The three previous feature films by the directing team of Aaron Moorehead and Justin Benson have earned them a great reputation in sci-fi/horror circles and been the sort of movies that fans build a festival schedule around, but their particular combination of meticulous construction, genre awareness, and emotional tensions has seemingly conspired to keep them from playing to a larger audience. Synchronic seems like a movie that could go wider; it's smart and witty and occasionally exciting without seeming quite so clearly focused on its own intricacy.
It starts with a couple of visitors to New Orleans having a really bad trip when they try new designer drug "Synchronic", and they're not alone - EMTs Steve Denube (Anthony Mackie) and Dennis Dannelly (Jamie Dornan) are finding themselves responding to calls that defy belief more frequently. Getting stuck with a needle at the scene of an overdose has Steve getting some tests that reveal a brain tumor, something he keeps from Dennis, who has problems of his own when his 18-year-old daughter Brianna (Ally Ioannides) seems to have been at the scene of another overdose and then vanished.
Where things are going, plot-wise, is clear enough that it's fairly easy to forgive the fair amount of shortcuts and coincidences Benson's script employs getting there, although it creates an odd sort of tension: The mechanism they built requires Steve to be empirical in how he approaches his rescue attempt and for the audience to pick up on details even as the situation is generally chaotic. It's ultimately something that the filmmakers manage to make work, and even play into the personalities of the characters: Steve is smart, but sloppy, an armchair scientist at best, so his stumbling and having to guess right without knowing the whole picture is a match for how he deals with his diagnosis and how Dennis approaches his more conventional search and the strain it puts on his marriage. People don't suddenly get super-competent when they've got a mission, and these guys are used to flying by the seat of their pants at their regular job.
Sea Fever
* * ¾ (out of four)
Sea Fever isn't fancy, but it's a rock-solid "danger from the deep" movie which does a good job with a lot of things which aren't necessarily exciting: Working around a limited budget for actually showing the monster, getting the cast to build characters around pretty thin specs and having them work as a bit more than cardboard figures, implying all of the backstory that would explain things. It's impressive craft that nobody in the audience would notice unless filmmaker Neasa Hardiman blew it.
It opens with graduate student Siobhán (Hermione Corfield) in her natural environment - a university laboratory, examining samples under strong lights, ignoring the other faculty and students celebrating something or other behind her. Ah, but a scientist needs experience in the field, so she heads to the docks and the Niamh Cinn Oir, whose married operators Gerard (Dougray Scott) and Freya (Connie Nielsen) supplement what a fishing crew can make by renting spots to researchers. She's impressed by the filtration system designed by engineer Omid (Ardanlan Esmaili) and maybe likes the look of Johnny (Jack Hickey) a bit, though other members of the crew (Olwen Fouéré & Elie Bouakaze) are a bit superstitious about her red hair. Of course, it's hard to argue that her hair is what leads Gerard to steer the boat into restricted waterways, or calls forth the creature(s) that attach themselves to the vessel.
It's not entirely unheard-of to but a character like Siobhán at the center of a monster movie, but it's not usually the way things go; it's usually more entertaining to have her feed information or be an eccentric foil the the person of action leading the fight. Choosing to do so shakes a familiar story up in interesting ways, though; Hardiman takes a lot of beats that you expect to see in the Siobhán/Johnny romance and playing them out in how she and Omid respect each other's technical savvy, for instance. It also reframes a lot of the movie as problem-solving, rather than fighting, which requires a bit less in the way of special effects and gives the audience a little more chance to play along.
Posted by Jason at 3:25 PM
Labels: Australia, Boston Science Fiction Film Festival, horror, independent, Ireland, sci-fi, Somerville, USA
Jason Seaver | Create Your Badge
Places I Hang Out (on- and off-line)
Somerville (and Capitol) Theaters
Coolidge Corner Theatre
The Brattle Theatre
Boston Sci-fi Film Festival
eFilmCritic
Next Week in Tickets: Films playing Boston 28 Febr...
This Week in Tickets: 17 February 2020 - 23 Februa...
The Woman Who Loves Giraffes
The Call of the Wild '20
These Weeks in Tickets: 3 February 2020 - 16 Febru...
Boston Sci-Fi Film Festival 2020.09: Volition, I A...
Boston Sci-Fi Film Festival 2020.08: Dead Dicks
Boston Sci-Fi Film Festival 2020.03: The Long Walk
Enter the Fat Dragon '20
Boston Sci-Fi Film Festival 2020.02: The Dustwalke...
The Man Standing Next
Boston Sci-Fi Film Festival 2020.01: Proxima
Fantasia 2019 Catch-up, Part 2: The Deeper You Di...
Short Stuff: The 2019 Oscar-Nominated Live-Action ...
Next Week in Tickets: Films playing Boston 7 Febru...
This Week in Tickets: 27 January 2020 - 2 February...
Things to Come: The Birth of Sci-Fi Cinema at the ...
Short Stuff: The 2019 Oscar-Nominated Animated Shorts
Short Stuff: The 2019 Oscar-Nominated Documentary ...
Cambridge, Massachusetts, United States
Web Page Counter


