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Schematic representation of the study population. ICU indicates intensive care unit; VRE, vancomycin-resistant enterococci.
Pulsed-field gel electrophoresis illustrating clonal isolates with epidemiological associations. Lane 1 is the Staphylococcus aureus American Tissue Culture Collection 8325 size marker. Lanes 2 through 5 represent a cluster of 4 patients colonized with strain II between March 7, 1995, and April 12, 1995. These patients were epidemiologically linked on the basis of overlapping hospital stays in 2 non–intensive care unit wards. Lanes 6 and 7 represent 2 additional temporally linked patients colonized with strain II May 1995 to June 1995. Lanes 9 and 10 represent patients colonized with strain I epidemiologically linked on Surgical Intensive Care Unit–West. Lanes 11-13 represent 3 other patients colonized with strain I with overlapping stays on Surgical Intensive Care Unit–East.
Demographic Data for 290 Patients Admitted to the Surgical Intensive Care Unit: Bivariate Analysis*
Bivariate Analysis of Antibiotic Exposures and Colonization With VRE* in 290 Patients Admitted to the Surgical Intensive Care Unit
Analysis of Antibiotic Exposures and Colonization With VRE in 290 Patients Admitted to the Surgical Intensive Care Unit, Crude and Adjusted for Length of Stay*
Logistic Regression of Risk Factors for Colonization With VRE*
Centers for Disease Control, Nosocomial enterococci resistant to vancomycin-United States, 1989-1993. MMWR Morbid Mortal Wkly Rep. 1993;42597- 599Google Scholar
Moellering RC Jr Emergence of enterococcus as a significant pathogen. Clin Infect Dis. 1992;141173- 1178Google ScholarCrossref
Quale JLandman DSaurina GAtwood EDiTorre VPatel K Manipulation of a hospital antimicrobial formulary to control an outbreak vancomycin-resistant enterococci. Clin Infect Dis. 1996;231020- 1025Google ScholarCrossref
Hospital Infection Control Practices Advisory Committee (HICPAC), Recommendations for preventing the spread of vancomycin resistance. Infect Control Hosp Epidemiol. 1995;16105- 113Google ScholarCrossref
Frieden TRMunsiff SSLow DE et al. Emergence of vancomycin-resistant enterococci in New York City. Lancet. 1993;34276- 79Google ScholarCrossref
Chow JWFine MJShlaes DM et al. Enterobacter bacteremia: clinical features and emergence of antibiotic resistance during therapy. Ann Intern Med. 1991;115585- 590Google ScholarCrossref
Morris JG JrShay DKHebden JN et al. Enterococci resistant to multiple antimicrobial agents, including vancomycin: establishment of endemicity in a university medical center. Ann Intern Med. 1995;123250- 259Google ScholarCrossref
Karanfil LVMurphy MJosephson A et al. A cluster of vancomycin-resistant Enterococcus faecium in an intensive care unit. Infect Control Hosp Epidemiol. 1992;13195- 200Google ScholarCrossref
Montecalvo MAShay DKPatel P et al. Bloodstream infections with vancomycin-resistant enterococci. Arch Intern Med. 1996;1561458- 1462Google ScholarCrossref
Luber AD Relative importance of oral versus intravenous vancomycin exposure in the development of vancomycin-resistant enterococci. J Infect Dis. 1996;1731292- 1293Google ScholarCrossref
Shay DKMaloney SAMontecalvo M et al. Epidemiology and mortality risk of vancomycin-resistant enterococcal bloodstream infections. J Infect Dis. 1995;172993- 1000Google ScholarCrossref
Boyle JFSoumakis SARendo A et al. Epidemiologic analysis and genotypic characterization of a nosocomial outbreak of vancomycin-resistant enterococci. J Clin Microbiol. 1993;311280- 1285Google Scholar
Edmond MBOber JFWeinbaum DL et al. Vancomycin-resistant Enterococcus faecium bacteremia: Risk factors for infection. Clin Infect Dis. 1995;201126- 1133Google ScholarCrossref
Quale JLandman DAtwood E et al. Experience with a hospital-wide outbreak of vancomycin-resistant enterococci. Am J Infect Control. 1996;24372- 379Google ScholarCrossref
Livornese LLDias SSamel C et al. Hospital-acquired infection with vancomycin-resistant Enterococcus faecium transmitted by electronic thermometers. Ann Intern Med. 1992;117112- 116Google ScholarCrossref
Bonten MHayden MNathan C et al. Epidemiology of colonization of patients and environment with vancomycin-resistant enterococci. Lancet. 1996;3481615- 1619Google ScholarCrossref
Slaughter SHayden MNathan C et al. A comparison of the effect of universal use of gloves and gowns with that of glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care unit. Ann Intern Med. 1996;125448- 456Google ScholarCrossref
Knaus WAWagner DPDraper EA et al. The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults. Chest. 1991;1001619- 1636Google ScholarCrossref
Charlson MEPompei PAles KLMackenzie CR A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40373- 383Google ScholarCrossref
D'Agata EVenkataraman LDeGirolami P et al. Colonization with broad spectrum cephalosporin-resistant gram negative bacilli in intensive care units during a non-outbreak period: prevalence, risk factors, and rate of infection. Crit Care Med. In press.Google Scholar
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Maslow JSlutsky AMArbeit RD The application of pulsed-field gel electrophoresis to molecular epidemiology. Persing DHSmith TFTenover FCWhite Jeds. Diagnostic Molecular Microbiology Principals and Applications. Washington, DC American Society for Microbiology1993;563- 572Google Scholar
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Critical Care Medicine Infectious Diseases Public Health
Ostrowsky BE, Venkataraman L, D'Agata EMC, Gold HS, DeGirolami PC, Samore MH. Vancomycin-Resistant Enterococci in Intensive Care Units: High Frequency of Stool Carriage During a Non–Outbreak Period. Arch Intern Med. 1999;159(13):1467–1472. doi:10.1001/archinte.159.13.1467
Vancomycin-Resistant Enterococci in Intensive Care Units: High Frequency of Stool Carriage During a Non–Outbreak Period
Belinda E. Ostrowsky, MD; Lata Venkataraman, MD; Erika M. C. D'Agata, MD; et al Howard S. Gold, MD; Paola C. DeGirolami, MD; Matthew H. Samore, MD
From the Division of Infectious Diseases, Department of Medicine (Drs Ostrowsky, Gold, and Samore), Microbiology Laboratory, Department of Pathology (Drs Venkataraman and DeGirolami), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass; Division of Infectious Diseases, Vanderbilt University, Nashville, Tenn (Dr D'Agata). Dr Ostrowsky is now with the National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga; Dr Samore is now with the University of Utah, Salt Lake City.
Background We aimed to define the epidemiological associations of vancomycin-resistant enterococci (VRE) in intensive care units (ICUs) during a non–outbreak period by examining prevalence, risk factors for colonization, frequency of acquisition, and molecular strain types.
Design A prospective cohort design was followed. Consecutive patient admissions to 2 surgical ICUs at a tertiary care hospital were enrolled. The main outcome measures were results of serial surveillance cultures screened for VRE.
Results Of 290 patients enrolled, 35 (12%) had colonization with VRE on admission. The VRE colonization or infection had been previously detected by clinical cultures in only 4 of these patients. Using logistic regression, VRE colonization at the time of ICU admission was associated with second- and third-generation cephalosporins (odds ratio [OR]=6.0, P<.0001), length of stay prior to surgical ICU admission (OR=1.06, P=.01) greater than 1 prior ICU stay (OR=9.6, P=.002), and a history of solid-organ transplantation (OR=3.8, P=.021). Eleven (12.8%) of 78 patients with follow-up cultures acquired VRE. By pulsed-field gel electrophoresis, 2 strains predominated, one of which was associated with an overt outbreak on a non-ICU ward near the end of the study period.
Conclusions Colonization was common and usually not recognized by clinical culture. Most patients who had colonization with VRE and were on the surgical ICU acquired VRE prior to surgical ICU entry. Exposure to second- and third-generation cephalosporins, but not vancomycin, was an independent risk factor for colonization. Prospective surveillance of hospitalized patients may yield useful insights about the dissemination of nosocomial VRE beyond what is appreciated by clinical cultures alone.
THE ENTEROCOCCUS is a significant nosocomial pathogen, currently ranked as the fourth most common cause of hospital-acquired infection by the National Nosocomial Surveillance System of the Centers for Disease Control and Prevention.1 It possesses inherent resistance to several antimicrobial agents and exhibits a propensity to acquire resistance to others.2 The emergence of vancomycin-resistant strains has brought particular attention to this organism and has led to intensive efforts at controlling its spread.3,4 Despite these control efforts, hospitals in the United States have experienced a rapid increase in the percentage of vancomycin-resistant enterococci (VRE).1,5-7 During the initial period of spread, the incidence of VRE was reported to be much higher among patients located in intensive care units (ICUs) compared with other wards.1,8,9 Significant associations were also observed between VRE infection and exposure to vancomycin.5,7,10 However, most studies of nosocomial VRE focused on patients identified only by clinical cultures,11-14 or were of relatively small size.8,15 Few studies have performed serial surveillance cultures in a large defined population.16,17
To address these epidemiological associations, we conducted a prospective surveillance study of patients admitted to 2 surgical ICUs (SICUs) during a non–outbreak period. The goals were to (1) define prevalence of VRE at the time of ICU admission and incidence of acquisition during follow-up, (2) assess risk factors for baseline VRE colonization and acquisition, focusing on antibiotic exposures, and (3) assess patient-to-patient transmission of VRE by correlating molecular typing with epidemiological factors.
Study population and sample collection
The Beth Israel Deaconess Medical Center, West Campus, in Boston, Mass, is a 420-bed tertiary care hospital with approximately 12,000 annual admissions. During the period of this study, there were 2 SICUs, (SICU-East and SICU-West) each with 8 single patient rooms and a nurse-patient ratio of 1:2, with occasional cross coverage. Patients were enrolled in the study between January 15, 1995, and June 15, 1995. This study was performed when the clinical detection of VRE was infrequent, approximately 2 cases per month in the entire hospital. At the time of the study, the prevalence of vancomycin-resistance among clinical enterococcal isolates was 8% to 9%.
Using cotton swabs (Starplex, Etoibicoke, Ontario), the following sites were cultured: rectum, oropharynx, skin, and gastric fluid if a nasogastric tube was present. Rectal swabs coated in stool were considered adequate specimens. The subset of rectal swabs was used for this analysis. Prior to specimen collection, verbal consent was obtained from the patient or family member.
Baseline surveillance cultures were obtained from patients within 24 hours of admission to the SICU. Follow-up cultures were collected from patients who remained in the SICU for 3 days or longer. Cultures were obtained at the following intervals: days 3 to 4, days 7 to 8, days 15 to 26, and every 2 weeks thereafter for as long as the patient remained in the SICU.
Demographic and clinical data were recorded on all patients on the day of their SICU admission, before culture results were available. Underlying diseases were classified according to the organ system involved. The Acute Physiology and Chronic Health Evaluation III score18 and Charlson criteria19 were used to measure the severity of illness of the patients admitted to the SICU and to classify co-morbid conditions, respectively. Computerized pharmacy databases were used to determine inpatient exposures to antibiotics. Chart review was used to identify additional demographic data.
Microbiologic methods
Samples were initially processed to identify resistant gram-negative bacilli; then swabs were frozen in separate glass vials containing 2 mL of 0.6% glycerol. The analysis of resistant gram-negative rods in this population has been reported elsewhere.20 To recover VRE, frozen rectal swabs were thawed, and plated on media containing colistin and nalidixic acid with (CNA) and without (CNV) vancomycin, 10 µg/mL (Remel, Lenexa, Kan). The swabs were sequentially inoculated onto CNA and then onto CNV plates. These plates were incubated at 35°C with 5% carbon dioxide and were examined for bacterial growth at 24 and 48 hours. Enterococci were identified by colony and Gram stain morphologic features and by standard biochemical tests.21 Enterococci from both CNA and CNV plates were screened for vancomycin resistance by plating on brain heart infusion media agar with 6-µg/mL vancomycin and then vancomycin resistance was confirmed by formal minimal inhibitory concentration (MIC) testing using the agar dilution method. Isolates with an MIC to vancomycin of 8 µg/mL or higher were classified as VRE. Isolates were speciated by use of API-Rapid Strep Strips (bioMerieux Vitex, Inc, Hazelwood, Mo), growth in motility media at 30°C (Remel), and evaluation of pigmentation. The MICs to antimicrobials including teicoplanin, ampicillin, doxycycline, chloramphenicol, and the new quinupristin-dalfopristin combination drug (Synercid; Rhone-Poulenc Rorer Pharmaceuticals Inc, Collegeville, Pa) were determined by serial dilution agar plate method using the National Committee for Clinical Laboratory Standards guidelines.22
Baseline colonization on SICU admission was defined as the presence of VRE in the initial culture. Acquisition of VRE was defined by at least 1 positive follow-up culture if baseline cultures were negative. Recent antibiotic exposure was defined as use of antibiotics within 30 days prior to study entry. Patients were considered to have epidemiological links if they had overlapping hospital stays on the same floor or in the same room within 1 month prior to culturing. Clinical cultures were defined as clinically directed cultures of sites other than stool.
In patients with more than 1 SICU admission, only the first admission was analyzed. Patients whose initial rectal swab was obtained more than 3 days after SICU admission were also excluded.
Statistical analysis was performed using SAS software (SAS Institute, Cary, NC). Categorical and continuous variables were analyzed using χ2 test and either the Student t test or nonparametric tests. Risk factors for colonization, demographics including underlying diseases, hospital and ICU exposures, and antibiotic exposures were evaluated by logistic regression using variables that were statistically significant on crude bivariate analysis (P ≤0.1) and those variables that were considered to be clinically relevant. Confounding was evaluated by assessing changes in β coefficients in models with and without putative confounders. A risk score model was developed using the covariates from the final regression model. The c statistic (area under the receiver operating characteristic curve) was calculated from this model. Survival analytic methods were used to examine acquisition of VRE.
Molecular typing
Pulsed-field gel electrophoresis (PFGE) was performed on the first VRE isolate from each patient. Plugs were prepared using standard methods.23SmaI restriction fragments were resolved using a CHEF-DRIII (Biorad, Richmond, Calif) at 6.0 V/cm for 22 hours with an initial switch time of 0.5 second and a final switch time of 35 seconds. After staining with ethidium bromide, gels were viewed and photographed under UV light. Indistinguishable isolates were assigned to the same subgroup. Isolates differing by 1 or 2 restriction bands, consistent with a single genetic event, were assigned to a subgroup within the same group.24
Description of the study population
Between January 15, 1995, and June 15, 1995, there were 416 admissions to the SICUs. One hundred twenty-six admissions were excluded from the study for the following reasons: (1) refusal and inability to collect rectal sample (44 patients), (2) SICU stay of less than 24 hours (63 patients), (3) prior admission to the SICU during same hospitalization (10 patients), and (4) other (9 patients). Thus, a study population of 290 patients was available for analysis (Figure 1).
The study patients had a mean age of 65.7 years; 55% were men and 45%, women. The most common reasons for admission to the SICU were postoperative care 195 (67.2%), cardiac disease 38 (13.1%), and gastrointestinal disorders 20 (6.9%). Eighty-two patients (28.3%) were admitted directly to the SICU and the other 208 patients were transferred to the SICU from other wards. The mean interval from hospital admission to SICU transfer was 5.1 days.
Comparison of culture methods
A total of 419 rectal swabs from the 290 study patients were cultured on both CNA and CNV media. Enterococci were identified on CNA plates from 134 swabs (112 patients). Thirty-eight of these enterococcal isolates (from 32 patients) were demonstrated to be vancomycin-resistant on the basis of growth on the vancomycin-containing brain heart infusion agar media plates and MIC testing; the other 96 isolates were vancomycin susceptible. In contrast, enterococci were recovered on CNV plates from 51 swab cultures (41 patients); 50 (40 patients) were confirmed to be VRE. In total, 56 cultures from 46 patients grew VRE. Therefore, the sensitivity for detection of VRE was 67.9% (38 of 56) and 89.3% (50 of 56) for CNA and CNV plates, respectively. Of the 46 patients with VRE, 6 were identified on CNA plates only.
The VRE isolates from 40 patients were Enterococcus faecium, 6 were enterococci species other than E faecium and Enterococcus faecalis. Thirty-nine had the VanA phenotype, 1 the VanB, and 6 the VanC phenotype. Antimicrobial susceptibility results were as follows: vancomycin MIC range: 8 to 512 µg/mL or higher (MIC90≥128 µg/mL); teicoplanin MIC range: 0.05 to 128 µg/mL (MIC90≥8 µg/mL); ampicillin MIC range: 0.5 to 128 µg/mL (MIC90≥64 µg/mL); chloramphenicol MIC range: 2 to 32 µg/mL (MIC90=8 µg/mL); doxycycline MIC range: 0.12 to 32 µg/mL (MIC90≤8 µg/mL); and the combination drug quinupristin-dalfopristin MIC range: 1 to 4 µg/mL (MIC90≤1 µg/mL).
Results of initial culture
Thirty-five (12.1% of the 290 study patients) were detected to be colonized with VRE on the initial culture. In 7 of these patients, organisms were cultured within 24 hours of admission to the hospital, whereas the other 28 patients with positive baseline cultures were transferred to the SICU from other wards. The 28 transferred patients with positive initial cultures came from 8 distinct non-SICU wards, the most common which was the surgical ward housing solid-organ transplant patients (10 patients). Six of 7 patients admitted directly to the SICU had either been transferred from outside healthcare facilities or had recent prior hospitalizations at our facility. Thus, only 1 patient with VRE colonization detected in the initial culture had no prior hospital exposure.
Four patients with positive baseline cultures had previous clinical cultures that grew VRE, from 1 to 301 days prior to study entry. The sites of positive clinical cultures were urine and wound. Only 2 patients with baseline colonization had subsequent positive clinical cultures during the study admission. One of these patients, a liver transplant recipient, developed an intra-abdominal infection due to VRE and received a prolonged course of treatment with the combination drug quinupristin-dalfopristin.
In the crude analysis, underlying diseases and measures of acuity that were associated with baseline VRE colonization included: history of a gastrointestinal tract disorder, a previous solid-organ transplantation, and a higher Acute Physiology and Chronic Health Evaluation score (Table 1). Indices of hospital exposure that correlated with VRE colonization included: a longer length of stay, hospitalization prior to this SICU admission, and multiple prior ICU stays (Table 1). Specific antibiotic exposures associated with VRE were metronidazole and second- or third-generation cephalosporins. The crude relative risk associated with intravenous vancomycin was 2.2 (P=0.06) (Table 2). None of the patients with baseline VRE colonization had received oral vancomycin.
Most antibiotic exposures were confounded by the duration of hospital stay prior to culturing (Table 3). This confounding was most severe for vancomycin: adjusting for length of stay reduced the β coefficient for vancomycin by 75%. Smaller degrees of confounding were seen when the crude and adjusted β coefficients were compared for other antibiotic categories (Table 3).
In the multivariable logistic regression model, the following 4 variables were identified as having the strongest independent association with VRE colonization: history of prior solid-organ transplantation (OR=3.8, P=.02), second- or third-generation cephalosporin treatment prior to ICU stay (OR=6.0, P=.001), duration of hospital stay prior to ICU admission, in days (OR=1.06, P=.01), and more than 1 prior ICU admission (OR=9.6, P=.002) (Table 4).
To examine the predictive value associated with these risk factors, patients were stratified into risk groups on the basis of the number of risk factors present. In this risk score model, length of stay was dichotomized at 6 days, the 75th percentile. The prevalence of colonization was 2.7% (4 of 143) in patients with 0 risk factors, 13% (13 of 97) in patients with 1 risk factor, and 39% (18 of 46 patients) in patients with 2 or more risk factors. The c statistic (area under the receiver operating characteristic curve) for this model was 0.79.
Results of follow-up cultures
A total of 136 follow-up cultures were obtained from 84 patients. Including patients with both positive and negative baseline cultures, the proportion of patients with a positive culture increased from 13.9% on the first follow-up culture (days 3-4) to 30.4% on day 11 or later. Among 78 patients whose cultures were negative for VRE at baseline, 11 (14.1%) acquired VRE during follow-up. The Kaplan-Meier estimate of the 25th percentile of time to acquisition was 15 days. Vancomycin was the single most frequent antibiotic exposure in patients who acquired VRE: 8 of 11 patients who acquired VRE received intravenous vancomycin either prior to or during their SICU admission compared with 31 of 67 patients who did not acquire VRE. However, the hazard ratio (relative risk) associated with vancomycin was only 0.7 when length of stay in the SICU was controlled for using Cox proportional hazards regression. The small number of patients who acquired VRE precluded use of a multivariable survival model.
All 9 follow-up cultures from the 6 patients with positive baseline cultures were positive.
Results of pfge analysis
The PFGE was performed on the first VRE isolate from each of the 46 patients who had colonization with VRE. Sixteen distinct groups were seen of which 12 were unique (1 patient each). Two groups (designated I and II) accounted for 56.5% of isolates (10 and 16 isolates, respectively). Neither of these strains exhibited temporal clustering. Nonetheless, prior to their positive cultures, 3 of 10 patients with strain I and 4 of 16 patients with strain II were closely linked to another patient who had colonization with VRE with the same strain by virtue of an overlapping hospital stay on the same ward or ICU. Two patients with strain II were in the same hospital room prior to their SICU admission (lanes 2 and 3 on Figure 2). Four patients with strain II were culture positive within 24 hours of admission to the hospital but could not be epidemiologically linked to each other or to other patients harboring strain II prior to their index hospitalization.
Near the end of the study period (June 1995), an overt outbreak of VRE on the transplantation ward occurred, manifested by 5 patients with positive clinical cultures for VRE during a 16-day period. The PFGE typing of isolates from this outbreak revealed strain II to be the culprit.
We examined VRE colonization in a cohort of patients admitted to 2 SICUs during a period when the incidence of VRE in the hospital as detected by clinical cultures was low. Our major findings were (1) colonization with VRE had already occurred in 12% of patients at the time of admission to the ICU, and only 4 of the 35 patients who had colonization with VRE previously or concurrently had clinical cultures positive for VRE; (2) exposure to second- and third-generation cephalosporins but not vancomycin was an independent risk factor for colonization with VRE; (3) 2 predominant VRE strains were observed, suggestive of clonal dissemination.
Vancomycin has been identified as a risk factor for VRE colonization or infection in some but not all studies.16,17,25,26 Our results demonstrate the dramatic confounding effect of length of hospital stay on the association between vancomycin and VRE, owing to the strong correlation between length of stay and VRE colonization and between length of stay and vancomycin use. Indeed, we have previously found that vancomycin is the single most common antibiotic administered to patients with long length of stay (unpublished data, 1995-1996). In contrast, adjustment for length of stay attenuated the association between VRE colonization and broad-spectrum cephalosporins to a much lesser degree. These results are compatible with other studies demonstrating a role of cephalosporins to promote VRE colonization and enterococcal superinfection.15,27
Our study also illustrates the limitation of clinical cultures alone to define the true extent of VRE within hospital populations. The greater sensitivity of stool cultures compared with clinical cultures for detection of VRE colonization is well documented.3,16,17 An unusual feature of our investigation is that the molecular typing revealed predominance of 2 strains at a time when hospital-wide clinical strains were diverse. A previous analysis of contemporaneous VRE isolates from 40 patients who had colonization or infection with VRE on the basis of clinical cultures had revealed 20 distinct PFGE restriction profiles.28 Thus, the extent of transmission of VRE during the period of the study was significantly underestimated both by the low frequency of clinical isolation and by the inability to identify an outbreak strain among clinical isolates. The high prevalence of colonization on admission to the ICU was related, at least in part, to the unrecognized spread of VRE among patients on the transplantation ward who were subsequently transferred to the ICU. At the end of the study period, an overt outbreak detected by clinical cultures was manifested on this ward. Conceivably, if the surveillance culture results had been available during the course of the study, an intervention to reduce transmission could have been implemented and might have circumvented the clinical outbreak.
A potential limitation of our study was that rectal swabs were frozen prior to culturing for VRE. Therefore, it is possible that despite the high frequency of VRE isolation, the true prevalence of VRE colonization was actually greater than observed. However, other data have shown that enterococci remain viable after freezing and so it is unlikely that this procedure caused a significant decrease in sensitivity for detection of VRE.29 We also attempted to maximize our yield of VRE by plating to both selective and nonselective media. Another limitation of this study was that an effective analysis of risk factors for acquisition of VRE was not possible owing to the small number of patients who acquired VRE after ICU admission.
We conclude that VRE acquisition among ICU patients frequently occurs prior to ICU admission and that prospective surveillance may yield useful insights into the dissemination of nosocomial VRE beyond what is appreciated by clinical cultures alone. In addition, these results suggest that screening of high-risk patients at the time of admission to the ICU to identify individuals in whom colonization with VRE had already taken place may be a useful infection control strategy. In concordance with several other studies, we were unable to establish vancomycin use as an independent risk factor for VRE colonization.16,17 Further studies are needed to assess the impact of antibiotic control programs on the incidence of VRE.
Accepted for publication September 9, 1998.
We acknowledge partial funding provided by Postdoctoral Training grant 440 from the Centers for Diseases Control and Prevention, Atlanta, Ga.
Reprints: Belinda E. Ostrowsky, MD, Centers for Disease Control and Prevention, National Center for Infectious Diseases, Hospital Infections Program, MS-A07, Atlanta, GA 30333 (e-mail: bao6@cdc.gov).


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Movie Review – Inception
Plot: In a world where technology exists to enter people's dreams, Cobb (Leonardo DiCaprio) has stolen ideas in people's minds for years. Saito (Ken Watanabe), a successful business tycoon, hires Cobb and his team for a very different kind of dream invasion known as Inception, where they will attempt to plant an idea into the head of Robert Fischer (Cillian Murphy), the owner of Saito's rival company.
The best way to describe Inception is that it's Ocean's 11 on steroids. This movie kicks ass. There's no other way to put it. Spearheaded by the best actor working in entertainment today (Leonardo DiCaprio) and several other fantastic performances, this team of dream invaders takes us on a ride that can only be described as OMG. This is a movie experience unlike anything ever tried before. Inception is like a house of cards. It's so ambitious and daring that all signs point to the house crumbling by the end, but what makes it so damn good is that the nine story house of cards stays in tact once the end credits come on. As great as the acting is, the man who deserves most of the credit is the best director working in film today – Christopher Nolan (The Dark Knight, Memento).
For a movie about mind invasion, I can only imagine what it would have been like to be inside Christopher Nolan's head when he constructed this masterpiece. And the organization is this movie's greatest strength. Everything is so complicated and mind bending, but if you are a good movie-goer and pay attention, you will find he doesn't leave many holes.
What's so fun about watching Inception play out is that the audience's focus is rewarded as the movie goes on. As Cobb and his team go deeper into the human mind, it gets crazier. Watching the progression play out towards the climax is beautiful. If you stick with it, you get more and more excited as the story plays out. There is nothing more I can say about Nolan. This is a perfectly directed film.
What's equal to the directing is the acting. Leonardo DiCaprio is flawless as always. My favorite scenes with him are just his facial expressions as he looks ravaged after doing this for so many years. His face says it all. He looks like he just sat through a movie that is fifty times more complicated than Inception. My other favorite performance is Joseph Gordon-Levitt as Arthur, Cobb's right hand man. This guy truly elevated the character. Arthur is written kind of weak, but Levitt's performance really propels him as not only one of the more likable characters, but a bad ass one at that. I found myself rooting for him the most. I hope to see this guy in a lot more movies.
Ellen Page as Ariadne, the rookie in Cobb's crew, was perfect casting. Ariadne, like the audience, is learning about all this crazy crap for the first time. We see a lot of the movie through her perspective, so it's crucial this character be very likable. It doesn't get more likable than Ellen Page. Rounding out the cast is Tom Hardy, Ken Watanabe and Cillian Murphy. They are all excellent. Unfortunately, Marion Cotillard as Cobb's wife was a little disappointing. She carries a lot of weight in the film, but aside from a couple solid scenes, her performance wasn't very memorable compared to the others.
The storyline involving Cobb and his wife takes a little while to get into, but much like everything else in this film, it pays off big time. One of the weaknesses of Inception though is that it does move a bit slow. As tension filled and action packed as a lot of these scenes are, it does take a while for them to play out. There is a long sequence in a snowy setting that drags on for a while, making it at times just another run of the mill action flick, which is inconsistent with the rest of the movie.
I didn't mind this though because every setting and visual in this film is downright gorgeous to watch. And what makes Inception so much better in the visual department as opposed to something like Avatar is they are constantly changing and doing different things with the effects and settings. Inception has visuals that destroy those lame Navi's that I wouldn't dare give any of them away here. One thing I will say is that I witnessed one of the greatest fight sequences in the history of movies.
All in all, Inception does things that movies rarely do. It reaches for perfection with new ideas and great ambition and nearly achieves them where as so many films try and do something different and bold but fail horribly. Christopher Nolan movies will now be similar to going to see a James Cameron movie in that they will be an event. I can't wait to see what other tricks this guy has up his sleeve.
Rating: 9 out of 10 (OMG)
Written by bagelcinemas Posted in Movie Reviews Tagged with Avatar hater, Christopher Nolan best director, Inception best acting, Inception better than Avatar, Inception bold, Inception movie of year, Inception Movie Review, Inception points, Inception praise, Inception Review, Leonardo DiCaprio best actor, Nolan fan
Movie Review – The Last Airbender
Top 25 All Time Villains