text:
The Critical Care Management of Aneurysmal Subarachnoid Hemorrhage
By Vishal N. Patel and Owen B. Samuels
Submitted: November 30th 2011Reviewed: April 30th 2012Published: August 29th 2012
Home > Books > Aneurysm
chapter and author info
Vishal N. Patel
Emory University School of Medicine,Marcus Stroke & NeuroScience Critical Care Center, Grady Memorial Hospital, Atlanta, GA, USA
Owen B. Samuels
Emory University School of Medicine, Division of Neurointensive Care, Emory University Hospital, Neuroscience Critical Care and Stroke Units, Atlanta, GA, USA
*Address all correspondence to:
From the Edited Volume
AneurysmEdited by Yasuo Murai
Edited by Yasuo Murai
Aneurysmal subarachnoid hemorrhage (SAH) is a neurosurgical emergency that results from the rupture of an aneurysm in the subarachnoid space (see figure 1). SAH carries a high mortality rate, estimated at 45%; additionally, a significant amount of patients are left with impaired neurologic function [1]. The critical care management of SAH requires an appreciation of both neurologic and general critical care principles; it is best thought of as a systemic multi-organ disease.
1.1.	Epidemiology. & morbidity
The clinical burden of aneurysmal SAH is immense. Case fatality approaches 50%, and approximately 1 in 8 patients die prior to reaching the hospital [2]. Of those that survive, nearly 50% will have significant functional impairment [3]. Aneurysmal SAH accounts for approximately 85% of all non-traumatic SAH. Approximately 30,000 Americans are affected annually [1]. The incidence of aneurysmal SAH ranges from 6-21/100,000 patient years [4].
1.2. Risk factors
Risk factors for development of aneurysmal SAH can be categorized as modifiable and non-modifiable. Modifiable risk factors include cocaine abuse, hypertension, and cigarette smoking [4]. It is estimated that cigarette use increases the risk of aneurysmal SAH by a factor of 3.7-3.9 [5]. Non-modifiable risk factors include sex, ethnicity, family history, and collagen-vascular diseases. The female:male ratio for aneurysmal SAH is approximately 2:1 [6]. The incidence of aneurysmal SAH is higher amongst people of Finnish and Japanese descent; and the incidence of aneurysmal SAH is almost three times greater in Finland than other parts of the world [4]. The incidence of intracranial aneurysms is higher in patients with collagen vascular diseases, such as Marfan's Syndrome, Ehlor's-Danlos Disease, Neurofibromatosis Type 1, and Autosomal dominant polycystic kidney disease [7].
The arterial blood supply to the brain is located primarily in the subarachnoid space (Panel B). Aneurysm formation occurs in the subarachnoid space (Panel C), which must be surgically accessed to provide definitive treatment of the aneurysm (Panel E).
2. Diagnosis
2.1. Clinical presentation
The classic presentation of a patient with aneurysmal SAH is thunderclap headache, often described as the "worst headache of my life." It is generally abrupt in onset and reaches maximal intensity instantly. However, this classic description is seen in only 50% of patients presenting with aneurysmal SAH [8]. Conversely, in those patients prospectively screened for acute severe headache, only 6-17% were demonstrated to have SAH [9,10]. Common features at presentation can include seizure, loss of consciousness, and nausea and emesis preceding onset of headache [9]. The concept of 'sentinel headache' remains controversial; it is thought to be related to changes in the wall of the aneurysm versus a microbleed. A sentinel headache generally presents as a severe headache lasting greater than an hour, but diagnostic evaluation does not lead to the confirmation of SAH. These patients are at higher risk for early re-bleeding and aneurysmal SAH. The estimated relative odds ratio is 2.5-3.8 increase in early re-bleeding in patients who present initially with a sentinel headache [11].
2.2. Physical examination
Patients with aneurysmal SAH can have a variety of examination findings at presentation. These may range from a headache without focal neurologic deficits to being comatose. Most commonly, patients may have a depressed level of consciousness or confusional state. Cranial nerve palsies are also frequently seen as a direct result of an aneurysm; though cranial nerve 6 palsy may be a sign of elevated intracranial pressure. Focal weakness is also noted in a small percentage of patients. Fundoscopic examination may reveal subhyaloid hemorrhages and papilledema. Clinical correlation with outcome is best defined by the Hunt & Hess grading scale (see Table 1) [12].
2.3. Neuro-imaging
In addition to clinical presentation, the vast majority of SAH is diagnosed with correlating neuro-imaging. Non-contrast Head CT is the preferred modality of choice for the initial evaluation. Retrospective analysis has reported a sensitivity of 91-100% [13]. The sensitivity of non-contrast head CT diminishes as time elapses from the time of onset. It is best during the first 24 hours and diminishes to 85% at 5 days and subsequently to 50% at 1 week [14]. False negatives may occur in patients with anemia and is dependent upon the experience of the reading neuroradiologist [15]. MRI offers a higher sensitivity to detect SAH in patients presenting outside of first 48 hours after onset; however MRI is not readily available at most institutions and some patients may not be suitable for MRI. The FLAIR (fluid attenuated inversion recovery) and GRE (gradient echo) sequences are the most reliable method for detection of SAH in MRI [16].
Detection of aneurysms is best with catheter digital subtraction angiography, which remains the gold standard. In our practice, we perform a CT angiogram at admission, which carries a 85-98% sensitivity in comparison to catheter angiography. On average, 10-20% of patients with non-traumatic SAH will have a non-diagnostic catheter angiogram [17]. Practice varies in terms of repeat angiography; our current practice is to repeat an angiogram between 10-14 days.
2.4. Lumbar puncture
Cerebro-spinal fluid (CSF) analysis remains an essential aid in diagnosis in CT-Negative patients presenting with acute onset of severe thunderclap headache. Lumbar puncture should ideally occur 6-12 hours after onset of symptoms to optimize sensitivity. Lysis of red cells and the formation of oxyhemoglobin and bilirubin produce xanthochromia, ideally detected visually by inspection and confirmed by spectophotometry. CSF can remain positive for up to 7 days following ictus [18].
Various classifications exist for SAH. These range from clinical grading systems to radiographic scales. The most commonly used scales are Hunt & Hess, and World Federation of Neurological Surgeons (WFNS) scales [19]. (See Table 1)
Grade Hunt & Hess WFNS Survival
1 Asymptomatic or minimal headache and
slight nuchal rigidity GCS 15, no motor deficit 70%
2 Moderate to severe headache, nuchal rigidity, no neurology deficit other than cranial nerve palsy GCS 13-14, no motor deficit 60%
3 Drowsy, confusion, or mild focal deficit GCS 13-14, motor deficit 50%
4 Stupor, moderate to severe hemiparesis, possibly early decerebrate rigidity and vegetative disturbances GCS 7-12 with or without motor deficit 20%
5 Deep coma, decerebrate rigidity, moribund appearance GCS 3-6 with or without motor deficit 10%
Clinical grading scales for aneurysmal SAH and percent survival correlated with Hunt & Hess.
2.6. Differential diagnosis
Not all non-traumatic SAH is necessarily aneurysmal; however all non-traumatic SAH is treated as aneurysmal unless it is evident from clinical history or radiographic imaging that it is low risk. Most commonly, angiographic negative SAH is secondary to perimesencephalic hemorrhages. These compromise 10% of all SAH and two-thirds of non-traumatic SAH with negative angiograms. Blood is generally located ventral to brainstem in the prepontine and perimesencephalic cisterns. Generally, intraventricular hemorrhage (IVH) is rare. The average patient with perimesencephalic SAH is above the age of 50 and has less severe deficits. Rebleeding and vasospasm are infrequent in these patients [17].
Most SAH is in fact traumatic; however a collaborating history is not always obtained. Of those patients that have non-traumatic, non-aneurysmal SAH, intradural dissection is a concern; this is typically of the vertebral artery. Rupture of arteriovenous malformations (AVM) can occasionally extravasate blood into the cisternal space. Additionally, Arteriovenous Dural fistulas, mycotic aneurysms, pituitary apoplexy, and moya moya disease should remain on the differential, though there is generally additional history to suggest these. Cerebral vasculitis should remain a diagnosis of exclusion in patients with unexplained subarachnoid hemorrhage. The pattern of SAH on neuroimaging directs further work up. A non-classic pattern of cisternal hemorrhage suggests perimesencephalic or AVM related SAH. Blood present in the cortical sulci is generally thought to be traumatic, though can be associated with AVM rupture and vasculitis [17].
The critical care management of aneurysmal SAH can be thought of as three distinct phases: Immediate management (prior to securing the culprit aneurysm), entrapment of the aneurysm, and post entrapment management. Technical aspects and surgical management in entrapment of the aneurysm are described elsewhere [20, 21]. In this chapter we focus primarily on critical care management of aneurysmal SAH and potential complications.
3.1. Immediate management
The major risk of fatality following aneurysmal SAH occurs within the first 24 hours and is related to the risk of re-rupture of the aneurysm. Rebleeding occurs primarily within the first 8 hours and is present in 9-17% of patients within the first 72 hours [22]. Rebleeding carries a significant mortality rate – up to 50% [17]. Therefore, prevention of rebleeding is key in management.
Management in the 1980's of aneurysmal SAH incorporated the use of antifibrinolytics to diminish the risk of rebleeding. In these patients, antifibrinolytics were continued for weeks at a time. However, this practice was subsequently abandoned when further studies suggested that though rebleeding was diminished, complications of delayed cerebral ischemia, primarily vasospasm, increased and there was little difference in outcomes [23].
Recently, there has been renewed interest in the use of short-term (12-48 hours) antifibrinolytic therapy. Because complications of delayed cerebral ischemia and vasospasm generally occur after day 3, and the greatest risk of re-rupture is within the first 48 hours, a short duration of antifibrinolytic therapy may improve outcomes. A significant reduction in the rate of rebleeding, 11% to 2.5% has been observed in patients treated with an early short course of the antifibrinolytic tranexamic acid [24]. However, no study to date has been powered adequately to assess clinical outcome benefit with early short duration antifibrinolytic therapy. One study, however, has shown an increase in the rate of DVT's associated with the use antifibrinolytic therapy [25]. The Neurocritical Care Society's consensus statement on management of SAH recommends considering an initial early short course of an antifibrinolytic with early definitive treatment of the aneurysm [26]. Our current practice is to utilize antifibrinolytic therapy as early surgery/intervention is being arranged.
No clear hemodynamic goals have been defined in patients with aneurysmal SAH prior to entrapment of the aneurysm. Practice varies from center to center with the general consensus that elevated blood pressure raises the concern for early rebleeding. Early studies reported that induced hypertension and hypervolemia were associated with aneurysmal rebleeding and hemorrhagic transformation; however, further studies have failed to demonstrate this link. The consensus statement from the Neurocritical Care Society observed that modest hypertension (SBP <160mmHg, MAP < 110mmHg) was not associated with rebleeding [26].
Hydrocephalus is a frequent complication of aneurysmal SAH and is seen in 15-30% of SAH patients. The clinical impact of hydrocephalus is variable. Patients may be asymptomatic to obtunded. CSF diversion thru ventriculostomy generally resolves hydrocephalus and often times, a marked improvement is noted in level of consciousness [1]. Our clinical practice is to place ventriculostomies in all Hunt and Hess Grade 3 or higher aneurysmal SAH.
3.2. Securing the aneurysm
The key treatment of aneurysmal SAH is securing or trapping the aneurysm, thereby reducing the probability of rebleeding. Patients who have early surgery, within the first 72 hours, had an overall mortality rate equivalent to patients with delayed surgery (days 11-32); however, those with early surgery had significantly better clinical recovery [27]. The general consensus is that aneurysms should be secured within the first 24-48 hours following rupture The technical aspects and surgical management in entrapment of the aneurysm are beyond the scope of this chapter and are described elsewhere [20, 21]
3.3. Post entrapment management
The majority of the length of stay for aneurysmal SAH patients occurs post-surgical trapping. It is during this time that patients remain at high risk for neurologic deterioration secondary to vasospasm, delayed cerebral ischemia, seizures, hyponatremia, and other complications.
Management during this period relies on close serial neurologic assessment, and prompt management of complications.
Traditionally, patients with aneurysmal SAH have been treated with triple H therapy – consisting of hypervolemia, hemodilution, and hypertension. As our understanding of aneurysmal SAH advances, this strategy has changed significantly.
3.3.1. Volume status
Monitoring volume status in critically ill patients can be challenging, but remains essential to optimizing medical care. Patients with aneurysmal SAH frequently develop hypovolemia and hyponatremia as a consequence of cerebral salt wasting syndrome. Retrospective studies demonstrate an increase in ischemia and worse outcomes in patients with hypovolemia [28].
Fluid balance does not necessarily reflect intravascular volume [29]. Some have advocated CVP while others rely on PAC to optimize volume status. CVP appears to be unreliable as an indicator of volume status and the use of routine PAC is cumbersome and the risks outweigh the benefits [30, 31]. Few have shifted to beside ultrasound and distensibility of the inferior vena cava [32]. However, none of these measures of intravascular volume have proven reliable. A combination of both invasive and non-invasive monitoring in conjunction with other clinical indicators of volume status provide the best guide for targeting therapy [26].
Induced hypervolemia has been investigated in two prospective randomized trials – no benefit was found in vasospasm or clinical outcome [33, 34]. Therefore, our clinical practice is to target euvolemia. Preferred volume of choice is isotonic crystalloid [26]. Mineralocorticoid supplementation with fludrocortisone has demonstrated the reduction in need of intravenous fluids needed to maintain euvolemia [35].
3.3.2. Prophylactic measures
3.3.2.1. Nimodipine
Calcium antagonists have been studied as agents to reduce the incidence of vasospasm associated with aneurysmal SAH. To date, nimodipine, a member of the dihydropyridine family of calcium antagonists, has been the only medication shown to have significant improvement in clinical outcome in patients with aneurysmal SAH [37]. Typical dosing is 60mg every 4 hours orally and is continued for 21 days. Treatment with nimodipine led to a relative risk reduction of 24% for poor outcome [37].
3.3.2.2. Magnesium
Magnesium has attracted study in patients with aneurysmal SAH as it is a non-competitive calcium antagonist with important vascular and potential neuroprotective effects [38]. Dosing and optimal magnesium levels are not well agreed upon; however, hypomagnesemia is related to a worse outcome. Studies have yielded conflicting results. The largest trial to date did not demonstrate any outcome difference between those targeted with hypermagnesemia [39]. A second Phase III study, MASH-II, is currently underway. Our current practice is to target Magnesium levels between 2.0 and 3.0 mg/dL, and to avoid hypomagnesemia pending results of MASH-II [26].
3.3.2.3. Statins
The many beneficial effects of statins have made them targets for consideration as prophylactic agents in aneurysmal SAH patients. Clinical trials have, however, not demonstrated a consistent beneficial effect. A meta-analysis suggested that there may be a reduction in delayed cerebral ischemic (DCI) with statins, however, patients in these studies had a higher rate of DCI than typically reported elsewhere [40]. Another meta-analysis of 4 randomized trials showed no benefit with statin prophylaxis in Trans-Cranial Doppler (TCD) detected vasospasm, functional outcome, or mortality [41].
Though no studies have directly addressed continuing or withdrawing statins in patients with aneurysmal SAH, there is data from patients with ischemic stroke and myocardial infarction that suggests acute statin withdrawal can worsen outcome [42, 43]. Until further data is available from clinical trials, the consensus is not to initiate treatment with a statin; however, one should be continued if it has been prescribed prior to aneurysmal SAH [26].
3.3.2.4. Seizure
Seizures may occur with aneurysmal rupture; patients may also develop chronic epilepsy following aneurysmal SAH. The incidence of seizures during the acute phase of aneurysmal SAH varies: studies estimate a range between 8-30% [1]. Other estimates are more conservative ranging between 1-7% at the time of rupture [21]. Continuous EEG monitoring in patients with poor grade SAH demonstrated a 10-20% prevalence of non-convulsive seizures [44]. Risk factors for developing seizures include age > 65 years, thick subarachnoid clot, rupture of a middle cerebral artery aneurysm, and intraparenchymal hemorrhage [45].