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Variations of Domino
Post author:adminku
The basic game of Domino is played with two players using a double-six set of tiles. Each player draws seven tiles from the set, and then alternately extends the line of play, until one player is left with nine tiles. The winner has a score equal to the total pip count of the loser's hand. During the game, the players may change the strategy or play the game in different ways. It can be quite challenging to master different types of variants of Domino.
Traditionally, the game is played by placing tiles face-up on a table. Each player must match the end of one of their dominos to part of the tile laid by the preceding player. Occasionally, doubles can be added to a line. Doubles are played perpendicular to the line and count the pips on both ends. If no dominoes are played on a line, the players must draw from the remaining tiles.
The size of the dominoes is determined by how many players are playing. For two players, one domino has twelve tiles, two players draw eleven tiles, and so on. For three players, the number of tiles depends on their number. For five players, the number of tiles is increased. For six players, there are nine tiles. In addition to the normal size, there are two-six-six-seven-six-deck styles, which use seven tiles each.
There are many different kinds of dominoes. The most common type is double-six. A set with double-six dominoes has nine tiles. One tile contains a double-six tile, while a set with double-six dominoes has nine double-six tiles. The standard double-six set contains 28 tiles. The double-six domino set has nine doubles and one single-six dominoes.
Western dominoes were originally played with two to four players. They were brought to England by French prisoners. The game is generally a positional game in which players place dominoes edge-to-edge against each other. The highest domino is called the lead, and the player with the fewest pips is the winner. The game is called "Domino Effect" because it is the result of one country's reaction to another.
In scoring games, players accumulate points during the game. The most common version is known as Hector's Rules, and it grants an extra play if the opponent calls "domino" before placing the tile. There are also some other variations of this game. In a game with Hector's Rules, a player may score extra points if he/she plays a tile that matches the next tile. The last domino in a set of five is the matador, and it scores three points.
The WA Examiner estimates that there are roughly 34 million ways to make pizza. The fact that the pizzas are so varied makes Domino's difficult to determine what will satisfy their customers' cravings. However, if they can create an ExtravaganZZZa – a pizza with every topping imaginable – then they must have some type of product to offer. For cheese lovers, the company has five different cheese pizza styles. This way, customers can find the right one to fit their taste and budget.
Kemudahan Main Togel Singapore di Hp dan Laptop
What Is Pragmatic Linguistics?
How to Play Domino
What Is Dominoes?
What is Pragmatics?
Dominoes Basics