Prophylactic treatment of seizures has been commonplace; however, recent studies have investigated the benefit and risks involved [26]. Prophylactic use with phenytoin has been demonstrated to lead to worse outcomes [46]. Shorter duration prophylaxis has been advocated and a 3-7 day course of prophylaxis is general practice. Other anti-epileptic agents have been investigated and levetiracetam has been shown to be equally efficacious in reducing early seizures as well as improved functional recovery in comparison to those patients treated with phenytoin [47]. The current recommendation is to consider using short-term (3-7 days) of agents other than phenytoin, such as levetiracetam, for seizure prophylaxis. For patients with poor grade SAH with unexplained neurologic deterioration, continuous EEG monitoring is recommended [26].
3.3.2.5. DVT
Aneurysmal SAH induces a prothrombotic condition that can lead to an increase in deep venous thrombosis (DVT), and pulmonary embolism (PE). Incidence of DVT varies between 1.5-1.8%, with poor grade SAH having a higher incidence [48].
Conventionally, sequential compression devices (SCDs), unfractionated heparin, and low-molecular weight heparin have been used. One meta-analysis showed all were similarly effective in preventing DVT, but there was a trend towards higher rates of hemorrhage (intracerebral and non-cerebral) in those with low molecular weight heparins [49]. Timing of initiation is controversial, but generally, it is felt safe to assume pharmacologic prophylaxis after 24 hours from onset. Similarly, pharmacologic prophylaxis should be held 24 hours before and after intracranial procedures [26].
3.3.2.6. Glycemic control
Hyperglycemia is often diagnosed in patients with SAH; numerous studies have associated admission hyperglycemia with poor clinical grade and outcome [50]. The optimal range of glycemic control in patients with aneurysmal SAH is unknown. One study has shown improved outcomes with tight glycemic control: 80-140mg/dL, achieved thru insulin infusion [51]. However, when tightened to 80-110mg/dL, outcomes were worse secondary to episodic hypoglycemia and vasospasm [52]. Extrapolating data from other critically ill populations suggests that patients on insulin infusions are more likely to develop hypoglycemia [53]. Microdialysis studies have shown cerebral glucose levels to decrease, even without systemic hypoglycemia [54]. Based on the available data, hypoglycemia should be avoided and system glycemic control should target < 200mg/dL [26].
3.3.2.7. Pyrexia
Fever is very common in patients with SAH; studies report between 41-72% of patients with aneurysmal SAH will have fever. Fever is independently associated with poor outcome in retrospective studies of SAH [55]. As such, aggressive work up of fever is obligatory to look for underlying infection, drug reaction, or thrombosis. No clinical trial has prospectively examined induced normothermia and outcome; however, given the increased morbidity with fever, it is prudent to manage pyrexia [56]. Strategies to decrease fever include medications such acetaminophen, and NSAIDs. More aggressive devices include cooling blankets, and intravascular temperature modulation devices. The deleterious effects of aggressive cooling can include shivering and should be monitored for and aggressively combated [26].
3.3.2.8. Anemia
Anemia develops in over 50% of patients with Aneurysmal SAH and Hemoglobin concentrations decrease to less than 11g/dL in more than 80% of patients [57]. Because under normal circumstances when cerebral oxygen delivery demands metabolic demand, these levels are well tolerated. However, patients with aneurysmal SAH are at risk for developing vasospasm and DCI; their metabolic needs may not be met.
The optimal target hemoglobin in this patient population is not known. Retrospective studies have demonstrated that higher hemoglobin concentrations were associated with good functional outcomes [58]. PET imaging studies show an improvement in delivery of cerebral oxygen when hemoglobin is improved from 8g/dL to 10g/dL thru red cell transfusion [59]. However, evidence from broader based critically ill patients suggest that there is lower mortality in patients with a restrictive transfusion strategy [60].
Current guidelines suggest minimizing blood loss from blood drawing, as well as consideration of packed red cells to maintain hemoglobin concentrations between 8-10g/dL. Patients with DCI are the most likely to benefit from this higher transfusion strategy [26].
3.3.3. Complications of aneurysmal subarachnoid hemorrhage
Direct neurologic complications include cerebral vasospasm and delayed cerebral ischemia. Acute hydrocephalus and a diminished threshold for seizures have been discussed previously. Systemic complications of aneurysmal SAH include cardiac, pulmonary, and electrolyte abnormalities (see Figure 2). Fever, anemia, hyperglycemia are also common and have been discussed previously.
Cardio-pulmonary complications of aneurysmal SAH are related to the surge in catecholamines.
3.3.3.1. Cardiac complications
Cardiac complications following aneurysmal SAH are frequent and range from hemodynamic instability to cardiac arrhythmias to myocardial injury and heart failure. Given the high prevalence of cardiac complications, all patients with aneurysmal SAH should have an ECG, cardiac enzymes, and echocardiogram on admission.
ECG abnormalities most commonly seen following aneurysmal SAH are ST segment alterations, prominent U waves, QT-prolongation and other conduction abnormalities. Older age, hyperglycemia, and longer length of state are associated with atrial fibrillation and atrial flutter [61].
Troponin I is elevated on admission in 20-34% of patients with aneurysmal SAH. Studies have suggested that elevated troponin I is an independent risk factor for severe disability and death at hospital discharge. Higher grade SAH, IVH, and loss of consciousness at ictus have all been associated with elevated troponin I [62].
Acute heart failure and myocardial injury are most commonly seen in higher-grade SAH patients; the most severe form is neurogenic stunned myocardium. The surge of catecholamine release associated with SAH is thought to be responsible for neurogenic stunned myocardium, however the exact mechanism remains poorly understood. The classic pathologic findings are myocardial contraction band necrosis. Presentation includes transient lactic acidosis, cardiogenic shock, pulmonary edema, widespread T wave inversions, and reversible wall motion abnormalities [63]. One prospective study revealed a 18% (35% in Grade III-V) prevalence of wall motion abnormalities on echocardiogram in patients with aneurysmal SAH [64]. Takotsubo cardiac myopathy, also known as apical ballooning syndrome, is a subset of stunned myocardial injury seen most commonly in post-menopausal women and is associated with pulmonary edema and prolonged mechanical ventilation [65].
3.3.3.2. Pulmonary complications
Pulmonary complications are frequent (22%) and include impairment in gas exchange, pneumonia (20%), pulmonary edema (14%), and pulmonary embolism (0.3) [61]. These represent common manifestations of pulmonary disease in general critical care patients. Patients with aneurysmal SAH are however prone to develop aspiration pneumonias given a higher frequency of impaired consciousness. Thus, vigilant aggressive pulmonary toilet and aspiration precautions are important.
Neurogenic pulmonary edema (NPE) is associated with various neurologic insults, including SAH, seizures, and traumatic brain injury. It is thought to be a result of massive sympathetic discharge and catecholamine release at ictus, resulting in vasoconstriction and an increase in MAP with subsequent shift of intravascular volume to a lower-resistance pulmonary bed. The role of cardiac dysfunction in association aneurysmal SAH also contributes to pulmonary edema in these patients. NPE is associated with poor outcomes and is seen in patients with higher grade SAH. These patients are challenging to manage. Maintaining euvolemia in SAH patients decreases the risk of vasospasm; and it is well accepted that hypovolemia increases risk of vasospasm. Thus, cautious use of diuretic therapy is indicated when oxygenation and/or hemodynamic instability as a result of heart failure develop [66].
3.3.3.3. Hyponatremia
Hyponatremia is prevalent in up to 57% of patients with aneurysmal SAH [67]. It is the most commonly encountered electrolyte abnormality in NeuroScience ICU's. Severe hyponatremia is associated with seizures, and worsening of cerebral edema. In patients with aneurysmal SAH, hyponatremia is associated with increasing risk of vasospasm, likely secondary to its association with hypovolemia [68].
Hyponatremia in the setting of aneurysmal SAH can either be caused by Cerebral salt wasting (CSW) or the Syndrome of Inappropriate Antidiuresis (also known as Syndrome of Inappropriate Antidiuretic Hormone – SIADH). The proportion of patients with CSW versus SIADH as the cause of hyponatremia in aneurysmal SAH varies depending on the study, but CSW is more likely. Distinguishing CSW and SIADH is of clinical importance as the management is different, and can adversely affect outcomes in patients with aneurysmal SAH [68].
CSW is a result of natriuresis: loss of sodium resulting in loss of free water leading to hyponatremia; it is thus a hypovolemic hyponatremia. SIADH results from inappropriate anti-diuresis and is thus a euvolemic hyponatremia. Distinguishing the two is often difficult. Generally, patients with SIADH have decreased urine output in comparison to CSW. Urine osmolality is generally lower to normal in patients with CSW and high in patients with SIADH. Urine sodium levels are elevated in both. However, these are not always reliable; volume status, if determined reliably, is likely the most accurate method for distinguishing CSW from SIADH [69].
The mechanism of CSW is not completely understood. It is thought to result from interference of sympathetic input to the kidney and from elevated circulating natriuretic factors seen after cerebral injury [68].
CSW in patients with aneurysmal SAH are treated with Na supplementation and restoration of volume. This is achieved thru the use of salt tablets and hypertonic saline solutions. Mineralocorticoid supplementation is useful to increase Na and volume; typically, fludrocortisone is used. Therapy is targeted to maintain Na >135 [68].
More recently, the vasopressin receptor antagonist conivaptan has become available. It may cause an increase in diuresis and lead to a negative fluid balance. Though originally intended for the treatment of SIADH, it has been used cautiously in the hyponatremic patient with aneurysmal SAH [70].
3.3.3.4. Systemic Inflammatory Response (SIRS)
The catecholamine release associated with aneurysmal subarachnoid hemorrhage along with pro-inflammatory cytokines can lead to SIRS. The presence of SIRS criteria on admission (body temperature, heart rate, respiratory rate, and white blood cell count) in patients with aneurysmal SAH is a significant independent predictor of vasospasm and hydrocephalus. It is also associated with a higher mortality and morbidity rate [71].
3.3.3.5. Vasospasm and delayed cerebral ischemia
Vasospasm refers to the narrowing and vasoconstriction of cerebral arteries following aneurysmal SAH; it is prevalent in 70% of patients with aneurysmal SAH. Delayed cerebral ischemia refers specifically to the clinical and neurologic deterioration, often related to severe cerebral vasospasm, and occurs in 20-30% of patients with aneurysmal SAH.
The best predictor of cerebral vasospasm is thickness of cisternal clot and intraventricular hemorrhage, as seen on CT scan [72]. The Fisher and modified Fisher grading scales are used to predict expected risk of vasospasm (see table 2) [73].
Cerebral vasospasm typically starts after post-bleed day 3 and can extend thru 21 days, though most cases resolve within 14 days. The generation of microemboli, cortical spreading ischemia, and microcirculatory spasm are thought to add to DCI [74, 75]. (See Figure 3)
Grade Fisher Scale Percent with Symptomatic Vasospasm Modified Fisher Scale Percent with Symptomatic Vasospasm
1 Focal Thin 21% Focal or Diffuse Thin SAH, no IVH 24%
2 Diffuse Thin SAH 25% Focal or Diffuse Thin SAH, with IVH 33%
3 Thick SAH Present 37% Thick SAH Present, no IVH 33%
4 Focal or Diffuse thin SAH with significant ICH or IVH 31% Thick SAH Present, with IVH 40%
Adapted from – Frontera et al. (2006) Prediction of Symptomatic Vasospasm After Subarachnoid Hemorrhage: The Modified Fisher Scale. Neurosurgery. 58: 21-26
Fisher and Modified Fisher grading scales for aneurysmal SAH with percentage of patients within grade with symptomatic vasospasm.
Complications and risk against time in aneurysmal SAH.
Cerebral vasospasm is the highest contributing factor to morbidity in patients with aneurysmal SAH. Cerebral vasospasm may have evolved as a protective measure to prevent re-rupture of a cerebral aneurysm; however, its diffuse cerebral effects are deleterious and add significant morbidity to aneurysmal SAH. Vasospasm is thought to occur secondary to blood product degradation in the subarachnoid space. Deoxy-hemoglobin and oxy-hemoglobin decrease perivascular nitric oxide and increase endothelin-1 respectively. The net result is a pathologic prolongation of calcium in smooth muscle, leading to an increase in spasm, apoptosis, and vascular remodeling [75].
Monitoring for vasospasm is of great value in the management of aneurysmal SAH. TCD, CT Angiography with perfusion imaging, and conventional digital subtraction angiography are options for monitoring for cerebral vasospasm.
The advantages of TCD are its noninvasive low risk profile; however it's sensitivity is variable and dependent on the skill of the ultrasonographer. Many patients have poor trans-cranial windows, making monitoring with TCD's difficult, if not impossible. Mean flow velocities are typically utilized for detection of vasospasm. Using a mean fellow velocities less than 120cm/s has a 94% negative predictive value for cerebral vasospasm. Mean flow velocities greater than 130cm/s have been proposed as the threshold for mild-moderate vasospasm; this carries a 73% sensitivity and 100% specificity for detecting vasospasm. Mean flow velocities greater than 200cm/s reliably predict moderate to severe angiographic vasospasm. The Lindegaard ratio compares intracranial MCA mean flow velocity to extracranial ICA mean flow velocity; the advantage of a ratio is to distinguish hyperemic states from vasospasm. Ratios greater 4 are suggestive of vasospasm; a ratio greater than 6 reliably predicts cerebral vasospasm [76].
CT angiography has a 87-95% percent sensitivity for angiographic vasospasm, but carries a high negative predictive value approaching 99%. However, CT angiography and perfusion are cumbersome and may pose additional risk to the patient secondary to iodinated contrast. CT angiography with perfusion may be a surveillance option for patients who have poor TCD windows [26].
Non-interventional strategies to combat cerebral vasospasm include the traditional triple H model. Augmenting MAP has been utilized to decrease DCI associated with cerebral vasospasm [74]. Our practice utilizes MAP goals between 110-140 to treat cerebral vasospasm.
Few centers have utilized intrathecal calcium antagonists. Some have utilized intrathecal nicardapine with success in decreasing flow velocities as measured by TCD's [77]. Multicenter randomized trials utilizing have yet to be completed demonstrating efficacy.
The trigger for intervention varies between centers. Many centers choose an aggressive intervention including endovascular delivery of local intra-arterial verapamil (and other calcium antagonists) that have an immediate effect with resulting local vasodilatation. Specific management of interventional management of vasospasm associated with aneurysmal SAH are described in more detail elsewhere [78]. The current gold standard for refractory cerebral vasospasm includes angioplasty in conjunction with intra-arterial delivery of calcium channel antagonists [26].
4. System based practice
Most patients with aneurysmal SAH are treated at small volume centers seeing fewer than 18 cases per year. Mortality is substantially greater at small volume centers compared to larger high volume referral centers [79]. Moreover, studies suggest that the utilization of a dedicated neurocritical care team is associated with improvement in hospital discharge disposition in patients with aneurysmal SAH [80].
Aneurysmal SAH is a complex critical illness with multisystem complications that requires the close attention of a dedicated neurocritical care team. Mortality and morbidity are high; the likelihood of a good outcome depends on presentation grade and careful and diligent management of complications.
2.Diagnosis
3.Management
4.System based practice
5.Conclusion
Vishal N. Patel and Owen B. Samuels (August 29th 2012). The Critical Care Management of Aneurysmal Subarachnoid Hemorrhage, Aneurysm, Yasuo Murai, IntechOpen, DOI: 10.5772/48474. Available from:
False Aneurysms
By Igor Banzić, Lazar Davidović, Oliver Radmili, Igor Končar, Nikola Ilić and Miroslav Marković
CardiomyopathiesFrom Basic Research to Clinical ManagementEdited by Josef Veselka
Edited by Josef Veselka
Classification and Definitions of Cardiomyopathies
By Bhulan Kumar Singh, Krishna Kolappa Pillai, Kanchan Kohli and Syed Ehtaishamul Haque