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While more studies are needed to confirm the impact of GABA supplementation, early results are promising. Recently, researchers studied 30 healthy volunteers and found that 50 mg of GABA reduced stress and enhanced performance in subjects who were physically and emotionally stressed.* While synthetic GABA can be produced with harsh chemicals, ours is produced via a fermentation process that utilizes Lactobacillus hilgardii, a beneficial lactic acid bacteria that is used to in the traditional Korean dish kimchi.


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"Azillion" (estilizada "AZILLION") é uma canção da rapper australiana Iggy Azalea. A canção foi disponibilizada para streaming gratuito em 9 de janeiro de 2016 através de sua página no SoundCloud. "Azillion" foi lançada como single promocional do segundo álbum de Azelea, Digital Distortion, porém ele foi cancelado.

Antecedentes e lançamento
Em outubro de 2015, Azalea anunciou o título de seu segundo álbum, Digital Distortion, que seria lançado no ano seguinte, com uma faixa de promoção intitulada "Azillion" e um projeto de divulgação do primeiro single antes de seu lançamento. Em dezembro, durante um bate-papo com fãs no Twitter, ela revelou que o primeiro single seria intitulado "Team". Durante esse mês, ela também compartilhou trechos de ambas as faixas, juntamente com outra intitulada "7teen", via Twitter, afirmando que "o conteúdo, canções promocionais, vídeos virais e outras coisas legais" iriam estrear em janeiro de 2016. Em 9 de janeiro de 2016, "Azillion" foi lançada em sua página no SoundCloud. Azalea declarou que a faixa não será um single oficial do seu próximo álbum, mas sim uma prévia do que está por vir no disco.

Recepção da crítica
Edwin Ortiz, editor da Complex, escreveu: "A produção de "Azillion" inclina-se para o eletrônico, e Iggy entrega seu flow de assinatura e lirismo digestível sobre seu desempenho numa competição". Mitchell Peters, da Billboard, comentou que a faixa "club-ready" ("pronta para as festas") é cheia de sintetizadores acelerados misturados com "vertiginosas" batidas de trap. Escrevendo para o The Fader, Jeff Ihaza observou que "a música encontra o rap de Azalea sobre algo muito mais turbulento, com a produção maior do que em sua estreia em 2014".

Canções gravadas por Iggy Azalea
Canções de 2016
Canções de hip hop

redpajama_set_name: RedPajamaWikipedia


A bold dark chocolate with nostalgic notes of brownie, butterscotch, and blackberry.
Allergens: May contain traces of milk & nuts.
Review: Chocolate journalist (@thechocolatejournalist), Sharon Terenzi, recently reviewed the bar saying, "You don't become a multiple award-winner by luck. Smell of honey, incredible smooth texture (without being too creamy), notes of fudge, brownie, earthy brown butter, an incredible clean mouth and a long chocolatey aftertaste. Can't find one defect even if I wanted to!"
Origin story courtesy of Uncommon Cacao: On the southern pacific coast of Colombia, Tumaco is a region that has been hard hit by historic political conflict and plagued by narco trafficking. The predominantly Afro-Colombian population has faced a great deal of prejudice and sustainable local development has been hijacked by extensive penetration of paramilitary and narco groups. When Cacao de Colombia first explored the region back in 2011, they found cacao everywhere; drying on any flat surface farmers could find, including the road. The sheer volume of cacao was overwhelming, and the opportunity for quality and systemic improvement was obvious. Cacao de Colombia has worked with three community cooperatives to introduce centralized processing and drying. Because of the introduction of centralized processing and Cacao de Colombia's expertise in high-quality flavor development, farmers today earn 70% more income from cacao today than they did when selling dried beans to the commodity market supply chain, and have a true sustainable alternative to coca production or involvement in the narco groups.


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Paul Simon Sells Catalog To Sony Music Publishing
Paul Simon has sold his entire songwriting catalogue to Sony Music Publishing for what is expected to be a deal worth over $200 million.
Tagged as: 60s, 70s, folk, music industry, Paul Simon, publishing, rock, Simon & Garfunkel, songwriting, USA
Bob Dylan Sells Out To Universal Music
And just when you thought 2020 couldn't throw up any more surprises Bob Dylan has become a complete sell-out. Dylan has sold the publishing rights to his songwriting catalogue in a deal said to be worth around $300 million to Universal Music.
Tagged as: 60s, 70s, Abba, Adele, Al green, Alabama Shakes, Alex Da Kid, Alexandre Desplat, Alicia Keys, Ariana Grande, Axwell & Ingrosso, Bastille, Beach Boys, Beastie Boys, Bee Gees, Benny Blanco, Billie Eilish, Billy Joel, Bob Dylan, Brandi Carlile, Britney Spears, Bruce Springsteen, Carly Rae Jepsen, Carly Simon, Carole Bayer Sager, Chris Brown, Coldplay, DaBaby, Danny Elfman, Dave Matthews, Demi Lovato, Desmond child, Disclosure, Don Henley, Dua Lipa, Elton John/Bernie Taupin, Elvis Costello, Emile Haynie, Eminem, Florence + The Machine, folk, future, Gloria and Emilio Estefan, Gustavo Santaolalla, H.E.R., Halsey, Harry Styles, Imagine Dragons, Irving Berlin, J Balvin, Jack White, Jason Derulo, Jeff Bhasker, Jhené Aiko, Jimi Hendrix, Jody Gerson, Joe Jonas, Josh Groban, Justin Bieber, Justin Timberlake, Kane Brown, Keith Urban, Kendrick Lamar, Kenny Chesney, Leonard Bernstein, Lil Baby, Lil Mosey, Lil Yachty, Linkin Park, Logic, Lucian Grainge, Maren Morris, Mariah Carey, Maroon 5, Martin Garrix, Megan Thee Stallion, Metallica, Metro Boomin, Michael Chabon, Miguel, Mumford & Sons, Ne-Yo, Neil Diamond, New Order, Nick Jonas, Nicki Minaj, Otis Redding, Paul Simon, Pearl Jam, Post Malone, publishing, Quavo, R.E.M., Randy Newman, Red Hot Chili Peppers, Rex Orange County, rock, Rosalía, Sam Hunt, Selena Gomez, Sex Pistols, Shania Twain, Shawn Mendes, songwriting, Stax (East Memphis Music), Steve Mac, SZA, Taylor Swift, The Clash, the Mamas & the Papas, Tobias Jesso Jr., Troy Verges, U2, Universal Music Publishing, USA, Zedd
Apia, Shorrock and the Songs of Paul Simon … Wendy Matthews Has Some Busy Months Ahead
Over the next three months Wendy Matthews fans will have the chance to see her sing the songs of Paul Simon, make her first ever public performance of 'You've Always Got The Blues' with Kate Ceberano for Apia and sing at a very special show with Little River Band founder Glenn Shorrock in Little River, the Victorian town LRB was named after.
Tagged as: 00s, 10s, 20s, 80s, 90s, Australia, contemporary, Glenn Shorrock, Grace Jones, Paul Simon, Wendy Matthews
Mandy Patinkin Covers Paul Simon, Randy Newman on new album
Actor and singer Mandy Patinkin has taken on songs by Paul Simon and Randy Newman as part of his new album 'Diary: December 2018'.
Tagged as: 80s, classical, Mandy Patinkin, opera, Paul Simon, Randy Newman, USA
Paul Simon Plays His Last Show On Final Tour
Paul Simon has officially retired. Simon played the last show on his 'Homeward Bound The Farewell Tour' in Flushing Meadows Corona Park Flushing New York on Saturday night (22 September 2018).
Tagged as: 60s, Edie Brickell, folk, Paul Simon, Simon & Garfunkel, USA
New Music Releases For 6 September 2018
Major new titles coming this week from: Paul McCartney, Paul Simon, Krisiun, Led Zeppelin (re-issue), Skeggs, Lenny Kravitz, MNEK, Macy Gray, Clutch, Neil Diamond (Live), Lior, Paul Carrack and Mogwai.
Tagged as: Australia, Clutch, Krisiun, Led Zeppelin (re-issue), Lenny Kravitz, Macy Gray, MNEK, music industry, Neil Diamond, new music, new releases, Paul McCartney, Paul Simon, Skeggs
Paul Simon Plays British Summer Hyde Park 2018 Show
After six amazing days of music spanning from pop megastars in Bruno Mars to rock royalty The Cure, the final show of this year's British Summer Time Hyde Park was headlined by the great Paul Simon – performing the farewell date of his last tour, 'The Farewell Performance' (outside of North America).
Tagged as: 60s, 70s, 80s, 90s, contemporary, Paul Simon, rock, Simon & Garfunkel, songwriter, USA
Paul Simon Recreates Lesser Known Songs For 'Into The Blue Light'
Paul Simon has gone back to the studio to make a new album with old songs.
Paul Simon Opens Farewell Tour In Vancouver
Paul Simon says he has just one more tour in him and he opened it on Wednesday (May 16) night at Rogers Arena in Vancouver.
Tagged as: 60s, 70s, 80s, contemporary, folk, Paul Simon, pop, Simon & Garfunkel, songwriter
Paul Simon 'Graceland' Gets An EDM Make-Over
Paul Simon's iconic 'Graceland' is about to undergo a reformation with a complete make-over by Groove Armada, Richy Ahmed, MK & KC Lights and a stack of other DJs and producers.
Tagged as: 60s, 70s, 80s, Graceland, Paul Simon, pop, rock, USA, world music
Paul Simon Announces The Final End Of His USA Tour
Legendary songwriter, recording artist and performer Paul Simon has announced the final leg of Homeward Bound – The Farewell Tour.
Tagged as: 60s, 70s, contemporary, Paul Simon, pop, Simon & Garfunkel, USA
Paul Simon Final Tour Dates Revealed
Paul Simon, will embark on his farewell concert tour on May 16 in Vancouver, British Columbia, Canada at Rogers Arena.
Tagged as: 60s, 70s, 80s, folk, Paul Simon, pop, rock, Simon & Garfunkel, USA
Paul Simon Issues Statement To Explain His Retirement
It looks like Paul Simon's British Summer Time appearance in London may really be his "Final Performance"….sort of.
Paul Simon Is The Latest Legend To Say "Farewell"
Paul Simon has announced a farewell show for London in July. Simon's Hyde Park show in July is billed 'Homeward Bound: The Farewell Performance'.
R.I.P. Vincent Nguini Guitarist For Paul Simon At Age 65
Vincent Nguini, guitarist for Paul Simon since 1991, died on December 8 in Abadiânia, Brazil at the age of 65. He had been suffering from liver cancer.
Tagged as: 70s, 80s, Paul Simon, rock, USA, Vincent Nguini, world
Paul Simon 2012 Hyde Park Show To Become Live Album
Legacy Recordings has announced the June 9 release of Paul Simon: The Concert in Hyde Park, featuring Simon's July 15, 2012 performance in London.
Tagged as: 60s, 70s, contemporary, folk, Paul Simon, pop, songwriter, USA
Disturbed Recruit Myles Kennedy For 'The Sound of Silence' in Houston
Myles Kennedy of Alter Bridge became "Art Garfunkel to my Paul Simon" for David Draiman and Disturbed in Houston this week.
Tagged as: Alter Bridge, Art Garfunkel, Disturbed, Disturbed Recruit Myles Kennedy For 'The Sound of Silence' in Houston, Myles Kennedy, Paul Simon, Simon & Garfunkel, The Sound of Silence
Paul Simon Has Possibly Played His Last Ever US Show
Based on recent comments, Friday night may have been the last show on U.S. soil for Paul Simon.
Tagged as: music news, Paul Simon, Paul Simon Has Possibly Played His Last Ever US Show
Paul Simon Is Planning For Retirement
For Paul Simon, "Showbiz doesn't hold any interest for me. None."
Tagged as: music news, Paul Simon, Paul Simon Is Planning For Retirement
Paul Simon Has Highest Debut Album In 30 Years In UK
As projected, Paul Simon debuts at number 3 this week with his latest album Stranger to Stranger. The album was the biggest selling album in the U.S. over the last week but debuts at number 3 after streaming equivalents are added.
Tagged as: music news, Paul Simon, Paul Simon Has Highest Debut Album In 30 Years In UK, Stranger To Stranger
New Music Releases For 3 June 2016
Jimmy Barnes leads the weeks new music releases along with Tegan & Sara, Paul Simon, Rolling Stones, Roxette, Train, Michael Franti & Spearhead and The Kills.
Tagged as: Jimmy Barnes, Michael Franti & Spearhead, new music, new music releases, New Music Releases For 3 June 2016, Paul Simon, Rolling Stones, Roxette, Tegan & Sara, Train
Paul Simon Debuts Two New Songs in New Orleans
Paul Simon mesmerized the crowd on Friday night at the New Orleans Jazz & Heritage Festival with an eighteen-song set that included two Simon & Garfunkel songs and two from his upcoming album, Stranger to Stranger.
Tagged as: music news, New Orleans Jazz & Heritage Festival, Paul Simon
New Paul Simon 'Cool Papa Bell' #LISTEN
Paul Simon has shared Cool Papa Bell, a new track from his forthcoming album, Stranger to Stranger.
Tagged as: Cool Papa Bell, music news, New Paul Simon 'Cool Papa Bell' #LISTEN, Paul Simon
Paul Simon Raves About Disturbed Version of 'The Sound of Silence'
Paul Simon has posted a message on Facebook calling the Disturbed version of his song "Wonderful".
Tagged as: Disturbed, music news, Paul Simon, Paul Simon Raves About Disturbed Version of 'The Sound of Silence', The Sound of Silence
Paul Simon Announces 2016 US Dates
Paul Simon will be back on the road this summer with a lengthy series of dates starting with the New Orleans Jazz and Heritage Festival on April 29.
Tagged as: music news, Paul Simon, Paul Simon Announces 2016 US Dates
Paul Simon, Mavis Staples To Honor Joan Baez
Joan Baez turned 75 last Saturday (January 9) and, on January 27, a long list of veteran artists will come together at the Beacon Theatre in New York to celebrate her milestone and career.
Tagged as: Joan Baez, Mavis Staples To Honor Joan Baez, music news, Paul Simon
Dion And Paul Simon Record A Song Together
Rock 'n' roll legend Dion (DiMucci) has teamed with Paul Simon for a song for his next album coming February.
Tagged as: Dion, Dion DiMucci, music news, New York Is My Home, Paul Simon
Stephen Colbert Introduces Singer Who Looks A Lot Like Paul Simon
Stephen Colbert picked a Simon & Garfunkel covers act Troubled Waters to perform in his inaugural week for the Late Show and the lead singer looked a lot like Paul Simon.
Tagged as: music news, Paul Simon, Simon & Garfunkel, Stephen Colbert, Stephen Colbert Introduces Singer Who Looks A Lot Like Paul Simon, The Late Show
Simon & Garfunkel Come Full Circle Back To Vinyl
Legacy Recordings, the catalog division of Sony Music Entertainment, will commemorate five decades of Simon & Garfunkel's extraordinary sound with two special career-defining collections to be released in August.
Tagged as: Art Garfunkel, music news, Paul Simon, Simon & Garfunkel, Simon and Garfunkel
Paul Simon and Sting Play Italy
Paul Simon and Sting sharing a stage is a very intriguing combination even if my instinct on the matter, is the same as let's say, pizza and pineapple; wonderful as separate foods but together?!
Tagged as: Italy, Milan, music news, Paul Simon, Sting
Iggy Pop Joins Máneskin for 'I Wanna Be Your Slave'
Iggy Pop has teamed up with Italy's Máneskin for 'I Wanna Be Your Slave'.
Eurovision Winner Damiano David Cleared Of Drug Use
Eurovision Song Contest winner Damiano David has been cleared of using drugs at the event on Saturday.
Composer Ennio Morricone Dies At Age 91
Ennio Morricone, one of the world's most famous soundtrack composers, has died at the age of 91.
Andrea Bocelli Confirms He Has Recovered From COVID-19
Opera legend Andrea Bocelli has confirmed that he had, and has recovered from, the coronavirus COVID-19.
Remember When Zucchero and Paul Young Got Together And Had A Global Hit
In 1992 Italian superstar recorded a duet with Paul Young. 'Senza una donna' became a global hit.
Zucchero Has A Lot Of Famous Friends
Zucchero will perform at Bluesfest 2020. Auckland, Sydney and Melbourne will have an extra chance to see one of Europe's biggest stars.
Ron Howard is making a movie about Pavarotti
Filmmaker Ron Howard's much-anticipated Luciano Pavarotti documentary will feature unseen footage of the iconic opera singer and interviews with his widow Nicoletta and rocker Bono.