redpajama_set_name: RedPajamaCommonCrawl


Have you ever been to such a house 🏡 built up on the lap of Mother Nature.
Its a beautiful click from Jharkhand in India during one of my trips with greenery all around and a solitary home in between.Time is ripe enough we should all look back to such days of civilisation where we used to enjoy the Mother Nature more and destroyed less.
Unless we all try to save this planet from our wrong doings in the name of modernisation A day will come when only concrete and concrete will only be present on the surface of earth.
Very very lovely pic. I think you are lucky person who see this mother nature.
Right but you just need an eye to see all these natural beauties.
It's a lovely photograph! All the lush green with just one little house there is my idea of perfection!


Cast Iron Repair | EAGLE WELDING SERVICES INC.
This is part of an exhaust manifold off of a large CAT generator. It was cracked in the crotch of the "Y". We ground out the crack to the full depth of the material then started welding the crack back up.
The repair was completed to the satisfaction of our customer and no leaks were reported. We do not have an oven so this cast iron was welded slowly and in a way that protected the piece from over heating.


MERCEDES-BENZ A-Klasse (W168) A 160 CDI OM 668.941 44 60 02.1999-03.2001 optional extra Exportmod.
MERCEDES-BENZ A-Klasse (W168) A 160 CDI OM 668 55 75 02.2001-08.2004 optional extra Exportmod.
MERCEDES-BENZ A-Klasse (W168) A 170 CDI OM 668.940 66 90 02.1999-03.2001 optional extra Exportmod.
MERCEDES-BENZ A-Klasse (W168) A 170 CDI OM 668 70 95 02.2001-08.2004 optional extra Exportmod.
MERCEDES-BENZ Sprinter 616 (905.612-905.623) 01-06 616 CDI (Sprinter) OM 612.981 DE27LA 115 156 01.2001--> optional extra Exportmod.
MERCEDES-BENZ Sprinter I (901/902/903/904) 216 CDI OM 612 DELA 115 156 04.2000--> export model Sonderausstatt.
MERCEDES-BENZ Sprinter I (901/902/903/904) 316 CDI OM 612 DELA 115 156 04.2000-05.2006 export model Sonderausstatt.
MERCEDES-BENZ Sprinter I (901/902/903/904) 416 CDI OM 612 115 156 04.2000-05.2006 export model Sonderausstatt.
MERCEDES-BENZ Vaneo (W414) 1.6 CDI OM 668 55 75 09.2001-09.2005 optional extra Exportmod.
MERCEDES-BENZ Vaneo (W414) 1.7 CDI OM 668 66 90 09.2001-09.2005 optional extra Exportmod.
MERCEDES-BENZ Vito I (638) 108 CDI OM 611 60 82 01.1999-10.2003 optional extra Exportmod.
MERCEDES-BENZ Vito I (638) 110 CDI OM 611 75 102 01.1999-10.2003 optional extra Exportmod.
MERCEDES-BENZ Vito I (638) 112 CDI OM 611 90 122 01.1999-10.2003 optional extra Exportmod.