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Q: Create and use static property on static class in Delphi just like .NET I am a .NET developer and very beginner with Delphi.
I want to create a static class and use the properties like this
MyVariable := MyStaticClass.MyProperty;

I don't know how to do that.

A: Use Class Properties for this;
 type
    TMyClass = class
      strict private
        class var         // Note fields must be declared as class fields
           FRed: Integer;
           FGreen: Integer;
           FBlue: Integer;
        public             // ends the class var block
           class property Red: Integer read FRed write FRed;
           class property Green: Integer read FGreen write FGreen;
           class property Blue: Integer read FBlue write FBlue;
    end

In this example, properties named Red, Green and Blue can be used without an object reference. For document; Class Properties
To declare a readonly class (static) property;
  TMyClass = class
    private
      const FRedValue:Integer = 10;
    public
      class property Red: Integer read FRedValue;
  end;

To use this;
aColorVariable := TMyClass.Red;

A: Tips : Unit somhow equals to Class on .NET
Finally i resolve my problem by add those properties to my unit like below :

*

*create a unit by right click on the solution name and add > unit

*declare a const like below :
const myPropertyName:Integer = 0;

*add it to your form who you want to use it by
uses
YOUR_UNIT_NAME;
After

interface

section on the form

*And all i need to do is type my property name who i declared on the unit( myPropertyName)

redpajama_set_name: RedPajamaStackExchange


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package com.pchudzik.docs.feed.model;

import com.pchudzik.docs.infrastructure.test.DescriptiveCondition;
import lombok.AccessLevel;
import lombok.NoArgsConstructor;
import org.assertj.core.api.Condition;

import java.util.Objects;

/**
 * Created by pawel on 15.03.15.
 */
@NoArgsConstructor(access = AccessLevel.PRIVATE)
public class FeedCategoryAssertHelper {
	public static Condition<? super FeedCategory> name(String name) {
		return DescriptiveCondition.builderFor(FeedCategory.class)
					.predicate(category -> Objects.equals(category.getName(), name))
					.toString(category -> String.format("%n" +
							"  name equal to:%n" +
							"    <%s>%n" +
							"  but was%n" +
							"    <%s>%n", name, category.getName()))
					.build();
	}
}

redpajama_set_name: RedPajamaGithub


Bayer Leverkusen grabbed 6-2 victory at Werder Bremen, Karim Bellarabi scored one and set up two more as Leverkusen claimed its third win from nine games to finish the weekend in 12th place. Bremen remained fourth, four points behind leader Borussia Dortmund.
Kevin Volland gave Bayer Leverkusen an early lead but Bremen coach Florian Kohfeldt was angry as his team failed to be awarded a throw-in before the goal. Instead, Leverkusen was awarded the ball, Julian Brandt sent Bellarabi through on the right and the winger crossed for Volland to score from close range.
The host was amazed minutes before the break when Bellarabi set up Brandt and then scored himself on a counterattack. Bellarabi also struck the post before coming off early in the second half.
Bremen was given hope of a comeback, however, when the 40-year-old Claudio Pizarro, brought on as a halftime substitute, pulled one back on the hour mark, three minutes before Yuya Osako scored to make it 3-2.
Osako goal was initially ruled out for offside, but the ball came off a Leverkusen defender and it was awarded by VAR. Kai Havertz shocked fans at the Weser-Stadion with a chip over the goalkeeper in the 67th. Aleksandar Dragovic then made it 5-2 and Leverkusen missed further chances as Bremen's defense collapsed.
The home side miserable evening was completed with an own-goal from Sebastian Langkamp in the 77th.


Dekton® is the perfect material for ensuring that the design flows from the inside out – or vice versa – to achieving the desired harmony and continuity. Cosentino's surface is able to remain unmarked and perfect regardless of where it is placed. It adapts to the climate of its surroundings, including temperature changes, and is highly resistant to UV rays.
Dekton® makes Villa Omnia's 20-metre-long pool stand out. Its design, based on straight lines, is restrained and elegant. In it, aesthetics and safety come hand in hand.
The pool is made of custom pieces of Dekton® in Sirocco, a limestone-like rough grey that provides a natural, restrained look. The entire paved area is also equipped with no-slip grip technology to prevent slips and ensure maximum safety.
Thanks to its excellent performance when wet, Dekton® is perfect for pool applications. Neither the composition nor the aesthetics of Dekton® change over time, ensuring its long-term durability and original beauty.
Special and custom-made indoor and outdoor architectural items are made possible by the versatility of Dekton®. Villa Omnia is an impeccable example of the same.
The stairs of the villa, located both inside and outside the house, are made out of 2-cm-thick pieces of Dekton® custom-cut to size. The chosen colour is the one that dominates most of the floor of the project: the grey and urban Strato.
Every one of the bathrooms in the villa is equipped with a counter made of the quartz surface Silestone®, with one or two built-in Elegance sinks from the Bath Collection by Cosentino. The assembly creates a unique architectural piece with an a superb aesthetic result. The bold, eternal personality of the colour Blanco Zeus is simply perfect for each of the rooms.
The house's majestic open-plan kitchen features a large Silestone® island that dominates the space due to its size and brightness. Silestone® Iconic White, the purest white currently in the world of quartz surfaces, blends with the other light colours of its surroundings and contrasts with the large solid wood table.
In both bathroom and kitchen, the Silestone® surface offers beauty, visual continuity, light, quality, maximum hygiene, durability, safety and ease of cleaning. There is no doubt that it is a splendid choice for both indoor spaces.


I played this using only 5 ducks numbered one to five. I then had five boxes with different types of gifts in them numbered one to five. Then the kids would pick from ALL FIVE ducks every time and grab a gift from that numbered box. The game lasted a little longer and the kids got to pick a duck several times. The prizes in the boxes were of course simple little things.


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Home » Entertainment » Who is Mumbai born Priya Darshini? Nominated for Grammy Awards
Who is Mumbai born Priya Darshini? Nominated for Grammy Awards
Mumbai-born 36-year-old singer Priya Darshini's album 'Periphery' was recently nominated for the 2021 Grammy Awards for Best New Age Album.
Published on : Mon 30th November 2020, 10:44 AM
Mumbai-born 36-year-old singer Priya Darshini's album 'Periphery' was recently nominated for the 2021 Grammy Awards for Best New Age Album. She's trained in Carnatic music and derived her interest in music from her grandmother who was a Bharatnatyam dancer and vocalist. New York-based Priya Darshini has sung for a hundred TV and radio commercials and recorded for several Indian movie soundtracks.
Comprising of nine songs, the album is a piece of soulful music out of the harmony of different styles, genres and cultures. Darshini not only explores a feminist perspective in the album but also traces her identity as a South Indian living in New York.
Priya Darshini has sung for over 100 TV and radio commercials and has also recorded award-winning soundtracks for Indian movies. Throughout her singing career, she has worked with renowned musicians like Pearl Jam, Roy "Futureman" Wooten, Jeff Coffin, Philip Lassiter, and ukulele player Jake Shimabukuro, among others. Recording mainly Carnatic music, Darshini made her debut album in American hip hop with the Grammy-nominated Periphery, manufactured by Chesky Records. The album is a fusion of traditional Carnatic music and American pop.
The songs featured in the album are "Jahaan", "Loneliest Star", "The Banyan Tree" and "Sanware Sanware" among others. Through the album, Darshini explores the meaning of home while exploring her multicultural identity as a Tamil girl, born in Mumbai and transplanted to New York.
Darshini is also a part of many bands like Epichorus, the Karsh Kale ensemble and Priya Darshini Trio and Woman's Raga Massive. She is the founder and lead of Priya Darshini Trio and co-lead of Woman's Raga Massive. She also co-produces a festival known as Out of the Wood running for three years.
China's Chang'e-5 probe prepares to land on moon
Israel ratifies aviation, science cooperation deals with UAE
Ananya Panday: 'Khaali Peeli' gave me a character that resonates with me
Himanshi Khurana getting over Rs 1 crore to judge Punjabi reality show?
Javed Akhtar Birthday Special: A look at his legendary career in Bollywood
Ranveer Singh Upcoming Movies in 2021: Release Date, and all other details
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Tandav star Kritika Kamra said she faced prejudice coming from TV serials to Bollywood
Phone numbers of WhatsApp web users available on google search
Sunday 17th January 2021, 12:27 PM
Major accident on Lucknow- Agra expressway, one dead, several injured
Team India's courage can be described as 'dabanng': Sehwag
Another spell of light snow, rain likely in J&K soon