Begin you day with a consecration, where you offer all the results of all your actions to the Divine. Thank for the fact that you're being given a new day, full of possibilities. Thank for it!
You get dressed anyhow, so do it as a ritual, there you adorn a god/goddess, having the corresponding transfiguration.
Avoid dull, dark, greyish colours in your clothing. Avoid synthetic materials.
Stop acting mechanically. Be aware of everything you do/feel/think/intend!
In your way to your job/school, do simple breathing techniques, or visualize the subtle streams of colour, or program your subconscious mind . Do these in all your "dead-times".
Choose carefully the music you listen to. Use only music that is beneficial.
Look at people around you, regardless whether you know them or not, in a very transfiguring way. See beyond their personality, their status; see in them a sparkle of God.
"IT IS NOT IMPORTANT WHAT HAPPENS TO US, IMPORTANT IS HOW WE REACT TO WHAT HAPPENS TO US!" Remind yourself of this liberating fact every time you are in situations less pleasant.
Take short breaks in which you remember your SELF!
When you eat, eat slowly; chew thoroughly, until the taste of the bit you're chewing is gone. Eat consciously. Do not do something else meanwhile. Eat in the Ayurvedic order: sweet, salty, sour, hot, bitter and astringent.
When you cook, charge your food with positive energy, do not do it in a hurry, do not cook when you are in a bad mood. Do not use microwave oven and fast food, or ready-made food.
When you take a shower/bath, think that the water washes off all the subtle impurities. Be conscious of what you do. Finish it with cold water.
Prioritize things so that you have time for yourself, for your soul every day. Do a short interioriz ation daily.
Do small favours to those around you. Do it as if you serve God.
Say at least a compliment to your dear ones every day!
"TREAT THE OTHERS THE WAY YOU LIKE TO BE TREATED YOURSELF!" This a the foundation of common sense. Live according to it, and you will create for yourself a happy, harmonious life!
See and mentalise what is good in people around you.
Stop comparing yourself to others! Stop criticizing them in your mind!
Show people around you that you trust them, that you do not judge them, that you do not blame them.
Connect yourself to the Cosmic Will Power. Avoid involving yourself egoistically.
Give help every time you have the opportunity, every time you notice that help is needed.
Learn to say "NO", to all that is negative, destructive, detrimental.
In the mental "dead times" focus your mind only on one (beneficial) thing.
Take care that you have the proper carriage of the body and that you choose the proper words when you speak and think.
Every time you have negative feelings/emotions, do your best to identify the cause. You will notice that most of the times is because a form of fear. Confront your fear, understand that it is not grounded. Do your best to stop yourself before letting the negative feelings surface.
Make a list with the faults you want to get rid of, and begin with the one is most disturbing. Put the opposite quality in its place. Do not struggle the vice. Have patience with yourself.
Make a list with all your qualities and carry it around with you. Every time you feel your self-confidence is shaky, read the list.
Stop from whatever you're doing from time to time, close your eyes and thing of the most beautiful, pure and elevated things that exist.
Teach yourself to SEE. Pay attention to details, gaze consciously.
Do your best to LOVE more today than you did yesterday. Strive to awaken in you the endless, true, divine LOVE.
In the end of the day, remember everything you have done/felt/thought, and "repair" the mistakes by visualising the same situation, though now you do it right. Learn from what you have done.
In the end of the day say with sincere gratitude: "Thank you!" for everything that you experienced, and see this as a tremendous gift that comes from God!


text:
Tag Archives: bill hicks
January 26, 2015 · 17:02
A Slow Day for Blogging
A couple of days ago my friend Matt challenged me to answer something he called the "Proust Questionnaire."
Really? An opportunity to talk more about myself? Challenge Accepted!
Also, our mutual friend, Adriana put hers up on her blog, "Des Etoiles Filantes," and I thought I would do the same.
So without having done any research on what the questionnaire is all about or what it helps determine, here are my answers:
1. What is your idea of perfect happiness? -The absence of craving and aversion.
2. What is your greatest fear? -That a mechanistic worldview which views human beings as nothing more than biological machines, is true.
3. What is the trait you most deplore in yourself? -Laziness.
4. What is the trait you most deplore in others? -Intransigence.
5. Which living person do you most admire? -There are certain people in my life who have inspired me to follow my dreams and i would say it is cumulatively them.
6. What is your greatest extravagance? -My morning coffees.
7. What is your current state of mind? Benevolent mostly, peppered with self-doubt, enthusiasm, and amusement.
8. What do you consider the most overrated virtue? -Hard work. Hard work should be applied toward virtuous things but it isn't a virtue unto itself.
9. On what occasion do you lie? -Any time I say what objectively happened in a given situation and informing that account with only my own limited observations and perceptions.
10. What do you most dislike about your appearance? -My posture needs work and my abs aren't as hard as I'd like them to be. I've come to terms with my crooked jaw though and actually see it as a blessing in disguise.
11. Which living person do you most despise? -I don't really despise anyone but I am averse to Bill Maher. He's just kind of a smarmy, slimy dude who perpetuates a cynical faux-intellectualism.
12. What is the quality you most like in a man? -Follow-through.
13. What is the quality you most like in a woman? -Taking action to remedy their problems instead of just idly complaining about them.
14. Which words or phrases do you most overuse? -Lately, I have been using the phrase "elephant in the room" quite a bit.
15. What or who is the greatest love of your life? I'm tempted to say my ex, but it would actually be myself/everyone. I try to love everyone as myself.
16. When and where were you happiest?
-First year residence in Matthews Hall.
-January 2009 in Afghanistan.
-Anytime I sat with a drink and/or smoke and/or listening to Gordon Lightfoot and watched the sun set while on a backpacking excursion.
-Oct. 2008, out in the middle of nowhere in the Afghan desert on a three week patrol, sitting in a trench under a beautiful blue sky, shitting into a bucket with my pipe in one hand and my coffee in the other and thinking "This isn't so bad."
17. Which talent would you most like to have? -Pro-level skateboarding parkour and freestyle rapping
18. If you could change one thing about yourself, what would it be? -My shitty Riddler tattoo has to go.
19. What do you consider your greatest achievement? -Escaping the anger phase of my awakening process/not succumbing to hate.
20. If you were to die and come back as a person or a thing, what would it be? -I'd like to come back as a squirrel in a lush forest that was warm year-round and have no natural predators. The squirrel life would be fun .
21. Where would you most like to live? -On a deserted island in the South Pacific.
22. What is your most treasured possession? I guess my dog-tags are, but I don't really like the idea of treasured possessions. If they ever go I hope I will have serenity to not grieve too hard.
23. What do you regard as the lowest depth of misery? -There was one night back in Spring 2007 where I had gotten some bad news, ate a few too many weed cookies and ended up having the worst, most emotionally painful night of my life. More than anything I felt alienated and like I had wasted a year of my life. Looking back it was one of my most important single instances of growth. Not gonna say too much more than that but it was one of those wake-up calls that come when we need them.
24. What is your favorite occupation? -None.
25. What is your most marked characteristic? -Sense of humor, eyes, or affinity for wife beaters, camo and bandanas.
26. What do you most value in your friends? -Comfort. I like people I can be myself around.
27. Who are your favorite writers? -Orwell, James Clavell, Gary Jennings and Cervantes. Tolle writes beautifully and Vizinczey makes profound observations.Thoreau too has shaped my outlook with his beautiful observations about living in harmony with the natural world.
28. Who is your hero of fiction? -Venom. Or Jesus. I try and emulate the latter more.
29. Which historical figure do you most identify with? -Marco Polo.
30. Who are your heroes in real life? -Peter Joseph, George Carlin, Russell Brand, Bill Hicks, Martin Luther King, Gandhi, and myself.
31. What are your favorite names? -Natasha and George.
32. What is it that you most dislike? -Righteous Indignation.
33. What is your greatest regret? -Letting a girl get between me and a dear friend.
34. How would you like to die? -Serenely.
35. What is your motto? "There's nothing to be afraid of; It's just me out there." -George Carlin
Instagram: @dreguan
Twitter: @dreguan
Youtube: dreguan
Facebook: Andre Guantanamo
IMDb: Andre Guantanamo
Demo Reel: https://www.youtube.com/watch?v=6gdwhemiqzc
Tagged as acceptance, bill hicks, Blog, buddhism, gandhi, Geroge Carlin, martin luther king, mlk, opinion, peter joseph, Proust, self-indulgence, serentiy, the zeitgeist movement, tolerance, tzm, vipassana, zen
"He Who Laughs Last Probably Died Laughing"
An army friend of mine once related a story to me when we were in Afghanistan about a game he used to play in university lectures called, "Bait the Jew." The premise of the game was simple: in class discussions he would say deliberately inflammatory things which would rile the Jewish students, particularly those with Zionist sympathies. He would then have a laugh at their expense. I cringed at this and felt kind of embarrassed for him but it was one of those situations you find yourself in all-too-often in the military where you gotta let some repugnant shit slide because for better or worse, this dude has my back when shit hits the fan.
But if you think about it, Bait the Jew is emblematic of how humor is generally done these days: inflammatory remarks are levied at various demographics (with various degrees of cleverness) and the "injured" party's reaction only increases the mirth of those who see the humor in it. Sometimes, the injured party's reaction is relatively benign (legal recourse, appeals to the government or similar jests in kind), but sometimes it's pretty severe:
I'm gonna go ahead and say exactly what's on my mind here: Some people are VERY happy about the Charlie Hebdo massacre.
Well, to me, I think it validated a lot of pent-up xenophobia and and Islamophobia and it certainly made a fair number of self-described atheists pretty euphoric. There is a definite under-current of these emotions in the wake of the attacks and a jubilation which some are hard-pressed to contain. It goes deeper than the validation of prejudice though. Some, like certain military friends of mine, have a vested financial interest in war because (at least in the Canadian military) there's lots of delicious tax-free money to be made fighting commies/Nazis/insurgents. But there's also the awards, honours, medals and respect that come from service overseas.
You basically get some new bling to keep your uniform frosty.
Medals are a status symbol in the military and the worthiness of your career is (unofficially) related to the size of your rack of medals. In the context of being in the military, it's considered a more or less objective indicator of whether or not someone is a good soldier. Sure, a guy may be an insubordinate, racist drunkard, but look at all his medals. Also, there is an unspoken resentment against superior officers who presume to command subordinates with more operational experience, and thus more medals, than them. So in my estimation, a lot of war-mongering has to do with guys who want to legitimize their careers and authority, while at the same time becoming one of the highly decorated veterans they vaunt.
I'll defer to Bill Hicks here:
"What kind of people are these with such low self-esteem that they need a war to feel better about themselves? May I suggest, instead of a war to feel better about yourself, perhaps … sit-ups? Maybe a fruit cup? Eight glasses of water a day?"
I was one of these guys when I got into the army. I saw dudes who had deployed to Afghanistan, Bosnia, Cyprus, the Golan Heights and when they'd rock their medals on parades I wanted my own taste of that. Well, I got it. And, surprise surprise, all of that admiration and veneration from the younger generation didn't mean all that much when I finally had it.
How far do you have to go down that road before you see where it leads?
But I digress here because I didn't set out to write a scathing indictment of the military mindset wherein a solider validates himself, his existence and his career through violent campaigns and occupations which leave people dead, orphaned, bereaved and embittered.
Rather I was writing about humour and the way it is done. This hits a little close to home for me because as of late I have been trying my hand at stand up comedy so I find myself very much concerned with what is funny and what is not. Now at the outset, let me be clear: I am not above laughing at crude, insensitive, racist, sexist, etc. jokes. I'd like to qualify that by saying that I only laugh at them if they are clever, good-natured and well-wrought but that would be lying. I've laughed at the worst of the worst and will continue to do so provided I find the joke in question funny.
Now I think many of us would agree that if I, as a white male, went around making racist jokes about blacks, saying the word nigger all willy-nilly and advertising bigotry, the people who were the butt of my jokes would have a legitimate qualm and reason to not find them funny. If things were taken a step further and I got my ass kicked by the injured parties, a lot of people would probably be like, "Well he got what he deserved."
Now notwithstanding the fact that there are orders of magnitude of difference between the shit-kicking I deserve and a shoot-out in the streets, can we at least acknowledge that a similar dynamic is at play here?
1)Someone makes a joke at another party's expense
2)The second party is offended by the joke
3)To vindicate their bruised honor, the injured party does (decidedly less whimsical) violence against the jokester (and anyone else unfortunate enough to be nearby)
Some of you may say that I have abstracted the Charlie Hebdo massacre too much to make it congruent with my hypothetical black joke scenario, but I maintain that this is an important mental exercise which helps us to recognize common kernels of causality. So yes, while there are worlds of differences between the CH massacre and me getting my ass tuned up by a bunch of hypothetical aggrieved African-Americans (Canadians???), there is a similar dynamic of vindication here.
Or how about this: A lot of people here in the west think it's stupid for Muslims to freak out over pictures of the Prophet Mohammed, BUT GOD HELP YOU IF YOU DON"T STAND FOR THE NATIONAL ANTHEM AT A HOCKEY GAME!!!
Yes, cause that makes infinitely more sense.
Or a lot of people might hate on (again) Muslims for those honor killings we hear so much about, but I would posit that "vindication of the national honour" (i.e. "honor killing" on a massive scale) is the main mobilizing premise used to dupe scared people into joining the war effort in the wake of some (usually trifling or made-up) initial provocation.
Don't get me wrong I am no apologist for Islamic violence, but I recognize that it's pretty presumptuous for us to poo-poo them for their violence when we cumulatively as "the West" are perhaps the greatest purveyors of direct violence (war), indirect violence (proxy wars) and war profiteering that have ever existed.
But again I need to digress, because this is neither meant to be a scathing indictment of Western foreign policy.
So what is funny and what is worth killing someone over? I think the answer to both is, "It's all relative." Furthermore, there is a degree of overlap, so some hilarious shit might get someone killed.
"He who laughs last, probably died laughing."
I recognize doing stand-up that a joke which I find funny might get my ass kicked if it offends someone, and whether popular opinion is with me or against me depends on a number of factors: The disposition of the general public, whether I am part of the privileged class, whether the subject of my ridicule is a downtrodden minority and last but not least, the prejudices of the general public. Let's face it, if Charlie Hebdo cartoonists saw some humour in making cartoons at the expense of rape victims and a bunch of feminist extremists IRL pwned (killed) them, there would be a lot of people of the mindset of, "Well, that's what you get for talking shit." But since the indignant transgressors were Muslims, the attitude seems to be "Fuck them and their feelings!"
So, should Charlie Hebdo cartoonists have showed some restraint with regard to their jokes about Islam? Absolutely-the-fuck-NOT! We NEED people to push limits and say things that are on their minds even if the group-mind doesn't deem it politically correct. The fact of the matter is that it takes a lot of guts to say some shit that you know isn't popular, which incidentally, is why I mostly reserve judgement against the Westboro Baptist Church. Much as I might disagree with their message I have to laud their guts.
And while I think it sucks that people sometimes get killed for speaking their mind, I also think it sucks that we live in a system which necessitates the speaking of one's mind in the first place.
What do I mean by that? Well, speaking one's mind (whether that is asking for a raise, telling off a rival, or making an unpopular joke) is a form of asserting oneself and one's views. But the necessity of self-assertion pre-supposes some marginalization happened as a pre-cursor. So the Charlie Hebdo cartoonists felt they had to assert themselves at the expense of devout Muslims, and the devout, more extremist elements of that group felt they had to re-assert themselves against those who had made light of their faith. Like so many struggles within a competitive socio-economic system, it's just another case of one group trying to get ahead at the expense of another.
So again, for perhaps the hundredth time, I want to ask, "Shouldn't we, instead of focusing on the individual acts of violence or insult (the latter being just another form of violence), instead look to transcend the structural mechanisms which pit people against one another in the first place?"
It doesn't matter whether you identify more with Muslims or the cartoonists, cause while you bicker over who was in the right or wrong, someone is profiting from this whole debacle at the expense of both groups.
And what I find incredibly offensive about any new legislation pertaining to surveillance and privacy that will come to pass from this massacre is that it will likely disproportionately target Muslims (at least initially) and also that it flies in the face of the freedom of speech which Charlie Hebdo stood for.
So while we take sides, everyone loses.
Problem => Reaction => Solution
But I digress, because I didn't set out to talk about how we are being manipulated and played against each other.
Also, I ran out of clever shit to say.
Tagged as Afghanistan, america, batman, bill hicks, Blog, cartoon, charlie hebdo, comedy, conflict, Critique, crusade, danny elfman, Deconstruction, discussion, France, islamism, islamist, jack nicholson, je suis charlie, jihad, joke, michael keaton, middle-east, muhammad, muslin, obama, oil, opinion, paris, philosophy, standup, stephen harper, syria, the joker, the killing joke, the prophet, the west, tim burton, Uncategorized, United States, war


text:
Q: Any way to run play framework (1.x) auto-test on different databases? In local development I want to connect to my personal database for auto-test. In the build farm, I want to connect to a different database for auto-test. How can that be done?
Play seems very flexible with configuration, except with running auto-tests. Have I missed a secret special trick somewhere?

A: See this thread...
Test and auto-test always uses test as ID, so you can't overwrite the value depending on which test environment you are on. I am not aware if this bug has been fixed, but I couldnt find an associated bug or fix on lighthouse.
You can use environment variables in your application.conf, see here, which means you can pass in the db name using a -Dvariable. So
play auto-test -Dtestdb=your-cit-db
then in you application.conf, you would do
%test.db.name={testdb}