text:
How Do Faraday Cage Relate To Electromagenetic Spectrum – EMP Attack Survival Guide
How Do Faraday Cage Relate To Electromagenetic Spectrum
How Do Faraday Cage Relate To Electromagenetic Spectrum The Electromagnetic Pulse (EMP) Commission was established to study the potential dangers of high-altitude electromagnetic pulses. It's important to learn about the impact of these waves on the environment and the health of humans. A few decades ago, the EMP Commission published a report assessing the impact of a high-altitude electromagnetic pulse on human health. While this report was not particularly scientifically sound, it does offer some important information.
The EMP Overview provides an overview of the basic principles and techniques of the EMP. The most common method involves the use of control charts. An individual control chart is used in a consistency study. Short EMP studies are based on the X-R method. An EMP Knowledge Base article explains each of these techniques in detail. The table below shows the relationship between the two variances. The results of the study will be used to develop recommendations to prevent an EMP attack. How Do Faraday Cage Relate To Electromagenetic Spectrum
The EMP is a powerful method of testing the ability of a measurement system to cause a large amount of damage. It works by comparing the results of several tests of the same part. The test is a way to ensure that your measurement system is accurate. In case of a short EMP, one operator measures a small number of parts three times. The result of this test is a measure of how much damage it causes. How Do Faraday Cage Relate To Electromagenetic Spectrum
Several agencies and commissions have examined the possibility of an EMP attack on the U.S. and recommended actions for preventing it. The White House has also issued an executive order called Coordinating National Resilience to Electromagnetic Pulses. Although EMP weapons pose a threat to the U.S., the United States should take all necessary steps to protect its vital infrastructure. The danger of an EMP attack is so great that the risk of being attacked directly will continue to grow, regardless of how the United States reacts. How Do Faraday Cage Relate To Electromagenetic Spectrum
An EMP attack is not the only threat to our nation. It can happen to any country at any time. A large-scale EMP attack can severely damage infrastructure, including critical power grids. In addition, an EMP attack can cripple entire cities, including their economies. While the risk of an EMP attack is very small, it is important to prepare for it. This threat is one of the most pressing issues that the country must prepare for. How Do Faraday Cage Relate To Electromagenetic Spectrum
Protecting Your Family From An EMP Attack How Do Faraday Cage Relate To Electromagenetic Spectrum
One of the best ways to protect your family from EMPs is to prepare a disaster kit that includes several gallons of clean water, non-perishable foods, and emergency rations. While a natural disaster will mobilize resources, an EMP will have a longer impact and last much longer. The people closest to you might not help each other or turn on each other – an EMP could have a similar impact. How Do Faraday Cage Relate To Electromagenetic Spectrum
For communication devices, try putting them in a Faraday cage. While cell phones might work for a time after an EMP, you can't count on them. Consider buying walkie-talkies or CB radios instead. Even the best cell phones won't work after an EMP. These are cheaper options, but they will probably not work for long after the EMP strikes. But if you can afford them, make sure they're not too expensive. How Do Faraday Cage Relate To Electromagenetic Spectrum
During an EMP, you should take precautions to prevent the effects on your life. First, make sure to have a good emergency kit. The best EMP shields protect electrical appliances from electricity, solar panels, and mobile devices. Having a protective shield will keep your home and your family safe and protected. It is also an excellent way to prevent lightning strikes. You should also prepare your family by learning about EMPs. How Do Faraday Cage Relate To Electromagenetic Spectrum
A massive EMP can cause massive destruction. In the US, one nuclear bomb in the sky will disable seven million cell phones. A single EMP will cripple the nation's ability to travel, communicate, and receive medical care. An EMP is the worst disaster that could happen to humans. You'll need to make sure that your family's life and property is protected against an EMP attack. When an EMP happens, you'll be glad you prepared. How Do Faraday Cage Relate To Electromagenetic Spectrum
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Home inSight Russia and the Middle East: Oil, War, and Peace (Audio)
Russia and the Middle East: Oil, War, and Peace (Audio)
Stephen Blank • April 14, 2020
Event Date: April 14, 2020
https://www.jewishpolicycenter.org/podcast-player/19684/russia-and-the-middle-east-oil-war-and-peace-a-conference-call-with-stephen-blank.mp3
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President Barack Obama infuriated Russians in 2014, especially leader Vladimir Putin, by calling the country a "regional power" that seized part of Ukraine out of weakness, not strength. This provoked Putin and his regime to "double down" on their existing efforts to undermine U.S. interests around the world, Russian expert Dr. Stephen Blank told participants in a Jewish Policy Center conference call April 14.
Blank, a former professor of national security studies at the Strategic Studies Institute of the U.S. Army War College, has consulted for the Central Intelligence Agency and is an internationally-known authority on Russia and the former Soviet Union. He said recognizing "the paranoid mindset" is key to analyzing Moscow's international behavior.
Referring to the "color revolutions" that overthrew authoritarian rulers, sometimes Russian clients, in Ukraine, Georgia, Kyrgyzstan, Lebanon and to the "Arab spring" upheavals of 2011, Blank said "Russians believe all those revolutions were U.S. conspiracies" aimed at Moscow. So Putin's policies attempt "to thwart U.S. interests wherever possible," Blank told approximately 200 JPC call listeners.
In the Middle East, Russia is "obsessed" with gaining access to and if possible control over energy supplies, he said. But it suffered "a major defeat at the hands of the Saudis and United States" this week in the oil price war it had begun with Saudi Arabia. Russia has "lost billions of dollar in its attempt to drive Saudi Arabia out of key markets."
Blank noted that Russia and the Soviet Union before it traditionally have tried to project power beyond their borders. However, the dispatch of troops and mercenaries into the Middle East is simultaneously new for Moscow and an attempt to regain Mediterranean naval bases lost with the collapse of the Soviet Union in 1991.
In the Middle East, the Russians "are not looking for stability," according to Blank. Rather, they seek to use existing conflicts and incite new ones to "prolong the game" in which all parties look to Moscow as the influential mediator. In Syria, Russia remains determined to see its client, Bashar al-Assad, firmly restored to power after nine years of civil war.
Vladimir and Bibi – It's Only Tactical
Russia and Israel, or rather Putin and Israeli Prime Minister Benjamin Netanyahu, maintain a "purely tactical" relationship, Blank said. "Russia deters Iran from provoking Israel [and] always has been opposed to Iran having nuclear weapons." But Moscow also enables Iran, sells weapons to it and its major international surrogate, Hezbollah in Lebanon, and promotes the political recognition of Hamas, the Palestinian Islamic Resistance Movement, a U.S.-designated terrorist organization.
Russian and Turkish interests in Syria, regarding Iran, in Libya and elsewhere both overlap and conflict. That means, Blank said, that "Turkey and other Middle Eastern countries … are doing what they've done for the past 50 or 60 years—playing both sides [Russia and the United States] against the middle."
Putin, a former KGB officer, in 2005 called implosion of the Soviet Union "the greatest geopolitical catastrophe of the century." Blank said Russian activities, whether in arms sales, dispatch of military forces—as to Syria and Libya—information warfare, energy and diplomacy should be understood as part of an overall attempt to recoup the great power status and influence lost with the Soviet downfall.
Russia carried out an "impressive" military modernization over the past ten years, Blank said. Improvements include "terrific missiles of great lethality," submarines with "imposing range" and a renewed nuclear arsenal. But even before the coronavirus" pandemic the upgrades "hit a ceiling," he asserted.
Blank does not believe Russia can deny U.S. forces access to European NATO allies or NATO's movement to an eastern European front facing Putin's military. Nor does he think it could stop northward support of non-NATO states Sweden and Finland. Moscow could "inflict immense damage" on such forces if through miscalculation it precipitated armed conflict. But it would not prevail, he said.
Nevertheless, "Russia has been waging war on NATO since 2005," when the defense minister publicly declared that to be the case, Blank said. Given Kremlin paranoia about outside threats—historically useful to Russian leaders worried about domestic complaints and aware of their own political illegitimacy—information warfare and cyberweapons are aimed at Western countries every day.
Relentless Subversion
"They keep coming at us … even without success," Bland said. Such rally 'round the fatherland aggression is "the only way they can survive … to postulate a threat and fight it."
Putin "wants to subvert the Baltic governments, pressure them and reorient them toward Russia" and away from the United States and the West. But Blank doesn't believe Russia will risk war with the West by attacking Lithuania, Latvia or Estonia.
Although Russia's economy already was brittle, it's now under "a double whammy of low oil prices and the corona virus." The pandemic's effects in Russia "are worse than they are admitting," Blank said. He noted that "medical care in the provinces is not good."
With oil revenue plunging and many Russians out of work, Blank said he did not see how Putin could continue to pay for great power adventurism without high inflation. However, the Russian leader "is a deficit hawk" who might resist accumulating even greater debt. There "will be more social discontent," Blank said, but if there were a likely challenger to Putin in Russia, that person is keeping a very low profile.
Russia suffers demographic decline, but Blank does not anticipate a population collapse. Yet, along with warming brought by climate change "with the potential to devastate the Arctic and Russia itself," Moscow already must accommodate itself to China, its far eastern neighbor.
More Sanctions Won't Fix This
Is It Realistic To Ask Israel To Meddle In The Ukraine-Russia War?


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Look up a term in Redfin's Real Estate Glossary.


INGESER | SOLENIS HISPANIA S.A. WITH INGESER REACHES AGREEMENT TO CARRY OUT THE INSTALLATION OF A NEW REACTOR IN CHEMICAL PLANT Tarragona .
14 Apr SOLENIS HISPANIA S.A. WITH INGESER REACHES AGREEMENT TO CARRY OUT THE INSTALLATION OF A NEW REACTOR IN CHEMICAL PLANT Tarragona .
April 2016 was the date of award of the project .