redpajama_set_name: RedPajamaStackExchange


text:
Review finds no fault in dismissal of protective order against Wilton man who shot former partner
File photo '; }
Published: 12/1/2021 1:10:19 PM
A review of the denial of an order of protection for a woman who was then shot and critically injured by her former partner found no fault with the decision under current law, but made seven recommendations for improving court practices.
On Nov. 15, Richard Lorman, 55, of Wilton, waited outside of his former girlfriend's workplace in Salem, Mass., and shot her when she left work, according to police. She was shot in the head, but survived the attack. Lorman then turned the gun on himself, and died at the scene.
The same woman had sought a domestic violence order of protection against Lorman two months prior. A temporary order was granted Sept. 21, but the final order of protection was dismissed by Judge Polly Hall on Oct. 20 for lack of a "credible, present threat."
An internal review committee of the New Hampshire Judicial Branch reviewed the case, and concluded that the final hearing where the order was dismissed "was conducted in accordance with all applicable laws and protocols, as well as the principles for procedural fairness and proper judicial conduct," according to the report issued following the completion of the investigation.
The committee concluded that the denial was a "reasonable application" of state law.
In addition to their findings on the domestic violence order, the committee, made up of Circuit Court and Superior Court judges and staff, took a larger view of the process and made several recommendations for the court to adopt moving forward.
Seven recommendations for improvements
The recommendations from the committee include ways to increase public knowledge among the public on both the process and the resources available to them, additional training for court personnel and updating the legal definition of "abuse."
This last p oint was the issue which led to the dismissal of the order of protection against Lorman. Under New Hampshire law, in order to obtain a domestic violence order of protection, there are three standards that must be met: the people involved having a qualifying relationship, the defendant having committed one or more criminal acts specified by statute and there a "credible present threat" to the safety of the plaintiff.
In the case against Lorman, it was this third point that was found lacking, and the committee focused its review on how the law defines the term.
"To constitute a credible present threat, the defendant's conduct must threaten the plaintiff's physical safety, as opposed to his or her emotional or financial wellbeing," the report states. "Additionally, the defendant's threat to the plaintiff's physical safety must be ongoing and specific."
It is not enough, under the current law, for there to be a general fear for personal safety based upon past physical violence, recent nonviolent harassment or both paired together.
Multiple court cases have upheld this issue, according to the report, including the U.S. Supreme Court, which has ruled that even in cases where ongoing behavior was having a negative impact on a persons emotional well-being, it might not constitute an "ongoing credible threat to physical safety."
A long history
In the case against Lorman, his former partner, identified in the report by her initials, the committee found that there was a basis of a long history of interpersonal violence between the two, including coercion and control tactics.
Based on the woman's testimony during her domestic violence protection order hearings, the woman alleged that Lorman was "sexually violent and coercive" and used sex as "punishment." The woman told the court that she and Lorman would made "deals," sometimes in writing, about various sexual acts as punishment. Hall found that the testimony revealed that Lorman was coercive and controlling, but that the sexual acts were legally consensual, at least in some points in the relationship.
The woman alleged Lorman assaulted her in 2016, causing bruises on her chest, legs and genitals, and that Lorman had told her about previous acts of violence in his past, related to participation in criminal organizations.
The woman also alleged Lorman had called her place of employment and members of her family to tell them "horrible things" and had isolated her and abused her emotionally and financially.
There were also multiple incidents more recently, leading to the woman's attempt to obtain an order of protection. On Aug. 27, the woman alleged Lorman had reorganized his guns in front of her while angry, which sher perceived as an attempt to intimidate her.
On Aug. 30, Lorman reportedly searched the woman's emails to learn that she had rented a room at a yacht club.
On Sept. 6, Lorman reportedly tracked the woman to Marblehead, Mass., using her cellphone and texted her messages telling her he knew where she was and using language such as "I will make you pay." When the woman agreed to meet him in a public park, he allegedly yelled profanities at her, telling her "I am going to (expletive) you up. I am going to (expletive) up your whole life. … You can't trust anything to be OK anymore. I am going to turn your world upside down. You'll see. You'll pay. You chose this."
The woman told the court the incident at the park made her fear to return to the home she shared with Lorman and that it was the main motivation behind her desire to seek a protective order, and that she took his comments as a threat to her physical safety.
Lorman reportedly blackmailed the woman to agreeing to talk to him at their home on Sept. 15. She did not go to the meeting, but went to the local police, who advised her to seek a restraining order.
When a neighbor informed the woman Lorman had left the house, she returned to collect her belongings. Lorman returned while the woman was there and allegedly presented her with an "ultimatum," threatening to tell friends and family "sordid details" of her personal life with her friends and family unless she agreed to be his "sex slave" for five days.
Police arrived during the confrontation, and ordered Lorman to return the keys to the woman and leave the home, which he did. The woman did not stay in the home out of fear of Lorman. On that day, Lorman allegedly began texting and calling her employers and family.
Dismissal of the protection order
While the committee ultimately did not find fault with Hall's ruling on the dismissal of the order of protection against Lorman, they did note the court appeared to focus on the woman's concerns about blackmail and damage to her reputation, rather than fears of physical harm.
The court, the report found, took statements about "[turning] your world upside down," and "final ultimatum" to mean that Lorman would harm the woman's reputation.
"The court understood the plaintiff's expressed fear for her physical safety to be a generalized fear about what the defendant might do in the future, rather than a fear of specific violence as required to establish a credible present threat," the report stated. "Judge Hall noted that her perception about the lack of present threat was strengthened by the absence of any testimony about acts of physical violence since 2016."
The committee noted that with additional time and the ability to review the recording of the hearing multiple times, there were statements from the woman indicating she feared for her physical safety.
"Judge Hall, who did not review the audio of the hearing prior to meeting with the committee, candidly admitted she did not recall all of these statement from the hearing," according to the report.
Still, the committee concluded "...the court's understanding of the facts was not unreasonable, even if other jurists or members of the Committee may have reached different factual conclusions."
The next steps
The committee noted that the current standards for defining "abuse" under the law fail to capture modern understandings of intimate partner violence and coercive control tactics used by abusers, doesn't take into account how nonviolent behaviors can be a precursor to violence or use evidence-based practices for identifying violence risk.
In its recommendations, the committee suggested the court conduct a review of protection order forms, to make it more clear the elements a plaintiff is required to prove in order to gain relief; develop better tools to ensure that survivors of partner violence can access all protection order options; update the legal definition of abuse; increase awareness on non-precedent opinions in protection order cases among attorneys, advocates and the public; provide guidance to plaintiffs and defendants on what to expect and how best to prepare their case; explore steps the court can take to ensure survivors of abuse receive assistance from counsel and victim advocates; and offer training to victim advocates in completing petitions and preparing for hearings.
The New Hampshire Judicial Branch has already taken the first step in responding to the recommendations of the committee by setting up a multidisciplinary task force.
Chaired by New Hampshire Supreme Court Associate Justice Anna Barbara Hantz Marconi, the task force will be conducting a systemic review of domestic violence cases in the court system.
The task force is expected to meet throughout the winter, and submit a final report by late February.
wilton nh