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When You Discover You're a Character in Someone Else's Novel
John Wray on the Anxiety of Reading About "John Wray"
By John Wray
The first thing I did when I learned that I was going to appear, as a fictional character, in a novel by someone that I barely knew, was to ask my best friend what to do about it. Actually, the first thing I did was to wander around my kitchen in a mild state of shock, trying to get my head around all the possible consequences, rationales, and meta-fictional implications of what was arguably the most fiction-like event of my non-fictional life. I made zero headway with that, so I called Matt at work. He's a writer himself, and compulsively candid, and the most level-headed person that I know. Nothing fazes or surprises him. He began with the basics.
"Who's writing this thing?"
"Verena Rossbacher. She's Austrian. We knew each other years ago, when I was living in Berlin."
"Hmm." A pause. "Is this someone you dated?"
"We met for lunch a few times. We like each other's writing. Nothing romantic. She's got a long-term partner and a kid."
A longer pause. Matt considered my answer. He seemed dubious—but Matt is permanently dubious. I didn't take it personally.
"Okay. So what sort of fictional character are we talking about? A character based on you? The way Roth writes about his ex-wife? The way Iris Murdoch writes about everybody?"
"I don't think so," I said. "This is going to be a character in a novel, but with my actual name. And not just my name—my background, my job, my character traits. Everything."
"People do that all the time now," Matt said in a world-weary voice. "They write memoirs and call them novels. Lerner, Heti, Knausgaard. Tell-alls with fictional frosting."
"This wouldn't be that."
"I don't get it. Explain."
I wasn't sure I could. "This would be me—the most accurate version of me that Verena can write—used as a character in an otherwise fictional world. Me, but in the service of someone else's narrative. She's only making one small change—"
"You'll be a plot device," Matt interrupted me. "In someone else's book."
"Why would she want to do that?"
"That's pretty much my worst nightmare," Matt said, and hung up.
I'd gotten Verena's email that morning, out of the blue. She'd been meaning to get in touch for ages, she wrote, in part because she remembered our handful of lunches and coffee dates very fondly—but mostly because her third novel, I Served in the House of Hobbs, was about to be published in Germany, and I happened to be in it. That's exactly how she put it: John, you happen to be in it. Which somehow made it hard to feel flattered.
Verena couldn't give me a reason, she went on, as to why I'd come to play a part in the development of her new novel, which had nothing to do with me otherwise: its protagonist was a butler to a wealthy banking family in Switzerland, a country I've only ever passed through on the train. The best Verena could come up with was this: in one of our Berlin conversations, I'd mentioned that I liked to re-read parts of a favorite book in my grandmother's garden in the summertime, under an old but very beautiful apricot tree. I'd described that tree so lovingly, she said, that she sometimes imagined herself under it, writing rather than reading. That tree had reappeared in her imagination, Verena said, while she was working on her novel, and eventually it had pulled me in with it, along with deck chair and dog-eared copy of Through the Looking-Glass. In any case, I was now in the book: John Wray, six-foot-two inches tall, greenish eyes, lousy posture, American writer. Did I mind very much?
Please understand me correctly, Verena wrote. This is genuinely only intended as a tribute to your person and your work. Nothing in my portrait could in any way be damaging to your reputation—unless it would not be desirable, for some possible reason, that someone should believe that you are gay.
I've never been the kind of writer who claims that his or her characters are more real to them than their actual friends and family. I've never said, in interviews, that I missed them when a manuscript was finished, or that I felt pangs of conscience when misfortune befalls them, or that I could predict the toppings they might order on a pizza. I'm not a superstitious person, I don't think, or more severely delusional than most people who make things up for a living. But in spite of all the above-mentioned disclaimers, I have to confess: Verena's email sent an icy shiver up my spinal column. Not an unpleasant sensation, necessarily, but a mystifying one. I was just finishing a novel of my own for which I wrote a character based on the infamous "American Taliban," John Walker Lindh; but that, I told myself repeatedly, was different. I could dish it out, apparently, but I couldn't take it.
Unless… that icy prickling down my backside… was a tingle of excitement?
I put off answering Verena's email. I was too perplexed to answer. Over the next few days, I spoke to other friends, writers all, in hopes of gaining something like perspective. Nathan shared Matt's bug-eyed horror at the whole idea; Marlon accused me of bragging; Alice thought a gay John Wray would be a step up from the bland cisgender model. I agreed with all of them, except maybe for Marlon. Verena's email, which I'd repeatedly marked as "unread," glared at me each time I opened my laptop. Days went by like this, then weeks. In the way of all human correspondence, electronic and otherwise, it grew harder with each passing day to imagine myself answering at all. Whatever the precise nature of my crisis was, it deepened. If I myself had been a character in a novel—which I definitely wasn't!—my reflection in the mirror would have flickered as I passed it, or gone weirdly translucent, or possibly not have been there at all. God knows how things might have turned out if Matt hadn't taken pity on me.
"Write your girlfriend back yet?"
"I'll take that as a no."
"In order to write her back, I'd have to know what the hell to tell her."
"So this isn't your absolute worst nightmare? Stuck in someone else's book, a puppet to their every whim?"
"I don't know." I hesitated. "I have no idea."
"What's it like, by the way?"
"What's what like?"
"Her book. Is it garbage? Not garbage? The best of all time?"
That was all it took to knock me out of my ontological fog. I hadn't even thought to ask to read the manuscript. My feelings about appearing in someone else's novel, I realized, should be entirely dependent on whether the novel was good.
On that score, thank God, there was no need to worry. I Served in the House of Hobbs (which, like most of the best foreign fiction, has yet to find a US publisher) turned out to be gob-smackingly brilliant, which shouldn't have surprised me at all. I adore Verena's writing: that was the reason for our friendship in the first place. What was more, she hadn't exaggerated one bit—the fictional John Wray, who begins a relationship with the protagonist on page 130 and sticks around for the duration, is significantly smarter, better dressed, and more likable than the John Wray he's supposedly based on. Most flattering of all, however, was the simple fact of my inclusion in so intelligent a book. I'd been granted honorary membership in the most elegant and rarefied of clubs, with full bar and pool privileges, through no merit or achievement of my own. It was like winning the lottery with a ticket someone else had picked and paid for. What on earth could be sweeter than that?
I Served in the House of Hobbs was published in Germany, Austria, and Switzerland this August to raptures and raves. I took more pleasure in the book's success, I think, than I have with any of my own—for one thing, I wasn't half as terrified of failure. I knew this book was good. I was so childishly proud of Verena's success, in fact, that I passed the book on to my mother, who loved it; it currently holds the top spot in her coveted and extremely competitive Best of 2018 bedside-table book heap. My mom has only one criticism of the novel, she informed me. The John Wray character is entirely unnecessary.
autofictioncharactersGodsendJohn WraynovelistsVerena Rossbacherwriting
John Wray
John Wray is the author of the critically acclaimed novels The Lost Time Accidents, Lowboy, The Right Hand of Sleep, and Canaan's Tongue, and, most recently, Godsend. He was named one of Granta's Best Young American Novelists in 2007. The recipient of a Whiting Writers' Award and a Guggenheim Fellowship, he lives in Brooklyn and Mexico City.
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The International Integrated Reporting Council and the Institute of Chartered Accountants of Scotland have published a new report describing how businesses can achieve Sustainable Development Goals.
The report, produced in partnership with the Green Economy Coalition, was written by professor Carol Adams of Durham University Business School in Durham, England. The report aims to help organizations improve their contributions to the Sustainable Development Goals, or SDGs, a set of goals promulgated by the United Nations in 2015 as part of its 2030 Agenda for Sustainable Development, while reducing corporate risk and increasing opportunities that arise from sustainable development issues.


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රැගෙන ඒම සදහා රු 200/- ගාස්තුවක් අය කරනු ලැබේ.


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Home > Formula One > Bianchi family take legal action over Jules' death
Bianchi family take legal action over Jules' death
Jules Bianchi's family are set to take legal action against the FIA, the Marussia Formula 1 team and Bernie Ecclestone's Formula One Group.
The 25-year-old Frenchman suffered fatal head injuries at the 2014 Japanese Grand Prix when his car slid off the wet track and into a recovery vehicle.
Representing the Bianchi family is British firm Stewarts Law, who will act on the Bianchi family's beliefs that the actions of one or more of the three accused parties contributed to the crash.
"Jules Bianchi's death was avoidable," said lawyer Julian Chamberlayne.
"It was surprising and distressing to the Bianchi family that the FIA panel in its conclusions, whilst noting a number of contributing factors, blamed Jules.
"The Bianchi family are determined that this legal process should require those involved to provide answers and to take responsibility for any failings.
The claims were that the "planning, timing, organisation and conduct of the race" were primary reasons of the crash, and that the race "took place in dangerous conditions during the typhoon season in Japan".
"We seek justice for Jules and want to establish the truth about the decisions that led to our son's crash," Bianchi's father Philippe said.
"We have so many unanswered questions and feel that Jules' accident and death could have been avoided if a series of mistakes had not been made."
Bianchi succumbed to his injuries from Suzuka nine months later on July 17 2015, and became the first driver to die as a result of injuries during a race since Ayrton Senna in 1994.
"This is important if current and future drivers are to have confidence that safety in the sport will be put first," Chamberlayne added.
"If this had been the case in Suzuka, Jules Bianchi would most likely still be alive and competing in the sport he loved today."
Image via XPB Images
Josh Kruse
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