text:
Death of a Salesman: CliffsNotes
By: Jennifer L. Scheidt M.A.
Narrated by: Dan John Miller
Series: CliffsNotes
Categories: Literature & Fiction, Literary History & Criticism
Summary and Analysis of Death of a Salesman by Arthur Miller
By: Michael Peters
Narrated by: Ron Welch
Death of a Salesman is a 1949 play written by American playwright Arthur Miller. It was the recipient of the 1949 Pulitzer Prize for Drama and Tony Award for Best Play. The play premiered on Broadway in February 1949, running for 742 performances, and has been revived on Broadway four times, winning three Tony Awards for Best Revival. It is widely considered to be one of the greatest plays of the 20th century. (Disclaimer: This is NOT the original book. If you're looking for the original book, it is available from Amazon.)
By: Arthur Miller
Narrated by: Stacy Keach, Richard Dreyfuss, Ed Begley Jr., and others
Original Recording
In the rigid theocracy of Salem, Massachusetts, rumors that women are practicing witchcraft galvanize the town. In the ruthlessness of the prosecutors and the eagerness of neighbor to testify against neighbor, The Crucible mirrors the anti-Communist hysteria in the 1950s.
Abridged Version
By Michael G. Stoffel on 05-07-12
A Streetcar Named Desire (Dramatized)
By: Tennessee Williams
Narrated by: Rosemary Harris, James Farentino
Caedmon is proud to release this archival full-cast recording of Tennessee Williams's A Streetcar Named Desire. Blanche DuBois arrives at her sister Stella's New Orleans apartment seeking refuge from a troubled past but her ethereal spirit irks Stella's husband, the loutish Stanley Kowalski. Crudely, relentlessly, he unmasks the lies and delusions that sustain Blanche, until her frail hold on reality is shockingly severed.
Great play, questionable acting
By C Baum on 03-02-16
A BBC Radio 3 Full-Cast Production
Narrated by: Anastasia Hille, George MacKay, Patsy Ferran, and others
Tom shares the cramped and claustrophobic tenement home with his overbearing mother, Amanda, and painfully shy sister, Laura. He works in a warehouse but dreams of becoming a poet, escaping his mundane life. Laura hides at home, lacking the confidence to engage meaningfully with the outside world, preferring instead to lose herself in her collection of fragile glass animals. Amanda sells magazine subscriptions over the phone and commits herself to finding a match for her daughter. One day, Tom succumbs to his mother's pressure and brings home a gentleman caller....
Liberty Science
By Tuba Aytekin on 10-20-20
By: F. Scott Fitzgerald
Narrated by: Jake Gyllenhaal
F. Scott Fitzgerald's classic American novel of the Roaring Twenties is beloved by generations of readers and stands as his crowning work. This new audio edition, authorized by the Fitzgerald estate, is narrated by Oscar-nominated actor Jake Gyllenhaal (Brokeback Mountain). Gyllenhaal's performance is a faithful delivery in the voice of Nick Carraway, the Midwesterner turned New York bond salesman, who rents a small house next door to the mysterious millionaire Jay Gatsby....
Gyllenhaal is an incredible narrator
By Lauren on 04-24-13
By: Richard Wright
Narrated by: Peter Francis James
Right from the start, Bigger Thomas had been headed for jail. It could have been for assault or petty larceny; by chance, it was for murder and rape. Native Son tells the story of this young black man caught in a downward spiral after he kills a young white woman in a brief moment of panic. Set in Chicago in the 1930s, Richard Wright's powerful novel is an unsparing reflection on the poverty and feelings of hopelessness experienced by people in inner cities across the country and of what it means to be black in America.
By Patrick on 08-21-10
By: Eugene O'Neill
Narrated by: Paul Adelstein, Orson Bean, Amy Brenneman, and others
Eugene O'Neill's tale of Ephraim Cabot, greedy and hard like the stone walls that surround his farm, the family patriarch brings home his new young bride, Abbie. His grown sons dissaprove; one leaves but the other stays to fight for the family fortune. What follows is a tragedy of epic proportions.
A raw and modern take on a classic
By Maria on 08-06-10
Narrated by: Julie Harris, James Farentino, Arye Gross, and others
World War II is over and a family, mourning a son missing in action, plants a memorial tree and tries to go on with their lives. A storm blows down the tree and a devastating family secret is uprooted, setting the characters on a terrifying journey towards truth.
terrific play, great performances
By Calliope on 04-20-15
Adventures of Huckleberry Finn: A Signature Performance by Elijah Wood
By: Mark Twain
Narrated by: Elijah Wood
A Signature Performance: Elijah Wood becomes the first narrator to bring a youthful voice and energy to the story, perhaps making it the closest interpretation to Twain's original intent.
Masterful Narration
By Michael Balzoa on 03-11-11
Macbeth: Fully Dramatized Audio Edition
By: William Shakespeare
Narrated by: full cast
Macbeth, one of Shakespeare's most popular plays, is among the most powerful and influential tragedies in the English language. Promised a golden future as ruler of Scotland by three sinister witches, Macbeth murders the king in order to succeed to the throne. Tortured by his conscience and fearful of discovery, he becomes fatally enmeshed in a web of treachery and deceit.
By Laura W. on 05-25-18
By: Henrik Ibsen
Narrated by: Carson Beck
A Doll's House is a three-act play written by Norway's Henrik Ibsen. It premiered at the Royal Theatre in Copenhagen, Denmark, on December 21, 1879. The play is set in a Norwegian town circa 1879. A Doll's House was based on the life of Laura Kieler, a good friend of Ibsen. Much that happened between Nora and Torvald happened to Laura and her husband, Victor. Similar to the events in the play, Laura signed an illegal loan to save her husband. She wanted the money to find a cure for her husband's tuberculosis.
By: Luis Valdez
In 1943, Los Angeles exploded in the infamous Zoot Suit riots, provoked by the Sleepy Lagoon murder case that railroaded young Chicano gang members who happened to be in the wrong place at the wrong time. Valdez masterfully synthesizes fact and fiction, using the case to examine Chicano Zoot Suit culture of the '40s, prejudices, the role of the media in the judicial system, and Latino family culture.
By Lisa Canales on 04-05-16
By: Kate Chopin
Narrated by: Susie Berneis
Unsatisfied with the expectations of Creole society and unhappy with her family life, Edna Pontellier begins to fall in love with the dapper Robert Lebrun. Lebrun's flirtations, along with the lifestyle of renowned musician Mademoiselle Reisz, rejuvenates Edna's sense of freedom and independence. However, an affair with the womanizer Alcee Arobin provides Edna with a taste of the danger that comes with living outside of social convention.
Good story, great reading.
By Donald on 03-14-17
By: Zora Neale Hurston
Narrated by: Ruby Dee
Their Eyes Were Watching God, an American classic, is the luminous and haunting novel about Janie Crawford, a Southern Black woman in the 1930s, whose journey from a free-spirited girl to a woman of independence and substance has inspired writers and readers for close to 70 years.
Ruby Dee is amazing
By Jennifer on 04-20-13
By: Ivan Turgenev
Narrated by: David Horovitch
When Arkady Petrovich comes home from college, his father finds his eager, naive son changed almost beyond recognition, for the impressionable Arkady has fallen under the powerful influence of the friend he has brought with him. A self-proclaimed nihilist, the ardent young Bazarov shocks Arkady's father by criticising the landowning way of life and by his outspoken determination to sweep away the traditional values of contemporary Russian society.
Romantic Russian Novel
By Candida on 07-04-15
By: Nathaniel Hawthorne
Narrated by: Kate Petrie
One of the most important novels in classic literature, Nathaniel Hawthorne's The Scarlet Letter tackles the subject of adultery, with the notorious Hester Prynne at the forefront of the scandal in the Massachusetts Bay Colony. In the beginning of the novel, Hester is serving time in prison for having a child out of wedlock and is forced to wear a scarlet A on her clothing at all times, so she cannot run from her sin no matter where she goes.
'Thou Wast Not Bold! Thou Wast Not True!'
By Gretchen SLP on 12-20-15
Romeo and Juliet: The Fully Dramatized Audio Edition
In Romeo and Juliet, Shakespeare creates a tragic world in which two young people fall in love. It is not simply that their families disapprove; the Montagues and the Capulets are engaged in a blood feud. This play, set in an extraordinary world, has become the quintessential story of young love. This new full-cast recording - based on the most respected edition of Shakespeare's classic - expertly produced by the Folger Theatre, is perfect for students, teachers, and the everyday listener.
Great Dramatization!
By Karen Mitchell Smith on 04-26-16
Hamlet: Fully Dramatized Audio Edition
Hamlet, Shakespeare's most popular, and perhaps most puzzling play, follows the form of a "revenge tragedy", in which the hero, Hamlet, seeks vengeance against his father's murderer, his uncle Claudius, now the king of Denmark. Much of its fascination, however, lies in its uncertainties. This new full-cast recording - based on the most respected edition of Shakespeare's classic - expertly produced by the Folger Theatre, is perfect for students, teachers, and the everyday listener.
did they record this on mt everest?
By Kit on 01-11-20
This CliffsNotes study guide on Arthur Miller's Death of a Salesman supplements the original literary work, giving you background information about the author, an introduction to the work, and critical commentaries, all for you to use as an educational tool that will allow you to better understand the work. This study guide was written with the assumption that you have read Death of a Salesman.
Reading a literary work doesn't mean that you immediately grasp the major themes and devices used by the author; this study guide will help supplement you reading to be sure you get all you can from Miller's Death of a Salesman.
CliffsNotes Review tests your comprehension of the original text and reinforces learning with questions and answers, practice projects, and more. For further information on Arthur Miller and Death of a Salesman, check out the CliffsNotes Resource Center at www.cliffsnotes.com.
©2000 Wiley Publishing, Inc. Adaptation of original text © 2011 by Wiley Publishing, Inc. (P)2011 Brilliance Audio, Inc.
The Crucible: CliffsNotes
Napoleon Hill's Outwitting the Devil
It Was All a Lie
What listeners say about Death of a Salesman: CliffsNotes
Mary Beth Bretzlauf
Would you consider the audio edition of Death of a Salesman: CliffsNotes to be better than the print version?
I've not read the printed Cliff Notes, but the audio version was convenient and helpful. My time was so crazy at the time I needed to read the book. Listening to the Cliff Notes in the car gave me the insight I needed.
Would you be willing to try another book from Jennifer L. Scheidt, M.A.? Why or why not?
If I needed to, I would.
I would like to hear the play too!
Robert Saka
it really helped me to pass !!
I used this to study for my grade 12 .thanks to this ..I got an A
Great Aid
This is a great way to get a deeper understanding of the overall story. I recommend.
why ebook compasion not avaliable
This book wasn't for you, but who do you think might enjoy it more?
what the hell amazon are doing? If the ebook compassion is not avaliable, why don't someone/ some signs tell me before l buy it. I buy a useless book
What could Jennifer L. Scheidt, M.A. have done to make this a more enjoyable book for you?
Make the ebook compassion avaliable as soon as possible
Would you be willing to try another one of Dan John Miller's performances?
Yes, to compensate me
muovikassi88
I've been reading Miller's death of salesman as a part of a university course and this guide has been truly helpful, just remember that it is import and fun to first read the work, in this I recommend reading it twice before using cliffnotes, and then compare your own ideas, this course by cliffnotes actually gave me much more food for thought than the four lectures at uni, though of course some points of view from the professor were different as were some of my views,but this is a good thing since reader response is infinitive in nature. if you are doubting whether to buy the guide, do it!


Steffi is here to help people plan their life/career goals and strategically plan their future. She is an inspirational and intuitive coach who believes strongly in helping others set goals to achieve their personal dreams. Steffi actively listens to your vision and values and guides you step-by-step, and through action-oriented conversation, to create a pro-active life and career template. Call it a life action plan, and it works.
Through her own core life work and career planning, she has changed her career from a reporter/producer (decade at Global Television) to a media trainer to a marketing specialist for a healthcare system and now, today, her most fitting role is a personal transformation coach. She has had her own mentors/coaches who have supported her personal and spiritual development, and she believes a great coach can partner with someone to design their life changes in a compassionate and empowering way.
Her professional experience involves business development, governance, and high-level marketing as evidenced in her role as Vice-President of Communications and Marketing at St. Peter's Health System, Senior Marketing/Communications for GCY ,a boutique law firm in Toronto (www.gcylaw.com) . Her background also includes journalism, producing, and hosting of AM900CHML radio program "Successful Aging", and public speaking - she presents workshops and keynotes on The Importance of a Life and Career Plan and Why Kindness Matters in schools and corporations. Steffi is also the founder of Connection Corner, a virtual on-line support group for women as they make career and life changes.
Stephanie holds an Honours BA degree in English and Drama from Queen's University, Certificate of Achievement, Leadership Program at Queen's University, a Women in Management Certificate from Ryerson University, and a Leadership Certificate from the Bay Area Leadership Program, Hamilton. She was also nominated for a Spirit Award at Global Television and nominated for the City of Hamilton Women in the Workplace Award while at St. Peter's as Vice President of Marketing & Communications.
How to Start? Your First Step is Simple.
Contact Steffi about a complimentary phone chat - and see where things go from there.


In 2014 they received an Obie award and in 2016 the New York Foundation for the Arts named them artist fellows. They will use their CAI residency to develop a new piece entitled Manmade Earth.
Manmade Earth is at the intersection of performance and installation. A guided performance that is created by the attending audience, this piece continues 600 HWM's singular trajectory of making work both for and by community. The audience that comes together for the performance are the authors of the work. In this piece, an ever-shifting landscape of objects and materials are manipulated by the audience. Manmade Earth examines the evolution of our society; how we come together to create what we could not on our own. Buildings get built, destroyed, built again. How do the structures that we make push us together or keep us apart?


I have listed a new property at 1525 Coy AVE in Saskatoon.
OPEN HOUSE SUNDAY JAN. 20, 2019 12:30-2:00 pm. Beautiful 1902 sq.ft. semi-detached 2-storey home with an absolutely amazing layout in the mature area of Buena Vista. On the main floor is a spectacular kitchen with a large island, quartz counter tops, numerous cabinets and a oversized spacious walk in pantry. To assist in food preparation and for entertaining purpose there is a butlers pantry. Stainless steel refrigerator, stove, built-in dishwasher and microwave are included. The living room is bright and open to the dining area and kitchen and has an electric wall fireplace. Also on the main floor is a large 2 piece bathroom and separate main floor laundry. On the second floor is an extra large master bedroom with a separate closet area with 2 large closets with customized shelving and a large ensuite bathroom. The 2 bedrooms on this level are also spacious with customized shelving in closets as well as the four piece bath. The basement consists of a recreation room, bedroom, rough in for bathroom and utility room. The basement finishing has been completed with drywall and is awaiting the finishing touches by the new owner. This property has been completely renovated and all the mechanical has been replaced and new central air conditioning is included. The condo fees are set at $90 per month and include water and sewer. There are 2 parking spaces at the back with an opportunity for a carport or an oversized garage at new owners expense. The back part of the duplex will be completed and up for sale at a later date. This is a must see property! Call your REALTOR® today to arrange a viewing.